 The pelvic floor: An introduction
The floor of the pelvis is made up of layers of muscle. These muscles stretch like a hammock from the tail bone at the back to the pubic bone in front and are referred to as the pelvic floor. Figure 1 demonstrates where the pelvic floor muscles are situated in men and women. Strong pelvic floor muscles are important for maintaining continence since the bladder is supported by these muscles, helping it to stay closed, and the urethra passes through them.
Pelvic floor rehabilitation has evolved into a widely accepted form of therapy for helping people with different types of bladder problems. The few studies conducted on the effectiveness of pelvic floor rehabilitation for people with MS and clinical experience show that it can improve bladder symptoms in some patients. Pelvic floor rehabilitation can also play a preventative role in strengthening the pelvic floor area before symptoms occur.
People can have a weakened pelvic floor for all kinds of reasons whether or not they have MS. For example, it can be caused by continual straining to empty bowels (usually due to constipation), chronic cough (such as smoker’s cough), persistent heavy lifting, pregnancy and being overweight. For people with MS, poor pelvic muscle functioning (either weakened or overactive muscles) is due to neurological damage and can be even worse if compounded by these other causes.
‘It really upsets me when I have accidents at the office. I think this is going to drive me out of working, as you can’t go to meetings etc when you’re incontinent.’
Eva
Increasing awareness of and strengthening the pelvic floor muscles can help to improve bladder symptoms common in MS such as frequency, urgency, incontinence, hesitancy and an intermittent stream or flow of urine. These exercises can also be helpful for people with MS who have sexual and bowel problems due to weak muscles, and bowel problems related to weak or spastic pelvic floor muscles. Pelvic floor rehabilitation combines work with a physiotherapist and a home programme. Rehabilitation is based on the initial strength of the person and also takes into consideration the presence of fatigue, spasticity and mobility problems.
Does pelvic floor rehabilitation help everyone with bladder problems and MS?
A neurologist or urologist can determine who is appropriate for pelvic floor rehabilitation. This therapy is most effective when the individual:
• is able to contract and release the pelvic floor muscles on command and can relax after contraction, immediately or with only a slight delay;
• is able to walk, preferably without using assistance, although people needing a stick or walker may also benefit from these exercises;
• is motivated, since exercises must be performed at home regularly.
Pelvic floor rehabilitation
Pelvic floor rehabilitation is planned by a physiotherapist who first instructs the person on how to identify the pelvic floor muscles that need to be exercised and strengthened. Increasing awareness of contracting and relaxing pelvic floor muscles are key to this type of rehabilitation. Learning to relax them, even without strengthening exercises, can help promote smoother urine flow. Table 1 describes two ways of identifying these muscles. Patients are also provided with an individualised exercise schedule to follow at home.
Doing pelvic floor exercises
Once the person has identified the pelvic floor muscles he or she can begin strengthening exercises. Table 2 describes how to perform pelvic floor exercises to help to increase endurance.
To increase strength, a strong contraction is held for one second, followed by a two to three second relaxation period then repeated. The number of repetitions depends on the initial endurance and strength of the patient.
A key to successful muscle training is to achieve total relaxation of the muscles between every contraction. It is also important that relaxation time is at least double that of contraction time in order to achieve full recuperation of pelvic floor muscles.
Biofeedback
Biofeedback uses an electronic device to provide the individual with visual feedback about how pelvic floor muscles are working (and improving). For people with MS who experience bladder problems, pelvic floor muscle training together with biofeedback can help teach the person how to relax over-active muscles. This technique is performed by a healthcare professional (usually a physiotherapist) and though not directly beneficial, biofeedback helps ensure patients gain maximum benefit from their pelvic floor muscle exercises
Electrical stimulation
Electrical stimulation applies an electric current to strengthen the muscles around the bladder. This current is passed via a small anal (or vaginal) probe in close contact with the pelvic floor muscles. It is not painful and can also be self-administered using a portable stimulator at home. For people with MS it is a therapy that should be monitored by the physiotherapist.
This treatment may be used for between 20 minutes and an hour per day for a period of up to 20 days. Some people have found this treatment very effective, and there is evidence it can be as useful as pelvic floor exercises. For long-term treatment these techniques are typically used in combination.
What to expect from pelvic floor rehabilitation
It is important that people with MS have realistic expectations of the possibilities of pelvic floor rehabilitation. It cannot completely solve bladder problems, but helps the person to regain some control of bladder functioning. In turn, this helps to improve a person’s self-image and self-confidence. Good results require a commitment from the person with MS to do the exercises carefully and regularly.
A physiotherapist can help you identify your pelvic floor muscles.
Strengthening the pelvic floor muscles can help improve bladder symptoms common in MS
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