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Use Of Transabdominal Ultrasound Imaging In Retraining The Pelvic-Floor Muscles Of A Woman Postpartum

May 14, 2017

UroToday - Urinary incontinence not only causes hygienic issues, but also affects a person's ability to participate in regular daily routines, social or community events, and intimate relations. It is widely known that postpartum women often experience stress urinary incontinence (SUI). A recent study has shown that up to 29% of postpartum women report incontinence that significantly affects their quality of life.1 Incontinence has been correlated with weakness of the pelvic floor muscles (PFMs).2,3,4 Pelvic floor strengthening has been shown to be helpful in reducing both the severity and frequency of SUI in postpartum women.5,6 However, the optimal teaching method which is most effective to create motor learning of a PFM contraction has yet to be determined. Pelvic floor assessment and motor training methods include verbal instruction alone, manual palpation, pressure perineometry, surface EMG, or the newer technique of transabdominal ultrasound (TAUS) imaging. The purpose of this case report is to demonstrate the use of TAUS imaging as a PFM assessment and retraining tool, and to examine the outcomes obtained when this new intervention is used to retrain the PFMs in a postpartum woman.

The patient was a 29-year-old mother of two presenting with SUI symptoms during high-impact activities. She had a history of two vaginal deliveries, one that resulted in a grade III perineal laceration. At the time of the physical therapy examination, the patient reported having no major medical problems and normal menstrual cycles. She had never used any type of pelvic floor strengthening or retraining devices and was unfamiliar with Kegel exercises. The client's OB/GYN noted she did not have any pelvic organ prolapse greater than grade 1.

TAUS imaging was used to assess this patient's ability to activate her pelvic floor muscles. During the initial examination, the patient demonstrated only Valsalva maneuvers and was unable to activate a correct pelvic floor contraction. Various cueing and positions were attempted by the patient to assist in achieving a pelvic floor contraction to no avail. Throughout the intervention, TAUS imaging was used to confirm a PFM contraction and to verify proper strategy. TAUS imaging also doubled as a biofeedback tool for the patient until she improved her kinesthetic awareness enough to consistently identify when a correct PFM contraction was achieved and maintained. Using TAUS imaging, the patient learned to isolate a PFM contraction. With continued treatment, she further strengthened her PFMs by increasing the number of repetitions she was performing, as well as increasing the length of time each contraction was maintained. In order to further advance the strength and endurance of her PFMs, the patient worked towards gravity-resisted positions for the PFMs, and performed motor tasks while maintaining a PFM contraction. All goals were achieved and the patient was able to return to a running program with no SUI symptoms.

TAUS imaging is a useful tool for physical therapists specializing in women's health. One of the major advantages of TAUS imaging is the ability for non-invasive strength assessment of the PFMs. This is beneficial when an internal examination is contraindicated or refused by the patient. Additional advantages include the ability to examine the function of the PFMs with simultaneous movement of the lower extremities, or while in weight bearing positions. This is important when attempting to functionally train the PFMs. The use of TAUS imaging has the potential to greatly affect the way women's health physical therapists approach examination and treatment of urogynecological patients.

References

1. Glazener CMA, Herbison GP, MacArthur C, Lancashire R, McGee MA, Grant AM, Wilson PD. New postnatal urinary incontinence: obstetric and other risk factors in primiparae. BJOG. Feb 2006; 113(2): 208-217.
2. Amaro JL, Moreira ECH, De Oliveira OG, Padovani CR. Pelvic floor muscle evaluation in incontinent patients. Int Urogynecol J. Sep-Oct 2005; 15(5): 352-4.
3. Bo K. Pelvic floor muscle strength and response to pelvic floor muscle training for stress urinary incontinence. Neurourol Urodyn. 2003; 22(7): 6554-8.
4. Bo K, Sherburn M. Evaluation of female pelvic-floor muscle function and strength. Phys Ther. Mar 2005; 85(3): 269-82.
5. Bo K, Sherburn M., Allen T. Transabdominal ultrasound measurement of pelvic floor muscle activity when activated directly or via a transverses abdominis muscle contraction. Neurourol Urodyn. 2003; 22(6): 582-8.
6. Morkved S, Bo K. Effect of postpartum pelvic floor muscles training in prevention and treatment of urinary incontinence: a one-year follow up. BJOG. Aug 2000; 107(8): 1022-8.
Allison Ariail, PT, DPT, CLT, as part of Beyond the Abstract on UroToday

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