Incontinence, overactive bladder, pelvic organ prolapse, and constipation: physical therapy to the rescue

As a women’s health physical therapist, I see many women suffering from urinary and bowel incontinence, overactive bladder, pelvic organ prolapse, and constipation. Please know that there is hope, there is help—in most cases, there is even a cure. And it doesn’t involve drugs or surgery.

Bladder incontinence (urine leakage), fecal incontinence (stool leakage), and pelvic organ prolapse (dropped abdominal organs): all are common consequences of pregnancy and menopause. Unfortunately, many women don’t seek treatment because they believe their problem is unavoidable and untreatable—something they “just have to live with.” Fortunately, that’s not true.

The link between these conditions is a weakened pelvic floor: the “sling” of muscles and tissues in the lower abdomen that supports, and holds in place, the bladder, uterus, and rectum. The sling can stretch, sag, and get injured after pregnancy and vaginal childbirth. It can further weaken from menopause, loss of estrogen, and aging.

Just like other muscle and soft tissue problems, pelvic floor dysfunction usually responds beautifully to physical therapy. Pelvic floor physical therapy may be just what the doctor ordered for incontinence and prolapse—as well as overactive bladder and constipation, which can also arise from pelvic floor problems.

About incontinence

Up to half of older women struggle with urinary incontinence. You may be surprised that urinary incontinence strikes 30 to 40 percent of middle-aged women and 20 to 30 percent of young women—many, but not all, after giving birth. (Source: WebMD)

In new moms, urinary incontinence stems from weakened or injured pelvic floor muscles (a result of pregnancy or delivery); injured pelvic nerves; or diastasis recti, a surprisingly common condition in which the growing fetus stretches the mother’s abdomen until bands of muscle separate. There are several types on incontinence:

* Urge incontinence—the loss of urine with a sudden, strong urge to urinate

* Stress incontinence—the loss of urine with lifting, exercising, coughing, sneezing, crying, or laughing—in other words, anything that stresses the bladder, abdominal muscles or pelvic muscles

* Mixed incontinence—a combination of urge incontinence and stress incontinence

* Fecal incontinence—loss of control of bowel movements, causing stool leakage

About overactive bladder

To prevent urine or stool leakage, many incontinence sufferers subconsciously clench their pelvic floor muscles. These muscles can tighten and fatigue, go into spasm, and develop painful tender points and trigger points (sore “knots” that refer pain elsewhere). Also, the bladder muscles may contract, triggering “gotta go” urges even when urine levels are low—and sending sufferers to the bathroom many times a day.

Overactive bladder can arise for other reasons: bladder muscle or bladder nerve dysfunction, urinary tract infection, interstitial cystitis, bladder-irritating foods, kidney or bladder stones, bladder tumor, or neurological conditions. Sometimes doctors aren’t able to pinpoint a cause.  

About pelvic organ prolapse

Pelvic organ prolapse means that an abdominal organ—usually the uterus, bladder, or rectum—has dropped out of place. Sometimes the organ pushes into the vaginal walls; in extreme cases, it protrudes outside the vaginal opening. When the rectum pushes into the vagina, the resulting bulge is called a rectocele; when the bladder pushes into the vagina, the bulge is called a cystocele; when the uterus pushes into the vagina, it’s called a uterine prolapse.

In a subconscious effort to pull in their protrusion, many women clench their pelvic floor muscles. Here again, these muscles can tighten and fatigue, go into spams, and develop tender points and trigger points.  Not surprisingly, the net result of prolapse can be pain during intercourse, urination problems, constipation, and pain in the lower back and pelvis. 

Pelvic organ prolapse is more common than you may think: it occurs in 40 percent of women over 60 who have not had a hysterectomy. (Source: American Family Physician)

About constipation

Constipation can also stem from pelvic floor dyssynergia (also called anismus), meaning incoordination of pelvic floor muscles. Normally, anal and rectal muscles relax during a bowel movement. But in some people, the muscles contract instead, causing straining, a feeling of incomplete emptying, and constipation. (Please note that there are many possible causes of constipation. My focus is on musculoskeletal factors.)

How pelvic floor physical therapy can help

Today there’s a new specialty at the intersection of physical therapy, urology, and gynecology. Called women’s health physical therapy or pelvic floor physical therapy, it’s a first-line treatment for pelvic floor problems, including incontinence, overactive bladder, prolapse, and constipation. Specially trained physical therapists employ these gentle, proven techniques, tailoring treatment to the patient’s diagnosis and needs.

Manual therapy: Hands-on treatments—for example, soft-tissue massage, myofascial release, and trigger-point release—help relax tight tissues, balance muscles, move stiff joints, and melt away tender points and trigger points in the back, pelvis, abdomen, hips, and thighs. Your therapist may add trigger-point release and stretching inside the vagina.

Therapeutic exercise: Your physical therapist may also teach you core-stabilization exercises, postural exercises, and exercises to strengthen your abdomen, back, hips, and legs.

Pelvic floor biofeedback: Safe and painless, biofeedback trains you to isolate and rehabilitate your pelvic floor muscles—including the muscles that control urination. You insert a tiny probe into your vagina or rectum, then view your pelvic muscle function via a graph on a monitor. (If you can’t insert the probe, your physical therapist may place sensors on the skin between your vagina and rectum.) If your muscles are tight and in spasm, your therapist uses biofeedback to guide pelvic release exercises called pelvic drops. If your muscles are weak, she uses biofeedback to guide pelvic strengthening exercises. Home practice is vital to your recovery.

Electrical stimulation: If you can’t isolate and recruit the muscles that control urination, your physical therapist may “jump-start” and strengthen them with therapeutic “e-stim.”

(Note: Biofeedback and e-stim are not advised for pregnant women.)

After a course of pelvic floor physical therapy, most women report that their symptoms are significantly or completely better.

In addition, women with urinary urgency, urinary frequency, and bladder spasms may benefit from avoiding foods that irritate the bladder. They may also benefit from bladder retraining: holding urine for increasing periods of time to prevent leaks and emergencies. Talk to your urologist or urogynecologist.

For more information, visit:

American Association of Sexuality Educators, Counselors and Therapists

American Physical Therapy Association Section on Women’s Health

International Pelvic Pain Society

The International Society for the Study of Vulvovaginal Disease

National Vulvodynia Association

The North American Menopause Society

The V Book: A Doctor’s Guide to Complete Vulvovaginal Health, by Elizabeth G. Stewart, M.D.

The Vulvar Pain Foundation