Pelvic Floor Dysfunction: Determining When Your Patient Might Need Pelvic PT

Pelvic Floor Dysfunction:
Determining When Your
Patient Might Need Pelvic PT
Alyssa RM George, DPT, OCS
April 26, 2014
Objectives
Define the various types of
incontinence and pelvic floor
dysfunction (PFD)
Describe the prevalence of PFD
Identify risk factors for PFD
Describe evaluation and
treatment for PFD by pelvic PTs
2
Definitions
 Incontinence: involuntary leakage of urine, feces, flatus
 Stress Incontinence: involuntary leakage on effort or
exertion, or on sneezing or coughing (most frequent)
 Urge Incontinence: involuntary leakage associated with
urgency
 Mixed: both SUI and UUI
Definitions Continued
 Pelvic Organ Prolapse (POP): muscles and ligaments
supporting a woman’s pelvic organs weaken and the
pelvic organs slip out of place (www.mayoclinic.org)
 Diastasis Recti Abdominis (DRA): separation of two
bellies of rectus abdominis (www.mayoclinic.org)
 Pelvic Floor Muscle Dysfunction
 Overactive
 Underactive
 Incoordination
Prevalence Rates of UI
 25-45% of women any leakage ≥1x/year (Buckley & Lapitan 2010)
 10% of women leak urine weekly (Tennstedt et al, 2008)
 30% of exercising women leak during at least one type of exercise
(Goldstick & Constantini 2014)
 28-80% prevalence of UI in female athletes (Goldstick & Constantini
2014)
 Highest prevalence in high impact (both feet leave the ground)
sports: gymnastics, track and field, volleyball, basketball (Goldstick &
Constantini 2014)
 Urgency most apparent in cyclists and soccer players (Goldstick &
Constantini 2014)
UI Risk Factors in Athletes
 Low BMI
 Eating disorders (Araujo et al 2008)
 Inadequate nutritional support for tissues
 Vomiting = increased IAP
 High impact sport
 Symptoms at the end of training/race/competition
indicates poor endurance of PFMs (Caylet et al, 2006)
Additional UI Risk Factors
 Former/current smoking >20 cigarettes/day (Hannestad
et al 2003)
 High BMI (Hannestad et al 2003)
 Age > 40 (Peyrat et al, 2008)
 Multiple pregnancies, s/p hysterectomy (Peyrat et al,
2008)
 More than 90% do not report problem and have no
knowledge of preventive measures (Carls 2007)
Myofascial Pain Syndrome
 Chronic pain disorder
 Pressure on sensitive points in muscles (trigger points)
causes pain in seemingly unrelated parts of your body
(referred pain).
 Occurs after a muscle has been contracted repetitively
(jobs, hobbies, stress-related muscle guarding)
(www.mayoclinic.org)
Key Pain Generating Muscles Within The Pelvis
 Coccygeus
 Levator Ani
 Obturator Internus
 Piriformis
http://medicina.ronnie.cz/c-1451-svaly-kycelniho-kloubu.html
http://belleamiemotherofthree.com/wordpress/?p=5000
Key Pain Generating Muscles Within The Pelvis
 To a lesser degree,
muscles of urogenital
diaphragm (Bo and
Sherburn, 2005)
http://withfriendship.com/user/mithunss/pubococcygeus-muscle.php
Trigger Point Referral Patterns
Obturator Internus, Levator Ani
Gluteus Medius

TriggerPoints.net

Travell and Simons, 1992
Adductors
 Adductor origins at pubic ramus
and ischial tuberosity
 Adductor fascia at pubic rami is
in close proximity to superficial
perineal muscle fascia
http://en.wikipedia.org/wiki/Adductor_longus_muscle
Iliopsoas
 “Hidden prankster” (Travell
and Simons, 1992)
 Important to treat in
lumbopelvic dysfunctions
http://en.wikipedia.org/wiki/Iliopsoas
Questions To Ask Your Patients
 Do you experience frequent urination? (>8-10 times/day)
 Do you experience strong urges to urinate and need to rush to
the toilet?
 Do you leak urine, stool, or gas at inappropriate times?
 Do you experience pain in your genitals?
 Do you experience pain with intercourse?
 Ask patient “on a scale of 0 to 10, how severely does your
condition affect your life?”
(0= no effect; 10= severely limiting)
Questions To Ask Yourself
 Am I able to reproduce my patient’s pain?
 Is it possible this patient’s musculoskeletal dysfunction is
causing urogenital dysfunction?
 Is this patient a good candidate for PFM therapy?
(requires motivation and persistence as progress is often
slow and gradual)
What Pelvic PTs Can Do
 Internal (gold standard) or external assessment and
treatment of pelvic floor muscles including deep hip
rotators







Muscle strength (power & endurance)
Trigger points
Atrophy/bulk
Urethral mobility
Coordination, ability to rest between contractions
Sensation
Scars/adhesions
Additional Methods Of Muscle Assessment
 Ultrasound and MRI more objective of lifting
 Dynamometers measure force directly (Bo and Sherburn,
2005)
 Surface EMG
What Pelvic PTs Can Do
 Modalities
 Orthopedic PT interventions
 Biofeedback assessment and treatment of pelvic floor
muscle activity using surface EMG or internal vaginal or
rectal sensors
 Internal electrical stimulation for strengthening very weak
pelvic floor muscles or reducing urgency
 Dry Needling (Alyssa George)
Common Conditions We Can Treat
Abdominal Pain, Adhesions of intestine,
bowel, uterus, peritoneum
Levator Ani Syndrome
SIJ Dysfunction
Abdominal Phrenic Dyssynergia
Painful Bladder Syndrome
Sciatica/LBP/Piriformis/OI
Dysfunction, Painful Scar
Coccydynia
Pelvic Girdle Pain
Urinary Incontinence
Constipation
Pelvic Organ Prolapse
Urinary Retention
Cystocele
Pelvic Pain
Urinary Urgency
Diastasis Recti
Post-radiation PF Pain
Urinary Frequency
Dyspareunia
Pubic Symphysis Dysfunction
Uterocele
Dyssynergic Defecation
Pudendal Neuralgia
Vaginismus
Fecal/Anal Incontinence
Rectal Pain
Vulvodynia
Interstitial Cystitis
Rectocele
Prostatitis, Scrotum/Testes Pain,
Perineal Spasm
Questions?
20
References
Araujo MP, Oliveira E, Zucchi EV, et al. 2008. The relationship between urinary incontinence and eating disorders in female longdistance runners. Rev Assoc Med Bras 54:146-9.
Bo K, Sherburn M. 2005. Evaluation of female pelvic-floor muscle function and strength. Phys Ther 85:269-282.
Buckley BS, Lapitan MC. 2010. Prevalence of urinary incontinence in men, women and children—current evidence: finding of the
Fourth International Consultation on Incontinence. Urology 76:265-70.
Carls C. 2007. The prevalence of stress urinary incontinence in high school and college-aged female athletes in the Midwest:
implications for education and prevention. Urol Nsg 27(1): 21-24.
Caylet et al. 2006. Prevalence and occurrence of stress urinary incontinence in elite women athletes. Can J Urol 13:3174-9.
Goldstick O, Constantini N. 2014. Urinary incontinence in physically active women and female athletes. BJSM 48:296-298
Hall C, Thein Brody L. Therapeutic Exercise: Moving Toward Function, 2nd ed. Baltimore: Williams & Wilkins, 2005.
Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. 2003. Are smoking and other lifestyle factors associated with female urinary
incontinence? The Norwegian EPINCONT Study. BJOG: An International Journal of Obstetrics & Gynaecology, 110:247-254.
Peyrat L, Haillot O, Bruyere F, Boutin JM, Bertrand P, Lanson Y. 2008. Prevalence and risk factors of urinary incontinence in
young and middle aged women. BJU International, 89:61-66.
Tennstedt SL, Link CL, Steers WD, et al. 2008. Prevalence of and risk factors for urine leakage in a racially and ethnically diverse
population of adults: the Boston Area Community Health (BACH) Survey. Am J Epidemiol 167:390-9.
Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual, vol 2. Baltimore: Williams & Wilkins, 1992.
References
http://www.mayoclinic.org/diseases-conditions/pelvic-organprolapse/basics/definition/con-20036092 Accessed: 04/04/14
http://www.triggerpoints.net/triggerpoints/glut-med.htm Accessed: 04/12/14
http://www.triggerpoints.net/triggerpoints/sphincter-ani--levator-ani--coccygeus-obturator-in.htm Accessed: 04/12/14
http://en.wikipedia.org/wiki/Iliopsoas Accessed: 04/14/14
http://en.wikipedia.org/wiki/Adductor_longus_muscle Accessed: 04/14/14
http://withfriendship.com/user/mithunss/pubococcygeus-muscle.php Accessed:
04/15/14
http://belleamiemotherofthree.com/wordpress/?p=5000 Accessed: 04/15/14
http://medicina.ronnie.cz/c-1451-svaly-kycelniho-kloubu.html Accessed: 04/15/14