Login / Create an Account

Phone646.355.8777

Tags >> Male Pelvic Floor
Sep 23, 2014

male sling

Surgery for prostate cancer can impair urinary function, and in the case of persistent urinary incontinence, patients may progress to surgical interventions. In order for physicians to conduct optimal patient counseling and surgical candidate selection for post-prostatectomy urinary incontinence (UI), the records of 95 patients were reviewed in this study. The patients were retrospectively placed into "ideal", n = 72, or "non-ideal", n = 23, categories based on chosen characteristics, and the results of their outcomes and satisfaction were consolidated. Men in the "ideal" group had the following characteristics: mild to moderate UI, external urethral sphincter that appeared intact on cystoscopy, no prior history of pelvic radiation or cryotherapy, no previous UI surgeries, volitional detrusor contraction with emptying of the bladder, and a post-void residual of < 100 mL. Patients who did not meet all listed criteria for the "ideal" group were placed into the "non-ideal" classification.

 

A cure for the surgery was considered total resolution of post-prostatectomy incontinence with the sling. Of the patients fitting into the ideal classification, 50% reported cure, and of the non-ideal group, 22% reported a cure. Satisfaction rates within the ideal group for the procedure were 92%, whereas the non-ideal group reported a 30% satisfaction. Although uncommon, complications occurring in both groups included prolonged pelvic pain and worsened urinary incontinence. The authors describe the importance of placing the correct amount of tension through the sling, and of leaving as much of the external urethral sphincter in place as possible. Another complication that occurred more frequently is that of acute urinary retention. In the ideal cohort, the 11 cases of urinary retention resolved within 6 weeks of surgery. Of interest is that 12 of the 23 men in the "non-ideal" category had to undergo further surgery with an artificial urethral sphincter.

 

This information can assist surgeons in guiding and advising patients about operative procedures for post-prostatectomy incontinence. (Ideally, every patient would "fail" a trial of pelvic rehabilitation prior to progressing to a surgery!) If a patient wishes to proceed with a sling surgery despite being in a "non-ideal" category, he could be advised of the known potential outcomes. This article offers support for pre-operative investigation techniques such as urodynamics. Our role as pelvic rehabilitation providers may allow us to discuss such research with patients and providers, and participate in discussions about the role of rehabilitation pre-operatively or post-operatively. If you would like to learn more about working with men who have pelvic floor dysfunctions, you still have time to book a flight to Orlando for the Male Pelvic Floor Function, Dysfunction, & Treatment course, where you can learn about male pelvic pain, incontinence and BPH, and male sexual dysfunction. This is the last opportunity to take this course this year!


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 26, 2014

In an article describing vascular dysfunction in women with chronic pelvic pain (CPP), Foong and colleagues describe the common finding of pelvic venous congestion. This study aimed to determine changes in microcirculatory function in women with chronic pelvic pain compared to controls. Eighteen women presenting with chronic pelvic pain of at least 1 year and 13 women without pelvic pain or congestion were evaluated for isovolumetric venous pressure, miscrovascular filtration capacity, and limb blood flow. All women were of reproductive age, menstruating regularly, and measurements were made during the mid follicular and the midluteal stages of the same 28 day cycle. The 18 women with CPP fit previously established criteria for pelvic congestion.

 

The women in the patient group were re-evaluated at 5-6 months following treatment for pelvic congestion, with treatment including medication-induced suppression of ovarian function for 6 months, and in 4 patients, hysterectomy and bilateral salpingo-oopherectomy. All of the patients received daily hormone replacement therapy (Premarin and Provera) "…to minimize the hypo-oestrogenic effects of treatment."

 

Findings of the research include an elevation in isovolumetric venous pressure, or Pvi in women with CPP compared to controls. Interestingly, there were no changes related to menstrual cycle in measures of microvascular filtration capacity and and limb blood flow. The conclusion of this study is that women with chronic pelvic pain may present with systemic microvascular dysfunction. The noted increase in Pvi "…may be attributable to systemic increases in post capillary resistance secondary to neutrophil activation." Following treatment for pelvic congestion, the value changes in isovolumetric venous pressure were no longer present.

 

This research highlights the noted changes in microcirculatory function in women with chronic pelvic pain. The obligatory chicken and egg conversation weighs in: does pelvic congestion lead to pelvic pain, or does pelvic pain always precede pelvic congestion? While the answer is probably that either condition can cause and perpetuate the other, as pelvic rehabilitation providers, our first thought might be: what would the research outcomes be if the treatment were not medication-induced ovarian suppression or surgery, but therapy directed to the pelvic pain and congestion? The Institute offered, for the first time last year, a course that allows the therapist to address pelvic pain through treatment of pelvic lymphatic drainage. The Lymphatic Drainage for Pelvic Pain continuing education course is a 2-day class instructed by Debora Hickman, a certified lymphedema therapist. Sign up now to save your seat in October in San Diego, and if you can't make this course, contact us to let us know you are interested in this special topics course, and we will keep you informed of any new course bookings!


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. 

 

 


Jul 31, 2014

Hip

While many of the Herman & Wallace Pelvic Rehabilitation continuing education courses focus on study of the pelvic floor muscles, the inclusion and consideration of the trunk, breathing, form and force closure, and posture are also needed to truly understand the pelvis. Our professional education does not prepare us well in regards to understanding the pelvic floor and pelvic girdle, and the foundational concepts that provide clinical meaningfulness come from a variety of research camps. If you feel that you were never provided this foundational information about the pelvic girdle and trunk, and wish to better apply practical concepts in movement and muscle facilitation (or inhibition), you might be looking for the Pelvic Floor/Pelvic Girdle continuing education course that is coming to Atlanta in late September.

 

The course covers interesting topics such as pelvic floor muscle activation patterns in health and in dysfunction, use of load transfer tests such as the active straight leg raise, orthopedic considerations of pelvic dysfunction, pelvic floor muscle (PFM) exercise cues, risk factors for pelvic dysfunction, and treatment of the coccyx. If you (or a friend you want to take a course with) is not quite sure about internal pelvic floor coursework at this time, the good news is that this course addresses pelvic dysfunction using an external approach. Experienced therapists can appreciate the research-based approach to muscle dysfunctions that can cause or perpetuate a variety of symptoms, and newer therapists have the chance to learn how to integrate pelvic floor/pelvic girdle concepts into current practice. A biofeedback lab introduces use of surface electromyography (sEMG) as well.

 

There is still time to sign up for the September course in Atlanta, the only remaining opportunity to take the Pelvic Floor/Pelvic Girdle continuing education course this year. Bring a friend, or a colleague, and work together to combine external and internal approaches to pelvic dysfunction.


Jun 18, 2014

Fascia is finally getting proper respect, rather than being that "white stuff" that was cut away during anatomy labs. Researchers continue to explore the cellular mechanisms and the total body functions that require healthy fascial layers. Fascial planes and connections are increasingly considered in strengthening programs as well, rather than only being considered in the design of stretching or flexibility programs. Tom Myers author of Anatomy Trains, and student of Rolfing founder Ida Rolf, contributes not only to the anatomical knowledge of therapists, but also to the functional applications of fascia in daily life and in exercise regimens.

 

Within the world of exercise training and physical fitness, muscles have often been considered in isolation, as is pointed out in this article written by Tom Myers in IDEA Fitness Journal. Yet muscles rarely work functionally as an isolated structure. Consider this fact when teaching pelvic floor muscle training. How many times have you instructed a patient to utilize thigh adductor muscles, exhale (respiratory diaphragm), or activate transversus abdominis to augment or facilitate the pelvic floor? While there is value in requesting that a patient focus on or emphasize a pelvic muscle contraction, or in teaching a patient to quiet dominant abdominals or gluteals, rarely do we find it effective to teach total isolation of a muscle in functional re-training.

 

Mr. Meyers uses anatomical information to drive the emphasis on fascial training, pointing out that there are ten times more sensory nerve endings in fascia than in muscles, and describes fascia as requiring our knowledge of accurate anatomy to engage the fascial planes as an "organ system of stability." Myers makes the case that fascia responds better to variation than to a repeated program when aiming to build fascial resilience. Varied tempo, varied loads, and varied movements are key to improving fascial health and efficiency. Integration of kinesthetic awareness via the fascial tissues rather than the muscles is also an important concept that is discussed- bringing awareness to movement through skin and superficial tissue movement rather than directing attention only to joint motion is another concept proposed for advancing movement training programs.

 

Considering these concepts may or may not change how you are currently designing your patients' fitness and rehabilitation programs, depending upon how you were trained and upon how you have continued to access continuing education and research. Breaking old habits and re-learning how to train movement does take effort on the part of the rehabilitation therapist, and fortunately, many instructors are integrating concepts of fascial planes into coursework. One such course that focuses clearly on integrating fascial training into sports-specific rehabilitation is Biomechanical Assessment of the Hip and Pelvis taking place this August in Arlington, Virginia. Instructor Steve Dischiavi, physical therapist and athletic trainer to the Florida Panthers, offers an excellent course that includes exercise concepts specific to the idea of fascial "slings" and that is sure to add some new exercises to your tool bag.


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. 


  • «
  •  Start 
  •  Prev 
  •  1 
  •  2 
  •  3 
  •  4 
  •  Next 
  •  End 
  • »

Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Oakland, CA (SOLD OUT)
Jan 09, 2015 - Jan 11, 2015
Location: Samuel Merritt University

Care of the Postpartum Patient - Santa Barbara, CA
Jan 10, 2015 - Jan 11, 2015
Location: Human Performance Center

Visceral Mobilization of the Urologic System - Fairlawn, NJ
Jan 16, 2015 - Jan 18, 2015
Location: Bella Physical Therapy

Sexual Medicine for Men and Women - Houston, TX
Jan 23, 2015 - Jan 25, 2015
Location: Women's Hospital of Texas

Pelvic Floor Level 1 - Maywood, IL (SOLD OUT!)
Jan 23, 2015 - Jan 25, 2015
Location: Loyola University Stritch School of Medicine

Sacroiliac Joint Evaluation and Treatment - Seattle, WA
Jan 24, 2015 - Jan 25, 2015
Location: Pacific Medical Center

Menopause: A Rehabilitation Approach - Orlando, FL
Feb 21, 2015 - Feb 22, 2015
Location: Florida Hospital Sports Medicine and Rehabilitation

Breast Oncology - Phoenix, AZ
Feb 21, 2015 - Feb 22, 2015
Location: Spooner Physical Therapy

Pelvic Floor Level 2B - Houston, TX
Feb 27, 2015 - Mar 01, 2015
Location: Texas Children’s Hospital

Special Topics in Women's Health - San Diego, CA
Feb 28, 2015 - Mar 01, 2015
Location: Comprehensive Therapy Services

Pelvic Floor Level 1 - Bayshore, NY
Mar 01, 2015 - Mar 03, 2015
Location: Touro College: Bayshore

Care of the Pregnant Patient - Seattle, WA
Mar 07, 2015 - Mar 08, 2015
Location: Pacific Medical Center

Pilates for the Pelvic Floor - Denver, CO
Mar 07, 2015 - Mar 08, 2015
Location: Cherry Creek Wellness Center

Pelvic Floor Level 3 - Fairfield, CA
Mar 13, 2015 - Mar 15, 2015
Location: NorthBay HealthCare

Male Pelvic Floor - Nashville, TN
Mar 14, 2015 - Mar 15, 2015
Location: Vanderbilt University Medical Center