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Contrary to the message perpetuated by the plethora of television and print ads for absorbent undergarments, diapers are not the only option for incontinence. Kendra Harrington, PT, DPT, BCIA-C, PMDB [pelvic muscle dysfunction biofeedback], has many success stories to relay about overcoming incontinence with a PT regimen. The pelvic floor physical therapist at Walter Reed Army Medical Center in Washington, Harrington remembers one 96-year-old woman in particular who had been referred to PT because of symptoms of urge incontinence (overactive bladder). The elderly woman had curtailed traveling and visiting family — her favorite pastimes — because she was urinating frequently and had episodes of leaking.

Using a behavioral approach to rectify habits exacerbating incontinence, a bladder retraining program to increase bladder capacity, and instruction in pelvic floor muscle exercises with biofeedback training, Harrington was able to help the woman regain control of her bladder, and her life.

“After about four visits we got her back to normal bladder functioning. No more leakages. I had one more visit to go with her just to finalize the exercises, but I couldn’t get her back through the door because she started driving again and started traveling and visiting family,” Harrington says. “Sometimes you fix them so good you can’t get them back in [the clinic]!”

Not alone

Other PTs have been quite successful in treating both urinary and fecal incontinence using a combination of behavioral approaches, bowel and bladder retraining, and exercises, sometimes in conjunction with biofeedback or electrical stimulation. But getting the word out to patients and physicians can be difficult, says Raquel K. Perlis, PT, owner of Raquel K. Perlis Physical Therapy Inc. in Wellesley Hills, Mass., who frequently treats incontinence.

Unfortunately, many doctors will unnecessarily dismiss patients’ complaints. “They’ll say, ‘You’re 70-something years old. That’s part of life,’” she says. “For me, that is not acceptable.”

Incontinence is not an inevitable consequence of aging, Harrington stresses, but it is a major problem for a lot of people. “It’s generally not a medical emergency, but it has a major quality-of-life impact.”

The National Association for Continence (NAFC), based in Charleston, S.C., reports some alarming statistics about incontinence, the involuntary loss of bladder or bowel control:
• Urinary incontinence affects 200 million people worldwide.
• Fecal incontinence affects more than 6.5 million Americans.
• 53 percent of homebound elderly are incontinent.
• More than half of all nursing home patients are incontinent.
• Incontinence is the second leading cause of institutionalization.
• Those with severe incontinence spend, on average, $900 annually on adult diapers, extra laundry expenses, and other related expenses.

Yet two-thirds of men and women age 30 to 70 have never discussed bladder health with their physician, and women generally wait six and a half years to seek treatment.

Half of men who have had prostate surgery report episodes of stress urinary incontinence (SUI, which is involuntary loss of urine during exertion such as exercise, laughing, or coughing) in the first few weeks following surgery, and 20 percent experienced some SUI one year post surgery. Young women may experience incontinence during pregnancy or after childbirth. Even a chronic cough can result in incontinence. Other conditions and diseases that may cause incontinence include pelvic surgeries, spinal cord injuries, multiple sclerosis, infection, and neurological diseases.

Incontinence in the elderly may not be due to poor bowel and bladder control, but rather to diminished cognitive skills and poor mobility, which may prevent them from reaching the bathroom in a timely manner, notes Tina Maynard, MPT, director of physical and occupational therapy at Memorial Hospital Inc. in Towanda, Pa. Since November 2007, she has been working with patients in the skilled nursing unit. Occasionally she has worked with nursing on setting up a bowel and bladder program, but says, “It’s hard in skilled. They can do the voiding, where the aide helps them, but it’s hard to have enough staffing to run effectively for every patient that needs it.”

No matter what the cause, “most people won’t talk about it,” says Caryn Antos, an NAFC spokesperson. “In an ideal world, every healthcare provider would ask about incontinence.”

Too often, though, providers don’t want to talk about incontinence, and neither do their patients. Antos suggests broaching the subject by mentioning how prevalent incontinence is and stressing that noninvasive treatment can alleviate symptoms in many cases. She advises asking the patient in a private setting, which is more likely to yield candid answers.

Slowing the flow

Physical therapy for incontinence generally begins with education and behavioral changes. Maynard discusses a typical day with a patient, focusing on his or her food and beverage consumption, including amounts and timing, as well as voiding habits. “There are certain foods that are bladder irritants,” she says. These include caffeinated beverages, tomato-based products, citrus juices, and milk.

A typical breakfast of coffee, orange juice, and cereal with milk actually contains a trifecta of irritants, which puts considerable strain on the bladder. By limiting coffee, swapping apple juice for the orange juice, and eggs for the milk and cereal, many patients experience some symptom relief.

Other habits can exacerbate incontinence as well. “Often people don’t realize they’re setting themselves up [to be incontinent],” Maynard says. “People will sometimes have a strong urge the minute they put their keys in the door, because the first thing they do when they get home is go to the bathroom. Now all of a sudden you’ve trained yourself and your thought processes to think you have to go to the bathroom every time you come home.”

Going to the bathroom frequently (for example, “just in case” there isn’t a bathroom nearby in the future) can decrease bladder capacity and set up a false sense of urgency even when the bladder is near empty. “A lot of people that I found who have incontinence started out with urinary frequency,” Maynard says.

Setting up a voiding schedule is a component of treatment known as bowel and bladder retraining. By keeping a “bladder diary,” frequency of voiding can be determined. Working from that baseline, the goal is to slowly increase intervals between voiding to a minimum of every two hours and an ideal of every three to four hours.

A third tactic is therapeutic exercise. Patients are instructed in pelvic muscle exercises, commonly known as Kegel exercises. Studies show, Harrington says, that “upward of about 55 percent of women do them wrong if they just read about it or are just verbally educated in it.” Because of that, therapists will use biofeedback or real-time ultrasound to assist patients in recognizing proper isolation of muscle groups.

Therapists may use electrical stimulation vaginally or rectally to assist patients in developing muscle strength. “If the patient is extremely weak and they cannot elicit a contraction voluntarily, we use electrical stimulation. It’s the same sensors used with the biofeedback machine. We do it in the office, but we also recommend that the patient rents a machine and [uses] it daily. Or even twice a day.” Perlis says. “It’s very successful for fecal and urinary incontinence.”

Maynard often instructs patients to do their pelvic exercises during driving or another frequent activity. “When you tell them to incorporate the exercises into a daily function, you get better carryover,” she says.

Treatment times vary with conditions and individuals. “Each person’s a little bit different. I would say about four to eight visits is generally standard,” Harrington says. Though studies suggest that it takes six to eight months for ideal symptom improvement, “you don’t necessarily have to follow the patient to 100 percent leak-free,” she says.

Harrington recently ran into her former patient, now 100 years old. She is still continent and quite happy to be able to travel to visit family and friends without worrying about bladder control.