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

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 dyspareunia, 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 stimulation 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 pudendal nerve, which supplies the perineal surface 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 performed 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 infection 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- gia of the pelvic floor to describe a sample of 276 LUKBAN AND WHITMORE

94 patients with spastic, tender pelvic floor in the area of the bladder, but also in the re- musculature. Common symptoms included gions of the sacrum, coccyx, and anus, they low back pain in 82% and a “heavy feeling investigated the presence of concomitant in the pelvis” in 64%, with the appearance of pelvic floor musculature spasm. Twenty- symptom aggravation in 88% of patients af- five (81%) of 31 patients with interstitial ter prolonged sitting. Pelvic floor muscle cystitis were found to have spasm and ten- spasm was attributed to habitual contraction derness of the levator ani musculature, of the pelvic floor in addition to a compo- which they termed levator ani spasm syn- nent of hypochondriasis. drome. The authors postulated that such Paradis and Marganoff9 used the term muscle activity was, in part, the result of coccygeus-levator spasm syndrome to char- bladder pathology, with increased pelvic acterize 92 patients with pelvic floor spasm floor musculature tone appearing in re- and “rectal” pain. Patients were found to be sponse to afferent autonomic impulses ema- particularly tender at muscular sites adjacent nating from the bladder wall. These authors to the ischial spines and coccyx, with a sug- also assigned importance to poor sitting or gestion by the authors of a more significant working posture as contributing to the de- involvement of musculofascial, ligamen- velopment of levator ani spasm syndrome. tous, and tendinous structures than of the Their excellent clinical observations, sug- muscles themselves. Neither infection nor gest both a neurologic and musculoskeletal trauma was identified in these patients as etiology in the development of high-tone etiologic factors, with the attribution of dis- pelvic floor dysfunction in patients with in- ease presence to psychoneurosis. terstitial cystitis. Grant et al.10 used the term levator syn- In a nondiseased bladder, mechanorecep- drome to describe a sample of 316 patients tion in the detection of bladder wall tension exhibiting pelvic floor musculature spasm is mediated by lightly myelinated A-␦ fi- and tenderness. The predominant symptom bers. Nociceptive afferents, known as (un- was rectal discomfort. The etiology of leva- myelinated) C-fibers, are typically silent, tor syndrome was reported as unknown. becoming active in response to bladder in- All of the syndromes as presented above flammation or irritation. It is thought from represent a similar clinical condition charac- feline studies that such fibers, once trig- terized by tender, spastic pelvic floor mus- gered, not only fire at low thresholds, but culature manifesting as pain localized to the may also fire spontaneously, resulting in coccyx and lower sacrum, rectal pain, or pain and reflex voiding.12 In the normal generalized pelvic discomfort. Etiologic guarding reflex, parasympathetic afferents factors as reported are varied and include in- lead to a gradual increase in pelvic floor fection, chronic sacrococcygeal trauma musculature tone as mediated by somatic ef- from poor posture or prolonged sitting, and ferents from the sacral spinal cord, as de- hypochondriasis or hysteria. A definitive scribed above. One speculative possibility cause of high-tone pelvic floor dysfunction in the development of high-tone pelvic floor as encountered in patients with interstitial dysfunction is that the afferent autonomic cystitis has not been established and is most “bombardment” seen in patients with inter- likely the result of several co-existing fac- stitial cystitis may enhance and maintain a tors. guarding reflex that manifests as pelvic floor hypertonus. This concept of pelvic floor ETIOLOGY spasticity appearing as a result of a sustained In 1973, Lilius et al11 published a thoughtful guarding reflex has been previously alluded study on the prevalence of levator spasm in to by Chancellor.13 patients with interstitial cystitis. Because A musculoskeletal etiology for high-tone many of their patients reported pain not only pelvic floor dysfunction has been suggested Pelvic Floor Muscle Re-education 277 by several authors. Thiele,7 Sinaki et al,8 and Lilius et al.11 have associated pelvic floor musculature spasm with poor posture and prolonged sitting. This “typical pelvic pain posture,” as termed by Baker,14 characterized by exaggerated lumbar lordosis, ante- rior pelvic tilt, and thoracic kyphosis, has been implicated in the subsequent development of sacroiliac pathology. As the sacroiliac joint moves, however slightly, through upslip, downslip, or torsion, the pelvic floor musculature to which it is attached is also subject to dynamic change.15 Muscles that are stretched or compressed are prevented from maintaining a normal resting tone and are prone to trigger point formation and hy- pertonicity.14 Pelvic floor dysfunction is also thought to appear in reaction to over- FIG. 1. Pelvic floor muscle contraction scale. flexion of the coccyx while sitting with in- correct posture.7 Spasm in these patients may be the result of a change in tension of floor musculature isolation. The contraction the pelvic floor musculature to which the 17 7 is based on a five-point scale (Fig. 1). The coccyx is attached. The presence of sacro- same protocol is performed for both the right iliac dysfunction with or without the contri- and left pelvic floor musculature. The pa- bution of poor posture may reasonably serve tient is then asked to relax her muscles and as a trigger for the development of high-tone tenderness (hypertonus) is graded on a zero- pelvic floor dysfunction. It is likely that the to-four scale (Fig. 2).17 degree of high-tone pelvic floor dysfunction Digital evaluation of the pelvic floor encountered in interstitial cystitis represents musculature has been described by several the sum of both neurologic and musculo- authors and varies in regard to scale, number skeletal components.16

Evaluation of the Pelvic Floor Assessment of the pelvic floor is performed in an effort to determine a patient’s ability to isolate, contract, and relax the pelvic floor musculature. Evaluation is made through intravaginal (or trans-rectal) examination and may include the use of measuring devices for complementary assessment. Evaluation begins with a single-finger digital examination with light pressure against the inferior lateral wall of the vagina. The patient is then asked to perform a contraction, squeezing the finger to “lift up” the floor of the vagina. Abdominal, gluteal, and adductor muscle recruitment should be ob- FIG. 2. Pelvic floor muscle tenderness (hyper- served as a general assessment of pelvic tonus) scale. 278 LUKBAN AND WHITMORE of fingers used, and specific parameters as- floor musculature, because these devices sessed. Worth et al.18 described a one-to- can receive input from nonpelvic muscles, three scale using a one-finger assessment of including abdominal, gluteal, and adductor pressure, duration, “ribbing” (tone during musculature. A concomitant assessment contraction), and position (degree of dis- through palpation of these extrapelvic placement). Interobserver and test–retest re- muscle groups should be made during test- liability for this technique was proved. ing to provide clinical perspective regarding Brink et al19 reported a one-to-four scale us- absolute intravaginal readings. ing a two-finger assessment of lateral and Findings in patients with low-tone pelvic anteroposterior pressure, duration, and ver- floor dysfunction include impaired muscle tical displacement. Interrater and test–retest isolation and contraction on digital exami- reliability for this scale was also proved. The nation. Perineometry in this population re- most notable pelvic floor musculature digi- veals decreased contraction amplitude and tal assessment tool is that described by Lay- duration. Those with high-tone pelvic floor cock.20 This zero-to-five scale is reproduc- dysfunction exhibit poor muscle isolation, ible and assesses pressure and displacement. impaired contraction, tenderness, spasticity, There is a relative paucity of data regarding and impaired relaxation on digital examina- digital scoring systems in the evaluation of tion. Perineometry in these patients typi- high-tone pelvic floor dysfunction; most cally reveals elevated baseline pressures scales seem to address a patient’s ability to with no significant change in measurement contract her pelvic floor musculature with- from baseline upon contraction and subse- out an assessment of tenderness or impaired quent relaxation. Patients with high-tone relaxation. pelvic floor dysfunction who respond to pel- Perineometry is performed to more ob- vic floor rehabilitation exhibit a decrease in jectively assess pelvic muscle strength and muscle tenderness, a decrease in resting baseline tone. A pressure-sensitive intra- tone, and an increase in the degree of change vaginal probe within a disposable rubber between resting and contraction perineom- sheath or glove is zeroed and placed in the etry measurements. No standard values for vagina to determine resting pelvic floor establishing diagnoses of low or high-tone musculature tone. The patient is then asked pelvic floor dysfunction through digital ex- to offer and sustain a contraction, the amination, perineometry, or EMG have strength and duration of which are mea- been established. sured. She is asked to consciously relax her pelvic floor musculature, and a final perineometry reading is obtained to evaluate the Behavioral Therapy patient’s ability to return to a flaccid state. Initial therapy for overactive bladder typi- This tool offers the benefit of measuring im- cally exists in the form of behavioral tech- paired relaxation in the form of both an el- niques, which include dietary modification evated baseline and high postcontraction to limit acidic foods and known bladder irri- tone. Perineometry has been shown to cor- tants, timed voiding to maintain predictable relate with digital examination employing intravesical volumes, and bladder training, the Oxford Scale in the assessment of im- in which the patient is instructed to follow a paired pelvic floor musculature function.21 regimen of urge inhibition in an effort to ex- Assessment of the pelvic floor musculature tend voiding intervals and reduce the num- can also be made by intracavitary or surface ber of incontinence episodes. Bladder drill EMG, which has also been shown to corre- (also known as bladder training or bladder late with digital evaluation of the pelvic retraining) in theory functions by increasing floor.18,22 Both perineometry and EMG may cortical control over lower urinary tract not measure solely the activity of the pelvic function. In a review by Fantl23 examining Pelvic Floor Muscle Re-education 279 the effect of this technique in a community- exercises. Seven (50%) participants exhib- dwelling population with urinary inconti- ited excellent or good results at 6-month fol- nence, fewer than 15% of patients exhibited low-up. It is thought that pelvic floor mus- complete symptom resolution, and more culature exercises in patients with overac- than 50% of subjects showed a 50–75% re- tive bladder create a reflex inhibition of the duction in symptoms. These numbers were bladder in addition to the provision of en- based on the collective findings of three ran- hanced periurethral support. domized clinical trials and seven patient se- To ensure proper performance of pelvic ries with urodynamic evidence of detrusor floor musculature exercises, patients are instability, and one series of subjects exhib- educated on basic pelvic floor musculature iting sensory urgency. anatomy and assessed with digital examina- Some authors have reported success with tion to ensure pelvic floor musculature iso- behavioral therapy in samples of women lation. Concomitant monitoring of abdomi- with interstitial cystitis. Parsons and nal, gluteal, and adductor musculature is Kaprowski24 used bladder training in a performed to detect extrapelvic muscular ef- sample of 21 patients with interstitial cystitis forts. The patient is instructed to squeeze or and predominant symptoms of frequency “lift up” the pelvic floor musculature and and urgency. Subjects were placed on a pro- liken the exercise to an effort to prevent tocol involving progressive increases in leakage of urine or stool. The typical proto- time between voids, adding 15 to 30 minutes col for pelvic floor musculature strengthen- to the voiding interval every 3 to 4 weeks, ing involves the performance of 50 contrac- with a goal of 31⁄2 to 4 hours between voids. tions per day in two or three divided ses- Fifteen (71%) patients exhibited a 50% de- sions. Each contraction is sustained for 5 crease in symptoms. Data reflecting the use seconds, followed by a 10-second period of of bladder training in patients with intersti- relaxation. In patients with overactive blad- tial cystitis versus overactive bladder are der, urge inhibition is achieved with 5 to 10 scarce. quick contractions 1 to 2 seconds in duration at the onset of symptoms. In patients who exhibit an impaired abil- Treatment of Overactive ity to isolate and contract their pelvic floor musculature despite appropriate education Bladder and coaching, biofeedback is added to aid in appropriate pelvic muscle identification. PELVIC FLOOR MUSCLE EXERCISES Imperceptible muscular activity becomes AND BIOFEEDBACK perceptible through visual and/or audio Conservative therapy for stress urinary in- cues, enhancing the patient’s ability to con- continence has commonly included pelvic trol previously unfamiliar musculature. An floor musculature exercises, performed to intravaginal EMG probe is used to sense pel- strengthen periurethral striated musculature vic floor musculature activity, with signal and enhance the patient’s ability to inhibit conversion to a computer screen or audio leakage on provocation. Several investiga- source. Abdominal muscular activity is tors have more recently described the use of monitored concomitantly with surface EMG pelvic floor musculature exercises in the patches to ensure pelvic floor musculature treatment of overactive bladder. Nygard et isolation. The patient is instructed to per- al25 reported a significant decrease in the form a contraction around the probe for 5 mean number of incontinent episodes per seconds, followed by rest for 10 seconds. day (from 2.8 to 0.5) in a sample of 14 Visually, the patient can see contraction and women with detrusor instability after a relaxation cycles, with a goal of sustained 3-month course of pelvic floor musculature peaks of 12.5 µV and resting values of less 280 LUKBAN AND WHITMORE than or equal to 2 µV. Each session lasts 15 cystometry performed at the end of the minutes and is repeated one or two times a 8-week treatment period. In a more recent week for 6 weeks. No large randomized double-blind, sham-controlled randomized studies on the use of biofeedback in patients trial of 68 patients (39 women, 29 men) with with overactive bladder have, to our knowl- detrusor overactivity, Yamanishi et al31 re- edge, been published.26 ported 25% and 62.5% cured and improved rates, respectively, after electrical stimula- ELECTRAL STIMULATION tion (10 Hz, 15 minutes twice daily for 4 Electrical stimulation has been used in the weeks) in patients with detrusor overactiv- treatment of stress urinary incontinence ity. Cure was defined as a stable cystomet- since its initial description for such by rogram or no evidence of incontinence on Caldwell in 1963.27 Its therapeutic role in voiding diary. “Improved” was defined as a patients with overactive bladder has since decrease in frequency by greater than 50% been reported. The mechanism of electrical or an increase in cystometric capacity by stimulation in inhibiting detrusor overactiv- more than 50 mL. Thirteen of 17 patients in ity involves the inhibition of parasympa- the active group were said to have been thetic efferent activity following peripheral cured or improved at an average of 8.4 somatic afferent stimulation as mediated by months after completion of the 4-week treat- central parasympathetic suppression and in- ment regimen. Clinical benefit in those re- direct sympathetic inhibitory impulses.28 ceiving electrical stimulation was signifi- The application of electrical stimulation cantly greater than that seen in the sham in women commonly involves the use of an group. intravaginal or intrarectal probe (anogenital stimulation) with somatic afferent delivery COMBINATION THERAPY to branches of the pudendal nerve. Stimula- Pelvic floor muscle exercises, biofeedback, tion may be provided at subsensory thresh- and electrical stimulation are commonly old levels (chronic electrical stimulation) performed in combination. Our protocol is without the elicitation of pelvic floor mus- that of weekly 23-minute sessions over 6 culature contractions or at maximum toler- weeks using pelvic floor musculature exer- ated levels (maximal electrical stimulation) cises with intravaginal biofeedback and with accompanying pelvic floor muscula- electrical stimulation. Each session begins ture activity. For the purpose of this discus- with 4 minutes of biofeedback with con- sion, electrical stimulation will refer to comitant abdominal surface EMG measure- maximal electrical stimulation delivered via ments, during which the patient is asked to the anogenital route. In a review by Payne,29 offer pelvic floor musculature contractions 361 patients with overactive bladder treated for 5 seconds, followed by 10-second inter- with electrical stimulation were examined. vals of relaxation. A contraction amplitude Seventy-seven (20%) became dry, and 134 of 12.5 µV with a baseline of less than 2 µV (37%) showed significant improvement. In is desired without significant abdominal a double-blind, randomized, sham- muscle activity. Intravaginal stimulation for controlled clinical trial of 121 incontinent 15 minutes at 20 Hz is then applied, fol- women, Brubaker et al30 reported that 49% lowed by 4 additional minutes of pelvic of patients with detrusor instability were floor musculature exercises and biofeed- cured after electrical stimulation (20 Hz, 20 back. Stein et al32 prospectively evaluated minutes twice daily for 8 weeks), with no 21 patients with urge (n = 14) or mixed (n = significant postintervention improvement 17) incontinence treated with six sessions of seen in those who used the sham device. office biofeedback and electrical stimula- Cure was defined as the absence of detrusor tion over a 3-week period. Each session con- instability on posttreatment provocative sisted of 15 minutes of transvaginal or trans- Pelvic Floor Muscle Re-education 281 rectal electrical stimulation at a frequency of dysfunction, and interstitial cystitis, manual 20 Hz. pelvic floor musculature exercises physical therapy was performed to assess were then performed for 15 minutes, with si- the benefit of such treatment in reducing in- multaneous assessment of abdominal terstitial cystitis symptoms (frequency, ur- muscle activity by surface EMG. Four gency, nocturia, pain) as measured by the (19%) patients were cured and five (24%) O’Leary-Sant Symptom and Problem In- were significantly improved at a median fol- dex.33 Dyspareunia was also evaluated in low-up of 18 months (range 3–36 months). these patients using the “sex life” question This study’s poor rate of success may have from the Modified Oswestry Disability been due to the use of relatively rigid defini- Scale. A comparison of pre- and posttreat- tions of both cure (no pad use, with less than ment Modified Oswestry scores revealed an one incontinent episode per month) and sig- improvement in dyspareunia in 15 (94%) nificant improvement (no pad use, with less patients. A comparison of pre- and posttreat- than one incontinent episode per week). ment O’Leary-Sant scores also showed im- Combination therapy may also be offered in provement in 15 (94%) subjects. Schroeder the form of a home unit. Although more con- et al.34 reported the use of an undefined regi- venient, home therapy lacks the benefit of men of physical therapy in a pediatric and the presence of a skilled practitioner. adolescent population in which 20 out of 21 patients with musculoskeletal pelvic pain were successfully treated. Treatment of High-Tone THIELE MASSAGE Pelvic Floor Dysfunction After sacroiliac realignment, patients are re- assessed by digital examination and peri- PHYSICAL THERAPY neometry. If pelvic floor musculature spasm Patients diagnosed with high-tone pelvic persists as either diffuse or localized hyper- floor dysfunction are referred to a physical tonicity, subjects undergo a regimen of therapist for assessment to identify sacro- Thiele massage. In his original description iliac malalignment, also known as sacroiliac of this technique, Thiele6 reported a per- dysfunction. Evaluation in brief includes a sonal series of 31 cases of coccygodynia and specific assessment of pelvic alignment, pelvic floor musculature spasm in which 19 lumbar and hip active and passive range of (61.3%) were cured and 17 (35.5%) were motion, strength and flexibility of the spinal improved (undefined criteria) after transrec- and pelvic stabilizers, and tenderness and tal massage. The author combined his data spasm of the pelvic supportive musculature. with those taken from eight other proctolo- Typical manual therapy techniques used in gists using the same technique and reported the correction of sacroiliac dysfunction, if a 93.7% cured and improved rate in a total of identified, include myofascial release, joint 80 patients. Treatment consisted of an aver- mobilization, muscle energy, strengthening, age of 11 treatments over an average of 11 stretching, neuromuscular re-education, and weeks. instruction in an extensive home exercise In our practice, we perform Thiele mas- program. The speculative logic in correcting sage transvaginally because this is more sacroiliac dysfunction in patients with high- comfortable for our patients. In performing tone pelvic floor dysfunction is such that if this technique, pressure is applied to the pel- sacroiliac alignment is restored, normal ten- vic floor musculature fibers longitudinally sion to the pelvic floor musculature returns, from origin to insertion. Ten to 15 sweeps of allowing the resolution of a high-tone state. maximally tolerated pressure are performed In a pilot study of 16 patients with high- on each side, followed by myofascial mas- tone pelvic floor dysfunction, sacroiliac sage (10 to 15 seconds of sustained pressure) 282 LUKBAN AND WHITMORE to tender points. Patients are treated once or up). The mechanism of pain relief in these twice a week for 6 to 8 weeks; this is less patients was reported as muscle fatigue after frequently than practiced by Thiele, who ap- sustained contractions, in addition to moto- plied therapy every day for 5 or 6 days and neuron suppression. Other investigators then every other day for 7 to 10 days as an have reported the use of electrogalvanic initial course. stimulation in patients with levator syndrome, reporting variable results with excel- PELVIC FLOOR MUSCLE EXERCISES lent or good improvement ranging from 43– AND BIOFEEDBACK 91%.38–41 Electrical stimulation in patients Patients with persistent high-tone pelvic with high-tone pelvic floor dysfunction is floor dysfunction despite appropriate delivered with the same intention as electro- manual physical therapy and Thiele mas- galvanic stimulation in creating muscle fa- sage may benefit from pelvic floor muscle exercises and biofeedback. In a study of 60 patients with intractable rectal pain, 70% of whom were diagnosed with either levator spasm or coccygodynia, Ger et al35 performed biofeedback on 14 subjects, using rectal EMG. After a minimum of six weekly 30- to 60-minute sessions, pain relief was rated as excellent or good (undefined) in six (43%) patients at a mean follow-up of 15 months. Heah et al36 prospectively treated 16 patients with levator ani syndrome with biofeedback, using a rectal manometric bal- loon. A significant improvement in pain was achieved with scores recorded on a 0-to-10 linear analog scale (median pain score before biofeedback = 8; median pain score after biofeedback = 2). All patients exhibited nontender musculature after therapy. The goal of biofeedback in the treatment of high- tone pelvic floor dysfunction is to achieve conscious control over pelvic floor musculature contraction and relaxation, thus breaking the cycle of spasm.

ELECTRICAL STIMULATION The use of electrogalvanic stimulation in patients with levator syndrome was first described by Sohn et al.37 Seventy-two patients were treated with electrogalvanic stimulation at 80 Hz to a point of mild discomfort for 1 hour per day for three sessions over a 3- to 10-day period. Fifty (69%) patients rated treatment as excellent (complete pain relief) and 15 (21%) rated therapy as good (pain resolution with fewer than three FIG. 3. Pelvic floor re-education in the treat- recurrences in the 6 to 30 months of follow- ment of overactive bladder. Pelvic Floor Muscle Re-education 283 tigue with resultant relaxation; however, PHARMACOLOGIC THERAPY electrical stimulation employs low-voltage Several authors have reported success in the alternating current, whereas electrogalvanic treatment of high-tone pelvic floor dysfunc- stimulation employs high-voltage direct tion with diazepam. Grant et al10 reported current.42 the use of this medication in conjunction with heat and transrectal massage, with 68% COMBINATION THERAPY of patients reporting good results (symptom Electrical stimulation may be provided for relief by three or less massage treatments). patients with high-tone pelvic floor dysfunc- In a smaller series of six women with exter- tion at the time of biofeedback therapy. Ad- nal sphincter spasm, sustained relief from ministration of anogenital electrical stimula- urgency, suprapubic discomfort, and void- tion is as described for overactive bladder; ing dysfunction was achieved after a 2- to however, a frequency of 50 Hz is used, with 6-month course of diazepam taken in doses the delivery of stimulation to a point of mild of 2 to 6 mg daily.43 discomfort. Patients with high-tone pelvic We have had anecdotal success with tiza- floor dysfunction may maintain pelvic floor nidine hydrochloride in relieving high-tone musculature fitness with a home device. pelvic floor dysfunction. Because it is a centrally acting ␣-adrenergic agonist, it should be used with caution in patients taking other centrally acting agents. We usually begin with a low dose of 2 mg at bedtime daily and titrate as appropriate. Treatment Algorithms In the treatment of overactive bladder, pelvic floor re-education usually follows an initial trial of behavioral therapy, as described above (Fig. 3). Practitioners commonly offer their patients pharmacologic agents before or in lieu of pelvic floor re-education, because clinicians may not have the equip- ment or staff to perform appropriate re- education. Additionally, patients may view pharmacologic therapy as more immediate and less labor-intensive. Sacral nerve root stimulation has shown recent success in patients with refractory symptoms. Surgical therapy remains a last resort in the treatment of overactive bladder (and interstitial cystitis). The best therapy before sacral neuromodulation or surgery may be a combination of conservative techniques and oral agents. Magnetic stimulation and peripheral neuromodulation have also been used in patients with overactive bladder. High-tone pelvic floor dysfunction is treated initially with manual physical ther- FIG. 4. Pelvic floor re-education in the treatment of high tone pelvic floor dysfunction. apy performed in an effort to restore sacroiliac and sacrococcygeal alignment, with re- 284 LUKBAN AND WHITMORE sultant relief from abnormal muscular ten- 3. Gosling JA, Dixon JS, Critchley HOD, et al. sion (Fig. 4). Thiele massage is initiated if A comparative study of the human external the pelvic floor musculature exhibits persis- sphincter and periurethral levator ani mus- tent hypertonus despite appropriate bony cles. Br J Urol 1981;53:35–41. alignment. Pelvic floor muscle exercise, 4. Allen RE, Hosker GL, Smith ARB, et al. biofeedback, and electrical stimulation then Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol. provide a mechanism to achieve maximal 1990;97:770–779. pelvic floor musculature contraction and re- 5. Smith ARB, Hosker GL, Warrell DW. The laxation in restoration of normal muscular role of partial denervation of the pelvic floor function. Pharmacologic therapy may be in the aetiology of genitourinary prolapse used as adjunctive therapy in patients with and stress incontinence of urine. A neuro- high-tone pelvic floor dysfunction. physiological study. Br J Obstet Gynaecol. 1989;96:24–28. 6. Thiele GH. Coccygodynia and pain in the superior gluteal region. JAMA. 1937;109: Summary 1271–1275. Rehabilitation of the pelvic floor muscula- 7. Thiele GH. Coccygodynia: Cause and treat- ture has proven effective in patients with ment. Dis Colon Rectum. 1963;6:422–436. overactive bladder and in those with intersti- 8. Sinaki M, Merritt JL, Stillwell GK. Tension tial cystitis and high-tone pelvic floor dys- myalgia of the pelvic floor. Mayo Clin Proc. function. Despite the relative time and effort 1977;52:717–722. required of both patient and staff in perform- 9. Paradis H, Marganoff H. Rectal pain of ex- ing these techniques, properly executed pel- trarectal origin. Dis Colon Rectum. 1969; vic floor re-education has the potential to 12:306–312. yield great benefit at minimal risk. Studies 10. Grant SR, Salvati EP, Rubin RJ. Levator prospectively evaluating the benefit of pel- syndrome: An analysis of 316 cases. Dis Co- vic floor musculature treatment through ob- lon Rectum. 1975;18:16–163. jective measures such as perineometry and 11. Lilius HG, Oravisto KJ, Valtonen EJ. Origin of pain in interstitial cystitis. Scand J Urol EMG, in addition to validated symptom Nephrol. 1973;7:150–152. scales, would do well to further our convic- 12. De Groat WC. A neurologic basis for the tion in employing such therapy. overactive bladder. Urology. 1997;50(suppl 6A):36–52. 13. Das AK, White MD, Longhurst PA. Sacral Acknowledgment nerve stimulation for the management of void- The authors thank Andrew Lesher, MSPT, ing dysfunction. Rev Urol. 2000;1:43–60. and Erica Fletcher, MSPT, for their expert 14. Baker PK. Musculoskeletal origins of contributions regarding physical therapy chronic pelvic pain. Obstet Gynecol Clin evaluation and treatment techniques. North Am. 1993;20:719–741. 15. Woerman AL. Evaluation and treatment of dysfunction in the lumbar-pelvic-hip com- plex. In: Donatelli R, Wooden MJ, eds. Or- References thopaedic Physical Therapy, ed 1. New York: 1. DeLancey JOL. Surgical anatomy of the fe- Churchill Livingstone, 1989:403–483. male pelvis. In: Rock JA, Thompson JD, 16. Messelink EJ. The overactive bladder and eds. TeLinde’s Operative Gynecology, ed 8. the role of the pelvic floor muscles. BJU Int. Philadelphia: Lippincott-Raven; 1997:63–93. 1999;83(suppl 2):31–35. 2. Steers WD. Physiology and pharmacology 17. Whitmore K, Kellogg-Spadt S, Fletcher E. of the bladder and urethra. In: Walsh PC, Comprehensive assessment of pelvic floor Retig AB, Vaughan ED, Wein AJ, eds. dysfunction. Issues in Incontinence. 1998; Campbell’s Urology, ed 7. Philadelphia: Fall:1–10. WB Saunders; 1998:870–915. 18. Worth AM, Dougherty MC, Mckey PL. De- Pelvic Floor Muscle Re-education 285

velopment and testing of the circumvaginal cal stimulation for urinary incontinence due muscles rating scale. Nurs Res. 1986;35: to detrusor overactivity Urology. 2000;55: 166–168. 353–357. 19. Brink CA, Sampselle CM, Wells TJ, et al. A 32. Stein M, Discippio W, Davia M, et al. Bio- digital test for pelvic muscle strength in feedback for the treatment of stress and urge older women with urinary incontinence. incontinence. J Urol. 1995;153:641–643. Nurs Res. 1989;38:196–199. 33. Lukban J, Whitmore K, Kellog-Spadt S, et 20. Tries J, Eisman E. Urinary incontinence: al. The effect of manual physical therapy in Evaluation and biofeedback treatment. In: patients diagnosed with interstitial cystitis, Schwartz MS, ed. Biofeedback: Practitio- high-tone pelvic floor dysfunction, and sac- ner’s Guide. New York: Guilford Press; 1995. roiliac dysfunction (abstract). Urology. 21. Isherwood PJ, Rane A. Comparative assess- 2001;57(suppl 6A):121. ment of pelvic floor strength using a perie- 34. Schroeder B, Sanfilippo JS, Hertweck P. ometer and digital examination. Br J Obstet Musculoskeletal pelvic pain in a pediatric Gynaecol. 2000;107:1007–1011. and adolescent gynecology practice. J Pedi- 22. Romananzi LJ, Polaneczky M, Glazer HI. atr Adolesc Gynecol. 2001;13:90. Simple test of pelvic muscle contraction 35. Ger GC, Wexner SD, Jorge JMN, et al. during pelvic examination: correlation to Evaluation and treatment of chronic intrac- surface electromyography. Neurourol Uro- table rectal pain—A frustrating endeavor. dyn 1999;18:603–612. Dis Colon Rectum. 1993;36:139–145. 23. Fantl JA. Behavioral intervention for com- 36. Heah SM, Ho YH, Tan M, et al. Biofeed- munity-dwelling individuals with urinary back is effective treatment for levator ani incontinence. Urology. 1998;51(suppl 2A): syndrome. Dis Colon Rectum. 1997;40: 30–34. 187–189. 24. Parsons CL, Koprowski PF. Interstitial cys- 37. Sohn N, Weinstein MA, Robbins RD. The titis: Successful management by increasing levator syndrome and its treatment with urinary voiding intervals. Urology. 1991; high-voltage electrogalvanic stimulation. 37:207–212. Am J Surg. 1982;144:580–582. 25. Nygaard IE, Kreder KJ, Lepic MM, et al. Ef- ficacy of pelvic floor muscle exercises in 38. Nicosia JF, Abcarian H. Levator syndrome: woman with stress urge, and mixed urinary A treatment that works. Dis Colon Rectum. incontinence. Am J Obstet Gynecol. 1996; 1985;28:406–408. 174:120–125. 39. Oliver GC, Rubin RJ, Salvati EP, et al. Elec- 26. Payne CK. Conservative therapy for female trogalvanic stimulation in the treatment of urinary incontinence. AUA Update Series. levator syndrome. Dis Colon Rectum. 1985; Houston, American Urologic Association Of- 28:662–663. fice of Education, 1996, Lesson 34, vol. xv. 40. Billingham RP, Isler JT, Friend WG, et al. 27. Caldwell KPS. The electrical control of Treatment of levator syndrome using high- sphincter incompetence. Lancet. 1963;2: voltage galvanic stimulation. Dis Colon 174–175. Rectum. 1987;30:584–587. 28. Linstrom S, Fall M, Carlsson CA, et al. The 41. Hull TL, Milsom JW, Church J, et al. Elec- neurophysiological basis of bladder inhibi- trogalvanic stimulation for levator syn- tion in response to intravaginal electrical drome: How effective is it in the long term? stimulation. J Urol. 1982;129:405–410. Dis Colon Rectum. 1993;36:731–733. 29. Payne CK. Electrostimulation. In: O’Don- 42. Lampe G. Transcutaneous electrical nerve nell PD, ed. Urinary Incontinence. St. Louis: stimulation. In: O’Sullivan SB, Schmitz TJ, Mosby; 1997:287–294. eds. Physical Rehabilitation: Assessment 30. Brubaker L, Benson JT, Bent A, et al. Trans- and Treatment, ed 2. Philadelphia: FA vaginal electrical stimulation for female uri- Davis; 1988:647–665. nary incontinence. Am J Obstet Gynecol. 43. Kaplan WE, Firlit CF, Schoenberg HW. The 1997;177:536–540. female urethral syndrome: External sphinc- 31. Yamanishi T, Yasuda K, Sakakibara R, et al. ter spasm as etiology. J Urol. 1980;124:48– Randomized, double-blind study of electri- 49.