Pelvic Floor Dysfunction
What causes pelvic floor dysfunction? A deconditioning of the pelvic floor muscles causes such pelvic floor dysfunction as incontinence, pelvic organ prolapse, or pelvic pain. A woman may have lost her vaginal tissue strength following a normal birth delivery and have an increased risk of pelvic organ prolapse. Other causes include nerve injuries during delivery, impact trauma, muscular trauma, fascial tearing, constipation and straining, an enlarged prostate or a prostatectomy, lack of estrogen, sexual abuse, obesity, medications, behavioral habits, or musculoskeletal factors.
Urge incontinence, Stress incontinence, Mixed incontinence, Overflow incontinence, Reflex incontinence, Functional incontinence, Enuresis
What is incontinence? Incontinence is an involuntary loss of urine, which can occur when there is more pressure in the bladder than in the sphincter. It is not only embarrassing but can also cause a hygiene problem. The different classifications of incontinence are as follows:
Urge incontinence – The bladder is overactive. The person visits the bathroom frequently, feels “an urge” to urinate, is unable to “hold it” long enough to get to the toilet, urinates more than eight times per 24-hour period, awakens more than once during the night to urinate, or leaks a moderate-to-large amount. Any of these symptoms is indicative of urge incontinence.
Stress incontinence – The urethra is incompetent and won’t remain closed; therefore, the sphincter doesn’t close. Without warning, the person may lose a small volume of urine while laughing, coughing, or jumping or at any time when there is an increase in intra-abdominal pressure. This is a result of weak pelvic floor muscles. Pelvic traumas, such as childbirth or impact injuries, are common causes.
Mixed incontinence – This is a combination of urge and stress incontinence.
Overflow incontinence – The bladder is under active and does not empty well. This is the result of an outlet obstruction or under active neurogenic bladder. There is no urge present, and the bladder fails to empty normally. Self-catheterization is the usual management strategy, although timed voiding and functional voiding training may be helpful.
Reflex incontinence – There is no sensation and no control of the sphincters. The cause is a suprasacral lesion such as those experienced by a person with a CVA or spinal cord injury.
Functional incontinence – A person is unable to get to the bathroom in time. It could be due to a lack of mobility, such as experienced by an elderly person; limitations in the person’s environment, such as in a skilled nursing facility; or poor cognition.
Enuresis – There is a moderate loss of urine with no stress or sensation. The bladder contracts but the person doesn’t feel it. This sometimes happens with children who experience a problem with bedwetting. A bedwetting device used consistently will help train the child to awaken as soon as he or she begins to urinate. The alarm will sound and awaken the child, thus providing the biofeedback that the child needs to urinate.
How can physical therapy help with incontinence? A physical therapist trained in incontinence will complete a thorough history and medical screening, which will include medical, surgical, gynecological, childbearing, diet, hobbies, exercise, and bladder symptom information. You will be asked to keep a diary for two work and two nonworking days, consisting of symptoms, number of voids or wet episodes, related activities, amount lost, perception of need to urinate, observation, dietary and fluid intake, personal attitude, and physical limitations related to incontinence. The physical therapist will conduct (1) a musculoskeletal exam for posture, breathing, flexibility, and strength; (2) an abdominal exam for strength and scar tissue; and (3) a pelvic floor exam for skin condition, sensation, and muscular strength. You may be asked to contract and relax your pelvic floor muscles, bear down, or cough, as well as have your reflexes and pain response checked. The physical therapist will do an EMG test using biofeedback to determine the quality of your pelvic floor to contract, sustain a contraction, and relax following a contraction. If you are uncomfortable with the procedure, talk with your physical therapist, who will find alternative ways to help you feel more comfortable. Treatment will depend on the type of incontinence you may have, which will be evaluated by your therapist. Treatment possibilities include behavioral modification, dietary counseling, urge-suppression techniques, timed voiding, habit training, biofeedback, neuromuscular electrical stimulation, connective tissue realignment, and of course pelvic floor strengthening during non-functional activities progressing to functional activities. Biofeedback is a device that will help you isolate the pelvic floor muscles, increase awareness of contraction and relaxation, relax the nearby muscles, and retrain breathing patterns during pelvic floor strengthening. Urge incontinence also benefits from an NMES, an electrical stimulation device that either can be inserted into your vagina or its electrodes can be placed around your anus or on your sacrum. The NMES, a muscle reeducation device, is effective at the cellular and tissue level, causing improved permeability of cellular activity and tissue remodeling, as well as stimulating the nerves to function properly in turning on and turning off nerves to change urgency sensitivity.
Pelvic Organ Prolapse
What is pelvic organ prolapse? The symptoms of a pelvic organ prolapse include a bulging feeling in the vagina that worsens as the day progresses, urinary incontinence, or constipation. The types of pelvic organ prolapse are listed below:
Cystocele – The bladder bulges into the vagina through the tissue between the bladder and vagina, causing the bladder to come down into the vagina; it does not break through the tissue. It is graded from 1 to 3 according to the amount of descent.
Rectocele – The anterior wall of the rectum bulges into the posterior wall of the vagina and can cause a feeling of increased pressure and difficulty moving bowels.
Urethrocele – The tissue between the vagina and the urethra weakens, causing the urethra to push into the vagina.
Uterine prolapse – The uterus slips into the vagina, causing a bulging sensation. It is measured in grades between 1 and 4, with 4 being the most involved.
Enterocele – Organs such as the small intestine can bulge through the vagina. This is more commonly seen following a hysterectomy. This does not mean that after a hysterectomy you are likely to have an enterocele.
How can physical therapy help me with pelvic organ prolapse? A physical therapist trained in women’s health cannot repair the fascia or damaged tissue, although the therapist can assist you in supporting the prolapse with a strong pelvic floor, which will alleviate the symptoms of a pelvic organ prolapse.
Pelvic Floor Strengthening and Kegel’s Exercises
How can I strengthen my pelvic floor on my own?
Picture your pelvis as an empty bowl. In your picture, place a nonstretch hammock at the base of your pelvis. Visualize lifting the hammock and squeezing around it. “Suck up and pucker up.” Now hold that squeeze for 10 seconds. After holding for five seconds, tighten harder. Repeat this exercise nine more times. Repeat this set three times a day. Start out performing this exercise while lying down and progress to sitting, standing, the transition of sit to stand and stand to sit, walking, etc. If you are having difficulty knowing whether you are contracting your pelvic floor, try squeezing a ball between your knees or lie on your back with your knees bent and lift your bottom up in the air. You use your pelvic floor during functional movements. Next time prior to sneezing or coughing, contract your pelvic floor. You must be consistent with this exercise for at least three months before you get the desired results. Once you’ve achieved the desired results, continue with the exercises indefinitely, performing10 repetitions daily to prevent relapse.
Tension syndrome, Interstitial cystitis, Vulvodynia, Coccydnia, Sacro-iliac joint dysfunction, Myofascial pain, Constipation, Vaginal pain, Painful sex
What is pelvic pain? The pelvic floor does not relax, resulting in pain; no disease is present and the pain has lasted longer than six months. It is called a syndrome because it is frequently associated with other symptoms such as irregular bowel function, bladder irritation, and stress incontinence. There is frequently a musculoskeletal component such as poor posture, lack of flexibility or strength, core muscle weakness, pelvic floor muscle weakness, sacroiliac joint (SIJ) pain, and past trauma or injury below the waist or involving the spine. Some of the pelvic pain syndromes include non-relaxing pelvic floor muscles, tension syndrome, interstitial cystitis, vulvar pain syndrome, painful sexual intercourse, constipation, coccydynia, sacroiliac joint dysfunction, and myofascial pain.
Non=relaxing pelvic floor/tension syndrome – The pelvic floor muscle holds tension, which sets off a pain syndrome. Frequently, trauma, surgery, or sexual abuse is the primary cause. Posture alterations resulting in pain occur because of the tissue tension patterns. The holding patterns may result in bowel and bladder incontinence and uncomfortable intercourse.
How can physical therapy help me with tension syndrome? After ruling out an acute infection or active herpes, physical therapy would proceed with manual therapy, vaginal dilators, modalities, biofeedback, exercise, posture training, and reeducation in activities of daily living. Manual therapy may include myofascial release, scar tissue release, connective tissue realignment, joint mobilization, strain counter strain, and visceral or urogenital mobilization or acupressure.
Interstitial cystitis – Symptoms present with this diagnosis include pain above the pubic bone that is relieved by urinating. There is pain on the bladder as it fills, and relief is achieved when it empties. A person may urinate 30 times a day. Sixty percent report painful intercourse.
How can physical therapy help me with interstitial cystitis? A physician will make this diagnosis and may prescribe medication along with physical therapy. Physical therapy may include biofeedback, neuromuscular electrical stimulation, manual therapy, and diet. Biofeedback will improve the strength, endurance, and relaxation of the pelvic floor muscles. A person will need to learn to relax the pelvic floor muscles before urinating. Electrical stimulation will decrease the urgency felt to urinate and provide pain relief. Manual therapy will realign the connective tissue, which consists of muscles, fascia, bone, viscera, and vessels. Dietary suggestions will address the foods and beverages that are irritants to the bladder.
Vulvodynia– A vulvar pain syndrome is characterized by burning, stinging, and irritation or rawness on the perineum or female genitals. A physician will diagnose if there is pudendal nerve damage, an infection, or skin disease and may prescribe medication such as topical estrogen, pain medication, anti-inflammatories, or antidepressants. A diet low in oxalates is recommended.
How can physical therapy help with vulvar pain syndrome? A physical therapist may use biofeedback to improve relaxation, strength, and endurance as well as ultrasound or microcurrent and manual therapy to realign connective tissue such as muscles, fascia, bone, viscera, and vessels.
Coccydynia – Pain is felt in the tailbone, especially when sitting, and is caused by an injury to the coccyx. It can be the cause of non=relaxing pelvic floor muscles, sacroiliac joint pain, and myofascial pain.
What can physical therapy do to help with coccydynia? Treatment consists of a joint mobilization to the coccyx, most often done through the rectum. The therapist must test the body’s response system to determine the direction to mobilize the coccyx. A gentle touch in the correct direction will mobilize the coccyx and reduce the pain. Usually this is accomplished in one treatment but occasionally requires two treatments.
Sacroiliac joint dysfunction – The two bones that make up the SIJ are the sacrum and the ilium. SIJ dysfunction can initiate from a variety of areas. It can result from a fall or strain causing the connective tissue, muscles, bones, fascia, and vessels to torque, resulting in improper alignment of the connective tissue.
How can physical therapy help with sacroiliac joint dysfunction? A physical therapist will determine what is causing the connective tissue alignment alteration. Manually aligning the connective tissue will automatically alter and improve the posture. Treatments may include manual therapy, posture reeducation, strengthening and stretching exercises, and electrical stimulation.
Myofascial pain – This is a condition in which trauma or emotional energy is causing a blockage and tissue alignment problem resulting in a generalized pain syndrome.
How can physical therapy help with myofascial pain? The physical therapist will determine the root cause of the pain by addressing bone, muscle, fascia, vessel, and fluid involvement. Creative insight into patients is a must to resolve myofascial pain. Frequently a person must find a physical therapist trained in unconventional techniques. Preferred techniques include Matrix Repatterning or biotensegrity to get to the root of the problem.
What are some causes of constipation and how can physical therapy help? Constipation is often due to a nonrelaxing pelvic floor and a lack of fiber and water. A physical therapist may use biofeedback to improve relaxation of the pelvic floor, manual therapy to relax and align the muscles and fascia, scar tissue mobilization, and electrical stimulation. Relaxation techniques such as tapping along emotional meridians may also be beneficial.
What are some causes of vaginal pain or painful sexual intercourse and how can physical therapy help? Childbirth and episiotomy or tearing from a vaginal delivery can trigger vaginal pain or painful sexual intercourse which may persist after delivery. Other causes can be past physical or emotional trauma such as an impact injury or sexual abuse. A physical therapist can help by using biofeedback to improve relaxation of the pelvic floor, manual therapy to relax and align the muscles and fascia, scar tissue mobilization, and electrical stimulation. Relaxation techniques such as tapping along emotional meridians are frequently helpful.
Which foods and beverages are potential irritants to the bladder? Foods and drinks that are likely to cause bladder irritation and increase urine leakage include alcoholic beverages, including beer and wine; carbonated or caffeinated drinks; milk products; citrus juices and fruits; medications with caffeine; tomatoes and tomato-based products; highly spiced foods; and sweeteners and artificial sweeteners such as sugar, honey, corn syrup and chocolate.
Daily Bladder Habits
How do my daily habits affect my bladder? Drink a lot of water—the number of ounces should equal half of your body weight expressed in pounds—to decrease your urine concentration. This will reduce bacterial growth. If you weigh 150 pounds, you should drink 75 ounces of water per day, which is a little more than a half gallon per day. If your urine has an abnormal odor that is not caused by something you ate, consult your physician; you may have an infection. Constipation may cause a sense of urgency to urinate. You can increase dietary fiber and water to reduce constipation. Bowel straining and coughing contribute to pelvic floor weakness and may cause bladder leakage. Cigarette smoking irritates the bladder surface. Nylon underpants and pantyhose against the skin can cause irritation. Avoid perfumed toilet tissue and sanitary napkins, which can irritate the skin and bladder. Consult your pharmacist regarding medications you are taking that may irritate your bladder.