Pelvis Disorers Theoritical

Physical Therapy for Pelvis disorders in Women
Editors
Prof. Dr. Abeer M. ElDeeb, PT PhD

Professor of Physical Therapy for Women’s Health,
Faculty of Physical Therapy, Cairo University
Dr. Dina M. Mohamed, PT PhD
Lecturer of Physical Therapy for Women’s Health,
Revised By
Prof. Dr. Amel M. Yousef, PT PhD
Professor of Physical Therapy for Women’s Health,
Preface
This book is developed to provide a source of elaborated and explanatory materials

to highlight the role of physical therapy in the discipline of pelvis disorders.
In this version, there is a flow of chapters of pelvis disorders related to females

during her life phases. There is highlighting of physical therapy examination and
treatment that can be applied to these disorders.
Authors
Authors
Prof Dr. Salwa Moustafa El-Badry, PT PhD Prof Dr. Amel M. Youssef, PT PhD
Professor of Physical Therapy for Women’s Health Professor of Physical Therapy for Women’s Health
Faculty of Physical Therapy Faculty of Physical Therapy
Cairo University Cairo University
Prof Dr. Soheir M. El-kosery, PT PhD Prof Dr. Dalia M. Kamel, PT PhD
Prof Dr. Azza B Nashed, PT PhD Prof Dr. Mohamed Awad, PT PhD
Prof Dr. Abeer M. ElDeeb, PT PhD Ass Prof. Afaf M. Bolta, PT PhD
Professor of Physical Therapy for Women’s Health Ass Professor of Physical Therapy for Women’s Health
Dr. Elham S. Hassan, PT PhD Dr. Sara M. Ahmed, PT PhD

Lecturer of Physical Therapy for Women’s Health Lecturer of Physical Therapy for Women’s Health
Dr. Reham E. Hamoda, PT PhD Dr. Dina M. Mohamed, PT PhD

Dr. Mai M. Shehata Dr. Manal A. El-Shafei

Dr. Mahitab M. Yosri, PT PhD Dr. Shreen R Aboelmagd

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CONTENT
Anatomy of female pelvis …………………………………………………… 4
Anatomy of female genital tract……………………………………………… 10
Physical therapy for symphysis pubis dysfunction…………………………... 24
Physical therapy for pelvic girdle pain………………………………………. 34
Physical therapy for Low back pain and coccydenia………………………… 50
Physical therapy for stress urinary incontinence…………………………….. 66
Physical therapy for Overactive bladder…………………………………….. 100
Physical therapy for fecal disorders…………………………………………. 111
Physical therapy for genital prolapse………………………………………… 125
Physical therapy for retroversion retroflexion of the uterus…………………. 136
Physical therapy for sexual disorders………………………………………… 147
Physical therapy for Infertility part I…………………………………………. 157
Physical therapy for Infertility part II………………………………………... 178
Physical therapy for dysmenorrhea…………………………………………... 187
Anatomy of Female Pelvis

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Dr. Mahitab M. Yosri, PT PhD
The pelvic girdle represents a ring-like bony structure that connects the axial
skeleton to the lower extremities. The pelvis contains and protects the important
abdominopelvic contents, supports the trunk, provides muscular and ligamentum
attachments, and constitutes the bony part in the mechanism of weight transfer to
the lower limbs during walking, and to the ischial tuberosities while sitting.
Structure of the Pelvic Girdle
The bony pelvis comprises the two hip/ innominate bones, the sacrum, and the
coccyx, forming four articulations within the pelvis (Fig. 1-1):
• Two sacroiliac joints: between the ilium, and the sacrum

• Sacrococcygeal symphysis: between the sacrum and the coccyx.
• Pubic symphysis: between the bodies of pubis of the two hip bones.
Fig.1-1. The pelvic girdle formed by the hip bones, sacrum, and coccyx.
The bony pelvis allows the pelvic region to be divided into:
Greater pelvis (false pelvis): It has little obstetric relevance, located superiorly,
and provides support to the lower abdominal viscera (Fig. 1-2).
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Lesser pelvis (true pelvis): It is located inferiorly and contains the pelvic cavity
and viscera.
The pelvic inlet: It is the junction between the greater and lesser pelvis. Its outer
bony edge is the pelvic brim. The boundaries of the inlet are the sacral promontory
posteriorly, iliopectineal line laterally, and symphysis pubis anteriorly. Its longest
dimension is side-to -side diameter (Fig. 1-3).
The pelvic outlet: It is located at the end of lesser pelvis, at the beginning of the
pelvic walls. It is defined by the tip of coccyx posteriorly, ischial spines and
sacrotuberous ligaments laterally, and the pubic arch anteriorly. Its longest
dimension is anteroposterior diameter (Fig. 1-4).
N.B: The angle beneath the pubic arch is known as the sub-pubic angle and is
greater in females.
Fig. 1-2. The greater and lesser pelvis.
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Fig. 1-3. The pelvic inlet. Fig.1- 4. The borders of the pelvic outlet.
Most women have a gynecoid pelvis, compared to the male android pelvis. Other
variations include anthropoid (heart-shaped) and platypelloid (flat). The gynecoid
pelvis is structured to aid in the labor process by creating greater pelvic outlet as it
has a wider and broader structure, oval- shaped inlet, less prominent ischial spines,
greater sub-pubic angle, more curved sacrum, and less pronounced sacral
promontory (Fig. 1-5).
Fig. (1- 5): Gynecoid pelvis vs the android pelvis.
Diameters of the Pelvis
The lesser pelvis is the bony passage the fetus must pass through during labor. So,
to detect the mother’s childbearing capacity by detecting the narrowest fixed
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distance the fetus needs to convey, the diameter of this passage needs to be
identified either radiographically or by a pelvic examination (Fig. 1-6).
Obstetric conjugate (true conjugate): It is the minimum antero-posterior

diameter of the pelvic inlet measured by the distance between the sacral
promontory and the mid symphysis pubis (where the pubic bone is thickest).
Diagonal Conjugate: It is an alternative conjugate measured from the inferior

border of the symphysis pubis to the sacral promontory and can be manually
assessed through the vagina.
Fig. 1-6. Assessment of the female pelvis, via the diagonal conjugate.
Ligaments of the Pelvic Girdle
The bony pelvis is held together with the support of three of the strongest
vertebropelvic ligaments. These ligaments, along with others, present significant
structural support in and around the pelvis. Of these ligaments are iliolumbar,
sacroiliac, sacrospinous, sacrotuberous, sacrococcygeal, pubic symphysis, and
endopelvic fascia ligaments (Fig. 1-7).
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Iliolumbar ligament: They are a thick and strong connective tissue fibrous bands
extending from the tip of the 5th lumbar vertebra transverse process to the posterior
part of the inner lip of the iliac crest. They stabilize and strengthen the lumbosacral
joint and upper sacrum. The iliolumbar ligaments also restrict the rotational
movement at the lumbosacral joint.
Sacroiliac ligament: It is a connective tissue band connecting the anterior surface

of the lateral part of the sacrum to the ilium. The posterior sacroiliac ligament is
exceptionally tough and is situated in a deep depression between
the sacrum and hindmost ilium, connecting the posterior sacral surface to the ilium.
Sacrotuberous ligament: It is a fan-shaped connective tissue fibrous band that

runs from the sacrum and the upper coccyx to the ischial tuberosity.
Sacrospinous ligament: It is a triangular connective tissue band attaching the

ischial spine to the lateral side of the sacrum and coccyx. Sacrospinous ligament
divides the greater sciatic notch into the greater sciatic and the lesser sciatic
foramen.
Fig.1-7. Pelvic ligaments, posterior sacroiliac ligament,

sacrospinous ligament, sacrotuberous ligament.
8
References
- Chaudhry SR, Imonugo O, Chaudhry K. Anatomy, Abdomen and Pelvis,

Ligaments. [Updated 2021 Jan 21]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK493215/
- Chaudhry SR, Imonugo O, Chaudhry K. StatPearls
[Internet]. StatPearls Publishing; Treasure Island (FL): Jan 21, 2021.
Anatomy, Abdomen and Pelvis, Ligaments.
- Gatt A, Agarwal S, Zito PM. StatPearls [Internet]. StatPearls Publishing;
Treasure Island (FL): Aug 15, 2020. Anatomy, Fascia Layers.
- Netter, F. (2014). Atlas of Human Anatomy. 6th ed. Philadelphia, PA:
Elsevier: Saunders, pp.157-158, 160, 161, 167, 332-334, 477-478.
- Some figures adapted from google images
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Anatomy of Female Reproductive System
Dr. Reham E. Hamoda, PT PhD
Female reproductive system

The female sex organs consist of both internal and external genitalia. Together they
comprise the female reproductive system, supporting sexual and reproductive
activities. The external genital organs, or vulva, are held by the female perineum.
These are the mons pubis, labia majora and minora, clitoris, vestibule, vestibular
bulb, and glands. The vagina, uterus, ovaries and uterine tubes compose the internal
genital organs.
Female reproductive organs undergo substantial structural and functional changes
every month. These changes are not only there to make women’s lives miserable,
but they also have a crucial function in the initiation of pregnancy. If pregnancy does
not occur, the proliferated endometrial lining breaks down and sheds, passing
through the vagina as menstrual blood. These activities occur under the influence of
hormones secreted by the female sex organs (ovaries), as determined by
the endocrine system. The female sex hormones also have a major role in sexual
maturation.
I- The External Genitalia:
• Mons Pubis: It is a mass of subcutaneous adipose tissue located anterior to
the pubic symphysis. The skin overlying the mons pubis is covered with a
triangular patch of pubic hair.
• Labia Majora: The labia majora (“large lips”) encloses and protects the
other external reproductive organs. During puberty, hair growth occurs on
the skin of the labia majora, which also contains sweat and oil-secreting
glands.
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• Labia Minora: The labia minora (“small lips”) can have a variety of sizes
and shapes. They lie just inside the labia majora, and surround the openings
to the vagina (the canal that joins the lower part of the uterus to the outside
of the body) and urethra (the tube that carries urine from the bladder to the
outside of the body). This skin is very delicate and can become easily
irritated and swollen.
• Vestibule: It is the space within the two the labia minora.
• Bartholin’s gland (Greater vestibular gland): These glands are located
next to the vaginal opening on each side and produce a fluid (mucus)
secretion.
• Clitoris: The two labia minora meet at the clitoris, a small, sensitive
protrusion that is comparable to the penis in males. The clitoris is covered by
a fold of skin, called the prepuce, which is similar to the foreskin at the end
of the penis. Like the penis, the clitoris is very sensitive to stimulation and
can become erect
• Hymen: Thin vascular membrane separating vaginal orifice from vestibule
(Fig. 2-1).
Fig. (2-1): External genital organ.
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Blood supply and innervation
The external genitalia are supplied by the pudendal arteries (internal, external),
which are branches of the internal iliac and femoral arteries, respectively. Venous
drainage is mediated by the internal and external pudendal veins.
The anterior aspect of the vulva receives sensory innervation from the ilioinguinal
nerve and genitofemoral nerve. The posterior aspect is supplied by the pudendal
nerve and the posterior cutaneous nerve of the thigh. The bulb of the vestibule and
the clitoris receive parasympathetic innervation from the uterovaginal nerve plexus.
Lymph from the external genitalia is drained by the superficial and deep inguinal
lymph nodes, or directly into the internal iliac lymph nodes.
II- The internal genital organs:
1- Vagina:
The vagina is the outermost internal female sex organ. It extends from the uterus to
the vulva (external genitalia). Functionally, it facilitates menstruation, sexual
intercourse and childbirth. The vagina is located posterior to the urinary bladder and
urethra, and anterior to the rectum (Fig. 2-2).
The upper end of the vagina is attached to the cervix of the uterus. These structures
form a pouch (vaginal fornix), which has anterior, posterior, and lateral parts. The
lower end of the vagina (vaginal orifice) opens into the vaginal vestibule just behind
the urethral orifice. The vaginal orifice may be partially covered with a membrane
called hymen.
The vagina is supplied by branches of the internal iliac artery; uterine, vaginal,
and internal pudendal arteries. Venous drainage of the vagina is provided by the
vaginal veins, which flow into the internal iliac veins. Nervous supply is derived
from the:
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• Inferior hypogastric plexus via the uterovaginal plexus -
the sympathetic and parasympathetic fibers are conveyed by the thoracolumbar
(T12-L1) and pelvic splanchnic nerves (S2-S4), respectively.
• Pudendal nerve via the deep perineal nerve.
• Lymph is drained from the vagina into the iliac and superficial inguinal lymph
nodes.
Fig. (2-2): Vagina.

2-Uterus:
It is a hollow muscular organ located deep within the pelvic cavity. Anterior to the
rectum and posterosuperior to the urinary bladder, the uterus normally sits in a
position of anteversion and anteflexion. The endometrial lining of the uterus
proliferates each month in preparation for embryo implantation. If fertilization
occurs, the uterus acts to house the growing fetus and its placenta. If pregnancy does
not occur, the endometrial lining is shed during menstruation.
The uterus is divided into three parts:
• Body (corpus): It is the main part of the uterus, which is connected to the uterine
(fallopian) tubes via the uterine horns. The body has a base (fundus) and an
internal chamber (uterine cavity).
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• Isthmus: It is the constricted part of the uterus, which is located between the
body and the cervix.
• Cervix:
It is the inferior portion of the uterus. It consists of two parts (supravaginal,
vaginal), two openings (internal os, external os), and a cervical canal (Fig. 2-3).
The uterus is partially covered by peritoneum. As it reflects from the uterus to the
rectum and urinary bladder, two folds are formed: the rectouterine pouch (of
Douglas) and the vesicouterine pouch, respectively. Several peritoneal
ligaments support the uterus and hold it in place, which are broad ligament,
round ligament, cardinal ligament, uterosacral ligament, and pubocervical
ligament.
The uterus is supplied mainly by the uterine artery, which arises from the internal
iliac artery. The superior branch of the uterine artery supplies the body and fundus,
while the inferior branch supplies the cervix. The venous blood of the uterus is
drained via the uterine venous plexus into the internal iliac vein.
The uterus receives innervation from the inferior hypogastric plexus via the
uterovaginal nervous plexus, like the vagina. Lymphatic drainage of the uterus is
into the lumbar, superficial inguinal, iliac (internal, external), and sacral lymph
nodes.
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Fig. (2-3). Uterus
3- Fallopian tubes:
The uterine (fallopian) tubes are bilateral muscular organs that extend from
the uterine horns to the superior poles of the ovaries. The fallopian tubes represent
the usual site for ovum fertilization. They also transport the resulting zygote into the
uterus for implantation.
The uterine tubes are intraperitoneal organs, covered completely by a part of the
broad ligament of the uterus called the mesosalpinx. They consist of four main
parts:
• Infundibulum: It is the distal part of the uterine tube that opens into the
peritoneal cavity via the abdominal ostium. The infundibulum contains finger-
like projections called fimbriae, which extend over the medial surface of the
ovaries.
• Ampulla: It is the longest and widest part of the uterine tube. It is the most
common site of fertilization.
• Isthmus: It is the narrowest part of the uterine tube.
• Intramural (uterine) part: It communicates directly with the uterine cavity
via the uterine ostium (Fig. 2-4).
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The uterine tube receives arterial supply from the uterine and ovarian arteries. The
former is a branch of the internal iliac artery, and the latter arises from the
abdominal aorta. Venous drainage of the uterine tubes is mediated by the tubal
veins. These drain into the uterine and pampiniform venous plexuses.
The uterine tube receives sympathetic innervation from the superior hypogastric
plexus (T10-L2) via the hypogastric nerve. Parasympathetic innervation stems from
the pelvic splanchnic nerves and the vagus nerve. Lymph is drained from the uterine
tubes to the para-aortic, internal iliac and inguinal nodes.
4- Ovaries:
The ovaries are bilateral female gonads and the equivalent of the male testes. They
release the ovum (egg) for the purpose of fertilization. In addition, they act
as endocrine glands, secreting various hormones necessary for fertility,
menstruation, and sexual maturation of the female (Fig. 2-4).
Each ovary is in the ovarian fossa of the true pelvis, adjacent to the uterus and below
the fallopian tubes. The ovary contains four surfaces (anterior, posterior, medial,
lateral) and two poles (superior, inferior). It is held in its normal position by several
paired ligaments: suspensory ligament of the ovary, proper ovarian ligaments
(ligament of ovary), and mesovarium.
Ovaries receive arterial supply from the ovarian arteries, which arise from the
abdominal aorta. These blood vessels reach the gonads by traveling within the
suspensory ligaments.
Venous blood of the ovaries is drained by the pampiniform plexus. These veins later
coalesce and form the ovarian veins. The right ovarian vein drains into the inferior
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vena cava, whereas the left ovarian vein flows into the left renal vein. The ovaries
are innervated by the ovarian nervous plexus, which receives fibers from the aortic,
renal, and hypogastric (superior, inferior) plexuses. Sympathetic fibers are derived
from the lesser splanchnic nerves (T10-T11). Parasympathetic innervation arises
from the pelvic splanchnic nerves (S2-S4). Lumbar lymph nodes are responsible for
lymphatic drainage of the ovaries.
Fig. (2-4): Ovaries and fallopian tubes.
Levator ani muscle:

The levator ani is a broad muscular sheet located in the pelvis. Together with
the coccygeus muscle and their associated fascia, it forms the pelvic diaphragm. The
levator ani is collection of three muscles: puborectalis (puboanalis), pubococcygeus,
and iliococcygeus.
The function of the levator ani muscle is crucial, in that it stabilizes the abdominal
and pelvic organs. It literally stops the organs from falling straight out of the pelvis
and abdomen.
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Origins and insertions
The levator ani is formed of the following three muscles:
• Puborectalis muscle: It originates lateral from the symphysis on both sides and
encircles the rectum (anorectal junction) which causes a ventral bend between
the rectum and anal canal. Partly it is interwoven with the external anal sphincter.
Also known as the puboanalis muscle.
• Pubococcygeus muscle: It runs from the pubic bone (lateral of the origin of the
puborectalis muscle) to the tendinous center of the perineum, anococcygeal body
and tailbone. In men, medial muscle fibers are partly connected to the prostate.
• Iliococcygeus muscle: It extends more laterally from the fascia of obturator internus
muscle to the tailbone. As a whole the levator ani builds a V-shaped structure. Both
levator arms limit a triangle opening (levator hiatus), which is divided by prerectal
fibers into the urogenital hiatus (ventral) and anal hiatus (dorsal). The urogenital
hiatus is the pathway for the urethra and, in women, the vagina. The rectum runs
through the anal hiatus (Fig.2-5).
Innervation
It is primarily supplied by nerve to levator ani (S4). To a small degree the pudendal
nerve (S2-S4) contributes to its innervation as well.
Blood supply
Blood supply to levator ani comes from the branches of the inferior gluteal, inferior
vesical and pudendal arteries.
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Function
The levator ani stabilizes the abdominal and pelvic organs and controls the opening
and closing of the levator hiatus on the other hand.
While in quiescent state, the urethra and the rectum are mechanically closed at the
levator hiatus. The muscle relaxes at the beginning of urination and defecation. By
this means, the levator ani muscle plays a crucial role in
the preservation of urinary and bowel continence.
Fig. (2-5): Levator ani muscle
Perineal muscle
It is composed of:
Superficial transverse perinei:
It courses transversely across the superficial perineal space with the anus posterior to
it. It has attachments on the anteromedial surface of the ischial tuberosity and
perineal body.
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• Deep transverse perinei:
It has several attachments in the deep perineal pouch. As it spans the space in a
transverse manner (albeit, incompletely), the muscle attaches to the perineal body
posteriorly and the ischiopubic rami laterally. The muscle has an anterior
deficiency.
• Bulbospongiosus:
It differs between males and females. In the latter, the muscle is superficial to the
bulbs of the vestibule and the associated glands. They subsequently travel lateral to
the vagina and insert into the corpora cavernosa of the clitoris along with the body of
the glans clitoris itself.
However, in the former, the muscle starts as identical halves and fibers decussate in
the perineal body and are attached to transverse superficial perinei muscles. The
muscle assists with voiding the urethra after micturition and in expelling semen or
vaginal secretions during the ejaculatory process.
• Ischiocavernosus:
It is found in both males and females, although it is significantly larger in males. It is
attached medially to the ischial tuberosity and ischial rami. The aponeurotic ending
of the muscle merges into the crus of the penis (clitoris). The primary action in
males is to aid in stabilizing the erect penis; and in females it assists in promoting
clitoral erection (Fig. 2-6).
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Fig. (2-6): Perineal muscle.
Uterine ligaments
1- Cervical ligament (true):
Anteriorly: Pubocervial ligament.
The two pubocervical ligament extend from the anterior aspect of the cervix and
upper vagina to the posterior aspect of the pubic bones.
Laterally: Transverse cervical ligament (Cardinal, Machenrodt’s ligament).
It runs from lateral part of cervix and upper part of vagina to lateral pelvic wall
Posteriorly: Uterosacral ligament.
It runs from back of cervix to middle sacral piece (Fig. 2-7).
2- Corporal ligament (false):
Broad ligament: It runs from Lateral uterine border to lateral wall of the pelvis.
Round ligament: It runs from utrine cornu to the labia majora.
Ovarian ligament: It runs from utrine cornu to the ovaries.
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Fig. (2-7): Cervical ligament.
22
Reference:
- Mahadevan, Harold Ellis, Vishy (2013). Clinical anatomy applied
anatomy for students and junior doctors (13th ed.). Chichester, West Sussex,
UK: Wiley-Blackwell.The American College of Obstetricians and
Gynecologists. Accessed 2/5/2019.Your Changing Body: Puberty in Girls
(Especially for Teens)
- Drake, R. L., Vogl, A. W., & Mitchell, A. W. M. (2015). Gray’s Anatomy
for Students (3rd ed.). Philadelphia, PA: Churchill Livingstone.
- Moore, K. L., Dalley, A. F., & Agur, A. M. R. (2014). Clinically Oriented
Anatomy (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
- R.Tunn/E. Hanzal/ D. Perucchini: Urogynäkologie in Praxis und Klinik,
2.Auflage, De Gruyter (2009), S.29-36
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Physical Therapy for Symphysis Pubis Dysfunction
Dr. Mai M. Shehata, PT PhD
Anatomy of symphysis pubis

Pubic symphysis is a fibro-cartilaginous joint between the two pubic bones. The
joint keeps the two bones of the pelvis together and steady during activity. In
cooperation with the sacroiliac joints, the symphysis forms a stable pelvic ring.
This ring allows only small mobility.
The pubic symphysis is covered by hyaline cartilage and united by a disc
of fibrocartilage. The fibrocartilage disc is then reinforced by ligaments and
tendons from the rectus abdominis, adductor longus and gracilis. More specifically,
it is located above any external genitalia and in front of the bladder.
Ligaments of pubic symphysis:

Anteriorly: the anterior pubic ligament-blends with periosteum laterally as well
as the inter-pubic disc.
Posteriorly: the posterior pubic ligament- blends with periosteum of both pubic
bodies posteriorly
Superiorly: the superior pubic ligament connects the bones above- runs from
pubic crest to pubic crest
Inferiorly: the arcuate pubic ligament connects the lower borders - runs from
inferior pubic ramus to inferior pubic ramus
N.B: The main ligaments of pubic symphysis are superior pubic ligaments and
arcuate pubic ligament.
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Further support is provided by an aponeurosis created by the tendons of the rectus
abdominis above and the gracilis and adductor longus below giving anterior and
inferior support where they merge with the arcuate ligament
Definition:
Symphysis pubis dysfunction (SPD) is a common musculoskeletal disorder, which
affects women during pregnancy and the postpartum period. It can have a
significant impact on quality of life, which can lead to complications as severe
anxiety and depression.
SPD has been described as a collection of signs and symptoms of discomfort and
pain in the pelvic area, including pelvic pain radiating to the upper thighs and
perineum.
Etiology and pathophysiology:

● The hormonal influence of pregnancy on ligaments: relaxin and
progesterone hormones peaks during late pregnancy cause softening of
connective tissue in preparation for labor. It affects all joints of the body as it
decreases ligaments tensile strength and increases the mobility predisposing
to joint injury especially in weight bearing joints of back and pelvis. It
affects the biomechanics of the pelvic girdle and the vertebral column
leading to pain.
● Other factors contribute to symphysis pubis dysfunction include physically

strenuous work during pregnancy, weight gain, macrosomia, multiparity,
poor posture, and lack of exercise and cephalopelvic disproportion.
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● Labor causes excessive movement of the pubic symphysis, either anterior or
lateral, as well as associated pain, possibly because of a misalignment of the
pelvis most associated with pregnancy and childbirth as fetal head exerting
pressure on the pelvic ligaments weakened or relaxed by the pregnancy
hormones. This excessive movement occurs especially during complicated
deliveries such as contracted pelvis, shoulder dystocia, and a long second
stage of labor.
Diagnosis of symphysis pubis dysfunction

The diagnosis is often made symptomatically
A) Symptoms
- Burning or shooting pain, which may radiate to lower abdomen, groin,
perineum, and upper thigh.
- Onset of pain may develop in the first trimester, second or third trimester. It
may occur in labor or in the puerperium.
- Symptoms commonly disappear shortly after delivery. However, some
women can suffer for several months afterwards and in a few cases, pain can
persist for much longer.
- Pain decreased with rest.
- Pain increased with:
o Walking.
o Ascending and descending stairs.
o Rising from chair.
o Bending forward.
o Weight bearing activities
o Standing on one leg.
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o Turning in bed.
- Intensity: high versus low level. is measured on a horizontal 100mm visual
analogue scale (VAS) with the endpoints “no pain” on the left side and “worst
pain” on the right side.
-The start of pain may be gradual and on a visual analogue scale is most
commonly described as scoring 7 out of 10 for intensity. It is usually relieved by
rest.
2)- Physical examination:
A) By observation:
• A waddling gait with short steps, this can be the result of a tendency of the
gluteus medius, which loses its function as abductor.
• Hearing a clicking sound when patient walking.
• Suprapubic edema and swelling.
B) By palpation:
• Palpation of the entire anterior surface of the symphysis pubis, with the
woman supine, typically elicits pain that persists for more than five seconds
after removal of the examiner’s hand.
• Palpable gap in the pubic symphysis.
C) Tests:
• Active straight leg raising (ASLR) may be limited or impossible to perform,
yielding pain as well as palpable displacement of the symphysis pubis joint.
This is less painful if the pelvis is stabilized by manual compression and
ASLR test then becomes easier to perform. Bilateral trochanteric
compression may also increase pain.
• Trendelenburg test: Positive Trendelenburg sign (on one or both sides):
Patients are unable to stand on one leg “stance leg”. They are unable to
27
maintain their pelvis in the horizontal plane and that causes pelvis drops on
the side opposite to the stance leg.
D) Range of motion:
• Range of motion can be limited by pain, particularly during lateral rotation
and during abduction.
3) Imaging studies:
Imaging is the only way to confirm diastasis of the symphysis pubis. The non-
pregnant woman’s symphysis pubis gap is 4–5 mm and it is normal for it to widen
2–3 mm, without discomfort. The average symphysis pubis gap during the last two
months of pregnancy is 7.7 mm; 24% of women have gap greater than 9mm.
• X-ray:
To demonstrate the instability of the joint, the women are required to stand
in the ‘’flamingo’’ position, (standing on one leg and the other leg bent). A
vertical displacement of more than 1 cm is an indicator of symphysis
instability. A displacement of more than 2 cm usually indicates involvement
of sacroiliac joints.
• MRI and CT: Images will show degrees of soft tissues injury.
• Transvaginal or trans perineal ultrasound: It has been used to confirm

the separation of the symphysis pubis in pregnancy without the concerns of
fetal radiation exposure.
Management
A- Management during pregnancy:
1-Advice
28
● Avoid activities, which cause discomfort and increase pain.
● Rest more frequently.
● Ice cube can be rubbed on the symphysis pubis for 20–30 seconds.
● Elbow crutches, a walking frame or wheelchair may have to be used
when mobility is compromised in extremely painful cases.
2. Pelvic belts:
To increase the stability of the pelvis. Both elastic and non-elastic belts are
used.
3. Exercises:
- Stabilizing exercises aims at improving stability through forced closure of
the pelvis. There are significant improvements in pain, functional status, and
physical health after two years of stabilizing exercises.
- Pelvic floor exercises from early pregnancy are thought to reduce the risk of
developing symphysis pubis dysfunction.
- Deep abdominal exercises increase core stability, preventing the onset of
pelvic and lower back pain. These exercises and others such as Pilates may
prevent complications of symphysis pubis dysfunction if performed before
or early pregnancy.
- Relaxation exercises.
B) Management during labor:

A- normal vaginal delivery:
Attention should be given to the prevention of extreme pain during delivery and
even more to the duration of the labor.
The following measurements should be noted:
29
Pain free range of hip abduction in sitting, supine, and side lying.
Pain free range of hip flexion in sitting, supine, and side lying.
Positions of comfort, bed mobility and gait pattern should be recorded.
1. First stage of labor:
Induction for labor is offered to those who are in extreme pain or who are
severely limited in their activities.
Avoid asymmetric posture that compromise symphysis pubis pain.
A birth pool is recommended.
2. Second stage of labor:
It is important to pay attention to:
- Women should assume a comfortable birthing position. Women with
symphysis pubis dysfunction should give birth in an upright and forward
leaning position, with knees slightly open or in an assisted squatting (Fig.3).
- During labor and delivery leg abduction should be kept to a minimum and
never exceeds the maximal comfort zone.
- Forceps should be avoided in the delivery room if possible because they can
strain ligaments further.
Fig. (3) Positions of delivery

B- Cesarean section: It is indicated for women with severely disability due to
pelvic girdle pain.
30
It is important to pay attention to:
- During catheterization of the bladder.
Don’t abduct or laterally rotate the hips further the pain free range of hip
abduction.
- With epidural anesthesia:
Side-lying with the leg supported as long as the top leg is not too widely abducted.
c) Postpartum rehabilitation:
In the early post-partum phase:
1. Rest in bed for 24-48 hours until discomfort subsides. Thromboembolism is a
risk of immobilization. Thromboembolism detergent stocking and heparin, along
with gradual mobilization and individualized physiotherapy treatment should be
instituted early.
2. Modalities:
a) Ice for 10-15 min. every 2 hours in the first 24 hours may relieve pain.
b) Warm baths may ease symptoms after 24 hours.
c) Transcutaneous electrical nerve stimulation or massage may also be of value.
d) Pulsed ultrasound may speed healing and absorption of edema.
e) Exercises: Static abdominal exercises before movement around the bed.
In the late post-partum phase after discharge:

1. Specific stabilization exercises.
2. Isometric adductor squeeze against fists, forearm, pillow, or ball in supine or
sitting.
3. Core/spinal stabilization exercise on the land or in the water.
31
4. Continuing pelvic floor exercises.
- Avoid provoking activities.
- If the pain becomes chronic pain leading to high disability with resistance to
physical interventions. Management of these women must be
multidisciplinary involving medical and psychological intervention.
32
References:
- Howell E. R. (2012). Pregnancy-related symphysis pubis dysfunction
management and postpartum rehabilitation: two case reports. The Journal of
the Canadian Chiropractic Association, 56(2), 102–111.
- Becker, I., Woodley, S. J., & Stringer, M. D. (2010). The adult human pubic
symphysis: a systematic review. Journal of anatomy, 217(5), 475–487.
- Jill Depledge, J. McNair, P, Smith, C and Maynard Williams, M:
Management of Symphysis Pubis Dysfunction During Pregnancy Using
Exercise and Pelvic Support Belts, Physical Therapy, Volume 85, Issue 12, 1
December 2005, Pages 1290–1300.
- Urraca-Gesto MA, Plaza-Manzano G, Ferragut-Garcías A, Pecos-Martín
D, Gallego-Izquierdo T, Romero-Franco N. Diastasis of Symphysis Pubis
and Labor: a Systematic Review. Journal of Rehabilitation Research and
Development, 2015, vol. 52, num. 6, p. 629-640. 2015.
- Herren C, Sobottke R, Dadgar A, Ringe MJ, Graf M, Keller K, Eysel P,
Mallmann P, Siewe J. Peripartum pubic symphysis separation–Current
strategies in diagnosis and therapy and presentation of two cases. Injury. 2015
Jun 1;46(6):1074-80.
- Some images adapted from google images.
33
Physical Therapy for Pelvic Girdle Pain
Prof. Dr. Abeer M. ElDeeb, PT PhD
Anatomy of sacroiliac joint:

It is the articulation between ilium and sacrum. Movement of sacroiliac joint is
small. It is about 2-4mm.
It is diarthrodial joint. Articular surfaces are ear shaped or C shaped containing
irregular ridges and depression. Concave sacral surface is covered by thick hyaline
cartilage and convex ilium surface is lined by fibrocartilage (Fig. 4-1).
Fig. (4-1): Sacroiliac joint

In the upper portion of the joint, the sacrum and ilium are not in contact but
connected with powerful posterior, inter-osseous and anterior ligaments, and the
anterior and lower half is a typical synovial joint with a hyaline cartilage.
Stability of the joint comes from structures of the joint and strong ligaments.
1-Anterior sacroiliac ligament is just thickening of anterior joint capsule.
2-Posterior sacroiliac ligament is divided into short and long ligament.
3-Inter-osseous sacroiliac ligaments are very strong ligament that pelvis fracture
before ligament tears. Long dorsal ligament runs in oblique and vertical direction.
34
Short dorsal ligament runs behind articular surface of ilium and sacrum to prevent
from opening or distracting.
4-Sacrotuberous ligament
5-Sacrospinous ligament
Function
1-It provides shock absorption of the spine. It allows transfer of weight between
upper body and legs. It allows transfer transverse rotation that takes place in the
lower extremity to be transmitted to the spine.
2-Self-locking mechanism “close back position” during push-off position of
walking.
Motions
1-Anterior innominate tilt of ilium on sacrum.
2-Posterior innominate tilt of ilium on sacrum.
3-Anterior innominate tilt on one side, while posterior tilt on the opposite. This
occurs during push-off phase of the gait.
4-Sacral flexion: motion of sacrum occurs with motion of ilium.
5-Sacral extension: motion of sacrum occurs with motion of ilium.
Pelvic girdle pain

Definition
According to European guidelines, pelvic girdle pain (PGP) is a specific form of
low back pain that can occur separately or concurrently with low back pain.
“Pelvic girdle pain (PGP) generally arises in relation to pregnancy, trauma or
reactive arthritis. Pain is experienced between the posterior iliac crest and the
gluteal fold, particularly in the vicinity of the sacroiliac joints. The pain may
35
radiate in the posterior thigh and can also occur in conjunction with/or separately
in the symphysis.
Incidence
The point prevalence of PGP during pregnancy is close to 20%. Most women
recover from PGP after delivery; however, it is a serious problem for those young
women for whom pain, and disability persist after delivery.
Women with PGP significantly are more afflicted than women with low back pain.
Furthermore, women with pain located in all three pelvic joints (the symphysis and
the two sacroiliac joints) are more disabled than other subgroups of pain locations
in the pelvis.
The etiology and pathogenesis

It is unclear and most likely multifactorial. Possible underlying causes include
hormonal and biomechanical aspects, stress on ligament structures, and inadequate
motor control.
The pelvis transfers load from the trunk to the legs and for the load to be
effectively transferred, and for the shear forces to be minimized across the joints;
the pelvis needs to be optimally stabilized.
Stability is obtained by ridges and grooves in the articular surfaces of the sacroiliac
joints (form closure) and additional compression forces (force closure), which are
generated by muscles, fascia, and ligaments.
The self-locking mechanism of the sacroiliac joints with the principles of form and
force closure, based on a theoretical model from anatomical and biomechanical
studies.
36
The evidence for the association between PGP and the hormone relaxin is low. The
movements that occur in the pelvic joints are traced. A larger motion of the
symphysis during pregnancy and puerperium in patients with PGP are more than in
those without PGP.
• Failure of the self-locking mechanism and load transfer through the pelvis
are suspected in patients with sacroiliac pain and asymmetric laxity of the
sacroiliac joints correlates with moderate to severe levels of symptoms in
subjects with postpartum PGP.
• An impaired load transfer may result in overload of the ligaments of the
pelvis. Both the sacrospinous ligament and superficial sacroiliac joint
structures such as the long dorsal sacroiliac ligament are a potential source
of pain in PGP and have a negative influence on muscle activity with
excessive muscle stabilization.
Both increased lumbar lordosis and a tendency for lumbar kyphosis is prevalent
during pregnancy. These frequent or sustained pain provoking postures might
influence the pelvic ligaments and in turn causes relevant symptoms.
PGP disorders are associated with an alteration in the strategy for lumbopelvic
stabilization with excessive and insufficient motor activation of the lumbopelvic
and surrounding musculature.
• Motor control of local muscles, such as the transverse abdominals is
affected.
• Also, a smaller levator hiatus is present in women with PGP at rest and
during voluntary and automatic contraction of the pelvic floor muscle,
indicating an increased muscle activity.
• There are lower trunk muscle endurance and hip extension strength.
• Difficulties in walking might be a consequence of impaired motor control.
37
• Positive changes in motor control are associated with relief of pain and
disability.
However, the knowledge about PGP and its underlying mechanisms is still limited
and hampers the ability to treat and help women with postpartum PGP in an
optimal manner.
Risk factors for PGP

1-Previous pelvic or lower back pain in and/or out of pregnancy
2-A history of trauma to the back or pelvis
3-Multiparity
4-Increased body mass index
5-Physically demanding work
6-Emotional distress
7-Smoking
Differential diagnosis of PGP in pregnancy

Orthopedic/musculoskeletal
• Osteitis pubis
• Rupture of the pubic symphysis
• Sciatica
• Lumbar disc prolapse
• Osteoarthritis
• Transient osteoporosis of pregnancy
• Lumbar canal stenosis
• Ankylosing spondylitis
• Cauda equine syndrome
• Bony tumor/malignancy
• Spondylolisthesis
• Osteonecrosis
38
Obstetric and gynecological
• Preterm labor
• Placental abruption
• Chorioamnionitis
• Round ligament pain
• Carneous degeneration of leiomyoma
Infective
• Urinary tract infection
• Osteomyelitis
Vascular
Femoral vein thrombosis
Examination
1-History
A thorough history, including an obstetric and pain history, is essential in assessing
a pregnant patient presenting with pelvic pain.
It is important to determine that the pain is mechanical in nature that is associated
with activity and eases with rest because pain that arises in the absence of
mechanical stimuli is unlikely to be PGP. Initial history will also identify ‘red
flags’ of possible serious pathology.
2-Red flags history points

• Pain in the absence of mechanical stimuli
• Unexplained weight loss
• Neurological symptoms: saddle paraesthesia, acute onset radicular pain with
associated numbness, weakness, or paralysis
• Incontinence or bladder and bowel dysfunction
• Significant trauma history such as a fall from height, heavy lifting)
• Vaginal bleeding/fluid loss
39
• Pyrexia of unknown origin
3-Examination
1-PGP is diagnosed based on the site of pain and the ability to reproduce the
pain using specific provocation tests.
2-Special tests
Active straight leg raising (ASLR)
• Patient lies supine with legs straight, and then raises one leg to 20 cm off the
bed. The degree of difficulty in performing this test is an indicator of
disability.
Modified Trendelenburg test:
• Patient stands on one leg and flexes the other leg to 90 degrees at hip and
knee. The test is positive if pain experienced at pubic symphysis.
Posterior pelvic pain provocation test (P4)
• Patient lies supine and hip flexed to 90 degrees. Downward pressure is

applied to the knee along the axis of the femur. The test is positive if pain is
elicited in the gluteal region.
“Faber” test (flexion abduction external rotation) or Patrick’s sign:
• Patient lies supine with hip flexed. Patient’s leg is then externally rotated
and abducted with ipsilateral heel resting on opposite knee. The test is
positive if it elicits pain in ipsilateral joints of the pelvis.
The palpation of the symphysis test and modified Trendelenburg’s test are the
most sensitive and specific for symphysis pubis pain.
3-The endurance capacity for standing, walking, and sitting is diminished.
Interpretation of the tests

According to the definition in the European guidelines, all criteria must be
fulfilled to diagnose pelvic girdle pain.
40
• Pain experienced between the posterior iliac crest and the gluteal fold,
particularly in the vicinity of the sacroiliac joints in conjunction with/or
separately in the symphysis.
• Reports by the women of weight-bearing related pain and its duration in the
pelvic girdle.
• Diminished capacity to stand, walk and sit.
• Positive clinical diagnostic tests, which reproduced pain in the pelvic girdle.
No nerve root syndrome (Negative SLR test).
Investigations
Investigations are not an integral part of diagnosing PGP because the diagnosis is
clinical; however, investigations may be helpful if there is concern about more
complicated differential diagnoses. Imaging should be used judicially after a
thorough clinical assessment, especially as there are ongoing concerns regarding
the effects of ionizing radiation exposure on the fetus. Imaging does not aid in
assessing the severity of PGP and should only be used in rare cases.
Indications for imaging include, but are not limited to, persisting non-mechanical
pelvic pain, severe mechanical pain that is not responding to appropriate
management, an inability to weight-bear, clinical suspicion of sinister pathology or
presence of any red flags described above. Plain pelvic X-rays can assist in
measuring the degree of symphyseal separation and identifying cortical
abnormalities such as sclerosis and rarefaction if suspected.
Intervention
1-Exercise therapy (individual or in groups, home based, land or water based)
Exercise therapy includes
41
1. General physical fitness or aerobic exercise
2. Muscle strengthening,
3. Flexibility exercises
4. Stretching exercises.
5. Stabilizing exercises
N.B. Exercises are performed without provoking pain. Individualization of

exercise positions and dosage might easily be performed with sling suspension (see
all exercise description in the practical book).
Stabilizing exercises
• Exercises started with isolated low force co-contractions in Transversus
Abdominis and Multifidi in static postures. It includes pillow squeeze, Band
exercise, bridging exercise, pull up belly exercise, modified plank exercise,
wall slide exercise.
• Exercises in slings are also, used as an aid to prevent weight‐bearing pain
during exercise.
• These exercises are followed by increasingly more difficult challenges as the
patient's skills improved (see all exercise description in the practical book).
The effect of exercise therapy includes
It improves muscle strength, range of motion, coordination, motor control and
cardiovascular fitness, and decreases muscle tension.
2-Manual therapy (mobilization)
Joint mobilization is a common intervention used to restore normal joint motion
and involves hands on low velocity passive movements within or at the limit of
range of motion for the joint.
42
Direct mobilization techniques are applied to correct dysfunction:
1-Correction of left unilateral sacral flexion is performed in right side lying.
2-Correction of anteriorly rotated ilium in a side lying.
3-Self correction of posteriorly rotated ilium using a modified Thomas Test
position.
4-Direct mobilization of sacral torsion or rotation with the patient in forward
leaning seated position.
6-Bilateral contraction of the hip abductors against resistance of the hands in
seated position to encourage gentle shifting of the sacrum at the ilium. (All
techniques are described in the clinical book)
3-Acupuncture
-Women with PGP report a reduction of morning and evening pain and improved
functional outcomes with acupuncture.
-The aim with the stimulation is to activate both the segmental pain inhibitory
system, involving the so-called gate control mechanism and the central pain
inhibitory system, involving secretion of endogenous opioids.
-Ten classical acupuncture points (BL26,32,33,54,60, KI11, EX21, GB30, SP,

ST36) are selected individually in the same segments as the location of PGP after
diagnostic palpation to identify sensitive spots. Two acupuncture points on the
medial side of the leg and foot are selected in the same segment as the PGP and
extra-segmental points to the lumbosacral area are used to strengthen and lengthen
the effect of the central control systems.
43
4-Pelvic belts
Pelvic belts, as treatment for PGP, are thought to increase the stability of the
pelvis. The pelvic belt application increases sacroiliac motion around the sagittal
axis but decreases motion around the transverse axis, and relieves strain of the
sacroiliac joint ligaments, especially for the sacrospinous, sacrotuberous, and the
interosseous sacroiliac ligaments.
6-Analgesia
Pain control is the most important aspects of management to prevent the vicious
cycle of chronic pain and depressed mood. Regular analgesia in the form of
paracetamol and codeine-based preparations may be prescribed during pregnancy
with close monitoring of effectiveness and side effects. Non- steroidal anti-
inflammatory drugs (NSAIDS) should only be used after delivery.
7-Education is often used as a supplement to these interventions.

Patient education programs are designed to improve patients' understanding of
their PGP problems and how to handle them.
National Health and Medical Research Council (NHMRC) antenatal care guidelines –
Practical advice for minimizing pain
• Wearing low-heeled shoes
• Seeking advice from a physiotherapist regarding exercise and posture
• Reducing non-essential weight bearing activities (e.g climbing stairs,
standing/walking for long periods of time)
• Avoiding standing on one leg (e.g by sitting down to get dressed)
• Avoiding movements involving hip abduction (e.g getting in/out of cars,
baths, or squatting)
• Applying heat to painful areas
44
Referral
Referral to appropriate specialist services is indicated in the following:
1-The presence of any red flag symptoms.
2- Neurological deficits are not a normal feature of PGP.
3-Refractory pain that is not reduced or able to be managed using the methods
outlined in the management described above.
Prognosis and recurrence risk

The outcomes for women with PGP in pregnancy are good, with 93% of women
reporting symptomatic resolution within three months postpartum. However, PGP
frequently recurs in subsequent pregnancies, and increasing the interval between
pregnancies does not change the recurrence risk or severity of subsequent PGP.
In one study, 68% of multiparous women reported recurrence of PGP, and 70% of
these women reported PGP being worse in the subsequent pregnancy.
Management during delivery

Attention should be given to the prevention of extreme pain during delivery and
even more to the duration of the labor. The longer the duration of the labor, the
greater risk of being symptomatic at 18 months follow up.
The following measurements should be noted for women with high disability
scores in their obstetric chart.
• Range of movement of the lumbar spine (if necessary).
• Pain free range of hip abduction in sitting supine and side lying.
• Pain free range of hip flexion in sitting, supine and side lying.
• Positions of comfort, bed mobility and gait pattern should also be recorded.
45
Recommended positions of labor for PGP/LBP
Recent Cochrane reviews have found that women who utilize upright positions
during labor have a shorter duration of the first and second stage of labor,
experience less intervention, report less severe pain and report increased
satisfaction with their childbirth experience compared to a semi recumbent or
supine/lithotomy position. Increased blood loss during third stage is the only
disadvantage identified but this may be due to increased perineal edema associated
with upright positions.
First stage of labor
1-If there is disability with gait, the mother adopts upright position and restricts
unnecessary movement.
2-Avoid asymmetric posture that compromise sacroiliac joint.
3-Abirth pool or exercise ball is recommended (Fig. 4-2).
Fig. (4-2): An exercise ball

Second stage of labor
1-Upright and forward leaning
2–4-point kneeling
3-Assissted squatting (Fig 4-3).
46
Fig. (4-3): Positions of delivery
Mode of delivery
A-Normal vaginal delivery, there would be
• Spontaneous onset of labor. Induction for labor is occasionally offered to
those who are in extreme pain or who are severely limited in their activities.
B-Cesarean section (CS) is indicated for women with severe disability due to
PGP. Hip abduction and flexion are severely restricted, and a comfortable birthing
position cannot be maintained.
Management in the post-partum period

Women with moderate to severe PGP rest in bed for 24–48 hours until discomfort
subsides.
In the early post-partum phase:
1- Pain relief (first choice: paracetamol, second choice: NSAIDs).
2- Management of symptoms including adequate rest, ice to reduce
inflammation, pelvic supports for instability and muscle weakness, aids for
mobility and gait re-education, if necessary, family support and nursing staff
support to look after the new baby and mother.
3- The mother should be assisted in finding a comfortable position for feeding
such as side-lying or supported sitting.
47
In the later post-partum phase after discharge
If symptoms persist post-partum, out-patient physiotherapy should be resumed if
the woman is able to attend.
Individualized assessment and treatment are recommended, focusing on specific
stabilizing exercises as part of a multifactorial treatment for PGP postpartum.
All treatment that are applies during pregnancy can be used especially
stabilizing exercises.
N. B. See all descriptions of exercises in the practical book
Fig. (4-4): Stabilizing exercises using slings
48
References
- Robinson HS, Mengshoel AM, Bjelland EK, Vøllestad NK .Pelvic

girdle pain, clinical tests and disability in late pregnancy, Manual Therapy,
Volume 15, Issue 3, June 2010, Pages 280-285.
- Vermani E, Mittal R, Weeks A. Pelvic girdle pain and low
back pain in pregnancy: a review. Pain Pract. 2010 Jan-Feb;10(1):60-71.
- Walters C, West S, A Nippita T. Pelvic girdle pain in pregnancy. Aust J
Gen Pract. 2018 Jul;47(7):439-443.
- Almousa S, Lamprianidou E, Kitsoulis G. The effectiveness of stabilising
exercises in pelvic girdle pain during pregnancy and after delivery: A
systematic review. Physiother Res Int. 2018 Jan;23(1).
- Fagevik Olsén M, Elden H, Gutke A. Evaluation of self-
administered tests for pelvic girdle pain in pregnancy. BMC Musculoskelet
Disord. 2014 Apr 27;15:138.
49
Low Back Pain and Coccydenia
Dr. Elham S. Hassan, PT PhD
Low Back Pain (LBP) During Pregnancy

Pregnancy related low back pain is a common complaint that occurs in 60-70% of
pregnancies and can be defined as pain between the 12th rib and the gluteal folds
during the course of pregnancy, possibly radiating to the posterolateral thigh, to the
knee and calf.
Causes in the first trimester
• Hormonal changes during pregnancy can cause pain in the back.
• During the first trimester, levels of progesterone in the body increase
rapidly. High levels of this hormone relax the muscles and ligaments of the
pelvis and lower back, which can affect the stability and alignment of the
joints.
• Relaxin hormone increases 10-fold in concentration during pregnancy,
softening the collagen and causes ligamentous laxity and discomfort.
• The sacroiliac ligaments, ligaments that stabilize the spine and other
ligaments surround the pelvic girdle become loose. This causes instability
and brings on a potential strain in the pelvic girdle and low back area.
Causes in the second and third trimesters
1- Mechanical
During pregnancy, the enlarging gravid uterus changes the load and body
mechanics. It shifts the center of gravity forwards, increasing the stress on the
lower back.
50
Postural changes can be used to balance the anterior shift possibly causing an extra
lordosis. This increases the natural inward curvature of the spine, which increases
the mechanical strain on the lower back. It also puts an extra stress on the
intervertebral disc, possibly causing a decreased height an overall compression of
the spine.
2- Weight gain
Weight gain increases the amount of force placed across joints, changes the center
of gravity, and forces the patient into an anterior pelvic tilt.
The anterior displacement of the center of gravity will cause women to shift their
heads and upper body posteriorly over the pelvis, causing hyper lordosis of the
lumbar spine. This in turn, places additional stress on the intervertebral discs,
ligaments, and facet joints and can lead to joint inflammation.
3- Muscle separation (diastasis recti)

During pregnancy, the growing fetus pushes against the abdominal muscles,
causing them to stretch and, in some cases, separate abdominal muscles are
stretched and weakened, and the added weight can compress on the lumbosacral
plexus. This can increase a woman's risk of injuring her back or developing low-
back or pelvic pain.
Risk factors
a. LBP history.
b. Multiple abortions.
c. Smoking.
d. Pain during previous pregnancy.
e. Number of pregnancies.
f. History of hypermobility.
51
g. Periods of amenorrhea.
h. Increased physical workload.
i. High body mass index.
j. Lack of exercise/sedentary lifestyle.
Clinical Presentation
• Onset: tends to be during the 5th and 6th month of pregnancy, and the pain
is usually worse in the evening. About 67% of women experience pain at
night.
• Factors that aggravate the pain include standing, sitting, coughing, or
sneezing, walking, and straining during a bowel movement.
• Pregnancy-related LBP is characterized by a dull pain and is more
pronounced in forward flexion with associated restriction in spine movement
and palpation of the erector spinae muscles exacerbates pain.
Physical Examination
Examination should include:
Ø observation of the posture and gait
Ø Neurologic screen to rule out underlying pathology
Ø Range of motion, muscle tests
Ø palpation.
Ø Muscle length tests.
Ø Assessment of joint mobility.
Physical Therapy Management

Physical therapy goals:
52
1- Restore biomechanics during daily activities
2- Lumbo-pelvic stabilization
3- Education and prevention
Physical therapy should be focused on the following
1-Patient instructions.
2-Physical therapy.
1-Patient instructions
It’s important to communicate with the patient and provide information about the
relevant anatomy, ergonomics, to prevent unnecessary mechanical stress on the
back, and how to manage daily living activities such as walking, standing, sitting,
lying, and work position, learning how to control pain (see patient education in
PGP).
2-Physical therapy
1) Ice
Ice cube Massage for 10 minutes or ice backs for about 25 minutes under painful
area from crock lying position.
2) TENS:
* Electrode placement:
It is applied paravertebral at lumbosacral region.
First channel: one electrode on L5 nerve root and the other on mid-gluteus
maximus.
Second channel: one electrode on popliteal fossa and the other behind lateral
malleolus.
Parameters: Frequency: 80-120 HZ, Pulse width: 150 microseconds, Intensity:
according to patient's tolerance, Duration: 1 hour, 3-4 times daily.
53
Mechanism of action of TENS:
1-Gate control theory:
Electrical stimulation of large diameter, high velocity nerve fibers prevents
pain transmission through small diameter, slow velocity pain carrying nerve
fibers (A delta and C fibers) from transmitting pain signals to higher brain
centers.
2-Opiate theory:
Mild electrical stimulation to the neural system enhances production of beta
endorphin and encephalin (endogenous pain killer).
3) Interferential (I.F.)
Coplanar application using 4 electrodes paravertebral at lumbosacral region.
Frequency is 80-100 HZ. Duration is 20 minutes.
Mechanism of action:
1. It causes fine vibrations of ions, which makes stimulation of large diameter
nerve fibers. It causes a tingling sensation, which interferes with pain
perception.
2. Using high frequency current causes rapid fatigue for pain receptors.
3. It improves circulation resulting in clearance of metabolites and waste
products.
4. It has also a massaging effect which causes muscle relaxation.
5. It changes PH to the alkaline side helping to remove adhesions.
4) Manual therapy techniques

5) Exercises
1-Strengthening Gluteus Medius
54
2-Abdominal drawing in maneuver on physio ball.
3-Pelvic tilting: concentrate on Posterior pelvic tilting Exercise from creeping
position.
4-Stretching lower back.
6) Supportive belt
A maternity belt that helps to supply relief of pain for strained muscles and
ligaments through distributing the weight from the abdomen more evenly, reducing
painful gravitational forces.
Postnatal back pain

Back pain is a very common postnatal complaint. The pain is most frequently
located in the posterior pelvic and lumbar areas, also cervical and thoracic pain
following delivery and in the immediate post delivery period. Hormonal and
biomechanical changes may produce pain during pregnancy, which may persist
after delivery.
Management
• Following ergonomic principles in all functional activities.
• Gentle joint mobilization.
• Strengthening exercises for the abdominal and back muscles.
• Postural correction advices and exercises.
• Hot or ice packs may be effective.
• Posterior pelvic tilt throughout the day.
• Muscle energy techniques.
• Lumber paraspinal stretching.
55
• Electrotherapy: TENS,IF,US and (laser for chronic LPB)
Ultrasound for Postnatal LBP:

Through heating and micro massage effects, ultrasound reliefs pain and muscle
spasm and improving the circulation. It is applied paravertebral over the site of
pain. Its parameters are Frequency:1 or 3 MHZ, Intensity: 0.5-1 W/Cm2, Mode:
continuous and pulsed, Time: 5 min.
Laser for chronic LBP:

High-intensity laser therapy (HILT) can reduce pain due to its anti-inflammatory
effects, increase in microcirculation, and stimulation of immunological processes,
nerve regeneration and increased secretion of β-endorphins. Scanning was
performed longitudinally in the lower-back area of L1-L5 and S1, Laser probe was
in contact with the skin. Parameters: power of 4 W, the intensity of 1.5 J/cm², time
for 15 minutes.
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Coccydynia
Coccydynia is defined as a painful condition of the coccyx. The term “coccyx”
comes from the Greek word for “cuckoo” as it resembles a bird’s beak with the tip
pointed down. “Dynia” means “pain,” and so “coccydynia” literally means “pain of
the coccyx.” And because the bone corresponds to the location of an animal’s tail,
it’s called the “tailbone”. Coccyx is made up of three to five fused vertebrae. It lies
beneath the sacrum (Fig. 5-1).
Fig. (5-1): Sacrum and coccyx
Function of the Coccyx

The coccyx is one part of a three-part support for a person in the seated position.
Weight is distributed between the ischial tuberosities and the coccyx, providing
balance and stability when a person is seated.
The coccyx is the connecting point for pelvic floor muscles. These muscles support
the anus and aid in defecation, support the vagina in females, and assist in walking,
running, and moving the legs (Fig. 5-2).
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Fig. (5-2): Muscular attachment to the coccyx
Coccydynia is typically caused by the following underlying anatomical issues:

Hypermobility, or too much movement of the coccyx puts added stress on the
joint between the sacrum and coccyx and on the coccyx itself. Too much mobility
can also pull the pelvic floor muscles that attach to the coccyx, resulting in tailbone
and pelvic pain.
Limited mobility of the coccyx causes the tailbone to jut outward when sitting and
can put increased pressure on the bones and the sacrococcygeal joint. Limited
coccyx movement may also result in pelvic floor muscle tension, adding to
discomfort (Fig. 5-3).
In rare cases, part of the sacrococcygeal joint may become dislocated at the front or
back of the tailbone, causing coccyx pain. The above factors may result from an
injury to the coccyx, or may develop as idiopathic coccydynia
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Fig. (5-3): Normal and abnormal tension
Possible Causes of Coccydynia

1- Local trauma:
A direct injury to the coccyx is probably the most common cause of coccydynia.
A fall on the tailbone can inflame the ligaments and injure the coccyx or the
coccygeal attachment to the sacrum. Trauma can cause fracture (Fig. 5- 4).
Fig. (5-4): Coccygeal fracture

2-Repetitive stress
Activities that put prolonged pressure on the tailbone, such as horseback riding
and sitting on hard surfaces for long periods of time, may cause the onset of
coccyx pain.
3-Childbirth: During delivery, the baby's head passes over the top of the coccyx,
and the pressure against the coccyx can sometimes result in injury to the coccygeal
59
structures (the disc, ligaments, and bones). While uncommon, the pressure can also
cause a fracture in the coccyx (Fig. 5-5).
Fig. (5-5): coccygeal injury during delivery
4)Tumor or infection: Rarely, coccydynia can be caused by a nearby tumor or

infection that puts pressure on the coccyx.
5) Referred coccyx pain: In rare cases pain will be referred to the coccyx from
elsewhere in the spine or pelvis, such as a lumbar herniated disc or degenerative
lumbar disc.
6) Obesity: Pelvic rotation, including movement of the coccyx, is usually lessened
in individuals who are overweight, leading to more continual stress being placed
on the coccyx and increasing the chances of developing coccyx pain.
7) Gender: Women have a higher chance of developing coccydynia than men, due
to a wider pelvic angle as well as trauma to the coccyx endured during childbirth.
Symptoms of coccydynia
-Localized pain and tenderness.
Pain is generally confined to the tailbone and does not radiate through the pelvis or
to the lower extremities. Pain is usually described as an aching soreness and can
60
range from mild to severe. Tightness or general discomfort around the tailbone
may be constant, or pain may come and go with movement or pressure.
-Increased pain with sitting.

Coccydynia is generally more intense when weight is placed on the tailbone, as in
when a person leans backward in a sitting position. Likewise, sitting on hard
surfaces without a cushion (such as a wooden bench or a metal folding chair) or
leaning back against a wall puts added pressure on the tailbone, causing pain to
worsen.
-Pain that is worse when moving from sitting to standing:

When moving from a seated position to standing or vice versa, the rotation of the
pelvic bones and muscle movements that assist this rotation may be painful. It may
be difficult to stand or sit, the patient sits down slowly and carefully, often shifting
her weight from one buttock to another.
-Pain that may increase with bowel movement or sexual intercourse:

Some patients experience heightened pain during defecation or sexual intercourse,
due to the proximity of the coccyx to the anus and genitals.
Diagnosis:
The diagnosis of coccydynia is based on patient history and clinical examination.
Physical examination:
1- Palpation can identify coccygeal tenderness and hyper mobility.
61
2- Intrarectal exam and manipulation: manipulation of the coccyx manually
through the rectum, in order to assess limited or excessive mobility of the
sacrococcygeal joint. It may also be used to assess any muscle tension in the pelvis
connecting to the coccyx.
Diagnostic Tests for Coccydynia

-Dynamic X-ray imaging tests:
A dynamic X-ray produces two images, one while the patient in sitting and another
while the patient in standing. A doctor will compare the images and measure the
angle of pelvic rotation as well as the coccyx’s change in position from sitting to
standing. If these measurements are outside of the normal range (between 5 and 25
degrees), too much or too little coccygeal movement can be identified as the cause
of pain
-Coccygeal discogram:
It involves an injection of local anesthesia in the sacrococcygeal region. The
injection targets a specific area in the spine, such as an intervertebral joint or disc,
to identify the precise location where pain is being caused.
-CT or MRI scans:

A static image of the coccyx taken by MRI or CT scan may be used if the
suspected cause of pain is a fracture, tumor, or abnormal mobility of the
sacrococcygeal joint
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Treatment of postpartum coccydynia:
• Non-steroidal anti-inflammatory drugs (NSAIDs): Common NSAIDs,
such as ibuprofen, naproxen reduces the inflammation around the coccyx
that is usually a cause of the pain.
• Ice or cold pack: Applying ice or a cold pack to the area several times a day
for the first few days after pain starts can help reduce inflammation.
• Heating pad: Applying heat to the bottom of the spine after the first few
days of pain may help relieve muscle tension, which may accompany or
exacerbate coccyx pain.
• Supportive pillows: A custom pillow that takes pressure off the coccyx
when sitting may be used. Pillows for alleviating coccydynia may include U-
or V-shaped pillows, or wedge-shaped pillows.
• Instructions for patient to deal with pain.
• Massage: Coccydynia may be reduced or alleviated by massaging tense
pelvic floor muscles that attach to the coccyx. Tense muscles in this region
can place added strain on the ligaments and sacrococcygeal joint, limiting its
mobility or pulling on the coccyx. To exclude the possibility of muscles
pulling on the os coccyx, relaxation of the pelvic floor muscles can be
integrated by using biofeedback.
• Stretching: Gently stretching the ligaments attached to the coccyx can be
helpful in reducing muscle tension in the coccygeal area.
• Coccygeal manipulation: Some patients find pain relief through manual
manipulation of the coccyx. Coccygeal manipulation could modulate the
pain through its mechanical effects by correction of mal alignment of
coccygeal vertebrae that could have been the cause of mechanical pain or
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neurophysiological effects through the stimulation of articular receptors type
I& II.
Muscle Energy Technique (MET)
v MET is an effective conservative modality to alleviate lumbopelvic pain.
The touch of the clinician, along with stimulation of agonist and antagonist
muscles, seems to decrease perception of pain.
v MET is a low-force isometric contraction in a pain- free position. In
conclusion, this technique is not painful or harmful to the patient. The
therapist provides resistive force counter to push patients' muscle
contraction, aimed to help in restoring musculoskeletal functions
v This technique could be applied prior to other rehabilitation techniques, such
as strengthening exercises, to decrease pain and enhance the effect of an
applied exercise program.
Phonophoresis for postpartum coccydynia

Phonophoresis (PP) is a non-invasive method of ultrasound application to deliver
medications, usually topical analgesics, or steroid, through the skin to deep tissues
to relieve the pain.
TENS for postpartum coccydynia

Applying high Frequency TENS for 20 minutes in acute cases and low Frequency
TENS for 30 minutes in chronic cases.
64
References:
- Lirette L, , Chaiban G, , Tolba R, and Eissa H, " Coccydynia: An

Overview of the Anatomy, Etiology, and Treatment of Coccyx Pain" Ochsner J.
2014 Spring; 14(1): 84–87.
- Howard P, Dolan A, Falco A, Holland B, Wilkinson C, and Zink A" A
comparison of conservative interventions and their effectiveness for coccydynia: a
systematic review",J Man Manip Ther. 2013 Nov; 21(4): 213–219.
- Khatri S, Nitsure P and Jatti R "Effectiveness of Coccygeal Manipulation in
Coccydynia: A randomized control trial". Indian Journal of Physiotherapy and
Occupational Therapy. July-Sep., 2011, Vol.5, No.3
- Gocevska M, Nikolikj-Dimitrova E, and Gjerakaroska-Savevska C. "Effects
of High - Intensity Laser in Treatment of Patients with Chronic Low Back Pain”,
Open. 2019 Mar 30; 7(6): 949–954.
- Embaby, H., S. Elgendy, and M. E. Hasanin, "Effect of muscle energy
technique in treating post-partum coccydynia: A randomized control trial",
Physical Therapy and Rehabilitation, vol. 4, issue SSN 2055-2386, pp. 4-5, 2017.
- Jeffcoat H. Exercises for low back pain in pregnancy. Int J Childbirth Educ.
2008; 23: 9-12.
- Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy:
prevalence and risk factors. Spine. 2005;30(8);983-91.
- Chang, Hao‐Yuan, et al. Factors associated with low back pain changes during
the third trimester of pregnancy. Journal of advanced nursing. 2014; 70(5): 1054-
1064.
65
Physical Therapy for Stress Urinary incontinence (SUI)
Prof Dr. Salwa Moustafa El-Badry, PT Ph D

Prof Dr. Mohamed Awad, PT PhD
Introduction:
According to the ICS definitions, urinary incontinence denotes a symptom, a sign,
and a condition. The symptom indicates the patient's statement of involuntary urine
loss. The sign is the objective demonstration of urine loss. The condition is the
urodynamic demonstration of urine loss.
Epidemiology:
Prevalence and Incidence of UI:
In children, between 4 and 11 years of age, 6.9% of boys and 5.1% of girls have
regular incontinence, whereas 10.9% of boys and 11.2% of girls have occasional
incontinence. In adolescents, from 12 years of age on, the prevalence of urinary
incontinence increases with age and is higher in girls than it is in boys.
In a study, of 421 healthy nulliparous student nurses (17-25 years old), Wolin
(1969) found some degree of stress incontinence in 51 %, and a daily problem with
urinary leakage in 16%. Among women less than 45 years of age, prevalence
figures of urine incontinence ranged from 24 to 52%. In another random sample of
541 healthy mid-aged women (42-50 years of age), 58% of participants had urine
loss at some time and 31 % repeated incontinence on a regular basis at least once
per month.
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In elderly, the prevalence of urinary incontinence, has been noted to range from
40% to 60%, most of them are related to urge incontinence. However, the
prevalence of stress incontinence is reported to be the predominant type of
incontinence, with rates of 14.752%, while mixed incontinence is reported with
rates of 3.1-47%, and urge incontinence occurs often with rates of 2.4- 13.3%.
Psychosocial Impact of UI:

Urinary incontinence, whether present in elderly or young women, can have
devastating effects on self-esteem, psychological well-being, and overall physical
health. However, the psychosocial impact of UI is considerable, with 34% of
patients complaining that it interferes significantly with household chores and
other daily activities. Hence, the psychological reaction to incontinence resembles
reactive depression, tension and sleep disorders. As well as, UI is a socially
embarrassing condition, causing withdrawal from social situations and reduced
quality of life.
Types of Female Urinary Incontinence:

True incontinence is a continuous loss of urine through the vagina caused by
genitourinary fistula.
Stress (sphincter) incontinence is due to loss of support and weakness of the
urethra-vesical junction.
Urge incontinence caused by severe inflammation leading to marked irritation
of the bladder and so the urge to pass urine cannot be inhibited, and urine will pass
involuntarily, while the patient is on her way to micturate.
False incontinence (retention with over flow) occurs when the intra-vesical
pressure exceeds the intra-urethral pressure, because of excessive bladder
distension, while detrusor activity is absent.
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Nocturnal enuresis means an involuntary loss of urine during sleep.
Giggle incontinence is found in younger adolescents, there is a sudden
involuntary partial or complete emptying of the bladder. It occurs without warning
during/after a bout of giggling or, hysterical laughter. It often begins around 5-7
years and tend to resolve by 12 years, though urgency and leakage can continue
into adult life.
Stress (Sphincter) Incontinence

Stress incontinence (SI) is involuntary leakage of urine, from the urethra and such
leakage occurs on sudden rise of intraabdominal pressure, as in coughing,
laughing, or any other physical activities, in the absence of detrusor contraction.
Genuine stress incontinence (GSI) is urodynamically proved involuntary loss of
urine, when the intravesical pressure exceeds that of the urethra with no
simultaneous detrusor contraction.
A major cause of genuine stress incontinence is the loss of anatomic support of the
urethra, bladder, and urethrovesical junction. When the bladder and proximal
urethra are supported in a retropubic position, increases in intraabdominal pressure
are transmitted equally to both structures and continence is maintained, lack of
anatomic support displaces the proximal urethra outside the abdominal pressure
zone. Intraabdominal pressure increases are then fully transmitted to the bladder
but to a lesser extent to the urethra, and urine loss occur.
However, the main defect in stress incontinence is that the normal closure
mechanism of the urethrovesical junction is inadequate, the bladder base is
funneled not flat, and the posterior urethrovesical angle is diminished or lost. As
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well, the descent of the urethrovesical junction prevents the proximal urethra from
receiving the benefits of raised intraabdominal pressure when stress occurs.
Pathophysiology of Stress Incontinence:

The most commonly accepted theory for the pathophysiology of stress
incontinence is that the proximal urethra drops below the pelvic floor because of
pelvic relaxation defects. Therefore, the increase in intraabdominal pressure
induced by coughing is not transmitted equally to the bladder and proximal urethra.
The urethral resistance is overcomed by the increased bladder pressure, and
leakage of urine results.
Grades of stress incontinence:

Grade I. Incontinence only with severe stress, such as coughing, sneezing, or
jogging.
Grade II. Incontinence with moderate stress, such as rapid movement or walking
up and down stairs.
Grade III. Incontinence with mild stress, such as standing. The patient is continent
in the supine position.
Incidence of stress incontinence:

* It occurs most often in white parous women,
* It is infrequent in black and oriental women, and
* It is rare in nulliparous women.
Aetiology:
1. Congenital:
* Due to defective development of the vesical and urethral muscles.
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* Congenital inherited defect of either intrinsic vesical sphincter or the
support of the bladder and/or urethra.
* Spina bifida which affects the innervation of the sphincter mechanism can
produce stress incontinence and prolapse.
2. Traumatic:
(Resulting from childbirth or operative trauma).
* Parturition is the commonest traumatic cause as using forceps, ventose or
an oversize fetus that resulting in over stretching on the urogenital
diaphragm which damage the bladder neck supports.
* Operative trauma, as after hysterectomy, and repair of the vesico-vaginal
fistula.
3. Hormonal dysfunction as postmenopausal atrophy and sometimes during
pregnancy:
* Stress incontinence is common after menopause due to decrease estrogen
level which leads to atrophy of the muscles and ligaments of the pelvic
floor structure.
* Levator ani and pelvic cellular tissue contains receptors to estrogen
hormone, so when the level of estrogen hormone decreased atrophy of the
muscles (levator ani) and ligaments occurs.
* Also, during pregnancy stress incontinence is aggravated as the muscles of
the bladder and proximal urethra relax under the influence of progesterone.
Factors that provoke or aggravate incontinence:
The patient should be informed about factors that may provoke or aggravate
incontinence such as, excess body weight places extra pressure on the bladder and
increase stress on the pelvic floor. So that, weight reduction in obese patients
alleviates some of the symptoms; chronic coughing from respiratory diseases
should be treated because it aggravates stress incontinence; smoking should be
70
stopped, so we must draw the patient's attention to smoking as precipitating factor
for incontinence and encourage her to stop smoking. infections as well as
inflammation of the urethra and/or bladder should be treated, patient should be
informed about reducing the caffeine intake (tea, coffee and cola drinks), because
it has an effect on reducing frequency of micturition and urge leakage; and either
drugs that may cause incontinence or sedative-hypnotic drugs, should be reviewed
by the patient's gynecologist because drugs with a diuretic action, increases urine
output as well as urgency, while sedative hypnotic drugs may cause confusion and
a depressed ability to inhibit bladder contractions.
Evaluation of Stress Urinary Incontinence:

Diagnostic Evaluation:
(Done by gynecologist, urologist, and clinical pathologist).
Diagnostic evaluation of UI commences with a thorough history taking, physical
examination, and routine laboratory studies including: urine analysis, urine culture,
and renal function tests. Hematuria should be evaluated by urinary cytologic
studies, intravenous pyelography, and cystourethroscopy. And urodynamic
investigation will help to identify the cause of incontinence in the vast majority of
patients
Pelvic Examination:
Inspection of the vaginal walls should be performed with a Sims speculum, which
allows optimal visualization of the anterior vaginal wall and urethrovesical
junction. Scarring, tenderness, and rigidity of the urethra from previous vaginal
surgeries or pelvic trauma may be reflected by a scarred anterior vaginal wall.
Because the distal urethra is estrogen dependent, the patient with atrophic vaginitis
also has atrophic urethritis.
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Diagnostic Tests:
1- Stress Test:
This test objectively demonstrates urinary incontinence. The patient is examined
with a full bladder in the lithotomy position. While the gynecologist observed the
urethral meatus. The patient is asked to strain and cough. If SUI is present, small
drops of urine will be observed escaping from the urethral meatus.
2- Bonney's test:
If urine escapes from the urethra on coughing, the test is repeated after elevation of
the bladder neck upwards. If no urine escapes on coughing, this means that the
cause is descent of the bladder neck.
3- Q-Tip Test:
To test for the position of the urethra relative to the base of the bladder on
straining. With the patient in the lithotomy position, the gynecologist inserts a
lubricated cotton swab (Q-tip) into the urethra to the level of the urethrovesical
junction and measures the angle between the Q-tip and the horizontal normally the
Q-Tip points downward (normal change in angle is up to 30 degrees). In stress
incontinence the Q-Tip points upward (the change in Q- Tip angle is in the range
of 50-60 degrees or more).
Basic urodynamic investigations:

1- Cytometry:
It is the mainstay of basic urodynamic investigations. It is a graphic representation
of vesical pressure as a function of bladder volume. It is used to assess detrusor
activity, sensation, capacity and compliance. Because of this requires
catheterization, it is important that no patient with a urinary tract infection undergo
this procedure. Hence, cytometry is a dynamic investigation in that the intravesical
pressure is measured not only during filling but also at capacity and during
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voiding. Because the bladder is an intraabdominal organ, any changes that occur in
intraabdominal pressure will be reflected in the intravesical pressure.
2- Cystourethrography:
In this radiologic investigation, fluoroscopy is used to observe bladder filling, the
mobility of the urethra as well as bladder base, and the anatomic changes during
voiding. The procedure provides valuable information regarding bladder size and
the competence of the bladder neck during coughing. It may detect any bladder
trabeculation, vesicoureteral reflux during voiding, funneling of the bladder neck,
bladder, outflow obstruction, and urethral diverticula.
3- Urethral Closing Pressure Profile:
The urethral closing pressure profile (UCPP) is a graphic record of pressure along
the length of the urethra obtained by means of a pressure-sensitive recording
catheter, which is slowly and progressively withdrawn through the urethra. The
resulting bell-shaped curve provides a measurement of the urethral closing
pressure (intraurethral minus intravesical pressure) and the functional length of the
urethra (the length of the urethra along which urethral pressure exceeds bladder
pressure). The urethral closing pressure normally varies between 50 and 100 cm
H2O and the functional length between 3 and 5 cm. A normal continent woman
responds to the stress of bladder filling, postural change, coughing, sneezing, or
jolting by increasing the urethral closing pressure and urethral length. Patients with
stress urinary incontinence characteristically demonstrate decreases in urethral
closing pressure
4- Cystourethroscopy:
It is an important part of the evaluation and should be done in all cases. It allows
for visual assessment of the coaptation of the urethral mucosa and presence of
diverticulum as well as ruling out other urethral pathology. It is useful in older
73
patients in whom symptoms of frequency and urgency may be associated with
bladder disease.
5- Electromyographic Studies:
They provide information about the activity and integrity of innervation of the
external sphincter and perineal floor muscles. Surface electromyography is used to
study the pattern of micturition, and needle electromyography is to evaluate
individual motor unit potential. Electromyography in SUI may show evidence of
pelvic floor denervation. However, the main use is in-patients suspected of having
a neurologic disorder (e.g. multiple sclerosis, myelodysplasia and spinal cord
injury).
6- Video-Urodynamics:
Video-urodynamic testing is the most useful test for evaluation of the lower
urinary tract. Essentially, the investigation involves cystometry using radiographic
contrast medium and fluoroscopy so that the bladder and the urethra can be imaged
while pressure recordings are made. This form-and-function test can be recorded
on videotape and reviewed at a later date for analysis and for teaching purposes.
Video-urodynamic testing is considered the best urodynamic test because it yields
a comprehensive array of information about the lower urinary tract. However, the
technique yields more information than simple cystometry. It is most useful for
investigating patients who have undergone previous failed surgery and for those
with a voiding dysfunction or a neurologic abnormality (Fig. 6-1).
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Fig. (6-1): Video-Urodynamic apparatus.
Physiotherapy Assessment:
The patient with urinary problems should be interviewed and examined in a quiet,
private and unhurried atmosphere.
Examination of the perineum and pelvic floor:

The perineum is observed first for skin condition, hemorrhoids, prolapse and
evidence of episiotomy or previous surgery. The patient is asked to cough and
strain, evidence of prolapse, purging of the perineum or any leakage of urine is
noted. The therapist test the ability of the patient to contract her pelvic floor or not,
is recorded, together with an estimate of strength and the maximum length of time,
the contraction can be maintained.
Tests used by physiotherapist:

1- Frequency/Volume Chart:
The frequency/volume chart is a specific urodynamic investigation recording
fluid intake, and urine output per 24 hours period. The chart gives objective
information on the number of voiding, the distribution of voiding between daytime,
nighttime and each voided volume. The chart can also be used to record episodes
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of urgency, leakage and the number of incontinence pads used. The
frequency/volume chart is very useful in the assessment of voiding disorders, and
in the follow-up of treatment.
2- The Pad Test:

a- One-Hour office Pad Test:
The test approved by the ICS takes one hour. At the end of the hour, the pad is
removed and weighed; any difference from the starting pad weight constitutes fluid
loss, and this is recorded. In assessment an increase of <2 gm is allowed as vaginal
discharge and perspiration.
b- Twelve-Hour Home Pad Test:

A 24 and a 48-hour pad test have been devised whereby the patient wears pre-
weighted perineal pads continuously for 24 or 48 hours, removing them only to
void or to change to a fresh pad. Discarded pads may be weighed immediately by
the patient using a supplied spring balance or seals the used pads back in the
individual bags. Evaporation loss was found to be minimal: 0.2 gin after 24 hours.
This test has some advantages in measuring the patient in more normal
circumstances and over a long period.
3- Perineometry
The Bradford perineometer used before and after treatment and at monthly
intervals to confirm reliably whether or not the pelvic floor muscles are being
contracted. And to measure the intra-vaginal pressure, which reflect the
constructional force of the perineal musculature. Also, it provides the patient by
sensory and visible biofeedback. So, it serves to motivate the patient not only to
practice but also to perform the exercise for longer and stronger contractions.
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4- Manual grading to assess pelvic floor strength:
Muscle Contraction:
The physical therapist introduces a gloved index and middle fingers, into the
patient's vagina, ask the patient to perform a maximal voluntary contraction and
categorize what is felt according to the Modified Oxford Grading Score for Pelvic
Floor Muscles.
5- Visual Analogue Scale:
A helpful measure to assess the severity of symptoms of SUI as they affect the
patient may be gauged on a visual analogue scale (VAS). It gives insight into the
patient's perception of any problem. The patient is asked to place a cross at the
appropriate point on a 10 cm line.
6- Electromyography:
This is the most accurate method of objectively recording muscle activity when
data are collected by fine wire or needle electrodes. External electrode placement
on the perineum records superficial muscle activity. Surface electrodes are used
intravaginally or intra-anally in some rehabilitation units as a biofeedback
mechanism. Objective EMG data cannot be used to compare-day-to-day progress,
as electrode placement varies.
Treatment of stress urinary incontinence:

I. Prophylaxis
a- Parturition is the commonest traumatic cause and it is prevented through
proper ante, intra and postnatal care.
b- Postmenopausal cases are treated by hormonal replacement therapy, Kegel
exercise, and bladder training.
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II. Actual Treatment
- Early, mild, and puerperal cases are curative by physical therapy.
III. Surgical Treatment
- Severe and recurrent cases are treated by re-constructive surgery to restore
the normal anatomy.
Physical Treatment for SUI

Aims of Treatment
1- To inform patients of factors which may provoke or aggravate incontinence.
2- To establish awareness of the function of the pubococcygeus muscle and
urethral sphincter.
3- To normalizes the pelvic support and sphincter mechanism.
4- To strengthen the pubococcygeus muscle.
I- Prophylaxis treatment:
Parturition is the commonest traumatic cause and is prevented by:
A- Proper intra-natal care (during delivery):
To avoid and minimize trauma and injury to the fasciomuscular pelvic floor
through:
- Keep bladder empty during the 1st stage of labor,
- Proper management of 2nd stage of labor (Firm support to the perineum
from the start of the 2nd stage of labor - during uterine contractions - to
avoid perineal overstretching or lacerations, which predispose to stress
(sphincter) incontinence and prolapse later),
- Avoid using forceps and ventose before full. cervical dilatation,
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- At crowning, ask the mother to stop bearing. down during uterine
contractions, and to pant, and
- Proper time episiotomy (at crowning if indicated).
B- Proper post-natal care (after delivery):

- Any perineal tear or lacerations should be repaired carefully within 24
hours,
- Strengthening exercises to strength the pelvic floor muscles
(pubococcygeus muscle), which may be stretched or injured during
parturition (birth trauma),
- Avoidance of bladder infection (nursing care for washing the vulva and
perineum) to guard against urgency incontinence.
II- Curative Treatment:

Physical therapy: Is divided into two phases:
A) Muscle re-education of pubococcygeus muscle:

Is important as the patient who complains from stress incontinence, lack
awareness of the function of her pubococcygeus muscle.
Urethral closure pressure must be higher than the intra-vesical pressure both at
rest and in situations of increased intra-abdominal pressure. The pelvic floor
muscles are one of several known factors which contribute to urethral closure
pressure. They demonstrate a reflex increase in activity during increases in intra-
abdominal pressure, and if weakened they may allow leakage of urine as in
situations of increased intra-abdominal pressure, e.g. sneezing or coughing.
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The urethral closure mechanism consists of the intrinsic urethral sphincter and
the periurethral muscles of the pelvic floor, mainly the pubococcygeus. This
muscle consists of a heterogeneous mixture of slow and fast twitch muscle cells,
innervated by the pudendal nerve. Large diameter fibers form the bulk of this
striated muscle, and a proportion are functionally of the fast twitch type, capable of
rapid contraction, but only for short time periods. Consequently, the
pubococcygeus reinforces the intrinsic urethral sphincter by increasing the urethral
resistance during coughing, straining, etc. It also plays an important role in the
forceful closure of the urethra, which occurs when micturition is voluntarily
interrupted during the 'stop test'.
Age is associated with a decrease in fast twitch muscle fibers; also, fast twitch
fiber atrophy frequently occurs in patients who have been confined to bed, or who
have been engaging in very limited physical activity.
The effects of contraction of the pubococcygeus are to support, lengthens and

compress the urethra, and to elevate the urethro-vesical junction into an area of
transmitted abdominal pressure. Also, the detrusor nucleus in the sacral micturition
center is directly inhibited, so pelvic floor exercises can be utilized in the
management of detrusor instability. An increase in the tone of the pelvic floor
muscles is said to raise the micturition threshold and this explains why patients
report a decrease in frequency and urgency following a course of pelvic floor
exercises.
Many women are ignorant of the location and function of their pelvic floor and
are unable to contract these muscles. Approximately 30% of women are unable to
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perform pelvic floor contraction following written or verbal instructions.
Therefore, these women are in need to re-educate them about awareness of the
pubococcygeus muscle and sphincter vesica through repeated strong contraction
and relaxation of their pelvic floor.
The aims of pelvic floor exercises are to increase the static tone and strengthen
the rapid response of the levator ani, and will therefore include repetitive
contractions and resistive exercises.
When re-educating the pelvic floor muscles, attention must be paid to the
different needs of fast and slow twitch muscle fibers. In any progressive
contraction, slow twitch motor units are activated before fast twitch motor units.
To train fast twitch muscle fibers, requires maximum effort - either maximum
tension or maximum speed. Exercise induced changes in slow twitch fibers will
require many repeated contractions.
The ideal pelvic floor contraction involves movement of the pelvic musculature
in a cephalad direction with minimal activity of the abdominal muscles because
excessive abdominal activity leads to increased intra-abdominal pressure which is
undesirable.
Once pelvic floor muscle contractions can be isolated the patient gains
improved awareness of this muscle action. So that, the patient will asked to try to
contract as if she controls the bowel action, urethral orifice and draws the vagina
up through lowering the lower abdomen, concentrate in this action, hold, then relax
(Refer to pelvic floor ex's).
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1- Graduations of pubococcygeus muscle exercises:
"Quick Flick": Tighten and relax the muscle as quickly as possible 10-20 times.
Relax for a count of 10, then repeat. Do --- repetitions of this exercise,
increasing by 5 repetitions each week up to a maximum of 50 repetitions.
"Slow Contraction": Tighten the muscle as hard as you can for a count of 10-20.
Relax for a count of 10, then repeat. Do --- repetitions of the exercise,
increasing by 5 repetitions each week up to a maximum of 50 repetitions.
"Sustained Contraction": Tighten the muscle "halfway" (half as hard as you did
for the slow contraction) and hold it for 60 seconds. Relax for a count of 20,
then repeat. Do --- repetitions of this exercise, increasing by 2 repetitions each
week up a maximum of 10 repetitions.
Once awareness and function of the muscle group have been established, the
patient is instructed to perform a series of "quick flick" maximal and sustained
contractions as a part of daily exercise regimen. Le. patients are taught to contract
their pelvic floor muscles and instructed to practice contractions a little and often,
some quick 3 seconds contractions, and some lasting 60 seconds, with relaxation
period about (2 - 5) minutes after each contraction. These exercises should be
performed during daily activities in standing, sitting and lying positions.
Digital evaluation of the pelvic floor muscle contraction is an essential part of

the physiotherapy assessment, with suggested grading as follows: nil = 0; poor = 1;
fair = 2; good = 3; very good = 4.
Isolation from abdominal, glutei, and adductor muscle contractions is

important, as these may mask the pelvic floor contraction and fatigue the patient.
So that, a strong abdominal contraction may irritate an unstable bladder. Also,
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Kegel (1948) recommended 300 contractions per day and the use of a perineometer
twice daily.
2- Biofeedback (Kegel perineometer and EMG biofeedback):

Biofeedback is the use of electronic instrumentation to provide objective
information (feedback) to an individual about a physiological function or response
so that the individual becomes aware of her response. The individual then attempts
to alter the feedback signal to modify the physiological response.
In a biofeedback system the patient is the source, and the biofeedback is the
technique whereby information presented to the patient as an auditory or visual
signal creates a learning situation and facilitates the development of self-regulatory
mechanisms.
EMG biofeedback is used to detect and feedback the myoelectric signals from
skeletal muscle and translates it into a more understandable event either to train
patients to relax hyperactive muscles or to increase the discharge rate and number
of motor units activated to increase the strength of contraction.
Biofeedback training in physiotherapy may take a number of forms, but one of

the most commonly used is to apply surface EMG electrodes over particular
muscles and present the patient with an auditory or visual measure of the muscles
activity. Also, by using an intravaginal (EMG) electrode, patients are taught to
selectively contract their pelvic muscles around the electrode and to sustain a
contraction for 10-seconds intervals.
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EMG biofeedback is not a treatment rather, it is a tool that clinicians can use to
help their patients to learn a new tasks or modify existing motor patterns by
providing useful Information both to the clinician and patient. So, biofeedback,
serve to motivate the patient not only to practice the exercise, but also to perform
the exercise for longer and stronger contractions.
Hence, myofeedback as a treatment modality for incontinence has been

demonstrated to be of benefit as primary treatment for stress and urge
incontinence, as an adjunctive augmentation to pelvic floor exercise programs and
as a method to facilitate proprioception of pelvic floor contraction in biofeedback
therapies.
a- Kegel perineometer (Fig. 6-2):

Kegel (1948), have found that approximately 30% of women could not exert
conscious control over their pelvic floor musculature so that he used a so-called
perineometer to measure intra vaginal pressure, reflecting the constructional force
of the perineal musculature.
Kegel perineometer provides the patient by powerful sensory and visible

biofeedback, for initiating the pelvic floor muscles to contracts through resistive
isometric exercising of the pubococcygeus muscle. It is a pneumatic pressure
transducer that can be used as a dynamometer. It is simple in design, consists of a
cylindrical rubber vaginal chamber, which fits in the vagina. The rubber vaginal
part is connected to a manometer (visible to the patient) by a rubber tube.
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Levator ani muscle contractions particularly the pubococcygeus muscle
portion, squeeze the pneumatic tube, the dynamometer records the pressure change
in millimeters of mercury.
Kegel perineometer is able to measure pubococcygeus muscle contractions up

to 100 mmHg, so that changes in pelvic floor strength can be measured.
Before introducing the vaginal chamber into the vagina it must be lubricated by
KY gel. Then it is inserted by the subject into her vagina while she assumes
comfortable crock lying position with pillows under head and knees.
Fig. (6-2A): Kegel perineometer Fig. (6-2B): Kegel perineometer in situ.
b- Electromyographic biofeedback (EMG Biofeedback):

Electromyographic (EMG) biofeedback provides the patient by sensory, visible
and auditory biofeedback (Fig. 3).
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Fig. (6-3): EMG Biofeedback.
EMG biofeedback is useful in both increasing the level of pubococcygeus

muscle activity and improving the ability of the muscle to relax on volition. The
recruitment of additional motor units during an active, volitional contraction results
in increased EMG activity. It consists of vaginal electrode, 3 surfaces electrodes,
screen, and earphone.
The vaginal electrode is a small, dumb-bell shaped probe, made of strong

dental acrylic, embedded in its central position three pure silver sensors, which are
capable of detecting the very tiny (1.25 micro volt) signals, that are given off the
pelvic floor muscles, when they are contracted. And the three surface electrodes
are formed of metal strips imbedded in a dental porcelain material, they are
positioned on the perineum in a triangular shape its apex downwards. Contractions
of the pubococcygeus muscle are held for 3, 10, 30 & 60 seconds with 2 - 5
minutes rest intervals between contractions.
Both EMG devices and perineometers appears to be useful tools for physical
therapist in evaluation, prophylaxis, and actual treatment of pelvic floor
dysfunction.
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3- Cyriax method of treatment for stress incontinence:
Cyriax method of treatment for stress incontinence is also suitable for early
cases of genital prolapse. This method aims to strength: pubococcygeus, gluteal,
anal, and abdominal muscles.
The patient is asked to lie in crock-lying position, instruct her to breathe in

deeply from her nose, and at the same time contract pubococcygeus, gluteal, anal
and abdominal muscles, this is associated with drawing all internal viscera up
towards the diaphragm, then she will asked to relax and expire air from her month
with a sigh. This exercise will be done also from supine lying and stride standing
positions, as a progression.
B) Resistive Pelvic floor Exercises:

1- An inflated cuffed catheter:
By using a small quantity of KY jelly, or similar lubricant, an inflated cuffed
catheter is inserted into the vagina, into the area where a tampon would be located.
The patient is then instructed to tighten the pelvic floor muscles to prevent the
withdrawal of the catheter by the therapist. Gentle traction is applied which
stretches the pelvic floor muscles, and provides a sensory biofeedback to initiate
their contraction. The procedure is repeated with varying amounts of traction, and
the patient shown how to manipulate the catheter and give self-resistance. As a
progression the exercise involves maintaining the catheter in the vagina by
contracting the pelvic floor muscles, during coughing, bending, lifting, etc. The
catheter is washed with soap and water, and dried between practice sessions; a
weekly soaking in disinfectant will help to avoid infection. The cuff can be inflated
with air or water (5 ml to 30 ml), depending on the laxity of the vagina.
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2- Vaginal Cones (Fig. 6-4):
Vaginal cones (weights) are easy to use, safe training aid specifically
developed to provide the patient with a strong sensory feedback. So, women can be
trained to contract their pelvic floor muscles in order to retain cones of increasing
weight in the vagina. When a cone of the appropriate weight is inserted into the
vagina, it tends to slip out. The feeling of 'losing the cone' provides a powerful
sensory biofeedback, which makes the pelvic floor muscles contract around the
cone to retain it.
Resting muscle strength is assessed as the heaviest cone retained in the vagina
for one minute while walking. Active pelvic muscle strength is considered as the
weight of the heaviest cone that the patient can retain by contracting the pelvic
floor muscles. Patients are assessed and given the appropriate cone. The next
heaviest cone is given when the previous cone can be retained for ten minutes
while walking. As muscle strength increases, there is less effect on fast twitch
muscle fibers, as maximum effort is not required. However, the fast twitch fibers
are again recruited when a heavier cone is used, and resistance increased.
Cones are available in a set of 5, with weights varying from 20 g to 70 g.

Vaginal cones to be effective in exercising the pubococcygeus (PC) muscle, and
reducing urine loss in women with stress incontinence, they must be done twice
daily for 10 -15 minutes. Hence, resistive exercises for the pubococcygeus muscle
with vaginal cones, most probably useful for the actual treatment of stress
incontinence, prevention of genital prolapse, and as an aid to enhanced sexual
satisfaction.
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Fig. (6-4): Vaginal Cones.
Pelvic floor exercises (PFEs) performed with the aid of vaginal cones:
Firstly: Self conducted pelvic floor ex's:
The patient well instructed about a detailed verbal information and a written
instruction sheet describing the PFE, to be performed at home, over a period of 12
weeks. The written instruction which will be given to the patient:
1. Lie on your back with your legs slightly apart and relax. Tighten the pelvic
floor muscles and hold the contraction for 3 - 5 sec. Then relax completely
again. Breathe calmly and check with your hands the lower part of your
abdomen to ensure that the muscles are relaxed. Repeat the exercise 15 - 20
times.
2. Repeat the same exercise, but with your knees flexed.
3. Do the same exercise standing up with your feet slightly apart. As you feel the
contractions getting stronger you may increase them to 25 times.
4. Stand erect with your heels together and your feet turned slightly outwards.
Contract the pelvic muscles and hold the contraction for 5 - 10 sec; then relax.
Repeat 15 - 20 times.
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Secondly: PFE with the aid of vaginal cones (Fig. 6-5):
The patient will be informed about a detailed verbal and written instructions,
that describing the PFE with the aid of vaginal cones to perform them at home over
a period of 12 weeks, as follows:
Fig. (6-5): Placement of the vaginal cone.
Begin with the cone that you can comfortably retain. While standing up, insert
the cone into the vagina with its tip pointing down. Use some lubricant to facilitate
insertion. Try to retain the cone for 15 min. twice daily while standing or walking
around. The cone will tend to slip out, and you should try to prevent this by
contracting the muscles - the situation with the cone will dictate the required
reaction. After several successful exercises, you can try with the next heavier cone.
Use the string to withdraw the cone, wash and rinse it after use.
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3- Interferential therapy (medium frequency current):
The best treatment for the weak pubococcygeus muscle is by the combination
of pelvic floor exercises (PFE) and electrotherapy. So, electrical stimulation is
necessary to achieve full potential of the pelvic floor muscles, and this could be
provided by a medium-frequency modulated current produced by an interferential
machine.
It is new widely used as means of producing a contraction of pelvic floor
musculature by electro-stimulation. The purpose of interferential is production of
contraction for the pelvic floor musculature as a means of increasing the patient's
cortical awareness, thus facilitating the ability of the patient to perform voluntary
contractions (very weak m's).
Techniques of interferential:
a. Bipolar electrodes:
Patient in semi crock lying position. The posterior (6 ´ 8 cm) electrode, enclosed in
a cellulose sponge pad moisted with warm tap water, was placed directly over the
subject's anal region (under ischial tuberosities). The anterior electrode (4 ´ 6 cm),
similarly enclosed was placed in the median plane, immediately inferior to the
symphysis pubis. The electrodes will be secured in their position by a rubber belt
around the patient's waist. Using frequency of 10 to 40 Hz is applied for 12
sessions, with maximum tolerable intensity to the patient, three / week and each
session for 15 to 20 minutes.
b. Quadripolar electrodes (Vacuum electrodes):
Two electrodes are placed on both sides of lower abdomen just above inguinal
ligament with a distance between them 3 cm and the other two electrodes on the
upper inner side of the thigh, just below inferior border of the femoral triangle.
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Frequency of 0 to 100 Hz is used for 8 to 18 minutes for 12 sessions (3 per week)
(Fig. 6-6).
c. 4 plate electrodes:
Two plate electrodes, 100 cm2 in size, are placed para vertebral low in the lumbar
area and the other two, 50 cm2 in size on the inguinal folds. Six to 15 treatment are
applied for 10 minutes daily at a rhythmical frequency of 0- 100 Hz and 0 -10Hz.
d. Vaginal electrode:
Pre warm the intra vaginal electrodes, coat it with transmission gel and slowly
insert it in the vagina, place the indifferent electrode in the suprapubic region and
secure it with a light weight sandbag. Administer surged alternating current at 100
Hz. Six surges/minute for 10 to 15 minutes, twice weekly for 12 sessions (Fig.6-7).
Interferential current has been suggested as a means of overcoming the
problem of stimulating deep seated structures more effectively through decreasing
the capacitive component (reactance) of the tissue resistance. By decreasing the
reactance, the overall tissue resistance will diminish, thereby facilitating the
stimulation of the deep structures. As a result of that the patients' cortical
awareness increase, thus facilitating the ability of the patient to perform voluntary
contraction of a very weak muscles.
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Fig. (6-6): Position of vacuum electrodes for the application of interferential in stress
incontinence.
Fig. (6-7): A warmed, lubricated vaginal electrode is inserted appropriately, with a

dispersal electrode placed in the suprapubic region, surged alternating interferential
current is preferable in the management of stress incontinence.
4- Faradic stimulation:
Faradic current used to re-educate the pelvic floor muscles, in cases of (1)
stress incontinence of micturition or defecation, (2) frequency symptoms with lack
93
of control of micturition, (4) damaged anal or urinary bladder sphincter, and (4)
insidious occurrence of involuntary and intermittent loss of urine.
a- Technique I :
The patient lies in prone lying position with a pillow under the hips to keep the
hips well flexed. Make sure no fluids have been taken for 2 hours prior treatment.
The rectal or vaginal electrode is rubbed with jelly and inserted into the anus or
vagina. Place the large electrode pad over the lumbosacral region. Select a faradic
current (0.5 to 1 ms pulse duration, 50 to 70 Hz frequency) Faradic surges of 2
seconds duration at a repetition rate of 12 surges per minute. The contractions must
be as strong as the patient can bear.
b- Technique II :
Position the patient in lying position with 3 pillows under the knees and a small
rubber ball between legs. The legs are slightly abducted and rotated externally.
This is to encourage the action of gluteus medius, which is synergist for the levator
ani muscles. Select a faradic current (1 ms pulse duration, 50 Hz frequency). The
rectal or vaginal electrode is rubbed with jelly and inserted into the rectum or
vagina. Place the large electrode pad over the lumbosacral region. The contractions
must be as strong as the patient can bear. The patient compresses the rubber ball
between the legs when the current contracts the pelvic floor muscles and relaxes
with the cessation of the current. Generally, one course of treatment is sufficient to
improve muscle tone (one course is 6 to 10 treatments for 30 minutes).
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5- Functional Retraining for Pelvic Floor Muscles:
PFM should provide ongoing organ support in normal activity and with
increased load and should respond rapidly to stress situations. A voluntary
contraction and hold is needed to improve urethral closure.
Hence, in all effort activities-sneeze, cough, lift, push, drag, nose blow PF
support is required.
6- Stress Exercises:
Are involving active pelvic floor contraction prior to any incontinence
provoking act, such as coughing, sneezing, bending, are taught and progressed, so
that confidence is increased with practice.
7- Pelvic Floor Bracing Instructions:

The patient is instructed that when she is placing additional strain on her pelvic
floor musculature, e.g., coughing, laughing, sneezing or lifting, she must tight and
brace her pelvic floor muscles.
8- Mid-Stream Urine Flow (stop test):

Young et al. (1926) were among the first urologists to recommend exercising
the sphincter muscles during micturition 'by cutting off the flow of urine and
retaining urine as long as possible'.
So that, pelvic floor exercises (Kegel exercises) are known to improve or cure
mild forms of stress incontinence. Because the entire pelvic floor exerts sphincteric
action on the urethra, an increase in resting and active muscle tone will increase
urethral closing pressure.
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Firstly, patients are instructed to stop or slow down the flow of urine during
micturition, through contracting their pubococcygeus muscle (pubovaginalis) near
to the end of micturition. Secondly and as a progression, patients are instructed to
contract their pubococcygeus muscle at the beginning of micturition, which is
more difficult because it needs more muscle power to contract and stop micturition
and more muscle endurance to maintain the muscle contraction and holding. Then
patients are instructed to interrupt their urine during micturition i.e. stop flow of
urine, then allow it to flow, then stop it again, and so on.
Mechanical Devices:
1- Vaginal pessaries:
Have been more widely used for individuals who experience urine loss
associated with specific stressful activities such as jogging, volleyball, or tennis,
the use of vaginal pessaries (cook continence ring, Smith Hodge), worn during the
specific activity may eliminate SUI. By preventing urethral hypermobility through
supporting the proximal urethra during stressful conditions. These pessaries allow
an individual to continue their activities without the embarrassment of leakage.
Use - of the barrier method should be employed with a specific program of pelvic
muscle exercises to strengthen the muscle. A significant improvement resulted in
its use, nevertheless, 26% of the patients reported side effects such as pain,
bleeding, irritation and vaginal laceration.
2- Intra-urethral inserts (urethral plug):

These are small devices similar to a very short urethral catheter, which women
place themselves and remove for urination. While in place, the inserts act as a
barrier to the loss of urine. They are being used for SUI in the absence of
involuntary detrusor contractions. These devices have been shown to be effective
96
in controlling incontinence, but they have a significant side effect such as
haematuria, bacterial cystitis and intravesical migration.
3- Fem Assist device:

The Fem Assist urinary control device, has been introduced recently and fits
over the external urethral meatus rather than within the urethra. The distal urethra
is closed and supported by the device. It appears to be a useful device for the short-
term management of moderate to mild stress incontinence. Fem Assist devices,
decreases incontinence objectively, improves the patient's quality of life, and it is
not associated with urinary tract infection. Because it is held in place by suction, it
may cause urethral prolapse and is contraindicated if this condition is already
present.
4- Pads and Protective Sheets:

A modern incontinence pad has a thin, non-absorbent surface next to the skin
through which urine flows, keeping the perineal skin dry, highly absorbent center
and a waterproof backing. Most women seem to prefer sanitary pads for mild
incontinence, perhaps because they are accustomed to using them during
menstruation.
Hormonal Replacement Therapy (HRT):

Deteriorating ovarian function during the climacteric and following the
menopause, results in a decrease of endogenous estrogen production, and an
increased incidence of urinary symptoms including dysuria, frequency, nocturia,
urgency and 'incontinence. These symptoms are common, but potentially reversible
with erogenous estrogen replacement therapy. However, estrogen becomes an
important issue around menopause and estrogen replacement can be extremely
97
helpful in maintaining normal functioning for the bladder and urethra, as well as
strength of the pelvic muscles. Estrogen pills, patches, or vaginal creams can be
used, the latter providing the most immediate positive effect on the urinary tract.
Combination Therapy:
Despite the seemingly poor response of stress incontinence to estrogen
replacement therapy alone, combination therapy with alpha adrenergic agonists
(e.g. Phenylpropanolamine 50 mg bd) appears promising. Alpha adrenergic
agonists act on the smooth muscles of the urethra to increase urethral closure
pressure and their effect is potentiated by concomitant estrogen therapy. Hence,
combination therapy is more effective than either treatment alone for the
management of genuine stress incontinence.
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References:
Mantle J, Haslam J and Barton S (2019): Physiotherapy in Obstetrics and
Gynaecology, 2nd Eds, Elesiver, London, United Kingdom.
Herbert R, Jamtvedt G, Mead J, et al.: Practical evidence-based physiotherapy.
2nd ed. Oxford: Elsevier; 2011.
Shannon L. Wallacea, Millerb L and Mishraa K (2019): Pelvic floor physical
therapy in the treatment of pelvic floor dysfunction in women, Urogynecology.
;31:1-9.
Sankarganesh A, Arthi M and Siva Kumar V (2018): Interfrential Therapy
Versus Pelvic Floor Exercise for the Management of Stress Urinary in Women,
Journal of Physiotherapy Research; 2:1-11.
Ibrahim I, Taher E and Shaheen E (2015): Efficacy of biofeedback-assisted
pelvic floor muscle training in females with pelvic floor dysfunction. Alexandria
Journal of Medicine; 51:137-142.
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Physical Therapy for Overactive Bladder
Ass. Prof. Afaf M. Botla, PT PhD
Anatomy of urinary bladder and urethra

The urinary bladder is a hollow muscular organ and low-pressure reservoir for
urine that is excreted by the kidneys. In the adult, the bladder is an extraperitoneal
pelvic organ that lies behind the pubic symphysis. It has the shape of a tetrahedron,
which is a 3-sided pyramid.
The walls of the bladder are mainly formed by detrusor muscle, which allows the
bladder to contract to excrete urine or relax to hold urine. At the inferior end of the
bladder, the detrusor muscle is continuous with the internal urethral sphincter. The
combination of detrusor contraction and urethral sphincter relaxation leads to
urination. The detrusor muscle is under control from the autonomic system and is
composed of smooth muscle.
Normal position of the bladder

The normal position of the bladder can vary depending on the volume of the urine
and the muscular distension, as well as on the anatomic integrity of the supporting
structures, especially in the elderly females. A full urinary bladder can be palpated
abdominally as it rises anteriorly and superiorly.
Physiology of Micturition
The bladder is a sophisticated organ, which stores urine until it is appropriate to
initiate the micturition in response to internal and external stimuli. Micturition
involves the higher brain cortex, pons, spinal cord, and peripheral autonomic,
100
somatic, and sensory afferent innervation of the lower urinary tract, as well as the
anatomical components of the lower urinary tract itself.
Under normal physiological circumstances, micturition in humans occurs in

response to afferent signals from the urinary bladder. It is controlled by neural
circuits in the brain and spinal cord, which coordinate the activity of the smooth
muscle in the detrusor and urethra with that of the striated muscle in the urethral
sphincter and pelvic floor. The lower urinary tract is innervated by an integrated
afferent and efferent neuronal complex of peripheral neural circuits involving
sympathetic, parasympathetic, and somatic neurons.
The sensation of bladder fullness that precedes normal micturition occurs through
stimulation of stretch-sensitive receptors during the filling phase. These receptors
activate mechanosensitive axons that convey impulses informing the brain that the
bladder is reaching capacity. Thus, the bladder contraction is believed to be
initiated by these sensory stimuli.
The sympathetic nervous system stimulates the sphincter closure in the urethra and
relaxes the detrusor muscle during filling. On the other hand, the parasympathetic
nervous system is responsible for the contraction of the detrusor muscle during
micturition while simultaneously relaxing the urethral sphincter. Somatic
innervation tends to maintain active tone in the pelvic floor musculature. It
provides excitatory innervation to the striated muscles of the external urethral
sphincter.
Any disease process or injury to the central nervous system in adults can disrupt
the voluntary control of micturition and cause the reemergence of reflex
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micturition, causing overactive bladder (OAB), detrusor overactivity, and urinary
incontinence.
Definition of OAB:
The OAB is characterized by frequency and nocturia with or without urgency
urinary incontinence (UUI). Women with severe OAB experience significant
social and physical impairment, sexual dysfunction, sleep disturbance, and
depression. OAB is associated with higher rates of disability, missed days of work,
and nursing home admissions
Prevalence of OAB
OAB is prevalent in women. It occurs at least in 30% of women compared with
16.4% of men among 10,000 survey respondents who were 18 to 70 years of age.
African American women have higher rates of overactive bladder (45.9%) than
white (43.4%), Hispanic (42%), and Asian (26.6%) women. OAB prevalence
increases with age, with 54.5% of women 66 to 75 years old, and 63.6% of women
76 to 85 years old reporting symptoms.
Causes of OAB
Owing to the difficulty in identifying the underlying pathology for the
development of OAB in most patients, it is often labelled as “idiopathic”. It has
been suggested that there are several subtypes of OAB based on the underlying
mechanism or pathophysiology
1-Metabolic syndrome
OAB may have its own pathophysiology in patients with metabolic syndrome.
Increased weight stimulates sensory afferents of the trigone and bladder neck.
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Also, oxidative stress, systemic inflammation, and insulin resistance promote
chronic pelvic ischemia and urothelial dysfunction.
2-Affective disorders
Emotional stress and a history of anxiety/depression may be risk factors for the
development of OAB in women. This is not surprising in view of the central
processing of afferent impulses in the limbic region of the brain.
3-Sex hormone deficiency

The impact of sex hormone deficiency on the lower urinary tract in female patients
has been clearly established due to presence of the estrogen and progesterone
receptors in the urethra, bladder, and pelvic floor muscles.
Several mechanisms could explain the role of estrogen deprivation in the onset of
urinary urgency. Increased detrusor contractility occurs through Rho-kinase
pathway activation, increased acetylcholine release, changes in urothelial afferent
signaling.
4- Urinary microbiota
The urinary microbiota may play a role in the pathogenesis of OAB, although the
mechanisms underlying the causative relationship, as well as its possible
therapeutic implications, are still unclear. Bacterial DNA and a higher load of
bacteria are more frequently detected in patients with urinary incontinence, with
possibly decreased urinary microbiome diversity.
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5-Functional gastrointestinal disorders
The bladder and colorectum have the same embryological origin and thus share
spinally derived neural pathways with dichotomized afferents innervating both
organs and converging at a single dorsal ganglion root. This same origin allows
mechanisms of communication between the bladder and the colon known as cross-
talk.
The co-occurrence of urological and gastrointestinal functional disorders is

thought to be underpinned at least partly by the pelvic organ crosstalk and cross-
sensitization mechanisms.
Bidirectional relationships between OAB and fecal incontinence or constipation

have been suggested. However, the gastrointestinal condition that has most
frequently been inter-related to OAB is irritable bowel syndrome. The prevalence
of irritable bowel syndrome is as high as 33.3% in patients with OAB.
6-Autonomic nervous system dysfunction

Sympathetic, parasympathetic, and somatic nerves are well-known determinants of
lower urinary tract physiological functioning. So, subclinical autonomic nervous
system dysfunction may be a causative factor of “idiopathic” OAB.
Risk Factors of OAB

There are many risk factors associated with OAB such as pelvic organ prolapse,
which can cause bladder obstruction that plays an important role in the occurrence
of OAB, smoking, previous surgery for urinary incontinence, advanced age,
obesity, multiparty, and post-menopausal status
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Other factors may also play a role. For example, lower socioeconomic status has
been associated with more severe urinary incontinence. Anxiety and depression
have also been linked with urinary incontinence. There is growing evidence that
central nervous system dysregulation, particularly in response to psychological
stress, may contribute to the pathophysiology of OAB and urinary incontinence.
Impacts of OAB on Life

Women who have daily urinary incontinence symptoms have a higher risk of falls
and fractures, because presumably they often rush to the toilet to prevent leakage.
Symptoms of OAB have a negative effect on a woman’s well-being, including her
quality of life causing functional limitations. OAB affects performance of daily
activities and social function such as work, traveling, physical exercise, sleep, and
sexual function.
Diagnosis of OAB
1- History taking
The diagnosis of OAB is based in part on information that patients provide on their
symptoms, the degree of discomfort and how it impacts their quality of life.
Diagnosis of OAB is considered in the absence of urinary tract infection, metabolic
disorders affecting urination, or urinary stress incontinence generated by effort or
overexertion. Only a third of OAB patients show urge incontinence also called wet
OAB.
2- Urodynamic investigations
Urodynamics is a mandatory for diagnosis and treatment among women with OAB
symptoms, because diagnosis based on urinary symptoms alone would lead to
under-diagnosis of detrusor contraction (DO). Urodynamics is usually considered
105
when primary treatment for OAB fails. Urodynamics may be necessary for
accurate diagnosis in women with OAB.
Treatment of OAB
The American Urological Association’s treatment guideline for OAB has three
levels: first-line treatment is lifestyle modifications and behavioral bladder
retraining, second-line treatment is pharmacological therapy, and third-line
treatment involves neuromodulation.
I-First Line Treatment

A- Lifestyle Modification
Lifestyle modification includes:
1- Weight loss
Sustained weight loss can improve incontinence symptoms. Encouraging women
to lose excess weight is an important clinical intervention, considering the
significant increase in the prevalence of obesity from among female with ages of
60 and older.
2- Dietary changes
Modifications in fluid intake, constipation prevention measures and a
reduced intake of caffeinated, carbonated, and alcoholic drinks are very important
measures. Reducing fluid intake by 25% with daily fluid intake not less than one
liter per day has been recommended to manage OAB.
3- Smoking cessation
4- Increased physical activity
B-Behavioral bladder retraining
The main components of bladder retraining are timed and delayed voiding, as well
as pelvic floor muscle rehabilitation, with or without biofeedback.
106
1- Bladder retraining
Timed voiding involves urinating at regular set intervals that disregard the normal
urge to void. Initially, voiding intervals may be as short as every 30 minutes. Then,
the time between voids is being slowly increased over several weeks until the
patient can maintain control for periods of three to four hours.
This regimen slowly increases the bladder capacity and may reduce the number of
episodes of urgency and urgency incontinence. Patients need to keep a written
urination log so that they can verify improvement or worsening of symptoms.
2- Pelvic floor exercises

Pelvic floor exercises are inexpensive and are done at home after some focused
learning under the instructions of a physiotherapist. Sustaining these exercises for
periods of 10 minutes several times of the day has contributed to success to bladder
drills especially in those with mixed urinary incontinence.
II-Second line treatment (Pharmacological therapy)

Drugs including anticholinergics are the mainstay of current medical management
of OAB. Anticholinergics, which is also known as antimuscarinics, improve
symptoms of OAB via two mechanisms. The first mechanism leads to decrease the
amplitude of bladder contractions improving bladder capacity, second mechanism
may work on urothelial sensory receptors inhibiting afferent nerve activity. Side
effects of drugs may include mental confusion, dry mouth, and constipation,
papillary dilatation, and difficulties in lens accommodation
107
3-Third line treatment (Neuromodulation)
If first and second line treatments do not improve symptoms of OAB, the condition
is considered to be refractory. In that case, treatment may involve regulation of the
nerves that control the bladder through the use of one of three neuromodulation
techniques: tibial nerve stimulation, sacral neuromodulation
The innervation of the lower urinary tract comes from the lumbar, sacral, and
coccygeal segmental nerves originating from L2-S4. Neuromodulation uses direct
electrical stimulation to modify bladder sensation and contraction. Various forms
of neuromodulation are also available and might be preferred by women with
incontinence who wish to avoid daily oral medication.
1- Sacral nerve stimulation
Sacral-nerve stimulation consists of implantation of a wire electrode in one of the
sacral foramina, usually S3, which is then connected to a stimulator device. Sacral
neuromodulation could play a role in restoring balance between the inhibitory and
excitatory control system of the bladder. It could inhibit activation of the
exacerbated guard reflex after spinal cord injury and facilitate voiding by
interrupting excitatory outflow of the external urethral sphincter.
Sacral nerve stimulation (SNS) has been proved to be effective in the treatment
OAB but is considered invasive and related to complications such as infection,
pain, and need of surgical revision because of lead migration in 33% of cases.
2- Tibial nerve stimulation

Tibial nerve stimulation provides a non-invasive (transcutaneous) or minimally
invasive (percutaneous) option in the treatment of neurogenic lower urinary tract
dysfunction. Tibial-nerve stimulation delivers neuromodulation to the pelvic floor
108
through the S2-S4 junction of the sacral nerve plexus via the less invasive route of
the posterior tibial nerve. This anatomical area has projections to the sacral nerve
plexus, creating a feed-back loop that modulates bladder innervations. Multiple
studies indicate that tibial nerve stimulation might be effective and safe for OAB
patients
109
References
- Mangera, A., Osman, NI. And Chapple CR. (2013): “Anatomy of the
lower urinary tract”. Surgery (Oxford), 31 (7): 319-325.
- He, Q., Wang, Z., Liu, G., Daneshgari, F., MacLennan, GT. And Gupta,
S. (2016):’’ Metabolic syndrome, inflammation and lower urinary tract
symptoms: possible translational links’’. Prostate Cancer and Prostatic
Diseases, 19(1): 7–13.
- Vrijens, D., Drossaerts, J., van Koeveringe, G., Van Kerrebroeck, P.,
van Os, J. and Leue, C. (2015):’’Affective symptoms and the overactive
bladder—A systematic review’’. Journal of Psychosomatic Research ,78(2):
95–108.
- Aragón, IM., Herrera-Imbroda, B., Queipo-Ortuño, MI., Castilo, E.,
Sequeira-Garcia Del Moral, J., Gomez-Millan, J., Yucel, G. and Lara,
M. (2018):’’The urinary tract microbiome in health and disease’’. European
Urology Focus, 4(1):128–138.
- Tellechea, L., Zuo, S., Kohn, JR., Fazzari, MJ., Eisenberg, R., Lee, J.,
Laudano, M., Chen, C. and Abraham, N. (2020):’’The effect of social
determinants of health on overactive bladder symptom severity’’. The
Journal of Urology, 205(5): 1415-1420.
- Cho, KJ., Kim, HS., Koh, JS. And Kim, JC. (2015):’’Evaluation of
female overactive bladder using urodynamics: relationship with female
voiding dysfunction’’. International Braz J Urol: Official Journal of the
Brazilian Society of Urology, 41(4): 722–728.
- Pratt, TS. And Suskind, AM. (2018):’’Management of overactive bladder
in older women’’. Current Urology Reports, 19(11): 92.
110
Physical Therapy for Fecal incontinence
Dr. Sara M. Ahmed, PT PhD
Dr. Shreen R Aboelmagd
Definition:
The uncontrolled passage of feces or gas over at least 1 month’s duration, in an
individual of at least 4 years of age, who had previously achieved control. Fecal
incontinence (FI) affects the quality of life, leads to embarrassment and social
isolation, and strains personal and family relationships.
Prevalence
It has been shown to be more prevalent in multiparous women, those women who
have undergone instrument-assisted vaginal deliveries and in women following
traumatic deliveries involving significant vaginal tears, and with increasing age.
Mechanisms of Fecal Continence
• The anal sphincter complex involves two muscles, the internal sphincter and
the external sphincter. The internal sphincter muscle is a continuation of the
circular muscles of the rectal wall, consists of smooth muscles, and is under
autonomic nervous system control. The external sphincter muscle is a
continuation of the pelvic floor musculature, consists of skeletal muscles,
and is under voluntary nervous system control (Fig.7-1).
Fig. (7-1) The anal sphincter complex
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• The acute angle of the anorectal junction provides some degree of
continence control (Fig.7-2).
Fig. (7-2): Acute angle of the anorectal junction
• Rectal distension by stool induces rectal contraction, the sensation of

urgency, reflex relaxation of the internal anal sphincter, and relaxation of the
pelvic floor muscles, the puborectalis and external anal sphincter, prompting
defecation if it is socially convenient. If not, rectal contractions and the
sensation of urgency generally subside as the rectum accommodates to
continued distention. This accommodation, together with voluntary
contraction of the external anal sphincter and puborectalis muscles, allows
defecation to be postponed when necessary (Fig.7-3).
Fig. (7-3): Process of defecation
Etiology of fecal incontinence

The etiology of FI is multifactorial and caused by the disruption of the continence
mechanism depended on anal sphincter function, intact rectal sensation, adequate
rectal capacity, colonic transit time, stool consistency, cognitive and neurologic
112
factors. It was reported that 80% of patients with FI had more than one continence
factor compromised.
1. Muscle damage: Injury to anal sphincter may make it difficult to hold stool
back properly. This kind of damage can occur during childbirth, especially if
an episiotomy or forceps was used during delivery.
2. Nerve damage: Injury to the nerves that sense stool in the rectum or those
that control the anal sphincter can lead to fecal incontinence. The nerve
damage can be caused by childbirth, constant straining during bowel
movements, spinal cord injury or stroke. Some diseases, such as diabetes
and multiple sclerosis, also can affect these nerves and cause damage that
leads to fecal incontinence.
3. Constipation: Chronic constipation may cause a dry, hard mass of stool
(impacted stool) to form in the rectum and become too large to pass. The
muscles of the rectum and intestines stretch and eventually weaken, allowing
watery stool from farther up the digestive tract to move around the impacted
stool and leak out. Chronic constipation may also cause nerve damage that
leads to fecal incontinence.
4. Diarrhea: Solid stool is easier to retain in the rectum than is loose stool, so
the loose stools of diarrhea can cause or worsen fecal incontinence.
5. Hemorrhoids: When the veins in the rectum swell, causing hemorrhoids,
this keeps your anus from closing completely, which can allow stool to leak
out.
6. Loss of storage capacity in the rectum: Normally, the rectum stretches to
accommodate stool. If the rectum is scarred or the rectal walls have stiffened
from surgery, radiation treatment, the rectum can't stretch as much as it
needs to, and excess stool can leak out.
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7. Surgery: Surgery to treat enlarged veins in the rectum or anus
(hemorrhoids), as well as more-complex operations involving the rectum
and anus, can cause muscle and nerve damage that leads to fecal
incontinence.
8. Rectal prolapse: Fecal incontinence can be a result of this condition, in
which the rectum drops down into the anus.
9. Rectocele. In women, fecal incontinence can occur if the rectum protrudes
through the vagina.
Fecal incontinence can be separated into clinical subtypes:
• Passive incontinence: which occurs without warning
• Urge incontinence: which occurs despite active efforts to retain stool
• Mixed presentation
Grading system
• The Parks’ scale: It is easy to use and remember. It has several major
shortcomings as it did not address symptom severity, the frequency of
incontinence episodes or any impact that the incontinence might have on
health-related quality of life.
• The Pescatori AI score: It is a grading system widely used throughout Italy

and combines both degree of incontinence (flatus–mucus/liquid stool/solid
stool) with frequency.
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• Symptom-Severity Scale in Fecal Incontinence:
Assessment of fecal incontinence

I. A detailed history of incontinent symptoms, medical and surgical history,
medications, and quality of life.
II. Physical examination:
§ Careful anorectal examination should be performed, first addressing the
perineum for presence of skin irritation, moisture, fecal soilage, scars,
deformities, anal stenosis, hemorrhoids, fistula, or abscess. Also, whether the
anal canal is open or closed at rest and the sphincter action while squeezing
should be observed and documented.
§ Digital rectal exam will evaluate the presence of sphincter defect, resting
tone, anal or rectal masses, squeezing pressure, and the presence of mucosal
or rectal prolapse.
§ Vaginal exam should be performed to evaluate for presence of rectoceles,
cystoceles, enteroceles or vaginal prolapse.
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§ Anorectal manometry: It consists of a catheter with a balloon on the end
which is inserted rectally. It evaluates the anal resting pressure (normally
around 30-40mmHg), anal squeeze pressure (around 150% of resting
pressure), recto-anal inhibitory reflex, compliance of the rectum, and sensory
thresholds in response to balloon distension “the volume that should fill your
rectum to indicate that first sensation (20-35mL), an urge to poop (120-
150mL), and reach maximum tolerance for stretch (200-300mL)” (Fig.7-4)
Fig. (7-4): Anorectal manometry
§ Defecography: It provides a radiographic picture of the act of defecation

allowing visualization of the action of the pelvic floor. The anorectal angle
during defecation, presence of rectocele, and completion of rectal emptying
can be assessed (Fig.7-5).
Fig. (7-5): Defecography
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§ Anal endosonography: It visualizes the internal and external sphincters,
assesses their length and width and any scar tissue or defects that may be
present. This tool should be used to evaluate FI in female patients with a
history of vaginal delivery or suspicion of obstetric trauma (Fig.7-6).
Fig. (7-6): Anal endosonography
§ Pudendal nerve terminal motor latency: (Fig.7-7)

This tool measures the time it takes for stimulation of the pudendal nerve,
from the ischial tuberosity to the anal canal, to elicit contraction of the pelvic
floor muscles. Delayed response is associated with pudendal neuropathy,
which can contribute to FI .
Fig. (7-7): Pudendal nerve terminal motor latency
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§ Magnetic resonance imaging (MRI): It is the only imaging modality that
can visualize both anal sphincter anatomy and global pelvic floor motion
(anterior, middle, and posterior compartments).
TREATMENT
I. Conservative treatment
v Dietary Consideration:
1. Patients should be educated on factors contributing to bowel disturbances
and loose stool consistency including foods containing incompletely
digested sugars (fructose, lactose), sweeteners, carbonated beverages,
caffeine, alcohol, cured or smoked meat (sausage, ham, turkey), spicy foods,
fatty and greasy foods.
2. Fiber supplementation: The mechanisms of dietary fiber depend on stool
composition and consistency, which vary among the types of fiber ingested.
Fiber, when fermented but not completely degraded by colonic bacteria, has
been shown to increase stool bulk fiber with high water-holding capacity
(psyllium). It allows a gel formation, which normalizes stool consistency.
Increasing rectal distension can improve sensory awareness of the need to
defecate, which may reduce FI episodes and promote complete evacuation of
stool, leaving less in the rectum to leak.
v Behavioral modification:
- Weight reduction is typically encouraged, as obesity is a well-documented
risk factor for the development of FI.
- Also, stopping smoking is encouraged as it causes atrophy of external anal
sphincter (EAS).
- Avoid straining as straining during bowel movements can eventually weaken
anal sphincter muscles or damage nerves.
- Improving perianal skin hygiene.
118
v Pharmacologic Approaches:
- Loperamide reduces diarrhea and slightly increases internal sphincter tone,
thereby reducing FI. It is important to ensure that adequate doses are
administered (2–4 mg, 30 min before meals, up to 16 mg daily).
- Patients with constipation, fecal impaction, and overflow incontinence may
benefit from a regular evacuation program using timed evacuation by digital
stimulation and/or glycerol suppositories, fiber supplementation, and
selective use of oral laxatives.
v Pelvic Floor Muscle Training (PFMT)

a) PFMT typically consists of verbally guided instruction in pelvic floor and
sphincter contractions (Kegel contractions). Patients can be taught to
contract in a variety of ways, for examples include maximal voluntary
sustained sphincter contractions, submaximal sustained contractions, and
fast-twitch or “quick-flick” contractions.
b) Thoracoabdominopelvic muscle training has also been advocated, as it has
been theorized that training all core muscles to work in tandem would be
more effective than a narrow focus on the pelvic floor muscles alone.
v Biofeedback therapy (BFT): There are three main approaches in how

biofeedback is used as a part of pelvic floor rehabilitation for FI
a) The most common type is for strength and endurance training for the pelvic
floor and/or anal sphincter. The biofeedback apparatus gives information
about how strongly the muscles are being contracted, and the patient can use
that information to learn how to do the pelvic floor exercises more
effectively.
119
The theory behind strength and endurance training is that if the sphincter
muscles are stronger, the patient will be able to hold in the stool for a longer
period and enable them to make it to the restroom with less accident.
b) The second treatment modality is to use BFT to improve rectal sensitivity or

compliance. This type of treatment has also been termed (volumetric
rehabilitation) and is typically done with rectal balloons. The balloon is
inflated with air or water to determine the first sensation of rectal filling. It is
then gradually inflated with decreasing amounts of air or water to teach the
patient to appreciate stool in the rectal vault at progressively lower volumes.
The rationale behind sensory retraining is to allow the patient to detect

smaller volumes of stool at an earlier time, again making it possible for them
to reach the restroom before an accident occurs. It also allows for the patient
to have more time to perform a voluntary anal sphincter contraction before
the volume of stool in the rectal vault overwhelms the patient’s ability to
hold it inside.
c) The third BFT approach deals with coordination training for the anal
sphincter. Multiple balloons are again inserted, a large one in the rectum
itself and one or two smaller ones in the anal canals. These are typically
connected to a manometric pressure-recording device. When the larger
balloon is inflated, the rectal–anal inhibitory reflex is triggered, and the
patient is taught to appreciate the momentary internal anal sphincter
relaxation that results. The patient can then be taught to do a voluntary
external sphincter contraction to counteract the involuntary relaxation of the
internal sphincter.
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v Electrical Stimulation
§ In endoanal electrical stimulation, the vulva nerve and anal sphincter are
stimulated, which leads to improved strength and endurance of the striated
muscle (external anal sphincter). Electrostimulation of the rectum reduces
the tendency of the sphincter to fatigue and improves the sensory function of
the rectum.
§ Passive muscle stimulation, it is a valuable therapeutic tool in the case of
severe muscle weakness.
v PFM Magnetic Stimulation

§ Trans-lumbar magnetic stimulation and trans-sacral magnetic stimulation
(rTSMS) will significantly improve FI symptoms through neuroplasticity.
§ Therapeutic benefit: It enhances anal muscle strength, improve neuropathy,
improve stool awareness, and improve rectal capacity.
v Radiofrequency Energy Delivery to the Anal Canal

The device delivers temperature-controlled radiofrequency energy to the
anal sphincter complex and is based upon the biologic rationale that the
procedure results in collagen deposition and tissue remodeling.
v Laser acupuncture:
v Neuromodulation therapy for FI
a) Sacral Nerve Stimulation
b) Posterior tibial nerve stimulation
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II-Surgical options for the Treatment of FI
a) Stimulated Graciloplasty: Gracilis muscle transposition has been used in
treating FI. Electrical stimulation converts the gracilis muscle to slow twitch
(Type I) muscle allowing it to function as a sphincter.
b) Gluteoplasty: Surgical transposition of gluteal muscles, it is larger and
stronger than the gracilis muscle and provides more bulk to help reinforce
the anal canal.
c) Artificial Bowel Sphincter
d) Antegrade Colonic Enemas (ACE): A connection is created between the
abdominal wall and the colon using the appendix or from a piece of small
intestine. This duct is brought to the surface of the skin via a small opening
called a stoma. This procedure is designed to help empty the bowel of feces
using fluid (like an enema) inserted into a small opening in the side of the
abdomen rather than into the rectum.
e) Local Injection of the Internal Sphincter: Although the internal sphincter
cannot be surgically repaired, a variety of substances have been locally
injected to improve continence. These substances as: autologous fat and,
silicone based Bioplastique.
v Mechanical inserts:
a) Vaginal Bowel Control (VBC) System
b) Anal inserts.
c) Procon Incontinence Device: Single-use disposable balloon cuff, silicon
catheter with an IR photo interrupter sensor and flatus vent holes at distal
end connected to a pager and allows escape of gas n Silicone balloon water-
filled to 25-30 mL n When stool enters rectum, photo-interruptor sensor
122
sends signal indicating imminent BM. Voluntary evacuation by deflating
balloon and removing catheter (Fig.7-8).
Fig.(7-8): Procon Incontinence Device
123
References
- Kelly M. (2014): Pelvic Floor Rehabilitation in the Treatment of Fecal
Incontinence. Clin Colon Rectal Surg, 27(3): 99–105.
- Dana M. and Eric G. (2011): Fecal Incontinence: Etiology, Evaluation, and
Treatment. Clinics in colon and rectal surgery,24(1):64-70.
- Ian M., Madhulika G., Andreas M., Scott R., and Janice F. (2015): Clinical
Practice Guideline for the Treatment of Fecal Incontinence. Diseases of the
Colon & ReCtum, 58(7): 623-36.
- Kristen B.and Bhumy Davé-Heliker (2019): Mechanical inserts for the
treatment of faecal incontinence:A systematic review. Arab journal of
Urology,17(1): 69-76.
- Avinoam N. (2014): The epidemiology of anal incontinence and symptom
severity scoring. Gastroenterology Report 2(2): 79–84.
- Meyer I. and Richter H. (2016): Evidence-Based Update on Treatments for Fecal
Incontinence in Women. Obstet Gynecol Clin North Am, 43(1): 93–119.
- Jennifer Y and Maher A (2013): Current Management of Fecal
Incontinence. The Permanente Journal, 17(3):65-73.
- Van Koughnett and Wexner S. (2013): Current management of fecal
incontinence: Choosing amongst treatment options to optimize outcomes. World
J Gastroenterol, 19(48): 9216-9230.
- Wald A. (2016): Update on the Management of Fecal Incontinence for the
Gastroenterologist. Gastroenterology & Hepatology 12(Issue 3).
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Genital prolapse
Dr. Manal A. El shafei, PT PhD
Definition:
Descent of one or more of genital organs (uterus, vagina, bladder, urethra, rectum,
Douglas pouch) through the fasciomuscular pelvic floor below their normal level.
Types of prolapse
I. Vaginal prolapse:
1-Anterior vaginal wall prolapse:
a. Cystocele: It is a prolapse of the upper part of the anterior vaginal wall with
the base of the bladder.
b. Urethrocele: It is a prolapse of the lower part of the anterior vaginal wall with
urethra.
c. Cysto-urethrocele: It is a complete anterior vaginal wall prolapse.
2- Posterior vaginal wall prolapse:

a. Rectocele: It is a prolapse of middle third of posterior vaginal wall with
anterior wall of the rectum.
b. Enterocele: It is a hernia of Douglas pouch. It occurs if upper third of
posterior vaginal wall descends lined by peritoneum of Douglas pouch and
containing loops of intestine (Fig. 8-1).
II. Vault prolapse: It is a descent of vaginal vault or inversion of the vagina after
hysterectomy.
125
Fig. (8-1): Cystocele and rectocele
III. Uterine prolapse
1-Utero-vaginal: The uterus descends firstly followed by vagina, usually
occurs in virgins or nulliparous due to congenital weakness of the cervical
ligaments.
2-Vagino-uterine: The vagina descends firstly followed by the uterus, usually
results from obstetric trauma.
Degrees of uterine prolapse:

1st degree: The cervix descends below its normal level on straining but does not
protrude from the vulva.
N.B: the external os of the cervix is at the level of the ischial spine.
2nd degree: The cervix protruds from the vulva on straining.
3rd degree (complete procidentia): The whole of the uterus is completely
prolapsed outside the vulva and the vaginal wall becomes completely inverted
over it (Fig. 8-2).
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Fig. (8-2): Degrees of uterine prolapse
Causes of prolapse
• Predisposing factors:
1- Weakness of pelvic cellular tissue:
The cervical ligaments, which act as the main uterine support may become
weakened by the following:
st
a- Obstetric trauma (large sized fetus, straining during 1 stage, prolonged
nd rd
2 stage with delayed episiotomy, fundal pressure to deliver placenta in 3
stage).
b- Congenital weakness (as in spina bifida which interfere with innervation of
pelvic floor).
c- postmenopausal atrophy (low estrogen level cause atrophy of pelvic cellular
tissue, ligaments, and levator ani).
2- Injury of the pelvic floor (badly repaired or un sutured perineal tear, hidden
perineal laceration).
Activating factors: It includes factors increase intra-abdominal pressure
(IAP) as cough and constipation, retroversion retroflexed uterus (RVF),
heavy bulky uterus)
127
Symptoms:
Early: Sensation of weakness in the perineum at the end of the day.
Later: There is mass appearing on straining and disappearing when patient
lies down.
Urinary symptoms:
- Urgency and frequency by day.
- Stress incontinence
Rectal symptoms: Heaviness in the rectum and constant desire to defecate.
Backache, congestive dysmenorrhea and menorrhagia.
Leucorrhea.
Treatment of genital prolapse:

Prophylactic treatment.
Palliative treatment
Actual treatment (physiotherapy role).
Surgical treatment.
1- Prophylactic treatment
Careful attention for the obstetric cases can prevent subsequent prolapse and
incontinence.
A- proper antenatal care:
Pelvic floor exercises should be done during pregnancy as pelvic floor muscle
(PFM) should be strong and elastic:
- Strong to be able to perform gutter like action (internal rotation of fetal
head during second stage of labor).
128
- Elastic to allow easy passage of fetus without or with minimal tear or
trauma.
B- proper intra-natal care:
Proper management of first stage:
st
- Keep bladder empty during 1 stage of labor.
- Avoid straining during the first stage of labor before full cervical dilatation.
- Avoid forceps usage before full cervical dilatation.
Proper management of second stage:
- Firm support to the perineum during the uterine contractions to avoid
overstretching or laceration of perineum.
- The mother should stop bearing down during contraction and to pant.
- Proper timing of episiotomy (at crowning if indicated) should be done to
avoid hidden perineal laceration.
- Avoid fundal pressure to deliver the placenta during third stage of labor.
Proper post natal care:
- Any perineal tear or laceration should be repaired carefully within 24 hours.
- Strengthening exercises of PFM to regain its strength, which may be
stretched or injured during delivery.
- Avoid retroversion flexion (RVF) by positioning (relaxation on face, knee
chest position).
- Avoid bladder infection to guard against urgency incontinence.
- Avoid constipation and maintain good general health.
2- Palliative treatment:
- Pessaries are only temporary methods to give relief of symptoms.
Indications of pessary:
- Slight degree of prolapse in young patient.
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- Prolapse of the uterus with early pregnancy.
- Temporary contraindications to operations as lactation, sever cough.
- Bad surgical risks as old patient with severe hypertension or uncontrolled
diabetes.
Types of pessary:
- Ring pessary: It is introduced above level of levator ani to stretch redundant
vaginal wall and prevent descent of uterus
- Cup and stem pessary: It is used when PFM are so weak or lacerated so ring
pessary cannot be retained in vagina.
3- Actual treatment ( physical therapy role):
In early and mild cases and as a prophylactic measure for puerperal cases.
Aims of treatment:
- To normalize the pelvic floor support and sphincter mechanism.
- To strengthen the pubococcygeus muscle.
Physical therapy treatment is divided into two phases:

1- Muscle re-education: to increase awareness of patient about function of
pubococcygeus muscle. It includes:
A- Muscle reeducation for pubococcygeus muscle.
B- Biofeedback (kegel perineometer and EMG biofeedback.
c- Cyriax method.
2- Resistive exercises for pubococcygeus muscle:
A- An inflated cuffed catheter.
B- Vaginal cones.
130
A- muscle reeducation of pubococcygeus muscle:
- PFM consists of slow twitch muscle fiber and fast twitch muscle fiber
- Slow →responsible for maintain resting tone of muscle.so, it can be strengthened
by increase repetitions of ex.
- Fast→ save closure mechanism and guard against involuntary leakage of urine.
So, it can be strengthened by resistive ex.
Graduations of pubococcygeus muscle exercise: (as in stress incontinence).
B- Biofeedback:
1- Kegel perineometer:
- It consists of cylindrical rubber vaginal chamber connected to manometer by
rubber tube.
- Vaginal chamber is lubricated by KY gel and inserted into vagina while the
patient in comfortable crock lying position with pillows under head and
knees. The patient was asked to contract pubococcygeus muscles as she can
and hold contraction.
- It measures intra-vaginal pressure reflecting force of contraction of PFM., it
can measure contractions up to 100 mmHg.
- It provides patient with sensory and visual feedback (Fig. 8-3).
Fig. (8-3): Perineometer

2- EMG biofeedback:
- It consists of vaginal electrode, 3 surface electrodes, earphone, and screen.
131
- It provides patient with sensory, visual, and auditory feedback.
-It is used in both evaluation and actual treatment of pelvic floor dysfunction.
- It is useful in both increasing level of PFM contractions and improving ability
of the muscle to relax. The time spent on biofeedback session is dependent on
the female’s response, for example when PFM contractions begin to show
fatigue, or the female begins to compensate with abdominal muscles, it is time
to end the session.
C-Cyriax method:
-It aims to strengthen pubococcygeus, glutei, anal and abdominal muscles.
Resistive pelvic floor exercises:

To strengthen PFM, it should be started after restoring normal muscle tone.
A- An inflated cuffed catheter:
- It is a catheter that is inflated with air or water according to the degree of
vaginal laxity. Exercises of the pelvic floor is done from various positions. As a
progression, it can be done during coughing, bending, and lifting.
B- Vaginal cones:
- Cones are available in 5 sets with weights ranged from 20-70 g.
- It is useful for actual treatment of genital prolapse and aid to enhance sexual
satisfaction.
- It provides patient with strong sensory feedback as once cone is inserted in
vagina, it tends to slip out. The feeling of losing makes pelvic floor muscle to
contract around cone to retain it.
- Resting muscle tone is assessed as the heaviest cone retained in vagina for one
minute while walking.
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- Active pelvic muscle strength is considered as the heaviest cone that the
patient can retained by contracting PFM.
- The next heavier cone is used when the patient become able to retain the
previous cone for 10 min during walking. The resistance should be increased by
using the heavier cone for recruiting further fast twitch muscle fiber and
increase muscle strength.
- PFM exercise with aid of vaginal cones should be used twice daily for 10- 15
min (Fig. 8-4).
Fig. (8-4): Vaginal cones

Interferential therapy:
- It is a medium frequency current used to overcome skin resistance and reach
to deep tissue producing contraction of pelvic floor muscle.
- The best treatment for weak pubococcygeus muscles by combination of pelvic
floor exercise (PFE) and electro therapy.
- The aim of interferential is to increase cortical awareness of patient, thus
facilitating ability of the patient to perform voluntary contractions (very weak
muscle).
Techniques of interferential:
D- Bipolar technique:
Parameters:
Frequency: 10-40 HZ, Intensity: maximum tolerable intensity.
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Duration: 15- 20 minutes, 3 times per week for 4 weeks.
2-Quadripolar technique:
Parameters:
Technique: The same as in stress incontinence.
Frequency: 10-100 HZ, Intensity: maximum tolerable intensity.
Duration: 15- 20 minutes, 3 times per week for 4 weeks.
D-Surgical treatment:
It is indicated for moderate and severe degrees of genital prolapse and physical
therapy management for such cases consist of pre and post treatment.
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References:
-Mantle J, Haslam J and Barton S (2019): Physiotherapy in Obstetrics and
Gynaecology”,2nd Eds, Elesiver, London, United Kingdom,2019.
-Herbert R, Jamtvedt G, Mead J, et al.: Practical evidence-based physiotherapy.
2nd ed. Oxford: Elsevier; 2011.
-Shannon L. Wallacea, Millerb L and Mishraa K (2019): “Pelvic floor physical
therapy in the treatment of pelvic floor dysfunction in women”,
Urogynecology;31:1-9.
-Sankarganesh A, Arthi M and Siva Kumar V (2018):”Interfrential Therapy
Versus Pelvic Floor Exercise for the Management of Stress Urinary in Women”,
Journal of Physiotherapy Research;2:1-11.
-Ibrahim I, Taher E and Shaheen E (2015):” Efficacy of biofeedback-assisted
pelvic floor muscle training in females with pelvic floor dysfunction” Alexandria
Journal of Medicine; 51:137-142.
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Retroversion and Retroflexion of the uterus (RVF)
Prof. Dr. Soheir M. El-kosery, PT PhD
Version:
It is the angle between the longitudinal axis of the cervix and that of the vagina.
Flexion:
It is the angle between the longitudinal axis of the uterine body and that of the
cervix.
Normally, the uterus is anteverted, anteflexed, (Fig.9-1)
Fig. (9-1): Normal anteverted, anteflexed uterus
Ante-version
• The longitudinal axis of the cervix bent forward on the longitudinal axis of
the vagina by 90 ̊ (Fig. 9-2).
Fig. (9-2): Axis of ant-version
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Factors maintaining ante-version
1- Round ligament
2- Uterosacral ligament
3- Intra-abdominal pressure (Fig. 9-3).
Fig. (9-3): Factors maintaining ante-version
Ante-flexion
The longitudinal axis of the uterine body bent forward on the longitudinal
axis of the cervix by 170 ̊ (Fig 9-4).
Fig. (9-4): Axis of ant-version
Factors maintaining ante-flexion
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1. Factors maintaining ante-version.
2. Tone of uterine muscles (Fig. 9-5).
Fig. (9-5): Factors maintaining ante-flexion
Retro-version
The uterus is directed backward towards the sacrum at level of the external os.
Retro-flexion
The uterus is directed backward towards the sacrum at level of the internal os
(Fig.9-6).
Fig. (9-6): Normal, retroflexion, and retroflexion uterus
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Varieties of RVF
A) Congenital:
1) Retroversion of hypoplastic uterus (underdevelopment).
In infancy, the uterus is smaller than the cervix, has poor vascular supply
and is retroverted. With the onset of ovarian function, the uterus grows
rapidly, the blood supply increases and it is anteverted. 20% of women
anteversion doesn’t occur.
2) Retroversion of a normal uterus.

This type is common and give rise to no symptoms. It is often discovered
accidentally. It requires no treatment, except in cases of infertility (high
position of external os).
B) Acquired:
1) Retroversion complicated by pelvic pathological lesions.
The uterus may be pushed backwards by an anterior wall fibroid or may be
pulled backwards by adhesions.
2) Puerperal retroversion:
It is usually associated with a bulky heavy sub-involuted uterus and is
caused by:
• Laxity of the uterine support.
• Increased bulk and weight of the body of the uterus.
• Lying in the dorsal position, gravity helps the retro-displacement.
• Persistent distention of the bladder during puerperium.
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Puerperal
retroversion
Heavy Uterine
bulky congestion
uterus
Sub-
involution
Fig. (9-7): Vicious circle of RVF
Degrees of RVF
1st degree: The fundus is directed towards the promontory of the sacrum.
2nd degree: The fundus is directed towards the sacral concavity.
3rd degree: The fundus is directed towards the tip of the sacrum (Fig. 9-8)
Fig. (9-8): Degrees of RVF
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Symptoms of RVF:
a) Backache.
b) Congestive dysmenorrhea.
c) Menorrhagia.
d) Dyspareunia.
e) Leucorrhoea.
f) Infertility.
Methods of correction of mobile RVF
Bimanual
Instrumental Postural
Fig. (9-9): Methods of correction of mobile RVF
Fig. (9-10): Bimanual correction
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Postural correction
Fig. (9-11): Postural correction (Knee chest position)
Fig. (9-12): Vulsellum forceps used for

Instrumental correction
Treatment of RVF
Prophylactic Treatment
1. Avoid crock lying or dorsal position, in which gravity helps the retro-
displacement of a heavy and bulky uterus.
2. Encourage relaxation on face & knee-chest position.
3. Evacuate the bladder every two hours.
4. Encourage the mother to lactate her baby.
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Palliative Treatment
- Wearing Hodge Smith pessary (Fig. 9-13)
Fig. (9-13): Hodge Smith Pessary
The upper end lies in the posterior fornix, while the lower end is in contact with
the anterior vaginal wall behind the symphysis pubis.
N.B: Pessaries are not used in cases of fixed RVF.
Indications of pessaries:
1. As a pessary test before operation of correction.
2. Early pregnancy with RVF (history of previous abortion with no other cause can
be found).
3. RVF during puerperium.
4. Patients refusing operation or with bad surgical risks.
Surgical Treatment
Indications:
• In cases of mobile or fixed RVF with marked symptoms.
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P.T. role
Pre and postoperative (same as cesarean section except arm exercises).
Pre-operative role:
1-Prepare the woman emotionally:
- By reassurance to eliminate negative feeling about the operation.
2-Improve pulmonary function and prevent post-operative pulmonary
complications:
- By deep breathing exercises and teach right way of cough to get rid of
expectoration postoperatively.
3-Improve circulation and prevent post-operative circulatory complications
- By circulatory exercises.
4- Prepare the woman physically for rapid mobilization.
- By teaching the right way of getting up early from the bed with minimal
strain and pain.
Post-operative Role:
First Day:
- Circulatory Exercises
- Respiratory exercises
- Static abdominal contraction
- Leg exercises
Second Day: Repeat previous exercises and add
- Early ambulation
Third Day: Repeat previous exercises and add
- Pelvic floor exercises
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Fourth Day: Repeat previous exercises and add
- Pelvic rocking exercises
Fifth Day: Repeat previous exercises and add
- Postural correction exercises.
- Hip shrugging exercises.
Sixth Day: Repeat previous exercises and add
- Pelvic rotation exercises.
Seventh Day: Repeat previous exercises and add
- First step of trunk rotation
- First step of trunk flexion.
- First step of trunk lateral flexion.
Eighth day:
-Increase the repetition of the previous exercises up to 20 times, till the end
of puerperium.
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References
- "Retroverted Uterus" Women's Health, 2009, Web. 5 Mar. 2010.
"What is a Tilted Uterus" International Society for Sexual Medicine, 9 May.
2021.
- Mary P FitzGerald, Scott Graziano. Anatomic and Functional Changes of the
Lower Urinary Tract During Pregnancy. Urologic Clinics of North America -
Volume 34, Issue 1 (February 2007)
- I. Dierickx, C. V. van Holsbeke, et al. “Colonoscopy-assisted reposition of the
incarcerated uterus in mid-pregnancy: a report of four cases and a literature
review. Medicine. European journal of obstetrics, gynecology, and reproductive
biology. 2011.
- Häggström, Mikael (2014)" Retroverted uterus in pregnancy. Png"
WikiJournal of Medicine 1 (2).
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Physical Therapy for Sexual Disorders
Dr. Dina M. Shehata, PT PhD
Definition: Recurrent or persistent pain during sexual intercourse and is

often one component of chronic pelvic pain complex.
Categories:
1- Superficial or deep:
Superficial dyspareunia: Pain with initial penetration of the vaginal
introitus.
Deep dyspareunia: Pain with deep vaginal penetration.
2- Primary or secondary:
Primary dyspareunia: if sexual intercourse has always been painful.
Secondary dyspareunia: if it occurs after a period of pain-free sexual
intercourse.
Etiology of superficial dyspareunia:
Congenital conditions such as rigid hymen or vaginal stenosis, episiotomy scars,
atrophic vaginitis (thinning of the vaginal wall in postmenopausal women),
radiotherapy (radiation vaginitis), inadequate genital lubrication due to
psychological factors, following childbirth or surgery, postmenopausal, sexual
trauma, vulvar infections, and urethritis.
Etiology of deep dyspareunia:

Retroverted retroflexed uterus (RVF), genital prolapse, urinary tract infections,
constipation, acute or chronic pelvic inflammatory disease, endometriosis,
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gynecological pelvic or abdominal surgery, postoperative adhesions, neoplasm, and
fibroids are etiological factors for dyspareunia.
2. Vaginismus
Definition: Involuntary spasm of the perineal muscles making vaginal
penetration difficult, painful, or impossible. It may be associated with spasm of
levator ani, hip adductors and abdominal muscles.
Categories:
Primary or secondary:
Primary vaginismus: for females who have never been able to have
vaginal penetration.
Secondary vaginismus: may develop following symptoms of
dyspareunia after a period of successful vaginal penetration.
Etiology:
Dyspareunia, past sexual abuse, relationship problems and psychological factors.
Both dyspareunia and vaginismus are closely related and cause symptoms of pelvic
floor muscle spasm.
A return to normal muscle tone and flexibility is a common goal in treating these
disorders.
I) P.T examination
History taking:
This can be achieved through completing a pelvic pain intake
questionnaire, which should include the following elements:
148
-Obstetric history, types of deliveries, episiotomies, forceps deliveries, a detailed
menstrual history, history of pelvic inflammatory disease, history of pelvic
surgery, history of sexual abuse, history of depression or any other psychological
disorders, information about the urinary systems, previous treatments including
medication, surgery, and non-traditional therapies.
-Pain assessment
Nature of pain: (burning versus aching, local versus diffuse, spontaneous
versus provoked).
Intensity: high versus low level, location: (superficial versus deep). A pain
map is included to mark the location of pain, duration: Overall time frame,
associated events: Menses, exercise, urination, defecation, sleep, and Coping
mechanisms.
-Pelvic floor examination

The patient should be examined in quite, private and unhurried atmosphere.
Prior to examination, the patient should be instructed to empty the bladder,
remove all clothes from the waist down, place a sheet on her lower body and
lie on the examination table.
Pelvic floor examination should include:

Visual examination, internal examination, and EMG biofeedback.
A) Visual examination
Observation of the perineum for normal anatomical structures, skin integrity
(scar tissues, erythema, abrasions, and inflammation).
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Observation of the voluntary movement of the pelvic floor in two directions:
-First, the physical therapist notes this initial ability to locate and contract the
pelvic floor muscles. Also, any use of accessory muscles such as gluteal, hip
adductors or abdominal muscles should be noted.
-Second, the physical therapist assesses any evidence of genital prolapse or
leakage of urine.
B) Internal examination
• The Section on Women's Health of American Physical Therapy
Association advises internal pelvic examination only for females who can
express clear understanding of the examination nature and can provide their
informed consent.
• Through internal examination, the following can be evaluated
-Soft tissue integrity, tone and symmetry, tightness or loosening of the
introitus and any muscle guarding during the internal examination should be
noted.
-The strength of the pelvic floor muscles contraction can be graded on
Modified Oxford scale. The physical therapist counts in seconds the duration
of holding the contraction of pelvic floor muscles to establish the endurance
score.
-Also, the quality of motion should be evaluated. If pain is present, the patient
may have a difficulty for performing proper contraction or complete relaxation
after contraction.
-In the presence of any sign of unhappiness of the patient to continue the
internal examination (e.g. legs adduction or breathing disorder), the
examination should be stopped (Fig. 10-1).
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Grade Description
0 No contraction
1 Flick contraction
2 Weak squeeze
3 Fair squeeze with definite "lift"
4 Good squeeze with repeatable hold and lift
5 Strong, solid squeeze with repeatable hold and lift
Fig. (10-1): Modified oxford scale
C) EMG biofeedback
If internal examination is not possible, EMG biofeedback can be used for
assessment of the pelvic floor muscles.
Surface electrodes can be placed on the external anal sphincters with the
reference electrode placed on the inner thigh muscle or gluteal muscle.
The patient is guided to perform isolated pelvic floor muscles contractions.
Strength and endurance of the pelvic floor can be assessed through visual
feedback.
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II) P.T treatment
Goals of physical therapy treatment
1) Modalities for pain relief
-Moist heat:
It may be helpful to relax muscles in spasm.
-Ultrasound:
It has a heating effect and decreases tension within the muscle.
It helps resorption of scars by depolymerization of mucopolysaccharides,
mucoproteins and glycoproteins.
It increases the extensibility of collagen bands on the surface of the scar.
Both moist heat and ultrasound can be used in preparation for stretching
and desensitization.
Intravaginal TENS:
It induces analgesia and pain relief through the gate control theory &
opiate theory.
2) Musculoskeletal flexibility
A) Stretching of pelvic floor muscles:
Through squatting position for 1 minute.
B) Pelvic mobility on therapeutic ball:
The patient slowly moves the pelvis forward, backward, side to side and in
circles while sitting on the ball to increase overall pelvic mobility.
C) Hip adductors stretch:
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3) Breathing exercises
In the form of deep diaphragmatic breathing.
Values:
-It helps relaxation and reduces anxiety.
-It facilitates mobilization of the pelvic and abdominal contents.
4) Pelvic floor graduations
-Repeated contraction and relaxation of the pelvic floor muscles
(contract/relax technique).
As a graduation, the patient may focus on a "stair step" approach:
It requires more fine control of the pelvic floor.
Patients should focus on the relaxation phase (down training).
Values:
- It improves pelvic floor muscle discrimination and relaxation
- It normalizes muscle tone.
- It improves the circulation and removes the waste products resulting in pain
relief.
5) EMG biofeedback
Technique:
It involves insertion of a vaginal probe into the vagina to measure the pelvic floor
muscles activity. The patient can perform the previous pelvic floor exercises
(contract/relax, stair step and down training) with the help of EMG biofeedback.
Values:
- It has the same values of pelvic floor exercise
- It educates the patient how to isolate the pelvic floor muscles.
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6) Trigger point therapy
a) Transvaginal Thiele's massage:
It is a classic manual intervention for relieving pain and trigger points in the
levator ani. This technique emphasizes a stripping motion of the muscle from
origin to insertion using as much pressure as the patient can tolerate.
b) Manual therapy:
The protocol aims to relieve pain and trigger points mainly in hip adductors and
abdominal muscles, by direct finger pressure on the trigger zone. Decrease in
pain usually occurs within 15 to 20 seconds of compression.
Compression is followed by a firm stretch of the local segment of muscle through
running a finger along the taut band for about 1 to 2 inches for about 3 to 5
repeats.
7) Desensitization
1st technique:
The therapist performs a sweeping motion in the vaginal opening by moving
one finger in a "U-shaped" manner.
2nd technique:
The therapist slowly makes a semicircle sweeping massage moving 3 then 6
then 9 and 9 then 6 then 3.
3rd technique: Use of different sizes of dilators depending on the patient's
pain tolerance for 15-20 minutes daily (Fig. 9-2).
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Fig. (10-2): Different sizes of dilators
Values:
- To restore normal sensation and tolerance at the vaginal opening.
- Increase elasticity at the vaginal opening.
- Decrease fear of vaginal penetration.
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References
- Mullard, Asher (1 October 2015). "FDA approves female sexual dysfunction
drug". Nature Reviews Drug Discovery. 14(10): 669.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Fifth ed.).
Arlington, VA: American Psychiatric Publishing. 2013. p. 433.
- Aydın S, Arıoğlu Aydın C, Batmaz G, Dansuk R. Effect of vaginal electrical
stimulation on female sexual functions: a randomized study. J Sex
Med. 2015;12:463–469.Reissing ED, Armstrong HL, Allen C. "Pelvic floor
physical therapy for lifelong vaginismus: a retrospective chart review and
interview study". J Sex Marital Ther. 2013;39(4):306-320.
- Aredo JV, Heyrana KJ, Karp BI, Shah JP, Stratton P. Relating chronic pelvic
pain and endometriosis to signs of sensitization and Myofascial pain and
dysfunction. Semin Reprod Med. 2017;35:88–97.
- Bo K, Frawley HC, Haylen BT, Abramov Y, Almeida FG, Berghmans B,
Bortolini M, Dumoulin C, Gomes M, McClurg D, Meijlink J, Shelly E,
Trabuco E, Walker C, Wells A. An international Urogynecological association
(IUGA)/international continence society (ICS) joint report on the terminology for
the conservative and nonpharmacological management of female pelvic floor
dysfunction. Int Urogynecol J. 2017;28(2):191–213.
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Physical Therapy for Infertility (Part I)
Prof. Dr. Amel M. Yousef, PT PhD
Definition:
Infertility is the failure of a couple to conceive pregnancy after trying to do
for at least one full year of regular unprotected sexual intercourse. So, it is a
disease of the male and female reproductive system. The female is responsible of
about 50-60% and male about 40% of infertility.
Types of infertility:
Primary and secondary infertility. In primary infertility, pregnancy has
never occurred. In secondary infertility, one or both members of the couple have
previously conceived but are unable to conceive again after a full year of trying.
Causes of infertility:
Infertility may be caused by several different factors, in either the male or
female reproductive systems. However, it is sometimes not possible to explain the
causes of infertility.
Environmental and lifestyle factors such as smoking, excessive alcohol
intake and obesity can affect fertility. In addition, exposure to environmental
pollutants and toxins can be directly toxic to gametes (eggs and sperm), resulting
in their decreased numbers and poor quality, leading to infertility.
In the female reproductive system, infertility may be caused by:
• Tubal disorders and peritoneal factor such as blocked fallopian tubes, which are
in turn caused by untreated sexually transmitted infections (STIs) or pelvic
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inflammatory disease (PID) or complications of unsafe abortion, postpartum
sepsis, or abdominal/pelvic surgery.
• Uterine disorders which could be inflammatory in nature (such as such
endometriosis), congenital in nature (such as septate uterus), or benign in nature
(such as fibroids).
• Disorders of the ovaries, such as polycystic ovarian syndrome and other follicular
disorders.
• Disorders of the endocrine system causing imbalances of reproductive hormones.
The endocrine system includes hypothalamus and the pituitary glands. Examples
of common disorders affecting this system include pituitary cancers and
hypopituitarism. Hyperprolactinemia, disorders at thyroid, adrenal, hypothalamus,
excessive exercise, obesity.
• Cervical factor as abnormal cervical mucus or cervicitis.
• Coital dysfunction as dyspareunia, vaginismus.
• Unexplained infertility occurs in 15% of infertile couples.
The relative importance of these causes of female infertility may differ from
country to country, for example due to differences in the background prevalence of
STDs or differing ages of populations studied.
In the male reproductive system, infertility may be caused by:

• Obstruction of the reproductive tract causing dysfunctionalities in the ejection of
semen. This blockage can occur in the tubes that carry semen (such as ejaculatory
ducts and seminal vesicles). Blockages are commonly due to injuries or infections
of the genital tract.
• Hormonal disorders leading to abnormalities in hormones produced by the
pituitary gland, hypothalamus, and testicles. Hormones such as testosterone
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regulate sperm production. Example of disorders that result in hormonal imbalance
include pituitary or testicular cancers.
• Testicular failure to produce sperm, for example due to varicoceles or medical
treatments that impair sperm-producing cells (such as chemotherapy).
• Abnormal sperm function and quality. Conditions or situations that cause
abnormal shape (morphology) and movement (motility) of the sperm negatively
affect fertility. For example, the use of anabolic steroids can cause abnormal semen
parameters such sperm count and shape.
So, abnormal spermatogenesis, failure of sperm transport and failure of semen
deposition (Ejaculatory and erectile dysfunction).
Diagnosis of male factor:

• Semen analysis: count 15million/ml, mobility 50% forward progressive mobility,
30% with normal morphology.
• Hormonal assay as FSH, LH, prolactin, testosterone.
• Doppler US on testicles to detect varicocele.
• Testicular biopsy to differentiate between spermatogensis and obstructive
disorders.
• Chromosomal studies
• Imaging. In certain situations, imaging studies such as a brain MRI, transrectal or
scrotal ultrasound, or a test of the vas deferens (vasography) may be performed.
• Other specialty testing. In rare cases, other tests to evaluate the quality of the
sperm may be performed, such as evaluating a semen specimen for DNA
abnormalities.
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Treatment of male infertility:
Aim to improve semen parameter (3-6months):
Changing lifestyle factors:

• Stop smoking, drugs and drinking alcohol to improve oxygenation.
• Avoid high temperatures found in hot tubs and hot baths, as they can
temporarily affect sperm production and motility.
• Avoid exposure to industrial or environmental toxins, which can affect sperm
production.
• Exercise moderately. Regular exercise may improve sperm quality and increase
the chances for achieving a pregnancy.
• Multivitamins and antioxidant (Improve semen count and mobility).
• Treat erection disorders by Viagra & electrical stimulation, biofeedback.
Medications: Certain medications may improve sperm count and likelihood for
achieving a successful pregnancy. These medicines may increase testicular
function, including sperm production and quality.
Surgery: For some conditions, surgery may be able to reverse a sperm blockage
and restore fertility. In other cases, surgically repairing a varicocele may improve
overall chances for pregnancy.
Sperm retrieval: These techniques obtain sperm when ejaculation is a problem or

when no sperm are present in the ejaculated fluid. They may also be used in cases
in which assisted reproductive techniques are planned and sperm counts are low or
otherwise abnormal.
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Fallopian tubes adhesions
Function of fallopian tubes:

• Fallopian tubes are female reproductive organs that connect the ovaries and the
uterus.
• The fallopian tubes carry an egg from an ovary to the uterus.
• Conception also happens in the fallopian tube. If an egg is fertilized by sperm, it
moves through the tube to the uterus for implantation.
• If a fallopian tube is blocked, the passage for sperm to get to the eggs, as well as
the path back to the uterus for the fertilized egg, is blocked.
Symptoms of blocked fallopian tubes:

• Blocked fallopian tubes don’t often cause symptoms. Many women don’t know
they have blocked tubes until they try to get pregnant and have trouble.
• In some cases, blocked fallopian tubes can lead to mild, regular pain on one side
of the abdomen. This usually happens in a type of blockage called a
hydrosalpinx. This is when fluid fills and enlarges a blocked fallopian tube.
Effect of blocked fallopian tubes on fertility

• Blocked fallopian tubes are a common cause of infertility. Sperm and an egg
meet in the fallopian tube for fertilization. A blocked tube can prevent them
from joining.
• If both tubes are fully blocked, pregnancy without treatment will be impossible.
If the fallopian tubes are partially blocked, you can potentially get pregnant.
However, the risk of an ectopic pregnancy increases.
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• This is because it’s harder for a fertilized egg to move through a blockage to the
uterus. In these cases, your doctor might recommend in vitro fertilization (IVF),
depending on whether treatment is possible.
• If only one fallopian tube is blocked, the blockage most likely won’t affect
fertility because an egg can still travel through the unaffected fallopian tube.
Fertility drugs can help increase your chance of ovulating on the open side.
Causes of blocked fallopian tubes:

Fallopian tubes are usually blocked by scar tissue or pelvic adhesions. These can
be caused by many factors, including:
• Pelvic inflammatory disease. This disease can cause scarring or hydrosalpinx.
• Endometriosis. Endometrial tissue can build up in the fallopian tubes and cause
a blockage. Endometrial tissue on the outside of other organs can also cause
adhesions that block the fallopian tubes.
• Certain sexually transmitted infections (STIs). Chlamydia and gonorrhea can
cause scarring and lead to pelvic inflammatory disease.
• Past ectopic pregnancy. This can scar the fallopian tubes.
• Fibroids, these growths can block the fallopian tube, particularly where they
attach to the uterus.
• Past abdominal surgery. Past surgery, especially on the fallopian tubes
themselves, can lead to pelvic adhesions that block the tubes.
Diagnosing of blocked fallopian tube

• Hysterosalpingography (HSG) is a type of X-ray used to examine the inside
of fallopian tubes to help diagnose blockages. During HSG, doctor
introduces a dye into your uterus and fallopian tubes.
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Physical therapy treatment for blocked fallopian tubes
1- Electromagnetic field
• It can be used in cases having tubal infertility of inflammatory etiology.
• It increases tubal patency in 50% of cases because of increase venous return
and resorption of the edema exudates
2- Ultrasound therapy
• The treated areas (suprapubic region, as well as right and /or left iliac
fossa.
• Frequency: 1 MHz.
• Continuous mode.
• Intensity: 1.5 w/cm
• Duration: 10 minutes each area
• Biological effect:
US increase extensibility of collagen bands on the surface of scars and
adhesions. Also, it aids resorption of adhesion by depolymerization of
mucopolysaccharide, mucoproteins and glycoprotein, so converts adhesions
from gel form to soluble state.
3- Ozone therapy
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Application of Ozone:
Two disposable syringes of 50 ml filled with ozone gas with concentration
of 40μg/m. Syringe connected to cohen’s cannula which introduced to the
cervices and inject ozone slowly into uterine cavity (20minutes).
4- Manual therapy
• Wurn technique, in which it accesses some of the deeper structures such as
fallopian tubes indirectly by manipulating the peritoneum, uterus and
ovarian ligaments.
• Manual soft tissue improves mobility and motility of the reproductive organs
through breaking down the collagenous cross links and adhesions.
Endometriosis
Endometriosis is a chronic condition in which endometrial tissue that lies
inside the uterus migrates outside of the uterus and attaches to the lining of the
abdominal cavity and to internal organs inside the pelvis, including the ovaries,
fallopian tubes, bladder, and bowel.
• Endometriosis is typically a disease of reproductive years.

• It is estimated to occur in 7- 10% of reproductive age women.
• Although there are statistics in the literature, the true prevalence of
endometriosis is unknown because many women remain asymptomatic.
Pathogenesis of endometriosis:
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Adhesions and fibrous bands of scar tissue that are formed between surfaces within
the body due to endometriosis, may change the internal anatomy and result in
organs coming together “frozen pelvis”.
When an organ, like the uterus, cannot move in harmony with it’s surrounding
structures, the resulting disharmony creates fixed, abnormal points of tension that
force the body of the uterus to move around it. This chronic irritation, in turn,
paves the way for disease and dysfunction.
Signs and symptoms of endometriosis:
• Painful periods (dysmenorrhea).
• Pain with intercourse.
• Pain with bowel movements or urination.
• Excessive bleeding. (menorrhagia) or (menometrorrhagia).
• Infertility (30%).
• Other symptoms, as fatigue, diarrhea, constipation, bloating or nausea,
especially during menstrual periods.
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Unfortunately, Endometriosis is sometimes mistaken for other conditions that can
cause pelvic pain, such as pelvic inflammatory disease (PID) or ovarian cysts. It
may be confused with irritable bowel syndrome, that causes bouts of diarrhea,
constipation, and abdominal cramping.
Diagnosis of Endometriosis:
• Bimanual Examination:
-Uterus: fixed AVF or RVF
-Tense tender nodules in Douglas pouch or uterosacral ligament.
-Endometrioma may be felt in non-obese patients.
• CA-125 level:
-Slightly elevated
-Normal level (5-35µ/ml)
-For follow up
• Transvaginal US and MRI:
-Diagnostic for chocolate cyst even if small.
• Laparoscopy:
-Gold standard for diagnosis and treatment.
The American Society of Reproductive Medicine assigns points to the stages of
endometriosis as follows:
• Stage I or minimal endometriosis: 1 to 5 points.
• Stage II or mild endometriosis: 6 to 15 points.
• Stage III or moderate endometriosis: 16 to 40 points.
• Stage IV or severe endometriosis: greater than 40 points.
Classification is according to:
1. Implants whether superficial or deep and their size
2. Involvement of ovaries
3. Type of adhesions (filmy or dense)
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Despite these classifications, symptoms do not always correlate with disease
severity. Many women with severe endometriosis have little pain or
remain asymptomatic, while some with minimal or mild classification may
experience intense symptoms affecting quality of life.
Treatment of endometriosis
It depends on the severity of signs and symptoms and the case desire for fertility.
Conservative treatment approaches are recommended firstly
• Pain medication, such as the non-steroidal anti-inflammatory.
• Hormone therapy is sometimes effective in reducing the pain of
endometriosis & may slow endometrial tissue growth and prevent new
implants of endometrial tissue as contraceptives pills.
• Conservative surgery for endometriosis (laparoscope).
• Fertility treatment for stimulating ovaries to make more eggs for in vitro
fertilization
• Hysterectomy with removal of the ovaries considered the most effective
treatment for endometriosis
• Physical therapy may be an integral treatment option for patient with
endometriosis aiming for:
-Decreasing pain.
-Increasing functional capabilities.
Thus, Allowing for a greater quality of life.
For pain For adhesion
• TENS • Wurn technique
• Thermal pad • Ultrasound
• Relaxation technique • Pulsed high-intensity
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• Acupuncture laser
• Nutrition
• Exercise
1- Transcutaneous electrical nerve stimulation (TENS) and acupuncture

can be used effectively in the treatment of dysmenorrhea associated with
endometriosis. TENS alone represents a suitable alternative for women having
endometriosis associated with dysmenorrhea who prefer not to use medication or
wish to minimize their intake of NSAIDs.
2- Acupuncture Used for controlling chronic pelvic pain (CPP).
3- EndoFEMM pad can be used for applying effectively deep thermal heat to
a women's body so, provides temporary natural relief for the discomfort of chronic
pelvic pain caused by adhesions, endometriosis, menstrual cramps and vulvodynea.
This pad used safely for women with endometriosis and provides a nontoxic,
noninvasive solution for relieving their chronic pelvic pain.
4- Relaxation (Yoga), the overall goal of treatment is for the patient to learn how
to relax (or, down train) the muscles, which in turn helps break the pain cycle. This
will help the muscles to return to their normal resting tone.
4- Nutrition, Endometriosis is an inflammatory condition, thus an anti-
inflammatory diet involves eating antioxidant as:
• Fruits and vegetables,
• Protein from sources such as salmon, turkey, chicken, bean, and soy nuts as
well as other healthy sources of omega-3 fatty acids.
• Calcium, vitamin D, E and magnesium.
Decreased consumption of all animal fats, all food containing sugar, chocolate,
caffeine and alcohol. which has tracked over 116,000 women for nearly 30 years.
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5- Exercise: Patients with mild or moderate endometriosis and postural kyphosis
participated in an exercise program which included:
• Posture correction exercises from different positions.
• Diaphragmatic and lateral costal breathing exercises
• General relaxation, teaching muscle sense & Diversion drill.
• Positional education on cross-sitting and squatting positions.
• Stretching exercises for lower back, adductor, hamstrings, and pelvic floor
muscles.
• Each exercise session was terminated by walking on treadmill for 20 min.
Patients attended exercise sessions 3 times/week for 8 weeks. So, exercise program
is very effective in decreasing pain and postural abnormalities associated with
endometriosis.
5- Wurn Technique: In Wurn technique, the therapist uses his hands to find and
decrease adhesions in tightened areas (uterus, ovaries, bladder, and other internal
organs) until the tension is released, this result in an apparent decrease of
adhesions as well as pain and improved mobility of the soft tissue. According to
Wurn technique this release of tension suggests a breakdown of cross-links, which
have been adhering structures; this release allows those structures to move freely,
generally with decreased pain.
6- Ultrasound therapy:
Parameters of ultrasonic therapy:
• Frequency of 1MHz.
• Mode: Continuous wave.
• Intensity: 1.5W/cm2.
• Duration of treatment: 15 minutes for each treatment site (i.e. supra pubic
region, right iliac fossa, left iliac fossa and/or lumbar region).i.e if all areas
involved in the treatment, the duration of session extended to one hour.
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3 session per week (total 24 sessions)
7- Pulsed high intensity LASER:

LASER was delivered in two different phases, Initial phase, and terminal phase. In
initial phase, three sub-phases of fast manual scan (every10 cm scanned in about
1.5 second) was performed to lower abdomen with increasing fluences (710 -910 -
1530 mJ/cm2) and decreasing frequencies (30-20-15 Hz) with total energy of 2000
joules reached abdominal region. In Final phase: 3 sub-phases of slow scanning
(every 10 cm scanned in about three second) with increasing fluences (710-910-
1530 mJ/cm2) and decreasing frequencies (30- 20-15 Hz) with total energy of
2000 joules reached abdominal region. Scans can be longitudinal and transversal to
the anatomical structure to be treated, ideally following a straight lines path.
LASER is effective for reducing pain, adhesion and improving quality of life.
Pelvic inflammatory disease (PID)

Pelvic inflammatory disease (PID) is the inflammation of the upper genital tract
involving the fallopian tubes as well as the ovaries. The inflammation is often
bilateral because most of the PID is caused by the ascending or blood borne
infection and the close anatomic association of the ovaries with the fallopian tubes
favors the bilateral involvement, though one tube may be more affected than the
other.
Causes of PID
The most common cause of PID is sexually transmitted diseases (STD) in 60-75%.
Most common being gonococcal and chlamydial infections nts for about 30% in
the developed countries. Gonoccoci and Chlamydia travel up the genital tract along
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the mucous membrane to reach the fallopian salpingo-oophoritis. Other organisms
that cause PID include mycoplasma, tubercular bacillus, viruses, and E. coli.
Signs and symptoms of PID

• The most common symptom of acute PID is lower pelvic pain. Pain is
bilateral and restricted to lower abdomen.
• Pain spreads upwards if general peritonitis ensues.
• Pain is severe in acute stage and is followed by a high temperature. Vomiting
may also follow.
• Discharge from the vagina and dysuria also occur.
• Menstrual irregularity if any, is due to preceding endometritis in case of
ascending infection or to the antecedent abortion or delivery.
• The patient may develop uterine bleeding at a time when menstruation is not
expected, and the bleeding is often profuse and prolonged.
• In case of pelvic abscess, the patient develops severe diarrhea due to rectal
irritation.
Investigation for PID

• Hemoglobin, leucocyte count and ESR.
• Cervical and high vaginal swab culture for both aerobic and anaerobic
organisms.
• Blood culture if bacteremia sets in. C reactive protein distinguishes between
infective and non-infective mass.
• Ultrasound: Tubo-ovarian abscess appears on the ultrasound.
• Computed tomography shows a spherical or tubular structure with a low
attenuation center.
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Treatment of PID
A- Acute stage:
• Medical Treatment: It consists of removal of the causative organisms by
proper administration of the antibiotics. Mild cases are treated at home with
antibiotics. Moderate and severe cases of Pelvic inflammatory diseases may
need hospitalization.
• Physiotherapy treatment aims to decrease the pain and inflammation along
with the pharmacological therapy. In mild cases of Pelvic inflammatory
disease where the patient does not need hospitalization, pain relieving
modality like short wave diathermy can be given. Short wave diathermy is a
deep heating modality, produces heat in both deep and superficial tissues. In
the acute stage very mild or pulsed short wave diathermy is used to promote
healing and reduce pain.
• For the PID treatment short wave diathermy can be given for 5-10 minutes for
a period of three days a week using the cross- fire method of diathermy.
Cross-fire method involves moving the electrodes to a position at right angles
to their previous position half way through the treatment. Half the PID
treatment is given antero-posteriorly through the pelvis with the patients in
the lying position and second half in the side lying with the legs curled up or
in sitting position and the electrodes placed over the pelvic outlets and the
lumbo-sacral area of the spine.
B- Chronic stage:
Physiotherapy aims are:-
• Relieving pain
• Promote healing around the area.
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• Treat existing musculoskeletal dysfunction or prevent further musculoskeletal
dysfunction.
• Increase function.
1- Short wave diathermy
• It can be used to reduce pain and swelling, accelerate the inflammation
process and promote healing in tissues with chronic inflammation. It leads to
increased circulation around the area by vasodilatation leading to better
healing. It also increases the metabolic activity of the area leading to more
nutrients, more cellular activity and healing and increasing collagen
extensibility. It helps in the repair of pelvic microcirculation, thus enabling
lysis of scar tissues, relaxation of contracted muscles in the pelvis and pelvic
floor
• For the PID treatment in the chronic stage short wave diathermy is given for
15-30 minutes, two times a day for three weeks using the cross-fire method of
treatment.
2- TENS
• It is used to the lumbar region to treat low back pain.
• TENS works at both spinal cord level and higher brain centers to inhibit the
transmission of nocioceptors thus relieving the perception of pain.
3- Moist hot pack can be given the low back to relieve pain in the lower back.
4- Pelvic floor exercise
• The pelvic floor muscles in chronic PID cases may be in the hypertonic state
due to pain, delayed healing, scar tissue adhesions or generalized spasm
throughout the pelvic floor tissues.
• So, Pelvic floor rehabilitation is indicated in the PID treatment in such
patients.
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• Teaching control and relaxation of the pelvic floor musculature is important
in these patients.
• Biofeedback including surface EMG can be used to induce relaxation in
these muscles.
• For treating a woman with hyper tonus, increase the rest time between the
pelvic floor contractions and sets.
• Emphasis on relaxation is equally important for strength training in these
clients. Use of surface EMG for feedback is invaluable for enhancing
awareness of holding patterns and resting tone.
• Instruct the woman to contract the pelvic floor as in the strengthening
exercises then allow total voluntary release and relaxation of the pelvic floor
muscles. This activity can be coordinated with breathing. Instruct the woman
to concentrate on a slow deep breath and allow the pelvic floor to completely
relax.
5- Interferential current (IFC)
Using 4 plate electrodes, two of 200 cm2 placed under the lumbosacral region
(bilaterally) and two of 100 cm2 placed over the lower abdomen. A constant
frequency of 100 Hz was used in the 1st 3 sessions, followed by a rhythmical
frequency of 0-100 Hz. The dosage being from 12-25 mA depending on the
individual tolerance of the patient. The duration of each session is 15 - 20 minutes
daily or every other day for 15 sessions
• Fine vibration of ions-->stimulate large afferent to interfere with pain. As
well as facilitate ion movement in the cells & increase cellular activity.
• High frequency leads to rapid fatigue of the pain receptors.
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• Vasodilatation-> remove pain (toxic) metabolites & ensure better oxygen
supply to tissue.
• IFC changes the PH to the alkaline side and help to disperse infiltration and
adhesions.
Cervicitis
The cervix is the opening from the vagina into the uterus through which
the sperm must pass. Mucus produced by the cervix helps to transport the sperm int
o the uterus.
Injury to the cervix or scarring of the cervix after surgery or infection can result in
:
• A smaller than normal cervical opening, making it difficult for the sperm to
enter.
• Decrease the number of glands in the cervix, leading to a smaller
amount of cervical mucus.
• In other situations, the mucus produced is the wrong consistency
(Perhaps too thick) to allow sperm to travel through.
• In addition, some women produce antibodies (immune cells) that
are specifically directed to identify sperm as foreign invaders and
to kill them.
Diagnosis
Cervical mucus can be examined under a microscope to diagnose whether cervical
factors are contributing to infertility. The interaction of a live
sperm sample from the male partner and a sample of cervical mucus
from the female partner can also be examined. This procedure is called a post-
coital test.
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Treatment of Cervicitis
*Antibiotics in the case of an infection.
*Steroids to decrease production of anti-sperm antibodies.
*Artificial insemination techniques to bypass the cervical mucus.
Physical therapy for cervicitis includes:

- Low-intensity laser:
It is effective in treating cervical secretion neutrophils in females suffering
from Chlamidia infection. Dysfunction of neutrophil granulocytes in cases of
cervicitis causes decrease in the number of phagocytes and lower rates of
phagocytosis as well as intracellular forms of oxygen. Low-intensity laser
stimulated not only phagocytosis but also intracellular generation of active oxygen
forms. Thus, low-intensity laser eliminates dysfunction of cervical secretion
neutrophils.
- Iontophoresis:
Copper iontophoresis was used for the treatment of chronic cervicitis. A
special copper electrode shaped to fit the os cervix is held in an insulated handle
and connected to the positive terminal of the source of current. The large negative
electrode is placed against the back or abdomen. Preliminary cleaning of the
vagina is necessary, and the electrode and the handle must be sterilized.
A current of 2-3 mA is slowly advanced up to 10-15 mA for 10-20 minutes. At

the end of the treatment, the current is reversed for 1-2 minutes to free the
electrode, which usually adheres to the surface. Treatment is not repeated until the
dense membrane formed is sloughed away, usually occurs in about one week.
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References:
- Awad, E. et al., Efficacy of exercise on pelvic pain and posture associated with
endometriosis: within subject design, J Phys Ther Sci, 2017, 29 : 2112-2116.
- Gizinger OA, Dolgushin II, Letiaeva OI. Analysis of parameters of
reproductive tract mucosal immunity in women with chlamydial infection
before and after local magnetolaser therapy, Vopr Kurortol Fizioter Lech Fiz
Kult, 2010;(5):30-3.
- Mansour, S et al., Effect of ultrasound therapy on alleviating pain and
adhesions in endometriosis, Egyptian Fertility and sterility Society, 2009, 13(
Issue 1): 13-20.
- Mascarenhas MN, Flaxman SR, Boerma T, et al. National, regional, and
global trends in infertility prevalence since 1990: a systematic analysis of 277
health surveys. PLoS Med 2012;9(12):e1001356.
- Thabet, A. et al. Effect of pulsed high intensity laser therapy on pain, adhesion
and quality of life in women having endometriosis: A randomized controlled
trail, Photomedicine and laser surgery, 2018, 10: 1-7.
- Wurn B. et al., Treating fallopian tube occlusion with a manual pelvic physical
therapy, Altern Ther Health Med, 2008;14(1):18-23.
177
Physical Therapy for Infertility (Part II)
Polycystic ovarian syndrome
Prof. Dr. Azza B. Nashed, PT PhD
Objectives:
1. To identify the definition of PCOS.
2. To know the clinical picture of PCOS.
3. To identify the pathophysiology of PCOS.
4. To know the relation between obesity and PCOS.
5. To determine the treatment of PCOS.
Definition of PCOS:
It is a heterogeneous endocrine disorder, it may present at one end of the spectrum
with a single finding of polycystic ovarian morphology as detected by pelvic
ultrasonography at the other end of the spectrum, symptoms such as obesity,
hyperandrogenism, menstrual cycle disturbance and infertility. Also, PCOS Is
characterized by metabolic and endocrine disturbance as elevated serum
concentration of LH, testosterone, insulin and prolactin.
Clinical picture:
• Infertility
• Obesity
• Hirsutism
• Amenorrhea
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Pathophysiology:
It is attributed to insulin resistance, androgen excess and abnormal gonadotropin
dynamics. The excess of insulin in combination with an elevated LH concentration
leads to increase androgen secretion, arrest of follicular development and
menstrual disturbance.
Investigation:
1-Hormonal evaluation for measurement of:
• Androgen
• Estrogen
• Prolactin
• Insulin
2-Metabolic evaluation which includes:
• Glucose tolerance curve.
• Lipid profile.
3-Sonographic evaluation.
4-MRI
5-Laparoscopic examination.
Obesity and PCOS:

Obese women often suffer from menstrual cycle abnormality including amenorrhea,
infertility and premature menopause. As 80% of obese patients were found to have
PCOS. There is characteristic distribution of body fat, known as android obesity, due
to fat deposition in the abdominal wall, which is associated with hyperinsulinemia
and diabetes mellitus.
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Treatment of PCOS:
1-Prior to any treatment, must exclude other causes of infertility as tubal adhesion
or endometriosis.
2-Weight loss is the first line of therapeutic option in all women with obesity and
PCOS. As it is associated with improvement in menses abnormalities, ovulation
and fertility rate with reduction of hyperandrogenism.
Nutritional education of low caloric diet ( low glycemic index levels)

Low glycemic index diet is a rating system for food based on how much they rise
blood glucose level two hours after their consumption. High insulin is a problem
for PCOS women, because insulin alters overall hormone balance. So control of
insulin by avoiding upward spikes in blood sugar from eating the Wrong kinds of
food can be done by low glycemic index diet.
-Caloric restriction is of 2 types:

• Moderate energy restriction (1200kcal/day).
• Severe energy restriction (400-800kcal/day) and this could result in lowering
of androgen level and decrease level of circulating insulin and testosterone.
-Exercise:
The recommended dose for exercise to induce weight loss in obese PCOS women
is moderate aerobic exercise at 50-70% of Vo2 max for more than 45 minutes
daily for 3-6 months.
Benefits of exercise for PCOS:
The Best predictor of success in weight maintenance after a period of weight loss:
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1. Stimulate fat oxidation.
2. Improve lipid profile.
3. Increase energy expenditure.
4. Improve psychological factors.
5. Suppress appetite.
6. Protect clean body mass.
Low caloric diet and exercise:

Addition of exercise to low caloric diet advocated to counteract the negative
metabolic adaptations that occur during caloric restriction, because exercise
training prevent decline in fat oxidation.
Low caloric diet and anti diabetic drugs:

Metformin is the most widely used drug for the treatment of type 2 diabetes. Its
mechanism of action include a reduction of hepatic glucose production and an
increase sensitivity of peripheral tissue to insulin. This combination aimed to
reduce insulin resistance, as well as hyperinsulinemia and correct LH
abnormalities.
Low caloric diet and Electrolipolysis:

Parameters of electrolipolysis:
Frequency:100 pulse/min.
Pulse width: 400 microseconds
Electrodes placement: on the abdominal and gluteal regions.
Duration: 30 min. On the abdominal region and 30min. On each gluteal side.
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Biological effect:
Electrolipolysis increases fat oxidation and glucose uptake, so it reduces weight,
waist/hip ratio, LH and LH/FSH ratio, increasing FSH, resuming normal
menstrual cycle and occurence of pregnancy.
Effect of Electrolipolysis:
A. On skeletal muscle activities and metabolism:
When muscle contracts as a result of electrical stimulation, the chemical
changes taking place within the muscle are similar to those associated with
voluntary contractions in normal exercising muscles. These chemical
reactions, which result from muscle contractions utilize glycogen, fat, and
nutrients stored in the muscle.
Also, it stimulate the adrenergic interstitial nerve ending leads to release of

catecholamines hormones leading to stimulation of adenilate cyclase which
converts adenosine triphosphate to cyclic adenosine monophosphate, thus
activating lipases. It is well known that lipases hydrolysis fat into glycerol
and fatty acid.
B. On adipose tissue and fat tissue lipolysis:

In human, adipose fat cells are stored as triglyceride. Lipolysis breaks the
bond of TG molecules. These easily pass through the cell wall and into the
interstitial fluid as the fat cells reduce in size and volume, to be further
transported by the lymph vessels.
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Induction of ovulation
It is done either medically, surgically, and non-pharmacological methods.
A. Medical approach: including anti-estrogens and gonadotropin. But it has
side effects as nausea, vomiting, blurring of vision, headache and fetal
malformations.
B. Surgical methods: including ovarian wedge resection and laparoscopic
approach. The aim of the surgical methods is to remove the affected tissue
of the ovary. So, the most common side effect of the operation is the
formation of postoperative adhesions.
As pharmacological and surgical induction of ovulation is associated with
negative side effects so, complementary methods are needed. Thus,
electrolipolysis and herbal treatment may be an alternative to
pharmacological induction of ovulation in women with PCOS.
C-Non-Pharmacological methods:
1-Electroacupuncture
- It is effective in women with minor metabolic disturbance. The needles
must be applied to the effective acupuncture points in somatic segments that
innervate the ovary and uterus ( Th12-L2 and S2-S4).
- Electric stimulation with low frequency (2Hz, pulse width 0.5 ms) for 30
min.
- Electroacupuncture is given two times/week for 2 weeks, then once a
week, of total treatment sessions from 10-14.
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- Electroacupuncture corrects the hypothalamic pituitary ovarian axis that
results in the correction of some hormones such as LH, FSH and
gonadotropin.
-Herbal approach for induction of ovulation

It correct the hypothalamic pituitary ovarian axis and the resultant hormonal
imbalance
Example:
A. Some herbs is used to induce ovulation through Sex gland regulation as:
Mixture of traditional women’s remedies.
Tonifying kidney herbs.
B. Some herbs reduce body weight and induce ovulation as special herbal
tea.
184
References:
- Awad, E. et al., Efficacy of exercise on pelvic pain and posture associated with
endometriosis: within subject design, J Phys Ther Sci, 2017, 29 : 2112-2116.
- Gizinger OA, Dolgushin II, Letiaeva OI. Analysis of parameters of
reproductive tract mucosal immunity in women with chlamydial infection before
and after local magnetolaser therapy, Vopr Kurortol Fizioter Lech Fiz Kult,
2010;(5):30-3.
- Mansour, S et al., Effect of ultrasound therapy on alleviating pain and
adhesions in endometriosis, Egyptian Fertility and sterility Society, 2009, 13(
Issue 1): 13-20.
- Mascarenhas MN, Flaxman SR, Boerma T, et al. National, regional, and
global trends in infertility prevalence since 1990: a systematic analysis of 277
health surveys. PLoS Med 2012;9(12):e1001356.
- Thabet, A. et al. Effect of pulsed high intensity laser therapy on pain, adhesion
and quality of life in women having endometriosis: A randomized controlled
trail, Photomedicine and laser surgery, 2018, 10: 1-7.
- Wurn B. et al., Treating fallopian tube occlusion with a manual pelvic physical
therapy, Altern Ther Health Med, 2008;14(1):18-23.
185
Physical Therapy for Dysmenorrhea
Prof. Dr. Dalia M. Kamel, PT PhD
Definition
Dysmenorrhea or painful menstruation is the commonest of all gynecological
symptoms. Dysmenorrhea is defined as severe, cramping pain in the lower
abdomen that occurs just before or during menses.
There are two main types of dysmenorrhea, namely, primary and secondary.
Primary dysmenorrhea (PD), which usually begins during adolescence and
is defined as painful menses in women with normal pelvic anatomy.
Prevalence
The prevalence of (PD) was investigated in different parts of the world and was
found to vary with the geographical location. Specifically, the prevalence of PD
among university students was reported at 84.01% in Egypt 87.8% and 72.7% in
Turkey,8,9 89.1% in Iran,10 65% in India,11 76% in Malaysia,12 and 60% in
Canada. In the United States, work absenteeism due to dysmenorrhea is estimated
at 600 million work hours, and the economic consequences are estimated to be $2
billion per year.
Pathophysiology of primary dysmenorrhea

Primary dysmenorrhea is a feature of ovulatory cycles and usually appears within 6
to 12 months of the menarche. The etiology of primary dysmenorrhea has been
attributed to uterine contractions or ischemia, psychological factors, and cervical
186
factors. Psychological factors may alter the perception of pain but are not unique to
the problem of dysmenorrheal. There is no convincing evidence of cervical
stenosis in patients with dysmenorrhea, so there is no basis for incriminating
cervical stenosis or psychological factors as major contributors to the problem of
primary dysmenorrhea.
Women with dysmenorrhea have increased uterine activity, which may manifest as
increased resting tone, increased contractility, increased frequency of contractions,
or incoordinate action. Prostaglandins are released as a consequence of endometrial
cell lysis with instability of lysosomes and release of enzymes, which break down
cell membranes. The evidence that prostaglandins are involved in primary
dysmenorrhea is convincing. Menstrual fluid from women with dysmenorrhea has
higher than normal levels of prostaglandins (especially PGF2a and PGE2), and
these levels can be reduced to below normal with nonsteroidal anti-inflammatory
drugs (NSAIDs), which are effective treatments (Fig. 11-1).
Fig. (11-1): Pathophysiology of Primary dysmenorrhea
187
Clinical Symptoms
1- Primary dysmenorrhea usually begins 6 to 12 months after menarche, almost
invariably coinciding with the onset of ovulatory cycles.
2-Patients complain of spasmodic or cramping lower abdominal pain that may
radiate supra-pubically or to the inner aspect of the thighs.
3-They may have backache of varying severity.
4-They may also have other accompanying symptoms, such as headache,
nausea, vomiting, diarrhea, or fatigue. Symptoms typically last 48 hours or less,
but sometimes may last up to 72 hours.
Primary dysmenorrhea usually develops with a strong likelihood that the attitude of
the mother may influence the response of the daughter. The pain is often intense,
cramping, crippling and severely incapacitating so that it causes a major disruption
of social activities. It is usually associated with the onset of menstrual blood loss
but may begin on the day preceding menstruation. The Primary dysmenorrhea
often disappears or improves after the birth of the first child.
A careful history and detailed examination are the key to diagnosing primary
dysmenorrhea. It is a diagnosis of exclusion. The general physical examination and
pelvic examination reveal no abnormality. Sometimes a laparoscopy may have to
be performed to rule out pelvic pathology, particularly endometriosis.
Secondary dysmenorrhea
It is continuous dull aching lower abdominal pain accompanied by backache
occurring in multiparous women after many years of relatively painless
menstruation due to pelvic congestion which is more marked in premenstrual
period.
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Any woman who develops secondary dysmenorrhea should be considered to
have organic pathology in the pelvis until proved otherwise.
Pelvic examination is particularly important in this situation and, if the findings
are negative, laparoscopy is indicated. Common associated pathologies include
endometriosis, adenomyosis, pelvic infections and intra-uterine lesions such as
submucous. fibroid polyps.
Pathophysiology of secondary dysmenorrhea

The mechanism of pain in secondary dysmenorrhea is due to pelvic congestion
which is more marked in the premenstrual period. Pain increases in its severity as
menstruation approaches and is relieved by the onset of menstrual flow, due to the
diminution of pelvic congestion.
Clinical Symptoms
1- Secondary dysmenorrhea usually starts few days (about 3 to 5 days) before
menstruation. 2-Pain is continuous dull aching lower abdominal pain accompanied
by backache occurring in parous women after many years of relatively painless
menstruation.
3- It may be associated with other symptoms as dyspareunia, infertility and
abnormal bleeding.
Investigations
A careful history is of great importance in this condition. Pelvic examination is
essential in secondary dysmenorrhea and, if pelvic pathology is not palpable,
laparoscopy is advisable.
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Management of Dysmenorrhea
* Primary dysmenorrhea:
1. General and psychological treatment:
Discussion and reassurance are an essential part of management. The intensity
of pain may be aggravated by apprehension and fear. Reassurance that the pain
does not indicate any serious disorder may lessen the symptoms. It is also
common for the pain to either disappear or substantially lessen after the birth of
the first child.
2. Drug therapy:
Dysmenorrhea can be effectively treated by drugs that inhibit prostaglandin
synthesis and hence lessen uterine contractility. These drugs include aspirin,
Mefenamic acid, naproxen or ibuprofen.
As dysmenorrhea is often associated with vomiting, headache and dizziness, it
may be advisable to start therapy either on the day before the period is
expected, or as soon as the menstrual flow commences. Mefenamic acid is
given in a dose of 250 mg 6-hourly. This drug also reduces menstrual flow in
some women with menorrhagia.
If these drugs are inadequate, suppression of ovulation with the
contraceptive pill is highly effective in reducing the severity of dysmenorrhea.
Where it is ineffective, then careful consideration should be given to the
possibility of underlying pathology.
If all conservative medical therapy fails, then relief may sometimes be
achieved by mechanical dilatation of the cervix or by the surgical removal of
the pain fibers to the uterus in an operation known as presacral neurectomy, but
these methods of treatment should be approached with considerable caution.
3. Physical therapy:
190
- Encourage regular and aerobic exercises to raise their general health. as
walking, swimming, running, and bicycling. Exercise intensity: 40-60% of
maximal heart rate, 30 minutes, 3 days/week. Aerobic exercise can
decrease menstrual pain by: a- Release of endorphins; b-Inhibit
prostaglandins; c- Relaxation, stress relief and improving blood flow
- Relaxation techniques, as well as meditation and hypnosis may be helpful
for raising their pain threshold.
- Avoid constipation.
- Massage.
- Hot packs on the lower abdomen for 10-15 minutes.
- Acupressure on the lumbosacral area and 3 cm superior to the medial
malleolus.
- Transcutaneous electrical nerve stimulation (TENS).
- Low level laser therapy (LLLT).
TENS:
The following figures illustrate different electrode placement techniques developed
for dysmenorrhea (Figs. 11-2, 3, 4, 5, 6). Parameter settings should be the same as
for acute pain at a rate: 80-120 Hz, pulse width: 150 µs, minimal intensity: 1 hour
several times daily.
191
Fig. (11-2): Dual-channel, V-shaped pathway, using three-lead cable system. Electrode
placement sites: A, Uppermost painful anterolateral aspect of abdomen, below umbilicus
on left (negative electrode of channel 1). B, Uppermost painful anterolateral aspect of
abdomen, below umbilicus on right (negative electrode of channel 2). C, Most intense
area of pain at midline below umbilicus. (Positive electrode).
Fig. (11-3): Dual-channel, crisscross. Electrode placement sites. A1, On abdomen at most
anterolateral area of pain below umbilicus on right. A2, On abdomen at most anterolateral area
of pain above anterior-superior iliac spine (ASIS) on left (channel 1). B1, same as A1, but on
left. B2, Same as A2, but on right.
192
Fig. (11-4): Dual-channel, bilateral. Electrode placement sites: A1, Two inches above the medial
aspect of patellar base. A2, Three Inches above medial malleolus Just behind tibia (channel 1 ).
Bi and B2, Same as above, but placement is on opposite extremity (channel 2). Anatomic
characteristics: A1 and Bi, Motor/trigger point of vastus medialis. Corresponds to acupuncture
point SP 10. A2 and B2, Motor point of flexor digitourm longus. Corresponds to acupuncture
point SP 6.
Fig. (11-5): For pre-menstrual pain, recommended electrode placements are at the lumbosacral
nerve roots (L4 to S3) and suprapubic on the anterior abdomen.
193
Fig. (11-6): TENS electrode placement over four classical acupuncture points: Spleen 6,
stomach 36, bladder 29. The treatment was given for a total of 30 minutes.
Laser:
Using laser type Gallium Arsenide laser diode, its wavelength 904 nm with
maximum peak power 5 milliwatts. The 1st session was carried out when the
subject complained of unbearable pain (few hours or half a day before the
beginning of the menstrual blood flow) while 2nd and 3rd sessions were carried
out in the other next two consecutive days.
The subject lies in crock lying position for the application of low-level laser
therapy (LLLT) on the supra pubic region (3 shoots) the head of the machine must
be perpendicular, with direct contact to each treatment point and each shoot lasted
60 seconds. Then, the subject was asked to lie prone. Laser was applied on the para
vertebral region from L4 - S3, this area was treated by three shoots for each side
and each shoot for 60 seconds (Fig. 11-7a,b).
194
Laser may reduce pain through its effect on: a. the serotonin metabolism by
increasing 5 hydroxyindoleactic acid in the urine. b. stimulating the Beta
endorphin secretion which is associated with inhibiting synthesis of prostaglandin.
c. Laser has photochemical and photobiological effect because it acts as a trigger
for cellular metabolism regulation and activate the respiratory chain. d. It
decreased the conduction velocity of the sensory nerve and increased its distal
latency. e. Also laser stimulates the gate control to inhibit pain pathway.
Fig. (11-7 a): Site of laser Fig. (11-7 b): Site of laser application
application on the supra pubic on the paravertebral region (L4-S3).
region.
Interferential current (IF):

Using 4 plate electrodes, two of 200 cm2 placed over the lumbosacral region
(bilaterally) and two of 100 cm2 placed over the lower abdomen. A constant
frequency of 100 Hz was used in the 1st 3 sessions, followed by a rhythmical
frequency of 0-100 Hz. The dosage being from 12-25 mA depending on the
individual tolerance of the patient. The duration of each session is 15 - 20 minutes
daily or every other day for 15 sessions (Fig. 11-8).
195
IF has an analgesic and vasodilating effects by allowing the rapid elimination of
toxic metabolic products and ensures better oxygen supply to tissues as a result of
improving the circulation. In addition, it changes pH to the alkaline side and helps
to disperse infiltrations and adhesions.
Fig. (11-8): Position of electrodes in treating dysmenorrhea by interferential.
Short Wave Diathermy (SWD)

Between 5% and 10% of young women suffer severe dysmenorrhea. Although
pathophysiological mechanism is not certain, and many theories have been
suggested, poor uterine vascularity is one theory that has been put forward.
196
Gynecologists may occasionally refer women for pelvic short-wave diathermy in
an effort to improve the uterine circulation. Superficial heat application to the back
or abdomen (hot packs or a hot water bottle) can also relieve menstrual cramps.
SW session applied for 10-20 minutes by placing one pad electrode under pelvis
and the other one over the lower abdomen.
Microwave Diathermy
Microwave diathermy can be used for females suffer from dysmenorrhea. The
application of it through exposure of the lower abdomen for 1/2 hour.
The possible mechanism for the relieve of dysmenorrhea following microwave

diathermy arises from the fact that uterine contraction cause's the pain and deep
heat relieves deep pain and muscle spasm. So, uterine relaxation occurred with a
concomitant decrease in pain. Also, increased blood flow caused by heating the
uterus may have facilitated "washout" of the prostaglandins, which also have been
implicated in causing the myometrial contractions.
Kinesio-taping (KT)
Apply KT on the genital zone and viscerotome S1 of the genital organs and over
the uterus with (75%–100% stretch). K-tape physiological effects including:
a- Decreasing pain by the stimulation of low-threshold mechanoreceptors,
leads to inhibition of ongoing nociceptive transmission from centrally transmitting
nociceptive cells, in line with the gate control theory of pain
b-Removing congestion of lymphatic fluid and the circulatory system.
197
Fig. (11-9): KT application for dysmenorrhea
** Secondary dysmenorrhea:
In cases of secondary dysmenorrhea, the treatment is dependent on the nature of
the underlying pathology. If the pathology is not amenable to medical therapy, the
symptoms may only relieved by hysterectomy. However, the role of physical
therapy in such cases will consist of pre and post-operative physical treatment.
198
References:
- Kamel DM, Tantawy SA, Gehan A Abdelsamea GA. Experience of
dysmenorrhea among a group of physical therapy students from Cairo
University: an exploratory study. J Pain Res. 2017; 10: 1079–1085.
- Esimai O, Esan GO. Awareness of menstrual abnormality amongst college
students in urban area of Ile-Ife, Osun state, Nigeria. Indian J Community
Med. 2010; 35:63–66.
- Emans SJ, Laufer RL, Goldstein DP. Pediatric & Adolescent Gynecology.
5th ed. Philadelphia, PA: Lippincott, Williams & Wilkins; 2005.
- Bai, Hai-Yan MBa; Bai, Hong-Yan MBb; Yang, Zhi-Qin MBc,* Effect of
transcutaneous electrical nerve stimulation therapy for the treatment of
primary dysmenorrheal, Medicine: September 2017 - Volume 96 - Issue 36 -
p e7959 doi: 10.1097/MD.0000000000007959.
- Elham Saffarieh and Ramin Pazoki., Low Level Laser Therapy In
The Relief of Primary Dysmenorrhoea. Adv. Environ. Biol., 9(3), 871-
873, 2015
- Mayur Tukaram Revadkar, Trineta Mohan Bhojwani. Comparison of
the effectiveness of transcutaneous electrical nerve stimulation (TENS) vs
interferential therapy (IFT) for relief of pain in primary dysmenorrhea. Int J
Physio [Internet]. 2019
199

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Pelvis Disorers Theoritical

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Physical Therapy for Pelvis disorders in Women

Prof. Dr. Abeer M. ElDeeb, PT PhD

This book is developed to provide a source of elaborated and explanatory materials

In this version, there is a flow of chapters of pelvis disorders related to females

Dr. Elham S. Hassan, PT PhD Dr. Sara M. Ahmed, PT PhD

Dr. Reham E. Hamoda, PT PhD Dr. Dina M. Mohamed, PT PhD

Dr. Mai M. Shehata Dr. Manal A. El-Shafei

Dr. Mahitab M. Yosri, PT PhD Dr. Shreen R Aboelmagd

Anatomy of Female Pelvis

Structure of the Pelvic Girdle

• Two sacroiliac joints: between the ilium, and the sacrum

The bony pelvis allows the pelvic region to be divided into:

Fig. 1-2. The greater and lesser pelvis.

Fig. (1- 5): Gynecoid pelvis vs the android pelvis.

Diameters of the Pelvis

Obstetric conjugate (true conjugate): It is the minimum antero-posterior

Diagonal Conjugate: It is an alternative conjugate measured from the inferior

Ligaments of the Pelvic Girdle

Sacroiliac ligament: It is a connective tissue band connecting the anterior surface

Sacrotuberous ligament: It is a fan-shaped connective tissue fibrous band that

Sacrospinous ligament: It is a triangular connective tissue band attaching the

Fig.1-7. Pelvic ligaments, posterior sacroiliac ligament,

- Chaudhry SR, Imonugo O, Chaudhry K. Anatomy, Abdomen and Pelvis,

Female reproductive system

Fig. (2-1): External genital organ.

Fig. (2-2): Vagina.

Fig. (2-4): Ovaries and fallopian tubes.

Levator ani muscle:

Fig. (2-5): Levator ani muscle

Anatomy of symphysis pubis

Ligaments of pubic symphysis:

Etiology and pathophysiology:

● Other factors contribute to symphysis pubis dysfunction include physically

Diagnosis of symphysis pubis dysfunction

• Transvaginal or trans perineal ultrasound: It has been used to confirm

B) Management during labor:

The following measurements should be noted:

Fig. (3) Positions of delivery

In the late post-partum phase after discharge:

Anatomy of sacroiliac joint:

Fig. (4-1): Sacroiliac joint

Pelvic girdle pain

The etiology and pathogenesis

Risk factors for PGP

Differential diagnosis of PGP in pregnancy

2-Red flags history points

Modified Trendelenburg test:

Posterior pelvic pain provocation test (P4)

• Patient lies supine and hip flexed to 90 degrees. Downward pressure is

“Faber” test (flexion abduction external rotation) or Patrick’s sign:

Interpretation of the tests

N.B. Exercises are performed without provoking pain. Individualization of

-Ten classical acupuncture points (BL26,32,33,54,60, KI11, EX21, GB30, SP,

7-Education is often used as a supplement to these interventions.

Prognosis and recurrence risk

Management during delivery

Fig. (4-2): An exercise ball

Management in the post-partum period

Fig. (4-4): Stabilizing exercises using slings

- Robinson HS, Mengshoel AM, Bjelland EK, Vøllestad NK .Pelvic

Low Back Pain (LBP) During Pregnancy

3- Muscle separation (diastasis recti)

Physical Therapy Management

4) Manual therapy techniques