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Jun 02, 2013

In this article titled "Too Posh to Push?" the value of elective cesarean (or "c-section") deliveries for childbirth is revisited. Statistics in Britain are referenced, as rates for the procedure have increased from 4.5% in 1970 to nearly 25% today. This trend is stated to have occurred without a corresponding obstetric need for the the procedure. The US has experienced a similar debate, with stories of women demanding an elective surgery, sometimes for the preservation of the pelvic floor, other times because she is interested in avoiding the pain of pushing. Some providers also promote elective cesareans for birth, perhaps due to their own beliefs about potential benefits, or for the value of having more control over a schedule. Regardless of the motivations and beliefs of the patients or providers, pelvic rehabilitation providers can land in the middle of such an important discussion.

 

The choice about desired birth practices is between a mother, her family, and her providers. At no time is it appropriate for a pelvic rehab therapist to impose an opinion upon a woman who is pregnant. It is, however, most appropriate to answer questions that may arise in relation to musculoskeletal health and about discussions the patient may be hearing or reading about elective cesareans. The literature in the past decade has been decidedly in favor of avoiding vaginal births in order to avoid pelvic floor injuries. The other half of the story is that birth is not the only factor in pelvic floor health and injury, and that cesarean deliveries also carry risks- some of those risks are lessened in a vaginal birth.

 

Basic information about a cesarean delivery are available on many sites, including the National Institute of Health's MedLinePlus. While c-sections are always described as a "safe" surgery, all surgeries carry risks. Personally, I have been amazed at the nonchalance of surgeons who give an air of "no-big-deal" for common surgeries that is contrasted with the informed consent waiver a person is asked to sign before entering the operating room. All surgeries have risks. While it is acknowledged that vaginal deliveries are associated with increased incontinence, the actual cause of the pelvic floor injuries cannot be directly correlated with the delivery itself. 


Sep 12, 2012

In the current issue of the journal Physical Therapy, Wang and colleagues describe the characteristics of patients (and their pelvic floor diagnoses) presenting for outpatient physical therapy. 109 outpatient clinics participated in this data collection and included information about 2452 patients. The system used for collecting data is FOTO (Focus On Therapeutic Outcomes), and you may have heard the results of this research presented at the most recent Combined Sections Meeting of the American Physical Therapy Association. The results of the study include that most of the people presenting to the clinics for pelvic floor dysfunction were women (92%), and that many reported a combination of urinary, bowel, or pelvic pain symptoms. The authors found a mean patient age of 50 with a standard deviation of 16. Most patients reported symptoms as chronic (74%). You can see from the following chart that is adapted from the article that subgroups of patient populations were noted, and the categories used for reporting include urinary disorders, bowel disorders, and pain (not all subgroups of combinations of pain are included in the chart below.) In general, 67% of the patients reported urinary dysfunction, 27% reported bowel dysfunction, and  39% reported pelvic pain. 

 

Breakdown of Diagnoses and Subtypes
Urinary  Bowel Pain
Leakage (32.1%) Constipation (53.7%) Abdominal (15.1%)
Frequency (10.9%) Leakage (27.9%) Rectal (3.7%)
Retention (2.7%) Leakage, constipation (18.4%)  Sacroiliac (5.9%)
Leakage, frequency (30.2%)   Vaginal (23.9%)
Leakage, retention (5.1%)   Abdominal, sacroiliac (4.5%)
Frequency, retention (4.7%)   Abdominal, vaginal (17.1%)
Leakage, frequency, retention (14.3%)    Abdominal, rectal, vaginal (5.1%)

 

 

 


Aug 19, 2012

As many of you know, the Herman & Wallace Pelvic Rehabilitation Institute is currently developing a Pelvic Therapy Practitioner Certification process (PTPC). As part of the multi-step process involved in the development of a robust certification, the job task analysis survey was completed by more than four hundred providers (403 to be exact.) The Institute was thrilled that so many current, past, or future course participants believe in this process so strongly that even a seemingly endless survey could not deter you from completing the tedious, yet crucial questions that were posed. In another step of the process that occurred after the results of the survey were tallied, I was able to view the tables of responses and I found the information very interesting- I thought that you might also be interested to know a bit more about the answers that we received in the survey.

 

Keeping in mind that the pelvic rehabilitation specialty is one that is not as well-represented in the clinic as orthopedics, for example, and yet is a specialty that is gaining in popularity, it was interesting to note that nearly 1 in 5 therapists completing the survey had less than one year of experience working in pelvic rehabilitation. Approximately 82% of the more than 400 people completing the questions has been working within pelvic rehabilitation for 10 years or less. In terms of the education of the people represented, the highest degree earned at the time of the survey was a doctorate for 41.4% of people, with 8.4% of those represented by transitional doctorate degrees, and less than 1% by an academic doctorate.

 

Several people indicated that they had board certifications in either cardiovascular and pulmonary (2), geriatrics (2), neurology (1), pediatrics (1), sports (3), and orthopedics (23), or women's health (17). Other qualifications listed by those completing the survey included LANA certification for lymphedema therapy, manual therapy certifications, yoga, Pilates, and biofeedback certifications, to name a few that appeared frequently.


May 26, 2012

Research presented recently at the annual Scientific Meeting of the American Urological Association (AUA) addresses the increased risk for urinary and sexual dysfunction among men who have served in the military.  In a press release issued by UroToday, it is noted that men who have prior military service have up to 3 times the risk for developing urinary incontinence.  Data was collected on nearly 5300 men and the results were categorized into 3 age groups: < 55, 55-59, and > 70 years of age. 23% of the men in this general population sample reported military exposure, and the rate of urinary incontinence (UI) was 18.8% in the military group versus in the men without military experience (10.4%). Interestingly, it was the age group of < 55 years that had the most significant increase in risk for UI, as the men older than 55 did not have a significant difference in rates of incontinence. 

 

Not only has prior military service been found to be an independent risk factor for men under age 55 developing urinary incontinence, but the diagnosis of posttraumatic stress syndrome (PTSD) in male Iraq and Afghanistan veterans is linked with a higher rate of lower urinary tract symptoms as well as sexual dysfunction. Male veterans who suffer from PTSD are more likely to suffer lower urinary tract symptoms (LUTS) than men without PTSD, even when medications for the syndrome are taken into consideration. In other research presented at the AUA meeting, the prevalence of sexual dysfunction in men who have PTSD was discussed. Conditions including erectile dysfunction and premature ejaculation were analyzed in health histories of men with and without PTSD. The rate of sexual dysfunction in men with PTSD was nearly 10%, while in men without PTSD, the rate was 3.3%. The authors concluded that while certain medications taken for PTSD can cause sexual dysfunction, medications alone are not responsible for all cases of sexual dysfunction in men with a military service history. Issues of avoidance, emotional numbing, and hyperarousal (all symptoms of PTSD) were found to be important factors in the dysfunction.

 

Increased awareness of these issues may lead to better identification of the conditions as well as improved emphasis on effective treatments. In my role as faculty for the Herman & Wallace Pelvic Rehabilitation Institute, I have met several pelvic rehab providers who work within the VA system, providing care for the men and women who have served in the military. There is increased awareness of and interest in integrating pelvic rehabilitation programs for veterans, and this is a trend that will hopefully expand into comprehensive pelvic rehab care. With Memorial Day so recently behind us, it is timely to have increased light shed on these significant issues so that care may be directed to treat these sensitive issues that can impair quality of life.


Dec 19, 2011

Researchers in the UK recently asked this question: For women in the UK who have given birth, what is the risk for pelvic floor surgery and for repeat surgery? Surgery for pelvic organ prolapse (POP), urinary incontinence (UI), and rectal prolapse or fecal incontinence (RP-FI) were included in the study. The research also addressed re-operation rates and the length of time between repeat surgery for prolapse and incontinence.

 

From the national registry in Scotland, 34,630 health records of women were accessed. The lifetime risk for women (up to age 80) having pelvic floor surgery was just over 12%. Re-operation rate was 19%; women who had a mid-urethral sling (MUR) versus a retropubic operation  had reduced rates of re-operation.  The average time between repeat surgeries for prolapse or incontinence was 2.8-3 years. A woman who gave birth to a first child when she was less than 20 years old, or women who had all births via c-section had reduced lifetime rates of surgery. Conversely, increased body mass index (BMI), having one perineal laceration,  or having 1 birth that involved forceps for delivery increased rate of surgery. (Sustaining a third degree perineal tear was a risk factor for rectal prolapse-fecal incontinence.)


The bottom line: in the UK, more than 1 in 10 parous women will undergo pelvic floor surgery. This is a general population study, therefore the authors express confidence that these rates should hold true for the general UK or for the European communities. The authors also compare their findings to several other epidemiological studies completed in the US, Australia, and France, and it is interesting to read the discussion related to comparison of populations in these studies. As in all the studies addressing pelvic floor surgery rates, the numbers are sufficiently high to warrant increased national attention towards prevention, including pelvic rehabilitation. The average time interval between surgeries struck me as being relatively short, and it would be valuable to have more research that compares repeat surgeries in those patients who have had pelvic rehabilitation versus those who have not been educated about pelvic floor functional use and/or strengthening. If you are interested in reading the full, free-access article, please click here.


Jul 10, 2011

In the Journal of Urology, data was presented by Markland et al following data analysis of nearly 18,000 adults (age 20 or older) participating in the National Health and Nutrition Examination Surveys between 2001 and 2008.


In the combined surveys the prevalence of urinary incontinence (UI) in women was 51.1%, in men it was 13.9%. In the combined surveys the prevalence of urinary incontinence (UI) in women was 51.1%, in men it was 13.9%. Factors that the authors associated with UI included "...age, race/athnicity, obesity, diabetes and chronic medical conditions (prostate disease in men.)"  After standardization for age, it was noted that prevalence of UI increased in both men and women over the time during which the surveys were completed.  


The authors point out that especially for women, decreasing obesity and diabetes may contribute to lower rates of urinary incontinence. Prior research has concurred that even a 5-10% loss of body weight in obese women can improve urinary symptoms. Although weight loss may feel like a sensitive subjective to discuss with our patients, it seems an appropriate topic to share when our patients are inquiring about prognosis and interventions.


Apr 21, 2011

Earlier this month, Datamonitor released a report on Urinary Incontinence in the 7 major global markets (The US, Japan, France, Germany, Italy, Spain, and the UK). Check out the highlights here. The whole report is pretty expensive, but they touch on a point that we have long emphasized: the prevalence of urinary incontinence will grow over the next ten years, with the most cases occurring in the United States.

Demand for innovative and effective treatments for urinary incontinence will continue to increase for years to come. Therapists with extensive clinical experience treating urinary incontinence will be well positioned for this demographic trend.


Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Durham, NC (SOLD OUT)
Apr 25, 2014 - Apr 27, 2014
Location: Duke University Medical Center

Myofascial Release for Pelvic Dysfunction - Portland, OR
Apr 25, 2014 - Apr 27, 2014
Location: Legacy Meridian Park Medical Center

Finding the Driver in Pelvic Pain - Milwaukee, WI
May 01, 2014 - May 03, 2014
Location: Marquette University

Visceral Mobilization of the Urologic System - Winfield, IL
May 02, 2014 - May 04, 2014
Location: Central DuPage Hospital Conference Room

Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics - Seattle, WA
May 03, 2014 - May 05, 2014
Location: Swedish Hospital - Issaquah campus

Rehabilitative Ultrasound Imaging Orthopedic Topics - Seattle, WA
May 03, 2014 - May 04, 2014
Location: Swedish Hospital - Issaquah campus

Pelvic Floor Level 1 - Scottsdale, AZ (SOLD OUT)
May 16, 2014 - May 18, 2014
Location: Womens Center for Wellness and Rehabilitation

Pelvic Floor Level 2A - Maywood, IL (SOLD OUT!)
May 16, 2014 - May 18, 2014
Location: Loyola University Stritch School of Medicine

Pelvic Floor Level 3 - San Diego, CA
May 30, 2014 - Jun 01, 2014
Location: FunctionSmart Physical Therapy

Pelvic Floor Level 1 - Arlington, VA (SOLD OUT)
Jun 06, 2014 - Jun 08, 2014
Location: Virginia Hospital Center

Care of the Postpartum Patient - Houston, TX
Jun 07, 2014 - Jun 08, 2014
Location: Texas Children’s Hospital

Bowel Pathology and Function - Minneapolis, MN
Jun 07, 2014 - Jun 08, 2014
Location: Park Nicollet Clinic--St. Louis Park

Oncology and the Female Pelvic Floor - Orlando, FL
Jun 21, 2014 - Jun 22, 2014
Location: Florida Hospital Sports Medicine and Rehabilitation

Myofascial Release for Pelvic Dysfunction - Dayton, OH
Jun 22, 2014 - Jun 23, 2014
Location: Southview Hospital

Pelvic Floor Level 2A - Derby, CT
Jun 27, 2014 - Jun 29, 2014
Location: Griffin Hospital