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Pelvic Physiotherapy – A summary from our Knowledge Building Seminar

April 07, 2017

What is the Pelvic Health Physiotherapist assessing with my Pelvic Floor Muscles?

When we do the internal assessments, there are two global themes that we are looking at. Firstly we want to determine what is the resting muscle tone of the muscles are.  Sometimes the muscles can be tight and stiff, or on the other hand they can be loose and lax.

The 2nd component of the internal assessment is evaluating the strength of the muscles. So, just like we would assess the strength of the biceps (the muscle in your arm), we can also get patients to contract these muscles in their pelvic floor, and we can assess the different layers. Sometimes the individuals have weak muscles, and sometimes they’re strong. And depending on which one, it can be a factor with incontinence and prolapse (explained later).

The last component that we are always considering is the presence of pain.  In either situation of tight or soft muscles, we may be able to feel areas that are more painful.  Sometimes this pain is new to the patient, but often we can reproduce pain that has been present for a long time.

The pelvic floor muscles are an important part of how we maintain continence.

The urethra (a tube like structure) comes out through the bladder, and sphincters help to close it off.   There’s an internal sphincter, which is within the bladder, and the external sphincters, which are the pelvic floor muscles. When the pelvic floor muscles aren’t strong enough, they can’t play the external sphincter role, and close off the urethra, and if they aren’t strong enough, that is where we get some incontinence.

The muscles also play a supportive role.  Above the pelvic floor muscles, you have your bladder, urethra, rectum, ovaries and uterus.  These muscles need to be strong in order to support those organs. If they are not offering that support, some individuals will experience symptoms associated with prolapse.  For example, without good support the bladder may rest in a slightly different position which can lead to incontinence, but it can also lead to symptoms of vaginal heaviness or budging.

Pelvic floor muscles also play a role in sexual function and overall core stability. Many individuals suffer from low back pain, and as part of their core stability program physiotherapists include pelvic floor muscle strengthening.   When we think about core stability the analogy of a barrel wrapping all the way around can give a nice visual of the muscles and tissue that are important in core stability.  Ultimately we aim to have strong abdominal muscles at the front of the barrel, strong back muscles, strong pelvic floor muscles at the bottom and lastly we also consider the diaphragm at the top of the barrel.

What is a Physiotherapist treating in the pelvic floor?

Common pelvic floor dysfunctions that physiotherapists treat include the three different types of incontinence. Stress incontinence occurs when you experience a loss of urine when you cough or sneeze or laugh.  The loss of urine is a consequence of an increase in abdominal pressure that is not successfully countered by opposing strength of the pelvic floor muscle. Urge incontinence occurs when you have an uncontrollable or sudden urge to go to the washroom all the time.  Sometimes you can’t make it there in time and experience some of that loss of urine. Mixed incontinence occurs when you have both stress and urge incontinence.

In addition to urinary incontinence, the same can occur with fecal incontinence.  Typically Urge incontinence is related to tight pelvic floor muscles, and stress incontinence is more typically from weak pelvic floor muscles – many people have some of both.

Another common pelvic dysfunction is prolapse.  Pelvic organ prolapse is due to weak pelvic floor muscles not playing their supportive role.

But pelvic floor dysfunction is not limited to exclusively incontinence or prolapse.  Other areas include sexual dysfunction and pain, lower back and girdle pain and constipation.

In addition to the pelvic floor muscles, we look at the bigger picture and include the actual bones of the pelvis, the lower back, and the hips. Our assessment includes an area on the body that starts just above the diaphragm and ends just above the knees. We take special care to notice and assess how well the connective tissue and any scar tissue moves over the abdomen, pelvis, lower back, and thighs.   This assessment combined with the internal assessment gives a thorough overview of all the areas that can be contributing to pelvic floor dysfunction.

Why do we do an internal exam?

In previous years physiotherapists and doctors often used to give individuals self-directed home exercise programs, however, the health care providers didn’t truly know if the patients were doing them correctly because there wasn’t a manual confirmation from an internal exam.

Pelvic floor exercises are often hard for the patient to even know if they are doing them correctly because the pelvic floor muscles lack the proprioception (which means knowing where the muscle is in space).  This means we often cannot feel when the muscles are contracting very well.  The benefit of the internal assessment is that the physiotherapist can confirm that the patient is contracting correctly and the patient can learn what the correct contraction feels like.  This results in more success with home exercises.

Muscle tone?

Muscle tone describes how the muscle is resting and how well it contracts.  For individuals who have a looser muscle tone, they usually are the patients who have stress incontinence.  The pelvic floor muscles do not have the strength to close off the urethra when they cough or sneeze. Also, low muscle tone at rest can lead to prolapse.  Even when the muscles are not actively contracting they need to have a certain amount of tone to provide support for the organs.  Without that support prolapse can occur.

Tight Pelvic Floor Muscles?

Individuals who have a tight pelvic floor are usually the ones who have urge incontinence.  In addition to incontinence tight pelvic floor muscles are typically more painful. This can result in local pelvic floor pain, pelvic girdle pain (in the hips or low back) and dyspareunia, which is painful sexual intercourse.

A hypertonic pelvic floor is when individuals have a very tight pelvic floor muscles. Tight muscles can lead to dyspareunia, increase in urgency to use the washroom, urinary retention (holding urine in, often refusing to go to the washroom), chronic pelvic pain, vulvodynia, endometriosis, Interstitial cystitis (IC) and bladder pain syndrome (BPS).  Treatment for the hypertonic pelvic floor include often include internal release or massage, postural education, scar tissue treatment, breathing and stretching and lengthening the pelvic floor ( such as reverse Kegels). It is really important that the patient knows how to relax and be mindful, because when the individual is stressed and tense, so are the pelvic muscles.

Weak Pelvic Floor Muscles?

Pelvic floor muscle training is the first line of treatment to target weakness.  Strengthening pelvic floor muscles increases the ability to close your urethra and reduce incontinence. Pelvic floor strengthening has also been shown to prevent surgery, and when surgery is necessary offers better success for good strength post-surgery. Pelvic Floor Strengthening has an 80-85% success rate but it does require a level of commitment from the patient. Typically gynecologists and other specialists will send patients to physiotherapy before they send their patients to surgery.

Prolapse?

50% of childbearing women experience prolapse.  Prolapse has a higher surgery rate than stress incontinence and 30% of people will require an additional surgery. Symptoms that patients report are heaviness in the pelvis area, as well as low back pain, bladder dysfunction, and sexual dysfunction.

Prolapse is graded by how much protrusion is visible.  For individuals who have a grade 1 to 3 prolapse, physiotherapy has been found useful, however people who have a grade 4 will likely require surgery.  When pelvic floor strengthening is used prior to surgery individuals will experience significantly less subsequent additional surgeries.

Menopause?

Incontinence and prolapse can become worse for women entering menopause largely due to the decrease in estrogen and its affects.  The lack of estrogen results in the pelvic floor muscles decreasing in size which often results in low tone or vaginal muscles weakness. Menopause can exaggerate issues that were already there but not interrupting function. For example, if an individual has a little bit of intermittent incontinence with a cough or sneeze, the stages of menopause can exaggerate its effects.

A hypertonic pelvic floor is when individuals have a very tight pelvic floor muscles. Tight muscles can lead to dyspareunia, increase in urgency to use the washroom, urinary retention (holding urine in- refusing to go to the washroom), chronic pelvic pain, valvodynia, endometriosis, and Interstitial cystitis (IC)/bladder pain syndrome (BPS). Treatment for the hypertonic pelvic floor include massage, postural education, scar tissue treatment, and stretching and lengthening the pelvic flood (reverse kegels). It is really important that the patient knows how to relax and be mindful, because when the individual is stressed and tense, so are the pelvic muscles.

Pelvic Girdle Pain?

It is important that patients always remember that there is no magic cure to treat pelvic pain.  Treating pelvic pain is a collaborative effort between the patient and the physiotherapist and often other allied health professionals.  Pelvic pain is multi-casual and neuropathic based – meaning nerves play a big role. There are many different factors that can contribute to pelvic pain, so being able to relax is very important. Some treatments include desensitization of the entire body, yoga, body awareness training and pain education, core education, and muscle energy techniques (relaxing/contracting).

Pelvic girdle pain is common for women both during pregnancy and after. Some of the reasons why females might be experiencing pain is due to pelvic joint asymmetry, ligament laxity (can be due to influx of hormones), and weakness/abnormal tension of the pelvic floor and abdominal muscles. An effective way to treat pelvic girdle pain in pregnancy is through pelvic symmetry exercises, in addition to gluteal strengthening and pelvic floor normalization

Constipation?

Constipation can lead to muscle incoordination.  Patients often lose the ability to relax their pelvic floor muscles. Chronic pain can lead to pain and/or incontinence. Treatment includes toileting education, fiber and fluid intake education.

Q: Should you do sports/aerobics with a tight pelvic floor?

You want to work on normalizing the muscle tone first through lengthening or relaxation exercise for the pelvic floor.  A muscle needs to be in a normal resting state in order for the muscle to generate appropriate and needed counter force during sport or aerobics.  If you are jumping it increases the abdominal pressure which only further pushes down on the organs. Walking and jogging is OK, but if that could also be avoided until your pelvic floor tone is normalized, even better.

Q: If you feel like you have to go to the bathroom often, should you restrict your fluid intake?

Unfortunately this is a common misconception.  You should NOT restrict your fluid intake. The only thing that you do by limiting fluids is increase the concentration of urine in your bladder.  When urine is concentrated it acts like a bladder irritant which in turn makes you feel like you need to use the washroom. So, it’s important that you are hydrating properly and drinking the right amount of water throughout the day.

One thing that you could try doing is training yourself to use the bathroom every 3-4 hours opposed to every hour or twice an hour. If you are frequently voiding your natural bladder “reflex”  changes and becomes hypersensitive and triggers a cycle that is difficult to break.  Hydrating well and voiding a good volume every 3-4 hours is the best strategy.

Q: And what about if they are really strong and really tight?

Muscles that are too strong (and have tender painful areas) and tight often lead to urge continence.  Tight muscles can push up against the bladder and make you feel like you constantly have to go to the washroom.

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