Physical Therapy for Women's Health

4. *Pelvic floor dysfunction is an umbrella term for a
variety of disorders that occur when pelvic floor muscles and
ligaments are impaired.
*Pelvic floor dysfunction affects up to 50% of
women who have given birth.
*Pelvic floor dysfunction can adversely affect the
quality of life (QoL) of a woman, and they can occur during
different stages of female life such as during pregnancy, early
postpartum period or during menopause.
*Epidemiologic studies indicate that approximately one in three to
four (25%−37%) community-dwelling women are affected by pelvic
floor dysfunctions, with the highest rates in menopausal women.

5. *Pelvic floor dysfunction (PFD) is present in a wide range of clinical
conditions, such as:
(1) Hypotonic Pelvic Floor Dysfunction:
- Urinary Incontinence
- Pelvic Organ Prolapse
- Fecal Incontinence
(2) Hypertonic Pelvic Floor Dysfunction:
- Dyspareunia
- Vaginismus - Vulvodynia - Pudendal Neuralgia
- Paradoxical Puborectalis Syndrome

6. *Pelvic Floor Musculature:
-The pelvic floor musculature is composed of three layers in a
funnel-shaped orientation, with boney attachments to the pubic
bone and the coccyx. Laterally, the tissues blend into a fascial
layer overlying the obturator internus.
- The Pelvic Floor Muscles have both types of muscle fibers:
type I fibers (tonic) are about 70% and type II fibers (phasic)
are about 30%.
-The prime mover of the pelvic floor is the levator ani.
-The levator ani, in combination with coccygeus, forms the
pelvic diaphragm.
-The combined action of these layers of muscles creates a
superior force toward the heart and a puckering or drawstring
motion around the sphincters.

7. MUSCLES OF THE FEMALE PELVIS:​
Layer One:
• Bulbocavernosus muscle
• Ischiocavernosus muscle
• Superficial transverse perineal m.
• External anal sphincter muscle
• Gluteus maximus muscle

8. Layer Two:
*External urethral sphincter m. *Sphincter urethral vaginalis muscle
*Compressor urethrae m. *Deep transverse perineal muscle

9. Layer Three:
*Levator ani muscle
(pubococcygeus,
puborectalis and
iliococcygeus)
*Coccygeus
(Ischiococcygeus) m.
*Piriformis muscle
*Obturator internus m.

10. Origins:
Puborectalis: Posterior surface of bodies of pubic bones
Pubococcygeus: Posterior surface of bodies of pubic bones
Just lateral to puborectalis
Iliococcygeus: Tendinous arch of interal obturator fascia
Ischiococcygeus: Ischial spine and Sacrospinous ligament
Insertions:
Puborectalis: None (forms 'puborectal sling' posterior to rectum)
Pubococcygeus: Anococcygeal ligament, Coccyx, Perineal body and
musculature of vagina
Iliococcygeus: Anococcygeal ligament, Coccyx
Ischiococcygeus: Inferior end of sacrum, coccyx

11. *Functions of the female pelvic floor muscles:
1.To support the pelvic organs as pubovaginalis which forms
a ‘U’ shaped sling, supports the vagina which in turn supports
the bladder and uterus and to provide a volitional sphincteric action on urethra .
2.Puborectalis plays an accessory role to the action of external anal sphincter.
3.Counteracts the downward thrust of increased intra-abdominal pressure (local
core) and Ischiococcygeus helps to stabilize sacroiliac & sacrococcygeal joints.
4.Facilitates anterior internal rotation of the presenting part of the fetus when
it presses on the pelvic floor during the second stage of normal labor.

12. *Function:
*The pelvic floor musculature
has the following essential roles:
■ Provide support for the pelvic
organs and their contents.
■ Withstand increases in
intra-abdominal pressure.
■ Contribute to stabilization of the
spine/pelvis.
■ Maintain continence at the
urethral and anal sphincters.
■ Reproductive and sexual functions.

13. *Ligaments of the uterus:
-They can be divided by where
they attach to the uterus:
*Superior aspect→ supported by
the broad ligament (mesovarium,
mesosalpinx and mesometrium)
and the round ligament.
*Middle aspect→ supported by
the cardinal, pubocervical and
uterosacral ligaments.

14. -Broad ligament→ extends from the sides of uterus to the lateral walls and floor of pelvis,
made of mesosalpinx (encloses uterine tube), mesovarium (carries ovarian vessels and
nerves), mesometrium (contains part of Mackenrodt’s ligament).
-Uterovesical fold→ extends from the junction of uterine body and cervix to the bladder;
creates uterovesical pouch.
-Rectovaginal fold→ extends from the posterior vaginal fornix to
the rectum; creates rectouterine (pouch of Douglas).
-Round ligament→ extends from the lateral cornu of uterus through
broad ligament to the connective tissue of labia majora.
-Transverse cervical (Mackenrodt’s) ligament→ extend from the
lateral pelvic walls to the supravaginal part of cervix; carries uterine artery.
-Pubocervical ligaments→ extend from the anterior aspect of the cervix and upper vagina to
the posterior aspect of the pubic bones.
-Uterosacral ligament→ extend from the anterior side of sacrum to sides of the cervix and
uterine body.

17. -Stress Urinary Incontinence (SUI) and Pelvic Oran Prolapse (POP) can be associated with
histological changes in the connective tissues, namely changes in the collagen that is the main
structural component of the pelvic tissues, But these changes are not visible in the MRI.
*In case of the SUI, there is a significant reduction of type III collagen. While in the POP
have a decreasing total collagen content and increasing concentration of collagen type III.
-Pelvic Floor Dysfunctions (PFDs) may be associated with impaired or injured
muscles and connective tissues in the pelvic cavity due to overstretched pelvic
floor. Progressive weakening of the muscle, especially of pubococcygeus and its lateral
connective tissue attachment to the vaginal walls fails to contract effectively to close the hiatal
opening. As a result, vaginal walls move downward and are exposed to the differential
pressure between abdominal and atmospheric pressure. This pressure difference further
widens the levator hiatus and pulls the rest of the pelvic organs, which in turn, stress and
stretch the supporting ligaments. Over time, due to excessive stretching, ligaments lengthen
permanently and fail to support. Results are often seen as incontinence and prolapse.

18. Neural Control of Micturition

19. *Sensation:
-Sensory afferent nerve fibers regarding bladder fullness enter the spinal cord via the
hypogastric nerve (T10-L2) and the pelvic splanchnic nerves (S2-S4).
*Autonomic motion:
-Sympathetic efferent nerve fibers through the hypogastric nerve (T10-L2) send inhibitory
signals to the detrusor muscle (via Beta adrenergic receptors with Norepinephrine as a
neurotransmitter) and excitatory signals to the internal urethral sphincter (via alpha
adrenergic receptors also, with Norepinephrine as a neurotransmitter).
-Parasympathetic efferent nerve fibers through the pelvic splanchnic nerves (S2-S4) send
excitatory signals to the detrusor muscle (Via muscarinic receptors with Acetylcholine as a
neurotransmitter) and inhibitory signals to the internal urethral sphincter (via the release of
Nitric Oxide NO).
*Somatic control:
-Pudendal nerve fibers provide voluntary motor control to the external urethral sphincter
and the pelvic floor muscles (via nicotinic receptors with Acetylcholine as a neurotransmitter).

20. -Neonates and infants have involuntary micturition reflex, but
about 90% of children have volitional control by 5 years of age.
-The micturition reflex involves a coordinated and sustained
contraction of the detrusor muscle along with simultaneous
relaxation of the internal urethral sphincter.
-Micturition reflex occurs after definite bladder fullness; sensory signals passes to the
pontine micturition center (PMC) then automatically activation of the parasympathetic
pathway that cause contraction of detrusor muscle & relaxation of internal urethral sphincter.
-Prefrontal cortex has a voluntary inhibitory effect on this micturition reflex via
inhibition of the parasympathetic pathway until a convenient time presents itself.

21. 1) Stress Urinary Incontinence
*Definition: Involuntary leakage of urine during Suddenly increased intra-abdominal
pressure, i.e., physical exertion, physical activity, sneezing or coughing.
-In the elderly, it may result from
rolling over in bed, sitting up from
reclining, or getting up from a chair.
-In a younger population, running, bending over,
lifting and jumping.
*Grades of stress incontinence:
-Grade I:incontinence with server stresses as: coughing or jogging.
-Grade II: incontinence with moderate stresses as: rapid movements or walking and up
and down stairs.
-Grade III: incontinence with mild stresses as: changing positions.

22. -Stress urinary incontinence is more frequent in women than in men.
- Prevelance OF SUI:
*5% of females < 45 years
*10% of females between 45-60 years
*> 30% in women over 65 years
*Causes and risk factors of SUI:
(A) Weakness of pelvic floor muscles and support:
*Congenital (rare): occurring in young and nulliparous women with no risk factors.
*Childbirth trauma: due to overstretching of the pelvic floor muscles and the
endopelvic fascia, with damage to its nerve supply, especially after prolonged and
difficult deliveries.
*Postmenopausal: due to atrophic changes affecting pelvic fascia and urogenital
tract secondary to estrogen deficiency.

23. (B) Anterior vaginal wall prolapse:
*Due to descent of the bladder neck
and proximal urethera.
(C) Chronic increase in intra-abdominal pressure:
*Marked obesity, chronic lung disease, chronic constipation, smoking may precipitate
the condition in women with weak pelvic floor musculature and vaginal prolapse.
*Pathophysiology of SUI:
-Normally, the bladder neck and proximal urethra are situated in an intra-abdominal
retropubic position resting on pelvic floor muscles and supported by pubouretheral
ligaments.
-Equal transmission of intra-abdominal pressure to the bladder and proximal urethra is
provided by their intra-abdominal retropubic position and this maintaining a
persistently higher intra-uretheral pressure over the intra-vesicular pressure.

24. -This difference in pressure gradient results in urethral closure and continence even with
sudden increases in the intra-abdominal pressure except during voiding.
-Descent of the bladder neck and
proximal urethra below Symphysis
pubis, due to damage or weakness of pelvic floor muscles especially
levator ani or pubo-uretheral ligament, will make them no longer
intra-abdominal organ and will result in unequal transmission of intra-abdominal
pressure to the bladder and urethra.
-During sudden increases in intra-abdominal pressure, the intra-vesicular will exceed
intra-urethral pressure and urine will involuntarily escape through the urethra leading to
stress urinary incontinence, which is limited to the period of increased intra-abdominal
pressure as during cough, sneezing and laughing.
-The patient neither have the desire to void nor the control on voiding.

25. *Stress Urinary Incontinence is different from Nocturnal Enuresis (NE).
▪ Nocturnal Enuresis: is defined as emptying of the bladder during sleep.
-Prevalence of NE differs by gender in children under 12 years of age,
but shows no gender bias in older adolescents and adults.
From the age of 16 years onward, prevalence remains constant at around 2.3%, but
most sufferers wet more than three nights per week.
-Nocturnal enuresis may be due to polyurea, small bladder capacity or nocturnal onset of
covert detrusor overactivity and an associated reduction in nocturnal bladder capacity.

26. *Cochrane reviews evaluating different interventions for
Nocturnal enuresis conclude that:
• Simple changes to behavior by the child or family (e.g., charting,
rewards, lifting at night, bladder training) are better than doing nothing.
• Simple behavioral strategies are less effective than
enuresis alarm or pharmacotherapy.
• Combination therapy with anticholinergic medication and
enuresis alarm/antidiuresis drugs (Desmopressin) reduces relapse rates.
• Compared to no treatment, about two-thirds of children became dry during alarm use.
*Physical Therapy should focus on: Advices regarding regular voiding,
development of pelvic floor muscle (PFM) awareness (Biofeedback) and
neuromodulation through posterior tibial nerve stimulation at 10 Hz,
Continuous stimulation at a pulse width of 200 μm, 30 min. session, for at least 3 months.

27. *Diagnosis:
Basic diagnostic testing
-Detailed medical history (including medication)
-Voiding diary to assess frequency and volume of micturition
-Neurological, vaginal, and rectal examination
Laboratory tests
-Urine culture to exclude urinary tract infections
Ultrasonography
-Quantification of residual urine after micturition
Pad test
-Quantification of leaked urine.
-One hour office pad test: the patient is asked to do exercise for 30 min. if pad weight 2-
10gm (mild incontinence), 11-50gm (moderate incontinence) and >50gm (sever
incontinence).

28. -24 hours home pad test: normal physical activity at home, the pad is removed every
4-6 hours and are weighted immediately or stored in a bag and weighted after 24
hours:
4-20gm (mild incontinence), 21-75gm (moderate incontinence) and >75gm (sever
incontinence).
Additional diagnostic testing
-Micturating cysto-urethrogram (MCU) to detect morphological abnormalities
-Cystoscopy to rule out tumors and vesicoureteral or vesicovaginal fistulae
-Q-Tip test: to test the position of the urethra relative to the base of
bladder on straining, normal finding are the Q-Tip points downward
and normal angel with the horizontal is up to
30 degrees. While in stress urinary incontinence the Q-Tip points
upward and the angel may be > 50 degrees.

29. -Urodynamic examination to evaluate bladder
storage and emptying and is consisted of types: Video testing (when
using x-ray) or Non-video testing (without x-ray) and urodynamic
testing may contain the next following aspects:
1)Non-invasive uroflow test:
-The patient is asked to urinate in a
special toilet (Commode) to
measure urine frequency, volume
and duration after that small
catheter is passed into bladder to
assess (Residual Volume) or
bladder scanned with
ultrasonography.

30. 2)Invasive multichannel test:
-The patient then sit on a special bed or chair and tiny catheter passed into bladder
connected to the computer, another rectal catheter to assess changes in the intra-
abdominal pressure that affect on bladder and surface electrodes are placed on the
perineum to record superficial pelvic floor muscles or fine needle
electrodes to record deep pelvic floor muscles electrical activity.
-Then bladder is filled through the catheter with a sterile water
or contrast solution will be slowly run into bladder
-Computer will measure pressure changes in bladder and the patient will be asked to
report any sensations of fullness or urge for urination the computer will measure (Filling
Cystometrogram) to assess detrusor activity, sensation and capacity.

31. -The patient may be asked to bear down or cough, the pressure at which leakage begins will
be recorded (Leak Point Pressure).
-Sometimes, at the end of bladder filling, the catheter will be pulled back to measure
(Urethral Closure Pressure Profile) and assess strength of pelvic floor and ability of
urethra to close off.
-Once bladder full, the patient is asked to urinate again in the (Commode) while catheter
connected with computer will record pressure with urination (Pressure-Flow Study).
-Parameters of normal bladder function on urodynamic:
*Detrusor pressure filling:- < 15 cm H2O *Absence of detrusor contractions
*First desire to void:- 150-200 ml. *Capacity:- strong desire 400-600 ml.
*Residual volume after voiding:- < 50 ml

32. *Complications of SUI:
-General: depression, psychosocial distress.
-From prolonged contact with urine: dermatitis and skin infections.
-Urinary tract: increased risk of urinary tract infections.
*Treatment of Stress Urinary Incontinence:
(A)Conservative Measures for Mild cases:
1- Pelvic floor Physical Therapy:
*Active pelvic floor muscle training known as Kegel exercises
*Passive electrical pelvic floor muscle stimulation
2-Lisestyle: Scheduled voiding, avoid caffeine, alcohol and smoking
3-Estrogen therapy : vaginal cream in cases of menopausal atrophy
4-Pessary treatment: if SUI is associated with prolapse

33. (B)Surgical Measures for Moderate and sever cases:
*Surgery is the gold standard in treatment of such cases.
*permanent correction of proximal urethra & bladder neck descent
Prophylaxis:
*Because of childbirth is the commonest
traumatic cause it can be prevented through:
(A)Proper intranatal care:
-Keeping bladder empty during the 1st stage of labor.
-Supporting perineum during uterine contractions in the 2nd stage.
-Avoidance of using forceps or ventose before full cervical dilation.
-Relaxation at crowning with avoidance of bearing down and shallow
panting breathing should start.
-Proper timing of episiotomy (Just before crowning).

34. (B)Proper postnatal care:
-Careful fast repair of any perineal tear or laceration.
-Proper bladder hygiene to avoid urinary tract infections.
-Early physical therapy program include gradual strengthening pelvic floor exercises.
-Avoidance of aggravating factors as: chronic cough or constipation.
*Perineum and Adductor Flexibility
-In addition to the modified squatting exercises, these
flexibility exercises prepare the legs and pelvis for childbirth.
Self-Stretching
■ Patient position and procedure: Supine or side-lying. Instruct the
woman to abduct the hips and pull the knees toward the sides of
her chest and hold the position for as long as is comfortable (for 20-30 sec).
■ Patient position and procedure: Sitting on a short stool with the hips abducted
as far as possible and feet flat on the floor. Have her flex forward slightly at the
hips (keeping the back straight).

35. Physical Therapy Management for
Stress Urinary Incontinence
*Physical Therapy Assessment:
1)Frequency/Volume Chart:
-It is a specific urodynamic investigation
-Recording fluid intake and urine output per 24h.
-Give information on :
*Number of voiding
*Distribution of voiding between day and nighttime
*Each voided volume
-Can record episodes of :
*Urgency *Leakage
*Number of incontinence pad used
-Very useful in assessment of voiding disorders and follow-up.

36. 2)Pad test:
one hour office and 24 hours home testing as mentioned before.
3)Modified Oxford Grading System:
-The physical Therapist introduce a gloved index and middle fingers
inside the patient’s vagina and ask the patient to perform a maximal
voluntary contraction, but it is a subjective assessment tool.
-Grade 0: No active muscular contractions
-Grade 1: Very slight flicker contractions
-Grade 2: Weak squeeze with no lift
-Grade 3: Fair squeeze with a lift
-Grade 4: Good squeeze with a lift
-Grade 5: Strong squeeze with a lift
4)Visual analogue scale:
-A subjective helpful method to assess severity of symptoms of SUI.

37. 5)Perineometry:
-Kegel or Bradford perineometry used before and after treatment to confirm the objective
strength of pelvic floor muscles
-It measure the intra-vaginal Pressure which reflect the
force that can Be exerted by the pelvic floor muscles
-Provide both sensory and visible feedback to the patient.
-If the patient is Virgin, it is contraindicated
to perform: Kegel perineometry, Inflated Cuffed
Catheter, Vaginal Cones, Modified Oxford Grading
System and Vaginal electrode of EMG. Biofeedback.

38. 6)Electromyography:
-This is the most accurate and objective method to record electrical
activity during rest and contraction of pelvic floor muscles by surface
electrodes on the perineum to record signals from superficial pelvic
floor muscles or fine needle electrode is introduced in the deep pelvic
floor muscles
(Needle EMG may need a certificate for physiotherapists)
-Surface electrodes can be used as biofeedback mechanism that
provide sensory, visual and auditory feedback.

39. 7)MyotonPRO Device:
-Recently, the MyotonPRO, a hand-held, non-invasive device designed
to measure muscle mechanical properties, has shown good clinical
applicability and sufficient validity and reliability in different
contractile and non-contractile tissues and disorders.
-TONE OR STATE OF TENSION
*F→ Natural Oscillation Frequency [Hz], characterizing Tone or Tension.
-BIOMECHANICAL PROPERTIES
*S→ Dynamic Stiffness [N/m]
*D→ Logarithmic Decrement of natural oscillation, characterizing
Elasticity.
-VISCOELASTIC PROPERTIES
*R→ Mechanical Stress Relaxation Time [ms].
*C→ Ratio of deformation and Relaxation time, characterizing Creep.

40. -Muscle stiffness of the smaller muscles of the body Such
as Perineal muscles can be reliably measured using the
MyotonPRO. The device could be used as a reference
standard in the development of a digital palpation scale
that would facilitate accurate diagnosis of muscle tone
(Davidson et al., 2017).
-The relative reliability of tone, stiffness, and the
assessment of the decrement or the Elasticity of Pelvic
Floor Muscles (PFMs) with MyotonPRO is good to
excellent for Urinary Incontinence and healthy women.
The Standard Error of Measurement (SEM) and
Minimum Detectable Changes (MDC) values were
acceptable for their application in clinical settings
(Rodrigues-de-Souza et al., 2021).

41. *Physical Therapy Treatment:
1)Prophylaxis:
*During ante, intra and postnatal physical
therapy care as childbirth is the commonest
traumatic cause for pelvic floor dysfunction
*Chronic constipation, chronic bronchitis and postmenopausal cases
2)Actual treatment:
*For a diagnosed pelvic floor dysfunction such as: Stress Urinary Incontinence or Pelvic
Organ Prolapse cases during the conservative rehabilitation program or during pre &
postoperative program.
*Aims of Physical Therapy for Pelvic Floor Dysfunction:
-To educate the patient briefly the normal anatomy and physiology of pelvic floor muscles and pelvic organs.
-To establish cortical awareness of pelvic floor contraction.
-To inform the patient with factors that may provoke incontinence.
-To increase pelvic floor muscles strength and improve its elasticity.

42. Physical Therapy: is divided into two phases
(A) Pelvic floor muscles re-education:
- First: ask the patient to contract pubococcygeus muscles actively.
- Second: if the patient is unable to contract pubococcygeus muscle actively and not
aware about its definitive contraction, passive electrical stimulation may start then after
improving the cortical awareness about pubococcygeus contraction (Electrical
Stimulation Superimposed Onto Voluntary Contraction) should be focused.
(1) Pelvic Floor (Kegel) Exercise:
-Begin pelvic floor exercise training with an empty bladder.
Gravity-assisted positioning (as supported bridge position)
may be indicated initially for some women with extreme weakness
and proprioceptive deficits. Varied positions may need to be
explored initially to maximize patient awareness and motor learning
with progression into more challenging activities.

43. *Graduations of pubococcygeus exercises:
1)Quick Flick:
-Repeated quick contractions for 10-20 times,
relax for 10sec for 3 sets.
-Increasing by 5 sets each week up to a maximum of 50 sets.
2)Slow Contraction:
-Tighten the muscle as hard as and hold for 10-20 sec, relax for 10 sec for 3 sets.
-Increasing by 5 sets each week up to a maximum of 50 sets.
3)Sustained Contraction:
-Tighten the muscle (halfway) and hold
for 60 sec, relax for 20 sec for 3 sets.
-Increasing by 2 sets each week up to a maximum of 10 sets.
*Kegel exercises involve both slow and fast twitch muscle fibers.
*Avoid excessive abdominal contraction at all and especially during early period in pelvic
floor rehabilitation as it will develop undesirable increase in IAPR.

44. *Changing the bony dimensions of the pelvis will lead to alterations in pelvic floor tone.
For example, standing with heels raised (plantarflexion) will result in lower pelvic floor
resting tone, compared to standing on the heels
(dorsiflexion) which leads to an increase in its tone.

45. (2) Biofeedback (Kegel perineometer & EMG biofeedback:
*The perinometer is inserted by the patient into her vagina while
assuming crock lying to monitor PFM contraction after disinfection
and lubrication by KY gel
*Perineometer can be used to enhance the effectiveness of Kegel
exercises as a method for treatment & also assessment
*EMG Biofeedback is consisted of vaginal electrode, 3 surface
electrodes,
screen and earphone.
* EMG Biofeedback is useful in both increasing the level of
contraction and volitional relaxation ability.
* Vaginal electrode has sensors capable of detecting the very tiny
signals and the 3 surface electrodes are positioned on the perineun and
contractions are held for 3,10,30 & 60 sec. with monitoring feedback.

46. (3) Cyriax method:
*Cyriax method for treatment of Stress Urinary Incontinence and mild cases of
pelvic organ prolapse aim to strength pubococcygeus, gluteal and abdominal
muscles in a consequence harmony between them.
*It starts from crock lying position then progress into supine and stride standing
as a progression.
(B) Resistive pelvic floor exercises:
(1) Vaginal Cones:
-Provide the patient with strong sensory feedback.
-Women contract pelvic floor to retain cones in the vagina.
-After proper self insertion of the cone of appropriate weight at certain
level, it tends to slip out, feeling of losing the cone provide a powerful sensory feedback.
-Resting muscle strength is assessed as the heaviest cone retrained in the vagina for 1
min. while walking.

47. -Patient is reassessed for progression to the next heaviest cone by her ability to
retain the previous cone for 10 min.
while walking.
-Kegel exercises with Vaginal cones:
*Firstly: Self conducted PFMT:
Designed program for 12 weeks.
-Begin PFMT from supine with knees slightly apart &
extended. and hold contractions for 3-5 sec & repeat 15-20 times.
-Then, repeat the same exercise, but with knee flexed.
-Repeat the same exercise, but from stride standing and hold
contractions for 5-10 sec & repeat 25 times.
-Repeat the same exercise, but from standing with heels together
and feet outward and hold for 5-10 sec & repeat 15-20 times.
*Secondly: PFMT with Vaginal cones:
Designed program for another 12 weeks.

48. (2) Inflated Cuffed Catheter:
-By using a small quantity of KY gel on the tip of a sterile
catheter with balloon at its end, it is inserted by the patient
into the vagina above the level of levator ani then the balloon
is inflated with air or saline.
-The patient is asked to tighten the pelvic floor to prevent its
withdrawal because of gentle traction of the catheter by the
patient or the therapist
-As a progression, the exercise involves maintaining the catheter
in the vagina by contracting the pelvic floor during coughing,
bending forward and lifting.
-The catheter is washed and disinfected to prevent infection.

49. .
*FOCUS ON EVIDENCE
*In a Cochrane Database
Systematic Review for 31 studies
(Dumoulin et al., 2018) concluded that:
based on the data available, we can be confident
that pelvic floor muscle training (PFMT) can
cure or improve symptoms of stress urinary
incontinence (SUI) and all other types of UI. It may reduce the number of leakage
episodes, the quantity of leakage on the short pad tests in the clinic and symptoms on UI-
specific symptom questionnaires.
-The authors of the one economic evaluation identified for the Brief Economic Commentary
reported that the cost-effectiveness of PFMT looks promising.
-The findings of the review suggest that PFMT could be included in first-line conservative
management programs for women with UI.

50. Electrical Stimulation for Pelvic Floor Muscles
(1)Interferential Current:
-Electrode placement: Quadripolar technique is used with 1st channel
which has 2 electrodes preferably vacuum electrodes (one electrode
on right inguinal ligament and the other electrode on the left ischial
tuberosity) and 2nd channel is the same but on the opposite sides.
-Dynamic cross vector.
-Frequency: (Carrier freq. 4 KHZ and Beat freq. 10-25 Hz).
-Intensity: according to patient’s tolerance.
-Duration: 20-30 min.

51. (2)Faradic Current:
-Electrode placement: Vaginal electrode is
used with introduction by the patient into her
vagina with two contact plates which should be
facing hips (on left and right) not tailbone and
pubic bone and the upper plate should be at the
level of levator ani muscle.
-Pulse duration: 0.5-1 ms.
-Frequency: (50 HZ).
-Intensity: according to patient’s tolerance.
-Duration: 30 min.

52. *This physical therapy program (Kegel
exercises and interferential current) for
3 sessions weekly and for 5 weeks was found to be more effective in mild and moderate
SUI than severe SUI (Turkan et al., 2005).
*Posterior tibial nerve and intravaginal stimulation have shown effectiveness in treating
urge urinary incontinence. Sacral-nerve stimulation provided benefits in refractory cases
(Schreiner et al., 2013).
*Surface electrical stimulation and intra-vaginal electrical stimulation are important
treatments to improve the stress urinary incontinence (SUI) in women. Both improved
the QOL, urinary leakage, and strength and pressure of PFM contraction (Correia et al.,
2014).
*FOCUS ON EVIDENCE

53. * Focused Mechano-Acoustic Vibration:
-Stress urinary incontinence (SUI, involuntary leakage on
effort or exertion), Urge incontinence (UI, an involuntary
leakage that is accompanied or immediately preceded by
urgency due to overactive bladder), Mixed incontinence (MI,
involuntary leakage that is associated with urgency & exertion).
-It is a new approach to MUI, the mechanism of action on
the PFMs that could be attributed to stimulation of
mechanoreceptors (Pacinian corpuscles), at a frequency of
250–300 Hz, for 15 min for every muscle, for 10 sessions. and
our results were encouraging and suggested the use of focal
mechanical vibration as a novel tool for treating mix urinary
incontinence in women to complete and help the rehabilitative
therapeutic protocol (Paolucci et al., 2019).

54. 2) Pelvic Organ Prolapse
*Definition: Pelvic organ prolapse (POP) is a gynecological condition in which the pelvic
organs descend or herniate from the normal
anatomic location toward or through the vagina
due to ligament or muscular weakness.
*Pelvic organ prolapse is a common condition
affecting 41–50% of women over the age of 40.
*The genital prolapse is broadly grouped into:
1) Vaginal prolapse
2) Uterine prolapse
-While vaginal prolapse can occur
Independently without uterine descent, the
uterine prolapse is usually associated with
variable degrees of vaginal descent.

55. 1) Vaginal Prolapse
Anterior wall:
*Cystocele: The cystocele is formed by laxity
and descent of the upper two-thirds of the
anterior vaginal wall. As the bladder base is
closely related to this area, there is herniation of
the bladder through the lax anterior wall.
*Urethrocele: When there is laxity of the
lower-third of the anterior vaginal wall, the
urethra herniates through it. This may appear
independently or usually along with cystocele
and is called cystourethrocele.

56. Posterior wall:
*Rectocele: There is laxity of the middle-third of
the posterior vaginal wall and the adjacent
rectovaginal septum. As a result, there is herniation
of the rectum through the lax area.
*Enterocele: Laxity of the upper-third of the
posterior vaginal wall results in herniation of the
pouch of Douglas. It may contain omentum or even
loop of small bowel and hence, called enterocele.
-Traction enterocele is secondary to uterovaginal
prolapse.

57. There are two types :
*Uterovaginal prolapse:
It is the prolapse of the uterus, cervix and upper vagina.
This is the commonest type. Cystocele occurs first
followed by traction effect on the cervix causing
retroversion of the uterus. Intra-abdominal pressure
has got piston like action on the uterus thereby pushing
it down into the vagina.
*Congenital:
There is usually no cystocele. The uterus herniates
down along with inverted upper vagina. This is often
met in nulliparous women and hence called nulliparous
prolapse. The cause is congenital weakness of the
supporting structures holding the uterus in position.
2) Uterine Prolapse

59. -First degree: The uterus descends from its normal
anatomical position (external os at the level of ischial
spines) but the external os still remains inside the vagina.
-Second degree: The external os protrudes outside the
introitus but the uterine body remains inside the vagina.
-Third degree (Procidentia, Complete prolapse): The
uterine cervix and body descends to outside the introitus.
*Procidentia involves prolapse of the uterus with
eversion of the entire vagina.
*Complex prolapse is one when prolapse is associated with some
other specific defects. Complex prolapse includes the following:
prolapse with urinary or fecal incontinence, vaginal and rectal prolapse.
Degrees of Uterine Prolapse (Clinical)

60. *Symptoms of Pelvic Organ Prolapse:
The symptoms are variable. Even with minor degree, the symptoms may be
pronounced, paradoxically there may not be any appreciable symptom even in
severe degree. However, the following symptoms are usually associated:
(a) Feeling of something coming down through the vagina, especially while
she is moving about. There may be variable discomfort on walking
when the mass comes outside the introitus and in some advanced cases the
Patient can see the mass comes outside the introitus during bearing down or
Performing the Valsalva maneuver.
-Prolapse may be asymptomatic until the descending organ reaches the introitus,
and therefore POP may not be recognized until an advanced condition is present.
(b) Backache or dragging pain in the pelvis especially due to the sprain of
uterosacral and mackenrodt’s ligaments.
-The above two symptoms are usually relieved on lying down.
(c) Dyspareunia is common.

61. (d) Urinary symptoms (in presence of cystocele):
-Difficulty in passing urine, more the strenuous effort, the less effective is the evacuation. The
patient must elevate the anterior vaginal wall for evacuation of the bladder.
-Incomplete evacuation may lead to frequent desire to pass urine.
-Urgency and frequency of micturition may also be due to cystitis.
-Painful micturition is due to infection.
-Stress incontinence is usually due to associated urethrocele.
-Retention of urine may rarely occur.
(e) Bowel symptom (in presence of rectocele):
-Difficulty in passing stool. The patient must push back the
posterior vaginal wall in position to complete the evacuation
of feces. Also, Fecal incontinence may be associated.
(f) Excessive white or blood-stained discharge through the vagina is due to associated
vaginitis or decubitus ulcer.

62. MANAGEMENT OF PROLAPSE
*Preventive *Conservative *Surgery
1)PREVENTIVE:
*The following guidelines may be prescribed to prevent or minimize genital prolapse.
Adequate antenatal and intranatal care →
-To enhance elastic and strong pelvic floor. -Proper timing of episiotomy if it is indicated.
-To avoid injury to the supporting structures especially in vaginal instrumental delivery.
-To avoid straining at crowning in vaginal delivery and encourage shallow sternal breathing.
Adequate postnatal care →
-To encourage early ambulance.
-To encourage pelvic floor exercises.
General measures →
-To avoid strenuous activities, chronic cough, constipation and heavy weight-lifting.
-To provide sufficient duration between pregnancies.

63. 2)CONSERVATIVE
*Indications of conservative management are:
-Asymptomatic women.
-Mild degree prolapse.
-Pelvic organ prolapse in early pregnancy.
*Meanwhile, following measures may be taken:
-Improvement of general measures.
-Estrogen replacement therapy may improve
minor degree prolapse in postmenopausal
women.
-Pelvic floor exercises to strengthen the muscles
(Kegel exercises).
-Pessary treatment.

64. The independent predictors of Pelvic floor muscle training for POP success:
1) Presence of 1 or more indicators of obstetric trauma such as:
*High birth weight
*Episiotomy
*Perineal laceration during vaginal delivery
*Forceps delivery or vacuum extraction
-A possible explanation is that women with a history of obstetric trauma might have some
other damage to their pelvic floor that is lacking in women without any obstetric trauma,
and that this damage is partially reversible. Thus, prolapse symptoms can improve to
a satisfactory level with pelvic floor muscle training alone in some of these women.
2) Younger age.
-A possible explanation is that the older women may be less able to build muscle strength and
they are more accepting of their symptoms. So, they are less likely to adhere to home exercises.

65. -There are two main hypotheses of mechanisms of how PFMT may be
effective in prevention and treatment of Stress Urinary Incontinence (SUI)
and the same theories may apply for a possible effect of PFMT to prevent
and treat Pelvic Organ Prolapse (POP).
*Hypothesis 1:
Women learn to consciously contract before and during increases in abdominal
pressure (also termed ‘bracing’ ) and continue to perform such contractions as a
behavior modification to prevent descent of the pelvic floor.
*Hypothesis 2:
Women are taught to perform regular strength training in order to build up ‘stiffness’ and
structural support of the pelvic floor over time.
What are the mechanisms of PFMT in SUI-POP prevention & treatment ?

66. *The boat theory:
-Think of this as a boat in a dry dock.
-The Pelvic ligaments and fascia are
the ropes holding the boat (pelvic organs) in place & water is the pelvic floor muscles.
-If the water is low (pelvic floor muscles are weak and lengthened) the full weight of the
boat is taken by the ropes. Over time, this will lead to gradual lengthening of the ropes
(ligaments and fascia) and cause the pelvic organs to drop.
-However, if the water rises again, the load is taken off the ropes and the boat is
supported again. This is the same with the pelvic floor muscles – strengthen them and
improve their resting tone, and the pelvic organs will get more support.
-If the pelvic floor muscles are weak, the prolapse may worsen over time as the non-stretch
tissues are further loaded and stretched.

67. • There are convincing results from eight RCTs that PFMT is effective
in reducing symptoms of POP and stage of POP in women who have
not had previous POP surgery, therefore PFMT should be
first-line treatment for women presenting with symptoms of POP.
• Given the high incidence of de novo (new compartment) or recurrent POP
after POP surgery and complications after POP surgery, PFMT may be considered
as an adjunct to surgery for POP, as the treatment does no harm and may improve results.
• PFMT for POP patients requires proper teaching, assessment and feedback of correct
contraction.
• PFMT must be supervised in addition to a home training program.
Why are pelvic floor muscle exercises very important for POP ?

68. Evidence-based pelvic floor muscle training recommended protocol for
Pelvic Organ Prolapse
- The Physical Therapist should focus on both pelvic floor
muscle endurance ( type I muscle fibers ) and muscle
power ( type II muscle fibers ).
- The set of exercises is consisted of 10 maximum strength
pelvic floor muscle contractions, holding each contraction
for up to 10 s with a 4 s rest between contractions,
followed by up to 50 fast contractions.
- Exercise position is tailored to the individual woman (lying, sitting, standing, squatting).
- Three to five sets per day should be performed.
- 2 to 5 days per week.
- 4 to 6 months Rehabilitation.
- Home exercises should be prescribed.

69. CLINICAL RECOMMENDATIONS
IN PT FOR PELVIC ORGAN PROLAPSE
-PFMT for POP can be performed for prevention, conservative treatment
and pre & postoperative.
-Positions can add progression for PFMT: high crock-lying → crock-lying →
supine or prone → sitting → standing → squatting.
-Many women can perform PFMT while they are using pessary.
-PFMT for POP is similar to PFMT for SUI. however, some modifications may be done as in
stage 3 or stage 4 (complete procidentia) preoperative rehabilitation, PFMT from supported
high crock-lying position should be performed especially if there is no pessary or packing
(Yousef., 2020), and it is advised to avoid performing PFMT from antigravity positions as:
standing or squatting.

70. -Electrical stimulation can be used in POP after manual, pessary or packing correction with
the best results in mild degrees.
-Intravaginal electrical stimulation, biofeedback therapy combined with pelvic floor
functional exercise has a noticeable curative effect and can significantly alleviate pelvic
floor prolapse and improve the quality of life of stage 1 POP patients (Zhong et al., 2021).
*Parameters:
-The initial current intensity gradually increasing from 0 mA to 60 mA.
-The initial frequency of type I muscle fibers could be set as 10-35 Hz, and
then it could be increased to 35-50 Hz according to the patient’s tolerance.
-The initial frequency of type II muscle fibers could be set as 20-50 Hz, and
then it could be expanded to 70-80 Hz according to the patient’s tolerance.
-The pulse width of type I muscle fibers was adjusted to 320-740 us.
-The pulse width of type II muscle fibers was adjusted to 20-320 us.
-The duration of the session lasted for 30 min, two times a week.
Electrical stimulation for Pelvic Organ Prolapse

71. -It was concluded that both stabilization exercises and pelvic floor muscle training (PFMT)
increased the pelvic floor muscle strength, provided a decline in prolapse stages.
Stabilization exercise has increased general health perception unlike home training; thus, these
exercises can be added to the treatment of women with prolapse (Özengin et al., 2015).
-In the Cochrane library: There is now some evidence
available indicating a positive effect of PFMT for prolapse symptoms
and severity. 6 trials [ Four trials compared pelvic floor muscle training
(PFMT) with no intervention, and two trials compared pelvic floor
muscle training plus surgery to surgery alone ].
*The largest most rigorous trial to date suggests that 6 months of supervised PFMT has
benefits in terms of anatomical and symptom improvement (if symptomatic) immediately
post-intervention.
*A large trial of PFMT supplementing surgery is needed to give clear evidence about the
usefulness of combining these treatments (Hagen and Stark., 2011).

72. 3)SURGERY
-Surgery is the treatment of symptomatic prolapse where
conservative management has failed or is not indicated.
-Surgical procedures may be :
(A) Restorative→
*Correcting her own support tissues as in anterior colporrhaphy
(for anterior vaginal wall prolapse), posterior colporrhaphy (for posterior vaginal wall
prolapse), Sacrospinous colpopexy (for vaginal vault prolapse following vaginal
hysterectomy), Sacral colpopexy (for vaginal vault prolapse following abdominal
hysterectomy) and Uterosacral ligament suspension (for vaginal vault prolapse).
*Compensatory through using permanent mesh graft material.
(B) Extirpative → Removing the uterus and correcting the support tissues as
in Vaginal hysterectomy with pelvic floor repair (for uterovaginal prolapse).
(C) Obliterative → closing the vagina (colpocleisis).

74. 3) Paradoxical Puborectalis Syndrome
*Definition: Paradoxical Puborectalis Syndrome (PPS) is a
spastic pelvic floor syndrome, and it is a is a recently described
subtype of dyssynergic defecation in which the puborectalis
muscle either paradoxically contracts or fails to relax during
attempted defecation, leading to a lack of straightening of the
anorectal angle and resulting outlet obstruction.
-The anorectal angle is the angle formed between the posterior wall of the distal rectum and
the central axis of the anal canal which normally measures 108°-127° at rest with 15°-20°
increase during defecation and 15°-20° decrease during squeezing.
-Dyssynergic defecation is common & affects up to 50% of patients with chronic constipation.
-It can occur in both children and adults, and in both men and women
(although it is more common in women).

75. *Causes and Pathophysiology:
-Patients with dyssynergic defecation demonstrate the
inability to coordinate the abdominal and pelvic floor
muscles to facilitate defecation. This failure of rectoanal
coordination consists of inadequate propulsive force,
paradoxical anal contraction or inadequate anal relaxation.
Thus, incoordination or dyssynergia of the muscles that are
involved in defecation is primarily responsible for this
condition.
-In addition, 50-60% of patients also demonstrate an
impaired rectal sensation as in Pudendal Neuropathy.
-Extrapyramidal motor disturbance as in Parkinson’s disease.
-Spinal cord lesions.
-Anxiety and Spastic colon.
-Anorectal malformation.

76. *Diagnosis:
-Physical examination
-Dynamic defecation proctography
-Dynamic MRI
-Electromyography (both surface and needle) can be utilized
to diagnose puborectalis dysfunction as registered by a maintained or increased activity.
*Symptoms of Paradoxical Puborectalis Syndrome:
-Lower abdominal/rectal pain
-Tenesmus i.e., feeling of incomplete evacuation of the rectum
-Sense of Pelvic heaviness and it may be associated with rectocele
-Need to strain with bowel movement
-Difficulty initiating and completing bowel movements
-Chronic Constipation
-Depression or Anxiety

77. *TREATMENT OF PARADOXICAL PUBORECTALIS SYNDROME
*Conservative *Surgery
1)CONSERVATIVE:
A-EMG BIOFEEDBACK THERAPY:
-It is an instrument-based learning process that is based on
“operant conditioning” techniques. The governing principal is
that any behavior-be it a complex maneuver such as eating or a simple task such as muscle
contraction-when reinforced its likelihood of being repeated and perfected increases several
fold. In patients with dyssynergic defecation, the goal of neuromuscular training is two-fold:
*To correct the dyssynergia or incoordination of the abdominal, rectal, puborectalis and anal
sphincter muscles in order to achieve a normal and complete evacuation.
*To enhance rectal sensory perception in patients with impaired rectal sensation.

78. -Biofeedback is an effective treatment for patients with dyssynergic defecation and the
improvement is maintained after one-year follow-up. Patients with chronic constipation
not improved by fiber and laxatives should be referred to a tertiary center with facilities for
biofeedback therapy (Koh et al., 2012).
-In Chronically Constipated Elderly Female Patients due
to Dyssynergic Defecation, there were Significant decrease
in the evacuation difficulty level and pain grade during
defecation following behavioral treatment through
Biofeedback (45 min. session duration, 2 sessions weekly, for 4 weeks). At the same time ,
the treatment produced significant improvements in the weekly defecation frequency and a
decrease in the mean electromyographic activity of external anal sphincter during straining to
defecate. Clinical gains were maintained during the follow-up carried out 6 months later
(Simon et al., 2019).

79. B-SACRAL MAGNETIC STIMULATION:
-Sacral Magnetic stimulation (The magnetic coil was placed on the back
with its center located between L4 and L5. Stimulation parameters were set
at 70% of maximum intensity, 40 Hz frequency and 2 s burst length with
2 s off ) was simple, easy, non-invasive, non-radiologic and can be performed on an outpatient
basis in the treatment of Paradoxical Puborectalis Syndrome (PPS) (Shafik A., 2000).
-Spinal Magnetic Stimulation (The magnetic coil being placed at T9 spinal process with 10
minutes of thoracic nerve stimulation; the coil was then placed at L3 spinal process for another
10 minutes of lumbosacral nerve stimulation. the stimulation intensities were set at 50% of
maximal output (2.2 Tesla), 20 Hz, 1 session daily for 12 sessions) may benefit elderly patients
with severe constipation associated with pelvic floor dysfunctions (Wang and Tsai., 2012).
-Magnetic fields increase motion of ions and electrolytes in the tissues and
fluids of the body. so, regaining the resting membrane potential of the cell.

80. C-STRETCHING PELVIC FLOOR EXERCISES AND POSITIONS:
-Prolonged stretch inhibits muscles through
stimulation of Golgi tendon organ reflex.
-Pelvic floor muscles can be stretched by
crossed sitting position, squatting position
and Knee to chest position.
-Defecation Postural Modification Device
( was developed to replicate the alignment
achieved with squatting while using a toilet ) positively influenced bowel movement
duration, straining patterns, and complete evacuation of bowels in this study, and it offer
a nonpharmacologic option for those individuals who suffer from inadequate bowel
emptying or increased straining (Modi et al., 2019).

81. CLINICAL RECOMMENDATIONS
IN PT FOR PARADOXICAL PUBORECTALIS SYNDROME
-Biofeedback is the treatment of choice for constipated
patients with Paradoxical Puborectalis Contraction.
-Targeting the cause of Paradoxical Puborectalis Syndrome
is very important in its prognosis as in neurological cases.
-Pulsed Magnetic Therapy devices usually utilize magnetic
influx energy less than 0.4 Tesla. But Pulsed Magnetic Stimulation
devices such as that had been used in the two previous studies for
Paradoxical Puborectalis Syndrome usually utilize magnetic influx
energy near to 1 Tesla or more.

82. -Paradoxical Puborectalis Syndrome is a recently described subtype of dyssynergic
defecation, Low level of evidence that might came from clinical settings and
expert opinions, support the following modalities:
*Relaxation training and Psychological support.
*Maitland PA Sacral glide grade 1 or 2 to assist in the
reduction of pelvic pain associated with pelvic heaviness.
*Pulsed Shortwave Therapy on the Perineum and Sacral
Spine may provide deep thermal effect (3-5cm penetration
depth) that help in relaxation of the spastic muscle.
*Low Intensity Shockwave Therapy and LLLT may be
beneficial in reduction of puborectalis muscle spasm and puborectalis trigger points pain.

83. D-BOTULINUM TOXIN-A INJECTION:
*In a systematic review included 7 studies, The authors concluded that: Initial
satisfactory improvement of symptoms after BTX-A injection remarkably deteriorated after
3 months of the procedure. However, repeated injection may provide better sustained
results with no additional morbidities for Paradoxical Puborectalis Contraction Syndrome
(Emile et al., 2016).
-Botulinum toxin, the product of Clostridium botulinum
anaerobic bacterium, divides into seven subtypes.
-Botulinum toxin type A (BTX-A) prevents the secretion
of acetylcholine causing neuromuscular blockage and muscle paralysis.
*BTX-A injection combined with pelvic floor biofeedback training seems to be successful
for intractable Paradoxical Puborectalis Syndrome (Zhang et al., 2014).

84. -Ileostomy
-Colostomy
-Partial Division of
Puborectalis Muscle
*Surgery may be
offered after failure
of Biofeedback and
Botox injection, but
it has little or no role
in these conditions.
2)SURGERY:

85. 4) Genito-Pelvic Pain Disorders (Vaginismus)
*Definition: Vaginismus is defined as the psychologically mediated recurrent or persistent
involuntary spasm of the vaginal muscles including the levator ani muscles and/or the thigh
adductor muscles. This results in inability of penetrative pelvic examination or intercourse.
-The prevalence rate of vaginismus in a clinical setting
has been estimated as 5% to 17%.
-The pelvic floor muscles of vaginismus patients
exhibited increased EMG activity at rest and on vaginismus
induction; the cause is unknown (Shafik and El-Sibai., 2002).
*Vaginismus may be primary or secondary.
A)Primary Vaginismus: when vaginal penetration has never been achieved. However, the
vagina is normal anatomically and physiologically. The cause is unknown, and it may be
mostly psychological in origin such as fear of pain.
B)Secondary Vaginismus: when vaginal penetration was once achieved, but is no longer
possible, potentially due to gynecologic surgery, trauma, tender perineal scar, or radiation.

86. *Clinical presentation: The woman with vaginismus avoids vaginal
examination and she might present with painful intercourse or with infertility.
Degree Classification
First Pelvic floor spasm during pelvic examination, relieved with reassurance
Second Pelvic floor spasm during examination, NOT relieved with reassurance
Third Pelvic floor spasm that is sufficiently severe that the patient lift buttocks
in an attempt to avoid being examined
Fourth Pelvic floor spasm that is more severe that the patient lift buttocks,
moving away from the pelvic exam, and tightly closing the thighs to
prevent any examination
Fifth visceral reaction manifested by increased heart rate, palpitations,
hyperventilation, nausea or vomiting
*Classification of degrees of vaginismus:

87. *Treatment of Vaginismus:
▪ Primary → The following guidelines are prescribed :
-Psychodynamic Therapy: Main causes of fear are removed. To educate
and to gain confidence of the husband and wife. This may take time.
-Cognitive behavioral therapy (CBT): helps to understand how thoughts affect emotions
and behaviors. It is effective for anxiety and depression.
-Vaginal dilators: Daily introduction of the dilators with progressive increase in their size
for 1–2 weeks and to keep it inside for 10–15 minutes to stretch
Bulbocavernosus and Pubovaginalis muscles and to be less sensitive
to vaginal penetration.
-Topical Lidocaine, Skeletal muscle relaxant and Lower doses of
Botulinum toxin injection can be considered to relax the vaginal muscles.
-Surgery: A classic case of vaginismus needs no surgery. However, surgery may be
required, if the hymen is found tight as in hymenotomy.
▪ Secondary →The causative local lesion is to be treated medically or surgically.

88. A)BIOFEEDBACK THERAPY:
Physical Therapy for Vaginismus
-Biofeedback and muscular inhibitory stimulation along with cognitive-
behavioral therapy are effective and short-term therapies for patients with Grade 3 and
4 vaginismus (Nejat et al., 2020).
B)PELVIC FLOOR STRETCHING EXERCISES:
-Prolonged stretching activate Golgi tendon reflex (inverse stretch reflex,
autogenic inhibition), When the Golgi tendon organs are stimulated by a
prolonged stretch, they cause the stretched muscle to relax.
-Adding pelvic floor stretching exercises to EMG biofeedback training with vaginal
electrode, twice/week for three weeks was more effective and successful treatment for
treating pelvic floor muscle spasm and pain than EMG biofeedback alone in women with
primary vaginismus (Ahmed et al., 2014).

89. C)PELVIC FLOOR STRETCHING EXERCISES AUGMENTED WITH LASER :
-Vaginal stretching associated or not with photobiomodulation (4 Joules of
near-infrared light-808 nm at 3 points) may be effective in reducing complaints
of painful intercourse, pain severity, and reducing number of women with
pelvic floor myofascial pain suffering from sexual dysfunction (Frederice et al., Jan 2022).
D)RELAXATION TRAININ AUMENTED WITH BIOFEEDBACK:
-This study confirms and adds strong evidence that relaxation training augmented by EMG
Biofeedback, is an excellent additional physical therapy method for treating pain as well as,
spasm in patients suffering from primary vaginismus (El-Badry and Kotb., 2007).
*A Systematic Review regarding the effectiveness of Pelvic Floor Physical
Therapy (PFPT) for pelvic floor hypertonicity studied 10 eligible studies: 4 RCTs,
5 prospective studies, and 1 case study published between 2000 and 2019 Concluded that
PFPT can be beneficial in patients with hypertonic pelvic floor (Reijn-Baggen et al., 2021).