Pelvic Health 101 Mairead Hughes Specialist Physiotherapist The National Aspergillus Centre Wythenshawe Hospital Manchester University NHS Foundation Trust

Aims of todays talk… Introduce topics related to pelvic health Raise awareness of assessment protocols and treatment options Signpost patients to resources for education and self management Improve general health and well being: important in holistic care of aspergillus related illnesses

Why…? Having poor control of bodily functions quietly disempowers people by interfering with every single aspect of their lives; planning trips around rest room locations and breaks, fluid intake around planned activities or not going out at all. May is Pelvic Pain Awareness Month

True or False… Urinary incontinence is normal in females… Urinary incontinence can only be fixed by surgical procedures…

Role of the Pelvis Structural Support: primary role is to support the weight of the upper body when sitting and to transfer this weight to the lower limbs when standing. It serves as an attachment point for trunk and lower limb muscles, and also protects the internal pelvic organs. Excretion of waste products: urine, menstruation, faeces Reproduction and Sexual Well Being

The World Health Organization stated… incontinence is a largely preventable and treatable condition and “certainly not an inevitable consequence of ageing” World Health Organization Calls First International Consultation on Incontinence. Press Release WHO/49, 1 July 1998. 

Pelvic Diaphragm Deepest Layer Function: Levator Ani Muscles Pubococcygeus Pubovaginalis Puborectalis Iliococcygeus Coccygeus Function: Support the pelvis Support the organs Assist abdominals Sphinteric Sexual appreciation Muscle Fibers 30% fast twitch 70% slow twitch The deepest layer of muscles of the pelvic floor is the Levator Ani Muscles. These muscles act as a sling to support the pelvis and internal organs with continuous resting tone. Additionally the levator ani assist the abdominals during forced urination, expiration or any time the abdominals need assist with contracting. They assist with sphinteric closure as well. These muscle fibers consist of slow and fast twitch fibers which we will discuss more later. The coccygeus is not part of the levator ani, but it is a deep muscle of the pelvic floor and stabilizes the sacro-iliac joint.

Mobility vs. Stability Pelvic floor- function Supportive Sphinteric Sexual Too much mobility-prolapse or incontinence Too much fixation-pain The pelvic floor needs to perform the functions as listed above. Due to the nature of the structures-layers of muscles surrounded by fascia -a balance of stability versus mobility is needed for the pelvic floor to function properly. There needs to be a certain amount of pliability allowing for urine and stool to pass, as well as stretching for reproductive functions. Additionally, there needs to be adequate muscle tone to provide stability, to support the pelvic organs, maintain continence, and prevent prolapse as well as allow for sexual appreciation. Physical therapists can address this by determining if the patient requires stretching and relaxation to assist with mobility, or strengthening and muscle reeducation to improve support and tone.

The Male Pelvic Floor

Female Pelvic Floor Within the superficial muscle layer is made up of the superficial transverse perineal, bulbocavernosus and ischiocavernosus (see diagram). Within the perineal membrane layer are the deep transverse perineal, compressor urethra and the sphincter urethra muscle. These muscles assist with sphincter control. These two layers in combination with the fascia are also known as the urogential triangle. Note the anal triangle. Within the anal triangle are two muscles: the internal sphincter and the external sphincter. The Internal sphincter may suffer trauma with childbirth. The external sphincter is voluntary. Special attention to the perineal body. This is made up of a fibromuscular node known as the central perineal tendon. It is the insertion for the urogential triangle muscles, as well as the external anal sphincter and portions of the levator ani muscles. This is the region where an episiotomy may be performed or tears during childbirth most often occurs. This can later affect sphincter control and sensation. In this diagram you can also see the gluteus maximus and a portion of the levator ani which is the deeper layer.

True or false It is normal to leak when you cough or sneeze Only females get stress incontinence

Incontinence in Respiratory Conditions hyperinflation  BMD (osteoporosis) infection exacerbation kyphosis  inflammatory markers abnormal posture Coughing  muscle strength pain  LBM Incontinence autonomic control constipation

Urinary Incontinence: Post Prostatectomy 99% Glina 2009, 1 year occasional 90% Peterson 2012 Stress incontinence Urge Incontinence Passive Incontinence Frequency/low capacity Nocturia Post void retention Post void dribble 80% Milios Climacturia 70% Milios unpublished

Pelvic Floor “The Knack” (Bracing Techniques) Brace with your pelvic floor and deep abdominal muscles when you cough, sneeze, lift or exercise Need to master in controlled environment, cortical before anticipatory subconscious

Treatment Strategies-Incontinence Stress and Urge Scheduled voiding Bladder retraining Relaxation techniques Type and amount of fluid intake Patients benefit from being placed on a voiding schedule with gradual increase in time between voids. Initially start with schedule that patient can comfortably tolerate and gradually increase time. Goal is 3-4 hours between voids. Patient uses pelvic floor muscle contraction, relaxation and behavioral techniques to gradually achieve this goal. Also encouraged is type and amount of fluid intake, as well as dietary factors that may contribute to irritable bladder.

How long and how many? To strengthen a muscle you need to find the isolated muscle then gradually fatigue a muscle Must be individualised: - How long can YOU hold for? How many can YOU do? How fast- time 10 quick lifts At the righ time- c/sn/lift bucket

Urinary Incontinence Summary Prevalence of UI is higher than ‘healthy’ population Patients often more tolerant of UI symptoms as have significant other symptoms or functional issues Major cause is coughing Likely to impact on spirometry and ACT Unlikely to ask for help Big problem when severely affected Reluctant to be assessed McVean 2002

Bowel Health

True or False You should chew your food 20 times before swallowing ‘Al Dente’ vegetables are the best for your digestive health Digestion begins in the stomach

True or False It is normal to have your bowels open once every three days…. It is normal to have your bowels open three times per day…

Good Bowel Habits Optimal stool consistency- Ensure Adequate Fluids, movicol v metamucil Eat sufficient Fibre ** Light pressure to initiate evacuation Perineum drops, puborectalis relax, EAS open Use Optimum Defecation Position- stool, knees Very high priority for all pelvic floor conditions KISS – balloon expulsion

True or False It is normal to pass wind 10 times per day

Wind

Fight or Flight vs Rest and Digest Over stimulation in current lifestyle vs ‘caveman days’ of fight or flight Sit to eat and take time to rest following food, allows your body to focus on digestion

Relaxation, mindfulness… Can help general well being as well as digestive and respiratory health Mindfulness can help manage symptoms of breathlessness and panic https://www.nhs.uk/conditions/stress-anxiety-depression/mindfulness/

www.bladderandbowel.org www.eric.org.uk https://www.nhs.uk/conditions/

References Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice, New York, Springer-Verlag, 1994 Wallace K: Female pelvic floor functions, dysfunctions, and behavioral approaches to treatment. Clinics in Sports Med, 13:2:459-480, 1994 Gray, H : Gray’s Anatomy of the Human Body. Philadelphia, Lea & Febiger, 1918 Moore, K: Clinically Oriented Anatomy (ed 2) Baltimore, Williams & Wilkins, 1985 Wall LL, Norton PA, DeLancey JO: Practical Urogynecology. Baltimore, Williams & Wilkins, 1993 Pastore, E. A., & Katzman, W. B. (2012). Recognizing Myofascial Pelvic Pain in the Female Patient with Chronic Pelvic Pain. JOGNN: Journal Of Obstetric, Gynecologic & Neonatal Nursing, 41(5), 680-691 Gentilcore-Saulnier, E., McLean, L., Goldfinger, C., Pukall, C. F., & Chamberlain, S. (2010). Pelvic Floor Muscle Assessment Outcomes in Women With and Without Provoked Vestibulodynia and the Impact of a Physical Therapy Program. Journal Of Sexual Medicine, 7(2), 1003-1022. Schussler B, Laycock J, Norton P: Pelvic Floor Re-education: Principles and Practice. New York, Springer-Verlag, 1994