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Comprehensive Assessment & Physiotherapy Management

Case Study: 4-Week Postnatal Woman with Urinary Incontinence, Low Back Pain & Postpartum Depression

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CASE PROFILE

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PART 1: UNDERSTANDING THE CONDITIONS

1.1 Urinary Incontinence (UI) Postpartum

• Pelvic floor muscle (PFM) weakness from labour/delivery trauma
• Pudendal nerve stretch injury
• Levator ani muscle avulsion or overstretch
• Urethral sphincter incompetence
• Intra-abdominal pressure dysregulation

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1.2 Low Back Pain (LBP) Postpartum

• Pelvic girdle pain (PGP) — sacroiliac joint laxity from relaxin
• Lumbar instability — weakened transversus abdominis and multifidus
• Postural strain — feeding postures, carrying, sleep deprivation
• Diastasis recti abdominis (DRA) — linea alba separation reducing core stability
• Coccyx injury from parturition

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1.3 Postpartum Depression (PPD)

• Affects 10–15% of postnatal women
• Onset: within 4 weeks to 1 year postdelivery (most common: weeks 2–8)
• Relevance to physiotherapy: PPD affects motivation, compliance, pain perception, functional activity, infant bonding, and breastfeeding — all directly impacting rehab outcomes
• Physiotherapists are NOT primary managers of PPD but play a role in screening, referral, and incorporating psychological sensitivity into management

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PART 2: PHYSIOTHERAPY ASSESSMENT

2.1 Subjective Assessment (History Taking)

A. Patient Profile

• Age, parity (G/P), BMI
• Mode of delivery (vaginal / instrumental / caesarean section)
• Perineal trauma: episiotomy, degree of tear (1st–4th degree), repair status
• Duration and intensity of labour
• Birth weight of baby (macrosomia → increased pelvic floor stretch)
• Breastfeeding status (affects oestrogen, vaginal/pelvic tissue health)

B. UI-Specific History

• International Consultation on Incontinence Questionnaire – Urinary Incontinence Short Form (ICIQ-UI SF) — Gold standard
• Bladder diary (3-day voiding diary): records fluid intake, voiding times, leakage episodes, urgency scores, pad weights
• Pelvic Floor Distress Inventory (PFDI-20)
• Urogenital Distress Inventory (UDI-6)

C. Low Back Pain History

• Location: lumbar / sacroiliac / coccyx / buttock radiation
• Onset: during pregnancy or post-delivery?
• Aggravating factors: walking, sitting to standing, stairs, lifting baby, feeding posture
• Relieving factors: rest, support belt
• Posterior Pelvic Pain Provocation (P4 test) history
• Neurological symptoms: leg weakness, foot drop, saddle anaesthesia (red flags)

• Cauda equina syndrome (urinary/bowel retention or incontinence + bilateral leg weakness)
• Vertebral fracture
• Spinal infection / malignancy

D. Postpartum Depression Screening

• 10-item self-report questionnaire
• Score ≥ 10: possible PPD — refer to GP/obstetrician/mental health
• Score ≥ 13: likely PPD
• Question 10 (suicidal ideation) is always actioned immediately regardless of total score

• PHQ-9 (Patient Health Questionnaire-9)
• Clinical observation: flat affect, poor eye contact, tearfulness, disengagement

Important: Physiotherapists screen and refer — they do NOT diagnose or manage PPD independently. Any positive screen must trigger same-day referral to the GP, midwife, or obstetrician.

E. Functional and Activity Assessment

• Daily activities: infant care, feeding positions, lifting, housework
• Sleep pattern and duration (fragmented sleep worsens pain and depression)
• Social support system
• Return to work plans
• Exercise history (pre- and post-partum)

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2.2 Objective Assessment

A. Observation

• Posture: increased lumbar lordosis, forward head posture, rounded shoulders (feeding posture)
• Abdominal contour: assess for diastasis recti abdominis (DRA) visually
• Gait: antalgic gait, Trendelenburg sign (gluteal weakness)
• Perineum: visible prolapse, perineal scarring (episiotomy/tear)

B. Diastasis Recti Abdominis (DRA) Assessment

• Finger-width test: patient supine, partial curl-up — palpate linea alba at umbilicus
  • Normal: < 2 finger-widths (< 2 cm)
  • DRA: ≥ 2 finger-widths with poor tension/depth
• Real-time ultrasound (RTUS): gold standard for inter-recti distance measurement

DRA is critical because it directly reduces core stability and contributes to both LBP and UI through poor intra-abdominal pressure management.

C. Lumbar Spine & Pelvic Girdle Assessment

D. Pelvic Floor Muscle (PFM) Assessment

• Perineal inspection: scarring, prolapse (Pelvic Organ Prolapse Quantification — POP-Q staging), redness
• Perineal body integrity
• Anal wink reflex (S2–S4 integrity)

According to Management of Pregnancy (p. 40), pelvic floor muscle function examination with single-digit vaginal palpation for muscle activation confirmation and objective strength tests vaginally and rectally with a manometer device are standard components of postpartum assessment.

• Surface EMG biofeedback: objective measure of PFM recruitment and endurance
• Real-time ultrasound (RTUS): visualises bladder base descent and PFM contraction

E. Bladder Function Assessment

• Post-void residual (PVR) via bladder scan: normal < 50 ml; > 150 ml = clinically significant retention
• Pad test (1-hour or 24-hour): quantifies leakage volume
  • 1-hour pad test: < 1 g = continent; 1–10 g = mild; 10–50 g = moderate; > 50 g = severe

F. Psychological Assessment Integration

• Observe for signs of PPD during assessment: crying, hopelessness, difficulty concentrating
• Administer EPDS as part of routine postnatal assessment
• Note pain catastrophising using Pain Catastrophising Scale (PCS) (links PPD and pain)
• Assess self-efficacy and motivation for exercise

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PART 3: PHYSIOTHERAPY MANAGEMENT

3.1 Multidisciplinary Coordination (Priority at Week 4)

The physiotherapist must first acknowledge the PPD, adopt a compassionate, empathetic communication style, ensure the patient feels heard, and then integrate a gentle, achievable rehab plan that does not overwhelm a depressed new mother.

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3.2 Goals of Physiotherapy Management

• Educate patient on pelvic floor anatomy, bladder and bowel habits
• Improve PFM awareness and voluntary contraction ability
• Reduce urinary leakage episodes
• Begin core stability rehabilitation
• Reduce LBP and improve functional movement

• Achieve continence or significant reduction in leakage
• Full return to functional activities including exercise
• Restore lumbopelvic stability
• Support overall postnatal recovery alongside PPD management team

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3.3 Management of Urinary Incontinence

A. Education (Session 1 — Foundation)

• Anatomy of the pelvic floor, bladder and urethra
• Bladder training principles: normal voiding frequency (every 3–4 hours), urgency suppression strategies
• Bladder diary education: self-monitoring tool
• Fluid intake advice:
  • Target: 1.5–2 litres/day of water
  • Reduce/eliminate bladder irritants: caffeine, alcohol, carbonated drinks, citrus
• Avoid straining at stool (increased pelvic floor loading)
• Correct technique: no "just-in-case" voiding (worsens urgency and reduces bladder capacity)

B. Pelvic Floor Muscle Training (PFMT) — Core Treatment

1. Patient position: supine with knees bent (gravity-eliminated position first)
2. Instruction: "Imagine you are stopping the flow of urine AND stopping passing wind at the same time — squeeze and lift inward and upward"
3. Confirm contraction via vaginal palpation (no gluteal, adductor, or abdominal substitution)
4. Progress to sitting, then standing positions

Per Management of Pregnancy (p. 40): individualized physiotherapist-guided PFMT with biofeedback consisting of 12 weekly sessions significantly reduced urinary incontinence and related bother and increased pelvic floor muscle strength and endurance at 6 months postpartum.

• Patient taught to consciously contract PFM before and during activities that trigger leakage
• Anticipatory contraction before: cough, sneeze, lifting baby, standing up
• Reduces SUI immediately and builds habitual motor pattern

C. Bladder Training (for Urge UI component)

1. "Freeze, don't rush" — stop all movement when urge hits
2. Perform 5 rapid PFM contractions (inhibits detrusor via the guarding reflex)
3. Distract attention from bladder: mental arithmetic, toe curling
4. Walk calmly to the toilet once urge subsides
5. Gradually extend voiding intervals by 15–30 minutes per week (target: every 3–4 hours)

D. Biofeedback Therapy

• Surface EMG biofeedback: real-time visual feedback of PFM activity
• Helps patients with poor PFM awareness (very common postpartum)
• Improves motor learning and contraction coordination
• Can be used with home device programs between sessions

E. Electrical Stimulation (if PFM Grade 0–1 on Oxford scale)

• Neuromuscular Electrical Stimulation (NMES): Passive stimulation of PFM via vaginal probe at 35–50 Hz
• Indicated when patient cannot voluntarily contract PFM
• Improves afferent awareness, re-educates motor pattern
• Used until voluntary contraction achievable, then progressed to active PFMT

F. Functional Rehabilitation and Core Integration

• PFMT is NOT isolated — it must be integrated with core stability (see LBP management below)
• Transversus abdominis activation and PFM co-contraction (the core canister concept)
• Gradual return to aerobic activity: walking programme first, then swimming (avoid high-impact initially)

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3.4 Management of Low Back Pain (Postpartum)

A. Education and Postural Correction

• Feeding posture: lumbar support while breastfeeding, arm supported, baby at breast height (pillow support)
• Lifting technique: squat lift with neutral spine when picking up baby
• Sleep positioning: side-lying with pillow between knees
• Pelvic belt / sacroiliac support belt: indicated for PGP — provides external proprioceptive support during acute phase (use symptom-guided, not continuously)

B. Core Stability Rehabilitation (Lumbopelvic Programme)

C. Manual Therapy (if appropriate at 4 weeks)

• Gentle joint mobilisation of lumbar spine (Grade I–II Maitland) for pain relief
• Sacroiliac joint mobilisation if PGP confirmed
• Soft tissue release: lumbar paraspinals, piriformis, iliopsoas (shortened from posture)
• Scar tissue mobilisation: episiotomy/perineal scar (only after scar is well-healed, typically 6–8 weeks — check at 4 weeks, usually not yet ready for deep work)

D. Hydrotherapy (from 6 weeks once lochia stopped)

• Warm water reduces pain, supports joints, allows movement in gravity-reduced environment
• Gentle lumbopelvic exercises in pool

E. Acupuncture / Dry Needling (Adjunct)

• For myofascial trigger points in lumbar paraspinals, gluteals, piriformis
• Evidence supporting its use for LBP in postpartum women

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3.5 Management Integrating Postpartum Depression

A. Communication Principles

• Use trauma-informed, compassionate care approach
• Validate the patient's experience: "What you are feeling is a real medical condition, and it is not your fault."
• Set realistic, achievable goals — avoid overwhelming the patient with large home programmes
• Regular positive reinforcement for any progress
• Ask about her support system, sleep, infant feeding challenges

B. Exercise as Adjunct for PPD

• Aerobic exercise (walking): 20–30 minutes, 3–5 days/week
  • Raises serotonin and endorphin levels
  • Provides structured daily activity and social connection
• Group exercise classes: mother-and-baby yoga/Pilates — social connection reduces isolation
• Mind-body exercise: yoga and mindfulness-based movement reduce anxiety and depressive symptoms

C. Goal Setting in the Context of PPD

• Keep home exercises to a maximum of 2–3 exercises initially — do not overwhelm
• Use a simple written programme with diagrams (cognitive symptoms of PPD impair memory)
• Progress slowly and celebrate small wins
• Address sleep hygiene and infant care ergonomics as part of treatment (reduce physical load and fatigue)

D. Referral Pathway for PPD

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PART 4: INTEGRATED TREATMENT PROGRAMME (4-WEEK CASE)

Week-by-Week Physiotherapy Plan

Week 1 (Patient is at 4 weeks postpartum — INITIAL SESSION)

Week 2 (Patient at 5 weeks postpartum)

Week 3 (Patient at 6 weeks postpartum)

Week 4 (Patient at 7 weeks postpartum — REASSESSMENT)

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PART 5: OUTCOME MEASURES

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PART 6: PRECAUTIONS & CONTRAINDICATIONS AT 4 WEEKS POSTPARTUM

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SUMMARY TABLE: Physiotherapy Management at a Glance

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URINARY INCONTINENCE (UI)

Detailed Assessment & Physiotherapy Management

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SECTION 1: DEFINITION & OVERVIEW

• Affects approximately 25–45% of women at some point in their lifetime
• Prevalence increases with age, parity, and obesity
• Highly underreported due to social stigma
• Postpartum period is a critical window — prevalence peaks at 30–40% in postnatal women

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SECTION 2: ANATOMY RELEVANT TO URINARY CONTINENCE

2.1 The Pelvic Floor — Structural Layers

• Deep transverse perineal muscle
• External urethral sphincter (EUS)

• Bulbospongiosus, ischiocavernosus, superficial transverse perineal muscles

2.2 Urethral Continence Mechanism

1. Urethral closure pressure > bladder pressure at all times
2. Hammock hypothesis (DeLancey): urethral compression against the anterior vaginal wall and endopelvic fascia during increases in intra-abdominal pressure
3. Intact pudendal nerve (S2, S3, S4): controls external urethral sphincter
4. Detrusor muscle stability: no uninhibited contractions during filling phase

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SECTION 3: CLASSIFICATION OF URINARY INCONTINENCE

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SECTION 4: PHYSIOTHERAPY ASSESSMENT

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4.1 SUBJECTIVE ASSESSMENT (History Taking)

A. Patient Demographics and Obstetric History

• Age, height, weight, BMI
• Gravida / Para (G_P_)
• Mode of delivery: spontaneous vaginal delivery (SVD), instrumental (forceps/ventouse), caesarean section (LSCS)
• Perineal trauma:
  • 1st degree: skin only
  • 2nd degree: skin + perineal body muscles
  • 3rd degree: involves anal sphincter (3a, 3b, 3c)
  • 4th degree: extends to rectal mucosa
• Episiotomy: mediolateral or midline
• Duration of second stage of labour
• Birth weight of baby
• Epidural anaesthesia (risk of transient bladder dysfunction)
• Breastfeeding status (hypoestrogenic state → vaginal and urethral atrophy)

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B. Urinary Incontinence-Specific History

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C. Validated Self-Report Questionnaires

1. ICIQ-UI SF (International Consultation on Incontinence Questionnaire — Urinary Incontinence Short Form)

• Gold standard for UI severity and impact
• 3 scored questions + 1 diagnostic question:
  • How often do you leak urine?
  • How much urine do you usually leak?
  • Overall how much does leaking urine interfere with everyday life? (0–10 scale)
• Total score: 0–21

2. Bladder Diary (3-Day Voiding Diary)

• Daytime voids: 6–8 per day
• Nocturia: 0–1
• Functional bladder capacity: 300–500 ml
• First sensation to void: ~150–250 ml
• Maximum cystometric capacity: ~400–600 ml

3. Other Validated Tools

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D. Medical and Medication History

• Previous pelvic/abdominal surgery (colposuspension, hysterectomy, bladder surgery)
• Neurological conditions (multiple sclerosis, Parkinson's, stroke, spinal cord injury)
• Diabetes mellitus (diabetic cystopathy → overflow UI)
• Recurrent UTIs
• Pelvic organ prolapse history
• Current medications that may cause/worsen UI:

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4.2 OBJECTIVE ASSESSMENT

A. General Observation

• Body habitus: BMI (obesity significantly increases intra-abdominal pressure)
• Posture: increased lumbar lordosis → altered PFM resting position; forward head posture
• Gait: observe for pelvic drop (gluteal weakness), guarding, antalgic patterns
• Abdominal wall: visible separation at linea alba (diastasis recti), abdominal doming on exertion

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B. Abdominal Assessment

• Assessed in supine, partial curl-up position
• Palpate linea alba above, at, and below umbilicus
• Measure inter-recti distance (IRD) in finger widths or with callipers/ultrasound
• Normal: < 2 finger widths (< 2 cm)
• DRA: ≥ 2 finger widths with palpable depth/poor tension
• Clinical significance: DRA impairs intra-abdominal pressure regulation, worsens both UI and LBP

• Suprapubic tenderness (full bladder, cystitis)
• Uterine size at 4 weeks postpartum (should be involuting — non-palpable abdominally by 6 weeks)

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C. Perineal and Vulval Inspection (External)

• Standardised system using anatomical reference points (Aa, Ba, C, D, Ap, Bp, genital hiatus, perineal body, total vaginal length)
• Stage 0 = no prolapse; Stage IV = complete eversion

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D. Pelvic Floor Muscle (PFM) Assessment — Internal Vaginal Examination

This is performed only with full informed written/verbal consent, adequate explanation, and in a private, comfortable environment.

• Gloved, lubricated index finger inserted to second knuckle depth
• Assess: anterior and posterior vaginal walls, pubococcygeus bilaterally

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1. Modified Oxford Grading Scale (MOGS) — PFM Strength

2. PERFECT Scheme — Comprehensive PFM Assessment Tool

3. Resting Tone Assessment

• Hypertonia (overactive PFM): tight, tender on palpation; poor ability to relax; associated with pelvic pain, dyspareunia, urge symptoms
• Hypotonia (underactive PFM): no resting tone; poor contraction; associated with SUI and prolapse
• Both conditions can coexist postpartum

4. Objective Instrumented Assessment of PFM

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E. Bladder Function Tests

1. Pad Test — Quantifies Urine Loss

• Wear pre-weighed pad; drink 500 ml water; wait 30 min
• Perform: 20 min walking, 10 stair climbs, sit/stand × 10, cough × 10, running 1 min, bend to pick up object × 5, wash hands in running water 1 min
• Weigh pad at end

2. Post-Void Residual (PVR)

• Measured via bladder ultrasound scan immediately after voiding
• Normal: < 50 ml
• Clinically significant: > 150 ml
• PVR > 150 ml suggests voiding dysfunction / overflow UI → requires specialist referral

3. Cough Stress Test

• Patient with comfortably full bladder in standing or supine
• Asked to cough vigorously × 3
• Positive test: immediate simultaneous urine leakage at moment of cough = SUI confirmed
• Delayed leakage after cough = suggests UUI/detrusor response

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F. Neurological Assessment

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G. Functional Assessment

• Active Straight Leg Raise (ASLR): tests lumbopelvic load transfer; positive in pelvic girdle dysfunction
• Functional tasks observation: lifting baby, sit-to-stand, walking up stairs — identify leakage triggers
• Posture analysis: effect of thoracopelvic alignment on PFM function
• Breathing pattern: assess for breath-holding and Valsalva during lifting (increases abdominal pressure and worsens SUI)

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H. RED FLAGS — Require Immediate Referral

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SECTION 5: PHYSIOTHERAPY MANAGEMENT OF URINARY INCONTINENCE

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5.1 Education — The Foundation of All Treatment

A. Bladder Anatomy and Function Education

• Explain normal bladder filling, the urge sensation, and normal voiding
• Diagram/model of the pelvic floor anatomy
• Explain the concept of "a leaky tap vs. a strong tap" — simple analogies
• Explain why the pelvic floor weakened during pregnancy and delivery
• Normalise the condition — reassure that UI is common but not normal and is treatable

B. Lifestyle Modification Advice

Fluid Management:

Bowel Management:

• Constipation is a major aggravating factor for UI — straining raises intra-abdominal pressure chronically, weakens pelvic floor
• High fibre diet, adequate hydration, respond to defecatory urge promptly
• Correct toilet posture: feet elevated on footstool (Squatty Potty position) — reduces straining significantly
• Avoid prolonged sitting on the toilet

Weight Management:

• Each unit increase in BMI increases UI risk by ~8–10%
• Even a 5–10% reduction in body weight significantly reduces UI episodes in overweight women
• Physiotherapist provides appropriate advice and refers to dietitian if needed

Smoking Cessation:

• Chronic cough from smoking is a persistent SUI trigger
• Refer to smoking cessation services

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5.2 Pelvic Floor Muscle Training (PFMT)

Step 1 — Teaching Correct PFM Contraction

1. Anatomy education: show diagram of pelvic floor, explain which muscles to contract
2. Verbal cue: "Imagine you are trying to stop passing wind AND stop the flow of urine at the same time — squeeze and lift inward and upward"
3. Confirm activation via vaginal palpation — feel for squeeze and cranial lift
4. Rule out substitution: patient must NOT:
   • Tighten gluteals (buttock squeeze)
   • Adduct thighs (squeeze legs together)
   • Hold breath / Valsalva
   • Suck in entire abdomen with force
5. Teach correct gentle co-activation of lower transversus abdominis with PFM contraction

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Step 2 — PFMT Exercise Programme

Type 1 Fibres — Slow-Twitch (Endurance, Resting Tone): Sustained Hold Exercises

Type 2 Fibres — Fast-Twitch (Power, Reaction): Quick Flick Exercises

PFMT Programme Progression Table:

Key Principles of PFMT Prescription:

1. Quality over quantity — a correctly performed contraction is better than 100 incorrect ones
2. Full relaxation after each contraction is as important as the contraction itself
3. Gradual overload — progressive increase in hold time, reps, and position challenge
4. Maintenance programme — once goals achieved, maintenance of 1–2 sets/day prevents relapse
5. Minimum treatment duration: 12 weeks for clinically significant improvement

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Step 3 — The Knack Manoeuvre (Pre-Contraction / Anticipatory Strategy)

• "Just before you cough, sneeze, laugh, stand up, or lift — quickly squeeze your pelvic floor as if stopping urine flow"
• The contraction must precede the increase in intra-abdominal pressure
• With practice it becomes automatic (habitual)

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5.3 Bladder Training (Primarily for UUI / OAB)

Principles:

• The sensation of urgency is a learned response that can be modified
• Goal: gradually increase the interval between voids and re-establish normal bladder capacity (300–500 ml)

Urgency Suppression Techniques:

Bladder Retraining Schedule:

1. Establish baseline voiding interval from bladder diary (e.g., voiding every 60 min)
2. Increase interval by 15–30 minutes every 1–2 weeks
3. Target: voiding every 3–4 hours during the day
4. Advise against just-in-case voiding — this reduces bladder capacity and worsens urgency
5. Continue for minimum 6–8 weeks

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5.4 Biofeedback Therapy

Types:

Benefits:

• Reduces learning time for correct PFM contraction
• Identifies compensatory muscles (gluteals, adductors)
• Provides objective progress monitoring
• Highly motivating — patient sees real-time improvement
• Identifies poor relaxation (hypertonic PFM)

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5.5 Electrical Stimulation

Types:

1. Neuromuscular Electrical Stimulation (NMES) — For SUI

2. Interferential Therapy (IFT) — For UUI / Detrusor Overactivity

3. Transcutaneous Tibial Nerve Stimulation (TTNS)

• Electrodes placed at medial ankle (posterior tibial nerve — S3 level)
• 12-week protocol: weekly 30-minute sessions
• Inhibits detrusor overactivity via sacral nerve modulation
• Non-invasive, well-tolerated
• Evidence: significant reduction in urgency and urge incontinence frequency

4. Percutaneous Tibial Nerve Stimulation (PTNS)

• Needle electrode near tibial nerve
• Higher intensity modulation for refractory OAB
• Delivered in specialist clinics

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5.6 Core Stability and Functional Rehabilitation

The Core Canister:

Core Integration Exercises:

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5.7 Postural Re-education

• Anterior pelvic tilt (hyperlordosis): shortens PFM, reduces PFM endurance
• Posterior pelvic tilt (flat back): lengthens PFM, reduces activation efficiency
• Optimal: neutral pelvis — best resting position for PFM activation

• Neutral lumbar spine awareness (supine → sitting → standing)
• Thoracic extension exercises (corrects rounded shoulder feeding posture)
• Hip flexor stretching (tightened from prolonged sitting/feeding)
• Gluteal strengthening (hip extension, abduction)

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5.8 Return to Exercise / Activity Progression

Return-to-Running Guidelines (Based on Groom, Donnelly & Brockwell, 2019):

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5.9 Manual Therapy Techniques

A. Perineal Scar Massage (after 6–8 weeks once healed)

• Episiotomy or tear scars can cause restricted tissue mobility, altered sensation, pain, and secondary pelvic floor dysfunction
• Technique: gentle circular and longitudinal scar mobilisation with small amount of oil
• Patient taught self-massage at home
• Improves tissue pliability, reduces dyspareunia, restores normal tissue mechanics

B. Internal Soft Tissue Techniques (Specialist — for Hypertonic PFM)

• If resting PFM tone is high (hypertonia) → paradoxical difficulty contracting effectively
• Intravaginal soft tissue release of tight levator ani muscles
• Trigger point release of puborectalis and obturator internus
• Stretching and lengthening hypertonic PFM before strengthening

C. Visceral Mobilisation (if bladder ptosis/descent noted)

• Gentle bladder repositioning techniques
• Specialist women's health physiotherapy skill

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5.10 Technology-Assisted and Home-Based Interventions

Pelvic Floor Muscle Training Apps:

• Squeezy (NHS recommended app — UK)
• Kegel Trainer apps
• Provide reminders, timed contractions, and progress tracking

Home Biofeedback Devices:

• Elvie, Perifit — vaginal devices with smartphone feedback
• Allow home practice with real-time guidance
• Useful for motivated patients between clinic sessions

Vaginal Cones / Weighted Vaginal Trainers:

• Conical weights inserted vaginally; patient must contract PFM to retain
• Provides resistance training stimulus for PFM
• Effective for improving strength in women with Oxford Grade ≥ 2
• Not indicated for Grade 0–1 (cannot retain the cone)

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SECTION 6: OUTCOME MEASURES AND REASSESSMENT

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SECTION 7: CRITERIA FOR SPECIALIST REFERRAL

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SECTION 8: SUMMARY ALGORITHM — PHYSIOTHERAPY MANAGEMENT OF UI

URINARY INCONTINENCE CONFIRMED
            ↓
RULE OUT RED FLAGS (haematuria, CES, fistula, PVR > 300)
            ↓
CLASSIFY TYPE (SUI / UUI / MUI / Overflow)
            ↓
FULL SUBJECTIVE + OBJECTIVE ASSESSMENT
(ICIQ-UI SF, Bladder Diary, Oxford PFM Grade, Pad Test, PVR)
            ↓
EDUCATION
(Bladder anatomy, fluid management, bowel habits, lifestyle)
            ↓
      ┌─────────────────────────┐
      ↓                         ↓
   SUI / MUI                   UUI / OAB
      ↓                         ↓
  PFMT + Knack              Bladder Training +
 Core Stability             Urgency Suppression +
 Biofeedback                PFMT (Type 2 fibres)
                            TTNS / IFT
      ↓                         ↓
      └─────────────────────────┘
            ↓
  UNABLE TO CONTRACT (Oxford 0–1)?
            ↓
      Add NMES → then progress to active PFMT
            ↓
  12-WEEK SUPERVISED PROGRAMME
            ↓
  REASSESS with ICIQ-UI SF, Pad Test, PFM Grade
            ↓
  IMPROVED → Maintenance + Return to Activity
  NOT IMPROVED → Refer Urogynaecologist

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SECTION 9: EVIDENCE SUMMARY

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