Assessment & diagnosis
- History and pattern of your symptoms
- Contributing lifestyle and medical factors
- A bladder, bowel and fluid-intake diary
- Triggers and easing factors
- Pelvic floor muscle tone, co-ordination and strength
Incontinence
Incontinence is the unintentional leakage of the bladder or bowels. It is common, around 1 in 3 adults experience it in some form, rarely talked about, and very treatable.
Understanding incontinence
Incontinence is the unintentional leakage of the bladder or the involuntary evacuation of the bowels, and it can happen on its own or with both together. Urinary incontinence is the more common of the two, with around 1 in 3 adults experiencing it in some form, and roughly 70% of those affected are over 65. It affects women more often than men, partly because of the bladder and body changes that come with pregnancy and delivery, but also because of the shorter urethra and the comparatively shorter, smaller muscles around it that give you the stopping power when you try to hold on.
Bowel incontinence is less common, affecting around 1 in 30 people, but it is just as impactful on quality of life when you feel uncertain about what your bowels are doing.
Types of urinary incontinence
- Urgency - the alarm system that tells you it is time to go gives little warning, so many (if not all) trips to the bathroom become an urgent event.
- Frequency - you have difficulty holding on and need the bathroom more often, either because the bladder's alarm system is over-sensitive to pressure, or because the muscles around the urethra and pelvic floor cannot work against that pressure and need releasing more often. Urgency and frequency can be "wet" (actual spotting or leakage) or "dry" (you make it in time, but it still affects your day and night).
- Stress incontinence - leakage when the body is under extra physical load: a cough, sneeze or laugh, but also breath-holding to pick something up, lifting weights, running or jumping, or any sudden change in pressure the bladder or pelvic floor cannot accommodate quickly enough.
- Overflow - often after abdominal or prostate surgery, pregnancy or nerve damage, the bladder does not empty fully and fills beyond what it can hold, causing frequent (and sometimes continuous) leakage, difficulty deliberately starting the flow, and often a weak stream.
What incontinence can feel like
Not everyone gets all of these at once, and some people only notice a few. If you are unsure whether your combination of symptoms is incontinence, the Australian Incontinence Questionnaire is a useful place to start.
Bladder
- Leaking urine through the day with little to no warning
- Leaking when you bend over, strain, lift, or exert yourself
- Strong urges to urinate with little notice before you need to go
- Noticing urine spotting on your underwear through the day
- Needing to go again soon after finishing, as though there is more
- Waking through the night to urinate, or waking having already leaked
- Leaking urine during intercourse or ejaculation
Bowel
- Faecal smearing on your underwear through the day
- Passing stool unintentionally with little to no warning
- Strong or sudden urges to empty your bowels, regularly or without much notice
- Passing stool when you pass wind
Typical incontinence is frustrating but not painful. Severe pain when urinating, constant difficulty starting to urinate with deep bladder pain, or regular blood in the urine can point to more serious bladder conditions and need prompt medical review.
Inflammatory and irritable bowel conditions, including diverticulitis, IBS/IBD and colorectal cancer, can cause these bowel symptoms during flare-ups. They are not always cause for alarm when your condition is well managed, but recurrent symptoms should be assessed.
Why incontinence happens
There is no single pathway that leads straight to incontinence, but a range of lifestyle and medical factors can raise your risk.
Urinary risk factors
- Pregnancy and childbirth
- Perimenopause and post-menopause
- Prostate issues (cancer, BPH / hyperplasia)
- Surgery to the urinary and pelvic organs
- Constipation
- Cardiovascular conditions, including stroke and heart disease
- Neurological conditions, including stroke, Parkinson's, epilepsy and multiple sclerosis
- Diabetes
- Dementia
- Urinary tract infections
- Sexually transmitted infections
- Obesity
Some medications also raise the risk, including kidney medications, ACE inhibitors (a class of heart medication), muscle relaxants, antihistamines, and antidepressants and antipsychotics.
Bowel risk factors
- Many of the same factors as urinary incontinence, plus:
- Recurrent diarrhoea
- Regular straining on the toilet
- Haemorrhoids, fissures and fistulae
- Surgery to the abdomen, intestines and rectum
- Inflammatory and irritable bowel disorders
Few medications directly increase incontinence risk, but some carry a "laxative effect" warning that can make bowel control harder, including metformin (for diabetes), GLP-1 medications (like Ozempic), some broad-spectrum antibiotics, and overuse of products marketed for stomach cramping and constipation (De-Gas, Buscopan, and similar).
How I treat incontinence
Treatment techniques
- Pelvic floor strengthening with ultrasound feedback
- Micturition (urination) reflex training
- Bladder and bowel training strategies
- Fibre and fluid optimisation
- Reducing or removing contributing factors
Your home program
- Prescribed pelvic floor exercises
- Repeat bladder and bowel diaries
- Breath work to co-ordinate the pelvic floor
- Progressing load on the pelvic floor (positions, movement, external stress on the body)
Your first visit
During your first visit, I'll go through what has brought you in and the factors that might be contributing, both lifestyle and medical or surgical, anything you have already tried, and what your main goals are. I'll also ask about your bladder and bowel habits, your fluid and fibre intake, and any medication that might influence your symptoms.
To diagnose accurately and build a treatment plan, I'll assess the pelvic floor. In men with urinary incontinence this is done externally, as the muscles can be seen and felt from the outside. In women it is usually done internally (vaginally), as the muscles are most accurately examined about one knuckle's depth inside the vagina. For bowel incontinence, a digital examination of the rectum gives useful information about the tone of the back half of the pelvic floor, though an external examination looking at the anal ring and the movement of the muscles around the sphincter can also be done.
After the examination, treatment usually begins in the same session, often by training the pelvic floor muscles in some way - activation and co-ordination if the muscles are hard to feel working, or endurance and strength if you can activate them but they cannot yet overcome the bladder or abdominal pressure. If I find other contributing factors during our initial discussion, I can also introduce changes to fluid intake, fibre intake and supplementation, and set up a bladder diary and timed toileting.
All of this is packaged into a plan to continue at home between sessions, where I track your progress and gradually increase the intensity or complexity of the exercises and adjust the bladder training as you improve.
Consent is ongoing, specific, and yours to withdraw at any time.
Common questions about incontinence
Can physiotherapy really stop bladder leakage?
Physiotherapy has been shown to be around 80% effective in managing incontinence through pelvic floor muscle training and lifestyle strategies. For some people it works even better alongside other treatments, such as medication from your GP or urologist, or nerve stimulation (PTNS). Some people take longer to see improvement, and that can vary with muscle activity, neurohormonal factors, and what triggers your symptoms.
Do I have to do an internal examination?
No. Internal examination gives the clearest information to guide diagnosis and treatment, but there are alternatives, including external examination and transperineal ultrasound (an ultrasound probe placed on the skin between the scrotum and anus in men, or in front of or behind the vagina in women) to view different parts of the pelvic floor, organs and bladder. This still involves exposing the genital region, but it is not penetrative.
How long until I see results?
There is no single answer. Some people notice changes within 1 to 2 weeks, while others take longer to feel a difference even when their bladder diary and measured strength on examination or ultrasound have already improved. How quickly you feel improvement often depends on how in tune you are with your bladder and how aware you were of your symptoms to begin with.
Book an assessment
Not sure if I'm who you need? Ask me and I'll let you know if physiotherapy is the right fit, or point you to who is.