Sunday, February 7, 2010

The Pelvic floor: Part 2 (problems, clue to guideline for treatment & the primary clinicians)

The pelvic floor is a highly complex structure made up of skeletal and striated muscles, support and suspensory ligaments, fascial coverings and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs (4). So the pelvic floor represents the neuromuscular unit that provides support and functional control for the pelvic viscera. Its integrity, both anatomic and functional, is the key in some of the basic functions of life (1):

a. Storage of urine and feces
b. Evacuation of urine and feces
c. Support of pelvic organs, and
d. Sexual function

In pelvic floor dysfunction the aetiology is inevitably multi-factorial, and seldom as a consequence of a single aetiological factor (4). However, the problems that are encountered with pelvic floor can be broadly grouped into due to hypotonic or hypertonic status.

The hypotonic condition leads to: stress incontinence, fecal incontinence, and pelvic organ prolapse.
The hypertonic condition leads to: elimination problems, chronic pelvic pain, and bladder disorders that include bladder pain syndromes, retention, and incontinence. The hypertonic disorders are very common and are often not considered in the evaluation and management of patients with these problems (1).

A. The pelvic floor muscle (PFM) & respiration interaction:

Working on 40 female healthy nulliparous women, one study found a correlation between PFM contraction strength and forced expiratory flows. They found a positive correlation between PFM & forced expiratory flow i.e. better is the strength of PFM better is the forced expiratory flow. Basis on this correlation the researchers of this study recommended a coordinated abdominal and PFM training in diseases with expiratory flow limitations (2).

B. The PFM, abdominal muscle & intravaginal pressure:

Activation of the abdominal muscles might contribute to the generation of a strong pelvic floor muscle contraction, and consequently may contribute to the continence mechanism in women (3).

One study found defined patterns of abdominal muscle activity were found in response to voluntary PFM contractions in healthy continent women (3). Crucial findings from this study is discussed below:

1. During voluntary maximal PFM contractions: The transversus abdominus, internal oblique, and rectus abdominus muscles works with the PFM in the initial generation of maximal intravaginal pressure.
2. 2 phases of intravaginal pressure rise: PFM activity predominated in the initial rise in lower vaginal pressure, with later increases in pressure (up to 70% maximum pressure) being associated with the combined activation of the PFM, rectus abdominus, internal obliques, and transverses abdominus.

These abdominal muscles were the primary source of intravaginal pressure increases in the latter 30% of the task, whereas there was little increase in PFM activation from this point on.

This study suggests among the abdominal muscles EO (external oblique) muscle does not show any clear activation pattern along with PFM. The supposed work of this muscle thus is predominantly in postural setting prior to the initiation of intravaginal pressure increases.

C. Complexity of medical problems & consultation areas in pelvic floor dysfunction:

Complex problems of the pelvic floor: Pelvic floor problems affect either one or all the three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (faecal incontinence), vagina and/or uterus (sexual dysfunction) (4).

In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialities (4).

Who must attend these patients?

This compartmentalisation of the pelvic floor has resulted in the partitioning of patients into urology, colo-rectal surgery or gynaecology, respectively, depending on the patients presenting symptoms (4).

1. Butrick CW; Obstet Gynecol Clin North Am. 2009 Sep;36(3):699-705.
2. Talasz H et al; Int Urogynecol J Pelvic Floor Dysfunct. 2009 Dec 8.
3. Madill SJ et al; Neurourol Urodyn. 2006;25(7):722-30.
4. Elneil S et al; Best Pract Res Clin Gastroenterol. 2009; 23(4):555-73.

* Dear friends I have a musculoskeletal back ground. While reviewing these papers I hoped to review the musculoskeletal issues around the pelvic floor. This is not exactly what I wanted to review but I really wanted to present the full picture. Point A, B refers to arena of MSK physiotherapists.

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