Introduction to Pelvic Floor
Physical Therapy
Presented by:
Carin Cappadocia, PT, DPT
April 18, 2015
Objectives
Identify pelvic floor muscles and their functions
2. Differentiate diagnoses of pelvic pain vs. incontinence
symptoms
3. Explain universal precautions, contraindications,
indications for pelvic floor muscle examination and
treatments
4. Understand pelvic floor muscle relaxation and
strengthening techniques
1.
What is the Pelvic Floor?
“All visceral, neurovascular, and myofascial structures
contained in the bony pelvis from pubis to coccyx and
between lateral ischial walls” – APTA SOWH
Function of the Pelvic Floor Muscles
1. Support
2. Sphincteric
3. Sexual Function
4. Trunk and Pelvic Stabilization
5. Lymphatic
Bony Landmarks
http://classconnection.s3.amazonaws.com/551/flashcards/1673551/png/screen_shot_2014-03-07_at_40412_pm-1449E5C571029BC2ABD.png
Female Perineum
http://iahealth.net/vagina/
First Layer Pelvic Floor Muscles
 Ischiocavernosus (S2,3,4)
 O: Ischial tuberosity and ramus
 I: Inferolateral apponeurosis over cura of clitoris/penis
 A: Erection (clitoral, penile)
 Bulbocavernosus/Bulbospongiosus (S2,3,4)
 O: Central perineal tendon, (F) Palpable under labia
(M) Midline Scrotum
 I: Fascia over the (F) Corpus cavernosum of the clitoris
(M) Shaft of Penis
 A: (F) Vaginal Sphincter and clitoral erection
(M) Penile Erection
First Layer Muscles
 Superficial Transverse Perineal Muscle (S2,3,4)
 O: Ischial Tuberosity
 I: Central perinal tendon/Perineal Body
 A: Pelvic Floor Stability
 External Anal Sphincter
 O: Perineal Body
 I: Partial coccyx and surrounds anal canal
 A: Voluntary opening of anal orifice
First Layer Pelvic Floor Muscles
Female
Second Layer Pelvic Floor Muscles
 Sphincter Urethra (S2-4)
 Compressor Urethrae (S2, 3, 4)
 O: Inferior pubic arch and wraps
 O:B Ischiopubic ramus
around the urethra
 A: Urethral constriction and
relaxation
 I: Joins to opposite side and passes
 Urethrovaginal Sphincter
 O: Vaginal wall
 I: Superior surface of urethra
 A: Compresses urethra and assists
in continence
anterior to urethra and vaginal
wall
 A: Compresses urethra and vagina
 Deep Transverse Perineal (S 2,3,4)
 O: Inferior Rami of ischium
 I: Deep transverse perineum of
opposite side (through perineum)
 A: Stabilize pelvic floor
Second Layer Pelvic Floor Muscles
http://quizlet.com/8113450/gimner-urogenital-triangle-flash-cards/
Third Layer Pelvic Floor Muscles
Levator Ani
 Puborectalis*
 Pubococcygeus
 Iliococcygeus
 Coccygeus*
Levator Ani
 Puborectalis (S2,3,4)
 O: Posterior pubis and fascia
 Iliococcygeus (S3,4)
 O: ArchusTendineus Levator Ani
of obtuator internus
(ATLA)
 I: Anococcygeal ligament,
 I: Anococcygeal body and coccyx
around rectum and anal canal
 A: Visceral and lateral coccyx
 A: Voluntary sphincter of anal
support
canal
 Coccygeus [Ischiococcygeus]
 Pubococcygeus (S3,4,5)
 O: Posterior pubis and fascia
of obtuator Internus
 I: Anococcygeal ligament
 A: Pelvic visceral support
(S4,5)
 O: Ischial Spine and Sacrospinous
ligament
 I: Lower sacrum and coccyx
 A: Visceral support, Coccyx
mobility (flex), stability of SI joint
Accessory Muscles
• Piriformis (L5,S1,2)
 O: Sacral border, through greater sciatic foramen
 I: Superior border of the greater trochanter of the
femur
 A: Lateral hip rotation
• Obturator Internus (L5,S1,2)
 O: Internal aspect of pelvic foramen
 I: Medial greater trochanter of femur, proximal to
trochanteric fossa
 A: Lateral hip rotation
http://web.uni-plovdiv.bg/stu1104541018/docs/res/anatomy_atlas_-_Patrick_W._Tank/6%20-%20The%20Pelvis%20and%20Perineum.htm
Pudendal Nerve
 Pudendal Nerve divides
into 3 branches:
 Inferior rectal branch
 Perineal branch
(sometimes divided into
deep and superficial)
 Dorsal branch of the
clitoris/penis
http://www.pudendalhope.info/node/13#Female_Pudendal_Nerve
Male Pudendal Nerve
http://en.wikipedia.org/wiki/Pudendal_nerve#mediaviewer/File:Pudendal_nerve.svg
Organs in Relation to Pelvic Floor
http://my.clevelandclinic.org/services/ob-gyn-womens-health/diseases-conditions/pelvic-organ-prolapse
http://www.mendoza-massoer.dk/primal/primal_13.jpg
Normal Urinary Function
 Takes 3-4 hours to fill bladder
 Normal day time voiding 6-8 times per day
 Void Stream Duration: 8-10 seconds
 Nocturia: 1 times per night (1-2x/ ages 65+)
 Sensory receptors notify brain when bladder is full
 Capacity: Max. ~600mL
Pearson BD, 1992
Pelvic Floor Muscle
Dysfunctions and Diagnoses
Mobility vs. Stability Concept
 Too Much Stability/Fixation
 Pain
 Incontinence
 Retention
 Too Much Mobility
 Prolapse
 Incontinence
Overactive Pelvic Floor
 Dyspareunia
 Vulvodynia
 Dysuria
 Vaginismus
 Chronic Urinary Tract
Infections
 Overactive bladder*
Edwards, 2015
Haefner, 2007
Basson et al, 2000
 Interstitial Cystitis (IC)
 Pudendal Neuralgia
Physical Therapy and Vulvodynia
 McKay et al, 2001
 N=29 women with moderate to severe Vulvodynia
 Biofeedback and manual assessment of pelvic floor monthly
with home portable biofeedback unit with daily pelvic floor
muscle training exercises
 Post Treatment, 20/29 patients (69%) had a significant decrease
in introital tenderness and were able to resume sexual activity
Physical Therapy and Vaginismus
 Seo et al, 2005
 N=12 patients with primary vaginismus
 Biofeedback and electrical stimulation assisted
pelvic floor muscle training followed by manual
therapy and use of vaginal dialators
 12/12 were able to participate in painfree
vaginal intercourse
Pudendal Neuralgia
“Pudendal neuralgia is a painful, neuropathic condition
involving the dermatome of the pudendal nerve” – Hibner
et al, 2010
 Parasthesias and/or pain throughout any portion of the
pudendal dermatome
 may extend into the groin, abdomen, legs, and buttocks
Hibner, 2010
Pudendal Neuralgia
Causes
1.
2.
3.
4.
5.
6.
7.
Pelvic surgery especially
with use of mesh
Pelvic trauma
Childbirth
Bicycle riding
Prolonged sitting
Constipation
Severe tightness
(muscle and fascial
restrictions)
Treatments
1.
2.
3.
4.
5.
6.
Physical Therapy is the
gold standard treatment
in patients with muscle
spasms
Behavioral modifications
Medical Therapy
Botox Injections
Steroid Injections
Surgery
Underactive Pelvic Floor
 Potential Related Diagnoses
Urinary Incontinence
Pelvic Organ Prolapse
Urinary Incontinence
 Stress Urinary Incontinence
 Episodes of urinary leakage with increased valsalva or stress;
such as cough, laugh, sneeze
 Urge Incontinence
 Episodes of urinary leakage with severe sense of urgency
 Mixed Incontinence
 Symptoms of both Stress and Urge Incontinence
 Incontinence without Sensory Awareness
http://www.iuga.org/
Urinary Incontinence
 Dannecker et al, 2005
“EMG-biofeedback assisted pelvic floor muscle training
is an effective therapy of stress urinary or mixed
incontinence: a 7-year experience with 390 patients”
 390 women; stress incontinence (80%), mixed (20%)
 263 completed the training
 Self reported improvement was 95%
 Statistically significant improvement of the stress provocation
test (Cough Test)
 Long term follow-up (average follow up time 2.8 years)
 71% self-reported persisting improvement of UI
 13% underwent incontinence surgery following completion
of conservative therapy
Pelvic Organ Prolapse
 A dropping of one or more organs into or out of
the vagina; from a weakening of muscles,
ligaments, and fascia.
 Causes
 Pregnancy and child birth
 Aging and menopause
 Conditions that cause increased pressure on the pelvic floor
 Genetics
 Underactive pelvic floor
http://www.iuga.org/
Pelvic Organ Prolapse
 Symptoms:
 Pelvic or low back Heaviness
 Feeling of a bulge in or out of the vagina
 Change in urinary symptoms: Slowed stream,
incomplete emptying, urgency, frequency,
incontinence
 Bowel Symptoms: difficulty emptying bowels,
incomplete emptying, the need to Splint
 Discomfort with sexual activity
http://www.iuga.org/
Types of Prolapse
 Cystocele
 Uterine Prolapse
 Rectocele
 Enterocele
 Rectal Prolapse
Cystocele
http://www.lifescript.com/health/centers/pms/related_conditions/cystocele-rectocele.aspx
Uterine Prolapse
https://biotextiles.wordpress.com/prolapse-repair-mesh/
Rectocele
Copyright © Nucleus Medical Media, Inc.
Enterocele
Rectal Prolapse
Pelvic Organ Prolapse
 Braekken et al, 2011
“ Can pelvic floor muscle training revere pelvic organ
prolapse and reduce prolapse symptoms? An
assessor-blinded, randomized, control trial”
 n= 109 women
 PFM Training: (n=59) Prolapse Sages I,II,III; Control (n=50)
 comparing PFMT and lifestyle advise versus lifestyle
advise alone
 Short Term Effects: 19% of women with PFMT
improved 1 stage on the POPQ verses 8% of controls
 6 Months: PFMT had significantly greater elevation of
the bladder and rectum and reduced frequency than
the control group.
Pelvic Floor Physical Therapy
Indications for Pelvic Floor Examination
 Urinary and Fecal Incontinence
 Abdominopelvic surgery
 Urinary Urgency/Frequency
 Incomplete Bowel Evacuation
 Dysfunctional Voiding
 Constipation
 Dysuria
 Postpartum
 Recurrent Urinary Tract
 Pregnancy Related






Infections
Dyschezia (Pain with defecation)
Pelvic Pain
Abdominal Pain
Lumbosacral Pain
Hip Pain
Pelvic Organ Prolapse
Musculoskeletal
Pain/Dysfunction
 Infertility
Contraindications and Precautions
 Lack of patient or physician
 Severe atrophic vaginitis
consent
 Under 6 weeks PostPartum
 Under 6 weeks Post-Op
(except abdominal
exploratory surgery)
 History of sexual abuse
 Children under the age of 5
2010 Herman and Wallace Rehabilitation Institute PF1
or anyone without prior
medical examination
So What Do We Do????
Evaluation (Average 60 Min)
 Detailed History Taking
 Question bowel/bladder/sexual history regardless of diagnosis
 Abdominopelvic surgical history
 Orthopedic history
 Gross Assessment of Posture and Gait
 External Soft Tissue Palpation
 Muscles: Abdominals, iliopsoas, gluteals, piriformis, hamstrings,
ITB, TFL
 Connective tissue: abdomen, gluteals,
posterior/anterior/medial/lateral thigh, lumbar region
 Muscle Length Testing
Evaluation (continued)
 Gross Lumbar and Hip ROM and MMT
 Special Tests
 Pelvic Floor Muscle Assessment
 Observation
 External palpation
 Contraction/lengthening observation
 Reflex
 Internal palpation
 MMT
 Prolapse/vaginal wall stability assessment
 Biofeedback assessment
Treatments
 Manual Therapy (97140)
 Over Active: Trigger Point Release, Myofascial Release,
Thieles Massage, Visceral Fascial Manipulation, Connective
Tissue Mobilization, desensitization techniques, Soft Tissue
Mobilization
 Under Active: Quick stretching for improved PFM fiber
recruitment
 Neuromuscular Re-Education (97112)
 Over Active: Contract Relax, Strain-Counterstrain,
diaphragmatic breathing, relaxation techniques, pelvic floor
muscle downtraining with biofeedback, MET
 Underactive: Biofeedback or tactile cuing for improved
PFM awareness and isolation, as well as transverse abdominus
co-contraction
Treatments
 Therapeutic Exercise (97110)
 Over Active: Pelvic floor muscle repeated contractions,
endurance and quick contractions, can be biofeedback
assissted/guided
 Under Active: Initiate with accessory muscle activation
Transverse abdominus co-contraction
 Kegels
 “Pelvic Brace” or the “Knack”
 Initiate in gravity-eliminated or gravity-assisted position
 Biofeedback

Treatments
 Electrical Stimulation
(97014, 97032)
 Behavioral Retraining
 Bladder diary
 FES
 Scheduled voiding
 TENS
 Bladder retraining
 Modalities (97010,
97035)
 Cold, Heat, Ultrasound
 Home Treatments
 Vaginal Dilators
 Therawand
 Urge suppression
 Relaxation
 Patient Education!
Body Positioning with Toileting
http://squattypotty.com/
Interested in learning more?
 APTA SOWH courses
 Shadowing
 Online Courses and
Continuing Education
 Herman and Wallace Pelvic
Rehabilitation Institute
 National/International
Organizations
Contact Information
 Carin Cappadocia
Cappadc@mail.amc.edu
Albany Medical Center
Outpatient Physical Therapy
618 Central Ave.
Albany, NY 12206
(518)262-9700
References
Baker J, Costa D, Guarino JM, Nygaard I. Comparison of mindfulness based stress reduction versis yoga on urinary
urge incontinence: a randomized pilot study with 6 month and 1 year follow-up visits. Female Pelvic Med
Reconstructr Surg. 2014;20(3):141-6.
Basson R, Berman J, burnett A, et al. Report of the international consensus development conference on female
sexual dysfunction: definitions and classifications. J urol 163: 888-893. 2000.
Bendana EE, Belarmino JM, Dinh JH, Cook CL, Murray BP, Feustel PJ, De EL. Efficacy of transvaginal biofeedback
and electrical stimulation in women with urinary urgency and frequency and associated pelvic floor muscle slasm.
Urol Nurs. 2009;29(3):171-6.
Braekken IH, Majida M, Engh ME, Bo K. Can pelvic floor muscle training reverse pelvic organ prolapse and reduce
prolapse symptoms? An assessor-blinded, randomized control trial. Am J Obstet Gynecol. 2010;203(2):170
Dannecker C, Wolf V, Raab R, Hepp H, Anthuber C. EMG biofeedback assisted pelvic floor muscle training is an
effective therapy of stress urinary incontinence or mixed incontinence; a 7-year experience with 390 patients. Arch
Gynecol Obstet. 2005;273(2):93-7.
Drake RL, Vogl W, Mitchell AWM. Gray’s Anatomy for Students. Philadelphia, Pennsylvania. Elsevier Inc;2005.
Edwards L. Vulvodynia. Clin Obstet Gynecol. 2015 Mar;58(1):143-52
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Riley MA, Organist L. Streamlining biofeedback for urge incontinence, Urol Nurse. 2014;34(1):19-26.
Seo JT, Choe JH, Lee WS, Kim Kh. Efficacy of functional electrical stimulation-biofeedback with sexual cognitivebehavioral therapy as a treatment of vaginismus. Urology. 2005;66(1):77-81.
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Questions?