Call to Action: Orthopedic PTs Need to Address Urinary Incontinence in Patients w/ Impaired Mobility

For new pelvic health therapists, management of the urinary incontinence (UI) patient is commonly considered “Pelvic Floor 101.” I now know that many of these cases are more complex than I originally thought and, in my opinion, they can be imperative to address. Not only do these patients often suffer for years with the erroneous belief that these issues are a normal (1) part of aging (common does not equal normal) but they underestimate the widespread impacts that incontinence can have on health and quality of life (2) until their symptoms become unbearable. Many times, I have been the first provider with whom they spend significant time sharing deeply personal details surrounding their struggles to hold their bladder.

As an orthopedic and pelvic floor physical therapist, I have learned of the incredible crossover between these two populations. Many of my orthopedic patients are surprised when I ask them about their urinary habits and divulge their struggles when I do. They may make jokes about how their bladder wakes them up several times a night – leading to many midnight trips rushing to the bathroom and preventing a good night’s sleep (3). Especially for patients with impaired mobility, I have to set the record straight that while this issue may be awkward or uncomfortable to discuss, urinary troubles are no laughing matter. 

Of particular interest to me is a condition known as urinary urge incontinence (UUI). Sudden, frequent, and overwhelming urges to urinate are referred to as urinary urgency. Related leaking is what we call urge incontinence. The association between urinary urgency and fall risk is well documented (4,5). Picture your patient with mobility impairments suddenly feeling like they need to get to the toilet NOW or risk leaking urine. Do you think that they are practicing safe obstacle avoidance while rushing to the toilet? Probably not.  Would you?

Ninety percent of hip fractures result from falls, and the relationship between hip fractures and overall morbidity and mortality is undeniable (6). Gait speed is also an important predictor to consider surrounding the discussion of fall risk, urge incontinence, and overall health status (7). Throw in other geriatric syndromes like frailty and osteoporosis/penia and we have an issue that is even more dire (8). As physical therapists, this issue is clearly vital and within our scope of practice to address.

Awareness of and access to pelvic floor therapists is often limited. You do not need to be a pelvic health physical therapist to discuss incontinence with your patients. You can (and _should_, in my opinion) offer some basic interventions while they are in your care if you suspect urinary issues. Even a simple handout can make a world of difference. Here are some simple ways to empower these patients in the outpatient orthopedic setting:

Normalize the Conversation

Be simple and straightforward. Expressing concern for their safety is an easy way to relate bladder problems to mobility. For example:

• Do you have any difficulty with holding your bladder and feel like you need to rush to get there?
• Do you usually have to wake up in the middle of the night to void?
• Do you have a clear, well-lit pathway without obstacles in the home, especially en route to the bathroom?

I find that asking these questions can help even orthopedic patients feel more comfortable discussing their bathroom habits and, in my experience, strengthens patient rapport.

Patient Education on Healthy Bladder Function

According to a 2011 consensus statement published in the International Journal of Clinical practice, a healthy bladder generally needs to eliminate every 3-4 hours (or no more than 8 times) in the daytime and 0-1 times per night (9). These ranges can vary widely (10) depending on the source, and it should be acknowledged that bladder capacity is influenced by factors such as age and presence of other health conditions (i.e. diabetes) (11). Convenience voids (the habit of toileting “just in case”) interfere with bladder retraining and are generally discouraged whenever reasonable.

Teach an Urge Suppression Technique

A quick intervention that you can share with this population is an urge suppression technique. The bladder does not always communicate urges because it is full but rather the detrusor muscle may be overactive or the bladder lining irritated. Urge suppression works through the voluntary urinary inhibition reflex and aids the patient in bladder control and improved void timing (12).

Urge suppression involves performing approximately 10 quick pelvic floor muscle contractions (or Kegel exercises) followed by distracting oneself (12). Research has shown that cueing activation of the posterior pelvic floor muscles results in better overall recruitment of the levator ani (13). Some common cues are: imagine lifting a marble with the anus and lifting an elevator up the vaginal canal or scrotum. Distraction is an important element as the bladder is very susceptible to suggestion.

Note: Establish that urinary urgency does not necessarily indicate that the pelvic floor is weak. Urge suppression is a behavioral strategy as part of bladder retraining, not to be confused with a green light to do Kegel exercises all the live-long day.

Lower Extremity Tibial Nerve Stimulation

Neuromuscular electrical stimulation (NMES) of the tibial nerve at the medial malleolus is another tool that orthopedic therapists can employ for this population. Transcutaneous Tibial Nerve Stimulation (TTNS) with a traditional at-home NMES device can reduce urinary urgency with similar results to Percutaneous Tibial Nerve Stimulation, a common treatment in urologic practice (14). Personally, TTNS has become one of my favorite interventions for UUI combined with a solid home exercise program, as it can help the patient feel successful right away. Some orthopedic patients already own NMES devices, and protocols for overactive bladder are freely available (15).

Alternatively, plantarflexion exercises like heel raises are another way to stimulate the tibial nerve and are often used by pelvic floor therapists for bladder inhibition. These can be performed seated or standing.

Referral

Urinary urgency can be part of the Genitourinary Syndrome of Menopause (GSM). Patients assigned female at birth who are in their perimenopausal or menopausal years may benefit from topical vaginal estrogen, which is a local (read: non-systemic) and form of hormone replacement therapy with very little associated risk. Local estrogen can help repair atrophied tissues of the urethra, vulva, and vagina and has been proven to aid symptoms of GSM (16). This is often an option of which many patients are unaware and deserves a thorough conversation with their physician.

Urinary incontinence is a stigmatized (8) condition that patients are often not asked about by their providers. As a result, many patients suffer in silence. Your orthopedic patients will likely be relieved that you have opened the discussion on their UI. Discovering one pelvic floor issue is often like opening Pandora’s Box – other issues often quickly rise to awareness. To be sure that further pelvic floor issues are addressed, recommend that your patients seek the help of a pelvic floor physical therapist. They often do not know that we exist but will be grateful once they do…and they’ll be thankful for you, too, for caring enough to start the conversation.

References

1. Goodridge, Sophia Delpe MD∗; Chisholm, Leah P. BS†; Heft, Jessica MD‡; Hartigan, Siobhan MD∗; Kaufman, Melissa MD, PhD∗; Dmochowski, Roger R. MD∗; Stewart, Thomas PhD§; Reynolds, William Stuart MD, MPH∗. Association of Knowledge and Presence of Pelvic Floor Disorders and Participation in Pelvic Floor Exercises: A Cross-sectional Study. Female Pelvic Medicine & Reconstructive Surgery 27(5):p 310-314, May 2021. | DOI: 10.1097/SPV.0000000000000813. Accessed 29 Jun 2024.

2. Pizzol D, Demurtas J, Celotto S, et al. Urinary incontinence and quality of life: a systematic review and meta-analysis. Aging Clin Exp Res. 2021;33(1):25-35. doi:10.1007/s40520-020-01712-y. Accessed 29 Jun 2024.

3. Winkelman, William D. MD\; Warsi, Ann MBBS†; Huang, Alison J. MD, MAS†; Schembri, Michael BS†; Rogers, Rebecca G. MD‡; Richter, Holly E. MD, PhD§; Myers, Deborah L. MD∥; Kraus, Stephen R. MD¶; Johnson, Karen C. MD\\; Hess, Rachel MD, MS††; Gregory, Thomas MD‡‡; Bradley, Catherine S. MD, MSCE§§; Arya, Lily A. MD∥∥; Brown, Jeanette S. MD†; Stone, Katie L. PhD¶¶; Subak, Leslee L. MD\\\. Sleep Quality and Daytime Sleepiness Among Women With Urgency Predominant Urinary Incontinence. Female Pelvic Medicine & Reconstructive Surgery 24(2):p 76-81, 3/4 2018. | DOI: 10.1097/SPV.0000000000000547. Accessed 29 Jun 2024.

4. Chiarelli PE, Mackenzie LA, Osmotherly PG. Urinary incontinence is associated with an increase in falls: a systematic review. _Aust J Physiother_. 2009;55(2):89-95. doi:10.1016/s0004-9514(09)70038-8. Accessed 29 Jun 2024.

5. Moon S, Chung HS, Kim YJ, et al. The impact of urinary incontinence on falls: A systematic review and meta-analysis. PLoS One. 2021;16(5):e0251711. Published 2021 May 19. doi:10.1371/journal.pone.0251711. Accessed 29 Jun 2024.

6. LeBlanc KE, Muncie HL Jr, LeBlanc LL. Hip fracture: diagnosis, treatment, and secondary prevention. Am Fam Physician. 2014;89(12):945-951. Accessed 29 Jun 2024.

7. Omae K, Yamamoto Y, Kurita N, et al. Gait speed and overactive bladder in the healthy community-dwelling super elderly: The Sukagawa Study. Neurourol Urodyn. 2019;38(8):2324-2332. doi:10.1002/nau.24148. Accessed 29 Jun 2024. 

8. Smith EM, Shah AA. Screening for Geriatric Syndromes: Falls, Urinary/Fecal Incontinence, and Osteoporosis. Clin Geriatr Med. 2018;34(1):55-67. doi:10.1016/j.cger.2017.08.002. Accessed 29 Jun 2024.

9. Lukacz ES, Sampselle C, Gray M, et al. A healthy bladder: a consensus statement. _Int J Clin Pract_. 2011;65(10):1026-1036. doi:10.1111/j.1742-1241.2011.02763.x. Accessed 29 Jun 2024.

10. Wyman JF, Cain CH, Epperson CN, et al. Urination Frequency Ranges in Healthy Women. _Nurs Res_. 2022;71(5):341-352. doi:10.1097/NNR.0000000000000595. Accessed 29 Jun 2024.

11. Yuan Z, Tang Z, He C, Tang W. Diabetic cystopathy: A review [published correction appears in J Diabetes. 2016 Jan;8(1):170. doi: 10.1111/1753-0407.12334]. J Diabetes. 2015;7(4):442-447. doi:10.1111/1753-0407.12272. Accessed 29 Jun 2024.

12. Pal M, Chowdhury RR, Bandyopadhyay S. Urge suppression and modified fluid consumption in the management of female overactive bladder symptoms. Urol Ann. 2021;13(3):263-267. doi:10.4103/UA.UA\52\20. Accessed 29 Jun 2024.

13. Ben Ami N, Dar G. What is the most effective verbal instruction for correctly contracting the pelvic floor muscles?. Neurourol Urodyn. 2018;37(8):2904-2910. doi:10.1002/nau.23810. Accessed 29 Jun 2024.

14. Sayner AM, Rogers F, Tran J, Jovanovic E, Henningham L, Nahon I. Transcutaneous Tibial Nerve Stimulation in the Management of Overactive Bladder: A Scoping Review. Neuromodulation. 2022;25(8):1086-1096. doi:10.1016/j.neurom.2022.04.034. Accessed 29 Jun 2024.

15. Sonmez R, Yildiz N, Alkan H. Efficacy of percutaneous and transcutaneous tibial nerve stimulation in women with idiopathic overactive bladder: A prospective randomised controlled trial. _Ann Phys Rehabil Med_. 2022;65(1):101486. doi:10.1016/j.rehab.2021.101486. Accessed 30 Jun 2024. 

16. Rahn, David D. MD; Carberry, Cassandra MD; Sanses, Tatiana V. MD; Mamik, Mamta M. MD, MS; Ward, Renée M. MD; Meriwether, Kate V. MD; Olivera, Cedric K. MD, MS; Abed, Husam MD; Balk, Ethan M. MD, MPH; Murphy, Miles MD for the Society of Gynecologic Surgeons Systematic Review Group. Vaginal Estrogen for Genitourinary Syndrome of Menopause: A Systematic Review. Obstetrics & Gynecology 124(6):p 1147-1156, December 2014. | DOI: 10.1097/AOG.0000000000000526. Accessed 30 Jun 2024.

Author: Nikki-Rae Alkema, PT, DPT, 2024 CAPP  Course Scholarship Recipient

Author Bio: Dr. Alkema (Doctor of Physical Therapy) is a pelvic health and orthopedic licensed physical therapist in California. In 2022, she received the esteemed Excellence in Biomechanics Award from the Doctor of Physical Therapy program at California State University, Long Beach. She believes that providing access to pelvic health knowledge is an essential part of creating a more equitable healthcare model. Some of her areas of special interest include Parkinson’s Disease, women’s soccer, and the biomechanics of road cycling. 

Connect with Nikki: @nikkidashrae