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PELVIC HEALTH IN WOMEN
Beth Lonberger, APRN, Family Nurse Practitioner
Julie Starr, APRN, Family Nurse Practitioner
University of Missouri Hospital and Clinics
Women’s and Children’s Hospital
Center for Female Continence and Advanced Pelvic Surgery
OBJECTIVES
• The participant will be able to:
– Define pelvic health in the female
– List common diagnosis contributing to pelvic floor
dysfunction
– Understand how pelvic organ prolapse, recurrent UTI
and constipation effect bladder/bowel function
– Discuss treatment options for pelvic floor dysfunction
PELVIC HEALTH
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Urinary continence
Voiding less than 9xday and 0-1xnight
Absence of infection
Complete emptying of rectum every day
Adequate support of pelvic organs
Well estrogenized vaginal tissue
Sexual wellbeing
COMMON DIAGNOSIS CONTRIBUTING
TO PELVIC FLOOR DYSFUNCTION
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Urinary Dysfunction
– Urinary Incontinence
– Urinary urgency/frequency
– Nocturia
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Defecatory Dysfunction
– Constipation
– Fecal Incontinence
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Pelvic Floor Dyssynergia
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Pelvic Organ Prolapse
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Levator Ani Muscle Spasm
– Pelvic Pain
– Dyspareunia
– Urinary urgency/frequency/incontinence
– Obstructive outlet defecation
Urinary Incontinence
• Stress Urinary Incontinence
– Coughing, Laughing, Sneezing, Lifting, Walking
• Urge Incontinence
– Urgency, Frequency, Triggers, Nocturia
• Overflow Incontinence
– Retention, Obstruction
• Functional Incontinence
– Frail, Decreased mobility
Prevalence of Urinary incontinence
Treatment Options: Stress Incontinence
• Surgical
– Midurethral sling
– Bulking agents
• Nonsurgical
– Pessary
– Femsoft urethral insert
– Pelvic floor physical therapy
Treatment Options: Urge Incontinence
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Behavior modification
Bowel regimen
Premarin vaginal cream
Medications
Pelvic floor physical therapy
URINARY FREQUENCY
Voiding >8 times during the day
Negatively effects quality of life, especially
when associated with incontinence.
Social isolation
Depression
Inactivity contributes to more serious health
problems
NOCTURIA
GETTING UP MORE THAN ONCE IN THE NIGHT TO VOID
Causes:
Recurrent UTIs, chronic renal failure, congestive heart
failure, cystitis, diabetes, excessive fluid intake, elevated
Ca+ level, sleep apnea.
Increase risk of falls
Disrupted sleep cycles
Treatment: Imipramine 25-50mg q hs. Take Diuretic at noon.
Gillen, L., Marinkovic, L., Stanton, S. Managing Nocturia. BMJ. 2004;328:1063-1066.
RECURRENT URINARY TRACT
INFECTION
SYMPTOMS UTI
Urinary urgency/frequency, incontinence,
dysuria, low back pain, delirium.
Elderly often asymptomatic
DIAGNOSIS RECURRENT UTIs
• Three or more UTIs in the past year or >2 in the
past six months
• In and out cath specimen culture positive
Cunha, BA, Tessler, JM, Bavaro, MF. Urinary Tract Infection, Females. Medscape. October, 19, 2009.
UROGENITAL ATROPHY
Vaginal atrophy (atrophic vaginitis) is thinning and
inflammation of the vaginal walls which occurs
after menopause due to a decline in estrogen.
Results in vaginal dryness, itching, burning and
inadequate lubrication.
Urinary symptoms include urgency/frequency,
incontinence and recurrent UTIs.
Pinkerton, J. Vaginal impact of menopause-related estrogen deficiency. OBG Management. 2010; S1116.
UROGENITAL ATROPHY
TREATMENT
• Premarin vaginal cream 0.625%
– ½ applicatorful 3 x week at bedtime for 4-6 weeks
then decrease to ½ applicatorful 1xweek q hs for
maintenance dose
• Estring (Estradiol vaginal ring)
– Vaginal ring containing 2mg of Estradiol releasing
0.75mcg in 24 hour period
– To be changed every 90 days
Defecatory Dysfunction
Refers to a multitude of complaints that may include
having frequent and uncomfortable sensations to have a
bowel movement, constipation or the feeling of poor
emptying, and leakage of gas/ diarrhea/ and/or solid
stool.
20% of women suffer from defecatory dysfunction.
Among women with pelvic floor disorders, the
prevalence of defecatory dysfunction was 60%.
Whitcomb, E.; Lukacz, E.; Lawrence, J.; Nager, C.; Luber, K. Prevalence of Defecatory Dysfunction in Women with and
Without Pelvic Floor Dysfunction. Journal of Pelvic Medicine & Surgery. 15(4):179-187, July/August 2009.
Causes of Defecatory Dysfunction
• Incomplete emptying
– Rectocele or perineal rectocele
– Pelvic floor muscle (Levator ani) spasm
• Sphincter incompetence
– Thickening of IAS and thinning of EAS
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Diet
Dehydration
Medications
Decreased sensation
Irritable Bowel Syndrome
Treatment of Defecatory Dysfunction
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Bowel regimen
Pessary
Pelvic floor therapy
Behavior modification
– Do not resist the urge to defecate
– Proper hydration
– Dietary changes
– Medication changes
– Exercise
BOWEL REGIMEN
1.Mix 1 rounded teaspoon of psyllium fiber
(Metamucil® brand or Wal-Mart® Equate generic) in 6-8
ounces of cold water. Take this dose of fiber
supplement a minimum of once per day. You may
repeat this dose up to 3 times per day. Please do not
take Metamucil within two hours of any medications.
2. IF YOU DO NOT HAVE A BOWEL MOVEMENT
WITHIN ONE HOUR OF RISING EACH MORNING, take
one tablespoon of magnesium hydroxide (Phillips®
Milk of Magnesia or a generic equivalent). Repeat
this dose each hour until you have a bowel
movement (do not exceed 6 doses in a day). Most
patients will begin having daily bowel movements
without the need for magnesium hydroxide within
one week of therapy.
FECAL INCONTINENCE
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6% of women <40 years old
15% of women >40
Nursing Home residents 45-47%
7% of all women have fecal smearing
50% of affected women keep FI a secret
TREATMENT OF FECAL INCONTINENCE
• Behavior modification/dietary changes
• Metamucil daily and Immodium prn
• Pelvic floor therapy
• Surgical options
– Sphincteroplasty
PHARMACOLOGICAL MANAGEMENT
• METAMUCIL daily
• Loperamide
• 1 tab (2mg/tab) before each meal and bedtime up to 8 tabs/day
• 2 tabs (2mg/tab) at q meal and hs up to 16 tabs/day
• Diphenoxylate with atropine sulfate
– 1 tab (2.5mg/tab) at q meal and hs up to 8 tabs
– 2 tabs (2.5mg/tab) at q meal and h.s up to 8 tabs/day
• Bismuth subsilicylate
– 1-2 tabs (262mg/tab) before meals and h.s. not to
exceed 4.2 g/day
PELVIC FLOOR (LEVATOR ANI) SPASM
Pelvic Floor Muscles
(Levator Ani complex)
• Pubococcygeus
• Coccygeus
• Ileococcygeus
This group of muscles acts as a single neuromuscular unit to
assist with proper support and function of the pelvis organs
including normal urinary and fecal continence as well as
genitourinary and rectal support.
LEVATOR ANI SYNDROME
A COLLECTION OF SYMPTOMS AND FINDINGS
The most common symptoms include
• Deep dull aching in the rectum/vagina
• Referred pain to the pelvis, thigh and buttock
• Pain worsens with sitting and bowel movements
• Spasms and pain in the pelvic floor muscle
• Pain during or after intercourse
• Urinary urgency/frequency possibly incontinence
• Constipation
• Prior testing usually rules out other pathologies
TREATMENT PELVIC MUSCLE SPASM
PELVIC FLOOR PHYSICAL THERAPY
Biofeedback
Vaginal E-stim
MEDICATIONS
• Flexeril 5-10mg tid prn
• Ultram 50-100mg BID
• Valium suppositories 10mg vaginally bid prn
BEHAVIOR MANAGEMENT
• Warm baths/heat daily
• Yoga/daily stretching
• Relaxation and stress management
Pelvic Floor Therapy with
Neuromuscular Stimulation
WHAT IS PELVIC FLOOR THERAPY
• Pelvic Floor Muscle Awareness & Strength
Training
• Electric Stimulation (enhances muscle
awareness and strength, relaxes spasm)
• 4-6 sessions of therapy
Folkerts, D., Wood, K. Overactive bladder and urinary incontinence: A multitherapy approach to treatment.
Sexuality, Reproduction & Menopause. 4(2), 2006.
INDICATIONS
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Urge Incontinence
Stress Incontinence
Fecal Incontinence
Pelvic Muscle Spasm
Pelvic Floor Dyssynergia
Pelvic Floor Muscle Weakness
PATIENT REQUIREMENTS
• Cognitive awareness
• Active participation
• At least partial innervation of PFM
Components of Pelvic Floor Therapy
• Rectal manometry
– Measure muscle strength
• Vaginal EMG
– Measure resting tone
• Abdominal EMG
– Measure use of accessory muscles
• Stim
– Neuromuscular stimulation (NMS)
Anorectal Manometry
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Air filled balloon placed in the rectum
Records squeeze pressure of Levator Ani
Can pick up valsalva and register as pressure
Manometry is measured from zero
Best for measuring true strength of muscle
Pelvic Floor Muscle EMG
At rest, continuous baseline activity
consists of motor unit potentials of
2-4 MicroVolts
Duel Channel EMG
Abdominal EMG
• Purpose:
To a assist in isolation of PFM
To monitor contraction of abdominal
muscle as an accessory muscle
Amplitude
Conduction volume of contraction
Stimulation (NMS)
• Inhibits involuntary detrusor contractions
• Increases bladder capacity
• Decreases the intensity of urge sensation
• Decreases pelvic floor muscle spasm
Stimulation
Increases muscle:
• Recruitment
• Strength
• Awareness
Mechanism of Action
• Produces a reflex muscle contraction
• Contracts pelvic floor muscles
• Relaxation and inhibition of detrusor
Frequency of Exercise
• Usually 4x per day
• More frequent with less repetitions for very
weak muscle.
• Too much exercise will fatigue muscle and
worsen symptoms.
Essentials of Pelvic Muscle Exercise
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Muscle Awareness
Activation Promotes Function
Must have regular exercise
Avoid accessory muscles
Overload Principle
Progression
Methods of Teaching
• HOLDING BACK GAS
• Stopping urine stream
• Contracting vagina
• Contracting rectum
Unstable Resting EMG
Amplitude
Conduction volume of contraction
Patient Initial Visit
Patient Final Visit
Pelvic Organ Prolapse
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Uterine Prolapse (uterus)
Cystocele (bladder)
Rectocele (rectum)
Perineal Rectocele (perineum)
Enterocele (vagina)
PELVIC ORGAN PROLAPSE
• http://www.bardurological.com/pop-q/pop-q.aspx
Conservative Management of Pelvic
Organ Prolapse
• Bowel Program
• Vaginal Estrogen
• Pessary
Pessary
Vaginal support device for relief of symptoms of
pelvic organ prolapse
Indicated for women who do not desire surgery or
are not good surgical candidates
• 92% satisfaction after 2 months
• Improvement of prolapse in 21% of patients after
1 year.
• Success is in patient selection
• Physical exam
Types of Pessaries
PESSARY MANAGEMENT
• Proper fitting may require more than one visit
every 2-3 weeks.
• Patient can be instructed on managing their
pessary at home or return to clinic every 1-3
months for removal/reinsertion and exam.
• Estring can be replaced at this time
ETHEL
• HPI: Ethel is a 90 y/o G4P3 with complaints of
over active bladder x 2 years. Her bladder
symptoms worsened with recent sacroplasty.
She describes symptoms of stress
incontinence, urgency/frequency and urge
incontinence which worsened at night. She
wears a Depends pad and a large Poise pad
and changes this ensemble 5 x day
HPI cont.
On an average day she drinks 3 glasses of water,
2 glasses of juice, 1 cup of coffee and 1 soda.
She reports 4 UTIs in the past year.
She takes Miralax every morning and reports
1-2 bowel movements per day and strains at
stool.
24 hour pad weight 803 grams
Bladder diary indicates 16 voids/24 hours
She gets up 4 x night to void.
MEDICAL/SURGICAL HISTORY
Patient reports conditions of HPTN, anemia,
hernia, sinusitis, GERD, hypothyroidism,
Raynaud’s syndrome, constipationpredominant irritable bowel syndrome.
Surgical history includes sacroplasty,
cholecystectomy, appendectomy,
hysterectomy and ovariectomy.
DIAGNOSIS
Stage II rectocele
Perineal rectocele
Defecatory dysfunction
Urogenital atrophy
Urinary urgency/frequency
Urge incontinence
Stress incontinence
Urinary tract infection
Recurrent urinary tract infections
TREATMENT PLAN
Bowel regimen for her defecatory dysfunction.
Premarin vaginal cream for urogenital atrophy.
Fosfomycin 1 x dose to treat UTI.
Trimethoprim 100mg q hs for recurrent UTIs.
Oxybutynin prn for OAB.
Pelvic floor therapy x 5 sessions.
Imipramine 25mg q hs for nocturia.
OUTCOME
Patient reported 100% improvement after 5
sessions of pelvic floor therapy.
She voids 7-8 x day and 2 x night.
Her daytime incontinence completely resolved and
she leaks only drops during the night.
She wears a panty liner for peace of mind.
She remains on Trimethoprim at bedtime.
She remains on Imipramine q hs.
She takes Oxybutynin only when going out.
OUTCOME cont
She continues with Premarin vaginal cream 1 x
week.
She continues to do pelvic floor exercises 4 x
day.
She takes Metamucil daily and reports 1-2 bowel
movements per day without straining.
She just returned from a vacation with her
family in which they drove over 500 miles in
the car.
ANNE
HPI: Anne is a 70 y/o G2P2 with complaints of
stress incontinence, urgency/frequency, urge
incontinence and nocturia for the past 6-8
months.
She wears a panty liner for protection but not
every day.
She reports one bowel movement every other
day and strains at stool.
HPI cont
On an average day she drinks 5-6 glasses of
water, 1 glass of juice, 1 glass of milk, 2 cups of
coffee, 1 glass of tea and 1 soda.
Her bladder diary indicates she voids 7 x in 24
hours.
Her 24 hour output averages 3400cc.
MEDICAL/SURGICAL HISTORY
Patient reports no medical problems and has
never had surgery.
She reports two vaginal deliveries with a
maximum birthweight of 8#15oz..
DIAGNOSIS
Stage II cystocele
Stage II rectocele
Perineal rectocele
Nocturia
Urodynamic stress incontinence
Urge incontinence
Urogenital atrophy
Defecatory dysfunction
TREATMENT
Bowel regimen to treat defecatory dysfunction.
Premarin vaginal cream for urogenital atrophy.
Moderate fluids, especially in the evening.
Pelvic floor therapy for urge and stress
incontinence.
OUTCOME
Patient reports 85% improvement in her
symptoms after 6 sessions of pelvic floor
therapy.
Her urge incontinence has resolved and she
continues with mild stress incontinence 2-3 x
month.
She continues on Premarin vaginal cream 1 x week
for urogenital atrophy.
She continues with pelvic floor exercises and urge
suppression techniqes daily.
She continues to moderate her caffeine intake.
OUTCOME cont
Anne was so pleased with her results but her
best friend’s bladder was limiting her lifestyle.
Her friend completed a course of pelvic floor
therapy.
They have just returned from two weeks in Italy
and reported complete bladder control and no
anxiety about being on a tour bus all day
PATRICIA
Patricia is a 78 y/o patient with a lifelong history
of diarrhea predominant irritable bowel
syndrome. She presents with symptoms of
fecal incontinence for the past year. She
reports leaking stool five minutes after she
starts to exercise.
She reports 1-2 bowel movements per day and
strains at stool.
HPI cont
Her urinary complaints include only mild stress
incontinence.
She wears a panty liner for peace of mind.
She denies urinary urgency/frequency and gets
up 1-2 times per night to void.
She describes a burning perineal pain after
intercourse and a soreness which lasts several
hours.
She uses Estrace cream for vaginal dryness.
MEDICAL/SURGICAL HISTORY
Osteoporosis, diverticulosis and diarrhea
predominant irritable bowel syndrome.
G2P2 SVDx2 with largest birthweight 8# 13oz
Surgical history includes hysterectomy, cystocele
repair, cataract repair.
DIAGNOSIS
Diarrhea predominant IBS
Fecal incontinence
Defecatory dysfunction
Stress incontinence
Stage I cystocele
Stage I rectocele
Lichen planus (bx positive)
TREATMENT
Metamucil and Loperamide for treatment of
defecatory dysfunction/IBS
Continue Estrace cream for urogenital atrophy
Clobetasol ointment for lichen planus
Pelvic floor therapy x 4 sessions for fecal
incontinence.
OUTCOME
Patient reports 100% improvement in her fecal
incontinence after 4 sessions of pelvic floor
therapy.
She reports 1 stool/day without straining with
daily use of Metamucil.
She is able to eat fruits and vegetables without
GI complaints for the first time in years
Her perineal burning/soreness have resolved.
She exercises daily and no longer wears a pad.
LORI
HPI: Lori is an 18 y/o G0 with history of sexual
abuse starting at the age of 7. She was
recently treated by Dr. Courtney Barr at the
Center for Vulvar Diseases for vulvodynia
which she reports is completely resolved.
She describes an intermittent, stabbing LLQ
pelvic pain which occurs 5-6 x day.
She reports urinary urgency/frequency and mild
urge incontinence.
HPI cont
She often has a sensation that she is not
emptying her bladder completely.
Lori reports bowel movements every other day
and strains at stool.
She is not sexually active at this time.
MEDICAL/SURGICAL HISTORY
Patient describes history of asthma and
headaches.
Surgical history negative.
DIAGNOSIS
Urinary urge incontinence
Defecatory dysfunction
Levator spasm
TREATMENT PLAN
Bowel regimen for her defecatory dysfunction.
Pelvic floor therapy for levator spasm.
OUTCOME
Patient reports 100% improvement in her
symptoms after 4 sessions of pelvic floor
therapy.
She takes a daily dose of Metamucil and reports
one bowel movement per day without
straining.
Her pelvic pain is completely resolved.
PELVIC FLOOR MUSCLE EXERCISES
How to Identify the Correct Muscle
To find the proper muscle, imagine having to pass gas while with a group of people. In order not to embarrass yourself, you squeeze the
muscles around your rectum to hold the gas back. This is the muscle you want to exercise.
Common Mistakes
Never use the muscles in your stomach, legs, buttocks, and don’t hold your breath. To be sure you are not using your abdominal
muscles, place your hand on your abdomen while you squeeze the pelvic floor muscle. If you are feeling your abdomen move, you are
also using your stomach muscle.
How to Exercise
When exercising it is important to squeeze and relax your muscles as prescribed. One work/ rest cycle is one exercise. If while you
exercise you no longer feel the contraction, the muscle is tired. Stop and rest for a few minutes and then go back to the exercises.
Where to Exercise
These exercises can be done anywhere at any time. If you are doing them properly, your legs, stomach, thighs and buttocks will not
move, and no one will know you are doing your exercises. Do the exercise sitting or lying down when you first start the program. After
eight weeks you can do them standing, sitting or lying.
Can These Exercises Harm Me?
NO! These exercises cannot harm you in any way. If you experience back or stomach discomfort after you exercise, then you are trying
too hard and using extra muscles. Relax, and start over.
Prescribed Exercise
Contract the muscle for 5 seconds, and then relax for 10 seconds (this is one exercise or cycle). Do 5 exercises in a row. Repeat this 4
times each day. If you perform them with an activity that you routinely do every day, you will be more likely to remember them.
Mealtimes, bedtime and driving in the car are very common. New mothers can perform them while bottle/breast feeding.
Increase the contraction time by one second and one repetition every two weeks (always continue 4 x day). Your goal is contract for ten
seconds, relax for ten seconds. Do 10 exercises in a row 4 x day.
Urge Suppression
When you feel the urge:
•Stop what you are doing.
•Sit down, if it is possible, or stand quietly.
•Remain still.
•Rushing to the bathroom may cause you to lose control of your bladder.
•When you are still, the urge is easier to control.
•Squeeze your pelvic floor muscles quickly several times. (Contract 2 seconds, relax for one
second, 5-6 times in a row)
•Relax the rest of your body.
•Take a few breaths to help you relax.
•Wait until the urge goes away.
•Walk slowly to the toilet. Do not rush.
BOWEL REGIMEN
1.Mix 1 rounded teaspoon of psyllium fiber
(Metamucil® brand or Wal-Mart® Equate generic) in
6-8 ounces of cold water. Take this dose of fiber
supplement a minimum of once per day. You may
repeat this dose up to 3 times per day. Please do
not take Metamucil within two hours of any
medications.
2. IF YOU DO NOT HAVE A BOWEL MOVEMENT
WITHIN ONE HOUR OF RISING EACH MORNING,
take one tablespoon of magnesium hydroxide
(Phillips® Milk of Magnesia or a generic
equivalent). Repeat this dose each hour until you
have a bowel movement (do not exceed 6 doses
in a day). Most patients will begin having daily
bowel movements without the need for
magnesium hydroxide within one week of
therapy.
SKIN CARE
• www.kerryskincompany.com