Continence Clinic

Support for bladder and bowel control

Bladder or bowel-control problems can affect everyday routines, exercise, work, sleep and confidence when leaving the house. Symptoms may include leakage, urgency, frequent toilet visits, difficulty controlling wind or bowel movements, or changes following pregnancy, childbirth or pelvic surgery.

A continence clinic provides assessment and conservative treatment for bladder and bowel symptoms, with rehabilitation based on the type of difficulty you are experiencing.

Treatment may include pelvic floor rehabilitation, bladder training, bowel-management strategies, advice around everyday habits and exercises designed to improve strength and control.

What is a continence clinic?

A continence clinic supports people experiencing difficulties with bladder or bowel control.

Symptoms can develop for many reasons, including:

• Pelvic floor weakness
• Pregnancy and childbirth
• Prostate surgery
• Pelvic surgery
• Changes associated with ageing
• Neurological conditions
• Bladder urgency
• Constipation
• Poor pelvic floor coordination
• Reduced mobility
• Other bladder or bowel conditions

The first step is understanding the pattern of your symptoms rather than assuming every continence problem has the same cause.

When a continence assessment may help

An assessment may be useful if you are experiencing:

• Urine leakage
• Leakage when coughing or sneezing
• Leakage during exercise
• Sudden urinary urgency
• Difficulty reaching the toilet in time
• Frequent urination
• Waking repeatedly during the night to pass urine
• Leakage after prostate surgery
• Post-void dribbling
• Difficulty controlling wind
• Bowel leakage
• Faecal urgency
• Difficulty emptying the bowel
• Constipation associated with pelvic floor problems
• Reduced confidence leaving the house because of toilet concerns

Continence problems are common, but persistent symptoms do not have to be accepted as an unavoidable part of ageing, pregnancy or surgery.

What happens during your first appointment?

Your first appointment begins with a private discussion about your symptoms.

The clinician may ask about:

• When the symptoms began
• How often leakage occurs
• Activities that trigger leakage
• Urinary urgency
• Toilet frequency
• Night-time urination
• Bowel function
• Constipation
• Pregnancy and childbirth history where relevant
• Previous prostate or pelvic surgery
• Medication
• Fluid intake
• Caffeine and alcohol intake
• Current exercise
• Other medical conditions
• How symptoms affect work and everyday life

The aim is to understand both the symptoms and the situations in which they occur.

Depending on your presentation, you may also be asked to complete a bladder or bowel diary.

Physical assessment

Where appropriate, the assessment may include:

• Breathing
• Abdominal movement
• Hip and pelvic movement
• General strength
• Functional movement
• Pelvic floor muscle control

An internal pelvic floor assessment may sometimes provide useful information about muscle strength, coordination and the ability to relax.

This should only be carried out when clinically appropriate, after it has been clearly explained and with your informed consent.

You can decline or stop an internal assessment at any stage.

What treatment may include

Treatment depends on whether your symptoms are mainly related to weakness, urgency, pelvic floor coordination, bowel function or another factor.

Pelvic floor muscle training

If the pelvic floor muscles are weak, exercises may be used to improve strength and endurance.

Training may include:

• Short contractions
• Longer controlled holds
• Full relaxation between contractions
• Using the pelvic floor during coughing or movement

The number and difficulty of exercises should be adapted to your current ability.

Correct technique is more important than completing a large number of repetitions.

Pelvic floor relaxation

Not every continence problem is caused by weak muscles.

Some people have difficulty relaxing the pelvic floor properly.

This can contribute to problems such as:

• Difficulty emptying the bladder
• Difficulty emptying the bowel
• Pelvic pain
• Excessive straining

Treatment may therefore include breathing, relaxation and pelvic floor coordination rather than strengthening alone.

Bladder training

Bladder training may be used when urgency or frequent urination is a significant problem.

Treatment may involve:

• Understanding your current bladder pattern
• Gradually changing toilet frequency
• Strategies for managing urgency
• Reducing precautionary toilet visits
• Reviewing fluid habits

The programme is progressed gradually rather than simply asking you to hold urine for as long as possible.

Bowel rehabilitation

Where bowel control or emptying is affected, treatment may include:

• Pelvic floor exercises
• Pelvic floor relaxation
• Toilet positioning
• Bowel retraining
• Strategies for managing urgency
• Reducing unnecessary straining

More complex bowel symptoms may require additional assessment from a GP, colorectal team or another appropriate healthcare professional.

Home programme

You may receive exercises and management strategies to continue between appointments.

These can be adjusted as symptoms and pelvic floor control improve.

Stress urinary incontinence

Stress urinary incontinence refers to urine leakage when pressure increases through the abdomen.

This may occur during:

• Coughing
• Sneezing
• Laughing
• Lifting
• Running
• Jumping
• Gym exercise

Pelvic floor rehabilitation may focus on improving muscle strength and teaching the pelvic floor to respond appropriately during these activities.

Treatment should gradually progress towards the actual movements that cause symptoms.

Urgency and urge incontinence

Urinary urgency is a sudden need to pass urine that can be difficult to delay.

If leakage occurs before reaching the toilet, this may be described as urge incontinence.

You may notice that certain situations trigger urgency, such as:

• Arriving home
• Hearing running water
• Standing up
• Walking towards the bathroom

Bladder training and urgency-management strategies may help improve control.

Pelvic floor rehabilitation may also be included where appropriate.

Mixed urinary incontinence

Some people experience both stress and urgency-related leakage.

For example, you may leak when coughing but also have difficulty reaching the toilet when urgency develops.

Treatment may therefore combine:

• Pelvic floor strengthening
• Bladder training
• Urgency strategies
• Activity management

The programme can focus on whichever symptoms are causing the greatest difficulty.

Frequent urination

Passing urine very frequently can become disruptive to work, sleep and everyday life.

An assessment may consider:

• How often you are going
• How much you drink
• Caffeine intake
• Urgency
• Bladder habits
• Medication
• Other medical conditions

Some people develop a habit of going to the toilet very frequently because they are worried about becoming desperate later.

Where appropriate, bladder training may help gradually establish a more manageable pattern.

Going to the toilet “just in case”

Frequently emptying the bladder before it is reasonably full can sometimes reinforce frequent toilet habits.

Examples might include going:

• Before leaving home
• Before every meeting
• Before travelling
• Whenever a toilet is nearby

Not every precautionary toilet visit is a problem.

However, if frequent “just in case” urination is contributing to urgency or significantly controlling your routine, it may be addressed during bladder training.

Managing urinary urgency

Urgency can feel as though you need to reach the toilet immediately.

Strategies may include:

• Remaining still briefly
• Relaxing the body
• Controlled breathing
• Using an appropriate pelvic floor contraction
• Allowing the initial urgency to reduce
• Walking to the toilet rather than rushing

The most suitable approach depends on your symptoms and pelvic floor function.

Night-time urination

Waking during the night to pass urine is sometimes called nocturia.

There can be several contributing factors, including:

• Fluid habits
• Sleep problems
• Medication
• Bladder conditions
• Other health problems

If night-time urination is frequent or has changed significantly, it may require medical assessment as well as continence management.

Bladder diary

A bladder diary can provide useful information about your symptoms.

You may be asked to record:

• What you drink
• When you drink
• When you pass urine
• Approximate urine volume where practical
• Episodes of urgency
• Episodes of leakage
• Activities associated with leakage

Recording a few typical days can make patterns easier to identify and help guide treatment.

Fluid intake

Reducing fluid dramatically is not usually a good long-term solution for continence problems.

Very low fluid intake may contribute to concentrated urine and can also affect bowel function.

Instead, your current drinking habits can be reviewed to determine whether adjustments are useful.

Advice should take account of:

• Medical conditions
• Activity level
• Climate
• Medication
• Individual bladder symptoms

Caffeine and bladder symptoms

Caffeine can affect bladder symptoms in some people.

Common sources include:

• Coffee
• Tea
• Energy drinks
• Some fizzy drinks

If you consume significant amounts and experience urgency or frequency, a gradual reduction may sometimes be worth exploring.

There is no need for everyone attending a continence clinic to avoid caffeine completely.

Changes should be based on your individual symptoms.

Urinary leakage after childbirth

Pregnancy and childbirth can affect pelvic floor strength and bladder control.

Leakage may occur when:

• Coughing
• Sneezing
• Running
• Jumping
• Lifting your baby
• Exercising

Postnatal continence rehabilitation may combine pelvic floor strengthening with general physical rehabilitation and gradual return to exercise.

Symptoms can still be treated even if childbirth was months or years ago.

Continence after prostate surgery

Urinary leakage can occur following some types of prostate surgery.

Symptoms may be noticeable during:

• Standing
• Walking
• Coughing
• Exercise
• Lifting
• Changes of position

Pelvic floor rehabilitation may focus on:

• Correct muscle activation
• Strength
• Endurance
• Relaxation
• Timing during movement

Where surgery is planned, learning pelvic floor exercises beforehand may also help you become familiar with the technique.

Post-void dribbling

Post-void dribbling describes a small amount of urine leaking shortly after you have finished passing urine.

Pelvic floor exercises and practical emptying strategies may help some people.

Persistent urinary changes should still be medically assessed where appropriate, particularly if they are accompanied by difficulty passing urine or other new symptoms.

Bowel leakage

Bowel leakage can range from difficulty controlling wind to accidental loss of stool.

Symptoms may be influenced by:

• Pelvic floor weakness
• Stool consistency
• Urgency
• Previous childbirth injury
• Surgery
• Neurological conditions
• Other bowel problems

Assessment aims to identify the factors contributing to the symptoms.

Treatment may then include pelvic floor rehabilitation, bowel retraining and management strategies.

Difficulty controlling wind

Difficulty controlling wind can occur when pelvic floor or anal sphincter control is reduced.

This may be particularly noticeable after childbirth or pelvic surgery.

Pelvic floor rehabilitation may focus on improving:

• Strength
• Endurance
• Timing
• Coordination

Bowel habits may also need to be considered.

Bowel urgency

Some people experience very little warning before needing to open their bowels.

This can make travelling or leaving home difficult.

Assessment may consider:

• Stool consistency
• Bowel frequency
• Diet
• Pelvic floor function
• Medication
• Other bowel symptoms

Bowel retraining and pelvic floor rehabilitation may form part of treatment depending on the cause.

Constipation and straining

Constipation can be associated with several different factors.

When pelvic floor coordination contributes, you may feel the need to strain repeatedly or feel that the bowel has not emptied completely.

Treatment may include:

• Toilet positioning
• Breathing
• Pelvic floor relaxation
• Reducing prolonged straining
• Movement and activity advice

Persistent constipation may also require dietary or medical assessment.

Toilet positioning

Position can influence how easily the bowel empties.

For some people, using a small foot support to raise the knees can create a more comfortable position.

The focus is on allowing the pelvic floor to relax rather than repeatedly pushing or straining.

Individual recommendations can be discussed during your assessment.

Continence and pelvic organ prolapse

Bladder and bowel symptoms can sometimes occur alongside pelvic organ prolapse.

You may experience:

• Leakage
• Urgency
• Difficulty emptying the bladder
• Difficulty emptying the bowel
• Pelvic heaviness
• Vaginal pressure or bulging

Treatment may include pelvic floor rehabilitation and prolapse-management strategies.

A pessary or further medical assessment may also be considered where appropriate.

Continence and menopause

Bladder and pelvic floor symptoms may change around and after menopause.

Some people notice:

• Increased urgency
• More frequent urination
• Leakage
• Recurrent urinary symptoms
• Changes in pelvic support

Pelvic floor and bladder rehabilitation may help with some symptoms.

Other treatment may require discussion with a GP or pelvic health specialist depending on the underlying cause.

Continence and neurological conditions

Neurological conditions can sometimes affect communication between the nervous system, bladder, bowel and pelvic floor.

Continence problems may occur alongside conditions such as:

• Multiple sclerosis
• Parkinson’s disease
• Stroke
• Spinal cord conditions
• Other neurological disorders

Management may require coordination between physiotherapy and the neurological or continence medical team.

Treatment will depend on the neurological condition and the type of bladder or bowel difficulty present.

Mobility and continence

Sometimes the main difficulty is not bladder control itself but reaching the toilet quickly enough.

Reduced mobility may occur because of:

• Arthritis
• Neurological conditions
• Weakness
• Frailty
• Recent surgery
• Balance problems

In these situations, rehabilitation may also focus on:

• Walking
• Transfers
• Sit-to-stand strength
• Balance
• Managing clothing
• Accessing the bathroom more efficiently

The wider physical problem needs to be considered alongside continence.

Continence during exercise

Bladder or bowel symptoms can cause people to reduce or stop exercise.

You may avoid:

• Running
• Jumping
• Gym training
• Exercise classes
• Sport

Rehabilitation aims to address the physical problem rather than simply telling you to avoid every activity that triggers symptoms.

Treatment may include:

• Pelvic floor strengthening
• Pressure management
• General strength
• Exercise modification
• Gradual return to impact

The longer-term aim may be to return to the activity with improved control.

Returning to running

Running places repeated demand on the pelvic floor.

If leakage occurs, rehabilitation may consider:

• Pelvic floor strength
• Pelvic floor timing
• Leg strength
• Impact tolerance
• Running volume
• General fitness

Running may initially be modified while strength and control are developed.

The programme can then gradually progress.

Returning to the gym

Continence symptoms do not necessarily mean that resistance training should be stopped.

If leakage occurs during lifting, treatment may look at:

• Exercise load
• Breathing
• Pelvic floor coordination
• General strength
• Exercise technique

You may initially reduce resistance before gradually building back towards your normal training.

The aim is to improve your ability to manage load rather than permanently avoiding heavier exercise.

Lifting and continence

Coughing, lifting and other demanding movements increase pressure through the abdomen.

The pelvic floor normally contributes to managing this pressure.

Rehabilitation may involve practising pelvic floor coordination during:

• Lifting
• Carrying
• Squatting
• Standing
• Gym exercise

The goal is not to keep the pelvic floor contracted all day.

The muscles need to contract when required and relax normally afterwards.

Continence and confidence

Continence symptoms can affect much more than physical health.

You may begin:

• Planning routes around toilets
• Avoiding long journeys
• Exercising less
• Avoiding social activities
• Carrying spare clothes
• Restricting fluid intake
• Feeling uncertain about returning to work

A continence programme should therefore consider how symptoms affect your normal routine, not only how many episodes of leakage occur.

Pads and continence products

Pads and other continence products can be useful for managing symptoms while treatment is progressing.

Using a pad does not prevent you from completing rehabilitation.

The longer-term goal may be to:

• Reduce the amount of leakage
• Use lighter protection
• Reduce reliance on products
• Feel more confident during activity

For some long-term conditions, continence products may continue to form part of practical management.

Working with other healthcare professionals

Continence symptoms can have different causes, so physiotherapy may form one part of your care.

Depending on your symptoms, additional input may involve:

• GPs
• Urologists
• Urogynaecologists
• Colorectal specialists
• Continence nurses
• Pelvic health physiotherapists
• Neurology services
• Other relevant healthcare professionals

Physiotherapy mainly focuses on pelvic floor function, bladder and bowel strategies, movement and physical rehabilitation.

Medical investigation may be required where symptoms suggest another bladder, bowel or neurological condition.

When further medical assessment may be needed

Some symptoms require medical investigation rather than continence rehabilitation alone.

Seek appropriate medical advice if you experience:

• Blood in the urine
• Blood in the stool
• Difficulty or inability to pass urine
• Repeated urinary infections
• New or severe pelvic or abdominal pain
• A significant unexplained change in bladder habits
• A significant change in bowel habits
• Unexplained weight loss
• New significant bowel-control problems
• Fever associated with urinary symptoms

Urgent medical assessment is required if new bladder or bowel-control problems occur alongside symptoms such as:

• Significant new back pain
• New leg weakness
• Numbness around the saddle or genital area
• Sudden neurological symptoms

These symptoms should not be managed through pelvic floor exercises alone.

Treatment based on your goals

Continence rehabilitation should focus on the symptoms and activities that matter to you.

Your goals may include:

• Reducing urinary leakage
• Improving bladder control
• Managing urgency
• Reducing frequent toilet visits
• Sleeping with fewer interruptions
• Improving bowel control
• Reducing post-void dribbling
• Returning to exercise
• Running without leakage
• Returning to the gym
• Improving continence after prostate surgery
• Improving symptoms after childbirth
• Feeling more confident leaving the house

Your treatment programme can be developed around these priorities.

How long does continence rehabilitation take?

There is no single timeline.

The length of treatment depends on:

• The type of continence problem
• How long symptoms have been present
• Pelvic floor strength and coordination
• Previous surgery
• Pregnancy and childbirth history
• Neurological or other medical conditions
• Bladder or bowel habits
• The activities you want to return to

Pelvic floor muscle strength usually requires regular training over time, and bladder retraining also involves gradual changes rather than immediate results.

Your programme can be reviewed and progressed as symptoms improve.