Pelvic Floor Approaches for Stress Incontinence: Lessons from PelviCon
Wow, we had such a wonderful time at PelviCon 2023 last weekend! I can’t tell yall how incredible it was to have 625 pelvic rehab providers in one space, learning and growing together. The community, the passion… and the practice-changing clinical pearls. They were just AMAZING! If you are a pelvic rehab provider and missed the conference, be sure to stay connected to www.pelvicon.com for future events! The PelviCon recording is also available for just 1 more day (through Tuesday 9/19!)
One of the speakers that really impacted clinicians significantly this year was Taryn Hallam, a physiotherapist from Sydney, Australia who is a skilled instructor, experienced clinician, and excellent at delving into research. Taryn was the instructor who actually trained our team at SPH how to fit pessaries to help with pelvic organ prolapse and urinary incontinence last year. And she was AMAZING– we LOVE that we now have even more options to offer our patients dealing with these problems.
She shared 2 lectures at PelviCon this year– the first was regarding pelvic organ prolapse, and she reviewed what pelvic rehab can do to help, and taught us about the role of pessaries and the differences they can make for patients. The second lecture dove into stress urinary incontinence.
Stress urinary incontinence is bladder leakage that occurs when there is pressure on the bladder (like occurs with coughing, sneezing, laughing, or exercise) that exceeds the pressure able to be generated around the urethra. It then leads to urine leaking out through the urethra.
How Pelvic Floor Muscles Contribute To Urinary Leakage
Taryn shared 3 potential mechanisms in which the muscles of the pelvic floor can be involved when a person is experiencing urinary leakage, and we’re going to dive into each of them during this blog so that you, my friend, can also better understand these mechanisms.
Those mechanisms are:
Urethral Hypermobility
Urethral Sphincter Weakness
Increased Tension in the Pelvic Floor Muscles
Urethral Hypermobility (ie, the “hammock theory”)
The first, is often described as the “hammock theory.” In this description, the levator ani muscle group (they’re the deepest layer of the pelvic floor muscles) works together with the pubocervical fascia (the fascia underlying the bladder neck) to lift and provide a firm backstop against increases of pressure. So, in this case, it is thought that people are leaking because they have too much mobility at the urethra, and our goal here is to improve the support so the urethra has a firm stop (THINK: the difference between stepping on a hose to stop the flow in soft, cushy grass…vs. Stepping on a hose on the sidewalk.).
This theory can account for some of the cases of bladder leakage, and has been used to explain leakage for quite some time. The problems that Taryn really helped to point out, however, are that this doesn’t really account for everyone. There are a few main issues and factors to consider:
In order for the levator ani muscles to support the bladder neck, the person needs to have in-tact pubocervical fascia.
If the pubocervical fascia is injured (like during childbirth), the patient is less likely to respond well to treatment that focuses on retraining the deep pelvic floor muscles (because the muscles NEED the fascia to support the bladder. This is why pessaries can be awesome for these individuals!)
There are people who have strong, well-coordinated deep pelvic floor muscles, in-tact fascia, but are still leaking…
Urethral Sphincter Deficits
So, here’s where it got fun– Taryn then dove into the research for us to help us understand a little about why someone could have strong levator ani muscles, intact fascia, but still leak. She shared a tough statistic, described by DeLancey in 2012, the “maximal urethral closure pressure is known to decline by around 15 cmH20 per decade in life.” Thus, urethral hypermobility may not be the dominant cause of bladder leakage–but it is likely more related to urethral sphincter weakness. She shared a quote from Falah-Hallani in 2021, that “when comparing urethral closure pressure, measures of urethral support and other parameters… maximal urethral closure pressure was the strongest determinant of stress urinary incontinence.”
Tension in the Pelvic Floor Muscles
Lastly, Taryn took some time to chat through tension in the pelvic floor muscles and how this connects to stress urinary incontinence. We often see patients who have increased tension and poor mobility in their pelvic floor muscles and are experiencing bladder leakage. So, the question comes– why does helping them improve mobility of the pelvic floor muscles improve their urinary leakage? I always thought this was due to improvement in the overall pressure system and improving the spread of the load. However, Taryn presented excellent information regarding a neural effect that seems to make a lot of sense. The thought being that tension in the pelvic floor muscles can lead to compression around the pudendal nerve, decreasing the ability of the urethral sphincter to contract. Thus, improved mobility around the pelvic floor muscles would then improve blood flow and space around the nerve allowing better conductivity, and ultimately, improving the ability of the muscles to contract.
What does this mean for pelvic rehabilitation?
Basically, it means that how we address and approach retraining of the pelvic floor muscles matters. As rehab providers, we have to make sure to get to the root of the “why” before we target our interventions. Of course, you know at SPH we aim for a full-body approach to pelvic health challenges. This means that we recognize that problems like stress urinary leakage are more than simply “pelvic problems” and aim to consider all other factors that can be involved when someone is leaking! Check out this past blog for more on the interconnectedness of the pelvic floor muscles with the rest of the body.
That all being said, there are times when we need to specifically target retraining the pelvic floor muscles. So, in the case of urinary leakage, we need to make sure to get to the root of why the person is leaking. If a person seems to have intact fascia, but weakness and poor coordination at the deeper pelvic floor muscles, cues that really target those muscles are likely to be needed. This could mean aiming to contract the muscles used to hold back gas or stool. BUT, there are likely more patients who need specific cueing around the urethral sphincter instead. And, there may be patients who need to relax their pelvic floor muscles too!
I hope this improves your knowledge of SUI!
Be sure to stay connected with us on instagram @southernpelvichealth to stay in the know on all pelvic health info! If you are a pelvic rehab provider and want to learn more about PelviCon~ check out www.pelvicon.com You can also follow us at @pelvicon_official on instagram!