TREATING PELVIC MUSCLE DYSFUNCTION THROUGH PELVIC FLOOR PHYSICAL THERAPY Kendra L. Harrington, PT, DPT, BCIA-C, PMDB [email protected] 202-782-5716 OBJECTIVES • Identify the benefits of pelvic floor physical therapy in the multidisciplinary care of pelvic muscle dysfunction. • Evaluate patients who could benefit from a referral to pelvic floor physical therapy. • Appreciate key pelvic floor physical therapy treatment options for pelvic muscle dysfunction. DEFINING PELVIC FLOOR PT • Sub-specialized position within the field of PT • Examine & treat musculoskeletal and neuromuscular problems in order to reduce pain, regain function, and prevent further injury or loss of motion within the pelvic complex • Large role of Pelvic Floor PT is patient education HISTORY OF GYN PT • 1977: Elizabeth Nobel (front runner of Women’s Health PT) founded the Section on Obstetrics & Gynecology of the APTA – Focused on the healthcare of women before, during, and after pregnancy • 1995: Section changed its name to the Section on Women’s Health – Focus on the health of women across the lifespan from the young athlete to the elderly – *also treat men • Currently over 2,000 members of SoWH of more than 60,000 APTA members FUNCTIONS OF THE PELVIC FLOOR MUSCLES • SUPPORTIVE • SPHINCTERIC • SEXUAL PELVIC FLOOR DYSFUNCTION TWO MAIN TYPES: 1. SUPPORTIVE 2. HYPERTONUS SUPPORTIVE DYSFUNCTIONS • Increased risk for pelvic organ prolapse • Common associated symptoms: – Urinary Incontinence and/or – Fecal Incontinence COMMON DIAGNOSES ASSOCIATED WITH SUPPORTIVE DYSFUNCTIONS • • • • • • • • Urinary Incontinence; unspecified Stress Urinary Incontinence Urge Incontinence/Detrussor Instability Mixed Incontinence Urinary Urgency/Frequency Fecal Incontinence Cystocele/Rectocele Uterine Prolapse MULTIPLE RISK FACTORS OF INCONTINENCE • • • • • • • • • • • • Immobility commonly associated with chronic degenerative disease Diminished cognitive status (Alzheimer’s Disease) Blocked bladder outlet/urethra Medications Smoking Fecal impaction/Chronic constipation Environmental barriers Low fluid intake/dehydration Asthma, allergies, COPD Depression Pelvic or abdominal surgeries Birth defects (Spina Bifida) • • • • • • • • • • • • • High-impact physical activities Diabetes Stroke, Multiple Sclerosis, SCI Obesity Dietary influences Pelvic muscle weakness Weak urethral sphincter muscle Overactive/Under active bladder Estrogen depletion/Menopause Pregnancy, vaginal delivery, and episiotomy UTI’s Vaginal infection or irritation UI STATS • Stewart et al (2003) – >34 million people in US affected by OAB • NAFC Quality of Care (www.nafc.org) 16 September 2005: – 1 in 4 women over age 18 experience episodes of UI – 1 in 5 adults over age 40 are affected by overactive bladder or urgency/frequency with associated incontinence • NAFC Quality of Care (Vol 23, 1st Quarter, 2005): – 66% of men and women ages 30-70 have never discussed their bladder health with their health care provider – One third think loss of bladder control is a natural part of aging and is something to accept • Smith et al (2006) – Only 1 in 4 symptomatic women will seek treatment • Subak et al (2006) – women with severe UI pay $900/year for incontinence routine care – *all out of pocket expenses (laundry, dry cleaning, pads, toilet paper/paper towel) • The Society of Women’s Health Research Survey in 2002: – Lifetime medical costs for each woman treated for SUI reached nearly $60,000 • Hu et al (2004) – $19.5 billion cost to the U.S. HYPERTONUS DYSFUNCTIONS • Common side effect is pain • Symptoms may include back, peri-vaginal, rectal, lower abdomen, coccyx, posterior thigh pain; vulvar/clitoral burning • PFM may have resultant weakness secondary to constant bracing/holding COMMON DIAGNOSES ASSOCIATED WITH HYPERTONUS DYSFUNCTIONS • • • • • • • • • • • • • • Coccygodynia Anismus Pain in Pelvic Region/Joint Painful Episiotomy Vaginismus Proctalgia Fugax Anal or Rectal Pain Levator Ani Syndrome Anal Spasm Interstitial Cystitis Vulvodynia Pelvic Pain Vulvar Vestibulitis Dyspareunia OTHER COMMON PT/GYN DIAGNOSES • • • • • • • Constipation Sacroiliac Dysfunction Obstetrical Low Back Pain Prostatitis Male Dyspareunia Prostadynia Painful Scar PT/GYN EXAMINATION • SUBJECTIVE • OBJECTIVE SUBJECTIVE: GENERAL HISTORY • • • • • • Age Sex Chief Complaint Drug/Latex Allergies Patient’s Goals Perceived Severity of Problem on Quality of Life • Current Exercise Level • Occupation (lifting, straining, heavy carrying) SUBJECTIVE: URINARY HISTORY • Water intake: 64 fl oz normal • Frequency of day voids: every 2-4 hours (68x/day) is normal – Increased frequency could indicate cystocele – Does frequency fluctuate throughout the day? • Sleep interrupted: 0-1x/night normal – up to 2x/night for over age 65 normal • Wear pads: type and thickness – # per day – Change when wet (if perineum constantly damp/wet, increase chance of skin irritation/infection) – Amount of pad wetness: dry, damp, saturated • Frequency of leaks • Amount of leak: – few drops/small (usually associated with SUI) – large (usually associated with Urge Incontinence) • Hard to initiate urine flow: outlet obstruction/overflow incontinence • Slow urine stream: possible result of prolapse • Intermittent stream (start/stop): possible prolapse • Blood in urine • Urgency: may have overstretching of bladder base due to a cystocele • Strain to pass urine: possible result of prolapse • After urinating: – Completely Empty/Still Feel Full: could be a cystocele or decreased bladder contractility – Residual dribble upon standing: overflow incontinence/outlet obstruction SUBJECTIVE: BOWEL HISTORY • Regular Bowel Movements & Frequency – Chronic constipation can lead to pudendal nerve damage • Consistency of BM: normal is similar to a ripe banana – Loose – Hard: increase risk of fissures, hemorrhoids, tearing anal sphincter • • • • Experience Fecal Incontinence Frequency of Incontinence Type of Incontinence: flatus, liquid, formed stool History of suppressing urge: increased risk of pelvic floor tension • Strain during BM: increased risk of rectal prolapse • Completely evacuate: may indicate prolapse if incomplete emptying • Use of assistive devices: enemas, suppositories, laxatives, stool softeners, manual – Laxative abuse may result in rectal prolapse SUBJECTIVE: PAIN HISTORY • Description: constant, intermittent, dull, ache, burning, sharp, shooting • Location • Current Pain Level • Pain with Activity AGGRAVATING/RELIEVING FACTORS ON PROBLEM • Aggravating Factors: – Sitting, standing, bending, walking, coughing, laughing, sneezing, intercourse (pain or leakage; leakage=detrussor instability), BM, urinating, tight clothing, menses, exercise, lifting, time of day, change in position * If lying down position worsens symptoms of prolapse, need to further evaluate to r/o tumor, neurological involvement, obstruction, and infectious disease • Relieving Factors: – Lying (normal for prolapse issues), sitting, standing, heat, cold, medications, massage SUBJECTIVE: GYN HISTORY •Looking for increased risk of PFM dysfunctions: – – – – – – – – Menopausal state Dysmenorrhea Fibroids Cysts Dyspareunia Frequent UTI’s PID/STD’s Frequent yeast infections – Current pelvic infections – Hemorrhoids – Endometriosis – GYN cancer – Urine retention – Urethral obstruction – Currently pregnant – Prolapse SUBJECTIVE: PREGNANCY HISTORY • • • • • • • • • Gravida/Parity Miscarriages Type of births Episiotomy/Tearing Long labors Rapid birth Large babies Forceps/vacuum/suctioning Position of delivery: on your back is an antigravity position • Painful episiotomy/infection SUBJECTIVE: MEDICATIONS • Medications that Contribute to Incontinence – – – – – – – – – Diuretics Sedatives and hypnotics Pain relievers Antihistamines/Anticholinergics Cold remedies Antipsychotics Antidepressants Alpha adrenergic agonist Alpha adrenergic antagonist SUBJECTIVE: GENERAL PMHx • Key questions: refer to incontinence risk factor list • Cancer: affects certain modality use • Pacemaker: affects certain modality use • Any abdominal, low back, pelvic trauma/injury including surgeries OBJECTIVE • • • • • • Postural Assessment Gross ROM/Strength of Extremities Abdominal Strength Mobility SI Joint Screen Soft Tissue Assessment OBJECTIVE: UROGYN PT EXAM • External • Internal EXTERNAL PT/GYN EXAM • Skin integrity – Scars (dry, intact, scab, open, no drainage, pain, mobility) • Introitus – WNL, asymmetrical, tight, loose • Provocation – Pelvic clock: look for pain, tenderness, trigger points, hypo/hypersensitivity • Excursion – WNL, Nil • Color • Urogenital Reflexes – Anal sphincter, bulbocavernosus, cough • Edema EXTERNAL EXAM CONT… • Ability to do/isolate Kegel • Accessory Muscle Recruitment – Abdominals – Gluteals – Hip adductors • Breath holding INTERNAL PT/GYN EXAM • APTA Section on Obstetrics and Gynecology, 1993: “Internal examination of the pelvic floor muscles is consistent with physical therapy practice. It complies with national physical therapy policies requiring the performance of test and measurements of neuromuscular function as an aid to the evaluation and treatment of a specific medical condition.” INTERNAL PT/GYN EXAM CONT… • Tone – WNL, increased, decreased • Urogenital Sensation – Intact, diminished, absent (R/L/ant/post) • Trigger Points – Levator ani, obturator internus, puborectalis/coccygeus • SC Joint Mobility – WNL, diminished • Prolapse – Cystocele, urethrocele, rectocele, enterocele, uterine • Pelvic Floor Muscle Strength – Laycock’s Scale: Power, Endurance, Reps, Fast Contractions – Brink’s Scale PRECAUTIONS FOR INTENAL EXAM • • • • • • • • • Pregnancy or post-partum before 6 weeks Active infection Abuse Children Post-op less than 6 weeks Frail vagina S/P radiation Menstruation Hemorrhoids BIOFEEDBACK • Method of providing instantaneous and continuous information through visual and/or auditory reporting in order to retrain automatic/subconscious physiological responses • Increases the patient’s ability to perform an isolated muscle activity (limit use of accessory muscles) • Benefits of using biofeedback is that muscle testing can be performed in functional positions, motivates patients, provides an objective measure BIOFEEDBACK CONT… • Various electrodes – Surface electrodes (Peri-anal & Abdominals) – Internal vaginal probe – Internal rectal probe • Precautions/Contraindications for Internal Probes: – – – – – – – – – – – Menstruation Vaginal Infection UTI Hemorrhoids Pregnancy Postpartum before 6 weeks Post-op before 6 weeks Frail vagina Vaginal/Rectal pain* S/P Radiation Vaginal/Rectal Stenosis PATIENT EVALUATION WITH BIOFEEDBACK • Normal resting tone of PFM: – Supine/Hooklying: 2mv – Sitting: 2mv – Standing: 3-4mv • Normal resting tone of abdominals: – Supine/Hooklying: 2-5mv – Sitting: 2-5mv – Standing: 5-10mv • • • • • • Accessory muscle use Breath holding Quick rise Muscle endurance Return to baseline PFM during functional activities: coughing, jumping, lifting COMMON PT INTERVENTIONS • Behavioral Therapy • Bladder Exercises • Therapeutic Exercise • Biofeedback Training • Electrical Stimulation BEHAVIORAL THERAPY • Anatomy & Function of the PFM • Definitions of UI • Normal bladder functioning • Fluid Management – Swinthinbank, Hashim, & Abrams (2005) • “Just in case” • Bladder dietary irritants • Urge suppression techniques: – Affects Bradley’s Reflex Loop #3: Vesical-sacral-sphincter loop BLADDER DIETARY IRRITANTS • • • • • • • • • • • • • • • • • Alcohol Apples/Apple Juice Beans Sugar/Artificial Sweeteners (added to many processed foods) Cantaloupe Chilies Chocolate/Cocoa Bean Cranberries Grapes Guava Cigarettes/Tobacco Lemons/Lemonade Milk & Dairy Products (Yogurt, Aged Cheeses, Sour Cream) Peaches Pineapple/Pineapple Juice Plums Onions • • • • • • • • • • • • • • • • Tomatoes/Juice/Paste Vegetable Fat Vinegar Vitamin B Complex Coffee (including decaf) Hot or Iced Tea (including decaf) Wheat, Rye, Corn, Oat, Barley, and their derivatives Soda/Carbonated Beverages (including caffeine free) Spicy Foods (Mexican, Peppers, Thai, Indian, Cajun, Southwestern) Honey/Corn Syrup Barbecue Sauce/Chili Caffeine Citrus Foods/Juices (Orange, Grapefruit, Lemon/Lime) Nuts (Walnuts/Peanuts) Strawberries Spices: especially HOT spices URGE SUPPRESSION TECHNIQUES • WHAT TO DO WHEN THE URGE STRIKES: – Stop what you are doing; sit down if possible; stay calm; take a few deep breaths – Perform 2 or 3 quick pelvic floor muscle contractions (Kegels) – Apply pressure on the area of skin between your vaginal/testicle and anal openings (just like children do when they have to urinate badly). If you are in public and cannot place your hand down in the pelvic region, try one of these tips: • Sit on a towel roll • Sit on the heel of your foot • Lean against the corner of a desk or table – Distract your mind: • • • • • Balance your checkbook Sort your mail Count down from 100 by sevens Make a quick phone call to someone Talk to yourself in a calming manner – Wait until the urge subsides – SLOWLY walk to the bathroom; DO NOT RUSH RESEARCH RELATED TO BEHAVIORAL THERAPY • Burgio et al (2000) – 80.7% improvement after 8 weeks of behavioral therapy – 68.5% improvement after 8 weeks Ditropan – Behavioral therapy with added medication=88.5% improvement – Medication therapy with added behavioral therapy=84.3% RESEARCH RELATED TO BEHAVIORAL THERAPY • Khan & Tariq (2004) – Review of studies of behavioral therapy for SUI or UUI results in improvement rates from 78-94% • Smith et al (2006) – Given the relatively low costs & risks of behavioral and/or medical therapy, these should be the first step in treatment for urinary urgency/UUI BLADDER (RE)TRAINING • INDICATIONS: – Various urinary incontinence – Patients with mental cognition intact • CONTRAINDICATIONS: – Overflow incontinence/Urinary retention – UTI • EVALUATION: – Bladder diary • High test-retest reliability for urinary frequency and UI episodes BLADDER (RE)TRAINING • Habit training (retraining): – Used in nursing home – Goal: have patient void before time of usual accidents/keep patient dry • Timed voiding: – Set time to void within normal bladder capacity that is not changed – Goal: establish a predictable pattern of urination • Scheduled voiding: – Used most often in outpatient clinic – Voiding intervals are progressively increased as urgency and UI decreases RESEARCH RELATED TO BLADDER (RE)TRAINING • Borello-France & Burgio (2004) – 1970’s Frewen found 82-86% cure rate with intense 7-10 day bladder retraining with anticholinergic & sedatives in women 15-77 y/o – Less intense outpatient programs have cure rates of 44-90% THERAPEUTIC EXERCISE • Kegels – – – – – 30-80/day Concentric vs. Eccentric Multiple Positions Slow vs. quick vs. elevator (Miller et al., 1998) Position (Borello-France et al., 2006) • Core Strengthening Exercises • Physiological Quieting Exercises – Used for urge incontinence/nocturia RESEARCH RELATED TO THER EX • Balmforth et al (2006): – After 14 weeks of PFMT & Behavioral modification, significant elevation of the bladder neck position was noted and displacement of the bladder neck on valsalva was reduced – This suggests levator “stiffness”. – These changes in anatomy resulted in clinically significant reduction in UI & improved QOL. • Hay-Smith et al (2002) – Use of PME to treat SUI are unclear & inconsistent with respect to PME variables • Daily practice? • PFM contraction duration? • Frequency of contractions prescribed each day? • Hay-Smith & Dumoulin (2006) – Kegel exercise programs are more effective if steps are taken to ensure that patients are exercising the correct muscles and are given support in sticking with the exercises • Borello-France & Burgio (2004) – Improvement and cure rates found between 50-90% for PME • Neumann et al (2006) – Women with weaker PFM have >improvements in UI symptoms • Neumann et al (2006) – Treatment programs < 3 months may result in improve UI as well as increased PFM strength • Good for patients with financial or time restraints VAGINAL WEIGHTS • Indications: – – – – – – – Pelvic floor laxity/weakness Pelvic floor disuse atrophy Stress incontinence/urge incontinence Mild to moderate genital prolapse Decreased PFM proprioception Sexual dysfunction Poor coordination of pelvic floor/abdominals during ADL’s • Contraindications: – During intercourse – Any reason that Urogyn PT examination would be contraindicated • Uses: – PFM strength grade: 0-2 (supine); 3 (upright); 4-5 (strenuous activities/ADL’s) • Types: – Vaginal cones – Feminine personal trainer – Pressure sensor RESEARCH RELATED TO VAGINAL WEIGHTS • Cammu & Van Nylen (1995) – 47% of women assigned to vaginal weight group withdrew from the study (caused unpleasant feeling, too time consuming, or caused muscle fatigue) • Bø et al (1999) – Looked at PME alone vs. vaginal weights – No adverse events with PME alone; pain, infection, and compliance with weights – 93% adherence in PME only compared to 78% in vaginal weight group – Also found PFM strength increased & UI decreased more in PME only group • Herbison et al (2002) – Systematic review found little evidence to support vaginal weight training as superior to PME alone BIOFEEDBACK • Findings: – – – – – – – – Poor awareness of contraction Minimal peak contraction Minimal net rise of 0-3mv Difficulty with initiation of contraction Difficulty sustaining contraction Fatigues easy, poor endurance Increased abdominal contraction Accessory muscle use or muscle substitutions from feet, knees, jaws, eyes – At times, may have an elevated resting tone due to breath holding • Treatment Techniques: – Uptraining/Coordination Training RESEARCH RELATED TO BF • Khan & Tariq (2004) – BF is helpful as an adjunct to PME, but no evidence that PFMT with BF is more effective • BF is a teaching technique; real improvement in muscle strength and UI depends on patient participation & effort in therapy • Neumann et al (2006) – There is no benefit in adding adjunct therapies (BF, ES, or abdominal muscle training) to a PFMT program – BF is useful for patients with poor PFM proprioception or decreased motivation to exercise (also noted in Hay-Smith et al., 2002) ELECTRICAL STIMULATION • Uses: – Decreased PFM awareness – Weakness: 50Hz – Overactive bladder: 5-10Hz (bladder inhibition: Bradley Loop #3) • Duration: 30 min max; daily or at least 3x/week for 12 treatments – Stress incontinence: 10-50Hz • Slow twitch activated at 10-20Hz; Fast twitch activated at 3050Hz • Duration: 3x/week for 30 min for 12 treatments • Initially start with 15 min to assess patient tolerance – Mixed UI: • 15 min @ 10Hz • 15 min @ 50Hz – Side effects reported: vaginal irritation, pain, bleeding, vaginal infection, and UTI RESEARCH REGARDING ES • Amaro et al (2005) – There was significant improvement in PFM strength from both effective & sham ES – Larger decrease in UUI with sham device, however greater subjective improvement & satisfaction in treatment rates in actual stimulation group • Bo (1998) – ES may be most appropriate for patients who are initially unable to contract their PFM – Once PFM activation is possible, PME alone may be more effective COMMON RX FOR HYPERTONUS DYSFUNCTIONS • • • • • • • Patient Education Biofeedback Manual Therapy Dilator Program Electrical Stimulation Therapeutic Ultrasound Therapeutic Exercise PATIENT EDUCATION • Anatomy/Function of PFM • Home care techniques for pain management • Explanation of Common GYN Hypertonus Diagnoses • Pelvic Pain Reference • Vaginal Lubrication • Vulvar Care Reference – Low oxalate diet – Techniques for Personal Care – Avoid Sensitizing Agents • Use of “U” shaped cushion for pain relief while sitting BIOFEEDBACK • Findings: – Elevated resting baseline – Minimal peak of contraction – Minimal net rise – Difficulty returning to baseline – Use of accessory muscles secondary to resultant weakness – Decreased awareness of muscle release/contraction • Training technique: – Downtraining MANUAL THERAPY • Myofascial Release (vaginally or rectally) • Theile’s Massage (vaginally or rectally) – Oyama et al (2004) • Found to be effective in improving irritative bladder symptoms and decreasing PFM tone in patients with IC & hypertonicity • • • • • DTM to tender hip/thigh musculature MET’s SC/SI joint mobilizations Scar tissue massage Visceral mobilization DILATOR PROGRAM • • • • Used to decrease PFM tone Used to stretch PFM Return to pain-free intercourse Allows patients to perform home internal vaginal MFR • Progress in size • Used 3-4x/week (skipping one day between each use) • Program: – – – – Static stretch x 10 min MFR x 5 min (R) and (L) Kegels (5/20 second work/rest phase) x 10 reps Insert/remove with one minute stretch x10 ELECTRICAL STIMULATION • • • • • Used with pain/hypertonicity Increase blood flow to PFM Assists in muscle relaxation Often use IFC (TENS home unit if beneficial) Contraindications: – – – – – – – – – – See PT/GYN examination Urethral obstruction Residual volume >200cc History of urine retention Vaginal, rectal, or urinary infections Acute inflammation or danger of hemorrhage Pelvic cancer Fistula Complete peripheral muscle dennervation Pacemaker ULTRASOUND • Indications: – – – – – – – – – Episiotomy Perineal laceration Dyspareunia due to soft tissue adhesion Vaginismus Hemorrhoids Gynecological surgery scars Vulvodynia Fractured coccyx Post-partum day one: used for scar healing and reduce swelling ULTRASOUND CONTINUED • Expected Outcomes: – – – – – – – Decreased pain Increased circulation Increased extensibility of tissues Reduced swelling and reduced hemorrhoid size Enhanced healing of tissue Decreased spasm Stimulated tissue repair • Contraindications: – – – – – – Pregnancy Infection of perineal tissues Anesthetized areas Vascular abnormalities (DVT/emboli) Patients with hemophilia Ultrasound application over the ovaries THERAPEUTIC EXERCISE • Physiological quieting exercises • Initiation of stretching trunk/lower extremities • Kegels (double resting phase) • Core Strengthening Exercises SUMMARY • The PFM serves 3 main functions • Dysfunction of the PFM can lead to prolapse or UI • It is within the scope of PT practice to perform an internal PFM examination • PT’s can play an active role in resolving symptoms of UI REFERENCES • Balmforth JR, Mantle J, Bidmead J, Cardozo L. A prospective observational trial of pelvic floor muscle training for female stress urinary incontinence. BJU Int. 2006;98:811-17. • Brink C, Wells TJ, Sampselle CM, Tallie ER, Mayer R. A digital test for pelvic muscle strength in women with urinary incontinence. Nurs Res. 1994;43:352-356. • Bo, K. Effect of electrical stimulation on stress and urge urinary incontinence. Acta Obstet Gynecol Scand. 1998;77:3-11. • Bø K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. 2005;85:269-282. • Bø K, Talseth T, Holm I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ. 1999;318:487793. • Borello-France D, Burgio KL. Nonsurgical treatment of urinary incontinence. Clin Obstet Gynecol. 2004;47:70-82. • Borello-France DF, Zyczynski HM, Downey PA et al. Effect of pelvic-floor muscle exercise position on continence and quality-of-life outcomes in women with stress urinary incontinence. Phys Ther. 2006;86:974-986. • Burgio KL, Locher JL, Goode PS. Combined behavioral and drug therapy for urge incontinence in older women. J Am. Geriatrics Society. 2000;48:370-374. • Cammu H, Van Nylen M. Pelvic floor muscle exercises: 5 years later. Urology.1995;45:113-118. • Chiarelli P. Women’s Waterworks, Curing Incontinence. Australia: George Parry; 2002. • Christofi N, Hextall A. Which procedure for incontinence? J Br Menopause Soc. 2005;11:23-27. • Dannecker C, Wolf V, Raab R, Hepp H, Anthuber C. EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Arch Gynecol Obstet. 2005;273:93-97. • Duckett JRA, Tamilselvi A. Effect of tension-free vaginal tape in women with a urodynamic diagnosis of idiopathic detrussor overactivity and stress incontinence. BJOG.2006;113:30-33. • Fritel X, Ringa V, Varnoux N, et al. Mode of delivery and severe stress incontinence. A cross-sectional study among 2625 perimenopausal women. BJOG.2005;112:1646-1651. • Ghoniem GM, Schagen Van Leewen J, Elser DM, et al. A randomized controlled trial of Duloxetine alone, pelvic floor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. J. Urol. 2005;173:1647-1653. • Gray D, David DJ. Does biofeedback improve the efficacy of pelvic floor muscle rehabilitation for urinary incontinence or overactive bladder dysfunction in women. JWOCN. 2005;32:222-225. • Hay-Smith EJC, Bo K, Berghmans LCM et al. Pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2002;1:CD001407. • Hay-Smith E, Dumoulin C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2006 Jan 25; (1):CD005654. • Hendrix SL, Cochrane BB, Nygaard IE, Handa VL, Barnabei VM, Iglesia C, Aragaki A, Naughton MJ, Wallace RB, McNeeley SG. Effects of estrogen with and without progestin on urinary incontinence. JAMA. 2005 Feb 23;293(8):935-48. • Herbison P, Plevnik S, Mantel J. Weighted vaginal cones for urinary incontinence (systematic review). Cochrane Database Syst Rev. 2002;3. • Hu TW, Wagner TH, Bentkover JD, et al. Costs of urinary incontinence and overactive bladder in the United States: a comparative study. Urology. 2004;63:461-5. • Jarvis SK, Hallam TK, Lujic S, et al. Peri-operative physiotherapy improves outcomes for women undergoing incontinence and or prolapse surgery: results of a randomised controlled trial. Aust N Z Obstet Gynaecol. 2005;45:300-3. • Kahn IJ, Tariq SH. Urinary incontinence: behavioral modification therapy in older adult. Clin Geriatr Med. 2004;20:499-509. • Lembo A, Camilleri M. Current concepts: chronic constipation. N Engl J Med. 2003;349:1360-1368. • Madersbacher H. Overactive bladder-a practical approach to evaluation and management. J Med Liban. 2004;52:220-226. • McCrink A. Evaluating the female pelvic floor. AWHONN Lifelines. 2003 Dec-2004 Jan;7(6):516-522. • Messelink B, Benson T, Bergham B et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol & Urodynam.2005;24:374-380. • Miller JM, Ashton-Miller JA, DeLancey JO. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc. 1998;46:870874. • Moehrer B, Hextall A, Jackson S. Oestogens for urinary incontinence in women. Cochrane Database Syst Rev. 2003;2;CD001405. • Oyama IA, Rejba A, Lukban JC, et al. Modified thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology. 2004;64:862-5. • Perrin L, Dauphinée SW, Corcos J, et al. Pelvic floor muscle training with biofeedback and bladder training in elderly women. J Wound Ostomy Continence Nurs. 2005;32:186-99. • Sampselle CM, Messer KL, Seng JS, et al. Learning outcomes of a group behavioral modification program to prevent urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16;441-6. • Schwartz MS, Andrasik F. Biofeedback. A practitioner’s guide. New York, NY: The Guilford Press; 2003:34-36. • Smith DB. Bladder Control is No Accident: A Woman’s Guide. Bend, Oh: DesChutes Medical Products, Inc; 2001. • Smith PP, McCrery RJ, Appell RA. Current trends in the evaluation and management of female urinary incontinence. CMAJ. 2006;175:1233-40. • Stewart WF, Van Rooyen J, Cundiff G et al. Prevalence and burden of overactive bladder in the United States. World J Urology. 2003,20:327-36. • Subak LL, Brown JS, Kraus SR et al. The “costs” of urinary incontinence for women. Obstet Gynecol. 2006;107:908-916. • Subak LL, Waetjen LE, van den Eeden S et al. Cost of pelvic organ prolapse surgery in the United States. Obstet Gynecol. 2001;98:646-651. • Swithinbank L, Hashim H, Abrams P. The effect of fluid intake on urinary symptoms in women. J Urol. 2005;174:187-189. • ter Meulen H, van Kerrebroeck E. Injection therapy for stress urinary incontinence in adult women. Expert Rev Med Devices. 2004;1:205-213. • Tincello DG, Williams KS, Joshi M, et al. Urinary diaries. Obstet Gynecol. 2007;109:277-80. • Trowbridge ER, Fenner DE. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol. 2005;48:668-681. • Weber AM, Richter HE. Pelvic organ prolapse. Obstet Gynecol. 2005;106:615634. • Wilder E, ed. The Gynecological Manual. Alexandria, Va: The American Physical Therapy Association; 2002. • Williams KS, Assassa RP, Gillies CL, et al. A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence. BJU Int. 2006;98:1043-50. • Wyman JF, Fantl JA, McClish DK, Bump RC. Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Am J Obtet Gynecol. 1998;179:999-1007. RESOURCES • Section on Women’s Health (APTA): www.womenshealthapta.org • National Association for Continence: www.nafc.org • Society of Women’s Health Research: www.womenshealthresearch.org • Agency for Health Care Policy & Research (AHCPR): www.ahcpr.gov • American Urogynecologic Society: www.augs.org • www.womhealth.org