Pelvic Floor Dysfunction: Determining When Your Patient Might Need Pelvic PT

Pelvic Floor Dysfunction:
Determining When Your
Patient Might Need Pelvic PT
Alyssa RM George, DPT, OCS
April 26, 2014
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
 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
 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 (
 Diastasis Recti Abdominis (DRA): separation of two
bellies of rectus abdominis (
 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
 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,
 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)
Key Pain Generating Muscles Within The Pelvis
 Coccygeus
 Levator Ani
 Obturator Internus
 Piriformis
Key Pain Generating Muscles Within The Pelvis
 To a lesser degree,
muscles of urogenital
diaphragm (Bo and
Sherburn, 2005)
Trigger Point Referral Patterns
Obturator Internus, Levator Ani
Gluteus Medius
Travell and Simons, 1992
 Adductor origins at pubic ramus
and ischial tuberosity
 Adductor fascia at pubic rami is
in close proximity to superficial
perineal muscle fascia
 “Hidden prankster” (Travell
and Simons, 1992)
 Important to treat in
lumbopelvic dysfunctions
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
Muscle strength (power & endurance)
Trigger points
Urethral mobility
Coordination, ability to rest between contractions
Additional Methods Of Muscle Assessment
 Ultrasound and MRI more objective of lifting
 Dynamometers measure force directly (Bo and Sherburn,
 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
Dysfunction, Painful Scar
Pelvic Girdle Pain
Urinary Incontinence
Pelvic Organ Prolapse
Urinary Retention
Pelvic Pain
Urinary Urgency
Diastasis Recti
Post-radiation PF Pain
Urinary Frequency
Pubic Symphysis Dysfunction
Dyssynergic Defecation
Pudendal Neuralgia
Fecal/Anal Incontinence
Rectal Pain
Interstitial Cystitis
Prostatitis, Scrotum/Testes Pain,
Perineal Spasm
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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
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