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Blog posts tagged in Male Pelvic Floor

Varicoceles are enlarged veins that occur in the scrotum. They can be common in adolescent boys and men, with an incidence rate of approximately 15%. Because up to 1/3 of men dealing with infertility have a varicocele, a repair of this venous herniation may be a first line treatment for male fertility. Varicoceles are sometimes referred to as feeling like a "bag of worms" due to the distended veins that coil through the area (the U.S. National Library of Medicine provides a useful illustration). Although varicoceles may be painless, they are thought to be symptomatic in up to 10% of men. Symptoms can be dull, aching, throbbing, and can worsen with physical activity. Conservative care includes scrotal support, limiting physical activity, and using anti-inflammatory medications.


Vericoceles

Pelvic rehabilitation providers may work with a male patient who complains of scrotal pain, and who has a known diagnosis of a varicocele. If the patient is unsure of such a diagnosis, questioning the patient about prior discussions with his medical providers may reveal that he was told about “enlarged veins in the scrotum” or similar description. Visual inspection may reveal the tell-tale appearance of distended veins inside the scrotum, and palpation may reveal a significant difference among sides (unless both sides are involved of course.) Physical examination for a varicocele is usually completed in supine and standing positions and may be palpable with or without Valsalva maneuver. Keeping in mind that the differential diagnosis for pain in the scrotum can include medical conditions such as testicular torsion, epididymitis, inguinal hernia, testicular tumor, hydrocele, epididymal cyst, or sperm granuloma, patients who have complaints must see an appropriate medical provider to rule out such conditions. It is also possible for a patient’s condition to change or worsen if a period of time has passed, with communication with the referring provider recommended. Post-surgical complications that should also be considered are inguinal hernia repair for nerve entrapment or vasectomy.

 

Because of the nerves traveling in the same pathway as the involved veins, we can also consider the neural tension potentially created from the increased venous distension creating either (or both) compression and drag. Surgical options may be discussed by the medical provider, and these might include a microsurgical ligation or a varicolectomy. According to Park & Lee (2013) “A varicocelectomy should be considered in patients with no alleviation of their pain after conservative management, including resting, scrotal elevation, and nonsteroidal anti-inflammatory analgesics.” Conservative management is exactly where we can fit in as providers of pelvic rehabilitation. Including a condition such as a varicocele in our differential diagnosis and treating planning can further our success with patients.

 

Tagged in: Male Pelvic Floor

What are you saying when giving directions to men during pelvic floor muscle training, and how do those instructions affect the effectiveness of a contraction? These questions are tackled in a study that is very interesting to therapists working in pelvic dysfunction. 15 healthy men ages 28-44 (with no prior training in pelvic floor training) were instructed to complete a submaximal effort pelvic muscle contraction. Tools utilized to acquire data in the study include those below:

Assessment tool Measuring
Transperineal ultrasound displacement of pelvic floor landmarks
Surface EMG (electromyography) abdominal, anal sphincter muscle activation
Nasogastric transducer intra-abdominal pressure (IAP)
Fine wire electromyography (3 participants only) puborectalis, bulbocavernosus muscles

 

Participants sat upright on a plinth (backrest reclined at ~20 degrees with their knees extended). Directions for the submaximal efforts were given by telling the men to produce a level 3/10 effort with 10 being a maximal contraction. The men were instructed to hold the contraction for 3 seconds, and they were given 10 seconds rest between each of the 4 contractions using different verbal cues. (This series of 4 contractions was repeated with randomization for verbal cues, with a 2 minute rest in-between.) Verbal instructions were intended to target specific contractile tissues as described below- some of this theory could be validated via the fine wire EMG.

Verbal cue Targeting
"tighten around the anus" anal sphincter
"elevate the bladder" puborectalis
"shorten the penis" striated urethral sphincter
"stop the flow of urine" striated urethral sphincter, puborectalis

 

Displacement, IAP, and abdominal/anal EMG were compared for the different verbal instructions. The greatest dorsal displacement of the mid-urethra and striated urethral sphincter activity was noted with the instruction to "shorten the penis." "Elevate the bladder" encouraged the greatest increase in abdominal EMG and IAP, while "tighten around the anus" induced the greatest anal sphincter activity. Displacement of pelvic landmarks correlated with EMG readings of the muscles thought to produce the targeted movement. The authors conclude that the therapist's choice of verbal instructions can influence the muscle activation and urethral movement in men. They suggest "shorten the penis" and "stop the flow of urine" for optimal activation of the striated urethral sphincter. They also point out the fact that by using the fine wire EMG and correlating muscle activation to observations with the transperineal ultrasound, the study validates the use of the less invasive method. If you are ready to jump into more education about male pelvic rehabilitation, join us in Denver in early August, or Seattle in November.

Physical therapist, educator, researcher, and clinical instructor Daniel Kirages, who was mentioned in Do Male Therapists Belong in Pelvic Rehab: Part I, shares his viewpoint from the perspective of his various roles.

 

“As a male, how did you get involved in pelvic rehab?” This is a question I have been asked countless times and the answer can be pretty simple, I usually say “It’s really not much different than any other musculoskeletal related issue. I’m just not afraid of working below the belt.” Working within the domain of neuro-musculo-skeletal physical therapy offers an endless supply of opportunities. Pelvic rehab is just one subcategory amongst many and this can be further subdivided into several categorizations as well – incontinence, voiding dysfunction, pain, etc. Despite a heavy dose of specialized knowledge necessary for these topics, ultimately we view the patient/client using a similar lens as any neuro-musculo-skeletal condition. This would include the need to examine and intervene for identified deficits in motor coordination, mobility, flexibility, strength, awareness and knowledge. Therefore, all PTs are primed to enter the world of pelvic rehab and they should consider “uploading the mental software” of pelvic specific knowledge by taking courses and finding a mentor to get started.

 

Being a male within what is typically considered a female related health domain never really bothered me. It just made me witness what a great opportunity it is and how I can be somewhat unique with my practice because there was and still is a need for more male PTs to be involved in pelvic rehab. Early on in my career I would see more females than I do now because our clinic needed the coverage and I wanted to use all aspects of the pelvic related knowledge I acquired. There was never an issue because the patients were willing to work with me; it was not a big deal to them because most of the time a male physician referred them to me in the first place. I would protect myself from any concerns by having a female aide or student be my chaperone in the room. This way a witness was present. It was not a burden on the clinic in any way, and actually the chaperones reported feeling very enlightened about what I do and I believe having a chaperone comforted the patient as well. The male patients I treat are so grateful and many express how they would be uncomfortable with a female therapist although they would go "if they had to". Of course, we as the practitioners know that the care offered by a PT of any gender will be therapeutic and professional, but the patient would not know until they had a positive experience. Some of my patients have avoided going to PT for their pelvic dysfunction until they discovered they can see a male PT. Unfortunate, but true.

Tagged in: Male Pelvic Floor

Earlier this week a blog post asked the question "Do male therapists belong in pelvic rehab?" With increased frequency, male therapists are participating in pelvic rehab coursework and practices. Some of the male therapists are even attending coursework as students. I asked Justin Stambaugh, a student from Duke University (who very much impressed me with his command of the material, and his calm, curious, and competent demeanor), a few questions about his path into pelvic rehab. Below are his responses.

 

Holly: How did your path lead towards pelvic rehab in general?

Justin: Pelvic rehab really necessitates an openness and sense of comfort regarding issues that can be seen as very personal, private, and even taboo. I was drawn to pelvic rehab because I am the type of person who doesn’t believe that individuals should have to suffer in silence because of fear or embarrassment of addressing their issues. I want people to know that they can and should seek treatment for their pelvic health issues, and that physical therapy can be a valuable resource in this regard.

I also value the complexity of pelvic rehab. In addition to the clinical aspect of care there is also the psychosocial element that adds to the scope and depth of treatment. I appreciate that pelvic rehab requires the clinician to continuously evaluate and adapt their approach in order to be proficient.

Tagged in: Male Pelvic Floor

This question is one that, a decade ago, may have made more sense to ask, as very few male therapists were engaged in the world of pelvic rehabilitation. Most pelvic rehabilitation practices still stem from programs developed in "Women's Health" so it's logical to see more female patients being treated, usually by female therapists. We are at an exciting time in the healing professions, and particularly in pelvic rehabilitation, when choice of provider may come to be based more on experience, personality and qualifications of the treating therapist than on the provider's or patient's gender. At the Institute's most recent entry-level Pelvic Floor 1 (PF1) courses, 2 male therapists were in attendance at 2 different PF1 courses on opposite sides of the nation. This shift (we tend to have an occasional male therapist within the pelvic floor series courses) has been noticed, and at the Institute, we have committed efforts at exploring if and how this shift affects our coursework. For example, are the instructors comfortable, are the female participants cool with it, and do the men feel welcomed? To find out a little more about the subject, I bring your attention to a few of the men who are currently representing the field of pelvic health.

 

Herman & Wallace Institute faculty member, Peter Philip, has treated both men and women in his practice for years. This treatment involves internal assessment and intervention when needed, and Peter approaches all of his patients with the same matter-of-fact, clearly defined consent. As a private practice owner, it makes sense that Peter is able to retain his patients regardless of the condition for which they are seeking care. Having to refer a patient to another therapist or clinic would negate the ability for a therapist to provide comprehensive care. On his website you will find a listing of women's health issues described next to sports, work, and other lifestyle injuries.

 

I posed the following question to Jake Bartholomy , physical therapist in Seattle, Washington: "Why is it so important for a male therapist to be involved in pelvic rehab, regardless if the goal is to focus on working with male or female or other gendered patients?" Jake's response reflects the value of offering choices to the patients he serves: "I believe it's important for people to have a choice in their therapist. Many people are shy and nervous to discuss their pelvic issues and if male or transgendered patients are more comfortable working with a male therapist, I'm proud to offer that service in the Seattle area."

 

Tagged in: Male Pelvic Floor

Blog by Holly Tanner

Among the challenges in research for chronic pelvic pain is the lack of consensus about diagnosis and intervention. Prominent researchers and physicians J. Curtis Nickel and Daniel Shoskes describe a methodology for classification of male chronic pelvic pain using phenotyping, which can be simply described as “a set of observable characteristics.” The authors point out in this article that men with complaints of pelvic pain have historically been treated with antibiotics, even though now it is known that most cases of “prostatitis” are not true infections. With most patients having chronic pelvic pain presenting with varied causes, symptoms, and responses to treatment, Nickel and Shoskes acknowledge that traditional medical approaches have not been successful.

 

In an attempt to improve classification of patients and subsequent treatment approaches, the UPOINT system was developed. The domains of the system include urinary, psychosocial, organ specific, infection, neurological/systemic conditions, and tenderness of skeletal muscles, and are listed below. Within each domain, the clinical description has been adapted from the original study (which can be accessed full text at the link above.)

 

UPOINT Domains

Tagged in: Male Pelvic Floor

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