171. Demystifying Urinary Incontinence for Ortho PTs: Differentiating Between 5 Types

In this PT Snacks episode, host Kasey introduces urinary incontinence for physical therapists and students, emphasizing its prevalence, quality-of-life impact, and the importance of reducing taboo. The episode defines urinary incontinence as involuntary urine leakage, reviews key anatomy and neural control, and explains five types: stress, urge, mixed, overflow, and functional incontinence. Kasey highlights distinguishing features, common associations, and prevalence examples. The discussion outlines basic next steps and general management concepts like stress tolerance training and bladder training.

00:00 Welcome to PT Snacks
00:13 Why Incontinence Matters
01:40 Defining Urinary Incontinence
02:19 Key Anatomy Overview
04:00 Five Types Explained
04:14 Stress Incontinence Signs
05:34 Urge Incontinence Basics
06:49 Mixed Overflow Functional
08:30 What To Do Next
09:18 Assessment Bladder Diary
10:32 History And Risk Factors
11:20 Treatment Overview
11:59 Stress Vs Urgency Strategies
13:16 Key Takeaways And Support

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Transcript

Hey, welcome to PT Snacks podcast. This is Kasey, your host, and if you're tuning in for the very first time, I just need you to know that this has meant for physical therapists and physical therapist students who are looking to grow your fundamentals in bite-size segments of time. And today's topic, we're gonna be talking about incontinence, which may not be every ortho PTs favorite topic, but it affects so many people. And it's a topic that. Is often counted as taboo, but something that I don't really feel should be. This is something that. Being able to help people with can really make an impact on their quality of life and what they're able to do and just how they feel about themselves. So the more that we can understand it and at least talk with our patients on what they're dealing with, the more we could either help them or help them to get help by someone who is an expert in this area, whether they need, to see another specialty, a pelvic health pt, or if you're an aspiring pelvic health pt it's good to remember these things. 'cause I know for me, for PT school, this chapter was very, very short and so I didn't really remember it without being able to like go back and review it. So we're gonna talk about like the main. Types of incontinence, the type that you might see more often in ortho slash pelvic health, pt and. Not as much time on how to treat this per se. This is more about, Hey, let's build familiarity with some terms here. Let's use this as a launchpad for understanding what someone's dealing with so that you can do some further research on it. Or maybe I'll do a future episode if the people would like it. Um, so with that being said, let's actually define what urinary incontinence is. This is basically the involuntary leakage of urine. Uh, this is very prevalent in older adults in a lot of nursing homes and younger adults, men, women, we see in a lot of people, and in fact, it's estimated that approximately 423 million people age 20 or older worldwide are experiencing some form of urinary incontinence. That's a lot of people. So something that again, we should have some familiarity with so that we can best help those people. So let's go over some relevant anatomy and then we'll go over the main types of incontinence. So as far as anatomy, we have our urethra and sphincters. So we have our internal sphincter, which helps to maintain resting closure pressure at the bladder neck. And then we have the the external urethral sphincter, I've been having the hardest time of saying this for whatever reason. Uh, this is striated muscle that's around the mid urethra that blends into the pelvic floor. A big component of voluntary continence and stress resistance. We also have the, something that's relevant is the functional urethral length and closure pressure. So it's been found that a shorter length and lower closure pressures are very characteristic of stress incontinence, which we will go over in just a little bit. Um, and then we have our pelvic floor. I'm not gonna name off every single muscle on the pelvic floor, but we have our levator ani complex, which is basically the name, the main diaphragm that's supporting the bladder, urethra, vagina, and rectum. As well as we also have a lot of passive support from fascia, ligament in the area, et cetera. And our hiatus or levator hiatus, which is an opening through where the urethra vagina and the rectum pass. So pelvic floor. Now in our bladder and neural control, this is also important, right? We have our detrusor muscle, which is the bladder wall, which is made up of smooth muscle. And then we have our innervation that comes from both the parasympathetic system, sympathetic system, and somatic system. What types are there? So there's five that I'm gonna mention. Some I'm gonna talk about more than others. So we have stress incontinence, urge incontinence, mixed, overflow, and functional. So with stress, basically leakage occurs with increased stress to the structures that. Keep us from leaking. So that could happen with increased intraabdominal pressure from exertion, straining al salva, sneezing, coughing, all of those things. They're causing a stress, stress incontinence, that stress is causing an involuntary leakage. Of urine. Um, so this can be associated with urethral sphincter weakness, pelvic floor weakness, urethral hypermobility. We see this a lot in young women, pregnancy and postpartum, or men after prostate surgeries. 24 to 45% of women older than the age of 30 have been found to have this at one time or other. And usually with these patients. They can tell like, oh, laughing, coughing, sneezing, or straining, that is going to cause my incontinence. So it's very specific with some sort of inciting activity. Is this all I can say about stress incontinence? No. But the main purpose of this episode is to help you differentiate between the different types of incontinence so that if you are someone who is treating this, you understand what you're treating. So beyond stress, we have urge incontinence. So leakage is proceeded or accompanied by a sense of urinary urgency. Hence the name urge. Hopefully you're catching a rhythm with why we're naming certain things and what they mean. It can be asymptomatic also but it's essentially due to detrusor overactivity, so it could be from some sort of bladder irritation. Loss of neurological control detrusor instability, overactive bladder, neurological conditions such as Parkinson's multiple sclerosis or stroke. In fact, 9% of women between the ages of 40 and 44 have been found to have some sort of, or reported some sort of urge incontinence. 31% women older than 75 years old, and 42% of men older than 75 years old. With these patients they could have a history of frequency, urgency in nocturia. All present. And the volume that they are actually expelling can be very variable, ranging from almost nothing to absolute flooding. So bladder post void, residual urine volume though is typically pretty low. So now that brings us to mixed, which is basically a combination of stress and urge. Yes, you can have a combination of these two. Um, it's not always one or the other. So something to keep in mind when if you're talking with your patient and you're confused on their symptoms, keep in mind they could have both things. Next, we have overflow. So this is essentially leakage from an overdistended bladder due to detrusor, contractility, and bladder outlet obstruction. So this is more common. So in patients with spinal cord injuries, or if they have multiple sclerosis, even diabetes, can actually impair to detrusor function which all these conditions. Can be associated with a hypotonic neurogenic bladder. Bladder outlet. Obstruction can be obtained from external compression, from abdominal or pelvic masses, urethral structures, pelvic organ prolapse, all things to keep in mind, but essentially leakage from an over distended bladder overflow. Then lastly, we have functional incontinence. And essentially this is more derived from environmental or physical barriers to toileting. So an example of this could be someone experienced leakage because they couldn't make it to the toilet. Whether they have physical inability, there is no toilet, things like that. It's more from a functional aspect. There is some sort of barrier that is preventing them from being able to go to the restroom and make it in time. So functional, not necessarily a part of the anatomy that I mentioned at the beginning of the session. An issue with that, per se. Okay, so far you should be able to name the five types of incontinence. If not, go rewind a little bit, but now what do we do about it? If you don't treat this patient population, you might be more so sending that patient on to someone who does, and that's great. Go help them to see an expert. At least at this point in time where I'm making this episode where I am, a lot of pelvic health, physical therapists, uh, can have very, very long waiting lists. And part of that is people are just realizing how awesome they are or there's not enough therapists. So, I think it's good to just kind of have an overview of what they might do about it, because not everybody gets kegels. That's not the only pelvic health thing that is out there, even though that's what most of people think you do. That patient. A lot of times what they might start off with is just capturing a bladder diary, so that could be like 24 hours or a three day voiding diary, and they're basically writing down the time and amount or urine voided in milliliters. This is a little bit more intensive, but they're just trying to capture like a normal day for. So if they have more of an overactive bladder, they might have small volumes. Frequently, if they have global polyuria, which is large amounts of urine voided. A lot during the day and the night. Polyuria means lots of urine that also can get captured. Just fun fact, normal 24 hour urine total is usually about 1300 milliliters. So more than 3000 milliliters is considered polyuria. But beyond maybe a bladder diary, see if there's some sort of pattern to. When they void, if after some sort of irritant to their bladder that they're having is there some sort of cue that they're experiencing before they go to the bathroom? Uh, whether it's a habit in their day, something that they're drinking, or maybe just how much water they've had before they typically go. So just helps to get an idea on what someone's normal is for them. But you'd also wanna know about what's their surgical history. For instance, males often a complication for a urologic surgery can cause incontinence. Obviously females too, right? And females asking them, about their gynecologic history. How many births have they had, the mode of deliveries, was it cesarean or vaginal? What's their current pregnancy status or estrogen status for potential perimenopause symptoms from like atrophic vaginitis or a otitis? Are they taking any medications or substances that can cause. Medications or substances that can cause a little bit more of these symptoms like diuretics, alcohol, caffeine all of these different things. It's just to get a capture on like, who is this person that is in front of me right now? And then in terms of treatment, now, if it's a functional incontinence, we want to try and either if that person can't physically get to the toilet, help them to address that. If it's environmental. , if it's the physical, like they need to be able to have quad strength to be able to get up and go these are things that are important to attribute to if they are experiencing more of like the overflow or other symptoms because of. Neurologic conditions. If you're not , neurologic, physical therapists, that may not be your wheelhouse. And it's certainly not mine, so I'm not gonna speak to that. But there are resources out there. And then in terms of stress and urgency, with stress, we're going to try and improve their tolerance to stress. Ideally, in a good examination, you are determining why they are not tolerating stress well, not just giving them Kegels, but helping them to build up their ability to control for leakage to the point where you're mimicking what they need to do, or they're living an active lifestyle, you're taking them through weight training, jumping, running, things like that. These patients should not just be laying on the table. Doing Kegels. Maybe some patients need to start there. Yes. But, that's where a good evaluation comes from to look at the person as a whole on how the surrounding area is and is that impacting that. Again, that could be a whole nother episode. And it's not today's episode Urgency. Then it comes down to a little bit more of bladder training. Um, timed voiding fluid and caffeine moderation, maybe even behavioral therapy. If not, there are some medications. Anti-muscarinics. I may be saying that wrong. Um, and beta three agonists can help also to reduce urgency and leakage in these patients. And there's additional. A medication beyond that too that can help these patients. So with all that being said, what you should have taken away from today is the ability to build one, a familiarity with what incontinence is from a overall umbrella view. And two, be able to identify between the main different types of incontinence. If you have any questions, feel free to let me know at ptsnackspodcast@gmail.com. Other than that, if you've been listening to the show and you wanna show your support there's a couple ways that you can do that. You can write a review wherever you're listening to this. Those really make a huge difference for helping the show grow, or there's a way that you can financially support the show. So all of this, I pretty much just finance myself. I do this just for fun because I feel like. It's important to educate yourself and so there is a support the show button down below if that is something that speaks to your heart. No pressure. One or the other is very helpful. I hope you guys enjoy a great rest of your day, and until next time.