The first step in starting a pelvic floor muscle (PFM) training program should be done during the physical exam (see Figure 6.1). That is, palpate PFM digitally; Make sure the patient can contract the correct muscles. On palpation, you may find partial or complete absence of PFM (called levator avulsion defect), which may make it difficult for her to contract muscles [12]. If the muscles are intact, she shouldn't:
- Contract the hip muscles (lift the buttocks off the bed).
- Contract the adductor muscles (tighten the thighs together).
- Contract the abdominal muscles (press down on the pelvic floor).
- Contracting these muscles will not help and may make the leakage worse.
Figure 6.1
Assess the pelvic floor muscles
Once the patient can contract the PFM properly, ask her to squeeze as hard as possible and count to a maximum of 10 seconds. Watch when the muscles start to fatigue and stop counting there, for example, for 6 seconds.
After the patient is dressed, explain to her that PFM is a muscle that runs from the pubic bone to the coccyx with three openings (urethra, vagina, anus). We found it helpful to show the chart shown in Figure 6.2, as many patients do not understand this basic anatomy. Explain that PFM is a postural muscle, just like the erector spinal muscles of the back. Think of a weightlifter who goes to the gym. Due to the strong resting tension of his massive back muscles, his posture is usually very upright, but he is also able to lift heavyweight objects. A woman needs to gradually train her PFM over 12-24 weeks to increase resting tone of the muscles, which can also be hypertrophied. The patient can then be trained to squeeze the muscles to resist the "load" of coughing or sneezing.
Figure 6.2
Pelvic floor muscles
The role of the therapist
Evaluation and basic interpretation of PFM (above) is a task that any registrar or clinician should be able to perform, as it only requires 1 minute of physical examination time and 3 or 4 minutes of interpretation time.
The following description of how to start a PFM training program can be too time-consuming in the context of a busy outpatient clinic. In this case, the patient should be referred to a nurse restraint counselor (NCA) for detailed training below. If her PFM is very weak, then a referral to physiotherapy is more appropriate, as she may require electrical stimulation (see below). Sometimes, what type of therapist you are referring to may depend on availability and cost.
- First, women must contract their muscles as forcefully as possible, reaching a maximum contraction (e.g., 3 seconds) when fatigue is noticed.
- Then let the muscles rest for 5 seconds to allow oxygen to re-enter the muscles.
- To explain, without this oxygen interruption, just squeezing the muscle over and over again causes it to get tired, not strengthen.
- For ease of memory, we usually set up a program that starts with her 3-second maximum for digital construction, such as 3-second squeeze, 4 squeezes per "group" or group, 5 sets per day.
- In this example, she has 20 contractions a day.
- The five sets per day should be spread out throughout the day rather than done all at once in the morning (as this can also lead to fatigue).
- To help remember this, we place five red sticky dots in places visited at different times of the day (near toothbrushes, kettles, phones, TV remotes, etc.). See Figure 6.3.
Figure 6.3
PFM training program written for patients whose initial pelvic floor contractions last only 3 seconds and who contracted four times per set, five sets per day (five red dots are given)
After 3-4 weeks of strengthening PFM, she should learn how to contract muscles before coughing or sneezing. This technique, called "know-how", has been shown in pad tests to reduce leakage by up to 60%/day.
In subsequent visits, the nurse temperance counselor reiterated the original explanation and escalated the procedure (to make it harder). If a patient is sent to physical therapy, the first visit always includes this type of interpretation and is escalated at a later date. PFM is used to delay urination even if the complaint is urge incontinence, so the patient needs to know how to contract it.
Cite this chapter
Moore, K.H. (2022). Conservative Therapy of Stress Incontinence . In: Urogynecology . Springer, Cham. https://doi.org/10.1007/978-3-030-93367-8_6