“Pelvic floor rehabilitation" in our hands, consists of specific exercise prescription, prescribed by a licensed provider, based on results of diagnostic manometry and diagnostic EMG, usually in sets, reps and frequencies designed specifically for muscle building, for spasm or for endurance, depending on the exact nature of the neuromuscular pelvic floor problem, and baseline strength of the muscle based on regular muscle testing over a period of time defined by the individual's progress, but typically 6-10 weeks. During this intense training period, the optimal exercise regimen for your pelvic floor muscles will vary. Sometimes as a very weak muscle becomes stronger, spasm appears for the first time after 4-5 weeks, for example. For optimal results, this spasm needs to be treated, and sometimes the exercise prescription needs to be modified. In general, the exercise prescription is based on the maximal amount of exercise that can be done to build the muscle as quickly as possible, without putting the muscle into spasm, or fatiguing it to the point that it does not improve optimally. As with any form of exercise, it can be overdone, and underdone. This program is designed to achieve optimal results as quickly as possible.
It has generally had an enormous benefit for our patients, and our patients typically report 60 to 90% improvements in their urinary and fecal urgency, frequency, and incontinence, over a 6-10 week period of time. We have found 50 to 60% improvements in pelvic pain syndromes such as interstitial cystitis, endometriosis, vaginismus and dyspareunia. It has been helpful in mild non-obstructive urinary retention and constipation caused by pelvic floor spasm as well. It has been very helpful for anterior prolapse such as cystoceles, which are generally the result of muscle weakness, and somewhat helpful for prolapse of the posterior vaginal wall, such as rectoceles, which are usually more the result of fascial tears, but also to some degree the result of pelvic floor muscle weakness. As with any form of conservative therapy, there are some people who do not respond to this regime. In general, we can start to see progress on the EMG and manometry as early as 1-2 weeks after starting, but it takes 3 to 5 weeks before most patients start to notice clinical improvement. Optimal results are noted around 6-8 weeks for strengthening, and around 8-10 weeks for those with pelvic floor spasm. Once we are not seeing further improvement on the diagnostic assessments of muscle and nerve function, over 2-3 sessions (ie we notice “plateauing”), the regimen is stopped, and we give you a set of maintenance exercises.
We fairly regularly assess the use of accessory muscles in doing Kegals. In particular, we measure the extent to which you are needing to use your abdominal muscles, because we see optimal improvement once you are able to completely isolate the pelvic muscles. However, some use of accessory muscles can be normal at the beginning of the regime, when the muscles are very weak. Generally we see this improve with time. If we do not, we may change your exercise regime slightly.
The testing, done at regular intervals over the 2-3 months of intense exercise and muscle building, consists of three diagnostic tests, which are used to prescribe and plan your muscle building regime. They are as follows:
- Pelvic floor EMG
- Tests of ancillary muscle use, such as abdominal muscles (usually this test is done only if your pelvic muscle is very weak)
These tests assess the strength and endurance of this pelvic floor muscle and writing an exercise prescription for you. This exercise prescription may change periodically depending on your progress.
These tests are important because no two people are exactly alike. The level of exercises we recommend will be based on the muscle testing. If too many exercises are performed it may actually fatigue the muscle, and while that may increase endurance of the muscle, it is not optimal for muscle building, which is really what we are after. Sometimes an overly aggressive routine results in spasm, which slows progress, and we are assessing for this as well. If not enough are performed the muscle also will not improve, for obvious reasons. During our assessment we also assess the extent to which you are using your abdominal muscles. Ideally we like to be able to see you use you exercise your pelvic floor muscles without using your abdominal muscles very much, but this comes with time and practice.
So the therapy and actual rehabilitation and strengthening of your muscle, is what happens at home. We often supplement these efforts with a low frequency neuromodulation to help the muscle get stronger faster, or a higher frequency of neuromodulation if spasm is present.
The therapy primarily consists of the muscle building regime for your pelvic floor that we base off the results of these tests, and is done by your at home.
This program is particularly useful for syndromes resulting from a weak pelvic floor, such as urinary stress incontinence, fecal incontinence and prolapse. It can also be useful for syndromes resulting from a spastic pelvic floor, (such as overactive bladder, interstitial cystitis and others) since spastic muscles are often weak. When spasm is present, different levels of neuromodulation may be introduced as well.
We have avoided the need for many more invasive and expensive techniques and surgeries with this approach, although we do resort to surgical procedures and other techniques when this approach is not successful or the patient declines these more conservative approaches.
Generally we are seeing a 70 to 90% improvement in syndromes that result from pelvic floor weakness. In particular, “anterior compartment” syndromes, such as stress incontinence, and cystoceles and urethroceles respond fairly well. “Posterior compartment” syndromes, such as rectoceles and enteroceles and fecal incontinence respond to some extent, but slightly less so than the anterior compartment. Typically 6-8 sessions are required for pelvic floor weakness.
Pelvic floor spasm syndromes (overactive bladder, interstitial cystitis, painful intercourse, vaginismus, urethral syndrome, urinary retention secondary to spasm) also respond, (60 to 80% have a significant improvement) but over a longer period of time, usually 8 to 12 sessions. Usually neuromodulation at some level must also be used to obtain an optimal response.
Our experience is that women are usually very happy for the clinical improvements they have with this approach to pelvic floor problems. It seems to work much better than we have noticed in the past with techniques called “biofeedback” which do not actually make use of diagnostic assessments to plan and maximize the exercise prescription. Biofeedback is a therapeutic technique that takes place while you are in the office. EMG and manometry are set to a therapeutic rather than a diagnostic mode, and hooked up to a screen. You are asked to contract the muscle at regular intervals and you receive an immediate visual or auditory signal as to whether or not you are reaching a specific goal. This is typically done for a preset time of 30 minutes. We use this technique very occasionally to help patients “find” their pelvic floor muscles, but in general we have not found it to be as helpful as the techniques described above. Typically, if only biofeedback is used, patients report improvements in stress incontinence of 20-30% and minimal improvement in spasm related symptoms.