THE PELVIC FLOOR ANATOMY FUNCTION AND CLINICAL INTEGRATION

THE PELVIC FLOOR: ANATOMY, FUNCTION AND CLINICAL INTEGRATION Heather Grewar BSc. PT, MSc. PT, FCAMT core-connections. ca heather@core-connections. ca

OBJECTIVES • To review the anatomy and function of the female pelvic floor • To review the pathophysiology of stress urinary incontinence (SUI) • To review the evidence for pelvic floor physiotherapy in the management of SUI • To consider the clinical management of SUI

ANATOMY

THE FEMALE PELVIS Petros 2004

THE ENDOPELVIC FASCIA Netter 2006

THE LEVATOR ANI MUSCLES PR U PC V ATFP R OI IC CG C P U urethra V vagina R rectum C coccyx PR puborectalis PC pubococcygeus IC iliococcygeus CG coccygeus P piriformis ATFP arcus tendineus fascia pelvis OI obturator internus Netter 2006

PUBORECTALIS- A CLOSER LOOK Dietz 2009

URETHRAL SUPPORTS De. Lancey 1988

THE URETHRAL SPHINCTER De. Lancey 1988

INNERVATION Thor & de Groat 2010

MICTURITION: AUTONOMIC CONTROL Parasympathetic = Pee (bladder contraction) Sympathetic = Storage (bladder inhibition)

MICTURITION: SENSORY CONTROL

MICTURITION: CONTROL FROM HIGHER CENTRES

PELVIC FLOOR MUSCLE FUNCTION

THE PELVIC FLOOR MUSCLES AN EXTRAORDINARY MULTI-TASKER! pelvic organ support breathing urinary continence fecal continence lumbar stability voiding pelvic stability sexual function childbirth

HOW DO THE PFM CONTRIBUTE TO URINARY CONTINENCE? • urethral support (Ashton Miller & De. Lancey, 2001) De. Lancey 1988

• stabilization of the bladder neck (Peschers et al. , 2001) • increased intraurethral pressure (Thind et al. , 1990) De. Lancey 1990

HOW DO THE PFM CONTRIBUTE TO LUMBAR STABILITY? The PFM play a role in: • increasing the IAP (Hemborg, 1985) • increasing the thoracolumbar fascia tension (Tesh, 1984) Hodges 2006

• anticipatory postural adjustments Hodges et al. 2007

HOW DO THE PFM CONTRIBUTE TO PELVIC STABILITY? • increase SIJ stiffness • sacral counternutation (Pool-Goodzwaard et al. 2004) Lee 2011

HOW DO THE PFM CONTRIBUTE TO BREATHING? • modulation of PFM during breathing • increased PFM activity during expiration Hodges et al. 2007

THEORY: SYNERGIES OF THE ABDOMINAL CANISTER Talasz et al. , 2010

COORDINATING AND COMPETING FUNCTIONS postural control breathing continence Smith et al. , 2006

PATHOPHYSIOLOGY OF STRESS URINARY INCONTINENCE

STRESS URINARY INCONTINENCE “the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing” Abrams et al. , 2010

PATHOPHYSIOLOGY OF SUI • insufficient urethral support • increased compliance of the supportive layer Netter 2006

ETIOLOGY • parity • childbirth • damage to PFM, nerves and fascial supports Chaliha 2009

DOES AVULSION OF THE PUBORECTALIS AFFECT SUI? Dietz et al. , 2009

IS PREGNANCY A FACTOR? Prevalence of incontinence (EPINCONT study): Nulliparous group: 10. 1% Cesarean group: 15. 9% Vaginal group: 21. 0% (Rortveit et al. 2003)

IS NERVE INJURY A FACTOR? • compression • denervation Thor & de Groat 2010

THE INTEGRATED CONTINENCE SYSTEM Grewar & Mc. Lean, 2008

MODIFIABLE FACTORS ASSOCIATED WITH SUI: MOTOR CONTROL • pelvic floor muscles • abdominal muscles • diaphragm

MUSCULOSKELETAL FACTORS • ie. PFM strength BEHAVIOURAL FACTORS • ie. increased BMI (Wing et al. 2010)

EFFICACY OF PELVIC FLOOR PHYSIO Level A evidence that PFM training can effectively treat SUI (Wilson et al. , 2005) with cure rates of 44 -80% in the adult female population (Hay-Smith et al. 2007; Bo, 2007)

PFM training is recommended as a firstline treatment for SUI (4 th International Consultation on Incontinence, 2010)

WHAT IS THE RATIONALE FOR PELVIC FLOOR PHYSIO? • • • elevation of the resting position of the bladder and rectum increased pelvic floor thickness reduced hiatal area at maximum Valsalva Brækken et al. 2010

GOALS OF PFM TRAINING FOR SUI BLADDER NECK ELEVATION! • bladder neck elevation occurs with PFM and TA recruitment SUP INF IO recruitment does not elevate the bladder neck • Junginger et al. 2010 (b) Lee, 2004

CLINICAL INTEGRATION

KEY COMPLAINTS • • • SUI with coughing, jogging, sneezing and jumping avoiding ability to run and dance restricting fluids protective padding nocturia

KEY OBJECTIVE FINDINGS: Lumbo-pelvic hip and thorax • • abdominal bracing reduced rib cage wiggle buttocks clenching upper chest breathing pattern reduced lumbar lordosis absent TA co-contraction stretched and decreased lower abdominal tone

KEY OBJECTIVE FINDINGS: Internal pelvic exam • • • PFM contractility (MOS): 3/5 PFM hypertonus absent PFM contraction during coughing MODIFIED OXFORD SCALE (Laycock 1994) 1 Flicker 2 Weak 3 Squeeze and lift 4 Moderate resistance 5 Maximum resistance

TRANSLABIAL ULTRASOUND: Maximum voluntary PFM contraction

TRANSVAGINAL ULTRASOUND: Urethral cross-sectional area

TRANSLABIAL ULTRASOUND: Real-time maximum valsalva

TRANSLABIAL ULTRASOUND: Real-time maximum cough

PHYSIOTHERAPY TREATMENT Education • anatomy • pathophysiology • efficacy of PF physiotherapy • bladder training Manual pelvic floor muscle techniques • proprioception • neuromuscular recruitment • decrease hypertonus

HOME EXERCISES • PFM exercises • maximum contractions • motor control exercises • functional integration • submaximal TA co-contraction • thoracic mobilization exercises • body awareness • diaphragmatic breathing without abdominal bracing • strengthening of the gluteals and lower abdominals

RESULTS OUTCOMES PRE POST 44. 3/100 9. 6/100 PAD TEST (g) 22. 86 11. 07 BLADDER DIARY (# leaks per day) 1. 67 1. 33 IIQ-7

RESULTS • • no signs of global rigidity diaphragmatic breathing improved lumbar lordosis in sitting and standing TA co-contraction improved lower abdominal tonus PFM contractility (MOS): 4+/5 PFM tonus: within normal precontraction with coughing

ULTRASOUND MEASUREMENTS PRE POST Bladder neck position start 0. 626 1. 399 0. 02 0. 414667 2. 065582 0. 67449 1. 693836 1. 29803 1. 236667 1. 336667 (standing) (cm) Bladder neck position end valsalva (standing) (cm) Bladder neck excursion during coughing (supine) (cm) Bladder neck excursion during coughing (standing) (cm) Urethral sphincter cross sectional area (cm 2)

DISCUSSION • • • Improvement, not cure Evidence of morphological changes Not fully cured- possible contributing factors: • time constraints of the study • inconsistent TA co-contraction • PFM hypertonus

TAKE HOME MESSAGES • Look at the entire abdominal canister • • • Reduce rigid bracing strategies around the lumbopelvic-hip region and thorax Retrain diaphragmatic breathing Retrain the synergies of the PFM, lower abdominals and diaphragm Consider strategies for bladder neck elevation • Watch out for strategies that increase the IAP Pelvic floor physiotherapy is effective in treating SUI! • • It takes time (3 -6 months), diligence and awareness Everyone improves, many are cured!

Thank you for your interest

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