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Female pelvic floor 2: assessment and rehabilitation

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Women who present with a weakened pelvic floor benefit from a pelvic floor education and exercise. This article, the second in a two-part series, comes with a handout for a journal club discussion

Abstract

A weakened pelvic floor can have two major negative consequences for women: incontinence (urinary and/or faecal) and pelvic organ prolapse. However, rehabilitation exercises have proven benefits in reducing – or even curing – symptoms. Women presenting with symptoms of pelvic floor dysfunction need a comprehensive assessment and examination. They also need education and an exercise programme tailored to their capabilities and needs. This second part of a two-part series about the female pelvic floor provides guidance for nurses on how to examine patients and teach them rehabilitation exercises.

Citation: Yates A (2019) Female pelvic floor 2: assessment and rehabilitation. Nursing Times [online]; 115: 6, 30-33.

Author: Ann Yates is director of continence services, Cardiff and Vale University Health Board.

Introduction

The pelvic floor muscles have a multitude of functions, one of the most important ones being to help maintain urinary and faecal continence. In women, weakened pelvic floor muscles can lead to pelvic organ prolapse and continence issues. Dumoulin et al (2018) concluded that pelvic floor rehabilitation can reduce – or even cure – symptoms of incontinence in women. However, despite this encouraging fact, women often lack knowledge on pelvic floor anatomy, dysfunction and rehabilitation (De Andrade et al, 2018).

This article – the second in a two-part series on the female pelvic floor – discusses pelvic floor assessment and rehabilitation, with practical guidance on how to examine patients and teach them pelvic floor exercises. Part 1 described the anatomy and functions of the female pelvic floor and the causes and consequences of pelvic floor weakness.

Assessing the pelvic floor

Before assessing a patient’s pelvic floor, nurses need to conduct a comprehensive continence assessment that includes a full medical, surgical and obstetric history, medication, weight, presenting symptoms and lifestyle factors (National Institute for Health and Care Excellence, 2013). The pelvic floor assessment itself usually comprises an external visual examination followed by an internal examination – although the latter is not always appropriate or recommended (see below).

Skills and precautions

It is vital that nurses are knowledgeable in, and competent to undertake, both types of pelvic floor examination (Nursing and Midwifery Council, 2018) and that they have discussed them with the person involved and obtained their consent. Nurses need to record verbal consent in the patient’s record and, if local policy requires, also obtain their written consent (Royal College of Nursing, 2016). Individuals can give consent to one form of examination but not the other. Arrange a chaperone, if required, to safeguard both parties (RCN, 2016).

An internal examination should only be undertaken by a professional competent in pelvic floor assessment. Before conducting an internal examination, nurses need to check for:

  • Infection, infestation or foreign body;
  • Fragile tissues, soreness, pelvic pain, tension in the pelvic floor area;
  • History of sexual abuse;
  • Menstruation.

If any of the above is present, it may be better to postpone the examination until the problem has been resolved. An internal examination is contra-indicated if the patient:

  • Is <18 years of age (due to consent issues);
  • Has given birth in the previous six weeks;
  • Has had pelvic surgery in the past three months.

External examination

For an external examination, the person should be in the supine position with knees bent, feet apart and pelvic area exposed, but dignity maintained (Haslam and Laycock, 2008). Staff must comply with all infection control procedures.

Wearing non-sterile, non-latex gloves and using lubricating gel, nurses will gently part the labia and examine the patient’s perineal area, checking it for:

  • Red, excoriated skin;
  • Infections, infestations, piercings;
  • Skin tags;
  • Abnormal lumps;
  • Faecal and/or urinary leakage;
  • Pelvic organ prolapse (see part 1);
  • Signs of atrophic vaginitis and/or lichen sclerosus;
  • Alterations to genital area that may indicate female genital mutilation (FGM); if nurses suspect FGM, they must report it as per the national guidance issued by the Home Office (2015).

Asking the patient to cough will allow nurses to check whether there is descent – tissue protrusion that may indicate a degree of prolapse – and/or leakage of urine/faeces on coughing. Asking the patient to tighten (pull in) their pelvic floor muscles will allow nurses to observe whether there is contraction and thereby evaluate the strength of the muscles.

Internal examination

For an internal examination, the patient should be in the same position as for an external examination. Nurses need to observe all local consent, chaperone and infection-control guidance and procedures. Wearing non-latex gloves, nurses will lubricate their index finger, introduce it into the vagina and:

  • Sweep in a circular motion to check muscle symmetry, assess the patient for pain and detect any ridges or valleys that may be the sign of scars caused by tears and/or episiotomy;
  • Ask the patient to cough, then check for prolapse (anterior, posterior or vaginal) or urinary/faecal leakage on coughing;
  • Ask the patient to pull in their pelvic floor muscles, check how these are working using the PERFECTR method (Box 1), then grade their strength using the Modified Oxford Grading (MOG) classification system (Box 2).

The PERFECTR method allows health professionals to measure a range of factors relating to pelvic floor muscle contraction (PFMC) that will help them assess pelvic floor health. A PFMC with a MOG of ≥3 is usually discernible on visual perineal examination; it is called a ‘wink’.

Box 1. PERFECTR method of pelvic floor muscle assessment 

  • P (power) – grade of muscle strength according to Modified Oxford Grading
  • E (endurance) – time in seconds during which patient can tighten pelvic floor before muscle strength is reduced by 50% (usually around 10 seconds per contraction)
  • R (repetition) – number of PFMCs patient can perform allowing 4 seconds rest between each (usually around 10)
  • F (fast) – number of fast PFMCs patient can perform, contracting muscles as strongly as possible and relaxing them as quickly as possible
  • E (elevation) – does the posterior vaginal wall lift during PFMC?
  • C (co-contraction) – do the lower abdominal muscles (ancillary muscles) contract during PFMC?
  • T (timing) – synchronous involuntary contraction of pelvic floor muscles on coughing
  • R (relax) – ability to relax between PFMC

PFMC = pelvic floor muscle contraction.
Source: Adapted from Haslam and Laycock (2008) 

Box 2. Modified Oxford Grading classification 

  • Grade 0 – no discernible contraction
  • Grade 1 – very weak contraction (‘flicker’)
  • Grade 2 – weak contraction (increase in tension without lift or squeeze)
  • Grade 3 – moderate contraction with some degree of lift and squeeze
  • Grade 4 – good contraction producing elevation with some resistance
  • Grade 5 – strong contraction and strong resistance

Source: Adapted from Haslam and Laycock (2008) 

Checking for nerve damage

After having examined the pelvic floor, nurses need to check dermatomes in the pelvic region (Fig 1) to identify potential nerve damage, as this could delay the effects of pelvic floor rehabilitation.

fig 1 female pelvic floor dermatomes

Recording findings

Before discussing an exercise programme with the patient, it is important that nurses record the findings of their investigations. This can be done in two ways:

  • Using the ring of continence;
  • Using the PERFECTR method.

The ring of continence is a schematic representation of the urethra, vagina and anus: the vagina is a clock, with the urethra positioned at 12 o’clock and the anus at 6 o’clock (Fig 2). Nurses can record their findings according to location. For example, Fig 2 shows that there is an anterior prolapse (1 o’clock), a posterior prolapse (5 o’clock), and a vaginal scar (8 o’clock).

fig 2 ring of continence

Table 1 shows an example of pelvic floor assessment findings recorded with the PERFECTR method; the findings are explained as follows:

  • P: muscle strength was 3 on the MOG;
  • E: the patient was able to tighten their muscles for five seconds;
  • R: the patient was able to perform four PFMCs;
  • F: the patient was able to perform seven fast PFMCs;
  • E: there was elevation of the posterior vaginal wall during PFMC;
  • C: there was some use of ancillary abdominal muscles;
  • T: there was no muscle contraction on coughing;
  • R: the patient was able to relax their muscles between each contraction.

This patient was able to contract their own pelvic floor, which is classed as moderately good. They can hold for five seconds – a moderate hold – and can undertake four PFMCs, but there is room for improvement. As such, they could be given supporting literature and undertake the course of rehabilitation themselves at home with frequent monitoring by the continence service or the professional instigating treatment to check for improvement.

table 1 example of pelvic floor assessment findings

Teaching pelvic floor exercises

Once a full continence assessment and pelvic floor examination have been carried out in line with NICE’s (2013) guidance, patients need education and a pelvic floor rehabilitation programme that has been tailored to their capabilities and needs. It is crucial that they understand:

  • Where the pelvic muscles are;
  • What they do;
  • How they work;
  • What the rehabilitation will hopefully achieve (Bø et al, 2007a).

Patients need to be told that it can take more than three months before they notice any improvement and that their perseverance with, and adherence to, the exercise programme will be paramount.

Box 3 shows an example of a pelvic floor exercise programme as it might be explained and handed out to a patient. While there is no recognised agreed programme for pelvic floor rehabilitation (Dumoulin et al, 2018; NICE, 2013), there seems to be a consensus that, in most cases exercise should be:

  • Undertaken in a variety of positions – lying down, sitting and standing – to improve function;
  • Performed to maximum strength;
  • Stepped up progressively to muscle overload to increase bulk;
  • Patients should be instructed to:
    • Imagine that they are trying to stop themselves from passing wind;
    • Tighten around the back passage (anus) and pull up towards the front passage (urethra);
    • Try to avoid holding their breath, pulling in their abdomen, squeezing their legs together or tensing their buttocks.

Previously, women were instructed to try to stop the urine flow when passing urine; this is no longer recommended because of back flow of urine into the bladder and because it can cause bladder dysfunction (Bø et al, 2007b). Women can, however, practise their pelvic floor exercises after emptying their bladder while they are still sitting on the toilet (Pelvic Obstetric and Gynaecological Physiotherapy, 2018).

Box 3. Example of a pelvic floor rehabilitation programme

Rehabilitation comprises exercises in three positions: lying down, sitting and standing

Slow muscle contractions

  • Lying down: lie down on your back on your bed with your knees bent and feet slightly apart. Tighten your pelvic floor as if trying to stop wind escaping. Hold contraction for ____ seconds. Relax for four seconds. Avoid holding your breath or tensing buttock muscles
  • Sitting: sit on the edge of a chair or bed with your knees apart and feet facing forward. Tighten your pelvic floor and hold contraction for ____ seconds. Relax for four seconds. Avoid holding your breath or tensing buttock muscles
  • Standing: stand with weight evenly distributed, and feet apart and facing forward. Tighten your pelvic floor and hold contraction for ____ seconds. Relax for four seconds. Avoid holding your breath or tensing buttock muscles

Perform three contractions to maximum strength three times daily in each position, building up to 10 three times daily

Fast muscle contractions

In the same three positions as above, tighten pelvic floor as if trying to stop wind escaping but do not hold. Relax and repeat.

Perform three contractions to maximum strength twice daily in each position, building up to 10 three times daily

Other activities

  • 50% lift: contract your pelvic floor to 50% of the maximum strength only while walking, climbing stairs and so on. This will increase endurance
  • The knack: tighten your pelvic floor strongly and quickly before coughing, sneezing, getting up from a chair, lifting, and so on. This will help prevent leakage
  • After urinating: tighten your pelvic floor strongly to ‘squeeze out’ the last few drops before leaving the toilet
  • After defecating: tighten your pelvic floor to ‘push back’ any faecal matter left in the anal canal into the bowel
  • During sexual activity: tighten the pelvic floor, as this will help enhance sexual intercourse

Remember to do your exercises

  • Put an alert on your phone
  • Try using a pelvic floor exercise app
  • Maintain an exercise routine (such as morning and evening, like brushing your teeth)

Other useful tips

  • Avoid constipation and straining
  • Eat the recommended five portions of fruit and vegetable per day 
  • Shed those extra pounds
  • Drink plenty (1-1.5 litres daily) of fluids, preferably water
  • Favour low-impact exercise (such as walking, swimming and pilates)
  • Avoid smoking
  • Remember that relaxing your pelvic floor muscles is just as important as contracting them

Sources: Adapted from Pelvic Obstetric and Gynaecological Physiotherapy (2018) and Dorey (2003)

Treat or prevent?

Usually, pelvic floor rehabilitation is only initiated when a woman presents with symptoms. There is evidence that pelvic floor rehabilitation is beneficial (De Andrade et al, 2018; Dumoulin et al, 2018; Radzimińska et al, 2018; NICE, 2013), but there is a lack of studies on the benefits of pelvic floor education and exercise before symptoms occur. However, as is so often the case, instead of treating symptoms once they have occurred, prevention is better than cure: prophylactic patient education and exercise may well be the most beneficial courses of action to take to prevent the negative consequences of pelvic floor weakness discussed in this series. 

Key points

  • In women, weakened pelvic floor muscles can lead to prolapse and incontinence
  • Examination of a female patient’s pelvic floor must be preceded by a full continence assessment
  • Pelvic floor examination is a skilled procedure that requires compliance with consent, chaperone and infection control policies
  • Female pelvic floor health needs to be assessed and recorded using specific tools
  • Patients need education about pelvic floor health and tailored exercise programmes
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