URINARY FUNCTION AND
DYSFUNCTION
D r . Yu m n a I l y a s
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INTRODUCTION
The term ‘continence’ is used to describe
the normal ability of a person to store urine and faeces temporarily, with
conscious control over the time and place of micturition and defecation.
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⚫ ‘Incontinence’ has been defined as
the involuntary or inappropriate passing of urine or faeces, or both,
that has an impact on social functioning or hygiene.
⚫ It may be a temporary state associated with a transient cause (e.g. transient
unconsciousness, infection, or drug side-effects), or it may be persistent
resulting from longer-lasting or even permanent causes (e.g. trauma in
childbirth, stroke)
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• Continence of urine and faeces is fundamental to the sociological,
psychological and physical well-being of an individual.
• Develops in 3-4 years of age
• Fecal incontinence is probably less common than urinary
incontinence
• Repetitive coughing, smoking, frequent constipation, obesity,
repeated heavy lifting and poorly controlled diabetes are just some of
the factors that can lead to continence problems and over which an
individual has some control
• Following childbirth, it is important to regain pre-pregnancy strength
of the pelvic floor muscles
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Patients Master
at risk title
can be style
with:
• hay fever
• asthma, chronic chest conditions
• back problems
• stroke
• multiple sclerosis
• Parkinson’s disease
• Alzheimer’s disease
• hypertension and diabetes
• hip replacement
• the elderly, the obese, those on crutches and those confined to a wheel chair
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LOWERto edit Master title
URINARY style DYSFUNCTION
TRACT
⚫ The ICS divides LUTS into three main groups: storage, voiding and postmicturition
symptoms
⚫ Storage symptoms are experienced during the storage phase (e.g. abnormal bladder
sensations, frequency, urgency and leakage of urine).
⚫ Voiding symptoms are experienced during the voiding phase, and include any
description or deviation from a speedy and continuous flow of urine (e.g. a slow or
intermittent stream, hesitancy at the start of micturition, terminal dribble).
⚫ Postmicturition symptoms are experienced immediately after micturition (e.g. a
feeling of incomplete emptying, and postmicturition dribble).
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THE Master title style CYCLE
MICTURITION
• It consists of two phases: bladder filling
and bladder emptying.
• The elastic ability of the bladder to
accommodate an increasing volume of
fluid without a rise of pressure is called
‘compliance’
• The average daytime tolerable bladder
capacity in women is between 350 and
500 mL
• The first void of the day may be greatest
and may be greater than 500 mL.
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VOIDINGtitle OF
styleURINE
Micturition is normally achieved by voluntary, cortically
mediated relaxation of the external urethral sphincter and
levator ani muscles.
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TERMINOLOGIES
⮚ Enuresis means any involuntary loss of urine.
⮚ Nocturnal enuresis is involuntary loss of urine during sleep.
⮚ Nocturia is the complaint that the individual has to wake at
night one or more times to void.
⮚ Increased daytime frequency (pollakisuria) is the complaint
by patients who consider that they void too often during the
day.
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⮚ Urgency is the complaint of a compelling desire to pass urine which is difficult to defer.
⮚ A normal desire to void is defined as the feeling that leads a person to pass urine at the
next convenient moment, but voiding can be delayed if necessary.
⮚ The urinary voiding stream may be described as slow, spitting or spraying, or intermittent
(i.e. stops and starts).
⮚ Hesitancy describes difficulty in initiating flow.
⮚ Dysuria is pain on passing urine.
⮚ A postvoid residual (PVR) is defined as the volume of urine left in the bladder at the end
of micturition. 1
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COMMON TYPES OF URINARY
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INCONTINENCE
⚫ Loss of urine through channels other than the
urethra is called extraurethral incontinence.
⚫ This may be due to congenital abnormality
(e.g. an aberrant ureter draining into the vault
of the vagina).
⚫ Fistulae between the bladder or urethra and
the vagina are most commonly the result of
trauma at pelvic surgery such as
hysterectomy. 1
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Click to edit MasterINCONTINENCE
STRESS title style
⚫ Loss of urine with increases in abdominal pressure
⚫ Caused by pelvic floor damage/weakness or weak sphincter(s)
⚫ Symptoms include loss of urine with cough, laugh, sneeze, running, lifting,
walking
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MasterINCONTINENCE
title style
⚫ The involuntary loss of large amounts of urine associated
with an abrupt and strong desire to urinate and is often due to
an oversensitive bladder.
⚫ Complaints of urgency, frequency, inability to reach the toilet
in time, up a lot at night to use the toilet
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⚫ Involuntary leakage associated with,
✔ Elder age.
✔ Restricted mobility
✔ Severe constipation
✔ Urinary tract infection
✔ Medication – diuretics, antipsychotics
✔ Psychological/cognitive
Without failure of the bladder's capacity for storage and emptying.
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Other edit Master
Types title style
Of Incontinence
• Detrusor Overactivity incontinence (motor and senory)
• Mixed urinary incontinence is the complaint of involuntary leakage
associated with urgency and also with exertion, effort, sneezing or co
• Urodynamic stress incontinence (USI) denotes the condition in which
there is involuntary loss of urine in the absence of a detrusor contraction or
the intravesical pressure (pressure in the bladder) exceeds the maximum
urethral pressure. Essentially the detrusor activity is normal but the urethral
closure mechanism is incompetent.
• Giggle Incontinence
• Incontinence associated with sexual activity (Honeymoon cystitis’ or
postcoital dysuria)
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URODYNAMICS
⚫ Study of pressure and flow relationships during the storage and transport of
urine within the urinary tract
⚫ Urodynamic tests:
❖ Urine flow rates: Ages 14 to 65; The average flow rate for females is 18 ml/sec.
❖ Cystometry: determines the relationship between the volume of fluid and the
pressure in the bladder, during both filling and voiding
❖ Urethral pressure profilometry
❖ Uroflowmetry: reliable indicator of normal detrusor contraction and urethral
relaxation.
❖ Electrophysiological Test:
✔ Electromyograph
✔ Motor conduction test 1
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VOIDING style
DIFFICULTIES
• Urethral dyssynergia,
which occurs often with multiple sclerosis, is a condition in which the urethral musculature does not relax
when the detrusor contracts for voiding. The result may be chronic urinary retention.
• This situation can arise from neurological damage affecting the pelvic innervation, for example diabetic
neuropathy; some damage may result in detrusor atonia, for example spinal shock, or cauda equina
lesions. Urethral obstruction in women may be caused by faecal impaction or acute infection in the
urethra, or can result from fibrosis following, for example, bladder neck surgery or pelvic irradiation for
carcinoma. Assessment should first be by uroflowmetry to assess the flow rate, if any, and a bladder
scan will give an indication of the volume of urine in the bladder following voiding. Management
consists of removing the cause where possible. Faecal impaction can be relieved and followed by
attention to diet and bowel training. Urethral obstruction due to urethral fibrosis may be improved by
laser treatment or urethral stretching.
• Weak detrusor activity may sometimes be enhanced by drugs such as bethanechol chloride. In
intractable neurological cases, clean intermittent self-catheterisation may be taught, or a suprapubic
catheter implanted.
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Physiotherapy assessment method
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⚫ History of the patient’s condition and detail of present state
⚫ QOL-Q
⚫ Urinalysis
⚫ Frequency/volume chart (bladder diary)
⚫ Perineal and vaginal assessment
⚫ Biofeedback
⚫ Visual Analogue Scale
⚫ Ultrasound
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• PAD TEST
The test approved by the ICS takes 1 hour and comprises the following sequence:
1. The test is started without the patient voiding. 2.
A preweighed absorbent perineal pad is put on and the timing begins. The patient is asked not to void until
the end of the test.
3. The patient drinks 500 mL of sodium-free liquid (e.g. distilled water) within 15 minutes, then sits or
rests to the end of the first half hour.
4. In the following half hour the patient walks around, climbs up and down one flight of stairs, and
performs the following exercises: standing up from sitting (10); coughing vigorously (10); running on
the spot for 1 minute; bending down to pick up a small object (5); washing the hands under cold
running water for 1 minute.
At the end of the hour the pad is removed and weighed; any difference from the starting pad weight
constitutes fluid loss, and this is recorded. If the pad becomes saturated during the test then a second
pad may be used. In this assessment, an increase of up to 1 g is considered normal to allow for possible
sweating and vaginal discharge
• PAPER TOWEL TEST
In standing, the patient holds a coloured paper towel against the perineum and coughs strongly three times. Any
leakage is absorbed by the paper towel, which, where damp, changes colour..
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title style
⚫ Modified Oxford grading system for strength of PFM
contraction;
✔ 0 nil contraction
✔ 1 flicker
✔ 2 weak
✔ 3 moderate
✔ 4 good
✔ 5 strong
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PALPATION
⚫ Palpation of the pelvic floor muscles per the vagina in females and per the
rectum in male patients.
⚫ PERFECT mnemonic assessment:
⚫ P - power, may use the Modified Oxford grading scale
⚫ E - endurance, the time (in seconds) that a maximum contraction can be
sustained
⚫ R - repetition, the number of repetitions of a maximum voluntary contraction
⚫ F - fast contractions, the number of fast (one second) maximum contractions
⚫ ECT - every contraction timed, reminds the therapist to continually overload
the muscle activity for strengthening 2
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Thirteen waysMaster title stylea contraction of the
of confirming
PFM
• vaginal examination by the physiotherapist
• self-examination by the patient
• hand on perineum by the physiotherapist
• hand on perineum by the patient
• observation of perineum by the physiotherapist
• observation of perineum by the patient – using a mirror
• stop and start midstream – only occasionally for suitable patients
• using devices like ‘Educator’
• using a cone in the vagina and applying traction to the string while trying to grip the cone
• asking the partner at intercourse
• manometric and EMG biofeedback
• transperineal or labial ultrasound. 2
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MANAGEMENT/INTERVENTION
⚫ The Knack maneuver:
⚫ The Knack maneuver essentially is a voluntary contraction performed in
response to a specific situation.
⚫ Teach a voluntary contraction of the pelvic floor muscles with appropriate
timing, for example, just prior to a cough or sneeze.
⚫ It is a useful strategy in patients with stress urinary incontinence
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FLOOR title style
MUSCLE TRAINING
⚫ The goal of pelvic floor muscle training is to strengthen weak urinary
sphincter and pelvic floor muscles – the muscles that control urination and
defecation.
⚫ Pelvic floor muscle exercises are often referred to as “Kegel” exercises.
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Master titleRETRAINING
style
⚫ To achieve this the patient must be mentally intact, motivated and able to go
to the toilet independently. It may be used in combination with
pharmacotherapy.
⚫ Teach the patient to contract the pelvic floor to cause detrusor inhibition
⚫ A voluntary contraction of the pelvic floor muscles helps increase pressure
in the urethra, inhibit detrusor contractions, and control urinary leakage.
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BIOFEEDBACK
⚫ It is a technique that provides real-
time information about activity in
the bladder and pelvic muscles to
help you learn to contract PFM
properly.
⚫ Sensors are placed internally and/or
externally within or around the
vagina or rectum.
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⚫ Can be used to attempt to assist patients who seem unable to
produce a VPFMC or have very weak PFM.
⚫ The other use of electrical stimulation is to utilize the sensory
stimulation it causes to inhibit detrusor overactivity and
normalize reflex activity, so this is useful for some patients who
experience urgency and urge incontinence
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FUNCTIONAL ACTIVITY
⚫ It is important for the physiotherapist to determine to what
extent poor balance, joint stiffness or lack of strength and
endurance in muscles other than the pelvic floor may be actually
contributing to the incontinence or aggravating it.
⚫ Functional activities should be part of an integrated treatment
programme.
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DEVICES
⚫ Perineometer- record changes in activity in the
region of the vagina. There are two types, one
recording pressure changes, the other monitoring
electromyographic activity (EMG).
The most commonly used simple perineometer in the UK is the
Peritron .It is designed to record the changes in pressure produced
by voluntary contraction of the PFMs.
⚫ The Educator
⚫ Other Small intravaginal and intraurethral devices have been
produced. Some promote continence by supporting the bladder neck
and others are designed to stop urine loss by blocking the urethra.
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MANOMETRY
• Manometry is
used to measure
bladder pressure
via a Foley
catheter.
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Imaging-Ultrasound
To calculate the
volume of urine in
the bladder and
diagnose any
abnormalities
present
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URODYNAMIC,
RADIOLOGICAL AND
ELECTROMYOGRAPHICAL
ASSESSMENT
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CYSTOMETRY
• This test determines the relationship
between the volume of fluid and the
pressure in the bladder, during both
filling and voiding.
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URETHRAL title style
PRESSURE PROFILOMETRY
• To measure urethral pressure at rest
• Used in the diagnosis of stress urinary incontinence
• The procedure involves passing a very fine tube into
and out of the bladder 2-3 times after local anaesthetic
gel is passed into the urethra
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UROFLOWMETRY
• This device measures the quantity
of fluid passed per unit of time.
• This is quite a reliable indicator
of normal detrusor contraction
and urethral relaxation. The
patient is asked to void, in
private, into a toilet in which a
flow meter has been fitted. It is
important that the patient sits to
void.
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DISTAL URETHRAL ELECTRIC
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CONDUCTANCE
• Distal urethral electrical conductance (DUEC)
has been used to detect the
movement of urine along the distal urethra.
• The accurate detection of leakage of urine is
obtained by inserting a short probe with two ring
electrodes into the distal part of the urethra until
the distal ring is 1.5 cm. Passage of urine past
the electrodes increases conductivity between
them, and this can be recorded electronically
• An alternative to the time consuming and
sometimes inaccurate pad test.
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Click to edit Master title style TESTS
ELECTROPHYSIOLOGICAL
1. Electromyography- Single
fiber density (Single needle
EMG)
The normal FD in the puborectalis and anal
anal sphincter muscles is 1.5.
It is calculated by taking 20 recordings during
mild contraction in various parts of a muscle
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2. Motor conduction tests
• Pudendal nerve terminal motor latency
An intrarectal stimulating and recording device is introduced into the anus
to stimulate the pudendal nerve and record the response of the external anal
sphincter muscle. The latency of the response is measured and recorded on a
graphic printout
• Perineal nerve terminal motor latency
Uses a catheter-mounted recording electrode in the urethra
• Central motor conduction times
Stimulating the motor cortex records a response from the pelvic floor. Eg. patients with
multiple sclerosis have longer cortical conduction times than healthy persons 4
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IMAGING
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OTHER Master title style
TESTS
• Measurement of perineal
descent
Perineal descent is recognized
clinically by ballooning of the
perineum during straining effort.
This is measured using a graduated
latex cylinder held against the anus
• Cystourethroscopy or
cystoscopy
Endoscopic investigation of the
bladder and urethra to look for
pathological lesions
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TREATMENT
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ADDITIONAL title style
TECHNIQUES
• For patients with stress urinary incontinence- If no VPFMC is
possible then biofeedback and electrical stimulation should be
considered
• For patients with stress urinary incontinence- Assuming VPFMC
is possible, patients should be taught deferment techniques such as
‘the knack’, series of repeated strong PFM contractions, distraction,
or perineal pressure, and encouraged to desist from going ‘to the loo
just in case’, to increase the period between voids.
• For patients with mixed symptoms- Combination of VPFMC &
electrical stimulation
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CONTINENCE title style ADVICE
PROMOTING
• An adult should drink 1000–1500 mL per day
• More fluid content in diet
• Restrict caffeine and alcohol intake, as both are diuretics
• No Smoking
• Reduction of weight for obese individuals
• Women should sit, not crouch to void and defaecate.
• Activities/occupations that involve heavy lifting and leisure activities
that result in ballistic movements (e.g. netball, aerobics or weight
training)
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TEACHING PFM CONTRACTIONS
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• Teaching points- Visualization, Language, starting
position, instruction to the patient, duration and
repetition of contractions, changing the starting
positions, Confirmation of a PFM contraction, General
advice/techniques ([Link])
• Number and content of practice sessions
• Reassessment and Progression
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Click to ELECTRICAL
edit Master title STIMULATION
style
• It can be used for two purposes:
o To produce muscle contraction for very weak PFM,
(urodynamic stress incontinence).
o To utilize the sensory stimulation caused by electrical
stimulation to inhibit detrusor overactivity and
nomalise reflex activity(urgency and urge
incontinence)
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Interferential title style
therapy
• Interferential therapy (IT) which
employed medium-frequency currents in
the region of either 4000 Hz (4 kHz) or
2000 Hz (2 kHz) was used extensively
therapeutically in the treatment of urinary
incontinence previously. However, with
the increasing use of biofeedback it has
become less popular, and some experts
have cast doubt on the specificity of the
spread of the current even using a vaginal
electrode.
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Low-frequency titlestimulation
muscle style
There are two main types of equipment used to apply
electrical stimulation in the treatment of urinary
incontinence: computerised clinic-based machines and
small battery-operated devices for home use.
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Computerised title style
clinic-based electrical stimulation
equipment
• Some equipment can be used for both EMG and
electrical stimulation either separately or in
combination.
• The equipment allows for seemingly infinite
permutations, but for stimulating PFM contractions
it is usual to use a 250s pulse duration and a
frequency of 35–40 Hz. The duty cycle is chosen
with great care.
• Where a patient cannot contract, a starting duty
cycle of 2 seconds on and 4 off would be
appropriate, for 5 minutes in the first instance.
Progress will match the patient’s ability to hold
contractions, need less rest and tolerate longer
treatment sessions up to 30 minutes.
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Battery-operated
Click electrical
to edit Master stimulation devices
title style
for clinic-based or home electrical stimulation
• Has options for setting the pulse width,
frequency and duty cycle to those most
appropriate for each patient
• These are particularly well suited to treating
urgency and urge incontinence
• Cost effective.
• In this case a vaginal electrode is used.
• A pulse width of about 500s, a frequency of
5–10 Hz and the maximum tolerable
intensity are used.
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Click to editBLADDER
Master titleRETRAINING
style
• Was formerly called ‘bladder
discipline’
• Used in the management of
frequency, urgency without leakage
and urge incontinence (bladder
overactivity)
• PFM exercises and biofeedback were
as effective as bladder retraining for
patients with urodynamic stress
incontinence, bladder overactivity or
mixed symptoms
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• The main aims are to:
• correct faulty habits
• control urgency
• prolong periods between voids
• reduce incontinence episodes
• reduce the daily number of voids and increase voided volumes
• build up the patient’s confidence
To achieve this the patient must be mentally intact, motivated and able to go to
the toilet independently. It may be used in combination with pharmacotherapy.
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• Deferment techniques are taught such as:
• repeated maximal pelvic floor contractions at times when
urgency is felt
• perineal pressure (e.g. sitting on a rolled towel or arm of a
chair)
• standing on tip toes
• distraction – such as companionship, games, television or
music
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AND PROMPTED VOIDING
• It is important to determine to what extent
poor balance, joint stiffness or lack of
strength and endurance in muscles other than
the pelvic floor may be actually contributing
to the incontinence or aggravating it
• Social withdrawal can be another reason
• General lack of fitness is responsible for
weakness of the pelvic floor musculature and
perineal muscles E.g. Knee Osteoarthritis.
• Treatment should be specific to diagnosis
adjuvant to PFM 5
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FUNCTIONAL ACTIVITY
• Where patients are unable to toilet independently or are
confused, or both, timed voiding may be helpful to avoid
‘accidents’.
• The patient’s need for the toilet is observed and charted over
several days, a routine of toileting times is then set – ideally
this is individualized.
• Commonly in residential and nursing homes this is set at 2-
hourly intervals and the patient is taken to the toilet or sat on a
commode whether or not they express a desire to void.
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The physiotherapist may be able to contribute toward
these goals with treatment that produces just a little more
strength or range of movement. This may enable a patient
to become independent by coping with maneuvers such
as ISC or pad changing for themselves, or make it
possible for the patient, in spite of all the problems, to get
out and about and enjoy life.
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