These days most people are aware that pregnancy and childbirth are risk factors for weakening and injury to the perineum and pelvic floor. This may result in urinary and faecal incontinence, pelvic organ prolapse, defecation dysfunction, sexual dysfunction, sensory and emptying abnormalities of the lower urinary tract, and chronic pain syndromes. Up to 50% of women lose some of the support function of the pelvic floor following childbirth. Recent research using ultrasound and magnetic resonance imaging reports major injuries to the pelvic floor muscles as 20-26% following vaginal delivery. However, having a cesarian delivery does not mean you are exempt from pelvic floor weakness. The nine month gestation and the weight of the baby pushing down on these muscles also has a large impact on the pelvic floor. Other risk factors for pelvic floor weakness include the number of pregnancies, previous occurrence of UI, obesity, long second stage of labour and a large baby.
Urinary incontinence (UI) is the most common symptom of pelvic floor weakness and its prevalence varies between 32% and 64%. Stress urinary incontinence (SUI) is the most common form. This is defined as an involuntary loss of urine on effort or physical exertion such as laugh, cough, sneeze, lift or jump. A systematic review showed that SUI during pregnancy varied from 6% to 67%, and from 3% to 38% two to three months after delivery. Many people we see at Physiotherapy think that having some UI after childbirth is “normal” and just “put up with it”. This is not the case. It is actually a significant problem that impacts women’s physical, sexual and psychological health. It can also interfere with family recreational activities and overall quality of life.
A wide range of interventions can be used to treat urinary and faecal incontinence, including pelvic floor muscle training (PFMT), lifestyle interventions, behavioural training, pharmaceutical intervention and surgery. As women’s health Physiotherapists, we advocate conservative management by assessing pelvic floor strength and teaching a pelvic floor program. Pelvic floor muscle training involves repetitive contraction of the pelvic floor muscles, which builds strength and perineal support and improves muscle tone. It strengthens the peri-vaginal and perianal musculature to increase control of urine leakage. An evidence-based recommended practice suggested that a PFMT program should include an assessment of patient needs, detailed instructions of how to perform a pelvic floor muscle contraction, and most importantly a confirmation of correct contraction via an internal examination and/or diagnostic ultrasound. Vaginal palpation is used to grade muscle power from zero to five according to the Oxford grading system. The amount of exercise should reach a total of 30-100 contractions per day. Recent studies showed that verbal instruction alone is not adequate for most women to successfully perform PFMT. Individualized training and support including biofeedback, exercise diaries and regular appointments can improve the correct activation of the exercises and the frequency with which PFMT is undertaken.
Training programs and instructions described in different studies can be highly variable, as can the recommended posture for the exercise regime and duration. It varied from one week to six months, with three months being the most frequently recommended. We recommend working through gravity reduced postures such as lying flat or on your back, and working to anti-gravity positions such as sitting and standing. We recommend doing 3 sets of 10 reps per day which is a total of 30 pelvic floor contractions daily in the strengthening phase. In the maintenance phase the total daily repetitions can be reduced.
It must be remembered that PFMT, first introduced by Kegel in 1948 for the treatment of SUI, is now recommended by leading health organizations as first line therapy to all women with stress, urgency or mixed urinary incontinence. Women who have not had children can also present with different combinations and degrees of incontinence and/or pelvic floor weakness. It is never too late to seek assistance from a women’s health Physiotherapist to be taught how to do pelvic floor exercises and have a huge positive impact on daily activities and quality of life. An up-to-date Cochrane systematic review of 21 randomized or quasi-randomized trials involving 1,281 women show that SUI who undergo PFMT are 17 times more likely than controls to report short-term cure or improvement. Unfortunately long-term outcome results of more than one year after treatment were not reported. We are aware that long-term adherence to PFMT is associated with better outcomes, however the adherence rate is known to be poor. This is where we as Physiotherapist hope to make a difference by promoting people to continue PFMT throughout their lives.
If you have any concerns about your pelvic floor strength, are having episodes of incontinence or want to check if you are doing your pelvic floor exercises correctly, please call Q Pilates Indooroopilly on 32781008 to book an appointment with our Women’s health Physiotherapist.
Written by Rebekah Kenos- Women’s Health Physiotherapist
Weijie Xing, Yu Zhang, Chunyi Gu, Lucylynn Lizarondo. “Pelvic floor muscle training for the prevention of urinary incontinence in antenatal and postnatal women: a best practice implementation project”. JBI Database System Rev Implement Rep 2017; 15(2): 567-583
Netta Beyar, Asnat Groutz. “Pelvic floor muscle training for female stress uninary incontinence: Five years outcomes”. Neurourology and Urodynamics Volume 36, Issue 1 January 2017 Pages 132-135