Discuss the different types of urinary incontinence you treat.
JEFFREY-THOMAS: When it comes to urinary incontinence, there are many different types. Two of the most common types are stress urinary incontinence (SUI) and urge-related urinary incontinence, and I treat both.
Let's talk about stress urinary incontinence first. What is it, how does it present itself, and how is it different for women and men?
JEFFREY-THOMAS: Stress urinary incontinence refers to any leakage of urine related to movement, activity, and/or changes in pressure in the abdominal cavities. So if you think about coughing, sneezing, or picking up something that's really heavy and you leak urine, that's classic textbook stress urinary incontinence. [Editor's note: SUI is sometimes simply referred to as stress incontinence, or SI.]
For women, we often see stress incontinence after childbirth, or further down the road post-menopause once they've experienced the associated hormonal changes. We also see stress incontinence in elite athletes because they're doing very exertional things and sometimes their ability to stabilize isn't necessarily as great in the pelvic floor as it is everywhere else in their body.
As for men, we don't typically see stress incontinence in men unless they've had a prostatectomy, which is the removal of the prostate gland. The prostate, which is about the size of a walnut, sits at the base of the bladder. When the prostate is removed, there is less support for the bladder and urethra and sometimes damage to part of the sphincter at the base of the bladder, resulting in urine leakage. The pelvic floor muscles can help compensate and control the leakage. But, in men, often these muscles need to be "trained" to compensate.
Sometimes men need to break some habits. For example, when they get up from a chair or they lift something heavy, they tend to hold their breath. All of that extra pressure is now being forced down through their abdominal cavity and they don't have that extra support in their pelvic floor muscles to keep them from leaking. So they will often comment, "Oh gosh, I feel like I'm leaking like a faucet all the time."
Does this mean their pelvic floor muscles are weak?
JEFFREY-THOMAS: Not necessarily. You can have stress incontinence that's related to the whole spectrum of what's going on with the pelvic floor. Sure, in the majority of these cases in men, the pelvic floor muscles are probably weak. But you can't know for sure without an exam. This is why we never prescribe Kegel exercises across the board for stress incontinence without an exam first.
In fact, if there's one thing that people take away from this article, I want it to be these two important points:
- Kegels are not necessarily the exercise that everybody needs to do if they have incontinence.
- Make sure that you're evaluated by a professional trained in pelvic floor health, meaning someone who can assess the tone of the pelvic floor muscle. This person should then provide an individualized plan based on how your body is functioning. Do not rely on the Internet or social media or what worked for your mother or father or best friend.
OK, now let's discuss urge-related urinary incontinence.
JEFFREY-THOMAS: Urge-related urinary incontinence or urgency incontinence is exactly what it sounds like: when you have the urge to go to the bathroom. Often, the urine leakage happens so urgently that you don't even make it to the bathroom.
Basically, you have urgency-related leakage when the pelvic floor and the muscle around the bladder, which is the detrusor muscle, aren't talking to each other well.
There's supposed to be this relationship between the pelvic floor and the muscle around the bladder where when one is on, the other one should be off. So normally when you go to the toilet to urinate, the muscle around the bladder should contract to empty the urine out, and the pelvic floor muscles should relax and get out of the way, opening the doors, if you will, and letting the urine come out.
But you can train the pelvic floor to engage in an effort to help with urgency regulation. So, if the bladder's starting to say, "Hey, we got to go, we got to go, we got to go," instead of leaking from the urgency, we can teach the pelvic floor to engage.
So, in essence, the pelvic floor muscle will send a signal up to the bladder and basically say, "Hey, quit it. Cut it out. It's not time for us to go right now." We're able to regulate urge that way.
But again, if the pelvic floor muscles aren't working correctly—if they're too weak to talk to the bladder muscle, or they're in a tight guarded state and they don't have the range of motion to be able to contract to send a message—then we have this uncontrolled urgency and there's no check on that bladder muscle contracting. So we don't get the proper feedback there and so sometimes we have leakage before we can get to the bathroom.
What causes urgency incontinence in women and men?
JEFFREY-THOMAS: A lot of times, urgency can be related to what you're putting into your body. There are known bladder "irritants," such as coffee, tea, carbonated beverages like Coke or seltzer, and alcohol. All of those things can irritate the inside of the bladder and cause the detrusor muscle around the bladder to freak out and send that urgent signal more frequently and more urgently.
Another thing that can cause urgency is stress. If your nervous system is getting ramped up for whatever reason, then your whole ability to regulate your autonomic nervous system goes away and there's a big autonomic influence on urgency. It's that fight or flight, panicky, "Oh my gosh, I'm not going to make it," kind of feeling.
So if there's a lot of stress or if we're not able to maintain being calm when we get the urge to go, that becomes the driving force there.
Another thing that can cause urgency is when people try to stave off the urgent feeling and subsequent leakage by peeing more often. They think "well, if I pee more often, I'll never get to that urgent point." So instead of going every 2.5 hours, they make themselves go every two hours. But that becomes this self-perpetuating cycle where then the bladder learns to start sending that urgent signal at two hours instead of 2.5 hours.
How do you work with patients who are experiencing stress incontinence? How does pelvic floor physical therapy help?
JEFFREY-THOMAS: For stress urinary incontinence, I start by doing an assessment of the pelvic floor muscles because I want to see what end of the spectrum the patient's muscles are on: low tone pelvic floor muscles (not enough tension) vs high tone pelvic floor muscles (too much tension).
On the low-tone end of the spectrum:
Picture yourself doing a bicep curl, but your arm doesn't want to move; it just stays straight. That's one end of the spectrum. So for women, something might happen during childbirth. Or they're post-menopausal and they have a decrease in hormonal support and their pelvic floor muscles are atrophying.
Or if you have a male who's had a prostatectomy—as I mentioned earlier, men don't normally rely on their pelvic floor muscles to keep themselves continent, because the prostate itself provides some internal support to the urethra. As such, the pelvic floor muscles don't have a lot of baseline strength to them.
For people with low-tone pelvic floor muscles, we work on strengthening those muscles.
We accomplish this through Kegel exercises, working on coordinating the pelvic floor with your breath, and making sure that your abdominals aren't overpowering your pelvic floor. Then, we integrate these concepts into specific scenarios.
So, for example, if you leak every time you cough and sneeze, we work on trying to teach your body to anticipate that and how to support all of the organs with the pelvic floor before any big changes in pressure happen from the cough or sneeze.
Or if we're leaking with working out, we work on how to build up to doing a squat or an explosive activity while maintaining good balance between the pelvic floor muscles, the core, and the breath.
And that's when we get into more of the functional exercises.
So, to recap, for low-tone, we start with baseline strengthening and coordination of the pelvic floor and then broadly generalize that to larger body movements—all while paying respect to what's going on with the pelvic floor.
On high-tone end of the spectrum:
Imagine that you've done a bicep curl and so your elbow is bent. You try to contract further than that, but there's not anywhere for that muscle to go, so it's not able to dynamically respond.
So, for people with high-tone pelvic floor muscles, we focus on getting the muscle to lengthen first.
My patients in this category hear me say all the time "Length before strength." Because you can't strengthen a muscle that can't move any further than it already is. So we focus first on getting that muscle to relax all the way. Then, we do more range of motion exercises in an effort to get the muscle to respond more dynamically.
Then once that high tone issue resolves, we take it through the same kind of functional exercises that we do with the low tone folks.
Whether low tone or high tone, everybody ends up doing the same thing, but how you get there and the order you do things in depends on where your muscles start out.
What's your approach to treating urge incontinence?
JEFFREY-THOMAS: From an urge incontinence standpoint, we start by looking at lifestyle factors. So if you're drinking a lot of bladder irritants, or if you have dysfunctional voiding habits (for example, you're going every hour to try to stay ahead of it).
Regarding lifestyle factors, like bladder irritants, the patient needs to commit to making changes, which I know can be hard. But incremental changes can help. So instead of giving up coffee altogether, you work towards an overall reduction in consumption over time.
When it comes to dysfunctional voiding habits, we work on different techniques to say, "Okay, when we get the urge to go, how do we talk to the bladder?" So I take them through different urge suppression techniques depending on where their muscles are to start out (again, low tone vs. high tone, like we talked about earlier).
- Generally, we talk about using the pelvic floor contraction to get the bladder muscle to relax a little bit to help quell some of that urgency.
- We talk about using diaphragmatic breathing to calm down the autonomic nervous system so that we don't have that fight or flight response going on.
- We talk about different distraction techniques that we can use to redirect our brains, so that it's not quite so "level 10" urgent.
Then, basically, we work towards training your bladder to think, "Okay, I'm going to do these things first. I'm going to calm down that urgency. Then I'm going to try to make my way to the bathroom. I'm not going to try to give in and just try to sprint to the bathroom as fast as I possibly can."
An analogy I use a lot is the kid throwing a tantrum in the store. If you give that kid a piece of candy, he'll stop that tantrum. But then he'll know, "Oh, if I throw a temper tantrum, I'm going to get candy every time." So he continues to throw that same tantrum looking for that same response unless you, as the adult, institute rules that don’t reward the behavior.
The bladder acts like the kid throwing a tantrum. So we need to give the bladder a new set of rules to follow so that your bladder will start to behave the way that you want it to. We talk about gradually increasing the time between trips to the bathroom as we get more comfortable with that.
We also talk about the effect that your bowels can have on your bladder. In fact, a lot of times, there can be underlying constipation issues that can impact urgency. I call it the "theory of stuff" because there's only so much room in the pelvis for all of your organs to coexist. So if you're backed up in your bowel, then that can start to put extra pressure on your bladder and your bladder doesn't feel like it can fill up as much.
So I also work through bowel education with a lot of these patients and anything else that we can look at from a musculoskeletal perspective that's keeping their muscle systems from working the way that they should.
Do people in either category—SI or UI—need to do the exercises or follow the strategies you give them for the rest of their lives?
JEFFREY-THOMAS: When it comes to exercises, remember that the pelvic floor is a muscle just like any other muscle. So if you've got strong arm and leg muscles because you've been going regularly to the gym, but then you stop going to the gym, what's going to happen? Your legs and arms are going to get weaker, and you're not going to have as much endurance.
The same thing happens with your pelvic floor if you stop exercising it. Now, that's not to say that for the rest of your life, your pelvic floor "workout" will be as intense as it is when you're working regularly with me in the beginning. But, yeah—you'll have an ongoing lifelong maintenance program.
Some of those muscle patterns should become more second nature. So, you won't have to cognitively process, "Okay, I need to sneeze before I do this activity."
And those lifestyle changes we discussed earlier for the urge incontinence folks—like limiting coffee, tea, and other bladder irritants—those need to be lifelong changes.
When someone works with you to manage their SI or UI, how long does it take, on average, before he or she can expect to see some forward progress?
JEFFREY-THOMAS: When it comes to offering a timeline for improvement, if you look at any muscle in the body and what science says about that, it typically takes six to eight weeks to see some sort of improvement.
The first six to eight weeks of any muscle strengthening program is all about neuromuscular reeducation. You're dusting off the cobwebs and you're saying, "Okay, this is how I want my muscles to work." You're telling your body, "This is what you need to do," and your body is slowly learning.
So past that six- to eight-week mark, then you actually start getting muscle hypertrophy and growth—and improved muscle memory as well.
Now, that's not to say that you won't notice improvements before you hit the six- or eight-week mark. But this is very much a marathon, not a sprint. We want to lay down a good foundation and make sure that we establish good habits now so that we can take those habits into the future.
Patients dealing with urge incontinency tend to notice improvements first, because it's a little easier to make those lifestyle changes, like drinking less coffee, and creating smaller, measurable goals, like increasing time between trips to the bathroom. UI patients might start to notice improvements within a couple of weeks.
Stress incontinence usually takes a little longer before patients see those initial improvements. That said, I do try to work with patients on specific activities right away where they're leaking so they can start seeing results sooner rather than later.
I want all my patients to experience positive results as quickly as possible. These are quality of life issues, after all. SI and UI aren't going to kill you. But they dramatically affect your quality of life. And your quality of life matters. Let me help!
Speaking of help, if someone wants to see you, what should they do next?
JEFFREY-THOMAS: If you're currently a GBU patient, talk to your GBU physician. He or she can easily make the referral. I also see patients outside of GBU, as long as they have a prescription for physical therapy from their PCP. If you need assistance or have questions, don't hesitate to call our Dedham Care Center. Our staff will happily assist you with navigating insurance and making sure you have any necessary paperwork.
And here's the really good news! We now have another pelvic floor physical therapist in our Dedham Care Center. Her name is Dr. Tonya Yanok, and she's great. She treats women and men, just like I do (and this is unusual in the pelvic floor PT space—not every physical therapist treats men).
So reach out now and make an appointment with one of us. I look forward to working with you and getting you back to living a full life!