Womens Health and Physical Therapy

Christi Rathsack, PT, DPT craths2@uic.edu

Lecture Objectives
     

Identify areas of practice in womens health physical therapy Identify female abdominal anatomic structures Understand modifications to subjective and objective portions of patient evaluations Understand treatment options for various womens health dysfunctions Identify commonly used modality applications for various womens health dysfunctions Formulate wellness exercise programs for women with varying conditions

Topics of Discussion
    

Obstetrics and Complications Musculoskeletal Pain of Pregnancy Fibromyalgia Pelvic pain Incontinence

Terminology (Messlink et al 2005)



Pelvic floor: compound structure which closes the boney outlet

Cranial: peritoneum of the pelvic viscera Middle: Muscles, fibromuscular elements i.e. endo pelvic fascia Caudal: skin of the vulva, scrotum, perineum

Pelvic floor muscles: muscular layer of the pelvic floor

Superficial


Bulbospongiosus, Ischiocavernousus, Superficial transverse perineal muscle Pubococcygeus, Pubovaginalis, Puborectalis, Illiococcygeus

Deep


Anatomy


Bony Pelvis

Illium Ischium Pubis Sacrum Coccyx

Anatomy


Levator Ani

Pubovaginalis Puborectalis Pubococcygeus Illiococcygeus

Anatomy


Urogenital Diaphragm (triangle)

Bulbospongiosus Ischiocavernousus Superficial transverse perineal muscle

External Sphincters

Anatomy


Other Contributing Musculature

TA Diaphragm Multifidus Obterator Internis Piriformis

Pregnancy Complications
       

Gestational Diabetes Pregnancy Induced Hypertension HELLP Syndrome Anemia Preterm Labor Premature Rupture of Membranes Placenta Previa Placental Abruption

Gestational Diabetes


Review: Diabetes

Insulin is not produced or the body cannot use it properly Insulin is the hormone that allows glucose to enter cells of the body Glucose (unable to enter cells) builds in the blood stream, cells starve When a pregnant woman that does not have diabetes, develops a resistance to insulin because of the hormones of pregnancy. Hormones (estrogen, cortisol, human placental lactogen) can have blocking effect on insulin (generally occurs at 20-24 weeks) Usually the pancreas can respond and produce more insulin

Gestational Diabetes

Gestational Diabetes


Risk factors:

Family history Obesity Previous delivery of very large baby, stillborn, or child with a birth defect Mothers age >25 increases risk Glucose screening test performed at 24 and 28 weeks Diet, exercise, blood glucose monitoring, insulin injections

 

Diagnosis:

Treatment:

Gestational Diabetes


Risks for Baby

Macrosomia


excessive glucose in blood is turned into fat, resulting in a very large (fat) baby size of baby can make delivery difficult baby develops increased insulin production secondary to increased glucose from mother immediately post delivery, no glucose from mother, continues to have elevated insulin glucose levels drop rapidly and supplemental glucose may be administered excess glucose can delay fetal lung development

Birth injury
   

Hypoglycemia

Respiratory distress


Pregnancy Induced Hypertension



PIH, toxemia, preeclampsia

HTN during pregnancy occurs in 5-8% of all pregnancies Most common in younger women during first pregnancy HTN >140/90 Protein in urine Edema Occurs 1 in 1,600 pregnancies Mostly near end of pregnancy, seizures

3 Primary Characteristics

Eclampsia: severe form of PIH

Pregnancy Induced Hypertension



Causes: Unknown

Risks
    

Pre-existing HTN Kidney disease PIH in previous pregnancies Mothers age: <20 or >40 Multiples

Pregnancy Induced Hypertension



Symptoms

Elevated blood pressure Protein in the urine Edema Sudden weight gain Visual changes, blurred or double vision Nausea and/or vomiting R sided abdominal or stomach pain Urinating small amounts

Pregnancy Induced Hypertension



Diagnosis

Blood pressure measurements Urine testing Edema assessments Frequent weight measurements Eye exams, looking for retinal changes Liver and kidney function tests Blood clotting testes

Pregnancy Induced Hypertension



Treatment

Bedrest Hospitalization Magnesium sulfite (or other antihypertensive) Fetal monitoring Continue lab testing of urine and blood Corticosteroids to expedite fetal lung development Delivery

Early detection is important

HELLP Syndrome


 

Serious complication of severe pregnancy induced hypertension (PIH) Occurrence: 2-12% of the women with PIH Usually develops prior to delivery, but may occur postpartum HELLP Consists of:

Hemolysis: red blood cell breakdown Elevated Liver enzymes: damage to liver Low Platelets: decreased clotting ability

HELLP Syndrome


Causes: unknown

Risk Factors
 

PIH during pregnancy Previous pregnancy with HELLP syndrome

Concerns:

HTN risks: poor blood flow to organs, possible seizures, anemia, clotting difficulties Disseminated Intravascular Coagulation (DIC) is a serious clotting complication that can lead to severe bleeding, hemorrhage, placental abruption, and pulmonary edema May need to deliver early secondary to complications

HELLP Syndrome


Symptoms

Right sided upper abdominal pain Pain around the stomach Nausea and/or vomiting Headache Increased blood pressure Protein in the urine edema

HELLP Syndrome


Diagnosis

Blood pressure measurements Red blood cell count Bilirubin levels (breakdown of RBCs) Liver function tests Platelet counts Urine protein testing

HELLP Syndrome


Treatment options

Bedrest Hospitalization Blood transfusions (severe anemia, low platelets) Magnesium sulfate (prevent seizures) Antihypertensives Fetal monitoring Lab tests to continue to monitor progression of syndrome Corticosteroids to expedite fetal lung development Delivery

Anemia


Too few red blood cells, or a lowered ability of the red blood cells to carry oxygen or iron through the body Anemia can cause: poor fetal growth, preterm birth, low birth weight Common types of anemia associated with pregnancy: iron deficiency, Vitamin B12 deficiency, folate deficiency

Anemia


Pregnancy Anemia

Mothers blood volume can increase up to 50%, this can cause dilution of RBCs. Is considered normal unless RBC levels drop too low Occurs at delivery and postpartum
 

Blood Loss Anemia

Vaginal birth: blood loss ~500 milliliters C-section birth: blood loss ~1000 milliliters

Anemia


Iron Deficiency

Most common Healthy mother has stored RBCs in her bone marrow prior to conception and this prevents anemia Iron is needed for hemoglobin Most common in Vegans B12 helps build RBCs and protein synthesis Folate/Folic acid is a B vitamin that with iron helps cell growth Associated with iron deficiency as they are found in the same foods Folic acid has been shown to decrease risk of birth defects of the brain and spinal cord if taken prior to conception and in early pregnancy

Vitamin B12 Deficiency

Folate Deficiency

Anemia


Symptoms

Pale skin, lips, nails, palms of hands, and underside of eyelids Fatigue Vertigo/dizziness Labored breathing Tachycardia Hemoglobin and hematocrit lab testing

Diagnosis

Anemia


Treatment

Supplements, balanced diets

 

Antacids can decrease the absorption of Iron Sources of Iron

Meats, poultry, fish, leafy greens, legumes, yeast leavened whole wheat breads, iron-enriched white breads, pastas, cereal Leafy dark green vegetables, dried beans and peas, citrus fruits and juices, most berries, fortified breakfast cereals, enriched grain products

Sources of Folate

Preterm Labor
 

Labor beginning before 37 weeks Includes one or more factors

Uterine contractions Rupture of membranes Cervical dilation Maternal



Causes: unknown

Preeclampsia, chronic medical illness, infection, drug use, abnormal uterine structure, cervical incompetence, previous preterm birth Abnormal or decreased function of placenta, placenta previa, placental abruption, premature rupture of membranes, hydramnios

Preganacy


Preterm Labor


Symptoms

Uterine contactions (more than 4 and hour) Menstrual type cramps Pelvic pressure Backache Intestinal upset Vaginal discharge of blood, mucus, or water Cervical examination, ultrasound, status of membranes, fetal fibronectin test

Diagnosis

Preterm Labor


Treatment

Bed rest Hospitalization Tocolytic medications - stop uterine contractions Corticosteroids - increase fetal lung maturity Cervical cerclage Antibiotics - infection Delivery Prenatal care, good mother health, education ***Progesterone


Prevention

For mothers at risk, new treatment, needs more research

Premature Rupture of Membranes



Premature rupture of membranes = PROM

Breaking of amniotic sac before labor begins PROM prior to 37 weeks PROM: 10% of pregnancies PPROM: 2% of pregnancies

Preterm PROM = PPROM

Incidence

Premature Rupture of Membranes



Causes

PPROM is often due to infection PROM caused by weakening of membranes or from force of contractions Other factors
    

Low socioeconomic status (prenatal care) STDs Previos preterm birth Vaginal bleeding Cigarette smoking during pregnancy

Symptoms:

Leakage or gush of watery fluid from vagina Constant wetness in panties

Premature Rupture of Membranes



Treatment

Bed rest Hospitalization Expectant management (self resolution of situation) Monitoring for signs of infection Corticosteroids - increase fetal lung maturity Tocolytic medications - stop uterine contractions Antibiotics - infection Delivery None Strong correlation with smoking during pregnancy

Prevention

Bleeding in Pregnancy Placenta Previa & Placental Abruption

 

Bleeding may or may not be a cause for alarm First Trimester bleeding is common

Miscarriage Ectopic pregnancy Implantation of placenta to uterus Infection Placenta Previa Placental Abruption

Late pregnancy bleeding

Placenta Previa


Condition in which the placenta is attached close to or covering the cervix 1 in every 200 live births

Placenta Previa


Symptoms: bright red vaginal bleeding without abdominal tenderness or pain Risks:

Slowed fetal growth Preterm birth Birth defects Infection after delivery

Most cases require c-section for delivery

Placental Abruption


Premature separation of placenta from the uterus 1 in every 120 births

Placental Abruption


Causes: generally unknown

Direct trauma Increased risk: HTN, cigarettes, multiples Dark red vaginal bleeding with pain Non-relaxing uterine contractions Blood in amniotic fluid Nausea Thirst Decreased fetal movements Emergency delivery dependent on amount of blood loss and fetal distress

Symptoms:

No treatment

Other Pregnancy Risks

  

Infection Rh Disease Amniotic fluid problems

Hydramnios Oligohydramnios

  

Post Term Pregnancy (>42 weeks) Postpartum Hemorrhage Digestive and liver disorders

General Pregnancy Problems

          

Back pain Constipation Dehydration Edema Gastroesophageal Reflux Disease Hemorrhoids Lower Abdominal Pain Urinary frequency Varicose Veins Diastasis Recti Pica Disorder

Musculoskeletal Disorders and Pregnancy

    

Pelvic pain Low back pain Nerve injury Upper extremity pain Lower extremity pain

Musculoskeletal Disorders and Pregnancy (Borg-Stein, Dugan 2007)



Most mothers report some form of musculoskeletal pain during pregnancy

25% have temporarily disability symptoms 50% report low back pain

Physiologic Changes in Pregnancy



Edema

~80%, most pronounced later in pregnancy relaxin hormone Begins during 10-12th week, relaxin 20% gain can increase joint force by 100%

Ligamentous laxaty

Symphysis pubis widening

Weight gain

Lumbar hyperlordosis

Pelvic Pain of Pregnancy



 

Increased ligamentous laxity causes increased motion of the pubic symphysis Prevalence: ~20-28% Risk factors

Previous low back pain, trauma of the back or pelvis, multiparae, increased weight, high stress levels Mild cases respond well to rest and ice Sacroiliac belt

Treatment

Osteitis Pubis
  

Bone resorption followed by spontaneous reossification Pregnancy or postpartum Course

Gradual onset of pubic symphysis pain Rapid progression to excruciating pain that can radiate to medial thighs

 

Prognosis: good recovery, several days to weeks Treatment

Bed rest followed by progressive mobility using walker, accupuncture, SI belt, stabilization exercises Post-delivery: Anti-inflammatory meds, intrasymphyseal injections of lidocaine and steroids

Rupture of the Symphysis Pubis

 

Rarely reported Symptoms

pain of the symphysis pubis with radiation to back or thighs Forceful descent of the fetal head against pelvic ring during delivery Forceful and excessive abduction of the thighs during delivery

Causes

Rupture of the Symphysis Pubis

Rupture of the Symphysis Pubis



Assessment

Palpable gap may be present Soft tissue swelling Bed rest in sidelying with pelvic binder Progress weightbearing with walker Severe cases may require ORIF

Treatment

Low Back Pain of Pregnancy



Causes

Mechanical strain


Large gravid uterus and increased lumbar lordosis creates increased stress Relaxin hormone effecting pelvic and lumbar ligaments Referred pain Local compression causing decreased O2 saturation leading to hypoxemia of neural structures leading to pain Predisposition may lead to slippage or increase in slippage Uncommon, 1 in 10,000 back pain cases

Ligamentous laxity
  

Sacroiliac pain Vascular compression Spodylolisthesis



Disk herniation


Hip pathology

Low Back Pain of Pregnancy



Subjective

Pain in lumbar, pelvic or sacroiliac region, may radiate to posterior thigh or inguinal region Aggrivating factors: weight bearing or activity Relieving factors: rest, sitting, support pillows Observation, palpation, range-of-motion, muscle imbalance tests, neuro Posture, degree of lumbar lordosis Sacroiliac and lumbar paraspinal muscle tenderness is usually present Thorough hip assessment

Evaluation

Low Back Pain of Pregnancy



Treatment

Rest
 

Elevated legs Reduce lumbar lordosis Sitting pelvic tilts Aquatic activity Stabilization

Exercise
  

Support binders Medications

  

Aspirin and nonsteroidal anti-inflammatorys are generally contraindicated, cause premature closure of ductus arteriosis Acetamenophen is the medication of choice Cyclobenzaprine, oxycodone and prednisone

Support Binder


Gabrialla

Target.com $32.99

Carpel Tunnel Syndrome



Hand pain is the 2nd most common musculoskeletal pain Median nerve trapped between carpal bones and transverse carpal ligament Causes: swelling, awkward hand positioning Incidence: 2-25%

Carpel Tunnel Syndrome

 

Evaluation

Pain is worst at night or with repetitive movements Splinting Education for proper body mechanics Severe cases require surgery 43-95% resolve within 2 weeks post delivery >80% women have some relief in symtoms with 2 weeks using night splints

Treatment

Prognosis

Meralgia Paresthetica


Lateral femoral cutaneous neuropathy

Pure sensory to anterior lateral thigh Injury causes burning pain or numbness Stretching and or compression of nerve during delivery (vaginal and c-section) Position changes during labor and delivery shortening pushing stages of delivery Smaller c-section incisions

Causes

Prevention

Prognosis: typically resolves shortly after delivery

Femoral Neuropathy


Cause

Prolonged labor, compression under the inguinal ligament Functional imparements



Symptoms

Stairs, walking, transfers

Treatment

Temporary modification of mobility, Strengthening Good, recovery in <6 months with demyelinating injury

Prognosis

DeQuervains Tenosynovitis


Inflammatory condition of abductor pollicis longus and extensor pollicis brevis tendons Symptoms

Localized pain along the radial side of the wrist Fluid retention and hormonal status Overuse during childcare activities

Causes

DeQuervains Tenosynovitis
 

Assessment

Provocative maneuvers, Finkelsteins test Thumb spica splint Ice Activity modification Corticosteroid injections Post partum
 

Treatment

Anti-inflammatory medication Surgery

Hip Pain of Pregnancy



Transient osteoporosis of the hip

Rare 3rd trimester Pain with weight bearing Early protective weight bearing Good if osteoporosis is only associated c pregnancy

Treatment

Prognosis

Hip Pain of Pregnancy



Osteonecrosis of the femoral head

3rd trimester Pain with weight bearing



Hip, pelvic, or groin, can radiate to knee

Treatment

Restricted weight bearing Postpartum: medications, surgery

BREAK

Fibromyalgia (Busch et al 2009)



American College of Rheumatology (ACR)

Widespread pain >3 months Palpation pain 11/18 points Widespread pain >3 months Palpation pain 9/11 points

American Pain Society

Fibromyalgia


Incidence ~2% of the population

Females > males

 

Negative impact on work and social lives Sedentary, decreased cardiorespiratory fitness

Fibromyalgia


Symptoms

Widespread pain Decreased pain threshold Non restorative sleep patterns Fatigue Stiffness Mood disturbance Irritable bowel syndrome Headaches Paresthesia

Fibromyalgia (www.mayoclinic.com 2009)



Co-existing conditions

Chronic fatigue syndrome Depression Endometriosis Headaches Irritable bowel syndrome Lupus Osteoarthritis Post-traumatic stress disorder Restless leg syndrome Rheumatoid arthritis

Fibromyalgia


Multi-disciplinary approach

Medications


Analgesics, antidepressants, anti-epileptics Cognitive behavior modification, stress reduction Generalized exercise program Cardio and strength Treat any pressing joint pains Aquatic therapy

Counseling


Physical therapy
   

Vulvodynia (Damsted et al 2008)

 

Pain in the vulva without objective findings General criteria

Pain on vaginal penetration Tenderness on local pressure in the vestibule Age 16-80 years, most common 20-50 years Burning, sharp stinging

 

Incidence: ~9-12% of women

Pain descriptors

Vulvodynia


Localized vs general

vestibulodynia Penetration, pressure

Provoked vs unprovoked

Primary vs secondary

Vulvodynia


Etiology

Increased c-afferent nociceptors Chronic inflammation



Infections, secondary Decreased pain thresholds

Central Sensitization


Diagnosis of exclusion

Infection, inflammation, neoplasia, neurologic disorder

Cotton Swab Test

Vulvodynia


Hypertonicity or spasms of pelvic floor muscles

Vaginismus


Spasm of pelvic floor muscles with attempt to insert object into the introitis Dyspareunia sexual dysfunction

  

Depression Anxiety Low self-esteem

Vulvodynia


Treatment

Topical agents


Lidocaine Used as low level muscle relaxants Lidocaine, botox Muscle imbalances, dilators, biofeedback

Antidepressants


Injections


Physical Therapy


Vaginal Dilators

www.vaginismus.com

General Pelvic Pain



Various causes

Lumber Sacroiliac Hip Instability Muscular Myofacial Viceral

Pelvic Pain


Evaluation

Subjective


Trauma, sexual abuse, obstetric and gynecologic history Postural screen Breathing assessment Spine, pelvis, hips Muscular assessment Pelvic floor muscles, abdominals, iliopsoas, glutes, hip adductors Carnetts Test

Objective
   

Pelvic Pain


Treatment

Postural modification Joint mobilization Muscle: stretching, massage, trigger point, strengthening Breathing modification Relaxation strategies Myofacial: scar and adhesion mobilizations

Incontinence (Smith et al 2006)



Up to 2/3 of women suffer from UI at some point in their lifetime General underestimation of the number of individuals with UI secondary to shame/embarrassment and lack of understanding of treatment Estimated 1 in 4 individuals that suffer from UI actually seek help Total annual cost to treat UI in the US is 19.5 billion dollars

Incontinence


Involuntary loss of urine, which is objectively demonstrable, with such a degree of severity that it is a social or hygienic problem Types

Stress Incontinence Urge Incontinence Mixed Incontinence Overflow Incontinence Functional Incontinence

Stress Incontinence


Definition: Involuntary loss of urine accompanying sudden increases in intraabdominal pressure Symptoms: Loss of small amount of urine with exertion (cough, sneeze, laugh, lifting heavy objects) Causes:

Weak pelvic floor Poor muscular timing Hyper-mobile Urethra Urethral Insufficiency

Urge Incontinence
 

Definition: Involuntary loss of urine associated with a strong desire to void Symptoms: loss of large amounts of urine associated with an irritant (walking by the bathroom, running water, putting a key in the door, nervousness Causes

Detrusor Overactivity

Mixed Incontinence


Definition: Combination of Stress and Urge Incontinence Symptoms: frequency, urgency, loss of urine with increase in intra-abdominal pressure Causes

Pelvic floor weakness Detrusor Overactivity

Overflow Incontinence


Definition: The involuntary loss of urine associated with over distension of the bladder Symptoms: small loss of urine (similar to stress incontinence) occuring with full bladder Causes

Urine Volume Exceeds Bladder Capacity

  

Hypotonic bladder SCI CVA

Functional Incontinence


Definition: Urinary leakage associated with mental or physical impairments that may impede normal voiding

Cognition, mobility, communication

Symptoms: slow gait, difficulty with sit<>stand transfers, inability to remove clothing quickly Causes: muscle weakness, physical disability, deconditioning, poor environmental set up

Risk Factors for Stress Urinary Incontinence

 

White race Obesity

 

Labor

Normal vs Abnormal Elective vs post obstructive labor

Cesarian Delivery Number of vaginal deliveries Instrumented vaginal deliveries

BMI >30 have twice the risk

 

Pregnancy and childbirth (Rogers 2008)

Vacuum or forceps

  

Fetal weight Maternal age at delivery Time since delivery (Miller 2005)

Evaluation


Subjective

Establish history of specific symptoms Prior med Hx, social Hx Medications Screen for pre-existing musculoskeletal dysfunction Establish baseline to assist with goal setting Prioritize order of objective assessment

Evaluation (Smith et al 2006)



Possible effects of medical conditions on bladder function

Impaired neuromuscular function or tissue integrity

 

Gravada/Para Pelvic surgery DM Neurologic disease: Parkonsonism, CVA, MS, SCI, congenital defect CHF COPD Dementia Psychiatric disease

Impaired sensorimotor function

 

Abnormal stressors (volume, pressure)

 

Cognitive impairment or failure of voluntary bladder control

 

Evaluation (Smith et al 2006)



Urinary changes from common medications

Decreased urethral pressure (

benzodiazepines) cisapride)

-adrenergic blockers, neuroleptics,

Increased bladder pressure, muscular effects (bethanechol, Increased bladder pressure, volume of urine (diuretics) Increased bladder pressure, impaired voiding (anticholinergics,
antiparkinsonism agents, -blockers, disopyramide)

Indirect effects: cough (angiotensin-converting-enzyme inhibitors), constipation (iron, narcotics), mental status changes (psychotropics)

Evaluation


Objective

Posture


Pelvic position Hips and spine determined from subjective portion of evaluation

Muscle length


General screens


Evaluation Internal Exam Contraindications/Precautions



Contraindications

Lack of patient consent Pregnancy Active pelvic infection (vagina or bladder) Active infectious lesions (genital herpes) Absence of previous pelvic exam (pediatric) Inadequate training on part of examiner Immediate Post partum (6-8 weeks)


Precautions

MD clearance surgeon clearance

Post Op vaginal/rectal surgery (6-8 weeks)



Severe pelvic pain Atrophic vaginitis History of sexual abuse be very cautious


May want second person in the examination room

Muscle Function in the Pelvic Floor (Messelink et al 2005)



Voluntary Contraction

Ability to contract PFM on command



Absent, weak, normal, strong

Voluntary Relaxation

Ability to relax PFM after voluntary contraction



Absent, partial, complete

Involuntary Contraction

Contraction of the PFM that occurs prior to increase in abdominal pressure



Absent or present

Involuntary Relaxation

Relaxation of PFM that occurs with bearing down



Absent or present

Evaluation of Strength

Evaluation


Laycocks PERFect method

Power: strength using mod Oxford Endurance: How long can pt hold contraction Repetitions; How many times can pt perform Flicks: Quick flicks, contract and relax in 10 sec

Result 4 number representation of pelvic floor strength, endurance and coordination Example 4/7/3/6

Outcome Tools for Pelvic Floor Dysfunction

 

PFDI-20

Pelvic Floor Distress Inventory short form 20 Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire Pelvic Floor Impact Questionnaire short form 7 Urogenital Distress Inventory short form 6 Incontinence Impact Questionnaire

PISQ-12

  

PFIQ-7

UDI-6

IIQ

Management of Urinary Incontinence



Absorptive Devices

Sanitary napkins
  

Less expensive No stigma surrounding purchase Can minimize odor For small amounts of leakage More expensive Designed for urine absorption Come in a variety of different absorptive amounts to fit patient needs

Panty liners
   

Continence pads

Management of Stress Urinary Incontinence



Behavioral

Decrease bladder irritant consumption



Caffeine, acidic juices Helps balance pH in bladder Reduction in 5-10% in baseline weight has been shown to reduce frequency of incontinent episodes by 50%
(Rogers 2008)

Increase water consumption



Weight loss


Cessation of smoking and cough suppression (Miller

2005)

Management of Stress Urinary Incontinence



Devices

Tampons


Can be used to decrease urethral excursion during a stress maneuver (coughing, lifting) (Miller 2005)
(Roger 2008)

Pessaries
    

Intravaginal devices that support pelvic organs Incontinence pessaries are designed with knobs to provide increased urethral support Require regular upkeep and cleaning Must be fit for comfort and optimal management of symptoms Risks include: erosion of vaginal tissue, vaginal discharge

Examples of Pessaries

Management of Stress Urinary Incontinence



Bulking agent injections

some research showing effectiveness, not permanent, unsure of cost vs outcome as compared to surgery (Smith
et al 2006)

Most common agent is glutaraldehyde cross linked collagen; injected in physician office under cystoscopic control (Miller 2005) Have low cure rates but low morbidity (Miller 2005)

Surgery options: retropubic operations, bladderneck slings, and tension free midurethral slings
(Smith et al 2006)

Management of Stress Urinary Incontinence



Surgery (Rogers 2008)

More than 100 surgical procedures Gold standards - designed to increase urethral support
 

Burch colposuspention Fascial sling Tension free vaginal taping success rate at 2 years was similar to Burch

Minimally invasive


Risks: overactive bladder, voiding dysfunction, increased risk of UTI, failure to treat incontinence symptoms

Treatment Stress Urinary Incontinence



Tension-free midurethral sling

Management of Urge Urinary Incontinence



Medications (Smith et al 2006)

Goal: reduce undesired detrusor activity through reversible blockade of the muscularinic receptors and the detrusor NMJ (antimuscarinic) 2 types of muscularinic receptors in bladder


M2 and M3 are most common in bladder

M3 is primarily responsible for detrusor contractility Drugs: oxybutynin, tolterodine, trospium chloride, solifenacin, darifenacin

Long term compliance is poor

  

Recent study 2496 pts: 36.9% had not refilled initial prescription in a 90 day period Additional study: 80% of patients c overactive bladder stopped meds within 6 months Side effects: dry mouth, constipation, blurred vision, etc

Physical Therapy Treatment



Behavioral Modification

Bladder diary (also an evaluation tool) Toileting posture/Voiding mechanics Timed voiding Fluid management Avoidance of bladder irritants Gradual exposure to bladder triggers Fiber intake guide

Physical Therapy Treatment



Methods for Muscle Training

Diaphragmatic Breathing Pelvic floor strengthening, endurance training Pelvic floor coordination Vaginal cones and vaginal balls Manual techniques Biofeedback Electrical Stimulation

Physical Therapy Treatment



Home muscle strengthening

Use of tactile feedback

  

Insertion of fingertip into vagina or rectum Sitting on rolled hand towel Vaginal weights Mirror to observe movement of clitoris, introitus, anus Proper contraction: downward clitoris, inward introitus, tightening anus Improper contraction: movement of abdomen, glute squeezing, hip movements

Visualization of Pelvic Floor

  

Questions
 

Email: craths2@uic.edu Phone: UIC PT Dept. 312-355-4394

References
          

Arnonen T, Fianu-Jonassen A, Tyni-Lynne R. Effectiveness of two conservative modes of physical therapy in women with urinary stress incontinence. Neurology and Urodynamics. (2001) 20: 591-599. Berghmans LCM, HendriksHJM, De Bie RA, et al. Conservative treatment of urge urinary incontinence in women: a systematic review of random clinical trials. BJU International. (2000) 85: 254-263. Bo K, Sherburn M. Evaluation of female pelvic floor muscle function and strength. Physical Therapy (2005) 85;3: 269-282. Dannecker C, Wolf V, Raab R, et al. 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 Obst. (2005) 273: 93-97. Devreese AM, Nuyens G, Staes F, et al. Do posture and straining influence urinary-flow parameters in normal women? Neurology and Urodynamics. (2000) 19: 3-8 Dougherty MC. Current status of research on pelvic muscle strengthening techniques. J WOCN. (1998) 25: 75-83. Dumoulin C, Hay-Smith J. Pelvic floor muscle training versus no treatment for urinary incontinence in women. A Cochrane systematic review. Eur J Phys Rehabil Med (2008) 44: 47-63. Fitzgerald MP and Kotarinos R. Rehabilitation of the short pelvic floor I: Background and patient evaluation. Int Urogynecol J. (2003) 14: 261-268 Fitzgerald MP and Kotarinos R. Rehabilitation of the short pelvic floor II: Treatment of the patient with the short pelvic floor. Int Urogynecol J. (2003) 14: 269-275. Kafri R, Langer R, Dvir Z, et al. Rehabilitation vs drug therapy for urge urinary incontinence: long-term outcome. Int Urogynecol J. (2008) 19: 47-521. Kafri R, Langer R, Dvir Z, et al. Rehabilitation vs drug therapy for urge urinary incontinence: short-term outcome. Int Urogynecol J. (2007) 18: 407-411.

References
 

    

  

Leroi AM, Weber J, Menard JF, et al. Prevalence of anal incontinence in 409 patients investigated for stress incontinence. Neurology and Urodynamics. (1999) 18: 579-590. Messelink B, Benson T, Berghmans 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. Neurology and Urodynamics. (2005) 24: 374-380. Miller KL. Stress urinary incontinence in women: review and update on neurological control. Journal of Womens Health. (2005) 14;7: 595-608 Neumann P, Blizzard L, grimmer K, et al. Expanded paper towel test: an objective test of urine loss for stress incontinence. Neurology and Urodynamics. (2004) 23: 649-655. Neumann PB, Grimmer KA, grant RE, et al. Physiotherapy for female stress urinary incontinence: a multicentre observational study. Austrailian and New Zealand Journal of Obstetrics and Gynaecology. (2005) 45: 226-232. Ostaszkiewicz J, Roe B, Johnston L. Effects of times voiding for the management of urinary incontinence in adults: systematic review. Journal of Advanced Nursing. (2005) 52(4): 420-431. Parkkinen A, Karjalainen E, Vartiainen M, et al. Physiotherapy for female stress urinary incontinence: individual therapy at the outpatient clinic versus home-based pelvic floor training: a 5-year follow-up study. Neurology and Urodynamics. (2004) 23: 643-648. Porru D, Campus G, Caria A, et al. Impact of early pelvic floor rehabilitation after transurethral resection of the prostate. Neurology and Urodynamics. (2001) 20: 53-59. Rogers RG. Urinary stress incontinence in women. N Engl J Med. (2008) 358;10: 1029-1036. Smith PP, McCrey RJ, Appell RA. Current trends in the evaluation and management of female incontinence. CMAJ. (2006) 175: 1233-1240.

References