Osteoporosis: It’s not just the bones that need conditioning!
Osteoporosis and incontinence
Let’s start by putting the uncomfortable truth out there – menopausal women with osteoporosis are at a higher risk of incontinence compared to menopausal women with healthy bones. The upside of this message is that the risk can be addressed with little effort and input.
A study led by Dr Dumoulin and colleagues , published in the Journal of the North American Menopausal Society, found that pelvic floor muscle exercises produced dramatic improvements. Forty-six volunteers were recruited for the study; all the women were menopausal, had osteoporosis, and were affected by stress, urge incontinence, or both. Half received 12 weekly physical therapy classes that incorporated pelvic floor muscle exercises, while the remainder were counselled on diet and medications that would improve their bone density. This group was also advised on the value of physical activity but was not given physical therapy classes.
At the end of 12 weeks, the women in the physical therapy group had a 75% reduction in leakage episodes. There was no change in the other group. Furthermore, one year later, the women in the physical therapy group maintained or improved their leakage rates, while the other group’s incontinence stayed the same or worsened.
This study was the first to use robust research methodology to evaluate the use of pelvic floor muscle training for women with osteoporosis and either stress or urge incontinence. Dr Dumoulin said, “The main message for women who have osteoporosis is they should do pelvic floor exercises even if they don’t have incontinence because fractures of the lumbar spine cause them to slump, and that puts more pressure on the pelvic floor,”
For women and men diagnosed with osteoporosis and arthritis, it is recommended to participate in regular exercise programs, including increased weight bearing and impact exercises to strengthen the load-bearing muscles and the “core”. This increased load is good for bone strengthening and muscle building but can potentially increase intra-abdominal pressure (IAP) and internal pressure down on the pelvic floor.
The pelvic floor muscles are the “hidden” internal muscles that support the bladder, uterus, and bowel in women and the bladder and bowel in men. The pelvic floor muscles form the base of your “core” and work alongside your lower abdominal muscles (Transversus Abdominals) to support the spine and control changes in intraabdominal pressure.
This group of muscles regulates the pressure inside the abdomen during everyday tasks such as coughing, lifting, and during exercise. However, if any of the muscles within the “core” are not working optimally, this regulation system becomes imbalanced, and the pelvic floor muscles can be overloaded and weakened.
Situations that can cause these muscles to become weakened include:
- Pregnancy and childbirth
- Gynaecological or prostate surgery
- Constipation and straining to use the bowels
- Recurrent coughing
- Being overweight/obese
- General exercise performance, i.e., high impact, weight loaded exercise or incorrect “core bracing”
- Incorrect postural tension, such as hunching over or bracing your abdomen
- Lifestyle habits around poor fluids and toileting habits
If the pelvic floor and abdominal muscles are not functioning optimally, it may result in problems such as incontinence, difficulty emptying the bladder or bowel, pelvic organ prolapse in women, sexual difficulties in men and women, and/or pelvic pain.
Additional factors in women with aging are the changing levels of hormones during perimenopause and menopause, which have been shown to affect the pelvic support tissues.
Reduced oestrogen results in thinning of the lining of the vagina and urethra and can result in increased urinary tract infections and incontinence; it may also result in vaginal dryness and pain during sexual intercourse. Additional factors for men with aging include prostate problems such as prostate enlargement or prostate cancer, which may result in difficulties with urine flow and bladder control.
Pelvic floor problems are more common with aging.
- Urinary incontinence affects 30% of women and 10% of men,
- Bowel incontinence affects 3-10% of women and men,
- Constipation affects 30% of women and men
- Pelvic organ prolapse affects 30-50% of women
Only 25% of people with incontinence have discussed their problem with a health care provider. However, pelvic floor problems can be distressing and embarrassing. They can make people withdraw from many aspects of life, including exercise, social engagements, holidays, or even playing with children and grandchildren.
The International Continence Society recommends pelvic floor muscle training as the first- line treatment for women and men with incontinence and pelvic pain. Physiotherapist-led programs are more effective than self-directed programs. The pelvic floor muscles can be hard to identify inside the body, and up to 40% of women perform pelvic floor exercises incorrectly , which can worsen their problem.
Physiotherapists with additional Post Graduate training in Continence and Pelvic Health can assess the pelvic floor muscles using real-time ultrasound biofeedback or directly evaluate the pelvic floor muscles via palpation.
At The Pelvic Health Clinic at Body Logic Physiotherapy, we believe in individualised and holistic treatment. We aim to work closely with you to determine the best management plan for you and your life and to empower you to reach your health goals.
Exercise, particularly impact and strength training, is recommended in OP; however, it is also being identified here as a potential contributing factor in incontinence.
About the author:
Judith is a specialist pelvic health physiotherapist at The Pelvic Health Clinic, Body Logic Physiotherapy, Subiaco and Alfred Cove.