The Female Pelvic Floor and

G ldil k
Goldilocks

Too weak, too tight and just right!

(or just right, too weak and too tight)

Meagan Matteson, RN, MS, CNP

meagan.matteson@osumc.edu
Feel free to contact me with ?s

www.augs.org (great resource!)

J t Right…
Just Ri ht

{ Specific
f grouping off muscles,
ligaments and fascia which interlace
and provide support-includes
support includes
pubococcygeus and levator ani
{ Keep pelvic organs in the pelvis
z Bladder
z Uterus
z Rectum
J t Right…
Just Ri ht

{ Muscles create circles (sphincters)

around outlets of those organs to
keep us clean and dry
z For example-urination
z Bladder muscle is relaxed until need to
void-pelvic floor muscles are contracted
z When voiding g bladder muscle contracts
and pelvic floor relaxes
J t right…
Just i ht

{ Roll in sexual function

f
z Orgasm is essentially a rhythmic
muscular contraction-stronger
contraction stronger
muscle=stronger contraction?
T Weak…
Too W k

{ Increased risk off stress urinary

incontinence due to weakness of
both the urethral sphincter and
hypermobility of the urethra
z Leaking with coughing,
coughing laughing,
laughing etc.
etc
{ Increased risk of pelvic organ
prolapse or relaxation
z “My bladder is falling out…”
T
Types off Pelvic
P l i Organ
O Prolapse
P l
C
Causes ffor pelvic
l i fl
floor relaxation
l ti

{ Childbearing (not just vaginal

delivery!)
z IIncreasedd pressure intra-abdominally
i t bd i ll
due to pregnancy forces muscles down
z Vaginal delivery disrupts integrity of
the musculature if everything goes well
(intact)
z Increased risk with perineal trauma
such as tearing or episiotomy
C
Causes ffor pelvic
l i fl
floor relaxation
l ti

{ Heredity
z Genetic predisposition to poor tissue
integrity
{ Can be seen in need for multiple
reconstructions
z Prolapse and incontinence can often
“run in the family”
C
Causes ffor pelvic
l i fl
floor relaxation
l ti

{ Age
z GRAVITY!!
{ Anything that increases abdominal
pressure
z Runners
R
z Horseback riders
z Gymnasts
P
Prevalence
l off St
Stress Incontinence
I ti
{ 1 in
i three
th women willill have
h leaking
l ki
with stress maneuvers within 5
years of a vaginal delivery
{ 50-75% of women who have it
won’t even tell their p
physician.
y Of
those who did, 61% waited 4 years
{ In the U.S. more feminine pads are
usedd for
f iincontinence
i than
h for
f
menstruation
Prevalence of pelvic organ prolapse

{ 40% off women over the age off 40

have some pelvic organ prolapse
{ 50% off women whoh deliver
d l
vaginally have some degree of
prolapse
T Tight
Too Ti ht (Hypertonic)…
(H t i )
{ Detrusor
D t sphincter
hi t dyssynergia
d i
(DSD)-inability to appropriately
relax the pelvic floor with a
contraction of the bladder-leads to
poor emptying or painful voiding
{ Pelvic pain syndromes such as
vestibulodynia or vulvar vestibulitis
{ M
May contribute
ib to Irritable
I i bl Bowel
B l
Syndrome and Interstitial Cystitis
Causes for pelvic floor hypertonicity

{ Spinal cord injury

{ Dysfunctional habits in response to
chronic
h pain
z Severe vaginal atrophy
z P l i ttrauma
Pelvic
z Repeated infections
{ Pain-fear
Pain fear cycle=pain causes fear causes
tension causes more pain
Wh t can we do?
What d ?

{ Talk about the pelvic floor

f with your
patients or your clinician
z IInitiate
iti t hhonestt di
discussion
i about
b t pelvic
l i
health or symptoms!!
{ Start young-easier for patients to
identify and strengthen when they
are young and muscles are strong
{ Elicit pelvic floor history to aid in
intervention!
Ph i l exam-What
Physical Wh t to
t expectt

{ Done at time off bimanual exam

{ Ask patient to squeeze around your
f
fingers, aka…
k
z Squeeze like you are trying to hold in
gas in a crowded room
St your urine
Stop i on th
the ttoilet…
il t

{ Not a great idea long term-confuses

f
the voiding messages
{ Patient should
h ld ffeell a llifting
f
sensation-like a string pulling their
vagina up
{ Do on a hard chair for most
feedback hardest to do standing
feedback-hardest
(gravity)
Ph i l exam
Physical

{ Give patient a grade 0-5/5

z 0-no movement to the pelvic floor
z 1 fli k
1-flicker
z 2-weak
z 3 moderate (lift)
3-moderate
z 4-good (lift)
z 5-strong (lift)
Ph i l exam
Physical

{ Grade
{ Accessory muscle use
z Most common-bottom, thighs and
abdominal muscles
z Make note if patient is using
z When a Kegel is done correctly the
contraction is in pelvic floor only!!
Ed
Education
ti

{ Not just for

f older women or people
who are incontinent!
{ Start early
l anddhhelp
l the
h musclesl
stay toned.
{ R
Re-visit
i i this
hi every year at annuall
exam starting at initial
appointment.
appointment
Ed
Education
ti

{ 2 types off exercises-long holds and

quick flicks
z Long holds
L h ld workk slow-twitch
l t it h musclel
fibers used long term to keep patients
continent-unconscious (70%)
( )
z Quick flicks work fast-twitch fibers used
during stress maneuvers (30%)
P
Progressive
i exercise
i program

{ No special devices are needed

{ Patient compliance is key!
{ Only works while patients do them-
use it or lose it!
{ Informal or formal training (at
home versus physical therapy)
P
Progressive
i exercise
i program

{ Identify
f muscle
{ Start doing 3 long hold exercises in
a set
z Hold for 3 seconds and relax for 3
seconds in between
z 4 sets/day
z May not feel the entire 3 seconds but
should strive for them
P
Progressive
i exercise
i program

{ When you feel

f the hold for
f 3
seconds increase the hold/relax
time and number of reps by 2
z 5 reps, hold 5 seconds, relax 5 seconds
4x/day
P
Progressive
i exercise
i program

{ Continue to add 2 until patient can

ultimately hold…
z 12 seconds
d and dddo 12 in
i a row without
ith t
fatigue!
z Can you??????
z Rest period is as important as the
contraction for a healthy pelvic floor
Q i k flicks
Quick fli k

{ These are fast

f up and down
exercises
{ Do these
h daily
d l at stop signs, red
d
lights, meals, brushing their teeth
{ A
Attachh to a daily
d il activity
i i for
f best
b
compliance
Ad
Advanced
dEExercises
i

{ Standing
{ Elevator
z Sit on floor and increase the
contraction in stages
z Think about as floors until top floor and
back down
z Takes a lot of concentration and control
F
Formal
l ttraining
i i

{ Done by experienced RN, NP or PT

{ Done over course of several months
{ May use biofeedback or electrical
stimulation to enhance results
{ Good for patients who are having
trouble identifying the correct
muscles
l
{ Creates incentive to comply
A
Across the
th Lifespan
Lif
{ B f
Before childbearing
hildb i
z Easiest time to identify and tone
muscles
z Encourage patients to be proactive and
talk to relatives about their experience
z Of
Often taught
h in
i yoga/Pilates
/ il courses
z Reminders are important-these
individuals often do not have
symptoms so easily forgotten
z SEX!!
A
Across the
th lifespan
lif

{ Before
f childbearing
z Can see hypertonicity in this group
z A k about
Ask b pain
i with
i h intercourse
i or
during voiding
Pregnancy

{ Most helpful
f to have strong pelvic
floor going into pregnancy and
continue to do exercises throughout
z No specific guidelines regarding
trimester variations
z OK to do immediately after delivery
z Often taught
g in p prenatal y
yoga
g classes
D li
Delivery

{ C/S may be somewhat protective

with first child but looses that
protection with second pregnancy
{ Strive for intact perineum
{ Wh effect
What ff does
d perineal
i l massage
have?
P
Pre-menopausal
l

{ Often
f when dysfunction
f begins to
appear in terms of incontinence and
prolapse
z Stress and urge related incontinence
z May be more compliant after symptoms
appear
z Must ask about these symptoms
y p to
open a dialogue!
P t
Post-menopausal
l

{ Estrogen depletion
z Consider vaginal estrogen for stress
incontinence research not definitive
incontinence-research
z May have more time for physical
therapy
z May be more interested in non-surgical
intervention due to co-morbidities
z Sometimes have hard time identifying
the muscles due to weakness
Wh t do
What d Kegels
K l NOT d
do?
?

{ Kegels cannot put us “back together

again”
{ Depending
d on the
h amount off pelvic
l
floor descent exercises may not be
enough
z Pessary
z Surgery
T k home
Take h message (literally!)
(lit ll !)
{ Whether
Wh th a clinician,
li i i a woman or
someone who loves a woman talk
about pelvic health!!
z Serious impact on quality of life!
{ Pelvic floor exercises are more
effective if initiated early in
symptom complex
{ Speak to the doctor you feelf most
comfortable with and be vigilant!