Women’s Health

12 Jul 2016 10:20 AM - Stress Urinary Incontinence (SUI)

Urinary Incontinence affects up to 37% of Australian women. That’s more than 1 in 3! (Australian Institute of Health & Welfare, 2006)

Stress Urinary Incontinence (SUI) is the leaking of small amounts of urine during activities that put stress on the bladder. “Stress” refers to an increase in pressure on the bladder; a physical stress. Increased pressure can be caused by coughing, sneezing, laughing and heavily lifting, and it can also be caused by jumping, running or any large downwards force on the body. All of these things are an increase in abdominal pressure, which translates to an increase in pressure downwards on the bladder and pelvic organs.

Risk Factors:

Pregnancy, childbirth and menopause are very common predisposing factors to experiencing SUI. As previously discussed, pregnancy and childbirth can cause stretching, weakness or incoordination in the pelvic floor muscles. In the case of menopause though, it is a lack of oestrogen that can lead to physiological changes in the urethral lining that causes some leaking. Elite sportswomen also suffer from SUI commonly due to jumping, running, heavy lifting, straining and/or decreased amounts of oestrogen. Trampolining, parachuting and base jumping have been identified as a sports with high incidences of SUI within their female populations.

SUI can be mild, moderate or severe;

For some women it can make them feel uneasy about their chosen sport, and others it can make a sneeze in public their worst nightmare.

So why does it happen?

Well firstly, we have to understand the fundamentals. Yes, it is linked to your deep pelvic floor muscles! But no, it is not because the deep pelvic floor constricts around your urethra! Following on from the last post- your pelvic floor helps to hold your abdominal organs up and in the most advantageous position. In the case of the bladder and urethra, this a position where the urethra and bladder neck (where the bladder turns into the urethra) are upright and supported.

As seen below, when the bladder neck is well supported and we have an increase in abdominal pressure the pressure is equally applied to the whole system. This causes a forced closure of the urethra equal to the pressure applied to the bladder, and hence there is no loss of urine. However, on the right hand side, when these structures are less supported, the force is not applied evenly and urine escapes. The pressure downwards may just move the urethra instead of stinting it closed up against a firm, contracted pelvic floor muscle (or fascia).

So what can we do about this?

Let’s not forget that the deep pelvic floor muscles are in fact muscles! And just like all other skeletal muscles in our body, they can adapt to loading. That’s right- if you want a strong bicep, you’d have to do bicep curls regularly to increase its strength, and it’s no different for the pelvic floor.

There are a few ways we can go about this strength training though depending on symptoms. So let’s think about these two different examples:

1. you suffer from mild SUI only when you cough or sneeze 

2. you suffer from mild SUI only when you go for a 5km run

In the first example, we would focus more on maximal strength and coordination of the pelvic floor (equivalent to a persons’ 1 rep maximum). And in the second example, we would focus more on the resting tone and endurance of the pelvic floor (more like, how many reps you can do at the same lower weight).

Why is this? Consider the time frame of each event: Even in running, we turn on and off our muscles in a rhythm, but we would never expect a single muscle to contract the entire time. Muscles don’t like to be turned on and kept on. So we would never try and train the pelvic floor to turn on and hold for 5km!! However, if it is a single, shorter event that you can predict that causes SUI, it makes sense that you need a very strong, effective contraction to make a change in leakage.

Some treatment ideas could be (corresponding to the different symptoms above):

1. Frist of all we would teach the patient how to coordinate a strong contraction during a cough or sneeze. Interestingly, this reflex is usually lost after giving birth and it is more a coordination issue rather than a strength one. Depending on this efficacy then, we would prescribe pelvic floor exercises focusing on fast activation, maximal holds and/or pulsing holds towards maximum. Importantly these exercises are based at fatiguing your pelvic floor and should only be done at the end of the day in bed, before sleep.   

2. In order to change the endurance and resting tone of your pelvic floor, we need to build muscle bulk in the pelvic floor. For this we would be aiming for 8-12 repetitions pushing the muscle to fatigue, and doing 1-2 sets per day. It is recommended that strength training occurs for three to four months. Additionally, for women with good strength, but lifestyles that exceed normal pelvic floor requirements (such as elite sportswomen, powerlifters or cross-fitters), vaginal weights can be excellent to increase resistance and hence build the needed muscle bulk.

But…

SUI symptoms may be caused by other pelvic floor or bladder issues, and it is always worth seeing a medical professional about your issues before attempting anything by yourself. A lot of women don’t contract their pelvic floor muscles properly, and are often pushing down instead of pulling up, hence worsening their problems, not making it better! Furthermore, severe SUI can be a sign of other issues in the pelvis and a multifactorial approach may need to be taken, not just pelvic floor retraining.

If you have any issues or you want to discuss anything further about any symptoms you may be experiencing you can call us on 8361 8182 to book an appointment today with Suzannah. Women’s Health is an area that only Women’s Health specifically trained professionals will be able to fully assess and treat, so give us a call to help you on your way.

Suzannah Michell

APA Physiotherapist- Women’s Health