I recently found this article from the Psychology Research and Behavior Management Journal. I found myself curious about how other healthcare disciplines treat a diagnosis that often presents in conjunction with pelvic floor dysfunction. Irritable bowel syndrome, or IBS, affects nearly 35 million Americans. It is considered a ‘functional’ condition meaning that symptoms occur without structural or biochemical pathology. There is often a stigma with functional diagnosis that the symptoms are “all in their heads”, and while there are many theories about what predisposes individuals to IBS, the experts now think of IBS as a “disorder of gut brain interaction”. Generally, there are 3 subtypes of IBS where people note either constipation dominant, diarrhea dominant or mixed. In order to be diagnosed an individual must report abdominal pain at least 1 day per week in the last 3 months which is related to stooling and a change in frequency or form. Other symptoms that are common are bloating, nausea, incomplete emptying, and urgency.
The author suggests a biopsychosocial framework to help understand IBS. An interdependent relationship between biology (gut microbiota, inflammation, genes), behavior (symptom avoidance, behaviors), cognitive processes (“brain-gut dysregulation, visceral anxiety, coping skills”), and environment (trauma, stress). The brain-gut connection by a variety of nerve pathways is how the brain and gut communicate in either direction; top down or bottom up. Stress and trauma can dysregulate gut function and can contribute to IBS symptoms.
Stress affects the autonomic nervous system that contributes to sympathetic (fight/flight) and parasympathetic (rest/digest). Patients with IBS may have dysfunction with autonomic nervous system regulation. Symptoms of dysregulated gut function can present as visceral hypersensitivity, visceral sensitivity, and visceral anxiety. Visceral hypersensitivity is explained as an upregulation of nerve pathways. The author sites studies that note that IBS patients have a lower pain tolerance to rectal balloon distention than healthy controls. Visceral sensitivity is another sign of upregulation where IBS patients have a greater emotional arousal to visceral stimulation and are less able to downregulate pain. The author notes that the IBS population show particular patterns of anxiety with visceral anxiety and catastrophizing. Visceral anxiety is described hypervigilance to bowel movements and fear avoidance of situational symptoms. For example, fear of not knowing where the bathroom is located.
Cognitive behavioral therapy (CBT) has been shown to be an effective treatment to decrease the impact of IBS symptoms. CBT is focused on modifying behaviors and challenging dysfunctional beliefs. CBT can be presented in a variety of ways, however most include techniques consisting of education of how behaviors and physiology interplay for example the gut and stress response; relaxation strategies, usually diaphragmatic breathing and progressive relaxation; cognitive restructuring to help individuals see the relationship between thought patterns and stress responses; problem-solving skills with shift to emotion focused strategies (“acceptance, diaphragmatic breathing, cognitive restructuring, exercise, social support”) instead of problem focused strategies, and finally exposure techniques to help the individual slowly face fear avoidance behaviors. So much of the techniques are similar to what pelvic floor therapists try to educate our patients in. It is reassuring to me that through we may be different disciplines we are on the same team are moving towards the same goal. The author recommends a 10 session treatment duration, and notes that may be a barrier for some. Integrated practice with other healthcare professionals is also recommended. The more we can know about what our other team members are doing to help support patients the more effective we all are.
Kinsinger, Sarah W. “Cognitive-behavioral therapy for patients with irritable bowel syndrome: current insights” Psychology research and behavior management vol. 10 231-237. 19 Jul. 2017, doi:10.2147/PRBM. S120817
As pelvic health physical therapists we take care of people suffering from bladder and bowel incontinence and/or dysfunction as well as pre-natal/ post-partum back pain, weak core muscles and pelvic pain. I was approached over 30 years ago by a urologist to take care of his pediatric patients. My reply: “What’s wrong with children?” It’s been a whirlwind of learning since that day!
Pediatric pelvic floor dysfunction is common and can have significant consequences on quality of life for the child and the family, as well as negative health consequences to the lower urinary tract if left untreated.
According to the National Institute of Diabetes and Digestive and Kidney Diseases, by 5 years of age, over 90% of children have daytime bladder control (NIDDK, 2013) What is life like for the other 10% who experience urinary leakage during the day?
Bed-wetting is also a pediatric issue with significant negative quality of life impact for both children and their caregivers, with as much as 30% of 4-year-olds experiencing urinary leakage at night (Neveus, 2010). Children who experience anxiety-causing events may have a higher risk of developing urinary incontinence, and in turn, having incontinence causes considerable stress and anxiety for children (Austin, 2014; Neveus, 2010).
Additionally, bowel dysfunction, such as constipation, is a contributor to urinary leakage or urgency. With nearly 5% of pediatric office visits occurring for constipation (Thibodeau 2013, NIDDK, 2013), the need to address these issues is great! And, since pediatric bladder and bowel dysfunction can persist into adulthood, we must direct attention to the pediatric population to improve the health of all our patients.
Children suffer from many diagnoses that affect the pelvic floor including (Austin et al, 2014);
The most common diagnoses I treat are voiding dysfunction and constipation. Pediatric voiding dysfunction is defined as involuntary and intermittent contraction or failure to relax the urethral muscles while emptying the bladder. (Austin et al, 2014); The dysfunctional voiding can present with variable symptoms including urinary urgency, urinary frequency, incontinence, urinary tract infections, and vesicoureteral reflux. Frequently, constipation is a culprit or cause. (Austin et al, 2014; Hodges S. 2012); Managing constipation can have a very positive effect on voiding dysfunction.
Common questions I am asked include:
If you have pondered these questions, let’s delve in! I see children as young as 4 who have been able to master biofeedback and recite back to me how their pelvic floor works with bowel and bladder function! Children are so eager to please and they love working with animated biofeedback sessions. The research supports the potential benefit of biofeedback training for children with pelvic floor dysfunction (DePaepe et al. 2002, Kaye 2008, Kajbafzadeh 2011, Fazeli 2014). The children are engaged and learn how to isolate their pelvic floor muscles (PFM) through positioning and breathing. The exercises are fun and easy to do. We also incorporate the core! What a wonderful opportunity we have to educate the younger population on these vital muscles as well as proper diet and bowel/bladder habits!
It is not typical to complete an internal pelvic muscle assessment on children, as this would not be appropriate.
In the literature on pediatric bowel and bladder dysfunction you will often come across the word "Urotherapy". It is, by definition, a conservative management-based program used to treat lower urinary tract (LUT) dysfunction. (Austin 2014)
Basic Urotherapy includes education on the anatomy, behavior modifications including fluid intake, timed or scheduled voids, toileting postures and avoidance of holding maneuvers, diet, avoiding bladder irritants and constipation. Parents are often not aware of their children’s voiding habits once they are cleared from diaper duty after successful potty training occurs.
Urotherapy alone can be helpful however a recent study (Chase, 2010) demonstrated a much greater improvement in those patients who received pelvic floor muscle training as compared to Urotherapy alone.
The International Children’s Continence Society (ICCS) has now expanded the definition of Urotherapy to include Specific Urotherapy (Austin et al, 2014). This includes biofeedback of the pelvic floor muscles by a trained professional who can teach the child how to alter pelvic floor muscle activity specifically for voiding. Cognitive behavioral therapy and psychotherapy are also important and can be a needed in combination with biofeedback in specific cases.
As you can see, PFM exercise combined with Urotherapy is a safe, inexpensive, and effective treatment option for children with pediatric voiding dysfunction.
When we think of pediatric bowel and bladder issues, we primarily focus on what is happening to cause the bowel or bladder leakage and treat it accordingly. It is imperative to teach a child that she/he did not have an “accident”, but their bladder or bowel had a leak. It makes the incident a physiological problem and not something they did. See my blog post on “Accident” for more information.
It is not always apparent how much the child is suffering from issues with self-esteem, embarrassment, internalizing behaviors, externalizing behaviors or oppositional defiant disorders. Dr. Hinman recognized theses issues years ago (1986) and commented that voiding dysfunctions might cause psychological disturbances rather than the reverse being true. Dr. Rushton in 1995 wrote that although a high number of children with enuresis are maladjusted and exhibit measurable behavioral symptoms, only a small percentage have significant underlying psychopathology. In other more recent studies (Joinson et al. 2006a, 2006b, 2008, Kodman-Jones et al, 2001) it was noted that elevated psychological test scores returned to normal after the urologic problem was cured.
I frequently get testimonials from my patients. I would say the common denominator is the child and/or caregivers report that the child is “much better adjusted,” “happier”, “come out of his shell”, “more outgoing”, “making friends.” As a side note -- they’re happy they don’t leak anymore.
You can learn more about treating pediatric patients in my courses,
Austin, P., Bauer, S.B., Bower, W., et al. The standardization of terminology of lower urinary tract function in children and adolescence: update report from the standardization committee of the international children’s continence society. J Urol (2014) 191.
Chase J, Austin P, Hoebeke P, McKenna P. The management of dysfunctional voiding in children: a report from the standarisation committee of the international children’s continence society. 2010; J Urol183:1296-1302.
Constipation in Children. (2013)retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx
DePaepe H., Renson C., Hoebeke P., et al: The role of pelvic- floor therapy in the treatment of lower urinary tract dysfunctions in children. Scan J of Urol and Neph 2002; 36: 260-7.
Farahmand, F., Abedi, A., Esmaeili-dooki, M. R., Jalilian, R., & Tabari, S. M. (2015). Pelvic Floor Muscle Exercise for Paediatric Functional Constipation.Journal of Clinical and Diagnostic Research : JCDR, 9(6), SC16–SC17. http://doi.org/10.7860/JCDR/2015/12726.6036
Fazeli MS, Lin Y, Nikoo N, Jaggumantri S1, Collet JP, Afshar K. Biofeedback for Non-neuropathic daytime voiding disorders in children: A systematic review and meta-analysis of randomized controlled trials. J Urol. 2014 Jul 26. pii: S0022-5347(14)04048-8.
Hinman, F. Nonneurogenic neurogenic bladder (the Hinman Syndrome)-15 years later. J Urol 1986;136, 769-777.
Hodges SJ, Anthony E. Occult megarectum:a commonly unrecognized cause of enuresis. Urology. 2012 Feb;79(2):421-4. doi: 10.1016/j.urology.2011.10.015. Epub 2011 Dec 14.
Hoebeke, P., Walle, J. V., Theunis, M., De Paepe, H., Oosterlinck, W., & Renson, C. Outpatient pelvic-floor therapy in girls with daytime incontinence and dysfunctional voiding. Urology 1996; 48, 923-927.
Joinson, C., Heron, J., von Gontard, A. and the ALSPAC study team: Psychological problems in children with daytime wetting. Pediatrics 2006a; 118, 1985-1993.
Joinson, C., Heron, J., Butler, U., von Gontard, A. and the ALSPAC study team: Psychological differences between children with and without soiling problems. Pediatrics 2006b; 117, 1575-1584.
Joinson, C., Heron, J., von Gontard, A., Butler, R., Golding, J., Emond, A.: Early childhood risk factors associated with daytime wetting and soiling in school-age children. Journal of Pediatric Psychology2008; e-published.
Kajbafzadeh AM, harifi-Rad L, Ghahestani SM, Ahmadi H, Kajbafzadeh M, Mahboubi AH. (2011) Animated biofeedback: an ideal treatment for children with dysfunctional elimination syndrome. J Urol;186, 2379-2385.
Kaye JD, Palmer LS (2008) Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. J Urol 180, 300-305
Kodman-Jones, C., Hawkins, L., Schulman, SL. Behavioral characteristics of children with daytime wetting. J Urol 2001;Dec(6):2392-5.
Neveus, T, Eggert P, Evans J, et al. Evaluation of the treatment for monosymptomatic enuresis: a standarisation document from the international children’s continence society. J Urol 2010; 183: 441-447
Rushton, H. G. Wetting and functional voiding disorders. Urologic Clinics of North America, 1995; 22(1), 75-93.
Seyedian, S. S. L., Sharifi-Rad, L., Ebadi, M., & Kajbafzadeh, A. M. (2014). Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial. European Journal of Pediatrics, 173(10), 1347-1353.
Thibodeau, B. A., Metcalfe, P., Koop, P., & Moore, K. (2013). Urinary incontinence and quality of life in children. Journal of pediatric urology, 9(1), 78-83.
Urinary Incontinence in Children. (2012). Retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx
Zivkovic V, Lazovic M, Vlajkovic M, Slavkovic A, Dimitrijevic L, Stankovic I, Vacic N. (2012). Diaphragmatic breathing exercises and pelvic floor retraining in children with dysfunctional voiding. European Journal of Physical Rehabilitation Medicine. 48(3):413-21. Epub 2012 Jun 5.
Andrea Wood, PT, DPT, WCS, PRPC is a pelvic health specialist at the University of Miami downtown location. She is a board certified women’s health clinical specialist (WCS) and a certified pelvic rehabilitation practitioner (PRPC). She is passionate about orthopedics and pelvic health. In her spare time, you can find her enjoying the south Florida outdoors.
Inflammatory bowel disease (IBD) includes the two diagnosis of Crohn’s Disease and Ulcerative Colitis. While both can cause similar health effects, the differences of the disease pathologies are listed below:1
|Ulcerative Colitis||Crohn’s Disease|
|Pattern of Damage||
Common complications experienced by patients with IBD include fecal incontinence, fecal urgency, night time soiling, urinary incontinence, abdominal pain, hip and core weakness, pelvic pain, fatigue, osteoporosis, and sarcopenia. In a sample of 1,092 patients with Crohn’s Disease, Ulcerative Colitis, or unclassified IBD, 57% reported fecal incontinence. Fecal incontinence was reported not only during periods of flare ups, but also during remission periods.2 One common factor affecting fecal incontinence is external anal sphincter fatigue. External anal sphincter fatigue has also been shown to be present in IBD patients who are not experiencing fecal incontinence or fecal urgency. IBD patients have been shown in studies to have similar baseline pressures versus healthy matched controls, thus indicating the possibility that deficits in endurance versus strength can play a larger role in fecal incontinence.3 Other factors contributing to fecal incontinence include post inflammatory changes that may alter anorectal sensitivity, anorectal compliance, neuromuscular coordination, and cause visceral hypersensitivity. Visceral hypersensitivity may be caused by continuous release of inflammatory mediators found in patients with IBD. It is also important to screen properly for incomplete bowel emptying and stool consistency to rule out overflow diarrhea or fecal impaction. Reports of need to splint digitally for full evacuation may indicate incomplete bowel emptying and defaectory disorders such as paradoxical contraction of the puborectalis muscle or rectocele. Anorectal manometry testing may be highly useful in identifying patients likely to improve from biofeedback therapy.4
Urinary incontinence can also be another secondary consequence to IBD. In a sample of 4,827 patients with IBD, 1/3 of responders reported urinary incontinence that was strongly associated with the presence of fecal incontinence. Frequent toilet visits for defecation may stimulate overactive bladder. Women were more likely to experience fecal incontinence versus men. One possible mechanism for increased fecal incontinence in women is men often have a longer and more complete anal sphincter that may be protective of fecal incontinence.5
Physical activity has been shown to be lower in patients with IBD versus healthy controls. 6, 7 Guiding IBD patients in proper exercises programs can have great benefits. Exercise may reduce inflammation in the gut and maintain the integrity of the intestines, reducing inflammatory bowel disease risk.8 It can also help increase bone mass density, an important factor in IBD patients who are at greater risk for osteoporosis. It has also been shown to help general fatigue in IBD patients. Patients with Crohn’s disease who participate in higher exercise levels may be less likely to develop active disease at 6 months. Treadmill training at 60% VO2 max and running three times a week has not been shown to evoke gastrointestinal symptoms in IBD patients. An increase of BMI predicts poorer outcomes and shorter time to first surgery in patients with Crohn’s disease.6
Conservative physical therapy interventions for treating IBD symptoms can include the following:
|Symptoms resulting from IBD||Physical Therapy Interventions|
|Fecal Incontinence (FI)||
Surgical interventions for IBD are dependent upon what type of disease the patient has and what areas of the intestines are affected the most. Surgery may be considered once the disease has become non responsive to medication therapy and quality of life continues to decline. A colectomy involves removing the colon while a proctocolectomy involves both removal of the colon and rectum. For ulcerative colitis patients, options include total proctocolectomy with end ileostomy or a restorative proctocolectomy with ileal pouch anal anastomosis. Restorative proctocolectomy eliminates the need for an ostomy bag making it the preferred surgery of choice if possible and gold standard for ulcerative colitis patients.10 For patients with Crohn’s disease, options include resection of part of the intestines followed by an anastomosis of the remaining healthy ends of the intestines, widening of the narrowed intestine in a procedure called a strictureplasty, colectomy or proctocolectomy, fistula repair, and removal of abscesses if needed.11
1. Crohn’s and Colitis Foundation. 2019. What is Crohn’s Disease. Retrieved from: http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/
2. Vollebregt PF, van Bodegraven A, Markus-de Kwaadsteniet T, et al. Impacts on perianal disease and faecal incontinence on quality of life and employment in 1092 patients with inflammatory bowel disease. Ailment Pharmacol Ther. 2018; 47: 1253-1260
3. Athanasios A, Kostantinos H, Tatsioni A et al. Increased fatigability of external anal sphincter in inflammatory bowel disease: significance in fecal urgency and incontinence. J Crohns Colitis (2010) 4: 553-560.
4. Nigam G, Limdi J, Vasant D. Current perspectives on the diagnosis and management of functional anorectal disorders in patients with inflammatory bowel disease. Therap Adv Gastroenterol. 2018 Dec 6: doi: 10.1177/1756284818816956
5. Norton C, Dibley L, Basset P. Faecal incontinence in inflammatory bowel disease: Associations and effect on quality of life. J Crohn’s Colitis. (2013) 7, e302-e311.
6. Biliski J, Mazur-Bialy A, Brzozowski B et al. Can exercise affect the course of inflammatory bowel disease? Experimental and clinical evidence. Pharmacological Reports. 2016 (68): 827-836.
7. Tew G, Jones K, Mikocka-Walus A. Physical activity habits, limitations, and preditors in people with inflammatory bowel disease: a large cross-sectional online survey. Inflamm Bowel Dis. 2016; 22(12): 2933-2942.
8. Vincenzo M, Villano I, Messina A. Exercise modifies the gut microbiota with positive health effects. Oxidative Medicine and Cellular Longevitiy. 2017: Article ID 3831972.
9. Cramer H, Schafer M, Schols M. Randomised clinical trial: yoga vs written self care advice for ulcerative colitis. Aliment Pharmacol Ther. 2017; 45: 1379-1389.
10. Cornish J, Wooding K, Tan E, et al. Study of sexual, urinary, and fecal function in females following restorative proctocolectomy. Inflamm Bowel Dis. 18 (9) 2012. 1601-160
11. Crohn’s and Colitis Foundation. 2019. Surgery Options. Retrieved from: http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-crohns-disease/surgery-options.html
A question that often comes up in conversation around menopause is that of pelvic health – the effects on bladder, bowel or sexual health…what works, what’s safe, what’s not? Is hormone therapy better, worse or the same in terms of efficacy when compared to pelvic rehab? Do we have a role here?
An awareness of pelvic health issues that arise at menopause was explored in Oskay’s 2005 paper ‘A study on urogenital complaints of postmenopausal women aged 50 and over’ stating ‘…Urinary incontinence and sexual problems, particularly decline in sexual desire, are widespread among postmenopausal women. Frequent urinary tract infections, obesity, chronic constipation and other chronic illnesses seem to be the predictors of UI.’
Moller’s 2006 paper explored the link between LUTS (Lower Urinary Tract Symptoms) and sexual activity at midlife: the paper discussed how lower urinary tract symptoms (LUTS) have a profound impact on women’s physical, social, and sexual well being, and confirmed that LUTS are likely to affect sexual activity. However, they also found that conversely, sexual activity may affect the occurrence of LUTS – in their study a questionnaire was sent to 4,000 unselected women aged 40–60 years, and they found that compared to women having sexual relationship, a statistically significant 3 to 6 fold higher prevalence of LUTS was observed in women with no sexual relationship. They also found that women who ceased sexual relationship an increase in the de novo occurrence of most LUTS was observed, concluding that ‘…sexual inactivity may lead to LUTS and vice versa’.
So, who advises women going through menopause about issues such as sexual ergonomics, the use of lubricants or moisturisers, or provide a discussion about the benefits of local topical estrogen? As well as providing a skillset that includes orthopaedic assessment to rule out any musculo-skeletal influences that could be a driver for sexual dysfunction? That would be the pelvic rehab specialist clinician! Tosun et al asked the question ‘Do stages of menopause affect the outcomes of pelvic floor muscle training?’ and the answer in this and other papers was yes; with the research comparing pelvic rehab vs hormone therapy vs a combination approach of pelvic rehab and topical estrogen providing the best outcomes. Nygaard’s paper looked at the ‘Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence’ and concluded that : ‘…(both pre and postmenopausal women) benefit from motor learning strategies and adopt functional training to improve their urinary symptoms in similar ways, irrespective of hormonal status or HRT and BMI category’.
We must also factor in some of the other health concerns that pelvic health can impact at midlife for women – Brown et al asked the question ‘Urinary incontinence: does it increase risk for falls and fractures?’ They answered their question by concluding that ‘‘… urge incontinence was associated independently with an increased risk of falls and non-spine, nontraumatic fractures in older women. Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in fractures. Early diagnosis and appropriate treatment of urge incontinence may decrease the risk of fracture.’
If you are interested in learning more about pelvic health, sexual function and bone health at Menopause, consider attending Menopause Rehabilitation and Symptom Management.
Sexual activity and lower urinary tract symptoms’ Møller LA1, Lose G. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):18-21. Epub 2005 Jul 29.
A study on urogenital complaints of postmenopausal women aged 50 and over. Oskay UY1, Beji NK, Yalcin O. Acta Obstet Gynecol Scand. 2005 Jan;84(1):72-8.
Do stages of menopause affect the outcomes of pelvic floor muscle training? Tosun ÖÇ1, Mutlu EK, Tosun G, Ergenoğlu AM, Yeniel AÖ, Malkoç M, Aşkar N, İtil İM. Menopause. 2015 Feb;22(2):175-84. doi: 10.1097/GME.0000000000000278.
‘Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence.’ Nygaard CC1, Betschart C, Hafez AA, Lewis E, Chasiotis I, Doumouchtsis SK. Int Urogynecol J. 2013 Dec;24(12):2071-6. doi: 10.1007/s00192-013-2179-7. Epub 2013 Jul 17
After completing an intake on a patient and learning that her history of constipation started about 3 years ago with insidious onset, the story wasn’t really making any sense of how or why this started. Yes, she was menopausal. Yes, she seemed to be eating fiber and drinking water. Yes, she got a bowel movement urge daily, but her bowel movements felt incomplete. Yes, she was a little older, using Estrace cream, and her mobility had slowed down, but nothing seemed to make sense in the story that was leading me to believe it was an emptying problem or a stool consistency issue. She had a bowel movement urge, she could empty, but it was incomplete.
So, after explaining about physical therapy, the muscle problems involved and what we do here, it led us to the physical examination portion. I explained that we check both the vaginal and rectal pelvic floor muscle compartments to determine rectal fullness internally, check for a rectocele, check for muscle lengthening (excursion) and shortening (contraction). She was on board and desperate to find an answer. She was eager for me to help her find an answer to her emptying problem that she had for the last 3 years.
Upon entering her vaginal canal slowly, I start to move around and felt a ring of plastic. “Are you wearing a pessary?” I asked. “Pessary? Oh, yes, I forgot to tell you about that!”, she exclaimed. “How long have you been using it?” I asked. “About 3 years…” she answered.
I sent her back to the urogynecologist to get fit for another type of pessary as her muscle examination proved to be negative. Since that time, I have added the question “Do you wear a pessary?” as part of the constipation intake questions. Pessary use creates the ability for a patient to forgo or to extend their time for a surgical intervention due to pelvic organ prolapse.
Looking at the dynamics of the pessary, it may block bowel movement emptying. The recent study by Dengle, et al, published in the October 2018 in the International Urogynecological Journal confirms this anecdotal, clinical finding. The article, Defecatory Dysfunction and Other Clinical Variables Are Predictors of Pessary Discontinuation, looked at reasons for discontinuation of pessary use from April 2014 to January 2017 and did a retrospective chart review on a selected 1071 women. Incomplete defecation had the largest association with pessary discontinuation.
While there are over 20 sizes of pessaries on the market, patients will discontinue use without having a better conversation with their practitioner. From a PT perspective, when the patient comes in with bowel emptying issues, if no muscle dysfunction is found, it needs to be brought to the provider’s attention. Our role in educating the patient on the options that are available and creating this dialogue can prove to be very helpful in those suffering from pelvic organ prolapse and defecatory dysfunction.
Dengler, EG et al. "Defecatory dysfunction and other clinical variables are predictors of pessary discontinuation." Int Urogynecol J. 2018 Oct 20. doi: 10.1007/s00192-018-3777-1. https://www.ncbi.nlm.nih.gov/pubmed/30343377
The British author, John Donne, wrote, “No man is an island, entire of itself; every man is a piece of the continent.” In a similar idea, no neurological symptom is independent and isolated; every system has potential to impact the whole body. Neurogenic bladder should cue a clinician to check for neurogenic bowel and to assess the pelvic floor in order to get a complete map of what to address in treatment.
Martinez, Neshatian, & Khavari (2016) reviewed literature on neurogenic bowel dysfunction (NBD) and neurogenic bladder in patients with neurological conditions such as multiple sclerosis (MS). Constipation and fecal incontinence can coexist with NBD, and a multifactorial bowel regimen is vital to conservative management in patients with neurological disorders. Nonpharmacological, pharmacological, and surgical approaches were reviewed in the article. Specific results for MS were reported only for transanal irrigation (TAI) and biofeedback. In TAI, fluid is used to stimulate the bowel and clean out stool from the rectum. A study showed 53% of the 30 patients with MS demonstrated a 50% or better improvement in bowel symptoms with TAI. In anorectal biofeedback, operant conditioning retrains motor and sensory responses via exercises guided by manometry. With biofeedback, a study showed 38% of patients had a beneficial impact with the intervention. The list of treatment approaches not specifically researched for MS patients in this review includes: dietary modifications, perianal/anorectal stimulation, abdominal massage, suppositories, oral medications such as stool softeners or prokinetic agents, sacral neuromodulation, antegrade continence enema, and colostomy.
Miletta, Bogliatto, & Bacchio (2017) presented a case study about management of sexual dysfunction, perineal pain, and elimination dysfunction in a 40 year old female with multiple sclerosis. She had been experiencing perineal pain for 5 months and had chronic MS symptoms of lower anourogenital dysfunction, including bladder retention and obstructed defecation syndrome. Physical therapy treatment included pelvic floor muscle training (primarily decreasing overactivity of pelvic muscles in this case), perineal massage, biofeedback, postural correction, global relaxation techniques, and a home self-training program. After 5 months of physical therapy, the woman had improved pelvic floor muscle contraction strength, resolution of pelvic floor muscle overactivity, increased sexual satisfaction (according to the Female Sexual Function Index score), a visual analog scale improvement of vulvar and perineal pain by 4 points, normalization of obstructed defecation syndrome, and decreased bladder retention symptoms. The authors concluded the variety of symptoms in MS require a multimodal approach for treatment, considering all the motor, autonomic, and cognitive impairments as well as side effects of medications that try to improve those symptoms. The quality of life of women with MS has potential to be improved significantly if pelvic floor disorders related to MS are addressed appropriately.
Ultimately, treating urinary dysfunction but avoiding bowel dysfunction does neurological patients a disservice. Systems are intertwined in a series of cause and effects throughout the body. The “Neurologic Conditions and the Pelvic Floor” course can expand your knowledge and understanding of how the symptoms of conditions such as multiple sclerosis can impact pelvic health and how we can better address the whole patient for optimal outcomes.
Martinez, L., Neshatian, L., & Khavari, R. (2016). Neurogenic Bowel Dysfunction in Patients with Neurogenic Bladder. Current Bladder Dysfunction Reports, 11(4), 334–340. http://doi.org/10.1007/s11884-016-0390-3
Miletta, M., Bogliatto, F., & Bacchio, L. (2017). Multidisciplinary Management of Sexual Dysfunction, Perineal Pain, and Elimination Dysfunction in a Woman with Multiple Sclerosis. International Journal of MS Care, 19(1), 25–28. http://doi.org/10.7224/1537-2073.2015-082
Gratitude filled my heart after being able to take part in the pre-conference course sponsored by the APTA Orthopedic Section’s Pain Management Special Interest Group this past February. For two days, participants heard from leaders in the field of progressive pain management with integrative topics including neuroscience, cognitive behavioral therapy, motivational interviewing, sleep, yoga, and mindfulness to name a few. It’s exciting to witness and participate in the evolution of integrative thinking in physical therapy. When it was my turn to deliver the presentation, I had prepared about nutrition and pain, I could hardly contain my passion. While so much of our pain-related focus is placed on the brain, I realized acutely the stone yet unturned is the involvement of the enteric nervous system (aka the gut) on pain and….well…everything.
Much appreciation is due to those on the forefront of pain sciences for their research, their insight, their tireless work to fill our tool boxes with pain education concepts. Neuroscience has made tremendous leaps and bounds as has corresponding digital media to help explain pain to our patients. One such brilliant 5-minute tool can be found on the Live Active YouTube channel.
What I love about this video is how intelligently (and artistically!) it puts into accessible language some incredibly complex processes. It even mentions lifestyle and nutrition as playing a role in what is commonly referred to as a maladaptive central nervous system.
Ok. I’ll admit, I struggle with the implications of this term. However, what doesn’t sit right with me is the concept of chronic or persistent pain being entirely in the brain as though the brain is a static entity. We know the brain to be plastic but often do not identify just how this is so.
What about the role of our second brain…. the one with 200-600 million neurons that live in that middle part of our body (right next to / inside our pelvis)? Termed the enteric nervous system, this second brain both stores and produces neurotransmittersTurna, et.al., 2016, serves as the scaffolding of interplay between the ENS, SNS, and CNS. This ENS is home to the interface of “bugs, gut, and glial” which are “not only in anatomical proximity, but also influence and regulate each other…interconnected for mutual homeostasis.”Lerner, et.al., 2017 In fact, part of this process then directly impacts the brain. “Healthy brain function and modulation are dependent upon the microbiota’s [gut bugs] activity of the vagus nerve.”Turna, et.al., 2016. Further, “by direct routes or indirectly, through the gut mucosal system and its local immune system, microbial factors, cytokines, and gut hormones find their ways to the brain, thus impacting cognition, emotion, mood, stress resilience, recovery, appetite, metabolic balance, interoception and PAIN.”Lerner, et.al., 2017
So, by process of logic, it requires little convincing to conclude that the food we eat or fail to eat directly impacts the health or dysfunction of this magnificently orchestrated system. One that directly and profoundly impacts our brain, our body, our being. And it’s a concept that our patients, our clients, ourselves, know in our gut to be true.
And it’s thanks to all the hard work of those who have come before us that we can share in the advancing understanding for the benefit of thousands who need your help, expertise and guidance. Please join me for Nutrition Perspectives for the Pelvic Rehab Therapist. The next course will be in Springfield, MO on June 23-24, 2018. Vital and clarifying information awaits you!
Live Active. (2013, Jan) Understanding Pain in less than 5 minutes, and what to do about it! https://www.youtube.com/watch?v=C_3phB93rvI Retrieved March 28, 2018.
Lerner, A., Neidhofer, S., & Matthias, T. (2017). The Gut Microbiome Feelings of the Brain: A Perspective for Non-Microbiologists. Microorganisms, 5(4). doi:10.3390/microorganisms5040066
Turna, J., Grosman Kaplan, K., Anglin, R., & Van Ameringen, M. (2016). "What's Bugging the Gut in Ocd?" a Review of the Gut Microbiome in Obsessive-Compulsive Disorder. Depress Anxiety, 33(3), 171-178. doi:10.1002/da.22454
Curing cancer but not addressing life-altering complications can be compared to feeding the homeless on Thanksgiving but turning your back on them the rest of the year. We love hearing positive outcomes of a surgery, but we are not always aware of what happens beyond that. Colorectal cancer is often treated by colectomy, and sometimes the survivor of cancer is left with urological or sexual dysfunction, small bowel obstruction, or pelvic lymphedema.
Panteleimonitis et al., (2017) recognized the prevalence of urological and sexual dysfunction after rectal cancer surgery and compared robotic versus laparoscopic approaches to see how each impacted urogenital function. In this study, 49 males and 29 females underwent laparoscopic surgery, and 35 males and 13 females underwent robotic surgery. Prior to surgery, 36 men and 9 women were sexually active in the first group and 13 men and 4 women were sexually active in the latter group. Focusing on the male results, male urological function (MUF) scores were worse pre-operatively in the robotic group for frequency, nocturia, and urgency compared to the laparoscopic group. Post-operatively, urological function scores improved in all areas except initiation/straining for the robotic group; however, the MUF median scores declined in the laparoscopic group. Regarding male sexual function (MSF) scores for libido, erection, stiffness for penetration and orgasm/ ejaculation, the mean scores worsened in all areas for the laparoscopic group but showed positive outcomes for the robotic group. In spite of limitations of the study, the authors concluded robotic rectal cancer surgery may afford males and females more promising urological and sexual outcomes as robotic.
Husarić et al., (2016) considered the risk factors for adhesive small bowel obstruction (SBO) after colorectal cancer colectomy, as SBO is a common morbidity that causes a decrease in quality of life. They performed a retrospective study of 248 patients who underwent colon cancer surgery, and 13.7% of all the patients had SBO. Thirty (14%) of the 213 males and 9 (12.7%) of the 71 females had SBO; consequently, they found patients being >60 years old was a more significant risk factor than sex regarding occurrence of SBO. The authors concluded a Tumor-Node Metastasis stage of >3 and immediate postoperative complications were found to be the greatest risk factors for SBO.
Vannelli et al., (2013) explored the prevalence of pelvic lymphedema after lymphadenectomy in patients treated surgically for rectal cancer. Five males and 8 females were examined one week before and 12 months after being discharged from the hospital. All 9 of the patients (4 males, 5 females) with extra-peritoneal cancer exhibited lymphedema via MRI, but the 4 (1 male, 3 females) patients with intra-peritoneal cancer had none. The authors concluded pelvic lymphedema can be elusive after rectal surgery, but pelvic disorders persist and patients should be routinely examined for it.
Obviously saving a life is the primary goal when it comes to cancer. But just like caring for the destitute for one day doesn’t cure a lifetime of hunger, ignoring the negative post-surgical sequelae of a colectomy prevents a cancer survivor from living a healthy life. Herman & Wallace offers two pelvic floor oncology courses, “Oncology and the Male Pelvic Floor” and "Oncology and the Female Pelvic Floor" , which address how pelvic cancers affect the quality of life of our patients and how practitioners can make a positive impact.
Panteleimonitis, S., Ahmed, J., Ramachandra, M., Farooq, M., Harper, M., & Parvaiz, A. (2017). Urogenital function in robotic vs laparoscopic rectal cancer surgery: a comparative study. International Journal of Colorectal Disease, 32(2), 241–248. http://doi.org/10.1007/s00384-016-2682-7
Husarić E., Hasukić Š, Hotić N, Halilbašić A, Husarić S, Hasukić I. (2016). Risk factors for post-colectomy adhesive small bowel obstruction. Acta
When I work prn in inpatient rehabilitation, I have access to each patient’s chart and can really focus on the systems review and past medical history, which often gives me ample reasons to ask about pelvic floor dysfunction. So, of course, I do. I have yet to find a gynecological cancer survivor who does not report an ongoing struggle with urinary incontinence. And sadly, they all report that they just deal with it.
Bretschneider et al.2016 researched the presence of pelvic floor disorders in females with presumed gynecological malignancy prior to surgical intervention. Baseline assessments were completed by 152 of the 186 women scheduled for surgery. The rate of urinary incontinence (UI) at baseline was 40.9% for the subjects, all of whom had uterine, ovarian, or cervical cancer. Stress urinary incontinence (SUI) was reported by 33.3% of the women, urge incontinence (UI) by 25%, fecal incontinence (FI) by 3.9%, abdominal pain by 47.4%, constipation by 37.7%, and diarrhea by 20.1%. The authors concluded pelvic floor disorders are prevalent among women with suspected gynecologic cancer and should be noted prior to surgery in order to provide more thorough rehabilitation for these women post-operatively.
Ramaseshan et al.2017 performed a systematic review of 31 articles to study pelvic floor disorder prevalence among women with gynecologic malignant cancers. Before treatment of cervical cancer, the prevalence of SUI was 24-29% (4-76% post-treatment), UI was 8-18% (4-59% post-treatment), and FI was 6% (2-34% post- treatment). Cervical cancer treatment also caused urinary retention (0.4-39%), fecal urge (3-49%), dyspareunia (12-58%), and vaginal dryness (15-47%). Uterine cancer showed a pre-treatment prevalence of SUI (29-36%), UUI (15-25%), and FI (3%) and post-treatment prevalence of UI (2-44%) and dyspareunia (7-39%). Vulvar cancer survivors had post-treatment prevalence of UI (4-32%), SUI (6-20%), and FI (1-20%). Ovarian cancer survivors had prevalence of SUI (32-42%), UUI (15-39%), prolapse (17%) and sexual dysfunction (62-75%). The authors concluded pelvic floor dysfunction is prevalent among gynecologic cancer survivors and needs to be addressed.
Lindgren, Dunberger, & Enblom2017 explored how gynecological cancer survivors (GCS) relate their incontinence to quality of life, view their physical activity/exercise ability, and perceive pelvic floor muscle training. The authors used a qualitative interview content analysis study with 13 women, age 48–82. Ten women had UI and 3 had FI after treatment (2 had radiation therapy, 5 had surgery, and 6 had surgery as well as radiation therapy). The results showed a reduction in physical and psychological quality of life and sexual activity because of incontinence. Having minimal to no experience or even awareness of pelvic floor training, 9 out of the 10 women were willing to spend 7 hours a week to improve their incontinence. Practical and emotional coping strategies also helped these women, and they all declared they had the cancer treatments without being informed of the risk of incontinence, which impacted their attitude and means of handling the situation.
Research shows incontinence is a common occurrence after gynecological cancer treatment. It impacts quality of life after surviving a serious illness, and many women do not know pelvic floor therapy can improve their situation. Oncology and the Female Pelvic Floor is an ideal course for practitioners to take to help increase their knowledge on how to educate and treat this population.
Bretschneider, C. E., Doll, K. M., Bensen, J. T., Gehrig, P. A., Wu, J. M., & Geller, E. J. (2016). Prevalence of pelvic floor disorders in women with suspected gynecological malignancy: a survey-based study. International Urogynecology Journal, 27(9), 1409–1414. http://doi.org/10.1007/s00192-016-2962-3
Ramaseshan, A.S., Felton, J., Roque, D., Rao, G., Shipper, A.G., Sanses, T.V.D. (2017). Pelvic floor disorders in women with gynecologic malignancies: a systematic review. International Urogynecology Journal. http://doi.org/10.1007/s00192-017-3467-4
Lindgren, A., Dunberger, G., & Enblom, A. (2017). Experiences of incontinence and pelvic floor muscle training after gynaecologic cancer treatment. Supportive Care in Cancer, 25(1), 157–166. http://doi.org/10.1007/s00520-016-3394-9
While recently visiting Seattle with my daughter, we had the pleasure of talking with Dr. Ghislaine Robert, owner of Sparclaine Regenerative Medicine. She is a highly respected sports medicine doctor who has steered much of her practice towards regenerative medicine, with a focus on stem cell and platelet enriched plasma (PRP) injections. She brought to my attention the use of stem cells for pelvic floor disorders. And, like any successful practitioner, she encouraged me to research it for myself.
In 2015, Cestaro et al. reported early results of 3 patients with fecal incontinence receiving intersphincteric anal groove injections of fat tissue. They aspirated about 150ml of the fat tissue and used the Lipogem system technology lipofilling technique to provide micro-fragmented and transplantable clusters of lipoaspirate. The intersphincteric space was then injected with the lipoaspirate. A proctology exam was performed at 1 week, 1 month, and 6 months following the procedure. All 3 patients all had reduced Wexner incontinence scores 1 month post-treatment and a significant improvement in quality of life 6 months post-procedure. Resting pressure of the internal anal sphincter increased after 6 months, and the internal anal sphincter showed increased thickness.
A 2016 study by Mazzanti et al., used rats to explore whether unexpanded bone marrow-derived mononuclear mesynchymal cells (MNC) could effectively repair anal sphincter healing since expanded ones (MSC) had already been shown to enhance healing after injury in a rat model. They divided 32 rats into 4 groups: sphincterotomy and repair (SR) with primary suture of anal sphincters and a saline intrasphincteric injection (CTR); SR of anal sphincter with in-vitro expanded MSC; SR of anal sphincter with minimally manipulated MNC; and, a sham operation with saline injection. Muscle regeneration as well as contractile function was observed in the MSC and MNC groups, while the control surgical group demonstrated development of scar tissue, inflammatory cells and mast cells between the ends of the interrupted muscle layer 30 days post-surgery. Ultimately, the authors found no significant difference between expanded or unexpanded bone marrow stem cell types used. Post-sphincter repair can be enhanced by stem cell therapy for anal incontinence, even when the cells are minimally manipulated.
Finally, in 2017, Sarveazad et al. performed a double-blind clinical trial in humans using human adipose-derived stromal/stem cells (hADSCs) from adipose tissue for fecal incontinence. The hADSCs secrete growth factor and can potentially differentiate into muscle cells, which make them worth testing for improvement of anal sphincter incontinence. They used 18 subjects with sphincter defects, 9 undergoing sphincter repair with injection of hADSCs and 9 having surgery with a phosphate buffer saline injection. After 2 months, there was a 7.91% increase in the muscle mass in the area of the lesion for the cell group compared to the control. Fibrous tissue replacement with muscle tissue, allowing contractile function, may be a key in the long term for treatment of fecal incontinence.
As long as accessing human-derived stem cells is a viable option for patients, the preliminary studies show promise for success. With fecal incontinence being such a debilitating problem for people, especially socially, stem cells are definitely an up and coming treatment, and we should all keep up on this research. After all, who wouldn’t spare some adipose tissue for life-changing, functional gains?
Cestaro, G., De Rosa, M., Massa, S., Amato, B., & Gentile, M. (2015). Intersphincteric anal lipofilling with micro-fragmented fat tissue for the treatment of faecal incontinence: preliminary results of three patients. Videosurgery and Other Miniinvasive Techniques, 10(2), 337–341. http://doi.org/10.5114/wiitm.2014.47435
Mazzanti, B., Lorenzi, B., Borghini, A., Boieri, M., Ballerini, L., Saccardi, R., … Pessina, F. (2016). Local injection of bone marrow progenitor cells for the treatment of anal sphincter injury: in-vitro expanded versus minimally-manipulated cells. Stem Cell Research & Therapy, 7, 85. http://doi.org/10.1186/s13287-016-0344-x
Sarveazad, A., Newstead, G. L., Mirzaei, R., Joghataei, M. T., Bakhtiari, M., Babahajian, A., & Mahjoubi, B. (2017). A new method for treating fecal incontinence by implanting stem cells derived from human adipose tissue: preliminary findings of a randomized double-blind clinical trial. Stem Cell Research & Therapy, 8, 40. http://doi.org/10.1186/s13287-017-0489-2