Fitness for the Pelvic Floor (eBook)

1 Introduction

The pelvic floor is contained within the bony pelvis (Fig. 1.1) and is made up of muscles, ligaments, nerves, fascia, and vascular structures that come together, creating a hammocklike support for the organs in the lowest part of the pelvis. It has four essential functions that are intimately related to one another. In addition to supporting the organs within the pelvis, it plays a role in bladder and bowel control, contributes to static and dynamic stabilization of the pelvic girdle, lumbar spine, and torso, and assists with sexual function.24 The overlap in roles explains why muscular dysfunction in this area can cause a broad spectrum of challenges for men and women.

Pelvic floor muscular dysfunction (PFMD) refers to a wide range of disorders affecting one or, more commonly, a combination of the functions described. It occurs when the muscles are weak, tight, or torn, ligaments and/or fascia are stretched or damaged, resulting in an ineffective system for transferring loads through the pelvis. Often the direct causes are unknown; however, traumatic injuries, sexual abuse, strenuous exercise without proper breathing mechanics, and complications related to childbirth can contribute to the problem. The necessary support for the organs becomes imbalanced, affecting the normal functioning of the lower intestines, bowel, bladder, uterus, vagina, and rectum.

A careful evaluation prior to treatment may indicate which systems are involved. Sometimes the dysfunction can be very complicated and warrants a thorough investigation by a knowledgeable physical therapist and a physician. An experienced therapist may, in addition to training the fast and slow muscle fibers, select other treatment options (e.g., breathing exercises, manual therapy, connective tissue manipulation, soft-tissue mobilization, biofeedback, electrical stimulation, and heat or cold application). Understanding the complexity of possible involvement is especially important when treating patients with pelvic floor pain.67 A one-size-fits-all approach to addressing PFMD simply will not work. Taking a biographical approach to obtaining a client's history can help tell the story that lies within the tissues and informs what is necessary to help the client in a meaningful way. Consideration of the client's individuality and sensitivity to challenges which may be related to emotional and physical abuse are essential to creating a nonthreatening environment where one can heal. The effects of trauma can impact the survivor's experience of the entire process of care, health-related behaviors, and outcomes.60 Establishing rapport, detailing the process, expectations, and placing the client in a position of comfort while being mindful of language use are essential. Being aware not to sit higher than the client during the intake can make a world of difference.

The muscles of the pelvic floor have the same capabilities as any other muscle in the body; they must be able to contract, relax, elongate, and give feedback. If one cannot effectively contract the muscles, they may experience inadequate support for the organs, pelvic girdle, urethra, or sphincter. Difficulty with relaxing the muscles can result in lower back pain, pain during intercourse, inability to completely empty the bladder, and painful trigger points within the muscles of the pelvic girdle. The inability to elongate the muscles can also result in constipation and digestive issues.

The debilitating impact of urinary incontinence (UI) represents a condition in young people that has the most substantial negative impact on “health-related quality of life” (Fig. 1.1). In older individuals, next to stroke and Alzheimer's disease, UI is reported to have the most negative effect on “health-related quality of life.”59,62 The cost of incontinence-related care is astonishing. This fact, combined with the 6.5-year average length of time from when individuals first experience bladder control symptoms to when they seek medical attention, is our call to action. The time has come to address the issue through education, conversation, and a specialized approach to designing pelvic floor fitness programs.

1.1 Basic Bladder Neurophysiology

Various micturition (voiding) centers in the brain and spinal cord are involved in emptying the bladder. These centers control the reflexes to empty the bladder and coordinate its filling. Some of the reflexes involved in this process can be inhibited by voluntary control. In the bladder emptying phase, a signal from these nerves coordinates the detrusor contraction and urethral sphincter relaxation. The voluntary relaxation of the urethral sphincter and pelvic floor while the detrusor muscle contracts and empties the bladder (Fig. 1.2).

A unique feature of the bladder is that emptying (voiding) can be delayed or done early, even when the bladder is not full. A person usually empties the bladder when it is most convenient, typically every 2 to 4 hours during the daytime and less at night.

An important micturition center lies in the brainstem. Information from the bladder first reaches the micturition center of the sacral spine before being relayed to the brainstem. The micturition center of the brainstem conveys the information that the bladder is filling up to the brain (cortex). It also relays messages to other essential areas within the brain, such as the limbic system (center for motivation and memory) and the cerebellum (responsible for muscle control). The connection to the cortex enables a person to make a conscious decision to delay micturition or to empty the bladder early.

Therefore, patients who suffer from a stroke or Alzheimer's disease, which can result in damage to some regions of the brain, can experience problems. They may not remember that they can postpone emptying the bladder, or they may be unmotivated, depending on the injury to the brain. It is also possible that the cerebellum is damaged and that the muscles cannot be well adjusted and therefore do not function optimally.

With poor memory, it may be necessary to prompt voiding by reminding the patient to empty the bladder regularly. With other patients, timed voiding may be required, which means that the patient is placed at regular intervals on a toilet to empty the bowel or bladder. With timed voiding, some patients afflicted with dementia can stay dry.

Patients with spinal cord injuries often suffer from damage to the tracts connecting the micturition center in the sacral region with that in the brainstem. These patients are no longer able to influence voiding voluntarily. The use of a catheter may be required. Tapping the bladder or other tricks (such as a brief manual stretch of the external anal sphincter muscle) can trigger bladder emptying by eliciting relaxation of the pelvic floor muscles. Relaxation is a prerequisite for the contraction of the bladder muscle. If it works, the short reflex arc from the bladder to the sacral micturition center and back to the bladder causes the bladder to empty.

Bladder infections may cause the short arc reflex to be overactive, resulting in a great desire to empty the bladder, called an “urgency.” If the reflex activity is not functioning correctly, it can also cause a “spasm” of the bladder muscle, resulting in a strong urge to empty the bladder immediately. It is most important not to move when this happens; in fact, it helps to try to actively relax the muscles with deep breathing and a conscious effort to relax. It may also be beneficial to perform a few quick contractions of the pelvic floor muscles (“quick flicks”), as this may contribute to normalizing the irregular reflex activity. Distraction can help in some cases. With practice, such contractions can help to delay emptying consciously and to overcome the urgency.

Finally, strong pelvic floor muscles provide a solid base for the bladder and can be instrumental in overcoming urge incontinence. Because the external sphincter muscles are part of the skeletal pelvic floor muscles, their strength may help to control urgencies.

The pelvic floor muscles are innervated by the pudendal nerve, which originates in sacral roots 2 to 4 of the spinal cord. The nerve reacts to information from the micturition centers. Injury to the pudendal nerve (such as stretching during a difficult birth or damage sustained through a fall on the sacrum) prevents the pelvic floor muscles from contracting correctly. The muscle tonus may be too low and the muscles weak. This can result in urinary or anal incontinence, inability to control gas, or dysfunction of the pelvic floor muscles, even if all reflexes are intact. Interestingly, the pelvic floor muscles have a higher resting tone than other skeletal muscles. This is to ensure continence at night.

Various reflexes (some of which are not yet fully understood) are finely coordinated with the activity of the pelvic floor muscles. It is believed that the transverse abdominal muscle influences the strength of the pelvic floor and assists in providing continence.58

The autonomic nervous system (Fig. 1.3) is connected in the sacral area (parasympathetic nerve fibers) and upper lumbar region (sympathetic nerve fibers) with the spinal cord and helps regulate all the reflexes. The autonomic...