pelvic floor muscle re-education treatment of the

Pelvic Floor MuscleRe-educationTreatment of theOveractive Bladderand Painful BladderSyndromeJAMES CHIVIAN LUKBAN, DO andKRISTENE E. WHITMORE, MDThe Pelvic Floor Institute, Graduate Hospital,Philadelphia, Pennsylvania

Normal function of the pelvic floor muscu-lature is essential in maintaining appropriatefunction of the pelvic viscera. Low-tonepelvic floor dysfunction, as may be seen inpatients with pelvic floor musculature de-nervation, can contribute to pelvic organprolapse, transurethral urinary incontinence,vaginal laxity, or transrectal fecal inconti-nence. High-tone pelvic floor dysfunction,as may occur in patients with overactivebladder or painful bladder syndrome (inter-stitial cystitis), can manifest as voidingdysfunction, sexual dysfunction with dyspa-reunia, or fecal retention. Pelvic floor reha-bilitation for patients with pelvic floor dys-function is performed in an effort to restorenormal tone and function to the muscles of

the pelvic floor, and in patients with overac-tive bladder may provide an additional ele-ment of reflex bladder inhibition. Muscle re-education techniques, typically preceded bya trial of behavioral therapy, include pelvicfloor musculature exercises, pelvic floormusculature exercises with biofeedback,and electrical stimulation. The purpose ofthis chapter is to discuss the use of pelvicfloor musculature rehabilitation to treatoveractive bladder and to correct high-tonepelvic floor dysfunction.

Anatomy of the Pelvic FloorThe pelvic floor contains layers of connec-tive tissue and muscle that provide supportto the pelvic viscera. The urethra, vagina,and rectum are attached to the pelvic side-walls by the endopelvic fascia, penetratingthe pelvic floor at the urogenital hiatus. Im-

Correspondence: James Chivian Lukban, DO, Directorof Urodynamics, Graduate Hospital, Pepper Pavilion,Suite 900, 1800 Lombard Street, Philadelphia, PA 19146.

CLINICAL OBSTETRICS AND GYNECOLOGYVolume 45, Number 1, 273–285© 2002, Lippincott Williams & Wilkins, Inc.

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mediately beneath the endopelvic fascia isthe pelvic floor musculature. It is composedof the puborectalis, levator ani (pubococ-cygeus and iliococcygeus), and coccygeusmuscles. The puborectalis originates fromthe pubis and runs posteriorly to join its con-tralateral muscle behind the anorectal junc-tion, forming a U-shaped sling. The pubo-coccygeus muscle emanates from the pubis,traveling posteromedially to insert on the su-perior surface of the coccyx and the anococ-cygeal raphe. The iliococcygeus arises fromthe arcus tendineus levator ani, running pos-teromedially to insert on the coccyx andanococcygeal raphe. The coccygeus muscleoriginates from the ischial spine and sacro-spinous ligament, inserting onto the lateralcoccyx and lower sacrum. Beneath the pel-vic floor musculature is the perineal mem-brane, which together with the pelvic floormusculature defines the pelvic floor. Theperineal membrane is a triangular sheet ofdense fibromuscular tissue spanning the an-terior half of the pelvic outlet. Its attach-ments include the urethra, vagina, and peri-neal body medially and the inferior ischio-pubic rami laterally.1

Innervation of the PelvicFloorThe nerve supply to the pelvic floor includesboth somatic and autonomic innervation.Somatic fibers from S2–S4 form the puden-dal nerve, which supplies the perineal sur-face of the pelvic floor musculature. Sacralnerve root branches also innervate the pelvicfloor directly through fibers traveling to thevisceral surface of the pelvic floor muscula-ture. Parasympathetic innervation beginswith preganglionic fibers emanating fromS2–S4, and ends in the postganglionic mus-carinic receptors of the bladder wall. Sym-pathetic innervation arises from T10–L2,with postganglionic fibers traveling to beta-adrenergic receptors in the smooth muscleof the bladder wall and alpha-adrenergic re-ceptors in the smooth muscle of the bladderneck and proximal urethra.2

Normal Pelvic Floor Functionin Pelvic Organ Support andUrinary ContinenceThe pelvic floor musculature performs animportant role in tonic support of the pelvicviscera. Such support is provided by a pre-ponderance of type I (slow twitch) fiberswithin the pelvic floor musculature. In themaintenance of urinary continence, tonicmuscular forces are provided by the externalstriated urethral sphincter (composed of theintramural striated sphincter and the periure-thral levator ani musculature) and are impor-tant in effecting adequate urethral support.In addition, a minority population of type II(fast twitch) fibers within the levator animusculature provides a mechanism for ac-tive periurethral muscular contraction at thetime of provocative increases in intra-abdominal pressure.3 Less perceptible tonicincreases in the pelvic floor musculature oc-cur during bladder filling as part of a primi-tive sacral spinal mechanism known as theguarding reflex whereby mechanoreceptiveparasympathetic impulses triggered by vesi-cal distention lead to somatic efferent stimu-lation of the pelvic floor musculature and theexternal striated urethral sphincter.2 One’sthreshold of continence is thus increasedthroughout bladder distention through aneurologically responsive pelvic floor mus-culature.

Low-Tone Pelvic FloorDysfunction

DEFINITIONLow-tone pelvic floor dysfunction refers tothe clinical finding of an impaired ability toisolate and contract the pelvic floor muscu-lature in the presence of weak or atrophicmusculature. Urologic and gynecologicmanifestations include progressive pelvicorgan descent and stress urinary inconti-nence secondary to a loss of both pelvicfloor musculature tone and active periure-thral contractile forces.

274 LUKBAN AND WHITMORE

ETIOLOGYLow-tone pelvic floor dysfunction may beencountered in patients with partial pelvicfloor denervation as a result of parturition,senescence, or some combination. In asample of 96 nulliparous women, Allen etal.4 examined the effects of childbirth on thenerve supply to the pelvic floor and the pel-vic floor musculature. Evaluation per-formed at 36 weeks’ gestation and at 2months after delivery included concentricneedle electromyography (EMG) and peri-neometry. Mean duration of motor unit po-tentials was found to be significantly in-creased on postpartum EMG studies com-pared with antepartum values, indicative ofthe presence of denervated muscle fiberswith subsequent peripheral reinnervation af-ter injury. Mean motor unit potential dura-tion was also found to be greater in postpar-tum samples of women who experienced aprolonged second stage of labor, and inthose giving birth to babies with an above-average birthweight. Perineometry mea-surements antenatally and 2 months postpar-tum were 15.6 cm H2O and 10.1 cm H2O,respectively, consistent with a significantreduction in pelvic floor musculaturestrength after delivery.

Smith et al5 used single-fiber EMG toprovide evidence of age-associated pelvicfloor musculature denervation. An increasein motor unit fiber density, consistent withcompensatory reinnervation after injury,was found to correlate with increasing age in41 nulliparous asymptomatic women. Val-ues ranged from 1.2 at 20 years to 1.6 at 77years, representing an increase of 0.07 fibersper year.

High-Tone Pelvic FloorDysfunction

DEFINITIONHigh-tone pelvic floor dysfunction refers tothe clinical condition of hypertonic, spasticpelvic floor musculature with resultant im-

pairment of muscle isolation, contraction,and relaxation. Urologic and gynecologicmanifestations include voiding dysfunction,urinary frequency, urgency, and pelvic pain.Spastic pelvic floor musculature is com-monly encountered in those with interstitialcystitis, and may be seen in those with over-active bladder.

LITERATURE REVIEWHigh-tone pelvic floor dysfunction has beendescribed infrequently in the urologic or gy-necologic literature; however, the sameclinical condition has been reported in colo-rectal publications as any one of the follow-ing clinical entities: coccygodynia, as de-scribed by Thiele; tension myalgia of thepelvic floor, coccygeus-levator spasm syn-drome; levator syndrome; and levator anispasm syndrome.

Thiele6 described coccygodynia in 1937not only as an entity characterized by painlocalized to the coccyx, but also as a syn-drome noteworthy for the presence of leva-tor ani and coccygeus muscle spasm. In hisoriginal communication, 64 of 69 patientswith coccygeal pain were found to havespastic pelvic floor musculature on rectalexamination. Work published by the sameauthor in 1963 further characterized coccy-godynia based on a review of 324 case rec-ords.7 Patient symptoms included pain lo-calized to the lower sacrum and coccyx, of-ten exacerbated by prolonged sitting. Few ofhis patients, however, exhibited tendernessof the coccyx on direct palpation or manipu-lation, a finding consistent with pain born ofpelvic floor musculature spasm and not ofprimary sacrococcygeal pathology. Com-mon etiologic factors included anal infec-tion and chronic trauma, as identified in 178(55%) and 106 (33%) patients, respectively.Anal infection was thought to cause reflexpelvic floor musculature spasm throughlymphatic drainage of organism-ladenlymph. Chronic trauma included poor sittingposture and extended vehicle rides.

Sinaki et al8 used the term tension myal-gia of the pelvic floor to describe a sample of

Pelvic Floor Muscle Re-education 275

94 patients with spastic, tender pelvic floormusculature. Common symptoms includedlow back pain in 82% and a “heavy feelingin the pelvis” in 64%, with the appearance ofsymptom aggravation in 88% of patients af-ter prolonged sitting. Pelvic floor musclespasm was attributed to habitual contractionof the pelvic floor in addition to a compo-nent of hypochondriasis.

Paradis and Marganoff9 used the termcoccygeus-levator spasm syndrome to char-acterize 92 patients with pelvic floor spasmand “rectal” pain. Patients were found to beparticularly tender at muscular sites adjacentto the ischial spines and coccyx, with a sug-gestion by the authors of a more significantinvolvement of musculofascial, ligamen-tous, and tendinous structures than of themuscles themselves. Neither infection nortrauma was identified in these patients asetiologic factors, with the attribution of dis-ease presence to psychoneurosis.

Grant et al.10 used the term levator syn-drome to describe a sample of 316 patientsexhibiting pelvic floor musculature spasmand tenderness. The predominant symptomwas rectal discomfort. The etiology of leva-tor syndrome was reported as unknown.

All of the syndromes as presented aboverepresent a similar clinical condition charac-terized by tender, spastic pelvic floor mus-culature manifesting as pain localized to thecoccyx and lower sacrum, rectal pain, orgeneralized pelvic discomfort. Etiologicfactors as reported are varied and include in-fection, chronic sacrococcygeal traumafrom poor posture or prolonged sitting, andhypochondriasis or hysteria. A definitivecause of high-tone pelvic floor dysfunctionas encountered in patients with interstitialcystitis has not been established and is mostlikely the result of several co-existing fac-tors.

ETIOLOGYIn 1973, Lilius et al11 published a thoughtfulstudy on the prevalence of levator spasm inpatients with interstitial cystitis. Becausemany of their patients reported pain not only

in the area of the bladder, but also in the re-gions of the sacrum, coccyx, and anus, theyinvestigated the presence of concomitantpelvic floor musculature spasm. Twenty-five (81%) of 31 patients with interstitialcystitis were found to have spasm and ten-derness of the levator ani musculature,which they termed levator ani spasm syn-drome. The authors postulated that suchmuscle activity was, in part, the result ofbladder pathology, with increased pelvicfloor musculature tone appearing in re-sponse to afferent autonomic impulses ema-nating from the bladder wall. These authorsalso assigned importance to poor sitting orworking posture as contributing to the de-velopment of levator ani spasm syndrome.Their excellent clinical observations, sug-gest both a neurologic and musculoskeletaletiology in the development of high-tonepelvic floor dysfunction in patients with in-terstitial cystitis.

In a nondiseased bladder, mechanorecep-tion in the detection of bladder wall tensionis mediated by lightly myelinated A-� fi-bers. Nociceptive afferents, known as (un-myelinated) C-fibers, are typically silent,becoming active in response to bladder in-flammation or irritation. It is thought fromfeline studies that such fibers, once trig-gered, not only fire at low thresholds, butmay also fire spontaneously, resulting inpain and reflex voiding.12 In the normalguarding reflex, parasympathetic afferentslead to a gradual increase in pelvic floormusculature tone as mediated by somatic ef-ferents from the sacral spinal cord, as de-scribed above. One speculative possibilityin the development of high-tone pelvic floordysfunction is that the afferent autonomic“bombardment” seen in patients with inter-stitial cystitis may enhance and maintain aguarding reflex that manifests as pelvic floorhypertonus. This concept of pelvic floorspasticity appearing as a result of a sustainedguarding reflex has been previously alludedto by Chancellor.13

A musculoskeletal etiology for high-tonepelvic floor dysfunction has been suggested


by several authors. Thiele,7 Sinaki et al,8 andLilius et al.11 have associated pelvic floormusculature spasm with poor posture andprolonged sitting. This “typical pelvic painposture,” as termed by Baker,14 character-ized by exaggerated lumbar lordosis, ante-rior pelvic tilt, and thoracic kyphosis, hasbeen implicated in the subsequent develop-ment of sacroiliac pathology. As the sacro-iliac joint moves, however slightly, throughupslip, downslip, or torsion, the pelvic floormusculature to which it is attached is alsosubject to dynamic change.15 Muscles thatare stretched or compressed are preventedfrom maintaining a normal resting tone andare prone to trigger point formation and hy-pertonicity.14 Pelvic floor dysfunction isalso thought to appear in reaction to over-flexion of the coccyx while sitting with in-correct posture.7 Spasm in these patientsmay be the result of a change in tension ofthe pelvic floor musculature to which thecoccyx is attached.7 The presence of sacro-iliac dysfunction with or without the contri-bution of poor posture may reasonably serveas a trigger for the development of high-tonepelvic floor dysfunction. It is likely that thedegree of high-tone pelvic floor dysfunctionencountered in interstitial cystitis representsthe sum of both neurologic and musculo-skeletal components.16

Evaluation of the Pelvic FloorAssessment of the pelvic floor is performedin an effort to determine a patient’s ability toisolate, contract, and relax the pelvic floormusculature. Evaluation is made through in-travaginal (or trans-rectal) examination andmay include the use of measuring devicesfor complementary assessment.

Evaluation begins with a single-fingerdigital examination with light pressureagainst the inferior lateral wall of the vagina.The patient is then asked to perform a con-traction, squeezing the finger to “lift up” thefloor of the vagina. Abdominal, gluteal, andadductor muscle recruitment should be ob-served as a general assessment of pelvic

floor musculature isolation. The contractionis based on a five-point scale (Fig. 1).17 Thesame protocol is performed for both the rightand left pelvic floor musculature. The pa-tient is then asked to relax her muscles andtenderness (hypertonus) is graded on a zero-to-four scale (Fig. 2).17

Digital evaluation of the pelvic floormusculature has been described by severalauthors and varies in regard to scale, number

FIG. 1. Pelvic floor muscle contraction scale.

FIG. 2. Pelvic floor muscle tenderness (hyper-tonus) scale.


of fingers used, and specific parameters as-sessed. Worth et al.18 described a one-to-three scale using a one-finger assessment ofpressure, duration, “ribbing” (tone duringcontraction), and position (degree of dis-placement). Interobserver and test–retest re-liability for this technique was proved.Brink et al19 reported a one-to-four scale us-ing a two-finger assessment of lateral andanteroposterior pressure, duration, and ver-tical displacement. Interrater and test–retestreliability for this scale was also proved. Themost notable pelvic floor musculature digi-tal assessment tool is that described by Lay-cock.20 This zero-to-five scale is reproduc-ible and assesses pressure and displacement.There is a relative paucity of data regardingdigital scoring systems in the evaluation ofhigh-tone pelvic floor dysfunction; mostscales seem to address a patient’s ability tocontract her pelvic floor musculature with-out an assessment of tenderness or impairedrelaxation.

Perineometry is performed to more ob-jectively assess pelvic muscle strength andbaseline tone. A pressure-sensitive intra-vaginal probe within a disposable rubbersheath or glove is zeroed and placed in thevagina to determine resting pelvic floormusculature tone. The patient is then askedto offer and sustain a contraction, thestrength and duration of which are mea-sured. She is asked to consciously relax herpelvic floor musculature, and a final perine-ometry reading is obtained to evaluate thepatient’s ability to return to a flaccid state.This tool offers the benefit of measuring im-paired relaxation in the form of both an el-evated baseline and high postcontractiontone. Perineometry has been shown to cor-relate with digital examination employingthe Oxford Scale in the assessment of im-paired pelvic floor musculature function.21

Assessment of the pelvic floor musculaturecan also be made by intracavitary or surfaceEMG, which has also been shown to corre-late with digital evaluation of the pelvicfloor.18,22 Both perineometry and EMG maynot measure solely the activity of the pelvic

floor musculature, because these devicescan receive input from nonpelvic muscles,including abdominal, gluteal, and adductormusculature. A concomitant assessmentthrough palpation of these extrapelvicmuscle groups should be made during test-ing to provide clinical perspective regardingabsolute intravaginal readings.

Findings in patients with low-tone pelvicfloor dysfunction include impaired muscleisolation and contraction on digital exami-nation. Perineometry in this population re-veals decreased contraction amplitude andduration. Those with high-tone pelvic floordysfunction exhibit poor muscle isolation,impaired contraction, tenderness, spasticity,and impaired relaxation on digital examina-tion. Perineometry in these patients typi-cally reveals elevated baseline pressureswith no significant change in measurementfrom baseline upon contraction and subse-quent relaxation. Patients with high-tonepelvic floor dysfunction who respond to pel-vic floor rehabilitation exhibit a decrease inmuscle tenderness, a decrease in restingtone, and an increase in the degree of changebetween resting and contraction perineom-etry measurements. No standard values forestablishing diagnoses of low or high-tonepelvic floor dysfunction through digital ex-amination, perineometry, or EMG havebeen established.

Behavioral TherapyInitial therapy for overactive bladder typi-cally exists in the form of behavioral tech-niques, which include dietary modificationto limit acidic foods and known bladder irri-tants, timed voiding to maintain predictableintravesical volumes, and bladder training,in which the patient is instructed to follow aregimen of urge inhibition in an effort to ex-tend voiding intervals and reduce the num-ber of incontinence episodes. Bladder drill(also known as bladder training or bladderretraining) in theory functions by increasingcortical control over lower urinary tractfunction. In a review by Fantl23 examining


the effect of this technique in a community-dwelling population with urinary inconti-nence, fewer than 15% of patients exhibitedcomplete symptom resolution, and morethan 50% of subjects showed a 50–75% re-duction in symptoms. These numbers werebased on the collective findings of three ran-domized clinical trials and seven patient se-ries with urodynamic evidence of detrusorinstability, and one series of subjects exhib-iting sensory urgency.

Some authors have reported success withbehavioral therapy in samples of womenwith interstitial cystitis. Parsons andKaprowski24 used bladder training in asample of 21 patients with interstitial cystitisand predominant symptoms of frequencyand urgency. Subjects were placed on a pro-tocol involving progressive increases intime between voids, adding 15 to 30 minutesto the voiding interval every 3 to 4 weeks,with a goal of 31⁄2 to 4 hours between voids.Fifteen (71%) patients exhibited a 50% de-crease in symptoms. Data reflecting the useof bladder training in patients with intersti-tial cystitis versus overactive bladder arescarce.

Treatment of OveractiveBladder

PELVIC FLOOR MUSCLE EXERCISESAND BIOFEEDBACKConservative therapy for stress urinary in-continence has commonly included pelvicfloor musculature exercises, performed tostrengthen periurethral striated musculatureand enhance the patient’s ability to inhibitleakage on provocation. Several investiga-tors have more recently described the use ofpelvic floor musculature exercises in thetreatment of overactive bladder. Nygard etal25 reported a significant decrease in themean number of incontinent episodes perday (from 2.8 to 0.5) in a sample of 14women with detrusor instability after a3-month course of pelvic floor musculature

exercises. Seven (50%) participants exhib-ited excellent or good results at 6-month fol-low-up. It is thought that pelvic floor mus-culature exercises in patients with overac-tive bladder create a reflex inhibition of thebladder in addition to the provision of en-hanced periurethral support.

To ensure proper performance of pelvicfloor musculature exercises, patients areeducated on basic pelvic floor musculatureanatomy and assessed with digital examina-tion to ensure pelvic floor musculature iso-lation. Concomitant monitoring of abdomi-nal, gluteal, and adductor musculature isperformed to detect extrapelvic muscular ef-forts. The patient is instructed to squeeze or“lift up” the pelvic floor musculature andliken the exercise to an effort to preventleakage of urine or stool. The typical proto-col for pelvic floor musculature strengthen-ing involves the performance of 50 contrac-tions per day in two or three divided ses-sions. Each contraction is sustained for 5seconds, followed by a 10-second period ofrelaxation. In patients with overactive blad-der, urge inhibition is achieved with 5 to 10quick contractions 1 to 2 seconds in durationat the onset of symptoms.

In patients who exhibit an impaired abil-ity to isolate and contract their pelvic floormusculature despite appropriate educationand coaching, biofeedback is added to aid inappropriate pelvic muscle identification.Imperceptible muscular activity becomesperceptible through visual and/or audiocues, enhancing the patient’s ability to con-trol previously unfamiliar musculature. Anintravaginal EMG probe is used to sense pel-vic floor musculature activity, with signalconversion to a computer screen or audiosource. Abdominal muscular activity ismonitored concomitantly with surface EMGpatches to ensure pelvic floor musculatureisolation. The patient is instructed to per-form a contraction around the probe for 5seconds, followed by rest for 10 seconds.Visually, the patient can see contraction andrelaxation cycles, with a goal of sustainedpeaks of 12.5 µV and resting values of less


than or equal to 2 µV. Each session lasts 15minutes and is repeated one or two times aweek for 6 weeks. No large randomizedstudies on the use of biofeedback in patientswith overactive bladder have, to our knowl-edge, been published.26

ELECTRAL STIMULATIONElectrical stimulation has been used in thetreatment of stress urinary incontinencesince its initial description for such byCaldwell in 1963.27 Its therapeutic role inpatients with overactive bladder has sincebeen reported. The mechanism of electricalstimulation in inhibiting detrusor overactiv-ity involves the inhibition of parasympa-thetic efferent activity following peripheralsomatic afferent stimulation as mediated bycentral parasympathetic suppression and in-direct sympathetic inhibitory impulses.28

The application of electrical stimulationin women commonly involves the use of anintravaginal or intrarectal probe (anogenitalstimulation) with somatic afferent deliveryto branches of the pudendal nerve. Stimula-tion may be provided at subsensory thresh-old levels (chronic electrical stimulation)without the elicitation of pelvic floor mus-culature contractions or at maximum toler-ated levels (maximal electrical stimulation)with accompanying pelvic floor muscula-ture activity. For the purpose of this discus-sion, electrical stimulation will refer tomaximal electrical stimulation delivered viathe anogenital route. In a review by Payne,29

361 patients with overactive bladder treatedwith electrical stimulation were examined.Seventy-seven (20%) became dry, and 134(37%) showed significant improvement. Ina double-bl ind, randomized, sham-controlled clinical trial of 121 incontinentwomen, Brubaker et al30 reported that 49%of patients with detrusor instability werecured after electrical stimulation (20 Hz, 20minutes twice daily for 8 weeks), with nosignificant postintervention improvementseen in those who used the sham device.Cure was defined as the absence of detrusorinstability on posttreatment provocative

cystometry performed at the end of the8-week treatment period. In a more recentdouble-blind, sham-controlled randomizedtrial of 68 patients (39 women, 29 men) withdetrusor overactivity, Yamanishi et al31 re-ported 25% and 62.5% cured and improvedrates, respectively, after electrical stimula-tion (10 Hz, 15 minutes twice daily for 4weeks) in patients with detrusor overactiv-ity. Cure was defined as a stable cystomet-rogram or no evidence of incontinence onvoiding diary. “Improved” was defined as adecrease in frequency by greater than 50%or an increase in cystometric capacity bymore than 50 mL. Thirteen of 17 patients inthe active group were said to have beencured or improved at an average of 8.4months after completion of the 4-week treat-ment regimen. Clinical benefit in those re-ceiving electrical stimulation was signifi-cantly greater than that seen in the shamgroup.

COMBINATION THERAPYPelvic floor muscle exercises, biofeedback,and electrical stimulation are commonlyperformed in combination. Our protocol isthat of weekly 23-minute sessions over 6weeks using pelvic floor musculature exer-cises with intravaginal biofeedback andelectrical stimulation. Each session beginswith 4 minutes of biofeedback with con-comitant abdominal surface EMG measure-ments, during which the patient is asked tooffer pelvic floor musculature contractionsfor 5 seconds, followed by 10-second inter-vals of relaxation. A contraction amplitudeof 12.5 µV with a baseline of less than 2 µVis desired without significant abdominalmuscle activity. Intravaginal stimulation for15 minutes at 20 Hz is then applied, fol-lowed by 4 additional minutes of pelvicfloor musculature exercises and biofeed-back. Stein et al32 prospectively evaluated21 patients with urge (n = 14) or mixed (n =17) incontinence treated with six sessions ofoffice biofeedback and electrical stimula-tion over a 3-week period. Each session con-sisted of 15 minutes of transvaginal or trans-


rectal electrical stimulation at a frequency of20 Hz. pelvic floor musculature exerciseswere then performed for 15 minutes, with si-multaneous assessment of abdominalmuscle activity by surface EMG. Four(19%) patients were cured and five (24%)were significantly improved at a median fol-low-up of 18 months (range 3–36 months).This study’s poor rate of success may havebeen due to the use of relatively rigid defini-tions of both cure (no pad use, with less thanone incontinent episode per month) and sig-nificant improvement (no pad use, with lessthan one incontinent episode per week).Combination therapy may also be offered inthe form of a home unit. Although more con-venient, home therapy lacks the benefit ofthe presence of a skilled practitioner.

Treatment of High-TonePelvic Floor Dysfunction

PHYSICAL THERAPYPatients diagnosed with high-tone pelvicfloor dysfunction are referred to a physicaltherapist for assessment to identify sacro-iliac malalignment, also known as sacroiliacdysfunction. Evaluation in brief includes aspecific assessment of pelvic alignment,lumbar and hip active and passive range ofmotion, strength and flexibility of the spinaland pelvic stabilizers, and tenderness andspasm of the pelvic supportive musculature.Typical manual therapy techniques used inthe correction of sacroiliac dysfunction, ifidentified, include myofascial release, jointmobilization, muscle energy, strengthening,stretching, neuromuscular re-education, andinstruction in an extensive home exerciseprogram. The speculative logic in correctingsacroiliac dysfunction in patients with high-tone pelvic floor dysfunction is such that ifsacroiliac alignment is restored, normal ten-sion to the pelvic floor musculature returns,allowing the resolution of a high-tone state.

In a pilot study of 16 patients with high-tone pelvic floor dysfunction, sacroiliac

dysfunction, and interstitial cystitis, manualphysical therapy was performed to assessthe benefit of such treatment in reducing in-terstitial cystitis symptoms (frequency, ur-gency, nocturia, pain) as measured by theO’Leary-Sant Symptom and Problem In-dex.33 Dyspareunia was also evaluated inthese patients using the “sex life” questionfrom the Modified Oswestry DisabilityScale. A comparison of pre- and posttreat-ment Modified Oswestry scores revealed animprovement in dyspareunia in 15 (94%)patients. A comparison of pre- and posttreat-ment O’Leary-Sant scores also showed im-provement in 15 (94%) subjects. Schroederet al.34 reported the use of an undefined regi-men of physical therapy in a pediatric andadolescent population in which 20 out of 21patients with musculoskeletal pelvic painwere successfully treated.

THIELE MASSAGEAfter sacroiliac realignment, patients are re-assessed by digital examination and peri-neometry. If pelvic floor musculature spasmpersists as either diffuse or localized hyper-tonicity, subjects undergo a regimen ofThiele massage. In his original descriptionof this technique, Thiele6 reported a per-sonal series of 31 cases of coccygodynia andpelvic floor musculature spasm in which 19(61.3%) were cured and 17 (35.5%) wereimproved (undefined criteria) after transrec-tal massage. The author combined his datawith those taken from eight other proctolo-gists using the same technique and reporteda 93.7% cured and improved rate in a total of80 patients. Treatment consisted of an aver-age of 11 treatments over an average of 11weeks.

In our practice, we perform Thiele mas-sage transvaginally because this is morecomfortable for our patients. In performingthis technique, pressure is applied to the pel-vic floor musculature fibers longitudinallyfrom origin to insertion. Ten to 15 sweeps ofmaximally tolerated pressure are performedon each side, followed by myofascial mas-sage (10 to 15 seconds of sustained pressure)


to tender points. Patients are treated once ortwice a week for 6 to 8 weeks; this is lessfrequently than practiced by Thiele, who ap-plied therapy every day for 5 or 6 days andthen every other day for 7 to 10 days as aninitial course.

PELVIC FLOOR MUSCLE EXERCISESAND BIOFEEDBACKPatients with persistent high-tone pelvicfloor dysfunction despite appropriatemanual physical therapy and Thiele mas-sage may benefit from pelvic floor muscleexercises and biofeedback. In a study of 60patients with intractable rectal pain, 70% ofwhom were diagnosed with either levatorspasm or coccygodynia, Ger et al35 per-formed biofeedback on 14 subjects, usingrectal EMG. After a minimum of six weekly30- to 60-minute sessions, pain relief wasrated as excellent or good (undefined) in six(43%) patients at a mean follow-up of 15months. Heah et al36 prospectively treated16 patients with levator ani syndrome withbiofeedback, using a rectal manometric bal-loon. A significant improvement in pain wasachieved with scores recorded on a 0-to-10linear analog scale (median pain score be-fore biofeedback = 8; median pain score af-ter biofeedback = 2). All patients exhibitednontender musculature after therapy. Thegoal of biofeedback in the treatment of high-tone pelvic floor dysfunction is to achieveconscious control over pelvic floor muscu-lature contraction and relaxation, thusbreaking the cycle of spasm.

ELECTRICAL STIMULATIONThe use of electrogalvanic stimulation in pa-tients with levator syndrome was first de-scribed by Sohn et al.37 Seventy-two pa-tients were treated with electrogalvanicstimulation at 80 Hz to a point of mild dis-comfort for 1 hour per day for three sessionsover a 3- to 10-day period. Fifty (69%) pa-tients rated treatment as excellent (completepain relief) and 15 (21%) rated therapy asgood (pain resolution with fewer than threerecurrences in the 6 to 30 months of follow-

up). The mechanism of pain relief in thesepatients was reported as muscle fatigue aftersustained contractions, in addition to moto-neuron suppression. Other investigatorshave reported the use of electrogalvanicstimulation in patients with levator syn-drome, reporting variable results with excel-lent or good improvement ranging from 43–91%.38–41 Electrical stimulation in patientswith high-tone pelvic floor dysfunction isdelivered with the same intention as electro-galvanic stimulation in creating muscle fa-

FIG. 3. Pelvic floor re-education in the treat-ment of overactive bladder.


tigue with resultant relaxation; however,electrical stimulation employs low-voltagealternating current, whereas electrogalvanicstimulation employs high-voltage directcurrent.42

COMBINATION THERAPYElectrical stimulation may be provided forpatients with high-tone pelvic floor dysfunc-tion at the time of biofeedback therapy. Ad-ministration of anogenital electrical stimula-tion is as described for overactive bladder;however, a frequency of 50 Hz is used, withthe delivery of stimulation to a point of milddiscomfort. Patients with high-tone pelvicfloor dysfunction may maintain pelvic floormusculature fitness with a home device.

PHARMACOLOGIC THERAPYSeveral authors have reported success in thetreatment of high-tone pelvic floor dysfunc-tion with diazepam. Grant et al10 reportedthe use of this medication in conjunctionwith heat and transrectal massage, with 68%of patients reporting good results (symptomrelief by three or less massage treatments).In a smaller series of six women with exter-nal sphincter spasm, sustained relief fromurgency, suprapubic discomfort, and void-ing dysfunction was achieved after a 2- to6-month course of diazepam taken in dosesof 2 to 6 mg daily.43

We have had anecdotal success with tiza-nidine hydrochloride in relieving high-tonepelvic floor dysfunction. Because it is a cen-trally acting �-adrenergic agonist, it shouldbe used with caution in patients taking othercentrally acting agents. We usually beginwith a low dose of 2 mg at bedtime daily andtitrate as appropriate.

Treatment AlgorithmsIn the treatment of overactive bladder, pel-vic floor re-education usually follows an ini-tial trial of behavioral therapy, as describedabove (Fig. 3). Practitioners commonly of-fer their patients pharmacologic agents be-fore or in lieu of pelvic floor re-education,because clinicians may not have the equip-ment or staff to perform appropriate re-education. Additionally, patients may viewpharmacologic therapy as more immediateand less labor-intensive. Sacral nerve rootstimulation has shown recent success in pa-tients with refractory symptoms. Surgicaltherapy remains a last resort in the treatmentof overactive bladder (and interstitial cysti-tis). The best therapy before sacral neuro-modulation or surgery may be a combina-tion of conservative techniques and oralagents. Magnetic stimulation and peripheralneuromodulation have also been used in pa-tients with overactive bladder.

High-tone pelvic floor dysfunction istreated initially with manual physical ther-apy performed in an effort to restore sacro-iliac and sacrococcygeal alignment, with re-

FIG. 4. Pelvic floor re-education in the treat-ment of high tone pelvic floor dysfunction.


sultant relief from abnormal muscular ten-sion (Fig. 4). Thiele massage is initiated ifthe pelvic floor musculature exhibits persis-tent hypertonus despite appropriate bonyalignment. Pelvic floor muscle exercise,biofeedback, and electrical stimulation thenprovide a mechanism to achieve maximalpelvic floor musculature contraction and re-laxation in restoration of normal muscularfunction. Pharmacologic therapy may beused as adjunctive therapy in patients withhigh-tone pelvic floor dysfunction.

SummaryRehabilitation of the pelvic floor muscula-ture has proven effective in patients withoveractive bladder and in those with intersti-tial cystitis and high-tone pelvic floor dys-function. Despite the relative time and effortrequired of both patient and staff in perform-ing these techniques, properly executed pel-vic floor re-education has the potential toyield great benefit at minimal risk. Studiesprospectively evaluating the benefit of pel-vic floor musculature treatment through ob-jective measures such as perineometry andEMG, in addition to validated symptomscales, would do well to further our convic-tion in employing such therapy.

AcknowledgmentThe authors thank Andrew Lesher, MSPT,and Erica Fletcher, MSPT, for their expertcontributions regarding physical therapyevaluation and treatment techniques.

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