1. Women’s Health Topics in Physical Therapy
Holly Bommersbach PT, MPT
Angela Avalos PT, MPT

2. Objectives
Identify types of pelvic pain and dysfunction, potential causes, and physical therapy approaches
Discuss types of bladder and bowel dysfunctions and physical therapy approaches
Discuss the effects of pregnancy and delivery on the body and physical therapy approaches

3. Pelvic Pain and Dysfunction

5. Pelvic Pain and Dysfunction
Pain which occurs in the perineal and/or anal areas
Pain in the lower abdomen, low back and/or pelvic girdle
Pain may often affect other areas, making defecation and/or penetration painful or can cause bowel/bladder urgency/frequency

6. Pelvic Pain and Dysfunction
Study of 5000 US women years old found 1 in 7 affected by chronic pelvic pain (CPP)
Of 500 employed women with CPP, over half reported lost time from work or reduced work productivity
Estimated medical costs of outpatient visits for CPP in US population of women aged years at $881 million/year

7. Pelvic Pain and Dysfunction
Musculoskeletal dysfunctions often contribute to the signs/symptoms of CPP and in many cases are the primary factor
Physical Therapists can specialize to be skilled in the evaluation and treatment of pelvic floor musculoskeletal dysfunctions and are often successful in treating/managing CPP

8. Frequently Seen Pelvic Pain Diagnoses
Endometrial adhesions or nodules on pelvic ligaments
Referred from the low back or spine
Pelvic trigger points
Fibromyalgia
Abdominal or perineal scar adhesions
Pelvic floor dysfunction
Levator ani syndrome
Pelvic relaxation
Pelvic fractures
Coccydynia
Vulvodynia
Vaginismus- pelvic floor tension, myalgia and hypertonus
Vulvar vestibulitis syndrome
Injury sustained during sexual assault
Results of childbirth, vaginal or cesarean section
Pelvis alignment
Pudendal nerve entrapment

9. Dysfunction Terminology
Tone: resistance to displacement of the pelvic floor muscles at rest
“Spring System”
Normotonus
Hypertonus
Hypotonus
“Spring System”- role is to counterbalance the weight effect of the pelvic and abdominal organs
Normotonus: muscle tension is adequate to counterbalance forces working on it
Normal PF muscles can voluntarily and involutarily contract and relax
Hypertonus: increased PF m. tone
More or less continuous state of contraction
And impaired contraction due to m. fatigue

10. Dysfunction Terminology
Overactive Pelvic Floor
Muscles do not relax and may even contract when relaxation is needed such as when urinating or having a BM

11. Dysfunction Terminology
Underactive Pelvic Floor
Unable to voluntarily contract when this is appropriate

12. Dysfunction Terminology:
Nonfunctioning Pelvic Floor Muscles- Pelvic floor muscles with no action palpable

13. Dysfunction Terminology
Short Pelvic Floor
Usually without increased muscle activity
Doesn’t respond to palpation with normal spring
Muscles feel like “firm shelves and violin strings”
Display trigger points (points of marked tenderness)
Relaxation difficult; slow, if at all
Weakness due to shortened length of muscle

14. Treatment Trigger point release, vaginal dilators, manual therapy
Therapeutic US, heat, cold, electrical stimulation
Stretching, strengthening, stabilization, relaxation, muscle energy techniques, behavioral activities, progressive exercise program

15. Pelvic Floor Pain Treatment Planning

16. Case studies

17. Bowel and Bladder Dysfunctions

18. Bowel and Bladder Dysfunctions:
Urinary Incontinence
Voiding Dysfunction
Bowel Incontinence
Constipation

19. Urinary Incontinence (UI)- “Bladder Leakage”
Condition in which involuntary loss of urine is a social or hygienic problem
UI is not a disease process
UI is a symptom or a sign
UI is NOT a natural part of aging

20. Attitudes Toward Incontinence
Most people do not understand treatment options
Studies show an average of 7-9 years for someone to seek treatment
Social Isolation may occur
Quality of life affected

21. Impact of Incontinence
Affects 13 million people of all ages
Women are twice as likely as men to be incontinent
As many as 30% of men and women over the age of 60 living at home experience some bladder control problems
Cost estimated at 10+ billion annually

22. Causes of Incontinence
Overactive bladder muscles
Weakness of muscles that support and hold the bladder in place
Weakness of the urethral sphincter and muscles
Blocked urethra- enlarged prostate
Hormone imbalance in women
Neurologic disorders and immobility

23. Common Types of Incontinence
Stress Incontinence
Urge Incontinence
Mixed Incontinence
Overflow Incontinence
Functional Incontinence

24. Stress Incontinence Involuntary loss of urine during physical exertion
Laughing
Lifting
Coughing
Sneezing
Running
Jumping
Dancing

25. Urge Incontinence
Involuntary loss of urine with a strong need/urge to go to the bathroom
Can’t get to the bathroom quickly enough
Frequent urination
Strong link to diet: caffeine, artificial sweeteners, acidic fruits/vegetables/juices

26. Mixed Incontinence
A combination of both stress and urge incontinence (present together)

27. Overflow Incontinence
The involuntary loss of urine from an overfull bladder, often in the absence of any urge to urinate

28. Functional Incontinence
A form of incontinence in which a person is usually aware of the need to urinate, but for one or more physical or mental reasons, they are unable to get to a bathroom.
The loss of urine can vary from small amount of leakage to full emptying of bladder

29. Treatment for Incontinence
Behavioral techniques/Physical Therapy
Surgical Techniques
Pharmacological treatment

30. Physical Therapy Treatment
3-4 visits over 2 month time frame
Focus:
May use strengthening, relaxation, and/or muscle coordination exercises
Dietary changes
Behavioral techniques
Patient education

31. Voiding Dysfunction
Voiding dysfunction- a broad term used to describe conditions where there is poor coordination between the bladder muscles and the urethra which results in incomplete relaxation or over-activity of the pelvic floor muscles

32. Physical Therapy Treatment focus:
Bladder training
Pelvic floor relaxation
Biofeedback
Manual therapy
Vaginal scar massage, if indicated
Internal self-mobilization/massage (with/without dilator)

33. Bowel Incontinence
Urge Incontinence: Being unable to resist the urge to defecate, which comes on so suddenly that person is unable to make it to the toilet on time
Passive Incontinence: Bowel leakage in which person is unaware of the need to pass stool
*may be accompanied by diarrhea, constipation, gas, and/or bloating

34. Causes Muscle damage Nerve damage Constipation Diarrhea
Loss of storage capacity in the rectum
Surgery
Rectal prolapse
Rectocele

35. Physical Therapy Treatment
Patient Education
Muscle Relaxation (biofeedback)
Strengthening
PF muscle control/awareness/coordination
Manual therapy
Pain relief modalities
Home exercise program: dependent upon what is indicated

36. Constipation
Defined as the difficult passage and infrequent (fewer than 3) bowel movements per week, straining during bowel movements more than 25% of the time, and/or the feeling of incomplete evacuation

37. Causes Limited fluid intake Laxative abuse
Imbalanced diet (too much sugar and animal fat)
Medications
Neurological diseases

38. Physical Therapy Treatment
Discussion re: diet and exercise
Increasing physical activity
Addressing musculoskeletal concerns: muscle coordination
Instruction in proper toileting techniques
Designing and instruction in toileting schedule/training

39. Case studies

40. Physical Therapy in Obstetrics

41. Physical Therapists provide:
Treatment for musculoskeletal pain
Exercise ideas and guidelines
Post-partum care for Mom

42. Effects of Pregnancy Hormonal Respiratory changes Tissue Laxity
Variable Blood sugar-gestational diabetes
Increased fat storage
Decreased gastric motility
Respiratory changes
Diaphragm rises, ribs spread
Decreased efficiency of breathing
Decreased space for brachial plexus

43. Effects of Pregnancy Musculoskeletal Posture Increasing body weight
Strain on joints
Weakness from stretched muscles 
More susceptible to injury

44. Physical Therapy Approaches
Exercise for
Gestational Diabetes
Postural aches and pains
Stretch
Strengthen
Enhance blood flow
Enhance muscle relaxation
Emotional boost
Post-partum care

45. Areas of Exercise Emphasis
Back
Pain relief-stretching, postural correction
Strengthening for trunk stability
Pelvic girdle alignment
Belly
Abdominal muscles weaken as they stretch
Strengthening core for overall stability

46. Areas of Exercise Emphasis
Bottom
Muscles weaken due to:
Hormonal changes
Weight of baby
Stress of delivery
Strength pelvic floor to :
Avoid and/or treat urinary or fecal incontinence
Treat pelvic pain issues
Cardiovascular fitness
Weight loss
Increase stamina for the physical challenges to motherhood

47. More Post-partum issues
Diastasis Rectus
Linear separation of the abdominal wall (rectus abdominus) to accommodate the growing fetus
If separation is excessive it may lead to abdominal and back pain. Mom may need to avoid certain exercises and activities and perform specialized exercises to help knit these muscles back together.

48. Post-partum Issues Pelvic Floor Pain/Inflammation after delivery
Pelvic Floor Therapeutic Ultrasound
C-section Scarring
May be painful or hypersensitive
Adjacent tissues/muscle may become adherent causing pain/dysfunction and require manipulation to break up scar tissue and release adhesions
Symphysis Pubis Separation
25% of women have 7-9 mm separation between 7-9 months pregnancy
May separate up to 12 mm
May remain painful after delivery

49. Case studies

50. References:
Herman, H., Wallace, K. The Prometheus Group, course notes: Female Pelvic Floor: Function, Dysfunction, and Treatment Level 1, October 2006
Tanner, H., Downey, P. Herman and Wallace Inc. Pelvic Rehabilitation Institute, course notes: Intermediate Pelvic Floor 2A: Pelvic Floor Function, Dysfunction, and Treatment, July 2012
Hampton, E., Vande Vagte, J. Herman and Wallace Inc, Pelvic Rehabilitation Institute, course notes: Pelvic Floor Function, Dysfunction, and Treatment- Intermediate PF 2B, Nov 2010
Stephenson, R., O’Connor, L. Obstetrics and Gynecological Care in Physical Therapy, 2000
Pirie, A., Herman, H. How to Raise Children Without Breaking Your Back, 1995
Herman, H. The Prometheus Group, course notes: Pregnancy and Postpartum: Clinical Highlights, June 2004