1. Women’s Health Program
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Women’s Health Program
Physical Therapy Specialists in
Pelvic Floor Dysfunction and Rehabilitation

2. Female Urogenital and Musculoskeletal Anatomy
Contents of the Pelvic Floor:
Perineum
Genitals
Muscle
Fascia
Connective tissue
We will begin by discussing the anatomy of the pelvic floor. It is important to understand the anatomy and structure of the pelvic floor as physical therapists evaluate and treat each patient specific to their individual dysfunction.
The pelvic floor has many layers. Within the musculature there are three layers of muscle that we will delve into more detail shortly.

3. Female Perineum Superficial muscles Perineal Membrane Layer
Anal Triangle
Perineal Body
Within the superficial muscle layer is made up of the superficial transverse perineal, bulbocavernosus and ischiocavernosus (see diagram).
Within the perineal membrane layer are the deep transverse perineal, compressor urethra and the sphincter urethra muscle. These muscles assist with sphincter control.
These two layers in combination with the fascia are also known as the urogential triangle.
Note the anal triangle. Within the anal triangle are two muscles: the internal sphincter and the external sphincter. The Internal sphincter may suffer trauma with childbirth. The external sphincter is voluntary.
Special attention to the perineal body. This is made up of a fibromuscular node known as the central perineal tendon. It is the insertion for the urogential triangle muscles, as well as the external anal sphincter and portions of the levator ani muscles. This is the region where an episiotomy may be performed or tears during childbirth most often occurs. This can later affect sphincter control and sensation.
In this diagram you can also see the gluteus maximus and a portion of the levator ani which is the deeper layer.

4. Pelvic Diaphragm Deepest Layer Function: Levator Ani Muscles
Pubococcygeus
Pubovaginalis
Puborectalis
Iliococcygeus
Coccygeus
Function:
Support the pelvis
Support the organs
Assist abdominals
Sphinteric
Sexual appreciation
Muscle Fibers
30% fast twitch
70% slow twitch
The deepest layer of muscles of the pelvic floor is the Levator Ani Muscles. These muscles act as a sling to support the pelvis and internal organs with continuous resting tone. Additionally the levator ani assist the abdominals during forced urination, expiration or any time the abdominals need assist with contracting. They assist with sphinteric closure as well. These muscle fibers consist of slow and fast twitch fibers which we will discuss more later.
The coccygeus is not part of the levator ani, but it is a deep muscle of the pelvic floor and stabilizes the sacro-iliac joint.

5. Levator Ani Muscle attachments to coccyx, sacrum, piriformis and pubis
Continuous with piriformis and obturator internus
This is a view from the side showing the support of the levator ani muscles. These muscles are attached to the coccyx, sacrum, piriformis and pubis. They are also continuous with the piriformis and obturator internus which is a hip rotator. Dysfunction with these muscles can cause dysfunctions with all these structures. There can also be pain referred to the hip, pubis or buttock. (see next slide)

6. Obturator Internus and Piriformis Muscles
Lateral hip rotators
Hypertonus or trigger points cause vaginal, rectal or clitoral pain
Piriformis syndrome
Referred pain mimics other dysfunctions
Hypertonus or trigger points in these muscles can manifest as vaginal, rectal or clitoral pain
Piriformis syndrome-the piriformis, sciatic nerve and obturator internus form a sandwich where the sciatic nerve is impinged upon
The patient reports buttock, post. thigh, rectal or radicular pain similar to a disc or piriformis muscle problem.

7. Muscle Fibers 70 % slow twitch 30% fast twitch
Both fast and slow twitch fibers are present in the levator ani muscles
Fast twitch facilitate rapid sphincter closure
Slow twitch maintain tone and support the pelvic organs
Fast and slow twitch are assessed during evaluation and will be addressed as needed in treatment program.

8. Mobility vs. Stability Pelvic floor- function
Supportive
Sphinteric
Sexual
Too much mobility-prolapse or incontinence
Too much fixation-pain
The pelvic floor needs to perform the functions as listed above. Due to the nature of the structures-layers of muscles surrounded by fascia -a balance of stability versus mobility is needed for the pelvic floor to function properly. There needs to be a certain amount of pliability allowing for urine and stool to pass, as well as stretching for reproductive functions. Additionally, there needs to be adequate muscle tone to provide stability, to support the pelvic organs, maintain continence, and prevent prolapse as well as allow for sexual appreciation. Physical therapists can address this by determining if the patient requires stretching and relaxation to assist with mobility, or strengthening and muscle reeducation to improve support and tone.

9. Indications for PT Urinary and fecal incontinence Pelvic pain
Pelvic organ prolapse
To assess for a PF exercise program
When would a patient be an appropriate referral to physical Therapy?

10. Contraindications for PT
Lack of patient or physician consent
Under 6 wks. Post partum
Under 6 wks. Post-op
Severe atrophic vaginitis
Severe pelvic pain
Children or anyone w/o prior medical pelvic exam
Sexual abuse
Pregnancy

11. Physical Therapy Evaluation of The Pelvic Floor
History
Observation and Manual techniques
Manual Muscle test
Biofeedback
Clear spine/sacroiliac joint
Each of these areas of evaluation will be reviewed individually on subsequent slides.

12. History Extensive questionnaire Consent form Bladder or bowel diary
3 days
Frequency, intake, amount voided
The therapist takes a thorough history of symptoms surrounding the pelvic floor dysfunction. This gives the therapist an understanding of whether there is stress, urge, or mixed incontinence, or what types of pain syndromes may be present. It can also help detect symptoms of prolapse. The bladder diary gives insight into whether the patient truly has urge incontinence, precipitating factors, and other lifestyle factors that may impact the treatment program.

13. Observation and Manual techniques
External assessment
Palpation and Internal assessment
Complete assessment of vaginal tone and size, contractility, muscle symmetry, reflexes (anal, clitoral), sensation, pain and strength
Observe for cystocele or rectocele
External assessment includes the skin, symmetry and color of tissues, resting position and appearance and observation of muscles performing PF contraction externally.
Palpation includes checking for sensation and increased reaction to touch of superficial PF muscles.
Internal assessment includes checking all layers of pelvic floor for strength, mobility, pain, symmetry and control. Therapist will also palpate muscle in all three layers of the pelvic floor. Therapist check for muscle tone, contractibility, pain and symmetry. Obturator internus is palpated when assessing levator ani muscles.
Reflexes are checked to determine integrity of innervation and possible hyper-tonicity of muscles.
Therapist will perform observation technique to assess if the an anterior or posterior wall prolapse exists and will grade it as mild, moderate or severe depending on how far the wall bulges in vaginal canal.

14. Pelvic Floor Manual Muscle Testing
Power: Grade 0-5
Symmetry
Fast contraction
Endurance
Repetitions
# of repeatable contractions up to 10 seconds at grade of power test
Pelvic floor muscle strength is initially assessed manually with one finger internally. 0= no palpable contraction; 1=flicker contraction; 2=contraction-no lift; 3=palpable contraction and lift posterior more than anterior; 4= strong contraction and lift with compression from anterior, posterior and side walks; 5=strong lift and compression with inferior deflection of the finger.
Therapist also checks for symmetry of movement; checks for quick contractions (fast twitch) up to 10 repetitions; checks for endurance of muscles which is the duration of maximal contractions at muscle grade scored (up to 10 seconds); then the repetitions up to 10 seconds of repeatable maximal contractions.

15. Biofeedback Assessment
Surface electrodes vs. vaginal internal surface electrodes
Baseline reading
Initial rise
Stability of hold
Quick contractions
Ability to return to baseline
Ability to repeat contraction
Substitution
Compare sub maximal to maximal
After manual assessment, the therapist can get a better picture of the patient’s pelvic floor muscle function by performing a biofeedback assessment. This can be done at the initial visit or a subsequent visit.
Therapist can determine if the patient would use a surface or internal vaginal surface electrode to perform assessment. Surface electrode is less expensive but may not give as detailed data especially if patient if very weak. Conversely, if the patient if in significant pain, an internal electrode may not be tolerated initially.
The therapist gets the following data on the biofeedback assessment:
Baseline reading- this is for one minute to determine if there is elevated resting tone. Resting tone should average at 2 millivolts or less.
Initial rise- How quickly the patient can reach maximal contraction
Stability of hold-can they maintain that level of hold for 10 seconds (then rest for 10 seconds)
Quick contractions- perform 10 contractions, 2 seconds on /4 seconds off- are they able to contract quickly and relax in between holds
Ability to return to baseline-can they relax in between contraction or do they not have the muscle control to do this.
Ability to repeat contraction-is there enough endurance to repeat at least 10 maximal, 10 second contractions.
Substitution-are they substitution with abdominals in place of pelvic floor muscles.
Submaximal compare to maximal-can they partially contract the PF muscles or is it just off and on.

16. Biofeedback readouts Low Tone High Tone
Difficulty in return to baseline
Unstable curve
Fast vs. Slow twitch
The therapist synthesizes all the information from the biofeedback assessment to assist in determining problem areas and goal planning. From the biofeedback information the therapist can see if the patient is exhibiting a high or low tone pattern. Or they do not have good control over their muscles or need help figuring out how to control them or if there is an uncoordinated learned muscle pattern. They may be using their abdominals incorrectly. The therapist can also determine if the patient needs to work on slow or fast twitch muscle contractions or both.

17. Treatment: Exercise Teaching and prescribing pelvic floor exercises
Progression
Based on evaluation findings and history
Accessory muscles
Self Assessment Techniques:
Mirror observation
Self palpation-external and internal
Partner feedback
Therapist designs individualized exercise program depending on what findings are from evaluation. Patient may receive graded pelvic floor exercises to match their abilities and then progress in repetitions and seconds of contracting. Therapist will prescribe quick or sustained holds depending on patient’s symptoms and needs. Exercises can be concentric or eccentric. Therapist will determine if accessory muscles are necessary to gain strength or if PF muscles need to be isolated to progress. Patient may initially require assisted neuromuscular training such as manual feedback or a quick stretch to facilitate contraction.
Exercises can later be progressed from supine (gravity eliminated) to sitting and standing or during functional movement (against gravity).
Patient is instructed in self assessment techniques to assist in muscle re-education and to make sure they are doing exercises properly at home.

18. Treatment: Biofeedback
Surface vs. vaginal electrode
Baseline tone
Sustained contraction and return to baseline
Isolate PFM
Endurance changes
Strength changes
Very motivating-visual and immediate results
Excellent for patients with poor motor awareness
Biofeedback will be the most useful tool for the therapist treating patient’s with PF dysfunction as it gives the patient immediate feedback of how they are doing when exercising. The therapist can choose to use surface or vaginal (internal) electrodes depending on patient’s needs. Therapist can work on baseline function in patients that show high resting tone. Additionally, this is an excellent tool to help the patient isolate PFM from abdominals. Patients can work toward their goals of increasing endurance, strength, slow of fast contractions, based on the program that the therapist sets for them each visit. Patients are very motivated to use the biofeedback as they get immediate results and generally improve each treatment session.

19. Treatment Strategies-Incontinence
Stress and Urge
Scheduled voiding
Bladder retraining
Relaxation techniques
Type and amount of fluid intake
Patients benefit from being placed on a voiding schedule with gradual increase in time between voids. Initially start with schedule that patient can comfortably tolerate and gradually increase time. Goal is 3-4 hours between voids. Patient uses pelvic floor muscle contraction, relaxation and behavioral techniques to gradually achieve this goal. Also encouraged is type and amount of fluid intake, as well as dietary factors that may contribute to irritable bladder.

20. Treatment Strategies Electrical stimulation Ultrasound Vaginal weights
Indications: stress and urge incontinence, pelvic floor re-education or weakness, overactive bladder
Strengthening -efferent
Inhibiting (TENS) -afferent
Contraindications: infection, pregnancy, pacemaker, cancer, poor cognition
Ultrasound
Vaginal weights
Electrical stimulation can be performed to the pelvic floor muscles in cases of extreme weakness or very poor muscle control. In some cases, electrical stimulation can be used as a pain relief to patients suffering from chronic pain.
Ultrasound may be used to treat scar tissue externally.
Some patients will benefit from vaginal weights to assist in strengthening and home re-education and functional training, e.g. having a patient use weights when transitioning sit to stand when they usually have leakage during this movement.

21. Treatment: Chronic Pain
Variety of diagnoses and indications
Note high resting sEMG, trigger points, urinary frequency and urgency
Techniques
Modalities-cold, heat, US, ES
Muscle re-education with sEMG
Soft tissue mobilization, trigger point techniques
Dilators
Perineal massage
Pelvic alignment
Exercise program
Scar mobility
In many cases, patients with chronic pain also have high resting tone. The patient benefits from learning how to decrease muscle tone through biofeedback, inhibition with exercise and relaxation techniques. Additionally other PT modalities can be used as listed above. Soft tissue mobilization and manual stretching techniques are very effective for patient with decreased soft tissue mobility or pain with vaginal insertion. Use dilators with gradual increasing diameter

22. Treatment for Surgical Patients
Phase one: Pre-op
Pelvic floor anatomy and function
How diet may affect the bladder
Avoidance of valsalva—proper use of lower abdominal muscles to support the pelvic girdle
EMG of the pelvic floor to identify muscle and improve strength
Phase two: 6 weeks post-op
Gradual increase in strengthening exercise
Pelvic floor strengthening program as needed
Surgical patients do better after surgery if they learn how to use and improve their pelvic floor strength prior to their procedure.

23. Referral Evaluate and treat or specific orders Feedback from EMG
Usually one time per week for 6-8 wks.
Covered by insurance
Patient can come in for conference prior to initial assessment
Thank you!
Therapist can evaluate patient and make recommendations on treatment program or physician can request specific treatment.
Therapist can send copy of biofeedback readout to Dr. to give information on evaluation and follow-up assessments.
Treatment program is typically short and patient can improve rapidly if compliant.
Reimbursable by all insurance types including Medicare (some stipulations may apply-such as patient needs to have tried to do pelvic exercises on their own and failed)
Therapist may want to offer opportunity for patient to come in prior to initial visit to discuss treatment program and options.

24. References
Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice, New York, Springer-Verlag, 1994
Wallace K: Female pelvic floor functions, dysfunctions, and behavioral approaches to treatment. Clinics in Sports Med, 13:2: , 1994
Gray, H : Gray’s Anatomy of the Human Body. Philadelphia, Lea & Febiger, 1918
Moore, K: Clinically Oriented Anatomy (ed 2) Baltimore, Williams & Wilkins, 1985
Wall LL, Norton PA, DeLancey JO: Practical Urogynecology. Baltimore, Williams & Wilkins, 1993
Pastore, E. A., & Katzman, W. B. (2012). Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5),
Gentilcore-Saulnier, E., McLean, L., Goldfinger, C., Pukall, C. F., & Chamberlain, S. (2010). Pelvic Floor Muscle Assessment Outcomes in Women With and Without Provoked Vestibulodynia and the Impact of a Physical Therapy Program. Journal Of Sexual Medicine, 7(2),
Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice. New York, Springer-Verlag, 1994