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Volume 32, 12 Issues, 2022
  Letter to the Editor     October 2022  

The Role of Rehabilitation Services in the Optimal Management of Urinary Incontinence in Women

By Huma Riaz1, Farooq Azam Rathore2

Affiliations

  1. Faculty of Rehabilitation and Allied Health Sciences, Riphah International University, Islamabad, Pakistan
  2. Department of Rehabilitation Medicine, PNS Shifa Hospital, Karachi, Pakistan
doi: 10.29271/jcpsp.2022.10.1374

Sir,

We have read the commentary “Urinary Incontinence: Understanding the silent plight of women” by Parpio and colleagues with interest.1 They have correctly highlighted urinary incontinence (UI) as a common and distressing condition that affects women of all ages. They have discussed the multidisciplinary care of women with UI as one of the management approaches. However, there is no mention of the role of the rehabilitation team, particularly of Women’s health physical therapists who provide a variety of preventive and therapeutic services for UI within their scope of practice.

The international consultation on continence, recommends pelvic floor physical therapy as a first-line conservative treatment for stress, urge, or mixed UI for women across their life span.2 It is low risk, minimally invasive, and an evidence-based management approach for UI in women. Stress UI weakens pelvic floor muscles (PFMs) that may contribute to hypermobility of the bladder and weakness of the urethral sphincter resulting in involuntary urine leakage with raised intraabdominal pressure (e.g. during coughing and laughing).In these patients, supervised pelvic floor or Kegel exercises are effective in improving PFM strength, endurance, and coordination resulting in better voiding control with no adverse effects.4 These exercises raise the pelvic diaphragm, compress the urethra, and increase urethral pressure.2,3 For optimal effects, the exercise program should last 6-12 weeks, with >3 sessions/week and a length of session <45 minutes. A success rate of 56-75% has been reported with good adherence to exercise regimes.5

PFMs training in urge UI inhibits detrusor over activity and controls urinary leakage. Adequate patient instructions are necessary to achieve appropriate PFM contractions PFM can also be assessed and facilitated with intra vaginal digital palpation. While performing digital examination physical therapists can assess the muscle tone and strength of PFMs using a modified Oxford scale for muscle testing.6

In patients unable to perform voluntary contractions. Different physiotherapeutic modalities can also be used to facilitate PFM contractions. Biofeedback devices with or without electromyography provide audio and video feedback of muscle strength using vaginal or rectal sensor electrodes. It is helpful in women having difficulty isolating their PFMs.2,6 Severely weakened pelvic floor muscles can be stimulated and detrusor over activity can be inhibited by neuromuscular electrical stimulation using small vaginal or rectal electrodes. Low to medium frequency currents are suitable for this purpose.4,6

These electrotherapeutic tools are useful adjuncts for functional awareness, better muscles coordination, endurance, and strength to promote maximal functioning. Supervised training sessions using weighted vaginal cones provide progressive muscle loading and are also recommended for UI. Vaginal cones are inserted into the vagina and held in place by pelvic floor contraction during activity.2,6 Bladder training or scheduled voiding regimens is another appropriate conservative intervention followed by a pelvic floor physical therapist.2,6 It helps to increase the time interval between voiding and teaches prompt voiding in dependent individuals. The number of female physical therapists trained in women’s health are increasing in Pakistan. However, there are still challenges like lack of awareness amongst medical professionals and patient community resulting in delayed or no referrals.

We conclude that there is a need to recognise and promote the role of rehabilitation services in the optimal management of women with UI in Pakistan. Urologists and gynaecologists dealing with these issues must refer patients with UI to physical therapists trained in women’s health to provide appropriate rehabilitation services. This will not only help in optimising better patient outcomes but also improving their quality of life. 

COMPETING INTEREST:
The authors declared no competing interest.

AUTHORS’ CONTRIBUTION:
HR: Initial draft writing, literature search, and final approval.
FAR: Study concept and design, critical revision of the manuscript and final approval.

REFERENCES

  1. Parpio YN, Minaz A, Haider SI. Urinary incontinence: Understanding the silent plight of women. J Coll Physicians Surg Pak 2022; 32(4):519-21.  doi: 10.29271/jcpsp.2022. 04.519.
  2. Dumoulin C, Hunter KF, Moore K, Bradley CS, Burgio KL, Hagen S, et al. Conservative management for female urinary incontinence and pelvic organ prolapse review 2013: Summary of the 5th International consultation on incontinence. Neurourol Urodyn 2016; 35(1):15-20. doi: 10.1002/nau.22677.
  3. Lawson S, Sacks A. Pelvic floor physical therapy and women's health promotion. J Midwifery Women's Health 2018; 63(4):410-7. doi: 10.1111/jmwh.12736.
  4. López-Liria R, Varverde-Martínez MLÁ, Padilla-Góngora D, Rocamora-Pérez P. Effectiveness of physiotherapy treat-ment for urinary incontinence in women: A systematic review. J Womens Health (Larchmt) 2019; 28(4):490-501. doi: 10.1089/jwh.2018.7140.
  5. García-Sánchez E, Ávila-Gandía V, López-Román J, Martínez-Rodríguez A, Rubio-Arias JÁ. What Pelvic floor muscle training load is optimal in minimizing urine loss in women with stress urinary incontinence? A systematic review and meta-analysis. Int J Environ Res Public Health 2019; 16(22):4358. doi: 10.3390/ijerph16224358.
  6. Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol 2019; 31(6):485-93. doi: 10.1097/GCO.0000000000000584.

Authors Reply Section

By Sonia Ijaz Haider

Affiliations

  1. Dr. Sonia Ijaz Haider, Department for Educational Development, Faculty of Health Sciences, The Aga Khan University, Karachi, Pakistan


AUTHOR’S REPLY:

We certainly agree and acknowledge the importance of the role of the rehabilitation team, particularly physical therapists for women who provide different preventive and therapeutic services for UI within their scope of practice. However, the question is the availability of physical therapists prepared enough to exercise this role in local context. This letter opens up a new avenue to advocate the role of rehabilitation centres and look into the training of physical therapists to deal with women with UI.

In addition, in the paper we have explicitly emphasised the inclusiveness of psychologists in the team who can take care of the mental well-being of women suffering from this condition. The paper highlights to follow a multi-disciplinary approach involving professionals from different disciplines and tackling it with collaborative and collective efforts.