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Pelvic-floor exercises for incontinence
STRESS INCONTINENCE
Pelvic-floor exercises for incontinence
Leg
Georgina Evans Urethra
Pelvic floor muscles
Vagina Anus
The role of the pelvic floor (Figure 1) is to: • support the pelvic organs • respond to increases in intra-abdominal pressure • maintain the anorectal angle so as to maintain faecal continence • provide rectal support during defecation • reinforce the urethral and anal closure • inhibit bladder activity • assist in ‘unloading’ the spine • reinforce pelvispinal stability • contribute to sexual arousal and performance. Most women have little or no idea of where their pelvic-floor muscles are, what they do or how they can be exercised. A research study demonstrated that fewer than half the women in a group were able to perform an optimal or correct pelvic-floor contraction when given written or verbal instruction; feedback after digital examination was the only way to ensure appropriate pelvic-floor muscle activity.1
1 The pelvic-floor muscles.
Management of incontinence A careful history of a patient’s symptoms, together with a vaginal examination and grading of the pelvic floor, enables the specialist physiotherapist to undertake appropriate management, which may involve: • pelvic-floor re-education • bladder training • biofeedback • electrotherapy • vaginal cones • advice.
Pelvic-floor exercises The pelvic floor and urinary incontinence
The instructions shown in Figure 2 may be used to explain to the patient how a pelvic-floor exercise may be performed correctly. This exercise works the slow fibres in the pelvic-floor muscle and
In 1999 a Department of Health working party report stated that all women presenting with incontinence should be offered, as a minimum, one-to-one training, vaginal examination to determine correct muscle action, and three months of exercise taught by a specialist physiotherapist or other professional with specialist knowledge.2 Physiotherapy should be the first-line treatment for women with stress or urge incontinence or genital prolapse, as it has been shown to be cost-effective and to have no side-effects. It is appropriate both for women who wish to avoid surgery and for those who wish to build up the strength of their pelvic-floor muscles before surgery. The women most likely to benefit from re-education of the pelvic-floor muscles are those found to have: • post-parturition urinary stress incontinence • urinary stress or urge incontinence • a prolapse (provided there is no gross fascial stretching) • first-degree uterine descent • second-degree uterine descent requiring surgery (pre-operative physiotherapy can aid recovery and reduce the likelihood of further problems) • vaginal laxity with no gross cystocele, rectocele or urethrocele.
How to perform pelvic-floor exercises • Close around the back passage as if you are trying to stop the release of wind • Then close the front passages as if stopping the flow of urine • Lift the passages and hold them for as long as you can, up to a maximum of 10 seconds • Release and rest for a few seconds • Repeat this exercise as many times as you can, to a maximum of 10 While doing the pelvic-floor exercises do not: • hold your breath • tighten your buttocks or thighs • pull in your upper abdominal muscles Do not routinely attempt to stop midstream while passing urine, as this may prevent complete emptying of the bladder and lead to infection. These exercises can be performed in any position, but you should concentrate on doing them correctly and should not do them while engaged in some other activity (e.g. while washing up).
Georgina Evans practises in Oxford as a women’s health physiotherapist. She has served on the executive and education committees of the Association of Chartered Physiotherapists in Women’s Health, and has a particular interest in the treatment of incontinence.
WOMEN’S HEALTH MEDICINE 2:6
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29
© 2005 The Medicine Publishing Company Ltd
STRESS INCONTINENCE
Oxford grading system for assessment of pelvic-floor strength • • • • •
nil (lack of movement) flicker (flickering of the muscle) weak (weak pressure but more than a flicker) moderate (pressure compressing the examiner’s fingers) good (firm squeeze and lifting of fingers towards the pubic bone) • strong (strong grip and positive movement in the cranial direction) 3
helps to build up its endurance. The emphasis is on the lifting and holding. The pelvic-floor muscles also have fast fibres that come into play when we cough, sneeze or laugh, and it is important that these muscles should be able to react quickly to counteract a rise in intra-abdominal pressure. To exercise the fast fibres, the back and front passages should be lifted and held for a second before being released: now the emphasis is on the lift being strong and fast. Ideally the exercise should be taught by an expert, as it is hard to learn from written instructions. Specialist physiotherapists frequently encounter patients who have been performing pelvic-floor exercises regularly, but entirely incorrectly and ineffectually. If possible the woman should learn to make a digital vaginal assessment herself to check whether she is doing the exercise correctly; this is a useful biofeedback technique. The best positions for the woman to examine herself are either lying (for example in the bath) or standing. She introduces two fingers into the distal 3 cm of her vagina (or one finger for those with a smaller vagina). She then contracts her pelvic-floor muscles to assess their power, and counts the seconds she can hold the lift and the number of repetitions she is able to do before the muscle weakens. She can then assess the fast fibres in the muscle. Physiotherapists generally use the internationally accepted Oxford grading system (Figure 3) to assess the strength of a woman’s pelvic-floor muscles. Continuing management of incontinence A critical factor in the effectiveness of pelvic-floor exercises is self-motivation, and this can be hard to maintain. The maximum improvement is thought to take between 3 and 6 months. Periodic review by the physiotherapist ensures that the exercises continue to be performed correctly, and can help to sustain commitment. Correctly performed pelvic-floor exercises are extremely beneficial and should be continued for life, not simply to overcome an immediate problem. REFERENCES 1 Bump R, Hurt W G, Fantl A, Wyman J. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol 1991; 165: 322–9. 2 Brocklehurst J, Amess M et al. Outcome indicators for urinary incontinence. Oxford: National Centre for Health Outcomes Development, 1999: 38.
WOMEN’S HEALTH MEDICINE 2:6
30
© 2005 The Medicine Publishing Company Ltd
Pelvic-floor exercises for incontinence
Leg
Georgina Evans Urethra
Pelvic floor muscles
Vagina Anus
The role of the pelvic floor (Figure 1) is to: • support the pelvic organs • respond to increases in intra-abdominal pressure • maintain the anorectal angle so as to maintain faecal continence • provide rectal support during defecation • reinforce the urethral and anal closure • inhibit bladder activity • assist in ‘unloading’ the spine • reinforce pelvispinal stability • contribute to sexual arousal and performance. Most women have little or no idea of where their pelvic-floor muscles are, what they do or how they can be exercised. A research study demonstrated that fewer than half the women in a group were able to perform an optimal or correct pelvic-floor contraction when given written or verbal instruction; feedback after digital examination was the only way to ensure appropriate pelvic-floor muscle activity.1
1 The pelvic-floor muscles.
Management of incontinence A careful history of a patient’s symptoms, together with a vaginal examination and grading of the pelvic floor, enables the specialist physiotherapist to undertake appropriate management, which may involve: • pelvic-floor re-education • bladder training • biofeedback • electrotherapy • vaginal cones • advice.
Pelvic-floor exercises The pelvic floor and urinary incontinence
The instructions shown in Figure 2 may be used to explain to the patient how a pelvic-floor exercise may be performed correctly. This exercise works the slow fibres in the pelvic-floor muscle and
In 1999 a Department of Health working party report stated that all women presenting with incontinence should be offered, as a minimum, one-to-one training, vaginal examination to determine correct muscle action, and three months of exercise taught by a specialist physiotherapist or other professional with specialist knowledge.2 Physiotherapy should be the first-line treatment for women with stress or urge incontinence or genital prolapse, as it has been shown to be cost-effective and to have no side-effects. It is appropriate both for women who wish to avoid surgery and for those who wish to build up the strength of their pelvic-floor muscles before surgery. The women most likely to benefit from re-education of the pelvic-floor muscles are those found to have: • post-parturition urinary stress incontinence • urinary stress or urge incontinence • a prolapse (provided there is no gross fascial stretching) • first-degree uterine descent • second-degree uterine descent requiring surgery (pre-operative physiotherapy can aid recovery and reduce the likelihood of further problems) • vaginal laxity with no gross cystocele, rectocele or urethrocele.
How to perform pelvic-floor exercises • Close around the back passage as if you are trying to stop the release of wind • Then close the front passages as if stopping the flow of urine • Lift the passages and hold them for as long as you can, up to a maximum of 10 seconds • Release and rest for a few seconds • Repeat this exercise as many times as you can, to a maximum of 10 While doing the pelvic-floor exercises do not: • hold your breath • tighten your buttocks or thighs • pull in your upper abdominal muscles Do not routinely attempt to stop midstream while passing urine, as this may prevent complete emptying of the bladder and lead to infection. These exercises can be performed in any position, but you should concentrate on doing them correctly and should not do them while engaged in some other activity (e.g. while washing up).
Georgina Evans practises in Oxford as a women’s health physiotherapist. She has served on the executive and education committees of the Association of Chartered Physiotherapists in Women’s Health, and has a particular interest in the treatment of incontinence.
WOMEN’S HEALTH MEDICINE 2:6
2
29
© 2005 The Medicine Publishing Company Ltd
STRESS INCONTINENCE
Oxford grading system for assessment of pelvic-floor strength • • • • •
nil (lack of movement) flicker (flickering of the muscle) weak (weak pressure but more than a flicker) moderate (pressure compressing the examiner’s fingers) good (firm squeeze and lifting of fingers towards the pubic bone) • strong (strong grip and positive movement in the cranial direction) 3
helps to build up its endurance. The emphasis is on the lifting and holding. The pelvic-floor muscles also have fast fibres that come into play when we cough, sneeze or laugh, and it is important that these muscles should be able to react quickly to counteract a rise in intra-abdominal pressure. To exercise the fast fibres, the back and front passages should be lifted and held for a second before being released: now the emphasis is on the lift being strong and fast. Ideally the exercise should be taught by an expert, as it is hard to learn from written instructions. Specialist physiotherapists frequently encounter patients who have been performing pelvic-floor exercises regularly, but entirely incorrectly and ineffectually. If possible the woman should learn to make a digital vaginal assessment herself to check whether she is doing the exercise correctly; this is a useful biofeedback technique. The best positions for the woman to examine herself are either lying (for example in the bath) or standing. She introduces two fingers into the distal 3 cm of her vagina (or one finger for those with a smaller vagina). She then contracts her pelvic-floor muscles to assess their power, and counts the seconds she can hold the lift and the number of repetitions she is able to do before the muscle weakens. She can then assess the fast fibres in the muscle. Physiotherapists generally use the internationally accepted Oxford grading system (Figure 3) to assess the strength of a woman’s pelvic-floor muscles. Continuing management of incontinence A critical factor in the effectiveness of pelvic-floor exercises is self-motivation, and this can be hard to maintain. The maximum improvement is thought to take between 3 and 6 months. Periodic review by the physiotherapist ensures that the exercises continue to be performed correctly, and can help to sustain commitment. Correctly performed pelvic-floor exercises are extremely beneficial and should be continued for life, not simply to overcome an immediate problem. REFERENCES 1 Bump R, Hurt W G, Fantl A, Wyman J. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol 1991; 165: 322–9. 2 Brocklehurst J, Amess M et al. Outcome indicators for urinary incontinence. Oxford: National Centre for Health Outcomes Development, 1999: 38.
WOMEN’S HEALTH MEDICINE 2:6
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© 2005 The Medicine Publishing Company Ltd