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Pessaries

Mon, 10 Feb 2025 21:15:52 GMT

Pessary Fittings

A pessary is a medical device that is inserted into the vagina to provide support for the pelvic organs. It's primarily used in the management of conditions like pelvic organ prolapse (where organs like the bladder, uterus, or rectum drop from their normal position) and urinary incontinence. There are several uses and benefits of pessaries, including:

Pelvic Organ Prolapse (POP) : In women with prolapsed organs, the pessary helps to hold the organs in place and prevent them from descending further. It’s often used in cases where surgery isn't an option, or a non-surgical approach is preferred.
Urinary Incontinence : Pessaries can help in cases of stress urinary incontinence by supporting the bladder and urethra, thus reducing leakage of urine during activities like coughing or sneezing.
Support During Pregnancy : Some women with a weakened pelvic floor or those experiencing symptoms of prolapse during pregnancy may use a pessary to provide additional support.

Pessaries come in various shapes and sizes, and they are usually made of medical-grade silicone. A healthcare professional will typically help determine the right type and size for the individual, and the device needs to be cleaned and removed regularly. They are considered a safe and non-invasive option to manage these conditions, but it’s important for users to follow the guidance of their healthcare provider.

Patients with symptoms like the ones listed below can often benefit from a pessary:

The feeling of, or seeing, something “falling out” of the vagina
Heaviness, fullness, pressure inside the vaginal canal
Urinary incontinence with coughing, sneezing, laughing, lifting, exercise
General heaviness, pressure, dull ache, pulling sensation within the pelvis and lower abdomen

Our therapists are trained in pelvic examinations specifically for pessary fittings. The size and shape of the pessary depends on what organ is descended, how significant it is, and your individual vaginal anatomy. If you’re experiencing any of the above symptoms, speak with your gynecologist and ask about the possibility of a pessary. There are special considerations in the post menopausal population for pessary use, most notably vaginal estrogen replacement. With the addition of a medical product inside the vagina, it’s important to make sure the vaginal walls are as healthy as possible. Not every single person is a candidate for vaginal estrogen, but the vast majority of women are. This is a discussion to have with your health care provider prior to pessary fitting.

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Testicular Pain

Tue, 30 Jul 2024 13:51:16 GMT

Pain Driving you nuts?

Let’s face it, talking about your “land down under” can be uncomfortable, but not as uncomfortable as living with testicular pain! Did you know that chronic testicular pain, or orchialgia, affects approximately 100,000 men in the United States alone? So you are not alone, and there is help!

The testicles are the male gonads, or sexual reproductive organs, and are housed externally by the scrotum. The scrotum is actually an outpouching of the abdominal wall from embryological development, meaning some of the musculature and fascia is continuous with that of the abdomen - see picture below.

So what does this mean? Why am I having testicular pain? The answer may surprise you.

Genitourinary Syndrome of Menopause

Tue, 30 Jul 2024 13:50:08 GMT

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Genitourinary syndrome of menopause (GSM) is a broad term that encompasses all vaginal, sexual, urinary, and pelvic floor symptoms that are associated with a lower-estrogen state (i.e. menopause). These include:

Vaginal symptoms
Vaginal dryness
Burning, pain, irritation, itching, or tears in the tissue of the vulva (external female genitalia)
thing/graying of pubic hair
Vaginal wall prolapse
Vaginal pain or pressure
Sexual symptoms
Loss of lubrication
Pain or bleeding with sex
Loss of libido, arousal, or orgasm
Urinary symptoms
Painful urination
Recurrent UTI’s
Urinary urgency and frequency
Stress , urge, or mixed incontinence
Urethral caruncle (red growth on urethra)

GSM is more common than you may believe. GSM affects 50% of women by the age of 60 and 75% by the age of 70. Even though this is common many women may feel uncomfortable voicing these symptoms to their medical providers, but the good news is there is treatment!

There are several treatments for GSM. Vaginal estrogen is the number one treatment for GSM. Vaginal estrogen is safe with one of the only possible side effects being yeast or thrush although this is not common. Vaginal estrogen can also help prevent bacterial vaginosis (BV) which is an overgrowth of one or more species of normal vaginal bacteria. A lot of women have concerns with estrogen but overall studies have shown vaginal estrogen does NOT increase the risk of cardiovascular disease or cancer. However, it is encouraged to talk to your provider to see if this is an option for you based on your personal medical history.

Other treatments for GSM include:

Pelvic floor physical therapy can help reduce urinary incontinence, reduce pain, and teach you all of the things to help improve your knowledge of vulvar care. Vaginal moisturizers and lubricants can help with dryness and pain with penetration. Some recommended brands include Good, Clean Love and Replens. There are some products that are better than others (see our previous blog on Lubricants) so be cautious when choosing these products.

Diet and lifestyle can make a huge impact beyond just the use of estrogen.

Avoiding antibiotics (as much as possible) helps to prevent damage to the microbiome in the vaginal canal. Tobacco use lowers estrogen and also damages the microbiome. Avoid using anything such as wipes or douches that would alter microbiome. The vagina is a self cleaning oven, we do not need anything to clean it! Lastly, exercise and functional activities (our specialty!) for the abdominals and back musculature can help with pelvic floor function.

Bottom line: GSM is common, but not talked about enough. Reach out to your provider to voice your concerns regarding your symptoms. There is help!

Endometriosis

Tue, 30 Jul 2024 13:32:51 GMT

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What is Endometriosis?

Endometriosis is a disorder in which the tissue that normally lines the inside of your uterus — the endometrium — grows outside your uterus. This endometrium most commonly implants on your ovaries, fallopian tubes and the tissue lining your pelvis. Rarely it can occur beyond the area where pelvic organs are located, like your diaphragm or skeletal muscle.

The endometrium acts as uterine tissue and is sensitive to your body's estrogen levels — it thickens, breaks down and bleeds with each menstrual cycle. This is why those folks with endometriosis have a significant increase in symptoms around their period, and also why hormonal birth control that limits periods can be helpful in pain management. The pain from endometriosis is present because this tissue has no way to exit your body, and eventually develops scar tissue and adhesions.

What are the symptoms?

The most common symptom of endometriosis is pelvic and abdominal pain, but you may also experience any of the following:

Painful Periods (sometimes very severe pain)
Pain with penetrative sex, pelvic exams, or tampon placement
Pain when emptying the bladder or bowels
Excessive bleeding during periods and bleeding in between periods
Infertility
And more…fatigue, diarrhea, constipation, bloating or nausea, especially during menstrual periods

What are the risk factors?

Several factors place you at greater risk of developing endometriosis, such as:

Never having given birth
Starting your period at an early age
Going through menopause at an older age
Short menstrual cycles — for instance, less than 27 days
Heavy menstrual periods that last longer than seven days
Having higher levels of estrogen in your body or a greater lifetime exposure to estrogen
Low body mass index
A family history of endometriosis

Endometriosis usually develops several years after the onset of menstruation. Signs and symptoms of endometriosis may temporarily improve with pregnancy and may go away completely with menopause, unless you're taking estrogen

What treatments are available?

Treatment for endometriosis usually involves medication or surgery. The approach you and your doctor choose will depend on how severe your signs and symptoms are and whether you hope to become pregnant.

Options for treatment include:

Pain management: often in the form of oral medications
Hormone therapy: most common type is oral contraceptives
Surgeries - excision of the affected tissue, ablations, or hysterectomy
PELVIC FLOOR PHYSICAL THERAPY

As Pelvic Floor Physical Therapists we cannot “CURE” your endometriosis, but we play a large part in helping you manage the symptoms and get back to a pain free life.

In endometriosis, the original “driver” of your pain is the uterine lining that becomes implanted in places other than the uterus. These tissues have their own highway to the brain, and are sending pain signals each time they grow, shed, and bleed. This causes your brain to “sound the alarm” and put the pelvis into a “fight or flight” response.

When the brain does this, it does not selectively send an alarm to the uterus alone. It sends the alarm to the entire pelvis: the bowel, bladder, vagina, and pelvic floor muscles. When our pelvic floor muscles receive this alarm, their response is to tighten up, get guarded, and stay that way until they’ve been told there is no more alarm.

THIS is where your pelvic health PT/OT comes into play! It’s often very difficult for you as the patient to realize which of your muscles are in this “fight or flight” response. We help you locate the muscle(s), and teach you how to release that tension. People with endometriosis will often also have tension in the muscles of the abdomen, hips, and low back.

Pelvic health practitioners are experts in all things bowel, bladder, and sexual dysfunction. We are specialists in working with pelvic and abdominal pain, scar tissue, muscular tightness, and more!

Once you’ve received a diagnosis of endometriosis, it’s time to find your pelvic rehab provider. Go to www.pelvicrehab.com to find a practitioner near you!

Irritable Bowel Syndrome

Tue, 30 Jul 2024 13:31:07 GMT

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I have heard physicians say that food and nutrition are not important in the management

of IBS and other gastrointestinal conditions. As infuriating as that sounds, many other dietitians have shared similar experiences with me. In honor of IBS Awareness Month, let’s learn about this condition and the tremendous effects that food, nutrition, and lifestyle change can have for those with IBS.

Approximately 12% of people in the United States have Irritable Bowel Syndrome (IBS),

a chronic, functional bowel disorder characterized by symptoms such as bloating, abdominal

pain, diarrhea, or constipation. There is no specific test for IBS but at least two of the following must occur once a week for 3 months: pain and discomfort related to defecation, a change in the frequency of defecation, or a change in stool consistency (1). There are three main types of IBS: diarrhea predominant (IBS-D), constipation predominant (IBS-C), and a mixture of the two (IBS-M). Various conditions may need to be ruled out such as Intestinal Bowel Disease (Crohn’s and Ulcerative Colitis) or Celiac Disease.

Underlying Causes

Etiologies of IBS may be elusive but several that have been proposed by research

include foodborne illness, “visceral hyperalgesia [hypersensitivity], intestinal permeability,

immune activation, altered gastrointestinal motility, autoimmunity, and alteration of the gut

microbiome” (1). Every case is unique, so a general recommendation such as “eat more fiber” could have detrimental repercussions while a suggestion to only “eat what you tolerate” is not very helpful. A comprehensive nutrition and lifestyle assessment is essential. That is why someone with a gastrointestinal disorder should add a registered dietitian to their healthcare team.

Conventional Treatments

Examples of medications that may be used to control symptoms include

antidepressants, prokinetics, antibiotics, pain medications, and laxatives. Their effectiveness

varies, and they are often unsuitable for long-term use and carry a risk of side effects.

Medications for IBS have often been categorized as “band-aids'' which do not address the root cause of the issue. The relapse rate of symptoms is high, and it is common for someone to spend decades searching for the right treatment and tens of thousands of dollars on tests.

You may be asking: “Do you have any good news, then, Nathan?” Yes, I do, but I think it

is important to validate the experiences of each and everyone’s health journey and the long road that many with IBS travel to find symptom relief. It breaks my heart to see so many dismissed by their healthcare providers and given lackluster nutrition advice.

Flare Ups

Before diving into strategies that can address the root causes of IBS, let’s discuss some

basic steps to manage symptoms through a food and nutrition lens. After all, it is important to address what to do in a flare up.

It is essential to replace fluids and electrolytes lost during periods of frequent diarrhea or

vomiting. For constipation, proper hydration is important to help soften stools and encourage their progression through the GI tract. Avoid alcohol, caffeine, and smoking which can irritate the gut and worsen IBS symptoms. Avoid high fat foods (such as fried food, full fat dairy, and processed meat) and spicy foods. Ask your dietitian how much fiber to consume and choose cooked vegetables over raw and softer fruits such as bananas. Eat small, frequent meals and snacks, opting for pureed or liquid consistency (like a meal replacement shake) as needed. Watch out for sugar alcohols (sorbitol, erythritol, mannitol, xylitol, isomalt, maltitol, lactitol) which are one of the most common triggers for gastrointestinal symptoms. They are often used in place of sugar in sugar-free foods and beverages. Eat sitting down in a relaxed setting, chewing food thoroughly, and taking deep breaths. Try to reduce stress as much as possible and consider a free guided meditation video. Avoid strenuous exercise and get plenty of sleep and rest.

Low FODMAP Diet

The Low Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols

(FODMAP) diet is one of the most popular dietary approaches to reduce IBS symptoms, though it is certainly not the only one. Monash University, which created the Low FODMAP diet, explains that FODMAPs are short-chain carbohydrates that may not be absorbed properly in the gut, drawing water into the intestines. They are also highly fermented by gut bacteria, which cause gas. Let me be clear, the FODMAP content alone does not determine if a food is nutrient-dense or not. Some of the healthiest foods (beans, mango, mushrooms, avocado, watermelon, etc.) are high in FODMAPs while some processed food products are high in FODMAPs (like high fructose corn syrup). The goal of the Low FODMAP diet, like any

elimination diet, is to reintroduce foods to keep as many foods as possible in someone’s diet

moving forward. Some limitations of the low FODMAP diet include that 1) it is restrictive and can be challenging to follow 2) around 30% do not achieve significant symptom relief and 3) it still does not determine the “root cause” of what is triggering symptoms in the first place.

SIBO and IMO

If you have heard of gut bacteria, probiotics, or the gut microbiome, then you may know

that bacteria in the intestines provide many essential health benefits from improved function tobetter digestion to improved cardiovascular health. Many trillions of these bacteria are

located in the large intestine while not so many reside in the small intestine. If you have an improper balance of the different types of gut bacteria, it is called gut dysbiosis. If there are too many bacteria in the small intestine, it is a condition called small intestinal bacterial overgrowth (SIBO). Research suggests that as many as half of people with diarrhea-predominant irritable bowel syndrome have SIBO (2). Recently, a new condition (intestinal methanogenic overgrowth) was identified that is related to but different from small intestinal bacterial overgrowth. Intestinal methanogen overgrowth (IMO) is more often associated with constipation while SIBO is often associated with IBS-D or IBS-M. The practical way of testing for SIBO or IMO is a breath test that detects levels of hydrogen, methane, and hydrogen sulfide. Identifying the presence of SIBO or IMO is very helpful for determining treatment options for IBS, but the road to symptom relief can still be quite difficult. There are two antibiotics that can be effective for the treatment of SIBO or IMO: xifaxan and nystatin. Sadly, the relapse rate is very high. Limited research indicates that herbal antimicrobials may work just as well (3). Probiotics can help, and three brands in particular have many supporting studies: VSL#3, LacClean, and Visbiome.

However, there should be caution since probiotics can also make symptoms worse.

Yet once again, what is the root cause? What caused the bacterial overgrowth in the first

place? There are multiple proposed etiologies including motility problems, overuse of proton pump inhibitors, and adhesions caused by abdominal surgeries. Addressing the root cause can help prevent relapse of symptoms.

Stress

The gut and brain are connected via the vagus nerve, part of the parasympathetic

nervous system, which plays a major role in controlling digestion. There is no doubt that stress can greatly affect IBS. For instance, nerves in the gut may be hyper-sensitive, registering more pain from bloating for someone with IBS than for someone without the condition. Stress-reducing approaches, such as yoga, have been studied extensively with good success in reducing IBS symptoms.

Conclusion

There are a multitude of approaches for treating IBS and each one claims to be “the

best.” However, the best approach for alleviating the symptoms of irritable bowel syndrome is to determine the root cause and that varies from person to person. Long-term symptom relief requires a lot of patience, but my hope is that it will not require more blood, sweat, and tears than is absolutely necessary. Medications might bring short-term relief, but their use should be evaluated critically with the knowledge that they could even make symptoms worse over time. Complementary approaches that address food, lifestyle, and stress are essential, and a registered dietitian is a valuable addition to the treatment team.

Lichen Sclerosis

Tue, 30 Jul 2024 13:29:41 GMT

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Lichen sclerosus (LS) is an inflammatory, auto immune skin condition that can affect any area of the body. It is most common in the skin around the genitals and causes the tissues to become pale, thin, and tight. Lichen sclerosus can affect both men and women, but more commonly presents in post menopausal women. The hallmark sign of LS is white patches (sometimes shaped like a figure of 8 or a keyhole) around the genital region that can itch, crack, tear, and cause pain with intercourse. In males, it can create narrowing of the opening at the end of the penis, causing difficulty urinating. In females, it can create restriction around the vagina, clitoris, and anus, making intercouse and bowel movements painful. The cause of LS is unknown, but it can be related to hormonal changes, trauma, and immune dysfunction. It is not contagious and is not spread by sexual contact. This condition may be more common than we realize, as we are seeing more and more cases in

young females in the clinic.

Treatment for lichens generally consists of steroid ointment that reduces inflammation and restores plumpness to the tissues. The goal is to reduce scarring, reduce pain and itching, and improve tissue color and quality. I have seen patients improve DRAMATICALLY after even just two weeks of using the creams as prescribed.

Pelvic therapy is imperative in this population. When you have pain in the genital area the pelvic floor muscles can also become tight and tense, leading to more pain. When our muscles become tight, this creates more problems like painful urination, urinary leakage, vaginal tearing, and painful intercourse. Once you've started taking the prescribed medication, the muscles still need rehab! A specialized pelvic floor therapist can perform a vaginal exam, testing for muscle tension and strength. For the vast majority of patients with LS, the goal is to relax and lengthen the pelvic floor muscles - NOT to squeeze, kegel, or strengthen. Your therapist will apply gentle manual therapy to help restore tissue nutrition, increase blood flow, and improve mobility. This reduces the risk of tissue scarring, and also decreases your pain. They will also teach you proper stretches and techniques that you can perform at home. Your pelvic PT/OT will also teach you about the importance of gut health, vaginal pH balance, and reducing acidity in your diet. All of these things together help reduce the severity of LS on your quality of life. So not only can therapy help improve tissue health, but mental health!

This condition can be distressing, but medical and therapeutic interventions can restore the quality of your tissues and quality of life! If you have been diagnosed with lichen sclerosus, you can talk to a pelvic health therapist about treatment. This is a treatable problem, and most insurances cover therapy services. We are here to help you on your journey to restoring great health!

Case Study: Post Prostate Removal

Tue, 30 Jul 2024 13:28:32 GMT

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Today’s case study is one of my favorites, because this patient used physical therapy exactly the way we recommend - and it paid off! This patient is a 62 y.o. male with prostate cancer. He is scheduled for prostate removal January 9, 2023 and presents to PT for prehab in December 2022. Let’s begin with his medical history before his surgery, and then we’ll review his symptoms post surgery.

Pre Surgery History:

“The patient presents to PT for prehab for RALP (prostate removal) surgery scheduled on Jan 9. He is doing kegels 3 sets of 20 per day currently, mostly quick flicks. He states he can stop the urine stream. He reports history of Ulcerative Colitis but is in remission right now. He exercises by walking about one mile per day”

Where do we start?

The purpose of seeing a PT prior to prostate removal is to get instruction on how to perform pelvic floor muscle exercises. We know that seeing a therapist PRE surgery gives better results in the short term, following surgery.Typically clients do not need more than 1-2 visits pre - op. There are many ways your therapist can help you understand how to perform pelvic floor muscle training:

Biofeedback with external and/or internal sensors ( See example here )
Internal rectal exam
Verbal instruction for how to contract and relax the pelvic floor

With this particular client, he declined an internal rectal exam and biofeedback. I gave him verbal instruction on how to perform kegels, and gave him a specific routine. I wanted him practicing long endurance holds AND quick contractions daily. Three times per day he would perform 10, 10s contractions and 10 “quick flick” contractions.

I also educated the patient on how to use his breathing diaphragm and his abdominal muscles to reduce the strain on his pelvic floor. Learning to coordinate the pelvic floor, abdomen, and diaphragm is a huge component of post surgery rehab, so we want to train the brain early.

The last portion of a prehab visit includes education on what to expect post surgery. We spoke about the following:

Having a catheter in, and how long that would be in place (about 10 days)
When to start kegels again after surgery (once the catheter is removed)
When to start PT again (once the catheter is out)
Expectations for erectile dysfunction and potential treatments ( Information here )
The use of penile clamps, how and when to use them ( Directions here )

With this client, we were able to cover all of this in one visit, and the next time I saw him was about one month post surgery. Here is his symptom report as of Feb 2023:

“Pt notes leakage while standing, coughing, laughing. He is getting bladder urges but will go more often because it decreases leakage. He had a catheter for 25 days post surgery. He now wears one Depends per day and goes through 6-7 pads within the Depends, per day. He is leaking through the night while asleep. He does 20 kegels at a time, x 3 per day and holds for "a few seconds." He can stop the stream of urine, the urine stream is strong. He reports constipation off and on and is taking Senna daily. Stool is "hard and large." He is taking Cialis and using a penis pump daily.``

Because the patient had a lot of prehab education, he was already managing his constipation and erectile dysfunction well. Had he not been doing these things, I would have recommended oral medication and penile pump for E.D. The symptoms he’s reporting here are extremely common for a man one month post prostate removal.

Where did we start?

We scheduled the patient twice weekly for one month, and then once weekly for another month. At this first session we did an internal rectal exam to test for pelvic floor muscle strength and coordination. The patient was able to contract his muscles well, but had difficulty with complete relaxation. For this reason I recommended biofeedback, which is a tool we use to give patients a visual picture of their muscles working in real time. The patient declined using biofeedback so that was not a part of his treatment plan. I did have him continue with kegel training at the following intervals: 10s contraction x 10 reps, 2s contraction x 10 reps, SIX times per day, all contraction done in standing. ( Research here )

A large part of his rehab in the beginning was retraining his abdominal muscles to work together with his pelvic floor. If the patient isn’t able to use these muscles correctly, it ends up creating more pressure on the pelvic floor, resulting in more leakage. The first few visits consisted of table exercises with little to no resistance, making sure the patient was able to coordinate all movements and continue to breath (breath holding is also a common culprit of leakage).

Once the patient was performing the basics better, we transitioned to more functional movements in the gym i.e., sitting, standing, walking, squatting, bending, lifting, etc. With each week, the patient was reporting less and less leakage. His leakage at night was eliminated first, which is the case with most patients. By the end of February the patient had completely eliminated the need for Depends and was using about 5 regular pads per day. His pads at night were dry. Exercises continued to become more challenging in the gym and at home. At the end of March the patient was using 2-3 pads per day, depending on his activity level.

In regards to his erectile function, the patient was still unable to achieve spontaneous erection two months post surgery. This is also extremely common. He was taking oral medication and using the penile pump daily. Although he could not achieve full erections, he was able to achieve orgasms. Because the patient had no trouble with E.D prior to surgery, we expected him to make a full recovery with continued use of meds and the pump.

The patient was discharged after two months of therapy. He was still experiencing leakage but we were confident that his symptoms would continue to improve as long as he was compliant with the kegel program and general strengthening progra m

Case Study: Penile Pain

Mon, 29 Jul 2024 20:37:43 GMT

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This week we’re reviewing a case of a male patient, 54 y.o, with chief complaint of penile pain. This was a somewhat unusual case because of how soon the patient was referred to us. Typically in men with penile pain, physical therapy is their “last ditch effort” after they’ve tried everything and have been in pain for months. With this client, his pain had only been present for two months before he found our clinic.

He presented to the clinic in March of 2023, his history is noted here:

“The pain started this winter. He was given a urine culture that came back negative but was given antibiotics anyway. They helped but when he stopped, pain came back. He was then prescribed a one month antibiotic, but the pain came back. He reports a steady ache at the tip of the penis. He denies textural or sensation changes and he reports no difficulty with erection or orgasm. Intercourse is aggravating afterwards, but not during. Around this time he was also doing less cycling and more weight lifting. He is not maxing out but doing mostly super sets 30 minutes x 3 per week. When he lifts, that doesn't change the pain for better or worse. Pt works in a high stress sales job with frequent air travel, prolonged sitting aggravates the pain. Pt is an avid cyclist and has been for years, riding x 6 days per week 25-35 miles each time. Cycling does increase his pain. His bike is specifically fitted to him and there have been no recent changes to his bike since the pain started. Pt denies pain with urination but has a mild sensation he isn't emptying fully.”

Where did we start?

When it comes to treating penile pain, the trick is to remember this: it’s almost never the penis itself! It is commonly caused by tension in the muscles and nerves that supply feeling and blood flow to the penis. Our first visit involved assessing the following areas for tension, pain, and/or decreased flexibility:

Abdominal wall
Hips
Low back
Thighs

The patient had limited motion in his lumbar spine (difficulty rotating to the right and the left), and his muscles were especially tight in his hamstrings and inner thigh on the R side. His abdomen was normal, no excessive tension there, although the abdominal wall can be a common culprit for penile pain. I also noticed he had very tight hips and poor range of motion on each side. We hadn’t yet assessed his pelvic floor muscles and had already found plenty to work on!

On the next visit, we looked at the pelvis and the nerves and muscles within it. When someone reports penile pain, one of the things we need to rule out is pudendal nerve involvement. This is a small nerve that can wreak havoc on a pelvis if irritated. It directly innervates the areas of the anal opening, perineum (area between rectum and base of penis), and full length of the penis. What you see here is an example of a male lying on his back, and we’re looking at the front of his pelvis: penis along the top, tailbone at the very bottom, and rectum in between. The yellow lines demonstrate the path of the pudendal nerve. If this nerve is irritated, you could have pain anywhere along this distribution.

Here is a detailed video on the anatomy of the male pelvis and the pudendal nerve ( Link here )

During the pelvic assessment the patient is disrobed from the waist down, lying on his back on the treatment table, draped with a sheet. From this position I was able to feel all the muscles you see above (pictured in red), and assess for pain. It makes sense that if these muscles are tight, that would create tension around the nerve, leading to irritation and pain. The patient had mild tension here, but nothing we touched reproduced his pain.

The next step is performing an intrarectal exam. Muscles called the levator ani are the muscles we most commonly think of as our “kegel” muscles. These can only be accessed via an intra vaginal or intra rectal exam and if they are tight, can be a direct cause of nerve pain. This patient showed significant muscle tension during his exam, and when I touched the muscle named puborectalis (pictured below), it reproduced his penile pain.

So far, we have significant findings in the following areas:

Tight hamstrings and middle thigh muscles, with decreased hip joint flexibility
Significant tension to the muscles inside the pelvis
Stiff lumbar spine with limited motion

Where did we go from here?

At the next few appointments, we worked on the muscles in his legs and hips to promote relaxation. We also continued with intra rectal pelvic floor muscle release. At the end of each session we would perform hip and lumbar mobility exercises, and the patient was encouraged to continue with these at home.

Two of the main triggers for penile pain were travel and stress. During this time the patient was traveling via car and plane for work, with high stress related to public speaking and work responsibilities on these trips. Each time he would travel and get stressed, his pain would increase. Once he realized the pain was back, he would become more stressed, triggering more pain. We see this often in our pelvic pain patients. We used several strategies to help him through this busy work and travel season:

He purchased a cushion to sit on when he traveled. He actually purchased a travel neck pillow, but used it as a seat cushion. This significantly reduced his pain with travel, and he didn’t have to feel embarrassed carrying around an extra butt cushion. ( Click here for more cushion info )

We did a LOT of pain science education. The patient felt much more in control once he understood how his pain was working and how he could prevent it.

The patient was still cycling pretty consistently, but I encouraged him to be mindful of his pain when choosing when, and how long, to cycle. If he was already in pain, we took cycling off the agenda that day.

We’re now into mid April 2023. The patient has had eight visits of PT, once or twice a week for the past month. He’s been on his last work trip of the year and experienced no pain, and continues to cycle with no pain. He was discharged on April 25, 2023 and did not need to return.

II believe he was so successful because he made it to PT quickly after his pain started. If you’re having any type of pelvic pain the sooner we can see, the better!

Persistent Genital Arousal Disorder (PGAD)

Mon, 29 Jul 2024 20:37:27 GMT

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Persistent genital arousal disorder, or PGAD, is the unwanted sensation of genital arousal that is not resolved with orgasm. It is classified as a pain disorder, not a sexual disorder, and is characterized by throbbing, tingling, pain, tension, or irritation in the genitals with or without spontaneous orgasm. It occurs without sexual interest and is distracting and, at times, debilitating. The underlying cause of PGAD is uncertain, but it can be related to or associated with certain medications, cysts, anxiety, stress, scar tissue, constipation, bladder dysfunction, pudendal nerve dysfunction, surgery, IBS, or a prolonged period of genital irritation. Treatment for PGAD varies, but may include tri-cyclic antidepressants, transcutaneous electrical nerve stimulation, botox injections, hormone or anesthetic creams, and physical therapy.

How can physical/occupational therapy help with something that doesn’t seem… well, related to physical therapy? Pelvic health therapy is extremely beneficial in the treatment of PGAD, because its aim is to calm a sensitized nervous system and the tight muscles that can result. When patients experience PGAD, the nervous system becomes alerted that something is amiss, so the pelvic floor muscles tighten in order to “protect” the area involved. This compounds nerve compression and restricts blood flow to the pelvic structures, leading to trigger points, and an even MORE sensitized nervous system. Pelvic health specialists work with gentle manual techniques to release tight muscles and connective tissue restrictions, as well as instruct patients in how to manage symptoms. This may include leg and pelvic stretches, breathing and postural exercise that maximize neuromuscular function, the use of a device at home to help release tight muscles, or the use of a TENS unit (transcutaneous electrical stimulation) to calm the nerves in the area. Pelvic specialists are also skilled in techniques that address pudendal nerve hypersensitivity and abnormal signaling. Your therapist will address any scar tissue restrictions you may have from endometriosis or abdominal surgeries, as these can contribute to PGAD. Constipation and/or bladder dysfunction will also be discussed and treated.

Many patients with PGAD suffer in silence. Please know that there is help available to you! Yes, there is therapy for that! Let us help relieve the symptoms that are keeping you from enjoying life to its fullest.

Case Study: Nerve Pain Post Cesarean Delivery

Mon, 29 Jul 2024 20:36:57 GMT

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Our patient presented three days after her Cesarean delivery . This was her third C section, and recovery from her previous two had been no problem at all. Since her delivery she was having sharp, stabbing, 10/10 pain in the left lower portion of her abdomen. She went to see her O.B. who cleared her scar and ensured there was no infection, and sent her to us. (The perfect course of action, might I add. The answer here is NOT to "wait and see if the pain goes away.")

The patient admitted she was nervous to go to PT because she could barely walk. She couldn't pick up her new baby girl, could barely go to the bathroom without pain. She was nervous we were going to put her through the ringer in the gym! But luckily she came, and after one visit has cut her pain in half.

The first visit consisted of gentle massage and manual therapy to her abdominal muscles. Because she was only three days post delivery at the time of this visit, she had steri strips on her scar. We typically recommend gentle touch around the scar up to 6 weeks PP. Then once the scar is fully healed and cleared, we can begin touch and gentle massage on the scar. Our PT also encouraged the use of a TENS unit ( Linked here ).

The nerves that supply the abdomen and groin start in the mid/lower spine, wrap around to the front of the body and continue down towards the vulva/groin. This group of nerves are typically the ones to be irritated post cesarean. We can use a TENS unit for pain relief along the pathway of these nerves. In this particular patient, we used TENS electrodes placed as pictured below in white squares: to the midback at the level of your bottom rib, and directly on the area of pain on the abdomen.

The patient was encouraged to use the TENS unit daily, along with ice to her abdomen. You should not use a TENS unit if you have any of the following:

Cardiac pacemaker or difibrillator
Spinal stimulator for pain or otherwise
Numbness or decreased sensation to area where you will place the TENS
Diabetic neuropathy

The patient did this consistently over the weekend and returned the following Monday with signifciantly less pain. Amazing! Her next session we continued massage along her painful areas, and began doing very gentle deep core activation and deep breathing. This will help her low back feel more supported during the day, and will keep that irritated nerve happy with gentle movement and good blood supply. As her pain continues to decrease, we will do less manual therapies and progress her towards core exercise.

The thing we cannot stress enough about this patient is - get here sooner rather than later! Sharp, intense pain is not normal following a Cesarean. If you have any of these symptoms, be sure to call your OB and your physical therapist as soon as it starts. If this patient, or her OB, had let the pain drag on without intervention, it would be a much longer fix.

Osteoporosis

Mon, 29 Jul 2024 20:36:43 GMT

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Did you know that your bones are living, dynamic tissue that can be fed and strengthened? Make no bones about it, our skeleton is an amazing structure that is being transformed day in, day out. Old bone is absorbed via osteoclasts and new bone is created by osteoblasts, creating a strong matrix to support our frame. Osteoporosis and osteopenia develop when bone mineral density decreases. It affects men and women of any age, but the risk increases with age and is most common in Caucasian women during the perimenopausal years. Low bone mass affects 43% of women age 50 or older. Bone loss can occur due to decreasing hormone output, chronic use of steroids or proton-pump inhibitors, smoking, excessive alcohol use, poor diet, and lack of weight bearing exercise.

Bone tissue grows and becomes stronger through exercise and a mineral-rich diet. Eating foods that are naturally high in calcium and minerals, such as dark leafy greens, salmon, and almonds helps support bone health. Weight bearing exercises place graded stress on the bone, stimulating osteoblast cells to synthesize healthy,

flexible bone. Physical therapists can help direct you in your bone-building program by teaching you exercises that challenge the bones in multiple planes and directions. This is important in order to help protect your bones during a fall or injury. If your bones, which are dynamic and flexible, are trained to respond to multiple forces from different directions, you will be much less prone to fracture. Your therapist will also devise an appropriate program to improve your balance and strengthen your postural muscles, both of which are critical in reducing fall risk and fracture potential.

At Advanced Physical Therapy, we have physical therapists who are trained to devise a bone-building, balance-maximizing program specifically for you and your body. Come see us today to live your best life!

Vulvar Health

Mon, 29 Jul 2024 20:36:19 GMT

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Here are a lot of things I wish, as women, we were briefed on at a young age. Bowel and bladder habits (anyone ever teach you the right way to have a bowel movement? Me either.), anatomy and function of our pelvis and reproductive system, how a period works and why we have one, etc. Everything that makes us women is often swept under the rug and spoken about in “hush hush” tones, especially if you went to a school where the Health Education teacher was also the football coach….but I digress.

As a pelvic floor physical therapist I do my best to educate my clients on these exact things, and one of the most common topics that women know little about is vulvar and vaginal hygiene. Almost none of us were told what we should and shouldn’t put on our vaginas, what practices can protect us from urinary tract infections, or what lubricants are safe and healthy for intercourse. Just walking down the self care aisle at Walmart can be so intimidating! Do I need this stuff? Does my vagina really need to smell like lavender chamomile, as the Summer’s Eve products so gracefully describe? The answer for the overwhelming majority of us is no.

Think about your vulva and vaginal canal as a self cleaning oven. The only thing these tissues need to stay clean and healthy is warm water. No body wash, soaps, cleansing wipes, perfumes, douches, none of it. In fact those products can be harmful to our tissue and cause pain, burning, itching, redness, irritation, or all of the above if we aren’t careful. This is because our vaginal canal has a very specific pH level, meaning just the right amount of acidity. When our pH levels are where they should be the healthy bacteria inside the vagina outweigh the bad, resulting in a decreased risk for UTI, yeast, or other infections. Products that are marketed to “balance your vaginal pH” or “refresh the vagina” introduce chemicals that can change your ratio of healthy and harmful bacteria and can lead to all of the negative symptoms listed above. Assuming all of your hormones are within normal limits, your vaginal pH is maintained on it’s own, without any outside help. If you don’t get anything else out of this post, understand that warm water alone can keep your pelvic area clean, healthy, and free of infection.

Best Practices

Vulvar cleansing with warm water only, using the finger tips. Pat dry, do not rub with loofah or towel

Wash clothes and undergarments with unscented detergents. Use double rinsing if your skin is sensitive.

If you must use soap in the shower or bath, use fragrance free pH neutral products

For intercourse, use lubricants without propylene glycol (see below for more lubricant details)

Activities to Avoid

Washing the vulva and perineum with scented soaps

Scrubbing the perineum with rough materials, i.e. loofah, washcloth, towel

Douching of any kind

Washing clothes with scented detergents

As is with most rules, there are always exceptions. In certain populations of women based on their stage of life, products applied to the vulva and vagina can improve symptoms of dryness, irritation, and pain. The two groups I most commonly see are postpartum moms who are breastfeeding, and post menopausal women. In both of these populations the levels of estrogen are typically depleted, which can have a big impact on the vaginal tissue. Things that these women will report include:

Pain with intercourse
Burning or stinging of the outer vulva, just outside of the vagina, or inside the vaginal canal
Burning or stinging with urination
Vaginal dryness or itching
Skin that appears red and irritated

If you are experiencing any of these symptoms, my first suggestion would be to visit your primary care physician or gynecologist. These symptoms can overlap with those of urinary tract infections so ruling that out is an important first step. If your infection is treated with antibiotics but you don’t experience any change, speak with your medical provider again about what you’re experiencing. This is a side note but important nonetheless: If you are postmenopausal or have had a hysterectomy, you still need to have a gynecologist on your medical team! Women need to be screened for female risk factors throughout the entire lifespan, and just because you no longer have periods doesn’t mean you don’t need a gynecologist. Schedule your annual visit today!

Like we said before, women in these stages of life are often experiencing low levels of estrogen. Although hormones are an option, it doesn’t have to be the first or the only option. Non-hormonal vaginal moisturizers have been shown to be just as helpful as vaginal hormones in the post menopausal population. (SOURCE?). If you are experiencing these symptoms and want to try something without hormones, the following are recommended by the World Health Organization for de-estrogenized tissues:

The Safe Seven

Dew Enchante

YES Vaginal Moisturizer

Good Clean Love

Durex Sensilube Hydrating Intimate Gel

YES Water Based Intimate Lubricant

Yes Baby Vaginal-Friendly Lubricant
Yes Baby Sperm-Friendly Lubricant

These products can be used as a personal moisturizer, lubricant for intercourse, or both. Talk to your medical provider about these options to ensure it is safe for you. You’ll notice that none of the popular lubricants are listed - KY, Astroglide, etc. That is because these products do not meet any of the requirements for healthy moisturizers and can actually make your vaginal symptoms worse. If you are buying your lubricant at a local drug store or supermarket, check the labels for these “red flag” words to avoid:

Paraben(s)
Glycerin
Propylene Glycol
Colors

Perfumes

Glycol
Glycerol
Microbicides
Dyes

Alcohols

Every woman’s body is different and responds in varied ways to various products. However, as a general rule for keeping your vulva and vaginal area health - less is more. If you’re experiencing any symptoms of pain or discomfort, talk to a medical provider about your options.

Prostate Health

Mon, 29 Jul 2024 20:35:56 GMT

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Can men have pelvic floor muscle dysfunction too? Yes they can! It is much more common to hear about pelvic dysfunction in women due to pregnancies and deliveries - during this time in a woman’s life she and her providers are much more apt to talk about the health of her pelvis, along with signs and symptoms of dysfunction. As a result we can sometimes forget that men even have a pelvic floor, much less experience symptoms that can lead to a decrease in quality of life.

Pelvic health (or dysfunction) of the male population often shows up like this:

Pelvic pain - Men and women alike can have pain in the pelvis that causes discomfort with sitting, pain with bowel movements, or pain with intercourse.
Constipation - Again, not specific to men but a common problem in both genders. The pelvic floor muscles can often play a role in not being able to empty your bowels.
Urinary urgency and frequency, slow stream, leakage, and/or nocturia (voiding your bladder multiple times through the night) - In men, voiding difficulties can be a sign of prostate enlargement (often referred to as Benign Prostate Hypertrophy) and other prostate issues. The prostate is uniquely male, and is where we will focus the rest of our attention.

The picture above is a male pelvis with the bladder, prostate, and pelvic floor muscles noted. If you locate the bladder and follow it down you see the urethra, the tube that carries the urine from the bladder and out of the penis. Notice that a part of the urethra runs directly through the prostate. This can be a big reason why men with an enlarged prostate have difficulty starting a stream of urine or fully emptying the bladder. This enlargement of the prostate is referred to as Benign Prostate Hypertrophy (BPH) and is fairly common. It occurs in about one quarter of men in their 50s, one third of men in their 60s, and about half of all men 80 years or older.¹

There are various treatment options for BPH but for the purposes of today’s post we’ll focus on a procedure called Transurethral Resection of the Prostate (TURP). This is a surgical procedure that involves a tool being placed into the urethra through the penis and used to trim away pieces of the prostate that are bulging or blocking the urethra.² In men with prostate cancer, they may skip the TURP and undergo complete removal of the prostate gland. Regardless of treatment approach, these procedures can affect your pelvic floor muscles and your ability to maintain control of your bladder. Specifically in the men who have complete prostate removal, urinary incontinence is a very common post surgical symptom. The prostate gland has contributed to bladder control their entire lives, and that stability has been removed. The pelvic floor muscles can become weak as a result of the surgery, leading to urinary leakage with standing, playing golf, exercising, or even at rest. That is where a pelvic floor physical therapist can help!

If you revisit the picture above, you can see the pelvic floor muscles labeled.These muscles can become weak post surgery. If you schedule an appointment for therapy after prostate removal or TURP procedure, your therapist will perform a few things within the first few visits:

Obtain a medical history - you and your therapist will spend plenty of time going through your medical history, talking about your symptoms, and giving you plenty of education about pelvic floor PT. By the end of your first session you should feel that all of your questions have been answered!
Perform an assessment of the pelvic floor muscles - in order for your therapist to decide if your muscles are playing a role in your symptoms, an internal rectal assessment is performed. This will be similar to the prostate exam you would have likely received from your physician. Your therapist will test the strength of your muscles, their endurance, and coordination.
Assign an exercise program - depending on the current state of your pelvic floor muscles, the therapist will give you exercises to perform at home. This can involve Kegel exercises, muscle relaxation, or a combination of both. Your program will likely involve exercise for your core muscles too, as they are closely related to your pelvic floor.

If you are experiencing any of the symptoms noted but have not seen a medical provider, think about seeking help from your primary care physician or a urologist. He or she will be able to rule in, or out, any prostate dysfunction and point you in the right direction for possible treatment. Not sure if you’re having the symptoms necessary to seek help? Follow the link here for a prostate questionnaire.³

McVary, Kevin MD. BPH: Epidemiology and Comorbidities. American Journal of Managed Care. April 2006
Transurethral Resection of the Prostate. www.johnshopkins.org/healthlibrary.
www.urologix.com. BPH Symptoms Score Questionnaire.
Filocamo et al. Effectiveness of Early Pelvic Floor Rehabilitation Treatment for Post-Prostatectomy Incontinence. European Urology. November 2005
Urology Care Foundation. Benign Prostatic Hyperplasia. www.urologyhealth.org

Pelvic Organ Prolapse

Mon, 29 Jul 2024 20:35:38 GMT

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Pelvic organ prolapse (POP). The all too familiar sensation for women that their bladder or uterus is “falling out” of their bodies. That heavy, bulging sensation in the pelvis that’s often accompanied by abdominal pain, urinary incontinence, and an overall feeling of pressure and bother. What is this all about?! What causes it, what are the risk factors, and how can you avoid it?

As a PT my first educational point is always anatomy. We can’t fully understand abnormal if we don’t have an idea of normal, right? In the picture below, the top image is a woman’s pelvis showing all the organs in the correct place; the bladder is situated directly behind the pubic bone and in front of the uterus, and the rectum is in its’ place behind the uterus. All of these organs are supported above by ligaments and fascial connections, and below by your pelvic floor muscles (neither are pictured here). In the three images below, you can see examples of the three types of POP: cystocele (prolapse of the bladder), rectocele (prolapse of the rectum), and apical prolapse (prolapse of the uterus).

POP is defined as the descent of one or more of the pelvic structures (bladder, uterus, rectum, or vagina) from the normal anatomic location or through the vaginal opening. What causes this descent, or drop, of the pelvic organs? POP is often associated with pregnancy and vaginal deliveries due to the immense stretch the pelvic floor muscles go through during pregnancy and the increase in intra-abdominal pressure that is created with pushing during delivery. Your risk for POP is higher if your child is delivered vaginally, but women who have a Cesarean section are still at risk. Hysterectomy, pelvic surgery, obesity, chronic cough or constipation, and/or repeated heavy lifting are also a few known risk factors for POP (1, 2). When we have an increase in pressure through our abdomen, this puts stress on the ligaments that help to support our pelvic organs. As time passes and we continue to put that pressure on the organs, the ligaments can become stretched and lose the ability to hold the organs in place. As a result, you can have the feeling that something is “falling out,” that something just isn’t right within the pelvis. You might even be able to see something coming out of the vagina that makes it uncomfortable to walk, stand, or exercise.

Because prolapse can involve any or all of the pelvic organs, women with POP may have any of the following bladder, bowel, and/or sexual complaints:

Inability to fully empty the bowel or the bladder - Ever go to the bathroom, void your bladder, and 20 minutes later feel like you could go again? This could be due to the fallen position of your bladder, making it difficult for you to fully empty.
Urinary and/or fecal leakage - If your bladder or rectum is not in the correct place, it can be difficult to fully empty. When there is residual stool or urine present, it can leak out during laughing, coughing, sneezing, or exercise. We often see a connection between POP and weak PFM, and when our PFM are weak we can have leakage.
Discomfort with intercourse - in cases of POP, women have tissue descended down through the vaginal canal that is not supposed to be there. This tissue can cause an increase in pressure, discomfort, or even pain with intercourse.
Pain or pressure in the low back and abdomen - patients with POP often describe a heaviness, pressure, and general discomfort in the abdomen. When your pelvic organs are descended further than they should be, this puts pressure on the areas to which the organs attach - your abdominal wall and the bones of your lower spine/sacral area.

So, what can be done for this?

Pelvic health physical therapy for POP targets a few things:

First, we work on strengthening the pelvic floor muscles. Since these muscles are located at the bottom of your pelvis, just underneath all of these internal organs, they serve as a big support system for your bladder, uterus, and rectum. If the ligaments that help to maintain stability are loose, it’s even more important that the pelvic floor muscles are strong enough to provide dynamic support throughout your day. Often times women have been experiencing symptoms of bulging or heaviness in the pelvis for awhile and their pelvic floor muscles have been working overtime to support the prolapse, resulting in a pelvic floor that is overactive or too tight. In this case, we would focus on teaching you to relax your muscles, and then move on to strengthening. Not sure if your muscles are too tight or too loose? See a pelvic health PT!
Another big component of prolapse management is core stabilization and control of intra-abdominal pressure (IAP). The majority of risk factors for POP involve some sort of increase in the pressure throughout your abdomen and pelvis: pregnancy, delivery, increased weight, heavy weight lifting, chronic cough or straining with bowel movements, etc. We will naturally do things throughout our day that increase this pressure, but if our deep core muscles are not coordinated and strong enough to equally distribute that pressure, it can be directed straight down onto the pelvic organs and make the prolapse worse. For full understanding of this, sit up straight in your chair, close your mouth, and push down into your pelvis as if you’re trying to have a bowel movement or deliver a baby vaginally. Can you feel all of that pressure going straight downwards? That is what we want to avoid, specifically for women with prolapse but for all women! This kind of pressure is not beneficial for your pelvic floor, abdomen, or pelvis. In the picture below, you can see the four muscles of our “deep core.” Each of these muscles will be strengthened with therapy so they are able to evenly distribute that IAP throughout your day. See references at the end of the post for more details about your core and how to manage it (4).

Posture is also an important component of care. The ideal position of your core involves getting your rib cage “stacked” on top of your pelvis, without too much curve or flattening of your lower back. When the bones of our pelvis and spine are aligned just right, the muscles that attach to them (our deep core muscles) are able to function at their very best.

If you’re curious about whether or not you’re experiencing symptoms of POP, see the questionnaire below for more detailed questions (3). Pelvic floor PT is a great first step if you’re experiencing any symptoms of pelvic organ prolapse, as it carries very few risks. If you finish your therapy and are still having symptoms, there are interventions from other members of your medical team that can be beneficial, including pessary placement or surgery. Always feel free to talk to your medical provider about the symptoms you are having and the options available!

Iglesia CB 1, Smithling KR . Pelvic Organ Prolapse. Am Fam Physician. 2017 Aug 1;96(3):179-185.
Gyhagen M, Bullarbo M, Nielsen T, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primipara after vaginal or cesarean delivery. BJOG 2012; DOI : 10.1111/1471-0528.12020.
Pelvic Floor Distress Inventory. https://legacybhsapps.beaumont.edu/Global/Urology/WUC_Pelvic_Floor_Questionnaire.PDF/

4. Julie Wiebe, PT. Dear Coach. http://www.juliewiebept.com/alignment/dear-coach/

Pelvic Therapy and Gynecological Cancer

Mon, 29 Jul 2024 20:35:24 GMT

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When someone hears the diagnosis of cancer, the medical model immediately presents your treatment options and prognosis. Each patient is different, but we can imagine the brain goes “fight or flight” and pushes through whatever treatment is needed in order to beat the cancer. Often, very little thought is given to “life after cancer.”

What symptoms will I have?

Will I have to get treatment for symptoms caused by my cancer treatment?

When will this end?

Will I ever be “normal” again?

These questions are valid, and you may not have someone on your healthcare team who is readily available to answer them. They can be difficult to ask, especially in women who have survived gynecological cancers, or cancer of the uterus, ovaries, breast, or cervix. Some of the biggest complaints following treatment of GYN cancers include pelvic pain, painful sex, urinary urgency and urinary leakage. Imagine just finishing your chemotherapy or radiation and then having to deal with that!

A recent study followed 31 women who had finished their cancer treatment at least three months prior. They were cancer free, but were complaining of painful sex, decreased sexual desire and urinary symptoms. The participants attended 12 visits of pelvic floor physical therapy, one visit per week. The study states,

“At each session, the physical therapist provided information, advice and support to women. She explained the underlying mechanisms of chronic pain experienced during sexual intercourse after gynecological cancer including the role of the pelvic floor muscles and how the treatment could help to reduce the pain. She gave additional information about how to manage chronic pain and other pelvic floor disorder symptoms (e.g., bladder training). The use of relaxation techniques using deep breathing as well as the application of vaginal lubricants and moisturizers were encouraged. The physical therapist also helped the participants gain more knowledge about sexual functioning (i.e., physiology of desire, excitation and orgasm) and guided them into resuming non-painful sexual activities with their partners.”

They continued,

“At each session, manual therapy techniques (i.e., stretching, myofascial release and tissue desensitization) and pelvic floor muscle exercises with electromyography biofeedback (i.e., relaxation, motor control, strength and endurance) using a small intra-vaginal probe were used. Women were also asked to perform home exercises resembling those performed under supervision five times per week as well as auto-insertion exercises with a finger or graded vaginal dilator in addition to desensitization techniques three times per week.”

In a nutshell, the PTs used biofeedback, muscle stretching, relaxation and breathing exercises, vaginal dilators, and lots of education during their treatment sessions. The combination of these interventions would look different depending on the patient but, to an extent, all would be used.

Did it work?

This is a table showing what the participants reported. The left column describes their report in terms of how their physical bodies felt, and the right lists improvements in psychological health.

We would say absolutely yes , physical therapy helped significantly!

The authors stated “All participants reported experiencing less pain during intercourse, with several stating having no pain at all since the end of the PFPT........the vast majority mentioned their vagina being less dry and more naturally lubricated during sexual activities. Among other things, several women emphasized not needing to use vaginal products anymore and reported being less stressed and more interested in engaging in sexual activities.”

Some participants stated:

“All the exercises [contraction and stretching] I had done and what the physical therapist had done removed the tension and loosened me up. It felt good. Penetration was easier.” –C01

“It helped me to understand how my body reacted to a lot of things, to understand that I was not alone and it helped me to accept myself and accept living my sex life in a different way. It [the treatment] allowed us to make different connections. There is a lot, really a lot of affection. It starts slowly, and, in the end, it becomes intense. This is what is new, this is what we learned.” –C17B

Half of the participants experienced either stress urinary incontinence, urgency urinary incontinence or symptoms of urinary urgency before the study. All women reported significant improvements following PFPT.

Another participant stated:

“All the exercises, the squeezing and all that helped. You squeeze and it calms your bladder. I didn’t think it would work. Listen, I can even hold my urine when I go to the bathroom. . . Before, when I saw the toilet, I had to run and when I saw the toilet bowl, I leaked two or three drops. But now, I am able to hold it. I know what to do.” –C10

Entering cancer treatment can be very scary. It can alter our sense of self. One of the study participants described it perfectly,

“After cancer treatments, you feel diminished. Will it come back as before? I was starting to be afraid. With physical therapy, you feel less diminished. It seemed as if it was finally possible that things could get better. When I got into the program, it was another story as I realized it was possible to improve, and it was much less upsetting, less scary. It’s because we found where it hurt most. It’s about understanding. . . It’s partly confidence, partly the fear that’s gone.”–C124

If you have pelvic floor symptoms of any kind following your cancer treatment, know there is a team waiting to help you.

Chronic Pelvic Pain

Mon, 29 Jul 2024 20:35:06 GMT

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We’ve all heard of asthma, right? This respiratory condition affects 8% of Americans, and almost everyone knows someone who has it.¹ Depending on the type of asthma, it can lead to a significant decrease in activity tolerance and overall quality of life. Although asthma is important and affects a lot of people, it doesn’t have much to do with pelvic health. So why are we talking about it?

Pelvic pain is similar to asthma in that depending on the type, it can cause a very significant shift in your ability to perform daily responsibilities and decrease quality of life. The prevalence of pelvic pain doubles that of asthma. One study noted 25% of women experience this at some point in their lives, and another reports 8% prevalence in men.² ³

Your pelvis begins just below your belly button, and ends at the bottom of the gluteal folds (just below your gluteal muscles). Within this area of the body we have all kinds of muscles, bones, nerves, arteries, and organs that could potentially contribute to pain - uterus and ovaries, bladder, colon, sacroiliac joint, abdominal muscles, prostate, sciatic nerve, just to name a few. You can see in the pictures below just how involved the pelvis really is!

Dysfunction in any of the structures within the pelvis can cause pain, which can make diagnosing the core of the problem difficult. Often, we see clients who have had this pelvic pain for years, seen a multitude of providers, tried every treatment option in the book, to no avail. It can be extremely troubling, disheartening, and defeating to have constant pain with no answer as to where it’s coming from.

So, what causes pelvic pain? According to a paper written by Dr. Fred Howard in 2011, the leading causes of pelvic pain in women include pelvic nerve neuralgia, myofascial pain and trigger points, Irritable Bowel Syndrome, Interstitial Cystitis, and endometriosis.4 We will talk in detail about myofascial (muscle) pain and trigger points later in this post. See the link in reference list for the complete list of diagnoses and their definitions. If you have ever been diagnosed with any one of these, it is likely that you’re experiencing pelvic pain. That does not mean that if you haven’t received a diagnosis like the ones listed above, that you don’t have pelvic pain. If you are having pain in the pelvic area at all, that warrants seeking help!

When clients come in with a main complaint of pelvic pain, we often hear them report the same kinds of things. Some of the most common reports include:

“I have pain in my buttock and around my vaginal area if I sit for longer than 30 minutes.”
“Sex is okay, but sometimes it feels like my partner is hitting a bruise when we try certain positions.”
“My periods have always been really heavy and painful, and I’ve never been able to insert a tampon without pain.”
“My doctor diagnosed me with chronic prostatitis and I’ve had the surgery, but my pain never went away.”
“I have constant pain in my abdomen, and I’ve noticed it gets worse when I eat my favorite spicy meal or drink a Diet Coke.”
“I’ve struggled with constipation for years, and lately it’s started to hurt when I have bowel movements.”
I’m waking up 5 or 6 times a night to go to the bathroom. It feel like I have the urge to go all day long!”

Have you ever said or thought these things? Have you tried antibiotics, elimination diets, MRI and x rays, injections, and more to get rid of that nagging pain between your belly and your bum? Or maybe you have just started experiencing this type of pain and have chalked it up to the aging process and don’t plan on seeking help. Whatever your personal history may be, pelvic pain is common but never normal. Pelvic health physical therapy is one option that you may have never heard of, but that offers relief to so many people!

The great thing about seeing a pelvic health PT is that you can almost guarantee we’ve heard all of your symptoms before, and have treated hundreds of other people just like you. If you’ve read any of the previous blogs on this page, you’re familiar with the set of muscles at the bottom of your pelvis, so rightly named the “pelvic floor muscles (PFM)”. In patients with pelvic pain these muscles are often too tight and are holding tension. Picture this: you just had the most stressful day at work. The to-do list is longer than ever, your cubicle neighbor is getting on your nerves, and you and your boss get into a disagreement. You finally head home at the end of the day only to be greeted with a sink full of dirty dishes, two kids waiting on dinner to be cooked, and the house has to be cleaned for the dinner party you’re hosting tomorrow night. Not to mention you have a work deadline, due tomorrow. Sound familiar? Maybe this doesn’t describe your current season of life, but we all know the feeling of being stressed and feeling like there just isn’t enough time in the day. When we become stressed, our body reacts and we get tense. We’ve all had those days when we get home and it feels like our shoulders are up to our ears and we just can’t seem to relax. Oddly enough, that small group of PFM that we can’t even see (and often ignore) can carry tension in the same way our shoulder and neck muscles do. When these muscles stay in a tensed, contracted state for long periods of time, they can forget how to relax. When that happens less blood flow is delivered to the muscles, they aren’t able to get the oxygen and nutrients they need, and you begin to experience pain. We don’t always know why our PFM tense up and stay there, but there are some risk factors that can lead to an overactive pelvic floor: stress, pregnancy and delivery, pelvic surgery, and/or sexual abuse.5 Up to 25% of all women have experienced some type of sexual abuse, which often has implications for pelvic, and overall, health. In one study 17% of the women who visited an OBGYN clinic reported sexual abuse in their past, and in the study analysis chronic pelvic pain was significantly associated with a history of abuse .6

Regardless of cause, these muscles need to learn how to release, relax, and let go of the tension they’ve been holding on to, but this can be harder than it sounds. A pelvic floor physical therapist is an expert at assessing whether or not your PFM are too tight, and deciding which treatment options are best suited for you. Here are some things a pelvic floor PT may do to help with your pelvic pain:

Assess your posture - our PFM work best when we are in a neutral posture and our core is most stable. Your PT can teach you how to find that posture and how to maintain it.
Assess your leg, abdominal, and gluteal muscles - sometimes the muscles surrounding your pelvis get too tense and irritable as well. Your therapist can massage these tense spots out, resulting in a decrease in pain.
Teach you to breath - sounds easy, right? Well, not always. Your posture and breath are intimately related, as are your breathing diaphragm and the PFM. With a good foundation in place for breathing, it can make relaxation a much easier task.
Relaxing - your therapist can give you tips and tricks on how to implement relaxation and stress relief into your daily routine, and make sure that your bones and muscles are in the right “state of mind” to aid that relaxation.
Assess your PFM - Pelvic health PTs have the unique ability to assess your muscles on the inside of your pelvis, similar to a routine pelvic exam (minus the stirrups and speculums). This is one of the best ways to get to the root of your pain, and decide if the muscles are too tensed. If you are having pain and an internal exam seems out of the question for you, there are plenty of other ways to help. See the “FAQs” blog post for more detail about the internal muscle assessment.
Massage and stretching for the PFM - your therapist is able to access these muscles and find “trigger points” that can contribute to pain. With very gentle pressure and light stretching to these muscles, your trigger points can be resolved and blood flow restored to the muscles, giving them the ability to fully relax again.
Other stretches and exercise programs - when people think of pelvic health PT they mostly think of Kegels, or repetitive contraction and relaxation of the PFM in order to strengthen them. For someone with true pelvic pain Kegels are not the answer , especially in the beginning. Your therapist will first give you stretches that help your PFM fully relax. Once you’ve learned to establish a healthy resting tone, then it is safe to begin strengthening the muscles with Kegels. It is essential that you have a therapist to give you the right exercises at the right time, in order to achieve full resolution of symptoms.

Pelvic pain can be confusing and scary, but there is help. Pelvic health physical therapists are here to be a part of your medical team, and to work alongside your doctors to make sure you live a healthy and happy life.

Center for Disease Control and Prevention. Trends in Asthma Prevalence, Health Care Use, and Mortality in the United States. 2012
Ahangari, A. Prevalence of Chronic Pelvic Pain Among Women: An Updated Review. Pain Physician. 2014
Ferris et al. National Prevalence of Urogenital Pain and Prostatitis-Like Symptoms in Australian Men Using the NIH Prostatitis Index. BJUI. 2009 Apr 8.
Howard F MD, Barberei R MD, Faulk S MD. Causes of Chronic Pelvic Pain in Women. 2011.
Faubion S, Shuster L, Bharucha A. Recognition and Management of Nonrelaxing Pelvic Floor Dysfunction. Mayo Clin. Proc. 2012.
Chichowski et al. Sexual Abuse History and Pelvic Floor Disorders in Women. South Med Journal. 2013.
www.pelvicpain.org

Periods 101

Mon, 29 Jul 2024 20:34:49 GMT

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Raise your hand if you never got the “period” talk? If you did, we’re happy for you! You’re in the minority, as most of us were handed a book or an instruction pamphlet on a tampon box and told “Good luck.”

We’re here to give you the information we all need but rarely get. Let’s break it down.

What is a menstrual cycle?

It is the process of our bodies preparing to become pregnant. We count our cycles over a 28 day time period. Over 28 days (give or take a few days) our bodies go through three phases: Follicular, Ovulation, + Luteal.

Follicular phase is day 1-13 of the month, and is marked by the first day of vaginal bleeding. Vaginal bleeding occurs when the uterus sheds its lining, signifying that a pregnancy did not occur. After bleeding has finished, your body begins to prepare an egg for ovulation

Ovulation is the release of an egg to meet a sperm and become fertilized. This usually occurs around day 14 of the cycle, or 14 days after the first day of bleeding.

The luteal phase is spent preparing the uterus for the embryo. If you become pregnant, the luteal phase will continue and you will not have any vaginal bleeding. If you do not become pregnant, the follicular phase begins and vaginal bleeding will start, signifying Day 1 of your next cycle.

The health of a woman’s cycle is considered her fifth vital sign, and can be an incredibly helpful insight into how her body is performing. At the clinic we see women all the time with long, heavy, painful periods. Since we mostly get our period information from our health teacher in high school (eye roll emoji) or the internet, it’s hard to know what is normal and what isn’t. Especially if your mom, aunt, or grandma also have problems with their cycles, it can feel like what you’re experiencing is the norm.

So…what is normal?

Your full cycle (from the first day of bleeding to the next first day bleeding) could be between 21 - 40 days and be considered normal.
The amount of time you spend with active bleeding can be anywhere between 3 - 7 days. According to the CDC, if you bleed for longer than 7 days that is considered abnormal. If you need to change your tampon or pad after less than 2 hours or you pass clots the size of a quarter or larger, that is heavy bleeding and you should see a doctor.
If your period symptoms keep you from going to work, school, or social activities you are experiencing an abnormal period . Period pain should not make you bedridden, or cause you to need strong prescription pain medication. If this is you, schedule an appointment with your gynecologist.

When it comes to period management, there is no wrong choice. Options include tampons, pads, or menstrual cups. Choose whatever option makes you feel most comfortable, and handles your amount of bleeding best.

Pain while placing or removing menstrual products is not normal. If you have anxiety or pain surrounding your menstrual care, talk with your doctor and see a pelvic floor therapist. It does not have to be your normal!

The History of Pelvic Health Therapy

Mon, 29 Jul 2024 20:34:35 GMT

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It's Not A Pelvic Revolution, It's a Renaissance

What's a Kegel? Most people think that it is squeezing the muscles of their pelvic floor, which surround the urethra, vagina, and anal openings for exercise. Most people believe that these exercises are relatively new, and have been around only since 1948 when Dr. Arnold Kegel coined the term “Kegel exercise.” Those people would be wrong! The idea of exercising the muscles of the pelvis have been present in recorded history for at least the last 6,000 years. The ancient peoples of China, India, Greece, and Rome all knew how essential a strong pelvic floor was to health and wellness.³ In fact, it was viewed as so important to the ancient Greeks that courtesans would use their muscles to split clay phalluses as a demonstration of their pelvic floor muscle strength.⁴ Surprised? So was I. You see, we aren’t experiencing a pelvic health revolution, we are experiencing a pelvic health renaissance.

Sometime in the interim we landed in the pelvic dark ages when talking about the pelvis and the bodily functions that take place there became taboo. People were treated like they didn’t have pelvises. Women didn’t pee or poop, and they certainly didn’t leak! To see a glimmer of the light we have to fast forward to 1936 when Margaret Morris, a UK physical therapist began describing and teaching pelvic exercise to prevent and treat urinary incontinence, a full twelve years before Dr. Kegel arrived on the scene to claim all the glory.³

Today you most often hear of Kegels being prescribed after pregnancy to deal with “leaking” that is a “normal” part of motherhood. The instructions may range from a description from a doctor or nurse saying, “squeeze like you are trying to stop from urinating,” to a pamphlet explaining how to perform them with written instructions. But, Kegels aren’t just for when we’ve sprung a leak, they do so, so much more. And, here is the kicker, they only work, as long as they are performed correctly and at the correct time. Therein lies the problem: 50% of symptomatic women do not perform Kegels correctly when given verbal cues alone.³

What if I told you that 25-35% of people in the United States suffer from urinary incontinence?¹ Or that 50% of pregnant women will suffer from some kind of low back pain during their pregnancy?² What if these two problems were really the same problem? A problem with the control and strength of the deepest muscles in our body. As we continue to come out of the pelvic dark ages, these topics can still feel like “pelvic taboo” and aren’t discussed with the openness and honesty they deserve. The result? People across the country of all ages and genders living with debilitating symptoms in secret. If you’re reading this and thinking “I thought I was the only one!,” you aren’t alone. The good news? There is help! Help that is virtually risk free, beneficial for your overall health, and can put you on the path for complete resolution of your symptoms.

This is where a specialized pelvic health physical therapist can make all of the difference. We specialize in the small group of muscles at the base of the pelvis, often referred to as the “pelvic floor muscles” or the “pelvic diaphragm.” When you perform a Kegel, you are contracting these muscles. A pelvic health physical therapist can help you perform a pelvic floor muscle contraction correctly, and teach you how to translate this new skill to all of your daily activities: walking, standing, lifting, and exercise. On the flip side of the coin, Kegel contractions are not the answer for everybody. If you are having pain with intercourse or gynecological exams, constipation, abdominal pain, or even urinary leakage, performing Kegels routinely may be detrimental. This is another reason why seeing a pelvic health physical therapist can be so beneficial - he or she will be able to prescribe an exercise routine that fits your specific needs.

Pelvic floor physical therapy can be beneficial for men and women for a host of diagnoses, some of the most common being:

Urinary and fecal incontinence
Do you ever leak urine, gas, or stool when you cough or laugh? What about when you’re headed to the bathroom and you just can’t quite get there soon enough? Leakage is very common but never normal, regardless of the amount.
Constipation
Are your bowel movements few and far between? Is your stool too hard, making it difficult to pass? Have you gone a week or more without having a bowel movement? There are many factors that contribute to constipation, and your pelvic floor muscles are major players.
Pain with intercourse
Is any part of your sexual experience painful? This is a very common report in women and men throughout the lifespan but again, it is not normal. If you’re having pain with tampon insertion, intercourse, gynecological or prostate exams, or sexual climax, it could be due to your pelvic floor muscles.
Cesarean and episiotomy scar tissue
Delivery of a baby, no matter how it is delivered, can take its’ toll on the mother. If you had a C-section, you will have scar tissue around the area of the incision. If this tissue is not moved and worked on after your delivery, it can become stiff and painful. The same is true if your doctor had to perform an episiotomy, or a small incision around the vaginal canal, to help deliver your baby. This tissue can also become painful making it difficult to empty your bowel and bladder, have sex, or sit for a long time. This tissue can also be worked on to promote healing and decrease pain.
Pelvic Organ Prolapse
Have you ever had the feeling that something in the pelvis just doesn’t feel right? That something is hanging a little lower than it should? Sometimes women will report a feeling that their bladder is falling out of their pelvis! This is called pelvic organ prolapse, and is extremely common. Risk factors include increased BMI, 2 or greater pregnancies/deliveries, and chronic constipation. Your pelvic floor muscles contribute to the support of your organs and strengthening these muscles can help in cases of prolapse.

If you are experiencing any of these symptoms you are not alone, and help is available! Stay tuned to upcoming blog posts for details about how pelvic floor physical therapy can help you. Join the Pelvic Renaissance and benefit from the knowledge that has been around for millenia; the muscles at the base of our pelvis are important and we have the power to change them.

Nittis, Victor W. The Prevalence of Urinary Incontinence. Rev Urol . 2001; 3(Suppl 1): S2–S6.
Katonis et al. Pregnancy Related Low Back Pain. Hippokratia . 2011 Jul-Sep; 15(3): 205–210.
Price, Natalia, Rehana Dawood, and Simon R. Jackson. "Pelvic floor exercise for urinary incontinence: a systematic literature review." Maturitas 67.4 (2010): 309-315.
Blackledge C. 48. The story of V: A Natural History of Female Sexuality. Piscataway, NJ: Rutgers University Press; 2004.
Bump et al. Assessment of Kegel Pelvic Muscle Exercise Performance After Brief Verbal Instruction Am J Obstet Gynecol. 1991 Aug;165(2):322-7; discussion 327-9.
Common….Not Normal. Claire Baker. www.youtube.com

Infertility and Pelvic Health Therapy

Mon, 29 Jul 2024 20:34:05 GMT

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Infertility is not within our scope as PTs and OTs. We don’t claim to increase your fertility by coming to treatment. However…

We do see many women who have chronic pelvic pain due to diagnoses often associated with infertility. These can include:

Endometriosis
Polycystic Ovarian Syndrome (PCOS)
Young female athletes (specifically those in sports with a focus on body image)

Let’s break these down individually. These are extremely complex diagnoses that each warrant their own blog post alone! This is just a (very) broad overview.

Endometriosis is a disease in which endometrium, the lining of the uterus, is present outside of the uterus. One out of every ten women receive an endometriosis diagnosis. Endometrium can be found on the rectum, bladder, ovaries, even the diaphragm, and can cause tremendous amounts of pain. One of the most common ways women discover they have endometriosis is infertility. Scarring throughout the reproductive tract can make it difficult to conceive.

PCOS is a disorder in which the ovaries produce more androgens (male sex hormones) than normal. Women with PCOS can present with small cysts on the ovaries, but some may not. On the other hand, a woman could have an ovarian cyst but not have the diagnosis of PCOS. Symptoms can include irregular periods, excessive hair growth, weight gain, acne, insulin resistance, and infertility. The imbalance in hormone production leads to irregular periods, which in turn can cause difficulty conceiving.

The young female athlete group presents a very specific reason for possible infertility - Relative Energy Deficiency Syndrome (RED-S). RED-S occurs when our calorie intake cannot keep up with our energy output. When we are in a calorie deficient state, our body will use whatever energy it has for vital functions → heart and lungs, brain and nervous system, and musculoskeletal system. Our GI and reproductive systems can be left off the priority list. To say it plainly, our body will not prioritize ovulation, menses, and conception when it is starving for nutrition. Body fat of less than 15% has been shown to possibly cause complications with fertility. This can also lead to what we call the female athlete tetrad: anorexia, osteoporosis, amenorrhea (no periods), and changes in cardiovascular health.

How does all of this relate to physical/occupational therapy? We give education regarding exercise, diet, and lifestyle modifications to decrease pelvic pain associated. If you need help managing your chronic pelvic pain, PT/OT pelvic floor therapy is the perfect place to start.

Thirty minutes of moderate intensity exercise daily is supported in the research for the chronic pelvic pain population. Because those with PCOS are often resistant to insulin, high intensity interval training (HIIT) has been shown to be very beneficial. Research recommendation for PCOS HIIT are as follows:

HIIT training for 7-12 minutes at 45s high intensity, 20s lower intensity
3x/week, alternating HIIT with yoga

It’s an age old tale that stress increases chronic pelvic pain. We know this, but it can be difficult to manage on your own. Your PT/OT should be asking about your stress level and your coping mechanisms, and help you to nail down what works best for you. Things to consider:

What are your stress levels related to pain, job, family, relationship, etc?
What are your coping mechanisms?
Try introducing mindfulness techniques: meditation, breathing, apps can be helpful (Headspace, Calm, Insight Timer, Universal Breathing)
Consider speaking with a trained counselor if stress feels unmanageable.

Sleep feels hard to come by these days for a number of reasons. We know that our bodies are healing and repairing while we sleep, so it’s imperative that we get plenty of rest. Things to consider:

Going to bed at the same time every night helps our brain shift from day to night.
Get 5-10 minutes of sunlight as soon as you wake up
Avoid exercise and electronics from between the hours of 10 pm - 4 am.
Use your bedroom for sex and sleep only
Talk with your doctor about supplements for sleep

As we study more on the GI system, we realize just how much it’s responsible for. Our nutrition helps get the body what it needs, and the gut helps to get rid of what we don’t need. Yoga and daily walks have been shown to be beneficial for those with constipation, pelvic pain, and IBS. A well rounded diet has also been extensively studied and shows great benefit for those with any chronic condition. Options to consider:

Dark green leafy vegetables
Help stimulate the liver to aid in hormone synthesis
High levels of fiber
Bright colored berries and other fruits provide high levels of Vitamin C
Overall, a Mediterranean style diet covers a lot of these recommendations.
Avoid certain foods that are high in pesticide use, as pesticides are thought to be “hormone disruptors”
“Dirty Dozen” is off hand name for fruits and veggies that have high pesticide use

FAQ about Pelvic Health Therapy

Mon, 29 Jul 2024 20:33:48 GMT

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We’ve all had that one doctor’s appointment that we’d do just about anything to avoid. Maybe it’s a dermatologist appointment to get that mole checked out, or the yearly mammogram, or even your annual check up with your primary care physician. What is it about these appointments that give us that anxious, nervous, “pit in my stomach” feeling? For most of us, I believe it’s the feeling of the unknown, the unanswered questions, the “what ifs” that can really deter us from getting the medical care we need.

This is especially true in the world of pelvic health physical therapy. Imagine this: You’ve been having occasional urinary leakage when your husband makes you laugh really hard. It’s not too bothersome, but you mention it to your OBGYN and he or she refers you to physical therapy. You think, “Physical therapy? I thought that was only for low back pain and total knee replacements?” But you trust your doctor so you make the appointment anyway. As your consultation looms, you begin to think of all the reasons you DON’T want to do this:

I don’t even talk about this with my partner! Now I have to go talk about my bowel and bladder with a total stranger?
My friend from college did this once and said they did an internal pelvic exam. What?!
I mentioned this problem to other medical providers and was dismissed. What is the point of putting myself through that again?
My main complaint is pain. What if they want to do an examination that will make my pain worse?
My doctor said they might use some kind of vaginal electrode for treatment. That freaks me out a little bit!

And the list goes on, all of which are completely understandable. This post is here to answer the most frequently asked questions about pelvic health PT, in hopes to ease your mind and give you the confidence to seek treatment.

FAQs About Pelvic Health Physical Therapy

What will happen at my first appointment?
Your first visit with a pelvic health PT will typically consist of paperwork that gives us an idea of your main complaints (urinary leakage, pain with intercourse, constipation, etc). Once you complete these, you will have a 1 on 1 consultation with your PT. This will involve us asking questions about your bowel, bladder, and sexual health. Your PT will also give education on pelvic anatomy and the pelvic floor muscles, so that you have a better understanding of your specific condition and how PT can help. In most cases, no examination is performed on the first visit. We like to meet you, build rapport, and make sure all of your questions are answered prior to any exam.

Tell me about this pelvic exam.
As physical therapists we are experts in the musculoskeletal system, meaning we treat the muscles and bones of your body. In pelvic health practice, we are able to assess the muscles of your pelvic floor, which are located at the bottom of your pelvis. Because these muscles are located on the inside of our bodies, the best way to assess them is an internal pelvic exam. We do not use a speculum or stirrups during our exams, and we only perform the exam with your complete consent and understanding of all the steps included. Most clients, if not all, will benefit from this exam as it tells us exactly what is going on with your muscles. However, we see plenty of men and women who are experiencing pelvic pain. Would we still perform an exam if it’s painful? In short, it depends.
If I am in pain, will you still do an exam?
We see a lot of men and women with pelvic pain, pain with intercourse, abdominal pain, and many other diagnoses that are rooted in pain. When someone is having pain in these areas, the pelvic floor muscles are often over-active, or too tight. Think about it this way: when we get stressed we tend to carry tension in the muscles of our neck and shoulders. After a while, it becomes difficult for these muscles to fully relax and they can become sore, even forming “trigger points” within the muscle. Our pelvic floor muscles can carry tension in the same way, and it can become difficult for them to fully relax as they should. These muscles can become tense for many reasons: stress, pregnancy and delivery, or pelvic organ prolapse to name just a few. Our goal is to teach you to become aware of these muscles and how to relax them voluntarily.
Everyone’s pain is different, and everyone’s tolerance to a pelvic floor muscle assessment is different. An internal pelvic exam can give us valuable information on the origins of your pain. However, it is very important that your brain begins to have positive, pain free experiences related to your pelvis and your pelvic floor muscles. So if you come to your appointment for an examination and that exam is too painful for you, it is in your best interest that it not be performed until you and your muscles are ready. Your therapist may perform an external examination of the muscles, assess the muscles of your hips, legs, and abdomen, or teach you meditative relaxation techniques. There are a number of things we can do to help you relax these muscles outside of an internal exam, and we can always save the exam for later once your pain has decreased.
Will I always see the same physical therapist for each visit?
Due to the sensitive nature of topics discussed during your initial consultation and overall treatment of the PFM, you will always work with the same therapist every single visit. It is so important to build a trusting and positive relationship with your therapist so that you’re able to share details of your signs and symptoms as you progress. This type of relationship can only be reached if you attend each treatment session with the same therapist. This also alleviates the anxiety that can come with sharing your symptoms with multiple people.
Do you treat men and women?
Yes! Men and women alike have pelvic floor muscles, even though their anatomy is slightly different. It is traditionally thought that women are the only ones who struggle with dysfunction of the pelvis, but men can also experience urinary leakage, pain with intercourse, pain with sitting, and constipation. We can still treat these conditions in men, we just access their PFM with a rectal examination instead of the vaginal examination performed for women.
What is the vaginal electrode that is sometimes used during therapy?
Your therapist may use something called biofeedback as a way to re-train your pelvic floor muscles. This involves placing sensors on your muscles and connecting them to a computer. When you squeeze and relax your muscles the sensors show that activity in a graph on the computer screen, so that you are able to see what your muscles are doing in real time. This is a great way for your brain to connect with your muscles, especially since they are on the inside of our body and it’s sometimes hard to tell if we’re activating them in the right way. For biofeedback we can use sensors placed on the outside, or a sensor placed internally into the vaginal or rectal canal. Your therapist will choose which sensor type and placement is most appropriate for you. It’s important to note here that these sensors do not give off any type of sensation to your muscles, and once it is placed you will hardly even notice it’s there.

These are questions we get on a daily basis, but there are many many more to address. Be confident in yourself, and take charge of your own health by asking questions to your medical providers about different options for your pelvic symptoms!

Diastasis Rectus Abdominus

Mon, 29 Jul 2024 20:33:27 GMT

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Diastasis Rectus Abdominis (DRA) is the separation of abdominal muscles away from midline due to a sustained stretch. This is most commonly seen postpartum but can also occur in women and men of any age.

DRA occurs when the abdominal muscles are stretched apart during pregnancy , cut through for surgeries, or put under inappropriate stress for prolonged periods of time (like with long, steady weight gain around the abdomen).

One study showed 100% of women in their 40th week of pregnancy demonstrated a DRA - 100%! If you’re currently pregnant and afraid of getting a DRA, this should ease your mind. Everyone gets DRA at the end of the pregnancy, for good reason. The skin is stretched to capacity, and our muscles need to move to make room for the baby. However, we do want to be screened for DRA postpartum, as that same study showed almost 40% of women 6 months postpartum still had a diastasis.

There is no connection between mom’s BMI, baby’s birth weight or abdominal circumference to DRA. Research is showing our genetics and connective tissue have a larger role in DRA than our weight. Research is also showing that people with no previous pregnancies or other risk factors may have a small diastasis. This tells us that a DRA in and of itself is not necessarily a problem. It’s in the way we use it that could be problematic.

Symptoms of DRA can include:

A gap or bulge in the abdominal wall that is usually worse when the abs are under strain
Lower back pain or abdominal pain
Feeling like something will “fall out” or protrude from the abdomen

Seeing a physical or occupational therapist should be the first line of treatment for DRA. Many different techniques can be used to correct: exercise, manual therapy, and bowel and bladder management.

Exercise: Old school management of DRA focused on NOT loading the abdominal muscles, i.e. avoiding crunches and sit ups. Things have changed since the early days of DRA research, and we now know that putting tension on the abdomen is the best way for it to heal! DRA rehab is not a “one size fits all” process. You need a professional who is trained in monitoring your DRA during exercise, to ensure you’re loading the tissue correctly, in a safe but helpful way. It can be really confusing trying to find exercise programs online, mostly because there is no room for nuance there. Seeing a rehab professional is the best way to get your exercise program tailor made to you and your needs.

Manual Therapy: DRA management is not all about strength training. We have to understand that our abdominal muscles do not function in isolation but work as a unit, in coordination with the muscles in our low back. If our abdominal muscles are not “coming together” in the front, it could be due to muscle tension in the back which is resolved with manual therapy. There are also techniques your therapist can use to the abdominal tissue around the belly button to promote closure of the stomach muscles.

Bowel Management: Most wouldn’t think to ask about constipation or GI upset when dealing with DRA, but it can add to the patient’s report of bloating, “mommy tummy,” and an overall dislike of the way her abdomen looks. We want to make sure you are having regular, complete bowel movements without straining or pain. We also want to screen for any GI upset or a lot of gas after meals, as this can keep your abdomen distended with poorer response to PT.

We understand the temptation to find the “one size fits all” diastasis program. The problem is, it doesn’t exist! That is why getting a program online without having a PT assess you in person can be unhelpful at best, detrimental at worst. If you’re concerned you have a DRA, make an appointment with a therapist near you for an in person visit!

If you need help finding a therapist, go to www.pelvicrehab.com for therapists near you.

If you want to check for a Diastasis on your own first, try this video:

How to Check Diastasis Depth

Constipation

Mon, 29 Jul 2024 20:32:53 GMT

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We’ve all been there! Maybe it was on that trip to the beach where you got out of your routine, or on vacation when you had to share a bathroom with multiple people. Maybe you just had surgery and are taking pain medication, or you’re eight months pregnant . What do all of these scenarios have in common? They all have the potential for constipation. The dreaded feeling of being bloated and full, feeling like you might never have a bowel movement again. Most of us experience constipation occasionally, three or four times a year. However, there are people who have struggled with this issue for years, since they were children. What causes it? Why do some people deal with it more often than others? What is considered normal and abnormal when it comes to gut and bowel health?

Let’s begin with some common causes of constipation:

Lack of fiber and water in diet
The recommended amount of fiber for an adult is 25 - 35 grams per day. Most adults in the U.S. include about half of that in their diet, 15 grams.¹ One way to keep track of your water is to consume half of your body weight in ounces of water per day. For instance, if you weigh 150 lbs, try to drink 75 ounces of water a day.
Lack of movement or exercise
Exercise is a natural way to stimulate your gut and get things moving through the intestines. The American Heart Association recommends a starting goal of 150 minutes of exercise per week but if you aren’t able to do that right now, start slow and add in more exercise as your body allows. Talk with your physician before starting an exercise routine.
Repeatedly delaying or ignoring the urge to have a bowel movement
Because we can trust our gut to get food and fluids through the system, whenever we get the urge to empty, we should listen. Ignoring the urge to empty your bowels or putting it off for another time can lead to you feeling the urge less often, resulting in constipation.
Medications
Various medications, the most common ones being opioids, can cause constipation. Talk with your doctor and read labels for all medications for complete knowledge of side effects.
Travel, new home, big move, or change in schedule
Any time we increase the stress in our lives or change up our typical routine, our bowels can suffer. Your gut is a creature of habit - it likes to work in the same environment, with the same scents, and at the same time. Whatever your bowel habits are, it’s best to stick to those as best you can.

How do you know if you’re constipated? With bowel health, it all depends on your definition of “regular.” If you are someone who only empties your bowels once every other day, and each time you do so it is pain free and your stool is of good consistency, that is normal. Consider the “3 and 3” rule when determining what’s normal: 3 bowel movements per day to 3 bowel movements per week. Anywhere in between is considered normal.³

There are a few criteria that help your doctors come to a diagnosis of chronic constipation. They’re listed below, and two or more must be met to be diagnosed with chronic constipation:⁴

Less than three bowel movements per week
Manual maneuvers necessary to facilitate defecation more than 25% of the time.
Hard or lumpy stools more than 25% of the time
Sensation of incomplete evacuation more than 25% of the time
Sensation of anorectal obstruction more than 25%of the time
Straining with defecation more than 25% of the time.

If you have been experiencing two or more of these symptoms for the last 3-6 months, it would be beneficial to see your primary care physician or a gastroenterologist to talk about treatment options. Already seeing a medical provider for your constipation? Ask them about adding a Pelvic Floor PT to your medical management team! It may seem strange to ask a physical therapist for help with your bowels, but depending on the reason for your constipation a PT can be a huge help! Sometimes constipation is caused by dysfunction in your pelvic floor muscles, and more specifically the muscles that surround the anal opening. Having regular bowel movements requires multiple things to go correctly: you need the right amount of water and fiber in your diet, your bowels have to be functioning properly so that they can move things along in a timely manner, and once the stool reaches the rectum to be emptied, your pelvic floor muscles have to be able to relax and allow the stool to pass through.

In this picture, you can see the colon/rectum directly in front of the tailbone. Surrounding the rectum like a small ring are your pelvic floor muscles. When these muscles are relaxed, your rectum and rectal canal are at the perfect angle to allow stool to pass through. However, if these muscles are not relaxing this can put a “kink in the hose” so to speak. This changes the angle of the rectum and can make it difficult for anything to pass through.This is where your PT can help. He or she will be equipped to assess the muscles of your pelvic floor for strength and coordination, and give you many tips and tricks to make bowel movements easier. Here are a few things your therapist might suggest:

Bowel Do’s:

Be sure you’re getting enough water and fiber

Initiate a bowel routine

Elevate your feet using a stool or Squatty Potty when sitting on the toilet -- see video link below

Get 10-20 minutes of exercise daily

Inhale, then exhale as you try to empty the stool

Look before you flush - thin pencil like stool or round hard pellets are not normal. See link to Bristol Stool chart, Type 4 is ideal⁷

Dont's:

Strain to have a bowel movement

Restrict food intake

Sit on the toilet with your hips higher than your knees

Maintain a sedentary lifestyle

Hold your breath while having a bowel movement

Empty your bowels in a hurry. Find a good bathroom read and take your time!

The gut is a complex system. If you are struggling with constipation, talk to your provider about treatment options. A pelvic floor physical therapist can be a great addition to your medical team, and can give you unique insight on how to move towards complete bowel health.

www.ucsfhealth.org/increasing_fiber_intake . University of California San Francisco Medical Center.
Institute of Medicine. Dietary Reference Intakes for Water, Potassium, Sodium, Chloride, and Sulfate. Institute of Medicine Panel on Dietary Reference Intakes for Electrolytes and Water, Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Washington, D.C. National Academies Press 2005.
Mitsuhasi et al. Characterizing Normal Bowel Frequency and Consistency in a Representative Sample of Adults in the United States. American Journal of Gastroenterology. May 2017
Shih D M.D. and Kwan L M.D. All Roads Lead to Rome: Update on Rome III Criteria and New Treatment Options. Gastroenterol Rep. 2007 Winter
Heymen S, Scarlett Y, Jones K et al. Randomized, controlled trial shows biofeedback to be superior to alternative treatments for patients with pelvic floor dyssynergia-type. Dis Colon Rectum. 2007 Apr; 50(4):428-41.
http://www.pelvicexercises.com . How to Empty Your Bowels to Overcome Bowel Movement Problems.
https://www.continence.org.au/pages/bristol-stool-chart.html . Bristol Stool Chart

Clogged Ducts

Mon, 29 Jul 2024 20:32:33 GMT

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Breastfeeding is truly a miracle. Everything your baby needs in this one substance, often referred to as “liquid gold.” It gives nutrients, fat, protein, and immunity to your growing baby, and our bodies intuitively know how much to make. The composition of our breast milk will change depending on the needs of the baby, and can wax and wane based on life events (think return to work, stress, change in diet, sickness, etc). In these moments, the ducts that carry the milk can become clogged, or blocked.

A clogged or plugged milk duct is a common problem when breastfeeding. When you’re lactating, milk flows through your breasts in a pipe-like system of ducts to be excreted by the nipple. If a duct gets blocked or milk has trouble flowing through, a clog can form. The result is a small lump in the breast that might appear red and may be sore to the touch. If you’re lactating and experience breast tenderness, redness, or feel a lump in the breast tissue you should contact a pelvic floor physical therapist trained in treatment for clogged ducts right away . If you’re experiencing fever, nipple discharge, streaking on the breast tissue or the tissue is hot to the touch you should contact your physician, as these are signs of mastitis -- an infection of the breast tissue that requires antibiotic treatment.

If you are not showing signs of mastitis and think you have a clogged duct, quickly treating the area is key. Call your pelvic floor PT/OT and while you wait for your appointment, try these things at home:

Use heat on the breast tissue prior to nursing, and cold on the breast after nursing to help with the pain. Heat can include a hot pack, warm towel, or warm water in the shower
Nurse or pump at least once every 2-3 hours. Do not go longer than 3 hours without emptying the breast
Massage the breast, starting at the base and working down towards the nipple, to clear the duct.
Apply gentle vibration over the clogged duct (electric toothbrush) to promote movement of the milk.
Avoid garments that compress the breast tissue, i.e. tight tank tops or bras.

When you come in to see the therapist, she will examine your breast and obtain a quick lactation history from you. If they determine that you have a clogged duct, treatment includes placing a heating pad over the affected area, using ultrasound to help clear the clog, followed by manual breast massage to restore milk flow through the breast. We also recommend you bring your infant or breast pump to more fully clear the breast after the session. The clog may clear in a single visit, or may require 2 to 3 successive visits.

If clogged ducts continue to be a problem, try these things:

Continue seeing your PT/OT each time. We don’t want the duct to become infected
Be sure you are nursing or pumping every 2-3 hours
If you are exclusively pumping, make sure your falange sizes are correct. If they are too big or too small you may not be completely emptying the breast, which can lead to clogged ducts. @milkymamma on Instagram has a free consultation online to determine appropriate size.
Drink at least 8 oz of water every time you nurse/pump. Breast milk is mostly water. If we’re dehydrated the milk becomes thicker, making it harder to be emptied.
Avoid tight fitting tank tops or bras during all hours of the day

Chronic Prostatitis

Mon, 29 Jul 2024 20:32:09 GMT

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Pelvic health isn’t just for women. We see men of all ages too! If you’re a young man with pelvic pain or if you know one, listen up!

We’re talking about prostatitis - a catch all word for inflammation of the prostate. The prostate is a male reproductive organ located just underneath the bladder that contributes to semen production, and also helps keep men continent (no leakage). When the prostate becomes inflamed it can cause symptoms of:

Slow urine stream

Difficulty emptying the bladder

A “headache” inside the pelvis

Rectal pain

Prostatitis is categorized into four major groups:

Acute Bacterial occurs when you get sudden onset of bacterial infection. This could be from a UTI or STI. Chronic Bacterial still has some kind of infection present, but it keeps returning after medical treatment. The illness is categorized as Chronic Nonbacterial when the symptoms are still present, but there is no infection to be found. In patients with Asymptomatic Inflammatory Prostatitis , the prostate is inflamed but the patient has no symptoms of pain or urinary dysfunction.

Medical management often includes antibiotics that may clear the original infection. However, a lot of men will have a return in symptoms even with repeated antibiotic use.

Once you have had symptoms for longer than three months and there is no infection present, it is considered Chronic Nonbacterial Prostatitis. Also called Chronic Pelvic Pain Syndrome (CPPS), prescription medication alone will not solve your problem.

When we have pain in one area for a long time the muscles, nerves, blood vessels and fascia respond by getting tighter and more sensitive. Imagine all the tissues around the prostate being on “high alert” because there has been pain and inflammation around them for so long. Our muscles and nerves are not meant to live in this “fight or flight” state and over time, they start to generate their own levels of pain.

This means that in the beginning of your symptoms the cause may have been the prostate itself. But now, the prostate is healed but the tissues around it have not recovered. Antibiotics will have no effect on your muscles and nerves, but PTs/OTs are neuromuscular experts.

Things that we can help with:

Stress management
Addressing tight muscles in the pelvic floor + abdomen
Improving back and hip mobility
Nutrition and bowel function
And did we say stress management?

This is not a hopeless condition. The research gives us plenty of ways to take control over CPPS.

Exercise: any type you like, in moderate to vigorous intensity , averaging two hours per week. Even a daily brisk walk can help!

Diet: Limit caffeine and alcohol, and foods high in sugar. Foods found to be helpful include berries, citrus fruits, cruciferous vegetables, pumpkin seeds, nuts, salmon, garlic and onions.

Supplements: Some research shows over the counter supplements have properties that protect the prostate. Some include pumpkin seed oil, Certilin (pollen extract), and Quercetin. Talk with your doctor before trying these, as they could interfere with certain prescription medications.

Mental health: Stress plays a MAJOR role in managing chronic pain. Find a therapist who can give you tools to manage life with chronic pain. Our brains, after all, are the ones running the show

Case Study: Young Lawyer with Cystitis

Mon, 29 Jul 2024 19:01:02 GMT

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Today’s case study is a 22 year old female, with complaints of life long “cystitis.” We’ll start with her symptom report:

“Pt notes kidney reflux for years as a child, so she assumed all of her symptoms were from that. Since the start of her cystitis her kidneys have been "cleared." She has had PVR testing was "a little high but nothing crazy." While her bladder is filling she feels discomfort especially if she's drinking something other than water. She has painful urination and hesitancy, start and stop urine flow, and her urinary tract will feel irritated for a couple of days. She feels incomplete emptying of her bladder "all the time" but will have these flare ups 3-4 days per week. She notes some form of urinary leakage every day, even when sitting still. She has BMs 1-2x/day, she notes constipation if she's dehydrated or eats lots of carbs. Intercourse is painful but she "pushes through." She feels this has worsened since starting her new birth control (Dospirenone Ethinyl Estradiol)”

Where did we start?

Her first visit was strictly listening to her story, asking questions, and educating on anatomy of the pelvic floor muscles. We spoke about what therapy might look like and explained how we would perform an intra vaginal exam at her next appointment. We scheduled the patient for one visit per week, for eight weeks.

At the next appointment, I performed a full body assessment. We looked at the following things:

Thoracic and lumbar spine motion
Muscle tension in the abdomen
Hip motion and muscle tension
Pelvic floor muscles via vaginal exam

The patient’s spine moved well, and there were no significant findings in her hip joints. Once we got to her abdomen, she was very sensitive. The most tender places were those pictured below:

This makes sense for a number of reasons. She has a long history of bladder irritation and inflammation. Even if her bladder was the reason for her pain, all the muscles surrounding the bladder will become tense and guarded as a result. The patient is also a first year law student, which is a particularly stressful time. One of the most common places we hold our stress is our abdomen (I bet you're gripping your abdomen right now!)

There is also a lot of fascia in and around the bladder. The picture below is a bird's eye view looking down into the pelvis from the top. From top to bottom is the bladder, with the two ureter tubes on either side. The piece in the middle is a cross section of the uterus, and behind that is the rectum.

All of that white, spider webby looking tissue on the right and left of the bladder is fascia. Fascia helps suspend our organs inside the pelvis, and has a tendency to get “stuck” in patients with chronic pain. This was the case for our patient, which is why she had tenderness with touch around the pubic bone/bladder.

Moving along to her pelvic floor muscle assessment. As a reminder the patient has painful urination, slow urine stream, and pain with sex. When I visualized the skin around her vagina, it was bright red and appeared irritated. She reported burning with touch along the entire right side of the vaginal opening. The patient continued to report burning with an internal vaginal exam. Her muscles inside the pelvis were tight and tense, and performing a kegel made the pain worse. No wonder sex was painful!

After her pelvic exam, I recommended the following:

Good Clean Love vaginal moisturizer directly to the vulva, vaginal opening and urethra (bladder opening) every night. ( Example here )
An over the counter bladder supplement called D-mannose ( Info on D Mannose here )
Body scanning multiple times throughout the day, specifically checking the tension she’s holding in her abdomen. Being in law school, she needed good tools to check her stress. ( How - To Body Scan Here )
Speak with her gynecologist about other birth control options. Because we know certain birth control pills can increase pain at the vagina, AND the patient stated her pain with sex got worse after starting it, I recommended she ask her GYN for other options.

Her treatment sessions included manual therapy to the muscle groups that were tight and tense, mainly her abdomen and pelvic floor. Trigger point dry needling was used to the muscles in her abdomen, the patient responded very well. At each session we worked on the pelvic floor muscles intra vaginally, applying gentle pressure to tender points until the muscles relaxed. After seven visits, one per week, the patient reported the following:

“Has gotten easier to initiate a stream of urine, and the pain with urination is gone. As her bladder fills throughout the day she denies any pain associated with it. Her constant sense of urgency is much better. In general she states her cystitis is so much better. She still notes leakage 2-3x/day with working out or with standing up, she also notes a small amount after she stands up from the toilet.”

After this visit the patient performed her home program independently for two weeks. At her return visit she reported the only remaining symptom was occasional leakage with heavy lifting during her work outs. That session we reviewed lifting and breathing mechanics, and agreed to follow up in one month. The patient started therapy in October 2022, and was discharged from care symptom free on January 12, 2023.

Case Study: 77 Year Old Chronic Constipation

Mon, 29 Jul 2024 19:00:53 GMT

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Today we’re sharing the story of a 77 y.o. woman with laxative dependent constipation. We’ll begin with her medical history:

“The patient has been constipated her whole life, she was given enemas as a baby and used laxatives as a teen. Her constipation worsened in 2018 following a hysterectomy and bladder sling surgery. At this point in time, the patient requires prescription medication in order to have a bowel movement. She has tried Linzess but if she takes Linzess alone, the stool will "get down there but I can't get it out." She has recently tried Linzess, Miralax and Docusate and this has been working fairly well. Her GI provider just prescribed Trulance, she will start this week. Her colonoscopies show "redundant colon" but nothing else.”

Where do we start?

Chronic constipation, especially when it is laxative dependent, can take a long time to notice results. Historically the gut is slow to respond to intervention. For this reason I recommended the patient schedule two appointments per week, for ten weeks. As her symptoms improved, we decreased her visit frequency to once per week. She was seen for a total of twelve visits.

In someone with severe constipation, we have to start with the basics. Is the patient getting enough fiber and water in her diet? Is she eating three meals per day? Is she exercising? The answer to all of these questions, for this patient, was yes. This patient was getting on average 30g + of fiber per day, the recommended dose is 25-35g. Her water intake was good (80 + oz per day), she was eating enough calories, and walked regularly for exercise (15-30 minutes per day).

Once I knew she had the basics down, we started her on a home bowel program. Her intestines were not moving on their own, they needed the help of a medication. For this reason, her home program would be full of things that encouraged her bowels to process food on their own. We started this patient on a daily bowel routine that included the following:

Daily bowel massage ( Instructions here )
TENS unit protocol ( Protocol here ) + ( Amazon TENS Unit )
When performing bowel massage and TENS, use the senses to our advantage: perform in the same place, at the same time, with the same environment (think lighting the same candle, listening to the same music, watching the same tv show, etc).
Walking, or some kind of exercise, for 150 minutes per week
Continue taking prescription medication as prescribed

The patient was taking Trulance, a constipation prescription medication, daily when we started. She was also taking Miralax twice daily. These medications can be very expensive, and one of her main goals was to reduce her need for them. The patient was extremely compliant with her home bowel program, and after the first week of PT I encouraged her to reduce her Miralax to once per day. She was able to do this successfully over the next week, without a regression in symptoms. Over the next few weeks she continued reducing Miralax to ½ dose daily, which is where she remained for the remainder of treatment.

What does treatment look like?

During her sessions, I focused on manual therapy techniques to her abdominal wall. This included bowel massage, along with mobilization to her scars. The patient had a history of multiple abdominal surgeries, and scar tissue can be a factor in constipation. I also mobilized her cecum and sigmoid colon, and the various sphincters within her intestines. ( See anatomy here ). Following treatment to her abdomen, she would perform exercises in the gym focused on abdominal muscle activation and rotation. The deep abdominal muscles lie directly on top of and below the intestines, and contraction of these muscles can promote bowel motility.

As treatment continued, the patient felt comfortable trying days without her Trulance medication. At this point she was having a small bowel movement every day, but only felt fully emptied once or twice per week. I instructed her to skip Trulance on the day following a good, complete BM. It’s very important not to stop these medications “cold turkey,” as your bowels have become used to them. For the first two weeks of weaning, the patient skipped Trulance one day per week. She continued to wean, slowly, until she was taking Trulance twice per week.

Her bowel routine never changed throughout this entire process, she was still doing daily bowel massage and using her TENS unit. By the end of her twelfth visit, she was having some form of a bowel movement almost every day, and was thrilled.

There are many other things we could have addressed. Most people with constipation have tension in their pelvic floor muscles around the anus, preventing them from emptying all the way. The patient we reviewed here did not have that issue, so we did not spend time working directly with her pelvic floor muscles.

Key Takeaways

The bowel takes TIME and CONSISTENCY to respond to treatment
Working with your therapist to find a home bowel program you will actually stick to is key
This client was already doing very well with diet, but most patients need lots of education on water, diet, fiber, and exercise. Management of our bowels as we age takes effort on many fronts - and these are changes we need to plan to make for a lifetime.

Marathon Training Tips

Mon, 29 Jul 2024 19:00:22 GMT

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These tips are for you if:

You are a runner struggling with injury after injury
You are new to running and training for the 5K
You are returning to running after some time off, or postpartum
You mastered one race distance and are building endurance to complete the next distance benchmark
You are training to hit a PR in your distance of choice
You don’t really care about your finish time but it’s a bucket list thing so here you are
You are contemplating making casual running part of your exercise routine (beware, it’s highly addictive)

Tips for getting the most from your training:

Variety is key
Follow the 10% rule
Switch up your footwear

Variety is key

Organize your training schedule with several types of workouts each week.

Running is the main character, but you’ll get injured, burn out, or lose the ability to progress if all you ever do is run. Your gains are made from strength and power training, low impact cross training, mobility work, and breathwork. You should do all of these throughout the week.

Even your running needs to show variety: long slow distance, interval training, tempo runs, and sprints. This will include several different cadences, ground reaction times, cardiorespiratory demands, and joint/tendon impacts. If you are serious about performance, you may need to address 2 aspects of training each day. Perform them back to back for a longer training session, or allow for 6 hours between workouts for adequate recovery. Before you start two-a-days, be aware that a high impact/heavy work out within 2 hours of sleep can interfere with your ability to enter deep sleep - more on that later.

Example training schedule:

Monday: Strength training + core + breathwork.

Tuesday: Tempo run + that thing your PT wants you to work on.

Wednesday: Cross train (bike, rower, etc) + strength training + core

Thursday: Interval run or some miles followed by hill repeats + yoga flow

Friday : Strength training + low impact cross training + breathwork

Saturday: long slow distance run

Sunday: yoga flow + that thing your PT wants you to work on

This is an example, your training program may be vastly different from this and still be perfect for your needs and training goal. A physio versed in endurance sports can help you create an individualized plan if you are having trouble.

Follow the 10% rule

When progressing weekly mileage, stick to a 10% increase each week.

(BTW 3 bike miles = 1 running mile, and 1 swimming mile = 3 running miles)

If you keep getting injured every time you get 1 month deep into training, you may be progressing yourself too quickly.

This is going to feel painfully slow for most folks, but it will significantly reduce your chance of injury and give you the best long term outcome. Start where you are currently, divide by 10%, and add this amount to next week’s target. If you know you can only run 3x/wk due to your schedule, divide your target by 3 and this takes the guesswork out of how many miles you should run on a particular day.

Yes, this means you need to spend a few extra minutes each week thinking about your training. Yes, you need to start your training several weeks/months in advance. Yes, if you haven't already started training for the LR marathon, it might be unrealistic to cram your training into 6 weeks. Good news for you, there are several other races in Central Arkansas later this year you absolutely can and should train for.

Example progression:

Week 1: let’s say you are starting at 10 miles per week

Week 2: 11 miles per week

Week 3: 12.1 miles per week

Week 4: 13.31 miles per week

Week 5: 14.64 miles per week

Week 6: 16.1 miles per week

Week 7: 17.71 miles per week

Week 8: 19.48 miles per week

Etc…

You get to break these down however you want between running, distance, intervals, biking, etc.

Switch up your footwear

Work with a shoe specialist or physio to find what works for you, and don’t worry about what shoes Becky with the good hair is wearing.

There’s such a huge debate on whether footwear truly matters or not, minimalist vs corrective footwear, zero drop, the list goes on. What really matters is you have 2 good pairs of shoes (different models) that feel good to your feet and joints that you can alternate between.

Shoes are constructed from foam. When we run, that foam compresses and requires 48 hours to bounce back. Additionally, the muscles in our feet, ankles, hips, and core work differently depending on the shoe we have on (think about walking in high heels vs barefoot). Alternating shoes every run will 1) get you more miles out of your running shoes (cost saving in the long run) and 2) prevent overuse injuries from repeatedly placing increased demand on certain tissues.

Like tires, shoes need replacing. A general guideline is to replace running shoes every 300-500 miles depending on the model. You don’t have to buy the latest model, in fact you can often find last year’s model of any shoe on clearance online to save some dollars.

You may choose one minimalist shoe and one cushion shoe. Or maybe two corrective shoes are better for you if your over-supination causes you to twist your ankle every time you step on a crack in the sidewalk. You are the expert of your own body and everyone’s needs are different, so listen to what feels good for you. It may take some trial and error, and that’s normal. There is no one best recommendation for everyone.

And before each run, show gratitude and give yourself grace.

Your weekly mileage depends on several factors, so try not to compare yourself to your friends who may be training for the same race, OR who may have been training several years longer than you, OR who may not have recently undergone significant changes to their body associated with growing and birthing a tiny human and the sleep deprivation associated with raising said human.

When discussing training programs and running in general, it’s also important to recognize it’s a privilege to be a runner. Running requires adequate nutrition, abundant time, a safe environment, and an able body. Take some time to show gratitude for the things that got you here next time you hit the road.