1. How to spot a women’shealth patientif you’re an outpatientortho PT
PFM= pelvicfloormuscles
Didyou know???
 The average bladderholdsthe same amountas venti latte
 Urinatingmore than 7 timesa day (includingatnight) isa signof PFMdysfunction
 Consumingcertainfoodsandbeveragesincreasesurgency
 Vaginal/vulvarpaindoesnotalwaysmeanPFMdysfunction
 Kegalsare not the onlyexercise thatPFMtherapistsprescribe
 Stool consistencymore than bowel movementfrequencyisone waythat PFMdysfunction
relatingtothe bowel isdetermined.
 The bladderand anxietycentersinthe brainare rightnexttoeach other,whichmeansthatif a
personisanxious,commonlyhe/she feelsthe needtourinate. Conversely,frequenturination
can contribute toincreasinganxiety!
List statisticsof prevalence of PFMissues
 Presence of pelvicorganprolapse approximately41% inpostmenopausal women1
 78% of 200 questionedwomeninaSwedishstudyhadUIinconjunctionwithLBPregardlessof
parity2
 In 2005-2006, 23.7% of womensurveyedhadatleast1 PF disorderaccordingtothe National
Healthand NutritionExaminationSurvey.3
 By 2050, the prevalence of people havingatleast1 PFMdisorderwill increase from28.1million
in2010 to 58.2 million,assumingthatPFMdisorderratesremainconstant. Thisindicatesthata
growingnumberof practitionersable toassistwithPFMdisordersalsoneedstoincrease.4
What isthe pelvicfloor,andwhatdoesitdo???
 3 Layers
o Superficial layer–bulbospongiosus,ischiocavernosus, superficial transverse perinei,
external anal sphincter
o Intermediate–intrinsicurethral sphincter,deeptransverseperinei,andcompressor
urethrae andurethrovaginal sphincterinwomen
o Deep– levatorani (puborectalis,pubococcygeus,andiliococcygeus) and
ischiococcygeus
 ObteratorinternisalsocommonlyassociatedasPFM
 PFMis responsible forbowel,bladder,andsexualhealth. Itsitsunderneathall of the abdominal
organs andworksas a stabilizeralongwithabdominals,glutes,andlats,anditis
counterbalancedwiththe diaphragm.
 PFMis supposedtoco-contractwithtransverse abdominis andisactivatedduringanysudden
exertionsuchascoughing,laughing,orsneezing,thatincrease intra-abdominal pressure.
However,if there are anyproblemswith the PFM,thiswill notoccur,and that iswhenpeople
developaPFMdysfunction5
PFMDysfunctions,ashortlist

2.  Pelvicorganprolapse –whenanyof the pelvicorgansare no longerbeingsupportedinsideof
the bodyand begintobulge intothe vagina (anteriorvaginal prolapse,uterine prolapse,
posteriorprolapse)6
 Urinary incontinence6
o Stressurinaryincontinence–losingurine withexertionisNOTnormal.
o Urge urinaryincontinence –frequency(8+voidsper24 hour cycle),urgency(needto
voidto avoidleakage),nocturia(wakingatnightspecificallytovoid),urge urinary
incontinence (urgency+unintentionalleaking),nocturnal enuresis(lossof urine during
sleep)
 Fecal incontinence –lossof fecesorgas6
 Constipation6
 Sexual dysfunction??? Not mentionedindetailinanyarticle,butheavilytreatedbywomen’s
healthPTs. Painwithintercourse (dyspareunia),canbe causedby a varietyof factorsthat are
not treatable byPTs(lowestrogenorlow free testosterone),butif dyspareuniaisdeterminedto
be causedby a hypertonicpelvicfloor,women’shealthphysical therapyisthe answer!
(ISSWSH)
What PFMproblemscauseswhichdysfunctions???
 Poortonic support – frequency,urgency,seepage,vaginal prolapse
 Inadequate tonicsupportorstrength – stressurinaryincontinence,urge urinaryincontinence,
obstructeddefecation(inadequate emptyingof the bowel)
 Overactive PFM/hypertonicPFM– voidingdysfunction(hesitancy),dyspareunia,obstructed
defecation(inabilitytorelease the anus),perineal/perianal pain5
o Seepage/leakage canalsooccur witha hypertonicPFM. Imagine holding yourelbow
flexed inabicepcurl for 24 hoursa day, 7 daysa week. That muscle will notbe able to
continue holdingasstronglyasitneedsto,butit will eventuallynolongerbe able to
allowthe elbowtoextendfully,either. We call thisa short,weakPFM(Hermanand
Wallace)
What are PFMpainreferral patterns???
PFMtriggerpointstypicallyrefertothe perineum, vagina,urethra,andrectum. However,pain
can alsobe referredtothe abdomen,low back,midback,hip/buttocks,andlowerleg. Thisis
somethingtokeepinmindwhenworkingwithptswhohave LBPwith/withoutlegsymptoms.
Commonaggravatingfactorsinclude menstruation,intercourse,longwalks,sittingforlong
periodsof time,andbowel movements.7
SoundssomewhatfamiliarwithptswithLBP?
So howdo we spota patientwhoshouldbe referredtowomen’shealthif he/shecomesintothe clinic
complainingof LBP???
Simple. Whenindoubt,askthe patient.
Sample topics fromthe Urogenital DistressInventory(UDI),the VulvarPainFunctional
Questionnaire (V-Q),andthe PelvicOrganProlapse/UrinaryIncontinence Sexual Questionnaire
(PISQ-IR)
 Typesof clothingcontributingtopelvicpain

3.  Painwith sitting/walking
 Experiencing/beingbotheredbyurine leakageorurgency
 Problemswithintercourse
Most patientsare rarelyaskedaboutbowel,bladder,orsexual dysfunctionbyhealthcare
practitioners. Therefore,manyof these problemsgounrecognized. Because theyare
embarrassingtopics,manypatientsfeel uncomfortable talkingwithpractitionersabouttheir
PFMproblems. Therefore,we have aresponsibilitytoattempttorecognize themandapproach
the patient. Forall patientswithcomplaintsof pelvicorlow back pain,a goodquestiontoaskto
getthe ball rollingis,“Have younoticedanychanges,ordo youhave difficultywithbowel,
bladder,orsexual function?”
LBP, PFMdysfunction,andstabilization
 Instabilitycauses
o Decreasedactivationof core muscles(PFMincluded)
 CommonlyresultsinLBP
 HypotonicPFMdisorders
 UI, prolapse,etc.
o Decreasedactivationof somecore muscles(PFMnotincluded)
 CommonlyresultsinLBP
 ContributestoPFMhypertonicity
 Dyspareunia,leakage,bowel obstruction,etc.
 Treatment
o Core stabilizationexercises
o ProperPFMtraining – ofteninvolvesSEMG(surface electromyography),dilators,
bladdercontrol, etc.dependingonthe dysfunction
o Posture education
Pregnantwomenare women’shealthpatients,too…right???
 Notnecessarily!!!
 PregnancyandLBP (Commonlybeginsbetweenweeks14-24)
o Therapeuticexercise
 Gluteslike crazy!!!
 Some abdominals,butrememberthatthe abdominalsare beingelongated,
whichmakesthissomewhatdifficult
 Modifiedside planks
 Heel slidesand marchingif she canstill lie supine
o Postural training– sitting,standing
o Gait training– watch forthat Trendelenburg!
o Education,education,education
 Log roll
 Gettinginto/outof a car
 Householdchores
 Pillowsupportwhile sitting

4.  Pillowsupportinbed
 Diastasisavoidance
Whenindoubt,refer– althoughmostwomenwithPFMdysfunctionrequire strengtheningforproper
stabilizationinordertodecrease tonicityandLBP,there are many othertoolsthatPFM therapistsutilize
that are notavailable inthe typical outpatientorthosetting(SEMG,dilatoreducation,educationwith
bladdercontrol,etc.)
References
1. Ghetti C, Gregory WT, EdwardsSR, OttoLN, Clark AL. Pelvic organdescent and symptomsof
pelvic floor disorders. Am J ObstetGynecol. 2005;193(1):53-57.
2. EliassonK, Elfving B, NordgrenB, MattssonE. Urinary incontinence in women with low back
pain. Man Ther. 2008;13(3):206-212.
3. NygaardI, Barber MD, Burgio KL, et al. Prevalence of symptomaticpelvic floor disordersin US
women. JAMA. 2008;300(11):1311-1316.
4. Wu JM, Hundley AF, FultonRG, MyersER. Forecastingthe prevalence of pelvic floor disordersin
U.S. women:2010 to2050. ObstetGynecol. 2009;114(6):1278-1283.
5. SapsfordR. Rehabilitationof pelvic floor muscles utilizing trunk stabilization. Man Ther.
2004;9(1):3-12.
6. Weber AM, AbramsP, BrubakerL, et al. The standardizationofterminology for researchers in
female pelvic floor disorders. IntUrogynecolJ Pelvic FloorDysfunct. 2001;12(3):178-186.
7. PastoreEA, KatzmanWB. Recognizingmyofascial pelvic pain in the female patient with chronic
pelvic pain. Journalofobstetric, gynecologic, and neonatalnursing :JOGNN /NAACOG.
2012:10.1111/j.1552-6909.2012.01404.x.