PHYSIOTHERAPY MANAGEMENT
OF
PELVIC FLOOR DYSFUNCTION

PHYSIOTHERAPISTS WHO TREAT PATIENTS SUFFERING FROM PELVIC FLOOR DYSFUNCTION NEED TO BE AWARE OF THE SENSITIVITY OF WOMEN WITH REGARDS TO THESE CONDITIONS. URINARY OR FECAL INCONTINENCE IS OFTEN REGARDED AS SOMETHING TO BE ASHAMED OF OR AS REGRESSION TO INFANCY,

PARTICULARLY AMONG THE OLDER AGE GROUPS. THEY ARE RELUCTANT TO SEEK HELP OR DISCUSS THE PROBLEM WITH THEIR DOCTORS.

FORTUNATELY, THE INCREASE IN FEMALE GENERAL PRACTITIONERS HAS MADE IT EASIER FOR WOMEN TO RAISE THE TOPIC. THEREFORE IN ASSESSING AND TREATING THESE CONDITIONS PHYSIOTHERAPIST NOT ONLY NEED TO TAKE THE LEAD FROM THE PATIENTS ATTITUDE, BUT TO REALIZE THAT THESE AREA OF HEALTH REQUIRES A DIFFERENT APPROACH FROM THAT USED IN OTHER MUSCULOSKELETAL CONDITIONS.

PHYSIOTHERAPIST ARE RESPONSIBLE FOR ACCURATE ASSESSMENT AND DIAGNOSIS PRIOR TO TREATMENT .

ANATOMY OF THE PELVIC FLOOR

_STRUCTURE OF THE PELVIC FLOOR_

THE PELVIC FLOOR IS A MULTI LAYERED SHEET OF MUSCLE STRETCHED IN BETWEEN THE PUBIS AND THE COCCYX FORMING THE INFERIOR SUPPORT TO THE ABDOMINO-PELVIC CAVITY. THE MAJOR MUSCLE OF THE PELVIC FLOOR IS THE PUBOCOCCYGEUS MUSCLE.

OTHER MUSCLES INCLUDE

ISCHIOCOCCYGEUS, ILLIOCOCCYGEUS,

PUBOVAGINALIS, PUBORECTALIS.

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_FUNCTION OF PELVIC FLOOR_

*PROVIDES SUPPORT FOR THE PELVIC ORGANS AND THEIR CONTENTS.

*WITHSTANDS INCREASES IN INTRA ABDOMINAL PRESSURE.

*PROVIDES SPHINCTER CONTROL OF THE PERINEAL OPENINGS.

*FUNCTIONS IN REPRODUCTIVE AND SEXUAL ACTIVITY.

*ASSISTS IN UNLOADING THE SPINE.

*ASSISTS IN PELVI- SPINAL STABILITY.

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_DYSFUNCTION_

*MUSCLE AND SOFT TISSUE LAXITY.

vTHE PELVIC ORGANS DROP FROM THEIR NORMAL ALIGNMENT BECAUSE OF INCREASED PRESSURE ON THE PELVIC FLOOR.

vURINARY STRESS INCONTINENCE. (INVOLUNTARY URINE LOSS WITH INCREASE IN ABDOMINAL PRESSURE) MAY OCCUR AND WORSEN WITH SUBSEQUENT PREGNANCIES, INCREASE IN WEIGHT, AND AGEING.

B. PELVIC FLOOR DISRUPTION

v EPISIOTOMY : AN INCISION IN THE PELVIC FLOOR MADE DURING CHILDBIRTH TO ENLARGE THE VAGINAL OPENING AND ALLOW EASIER AND FASTER DELIVERY. IT CAN PRODUCE PAIN, CAUSE SCARRING OR BECOME INFECTED.

vTEARS AND LACERATIONS MAY OCCUR DURING CHILDBIRTH PARTICULARLY IF THE BABY IS LARGE OR IF A FORCEPS DELIVERY IS NECESSARY.

C. HYPERTONICITY

A INCREASE IN MUSCLE TENSION OR FASCIAL

TIGHTNESS OF PELVIC FLOOR SIGNIFICANT ENOUGH TO

IMPAIR NORMAL SEXUAL AND ELIMINATION FUNCTIONS.

THIS PROBLEM MAY OCCUR AS A RESULT OF IMPROPER

POST PARTUM HEALING AND MAY BE QUITE PAINFUL.

_PHYSIOTHERAPY ASSESSMENT_

ASSESSMENTS AND TREATMENTS MUST BE CARRIED OUT IN A PRIVATE ROOM.

PRESENTING SYMPTOMS IN ORDER OF IMPORTANCE:

* RELEVANT OBSTETRIC, MEDICAL GYNECOLOGICAL AND SURGICAL HISTORY.

* INVESTIGATIONS AND PREVIOUS AND CURRENT TREATMENTS.

* DETAILS OF ACTIVITY LEVELS, HARMONAL STATUS, AND MEDICATIONS, BOTH PRESCRIBED AND OVER THE COUNTER.

* DETAILS OF VOIDING - DYSFUNCTION /

INCONTINENCE.

* DETAILS FROM FREQUENCY VOLUME (F/ V CHART)

AND FLUID INTAKE.

* ANORECTAL FUNCTION AND CURRENT MANAGEMENT.

* OBJECTIVE ASSESSMENT - DEFECATION PATTERN.

* OBJECTIVE ASSESSMENT OF PELVIC FLOOR

MUSCULATURE.

OBJECTIVE ASSESSMENT OF PELVIC FLOOR INCLUDES

* EXTERNAL OBSERVATION.

* DIGITAL PER VAGINAM MUSCLE ASSESSMENT.

* DIGITAL PER ANUM MUSCLE ASSESSMENT.

* EFFECT OF COUGHING AND STRAINING ON THE

VAGINAL WALL AND ORGAN POSITION.

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_TREATMENT METHODS_ __

THE SEQUENCE IN WHICH THE PHYSIOTHERAPY

TREATMENT IS CARRIED OUT FOR PELVIC FLOOR

DYSFUNCTION DEPENDS ON INDIVIDUAL NEEDS.

MOST FORMS OF DYSFUNCTION REQUIRE MUSCLE

REHABILITATION AND / OR FUNCTIONAL TRAINING.

THERAPEUTIC EXERCISE TECHNIQUES TO THE

PELVIC FLOOR MUSCLES ARE TAUGHT TO IMPROVE CONTROL AND

FOR THE RELAXATION OF THE MUSCLES.

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_MUSCLE REHABILITATION_

IN A MAJORITY OF PATIENTS THE FIRST TREATMENT PRIORITY IS IMPROVING MUSCLE SUPPORT.

PUBOCOCCYGEUS IS THE PRINCIPAL MUSCLE REQUIRING ATTENTION, BUT BEFORE STRENGTHENING CAN BEGIN THE PATIENT MUST HAVE A AWARENESS OF WHAT SHE IS DOING AS VISUAL CUES ARE GENERALLY LIMITED.

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_MUSCLE AWARENESS_

* Recent clinical observations have

demonstrated that a pubococcygeus contraction

can be facilitated by a transverse abdominis

contraction.

* In some women activation of transverse abdominis requires specific re-education and this may take some time.

- Tactile input from the physiotherapist during

assessment enables sensory and verbal

feedback of a correct muscle action.

- This is often sufficient to enable progression

to a strengthening program.

- A vaginal weight is one of the best ways to

provide feed back of a correct muscle action.

This is often sufficient to enable progression

to a strengthening program.

* Neuromuscular stimulation using a vaginal

electrode to obtain a muscle contraction. This may

require the probe inserted by the patient to be

used on each pubococcygeus with the patient

controlling the position and the current intensity.

Palpation of the perineum can detect perennial lift

which accompanies the muscle contraction.

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_RE-EDUCATION_

HAVING DEVELOPED AN AWARENESS OF THE

CORRECT ACTION THE RE-EDUCATION COMMENCES.

*FREE EXERCISES.

*BIO FEED BACK OR NMS CAN BE USED IN THE PROCESS.

RECENT RESEARCH CONFIRMS THAT A

PUBOCOCCYGEAL LIFT IS EASIER TO ACTIVATE AND IS

MORE EFFECTIVE BY EXERCISING WITH A NORMAL

LUMBAR CURVE OR FIXED ANTERIOR PELVIC TILT POSITION.

ACTIVATION OF TRANSVERSE ABDOMINIS CAN BE

USED TO REINFORCE THE PELVIC FLOOR MUSCLE

CONTRACTION IN MOST PATIENTS.