How should physiotherapists manage urinary incontinence in spinal cord injury patients?

Physiotherapy Management of Urinary Incontinence in Spinal Cord Injury Patients

Primary Recommendation

Physiotherapists should implement pelvic floor muscle training (PFMT) for appropriately selected spinal cord injury patients, particularly those with incomplete motor lesions (AIS C or D), as this intervention can improve pelvic floor strength, reduce neurogenic detrusor overactivity, and decrease incontinence episodes. 1

However, PFMT is not the primary bladder management strategy for most SCI patients—intermittent catheterization combined with anticholinergic medications remains the foundation of care. 1, 2, 3

Patient Selection Criteria for PFMT

Physiotherapists should focus PFMT interventions on:

• Patients with incomplete motor spinal cord injuries (AIS C or D classifications) who retain some voluntary pelvic floor muscle control 4
• Patients with neurogenic detrusor overactivity causing reflex incontinence 4, 5
• Women with incomplete SCI and stress or mixed urinary incontinence 6

Critical caveat: PFMT is contraindicated or ineffective in patients with complete spinal cord injuries who lack voluntary pelvic floor muscle control. 4

Specific PFMT Protocol

Initial Assessment and Training

• Conduct vaginal palpation or anal canal pressure measurements to objectively assess baseline pelvic floor muscle strength and endurance 4, 6
• Use electromyography biofeedback during initial training sessions to help patients identify and isolate pelvic floor muscle contractions 6
• Apply the modified Oxford grading system for subjective strength assessment 4

Treatment Duration and Frequency

• Implement a minimum 6-week program of regular PFMT, with evidence supporting up to 12 weeks for optimal results 4, 6
• Schedule supervised physiotherapy sessions at least weekly during the initial training phase 6
• Prescribe daily home exercises between supervised sessions 6

Expected Outcomes

• Strength and endurance improvements exceeding 100% are achievable in selected patients after 6 weeks 4
• Reduction in neurogenic detrusor overactivity can be measured urodynamically, with some patients achieving near-complete voluntary suppression of bladder contractions 4
• Decreased incontinence episodes measured by ICIQ-UI-SF scores, with reductions of approximately 2.4 points possible 6

Adjunctive Electrical Stimulation

Do not routinely add intravaginal electrical stimulation (IVES) to PFMT, as the combination is not superior to PFMT alone for reducing urinary incontinence in women with incomplete SCI. 6

However, consider percutaneous pelvic floor electrical stimulation with implantable electrodes for patients with reflex incontinence from overactive bladder who fail conservative PFMT, as this can increase volume at first unstable contraction and may abolish incontinence in selected cases. 5

Integration with Primary Bladder Management

Physiotherapists must coordinate PFMT with the patient's primary bladder management strategy:

Intermittent Catheterization Education

• Teach proper hand hygiene using antibacterial soap or alcohol-based cleaners before and after catheter insertion 3
• Educate on clean catheterization technique as standard practice 3
• Emphasize single-use catheter protocols, as reuse increases UTI frequency 3
• Instruct on maintaining catheterization schedule every 4-6 hours, keeping urine volume below 500 mL per collection 3

Hydration Counseling

• Recommend fluid intake of 2-3 L per day unless contraindicated, to prevent UTIs and maintain adequate bladder function 1, 3
• Discourage voluntary dehydration to reduce catheterization frequency, as this increases UTI risk 1

UTI Prevention Education

• Educate on signs and symptoms of symptomatic UTI (fever, increased spasticity, autonomic dysreflexia, cloudy/foul-smelling urine with symptoms) 1
• Clarify that asymptomatic bacteriuria is common and does not require treatment 2, 3
• Teach proper perineal cleaning techniques before catheterization 1

Common Pitfalls to Avoid

• Attempting PFMT in patients with complete SCI who lack voluntary motor control—this wastes time and resources without benefit 4
• Relying solely on PFMT without addressing primary bladder management through intermittent catheterization and medications 1, 7
• Adding IVES routinely to PFMT without evidence of superior efficacy 6
• Treating asymptomatic bacteriuria based on urine appearance or dipstick results alone, which promotes antimicrobial resistance 2, 3
• Inadequate training duration—programs shorter than 6 weeks are unlikely to produce meaningful results 4, 6
• Failing to use objective measures (palpation, pressure measurements, EMG biofeedback) to verify proper muscle contraction technique 4, 6

Monitoring and Reassessment

• Reassess pelvic floor muscle strength objectively at 6 and 12 weeks using the same measurement tools employed at baseline 4, 6
• Track incontinence episodes using validated questionnaires (ICIQ-UI-SF) and bladder diaries 6
• Consider urodynamic testing before and after PFMT in patients with neurogenic detrusor overactivity to objectively measure changes in bladder pressure during overactivity 4
• Refer patients who fail conservative PFMT after 12 weeks to urology for consideration of more invasive interventions (botulinum toxin injection, neuromodulation, surgical options) 1, 7