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Woman Health-Incontinence&Pelvic Organ Prolapse

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Woman Health-Incontinence&Pelvic Organ Prolapse

  1. 1. RAHILA NAJIHAH BINTI ALI JURUPULIH PERUBATAN FISIOTERAPI HOSPITAL MUADZAM SHAH INCONTINENCE AND PELVIC ORGANS PROLAPSE
  2. 2. Incontinence
  3. 3. ANATOMY OF PELVIC FLOOR MUSCLES
  4. 4. Function of Pelvic Floor Muscle
  5. 5. Urinary Incontinence  Objectively demonstrable loss of urine, which is a social or hygienic problem (International Continence Society, 2002; Abrams et al 2003)  Common condition affecting all ages from different social, and cultural backgrounds (Hay-Smith et al; The Cochrane Library 2003)  The inappropriate involuntary passage of urine, resulting in wetting. (Oxford Concise Medical Dictionary, 7th edition)
  6. 6. Type of Incontinence  Stress incontinence:  Is the complaint of involuntary leakage of urine on effort or exertion during activities, on sneezing or coughing (increase intra-abdominal pressure) (Bo, 1999; ICS, 2002)  Is one of the most common types of urine leakage  > in women – short urethra & weakness of pelvic floor muscles after giving birth  The less common cause is an intrinsic sphincter deficiency usually secondary to pelvic surgeries.
  7. 7.  Urge incontinence :  result of uninhibited bladder contraction from detrusor hyperactivity  sudden strong desire to pass urine that is difficult to suppress leading to involuntary urine loss.  Usually entails urgency, frequency, or nocturia.  These symptoms are often referred to as the overactive bladder syndrome (OAB).
  8. 8.  Some individuals may have a pure sensory abnormality where they exhibit urinary frequency and urgency without urine loss.  This is often referred to as overactive bladder dry.  Elderly persons frequently experience urinary loss without the sensation of urge, but the underlying mechanism of detrusor hyperactivity is still the same.
  9. 9.  Mixed incontinence:  Coexistence of stress and urge incontinence.  Generally defined as detrusor overactivity and impaired urethral function.  Characterized by involuntary loss of urine associated with urgency as well as exertion, cough, sneeze, or any effort that increases intra-abdominal pressure.  This is the most common type of incontinence in women.
  10. 10.  Overflow incontinence:  Incomplete bladder emptying secondary to impaired detrusor contractility or bladder outlet obstruction.  Factors involved in the development of overflow incontinence are physical obstruction such as pelvic organ prolapse and enlarged prostate, and neurological abnormalities, such as spinal cord injuries.  It is also commonly associated with bladder neuropathy that occurs in the setting of diabetes mellitus.  Patients often complain of continuous small-volume leakage, dribbling, hesitancy, frequency, and nocturia.
  11. 11. Causes of Urge Incontinence  Bladder cancer  Bladder inflammation  Bladder outlet obstruction  Bladder stones  Infection  Neurological diseases (such as multiple sclerosis)  Neurological injuries
  12. 12. Causes of Overflow Incontinence  Injury of nerves that affect the bladder.  Nerve damage from diseases such as diabetes, alcoholism, Parkinson's disease, multiple sclerosis, or spina bifida.
  13. 13. General Causes  Pelvic floor muscles weakness.  Pregnancy and child birth.  Hysterectomy  Bladder stone  Neurological disoders  UTI  Medications  Alcohol and caffeine intake.
  14. 14. Risk Factors  Sex:  Women are more likely than men are to have stress incontinence.  Pregnancy, childbirth, menopause and normal female anatomy account for this difference.  However, men with prostate gland problems are at increased risk of urge and overflow incontinence.
  15. 15.  Age:  As individual get older, the muscles of bladder and urethra lose some of their strength.  Changes with age reduce how much bladder can hold and increase the chances of involuntary urine release.  However, getting older doesn't necessarily mean that the individual will have incontinence.
  16. 16.  Being overweight:  Being obese or overweight increases the pressure on bladder and surrounding muscles, which weakens them and allows urine to leak out when cough or sneeze.  Smoking:  A chronic cough associated with smoking can cause episodes of incontinence or aggravate incontinence that has other causes.  Constant coughing puts stress on urinary sphincter, leading to stress incontinence.  Smokers are also at risk of developing overactive bladder.
  17. 17.  Other diseases:  Kidney disease or diabetes may increase risk for incontinence.
  18. 18. Complications  Skin problems:  Urinary incontinence can lead to rashes, skin infections and sores (skin ulcers) from constantly wet skin.  Urinary tract infections:  Incontinence increases your risk of repeated urinary tract infections.  Changes in your activities.  Urinary incontinence may keep you from participating in normal activities.  You may stop exercising, quit attending social gatherings or even stop venturing away from familiar areas where you know the locations of toilets.
  19. 19.  Changes in your personal and work life:  Urinary incontinence may negatively affect work life.  The problem may disrupt concentration at work or keep awake at night, causing fatigue.
  20. 20. Pelvic Organs Prolapse
  21. 21. Uterine Prolapse  The uterus (womb) is a muscular structure that is held in place by pelvic muscles and ligaments. If these muscles or ligaments stretch or become weak, they are no longer able to support the uterus, causing prolapse.  Uterine prolapse occurs when the uterus sags or slips from its normal position and into the vagina (birth canal)
  22. 22.  Uterine prolapse may be incomplete or complete. An incomplete prolapse occurs when the uterus is only partly sagging into the vagina. A complete prolapse describes a situation in which the uterus falls so far down that some tissue rests outside the vagina.
  23. 23. Grade of prolapse
  24. 24. Cystocele  A cystocele, also called a prolapsed or dropped bladder, is the bulging or dropping of the bladder into the vagina.
  25. 25. Grade of cystocele  grade 1—mild, when the bladder drops only a short way into the vagina  grade 2—moderate, when the bladder drops far enough to reach the opening of the vagina  grade 3—most advanced, when the bladder bulges out through the opening of the vagina
  26. 26. Grade of Cystocele
  27. 27. Rectocele  A rectocele is a herniation (bulge) of the front wall of the rectum into the back wall of the vagina. The tissue between the rectum and the vagina is known as the rectovaginal septum and this structure can become thin and weak over time, resulting in a rectocele.  When rectoceles are small, most women have no symptoms. A rectocele may be an isolated finding or occur as part of a generalized weakening of the pelvic floor muscles.  Other pelvic organs such as the bladder (cystocele) and the small intestine (enterocele), can bulge into the vagina, leading to similar symptoms as rectocele.
  28. 28. Grade of Rectocele  GRADE 1 Rectocele = this is the mild stage of rectocele, little bulge can be observed.  GRADE 2 Rectocele = at this stage, the bulge sags down to the vaginal opening.  GRADE 3 Rectocele = at this stage, the rectocele bulges out of the vaginal opening
  29. 29. Symptoms  feeling like you are sitting on a ball  vaginal bleeding or increased discharge  problems with sexual intercourse  seeing the uterus or cervix coming out from the vagina  pulling or heavy feeling in pelvis  constipation  recurrent bladder infections
  30. 30. How To Diagnosed Prolaps  Doctor can diagnose by evaluating your symptoms and performing a pelvic exam. During this exam, your doctor will insert a speculum (device that allows the doctor to see inside of the vagina) to examine the vaginal canal and uterus. You may be lying down, or your doctor may ask you to stand during this exam.  To determine the degree of prolapse, your doctor may ask you to “bear down” as if you were having a bowel movement  Special imaging procedure : Defecography
  31. 31. Speculum Device
  32. 32. Treatment for Uterine Prolapse Nonsurgical treatments include:  weight loss (to take stress off of pelvic structures)  avoiding heavy lifting  Kegel exercises (pelvic floor exercises that help strengthen the vaginal muscles)  estrogen replacement therapy  pessary (a device inserted into the vagina that fits under the cervix and helps push up and stabilize the uterus and cervix)
  33. 33. Vaginal Pessary
  34. 34. How to insert vaginal pessary
  35. 35. Surgical treatments include:  hysterectomy (the uterus is removed from the body, either through the abdomen or through the vagina)  uterine suspension (the uterus is placed back into its original position by reattaching pelvic ligaments or using surgical materials)  Surgery is often effective, but it is not recommended for women who plan on having children in the future. Pregnancy and childbirth can put an immense strain on pelvic muscles, which can undo surgical repairs to the uterus
  36. 36. P E L V I C F L O O R A S S E S S M E N Y F O R M Physiotherapy Assessment
  37. 37. Physiotherapist’s Examination  Stress test for incontinence  Pad weighing examintion  Voiding diary  Periniometer Devices to mesure pelvic floor’s muscle strength
  38. 38. Perineometer
  39. 39. PFX2V performs a role of a simple perineometer, pelvic floor muscles assessment device. Simple visual measurements of the pelvic floor muscle strength form the basis of the biofeedback based pelvic floor training and rehabilitation with PFX2V
  40. 40. Physiotherapist Mx.
  41. 41.  Biofeedback o Via electromyography, presure sensor or-real time ultrasound o Cant measure the strength, but simply monitor the trend (ensure patient do kegel’s exercise correctly)
  42. 42.  Electrical stimulation : Neuromuscular electrical stimulation (NMES) o Additional means of strengthening and improving function of weakened pelvic floor o Detrusor inhibition may achieved by targetting the sensory afferent fibres of pudendal nerve, using frequency of 5-10Hz o Highest frequencies of 30-50Hz will reinforce cortical awareness and stimulate the type 2 fibres to produce contraction
  43. 43. E X E R C I S E F O R P E L V I C F L O O R M U S C L E KEGEL’S EXERCISE
  44. 44. Kegel’s Exercise  Named after Dr. Arnold Kegel, recommended in 1940s  is designed to strengthen the pubococcygeus muscles
  45. 45. Aims  To restore muscle tone and strength to the pubococcygeus muscles.  To prevent or reduce pelvic floor problems.  To prevent uterine prolapse in women.  To increase sexual gratification, easier for you to reach orgasm and make your orgasms stronger/better  To treat vagina prolapse and urinary incontinence in both men and women
  46. 46. Simple Instruction  Imagine that you are trying to stop yourself from passing wind, and at the same time trying to stop your flow of urine in mid-stream.  The feeling is one of ‘squeeze and lift’, closing and drawing up the back and front passages  Continue the lift as long as you can (up to 10 seconds) Release and rest for several seconds
  47. 47. Rules When Do Kegel’s Exercise  When exercising you should not use your stomach, leg, back or buttock muscles.  Breathe slowly and deeply.  Put your hand on your stomach when you squeeze your pelvic muscle.  If you feel your abdominal muscles move, then you are also using these muscles.  Your leg and buttocks muscles should not move
  48. 48. Types of Kegels Exercise  Basic Kegels o Squeze and release the PFM o 200 repetitions per day o Good for stress incontinence
  49. 49. • Sustained Kegels o Contract the PFM and hold for 10 seconds o 10 repetitions x 3 sets per day * Progressive Kegels – Squeeze a little, hold for 5 seconds. Squeeze harder and hold for 5 seconds. Squeeze as hard as possible and hold for 5 seconds. Then release it by stages and hold for 5 seconds at each stage
  50. 50. The Slow Kegel's:  Tighten your PC muscles just as you did when you tried to stop your flow of urine. Contract the PC muscles and then hold them for a slow count of three, 1 - - - 2 - - - 3 - - -. Then relax.
  51. 51. Quick Kegel's:  Tighten and relax your PC muscles as rapidly as you can until you become tired or for 2 to 3 minutes whichever come first. This should be somewhere around 100 to 150 times.
  52. 52. Pull In -- Push Out:  Tighten your PC muscle as before, hold for a count of three, then pull upward, as if you had a string on the top of your bladder  Once you have pulled up, hold for a count of three and then relax.  This exercise uses several sets of pelvic and abdominal muscles strengthening them.
  53. 53. Result??  For best results, you must exercise faithfully. The muscles won't increase in strength overnight.  Most women will notice changes after just three weeks.
  54. 54. Patients Education  Physical activities – Proper lifting technique and try to avoid strenous activity (e.g carry heavy items)  Remember to do kegel’s exercise befor any activities (sneezing, coughing or laughing), make it as a habit
  55. 55. Borang Saringan Bil. Perkara Ya Tidak Catatan 1 2 3 4 Adakah anda mengalami masalah terkencing? Adakah anda terkencing semasa batuk atau bersin? Adakah anda terasa sangat hendak membuang air kencing tetapi hanya mengeluarkan air kencing sedikit sahaja? Adakah anda terkencing sebelum sampai ke tandas?
  56. 56. Bil. Perkara Ya Tidak Catatan 5 6 7 8 Adakah anda membuang air kencing lebih daripada dua kali pada setiap malam? Adakah anda kerap atau sentiasa menitis keluar air kencing? Adakah pengambilan ubat yang menyebabkan anda kerap kencing? Adakah anda mempunyai masalah pergi ke tandas? Jika ya, mengapa? •Kelemahan badan •Sakit sendi •Jarak ke tandas Samb.

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