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.

Today we pick up on Jennafer Vande Vegte's interview with her patient, "Ben", about his experience overcoming chronic pelvic pain syndrome. Ben's quality of life improved so much that he has returned to school in order to become a PTA, with a focus on pelvic rehabilitation!

Describe your physical therapy experience. Talk about your recovery process. Include the physical, mental and emotional components.

For my initial visit, my therapist questioned and assessed my pain, then explained pelvic floor dysfunction. She made sure I understood that the evaluation and treatment process involved internal rectal work. After developing the condition and months of seeing doctors who didn’t listen, finally I found a physical therapist who was actually listening to me and determined to get to the bottom of what was going on. I could tell she already knew much about the mechanics (if not the exact cause) because she had treated other patients with the same issues. I immediately sensed a difference from any other health care professional in attitude, compassion, and knowledge. Of course, how do you know for sure? Well, you don’t. But after repeated visits and excellent results, you experience the difference. An important realization while going to Physical Therapy is learning to see the mind-body connection. In the back of my mind I sensed that my pain was being perpetuated by emotional trauma. This is not an intuitive way of thinking when you are in constant high-level, 5-alarm pain. I was obsessed with finding the cause of my pain, but chronic pain is extremely elusive and complicated.

Over the course of many months of PT though we couldn’t pinpoint what started the pain, we knew my nervous system was keeping it going. Sensory signals had somehow been rerouted through pain centers in the delicate and complicated highway interstate of the nervous system. It was as if the Fed Ex truck that was supposed to carry a package from Miami to Denver got rerouted to New York, stuck in traffic in Manhattan, flipped off by cab drivers, beaten up by gang members, contents of the truck shaken up by the driver trying to flee the city, and then finally finding the way out of New York to the true destination of Denver – with damaged goods, and shaking with anxiety. As to who the idiot dispatcher was who re-routed the truck to New York, well, he’s really good at keeping himself secret and innocent-looking. Jerk!

Physical therapy, over time, began to work for me. It released trigger points which are the first step in the long process of recovery. As we know, chronic tension must be addressed in tissues and nerves, and the mind must relearn how to remain in neutral. I found that as I gained periods of relief I could see that there truly was a mind-body connection beyond what I could imagine. My physical therapist and I both knew that nerves are the slowest recovering tissue in the body, and when you combine that with an anxious mind, you have a complicated puzzle to solve. There is definitely a closed circuit that develops with chronic pelvic pain. Pain causes anxiety, anxiety causes pain and circularly they feed one another.

During my physical therapy I joined a male pelvic pain message board online. I began understanding that most men who develop pelvic pain also have experienced traumatic emotional stress. And a large part of chronic pelvic pain is rooted in a mind-body dysfunction. I had to learn how to stop thinking catastrophically, especially during flare ups. I had to trust that my body would heal and think positively. I had to learn how to relax, take care of myself, eat well, stretch and exercise daily.

When I started physical therapy, I hoped to escape the pain. My first 5 month phase of physical therapy helped to loosen the chronically tightened pelvic sphincter muscles. However, I still had allodynia. In my second phase of physical therapy I began experiencing reduction of pain for a longer duration of time. After about a year of therapy, I finally got to a point where I could see there was significant improvement, even though some intermittent pain and anxious symptoms stubbornly persisted. In late spring of 2017, I finally felt like I had conquered the pain by 98%. Occasionally flares would still come, but they were brief and nothing like before physical therapy.

How has your experience with chronic pelvic pain changed you?

CPPS has profoundly changed me. I don’t take the little things for granted or sweat them anymore. I am grateful for not feeling that horrible, hellish sensation any longer. I appreciate having my mind pain and panic free. I speak my mind while respecting my own desires instead of belittling them. I am currently in school to become a Physical Therapy Assistant as through this process I learned that I’m actually much smarter than my middle school guidance counselor thought. I understand the mind is incredibly powerful, and fear rarely has the same power over me.

How do you handle flare ups?

I now handle brief flare ups with deep breaths, meditation, and/or just taking a step back and trying to zero in on what is really bothering me. At least now I can clearly think without debilitating pain and am able to function.

What would you like to say to other people who are struggling with chronic pelvic pain?

Oh, man. For the initial duration, I would say find a safe place where you can feel as comfortable as possible until the pain lessens. When it is bad, you sort of have to give in to it. However, part of this recovery is the physical mechanics of muscle and fascia. Physical Therapy is essential in the process of recovery to release this tension. I would tell them not to give up hope. You will not find many health professionals or websites that will tell you that you can beat this and recover 100%. But I will tell you, you can recover, 100%. You can. But for now, your full-time job is to work on recovery, and that includes lots of self-care, facing possible emotional pain, and physical therapy.

If you would like to learn more about addressing the mind body connection with patients please join us for Holistic Intervention and Meditation: Boundaries, Self-Care and Dialog in January. We will be exploring ways to help our patients heal to their fullest potential as well as keeping ourselves emotionally healthy in the process. Treating patients with persistent pain can be challenging for the best of us. Please come for this three-day course where you will leave feeling refreshed, renewed and reinvigorated to treat even your most complex patient.

Additional resources:
https://www.tamethebeast.org/#home
https://www.youtube.com/watch?v=jIsF8CXouk8
http://www.sciencedirect.com/science/article/pii/S1356689X11000737
http://www.noigroup.com/en/Home
https://bodyinmind.org/who-are-we/

Recently my coworkers and I celebrated a male patient’s recovery from a long and difficult journey with persistent pelvic pain.  “Ben’s” case had many elements of what we normally see in our patients: chronic muscle holding, restricted fascia, allodynia, hyperalgesia, castrophizing and kenisiophobia.  Ben was also very upfront about how his pain impacted his emotional well-being and vice versa.  His healing process taught us a lot about the biopsychosocial aspects of treating persistent pain.  Along his journey we dreamed of the day we could write a blog together and help other people learn from the experience. Ben also decided to make a career change entering school to become a PTA so that he could help others in pain. Here is my interview with this brave patient.

1.   Tell us about how your pain started
 
My pain started with urethral burning.  Tests showed there was no infection.  In retrospect, the cause of pain could have been the beginning of tension on pudendal nerve branches from extreme stress and a series of traumatic incidents that happened within weeks of each other.  They included a very embarrassing and stressful summer of unemployment, a father who had heart failure and triple bypass in the fall, and a girlfriend who gave me an ultimatum when I was too stressed to get an erection.

2.   What medical tests or treatments were done?
When the pain started, I first thought it was a basic urinary tract infection.  I went to the med center and was prescribed an antibiotic.  After 3 days without change, I went back in and although they still found no sign of infection, they prescribed an additional antibiotic.  The urethral pain never stopped and seemed to get worse.  Following a series of visits to numerous doctors and urologists, I repeated tests on the prostate fluid, blood tests, and more bacterial tests.  No infection.  My PCP also made a fairly large overture of testing me repeatedly for HIV.  For five months I had a blood test every month, all came back negative.  This was damaging to my psyche. For those months I was terrified my life was over.  In retrospect, that doctor was out of line, I changed doctors.

3.  What were your thoughts when your doctor suggested physical therapy?
When the doctor suggested pelvic floor physical therapy, I was a little skeptical because I was still convinced that something was wrong in a chemical or infectious way (as is typical for most men with pelvic floor dysfunction).  However, desperate to take away the constant pain, I followed the advice.

Stay tuned for part two of our conversation with Ben, coming up in our next post on the Pelvic Rehab Report!

As someone who has spent nearly two decades marketing myself, my practice, or practices for employers, I have learned a lot of skills by trial and error. One of my favorite strategies to expand my professional network is to “Follow the Patient.” By this I mean to follow the patient to a specialist consult, to a procedure, or to a referral that you helped to coordinate. This must be done with the patient in mind, first and foremost, and then also the provider and their practice environment, so as not to have that practice shut the door on you in the future. Of course, this process can look different if you are in a health network because as an insider, you will likely be more welcome and have all the right credentials in order to simply attend a patient’s provider visit. If you are in a private practice, there are sometimes more hoops and permissions to negotiate. Following are some tips I have learned about this strategy of nurturing referral sources.

Offer the idea to the patient and see if they are open to it. It might sound like this: “If you are interested, I may be able to accompany you to your upcoming appointment. Does that interest you?” It’s very important that the patient is consenting to you being in attendance at their appointment, as the visit is for them. It may be best to not promise that you can clear your schedule, or coordinate the visit, but finding out if the patient is open to the idea is the first step.

2. Check in with the provider’s office. This can be accomplished by you or by the patient. This might sound like this: “I’d like to be sure that your provider would welcome me at your appointment. Would you prefer to contact the provider’s office or shall I?” In my experience, the provider’s office will say “if it’s ok with the patient, it’s fine with us!” Typically, a patient can bring whomever they like to an appointment, so that’s not much of an issue, unless there is close quarters or some other limiting scenario. The good thing about giving a heads up is it allows the provider’s office the opportunity to know that you may be joining your patient. I was able to follow a patient into a hernia repair surgery, and the nurses were so surprised that a physical therapist was in the prep room, they asked me “does the doctor know you are here?” in which case I was able to affirm that I indeed had permission from the surgeon.

3. When you attend the visit, allow the patient to introduce you or politely introduce yourself. Then listen. This is not the time to tell the medical provider all of the wonderful things you have been doing, or all of the things you have to offer their patients. Sometimes when reporting their history, the patient will look questioningly at me to recall details, and unless I am needed to give a brief response, I like to be quiet and stay out of the story until later. This is the time for the patient and the provider to get to know each other, establish rapport, and fewer interruptions are best.

4. Be prepared to summarize your thoughts when given the opportunity to share. Typically I have found that a medical provider will at some point turn and ask me a few questions, or simply state, “Do you have anything to add?” at which point I try to make concise yet thoughtful statements about the patient’s progress, continued challenges, and the reasoning behind the referral if I was the one to coordinate it. The summary might sound like this: “The original severe pain locations have eased, function has improved in this way, and the symptom or issue that is persisting is this. I was interested in knowing if there is potentially something else going on, or if you have a recommendation towards furthering their progress.” At this point, it’s best to not get too far ahead of yourself, or put expectations in front of the patient beyond a brief summary. In other words, don’t request specific imaging or suggest a particular procedure, as this may create an imbalance in the patient’s expectations and the reality of what takes place. If the provider wants more details or thoughts from you, they are likely to ask directly. (You can also send a progress report or summary letter prior to your visit if you have specific thoughts or concerns about what is going on.)

5. Allow the visit to unfold, listen carefully and take mental or written notes. I have often found that I recall details of anatomy, medications, or suggested interventions easily and the patient may ask about the details in a follow-up visit. This type of partnership allows the patient to have “another pair of ears” and can serve as a valuable part of the rehabilitation care planning. For example, perhaps the provider said, “Let’s try this imaging, if nothing of interest shows up, continue rehabilitation for 6 weeks. If no significant progress, I’d like to see you back here within a couple of months from today.” This allows the therapist to note that a provider visit was requested at 6 weeks following the appointment.

Marketing our services, in the long run, and especially in pelvic health, is critical in sharing awareness of the role of pelvic rehabilitation. Marketing is about relationships, and the easiest way to create a relationship is face to face. “Following” a patient along their healing journey, while it may take time out of the clinic for you, is a valuable way of engaging with providers and of being part of a collaborative process. When another provider or therapist requests that I see their patient to offer another view, I find it helpful to welcome the referring therapist to join the patient as well. This can lead to valuable discussions, sharing of information, and ultimately the patient may experience more efficient care that is directed to optimal strategies.

When reading published research on a subject matter directly relating to what we do in our career, we may need to remember the expression, “Don’t throw the baby out with the bathwater.” Sometimes the test results for a promising hypothesis are not statistically significant, and we can close our minds to the concept entirely. If we skim the abstract and hone in on the “results” or “conclusion” rather than reading the whole article, particularly a study’s limitations, we may drop a sound clinical pearl down the drain.

A research article published in May 2017 by Amorim et al., looked at the force generation and maintenance of the pelvic floor muscles when combined with hip adduction or abduction contractions. They hypothesized that pelvic floor muscle (PFM) contraction combined with hip abduction contraction (rather than adduction) should produce a greater PFM contraction because of the myofascial connection of the obturator internus to the levator ani muscle. The study included 20 nulliparous women without pelvic floor dysfunction. The pelvic floor muscle contraction was measured in isolation, with 30% and 50% maximum hip adduction contraction, and with 30% and 50% maximum hip abduction contraction. The forces were measured with a cylindrical, intravaginal strain-gauge for PFM and another strain-gauge around the hips for adduction/abduction force generation. The women were given visual feedback to help them obtain the required hip contraction force. An average of 3 contractions (10 seconds each with a 1 minute rest) was used for each condition. This was all performed again 4 weeks later.

The results of this study by Amorim et al.²⁰¹⁷ did not support the hypothesis. No statistically significant difference was found among any of the conditions measured. The intravaginal PFM force generation was not different when combined with hip abduction versus hip adduction contraction. Neither hip adduction nor abduction made a significant change in force of the PFM contraction compared to isolated PFM contraction. The authors had to conclude there is no evidence to support the efficacy of combining PFM training with contraction of the hip abductors or adductors.

Even Amorim et al., admitted the study had limitations, and the benefit of PFM training combined with the hip contractions could exist under more “chronic” conditions rather than the brief testing period used in the research. They also used healthy women who had no children, which could make for a different outcome than if they used women with pelvic dysfunction. The specificity of the strain-gauges and the feedback given was not flawless. The authors encouraged further study on the subject. Perhaps there could be an important correlation between PFM and hip abduction contraction not yet found.

Reading research is an integral part of being a responsible healthcare professional, but without solid discernment, we could be entranced or blinded by bubbles as the “baby” escapes us. Taking a course (online or in person) that enhances overall understanding of a subject matter such as the correlation between the lumbopelvic region and the hip can equip the practitioner with a broader foundation upon which clinical decisions can be made. Recognize what concepts to keep and which to wash away, and realize one patient may benefit from what a randomized controlled trial could not cleanly prove to work.

Amorim, A. C., Cacciari, L. P., Passaro, A. C., Silveira, S. R. B., Amorim, C. F., Loss, J. F., & Sacco, I. C. N. (2017). Effect of combined actions of hip adduction/abduction on the force generation and maintenance of pelvic floor muscles in healthy women. PLoS ONE, 12(5), e0177575. http://doi.org/10.1371/journal.pone.0177575

One of my greatest nemeses when I was racing at 30 years of age was a woman in her 50’s. Although I hated losing to her, I was always inspired by her speed at her age. She motivated me to continue training hard, realizing my fastest days could be yet to come. As I now race in the “master’s” category in my 40’s, I still find myself crossing the line behind an older competitor occasionally. Research shows I should take heart and keep in step with females who continue to move their bodies beyond menopause.

Mazurek et al., (2017) studied how organized physical activity among post-menopausal women could reduce cardiovascular risk. The study included 35 sedentary women aged 64.7 ± 7.7 years who had no serious health issues. They all participated in the Active Leisure Time Programme (ALTP) 3 times per day for 40–75 minute sessions for 2 weeks, including 39 physical activities. Exercise intensity stayed within 40–60% of maximal HR, and ratings of perceived exertion (RPE) on the Borg scale stayed between 8 and 15 points. This exercise training was followed by 3 months of the Prevent Falls in the Elderly Programme (PFEP), which is a general fitness exercise program to prevent falls in the elderly. Health status was measured at baseline, 2 weeks into the program, and after 3 months. The results showed significant reductions in central obesity, which increased the exercise and aerobic capacity of the subjects and improved lipid profiles. A significant reduction also occurred in the absolute 10-year risk of death from cardiac complications. The authors concluded these exercise programs could be effective in preventing primary and secondary cardiovascular disease in the >55 years old female population.

Nyberg et al., (2016) took a physiological look at exercise training on the vascular function of pre- and postmenopausal women, studying the prostanoid system. Prostanoids are vasoconstrictors, and prostacyclins are vasodilators. The loss of estrogen in menopause affects the ability of the vasodilators to function properly or even be produced, thus contributing to vascular decline. The authors checked the vasodilator response to an intra-arterial fusion of a prostacyclin analog epoprostenol as well as acetylocholine in 20 premenopausal and 16 early postmenopausal women before and after a 12-week exercise program. Pre-exercise, the postmenopausal women had a reduced vasodilator response. The women also received infusion of ketorolac (an inhibitor of cyclooxygenase) along with acetylcholine, creating a vasoconstriction effect, and the vascular response was reduced in both groups. The infusions and analyses were performed again after 12 weeks of exercise training, and the exercise training increased the vasodilator response to epoprostenol and acetylcholine in the postmenopausal group. The reduced vasodilator response to epoprostenol prior to exercise in early postmenopausal women suggests hormonal changes affect the capacity of prostacyclin signaling; however, the prostanoid balance for pre and postmenopausal women was unchanged. Ultimately, the study showed exercise training can still have a positive effect on the vascularity of newly postmenopausal women.

There are randomized controlled clinical trials and scientific evidence supporting the importance to keep moving as women (and men) age. Menopause should not be a self-proclaimed pause from activity in life. Not everyone has to become a competitive athlete to preserve cardiac and vascular integrity as we age, but we need to engage in some physical activity to keep our systems running for years to come.

Those interested in learning more about menopause rehabilitation considerations should consider attending Menopause Rehabilitation and Symptom Management.

Mazurek, K., Żmijewski, P., Kozdroń, E., Fojt, A., Czajkowska, A., Szczypiorski, P., Tomasz Mazurek, T. (2017). Cardiovascular Risk Reduction in Sedentary Postmenopausal Women During Organised Physical Activity. Kardiologia Polska. 75, 5: 476–485. http://doi:10.5603/KP.a2017.0035
Nyberg, M., Egelund, J., Mandrup, C., Nielsen, M., Mogensen, A., Stallknecht, B., Bangsbo, J., Hellsten, Y. (2016). Early Postmenopausal Phase Is Associated With Reduced Prostacyclin-Induced Vasodilation That Is Reversed by Exercise Training: The Copenhagen Women Study. Hypertension. 68:1011-1020. https://doi.org/10.1161/HYPERTENSIONAHA.116.07866

As I read about male phimosis, I thought about a shirt that just won’t go over my son’s big noggin. I tug and pull, and he screams as his blond locks stick up from static electricity. Ultimately, if I want this shirt to be worn, I either have to cut it or provide a prolonged stretch to the material, or my child will suffocate in a polyester sheath. This is remotely similar to the male with physiological phimosis.

In a review article, Chan and Wong (2016) described urological problems among children, including phimosis. They reported “physiological phimosis” is when the prepuce cannot be retracted because of a natural adhesion to the glans. Almost all normal male babies are born with a foreskin that does not retract, and it becomes retractable in 90% of boys once they are 3 years old. A biological process occurs, and the prepuce becomes retractable. In “pathological phimosis” or balanitis xerotica obliterans, the prepuce, glans, and sometimes even the urethra experience a progressive inflammatory condition involving inflammation of the glans penis, an unusually dry lesion, and occasional endarteritis. Etiology is unknown, but males by their 15th birthday report a 0.6% incidence, and the clinical characteristics include a white tip of the foreskin with a ring of hard tissue, white patches covering the glans, sclerotic changes around the meatus, meatal stenosis, and sometimes urethral narrowing and urine retention.

This review article continues to discuss the appropriate treatment for phimosis (Chan & Wong 2016). Once phimosis is diagnosed, the parents of the young male need to be educated on keeping the prepuce clean. This involves retracting the prepuce gently and rinsing it with warm water daily to prevent infection. Parents are warned against forcibly retracting the prepuce. A study has shown complete resolution of the phimosis occurred in 76% of boys by simply stretching the prepuce daily for 3 months. Topical steroids have also been used effectively, resolving phimosis 68.2% to 95%. Circumcision is a surgical procedure removing foreskin to allow a non-covered glans. Jewish and Muslim boys undergo this procedure routinely, and >50% of US boys get circumcised at birth. Medical indications are penile malignancy, traumatic foreskin injury, recurrent attacks of severe balanoposthitis (inflammation of the glans and foreskin), and recurrent urinary tract infections.

Pedersini et al., (2017) evaluated the functional and cosmetic outcomes of “trident” preputial plasty using a modified-triple incision for surgically managing phimosis in children ages 3-15. All patients seen in a 1 year period who were unable to retract the foreskin and had posthitis or balanoposthitis or ballooning of the foreskin during urination were included and treated initially with a two-month trial of topic corticosteroids. Only the patients unresponsive to corticosteroids were treated with the "trident" preputial plasty. At 12 months post-surgery, 97.6% (all but one of the 41 subjects) of patients were able to retract the prepuce, and cosmetics and function were satisfactorily restored.

Phimosis is apparently not a highlight in medical school curriculum, and parents often seek attention for other issues that lead to the diagnosis of phimosis. Like the tight material lining the neck of a shirt, the prepuce can be given a prolonged static stretch, and, over time, may retract appropriately. Or, cutting the shirt material may be necessary for long term success. Similarly, surgical intervention such as circumcision or the newer “trident” preputial plasty may be required.

Chan, Ivy HY and Wong, Kenneth KY. (2016). Common urological problems in children: prepuce, phimosis, and buried penis. Hong Kong Medical Journal. 22(3):263–9. DOI: 10.12809/hkmj154645
Pedersini, P, Parolini, F, Bulotta, AL, Alberti, D. (2017). "Trident" preputial plasty for phimosis in childhood. Journal of Pediatric Urology. 13(3):278.e1-278.e4. doi:10.1016/j.jpurol.2017.01.024

Recently I had a patient referred to me for fecal incontinence. She looked so familiar to me and we realized she had seen me before, years ago, for bladder issues. She was a sweet 60 something single woman who had raised 6 kids on her own after her husband left her. We laughed as she remembered something funny I had said back then. Then we got down to business. In recent years my patient “Inez” had been diagnosed with both diabetes and Crohn’s disease. She was managing the Crohn’s very well but her sugars were much harder for her to get under control. When I asked her about her current complaints and symptoms she reported that most days her bowels were perfect. She reported one or two soft easy to pass stools per day. But when she had to leave the house for a doctor appointment, she would have explosive diarrhea. This didn’t happen if she went to the grocery store or to visit a friend. Upon further questioning she realized she was really anxious about her diabetes and her interactions with her medical provider regarding her diabetes had not been positive. She felt frustrated, scared, and powerless.

As a pelvic health PT I could have treated Inez in a variety of ways. With my initial exam I did not see any glaring musculoskeletal issues. I suggested to Inez the possibility that her nervous system was sending the wrong kind of signals to her bowels when she got anxious and that we could address this in PT. Inez agreed that she would like to try this approach. We decided that we would reevaluate after four visits to see if we needed to change the plan. Over four visits I used craniosacral therapy protocols to address nervous system upregulation and tension. I taught Inez relaxation techniques and encouraged 10 or 15 minutes of daily relaxation practice. Inez opened up about her relationship with her kids and how they tended to be takers but not givers. She would get frustrated and feel a bit used at times. We had conversations about boundaries and saying “no” and I shared some of my own experiences and struggles as well. Lastly we talked about how what we think can affect how we feel and what we do. Inez’s faith was important to her. She found a few bible verses that were meaningful to her about fear and anxiety and would repeat those during her daily relaxation time. On her fourth visit, Inez was all smiles. She brought me a jar of her homemade salsa as a graduation present. As we sat down to talk she reported to me that she saw her doctor yesterday. She had no bowel issues. And more than that, as her doctor began to talk over her she said to him, “No. Stop. You are always talking and never listening. I need you to listen to me today.” She went on to explain to him how it worried her that she was not able to control her diabetes well and she didn’t think he was doing enough to help her. Her physician did stop and listen and asked Inez, “what would you like me to do for you?” She asked for a referral to a specialist and he obliged. Inez was thrilled that she was able to manage her anxiety in a way that helped her bowels and to find the courage to confront her doctor to get the care she felt she needed.

As we grow in the knowledge of how the human body works it seems like all roads lead back to the nervous system. All of our treatments and interactions with patients affect the nervous system in one way or another. In our fast paced, stressed out world, finding ways to be intentional in addressing the nervous system can be a game changer for patients (as well as for ourselves). If this is an area you would like to grow in, please consider a new course being offered this January in Tampa, Florida. Participants taking Holistic Interventions and Meditation will experience and explore evidence-based information on strategies to address the nervous system. Topics covered include practical meditation, use of essential oils, supplements, yoga, calming and centering manual techniques and instruction in how to best dialogue with patients struggling with pain, anxiety and the effects of trauma. Nari Clemons and I hope to see you there.

Faurot, K. K. R., Gaylord, S., Palsson, O. S., Garland, E. L., Mann, J. D., & Whitehead, W. E. (2014). 715 Mindfulness Meditation Has Long-Term Therapeutic Benefits in Women With Irritable Bowel Syndrome (IBS): Follow-Up Results From a Randomized Controlled Trial. Gastroenterology, 146(5), S-124.
Kearney, D. J. (2012). Mindfulness meditation for women with irritable bowel syndrome–evidence of benefit from a randomised controlled trial. Evidence-based nursing, 15(3), 80-81.
Keefer, L., & Blanchard, E. B. (2001). The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: results of a controlled treatment study. Behaviour research and therapy, 39(7), 801-811.

On my son’s due date, I ran 5 miles (as I often did during my pregnancy), hoping he would be a New Year’s baby. The thought of low bone density never crossed my mind, even living in Seattle where the sun only intermittently showers people with Vitamin D. However, bone mineral density changes do occur over the course of carrying a fetus through the finish line of birth. And sometimes women experience a relatively rare condition referred to as pregnancy-related osteoporosis.

Krishnakumar, Kumar, and Kuzhimattam²⁰¹⁶ explored vertebral compression fracture due to pregnancy-related osteoporosis (PAO). The condition was first described over 60 years ago, and risk factors include low body mass index, physical inactivity, low calcium intake, family history, and poor nutrition. Of 535 osteoporotic fractures considered, 2 were secondary to PAO. A 27-year-old woman complained of back pain during her 8th month of pregnancy, and 3 months postpartum, she was found to have a T10 compression fracture. A 31-year-old with scoliosis had back pain at 1 month postpartum but did not seek treatment until 5 months after giving birth, and she had T12, L1, and L2 compression fractures. The women were treated with the following interventions: cessation of breastfeeding, oral calcium 100 mg/day, Vitamin D 800 IU/day, alendronate 70 mg/week, and thoracolumbar orthosis. Bone density improved significantly, and no new fractures developed during the 2-year follow up period.

Nakamura et al.²⁰¹⁵ reviewed literature on pregnancy-and-lactation-associated osteoporosis, focusing on 2 studies. The authors explained symptoms of severe low back, hip, and lower extremity joint pain that occur postpartum or in the 3rd trimester of pregnancy can be secondary to this disorder, but it is often not considered immediately. A 30-year-old woman with such debilitating pain in her spine with movement 2 months postpartum had to stop breastfeeding, and 10 months later, she was found to have 12 vertebral fractures. She had low bone mineral density (BMD) in her lumbar spine, and she was given 0.5mg/day alfacalcidol (ALF), an active vitamin D3 analog, as well as Vitamin K. No more fractures developed over the next 6 years. A 37-year-old female had severe back pain 2 months postpartum, and at 7 months was found to have 8 vertebral fractures due to PAO. Her pain subsided after stopping breastfeeding, using a lumbar brace, and supplementing with 0.5mg/day ALF and Vitamin K. The authors concluded goals for treating PAO include preventing vertebral fractures and increasing BMD and overall fracture resistance with Vitamins D and K.

Other treatment approaches for similar case presentations have been published. One gave credit to denosumab injections giving pain relief and improved BMD to 2 women, ages 35 and 33, after postpartum vertebral fractures (Sanchez, Zanchetta, & Danilowicz²⁰¹⁶). Guardio and Fiore²⁰¹⁶ reported success using the amino-bisphosphonates, neridronate, in a 38-year-old with PAO T4 fracture.

Thankfully for these women experiencing PAO vertebral fractures, supplements boosted their BMD and prevented further fractures. However, they all had to prematurely stop breastfeeding to reduce their pain as well. This rare condition can be used as a warning for women to proactively increase their BMD. The course, Meeks Method for Osteoporosis, can help therapists implement safe, effective, and active ways to promote bone health for all - especially the pregnant population in serious need of support.

Krishnakumar, R., Kumar, A. T., & Kuzhimattam, M. J. (2016). Spinal compression fractures due to pregnancy-associated osteoporosis. Journal of Craniovertebral Junction & Spine, 7(4), 224–227. http://doi.org/10.4103/0974-8237.193263
Nakamura, Y., Kamimura, M., Ikegami, S., Mukaiyama, K., Komatsu, M., Uchiyama, S., & Kato, H. (2015). A case series of pregnancy- and lactation-associated osteoporosis and a review of the literature. Therapeutics and Clinical Risk Management, 11, 1361–1365. http://doi.org/10.2147/TCRM.S87274
Sánchez, A., Zanchetta, M. B., & Danilowicz, K. (2016). Two cases of pregnancy- and lactation- associated osteoporosis successfully treated with denosumab. Clinical Cases in Mineral and Bone Metabolism, 13(3), 244–246. http://doi.org/10.11138/ccmbm/2016.13.3.244
Gaudio, A., & Fiore, C. E. (2016). Successful neridronate therapy in pregnancy-associated osteoporosis. Clinical Cases in Mineral and Bone Metabolism, 13(3), 241–243. http://doi.org/10.11138/ccmbm/2016.13.3.241