La riabilitazione perineale nella donna di benedetto


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GLUP_Gardone_Lettura Magistrale: “La riabilitazione perineale nella donna” – P. Di Benedetto

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La riabilitazione perineale nella donna di benedetto

  1. 1. GLUP (Gruppo di Lavoro Uroginecologia Pavimento Pelvico) Pavimento Pelvico ed Evento Ostetrico Gardone Val Trompia, 16 Aprile 2011 P. Di Benedetto, 2011
  2. 2. La Riabilitazione Perineale nella Donna Paolo Di Benedetto, Udine P. Di Benedetto, 2011
  3. 3. Conservative treatment <ul><li>Conservative treatment is any therapy that does not involve pharmacological or surgical intervention </li></ul><ul><li>It includes principally </li></ul><ul><li>- lifestyle interventions </li></ul><ul><li>- physical therapies </li></ul><ul><li>- scheduled voiding regimens </li></ul><ul><li>- complimentary therapies </li></ul><ul><li>- anti-incontinence devices </li></ul><ul><li>- supportive rings/pessaries </li></ul><ul><li>- pads/catheters </li></ul>P. Di Benedetto, 2011
  4. 4. Pelvic Floor Rehabilitation <ul><li>The use of PFMT as a treatment for stress urinary incontinence (SUI) appeared to become more widespread after Arnold Kegel reported on the successfull treatment of 64 cases of female SUI using pelvic floor muscle exercises, with a perineometer for resistance and biofeedback. </li></ul><ul><li>* 1992: Lower Urinary Tract Rehabilitation Techniques: seventh report on the standardization of terminology of lower urinary tract function (Neurourol Urodyn 1992;11:593-603) </li></ul><ul><li>* 1998: first International Consultation on Incontinence (Monaco) </li></ul><ul><li> -> algorithms for initial and specialised management of urinary incontinence </li></ul>P. Di Benedetto, 2011
  5. 5. P. Di Benedetto, 2011
  6. 6. Pelvic Floor Rehabilitation TECHNIQUES <ul><li>- Biofeedback (BFB) </li></ul><ul><li>Pelvic Floor Muscle Training (PFMT) </li></ul><ul><li>Functional Electrical Stimulation (FES) </li></ul><ul><li>- Endovaginal Cones </li></ul><ul><li>Bladder Retraining </li></ul>P. Di Benedetto, 2011
  7. 7. Pelvic Floor Rehabilitation <ul><li>* Pelvic floor muscle training (PFMT) </li></ul><ul><ul><li>- with or without biofeedback </li></ul></ul><ul><ul><li>- with or without adjuncts such as cones, resistance devices etc </li></ul></ul><ul><li>* Electrical stimulation </li></ul><ul><li>* Alternative methods? </li></ul>P. Di Benedetto, 2011
  8. 9. Pelvic Floor Skeletal Muscles <ul><li>Slow Twitch Fibers ( type I </li></ul><ul><li> support of the pelvic viscera ) </li></ul><ul><li>Fast Twitch Fibers ( type II </li></ul><ul><li> occlusive effect on the urethra, reflex detrusor inhibition ) </li></ul>P. Di Benedetto, 2011
  9. 10. Optimal function of the PFM? <ul><li>- Form a structural support (location, cross sectional area, stiffness) </li></ul><ul><li>- Give quick and strong unconscious co-contraction before/during increase in abdominal pressure </li></ul><ul><li>- Prevent descent of internal organs during increase in intra-abdominal pressure </li></ul><ul><li>- Relax before and during voiding/defecation </li></ul>P. Di Benedetto, 2011
  10. 11. Female pelvic floor dysfunction <ul><li>- Urinary incontinence </li></ul><ul><li>- Fecal incontinence </li></ul><ul><li>- Pelvic organ prolapse </li></ul><ul><li>- Sensory and emptying abnormalities of LUT </li></ul><ul><li>- Constipation </li></ul><ul><li>- Sexual dysfunction </li></ul><ul><li>- Chronic Pelvic Pain </li></ul>P. Di Benedetto, 2011
  11. 12. Pelvic Floor Rehabilitation <ul><li>Non-surgical therapy (PFMT, bladder retraining and lifestyle interventions) should be considered as the first line of therapy for urinary incontinence </li></ul><ul><li>- no side effects </li></ul><ul><li>good results </li></ul><ul><li>surgical option not compromised </li></ul>P. Di Benedetto, 2011
  12. 13. Pelvic Floor Dysfunction Pathophysiology P. Di Benedetto, 2011
  13. 14. JO DeLancey . Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6 The interaction between the pelvic floor muscles (PFM) and the supportive ligaments is critical to support of the pelvic organs. As long as the PFMs function normally, the pelvic floor is closed and the ligaments and fascia are under no tension. The fascia simply act to stabilize the organs in their position above the levator ani muscles. P. Di Benedetto, 2011
  14. 15. JO DeLancey . Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6 When the PFMs relax or are damaged, the pelvic floor opens and the vagina lies between the high abdominal pressure and low atmospheric pressure. In this situation it must be held in place by the ligaments. Although the ligaments can sustain these loads for short period of time, if the PFMs do not close the pelvic floor, then the connective tissue will became damaged and eventually fails to hold the vagina in place. P. Di Benedetto, 2011
  15. 16. PFM DYSFUNCTION Consequences <ul><li>Lack of the PFM “reflex” contraction </li></ul><ul><li>Genital prolapse </li></ul><ul><li>Genuine stress incontinence </li></ul><ul><li>Overactive bladder </li></ul><ul><li>Sexual problems </li></ul><ul><li>Constipation </li></ul><ul><li>Chronic pelvic pain </li></ul>P. Di Benedetto, 2011
  16. 17. PFM DYSFUNCTION <ul><li>Primary Weakness </li></ul><ul><li>(phasic and tonic components ) </li></ul><ul><li>Apraxia (?) </li></ul><ul><li>Secondary Weakness </li></ul><ul><li>(neurogenic, post-partum, post- surgery) </li></ul>P. Di Benedetto, 2011
  17. 18. P. Di Benedetto, 2011
  18. 19. PFM DYSFUNCTION <ul><li>Hypertonia </li></ul><ul><li>(nonneurogenic, neurogenic) </li></ul><ul><li>Dyssynergic patterns </li></ul>P. Di Benedetto, 2011
  19. 20. Boath in Dry Dock ( Norton PA, 1993) P. Di Benedetto, 2011
  20. 21. P. Di Benedetto, 2011
  21. 22. Pelvic Floor Consequences of <ul><li>Occupation </li></ul><ul><li>Sport </li></ul><ul><li>Pregnancy </li></ul><ul><li>Childbirth </li></ul><ul><li>Menopause </li></ul>P. Di Benedetto, 2011
  22. 23. URINARY INCONTINENCE Epidemiological Studies (1) <ul><li>Nygaard et al (1994) </li></ul><ul><li>158 athletes, mean age 19.9 years </li></ul><ul><li>all nulliparous </li></ul><ul><li>28% urinary incontinence during sport </li></ul><ul><li>activities (2/3 IU more often than rarely) </li></ul><ul><li>67% gymnastics </li></ul><ul><li>66% basketball </li></ul><ul><li>50% tennis </li></ul><ul><li>10% swimming </li></ul><ul><li> 0% golf </li></ul>P. Di Benedetto, 2011
  23. 24. URINARY INCONTINENCE Epidemiological Studies (2) <ul><li>Warren and Shantha </li></ul><ul><li>high impact sports activities may produce urinary incontinence </li></ul><ul><li>Greydanus and Patel </li></ul><ul><li>adolescent gynecology: </li></ul><ul><li> stress urinary incontinence is common in female athletes </li></ul>P. Di Benedetto, 2011
  24. 25. URINARY INCONTINENCE Epidemiological Studies (3) <ul><li>Bø and Borgen </li></ul><ul><li>high prevalence of stress and urge incontinence in female elite athletes, </li></ul><ul><li>mainly in eating disordered athletes compared with healthy athletes </li></ul>P. Di Benedetto, 2011
  25. 26. URINARY INCONTINENCE Epidemiological Studies (4) <ul><li>Thyssen et al </li></ul><ul><li>elite women athletes and dancers </li></ul><ul><li>291 women, mean age 22.8 years </li></ul><ul><li>51,9% urinary loss ( 43% during sport/dancing; 42% during daily life) </li></ul><ul><li>the activity most likely correlated with </li></ul><ul><li> urinary incontinence was jumping </li></ul>P. Di Benedetto, 2011
  26. 27. INCITE childbirth nerve damage muscle damage radiation tissue disruption radical surgery PREDISPOSE gender racial neurologic anatomic collagen muscular cultural enviromental PROMOTE constipation occupation recreation obesity surgery lung disease smoking menstrual cycle infection medication menopause INTERVENE behavioral pharmacologic devices surgical DECOMPENSATE aging dementia debility environment medication normal support or function abnormal support or function Model for the development of pelvic floor dysfunction in women (Bump et al, 1998) P. Di Benedetto, 2011
  27. 28. INCITING FACTORS <ul><li>Role of </li></ul><ul><li>- radical pelvic surgery </li></ul><ul><li>- pelvic radiation </li></ul><ul><li>- vaginal delivery </li></ul><ul><li>- nerve damage </li></ul><ul><li>- muscular damage </li></ul>P. Di Benedetto, 2011
  28. 29. <ul><li>PROMOTING FACTORS </li></ul><ul><li>It is intuitive that occupational or recreational activities result in excessive or repetitive increases in abdominal pressures that contribute to the development of pelvic floor dysfunction in presence of weak pelvic floor muscles. </li></ul>P. Di Benedetto, 2011
  29. 30. INTRAPARTUM INJURY CONNECTIVE TISSUE Breakage Stretching LEVATOR ANI MUSCLES Muscles Tears Pudendal Nerve Acute Denervation Loss of muscle tone Chronic Denervation Aging Connective tissue failure GENITAL PROLAPSE Proposed mechanism for acute injury to pelvic supportive structures at childbirth that may result in chronic denervation and pelvic organ prolapse (from Strohbehn, 1998) P. Di Benedetto, 2011
  30. 31. Vaginal childbirth <ul><li>It can contribute to pelvic floor dysfunction and POP by </li></ul><ul><li>- direct damage to the endopelvic fascia and walls of the vagina </li></ul><ul><li>- indirect damage to the muscles and nerves of the pelvic floor. </li></ul>P. Di Benedetto, 2011
  31. 32. After childbirth <ul><li>The connective tissue did not recovery! </li></ul><ul><li>Episiotomy and lacerations of the perineal musculature (and, sometimes, of the external anal sphincter and rectum) often provoke apraxia of the PFMs </li></ul><ul><li>The duration of this condition is an adjunctive risk for the endopelvic connective tissue </li></ul><ul><li>The eventual neurophatic injury is an other obstacle for the spontaneous recovery for the PFMs </li></ul>P. Di Benedetto, 2011
  32. 33. What can weaken connective tissue and pelvic floor muscles? <ul><li>- Overweight: 55-60% of US population over 18 years of age!!! INACTIVITY </li></ul><ul><li>- Constipation – straining with bowel motion </li></ul><ul><li>- Smoking – excessive coughing </li></ul><ul><li>- Strenous work/ heavy lifting/sport (??) </li></ul><ul><li>- Pregnancy and childbirth (stretch/rupture of muscles, connective tissue, nerve lesion) </li></ul><ul><li>- Pelvic surgery </li></ul><ul><li>- Inherited weak connective tissue </li></ul>P. Di Benedetto, 2011
  33. 34. Rationale of Pelvic Floor Rehabilitation <ul><li>Identification of pathophysiological mechanisms of bladder, sphincters and pelvic floor dysfunction </li></ul><ul><li>Absence of pelvic floor (complete) denervation </li></ul><ul><li>Good education of the physical therapist </li></ul><ul><li>Motivation, collaboration and compliance of the patient </li></ul>P. Di Benedetto, 2011
  34. 35. Rationale of Pelvic Floor Rehabilitation <ul><li>Previously trained PFM might be less prone to injury, and/or easier to </li></ul><ul><li>retrain after injury because the appropriate motor patterns are </li></ul><ul><li>already learned. </li></ul><ul><li>For childbearing women , PFMT during pregnancy might help </li></ul><ul><li>counteract the increased intra-abdominal pressure caused by the </li></ul><ul><li>growing fetus, the hormonally mediated reduction in urethral </li></ul><ul><li>pressure, and the increased laxity of fascia and ligaments in the </li></ul><ul><li>pelvic area. </li></ul>P. Di Benedetto, 2011
  35. 36. During voluntary PFM contraction <ul><li>- Levator hiatus constriction (urethra, vagina, anus) 25% (Brækken et al -09) </li></ul><ul><li>- ↑ MUCP: 11.1 (10.7)-23.2 (8.4) cm H 2 O (Miller et al-04, Bø & Talseth -97) </li></ul><ul><li>- Muscle length: 21% shortening (Brækken et al -09) </li></ul><ul><li>. Forward and upward movement: 1 cm (Bø et al 2001, Brækken et al 2008) </li></ul><ul><li>- Resistance to downward movement </li></ul><ul><li>- Inhibition of detrusor contraction </li></ul>P. Di Benedetto, 2011
  36. 37. Ability to contract PFM correctly <ul><li>- >30% not able to contract (Benvenuti et al 1987, Bø et al 1988,Hesse et al 1990) </li></ul><ul><li>- Only 49% increased urethral pressure during contraction (Bump et al 1991) </li></ul><ul><li>- 25% straining instead of contracting (Bump et al 1991) </li></ul>P. Di Benedetto, 2011
  37. 38. Rationale of Pelvic Floor Rehabilitation <ul><li>Standard PFMT should be advised to all postnatal women. </li></ul><ul><li>Intensive PFMT is mandatory in symptomatic women (UI or initial </li></ul><ul><li>prolapse). </li></ul>P. Di Benedetto, 2011
  38. 39. Rationale of Pelvic Floor Rehabilitation <ul><li>The biological rationale for PFMT in the management of SUI is that a </li></ul><ul><li>strong and fast PFM contraction will clamp the urethra, increasing </li></ul><ul><li>the urethral pressure to prevent leakage during an abrupt increase in </li></ul><ul><li>intra-abdominal pressure. </li></ul><ul><li>DeLancey has also suggested that an effective PFM contraction may </li></ul><ul><li>press the urethra against the pubic symphysis, creating a mechanical </li></ul><ul><li>pressure rise. </li></ul>P. Di Benedetto, 2011
  39. 40. Rationale of Pelvic Floor Rehabilitation <ul><li>Sometimes there is some evidence of PFM reflex contraction deficit </li></ul><ul><li>(feed-forward loop, as it precede bladder pressure rise by 200-240 </li></ul><ul><li>msec). </li></ul><ul><li>In these cases PFMT might normalize this reflex. </li></ul>P. Di Benedetto, 2011
  40. 41. Rationale of Pelvic Floor Rehabilitation <ul><li>There are two hypotheses to explain mechanisms of </li></ul><ul><li>PFMT: </li></ul><ul><li>1) Use of conscious contraction before and during increase in abdominal pressure ( the Knack) </li></ul><ul><li>2) Building up a structural support, thereby facilitating automatic co-contractions whenever needed </li></ul>P. Di Benedetto, 2011
  41. 42. The ”Knack” Miller et al 1998 <ul><li>- 27 women. Mean age 68.4 (5.5) years with mild to moderate SUI </li></ul><ul><li>- 1 week of voluntary PFM contraction before and during cough </li></ul><ul><li>- Results: </li></ul><ul><li>Reduced urine loss from medium/ deep cough by average 98% and 73% </li></ul>P. Di Benedetto, 2011
  42. 43. RCTs on PFMT versus control on SUI <ul><li>- Significantly more effective than no treatment (Henalla et al -89, Henalla et al -90, Lagro-Janssen et al -91, Miller et al -98, Bø et al -99, Sung et al -00,Bidmead et al -02, Aksac et al -03, Dumoulin et al -03) </li></ul><ul><li>- Cure/improvement rates (SUI /mixed) 56-70% </li></ul>P. Di Benedetto, 2011
  43. 44. Rationale of Pelvic Floor Rehabilitation <ul><li>PFMT may also be used in the management of urge </li></ul><ul><li>incontinence. Bladder muscle contraction </li></ul><ul><li>can be reflexly or voluntarily inhibited by PFM contraction. </li></ul><ul><li>Therefore, single or repeated voluntary pelvic floor muscle </li></ul><ul><li>contraction may be used to control urgency and prevent </li></ul><ul><li>urinary leakage. </li></ul>P. Di Benedetto, 2011
  44. 45. Rationale of Pelvic Floor Rehabilitation <ul><li>In cases of chronic pelvic pain the aim of pelvic floor </li></ul><ul><li>rehabilitation (PFMT, FES, BFB) is to intervene on the vicious </li></ul><ul><li>circle </li></ul><ul><li>pelvic floor overactivity-ischemia-pain </li></ul>P. Di Benedetto, 2011
  45. 46. Conclusions <ul><li>PFMT -> </li></ul><ul><li>fundamental role in the pelvic floor rehabilitation </li></ul>P. Di Benedetto, 2011
  46. 47. Conclusions <ul><li>BFB -> </li></ul><ul><li>* poor perineal control </li></ul><ul><li>* pelvic floor tension myalgia (CPP) </li></ul>P. Di Benedetto, 2011
  47. 48. Conclusions <ul><li>FES -> </li></ul><ul><li>* in all types of urinary incontinence </li></ul><ul><li>* overactive bladder </li></ul><ul><li>* chronic pelvic pain </li></ul>P. Di Benedetto, 2011
  48. 49. Conclusions <ul><li>Endovaginal cones -> </li></ul><ul><li>in stress urinary incontinence </li></ul>P. Di Benedetto, 2011
  49. 50. Conclusions <ul><li>Bladdder Retraining ( ± PFMT) -> </li></ul><ul><li>in urge urinary incontinence </li></ul>P. Di Benedetto, 2011
  50. 51. PFR Clinical Recommendations <ul><li>If no PFM contraction: </li></ul><ul><li>facilitations by manual techniques </li></ul><ul><li>( or FES/BFB) </li></ul><ul><li>When voluntary contraction: </li></ul><ul><li>intensive PFMT </li></ul><ul><li>* No results: surgery (+ PFMT ?) </li></ul>P. Di Benedetto, 2011
  51. 52. PFR Clinical Recommendations <ul><li>After surgery: </li></ul><ul><li>- weakness of PFM: intensive PFMT </li></ul><ul><li>- pain: aerobic programs, electrical stimulation </li></ul><ul><li>- detrusor instability: bladder retraining, drugs (PFMT,FES…) </li></ul>P. Di Benedetto, 2011
  52. 53. ” Alternative” methods to PFMT? P. Di Benedetto, 2011
  53. 54. <ul><li> The FUTURE </li></ul>P. Di Benedetto, 2011
  54. 55. The core of PFR is the pelvic floor muscle awareness associated to pelvic floor muscle training. P. Di Benedetto, 2011
  55. 56. Nowadays some non-medical pelvic floor grouped activities are rising, in order to widely offer PFMT as already happening in forms of adapted physical activity (APA) in other fields (low back pain, Parkinson, stroke, fibromyalgia). P. Di Benedetto, 2011
  56. 57. It should be very important also a sensitization of both patients and health care professionals that often underestimate pelvic floor dysfunction ( prevention and negative effects on quality of life). P. Di Benedetto, 2011