Urinary Urgency, Frequency, and Incontinence– What’s New in Research?

I’m sort of nerdy (you already knew that though, didn’t you!)… so periodically, I like to go to my favorite medical search engines to find what is new in the literature regarding all things pelvic health. This helps me to keep aware of new treatments that are available, and helps me to constantly re-evaluate the treatments I provide for patients to make sure I am providing the best treatment I can!

Urinary urgency/frequency, urge incontinence, and overactive bladder problems are often not as frequently discussed in physical therapy circles as stress incontinence. Surprisingly, pelvic PTs actually treat these problems equally as often, if not more! A comprehensive PT program can be extremely effective for these types of problems! (So, if you are having urinary urgency, frequency or overactive bladder problems, and you live near Atlanta, give me a call! :))

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So, what’s new in the research to help with overactive bladder problems and urge-related incontinence?  

  1. Myofascial release techniques can be very helpful for patients with urinary urgency and frequency. I was pretty excited to see this study come out in the Journal of Female Pelvic Medicine and Reconstructive Surgery. Pelvic PTs have noticed for quite a while that many men and women with urinary urgency  and frequency actually tend to have hypervigilant overactive pelvic floor muscles rather than the traditional weak and stretched out muscles people like to think they have. Manual therapy, included within a comprehensive rehabilitation approach, can be very effective for helping this population, and I’m excited to see a recent study supporting the same thing!
  2. Mindfulness-based stress reduction (MBSR) seems promising in helping to reduce symptoms of overactive bladder and urge incontinence.    I didn’t find this surprising at all, but was again, excited to see this coming out in the literature. If you see in my first note above, many people with urinary urgency and frequency actually have a “hypervigilant” or “overactive” pelvic floor muscles. Stress reduction and mindfulness techniques help to calm the whole body–pelvic floor included! Along with this, we often find that people with urgency/frequency problems tend to live in a more sympathetic nervous system dominated state (basically, the “fight or flight” response is in overdrive!). Calming this system can be very helpful in calming the bladder.
  3. Pelvic floor muscle training continues to be recommended as a first line treatment for stress, urge or mixed incontinence.  It’s true, the most updated Cochrane Review published in 2014 continued to recommend pelvic floor muscle training to assist in improving all bladder symptoms. Their review showed close to a 55% cure rate–which is pretty good, considering this was just retraining the muscles in isolation. Imagine what could happen when the right retraining of the pelvic floor muscle is combined with behavioral retraining, dietary training and retraining the pelvic floor within the body as a whole? I bet the results would be much much better.
  4. Percutaneous tibial nerve stimulation may help to reduce urinary frequency and urge-related incontinence. This started becoming popular a few years ago, and honestly, there needs to be more higher quality studies in order for us to really see how effective this treatment is or isn’t. But, that being said, some of the initial results seem promising. If you are not familiar with this technique, it utilizes a very thin needle which is placed near the ankle to stimulate the posterior tibial nerve with a low electrical current. The thought is that this nerve comes from the same level in the spinal cord that the nerves to the bladder originate, so stimulation could possibly help modulate an overactive bladder. (Similar concept to the Interstim treatment which stimulates at the sacral nerves, but less invasive) Looking forward to what the research shows on this treatment in the future!
  5. Losing weight can help improve bladder symptoms.  This is true for both urge related incontinence and stress incontinence (although, seems to help stress incontinence a bit more). In this particular study, 46% of the participants in the weight loss program achieved more than a 70% reduction in their incontinence symptoms. So, if you are overweight or obese, beginning a weight loss program may be a great first step toward improving your bladder function.

The great news is that we continue to learn more and advance in our understanding of helping men and women with these problems every day! What new research have you seen that is promising? As always, I’d love to hear from you!

**Note: I didn’t include medication in this list… not because I don’t think it’s effective or that the research is exciting, it really is! Mostly, because this is where my search took me this time around. The right medication can be a significant helper to many people having these problems– perhaps a future blog can talk about that! 🙂 

 

How should urgency suppression strategies be modified for the tender or “hypervigilant” pelvic floor muscles?

Urinary urgency, frequency and incontinence are complex and involve the interactions of multiple systems (somatic, visceral and neurological). These three problems are treated commonly in pelvic physical therapy and women’s health physical therapy practices. Urgency suppression strategies were initially developed based on these systems- with the understanding that the pelvic floor muscles were not contributing their part to the system.  In my opinion, this was largely based on the understanding the incontinence/urgency occurred when the pelvic floor muscles were not strong enough to properly hold back urine. But, over time we have learned that this is not always the case. (See my recent post here).

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So, do the same urgency suppression techniques apply for a tender pelvic floor muscle group? Hhow should urgency suppression techniques be modified for the overactive, shortened or hypervigilant pelvic floor?

To understand this, I first need to introduce you to the standard urgency suppression techniques.

UST Traditional

Now, please don’t take this as “Jessica doesn’t think urgency suppression techniques work,” because that is simply not true. I use these in the clinic all the time—for my patients who are experiencing urgency or urge incontinence and have weak, under-functioning pelvic floor muscles. These techniques work for this population a few different ways:

  • Deep breathing facilitates the parasympathetic nervous system which helps to keep the walls of the bladder relaxed thus allowing the bladder to fill and decreasing urgency. This breathing also helps to decrease the emotional fear that a person may feel (“Ahh, I hope I make it to the bathroom!”) which also will calm urgency due to the impact this has on the brain.
  • Strong, quick, contractions are thought to stimulate the neurological connection between the pelvic floor muscles and the bladder. Basically, quick contractions tell the bladder “it is not yet time to empty” and the bladder relaxes its contractions (which make us feel the strong urge) helping to calm urgency.
  • Distraction/Visualization are ways to get the mind off of the bladder and on to something else. Remember when you needed to go to the restroom, but got busy and forgot you needed to go? This aims to utilize that same mechanism to calm urgency and allow postponement of the urge.

Sounds great, right? And it is—really great for people who are experiencing urgency and have weak, underactive pelvic floor muscles. But what about for the people having overactive/shortened/hypervigilant pelvic floor muscles?

My thought process is that these techniques have to be modified to allow them to be effective for this population. First, we will keep a few steps and here’s why:

Deep breathing & Distraction/Visualization: I actually love these (especially the calm breathing) for my patients with difficulty relaxing the pelvic floor muscles. I often find that people with overactive pelvic floor muscles tend to be in a sympathetic-drive state for their nervous systems. Remember, the sympathetic nervous system is the “fight-or-flight” response. People who have chronic pain or chronic urgency/frequency often will have a significant amount of stress and fear, and I find that this state of their system often facilitates poor breathing patterns and overall increased tension and poor force modulation (meaning, choosing the right amount of muscle activity for the current task at hand). My colleague, Seth Oberst, wrote an amazing post about this very thing recently (I could write an entire post applying all of that to the pelvic floor!). So, we’ll keep these steps—with an emphasis on slow, calm breathing, utilizing the diaphragm and emphasizing relaxation of the pelvic floor with the inhale and returning to baseline with the exhale.

But here’s where we modify:

Quick, strong, pelvic floor contractions: My issue with this component for the overactive or hypervigilant or shortened pelvic floor muscles stems from a few key points. Traditional “kegels” or pelvic floor strengthening exercises are contraindicated for people with pelvic pain (or in my mind, anyone who has a tender, hypervigilant or overactive pelvic floor). Performing quick contractions for this population often will create pain, worsen the patient’s symptoms and actually increase urgency. You heard that right. Did you know that the pelvic floor muscles can actually refer to the bladder? I have had many instances when examining a person’s pelvic floor muscles that he/she reported that even lightly pressing on certain muscles made him/her feel urgency. And we know that somatovisceral convergence (a muscle impacting an organ) is real, and does occur.  So, what do we do about this step?

We use this relationship in our favor.

Instead of quick, hard contractions, the person can perform deep breathing and pelvic floor drops (emphasizing complete pelvic floor relaxation). Although initially, some of my clients will worry that relaxing the pelvic floor muscles will “open the flood gates” this does not typically occur. Instead, relaxation of the pelvic floor combined with breathing will often calm down the detrusor (bladder muscle) activity and allow them to feel decreased urgency.

So, what do these new urgency suppression strategies look like?

 New UST

 What do you think? If you have a tender pelvic floor and/or pelvic pain, I encourage you to give it a try! Let me know what you think! As always, I would love to hear from  you!

~ Jessica