Pelvic Floor Dysfunction Part 1 PDF

Pelvic Floor Dysfunction Part 1 By DR. HEND SAKR | Lecturer of Physical Therapy for Gynecology and Obstetrics, BUC. Physiology of micturition 1  PELVIC FLOOR DYSFUNCTION Pelvic floor structure: It is a soft structure that fills the pelvic outlet, situated at the bottom of th...

Pelvic Floor Dysfunction Part 1 By DR. HEND SAKR | Lecturer of Physical Therapy for Gynecology and Obstetrics, BUC. Physiology of micturition 1  PELVIC FLOOR DYSFUNCTION Pelvic floor structure: It is a soft structure that fills the pelvic outlet, situated at the bottom of the abdominal cavity forming A SUPPORTING SHELF for the abdominal and pelvic viscera. It has three layers: 1. Endopelvic fascia. 2. Levator ani muscle. 3. Perineal membrane (external anal sphincter). In women, the levator ani muscle forms a horizontal shelf with the urogenital hiatus (anterior midline cleft), where urethra, vagina and rectum passes. 2 Anatomy of the anal canal and rectum displaying pelvic floor muscle 3  Pelvic floor muscles Levator ani coccygeal muscles muscles Pubococcygeus Iliococcygeus Ischiococcygeus muscles muscles muscles Pubovaginalis Puborectalis Pubococcygeus muscle muscle proper muscle Anatomy of pelvic floor muscles and levator ani Levator ani has two types of fibers: 1. Slow twitch muscle fibers 70%, which is responsible for maintenance of the tone of levator ani at rest. 2. Fast twitch muscle fibers which are mainly activated during sudden increase in intra-abdominal pressure and can only maintain contraction over a short period of time. PELVIC FLOOR MUSCLES DYSFUNCTION It is divided mainly into two dysfunctions: 1. Pelvic floor muscles weakness. 2. Pelvic floor muscles over-contraction. 4  Pelvic floor muscles weakness resulting in: 1- Stress urinary incontinence. 2- Genital prolapse. 3- Fecal incontinence. Pelvic floor muscles over-contraction resulting in: 1- Vaginismus 2- Dysparunia Stress Urinary Incontinence It is involuntary leakage of urine from the urethra on sudden rise of intra-abdominal pressure as coughing and sneezing without detrusor contraction. Pathophysiology 1. Weakness of levator ani muscle leading to descent of bladder neck. 5  2. Sudden rise of intra-abdominal pressure leads to increase intra-vesical pressure more than intra-urethral pressure resulting in drop of urine. Grades: Grade 1: Incontinence with severe stress as coughing, laughing or sneezing. Grade 2: Incontinence with moderate stress as rapid movement, walking or up and down stairs. Grade 3: Incontinence with mild stress as standing and changing position. Factors provoking or aggravating incontinence: 1. Obesity. 6  2. Chronic cough. 3. Smoking. 4. Infections. 5. Caffeine intake. 6. Drugs as sedatives and hypnotics. Physical therapy assessment of SUI: 1. Frequency/Volume chart. It records the fluid intake and urinary output per 24 hours. It gives objective information about number of voiding, distribution of voiding per day and night and each voided volume. It is useful in assessment of voiding disorders and in follow up of treatment. 2. Pad test. One hour pad test: The patient uses a pre-weighted perineal pad for one hour in the office. The pad is then removed and weighted. Any difference from the starting pad weight is considered as fluid loss. 2 grams is allowed as vaginal discharge and perspiration. Twelve hour pad test: It is done in home as the patient wears the pre-weighted pad continuously for 24 to 48 hours, removing them only to void or change a fresh pad. Discharged pads are weighted immediately. It has advantage that it allows assessment in normal circumstances and over a long period. 7  Physical Therapy Treatment of Stress Urinary Incontinence Aims of Treatment: 1. To inform patients about the factors which may provoke or aggravate incontinence. 2. To establish awareness of and function of pubococcygeus muscle and urethral sphincter. 3. To normalize pelvic support and sphincter mechanism. 4. To strength pubococcygeus muscle. Treatment of Stress Urinary Incontinence SUI is divided into: Prophylaxis Actual Treatment Surgical treatment Parturition is the Early and mild Severe and most common cases are curative recurrent cases traumatic cause by physical are treated by and it is prevented therapy. reconstructive by proper intra surgery to restore and postnatal the normal care. anatomy. Postmenopausal women are treated by hormonal replacement therapy, kegel exercise and bladder training. 8  Prophylaxis Parturition is the commonest traumatic cause and is prevented by: ❖ Proper intra-natal care (during delivery): to avoid and minimize injury and trauma of perineum and pelvic floor structures by: ✓ Keeping bladder empty during 1st stage of labor. ✓ Proper management of 2nd stage of labor by firm support of perineum from the start of 2nd stage of labor (uterine contractions) to avoid perineal overstretch and lacerations. ✓ Avoid using forceps and ventose before full cervical dilatation. ✓ At crowning, ask the mother to stop bearing down during contractions and start to pant. ✓ Proper timing of episiotomy if needed. ❖ Proper post-natal care (after delivery): ✓ Any perineal tear or lacerations should be repaired carefully within 24 hours. ✓ Strengthening exercises to strength pubococcygeus muscle which may be injured during labor. ✓ Avoidance of bladder infection by washing vulva and perineum to avoid urge incontinence. 9  Curative treatment Physical therapy treatment is divided into two phases: a. Muscle re-education of pubococcygeus muscle. In patients who complains SUI resulting from lack of awareness of the function of PCM. We use: Graduations of PCM exercises, Biofeedback, Cyriax method. b. Resistive pelvic floor exercises The next gradution of exercise to strength PCM. we use: Inflated cuffed catheter and vaginal cones. A. Muscle re-education of pubococcygeus muscle: Normally, the urethral closure pressure must be higher than the intra-vesical pressure at rest and in situations of increased intra-abdominal pressure. Since, the pelvic floor muscles are one of the factors that contribute to urethral closure pressure, so that re-education and strengthening of PFMs is the key of treatment SUI. This can be achieved by: 1. Graduations of pubococcygeus muscle exercise: Graduations of Quick flick: Tighten and pubococcygeus muscle relax the muscle as exercise quickly as possible10-20 times. Relax and count 10 then repeat. Increase 5 repetitions per week up to 50 repetitions maximum. Slow contraction: 10  Tighten the muscle as hard as you can and count 10-20. Relax and count 10 then repeat. Increase 5 repetitions per week up to 50 repetitions maximum. Sustained contraction: Tighten the muscle half way, hold 60 seconds. Relax and count 20, then repeat. Increase 2 repetitions per week up to 10 repetition maximum. 2. Biofeedback (Kegel periniometerand EMG biofeedback): ❖ Kegel periniometer: 11 - It is used to measure intravaginal pressure reflecting the constructional force the perineal muscles. - It provides the patient with powerful sensory and visible biofeedback for initiating the pelvic floor muscles to contract. - It consists of : Pneumatic pressure transducer (Dynamometer): able to measure pubococcygeus contraction up to 100 mmHg. Cylindrical rubber vaginal chamber which introduced to the vagina after lubrication by KY gel. The rubber vaginal part is connected to the manometer by a rubber tube. - The patient lies in crook lying position, then the vaginal chamber is inserted into the vagina after lubrication and ask the patient to squeeze on the vaginal chamber. The position of the patient during application of kegel periniometer. ❖ EMG biofeedback: - It provides the patient with sensory, visible and auditory biofeedback. - It gives recruitment of additional motor units during active volitional contraction resulting in increased EMG activity and electrical signaling on the monitor. - It consists of : 12  Vaginal electrode. 3 surface electrodes. Screen. Ear phone. - The vaginal electrodes inserted into the vagina after lubrication with KY gel. It is capable of detecting very tiny signals during contraction. - The three surface electrodes are positioned on the perineum in a triangular shape, its apex is directed downward. - Contractions of PCM are held for 3, 10, 30 and 60 seconds with 2-5 minutes rest between contractions. 3. Cyriax method: - It is useful in early cases. - It aims strengthening of pubococcygeus, gluteal, anal and abdominal muscles. - The patient lies in crook lying position, instructing her to breath in deeply from her nose, and at the same time contract pubococcygeus ,gluteal and abdominal muscles associated with drawing all internal viscera up towards the diaphragm, then relax and expire the air from her mouth with a sigh. 13 B. Resistive pelvic floor exercises: 1. Inflated cuffed catheter - A catheter is inflated with air or water (5 ml to 30 ml) depending on the laxity of the vagina. - The inflated cuffed catheter is inserted into the vagina after good lubrication with KY gel. - The patient is instructed to tighten PFMs to prevent withdrawal of the catheter by the therapist. - Gentle traction is applied to provide sensory feedback to initiate contraction. - Increasing the amount of traction to increase resistance. - As a progression, maintain the catheter in the vagina during coughing, bending, lifting, …… 2. Vaginal cones - They are weights, easy to use and safe for training PCM, consisting of a set of 5 weights, varying from 20 gm to 70 gm. - Woman can be trained by retaining the weight in the vagina. 14  - Feeling “losing of the cone” provides a powerful sensory feedback. - Resting muscle strength is assessed by retaining the heaviest cone in the vagina for one min. while walking. - Patient is given the appropriate cone. - The next heaviest cone is given when the patient can retain the previous cone for 10 min. while walking. - It must be done twice daily for 10-15 min. - Resistive training of PCM with vaginal cones is very useful in treatment of SUI, genital prolapse and enhance sexual satisfaction. C. Interferential current (medium frequency current): - The purpose of interferential current is production of contraction for the pelvic floor muscles to increase the patient’s cortical awareness to facilitate the ability of the patient to perform voluntary contractions of very weak muscles. 15  Techniques of application: 1. Bipolar technique: - 1st electrode: is a posterior pad electrode placed under ischial tuberosity. - 2nd electrode: is an anterior pad below symphysis pubis. - Parameters: frequency 10-40 Hz, duration 15-20 minutes, maximum tolerable intensity for 4 weeks, 3 sessions per week. 2. Quadripolar technique: - Patient lies in crook lying position. - Four vacuum electrodes are used. - Two electrodes are placed on the abdomen above the inguinal ligaments, 3 cm apart. - The other two electrodes are placed on the inner aspect of the thigh below inferior border of femoral triangle. Mid-stream urine flow (stop test) Aim: increase resting and active tone so will increase urethral closing pressure by cutting off the flow of retaining urine if possible, in mild SUI. Technique: 1st progression: patient is instructed to stop or slow down the flow of urine during micturition by contracting PCM near the END of micturition. 16 2nd progression: the same procedure at BEGINNING of micturition. (more difficult as it needs more muscle power and endurance to contract and hold micturition). 3rd progression: patient is instructed to interrupt urine (stop the flow then allow then stop the flow then allow and so on….). PRE-AND POST-OPERATIVE TREATMENT VALUE OF PRE AND POST OPERATIVE TREATMENT: Surgical procedures for the correction of vaginal and urethral incompetence may be facilitated by pre-operative and post-operative exercises, improving tone and function of the perineal muscles. PRE-OPRATIVE TREATMENT: Can be given individually or in groups. It is done at least one week before major gynecological surgery (two to three physiotherapy sessions at least). It includes: 1. Understanding effect of anesthesia. 2. Performing slow, relaxed, deep, costal and diaphragmatic breathing. 17  3. Effective supportive cough and huff to keep airway clear. 4. Moving across the bed, transfer from supine to sitting on the side of the bed, getting out on a chair and crawling back into bed with decreasing stress on abdominal or perineal incisions. 5. Pelvic floor rehabilitation. 6. Abdominal exercises. 7. Pelvic rocking exercises. Post-operative physiotherapy Chief objective: Is to recover as early as possible without complications. After recovery from anesthesia: First day: 1. Deep Breathing exercise. 2. Supported cough and huff. 3. Circulatory exercise. 4. Static abdominal exercise. 5. Pelvic rocking exercises. 6. Pelvic floor exercise (once urethral catheter is removed). 18 SECOND DAY: 1. All the exercises above. 2. Early ambulation. 3. Further progression will be started for abdominal, pelvic rocking, pelvic floor and postural correction exercises. BLADDER DRILL AIM: to restore bladder capacity to near normal levels. It involves timed voiding (interval between voids is gradually increased). The patient is instructed to increase this time interval. At 1st week: patient should void with shortest interval (once/hour in a day). If the patient felt a strong urge before void interval is relapsed, she should try to suppress this urge. The following week, time interval should be increased to (once/1.5 hour). The following week, time interval (once/3 hours). 19  When the bladder is trained to hold mor urine, this takes 3 or more months. Fecal incontinence It is the uncontrolled passage of feces or gas over at least 1 month in an individual of at least 4 years old who had previously achieved control. Causes: 1. Muscle damage. 2. Nerve damage. 3. Constipation. 4. Hemorrhoids. 5. Surgery. 6. Rectal prolapse. 7. Rectocele. Grades: Using Park’s scale: Grade I: Normal continence (i.e. continent for solids, liquid stools and flatus). Grade II: Continent for solid and liquid stools but not flatus. Grade III: Continent for solid stools only. (Fecal leakage). Grade IV: Complete incontinence. 20  Assessment Of Fecal Incontinence: 1. A detailed history: of incontinent symptoms, medical and surgical history, medications and quality of life. 2. Anorectal manometry: consists of a catheter with balloon on the end which is inserted rectally. ❖ Evaluating Anal resting pressure (normally around 30-40 mm Hg). ❖ Anal squeeze pressure around 150% of resting pressure. ❖ The volume that should fill the rectum to indicate 1st sensation is 25-35 ml. ❖ Maximum tolerance for stretch is 200-300 ml. Treatment Of Fecal Incontinence: 1. Dietary consideration - Inform patients about factors that contribute to bowel disturbances and loose stool consistency. - This includes food containing incomplete digested sugars, carbonated beverage, caffeine, alcohol, spicy food, smoked meat and fatty food. - Fiber supplementation: ▪ Fibers increase stool bulk when fermented. ▪ Fiber with high water content allows gel formation which normalize stool consistency, increase rectal distension so it can improve sensory awareness of the need to defecate. 2. Behavioral modification - Weight reduction. - Cessation of smoking as it causes external anal sphincter atrophy. 21  - Avoid straining during bowel movement. 3. Pharmacological treatment - Loperamide to reduce diarrhea and increase internal sphincter tone. - Oral laxatives and glycerol suppositories to treat constipation. 4. Pelvic floor exercise - In the form of quick flicks, sustained sphincter contraction and submaximal sustained contractions (Kegel exercises). - Core stability training: by strengthening the abdominal muscles, pelvic floor muscles and diaphragm to decrease the focus on pelvic floor muscles only. (Thoraco- abdomino-pelvic muscle training). 5. Biofeedback therapy - 1st approach: is for strength and endurance of anal sphincter using biofeedback apparatus. This makes sphincteric muscles stronger and so it can hold the stool for a long period of time. - 2nd approach: using biofeedback in combination with rectal balloon. The balloon is inflated with water or air to determine first sensation of rectal filling. Then gradually decrease amount of air or water to teach patient how to hold stool at lower volumes. 6. Electrical stimulation - To enhance strength and endurance of muscles of external anal sphincter. - Using low frequency or medium frequency current stimulation. 7. Radiofrequency energy to the anal canal - It increases collagen deposition and tissue remodeling. 22 8. Mechanical inserts (Temporary). - Anal inserts ✓ Is a simple and safe aid for fecal incontinence. It prevents the uncontrolled loss of solid stool. - Procon incontinence device: ✓ Treatment of severe fecal incontinence (FI), who are unfit to undergo surgery, those in whom previous surgical treatments have failed. ✓ This device consists of a disposable rubber catheter with an infrared photo sensor and flatus vent holes on the distal tip that is connected to a beeper. ✓ The catheter is inserted in the rectum and held in place by a 20-cc capacity cuff, which acts as a temporary mechanical barrier to stool leakage. 23 ✓ Stool entering the rectum is sensed by the photo sensor, which then alerts the patient about bowel movement. 24 25