Pelvic floor and perineal rehabilitation in physiotherapy
What is pelvic floor and perineal rehabilitation in physiotherapy?
It is a field of physiotherapy that focuses on the muscles of the pelvic floor, which extend between the pubic bone and the coccyx, forming a hammock-like structure.
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The main role of these muscles is to ensure continence, meaning they help in retaining urine, feces, and gas to prevent embarrassing leaks. They also play an important role in supporting pelvic organs.
Pelvic floor and perineal rehabilitation can treat several conditions in both women and men, including:
- Urinary incontinence: stress incontinence, urge incontinence, or mixed incontinence.
- Pelvic organ prolapse (also known as organ descent): cystocele, rectocele, uterine prolapse, and others.
- Overactive bladder: increased urinary frequency and urgency.
- Pregnancy and postpartum.
- Pain during sexual intercourse and other perineal and pelvic pains: dyspareunia, vulvodynia, vestibulodynia, vaginismus, chronic pelvic pain syndrome (or type 3 prostatitis), pudendal neuralgia, endometriosis, interstitial cystitis, pubic and coccygeal pain.
- Anorectal issues: constipation, fecal urgency, and fecal incontinence.
- Pre- and post-prostatectomy in men.
- Urinary incontinence: stress incontinence, urge incontinence, or mixed incontinence.
Urinary incontinence: stress incontinence, urge incontinence, or mixed incontinence.
There are three main types of urinary incontinence:
- Stress incontinence: urine leakage occurs during activities such as coughing, sneezing, laughing, jumping, or other physical efforts. The amount of leakage is usually small. In this case, the muscles of the pelvic floor and urethra are often not strong enough to hold back urine.
- Urge incontinence: leakage occurs due to a sudden urgent need to urinate, which doesn't allow enough time to reach the toilet. The amount of leakage is usually significant. In this case, the main issue is an overactive bladder or a disruption in communication between the brain and the bladder.
- Mixed incontinence: a combination of the two types mentioned above.
Quality of life and risk factors:
Urinary incontinence can greatly impact the quality of life of those who experience it. According to scientific studies, one in three women will experience urinary incontinence during their lifetime, and one in two after the age of 60.
Several risk factors that contribute to urinary incontinence have been identified, including:
- Pregnancy and childbirth
- Obesity
- Constipation
- Consumption of irritating beverages and foods
- Certain medications
- Certain diseases and conditions
Pelvic floor and perineal rehabilitation:
The assessment and treatment in physiotherapy aim to ensure the proper function of the pelvic floor muscles. To prevent urinary leakage, these muscles need to be strong, endurance, and capable of activating at the right time. In cases of leakage during physical exertion, learning better management of intra-abdominal pressure during efforts is often necessary.
For urinary leakage related to urge incontinence, specific techniques for suppressing urgent urges and lifestyle habit changes will help address the issue.
Pelvic organ prolapse (also known as organ descent): cystocele, rectocele, uterine prolapse, and others.
A prolapse refers to the descent of a pelvic organ towards the vaginal opening, such as the bladder, uterus, or rectum. It can cause discomfort, pelvic heaviness, and even a sensation of "something" at the vaginal entrance.
Prolapse is often caused by a relaxation of the ligaments that support these organs and/or weakening and elongation of the pelvic floor muscles. Intense pushing efforts, whether during training or in situations of constipation, greatly contribute to this condition. The perinatal period is also sensitive to this issue.
Pelvic floor rehabilitation can help reduce discomfort. By improving the function of the pelvic floor muscles, it can help stabilize and, in some cases, reduce the prolapse.
Learning proper management of intra-abdominal pressure during exertion will ensure good abdominal-pelvic health in the short and long term.
Overactive bladder: when urinary frequency is increased and there are urgency episodes.
An overactive bladder tends to contract frequently and strongly, even when it's not full. It can cause urgency episodes, which are intense, sudden urges to urinate that are difficult to control.
An overactive bladder can also contribute to urinary leakage. Individuals with this condition tend to urinate frequently, sometimes even as a preventive measure, often eliminating a small amount of urine.
Over time, a vicious cycle can develop: urinary frequency continues to increase along with urgent urges. Contrary to what one might think, reducing water intake generally does not help the situation.
Overactive bladder can greatly affect quality of life and sleep. When a person's daily routine revolves around the presence or absence of nearby toilets (especially during outings and travel), it is high time to seek medical advice.
Pregnancy and postpartum period
During pregnancy, a woman's body undergoes several changes, with varying levels of discomfort for each individual. Hormonal changes and the growth of the baby will have an impact on posture, pelvis, breathing, pelvic floor muscles, and abdominal muscles, to name a few.
Specifically, the pelvic floor muscles tend to stretch and may weaken due to the increasing weight of the baby. Hormonal changes also affect the ligaments that provide stability to the pelvic organs (bladder, uterus, rectum) and the pelvis itself, making them less effective.
A woman during the perinatal period is therefore at a higher risk of developing pelvic organ prolapse or dysfunction of the pelvic floor muscles, which can lead to urinary leakage. The abdominal muscles also experience significant stretching as the belly expands, reducing their effectiveness and potentially contributing to back and pelvic pain.
Physiotherapy consultation during pregnancy aims to prevent and treat discomforts.
It is often appropriate at this time to start an exercise program to prepare the pregnant woman for childbirth and the postpartum period.
Studies have shown that the risk of urinary incontinence after childbirth is reduced when pelvic floor strengthening exercises are performed during pregnancy.
In the postpartum period, a perineal rehabilitation assessment will be beneficial, even if the new mother does not have urinary leakage or pelvic discomfort.
It mainly allows for evaluating the condition of the perineum after childbirth (strength, endurance, control, tone), ensuring proper healing of the incision (abdominal or perineal), and checking for diastasis recti (separation of abdominal muscles).
Personalized advice and a progression of exercises will help resume daily and sports activities safely while maintaining long-term pelvic and perineal health.
Pain during sexual intercourse, perineal pain, and pelvic pain: dyspareunia, vulvodynia, vestibulodynia, vaginismus, chronic pelvic pain syndrome (or type 3 prostatitis), pudendal neuralgia, endometriosis, interstitial cystitis, pubic and coccygeal pain.
Pain in women
Vulvar and vaginal pain can occur at a certain point in a woman's life or be present since the first sexual intercourse or insertion of the first tampon. Possible causes are varied: trauma (such as surgery or childbirth), dermatological conditions, genitourinary menopausal syndrome, congenital malformation, vaginismus, difficulty in relaxing the pelvic floor muscles, among others. Anxiety and stress that may result from these conditions will also have an impact on the condition and pain experienced. Pain during sexual intercourse is called dyspareunia. However, pain may also be present in other contexts, and different causes are possible.
The management in physiotherapy will be gentle. A lot of education will be provided about the causes of pain and the mechanisms contributing to it, in order to target the necessary changes to improve the situation. Generally, the focus will be on improving body awareness, working on the muscle function of the pelvic floor muscles and promoting their relaxation, and using manual desensitization techniques when appropriate. Rehabilitation with a dilator may also be initiated to promote pain-free sexual intercourse.
Pain in men
Men can also experience various perineal and pelvic pains. The physiotherapy evaluation will help identify possible causes and determine effective treatment modalities.
Anorectal issues: constipation, fecal urgency, and fecal incontinence.
Constipation
Difficulty in passing stool can lead to several complications if present for a long time or during certain periods of life, such as pregnancy and childbirth. People with constipation tend to hold their breath and strain to pass stool, which weakens the pelvic floor muscles and may lead to prolapse.
Physiotherapy interventions can be used to prevent constipation. The function of the pelvic floor muscles can be evaluated, effective bowel evacuation positioning and techniques can be taught, and changes in lifestyle habits can be suggested. Anorectal balloon catheter may also be used as an evaluation and treatment modality to re-educate abnormal sensitivity.
Fecal urgency and incontinence
Fecal incontinence, which is the involuntary loss of stool, can have several causes. It may be preceded or not by fecal urgency, where the urge to defecate is suddenly and significantly felt, making it difficult to get to the toilet on time. It is also possible to experience fecal urgency without incontinence.
These anorectal issues are often accompanied by a decrease in the strength of the pelvic floor muscles and anal sphincter. Rectal sensitivity disturbance may also be present.
In the context of prostatectomy in men, before and after surgery
After prostatectomy surgery, men may experience symptoms such as urinary incontinence and erectile dysfunction, among others. The partial or complete removal of the prostate will have an impact on several sphincters present in the urethra, whose role is to maintain continence (thus preventing leakage). Radical prostatectomy is the main cause of stress urinary incontinence in men. It can affect up to 60% of men when the catheter is removed, and this rate gradually decreases afterward, especially in the first year after surgery.
In perineal and pelvic rehabilitation, it will be possible to regain urinary control more quickly, which will have a significant impact on quality of life. Strengthening the pelvic floor muscles will be crucial to compensate for the decreased effectiveness of the urethral sphincters. Additionally, adopting proper effort management dynamics without holding the breath often leads to a significant reduction in leakage. Improving pelvic floor muscle function also promotes the return of erectile function. Specific advice can also be helpful in this regard.
Physiotherapy follow-up can begin before surgery. This will allow for specific recommendations during the perioperative period and to start exercises from that time. In the postoperative period, it will be necessary to wait until the catheter is removed to resume exercises and start physiotherapy.