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 noigroup.com. 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.

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Forgiveness....is 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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Female Genital Mutilation (FGM)

"Any form of female genital mutilation/cutting is a human rights violation that should be abandoned." So begins the conclusion of an article about FGM. From time to time, this is a topic that comes up during coursework for pelvic rehab professionals, yet it is not a common topic of discussion.

Female genital cutting is performed on girls at various ages, sometimes within weeks of birth, and it can refer to removal of the clitoris, the labia, and may include sewing of the structures to close the vaginal opening. The World Health Organization in 2008 estimated that annually 3 million girls go through FGM. Although the practice is wrongly associated with religious practices, anthropologically it is most related to the control of female sexuality. FGM obviously causes severe pain, but also frequently results in death, terrible infections, and urogynecologic dysfunctions. Imagine the breadth of sexual dysfunction that this mutilation creates.

If you would like to learn more about FGM, The World Health Organization (WHO) has an informational page about FGM. I found the work of Waris Dirie helpful because she also looks at the world of activism and shares the work of physicians who are trying to help heal injuries of FGM.

If you live in a larger city, it is likely that a cultural population exists there that includes women who have suffered from FGM. It may be through outreach to these women, or by communicating with the physicians who treat these women who have experienced FGM we can learn of the prevalence within our own neighborhoods. The role of the pelvic rehab therapist is not established for this population, and I was unable to find anything through a Pubmed literature search.

FGM is more addressed in European countries, but the challenges of prosecuting those who perform the ritual is difficult, because the practice simply goes "underground" or parents take their children on a holiday to another country and then return having gone through the cutting.It is no doubt a challenging issue to take on, and at the least we can become aware of the issue. It is very helpful to understand the cultural relevance of the ritual in addition to the potential risk to the woman who has experienced female genital mutilation. Hopefully, pelvic rehab professionals can have a more recognized role in helping women recover from female genital mutilation.

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Painful Bladder Syndrome

Painful bladder/interstitial cystitis (IC) may be undiagnosed in many women according to the Harvard Health Blogand according to research published in the Journal of Urology. The research results were based on phone interviews (60 minute interviews!) of nearly 13,000 household females. Results of the surveys estimate that the prevalence of painful bladder symptoms range from 2.70% to 6.53%. Only 9.7% of these women reported that they had been diagnosed with painful bladder/IC conditions.

The research community has also tried to create improved definitions of painful bladder/IC. One such study hypothesized that the pain of painful bladder could be utilized as criteria for diagnosis. The authors found the following information specific diagnostically for the condition: pain related to certain food and/or drink, or pain related to bladder filling and/or emptying. Physicians continue to base the diagnosis in large part on symptoms of urinary urgency, frequency, bladder pain and nocturia, and it remains elusive to find a medical test that can consistently determine the diagnosis.

As a population estimate, this translates to 3-8 million women over age 18 who are affected by this condition. Pelvic rehabilitation therapists can help women in part by dealing with the painful muscle tension that accompanies this debilitating pain. The treatment of painful bladder is covered in the Institute's intermediate "2B" course. Click here to see when this course is coming to a location near you, or near a warm, sunny beach (hint: San Diego, September.)

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