What We All Need To Know About Pelvic

Health

Presented By: Elizabeth Templeton DPT, GCS, CEEAA, PCES

January 28, 2020 FPTA Meeting

Objectives: 1. Explain the functional anatomy of the pelvic floor and its role in bladder and

bowel control, respiration, balance and lumbopelvic stability.

2. To provide participants with current evidence to enhance clinical reasoning in

the management of common pelvic floor dysfunction

3. To be able to perform basic interventions to address common bladder and

bowel dysfunctions.

4. To be able to describe the role of a pelvic floor physical therapist to a patient

and the process of referring to a specialist.

Did you know? ● Pelvic floor disorders affect almost 25% of women in the United States.

● Urinary Incontinence (UI) affect 25 Million people in the US.

● 50% of men report leakage after prostate surgery

● People with incontinence are more likely to also have low back pain

● Nearly 40% of Women between the ages of 20 and 45 have overactive bladder

● Women and Men with UI are 3X more likely to FALL than those without Leakage

● $66 billion in 2007 in the US

(National Association For Continence)

uber-docs.com

The Functions of the Pelvic Floor Support: Holding Things Up

Sexual : Use it or Lose it

Sphincteric: When You Gotta Go

Stabilization and Breath:Your Inner Core

Sump Pump:Circulating Blood and Lymph Image from adventpt

Pelvic Floor Muscles 101 Urogenital Triangle (Diaphragm)

Superficial

● Bulbospongiosus (cavernosus in men)

● Ischiocavernosus

● Superficial transverse Perineal

Middle Layer

● Deep Transverse Perineal

● Sphincter Urethra

Saved from studyblue.com

Pelvic Floor Muscles 101Anal Triangle

● Internal Anal Sphincter (Involuntary)

● External Anal Sphincter (voluntary)

Saved from studybible

Deep Muscles of the Pelvic FloorLevator Ani

● Pubococcygeus ○ Puborectalias

○ Pubovaginalias

● Iliococcygeus

● Coccygeus

● Obturator Internus

Wikipedia

Deep Hip/Pelvic Muscles Act as a Sling

Innervation Pudendal Nerve

● S2,3,4

● Motor and Sensory

● Nerve to the Levator Ani

https://www.pudendalhope.info/node/13

Let’s Find Our Pelvic Floor!

PFM Exercise Prescription● Individualized

● Correct performance of PFM contraction

● Quick contractions- 2 second hold, 4 second rest, 10 reps, 3 sets/day

● Endurance contractions- 5 second hold, 10 second rest, 10 reps, 3 sets/day

● Maximal intensity- 50%-75% of maximum contraction

The Power of Education “The belief of doing correct PFM contraction was false in at least one of five

postpartum women. Verbal instructions have a positive effect on performing

PFMC in 73.6 % of women” -Vermandel et al. 2015.

Functional Anatomy of the Bladder

Pelvic Floor and Bladder Control Storage Phase

● detrusor relaxed

● trigone contracted (internal sphincter)

● PFM contracted keeping all of the urine in

● outlet pressure > vesical pressure

Emptying Phase

● detrusor contracted

● trigone relaxed

● PFM relaxed

● outlet pressure< vesical pressure

NursingTimes.com

Pelvic Floor and Bowel Function

● At Rest=Sphincter muscles closed

● Defecation= ^ rectal pressure coordinated with relaxation of anal sphincters and PFM’s muscles

https://www.jaypeedigital.com/

Pooping Posture

● Sit fully on the toilet

● Knees higher than hips

● Rest forearms on legs

● Breathe

Pelvic Floor and Your Inner Core

researchgate.net

Preserve the Canister● Inhale: Diaphragm and PFM go down,

rib cage expands (umbrella)

● Exahe: Pelvic floor rises belly flattens

and ribs come back to resting

● Paradoxical breathing pattern can

cause leaking

● Re establish breathing pattern

Common Pelvic Floor Dysfunctions

Overactive Pelvic Floor Muscles

Definition: Pelvic floor muscles are unable to relax or will contract during function, including

defecation or micturition

Symptoms: Obstructive voiding or defecation, dyspareunia, pelvic pain

Signs: Absent voluntary relaxation, non relaxing pelvic floor and involuntary PFM contraction,

Non Contracting PFM

Common Pelvic Floor Dysfunctions

Non-functioning PFM

Definition: A situation in which there is no palpable pelvic floor muscle action

Symptoms: Any pelvic floor symptom may be present

Signs: Non- contracting, non-relaxing pelvic floor muscles

Common Pelvic Floor Dysfunctions

Underactive Pelvic Floor Muscles

Definition: Pelvic floor muscles are unable to contract when needed

Symptoms: Urinary or fecal incontinence, pelvic organ prolapse (POP)

Signs: Absent or weak voluntary and involuntary PFM contraction, Non Contracting PFM

Incontinence Urge Incontinence: Detrusor Overactivity

● Overactive Bladder (OAB): Sudden strong urge to urinate, “key in the door”

voiding more than 8x/24 hours, running water

● Nocturia: waking up at night 1+ times to urinate

Incontinence Stress Incontinence: PFM weakness or urethral hypermobility

● Failure to store urine secondary to decreased outlet resistance

● Loss of small volume of urine while laughing, coughing, jumping, etc

● Childbirth is a common cause

Mixed Incontinence: Combination of urge and stress

womenshealthmag.org

Incontinence Overflow Incontinence: Outlet obstruction or under active neurogenic bladder

Reflex Incontinence: No sensation and no control of sphincters (CVA, Spinal

Cord Lesion)

Functional Incontinence: Person can’t get to the bathroom fast enough

RED FLAGS

● Sudden onset of incontinence?

● Changes in sensation to the saddle area?

● Leaking occur after surgery or with a medication change?

● Burning/blood in urine/stool?

● Is there an odor change in vaginal discharge?

● Difficulty initiating the stream?

Putting it all together: Case Studies

Kim is a 45 y/o female, she’s a teacher and is on her feet all day, you are

evaluating her for low back pain.

During evaluation she tells you that she used to goes to boot camp 3x a week and

also used to run 2x a week. But since she had her hysterectomy she started

leaking with box jumps and stopped going and now only walks occasionally and

then she coughs, and says, “ Mom bladder strikes again, that’s normal for having 3

babies.”

What can you say next?

LEAKING IS NOT NORMAL, IT’S COMMON

“About one‐third of women have urinary incontinence and up

to one‐tenth have faecal incontinence after childbirth. Pelvic

floor muscle training (PFMT) is commonly recommended

during pregnancy and after birth for both prevention and

treatment of incontinence”

(Woodley SJ, et al. 2017)

Direct Follow Up Questions

● Do you get a strong urge to urinate?

● Do you to the bathroom more than 8x’s a day?

● Do you rush to go to the bathroom?

● Do you wear a pad?

● Do you wake up more than 2x’s at night to urinate?

External Palpation

• Palm Up

• Firm pressure to the perineum

• Cue patient to perform a PFM contraction

“Knack”Reduce downward pressure on Pelvic Floor

● Pre contraction of PFM’s

● Perform prior to cough, sneeze, laugh

● Use TrA to help

Clinical Pearl: “Blow before you go”

● Exhale and contract pelvic floor prior

to the “most challenging” part of any movement http://www.cfnaturalhealth.com/

● Pelvic Floor PT’s have to take certification courses in order to perform Internal

Examination

● Need a Rx. for Pelvic Floor Physical Therapy from a referring MD

● Thorough Obstetric/Gynecological History

● Musculoskeletal Examination

● Evaluation of Pelvic Floor Muscles (Digital palpation, RTUS, sEMG)

● Exercise, manual therapy, modalities

● Use of Accessories ie: vaginal weights, dilators

https://milltownphysiotherapy.com/

Prepare Your Patients For a Pelvic Health Evaluation

John 80 y/o male who was referred to you following a total knee replacement 5 days

post op. You are his home care PT and are at your follow up visit and notice a

smell of urine when you enter the house.

He did tell you during the evaluation that prior to his knee replacement he had a

fall going to bathroom at night because he gets up more times than he count to go

to the bathroom. He also told you that he had a prostatectomy 2 years ago.

His TUG score is 30 seconds

How can you help?

Bladder Retraining ● Bladder Diary

○ Assess Fluid Intake

■ 6-8, 8 oz of fluid/ day

■ ½ oz/pound of body weight in fluids

■ 50% should be water

○ Patients Behavior

○ Fluid Management Strategies

○ Bladder Irritants

■ ie: Alcohol, spicy foods, Citrus

Bladder Retraining ● Timed Voiding (Bladder Drills)

○ Implementing mandatory voiding times

○ Progress or decrease interval times based on success up to 3 hours

between voids

○ Do not void between unscheduled times

○ Don’t skip a void even if you don’t “have” to go

healthination.com

Bladder Retraining Urge Suppression Techniques “Bladder Wave”

● Heel/Toe Raises

● Count Backwards from 50

● Distraction

● Quick flicks

● Avoid Going “Just in case”

www.medbridge.com

Managing Nocturia ● Fluid Management

○ Limit Fluid to 2-3 hours before bedtime

○ Fluids during the day

● Elevate Legs

● Compression stockings during the day

● Practice diaphragmatic breathing to calm the urge

● 5-10 PFM contractions

Electrical Stimulation “Calm the Bladder”

Posterior Tibial Nerve

Intravaginal

Sacral Nerve

“There is promising evidence for the efficacy of a transcutaneous stimulation

approach for the treatment of OAB” -Slovaka et al. 2015

Electrical Stimulation ● Non invasive

● Low Cost

● Easy to use

● Patients can use it in their homes

● Parameters: (to calm the bladder) ○ Frequency: 10-20 Hz

○ 10s on 10 seconds off,

○ Duration:200-300µs

○ Intensity: Strong but comfortable

○ 5-7 days a week 30 minutes a day

Pelvic Floor Muscle Training is EVIDENCED BASED!

● ACP recommends first-line treatment with pelvic floor muscle training in

women with stress UI. (Grade: strong recommendation, high-quality

evidence)

● ACP recommends bladder training in women with urgency UI. (Grade: strong

recommendation, moderate-quality evidence)

AMERICAN COLLEGE OF PHYSICIANS RECOMMENDED

“ACP recommends against treatment with systemic

pharmacologic therapy for stress UI”

“ACP recommends pharmacologic treatment in women with

urgency UI if bladder training was unsuccessful”

Clinical Practice Guideline-2014

While I Have Your Attention…...There are approximately 4 million births/yr in the US

2.7 million are vaginal…

54,000-89,000 grade 3-4 Perineal Tearing……..

What if 80,000 people with a full ACL thickness tear didn’t get rehab and were

told: “You’ll be fine, and by the way: here’s a newborn to care for…..See you in 6

Weeks.”

@thedowntheredoc

Additional Resources https://www.homehealthsection.org/assets/docs/IncontToolkitLnkd_11-17.pdf

https://www.pelvicsanity.com/single-post/Screening

https://aptapelvichealth.org

https://hermanwallace.com/

https://pelvicguru.com/

References 1. Neville, C. Bladder Control Problems in Elders-Assessment and Treatment Strategies for All Rehabilitation Clinicians—

Clinical Commentary. Topics in GeriatricRehabilitation:2016;32(4):231-250

2. Pahwa AK, Andy UU, Newman DK, Stambakio H, Schmitz KH, Arya LA. Noctural Enuresis as a Risk Factor for Falls in

Older Community Dwelling Women with Urinary Incontinence. J Urol. 2016;195(5):1512–1516.

3. Wu J, et al. Prevalence and Trends of Symptomatic Pelvic Floor Disorders in U.S. Women Pelvic floor awareness and

the positive effect of verbal instructions in 958 women early postdelivery. Int Urogynecol J 2015;26, 223–228.

4. Wald A. Neuromuscular Physiology of the Pelvic Floor in Physiology of the Gastrointestinal Tract (Fifth Edition), 2012

37.5.4

5. Sakakibara R, Tsunoyama K, Hosoi H, et al. Influence of Body Position on Defecation in Humans. Low Urin Tract

Symptoms. 2010;2(1):16–21. doi:10.1111/j.1757-5672.2009.00057.x

6. Goodman C, Snyder T. Differential Diagnosis for Physical Therapists: Screening for Referral. Saunders, 2012

7. Park H, Han D. The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic

motion during breathing. J Phys Ther Sci. 2015;27(7):2113–2115. doi:10.1589/jpts.27.2113

8. Abrams,P, Cardozo, L, Wagg, A, Wein, A. (Eds) Incontinence 6th Edition (2017). ICI-ICS. International Continence Society, Bristol UK,

ISBN: 978-0956960733.

9. Garcia-Sanchez E et al. What Pelvic Floor Muscle Training Load is Optimal in Minimizing Urine Loss in Women with Stress Urinary

Incontinence? A Systematic Review and Meta-Analysis.Int J Environ ResPublic Health 2019 Nov 8;16(22). pii: E4358. doi:

10.3390/ijerph16224358

10. de Andrade RL, Bø K, Antonio FI, Driusso P, Mateus-Vasconcelos ECL, Ramos S, Julio MP, Ferreira CHJ. An education program

about pelvic floor muscles improved women's knowledge but not pelvic floor muscle function, urinary incontinence or sexual function: a

randomised trial. J Physiother. 2018 Apr;64(2):91-96. doi: 10.1016/j.jphys.2018.02.010. Epub 2018 Mar 21.

11. Allon EF, The role of neuromuscular electrical stimulation in the rehabilitation of the pelvic floor muscles. Br J Nurs 2019 Aug

8;28(15):968-974. doi: 10.12968/bjon.2019.28.15.968

12. Amir Qaseem, MD, PhD, MHA; Paul Dallas, MD., et al. Nonsurgical Management of Urinary Incontinence in Women: A Clinical

Practice Guideline From the American College of Physicians. AnnIntern Med. 2014;161:429-440. doi:10.7326/M13-2410

13. Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay‐Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary

and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.:

CD007471. DOI: 10.1002/14651858.CD007471.pub3.