1. Pelvic Health IN WOMEN Beth Lonberger, APRN, Family Nurse Practitioner
Julie Starr, APRN, Family Nurse Practitioner
University of Missouri Hospital and Clinics
Women’s and Children’s Hospital
Center for Female Continence and Advanced Pelvic Surgery
Our own backgrounds, who we work with and where exactly

2. objectives The participant will be able to:
Define pelvic health in the female
List common diagnosis contributing to pelvic floor dysfunction
Understand how pelvic organ prolapse, recurrent UTI and constipation effect bladder/bowel function
Discuss treatment options for pelvic floor dysfunction
Describe 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 infection
Complete emptying of rectum every day
Adequate support of pelvic organs
Well estrogenized vaginal tissue
Sexual wellbeing

4. COMMON DIAGNOSIS CONTRIBUTING TO PELVIC FLOOR DYSFUNCTION
Urinary Dysfunction
Urinary Incontinence
Urinary urgency/frequency
Nocturia
Defecatory Dysfunction
Constipation
Fecal Incontinence
Pelvic Floor Dyssynergia
Pelvic Organ Prolapse
Levator Ani Muscle Spasm
Pelvic Pain
Dyspareunia
Urinary urgency/frequency/incontinence
Obstructive outlet defecation

5. Urinary Incontinence Stress Urinary Incontinence Urge Incontinence
Coughing, Laughing, Sneezing, Lifting, Walking
Urge Incontinence
Urgency, Frequency, Triggers, Nocturia
Overflow Incontinence
Retention, Obstruction
Functional Incontinence
Frail, Decreased mobility

6. Prevalence

7. stress incontinence Treatment Options
Surgical
Midurethral sling
Bulking agents
Nonsurgical
Pessary
Femsoft urethral insert
Pelvic floor physical therapy

8. Urge Incontinence Treatment Options
Behavior modification
Bowel regimen
Premarin vaginal cream
Medications
Pelvic floor physical therapy (intracavity estim)
PTNS
Sacral Neuromodulation (Interstim)

9. URINARY FREQUENCY
Voiding >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. NOCTURIA
GETTING UP MORE THAN ONCE IN THE NIGHT TO VOID
Causes:
Recurrent UTIs, chronic renal failure, congestive heart failure, cystitis, diabetes, excessive fluid intake, elevated Ca+ level, sleep apnea.
Increase risk of falls
Disrupted sleep cycles
Treatment: 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 asymptomatic
DIAGNOSIS RECURRENT UTIs
Three or more UTIs in the past year or >2 in the past six months
In and out cath specimen culture positive
Cunha, BA, Tessler, JM, Bavaro, MF. Urinary Tract Infection, Females. Medscape. October, 19, 2009.

12. UROGENITAL ATROPHY
Vaginal 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 weeks
then decrease to ½ applicatorful 1xweek at hs for maintenance dose
Estring (Estradiol vaginal ring)
Vaginal ring containing 2mg of Estradiol releasing 0.75mcg in 24 hour period
To 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 emptying
Rectocele or perineal rectocele
Pelvic floor muscle (Levator ani) spasm
Sphincter incompetence
Thickening of IAS and thinning of EAS
Diet
Dehydration
Medications
Decreased sensation
Irritable Bowel Syndrome

16. Defecatory Dysfunction treatment
Bowel regimen (constipation, diarrhea…)
Pessary (rectocele)
Pelvic floor therapy
Behavior modification
Do not resist the urge to defecate
Proper hydration
Dietary changes
Medication changes
Exercise

17. BOWEL REGIMEN
1.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 smearing
50% of affected women keep FI a secret
Ashima 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 changes
Metamucil daily and Immodium prn
Pelvic floor therapy
Surgical options
Sphincteroplasty
5 year recurrence rate
Up to 60%

20. PHARMACOLOGICAL MANAGEMENT
Metamucil daily
Loperamide prn
1 tab (2mg/tab) before each meal and bedtime up to 8 tabs/day
2 tabs (2mg/tab) at q meal and hs up to 16 tabs/day
Diphenoxylate with atropine sulfate prn
1 tab (2.5mg/tab) at q meal and hs up to 8 tabs
2 tabs (2.5mg/tab) at q meal and h.s up to 8 tabs/day
Bismuth subsilicylate prn
1-2 tabs (262mg/tab) before meals and h.s. not to exceed 4.2 g/day

21. Pelvic floor muscles (Levator Ani complex)
Pubococcygeus
Coccygeus
Ileococcygeus
This 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.

22. PELVIC FLOOR (LEVATOR ANI) SPASM

23. A COLLECTION OF SYMPTOMS AND FINDINGS
LEVATOR ANI SYNDROME
A COLLECTION OF SYMPTOMS AND FINDINGS
The most common symptoms include
Deep dull aching in the rectum/vagina
Referred pain to the pelvis, thigh and buttock
Pain worsens with sitting and bowel movements
Spasms and pain in the pelvic floor muscle
Pain during or after intercourse
Urinary urgency/frequency possibly incontinence
Constipation
Prior testing usually rules out other pathologies

24. PELVIC FLOOR MUSCLE ASSESSMENT

25. PELVIC FLOOR MUSCLE SPASM ASSESSMENT
LEVATOR ANI COMPLEX
Palpate 4-5 o’clock and 7-8 o’clock positions
INTERNAL OBTURATOR
Palpate 2 o’clock and 10 o’clock positions
Single digit palpation of spastic muscle:
feels like a guitar string or hard object
reproduces the pain

26. PELVIC MUSCLE SPASM TREATMENT
PELVIC FLOOR PHYSICAL THERAPY
Pelvic floor muscle exercises 4 x day
Biofeedback
Vaginal E-stim
BEHAVIOR MANAGEMENT
Warm baths/heat daily
Yoga/daily stretching/Tai chi
Relaxation/stress management/counseling
MEDICATIONS
Flexeril 5-10mg tid prn
Ultram mg BID
Valium suppositories 10mg vaginally bid prn
Antidepressent/antianxiety agent

27. Pelvic Floor Therapy

28. Pelvic Floor Therapy Components
Abdominal EMG
Measure use of accessory muscle
Vaginal EMG
Measure resting tone
Anorectal manometry
Measure muscle strength
E-stim (vaginal or rectal)
Neuromuscular stimulation (NMS)

29. pelvic floor therapy Benefits
Promotes pelvic floor muscle awareness
Strength training
Electric stimulation
enhances muscle awareness and strength
increases urethral closure pressure
relaxes spasm
4-6 sessions of therapy
Folkerts, 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 Spasm
Pelvic Floor Dyssynergia
Pelvic Floor Muscle Weakness
Health 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 Ani
Can pick up valsalva and register as pressure
Manometry is measured from zero
Best for measuring true strength of muscle

35. Anorectal manometry initial visit

36. Anorectal Manometry Final visit

37. Abdominal EMG
PURPOSE To a assist in isolation of pelvic floor muscles To monitor contraction of abdominal muscle as an accessory muscle

38. Duel Channel EMG

39. VAGINAL EMG INITIAL VISIT

40. VAGINAL EMG THIRD VISIT

41. Intracavity Stimulation (e-stim)
Inhibits involuntary detrusor contractions
Increases bladder capacity
Decreases the intensity of urge sensation
Decreases pelvic floor muscle spasm
Increases urethral closure pressure

42. VAGINAL/RECTAL E-STIM
Increases muscle:
Recruitment
Strength
Awareness

43. ELECTRICAL STIM MECHANISM

44. NEURAL MECHANISMS INVOLVED IN BLADDER INHIBITION

45. NEUROMECHANISM INVOLVED IN URETHRAL CLOSURE

46. Mechanism of Action Produces a reflex muscle contraction
Contracts pelvic floor muscles
Relaxation and inhibition of detrusor

47. Pelvic Muscle Exercise Essentials
Muscle Awareness
Activation Promotes Function
Must have regular exercise
Avoid accessory muscles
Overload Principle
Progression

48. Methods of Teaching HOLDING BACK GAS Stopping urine stream
Contracting vagina
Contracting rectum

49. HOME EXERCISE PROGRAM Usually 4x per day
More frequent with less repetitions for very weak muscle.
Too much exercise will fatigue muscle and worsen symptoms.

50. Pelvic Organ Prolapse Uterine Prolapse (uterus) Cystocele (bladder)
Rectocele (rectum)
Perineal Rectocele (perineum)
Enterocele (vagina)
What is Pelvic prolapse. This is what we see.

51. PELVIC ORGAN PROLAPSE

52. Conservative Management of Pelvic Organ Prolapse
Bowel Program
Vaginal Estrogen
Pessary

53. Pessary
Vaginal support device for relief of symptoms of pelvic organ prolapse
Indicated for women who do not desire surgery or are not good surgical candidates
92% satisfaction after 2 months
Improvement of prolapse in 21% of patients after 1 year.
Success is in patient selection
Physical exam
If you select the correct patient and fit them with a comfortable pessary, they are happy.

54. Types of Pessaries

55. PESSARY MANAGEMENT
Proper 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. ETHEL
HPI: 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.

59. DIAGNOSIS
Stage II rectocele Perineal rectocele Defecatory dysfunction Urogenital atrophy Urinary urgency/frequency Urge incontinence Stress incontinence Urinary tract infection Recurrent urinary tract infections

60. TREATMENT PLAN
Bowel 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. OUTCOME
Patient 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. PATRICIA
Patricia 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 cont
Her 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. DIAGNOSIS
Diarrhea predominant IBS Fecal incontinence Defecatory dysfunction Stress incontinence Stage I cystocele Stage I rectocele Lichen planus (bx positive)

67. TREATMENT
Metamucil 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. OUTCOME
Patient 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. LORI
HPI: 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 cont
She 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.

72. DIAGNOSIS
Urinary urge incontinence Defecatory dysfunction Levator spasm

73. TREATMENT PLAN
Bowel regimen for her defecatory dysfunction. Pelvic floor therapy for levator spasm.

74. OUTCOME
Patient 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. SHELBY
HPI
24 y/o G0, RLQ pain for 9 months, appendectomy, 9 negative MRIs/CTs/Ultrasounds, seen in multiple clinics, ER throughout mid-MO
Pain 8-9/10, worse when moving around, improved with rest and heating pad
Urgency, urge incontinence (pad), sense of incomplete bladder emptying

76. HPI cont. Severe constipation with 1-2 BMs weekly Bloating
Pain with intercourse
Worried about serious problem with ovary

77. MEDICAL/SURGICAL HISTORY
Migraines
Hypothyroid
Appendectomy

78. DIAGNOSIS Urinary urgency Urge Incontinence Defecatory Dysfunction
Severe Levator spasm
Dyspareunia

79. TREATMENT PLAN Bowel Regimen Home Exercises
4-6 sessions of PFT with estim
Heat therapy
Will 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. ANNE
HPI: 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 cont
On 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. DIAGNOSIS
Stage II cystocele Stage II rectocele Perineal rectocele Nocturia Urodynamic stress incontinence Urge incontinence Urogenital atrophy Defecatory dysfunction

85. TREATMENT
Bowel 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. OUTCOME
Patient 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 cont
Anne 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 Muscle
To 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 Mistakes
Never 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 Exercise
When 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 Exercise
These 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 Exercise
Contract 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 REGIMEN
1.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.

91. Skin care