1. Copyright Barbara Hastings- Asatourian 2001 Pelvic Floorwork - for the prevention and management of stress incontinence FITPRO Convention 2001 Barbara Hastings-Asatourian MSc, Bnurs, Cert Ed, RN, RM, RHV, NDN Cert, SP General Practice Nursing

2. Copyright Barbara Hastings- Asatourian 2001 Pelvic floor - superficial muscles  Ischio Cavernosus  Transverse perineal muscle  Perineal body  Bulbo-cavernosus  Anal sphincter

3. Copyright Barbara Hastings- Asatourian 2001 Pelvic Floor - deep muscles  Ilio-coccygeus }  Ischio-coggygeus }  Pubo-coccygeus }  Pubo-rectalis } (Collectively levator ani

4. Copyright Barbara Hastings- Asatourian 2001 Functions of the pelvic floor  Support  contents of pelvis and abdomen  Maintain continence  - enable emptying  Reflex activity  - act quickly when coughing, sneezing  Improve sexual enjoyment  -“tantric sex” “coitus reservoirtus” have a focus on pelvic floor  Prevent prolapse (vagina, rectum)  I.e. to contract in response to abdominal pressure

5. Copyright Barbara Hastings- Asatourian 2001 The Bladder  Three layers of smooth muscle (the Detrusor)  The Trigone consists of 2 layers of smooth muscle - joins to the urethra and ureters  Rich cholinergic parasympathetic nerve supply  The bladder neck has little sphincteric effect

6. Copyright Barbara Hastings- Asatourian 2001 The Urethra  Smooth and striated muscle  Smooth is continuous with detrusor  The urethra has an external sphinctre made of striated muscle - fibres are slow twitch and maintain continence at rest  There is a peri-urethral component of the levator ani - fibres are fast twitch and maintain continence under stress  The urethra is lined with epithelium, in younger people this has a rich blood supply - engorgement helps close urethra  This epithelium thins with age and this thinning contributes to stress incontinence

7. Copyright Barbara Hastings- Asatourian 2001 Nerve Pathways  Impulses pass between bladder, urethra and brain.  As the bladder fills the brain inhibits the spinal reflex, the urethral sphinctres contract, and the detrusor muscle relaxes (hypogastric nerves)  When passing urine the inhibitory impulses are removed, the sphinctres relax and the detrusor contracts (pelvic nerves)  The pudendal nerves supplying the pelvic floor act as “Back-up”

8. Copyright Barbara Hastings- Asatourian 2001  Urethral pressure is therefore maintained by the urethral sphinctres and the pelvic floor  Bladder pressure is increased by contractions of the detrusor and rises in intra-abdominal pressure (e.g. running, coughing “bearing down”, obesity, weight gain of pregnancy

9. Copyright Barbara Hastings- Asatourian 2001 Stress incontinence - the causes  Weakness of the pelvic floor/ persistent pressure from  Childbirth  Coughing e.g. asthma or chronic obstructive pulmonary disease  Constipation  Normal hormonal changes in the menstrual cycle affecting smooth muscles  Menopause - absence of oestrogen causes a ‘wasting’ of muscle, reduction in blood supply and thinning of cell layers - known as urethral insufficiency

10. Copyright Barbara Hastings- Asatourian 2001 Research into stress incontinence  During pregnancy 23-67% of women report it (Iosif 1981, Francis 1960)  63% respondents leaking urine 3 months after childbirth  33% still leaking urine after 9 months (Mayne 1995 and Marshall 1996)  Health professionals not consistently taking responsibility for education (Mason 1999)

11. Copyright Barbara Hastings- Asatourian 2001 Stress incontinence - cont’d  Research by Gallup (1994) found 36 % of their sample ages 16 - 54 experienced some stress incontinence  69% of those just put up with it  44 % did not know what it was  60% claimed to have done pelvic floor exercises  28% did not understand the benefits of exercises

12. Copyright Barbara Hastings- Asatourian 2001 Other contributory factors  Ageing, mobility and dexterity  environment, drugs, fluids  recurrent UTI’s

13. Copyright Barbara Hastings- Asatourian 2001 The Effect of Pelvic Floor Exercise  Johnson (1989) found pelvic floor conditioning with weighted cones showed greater strength gains than muscle contractions alone (overload)  Candy (1994) suggests pelvic floor exercise promotion should begin in adolescence rather than “after the event”  Studies have found improvements with p.f. exercise (Henalla 1988, Lagro Janssen 1991, Hahn 1993, Berghmans 1998)

14. Copyright Barbara Hastings- Asatourian 2001 Pelvic floor exercises  Fast twitch and slow twitch fibres need exercising - so teach fast and slow contractions  Frequently  Any position - suggest trying pelvic floor exercises lying on back, on side, on front, sitting, standing, whilst having sex etc  Any time - suggest “every time the phone rings” or “whenever you’re waiting in a queue” or “before every squat in class”

15. Copyright Barbara Hastings- Asatourian 2001 Some suggestions for teaching pelvic floorwork  Legs slightly apart, draw up and close the anus ( some prefer “back passage”!)  I.e.“visualise trying to stop ‘breaking wind’, or a bout of diarrhoea”,  Pull up and close the urethra front passage “visualise trying to stop passing urine when desperate”  May have to shift position if sitting use “I.T” (Ischial tuberosities)  Women add a squeeze and lift inside the vagina - then add visualisations

16. Copyright Barbara Hastings- Asatourian 2001 Some Useful Visualisations  “Flower” (Kitzinger’s phrase)  “Lift” “Elevator”  “Kiss” (imagine kissing with labia)  “Imagine sucking up through perineum with a straw”  “Bringing IT’s closer together”  “Bringing the tailbone towards the pubis”  When having sex - contractions  Describe the difference between superficial and deep

17. Copyright Barbara Hastings- Asatourian 2001 Women  Vaginal cones produce weight training for the pelvic floor  Cones come in sets of 3 - 5  Lighter ones first  Build up to 15 minutes, walking around  Change to heavier ones  Build up to 15 minutes, walking around

18. Copyright Barbara Hastings- Asatourian 2001 Biofeedback  E.g. “Periform”  “Anuform”  Educator - the extension moves downwards with a correct pelvic floor contraction NB…….Consider other causes of incontinence - infection, irritation, detrusor instability, underactive detrusor, nerve damage, incompetent urethral closure