With menopause and the hormonal shifts that take place, some women suffer more than others with symptoms such as hot flashes. If you have ever been near someone during a hot flash, you know that this curious condition is more than feeling a little hot under the collar. During a hot flash, women will suddenly disrobe, wake from a deep sleep covered in sweat (so much so that they have to change the sheets!), or otherwise appear distressed and oftentimes suffer interference in whatever activity in which they were engaging. As we reported in an earlier post, women on average may have hot flashes for 5 years after the date of her last period. Some women (up to 1/3 in the referenced study) will report hot flashes for 10 or more years after menopause.
Hot flashes and night sweats also significantly disrupt sleep, according to research by Baker and colleagues. Menopausal women with insomnia may also have higher levels of psychologic, somatic, vasomotor symptoms, and score lower on the Beck Depression Inventory, and sleep efficiency and duration scores. Poor sleep can be associated with morbidity such as hypertension, stroke, diabetes and depression, so interrupted sleep is more than an inconvenience, but potentially a serious health issue.
A more recent study linked anxiety as a potential risk factor for menopausal hot flashes. In 233 women who are premenopausal at baseline and who were followed for at least a year after their final menstrual cycle, anxiety symptoms, hormone levels, hot flashes and other psychosocial variables were assessed. During the 14 year follow-up 72% of the women reported having moderate to severe hot flashes, and the researchers correlated somatic anxiety as a potential predictive association with anxiety. Somatic anxiety refers to the physical symptoms of anxiety, such as stomach ache, increased heart rate, sweating, muscle aches.
The following comes from a male patient who wanted to share his story about finding care for his pelvic floor dysfunction. His story highlights the important role pelvic rehab practitioners can play, and why we need to continue training more therapists in this field.
I’m 65 year old male and I developed pudendal neuralgia and pelvic floor issues as a result of an accident about four years ago. Shortly after my accident I started to experience pain in my testicles and perineum. At the time, I did not think that one had anything to do with the other. I made an appointment with my urologist who did an ultrasound and assured me that there was nothing physically wrong. I don’t think my testicles quite believe that but mentally I felt relieved. But the pain persisted and started to spread. Now it was also in my groin and penis. I was also having problems with chronic constipation, urinary retention and erectile dysfunction. Since I did have back surgery years ago I started to suspect my low back was causing the problem. I made an appointment with a well-respected orthopedic surgeon in New York. While he gave me his analysis with regards to my back problems he clearly avoided addressing the pelvic issues. I left there feeling lost. Suffice it to say that over the course of the next couple of years I saw several other specialists who either skirted around the issue or told me that nothing was wrong. A couple of years passed but the pelvic issues just continued to get worse and worse. I started seeing a new primary care physician who indicated that perhaps the source of the pelvic pain was coming from the pudendal nerve and felt that physical therapy might help. She gave me a prescription for physical therapy to evaluate for pudendal nerve.
Well, I have a diagnosis now so I start researching pudendal neuralgia and land on the Pudendal Hope website. Wow! What an eye opener that was. I’m reading the information on the website and it was like I had an epiphany. I realized that I was not going crazy and that Pudendal Neuralgia and pelvic pain are very real issues.
The following testimonial comes to us from Karen Dys, PTA. Karen recently attended the Care of the Pregnant Patient course, and she was inspired to send in the following review. Thanks for your contribution, Karen!
I have been working as a physical therapist assistant for 11 years and worked in a variety of settings. In the past two year I have become more focused on pelvic floor rehabilitation. During that time frame I have had a handful of pregnancy patient including being a pregnant woman myself. Since taking this course, my mind has been opened up of how I can treat my patients and educate them for their best future outcomes. I also can see now how I would have benefited myself if I knew some of these techniques that I’ve now learned. With knowing with my personal story and that my PT could have helped me more with avoiding bed rest and staying active longer with pregnancy, it has become my goal now to treat my pregnant patients differently. I am thankful for Herman and Wallace courses to gain these wonderful techniques to reach out and help so many people.
Within the first few moments of meeting the teacher at a continue education class I can tell if is going to be a good class or not. This course started out great with a very friendly and kind person. Sarah’s compassion and knowledge brightly shined throughout the weekend of teaching. It was very refreshing having a teacher who also has experienced some of the same problems are patients go through. It gave it a good personal perspective of how we can affect our patient outcomes.
My little boy has a t-shirt with a potato telling french fries, “I am your father,” to which the french fries cry, “NO!!!!” The Star Wars spoof makes me laugh, but sometimes the struggle is real. Testicular cancer and the toxic remedies for it can potentially prevent young men from having a successful reproductive life. Survivors of the cancer may one day have to tell their children they are adopted or came from a sperm donor. With the advances in technology and research, however, testicular cancer survivors have a greater chance for their own sperm to be spared or even produced naturally years later to create their offspring.
Vakalopoulos et al. (2015) discussed the impact cancer and the related treatments have on fertility of males. Better survival rates for oncology patients have made preservation of reproductive means more imperative for men. Testicular cancer represents 5% of male urologic cancers, disturbing spermatogenesis and impairing fertility. Chemotherapy, radiotherapy, and surgery can all have gonadotoxic effects in men. Thankfully, only 1 in 5000 men die from testicular cancer now with advanced treatments, but fertility does become a long term factor for survivors. This paper showed chemotherapy combined with radiotherapy was most detrimental to sperm than either treatment alone. Gonadal shielding and moving the testes out of the way to target the malignant cells can help decrease the deleterious effects of cancer treatments. Radiotherapy, however, has been shown to damage sperm up to 2 years after recovery of spermatogenesis. Regarding surgery, radical unilateral orchiectomy is the standard for testicular tumors, and within the first few months, a 50% decrease in sperm concentration occurs, and 10% of patients become azoospermic. On a more encouraging note, after receiving Hematopoietic Stem Cell Transplantation, recovery of sperm in the ejaculate was noted in 33% of patients after 1 year and 80% of patients after 7 years.
Regardless of advancements in decreasing toxicity of cancer treatments and being minimally invasive with surgery, the best guarantee for preservation of sperm is cryopreservation.
My job as a pelvic floor therapist is rewarding and challenging in so many ways. I have to say that one of my favorite "job duties" is differential diagnosis. Some days I feel like a detective, hunting down and piecing together important clues that join like the pieces of a puzzle and reveal the mystery of the root of a particular patient's problem. When I can accurately pinpoint the cause of someone's pain, then I can both offer hope and plan a road to healing.
Recently a lovely young woman came into my office with the diagnosis of dyspareunia. As you may know dyspareunia means painful penetration and is somewhat akin to getting a script that says "lower back pain." As a therapist you still have to use your skills to determine the cause of the pain and develop an appropriate treatment plan.
My patient relayed that she was 6 months post partum with her first child. She was nursing. Her labor and delivery were unremarkable but she tore a bit during the delivery. She had tried to have intercourse with her husband a few times. It was painful and she thought she needed more time to heal but the pain was not changing. She was a 0 on the Marinoff scare. She was convinced that her scar was restricted. "Oh Goodie," I thought. "I love working with scars!" But I said to her, "Well, we will certainly check your scar mobility but we will also look at the nerves and muscles and skin in that area and test each as a potential pain source, while also completing a musculoskeletal assessment of the rest of you."
We are all familiar with the old saying, “You are what you eat.” A functional medicine lecture I attended recently at the Cleveland Clinic explained how chronic pain can be a result of how the body fails to process the foods we eat. Patients who just don’t seem to get better despite our skilled intervention make us wonder if something systemic is fueling inflammation. Even symptoms of vulvodynia, an idiopathic dysfunction affecting 4-16% of women, have been shown to correlate to diet.
In a single case study of a 28 year old female athlete in Integrative Medicine (Drummond et al., 2016), vulvodynia and irritable bowel syndrome (IBS) were addressed with an elimination diet. After being treated by a pelvic floor specialist for 7 months for vulvodynia, the patient was referred out for a nutrition consultation. Physical therapy was continued during the vegetarian elimination diet. In the patient’s first follow up 2 weeks after starting eliminating meat, dairy, soy, grains, peanuts, corn, sugar/artificial sweeteners, she no longer had vulvodynia. The nutrition specialist had her add specific foods every 2 weeks and watched for symptoms. Soy, goat dairy, and gluten all caused flare ups of her vulvodynia throughout the process. Eliminating those items and supplementing with magnesium, vitamin D3, probiotics, vitamin B12, and omega-3 allowed the patient to be symptom free of both vulvodynia and IBS for 6 months post-treatment.
On the more scientific end of research, Vicki Ratner published a commentary called “Mast cell activitation syndrome” in 2015. She described how mast cells appear close to blood vessels and nerves, and they release inflammatory mediators when degranulated; however, mast cell activation syndrome (MCAS) involves mast cells that do not get degranulated properly and affect specific organs like the bladder. She proposed measuring the number of mast cells and inflammatory mediators in urine for more expedient diagnosis of interstitial cystisis and bladder pain syndrome.
As pelvic rehabilitation practitioners, we have all been there, looking ahead to see what patients are on our schedules and recognizing that several will require immense energy from us… all afternoon! Then we prepare ourselves, hoping we have enough stamina to get through, and do a good job to help meet the needs of these patients. Then we still have to go home, spend time with our families, do chores, run errands, and have endless endurance. This can happen day after day. Naturally, as rehabilitation practitioners, we are helpers and problems solvers. However, this requires that we work in emotionally demanding situations. Often in healthcare, we experience burnout. We endure prolonged stress and/or frustration resulting in exhaustion of physical and/or emotional strength and lack of motivation. Do we have any vitality left for ourselves and our loved ones? How can we help ourselves do a good job with our patients, but to also honor our own needs for our energy?
How do we as health care practitioners’ prevent burnout?
Ever hear of “mindfulness” ... I am being facetious. The last several years we have been hearing a lot about “mindfulness” (behavioral therapy or mindfulness-based stress reduction) and its positive effects in helping patients cope with chronic pain conditions. Mindfulness is defined as “the practice of maintaining a nonjudgmental state of heightened or complete awareness of one's thoughts, emotions, or experiences on a moment-to-moment basis,” according to Merriam-Webster’s Dictionary. One can practice mindfulness in many forms. Examples of mindfulness-based practice include, body scans, progressive relaxation, meditation, or mindful movement. Many of us pelvic rehabilitation providers teach our patients with pelvic pain some form of mindfulness in clinic, at home, or both, to help them holistically manage their pain. Whether it is as simple as diaphragmatic breathing, awareness of toileting schedules/behavior, or actual guided practices for their home exercise program, we are teaching mindfulness behavioral therapy daily.
Jennafer Vande Vegte, PT, BCB-PMD, PRPC is a H&W faculty member and one of the developers of the advanced Pelvic Floor Capstone course. In this guest post, she reflects on her own clinical and personal experience that informed her work on this advanced course, and her approach with patients.
Most days I feel like I am on a journey. Some days I make big strides forward, other days I might fall back. But I am always learning, and eventually I hope to grow. I think it is much the same for our patients. And also for ourselves.
My youngest daughter was diagnosed with eczema, allergies (food and others) and asthma at an early age. In my hubris I felt if I could learn all I could about what was going on in her body I could "fix" her. So began a journey that took me outside the realm of traditional medicine into holistic care. I learned so much! My daughter got a lot healthier. The rest of my family got a lot healthier. I got healthier too. And I began to recognize patients in my practice that needed more holistic care. Guess what, they got healthier too.
When I bring up the topic of pelvic floor dysfunction in athletes, stress urinary incontinence (SUI) is usually the first aspect of pelvic health that springs to mind – and rightly so, as professional sport is one of the risk factors for stress urinary incontinence Poswiata et al 2014. The majority of studies show that the average prevalence of urinary incontinence across all sports is 50%, with SUI being the most common lower urinary tract symptom. Athletes are constantly subject to repeated sudden & considerable rises in intra-abdominal pressure: e.g. heel striking, jumping, landing, dismounting and racquet loading.
What’s less often discussed is the topic of gastrointestinal dysfunction in athletes. Anal incontinence in athletes is not well documented, although a study from Vitton et al in 2011 found a higher prevalence than in age matched controls (conversely a study by Bo & Braekken in 2007 found no incidence). More recently, Nygaard reported earlier this year (2016) that young women participating in high-intensity activity are more likely to report anal incontinence than less active women.
A presentation by Colleen Fitzgerald, MD at the American Urogynecologic Society meeting in 2014 highlighted the multifaceted nature of pelvic floor dysfunction in female athletes, specifically in this case, triathletes. The study found that one in three female triathletes suffers from a pelvic floor disorder such as urinary incontinence, bowel incontinence and pelvic organ prolapse. One in four had one component of the "female athlete triad", a condition characterized by decreased energy, menstrual irregularities and abnormal bone density from excessive exercise and inadequate nutrition. Researchers surveyed 311 women for this study with a median age range of 35 – 44. These women were involved with triathlete groups and most (82 percent) were training for a triathlon at the time of the survey. On average, survey participants ran 3.7 days a week, biked 2.9 days a week and swam 2.4 days a week.
Our understanding of treating pelvic pain keeps growing as a profession. We have so many manual therapies such as visceral manipulation, strain counter strain, and positional release adding dimension to our treatment strategies for shortened and painful tissues. Pharmacologic interventions such as botox, valium, and antidepressants are becoming more popular and researched in the literature. We are beginning to work more collaboratively with vulvar dermatologists, urogynecologists, OB’s, family practitioners, urologists, and pain specialists.
Pelvic rehab providers are in a unique position of being able to offer more time with each patient and to see our patients for several visits. Frequently we are the ones being told stories about how a particular condition is really affecting our patient’s life and the emotional struggles around that. We are often the one who gets a clear picture of our patient’s emotional and mental disposition. A rehab provider may realize that a patient seems to exhibit mental patterns in their treatment. It can be anxiety from how the condition is changing their life, difficulty relaxing into a treatment, poor or shallow breathing patterns, frequently telling themselves they will never get better, or being able to perceive their body only as a source of pain or suffering, losing the subtlety of the other sensations within the body. Yet, aside from contacting a physician, who may offer a medication with side effects, or referring to a counselor or psychologist, our options and training may be limited. Patients may be resistant to seeing a mental health counselor, and we have to be careful to stay in our scope.
Research is showing us that meditation as an intervention can be very helpful in addressing these chronic pain issues.