Pelvic floor physical therapy

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Pelvic floor physical therapy (PFPT) is a specialty area within physical therapy focusing on the rehabilitation of muscles in the pelvic floor after injury or dysfunction. It can be used to address issues such as muscle weakness or tightness post childbirth, dyspareunia, vaginismus, vulvodynia, constipation, fecal or urinary incontinence, pelvic organ prolapse, and sexual dysfunction. Licensed physical therapists with specialized pelvic floor physical therapy training address dysfunction in individuals across the gender and sex spectra, though PFPT is often associated with women's health for its heavy focus on addressing issues of pelvic trauma after childbirth. [1]

Contents

Evaluating pelvic floor function

Pelvic floor physical therapists perform an initial examination to determine the likely underlying muscular or nerve dysfunction causing a patient's symptoms. Therapists will manually examine muscles of the pelvic floor both externally and internally, palpating to locate trigger points of pain and guide patients to manually tighten or loosen muscles to assess tone and function. During this initial exam, PFPT must isolate the cause of dysfunction to one of two broader categories: low-tone or high-tone disorders. Low-tone disorders, such as stress-urinary incontinence, overactive bladder, pelvic organ prolapse, and anal incontinence, are caused by weakened muscles in the pelvic floor. High-tone disorders, such as pelvic floor myofascial pain, dyspareunia, vaginismus, and vulvodynia, are caused by overly strong or active muscles in the pelvic floor. While low-tone disorders can be addressed through exercises such as Kegels meant to strengthen the pelvic floor, high-tone disorders can be worsened by such exercises and must be addressed through other means such as biofeedback or dilation training. [1]

Pelvic floor disorders treated with PFPT

Chronic pelvic pain

Chronic pelvic pain (CPP) is an umbrella category of dysfunctions of the pelvic region associated with long-term discomfort, and includes diagnoses such as dyspareunia, vaginismus, vulvodynia or vestibulodynia, endometriosis, interstitial cystitis, chronic nonbacterial prostatitis, chronic proctalgia, piriformis syndrome, hip dysfunction, and pudendal neuralgia. Around 1 in 4 women and between 2% and 10% of men experience chronic pelvic pain, making CPP of high clinical relevance. Just as chronic pain is conceptualized elsewhere in the body, CPP is considered to have many underlying and interconnected causes, and therefore treatment is often interdisciplinary. [2] PFPT is considered to be a key element in the treatment of CPP, working to reduce pain or enhance function by normalizing pelvic floor muscle tone and endurance. [1]

Sexual dysfunction

Many disorders that cause chronic pelvic pain (CPP), such as dyspareunia and vaginismus, are associated with discomfort during intercourse. As a result, the treatment of CPP with pelvic floor physical therapy is often related to the treatment of sexual dysfunction. [2] In terms of dyspareunia, patients often suffer from overactive pelvic floor muscles (PFMs) that are also weak in strength. Pelvic floor physical therapy can help to both strengthen the PFMs as well as reduce the muscles’ resting muscle tone. [3] Pelvici floor physical therapy has also been shown to be effective in the treatment of erectile dysfunction (ED), providing a treatment avenue with less risk of complication than commonly prescribed medications or surgical interventions. Multiple randomized controlled trials have seen a range from modest to significant success with pelvic floor physical therapy treatments for ED. Research has also shown success in treating premature ejaculation with pelvic floor physical therapy, although the underlying reasons for this success are unknown. It is possible that PFPT helps address disorders such as ED and premature ejaculation simply because it enhances awareness and control over individual muscles or muscle groups in the pelvic region. [4]

Urinary/fecal problems

Passive muscular support and voluntary/reflexive contractions of the pelvic floor are important for maintaining continence during bouts of increase in intra-abdominal pressure like coughing, sneezing, etc. [5] Large, systematic reviews have shown that stress incontinence can be treated with high success using PFPT. The treatment of overactive bladder syndrome, a more complex disorder characterized by a larger range of symptoms, as well as fecal incontinence with PFPT has shown more modest success. A pelvic floor physiotherapist will advise on simple exercises focused on the pelvic floor muscles and core muscles which help to strengthen those muscles and improve bladder control. For patients who have urinary incontinence along with some other health condition, such as interstitial cystitis or scarring of pelvic muscles after delivery, a physiotherapist will introduce a customized treatment plan to solve bladder problems, as well as offer relief from the pain and discomfort associated with the disease. [6] There are also many benefits associated with pelvic floor physical therapy specifically in postpartum women including increasing muscle strength and endurance on top of decreasing the rate of urinary incontinence. [7] More research is needed to determine the best treatments within PFPT and/or interdisciplinary approaches to treatments for these disorders. Higher than average pelvic floor physical tone is thought to be a component of constipation, anismus, and irritable bowel syndrome (IBS). In addition, research shows that it is more beneficial for women to train for longer periods (>12 weeks or ≥ 24 sessions) with shorter sessions (10–45 minutes). Those who accumulate a greater number of shorter sessions achieve a greater decrease in urine loss than those who participate in smaller number of longer sessions. [8] Because these disorders can be of unknown origin or may be caused by multiple lifestyles, genetic, and physical factors, PFPT may only be effective for some individuals with these conditions or may be most effective as part of a larger treatment plan. [4]

Benefits of prenatal and postpartum pelvic floor PT

Women suffering from pelvic floor dysfunction and urinary incontinence due to "pregnancy and vaginal delivery have independently been proved to be the risk factors for the development of severe urinary incontinent as they could obviously weaken the pelvic floor muscle (PFM) strength". [9] About 1/3 of women post-childbirth struggle with urinary incontinence, [10] and women who attend PT can decrease the likelihood of developing urinary incontinence. However, this study concluded that women who had already experienced urinary incontinence in the early stages of pregnancy may not decrease urinary incontinence when using late-pregnancy pelvic floor PT. [10] Therefore, it may be advisable to seek out a pelvic floor PT in the early stages of pregnancy, before any issues one may encounter. Postpartum women, whether they delivered via cesarean section or vaginal birth, can significantly benefit from PFPT, because "women after childbirth, regardless of the type of delivery, [are at a] high risk of new and prolonged signs of pre-existing signs of pelvic floor muscle dysfunction". [11] C-sections are becoming more prevalent and those who received PT afterward improved pelvic floor muscle tone and strength and positively impacted their daily function and sexual activity at 6 months postpartum. [11] Various modalities can be done alongside typical physical therapy treatment for pelvic floor dysfunction and urinary incontinence, "such as biofeedback, electrical stimulation, or multi‐modal exercise programmes". [10] [12]

Related Research Articles

<span class="mw-page-title-main">Interstitial cystitis</span> Medical condition

Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is chronic pain in the bladder and pelvic floor of unknown cause. It is the urologic chronic pelvic pain syndrome of women. Symptoms include feeling the need to urinate right away, needing to urinate often, and pain with sex. IC/BPS is associated with depression and lower quality of life. Many of those affected also have irritable bowel syndrome and fibromyalgia.

Vulvodynia is a chronic pain condition that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months.

<span class="mw-page-title-main">Urinary incontinence</span> Uncontrolled leakage of urine

Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.

<span class="mw-page-title-main">Levator ani</span> Broad, thin muscle group, situated on either side of the pelvis

The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis.

<span class="mw-page-title-main">Vaginismus</span> Involuntary muscle spasm that interferes with vaginal penetration

Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. This often results in pain with attempts at sex. Often it begins when vaginal intercourse is first attempted. Vaginismus may be considered an older term for pelvic floor dysfunction.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term dyspareunia covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

<span class="mw-page-title-main">Kegel exercise</span> Pelvic floor exercise

Kegel exercise, also known as pelvic floor exercise, involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". The exercise can be performed many times a day, for several minutes at a time but takes one to three months to begin to have an effect.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

<span class="mw-page-title-main">Pelvic floor</span> Anatomical structure

The pelvic floor or pelvic diaphragm is an anatomical location in the human body, which has an important role in urinary and anal continence, sexual function and support of the pelvic organs. The pelvic floor includes muscles, both skeletal and smooth, ligaments and fascia. and separates between the pelvic cavity from above, and the perineum from below. It is formed by the levator ani muscle and coccygeus muscle, and associated connective tissue.

<span class="mw-page-title-main">Pelvic floor dysfunction</span> Medical condition

Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarrassment and stigma.

Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.

<span class="mw-page-title-main">Cystocele</span> Medical condition

The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.

<span class="mw-page-title-main">Stress incontinence</span> Form of urinary incontinence from an inadequate closure of the bladder

Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the bladder outlet by the urethral sphincter.

Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis, is vulvodynia localized to the vulvar vestibule. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Until recently, "vulvar vestibulitis" was the term used for localized vulvar pain: the suffix "-itis" would normally imply inflammation, but in fact there is little evidence to support an inflammatory process in the condition. "Vestibulodynia" is the term now recognized by the International Society for the Study of Vulvovaginal Disease.

Sacral nerve stimulation, also termed sacral neuromodulation, is a type of medical electrical stimulation therapy.

<span class="mw-page-title-main">Chronic prostatitis/chronic pelvic pain syndrome</span> Medical condition

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), previously known as chronic nonbacterial prostatitis, is long-term pelvic pain and lower urinary tract symptoms (LUTS) without evidence of a bacterial infection. It affects about 2–6% of men. Together with IC/BPS, it makes up urologic chronic pelvic pain syndrome (UCPPS).

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

National Association for Continence (NAFC) is a national, private, non-profit organization dedicated to improving the quality of life of people with incontinence, voiding dysfunction, and related pelvic floor disorders.

Urethral hypermobility is a condition of excessive movement of the female urethra due to a weakened urogenital diaphragm. It describes the instability of the urethra in relation to the pelvic floor muscles. A weakened pelvic floor muscle fails to adequately close the urethra and hence can cause stress urinary incontinence. This condition may be diagnosed by primary care providers or urologists. Treatment may include pelvic floor muscle exercises, surgery, or minimally invasive procedures.

References

  1. 1 2 3 Wallace, Shannon L.; Miller, Lucia D.; Mishra, Kavita (December 2019). "Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women". Current Opinion in Obstetrics & Gynecology. 31 (6): 485–493. doi:10.1097/GCO.0000000000000584. ISSN   1040-872X. PMID   31609735. S2CID   204703488.
  2. 1 2 Bradley, Michelle H.; Rawlins, Ashley; Brinker, C. Anna (August 2017). "Physical Therapy Treatment of Pelvic Pain". Physical Medicine and Rehabilitation Clinics of North America. 28 (3): 589–601. doi:10.1016/j.pmr.2017.03.009. PMID   28676366.
  3. ↑ Ghaderi, Fariba; Bastani, Parvin; Hajebrahimi, Sakineh; Jafarabadi, Mohammad Asghari; Berghmans, Bary (November 2019). "Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial". International Urogynecology Journal. 30 (11): 1849–1855. doi:10.1007/s00192-019-04019-3. ISSN   0937-3462. PMC   6834927 . PMID   31286158.
  4. 1 2 Rosenbaum, Talli Yehuda (January 2007). "Reviews: Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the Role of Pelvic Floor Rehabilitation in Treatment: A Literature Review". The Journal of Sexual Medicine. 4 (1): 4–13. doi:10.1111/j.1743-6109.2006.00393.x. PMID   17233772.
  5. ↑ Wente, Karla; Dolan, Christina (March 2018). "Aging and the Pelvic Floor". Current Geriatrics Reports. 7 (1): 49–58. doi:10.1007/s13670-018-0238-0. ISSN   2196-7865.
  6. ↑ Physiomobility (2017-05-26). "Urinary incontinence and the role of pelvic health physiotherapist". Physiomobility. Retrieved 2021-04-26.
  7. ↑ Sigurdardottir, Thorgerdur; Steingrimsdottir, Thora; Geirsson, Reynir T.; Halldorsson, Thorhallur I.; Aspelund, Thor; Bø, Kari (March 2020). "Can postpartum pelvic floor muscle training reduce urinary and anal incontinence?: An assessor-blinded randomized controlled trial". American Journal of Obstetrics and Gynecology. 222 (3): 247.e1–247.e8. doi: 10.1016/j.ajog.2019.09.011 . ISSN   1097-6868. PMID   31526791. S2CID   202674386.
  8. ↑ García-Sánchez, Esther; Ávila-Gandía, Vicente; López-Román, Javier; Martínez-Rodríguez, Alejandro; Rubio-Arias, Jacobo Á (2019-11-08). "What Pelvic Floor Muscle Training Load is Optimal in Minimizing Urine Loss in Women with Stress Urinary Incontinence? A Systematic Review and Meta-Analysis". International Journal of Environmental Research and Public Health. 16 (22): E4358. doi: 10.3390/ijerph16224358 . ISSN   1660-4601. PMC   6887794 . PMID   31717291.
  9. ↑ Zhu, Hongmei; Zhang, Di; Gao, Lei; Liu, Huixin; Di, Yonghui; Xie, Bing; Jiao, Wei; Sun, Xiuli (January 2022). "Effect of Pelvic Floor Workout on Pelvic Floor Muscle Function Recovery of Postpartum Women: Protocol for a Randomized Controlled Trial". International Journal of Environmental Research and Public Health. 19 (17): 11073. doi: 10.3390/ijerph191711073 . ISSN   1660-4601. PMC   9517758 . PMID   36078788.
  10. 1 2 3 Woodley, Stephanie J.; Boyle, Rhianon; Cody, June D.; Mørkved, Siv; Hay-Smith, E. Jean C. (2017-12-22). "Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women". The Cochrane Database of Systematic Reviews. 12 (12): CD007471. doi:10.1002/14651858.CD007471.pub3. ISSN   1469-493X. PMC   6486304 . PMID   29271473.
  11. 1 2 Kuravska, Yuliia; Aravitska, Mariia; Churpiy, Ihor; Fedorivska, Lesia; Yaniv, Olesia (March 2022). "Efficacy of correction of pelvic floor muscle dysfunction using physical therapy in women who underwent Caesarean section". Journal of Physical Education and Sport. 22 (3): 715–723. doi: 10.7752/jpes.2022.03090 . ProQuest   2648269295.
  12. ↑ "What is pelvic floor therapy and do I need it?". Worth It PT: Pelvic Health & Physical Therapy. 9 August 2022.
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