9b - Rx Pelvic Floor Disorders

Question 1

Ways to check for correct PF activation

Answer 1

Vaginal Examination

RTUS

Question 2

What if a pt can’t perform PF contraction?

Answer 2

FIRST OPTIONS??
• Attempt to facilitate co-contraction with TA
OR
• Pt spends one week practicing by attempting to flow stop
once each day (ceasing if achieves) then returns for follow
up
SECOND OPTION??
• Neuromuscular Electrical Stimulation to facilitate
pelvic floor contraction

Question 3

After the patient can contract pelvic floor, what do you work on?

Answer 3

Strength, endurance and co-ordination (the knack)

Question 4

But what if someone is very weak and still wants to run /

jog or simply is on their feet all day??

Answer 4

Vaginal Pessaries

Question 5

3 Main Goals of Treatment for prolapse

Answer 5

1. Attempt to Increase Upward Support of organs
2. Attempt to Reduce Strain Down Through Organs / Fascia
3. Provide tips for Symptom Management

Question 6

Reducing Strain Down Through Fascia

Advice!!!!

Answer 6

1. Reduce heavy lifting
2. Manage constipation
3. Manage respiratory conditions
4. Importance of ideal body-weight
5. Rest in supine / everted in middle of day
6. Appropriate / inappropriate exercise

Question 7

Exercise advice

Answer 7

Strengthen pelvic floor first

Question 8

Management of Obstructed Defecation from Prolapse

Answer 8

Teach how to manually conrrect prolapse using a finger vaginally or with pressure on the perineum.

People who are uncomfortable or with poor dexterity - Femeeze

Question 9

Incomplete Bladder Emptying from Prolapse - Tips when there is an Anterior Vaginal Wall
Prolapse (Cystocele)

Answer 9

• Leaning forward /anterior pelvic tilt to facilitate
emptying
• Double void – stand up, walk around a little , sit
down and try again.

Question 10

Incomplete Bladder Emptying from Prolapse - Tips when there is a Uterine Prolapse

Answer 10

• Lean backward / posterior pelvic tilt to reduce

compression of urethra by uterus

Question 11

Options of treatment of stress incontinence

Answer 11

1. The knack (!)
2. PFMT
3. vaginal cones
4. weight loss
5. oestrogen replacement,
6. artificial supports of urethra

Question 12

Why is teaching The Knack important?

Answer 12

In people without urinary incontinence, the PFM automatically contract simultaneously with, or
just prior to increases in abdominal pressure, whilst in people with SUI this reflex often appears to
be absent

Question 13

Limitations of ‘The Knack’

Answer 13

Good temporarily but can’t be done for things like going for a jog or an exercise class

Question 14

Aims of PFMT - strengthening

Answer 14

1. Increase cross-sectional area of the muscle
2. Improve neuromuscular function by increasing the number of activated motor
   neurons and their frequency of excitation
3. Improve resting muscle tone

Question 15

Oestrogen and SUI (menopause results in)

Answer 15

Cessation of cyclical variation in reproductive hormones
– Cessation of menstrual periods
– Overall reduction in oestrogen levels
– Low oestrogen induced atrophy of lower reproductive and lower urinary tract tissues

Question 16

Device to provide pressure to increase urethral closure pressure

Answer 16

contiform (over the counter)

Question 17

3 Goals of Treatment: (lifestyle management urgency, frequency and incontinence)

Answer 17

– To enhance the patient’s understanding of normal bladder function and factors related
to their urgency / frequency / UUI

– Increase patient’s understanding of poor bladder habits that may be exacerbating their
symptoms

– Make necessary lifestyle changes to improve bladder function

Question 18

Lifestyle strategies urgency, frequency, incontinence

Answer 18

Strategies include

1. Management of fluid intake
2. Elimination of Bladder Irritants
3. Management of Bowel function

Question 19

Patient education lifestyle factors urgency

Answer 19

1. Start by explaining Normal Bladder Function
2. Educate on cause of OAB / Urgency Symptoms
3. Explain Factors that worsen DO / Urgency
4. Explain Role of PF in normalising bladder Fx

Question 20

Bladder irritants to eliminate

Answer 20

• Artificial sweeteners

- Caffeine (be careful, is a drug that can cause real dependence).

Question 21

Advice on appropriate fluid intake

Answer 21

Aim for Appropriate Fluid Intake
• ~1500mls – 1800mls / 24 hrs
• 25 - 30mls / kg bodyweight
Note: ~300mls of fluid daily comes from food

(in patients whose fluid intake is excessive, reducing by 25% can help)

Question 22

Effect of excessive fluid or reduced fluid on bladder

Answer 22

– Excessive fluid intake exacerbation of detrusor overactivity via polyuria / fast diuresis
– Reduced fluid intake increase urine concentration bladder irritation

Question 23

General Bowel Advice

Answer 23

– Ensure sufficient fluid intake
– Increase Fibre via a supplement eg metamucil, normafibre etc
– Don’t defer when urge to defecate occures
– Increase general exercise
– Defecation Retraining Techniques (we will cover later)

Question 24

Options for patients with urgency, frequency and urge urinary incontinence

Answer 24

Lifestyle
Behaviour retraining
Electrical stimulation

Question 25

Purpose of Behaviour Retraining

Answer 25

1. Reduce incontinence episodes associated with symptomatic urinary urgency ie eliminate Urge Urinary
   Incontinence
2. Teach patients strategies to reduce the sensation of urgency when urgency episodes occur
3. Improve patient confidence that they can take control of their bladder function and leave the house!!!

Question 26

Problem with rushing to toilet when experiencing detrusor overactivity

Answer 26

• Increased pressure on bladder

- anxiety can exacerbate DO (the more you rush, the stronger the urge)

Question 27

Why does behaviour retraining work for DO

Answer 27

Patient understands that sudden episodes of urgency / detrusor overactivity are likely to be temporary
• If person waits, sudden intense urgency sensation will probably pass and reduce to a more comfortable
urge.

Question 28

4 Commonly Used Urge Suppression Strategies

Answer 28

– Application of Pressure to the Perineum

– Pelvic Floor Contraction

– Activation of Posterior Tibial Nn

• Facilitation of Frontal Lobe

Question 29

When should patient go to toilet after behaviour retraining strategies

Answer 29

Walk once urgency sensation has subsided

Question 30

Electrical Stimulation for Urgency / DO

Answer 30

– Continuous mode

Types of Electrical Stimulation of urgency / detrusor overactivity:
– Vaginal Functional Electrical Stimulation
– Suprapubic or Sacral Electrical Stimulation
– Magnetic Stimulation – “The Chair”
– Posterior Tibial Nerve Stimulation

Question 31

Common Causes of NP (nocturnal polyuria)

Answer 31

– High fluid intake before bed
– Diuretic Medications before bed
– Lower Limb Fluid Pooling during the day
– Sleep Apnoea stimulation of diuresis

Question 32

Treatment of Nocturia due to Nocturnal Polyuria

Answer 32

• Restrict Fluid intake in 2-3hrs before bed
• Speak with GP regarding alteration of timing of medications
• Elevation of lower limbs and circulatory exercises before
bed
• Compression stockings during the day
• Treat sleep apnoea (CPAP)

Question 33

Why is TrA contraction during defecation a problem?

Answer 33

Co-contraction of PF mm - obstructed defecation

Question 34

Treatment of Paradoxical
Puborectalis
Goals of Treatment:

Answer 34

– Restore the normal co-ordination of puborectalis during defecation
Enable increase in IAP (to initiate rectal emptying) without triggering a PFC
– Release of External Anal Sphincters during defecation
– Allow defecation to occur with minimal strain and in an efficient manner.

Question 35

Defaction retraining for paradoxical puborectalis

Answer 35

BULGE - lengthening of rectus abdominus - facilitation of TrA relaxation - release of PR

Question 36

What does relaxed puborecatalis during defecatrion do

Answer 36

anal shortening and widening

increased anorectal angle