Comprehensive Overview of Pelvic Floor Physical Therapy Techniques and Considerations

Superficial muscles of pelvic floor

Superficial transverse perineal - stabilize perineal body

Bulbospongiosus - vaginal sphincter/compressor of urethra and assist erection

Ischiocavernosus - clitoral/penile erection

External anal sphincter

Middle layer of muscle for pelvic floor

Enveloped by fascia that integrates with abdominal wall

Sphincter urethra

Compressor urethrae

Deep transverse perineal

First and second layer innervation

Pudendal nerve

Deep layer pelvic floor

Innervated by branches S2-4

Levator ani - pubococcygeus, puborectalis, iliococcygeus

Coccygeus

Obturator internus

Piriformis

Male pelvic floor

Prostate sits on pelvic floor

Nerves of the pelvis

iliohypogastric - skin above pubic bone, lower abs, posterior gluts (mimic pubic symphysis dysfunction)

Ilioinguinal - external genitalia, inner thigh, inguinal area

Genitofemoral - upper anterior thigh, mons pubis

Sacral and coccygeal plexus - L4-S4

Function of pelvic floor muscles

Support with resting tone, contract for pelvic floor closure

Trunk fixation, assist abdominals in compressing

Sphincteric, encircle urethra, vaginal and rectal canal to provide tone and closure

Sexual, provide tone and support and proprioception in vaginal walls, orgasm

Potential issues with pelvic floor

Too much mobility = incontinence

Too much stiffness/fixation = pelvic pain

Conditions to consider with pelvic floor

Gyn

GI

Urologic

MSK

Neurological/vascular

How pelvic floor compensates for abdominal pain

Altered movement to avoid pressure, stretch, strain = hypomobile segments

Compensatory hypermobile segments increases muscular work to maintain dysfunctional posture

Pain-spasm-pain concept

Pelvic floor muscle contraction

Only 70-85% of women demonstrate correct - when cued improvement

Palpate externally = medial to ischial tuberosity in hooklying

Teaching PFM contraction

Feel between "sits" bones, pull up and in

-Stop stream of urine, hold in gas

-avoid use of glutes/adductors

-PFM contraction when exhaling

PFM internal assessment

Internal muscle mapping, evaluate contraction and relaxation, symmetry

Assess pain, trigger points

Can be performed vaginally/rectally

Strength testing PFM

At layer of levator ani (rectal or vaginal)

0 = no palpable contraction

1 = trace, flicker

2 = por, contract without lift

3 = fair, contract and lift post>ant

4 = good, strong contract and lift ant, post, sides

5 = strong, strong lift and contract with inferior deflection of finger

PFM and LBP

Women reporting back pain were twice as likely to also report UE

When treating LBP with PFM strengthening - improved QOL scores in regard to pain and urinary incontinence

PT intervention for spine

LBP associated with altered mechanics of diaphragm, transverse abdominis, PFM

-education = posture, body mechanics

- abdominal stabilization

- posture and trunk control during functional tasks

-PFM = enhance stabilization, decrease pain, urinary incontinence, pelvic pressure

PFM function on the spine

Contraction elevated intra-abdominal pressure = stabilization

TA and internal obliques are recruited with PFM contraction (prior to abdominals)

Stabilize SI joint - increase tension across interosseous and iliolumbar ligaments

Diaphragmatic breathing

Pelvic floor moves with diaphragm - deep inhale relaxes PFM

-regulate nervous system and stress/pain response

-promote healing

-Promote 360 degrees of breathing, not just belly breathing

PFM pain treatment - guarding

"no such thing as over-relaxing". = won't leak more, won't become weaker

-Contract/relax principle to show what relaxed is

Stretching = obturator internus, piriformis, adductor, hip openers

Prevalence of incontinence

27% of 450 female soldiers = limit fluids to compensate

28-49% of high school/college athletes

10% of men after prostate procedure

Types of incontinence

Urge

Stress

Mixed

Requirements for continence

bladder to expand and contract

Sensation to know if bladder is full/empty - stretch receptors

Mobility to get to bathroom

Ability to remove clothing

Mechanics of voiding

Reflexive loops to coordinate voiding

Detrusor contraction with sphincter relaxation

Bladder contracts long and hard enough to empty

Bladder relaxes, sphincter resume normal resting tone

Normal bladder

Average = 400-600 ml

takes 3 hours to fill

Frequency = 5-8x/24 hours

Urge incontinence

Loss that occurs with a strong urge

Strong bladder contractions inhibit pelvic floor and cause leakage

Triggers = key in door, running water, cold

Treatment = nervous system relaxation (PT), meds to reduce bladder contraction, nerve stimulation

PT treatment of urge incontinence

Volitional pelvic floor muscle contraction = suppress urge to turn off bladder

Must have good strength and endurance to be successful

Suppression = stand still/sit down, deep breathing

Pelvic floor contractions = quick or sustained

Voiding after urge suppressed = delay voiding for a few minutes

Stress incontinence

Involuntary loss of urine with physical exertion, increased intra-abdominal pressure

-sphincter deficit, bladder/urethra hypermobility, PF weakness or poor coordination

PT treatment of stress incontinence

Not just kegels

Need to work on strength and endurance of PFM

Cue to contract and fully relax

Contract quick, relax quickly for 10 reps

Contract hold for 5 sec repeat 5-10x with breathing

Weak PFM treatment

Use accessory muscles

Hip ADD, extensors, rotators: roll in/out

If can't isolate PF contraction, do in combination with accessory muscles

Gravity assisted/eliminated positions

Maintain contraction with movement

Co contract with TA and maintain during stabilization exercises

Maintain during functional tasks

Modalities

Biofeedback - pt education, PF awareness, feedback on exercise performance

Electrical stimulation - vaginal/rectal probe, assists PF contraction for neuro re-education