Introduction
This chapter will introduce the clinician to the role of pelvic floor therapy for rehabilitation of gynecological (GYN) cancer survivors. This population is unlike others with pelvic floor dysfunction because of overlapping local and systemic side effects of their cancer treatment. Many women do not seek evaluation of their pelvic floor symptoms for a variety of personal reasons or due to a lack of awareness on the part of the patient and their health-care providers. It is imperative that the rehabilitation specialists caring for these patients are well versed on the management of pelvic floor dysfunction. The goal of this chapter is to review the body systems affected by GYN cancer and investigate evidence-based rehabilitation interventions to treat them.
GYN cancers represent approximately 6% of the 1.8 million new cancer diagnoses that will be made in the United States in 2019. Uterine cancers are the most common, of all the cancers affecting the female reproductive system, followed by ovarian, cervical, and vulvar cancers. According to the National Cancer Institute annual report to the nation, the estimate of new cases for GYN-related cancers in 2019 is 109,000 with an overall survivorship of nearly 70%. Acute management of GYN cancers includes surgery, chemotherapy, radiation, hormonal, and targeted therapies, which can be used alone or jointly. These treatments are known to have long-term effects that significantly impact physical activity levels and quality of life. There is a growing body of research that identifies the impact GYN cancer treatments have on the pelvic floor, including bladder, bowel, and sexual function. The need for survivorship rehabilitation services in this population will certainly continue to increase as the general population ages.
GYN cancer survivors constitute a unique population, different from other women who have had pelvic injuries or age-related hormonal changes. Neron et al. compared pelvic floor dysfunction between GYN cancer survivors 1 year after hysterectomy, healthy controls in the general population, and controls with a history of benign hysterectomy. They found that the GYN cancer survivors had more pelvic floor dysfunction and greater severity of symptoms affecting quality of life than the other two groups. Ramaseshan et al. performed a systematic review to describe the prevalence of pelvic floor disorders among GYN cancer survivors and concluded that pelvic floor dysfunctions, including urinary and fecal incontinence, urinary retention, dyspareunia, vaginal dryness, prolapse, and sexual dysfunction, are up to three times more prevalent in GYN cancer survivors than controls. In a study of 152 women with suspected GYN malignancy who were scheduled for surgical intervention, Bretschneider et al. looked at the prevalence of pelvic floor disorders and found that this population had a high rate of pelvic floor symptoms even before surgical or adjuvant treatments.
The specific nature of GYN cancer treatment affects the pelvic structures acutely and leaves long-term systemic side effects. Surgical scars and radiation damage last for many years after the initial recovery phase. Chemotherapy-related cytotoxicity could cause pancytopenia and immunocompromise that may limit or restrict patient participation in activities such as exercise or sexual intercourse. Cognitive side effects, “chemo brain,” cardiac function, and cancer-related fatigue (CRF) as a result of chemotherapy regimens are significant considerations during rehabilitation. Hormonal changes can affect bone mineral density and risk of osteoporosis. Cancer survivors can be impacted by decreased activity levels years after active treatment, and studies show that there is a need for intervention in this population. Research supports that ongoing support and education throughout a survivorship program have the greatest potential for successful outcomes. Rehabilitation for each survivor is about restoring the quality of life that was disrupted by her cancer.
Pelvic floor rehabilitation must address multiple different body systems. The pathophysiology and tissue damage within each of the following systems will be examined separately: musculoskeletal, urinary, anorectal, and sexual. A brief review of the healthy physiology will help the clinician understand evaluation techniques that are readily available in the rehabilitation clinic as well as diagnostic imaging and testing performed outside the rehab setting. Due to these complex system interactions, management of the pelvic floor requires the integration of multiple clinical specialties as part of the comprehensive survivorship team. Valid and reliable quality of life questionnaires and assessment tools are available to assess and measure outcomes of pelvic floor therapy. These can be helpful to communicate within the multidisciplinary survivorship team.
Evidence-based treatment options are available for the general rehabilitation practitioner as well as the pelvic floor specialist. Treatment options available to all rehabilitation clinicians will focus on patient education, behavioral modifications, self-care, exercise, and ongoing support. More specialized biofeedback, electrical stimulation, manual therapy, and dilator training will also be reviewed. In following the International Classification of Functioning, Disability and Health we will look at how to write treatment goals that address the functional limitations and activity level of the whole person and ultimately can lead to greater participation in society and decreased handicap or disability.
Pelvic Floor Evaluation: Assessing Systems
Evaluation of the pelvic floor will be broken down into each of the following four systems: musculoskeletal, bladder, bowel, and sexual function.
The main functions of the pelvic floor are postural stabilization, support of the pelvic organs, sphincter control, and sexual function. It also helps control intraabdominal pressure, which is important in generating a strong Valsalva maneuver, during vomiting or coughing to clear the airway ( Fig. 19.1 ). When pelvic floor pathology or pain exists, these basic functions are affected. The initial evaluation is an opportunity to assess all aspects of pelvic health in each of these domains.
The pelvic floor rehabilitation intake visit should begin with history taking and assessment of the patient’s signs and symptoms, pain, vital signs, posture, and balance. A thorough screen of the abdominal wall, spine, sacroiliac joint (SIJ), hip, and lower extremities should be performed and can identify contributing musculoskeletal factors originating outside the pelvis. Sensation and reflex testing of the lumbar and sacral dermatomes and myotomes should be performed. Each of the following sections will review normal function of the pelvic floor, bladder, bowel, and sexual organs as well as how cancer treatments may cause impairments.
The treating therapist must be able to clearly articulate what they are doing next and why, in order to avoid any misunderstandings or appearances of sexual misconduct. Patients must be cognitively intact. She must be able to understand the instructions and able to give permission in order to be appropriate for modalities to the pelvic floor. It should always be made clear that the woman has a choice in her treatment and a chaperone should be available.
Pelvic Floor Musculoskeletal System
Anatomy and Physiology
The pelvic floor can be divided grossly into three muscular layers. The superficial layer consists of the ischiocavernosus, bulbocavernosus, transverse perineal, and external anal sphincter (EAS) muscles. The middle layer consists of the sphincter urethrae and the sphincter pubovaginalis as well as the internal transverse perineal muscles. The deepest layer, known as the levator ani, consists of the puborectalis, ischiococcygeus, and coccygeus muscles. The anterior muscle attachment is at the pubic symphysis and the fibers run along the arcus tendineus levator ani (ATLA) laterally to the ischial spine and posteriorly to the coccyx and sacrum. The piriformis and obturator internus are also important muscles of the deeper anatomy. The obturator internus muscle borders the levator ani and the endopelvic fascia along the ATLA ( Fig. 19.2 ).
During voluntary contraction the pelvic floor muscles lift superiorly and the sphincters tighten. During relaxation the general motion is descent and opening. The pelvic floor muscles are composed of approximately 70% slow twitch fibers and 30% fast twitch fibers. The percentage of fast twitch fibers is higher as you move anteriorly. Innervation of the pelvic floor muscles is by the branches of the pudendal nerve (S2, S3, S4) and the nerves to the levator ani and coccygeus (S3, S4). Normal sacral reflexes include the bulbocavernosus–clitoral reflex, anal wink, and cough reflexes.
The physiology of the pelvic floor is affected significantly by GYN cancer treatments. Surgery for cancer treatment has evolved significantly with laparoscopic, robotic, and nerve sparing procedures requiring less invasive techniques. Accelerated rehabilitation and enhanced recovery after surgery protocols are also evolving to help improve the patient experience and improve outcomes. Most importantly for cancer survivors, the surgical interventions have long-term side effects that impact a physical therapy (PT) plan of care long after the initial healing phase. Removal of support ligaments during hysterectomy and disruption of the endopelvic fascia decreases pelvic floor support function and can be a risk for future pelvic organ prolapse. Removal of lymph nodes can alter the circulation of the pelvis leading to lymphedema, pelvic congestion, and pelvic pain. Pelvic pain can lead to muscle guarding and overactivity. Shortened or overactive pelvic floor muscles contribute to muscle spasm, decreased blood flow, trigger points, pain, overactive bladder, dyspareunia, constipation, and possible pudendal neuralgia.
Tremendous advancement in the application of radiation therapies has led to greater specificity and dosage control with considerable implications in sparing healthy tissue. External beam radiation therapy and brachytherapy are commonly used with GYN cancer treatment. In the narrow space of the pelvic girdle, treatment for GYN cancer almost inevitably will have an impact on the urinary and gastrointestinal (GI) systems, pelvic floor muscles, and the neurological innervation. A systematic review examining the detrimental effects of radiation on the pelvic floor found decreased maximal voluntary contraction, evidence of acute and ongoing tissue damage affecting the structure of the pelvic muscles and increased fibrotic tissue.
Chemotherapy-induced fatigue and proximal muscle weakness are common symptoms among cancer survivors and may be associated with weakened pelvic floor muscles. The abdominal wall and pelvic floor cocontraction is a normal response during various exercises and postural activities. Pelvic floor weakness is also correlated highly with low back pain. Weak pelvic floor muscles do not provide sufficient sphincter contraction strength or organ support and are associated with urinary and fecal incontinence, sexual dysfunction, and pelvic organ prolapse.
Assessing Muscle Function of the Pelvic Floor
The most simple pelvic floor muscle assessment is observation, which can reveal one of the following outcomes: (1) the patient is able to contract with visible lift, (2) is not able to generate visible lift, or (3) strains to produce a downward descent of the perineum. External observation does not provide accurate information related to the deeper structures. As an initial screening tool, however, it provides useful information about the client’s ability to generate perineal lift and identify the appropriate muscles without producing a Valsalva maneuver or using excessive accessory muscle overflow. A simple external muscle test, palpating medial to the ischial tuberosities through clothing with the patient in hook lying position, can provide the treating therapist with similar information. External palpation provides an added benefit of greater patient privacy and may be useful when internal work is contraindicated ( Fig. 19.3A–D ). The validity and reliability of external palpation has not been studied for research purposes, but it may still be a useful screening tool in the clinic, at the bedside in acute care, or in other outpatient therapy settings that do not specialize in pelvic rehabilitation.
Practitioners who are trained in pelvic floor therapy may choose an internal muscle assessment. Manual muscle testing is the most convenient method to use in the rehabilitation clinic. Vaginal palpation is a low-cost tool and can discriminate between pelvic floor circumferential squeeze and lift, though the discrimination is poor ( Fig. 19.4 ). Note, however, that vaginal palpation is not appropriate less than 6 weeks postoperative or postpartum, in the presence of suspected or confirmed infection, severe vaginal atrophy, active cancer, active bleeding, or whenever the patient does not or is not able to give permission. Rectal palpation may also be a useful alternative approach for palpating the pelvic floor muscles and may be necessary to assess the anal sphincters. Kegel described vaginal palpation as a method to assess the ability to perform a correct or incorrect pelvic floor contraction, and he developed the “perineometer” to measure vaginal squeeze pressure and thereby quantify strength.
The Modified Oxford scale and Laycock PERFECT scale are two strength grading systems that are commonly used in pelvic floor rehabilitation. The Modified Oxford scale uses a six-point rating system from 0 to 5 with (+/−) for added specificity. A score of 0 means there is no palpable contraction. A score of 5 represents a strong contraction with palpable lift. The Laycock PERFECT scale is a reliable and validated tool for assessing pelvic floor muscle strength, which begins with the “P” for power using the Modified Oxford scale but additionally describes “E” endurance, “R” repetitions, and “F” fast twitch muscle properties as well. The Laycock PERFECT scale additionally provides a basis to recommend parameters for subsequent exercise prescription, which will be discussed later in the chapter.
The initial digital exam will also provide assessment of muscle symmetry, individual muscle strength, range of motion and tone, and tissue integrity. Cough test and Valsalva should be performed to assess laxity and prolapse during the initial assessments. Findings may vary in supine, sitting, and standing.
Electromyography (EMG) is a useful tool to examine the electrical potentials of the pelvic floor muscles during rest, reflexive activities, and voluntary contractions. Fine needle or concentric needle EMG can be used percutaneously to target local areas within a muscle and provide very specific information. However, this is not routinely performed in the PT setting. A doctor may also order EMG studies of the pudendal nerve motor latency.
Surface EMG (sEMG) with vaginal, rectal, or external electrodes can be an excellent method of pelvic floor evaluation in the rehabilitation setting and can be used for muscle reeducation through biofeedback. Manual assessment and sEMG together can differentiate overactive or paradoxical contraction from a shortened or contracted pelvic floor, which may be electrically more silent and may not be clearly discernable from manual palpation alone. External sEMG is not muscle specific and therefore cannot measure the action potentials from a single muscle, but it is useful to assess overall behavior and activation patterns. Dual channel sEMG is useful in differentiating pelvic floor from accessory muscles such as the rectus abdominus or gluteal muscles. Impedance from subcutaneous tissues and variation in electrode placement make it difficult to describe normative data. sEMG can, nevertheless, be an excellent tool to assess the behavior of the muscle relative to fatigue, coordination, and general return to resting levels after activity.
Pressure manometry can also be used for quantifying the amount of pressure generated within the vagina or rectum and many machines provide dual lead assessments for combined sEMG and manometry. Pressure measurements are not able to discriminate between forces produced intraabdominally or generated by the pelvic floor and therefore they are best used in conjunction with other observation. The inward drawing action on the sensor lead wire can help determine if the correct muscle action is occurring.
Ultrasonography is becoming more easily accessible and some facilities may have this technology available to rehabilitation practitioners. Visualization of correct movement and timing of the pelvic floor muscles can provide the patient and the therapist with real-time perspective on the actions of the pelvic floor muscles. Physicians may order ultrasound or dynamic MRI to identify the anatomy of impaired pelvic structures, which can impact the rehabilitation plan of care.
Bladder/Urinary System
Anatomy and Physiology
The healthy adult bladder receives urine via the ureters from the kidneys. As the bladder fills the muscular wall of the bladder, detrusor muscle is relaxed and gently accommodates a typical volume of up to 500 mL of urine, while the smooth muscle of the urethra remains closed. Autonomic sympathetic signals via the superior hypogastric plexus and hypogastric nerves and parasympathetic signals carried by the pelvic splanchnic nerves pass through the inferior hypogastric plexus to control the micturition reflex and urination. The somatic pelvic floor muscles, which are primarily innervated by the pudendal nerve and nerves to the levator ani, must contract with increased abdominal pressure to prevent accidental leaking. Autonomically controlled smooth muscle of the vesicle neck and circular and longitudinal muscle fibers of the internal urethral sphincter also help to control urinary continence through tonic activity at rest ( Fig. 19.5 ). The supportive connective tissue acts like a sling behind the urethra to support the urethra as intraabdominal pressures rise. In addition, coaptation of the vaginal lumen also helps to keep the urethra closed at rest.
During micturition the pelvic floor muscles must relax to allow for opening of the external urethral sphincters along with contraction of the detrusor muscle for optimal bladder emptying. Typical postvoiding residual values range from 0 to 75 mL of urine in the bladder. Normal bladder voiding frequency is approximately every 3–4 hours and 0–1 times at night for most adults based on 48–64 oz of fluid intake every 24 hours.
Cancer treatment may cause both bladder storage and voiding dysfunction. Donovan et al. found that bladder storage and incontinence symptoms were more prevalent in the cancer survivor group than in noncancer control groups. Bladder irritation can occur as a result of infection, surgery, radiation, diet, and anxiety and leads to overactive bladder, urinary frequency and urgency, nocturia, and urge incontinence. Surgical damage to the bladder innervation can lead to autonomic dysfunction of the micturition reflexes, decreased somatic control, neurogenic bladder, or internal sphincter deficiencies. Chemotherapy is associated with peripheral neuropathy, which may have sensory, motor, and autonomic components. For successful control of the bladder and bowel, a patient must have sensory awareness of bladder and rectal filling as well as proprioceptive awareness of the pelvic floor. Radiation fibrosis can significantly limit the elasticity of the bladder, vagina, and rectum and alters the ability to produce proper lubrication or protective secretions. The urethral and vaginal tissues are estrogen sensitive and can be affected by radiation and chemotherapy-induced mucositis.
Medical assessment of the patient with urinary incontinence should include a thorough history, physical examination by the physician, urine test to rule out infection, and assessment of postvoid residual volumes. Urodynamic testing may be ordered to examine bladder function. Stress incontinence, volume at first urge, postresidual volumes, and retention of urine can be detected with this procedure. Ultrasound and other imaging techniques can identify obstruction, postvoid volume, and abnormalities that may affect rehabilitation prognosis. Although pelvic floor therapy cannot treat all of these urological conditions, the physical therapist may have an important role in differential diagnosis by fully evaluating and treating the pelvic floor muscles.
Assessing Bladder Function
At the time of the evaluation the therapist should be able to identify predominant bladder storage problems such as stress, urge, or mixed incontinence. The International Continence Society defines incontinence as “involuntary loss of urine that is social or hygienic problem and is objectively demonstrable.” Urinary stress incontinence due to muscle weakness or damage is a common side effect after GYN cancer treatments and patients may benefit from pelvic floor rehabilitation for weak, uncoordinated muscles or to build endurance. The evaluation can identify the level of effort or intensity that is required to cause stress incontinence and therefore set strength training goals for functional rehabilitation. Urge incontinence may also result from the treatments affecting the neurological controls of the bladder and urethra. Overflow incontinence and functional incontinence may be present as a result of changes in mobility and fatigue that prevent the patient from getting to the bathroom in a consistent and timely manner.
Conversely, a patient may have voiding dysfunction such as urinary retention or difficulty voiding. Voiding dysfunction may be the result of overactive pelvic floor muscles. Mechanical or neurological changes after cancer therapy may cause increased resistance, urethral obstruction, neurogenic bladder, decreased detrusor muscle contraction, or poor coordination of the bladder and sphincter during micturition.
Objective measures and subjective reports are important to begin assessing the level of impairment and setting patient-specific functional goals. A careful interview and symptom review is crucial as well as careful analysis of the patient’s fluid intake and voiding behaviors. Quality of life questionnaires, such as the Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire, and Sandvik Scale, are valid and reliable baseline measurements to compare pre- and posttherapy progress. Bladder diaries are useful to help quantify the frequency of leaks initially and as follow-up to reinforce awareness and compliance to healthy toileting practices. Three-day diaries are considered valid and reliable. Formal pad tests where each pad is weighed may be used for research but are less desirable for patient assessment. Instead, observations about the number and saturation of pads can be easily documented on the bladder diaries ( Fig. 19.6 ). There are various smartphone apps that can facilitate keeping a bladder log.
Anorectal/Bowel Function
Anatomy and Physiology
Understanding how a healthy GI system functions is imperative before assessing patients who have undergone GYN cancer treatment. Digestion begins with consuming food and liquids by mouth. An appropriate appetite and regular meal times help maintain a consistent rhythm of digestion and elimination. Food entering the stomach triggers the gastrocolic reflex, which stimulates intestinal peristalsis. Stool is moved through the small intestines and colon into the rectum. Stretching of receptors in the rectal wall triggers the intrinsic defecation reflex and causes relaxation of the internal anal sphincter (IAS). Another reflex called the parasympathetic defecation reflex is activated by stretch of the rectal walls and causes increased peristaltic activity, which helps lead to defecation. If the woman is not able to defecate, increased sympathetic output and tonic contraction of the EAS and puborectalis, which hold the anorectal angle at approximately 80–100 degrees, can suppress peristalsis. The IAS closes and defecation is deferred. Over time deferring fecal urge may lead to constipation. Liquid stool, however, can pass the anorectal angle more easily, which can cause soiling.
Adjuvant chemotherapy and radiation as well as surgical resection of tissue can affect the function of the intestines; decrease rectal compliance; reduce or increase rectal sensitivity; and lead to fecal incontinence, constipation, and other problems with the bowel. The normal gastrocolic reflex, peristaltic activity, and intestinal mucosa may be impacted, which can lead to accelerated or impaired motility. GI toxicity is a common side effect, which can lead to chronic diarrhea. Narcotic pain management and decreased mobilization are known causes of decreased bowel motility and constipation. Neuropathy, decreased sampling reflex, reduced rectal sensation, pain, guarding, and fear may also lead to paradoxical pelvic floor contractions, outlet obstructive constipation, fecal smearing, and soiling, all of which have a devastating effect on quality of life.
Patients referred for fecal incontinence may have imaging in the form of colonoscopy, dynamic MRI defecography with or without contrast mimicking stool in the colon, or ultrasound. Other diagnostic testing that may be ordered include rectal sensation testing, balloon expulsion testing, or EMG studies of the anal sphincter or pudendal nerve. The physician, as part of comprehensive survivorship support, may order additional motility studies, allergy sensitivity tests, and nutritional evaluations.
Assessing Bowel Function
Questionnaires and pen-and-paper tools such as the Bristol Stool Chart, Longo ODS, Wexner, and PFDI-20 are useful to quantify subjective reports and objectively measure bowel symptom severity. Diaries and food logs can be helpful for patients to self-assess their habits and identify triggers that can lead to clustered bowel movements, urgency, and diarrhea.
As with urinary dysfunction, a thorough assessment of the pelvic floor muscles is necessary to evaluate bowel dysfunction. If possible, a rectal assessment allows better access to the EAS and IAS resting and squeeze pressure. Biofeedback and anorectal manometry can be used to assess muscle electrical activity and physical pressure within the anal canal, respectively. These assessments can be done on the exam table for ease of the therapist, but a functional assessment of the patient sitting on a commode may be more appropriate. Muscle strength should be assessed with special attention to muscle endurance. Reflexive mechanisms for fecal continence require sustained EAS control for 45—60 seconds in order to override the recto-anal inhibitory reflex and facilitate closure of the IAS when it is inappropriate to respond to fecal urgency. A thorough assessment for rectal wall prolapse and sensation is also important during the rehabilitation evaluation.
Genitalia and Sexual Health
Anatomy and Physiology
Fertility and reproductive medicine are not within the scope of the pelvic floor PT; however, sexual health can and should certainly be addressed. Objective assessment is extremely difficult, since female sexual function is a complex blend of physiological, physical, emotional, and psychological factors. Early research conducted by Masters and Johnson in the 1960s and 1970s characterized sexual response as a linear phasic system for women and men alike, which included excitement, plateau, orgasm, and resolution. Under this model, sexual desire was considered to emerge from an inherent internal drive. Clinical assessment tools were developed by the scientific and medical community to assess and define each phase of the sexual response. The initial phase includes central and peripheral changes to the autonomic nervous system, nonspecific increased sympathetic cardiovascular and respiratory responses, and increased pelvic muscle tone. Increased blood flow to the genitals and genital vasocongestion causes engorgement of the vulva, clitoris, and vagina as well as and genital lubrication and increased tactile sensitivity. Healthy orgasm is the result of sympathetic signals that trigger climax, which is accompanied by rhythmic muscle contraction and a sensation of pleasure or euphoria. Resolution is the return to homeostasis and reabsorption of engorged fluid.
More recent studies have looked at the sexual response of women and moved toward newer models, such as the Incentive Motivation Model, in which desire and arousal are reciprocally reinforcing. Basson proposed a more circular model and included a greater role of subjective context–dependent stimulation and cognitive feedback. Research by Chivers and Brotto suggested reconceptualizing sexual desire as a motivational state evoked by sexual stimuli and responsive to contextual factors, which significantly influence how and when desire is assessed.
Desire and arousal are two aspects of sexual behavior that are significantly impacted by the cancer treatment journey. Changes in personal relationships with a partner, body image, and CRF could be very significant. The relationship between physiological arousal and sexual desire is complex and not directly sequential as initially proposed by the early research. Modern models of the female sexual response cycle also address issues of gender identity and orientation, which can add additional layers of complexity to sexual rehabilitation. A referral to a psychologist specializing in sexual health is often recommended for GYN cancer survivors.
Radiation produces long-term side effects, including atrophy of vaginal mucosa, obliteration of muscle and vasculature, atrophy, fibrosis, telangiectasia, mucosal pallor, adhesions, decreased elasticity, fragility of vaginal tissues, dyspareunia, and postcoital bleeding. Studies estimate that the frequency of radiation-induced vaginal stenosis after radiation therapy for uterine, cervical, and vaginal cancers to be between 1.25% and 88%, with the highest probability occurring after cervical cancer treatments. Vaginal atrophy and vaginal dryness are common menopausal symptoms. Women who have already gone through menopause may have vaginal atrophy prior to their cancer treatments and be at a greater risk for vaginal stenosis. These changes often continue to evolve over the 10 years following radiation therapy; therefore ongoing patient monitoring and education is critical.
Assessing Sexual Function
All rehabilitation therapists should screen their clients for sexual dysfunction by asking them if they have concerns about their sexual health. The interview should include open-ended questions related to prior sexual history, sexual identity, and goals for future sexual activity. Past experiences, abuse, current relationships, and motivations for sex are as important as the physical condition of the vagina in assessing a woman’s sexual health. Neither self-reported frequency nor self-reported desire of sexual relations is an accurate measure of a woman’s physical sexual responses. Sexual function questionnaires such as the female sexual distress scale and female sexual function index (FSFI) are more objective measures and should be used in conjunction with the interview process.
During external assessment of the pelvic floor, physical therapists should check the integrity and mobility of the tissues of the perineum, vulva, vaginal vestibule, vaginal walls as well as the anus, thighs, and lower abdomen for fibrotic changes, swelling, irritation, sensation, and adhesions through gentle palpation. A Q-tip test can be performed for gentle pressure in all areas of the external vulva or vaginal vestibule to assess localized vestibulodynia. The fascial layers of the pelvic floor connect with the hip adductors, abdominal wall, and deep hip rotators. These can be impacted by fibrotic changes from radiation and limited mobility of the hip and back joints. Muscle assessment particularly of the superficial muscles by palpation is important. Sensation and sacral reflexes should be checked as well.
During the initial vaginal evaluation, assessing the patient’s tolerance of vaginal palpation as well as her openness to internal vaginal treatments will help the therapist set realistic goals for her plan of care. The presence of vaginal stenosis, narrowing of the urogenital hiatus, vaginal length, tissue mobility, and adhesions are significant in determining future treatment options such as vaginal dilation or manual techniques. Some patients need additional time to accept the physical changes to their body and may be more appropriate for external work or supportive education.
Rehabilitation: Treating Pelvic Floor Dysfunction
They are listed grossly from most general to most specialized: education, exercise, biofeedback, electrical stimulation, manual therapy, and vaginal dilators.
In the next section, we will look at the most common pelvic floor treatment interventions, and some of the research that supports their use. They are listed grossly from most general to most specialized.
Education
Patient education is a primary component of pelvic floor rehabilitation for all GYN oncology patients. With cancer survivorship rates improving overall, there is a significant need to educate patients about the long-term effects following cancer treatment and how these can impact pelvic floor function. Motivation to participate and belief in the effectiveness of pelvic floor rehabilitation are dependent on the successful communication between therapist and patient. Research shows that the amount of education provided needs to be tailored to each patient and must avoid causing excessive fear, frustration, or anxiety. Some patients are ready to learn how to cope with the “new normal” and can handle reeducation for bowel and bladder and sexual health. Other patients need more time to cope with these changes and a more supportive approach. Involving family and caregivers may be useful for some, but other patients are not prepared to share the details of their intimate pelvic dysfunctions with family and friends for a variety of social and cultural reasons. Patients who have cognitive limitations or learning impairments must have instructions that are designed to their specific needs. Smartphone apps, links to online resources, videos, and podcasts can supplement a traditional paper handout and provide various different learning tools for your patients.
Behavioral Modifications
Many pelvic floor symptoms related to urogenital and bowel function respond dramatically to behavioral modifications. Daily routine, fluid, diet, voiding, and toileting habits can significantly improve urinary urgency and frequency and bowel irregularity. Behavioral modifications have been shown to improve the quality of life in patients with stress and urgency incontinence, and especially those that are accompanied by clinical or group support programs to reinforce initial teaching over the treatment period. Quality of life questionnaires and bladder diaries can begin the process of identifying behaviors that lead to lower urinary tract symptoms. Patients may perceive their frequency to be elevated or insufficient when it is in fact within normal limits or the opposite. Any changes arising after cancer therapy may be perceived as problematic, and simple education can be useful to assuage those concerns. Risk factors for urinary incontinence may include elevated BMI, caffeine intake, carbonated beverages, and constipation.
Controlling urinary urgency and frequency are two steps in bladder training and can help manage overactive bladder. The onset of urinary urgency is a complex, reflexively mediated, neurological process. The treating therapist can teach the patient strategies for urge suppression. These include breathing and relaxation, pelvic floor contractions, and mental distraction techniques. Once the patient has tools to help control urgency, a bladder training program to increase voiding intervals can begin. Bladder training to regulate overactive bladder typically involves increasing the interval between voids by some prescribed amount each week, typically 5–20 minutes, until reaching a set goal or returning within normal limits. A 3-hour interval will allow for watching a movie or concert uninterrupted or traveling by car for a road trip. In a case where sensory awareness to bladder filling is impaired, however, patients may need a timed voiding schedule every 3–4 hours to avoid overflow or sudden onset of urgency.
Bowel function can also be affected by timing and control of defecation. Establishing a healthy bowel routine to manage constipation requires proper stimulation of the autonomic nervous system driving digestion, opportunity to find a bathroom, and the ability to respond to urge by relaxing the pelvic floor and avoiding paradoxical contractions. Regular physical activity, diet, and water intake are also highly important for good bowel management.
Poor pelvic floor support function can cause positional obstruction and patients can be taught strategies for perineal splinting, double voiding, toileting posture, or Crede maneuver to help facilitate better bladder and bowel emptying. Ergonomic education and postural awareness also help patients adapt their environment in proactive ways to facilitate their best function and recovery. These components of a comprehensive treatment plan are most effective when based on specific patient’s quality of life goals.
Diet and Fluid Intake
Comprehensive cancer rehabilitation today includes consultation with a registered dietician or nutritionist experienced with oncology survivorship. This interdisciplinary approach has great potential to help patients with pelvic floor dysfunction as the bladder and bowel are directly impacted by diet. Weight management, fatigue, muscle recovery, and hydration all have significant roles in the recovery of this patient population. Excessive fluid intake will naturally lead to frequent urination. Teaching patients to time their consumption and voiding intervals throughout the day can be very helpful, but there is little consensus on how much is enough water to drink. The National Academies of Sciences, Engineering, and Medicine has determined that an adequate total daily fluid intake for women is about 11.5 cups (2.7 L) of fluids a day, including fluids from water, other beverages, and food. About 20% of daily fluid intake usually comes from food and the rest from drinks. This equates with nine cups per day; however, this adequate intake does not represent a minimum threshold for individual hydration. As a treating clinician it is important to educate your patients on signs of dehydration. Patients with urinary symptoms often manipulate their intake well above and below this amount and may be unaware of how much they actually consume. In addition, patients benefit from education regarding bladder irritants and diuretics to avoid such as caffeine, carbonated beverages, acidic drinks, and artificial sweeteners. Patients may also experience dry mouth and should be educated on products to help moisturize their mouths and lips, avoiding products such as mouthwashes that contain alcohol.
GI toxicity and mucositis are common side effects after chemotherapy and radiation with devastating effects on bowel control. Patients with bowel control issues are in great need of nutritional counseling services with a registered dietician or nutritionist. Controlling the consistency and frequency of stool is very important in managing the anorectal outlet function. Learning to manage portion sizes; identifying food irritants; and balancing fluid, fiber, and other nutrients can help regulate the stools and minimize mass movements and dumping syndromes. Appetite and food tolerances can be seriously altered during cancer treatment. The loss and return of taste and pleasure with eating may have a significant impact on the patient’s social role within her family, as mealtime is a critical time for personal interaction.
Self-Care
Hygiene products and self-care techniques are an important part of maintaining vulvar and perineal health. Urinary and fecal control pads are different than feminine hygiene products and offer more absorbency ranges and styles. Perineal skin care products, moisturizers and barrier creams can protect the skin from breakdown, but most people are unaware of these products and may have misconceptions about their use.
Research has shown that vaginal and sexual health rehabilitation can improve the quality of life among GYN cancer survivors and should be part of comprehensive survivorship care with education being a significant component of every program. Baseline vaginal dryness and decreased lubrication during sexual arousal are symptoms that commonly occur in postmenopausal women. After GYN cancer treatment this dryness can be even more problematic and proper self-care should be reviewed with patients. Topical hormone creams, tablets, or rings can be inserted vaginally and provide replacement hormones to help keep the area moist and reduce vaginal atrophy. Hormonal treatments, however, may be not advised for cancer survivors or patients may choose to avoid them. Hyaluronic acid vaginal creams and vaginal moisturizers, such as Replens, are typically used to keep the tissues of the vagina and vulvar area moist during daily life. Many women are unaware of these products to keep the tissues healthy and reduce irritation, itching, and odor. Vaginal moisturizers used at a frequency sufficient to control symptoms after cancer therapy, three to five times per week, were found to improve vaginal and vulvar symptoms as well as improved scores on the FSFI for sexual response. Lubricants are more specifically for decreasing friction during sexual relations and help reduce dyspareunia. These are usually water or silicon based. Psychotherapists who specialize in sexual rehabilitation can compliment pelvic floor PT by addressing the psychosocial aspects of sexual relationships.
Exercise
Strength, Endurance, and Power
Among GYN cancer survivors, pelvic floor exercises have been shown to improve pelvic floor dysfunction and quality of life. Pelvic floor muscle exercises have been known to improve urinary incontinence, bowel incontinence, constipation, support dysfunction, and pelvic organ prolapse. Studies have revealed that pelvic floor muscle training improves the sexual function of women with urinary incontinence and women with a diagnosis of sexual dysfunction by increasing pelvic floor muscle strength. In addition, the research shows that pelvic floor muscle rehabilitation is more likely to succeed with a supervised program than with self-administered exercises.
In the literature there is very little agreement on what the best pelvic floor strengthening protocols should look like. Treatment protocols are highly variable and outcome measures differ between various studies. There is some basic consensus, however, that pelvic floor muscle training should follow principles of muscle physiology and include elements of overload, specificity, and reversibility. Muscle training should include exercises to address endurance, power, coordination, velocity, and flexibility. The treating therapist has considerable leeway in crafting a program that suits the specific needs of the GYN cancer patients.
Proper identification of the correct muscle action is the first step in muscle reeducation ( Fig. 19.7A ). Diaphragmatic breathing is an excellent tool to help quiet the autonomic nervous system and relax the patient so that she can feel and observe the pelvic floor motion. Research indicates that pelvic floor muscle isolation is not necessary for pelvic floor muscle strengthening to occur. It is important, however, that the patient is able to accurately contract the pelvic floor in order for strengthening to take place and that rest intervals are appropriate. Vaginal dilators or manual digital insertion can also provide additional proprioceptive feedback for improved muscle awareness during strengthening. In cases of severely decreased awareness, the therapist can teach exercises that utilize overflow from other muscle groups such as hip abduction and adduction to help facilitate the pelvic floor.
