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Tags >> Male Pelvic Floor
Sep 04, 2014

This post was written by H&W instructor Allison Ariail PT, DPT, CLT-LANA, BCB-PMD. Allison will be instructing the Pelvic Floor Level 1 course Boston this October.

 

Allison Ariail

Several weeks ago some of my fellow faculty members and I were discussing the resting tone of the pelvic floor. These days we take it for granted that we know there is constant low-level activity in the pelvic floor and anal sphincter in order to provide continence. However, how did this information come about? I took it upon myself to do some research to find out the beginnings of this knowledge. What I found was interesting and thought I would share.

 

In the late 1940’s and early 1950’s the belief was held that the pelvic floor and external anal sphincters were inactive at rest, like other striated muscle throughout the body. Activity was believed to be initiated by afferent impulses from the rectal ampulla and anal canal. In 1953 Floyd and Walls found activity in the external anal sphincters at rest, even during sleep. In 1962 Parks, Porter, and Melzak published a study examining the pelvic floor muscles and the external anal sphincters using electromyography recordings. They also found activity in these muscles at rest. They hypothesized the activity was maintained by spinal reflex. These researchers looked at the activity in a healthy population, a paraplegic population, and a population that had undergone a rectal excision. When examining the paraplegic population (all subjects had complete SCI injuries above L3), they did identify activity of the pelvic floor at rest.

 


Aug 15, 2014

baby

Concepts in "core" strengthening have been discussed ubiquitously, and clearly there is value in being accurate with a clinical treatment strategy, both for reasons of avoiding worsening of a dysfunctional movement or condition, and for engaging the patient in an appropriate rehabilitation activity. Because each patient presents with a unique clinical challenge, we do not (and may never) have reliable clinical protocols for trunk and pelvic rehabilitation. Rather, reliance upon excellent clinical reasoning skills combined with examination and evaluation, then intervention skills will remain paramount in providing valuable therapeutic approaches. 

 

 

Even (and especially) for the therapist who is not interested in learning how to assess the pelvic floor muscles internally for purposes of diagnosis and treatment, how can an "external" approach to patient care be optimized to understand how the pelvic floor plays a role in core rehabilitation, and when does the patient need to be examined by a therapist who can provide internal examination and treatment if deemed necessary? There are many valuable continuing education pathways to address these questions, including courses offered by the Herman & Wallace Institute that instruct in concepts focusing on neuromotor coordination and learning based in clinical research. 

 

 


May 11, 2014

During a pelvic muscle assessment, patients who have pelvic pain or other dysfunction that includes pelvic floor muscle tenderness will often ask the pelvic rehabilitation practitioner the following question: "Doesn't everyone have tenderness if you push on the muscles like that?" The answer should be "no," and we have research to support this claim. While it may seem incredibly simple to a pelvic rehabilitation provider that a "healthy muscle does not hurt" and that in order to optimize muscle function, the length-tension curve should be optimized, this knowledge is not universally understood by most patients.  Tenderness, especially if severe or if the intensity of the discomfort inhibits a healthy muscle contraction, can be eased so that a patient can learn to appropriately contract and relax the pelvic floor muscles.

 

 

While logical to rehabilitation providers, the concept that healthy muscles are typically devoid of significant tenderness must be well-established if we wish patients, providers, and payor sources to join in our belief that diminishing such tenderness can be a marker of progress. (Of course we keep in mind that function trumps tenderness, especially when a person has no functional limitations despite presenting with muscle tension or tenderness.) Researchers have aided our profession in establishing that significant muscle tenderness is not present in young, healthy, asymptomatic patients. 

 

 

In research published last year, Kavvadias and colleagues assessed pelvic floor muscle tenderness in 17 asymptomatic, nulliparous female volunteers (mean age 21.5 years), with results indicating low overall pain scores. The authors also aimed to examine inter-rater and test-retest reliability of specific muscle tenderness testing using a visual analog scale (VAS) and a muscle examination method recommended by the International Continence Society (ICS) over 2 testing sessions. This study used a cut-off score of 3 or less on the 0-10 VAS to determine clinically non-significant pain. Inter-rater and test-retest reliability was reported as good to excellent for palpation to the posterior levator ani, obturator internus, piriformis muscle, and for pelvic muscle contraction, yet found to be poor to fair for pelvic floor muscle tone and anterior levator ani palpation. Resulting scores on the VAS were less than 3 for all muscles tested, leading the investigators to conclude that in nulliparous women aged 18-30 who have no lower urinary tract (LUT) symptoms or history of back or pelvic pain, tenderness "…should be considered an uncommon finding." 


Apr 07, 2014

Michelle Lyons

This post was written by guest-blogger, H&W faculty member Michelle Lyons, PT, MISCP, who will be teaching her brand-new course, The Athlete and the Pelvic Floor, in Columbus,OH in August..


‘I approached my advisor and told him that for my PhD thesis I wanted to study the pelvis." He replied ‘That will be the shortest thesis ever…there are three bones and some ligaments. You will be done by next week.’ I told him ‘I think there is more to it’.  (Andry Vleeming Phd 2002)

 

In sports medicine, the primary source of specialist consultation is the orthopaedic surgeon, who may perform a wide ranging assessment of the musculo-skeletal system with no real evaluation of the pelvic girdle or pelvic floor musculature. The patient is unlikely to be asked about urinary, bowel or sexual dysfunction and often does not volunteer this information unless prompted (Jones et al 2013)

 


Mar 17, 2014

Pop Quiz

 

  1. Can a pelvic rehabilitation provider help a male patient who has erectile dysfunction (ED)?
  2. Is there research to support a claim that rehab helps with ED?
  3. Are there any medical conditions a pelvic rehab provider should suspect when a patient complains of ED?
  4. Are there any screening tests a pelvic rehab provider can complete to rule out medical causes of ED?
  5. Are there any pelvic rehabilitation courses that discuss ED in men? 
  6.  

     

 

If you answered "yes" to all of the above questions, well done. A pelvic rehabilitation provider can indeed help a patient who presents with complaints of erectile dysfunction, and the highest level of evidence (randomized, controlled clinical trial) has been completed to support this claim. Medically, a patient with ED may be suffering from heart disease, diabetes, metabolic syndrome, or even multiple sclerosis and should be screened by a medical provider prior to working with a pelvic rehabilitation provider. Skilled listening, and screening tests such as blood pressure, balance, and medication screening can be utilized in the clinic to alert the therapist to a medical issue.

 

 


Mar 13, 2014

A recent article titled "Pain, Catastrophizing, and Depression in Chronic Prostatitis/Chronic Pelvic Pain Syndrome" describes the variations in patient symptom report and perception of the condition. The article describes the  evidence-based links between chronic pelvic pain and anxiety, depression, and stress, and highlights the important role that coping mechanisms have in reported pain and quality of life levels. One of the ways in which a provider can assist in patient perception of health or lack thereof is to provide current information about the condition, instruct the patient in pathways for healing, and provide specific care that aims to alleviate concurrent neuromusculoskeletal dysfunction. 

 

 

Most pelvic rehabilitation providers will have graduated from training without being informed about chronic pelvic pain syndromes. And as most pelvic rehabilitation providers receive their pelvic health knowledge from continuing education courses, unless a therapist has attended coursework specifically about male patients, the awareness of male pelvic dysfunctions remains low. If you are interested in learning about male pelvic health issues, the Institute introduces participants to male pelvic health in the Level 2A series course. The practitioner who would like more information about male patients can attend the Male Pelvic Floor Function, Dysfunction, and Treatment course that is offered in Torrance, CA at the end of this month.

 

 

The authors in this study point out that chronic pelvic pain is not a disease, but rather is a symptom complex. Despite the persistent attempts to identify a specific pathogen as the cause of prostatitis-like pain, this article states that "…no postulated molecular mechanism explains the symptoms…" As with any other chronic pain condition, research in pain sciences tells us that behavioral tendencies such as catastrophizing is not associated with improved health. The authors utilized a psychotherapy model in developing a cognitive-behavioral symptom management approach and found significant reductions in CPP symptoms. The relevance of this information for our patient population includes having the ability to screen our patients for depression, to recognize tendencies to catastrophize, and to implement useful strategies for our patient. 


Feb 05, 2014

Treating patients who have chronic pelvic pain is challenging for many reasons. The nature of chronic pain in any body site often means that the patient has a multifactorial presentation that requires a team approach to interventions. And because the pelvis also contains the termination of several body systems such as the urologic, reproductive, and gastrointestinal, there exists potential for addressing a musculoskeletal issue that is masking a medical issue which requires intervention by a medical provider. The phrase "When you have a hammer, everything looks like a nail" can be applied to patient care for any discipline. When a patient presents with chronic pelvic pain, pelvic rehabilitation therapists can usually find tender pelvic muscles to treat. Is the pelvic muscle tenderness from guarding due to visceral pain or infection? 

 

In a 2013 article in the journal General Practitioner, Dr Croton describes red flag symptoms in acute pelvic pain. These include pregnancy, pelvic or testicular masses, and vaginal bleeding and/or pain in postmenopausal women. During the history taking, patients can be asked about menstrual patterns, possibility of pregnancy, and sexual history. Further medical evaluation may include a pregnancy test, ultrasound, laparoscopy, and urine tests to rule out infection. While the above is not an exhaustive list, it reminds the pelvic rehabilitation provider to always keep in mind the potential for medical evaluation and intervention. Once a patient has been deemed to have "only chronic pelvic pain," a new, equally challenging list emerges: is the pain generated by an articular issue, myofascial dysfunction, neuropathy, psychological stress, or postural pattern? Is the pain local, such as in the pubis symphysis or in the sacroiliac joint ligaments, or are the symptoms referred from a nearby structure, such as the abdominal wall or the thoracolumbar junction? And what are the best methods to examine in a systematic way the various theories about the origins of a patient's pain? 

 

Peter Philip has created a course to provide answers to the above questions. He combines skills in both orthopedics and manual therapy, and pulls from an extensive knowledge about pelvic pain and differential diagnosis which was the research topic of his Doctor of Science degree. Peter's course provides clearly instructed techniques in anatomical palpation, spinal and joint assessment, and he also instructs in how the nervous system and cognition can impact a patient's perception of pain. The course will be offered at the end of this month in Seattle- don't miss this chance to refine skills in differential diagnosis for chronic pelvic pain!


Jan 28, 2014

Allison Ariail, PT, DPT, CLT-LANAThis entry to Pelvic Rehab Report was written by guest-blogger and H&W instructor Allison Ariail, PT, DPT, CLT-LANA, who will be teaching Rehabilitative Ultrasound Imaging for Women's Health and Orthopedic Topics course in Seattle, WA this May.


 

 

In the past decades, evidence has been established showing the reliability and validity of rehabilitative ultrasound in the assessment of deeper musculature, including the pelvic floor muscles. This has emerged as a useful assessment tool for the pelvic floor pprofessional, as well as a valued biofeedback tool for the patient. The therapist and patient can view real-time what is occurring when a pelvic floor muscle contraction is attempted. Until recently most of the research validating rehabilitative ultrasound imaging, both transabdominally and transperineally, used women as subjects (Dietz 1998; Dietz 2002; Dietz 2004; Thompson 2003; Peng 2007; Constantinou 2009). In 2012, Khorasani and his team used transabdominal ultrasound imaging to compare the mobility of the pelvic floor in men with and without chronic pelvic pain. They found significant differences in the amount of elevation of the bladder base. Men with chronic pelvic pain had less lift of the bladder base compared to men without pelvic pain.

 

In 2012 and 2013 Stafford, Ashton-Miller, Constantinou, and Hodges published two studies examining the dynamics of male pelvic floor contraction and attempting to quantify displacement of the pelvic structures using transperineal ultrasound imaging. They found transperineal ultrasound imaging reliably calculates displacements of points that have been previously validated for women. Results showed the anorectal junction was strongly positively correlated with urethrovesical junction displacement in a superior/ventral vector. The displacement of the urethra in the area of the striated urethral sphincter was strongly negatively related to urethrovesical junction, and anorectal junction displacement. There was a weak inverse correlation between compression of the bulb of the penis and urethral displacement at the striated urethral sphincter. Both studies had high interclass correlation values providing evidence that transperineal ultrasound imaging is a reliable method in assessing the displacement of pelvic structures.


Jan 04, 2014

Late in 2013, the American Board of Obstetrics and Gynecology issued a revised definition for Board-Certified Obstetrician-Gynecologists. Included in this definition (for those who wish to maintain their certification status) is the restriction for OB-GYN's in treating male patients. The following exceptions are included: evaluation of fertility, sexually transmitted infections, transgender conditions, caring for men in active government service, for genetic counseling issues, administration of immunizations, family planning (excluding vasectomy), and for emergencies such as disaster response care. The full document can be found here

 

So where does this leave our male patients who have been fortunate enough, most likely after years of suffering, who find an OB-GYN who treats pelvic pain? The New York Times recently described the challenge of one such patient in this article. How many physicians are affected  by this issue? It's difficult to know exact numbers, but it is safe to assume that their patients are challenged in finding a replacement. 

 

What can be done to assure that male patients under the care of physicians impacted by the board's decision can still be treated? The International Pelvic Pain Society, of which many of our readers are members, has written to the gynecology board, requesting that treatment for male patients be allowed to continue. A petition started by "Male Patients Suffering from Pelvic Pain" has been started on change.org- you can access that petition here if interested. 

 

 


Nov 25, 2013

 

Urinary incontinence (UI) and erectile dysfunction (ED) are two well-known risks of a prostatectomy surgery. You may be familiar with research completed by Burgio et al. that treated men with one session of preoperative biofeedback training for pelvic muscle strengthening. The authors concluded that a single session of biofeedback and a daily home exercise program "…can hasten the recovery…and decrease the severity of incontinence following radical prostatectomy." While the conclusions of the study were positive, recommendations for preoperative care were difficult to make from one study.

 

A recent publication in The International Journal of Urology added to this body of work. Researchers in Australia retrospectively analyzed the results of 284 subjects operated on by one "high-volume" surgeon. The 152 men in the intervention group received physiotherapy-guided pelvic floor muscle (PFM) training preoperatively while the control group (n = 132) was instructed in pelvic floor muscle exercise by the surgeon alone. The surgeon's recommendations included verbal instructions to complete PFM exercises daily until the surgery. Postoperatively, all subjects were instructed in physiothrapist-guided PFM training. Outcome measures included 24-hour pad weight at 6 weeks and 3 months postoperatively, percentage of patients who were categorized as experiencing severe UI, and patient-reported time to one and zero pad usage daily. 

 

Therapist-guided PFM assessment and training consisted of the following: history and assessment of comorbidities, education in bladder, urethra, and pelvic floor muscle anatomy and function, and instruction in PFM activation in various functional positions. Transabdominal ultrasound was utilized to provide feedback to the patient during training. Technique was corrected so that overactivity in the superficial abdominals was avoided, and so that breath holding was avoided. Home exercise program instruction included completion in 10 contractions of 10 seconds each to be done in supine, in sitting, and in standing. Functional activation of PFM was encouraged such as during lifting, coughing, and squatting. 

 


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Upcoming Continuing Education Courses

Pelvic Floor/ Pelvic Girdle - Atlanta, GA
Sep 27, 2014 - Sep 28, 2014
Location: One on One Physical Therapy

Assessing and Treating Vulvodynia - Waterford, CT
Sep 27, 2014 - Sep 28, 2014
Location: Visiting Nurses Association - Southeastern

Pelvic Floor Level 2B - Durham, NC (SOLD OUT!)
Oct 03, 2014 - Oct 05, 2014
Location: Duke University Medical Center

Male Pelvic Floor - Tampa, FL
Oct 04, 2014 - Oct 05, 2014
Location: Florida Hospital - Wesley Chapel

Pelvic Floor Level 2A - St. Louis, MO (SOLD OUT!)
Oct 10, 2014 - Oct 12, 2014
Location: Washington University School of Medicine

Chronic Pelvic Pain - New Canaan, CT
Oct 10, 2014 - Oct 12, 2014
Location: Philip Physical Therapy

Pelvic Floor Level 3 - Maywood, IL
Oct 17, 2014 - Oct 19, 2014
Location: Loyola University Stritch School of Medicine

Lymphatic Drainage - San Diego, CA
Oct 18, 2014 - Oct 19, 2014
Location: FunctionSmart Physical Therapy

Pelvic Floor Level 1 - Boston, MA (SOLD OUT!)
Oct 24, 2014 - Oct 26, 2014
Location: Marathon Physical Therapy

Bowel Pathology and Function - Torrance, CA
Nov 08, 2014 - Nov 09, 2014
Location: HealthCare Partners - Torrance

Pelvic Floor Level 1 - San Diego, CA (SOLD OUT)
Nov 14, 2014 - Nov 16, 2014
Location: FunctionSmart Physical Therapy

Mindfulness- Based Biopsychosocial Approach to Chronic Pain - Seattle, WA
Nov 15, 2014 - Nov 16, 2014
Location: Swedish Hospital - Cherry Hill Campus

Yoga as Medicine for Pregnancy - New York, NY
Nov 16, 2014 - Nov 17, 2014
Location: Touro College

Pelvic Floor Level 2B - St. Louis, MO
Dec 05, 2014 - Dec 07, 2014
Location: Washington University School of Medicine

Pelvic Floor Level 1 - Omaha, NE (SOLD OUT!)
Dec 05, 2014 - Dec 07, 2014
Location: Methodist Physicians Clinic