1. THE PELVIC FLOOR: ANATOMY, FUNCTION AND CLINICAL INTEGRATION
The following is a powerpoint presentation on the functional anatomy and clinical integration of the pelvic floor.
Heather Grewar BScPT, MScPT, FCAMT
core-connections.ca

2. To review the anatomy and function of the female pelvic floor
OBJECTIVES
To review the anatomy and function of the female pelvic floor
To review the pathophysiology of stress urinary
incontinence (SUI)
To review the evidence for pelvic floor physiotherapy in the management of SUI
To consider the clinical management of SUI
This presentation will review the anatomy and function of the female pelvic floor, the pathophysiology of SUI, the evidence for PF physiotherapy and the clinical management of SUI

3. ANATOMY

4. THE FEMALE PELVIS Petros 2004
This is a picture of the female pelvic organs- the bladder, the uterus, vagina and rectum.
Petros 2004

5. THE ENDOPELVIC FASCIA Netter 2006
The endopelvic fascia is a dense fibrous connective tissue meshwork that envelops the pelvic viscera and binds them together. Note how the bladder, the uterus and the rectum are all intimately connected to eachother through their fascial connections.
(The role of the endopelvic fascia may be to fix the pelvic organs in their central location over the levator plate via attachments to the pelvic sidewall (DeLancey 1993).
Netter 2006

6. THE LEVATOR ANI MUSCLESPC IC C V R U P PR CG
ATFP OI
U urethra
V vagina
R rectum
C coccyx
PR puborectalis
PC pubococcygeus
IC iliococcygeus
CG coccygeus
P piriformis
ATFP arcus tendineus
fascia pelvis
OI obturator internus
The pelvic floor is a muscular plate that forms the caudal part of the abdominal canister. It is a multilayered muscle complex comprising a superficial layer, a middle layer and a deep layer, seen in the picture above, formed by the levator ani. The levator ani muscles refer to PR, PC and IC muscles that enclose the levator hiatus, the midline space containing the urethra, the vagina and the anorectum.
The PR, arises from the pubic bone anteriorly and extends behind the rectum to join with fibers from the opposite side.
2. The pubococcygeus arises from the pubic bone and the ATFP, a thickened band of obturator internus fascia extending from the pubic bone to the ischial spine. note how the PR and PC muscles form a U-shaped sling, encircling the urogenital hiatus.
3. The lliococcygeus arises laterally from the ATFP and travels medially and posteriorly, joining fibers from the opposite side behind the rectum, in a midline raphe that fuses with the coccyx.
The coccygeus and piriformis muscles are seen posteriorly.
(levator hiatus): the midline potential space through which the pelvic viscera could pass.
(Iliococcygeus: form a continuous shelf over the outlet of the bony pelvis)
Netter 2006 6

7. PUBORECTALIS- A CLOSER LOOK
The picture above is a 3D pelvic floor ultrasound of the puborectalis. The arrows indicate the gap between the muscle insertion and the urethra – a point which is important for palpation, as this muscle is commonly seen in avulsion tears associated with vaginal delivery. On levator contraction this gap should be little wider than your index finger, otherwise an avulsion injury is very likely.
(During defecation, the PR muscle relaxes and the anorectal junction straightens. Note its V shaped structure and that it is about as thick as the 5th finger. )
Dietz 2009

8. URETHRAL SUPPORTS DeLancey 1988
Let’s look in more detail at the urethra. In its proximal portion, just below the bladder neck, the urethra rests on a sling formed by the vaginal wall. The sling is suspended laterally by the ATFP and the levator ani (labelled as PD above for pelvic diaphragm). A contraction of the levator ani moves the vaginal wall anterosuperiorly, thus, elevating and compressing the proximal urethra. (
DeLancey 1988

9. THE URETHRAL SPHINCTER
Now let’s look at the urethral sphincter. Clinically, there are 2 parts to consider: the internal sphincter and the urethral rhabdosphincter, rhabdo derived from latin for striated. The internal sphincter lies at the level of the bladder neck and is under autonomic control. It contains a U-shaped loop of detrusor muscle and a layer of smooth muscle known as the trigonal ring (DeLancey 1990).
The rhabosphincter sphincter lies along the urethra itself. On the left, note that there are 3 parts to consider: the striated sphincter urethrae muscle, located from about 20-80% of the urethral length, the compressor urethrae and the urethrovaginal sphincter. These 3 striated muscles can be contracted voluntarily and are thought to contract reflexively during sudden increases in IAP. At its caudal end, the urethra enters the perineal membrane and is firmly fixed by it (DeLancey 2003).
On the right, note how the striated muscle surrounds 2 layers of smooth muscles: a longitudinal and circular layer. Note the innermost layer of the urethra- the mucusa. Lying within the mucosa is a well-developed vascular plexus which upon filling, may assist in forming a water-tight closure of the mucusal surfaces.
All of these mechanisms contribute to maintaining the urethral closure pressure greater than the bladder pressure in order to maintain continence.
Urethral closure is therefore, considered a dynamic process along the urethra (Peschers et al. 1999).
(The compressor urethrae and the urethrovaginal sphincter muscles make up the distal part of the external striated sphincter. These 2 bands of skeletal muscle arch over the ventral surface of the urethra and constrict the urethra when they contract. They are thought to contract reflexively during sudden increases in intraabdominal pressure (DeLancey 1988) and can be contracted voluntarily.
At its caudal end, the urethra enters the perineal membrane and is firmly fixed by it (DeLancey 2003). .
Surrounding the smooth muscle is the external striated urogenital sphincter, consisting of 3 parts: the striated sphincter urethrae muscle, located from about 20-80% of the urethral length, is composed primarily of type I muscle fibers- well suited for maintaining constant tone and for voluntary increases in pressure.
The internal urinary meatus must open for urinary incontinence to occur. The fact that it is pushed open by increases in IAP does not always mean that urine escapes from the distal urethra. It is possible for abdominal pressure to open the internal urinary meatus while the distal urethra is held closed.
(external urogenital sphincter seen on the right. The 3 main parts of the external urogenital sphincter consist of )
Smooth muscle layers.ain an inner longitudinal layer and an outer less developed circular layer.
DeLancey 1988

10. INNERVATION Thor & de Groat 2010
The levator ani nerve primarily arises from sacral spinal roots S3–S5 and travels across the internal surface of coccygeus (Cm), iliococcygeus (ICm), puborectalis (PRm), and pubococcygeus (PCm) muscles. intrapelvic face of the levator ani muscle with a high degree of variability in branching patterns (4). In humans, there is some controversy concerning whether or not the pudendal nerve also innervates the levator ani muscle (58, 186).(Thor & deGroat 2010)
B: drawing of a posterior view of the hip muscles showing the course of the pudendal nerve (PN) from the S2-S4 roots across the lateral surface of the superior gemellus (SG) and OIm, through the pudendal canal (PC) and its branching into the inferior rectal nerve (IRN) and perineal nerve (PeN). P, periformis muscle; STL, sacroturberous ligament; SSL, sacrospinous ligament; S, sciatic nerve; EAS, external anal sphincter; IG, inferior gemellus muscle.
Thor & de Groat 2010

11. MICTURITION: AUTONOMIC CONTROL
Parasympathetic = Pee
(bladder contraction)
Sympathetic = Storage
(bladder inhibition)
Micturition is under autonomic control. Parasympathetic fibers to the bladder leave the cord at S2-S4 -they stimulate bladder contraction and inhibit the internal sphincter, in order for micturition to occur. Efferent sympathetic fibers leave the spinal cord from T10-L2- they inhibit the bladder and promote the storage of urine.

12. MICTURITION: SENSORY CONTROL
The bladder wall contains afferent sensory nerve endings that conduct information related to the degree of filling, pain and temperature to the thoracolumbar part of the spinal cord (T10-L2) via the hypogastric nerve.

13. MICTURITION: CONTROL FROM HIGHER CENTRES
Micturition is not only an autonomic function; it is also a voluntary and emotional function under upper central nervous system control.
(Micturition is regulated voluntarily by cortical centers at the level of the frontal lobe. The emotional control of micturition is complex, involving a number of centres including the limbic system.

14. PELVIC FLOOR MUSCLE FUNCTION

15. THE PELVIC FLOOR MUSCLES- AN EXTRAORDINARY MULTI-TASKER!
sexual
function
pelvic organ
support
lumbar
stability
pelvic
urinary
continence
breathing
fecal
voiding
childbirth
The pelvic floor muscles are extraordinary because they perform a multitude of functions across a number of different systems. It appears that they are controlled by a number of integrated networks in the nervous system that allow their activity to be coordinated in order to perform a number of tasks concurrently.
The pelvic floor is the principal support for the pelvic organs (Moore, p. 285) and abdominal contents against gravity and the downward forces of intraabdominal pressure. The levator ani maintain a constant basal tone, thereby keeping the urogenital hiatus closed. If this basal tone is lossed or diminished, the urogenital hiatus can widen, facilitating descent of the pelvic viscera.
The pelvic floor plays an important role in maintaining urinary and fecal continence and in the evacuation of urine and stool.
During childbirth, the levator hiatus, in particular the puborectalis muscle, has to distend markedly, anywhere from % in order to allow vaginal childbirth- (Dietz 2009).
Note that the pelvic floor is also a sexual organ- this is because it contributes to the maintenance of clitoral erection during female sexual arousal. Pelvic floor muscle hypertonus can contribute to pelvic pain conditions such as dyspareunia (pain with sexual intercourse) and vaginismus, where sexual intercourse is prevented due to marked pelvic floor muscle hypertonus.
Let’s now look in more detail at how the pelvic floor muscles contribute to urinary continence, lumbopelvic stability and breathing.
(Optimal function requires continuous activity of the PFM in upright postures. 7,8 Continuous PFM electromyographic activity has been reported in lying, sitting, and standing at rest. This activity increases as people move into more upright positions (Sapsford et al, Pelvic Floor Muscle Activity in Different Sitting Postures in Continent and Incontinent Women Arch Phys Med Rehabil 2008;89: )
(Together with the coccygeus muscles, the levator ani muscles form a muscular diaphragm opposing the downwards forces of intra-abdominal pressure . )
(Insufficient support of the pelvic organs as in the case of pelvic organ prolapse, where one or more pelvic organs descend into the vaginal space, can cause urinary and fecal voiding difficulties.)

16. HOW DO THE PFM CONTRIBUTE TO URINARY CONTINENCE?
urethral support
(Ashton Miller & DeLancey, 2001)
There are 3 primary mechanisms by which the pelvic floor contribute to urinary continence.
Firstly, the pelvic floor muscles help to support the urethra by providing a firm backstop against which it can be compressed by increases in intraabdominal pressure (Abrams et al. 2002).
In the picture above, note how the urethra is inclined slightly off the vertical, away from the pubic bone. The force of IAP, indicated by the gray arrow, tends to move the urethra dorsally and caudally. The PFM, indicated by the black arrow, stabilize the urethra by pulling the vaginal wall anterosuperiorly. Further increases in IAP tend to compress the proximal urethra against the anterior vaginal wall and endopelvic fascia, thereby compressing its lumen closed (DeLancey 1990).
( This movement is resisted by the attachments of the anterior vaginal wall and endopelvic fascia, to the ATFP and PFM.)
DeLancey 1988

17. increased intraurethral pressure (Thind et al., 1990)
stabilization of the
bladder neck
(Peschers et al., 2001)
increased intraurethral
pressure
(Thind et al., 1990)
Secondly, the PFM assist in stabilizing the bladder neck. In the picture above, note the position of the bladder neck at rest, in white, and at the onset of micturition, in black. A tonic contraction of the PFM at rest maintains the bladder neck (DeLancey 1990) in an elevated and anterior position (Thompson and O’Sullivan, 2003). When the PFM relax, as at the onset of micturition, note how the bladder neck and proximal urethra descend. Under increases in IAP, the PFM increase in activity in order to stabilize the bladder and other abdominopelvic contents and prevent their downward displacement.
Lastly, the PFM also have been found to increase the pressure in the distal urethra [5, 6].
(Relaxation of these muscles during micturition obliterates the posterior urethrovesical angle (DeLancey 1990).
and help to maintain the position of the proximal urethra in the abdominal cavity [4].
DeLancey 1990

18. HOW DO THE PFM CONTRIBUTE TO LUMBAR STABILITY?
The PFM play a role in:
increasing the IAP (Hemborg, 1985)
increasing the thoracolumbar fascia tension (Tesh, 1984)
Now let’s focus on how the PFM contribute to lumbar stability. The PFM, in coordination with other muscles surrounding the abdominal cavity, can generate an increase in IAP (Hemborg et al., 1985). An increase in IAP has been shown to tension the thoracolumbar fascia (Tesh, 1984) and increase spinal stiffness (Hodges et al., 1997; Shirley et al., 2003; Essendrop et al., 2004; Cholewicky et al., 1999a,b ).
(Increased IAP—in the absence of abdominal and back extensor activity—augments stiffness of the spine (Hodges 2005)
Hodges 2006

19. anticipatory postural adjustments
The PFM are also an active component of the feedforward anticipatory system that prepares the body for predictable perturbations (Hodges, 2007). In this study by Hodges, the subjects perform rapid arm movements into flexion and extension. The picture on the left, shows vaginal and anal EMG increasing in advance of deltoid EMG, seen as the dotted line. The picture on the right shows fast continuous arm movements into flexion and extension. The PFM show tonic activity throughout the arm movement cycle with bursts of anal and vaginal EMG activity seen in association with each arm movement. The results of this study confirm that the PFM, along with the Transversus abdominis and diaphgram are part of the postural response associated with arm movements.
anticipatory postural adjustments
Hodges et al. 2007

20. HOW DO THE PFM CONTRIBUTE TO PELVIC STABILITY?
increase SIJ stiffness
sacral counternutation
(Pool-Goodzwaard et al. 2004)
The PFM have been shown to increase the stiffness of female sacroiliac joints in cadavers (Pool-Goudzwaard et al., 2004). According to Diane Lee, the inferior part of the SIJ can be compressed by hypertonus in the ischiococcygeus muscles. You may detect this in some of your clients when testing for the neutral zone in the AP plane. If so, you could then palpate the ischiococcygeus just lateral and inferior to the sacral ILA to confirm whether it is hypertonic. Clinically, very often women with incontinence present with unilateral or bilateral hypertonus of the ischiococcygeus muscles. Release of these muscles often significantly improves the neutral zone in the AP plane.
The PFM have also been shown to counternutate the sacrum (Pool-Goudzwaard). In this way, the PFM can assist in controlling the position of the sacrum by co-contracting with other muscles that nutate the sacrum such as the multifidus and the deeper lumbar parts of the erector spinae muscles (Williams and Warwick, 1986; Snijders et al., 1993a,b).
Lee 2011

21. HOW DO THE PFM CONTRIBUTE TO BREATHING?
Let’s look at the vaginal EMG recordings above. The expiratory phase is indicated in grey, inspiration in white. During quiet breathing, there is modulation of PFM activity in standing with a greater increase seen during expiration as seen in the grey boxes above than during inspiration. The same effect is seen when tidal volume is increased by blowing through increased dead space, PFM activity was increased during both respiratory phases compared to quiet breathing, but was greater during expiration. PFM activity was found to be more closely associated with activity of the abdominal muscles than with changes in IAP. (Hodges 2007).
Clinically, it is important to keep in mind that a gentle exhale may facilitate improved recruitment of the pelvic floor and abdominal muscles.
modulation of PFM during breathing
increased PFM activity during expiration
Hodges et al. 2007

22. OF THE ABDOMINAL CANISTER
THEORY: SYNERGIES
OF THE ABDOMINAL CANISTER
These authors found similar synergies of the muscles of the abdominal canister. They looked at the association between PFM strength and forced expiratory volumes. Women with stronger voluntary PFM contractions were shown to exhale more efficiently, especially during the later stages of expiration. The theoretical model above is based on their findings. In a) the diaphragm contracts concentrically during inspiration and the PFM are thought to contract eccentrically. In b) a contraction of the superficial abdominal muscles during forced expiration and coughing increases the IAP and can lead to PFM descent and bulging out of the lower abdominal muscles. This occurs in the absence of a PFM and deep lower abdominal muscle co-contraction. In c) a concentric co-contraction of the PFM and deep lower abdominal muscles is thought to enhance the expiratory effort during forced expiratory manoeuvres and coughing.
These synergies have important clinical implications: clinically, it is common that women with incontinence contract their PFMs during inspiration. In these cases, the synergies of the abdominal canister need to be retrained in order to coordinate the muscles of the abdominal canister during forced expiratory such as coughing.
[9, 11, 15–17] (Talasz et al., 2010
(thereby reducing the volume of the abdominal cavity and increasing the IAP, which forces the relaxing diaphragm upwards and).
Talasz et al., 2010 22

23. COORDINATING AND COMPETING FUNCTIONS
postural
control
breathing
continence
For optimal function of breathing, postural control and continence, coordinated activity of the muscles of the abdominal core is required. Consider what happens when the demand on one or more systems is increased. It appears that an increase in demand in one system may lead to compromised function in another. For example, there is increased prevalence of back pain in women with incontinence.
36. Smith MD, Russell A, Hodges PW (2006) Disorders of breathing
and continence have a stronger association with back pain than
obesity and physical activity. Aust J Physiother 52:11–16.
(The findings of epidemiology studies do not prove cause and effect relationships; they merely show associations. have a greater probability of developing back pain over a period of 2-5 years (Smith MD et al. 2006).
It is estimated that 44% of women experience incontinence during pregnancy
Smith et al., 2006

24. PATHOPHYSIOLOGY OF STRESS URINARY INCONTINENCE

25. STRESS URINARY INCONTINENCE
“the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing”
1 in every 3 women will have incontinence during her lifetime and 65% will recall that it began during their pregnancy or after childbirth (Handa et al. 1996).
Abrams et al., 2010

26. PATHOPHYSIOLOGY OF SUI
insufficient urethral
support
increased compliance of
the supportive layer
The pathophysiology of SUI is complex and multifactorial. It is poorly understood and the exact mechanisms not clear.
It appears that without an effective PFM contraction, the vagina fails to support the urethra during tasks that increase IAP; insufficient urethral support may result in delayed or ineffective pressure transmission to the urethra(Motswin et al. , 2005)
Netter 2006

27. damage to PFM, nerves and fascial supports
ETIOLOGY
parity
childbirth
damage to PFM, nerves and fascial supports
Epidemiology studies implicate parity and childbirth in the development of incontinence.
Imaging and functional studies reveal damage to the pelvic floor muscles, nerves and fascial supports however, it is unclear what the clinical significance of these findings is.
Chaliha 2009

28. DOES AVULSION OF THE PUBORECTALIS AFFECT SUI?
Injury to the puborectalis component of the levator ani is a common injury that occurs during the crowning of the fetal head at vaginal delivery. In 15–30% of all women who have given birth vaginally there is damage to the puborectalis component of the levator ani muscle.
The pictures above show a typical right-sided avulsion injury of the puborectalis muscle, as seen on translabial ultrasound. The avulsion injury is shown as an asterisk in the rendered volume picture on the left and in the tomographic slices in the picture on the right.
Interestingly, avulsion of the puborectalis has not been shown to be associated with SUI. Instead, women with avulsion of the puborectalis muscle were found to more likely present with prolapse.
(In a retrospective observational study (Dietz 2009) reviewed the records of 425 women with an avulsion of the puborectalis muscle identified by ultrasound of the pelvic floor. The results of the study indicated that
The authors of this study suggest that the epidemiological link between SUI and childbirth is likely due to factors unrelated to puborectalis muscle trauma; they suggest further research focusing on the contribution of muscular reflex activity, the integrity of urethral fixation, and the role of the urethral rhabdosphincter, all of which may be negatively affected by pregnancy and childbirth.
(Rendered volume is a semitransparent representation of volume data)
. The tomographic image shows a coronal reference image (b, top left) and eight consecutive axial plane slices.
Dietz et al., 2009

29. Prevalence of incontinence (EPINCONT study): Nulliparous group: 10.1%
IS PREGNANCY A FACTOR?
Prevalence of incontinence
(EPINCONT study):
Nulliparous group: 10.1%
Cesarean group: %
Vaginal group: %
(Rortveit et al. 2003)
In the largest community-based epidemiological study of incontinence (EPINCONT study) (Rortveit et al. 2003) over women under the age of 65 were assessed. They were grouped according to whether they had not delivered, or whether they had had cesarean sections or vaginal deliveries only. The prevalence of any incontinence was 10.1% in the nulliparous group, 15.9% in the cesarean section group and 21.0% in the vaginal delivery group.
The effect of mode of delivery is uncertain; it appears that although cesarean section reduces the risk of pelvic floor trauma, it is not entirely protective. Note also the incidence of incontinence in the group that had not had children.
(Further research is required into the effect of pregnancy on pelvic floor dysfunction and the effect of mode of delivery (Chaliha, 2009)

30. IS NERVE INJURY A FACTOR?
compression
denervation
The positioning of the levator ani nerve on the intrapelvic surface of the muscles may expose it to damage as the fetal
head passes through the birth canal (4) and may contribute to the correlation between parity and POP (3). A more recent series of elegant studies (161, 188 –191) have provided evidence that levator ani nerve damage accompanies parturition in 25% of women with approximately one-third of those continuing to show evidence of nerve damage at 6 mo after parturition (161). (Thor &deGroat, 2010)
161. South MM, Stinnett SS, Sanders DB, Weidner AC. Levator ani
denervation and reinnervation 6 months after childbirth. Am J Obstet
Gynecol 200: 519.e1–519.e7, 2009.
188. Weidner AC, Barber MD, Visco AG, Bump RC, Sanders DB. Pelvic
muscle electromyography of levator ani and external anal sphincter in
nulliparous women and women with pelvic floor dysfunction. Am J
Obstet Gynecol 183: 1390 –1399, 2000.
189. Weidner AC, Jamison MG, Branham V, South MM, Borawski KM,
Romero AA. Neuropathic injury to the levator ani occurs in 1 in 4
primiparous women. Am J Obstet Gynecol 195: 1851–1856, 2006.
190. Weidner AC, Sanders DB, Nandedkar SD, Bump RC. Quantitative
electromyographic analysis of levator ani and external anal sphincter
muscles of nulliparous women. Am J Obstet Gynecol 183: 1249 –1256,
2000.
191. Weidner AC, South MM, Sanders DB, Stinnett SS. Change in urethral
sphincter neuromuscular function during pregnancy per
Thor & de Groat 2010

31. THE INTEGRATED CONTINENCE SYSTEM
In addition to the possible structural deficits that we just talked about, it appears that there are a multitude of modifiable factors that can contribute to the development of SUI. The model above, the Integrated Continence System, explores many of these modifiable risk factors that can combine to adversely affect the continence system. The modifiable factors seen in green are grouped according to motor control, musculoskeletal and behavioural factors. These modifiable factors can be addressed through physiotherapy. The following 2 slides will show some examples.
Grewar & McLean, 2008

32. MODIFIABLE FACTORS ASSOCIATED WITH SUI:
MOTOR CONTROL
pelvic floor muscles
abdominal muscles
diaphragm
With respect to motor control, there is evidence in the literature to suggest that women with SUI demonstrate altered motor control of muscles of the abdominal canister:
In terms of the PFM, a number of authors have found increased PFM activity in quiet standing in women with SUI compared to continent women (Smith et al. 2007).
There is also evidence that PFM timing may be a problem. We know that PFM activity occurs after the onset of the anterior deltoid during rapid arm movements in women with SUI (Smith et al. 2007). We also know that teaching a PFM contraction before and during a cough is a very effective strategy for reducing urine leakage during a cough in women with incontinence. (Miller JM et al. 1998).
As for the abdominals: Increased EO EMG has been recorded in women with severe incontinence compared to women with mild incontinence and continent women (Hodges et al. 2007; Smith et al. 2007). What is wrong with too much EO? According to Hodges, diaphragm and superficial abdominal muscle contraction increases IAP, which in turn, increases the pressure within the bladder and causes levator plate descent (Hodges, course notes 2008).
As as for the diaphragm, in normal breathing, the diaphragm descends and causes the ribs to move up and out to expand the lower chest (Detroyer, 1989). When the abdominals are braced, as in the case of increased activity of the obliques, normal chest expansion is limited (McLaughlin 2009) and there is decreased descent of the diaphragm. Clinically, it appears that women who brace with their abdominals often have a hypertonic diaphragm and pelvic floor.
(People with back pain have been shown to brace with their superficial abdominal muscles and diaphragm and have been shown to have poor core muscle activation (Hodges and Richardson, 1999; Radebold et al., 2001; O’Sullivan and Beales, 2007).

33. MUSCULOSKELETAL FACTORS ie. PFM strength
BEHAVIOURAL FACTORS
ie. increased BMI (Wing et al. 2010)
As for MSK factors, PFM strength may contribute to SUI. The PFM need to contract with sufficient strength to overcome the downward force of IAP in order to maintain continence. Several studies have demonstrated that there is a significant difference in maximum PF strength in incontinent women vs continent and a positive association between increased strength and improvements in leakages has been demonstrated. (refs in Bo 2009). Other studies indicate that women with SUI do not demonstrate decreased PFM strength (Madill et al. 2009)
As for behavioural factors, obesity is one example that has been shown to be a strong risk factor for incontinence. In this RCT, overweight and obese women who lost as little as 5-10% of their BMI through diet and exercise had 3.7 times the odds of achieving a 70% or greater reduction in total incontinence episodes compared to women who gained weight.

34. EFFICACY OF PELVIC FLOOR PHYSIO
Level A evidence that PFM training can effectively treat SUI (Wilson et al., 2005)
with cure rates of 44-80% in the adult female population (Hay-Smith et al. 2007; Bo, 2007)
Cure rates, are measured as <2 g of leakage on pad testing (Bo, 2003)
According to the 4th International consultation on incontinence (2010)

35. PFM training is recommended as a first-line treatment for SUI (4th International Consultation on Incontinence, 2010)

36. WHAT IS THE RATIONALE FOR PELVIC FLOOR PHYSIO?
elevation of the resting position of the bladder and rectum
increased pelvic floor thickness
reduced hiatal area at maximum Valsalva
PFM training has been shown to produce morphological changes measured using 3 and 4D ultrasound in women with POP: In the study above, 109 women with different stages of POP did daily home exercises for 6 months 3 sets of 10 maximal contractions per day in lying, sitting and standing as well as individual sessions with a PT, once a week for 12 weeks and then once every 2 weeks for 3 months.The findings of the study indicated that the bladder and rectum were higher in the pelvis at rest, that the pelvic floor was thicker and that there was less opening of the hiatal area during maximum Valsalva indicating improved pelvic floor muscle stiffness.
Brækken et al. 2010

37. GOALS OF PFM TRAINING FOR SUI
BLADDER NECK ELEVATION!
bladder neck elevation occurs with PFM and TA recruitment
IO recruitment does not
elevate the bladder neck
SUP
INF
(b)
The primary functional goal of PFM training for SUI is bladder neck elevation. We know that an effective PFM contraction elevates the bladder neck. Little is known in the literature about the effect of TA on bladder neck elevation. In the study above, bladder neck elevation occurred consistently only during tasks involving PFM and TA co-contraction. More research is needed to understand the effects of TA on bladder neck elevation.
Interestingly, in the same study, VERY GENTLE exercises that recruited the IO, such as supine head lifts and bracing of the abdominal wall with a 20% effort, did not elevate the bladder neck. In these cases, the PFM co-contraction was not sufficient to overcome the greater increase in IAP and the bladder neck did not elevate. This is important to consider when prescribing exercises for clients with SUI: increased IAP from activity of superficial abdominals may prevent elevation or may cause caudal displacement of the bladder neck.
(Bladder neck occurs only when PFM activity is high relative to increases in IAP
increased IAP can prevent elevation or induce caudal displacement of the bladder neck)
Junginger et al. 2010
Lee, 2004

38. CLINICAL INTEGRATION

39. SUI with coughing, jogging, sneezing and jumping
KEY COMPLAINTS
SUI with coughing, jogging, sneezing and jumping
avoiding ability to run and dance
restricting fluids
protective padding
nocturia
The following clinical example was taken from a research study conducted by Linda McLean in Ottawa and Kingston. To date, over 30 women with SUI have been recruited from the waiting lists of 3 urogynecologists in Ottawa and Kingston. The study design includes a pre-treatment screening and physical assessment, 8-10 sessions of pelvic floor physiotherapy over a 12-week period and follow up testing.
This woman is a 45-year old mother of 3 children. She had 3 vaginal births with no complications. Her key complaints were SUI with …. She experienced urinary leakage approximately 3-5 times per week, of 1tbsp or more in volume. Her symptoms had been getting progressively worse over the last 8 years. She was avoiding running and dancing. She was restricting her fluids to prevent leaks. She was wearing protective padding day and night, getting up once in the night to empty her bladder 39

40. KEY OBJECTIVE FINDINGS: Lumbo-pelvic hip and thorax
abdominal bracing
reduced rib cage wiggle
buttocks clenching
upper chest breathing pattern
reduced lumbar lordosis
absent TA co-contraction
stretched and decreased lower abdominal tone
The key findings of the lumbopelvic hip and thoracic region indicated signs of global rigidity. abdominal bracing with a reduced rib cage wiggle, indicating overactivity of the superficial muscle system,
And clenching of hte buttocks in standing, indicating excessive muscle activity around the hip joint
She was breathing with an upper chest breathing pattern.
Her lumbar lordosis was reduced in sitting and in standing
She was not able to co-contract her TA
and her lower abdominals were stretched and had decreased tone in her lower abdominals.

41. KEY OBJECTIVE FINDINGS: Internal pelvic exam
MODIFIED OXFORD SCALE
(Laycock 1994)
1 Flicker
2 Weak
3 Squeeze and lift
4 Moderate resistance
5 Maximum resistance
PFM contractility (MOS): 3/5
PFM hypertonus
absent PFM contraction during coughing
The MOS is used to grade the contractility and strength of the PFM. At the initial assessment she scored a grade 3/5 indicating a squeeze and lift of the PFM.
And there was generalized resistance to passive stretch of the PFM indicating PFM hypertonus at rest.
There was no automatic PFM contraction during coughing.
She tested negative for pelvic organ prolapse
(Muscle resting tone can be clinically defined as compliance
on palpatory compression, or resistance to passive stretch or
distension [10]. Simons D, Mense S (1998) Understanding and measurement of
muscle tone as related to clinical muscle pain. Pain 75:1–17 In : H. P. Dietz & K. L. Shek The quantification of levator muscle resting tone
by digital assessmentInt Urogynecol J (2008) 19:1489–1493. 41

42. TRANSLABIAL ULTRASOUND: Maximum voluntary PFM contraction
The following images were taken during the initial pre-test. This is a 2D translabial ultrasound image of the pelvic floor during a maximum voluntary contraction. In the middle picture of the top row, note the pubic symphysis (PS) and the inferior pubic rami (IPR) on each side. On ultrasound, we diagnosed an
avulsion if there was evidence of a discontinuity between the pubovisceral muscle and the pelvic sidewall at the level of the levator hiatus and for at least 5 mm above this level, as previously described [3]. (Dietz 2008). Follow the straight line on the ramus on either side to the attachment of the puborectalis muscle (PR). The red arrow in the same picture indicates a partial tear of the right puborectalis muscle at its attachment to the inferior pubic ramus. The tear is evidenced by the change in direction of the collagen fibers.   42

43. TRANSVAGINAL ULTRASOUND: Urethral cross-sectional area
The two top pictures are 2D transvaginal ultrasound images of the urethra (blue arrow). The bottom picture shows a cross section of the urethra. Note the urethral lumen (blue arrow) and the external urethral sphincter (red arrow). The cross sectional area of the urethra can be calculated before and after treatment to determine whether muscle hypertrophy occurred with PFM training. 43

44. TRANSLABIAL ULTRASOUND: Real-time maximum valsalva
This is a translabial ultrasound showing the caudal descent of the bladder during a maximum voluntary valsalva maneuver. Click on the picture to start the video. 44

45. TRANSLABIAL ULTRASOUND: Real-time maximum cough
This is a translabial ultrasound showing the caudal descent of the bladder during a maximum cough. Click on the picture to start the video. 45

46. PHYSIOTHERAPY TREATMENT
Education
anatomy
pathophysiology
efficacy of PF physiotherapy
bladder training
Manual pelvic floor muscle techniques
proprioception
neuromuscular recruitment
decrease hypertonus
The treatment included education about anatomy, pathophysiology, efficacy of PFM retraining
Bladder goals included education to increase overall fluid intake, to decrease caffeine intake, to void at regular 3-4 hour-intervals, to avoid straining to empty bladder
Manual pelvic floor muscle techniques were done to improve proprioception, to improve neuromuscular recruitment, to decrease hypertonicity 46

47. HOME EXERCISES PFM exercises maximum contractions
motor control exercises
functional integration
submaximal TA co-contraction
thoracic mobilization exercises
body awareness
diaphragmatic breathing without abdominal bracing
strengthening of the gluteals and lower abdominals
Max contractions 30/day
Motor control exercises focusing on speed, pre-contractions before coughing and sneezing, elevators, waves, inner range contractions
Functional integration into squatting and sit-to-stand

48. RESULTS OUTCOMES PRE POST IIQ-7 44.3/100 9.6/100 PAD TEST (g) 22.86
11.07
BLADDER DIARY
(# leaks per day)
1.67
1.33
Incontinence Impact Questionnaire
Pad test involves weighing a pad before and after a series of provocative activities including jogging on the spot, jumping jacks, coughing, etc.
Bladder diary is filled out by the participant over a 3-day period.

49. no signs of global rigidity diaphragmatic breathing
RESULTS
no signs of global rigidity
diaphragmatic breathing
improved lumbar lordosis in sitting and standing
TA co-contraction
improved lower abdominal tonus
PFM contractility (MOS): 4+/5
PFM tonus: within normal
precontraction with coughing
Able to demonstrate
Could consistently demonstrate a maximum PFM precontraction with coughing

50. ULTRASOUND MEASUREMENTS PRE POST
Bladder neck position start
(standing) (cm)
0.626
1.399
Bladder neck position end valsalva
0.02
Bladder neck excursion during coughing (supine) (cm)
Bladder neck excursion during coughing (standing) (cm)
Urethral sphincter cross sectional area (cm2)
Note bladder neck positions were measured relative to a line drawn between the inferior margin of the pubic symphysis and the anorectal angle.  The greater the number, the greater the distance from the line. 50

51. Evidence of morphological changes
DISCUSSION
Improvement, not cure
Evidence of morphological changes
Not fully cured- possible contributing factors:
time constraints of the study
inconsistent TA co-contraction
PFM hypertonus
This participant did really well – all measures (ultrasound and outcomes) showed a significant improvement- but she was not perfectly cured with still 1.33 leakage episodes per day)
The pre-and post-treatment ultrasound measurements provide evidence that some morphological changes in the muscle did take place: post-treatment elevation of the bladder in standing and reduced descent of the bladder neck during Valsalva consistent with Bo article 2010
It’s not exactly clear why the participant’s continence was not completely resolved after treatment
According to the literature, the partial PR tear should not be a factor.
Perhaps this participant would have been cured with longer treatment time: ie physiotherapy and exercise over a 6-month rather than weeks- not possible in this case due to time constraints of the study
As discussed, there is some evidence that co-contraction of transversus abdominus is required for consistent elevation of the bladder neck- perhaps this participant did not fully develop this awareness and the ability to integrate it across a variety of positions.
It is also possible that the motor control retraining wasn’t sufficient to completely reduce the PFM hypertonus and that the residual resting hypertonus continued to be a factor in the timing and coordination of the PFM.
Problems with classification arise in injuries that are incomplete, e.g.
those that spare the most inferior aspect of the muscle,
which is probably the most crucial, given that it defines the
levator hiatus. (Dietz 2008) 51

52. TAKE HOME MESSAGES Look at the entire abdominal canister
Reduce rigid bracing strategies around the lumbopelvic-hip region and thorax
Retrain diaphragmatic breathing
Retrain the synergies of the PFM, lower abdominals and diaphragm
Consider strategies for bladder neck elevation
Watch out for strategies that increase the IAP
Pelvic floor physiotherapy is effective in treating SUI!
It takes time (3-6 months), diligence and awareness
Everyone improves, many are cured!

53. Thank you for your interest 

54. REFERENCES
Abrams et al. Fourth International Consultation on Incontinence Recommendations of the International Scientific Committee: Evaluation and Treatment of Urinary Incontinence, Pelvic Organ Prolapse, and Fecal Incontinence. Neurourology and Urodynamics 2010; 29:
Allen RE et al. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 1990; 97:770–779.
Ashton-Miller JA & Howard D, DeLancey JO (2001) The functional anatomy of the female pelvic floor and stress continence control system. Scand J Urol Nephrol Suppl:1–7.
Bo K. Pelvic floor muscle training for stress urinary incontinence. In: Bo K, Berghmans B, Morkved S, Kampen MV, editors. Evidence-based physical therapy for the pelvic floor. Philadelphia: Elsevier; 2007; 171–87
Braekken IH et al. Morphological Changes After Pelvic Floor Muscle Training Measured by 3-Dimensional Ultrasonography- A Randomized Controlled Trial. Obstetrics and Gynecology ; 115 (2):
Chaliha C. Postpartum pelvic floor trauma. Current Opinion in Obstetrics and Gynecology. 2009; 21: 474–479.
DeLancey J.O.L Structural aspects of the extrinsic continence mechanism. Obstetrical Gynecology. 72:
DeLancey J.O.L Anatomy and physiology of urinary continence. Clinical Obstetrics and Gynecology. 33: 2:
Detroyer A The mechanism of the inspiratory expansion of the rib cage. .Journal of Laboratory and Clinical Medicine 114: 97–104
Dietz HP. Pelvic floor assessment. Fetal and Maternal Medicine Review 20:1 49–

55. REFERENCES
Dietz HP et al. Does avulsion of the puborectalis muscle affect bladder function? Int Urogynecol J ; 20: 967–972
Dietz HP & Shek C. Validity and reproducibility of the digital detection of levator trauma. Int Urogynecol J. 2008; 19:1097–1101
Grewar H and McLean L. The integrated continence system: a manual therapy approach to the treatment of stress urinary incontinence. Manual Therapy ; 13:
Hay-Smith E et al. Pelvic floor muscle training for urinary incontinence in women. Cochrane Database of Systematic Reviews 2007; Issue 1. Art. No.:CD001407
Hemborg B, et al. Intra-abdominal pressure and trunk muscle activity during lifting. IV. The causal factors of the intra-abdominal pressure rise. Scand J Rehabil Med 1985; 17:25–38
Hodges PW. Low back pain and the pelvic floor. In: Carrière B, Markel Feldt C, editors. The pelvic floor. New York: Thieme; 2006
Hodges PW et al. Neurourology and Urodynamics. Postural and Respiratory Functions of the Pelvic Floor Muscles. 2007; 26:362–371
Junginger B et al. Effect of abdominal and pelvic floor tasks on muscle activity, abdominal pressure and bladder neck. Int urogynecol J ; 21: 69-77
Laycock J. Clinical evaluation of the pelvic floor. In: Schuessler B (ed) Pelvic floor re-education: principles and practice. Springer, London; 1994, pp 42–48
Lee D. The pelvic girdle- an integration of clinical expertise and research. 4th Edition. Toronto: Churchill Livingston; 2011
Lee D. The pelvic girdle: an approach to the examination and treatment of the lumbopelvichip region. 3rd ed. Toronto: Churchill Livingstone; 2004
McLaughlin L. Breathing evaluation and retraining in manual therapy. Journal of Bodywork and MovementTherapies. 2009; 13: 276–282
Miller JM, et al. A pelvic muscle precontraction can reduce cough-related urine loss in selected women with mild SUI. J Am Geriatr Soc 1998;46:870–4
Peschers UM et al. Pelvic muscle activity in nulliparous volunteers. Neurourol Urodyn 2001: 20:269–275

56. REFERENCES
Petros PE Papa. The female pelvic floor. Function, dysfunction and management according to the integral theory. Heidelberg: Springer; 2004
Pool-Goudzwaard A et al. Contribution of the pelvic floor muscles to stiffness of the pelvic ring. Clin Biomech 2004; 19: 564–71
Rortveit G et al. Urinary incontinence after vaginal delivery or caesarean section. N Engl J Med 2003; 348:900–907
Smith MD. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy ; 52: 11-16
Smith MD et al. Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence. Int Urogynecol J 2007; 18:901–911
Snooks SJ et al. Injury to the innervation of pelvic floor sphincter musculature in childbirth. Lancet 1984; 2:546–550
Talasz et al. Breathing with the pelvic floor? Correlation of pelvic floor muscle function and expiratory flows in healthy young nulliparous women. Int Urogynecol J ; 21:
Tesh KM et al. The abdominal muscles and vertebral stability. Spine ; 12:
Thind P et al. Variations in urethral and bladder pressure during stress episodes in healthy women. Br J Urol 1990; 66:389–392
ThorKB & deGroat. Neural control of the female urethral and anal rhabdosphincters and pelvic floor muscles. Am J Physiol Regul Integr Comp Physiol ; 299: R416-R438.
Uebersax JS et al. Short forms to assess life quality and symptom distress for urinary incontinence in women: the incontinence impact questionnaire and the urogenital distress inventory. Neurouroly and Urodynamics ;14:
Wilson PD et al. Adult conservative management. In: Abrams P, Cardozo L, Khoury S, Wein A (eds) Incontinence, vol 1: 255–312. 3rd International Consultation on Incontinence. Health Publications ; Chap 15:855–964
Wing RR et al. Improving Urinary Incontinence in Overweight and Obese Women Through Modest Weight Loss. Obstetrics and Gynecology ; 116: