Pelvic Floor Dysfunction (PFD) Interdisciplinary Treatment and Referral Consideration for Physician Assistants

Transcription

1 Pelvic Floor Dysfunction (PFD) Interdisciplinary Treatment and Referral Consideration for Physician Assistants Gerry Keenan, MMS, PA C Tammy Roehling, PT, DPT Learner Objectives 1. Recreate the pelvic floor anatomy using Theraband. 2. Properly instruct patients in pelvic floor strengthening exercise continuum. 3. Identify patients through case studies whose pelvic floor dysfunction can be treated by a pelvic floor physical therapist. Physical therapists can treat PFD? I didn t know that. Entry level education varies greatly across the country Training is primarily post professional To locate a PT, go to Physical therapists (PTs) who treat internally and/or externally 1

2 Why should PTs be involved in the treatment of PFD? Better outcomes! Eftekhar (2014) compared surgery (rectocele repair & perineorrhaphy) vs PT on sexual function. Both groups had improved libido and arousal but orgasm and dyspareunia were significantly better (p=.001) in PT group Knorst (2013) compared effectiveness of PT in women with urinary incontinence. 89% of patients reported continence or satisfied with treatment. Anderson (2006) examined the effectiveness of trigger point release and paradoxical relaxation training in men with refractory chronic pelvic pain. There was a greater than 50% improvement in sexual dysfunction. Functions of the Pelvic Floor Support organs and structures Sphincteric control Sexuality 3 S s Support Organs and Structures If organs aren t supported, prolapse may occur. Photo from floorexercises Photo from conditions/vaginal prolapse 2

3 Sphincteric Control Photo from Sexuality Let s recreate the pelvic floor! 3

4 Balance between Mobility and Stability Mobility Stability Let s talk about urinary incontinence Video link: Urinary Incontinence (UI) Not a normal part of aging Effects both men and women Can occur at any age Need to differentiate between UI vs. medical issue If UI, can approach from a functional approach as an interdisciplinary team 4

5 Photo from Photo from Kegel exercises can help urinary incontinence, anal incontinence, pelvic organ prolapse, back pain, erectile dysfunction, improve sexual response, and restore pelvic health after having a baby. Dumoulin, C., Hay Smith, E.C., & Mac Habee Seguin, G. (2014). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systemic Reviews, 5. Conclusion: Level 1/Grade A evidence Recommended pelvic floor strengthening should be taught by a physical therapist using internal assessment and treatment techniques and this should be first line of defense for urge and stress incontinence. 5

6 How to find the pelvic floor muscles Use cues like lift draw up and in close your openings hold back gas imagine squeezing out a sponge with your vagina Palpate perineum over clothing. Fingers should raise with contraction. Visually watch perineum and ask patient to contract, relax, and bulge. If men perform contraction correctly, scrotum will lift and penis will retract Stop the flow of urine midstream should not be done more than 1x/month Common errors Holding breath One should exhale with contraction and inhale with relaxation Bulging Contracting other muscles abdominals, gluteals, adductors Kegel Exercises Slow twitch contractions Fast twitch contractions Can progress these exercises and this has been termed Beyond Kegels Elevator Standing plies 6

7 Pharmacologic Intervention Remember, just because you hear the words urinary incontinence does not indicate an automatic prescription for an anticholinergic agent. You must know the type of incontinence before prescribing. When is an anticholinergic [oxybutynin (Ditropan), tolterodine (Detrol), solifenacin (VESIcare), darifenacin (Enablex)] indicated? When is vaginal estrogen cream (Estrace, Premarin) indicated? Pelvic Pain Where does it hurt? Women Lower abdomen Vagina/vulva Perineum Anus Coccyx Low back Men Lower abdomen Perineum Penis Testes Anus Coccyx Low back Both men and women c/o bladder, bowel, and sexual issues. Pain Characteristics & Associated Signs Burning, stabbing, cramping, aching, pressure Referred pain to low back, suprapubic region, abdominals, groin, and lower extremities Often aggravated by sitting, defecation, and intercourse Photo from 7

8 Sexual Dysfunction Pain with penetration, erection, and/or ejaculation Dissatisfaction Erectile dysfunction Constipation Hard stool Straining Sensation of incomplete emptying Fewer than 3 defecations/week Consequences: Weakening/bulging pelvic floor Pelvic organ prolapse Anal fissures Hemorrhoids How can PT help patients with PFD? Patient education Muscle testing Biofeedback Diaphragmatic breathing Diet and fluid changes Bladder retraining Pelvic floor strengthening Pelvic floor relaxation Double voiding Vaginal weights Electrical stimulation Vaginal dilators Proper position for toileting Manual therapy Dry needling 8

9 Treatment for PFD is an interdisciplinary team approach. Case Studies Case #1: 22 year old male with penile pain Case #2: 57 year old male with voiding dysfunction References Anderson, R.U., Wise, D., Sawyer, T., & Chan, C.A. (2006). Sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome: Improvement after trigger point release and paradoxical relaxation training. Adult Urology, 176(4), Eftekhar, T., Sohrabi, M., Haghollahi, F., Shariat, M., & Miri, E. (2014). Comparison effect of physiotherapy with surgery on sexual function in patients with pelvic floor disorder: A randomized clinical trial. Iranian Journal of Reproductive Medicine, 12(1), Knorst, M.R., Resende, T.L, Santos, T.G., & Goldim, J.R. (2013). The effect of outpatient physical therapy intervention on pelvic floor muscles in women with urinary incontinence. Brazilian Journal of Physical Therapy, 17(5), Rosenbaum, T.Y. (2008). The role of physical therapy in female sexual dysfunction. Women s Sexual Health, 5,