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18.2: The Scope of Physiotherapy and Aims of Pelvic Floor Rehabilitation

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    A broad range of complaints and conditions occur as a result of pelvic floor dysfunction and may therefore respond to pelvic floor rehabilitation.

    • Bladder dysfunction:
      • stress incontinence (SI)
      • overactive bladder (OAB)
      • frequency/urgency, nocturia
      • post void residuals (PVR) and other voiding dysfunction
      • hesitancy, interstitial cystitis
      • leaking with intercourse, recurrent urinary tract infections (RUTIs)
    • Sexual dysfunction:
      • pain on penetration
      • dyspareunia
      • post-coital pain
      • orgasmic disorder
      • vaginismus
    • Bowel dysfunction:
      • faecal incontinence (FI)
      • flatus, urgency
      • incomplete evacuation
      • constipation
      • disordered ano-rectal function
      • anismus
    • Pelvic organ prolapse (POP)

    The scope of physiotherapeutic management extends from conservative measures, including behavioural modification, pelvic floor muscle rehabilitation to electrotherapy

    Recent additions to the pelvic floor rehab repertoire include myofascial techniques, trigger points and low load vs. high load muscle activation.

    Table \(\PageIndex{1}\): Pelvic floor function and dysfunction

    Characteristics Function Dysfunction
    Base element of core Control charges in IAP Poor generation of IAP with function e.g. weak cough
    Lumbar and pelvic load Lumbopelvic stability Low back pain and chronic pelvic pain/pelvic girdle pain

    Fast twitch muscle activity

    High load

    With activity and physical stress SI, POP

    Slow twitch muscle activity

    Low load

    For antigravity support, bladder inhibition, anorectal angle

    POP, OAB, FI

    Eccentric muscle activity Release pelvic sling whilst supporting ano-rectum during declaration Obstructed defaecation, POP
    Tone and elasticity Supportive sling POP
    Sexual participation Sexual awareness/enjoyment Dysparuenia, decreased sexual enjoyment

    The physiology of micturition as it relates to the pelvic floor

    • The pelvic floor co-ordinates cortically stimulated activities (when and where to void). Other functions are mediated at the spinal level.
    • There are a number of reflexes acting between the pelvic floor and the bladder:
    • The Perineodetrusor inhibitory reflex inhibits detrusor activity in response to increasing tone in the pelvic floor muscles. (Storage phase - early)
    • The Perineobulbar detrusor inhibitory reflex inhibits contraction of the detrusor in response to contraction of the perineal and pelvic floor muscles. (Storage phase - late)
    • The Urethrosphincteric guarding reflex stimulates a powerful contraction of the external striated urethral sphincter in response to urine in the proximal urethra and/ or increasing tension in the trigone. (Storage phase - under stress)

    Abdominopelvic synergy

    The pelvic floor has been shown to have ‘partner muscles’ that coactivate to form functional slings.

    NB: Whilst the PF is defined along anatomical lines, its function should be considered as part of a greater unit. Indeed, the associated abdominal co-contraction may be more important than contracting the PF in its entirety.

    Table \(\PageIndex{2}\): Some of the notable partners are:

    Abdominal Muscle Pelvic Floor
    Transversus Abdominis(TA) Pubococcygeus(PC) & anterior PF
    Obliques Levator ani
    Rectus Abdominis(RA) Puborectalis

    The pelvic floor as a pressure mediator

    The normal pelvic floor, with intact fascia, needs little more than its inherent elasticity and reflex activity to function adequately. When the normal fascial attachments, however, are compromised by pregnancy and other factors increasing IAP, forces are exerted unequally through the pelvis, hence loading different compartments selectively and repeatedly. The pelvic floor therefore usually requires selective rehabilitation to ensure appropriate activation for either SI, OAB or POP.

    The pelvic floor as a pressure mediator for Stress

    Incontinence Rehabilitation aims to enhance the mechanical functioning of the pelvic floor, particularly speed and strength. The woman needs to learn to recruit the guarding reflex, which consists of a concomitant PF contraction with increasing IAP, when coughing or any other similar events. This is a focal contraction.

    The pelvic floor as a pressure mediator for OAB rehabilitation aims to normalize detrusor activity via tonal changes in the PF (see reflexes above). Functional use of the PF to mediate detrusor activity is usually focal.

    Postmenopausal women invariably have decreased pelvic floor tone secondary to atrophic changes, and therefore in this group particularly, prophylactic PF focused advice and education will be of benefit. If the inhibitory reflexes are insufficient, harnessing S2-4 dermatomes and myotomes may also improve the PF contraction. It is important that these are not used in place of, but in conjunction with an appropriate PF contraction.

    Table \(\PageIndex{3}\): S2-4 Dermatomes and Myotomes

    Dermatomes for S2-4 Myotomes for S2-4
    Saddle area (sitting on e.g. arm of chair) Gluteus Muscles (buttocks gripped)
    Back of legs (rubbing back of legs) Adductor (knees together)

    Clitoris (manual perineal pressure)

    Plantar flexors (up on toes)

    Intrinsic foot muscles (up on toes)

    The pelvic floor as a pressure mediator for frequency/ urgency rehabilitation aims to differentiate urgency secondary to decreased detrusor inhibition as opposed to urgency secondary to abnormal pelvic floor firing (autonomic up-regulation, disturbing normal detrusor activity) as a result of pelvic floor trigger points.

    The pelvic floor as a pressure mediator for hesitancy and incomplete emptying rehabilitation aims to normalize inappropriate PF activity with voiding (dyssynergia). Voluntary relaxation is essential and this usually co-exists with a functional inability to deactivate abdominal bracing.

    This page titled 18.2: The Scope of Physiotherapy and Aims of Pelvic Floor Rehabilitation is shared under a CC BY-NC-SA 2.5 license and was authored, remixed, and/or curated by Stephen Jeffery and Peter de Jong via source content that was edited to the style and standards of the LibreTexts platform.