It’s St Valentine’s day this week – you may have noticed hearts and flowers everywhere you look and a general theme of love and romance. For many women going through cancer treatment, sex may be the last thing on their mind…or not! Women who are going through treatment for gynecologic cancer are often handed a set of dilators with minimal instruction on how to use them, or as one patient reported, they are told to have sex three or four times a week during radiation therapy ‘to keep your vagina patent’. As a pelvic rehab practitioner with a special interest in oncology rehab, I know that we can (we must!) do better, in helping women live well after cancer treatment ends.

As Susan Gubar, an ovarian cancer survivor, writes in the New York Times ‘…It can be difficult to experience desire if you don’t love but fear your body or if you cannot recognize it as your own. Surgical scars, lost body parts and hair, chemically induced fatigue, radiological burns, nausea, hormone-blocking medications, numbness from neuropathies, weight gain or loss, and anxiety hardly function as aphrodisiacs…’

Although sexual changes can be categorised into physical, psychological and social, the categories cannot be neatly delineated in the lived experience (Malone at al 2017). The good news? Pelvic rehab therapists not only have the skills to enhance pelvic health after cancer treatment and are ideally positioned to be able to take a global and local approach to the sexual health difficulties women may face after cancer treatment ends, but there is also a good and growing body of evidence to support the work we do. Factors to consider include physical issues leading to dyspareunia, including musculo-skeletal/ orthopaedic, Psychological issues, including loss of libido and other pelvic health issues impacting sexual function such as faecal/ urinary incontinence, pain or fatigue.

In Hazewinkel’s 2010 paper, women reported that they thought their physicians would tell them if solutions were available…most reported reasons for not seeking help were that women found their symptoms bearable in the light of their cancer diagnosis and lacked knowledge about possible treatments but when informed of possible treatment strategies ‘…women stated that care should be improved, specifically by timely referral to pelvic floor specialists’. The good news: ‘‘Pelvic Floor Rehab Physiotherapy is effective even in gynecological cancer survivors who need it most.’ (Yang 2012)

The issue therefore may be one of awareness – for both the women who need our services and the physicians and healthcare team who work in the field of gynecologic oncology. What we need is acknowledgement of the issues and confident conversation and assessment by clinicians – interested in learning more? Come and join the conversation in Tampa next month at my Oncology & the Female Pelvic Floor course!

‘Sex after Cancer’ by Susan Gubar, https://www.nytimes.com/2018/01/18/well/live/sex-after-cancer.html
Malone et al 2017: ‘‘The patient’s voice: What are the views of women on living with pelvic floor problems following successful treatment for pelvic cancers?’
Hazewinkel et al 2010 ‘Reasons for not seeking medical help for severe pelvic floor symptoms: a qualitative study in survivors of gynaecological cancer’

As brain research in pain processing suggests, pain engages overlapping cortical networks responsible for nociception, cognition, emotion, stress and memory, a treatment model targeting nociceptive mechanisms alone can be inadequate to address the complexities of a patient’s pain experience.¹ To help physical therapists understand and more effectively address multiple factors influencing a patient’s pain, the APTA, Orthopaedic Section and Pain Management Special Interest Group have brought together 10 physical therapists and a physician from around the country to present an informative and dynamic 2-day pre-conference course, Keep Calm and Treat Pain, Feb 21 and 22 at CSM 2018 in New Orleans. Presentation topics include the Science of Pain, Pain Education, Pain Psychology, Motivational Interviewing and Sleep and Pain. In addition, I will present An Introduction to Mindful Awareness Training and Its Role in Pain Treatment, and my colleague at Herman and Wallace, Megan Pribyl, PT, MSPT, will present Pain and Nutrition: Building Resilience Through Nourishment.

As we are in the midst of the opioid crisis, this programming could not come at a better time. In this regard, I am especially excited to share information on how mindfulness training has been shown to help patients who are reducing opioid medications to increase positive affect, decrease pain interference and reduce opioid craving.^{2, 3} I will also describe how mindful awareness training helps address a patient’s fears and fear avoidant behavior and will guide mindfulness exercises.^{4, 5}

I am honored to be a part of this pioneering program that combines didactic presentations with experiential exercises and lab practice to offer participants the latest science of pain and practical skills to more successfully treat pain. In addition, I am presenting an Educational Session sponsored by the Federal Section on the topic Mindful Awareness Training for Veterans with Comorbid Pain and PTSD based on my research experience at the Puget Sound VA in Seattle. I hope to see you at CSM!

While these presentations offer a taste of mindfulness training to improve patient outcomes, they provide just a glimpse into its potential. My joy and passion is my course, Mindfulness-Based Pain Treatment, where I can offer an in-depth exploration of the role mindful awareness training in pain treatment through a thorough review of mindfulness and pain research, the detailed exploration of the application of mindful awareness training to the biopsychosocial pain model and multiple experiential exercises and lab practices that provide participants with practical strategies to bring into the clinic Monday morning. I hope you can attend a Mindfulness-Based Pain Treatment course offered by Herman and Wallace in 2018 at Samuel Merritt University in Oakland, CA, June 9 and 10, Virginia Hospital Center in Arlington VA Aug 4 and 5, or Pacific Medical Center in Seattle, WA Nov 3 and 4. I look forward to helping you expand your toolbox of treatment techniques for patients with pain conditions.

1. Simons LE, Elman, I, Borsook D. Psychological processing in chronic pain: a neural systems approach. Neurosci Biobehav Rev. 2014;39:61-78.
2. Garland EL, Thomas E, Howard MO. Mindfulness-Oriented Recovery Enhancement ameliorates the impact of pain on self-reported psychological and physical function among opioid-using chronic pain patients. J Pain Symptom Manage. 2014;48(6):1091-9.
 3. Garland EL, Froelinger B, Howard MO. Neurophysiological evidence for remediation of reward processing deficits in chronic pain and opioid misuse following treatment with Mindfulness-Oriented Recovery Enhancement: exploratory ERP findings from a pilot RTC. J Behav Med. 2015;38(2):327-36.
4. Schutze R, Rees C, Preece M, Schutze M. Low mindfulness predicts pain catastrophizing in fear avoidance model of chronic pain. Pain. 2010; 148(1):120-7.
5. Jay J, Brandt M, Jakobsen MD, et al. Ten weeks of physical-cognitive-mindfulness training reduces fear-avoidance beliefs about work-related activity. Medicine (Baltimore). 2016;95(34):e3945.

Interstitial cystitis is a chronic pain condition characterized by both pelvic pain and urinary symptoms.  It’s diagnosed by unexplained pain or pressure that is perceived to be related to the bladder, and affects more than 12 million Americans.  It’s often described as the sensation of a urinary tract infection, but without any bacterial infection.  Many patients report severe pain, often more intense than that associated with bladder cancer, and up to 85% of patients have accompanying pelvic floor dysfunction.

Pelvic floor physical therapy is the most proven treatment for interstitial cystitis.  It’s recommended by the American Urological Association (AUA) as a first-line medical treatment in their IC Guidelines, and is the only treatment given an evidence grade of ‘A’.  Furthermore, it’s the sole intervention that provides sustained relief; bladder treatments and oral medications must be continued indefinitely to provide benefit, if they work at all.

Research has demonstrated that at least 85% of patients with interstitial cystitis also have pelvic floor dysfunction.  In fact, many of the symptoms of IC can only be explained by the pelvic floor.  The majority of patients report painful intercourse, low back pain, hip pain, or constipation accompanying the condition; symptoms that have nothing to do with the bladder.

“More than 20 years of research supported by the National Institutes of Health and industry have failed to show that bladder-directed therapy is superior to placebo [for IC].  This fact suggests that the bladder may be an innocent bystander in a larger pelvic process.  As clinicians, we must be willing to look beyond the bladder and examine for pelvic floor issues and other causes of patient’s symptoms and not be too quick to begin bladder-focused treatments.” – Dr. Kenneth Peters

Despite this, many patients don’t learn about pelvic floor physical therapy for years after their diagnosis.  Many have to discover pelvic PT for themselves, or their doctor only mentions physical therapy as a last resort.  At PelvicSanity, we just published a study of our interstitial cystitis patients in the International Pelvic Pain Society (IPPS) meeting, reporting on both patient outcomes and their experience with the medical system following their IC diagnosis.

In following the results for thirteen consecutive patients with an interstitial cystitis diagnosis, patients reported more than a 60% improvement in pain, symptom bother, and how much symptoms limited their daily activities.  On average, their pain level was at a 7.6 out of 10 upon initial evaluation, which fell to 2.6 after treatment.

Patients saw a relatively rapid improvement in their symptoms with treatment.  Over half (54%) reported an improvement in symptoms within their first three visits; 31% saw their first improvement in visits 4-6 and 15% required ten or more visits for subjective improvement.  Importantly, all patients in the study reported a better understanding of their condition and feeling more hopeful for recovery after their initial evaluation.

More than half of these patients reported seeing five or more medical doctors for their condition prior to beginning pelvic floor physical therapy, and had been prescribed multiple medications and undergone bladder treatments without success.  However, only a single respondent (7.7%) believed they had been referred to pelvic PT by their doctor at the appropriate time.  Nearly half (46%) had to find out about pelvic floor physical therapy for interstitial cystitis themselves, while the remainder felt they had been referred by their doctor far too late, as a last resort.

With more than 12 million women and men suffering with this condition in the United States alone, increasing education – for both doctors and patients – is vital.  In our upcoming course for physical therapists in treating interstitial cystitis (April 28-29, 2018 in San Diego), we’ll focus on the most important physical therapy techniques for IC, home stretching and self-care programs, and information to guide patients in creating a holistic treatment plan

I work at University of Chicago and we are in the throes of preparing for a (big T) Trauma Center. But I am physical therapist who works with (little t) traumatized patients- as I treat only pelvic or oncology patients (and usually both).

From the online dictionary: Trauma is 1. A deeply distressing or disturbing experience (little t trauma) or 2. Physical injury (injury, damage, wound) yes- big T Trauma. In my experience, the Trauma creates the trauma and the body responds in characteristically uncharacteristic ways (more on this later).

People in distress/trauma-affected do not respond rationally or characteristically, so I have learned to respond to distress/trauma in a rational, ethical, legal and caring manner. Always. Every time. To the best of my ability, and without shame or blame.

Let’s talk briefly about Trauma Informed Approach

This is a (person), program, institution or system that:

1. Realizes the widespread impact of trauma and understands potential paths for recovery
2. Recognizes the signs and symptoms of trauma in clients, families, staff and others affected
3. Responds by fully integrating knowledge about trauma into policies, procedures and practices
4. Seeks to actively resist retraumatization

The Tenets of Trauma Informed Approach

1. Safety
2. Trustworthiness and transparency
3. Peer support
4. Collaboration and mutuality
5. Empowerment, voice and choice
6. Cultural, historical and gender issues

Trauma Specific Interventions

• Survivors need to be respected, informed, supported, connected, and hopeful- in their recovery
• Interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, anxiety, musculoskeletal presentation, and acute crisis- including suicidal/homicidal ideations (coordination with other service providers)
• Work in a collaborative way with survivors, families and friends of survivor, and other service providers in a way that will empower survivors

Types of trauma are varied but I usually treat survivors of emotional, verbal, sexual and medical trauma. I have even treated patients who felt traumatized by other pelvic floor physical therapists (again, no judgement). Since most of my clinical experience include sexual and medical trauma survivorship, I try to reframe these experiences as potential Post Traumatic Growth, especially when working with my oncology patients. For my pelvic patients who divulge sexual trauma, I don’t dictate or name anything. I allow the survivor to make the rules and definitions. Survivors of sexual trauma need extra care when treating pelvic floor dysfunction.

First, when treating survivors of sexual trauma: expect ‘characteristically uncharacteristic’ events to occur. These include the psychological/somatic effects of passing out, flashbacks, seizures, tremors, dissociation and other mechanisms of coping with the trauma. Have a plan ready for these patients.

Triaging the survivor to assess their needs, when trauma has been verbalized/disclosed:

• Are you safe right now?
• Do you need medical treatment right now?
• What do you need to feel in control of (PT session/immediately after disclosure of trauma)?
• You have choices in your treatment and in your response to trauma.
• I believe you.
• Lastly, is this a situation for mandated reporting?

After assisting the survivor in their journey towards healing, it is imperative that you take care of yourself. Making healthy boundaries (with patients and others), taking time to decompress, creating healthy ritualistic behaviors, mindfulness/relaxation and somatic release (like yoga, massage or working out) is crucial to successfully treating patients who have experienced trauma and who have shared that trauma experience with you.

Because I use gentle yoga for both my trauma survivors’ treatment and for my own self-care, my new course implements evidenced based trauma sensitive yoga. Additionally, modifications for manual therapy are explored. The class is designed to be informative and experiential while integrating the Trauma Informed Approaches of Safety, Trustworthiness and transparency, Peer support, Collaboration and mutuality, Empowerment, voice and choice and Cultural, historical and gender issues.

Join me in Trauma Awareness for the Pelvic Therapist, next available this March in Albany, NY.

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

“Keep Calm and Treat Pain” is perhaps an affirmation for therapists when encountering patients suffering from pain, whether acute or chronic. The reality is this: treating pain is complicated. Treating pain has brought many a health care provider to his or her proverbial knees. It has also led us as a nation into the depths of the opioid epidemic which claimed over 165,000 lives between the years of 1999 and 2014 (Dowell & Haegerich, 2016). That number has swollen to over 200,000 in up-to-date calculations and according to the CDC, 42,000 human beings, not statistics, were killed by opioids in 2016 - a record.

So why has treating pain eluded us as a nation? The answers are as complicated as treating pain itself. Which is why we as health care providers must seek out not simply alternatives, but the truth in the matter. Why are so many suffering? Why has chronic pain become the enormous beast that it has become? What might we do differently, collectively, and how might we examine this issue through a holistic mindset?

In just a few weeks, I have the privilege of teaching amongst 10 physical therapy professionals and one physician from around the nation who with coordinated efforts created a landmark pre-conference course at CSM in New Orleans through the Orthopaedic Section of the APTA. Included in the 11 are myself and another Herman & Wallace instructor Carolyn McManus, PT, MS, MA who teaches “Mindfulness Based Pain Treatment” through the Institute.

The CSM pre-conference course title is “Keep Calm and Treat Pain” representing a necessary effort to provide the clinician with ideas and inspiration for helping the profession as a whole treat pain with an integrative approach.

“Pain and Nutrition: Building Resilience Through Nourishment” is the section I look forward to sharing. It will introduce concepts we can leverage to allow us confidence in seeking alternate ways of taming this beast which is chronic pain - ways which can enhance health and well-being of our clients in pelvic rehabilitation. We must not be passive observers of the opioid epidemic. We must come to terms with the fact that our nations go-to tool for treating pain unfortunately causes side-effects which can and does include loss of life. We can do better. And we will.

While the CSM pre-conference course will give you a taste of the nutrition concepts available to you, it is a mere tip of the nourishment iceberg. I continue my passion and mission with the two-day course titled “Nutrition Perspectives for the Pelvic Rehab Therapist”, an experience that can elevate your conversations with clients. It will pave a path of understanding for the provider, allowing us to share options, understanding, and hope. “Nutrition Perspectives for the Pelvic Rehab Therapist is coming next to Maywood, IL March 3 & 4, 2018. I welcome you to join me.

APTA CSM: https://apta.expoplanner.com/index.cfm?do=expomap.sess&event_id=27&session_id=13763. Accessed January 8, 2018.
CDC: https://www.cdc.gov/drugoverdose/index.html. Accessed January 8, 2018.
Dowell, D., & Haegerich, T. M. (2016). Using the CDC Guideline and Tools for Opioid Prescribing in Patients with Chronic Pain. Am Fam Physician, 93(12), 970-972.
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
Murthy, V. H. (2016). Ending the Opioid Epidemic - A Call to Action. N Engl J Med, 375(25), 2413-2415. doi:10.1056/NEJMp1612578

While my dad was visiting Michigan, we had the day to ourselves as my kids were in school. I was so excited to have quality time with my dad. Unfortunately it was pouring down rain. We decided on a leisurely brunch and then a movie. Dad chose the movie, “Wind River.” While not a movie I would normally pick, I was happy to go along. A little more than half way through…there was a horribly violent scene against a young women. I panicked, plugged my ears and closed my eyes. Unfortunately some images were burned into the back of my mind. When the movie was over, I remained seated and tears just came. My dad held me while I cried. I was able to calm down and leave the theater, but the images continued to bother me. During the next few days, I made it a priority to care for myself and allow my nervous system to process and heal.

What happened to me? I have never had any traumatic personal experience. Why did I react so strongly? I talked with my therapist about it and she suggested I might have experienced secondary traumatic stress. We know, as pelvic health therapists, we need extra time to hear the “stories” of new patients. We do our best to create a safe space for them so they can trust us and we can help them discover pathways to healing. Yet no one has taught us what we are supposed to do with the traumatic stories our patients share. How are we to cope with holding space for their pain? How do we put on a happy face as we exit the room to get the next patient?

Teaching Capstone over the last few years, Nari Clemons and I have talked with many of you who were feeling emotionally overloaded especially when treating chronic pelvic pain and trauma survivors. Some of you were experiencing job burnout, others were deciding maybe it was time for a career shift, away from the pelvis. We realized something needed to be done as our field was losing talented pelvic health therapists. We have also struggled ourselves with various aspects of our profession.

There are no studies that directly look at job burn out, secondary traumatic stress, and compassion fatigue among pelvic health physical therapists. Yet these problems are common among social workers, physicians and other people groups in health care. There are individual as well as institutional risk factors that lead to the development of each. The solution, as one self-help module puts it, is developing resilience. A large part of this skill is making self-care a priority. The basics such as adequate sleep, nutrition, and exercise are foundational. Meditation, mindfulness, therapy, and spiritual practices, as well as supportive friends/groups are also imperative.

Nari and I realized that training to develop resilience in therapists was missing. Initially we equipped ourselves to have better boundaries, ground ourselves with meditation, mindfulness and exercise, which enhanced our skills in dealing with complex, chronic patients. We compiled what we have learned and want to share it with you. We would like to invite you to attend Holistic Interventions and Meditation: Boundaries, Self-Care, and Dialogue. We have designed this 3 day course to be partially educational and absolutely experiential. We are going to dig deeper into ways to calm our patient’s and our own nervous systems, explore and practice the latest recommendations on treatment of persistent pain, we will mediate and learn about mediation, play with essential oils, learn some new hands on techniques, and support and encourage one another as we build communication skills. We want you to leave feeling refreshed and equipped to continue to treat patients without losing yourself in the process. We want to invest in you so you can continue the investment you have made in your career and avoid job burnout, compassion fatigue and secondary trauma. We invite you to develop the resilience you need for a rewarding career in pelvic health physical therapy by joining us in Tampa this January.

Cieslak, R., Shoji, K., Douglas, A., Melville, E., Luszczynska, A., & Benight, C. C. (2014). A meta-analysis of the relationship between job burnout and secondary traumatic stress among workers with indirect exposure to trauma. Psychological services, 11(1), 75.
Meadors, P., Lamson, A., Swanson, M., White, M., & Sira, N. (2010). Secondary traumatization in pediatric healthcare providers: Compassion fatigue, burnout, and secondary traumatic stress. OMEGA-Journal of Death and Dying, 60(2), 103-128.
Sodeke-Gregson, E. A., Holttum, S., & Billings, J. (2013). Compassion satisfaction, burnout, and secondary traumatic stress in UK therapists who work with adult trauma clients. European journal of psychotraumatology, 4(1), 21869.
Stearns, S., & Benight, C. C. (2016). Organizational Factors in Burnout and Secondary Traumatic Stress. In Secondary Trauma and Burnout in Military Behavioral Health Providers (pp. 85-113). Palgrave Macmillan US.

The new year is here and with it, lots of motivational posting about exercise and weight loss…but how is this desire for ‘new year, new you’ affecting peri-menopausal women with urinary dysfunction? It has been established that the lower urinary tract is sensitive to the effects of estrogen, sharing a common embryological origin with the female genital tract, the urogenital sinus. Urge urinary incontinence is more prevalent after the menopause, and the peak prevalence of stress incontinence occurs around the time of the menopause (Quinn et al 2009). Zhu et al looked at the risk factors for urinary incontinence in women and found that some of the main contributors include peri/post-menopausal status, constipation and central obesity (women's waist circumference, >/=80 cm) along with vaginal delivery/multiparity.

Could weight loss directly impact urinary incontinence in menopausal women? In a word – yes. ‘Weight reduction is an effective treatment for overweight and obese women with UI. Weight loss of 5% to 10% has an efficacy similar to that of other nonsurgical treatments and should be considered a first line therapy for incontinence’ (Subak et al 2005) But do these benefits last? Again – yes! ‘Weight loss intervention reduced the frequency of stress incontinence episodes through 12 months and improved patient satisfaction with changes in incontinence through 18 months. Improving weight loss maintenance may provide longer term benefits for urinary incontinence.’ (Wing et al 2010)

The other major health issues facing women at midlife include an increased risk for cardiovascular disease, Type 2 Diabetes and Bone Health problems – all of which are responsive to lifestyle interventions, particularly exercise and stress management. In their paper looking at lifestyle weight loss interventions, Franz et al found that ‘…a weight loss of >5% appears necessary for beneficial effects on HbA1c, lipids, and blood pressure. Achieving this level of weight loss requires intense interventions, including energy restriction, regular physical activity, and frequent contact with health professionals’. 5% weight loss is the same amount of weight loss necessary to provide significant benefits for urinary incontinence at midlife.

Successful weight management depends on nutritional intake, exercise and psychosocial considerations such as stress management, but for the menopausal woman, hormonal balance can also have an effect on not only bladder and bowel dysfunction but changing metabolic rates, thyroid issues and altered weight distribution patterns. As pelvic rehab therapists, we are all aware that pelvic health issues can be a barrier to exercise participation but sensitive awareness of the other particular challenges facing midlife women can make the difference in developing a beneficial therapeutic alliance and a journey back to optimal health. If you would like to explore the topics surrounding optimal health at menopause, why not join me in California in February?

Climacteric. 2009 Apr;12(2):106-13. ‘The effects of hormones on urinary incontinence in postmenopausal women.’ Quinn SD, Domoney C. Menopause. 2009 Jul-Aug;16(4):831-6. The epidemiological study of women with urinary incontinence and risk factors for stress urinary incontinence in China’ Zhu L, Lang J, Liu C, Han S, Huang J, Li X. J Urol. 2005 Jul;174(1):190-5. Weight loss: a novel and effective treatment for urinary incontinence’ Subak LL, Whitcomb E, Shen H, Saxton J, Vittinghoff E, Brown JS. J Urol. 2010 Sep;184(3):1005-10. Effect of weight loss on urinary incontinence in overweight and obese women: results at 12 and 18 months Wing RR, West DS, Grady D, Creasman JM, Richter HE, Myers D, Burgio KL, Franklin F, Gorin AA, Vittinghoff E, Macer J, Kusek JW, Subak LL; Program to Reduce Incontinence by Diet and Exercise Group. J Acad Nutr Diet. 2015 Sep;115(9):1447-63. doi: 10.1016/j.jand.2015.02.031. Epub 2015 Apr 29. Lifestyle weight-loss intervention outcomes in overweight and obese adults with type 2 diabetes: a systematic review and meta-analysis of randomized clinical trials. Franz MJ, Boucher JL, Rutten-Ramos S, VanWormer JJ. Lean, M, & Lara, J & O Hill, J (2007) Strategies for preventing obesity. In: Sattar, N & Lean, M (eds.) ABC of Obesity. Oxford, Blackwell Publishing.

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

Perimenopausal pelvic health issues are, for many of us, some of the most common issues that we see in the women that we work with. Urinary incontinence is one of the most important issues for peri- and postmenopausal women. In Melville’s study¹ of U.S. women, half of the participants between the ages of 50 and 90 experienced urine leakage every month. Zhu’s 2008 study² looked at the risk factors for SUI - Multiple vaginal deliveries, Age/postmenopausal status, Chronic pelvic pain, Obesity, lack of exercise, constipation, and hypertension. But what is not often (enough) looked at in the research, is the link between urinary dysfunction and sexual dysfunction – usually because questions aren’t asked or assumptions are made. In Mestre et al’s 2015 paper³, they write ‘…Integrating sexual health in clinical practice is important. In women with pelvic floor disorders, the evaluation of the anatomical defects, lower urinary tract function and the anorectal function often receives more attention than sexual function.’

But are they linked?

In Moller’s exploration of this topic, they report that lower urinary tract symptoms (LUTS) have a profound impact on women’s physical, social, and sexual wellbeing. Unsurprisingly (to pelvic rehab specialists at least!), they found that the LUTS are likely to affect sexual activity. Conversely, sexual activity may affect the occurrence of LUTS. The aims of the Moller study were to elucidate to which extent LUTS affect sexual function and to which extent sexual function affect LUTS in an unselected population of middle-aged women in 1 year. A questionnaire was sent to 4,000 unselected women aged 40–60 years. 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. In women who ceased sexual relationship an increase in the de novo occurrence of most LUTS was observed. In women who resumed sexual relationship a decrease in LUTS was observed. In women whose sexual activity was unchanged no change in the occurrence of LUTS. So they rightfully concluded ‘…sexual inactivity may lead to LUTS and vice versa.’

In my Menopause course, we will explore the range of perimenopausal pelvic health issues that many women face and their inter-related nature – not just with each other but also how orthopaedic, endocrine and gastro-intestinal health issues influence pelvic health and wellness. Interested in learning more? Come and join the conversation in California in February 2018!

1. Melville JL, et al. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005;165(5):537-42 - See more at: http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=698029#sthash.cm8A90tS.dpuf
2. Zhu L1, Lang J, Wang H, Han S, Huang J. Menopause. 2008 May-Jun;15(3):566-9. The prevalence of and potential risk factors for female urinary incontinence in Beijing, China
3. Mestre M, Lleberia J, Pubill J, Espuña-Pons M Actas Urol Esp. 2015 Apr;39(3):175-82. Epub 2014 Aug 28. Questionnaires in the assessment of sexual function in women with urinary incontinence and pelvic organ prolapse.