Today the US Food and Drug Administration (FDA) issued an alert about mesh used in transvaginal placement for pelvic organ prolapse (POP). This mesh which can be made from synthetic or biologic material is placed permanently to repair weakened tissues.
Serious complications have been reported due to surgical mesh, the most common one is that of mesh erosion through the vaginal tissue. The mesh can also shrink and create vaginal tightening and pain, thereby limiting sexual function. This is not only known to be problematic for women, but men can experience pain during intercourse with a female partner due to mesh. This was identified in the literature as "hispareunia."
So, what does this mean for the pelvic rehab professional? Inquiring about surgical histories including the placement of mesh is very important. If a patient has mesh erosion, there may be no amount of relief to be gained until the mesh issue is resolved. You may feel the mesh yourself as a sharp or non-tissue like structure along the vagina. If you have any doubt that mesh erosion has occurred, or if your patient is dealing with significant stenosis or canal narrowing after their procedure, request that the patient return to the provider.
The alert contains recommendations for surgeons as well as for patients so that patients can make informed decisions with respect to the risk mesh placement can pose. A prior warning was issued by the FDA in 2008 stating that severe mesh complications were rare; the update on their website today indicates that the issue remains one of serious concern that is no longer considered to be rare. Watch for further updates from the FDA as they continue to meet and evaluate the research related to this topic.
I used to think that supercalifragilisticexpialidocious was a very cool word to know. (Ok, when I was 12 it seemed cool.) I found a new word that will perhaps light a fire for you, too, especially if your inner anatomy nerd is needing some attention during the heat of summer. While reading an original article by Yabuki et al in Female Pelvic Medicine & Reconstructive Surgery (2011;17: 60-66) I came across this word: sacrorectogenitovesicopubic. It was followed by the phrase lamina of Farabeuf.
The authors of this article lament the fact that anatomy terms are challenging to work with because the surgical anatomy is described differently from clinical anatomy. They set out to redefine pelvic connective tissue through cadaver dissection as well as through histology studies. A figure in the article divides the pelvic connective tissues into a "supporting system" and a "suspensory system" with various ligaments and named fascia.
This article highlights a few things in my opinion. One, anatomy is a living science, and it continues to be researched and redefined as surgeons and other disciplines find needs for sharing information and for shaping best practices. It is also important to remember that surgeons are amazing resources, and one can really "get" anatomy while observing a surgery and listening to a surgeon describe layers of fascia or muscles as they pertain to the procedure. Lastly, we can continue to be engaged in learning and re-learning anatomy, as it sets the foundation for the stories that bodies tell.
If you are inspired to study a bit of cadaver anatomy, here is an interesting link that will take you to an on-line education program's anatomy. Scroll down once you open the link to get to pelvis and perineum.
An intervention study involving physical therapy was included as an abstract and poster presentation at the American Society of Clinical Oncology (ASCO). Female breast cancer survivors have significant complaints of sexual dysfunction including vaginal dryness and dyspareunia. 37 women were enrolled in this study and were instructed to apply Replens( a vaginal moisturizer) 3 times per week, perform pelvic floor muscle exercises 2 times per day, and to utilize olive oil during intercourse.
A pelvic physiotherapist instructed the patient in the pelvic muscle intervention at 0, 4, 12 and 26 weeks, measuring pelvic muscle function with manometry and with surface EMG.
The women who participated in this study reported significant improvement in overall sexual function and in dyspareunia. Maximal benefits were reported at 12 weeks, with additional follow-up occurring at 26 weeks. Quality of life measures improved as well.
Because sexual dysfunction is reported in such high numbers in the literature (up to 50% as referenced in this study), there are clearly more women in our communities who need our assistance. Whether a patient needs more muscle activity or less is best determined by the physical therapist who can be a part of a cancer care multidisciplinary team. Are there oncologists in your area who would love to meet you and find out more about what you have to share?
In the Journal of Urology, data was presented by Markland et al following data analysis of nearly 18,000 adults (age 20 or older) participating in the National Health and Nutrition Examination Surveys between 2001 and 2008.
In the combined surveys the prevalence of urinary incontinence (UI) in women was 51.1%, in men it was 13.9%.In the combined surveys the prevalence of urinary incontinence (UI) in women was 51.1%, in men it was 13.9%. Factors that the authors associated with UI included "...age, race/athnicity, obesity, diabetes and chronic medical conditions (prostate disease in men.)" After standardization for age, it was noted that prevalence of UI increased in both men and women over the time during which the surveys were completed.
The authors point out that especially for women, decreasing obesity and diabetes may contribute to lower rates of urinary incontinence. Prior research has concurred that even a 5-10% loss of body weight in obese women can improve urinary symptoms. Although weight loss may feel like a sensitive subjective to discuss with our patients, it seems an appropriate topic to share when our patients are inquiring about prognosis and interventions.
It is remarkable that the prevalence of UI is so high, and it is imperative that the field of pelvic rehabilitation continues to grow so that we can best serve our patients.
It seems safe to say that if you are currently working with patients who have pelvic pain, you are familiar with the phrase "trigger point." Yet, what is a trigger point? This question has proved elusive for quite some time, given that there is not always a palpable structure or a visible change in the tissue that produces the pain.
Travell and Simons, in their 2 volume classic work on myofascial paindescribe the concepts of active and latent trigger points, with an active trigger point being a location in the tissue that when palpated, reproduces the patient's symptoms, often at a site distant to the one being palpated.
In a very interesting article, Hong-You Ge, MD, PhD, and colleagues describe a possible mechanism for a local pain site (trigger point) creating more global and chronic pain via central sensitization. The authors explain the concepts of spontaneous electrical activity (SEA) at the myofascial trigger point (MTP) via research over the last decade. Some of the article (which you can read full-text thanks to PubMed Central access) will bring you back to physiology class as you do your best to recall gamma motor units within the muscle spindles or extrafusal motor endplate potential (yeesh).
While the authors admit that the "how" in formation of a taut band in a muscle is still under debate, the evidence they cite as explanation to many of the tissue responses is very enlightening and interesting. Dr. Ge also describes how motor control strategies are impaired by active trigger points. We may observe this in the clinic through the patient who reports that her urinary leakage control improves following muscle tension release techniques to the pelvic floor that were administered due to pelvic pain.
As the scientific community continues to give attention to the physiology behind connective tissue dysfunction, we should hope to better explain why some of our interventions are helpful in alleviating impairments. If you feel like nerding out and catching up on some of the interesting research related to trigger points, read this article. And then, be sure to use the phrase "membrane depolarization" in your next conversation.
Pregnancy related pelvic girdle pain is a considerable issue for women that creates significant loss of function. An update on pelvic girdle dysfunction from Kanakaris et alcan be found here by opening the link to the free full access text to the right of the Pubmed abstract. They report that the incidence of pregnancy pelvic girdle pain ranges from 4-76% in the literature depending on the definition utilized.
Britt Stuge, PhD, PT, of Norway and colleagues recently published an article in the Physical Therapy Journal. The article includes a new tool that physical therapists can utilize to assess function in female patients who have pelvic girdle pain.
The tool is called the "PGP" for "pelvic girdle pain" and was designed for use in the pregnancy and post-partum period.20 of the questions refer specifically to activities and 5 questions are about symptoms. This is a rather specific tool and it was designed for use in the clinic or for research.
You can access this tool on the Herman Wallace website and you can use it in your practice. This is very valuable to therapists as not all tools can be used freely in the clinic or in research without specific permissions or fees paid.
In a cross-sectional study in The Netherlands, standardized surveys of 1380 women between the ages of 45-85 years were completed for urinary and bowel distress. The women also answered questions about prior pelvic floor surgery.
Prior pelvic floor surgery was recorded by approximately 8.6% of the participants. The likelihood of surgery taking place increased with age, and there was identified greater than 20% chance of prior pelvic floor surgery in the women aged 76-85 years. Higher rates of urinary and defaecatory distress were noted in women who had gone through prior surgery as well.
The factors associated with previous surgery were age, higher body mass index (BMI), pelvic organ prolapse symptoms during pregnancy and prior hernia surgery. The lifetime risk for pelvic organ prolapse surgery is estimated at 20% in The Netherlands.
In the US by the year 2050, research has estimated that pelvic organ prolapse will increase in women by 46% (WU JM 09). Rehabilitation efforts must continue to advance so that women can avoid surgery when possible, and so that women can be offered pre-surgery rehabilitation as well as follow-up post-surgically.
Researchers in Taiwan have reported on a clinical trial investigating the effects of pelvic muscle strengthening for urinary incontinence on bladder neck mobility.
23 female participants completed a pelvic muscle strengthening program for 4 months. Bladder neck position was measured by transperineal ultrasonography at rest, during a cough, and during a Valsalva maneuver. The interventions included instruction in pelvic muscle contraction confirmed by digital palpation and by use of pressure feedback. Participants were instructed to perform 6 near-maximal contractions holding up to 10 seconds, 3-5 sets/day, along with 6 sets of quick (1 second hold, 1 second rest) contractions. Study participants were also allowed but not required to make follow-up appointments with a physical therapist to assess exercise.
Results demonstrated that after the 4 month period, ability to elevate the bladder neck with a contraction improved. However, at rest or with a Valsalva, the bladder neck "stiffness" did not improve. All participants did report lessened urinary incontinence, and they had increases in pelvic floor muscle strength and in maximal vaginal squeeze pressure.
This study appears in the July edition of Physical Therapy journal.
Mindfulness meditation has been demonstrated in research trials to alter perceived pain, reduce depression, and decrease stress. Results of a pilot study were recently published in support of mindfulness meditation for women with chronic pelvic pain.
The mindfulness program the women participated in was 8 weeks long and assessment tools included (but were not limited to) daily pain scores, the SF-36, and a depressive scale. For the women who completed the program, significant improvements were noted in daily pain scores, physical function, mental health, and social function. Only 12 of 22 women enrolled completed the study, which may indicate that this type of program may not have global appeal or it may be difficult for women with chronic pain to commit to a daily regimen for 8 weeks.
This pilot study is encouraging in its outcomes and demonstrates that meditation can serve as another option for women dealing with chronic pain. There is significantly more research investigating the changes in the brain function of those who meditate. One such study describes increased brain connectivity in those who have practiced meditation long-term. Functional MRI has been used to describe mechanisms that allow pain modulation to occur for those in a meditative state.
It is helpful for us to be aware of the increased attention the scientific community has given to the potential benefits of meditation, and to be able to share mindfulness meditation as an option for our patients. You may find it helpful to have a few relaxation or meditation CD's in your practice space that a patient can listen to while on heat or electrical stimulation. That way a patient might better decide if it is something he or she would like to purchase for home use. You can find an example of various relaxation and meditation CD's available at the website of Carolyn McManus,a physical therapist in Seattle.
In the British Journal of Urology International a new study was published that addresses older men's fall risk in relation to urinary issues. The histories of 5872 male patients were investigated to determine if having urinary symptoms were independently associated with a risk for fall within the following 12 months.
The men who reported moderate (39% of men at baseline) or severe (7%) urinary symptoms had a significantly higher incidence of falls over a period of one year than those men who reported mild symptoms. Symptoms that were most associated with falls were urinary urgency, difficulty initiating urine, and nocturia (getting up at least 4x/night to urinate.) The authors reference other studies that reported urinary incontinence as a risk factor for increased fall risk in men as well.
Since benign prostatic hypertrophy (BPH), which causes difficulty initiating the urine stream, and overactive bladder both increase with age, the above urinary issues are understandably of concern when assessing fall risk.
It is also well-known in the orthopedic literature that falls in the elderly increase risk for hip fracture, and 1 year mortality rates are known to be significantly higher for those who have had a hip fracture. Many rehab providers have assisted these patients in their fall recovery, and many factors are at play in making such a recovery challenging. Oftentimes a patient who has suffered a fall and a significant injury have to spend time away from their home, enter environments in which iatrogenic illnesses can occur, and experience the effects of being bed-bound or of having reduced physical activity.
It is valuable to keep such research information in mind when we are educating our colleagues, patients, providers, and community members about the risks of urinary dysfunction. Helping a person maintain healthy bladder function may not only be helping to maximize a person's dignity, but also his level of independence, health, and longevity.