Presentation on theme: "Pelvic Health IN WOMEN Beth Lonberger, APRN, Family Nurse Practitioner"— Presentation transcript:
1 Pelvic Health IN WOMEN Beth Lonberger, APRN, Family Nurse Practitioner Julie Starr, APRN, Family Nurse PractitionerUniversity of Missouri Hospital and ClinicsWomen’s and Children’s HospitalCenter for Female Continence and Advanced Pelvic SurgeryOur own backgrounds, who we work with and where exactly
2 objectives The participant will be able to: Define pelvic health in the femaleList common diagnosis contributing to pelvic floor dysfunctionUnderstand how pelvic organ prolapse, recurrent UTI and constipation effect bladder/bowel functionDiscuss treatment options for pelvic floor dysfunctionDescribe what we want them to get out of this presentation. We want it to be informal and for them to interact/ask questions.
3 PELVIC HEALTH Urinary continence Voiding less than 9xday and 0-1xnight Absence of infectionComplete emptying of rectum every dayAdequate support of pelvic organsWell estrogenized vaginal tissueSexual wellbeing
4 COMMON DIAGNOSIS CONTRIBUTING TO PELVIC FLOOR DYSFUNCTION Urinary DysfunctionUrinary IncontinenceUrinary urgency/frequencyNocturiaDefecatory DysfunctionConstipationFecal IncontinencePelvic Floor DyssynergiaPelvic Organ ProlapseLevator Ani Muscle SpasmPelvic PainDyspareuniaUrinary urgency/frequency/incontinenceObstructive outlet defecation
9 URINARY FREQUENCYVoiding >8 times during the day Negatively effects quality of life, especially when associated with incontinence. Social isolation Depression Inactivity contributes to more serious health problems
10 NOCTURIAGETTING UP MORE THAN ONCE IN THE NIGHT TO VOIDCauses:Recurrent UTIs, chronic renal failure, congestive heart failure, cystitis, diabetes, excessive fluid intake, elevated Ca+ level, sleep apnea.Increase risk of fallsDisrupted sleep cyclesTreatment: Imipramine 25-50mg q hs. Take Diuretic at noon.Gillen, L., Marinkovic, L., Stanton, S. Managing Nocturia. BMJ. 2004;328:
11 Recurrent UTI SYMPTOMS UTI Urinary urgency/frequency, incontinence, dysuria, low back pain, delirium.Elderly often asymptomaticDIAGNOSIS RECURRENT UTIsThree or more UTIs in the past year or >2 in the past six monthsIn and out cath specimen culture positiveCunha, BA, Tessler, JM, Bavaro, MF. Urinary Tract Infection, Females. Medscape. October, 19, 2009.
12 UROGENITAL ATROPHYVaginal atrophy (atrophic vaginitis) is thinning and inflammation of the vaginal walls which occurs after menopause due to a decline in estrogen.Results in vaginal dryness, itching, burning and inadequate lubrication.Urinary symptoms include urgency/frequency, incontinence and recurrent UTIs.Pinkerton, J. Vaginal impact of menopause-related estrogen deficiency. OBG Management. 2010; S11-16.
13 UROGENITAL ATROPHY TREATMENT Premarin vaginal cream 0.625% ½ applicatorful 3 x week at bedtime for 4-6 weeksthen decrease to ½ applicatorful 1xweek at hs for maintenance doseEstring (Estradiol vaginal ring)Vaginal ring containing 2mg of Estradiol releasing 0.75mcg in 24 hour periodTo be changed every 90 days
14 DEFECATORY DYSFUNCTION Refers to a multitude of complaints that may include having frequent and uncomfortable sensations to have a bowel movement, constipation or the feeling of poor emptying, and leakage of gas/ diarrhea/ and/or solid stool.20% of women suffer from defecatory dysfunction. Among women with pelvic floor disorders, the prevalence of defecatory dysfunction was 60%.Whitcomb, E.; Lukacz, E.; Lawrence, J.; Nager, C.; Luber, K. Prevalence of Defecatory Dysfunction in Women with and Without Pelvic Floor Dysfunction. Journal of Pelvic Medicine & Surgery. 15(4): , July/August 2009.
15 Defecatory Dysfunction causes Incomplete emptyingRectocele or perineal rectocelePelvic floor muscle (Levator ani) spasmSphincter incompetenceThickening of IAS and thinning of EASDietDehydrationMedicationsDecreased sensationIrritable Bowel Syndrome
16 Defecatory Dysfunction treatment Bowel regimen (constipation, diarrhea…)Pessary (rectocele)Pelvic floor therapyBehavior modificationDo not resist the urge to defecateProper hydrationDietary changesMedication changesExercise
17 BOWEL REGIMEN1.Mix 1 rounded teaspoon of psyllium fiber (Metamucil® brand or Wal-Mart® Equate generic) in 6-8 ounces of cold water. Take this dose of fiber supplement a minimum of once per day. You may repeat this dose up to 3 times per day. Please do not take Metamucil within two hours of any medications.2. IF YOU DO NOT HAVE A BOWEL MOVEMENT WITHIN ONE HOUR OF RISING EACH MORNING, take one tablespoon of magnesium hydroxide (Phillips® Milk of Magnesia or a generic equivalent). Repeat this dose each hour until you have a bowel movement (do not exceed 6 doses in a day). Most patients will begin having daily bowel movements without the need for magnesium hydroxide within one week of therapy.
18 Fecal incontinence 6% of women <40 years old 15% of women >40 Nursing Home residents 45-47%7% of all women have fecal smearing50% of affected women keep FI a secretAshima Makol; Madhusudan Grover; William E Whitehead. Fecal Incontinence in Women: Causes and Treatment. Women's Health. 2008;4(5):
19 FECAL INCONTINENCE TREATMENT Behavior modification/dietary changesMetamucil daily and Immodium prnPelvic floor therapySurgical optionsSphincteroplasty5 year recurrence rateUp to 60%
20 PHARMACOLOGICAL MANAGEMENT Metamucil dailyLoperamide prn1 tab (2mg/tab) before each meal and bedtime up to 8 tabs/day2 tabs (2mg/tab) at q meal and hs up to 16 tabs/dayDiphenoxylate with atropine sulfate prn1 tab (2.5mg/tab) at q meal and hs up to 8 tabs2 tabs (2.5mg/tab) at q meal and h.s up to 8 tabs/dayBismuth subsilicylate prn1-2 tabs (262mg/tab) before meals and h.s. not to exceed 4.2 g/day
21 Pelvic floor muscles (Levator Ani complex) PubococcygeusCoccygeusIleococcygeusThis group of muscles acts as a single neuromuscular unit to assist with proper support and function of the pelvis organs including normal urinary and fecal continence as well as genitourinary and rectal support.
23 A COLLECTION OF SYMPTOMS AND FINDINGS LEVATOR ANI SYNDROMEA COLLECTION OF SYMPTOMS AND FINDINGSThe most common symptoms includeDeep dull aching in the rectum/vaginaReferred pain to the pelvis, thigh and buttockPain worsens with sitting and bowel movementsSpasms and pain in the pelvic floor musclePain during or after intercourseUrinary urgency/frequency possibly incontinenceConstipationPrior testing usually rules out other pathologies
25 PELVIC FLOOR MUSCLE SPASM ASSESSMENT LEVATOR ANI COMPLEXPalpate 4-5 o’clock and 7-8 o’clock positionsINTERNAL OBTURATORPalpate 2 o’clock and 10 o’clock positionsSingle digit palpation of spastic muscle:feels like a guitar string or hard objectreproduces the pain
28 Pelvic Floor Therapy Components Abdominal EMGMeasure use of accessory muscleVaginal EMGMeasure resting toneAnorectal manometryMeasure muscle strengthE-stim (vaginal or rectal)Neuromuscular stimulation (NMS)
29 pelvic floor therapy Benefits Promotes pelvic floor muscle awarenessStrength trainingElectric stimulationenhances muscle awareness and strengthincreases urethral closure pressurerelaxes spasm4-6 sessions of therapyFolkerts, D., Wood, K. Overactive bladder and urinary incontinence: A multitherapy approach to treatment. Sexuality, Reproduction & Menopause. 4(2), 2006.
30 INDICATIONS Urge Incontinence Stress Incontinence Fecal Incontinence Pelvic Muscle SpasmPelvic Floor DyssynergiaPelvic Floor Muscle WeaknessHealth care problems aging women face % of all geriatric patients are incontinent
31 PATIENT REQUIREMENTS Cognitive awareness Active participation At least partial innervation of PFM
32 Pelvic Floor Muscle EMG At rest, continuous baseline activity consists of motor unit potentials of 2-4 MicroVolts
34 Anorectal Manometry Air filled balloon placed in the rectum Records squeeze pressure of Levator AniCan pick up valsalva and register as pressureManometry is measured from zeroBest for measuring true strength of muscle
52 Conservative Management of Pelvic Organ Prolapse Bowel ProgramVaginal EstrogenPessary
53 PessaryVaginal support device for relief of symptoms of pelvic organ prolapseIndicated for women who do not desire surgery or are not good surgical candidates92% satisfaction after 2 monthsImprovement of prolapse in 21% of patients after 1 year.Success is in patient selectionPhysical examIf you select the correct patient and fit them with a comfortable pessary, they are happy.
55 PESSARY MANAGEMENTProper fitting may require more than one visit every 2-3 weeks.Patient can be instructed on managing their pessary at home or return to clinic every 1-3 months for removal/reinsertion and exam.Estring can be replaced at this time
56 ETHELHPI: Ethel is a 90 y/o with complaints of over active bladder x 2 years. Her bladder symptoms worsened with recent sacroplasty. She describes symptoms of stress incontinence, urgency/frequency and urge incontinence which worsened at night. She wears a Depends pad and a large Poise pad and changes this ensemble 5 x day
57 HPI cont.On an average day she drinks 3 glasses of water, 2 glasses of juice, 1 cup of coffee and 1 soda. She reports 4 UTIs in the past year. She takes Miralax every morning and reports 1-2 bowel movements per day and strains at stool. 24 hour pad weight 803 grams Bladder diary indicates 16 voids/24 hours She gets up 4 x night to void.
58 MEDICAL/SURGICAL HISTORY Patient reports conditions of HPTN, anemia, hernia, sinusitis, GERD, hypothyroidism, Raynaud’s syndrome, constipation-predominant irritable bowel syndrome. Surgical history includes sacroplasty, cholecystectomy, appendectomy, hysterectomy and ovariectomy.
60 TREATMENT PLANBowel regimen for her defecatory dysfunction. Premarin vaginal cream for urogenital atrophy. Fosfomycin 1 x dose to treat UTI. Trimethoprim 100mg q hs for recurrent UTIs. Oxybutynin prn for OAB. Pelvic floor therapy x 5 sessions. Imipramine 25mg q hs for nocturia.
61 OUTCOMEPatient reported 100% improvement after 5 sessions of pelvic floor therapy. She voids 7-8 x day and 2 x night. Her daytime incontinence completely resolved and she leaks only drops during the night. She wears a panty liner for peace of mind. She remains on Trimethoprim at bedtime. She remains on Imipramine q hs. She takes Oxybutynin only when going out.
62 OUTCOME cont She continues with Premarin vaginal cream 1 x week. She continues to do pelvic floor exercises 4 x day.She takes Metamucil daily and reports 1-2 bowel movements per day without straining.She just returned from a vacation with her family in which they drove over 500 miles in the car.
63 PATRICIAPatricia is a 78 y/o patient with a lifelong history of diarrhea predominant irritable bowel syndrome. She presents with symptoms of fecal incontinence for the past year. She reports leaking stool five minutes after she starts to exercise. She reports 1-2 bowel movements per day and strains at stool.
64 HPI contHer urinary complaints include only mild stress incontinence. She wears a panty liner for peace of mind. She denies urinary urgency/frequency and gets up 1-2 times per night to void. She describes a burning perineal pain after intercourse and a soreness which lasts several hours. She uses Estrace cream for vaginal dryness.
65 MEDICAL/SURGICAL HISTORY Osteoporosis, diverticulosis and diarrhea predominant irritable bowel syndrome. G2P2 SVDx2 with largest birthweight 8# 13oz Surgical history includes hysterectomy, cystocele repair, cataract repair.
66 DIAGNOSISDiarrhea predominant IBS Fecal incontinence Defecatory dysfunction Stress incontinence Stage I cystocele Stage I rectocele Lichen planus (bx positive)
67 TREATMENTMetamucil and Loperamide for treatment of defecatory dysfunction/IBS Continue Estrace cream for urogenital atrophy Clobetasol ointment for lichen planus Pelvic floor therapy x 4 sessions for fecal incontinence.
68 OUTCOMEPatient reports 100% improvement in her fecal incontinence after 4 sessions of pelvic floor therapy. She reports 1 stool/day without straining with daily use of Metamucil. She is able to eat fruits and vegetables without GI complaints for the first time in years Her perineal burning/soreness have resolved. She exercises daily and no longer wears a pad.
69 LORIHPI: Lori is an 18 y/o G0 with history of sexual abuse starting at the age of 7. She was recently treated by Dr. Courtney Barr at the Center for Vulvar Diseases for vulvodynia which she reports is completely resolved. She describes an intermittent, stabbing LLQ pelvic pain which occurs 5-6 x day. She reports urinary urgency/frequency and mild urge incontinence.
70 HPI contShe often has a sensation that she is not emptying her bladder completely. Lori reports bowel movements every other day and strains at stool. She is not sexually active at this time.
71 MEDICAL/SURGICAL HISTORY Patient describes history of asthma and headaches. Surgical history negative.
73 TREATMENT PLANBowel regimen for her defecatory dysfunction. Pelvic floor therapy for levator spasm.
74 OUTCOMEPatient reports 100% improvement in her symptoms after 4 sessions of pelvic floor therapy. She takes a daily dose of Metamucil and reports one bowel movement per day without straining. Her pelvic pain is completely resolved.
75 SHELBYHPI24 y/o G0, RLQ pain for 9 months, appendectomy, 9 negative MRIs/CTs/Ultrasounds, seen in multiple clinics, ER throughout mid-MOPain 8-9/10, worse when moving around, improved with rest and heating padUrgency, urge incontinence (pad), sense of incomplete bladder emptying
76 HPI cont. Severe constipation with 1-2 BMs weekly Bloating Pain with intercourseWorried about serious problem with ovary
77 MEDICAL/SURGICAL HISTORY MigrainesHypothyroidAppendectomy
79 TREATMENT PLAN Bowel Regimen Home Exercises 4-6 sessions of PFT with estimHeat therapyWill consider colorectal consult
80 UPDATE Pain improving and started home program of e stim. Defecatory dysfunction improving, but still a problem, BM every 2-3 days
81 ANNEHPI: Anne is a 70 y/o G2P2 with complaints of stress incontinence, urgency/frequency, urge incontinence and nocturia for the past 6-8 months. She wears a panty liner for protection but not every day. She reports one bowel movement every other day and strains at stool.
82 HPI contOn an average day she drinks 5-6 glasses of water, 1 glass of juice, 1 glass of milk, 2 cups of coffee, 1 glass of tea and 1 soda. Her bladder diary indicates she voids 7 x in 24 hours. Her 24 hour output averages 3400cc.
83 MEDICAL/SURGICAL HISTORY Patient reports no medical problems and has never had surgery. She reports two vaginal deliveries with a maximum birthweight of 8#15oz..
84 DIAGNOSISStage II cystocele Stage II rectocele Perineal rectocele Nocturia Urodynamic stress incontinence Urge incontinence Urogenital atrophy Defecatory dysfunction
85 TREATMENTBowel regimen to treat defecatory dysfunction. Premarin vaginal cream for urogenital atrophy. Moderate fluids, especially in the evening. Pelvic floor therapy for urge and stress incontinence.
86 OUTCOMEPatient reports 85% improvement in her symptoms after 6 sessions of pelvic floor therapy. Her urge incontinence has resolved and she continues with mild stress incontinence 2-3 x month. She continues on Premarin vaginal cream 1 x week for urogenital atrophy. She continues with pelvic floor exercises and urge suppression techniqes daily. She continues to moderate her caffeine intake.
87 OUTCOME contAnne was so pleased with her results but her best friend’s bladder was limiting her lifestyle. Her friend completed a course of pelvic floor therapy. They have just returned from two weeks in Italy and reported complete bladder control and no anxiety about being on a tour bus all day
88 PELVIC FLOOR MUSCLE EXERCISES How to Identify the Correct MuscleTo find the proper muscle, imagine having to pass gas while with a group of people. In order not to embarrass yourself, you squeeze the muscles around your rectum to hold the gas back. This is the muscle you want to exercise.Common MistakesNever use the muscles in your stomach, legs, buttocks, and don’t hold your breath. To be sure you are not using your abdominal muscles, place your hand on your abdomen while you squeeze the pelvic floor muscle. If you are feeling your abdomen move, you are also using your stomach muscle.How to ExerciseWhen exercising it is important to squeeze and relax your muscles as prescribed. One work/ rest cycle is one exercise. If while you exercise you no longer feel the contraction, the muscle is tired. Stop and rest for a few minutes and then go back to the exercises.Where to ExerciseThese exercises can be done anywhere at any time. If you are doing them properly, your legs, stomach, thighs and buttocks will not move, and no one will know you are doing your exercises. Do the exercise sitting or lying down when you first start the program. After eight weeks you can do them standing, sitting or lying.Can These Exercises Harm Me?NO! These exercises cannot harm you in any way. If you experience back or stomach discomfort after you exercise, then you are trying too hard and using extra muscles. Relax, and start over.Prescribed ExerciseContract the muscle for 5 seconds, and then relax for 10 seconds (this is one exercise or cycle). Do 5 exercises in a row. Repeat this 4 times each day. If you perform them with an activity that you routinely do every day, you will be more likely to remember them. Mealtimes, bedtime and driving in the car are very common. New mothers can perform them while bottle/breast feeding.Increase the contraction time by one second and one repetition every two weeks (always continue 4 x day). Your goal is contract for ten seconds, relax for ten seconds. Do 10 exercises in a row 4 x day.
89 URGE SUPPRESSION TECHNIQUES When you feel the urge:Stop what you are doing.Sit down, if it is possible, or stand quietly.Remain still.Rushing to the bathroom may cause you to lose control of your bladder.When you are still, the urge is easier to control.Squeeze your pelvic floor muscles quickly several times. (Contract 2 seconds, relax for one second, 5-6 times in a row)Relax the rest of your body.Take a few breaths to help you relax.Wait until the urge goes away.Walk slowly to the toilet. Do not rush.
90 BOWEL REGIMEN1.Mix 1 rounded teaspoon of psyllium fiber (Metamucil® brand or Wal-Mart® Equate generic) in 6-8 ounces of cold water. Take this dose of fiber supplement a minimum of once per day. You may repeat this dose up to 3 times per day. Please do not take Metamucil within two hours of any medications.2. IF YOU DO NOT HAVE A BOWEL MOVEMENT WITHIN ONE HOUR OF RISING EACH MORNING, take one tablespoon of magnesium hydroxide (Phillips® Milk of Magnesia or a generic equivalent). Repeat this dose each hour until you have a bowel movement (do not exceed 6 doses in a day). Most patients will begin having daily bowel movements without the need for magnesium hydroxide within one week of therapy.