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THE PELVIC FLOOR: ANATOMY, FUNCTION AND CLINICAL INTEGRATION

THE PELVIC FLOOR: ANATOMY, FUNCTION AND CLINICAL INTEGRATION. Heather Grewar BScPT, MScPT, FCAMT core-connections.ca heather@core-connections.ca. OBJECTIVES. To review the anatomy and function of the female pelvic floor To review the pathophysiology of stress urinary

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THE PELVIC FLOOR: ANATOMY, FUNCTION AND CLINICAL INTEGRATION

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  1. THE PELVIC FLOOR: ANATOMY, FUNCTION AND CLINICAL INTEGRATION Heather Grewar BScPT, MScPT, FCAMT core-connections.ca heather@core-connections.ca

  2. OBJECTIVES • To review the anatomy and function of the female pelvic floor • To review the pathophysiology of stress urinary incontinence (SUI) • To review the evidence for pelvic floor physiotherapy in the management of SUI • To consider the clinical management of SUI

  3. ANATOMY

  4. THE FEMALE PELVIS Petros 2004

  5. THE ENDOPELVIC FASCIA Netter 2006

  6. PR U PC V ATFP R OI IC CG P C THE LEVATOR ANI MUSCLES U urethra V vagina R rectum C coccyx PR puborectalis PC pubococcygeus IC iliococcygeus CG coccygeus P piriformis ATFP arcus tendineus fascia pelvis OI obturator internus Netter 2006

  7. PUBORECTALIS- A CLOSER LOOK Dietz 2009

  8. URETHRAL SUPPORTS DeLancey 1988

  9. THE URETHRAL SPHINCTER DeLancey 1988

  10. INNERVATION Thor & de Groat 2010

  11. MICTURITION: AUTONOMIC CONTROL Parasympathetic = Pee (bladder contraction) Sympathetic = Storage (bladder inhibition)

  12. MICTURITION: SENSORY CONTROL

  13. MICTURITION: CONTROL FROM HIGHER CENTRES

  14. PELVIC FLOOR MUSCLE FUNCTION

  15. pelvic organ support urinary continence breathing fecal continence lumbar stability voiding pelvic stability sexual function childbirth THE PELVIC FLOOR MUSCLES- AN EXTRAORDINARY MULTI-TASKER!

  16. HOW DO THE PFM CONTRIBUTE TO URINARY CONTINENCE? • urethral support (Ashton Miller & DeLancey, 2001) DeLancey 1988

  17. stabilization of the • bladder neck • (Peschers et al., 2001) • increased intraurethral • pressure • (Thind et al., 1990) DeLancey 1990

  18. HOW DO THE PFM CONTRIBUTE TO LUMBAR STABILITY? • The PFM play a role in: • increasing the IAP (Hemborg, 1985) • increasing the thoracolumbar fascia tension (Tesh, 1984) Hodges 2006

  19. anticipatory postural adjustments Hodges et al. 2007

  20. HOW DO THE PFM CONTRIBUTE TO PELVIC STABILITY? • increase SIJ stiffness • sacral counternutation • (Pool-Goodzwaard et al. 2004) Lee 2011

  21. HOW DO THE PFM CONTRIBUTE TO BREATHING? • modulation of PFM during breathing • increased PFM activity during expiration Hodges et al. 2007

  22. THEORY: SYNERGIES OF THE ABDOMINAL CANISTER Talasz et al., 2010

  23. postural control breathing continence COORDINATING AND COMPETING FUNCTIONS Smith et al., 2006

  24. PATHOPHYSIOLOGY OF STRESS URINARY INCONTINENCE

  25. STRESS URINARY INCONTINENCE “the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing” Abrams et al., 2010

  26. PATHOPHYSIOLOGY OF SUI • insufficient urethral • support • increased compliance of • the supportive layer Netter 2006

  27. ETIOLOGY parity childbirth damage to PFM, nerves and fascial supports Chaliha 2009

  28. DOES AVULSION OF THE PUBORECTALIS AFFECT SUI? Dietz et al., 2009

  29. IS PREGNANCY A FACTOR? Prevalence of incontinence (EPINCONT study): Nulliparous group: 10.1% Cesarean group: 15.9% Vaginal group: 21.0% (Rortveit et al. 2003)

  30. IS NERVE INJURY A FACTOR? • compression • denervation Thor & de Groat 2010

  31. THE INTEGRATED CONTINENCE SYSTEM Grewar & McLean, 2008

  32. MODIFIABLE FACTORS ASSOCIATED WITH SUI: MOTOR CONTROL pelvic floor muscles abdominal muscles diaphragm

  33. MUSCULOSKELETAL FACTORS ie. PFM strength BEHAVIOURAL FACTORS ie. increased BMI (Wing et al. 2010)

  34. EFFICACY OF PELVIC FLOOR PHYSIO Level A evidence that PFM training can effectively treat SUI (Wilson et al., 2005) with cure rates of 44-80% in the adult female population (Hay-Smith et al. 2007; Bo, 2007)

  35. PFM training is recommended as a first-line treatment for SUI(4th International Consultation on Incontinence, 2010)

  36. WHAT IS THE RATIONALE FOR PELVIC FLOOR PHYSIO? • elevation of the resting position of the bladder and rectum • increased pelvic floor thickness • reduced hiatal area at maximum Valsalva Brækkenet al. 2010

  37. GOALS OF PFM TRAINING FOR SUI BLADDER NECK ELEVATION! bladder neck elevation occurs with PFM and TA recruitment IO recruitment does not elevate the bladder neck SUP INF (b) Junginger et al. 2010 Lee, 2004

  38. CLINICAL INTEGRATION

  39. KEY COMPLAINTS SUI with coughing, jogging, sneezing and jumping avoiding ability to run and dance restricting fluids protective padding nocturia

  40. KEY OBJECTIVE FINDINGS: Lumbo-pelvic hip and thorax abdominal bracing reduced rib cage wiggle buttocks clenching upper chest breathing pattern reduced lumbar lordosis absent TA co-contraction stretched and decreased lower abdominal tone

  41. KEY OBJECTIVE FINDINGS: Internal pelvic exam PFM contractility (MOS): 3/5 PFM hypertonus absent PFM contraction during coughing MODIFIED OXFORD SCALE (Laycock 1994) 1 Flicker 2 Weak 3 Squeeze and lift 4 Moderate resistance 5 Maximum resistance

  42. TRANSLABIAL ULTRASOUND: Maximum voluntary PFM contraction

  43. TRANSVAGINAL ULTRASOUND: Urethral cross-sectional area

  44. TRANSLABIAL ULTRASOUND: Real-time maximum valsalva

  45. TRANSLABIAL ULTRASOUND: Real-time maximum cough

  46. PHYSIOTHERAPY TREATMENT Education anatomy pathophysiology efficacy of PF physiotherapy bladder training Manual pelvic floor muscle techniques proprioception neuromuscular recruitment decrease hypertonus

  47. HOME EXERCISES PFM exercises maximum contractions motor control exercises functional integration submaximal TA co-contraction thoracic mobilization exercises body awareness diaphragmatic breathing without abdominal bracing strengthening of the gluteals and lower abdominals

  48. RESULTS

  49. RESULTS no signs of global rigidity diaphragmatic breathing improved lumbar lordosis in sitting and standing TA co-contraction improved lower abdominal tonus PFM contractility (MOS): 4+/5 PFM tonus: within normal precontraction with coughing

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