Types of Incontinence (Leakage)
Incontinence is leakage. Leakage can be of the bowel (stool/gas) or bladder (urine). There are several different types of incontinence, but let’s list off and define some of the more common ones. We will discuss leakage in the context of bladder and bowel.
Urgency Incontinence
Urgency related incontinence can be defined by a sense of urgency to make it to the bathroom and inability to make it to the bathroom in time. This can look like you doing the ìpotty-danceî on the way to the bathroom. Usually, people who experience urgency incontinence struggle with leakage on their way to the toilet or while undressing.
Urgency urinary incontinence would be involuntary leakage of urine (pee) before sitting on the toilet. This can happen as a result of overactive (too-tight) pelvic floor muscles, poor urgency signaling to the brain, and behavioral triggers. Behavioral triggers would be things we do on a daily basis like hearing the sound of running water, putting the key in the door, garage door rising, etc.
Urgency bowel incontinence would be involuntary leakage of stool (poop) before sitting on the toilet. This usually happens because of poor stool consistency or looser stools. It can also happen for the same reasons as urgency urinary incontinence: overactive (too-tight) pelvic floor muscles, poor urgency signaling to the brain, and behavioral triggers (stress, anxiety, running).
Stress (Exertional) Incontinence
Stress related incontinence can be defined also as exertional incontinence. This would be due to a physical stress/exertional task that causes incontinence. Common forms would be sneezing, coughing, jumping, running, laughing, lifting, etc.
This can occur with urine (pee) or stool (poop) due to increased pressure in the abdomen. Causes of stress incontinence include pelvic muscle dysfunction meaning the muscles can be too tight or not provide enough support. Tight muscles do not equal strong muscles. Usually in cases of stress incontinence, a goal of treatment involves restoring coordination to the muscle. Like patting your head and rubbing your belly, training the pelvic muscles to engage during certain movements can be the key to incontinence.
Mixed Incontinence
Mixed incontinence is a combination of stress incontinence and urgency related incontinence. Most people who have incontinence fit into this category since it is heavily a muscle issue. We typically treat this type of incontinence by addressing the urgency related incontinence and then the stress (exertional) incontinence.
Urine Specific Incontinence
Overflow Urinary Incontinence
Overflow incontinence occurs more often in men occasionally due to enlarged prostate. It is characterized by a constant leak or dribble of the bladder. Nurses, teachers, and other service industry professionals have a tendency to hold their bladder for 5+ hours. The bladder is like a balloon and it will continue to stretch depending on the demands placed on it. If you hold your bladder for longer than 5 hours regularly, you may be teaching your bladder to dampen signals. This can also cause overflow incontinence.
Functional Incontinence
Functional incontinence can occur in those who are incapable of making it onto the toilet in time due to functional capacity. This could be someone who struggles with cognitive function (dementia, stroke, etc.), poor physical ability to transfer, or other factors that limit one’s independence of making it to the toilet on time. Usually, these patients will leak before they are allowed access to the toilet via help with an aide or caregiver.
Post Void Dribble
Post void dribble is incontinence immediately upon standing up from the toilet. This usually is a result of not fully emptying your bladder. This can be mitigated with double voiding techniques such as rocking back and forth on the toilet to fully empty the bladder, using a squatty potty while emptying, and releasing overactive or tight pelvic floor muscles.
Bowel Specific Incontinence
Fecal Smearing
Fecal smearing usually occurs after a bowel movement. It is when stool is unknowingly excreted from the anus without any awareness or a slight burning sensation. Looser stool is slightly more acidic than firm stool, and this can cause some burning around the anal opening. It can happen as a result of looser stools, hemorrhoids, or nerve damage around the anal opening.
Flatulence (Gas) Incontinence
If you were in a crowded elevator and felt the need to stop the passage of gas, would you be confident in your ability to do so? Gas incontinence can happen as a result of pelvic muscle dysfunction and can cause significant embarrassment and decreased quality of life. Controlling passing gas can be a critical part of pelvic floor health that can often be overlooked.
In Summary
Most types of incontinence (gas, bowel, and bladder) can be helped with pelvic floor physical therapy. Not only does pelvic floor PT address the muscular reasons that incontinence occurs, we also address nerve contributions, connective tissue support, coordination ability, and so much more.
Your symptoms may be similar to friends or family members, but the way we treat patients is completely individualized to assess what will work best for you. Pelvic floor PT can make a significant difference in your incontinence and set a plan in place to manage this through your life span.
Rectal balloon training is a safe and effective technique provided at Pelvic Health Solutions to help improve colorectal symptoms. Rectal balloon training has many benefits including improving sensation in the rectal canal, decreasing constipation, promoting better coordination of bowel movements, and decreasing fecal incontinence (bowel leakage and gas leakage).
Who can benefit from rectal balloon training?
Rectal balloon training is an effective treatment for anyone experiencing the following symptoms:
• Constipation
• Fecal Incontinence: Inability to control bowels
o Bowel movement smearing
o Bowel movement leakage (light, moderate, or heavy)
o Gas leakage
• Bowel movement urgency: Extreme urgency to have a bowel movement without much warning
• Dyssynergic Defecation: Inability to coordinate bowel movements
• Feelings of incomplete bowel emptying
What is a rectal balloon?
A rectal balloon is a catheter attached to a medical-grade balloon. This is inserted intra-rectally while the balloon is deflated. With rectal insertion, the balloon can be inflated and deflated. The changes in pressure gradients will promote increased sensory awareness into the rectal canal. Dependent on the person, some people may experience too much urgency with a bowel movement and could benefit from reducing sensation of the rectal canal. The balloon can also be repositioned within the rectal canal during treatment to improve different areas of the rectum. Rectal balloon training is a safe and effective way to promote strength, coordination, and sensation within the rectal canal.
How do rectal balloon pressures work?
When utilizing a rectal balloon, your therapist will initially gather data using pressure gradients while inflating or deflating the balloon. Some of the pressures we look for are: first sensation of pressure, desire to have a bowel movement, urgency to have a bowel movement, and the most tolerable pressure associated with having a bowel movement. These pressures help us determine the best treatment plan for you. The rectal balloon treatments will be based on what you demonstrate in the evaluation and how you respond to different pressures. The treatments are designed to help you improve sensation in the rectal canal – or decrease sensation in instances of bowel urgency.
Is rectal balloon training painful?
Absolutely not! The rectal canal is designed to sense pressure – not pain. This means working within the rectal canal will only promote sensations of fullness within the rectum. This allows us to work solely on the structures that sense when you need to go and improve sensory awareness – or decrease urgency dependent on your symptoms.
How can I be sure this treatment is for me?
Pelvic Health Solutions therapists are specifically trained in rectal balloon catheterization and screening for appropriateness of treatment. Call us at 561-899-7747 to determine if this treatment will benefit you!
The difference between common pelvic pain diagnoses and how they impact treatment.
Pelvic pain is often defined as any pain confined to the general torso area from your ribcage down to your genital area. Pelvic pain can stem from several origins: digestive organs, bladder, reproductive organs and structures, and bowels/rectum. Pelvic pain is an unspecific term that includes a variety of dysfunctions and diseases. Below, we will exam some common pelvic pain diagnosis. This list does not encompass all pelvic pain-related issues, and you should speak to your current health care provider if you believe pelvic floor PT can help you!
Dyspareunia: Dyspareunia is a very general term to describe any pelvic pain during sexual intercourse. This pain can be upon initial penetration or deeper penetration. This pain can be short-lived discomfort or a long-lasting pelvic ache. Dyspareunia can contribute to decreased intimacy between sexual partners, feelings of dissatisfaction, and a negative outlook toward sex. Dyspareunia can be caused by a variety of factors such as improper lubrication, poor positioning during intercourse, muscle spasms, poor tissue health, underlying conditions or hormone imbalance. Treatment for dyspareunia includes pelvic floor down training or relaxation, diaphragmatic breathing, potential dilator training or wand training, education on different positions during sexual intercourse, and promoting surrounding muscle and soft tissue extensibility. Dyspareunia is unique to the person experiencing it and should be treated as such. Pelvic floor PT’s are specially trained in determining the best treatment path for you.
Vaginismus: Vaginismus is a more specific dysfunction which describes pelvic muscle spasm in response to penetration of the vaginal canal. Vaginismus is most often a concern when one determines they cannot insert a tampon, participate in a gynecological examination, or participate in sexual intercourse or vaginal penetration in any form. Vaginismus involves pelvic floor muscle spasm that can be accompanied by extreme pain and anxiety. Different than vaginal stenosis (true narrowing of the vaginal canal), vaginismus is a reflexive narrowing of the vaginal canal due to muscle guarding.
As the saying goes, “you never touch a hot stove twice.” Touching a hot stove causes your arm to reflexively pull back and away from the heat source. The same thing is happening with your pelvic floor muscles as a response to pain. Once you experience pain in the pelvic floor/vaginal/vulvar region, your muscles will tense up to guard in future, potentially pain-provoking events. It is on a feedback loop that consistently sends this message out in response to vaginal penetration. It is possible to “rewire” this feedback loop and prevent the spasms. This requires graded desensitization techniques, dilator training, and promoting positive feelings towards sex and vaginal penetration. Pelvic floor PT can help retrain your pelvic floor muscles and promote improved ability to insert a tampon and participate in gynecological exams and sexual intercourse.
Vestibulodynia/Vulvodynia: This terminology is interchangeable. Vulvodynia is described as discomfort, pain, and itching in the vestibule (opening to the vagina), inner labia, or vulvar tissue. This pain is generally provoked through contact with this area via touch, clothing, or the surface you sit on. This pain is usually described as “raw” or “burning” pain. Vulvodynia can be treated through graded exposure and desensitization techniques, proper vulvar-vaginal hygiene habits, promoting tissue health, and education on good seat surface options for you.
Endometriosis: Endometriosis occurs when there is regurgitation of menstrual blood out of the fallopian tubes into the body. This blood specifically contains endometrial tissue which can lead to scar tissue build up throughout the body. Scar tissue build up is generally seen within the abdomen region – but can travel up towards the eyes and brain. Our body likes to move freely (including our organs), but scar tissue can bind down reproductive organs, bladder, bowels, and digestive organs making mobility difficult. Though we cannot stop the damage done by endometriosis, we can address the mobility dysfunctions that occur with it. We provide treatment for myofascial restrictions, soft tissue mobilization, scar tissue breakdown, and visceral mobilization. These hands-on treatments provide the body movement it needs to improve mobility between your organs/intestines and promote scar tissue breakdown within the body.
Vaginal Stenosis: Vaginal stenosis is the narrowing of the vaginal canal. It can occur rarely via birth (primary stenosis), or it can happen because of external factors (disease, infection, radiation, etc.) which is considered secondary stenosis. Vaginal stenosis can cause pain with sexual intercourse, muscle spasms, and overall vaginal discomfort. Treatment may include dilator therapy which works to expand the vaginal canal and promote tolerance to penetration of the vaginal canal. Other treatments can include muscle relaxation techniques, scar tissue massage, and pelvic floor range of motion training.
Constipation: Although not solely “pelvic pain,” constipation can result in abdominal cramping. Constipation (in an otherwise healthy colon) occurs due to decreased colon motility which causes overabsorption of water in the large intestine. With decreased movement and water, stool hardens which makes it more difficult to pass. Constipation can also be caused by pelvic floor muscle spasms. As the stool passes, an overactive pelvic floor can spasm and cut off the bowel movement before it completely evacuates. This “trapped” stool then gets harder to pass as the rectum absorbs more water from it. This is known as outlet constipation. Treatments for constipation include bowel massage, addressing soft tissue restrictions, decreasing pelvic floor muscle spasms, addressing underlying diet causes, and promoting healthy water intake.
Tailbone pain: Many people have – or know of someone who has – broken their tailbone. However, the tailbone does not have to experience trauma to cause discomfort. Persistent tailbone pain (a.k.a coccydynia) is also quite common in our population. The muscles around the tailbone (pelvic floor muscles) can experience spasms which lead to tailbone discomfort or pain. Overactivity of the pelvic floor muscles on the right side can “pull” the tailbone towards the right side of the body causing asymmetry. The same thing can happen on the left. Pelvic floor physical therapy works to reduce spasm in these muscles and decrease pain associated with coccydynia.
Interstitial Cystitis: Interstitial cystitis is also known as painful bladder syndrome. Here is a link (insert link to IC article) to our article which goes more in-depth on what IC is, and how pelvic floor PT can help.
Prostatitis: Prostatitis, or pain/inflammation of the prostate, can come in many forms. Prostatitis can occur due to a bacterial infection or overactivity of the pelvic floor muscles. Prostatitis can be acute (one time occurrence lasting under 4 weeks) or chronic (recurrent bouts lasting 3 months or longer). Prostatitis can manifest in many ways such as pain in the pelvis, urinary frequency, urinary urgency, burning during urination, pain with ejaculation, or a weak urinary stream. Pelvic floor physical therapy can reduce pain and associated symptoms of prostatitis by promoting pelvic floor relaxation, biofeedback to reduce pelvic floor tone, and education on voiding techniques to reduce future occurrences of prostatitis.
This is not an exhaustive list for causes of pelvic pain, and each patient has a unique set of signs and symptoms which will guide their treatment. Unfortunately, pelvic pain diagnoses tend to overlap and contribute to increasing pain and dysfunction. Fortunately, there are solutions that can end this cycle of pain, discomfort, and frustration. Pelvic floor physical therapy can address all the above dysfunctions by treating the pelvic floor muscles, behavioral modifications, and establishing a better connection between the nervous system and pelvis.
Hip Dysfunction: Is Your Pelvic Floor the Missing Link?
Hip structure and function directly impact the pelvic floor. Based on proximity alone, the pelvis and hips are closely related. Their muscle groups are interconnected and overflow into each other. Hip dysfunction can contribute to pelvic floor dysfunction and vice versa. Pelvic floor muscles are smaller, serve to promote continence, and support our internal organs. Hip muscles are larger and help us produce movement to ambulate throughout our life. If hip muscles are underactive, they can cause the pelvic floor to become overactive by not providing the stability it needs.
Hip strength is vital for pelvic floor function.Hip range of motion is also important to pelvic floor function. Hip flexibility is a good indicator of pelvic floor muscle activity and continence. If hip flexibility is decreased, pelvic floor muscles will not be working in their fullest capacity. In pelvic floor physical therapy, we work to assess what contributions are occurring from the joint above (low back) and below (hips). Someone who experiences pelvic floor dysfunction likely have some dysfunction in the low back or hips.
Conversely, someone who experiences back pain or hip problems will likely have an underlying pelvic floor dysfunction based on the proximity of these regions. Patients with hip problems (or those post-hip replacement) may report a deep, aching hip pain that does not resolve with only external treatments. This is pain potentially stemming from hip muscles that can be accessed within the pelvic floor. If we neglect pelvic floor contributions to hip pain, how would we expect our patients to get back to 100%?
Pelvic floor physical therapy can resolve hip-related dysfunctions by assessing the pelvic floor, hips, and low back to determine the best plan of care for a patient. We address hip mobility and strength, core strength, pelvic floor muscle tone and coordination, and pain management strategies to give you a holistic treatment method. Physical therapy can be considered a conservative treatment for those who may need a hip replacement. Reach out to us if you have any questions regarding treatments and approaches to the pelvic floor. Pelvic floor physical therapy may be the missing link to you living a pain-free life.
Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain. Spine (Phila Pa 1976). 1998;23(9):1009-1015. doi:10.1097/00007632-199805010-00009
Ike, Hiroyuki MD; Dorr, Lawrence D. MD; Trasolini, Nicholas MD; Stefl, Michael MD; McKnight, Braden MD; Heckmann, Nathanael MD Spine-Pelvis-Hip Relationship in the Functioning of a Total Hip Replacement, The Journal of Bone and Joint Surgery: September 19, 2018 – Volume 100 – Issue 18 – p 1606-1615 doi: 10.2106/JBJS.17.00403
Reiman MP, Matheson JW. Restricted hip mobility: clinical suggestions for self-mobilization and muscle re-education. Int J Sports Phys Ther. 2013;8(5):729-740.
Endometriosis is a condition where the endometrial tissue (lining of the uterus) exits the uterus and enters the body and blood stream. Endometrial tissue is expelled from the uterus during menstruation through the fallopian tubes. Endometrial tissue is healthy and normal within the uterus. Endometrial tissue, outside of the uterus, is harmful. Endometrial tissue can travel through the bloodstream and relocate to other areas of the body (studies have found endometrial tissue as far as the eyes and brain). When endometrial tissue exists outside of the uterus, it proliferates scar tissue. See, our organs like movement, and they are designed to slide and glide against each other. When scar tissue builds between organs, our bodies cannot move as well. Organs can become tethered together. The bladder can bind to the uterus, uterus to colon, colon to colon, and so on and so forth. This can affect our digestion, reproductive abilities, excretion of waste products, and overall comfort. Endometriosis can contribute to pelvic pain and dysfunction.
What can pelvic floor physical therapy do to address endometriosis?
Pelvic floor physical therapy cannot cure or treat the cause of endometriosis. However, pelvic floor PT can address symptoms associated with endometriosis. We can determine a plan of care that is individualized to each patient regarding their symptoms. About half of patients with endometriosis experience chronic pelvic pain in some way, shape, or form. This could be through pelvic pain during menstruation, sexual intercourse, or digestion. Other symptoms include constipation, decreased organ motility, and joint pain. Endometriosis can even have injurious effects of posture. Pelvic floor physical therapy can help with symptom management and promote organ motility. There are a variety of techniques we incorporate including soft tissue mobilization, visceral mobilization, promotion of movement, pelvic floor relaxation, recommendations for behavioral modifications, and so on.
Endometriosis is a distressing condition for those who experience it and their loved ones. With pelvic floor physical therapy, we can improve your quality of life with symptom management. If you struggle with endometriosis, reach out to us, and see what we can do for you!
Awad E, Ahmed HAH, Yousef A, Abbas R. Efficacy of exercise on pelvic pain and posture associated with endometriosis: within subject design. J Phys Ther Sci. 2017;29(12):2112-2115. doi:10.1589/jpts.29.2112
By Natalie Sterner, PT, DPT
Running is a common activity that many women and men enjoy daily. Frequent runners typically have a pre and post workout regime consisting of stretching for hip and knee musculature, foam rolling, and even icing in order to reduce pain and inflammation in various joints or muscles. One thing that is often left out of these routines is the pelvic floor – a vital component in core stabilization and injury prevention with exercise, particularly running. Many runners will seek out treatment for common orthopedic issues – plantar fasciitis, hip pain, ITBand dysfunction – which may be stemming from the pelvic floor and will not see complete results with therapy due to only being given “core” exercises without addressing the pelvic floor as well. Statistics show that at least 1 out of 4 women report having one or more pelvic floor related disorders such as urinary/fecal incontinence, pelvic pain, and pelvic organ prolapse (POP). A study by Thyssen in 2002 found 44% of young female athletes leaked during sports.
The pelvic floor is just as important as our other external musculature in proper running mechanics. The pelvic floor is part of the deep core muscles which are our anticipatory muscles. They stabilize our body by contracting prior to movement. Other muscles in this group are the transverse abdominus, multifidi, and diaphragm. The pelvic floor works during both phases of running. During the flight phase it works eccentrically or lengthens. During heel strike of the stance phase the pelvic floor and deep core muscles work concentrically meaning they shorten to allow for stability. Thus we need the full range of the pelvic floor for optimal mechanics during running.
Pelvic floor dysfunction can present in various signs/symptoms. Some common dysfunctions found in athletes/runners are listed below:
- Urinary/fecal urgency: This symptom is often caused by myofascial trigger points within the pelvic floor muscles which triggers neurogenic bladder symptoms. These trigger points can become active during running and lead to the feeling of immediate voiding! This can be extremely frustrating for runner who may limit their paths or routes to make sure a bathroom is close by or even needing to stop mid-run to not lose urine or feces.
- Urinary/fecal incontinence: Urinary or fecal leaking can be a very common occurrence with runners. In a study by Leitner in 2016, it was found that 41% of female athletes have experienced urinary leaking with running. This can range from a small dribble to fully soaking through leggings and running down legs. Running is very stressful on the pelvic floor muscles that work to support all the pelvic organs while maintaining continence. If leaking occurs, the pelvic floor is not able to tolerate this pressure. This could be caused by myofascial trigger points, muscle weakness, and/or decreased coordination.
- Pain: The pelvic floor muscles work just like any other muscles – they contract and relax and can become tight or weaken. Pelvic floor muscle trigger points can develop as well if not allowing lengthening to occur in the muscle. Common pain referrals from the pelvic floor are the lower abdomen, hip, buttock, posterior thigh. Pain may also be coming from external hip muscles as well. The adductors, our inner thigh muscles, can also refer pain to the pelvis. It is important to have both strength and flexibility in all of these muscle groups.
- Heaviness or pressure: This can be a potential sign of pelvic organ prolapse (POP) which is the downward descent of the pelvic organs. This can involve the uterus, bladder, and/or rectum. The pelvic floor muscles need to provide enough support with the increase of intra-abdominal pressure that occurs during running. If there is weakness and not enough support, this can lead to pulling on the ligaments and connective tissue leading to possible prolapse.
What can we do to ensure that the pelvic floor is working appropriately to reduce the risk of these symptoms? Breathing is the first step. When exercising we want to ensure that the diaphragm is moving properly. When we inhale the diaphragm should move down into our abdominal cavity allowing the rib cage to open and the belly to expand rather than just breathing using our chest. This will allow the pelvic floor and transverse abdominus muscles to lengthen. During our exhalation the diaphragm moves upward as the pelvic floor and transverse abdominus return to their prior position. The diaphragm and pelvic floor muscles move in tandem like a piston and generate good tension in the trunk which creates more stability while we run. Coordination of this is important.
Try not to hold/grip the abdominals or pelvic floor. This will limit trunk rotation and the ability to use the abdominals effectively. Same with the pelvic floor – there needs to be some absorption of pressure and holding can lead to overactivity of the muscles. We want all of the deep core muscles to work together in balance.
Posture is important for running as well. Proper running posture consists of leaning over so that your rib cage is on top of your pelvis in order to keep your head looking forward. This will allow better mobility through the hips and will keep your body over your heel as you land reducing the pressure through the body. Increasing your cadence, the number of steps you take per minute, can also decrease the forces through your body leading to less impact through the pelvic floor as well.
Making sure that your body is taken care of while doing what you love to do is important so that you can keep doing it! The demands of running are intensive and repetitive. It is important to specifically train the pelvic floor to meet these demands just as you would strengthen your back, hip and knees for fitness. If you feel you are having any of these issues the pelvic health therapists at Pelvic Health Solutions can assess you individually and work with you to continue with the sport that you love to do!
Resources:
Leitner M, Moser H, Eichelberger P, Kuhn A, Radlinger L. Evaluation of pelvic floor muscle activity during running in continent and incontinent women: An exploratory study. Neurology and Urodynamics. 2016;36(6): 1570-1576. Doi:10.1002/nau.23151
Thyssen HH, Clevin L, Olesen S, Lose G. Urinary incontinence in elite female athletes and dancers. Int Urogynecol J Pelvic Floor Dysfunction. 2002;13(1):15-7.
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