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Tags >> Male Pelvic Floor
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. 

 


Nov 18, 2013

A recent study asked if transcutaneous electrical nerve stimulation (TENS) can be a helpful treatment for men who have refractory chronic pelvic pain. 60 men completed pain diaries and the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) at baseline, after 12 weeks of TENS treatment, and at last known follow-up. The mean age of the subjects was 46.9 years. TENS was measured as an effective treatment in nearly half of the men, and the benefits of the treatment were sustained during a mean follow-up of 43.6 months in 21 of 29 patients. The primary measurement tool for pain, the Visual Analog Scale, or VAS, significantly decreased from 6.6 to 3.9. Quality of life measurement was also improved, with more men feeling mostly satisfied, pleased, or delighted versus dissatisfied, unhappy, or terrible. 

 

What's the take home message? Regardless of the limitations of the study (non-randomized, non-placebo), TENS was found to be a safe and effective treatment without any adverse responses within this study. As a means of neuromodulation, which we know is critical in conditions of chronic pain, the application of electrotherapy is inexpensive, low-risk, and is a useful tool in the healing process. That healing process should include therapies that the patient can apply himself, so that he recognizes his own capacity and necessity for participating in recovery of function. 

 

As there are few studies that address electrotherapy only for chronic pelvic pain, this research is useful in adding some weight to our clinical choices in modality use. Does a patient need to utilize TENS for 12 weeks to determine efficacy? Probably not, but this is an easy modality that can be trailed in the clinic, and utilized as a home program tool if recorded as beneficial for the patient. 


Nov 04, 2013

Can patients successfully perform a pelvic muscle contraction following verbal instruction? This question was asked by Bump and colleagues in the often-cited research article published in 1991. Urethral pressure profiles were assessed in forty-seven women at rest and during a pelvic muscle contraction following brief, standardized verbal instruction. In the article, the authors found that nearly half of the women performed with "an ideal effort" leading to urethral closure without a Valsalva effort. 25% of the women, unfortunately, demonstrated an effort at muscular contraction that could promote incontinence. The authors' conclusion is that simple verbal or written instruction is not the best approach for a patient engaging in a pelvic floor muscle training program.

 

The limitations of the above study (small number of subjects, arbitrary definition of "effective Kegel," and inability to predict patient outcomes based on urethral profile) are made very clear throughout the article, yet how do we see this apply to our patient population? How often do we complete a perineal observation during an examination and identify that the patient is not generating any perineal movement, demonstrating a bearing down maneuver rather than a shortening, protective contraction, or creating such force through the abdomen that even a well-contracted pelvic floor would struggle against the strain from above? The value of the Bump study reminds us that not all patients respond positively to verbal or written instruction only. 

 

What about men? A recent study aimed to assess the ability of 52 healthy men (mean age of 22.6 years with a standard deviation of 4.42 years) to complete a pelvic muscle contraction in standing or crook lying following brief, standardized instruction. Real-time transabdominal ultrasound was used to measure bladder base elevation. 6 participants were unable to contract the pelvic floor muscles in either position, 17 were unable to contract the muscles in crook lying, and 14 could not contract the muscles in standing. While many of the men we instruct in pelvic muscle rehabilitation strategies are significantly older than the men in this study, the major point matches that of the Bump article: it is not safe to assume that a patient (even a young, healthy patient) can contract the pelvic floor muscles following verbal instruction. The authors suggest that transabdominal ultrasound may be a useful clinical tool for measuring bladder base elevation and therefore pelvic muscle activity. 

 

To be fair, more people in general need to be educated about the pelvic floor muscles; we can likely agree that the lack of awareness and discussion about the roles the PFM play in daily life leads to persisting dysfunction. There are people within the population who can activate the pelvic muscles appropriately with verbal instruction, and for this portion of the population, verbal or written instruction may be better than no instruction. Group education in community or institutional settings may benefit patients who are unwilling, unable or uninterested in acquiring a referral to a pelvic rehab provider. But for the group of patients who is either not contracting the muscles or bearing down rather than lifting, the consequences of doing pelvic muscle strengthening incorrectly may be significant. Do we need to change how we are instructing the patient verbally? Should we offer assessment of pelvic muscle contraction ability in varied positions? Must we include other functional applications of the coordinating muscles such as the respiratory diaphragm? At this time, there is not one answer. If we can ask the questions, read the research, and participate in our own way to the research, or at a minimum, apply these questions to clinical care, we may find the best answer for each individual patient. 


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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Minneapolis, MN (SOLD OUT!)
Jul 25, 2014 - Jul 27, 2014
Location: Abbott Northwestern Hospital

Athlete and the Pelvic Floor - Columbus, OH
Aug 02, 2014 - Aug 03, 2014
Location: OhioHealth Neighborhood Care Rehabilitation

Pudendal Neuralgia - San Diego, CA
Aug 09, 2014 - Aug 10, 2014
Location: Comprehensive Therapy Services

Biomechanical Assessment - Arlington, VA
Aug 16, 2014 - Aug 17, 2014
Location: Virginia Hospital Center

Yoga as Medicine for Labor and Delivery and Postpartum - Seattle, WA
Aug 16, 2014 - Aug 17, 2014
Location: Pilates Seattle International

Pediatric Incontinence - Greenville, SC
Aug 23, 2014 - Aug 24, 2014
Location: Proaxis Therapy

Pelvic Floor Level 1 - St. Louis, MO (SOLD OUT!)
Sep 05, 2014 - Sep 07, 2014
Location: Washington University School of Medicine

Meditation and Pain Neuroscience - Winfield, IL
Sep 06, 2014 - Sep 07, 2014
Location: Central DuPage Hospital Conference Room

Visceral Mobilization Level Two - Boston, MA
Sep 12, 2014 - Sep 14, 2014
Location: Marathon Physical Therapy

Coccyx Pain - Nashua, NH
Sep 13, 2014 - Sep 14, 2014
Location: St. Joseph Hospital Rehabilitative Services

Visceral Mobilization of the Urologic System - Scottsdale, AZ
Sep 19, 2014 - Sep 21, 2014
Location: Womens Center for Wellness and Rehabilitation

Care of the Postpartum Patient - Maywood, IL
Sep 20, 2014 - Sep 21, 2014
Location: Loyola University Stritch School of Medicine

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
Oct 03, 2014 - Oct 05, 2014
Location: Duke University Medical Center