Pelvic Floor Dysfunction: Determining When Your Patient Might Need Pelvic PT Alyssa RM George, DPT, OCS April 26, 2014 Objectives Define the various types of incontinence and pelvic floor dysfunction (PFD) Describe the prevalence of PFD Identify risk factors for PFD Describe evaluation and treatment for PFD by pelvic PTs 2 Definitions  Incontinence: involuntary leakage of urine, feces, flatus  Stress Incontinence: involuntary leakage on effort or exertion, or on sneezing or coughing (most frequent)  Urge Incontinence: involuntary leakage associated with urgency  Mixed: both SUI and UUI Definitions Continued  Pelvic Organ Prolapse (POP): muscles and ligaments supporting a woman’s pelvic organs weaken and the pelvic organs slip out of place (www.mayoclinic.org)  Diastasis Recti Abdominis (DRA): separation of two bellies of rectus abdominis (www.mayoclinic.org)  Pelvic Floor Muscle Dysfunction  Overactive  Underactive  Incoordination Prevalence Rates of UI  25-45% of women any leakage ≥1x/year (Buckley & Lapitan 2010)  10% of women leak urine weekly (Tennstedt et al, 2008)  30% of exercising women leak during at least one type of exercise (Goldstick & Constantini 2014)  28-80% prevalence of UI in female athletes (Goldstick & Constantini 2014)  Highest prevalence in high impact (both feet leave the ground) sports: gymnastics, track and field, volleyball, basketball (Goldstick & Constantini 2014)  Urgency most apparent in cyclists and soccer players (Goldstick & Constantini 2014) UI Risk Factors in Athletes  Low BMI  Eating disorders (Araujo et al 2008)  Inadequate nutritional support for tissues  Vomiting = increased IAP  High impact sport  Symptoms at the end of training/race/competition indicates poor endurance of PFMs (Caylet et al, 2006) Additional UI Risk Factors  Former/current smoking >20 cigarettes/day (Hannestad et al 2003)  High BMI (Hannestad et al 2003)  Age > 40 (Peyrat et al, 2008)  Multiple pregnancies, s/p hysterectomy (Peyrat et al, 2008)  More than 90% do not report problem and have no knowledge of preventive measures (Carls 2007) Myofascial Pain Syndrome  Chronic pain disorder  Pressure on sensitive points in muscles (trigger points) causes pain in seemingly unrelated parts of your body (referred pain).  Occurs after a muscle has been contracted repetitively (jobs, hobbies, stress-related muscle guarding) (www.mayoclinic.org) Key Pain Generating Muscles Within The Pelvis  Coccygeus  Levator Ani  Obturator Internus  Piriformis http://medicina.ronnie.cz/c-1451-svaly-kycelniho-kloubu.html http://belleamiemotherofthree.com/wordpress/?p=5000 Key Pain Generating Muscles Within The Pelvis  To a lesser degree, muscles of urogenital diaphragm (Bo and Sherburn, 2005) http://withfriendship.com/user/mithunss/pubococcygeus-muscle.php Trigger Point Referral Patterns Obturator Internus, Levator Ani Gluteus Medius  TriggerPoints.net  Travell and Simons, 1992 Adductors  Adductor origins at pubic ramus and ischial tuberosity  Adductor fascia at pubic rami is in close proximity to superficial perineal muscle fascia http://en.wikipedia.org/wiki/Adductor_longus_muscle Iliopsoas  “Hidden prankster” (Travell and Simons, 1992)  Important to treat in lumbopelvic dysfunctions http://en.wikipedia.org/wiki/Iliopsoas Questions To Ask Your Patients  Do you experience frequent urination? (>8-10 times/day)  Do you experience strong urges to urinate and need to rush to the toilet?  Do you leak urine, stool, or gas at inappropriate times?  Do you experience pain in your genitals?  Do you experience pain with intercourse?  Ask patient “on a scale of 0 to 10, how severely does your condition affect your life?” (0= no effect; 10= severely limiting) Questions To Ask Yourself  Am I able to reproduce my patient’s pain?  Is it possible this patient’s musculoskeletal dysfunction is causing urogenital dysfunction?  Is this patient a good candidate for PFM therapy? (requires motivation and persistence as progress is often slow and gradual) What Pelvic PTs Can Do  Internal (gold standard) or external assessment and treatment of pelvic floor muscles including deep hip rotators        Muscle strength (power & endurance) Trigger points Atrophy/bulk Urethral mobility Coordination, ability to rest between contractions Sensation Scars/adhesions Additional Methods Of Muscle Assessment  Ultrasound and MRI more objective of lifting  Dynamometers measure force directly (Bo and Sherburn, 2005)  Surface EMG What Pelvic PTs Can Do  Modalities  Orthopedic PT interventions  Biofeedback assessment and treatment of pelvic floor muscle activity using surface EMG or internal vaginal or rectal sensors  Internal electrical stimulation for strengthening very weak pelvic floor muscles or reducing urgency  Dry Needling (Alyssa George) Common Conditions We Can Treat Abdominal Pain, Adhesions of intestine, bowel, uterus, peritoneum Levator Ani Syndrome SIJ Dysfunction Abdominal Phrenic Dyssynergia Painful Bladder Syndrome Sciatica/LBP/Piriformis/OI Dysfunction, Painful Scar Coccydynia Pelvic Girdle Pain Urinary Incontinence Constipation Pelvic Organ Prolapse Urinary Retention Cystocele Pelvic Pain Urinary Urgency Diastasis Recti Post-radiation PF Pain Urinary Frequency Dyspareunia Pubic Symphysis Dysfunction Uterocele Dyssynergic Defecation Pudendal Neuralgia Vaginismus Fecal/Anal Incontinence Rectal Pain Vulvodynia Interstitial Cystitis Rectocele Prostatitis, Scrotum/Testes Pain, Perineal Spasm Questions? 20 References Araujo MP, Oliveira E, Zucchi EV, et al. 2008. The relationship between urinary incontinence and eating disorders in female longdistance runners. Rev Assoc Med Bras 54:146-9. Bo K, Sherburn M. 2005. Evaluation of female pelvic-floor muscle function and strength. Phys Ther 85:269-282. Buckley BS, Lapitan MC. 2010. Prevalence of urinary incontinence in men, women and children—current evidence: finding of the Fourth International Consultation on Incontinence. Urology 76:265-70. Carls C. 2007. The prevalence of stress urinary incontinence in high school and college-aged female athletes in the Midwest: implications for education and prevention. Urol Nsg 27(1): 21-24. Caylet et al. 2006. Prevalence and occurrence of stress urinary incontinence in elite women athletes. Can J Urol 13:3174-9. Goldstick O, Constantini N. 2014. Urinary incontinence in physically active women and female athletes. BJSM 48:296-298 Hall C, Thein Brody L. Therapeutic Exercise: Moving Toward Function, 2nd ed. Baltimore: Williams & Wilkins, 2005. Hannestad YS, Rortveit G, Daltveit AK, Hunskaar S. 2003. Are smoking and other lifestyle factors associated with female urinary incontinence? The Norwegian EPINCONT Study. BJOG: An International Journal of Obstetrics & Gynaecology, 110:247-254. Peyrat L, Haillot O, Bruyere F, Boutin JM, Bertrand P, Lanson Y. 2008. Prevalence and risk factors of urinary incontinence in young and middle aged women. BJU International, 89:61-66. Tennstedt SL, Link CL, Steers WD, et al. 2008. Prevalence of and risk factors for urine leakage in a racially and ethnically diverse population of adults: the Boston Area Community Health (BACH) Survey. Am J Epidemiol 167:390-9. Travell J, Simons D. Myofascial Pain and Dysfunction: The Trigger Point Manual, vol 2. Baltimore: Williams & Wilkins, 1992. References http://www.mayoclinic.org/diseases-conditions/pelvic-organprolapse/basics/definition/con-20036092 Accessed: 04/04/14 http://www.triggerpoints.net/triggerpoints/glut-med.htm Accessed: 04/12/14 http://www.triggerpoints.net/triggerpoints/sphincter-ani--levator-ani--coccygeus-obturator-in.htm Accessed: 04/12/14 http://en.wikipedia.org/wiki/Iliopsoas Accessed: 04/14/14 http://en.wikipedia.org/wiki/Adductor_longus_muscle Accessed: 04/14/14 http://withfriendship.com/user/mithunss/pubococcygeus-muscle.php Accessed: 04/15/14 http://belleamiemotherofthree.com/wordpress/?p=5000 Accessed: 04/15/14 http://medicina.ronnie.cz/c-1451-svaly-kycelniho-kloubu.html Accessed: 04/15/14