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Herman & Wallace Blog

New Clinical Practice Guidelines for Overactive Bladder

The American Urological Association (AUA) issued new guidelines today for the treatment of overactive bladder. Overactive bladder (OAB) is described by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) as having to void or empty the bladder more than 8 times in a day or more than 2-3 times/night. Strong, sudden urges occur with OAB and may or may not be accompanied by urinary leakage. The first line of treatment recommended by the AUA includes behavioral therapy as well as possible combining of anti-muscarinic therapy (the only FDA-approved medication for overactive bladder.)

Behavioral therapy for bladder dysfunction is commonly instructed as part of a symptom management strategy by pelvic rehabilitation providers. Patients are instructed in normal bladder function, dietary factors that influence the bladder, bladder habits, the influence of medications on bladder function, in addition to pelvic muscle training. Behavioral therapy is one component, and a very important one at that, of the comprehensive care for the patient with bladder dysfunction.

Second line treatments discussed in the updated guideline all relate to medications and their potential uses and risks. Recommended third line treatments suggest more invasive options including tibial nerve stimulation and sacral nerve stimulation, which are both FDA-approved options. The guidelines are based on expert opinion as well as on research. As reported in prior posts about overactive bladder, more research is required to better define the symptom complex and more consistency within the research is needed in regards to definitions throughout the research.The AUA also has guidelines for other male and female urologic conditions such as urinary incontinence, erectile dysfunction, female surgeries, and interstitial cystitis/bladder pain syndrome. You can access the page with links to these documents by clicking here. To access the new AUA guidelines for overactive bladder only, please click here.

The value of seeing behavioral training listed as the number one treatment that providers should offer the patient is to be celebrated in a world when pharmacology and surgeries is the typical go-to medical suggestion. What a wonderful document to discuss with your urologists, urogynecologists, family practice providers, and fellow party-goers as we head into the Memorial Day weekend.

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Chronic Yeast Infections and Boric Acid

Recent research has confirmed prior work that suggests the use of boric acid is an effective treatment for vaginal yeast irritation. Chronic yeast irritation, commonly caused by Candida albicans, is a troubling condition that can cause symptoms of vulvar itching and burning, abnormal discharge, painful urination or intercourse, and vulvar swelling. Triggers for yeast imbalance include antibiotics use, pregnancy, changes in glucose metabolism, and use of certain oral birth control pills. Tight clothing and use of plastic pantiliners can also create an environment in which yeast growth can cause symptoms.

The availability of over-the-counter yeast treatment has led to patients misdiagnosing and often over-treating with such medications. The ingredients in many of the available creams or suppositories can cause allergic reactions, vaginal burning, irritation, or itching. Many of our patients who complain of pelvic pain may be dealing with a history of or a current case of low grade (non-acute), recurrent yeast overgrowth and subsequent tissue irritation that can create a chronic pain condition. There are several intravaginal treatments that have been used by patients including boric acid tablets. Knowing that I worked with a high population of women's health patients, I recall my naturopath handing me an article over a decade ago that described the superior results of boric acid over nystatin. Some providers recommend the use of boric acid in the evening, followed by intravaginal probiotics in the morning. Boric acid can cause local skin irritation as a side effect, but no other significant side effects have been reported when used vaginally.

In a reviewby Iavazzo and colleagues about recurrent vulvovaginal candidiasis, the use of boric acid is presented. The studies included in the review reported a 40-100% cure rate with minimal side effects. The authors conclude that boric acid is an economic, safe option for women who have non-albicans Candida strains of yeast overgrowth or for those who have azole-resistant strains. The National Institutes of Health recommends avoiding vaginal douching or feminine hygiene sprays, rinsing with water only (no soap), use of condoms to prevent spread of sexually transmitted infections, wearing cotton underwear and avoiding tight, non-breathing clothing, and keeping blood sugars in check.

We can keep this information in mind when working with patients who complain of pelvic pain, vaginal or vulvar burning. Of course, these symptoms can also be attributed to neuromuscular pain, referred symptoms, or a chronic pain cycle. The above information about boric acid can be presented to the patient if she reports a history of chronic yeast irritation and she can then discuss the option with her medical provider. According to Donders, patients often feel misunderstood, guilty, and feel sexually inferior due to chronic candidosis, requiring that medical providers consider this issue as one to be taken seriously. Having the information about options such as boric acid appear in medical journals helps to highlight the importance of managing this condition that is often recurrent and sometimes difficult to treat.

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PTPC Development Update

A big thanks to everyone who completed our PTPC Job Task Analysis Survey over the past few weeks. We received over 400 responses, which is more than enough data that we will need to perform the necessary analysis.


On May 2nd, we drew the names of our two lucky participants, who will each received a free course registration of their choosing. Congratulations to Christy Kline, PT and Kate Middleton, PT on winning the drawing!


Over the next few weeks, our subject matter experts and test development partner, Kryterion, will work together to finalize the quantitative blue print. This blue print will determine the relative amount of exam items that will be devoted to various sub-topics within pelvic rehabilitation. While not a "study guide", those interested inpursuing PTPC could use this test blue print to determine the topicson which to focus their studying efforts.


Our test developers will also use this test blue print to begin writing exam items. Similar to the JTA survey, we will need to beta test exam items in order to measure their validity for the actual exam.


Thanks again to everyone who participated, and please stay tuned for updates as we continue to work towards offering the PTPC exam for the first time. Also, if you completed the JTA survey, and have yet to redeem your $50 credit, let us know when you are ready to apply your credit to an upcoming course that you'd like to attend.

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Nonrelaxing pelvic floor dysfunction

In the February 2012 issue Mayo Clinic Proceedings, Dr. Faubion and colleagues discuss the symptoms and management of nonrelaxing pelvic floor issues. In this clinical review, the authors differentiate between conditions that involve relaxed pelvic floor muscles (pelvic organ prolapse, urinary incontinence) with conditions in which non-relaxing pelvic floor muscles play a key role. When the muscles of the pelvic floor have difficulty in relaxing, this can impair the person’s function with defecation, urination, and sexual activity. The review focuses on the symptom complex called “nonrelaxing pelvic floor” so that care providers can manage the condition effectively, and in the words of the authors, provide early referral to physical therapy that can address the muscle dysfunction.

When learning about the various diagnoses for pelvic floor pain conditions, medical providers and pelvic rehab therapists are faced with a long list of terms that have overlapping symptoms. Some of the terms listed in this article include coccygodynia, levator ani syndrome, piriformis syndrome, and puborectalis dyssynergia. It is pointed out that using the description of non-relaxing pelvic floor has the ability to encompass many of these other terms without inaccuracy in diagnosis. Dr. Faubion suggests that medical providers look for the cluster of symptoms that tend to accompany non-relaxing pelvic floor conditions, including voiding dysfunctions, constipation, dyspareunia, low back pain and pelvic pain.

What is so exciting about this article from the Mayo clinic is that physical therapy is identified as a “cornerstone of management.” Oftentimes, when we read clinical practice guidelines for various dysfunctions involving the pelvic floor, physical therapy or pelvic rehabilitation rarely gets an honorable mention. To read about the recognition of PT as such an important element of healing pelvic dysfunction can help improve awareness among the medical profession and expedite referrals to pelvic rehabilitation providers. Only time will tell if "nonrelaxing pelvic floor" will catch on as a replacement for the diagnostic terms that name single muscles. In the meanwhile, this article will hopefully serve as an educational tool to increase awareness of the evaluation and treatment options available to medical providers.

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Yoga for Menstrual Pain

In the Journal of Adolescent and Pediatric Gynecology, Rakhshaee reports on the evaluation of 3 yoga poses used to treat primary dysmenorrhea. Primary dysmenorrhea occurs in otherwise healthy young women around the time that the menstrual cycle begins. It has been reported byProctor in 2007that as many as 75% of adolescents have painful periods, and that up to 20% of them limit activities because of the pain. An article by Wilson and Keye report that premenstrual syndrome and dysmenorrhea are reported as a leading cause of missed school and as problems that affected academic performance.

In the study by Rakhshaee, 92 female students (ages 18-22) were randomly assigned to a treatment group (n=50) and to a control group (n=42). Over a period of 3 menstrual cycles, participants recorded pain using a Visual Analog Scale and reported pain duration in terms of hours. During the first menstrual cycle, symptoms were recorded, and then during the second and third cycles, the treatment group was asked to complete 3 yoga poses during the luteal phase. The control group received no intervention. Yoga poses instructed include the Cat, Fish, and Cobra. You can search the Yoga Journal website to view each of the poses by clicking here if you are interested.

In the experimental group, both the pain intensity and the pain duration showed significant differences with the participants who completed yoga poses having less pain intensity and pain duration. The authors conclude that yoga is a safe and simple treatment for primary dysmenorrhea. Oftentimes, patients who complain of dysmenorrhea lack access to care for this other than medications that might include pain medication or birth control pills. Instructing a patient in basic yoga postures presented in this research may be a simple alternative to such medications.There are several websites that offer free access not only to images of poses, but also to free classes. I often hear from patients that they enjoy taking advantage of free fitness classes including yoga on various television stations. This may be another "tool in the toolbox" that we can offer to patients who have pain related to the menstrual cycle.

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Botox for Overactive Bladder

Overactive bladder (OAB) is defined by the International Continence Society as urinary urgency, with or without urinary leakage, that is commonly associated with urinary frequency and nocturia (waking one or more times at night to void.) According to the ICS, this combination of symptoms suggest that detrusor instability is present, meaning that the bladder muscle is overactive. In the absence of proven infection or other pathology, overactive bladder, urge syndrome, or urge-frequency syndrome are terms used to describe the condition.

A double-blind placebo-controlled randomized trial was completed in the United Kingdom for 240 women who experienced "refractory" detrusor overactivity. 122 women with urodynamically proven detrusor overactivity were treated with onabotulinumtoxinA (onaBoNTA), and 118 women served as the placebo group. The medication is injected into the wall of the bladder during a cystoscope procedure. (The women in the placebo group received injections as well, only with 0.9% sodium chloride in saline solution.) The median voiding frequency within a 24 hour period was reduced from 9.67 voids to 8.33. Urgency episodes reduced from 6.33 to 3.83, and leakage episodes from 6.00 to 1.67. To summarize, urinary urgency and incontinence improved more than urinary frequency in this study. The authors conclude that, based on such a large, randomized study, the use of botulinum toxin is both safe and effective for women who have detrusor overactivity.

In reviewing this article, it also seems important to look beyond these recommendations, as clearly the use of this treatment is not safe for all involved, nor is it effective.

  1. The authors defined a "refractory" condition as one that did not respond to an 8 week trial of an anticholinergic medication. Was behavioral training implemented? Could these women have benefited significantly from education in dietary and behavioral strategies? The authors admit that their definition was chosen arbitrarily.
  2. 24.6% of the women in the treatment group did not report any significant improvement.
  3. One third of the women who received the onaBoNTA reported urinary tract infections (UTI) while in the placebo group one tenth of the women reported UTI.
  4. 16% of the women in the onaBoNTA group had voiding difficulties requiring intermittent catheterization compared to 4% of the placebo group.
It is important as pelvic rehabilitation providers that we are aware of options beyond rehabilitation, including procedures such as the onaBoNTA treatment described in this research. The potential risks of such procedures should be taken into consideration, and hopefully patients are given the option to trial the most conservative methods available. In relation to medications for OAB and their negative side effects, it may be helpful for the patient to discuss a change in dosage or a change in medication prior to abandoning use of such medications. You can find out what the standard practice is in your community, or if botulinum toxin is offered to your patients.Use of this medication often has to be repeated,so while there may be gains in function, it is not without risk.

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Laparoscopies and pelvic pain

In an article published in the Journal of Obstetrics and Gynaecology, the authors ask the following question: “How can we reduce negative laparoscopies for pelvic pain?” A retrospective audit of women receiving a laparoscopy (76 charts) was completed to determine how thoroughly the subjective examination was completed for women who complained of pelvic pain. Physical exam, the results of any ultrasound examination, reported usage of hormonal therapy, and the recommendation for multidisciplinary care was also assessed retrospectively. This study also aimed to determine if recommended guidelines for the initial assessment of chronic pelvic pain were followed by the physicians. These guidelines were developed by the Royal College of Obstetrics and Gynaecologists (RCOG) and can be accessed by clicking here.

Outcomes of the chart reviews indicated that history-taking was “deficient” and an integrated approach was not utilized much of the time, leading to a poor initial evaluation of the patient. 13% of the charts had no documentation of duration of symptoms. Only 21% of charts noted if the pain was cyclical or non-cyclical and this lead to failure to recognize the option of a trial of hormone therapy. Complaints of dyspareunia were documented for 31.5% of the women, and this, according to the authors, is less than expected based on general population studies and is likely due to poor history taking.

In this study, laparoscopy contributed to diagnosing and treating disease or other significant findings in 45% of the patients. Endometriosis and adhesions were the main findings reported following the procedure. I found it interesting that 50% of the patients who had negative ultrasound studies were found to have positive laparoscopy results. And despite the fact that the RCOG guidelines suggest psychology and physiotherapy referral for women who complain of dyspareunia, only 1 referral for psychosexual counseling was made.

The authors conclude that in order to reduce the number of negative laparoscopies for pelvic pain, a “…structured initial assessment and targeted selection of patients for laparoscopies…” is needed. It also appears that pelvic rehabilitation specialists must continue to address the lack of awareness of potential referral for chronic pelvic pain. Most medical providers and patients are unaware of the scope of the pelvic rehab therapist, and this study certainly highlights the need for more interdisciplinary communication and care provided to the patient who suffers from pelvic pain.

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New Hormone Therapy Position Statement

The North American Menopause Society (NAMS) has issued a new position statement related to recommendations for hormone therapy (HT) use in women. This topic has been debated intensely over the last decade since the publication of the Women's Health Initiative (WHI) research that was funded by the National Institutes of Health (NIH). Following this research, many women were instructed by their physician to stop taking their hormone therapy medication due to the increased risk of cardiovascular events. For more information about the background of the WHI, please click here.

This information is particularly relevant for the pelvic rehabilitation provider as many women in their perimenopausal years will experience pelvic symptoms related to a decline in hormone levels. The updated NAMS guidelines state that estrogen therapy (ET) is "...the most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy..." that may include vaginal dryness, pain with penetration, and atrophic vaginitis.Although the guidelines do not recommended hormone therapy for improving libido, use of local estrogen therapy may contribute to improvement in sexual function through improved lubrication, increased blood flow and increased sensation to vaginal tissues. Local estrogen has also been demonstrated to help some women who have overactive bladder or urinary tract infections, however, systemic hormone therapy may worsen symptoms of stress incontinence.

There are other important women's health topics in this position statement including potential benefits of hormone therapy for women who have or who are at risk for osteoporosis. The authors conclude that in healthy women ages 50-59 years old the absolute risks of HT are low. Older women who initiate use of HT or who use long-term HT are at higher risk for adverse effects. Successful implementation of hormone therapy for women depends on the route of administration, formulation of the hormones, and timing of the therapy. "Constructing an individual benefit-risk profile is essential..." when creating a plan of care for women according to the authors.

Unless it is within your scope of practice to prescribe medications such as hormones, the above choices will be made through patient discussions with the appropriate medical provider. We can alert a physician or medical provider if there is concern about the vaginal tissue health of a woman presenting to the clinic. We can also direct patients to these new guidelines developed by the NAMS group. It is helpful to note that many women do not have a medical provider who is actively managing her hormone issues, and simply asking her about HT can lead her to communicate more effectively with her medical providers.

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Do night lights cause cancer?

"Do night lights cause cancer?" is the title of a blog post written by biofeedback expert and PhD psychologist Dr. Erik Peper. Follow the link above and you can decide for yourself if the post is compelling. Researchers in this studypublished in the Cleveland Clinic Journal of Medicine asks "Does lack of sleep cause diabetes?" Poor sleep quality or not enough hours of sleep are often considered as precursors to health impairments as the body does much of its cellular regeneration and other restorative functions during the sleeping hours. These questions and concerns bring us to the concept of "Sleep Hygiene."

The American Academy of Family Physicians has published this full text articlethat describes several components of insomnia treatment, including sleep hygiene. Reasons for insomnia may include anxiety, depression, fibromyalgia, sleep apnea, menopause, pain, or restless legs syndrome. Medications that can contribute to lack of sleep include alcohol, nicotine, caffeine, diuretics, beta blockers, and stimulant laxatives. The authors describe sleep hygiene as one part of a cognitive behavioral therapy (CBT) approach to treat insomnia, which can be comprised of 4-8 sessions. Each session may be 60-90 minutes long and topics covered may include behavioral education for stimulus control, sleep restriction, relaxation therapy, and paradoxical intention (trying to stay awake.)

The concepts included in sleep hygiene (adapted from the above study) are as follows:

  1. Avoid caffeine and nicotine, particularly before bedtime.
  2. Avoid exercise 4 hours prior to bedtime.
  3. Avoid large evening meals.
  4. Avoid taking naps during the day.
  5. Rise and sleep at same times each day (even on weekends!)
  6. Keep a comfortable temperature in bedroom.
  7. Keep the bedroom very dark.
  8. Set aside time to unwind or use relaxation techniques before bed.
Patients may also find concepts in "stimulus control" very useful as patients are instructed to only associate the bedroom with sleep and sexual activity- no television! Some of the relaxation strategies referenced in this study include autogenic training, biofeedback training, imagery training, progressive relaxation and paced respirations.
The above are all strategies that a pelvic rehabilitation provider can effectively teach to her patient. If your patient's recovery may be limited by pain, medications, anxiety, and the unfortunate sequelae of sleep loss, education in the concepts described here can be practical ways to help the patient affect her sleep. The authors reference a meta-analysis by Perlis et al. (2003) that finds that CBT for general insomnia is comparable to pharmacotherapy, and that CBT for sleep-onset insomnia is superior to pharmacotherapy. It is also pointed out in this article that most patients can self-administer the sleep treatments once instructed. Consider guiding your patients to strategies for improved sleep, with the intention of helping patients to improve the bodies time in restful recovery.
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Herman & Wallace in Saudi Arabia!

Holly Herman, co-founder of the Herman & Wallace Pelvic Rehabilitation Institute, has just returned from Saudi Arabia, where she educated the first class of 34 female physical therapists in the art and science of women's health physical therapy.Holly Herman in Saudi Arabia

She was accompanied by esteemed colleague and well-known educator Fatima Hakeem. Together they created 11 days of intensive-training education, which they taught over a 14 day period. Topics instructed included pregnancy and postpartum, female pelvic floor dysfunction and female sexual health. Participants earned a Advanced Clinical Diploma in Pelvic Floor Treatment from the Saudi Physical Therapy Association (SPTA), as well as CAPA certificates through the Institute.

Jennafer Vande Vegte

Holly has already shared pictures of herself and new friends covered from head to toe in a traditional abaya, a garment that was required for modesty. She also had the opportunity to travel around the country and see historical landmarks and ride camels in the desert!

An amazing graduation ceremony took place this past week and the ceremony was graced by many high-ranking officials as well as the country's Princess, who made a pointed effort to thank Holly and Fatima for sharing their knowledge and wisdom so that many women and their families can benefit from improvements made in the lives of women in her country. Holly and the Institute were presented with 50lb glass plaque in a felt-lined mahogany box for contributing to women's health in the region. In light of this advanced and specialized training program, Saudi Arabia has created a Women's Health Section of the SPTA. At the ceremony, the Princess granted a million riyals ($375,000) to the new Women's Health Section. Herman & Wallace has committed to continuing to work with our partners, Rafeef Al-Juraifani PT, MSc and Othman Alkassabi, PT, PGD, MBA to bring continuing education to this region of the world.

Jennafer Vande Vegte

It is the goal of these students to all be certified PTPC practitioners. Herman & Wallace are currently in the phase of the project that requires defining the role of the pelvic rehab therapist. Please check your e-mail for this invitation to complete the survey or click here.

In September, Holly and Fatima will be traveling to Dubai to teach a similar seminar in the United Arab Emirates.

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Upcoming Continuing Education Courses

Jul 21, 2019 - Jul 23, 2019
Location: Rutgers University - Doctoral Programs in Physical Therapy

Jul 26, 2019 - Jul 28, 2019
Location: Bon Secours St. Francis Health System

Jul 27, 2019 - Jul 28, 2019
Location: Providence Healthcare

Aug 9, 2019 - Aug 11, 2019
Location: Robert Wood Johnson Medical Associates

Aug 9, 2019 - Aug 11, 2019
Location: Metro West Medical Center

Aug 9, 2019 - Aug 11, 2019
Location: Providence Holy Cross Medical Center of Mission Hills

Aug 16, 2019 - Aug 18, 2019
Location: WakeMed Health & Hospitals

Aug 16, 2019 - Aug 18, 2019
Location: BodyWorx Vitality

Aug 16, 2019 - Aug 18, 2019
Location: Piedmont Healthcare

Aug 16, 2019 - Aug 18, 2019
Location: Dignity Health Care of Stockton, CA

Aug 17, 2019 - Aug 18, 2019
Location: Ochsner Health System

Aug 23, 2019 - Aug 25, 2019
Location: PeaceHealth Southwest Medical Center

Aug 23, 2019 - Aug 25, 2019
Location: Inova Physical Therapy Center

Aug 23, 2019 - Aug 25, 2019
Location: The Sage Colleges

Aug 23, 2019 - Aug 25, 2019
Location: Loyola University Stritch School of Medicine

Aug 23, 2019 - Aug 24, 2019
Location: Mizzou University of Missouri

Aug 23, 2019 - Aug 25, 2019
Location: Mizzou University of Missouri

Sep 6, 2019 - Sep 8, 2019
Location: Advanced Physical Therapy of Little Rock

Sep 6, 2019 - Sep 8, 2019
Location: Bon Secours St. Francis Health System

Sep 7, 2019 - Sep 8, 2019
Location: Franklin Pierce University

Sep 7, 2019 - Sep 8, 2019
Location: Spooner Physical Therapy

Sep 13, 2019 - Sep 15, 2019
Location: Huntington Hospital

Sep 13, 2019 - Sep 15, 2019
Location: Mary Free Bed Rehabilitation Hospital

Sep 13, 2019 - Sep 15, 2019
Location: Loyola University Stritch School of Medicine

Sep 13, 2019 - Sep 15, 2019
Location: Lee's Summit Medical Center

Sep 13, 2019 - Sep 15, 2019
Location: Princeton Healthcare System

Sep 14, 2019 - Sep 15, 2019
Location: Aurora Medical Center

Sep 20, 2019 - Sep 22, 2019
Location: Wesley Medical Center

Sep 20, 2019 - Sep 22, 2019
Location: Marathon Physical Therapy

Sep 20, 2019 - Sep 22, 2019
Location: Viverant