5/23/2009

Just Right…
The Female Pelvic Floor and
Goldilocks { Specific grouping of muscles,
ligaments and fascia which interlace
Too weak, too tight and just right! and provide support-includes
pubococcygeus and levator ani
(or just right, too weak and too tight)
{ Keep pelvic organs in the pelvis
z Bladder
Meagan Matteson, RN, MS, CNP
z Uterus
meagan.matteson@osumc.edu
z Rectum
Feel free to contact me with ?s

www.augs.org (great resource!)

Just Right… Just right…

{ Muscles create circles (sphincters) { Roll in sexual function

around outlets of those organs to z Orgasm is essentially a rhythmic
keep us clean and dry muscular contraction-stronger
z For example-urination
example urination muscle=stronger
muscle stronger contraction?
z Bladder muscle is relaxed until need to
void-pelvic floor muscles are contracted
z When voiding bladder muscle contracts
and pelvic floor relaxes

Too Weak…

{ Increased risk of stress urinary

incontinence due to weakness of
both the urethral sphincter and
hypermobility of the urethra
z Leaking with coughing, laughing, etc.
{ Increased risk of pelvic organ
prolapse or relaxation
z “My bladder is falling out…”

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 5/23/2009

Types of Pelvic Organ Prolapse Causes for pelvic floor relaxation

{ Childbearing (not just vaginal

delivery!)
z Increased pressure intra-abdominally
due to pregnancy forces muscles down
z Vaginal delivery disrupts integrity of
the musculature if everything goes well
(intact)
z Increased risk with perineal trauma
such as tearing or episiotomy

Causes for pelvic floor relaxation Causes for pelvic floor relaxation

{ Heredity { Age
z Genetic predisposition to poor tissue z GRAVITY!!
integrity { Anything that increases abdominal
Can be seen in need for multiple
{
reconstructions
pressure
z Prolapse and incontinence can often z Runners
“run in the family” z Horseback riders
z Gymnasts

Prevalence of Stress Incontinence Prevalence of pelvic organ prolapse

{ 1 in three women will have leaking { 40% of women over the age of 40
with stress maneuvers within 5 have some pelvic organ prolapse
years of a vaginal delivery
{ 50% of women who deliver
{ 50-75%
50 75% of women who have it vaginally
i ll hhave some d
degree off
won’t even tell their physician. Of
those who did, 61% waited 4 years prolapse
{ In the U.S. more feminine pads are
used for incontinence than for
menstruation

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Too Tight (Hypertonic)… Causes for pelvic floor hypertonicity

{ Detrusor sphincter dyssynergia { Spinal cord injury

(DSD)-inability to appropriately
relax the pelvic floor with a
contraction of the bladder-leads to
poor emptying or painful voiding
{ Pelvic pain syndromes such as
vestibulodynia or vulvar vestibulitis
{ May contribute to Irritable Bowel
Syndrome and Interstitial Cystitis
{ Dysfunctional habits in response to
chronic pain
z Severe vaginal atrophy
z Pelvic trauma
z Repeated infections
Pain-fear cycle=pain causes fear causes
{
tension causes more pain

What can we do? Physical exam-What to expect

{ Talk about the pelvic floor with your { Done at time of bimanual exam
patients or your clinician { Ask patient to squeeze around your
z Initiate honest discussion about pelvic fingers, aka…
health or symptoms!! z Squeeze like you are trying to hold in
{ Start young-easier for patients to gas in a crowded room
identify and strengthen when they
are young and muscles are strong
{ Elicit pelvic floor history to aid in
intervention!

Stop your urine on the toilet… Physical exam

{ Not a great idea long term-confuses { Give patient a grade 0-5/5

the voiding messages z 0-no movement to the pelvic floor
{ Patient should feel a lifting z 1-flicker
sensation-like
ti lik a string
t i pulling
lli th
their
i z 2
2-weak k
vagina up z 3-moderate (lift)
{ Do on a hard chair for most z 4-good (lift)
feedback-hardest to do standing z 5-strong (lift)
(gravity)

3

Physical exam
{ Grade
{ Accessory muscle use
z Most common-bottom, thighs and
abdominal
bd i l muscles l
z Make note if patient is using
z When a Kegel is done correctly the
contraction is in pelvic floor only!!
Education
{ 2 types of exercises-long holds and
quick flicks
z Long holds work slow-twitch muscle
fibers used long term to keep patients
continent-unconscious (70%)
z Quick flicks work fast-twitch fibers used
during stress maneuvers (30%)
Progressive exercise program
{ Identify muscle
{ Start doing 3 long hold exercises in
a set
z Hold for 3 seconds and relax for 3
seconds in between
z 4 sets/day
z May not feel the entire 3 seconds but
should strive for them
5/23/2009
Education
{ Not just for older women or people
who are incontinent!
{ Start early and help the muscles
stay
t toned.
t d
{ Re-visit this every year at annual
exam starting at initial
appointment.
Progressive exercise program
{ No special devices are needed
{ Patient compliance is key!
{ Only works while patients do them-
use it or lose it!
{ Informal or formal training (at
home versus physical therapy)
Progressive exercise program
{ When you feel the hold for 3
seconds increase the hold/relax
time and number of reps by 2
z 5 reps
reps, hold 5 seconds,
seconds relax 5 seconds
4x/day
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Progressive exercise program Quick flicks

{ Continue to add 2 until patient can { These are fast up and down
ultimately hold… exercises
z 12 seconds and do 12 in a row without { Do these daily at stop signs, red
fatigue! li ht meals,
lights, l bbrushing
hi th
their
i tteeth
th
z Can you??????
{ Attach to a daily activity for best
z Rest period is as important as the
compliance
contraction for a healthy pelvic floor

Advanced Exercises Formal training

{ Standing { Done by experienced RN, NP or PT

{ Elevator { Done over course of several months
z Sit on floor and increase the { May use biofeedback or electrical
contraction
t ti iin stages
t stimulation to enhance results
z Think about as floors until top floor and
back down
{ Good for patients who are having
trouble identifying the correct
z Takes a lot of concentration and control
muscles
{ Creates incentive to comply

Across the Lifespan Across the lifespan

{ Before childbearing { Before childbearing
z Easiest time to identify and tone z Can see hypertonicity in this group
muscles
z Ask about pain with intercourse or
z Encourageg ppatients to be p
proactive and
during voiding
talk to relatives about their experience
z Often taught in yoga/Pilates courses
z Reminders are important-these
individuals often do not have
symptoms so easily forgotten
z SEX!!

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 5/23/2009

Pregnancy Delivery

{ Most helpful to have strong pelvic { C/S may be somewhat protective

floor going into pregnancy and with first child but looses that
continue to do exercises throughout protection with second pregnancy
z No specific guidelines regarding { St i
Strive for
f intact
i t t perineum
i
trimester variations
{ What effect does perineal massage
z OK to do immediately after delivery
have?
z Often taught in prenatal yoga classes

Pre-menopausal Post-menopausal

{ Often when dysfunction begins to { Estrogen depletion

appear in terms of incontinence and
prolapse
z Stress and urge related incontinence
z May be more compliant after symptoms
appear
z Must ask about these symptoms to
open a dialogue!
z Consider vaginal estrogen for stress
incontinence-research not definitive
z May have more time for physical
therapy
z May be more interested in non-surgical
intervention due to co-morbidities
z Sometimes have hard time identifying
the muscles due to weakness

What do Kegels NOT do? Take home message (literally!)

{ Kegels cannot put us “back together { Whether a clinician, a woman or

again” someone who loves a woman talk
about pelvic health!!
{ Depending on the amount of pelvic
z Serious impact
p on q
quality
y of life!
fl
floor descent
d t exercises
i may nott be
b
{ Pelvic floor exercises are more
enough
effective if initiated early in
z Pessary symptom complex
Surgery
z
{ Speak to the doctor you feel most
comfortable with and be vigilant!