The past century has seen a dramatic fall in maternal morbidity and mortality especially in developed counties. Women now have high expectations of pregnancy and childbirth and feel disillusioned when complications occur later. One such issue is pelvic floor problems.
The pelvic floor in a woman is a sheet of tissue comprising muscles and tendons that span the outlet of the pelvic bone at the level of the hip. It consists of symmetrically paired muscles (levator ani) enveloped by thickened supportive tissue called endopelvic fascia. The fascia not only separates these openings but also provides circumferential support. The pelvic floor supports important organs like the uterus, the bladder and the bowel, which exit the pelvis through their respective openings.
Constant tension
The pelvic floor muscles differ from other muscles in the body in that they are constantly under tension and relax only when the bladder or bowel is emptied. They have the ability to contract quickly during an acute stress like a cough or sneeze or distend considerably during childbirth to allow passage of the baby's head and then get back to normal after delivery.
Any damage to the pelvic floor results in pelvic floor dysfunction. Symptoms include urinary or faecal incontinence, prolapse of pelvic organs, sexual dysfunction and chronic pain in the region. These are debilitating conditions that prevent a woman from enjoying a full and active life.
Pregnancy itself has a considerable bearing on the pelvic floor. The weight of the growing foetus can compress and distend tissues. During delivery, when the foetal head presses on the pelvic floor, the organs are susceptible to injury. The pelvic floor muscles, the bladder and bowel are caught between two bony projections — the foetal head and pelvic bone — and compressed and distorted. The pudendal nerve, which supplies the sphincters of the urethra and bowel, is stretched as the head emerges through the birth canal. In most cases the nerve recovers in six weeks but sometimes the injury is permanent and becomes more telling when the woman ages.
Pelvic floor disorders like urinary incontinence, severely impact quality of life. Though surgery provides definitive treatment for most problems, many non-surgical techniques have developed to treat, if not eradicate, them. As early as 1948 Kegel advised Pelvic Floor Muscle Exercise (PFME) for pelvic floor rehabilitation in postpartum women.
This is a learned technique of contracting and relaxing the muscles that surround the vagina and the bladder and bowel sphincters. These exercises are simple, free of side effects and can be attempted by women in the privacy of their homes. They are effective and can be considered first line treatment for most pelvic floor dysfunction problems.
The first priority in teaching women PFME is to identify the muscles to be exercised. The patient should understand not only the location of muscles, but also how to contract them.
It is important for patients to understand that the pelvic floor muscle is under voluntary control and can be trained like any other muscle in the body. Like other muscles the pelvic muscles need sustained effort. However, overworking them can cause fatigue. Hence a recovery period of typically 10 seconds should be allowed between efforts.
Though there is no standardisation among clinicians about the frequency of PFME, the US department of health and human services recommends 30 to 80 pelvic muscle contractions a day to reduce stress urinary incontinence. Women are more likely to initiate and maintain a programme with lower repetitions. Exercises can be done in lying down, sitting or standing position. The results may not become apparent for four to six weeks. Exercises should be planned to fit into the daily routine. Patients need to go back for regular follow up to their physicians in six week intervals.
Biofeedback
Biofeedback is a technique that takes information about certain events in the body and presents it in a way that one can see or hear and understand. Biofeedback can be used as a teaching tool to help women learn to control and strengthen their pelvic floor muscles. It also allows the therapist to measure someone's muscle strength and individualise their exercise programme.
Vaginal cones are tampon-sized and available in sets of five incremental weights. They are used for resistance training of pelvic floor muscles. Clinical studies have shown this approach to be effective in incontinence reduction. In light of their simplicity, these are frequently prescribed as home adjuncts to office-based biofeedback sessions.
Functional electrical stimulation analogous to current that stimulates the muscles in back pain directly stimulates a pelvic muscle contraction. In clinical trials it has been found effective in the treatment of both stress and urgency incontinence. The frequency and the intensity of current are adjusted according to the woman's comfort level. It can be both home and office based.
A PFME program to rehabilitate the pelvic floor muscles should be as much a part of a woman's self care as a monthly self breast examination or an annual Pap smear. The physician should routinely offer PFME information to all female patients and incorporate evaluation of PFME technique into the regular gynaecologic examination.
