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. 

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. 

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. 

At the annual conference of the California Biofeedback Society last week, a new device was described for the treatment of jaw pain. The SleepGuard biofeedback headband can be worn by the user and when the band senses that the jaw is clenched, an alarm will sound to deter the patient from the clenching. It makes sense that a patient can re-train the body to avoid muscle tension with such a device. 

So what can we do about the butt grippers? Although some clever and potentially not-so-comfortable ideas come to mind in relation to biofeedback sensors and the pelvis during sleep, how do we educate our patients who tend to clench at night to let go and avoid that morning pain? If you are unfamiliar with the concept of "butt gripping," please check out the work of Diane Lee, from whom I first heard the term. In an article on her website, Diane discusses the concept of gripping with the chest, back, or butt. Chances are, you can think of a patient who fits one of the categories. (Not that any of us have movement dysfunction, but you might have "a friend" who could use some guidance in re-training one of the gripping patterns.)

Patients who tend to clench any muscle all night will be creating compression in nearby joints, and the muscles will not be getting proper recovery and rest time during sleep. These patients will often wake with increased pain in the area of tension or muscle guarding. The first step in treating a condition of gripping is awareness: if you have no idea that you are creating tension in a muscle, the re-training of the muscle won't happen. Help your patients understand that a tendency to tighten a muscle group may be a habit brought up by the body guarding a region for various purposes. Consider the patient who has low back pain- tightening or splinting the area with muscle contractions may be a useful strategy early in the injury. Once a patient is aware of the tension that may aggravate a painful area or promote a dysfunctional movement pattern, creating new strategies is critical. Your patients may require soft tissue or joint mobilization, muscle balancing techniques, movement re-training (to include functional patterns or tasks), and general awareness or relaxation techniques. 

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. 

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.

In the February 2012 issue Mayo Clinic Proceedings, Dr. Faubion and colleagues discuss the symptoms and management of nonrelaxing pelvic floor issues. In this clinical review, the authors differentiate between conditions that involve relaxed pelvic floor muscles (pelvic organ prolapse, urinary incontinence) with conditions in which non-relaxing pelvic floor muscles play a key role. When the muscles of the pelvic floor have difficulty in relaxing, this can impair the person’s function with defecation, urination, and sexual activity. The review focuses on the symptom complex called “nonrelaxing pelvic floor” so that care providers can manage the condition effectively, and in the words of the authors, provide early referral to physical therapy that can address the muscle dysfunction.

When learning about the various diagnoses for pelvic floor pain conditions, medical providers and pelvic rehab therapists are faced with a long list of terms that have overlapping symptoms. Some of the terms listed in this article include coccygodynia, levator ani syndrome, piriformis syndrome, and puborectalis dyssynergia. It is pointed out that using the description of non-relaxing pelvic floor has the ability to encompass many of these other terms without inaccuracy in diagnosis. Dr. Faubion suggests that medical providers look for the cluster of symptoms that tend to accompany non-relaxing pelvic floor conditions, including voiding dysfunctions, constipation,  dyspareunia, low back pain and pelvic pain. 

A recent Johns Hopkins Health Alert reflects a current issue in the family practice and urology clinics. For decades, men who presented to their medical care provider with symptoms of perineal aching and malaise were diagnosed with prostatitis, or inflammation of the prostate gland, and then they were given antibiotics. It is not uncommon to meet men who have been on multiple courses of antibiotics over a period of years. Due to research that has emerged over the past decade, the prescribing of antibiotics has been questioned since most men do not actually have an infection. 

Jeanette Potts, urologist, has written several articles and presented research about this issue. You can read an article about prostatitis by Dr. Potts by clicking here.  The article describes the importance of classifying patients accurately into true infection versus chronic pain or neuromuscular dysfunction. The general population estimate for prevalence of prostatitis is 5-10%, and the estimated number of patients diagnosed with prostatitis who actually have an infection (bacterial prostatitis) is also 5-10%. 

While it is well-documented that prostatectomy surgery negatively impacts sexual and urinary function in a significant portion of men, this case series asks if correcting the surgery-related incontinence can improve sexual function. This article looks at a group of men who were all treated by the same surgeon for radical prostatectomy (RP) surgery. 15 men who experienced urinary incontinence after the RP were then surgically treated with an anti-incontinence surgery, either a male sling or an artificial urinary sphincter  (AUS) . 11 of these 15 men were sexually active and they completed post-surgical outcomes for both urinary and sexual function.

Of the 11 men described in the study, 4 of them had the AUS and the remaining 7 had the sling surgery. All of the men reported significant improvements in urinary incontinence (the goal of the surgery.) Most of them also reported a significant increase in their sexual quality of life. It was noted that the 4 men treated with the AUS reported a marked improvement, and in the group of 7 men who had the sling procedure, more than half of them reported marked improvements. 

This is encouraging information for men who are suffering from the effects of prostate surgery. Could it be that overall sense of wellness and virility improved because urinary incontinence in general was improved, or that urinary leakage during sexual activity was improved? The authors acknowledge that more research is needed to determine if a UI surgery would be beneficial for men who have UI only with sexual health.