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Pelvic Floor Case Study – Female

Urinary Urgency and Incontinence 

History

A 76 year old female presenting with urinary urgency and incontinence symptoms for the last year.  She reported that her urge to urinate was too strong and would not make it to the bathroom 3-4 times a day.  She reported the worst urges were in the mornings while walking fast or sudden sprinting, experiencing increased levels of stress, and with breath-holding.  She also reported that dramatic exhales and sitting/lying down decreased her urge intensity and occasionally got rid of the urge completely.  She’s an active retiree and is frustrated that she can’t enjoy long brisk walks.

Patient goal

Control her urinary urges and reach a toilet in time without leaking urine, and return to her favorite activity and fast and brisk long walks.

Evaluation

Upon evaluation, her pelvic floor muscles (with patient consent) were weak and could not contract efficiently upon command. She demonstrated taking consistent quick short and shallow breaths during all her walking trials with “gripped” abdomen muscles. Since walking produced her symptoms, a gait analysis demonstrated absent shoulder and arm movement/swinging, and constantly raised and rigid shoulders.

Treatment

We had three main objectives, one was to make her pelvic floor muscles stronger and better coordinated to hold in her urine until she reached a toilet. The second objective pertained to her walking pattern. There were clear signs of abnormal movements and postures.  The third was to address her abnormal breathing patterns and excessive abdominal use with walking.  I explained that holding her belly in excessively and taking shallow breaths increased pressure on her abdominal organs and bladder. I compared it to sitting on a balloon, that with enough pressure something was going to give. In this case, it was her weak pelvic floor muscles (PFM) that could not hold back that excess pressure. I also explained that walking with her upper body rigid would also increase the pressure in her abdomen and make her breathing mechanics worse.

Outcomes

The patient required 19 visits to reach her goals. We used EMG biofeedback to train her PFM to contract with good coordination in all positions (lying, sitting, standing) and to gradually build the PFM strength. Her PFM contraction quality and breathing mechanics improved during the first 4-6 sessions in a lying and sitting position. Controlling her PFM endurance and demonstrating muscle control in standing and walking were achieved over the next 6-7 sessions. Movement re-education activities during sessions and at home were necessary to adjust her walking pattern. She was given a comprehensive home program to strengthen her PFM and her lower body. Her final 6-7 sessions focused on tying all the pieces together, instead of gripping her abdominals/core tightly, and how to adjust the PFM according to her activity level. She reported she no longer had any urgency or leaking with her desired activities at her discharge, and that her new habits were slowly becoming permanent mechanics.

Pelvic Floor Case Study – Male

Male Frequent Night Urination, Pain with Urination and Intercourse, Urinary Leakage and Groin Pain

History

A 72-year-old male presented with urinary leakage, burning both during and after urination. The patient was experiencing significant sleep disturbance due to his frequency of urination (3 or more times a night). In addition, he reported L groin and testicular pain. All his symptoms worsened with walking, eating spicy food, urination, and both during, after intercourse. Leakage occurred right after urinating. His symptoms lessened with resting and lying down.
Ultrasound imaging demonstrated an enlarged prostate, which is common within his age group.

Patient Goal

Abolish leaking, pain and burning with urination, decrease night time urination episodes, return to pain-free sex, and walking.

Evaluation

Palpation of his pelvic floor muscles revealed poor muscle coordination. His pelvic floor muscles, both hips, and lower abdomen were severely tense and painful to touch. After testing, nerve involvement was ruled out as a cause of his pain and symptoms. Since walking produced his pain, a gait analysis was performed and showed significant left hip stiffness and decreased stability. Muscle strength and length testing showed general L hip muscle weakness and tightness.

Treatment

We had four main objectives:
1. Decrease pain with all activities
2. Improve his pelvic floor muscle coordination and contraction/relaxation pattern
3. Address his Left hip weakness, muscle stiffness and tenderness
4. Correct abnormal gait pattern

We began his treatment program focused on addressing his pain with soft tissue mobilization, patient education, and self-massage. We prescribed a therapeutic stretch and strengthening exercise program to address his pain and improve his gait. In addition, we instructed specific pelvic floor muscle exercises with the goal to eliminate his leaking and pain with urination and sex. We used EMG Biofeedback in lying, sitting, and standing positions to improve his muscle coordination and decrease the muscle tension. Good muscle coordination is necessary to decrease urinary incontinence, frequency of night time voiding, and pain with urination and sex.

Outcomes

By session 4 the patient reported an 80% decrease in urinary pain, burning, and leakage. By session 6 the patient reported a perceived 50% decrease of pain with walking and 75% decrease in urinary leakage. At time of discharge, he reported pain free sex and L groin /testicular pain only with palpation. We feel the patient made very good progress because he consistently attended treatment and adherent to his Home Exercise Program. The patient was seen for a total of 9 sessions.