Conservative management is the first option for patients with stress urinary incontinence (SUI). However, successful management of women diagnosed with SUI is dependent on a proper assessment and a tailored treatment plan. This case report aims to show the effectiveness of physiotherapy management in a 42-year-old patient diagnosed with SUI.
The patient’s main complaints were involuntary loss of urine on coughing, sneezing and lifting of heavy objects, which started following the birth of her third child.
The patient was taught the ‘Knack’ manoeuvre and provided with a tailored pelvic floor exercise programme. Improvement was noted at the third visit and the patient no longer had involuntary episodes.
This case report shows the successful outcome of conservative management in a patient with stress urinary incontinence.
Stress urinary incontinence (SUI) is the most common subset of urinary incontinence affecting women (Elmissiry, Mahdy & Ghoniem
Factors that predispose women to SUI, such as ageing, smoking and obesity, have been highlighted in literature (Luber
Written patient consent was obtained prior to publication of this case history.
Mrs X reported that her problem started 5 months earlier, following the birth of her third child. She stated that she wet herself if she sneezed or coughed and had reduced her fluid intake in an effort to prevent this from occurring. She also urinated more frequently to ensure her bladder is empty. When her symptoms persisted, she made an appointment with her gynaecologist, who referred her to physiotherapy for management. Further questioning of her bladder symptoms revealed that she had started wearing a panty-liner. She stated that if she has to cough she ‘wees’ a few drops (but only if she coughs hard) and every time she sneezes she ‘wees’ a few drops, which is worse if her bladder is full. She had also noticed a few leakage episodes when she lifted her 2-year-old daughter (10 kg). She stated that she wet herself about twice a day and changed her panty-liner three times daily.
The patient had no relevant bowel problems and was menstruating normally. With regard to her obstetric and gynaecological history, all her deliveries were vaginal with no perineal injury and no urinary incontinence (UI) after the birth of her previous two children. The patient did not have any positive red flags as defined by the NICE guidelines (NICE
The patient was working as a secretary in a legal firm at the time. She did not exercise because of time constraints.
Following completion of the subjective assessment, a preliminary hypothesis of SUI was made. The patient’s history was in keeping with SUI symptoms, as outlined by the Haylen
At session two, the bladder diary of the patient was analysed and the following was found:
Average number of voids: 3
Average number of accidental episodes: 2
She changed her panty-liner 3 times per day
Maximum volume voided: 300 mL
Minimum volume voided: < 50 mL
No night-time micturition.
The patient’s Body Mass Index was within normal range (23). She was made comfortable prior to the examination and the procedure was briefly explained again. The therapist followed the infection control procedure as per protocol.
On initial examination the following was noted:
no abdominal tenderness or bloating was noted
no perineal abnormalities were present, that is, irritation or redness in the area
a mediolateral episiotomy was seen; the scar was small, healed and mobile
she had no dermatomal abnormalities at S2–4
she had perineal descent
cough: leakage noted.
The PERFECT scheme was used to determine the muscle function of the patient. The tool is a reliable and valid method of assessing pelvic floor function (Laycock, Whelan & Dumoulin
Participant’s PERFECT score on assessment.
Variable | Initial assessment | 3-week follow-up | 1-month follow-up |
---|---|---|---|
Strength of contraction (P) | 3 | 3 | 4 |
Length of hold (seconds) (E) | 5 | 7 | 9 |
Repetitions (number) (R) | 7 | 8 | 8 |
Fast contractions (number) (F) | 4 | 6 | 9 |
Elevation during contraction (E) | Yes | Yes | Yes |
Co-contraction of transverse abdominis (C) | Yes | Yes | Yes |
Coordination of contraction prior to cough (T) | No | Yes | Yes |
A final diagnosis of SUI was established based on the objective examination findings. The bladder diary revealed that the patient had a high micturition and low volume rate. This was coupled with leakage episodes that were brought upon in instances of physical exertion (lifting her child) and sudden increases in intra-abdominal pressure (coughing or sneezing). She also reported only two episodes of ‘urge’ UI. These symptoms are in keeping with SUI, as outlined by Haylen
Based on the vaginal examination, her muscle strength was a Grade 3. She was unable to time her muscle contraction and her cough that resulted in her leakage. A brief explanation of the above was given to the patient and the patient was also instructed that she needed to work on her endurance and the timing of her fast contractions. It was explained to the patient that compliance with the pelvic floor muscle exercises would aid in preventing accidental leakages.
The following tailored treatment plan was discussed with the patient:
the patient was taught to perform the ‘Knack’ manoeuvre prior to strenuous activities such as lifting, coughing or sneezing
4 × fast 1-second contractions; 3 × daily
7 × 5-second-hold contractions; 3 × daily.
The progression from the exercise follows the principles set out by Laycock and Jerwood (
gradually increase the number of fast contractions
increase the number of repetitions of long maximum voluntary contractions until 10 is reached
gradually increase the hold of the contractions until 10 seconds is reached (therefore reaching the ideal 10 contractions x 10-second hold).
This was accomplished gradually over 3 months (NICE
Lifestyle advice was given to correct voiding habits as she was voiding ‘just in case’ to prevent accidents. The patient was asked to slowly increase the time between voiding (15–30 minutes) until she reached an acceptable voiding interval of 2–4 hours (Rovner & Wein
Conservative management is the first option for patients with SUI (NICE
Conservative management is the first option for patients with SUI. This case report shows the successful management of a patient diagnosed with SUI following a patient-specific physiotherapy treatment plan. Although the results cannot be generalised, this case report highlights the importance of assessment and the effectiveness of physiotherapy in managing a patient with SUI.
The author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this article.