Physiotherapist's management

1. RAHILA NAJIHAH BINTI ALI
JURUPULIH PERUBATAN
FISIOTERAPI
HOSPITAL MUADZAM SHAH
INCONTINENCE AND PELVIC
ORGANS PROLAPSE

2. Incontinence

4. ANATOMY OF PELVIC FLOOR MUSCLES

6. Function of Pelvic Floor Muscle

7. 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)

9. 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.

10.  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).

11.  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.

12.  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.

13.  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.

14. Causes of Urge Incontinence
 Bladder cancer
 Bladder inflammation
 Bladder outlet obstruction
 Bladder stones
 Infection
 Neurological diseases (such as multiple sclerosis)
 Neurological injuries

15. 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.

16. General Causes
 Pelvic floor muscles weakness.
 Pregnancy and child birth.
 Hysterectomy
 Bladder stone
 Neurological disoders
 UTI
 Medications
 Alcohol and caffeine intake.

17. 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.

18.  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.

19.  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.

20.  Other diseases:
 Kidney disease or diabetes may increase risk for incontinence.

21. 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.

22.  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.

23. Pelvic Organs Prolapse

24. 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)

25.  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.

27. Grade of prolapse

28. Cystocele
 A cystocele, also called a prolapsed or dropped
bladder, is the bulging or dropping of the bladder
into the vagina.

29. 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

30. Grade of Cystocele

32. 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.

34. 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

35. 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

36. 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

37. Speculum Device

38. 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)

39. Vaginal Pessary

41. How to insert vaginal pessary

42. 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

43. 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

45. Physiotherapist’s Examination
 Stress test for incontinence
 Pad weighing examintion
 Voiding diary
 Periniometer Devices to mesure pelvic floor’s muscle
strength

46. Perineometer

48. 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

49. Physiotherapist Mx.

50.  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)

51.  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

52. 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

53. Kegel’s Exercise
 Named after Dr. Arnold Kegel, recommended in
1940s
 is designed to strengthen the pubococcygeus muscles

54. 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

55. 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

56. 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

57. Types of Kegels Exercise
 Basic Kegels
o Squeze and release the PFM
o 200 repetitions per day
o Good for stress incontinence

58. • 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

59. 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.

60. 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.

61. 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.

62. 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.

63. 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

65. 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?

66. 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.