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Prolapse uterus Incontinence

1.Pathophysiology 1.Definition
2.Causes 2.Causes and symptoms
3.Classification 3.Categorization
4.Grading 4.Diagnosis
5.Signs and symptoms 5.Treatment
6.Diagnosis
7.Treatment

PHYSIOTHERAPY
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Definition
•Uterine prolapse is the
condition of the uterus
collapsing, falling down, or
downward displacement of the
uterus with relation to the
vagina.
•It is also defined as the
bulging of the uterus into the
vagina.

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  Uterus is normally held in place by the pelvic
muscles and supporting ligaments
 When these muscles become weakened or
injured, uterine prolapse can occur
 In mild cases, a portion of the uterus descends
into the top of the vagina
 In more serious cases, the uterus may even
protrude through the vaginal opening and
outside the vagina

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  Multiple pregnancies and deliveries
 Obesity
 Trauma to pudendal or sacral nerves
 Aging related muscle changes
 Excessive strain during bowel movements
 Pelvic tumors
 Genetic predisposition

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  Cystocele: herniation of the urinary bladder
into the vagina

 Retrocele: herniation of the rectum into the

vagina. Part of the rectum protrudes into the
posterior wall of the vagina forming a pouch in
the intestine.

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  Cystourethrocele: bladder and urethra
prolapse into the vagina
 Urethrocele: bladder neck prolapses into the
vagina
 Enterocele: Part of the intestine and
peritoneum prolapses into the vagina
 Vaginal vault prolapse: apex of vagina
prolapses

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  Grade 1: Descent of the uterus to above the
hymen

 Grade 2: Descent of the uterus to the hymen

 Grade 3: Descent of the uterus beyond the

hymen

 Grade 4: Total prolapse

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  Abdominal discomfort or a feeling of heaviness in the
vagina

 Vague discomfort, pelvic pain, or pressure in the pelvic

region

 Backache that worsens with lifting

 Excessive menstrual bleeding or abnormal vaginal

discharge or bleeding

 May not exhibit any symptoms at all in some women

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  Frequent and painful urination

 Occasional stress incontinence

 Difficulty in moving bowels

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  History
 Physical examination
 Urine culture
 Pelvic ultrasonography or cystography

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  Hormone replacement therapy
 Vaginal pessaries
 Physiotherapy
 Surgery

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  Indicated or a possible treatment to assist in
maintaining elasticity of the pelvic floor
musculature.
 Vaginal tissue and supporting structures
depend on estrogen for their strength and
elasticity. As estrogen levels decrease in
certain situations (menopause and
breast feeding mothers), the symptom become
more apparent.

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  Estrogen replacement can come in the form of
pills, vaginal rings, patches, or vaginal
creams and are often indicated for lower
grades of prolapse as the primary form of
treatment.
 More severe prolapse is less likely to respond
to estrogen therapy alone, however, it can be
used as an adjunct to other treatments.
 Estrogen replacement can also be used after
surgery to maintain results of surgery and help
to revitalize dry and thin vaginal tissue.
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  A vaginal pessary is a small device, similar to a
diaphragm or cervical cap, which is inserted
into the vagina to hold the prolapsed organ(s)
in place.

 Pessaries are made of latex or silicone and

come in many different shapes and sizess

 Ring pessaries are the most common, but may

not be right for every woman
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  necessary when the
prolapse causes significant
symptoms
 There are two surgical
approaches to treating a
uterine prolapse:
✓ removing the uterus
altogether (hysterectomy)
✓ lifting it and holding it in
place (suspension)
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 Definition

 Involuntary loss of urine or stool in sufficient

amount or frequency to constitute a social
and/or health problem.
 A heterogeneous condition that ranges in
severity from dribbling small amounts of urine
to continuous urinary incontinence with
concomitant fecal incontinence

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 1.Inherited or genetic factors
 Race

 Anatomic differences

 Connective tissue

 Neurologic abnormalities

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 2. External factors
 Pregnancy and childbirth

 Aging

 Hormone effects

 Nonobstetric pelvic trauma and radical surgery

 Increased intra-abdominal pressure

 Drug effects

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  Urge incontinence
 Stress incontinence
 Mixed incontinence
 Chronic urinary retention
 Functional incontinence

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 1.Genuine Stress Incontinence:

 Loss of urine with increases in abdominal

pressure
 Caused by pelvic floor damage/weakness or
weak sphincter(s)
 Symptoms include loss of urine with cough,
laugh, sneeze, running, lifting, walking

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 2. Urge Incontinence:

 Loss of urine due to an involuntary bladder

spasm (contraction)
 Complaints of urgency, frequency, inability to
reach the toilet in time, gets up a lot at night to
use the toilet
 Multiple triggers

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 3.Mixed Incontinence:

 Combination of stress and urge incontinence

 Common presentation of mixed symptoms
 Urodynamics necessary to confirm

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 4. Chronic Urinary Retention:

 Outlet obstruction or bladder underactivity

 May be related to previous surgery, aging,
development of bad bladder habits, or
neurologic disorders
 Medication, such as antidepressants
 May present with symptoms of stress or
urge incontinence, continuous leakage, or
urinary tract infection

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 5. Functional Incontinence:

 Mostly in the elderly

 Urinary tract infection
 Restricted mobility
 Severe constipation
 Medication - diuretics, antipsychotics
 Psychological/cognitive deficiency

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  History
 Physical examination
 Urinalysis
 PVR - if indicated
 Symptoms of incomplete emptying
 Longstanding diabetes mellitus
 History of urinary retention
 Failure of pharmacologic therapy
 Pelvic floor prolapse
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 Previous incontinence surgery 32
 1.Non-surgical
 Fluid management

 Reduce caffeine, alcohol, and smoking

 Bladder retraining

 Pelvic floor exercises

 Pessaries

 Continence devices

 Hormone replacement therapy

 Medication to help strengthen the urethra

 Medication to help relax the bladder

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 2.Surgical
 Burch repair

 Marshall-marchetti-krantz repair

 Sling

 Needle suspension

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  Evaluation
1. History of symptoms
Pelvic pain, with/without sitting, urinary
frequency, constipation, dyspareunia,
bowel/bladder incontinence, history of trauma
including tailbone injury/fall
2. Inspection

3. Palpation

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 4.Examination

 Muscle testing
 EMG
 Postural examination

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  Relieve symptoms
 Improve pelvic support
 Improve strength
 Prevent further damage
 Improve bladder control
 Provide adequate ergonomic advise

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  Pelvic floor musculature re-education
 Kegel’s exercises
 Education
 Biofeedback and
 Electrical stimulation

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  Pelvic floor muscles are seventy percent slow-twitch
muscle fibers, which assist in muscle endurance with
generation of slow and sustained contractions.
 These muscles are designed to have a less intense
contraction, whereas the other thirty percent, which are
fast twitch, are designed for quick and forceful
contraction.
 Pelvic floor training is progressive resistive exercises
for the pelvic floor that are often titled Kegel exercises.

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  Kegel exercises are performed to strengthen the
muscles of the pelvic floor to help increase support of
the bladder and the urethra. They also can be used
postpartum to facilitate circulation to the perineum,
which promotes faster healing and increases pelvic
floor muscle tone.
 Have the woman contract the muscles in the
perineum/pelvic floor as if she is trying to prevent
passage of intestinal gas.
 She should feel the muscles draw upward and inward.

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  She should avoid straining or bearing-down
motions while performing the contractions.
(This can be avoided by exhaling gently
with an open mouth as she contracts the
muscles.)
 Contractions should be intense, but should
not involve abdomen, thighs, or buttocks.
 The woman should be able to hold this
contraction for 5 to 10 seconds, but may
need to work up to that.
 Kegels should be performed at least 10
times, 3 times a day, or from 30 to 80 times a
day.
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  Biofeedback is used to detect and amplify
internal physiological events and conditions
using a monitoring instrument.
 This training helps to develop conscious
control over these body processes.
 The objectives are to assist patients in gaining
greater awareness and voluntary control over
muscular control and contraction.

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  This allows for a refined control of pelvic
floor musculature for functional training.
 This technique uses a color video screen
connected to a computerized unit which
monitors different channels using
intravaginal probe or surface electrodes
depending on the muscles being selected

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  Electrical stimulation is used to inhibit the
micturition reflex and contract pelvic floor
muscles.
 Using a vaginal or anal probe, the electrical
stimulation produces a contraction of the
levator ani muscle.
 Electrical stimulation is also used based on the
theory that low-level electrical currents might
re-innervate the pelvic floor and change the
ratio of slow-to-fast-twitch muscle fibers.

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  Electrostimulation is used in treatment of stress
incontinence, enhancing the periurethral
sphincter and urge incontinence, inhibiting the
overactive detruser muscle.

 There are no side-effects except some

discomfort but it is contraindicated for
pregnancy, vaginal infection, retention and
demand pacemaker.
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  The patient keeps a voiding diary of all
episodes of urination and leaking,
 The patient uses this timetable to plan when
to empty the bladder to avoid accidental
leakage.
 Biofeedback and Kegel exercise help the
patient resist the sensation of urgency,
postpone urination, and urinate according
to the timetable.
 Such measures involve the imposition of a
regime of micturition by the clock with
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  Education is an important aspect of treatment,
especially education on positions of irritation
and management of pain.
 Education plays an important role during
exercise and discussion of sexual intercourse
with gravity assisted positions.
 Supine with a pillow or wedge support under
the pelvis can be useful position for rest and
also for pelvic floor exercise performance

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  Education is also important to help the patient
understand why maintaining an ideal body
weight limits the pressure the abdominal content
places on the pelvic floor.
 Patients also be instructed to squeeze or perform a
Kegel contraction when they are lifting or straining.
 Discussing bowel habits where the patient does not
strain using the pelvic floor when having a bowel
movement is an important component of bowel
movement retraining.
 Women should also be advised on correct posture to
aid in preventing strain on the pelvic floor muscles.
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 WHAT TO DO?????
✓ weight loss

✓ smoking cessation

✓ treatment of constipation to decrease intra-abdominal

pressure
✓ adequate hydration

✓ increased fiber intake

✓ developing regular bowel habits

✓ regular exercise

✓ Education for the use of tight undergarments to help

support and relieve symptoms of the prolapse.
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 AVOID……
 straining/constipation

 heavy lifting, pushing/pulling, bending

 smoking (to reduce coughing)

 high impact sports (e.g. jogging, sit-ups, horse-riding,

high impact aerobics)
 heavy resistance training

 intense core or abdominal exercises

 becoming overweight

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THANK YOU