La riabilitazione perineale nella donna di benedetto
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Transcript of La riabilitazione perineale nella donna di benedetto
GLUP(Gruppo di Lavoro Uroginecologia Pavimento Pelvico)
Pavimento Pelvico
ed
Evento Ostetrico
Gardone Val Trompia, 16 Aprile 2011P. Di Benedetto, 2011
La Riabilitazione Perineale
nella Donna
Paolo Di Benedetto, Udine P. Di Benedetto, 2011
Conservative treatment
Conservative treatment is any therapy that does not involve pharmacological or surgical intervention
It includes principally- lifestyle interventions- physical therapies- scheduled voiding regimens- complimentary therapies- anti-incontinence devices- supportive rings/pessaries- pads/catheters
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Pelvic Floor Rehabilitation
The use of PFMT as a treatment for stress urinary incontinence (SUI) appeared to become more widespread after Arnold Kegel reported on the successfull treatment of 64 cases of female SUI using pelvic floor muscle exercises, with a perineometer for resistance and biofeedback.
* 1992: Lower Urinary Tract Rehabilitation Techniques: seventh report on the standardization of terminology of lower urinary tract function (Neurourol Urodyn 1992;11:593-603)
* 1998: first International Consultation on Incontinence (Monaco)
→ algorithms for initial and specialised management of urinary incontinence
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Pelvic Floor Rehabilitation
TECHNIQUES- Biofeedback (BFB) - Pelvic Floor Muscle Training
(PFMT)- Functional Electrical Stimulation
(FES)- Endovaginal Cones- Bladder Retraining
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Pelvic Floor Rehabilitation
* Pelvic floor muscle training (PFMT)- with or without
biofeedback- with or without
adjuncts such as cones, resistance devices etc
* Electrical stimulation* Alternative methods?
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Pelvic Floor Skeletal Muscles
Slow Twitch Fibers (type I support of the pelvic viscera)Fast Twitch Fibers (type II occlusive effect on the urethra, reflex detrusor inhibition)
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Optimal function of the PFM?
- Form a structural support (location, cross sectional area, stiffness)
- Give quick and strong unconscious co-contraction before/during increase in abdominal pressure
- Prevent descent of internal organs during increase in intra-abdominal pressure
- Relax before and during voiding/defecation
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Female pelvic floor dysfunction
- Urinary incontinence
- Fecal incontinence- Pelvic organ
prolapse- Sensory and
emptying abnormalities of LUT
- Constipation- Sexual dysfunction- Chronic Pelvic Pain
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Pelvic Floor Rehabilitation
Non-surgical therapy (PFMT, bladder retraining and lifestyle interventions) should be considered as the first line of therapy for urinary incontinence
- no side effects- good results- surgical option not compromised
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Pelvic Floor Dysfunction
Pathophysiology
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JO DeLancey. Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6
The interaction between the pelvic floor muscles (PFM) and the supportive ligaments is critical to support of the pelvic organs.
As long as the PFMs function normally, the pelvic floor is closed and the ligaments and fascia are under no tension. The fascia simply act to stabilize the organs in their position above the levator ani muscles.
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JO DeLancey. Editorial. Current Opinion in Obstetrics and Gynecology 1994;6:313-6
When the PFMs relax or are damaged, the pelvic floor opens and the vagina lies between the high abdominal pressure and low atmospheric pressure. In this situation it must be held in place by the ligaments.
Although the ligaments can sustain these loads for short period of time, if the PFMs do not close the pelvic floor, then the connective tissue will became damaged and eventually fails to hold the vagina in place.
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PFM DYSFUNCTIONConsequences
Lack of the PFM “reflex” contractionGenital prolapseGenuine stress incontinenceOveractive bladderSexual problemsConstipationChronic pelvic pain
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PFM DYSFUNCTION
Primary Weakness (phasic and tonic components )
Apraxia (?)Secondary Weakness (neurogenic, post-partum, post- surgery)
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PFM DYSFUNCTION
Hypertonia(nonneurogenic, neurogenic)
Dyssynergic patterns
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Boath in Dry Dock( Norton PA, 1993)
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Pelvic Floor Consequences
ofOccupation SportPregnancyChildbirthMenopause
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URINARY INCONTINENCE Epidemiological Studies
(1)Nygaard et al (1994) 158 athletes, mean age 19.9 years all nulliparous 28% urinary incontinence during
sportactivities (2/3 IU more often than rarely)67% gymnastics66% basketball50% tennis10% swimming 0% golf
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URINARY INCONTINENCE Epidemiological Studies
(2)Warren and Shantha high impact sports activities may
produce urinary incontinence
Greydanus and Patel adolescent gynecology:
stress urinary incontinence is common in female athletes
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URINARY INCONTINENCE Epidemiological Studies
(3)
Bø and Borgen
high prevalence of stress and urge incontinence in female elite athletes,
mainly in eating disordered athletes compared with healthy athletes
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URINARY INCONTINENCE Epidemiological Studies
(4)
Thyssen et al elite women athletes and dancers 291 women, mean age 22.8 years 51,9% urinary loss (43% during
sport/dancing; 42% during daily life) the activity most likely correlated
with urinary incontinence was jumping
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INCITEchildbirth
nerve damagemuscle damage
radiationtissue disruptionradical surgery
PREDISPOSEgenderracial
neurologicanatomiccollagenmuscularcultural
enviromental
PROMOTEconstipationoccupationrecreation
obesitysurgery
lung diseasesmoking
menstrual cycleinfection
medicationmenopause
INTERVENEbehavioral
pharmacologicdevicessurgical
DECOMPENSATEaging
dementiadebility
environmentmedication
normal support or function
abnormal support or function
Model for the development of pelvic floor dysfunction in women (Bump et al, 1998)
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INCITING FACTORS
Role of
- radical pelvic surgery- pelvic radiation- vaginal delivery- nerve damage- muscular damage
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PROMOTING FACTORS
It is intuitive that occupational or recreational activities result in excessive or repetitive increases in abdominal pressures that contribute to the development of pelvic floor dysfunction in presence of weak pelvic floor muscles.
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INTRAPARTUM INJURY
CONNECTIVE TISSUE
BreakageStretching
LEVATOR ANI MUSCLES
Muscles Tears
Pudendal Nerve Acute Denervation
Loss of muscle tone Chronic Denervation
Aging
Connective tissue failure
GENITAL PROLAPSE
Proposed mechanism for acute injury to pelvic supportive structures at childbirth that may result in chronic denervation and pelvic organ prolapse (from Strohbehn, 1998)
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Vaginal childbirth
It can contribute to pelvic floor dysfunction and POP by
- direct damage to the endopelvic fascia and walls of the vagina
- indirect damage to the muscles and nerves of the pelvic floor.
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After childbirth
The connective tissue did not recovery!
Episiotomy and lacerations of the perineal musculature (and, sometimes, of the external anal
sphincter and rectum) often provoke apraxia of the PFMs
The duration of this condition is an adjunctive risk for the endopelvic connective tissue
The eventual neurophatic injury is an other obstacle for the spontaneous recovery for the PFMs
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What can weaken connective tissue and pelvic floor muscles?
- Overweight: 55-60% of US population over 18 years of age!!! INACTIVITYINACTIVITY
- Constipation – straining with bowel motion
- Smoking – excessive coughing
- Strenous work/ heavy lifting/sport (??)
- Pregnancy and childbirth (stretch/rupture of muscles, connective tissue, nerve lesion)
- Pelvic surgery- Inherited weak connective
tissue
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Rationale of Pelvic Floor
Rehabilitation• Identification of pathophysiological mechanisms of
bladder, sphincters and pelvic floor dysfunction
• Absence of pelvic floor (complete) denervation
• Good education of the physical therapist
• Motivation, collaboration and compliance of the patient
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Rationale of Pelvic Floor
RehabilitationPreviously trained PFM might be less prone to injury, and/or
easier to
retrain after injury because the appropriate motor patterns are
already learned.
For childbearing women , PFMT during pregnancy might help
counteract the increased intra-abdominal pressure caused by the
growing fetus, the hormonally mediated reduction in urethral
pressure, and the increased laxity of fascia and ligaments in the
pelvic area.
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During voluntary PFM contraction
- Levator hiatus constriction (urethra, vagina, anus) 25% (Brækken et al -09)
- ↑ MUCP: 11.1 (10.7)-23.2 (8.4) cm H2O (Miller et al-04, Bø & Talseth -97)
- Muscle length: 21% shortening (Brækken et al -09)
. Forward and upward movement: 1 cm (Bø et al 2001, Brækken et al 2008)
- Resistance to downward movement
- Inhibition of detrusor contraction
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Ability to contract PFM correctly
- >30% not able to contract (Benvenuti et al 1987, Bø et al 1988,Hesse et al 1990)
- Only 49% increased urethral pressure during contraction (Bump et al 1991)
- 25% straining instead of contracting (Bump et al 1991)
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Rationale of Pelvic Floor
Rehabilitation
Standard PFMT should be advised to all postnatal women.
Intensive PFMT is mandatory in symptomatic women (UI or initial
prolapse).
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Rationale of Pelvic Floor
Rehabilitation
The biological rationale for PFMT in the management of SUI is that astrong and fast PFM contraction will clamp the urethra, increasingthe urethral pressure to prevent leakage during an abrupt increase inintra-abdominal pressure.DeLancey has also suggested that an effective PFM contraction maypress the urethra against the pubic symphysis, creating a mechanicalpressure rise.
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Rationale of Pelvic Floor
Rehabilitation
Sometimes there is some evidence of PFM reflex contraction deficit
(feed-forward loop, as it precede bladder pressure rise by 200-240
msec).In these cases PFMT might normalize this reflex.
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Rationale of Pelvic Floor
Rehabilitation
There are two hypotheses to explain mechanisms of
PFMT:1) Use of conscious contraction before and
during increase in abdominal pressure (the Knack)
2) Building up a structural support, thereby facilitating automatic co-contractions whenever needed
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The ”Knack”Miller et al 1998
- 27 women. Mean age 68.4 (5.5) years with mild to moderate SUI
- 1 week of voluntary PFM contraction before and during cough
- Results: Reduced urine loss
from medium/ deep cough by average 98% and 73%
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RCTs on PFMT versus control on SUI
- Significantly more effective than no treatment (Henalla et al -89, Henalla et al -90, Lagro-Janssen et al -91, Miller et al -98, Bø et al -99, Sung et al -00,Bidmead et al -02, Aksac et al -03, Dumoulin et al -03)
- Cure/improvement rates (SUI /mixed) 56-70%
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Rationale of Pelvic Floor
RehabilitationPFMT may also be used in the management of urgeincontinence. Bladder muscle contractioncan be reflexly or voluntarily inhibited by PFM
contraction.Therefore, single or repeated voluntary pelvic floor
musclecontraction may be used to control urgency and preventurinary leakage.
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Rationale of Pelvic Floor
RehabilitationIn cases of chronic pelvic pain the aim of pelvic floorrehabilitation (PFMT, FES, BFB) is to intervene on the
viciouscircle
pelvic floor overactivity-ischemia-pain
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Conclusions
PFMT →
fundamental role in the pelvic floor rehabilitation
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Conclusions
BFB →
* poor perineal control
* pelvic floor tension myalgia (CPP)
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Conclusions
FES →
* in all types of urinary incontinence
* overactive bladder
* chronic pelvic pain
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Conclusions
Endovaginal cones →
in stress urinary incontinence
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Conclusions
Bladdder Retraining (± PFMT) →
in urge urinary incontinence
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PFRClinical
Recommendations
If no PFM contraction:facilitations by manual techniques( or FES/BFB)
When voluntary contraction:intensive PFMT
* No results: surgery (+ PFMT ?)
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PFRClinical
Recommendations
After surgery:
- weakness of PFM: intensive PFMT
- pain: aerobic programs, electrical stimulation
- detrusor instability: bladder retraining, drugs (PFMT,FES…)
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”Alternative” methods to PFMT?
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The FUTUREThe FUTURE
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The core of PFR is the pelvic floor muscle awareness associated to pelvic floor muscle training.
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Nowadays some non-medical pelvic floor grouped activities are rising, in order to widely offer PFMT as already happening in forms of adapted physical activity (APA) in other fields (low back pain, Parkinson, stroke, fibromyalgia).
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It should be very important also a sensitization of both patients and health care professionals that often underestimate pelvic floor dysfunction ( prevention and negative effects on quality of life).
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