Pelvic muscle rehabilitation: a standardized protocol for pelvic floor dysfunction

Abstract

Introduction. Pelvic floor dysfunction syndromes present with voiding, sexual, and anorectal disturbances, which may be associated with one another, resulting in complex presentation. Thus, an integrated diagnosis and management approach may be required. Pelvic muscle rehabilitation (PMR) is a noninvasive modality involving cognitive reeducation, modification, and retraining of the pelvic floor and associated musculature. We describe our standardized PMR protocol for the management of pelvic floor dysfunction syndromes. Pelvic Muscle Rehabilitation Program. The diagnostic assessment includes electromyography and manometry analyzed in 4 phases: (1) initial baseline phase; (2) rapid contraction phase; (3) tonic contraction and endurance phase; and (4) late baseline phase. This evaluation is performed at the onset of every session. PMR management consists of 6 possible therapeutic modalities, employed depending on the diagnostic evaluation: (1) down-training; (2) accessory muscle isolation; (3) discrimination training; (4) muscle strengthening; (5) endurance training; and (6) electrical stimulation. Eight to ten sessions are performed at one-week intervals with integration of home exercises and lifestyle modifications. Conclusions. The PMR protocol offers a standardized approach to diagnose and manage pelvic floor dysfunction syndromes with potential advantages over traditional biofeedback, involving additional interventions and a continuous pelvic floor assessment with management modifications over the clinical course.

Figures

Figure 1

Muscle isolation. (a) Electromyographic tracings of a patient with outlet obstruction defecation and anismus with excessive accessory muscle utilization (pink tracing) corresponding to contraction and relaxation of the pelvic floor complex. (b) Electromyography of the same patient following sessions of pelvic muscle rehabilitation revealing significant reduction of accessory muscle utilization during pelvic floor muscle contraction.

Figure 2

Discrimination training. The electromyographic tracings of a patient with postprostatectomy urinary incontinence showing accessory muscle hyperactivity (pink) during pelvic floor muscle contractions. The accessory muscle electrical activity is entirely suppressed following successful patient sensory awareness training (arrow).

Figure 3

Pelvic floor muscle strengthening. (a) Electromyographic tracing of a patient with stress urinary incontinence during a series of rapid contractions (“quick flicks”) in which the patient is asked to contract and relax over multiple 5-second intervals. The tracing reveals reduced electrical activity and recruitment during contractions (5 mcV) on the initial session. (b) Same patient following sessions of pelvic muscle rehabilitation revealing marked increased electromyographic activity during the contraction (15 mcV) phase of the rapid contraction (“quick flicks”).

Figure 4

Endurance training. (a) Electromyographic tracings of a patient with fecal incontinence (black tracing) showing inability to maintain sustained contractions (poor endurance) and characteristic sawtooth pattern indicating fatigue. (b) Electromyographic tracings of the same patient following pelvic muscle rehabilitation sessions revealing sustained contractions during each interval contraction.

Figure 5

Down-training. (a) Electromyographic tracing of a patient with chronic pelvic pain due to pelvic floor muscle spasm revealing elevated resting tone. (b) Same patient of (a): following 8 sessions of pelvic muscle rehabilitation, the resting muscle tone and symptoms decreased substantially.

Figure 6

Electrical stimulation. Tracing of a patient with urge urinary incontinence associated with pelvic floor spams. Electrical stimulation mode serves to desensitize muscles to graded elevation of muscle stimuli. With the baseline set to 15 mcV/mA, a baseline electromyographic pelvic floor activity is seen. As the stimulation mode increases to 30 mcV/mA, the electrical activity does not increase, as it is desensitized.

Figure 7

Algorithm illustrating the diagnostic decision tree and treatment approach. Reassessment is performed every time the patient returns for the next session.