Recent research has confirmed prior work that suggests the use of boric acid is an effective treatment for vaginal yeast irritation. Chronic yeast irritation, commonly caused by Candida albicans, is a troubling condition that can cause symptoms of vulvar itching and burning, abnormal discharge, painful urination or intercourse, and vulvar swelling. Triggers for yeast imbalance include antibiotics use, pregnancy, changes in glucose metabolism, and use of certain oral birth control pills. Tight clothing and use of plastic pantiliners can also create an environment in which yeast growth can cause symptoms. 

The availability of over-the-counter yeast treatment has led to patients misdiagnosing and often over-treating with such medications. The ingredients in many of the available creams or suppositories can cause allergic reactions, vaginal burning, irritation, or itching. Many of our patients who complain of pelvic pain may be dealing with a history of or a current case of low grade (non-acute), recurrent yeast overgrowth and subsequent tissue irritation that can create a chronic pain condition. There are several intravaginal treatments that have been used by patients including boric acid tablets. Knowing that I worked with a high population of women's health patients,  I recall my naturopath handing me an article over a decade ago that described the superior results of boric acid over nystatin. Some providers recommend the use of boric acid in the evening, followed by intravaginal probiotics in the morning. Boric acid can cause local skin irritation as a side effect, but no other significant side effects have been reported when used vaginally. 

A big thanks to everyone who completed our PTPC Job Task Analysis Survey over the past few weeks. We received over 400 responses, which is more than enough data that we will need to perform the necessary analysis.

On May 2nd, we drew the names of our two lucky participants, who will each received a free course registration of their choosing. Congratulations to Christy Kline, PT and Kate Middleton, PT on winning the drawing!

Over the next few weeks, our subject matter experts and test development partner, Kryterion, will work together to finalize the quantitative blue print. This blue print will determine the relative amount of exam items that will be devoted to various sub-topics within pelvic rehabilitation. While not a "study guide", those interested in pursuing PTPC could use this test blue print to determine the topics on which to focus their studying efforts.

In the February 2012 issue Mayo Clinic Proceedings, Dr. Faubion and colleagues discuss the symptoms and management of nonrelaxing pelvic floor issues. In this clinical review, the authors differentiate between conditions that involve relaxed pelvic floor muscles (pelvic organ prolapse, urinary incontinence) with conditions in which non-relaxing pelvic floor muscles play a key role. When the muscles of the pelvic floor have difficulty in relaxing, this can impair the person’s function with defecation, urination, and sexual activity. The review focuses on the symptom complex called “nonrelaxing pelvic floor” so that care providers can manage the condition effectively, and in the words of the authors, provide early referral to physical therapy that can address the muscle dysfunction.

In the Journal of Adolescent and Pediatric Gynecology, Rakhshaee reports on the evaluation of 3 yoga poses used to treat primary dysmenorrhea. Primary dysmenorrhea occurs in otherwise healthy young women around the time that the menstrual cycle begins. It has been reported by Proctor in 2007  that as many as 75% of adolescents have painful periods, and that up to 20% of them limit activities because of the pain. An article by Wilson and Keye report that premenstrual syndrome and dysmenorrhea are reported as a leading cause of missed school and as problems that affected academic performance. 

In the study by Rakhshaee, 92 female students (ages 18-22) were randomly assigned to a treatment group (n=50) and to a control group (n=42). Over a period of 3 menstrual cycles, participants recorded pain using a Visual Analog Scale and reported pain duration in terms of hours. During the first menstrual cycle, symptoms were recorded, and then during the second and third cycles, the treatment group was asked to complete 3 yoga poses during the luteal phase. The control group received no intervention. Yoga poses instructed include the Cat, Fish, and Cobra. You can search the Yoga Journal website to view each of the poses by clicking here if you are interested. 

Overactive bladder (OAB) is defined by the International Continence Society as urinary urgency, with or without urinary leakage, that is commonly associated with urinary frequency and nocturia (waking one or more times at night to void.) According to the ICS, this combination of symptoms suggest that detrusor instability is present, meaning that the bladder muscle is overactive. In the absence of proven infection or other pathology, overactive bladder, urge syndrome, or urge-frequency syndrome are terms used to describe the condition.

A double-blind placebo-controlled randomized trial was completed in the United Kingdom for 240 women who experienced "refractory" detrusor overactivity. 122 women with urodynamically proven detrusor overactivity were treated with onabotulinumtoxinA (onaBoNTA), and 118 women served as the placebo group. The medication is injected into the wall of the bladder during a cystoscope procedure. (The women in the placebo group received injections as well, only with 0.9% sodium chloride in saline solution.) The median voiding frequency within a 24 hour period was reduced from 9.67 voids to 8.33. Urgency episodes reduced from 6.33 to 3.83, and leakage episodes from 6.00 to 1.67. To summarize, urinary urgency and incontinence improved more than urinary frequency in this study. The authors conclude that, based on such a large, randomized study, the use of botulinum toxin is both safe and effective for women who have detrusor overactivity.

In an article published in the Journal of Obstetrics and Gynaecology, the authors ask the following question: “How can we reduce negative laparoscopies for pelvic pain?” A retrospective audit of women receiving a laparoscopy (76 charts) was completed to determine how thoroughly the subjective examination was completed for women who complained of pelvic pain. Physical exam, the results of any ultrasound examination, reported usage of hormonal therapy, and the recommendation for multidisciplinary care was also assessed retrospectively. This study also aimed to determine if recommended guidelines for the initial assessment of chronic pelvic pain were followed by the physicians. These guidelines were developed by the Royal College of Obstetrics and Gynaecologists (RCOG) and can be accessed by clicking here.

The North American Menopause Society (NAMS) has issued a new position statement related to recommendations for hormone therapy (HT) use in women. This topic has been debated intensely over the last decade since the publication of the Women's Health Initiative (WHI) research that was funded by the National Institutes of Health (NIH). Following this research, many women were instructed by their physician to stop taking their hormone therapy medication due to the increased risk of cardiovascular events. For more information about the background of the WHI, please click here.

This information is particularly relevant for the pelvic rehabilitation provider as many women in their perimenopausal years will experience pelvic symptoms related to a decline in hormone levels. The updated NAMS guidelines state that estrogen therapy (ET) is "...the most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy..." that may include vaginal dryness, pain with penetration, and atrophic vaginitis. Although the guidelines do not recommended hormone therapy for improving libido, use of local estrogen therapy may contribute to improvement in sexual function through improved lubrication, increased blood flow and increased sensation to vaginal tissues. Local estrogen has also been demonstrated to help some women who have overactive bladder or urinary tract infections, however, systemic hormone therapy may worsen symptoms of stress incontinence.

"Do night lights cause cancer?" is the title of a blog post written by biofeedback expert and PhD psychologist Dr. Erik Peper. Follow the link above and you can decide for yourself if the post is compelling. Researchers in this study published in the Cleveland Clinic Journal of Medicine asks "Does lack of sleep cause diabetes?" Poor sleep quality or not enough hours of sleep are often considered as precursors to health impairments as the body does much of its cellular regeneration and other restorative functions during the sleeping hours. These questions and concerns bring us to the concept of "Sleep Hygiene." 

The American Academy of Family Physicians has published this full text article that describes several components of insomnia treatment, including sleep hygiene. Reasons for insomnia may include anxiety, depression, fibromyalgia, sleep apnea, menopause, pain, or restless legs syndrome. Medications that can contribute to lack of sleep include alcohol, nicotine, caffeine, diuretics, beta blockers, and stimulant laxatives. The authors describe sleep hygiene as one part of a cognitive behavioral therapy (CBT) approach to treat insomnia, which can be comprised of 4-8 sessions. Each session may be 60-90 minutes long and topics covered may include behavioral education for stimulus control, sleep restriction, relaxation therapy, and paradoxical intention (trying to stay awake.)

Holly Herman, co-founder of the Herman & Wallace Pelvic Rehabilitation Institute, has just returned from Saudi Arabia, where she educated the first class of 34 female physical therapists in the art and science of women's health physical therapy.

She was accompanied by esteemed colleague and well-known educator Fatima Hakeem. Together they created 11 days of intensive-training education, which they taught over a 14 day period. Topics instructed included pregnancy and postpartum, female pelvic floor dysfunction and female sexual health. Participants earned a Advanced Clinical Diploma in Pelvic Floor Treatment from the Saudi Physical Therapy Association (SPTA), as well as CAPA certificates through the Institute.

Nocturia, defined by the International Continence Society (ICS) as waking one or more times at night to void, is a condition that has been correlated with severe health risks and mortality. Recent research brings this issue to the forefront and provides us with knowledge that we can share with our patients, providers, and perhaps with our loved ones. (Nocturnal enuresis, not to be confused with nocturia, is voiding while sleeping.)

Vaughan et al.  examined the association between falls and nocturia in a "...racially diverse, community-based sample..." of 692 older men and women. The authors found that having nocturia 3 or more times/night increased the risk of falls 28% over a 3 year period. Patients in this study who were classified as "fallers" were also more likely to be over 85 years of age, be female, have a diagnosis of diabetes, use diuretics, and they were found to have an abnormally slow gait speed. A longitudinal study from Japan reports that nearly half of their 784 community-based participants reported nocturia occurring 2 or more times/night. The authors of this study concluded that over a 5 year observation period, elderly individuals with nocturia were at greater risk for fracture and mortality. It is well reported within the orthopedic and rehabilitation literature that falls in the elderly can lead to significant mortality, morbidity, and inability to live independently.