Pelvic floor disorders include a wide-ranging group of potentially disabling, embarrassing, and often painful conditions that can greatly affect a person’s quality of life. The pelvic floor consists of muscles, fascia, and ligaments that support the pelvic organs and help to provide control for bodily functions. Pathology within the musculoskeletal and neurologic structures of the deep pelvis can lead to the development of pelvic pain, dyspareunia, voiding dysfunction including urinary incontinence or urinary urgency, fecal incontinence (FI), constipation, and pelvic organ prolapse (POP) . Both women and men can develop pelvic floor disorders, although women are at increased risk compared with men because of their unique anatomy and biomechanics. The female pelvis is broader and shallower, requiring greater muscular and ligamentous stiffness to provide support and stability. Women are also more likely to incur injury to the pelvic floor as a result of pregnancy and childbirth. As a result, abnormal biomechanics of the pelvic floor muscles (PFMs) may lead to changes in contraction, relaxation, muscle strength, and myofascial pain. In a 2014 study, the prevalence of symptomatic pelvic floor disorders in the United States was estimated to be approximately 25%. It is important to note that this percentage does not consider women with pelvic pain due to high-tone pelvic floor dysfunction. People with pelvic floor disorders benefit from an interdisciplinary rehabilitation approach to improve function and reduce pain. Physiatrists with experience in acute and chronic pain, neurologic and musculoskeletal conditions, and neurogenic bowel/bladder management are well suited to direct such a patient’s care.In addition to diagnosing and managing the patient’s pelvic floor disorder medically, the physiatrist plays a key role in providing a detailed prescription for physical therapy.

1. Pelvic floor rehabilitation
DR. JOE ANTONY
M.B.B.S, C.E.P.C, F.C.P
.C

2. Contents
 Anatomy of pelvic floor
 Functions of pelvic floor
 Pelvic floor dysfunctions
 Physical medicine evaluation
 Physical therapy program

3. Anatomy of pelvic floor
 Bony pelvic girdle - two innominate
bones and the sacrum, which are
connected by two posterior
sacroiliac joints and one anterior
pubic symphysis joint.
 Form closure- interlocking of the
ridges and grooves of the bony joint
surfaces in the pelvis.
 Force closure -compressive forces
of the muscles, ligaments, and
fascia, providing passive stability

4. Surface anatomy of perineum

5. Pelvic floor muscles
1. Superficial perineal layer
2. Deep urogenital diaphragm
3. Pelvic diaphragm

6. Superficial perineal layer
•Bulbocavernosus
•Ischiocavernosus
•Superficial transverse perineal
•External anal sphincter

7. Urogenital diaphragm
 AKA, triangular ligament,
 Strong, muscular membrane
occupying area between symphysis
pubis and ischial tuberosities and
stretches across triangular anterior
portion of pelvic outlet.
 External and inferior to pelvic
diaphragm.
1. Urethral sphincter (sphincter
urethrae)
2. Compressor urethrae
3. Sphincter urethral vaginalis
4. Deep transverse perineal
5. Perineal membrane

8. Pelvic diaphragm
 Wide but thin muscular layer of tissue
that forms inferior border of the
abdominopelvic cavity.
 Extends from the symphysis pubis to
the coccyx and from one lateral
sidewall to the other.
1. Levator Ani Muscle (pubococcygeus aka
pubovisceral, pubovaginalis,
puboanalis, puborectalis, iliococcygeus)
2. Coccygeus
3. Piriformis
4. Obturator internus
5. Arcus tendinous of levator ani
6. Arcus tendinous fasciae pelvis

11. Functions of the Pelvic Floor
 The pelvic floor is part of our core musculature.
 Functions include;
 Visceral support
 Sphincteric support (urethral meatus and anus)
 Sexual-contracting muscles to respond to arousal and to enhance gratification.

12. Common Diagnoses needing rehabilitation
 Urinary / Fecal Incontinence
 Dysfunctional Voiding /
Constipation
 Prolapse
 Dysparuenia
 Vulvodynia / Vestibulitis
 Vaginal / Rectal / Pelvic Pain
 Lower Quadrant Abdominal Pain
 Abdominal / Pelvic Floor Scar
Tissue
 Post Prostatectomy
 Oncology
 Pre / Post Natal Care
 Pediatric Pelvic Floor Dysfunction
 Gender Reassignment

13. Pelvic floor examination
 Inspection
 Swelling, cysts, scars, and lesions
 Visualizes the lift of the perineal body with a voluntary contraction
(termed a kegel contraction) and involuntary contraction (cough)
 Descent of the perineal body with voluntary relaxation and then
involuntary relaxation (valsalva maneuver).
 Vaginal vestibule is evaluated for any visible organ prolapse

14. Palpation
 External sensory examination of the S2 to S5 sacral dermatomes .
 Anal wink reflex is obtained near the anus to test the sacral reflex arc.
 Superficial PFMs are palpated for any tenderness
 Q-tip test for vulvodynia is performed by lightly touching a cotton swab at vulvar
and vestibular sites to elicit any pain or allodynia

15. Internal pelvic floor examination- Per
rectal and per vaginal examination
 Use a flat examining table without
stirrups.
 Vaginal examination is performed in
hook lying position, supine with the
knees bent, and ankles hip-width
apart.
 Rectal examination is typically
performed in a left lateral decubitus
position.
 One lubricated gloved finger is
inserted into the vaginal introitus or
anal canal to palpate the PFMs
internally.
 A clock-face diagram is useful to
correctly identify the anatomic
positions of the PFMs.

16. Muscle charting of PFMs
 Voluntary contraction of the PFMs
that occurs upon demand is felt as
a tightening, lifting, and squeezing
action under the examining finger.
 Voluntary contraction is graded
with the modified Oxford scale.

17.  Coordination is tested by performing “quick flicks” or asking the patient to
contract and relax the PFMs rapidly.
 Voluntary relaxation of the PFMs is felt as a termination of the contraction as
the muscles return to their resting state.
 Examiner then has the patient cough, to look for the presence or absence of
involuntary contraction, and then to perform a Valsalva maneuver, to look for
presence or absence of involuntary relaxation.
 It is important to assess for dyssynergia or inappropriate contraction of the
PFMs during attempts at Valsalva.

18. Physical Therapy PROGRAM
 Spinal/pelvic alignment
 Abdominal visceral/fascial releases
 Kegal exercises
 Ultrasound therapy
 TENS- electrical stimulation to LB, abdomen and pelvic floor
 Soft tissue mobilization, trigger point releases to trunk, pelvic floor and hip rotators.
 Scar tissue mobilization
 Laser therapy
 Physio Touch
 SEMG for relaxation
 Core strengthening

19. Visceral Mobilization

20. Ultrasound TREATMENT
The ultrasound waves that pass through the skin cause a vibration of the
local tissues. Can have a heating effect through a continuous transmission
or non-thermal when pulsed. Causes increases in tissue relaxation, local
blood flow, and scar tissue breakdown.

21. TENS TREATMENT

22. TENS UNIT

23. Low Level Laser
The laser helps to achieve a faster rate of healing and pain relief by
stimulating normal cellular function for faster repair and inhibiting
inflammation and nerve conduction for pain relief.

24. LED for lymphedema
LED is used to stimulate lymphatic drainage to reduce edema

25. Physio Touch
Physio Touch is an adjunct to manual therapy. Negative pressure
pulls skin and fascia away from body creating a fascial traction.
Relieves tension in tissue and improves fluid exchange, muscle tone,
tissue length and tissue hydration.

26. Treatment of Pelvic Floor Dysfunction
Pelvic floor muscle re-education
 Biofeedback
 Manual
 SEMG (surface electrode myography)

27. Kegal exercises
 Dr Arnold Kegel- explained in1948
 Worlds first ever biofeedback mechanism.
 Instructions to patients
 Learn to tighten the muscles around the vaginal/anal area
 Contract the vaginal and rectal muscles. Note that when you correctly perform
steps 1 and 2, you should also feel the muscles around the anus tighten slightly.
This is normal, but do not consciously try to tighten those muscles.
 In a quiet, relaxed setting with no distractions, practice your Kegels and determine
how long you can hold your contraction and how many you can do before becoming
fatigued. Do not do more than 5-10 reps at time with a 3-5 second hold.

28.  Benefits of kegal exercises
 Can prevent urinary and faecal incontinence during or post partum
 Enhanced sexual function
 Reduce pelvic related pain
 Conditioned muscles to make childbirth easier
 Decrease and/or prevent prolapse of pelvic organs
 Improve the ability of defecation
 Originally Dr.kegal described use of biofeedback with a manometer and per
vaginal bulb

29. Biofeedback
 Surface electrodes placed peri
anally or rectal/vaginal probe
with computer screen.
 Manual and verbal feedback
from PT
 For home treatment;
 iEase Pneumatic pelvic muscle
trainer
 Biofeedback with vaginal/rectal
probe

30. Dilator Therapy
Used for vaginal or rectal stretching in cases of
vaginismus, trigger point releases in cases of pelvic
muscle spasm and pain.

31. CORE STRENGTHENING

32. Treatment Plan
Pelvic floor pain, muscle spasm:
 Frequency/duration of treatment: 1 to 2 times per
week, 8-12 visits x 4-12 weeks. This may vary
depending on evaluation
Pelvic floor muscle weakness:
 Frequency / duration of treatment: 2-4 visits x 4-8
weeks. This may vary depending on evaluation.

33. Comprehensive rehabilitation program
 Address all the factors contributing to the patient’s dysfunction
 Educate and provide home program for symptom management
 Recommend counseling if history of sexual abuse
 Handle with care

34. Thank you