Chronic Urogenital Pain

Vulvodynia – Bladder Pain Syndrome/Interstitial Cystitis

Pelvic Floor Rehabilitation

Marek Jantos

The pelvic floor muscles (primarily the levator ani muscle group) provide essential support to pelvic organs (bladder, uterus, upper vagina and rectum) and constitute the closing mechanism by which intrauretheral and rectal resistance is maintained at times of increased intra-abdominal pressure(1). Anatomically, the pelvic floor musculature and the internal and external sphincteric mechanisms are of major importance in urinary and faecal continence. Trauma and damage of these structures will contribute to the development of pelvic floor dysfunction.

Lifestyle, childbearing, participation in the work force and the desire to maintain physical fitness through sport and regular exercise contribute to an increased rise of pelvic floor related dysfunctions. A study of physically active women found that: 47% of regularly exercising women reported a degree of incontinence. The reported incontinence was positively correlated with the number of vaginal deliveries and the type of sports engaged in. Of the incontinent women, 22% were nulliparous(2). Strenuous activities introduced a high risk factor to the pelvic floor. The problem is often compounded by under-reporting and under-diagnosis of complications. The majority of women (40-80%) with incontinence do not seek help. Those who eventually seek professional assistance may delay obtaining medical services for more than a year after symptoms become troublesome. Most common reasons given for not seeking treatment include, embarrassment, fear of surgery, hope improvement without-investigation and a belief that it is a normal part of the ageing process. Incontinence is never normal.

Incontinence often starts out as a loss of a few drops of urine but progressively gets worse over time. The physical and emotional repercussions associated with incontinence are very significant. It is not only a matter of concern for personal hygiene, but it also effects the psychological well being of the individual. Embarrassment, shame, depression, anger, frustration, secretiveness, loss of self-esteem, fear, guilt and denial are some of the common responses(3). It is important to note that most incontinence problems can be successfully treated without surgery or hospitalisation. Arnold Kegel, a gynaecologist and pioneer in conservative treatment of pelvic floor dysfunction summarised his extensive research and experience in the following words:

“The common type of simple stress incontinence is a reversible neuromuscular disturbance. It can be prevented by therapeutic measures instituted at the first sign of weakness of the pubococcygeus muscle…”(6).

His conclusions are supported by very convincing data: “… stress incontinence of urine, uncomplicated by severe trauma or systemic disease, was cured in 86% of cases by physiologic, non-operative therapy; in the remaining 14% it was improved but occasional loss of urine continued”(6). Pelvic floor exercises (often referred to as Kegel exercises) with the assistance of biofeedback is the therapy of choice for pelvic floor rehabilitation. Today such conservative therapy incorporates technologically advanced equipment and protocols providing the practitioner with a significant technical advantage.

“Computerised electromyography has made important contributions to the treatment of muscular pain and conditions mediated by autonomic regulation. Its contribution to the rehabilitation of pelvic floor dysfunction has been most significant”.
Marek Jantos M.A. M.A.Ps.S, Behavioural Medicine Consultant, Adelaide, SA.
“Biofeedback assisted rehabilitation of pelvic floor musculature has become the fastest growing and most rewarding part of my clinical practice”.
Howard I Glazer Ph.D. Clinical, Associate Professor of Psychology in Psychiatry, Cornell University Medical College
“Studies at our unit indicate that EMG of the pelvic floor is an important developing modality for both pain alleviation in vestibulitis and for relief of the symptoms of urinary incontinence in selected patients.”
Gordon White, F.A.C.Ven, Senior Staff Specialist, Sexual Medicine Unit, Woden Valley Hospital