Structure

7.1 Introduction
7.2 Physiotherapy for gynaecology outpatients.
7.3 Incontinence
7.4 Patients requiring pelvic floor reeducation
7.5 Stress Incontinence


7.1 Introduction

Physiotherapy cover on gynaecological wards varies throughout the country. In some hospitals the physiotherapist will only treat patients who develop a chest infection with an accumulation of secretions after a general anaesthetic; other hospitals will have a therapist in attendance for a short period every day.

Statistics indicate that 90 percent of the major operations in a gynaecology unit are hysterectomies and vaginal repairs. Most of these women will have borne children; thus there are a large number of women, of all ages, whose pelvic floor and abdominal muscles and backs have been subjected to the strains of childbearing.

It can be argued that these women will achieve a more complete recovery if they are shown how to strengthen their pelvic floor, abdominal and back muscles, and be given advice on self care at home. The following points indicate differences in treatment regimes which may be used for other surgical patients.

Deep vein thrombosis

Patients who have had a pelvic operation appear to be more susceptible to deep vein thrombosis, therefore special precautions should be taken:

1. If Tubigrip or anti embolic stockings have not been applied prior to operation or in the theatre, the physiotherapist may be asked to do this when the patient returns to the ward.

2. The foot of the bed can be elevated and a bed cradle used to facilitate frequent foot and leg movements. These are most effective if practised slowly and strongly.

3. Extra emphasis should be placed on full chest breathing, practised frequently, to improve venous return and move secretions in readiness for coughing.

Coughing

Secretions are most effectively dealt with if a patient is in a curled up position sitting up, or in side lying, with forearms ’cuddled’ over the incision to prevent movement. They should be shown (preferably pre operatively) how to move the secretions towards the bronchi with long, easy, slow breathing. Repeated ’huffs’ will project the mucus into the mouth with the minimum of discomfort.

For vaginal operations, one hand should be placed on the sanitary towel with firm pressure upwards when coughing.

Pelvic rocking

This activity encourages the viscera to move away from the incision, prevents protective muscle spasm in the abdomen and back and decreases the pain from flatulence by speeding the dispersal of gases. Pelvic rocking should be commenced as soon as possible on recovery of consciousness. It is most easily taught as follows:

The patient is in crook lying with hands resting on hip bones; she is then told to ‘Tilt your hip bones towards your face; hold for four seconds and put it down slowly.’

Repeat in a rocking rhythm several times an hour. The patient will also feel the tilting of her pelvis under her hands and notice her lumbar spine flattening and hollowing. This is a simple, non threatening and comfortable activity which can give patients confidence to make other movements even after extensive surgery, e.g. Wertheim’s hysterectomy.

Correction of posture

As soon as drainage tubes allow ambulation the patient should be encouraged to adopt an upright posture using the phrase ’stand tall’. As the top of the head is pressed upwards, the vertebral column is stretched and opened, the pelvis tilts back and alignment of hips, knees and ankles is corrected automatically. This becomes the ’new posture’ after a few days if it is practised whenever upright.

Further activity

The provision of an illustrated leaflet can be useful to promote further activity. If such a leaflet is available it should be given to patients in the pre operative period so that they are able to understand that a programme of continuous care and activity in hospital and at home will reduce the effects of an anaesthetic and surgery and speed their restoration to normality.

Suggested Contents of Leaflet

1. Pre and postoperative breathing and coughing.
2. Foot and leg Movements.
3. Pelvic rocking
4. Posture correction: ‘stand tall’.
5. Pelvic floor information and exercises. Starting dates to be discussed with surgeon after vaginal repairs.
6. Graduated exercises to strengthen abdominal and back muscles.
7. Advice for home care.

Advice for Home Care:
In addition to your exercises:

1. When you go home you will tire easily; lie on your bed for an extra rest during the day for several weeks.

2. Do not return to full time work until after your post operation clinic visit (about six weeks after the operation).

3. It is common to have twinges of pain around the site of your wound for a few weeks.

4. Forceful pulling or pushing (vacuuming or opening swing doors) will seem difficult start when you feel able.

5. Avoid straining to open your bowels seek advice if necessary.

6. Your bladder will take a week or two to settle down pelvic floor exercises will help

7. No heavy lifting. Moderate lifting and carrying must be avoided for six to eight weeks. After this, if the pelvic floor is braced when lifting, especially after vaginal repairs; the effect of the downward thrust in the pelvis is reduced. Get help to lift whenever possible.

Always remember:
Bend your knee hold heavy objects close to you, and twist from your feet and not your spine. Teach your family the safe way as well!

8. All operation are different. So it is better not to compare your progress with friends

Infra red irradiation and short wave diathermy

Heat can be very effective in speeding the healing of infected and slow healing wounds. Care should be taken to ensure that an adequate area of skin around the incision is exposed to the heat, as thermal sensation in the proximity of a wound is frequently impaired. The presence of metal within the tissues or in the form of metal clips or buttons anchoring a continuous suture is a contraindication to any form of heat treatment.

Infra red irradiation has been found to be particularly useful in promoting granulation of the open areas after a radical vulvectomy. Twice daily treatment, seven days a week, is recommended.

Short wave diathermy for an infected abdominal wound is most easily carried out using a coplanar method with medium sized disc electrodes placed over normal skin either side of the incision. After an initial thermal treatment of 10 minutes, a 20 minute period repeated twice
Daily seems most satisfactory.


7.2 PHYSIOTHERAPY FOR GYNAECOLOGY OUTPATIENTS

The pelvic floor comprises of three layers:

1. Superficial (perineal):
Bands of striated muscles radiating outwards to the pelvic bones from the central tendinous point of the perineum (perineal body).

2. Middle (urogenital diaphragm):
A sheet of fascia filling the triangular space below the symphysis pubis and the pubic rami. It is pierced by the urethra and vagina and contains some muscle fibres in the urethral portion (compressor urethrae) and below the vagina (deep transverse perineal). The latter are inserted into the perineal body.

3. Deep (levator ani):
A composite group of striated muscles which form the sling like base of the pelvic floor. They are made up of types 1 and 2 fibres. There is a predominance of type1 fibres throughout; the proportion of 1:2 varies in different parts of the muscle group.

The muscles originate from bone and fascia on each side of the pelvic brim and pass backwards towards the coccyx and insert centrally into the anococcygeal raphe (levator plate). The central portions (the pubococcygeal) have free inner borders as they do not meet around the urethra and vagina anteriorly, the gap being greatest when the muscles are stretched and weak. They are innervated by the pudendal nerve (S 2, 3, 4) - The puborectalis is different. It is a single continuous U-shaped loop of muscle originating from the posterior aspect of the pubis passing behind the rectum to form the acute anorectal angle and returning to the pubis for insertion.

The anorectal angle is an efficient flap valve mechanism due to the pull of puborectalis and the sealing effect of raised intraabdominal pressure.

The puborectalis lies in a vertical plane below the rest of levator ani so its upper fibres are apposed to the latter muscle. Innervation of the puborectalis is from a branch of the sacral nerve (S3, 4), which lies above the pelvic floor.

Urethral Musculature
The middle third of the female urethra contains a striated muscle collar, thicker anteriorly, which forms the External urethral sphincter (not to be confused with levator ani). The sphincter is made up of type 1 fibres and assists in maintaining urethral closure over long periods. Innervation is via the pelvic splanchnic nerves from S 2, 3, 4.

Fascia plays an important role in the pelvic floor as it tenses the muscles and forms most of their origins and insertions. Surgeons report that the proportion of muscle tissue to fascia is very variable. It is also known that the thinning and loss of muscle fibres laterally is accentuated in obese women and women of advancing age. After the menopause this can be due to substitution of muscle fibres by collagen tissue. There is also a correlation of levator muscle mass to general body musculature.

Comparative studies of the quality of the levator muscles in Occidental and Oriental women have highlighted the greater muscle bulk and less deterioration of the muscles with age in the latter group. Explanations to account for these changes include adoption of squatting positions for many daily activities, physically hard lifestyle, a diet which discourages obesity, and genetic difference.

One cause of dysfunction of the pelvic floor muscles is difficult childbearing; similarly, straining due to chronic constipation. Both can cause damage to the innervation of the pelvic floor muscles. It seems likely that this damage is cumulative and more likely to be irreversible as childbearing continues.

Function of the Pelvic Floor Muscles

1. Support of the viscera.

2. Compressive action as part of the closure mechanism of the urethra, vagina and bowel.

3. Reflex action in maintenance of intra abdominal pressure.


7.3 INCONTINENCE

Incontinence is a symptom, not a diagnosis. By definition it is the inability to control the passing of urine and faeces so that either or both excretions are passed at inappropriate times or places.

During the past 15 years this topic, previously hidden by sufferers and largely ignored by health professionals, has become a subject for research, education and discussion. International and national organizations have members with enthusiasm and dedication whose aim is to ensure incontinence is identified, then cured, reduced or managed well; but above all they want to ’promote continence’ and this commences with prevention.

To be continent a person has to:
- register the need to pass urine or faeces
- Know where the toilet or receptacle is located
- Or be able to summon assistance - be able to reach the toilet
- undress adequately
- sit or stand safely
- And perform all these activities in time!

A sudden or gradual change in a person’s health status or her/his environment can precipitate her into a cycle of events in which incontinence becomes a dominant and distressing factor.

Incontinence is a complex subject and the following discussion is designed to assist physiotherapists distinguish between the various types of incontinence when assessing patients. This will enable an effective physiotherapy treatment programme to be given or onward referral to a more appropriate adviser.

(In this text information about urinary incontinence predominates. Faecal incontinence will be mentioned when appropriate.)

Types of incontinence

Stress Incontinence
This may be a symptom, sign or a condition.

The symptom is an involuntary loss of urine on exertion, e.g. coughing or running. The sign is the observation of loss of urine from the urethra when coughing or straining, sometimes only when upright.

As a condition ’genuine stress incontinence’ (as defined by the International Continence Society) is ’the involuntary loss of urine when pressure in the bladder exceeds maximal urethral pressure in the absence of a detrusor contraction’.

When genuine stress incontinence is accompanied by a minor degree of vaginal wall prolapse, reeducation of the pelvic floor muscles can alleviate the incontinence. The exercises can also assist when surgical correction of the condition is only partially effective.

Idiopathic stress incontinence of faeces (particularly in the postpartum period) responds well to reeducation of the puborectalis.

Urge Incontinence
This is the involuntary loss of urine associated with a strong desire to void. It is most easily understood if it is divided into motor and sensory types.

Motor urge is characterized by uninhibited detrusor contractions (detrusor instability). It is responsible for at least 30 per cent of gynaecological referrals. It is more common in the elderly as it can be secondary to atherosclerosis. In many women the cause is never found.

Bladder training can be used to good effect.

Sensory urge is generally related to an acute or chronic infection, urinary calculi or bladder tumour.

Treatment is with antibiotics or by surgery.

Overflow Incontinence
This is the involuntary loss of residual urine in dribbles or jets (on movement) when the bladder is unable to empty completely. The condition is often caused by an obstruction to the outflow of urine, e.g. enlarged prostate gland or impacted faeces (especially in the elderly), a retroverted gravid uterus, pelvic tumour or urethral stenosis. But it can also occur in people who have overstretched atonic bladders that are unable to contract, e.g. after repeated overdistension or linked to diabetic neuropathy.

Reflex Incontinence (neurogenic)
This is the voluntary loss of urine due to abnormal reflex activity in the spinal cord in the absence of sensation usually associated with the desire to micturate. It is associated with a wide range of disorders which affect the brain and spinal cord, including trauma, e.g. paraplegia. Each type requires its own special management.

Continuous Incontinence
This may result from pathological or structural abnormality or be related to major trauma or surgery, e.g. a fistula.

Frequency
This is usually defined as the passage of urine seven or more times during the day and waking twice or more at night to void. It often presents with other types of incontinence. ’Self induced’ frequency is found in patients who make a habit of voiding regardless of a desire to do so because they are frightened of leaking urine. They can develop small ’just in case’ bladders which become very inconvenient with ageing as frequency will increase. The condition often responds well to bladder training.

In some patients urodynamic, radiological and electromyography studies are necessary to complete a diagnosis.


7.4 PATIENTS REQUIRING REEDUCATION OF THE PELVIC FLOOR

These fall into two groups - postpartum and menopausal.

This means that the age of patients being treated may vary from the early twenties to the late seventies. Referrals may come from many sources, e.g. gynaecologists, urologists, general practitioners, post natal clinics, family planning clinics, health visitors and self referral by women. The latter is particularly relevant for women who have their babies in hospitals where physiotherapists give them postnatal advice and exercises to combat the effects of childbearing. In such instances, if problems then arise at home in respect of these activities self referral allows the woman to contact the physiotherapist quickly and receive further advice.

Liaison with the general practitioner by the physiotherapist will follow when necessary.

Presenting symptoms

1. Pelvic floor laxity.

2. Stress incontinence.

One or both of these symptoms may be present in the menopausal group as a result of progressive oestrogen deficiency. Changes in the vaginal mucosa lead to the hot, dry irritation of senile vaginitis, while in the urethra the mucosa shrinks and allows urine to escape more easily.

Oestrogen therapy in the form of implant, oral tablets or topical cream is frequently beneficial.

Pelvic Floor Laxity when the pelvic floor muscles are stretched and weak the support for the pelvic organs is poor and patients complain of ’heaviness’ in the perineal area. Varying degrees of overstretch of the walls of the vagina and urethra (cystocele, rectocele and urethrocele) and uterine supports (1st, 2nd and 3rd degree uterine prolapse) may be found.

Reeducation of the levator muscles will relieve these symptoms if they are mild. If there is severe fascial stretching (e.g. gross cystocele or 2nd or 3rd degree uterine prolapse) surgery is required. Preoperative pelvic floor exercises are worthwhile in most cases.

Sexual problems can arise as a result of pelvic floor laxity. The vagina will feel slack and lacking in ’squeeze’ as the weak muscles are unable to compress the vagina during intercourse. There is also likely to be difficulty in retaining a contraceptive diaphragm or tampon.

Some women find air becomes trapped inside the slack vagina and become very distressed and embarrassed when this ’vaginal flatus’ escapes noisily as they move about.


7.5 Stress Incontinence

ASSESSMENT AND TREATMENT OF THE PELVIC FLOOR

Quiet, comfort, privacy and time are essential for the patient’s first visit; wherever possible the patient (client) should be seen in a consulting room as curtained cubicles are not acceptable. At least 45 minutes is required for the initial interview.

History An assessment chart is a useful way of recording the relevant facts about all aspects of the client’s history, lifestyle and the results of the digital assessments. In some cases an accurate record of the woman’s bladder function in the form of a urinary diary is necessary to determine if bladder training or other advice is required. This can be completed for five days and brought to the first appointment or between first and second visits.

Explanation this should include simple details about the anatomy of the pelvis with a diagram. Two cupped hands, palms uppermost, hypothenar eminences touching, and a 2.5cm (1”) gap between the little fingers is the best way of illustrating the levator muscles. The compression of the rectum, vagina and urethra by the pubococcygeus and puborectalis is shown by bringing the little fingers together and raising the central portion of the hands to simulate the ’squeeze and lift’ the woman is expected to feel.

The function of the muscles is explained mentioning the different sensations when the muscles are weak and strong and relating this to the person’s symptoms and the need for a reeducation programme.

Assessment of the pelvic floor muscles and initial instruction

This is an essential part of the treatment. The muscles are not visible so the therapist must use a digital check and/or a vaginal pressure gauge (perineometer) to monitor the strength of the pelvic floor muscles and whether the exercise is being performed accurately.

During this period the therapist must be particularly mindful of the woman’s sensibilities and use her words and actions with care.

Method
The woman is positioned on a couch in crook lying with her knees and feet apart and suitably covered. Additional lighting may be required to illuminate the perineum.

Wearing disposable gloves and using the thumb and finger of her left hand the therapist separates the labia and notes any sign of inflammation, discharge or uterovaginal prolapse. She asks the woman to cough twice and ’strain’ downwards, noticing any bulging at the introitus or leakage of urine.

She then applies some vaginal lubricant to her fingers. With the phrase ’I am going to slide two fingers into your birth canal, so make room for my fingers’, she introduces the index and middle fingers of her right hand into the vagina; slowly. This is not a difficult procedure if the direction of the vagina is visualized and the muscles relaxed by the use of the above mentioned phrase.

Keeping her fingers in place, the therapist asks the woman to ’strain’ and cough again, any descent of the base of the bladder, the cervix or anterior and posterior vaginal walls will be noted.

If there is a large degree of uterovaginal prolapse the therapist’s fingers may be pushed out of the vagina.

To assess the strength of the pelvic floor muscles the following phrases are useful:

(a) With fingers open palpating the pubococcygeii: ’Close my fingers’.

(b) With fingers closed: ’Don’t let me pull my fingers out’.

(c) With fingers closed: ’Squeeze my fingers’.

(d) With fingers palpating posterior vaginal wall: ’Imagine you have diarrhoea so close your back passage’.

Phrase (d) will elicit a contraction of puborectalis.

If the woman’s problem relates more to poor bowel control it is advisable to add another component to the assessment.

In the side lying position using new gloves check the strength of the puborectalis by inserting the index finger through the anus to the anorectal angle. Using (d) the muscle strength can be assessed and reeducated in this way.

Using the woman’s best visualization and contraction from (a) to (d) she must now learn to formulate this into an exercise which can be repeated many times a day.

Most people find this phrase useful: ’Close your back and front passages, draw them up inside so you feel a squeeze, and lift and hold for four seconds and let go slowly’. Some women will only start with a two or three second hold, all should aim to progress to 10 seconds.

When the therapist is satisfied the woman can do this, she concludes the assessment. A vaginal pressure gauge or perineometer is valuable as a teaching aid and over a period of time will demonstrate an improvement in the strength of the muscles as the readings on the gauge increase. Initially it should be used early in the assessment before the muscles become fatigued.

A few service units have their own perineometers; the Bourne Duo unit is made in the United Kingdom and has large and small diameter sensors. Women are encouraged to check their own pelvic floor muscles digitally at home.

Finally, explain to the woman that a definite daily routine must be followed if the treatment is to be effective.

Routine for exercises

It has been found that a position of sitting or standing with thighs slightly apart is most effective, as the weight of the pelvic contents acts as a resistance to the muscles. An effective command is, ’Close the back and front passages, draw them up inside, hold this squeeze and lift for up to six seconds, than let go slowly’.

Some women find it necessary to concentrate on closing the ’back’ and ’front’ components separately at first, combining them at a later date.

The therapist should check that the woman understands that she should not contract her glutei or abdominal muscles or hold her breath while practising pelvic floor contractions. This is not easy at first, especially if the muscles are very weak, but if she concentrates her attention on the central area from her coccyx to symphysis pubis she will find she can gradually feel the ’squeeze and lift’ in this area alone.

As the muscles tire after five or six contractions, the exercise needs to be repeated frequently each day. Discussion with the therapist will ensure that a routine is worked out to suit the person’s everyday activities.

It has been found useful to relate contractions to the clock, e.g. practice on the hour every hour (using an alarm clock or cake timer as an aural stimulus); or linking contractions to activities, e.g. at the sink, having coffee, on the lavatory.

Reminders should be given to the woman to brace her pelvic floor (to reduce the downward thrust) whenever she coughs, sneezes or lifts heavy objects. Stopping and starting a flow of urine while micturating is a good ’awareness’ test and provides an indication of progress if the stream of urine is stopped more completely, but it should not replace the exercises.

The use of a daily record chart is advisable for at least the first week of the pelvic floor exercise programme as it serves as a reminder to do the exercises until they become part of the daily routine.

Obesity:
If the patient is overweight she needs encouragement to reduce weight or be referred to a dietician.

Persistent cough and sneezing:
Chest or allergy clinics may be of assistance. Smoking must be reduced if that is the cause of the coughing.

Follow up appointments:
Patients return for assessment three weeks after the first appointment. Subsequent appointments are at four to six week intervals. Those with less severe symptoms will be ready for discharge after about three months.

Progression of the exercise programme is important so that the muscles relearn how to contract reflexly in response to a threat, as detailed in group therapy.

Group therapy

When several women living near the hospital require treatment weekly exercise sessions as a group can be very beneficial. Much can be gained from contact with others who have similar problems and an element of competition enters for the overweight patients during the weekly ’weigh in’.

The ’pelvic floor group’ meets once a week for about 20 minutes. Very little equipment is required; any moderate sized room is suitable.

Exercises

Pelvic floor contractions are practised in all the variations of lying, sitting and standing, making the positions relate to the woman’s daily life.

To prevent fatigue of the pelvic floor muscles, strengthening and mobilizing for the abdominal and back muscles are interspersed. Posture correction is also taught.

As the pelvic floor muscles increase in strength the contractions can be made more difficult to sustain by practising them while skipping, running or jumping. Coughing, sneezing and lifting with the pelvic floor contracted must also be taught.

Duplicated reminder lists of exercises will aid the woman’s memory as great emphasis is laid on home practice. The overweight women are weighed each week and their weight is recorded.

In very recent times, a few centres have begun assessing the use of ’vaginal cones’ in cases of stress incontinence.

Bladder retraining

Physiotherapists who are able to teach reeducation of the pelvic floor can be involved in bladder retraining. This may be done in the ward or in the outpatient department.

Each time the desire to pass urine is felt the pelvic floor is contracted in an effort to delay micturition. If the delay time is slowly lengthened an appreciable improvement in urgency and frequency can be obtained in a few weeks.

Pre and post treatment bladder function charts can motivate women to continue the retraining.

Geriatrics

If elderly people become inactive the pelvic floor muscles may atrophy through lack of stimulus of changing intra abdominal pressure, which leads to difficulty in stopping the act of voiding. Practice to ’stop and start’ a stream of urine can lead to greater awareness and increased confidence in controlling bladder and bowel.

Inactivity is a contributory factor to stasis in the gut, constipation and impaction of faeces. General exercise programmes can be designed (even for the chair bound) for individuals or groups.

Brisk walking and swimming for the ‘well aged’ benefits all the body systems.

ELECTRICAL TREATMENTS

Short wave diathermy

The resolution of some gynaecological conditions can be accelerated by the application of heat. The short wave diathermic current is of high frequency and alternating and does not stimulate motor or sensory nerves. It is therefore ideal for heating tissues as deeply placed in the pelvis as the female reproductive organs.

Treatment of infected wounds

Pelvic Inflammatory Disease:
This responds well to short wave diathermy. It is best treated by the cross fire method with the patient in lying and side lying positions on a couch or in a canvas or wooden deck chair. In most cases a thermic initial treatment of five minutes each way followed by treatments of 10 minutes each way daily for two weeks, then three times weekly for two or three weeks is required.

There has been a tendency to stop treatment too early with long standing pelvic inflammatory disease.

Precautions especially relevant in the treatment of gynaecological patients by short wave diathermy

Clothing
The patient should remove all her garments from her waist down to her feet. The skin of the abdomen, buttocks and thighs can then be adequately inspected for scars or other blemishes.

Skin Sensation
Every area that is to be treated should be checked for sensation to heat and cold, paying particular attention to any scarred area which may show altered reactions.

Moisture
Great care should be taken to see that the perineum and inner aspects of the thighs are dry, as moisture will cause a concentration of the electric field.

If the patient is obese a dry Turkish towel could be placed between her thighs.

Intra uterine Devices
These contraceptive devices have been found to lose their shape when subjected to short wave diathermy. Metal devices like the Copper T concentrate the field.

It is the author’s opinion that short wave diathermy is contraindicated for a patient fitted with an intra uterine device.

Menstruation:
It has been the practice not to treat a patient who is menstruating. The author has found it unnecessary to suspend treatment at this time unless the patient has very heavy periods or secondary dysmenorrhoea. The sanitary protection should be removed before treatment, whether it is a pad or tampon, and the perineum thoroughly dried.

The patient can sit on a paper towel if she feels she may soil the towelling. A clean pad or tampon can be replaced after treatment.

Pregnancy
The effects of short wave diathermy on a foetus are unknown, therefore pregnant women should not be treated. Patients anticipating or suspecting pregnancy should inform the therapist.

Laparoscopic Sterilization
If the Fallopian tubes have been occluded by plastic or metal ring clips, short wave diathermy is contraindicated.

The presence of pacemakers, hearing aids or items of replacement or fixation surgery should be checked by the physiotherapist.

Faradism and interrupted direct current (IDC)

If the pelvic floor muscles are very weak patients can experience difficulty in practising exercises; the resultant contractions are so small that the effect on the surrounding tissues and, therefore, the patient’s sensation is minimal.

Faradism and IDC are still used by therapists to enhance weak contractions of the pelvic floor muscles, and thus encourage patients to greater awareness and voluntary effort. It is not clear whether the modalities are used by choice or because an interferential unit is not available.

The placement of electrodes is variable. A vaginal or rectal electrode with a large indifferent electrode over the sacrum or lower abdomen is one option. It is the author’s experience when using faradism that two metal electrodes each in a sponge sleeve, placed either side of the perineum, parallel to it, stimulate the pelvic floor muscles effectively.

A routine of 10 contractions and one minute rest repeated 10 times for 12-14 treatments (3 times weekly) is proving useful.

Electronic stimulators for the pelvic floor muscles, either as implants or vaginal/rectal electrodes connected to batteries worn around the waist are still the subject of experiment with indefinite results at present.

Interferential therapy

This modality is used in many parts of the world to treat a variety of conditions including genuine stress incontinence of urine and detrusor instability.

Interferential therapy appears to facilitate healing by utilizing the bioelectric effect. Bioelectric currents occur throughout the body, but when tissues are damaged the bioelectric profile is altered. Tissues in the body, categorized as excitable and non excitable, respond to stimulation by electrical energy within a given frequency range.

At present for practical purposes this range is from 0.1 Hz to 200Hz.

In the treatment of micturition disorders interferential (IF) is generally used in conjunction with pelvic floor exercises to increase the efficiency of the treatment.

Confirmation of this theory is proving difficult: one study has already found that the addition of interferential or faradism to pelvic floor exercises in the treatment of genuine stress incontinence did not improve the results. Research continues and Laycock (1988) has described a study where interferential therapy was being used alone in the treatment of stress incontinence with some success.

Application
As treatment profiles for micturition disorders vary and the efficiency of each is unproven, the target tissues will be identified and interferential stimulation options given.

Genuine stress incontinence

(a) Urethra:
External urethral sphincter; smooth muscle walls. Low frequency range required.
(1) 0.5-15 Hz or
(2) 0-100Hz using slow rhythmic sweep,
(b) Pelvic floor muscles:
Medium frequency range required. Surge facility required to prevent tetanic contraction. (1) 40-80Hz fast sweep or
(2) 50 Hz. Two seconds on and six seconds off.

Electrodes:
Four plates or suction cups, place medial to ischial tuberosities and obturator foramina.

Two plates (pre modulated approach is more convenient), place either side of the perineum (medial to the ischial tuberosities).

Intensity:
Maximum that is comfortable, work up to it slowly.

Duration:
(A) 15-20 minutes for plate electrodes; 10-15 minutes for suction cups.

(b) 40-50 contractions in groups of 10 with a rest between each group.

Detrusor instability:

Interferential stimulation is reported to be useful in inhibiting the contractions of an unstable bladder. Two methods are described:

1. This method originates from the treatment of clients with detrusor instability who have multiple sclerosis where stimulation over the thoracic outflow may have an effect on motor neurones from spinal segments beginning below this level; also a direct action on the autonomic system is possible.

Position:
Client in lying or half lying.

Electrodes:
Two large plates (13 x 8cm). One is placed horizontally over the vertebrae T12-L1 and the other anteriorly at the same level and held in place with Velcro bands.

Current:
10 – 110 Hz fast sweep with intensity up to 40 mA within 2 - 4 minutes.

Duration:
30 minutes, three times weekly for 12 treatments.

2. Originates from the treatment protocol of Laycock (1988).

Electrodes:
Two or four are placed as for genuine stress incontinence.

Intensity:
5-10 Hz fast sweep, intensity maximum to tolerance.

Duration:
30 minutes, three times weekly for 12 treatments.

In all treatments using interferential therapy minor adjustments may be required to pad placement and current intensity to ensure a safe, comfortable treatment which gives optimum results.

Precautions and Contraindications

Short wave diathermy interference:
Interferential machines should never be operated close to active short wave diathermy units as the radio energy transmitted by the short wave diathermy can cause the interferential machine to malfunction or cause ’surges’ of current in the patient’s circuit.

A minimum of 3 metres distance is suggested with a reservation that this may not be enough for some machines and separate operating times or rooms would be safer.

Interferential is a relatively safe treatment as thermal and electrochemical build up does not occur. Normal safety checks for operating equipment are necessary and observation for adverse skin reactions due to sensitivity to electrical currents or high current density in the pad area.

Consideration should be given to the following:

1. Check condition of the skin (avoid or insulate open areas).

2. Skin test for sharp/blunt sensitivity to pain.

3. Avoid febrile conditions, malignancy, pulmonary tuberculosis or purulent conditions.

4. Interferential is contraindicated to the back, abdomen or pelvis in pregnancy or during menstruation.

5. Interferential is contraindicated in severe cardiac conditions, severe hypotension.

6. Interferential is contraindicated if cardiac pacemakers are in use.

7. Avoid using interferential on anyone who has comprehension difficulties.

8. Avoid using interferential in areas of excessive bleeding.

Ultrasound

Ultrasonic energy is a form of mechanical energy with frequencies beyond the range of audible sound, i.e. greater than 2000 Hz. Varying frequencies of ultrasound are used in medicine.

Therapeutic ultrasound is widely used in the treatment of recent injuries for its beneficial effect on pain, traumatic and inflammatory conditions and on scar tissue.

The immediate effects of childbearing on the perineal area are frequently pain, trauma and inflammation and these respond readily to isonation. Unfortunately that is not the end of the problem; the resulting scar tissue often gives rise to varying degrees of dyspareunia and distress and thus becomes a gynaecological problem.

New scar tissue will always shorten unless it is repeatedly stretched. This is due to the property of collagen to gradually shorten when it is fully formed. This occurs from the third week to the sixth month after the injury (Evans, 1980). This scar tissue may be superficial as a result of an episiotomy, or perineal tear, or in deeper tissues.

Treatment
The combination of pulsed ultrasound and stretching massage on perineal scars make this a successful treatment despite the absence of clinical trials.

Alternate daily pulsed ultrasound of 1MHz between 0.5 watts/cm2 and 0.8 watts/cm2 for five minutes with a pulse ratio of 2:1 works well.

The transducer is applied in contact with a suitable coupling agent. The woman is generally most comfortable in open knee crook lying.

Firm stretching massage by the therapist over the scarred area completes the treatment. The client is instructed to repeat the massage herself twice daily at home.

On average about four treatments are required before the client can resume coitus using a suitably adapted position.

The softening and stretching of the scar tissue which follows isonation appears to be permanent. Lehmann (1965) and Patrick (1978) report this ’softening’ effect, but opinions vary about the efficacy of isonation on scar tissue over six months old.

Precautions

Burns:
Pain or pins and needles are warning signs, care should be taken over desensitized areas.

Cavitation:
A non thermal effect where bubbles are generated in sound field, it can be stable or transient. Movement of the transducer lessens the chance of this occurring.

Overdose:
Opinions differ as to a safe dose, but it is generally advisable to increase duration of treatment rather than intensity.

Damage to crystal:
Tests should be carried out in the normal way prior to treatment. The transducer must remain in contact with coupling medium while emitting.

Contraindications

Deep venous thrombosis
Acute infections
Pregnant uterus (in area to be treated)
Tumours
Radiotherapy to the areas requiring treatment (for six months)
Cardiac patients should be treated with care
There are differing opinions as to excluding all patients with pacemakers from treatment

The role of the physiotherapist does not only lie in the assessment and treatment of the patient’s symptoms as mentioned in this chapter. Prophylaxis must be her aim. Her knowledge of the musculoskeletal changes in pregnancy, labor and the puerperium should be used to minimize the effects of these processes on women.

Patient care starts during antenatal classes and should include instruction to the student midwives, district midwives and health visitors who have no obstetric physiotherapist working with them.

Constant attention should be given to postnatal advice, particularly exercise schemes and booklets to ensure they are accurate and realistic in teaching self care to the patients.

Patients in the postnatal ward who have a history of stress incontinence or pelvic laxity should be checked in the physiotherapy outpatient department until they are symptom free. Antenatal, postnatal and gynaecology clinics should have access to a physiotherapist for consultation and referral of patients.

It is by this combination of prophylaxis and active treatment that the physiotherapist can contribute so much to the alleviation of many of the physical problems of modern women of all age groups.