Physical Therapy for Women's Health

2. MOHAMED GAMALABOUELYAZEED
ASSISTANT LECTURER OF PHYSICAL
THERAPY FOR WOMEN’S HEALTH
SOUTH VALLEY UNIVERSITY

3. Physical Therapy
for Specific
Female Pelvic Floor
Related Dysfunction
(Stress Urinary Incontinence)

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

7. *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 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.

8. 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.

10. 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.

11. -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.

12. (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.

13. -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
involuntary 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.

14. 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).
-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).

15. Additional diagnostic testing
-Micturating cysto-urethrogram (MCU) to detect morphological
abnormalities
-Cystoscopy to rule out tumors and
vesicorectal 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.
-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 contains the next following aspects:

16. -Urodynamic examination:
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.

17. 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.

18. -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.
*Uroflowmetry:- rate of urine flow through urethra 15 ml/sec.

19. *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
(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

20. 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).
(B)Proper postnatal care:
-Careful fast repair of any perineal tear or laceration.
-Proper bladder hyeigene to avoid urinary tract infections.
-Early physical therapy program include gradual strengthening
pelvic floor exercises.
-Avoidance of aggravating factors as: chronic cough or constipation.

21. 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 (at least 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), or have her gently press her knees
outward with her hands for an additional stretch.

22. 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 night time
*Each voided volume
-Can record episodes of :
*Urgency
*Leakage
*Number of incontinence pad used
-Very useful in assessment of voiding disorders and follow-up.

23. 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.
Modified Oxford Grading System:
-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.

24. 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.

25. 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.

26. *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.

27. 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 or elbows/knees 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.

28. *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.

29. (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 ear phone.
* 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.

30. (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
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.

31. -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 contractions for 5-10 sec & repeat 15-20
times.
*Secondly: PFMT with Vaginal cones:
Designed program for another 12 weeks.

32. (2) Inflated Cuffed Catheter:
-By using a small quantity of KY gel
on the tip of a sterile catheter with ballon
at its end, it is inserted by the patient into
the vagina above the level of levator ani
then the ballon 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.

33. .*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.

34. 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.

35. (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.

36. *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