Smoking and Bladder Symptoms

Ah, the dreaded smoking soapbox. In the orthopedic world, we know that smoking has been correlated in many studies with impaired healing following spinal surgery. Urinary urgency and incontinence has also been linked to the habit of smoking. Women who smoke are three times more likely to have urinary urgency and frequency than women who have never smoked according to a study in Obstetrics and Gynecology.

Researchers received completed surveys from over 2000 women in Finland ages 18-79. Urinary frequency was reported by 7.1% of the women, nocturia by 12.6%, stress urinary incontinence (SUI) by 11.2%, urinary urgency by 9.%, and urinary urge by 3.1%. In the analyses, smoking was correlated with both urinary urgency and with urinary frequency. Smoking did not correlate in this study with SUI or with nocturia (excessive urination at night.)

As mentioned in prior posts, sometimes having research make a point feels less confrontational to a patient or provider versus asking a question such as, "So when are you going to quit smoking?" Some ways to share this issue with a patient may include the following: post this abstract on your bulletin board, include the question on your intake forms, or create an informational brochure that is sent with the patient's pre-visit paperwork. Once you have gained some rapport with a patient, you might say, "Research does suggest that smoking can aggravate the bladder symptoms you have. Is quitting smoking something you are actively working on right now?" Recall that many patients have tried to quit smoking multiple times, and that research shows it takes many attempts before most people are able to quit. Your patient may be quite understandably defensive about this issue, yet it is very valuable to discuss as a part of bladder health education.

This study suggests a dose-response relationship between smoking and bladder symptoms. We can point out to a patient that a decrease in the amount of smoking may influence the bladder positively. Also keep in mind that each person's body and behaviors are different; maybe it's the seven diet sodas, or the poor hydration, or a familial factor in genetics that is the causative factor for her. I know spinal surgeons who refuse to perform surgery on patients who are currently smoking. They basically say, "come back when you have quit smoking." Most pelvic rehabilitation providers who I know would never take this approach because of our kind nature and our desire to have the patient return. It is important, however, for us to continue to acknowledge the research and educate our patients in all strategies for maximizing bladder health.

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Last week my patient walked into the office and proceeded to pull a magazine out of a brown paper bag. She proudly displayed her copy of “Women’s Health” and flipped to an article, saying “They mention you in here a couple of times.” My mind searched for the last time that I was interviewed by a national magazine with a readership of over a million women, and then I realized that by saying “you” she meant “us.” As in pelvic rehabilitation therapists.

The article that she referred to, “When Sex Hurts: How to turn the ouch back into ahh”, is a great read for the public learning basic information about pain during sex. Topics such as lubrication, using positions of comfort, increasing time of foreplay, post-partum hormonal shifts, and vaginismus are discussed. Physical therapy is listed specifically for the treatment of vulvodynia and for vaginismus. Although not all pelvic rehab specialists are physical therapists, the majority of the providers at Institute courses are PT’s. Any increase in public awareness is good for medical providers, for patients, and for us.

You might have seen the post on Oprah’s website about pelvic floor therapy. While I find myself cringing a bit when I read terms such as “ladyparts” (mostly because we work so diligently at normalizing anatomy terms including vagina, clitoris, penis) the truth is that the first thing to normalize is the fact that men and women need to share what is happening in their bodies. I meet so many patients who apologize for telling me what they are experiencing, and I wish each patient knew how often I have heard the same stories in the clinic.

Helping patients understand just how prevalent pelvic floor dysfunction is can be very encouraging for them. Take articles like this or opportunities when pelvic dysfunction makes it to Oprah to expose patients to the commonplace diagnoses that we hear about every day. Reach out to a local magazine, newspaper, or other media to share what you know and to educate your public about the opportunities that are available.

PS In the same issue of Women’s Health (September) there is an interesting article about male sexual health. You will find recommendations for Kegel exercises in it!

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Pessaries: A Review

A review addressing pessary use and quality of life is available in PubMed central. Pelvic rehabilitation providers are often in a role of educating patients in what a pessary is, in finding a provider to fit a pessary, or in discussing with the patient the potential benefit of such a device for reducing symptoms of pelvic organ prolapse. If you are unfamiliar with a pessary, click here for information from WebMD.

The history is pessaries is impressive, and this article begins with a reference to Hippocrates who used a pessary made of a halved pomegranate soaked in wine. They are now usually made of silicone, and come in many shapes such as a ring or a donut. In terms of which patients benefit from a pessary, the authors point out that from the literature, this appears to be mainly a subjective experience on the part of the patient related to perceived benefit of pessary use. Some patients have difficulty keeping the pessary in, especially with Valsalva, and then choose to stop using it.

In terms of measured outcomes of pessary use, the authors are critical of the lack of standardized gynecologic outcomes scores used in patients who are successfully fit with a pessary. One study by Abdool (2010) that is referenced, however, suggests that outcomes of pessary use match those of surgery. Factors influencing a successful fit may include use of local hormone supplement such as estrogen cream to improve tissue health and avoid vaginal irritation. An unsuccessful fitting may occur with a "...short vaginal length, a large genital hiatus, prior history of hysterectomy and prior repairs of POP [pelvic organ prolapse]."

Because there are known potential medical complications from use of a pessary, the Pelvic Rehabilitation Institute does not encourage physical therapists to fit for or manage a patient's use of a pessary. It may be incredibly helpful to a patient, however, if you can provide education about what a pessary may offer a patient. This might mean that you have to make phone calls and find out what providers in your community are fitting pessaries. Some providers discourage the patient from its use because of the challenges of getting the right fit. I encourage patients to follow-up readily with the provider doing the fitting so that this can be corrected. I found it to be a very useful option for many patients as it provides a conservative choice prior to surgery. Following one of my patients to her provider's office during a pessary fitting also helped me to better understand the procedure. What a wonderful way to demonstrate to your patient and to providers that you are engaged in a patient's care.

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Coughing and leaking.

In a very logical study, researchers assessed the prevalence of urinary incontinence in those patients suffering from chronic obstructive pulmonary disease (COPD). Because COPD can cause chronic coughing, and we know that one of the classic mechanisms of stress urinary incontinence is coughing, we might deduce that folks who cough more might leak more.

This study aimed to address such a prevalence in men and women aged 50-75 years. Over 700 men and women diagnosed with COPD were surveyed and 66% of them returned an evidence-based incontinence assessment tool. In women, 49.6% reported urinary incontinence (UI), in men, 30.3% experienced urinary leakage. 52.4% of the women described stress UI, whereas 66.3% of the men reported post-micturition dribble. Other differences noted between the genders in this study include that women were more likely to seek help for UI, had increased levels of bother from UI, and more women refrained from physical activities than men due to leakage.

The study concludes that patient management for those who care for patients with COPD must include assessment and appropriate treatment of UI. Depending upon the environment in which you treat patients (wouldn't it be fantastic if every skilled nursing facility, hospital, and outpatient center had a provider who can treat urinary incontinence?) you may meet patients of both genders who are dealing with COPD as a co-morbidity. Perhaps this information can be included at your next team or staff meeting. Are non-pelvic rehab providers aware of the relationship between coughing and leaking? Between leaking and avoiding social outings? Have you met the providers who serve the patients who seek treatment for COPD?

One of the amazing things about pelvic rehabilitation from a marketing standpoint is that you may have singular access to some medical care providers that other therapists do not access. Many medical providers are thrilled to learn that 1) their patients have broader treatment options than previously known, and 2) you can provide the services to the patient. Who markets to the pulmonologist? You can look at this from either a financial (cannot be ignored) or a humanitarian (where we like to live) standpoint. You might also remind the person who controls access to funds for a biofeedback unit that pelvic rehab therapists have the expertise and the power to reach patients and care providers who are not readily on many general practice's radar. A large and important part of our work is helping the public understand the treatment options that pelvic rehab specialists can provide.

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Be aware of the risk of urinary retention following prostate surgery.

I recall vividly the patient who attended his first physical therapy appointment one day after having his catheter removed following a radical prostatectomy surgery. He appeared a bit pale and mildly sweating. I asked him if how he was feeling, and he replied that he did not feel well. No fever, aches, chills, but something just did not seem right to him. I inquired if he had in fact been able to void since his catheter was removed. "Oh yes," he replied, "I have been peeing a little all night." I then asked him to quantify how much he was voiding, and he stated that it was 1-2 Tablespoons several times in the night. Although voiding amounts decrease typically in the evening, we also find that patients who have just had radical prostatectomies leak in the evening early in recovery. He had not been leaking during the evening. I was able to immediately contact the patient's surgeon and express my concern that the patient was in urinary retention. The patient was instructed to go immediately to the emergency room and an extraordinary amount of fluid was removed from his over-distended bladder.

This is a situation that pelvic rehab therapists need to be very alert towards. It is not only post-surgical patients who can be retaining urine, however, it is a common risk following a procedure such as a prostatectomy or a TURP (transurethral resection of the prostate.) An article appearing in the Urologic Nursing Journal identifies risk factors for such retention following a TURP procedure (these may be completed to remove part of an enlarged prostate gland that is limiting voiding.) A chart audit of 156 patients revealed that 15.4% of the patients had acute urinary retention. The risk factors included prostate size, clot retention, and pre-surgical UTI (urinary tract infection) or a failed voiding trial post-surgically.

Keep in mind that if you are treating patients who have recently had a procedure such as prostate surgery, urinary retention can be an even more urgent issue than urinary leakage. Even if a patient reports that he has been voiding, it is important to ask further questions to determine amounts voided. Because of the risk of post-operative infection, anytime a patient does not look right (perhaps pale, clammy, confused) it may be important to request that the patient follow-up with a physician or other medical provider. It is also helpful to keep screening items in your office such as a thermometer with disposable sleeves, blood pressure cuff, and to use them when needed.

If you are interested in joining the Society of Urologic Nurses, or in ordering their Journal, you can access the information here. It is only $45/year to receive the journal, and the annual conference will take place in San Antonio, Texas this October.

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Survivors of cervical cancer need care for pelvic pain.

A study completed in Norway adresses the importance of serving women who have survived cervical cancer. 91 patients who had been treated with radiotherapy and who were more than 5 years out from treatment were included in this research. Radiotherapy included both external beam and intra-cavity radiation. Participants did not receive chemotherapy. Pelvic pain included any pain in hips, low back. groin, or radiating pain.

Radiation of the pelvis is known to be a cause of pelvic fractures, proctitis, cystitis, enteritis, and it can also cause pelvic lymphedema, lumbosacral plexopathies, and radiation myelopathy. According to the authors, pain in cancer survivors is associated with anxiety, depression, and decreased quality of life.

38% of those surveyed described chronic pelvic pain. Of those with pelvic pain, 60% reported severe intestinal problems, 43% reported severe bladder problems. Intestinal and bladder issues reported by those in the study without pelvic pain were, respectively, 36% and 7%. Measures of anxiety and depression were all higher in the group who reported pelvic pain than in the group without pelvic pain. Compared to the general population who has not had pelvic radiation for cervical cancer, the incidence of low back pain and hip pain are higher in those in this study.

The implications of the study include that women who survive cervical cancer need to have chronic pelvic pain assessed as well as managed. Suggested options for pelvic pain management include a multi-disciplinary approach with analgesics, physical therapy, interventional procedures, and pyschosocial treatments. This study may be a useful tool when speaking with physicians who serve a population of women who have gone through any pelvic radiation therapy.

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Brain Mapping of Female Sexual Response

The Journal of Sexual Medicine reports on research involving functional MRI (fMRI) of the female brain during stimulation of varied parts of the body. The aim of the study was towards mapping of the brain so that female sexual response could be better understood. Such mapping, according to the article, has never been completed for females. Sensory cortical responses to self-stimulation of the clitoris, vagina, cervix, and the breast were mapped in addition to the thumb and the great toe for points of reference on the corticalhomunculus.

The findings of the study state that stimulation to the vagina, clitoris and cervix produced fMRI readings that could be differentiated. In other words, stimulation of the vagina does not produce the same neurologic response as stimulation to the clitoris. "Do we really need research to know this?" Yes, we do. While there is certainly complexity involved in sexual response, this now documented mapping provides very useful information. The authors also point out that breast stimulation activated the genital cortex.

For a fabulous report on the relevance of this research and on the potential implications of this research to pelvic pain, please see David Butler's always informational post on his website.His work consistently inspires me and you too can receive free Neuro Orthopedic Group (NOI) updates on research and the clinical implications by signing up at Pelvic pain will be specifically addressed at the 2012 NOI conference in Australia.

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Male urinary incontinence with sexual activity post-prostatectomy

The latest Journal of Urology reports on a single-center prevalence study of urinary incontinence during sexual activity that occurred in men following prostate cancer surgery.

Nearly 1500 men were surveyed to determine the post-operative prevalence of urinary incontinence (UI) with sexual activity and stress UI in the absence of sexual activity. The participants completed the UCLA-PCIpre-operatively and again at 3, 6, 12 and 24 months following surgery. All men had been treated by the same surgeon. 12.1% of men reported major bother from urinary incontinence with sexual activity at 24 months post-operatively. Of these men, more than half of them also experienced significant bother from stress urinary incontinence. Interestingly, more than 10% of men who did not report stress incontinence did report leakage with sexual activity. The take home point: men can have leakage during sexual activity even if coughing, laughing, golfing, transitional movements are leak-free.

The study concludes that treatment of the problem requires further research. While that is true, you can find some wonderful patient education materials related to post-prostatectomy pelvic muscle awareness and strengthening on physiotherapist Grace Dorey's website. One such resource is "Living and Loving After Prostate Surgery."It is so helpful to be able to direct patients to such resources that speak candidly about issues of urinary and sexual function for men.

Another terrific resource for the pelvic rehab therapist is Grace Dorey's textbook, Pelvic Dysfunction in Men: Diagnosis and Treatment of Male Incontinence and Erectile Dysfunction. You can also attend the Pelvic Rehab Institute's next Male Course, in which topics of male sexual health, pelvic pain, and urinary dysfunctions are discussed. Check out the course listing for upcoming dates.

Continue reading always good advice.

There is a new book on the market called Embitterment: Societal, psychological, and clinical perspectives. The feeling of embitterment, defined by on-line merriam-webster as "to excite bitter feelings in," even has a proposed disorder: Post-Traumatic Embitterment Disorder, also known as PTED. PTED refers to the state of a person who has an adjustment disorder based on a severe pyschological reaction to a negative life event. It is associated with feelings of injustice, intrusive memories of a life event, and frequently with thoughts of revenge.

Can you recall any patients who fit this picture? I imagine you have met a patient injured at work who presents with embitterment, another patient who is fixated on a divorce, or a patient who suffered a trauma and is unable to move forward.

One problem with being embittered, and angry, is that it creates significant health issues. Some well-researched health issues related to anger are higher blood pressure, heart rate, cardiac risk, even changes in brain response to auditory stimuli. Forgiveness, on the other hand, is known to be beneficial to health. In one study looking at low back pain and forgiveness, patients who had a higher index of forgiveness had lower levels of pain and disability. An article addressing the clinical implications of forgiveness for psychiatrists working with patients recommends that forgiveness should be utilized as a clinical intervention for patients.

What does this mean for the pelvic rehab therapist? Sometimes patients can hear information a little more objectively, less defensively, when it is brought up in the context of research. A patient may be much more able to hear the following: "It sounds like you are still really angry, and research shows that such anger or bitterness can have a negative impact on your health. Have you had the opportunity to discuss this with a friend, health care provider, spiritual advisor?" If your patient is interested in discussing the issue further, perhaps a referral can be made to the appropriate person.It has been my personal experience that when patients can relate a feeling (anger, fear, frustration, rejection) to the pain or dysfunction that is occurring in the body, this realization can expedite a healing that is difficult to explain by the application of modalities or exercises.

And patients are not the only people who can benefit from adding a bit more grace, or forgiveness, into his or her day. We can forgive not only others, but ourselves as well. Following is a quote from one of my favorite authors, Caroline Myss. "One of the greatest struggles of the healing process is to forgive both yourself and others and to stop expending valuable energy on the past hurts."

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The bladder and inflammation

In Therapeutic Advances in Urology, researchers report on the role of inflammation, acute or chronic, and its effect on bladder function. Although the etiology of painful bladder syndrome/interstitial cystitis (PBS/IC) is still unknown, it is agreed upon that inflammation plays a central role in the bladder dysfunction that accompanies the condition. It has been proposed that the inflammation may come from a chronic or subclinical infection, a genetic susceptibility, or an autoimmune response.

Although the naming of the condition has gone through proposed changes (from interstitial cystitis to painful bladder syndrome to bladder pain syndrome) you will see the terms used interchangeably in the literature.A more recent attempt at refining the definition of IC was completed by the European Society for the Study of Interstitial Cystitis. IC is described as "...chronic pelvic pain, pressure, or discomfort perceived to be related to the urinary bladder and accompanied by at least one other urinary system such as persistent urge to void or urinary frequency." Many physicians have based diagnosis on symptoms primarily, as more recent research has demonstrated that use of stringent diagnostic criteria or laboratory tests often excluded patients from being diagnosed appropriately.

This articleis useful in assimilating research about IC/PBS.The authors briefly list the pharmacology of several different oral medications that have been studied for use with patients with bladder pain. Some of the medications target the mucosal lining of the bladder, act as antihistamines, target the pro-inflammatatory agents found in patients with bladder pain, or help the patient manage the pain (narcotics.) Other medications cited include anticonvulsants, antidepressants, anticholinergics, or hormones modulators.

As for a nonpharmacological treatment approach for IC, physical therapy is recommended and modalities such as manual therapy, bladder training, biofeedback, and pelvic floor rehab are recommended. The authors conclude that in terms of management guidelines, because patients with bladder pain syndrome have such varied clinical presentations, it is necessary to individualize treatment approaches.

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