The Pelvic Rehab Report sat down with Allison Ariail, PT, DPT, CLT-LANA, BCB-PMD, PRPC to discuss her upcoming courses Rehabilitative Ultrasound Imaging - Orthopedic Topics and Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics scheduled for November 12-14, 2021. Allison specializes in the treatment of the pelvic ring and back using manual therapy and ultrasound imaging for instruction in a stabilization program. She also specializes in women’s and men’s health including conditions of chronic pelvic pain, bowel and bladder disorders, and coccyx pain.
As a pelvic floor clinician, you may have worked with patients who are suffering from urinary incontinence following prostatectomy. During a prostatectomy the prostate, seminal vesicles, prostatic urethra, and some connective tissues are removed. The extent of the removal will depend on the size of the tumor and if the tumor has spread into the surrounding tissues. Because of the surgery, and the loss of smooth muscle surrounding the urethra, there is an inherent risk that these patients will suffer from urinary incontinence. Recently, there have been studies that examined the difference between patients who return to continence and those who do not return to continence following prostatectomy. They found that continent prostatectomy men demonstrated increased displacement of the striated urethral sphincter, bulbocavernosus, and puborectalis compared to incontinent men. They also found that continent prostatectomy patients demonstrated better puborectalis and bulbocavernosus function than controls! (1) This has made researchers conclude that continent men following prostatectomy compensate for the loss of smooth muscle by having better than normal function in their pelvic floor.
In another recent article, researchers put together recommendations for a rehabilitation program. They argue that traditional methods that have been used in pelvic floor therapy are based on applied principles for stress incontinence in women, not men. Men suffer from incontinence for a different reason than women. Thus, their treatment should be approached differently as well. Additionally, the authors state that examining the pelvic floor muscles via a digital rectal exam does not allow the examiner to assess the underlying issue that leads to incontinence in men, the striated urethral sphincter. Instead, a digital rectal exam identifies issues in the external anal sphincter and puborectalis. They highly recommend the use of transperineal ultrasound imaging in order to view the contraction of the pelvic floor and confirm where the contraction is originating from. They also highly recommend the use of ultrasound in treatment for the use of motor re-learning(2).
We will discuss this more in-depth as well as learn how to use ultrasound imaging to help both male and female patients suffering from incontinence. We also will be learning how to use ultrasound imaging to address orthopedic conditions such as back pain, sacroiliac joint pain, and diastasis rectus. The course “Rehabilitative Ultrasound Imaging for the Pelvic Girdle” is now being offered with satellite locations as well as a limited number of self-hosted online groups and is scheduled for November 12-14, 2021. There are two courses being offered. The 2-day version, Rehabilitative Ultrasound Imaging - Orthopedic Topics, addresses the use of ultrasound imaging to help back and lumbopelvic conditions. While the 3-day course, Rehabilitative Ultrasound Imaging: Women's Health and Orthopedic Topics, includes more pelvic floor related conditions such as prolapse and post-prostatectomy issues. The course includes ample lab time so participants leave with the clinical skills to be able to use ultrasound imaging in their practice.
September is Gynae Cancer Awareness Month – but how aware are we as clinicians of the signs and symptoms, the epidemiology and the sequalae of treatment afterwards? As pelvic rehab specialists, we have the privilege of helping women live well after cancer treatment ends, both on a ‘local’ pelvic area (bladder, bowel, sexual and pelvic pain management strategies) but also on a more ‘global’ level – dealing with issues such as cancer related fatigue, bone health and cardiovascular concerns.
We know that women who are diagnosed with cancer of the vulva, vagina, cervix, endometrium or ovaries are treated with a combination of surgery, radiation or chemotherapy. However, with improving treatment and better survival rates, there is evidence that a variety of pelvic health concerns may arise for these women, both during and after treatment. (Hazewinkel et al 2010). For example, urinary incontinence is reported in 80% of women treated for endometrial cancer, with more severe symptoms and impact on quality of life in those who had adjuvant radiation (Erekson et al 2009) In Malone’s 2017 paper, ‘The patient’s voice: What are the views of women on living with pelvic floor problems following successful treatment for pelvic cancers?’, the author notes that ‘…there is currently a lack of knowledge regarding the effects of PFD on QoL in this cohort. Patients do not always report these problems to their health care providers and clinicians may underestimate symptoms…In the context of having survived cancer, PFD may be seen as relatively trivial. However, in the context of resuming normal living, the symptoms experienced by the survivors may be significant’.
This can present a clinical conundrum – often pelvic rehab therapists are nervous when working with a patient who has a current or previous gynecologic cancer diagnosis, but similarly oncology rehab specialists may have qualms about dealing with pelvic health issues, with the result that these women fall through the cracks and do not have their pelvic health issues managed properly (or at all). Theodore Roosevelt once said ‘No one cares how much you know, until they know how much you care’ and this is especially relevant for oncology pelvic rehab. Often you may be the first clinician to ask about bladder, bowel or sexual function or dysfunction. An understanding of the effects of cancer treatments on the pelvis is important but so too is the wealth of information you may already have about bladder, bowel and sexual health as well as neuroscience and pain education.
The most important thing is to ask these women about their pelvic health concerns – the National Coalition for Cancer Survivorship defined cancer survivorship as extending from ‘the time of diagnosis and for the balance of life’. An emphasis on quality of life has been emphasised – if we know that cancer survivors may not independently volunteer information about their pelvic floor dysfunction, it is our responsibility to ask the questions and comprehensively treat and advocate for these women, in order to help them live well after cancer treatment ends.