Pelvic Floor InsufficiencyJEANETTE BURNEY, PT, MSPT, CMPT, RYT

BOULDER COMMUNITY HEALTH OUTPATIENT REHABILITATION SERVICES

303-415-4400

Objectives

• Review the function of the pelvic floor muscles

• Discuss the prevalence of urinary incontinence through women’s lifespan

• Discuss the evidence supporting why and how physical therapy can help

The Pelvic Floor•Pelvic floor muscles and fascia are involved in multiple functions including continence, pelvic organ support, sexual function, respiration and containment of intra-abdominal pressure, and also to some extent range of motion of the hip joint and projected pain to the lower limbs. (Carriere & Markel-Feldt, 2006; Chaitow & Jones, 2012; Wise & Anderson, 2012; Verral et al., 2007)

•Continence requires the complex coordination of bladder, urethra, pelvic floor muscles and supporting ligaments. Normal pelvic floor contraction exerts a pull on the anterior vaginal wall toward the pubic symphysis to close the urethra and prevent urine leakage. (Delancey et al., 1994)

•Postural changes from misguided exercises, pregnancy, childbirth, obesity and changes in physiological curves of the spine may modify the structure of the pelvic basin thereby leading to urinary incontinence. (Fozzatti et al., 2010).

Prevalence of Pelvic Floor Issues•1 in 4 US women report moderate to severe symptoms of urinary incontinence, pelvic organ prolapse or fecal incontinence (Nygaard & Barber, 2008)

•Pelvic floor disorders increase with age (Nygaard & Barber, 2008)

•There appears to be a correlation in women exceeding 7.5 hours of strenuous activity per week during the teen years. (Nygaard, 2015)

•Almost every aspect of urinary incontinence was present in nulliparous women of all ages and prevalence increased with advancing age between 25-64 years. (Othman et al. 2017)

Incontinence in Teens•Elite trampolinists (mean age 15 years) 80% reported urinary leakage, 28% with perineometry showing good pelvic floor strength. (Eliasson et al., 2002)

•Carls et al. 2007 offered a small study. They found that greater 25% of female high school and collegiate athletes surveyed had stress incontinence with their sport.

•90% had not told anyone about their symptoms, nor had they heard of pelvic floor exercises.

•But say they would have performed the exercises if they knew how.

Incontinence in Teens•Incontinence correlates to:• body mass index

• self-reported psychological disorders

• history of constipation

• enuresis after age 5. (Bardino et al., 2015)

•Urge and stress incontinence was significantly more common in athletes with eating disorders (Bo & Borgen, 2001)

Incontinence in Athletes•Urinary incontinence during exercise is common and is more prevalent in women during high impact sports Nygaard et al (2016)

•Nulliparous women (mean age 19.9) reported incontinence with their sport. Gymnastics (67%), basketball (66%), tennis (50%), field hockey (42%), track (29%), swimming (10%), volleyball (9%), softball (6%) and golf (0%). (Nygaard et al., 1994)

•Incontinence was first noted during their sport while in high school and junior high. (Nygaard et al., 1994)

Incontinence and Athletes•Urinary incontinence is common among elite athletes and dancers (mean age 22.8 years), particularly during training, less in competition and daily life (Thyssen et al. 2002)• 51.9% had urinary incontinence with their sport

• 42% had urinary incontinence during daily life.

•Cross-sectional studies have shown that involvement in high-level sports is a significant risk factor for urinary and anal (loss of gas) incontinence and sexual symptoms (Almeida et al., 2016, Goldstick & Constantini, 2014, Vitton et al., 2011, respectively)

Incontinence in Pregnant Women•Incontinence, especially stress incontinence, is a common condition during pregnancy (Wesnes et al., 2010, Brown et al., 2010, Sangsawang et al., 2013)

•Positive correlation to the number of vaginal deliveries. (Nygaard et al. 1990)

•As a result women stop exercising, change the way they exercise or wear pads during exercise (Nygaard et al., 1990 & 2005)

Incontinence and Menopause•Urinary Incontinence during menopause appears due to mechanical factors rather than menopause transition. (Sherburn et al., 2001)• BMI

• History of gynecological surgery

• History of urinary tract infection

• Diarrhea or constipation

• 3 or more children

Incontinence, the Athlete and Pelvic Floor Muscle Training (PFMT)

•PFMT has been shown to improve strength and reduced frequency and amount of urinary incontinence (Da Roza et al., 2012, Hay-Smith et al., 2001, Bo, 2012, Sherburn et al, 2011)

•PFMT reduced urinary leakage during jumping and running (Bo et al. 1999)

•Combined PFMT with biofeedback demonstrated a cure rate of 67% during high impact sports. (Morkved et al. 2002)

Incontinence, the Athlete and Pelvic Floor Muscle Training (PFMT)•Instruction in proper breathing techniques to coordinate diaphragmatic and pelvic floor muscle contractions and modifications to the way athletes land and run can reduce repetitive stress to pelvic floor muscles and reduce incontinence during sport (Prather et al., 2009; Luginbuehl et al., 2016)

•Manual therapy of myofascial trigger points is an effective treatment method to decrease hypertonic pelvic floor and improve coordination of the pelvic floor muscle contraction. (FitzGerald et al., 2012)

Incontinence• Is seen across the

lifespan

• It is treatable

• Please ask the question

Thank You

References•Almeida MB, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AM, Figueiredo EM. Urinary incontinence and other pelvic floor dysfunctions in

female athletes in Brazil:A cross-sectional study. Scand J Med Sci Sports. 2016 Sep;26(9):1109-16.

•Bardino M et al. J Pediatr Adloesc Gynecol. 2015. Dec;28(6):462-70.

•Bo K, Talseth T, Holme I. Single blind, randomized controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. Bmj. 1999;318(7182):487-493.

•Bo K, Borgen S. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc. 2001. Nov;33(11):1797-802.

•Bo K. Pelvic floor muscle training in treatment of femail stress urinary incontinence, pelvic organ prolapse and sexual dysfunction. World J Urol. 2012 Aug;30(4):437-43.

•Brown SJ, Donath S, MacArthur C, McDonald EA, Kreastev AH. Urinary incontinence in nulliparour women before and during pregnancy: prevalence, incidence, and associated risk factors. Int Urogynecol J. 2010;21:193-202.

• Carriere B, Markel-Feldt C. 2006. The pelvic floor. Georg Thieme Verlag, Stuttgart.

• Carls C. The Prevalence of stress urinary incontinence in high school and college-age female athletes in the Midwest: implications for education and prevention. Urol Nurs. 2007 Feb;27(1):21-4, 39.

References• Chaitow L, Jones R. 2012 Chronic pelvic pain and dysfunction, Practical Physical Medicine. Churchill Lingstone Elsevier, China.

•Da Roza T, Poli de Araujo M, Viana R, Viana S, Jorge RN, Bo K, Mascarenhas T. Pelvic floor muscle training to improve urinary incontinence in young, nulliparous sport students: a pilot study. Int Urogynecol J. 2012 23:1069-1073.

•Delancey J. Structural support of the urethra as it relates to stress incontinence: the Harmmock hypothesis. Am J Obstet Gynecol170:1713-1723.

• Luginbuehl H, Naeff R, Zahnd A, et al. Pelvic floor muscle electromyography during different running speeds: an exploratory and reliabilitystudy. Arch Gynecol Obstet. 2016;293(1):117-124.

• Eliasson K, Larsson T, Mattsson E. Prevalance of stress incontinence in nulliparous elite trampolinists. Scand J Med Sci Sports. 2002 Apr;1292);106-10.

• Fazzotti C, Hermann V, Palma T, Riccettto CLZ, Palma P. Global postural re-education: alternative approach for stress urinary incontinence? Eur J Obstet Gynecol 152:218-224.

• Fitzgeral MP, Payne CK, Lukaca ES, Yang CC, Peters KM, Chai TC, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012 Jun;187(6):2113-8.

•Goldstick O, Constantini N. Uninary incontinence in physically active women and female athletes. Br J Sports Med. 2014 Feb;48(4):296-8.

•Hay-Smith E, Bo K, Berghmans L, et al. Pelvic floor muscle training for urinary incontinence in women. Available in TheCochrane Library [database on disk and CD ROM]. Updated quarterly. The Cochrane Collaboration; issue 3. Oxford: update Software 2001.

References•Morkved S, Bo K, Fjortoft T. Effect of adding biofeedback to pelvic floor muscle training to treat urodynamic stress incontinence.

Obstet Gynecol. 2002;100(4):730-739.

•Nygaard IE, DeLancey JO, Arnsdorf L, Murphy E. Exercise and Incontinence. Obstet Gynecol. May 1990; 75(5):848-851.

•Nygaard IE, Thompson FL, Svengalis S, Albright JP. Urinary Incontinence in Elite Nulliparous Athletes. Obstet Gynecol. 1994 84(2):183-187

•Nygaard IE & Barber M. Prevalence of Symptomatic Pelvic Floor Disorders in US Women. JAMA. 2008 September 17; 300(11):1311-1316.

•Nygaard IE, Shaw JM, Bardsley T, Egger, M. Lifetime physical activity and female stress urinary incontinence. Am J Obstet Gynecol July 2015; 40.e1-40.e10.

•Nygaard IE, Shaw JM. Physical activity and the pelvic floor. Am J Obstet Gynecol. 2016 February; 214(2):164-171.

•Ottman, JA, Sigvard A, Milsom I, Gyhagen M. Urinary incontinence in nulliparous women aged 25-64 years: a national survey. Am J ObstetGynecol. 2017 Feb;216(2):149.e1-149.e11.

•Prather H, DugnaS, Fitzgerald C, et al. Review of anatomy, evaluation, and treatment of musculoskeletal pelvic floor pain in women. PM & R; the journal of injury, function, and rehabilitation. 20009;1(4):346-358.

• Sangsawang B, SangsaWnag N. Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. Int Urogynecol J. 2013 Jun;24(6):901-12.

References• Sherburn M, Bird M, Carey M, Bo K., Galea MP. Incontinence improves in older women after intensive pelvic floor muscle training: an

assessor-blinded randomized controlled trial. Neurourol Urodyn. 2011 Mar;30(3):317-24.

• Sherburn M , Guthrie JR, Dudley EC, O’Connell HE, Dennerstein L. Is Incontinence Associated with Menopause? Obstet & Gynecol. 2001 Oct;98(4):628-33.

• Thyssen JJ, Clevin L, Osesen S, Lose G. Urinary incontinence in elite female atheltes and dancers. Int Urogynecol J Pelvic Floor Dysfunction. 2002;13(1):15-7.

•Verra GM, Slavotinek JP, Barnes PG, Esterman A, Oakeshott RD, Spriggins AG. 2007. Hip joint range of motion restriction precedes athletic chronic groin injury. J. Sci. Med. Sprot 10, 463-466.

•Vitton V, Baumstarck-BarrauK., Brardjanian S, Caballe I, Bouvier M, Grimaud JC. Impact of high-level sport practice on anal incontinence in a healthy young female population. J Women’s Health (Larchmt). 2011 May;20(5):757-63.

•Wesnes SL, Rortveit G, Bo K, Hunskaar S. Urninary incontinence during pregnancy. Obstet Bynecol. 2007 Apr;109(4):922-8.

•Wise D, Anderson R. 2012. Headache in the Pelvis – A new Understanding and Treatment of Chronic Pelvic Pain Syndromes, Revised expanded sixth ed. National Center for Pelvic Pain Research, California.