1. Introduction to Pelvic Floor Physical Therapy
Presented by:
Carin Cappadocia, PT, DPT
April 18, 2015
Thank you everyone for being here tonight!
I am Carin Cappadocia
It is a pleasure to be speaking to you all about Pelvic Physical therapy
pelvic PT is a strong passion of mine and talk of pee, poo and gas is very common at the dinner table with my family
If you have any questions don’t hesitate to ask

2. Objectives Identify pelvic floor muscles and their functions
Differentiate diagnoses of pelvic pain vs. incontinence symptoms
Explain universal precautions, contraindications, indications for pelvic floor muscle examination and treatments
Understand pelvic floor muscle relaxation and strengthening techniques
Here are our objectives, I initially had 9 objectives and then once I got started on the ppt, I realized we were speaking for 2 hours and not a full week with no sleep breaks.
First we are going to go over the anatomy and then the diagnoses.
There are so many diagnoses and parts to pelvic physical therapy, so we chose the most common diagnoses that we see in the clinic.
How many of your do pelvic floor work?
How many of you discuss bladder, bowel or sexual activity with your patients?
My goal for you all today to to get you all comfortable talking to your patients about their pelvic floors

3. What is the Pelvic Floor?
“All visceral, neurovascular, and myofascial structures contained in the bony pelvis from pubis to coccyx and between lateral ischial walls” – APTA SOWH

4. Function of the Pelvic Floor Muscles
Support
Sphincteric
Sexual Function
Trunk and Pelvic Stabilization
Lymphatic
support: The levator ani acts as a shelf to hold the bowel, bladder, and uterus. The contracted state increases pelvic floor closure during increased in intra-abdominal pressure
Sphincteric- Control bowel, bladder, and gas. The pelvic floor muscle encircle the urethra, vaginal and rectal canals and provide the tone and pressure to close them
Sexual- the pelvic floor muscles enables and sustains arousal
Trunk stabilization- abdomen and pelvic floor muscle work hand in hand. Being in the medical field we know every thing is connected. The abdomen feeds down into the pelvic floor muscles, comes around and up into your back. Like one big sling.
Lymphatic- Helps aid in lymphatic drainage- pts with c-sections- That can create a significant scar which can increase restriction and also restrict lymph drainage!

5. Bony Landmarks
TAKE PICTURE OUT
The boney land marks are the best way to orient yourself when determining where you are, when your are working with the pelvic floor.
You will see the
Pubic symphasis, pubic tubercle, obtuator foramen, Ischial tuberosity, Sacrum and tail bone

6. Female Perineum http://iahealth.net/vagina/
Mons Pubis- Fat pad of tissue over the pubic bone which is covered in hair
Labia Majora- runs from the mons pubis to the perineum with hair follicles
Labia Minora- Inside the labia majora, smaller tissue with no hair folicles
Clitoris- erectile tissue
Vulva- region below the mons pubis including labia majora, labia minora, and clitoris
Urethra
Introitus- Vaginal opening
Perineal Body
Anus

7. First Layer Pelvic Floor Muscles
Ischiocavernosus (S2,3,4)
O: Ischial tuberosity and ramus
I: Inferolateral apponeurosis over cura of clitoris/penis
A: Erection (clitoral, penile)
Bulbocavernosus/Bulbospongiosus (S2,3,4)
O: Central perineal tendon, (F) Palpable under labia
(M) Midline Scrotum
I: Fascia over the (F) Corpus cavernosum of the clitoris
(M) Shaft of Penis
A: (F) Vaginal Sphincter and clitoral erection
(M) Penile Erection
3 LAYERs OF MUSCLE
MALE Bulbospongiosis palpation************** Insertion and Action
Your first layer muscles are your POWER SQUEEZERS The First layer muscles can be palpated externally and internally
Ischiocavernosus
essentially maintains clitoral/penile erections For the males this muscle helps stabilize the penis.
Innervated by the perineal branch of the pudendal Nerve (S2,3,4)
If a patient is coming to you with difficulty reaching orgasm, this muscle can play a large role in this. It runs right along the ischiopubic rami
Bulbocavernosus: Surrounds and strengthens the vaginal orifice and constricts the urethra to expel the last drops of urine. If patients are coming to you complaining of pain with insertion.dyspareunia this muscle plays a large role in this.
BOTH of these muscles are innervated by the perineal branch of the pudendal nerve (S2,3,4)

8. First Layer Muscles Superficial Transverse Perineal Muscle (S2,3,4)
O: Ischial Tuberosity
I: Central perinal tendon/Perineal Body
A: Pelvic Floor Stability
External Anal Sphincter
O: Perineal Body
I: Partial coccyx and surrounds anal canal
A: Voluntary opening of anal orifice
Superficial Transverse Perineal supports the lower end of the vaginal introitus
Innervated by the perineal branch of the pudendal nerve
All these muscles can be palpated externally and internally

9. First Layer Pelvic Floor Muscles
Female
TAKE PICTURE OUT
FEMALE
Orient with boney landmarks and point out
Ischiocavernosus, bulbocavernosus
The superficial muscle layer is made up of the; superficial transverse perineal, bulbocavernosus and ischiocavernosus. These muscles can be palpated externally and internally.
Note the anal triangle.
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.

10. Second Layer Pelvic Floor Muscles
Sphincter Urethra (S2-4)
O: Inferior pubic arch and wraps around the urethra
A: Urethral constriction and relaxation
Urethrovaginal Sphincter
O: Vaginal wall
I: Superior surface of urethra
A: Compresses urethra and assists in continence
Compressor Urethrae (S2, 3, 4)
O:B Ischiopubic ramus
I: Joins to opposite side and passes
anterior to urethra and vaginal
wall
A: Compresses urethra and vagina
Deep Transverse Perineal (S 2,3,4)
O: Inferior Rami of ischium
I: Deep transverse perineum of
opposite side (through perineum)
A: Stabilize pelvic floor
Your second layer muscles are your LONG MARATHON RUNNERs
The Deep Transverse Perineals are a broader muscle under the superficial transverse perineal
Sphincter urethra is used for voluntary control of urine and is part of the deeper portion of the bulbocavernosus
Deep Transverse Perineum- Perineal branch of the pudendal nerve S2, 3, and 4. Also helps with expulsion of semen and
Can only be palpated internally

11. Second Layer Pelvic Floor Muscles
When the sphincter urethra is tight or in spasm, patients can report complaints of dysuria, microscopic hematuria.
The increased hypertonicity can be restricting blood flow around the sphincter or structure which decreased blood supply and and decrease tissue integrity
I wanted to talk more about the sphincter urethra later when I talk about diagnoses, but this is a great picture to talk about dysuria and chronic urinary tract infections
more about the sphincter urethra when we talk about dysfunctions, but patients can exhibit chronic urinary tract infections: one of the main causes for this is the sphincter urethra and 2nd layer muscles.
You can think of the sphincter urethra as a band aid. Think about putting a band aid really tight around your finger, what happens to your finger after you have it on there for a while? It starts to turn white, you start getting decreased blood flow to the area, you start getting tinglings, and then numb and eventually if you left it there, the tissue would start breaking down right? Which this is kind of what happens to the urethra when the 2nd layer gets tights. Patients will report burning or pain with urination which is called dysuria and a history of “chronic urinary tract infections” – but when they have the sensation of a UTI, they will go into the doctors and the test for a UTI will become negative… then the MD will write an Rx for antibiotics which may or may not temporarily help and then they symptoms return and it is a vicious cycle.
Take Picture OUT

12. Third Layer Pelvic Floor Muscles
Levator Ani
Puborectalis*
Pubococcygeus
Iliococcygeus
Coccygeus*
Levator ani is a term that refers to a group of the deep pelvic floor muscles: pubococcygeus, iliococcygeus, coccygeus
Depending on who you talk to the Puborectalis and Coccygeus are and are not included in the levator ani- so because there is such vary in this we typically just write out the muscles instead of categorizing them as the Levator Ani
** Not only do these muscles lift and support, the work against intra-abdominal pressures which we will discuss later.
These muscles support,
Stabilize: these muscles contracts prior to or with most movements to assist with postural core stabilization
Sphincteric- Muscle Contraction, with “inward Lift” these muscles squeeze around the urethra, vagina, and anus
Sexual contraction during orgasm
These are 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.

13. Levator Ani Puborectalis (S2,3,4) Pubococcygeus (S3,4,5)
O: Posterior pubis and fascia of obtuator internus
I: Anococcygeal ligament, around rectum and anal canal
A: Voluntary sphincter of anal canal
Pubococcygeus (S3,4,5)
O: Posterior pubis and fascia of obtuator Internus
I: Anococcygeal ligament
A: Pelvic visceral support
Iliococcygeus (S3,4)
O: Archus Tendineus Levator Ani (ATLA)
I: Anococcygeal body and coccyx
A: Visceral and lateral coccyx support
Coccygeus [Ischiococcygeus] (S4,5)
O: Ischial Spine and Sacrospinous ligament
I: Lower sacrum and coccyx
A: Visceral support, Coccyx mobility (flex), stability of SI joint
Anococcygeal ligament: between tip of coccyx and the anal canal
Pubococcygeus: Innervated by 3,4,5)
Iliococcygeus: posterior lateral fibers of levator ani and are cm thick. The specific function of this muscle is: it is a B sling that posteriorly circumvents the pelvic outlet through the levator iatus (which is the opening where the urethra, vagina, and rectum pass through)
Coccygeus Is the deepest muscle Stabilizes the sacroiliac joint and flexes the coccyx (wagging your tail) can be felt with diaphragmatic breathing. Innervated by the direct nerve roots of S4,5. This muscle has been debated whether or not to be included in the levator ani muscles because it does NOT elevate the anus.
Puborectalis: Acts as a lasso that maintains the anorectal angle (When standing this is pulled tighter, to hold gas or stool in creating an angle) Innervated by the inferior rectal branch of the pudendal nerve.
When this muscle contracts it decreases the anorectal angle which restrains from fecal incontinence.

14. Accessory Muscles 70% Slow Twitch (Type I) 30% Fast Twitch (Type II)
Piriformis (L5,S1,2)
O: Sacral border, through greater sciatic foramen
I: Superior border of the greater trochanter of the femur
A: Lateral hip rotation
Obturator Internus (L5,S1,2)
O: Internal aspect of pelvic foramen
I: Medial greater trochanter of femur, proximal to trochanteric fossa
These guys work as lateral hip rotators.
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.
These along with the Levator ani are sometimes referred to as the PELVIC DIAPHRAGM
70% Slow Twitch (Type I)
Maintain tonicity and support of pelvic organs.
30% Fast Twitch (Type II)
Rapid sphincter closure
Slow Twitch maintains tone and support of the pelvic organs.
First Recruited, capable of endurance repetitive contractions
Fast twitch facilitates rapid sphincter closure
Quick contractions but low endurance (PAGE 136 SOWH)
Both fast and slow twitch fibers are present in the levator ani muscles

15. (Intra abdominal pressures help create movement with pelvic floor)
Keep Picture

16. Pudendal Nerve Pudendal Nerve divides into 3 branches:
Inferior rectal branch
Perineal branch (sometimes divided into deep and superficial)
Dorsal branch of the clitoris/penis
KEEP PICTURE
The pudendal nerve is a sensory, autonomic and motor nerve that are supplied to genitals, anal area, and urethra.
The pudendal nerve is formed from sacral nerve roots 2, 3, and 4. and divides into 3 branches- These branches are known to be variations where the nerves branches in each person, but in general it goes to the genitals, perineal and anal region
This picture is really showing just one branch of the pudendal nerve
Dorsal nerve of the clitoris/penis
Perineal Branch (sometimes divided into deep and superficial)
Inferior rectal branch
You want to think Sympathetic as Holing urine in and Parasympathetic as letting it go!
Sympathetic innervations from the hypogastric plexus from the inferior mesenteric ganglion which is (T11, T12, L1, L2,3)
Parasympathetic innervations from sacral plexus from the pelvic splanchnic nerves (S2,3,4)

17. Male Pudendal Nerve
KEEP PICTURE

18. Organs in Relation to Pelvic Floor
You have your bladder which is posterior to the pubic symphasis and will move superiorly when filling and will move about 5 cm above pubis
Keep Picture

19. Keep Picture

20. Normal Urinary Function
Takes 3-4 hours to fill bladder
Normal day time voiding 6-8 times per day
Void Stream Duration: 8-10 seconds
Nocturia: 1 times per night (1-2x/ ages 65+)
Sensory receptors notify brain when bladder is full
Capacity: Max. ~600mL
(site: Pearson BD Improving elders’ continence state. Clin Nurs Res. 1992;1: ) –PAGE 63 on SOWH booklet
It takes 3-4 hours to fully fill the bladder, so normal day time voiding is every 3-4 hours. Voiding over 8 times per day is considered abnormal
The bladder fills at about 15 drops per minute and slows down at night (due to the Antidiuretic hormone) and will speed up when you ingest irritants (such as acidic, caffeine and carbonated fluids)
Normal Nocturia is 1 time per night, however in the geriatric population 2 times per night can be acceptable- review bladder irritants and normal day time voiding during the day
Our bladder is the sac that holds the urine, however our bladder has a muscle surrounding that sac which is called the Detrusor.
Our bladder is essentially like a balloon, when it is empty it is kind of loose with folds and then when it fills, the lining smoothes out.
The detrusor stays nice and relaxed when our bladder is filling and when it is time to go to the bathroom it will contract to allow the urine to come out.
Our Bladder has both Sympathetic and Parasympathetic innervations:
You want to think Sympathetic as Holing urine in and
Parasympathetic as letting it go!
Our bladder has stretch receptors and notifies us at different periods of filling-
When our bladder is about 40% full or around mL and give us an initial warning or SENSATION- saying okay get ready in the future to pee or if you are going on a long car ride you may want to empty your bladder- At this point we can either void or delay voiding for a later time
When our bladder is about 70-75% full or mL we get another signal to the brain saying “okay I’m full” we can go into the bathroom now. At this point you can go to the bathroom to void OR can be delayed AGAIN by the frontal lobe… The is okay to do every once in a while like when you are in a car and can’t stop, you start getting uncomfortable but can still hold it in.
The pelvic floor and bladder work together normally under involuntary control from the spinal and central nervous system.
Pearson BD, 1992

21. Pelvic Floor Muscle Dysfunctions and Diagnoses

22. Mobility vs. Stability Concept
Too Much Stability/Fixation
Pain
Incontinence
Retention
Too Much Mobility
Prolapse
The concept of organ mobility/stability is key to understanding dysfunctions of the pelvic floor. The organs are sacs that are meant to move, expand and empty;. These organs are the bladder, uterus, vagina, rectum and colon. If they are not be able to expand fully FROM adhesions, tissue changes or scarring from surgery, AN Overactive pelvic floor may present with symptoms of pain, pressure, constipation, urinary frequency, dysfunctional voiding or dyspareunia to name a few.
Just think about it, our organs are made to move (Everyone take in a deep belly breath and pay attention to how much movement you have in your abdomen) - think about when we are breathing how much movement we have in our abdomen
If the organs are not stabilized in their proper positioning because of weakened or torn muscles/ligaments, patients will report incontinence prolapse, pressure, pelvic heaviness, constipation and urinary retention may present. There is a fine balance of mobility and stability of the pelvic structure that maintains pelvic health
In relation to physical therapy and musculoskeletal anatomy, too much mobility is created by an underactive or weak pelvic floor, AND stability/fixation is created by an overactive/short/non-relaxing pelvic floor. This is the basis with which we are going to discuss common diagnoses and conditions a pelvic floor physical therapist might see
When people think of pelvic floor dysfunction, the majority of people think: incontinence, organs falling out or weakness.
The majority of our patients : and I would say 80% have HYPERTONICITY and spasm- Anxiety
There are lots of overlapping classifications for pelvic floor dysfunction.
Generally, the pelvic floor is either overactive or underactive just like every other part of the body,
An overactive pelvic floor is usually shortened and tender to palpation possibly presenting with trigger points. An overactive pelvic floor may be weak or it may not be. It will have decreased excursion of movement secondary to being active at rest. When pelvic floor is overactive, it is not able to functionally lengthen and is not relaxed at rest, which can lead to different urinary and bowel symptoms related to not being able to lengthen, such as urinary retention or outlet dysfunction constipation. A patient with an overactive pelvic floor may be leaking urine or feces as the overactive muscle is unable to effectively close around those openings. Often the overactive pelvic floor is correlated with pelvic pain syndromes which we will discuss further in the next few slides. Things are not always however clear cut. Sometimes a patient will present with symptoms of an overactive pelvic floor and the muscles will be tender to palpation, however biofeedback will not show elevated activity in these muscles at rest. This is then referred to a short pelvic floor, at which point it is assumed that the pelvic floor muscles have functionally shortened into this position and this will then change your treatment plan (which we will discuss later).
An underactive pelvic floor is more often associated with mobility dysfunctions – such as pelvic organ prolapse, urinary and fecal incontinence.
Symptomatic presentation is never enough to determine whether or not a patient has an overactive or underactive pelvic floor. This is why a pelvic floor examination must be performed manually, and why a biofeedback assessment is also useful in determining what exactly is going on with the pelvic floor. Often times, if a patient is having incontinence they are instructed to do kegels, but if the patient has an overactive pelvic floor the repeated pelvic floor contractions could worsen the overactive pelvic floor and actually make the symptoms worse.

23. Overactive Pelvic Floor
Dyspareunia
Dysuria
Chronic Urinary Tract Infections
Overactive bladder*
Vulvodynia
Vaginismus
Interstitial Cystitis (IC)
Pudendal Neuralgia
Dyspareunia: is pain with intercourse
Vulvodynia: Edwards in 2015 defined Vulvodynia as “Vaginal Discomfort that occurs in the absence of clinical abnormalities that could explain the discomfort” –Edwards, 2015
Vaginismus: is defined as “The recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration”
Overactive bladder may or may not be related to overactive pelvic floor
Interstitial Cystitis: According to the American Urological Association IC is defined as “An unpleasant sensation (pain, pressure, discomfort) perceived to be related to the urinary bladder, associated with lower urinary tract symptoms of more than six weeks duration, in the absence of infection or other identifiable causes”
– American Urological Association
Edwards, 2015
Haefner, 2007
Basson et al, 2000

24. Physical Therapy and Vulvodynia
McKay et al, 2001
N=29 women with moderate to severe Vulvodynia
Biofeedback and manual assessment of pelvic floor monthly with home portable biofeedback unit with daily pelvic floor muscle training exercises
Post Treatment, 20/29 patients (69%) had a significant decrease in introital tenderness and were able to resume sexual activity
McKay et al performed a study with 29 women with moderate to severe vulvodynia and performed a pelvic floor muscle assessment and biofeedback assessment, and then prescribed a home treatment program using portable biofeedback units with daily pelvic floor muscle training exercises with monthly in office assessments.
At the end of the treatment:
20/29 (69%) had a significant decreased in introital tenderness and were able to resume sexual activitiy.

25. Physical Therapy and Vaginismus
Seo et al, 2005
N=12 patients with primary vaginismus
Biofeedback and electrical stimulation assisted pelvic floor muscle training followed by manual therapy and use of vaginal dialators
12/12 were able to participate in painfree vaginal intercourse
Reissing did a retrospective chart review of 53 women who underwent physical therapy for lifelong (primary) vaginismus. The chart review revealed significant pelvic floor pathology and an average treatment course of 29 sessions. Internal manual techniques were found to be most effective, followed by patient education, dilatation exercises, and home exercises. Although participants were very satisfied with the physical therapy, some symptoms, such as pain, anxiety/fear, and pelvic floor tension remained and scores on the Female Sexual Distress Scale and Female Sexual Function Index indicated clinical levels of sexual distress and impaired sexual function after treatment. Although there appears to be no linear relation between symptom reduction and healthy sexual function,

26. Pudendal Neuralgia
“Pudendal neuralgia is a painful, neuropathic condition involving the dermatome of the pudendal nerve” – Hibner et al, 2010
Parasthesias and/or pain throughout any portion of the pudendal dermatome
may extend into the groin, abdomen, legs, and buttocks
The sensory symptoms could manifest as itching, burning, tingling, cold sensations, and/or burning and shooting pain
The pudendal nerve is the only peripheral nerve that has both somatic and autonomic fibers. Thus, a person can experience increased heart rate and blood pressure, decreased motility of the colon, decreased blood flow, and perspiration with pudendal nerve stimulation.
Therapy Treatment may consist of:rehabilitation of the pelvic floor, abdominal, gluteal, lumbosacral and hip rotator muscles.pudendal nerve mobilization, connective tissue mobilization and myofascial trigger point release of the surrounding muscles and tissues.range of motion and strengthening of certain muscles to improve core and lower extremity balance and stability.Surgical Management of the Pudendal NerveSurgery for pudendal nerve entrapment should be considered your last option, because it is an extensive surgery. We advise that you try physical therapy two to three times/week, including a home exercise program and relaxation techniques, for a minimum of 6 months before considering surgery. Trigger point injections and pudendal nerve blocks, also compliment the physical therapy treatment, but are not always necessary. If you experience an improvement in your symptoms, even if it is only 25% during that 6 months, then we recommend that you continue PT for another 6 months, prior to considering surgery. Fortunately, we have not had to send any of our patients for surgery.An entrapped pudendal nerve can be approached through 3 different types of surgeries:Trans-ischio-rectal (TIR)Trans-gluteal (TG)Trans-perineal (TP)In some cases, patients may experience post-operative pain. In this situation, physical therapy plays a big role in recovery. With the TIR surgery, men may have pain at the incision site and women may have vaginal scarring. Sacro-iliac joint dysfunction may also be present. In the TG approach, the gluteal muscle is severed and sciatic neural tension may occur.
Hibner, 2010

27. Pudendal Neuralgia Pelvic surgery especially with use of mesh
Causes
Treatments
Pelvic surgery especially with use of mesh
Pelvic trauma
Childbirth
Bicycle riding
Prolonged sitting
Constipation
Severe tightness
(muscle and fascial restrictions)
Physical Therapy is the gold standard treatment in patients with muscle spasms
Behavioral modifications
Medical Therapy
Botox Injections
Steroid Injections
Surgery
Treatment:
Behavior modification: discontinue exercise if that was trigger (cycling), 2. eliminate sitting, if unable to eliminate a cushion can be used to support ischial tuberosities and elevate the perineum, (20-30% improve with lifestyle modifications) – but is that realistic???
Medical therapy: muscle relaxants, anticonvulsants and analgesics
relaxations oral valium or valium suppositiories. Zanaflex orally
gabapentin and lyrica are use to treat neuopathic pain
In patients with muscle spasms, pelvic floor physical therapy is the gold standard treatment. It can help distinguish myalgia from neuralgia. The main role of physical therapy is relaxation of the pelvic floor muscles. Manual techniques that help release muscle spasm and lengthen the muscle include myofascial release, soft and connective tissue mobilization, and trigger point release. Other modalities include biofeedback, ultrasound, and electrical stimulation.
If PT fails, botox injections,
Anasthetic and steroid local injections are alise utilized. Performed transvaginally unguided in women, or image guided with fluroscopy, ultrasound of CT in both sexes
Surgery
4 approaches:
Transperineal – reaches rectal branch only, no disection beyond alcocks canal
Transgluteal – most coming *****sacrotuberous and sacrospinous ligament is transected , more recently they are trying to repair it
Transischiorectal – not utilized in the US due to poor outcomes
Lapsroscopic – outcomes have also been poor

28. Underactive Pelvic Floor
Potential Related Diagnoses
Urinary Incontinence
Pelvic Organ Prolapse

29. Urinary Incontinence Stress Urinary Incontinence Urge Incontinence
Episodes of urinary leakage with increased valsalva or stress; such as cough, laugh, sneeze
Urge Incontinence
Episodes of urinary leakage with severe sense of urgency
Mixed Incontinence
Symptoms of both Stress and Urge Incontinence
Incontinence without Sensory Awareness
Stress urinary incontinence is increased urinary leakage with increased pressure such as; coughing, laughing, sneezing, lifting, exercising, transitioning to different positions (anything which causes pressure or valsalva with movements. When you observe someone transitioning from sitting to standing and you see them holding their breath to push themselves up to sitting, that can create increased pressure on the internal organs causing the urine to escape.
In many instances people associate urinary incontinence to weak muscles, or a weak pelvic floor. People even some doctors will say “oh, just do your kegels!” However sometimes the incontinence can be from severe pelvic floor muscle tightening. Where the muscles are pulling the sphincter open. Similar to a balloon when you blow it up and pull the opening so the air makes a squeeking noise.**** Move
Causes of Stress Incontinence:
Pregnancy, Vaginal Birth
Obesity, chronic cough, chronic heavy lifting, and constipation: all these increase intra-abdominal pressures
Genetics
Urge incontinence is when a patient’s sense of urgency will go from 0 straight to These are the patients that will be sitting there and instantly pop up and say “I gotta go!”
With muscle weakness: pelvic floor muscle exercises are effective ways to treat this: According to the international urogynecological association states that Up to 75% of women show improvements in leakage with PF exercise training.

30. Urinary Incontinence Dannecker et al, 2005
“EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients”
390 women; stress incontinence (80%), mixed (20%)
263 completed the training
Self reported improvement was 95%
Statistically significant improvement of the stress provocation test (Cough Test)
Long term follow-up (average follow up time 2.8 years)
71% self-reported persisting improvement of UI
13% underwent incontinence surgery following completion of conservative therapy
80 % had stress incontinence and 20 % had mixed incontinence.
Short term results showed: a 95% self reported improvement immediately following treatment
Pelvic Floor muscle strength significantly improved from 2.9 to 4.1 on the oxford-score scale and EMG measured and increase from 11.3 microV to 21.5 microV.
Cough Test means the bladder was filled at 400mL and the patient was asked to cough in a supine and standing position
Following 3 years a through questionnaire was mailed to participated with an 80% return rate (which is very high)
71% reported persisting improvements
Only 13% of patients that finished with the PFMT underwent surgery
At the end of the article they report that motivation plays a big part and Pelvic floor muscle training can be done with or without biofeedback.

31. Pelvic Organ Prolapse
A dropping of one or more organs into or out of the vagina; from a weakening of muscles, ligaments, and fascia.
Causes
Pregnancy and child birth
Aging and menopause
Conditions that cause increased pressure on the pelvic floor
Genetics
Underactive pelvic floor
A dropping or pocketing of the bladder, uterus, vagina, and or rectum

32. Pelvic Organ Prolapse Symptoms: Pelvic or low back Heaviness
Feeling of a bulge in or out of the vagina
Change in urinary symptoms: Slowed stream, incomplete emptying, urgency, frequency, incontinence
Bowel Symptoms: difficulty emptying bowels, incomplete emptying, the need to Splint
Discomfort with sexual activity

33. Cystocele Uterine Prolapse Rectocele Enterocele Rectal Prolapse
Types of Prolapse
Cystocele
Uterine Prolapse
Rectocele
Enterocele
Rectal Prolapse

34. Cystocele

35. Uterine Prolapse

36. Rectocele Copyright © Nucleus Medical Media, Inc.
American Society of Colon and Rectal Surgeons
A thinning of the rectovaginal septum, creating a bulge into the posterior portion of the vaginal canal
Copyright © Nucleus Medical Media, Inc.

37. Enterocele

38. Rectal Prolapse
Rectal prolapse can happen in men or women, will also see in children.

39. Pelvic Organ Prolapse n= 109 women
Braekken et al, 2011
“ Can pelvic floor muscle training revere pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized, control trial”
n= 109 women
PFM Training: (n=59) Prolapse Sages I,II,III; Control (n=50)
comparing PFMT and lifestyle advise versus lifestyle advise alone
Short Term Effects: 19% of women with PFMT improved 1 stage on the POPQ verses 8% of controls
6 Months: PFMT had significantly greater elevation of the bladder and rectum and reduced frequency than the control group.
Want to get more specific data for % improvement of symptoms for both and % improvement of popq for first artcile
Prolapse Quality of Life questionnaire
Lifestyle advise- The Knack

40. Pelvic Floor Physical Therapy

41. Indications for Pelvic Floor Examination
Urinary and Fecal Incontinence
Urinary Urgency/Frequency
Dysfunctional Voiding
Dysuria
Recurrent Urinary Tract Infections
Dyschezia (Pain with defecation)
Pelvic Pain
Abdominal Pain
Lumbosacral Pain
Hip Pain
Pelvic Organ Prolapse
Abdominopelvic surgery
Incomplete Bowel Evacuation
Constipation
Postpartum
Pregnancy Related Musculoskeletal Pain/Dysfunction
Infertility
If any of your inpatient or outpatient patient my be complaining of these symptoms they may be an appropriate referral to pelvic physical therapy

42. Contraindications and Precautions
Lack of patient or physician consent
Under 6 weeks Post- Partum
Under 6 weeks Post-Op (except abdominal exploratory surgery)
Severe atrophic vaginitis
History of sexual abuse
Children under the age of 5 or anyone without prior medical examination
2010 Herman and Wallace Rehabilitation Institute PF1

43. So What Do We Do????

44. Evaluation (Average 60 Min)
Detailed History Taking
Question bowel/bladder/sexual history regardless of diagnosis
Abdominopelvic surgical history
Orthopedic history
Gross Assessment of Posture and Gait
External Soft Tissue Palpation
Muscles: Abdominals, iliopsoas, gluteals, piriformis, hamstrings, ITB, TFL
Connective tissue: abdomen, gluteals, posterior/anterior/medial/lateral thigh, lumbar region
Muscle Length Testing
Soft tissue assessment:

45. Evaluation (continued)
Gross Lumbar and Hip ROM and MMT
Special Tests
Pelvic Floor Muscle Assessment
Observation
External palpation
Contraction/lengthening observation
Reflex
Internal palpation
MMT
Prolapse/vaginal wall stability assessment
Biofeedback assessment
Special test: SIJ, hip assessment as needed
mostly with the hip such as March Test, Seated/standing Forward Flexion, FABER Test, Thigh Thrust
Anal wink test and clitoral nod

46. Treatments Manual Therapy (97140) Neuromuscular Re-Education (97112)
Over Active: Trigger Point Release, Myofascial Release, Thieles Massage, Visceral Fascial Manipulation, Connective Tissue Mobilization, desensitization techniques, Soft Tissue Mobilization
Under Active: Quick stretching for improved PFM fiber recruitment
Neuromuscular Re-Education (97112)
Over Active: Contract Relax, Strain-Counterstrain, diaphragmatic breathing, relaxation techniques, pelvic floor muscle downtraining with biofeedback, MET
Underactive: Biofeedback or tactile cuing for improved PFM awareness and isolation, as well as transverse abdominus co-contraction

47. Treatments Therapeutic Exercise (97110)
Over Active: Pelvic floor muscle repeated contractions, endurance and quick contractions, can be biofeedback assissted/guided
Under Active: Initiate with accessory muscle activation
Transverse abdominus co-contraction
Kegels
“Pelvic Brace” or the “Knack”
Initiate in gravity-eliminated or gravity-assisted position
Biofeedback

48. Treatments Education is key!! Pelvic floor anatomy and function
Electrical Stimulation (97014, 97032)
FES
TENS
Modalities (97010, )
Cold, Heat, Ultrasound
Home Treatments
Vaginal Dilators
Therawand
Behavioral Retraining
Bladder diary
Scheduled voiding
Bladder retraining
Urge suppression
Relaxation
Patient Education!
Suggestions of using a mirror to observe pelvic floor contractions,
sitting on a rolled towel for increased sensation.
Palpating perineum, digital insertion to vagina or rectum to feel muscle activity
Partner feedback
Common Mistakes
Valsalva
Contraction of abdominals or other accessory muscles
Bearing down or bulging
Education is key!!
Pelvic floor anatomy and function
Skin care/hygiene
Behavioral modification
Fluid intake/ Diet
Bladder diary
Pain log
Stress management

49. Body Positioning with Toileting

50. Interested in learning more?
APTA SOWH courses
Shadowing
Online Courses and Continuing Education
Herman and Wallace Pelvic Rehabilitation Institute
National/International Organizations
Contact Information
Carin Cappadocia
Albany Medical Center
Outpatient Physical Therapy
618 Central Ave.
Albany, NY 12206
(518)
ICS
IUGA
IPPS

51. References
Baker J, Costa D, Guarino JM, Nygaard I. Comparison of mindfulness based stress reduction versis yoga on urinary urge incontinence: a randomized pilot study with 6 month and 1 year follow-up visits. Female Pelvic Med Reconstructr Surg. 2014;20(3): Basson R, Berman J, burnett A, et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J urol 163: Bendana EE, Belarmino JM, Dinh JH, Cook CL, Murray BP, Feustel PJ, De EL. Efficacy of transvaginal biofeedback and electrical stimulation in women with urinary urgency and frequency and associated pelvic floor muscle slasm. Urol Nurs. 2009;29(3): Braekken IH, Majida M, Engh ME, Bo K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce prolapse symptoms? An assessor-blinded, randomized control trial. Am J Obstet Gynecol. 2010;203(2):170 Dannecker C, Wolf V, Raab R, Hepp H, Anthuber C. EMG biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary incontinence or mixed incontinence; a 7-year experience with 390 patients. Arch Gynecol Obstet. 2005;273(2):93-7. Drake RL, Vogl W, Mitchell AWM. Gray’s Anatomy for Students. Philadelphia, Pennsylvania. Elsevier Inc;2005. Edwards L. Vulvodynia. Clin Obstet Gynecol Mar;58(1): Goldfinger C, Pukall CF Gentilecore-Saulnier E, McLean L, Chamberlain S. A prospective study of pelvic floor physical therapy: pain and psychosexual outcomes in provoked vestibulodynia. J Sex Med. 2009;6(7): Haefner HK. Report of the international society for the study of vulvovcaginal disease classification of vulvodynia. J Low Gen Tract Dis. 2007; 11:

52. References
Hanno PM, Erickson D, Moldwin R, Faraday MM. Diagnosis and treatment of interstitual cystitis/bladder pain syndromeL AUA guidline amendment. J Urol doi: /j.juro [Epub ahead of print] Hartmann D. Chronic vulvar pain from a physical therapy prespective. Dermatol Ther. 2010; 23: Hibner, M, Castellanos, M, et al, Glob. libr. women's med., (ISSN: ) 2011; DOI /GLOWM Hibner M, Desai N, Robertson LJ, Nour M. Pudendal Neuralgia. J Minim Invasive Gynecol. 2010;17(2): McKay E, Kaufman RH, Doctor U, Berkova Z, Glazer H, Redko V. Treating vulvar vestibulitis with electromyographic biofeedback of pelvic floor musculature. J Reprod Med. 2001;46(4): Messelink EJ. The overactive bladder and the role of pelvic floor muscles. BJU Int. 1999;83(2): Minardi D, d’Anzeo G, Parri G, et al. The role of uroflowmetry biofeedback and biofeedback training of pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding; a randomized controlled prspective study. Urology. 2010;65(6): Reissing ED, Armstrong HL, Allen C. Pelvic floor physical therapy for lifelong vaginismus; a retrospective chart review and interview study. J Sex Marital Ther. 2013;39(4): Riley MA, Organist L. Streamlining biofeedback for urge incontinence, Urol Nurse. 2014;34(1): Seo JT, Choe JH, Lee WS, Kim Kh. Efficacy of functional electrical stimulation-biofeedback with sexual cognitive- behavioral therapy as a treatment of vaginismus. Urology. 2005;66(1): Shafik A, El Sabai O. Study of the pelvic floor muscles in vaginismus: a concept of pathogenesis. Eur J Obstet Gynecol Reprod Biol. 2002;105(1): Shafik A, Shafik IA. Overactive bladder inhibition in response to pelvic floor muscle exercises. World J Urol. 2003;20(6): Stupp L, Resende AP, Oliveira E, Castro RA, Girao MJ, Satori MG. Pelvic floor muscle training for treatment of pelvic organ prolapse: an assessor-blinded randomized control trial. Int Urogynecol J. 2011;22(10):

53. Questions?