The Female Pelvic Floor And Goldilocks-handout

5/23/2009

The Female Pelvic Floor and Goldilocks Too weak, too tight and just right! (or just right, too weak and too tight)

Just Right… {

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Specific grouping of muscles, ligaments and fascia which interlace and provide support-includes pubococcygeus and levator ani Keep pelvic organs in the pelvis z

Meagan Matteson, RN, MS, CNP

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[email protected] Feel free to contact me with ?s

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Bladder Uterus Rectum

www.augs.org (great resource!)

Just Right… {

Muscles create circles (sphincters) around outlets of those organs to keep us clean and dry z z

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Just right… {

Roll in sexual function z

For example-urination example urination Bladder muscle is relaxed until need to void-pelvic floor muscles are contracted When voiding bladder muscle contracts and pelvic floor relaxes

Orgasm is essentially a rhythmic muscular contraction-stronger muscle=stronger muscle stronger contraction?

Too Weak… {

Increased risk of stress urinary incontinence due to weakness of both the urethral sphincter and hypermobility of the urethra z

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Leaking with coughing, laughing, etc.

Increased risk of pelvic organ prolapse or relaxation z

“My bladder is falling out…”

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Types of Pelvic Organ Prolapse

Causes for pelvic floor relaxation {

Childbearing (not just vaginal delivery!) z

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Causes for pelvic floor relaxation {

Heredity z

Genetic predisposition to poor tissue integrity {

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Can be seen in need for multiple reconstructions

Causes for pelvic floor relaxation {

Age z

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1 in three women will have leaking with stress maneuvers within 5 years of a vaginal delivery 50-75% 50 75% of women who have it won’t even tell their physician. Of those who did, 61% waited 4 years In the U.S. more feminine pads are used for incontinence than for menstruation

GRAVITY!!

Anything that increases abdominal pressure z

Prolapse and incontinence can often “run in the family”

Prevalence of Stress Incontinence

Increased pressure intra-abdominally 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

Runners Horseback riders Gymnasts

Prevalence of pelvic organ prolapse {

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40% of women over the age of 40 have some pelvic organ prolapse 50% of women who deliver vaginally i ll h have some d degree off prolapse

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Too Tight (Hypertonic)… {

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Detrusor sphincter dyssynergia (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 May contribute to Irritable Bowel Syndrome and Interstitial Cystitis

What can we do? {

Talk about the pelvic floor with your patients or your clinician z

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Severe vaginal atrophy Pelvic trauma Repeated infections {

Pain-fear cycle=pain causes fear causes tension causes more pain

Physical exam-What to expect { {

Done at time of bimanual exam Ask patient to squeeze around your fingers, aka… z

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!

Not a great idea long term-confuses the voiding messages Patient should feel a lifting sensation-like ti lik a string t i pulling lli th their i vagina up Do on a hard chair for most feedback-hardest to do standing (gravity)

Spinal cord injury Dysfunctional habits in response to chronic pain z

Initiate honest discussion about pelvic health or symptoms!!

Stop your urine on the toilet… {

Causes for pelvic floor hypertonicity

Squeeze like you are trying to hold in gas in a crowded room

Physical exam {

Give patient a grade 0-5/5 z z z z z z

0-no movement to the pelvic floor 1-flicker 2 2-weak k 3-moderate (lift) 4-good (lift) 5-strong (lift)

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Physical exam { {

Grade Accessory muscle use z

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Most common-bottom, thighs and abdominal bd i l muscles l Make note if patient is using When a Kegel is done correctly the contraction is in pelvic floor only!!

Education {

2 types of exercises-long holds and quick flicks z

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Long holds work slow-twitch muscle fibers used long term to keep patients continent-unconscious (70%) Quick flicks work fast-twitch fibers used during stress maneuvers (30%)

Progressive exercise program { {

Identify muscle Start doing 3 long hold exercises in a set z

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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

Education {

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Not just for older women or people who are incontinent! Start early and help the muscles stay t toned. t d Re-visit this every year at annual exam starting at initial appointment.

Progressive exercise program { { {

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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)

Progressive exercise program {

When you feel the hold for 3 seconds increase the hold/relax time and number of reps by 2 z

5 reps reps, hold 5 seconds, seconds relax 5 seconds 4x/day

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Progressive exercise program {

Continue to add 2 until patient can ultimately hold… z

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12 seconds and do 12 in a row without fatigue! Can you?????? Rest period is as important as the contraction for a healthy pelvic floor

Advanced Exercises { {

Standing Elevator z

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Sit on floor and increase the contraction t ti iin stages t Think about as floors until top floor and back down Takes a lot of concentration and control

Quick flicks {

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Formal training { { {

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Across the Lifespan {

Before childbearing z z z z

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Easiest time to identify and tone muscles Encourage g p patients to be p proactive and talk to relatives about their experience Often taught in yoga/Pilates courses Reminders are important-these individuals often do not have symptoms so easily forgotten SEX!!

These are fast up and down exercises Do these daily at stop signs, red li ht meals, lights, l b brushing hi th their i tteeth th Attach to a daily activity for best compliance

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 Creates incentive to comply

Across the lifespan {

Before childbearing z z

Can see hypertonicity in this group Ask about pain with intercourse or during voiding

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Pregnancy {

Most helpful to have strong pelvic floor going into pregnancy and continue to do exercises throughout z

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No specific guidelines regarding trimester variations OK to do immediately after delivery Often taught in prenatal yoga classes

Pre-menopausal {

Often when dysfunction begins to appear in terms of incontinence and prolapse z z

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Kegels cannot put us “back together again” Depending on the amount of pelvic fl floor descent d t exercises i may nott be b enough z z

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Pessary Surgery

C/S may be somewhat protective with first child but looses that protection with second pregnancy St i Strive for f intact i t t perineum i What effect does perineal massage have?

Post-menopausal {

Estrogen depletion z

Stress and urge related incontinence May be more compliant after symptoms appear Must ask about these symptoms to open a dialogue!

What do Kegels NOT do? {

Delivery

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Consider vaginal estrogen for stress incontinence-research not definitive 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

Take home message (literally!) {

Whether a clinician, a woman or someone who loves a woman talk about pelvic health!! z

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Serious impact p on q quality y of life!

Pelvic floor exercises are more effective if initiated early in symptom complex Speak to the doctor you feel most comfortable with and be vigilant!

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