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INCONTINENCE AND PROLAPSE
INPTA & KPTA 2018 Joint Conference
Melissa McElroy DPT, WCS
Susan Dunn PT, WCS
Pressure Problems
Intra-abdominal pressure > Environmental pressure
= bad things happen
Incontinence (urinary, fecal, flatulence)
Diastasis Rectus Abdominis
Pelvic Organ Prolapse
The internal canister
Diaphragmatic Breathing
Facilitate true piston-ing of core for proper function
Improve core performance
Improve athletic performance
Core Pistoning via Diaphragmatic
Breathing
Failure with the Internal Canister
Low Back Pain
Hip Pain
Pelvic Pain
Incontinence
Prolapse
Diastasis Rectus Abdominis
Loss of strength/power/stability
Continence and
Incontinence
Urologic Function
Renal input into the bladder is 1-14ml/min
Bladder capacity in adult 400-600cc
Voiding Frequency WNL is 5-7x/day and up to 1x/night
40% capacity: First Sensation to void
60-70% capacity: First desire to void
>90% capacity: Strong desire to void
Perception of bladder fullness can be affected by state of mind
Anxiety increases urge
Distraction decreases urge
Urinary Continence
Via Voluntary contraction of the external urethral sphincter and LA muscles
Sphincter constricts the lumen of the urethra while the LA elevates the vagina and
bladder neck causing compression of the urethra.
Comprised of primarily slow twitch muscle
At rest exhibit enough tone to prevent urine into the urethra
Will reflexively contract against a sudden increase in intraabdominal pressure to keep urethral
pressure above that in the bladder
Incontinence
Can be Urinary, Fecal or Gas
Stress Incontinence: Occurs when internal pressure (intra-abdominal) is greater than
external pressures (environmental): cough, sneeze, laugh, transfers
Urge Incontinence: Environmental triggers, Poor bowel or bladder habits can contribute
Note: Kegels aren’t always the answer
Prevalence of UI in YOUR patients
Alappattu M, Neville C, et al. Urinary incontinence symptoms and impact on quality of life
in patients seeking outpatient physical therapy services. Physiotherapy Theory and
Practice. 2016; 32 (2) 107-112.
N=599; 94.7%Fm; Mean age:49.8years
“Have you leaked in the last 3 months (even a small amount)?”
25% had diagnosis of “spine pain”
10% had diagnosis of extremity disorders
17.2% had diagnosis of pelvic pain
44.2% had diagnosis of urinary disorder
Prevalence of UI with female athletes
Study evaluating 144 nulliparous military women using POP-Q and questionnaires. 50% had stage 0 POP, 50% had stage 1-2. 19% reported UI. Running associated with increased risk of UI. (POP stage 0-2 was considered normal) (Larsen WI 2006)
Study of 106 female athletes (basketball and soccer) via questionnaires. UI experienced by 41.5%. Lower body weight and lower BMI risk factor. 95.5% had never discussed symptoms with health care professional.(Jacome et al 2011)
Retrospective study of Competitive (CG) and recreational (RG) trampolinists (n = 305) during 1995-1999 with median age of 21 (18-44) mostly nulliparous via validated questionnaire. CG 57% with UI. RG 46%
with UI. 76% of both groups still had UI at time of questionnaire. Strong predictors inability to interrupt micturition and constipation. (Eliasson K 2008)
Study of 291 elite female athletes with mean age of 22.8 via questionnaire. Women were from a variety
of sports. 51.9% with UI with sport and some with ADL’s. Activity most likely to produce UI was jumping. More UI with training than with competition. (Thyssen HH 2002)
Study included 12 nulliparous women with mild SUI (mean age 25) and randomized into two groups. 90 minute interval training program or 90 minute rest in sitting position. PFM measured pre and post. In young nulliparous women with mild SUI, strenuous physical exercise resulted in lower max voluntary vaginal contraction pressure indicating fatigue. (Ree ML et al 2007)
Diastasis Rectus Abdominis
Diastasis Rectus Abdominis
Separation or stretch of the linea alba that causes inefficiency of
the core complex
NOT JUST ABOUT LOOKS,
(but sometime it is, i.e. The Mommy Pooch)
Long term implications: Chronic back issues, Prolapse,
Hernia, Incontinence
The relationship between incontinence, breathing disorders, gastrointestinal
symptoms, and back pain in women: A longitudinal cohort study.
Smith et al, The clinical journal of pain Vol 30(2), Feb, 2014 PP 162.167.
Subgroups consisted of:
No BP (n = 7259)
No UI (n = 18,480)
No breathing problems (n = 15,096)
No GI symptoms (n = 17623)
These subgroups were analyzed to
determine the relationship between the
development of absent condition and the
presence or development of other
conditions.
Results: Women with pre-existing and/or
newly developed UI (PR: 1.26 to 2.12) and
breathing problems (PR 1.38 to 2.11) had
an increased risk of developing BP. And
women with pre-existing and newly
developed BP were more likely to
develop UI and breathing problems. (PR:
1.18 to 2.44 and 1.53 to 2.62 respectively)
The presence or development of GI
problems was also identified as a risk
factor for development of these
conditions.
Courtesy of Susan Dunn, PT
Case Study
57yo fm comes to PT due to concerns of urinary “leakage” when exercising and playing
with her 4 yo grandson. Also reports urinary incontinence en route to the restroom.
2G2P via vaginal delivery and (+) episiotomy x2
Urinary Frequency: every 1-2 hours during the day, 2x/night
Admits to “Just in Case” voiding
Unable to “stop the flow”
H/o Constipation, but has been paying more attention to diet over the last year or so and
no longer has concerns: Daily BM, on schedule, without straining. #3-4 Bristol Stool Scale
Talks of “belly pooch” that has been present since delivery of first child 30 years ago
Objective Findings
PF MMT: 2/5, but with significant gluteal accessory use and (+) Valsalva
No activation of mm of urogenital triangle
PF endurance: 3 seconds
Gross PF extensibility: WNL
PF descent with cough
Scar tissue noted left of perineal body, with TTP
(+) Diastasis: 2finger width from xiphoid to pubis with moderate depth (past DIP)
Breathing Pattern: Chest breather
Treatment
Instruction in proper Diaphragmatic Breathing
Utilization of RUSI, as well as sEMG for Biofeedback
Manual facilitation for recruitment of muscles of urogenital triangle
Muscle re-education for coordinated activation of PF and TrA
Incorporated new strategies for functional tasks and ADLs
Progressed to higher level activity with balance, running, lifting.
Treatment sessions: 2x/week for 8 weeks (2 appointments missed d/t unforeseen
circumstances)
Outcome
Report of 80% improvement in continence: Can run, play, pick up grandson without UI with anticipated movements
60% improvement if it’s an unexpected reaction (Like keeping him from running into the street)
Proper DB, PF and TrA coordination
Endurance of coordinated activation 10+ seconds
(+) activation of muscles of the urogenital triangle as well as the levator ani
PF ascension with cough
Further progress can be made, but D/C to HEP.
Pelvic Organ Prolapse
Up to 50% over the age of 50
Viscera and the endopelvic fascia
Viscera are often thought of as being supported by the pelvic floor,
but are actually a part of it. Through connections to the pelvis by
such structures as the cardinal and uterosacral ligaments and the
pubocervical fascia the viscera play an important role in forming
the pelvic floor. (DeLancey)
Anterior compartment is divided by the genital tract at the point
where it passes through the urogenital hiatus where the organs pass
thru the pelvic floor.
Endopelvic fascia
Forms a continuous sheet-like mesentery
extending from the uterine artery at the cephalic
aspect, to where the vagina fuses with the
levator ani muscles below.
Parametrium = uterine attachments
Paracolpium = vaginal attachments
Prolapse
When the internal pressures become so great and/or prolonged that supportive structures
fail.
Childbirth, Chronic Constipation/Forcing BMs, Weakness, Poor activation techniques with
simple daily tasks (cough, sneeze, lift, transfers) as well as tasks with higher difficulty (heavy
lifting, athletic endeavors).
TYPES OF PROLAPSE
Cystocele- Bladder
Urethrocele-urethra
Rectocele- rectum
Uterine prolapse-uterus
Enterocele- small bowel
Sigmoidocele-turning inside outward of the descending colon
STAGES OF PROLAPSE
Grade III and Grade IV Prolapse
CONSERVATIVE TREATMENTS
PFMT has been found to be effective in reversing pelvic organ prolapse by one stage.
Studies by Bo in 2010 in the American Journal of obstetrics and Gynecology (n=55) 1X a week for 3 months, 2X a month for 3 months, lifestyle advice
6 months later: 74% reported decreased symptoms, 19% improved by one stage
Stupp et al in 2011 In the International Urogynocology Journal
(n=21) 7 appts over 14 weeks, 12 week HEP with phone calls every 2 weeks from PT, lifestyle advice
61% at least1 stage improvement, at baseline 81% felt a bulge, post-intervention only 9.5%
URETHRAL/ BLADDER DESCENT
SYMPTOMS OF PROLAPSE
Low back pain- caused by stretching of the uterosacral ligament
Hip and lower abdomen pain, leg fatigue
Feeling of “falling out” or heaviness
Cystocele- UI, post void dribble
Urethrocele- unusual spray
Recurrent bladder infections
Constipation
Urinary / Fecal Retention
Penetration can be painful secondary to stresses on the US ligament
THOSE AT RISK FOR PROLAPSE
Those who have had previous hysterectomy- increases risk of incontinence by 40% secondary to scarring urethra, loss of support of bladder, injury to plexus/nerves
Menopause- because estrogen helps to close everything off and fluff the tissues up.
Obesity / weight gain
weight loss (>10%)
Parity, increases with increase in number of vaginal deliveries
History of straining- diarrhea/ constipation lifestyle issues
Those with hypermobility- more correlation of CT laxity than strength of pelvic floor (EDS)
Scars affecting the abdominal wall
OBESITY EFFECT ON PROLAPSE
Kudish et al 2009 in Obsteteric Gynecology published a study about obesity and it’s effect on POP. 10% weight loss did not have a positive impact on POP. They did report an increase in urethrocele folllowing 10% weight loss.
Their conclusions: fat may play a role in pelvic organ support and the damage done by childbirth and obesity might take more time to regress following weight loss or is irreversible.
Clinical implications: avoid weight gain and prevent obesity and pay close attention to patients that present for other diagnoses (ie LBP) where therapy could cause POP if not performed properly.
Pessary
CONSERVATIVE TREATMENT
PT Treatment
Behavioral modifications
Utilizing proper recruitment strategies for control
Breaking old habits
sEMG/Biofeedback/Pressure Perionometry
Electrical Modalities
Resistive training/vaginal and anal weights
TDN
Pessary recommendation
Anal Balloon PFM retraining
POP CASE STUDY
35 y/o female 3G3P 1 C-section and 2 VBAC’s with grade 1 tears
BMI 26
Exercise varies between weight lifting/running/Pilates
Symptoms presented with bulge at introitus with BM, weight lifting, occasionally with Pilates and after running 3-4 miles
Was using a tampon as a pseudo pessary
Early symptoms low back pain, difficulty with complete evacuation BM, “heaviness” vaginally
Diagnosis Grade 2-3 rectocele. Grade 1 cystocele. Grade 1 Uterine Prolapse
Recommendation: PT first. If PT fails then surgery.
Objective Findings
MMT PFM 1/5 with endurance of 2-3 seconds. Used accessory of gluteals/adductors
Poor proprioceptive awareness of TrA and PFM
With activation of abdominals PFM would fail
Neurologic exam WNL
2 finger diastasis recti above and at the umbilicus
Poor recruitment pattern with only anal lift and no superficial urogenital activation
With attempt of abdominal contraction patient would valsalva
Treatment
Manual cuing for activation of the correct firing pattern of the PFM
Correct breathing techniques
Correct isolation of the TrA
All of these were performed individually and then layered on until eventually all three
could be performed together in static neutral spine various positions. Then progressed to
functional movement incorporating multiplane motion laying on IO/EO and RA
Correct BM for effort and consistency and ergonomics
Duration and Outcome
Patient seen 2x a week for 4 weeks and then 1x a week for 4 weeks
PFM strength improved to 2/5 with normal firing pattern and endurance WNL
Able to activate and maintain TrA with ADL’s/IADL’s and Moderate level of exercise
without symptoms. 60-90 minutes of gym activity (weights had to be reduced by 40-
50% of previous workout but will be progressed with HEP. Able to do a 40 minute run
at 10-11 minute pace which was slower than her previous pace but was going to progress
with HEP.
Patient was able to recognize signs of PFM and/or TrA fatigue so as to independently
adjust her HEP
No longer had presentation of POP at introitus.
Thank You!
Time for Lab ………………..
LAB
ISOLATION OF TRANSVERSUS ABDOMINUS
MANUAL CHECK (EXTERNALLY) FOR SIGNS OF POOR INTRA ABDOMINAL PRESSURE LENDING
TOWARD “PRESSURE PROBLEMS”
GUIDED US FOR TrA AND ORGAN DESCENT
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