pelvic_floor_dysfunction

2. Pelvic floor dysfunction
A- Genital prolapse
B- Stress incontinence

3. Genital prolapse
 Definition:
Descent of one or more of genital organs(uterus, vagina, bladder, urethra, rectum,
douglas pouch) through the fasciomuscular pelvic floor below their normal level.

4. Types of prolapse
 I- vaginal prolapse:
1-Anterior vaginal wall prolapse:
a. cystocele
b. urethrocele
c. cysto-urethrocele
2- Posterior vaginal wall prolapse:
a. rectocele
b. enterocele
3- Vault prolapse.

5. II- Uterine prolapse
 1-Utero-vaginal.
 2-Vagino-uterine.
 Degrees of uterine prolapse:

6. Causes of prolapse
 Predisposing factors:
 1- Weakness of pelvic cellular tissue:
The cervical ligaments which act as the main uterine support may become weakened by the
following:
a. obstetric trauma (large sized fetus, straining during 1ststage,prolonged 2ndstage with
delayed episiotomy, fundal pressure to deliver placenta in 3rd stage).
b. congenital weakness (as in spinabifida which interfere with innervation of pelvic floor).
c. postmenopausal atrophy (low estrogen level cause atrophy of pelvic cellular tissue,
ligaments and levator ani).
 2- Injury of the pelvic floor (badly repaired or unsutured perineal tear, hidden perineal
laceration).
 Activating factors:
(factor increase IAP as cough and constipation, RVF, heavy bulky uterus)

7. Symptoms:
 Early: sensation of weakness in the perineum at the end of the day.
 Later on: there is mass appearing on straining and disappearing when
patient lies down.
 Urinary symptoms:
-urgency and frequency by day.
-stress incontinence
 Rectal symptoms: heaviness in the rectum and constant desire to
defecate.
 Backache, congestive dysmenorrhea and menorrhagia.
 Leucorrhea.

8. 2- stress incontinence
 Definition:
Involuntary leakage of urine from the urethra which occurs on sudden increasing
of the intra-abdominal pressure as in coughing, laughing or in physical activities
in the absence of detrusor contraction.

9. Pathophysiology:
 Normally:
Bladder and proximal urethra are supported in retropubic position; so , the increase of
IAP distributed equally between bladder and urethra , therefore there is no leakage
occur.
 In case of stress incontinence:
There is lack or loss of anatomical support of bladder and urethra (urethra drops below
pelvic floor) so , the increase of IAB not equally distributed between bladder and
urethra (intravesical pressure exceeds intraurethral pressure) and leakage of urine
results.

10. Grades of stress incontinence:
 Grade 1: incontinence only occurs with severe stress as in coughing, sneezing
and heavy lifting.
 Grade 2: incontinence occurs with moderate stress as in rapid movements or
climbing stairs.
 Grade 3: incontinence occurs with mild stress as in standing. The patient
become continent in the supine position.

11. • Aetiology:
1- congenital:
- congenital defect of bladder or urethra support.
- spina bifida.
2- traumatic: obstetric or operative trauma.
3- hormonal dysfunction: as postmenopausal atrophy and sometimes during
pregnancy.
 Factors that provoke incontinence:
-Obesity, smoking and chronic cough.
-Infection and inflammation of urethra and bladder.
-Increase caffeine intake.
-Sedative hypnotic drugs.

12. Physiotherapy assessment for SUI:
 Examination of the perineum and pelvic floor.
 Modified oxford grading score for pelvic floor muscles.
 Objective tests:
- frequency/volume chart.
- one hour office pad test.
- 12 hours home pad test.
 Perineometer.
 EMG.

13. Treatment of pelvic floor dysfunction
 Prophylactic treatment.
 Palliative treatment for genital prolapse.
 Curative treatment for stress urinary incontinence.
 Actual treatment (physiotherapy role).
 Surgical treatment.

14. 1- Prophylactic treatment
 Careful attention for the obstetric cases can prevent subsequent prolapse and incontinence.
 A- proper antenatal care:
Pelvic floor exercises should be done during pregnancy as PFM should be strong and elastic
 Strong : to be able to perform gutter like action (internal rotation of fetal head during second
stage of labor).
 Elastic: to allow easy passage of fetus without or with minimal tear or trauma.
 B- proper intra-natal care:
-Proper management of first stage:
- Keep bladder empty during 1st stage of labour.
- Avoid straining during first stage of labour before full cervical dilatation.

15. - Avoid forceps usage before full cervical dilatation.
- Proper management of second stage:
- Firm support to the perineum during uterine contractions to avoid overstretching or laceration of
perineum.
- At crowning: ask the mother to stop bearing down during contraction and to pant.
- proper timing of episiotomy (at crowning if indicated) should be done to avoid hidden perineal
laceration.
- Avoid fundal pressure to deliver placenta during third stage of labor.
 Proper post natal care:
- Any perineal tear or laceration should be repaired carefully within 24 hours.
- strengthening ex of PFM to regain its strength which may be stretched or injured during delivery.
- Avoid RVF by positioning (relaxation on face , knee chest position).
- avoid bladder infection to guard against urgency incontinence.
- Avoid constipation and maintain good general health.

16. 2,a - palliative ttt:
- pessary are only temporary methods to give relief of symptoms.
 Indications of pessary:
- Slight degree of prolapse in young patient.
- Prolapse of the uterus with early pregnancy.
- Temporary contraindications to operations as lactation , sever cough.
- Bad surgical risks as old patient with severe hypertention or uncontrolled diabetes.
 Types of pessary:
- Ring pessary: it is introduced above level of levator ani to stretch redundant vaginal wall and
prevent descent of uterus
- Cup and stem pessary: it is used when PFM are so weak or lacerated so ring pessary cannot be
retained in vagina.
- Vaginal pessary as ring, Smith Hodge can be worn during spesific activities to eliminate SUI as it
prevent urethral hypermobility by supporting proximal urethra during stressful conditions.

17. 2,b- Curative ttt
 Advices are given to avoid activities which may aggravate SUI as heavy sports,
heavy lifting.
 stop smoking.
 Reduce body weight .
 Increase fluid and fibers intake to reduce constipation.

18. 3- actual treatment ( PT role):
In early and mild cases and as a prophylactic measure for puerperal cases.
 Aims of treatment:
- To inform patients of factors which may aggravate incontinence.
- To establish awareness of the function of pubococcygeus muscle and urethral
sphincter.
- To normalize the pelvic floor support and sphincter mechanism.
- To strengthen the pubococcygeus muscle.

19.  Physical therapy treatment is divided into two phases:
1- muscle re-education: to increase awareness of patient about function of
pubococcygeus muscle. It include:
A- Muscle reeducation for pubococcygeus muscle.
B-Biofeedback (kegel perineometer and EMG biofeedback.
C-Mid stream urine flow (stop test).
D-Cyriax method.
2- Resistive exercises for pubococcygeus muscle:
- An inflated cuffed catheter.
- Vaginal cones.

20.  A- muscle reeducation of pubococcygeus muscle:
-PFM consists of slow twitch muscle fiber and fast twitch muscle fiber
-Slow →responsible for maintain resting tone of muscle.so, it can be strengthened by increase
repetitions of ex.
-fast→ save closure mechanism and guard against involuntary leakage of urine. So , it can be
strengthened by resistive ex.
 Graduations of pubococcygeus ms ex:
- Quick flick: contract and relax the ms as quickly as possible for 10-20 times and relax for 10
counts, then repeat. Do ex with repetitions, increasing by 5 repetitions per week up to 50
repetitions.
- Slow contraction: tighten ms as hard as you can for 10-20 count and relax for 10 counts, then
repeat. Do ex with repetitions, increasing by 5 repetitions per week up to 50 repetitions.
- Sustained contraction: tighten ms halfway(half as hard as you did for slow contraction), hold for
60 sec and relax for 20 counts, then repeat. Do ex with repetitions, increasing by 2 repetitions per
week up to 10 repetitions.
-PF ex should be performed during daily activities from different positions with isolation of
abdominal, glutei and hip adductor muscles.

21.  B- Biofeedback:
1- kegel perineometer:
- It consists of cylindrical rubber vaginal chamber connected to manometer by rubber tube.
- Vaginal chamber is lubricated by KY gel and inserted into vagina while the patient in
comfortable crock lying position with pillows under head and knees. The patient was asked to
contract pubococcygeus ms as she can and hold contraction.
- It measures intra-vaginal pressure reflecting force of contraction of PFM., it can measure
contractions up to 100 mmHg.
- It provides patient with sensory and visual feed back.

22.  2- EMG biofeedback:
-it consists of vaginal electrode, 3 surface electrodes , ear phone and screen.
-Vaginal electrode is lubricated and inserted into vagina, 3 surface electrodes are
placed on perineum in triangle shape with its apex directed downward. The patient
was asked to contract pubococcygeus ms as she can and hold contraction for 3, 10,
30, 60 sec and relax 2-5 min between contraction.
-It provides patient with sensory , visual and auditory feed back.
-It is used in both evaluation and actual treatment of pelvic floor dysfunction.
-it is useful in both increasing level of PFM contractions and improving ability of
the muscle to relax.

23.  C- mid-stream urine flow (stop test):
- It improve mild cases of SUI as PFM exert sphinctric action on urethra, an
increase of active and resting ms tone will increase urethral closure pressure.
- Firstly: the patient was asked to stop urine flow by contracting pubovaginalis ms
at the end of urine flow.
- Secondly: stop urine flow at the beginning of micturition, it is more difficult as it
needs more ms power and endurance to maintain muscle contraction and holding.
- Then the patient was asked to interrupt urine flow during micturition (stop flow
then allow then stop again and so on).

24.  D- cyriax method:
-It is used in treatment of SUI and early cases of genital prolapse.
-It aims to strengthen pubococcygeus, glutei, anal and abdominal muscles.
-Patient was asked to lie in crock lying position, take deep breath from her nose and
contract four muscles (pubococcygeus, glutei, anal and abdominal) drawing viscera
up toward diaphragm the relax and expire air from the mouth with sigh.
-As a progression :it can be done from supine and standing positions.

25.  Resistive pelvic floor exercises:
 A- an inflated cuffed catheter:
- The catheter is inflated with air or water according to degree of vaginal laxity.
- It is lubricated and inserted into vagina then, the patient is instructed to contract
PFM to prevent withdrawal of the catheter by the therapist.
- Gentle traction is applied which stretch PFM and provide a sensory feedback to
initiate contraction.
- As a progression , it can be done during coughing, bending and lifting.

26.  B- Vaginal cones:
- Cones are available in 5 sets with weights ranged from 20-70 g.
- It is useful for actual treatment of SUI and genital prolapse and aid to enhance sexual satisfaction.
- It provides patient with strong sensory feedback as once cone is inserted in vagina , it tends to slip
out. The feeling of losing make pelvic floor muscle to contract around cone to retain it.
- Resting ms tone is assessed as the heaviest cone retained in vagina for one minute while walking.
- Active pelvic ms strength is considered as the heaviest cone that the patient can retained by
contracting PFM.
- The next heavier cone is used when the patient become able to retain the previous cone for 10 min
during walking. The resistance should be increased by using the heavier cone for recruiting more fast
twitch ms fiber and increase ms strength.
- PFM ex with aid of vaginal cones should be used twice daily for 10- 15 min.

28. Interferential therapy:
- It is a medium frequency current used to overcome skin resistance and reach to
deep tissue producing contraction of pelvic floor muscle.
- The best treatment for weak pubococcygeus muscles by combination of PFE and
electro therapy.
- The aim of interferential is to increase cortical awareness of patient ,thus
facilitating ability of the patient to perform voluntary contractions (very weak ms).

29. Techniques of interferential:
 1- bipolar technique:
 patient position: crock lying.
Position of electrodes: posterior electrode is placed under ischial tuberosity, anterior
electrode is placed on the perineum just below symphysis pubis. Electrodes are
secured in position by belt around patient waist.
 Parameters:
Frequency: 10-40 HZ
Intensity: maximum tolerable intensity.
Duration:15- 20 minutes, 3 times per week for 4 weeks.

30. 2- quadripolar technique:
 Patient position: semi reclined with hip and knee flexed and supported.
 Electrode placement:
4 vacuum electrodes are used, two placed on the abdomen above inguinal ligament 3 cm
apart. and two placed on the upper inner aspect of the thigh below inferior border of the
femoral triangle.
 Parameters:
Frequency: 10-100 HZ
Intensity: maximum tolerable intensity.
Duration:15- 20 minutes, 3 times per week for 4 weeks.