The Institute is sponsoring a radio show hosted by Dr. Melanie Barton and featuing Amy Stein, MPT, BCB-PMD. Amy will talk about Interstitial Cystitis and Pelvic Pain and the role of physical therapy in treating these problems

Tune in on April 28th or visit Dr. Melanie's site to download the podcast.

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.

On April 18th, a group of German and Italian researchers published this article on the impact of episiotomy on pelvic floor dysfunction. The paper found that "Episiotomy appears to be a protective factor for women's wellness. Women who had episiotomy and who experienced perineal symptoms have a better psycho-physical health status in the 12.79 months follow-up."

Available for download is a 15 page PDF of "Impact of episiotomy on pelvic floor disorders and their influence on women's wellness after the sixth month postpartum: a retrospective study". The PDF contains research highlights (including Abstract, Background, Methods, Results and Conclusion)

Much has been made of the research indicating that a Caesarean section has a protective effect on the pelvic floor, with some women requesting a CS in order to avoid pelvic floor dysfunction (PFD). This practices raises concern about an elective approach to CS versus natural vaginal birth, as CS are by no means without risk to the mother, the fetus, and to the neuromusculoskeletal system. Recent research contributes to this discussion by assessing several variables including quality of life factors and pelvic dysfunction following either a CS or natural vaginal birth. Twenty one women who had given birth in the prior 36 months were recruited from daycare facilities. Subjects were categorized into normal vaginal delivery (NVD) or Caesarean section (CS). Subjects were only included if they gave birth to singletons, had not previously participated in pelvic rehabilitation, or if they did not had a history of pelvic surgery, neurologic issues or trauma that affected bowel and bladder function. Outcomes tools included the SF-36, and the Pelvic Floor Distress Inventory (PFDI). Within the PFDI, outcomes tools assessed urinary, colorectal, prolapse, and pelvic floor functional impact.

Nearly 70% of the women in the group studied were between the ages of 30 and 39, with ages ranging from 21-45. The number of subjects who had given birth vaginally was 16, by Caesarean section, 5. The authors report that approximately 75% of their subjects were Caucasian, had a household income of 70,000 or more, and nearly 80% had at least a four-year degree. The women in the CS group reported higher rates of urinary incontinence and pelvic pain (90% and 67%, respectively) when compared to the NVD group (50% and 23%). Women who gave birth via CS also had higher mean scores on the Urinary Distress Inventory, Colorectal-Anal Distress Inventory, and the Pelvic Organ Prolapse Distress Inventory. The authors also noted a correlation between pelvic organ prolapse and body mass index (BMI) greater than 25.

This research contributes to the literature about birth mode and pelvic dysfunction, and the study conflicts with other data that describes a protective effect of Caesarean birth mode on the pelvic floor. While avoiding vaginal delivery may indeed help reduce some injury to the pelvic floor, this study, even though the sample size was not large, reminds us that CS delivery can be associated with pelvic dysfunction and symptoms. This study was different from many prior reports in that the subjects were surveyed in the chronic rather than immediate postpartum period. If you are interested in learning more about postpartum rehabilitation, check out the Institute's offerings on this page: http://hermanwallace.com/postpartum.

With words like jumping, diving, spiking, hitting, and blocking making up the game's activities, volleyball is clearly a sport that requires a healthy pelvic floor. We know that athletes are at risk for pelvic dysfunction, with symptoms ranging from tension to leakage, but what happens when the pelvic floor is reeducated? In a study addressing volleyball players, researchers assess the effectiveness of a pelvic muscle rehabilitation program on symptoms of urinary incontinence. 32 female athletes were divided evenly between a control group and an experimental group. Inclusions criteria for the sample was nulliparity, symptoms of stress urinary incontinence, age between 13 and 30, and leakage amount more than 1 gram on the pad weight test. Exclusion criteria is as follows: treatment time of less than six months, sport practice for less than two years, urinary tract infections (either current or repeated prior infections), intervention adherence less than 50%, or body mass index outside of the range of 18-25.

Before and after intervention, the athletes were given a baseline questionnaire, a pad test (in the first 15 minutes of volleyball practice), and they completed seven days of a bladder diary to track leakage. The treatment group were instructed in anatomy and physiology of the lower urinary tract, about urinary incontinence (UI) and UI in athletes, and in leakage prevention strategies. A 3-day bladder diary was completed to improve awareness of fluid intake and bladder habits. Pelvic muscle awareness and correct contractions, doing protective pre-contractions of the pelvic floor, and a home exercise program of quick and endurance pelvic muscle contractions in different positions were also instructed.

The results of the intervention include a significant decrease in urinary leakage in the treatment group. The education provided also allowed for prevention of negative coping strategies that were reported in the subjects: the athletes would conceal leakage by wearing a menstrual pad, decreased their fluid intake, or empty their bladder more frequently. This study contributes to the growing body of evidence linking sport to pelvic dysfunction, and more importantly, rehabilitation efforts to improvement. If you want to learn more about pelvic dysfunction in athletes, come to The Athlete and the Pelvic Floor with Michelle Lyons. This 2-day continuing education course took place recently in New York City and your next opportunity to take the class is in Denver in October!

In the treatment of pelvic dysfunction, collaboration among physicians and pelvic rehabilitation providers creates an optimal care situation for the patient. In a research article that will be published in the July issue of Journal of Lower Genital Tract Disease, physical therapist and Herman & Wallace Institute faculty member Stacey Futterman demonstrates how a partnership between disciplines provides information valuable to the field of pelvic rehabilitation. Stacey and physicians Deborah Coady, Dena Harris, and Straun Coleman hypothesized that persistent vulvar pain may be generated by femoroactebular impingement (FIA) and the resultant effects on pelvic floor muscles. Through the research, the authors attempted to determine if hip arthroscopy was a beneficial intervention for vulvar pain, and if so, which patient characteristics influenced improvements.

Twenty six patients diagnosed with generalized, unprovoked vulvodynia or clitorodynia underwent arthroscopy for femoroacetabular impingement. For 3-6 months following hip repair, patients were treated with physical therapy that included surgical postoperative rehabilitation combined with rehabilitation for vulvodynia. Time period for follow-up data collection ranged from 36-58 months. Six patients reported improvements in vulvar pain following surgery and did not require further treatment, and it is noted that these patients were all in the youngest age bracket (22-29). Among the patients who did not report sustained relief, relatively older ages (33-74) were noted, along with a tendency to have vulvar pain for 5 years or longer.

The relationship between hip and pelvic pain may come from the bony structures, hip muscles including but not limited to the obturator internus, and nerves such as the pudendal. The authors conclude that "All women with vulvodynia need to be routinely assessed for pelvic floor and hip disorders…" and if needed, treatment should be implemented to address the appropriate tissue dysfunctions. If you are interested in learning more about hip dysfunction so you can better screen for dysfunction such as femoroacetabular impingement, check out faculty member Steve Dischiavi's continuing education course. Biomechanical Assessment of the Hip & Pelvis: Manual Movement Therapy and the Myofascial Sling System takes place next in Durham, North Carolina in May.

Patients diagnosed with colorectal cancer may undergo a procedure called mesorectal excision as part of their oncology management. In this procedure, a significant portion of the bowel is removed along with the tumor. Total mesorectal excision refers to the entire rectum and mesorectum (peritoneum that connects the upper rectum.) The rectum is removed up to the level of the levator muscles, and this procedure is indicated for tumors of the middle and lower rectum. In a study published in the World Journal of Oncology, the authors report on female urogenital dysfunction following total mesorectal excision (TME).

Questionnaires were returned by 18 women (age range 34-86) who had undergone TME for rectal cancer. Results of the study are summarized in the chart below. (All patients had reported vaginal childbirth, and five had undergone total abdominal hysterectomy and oophrectomy.)

Sexual function

Urinary function

The authors conclude that rectal cancer treatment can worsen urinary symptoms of nocturia and stress incontinence. Patients who had also been treated with a hysterectomy were found to have more significant symptoms. A proposed mechanism of this increase in symptoms in women who had undergone a hysterectomy is the prior nerve dissection which, when added to the nerve dissection of the inferior hypogastric plexus and the hyogastric nerves for the total mesorectal excision, may have an additive effect. This study which is available full-text, free access, describes further the relationship between the autonomic nervous system in the female pelvis, pelvic function, and the surgery for rectal cancer. Data such as the information provided in this study allow medical providers and their patients to make well-informed decisions about surgeries and quality of life risk factors that may guide medical management of colorectal cancer.

If you would like to feel better prepared to manage post-surgical issues that arise following treatments for colorectal cancer in women, check out the Institute’s Oncology and the Female Pelvic Floor course taught by faculty member Michelle Lyons. This continuing education course happens next in May in Torrance, California.

You know how some women report that they have a mild prolapse that feels better if they wear a tampon during strenuous activity, or that a tampon worn (temporarily) helps avoid urinary leakage? Using a tampon instead of a pessary seems like a great fix, with one problem: tampons are not designed to be used as a pessary. They are designed to be absorptive and to expand to fill the vaginal canal as they expand. Some women can even suffer from toxic shock syndrome - a condition related to bacterial infection and associated with super-absorbent tampon use, contraceptives, and diaphragm use. What if an item could be used that is similar to a tampon, but not absorptive, and that provided more support than a cylindrical-shaped tampon? That must have been what Kimberly Clark, the manufacturer of a new product, created to fit this need.

The Impressa is marketed as a device for urinary incontinence that a patient can buy over-the-counter. The product comes in an applicator and can be inserted similarly to the way a tampon is, but the Impressa is not made to absorb leaks. Once inserted, the product has an interesting shape that is designed to help support the urethra. The device comes in 3 sizes labeled 1, 2, and 3, and the product has a "sizing kit" with 2 of each size in a box that can be trialed for finding the best fit. It will be interesting to see how valuable this product is and we will only know as we begin to hear feedback from their use. Pessary fit is a tough process in that providers and patients often have to go through a period of trial and error for best fit, and also because providers are poorly reimbursed for management of pessary fit and use. (Click here to read more on the blog about prolapse and pessaries.)

It appears that the product is not yet widely available, but it will be interesting to hear women's' experiences about the product. Having an option for an affordable, disposable pessary-like device that is available over-the-counter could be a very helpful option to know about. Health professionals can go to the website impressapro.com to send an email requesting a sample or more information. And thank you to certified Pelvic Rehabilitation Practitioner Joyce Steele for sharing information about the Impressa as this may be something your patients start asking more about. To learn more about prolapse management and female pelvic floor dysfunction, come to one of our intermediate-level continuing education courses, PF2B. The next opportunities to take this class (that aren't sold out!) are in Connecticut, North Carolina, and Missouri this year.

In a case report published within the past year by physical therapist Karen Litos, a detailed and thorough case study describes the therapeutic progression and outcomes for a woman with significant functional limitation due to a separation of her diastasis recti muscles. The patient in the case is described as a 32-year-old G2P2 African-American woman referred to PT at 7 weeks postpartum. Delivery occurred vaginally with epidural, no perineal tearing, and pushing time of less than an hour. Primary concerns of the patient included burning or sharp abdominal pain when lifting, standing, and walking. Uterine contractions that naturally occurred during breastfeeding also worsened the abdominal pain and caused the patient to discontinue breastfeeding. The patient furthermore reported sensations that her insides felt like they would fall out, and abdominal muscle weakness and fatigue with activity.

Although many other significant details related to history, examination and evaluation were included in the case report, I will focus on the signs, interventions, and outcomes recorded in the paper. Diastasis was measured using finger width assessment and a tape measure. (Although ultrasound is more accurate and valid, palpation of diastasis has been demonstrated to have good intra-rater reliability as used in this study. Measures for interrecti distance (IRD) at time of evaluation were 11.5 cm at the umbilicus, 8 cm above the umbilicus, and 5 cm below the umbilicus. The patient also reported pain on the visual analog scale (VAS) of 3-8/10.

Interventions in rehabilitation included, but were not limited to: instruction in wearing an abdominal binder, appropriate abdominal and trunk strengthening (promotion of efficient load transfer and avoidance of exercises that may worsen separation), biomechanics training with functional tasks such as transfers, self-bracing of abdominals, avoiding Valsalva, postural alignment and symmetrical weight-bearing strategies. Plan of care was developed as 2-3x/week for 2-3 weeks, the patient was seen for 18 visits over a four month period. Therapeutic exercise was progressed to include general hip and trunk muscle strengthening towards a goal of stability during movement. Cardiovascular training progressed to light treadmill jogging and use of an elliptical.

After 18 visits, functional goals were all met and included picking up her baby, holding her baby for 30 minutes, standing or walking for at least an hour. VAS pain score progressed to 0 on the 0-10 scale. The diastasis was measured at discharge to be 2 cm at the umbilicus, 1 cm above the umbilicus, and 0 cm below the umbilicus. This case report is first an excellent example of a detailed case example. Second, while the separation dramatically improved, most importantly, the patient’s function improved and her goals were met. This case is a wonderful example of how sharing details of a patient’s rehabilitation efforts can be useful for other rehabilitation therapists to consider when developing a plan of care.

If you are interested in discussing more about postpartum care, check out the first in our peripartum series, “Care of the Pregnant Patient” taking place next in Boston in May with Institute co-founder Holly Herman.

Sexual dysfunction is a common negative consequence of Multiple Sclerosis, and may be influenced by neurologic and physical changes, or by psychological changes associated with the disease progression. Because pelvic floor muscle health can contribute to sexual health, the relationship between the two has been the subject of research studies for patients with and without neurologic disease. Researchers in Brazil assessed the effects of treating sexual dysfunction with pelvic floor muscle training with or without electrical stimulation in women diagnosed with multiple sclerosis (MS.) Thirty women were allocated randomly into 3 treatment groups. All participants were evaluated before and after treatment for pelvic floor muscle (PFM) function, PFM tone, score on the PERFECT scheme, flexibility of the vaginal opening, ability to relax the PFM’s, and with the Female Sexual Function Index (FSFI). Rehabilitation interventions included pelvic floor muscle training (PFMT) using surface electromyographic (EMG) biofeedback, neuromuscular electrostimulation (NMES), sham NMES, or transcutaneous tibial nerve stimulation (TTNS). The treatments offered to each group are shown below.

The following factors made up some of the inclusion criteria for the study: age at least 18 years, diagnosis of relapsing-remitting MS, 4 month history of stable symptoms, currently participating in a sexually active relationship, and able to contract the pelvic floor muscles. Participants were excluded if they had delivered within the prior 6 months, had pelvic organ prolapse (POP) greater than stage I on the POP-Q, were perimenopausal or menopausal. Neurologic function symptoms were also monitored so that subjects could be evaluated for any potential flare-up. Home program instruction in PFMT included 30 slow and 30 fast PFM contractions to be completed in varied postures 3x/day.

Results included that all groups improved via the PERFECT scheme evaluation. Other specific indicators of improvement were noted for each group, and the use of the FSFI provided measures of sexual function. The authors conclude that pelvic floor muscle training (with or without electrostimulation) can produce positive changes in sexual arousal, vaginal lubrication, sexual satisfaction and sexual lives. The use of PFMT with intravaginal NMES "…appears to be a better treatment option than PFMT alone or in combination with PTNS in the management of the orgasm, desire and pain domains of [the FSFI]." You can find the abstract of the article by clicking here.

Patients who are managing disease symptoms of MS have many aspects of the disease that can interfere with sexual health, such as energy levels, neurologic impairment, and pain. Use of modalities such as biofeedback and/or electrotherapy may be useful adjuncts in the care of women who have MS. Prior research has identified the benefits of electrotherapy for urinary dysfunction in patients who have MS. The described research allows us to consider inclusion of these tools along with pelvic floor muscle training when working with women who experience sexual dysfunction as a part of MS.