INCONTINENCE AND PROLAPSE

INPTA & KPTA 2018 Joint Conference

Melissa McElroy DPT, WCS

Susan Dunn PT, WCS

Pressure Problems

Intra-abdominal pressure > Environmental pressure

= bad things happen

Incontinence (urinary, fecal, flatulence)

Diastasis Rectus Abdominis

Pelvic Organ Prolapse

The internal canister

Diaphragmatic Breathing

Facilitate true piston-ing of core for proper function

Improve core performance

Improve athletic performance

Core Pistoning via Diaphragmatic

Breathing

Failure with the Internal Canister

Low Back Pain

Hip Pain

Pelvic Pain

Incontinence

Prolapse

Diastasis Rectus Abdominis

Loss of strength/power/stability

Continence and

Incontinence

Urologic Function

Renal input into the bladder is 1-14ml/min

Bladder capacity in adult 400-600cc

Voiding Frequency WNL is 5-7x/day and up to 1x/night

40% capacity: First Sensation to void

60-70% capacity: First desire to void

>90% capacity: Strong desire to void

Perception of bladder fullness can be affected by state of mind

Anxiety increases urge

Distraction decreases urge

Urinary Continence

Via Voluntary contraction of the external urethral sphincter and LA muscles

Sphincter constricts the lumen of the urethra while the LA elevates the vagina and

bladder neck causing compression of the urethra.

Comprised of primarily slow twitch muscle

At rest exhibit enough tone to prevent urine into the urethra

Will reflexively contract against a sudden increase in intraabdominal pressure to keep urethral

pressure above that in the bladder

Incontinence

Can be Urinary, Fecal or Gas

Stress Incontinence: Occurs when internal pressure (intra-abdominal) is greater than

external pressures (environmental): cough, sneeze, laugh, transfers

Urge Incontinence: Environmental triggers, Poor bowel or bladder habits can contribute

Note: Kegels aren’t always the answer

Prevalence of UI in YOUR patients

Alappattu M, Neville C, et al. Urinary incontinence symptoms and impact on quality of life

in patients seeking outpatient physical therapy services. Physiotherapy Theory and

Practice. 2016; 32 (2) 107-112.

N=599; 94.7%Fm; Mean age:49.8years

“Have you leaked in the last 3 months (even a small amount)?”

25% had diagnosis of “spine pain”

10% had diagnosis of extremity disorders

17.2% had diagnosis of pelvic pain

44.2% had diagnosis of urinary disorder

Prevalence of UI with female athletes

Study evaluating 144 nulliparous military women using POP-Q and questionnaires. 50% had stage 0 POP, 50% had stage 1-2. 19% reported UI. Running associated with increased risk of UI. (POP stage 0-2 was considered normal) (Larsen WI 2006)

Study of 106 female athletes (basketball and soccer) via questionnaires. UI experienced by 41.5%. Lower body weight and lower BMI risk factor. 95.5% had never discussed symptoms with health care professional.(Jacome et al 2011)

Retrospective study of Competitive (CG) and recreational (RG) trampolinists (n = 305) during 1995-1999 with median age of 21 (18-44) mostly nulliparous via validated questionnaire. CG 57% with UI. RG 46%

with UI. 76% of both groups still had UI at time of questionnaire. Strong predictors inability to interrupt micturition and constipation. (Eliasson K 2008)

Study of 291 elite female athletes with mean age of 22.8 via questionnaire. Women were from a variety

of sports. 51.9% with UI with sport and some with ADL’s. Activity most likely to produce UI was jumping. More UI with training than with competition. (Thyssen HH 2002)

Study included 12 nulliparous women with mild SUI (mean age 25) and randomized into two groups. 90 minute interval training program or 90 minute rest in sitting position. PFM measured pre and post. In young nulliparous women with mild SUI, strenuous physical exercise resulted in lower max voluntary vaginal contraction pressure indicating fatigue. (Ree ML et al 2007)

Diastasis Rectus Abdominis

Diastasis Rectus Abdominis

Separation or stretch of the linea alba that causes inefficiency of

the core complex

NOT JUST ABOUT LOOKS,

(but sometime it is, i.e. The Mommy Pooch)

Long term implications: Chronic back issues, Prolapse,

Hernia, Incontinence

The relationship between incontinence, breathing disorders, gastrointestinal

symptoms, and back pain in women: A longitudinal cohort study.

Smith et al, The clinical journal of pain Vol 30(2), Feb, 2014 PP 162.167.

Subgroups consisted of:

No BP (n = 7259)

No UI (n = 18,480)

No breathing problems (n = 15,096)

No GI symptoms (n = 17623)

These subgroups were analyzed to

determine the relationship between the

development of absent condition and the

presence or development of other

conditions.

Results: Women with pre-existing and/or

newly developed UI (PR: 1.26 to 2.12) and

breathing problems (PR 1.38 to 2.11) had

an increased risk of developing BP. And

women with pre-existing and newly

developed BP were more likely to

develop UI and breathing problems. (PR:

1.18 to 2.44 and 1.53 to 2.62 respectively)

The presence or development of GI

problems was also identified as a risk

factor for development of these

conditions.

Courtesy of Susan Dunn, PT

Case Study

57yo fm comes to PT due to concerns of urinary “leakage” when exercising and playing

with her 4 yo grandson. Also reports urinary incontinence en route to the restroom.

2G2P via vaginal delivery and (+) episiotomy x2

Urinary Frequency: every 1-2 hours during the day, 2x/night

Admits to “Just in Case” voiding

Unable to “stop the flow”

H/o Constipation, but has been paying more attention to diet over the last year or so and

no longer has concerns: Daily BM, on schedule, without straining. #3-4 Bristol Stool Scale

Talks of “belly pooch” that has been present since delivery of first child 30 years ago

Objective Findings

PF MMT: 2/5, but with significant gluteal accessory use and (+) Valsalva

No activation of mm of urogenital triangle

PF endurance: 3 seconds

Gross PF extensibility: WNL

PF descent with cough

Scar tissue noted left of perineal body, with TTP

(+) Diastasis: 2finger width from xiphoid to pubis with moderate depth (past DIP)

Breathing Pattern: Chest breather

Treatment

Instruction in proper Diaphragmatic Breathing

Utilization of RUSI, as well as sEMG for Biofeedback

Manual facilitation for recruitment of muscles of urogenital triangle

Muscle re-education for coordinated activation of PF and TrA

Incorporated new strategies for functional tasks and ADLs

Progressed to higher level activity with balance, running, lifting.

Treatment sessions: 2x/week for 8 weeks (2 appointments missed d/t unforeseen

circumstances)

Outcome

Report of 80% improvement in continence: Can run, play, pick up grandson without UI with anticipated movements

60% improvement if it’s an unexpected reaction (Like keeping him from running into the street)

Proper DB, PF and TrA coordination

Endurance of coordinated activation 10+ seconds

(+) activation of muscles of the urogenital triangle as well as the levator ani

PF ascension with cough

Further progress can be made, but D/C to HEP.

Pelvic Organ Prolapse

Up to 50% over the age of 50

Viscera and the endopelvic fascia

Viscera are often thought of as being supported by the pelvic floor,

but are actually a part of it. Through connections to the pelvis by

such structures as the cardinal and uterosacral ligaments and the

pubocervical fascia the viscera play an important role in forming

the pelvic floor. (DeLancey)

Anterior compartment is divided by the genital tract at the point

where it passes through the urogenital hiatus where the organs pass

thru the pelvic floor.

Endopelvic fascia

Forms a continuous sheet-like mesentery

extending from the uterine artery at the cephalic

aspect, to where the vagina fuses with the

levator ani muscles below.

Parametrium = uterine attachments

Paracolpium = vaginal attachments

Prolapse

When the internal pressures become so great and/or prolonged that supportive structures

fail.

Childbirth, Chronic Constipation/Forcing BMs, Weakness, Poor activation techniques with

simple daily tasks (cough, sneeze, lift, transfers) as well as tasks with higher difficulty (heavy

lifting, athletic endeavors).

TYPES OF PROLAPSE

Cystocele- Bladder

Urethrocele-urethra

Rectocele- rectum

Uterine prolapse-uterus

Enterocele- small bowel

Sigmoidocele-turning inside outward of the descending colon

STAGES OF PROLAPSE

Grade III and Grade IV Prolapse

CONSERVATIVE TREATMENTS

PFMT has been found to be effective in reversing pelvic organ prolapse by one stage.

Studies by Bo in 2010 in the American Journal of obstetrics and Gynecology (n=55) 1X a week for 3 months, 2X a month for 3 months, lifestyle advice

6 months later: 74% reported decreased symptoms, 19% improved by one stage

Stupp et al in 2011 In the International Urogynocology Journal

(n=21) 7 appts over 14 weeks, 12 week HEP with phone calls every 2 weeks from PT, lifestyle advice

61% at least1 stage improvement, at baseline 81% felt a bulge, post-intervention only 9.5%

URETHRAL/ BLADDER DESCENT

SYMPTOMS OF PROLAPSE

Low back pain- caused by stretching of the uterosacral ligament

Hip and lower abdomen pain, leg fatigue

Feeling of “falling out” or heaviness

Cystocele- UI, post void dribble

Urethrocele- unusual spray

Recurrent bladder infections

Constipation

Urinary / Fecal Retention

Penetration can be painful secondary to stresses on the US ligament

THOSE AT RISK FOR PROLAPSE

Those who have had previous hysterectomy- increases risk of incontinence by 40% secondary to scarring urethra, loss of support of bladder, injury to plexus/nerves

Menopause- because estrogen helps to close everything off and fluff the tissues up.

Obesity / weight gain

weight loss (>10%)

Parity, increases with increase in number of vaginal deliveries

History of straining- diarrhea/ constipation lifestyle issues

Those with hypermobility- more correlation of CT laxity than strength of pelvic floor (EDS)

Scars affecting the abdominal wall

OBESITY EFFECT ON PROLAPSE

Kudish et al 2009 in Obsteteric Gynecology published a study about obesity and it’s effect on POP. 10% weight loss did not have a positive impact on POP. They did report an increase in urethrocele folllowing 10% weight loss.

Their conclusions: fat may play a role in pelvic organ support and the damage done by childbirth and obesity might take more time to regress following weight loss or is irreversible.

Clinical implications: avoid weight gain and prevent obesity and pay close attention to patients that present for other diagnoses (ie LBP) where therapy could cause POP if not performed properly.

Pessary

CONSERVATIVE TREATMENT

PT Treatment

Behavioral modifications

Utilizing proper recruitment strategies for control

Breaking old habits

sEMG/Biofeedback/Pressure Perionometry

Electrical Modalities

Resistive training/vaginal and anal weights

TDN

Pessary recommendation

Anal Balloon PFM retraining

POP CASE STUDY

35 y/o female 3G3P 1 C-section and 2 VBAC’s with grade 1 tears

BMI 26

Exercise varies between weight lifting/running/Pilates

Symptoms presented with bulge at introitus with BM, weight lifting, occasionally with Pilates and after running 3-4 miles

Was using a tampon as a pseudo pessary

Early symptoms low back pain, difficulty with complete evacuation BM, “heaviness” vaginally

Diagnosis Grade 2-3 rectocele. Grade 1 cystocele. Grade 1 Uterine Prolapse

Recommendation: PT first. If PT fails then surgery.

Objective Findings

MMT PFM 1/5 with endurance of 2-3 seconds. Used accessory of gluteals/adductors

Poor proprioceptive awareness of TrA and PFM

With activation of abdominals PFM would fail

Neurologic exam WNL

2 finger diastasis recti above and at the umbilicus

Poor recruitment pattern with only anal lift and no superficial urogenital activation

With attempt of abdominal contraction patient would valsalva

Treatment

Manual cuing for activation of the correct firing pattern of the PFM

Correct breathing techniques

Correct isolation of the TrA

All of these were performed individually and then layered on until eventually all three

could be performed together in static neutral spine various positions. Then progressed to

functional movement incorporating multiplane motion laying on IO/EO and RA

Correct BM for effort and consistency and ergonomics

Duration and Outcome

Patient seen 2x a week for 4 weeks and then 1x a week for 4 weeks

PFM strength improved to 2/5 with normal firing pattern and endurance WNL

Able to activate and maintain TrA with ADL’s/IADL’s and Moderate level of exercise

without symptoms. 60-90 minutes of gym activity (weights had to be reduced by 40-

50% of previous workout but will be progressed with HEP. Able to do a 40 minute run

at 10-11 minute pace which was slower than her previous pace but was going to progress

with HEP.

Patient was able to recognize signs of PFM and/or TrA fatigue so as to independently

adjust her HEP

No longer had presentation of POP at introitus.

Thank You!

Time for Lab ………………..

LAB

ISOLATION OF TRANSVERSUS ABDOMINUS

MANUAL CHECK (EXTERNALLY) FOR SIGNS OF POOR INTRA ABDOMINAL PRESSURE LENDING

TOWARD “PRESSURE PROBLEMS”

GUIDED US FOR TrA AND ORGAN DESCENT

References

Smith, M , Russell, A, Hodges, P. The relationship between incontinence, breathing disorders, gastrointestinal symptoms, and back pain in women: A longitudinal cohort study. The Clinical Journal of Pain, 2014, 30(2): 162-167.

Noh, D, Lee,J, You,J. Diaphragm Breathing Movement Measurement using Ultrasound and Radiographic Imaging: A concurrent Validity. Bio-Medical Materials and Engineering 2014, 24: 947.952.

Storheim, K, Bo,K,Pederstad,O, Jahnsen,R. Intra-tester reproducibility of pressure biofeedback in measurement of transversus abdominis function. Physiotherapy Research International, 2002, 7 (4): 239-249.

Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstetrics Gynecol. 1996: 175: 13.

Larsen,W. Pelvic organ prolapse and urinary incontinence in nulliparous women at the United States Military Academy. Int Urogynecol J Pelvic Floor Dysfunct. 2006 May, Vol 17 (3); 208-210

Jacome,C. Aveiro, P, Oliveira D, et al. Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecology and Obstetrics. 2011 Jul: Vol 114 (1).60-63.

Eliasson K, Edner A, Mattsson E. Urinary incontinence in very young and mostly nulliparous women with a history of regular organized high-impact trampoline training: occurrence and risk factors. IntUrogynecol J Pelvic Floor Dysfunction. 2008 May; Vol 19 (5). 687-96.

Thyssen HH, Clevin L, Olesen S, et al. Urinary incontinence in elite female athletes and dancers. IntUrogynecologic J Pelvic Floor Dysfunct 2002. Vol 13 (1). 15-27

Bo, K. Urinary Incontinence, Pelvic Floor Dysfunction, Exercise and Sport. Sports Medicine. 2010: 34 (7) 451-464.

Vitton,V, Baumstarck-Barrau,K, et al. Impact of High-Level Sport Practice on Anal Incontinence in a Healthy Young Female Population. Journal of Women’s Health. 2011 20 (5) 757-763.

Kruger,J, Murphy, B, Heai, SW. Alterations in levator ani morphology in elite nulliparous athletes: A pilot study. Australian and New Zealand Journal of Obstetrics and Gynaecology. 2005: 45 42-47.

Hides, JA, Stanton, WR, Wilson SJ, et al. Retraining motor control of abdominal muscles among elite cricketers with low back pain. Scand J Med Sci Sports. 2010: 20 834-842,

Tsao,H, Hodges, P, Galea, M. How fast are feedforward postural adjustments of the abdominal muscles? Behavioral Neuroscience. 2009, vol 123. No 3. 687-693.

Tsao, H. Hodges, P.W. Immediate changes in feedforward postural adjustments following voluntary motor training. Exp. Brain Res. 2007 181 (4) 537.

Tsao,H. Hodges, P.W. Persistence of improvements in postural strategies following motor control training in people with recurrent low back pain. J. Electromyography Kinesiology. 2008 18 (4) 559.

Tsao H. Galea, M.P. Hodges P.W. Reorganization of the motor cortex is associated with postural control deficits in recurrent low back pain. Brain 2008 131 (8), 2161.

Lee M. Romer and Michael I. Polkey, Exercise-induced respiratory muscle fatigue: implications for performance, Journal of Applied Physiology March 2008 vol. 104 no. 3 879-888

Illi, Sabine K; Held, Ulrike; Frank, Irène; Spengler, Christina M (2012). Effect of respiratory muscle training on exercise performance in healthy individuals: a systematic review and meta-analysis. Sports Medicine, 42(8):707-724

Poswiata, A, Socha T, Opara J. Prevalence of Stress Urinary Incontinence in elite female endurance athletes. Journal of Human Kinetics. 2014 vol 44.91-96.

Ree ML, Nygaard I, Bo K. Muscular fatigue in the pelvic floor muscles after strenuous physical activity. ActaObstetricia et Gynecologica. 2007: 86: 870-876.

Clemente CD; Gray’s Anatomy. ED 30. Lea & Febiger, Philadelphia, 1985(pp 490-491).

Lee,D, Lee LJ. The Pelvic Girdle. An Integration of Clinical Expertise and Research, 4th edition. Churchill Livingstone, Elsevier. 2011

Van Dieen, JH, 2007. Low-back pain and motor behavior: contingent adaptations, a common goal. In: Proceedings from the Sixth Interdisciplinary World Congress on Low Back and Pelvic Pain. Barcelona, November 7-10, p3.

Meyers, WC, Kahan, DM, Joseph,T, et al. Current Analysis of Women Athletes with Pelvic Pain. Medicine & Science in Sports & Exercise. 2011: 1387-1393

Bo,K, Backe-Hansen,KL. Do Elite Athletes experience low back, pelvic girdle and pelvic floor

complaints during and after pregnancy?. Scand J Med Sci Sports. 2007: 17 480-487.

Goldstick O, Constantine,N. Urinary incontinence in physically active women and female athletes.

Brittish Journal of Sports Medicine. 2014: 48 296-298.

Hamaoui A, Hudson, A, et al. Postural Disturbances resulting from unilateral and bilateral diaphragm

contractions: a phrenic nerve stimulation study. Journal of Applied Physiology. 2014 Vol 117, 8 825-

832.

Gething A.D, Williams M, Davies B. Inspiratory resistive loading improves cycling capacity: a placebo

controlled trial. Br J Sports Med. 2004 Dec;38(6):730-6.

Alappattu M, Neville C, et al. Urinary incontinence symptoms and impact on quality of life in patients

seeking outpatient physical therapy services. Physiotherapy Theory and Practice. 2016; 32 (2) 107-112.