Pelvic Floor Rehabilitation

Pelvic Floor Rehabilitation: Highly Recommended for Perineal Dysfunction

The pelvic floor is a complex neuro-musculo-fascial system that forms the bottom closure of the pelvis. It serves three primary functions: containing intra-abdominal pressure, suspending and supporting lower abdominal organs such as the uterus, bladder, and rectum. Additionally, it plays an active role during pregnancy by supporting the increased weight and the uterus, and is crucial during childbirth. Its proper distension allows for the expulsive phase, facilitating the baby’s transition to extrauterine life. Therefore, adequate perineal preparation for childbirth is essential, even if a cesarean section is planned, to ensure proper tissue condition and reduce the incidence of tears, episiotomies, and future perineal pathologies.

Types of Pelvic Floor Dysfunction

Pelvic floor dysfunctions can be categorized into two main types:

1. Hypotonic Dysfunction (muscle weakness):
   • Urinary incontinence (stress, urgency, or mixed)
   • Fecal or gas incontinence (stress, urgency, or mixed)
   • Organ prolapse (bladder, uterus, rectum, and/or vaginal wall)
2. Hypertonic Dysfunction (muscle tightness):
   • Chronic pelvic pain
   • Chronic constipation
   • Sexual dysfunctions such as dyspareunia and vulvodynia

Dysfunctions

Incontinence is defined as the occurrence of involuntary leaks and can be urinary or fecal, affecting both males and females. It can be classified into three types:

• Stress Incontinence: Leaks occur due to physical exertion, ranging from simple movements like standing up (severe), to coughing, sneezing, or laughing (moderate), to intense activities like climbing stairs, walking briskly, running, or playing sports (mild).
• Urgency Incontinence: Leaks happen due to an inability to delay or manage the urge to urinate. Overactive Bladder Syndrome, characterized by urgency with or without incontinence, usually associated with increased daytime and nighttime urination frequency, falls into this category. This condition involves both muscular alterations and bladder receptor issues, necessitating appropriate pharmacological support.
• Mixed Incontinence: A combination of the above two conditions.

Incontinence can result from direct trauma to the pelvic floor during childbirth, abdominal and/or urological surgeries (commonly after prostate operations), intense sports activities, debilitating work conditions, obesity, smoking, and alcohol consumption.

Organ prolapse exclusively affects women and involves the descent of organs located in the lower abdominal cavity, such as the uterus, bladder, and rectum. Predisposing factors include multiple pregnancies, complicated and operational deliveries, tears and episiotomies, abdominal surgeries, and menopause due to connective tissue deterioration, leading to weakened support structures for pelvic organs. Prolapse is graded based on the degree of organ descent into the vaginal cavity. First-degree prolapse has the highest rehabilitative recommendation to avoid surgery and resolve the issue conservatively. More advanced prolapses indicate surgery, where appropriate rehabilitation can prepare for the operation and is recommended post-operatively.

Rehabilitation

Pelvic floor rehabilitation begins with a thorough assessment by a specialized physiotherapist, identifying signs and symptoms of dysfunction and resulting in a personalized treatment plan.

The Rehabilitation Process Comprises Three Phases:

1. Awareness: Gaining awareness of the perineal area and voluntary motor activation. This phase aims for selective muscle contraction with the elimination of compensations, along with learning proper breathing, given the connection between the respiratory diaphragm and the perineal diaphragm.
2. Active Kinesiotherapy: Focused on muscle recovery through contraction and relaxation exercises.
3. Functional Recovery: The most delicate phase, where patients learn to use their muscles correctly to counteract the pathology. For stress incontinence, this involves contracting to prevent leaks during exertion; for urgency incontinence, contracting to manage the urge; for chronic pelvic pain, constipation, or sexual dysfunction, learning to release tension through breathing and massages of the affected areas.

Techniques

Pelvic floor rehabilitation employs various techniques:

• Pelvic-Perineal Kinesiotherapy (Kegel exercises): Exercises to learn correct contraction and relaxation movements of the pelvic floor muscles, making them functional based on the identified issue.
• Functional Electrical Stimulation: Used to stimulate perineal muscles that cannot be voluntarily contracted or if the contraction is inadequate.
• Biofeedback: Utilizes instruments to record muscle contractions or relaxations, providing acoustic or visual signals to greatly enhance the patient’s awareness of their voluntary muscle activation.