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Kegel exercises
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Pelvic floor muscle exercises are not a new concept in the treatment of urinary incontinence - they've been in use since the early 1930s. But it was the work of gynecologist Arnold Kegel, MD, that popularized the subject of pelvic muscle rehabilitation. In the late 1940s, Kegel invented the Kegel perineometer, basically a biofeedback device enabling a woman to observe the strength and duration of her pelvic floor muscle contractions to determine the effectiveness of the exercises.
Located in the bottom portion of the pelvis, pelvic floor muscles support internal organs and surround the urethra, vagina, and rectum. Loss of support of these muscles can lead to pelvic organ prolapse or incontinence of bladder and bowel.
To locate the pelvic floor muscles, pull in on your rectal muscles as if you were trying to retain gas. Try to keep the abdominal, thigh, and buttock muscles relaxed when tightening the muscles of the pelvic floor. At first, it may be difficult to tell if the muscles are getting stronger. Be patient and keep practicing, though - it can take two to eight weeks before you notice any significant change in muscle strength.
Attaching Kegel exercises to activities performed every day can help make them a healthful habit - try doing them whenever you stop at a red light, for example, or talk on the phone or perform household tasks. The exercises should take only about 10 minutes a day.
To perform pelvic muscle exercises -
Step 1: Slowly tighten the pelvic muscles and initially hold the contraction for three to five seconds, then relax the muscles for 10 seconds. Repeat 10 times. Work gradually up to a 10-second hold.
Step 2: Tighten the pelvic muscles in a quick, strong contraction. Relax the pelvic muscles. Repeat 10 times.
Then do Steps 1 and 2 above as a set.
Start by performing one to two sets each day, gradually building up to five a day. If your muscles become too tired to contract, stop and try again an hour or two later.
Do not hold your breath while forming these exercises. Instead, breathe out while tightening your pelvic muscles.
Remember, even when the muscles are stronger and leakage is no longer a problem, continuing Kegel exercises routinely will help maintain a healthy pelvic floor.
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Biofeedback also can augment pelvic floor strengthening. This is usually done with the help of a specially trained continence nurse or physical therapist, since the equipment is rarely available in primary care offices.3 The instruments relay information or sensory feedback to the patient, assisting her in correctly performing Kegel exercises.
Mechanical devices like continence rings or pessaries (see photo on opposite page) can be used to lessen urinary leakage by stabilizing the urethrovesical junction to allow proper pressure transmission when intraabdominal pressure increases, as during sneezing or coughing.6
Pharmaceutical treatment is not often the first choice of therapy for stress incontinence; phenylpropanola mine, pseudoephedrine, and estrogen have been shown to be useful.7 In cases of sphincter insufficiency, phenyl pro panol amine and pseudoephedrine have been beneficial in causing muscle contractions in the alpha-adrenergic receptors around the bladder, thereby increasing bladder outlet resistance. Estrogen has been useful in treating vaginal atrophy.7 Improving the overall health of pelvic floor tissue has been shown to enhance the urethral closure mechanism.
Pharmaceutical management can be helpful in trying to stop the uninhibited bladder contraction of OAB. Oxybutynin, an anticholinergic agent, is usually the first-line drug of choice. This pharmaceutical agent, however, is not without potential adverse effects or contraindications. These must be taken into consideration and thoroughly discussed with the patient when considering this treatment. The principle behind this therapy is an attempt to allow a greater volume of urine to be stored in the bladder and achieve fewer uninhibited bladder contractions.3 Pharmaceutical therapy works best when combined with the behavioral measures previously mentioned.
Because surgical correction is more invasive, it might be preferable to try behavioral therapy or pharmacological intervention first. But for some, surgery becomes a first-line treatment option; it is actually commonly prescribed for women with SUI.
Retropubic or needle suspensions are recommended with urethral hypermobility, while sling procedures or periurethral bulking agents are used to treat intrinsic sphincter deficiency.8
A major goal in treating OAB is to reduce the intake of bladder irritants, such as caffeine, alcohol, spicy foods, and nicotine. Sudden bladder distention, overly concentrated urine, and constipation also should be avoided. Along with potentially lessening urgency by reducing the causative stimuli, bladder retraining also is indicated. This form of therapy, however, works best for highly motivated women who can keep a bladder record and demonstrate the ability to suppress urgency episodes through bladder relaxation and sensory distraction. These women must also have supportive education to help them understand that any movement at the time OAB is experienced — such as running for the bathroom — may merely stimulate the bladder further. Avoiding movement, making an effort to relax, and performing a pelvic muscle contraction (Kegel) exercise is a three-step process for helping overcome the immediate urgency.3
Functional electrical stimulation, similar to biofeedback, has been used with some success. A probe is inserted in the vaginal canal that will emit an electrical impulse stimulating pelvic floor muscles to contract. The goal is once again to improve the strength of the pelvic floor and additionally override uninhibited blad der contraction.
Because a physiological cause — such as diabetes, spinal cord injury, or an obstruction — most often precipitates overflow incontinence, individuals experiencing this type of UI should be thoroughly evaluated, with a focus on underlying factors.
What nurses can do
By understanding more about the causes and treatments of UI, nurses can open the door to a more comfortable dialogue with female patients over the sensitive issues surrounding urinary leakage. Helping women understand that they are not alone and need not suffer the indignities of UI can help overcome the stigma that may have caused them to restrict their daily activities or abandon pursuits that gave them pleasure.
Though the incidence of UI is still greater in those older than 50, nurses should not forget that women can be at risk for UI anywhere in the life cycle. Active screening and careful listening are important skills for the nurse to practice. They may ultimately spare a patient the embarrassment and humiliation of untreated urinary incontinence.
Bonnie P. Ward, RN, BSN, is a nurse educator in the Patient & Health Education Department at Southern California Kaiser Permanente, San Diego.
References
1. Urinary Incontinence. American Foundation for Urologic Disease Website. Available at: www.afud.org/conditions/ui.asp. Accessed December 8, 2004.
2. Loughrey L. Taking a sensitive approach to urinary incontinence. Nurs 99. May 1999;29(5):60-61.
3. Krissovich M, Safran R. Differential diagnosis: urinary incontinence in adults. Lippincott’s Primary Care Pract. 1997;1(4):361-381.
4. Telford C. Understanding the problem of urinary incontinence. J Am Acad Physician Assistants. 2002;15(1):45-50.
5. McCallig Bates P. Helping women manage urinary incontinence. Advance Skin Wound Care. 2000;13(6):85-89.
6. Weinberger MJ. Conservative treatment of urinary incontinence. Clin Obstet Gynecol. 1995;38(1):175-188.
7. Urinary Incontinence: Embarrassing but Treatable. American Academy of Family Physicians Website. Available at: http://familydoctor.org/189.xml. Accessed December 8, 2004.
8. Fantl JA, Newman DK, Colling J, et al. Urinary incontinence in adults: acute and chronic management. Clinical Practice Guideline No. 2. Publication No. 96-0682. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. Agency for Health Care Policy and Research; 1996.
Bibliography
KFCnemann KP. The management of female urinary stress incontinence: II. the use of devices. Br J Urol Int. 2001;87:449-455.
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