Pelvic Floor Exercises

Pelvic floor muscles

Definition:

·         It is sheath of musculofascial structure occupying the outlet of pelvis and it includes all the tissues from the skin of perineum below to the superior fascia of levator ani muscle above.

Functions:

·         Closure of pelvic outlet

·         Support to the pelvic organs and viscera

·         Helps in coughing, sneezing and lifting activities

·         Helps in micturation, defection, parturition by raising the intra-abdominal pressure

·         Controls the sphincteric action of urethra, vagina and rectum

Pelvic floor exercises

Pelvic floor muscle contractions can be confirmed by

·         Vaginal examination by physiotherapist

·         Self-examination by patient

·         Hand an perineum by physiotherapist/patient

·         Perineometer

·         Stop and start midstream urine

·         Foley‘s catheter/tampon

·         During intercourse

·         EMG

·         Biofeedback

Teaching pelvic floor contractions

a. Visualization:

·         A large simple diagram of the pelvis, pelvic organs, levator ani muscles helps to show the three openings.

·         It also helps to show the lifting and gripping action of muscles

b. Language:

Words and images are chosen which are easily understand ask the patient to:

·         Stopping/passing urine

·         Stopping/passing/breaking wind

·         Blowing off/parking

·         Stopping diarrhea/shit/poo

·         Trying to stop from leaking/wetting your pants

·         Gripping to stop with a tampon falling out

·         Gripping your partners penis

c. Starting position: (for sensory feedback)

·         Sitting on a hard chair, leaning forwards to support forearms on knees with thighs and feet together is the initial starting position

d. Duration and repetition of contraction:

·         During the 1st session the patient is asked to hold a contraction strongly until she feels the muscles weakening

·         The duration is timed and recorded

·         Then long and strong contractions are repeated on after the other.

·         Also check for contractions of other muscles like gluteus, hip adductors and abdominal muscles.

e. General advice:

·         The patient is advised to contract the pelvic floor before sneezing, coughing or laughing may cause a strong desire to void.

·         This is called as counter bracing

f. Contractions and relaxation:

·         Ask the patient to contract the

·         Pelvic floor during

-          Passage of urine

-          To stop/pass wind

-          To stop diarrhea

·         Quick contraction of pelvic floor by hold and relax technique can be used

·         Elevator exercises: Ask the patient to imagine going up in an elevator and contract her pelvic floor by gradually increasing the intensity as the lift goes up by and floor and then to relax gradually as the lift comes down by floor

·         Pelvic tilting with rotations in supine position.

·         About 8-12 fast contractions followed by 3-4 slow –short contractions can be done.

g. Pelvic muscles strengthening exercises:

a. Perineometer

·         Kegel device is a pneumatic device which helps to measure the pressure inside the vagina and to motivate the women to practice pelvic floor exercises

·         A compressible air filled rubber cuff was inserted into the vagina which is connected to a manometer by a rubber tubing

·         Ask the women to contract her pelvic floor several times and note the highest reading in the dial. Also, note the length of time for which she could hold her contractions.

·         It is useful as biofeedback and for motivation

·         Take care that intra-abdominal pressure is not measured rather than pelvic floor

b. Foley’s catheter/Tampon

·         An air filled catheter is inserted into the vagina and the patient is asked to contract and hold the catheter against the traction given by the therapist

c. Vaginal cones:

·         It consists of 5-9 small cones or cylinders ranging from 10 gm to 100 gm

·         They are made up of lead coated with plastic and a nylon string is attached at one of the tapered ends

·         It is a size of a tampon

·         The lightest cone is inserted first and ask the patient to hold and walk for 15 min

·         Once the cone is retained for 15 min without slipping progression is made to the next cone

·         This helps to activate the motor units to support the cones and to increase woman‘s awareness of her ability to contract the pelvic floor muscles voluntarily.

d. Interferential therapy: (IFT)

·         This improves the woman‘s cortical awareness and the ability to perform voluntary contractions

·         Position is in ½ lying position with hips and knees slightly flexed

·         The electrode position should be such that the interference occurs at the pudendal and pelvic nerves

e. Low frequency muscle stimulation

·         Faradism (surged) is used in re-education of pelvic floor muscles

·         Levator ani muscles can be contracted using vaginal or anal electrode

·         Pulse width: 0.1 – 7 m/s

·         Frequency: 0.5 – 40 Hz

f. Pelvic tilting exercises:

·         Pelvic rolling       

·         Pelvic rocking with circular motion

·         Postural correction by pelvic tilting in standing

g. Lengthening of hip adductors:

·         Contract-relax techniques in cross leg sitting by pushing the knees to the floor

·         Modified squatting

·         Stretching activities