9b - Rx Pelvic Floor Disorders Flashcards
Ways to check for correct PF activation
Vaginal Examination
RTUS
What if a pt can’t perform PF contraction?
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
After the patient can contract pelvic floor, what do you work on?
Strength, endurance and co-ordination (the knack)
But what if someone is very weak and still wants to run /
jog or simply is on their feet all day??
Vaginal Pessaries
3 Main Goals of Treatment for prolapse
- Attempt to Increase Upward Support of organs
- Attempt to Reduce Strain Down Through Organs / Fascia
- Provide tips for Symptom Management
Reducing Strain Down Through Fascia
Advice!!!!
- Reduce heavy lifting
- Manage constipation
- Manage respiratory conditions
- Importance of ideal body-weight
- Rest in supine / everted in middle of day
- Appropriate / inappropriate exercise
Exercise advice
Strengthen pelvic floor first
Management of Obstructed Defecation from Prolapse
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
Incomplete Bladder Emptying from Prolapse - Tips when there is an Anterior Vaginal Wall
Prolapse (Cystocele)
• Leaning forward /anterior pelvic tilt to facilitate
emptying
• Double void – stand up, walk around a little , sit
down and try again.
Incomplete Bladder Emptying from Prolapse - Tips when there is a Uterine Prolapse
• Lean backward / posterior pelvic tilt to reduce
compression of urethra by uterus
Options of treatment of stress incontinence
- The knack (!)
- PFMT
- vaginal cones
- weight loss
- oestrogen replacement,
- artificial supports of urethra
Why is teaching The Knack important?
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
Limitations of ‘The Knack’
Good temporarily but can’t be done for things like going for a jog or an exercise class
Aims of PFMT - strengthening
- Increase cross-sectional area of the muscle
- Improve neuromuscular function by increasing the number of activated motor
neurons and their frequency of excitation - Improve resting muscle tone
Oestrogen and SUI (menopause results in)
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
Device to provide pressure to increase urethral closure pressure
contiform (over the counter)
3 Goals of Treatment: (lifestyle management urgency, frequency and incontinence)
– 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
Lifestyle strategies urgency, frequency, incontinence
Strategies include
- Management of fluid intake
- Elimination of Bladder Irritants
- Management of Bowel function
Patient education lifestyle factors urgency
- Start by explaining Normal Bladder Function
- Educate on cause of OAB / Urgency Symptoms
- Explain Factors that worsen DO / Urgency
- Explain Role of PF in normalising bladder Fx
Bladder irritants to eliminate
- Artificial sweeteners
- Caffeine (be careful, is a drug that can cause real dependence).
Advice on appropriate fluid intake
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)
Effect of excessive fluid or reduced fluid on bladder
– Excessive fluid intake exacerbation of detrusor overactivity via polyuria / fast diuresis
– Reduced fluid intake increase urine concentration bladder irritation
General Bowel Advice
– 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)
Options for patients with urgency, frequency and urge urinary incontinence
Lifestyle
Behaviour retraining
Electrical stimulation
Purpose of Behaviour Retraining
- Reduce incontinence episodes associated with symptomatic urinary urgency ie eliminate Urge Urinary
Incontinence - Teach patients strategies to reduce the sensation of urgency when urgency episodes occur
- Improve patient confidence that they can take control of their bladder function and leave the house!!!
Problem with rushing to toilet when experiencing detrusor overactivity
- Increased pressure on bladder
- anxiety can exacerbate DO (the more you rush, the stronger the urge)
Why does behaviour retraining work for DO
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.
4 Commonly Used Urge Suppression Strategies
– Application of Pressure to the Perineum
– Pelvic Floor Contraction
– Activation of Posterior Tibial Nn
• Facilitation of Frontal Lobe
When should patient go to toilet after behaviour retraining strategies
Walk once urgency sensation has subsided
Electrical Stimulation for Urgency / DO
– 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
Common Causes of NP (nocturnal polyuria)
– High fluid intake before bed
– Diuretic Medications before bed
– Lower Limb Fluid Pooling during the day
– Sleep Apnoea stimulation of diuresis
Treatment of Nocturia due to Nocturnal Polyuria
• 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)
Why is TrA contraction during defecation a problem?
Co-contraction of PF mm - obstructed defecation
Treatment of Paradoxical
Puborectalis
Goals of Treatment:
– 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.
Defaction retraining for paradoxical puborectalis
BULGE - lengthening of rectus abdominus - facilitation of TrA relaxation - release of PR
What does relaxed puborecatalis during defecatrion do
anal shortening and widening
increased anorectal angle
