With this kind of patient, I try to establish why she has stress incontience in the first place.
- How does her TrAb and Bladder look under U/S examination?
- Does she have a symmetric contraction of her TrAb and pelvic floor?
- Is she generating too much intra-abdominal pressure (IAP) via her muscular system (overactive obliques, rectus abdominus, intercostals, etc)?
I have found that some people have a pelvic floor that is essentially fine but they generate so much IAP that they push through their pelvic floor.
Perhaps she may have some scarring due to tearing or episiotomies from childbirth. This could lead to poor symmetry during pelvic floor contractions.
Perhaps she has a diastasis recti which stops that TrA, Lumbar multifidus and pelvic floor from doing their job.
Another thing may be that she thinks she is doing a pelvic floor contraction but is only doing her internal obliques or pubococcygeus and not the anterior pelvic floor. I have found this problem a lot with people who have been doing yoga and Pilates - the instructors don't seem to realise that core-activation is very subtle.
Sometimes a dysfunctional pelvis means that the core muscles aren't able to do their job effectively.
Does she have urinary urgency, loss of control or is it just stress incontinence?
I would start by look at her breathing, ensuring that her lateral basal expansion is correct and equal, that her tummy or chest is not moving more than the other.
Then I would look at her core activation and Active SLR to look for load transfer problems.
Let us know how she is going...