Transcript Abdominals and Pelvic FLoor

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
Copyright Barbara HastingsAsatourian 2001
Pelvic floor - superficial
muscles
Ischio Cavernosus
 Transverse perineal muscle
 Perineal body
 Bulbo-cavernosus
 Anal sphincter

Copyright Barbara HastingsAsatourian 2001
Pelvic Floor - deep muscles
Ilio-coccygeus }
 Ischio-coggygeus }
 Pubo-coccygeus }
 Pubo-rectalis }
(Collectively levator ani

Copyright Barbara HastingsAsatourian 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
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

Copyright Barbara HastingsAsatourian 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

Copyright Barbara HastingsAsatourian 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”

Copyright Barbara HastingsAsatourian 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
Copyright Barbara HastingsAsatourian 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
Copyright Barbara HastingsAsatourian 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)

Copyright Barbara HastingsAsatourian 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
Copyright Barbara HastingsAsatourian 2001
Other contributory factors
 Ageing,
mobility and dexterity
 environment, drugs, fluids
 recurrent UTI’s
Copyright Barbara HastingsAsatourian 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)

Copyright Barbara HastingsAsatourian 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”

Copyright Barbara HastingsAsatourian 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
Copyright Barbara HastingsAsatourian 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
Copyright Barbara HastingsAsatourian 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
Copyright Barbara HastingsAsatourian 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
Copyright Barbara HastingsAsatourian 2001