Best Pelvic Floor Disorder Disease Treatment, Symptoms, Repair Exercises: Under the dysfunction of the pelvic floor understand the complex dysfunction of the ligamentous apparatus and pelvic floor muscles, keeping the pelvic organs in a normal position and ensuring the retention of urine and feces.
Pelvic organ prolapse, various types of urinary and fecal incontinence, chronic cystourethritis, and sexual dysfunctions remain among the most common disorders in urogynecology. The frequency of omission and pelvic organ proliferation reaches 30%, and in 47.3% of cases, genital prolapse is accompanied by stress urinary incontinence.
Dysfunction of the pelvic floor muscles is due to a number of reasons: age, heredity, birth injuries, childbirth large fetus, heavy physical exertion associated with increased intra-abdominal pressure, etc. Recently, there has been a tendency to “rejuvenate” these disorders. The fact that genital prolapse occurs in young and nulliparous women indicates the role of connective tissue dysplasia in the development of the disease.
The combination of organic pathology and pelvic organ prolapse determines the diversity of clinical manifestations: foreign body sensation in the vagina, urge to urinate, urinary incontinence during urge and exercise, nocturia, a feeling of incomplete emptying of the bladder, discomfort, heaviness in the perineum and lower abdomen. In many patients, sexual dysfunction and / or dyspareunia occurs. Delayed urination or a feeling of incomplete emptying of the bladder is often associated with the omission of the anterior wall of the vagina. Clinical manifestations can occur in reproductive age and progress throughout life, which dramatically reduces the quality of life.
Urinary incontinence in women is the most frequent disease in the structure of pelvic floor dysfunction. About 50% of women aged 45 to 60 years at least once noted involuntary incontinence. Its prevalence among Russians is 33.6–36.8%. With age, the situation is getting worse. So, if in the age group from 25 to 34 years old this indicator reaches 8.7%, then in the group of 55 years old and older it exceeds 34%. Among women over 50, stress urinary incontinence is found in 70% of cases, which confirms the social significance of the problem. The real incidence of urinary incontinence may be even higher, because women are embarrassed to inform the doctor about this disorder and consider it an integral sign of aging.
In accordance with the recommendations of the International Continence Society (ICS), the term “urinary incontinence” refers to any involuntary, uncontrolled, volitional urine. The development of the disease is due, in particular, dysfunction of the detrusor (hyperactivity, low elasticity of the bladder wall), dysfunction of the sphincter apparatus (hypermobility of the urethra, insufficiency of the urethral sphincter), paradoxical ishuria. Not the last role is played by the condition of the ligaments of the pelvic floor.
In clinical practice, urinary incontinence is usually divided into three main types: imperative (or urgent), stress, mixed.
In 30–40% of cases, the stress component is combined with the urgent component, that is, there is a mixed form of urinary incontinence. With age, the prevalence of this type increases and reaches 60% after 60 years.
Among the Risk Factors for urinary incontinence are:
- features of labor (urinary incontinence occurs more often in women engaged in manual labor);
- the presence of neurological diseases;
- anatomical disorders;
- collagen status;
- surgical intervention on the pelvic organs;
- damage to the pelvic nerves and / or pelvic floor muscles;
- bowel disorders;
- lower urinary tract infections;
- mental status.
Pelvic dysfunction causes severe moral suffering, reduces the social activity of women. Discomfort and embarrassment dramatically worsen the quality of life, including sexual.
For a quantitative assessment of pelvic organ prolapse, standardized POP-Q (Pelvic Organ Prolapse Quantification), developed by ICS in 1996, is used. This system involves measuring the location of points on the anterior and posterior walls of the vagina, the cervix, in the vaginal fornix, determining the distance from the external opening urethra to the back edge of the hymen, the distance between the back edge of the hymen and the anus, the length of the vagina. This classification, which involves four degrees of pelvic organ prolapse, is complex and cumbersome. At the same time, it has advantages: reproducibility of results (the first level of evidence), the accuracy of quantifying a number of anatomical landmarks, including the treatment carried out.
Diagnosis of pelvic organ prolapse and various types of urinary incontinence is based on a thorough elucidation of the history, analysis of urination diaries, questionnaire data, the results of a combined urodynamic study, cystometry, cystourethroscopy, ultrasound and X-ray studies.
In uro-gynecological practice, urinary incontinence questionnaires are used. SF-36, King’s Questionnaire, and others. Pelvic Organ Prolapse and Incontinence Sexual Function Questionnaire (PISQ-31) is considered the standard questionnaire for assessing the sexual function of women with pelvic organ prolapse and / or incontinence. PISQ-12 is a shorter version that is recommended for use in clinical practice. The most common way to diagnose sexual dysfunction is the Female Sexual Function Index (FSFI).
The combined urodynamic study, recognized as one of the most effective methods for the differential diagnosis of types of urinary incontinence, is aimed at studying the state of the contractile ability of the detrusor and the closure function of the urethra and sphincter. Uroflowmetry is a simple diagnostic method that allows to estimate the speed and time of emptying the bladder. The results of uroflowmetry demonstrate the functional state of the detrusor and the closing device of the urethra. This non-invasive technique is recommended as a routine screening for any complaints of urination problems. Uroflowmetry does not require special training and preliminary examination of the patient.
For the diagnosis of pelvic organ prolapse sometimes retrograde cystourethrography, colpography and proctography are used at rest and under tension in the frontal and lateral projections. However, due to the danger of radiation exposure, the lack of clear visualization of the soft tissues of the pelvic floor, the need to use radiopaque substances, these methods are not widely used.
The possibilities of transvaginal ultrasound (US) are high enough to clarify the location of the urethrovesical segment and determine sphincter insufficiency in patients with stress type urinary incontinence. With perineal ultrasound, it is possible to determine the localization of the bottom of the bladder, its location relative to the upper edge of the womb, measure the length and diameter of the urethra throughout, the posterior urethrovesical angle (β) and the angle between the urethra and the vertical axis of the body (α), assess the configuration of the bladder neck, urethra, the position of the bladder neck in relation to the symphysis. When three-dimensional modeling of ultrasound images can determine the state of the inner surface of the mucous membrane, the diameter and cross-sectional area of the urethra in cross sections in the upper, middle and lower third of the urethra,
Currently, pelvic floor ultrasound is widely used to assess pelvic mobility. The advantages of this method include its availability, absence of ionizing radiation, non-invasiveness. In addition, it does not require special preparation of the patient. As a rule, a perineal scan is used to determine pelvic mobility.
In one study, pelvic floor mobility was assessed by the dynamics of changes in prolapse volume from rest to stress (intra-abdominal pressure increase / Valsalva maneuver) using a three-dimensional perineal scan. As the results showed, pelvic floor mobility in patients suffering from stress urinary incontinence was almost 1.6 times higher than that in patients without urinary incontinence. When scanning the pelvic organs in women without prolapse, the increase in its volume was 28%, which indicated the normal mobility of the pelvic floor. At the same time, in patients with asymptomatic pelvic organ prolapse, the studied index reached 75%. Pathological mobility of the pelvic floor, starting with a rate of 52% increase in the volume of omission, requires preventive measures to strengthen the muscles of the pelvic floor (biofeedback method), followed by dynamic observation. The researchers concluded that, unlike the POP-Q classification, only a three-dimensional ultrasound provides a complete picture of the mobility of the pelvic floor in patients with pronounced pelvic organ prolapse (third-fourth POP-Q classification), which varies widely.
That is why the degree of tension and fixation of the synthetic material when performing surgical correction, as well as the area of the mesh implant should be chosen individually in each case, taking into account the pelvic floor mobility reserve. that, in contrast to the POP-Q classification, only three-dimensional ultrasound provides a complete picture of the mobility of the pelvic floor in patients with pronounced prolapse of the pelvic organs (the third to fourth stage of the POP-Q classification), which varies widely. That is why the degree of tension and fixation of the synthetic material when performing surgical correction, as well as the area of the mesh implant should be chosen individually in each case, taking into account the pelvic floor mobility reserve. that, in contrast to the POP-Q classification, only three-dimensional ultrasound provides a complete picture of the mobility of the pelvic floor in patients with pronounced prolapse of the pelvic organs (the third to fourth stage of the POP-Q classification), which varies widely. That is why the degree of tension and fixation of the synthetic material when performing surgical correction, as well as the area of the mesh implant should be chosen individually in each case, taking into account the pelvic floor mobility reserve.
Thus, pelvic ultrasound ultrasound helps to identify its pathological mobility to clinical manifestations of prolapse, provides the possibility of preventive measures and dynamic monitoring, and also allows you to determine the functional reserves of pelvic floor mobility when planning surgical treatment of pelvic dysfunctions.
Currently, a wide range of digital perineometers, vaginal manometers and digital electromyographs are used to diagnose pelvic floor dysfunction.
Of the new diagnostic equipment, the innovative Vaginal Tactile Imager deserves attention, which guarantees a quantitative and qualitative assessment of the state of the pelvic floor muscles at rest, during contraction and Valsalva testing. Using this device, pressure, strength and degree of muscle rigidity are measured, their condition is monitored during and after childbirth. The latest technology, which developed a sensitive silicone sensor, allows you to transform tactile sensations into a computer image in real time. The device diagnoses a weakening of the tone of the muscles of the pelvic floor, vaginismus, vulvodynia, prolapse, muscle breaks during and after childbirth, and other pathological changes in the pelvic floor.
So, due to the diversity of the clinical picture of pelvic floor dysfunction and the involvement of neighboring organs (bowel, bladder) in the pathological process, the approach to treating patients should be multidisciplinary and involve the gynecologist, urologist, proctologist, sexologist, physical therapist.
Treatment of genital prolapse is complicated by the fact that the most severe and often recurrent forms occur in patients of old and old age. According to the American study, the prevalence of genital prolapse increases by about 40% with each subsequent decade of life.
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According to different authors, the frequency of prolapse recurrences after surgery is 28–43%. Postoperative complications and a high risk of recurrence require the development of new effective ways to solve this problem.
Modern hardware techniques for the treatment of pelvic dysfunction can solve the problem in a conservative way, which is important for patients with contraindications to surgical treatment, as well as for young and active women with mild pelvic organ prolapse, or first or second urinary incontinence.
Treatment methods for pelvic floor dysfunction are selected individually depending on the severity of the clinical manifestations of the disease, indications and contraindications.
The well-known set of exercises proposed by Kegel proved its effectiveness. Often, it is these exercises that are performed at home that help women avoid the progression of pelvic floor muscle dysfunction and, consequently, surgical intervention.
Kegel exercises complement the sets of vaginal simulators, which are loads of different weights for prolonged retention in the vagina. Examples of such medical simulators are vaginal cones (Yolana, Waker Step Free, Colpo Train, etc.) and vaginal balls (K-balls, G-balls, etc.). The set of vaginal cones for strengthening the muscles of the pelvic floor consists of four cones. Depending on the condition of the muscles, a specific cone is used for training. Training with vaginal cones helps to develop a sense of the muscles of the pelvic floor and contributes to their capacity. Due to its special shape and weight, the inserted cone slips out of the vagina. The pelvic muscles react to this reflex contraction (biofeedback-phenomenon). With regular training, the pelvic floor muscles are noticeably strengthened after a few weeks.
Medical simulators every year are becoming increasingly popular. In this regard, it is very important that the hardware techniques comply not only with quality and safety certificates, but also with current trends.
Today there are simulators that are connected via Bluetooth to the application on the smartphone (Magic Kegel Master, G-balls). The application has many programs and loads of medical, restorative and recreational nature, created on the basis of various indications (including urination diary). This includes preparing for childbirth, the postpartum period, improving the quality of sex life, etc.
On the modern market of medical equipment there are many electrostimulators for home use. One of them is MyoBravo, a multifunctional neuromuscular stimulant developed in collaboration with doctors, patients and athletes. This is a modern two-channel stimulator that provides simultaneous operation of four pairs of electrodes (eight surface electrodes) and, if necessary, allows the use of a probe for the treatment of urinary incontinence.
Particularly noteworthy is the pelvic floor muscle training method (TMTD) in the BOS mode, which is the first-line method in the treatment of urinary incontinence. As shown by meta-analysis (88 randomized trials involving 9721 women with stress urinary incontinence), the study was devoted to the comparison of different treatment methods (BOS, electrical stimulation of the pelvic floor muscles, the use of vaginal cones and balls, bladder training, drug therapy (anti-depressants)), TMTD based on biofeedback is effective (when conducting a long course).
Abroad, the BOS method has been successfully applied in gastroenterology and urogynecology since the 1970s. BFB is a group of therapeutic procedures using electronic or electromechanical tools that allow evaluating and processing patient information in order to enhance the properties of neuromuscular and autonomous activity, both normal and abnormal, in the form of auditory and / or visual feedback signals.
The TMTD method in BFB mode is aimed at restoring the tone of the muscles of the pelvic floor, correcting the switching function of urethrovesical sphincters, restoring the phases of physiological filling and emptying the bladder. TMTD helps to improve blood circulation in the pelvic organs and the normalization of psycho-emotional status.
The justified and combined use of TMTD can significantly improve the quality of life of patients with mild and moderate severity of stress urinary incontinence, who are not indicated for surgical treatment, as well as for those who have contraindications to surgical intervention. Due to the appearance of various individual and stationary physiotherapy devices, TMTD has become much more comfortable.
Modern TMTD devices using biofeedback are hardware-software systems that allow you to record and record the tone of the muscles of the pelvic floor using vaginal and rectal sensors in the form of electromyography – signals in real time. During the procedure, on the one hand, the control of its effectiveness and adequacy is guaranteed, on the other hand, the necessary confidentiality.
The device software for TMTD in the BFR mode helps to change the load and dynamics of muscle contractions in accordance with the increase in muscle strength. Due to additional options in the form of electromyostimulation included in hardware complexes, the range of therapeutic possibilities of the method is expanded. During the course of BFB training, patients are trained and new skills are developed.
One of the important advantages of the BFB method is its safety. This type of therapy has no absolute contraindications. Relative contraindications are associated with the physical or psychological impossibility of the patients performing their task. The effectiveness of TMTD in BFB regime is enhanced in combination with kinesitherapy, respiratory gymnastics, physical therapy and swimming.
Pneumatic pelvic floor muscle trainer (digital perineometer) – equipment that combines modern pneumatic system and BFB technology. This perineometer, developed on the basis of many years of research into the characteristics of the female body, effectively and safely helps women restore the muscles of the pelvic diaphragm and strengthen them, which has a beneficial effect on the health and quality of sex life.
The last decades of TMTD capabilities have consistently and actively expanded. Currently, the method of biofeedback is required in combination with electrostimulation of the pelvic floor muscles.
A significant event was the presentation of the latest equipment for TMTD at the 44th annual ICS congress. We are talking about the unique InTone and InToneMV devices that patients use independently. The principle of operation of these products is based on a combination of electromyostimulation and TMTD in the mode of visual, auditory and tactile feedback, which significantly improves compliance. The devices are effective not only in the treatment of pelvic floor dysfunction, but also in the case of prevention of weakening muscle tone after childbirth. Researchers from Brazil found that as a result of holding ten half-hour sessions twice a week, symptoms of urinary incontinence were stopped, the tone and strength of the pelvic muscles increased significantly, the quality of sexual life improved.
The results of domestic studies of clinical efficacy of biofeedback combined with electrical stimulation of the pelvic floor muscles in patients with mild and moderate stress urinary incontinence demonstrated the effectiveness of the combined treatment. At the first stage, all patients were electrostimulated by the pelvic floor muscles for three to five minutes in order to identify the muscle groups necessary for training. The biofeedback procedure was performed on the Urostim apparatus for 30 minutes. Multimedia game program increased the interest of patients and the effectiveness of training. As a result, immediately after the treatment, subjectively, the condition improved in 41 out of 50 patients. Objectively, after ten weeks of treatment, an increase in the mean maximum intraurethral pressure by 29% was observed. Analysis of visual analogue scales showed an improvement of 49%.m. levator ani , the rectus abdominis muscle, the gluteal and femoral muscles are reduced, which leads to an increase in intra-abdominal pressure.
In Russia, for almost 20 years, pessaries have been used in patients with prolapse or prolapse of the genitals . In case of stress type of urinary incontinence, special cup-urethral pessaries are effective. With the simultaneous use of pessaries and estriol, the efficiency of treatment of pelvic floor dysfunction in menopause is increased, which contributes to the physiological proliferation of tissues and preservation of the balance of vaginal microcenosis. The use of pessaries should be combined with the established urination regimen. This increases the therapeutic effect. Selection of the pessary depending on the type and degree of prolapse, as well as the possibility of self-administration, makes this method of treatment indispensable in urogynecological practice.
Today in practical medicine laser technologies are widespread. In gynecological practice, their active use began in the late 1980s. CO 2- lasers, erbium, diode and fiber-optic laser systems are used for surgical interventions. Laser systems are used for urinary incontinence, atrophy of the vaginal mucosa, as well as for intimate rejuvenation. As a result of laser exposure, intermolecular cross-links of the triple helix of collagen are shortened, which leads to an instantaneous reduction of fibers by two thirds of their length compared to the state before the procedure. Heating collagen causes it to instantly shrink, the fibers become shorter and thicker. In addition to the instantaneous reaction of collagen reduction in tissues, the processes of collagen fiber reconstruction and neocollagenesis are started. As a result, the treated tissue is enriched with new, young collagen, becomes elastic and elastic.
The technologies IncontiLase and IntimaLase (Slovenia) have been used since 2009. Over the past period, there have been no cases of complications from this type of treatment in the world. Currently, the method is used in 34 Russian medical institutions.
Collagen remodeling is also used fractional carbon dioxide laser Deka (Italy) (radiation wavelength of 10.6 microns). Under the influence of a thermal carbon dioxide laser, the secretion of fibroblast growth factors and the regulation of collagen synthesis, which prevents excessive fibrosis, effectively increase. Accumulated experience demonstrates the high efficiency and availability of this method in the treatment of mild pelvic organ prolapse and urinary incontinence in combination with involutive processes of the female genital organs.
The use of these methods with menopausal hormonal therapy allows to achieve a high therapeutic effect in patients with sexual dysfunction in combination with pelvic floor dysfunction.
In the presence of urgent desires and urge incontinence, additional pharmacotherapy is needed to reduce symptoms and improve the quality of life. According to ICS recommendations, M-cholinolytics are considered to be the drugs of choice in this case. The most frequently used representatives of this group are the selective inhibitor of the M3-cholinergic receptors, solifenacin. The drug reduces the frequency of urination, urgent urge and urinary incontinence and is characterized by an optimal tolerability profile compared with other M-cholinolytics. The usual starting dose is 5 mg once a day. If necessary, it can be increased to 10 mg / day.
A new class of drugs for the treatment of bladder hyperactivity symptoms – beta-3 adrenomimetics has appeared. The only representative of this group to date – Mirabegron – is better tolerated than M-holinolitikami and not inferior to them in effectiveness. Mirabegron is recommended for both primary patients and those who have previously taken M-holinolitiki, but stopped taking it due to adverse events or lack of effectiveness. The drug is prescribed in a dose of 50 mg / day.
Usually, assessment of results when prescribing M-anticholinergics or Mirabegron is carried out in a month and continuing therapy for a long time, since symptoms can resume after drug withdrawal.
Modern achievements of science make it possible to carry out a differentiated individual approach to the treatment of complex urogynecological diseases, taking into account the solution of not only medical but also social problems facing the doctor. Treatment is impossible without a comprehensive and comprehensive approach – a determining factor in the success of treatment and improving the quality of life.
Hardware techniques for the treatment of pelvic muscle dysfunction is one of the most important ways to reduce the number of surgical interventions in urogynecology. The possibility of conservative treatment in the case of urinary incontinence and genital prolapse contributes to an increase in the number of patients to a specialist, and the possibility of individual use on an outpatient basis of most methods increases compliance. The active introduction of a modern approach to the management of patients with pelvic muscle dysfunctions will improve the quality of medical care and reduce the cost of treatment.