Physical Therapy Guide to Urinary Incontinence

Urinary incontinence (bladder control problems) is any leakage of urine that can occur during the day or night. More than 13 million people in the United States have urinary incontinence. Physical therapists design treatment programs to improve help people gain control over the condition. They also help people reduce their need for medicines and surgery.

Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can contact a physical therapist directly for an evaluation. To find a physical therapist in your area, visit Find a PT.

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What Is Urinary Incontinence?

Urinary incontinence is any undesired leakage of urine. A person with the condition also may have trouble starting the urine stream or holding urine. Urinary incontinence involves the muscles of the pelvic floor. These muscles attach to the bottom of the pelvic bones. They run from front to back and create the base of your core (torso, between the pelvic floor and diaphragm). They form a hammock structure that lifts and supports the internal organs. The pelvic floor muscles also:

• Control the sphincter muscles (ringlike muscles that open and close certain body openings).
• Support the low back.
• Stabilize the pelvic bones.
• Help with sexual function.

Women may be more likely than men to have urinary incontinence. However, men may under-report the condition.

Different types of urinary incontinence include:

Stress incontinence. Leakage happens when movement or physical activity puts excess pressure on the bladder. Leakage may occur because the pelvic floor muscles are weak and lack control. Leakage due to stress incontinence often occurs during:

• Coughing, laughing, or sneezing.
• Physical activities such as running.
• Heavy lifting.

Urge incontinence. This is a sudden, strong need to pass urine. People with this type of incontinence often experience a leak before reaching the bathroom.

Mixed incontinence. Some people experience both stress and urge incontinence.

Functional incontinence. This type of incontinence results from problems other than weak pelvic floor muscles or

Urinary frequency. Some people feel the need to empty their bladder frequently throughout the day. They also need to go to the bathroom more than once during the night. It may be caused by infection or other conditions that affect the urinary tract (kidneys, bladder, and the tubes or ducts through which urine flows).

Stress Incontinence

The pelvic floor muscles and urogenital diaphragm (fibrous and muscle structures below the diaphragm) surround the urethra (the tube through which urine leaves the body). They help keep it closed when pressure is placed on the bladder. Stress incontinence occurs when these structures are weak or fail to support the urethra. It can occur with:

• Laughing, sneezing, or coughing.

• Activities such as lifting.

Women with stress incontinence often have pelvic-floor muscle dysfunction due to:

• Pregnancy and childbirth, which put stress or pressure on the bladder or cause trauma to the pelvic floor muscles.
• Episiotomy (a procedure often used to ease childbirth).
• Perineal injury or tearing during childbirth.
• Injury or trauma, such as a pelvic fracture.
• Inflammation, such as cystitis.
• Surgery in the vagina or rectum.
• Lack of exercise or a lifestyle that involves too much sitting.

Urge Incontinence

A strong coordinated contraction of the pelvic floor muscles helps decrease the urge to urinate. It also helps to keep the urethra closed. People with urge incontinence may lack this control due to pelvic-floor weakness or tightness. Or they may experience spasms that contribute to bladder contractions. Conditions such as anxiety may increase the urge to empty the bladder.

Urge incontinence also can be learned. This is also known as “just-in-case” voiding. For example, someone who always urinates upon arriving home from work can begin to associate this with a need to go to the bathroom. Over time, they may feel this urge on the way home. This high-urgency feeling may lead to incontinence.

Caffeine and sugar, acidic foods, and smoking can irritate the bladder. These can lead to inflammation or cause the bladder muscle (detrusor) to contract more. This contraction can contribute to incontinence.

Functional Incontinence

Leakage not directly related to the bladder or pelvic-floor muscles is called functional incontinence. The causes of functional incontinence include:

• Joint pain or muscle weakness (including low core, pelvic, or hip pain) that makes it hard to move.
• Confusion, dementia, or delirium.
• Depression or anger.
• Slow movement or mobility (such as when using a walker).
• Barriers or obstacles that block easy access to a bathroom (such as rugs or furniture).

Urinary Frequency

A person with an overactive bladder feels the need to empty it often during the day. They also get up more than once at night to urinate. Being sensitive to certain foods or drinks can also contribute to urinary frequency.

How Is It Diagnosed?

Your physical therapist will perform a thorough exam. Their goal is to identify the causes of your urinary incontinence. They will ask you to describe your symptoms and your daily experiences, and will assess:

• The muscles of your pelvis, hips, and lower back.
• Your coordination, strength, and flexibility.
• Whether you have pain in your pelvic floor muscles.

Your physical therapist also may refer you to a doctor for more tests to aid in diagnosis. These may include:

• Urodynamic testing (how well the bladder holds empties urine).
• Ultrasound or MRI to show any pelvic-floor muscle problems.

How Can a Physical Therapist Help?

Your physical therapist will create a treatment program to improve your specific pelvic-floor muscle function. Following this program can help you:

• Gain control over your symptoms.
• Reduce the need for pads, special underwear, and medicines.
• Possibly avoid surgery.

Treatments to Improve Pelvic-Floor Muscle Function

Your physical therapist will teach you how to find (sense the movement of) your pelvic floor muscles. They will design an exercise program based on your specific condition. The goal of these exercises is to help you improve your pelvic floor muscle function, to better control your bladder.

Your physical therapy treatment plan may include:

• Pelvic floor exercises. Pelvic floor contractions (or Kegel exercises) involve squeezing the sphincter muscles while imagining that you are trying to stop urine flow. Both the contraction and full release of the muscles are the goal in training.
• Exercises to improve muscle strength. Your physical therapist will teach you specific exercises to increase awareness and movement, to stretch, and to strengthen your muscles. Improving pelvic-floor muscle strength helps support proper bladder function.
• Biofeedback. This treatment depends on your symptoms. Your physical therapist will discuss this option with you. If you are comfortable starting this treatment, your physical therapist will use an internal sensor to read and measure pelvic floor muscle activity. The pressure on the sensor when you squeeze your muscles will display on a computer screen to indicate when you have contracted the right muscles. Biofeedback can guide you and help make you aware of the correct way to use your pelvic floor muscles.
• Electrical stimulation. Your physical therapist may apply gentle electrical stimulation. This can help make you more aware of your muscle function.
• Real-time ultrasound. Your physical therapist may use an ultrasound device to assess isolated contractions of the pelvic floor and abdominal wall muscles to ensure proper coordination. This can also help increase awareness of your pelvic floor and abdominal muscle function.

Can This Injury or Condition Be Prevented?

Lifestyle changes and healthy habits may help people avoid or improve urinary incontinence. A physical therapist can teach you the correct way to do pelvic floor muscle exercises. Once learned, you can include these exercises in your daily activities. Doing them as directed can improve incontinence and increase bladder control. Also, regular, timed bathroom visits and avoiding bladder irritants can reduce the risk for incontinence.

Your physical therapist will educate you about:

• Diet and nutrition. This knowledge will help you avoid foods and drinks (such as caffeine) that may irritate the bladder.
• Changing any behaviors that make your symptoms worse.
• Techniques to decrease urge and frequency (such as improving muscle strength and stretching).
• Setting and keeping a healthy bathroom schedule.
• Ways to achieve regular bowel movements. Constipation or a large amount of stool in the bowel can cause the bladder to not empty well. These also can place pressure around the bladder, increasing the urge to urinate.
• The importance of drinking healthy fluids regularly.
• Safe ways to achieve regular exercise or develop a more active lifestyle.

What Kind of Physical Therapist Do I Need?

All physical therapists are trained through education and experience to treat various symptoms and conditions. Women’s health or pelvic-floor physical therapy is a specialty area. Women or men with incontinence may want to consider seeing a physical therapist who has:

• Experience treating women’s health problems, pelvic floor dysfunction, and urinary incontinence.
• Board certification in women’s health physical therapy or who has completed a residency or fellowship in women’s health physical therapy. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
• A certificate of achievement in three to four levels of pelvic or obstetric physical therapy. This is also known as a CAPP Pelvic or OB certificate.

You can find physical therapists in your area with these credentials and clinical expertise through Find a PT, a tool built by the American Physical Therapy Association.

General tips when you’re looking for a physical therapist (or any other health care provider):

• Get recommendations from family, friends, or other health care providers.
• Ask about the PT’s experience treating incontinence before you make an appointment.
• Be prepared to describe your symptoms in as much detail as possible. Make a note of what makes your symptoms worse.

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Reference(s) 

The American Physical Therapy Association believes that consumers should have access to information to:

• Inform their health care decisions.
• Prepare them for their visit with a health care provider.

The following resources offer some of the best scientific evidence related to physical therapy treatment for incontinence. They report recent research and provide information on the standards of practice in the United States and internationally. They link to a PubMed* abstract (which may offer free access to the full text) or other resources. You can read them to learn more or bring a copy to your health care provider.

• Bo, K. Physiotherapy management of urinary incontinence in females. J Physiother. 2020;66(3); 147-154. Free Article.
• Borello-France D, Burgio KL, Goode PS, et al. Adherence to behavioral interventions for urge incontinence when combined with drug therapy adherence rates, barriers, and predictors. Phys Ther. 2010;90:1493–1505. Free Article
• Borello-France DF, Downey PA, Zyczynski HM, RauseCR. Continence and quality-of-life outcomes 6 months following an intensive pelvic-floor muscle exercise program for female stress urinary incontinence: a randomized trial comparing low-and high-frequency maintenance exercise. Phys Ther. 2008;88:1545–1553. Free Article
• Burgio KL, Goode PS, Urban DA, et al. Preoperative biofeedback assisted behavioral training to decrease post-prostatectomy incontinence: a randomized, controlled trial. J Urol. 2006;175:196–201. Article Summary on PubMed.
• Mungovan SF, Carlsson SV, Gass GC, et al. Preoperative exercise interventions to optimize continence outcomes following radical prostatectomy. Nat Rev Urol. 2021 May;18(5):259-281. doi: 10.1038/s41585-021-00445-5. Epub 2021 Apr 8.PMID: 33833445. Free Article.
• Quartly E, Hallam T, Kilbreath S, Refshauge K. Strength and endurance of the pelvic floor muscles in continent women: an observational study. Physiotherapy. 2010;96:311–316. Article Summary on PubMed
• Soave I, Scarani S, Mallozzi M, et al. Pelvic floor muscle training for prevention and treatment of urinary incontinence during pregnancy and after childbirth and its effect on urinary system and supportive structures assessed by objective measurement techniques. Arch Gynecol Obstet. 2019; 299(3):609-623. Article summary on PubMed
• *PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.
• Revised and reviewed on December 27, 2021, by Miranda Harvey, PT, DPT, board-certified clinical specialist in orthopaedic physical therapy with a certificate of achievement in pelvic health, on behalf of APTA Pelvic Health, an academy of the American Physical Therapy Association.