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 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 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 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 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.
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.
Have you been told to Kegels at some point in time? They are typically the first thing we think about when we think about strengthening the pelvic floor. A Kegel — regardless of how you pronounce it — is a voluntary contraction of the pelvic floor muscle group. The pelvic floor is a group of muscles that slings the bladder, rectum, uterus, and other organs up to prevent incontinence (leakage), prolapse, and dysfunctional core support.
The pelvic floor muscles can stretch and strengthen like most muscles in the body. Sometimes the pelvic floor can be too “loose” and not supportive enough which can cause problems for organ support and incontinence. However, sometimes the pelvic floor can be too “tight” which can also cause problems for organ support and incontinence. Usually, if one’s pelvic floor is too “loose,” Kegel strengthening can be helpful. If one’s pelvic floor is too “tight,” Kegel strengthening can make bladder/bowel leakage and prolapse more bothersome. The tricky part is that most patients cannot accurately gauge whether their pelvic floor muscles are “tight” or “loose.” Pelvic floor physical therapists are specially trained experts in determining the flexibility and strength of the pelvic floor. With hands on techniques, your therapist can tell you if your pelvic floor would benefit from Kegel training or not. Not everyone will benefit from Kegels.
A Kegel is not a one-size-fits all, and they can worsen symptoms in those experiencing pelvic overactivity (too “tight” of muscles ). You can be leaking if your muscles are stuck in elongation, and conversely if your muscles are stuck in tension. In either situation, you are not able to access that full breadth and width of our muscles. In fact, in therapy, we rarely talk about doing Kegels until you can demonstrate full relaxation of the pelvic floor muscles. Besides, there are so many other important things to talk about and address before you even get to Kegels.
Aside from Kegels, there are other important predictors of pelvic floor strength and stability. Hip strength and abdominal strength are important for pelvic strength. This includes your ability to balance on one leg, response time with balance, and endurance of exercise.
Your pelvic floor therapist will take everything into consideration during your intake examination to make the most appropriate game plan for you. Contrary to the popular belief, Kegel training is usually not the best place to start. If you are uncertain on if you should be doing Kegel training, call us to schedule an evaluation.
What is dry needling?
Dry needling is a technique where fine needles are inserted into a muscle or muscle tendon. Dry needling can be used to tap into a dysfunctional muscle. For example, if you have knee pain, we can dry needle around the knee to improve tissue mobility and healing surrounding the region. Needling into dysfunctional areas can stimulate bone growth, draw blood to the affected region, and decrease pain surrounding your dysfunctional area.
We can also use dry needling to tap into our nervous system. Most people live in a fight-or-flight response based on daily stressorsóneedling can help this. We know our needling techniques can improve your rest-and-digest functions by improving the parasympathetic nerve function. We can also improve vagus nerve tone. The vagus nerve has been studied more recently and has been shown to have large influences on our mood (including depression and anxiety), improving inflammation, and even our cardiovascular function! Yes, you heard correctly, dry needling can help improve cardiovascular function such as reducing high blood pressure, optimizing blood perfusion, and reducing instances of headaches.
You want to stick needles into an area that hurts?
Needles inserted are about a tenth of the size of needles used to draw blood. The needles being inserted are so thin you can wrap them around your finger. The needles generally do not cause pain as they are being inserted. The largest benefit of dry needling is improved blood flow and increased healing potential of a dysfunctional area.
How is this different than acupuncture?
As physical therapists, we do not cover the same skill set that acupuncturists study. Although we use relatively the same sized needles, acupuncture and dry needling are vastly different. Location of needle placement for dry needling is directly into the affected region of pain or a referral site of the pain. Acupuncture is a practice based in traditional Chinese medicine which focuses on needle placement to improve the flow of energy throughout the body along meridians.
What is your training for this?
All our therapists have gone through extensive training to perform the dry needling techniques we provide at our clinic. Aside from the 50 hours of rigorous dry needling education the state of Florida requires, each of our therapists has studied anatomy extensively including cadaver dissection. We are therapists who are trained to keep you as safe as possible.
How long do I have to participate before noticing an improvement?
It depends. Typically, patients will report improvement in symptoms after the first treatment. Patients who have had pain longer may require more treatments. On average, patients who participate in dry needling 6-8 visits should notice resolution of symptoms. Patients will typically participate in dry needling 2x/week with at least 48 hours between dry needling appointments.
How will I feel afterwards?
Immediately after a dry needling visit, you may feel sleepy or relaxed. You will likely feel moderate soreness immediately after dry needling or within 24 hours of a treatment. The soreness is no different than muscle soreness and should fade within 48 hours of a dry needling treatment. Occasionally, there can be bruising associated with dry needling although this is rare. Some patients will report immediate improvement in symptoms and others will report improvement within 1-2 days after dry needling.
How are the treatments set up?
Visits last for one hour. Needles are placed and left in for about 45 minutes. Therapists will educate before placing the needles. If it is appropriate for you, therapists will place electric stimulation through the needles to improve your tolerance to the treatment and overall benefit. Your therapist will occasionally rotate the needles throughout the treatment to improve overall benefit.
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:
• 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.
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