__Pelvic_Floor_Re_education__Principles_and_Practice__Second_Edition

296 Index I lSI. See Incontinence Severity healthy anatomy and, in ICIQ-SF. See International Index nulliparous women, 145-147 Consultation on Isotope retention, mean Incontinence segmental/total percentage imaging planes of, 145 Questionnaire-Short Form of, 128 introduction to, 144 ICS. See International Continence key messages of, 144 Society K of levator ani muscle thickness, Idiopathic lesions, PFMs and , Kegel perineometer, 202 31-32 Kinesthetic biofeedback, 186-187 146 IIQ. See Incontinence Impact \"The Knack,\" 13, 237 of middle urethra, 147 Questionnaire of proximal urethra, 149 Iliococcygeus muscle, 10 L static, 145-150 Imipramine, for OAB, 251 Large bowel, anatomy of, 75-76 Incontinence. See also Anal Laxatives, 262-263 anatomy and, 145 incontinence; Fecal Leakage frequency normal variation and, incontinence; Stress urinary incontinence; on bladder diary, 166 145 Urgency/urge incontinence; on frequency volume chart, pathology and, 145 Urinary incontinence of stress urinary incontinence, mixed ,67 166 electrical neurostimulation, Leak point pressure, 114 149-150 193-194 Levator ani muscles, 3 T2 weighted images, of pelvic pathogenesis of, 80 sexual dysfunction and, continence mechanism and, organs , 150, 151 254-255 12-13 T2 weighted transverse sports and , 4 true mixed, 122 innervation of, 12 sections, of bladder neck, Incontinence Impact macroscopic anatomy of, 10 148 Questionnaire (IIQ), 170 midurethral cross-section of, technique of, 144-145 Incontinence pessaries, 205 Manometric visual biofeedback, Incontinence Severity Index (IS!), 6 187-188 163 muscle fiber type of, 12 Manual therapy, for OAPF, 256 Ingelrnann-Sundberg Scale, 163 muscle physiology of, 12 Maximum urethral closure International Consultation on permanent changes in, 147-149 pressure (MUCP), 113 Incontinence reconstructed, 56 Maximum voluntary contraction Questionnaire-Short Form reversible changes in, 147-149 (MVC),97 (ICIQ-SF), 163, 164, 165 stretching of, 186 Medication, for FI, 263 International Continence Society Levator ani muscle thickness, Mediolateral episiotomy, different (ICS),62 rates of, 43 urodynamic measurements of, MRI of, 146 Micturition 109 Lifestyle changes , 218-219 muscle mechanism of, 11 Intrapartum interventions, pelvic Longitudinal smooth muscle neural control of, 28-29 floor anatomy/function OAPF and, 85-86 and,42-43 (LSM),7 sonographic evaluation of, Intraurethral ultrasound, 138 Lower urinary tract (LUT) 140 Intravaginal resistance devices, Midline episiotomy, 42-43 201 innervation of, 28 Midurethral tape , for SUI, 282 for pelvic organ prolapse, neural control of, 29 Milex pessaries, 272 202-204 LSM. See Longitudinal smooth Mixed incontinence, 67 for SUI, 204-206 electrical neurostimulation, Introital ultrasound, 136-137 muscle 193-194 Intussusception, 79 LUT. See Lower urinary tract true, 122 Ischiopubic rami, perineal Modified Faecal Incontinence membrane and, 17 M Score, 165 Magnetic resonance imaging Motor learning, biofeedback and, 184 (MRI), 144-154 Motor nerve conduction studies, axial section of, of middle of sphincter function, 126-127 urethra, 146 Motor unit , schematic of, 156 of bladder base , 147 dynamic, 150-154 significance of, 153-154 standard reference lines for, 150-151

Index 297 Motor unit potential, component o micturition and , 85-86 phases of, 156 muscle rehabilitation for, OAB. See Overactive bladder MRI. See Magnetic resonance syndrome 256-257 imaging musculoskeletal treatment of, OAPF. See Overactive pelvic floor MUCP. See Maximum urethral Observations in standing, PFMs 255 closure pressure psychological issues with, 255 and ,97 referred pain of, 83 Muscle. See also Levator ani l-hour pad tests , 166-167 sexual dysfunction and, muscles; Pelvic floor Onuf's nucleus , 64 muscles; Skeletal muscle Open pouch of Douglas, in female 253-257 introduction to, 253 awareness, of PFMs, 25 patient, 152 key messages of, 253 coordination assessment, of Orgasmic dysfunction, 254 symptoms/findings of, Overactive bladder syndrome PFMs,98 253-255 dysfunction (OAB), 66-67, 246-251 sexual function/sexual abuse antidepressants for, 251 clinical impact of, 57 antidiuretic agents for, 251 and,86 future directions in, 58 antimuscarinic drugs for, symptoms of, 83 fibers, innervation of, 52 urinary tract morbidity with, 85 function 250-251 voiding patterns and, 86 aging and, 49-58 behavioral/drug therapy Overload normal changes in, 57 general muscle training and, physiology, 49 combination for, 251 repair/rehabilitation, 53-57 behavioral interventions for, 178 cellular mechanisms for, PFMT and, 178-179 246 Oxford scale, 99 53-54 bladder training for, 246-248 Oxybutynin, for OAB, 249 clinical aspects of, 54-56 common causes for, 67 clinical assessment of, darifenacin for, 250-251 P desmopressin for, 251 Pad tests, 166-168 54-56 imipramine for, 251 Patient education, AI and , 259 clinical relevance of, 56 introduction to, 246 Patient symptom scores, pelvic for OAPF, 256-257 key messages of, 246 use, for accident prevention, oxybutynin for, 249 floor rehabilitation and, patient example of, 117-119 outcome measures in, 217 pharmacological therapy for, 163-165 Musculoskeletal treatment, of Pelvic attachment, of arcus 249-251 tendineus, 15 OAPF,255 propiverine for, 250 Pelvic dysfunction, electrical MVC. See Maximum voluntary solifenacin for, 250 stimulation for, application studies on, 198-199 of, 191 contraction tolterodine for, 250 Pelvic floor trospium for, 250 anatomic view of, 4 N Overactive pelvic floor (OAPF), anatomy of, 76 Neotonus chair, for awareness, enhancement of, 185 83-86 biomechanical stimulation of, electromagnetic induction abnormal tissue areas of, 84 211 therapy, 197 bladder and, 83-84 Cantienica training of, 210-211 Nerve conduction studies, of bowel and, 84 clam exercise for, 209 pelvic floor, 159-160 causes of, 84-85 connective tissue of, 13-14 Neurological lesions , PFMs and, conservative management of, contraction, 151, 152 31-32 sonographic evaluation of, Neurologic conceptualization, of 255-257 140 PFM physiotherapy, 33 defecation and, 86 deterioration of function, 4 Neuromuscular injury, to pelvic electrical neurostimulation for, disorders, 3 floor region , from vaginal devices for, 202-206 delivery,32 -33 194 distension, during vaginal Nocturia, 219 evaluation of, 255 delivery, 37 research on, 249 findings of, 85 Normal record ings, of anorectal introduction to, 83 manometry, 125 key message of, 83 Nulliparous woman , urethral local pa in of, 83 anatomy of, 6 manual therapy for, 256

298 Index Pelvic floor (cont.) coccyx and, 10 differing approaches to, dysfunction, identification of, contraction 229-230 95 electromyography activity assessment of, 96 effectiveness of, 228-230 from, 157 observations during, 96-97 exercise and, 179-180,216-217 endopelvic fascia of, 13-14 denervation of, 22 exercise protocol adherence for, evoked potentials of, 160-161 digital evaluation of, clinical external palpation activations 181-182 of,210 scale for, 101 initial exercise program for, Feldenkrais approach to, dysfunction, pelvic floor pain 209-210 223-224 function and,85 introduction to, 177-178 childbirth and, 39-44 exercise for, 100-101, 184 key messages of, 177 deterioration of, 4 function, visualization, 151 overload and, 178-179 loss reduction, 44 idiopathic lesions and, 31-32 PFM assessment and, 222-223 sonographic evaluation of, innervation of, 26-28 during pregnancy, antepartum/ 138-141 lateral view of, digital palpation functional anatomy, 3-19 postpartum urinary lateral view of, 16 of,94 incontinence prevention nerve conduction studies of, layers of, 93 and,231-232 159-160 muscle awareness of, 25-26 principles of, 178-179 pain, pelvic floor muscle muscle coordination assessment program descriptions of, 229, dysfunction and, 85 231 physiotherapy, for POP, 275-276 of,98 reversibility and, 179 Pilates method for, 208-209 neural control of, 22-33 review/follow-up, 224-225 POP and, 73-74 specificity and, 178-179 postpartum management of, activity of, 22-23 synergist coactivation, 179-180 235-241 introduction to, 22 voluntary contraction pudendal motor latency of, 160 key message of, 22 techniques for, 223 reflex studies of, 159 neurological lesions and, 31-32 Pelvic floor rehabilitation rehabilitation of, 3 observations in standing and, electromagnetic stimulation at rest, 150, 151-152 and,199 structures, lateral view of, 11 97 outcome measures in, 162-171 during valsalva maneuver, 151, palpation, 93-96 introduction to, 162 152-153 physiotherapy, neurologic patient symptom scores and, whole-body vibration therapy 163-165 for, 211 conceptualization of, 33 validation of, 162-163 yoga for, 208-209 rehabilitation/training of, SUI and, during sports/fitness activities, 267-268 Pelvic floor exercises (PFX), 238, 101-102 Pelvic muscle rating scale, 99 240. See also Exercise behavioral training with, Pelvic organ prolapse (POP), 71-74,105-108,271-276 program adherence to, 240 248 clinical findings of, 71 Pelvic floor muscle recruitment biofeedback and, 185-189 drydock boat concept of, 73 devices for, 201-206 etiology of, 71-72 in stress incontinence, 180-181 instrumentation for, 102 evaluation of, 272-276 in urge incontinence, 181 scales/assessment tools for, examination for, 72-73, 105 Pelvic floor muscle re-education, fembrace for, 276 98-100 historical perspective on, 222-226 schematic anatomy of, 92 271-272 Pelvic floor muscles (PFMs), 3, somatic motor pathways of, intravaginal resistance devices for, 202-204 22-23,91-103 26-27 introduction to, 71 afferent pathways of, 27-28 strength measurement of, 97-98 key messages of, 71 assessment of, 92-96 pelvic floor and, 73-74 clinical evaluation of, 91-103 other assessment methods pelvic floor physiotherapy for, for, 102-103 275-276 beginning of, 91-92 pessary treatment for, 271 introduction to, 91 tenderness scale of, 95 key message of, 91 tonic/phasic, 23-24 transvaginal palpation of, 94 two digital measurement of, 94 Pelvic floor muscle training (PFMT),121 anatomy education and, 222 compared to no treatment, 228-229 devices for, 201-206

Index 299 during pregnancy, 38-39 PFMT. See Pelvic floor muscle pelvic organ prolapse during, quantification system for, 72, training 38-39 106-107 PFX. See Pelvic floor exercises urodynamics during, 38-39 risk factors of, 71-72 Pharmacological therapy Pregnancylchildbirth effects space-occupying pessaries for, for OAB, 249-251 hormonal changes/impact and, 203 for SUI, 225-226 37 support pessaries for, 203 Physical activity. See also types of, 272-276 mechanical trauma and, 37-38 Pelvic organs, support of, 8-10 Exercise on pelvic floor, 36-45 Pelvic pain, point-form treatment bowel routine and, 260 Pilates method, for pelvic floor, introduction to, 36-37 of, 256 key messages on, 36 Pelvic re-education regimen 208-209 Pressure/flow recording, during PMC. See Pontine micturition digital self-assessment and, 97 filling/micturition, 112 monitoring therapy and, 103 center Pressure-flow studies, filling P.E.R.F. E. C. T. scale, 99 Point-form treatment examples of, 100 cystometryand, 111-112 Perfusion systems, anorectal of dyspareunia, 256 Pressure flow study, of patient, 118 of pelvic pain, 256 Primiparous women , 38 manometry and, 125 Pontine micturition center (PMC), Prolapse symptoms, illustrations Periform vaginal electrode, with 28-29 of,14 indicator, 224 POP. See Pelvic organ prolapse Propiverine, for OAB,250 Perineal clinic Posterior prolapse, 17 Psychological issues, with OAPF, Posterior support, 17-18 conditions treated in, 243-244 Postpartum continence promotion 255 experience in, 244 Pubic synphysis, as reference introduction to, 242 program, components of, key messages of, 242 239 structure, 137 referral reasons for, 244 Postpartum intervention, Pubococcygeus muscle, 10 role of, 242-244 effectiveness of, 239-240 structure of, 242-243 Postpartum management activation patterns of, 32, 33 Perineal descent/enterocele, after of pelvic floor, 235-241 Puborectalis muscle, 10 introduction to, 235 Pudendal electrode, disposable, hysterectomy, 153 key messages of, 235 Perineal massage, 44 perineal, outline of, 236-237 127 Perineal membrane Postpartum PFM rehabilitation, Pudendal latencies 238 external genital muscles and, Postpartum urinary incontinence normal mean, 126 16-17 prevention, with normal recordings of, 127 antepartum pelvic floor Pudendal motor latency, of pelvic ischiopubic rami and, 17 muscle training, 230-231 Perineal pain, management Posture, bowel routine and, 261 floor, 160 Pregnancy Pudendal nerve , from ventral pathway for, 244 antepartum/postpartum Perineal ultrasound, 136-137 urinary incontinence rami, 26 prevention and, PFMT Pudendal nerve terminal motor findings on childbirth, 40 during, 231-232 of minimally filled bladder, 138 bladder neck/perineum during, latency, 126-127 Pessaries 40 Pure detrusor overactivity, complications with , 275 continence and, 4 cup/stem, 272 pelvic floor during urodynamic findings and, fistulas with, 275 examination for, 38-39 118-122 fitting of, guidelines for, findings of, 38-39 Pure stress incontinence, imaging for, 39 urodynamic findings and, 273-274 symptoms of, 38 118-122 incontinence, 205 urodynamic studies for, 39 milex,272 pelvic floor dysfunction during, Q POP treatment with, 271 37 Quality of life scores , urinary success rates with, 274-275 types of, 274 incontinence and, 170 vaginal discharge with, 275 vaginal erosions with, 275 R PFMs. See Pelvic floor muscles Radioisotope colon transit study, 129 Randomized controlled trials (RCTs), of electromagnetic induction therapy, 197-198

300 Index RCTs. See Randomized controlled cross section of, 50 Stress-incontinent woman, trials denervation disorder of, 54 116-117 gross anatomical aspects of, Reconstructive techniques, for cough stress profile of, 117 anal sphincter, 290 49-50 urethral closure pressure profile mechanicallmyopathic damage Rectal prolapse, 79 of, 116 advanced uterovaginal prolapse of, 53 Stress strategies, 217 and, 79 micrograph of, 50 Stress urinary incontinence (SUI), neural damage of, 53 Rectal sensation, showing balloon normal adaptation of, 52 65-66,121,221-226 distension volumes, 127 normal function of, 49 alpha-agonists for, 225 structure/function of, 50 artificial urinary sphincter for, Rectoanalreflex,126 three-dimensional schematic of, Rectocele, 79 282-283 51 assessment of, 221 illustration of, 14 weakness, mechanisms of, biofeedback techniques for, surgery for, 287 Rectum , dynamic imaging of, 53-57 during sports/fitness Sling, for SUI, 282 activities, 268-269 130-132 Solifenacin , for OAB, 250 bulking agents for, 281 Reflex studies, of pelvic floor, 159 Somatic motor pathways, of PFMs, colposuspension for, 282 Resting anal pressure, anorectal contraceptive diaphragm for, 26-27 205 manometry and, 125-126 Sonographic evaluation. See also definition of, 221 Reversibility electrical neurostimulation for, Ultrasound imaging 193 general muscle training and, biofeedback with, 188 hormone therapy for, 225-226 178 of coughing, 138-140 intravaginal resistance devices of defecation, 140 for, 204-206 PFMT and, 179 of micturition, 140 introduction to, 221 Routine mediolateral episiotomy, of pelvic floor contraction, key messages of, 221 midurethral tape for, 282 42-43 140 MRI of, 149-150 of pelvic floor function, pelvic floor muscle recruitment S in, 180-181 Sacral nerve stimulation, anal 138-141 pharmacological therapy for, of straining, 138-140 225-226 sphincter and, 289-290 of valsalva, 138-140 pure, urodynamic findings and, Sagittal scan/plan, 137 Space-occupying pessaries, for 118-122 Schussler diagram, 72 selective serotonin- Selective serotonin- pelvic organ prolapse, norepinephrine reuptake 203 inh ibitors for, 226 norepinephrine reuptake Specificity sling for, 282 inhibitors, for SUI, 226 general muscle training and, during sports/fitness activities, Sexual dysfunction 178 267-269 incontinence and, 254-255 PFMT and, 178-179 etiology of, 267 OAPF and, 253-257 Sphincter function introduction to, 267 introduction to, 253 electrophysiology of, 126 key messages of, 267 key messages of, 253 motor nerve conduction studies pelvic floor rehabilitation symptoms/findings of, of, 126-127 and, 267-268 253-255 Sports/fitness activities surgical choices for, 281-283 Sexual function/sexual abuse, incontinence and, 4 tricyclic antidepressants for, 226 OAPF and, 86 SUI during, 267-269 urethral closure for, 283 Sexual response, neural control Stamey Grading, of incontinence, urinary diversion for, 283 of, 31 163 Striated anal sphincter, 156 Single-fiber electrode, St. George Score, 165 Striated muscle activity, superimposed on normal Stoma creation, 291 electromyography and, muscle, 128 Storage physiology, voiding phase 155-157 Single-fiber electromyography, and , 63-65 128 Storage reflex, 63 Skeletal muscle Straining, sonographic evaluation adaptation of, within pelvic of, 138-140 floor, 52-53 cardiovascular damage of, 53

Index 301 Striated pelvic floor muscles , 2-hour pad tests, 167 Urgency/urge incontinence evidence-based exercise Two digital measurement, of electrical neurostimulation for, parameters of, for 193-194 functional capacity PFMs,94 pelvic floor muscle recruitment improvement, 238 in, 181 U studies of, 198 Striated urinary sphincter, 7 UDI. See Urogenital Distress of urethra, 7 Urge suppression strategies, Inventory 217 SUI. See Stress urinary Ultrasound imaging, 135-141. See incontinence mechanism of, 248 also Sonographic patient instructions for, 249 Support pessaries, for pelvic evaluation Urinary diversion, for SUI, 283 organ prolapse, 203 applications of, 136-137 Urinary incontinence as biofeedback tool, 140-141 anatomical observations on, Surface electrodes, 158-159 dynamic, biofeedback with, 188 EMG recording with, 159 equipment for, 136-137 168-171 types of, 159 key messages of, 135 bowel management and, 219 scope of, 135-136 after childbirth, 41 Surgery UPP. See Urethral pressure clinical treatment for, 56-57 for anterior vaginal wall profilometry functional observations on, prolapse, 286 Urethra for genital prolapse, 285-288 anatomy of, 6-8 168-171 for rectocele, 287 anterior wall support and, obstetric/maternal risk factors for SUI, 281-283 14-16 introduction to, 281 endopelvic fascia of, 6 for, 41 key messages of, 281 innervation of, 8 pad test classification of, 168 minimally invasive middle, MRI of, 147 prevention opportunities for, procedures for, 281-282 palpation of, 96 for uterine prolapse, 286-287 proximal, MRI of, 149 56-57 support of, 8-10 quality oflife scores and, 170 T Urethral closure socioeconomic evaluation, Tactile/verbal feedback, 185-186 pressure profile, 115 Tactile/visual biofeedback, during of stress -incontinent woman, 170 116 symptom quantification for, cystourethroscopy, 188-189 for SUI, 283 Tenderness scale, of PFMs, 95 Urethral glands, 8 166-168 Three-dimensional ultrasound, Urethral pressure measurement, symptoms of, 12, 13 112-113 types of, 65-67 138 schematic drawing of, 113 UPP of, 169 Tolterodine , for OAB, 250 Urethral pressure profilometry urodynamic assessment of, Tonic motor unit, continuously (UPP), of urinary incontinence, 169 168-169 firing, falling leaf display Urethral pressure transducer, 113 voiding dysfunction and , of,23 Urethral smooth muscle, 7 Tonic muscle activity, inhibition Urethral sphincter, external, 62-69 of,24 MEPs of, 28 weight loss and, 218-219 TrA muscles. See Transversus Urethral sphincter muscle, EMG Urinary sphincter abdominis muscles recording of, 23 artificial, for SUI, 282-283 Transmuscular hook electrodes, Urethral submucosal vasculature, competent, 66 157 8 striated, 5-6 Transvaginal palpation, of PFMs, Urethrovesical angle, bladder Urinary tract, lower, anatomy of, 94 neck mobility and , Transversus abdominis (TrA) measurement of, 139 5-8 muscles, 97 Urgency/frequency Urinary tract morbidity, with Tricyclic antidepressants, for SUI, cycle, 247 226 research on, 249 OAPF,85 Trospium, for OAB, 250 Urine flow curve, descriptive True mixed incontinence, 122 24-hour pad tests, 167 terminology and, III criterion validity of, 168 Urodynamic(s), 109-119 repeatability of, 168 indications of, 109 key message of, 109 during pregnancy, 38-39 Urodynamic assessment, of urinary incontinence, 168-169

302 Index Urodynamic findings V Visual biofeedback, 186 in clinical practice, 118-123 Vaginal delivery VLPP. See Valsalva leak point introduction to, 118 key message of, 118 bladder neck/perineum after, 40 pressures pure detrusor overactivity and, clinical examination findings Voiding dysfunction 118-122 pure stress incontinence and, after, 39 classification of, 68 118-122 neuromuscular injury to, pelvic etiology of, 68 patient example of, 117 Urodynamic lab, with supine floor region , 32-33 prevention of, 69 patient, 110 neurophysiology of, 39-40 symptoms of, 67-68 pelvic floor distension during, treatment of, 69 Urodynamic measurements, of urinary incontinence and, ICS, 109 37 pelvic floor dysfunction after, 62-69 Urodynamic stress incontinence Voiding frequency (USI), studies on, 198 37 pelvic floor safety during, decreasing, 218 Urodynamic studies, for increasing, 218 pregnancy, pelvic floor 44-45 Voiding habits/schedules, 218 during, 39 pelvic floor symptoms during, Voiding patterns, OAPF and , Urodynamic techniques 37 86 definitions of, 109-110 Vaginal discharge, with pessaries, Voiding phase, storage physiology technical performance of, 109-110 275 and,63-65 Vaginal EMG-electrode, Voiding reflex, 63 Uroflow, with abdominal/pelvic Voiding response, voluntary, floor EMG, 114 biofeedback with, 188 Vaginal erosions, with pessaries, 64 Uroflowmetry, 110 Voluntary contraction pressure, Urogenital diaphragm, 16-17 275 Urogenital Distress Inventory Vaginal probes, for electrical 126 Voluntary contraction techniques, (UDI),170 stimulation, 192 Urogenital hiatus, 10 Vaginal prolapse, Bonney 's for PFMT, 223 U-shaped levator ani muscle, analogy of, 9 W schematic of, 8 Vaginal support Weight loss, urinary incontinence US!. See Urodynamic stress diagrammatic display of, 9 and, 218-219 incontinence levels, after hysterectomy, 13 Wexner scale, 165 Uterine prolapse Vaginismus, 254 Whole-body vibration therapy, for Valsalva, sonographic evaluation illustration of, 14 pelvic floor, 211 quantification of, 151 of,138-140 surgery for, 286-287 Va1salvaleak point pressures Y Uterovaginal support, 16 Yoga, for pelvic floor, 208-209 (VLPP), 169-170 Valsalva maneuver, pelvic floor during, 151, 152-153 Vesical pressure transducer, 113