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Clinically Relevant Anatomy
add text here relating to clinically relevant anatomy of the condition
The pelvic floor is made up of the muscles, ligaments, and fascial structures that act together to support the pelvic organs and to provide compressive forces to the urethra during increased intra-abdominal pressure.
The pelvic floor muscles refers to the muscular layer of the pelvic floor. It includes the levator ani, striated urogenital sphincter, external anal sphincter, ischiocavernosus, and bulbospongiosus.
The urethra, vagina, and rectum pass through the pelvic floor and are surrounded by the pelvic floor muscles. During increased intra-abdominal pressure, the pelvic floor muscles must contract to provide support. When the pelvic floor muscles contract the urethra, anus, and vagina close. The contraction is important in preventing involuntary loss of urine or rectal contents. The pelvic floor muscles must also relax in order to void.
Mechanism of Injury / Pathological Process
- Urinary incontinence (symptom): Complaint of involuntary loss of urine.
- Stress (urinary) incontinence: Complaint of involuntary loss of urine on effort or physical exertion (e.g. sporting activities), or on sneezing or coughing.
- Urgency (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency.
- Mixed (urinary) incontinence: Complaint of involuntary loss of urine associated with urgency and also effort or physical exertion or on sneezing or coughing.
- Urgency: Complaint of a sudden, compelling desire to pass urine which is difficult to defer.
- Overactive bladder (OAB, Urgency) syndrome: Urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection or other obvious pathology.
- Urinary Leaking
A large portion of women with urinary stress incontinence can be diagnosed from clinical history alone. In this systematic review, little evidence was found on the performance of urinary diaries, and pad-tests although they are common diagnostic assessments used in physical therapy.
Clinical history taking compared with multi-channel urodynamics was found to have 0.92 sensitivity and 0.56 specificity for the diagnosis of urinary stress incontinence based on the presence of stress incontinence symptoms.
Pelvic Floor Muscle Function and Strength
Pelvic Floor Muscle Strength
Modified Oxford grading system:
0 - no contraction
1 - flicker
2 - weak squeeze, no lift
3 - fair squeeze, definite lift
4 - good squeeze with lift
5 - strong squeeze with a lift
Palpation of the pelvic floor muscles per the vagina in females and per the rectum in male patients.
PERFECT mnemonic assessment, described by Jo Laycock:
P - power, may use the Modified Oxford grading scale
E - endurance, the time (in seconds) that a maximum contraction can be sustained
R - repetition, the number of repetitions of a maximum voluntary contraction
F - fast contractions, the number of fast (one second) maximum contractions
ECT - every contraction timed, reminds the therapist to continually overload the muscle activity for strengthening
The 1 hour pad test was found to have 0.94 sensitivity and 0.44 specificity for diagnosing any leakage compared with multi-channel urodynamics.
The 48 hour pad-test was found to have 0.92 sensitivity and 0.72 specificity for the diagnosis of urinary stress incontinence.
Urinary (Voiding) Diary
One study found a scale derived from a 7 day diary was 0.88 sensitive and 0.83 specific for the diagnosis of detrusor overactivity in women.
- Incontinence Quality of Life Instrument (I-QOL)
- Male Urogenital Distress Inventory (MUDI)
- Male Urinary Symptom Impact Questionnaire (MUSIQ)
- Patient Global Impression of Improvement (PGI-I)
- Patient Global Impression of Severity (PGI-S)
- Pelvic Floor Distress Inventory - 20 (PFDI - 20)
- Pelvic Floor Impact Questionnaire - 7 (PFIQ - 7)
Management / Interventions
The Knack maneuver:
The Knack maneuver essentially is a voluntary contraction performed in response to a specific situation. Teach a voluntary contraction of the pelvic floor muscles with appropriate timing, for example, just prior to a cough or sneeze. It is a useful strategy in patients with stress urinary incontinence.
Pelvic Floor Muscle Training
The pelvic floor muscles are known as the levator ani, made up of the pubococcygeus - puborectalis complex. Those muscles form a sling around the anorectal junction. They are made up of both Type I (slow-twitch) and Type II (fast-twitch) fibers. The majority are Type I (about 70%) which provide sustained support and are fatigue resistant. The remaining Type II fibers provide the quick compressive forces necessary to oppose leakage during increased abdominal pressure. A contraction of the pelvic floor muscles also causes a reflex inhibition of the detrusor muscle.
Patient specific training is necessary to ensure a proper contraction of the pelvic floor muscle group. It is also essential to train both the fast and slow-twitch muscle fibers. Also, training must include instruction in volitional contractions before and during an activity that may cause incontinence, such as coughing, sneezing, and lifting. Patients are typically recommended to perform the exercises four to five times daily.
In 2007, Zanetti, et al compared two groups of women who were assigned to either a supervised or unsupervised perineal exercise group. The supervised group performed the exercises with guidance from a physiotherapist (twice a week, for 45 minutes). The unsupervised group performed the exercises at home with monthly assessments from a physiotherapist. Both groups performed the exercises for 12 weeks. At 3 months, results obtained through the pad test, quality of life questionnaire (I-QOL) and urinary diary, demonstrated that the supervised group improved significantly more than the unsupervised group.
The focus of behavioral therapy is on lifestyle changes such as fluid or diet management, weight control, and bowel regulation. Education about bladder irritants, like caffeine, is an important consideration. Also, discussing bowel habits to determine if constipation is an issue as it is important to educate the patient about avoiding straining. Education and explanation about normal lower urinary tract function is also included. Patients should understand the role of the bladder and the pelvic floor muscles.
The information gathered from the bladder diary is used to guide decision making for bladder re-training, including a voiding schedule if necessary to increase the capacity of the bladder for people with frequency issues. Bladder training attempts to break the cycle by teaching patients to void on a schedule, rather than in response to urgency. Urge suppression techniques are taught, such as distraction and relaxation. It is also important to teach the patient to contract the pelvic floor to cause detrusor inhibition. A voluntary contraction of the pelvic floor muscles helps increase pressure in the urethra, inhibit detrusor contractions, and control urinary leakage. 
Multi-channel urodynamics testing is the gold standard for making a condition-specific diagnosis. This testing is typically done in secondary care, not in primary care or physical therapy.
add text here relating to key evidence with regards to any of the above headings
A systematic review published in the Annals of Internal Medicine in 2008 found good evidence that pelvic floor muscle training and bladder training resolved urinary incontinence in women. However, the effects of electrostimulation, medical devices, injectable bulking agents, and local estrogen therapy were inconsistent.
- American Urogynecologic Society (AUGS) at www.augs.org
- American Urological Association (AUA) at www.auanet.org
- International Continence Society (ICS) at www.icsoffice.org
- National Association for Continence (NAFC) at www.nafc.org
- National Institute on Aging at www.nia.nih.gov
- Section on Women's Health, APTA at www.women'shealthapta.org
- The Simon Foundation for Continence at www.simonfoundation.org
add links to case studies here (case studies should be added on new pages using the case study template)
Recent Related Research (from Pubmed)
- [Stress incontinence in elderly women.]
- Surgical Treatment of Recurrent Stress Urinary Incontinence in Women: A Systematic Review and Meta-analysis of Randomised Controlled Trials.
- Urinary incontinence and risk of functional decline in older women: data from the Norwegian HUNT-study.
- [Application of adipose-derived stem cells in lower urinary tract reconstruction].
- Setons in the treatment of anal fistula: review of variations in materials and techniques.
References will automatically be added here, see adding references tutorial.
- ↑ Natural Childbirth. Childbirth and your pelvic floor. http://childbirth.amuchbetterway.com/childbirth-and-your-pelvic-floor/ (accessed 15 March 2011).
- ↑ Abrams P, Cardozo L, Fall M, et al. The standardization of terminology in lower urinary tract function: report from the standardization sub-committee of the International Continence Society. Urology 2003;61:37-49.
- ↑ 4.0 4.1 4.2 4.3 4.4 Martin JL, Williams KS, Sutton AJ, Abrams KR, Assassa RP. Systematic review and meta-analysis of methods of diagnostic assessment for urinary incontinence. Neurourol Dynam 2006;25:674-683.
- ↑ 5.0 5.1 5.2 5.3 Laycock J. Pelvic muscle exercises: physiotherapy for the pelvic floor. Urologic Nursing 1994;14:136-40.
- ↑ Miller JM, Sampselle C, Ashton-Miller J, Son Hong G-R, De Lancey JOL. Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence. Int Urogynecol J 2008;19:773-782.
- ↑ Doughty DB. Promoting continence: simple strategies with major impact. Ostomy Wound Management 2003;49:46-52.
- ↑ Alewijnse D, Metsemakers JFM,Mesters I, van den Borne. Effectiveness of pelvic floor muscle exercise therapy supplemented with a health education program to promote long-term adherence among women with urinary incontinence. Neurology and Urodynamics 2003;22:284-295.
- ↑ Zanetti MRD, de Aquino Castro R, Rotta AL, dos Santos PD, Sartori M, Girao MJBC. Impact of supervised physiotherapeutic pelvic floor exercises for treating female stress urinary incontinence. Sao Paulo Med J 2007;125:265-9.
- ↑ 10.0 10.1 Burgio KL. Current perspectives on management of urgency using bladder and behavioral training. J Am Academy Nurse Pract 2004;16:4-7.
- ↑ 11.0 11.1 Payne CK. Behavioral therapy for overactive bladder. Urology 2000;55:3-6.
- ↑ Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med 2008;148:459-474.