Managing Pelvic Floor Disorders - PowerPoint Presentation

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Managing Pelvic Floor

DisordersPelvic Floor Dysfunction“PFD”Tarra Richard PTWomen’s Health and Pelvic Floor Physical TherapyMethodist Plaza OB/GYN1212 Pleasant Street Suite 405Des Moines, Iowa 50309515-241-4000

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Objectives

Understand what The Pelvic floor Is and basic anatomy and function of it.Understand what Pelvic Floor Dysfunction (PFD) is and symptoms of it.Verbalize benefits of Physical Therapy Treatments for Pelvic Floor Disorders

Have

an understanding of

how Cancer

Treatments

can cause PFD and impact Sexual Function

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What

is Pelvic Floor Physical Therapy? Or WHPT?Pelvic Floor Physical Therapy is the evaluation and treatment of symptoms and problems associated with the pelvic floor. This consists of evaluation of the pelvic floor muscles externally and internally (vaginally or rectally), the pelvic girdle and associated structures that attach and contribute to the function of the pelvic floor (abdominals, breathing diaphragm, back), and assesses and treats faulty posture, toileting, sexual and body mechanics.

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WHO

? Needs Pelvic Floor PT or WHPT?WomenMenChildrenTeensAthletesElderly

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WHO

? Women with:OB Pain- pre and postpartum stretch weakness and joint alignment and laxity complications.Incontinence- Urinary and bowel from weak inactive pelvic floor muscles and/or tight short pelvic floor muscles. “Incoordination”Prolapsed organsPelvic Pain- pubic, abdominal, SI, back, bladder (IC), vulvodynia and gynecological, pain with sex (Dysparunia, vaginismus,)

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WHO?

Men – pelvic, rectal, groin and testicular pain, post prostate/colon cancer treatments, sexual dysfunctionChildren - constipation, bedwetting, daytime wetting, FI.Teen girls- difficulty with tampon insertion, IncontinenceAthletes: leak running/jumping, lifting, exercise, nerve compression pain from bike seat, overactive pelvic floorElderly: weakness, hormones, surgery, prolapse, prostate, cancer, mobility

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What is the “Pelvic Floor”?

A 3 Layer Pelvic Diaphragm of Muscles and ligaments that create a floor in the base of the pelvic girdle.

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The

Pelvic Floor – 3 Layers3 muscle layers that span from the pubic bone to the tail bone front to back and side to side to each Ischial tuberosity “sit bone”. They make a sling or trampoline like layer for support and loops and circular muscles around each of the openings.

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3 Layers

: Deep Superficial

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The Pelvic Floor –

3 LayersSuperficial-Urogenital Diaphragm – surface muscle layer primarily responsible for sexual function, erection and orgasmic muscle responses. “Front door closes and opens”Perineal Membrane- Sphincter Layer- urethral and anal sphincters close and aid in loss of urine or bowel control.Deep-Levator Ani – responsible for supporting the internal organs. “lifting and dropping” the floor during core contractions, and aids in stopping leakage from occurring.

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What does the Pelvic Floor Do?

Supports pelvic organs (bladder, uterus, bowel)Sphincter closure (prevent leakage urine/bowel)Stretches and Relaxes to allow entry, elimination and childbirthStabilizes the pelvic girdle jointsSexual function Sump Pump

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When

things Go wrong in the Pelvic floor…Pelvic Floor Dysfunction? “PFD”When the “Pelvic Floor” is not functioning normally it results in disorders of the muscles and tissues that make it up and the organs that are supported by it.

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Causes of PFD

Gyn surgeries impair muscle function, position, scars (hysterectomy, cancer surgery)Pregnancy and Vaginal delivery/traumaObesityChronic Constipation (straining)Poor Lifting / PostureSexual abuse/TraumaHormone changesCancer effects of Chemo and Radiation scars

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Symptoms of “PFD”

Pain (pelvic, abdomen, back, vaginal, rectal)Urinary RetentionConstipation and strained elimination Pain with Vaginal entry (Sex, tampons, Gyn exams)Incontinence Leakage of Urine or BowelProlapse of pelvic organsFeelings of UTI but negative culturesVulvar, pressure, itching, stabbing, numbness

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Symptoms when muscles are

Too Tight! Overactive, non relaxing, shortened musclesPainStrained elimination UTI feelingConstipationSexual DysfnVaginismus

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Vaginismus

Involuntary muscle spasm of the vaginal entranceOccurs in 20% of all women (OB/GYN Special Edition)Treatment includes: -physical therapy muscle re-education of the pelvic floor-biofeedback-manual treatment -dilator

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Symptoms when Muscles are

Too Weak!! ProlapseIncontinence -from Damage, Disuse, Overstretching, Disease (diabetes, MS)

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Weak Pelvic Floor… Prolapse

CystoceleRectoceleUterine

Vaginal vault

Patients complain of “pressure or feeling of golf ball or lump in vagina

”, deep penetrative sex can be painful.

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Weak Pelvic Floor… Incontinence

* Any leak of urine! “Oops”!UrgeStressMixed“Involuntary loss of urine in any amt. from a few drops to complete bladder emptying), or the inability to control when and where emptying of the bladder will occur”.

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Think of the bladder as a balloon and the sphincter as the knot

Bladder

is an elastic muscle that stretches to hold urine being sent from the kidneys via ureters.

Sphincter muscles

remains tightly shut, preventing urine from leaking out.

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The sphincter and the bladder are perfectly coordinated in a person with good urinary control

Reflex Action/InhibitionWhen sitting on the toilet to void and the bladder is full, the bladder signals the brain, the brain in turn signals the sphincters to relax.The bladder contracts and squeezes the urine out.The sphincter closes tightly and the bladder relaxes so refilling can resume.

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Managing Pelvic Floor

DisordersHow Can Physical Therapy Help?

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Treatment of PFD

Education! (Anatomy and Function) BreathingExercise: strengthening, lengtheningBiofeedback, EstimPosture and Body MechanicsAlignment of pelvic jointsManual Therapy- Massage, Dilators, TheraWand

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Treatment of PFD

Core Abdominal, back and Hip strengtheningToileting posture and behavioral changesDietary modification–constipation, inflammationPsych referral -often emotional or fear based, marriage counselingPosture & Lifting instructionSkin Vulvar CareBowel and Bladder training

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Pelvic Floor Muscle Training

improves bladder/bowel controlprevents prolapse with support

improves sexual sensation

Improves strength & stability

Improves Flexibility

Improves vaginal entry

PFM training is recommended as the first-line treatment for women with stress, urge, or mixed incontinence as well as POP (Bo and Hilde2013)

Pre and Post Op PFM training- significant decrease post prostate UI in group that received pre-op exercises (

Sueppel

2001,

Centemero

2010)

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Pelvic Floor Muscle Training

The stuff below…Needs to be strongNeeds to relaxNeeds to be aligned

Needs to be coordinated

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Pelvic Breathing

4 inner core muscles form a team that works to brace the trunk called ‘the core”. These muscles surround the organs and spine like a canister supporting the trunk from the bottom, top, back and front.2016 Kathy Wallace PT. Pelvic Resources .com

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PFM Exercise:

Find the right musclesSuperficial and deep layersCoordinate it properly with Diaphragmatic breathing Exhale as you contract! Inhale Relax

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PFM Exercises after Prostate Surgery

PFM exercises begun as soon as the catheter is removedResulted in statistically better return to sexual functionCompared to a 3 month delay in starting PFM exercises (Lin 2012)PFM exercises should be performed before radiation therapy*Lin YH, et al. Effects of early pelvic floor muscle exercises for Sexual dysfunction in radical prostatectomy recipients. Caner Nurs 2012;35(2):106-114*Dorey G. Evidence for the role of physical therapy in the treatment of male sexual dysfn. Chapter in evidence based physical therapy for the pelvic floor second edition Bo K Berghman B,

Morkved

S, Van

Kampen

M Churchill Livingstone Elsevier 2015

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PFM training for Vaginal Pain“Dyspareunia” is a diagnosis for Painful Intercourse Dyspareunia after surgery or radiation (White 2006)67% of Gynecological cancer survivors treated with radiation therapy reported dyspareunia55% reported superficial pain40% reported deep pain36% reported both superficial and deep pain* White ID, Faithful S. Vaginal dilation assoc with pelvic radiation: a UK survey of current practice Int J Gyn

Cancer 2006 May-Jun;16(3):1140-6.

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Therapy for Dyspareunia

Pain in non-contractile structures: skin, organs, nerve hypersensitivity medical treatments to heal infections and thicken skinManually stretching adherent scarsDesensitization of nerves and sensitive skin with DilatorsOrgans- positions for penetration during sex Pain in Contractile Structures: PFM Muscle spasms Relaxation/Diaphragmatic Breathing/MeditationDilator therapy for training fear basedMuscle training Joint Dysfunction

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Vaginal Dilator Therapy

Indications:Fear and paradoxical muscle contraction in response to penetrationSkin sensitivity to sliding and penetrationVaginal Muscle spasmsChance to “practice intercourse”Use with Biofeedback – EMG or mirror

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Dilator Therapy

Relax, private comfort placeWarm tissues with heat/bath shower beforehandExercises – warm up tissues before and duringInsert smallest dilator Leave in 10 min dailyAs tolerable add movements with dilatorInvolve spouse as appropriate

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Biofeedback

MirrorPressure and electric EMG give information about a normally unconscious process by measuring the activity of the pelvic floor muscles’ contraction either by pressure or by electrical activity in the muscle.

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Manual Treatment

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Pelvic Effects from Cancer

Tx Radiation or Surgery effect the Pelvic Organs, tissues and muscles.Effects on bladder, Uterus and Rectum may cause Urinary burning and frequency Rectal irritation, diarrhea Incontinence Cramping, muscle spasms

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Pelvic Effects from Cancer

TxScarring from Gyn Surgery and RadiationVaginal dryness, lack of lubrication - tearingSexual Pain with Penetration/Vaginal entryMuscle weakness –> incontinence, prolapseMuscle stiffness, tightness, shortening->incontinence, pain, spasms, painful intercourse, back pain

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Cancer

Treatment Side Effects:Premature menopause -due to cancer treatment caused by surgery to remove ovaries, chemotherapy, radiation therapy, or hormone-blocking agents Every woman who goes through premature menopause is

at risk for sexual and vaginal health complications. Symptoms are more intense and severe than those experienced during the natural process, and can include:

-Vaginal

dryness, discomfort, and pain

-Difficulty

with sexual arousal

-Pain

during intercourse

Emotional feelings

of anxiety, sadness, and loss, as well as a loss of interest in sexual contact.

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Radiation Impact on Sexual Health

Breast Radiation- decrease sensation, tissue quality, burning, emotional effectsPelvic Radiation- effects vaginal tissues, pelvic floor muscles, entire genital area, inflammation, burning, tears from brittle tissues, weakness, stiffness, tightness, scars.TreatmentDilator therapy within 8 weeksExercisesManual TherapyVaginal Moisturizers/ Lubrication

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Treatments after Cancer for PFD

Treatments for all “PFD” patients are similar however timing of treatments and skin conditions and fragility of tissues with patients undergoing cancer treatments may be handled more gently as the tissues heal Discussion is Crucial! patients and providers need to communicate and ask about Sexual Dysfunction, concerns and Symptoms without fear or embarrassment Prevention is Key!

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Questions

???