Urinary incontinence is the involuntary loss of urine. Inability to retain urine in the bladder due to loss of voluntary control over the urinary sphincters resulting in involuntary passage of urine.

Most urinary incontinence can be effectively treated with physical therapy. Urinary incontinence has a solution and does not have to  limit the daily and social life of the affected person.

Types of urinary incontinence:

There are different types of urinary incontinence that respond to different causes, so it is important to make a correct physiotherapeutic diagnosis to adapt the treatment. You can have symptoms that belong to one or more of the types of urinary incontinence.

❖    Stress urinary incontinence is the involuntary loss of urine that is associated with a physical activity such as coughing, sneezing, laughing, walking, running, practicing physical exercise and lifting weights among others.

The origin of this type of incontinence occurs when intra-abdominal pressure increases during an effort and the abdominal girdle and / or the pelvic floor are weakened and cannot withstand the pressure. This causes urine to leak involuntarily through the urethra (the tube through which urine exits), especially when the support of the urethra is weakened.

❖    Urge incontinence is a sudden, intense urge to urinate, followed by an involuntary loss of urine. The person with urinary urgency cannot, in many cases, retain urine before reaching the bathroom. This symptom is usually accompanied by an increase in urinary frequency

The origin of this type of incontinence occurs with a combination of poor bladder control (bad habits), a weakened pelvic floor and transverse abdominal muscles.

❖    Mixed incontinence You experience stress and urge urinary symptoms.

Bowel incontinence (also called faecal incontinence) is when you're not able to control your bowel movements as involuntary loss of solid, liquid stool or not able to control wind. 

The origin of the bowel incontinence can be at the anal level or at the rectal level.

❖             Anal hypotonia

❖             Hypotonia of the pelvic floor muscle

❖             Alteration in the reflexes that preserves anal continence (rectus-reflex reflex). 

❖             It is due to an alteration of the anal-rectal compliance 

❖             Sensitivity

The most common causes of faecal incontinence are:

❖             Obstetric and gynaecological trauma

❖             Weak pelvic floor 

❖             Retroverted uterine positioning

❖             Direct trauma

❖             Rectal surgery

❖             Central neurological causes

Faecal incontinence is approached in a conservative way, using re-education techniques such as biofeedback, electrostimulation, the rectal balloon and a series of exercises that will help the patient to have a greater control over anal continence. 

In addition to these techniques, it is essential to follow some hygienic-dietary guidelines to empty the rectum well and avoid the production of gases, as well as a correction of the defecatory manoeuvre that may be further weakening the pelvic floor and favouring the appearance of uro-genital prolapse.

Pelvic organ prolapse is when 1 or more of the organs in the pelvis, such as the bladder, uterus or rectum,  slip down from their normal position. Depending on the prolapsed organ, we are going to differentiate between two types of prolapse:

❖    Prolapse of the anterior wall, when the organs that have descended are the bladder, urethra or uterus.

❖    Posterior wall prolapse, when the organ that has descended is the rectum or the intestines.

There are different degrees of prolapse that, if not treated in time, can go as far as the total exteriorization of some of these organs.

Normally this happens progressively, distinguishing up to 4 degrees of prolapse:

Grade 1: The organs have only slipped down a little. 

Grade 2: The organs have slipped down to the level of the vaginal opening.

Grade 3: The vagina or womb has dropped down so much that up to 1 cm of it is bulging out of the vaginal opening.

Grade 4:  More than 1 cm of the vagina or womb is bulging out of the vaginal opening.

Pelvic organ prolapse symptoms include:

❖    Feeling of heaviness or pressure  around your pelvis  and genitals

❖    Feeling like there's something coming down into your vagina. You may feel it in a sitting position.

❖    Sensation of a lump in the vagina or even a visible lump that was not there before and that sometimes you have to move out of the way with your fingers to be able to urinate.

❖    Discomfort or pain during sexual intercourse 

❖    Feeling like your bladder is not emptying fully, needing to go to the toilet more often, or leaking a small amount of pee when you cough, sneeze or exercise 

❖    Pelvic or lower back pain 

❖    Repetitive bladder infection

Chronic pelvic pain can affect men and women regardless of their age and can be very disabling. It is a pain of pelvic location, that is, in the lower abdomen, but it is also usually referred to the vulva, the lower limbs, buttocks, this is due to the connection that exists between all these structures and the pelvic floor. The pain evolves for a period of more than 6 months.

In many cases, chronic pelvic pain syndrome does not identify the cause that originates the pain and this leads those who suffer from it to a true pilgrimage, from one specialist to another, delaying diagnosis and treatment. When the main cause is not found, doctors often recommend medication, hormonal treatment, or surgery.

Its causes are multiple originating in the digestive, urinary, genital or neuromuscular system. In this way, it is also usually associated with sexual, behavioral, emotional and cognitive consequences, which can radically affect the habits of the patient's daily life.

In a great majority of cases, the initial cause of the problem is no longer present because it was treated by the specialist doctor and it was cured. but it left sequelae throughout the pelvic muscles and their reflexes, causing the pain to persist over time.

As physiotherapists, a specific and exhaustive assessment of the patient is necessary to understand the situation and to be able to detect which structures are failing or which need to be treated.

If the causes have their origin at the muscular level or this region has been affected as we mentioned before, physiotherapy can help to reduce pain considerably or a total recovery of the patient. With physiotherapy we treat the entire abdominal-pelvic structure. 

It is the branch of physiotherapy that addresses the rehabilitation of the pelvic floor and sexual dysfunction. Among them, the most common would be dyspareunia, vaginismus, anorgasmia.

Sexual health definition (WHO, 2006a);

“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

Dyspareunia is pain during or after sexual intercourse or for example inserting a tampon. Dyspareunia is considered one of the most common female sexual problems. Women with dyspareunia may have pain in vulva or in the vagina. 

To have pain during intercourse is common, but it is not normal, there are numerous causes of dyspareunia, many of which are treatable.

People affected with dyspareunia can experience a wide variety of pain, such as: burning sensation, burning, itching, cutting pain, stinging, tightness ... many times preventing the woman from reaching orgasm.

There are two types of dyspareunia according to the moment in which the woman feels the pain:

❖    Superficial dyspareunia is a pain at the entrance of the vagina. 

❖    Deep dyspareunia is deeper pain in the vagina or in the lower abdomen during penetration. 

Whether the dyspareunia is of physical, psychological or both origins, women usually present contracture of the pelvic floor muscles to a greater or lesser degree, secondary to painful sexual activity and other dysfunctions of the pelvic floor.

Expert pelvic floor physiotherapist to try to desensitize the painful area, reduce fear of penetration and treat musculoskeletal dysfunctions that they encounter. Due to the important emotional component of dyspareunia, this treatment should be done as a team together with a psychologist who is expert in sexual problems.

Vaginismus is the impossibility of vaginal penetration such as the insertion of a finger or tampon or during intercourse. There is a spasm of the pubovaginal and often perineal muscles. In many cases the vagina is normal and spasm only occurs in a situation of excitement.

There are two types of origins;

❖    Primary Vaginismus: Women have always suffered from it, where the causes can be very diverse from psycho-emotional to organic.

❖    Secondary vaginismus: the woman suffers from a certain moment, either after giving birth, after surgery, due to direct trauma, due to a traumatic event such as the death of a loved one, abuse.

The treatment of vaginismus with physiotherapy begins with sexual and anatomical education, with an approach from external structures such as the pelvis and vulva until reaching intracavitary treatment. The physiotherapist must avoid manipulations that cause pain, since the pain will cause spasm at the vulvar and vaginal level, which will prevent the evolution of the treatment.

The objective is to achieve muscle relaxation at the abdominoperineal level with myofascial techniques, external and intracavitary manual therapy, progressive vaginal dilators and negative biofeedback until the correction of these involuntary muscle contractions. We are also looking for good pelvic mobility to eliminate any joint blockage that may affect this musculature.

As we progress through the stages of treatment, we will send the patient different guidelines to continue with treatment at home.

In order to understand what an orgasm disorder is, the first thing we have to understand is what an orgasm is. 

“The highest point of sexual excitement, characterized by strong feelings of pleasure and marked normally  by involuntary vaginal contractions in the female.”

Anorgasmia is a type of sexual dysfunction in which a person cannot achieve orgasm despite adequate stimulation.

The physiotherapeutic approach in anorgasmia is little demanding due to the ignorance of the existence of this dysfunction, as well as the existence of effective treatment for it.

Anorgasmia can be due to alterations in the arousal phase of the female sexual response, preventing reaching the plateau and later orgasm. A lack of sexual desire physiologically suggests that the vagina has not been sufficiently dilated, the cervix will not be in the proper position and this will cause a lack of lubrication, inappropriate friction of the penis in the vagina and a shock that will cause pain.

Alterations in the female sexual response, usually manifests in patients with poor sexual education, poor knowledge of their sexual anatomy , after abuse or traumatic situations, due to lack of lubrication, hypotonia of the pelvic floor and associated libido alteration or not to menopause or hormonal problems. In this case, the treatment should be considered from a multidisciplinary perspective, the work of the psychologist specializing in sexuality being very important.

Anorgasmia or difficulty reaching orgasm is frequently associated with other dysfunctions of the pelvic floor, such as;

❖     Pain during sexual intercourse, which usually presents with increased tone of the pelvic floor muscles.

❖    Pelvic floor musculature weakness.

❖    Urinary stress incontinence, postpartum pain after episiotomy, chronic pelvic pain can contribute to the failure to trigger orgasm.

It is important to identify the main cause of anorgasmia in the patient in order to establish the objectives and the physiotherapeutic treatment plan. Treatment is based on

❖    Sex education, learning sexual anatomy, how our body works during sexual response.

❖    Guidelines for self-exploration to know your body.

❖     Learning relaxation techniques.

❖    External or intracavitary techniques to normalize the tone of the pelvic floor muscles.

❖    Techniques for strengthening the pelvic floor muscles.

❖    Techniques to improve motor control and proprioception of the pelvic floor, using instrumental techniques such as biofeedback and electrotherapy.