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Published by funmi, 2019-04-12 09:31:57

APP

APP Course Materials 2019

UROGYNECOLOGY

for the Advanced

Practice Provider 2019

COURSE MATERIALS

April 11-13, 2019
The LINE Austin Hotel
Austin, TX

Pelvic Anatomy and PFDs............................................................................................................................. 1
John Occhino, MD, MS
Pelvic Anatomy for the First Assistant......................................................................................................... 8
Cara King, DO, MS, FACOG
Sunrise Yoga: Get to the Core of Your Pelvic Floor (on the pool deck) .................................................... 27
Nicole Cookson, PT, DPT, WCS
Pessary - Tips and Tricks............................................................................................................................. 29
Randina Harvey-Springer, APRN, CNP, MS
Pelvic Floor Physical Therapy for PFDs ...................................................................................................... 42
Nicole Cookson, PT, DPT, WCS
Recurrent UTI ............................................................................................................................................. 54
Matthew Barker, MD, FACOG
OAB - How to Maximize Medical Therapy ................................................................................................ 69
Randina Harvey-Springer, APRN, CNP, MS
E-Stim for PFDs ........................................................................................................................................... 88
Julie Starr, FNP-PhD
Update in Third Line Therapies for OAB.................................................................................................. 105
Brian Linder, MD
Landmark Clinical Studies in FPMRS........................................................................................................ 119
Rebecca Rogers, MD
Irritable Bowel Syndrome ........................................................................................................................ 135
John Occhino, MD, MS
Fecal Incontinence.................................................................................................................................... 148
Christina Lewicky-Gaupp, MD
Vulvar Dermatology ................................................................................................................................. 162
Amy Park, MD
Compounded Medications for PFDs ........................................................................................................ 183
Cara King, DO, MS, FACOG
Physical Therapy for Large Muscle Dysfunction...................................................................................... 190
Nicole Cookson, PT, DPT, WCS
ERAS: Developing your Recovery Protocol.............................................................................................. 200
Cara King, DO, MS, FACOG

Recurrent Vaginitis................................................................................................................................... 213
Amy Park, MD
How to Manage Post-op Complications .................................................................................................. 226
Christina Lewicky-Gaupp, MD
Evaluation and Management of Vaginal Wall Masses............................................................................ 240
Brian Linder, MD
Creating a Postpartum Perineal Health Clinic ......................................................................................... 253
Christina Lewicky-Gaupp, MD
The Intricacies of Bladder Pain Syndrome............................................................................................... 269
Matthew Barker, MD, FACOG
Published Clinical Guidance Documents ................................................................................................. 283
Patient Fact Sheet: Botox® Injections to Improve Bladder Control ....................................................... 285
Patient Fact Sheet: Constipation ............................................................................................................. 287
Patient Fact Sheet: Interstitial Cystitis/Bladder Pain Syndrome............................................................ 289
Patient Fact Sheet: Mid-urethral Sling for Stress Urinary Incontinence ................................................ 291
Patient Fact Sheet: Overactive Bladder................................................................................................... 293
Patient Fact Sheet: Third and Fourth Degree Perineal Tears.................................................................. 295
Patient Fact Sheet: Urinary Tract Infections ........................................................................................... 297
Patient Fact Sheet: Vaginal Hysterectomy for Prolapse ......................................................................... 299
Patient Fact Sheet: Vaginal Pessaries ...................................................................................................... 301

Pelvic Floor Anatomy & PFD’s

John A. Occhino, MD, MS

John A. Occhino, MD, MS

@JohnOcchinoMD
• Mayo Clinic

• Associate Professor of ObGyn
• Program Director: FPMRS Fellowship

• Education:

• BA: Miami University, Oxford OH
• MD: University of Cincinnati College of Medicine, Cincinnati OH
• ObGyn Residency: Good Samaritan Hospital, Cincinnati OH
• FMPRS Fellowship: Mayo Clinic, Rochester MN

• Masters of Biomedical Sciences

• Board Certified

• Obstetrics and Gynecology
• FPMRS

Disclosures

• None

1

Objectives

• List 3 muscles of the pelvic Floor
• Describe the 3 levels of vaginal support

Overview

• Pelvic Floor Muscle Dysfunction
• Common associated Pelvic Floor Disorders (PDF’s)

Pelvic Floor

• Muscles
• Ligaments
• Connective tissues
• Nerves
• . . . That help support and control the rectum,

uterus, vaginal and bladder

2

Perineal membrane

• Sheet of fibrous connective tissue
• Separates superficial and deep compartments
• Anterior and Posterior Triangles of pelvic diaphragm

* Netter images unable to be printed due to copywright

Pelvic Floor Musculature

• Coccygeus

• Origin: ischial spine
• Insertion: side of the coccyx and lower sacrum
• Action: elevates the pelvic floor

• Obturator Internus

• Origin: internal surface of the obturator membrane
• Insertion: greater trochanter
• Action: laterally rotates and abducts the thigh

3

Pelvic Floor Musculature

• Iliococcygeus
• Origin: arcus tendineus levator ani and the ischial spine
• Insertion: anococcygeal raphe and the coccyx
• Action: elevates the pelvic floor

• Pubococcygeus
• Origin: posterior aspect of the superior pubic ramis
• Insertion: coccyx
• Action: elevates the pelvic floor

• Puborectalis
• Origin: posterior aspect of the body of the pubis
• Insertion: unites with puborectalis of other side, posterior to the rectum
• Action: draws the distal rectum forward and superiorly; aids in voluntary retention of
feces

• Levator Ani
• Puborectalis, Pubococcygeus & Iliococcygeus

4

Pelvic Floor Muscle Dysfunction

• Weakness

• Billing/coding tip – ICD-10: Pelvic Muscle Wasting: N81.84

• Spasm/Tension

• Billing/coding tip – ICD-10: Muscle Spasm (Other): M62.838

• Dysfunction/Dyssynergia

• Billing/coding tip – ICD-10
• 1) Somatic Dysfunction Pelvic: M99.05
• 2) Other Condition associated with Female Genital Organs: N94.89

Vagina

• Vaginal support occurs at 3 levels

• Level I: superior vagina/vaginal apex

• Cardinal and uterosacral ligaments

• Level II: mid vagina

• lateral attachments to the ATFP and levator muscles

• Level III: distal vagina

• Perineal membrane and perineal body

Levels of Support

5

POP-Q

Point Description Range

Aa Anterior vaginal wall 3cm -3cm to +3cm
proximal to hymen

Ba Most distal portion of the -3cm to +tvl
remaining anterior wall

C Most distal edge of the cervix
or vaginal cuff

D Posterior fornix (N/A if post-
hysterectomy)

gh Middle of external urethra to
posterior midline hymen

pb Posterior margin of gh to
middle anal opening

tvl Depth of vaginal when point D
or C reduced to normal

position

Ap Posterior vaginal wall 3cm -3cm to +3cm
proximal to hymen

Bp Most distal portion of the -3cm to +tvl
remaining posterior wall

Key Points

• Assess pelvic floor during each exam

• Standardize your examination, teach to learners

• Several PFD’s associated with pelvic floor muscle dysfunction
• Educate patients on importance of treatment of pelvic floor muscle

dysfunction as part of plan of care

6

Pelvic Floor Anatomy & PFD’s
7

Notes

Pelvic Anatomy for the
Surgical First Assistant

Cara R. King, DO, MS
Section Chief of Minimally Invasive Gynecologic Surgery

Assistant Professor, University of Wisconsin-Madison

Cara R. King, DO, MS

@drcaraking http://www.vimeo.com/drcaraking

• University of Wisconsin-Madison

• Assistant Professor of Obstetrics and Gynecology
• Section Chief: Minimally Invasive Gynecologic Surgery

• Education:

• BA: Michigan State University, East Lansing, MI
• DO: Michigan State University, East Lansing, MI
• ObGyn Residency: Tufts University School of Medicine,

Baystate Medical Center
• Minimally Invasive Gynecologic Surgery Fellowship: Magee Womens

Hospital, Pittsburgh, PA
• Masters in Medical Education

• Board Certified

• Obstetrics and Gynecology

Disclosures

• I have no conflicts of interest

8

Objectives

• Discuss the characteristics of an efficient surgical procedure
including visualization, exposure, and tension counter-tension

• Apply surgical techniques to optimize success as the first
assistant

• Understand the fundamental anatomy of pelvic surgery with
application to common gynecologic procedures

Role of Surgical First Assistant

• Aid and facilitate the surgeon in performing a safe and efficient
procedure

• Allow the surgeon to focus on crucial elements of the operation
• Fundamental knowledge of pelvic anatomy is pivotal in

optimizing his or her impact
• As an assistant gains experience, anticipation and precision

become important elements

9

Essential Components of Successful Surgery

1. Visualization
2. Exposure
3. Tension

counter-tension

1. Visualization

Laparoscopy Equipment

• Essential to ensure all areas of camera and laparoscope are
clear of fog and debris

• Adjust focus pending focal length

10

Visualization Video

2. Exposure

• Appropriate manipulation of tissue to allow the most direct view
of desired dissection
• Includes both laparoscopic manipulation and adjustment of
the uterine manipulator and rectal probe

• View often includes key adjacent structures including blood
vessels, bowel, and the ureter

• Surgeon often has specific view that he or she is desiring

Exposure Video

11

3. Tension Counter-Tension

Tension Counter-Tension Video

Pelvic Anatomy is Complex!

• Gynecologic: Uterus, cervix, fallopian tubes, ovaries
• Genitourinary: Bladder, ureters
• Gastrointestinal: Rectosigmoid colon
• Neurologic: Superior and inferior hypogastric nerves, obturator

nerve, genitofemoral nerve
• Vascular: Uterine artery, infundibulopelvic ligaments, iliac

vessels, middle rectal artery, superior vesical artery, presacral
vessels

12

Pelvic Anatomy Break Down

• Anterior abdominal wall
• Midline GYN structures: uterus, cervix, fallopian tubes, and ovaries

with associated ligaments and vascular supply
• Midline non-GYN structures: bladder, rectosigmoid colon
• Course of pelvic ureters
• Avascular spaces of the pelvis:

• Vesicovaginal and rectovaginal spaces
• Lateral pelvic side wall: pararectal and paravesical spaces
• Space of retzius
• Presacral space

Anterior Abdominal Wall

• Important to understand anterior abdominal wall anatomy for
abdominal entry and accessory trocar insertion

Thinnest area of the
abdomen is at the

umbilical ring

Palmers Point Entry: LUQ

• Location: 3cm below left costal
margin in the mid clavicular
plane

13

Palmers Point Entry Video

Anterior Abdominal Wall

• Location of deep and superficial
vessels are pivotal when placing
accessory trocars

Inferior
Epigastric Artery

(Deep)

14

Trocar Insertion Video
Inferior Epigastric Artery Injury

Uterus

Cervix Utero ovarian
ligament

Right
Ovary

Right Fallopian Tube

15

Sigmoid Uterosacral
ligaments

Bladder

Left Round Cervix Right
Ligament Uterus Round
Ligament

Left Round
Ligament

Left Ovary

Left Infundibulo- Cervi
pelvic (IP) x
Left ligament Left Fallopian Tube
Round
Ligament Uteru
s

16

Gynecologic Evaluation Video

Uterine manipulator

• Confirm cup is in the correct place
by using anatomic landmarks

Uterine manipulator video

17

Bladder Backfill Video

Course of Pelvic Ureter Video

Avascular planes of the pelvis

• 1. Pararectal space R
• 2. Paravesical space
• 3. Presacral space V
• 4. Rectovaginal space
• 5. Vesicovaginal space B
• 6. Space of Retzius

18

Avascular planes of the pelvis

• 1. Pararectal space R
• 2. Paravesical space
• 3. Presacral space V
• 4. Rectovaginal space
• 5. Vesicovaginal space B
• 6. Space of Retzius

Avascular planes of the pelvis

• 1. Pararectal space R
• 2. Paravesical space
• 3. Presacral space V
• 4. Rectovaginal space
• 5. Vesicovaginal space B
• 6. Space of Retzius

Avascular planes of the pelvis

• 1. Pararectal space R
• 2. Paravesical space
• 3. Presacral space V
• 4. Rectovaginal space
• 5. Vesicovaginal space B
• 6. Space of Retzius

19

Avascular planes of the pelvis

• 1. Pararectal space R
• 2. Paravesical space
• 3. Presacral space V
• 4. Rectovaginal space
• 5. Vesicovaginal space B
• 6. Space of Retzius

Avascular planes of the pelvis

• 1. Pararectal space R
• 2. Paravesical space
• 3. Presacral space V
• 4. Rectovaginal space
• 5. Vesicovaginal space B
• 6. Space of Retzius

Avascular planes of the pelvis

• 1. Pararectal space R
• 2. Paravesical space
• 3. Presacral space V
• 4. Rectovaginal space
• 5. Vesicovaginal space B
• 6. Space of Retzius

20

Lateral R
pelvic
side wall V

B

CRK [5]1 Uterine
artery
Lateral Side Wall
Int Iliac
Uterus artery

Rectosigmoid Ureter
colon

UUteterruuss

Ureter

21

Internal UUteteruruss
iliac
artery

Uterine
artery

UUteterruuss

Obliterated
medial umbilical

ligament

UUteterruuss

22

UUteteruruss

UUteteruruss

Paravesical Space

• Pubic bone
• External iliac artery,

obturator fossa
• Uterine artery
• Bladder, vagina

Pararectal
Space

• Internal iliac artery
• Ureter
• Uterine artery

23

Paravesical Space

• Pubic bone
• External iliac artery,

obturator fossa
• Uterine artery
• Bladder, vagina

Pararectal
Space

• Internal iliac artery
• Ureter
• Uterine artery

Where do you start?

Pelvic Sidewall Dissection Video

24

Presacral Space Video

Space of Retzius Video

Key Points

• The surgical first assistant plays an essential role in safe and
efficient surgery

• Visualization, exposure, and tension counter-tension are key
factors in a successful surgery

• The complexities of pelvic anatomy should be mastered to
provide optimal surgical assistance

25

Thank you.

[email protected]
@drcaraking

26

Notes

Sunrise Yoga

Nicole (Niki) Cookson, PT, DPT, WCS

Benefits of Yoga

• Improved mental health, decreased depression and anxiety
• Decreased pain
• Improved function
• Increased energy

Munishwar, Brijesh (2019); Williams et al (2009)

Up Training vs Downtraining

• Modify program dependent on goals
• Use breath, abdominals and

pelvic/spine orientation

27

Pelvic Floor Downtraining Yoga Sequence

Seated position, 3  Bring hands to knees, perform 10 pelvic circles in each direction.  10 Cat/cows; inhale to look forward, exhale rounding 
diaphragmatic breaths.

Gently lift and lower chest 3 times.  5 breaths in downward dog Lift right leg back Bring right foot to low 
lunge and lower back knee

Inhale, open chest Exhale, gently lengthen front  Forward fold with feet 3‐4  Back to low lunge. 
leg and bring hips back. Repeat  feet apart, hold for 5 
breaths.
3 times

Pelvic Floor Uptraining Yoga Sequence Laura Meihofer, LLC

Inhale Exhale Inhale Exhale Inhale Exhale Inhale Exhale Inhale
3‐5x
3‐5x Finding your neutral spine 3‐5x Engaging/firming pelvic floor and abdomen with inhale maintain gentle engagement with exhale

Exhale Inhale Exhale Continue Exhale Inhale Exhale Exhale Inhale Exhale
Neutral spine and breath Now do the other side
3‐5x through focusing on lifting pelvic floor especially during the motion into tall lunge 

Inhale Exhale Exhale Inhale Exhale Inhale Exhale Exhale Inhale

3‐5x noting how this side may vary from the other  3‐5x re‐establish your neutral spine with this new stance 

Key Points

• Yoga is an excellent mode of exercise to incorporate PFMT 
• Up training and/or downtraining of pelvic floor, dependent on need

28

Notes

Pessary – Which, When, Tips

Randina Harvey-Springer APRN, CNP

• Undergraduate; Winona State University 1999

• Bachelor of Science in Nursing

• Graduate School; University of Minnesota 2010

• Masters of Science

• National Certification Corporation

• Women’s Health Nurse Practitioner

• Mayo Clinic, Rochester MN 1999-present

• Department of OB/GYN
• Division of Female Pelvic Medicine and Reconstructive Surgery
• Instructor, Mayo Clinic College of Medicine

Objectives

• Review the indications for utilization of a vaginal pessary
• Review the historical context of the pessary device
• Understand the different types pessaries, management,

complications, and contraindications
• Case study review: tips and tricks to increase pessary

fitting success

29

What is a Pessary?

• A vaginally placed object used to support pelvic organ
prolapse and/or improve stress urinary incontinence or act as a
cerclage for cervical incompetence.

• Involuntary loss of urine with increased abdominal pressure

• Coughing
• Sneezing
• Laughing
• Jumping etc.

• Material: Flexible silicone
• Low-risk

Pelvic Organ Prolapse (POP)

• Loss of support for the pelvic organs leading to prolapse of
one or more of the organs into the vagina

• Uterine prolapse or apical prolapse
• Anterior prolapse (Cystocele)
• Posterior prolapse (Rectocele)

• ACOG prolapse video website

• https://www.acog.org/Patients/Patient-Education-Videos/Pelvic-Organ-Prolapse?IsMobileSet=false

Houman, J., Weinberger, J., & Eilber, K. (2017). Native Tissue Repairs for Pelvic Organ Prolapse. Curr Urol Rep. 18:6.

Stress Urinary Incontinence

• Involuntary loss of urine with increased abdominal pressure

• Coughing
• Sneezing
• Laughing
• Jumping etc.

30

Incompetent Cervix

• Cervical pessary

https://clinicaltrials.gov/ct2/show/NCT02405455 Cerclage vs Cervical Pessary in Women With Cervical Incompetence (CEPEIC)

Symptomatology

• General “prolapse” symptoms:

• Pelvic pressure, heaviness, tissue protrusion, RARELY pain.

• Cystocele:

• Incomplete bladder emptying, increase in urgency,
incontinence, often has to splint

• Rectocele:

• Difficulty initiating BM, emptying, often has to splint, incontinence.

• Uterine prolapse:

• pelvic heaviness, possibly interfering with urination or defecation

Epidemiology

• 50% of women will develop POP
• Stress urinary incontinence

• estimated 15 million adult women in the U.S.

• Negatively affects QOL
• 2005-2006: Cost US healthcare around $300 million

• 200,000 women each year undergo surgery for pelvic organ
prolapse

National Association for Incontinence, Facts and Statistics
Houman, J., Weinberger, J., & Eilber, K. (2017). Native Tissue Repairs for Pelvic Organ Prolapse. Curr Urol Rep. 18:6.

31

Who is at Risk?

• Parity
• Age
• Vaginal delivery vs C-section
• Pressure: COPD, lifting, chronic constipation, obesity
• Increased age: menopause/estrogen deficiency
• Prior pelvic surgery
• Congenital - collagen disease, race, anatomy.

Houman, J., Weinberger, J., & Eilber, K. (2017). Native Tissue Repairs for Pelvic Organ Prolapse. Curr Urol Rep. 18:6.

Systematic Pessary Review

• Seven articles

• Pessary use associated with improved quality of life
• Over half of the women continued using the pessary during the

follow-up with acceptable levels of satisfaction
• Reasons for discontinuation were discomfort, pain, and expulsion

of the device

de Albuquerque Coelho, S.C., de Castro, E.B. & Juliato, C.R.T. (2016). Female pelvic organ prolapse using pessaries: systematic review Int Urogynecol J 27: 1797

Objectives

• Review the indications for utilization of a vaginal pessary
• Review the historical context of the pessary device
• Understand the different types pessaries, management,

complications, and contraindications
• Case study review: tips and tricks to increase pessary

fitting success

32

Historical Perspective

• The Egyptians were the first to describe pelvic organ prolapse

• Used half pomegranates soaked in vinegar
• Ball pessary that was made of strips of linen
• A sponge tightly rolled and bound with string, dipped in wax, and

covered with oil or butter
• Gold, silver, bronze and brass pessaries of various shapes have been

found dating back to the late 16th century
• Cork with a hole in it to allow passage of discharges, plus wax pessaries

or cork dipped in wax.
• Charles Goodyear's discovery of the vulcanization of rubber in 1844

Lewicky-Gaupp, C, Glob. libr. women's med., (ISSN: 1756-2228) 2010; DOI 10.3843/GLOWM.10025.

Pessary Myths

• It stinks
• It’s difficult to manage
• I probably won’t like it; I heard a pessary is terribly

uncomfortable
• It is only an option for the elderly
• It will lead to yeast or other vaginal infections
• It might ‘put a hole’ in the vagina
• Dr. Google had nothing good to say about a pessary
• My provider said I wouldn’t like it

Pessary Reality

• Fairly easy to use
• Offers immediate correction to the problem
• Minimal care required

• Soap and water to clean

• Surprisingly comfortable
• The pessary is extremely durable
• Postpones surgery, sometimes indefinitely

33

Objectives

• Review the indications for utilization of a vaginal pessary
• Review the historical context of the pessary device
• Understand the different types pessaries, management,

complications, and contraindications
• Case study review: tips and tricks to increase pessary

fitting success

Pessary Indications

• Patients unfit for, awaiting, declining, or failing surgery
• Prolapse and SUI during pregnancy

Evaluation

• Careful discussion - patient is active participant
• Is she capable of managing a pessary independently?
• Assess vaginal size, shape and support
• Treat atrophy with estrogen cream prior to fitting
• Provide health education and appropriate follow up

34

Pessary Fitting

• Pelvic exam noting degree of prolapse, vaginal length/depth,
support at the introitus, atrophic changes

• Need a minimum of 4 inches of depth***
• Successful fitting by trial and error

• 1 fingerbreadth between vagina and pessary
• Have patient attempt to empty the bladder and also bear down

to evaluate movement
• Have patient walk around to check for comfort, sit/stand, squat if

possible
• Time for teaching and demonstration for insertion & removal

Maintenance

• Self management schedule

• Remove nightly to weekly and prior to intercourse
• Wash in soapy warm water
• Water based lubrication for insertion
• Vaginal estrogen medication (creams, ring, suppositories, tablet)
• Trimosan Jelly OTC helps to normalize the vaginal pH; cuts down on

pessary odor
• Take a break if a vaginal ulcer forms. Might possibly need a different

shape or size if this recurs.
• Follow up appointment or phone call every 12 months

Maintenance

• Continuous wear

• Appointment every 3 months
• Vaginal estrogen if appropriate
• Trimosan gel if needed
• Patient calls early if discomfort, bleeding or dislodges

35

Ring Pessaries

• 4 types: Ring, oval, ring with
ball, Marland

• Pros: Easy for 1-2 degree
prolapse

• Sizes: 0-9
• Placement: Folded insertion,

transverse set
• Use a monofilament if

needed: Fishing line

Donut Pessaries

• 2 types: Ring and inflatable
pessary

• Pros: For advanced prolapse
and poor perineal support

• Sizes: 0-7
• Placement: Squeezed for

insertion
• Con: Inflatable styles are to be

removed every night

Cube Pessary

• 2 type: single or tandem
• Pros: Easy to insert and remove
• Sizes: 0-7
• Placement: Suction achieved with high

placement
• Cons: Retains secretions, needs to be

removed at least every 48 hours

36

Gellhorn Pessaries

• Pros: For advanced prolapse and poor
perineal support

• Sizes: 1.5 - 3.5 inches
• Placement: Oblique insertion concave

placement against cervix/vault
(suction), stem rests vertical
• Cons: Difficult to remove

Other Pessary Styles

Out of the box thinking….

• Double pessary wear

• Saw a patient who had a pessary fit elsewhere
• She said they “went through many pessary styles until 1 fit”
• She wanted a second opinion on pessary or surgery
• Exam: I removed a dish + a ring

37

Objectives

• Review the indications for utilization of a vaginal pessary
• Review the historical context of the pessary device
• Understand the different types pessaries, management,

complications, and contraindications
• Case study review: tips and tricks to increase pessary

fitting success

Case Study: Cystocele

• Grade 3 cystocele
• Introitus/GH < 4 cm
• Strong pelvic floor
• She wants self management
• My first choice will be a ring style.

If this fails, will next try the
Marland and the cube.

Case study; Uterine Prolapse

• Grade 3 uterine prolapse
• Introitus/GH measurement is

large >4 cm
• Reduction of the uterus

doesn’t stay; it quickly
prolapses with minimal effort
• She wants continuous wear
• My first choice is the Gellhorn,
second is the donut

38

Case Study: Stress Incontinence

• Loss of urethral support
• Leaks with most activities
• She wants self management
• My first choice is the

continent pessary (ring with
ball/knob). Next styles would
be the Marland or the Hodge

Concerns From Patients

• Odor

• Solution: vaginal estrogen, TrimoSan jelly, removal of the pessary more
frequently

• Feels like it’s going to fall out with bowel movements

• Solution: either take the pessary out before bowel movements, or teach her to
splint/hold the pessary during BMs. Ensure adequate bowel regime.

• Bleeding

• Don’t panic. Call the office. Don’t go to the ED.

• I couldn’t get the pessary out

• Don’t panic. Don’t go to the ED. Have her return and reinstruct/watch her
technique, possibly tie a monofilament.

• This one doesn’t fit. I guess I have to have surgery.

• Solution: Try other shapes/sizes if she really doesn’t want to have surgery

Complications/Nuances

• Vaginitis / vaginal infections
• Poor fitting, expulsion, pressure/pain
• Erosions / ulcerations
• Severe bowel or bladder problems rare
• Neglected/forgotten pessaries

39

Cautious Use

• Dementia
• Pelvic pain
• Severe vaginal atrophy (prescribe vaginal estrogen for 1

month prior to attempting fitting)

Poor Candidates

• History of vaginal radiation
• Severe vaginal stenosis
• Shortened vagina

Key Points

• Normalize the pessary

• Compare it to other ‘supportive’ devices we use daily
• Pessary devices can offer significant immediate symptom relief from

pelvic organ prolapse and stress urinary incontinence

• Can be managed independently or worn continuously
• Have several different styles and sizes available for fitting

appointments
• Can be refitted as the body changes
• Can be abandoned at any time and proceed with a surgical

intervention

40

THANK YOU FOR YOUR
ATTENTION

[email protected]

41

Notes

Pelvic Floor Muscles  
and 

Relationship to Pelvic Floor Disorders 

Nicole (Niki) Cookson, PT, DPT, WCS

Nicole (Niki) Cookson, PT, DPT, WCS

• Lead Physical Therapist  ‐ Pelvic Health 
Mayo Clinic, Rochester

• Instructs women health curriculum at
Mayo’s DPT program

• B.S in Kinesiology
• Doctorate in Physical Therapy
• Board Certified in Women's Health Physical Therapy

Objectives

• Describe anatomy and functions of pelvic floor muscles
• Discuss pelvic floor muscles evaluation
• Provide overview of pelvic PT, including treatment interventions for

pelvic floor dysfunction
• Discuss what to look for from your PT’s  (plan of care, treatments, etc.)

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Pelvic Floor Muscle Function

Sphincter
Support the pelvic organs
Sexual function
Spine
Sump pump ‐ lymphatics

Kegel (1948), Sapsford et al(2009); Mitchell and Esler (2009); Hodges et al (2007

PFM Dysfunction – ICS/IUGA

Non‐functioning pelvic floor muscles (no contract or relax)
Underactive pelvic floor muscles

• UI
• Anal incontinence
• Prolapse
• Lumbopelvic—SI—hip dysfunction

Overactive pelvic floor muscles

• Pelvic floor muscle pain
• Painful bladder syndrome 
• Constipation
• Dyspareunia
• Lumbopelvic—SI—hip dysfunction
Bo et al (2017); Haylen et al. (2010); Messelink et al. (2005)

External PFM Exam

• Visual inspection  (vulva and perineal body)
• Integumentary
• Sensation/Q‐tip testing
• Bulbocavernosus reflex and anal wink
• PFM functioning – externally

• Voluntary contraction
• Voluntary relaxation
• Cough
• Diaphragmatic breathing

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