Sunday, February 7, 2010

The pelvic floor: part 3 (Guide line for care & physiotherapy)

Pelvic floor dysfunction is a disorder predominantly affecting females. It is common and undermines the quality of lives of at least one-third of adult women and is a growing component of women's health care needs (2). The reported prevalence rates of pain within the pelvis range from 3.8% to 24% in women aged 15 to 73 years (3). Pelvic floor dysfunction affects women of all ages and is associated with functional problems of the pelvic floor. Pelvic floor dysfunction describes a wide range of clinical problems that rarely occur in isolation (2).

Functional pelvic floor problems are perceived to have low priority compared with other health disorders, and treatment remains sub-optimal. Inherent in achieving and promoting better health care services for women is the need for better collaborative approaches to care(2,3).

There is a need to identify and develop comprehensive interdisciplinary, multi-professional strategies that improve the assessment and treatment of pelvic floor dysfunction in primary, secondary and tertiary settings(2).

The care guideline (1):

Whilst the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. As a consequence, these patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway.

The latter includes behavioural and lifestyle changes, conservative treatments (pelvic support pessaries, physiotherapy and biofeedback), pharmacotherapy, minimally invasive surgery (intravaginal slingoplasty, sacrospinous fixation and mid-urethral tapes) and radical specialised surgery (open or laparoscopic sacrocolpopexy). It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only essential, but also critical, if good clinical care and governance is to be ensured.

Physiotherapists in pelvic pain & pelvic floor management

* see the causes of CPC

Physiotherapists are uniquely qualified to manage these patients because of their knowledge of the musculoskeletal and nervous systems and their awareness of the relationships among pain, physiology, and function.

Physiotherapists approach to CPC (chronic pelvic pain) When evaluating women who have pelvic pain, practitioners must ask questions about history of urinary or fecal incontinence, dyspareunia, or pelvic pain with certain activities or associated with menses, surgery, or trauma.

* Common Diagnoses of Chronic Pelvic Pain (CPC)

• Pelvic Floor Tension Myalgia and Levator Ani Syndrome: Pain is produced in the back, vaginal, anorectal, lower abdominal, coccygeal, thigh & pubic regions.
• Dyspareunia: Pain occurs during vaginal penetration/intercourse in the vagina.
• Vaginismus: Vaginal muscles contract involuntarily when vaginal penetration is attempted, causing vaginal pain.
• Anismus: Pain is felt in the anorectal area. Constipation often results.
• Proctalgia Fugax: It produces rectal pain, often intense, of short duration or a strong dull ache of a longer duration. It can awaken you during sleep.
• Coccygodynia: It produces coccygeal (tailbone) and rectal pain.
• Chronic prostatitis: It produces urethral, bladder, testicular, penile, anal, & groin pain.
• Pudendal Neuralgia: It produces localized burning in perineal area, can be one sided.

Guide line of Physiotherapy for chronic pelvic pain & incontinence

Chronic pelvic pain can be due to an imbalance of musculoskeletal and neuromuscular functions. A source of pain can cause increased pelvic muscle spasm which creates more pain resulting in a vicious pain/spasm cycle. The pain felt from a normal touch can be intensified or abnormal i.e. burning, stinging and itching.

Physiotherapy treatment can help to relax the pelvic muscles and to release trigger points often found in these muscles, resulting in a decrease in pain. Desensitization of the tissues assists in returning the neuromuscular pain mechanisms to normal.

Tools for physical treatment in pelvic floor management:

1. Pain management techniques (included relaxation training)
2. Pelvic floor stimulation as a part of facilitation & strengthening
3. Strengthening of pelvic floor & abdominals (Excellent if EMG/US guided)
4. Posture & pelvic control
5. Biofeedback for pelvic floor including internal vaginal or rectal therapy techniques.
6. Teaching bladder &/or bowel management

Patient may need dietary management and dietary assessment also.

Pelvic floor exercises: Pelvic floor exercises are sometimes called Kegel exercises, after the obstetrician who developed them. Another name for the exercises is pelvic floor muscle training (PFMT). Pelvic floor exercises are one of the first-line treatments for stress urinary incontinence (SUI). Pelvic floor exercises make pelvic floor muscle stronger which tighten before pressure increases in abdomen, eg when you sneeze, cough or laugh. In 1998 Norwegian scientists carried out a six-month trial on different treatments for SUI with groups receiving pelvic floor exercises, electrical stimulation, vaginal cones or no treatment. The women who did pelvic floor exercises showed the most improvement.
Despite of training pelvic floor muscle if the muscles are not properly recruited during exercises then training may fail to show the benefits. Hence it is essential to
1. Identify the muscles.
2. Contract the muscles correctly.
3. Use fast and slow contractions
Pelvic floor exercises are best taught by a specialist physiotherapist.

References:
1. Elneil S et al; Best Pract Res Clin Gastroenterol. 2009; 23(4):555-73.
2. Davis K et al; J Adv Nurs. 2003 Sep;43(6):555-68.
3. Prather H et al; Phys Med Rehabil Clin N Am. 2007 Aug;18(3):477-96, ix.






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