Understanding and Managing Overactive Bladder and Anal Incontinence
1.What is consider Overactive Bladder
Syndrome (OAB)
? What is the incidence of the OAB? What are the symptoms of OAB? Is urinary urgency usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of urinary tract infection and obvious pathology. Incidence: All age groups; second leading cause of urinary incontinence in women Occurs more in women than in men (55% and 16%, respectively). Symptoms: Urinary incontinence; Urge incontinence; Postural incontinence; Mixed incontinence; Nocturia Frequency greater than 10 12 times/day (is usually socially unpleasant). 2. What is the clinical condition regarding OAB? What Urinary diary can provide in the assessment of OAB? How can the patient use the diary? Increased daytime urinary frequency, nocturia, urinary urgency and urge incontinence, incontinence to the associated efforts also experience decreased urinary flow, dysuria, pre voiding hesitation, incomplete bladder emptying, polyuria. The diary provides the examiner with the following information Urine volume voiding frequency the longest interval between urination and the average interval the largest urine volume the number and type of incontinence episodes The diaries can be made for 24 hours or 3 days, depending on each patient ICS consider the 24 hour diary to be good reliability and reproducibility, which makes it easier to carry out this method 3. What is the Urodynamic Assessment? What are the objectives of this assessment?
Urodynamic studies ( test how well the bladder, sphincters, and urethra hold and release urine These tests can show how well the bladder works and why there could be leaks or blockages. Aims to demonstrate the presence of involuntary detrusor contractions Assess bladder sensitivity and compliance Determine risk factors for upper urinary tract injury Evaluate the detrusor function in the bladder emptying period To rule out or confirm the presence of associated sphincter incontinence and/or obstructive processes.
Why do physiotherapists use the Bladder training for patients with OAB? How is it done?
Consists of an education program for the individual with guidance on programmed voiding intervals, associated with suppression and inhibition techniques Its main objective is to observe urination habits and patterns, in order to improve control over the bladder, decreasing urgency, prolonging the intervals between
urination and increasing the bladder filling capacity The technique can be easily administered in clinical practice, through which the patient receives information about bladder function, the scheduling of urination times based on his voiding diary and instructions on methods to control and suppress urgency
What is the “Guarding Reflex”? How does it work?
Is an increase in intraurethral pressure, a stimulus that controls urinary urgency symptoms According to Groat 1987 during urine storage, distention of the bladder produces afferent stimulus, which, in turn, stimulates the pudendal nerve, responsible for the innervation of the external urethral sphincter Consequently, there is an increase in intraurethral pressure, an effect called “guarding reflex”, a stimulus that controls urinary urgency symptoms.
What is Anal Incontinence? What are its symptoms? How can AI be classified?
Involuntary loss of both faecal material and gases and is marked by the inability to maintain physiological control of intestinal content at a socially appropriate time and place. A symptom of AI is the involuntary loss of stool or gas. Symptoms: Faecal incontinence (FI) – is characterized by the involuntary loss of solid or liquid stools and includes passive incontinence, when there is little loss (soiling) without sensation or warning and loss during intercourse with vaginal penetration. Flatus incontinence – is marked by involuntary gas loss. Faecal or rectal urgency – is also considered when there is a sudden and urgent desire to defecate, difficult to be postponed, and urinary, faecal or gas incontinence when there is an involuntary loss of faeces or gases associated with the urgency symptom. AI types: Sensory Incontinence: consists of passing stools without the patient’s perception, usually secondary to rectal prolapse and neuropathic disorders. Motor incontinence: patients are aware of the need to evacuate but are unable to control defecation. This occurs in patients with PF or sphincter disorder, but with normal innervation.
What is the functional of the Puborectalis muscle during the evacuation? How can people postpone the evacuation?
During evacuation, the relaxation of the puborectalis muscle increases this angle, facilitating the passage of stools.
8. What are the goals of a physiotherapeutic treatment for patients with AI? How would a physiotherapy program be for patients with AI? PFM training to increase contractile capacity and voluntary control of the external sphincter of the anus and of the levator ani muscle in response to rectal distension as long as there is at least partial preservation of innervation. Goals: Improve bowel habit; Increase the functional capacity of the PF, by improving control, coordination, muscle strength and endurance and anorectal sensitivity; Minimize functional motor and cognitive disabilities, such as difficulty in locomotion and access. In anorectal re-education, the exercises follow the same principles suggested for the treatment of urogenital disorders. Repetition and rest period: 30 to 100 contractions per day. Contraction duration: goal – sustained contraction period longer than 30s. Positioning: beginners – lying and sitting postures (to ensure isolated contraction of the PF muscles). Frequency: 1 to 3 times/week; guided and trained – daily exercise program for the PF. Program duration: 4 weeks to 12 months (improvement or cure by patients occur after 3 to 4 months of training).
Why is important to perform a functional assessment with AI patients?
A: Since incontinence may be associated with difficulties in walking, using toilets or handling clothing, it is important to carry out a functional assessment of gait, balance, positioning capacity, activities of daily living and fine manual motor activity.
How can we use Electrostimulation for patients with AI?
A: Directly over the PF muscles: used in cases where the patient is unable to contract the PF muscles or is unaware of how this contraction is. Parameters: for 20 to 40min per day, with a frequency of 35 Hz, 0.5s of pulse rise and fall time, 5s of sustention, 300ms pulse width, for 8 weeks. Neuromodulation: performed by percutaneous tibial nerve stimulation, a branching of the sacral nerves or on the parasacral roots. Some studies indicate the daily use of the technique; others cite its use only once or twice a week. The application time varies from 20 to 30 min and the treatment is done for 4 to 12 weeks.