VOL: 96, ISSUE: 42, PAGE NO: 2
Jeanette Haslam, MPhil, MCSP, SRP, is a clinical continence specialist, Munich, GermanyThe pelvic floor muscles are unique, somatically controlled muscles that are active throughout life, 24 hours a day. They form a dynamic platform which functions like a trampoline at the base of the pelvis to contain the pelvic and abdominal organs, preventing prolapse and assisting in the maintenance of continence.
The pelvic floor muscles are unique, somatically controlled muscles that are active throughout life, 24 hours a day. They form a dynamic platform which functions like a trampoline at the base of the pelvis to contain the pelvic and abdominal organs, preventing prolapse and assisting in the maintenance of continence.
The pelvic floor muscles relax to allow for urination and childbirth, while being discriminating in their activity to allow defecation. They are also thought to be able to improve the orgasmic potential of women and erectile function of men.
Most people take their bowel and bladder function for granted, until they have an acute attack of diarrhoea or cystitis. The pelvic floor muscles are hidden away and many people are not aware of the important role they play in maintaining continence, but a range of factors can stretch and weaken them, causing problems.
What can go wrong
The following factors are associated with pelvic floor problems:
- Repeated coughing as a result of smoking (Bump and McClish, 1994), recurrent chest infections or other chronic chest conditions can stretch the pelvic floor tissues;
- Intense sporting activity, particularly high-impact activities, can cause urinary leakage (Nygaard et al, 1994);
- Straining at defecation can cause pudendal nerve stretch damage (Spence-Jones et al, 1994);
- Pelvic surgery has been implicated as a possible factor in disordered colorectal motility (Smith et al, 1990);
- Obesity (Dwyer et al, 1988);
- Prolonged immobility;
- A reduction in oestrogen levels because of ageing;
- Pregnancy - increased frequency of micturition and softening of the pelvic tissues because of hormonal changes;
- Childbirth - this affects all parts of the pelvic floor, including the pudendal nerve and the genital hiatus, which is subjected to enormous stretch. There may also be nerve damage (Allen et al, 1990), increased urethral and vaginal mobility (Sch[up6]ssler et al, 1994), generalised tissue damage and pain.
Although most nurses involved in pelvic floor muscle re-education will deal mainly with women, men are also affected.
The four layers of the pelvic floor muscles, together with the endopelvic fascia, form a horizontal sheet between the pubic symphysis at the front of the pelvis and the coccyx at the back. They are also attached laterally to the pelvic side walls. The deeper muscles - the levatores ani or pubovisceral muscles - are responsible for the continence mechanism, whereas the superficial muscles are probably more important for sexual responsiveness (DeLancey, 1994).
Do pelvic floor muscle exercises work?
Many studies have demonstrated the effectiveness of pelvic floor muscle exercises in helping to restore strength and power to the pelvic floor muscles (Ferguson et al, 1990; Wells et al, 1991).
A systematic review of randomised controlled trials on the conservative treatment of urinary stress continence problems revealed strong evidence to support the effectiveness of pelvic floor muscle exercises (Berghmans et al, 1998). This corresponds with a finding that vaginal and urethral pressures correlate significantly with pelvic floor muscle contractions (Theofrastous et al, 1997).
Pelvic floor muscle exercises are also useful in managing the symptoms of urgency as a strong pelvic floor contraction can help to activate the perineo-detrusor inhibitory reflex (Mahony et al, 1977).
For pelvic floor muscle exercises to be effective, an individualised exercise regimen is essential as each person will have different abilities. The client must also be aware of the specific muscle activity of the levatores ani muscles and be able to contract them. This depends on the integrity of the somatic nerve supply, via the pudendal nerve, and an intact central nervous system.
Some women are not able to contract their pelvic floor muscles on demand and vaginal assessment is the only way to establish whether a women will be able to perform an adequate pelvic muscle contraction (Bump et al, 1991).
The muscle activity specific to the pelvic floor is a lift-and-squeeze movement, as if clients are trying to stop the midstream flow of urine or the passage of wind. However, they should be warned that actually attempting to stop the midstream urine flow may be harmful (Bump et al, 1991).
Getting the exercises right
To improve the strength and power of the pelvic floor muscles it is essential to perform the lift-and-squeeze movement accurately. Women can tell whether they are using the correct muscles by examining themselves with a mirror. During a pelvic floor muscle contraction they should see an anal squeeze and an upward movement of the perineum. There should be no bulging of the perineum.
A vaginal examination can be performed by palpating vaginally with a clean finger or thumb hooked over the pelvic floor muscles in a posterolateral position. When the pelvic floor muscles are being contracted, the woman or her partner should be able to feel a pressure compressing the vagina anteroposteriorly. If the pelvic floor muscles are fairly strong a sucking movement may also be felt.
If vaginal assessment is not possible, observation of the inward movement of the perineum denotes a reasonable contraction. If this is not observed, applying pressure to the perineum may give the woman a sensory guide to the required action. Telling a woman to 'squeeze and pull in', 'squeeze and lift' or 'try and stop me removing my finger' may help to indicate the desired action. If a contraction cannot be elicited, specialist help is recommended.
A muscle contraction must be greater than its everyday activity to increase in force and last longer to increase endurance. If pelvic floor muscle exercises are to be successful, clients need to gradually lengthen the amount of time they hold the contraction for, increase the number of times they do the exercise, reduce the rest intervals, or use a combination of all three techniques. This method is reported to have achieved an average improvement of 25-50% strength in skeletal muscle (B[s21], 1995).
The American College of Sports Medicine (1990) recommends an exercise period of at least 15-20 weeks. Improvements in the first six to eight weeks are the result of neural adaptation, with the increased frequency of excitation leading to the development of more effective motor units. Muscle hypertrophy takes longer and continues over many months. It has been shown that pelvic floor muscle exercises continue to have an effect on the pelvic floor five years after organised training has ended (B[s21] and Talseth, 1996).
For muscle strengthening to take place, the exercise must be specific to the group of muscles that is to be strengthened. To improve performance, muscles are best trained with movements as similar as possible to the desired activity.
When strengthening the pelvic floor it has been shown that contraction of the transversus abdominis, the deepest layer of stomach muscles, results in pelvic floor muscle contraction in healthy subjects (Sapsford and Hodges, 2000).
The transversus abdominis is seen to work when there is appropriate hollowing of the lower abdomen, while the upper abdomen remains still. But gross contraction of the other abdominal muscles, especially the rectus abdominis, results in raised intra-abdominal pressure and is contraindicated when re-educating the pelvic floor muscles. It is particularly important to explain this to those who participate in strenuous abdominal exercises.
A recommended exercise regimen to develop strength in skeletal muscle is to practise three to four sets of eight to 12 high-resistance, slow-velocity contractions three times a week (DiNubile, 1991). Successful strength training depends on three component parts:
- Sufficient effort of a suitable duration;
- Exercising often enough;
- Exercising for an adequate length of time. The aim is that, whenever necessary, the pelvic floor muscles will be able to generate more force and work in a coordinated fashion.
By teaching the exercises in conjunction with pelvic floor muscle awareness, there is a much higher chance of success. Teaching a patient to contract the pelvic floor muscles before and during a cough has been shown to reduce stress urinary loss on coughing by an average of 73.3% after one week of practice (Miller et al, 1998).
Practising pelvic floor muscle exercises in different positions with abducted legs is also desirable to ensure maximal pelvic floor fitness (B[s21], 1994). These positions may include abducted legs in standing, supine lying, prone lying and prone kneeling positions. The advice nurses can give patients to help them perform pelvic floor muscle exercises successfully is shown in Box 1.
Provided that their motivational levels are high and they are likely to comply with treatment, all those in need of treatment should be given the opportunity to participate in pelvic floor muscle re-education. If a person is prepared to practice assiduously for three to six months, this would be a fair trial of the conservative management of continence problems (Stanton, 1994).
It should, however, always be emphasised that maintaining any strength gains depends on the client continuing to exercise once or twice a day at the highest threshold achieved. Lack of exercise will result in regression.