Arjunan Tamilselvi Pelvic floor disorders of urinary incontinence, pelvic organ prolapse (POP) and anal dysfunction have the potential to significantly affect the quality of life (QoL). All these conditions are amenable to non‐surgical management and their efficacy has been studied in detail. Conservative measures of lifestyle changes, pelvic floor exercises (PFE), use of pessaries, and pharmacological interventions play a major role, either as a short‐term intervention or as a definitive treatment in pelvic floor disorders. Elements of general life‐style interventions of exercise, weight loss, smoking cessation, and avoiding constipation are all commonly applied in the management of pelvic floor disorders. The advantage of these interventions is that, they can be started solely based on the clinical history, without any exhaustive diagnostic work‐up. Weight loss in women who are overweight or obese has been shown to improve the symptoms of urinary and faecal incontinence. One study has shown in obese women, who lost 3–5% of their baseline weight, there was a 47% reduction in stress incontinence episodes. With weight loss surgeries, improvement in urinary and faecal incontinence symptoms has been demonstrated. In patients with POP, studies have shown that risk of prolapse progression increases in overweight and obese women compared to women with healthy body mass index and this progression was demonstrated consistently in all three compartments, anterior, apical, and posterior. However, weight loss has not been shown to improve prolapse symptoms and not associated with reduction in the grading of prolapse. The progression with increased BMI and the lack of regression with weight loss, suggests that damage to pelvic floor with obesity, might become irreversible over time. Smoking is associated with chronic cough and bronchitis, which can increase intra‐abdominal pressure and thereby weaken the pelvic floor muscle and connective tissue. Epidemiological studies have shown a strong association between urinary and anal incontinence and smoking. There are no studies to demonstrate that smoking cessation reduces the progression of urinary incontinence, overactive bladder symptom (OAB) and anal incontinence. The association between smoking and POP appears to be variable. Pelvic floor exercises (PFE) or pelvic floor muscle training (PFMT) have shown to be an important component in the treatment of pelvic floor disorders. Commonly referred to as Kegel’s exercise, it has been in practice since 1948. In PFMT, the pelvic floor muscles are assessed and regular contraction of the pelvic floor muscles is taught to improve the strength and endurance of muscles and thereby facilitate better support of the pelvic organs. Assessment of pelvic floor muscle involves vaginal palpation of the muscle to assess its strength and tone. The Modified Oxford grading system is widely used to quantify muscle strength (Table 6.1). PFMT, when done correctly, is likely to increase the pelvic muscle strength and thereby the levator plate. In both urinary and faecal incontinence, PFMT is used as first‐line intervention with or without behavioural approaches. In urinary incontinence, PFMT is more commonly employed in patients with stress urinary incontinence (SUI) and less commonly in those with urge or mixed incontinence. In a Cochrane review (2018), the cure rate for SUI with PFMT was 56% compared to 6% in the control group. The review also showed reduction in the number of leakage episodes and improvement in urinary incontinence specific to QoL, all reiterating the beneficial effect of PFMT in SUI. Table 6.1 Modified Oxford scale. PFMT and biofeedback have been shown to alleviate the symptoms of faecal incontinence. Compared to urinary incontinence, however, the data on PFMT in faecal incontinence management is limited. Biofeedback, is a way of notifying the patient when certain physiological events are occurring. Using an anorectal manometry or surface electromyography (EMG), biofeedback therapy focuses on rectal sensitivity training, strength training using visual or auditory signals for proper muscle isolation and coordination training focusing on rectal distension and anal sphincter contraction. The success rate for PFMT combined with biofeedback in faecal incontinence varies from 38 to 100%. The efficacy of PFE in the treatment of POP was evaluated in the multicentre randomised controlled POPPY trial (pelvic organ prolapse physiotherapy trial). The study evaluated whether one‐to‐one PFMT would reduce the symptoms of prolapse and the need for further treatment in women with stage I–III prolapse. There was a good improvement of prolapse symptoms and reduction in its severity, in women doing PFMT compared to the controls, but there was no statistically significant difference in the objective improvement of POP assessed by pelvic organ prolapse quantification staging (POP‐Q). Nevertheless, since treatment for POP is used to alleviate the POP symptoms, PFE remains the first mode of intervention in patients with POP. PFMT though being a simple exercise, about a third doing Kegel’s exercise do not contract the pelvic muscles and instead contract the lower abdominal, thigh or buttock muscles. Learning the correct technique is an important aspect in the success of PFMT. The first step is to identify the pelvic floor muscle and several techniques are taught, such as pretending to trying to avoid passing gas or trying to stop urine flow in mid‐stream. Once the correct muscles are identified, the PFE is initially practised in the lying position and thereafter can be done in sitting or standing position. The minimum number of contractions recommended is 30 per day, spread out throughout the day. Women receiving regular and frequent supervised PFMT with a health professional, are more likely to show improvement of their symptoms than women doing training with little or no supervision. The most intensive programmes in terms of supervision, weekly over three months, are shown to be the most successful. In an attempt to improve the efficacy of PFMT, it has been evaluated using other modalities as adjunct, such as vaginal cones, electrical stimulation, and use of magnetic chairs. Vaginal cones of increasing weight, in equal shape and volume are used. Starting with the lightest weight, gradually increasing the cone weight successively, women are taught to place the cone into the vagina while standing and hold it in place with voluntary contraction of the pelvic floor. The heaviest weight that can be retained by the women is called the active cone and women are advised to exercise the pelvic floor muscle using this. This effectively acts like a biofeedback helping in the PFMT.
6
Non‐Surgical Management of Pelvic Floor Disorders
General Life‐Style Interventions
Pelvic Floor Exercises
Modified Oxford Grading for Pelvic Floor Muscles
0
No contraction/muscle activity
1
Minor muscle flicker
2
Weak muscle activity with no circular contraction
3
Moderate muscle contraction
4
Good muscle contraction
5
Strong muscle contraction
Supervised PFMT and Biofeedback
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