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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Erectile Dysfunction and Physical Therapy

In a PubMed article about erectile function preservation following prostatectomy surgery, Dr's Segal and Burnett review treatment options. You may find this article interesting because, if you are treating male patients for pelvic rehabilitation, you will be asked some questions that you don't usually learn the answers to in school.

Urinary incontinence and erectile dysfunction are the 2 most common complications following prostate removal surgery. Erectile dysfunction affects not only the quality of life of the man who had surgery, but the man's partner can suffer as well. There are various types of erectile dysfunction, and this article describes several medication approaches towards the various types of dysfunction. One of the post-surgical approaches that has been prevalent in the literature over the past decade is the use of some type of medication to periodically produce erections immediately in the weeks following surgery to maximize functional recovery. You can familiarize yourself with some of the literature and medication approaches available in this review.

Why should we be familiar with medications such as those discussed in the article? It has been my experience that even when you don't "solve" the patient's sexual dysfunction, the patients are desperate to talk with someone about what is happening to the body and about what options are available for recovery. Oftentimes, male patients remark that they feel much more comfortable addressing the issue with a physician once they have some basic information. It is also much more interesting to engage in a discussion with a physician about his or her preferred practice pattern or clinical experience when you have perused the options that the doctor encounters in the literature.

One option missing from this article is physical therapy. Grace Dorey (physiotherapist) is primary author of some very encouraging research indicating that pelvic muscle strengthening helps men recover sexual function. Her study did not include post-prostatectomy patients, yet the education and exercises that she had the men complete are very easily instructed. Click here for her full article.

The bottom line is that the more you know, the more comfortable you will be when you ask questions and when you answer questions about erectile dysfunction. And, more likely than not, if you are currently only treating women, that will change. And, if it hasn't occurred already, you will soon be the go-to person whenever anyone in the clinic (or place of worship, restaurant, etc) asks a question about sexual health.

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Dysmenorrhea, or painful menstruation, is thought to affect nearly 20% of women. A recent study completed in Malaysia surveyed 1295 girls aged 13-19 from 16 different public schools. 76% of the participants reported having dysmenorrhea, and over half of these girls reported that concentration at school and participation in social events was most affected. 76% of them also stated they thought dysmenorrhea was a normal part of adolescence, and less than 15% sought help from the medical field.

One of the most simple and well-documented treatments for dysmenorrhea is a TENS unit, which has been recognized in the literature as decreasing need for pain medications and for decreasing absenteeism due to abdominal pain and cramping. In mmHG, uterine pressures due to menstrual cramping have been measured at numbers equal to uterine pressures measured in childbirth, a clear accounting of why these cramps can be so painfully debilitating.

We have little evidence to support physical therapy as a treatment recommendation for dysmenorrhea, as you can deduce from this summary article, however, it has been my professional experience that physical therapists and other pelvic rehab therapists can offer helpful stretches, self-care, and education to assist in diminishing symptoms. It has also been my experience that the mothers of the teenagers suffering from dysmenorrhea are the people who request care for such an issue. We can take the opportunity to inquire about our patient's daughters and discover if this is a concern of theirs. As the researchers in the above-mentioned Malaysian study state, there is a "...need for educating adolescent girls on effective management of dysmenorrhea.", and this education must be extended towards parents and school peer leaders.

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Male prostate cancer surgery patients are not getting what they expect…

In this brief and interesting Medscape video lecture, Dr. Gerald Chodak discusses the relevance of new research addressing men’s expectations following prostate surgery. 152 patients who had received extensive preoperative counseling regarding prostate surgery and expected outcomes completed a survey prior to and one year following their surgery. The surveys asked for responses about incontinence, bowel and sexual function, among other variables.

At one year following surgery, 47% and 44% of the men reported having lower than expected function for urinary incontinence and sexual function, respectively. The researchers report surprise that 12-17% of the men expected better than baseline urinary and sexual function following surgery. The study concludes that “Men have unrealistic expectations of…function after prostatectomy despite preoperative counseling.” The study also hypothesizes possible psychological causes for this reaction.

We have all met patients who are frustrated with post-surgical outcomes when their expectations are not achieved. These patients can sometimes be so frustrated that it may impair the ability to “move on” and focus on the level of function or healing that is available. It may be that we have opportunities to work with these men on a pre-operative basis, and it may be helpful for us to discuss the follow-up issues, if only for the patient to air any concerns and be directed towards the physician with any significant concerns.

Surgeons are often quick to remind patients that the goal of surgery is to “save lives, not preserve sexual function.” Some physicians focus on nerve-sparing techniques to minimize injury to the pelvic muscle function. Regardless of the surgeon’s approach, the patient may be interested in discussing the outcomes and the implications of the outcomes with his pelvic rehab professional. This research demonstrates that there is an important discrepancy between patient’s expectations and the outcomes.

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Are you treating kids yet?

I recently had the opportunity to sit down for a chat with Dawn Sandalcidi, PT, faculty member and national leading expert in pediatric continence. In truth, she was indulging me with her vast experience and giving me tips and encouragement towards treating children who have incontinence. I, perhaps like many of you reading this, have taken Dawn's pediatric incontinence course, yet I have not yet launched a pediatric incontinence program. Until now. After I took her course a few years ago, I vowed that I would begin treating children with bowel and bladder issues. After all, how many times have you heard the response "ever since I can remember?" when you ask your adult patients how long they have dealt with their current pelvic dysfunctions?

I (kindly and respectfully) challenge us as pelvic rehabilitation specialists to dive further into the realm of helping children who no doubt have no one else to turn to for meaningful advice. If you already treat children, good on you! It has been my experience that it is very difficult to find a provider who can treat children as well as adults. Often I believe that we get so busy with our clinic caseloads that it feels overwhelming to begin another program. Like many other challenges, if you take the first step, the rest you can figure out with some helpful resources.

If you have a biofeedback program, then you have all the special equipment you need. To begin a pediatric program, you might also like to acquire the Pediatric Pelvic Floor Manualas it has age-appropriate educational tools. Another great resource that Dawn recommends is the International Children's Continence Society website. It has an immense amount of evidenced-based work as well as patient-friendly literature. Click here to find out when the next pediatric course will be taught by Dawn Sandalcidi, or This email address is being protected from spambots. You need JavaScript enabled to view it. if you would like to host a course.

Perhaps if we all could treat the kids who need help with bowel and bladder function, we would hear fewer stories involving decades of struggle with pelvic floor issues. I have felt a little intimidated about beginning a pediatric program, yet I know that I have the tools, the education, and helpful experiences with adult populations. I hope this post will be encouragement for any of our readers who have thought about adding a pediatric program to your practice. As for me, I have some marketing to do.

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Intravaginal estriol plus pelvic floor rehab recommended for postmenopausal women.

In a study completed at the University of Sassari in Italy, physicians addressed post-menopausal pelvic floor changes such as stress urinary incontinence (UI), urogenital atrophy, and recurrent urinary tract infections. Half of the 206 post-menopausal women in this study were treated with intravaginal estriol (1 mg treatment daily for 2 weeks then 2 treatments/week for a total of 6 months). The other half was treated with estriol in addition to pelvic floor rehabilitation.

The outcomes measured at beginning and 6 months after start of treatment included urine cultures, urogenital symptomatology, and urethral pressure profiles, among other measures. At 6 months, urogenital atrophy was improved in both treatment groups. While in the control group (estriol only) patients reported a 9.71% improvement in urinary incontinence, 73.49% of the patients who were treated with estriol plus pelvic floor rehabilitation reported improvements in UI. Urethral closure pressures were also significantly improved in the estriol plus rehab group.

The authors conclude that pelvic floor rehabilitation in addition to estriol should be considered as first-line therapy for symptoms of urogenital aging in postmenopausal women.

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Pelvic Rehabilitation Recommended as First Line of Defense for Female Stress Incontinence

Dr. G. Willy Davila of the Cleveland Clinic Florida has published an article in Advances in Urology that describes non-surgical management of female stress urinary incontinence. He reviewed the literature for prospective clinical trials and included only those studies that had a minimum 12 months of follow-up. Interestingly, most of the studies involving pelvic floor rehab only had follow-up for 6 months.

This article confirms prior research reviews in identifying pelvic floor rehabilitation as a low cost, low risk treatment that has well-proven short term benefits with 60-77% of patients benefiting from conservative treatment. Dr. Davila points out that level one evidence (randomized, controlled trials) are difficult to complete for this population as blinding is difficult when varied treatments are needed to compare conservative management techniques.

Also described and reviewed in this full-access article are the non-surgical techniques of urethral bulking and transurethral radiofrequency collagen denaturation used for urethral hypermobility. Urethral bulking involves an injection that is designed to augment the urethral sphincter. While many patients report benefit from this treatment, the collagen injections usually have to be repeated within a year. The radiofrequency treatment, as pointed out in the article, is not the same as transvaginal radiofrequency tissue ablation because the newer technique requires no incision and uses a much lower temperature that avoids tissue necrosis and shrinking. The radiofrequency collagen denaturation instead creates tissue remodeling. In a 3 year follow up study using this technique, Appell et al reported a 50% or more reduction in stress incontinence for 56% of women in the study.

While patient adherence has been found to be understandably necessary for pelvic floor therapy to assist in patient recovery from stress incontinence, it is recommended as the first line of treatment. This review of available research is helpful towards understanding what literature is available to support pelvic rehab, and it is also useful in pointing out what needs remain: namely, more long-term follow-up (at least 12 months), and more standardized terminology and methodology.

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Chronic Pain Following Hernia Repair

Chronic pain following hernia repair has been estimated in the literature to be as high as 54% for inguinal hernia repair. Pain is often categorized as neuropathic or non-neuropathic. Recent research appearing in the Annals of Surgery and reported on in Medscape Today discusses nerve management in relation to post herniorrhaphy pain. (You can register with the Medscape site to receive weekly updates.)

The authors designed a prospective cohort study and they report on 781 elective hernia operations that were performed on 736 patients in a hernia center. The preoperative pain rate was 41%. At 6 months assessment, chronic pain was reported by 16.5%, sensory disorders (such as numbness or dysesthesia) were reported in almost 16% of patients. At 5 years following surgery, 571 men and 74 women were re-evaluated (follow-up rate of 82.6%) with chronic pain rate of 16.1% , sensory disorder of 20.3%. Independent predictors of post-surgical pain included pre-operative pain and a groin sensory disorder.

The authors make recommendations for surgical approaches, and they discuss the likelihood that nerve contact with surgical mesh or nerve tissue that is surrounded by fibrosis can create significant pain. While there is very little in the literature to support physical therapy and post-herniorrhaphy pain, this pain pattern may be very well treated post-surgically. The nerves that are most involved with a hernia repair (ilioinguinal, iliohypogastric, and the genital branch of the genitofemoral) can be assessed and may be treated with neurodynamics techniques, well described by David Butler and colleagues of the Neuro Orthopedic Institute. Patients with pain or dysesthesia stemming from these nerves may arrive in the clinic of the pelvic rehab practitioner as these nerves travel distally to the groin area.

For more information about current management of post-herniorraphy groin pain, click here for a recent update.

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Behavioral therapy for incontinence in patients with Parkinson disease.

A pilot study addressing urinary incontinence (UI) in patients who have Parkinson Disease (PD) appeared in the journal Neurology. The studyutilized biofeedback training of pelvic floor muscles and urge suppression techniques along with use of a bladder diary in a series of 5 visits over an 8 week period.

17 of 20 patients (90% male) who were recruited from movement disorders clinics completed the study. Mean age of the patients was 66 years and the mean length of time diagnosed with PD was nearly 7 years. At the time of entry to the study the participants had a median of 9 episodes of urinary leakage per week.

Following the intervention, weekly episodes of UI recorded by bladder diary was reduced to 1 time per week. Quality of life scores on the ICIQ-OAB were also significantly reduced. The authors note that following this pilot study, randomized controlled trials are needed to further validate the benefits of exercise-based behavioral intervention for urinary incontinence reduction in patients who have Parkinson Disease.

It has been recognized in the literature that additional burden is placed on patients and on caregivers when those who have PD. Reducing such comorbidities can thereby hope to reduce such burden.

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