The Female Pelvic Floor And Goldilocks-2
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The Female Pelvic Floor and G ldil k Goldilocks Too weak, too tight and just right! (or just right, too weak and too tight) Meagan Matteson, RN, MS, CNP [email protected] Feel free to contact me with ?s www.augs.org (great resource!)
J t Right… Just Ri ht {
{
Specific f grouping off muscles, ligaments and fascia which interlace and provide support-includes support includes pubococcygeus and levator ani Keep pelvic organs in the pelvis z z z
Bladder Uterus Rectum
J t Right… Just Ri ht {
Muscles create circles (sphincters) around outlets of those organs to keep us clean and dry z z
z
For example-urination Bladder muscle is relaxed until need to void-pelvic floor muscles are contracted When voiding g bladder muscle contracts and pelvic floor relaxes
J t right… Just i ht {
Roll in sexual function f z
Orgasm is essentially a rhythmic muscular contraction-stronger contraction stronger muscle=stronger contraction?
T Weak… Too W k {
Increased risk off stress urinary incontinence due to weakness of both the urethral sphincter and hypermobility of the urethra z
{
Leaking with coughing, coughing laughing, laughing etc. etc
Increased risk of pelvic organ prolapse or relaxation z
“My bladder is falling out…”
T Types off Pelvic P l i Organ O Prolapse P l
C Causes ffor pelvic l i fl floor relaxation l ti {
Childbearing (not just vaginal delivery!) z
z
z
IIncreased d pressure intra-abdominally i t bd i ll due to pregnancy forces muscles down Vaginal delivery disrupts integrity of the musculature if everything goes well (intact) Increased risk with perineal trauma such as tearing or episiotomy
C Causes ffor pelvic l i fl floor relaxation l ti {
Heredity z
Genetic predisposition to poor tissue integrity {
z
Can be seen in need for multiple reconstructions
Prolapse and incontinence can often “run in the family”
C Causes ffor pelvic l i fl floor relaxation l ti {
Age z
{
GRAVITY!!
Anything that increases abdominal pressure z z z
Runners R Horseback riders Gymnasts
P Prevalence l off St Stress Incontinence I ti {
{
{
1 in i three th women will ill have h leaking l ki with stress maneuvers within 5 years of a vaginal delivery 50-75% of women who have it won’t even tell their p physician. y Of those who did, 61% waited 4 years In the U.S. more feminine pads are used d for f iincontinence i than h for f menstruation
Prevalence of pelvic organ prolapse {
{
40% off women over the age off 40 have some pelvic organ prolapse 50% off women who h deliver d l vaginally have some degree of prolapse
T Tight Too Ti ht (Hypertonic)… (H t i ) {
{ {
Detrusor D t sphincter hi t dyssynergia d i (DSD)-inability to appropriately relax the pelvic floor with a contraction of the bladder-leads to poor emptying or painful voiding Pelvic pain syndromes such as vestibulodynia or vulvar vestibulitis M May contribute ib to Irritable I i bl Bowel B l Syndrome and Interstitial Cystitis
Causes for pelvic floor hypertonicity { {
Spinal cord injury Dysfunctional habits in response to chronic h pain z z z
Severe vaginal atrophy P l i ttrauma Pelvic Repeated infections {
Pain-fear Pain fear cycle=pain causes fear causes tension causes more pain
Wh t can we do? What d ? {
Talk about the pelvic floor f with your patients or your clinician z
{
{
IInitiate iti t h honestt di discussion i about b t pelvic l i health or symptoms!!
Start young-easier for patients to identify and strengthen when they are young and muscles are strong Elicit pelvic floor history to aid in intervention!
Ph i l exam-What Physical Wh t to t expectt { {
Done at time off bimanual exam Ask patient to squeeze around your f fingers, aka… k z
Squeeze like you are trying to hold in gas in a crowded room
St your urine Stop i on th the ttoilet… il t {
{
{
Not a great idea long term-confuses f the voiding messages Patient should h ld ffeell a llifting f sensation-like a string pulling their vagina up Do on a hard chair for most feedback hardest to do standing feedback-hardest (gravity)
Ph i l exam Physical {
Give patient a grade 0-5/5 z z z z z z
0-no movement to the pelvic floor 1 fli k 1-flicker 2-weak 3 moderate (lift) 3-moderate 4-good (lift) 5-strong (lift)
Ph i l exam Physical { {
Grade Accessory muscle use z
z z
Most common-bottom, thighs and abdominal muscles Make note if patient is using When a Kegel is done correctly the contraction is in pelvic floor only!!
Ed Education ti {
{
{
Not just for f older women or people who are incontinent! Start early l and dh help l the h muscles l stay toned. R Re-visit i i this hi every year at annuall exam starting at initial appointment. appointment
Ed Education ti {
2 types off exercises-long holds and quick flicks z
z
Long holds L h ld work k slow-twitch l t it h muscle l fibers used long term to keep patients continent-unconscious (70%) ( ) Quick flicks work fast-twitch fibers used during stress maneuvers (30%)
P Progressive i exercise i program { { {
{
No special devices are needed Patient compliance is key! Only works while patients do themuse it or lose it! Informal or formal training (at home versus physical therapy)
P Progressive i exercise i program { {
Identify f muscle Start doing 3 long hold exercises in a set z
z z
Hold for 3 seconds and relax for 3 seconds in between 4 sets/day May not feel the entire 3 seconds but should strive for them
P Progressive i exercise i program {
When you feel f the hold for f 3 seconds increase the hold/relax time and number of reps by 2 z
5 reps, hold 5 seconds, relax 5 seconds 4x/day
P Progressive i exercise i program {
Continue to add 2 until patient can ultimately hold… z
z z
12 seconds d and dd do 12 in i a row without ith t fatigue! Can you?????? Rest period is as important as the contraction for a healthy pelvic floor
Q i k flicks Quick fli k {
{
{
These are fast f up and down exercises Do these h daily d l at stop signs, red d lights, meals, brushing their teeth A Attach h to a daily d il activity i i for f best b compliance
Ad Advanced dE Exercises i { {
Standing Elevator z
z
z
Sit on floor and increase the contraction in stages Think about as floors until top floor and back down Takes a lot of concentration and control
F Formal l ttraining i i { { {
{
{
Done by experienced RN, NP or PT Done over course of several months May use biofeedback or electrical stimulation to enhance results Good for patients who are having trouble identifying the correct muscles l Creates incentive to comply
A Across the th Lifespan Lif {
B f Before childbearing hildb i z z z z
z
Easiest time to identify and tone muscles Encourage patients to be proactive and talk to relatives about their experience Of Often taught h in i yoga/Pilates / il courses Reminders are important-these individuals often do not have symptoms so easily forgotten SEX!!
A Across the th lifespan lif {
Before f childbearing z z
Can see hypertonicity in this group A k about Ask b pain i with i h intercourse i or during voiding
Pregnancy {
Most helpful f to have strong pelvic floor going into pregnancy and continue to do exercises throughout z
z z
No specific guidelines regarding trimester variations OK to do immediately after delivery Often taught g in p prenatal y yoga g classes
D li Delivery {
{ {
C/S may be somewhat protective with first child but looses that protection with second pregnancy Strive for intact perineum Wh effect What ff does d perineal i l massage have?
P Pre-menopausal l {
Often f when dysfunction f begins to appear in terms of incontinence and prolapse z z
z
Stress and urge related incontinence May be more compliant after symptoms appear Must ask about these symptoms y p to open a dialogue!
P t Post-menopausal l {
Estrogen depletion z
z
z
z
Consider vaginal estrogen for stress incontinence research not definitive incontinence-research May have more time for physical therapy May be more interested in non-surgical intervention due to co-morbidities Sometimes have hard time identifying the muscles due to weakness
Wh t do What d Kegels K l NOT d do? ? {
{
Kegels cannot put us “back together again” Depending d on the h amount off pelvic l floor descent exercises may not be enough z z
Pessary Surgery
T k home Take h message (literally!) (lit ll !) {
Whether Wh th a clinician, li i i a woman or someone who loves a woman talk about pelvic health!! z
{
{
Serious impact on quality of life!
Pelvic floor exercises are more effective if initiated early in symptom complex Speak to the doctor you feel f most comfortable with and be vigilant!
J t Right… Just Ri ht {
{
Specific f grouping off muscles, ligaments and fascia which interlace and provide support-includes support includes pubococcygeus and levator ani Keep pelvic organs in the pelvis z z z
Bladder Uterus Rectum
J t Right… Just Ri ht {
Muscles create circles (sphincters) around outlets of those organs to keep us clean and dry z z
z
For example-urination Bladder muscle is relaxed until need to void-pelvic floor muscles are contracted When voiding g bladder muscle contracts and pelvic floor relaxes
J t right… Just i ht {
Roll in sexual function f z
Orgasm is essentially a rhythmic muscular contraction-stronger contraction stronger muscle=stronger contraction?
T Weak… Too W k {
Increased risk off stress urinary incontinence due to weakness of both the urethral sphincter and hypermobility of the urethra z
{
Leaking with coughing, coughing laughing, laughing etc. etc
Increased risk of pelvic organ prolapse or relaxation z
“My bladder is falling out…”
T Types off Pelvic P l i Organ O Prolapse P l
C Causes ffor pelvic l i fl floor relaxation l ti {
Childbearing (not just vaginal delivery!) z
z
z
IIncreased d pressure intra-abdominally i t bd i ll due to pregnancy forces muscles down Vaginal delivery disrupts integrity of the musculature if everything goes well (intact) Increased risk with perineal trauma such as tearing or episiotomy
C Causes ffor pelvic l i fl floor relaxation l ti {
Heredity z
Genetic predisposition to poor tissue integrity {
z
Can be seen in need for multiple reconstructions
Prolapse and incontinence can often “run in the family”
C Causes ffor pelvic l i fl floor relaxation l ti {
Age z
{
GRAVITY!!
Anything that increases abdominal pressure z z z
Runners R Horseback riders Gymnasts
P Prevalence l off St Stress Incontinence I ti {
{
{
1 in i three th women will ill have h leaking l ki with stress maneuvers within 5 years of a vaginal delivery 50-75% of women who have it won’t even tell their p physician. y Of those who did, 61% waited 4 years In the U.S. more feminine pads are used d for f iincontinence i than h for f menstruation
Prevalence of pelvic organ prolapse {
{
40% off women over the age off 40 have some pelvic organ prolapse 50% off women who h deliver d l vaginally have some degree of prolapse
T Tight Too Ti ht (Hypertonic)… (H t i ) {
{ {
Detrusor D t sphincter hi t dyssynergia d i (DSD)-inability to appropriately relax the pelvic floor with a contraction of the bladder-leads to poor emptying or painful voiding Pelvic pain syndromes such as vestibulodynia or vulvar vestibulitis M May contribute ib to Irritable I i bl Bowel B l Syndrome and Interstitial Cystitis
Causes for pelvic floor hypertonicity { {
Spinal cord injury Dysfunctional habits in response to chronic h pain z z z
Severe vaginal atrophy P l i ttrauma Pelvic Repeated infections {
Pain-fear Pain fear cycle=pain causes fear causes tension causes more pain
Wh t can we do? What d ? {
Talk about the pelvic floor f with your patients or your clinician z
{
{
IInitiate iti t h honestt di discussion i about b t pelvic l i health or symptoms!!
Start young-easier for patients to identify and strengthen when they are young and muscles are strong Elicit pelvic floor history to aid in intervention!
Ph i l exam-What Physical Wh t to t expectt { {
Done at time off bimanual exam Ask patient to squeeze around your f fingers, aka… k z
Squeeze like you are trying to hold in gas in a crowded room
St your urine Stop i on th the ttoilet… il t {
{
{
Not a great idea long term-confuses f the voiding messages Patient should h ld ffeell a llifting f sensation-like a string pulling their vagina up Do on a hard chair for most feedback hardest to do standing feedback-hardest (gravity)
Ph i l exam Physical {
Give patient a grade 0-5/5 z z z z z z
0-no movement to the pelvic floor 1 fli k 1-flicker 2-weak 3 moderate (lift) 3-moderate 4-good (lift) 5-strong (lift)
Ph i l exam Physical { {
Grade Accessory muscle use z
z z
Most common-bottom, thighs and abdominal muscles Make note if patient is using When a Kegel is done correctly the contraction is in pelvic floor only!!
Ed Education ti {
{
{
Not just for f older women or people who are incontinent! Start early l and dh help l the h muscles l stay toned. R Re-visit i i this hi every year at annuall exam starting at initial appointment. appointment
Ed Education ti {
2 types off exercises-long holds and quick flicks z
z
Long holds L h ld work k slow-twitch l t it h muscle l fibers used long term to keep patients continent-unconscious (70%) ( ) Quick flicks work fast-twitch fibers used during stress maneuvers (30%)
P Progressive i exercise i program { { {
{
No special devices are needed Patient compliance is key! Only works while patients do themuse it or lose it! Informal or formal training (at home versus physical therapy)
P Progressive i exercise i program { {
Identify f muscle Start doing 3 long hold exercises in a set z
z z
Hold for 3 seconds and relax for 3 seconds in between 4 sets/day May not feel the entire 3 seconds but should strive for them
P Progressive i exercise i program {
When you feel f the hold for f 3 seconds increase the hold/relax time and number of reps by 2 z
5 reps, hold 5 seconds, relax 5 seconds 4x/day
P Progressive i exercise i program {
Continue to add 2 until patient can ultimately hold… z
z z
12 seconds d and dd do 12 in i a row without ith t fatigue! Can you?????? Rest period is as important as the contraction for a healthy pelvic floor
Q i k flicks Quick fli k {
{
{
These are fast f up and down exercises Do these h daily d l at stop signs, red d lights, meals, brushing their teeth A Attach h to a daily d il activity i i for f best b compliance
Ad Advanced dE Exercises i { {
Standing Elevator z
z
z
Sit on floor and increase the contraction in stages Think about as floors until top floor and back down Takes a lot of concentration and control
F Formal l ttraining i i { { {
{
{
Done by experienced RN, NP or PT Done over course of several months May use biofeedback or electrical stimulation to enhance results Good for patients who are having trouble identifying the correct muscles l Creates incentive to comply
A Across the th Lifespan Lif {
B f Before childbearing hildb i z z z z
z
Easiest time to identify and tone muscles Encourage patients to be proactive and talk to relatives about their experience Of Often taught h in i yoga/Pilates / il courses Reminders are important-these individuals often do not have symptoms so easily forgotten SEX!!
A Across the th lifespan lif {
Before f childbearing z z
Can see hypertonicity in this group A k about Ask b pain i with i h intercourse i or during voiding
Pregnancy {
Most helpful f to have strong pelvic floor going into pregnancy and continue to do exercises throughout z
z z
No specific guidelines regarding trimester variations OK to do immediately after delivery Often taught g in p prenatal y yoga g classes
D li Delivery {
{ {
C/S may be somewhat protective with first child but looses that protection with second pregnancy Strive for intact perineum Wh effect What ff does d perineal i l massage have?
P Pre-menopausal l {
Often f when dysfunction f begins to appear in terms of incontinence and prolapse z z
z
Stress and urge related incontinence May be more compliant after symptoms appear Must ask about these symptoms y p to open a dialogue!
P t Post-menopausal l {
Estrogen depletion z
z
z
z
Consider vaginal estrogen for stress incontinence research not definitive incontinence-research May have more time for physical therapy May be more interested in non-surgical intervention due to co-morbidities Sometimes have hard time identifying the muscles due to weakness
Wh t do What d Kegels K l NOT d do? ? {
{
Kegels cannot put us “back together again” Depending d on the h amount off pelvic l floor descent exercises may not be enough z z
Pessary Surgery
T k home Take h message (literally!) (lit ll !) {
Whether Wh th a clinician, li i i a woman or someone who loves a woman talk about pelvic health!! z
{
{
Serious impact on quality of life!
Pelvic floor exercises are more effective if initiated early in symptom complex Speak to the doctor you feel f most comfortable with and be vigilant!
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