La riabilitazione perineale nella donna di benedetto

GLUP(Gruppo di Lavoro Uroginecologia Pavimento Pelvico)

Pavimento Pelvico

ed

Evento Ostetrico

Gardone Val Trompia, 16 Aprile 2011P. Di Benedetto, 2011

La Riabilitazione Perineale

nella Donna

Paolo Di Benedetto, Udine P. Di Benedetto, 2011

Conservative treatment

Conservative treatment is any therapy that does not involve pharmacological or surgical intervention

It includes principally- lifestyle interventions- physical therapies- scheduled voiding regimens- complimentary therapies- anti-incontinence devices- supportive rings/pessaries- pads/catheters

P. Di Benedetto, 2011

Pelvic Floor Rehabilitation

The use of PFMT as a treatment for stress urinary incontinence (SUI) appeared to become more widespread after Arnold Kegel reported on the successfull treatment of 64 cases of female SUI using pelvic floor muscle exercises, with a perineometer for resistance and biofeedback.

* 1992: Lower Urinary Tract Rehabilitation Techniques: seventh report on the standardization of terminology of lower urinary tract function (Neurourol Urodyn 1992;11:593-603)

* 1998: first International Consultation on Incontinence (Monaco)

→ algorithms for initial and specialised management of urinary incontinence




TECHNIQUES- Biofeedback (BFB) - Pelvic Floor Muscle Training

(PFMT)- Functional Electrical Stimulation

(FES)- Endovaginal Cones- Bladder Retraining



* Pelvic floor muscle training (PFMT)- with or without

biofeedback- with or without

adjuncts such as cones, resistance devices etc

* Electrical stimulation* Alternative methods?


Pelvic Floor Skeletal Muscles

Slow Twitch Fibers (type I support of the pelvic viscera)Fast Twitch Fibers (type II occlusive effect on the urethra, reflex detrusor inhibition)


Optimal function of the PFM?

- Form a structural support (location, cross sectional area, stiffness)

- Give quick and strong unconscious co-contraction before/during increase in abdominal pressure

- Prevent descent of internal organs during increase in intra-abdominal pressure

- Relax before and during voiding/defecation


Female pelvic floor dysfunction

- Urinary incontinence

- Fecal incontinence- Pelvic organ

prolapse- Sensory and

emptying abnormalities of LUT

- Constipation- Sexual dysfunction- Chronic Pelvic Pain



Non-surgical therapy (PFMT, bladder retraining and lifestyle interventions) should be considered as the first line of therapy for urinary incontinence

- no side effects- good results- surgical option not compromised


Pelvic Floor Dysfunction

Pathophysiology


JO DeLancey. Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6

The interaction between the pelvic floor muscles (PFM) and the supportive ligaments is critical to support of the pelvic organs.

As long as the PFMs function normally, the pelvic floor is closed and the ligaments and fascia are under no tension. The fascia simply act to stabilize the organs in their position above the levator ani muscles.


JO DeLancey. Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6

When the PFMs relax or are damaged, the pelvic floor opens and the vagina lies between the high abdominal pressure and low atmospheric pressure. In this situation it must be held in place by the ligaments.

Although the ligaments can sustain these loads for short period of time, if the PFMs do not close the pelvic floor, then the connective tissue will became damaged and eventually fails to hold the vagina in place.


PFM DYSFUNCTIONConsequences

Lack of the PFM “reflex” contractionGenital prolapseGenuine stress incontinenceOveractive bladderSexual problemsConstipationChronic pelvic pain


PFM DYSFUNCTION

Primary Weakness (phasic and tonic components )

Apraxia (?)Secondary Weakness (neurogenic, post-partum, post- surgery)



PFM DYSFUNCTION

Hypertonia(nonneurogenic, neurogenic)

Dyssynergic patterns


Boath in Dry Dock( Norton PA, 1993)



Pelvic Floor Consequences

ofOccupation SportPregnancyChildbirthMenopause


URINARY INCONTINENCE Epidemiological Studies

(1)Nygaard et al (1994) 158 athletes, mean age 19.9 years all nulliparous 28% urinary incontinence during

sportactivities (2/3 IU more often than rarely)67% gymnastics66% basketball50% tennis10% swimming 0% golf



(2)Warren and Shantha high impact sports activities may

produce urinary incontinence

Greydanus and Patel adolescent gynecology:

stress urinary incontinence is common in female athletes



(3)

Bø and Borgen

high prevalence of stress and urge incontinence in female elite athletes,

mainly in eating disordered athletes compared with healthy athletes



(4)

Thyssen et al elite women athletes and dancers 291 women, mean age 22.8 years 51,9% urinary loss (43% during

sport/dancing; 42% during daily life) the activity most likely correlated

with urinary incontinence was jumping


INCITEchildbirth

nerve damagemuscle damage

radiationtissue disruptionradical surgery

PREDISPOSEgenderracial

neurologicanatomiccollagenmuscularcultural

enviromental

PROMOTEconstipationoccupationrecreation

obesitysurgery

lung diseasesmoking

menstrual cycleinfection

medicationmenopause

INTERVENEbehavioral

pharmacologicdevicessurgical

DECOMPENSATEaging

dementiadebility

environmentmedication

normal support or function

abnormal support or function

Model for the development of pelvic floor dysfunction in women (Bump et al, 1998)


INCITING FACTORS

Role of

- radical pelvic surgery- pelvic radiation- vaginal delivery- nerve damage- muscular damage


PROMOTING FACTORS

It is intuitive that occupational or recreational activities result in excessive or repetitive increases in abdominal pressures that contribute to the development of pelvic floor dysfunction in presence of weak pelvic floor muscles.


INTRAPARTUM INJURY

CONNECTIVE TISSUE

BreakageStretching

LEVATOR ANI MUSCLES

Muscles Tears

Pudendal Nerve Acute Denervation

Loss of muscle tone Chronic Denervation

Aging

Connective tissue failure

GENITAL PROLAPSE

Proposed mechanism for acute injury to pelvic supportive structures at childbirth that may result in chronic denervation and pelvic organ prolapse (from Strohbehn, 1998)


Vaginal childbirth

It can contribute to pelvic floor dysfunction and POP by

- direct damage to the endopelvic fascia and walls of the vagina

- indirect damage to the muscles and nerves of the pelvic floor.


After childbirth

The connective tissue did not recovery!

Episiotomy and lacerations of the perineal musculature (and, sometimes, of the external anal

sphincter and rectum) often provoke apraxia of the PFMs

The duration of this condition is an adjunctive risk for the endopelvic connective tissue

The eventual neurophatic injury is an other obstacle for the spontaneous recovery for the PFMs


What can weaken connective tissue and pelvic floor muscles?

- Overweight: 55-60% of US population over 18 years of age!!! INACTIVITYINACTIVITY

- Constipation – straining with bowel motion

- Smoking – excessive coughing

- Strenous work/ heavy lifting/sport (??)

- Pregnancy and childbirth (stretch/rupture of muscles, connective tissue, nerve lesion)

- Pelvic surgery- Inherited weak connective

tissue


Rationale of Pelvic Floor

Rehabilitation• Identification of pathophysiological mechanisms of

bladder, sphincters and pelvic floor dysfunction

• Absence of pelvic floor (complete) denervation

• Good education of the physical therapist

• Motivation, collaboration and compliance of the patient



RehabilitationPreviously trained PFM might be less prone to injury, and/or

easier to

retrain after injury because the appropriate motor patterns are

already learned.

For childbearing women , PFMT during pregnancy might help

counteract the increased intra-abdominal pressure caused by the

growing fetus, the hormonally mediated reduction in urethral

pressure, and the increased laxity of fascia and ligaments in the

pelvic area.


During voluntary PFM contraction

- Levator hiatus constriction (urethra, vagina, anus) 25% (Brækken et al -09)

- ↑ MUCP: 11.1 (10.7)-23.2 (8.4) cm H2O (Miller et al-04, Bø & Talseth -97)

- Muscle length: 21% shortening (Brækken et al -09)

. Forward and upward movement: 1 cm (Bø et al 2001, Brækken et al 2008)

- Resistance to downward movement

- Inhibition of detrusor contraction


Ability to contract PFM correctly

- >30% not able to contract (Benvenuti et al 1987, Bø et al 1988,Hesse et al 1990)

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

- 25% straining instead of contracting (Bump et al 1991)



Rehabilitation

Standard PFMT should be advised to all postnatal women.

Intensive PFMT is mandatory in symptomatic women (UI or initial

prolapse).



Rehabilitation

The biological rationale for PFMT in the management of SUI is that astrong and fast PFM contraction will clamp the urethra, increasingthe urethral pressure to prevent leakage during an abrupt increase inintra-abdominal pressure.DeLancey has also suggested that an effective PFM contraction maypress the urethra against the pubic symphysis, creating a mechanicalpressure rise.



Rehabilitation

Sometimes there is some evidence of PFM reflex contraction deficit

(feed-forward loop, as it precede bladder pressure rise by 200-240

msec).In these cases PFMT might normalize this reflex.



Rehabilitation

There are two hypotheses to explain mechanisms of

PFMT:1) Use of conscious contraction before and

during increase in abdominal pressure (the Knack)

2) Building up a structural support, thereby facilitating automatic co-contractions whenever needed


The ”Knack”Miller et al 1998

- 27 women. Mean age 68.4 (5.5) years with mild to moderate SUI

- 1 week of voluntary PFM contraction before and during cough

- Results: Reduced urine loss

from medium/ deep cough by average 98% and 73%


RCTs on PFMT versus control on SUI

- Significantly more effective than no treatment (Henalla et al -89, Henalla et al -90, Lagro-Janssen et al -91, Miller et al -98, Bø et al -99, Sung et al -00,Bidmead et al -02, Aksac et al -03, Dumoulin et al -03)

- Cure/improvement rates (SUI /mixed) 56-70%



RehabilitationPFMT may also be used in the management of urgeincontinence. Bladder muscle contractioncan be reflexly or voluntarily inhibited by PFM

contraction.Therefore, single or repeated voluntary pelvic floor

musclecontraction may be used to control urgency and preventurinary leakage.



RehabilitationIn cases of chronic pelvic pain the aim of pelvic floorrehabilitation (PFMT, FES, BFB) is to intervene on the

viciouscircle

pelvic floor overactivity-ischemia-pain


Conclusions

PFMT →

fundamental role in the pelvic floor rehabilitation


Conclusions

BFB →

* poor perineal control

* pelvic floor tension myalgia (CPP)


Conclusions

FES →

* in all types of urinary incontinence

* overactive bladder

* chronic pelvic pain


Conclusions

Endovaginal cones →

in stress urinary incontinence


Conclusions

Bladdder Retraining (± PFMT) →

in urge urinary incontinence


PFRClinical

Recommendations

If no PFM contraction:facilitations by manual techniques( or FES/BFB)

When voluntary contraction:intensive PFMT

* No results: surgery (+ PFMT ?)


PFRClinical

Recommendations

After surgery:

- weakness of PFM: intensive PFMT

- pain: aerobic programs, electrical stimulation

- detrusor instability: bladder retraining, drugs (PFMT,FES…)


”Alternative” methods to PFMT?


The FUTUREThe FUTURE

-


The core of PFR is the pelvic floor muscle awareness associated to pelvic floor muscle training.


Nowadays some non-medical pelvic floor grouped activities are rising, in order to widely offer PFMT as already happening in forms of adapted physical activity (APA) in other fields (low back pain, Parkinson, stroke, fibromyalgia).


It should be very important also a sensitization of both patients and health care professionals that often underestimate pelvic floor dysfunction ( prevention and negative effects on quality of life).


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