Pelvic Floor Muscle Rehabilitation
WHEC Practice Bulletin and Clinical Management Guidelines for healthcare providers. Educational grant provided by Women's Health and Education Center (WHEC).
Pregnancy and vaginal delivery have been considered main risk factors in the development of pelvic floor disorders and in the development of stress urinary incontinence. Urinary incontinence alone represents a $ 26 billion economic burden. There appears to be an increase in demand for care of these disorders that is disproportionate to the net growth of the population. In order to restore function of the pelvic floor muscles after childbirth, women in most industrialized countries have been encouraged to perform pelvic floor muscle exercises. The theoretical basis of using pelvic floor muscle exercise for the treatment and prevention of stress urinary incontinence is based on the muscular changes that may occur after specific strength training. A strong and well-functioning pelvic floor can build a structural support for the bladder and the urethra. Postpartum pelvic floor muscle training has been demonstrated to be effective in the prevention and treatment of stress urinary incontinence in the immediate postpartum period. The results also showed that the success of postpartum pelvic floor muscle exercise depended on training frequency and intensity. Many education techniques have been described, and physiotherapists skilled in uro-gynecology frequently use pelvic floor exercises, biofeedback, and electrostimulation techniques.
- No side effects
- Patient participation
- Does NOT limit future treatment
History of Pelvic Muscle Exercises:
Pelvic floor muscle exercises are also called Kegel exercises after Dr. Arnold Kegel, who developed them to strengthen the pelvic floor muscles. The exact names of the muscles involved in strengthening are the pubococcygeus muscles. These muscles contract and relax under patient's command to control the opening and closing of the urethral sphincters, or the muscles that provide urinary control. Regular exercise is necessary to increase and maintain function. Muscle activation promotes function. Avoid use of accessory muscles.
Helpful hints: Begin by locating the muscles to be exercised.
- As you begin urinating, try to stop or slow the stream of urine without tensing the muscles of your legs, buttocks or abdomen. It is very important not to use these muscles because only the pelvic floor muscles help with bladder control.
- When you are able to slow or stop the stream of urine, you have located the correct muscles. Feel the sensation of the muscles pulling inward and upward.
- When you have located the correct muscles, set aside two times each day for exercising, morning and evening.
Set # 1 Quick Contractions (QC): Tighten and relax the sphincter muscles as rapidly as you can.
Set # 2 Slow Contractions (SC): Contract the sphincter muscle and hold to a count of 3 (gradually increasing to 10 seconds per exercise daily) then RELAX completely before the next contraction.
Make pelvic muscle exercises a part of your daily routine. Whether you are doing pelvic muscle exercises to improve or to maintain bladder control, you must do them regularly on a lifetime basis. Continue at a rate of 50 QC and 50 SC daily; you may increase to more if desired. The total number can be divided up over the course of the entire day. Learn to squeeze before you sneeze, cough, laugh, get out of a chair, or pick up something heavy.
Electric stimulation is used for both pelvic floor muscle re-education related to stress incontinence and for inhibition of an unstable detrusor muscle as in urge incontinence. Transvaginal or transanal electrical stimulation is commonly used. It causes passive contraction of the pelvic floor musculature. Although not well documented, electrical stimulation relieves symptoms of pelvic pain in some patients. The mechanisms of action are:
- Increases muscle awareness, recruitment, strength and tone.
- Inhibits involuntary detrusor contractions, increases bladder capacity and decreases the intensity of the urge sensation.
- Pelvic floor muscle weakness
- Documented detrusor instability
- Normal sensation and reflexes
- Decreased anal sphincter control
- Metal implants (IUD)
- Vaginal or urinary infections
- Pediatric patients
- Absent or diminished sensation: denervation of the pelvic floor
Electrical stimulation units for home or office use are programmed to deliver stimulation at pre-set frequencies. For detrusor instability and other symptoms related to urge incontinence, 10 or 12.5 Hertz is used. Frequencies of 50 or 100 Hertz are used for stress incontinence. Mixed incontinence, a combination of urge and stress incontinence, responds to 20 Hertz. There are no known prognostic factors that identify those patients who will respond to electrical stimulation or those who will relapse after an initial improvement. Repeat electrical stimulation can be effective in patients who relapse. For these patients, intermittent maintenance stimulation may be appropriate.
Intermittent intravaginal maximal electrical stimulation is a safe procedure with no serious reported adverse effects. As compared to long-term stimulation, it is more convenient and tolerable for the patient. A major disadvantage of maximal electrical stimulation is the need for clinical time and trained personnel. Home therapy with a portable electrical stimulator obviates the need for these resources. This treatment option appears to be well accepted and successful. Home electrical stimulation would be ideal for patients who require intermittent maintenance therapy.
Biofeedback therapy of voiding dysfunctions represents a valuable therapeutic option for many patients. It is a management method that has low risk and therapeutic efficacy for selected patients. Biofeedback is a technique that uses graphs on a computer screen and sounds to help identify the muscles being trained. It helps patients locate the pelvic muscles by changing the graph or sound when the patient squeezes or tightens the pelvic floor muscles. It teaches the patient not to tighten other muscle groups such as the stomach muscles. The computer records muscle activity (the contraction or strength) and displays it on the monitor. The graphs and sounds are used as teaching tools to learn to control the correct muscles.
Methods: Two sensors are placed around the outside of the rectum and one sensor on the thigh. Sensors are sometimes used to test other muscles (stomach, buttocks or thighs) to teach the patient not to use these muscles. The biofeedback sessions are usually 20 to 30 minutes long. To get the best results, the average number of biofeedback sessions in the medical office is 12. Voiding and exercise diaries are also used to see the progress.
Conclusion: Biofeedback is recognized as an important alternative therapeutic option for treating patients having multiple voiding-related symptoms. Current biofeedback techniques are neither precise nor well standardized. The color graphic feedback and the pitch variable audio feedback allow the presentation of performance to the patient in an instructive way that can be easily understood. Patients with lower levels of cortical functions or lower levels of motivation are more likely to become involved in the learning process of changing their performance to acquire a voiding skill, since they can understand the technique used in presenting their performances.
Assisted Pelvic Floor Muscle Exercises:
To increase pelvic floor muscle strength the following methods have been tried with variable success. Other than compliance, studies have not consistently shown any significant improvement.
- Vaginal weighted cones
- Magnet chair
Pelvic Floor Disorders and Female Sexual Dysfunction:
Studies have found that sexual complaints are common among women with pelvic floor disorders. Childbirth is associated with short-term dyspareunia and other sexual complaints, including decreased libido, difficulty achieving orgasm, and vaginal dryness. The American Foundation for Urologic Disease recognizes four types of female sexual dysfunction: low libido, problems with sexual arousal, inability to achieve orgasm, and dyspareunia. Studies have found that sexual complaints are common among women with pelvic floor disorders. Pelvic floor symptoms are significantly associated with reduced sexual arousal, infrequent orgasm, and dyspareunia. Most of the studies have shown that sexual function is worse in women with symptomatic prolapse but not in women with asymptomatic prolapse.
Although the development of validated questionnaires to measure sexual function among women with pelvic floor disorders clearly represents an advance in our field, we still don't fully understand how to interpret the scores derived for these validated tools. Any experienced obstetrician knows that the injuries to perineum and anal sphincter can be mentally devastating and extremely painful. Even when attempting to remove known risk factors, we cannot always prevent or predict sphincter injuries. These new mothers should be informed of the special care required to keep their repair intact, and that they may experience a "slow road" to recovery compared with their friends and family who never had such an injury. We should also remember to specifically ask them about symptoms like fecal incontinence and sexual dysfunction during postpartum visits, as many women are reluctant to bring these things up. We should emphasize the importance of pelvic floor muscle strengthening, and possibly even refer them to pelvic floor physical therapist to optimize this training.
Trauma during vaginal delivery might result in a variety of pelvic floor complaints; stress incontinence and fecal incontinence are the most frequent and long lasting. Stress incontinence is observed in 20-34% of women after vaginal delivery, 3% with daily or more frequent leakage. The incidence of stress incontinence is significantly reduced with pelvic floor rehabilitation in the postpartum period and also later in life. In some studies, pelvic floor education with biofeedback techniques has shown benefit in 89% of women. Likewise, electrostimulation has shown significant improvement in long-term relief of stress and fecal incontinence.
Caring for women with pelvic floor disorders has become an increasingly important component of women's healthcare. These disorders, which include urinary and fecal incontinence, as well as pelvic organ prolapse, affect a large segment of the adult female population. Over the next 30 years, growth in demand for services to care for female pelvic floor disorders will increase at twice the rate of growth of the same population. Age plays a major role in the distribution of conditions with which patients present. These findings have broad implications for those responsible for administering programs to care for women, allocating research funds in women's health and geriatrics, and training physicians to meet this rapidly escalating demand.
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- Rogers RG, Coates KW, Kannerer-Dork D et al. A short form of the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Int Urogynecol J Pelvic Floor Dysfunct 2003;14:164-168
- Brubaker K, Handa VL, Bradley CS et al. Sexual function 6 months after first delivery. Obstet Gynecol 2008;111:1040-1044
- FitzGerald MP, Weber AM, Howden N et al for the Pelvic Floor Disorders Network. Risk factors for anal sphincter tear during vaginal delivery. Obstet Gynecol 2007;109:29-34
- Culligan PJ. The impact of pelvic floor dysfunction on sexuality: how should we counsel our patients? Obstet Gynecol 2008;111:1037-1038
- Handa VL, Cundiff G, Chang HH et al. Female sexual function and pelvic floor disorders. Obstet Gynecol 2008;111:1045-1052
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