It is estimated that almost 9 million people in the UK experience some form of bladder weakness. Stress incontinence is the most common type. It can affect men but will more commonly affect women. It is thought that 1 in 5 women over the age of 40 suffer from stress incontinence and it can have debilitating effects such as low self-esteem, fear of going out in public places incase of ‘accidents’ and in some cases, depression.
Stress incontinence is an involuntary leakage of urine which happens when there is an increase in intra-abdominal pressure i.e coughing, laughing, sneezing and straining. The pelvic floor muscles and urethral sphincter have weakened and cannot cope with the extra pressure. Small amounts of urine can leak but sometimes it is a substantial amount which can be extremely embarrassing for people. So what causes this condition?
Muscles can be weakened by child birth and a forceps/ventouse birth may increase any damage, as will muscle tearing/episiotomies. Operations such as hysterectomy or prostate surgery can also cause damage. Increasing age, especially after the menopause and obesity are also common factors. Pelvic imbalances can exacerbate the problem.
So lets think about our anatomy. *figure 1
The levator ani and coccygeus muscles that are attached to the inner surface of the pelvis form the muscular floor of the pelvis. With their coinciding muscles from the opposite side, they form the pelvic diaphragm. The levator ani is formed by 2 major muscles from medial to lateral: the pubococcygeus and iliococcygeus muscles. The medial portion of the levator ani is the pubococcygeus muscle that originates from the back of the body of the pubis and the anterior portion of the arcus tendineus (tendinous arch). The arcus tendineus of the levator ani is a dense connective tissue structure that runs from the ramus of the pubis to the ischial spine and advances along the surface of the obturator internus muscle.
Coccygeus forms the posterior part of the pelvic diaphragm and assists the levator ani. So together, levator ani, coccygeus, obturator internus and also piriformis make up the pelvic diaphragm which acts as a support sling to hold the contents of the pelvis. Taking this into account, we need to think about not only exercising the pelvic floor muscles, but also the lateral rotators of the hip. Hip joint function could also be taken into consideration. Other muscles that help to stabilise and control the pelvis ought to be strengthened too such as transversus abdominus, internal obliques, hamstrings and adductors.
One treatment option is to start with a program of exercises known as ‘Kegel’ exercises, devised by Dr . Arnold Kegel. They consist of contracting and relaxing the muscles of the pelvic floor to tone and strengthen them. Men should squeeze the muscles of the rectum and women will squeeze the muscles of the vagina and rectum. Squeezes should alternate between slow and sustained grips, held for 5 – 10 seconds to shorter, faster bursts. These exercises also contribute to sacroiliac joint stability which will help keep the pelvis stable.
Transversus abdominus was previously mentioned as an accessory muscle of the pelvic floor. This is a major ‘core’ muscle and provides thoracic and pelvic stability so any lesions in the ribs, thoracic vertebrae and restrictions in the thoracolumber fascia can be contributing factors to stress incontinence. So breathing must be taken into consideration too. Combining core strength exercise with breathing techniques can therefore have far reaching effects without the invasive route of surgery.
Unfortunately though, some people cannot avoid surgery. The operation will involve creating a hammock around the urethra or involve internal ‘taping’ *figure 2 for better sphincter control. The sling procedure is also used for men with stress incontinence. *figure 3
Medication in the form of duloxetine, is being offered. It is thought to increase the activity of the pudendal nerve that stimulates the urethral sphincter although there is little evidence to support this. Side effects of the drug are nausea, vomiting, suicidal thoughts, liver toxicity, drop or rise in blood pressure, withdrawal symptoms… the list goes on. This drug is usually prescribed for major depression problems, fibromyalgia and generalised anxiety disorders and there is very little evidence to support the success of this drug as a stress incontinence medication. Duloxetine actually failed to pass approval in America as a stress incontinences drug over concerns of liver toxicity and suicide attempts but, worryingly, it was passed in Europe in 2004. Some reviews state that it should not be used as a drug for stress incontinence.
Electrical stimulation can also be offered for rehabilitation of weak pelvic floor muscles.
Muscle and nerve strength must be improved to help this condition and herbal remedies can help. Magnesium and vitamin E can help strengthen the weakened sphincter muscles and calcium and B vitamins are essential for a healthy nervous system. Parsley, St John’s Wort and Skullcap will help ease nervous tension, a possible root cause of stress incontinence. Devil’s claw is thought to strengthen the bladder and Dandelion helps the kidneys function more efficiently. It is important to consult your G.P and/or qualified Herabilst before taking any herbal remedies as they may interfere with other medication. It is also wise to consult your G.P if you are experiencing any urinary/bowel changes.
Stress incontinence affects so many people and I always say prevention is better than cure so start those exercises now!! Doing pelvic floor exercises daily will substantially decrease the chance of suffering from stress incontinence in the future. If the problem has already started then you can do yourself a huge favour by starting to exercise the pelvic floor now to improve your situation. Regular remedial massage can help strengthen and tone the accessory muscles of the pelvic floor and Advanced remedial massage and/or Osteopathy will help keep the structure of the spine and pelvis in alignment.
Human Anatomy and Physiology 3rd edition by Elaine N. Marie
Advanced Remedial Massage notes