Clinical:Case Study:Pelvic Muscle Retraining

Original materials created in March 2000 by Tamara Bavendam, M.D. and Joyce D. Wallace, RN, MSN, CRNP

History

AP is a 36y/o AA woman with a lifelong history of urinary frequency and constipation. At age 34 she began having symptoms of pelvic pain that gradually increased in frequency and intensity. After evaluation, I diagnosed her with pelvic muscle dysfunction. Initially the symptoms resolved with gabapentin (Neurontin) and regular power walking. After several months of improved symptoms, she got a new job that did not allow her the time for her daily exercise. Her symptoms returned and intensified. This new job would not allow her the time off for routine physical therapy, so I put her on medical leave. While the pain gradually resolved with the physical therapy, the frequency and urgency of urination became more problematic for her. For a variety of reasons, including dissatisfaction with time for personal care, AP decided to enter job retraining to become a carpenter.

Medications

Gabapentin only, except for occasional over-the-counter laxative use Past Medical Hx: G1P1, and asthma as a child; no history of surgery Social Hx: AP is single parent of a 11 year old son. She quit smoking five years ago, and does not drink alcohol. She was a runner in high school, but did not participate in regular physical activity after graduation until recently.

Exam

Well-developed, well-nourished woman appearing younger than her stated age. Physical exam, including breast was normal. Pelvic exam revealed no pelvic organ prolapse or pelvic organ abnormalities on bimanual palpation. She had increased tone of the pelvic muscles which were tender to palpation and she could not voluntarily contract or relax the muscles. Urodynamic evaluation revealed an early urge to urinate with a normal bladder capacity and difficulty relaxing her pelvic floor muscles to urinate. There was no evidence of involuntary detrusor contraction accounting for her symptoms.

Data

Multiple studies, including urinalyses, had been normal.

Discussion

AP’s pelvic symptoms of pain, and bladder and bowel dysfunction were likely all attributible to her pelvic musculature. Often in a case such as this, physicians choose pharmacotherapy as the first line of action — anticholinergic, neurotropic, or otherwise. In AP’s case, however, prior neurotropic agents had helped only part of the symptoms. Furthermore, the presence of her significant chronic constipation, as well as her personal choices surrounding behavioral change versus “pills,” precluded the use of long-standing anticholinergic medication. She and I agreed on a change of tactic, and chose referral for behavioral treatment as the best option for her.

Biofeedback Biofeedback is a behavioral therapy technique used to obtain objective information about electrical activity of the pelvic floor muscles, and teach patients about their bodies. Pelvic floor biofeedback is performed by placing electrodes externally, vaginally, and/or rectally and measuring muscle activity. In particular it detects increased resting tension, and gives the patient feedback about physiologic processes during evaluation and treatment. It is particularly useful in detecting and aiding a patient who had difficulty with pelvic relaxation.

When AP presented for her first behavioral therapy/ biofeedback session, she complained of persistent daytime urinary urgency and frequency — as often as every 10-20 minutes, vaginal discomfort she described as “stinging”, and occasional “trickling” of urine after voiding. Her long-standing constipation had resumed after she became noncompliant with a very high fiber diet, necessitating use of laxatives and manual disimpaction of stool. Although her symptoms were severe, this woman was very motivated, which is a crucial requirement for a successful outcome in behavioral therapy.

Pelvic muscle evaluation by electromyography confirmed AP’s pelvic muscle spasm and identified 1) erratic bursts of activity of the muscles, even when the patient was resting; 2) inability to relax the pelvic muscles after contraction; and 3) poor endurance of the muscles overall

Plan

AP and I reviewed her biofeedback results, and how her pelvic musculature was contributing to her symptoms. Her training needed to focus on proper isolation of the pelvic floor muscles without the use of accessory muscles, “memorizing” how relaxed muscles felt, and using that knowledge to relax these muscles during urination and defecation. We agreed on additional biofeedback sessions as needed for continued “learning” of pelvic muscles and movement. Together we then devised a plan that would be effective, and also realistic for her on a daily basis. In addition to AP’s already established commitment to physical exercise, and her high-fiber, increased-fluid diet, we added:

• 25 Kegel exercises twice daily, holding contractions for 10 seconds and focusing on relaxation for 10 seconds.
• Use of a small step stool (on which to rest her feet) while evacuating bladder and bowel to enhance relaxation of the pelvic muscles.
• Avoid “straining” activity and “rushing” to urinate or defecate.
• Schedule urination breaks at 30 minute intervals, using a reminder device, and increase by 15 minute intervals weekly to decrease her day time frequency.

The key to bladder retraining is attempting to urinate according to the scheduled time and not according to the bladder urges. To accomplish this, AP was instructed to inhibit urges by doing 4-5 quick pelvic muscle contractions, calming her breathing, and focusing her attention away from her bladder symptoms.

• Schedule unrushed time for a bowel movements, preferably after a meal, to take advantage of increased peristaltic activity
• Avoid bladder irritants such as caffeine, carbonation, and acidic foods+

Follow-up

Four weeks later, after 3 biofeedback sessions, AP was urinating every 2-3 hours and having bowel movements 2-3 times week without the use of laxatives or disimpaction. She was successfully incorporating relaxation techniques, urge inhibition techniques, and dietary changes to manage her longstanding problems. Her post void dribbling and vaginal stinging had resolved. She had a new feeling of confidence and control of her wellbeing, and maintained energy and commitment to continue.

+For a practical and comprehensive review of bladder irritants and their potential effects, see “Water Works,” by Dr. Bavendam; August 1998 issue of In This Case

References

Wyman JF, Fantl, JA, et al. Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Am J Obstet Gynecology, 1998;179: 999-1007

Laycock, Jo,Wyndaele, Jean Jacques (1994). Understanding the Pelvic Floor-Abstracts of the Presentations and Edited Transcripts of the Discussion Sessions of the Pre-Conference Pelvic Floor Workshop-Rome 1993. Neen HealthBooks, United Kingdom

Steege, JF, Metzger, DA, and Levy, BS. Chronic Pelvic Pain: An Integrated Approach. WB Saunders Company:Philadelphia, 1998

Levy, Barbara S. Pelvic Pain=“Pelvic Organs.” In This Case, 1998; September