flow also has the potential to cause incomplete emptying of the bladder, which in turn could lead to an increased risk of urinary tract infection.

Identifying the pelvic floor muscles All in all it is better to advise women to identify their pelvic floor muscles by palpating the skin between the vagina and anus, feeling for a lifting upwards and forwards towards the bladder. Alternatively they can insert a finger or thumb into the vaginal opening and feel the contraction of the muscles, moving upwards and forwards towards the bladder. For men, the advice is to palpate the pelvic floor muscles by placing the fingertips over the skin between the scrotum and the anus. A correct contraction of the pelvic floor muscles will lift the testicles and draw the anus inwards.

MANAGING PELVIC MUSCLE WEAKNESS Exercise routines In order to be effective, specific exercises need to be performed regularly and to the point of fatigue. Having identified the correct contraction, activity of other muscle groups (such as the upper abdominals and gluteal muscles), as well as breath-holding, are common signs that the pelvic floor muscle is fatiguing. The NICE national guidelines for the management

of urinary incontinence in women (17) recommend that three sets of exercises, each comprising 8 to 12 maximal contractions, should be performed daily. Remember, though, that NICE only include evidence from randomised controlled trials, of which there are only a few relating on this subject, which limits application of their guidelines – especially because many women cannot carry out the recommended number of contractions to begin with. Applying the physiological principles for muscle strengthening (overload, specificity, maintenance and reversibility) is effective for both men and women at all levels of ability for strengthening the pelvic floor (18). A commonly used routine for pelvic floor exercises is to perform ten repetitions of 10-second maximal contractions, followed by ten repetitions of short strong contractions. This regimen ensures that both fast and slow activities within the pelvic floor muscles are addressed.

The pre-contraction “knack” One effective technique for improving urinary stress incontinence is to pre-contract the pelvic floor muscles before any increase in intra-abdominal pressure occurs. Getting its name from the group of American researchers who conducted this single-blind randomised controlled trial (19), the “knack” was used by subjects before coughing, and reduced urinary leakage by 98.2% and 73.3% for a medium and deep cough, respectively.

Improving muscle tone However, it is unlikely that continent elite athletes or participants in fitness activities will constantly think about tightening their pelvic floor muscles prior to every activity. In this group, therefore, the focus should be on building up the postural tone. This will provide a firm structural base whereby such contractions occur automatically (14). Improving postural tone allows the hammock-like effect of the pelvic floor to support the bladder

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BOX 2: SELF-IDENTIFICATION OF PELVIC FLOOR MUSCLES

Women: Palpate the skin between the vagina and anus and feel for a lifting upwards and forwards towards the bladder, OR insert a finger or thumb into the vaginal opening and feel for the contraction of the muscles, moving upwards and forwards towards the bladder. Men: Palpate the skin between the scrotum and anus and feel for a lifting upwards of the testicles, as well as in-drawing of the anus.

BOX 3: GUIDELINES FOR PELVIC MUSCLE EXERCISES IN WOMEN AND MEN

10 maximal contractions lasting 10 seconds each Followed by:

10 short strong contractions

and prevent leakage subconsciously without the need to produce a maximal pre-contraction before every stress event.

Biofeedback training

Dynamic ultrasound is an imaging technique that uses a curved linear array probe to scan the perineum, which clearly shows the action of the pelvic floor muscles. It can be used as a form of biofeedback for retraining the muscles, reinforcing the importance of not just “clenching” the muscles but of ensuring an upwards and forwards (cranioventral) lift.

Urethral and vaginal insertion devices

Excessive forces are placed on the pelvic floor muscles during some physical activities, requiring effective continence support mechanisms. Strengthening the pelvic floor muscles alone may not be sufficient to prevent urinary leakage in these cases, but there are a number of devices that can help. The first one available on prescription in the UK is the FemSoft™ (Figure 2). As the name suggests, this is for women only. It is made from soft silicone and designed to be inserted into the urethra. The sleeve is filled with mineral oil and the balloon at the tip holds it in the bladder where it forms a seal that prevents leakage of urine. In order to void, the device is simply pulled out and discarded. Another device is then inserted to maintain protection against leakage. Not all women are happy to insert a device into their urethra; instead they can use a vaginal insertion device (VIDs). Brands include the IncoStress™, Contiform™, Continence Guard™ and Activgard™. Note that these are not available on prescription, but can be obtained via the Internet. Vaginal space-occupying devices like these provide additional support to the urethral sphincter by increasing the ability of the pelvic floor muscles and fascia to exert pressure against the mid-portion of the urethra. They are made of a variety of materials and come in various designs, so some devices may work well in some women and not in others. Tampons used for menstrual flow work in the same way as a vaginal insertion device, but women should never be advised to use them solely for the management of urinary stress incontinence because they are not designed to be used in the absence of a menstrual flow and they carry the risk of toxic shock syndrome.

PELVIC PAIN

Figure 2: The FemSoft™

Myofascial pain within the pelvic floor muscles is recognised as one of the factors contributing to chronic pelvic pain

sportEX medicine 2010;46(Oct):23-27