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Pelvic Floor Muscle Re-Education Treatment of the Overactive Bladder and Painful Bladder Syndrome

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Pelvic Floor Muscle Re-Education Treatment of the Overactive Bladder and Painful Bladder Syndrome CLINICAL OBSTETRICS AND GYNECOLOGY Volume 45, Number 1, 273–285 © 2002, Lippincott Williams & Wilkins, Inc. Pelvic Floor Muscle Re-education Treatment of the Overactive Bladder and Painful Bladder Syndrome JAMES CHIVIAN LUKBAN, DO and KRISTENE E. WHITMORE, MD The Pelvic Floor Institute, Graduate Hospital, Philadelphia, Pennsylvania Normal function of the pelvic floor muscu- the pelvic floor, and in patients with overac- lature is essential in maintaining appropriate tive bladder may provide an additional ele- function of the pelvic viscera. Low-tone ment of reflex bladder inhibition. Muscle re- pelvic floor dysfunction, as may be seen in education techniques, typically preceded by patients with pelvic floor musculature de- a trial of behavioral therapy, include pelvic nervation, can contribute to pelvic organ floor musculature exercises, pelvic floor prolapse, transurethral urinary incontinence, musculature exercises with biofeedback, vaginal laxity, or transrectal fecal inconti- and electrical stimulation. The purpose of nence. High-tone pelvic floor dysfunction, this chapter is to discuss the use of pelvic as may occur in patients with overactive floor musculature rehabilitation to treat bladder or painful bladder syndrome (inter- overactive bladder and to correct high-tone stitial cystitis), can manifest as voiding pelvic floor dysfunction. dysfunction, sexual dysfunction with dyspa- reunia, or fecal retention. Pelvic floor reha- Anatomy of the Pelvic Floor bilitation for patients with pelvic floor dys- The pelvic floor contains layers of connec- function is performed in an effort to restore tive tissue and muscle that provide support normal tone and function to the muscles of to the pelvic viscera. The urethra, vagina, Correspondence: James Chivian Lukban, DO, Director and rectum are attached to the pelvic side- of Urodynamics, Graduate Hospital, Pepper Pavilion, walls by the endopelvic fascia, penetrating Suite 900, 1800 Lombard Street, Philadelphia, PA 19146. the pelvic floor at the urogenital hiatus. Im- CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 45 / NUMBER 1 / MARCH 2002 273 274 LUKBAN AND WHITMORE mediately beneath the endopelvic fascia is Normal Pelvic Floor Function the pelvic floor musculature. It is composed of the puborectalis, levator ani (pubococ- in Pelvic Organ Support and cygeus and iliococcygeus), and coccygeus Urinary Continence muscles. The puborectalis originates from The pelvic floor musculature performs an the pubis and runs posteriorly to join its con- important role in tonic support of the pelvic tralateral muscle behind the anorectal junc- viscera. Such support is provided by a pre- tion, forming a U-shaped sling. The pubo- ponderance of type I (slow twitch) fibers coccygeus muscle emanates from the pubis, within the pelvic floor musculature. In the traveling posteromedially to insert on the su- maintenance of urinary continence, tonic perior surface of the coccyx and the anococ- muscular forces are provided by the external cygeal raphe. The iliococcygeus arises from striated urethral sphincter (composed of the the arcus tendineus levator ani, running pos- intramural striated sphincter and the periure- teromedially to insert on the coccyx and thral levator ani musculature) and are impor- anococcygeal raphe. The coccygeus muscle tant in effecting adequate urethral support. originates from the ischial spine and sacro- In addition, a minority population of type II spinous ligament, inserting onto the lateral (fast twitch) fibers within the levator ani coccyx and lower sacrum. Beneath the pel- musculature provides a mechanism for ac- vic floor musculature is the perineal mem- tive periurethral muscular contraction at the time of provocative increases in intra- brane, which together with the pelvic floor 3 musculature defines the pelvic floor. The abdominal pressure. Less perceptible tonic perineal membrane is a triangular sheet of increases in the pelvic floor musculature oc- dense fibromuscular tissue spanning the an- cur during bladder filling as part of a primi- terior half of the pelvic outlet. Its attach- tive sacral spinal mechanism known as the ments include the urethra, vagina, and peri- guarding reflex whereby mechanoreceptive neal body medially and the inferior ischio- parasympathetic impulses triggered by vesi- pubic rami laterally.1 cal distention lead to somatic efferent stimu- lation of the pelvic floor musculature and the external striated urethral sphincter.2 One’s Innervation of the Pelvic threshold of continence is thus increased throughout bladder distention through a Floor neurologically responsive pelvic floor mus- The nerve supply to the pelvic floor includes culature. both somatic and autonomic innervation. Somatic fibers from S2–S4 form the puden- dal nerve, which supplies the perineal sur- face of the pelvic floor musculature. Sacral Low-Tone Pelvic Floor nerve root branches also innervate the pelvic Dysfunction floor directly through fibers traveling to the visceral surface of the pelvic floor muscula- DEFINITION ture. Parasympathetic innervation begins Low-tone pelvic floor dysfunction refers to with preganglionic fibers emanating from the clinical finding of an impaired ability to S2–S4, and ends in the postganglionic mus- isolate and contract the pelvic floor muscu- carinic receptors of the bladder wall. Sym- lature in the presence of weak or atrophic pathetic innervation arises from T10–L2, musculature. Urologic and gynecologic with postganglionic fibers traveling to beta- manifestations include progressive pelvic adrenergic receptors in the smooth muscle organ descent and stress urinary inconti- of the bladder wall and alpha-adrenergic re- nence secondary to a loss of both pelvic ceptors in the smooth muscle of the bladder floor musculature tone and active periure- neck and proximal urethra.2 thral contractile forces. Pelvic Floor Muscle Re-education 275 ETIOLOGY pairment of muscle isolation, contraction, Low-tone pelvic floor dysfunction may be and relaxation. Urologic and gynecologic encountered in patients with partial pelvic manifestations include voiding dysfunction, floor denervation as a result of parturition, urinary frequency, urgency, and pelvic pain. senescence, or some combination. In a Spastic pelvic floor musculature is com- sample of 96 nulliparous women, Allen et monly encountered in those with interstitial al.4 examined the effects of childbirth on the cystitis, and may be seen in those with over- nerve supply to the pelvic floor and the pel- active bladder. vic floor musculature. Evaluation per- formed at 36 weeks’ gestation and at 2 LITERATURE REVIEW months after delivery included concentric High-tone pelvic floor dysfunction has been needle electromyography (EMG) and peri- described infrequently in the urologic or gy- neometry. Mean duration of motor unit po- necologic literature; however, the same tentials was found to be significantly in- clinical condition has been reported in colo- creased on postpartum EMG studies com- rectal publications as any one of the follow- pared with antepartum values, indicative of ing clinical entities: coccygodynia, as de- the presence of denervated muscle fibers scribed by Thiele; tension myalgia of the with subsequent peripheral reinnervation af- pelvic floor, coccygeus-levator spasm syn- ter injury. Mean motor unit potential dura- drome; levator syndrome; and levator ani tion was also found to be greater in postpar- spasm syndrome. tum samples of women who experienced a Thiele6 described coccygodynia in 1937 prolonged second stage of labor, and in not only as an entity characterized by pain those giving birth to babies with an above- localized to the coccyx, but also as a syn- average birthweight. Perineometry mea- drome noteworthy for the presence of leva- surements antenatally and 2 months postpar- tor ani and coccygeus muscle spasm. In his tum were 15.6 cm H2O and 10.1 cm H2O, original communication, 64 of 69 patients respectively, consistent with a significant with coccygeal pain were found to have reduction in pelvic floor musculature spastic pelvic floor musculature on rectal strength after delivery. examination. Work published by the same Smith et al5 used single-fiber EMG to author in 1963 further characterized coccy- provide evidence of age-associated pelvic godynia based on a review of 324 case rec- floor musculature denervation. An increase ords.7 Patient symptoms included pain lo- in motor unit fiber density, consistent with calized to the lower sacrum and coccyx, of- compensatory reinnervation after injury, ten exacerbated by prolonged sitting. Few of was found to correlate with increasing age in his patients, however, exhibited tenderness 41 nulliparous asymptomatic women. Val- of the coccyx on direct palpation or manipu- ues ranged from 1.2 at 20 years to 1.6 at 77 lation, a finding consistent with pain born of years, representing an increase of 0.07 fibers pelvic floor musculature spasm and not of per year. primary sacrococcygeal pathology. Com- mon etiologic factors included anal infec- tion and chronic trauma, as identified in 178 High-Tone Pelvic Floor (55%) and 106 (33%) patients, respectively. Anal infection was thought to cause reflex Dysfunction pelvic floor musculature spasm through lymphatic drainage of organism-laden DEFINITION lymph. Chronic trauma included poor sitting High-tone pelvic floor dysfunction refers to posture and extended vehicle rides. the clinical condition of hypertonic, spastic Sinaki et al8 used the term tension myal- pelvic floor musculature with resultant im-
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