Physical Therapy Medical evidence from well-designed randomized clinical trials shows that supervised pelvic ﬂoor muscle training (Kegel exercises) is an effective treatment for stress urinary incontinence. The Cochrane Incontinence Group concluded that pelvic ﬂoor muscle training is consistently better than no treatment or placebo treatment for stress incontinence and should be offered as first-line conservative management to women. Intensive training sessions that include personal contact with a health care professional to teach and supervise pelvic ﬂoor muscle training may be more beneficial than standard care. Biofeedback provides no added benefit over pelvic ﬂoor muscle training alone in women with stress urinary incontinence (46).
Several factors improve the likelihood that pelvic muscle training will relieve stress urinary incontinence. The woman must do the exercises correctly, regularly, and for an adequate duration. Based on exercise training of skeletal muscles elsewhere in the body, many physical therapists recommend training sessions three to four times per week, with three repetitions of eight to ten sustained contractions each time.
Electrical stimulation therapy was used to treat incontinence by delivering low levels of current via a probe placed in the vagina or rectum. When compared with sham devices and pelvic ﬂoor exercises, electrostimulation produced mixed results in the treatment of stress urinary incontinence but may be more helpful in women with overactive bladders (47–50). Further research is needed to determine what niche this treatment may fill for women with urinary incontinence.
Bladder training focuses on modifying bladder function by changing voiding habits. Behavioral therapy focuses on improving voluntary control rather than bladder function (51). The key component to bladder training is a scheduled toileting program. After reviewing the patient’s voiding diary, an initial voiding interval is chosen that represents the longest interval between voiding that is comfortable. She is instructed to empty her bladder when she awakes, and then every time during the day that the interval is reached (for example, every 30 to 60 minutes). When the patient feels the urge to void during that interval, she is instructed to use urge-suppression strategies, such as distraction or relaxation techniques, until she gets to the stated interval. Effective distraction strategies include mental exercises (such as mathematical problems), deep breathing, or “singing” the words to a song silently. The main goal is to avoid running to the bathroom at the moment of severe urgency. Another strategy is to quickly contract the pelvic muscle several times in a row (“freeze and squeeze”), which often lessens urgency. Gradually, the interval is increased (usually weekly) until the patient voids every 2 to 3 hours. Bladder training is most effective when women record every void and check in (by telephone or in person) with a health care provider weekly. This program lasts for about 6 weeks. Bladder training is effective; in a trial in which bladder training was compared with treatment with oxybutynin, 73% of women in the bladder training group were clinically cured (52).
The primary technique of behavioral training is pelvic ﬂoor muscle training, as described previously, but with a focus on urge inhibition. Mastering voluntary pelvic ﬂoor muscle contractions helps to strengthen the outlet (decreasing leakage) and inhibit detrusor contractions. Other components of therapy may include voiding schedules, urge-inhibitions strategies, and ﬂuid management.
Patients with neurogenic detrusor overactivity, rather than idiopathic detrusor overactivity, do not respond as well to behavioral therapy because the problem is actually one of neural pathway destruction rather than the need to reestablish cortical control mechanisms. Frequently, these patients have a trigger volume of urine that sets off a contraction that they cannot control voluntarily. They may benefit from a timed schedule in which they void at regular intervals (such as every 2 hours) to keep their bladder volume below the trigger point. Attempting to lengthen the interval between voids often does not work well.