Transcript Slide 1

Beth Lonberger, APRN, Family Nurse Practitioner
Julie Starr, APRN, Family Nurse Practitioner
University of Missouri Hospital and Clinics
Women’s and Children’s Hospital
Center for Female Continence and Advanced Pelvic Surgery
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The participant will be able to:
 Define pelvic health in the female
 List common diagnosis contributing to pelvic floor
dysfunction
 Understand how pelvic organ prolapse, recurrent
UTI and constipation effect bladder/bowel
function
 Discuss treatment options for pelvic floor
dysfunction
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Urinary continence
Voiding less than 9xday and 0-1xnight
Absence of infection
Complete emptying of rectum every day
Adequate support of pelvic organs
Well estrogenized vaginal tissue
Sexual wellbeing
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Urinary Dysfunction
 Urinary Incontinence
 Urinary urgency/frequency
 Nocturia
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Defecatory Dysfunction
 Constipation
 Fecal Incontinence
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Pelvic Floor Dyssynergia
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Pelvic Organ Prolapse
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Levator Ani Muscle Spasm
 Pelvic Pain
 Dyspareunia
 Urinary urgency/frequency/incontinence
 Obstructive outlet defecation
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Stress Urinary Incontinence
 Coughing, Laughing, Sneezing, Lifting, Walking
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Urge Incontinence
 Urgency, Frequency, Triggers, Nocturia
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Overflow Incontinence
 Retention, Obstruction
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Functional Incontinence
 Frail, Decreased mobility
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Surgical
 Midurethral sling
 Bulking agents
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Nonsurgical
 Pessary
 Femsoft urethral insert
 Pelvic floor physical therapy
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Behavior modification
Bowel regimen
Premarin vaginal cream
Medications
Pelvic floor physical therapy (intracavity estim)
PTNS
Sacral Neuromodulation (Interstim)
Voiding >8 times during the day
Negatively effects quality of life, especially
when associated with incontinence.
Social isolation
Depression
Inactivity contributes to more serious health
problems
GETTING UP MORE THAN ONCE IN THE NIGHT TO VOID
Causes:
Recurrent UTIs, chronic renal failure, congestive heart
failure, cystitis, diabetes, excessive fluid intake,
elevated Ca+ level, sleep apnea.
Increase risk of falls
Disrupted sleep cycles
Treatment: Imipramine 25-50mg q hs. Take Diuretic at noon.
Gillen, L., Marinkovic, L., Stanton, S. Managing Nocturia. BMJ. 2004;328:1063-1066.
SYMPTOMS UTI
Urinary urgency/frequency, incontinence,
dysuria, low back pain, delirium.
Elderly often asymptomatic
DIAGNOSIS RECURRENT UTIs
 Three or more UTIs in the past year or >2 in
the past six months
 In and out cath specimen culture positive
Cunha, BA, Tessler, JM, Bavaro, MF. Urinary Tract Infection, Females. Medscape. October, 19,
2009.
Vaginal atrophy (atrophic vaginitis) is thinning and
inflammation of the vaginal walls which occurs
after menopause due to a decline in estrogen.
Results in vaginal dryness, itching, burning and
inadequate lubrication.
Urinary symptoms include urgency/frequency,
incontinence and recurrent UTIs.
Pinkerton, J. Vaginal impact of menopause-related estrogen deficiency. OBG Management. 2010;
S11-16.
TREATMENT
 Premarin vaginal cream 0.625%
 ½ applicatorful 3 x week at bedtime for 4-6 weeks
then decrease to ½ applicatorful 1xweek at hs for
maintenance dose
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Estring (Estradiol vaginal ring)
 Vaginal ring containing 2mg of Estradiol releasing
0.75mcg in 24 hour period
 To be changed every 90 days
Refers to a multitude of complaints that may
include having frequent and uncomfortable
sensations to have a bowel movement, constipation
or the feeling of poor emptying, and leakage of gas/
diarrhea/ and/or solid stool.
20% of women suffer from defecatory dysfunction.
Among women with pelvic floor disorders, the
prevalence of defecatory dysfunction was 60%.
Whitcomb, E.; Lukacz, E.; Lawrence, J.; Nager, C.; Luber, K. Prevalence of Defecatory Dysfunction in Women
with and Without Pelvic Floor Dysfunction. Journal of Pelvic Medicine & Surgery. 15(4):179-187,
July/August 2009.
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Incomplete emptying
 Rectocele or perineal rectocele
 Pelvic floor muscle (Levator ani) spasm
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Sphincter incompetence
 Thickening of IAS and thinning of EAS
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Diet
Dehydration
Medications
Decreased sensation
Irritable Bowel Syndrome
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Bowel regimen (constipation, diarrhea…)
Pessary (rectocele)
Pelvic floor therapy
Behavior modification
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Do not resist the urge to defecate
Proper hydration
Dietary changes
Medication changes
Exercise
BOWEL REGIMEN
1.Mix 1 rounded teaspoon of psyllium fiber
(Metamucil® brand or Wal-Mart® Equate generic) in 68 ounces of cold water. Take this dose of fiber
supplement a minimum of once per day. You may
repeat this dose up to 3 times per day. Please do not
take Metamucil within two hours of any medications.
2. IF YOU DO NOT HAVE A BOWEL MOVEMENT WITHIN
ONE HOUR OF RISING EACH MORNING, take one
tablespoon of magnesium hydroxide (Phillips® Milk of
Magnesia or a generic equivalent). Repeat this dose each
hour until you have a bowel movement (do not exceed 6
doses in a day). Most patients will begin having daily
bowel movements without the need for magnesium
hydroxide within one week of therapy.
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6% of women <40 years old
15% of women >40
Nursing Home residents 45-47%
7% of all women have fecal smearing
50% of affected women keep FI a secret
Ashima Makol; Madhusudan Grover; William E Whitehead. Fecal Incontinence in Women: Causes
and Treatment. Women's Health. 2008;4(5):517-528.
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Behavior modification/dietary changes
Metamucil daily and Immodium prn
Pelvic floor therapy
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Surgical options
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 Sphincteroplasty
▪ 5 year recurrence rate
Up to 60%
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Metamucil daily
Loperamide prn
▪ 1 tab (2mg/tab) before each meal and bedtime up to 8 tabs/day
▪ 2 tabs (2mg/tab) at q meal and hs up to 16 tabs/day
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Diphenoxylate with atropine sulfate prn
 1 tab (2.5mg/tab) at q meal and hs up to 8 tabs
 2 tabs (2.5mg/tab) at q meal and h.s up to 8 tabs/day
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Bismuth subsilicylate prn
 1-2 tabs (262mg/tab) before meals and h.s. not to
exceed 4.2 g/day
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Pubococcygeus
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Coccygeus
Ileococcygeus
This group of muscles acts as a single neuromuscular unit to
assist with proper support and function of the pelvis organs
including normal urinary and fecal continence as well as
genitourinary and rectal support.
A COLLECTION OF SYMPTOMS AND FINDINGS
The most common symptoms include
 Deep dull aching in the rectum/vagina
 Referred pain to the pelvis, thigh and buttock
 Pain worsens with sitting and bowel movements
 Spasms and pain in the pelvic floor muscle
 Pain during or after intercourse
 Urinary urgency/frequency possibly incontinence
 Constipation
 Prior testing usually rules out other pathologies
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LEVATOR ANI COMPLEX
Palpate 4-5 o’clock and 7-8 o’clock positions
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INTERNAL OBTURATOR
Palpate 2 o’clock and 10 o’clock positions
Single digit palpation of spastic muscle:
feels like a guitar string or hard object
reproduces the pain
PELVIC FLOOR PHYSICAL THERAPY
Pelvic floor muscle exercises 4 x day
Biofeedback
Vaginal E-stim
BEHAVIOR MANAGEMENT
 Warm baths/heat daily
 Yoga/daily stretching/Tai chi
 Relaxation/stress management/counseling
MEDICATIONS
 Flexeril 5-10mg tid prn
 Ultram 50-100mg BID
 Valium suppositories 10mg vaginally bid prn
 Antidepressent/antianxiety agent
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Abdominal EMG
 Measure use of accessory muscle
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Vaginal EMG
 Measure resting tone
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Anorectal manometry
 Measure muscle strength
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E-stim (vaginal or rectal)
 Neuromuscular stimulation (NMS)
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Promotes pelvic floor muscle awareness
Strength training
Electric stimulation
 enhances muscle awareness and strength
 increases urethral closure pressure
 relaxes spasm
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4-6 sessions of therapy
Folkerts, D., Wood, K. Overactive bladder and urinary incontinence: A multitherapy approach to treatment.
Sexuality, Reproduction & Menopause. 4(2), 2006.
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Urge Incontinence
Stress Incontinence
Fecal Incontinence
Pelvic Muscle Spasm
Pelvic Floor Dyssynergia
Pelvic Floor Muscle Weakness
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Cognitive awareness
Active participation
At least partial innervation of PFM
At rest, continuous baseline activity
consists of motor unit potentials of
2-4 MicroVolts
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Air filled balloon placed in the rectum
Records squeeze pressure of Levator Ani
Can pick up valsalva and register as pressure
Manometry is measured from zero
Best for measuring true strength of muscle
PURPOSE
To a assist in isolation of
pelvic floor muscles
To monitor contraction of abdominal
muscle as an accessory muscle
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Inhibits involuntary detrusor contractions
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Increases bladder capacity
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Decreases the intensity of urge sensation
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Decreases pelvic floor muscle spasm
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Increases urethral closure pressure
Increases muscle:
▪ Recruitment
▪ Strength
▪ Awareness
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Produces a reflex muscle contraction
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Contracts pelvic floor muscles
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Relaxation and inhibition of detrusor
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Muscle Awareness
Activation Promotes Function
Must have regular exercise
Avoid accessory muscles
Overload Principle
Progression
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HOLDING BACK GAS
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Stopping urine stream
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Contracting vagina
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Contracting rectum
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Usually 4x per day
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More frequent with less repetitions for very
weak muscle.
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Too much exercise will fatigue muscle and
worsen symptoms.
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Uterine Prolapse (uterus)
Cystocele (bladder)
Rectocele (rectum)
Perineal Rectocele (perineum)
Enterocele (vagina)
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http://www.bardurological.com/pop-q/pop-q.aspx
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Bowel Program
Vaginal Estrogen
Pessary
Vaginal support device for relief of
symptoms of pelvic organ prolapse
Indicated for women who do not desire
surgery or are not good surgical candidates
 92% satisfaction after 2 months
 Improvement of prolapse in 21% of patients
after 1 year.
 Success is in patient selection
 Physical exam
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Proper fitting may require more than one visit
every 2-3 weeks.
Patient can be instructed on managing their
pessary at home or return to clinic every 1-3
months for removal/reinsertion and exam.
Estring can be replaced at this time
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HPI: Ethel is a 90 y/o with complaints of over
active bladder x 2 years. Her bladder
symptoms worsened with recent sacroplasty.
She describes symptoms of stress
incontinence, urgency/frequency and urge
incontinence which worsened at night. She
wears a Depends pad and a large Poise pad
and changes this ensemble 5 x day
On an average day she drinks 3 glasses of
water, 2 glasses of juice, 1 cup of coffee and 1
soda.
She reports 4 UTIs in the past year.
She takes Miralax every morning and reports
1-2 bowel movements per day and strains at
stool.
24 hour pad weight 803 grams
Bladder diary indicates 16 voids/24 hours
She gets up 4 x night to void.
Patient reports conditions of HPTN, anemia,
hernia, sinusitis, GERD, hypothyroidism,
Raynaud’s syndrome, constipationpredominant irritable bowel syndrome.
Surgical history includes sacroplasty,
cholecystectomy, appendectomy,
hysterectomy and ovariectomy.
Stage II rectocele
Perineal rectocele
Defecatory dysfunction
Urogenital atrophy
Urinary urgency/frequency
Urge incontinence
Stress incontinence
Urinary tract infection
Recurrent urinary tract infections
Bowel regimen for her defecatory dysfunction.
Premarin vaginal cream for urogenital
atrophy.
Fosfomycin 1 x dose to treat UTI.
Trimethoprim 100mg q hs for recurrent UTIs.
Oxybutynin prn for OAB.
Pelvic floor therapy x 5 sessions.
Imipramine 25mg q hs for nocturia.
Patient reported 100% improvement after 5
sessions of pelvic floor therapy.
She voids 7-8 x day and 2 x night.
Her daytime incontinence completely resolved
and she leaks only drops during the night.
She wears a panty liner for peace of mind.
She remains on Trimethoprim at bedtime.
She remains on Imipramine q hs.
She takes Oxybutynin only when going out.
She continues with Premarin vaginal cream 1 x
week.
She continues to do pelvic floor exercises 4 x
day.
She takes Metamucil daily and reports 1-2
bowel movements per day without straining.
She just returned from a vacation with her
family in which they drove over 500 miles in
the car.
Patricia is a 78 y/o patient with a lifelong history
of diarrhea predominant irritable bowel
syndrome. She presents with symptoms of
fecal incontinence for the past year. She
reports leaking stool five minutes after she
starts to exercise.
She reports 1-2 bowel movements per day and
strains at stool.
Her urinary complaints include only mild stress
incontinence.
She wears a panty liner for peace of mind.
She denies urinary urgency/frequency and gets
up 1-2 times per night to void.
She describes a burning perineal pain after
intercourse and a soreness which lasts several
hours.
She uses Estrace cream for vaginal dryness.
Osteoporosis, diverticulosis and diarrhea
predominant irritable bowel syndrome.
G2P2 SVDx2 with largest birthweight 8# 13oz
Surgical history includes hysterectomy,
cystocele repair, cataract repair.
Diarrhea predominant IBS
Fecal incontinence
Defecatory dysfunction
Stress incontinence
Stage I cystocele
Stage I rectocele
Lichen planus (bx positive)
Metamucil and Loperamide for treatment of
defecatory dysfunction/IBS
Continue Estrace cream for urogenital atrophy
Clobetasol ointment for lichen planus
Pelvic floor therapy x 4 sessions for fecal
incontinence.
Patient reports 100% improvement in her fecal
incontinence after 4 sessions of pelvic floor
therapy.
She reports 1 stool/day without straining with
daily use of Metamucil.
She is able to eat fruits and vegetables without
GI complaints for the first time in years
Her perineal burning/soreness have resolved.
She exercises daily and no longer wears a pad.
HPI: Lori is an 18 y/o G0 with history of sexual
abuse starting at the age of 7. She was
recently treated by Dr. Courtney Barr at the
Center for Vulvar Diseases for vulvodynia
which she reports is completely resolved.
She describes an intermittent, stabbing LLQ
pelvic pain which occurs 5-6 x day.
She reports urinary urgency/frequency and mild
urge incontinence.
She often has a sensation that she is not
emptying her bladder completely.
Lori reports bowel movements every other day
and strains at stool.
She is not sexually active at this time.
Patient describes history of asthma and
headaches.
Surgical history negative.
Urinary urge incontinence
Defecatory dysfunction
Levator spasm
Bowel regimen for her defecatory dysfunction.
Pelvic floor therapy for levator spasm.
Patient reports 100% improvement in her
symptoms after 4 sessions of pelvic floor
therapy.
She takes a daily dose of Metamucil and reports
one bowel movement per day without
straining.
Her pelvic pain is completely resolved.
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HPI
 24 y/o G0, RLQ pain for 9 months, appendectomy,
9 negative MRIs/CTs/Ultrasounds, seen in multiple
clinics, ER throughout mid-MO
 Pain 8-9/10, worse when moving around,
improved with rest and heating pad
 Urgency, urge incontinence (pad), sense of
incomplete bladder emptying
 Severe constipation with 1-2 BMs weekly
 Bloating
 Pain with intercourse
 Worried about serious problem with ovary
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Migraines
Hypothyroid
Appendectomy
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Urinary urgency
Urge Incontinence
Defecatory Dysfunction
Severe Levator spasm
Dyspareunia
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Bowel Regimen
Home Exercises
4-6 sessions of PFT with estim
Heat therapy
Will consider colorectal consult
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Pain improving and started home program of
e stim.
Defecatory dysfunction improving, but still a
problem, BM every 2-3 days
HPI: Anne is a 70 y/o G2P2 with complaints of
stress incontinence, urgency/frequency, urge
incontinence and nocturia for the past 6-8
months.
She wears a panty liner for protection but not
every day.
She reports one bowel movement every other
day and strains at stool.
On an average day she drinks 5-6 glasses of
water, 1 glass of juice, 1 glass of milk, 2 cups
of coffee, 1 glass of tea and 1 soda.
Her bladder diary indicates she voids 7 x in 24
hours.
Her 24 hour output averages 3400cc.
Patient reports no medical problems and has
never had surgery.
She reports two vaginal deliveries with a
maximum birthweight of 8#15oz..
Stage II cystocele
Stage II rectocele
Perineal rectocele
Nocturia
Urodynamic stress incontinence
Urge incontinence
Urogenital atrophy
Defecatory dysfunction
Bowel regimen to treat defecatory
dysfunction.
Premarin vaginal cream for urogenital
atrophy.
Moderate fluids, especially in the evening.
Pelvic floor therapy for urge and stress
incontinence.
Patient reports 85% improvement in her
symptoms after 6 sessions of pelvic floor
therapy.
Her urge incontinence has resolved and she
continues with mild stress incontinence 2-3 x
month.
She continues on Premarin vaginal cream 1 x
week for urogenital atrophy.
She continues with pelvic floor exercises and urge
suppression techniqes daily.
She continues to moderate her caffeine intake.
Anne was so pleased with her results but her
best friend’s bladder was limiting her lifestyle.
Her friend completed a course of pelvic floor
therapy.
They have just returned from two weeks in Italy
and reported complete bladder control and
no anxiety about being on a tour bus all day
How to Identify the Correct Muscle
To find the proper muscle, imagine having to pass gas while with a group of people. In order not to embarrass yourself, you squeeze
the muscles around your rectum to hold the gas back. This is the muscle you want to exercise.
Common Mistakes
Never use the muscles in your stomach, legs, buttocks, and don’t hold your breath. To be sure you are not using your abdominal
muscles, place your hand on your abdomen while you squeeze the pelvic floor muscle. If you are feeling your abdomen move, you are
also using your stomach muscle.
How to Exercise
When exercising it is important to squeeze and relax your muscles as prescribed. One work/ rest cycle is one exercise. If while you
exercise you no longer feel the contraction, the muscle is tired. Stop and rest for a few minutes and then go back to the exercises.
Where to Exercise
These exercises can be done anywhere at any time. If you are doing them properly, your legs, stomach, thighs and buttocks will not
move, and no one will know you are doing your exercises. Do the exercise sitting or lying down when you first start the program. After
eight weeks you can do them standing, sitting or lying.
Can These Exercises Harm Me?
NO! These exercises cannot harm you in any way. If you experience back or stomach discomfort after you exercise, then you are trying
too hard and using extra muscles. Relax, and start over.
Prescribed Exercise
Contract the muscle for 5 seconds, and then relax for 10 seconds (this is one exercise or cycle). Do 5 exercises in a row. Repeat this 4
times each day. If you perform them with an activity that you routinely do every day, you will be more likely to remember them.
Mealtimes, bedtime and driving in the car are very common. New mothers can perform them while bottle/breast feeding.
Increase the contraction time by one second and one repetition every two weeks (always continue 4 x day). Your goal is contract for ten
seconds, relax for ten seconds. Do 10 exercises in a row 4 x day.
When you feel the urge:
•Stop what you are doing.
•Sit down, if it is possible, or stand quietly.
•Remain still.
•Rushing to the bathroom may cause you to lose control of your bladder.
•When you are still, the urge is easier to control.
•Squeeze your pelvic floor muscles quickly several times. (Contract 2 seconds, relax for one
second, 5-6 times in a row)
•Relax the rest of your body.
•Take a few breaths to help you relax.
•Wait until the urge goes away.
•Walk slowly to the toilet. Do not rush.
BOWEL REGIMEN
1.Mix 1 rounded teaspoon of psyllium fiber
(Metamucil® brand or Wal-Mart® Equate generic)
in 6-8 ounces of cold water. Take this dose of fiber
supplement a minimum of once per day. You may
repeat this dose up to 3 times per day. Please do
not take Metamucil within two hours of any
medications.
2. IF YOU DO NOT HAVE A BOWEL MOVEMENT
WITHIN ONE HOUR OF RISING EACH
MORNING, take one tablespoon of magnesium
hydroxide (Phillips® Milk of Magnesia or a
generic equivalent). Repeat this dose each hour
until you have a bowel movement (do not exceed
6 doses in a day). Most patients will begin having
daily bowel movements without the need for
magnesium hydroxide within one week of
therapy.
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www.kerryskincompany.com