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Herman & Wallace Blog

Female Genital Cosmetic Surgery (FGCS)

Female Genital Cosmetic Surgery

What is it?

Female surgeries for modifying the genitalia are completed for many reasons of aesthetics or for reconstruction purposes. These surgeries or procedures may include:

Labioplasty: the reduction or augmentation (injection) of the labia minora or labia majora

Vaginal tightening procedure: aka "vaginal rejuvination" this involves narrowing the lower third of the vagina to tighten the canal for improved sensation during intercourse

Hymenoplasty: Narrowing the vaginal orifice by stitching together the hymenal remnants (an unbroken hymen can be a sign in some cultures of virginal status and female worthiness)

Clitoroplasty: reduction of the clitoral hood, clitoral reduction

Others: Perineoplasty, pubic enhancement, G-spot amplification

For a summary of several of the procedures mentioned, please click here for an article from PubMed Central.

So what's the big deal?

From the article linked above by Dobbleir et al., in 2011: "The absence of guidelines and evidence about aesthetic genital surgery has led to a comparison with female genital mutilation." TheWorld Health Organizationdefines genital mutilation as "removing and damaging healthy and normal female genital tissue. The American Congress of Obstetricians and Gynecologists found this issue to be of concern and in 2007 issued a statement against non-medical procedures.

How is it marketed?

Women (and girls) interested in FGCS are likely to seek information on provider websites. More often these websites are from cosmetic surgery practices versus gynecology practices. An article in 2011 reported on the information found on such websites, and concluded that both the quality and quantity of the information on the websites was poor and included incorrect information.

How is it helpful for us to be aware of FGCS?

In a recent MedScape article, Dr. Iglesia describes how the media has influenced young women and girls in the fad of removed pubic hair and "Barbie-doll" genitalia, leaving little room for the typical variations that occur in size and shape of the female genitals. More young girls (and it is pointed out that mothers are bringing their young daughters in for these procedures) are requesting to have their genitals modified to fit this standard that appears in the media. We can serve as a resource when a girl or woman is asking about "how things should look" or about an aesthetic procedure. While there are medical indications for a vaginal surgery, a cosmetic indication must be considered carefully in light of the potential complications that can include permanent damage, nerve dysfunction, pain, and other known side effects. Dr. Iglesia also recommends that health professionals serve as educators, sharing information about the variety of genital anatomical presentations that are both normal and healthy. She also recommends the book Petals as a resource. Check out the website for the book and the other products and information on the website by author Nick Karras.

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Childhood Abuse and Pregnancy

Mirjam Lukasse of the University of Tromso in Norway and colleagues have completed interesting and relevant research among women who have experienced childhood sexual abuse and pregnancy. In a longitudinal cohort study based on data from the Norwegian Institute of Public Health, nearly 5000 women were questioned about childhood abuse and feelings about pregnancy. Between 18 and 30 weeks of gestation and again 6 months postpartum, subjects were sent questionnaires to assess associations between childhood abuse and women's fears about childbirth or preference for cesarean section (c-section) during pregnancy.In the study, 21% of the women reported experiencing childhood abuse. Women who were abused reported a significantly higher rate of fear of childbirth when compared to women who did not report abuse (23% and 15%, respectively.) Subjects who reported abuse were also more likely to state a preference for a c-section during the second pregnancy (6.4% versus 4%.)

The same author was the primary researcher on an article summarized as the following: "Abuse in childhood is associated with increased reporting of common complaints of pregnancy." The authors point out that clinicians need to consider the issue of childhood abuse when working with pregnant women who have multiple complaints or increased challenges from typical complaints in pregnancy. In a similar updated article, Lukasse and colleagues describe the relationship between sexual violence and pregnancy-related symptoms. You can access the full text article by clicking HERE. Prior or recent severe sexual violence is correlated in this research with suffering from equal to or greater than 8 pregnancy-related symptoms. Symptoms include backache, fatigue, constipation, pelvic girdle dysfunction, nausea/vomiting, edema, headache, urinary dysfunction, pruritus, and others.

Let's address the potential value of this information. Most of us who work in pelvic rehabilitation also treat women who are pregnant or who may become pregnant. While assuming that a woman who has significant pregnancy-related symptoms has been abused is not appropriate, considering that she has a history of abuse may be helpful to the patient. A woman who is experiencing abuse while pregnant may feel especially vulnerable as she considers how to care and provide for her child. Knowing how to ask questions in a respectful and clear way can be extremely helpful. The website "Survivors of Childhood Sexual Abuse" has a page of helpful language and strategies for the primary care provider who is engaging in a conversation about abuse. If you scroll down to the bottom of the page in the link you will find a printable summary of how to sensitively ask questions about abuse. Consider utilizing this information for an upcoming article review or inservice to staff or colleagues. Sharing statistics with patients and developing the habit of asking all patients about abuse can help to normalize the discussion so that patients feel safe enough to reach out when able.

Many of you are familiar with the foundational work of Penny Simkin, who is trained as a physical therapist and a childbirth educator. One of her more recent contributions to the field of childbirth is her book "When Survivors Give Birth" which discusses the challenging journey many women who have been abused face when in the midst of a pregnancy. In addition to having books for purchase, Penny also gives lectures on many topics including survivors and birthing. Her website can be accessed here.

These topics are covered in various ways throughout the pelvic rehab series and other specialty coursework such as the new peripartum courses offered this year. Sexual abuse can be a very sensitive and uncomfortable topic for both the provider and the patient. Being more aware of the high prevalence of abuse and also of the potential negative consequences of prior or current abuse leads the pelvic rehab provider to more proficient options.

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Faculty Presentations at Upcoming Conferences!

In addition to all the great things our faculty will be up to at this year's APTA Combined Sections Meeting (CSM) - read THIS ENTRY of Pelvic Rehab Report for an update on the happenings in San Diego - H&W faculty members Bill Gallagher and Richard Sabel will be presenting at two upcoming conferences.

On April 24th, Bill and Richard will present "Explore the Pelvic Floor Plus More: The Foundation of Health in the Body" at the American Occupational Therapy Aassociations's Annual Conference and Expo in San Diego CA.

In June, these two will present a similar seminar, this one geared towards the yoga therapist at the Symposium on Yoga Therapy and Research conference in Boston, MA. This seminar will cover how, by bringing awareness, strength, and suppleness to thes muscles of the pelvic floor, yoga therapists can not only address incontinence, sexual fulfillment, pregnancy and postpartum health issues, but can also alleviate pain in the pelvis, hips, knees, and back, improve respiration, and facilitate functional activities.

Congrats and thanks to Bill and Richard for spreading the "good word" on the pelvic floor!

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New Course on Medical Therapeutic Yoga!


We are thrilled to announce the launch of Part A of our brand new online course series, Medical Therapeutic Yoga!

This course was written and is instructed by Ginger Garner, MPT, ATC and presents an evidence- based method for using yoga as medicine in rehabilitation and wellness. Ginger has been lecturing on this topic throughout the United States since 2000. Her medical yoga graduate and post-graduate program, Professional Yoga Therapy, which teaches non-dogmatic, evidence-based care through fostering an east/west multi-disciplinary team approach, is a first of its kind in the US.

In addition to this brand new online course, H&W will be sponsoring two live seminars taught by Ginger in 2013: Yoga as Medicine for Labor and Delivery and Postpartum, which will be offered in Arlington, VA in October, and Yoga as Medicine for Pregnancy, which we will be offeing in Greenville, SC in September.

We are thrilled be offering these brand new courses!

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Herman & Wallace at CSM!

Have you packed your bags for Combined Sections Meeting? This year, many faces of the Pelvic Rehab Institute faculty and friends will be present and will be sharing thoughts, information, and cool products.If you would like to freshen your tech skills (or learn some completely new ones) check out the social media and technology presentation by Tracy Sher and Sandy Hilton. They will be training participants in how to gather information from Twitter, Facebook, LinkedIn, RSS feeds, in how to locate on-line exercise programs, health and research blogs, and in how to access the international on-line physical therapy community.

Planning on taking the Women's Health board certification offered through the American Board of Physical Therapy Specialties? Elizabeth Hampton, Stacy Tylka and colleagues will enlighten attendees about exam application, completing the case study, exam eligibility, and about the roles and responsibilities of the WCS in the clinic. An added touch: "Chocolates and encouragement are both provided..." Nice!

Dustienne Miller will share her knowledge integrating yoga for patients who have pelvic pain. The session is at maximum capacity, so if you signed up for it- get there early! Tracy Spitznagle and Christina Holladay will present cases and educate the participant in caring for the complicated patient, which is certainly necessary for therapist who treat patients who have pelvic dysfunction and multiple system involvement. Tracy will also present with Ryan DeGeeter on abdominal pain during running and how to differentiate between gastrointestinal symptoms versus mechanical symptoms.

Dawn Sandalcidi, who many of you will know from the pediatric bowel and bladder training coursework, will present on another of her valuable skills: trigger point dry needling. And if you plan to treat men or women with pelvic complaints, you absolutely must check out the table that faculty member Brandi Kirk designed for use in the clinic. The table optimizes body mechanics and allows the therapist to comfortably treat patients with pelvic dysfunction. The table has removable supports for the patient's lower extremities as well. You can find the table to check out at the Current Medical Technologies booth in the exhibitor hall (Booth 1403). There will be a demo of the table from 2-2:30 pm Tuesday, Wednesday, and Thursday.

One last mention: in a combined effort, the APTA Section on Women's Health and The Shae Foundation are hosting an event that will explore collaborative healthcare models in women's and men's health. The event is on January 22nd at 6 pm and it will be moderated by Karen Brandon. More details can be located here. Hope to see you at CSM!

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Pregnancy-related Pelvic Girdle Pain: In the News

Pregnancy-related pelvic girdle pain (PPGP) has received increased interest in the news and in the research community in the past few years. PPGP can cause significant movement dysfunction both during and after pregnancy, and therapists can play a valuable role in prevention, intervention and rehabilitation. In the news lately are several recent studies that I will summarize and for which I have provided abstract links below.

Is pelvic girdle pain predictable?

The International Association for the Study of Pain reports on predictors of pelvic girdle pain in the working mom. In the study, 548 pregnant Dutch working women were recruited, and at 12 weeks postpartum nearly half of the women reported pain in the pelvic girdle. The pregnancy-related predictors for pelvic girdle pain at 12 weeks were low back pain history, increased somatisation, 8 hours or more sleep or rest/day, and uncomfortable postures at work. Pregnancy and postpartum-related predictors included increased disability and having pelvic girdle pain at 6 weeks, higher somatisation, higher baby birth weight, uncomfortable postures at work, and number of days of bed rest. The authors concluded that when a woman has pelvic girdle pain during pregnancy, increased attention should be given to the woman to prevent serious pelvic girdle pain in the postpartum period and beyond.

Research addressing mode of delivery and pelvic girdle painin 10,400 women who had singleton pregnancies found an association between cesarean section and persistent pelvic girdle pain following birth. A planned c-section was associated with 2-3 times higher rates of pelvic girdle pain at 6 months postpartum. The authors conclude that for women who have pelvic girdle pain in pregnancy, unless there is a compelling medical reason for c-section birth, a vaginal birth is recommended. In a study by the same lead author,Dr. Bjelland of Norway, women were found overall to have high rates of recovery from pelvic girdle pain in the postpartum period, yet women who experienced significant emotional distress during 2 times points in pregnancy had an independent association with persistent pelvic girdle pain.

Another Norwegian study asked if women were following exercise guidelines in pregnancy and how that was related to pelvic girdle and low back pain. The authors conclude that most pregnant women in Norway do not follow the current exercise guidelines in mid-pregnancy. For women who exercised at or more than 3x/week, they had a lower rate of pelvic girdle pain. In the women who exercised 1-2x/week, rates of low back pain and depression were lessened. The study findings suggest that exercising during pregnancy may lower the risk of pelvic and low back pain.

The more we understand about the relationship between pregnancy-related pelvic girdle pain and postpartum persistent pelvic girdle pain, the better prepared we are as pelvic rehab providers to offer support and healing. The research addressing best rehabilitation approaches for pelvic girdle pain continues, with reviews of the literature often concluding that we need more and better research.

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The Value of Biofeedback: Perceived or Real?

A recent Cochrane summary about feedback and biofeedback for urinary incontinence has been published that supports patient perception of benefit for symptoms. The summary was first published on-line in July of 2011. 24 trials were included in this review, and the authors compared research of pelvic floor muscle training with studies that included feedback or biofeedback to augment the pelvic floor muscle training. Women who received biofeedback in their rehabilitation for urinary incontinence were less likely to report that they did not improve. Interestingly, compared to those who did not receive biofeedback, there was no significant difference in cure rates or in leakage episodes.

So why would a woman perceive that she has increased recovery of her symptoms simply through the addition of biofeedback to her rehabilitation program? The authors report that in the studies in which biofeedback was included, the subjects spent more time with the therapists. Is it this fact that leads to the increased rate of reported benefit? Speaking from professional experience, I utilized biofeedback consistently when I began working with patients who have urinary incontinence, and as I gained more skills, I used the biofeedback less. (Keep in mind that biofeedback is a global term accompanying any type of information, such as visual or auditory, and that in this article biofeedback refers to electromyographic (EMG) measurement of muscle activity.) As I resumed use of biofeedback, I was reminded of the value of having the patient really "see" the effects of their attempts at muscle activation. Perhaps the internal validation on the patient's part that he or she has a true impact on the machine via the body is quite powerful in itself.

We do know for a fact from the wide body of literature on the topic that urinary incontinence and the perceived interruption in function impacts quality of life ratings. Perhaps the patients who have an increased awareness of their own empowerment through muscular effort, home program practice, and therapist validation of patient effort with biofeedback training also affects the perceived impact of urinary incontinence. If a patient perceives increased benefit from therapy, does that perception then influence quailty of life?

An important take-home point from this research summary is this: the literature supports biofeedback as a tool that augmentspelvic floor muscle training. Biofeedback is not a tool that stands alone in rehabilitation; EMG training is utilized as a part of the process, following synthesis of information gained from the examination and evaluation of the patient. Some providers who refer for pelvic rehabiltation seem to think that biofeedback alone should be utilized, while other providers do not believe we should be using biofeedback with their patients. The needs of the specific patient should drive that decision making, and we as pelvic rehab providers must continually educate our providers about the various tools we have to treat urinary incontinence and other pelvic floor disorders.

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Only Five Seats Left in PF2A Boston!

There are only five seats left in the Pelvic Floor Level 2A course in Boston on March 22-24!

This course will be offered at Marathon Physical Therapy and is the designed as a next step (after Pelvic Floor Level One) in completing the clinicians’ ability to comprehensively evaluate the female and male pelvic floor by learning colorectal examination and treatments.

Don't miss this chance to build you clinical skill set and take advantage of the only Northeast offering of this course in 2013 - REGISTER today!

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Group shot of the Participants of our course in Dubai!


Our host asked the participants of the most recent 11-day pelvic rehab training seminar in Dubai, United Arab Emirates to hold the flag of their home country. Look at the "global village" that attended this course! These physiotherapists will be returning to their home countries as Herman & Wallace-trained "Pelvic Ambassadors".

There's Institute-founder, Holly Herman, who instructed this course, in the middle.

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What's in a name: IC or PBS?

If you have been following research in pelvic pain, you may be aware of the diagnostic terms interstitial cystitis (IC) as well as painful bladder syndrome (PBS). And there's always bladder pain syndrome (BPS), or hypersensitive bladder syndrome. While you may have heard at some point that health care providers should use PBS preferentially over IC, that recommendation does not seem to have stuck, and the Interstitial Cystitis Association (ICA) has decided to utilize "IC" until a more definitive diagnostic criteria and test are developed. Much of the literature you will continue to see published will choose to include both IC and PBS together in the title, and recent research has attempted to further define the diagnosis as having a relationship to ulcers versus no ulcers.

Recognized subtypes of IC include ulcerative (5-10% of those with IC) and non-ulcerative (90% of those with IC). According to the ICA, patients who have non-ulcerative IC have tiny glomerulations or hemorrhages on the bladder wall, indicative of inflammation, but not specific to IC. In patients who have ulcerative IC, Hunner's ulcer's or patches of red, bleeding areas are noted on cystoscopy. Recent research aimed to find out if female patients with ulcerative versus non-ulcerative IC have different symptoms or characteristics. 214 women (36 with ulcerative IC, 178 with non-ulcerative IC) were included in this research. While both groups reported triggers such as certain foods, exercise, and stress, more patients who had non-ulcerative IC reported pain with intercourse.

On the Brief Pain Inventory, one of the outcomes tools used in this study, both groups reported similar numbers of painful areas, with lower abdominal and pelvic pain followed by low back pain. Words used to describe the pain were, however, different among the two subtypes of IC: patients with non-ulcerative IC reported aching, cramping, and tenderness, while patients in the ulcerative group reported sharp, stabbing, and hot burning pain. Aside from these differences, the patients in the two groups did not share significant differences in the outcomes measured. The authors suggest that further research is needed to provide more information about the different presentations of patients who have IC/PBS.

For those of us in pelvic rehabilitation, the most important aspect of our care is to treat what is found, and that can only be accomplished through excellent examination and evaluation techniques. If you are interested in learning more about IC, the ICA website provides a wide array of tools for patients and providers. Until then, we will continue to see IC, PBS, BPS, and other abbreviations that point out that there is much yet to learn about this disabling condition.

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Upcoming Continuing Education Courses

Pelvic Floor Level 1 - Chicago, IL (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Cancer Treatment Centers of America - Chicago, IL

Male Pelvic Floor - St. Paul, MN (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Regions Hospital

Pelvic Floor Level 1 - Boston, MA (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Marathon Physical Therapy

Chronic Pelvic Pain - Kansas City, MO (Rescheduled)

Apr 3, 2020 - Apr 5, 2020
Location: Saint Luke\'s Health System

Pudendal Neuralgia and Nerve Entrapment - Philadelphia, PA (Rescheduled)

Apr 4, 2020 - Apr 5, 2020
Location: Core 3 Physical Therapy

Pelvic Floor Level 2B - Freehold, NJ (Rescheduled)

Apr 4, 2020 - Apr 6, 2020
Location: CentraState Medical Center

Sexual Interviewing for Pelvic Health Therapists - Seattle, WA (Rescheduled)

Apr 4, 2020 - Apr 5, 2020
Location: Evergreen Hospital Medical Center

Pelvic Floor Level 2A - Grand Rapids, MI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Mary Free Bed Rehabilitation Hospital

Pelvic Floor Level 1- Kansas City, MO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Centerpoint Medical Center

Oncology of the Pelvic Floor Level 1 - Grand Junction, CO (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Urological Associates of Western Colorado

Mobilization of Visceral Fascia: The Gastrointestinal System - Arlington, VA (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: Virginia Hospital Center

Pelvic Floor Level 2B - East Greenwich, RI (Rescheduled)

Apr 17, 2020 - Apr 19, 2020
Location: New England Institute of Technology

Pilates for the Pelvic Floor - Livingston, NJ (Rescheduled)

Apr 18, 2020 - Apr 19, 2020
Location: Ambulatory Care Center- RWJ Barnabas Health

Genital Lymphedema

Apr 24, 2020

Pelvic Floor Level 1- Canton, OH (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Aultman Hospital

Pelvic Floor Level 1 - Rochester, NY (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Unity Health System

Pediatric Functional Gastrointestinal Disorders - Ann Arbor, MI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Michigan Medicine

Lumbar Nerve Manual Assessment and Treatment - Madison, WI (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: University of Wisconsin Hospital

Pelvic Floor Level 2A - Winfield, IL (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Northwestern Medicine

Low Pressure Fitness for Pelvic Floor Care - Trenton, NJ (Rescheduled)

Apr 24, 2020 - Apr 26, 2020
Location: Robert Wood Johnson Medical Associates

Athletes & Pelvic Rehabilitation - Minneapolis, MN (Rescheduled)

Apr 25, 2020 - Apr 26, 2020
Location: Viverant

Sacral Nerve Manual Assessment and Treatment - Fairlawn, NJ

May 1, 2020 - May 3, 2020
Location: Bella Physical Therapy

Pelvic Floor Level 1 - Fayetteville, AR

May 1, 2020 - May 3, 2020
Location: Washington Regional Medical Center

Pelvic Floor Level 1 - Boise, ID

May 1, 2020 - May 3, 2020
Location: St Luke's Rehab Hospital

Pediatric Incontinence - Duluth, MN

May 1, 2020 - May 3, 2020
Location: Polinsky Medical Rehabilitation Center

Yoga for Pelvic Pain - Online Course

May 2, 2020 - May 3, 2020