References

1. Davila GW, Singh A, Karapanagiotou I, et al. Are women with urogenital atrophy symptomatic? Am J Obstet Gynecol 2003;188:382-388.

2. Blakeman PJ, Hilton P, Bulmer JN. Cellular proliferation in the female lower urinary tract with reference to oestrogen status. Br J Obstet Gynecol 2001;108:813-816.

3. Smith P, Heimer G, Norgren A, Ulmsten U. Steroid hormone receptors in pelvic muscles and ligaments in women. Gynecol Obstet Invest 1990;30:27-30.

4. Hulley S, Furberg C, Barrett-Connor E, et al. Noncardiovascular disease outcomes during 6.8 years of hormone therapy: heart and estrogen/ progestin replacement study follow-up (HERS II).JAMA 2002;288:58-66.

5. Handa VL, Bachus KE, Johnston WW, Robboy SJ, Hammond CB. Vaginal administration of low-dose conjugated estrogens: systemic absorption and effects on the endometrium. Obstet Gynecol 1994; 84:215-218.

6. Bhatia NN, Bergman A, Karram MM. Effects of estrogen on urethral function in women with urinary incontinence. Am J Obstet Gynecol 1989;160:176-181.

7. Hilton P, Stanton SL. The use of intravaginal oestrogen cream in genuine stress incontinence. Br J Obstet Gynecol 1983;90:940-944.

8. Haadem K, Ling L, Ferno M, Graffner H. Estrogen receptors in the external anal sphincter. Am J Obstet Gynecol 1991;164:609-610.

Section XII

Physiotherapeutic Approaches

Section XII

Physiotherapeutic Approaches

G.Willy Davila

Neuromuscular alterations underlie most, if not all, pelvic floor symptomatic dysfunctions.

Direct trauma to the pelvic floor muscles and the nerve supply to the pelvic organs occurring during pregnancy and the vaginal birth process is linked by increasing degrees of objective evidence to the development of pelvic floor problems in women.This also explains the greater propensity of these problems in women. In most women, anatomic and functional pelvic floor dysfunction symptoms tend to worsen over time, as a result of the increased trauma of further deliveries, chronic increases in intraabdominal pressure, bipedal ambulation, the aging process, and hormonal alterations such as menopause.

Similar to other medical conditions, which are attributable to neuromuscular dysfunction (such as chronic back pain), pelvic floor problems frequently respond to rehabilitative therapies. Behavioral approaches such as bladder retraining and directed muscle strengthening exercises, such as Kegel exercises, are effective in the treatment of most bladder, bowel,and pelvic support problems. Unfortunately, many clinicians are not aware of the utility of these conservative approaches for the treatment of their symptomatic patients. Kegel exercises were popularized during the 1950s, but it has not been until recently that their utilization has been supported in a more widespread manner. Because women cannot visualize or frequently feel their pelvic floor muscles, appropriate and correct performance of pelvic floor exercise can be quite challenging. The increased availability of biofeedback techniques has improved our ability to train women to perform pelvic floor exercises correctly. Directed functional electrical stimulation of the pelvic floor neuromuscular unit has demonstrated significant value in the treatment of specific forms of dysfunction.The use of functional electrical stimulation is limited in the United States. However, in Europe, where it has achieved a greater degree of acceptance, its usage is more extensive.

At our institution, we will use physiotherapy as first-line therapy for many conditions such as constipation, stress incontinence, and obstructive defecation syndromes. We will use it as concomitant therapy with pharmacotherapy in the treatment of overactive bladder, irritable bowel, and other irritative symptoms.We will use it sequentially with surgical therapy in patients with fecal incontinence, urinary stress incontinence, or genital prolapse. The use of physiotherapy in the peripartum phase is also very important and underutilized in the United States.We do not have an obstetrics unit at Cleveland Clinic Florida,and therefore will not be discussing this aspect of physiotherapy in great detail. However,the role of pelvic physiotherapy antepartum,and more importantly postpartum, should be given significant consideration, especially in patients at risk for pelvic floor dysfunction.

This section will review the various behavioral and rehabilitative techniques available for the treatment of symptomatic women. The importance of a well-trained and motivated therapist will be highlighted along with the importance of patient motivation on achieving success.The role of pelvic floor rehabilitative therapy by itself, before or after surgical therapy,and use in combination with pharmacotherapy, will be discussed in the hope that more clinicians will avail themselves and their patients of these effective and cost-efficient techniques.

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Constipation Prescription

Constipation Prescription

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