Pelvic floor (PF) hypertonicity/overactivity

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Pelvic floor (PF) hypertonicity/overactivity

• Synonymy
• PF essential /episodic hypertonicity
• Sphincter dyssynergia/ pseudodyssynergia-excessive
  PF activity during voiding
• Clinical diagnosis
• Spastic Urethral Sphincter(HPLF)
• Poor Pelvic Floor Relaxation (LPLF)
• Dysfunctional voiding
• Detrusor instability
• Frequency urgency syndrome

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Etiology

• Persistence of a reaction phase to noxious
  stimulus of LUTs (e.g. inflammation, infection,
  irritation, post-surgery)
• learned dysfunctional voiding behavior
• Persistent transitional phase in the development
  of micturition control
• Sexual abuse

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Urologic menifestation

• Lower urinary tract symptoms( LUTS)
• storage symptom Urgency, frequency, urge
  incontinence
• emptying symptoms poor stream, hesitancy,
  need to strain, a feeling of incomplete bladder
  emptying
• Childhood enuresis, recurrent urinary tract
  infection (UTI), reflux, hydronephrosis
• Adult LUTS, recurrent UTI, incomplete emptying,
  incontinence.
• Cocommittent symptoms constipation, pelvic/
  perianal pain

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Diagnosis

• Clinical history
• Urinalysis infection
• Cystourethroscopy exclude bladder
  cancer/anatomic bladder outlet obstruction
• Uroflowmetry with EMG ultrosonography
  Videourodynamic study
• ?sphincter EMG during voiding

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Frequency urgency syndrome NPLF and poorly
relaxed urethral sphincter
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-incontinence -reflux -mucosal ischaemia
-diet regulation -drinking and voiding
chart -pharmacotherapy
Bladder dysfunction
Overtraining of the pelvic floor muscles
Pelvic floor dysfunction
Biofeedback electrical stimulation manual
technique
-milk-back of urine -residual urine -pelvic pain
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EVALUATIONhistory

• Current symptoms
• micturition, pain, defecation, sex life
• Childhood prolonged bedwetting, excessive ex to
  achieve urinary continence, punishment for
  bedwetting, retentive voiding habit, sexual abuse
• Adolescence painful menses, frequent UTI
• Adulthood childbirth, vaginal delivery, pelvic
  surgery, voids habits, profession, social life

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Evaluation

• A complete history
• Frequency /volume chart for 3 days
• Neurological examination (lower quarter)
• proprioception, sensation
• Peripheral reflexes
• Physical examination
• Sacroiliac coccygeal position /mobility
• PF assessment
• External observation
• Digital per vagina or anus
• Periometry
• EMG assessment

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Pelvic floor assessment

• Digital examination tone,contractility,endurance
  
• -Poor muscle isolation,impaired contract and
• relax voluntarily
• -trigger point, tenderness, spasm
• EMG assessment
• -abnormal tension and instability at rest
• -slow recruitment and recovery time
• -weak and instability during phasic, Tonic and
  endurance voluntary contraction

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Management-Behavioral modification

• Education on urinary system and PF dysfunction
• Individually adapted drinking/voiding schedule
• Diet avoid bladder stimulants, high fiber
• adequate daily intake of water
• General recommendations for changing wrong
  voiding behavior
• take time for micturition, do not push
• Instruct a proper toilet posture
• --sit or squat for voiding every time (men also)
• no straining
• timed voiding (24 hours)

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Pelvic floor retraining with EMG biofeedback

• A series of contraction to enhance awareness of
  levels of relaxation
• Goal
• to help identify pelvic floor musculature
• to perceive difference between
• contraction, relaxation, and straining
• to voluntary relax pelvic floor during
• voiding

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Pelvic floor retraining with EMG biofeedback
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EMG biofeedback
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EMG biofeedback

• Surface or Intravaginal/intra-anal EMG sensor
• Protocol
• One minute rest, pre baseline
• Ten rapid contraction (phasic) with 10-s rest
  between each
• Ten 10-s contraction with 10-s rest between each
  (tonic)
• A single endurance contraction of 60-s
• One minute rest, post baseline

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PF relaxation trainingVoiding biofeedback
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• Home program
• Home sEMG unit
• 5-s contract/10-s relax, 20 reps twice
  daily
• ?10-s contract/10-s relax, 60 reps twice
  daily
• Diaphragmatic breathing
• Visualization the ischial tuberosity seperating,
  
• a hole getting
  larger
• Perineal bulging
• Relaxing environment guiet, relaxing music
• Total body relaxation, progression relaxation
• Practice in different posture and during voiding

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Combination therapy for concomitant urologic
symptoms

• Detrusor instability anticholinergic drugs
• Recurrent UTI antibiotics
• Chronic constipation
• regulation of diet,
• bowel training
• drug therapy

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clinical effect

• 51-83 improve for the long-term follow- up
• normal flow curve good pelvic floor
  relaxation
• no significant residual urine
• decrease occurrences of UTI, enuresis,
• hydronephrosis
• -- improve constipation
• Tzu-Chi general hospital, 2001 Nov2003Mar
• 70.7 achieve normal flow pattern
• significant symptom
  improvement

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Important factors for successful biofeedback
training

• --good motivation and cooperation
• --Appropriate selection of patients
• Intact nervous system

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Electrical stimulationTENS/IFC/NMES 5-20Hz,
210µs, --sacral dermatome, suprapubic,
posterior tibial n. --Large skin afferents
suppress spontaneous reflex activity
within the dermatome
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Electrical stimulationHigh voltage
electrogalvanic DC, 80-120Hz, --intravaginal
/Rectal probe --induce tentanic and fatique of
levator ani to break the spasm-pain high
relapse rate in 6 monthsEffectiveness depend on
frequent, ongoing treatment
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Manual technique

• To restore sacroiliac sacrococcygeal alignment
• Manual therapy to Realign sacroiliac
  sacrococcygeal joint
• To ? tension and promote m. relaxation, improve
  m. awareness
• Trigger point pressure (sustain 10-15 sec)
• Myofascial massage(10-15 sweeps)
• Muscle energy technique

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Treatment consideration

• Behavioral modification
• Pelvic floor retraining (Biofeedback)
• Electrical stimulation
• Manual technique
• pharmacotherapy

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Thanks