New moms, postmenopausal women, men with enlarged prostates or those who have had a prostatectomy, along with people suffering from multiple sclerosis, diabetes and Alzheimer’s disease, are especially at risk. Incontinence is a major reason seniors are admitted to nursing homes, Fitzgerald said.
Many people just live with the condition. They avoid public places and office work and do the best they can with adult diapers. That’s often because patients shy away from talking about problems down under with medical staff. “Peeing, pooping and sex are typically taboo subjects,” Fitzgerald said.
Doctors and therapists can help, however. During physical therapy, patients are taught exercises that strengthen the pelvic floor or group of muscles affecting urine flow.
Fitzgerald specializes in orthopedic and pelvic therapy. The rehab center where she works is part of Touro Infirmary, founded in 1852 and now a member of the LCMC Health network.
Incontinence is embarrassing and often painful. With “stress incontinence,” a small amount of urine leaks out after a quick build in internal pressure, caused by a sneeze, cough, laugh or lifting a heavy weight, she said.
“Urgency incontinence” stems from an overactive bladder, and the need to urinate comes on quickly, sometimes with leakage. For patients with “mixed incontinence,” leakage is caused by a combination of stress and urgency factors. Those with “functional incontinence” can’t reach the toilet in time because their mobility is limited by a physical condition. With “overflow incontinence,” leakage occurs when the urine produced exceeds that bladder’s capacity to hold it.
How do physical therapists help? “First, we see what’s causing the condition, get a long history, brainstorm to learn what the patient’s doing every day that’s contributing,” Fitzgerald said. Drinking lots of coffee, for instance, can contribute to urgency leaking. And ongoing constipation can lead to urinary incontinence.
“Sessions include an exam—an internal, vaginal one for women and a rectal exam for males,” she said. “We look at strength and endurance of the pelvic floor muscles, at posture and at strength and range of motion of the hips and back.”
“We need to know if the exercises can be done correctly,” Fitzgerald said. “And not everyone needs their muscles strengthened. Some people are overactive, in which case we would work on relaxation exercises.”
Fitzgerald, with a doctor of physical therapy degree from the University of Chicago at Illinois, is a former Pilates instructor. Yoga and Pilates can help incontinence sufferers, she said.
Fitzgerald teaches Kegel exercises to strengthen and tone pelvic muscles. The pelvic floor is a hammock at the bottom of the pelvis. Patients doing Kegels work on coordination of these floor muscles, by contracting and relaxing them quickly, she said. They also focus on endurance and the muscles’ holding abilities.
“Our treatments are one-on-one in a private room with a closed door,” she said. “We have a therapy table with lots of sheets, and the curtains are drawn. Privacy is the same as in an OB-GYN exam.”
Physical therapy sessions are typically an hour, she said. Patients visit Touro’s clinic once a week for six to twelve weeks and sometimes longer.
“Pelvic floor muscles can be identified by stopping urination midstream or by holding back gas,” Fitzgerald said. “To avoid a urinary tract infection, we don’t recommend practicing your Kegels regularly on the toilet.”
She said floor muscles fill the bottom of the pelvis like a hammock tied to two trees. These trees are the pubic bone and the tail bone. “With a Kegel or contraction, imagine the hammock becoming shorter and lifting into the body, supporting the pelvic organs,” she said. “With a relaxation, imagine the hammock spreading wider and lengthening away from the body, allowing more space for the pelvic organs.”
Patients start with ten three-second contractions and three-second relaxations while lying down, then progress to three sets of ten while sitting or standing. “If you’re doing Kegels right, no one would even know you’re doing them,” Fitzgerald said.
Not everyone benefits from Kegels, however. “Those who have already-tight pelvic floor muscles are often overactive, and their symptoms can decrease with relaxation techniques rather than Kegels,” she said. “Someone who has pelvic pain or pain during sexual intercourse should seek a pelvic floor therapist for an evaluation to see if Kegels are right for them or if they would only worsen symptoms.”
Biofeedback, using a computer screen, helps to identify pelvic floor muscles. “People can’t see these muscles, and they don’t know if they’re doing their exercises correctly,” Fitzgerald said. During a PT session, an internal sensor is placed vaginally or rectally. The patient is asked to do a Kegel. A monitor nearby shows whether the correct muscles contracted and how many seconds the contraction was held.
Stress incontinence in women is most commonly treated with pelvic floor exercises, with a documented success rate of 56.1 percent, according to a German study released in 2015.
Lifestyle changes can be key to feeling better too, Fitzgerald said. To help with incontinence, the National Institutes of Health in Maryland advises older Americans to avoid alcohol and caffeine, drink water instead of other beverages, lose weight, quit smoking, prevent constipation and avoid lifting heavy objects.
Solutions offered by urologists, urogynecologists and gynecologists, include pessaries, or removable vaginal inserts to support the urethra and prevent the bladder from leaking. Patients are fitted with a soft, 2.5- to 3-inch device. “Many of my patients have pessaries,” Fitzgerald said. “They come in various shapes and can be a wonderful solution for leaking urine.”
Posterior tibial nerve stimulation, used to treat an overactive bladder and urge incontinence, relies on a small electrode inserted through the skin of the lower leg. The electrode is connected to a simulator sending pulses. It stimulates the tibial nerve in the leg. The current affects the nerve in the lower back that controls bladder and pelvic floor functions.
With sacral nerve stimulation, used to treat an overactive bladder, an electrical stimulator is placed under the skin above the buttocks.
Doctors prescribe medications, including Oxybutynin or Ditropin, to calm an overactive bladder. Separately, Mirabegron or Myrbetriq is used to relax the bladder muscle and increase the amount of urine that can be held.
Injected medications can thicken the urethra wall so that it seals and stops urine from leaking. Botox injections can relax overactive bladder muscles.
Therapy is usually the first step up the treatment ladder, with surgery a later option, Fitzgerald said. Incontinence surgery is invasive and has a greater risk of complications than other therapies, but it can be a solution in tough cases. In a sling procedure, the surgeon uses strips of synthetic mesh or the patient’s tissue to make a hammock under the tube that carries urine from the bladder. The sling supports the urethra and helps keep it closed, especially during coughing or sneezing, to prevent urine from leaking.
According to the National Committee for Quality Assurance, a Washington-based nonprofit to improve health care, incontinence is significantly under-reported and under-diagnosed. Those with the condition suffer poorer physical and mental health and quality of life than other adults. Incontinence, particularly among seniors, limits one’s independence and social activities. NCQA suggests that health-care providers and health plans address the condition and recommend evidence-based treatments to their members.
To learn more about Touro Rehabilitation Center, phone 504-897-8157. “Our pelvic waiting list is about a month now and shorter than it has been,” Fitzgerald said. “We tell patients to stay close to their phones, and we call them as soon as spots open.” Touro accepts Medicare and Medicaid.
This article originally published in the November 4, 2019 print edition of The Louisiana Weekly newspaper.