Chapter 20: Physical Therapy for Pelvic Floor Dysfunction

INTRODUCTION

Pelvic floor dysfunction includes urinary and fecal incontinence, pelvic organ prolapse (POP), sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction, and chronic pain syndromes.¹ This chapter will focus on the effect of physiotherapy on urinary and fecal incontinence, POP, sexual disorders, and chronic pain syndromes in women.

In 1999 the member states of the World Confederation for Physical Therapy (WCPT) approved a position statement describing the nature and process of physiotherapy/physical therapy.² It is stated that physical therapy involves “using knowledge and skills unique to physical therapists, and is the service only provided by, or under the direction and supervision of a physical therapist.” The physical therapy process includes assessment, diagnosis, planning, intervention, and evaluation.² Physiotherapy for pelvic floor dysfunction involves thorough history taking and clinical evaluation of the patient’s total function and specific function of the PFMs before setting up an individual treatment plan.² Up to 30% of women with pelvic floor dysfunction may be unable to voluntarily contract the pelvic floor muscle (PFM); therefore, individual instruction and feedback is essential.³ Physiotherapy treatments for the pelvic floor may include bladder training, PFM training with or without biofeedback, use of vaginal cones, electrostimulation, or other adjuncts to pelvic floor training. The actual training can be done individually or in groups.^4,5 Supervised training is often followed by an individualized home training program.

There are both therapeutic and preventative indications for pelvic floor physical therapy. As outlined below, physical therapy is used to both treat and prevent the development of stress urinary incontinence (SUI), plays a role in the treatment of urgency incontinence and overactive bladder, and has been shown to have modest effects on the treatment of prolapse. Because of its central role in treatment paradigms, PFM training is indicated in any woman with incontinence or prolapse who can learn to voluntarily contract the pelvic floor.

STRESS URINARY INCONTINENCE

SUI is the involuntary leakage of urine associated with increases in intra-abdominal pressure, such as occurs with cough, laugh, or sneeze. It is attributed to the inability of the urethra to withstand increases in bladder pressure. The two main theories on how pelvic floor muscle training (PFMT) may be effective in prevention and treatment of SUI⁶ are supported by basic research and case–control studies.^6,7 The first is that women learn to consciously contract before and during increases in abdominal pressure, and continue to perform such contractions as a behavior modification to prevent descent of the pelvic floor. The second theory is that women who perform regular strength training over time ...