Uterine Prolapse

[junior_physiotherapist]

HI ALL:

would some one plz feed me more regarding the following case and it's physiotherapy.

The history:

-Female,49 yr., multipara,her wieght of body already within acceptable range.
-Nervouse woman,works teacher,she handles alot of things at her life.
-Suffer chronic sinusitis,no other health problems.
-Holds a contraceptive instrument in her uterus(sorry not familiar with it's name) since 8 yrs.
-Complete free active ROM at lower limbs with good muscles strength generally.
-Diagnosed as:Uterine Prolapse between 1 &2 degrees,moderate tightness & sever tenderness at inguinal region bilaterally more at her right side,her sore increases during standing activities,she fells like some thing going down!!,her complains since more months.

**My question is what is the appropriate physical therapy care for this case?
**Suggestive web sites plz!.

Regards

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[alophysio]

Hi.

Firstly, are you male or female because the following will probably only be possible if you are a female - for some reason, they don't mind male gynaes but any other male professional, the patient gets uncomfortable with it.

A uterine prolapse situation is usually where the uterus falls through the cervix into the vagina and even can come out - there are many people in the world who will tell you that when they cough and sneeze, they go to the toilet to "push it back in".

You may have to determine why she is prolapsing. Is it because of pelvic floor dysfunction? Or is there increased intraabdominal pressure? Or is there physical injury to the pelvic floor etc.

The best thing to do - and what i always do - is refer her to a pelvic floor physio for an assessment. If the cause is weak pelvic floor, i would often work in conjunction with the other physio. If the pelvic floor seems to be working ok, then i can fix the excessive intraabdominal pressure thing - it is usually bracing of the obliques inappropriately. If there is injury, then it is off to the doctor for her.

Of course, she may be trialling a course of conservative treatment before heading off to surgery.

A few other points...a contraceptive device in the uterus is usually called an IUD (intra-uterine device - imaginative name that!). She obviously hadn't had a hysterectomy then because that often makes these things worse.

The other pains are difficult to assess from here. However, the symptoms may be consistent with excessive IA pressure - she is nervous, tender down one side, c/o tightness. Does she have incontience? If she doesn't, i am willing to bet that her pelvic floor is ok and she is using her obliques.

Does she have a crease across her abdomen above the belly button? If so, you can bet that it will be an external oblique compression.

All the best and let us know what is going on.

[junior_physiotherapist]

Hi.

Firstly, are you male or female because the following will probably on>>

She obviously hadn't had a hysterectomy then because that often makes these things worse.

The other pains are difficult to assess from here. However, the symptoms may be consistent with excessive IA pressure - she is nervous, tender down one side, c/o tightness. Does she have incontience? If she doesn't, i am willing to bet that her pelvic floor is ok and she is using her obliques.

Does she have a crease across her abdomen above the belly button? If so, you can bet that it will be an external oblique compression.

All the best and let us know what is going on.

Thanks ..sir

Regarding ur questions: i'm a female physiotherapist .
sorry i didn't get what did u have advice me as
-how i can make assessment for her pelvic floor muscles
-u said she oboviously hadn't hyserectomy this bad ,So why!!!
-being use her obliques,,,and being have a creases across her abdomine above her belly line!!! actully i didn't get ur meanings??sorry
-she had her last 3 deliveries by ciseria, she is multipara,so there is lines marks across her lower part of her abdomine..
-about her incontinence i'll ask her :

once again many thanks sir

[wutti]

hi! concerning to the statement, that when pat. stands, feels like something falls out, i would suggest that pelvic floor is weak. I would start to show here exercises for pelvic floor muscle strengthening. Also you might show her some techniques for mild coughing and sneezing to minimize the abdominal pressure. also a study in our hospital (Emons et.al, if i remember it right) with the galileo 2000 vibration therapy divice showed that pelvic floor, abs and back muscles can be trained very well using vibration therapy.
but also menopause might be a reason for her problems. ask her if she have/had any postmenopausal problems or if she takes hormon replacement therapy. Also rule out all other things like back/disc problems, cauda equina syndrome etc. just in case and to be sure, that all this is fine.
cheers

[alophysio]

Hi junior_physio,

about your questions: If you aren't sure about what i have written, maybe she needs to be referred to a women's health physio...Better still, go along with her so you can learn as well.

For the following comments, i do not do these myself since i am a man...

1. internal examination of the pelvic floor function - this would be done vagainally using a PFX or similar device

2. Having a hysterectomy is bad - NOT having one is good. The uterus helps to support the organs in a fascial way

3. The crease across the lower abdomen is ABOVE the umbilicus (belly button) if external oblique is overactive. The lower ribs get drawn in and the lower abdomen pokes out somewhat

4. Ask her to kep a fluid diary - this is where she records in mL all her fluid intake and passing - that's right, she has to get a jug and measure her urine.

Honestly, the best thing to do is refer her to a specialist physiotherapist who knows this area well. If there is no one around, then i would start reading if i were you!!!

[junior_physiotherapist]

Hallo,

more about my case:
-No urine incontence.
-Sometimes she feels there is urge feeling to go to toilet then she found there is no more urine to be evacuated!!
-She diagnosed by her Gyna-physician that Uterin Prolapse BETWEEN DEGREE 1&2!!

**So my qestions are :
-i need an indicated theraputic exercises(strengthening and /or relaxation ) and other modalities??
-How i can clinically make distingshes between symptoms of increased intra abdominal pressure,weakness of plvic floor muscles,...??


Regads

[junior_physiotherapist]

Also you might show her some techniques for mild coughing and sneezing to minimize the abdominal pressure. also a study in our hospital (Emons et.al, if i remember it right) with the galileo 2000 vibration therapy divice showed that pelvic floor, abs and back muscles can be trained very well using vibration therapy.
but also menopause might be a reason for her problems. ask her if she have/had any postmenopausal problems or if she takes hormon replacement therapy. Also rule out all other things like back/disc problems, cauda equina syndrome etc. just in case and to be sure, that all this is fine.
cheers[/QUOTE]


Hi
-Firstly thanks alot of ..
-would u plz feed me more about techniques for mild coughing and sneezing..!!
-also the patient dosn't complain any other problems,regarding post menopausel signs like what questions can i ask her!!

Rrgards

[alophysio]

Hi Junior_physio,

Firstly, i can appreciate your willingness to learn and help but this sort of things is a subcpeciality area - i don't think it can be fairly taught over the internet within a few posts. People complete masters degrees to become proficient in this area.

Having said that, From the extremely limited amount of information we have and not ever having seen the patient move or have an objective examination (i am putting the disclaimer in deliberately!), it sounds like she has excessive pressure - the urge to go when there is no urine there, the fact that she is prolapsing, the fact that she does not have incontinence all point to increased abdominal pressure (in my opinion). Again, i don't see these people unless a women's health physio has been involved.

Perhaps a better question to ask is how did i learn to treat people with excessive muscle activation and increased abdominal pressure? I simply took a few courses. If you have ever been on a course, the material they cover on them can't just be covered in a few posts here. There is observation (which i have alluded to but difficult to teach you) of their control strategies, movement patterns/muscle coordination, passive structure testing, etc etc that goes into it.

As for coughing and sneezing - does this cause problems? If not, then why teach a strategy for it?

Ask her if it feels differently when she exercises like goes for a run or fast walk. If she feels a little better, then i would almost certainly bet she has excessive activation of her obliques - during exercise, they will probably act phasically like they should and so relax a little when they are supposed to. This might decrease the pressure temporarily and ease the symptoms. The worst is probably when she is standing still.

Anyway, i still recommend that she see a specialist in this area - it is only fair to her and to you. I would ask if i could go along as well to learn more. If you are interested in the area, i would take more courses or at least buy a book about it. I think the statistics are 1/3 of all women post-menopause have some issue with pelvic floor etc. It won't be like you are wasting your money!

Good luck.

[Laura01]

I agree that if you are not experienced in this area then go along and see a womens health Physiotherapist. They deal with these intimate problems everyday and better not putting the woman through endless assessments when your not entirely sure. In the mean time, until you get to see the specialist, I would teach transversus abdominus contractions in crook lying then pelvic floor contractions, making sure to teach fast and slow contractions. These certainly wouldn't do any harm especially if she has had a previous section. She may we'll have or still have poor pelvic stablity.

[junior_physiotherapist]

I agree that if you are not experienced in this area then go along and see a womens health Physiotherapist. They deal with these intimate problems everyday and better not putting the woman through endless assessments when your not entirely sure. In the mean time, until you get to see the specialist, I would teach transversus abdominus contractions in crook lying then pelvic floor contractions, making sure to teach fast and slow contractions. These certainly wouldn't do any harm especially if she has had a previous section. She may we'll have or still have poor pelvic stablity.

Hi Laura
Thanks for ur input.
now let me ask u about ur meaning regarding (make sure to teach fast and slow contractions)?
i mean do u want to make fast and slow contractions in sucession manner or at same session separetly, or what!!!

Reards

[Laura01]

I mean to educate the different types of fibres responsible for each type of contraction. Fast twitch fibres are activated for instance in a quick reaction type situation where for example you cough or sneeze and have a sudden increase in intra-abdominal pressure which needs to be counter balanced. So this exercise I would and very politely ask the patient to imagine that they were about to pass wind and wanted to prevent this from happening!I would then ask them to squeeze the muscles around the back passage and take the contraction all the way under the pelvis to the front to the muscles which stop you passing water. I would then tell them they should feel everything lifting up inside. i would double check that they are not holding their breath. I would ask them to do this exercise squeezing up and then letting go over a count of two repeating 10 times then do 3 sets or so. Next the slow twitch fibres responsible for maintaining fluid in the bladder over the course of the day without the immediate sensation of wanting to void so these are the endurance fibres if you like. This is the same action but this time hold the contraction say for 5 secs. The length of time your patient will be able to hold the contraction will vary depending on their strength. If they are struggling, start with 2 seconds then build up but they should always be able to feel the contraction release if no they have lost it long ago or maybe don't get it. Work towards holding for 10 or 15 seconds with 10 repetitions Also get them to try the exercises in different positions remembering that if the patient is standing then they are having to work against gravity and the exercise will be harder. On the contrary some women find this position better since they get more feedback from the muscles. You can try crook or side lying to start with. try to combine the pelvic floor action with deep abdominal contraction and breathing is very important. Some women really struggle to identify the pelvic floor and whether it is working or not I normally explain it is like a hammock holding all the abdominal organs so they can see how it can become a problem, also that if any of these organs are removed as in hysterectomy it can alter the stabilty.
hope this helps!

[alophysio]

Hmmm,

Just thinking that her back passage is probably ok - I see a lot of problems from people who are overactive in the posterior pelvic floor.

Also, there is nothing to suggest that she has pelvic floor insufficiency - no incontinence. So in fact, her pelvic floor might be just fine but unable to cope with excessive intra-abdominal pressure.

If you really want to assess this lady, then glove up, put some KY jelly (without lidocaine!) on 2 fingers (middle and index) and insert into the vagina. Then have her use her pelvic floor muscles. Try to assess if she is pushing down into your hand or squeezing circumferentially etc.

An alternative method may be to get her to sit. Either you or her could then put the palm of the hand on the seat under the perineum - it would be like holding her genitals while she sat on your hand. Then ask her to use her pelvic floor muscles. Normal is a nice gradual lift away from your hand (try it now!!) Abnormal / increased intraabdominal pressure / "bearing down" would be pressure into your hand.

As i stated before, i am willing to bet she is excessively active in her abdominals and pushing that uterus out with excessive IAP.

If you choose to do the internal examination, i think it is only prudent to advise her EXACTLY what you are doing, why you are doing it and why it will help. That is why i don't do it - not only because i am a man (which really shouldn't have anything to do with it - there are loads of male OBGYNs - but because my wife wouldn't like it if i was doing these assessments! There are too many good physios around who do this sort of thing every day. I don't need to do it!).

Hope it helps

[junior_physiotherapist]

Hallo All,

Regarding Mr alophyio & Laura,really many thanks for ur so kind and informative posts ,really i'm so happy for these information.

Once again ,many thanks..

Regards

[alophysio]

Hi Junior_physio - i just noticed you are located in Palestine - is there actualy any women's health physios where you are?? For some reason, i thought you were based in the UK

[junior_physiotherapist]

Hi Junior_physio - i just noticed you are located in Palestine - is there actualy any women's health physios where you are?? For some reason, i thought you were based in the UK

Hallo all,

Regading to ur question..AAAAm!!actually in Palestine generally we have very few woman's health phsios so some times we have to go back to some experinced phsios via internet or any type of communications ,books,informative magazines,conferences,..
and usually we've to keep in minds that to give patients correct and useful physical therapy cares

Thank u sir for ur intersts
Regards

[alophysio]

Hi,

Have you tried the internal examination or the other things mentioned in one of my posts above?

How is the patient going?

[junior_physiotherapist]

Hi,

Have you tried the internal examination or the other things mentioned in one of my posts above?

How is the patient going?

Thanks sir once again ...
Really this patient is my close relative so frankly I'm so shy when i'll do test of perineum so,i told her this test of alternative method the second one then she did it by her self (may i'm wrong to let my patient to do the test by her self but really i cann't do this to her by my self ...) so her test was negative and then i advice her to strenghten her pelvic floor she felt well when do that excercises but her main promlem (pain felt down)still increase when she being nervous...

Regards

[alophysio]

ok. I guess it is difficult when it is a relation!

Good luck with it all

[junior_physiotherapist]

ok. I guess it is difficult when it is a relation!

Good luck with it all

Hi all


Regarding Mr alophysio thanks alot of sir for all of ur appreciated information...

Kind Regards