Pelvic rehabilitation providers tend to have personalities that inspire patients to share intimate concerns and issues. One issue that we can play a part in bringing to light is that of medication usage for male sexual performance. Viagra, or the generic version, sildenafil, is a drug that improves blood flow to the penis. It is also one of the the most counterfeited drugs in the world, according to this report. The issue has been in the media for several reasons in recent weeks, with counterfeit manufacturing as one of the concerns. 

The United States Food and Drug Administration recently issued a warning about a recall for an over-the-counter male sexual enhancement supplement, "Lighthening Rod," because the supplement contained an undeclared amount of the medication sildenafil. What's the harm? Drugs.com lists 34 major drug reactions for sildenafil, including blood pressure changes (hypotension) or other cardiac effects when taken with nitroglycerines. A national study completed in Australia reports that erectile dysfunction may be a clinically relevant predictive tool for cardiovascular risk, and it may be that men are not sharing information about their sexual function with providers due to embarrassment. In fact, in a news report about a presentation at the American Urologic Association, research presented found that only 25% of men with erectile dysfunction seek treatment. In what has been described as an unprecedented move, Viagra has now made the drug available for purchase on its website, issuing a warning about acquiring the drug without a prescription or ordering a counterfeit drug. While this approach may help to avoid black market purchases of the medication, it also may allow men who don't feel comfortable filling prescriptions for the drug to purchase it in the privacy of their own home. 

In terms of our role in helping men avoid the pitfalls of the diagnosis of erectile dysfunction as well as the potential harm from medication available without a prescription, we can start by asking more questions. A good question to start with is "Are there any other supplements or medications that are not on your medication list?" or "Are there any medications or supplements that you purchase from the internet or from a local store?" We can also be sure to include questions about sexual function and health on patient intake forms, and include such verbal questions in our history taking. Because the patient may not feel comfortable on a first visit discussing intimate issues such as erectile dysfunction, in our education of the patient we can provide anatomy and physiology lessons related to sexual function. For any patient who admits to purchasing sexual enhancement drugs that have questionable contents, the patient should be referred to his medical provider to discuss the issue immediately, and the patient can be instructed in the potential adverse effects and in the need to discontinue such medications. 

While the co-existence of fecal incontinence (FI) and constipation is well-recognized in the pediatric and geriatric population, the authors of this article suggest that the relationship is under-appreciated in the adult population. Samuel Nurko, MD, and Mark Scott, PhD, describe the association between pediatric functional fecal incontinence and constipation, stool retention, and incomplete evacuation. In adults, they point out, constipation may also be related to pelvic floor dysfunction and denervation. The negative impact on quality of life creates the need for these issues to be addressed more readily, both in adults and in children. 

The study mentioned above cites a prevalence of fecal incontinence in school-aged children of 1-4%. The majority of the research cited in the article report that this incontinence is related to underlying constipation. Factors that may contribute to childhood holding of stool or to rectal dysfunction include constipation early in childhood, painful bowel function, "coercive toilet training practices and social stressors", fecal impaction, and treatments involving anal manipulation. It has been surprising to me how many adult patients describe psychologically stressful childhood associations with bowel function. Fortunately, the psychological stress, low self-esteem, and decreased quality of life that is associated with childhood bowel dysfunction improves with successful treatment of the condition. Childhood behavioral issues including bullying, disruptive behavior, and social withdrawal also are noted to improve following improvement in fecal issues, suggesting that the terrible social impact of fecal incontinence may be to blame for some of the behavioral issues. 

In relation to the adult population, the authors state that while the coexistence of constipation and FI may not be known, constipation has been shown to be an independent risk factor for FI and incomplete emptying is associated with fecal incontinence.  In the patient who has poor emptying of the bowels, overflow can occur, and this type of leakage is then associated with constipation. It follows, then, that treatment of the constipation should improve the fecal leakage.  Three mechanisms are described regarding the pathophysiology of incontinence caused by constipation: overflow due to fecal impaction; post-defecation leakage caused by rectal stool retention from a rectal evacuatory disorder; and general pelvic floor weakness or denervation. Certainly, neurological or other disease conditions can cause bowel dysfunction, yet this article focuses on "functional" constipation not caused by such diseases. 

In the April Physical Therapy Journal, authors ask the question: does the relationship between the patient and the physical therapist impact patient outcome? This relationship, or therapeutic alliance, was measured through use of the Working Alliance Inventory at the second treatment session. The 182 patients included in the reporting were all diagnosed with chronic low back pain, and they completed outcomes before and after 8 weeks of treatment including the Patient-Specific Functional Scale, the Global Perceived Effect Scale, the visual analog scale, and the Roland-Morris Disability Questionnaire. The patients were divided among 7 experienced physical therapists. 

The authors conclude that "Higher levels of therapeutic alliance...were associated with greater improvements in perceived effect of treatment, function, and reductions in pain and disability." Considering that this alliance was measured at the second visit, it clearly does not take a patient long to decide if there is a positive alliance formed. So how do we create that alliance? One of the reported limitations of the study is the lack of knowledge about the therapists' behaviors or interpersonal skills, therefore a correlation between such skills and patient's perceived alliance cannot be made. Another research article appearing in the same journal may offer some clues towards this issue.

An article titled "Measuring Verbal Communication in Initial Physical Therapy Encounters" suggests that clinical communication is critical in providing the patient with a positive experience. How can that be measured? 27 patient initial evaluations completed among 9 physical therapists were observed, audio recorded, and categorized using the Medical Communications Behavior System, a tool created to measure information-providing interactions. The results of the categorizations included that the therapists spoke for nearly 50% of the time compared to the patient's 33%. Emotional content was rarely included. Experienced clinicians were found to give more advice or suggestions, to utilize less restatement, and were also noted to be more likely to talk concurrently or interrupt the patient. 

Among the patients who we serve, the diagnosis of orthotopic neobladder, or "neobladder" can leave the pelvic rehab therapist wondering about the procedure itself as well as the best course of therapy. Understanding the anatomy and physiology of the  surgical diversion, the risks and benefits, and the common urinary dysfunctions can assist in development of the plan of care. The neobladder surgery is one option for patients who must have the bladder removed, often in the event of bladder cancer. As the 4th most common cancer in the United States, the National Cancer Institute estimates that there will be over 72,000 new cases of bladder cancer in the US in 2013. Other reasons a patient may be a candidate for a neobladder surgery include a neurogenic bladder that risks renal function, radiation injury to the bladder, severe urinary incontinence, and pelvic pain syndromes. 

The surgery involves creating a pouch for storage of urine from a portion of the small intestine. For a brief and helpful video of how this surgery is completed, click here. Early complications of the surgery include rupture of the new bladder reservoir and bacterial peritoneal infection. This is a medical emergency and would be treated with antibiotics and surgical revision. Late complications can include urinary obstruction. More commonly, patients who are referred for pelvic rehabilitation may experience dysfunctions including urinary incontinence and retention. While the latter tends to be an issue in the immediate post-surgical period, incontinence is more prevalent in later recovery.  A Medscape article about urinary diversions and neobladder can be accessed here. 

An article reviewing 1000 cases of neobladder surgery over 25 years reports complications including hydronephrosis, incisional hernia, ileus or small bowel obstruction, urinary tract infection, B12 deficiency, and occasional obstruction and even death. The authors conclude that patient age and comorbidities contribute to the challenge of avoiding such complications, and that patients are best managed in a surgical center where many of the operations are completed. In another article describing the urinary function outcomes in 49 women who were treated with a neobladder diversion, daytime incontinence was reported in 43%, nightime incontinence in 55%, and hypercontinence in 31%. Hypercontinence refers to difficulty emptying the neobladder. A web posting on a site for survivors of bladder cancer describes a technique that women can use to aid in emptying the pouch. 

Pelvic Floor Muscles: To Strengthen or Not to Strengthen? 

If that is the question, then who should provide the answer? As I was reading yet another article about how women should strengthen the pelvic floor muscles to have a better orgasm, I can't help but think about the unfortunate women for whom this is a bad idea. Yes, having healthy awareness of and strength in the pelvic floor muscles is important for healthy sexual function, but healthy muscles and building of awareness is challenging to achieve from viewing a view images. 

If you clicked on the link above about the article in question, you will see that the recommendation is for activating the pelvic floor muscles and engaging in pelvic strengthening exercises for up to a couple minutes per exercise, with several exercises prescribed up to 2x/day for a period of weeks. And that if you visualize stopping the flow of urine, you will surely feel the muscles activate. Based on clinical experience, we know that this is not the case for most women. One verbal cue may not be enough. The woman may not feel the muscle activation. She may have tight, painful pelvic muscles that are limiting healthy sexual function. These are issues that pelvic rehab providers face on a daily basis: when and how to strengthen the muscles. 

I would estimate that a large majority of pelvic rehabilitation providers are current or past students of yoga- some of you may even be experienced or new yoga teachers. As a yoga student myself (of various teachers and approaches, and a tendency to wish I was more consistent with my own practice) I have often marveled at how old and well-founded so many yogic practices are in relation to the "new" techniques "discovered" by entrepreneurial practitioners in health-related fields. Look at pelvic muscle activation: by engaging our patients in awareness techniques involving the pelvic floor we are continuing a long tradition of a yogic principle. This principle, known to many as mula bandha, is an ancient phrase often interpreted as referring to "root" and "lock." 

Over the past 5 years I have observed a tremendous increase in yoga practitioners who are interested in not only exploring the ability of the locking or stabilizing ability of the pelvic muscles, but also in exploring the necessity to "unlock" the person who is holding too much tension in the base of the spine and pelvis. The discussions related to this issue are at times hotly debated as well as thoughtful and elegant. One article might suggest a flow within which mula bandha can be integrated, and  other articles warn against the overuse of the lock and the lack of awareness required to properly use mula bandha during asanas. 

Last year I was approached by a local yoga school and studio, Yoga North, to learn more about how they were already incorporating pelvic floor awareness and practices into curriculum and classes dedicated to pelvic health. I had an opportunity to attend a class by a yoga teacher trained in their curriculum and in somatics, and I was very impressed at the language and techniques used to improve pelvic muscle awareness. More than ever, pelvic rehabilitation providers have an opportunity to engage other community practitioners and teachers so that we can learn from each other. It is not necessary that we speak each other's languages fluently, but that we find the common principles and share successes and challenges with which our patients/students present. 

You may recall that late in 2011, the United States Preventive Services Task Force created significant controversy by recommending against routine PSA (prostate specific antigen) testing. (A blog post from November 2011 covers the topic if you would like to review the recommendations.) The recommendations against use of routine PSA for prostate cancer screening is thought to avoid unnecessary biopsies as well as prevent urinary incontinence and erectile dysfunction related to procedures for prostate cancer.  In this year's January edition of the Annals of Internal Medicine we have updated information that addresses the implications of screening among different age groups.

Authors from the Fred Hutchinson Cancer Research Center and the University of Washington in Seattle ran computer models to determine risk reduction and mortality levels in populations of men. The bottom line is this: in men who are at low risk of developing prostate cancer, reducing the frequency of PSA testing significantly reduces the potential for harm from interventions, while not significantly increasing the risk of death. For example, in men ages 50-74 (who have low PSA levels) screening every other year versus annually increases lifetime death risk by 0.1% The number of PSA tests would be reduced by 59% and false positive tests (blamed for significant amount of pain and unnecessary treatments) would be reduced by nearly half. Click here for the journal abstract. 

Even if you are not working specifically with male pelvic rehab patients, you are likely working with male patients who are at an age when screening for prostate disease is recommended. How else can we promote prostate health with our patients? The Fred Hutchinson Cancer Research Center has found that eating dark green and cruciferous vegetables, drinking moderate amounts of red wine, and avoiding deep fried foods, smoking, and obesity can improve a man's chances of avoiding prostate cancer. As with many cancers, family history plays a role. Screening male patients, especially those who are in their 5th decade of life, is important. The American Cancer Society estimates more than 238,000 new cases of  prostate cancer will be diagnosed this year in the US. Be alert to male patients who have pain in the low back or pelvis, as these areas are typical sites of metastasis. The National Cancer Institute has an excellent summary of prostate cancer risks, general information, and images related to anatomy that you might find useful for your own knowledge or for patient education. 

Female Genital Cosmetic Surgery

What is it?

Female surgeries for modifying the genitalia are completed for many reasons of aesthetics or for reconstruction purposes. These surgeries or procedures may include:

Labioplasty: the reduction or augmentation (injection) of the labia minora or labia majora

Vaginal tightening procedure: aka "vaginal rejuvination" this involves narrowing the lower third of the vagina to tighten the canal for improved sensation during intercourse

Mirjam Lukasse of the University of Tromso in Norway and colleagues have completed interesting and relevant research among women who have experienced childhood sexual abuse and pregnancy. In a longitudinal cohort study based on data from the Norwegian Institute of Public Health, nearly 5000 women were questioned about childhood abuse and feelings about pregnancy. Between 18 and 30 weeks of gestation and again 6 months postpartum, subjects were sent questionnaires to assess associations between childhood abuse and women's fears about childbirth or preference for cesarean section (c-section) during pregnancy. In the study, 21% of the women reported experiencing childhood abuse. Women who were abused reported a significantly higher rate of fear of childbirth when compared to women who did not report abuse (23% and 15%, respectively.) Subjects who reported abuse were also more likely to state a preference for a c-section during the second pregnancy (6.4% versus 4%.) 

The same author was the primary researcher on an article summarized as the following: "Abuse in childhood is associated with increased reporting of common complaints of pregnancy." The authors point out that clinicians need to consider the issue of childhood abuse when working with pregnant women who have multiple complaints or increased challenges from typical complaints in pregnancy. In a similar updated article, Lukasse and colleagues describe the relationship between sexual violence and pregnancy-related symptoms. You can access the full text article by clicking HERE. Prior or recent severe sexual violence is correlated in this research with suffering from equal to or greater than 8 pregnancy-related symptoms. Symptoms include backache, fatigue, constipation, pelvic girdle dysfunction, nausea/vomiting, edema, headache, urinary dysfunction, pruritus, and others. 

Let's address the potential value of this information. Most of us who work in pelvic rehabilitation also treat women who are pregnant or who may become pregnant. While assuming that a woman who has significant pregnancy-related symptoms has been abused is not appropriate, considering that she has a history of abuse may be helpful to the patient. A woman who is experiencing abuse while pregnant may feel especially vulnerable as she considers how to care and provide for her child. Knowing how to ask questions in a respectful and clear way can be extremely helpful. The website "Survivors of Childhood Sexual Abuse" has a page of helpful language and strategies for the primary care provider who is engaging in a conversation about abuse. If you scroll down to the bottom of the page in the link you will find a printable summary of how to sensitively ask questions about abuse. Consider utilizing this information for an upcoming article review or inservice to staff or colleagues. Sharing statistics with patients and developing the habit of asking all patients about abuse can help to normalize the discussion so that patients feel safe enough to reach out when able.

Have you packed your bags for Combined Sections Meeting? This year, many faces of the Pelvic Rehab Institute faculty and friends will be present and will be sharing thoughts, information, and cool products. If you would like to freshen your tech skills (or learn some completely new ones) check out the social media and technology presentation by Tracy Sher and Sandy Hilton. They will be training participants in how to gather information from Twitter, Facebook, LinkedIn, RSS feeds, in how to locate on-line exercise programs, health and research blogs, and in how to access the international on-line physical therapy community.

Planning on taking the Women's Health board certification offered through the American Board of Physical Therapy Specialties? Elizabeth Hampton, Stacy Tylka and colleagues will enlighten attendees about exam application, completing the case study, exam eligibility, and about the roles and responsibilities of the WCS in the clinic. An added touch: "Chocolates and encouragement are both provided..." Nice!

Dustienne Miller will share her knowledge integrating yoga for patients who have pelvic pain. The session is at maximum capacity, so if you signed up for it- get there early! Tracy Spitznagle and Christina Holladay will present cases and educate the participant in caring for the complicated patient, which is certainly necessary for therapist who treat patients who have pelvic dysfunction and multiple system involvement. Tracy will also present with Ryan DeGeeter on abdominal pain during running and how to differentiate between gastrointestinal symptoms versus mechanical symptoms.