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Fitness and pelvic floor dysfunction:

what are the clinical issues and what is

the evidence?

Dr Margaret Sherburn PhD FACPManager, Physiotherapy, The Women’s Hospital,

Senior Lecturer in Physiotherapy, Melbourne School of Health Sciences,

The University of Melbourne

Why this presentation?

Because: • An opportunity to ‘bridge the gap’ • Sufferers suffer in silence• Incontinence is curable• Opportunity for holistic client care• There’s a lot of it about‒ 3.8 million Australians are incontinent, 70% are

women‒ 1 in 3 women who have had a baby

(NCMS 2003)

‘Sufferers’ suffer in silence

• Incontinence is embarrassing• If long term, leads to acceptance• Misinformation; ageing, treatment• TV advertising - pads • Women more than men• Withdrawal from physical activity

(Physical Activity in Australia, Dept Health & Ageing 2003)

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Relevance

• Withdrawal from sports & physical activity participation

• Continuing physical activity but worsening the condition by doing so

What do we mean by‘pelvic floor dysfunction’?

• Urinary Incontinence– stress (SUI) approx. 50%– mixed -less

– urge (UUI) -least– voiding dysfunction

• Faecal incontinence (FI)– faecal urgency (FU)

– defaecation difficulty

What else can be associated with pelvic floor dysfunction?

• Prolapse – anterior vaginal wall

(cystocoele, urethrocoele)

– posterior vaginal wall (enterocoele, rectocoele)

– Vaginal vault (Uterine descent, grade 1,2,3)

• Pelvic Pain• Sexual Problems• Back Pain

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Anatomy of PFM- Inferior view

Corton et al 2005

Anatomy of PFM- Superior view

Netter, F.H. Interactive Atlas of Human Anatomy. 3rd ed. New Jersey, Icon Learning Systems, 2003, ISBN: 1-929007-15-9, Plate # 341B

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TA US Imaging sagittal view

Function of the pelvic floor

1. Support the pelvic organs‒ Resist downward movement due

to raised intra-abdominal pressure (IAP)

2. Closure of urethral and anal sphincters

We need:• PFM that is responsive to

IAP and postural changes‒ Fast, strong response‒ Ability to relax

Risk factors for pelvic floor dysfunction – a balance

• Obesity• High impact

exercise• Coughing• Constipation• Heavy lifting

• PFM function• Trunk posture• Physical activity• Pelvic surgery• Pelvic neuropathy• Childbirth/parity• Gender• Increasing age

Simeonova et al 1999, Sapsford et al 2001, Davila et al 2003, Weir & Nygaard 2006

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PFM strength & surgical failure rates

Vakili et al AmJO&G 2005

PFM strength correlated most strongly with:‒ addition surgery‒ recurrent incontinenceRecurrent prolapse correlated most strongly with:‒ Urogenital hiatus size

N=358, mean age 61y, median follow-up period 5 mths

Risk factors for pelvic floor dysfunction – a balance

• Obesity• High impact

exercise• Coughing• Constipation• Heavy lifting

• PFM function• Trunk posture• Physical activity• Pelvic surgery• Pelvic neuropathy• Childbirth/parity• Gender• Increasing age

Simeonova et al 1999, Sapsford et al 2001, Davila et al 2003, Weir & Nygaard 2006

And risk factors for the men?

• Risk factors– Getting older

– Prostate enlargement

– Trauma to pelvis• Falls• Surgery

• Incontinence is more common in women

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Cost utility of incontinence treatment

SA Omnibus Health Survey 1998

Level 1a evidence, Grade A recommendation 4th International Consultation on Incontinence

Abrams et al ICI 2009

‘Pelvic floor muscle training should be offered, as first line therapy, to all women with stress, urge or mixed urinary incontinence’

‘Pelvic floor muscle training should be offered, as first line therapy, to all women with stress, urge or mixed urinary incontinence’

PFMT is the mainstay of physiotherapy treatment

‘Training’ for PFM• Motor control, coordination

• Strength, power

• Endurance

• Function

(Bø & Sherburn 2005)

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Looking beyond the Pelvis: Pelvic floor function as part of an abdominal capsu le

• The PFM contract synergistically with lowest transversusabdominis (TrA)

(Sapsford 2001, Neumann 2002, Urquhart et al 2006)

• PFM are more effective in normal lumbar lordosis (Sapsford 2006)

• This is commonly disrupted in urgency & prolapse, in 43% of subjects

(Thompson et al 2003)

• 30% depressed pelvic floor when asked to perform TrAcontraction alone

(BØ & Sherburn 2003)

Looking beyond the pelvis: Understanding trunk muscle mechanisms

Pelvic floor forms base of pressurised abdominal capsule.

Is there a relationship between diaphragm, trunk and pelvic floor muscles?

All have postural & dynamic roles

(Hodges et al 1997, 2002))

Compromise:When respiratory demand increases postural activity of diaphragm, TrA and PFM all decrease.

How does IAP affect the pelvic floor?

It’s all in the physics– The trunk is a sealed pressurised elastic cavity– Pressure equal throughout (Pascal)– Capsule wall tension varies according to the radius of the capsule

(LaPlace)

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How does IAP affect the pelvic floor?

It’s all in the physics– The trunk is a sealed pressurised elastic cavity– Pressure equal throughout (Pascal)– Capsule wall tension varies according to the radius of the capsule

(LaPlace)• PFM overpowered by the abdominals

Functional PFM training

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Functional PFM training

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Who is at risk?

Those who do activities which raise intra-abdominal pressure (IAP):

– High impact sports/activity– Heavy lifting sports/activity– Deconditioned status– Chronic lung disease– Overweight– Constipation

Then add pregnancy …

Pre-exercise screening is important

Risk factors: red & blue flags

Red flags• Already incontinent or with symptoms

of other pelvic floor dysfunctions– Loss of urine, flatus, bowel motion during

training/treatment– Bladder or bowel urgency during

training/treatment– c/o vaginal heaviness, bulging, pain– Lumbar or sacral neurological signs

Risk factorsBlue flags• At risk of incontinence or other pelvic floor

dysfunctions• Biomechanical or medical/surgical factors

– Female– Older age– Pregnancy/postnatal– Elite training in high impact or weight lifting sports– Poor motor control patterns– Medical – CTissue, lung, neuro, spinal, bowel disorders– Diabetes– Medications – NSAIDS, anti-depressants, diuretics

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Problem identified … what next?

• Offer advice/treatment?• But what is the evidence?• Who is best placed to deliver the most

effective service?

Clinical effectiveness – the 6 R’s

• Right person• Right thing• Right way • Right place

• Right time• Right results

Right person

• Strong evidence for good outcomes‒ If treated by PF physiotherapists‒ With evidence based management

• Outcomes not generalisable to other health practitioners without specific training

(Hay-Smith & Dumoulin 2006, Neumann et al 2006)

• Fitness leaders are at the ‘coal-face’ ‒ For screening women‒ Referring for a PF check

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Right thing• Self help is not the best help

– > 30 % not able to contract at first session (Benvenuti et al 1987, Bø et al 1988, Hesse et al 1990)

– Only 49% increased urethral pressure during contraction (Bump et al 1991)

– 25% were straining instead (Bump et al 1991)

• Failing is de-motivating– Lost opportunity– ‘PF exercises don’t work’– ‘I need surgery’ – re-operation rate is high

• Duty of care to talk about PF issues– Including male instructors

Right way

• Think further than the pelvic floor - to trunk mechanics– But don’t ignore the pelvic floor– And don’t think clients/athletes have got it right without checking

• Ban star jumps• Transabdominal ultrasound??

– Excellent biofeedback for muscle activation• Valid, reliable, intuitive, accepted by patients

– But does it give us the whole picture?• No information on m tone, m defects, prolapse, pain etc

– Does not qualify the US practitioner to treat PF problems

Right place

• Appropriate environment– Privacy to discuss PF issues

• Eg. why not fully participating in a class

• General information placed in gyms/change rooms

• Beginning of, and during a class– Leaders must feel comfortable talking about

the pelvis

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Right time

Is now … for us as professionalsFor our clients:• Timeliness of information important• Availability of services

• Access to services

Right results

Optimal outcomes if these principles are adhered to

Optimal outcomes if these principles are adhered to

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And finally …

• Understand each profession’s strengths and boundaries for best:– Collaboration between

professionals– For quality service

– Patient satisfaction• Communication between us:

– what’s the best way?

• PF problems are complex– Require trained

practitioners– Respond to appropriate

management• Be aware of the

signs/symptoms‒ Be prepared to ask

References

Bo K, Sherburn M, Allen T 2003 Transabdominal ultrasound measurement of pelvic floor muscle activity when activated directly or via a transversus abdominis muscle contraction. Neurourology and Urodynamics 22(6):582-588

Dietz H P, Jarvis S K, Vancaille T G 2002 The assessment of levator muscle strength: A validation of three ultrasound techniques. Int Urogynecol Journal 13:156–159

Dietz H P 2004 Ultrasound imaging of the pelvic floor. Part I: Two-dimensional aspects. Ultrasound Obstet Gynecol. 23(1):80-92.

Dietz H P 2004 Levator function before and after childbirth. Australian and New Zealand Journal of Obsetrics and Gynecology 44:19-23

Dietz, H.P., P.D. Wilson, and B. Clarke 2001 The use of perineal ultrasound to quantify levator activity and teach pelvic floor muscle exercises. Int Urogynecol J Pelvic Floor Dysfunct 12(3):166-9

Peng, Q, R.C. Jones, and C E Constantinou 2006 2D Ultrasound image processing in identifying responses of urogenital structures to pelvic floor muscle activity. Ann Biomed Eng. 34(3):477-93.

References

Sherburn M, Murphy C A, Carroll S, Allen T J, Galea M P 2005 Investigation of transabdominal real-time ultrasound to visualise the muscles of the pelvic floor. Australian Journal of Physiotherapy 51(3):167-170

Thompson J A, O'Sullivan P B 2003 Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross-sectional study and review. Int Urogynaecol J 12(4):84-88

Thompson J A, O'Sullivan P B, Briffa K, Neumann P, Court S 2005 Assessment of pelvic floor movement using transabdominal and transperineal ultrasound. International Urogynecology Journal 16(4):285-292

Thompson J A, O'Sullivan P B, Briffa K, Neumann P 2006 Differences in Muscle Activation Patterns during Pelvic Floor Muscle Contraction and Valsalva Manoeuvre.Neurourol and Urodyn 25:148-155.

Whittaker JL 2007 Ultrasound imaging for Rehabilitation of the Lumbopelvic Region Churchill Livingston, Edinburgh