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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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Nocturia- What's the Big Deal?

Nocturia, defined by the International Continence Society(ICS) as waking one or more times at night to void, is a condition that has been correlated with severe health risks and mortality. Recent research brings this issue to the forefront and provides us with knowledge that we can share with our patients, providers, and perhaps with our loved ones. (Nocturnal enuresis, not to be confused with nocturia, is voiding while sleeping.)

Vaughan et al. examined the association between falls and nocturia in a "...racially diverse, community-based sample..." of 692 older men and women. The authors found that having nocturia 3 or more times/night increased the risk of falls 28% over a 3 year period. Patients in this study who were classified as "fallers" were also more likely to be over 85 years of age, be female, have a diagnosis of diabetes, use diuretics, and they were found to have an abnormally slow gait speed. A longitudinal study from Japan reports that nearly half of their 784 community-based participants reported nocturia occurring 2 or more times/night. The authors of this study concluded that over a 5 year observation period, elderly individuals with nocturia were at greater risk for fracture and mortality. It is well reported within the orthopedic and rehabilitation literature that falls in the elderly can lead to significant mortality, morbidity, and inability to live independently.

The association of nocturia and mortality was also documented in a United States population study and was reported to have a dose-response relationship (the more episodes of nocturia/evening increased the risk of mortality.) Data from the Third National Health and Nutrition Examination Survey was utilized to demonstrate this association. In 15,988 men and women at or above age 20, the incidence of nocturia was 15.5% in men and 20.9% in women. The authors suggest that the loss of sleep leading to other comorbid conditions is a likely cause of the relationship between night voids and mortality.

If nocturia is correlated to poorer health and increased risk of mortality, what can be done to alleviate it? The ICS standardisation report on terminology for nocturia describes the importance of first screening for the condition. A screen can include detailed history taking and the use of a bladder diary. Advice relating to decreasing caffeine, alcohol intake or any food/fluid intake near bedtime may alleviate the condition. A patient also needs to discuss the issue with a medical provider as a sleep disorder, diabetes, bladder storage issue, kidney or cardiac condition could be the causative factor in a patient's frequent night voids.

As Pelvic Rehabilitation Institute faculty Ramona Horton (who I can thank for sending me the above articles) communicated to me, the information in the above articles make sense as it corresponds to what we observe in the clinic and in the community. Having the information appear in the literature validates these observations and allows us to describe to patients that nocturia is more than an annoyance- it's harmful to one's health. Pelvic rehabilitation providers can educate patients in behavioral strategies and can assist the provider in determining the best plan of care for the patient based on a thorough evaluation.

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Genital Piercing

As reported in the American Journal of Clinical Dermatology, body piercings in general can cause complications of infection, bleeding, contact dermatitis, scarring, or nerve damage. Genital piercings carry a risk of infertility following significant infection, urethral obstruction, priapism or fistula formation in males. In anarticle about the care of young women who have genital piercings, Young and colleagues report that young women who have complications from a genital piercing often seek help from the piercer or from the internet rather than from a medical provider. The authors also point out that there are many assumptions written in the literature (such as high rates of loss of sexual response or high rates of sexually transmitted diseases) that is not based in scientific evidence. The aim of the latter article is to utilize descriptive evidence to establish helpful care options for providers. In order to obtain data, surveys were completed by 240 females with genital piercings as well as health care providers who offered care to women with genital piercings.

Two qualitative research studies are described in the article and include reasons for a female acquiring a genital piercing. These reasons range from sexual enhancement to psychological healing from events such as rape. "These deeply personal events produce feelings of loss that often predispose an individual to reclaim that part of the body..." In one of the studies with 35 females who had genital piercings, some of the issues they faced as complications included local sensitivity, skin irritation, sexual problems, infection, scarring, and UTI. In the research by Young et al. that appears in the Journal of the American Academy of Nurse Practitioners the results showed that most of the 240 women were Caucasian, heterosexual, married, in excellent health, college-educated women who declared salaries around 45,000/year. The researchers were surprised to learn that over half of the women with genital piercings reported abuse, more than one third had reported some type of forced sexual experience against their will, and most had been told that they suffered from depression.

Although many of the women reported that they attended to skin care near the genital piercing, there was little mention of limitation of physical activities due to the piercing including vigorous fitness activities. The women who completed the survey had very positive feelings about the piercing, and most chose a piercing at the clitoral hood. When the participants were asked about the response from health care providers towards the genital piercing, many described that the provider was shocked and often told the patient that cleanliness was very important and at times to remove the jewelry. Some patients decided to take the jewelry out prior to an annual exam to avoid judgement. Of the 60 health care providers who responded to the survey, many of the comments to the open-ended questions were related to labor and delivery, many of the comments were positive, and some of the comments were very judgmental towards the character of the patient who had genital piercings.

Regarding the "implications for nurse practitioners" in this article, the authors suggest that the health care provider be responsive to women about the genital piercing. In other words, acknowledge that it is there in a non-judgmental manner, and inquire about it if there are concerns. It is also suggested that the provider collaborate with the patient if removal of the jewelry seems necessary. It is very interesting that in the survey respondents who were pregnant with a piercing, over half of them did not remove the jewelry for labor and delivery, and no complications have been noted in the literature regarding labor and genital piercings according to the authors.

As always, we want to ask ourselves if and how this information can relate to our role in providing pelvic rehabilitation care. If a patient presents for an examination, we can follow the recommendation in this article to "be responsive" and acknowledge the piercing. It should not need to be removed for an examination and/or treatment. Could the piercing itself be a possible source of scar tissue, nerve irritation, tender point, or hypersensitivity? That seems entirely possible, and this possibility can be explored with the patient and with the referring provider as appropriate. Because genital piercings (and piercings in general) are more popular, we may have questions posed to us by patients, colleagues, or by a patient's family members. Awareness of this descriptive data may allow us to give a more thoughtful answer, and to feel more confident in our approach when examining or treating a patient who has a genital piercing.

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Lumbopelvic Pain and Catastrophizing in Pregnancy

As reported in Physical Therapy, the tendency to catastrophize may not be a stable one, as women demonstrated measurable changes across time during pregnancy and during the postpartum period. Pain catastrophizing, as described in this article, is "...an exaggerated negative orientation toward noxious stimuli." In this research, 242 women were assessed using the Pain Catastrophizing Scale during weeks 19-21, weeks 34-37, and at 6 months postpartum. You can learn more about the Scale by clickinghere. The Disability Rating Index was also utilized at 6 months postpartum to assess physical ability.

What the researchers found is that most of the women (57.9% ) did not catastrophize during any of the test scoring, while 10.3% reported catastrophizing during all test events. The remaining number of women had variable test scores towards pain catastrophizing, and they also reported higher levels of postpartum lumbopelvic pain as well as higher levels of activity restriction when compared to the women who did not catastrophize. Lumbopelvic pain included self-reported pain in the low back, anterior or posterior pelvis.

The authors point out that other research has correlated catastrophizing about labor with increased pain intensity during labor, and decreased social functioning and physical ability in the postpartum period. While other studies mentioned have reported a consistent response towards catastrophizing, this study identifies variation in catastrophizing that occurs for some women over the course of pregnancy.

Regarding the clinical implications of this research, the authors conclude that the study design does not allow for prediction of disability based on catastrophizing scores. It may be useful, however, to identify women who are catastrophizing their pain during pregnancy so that interventions may be offered. The authors of this study refer to interventions such as cognitive behavioral therapy, education, exercise, and treatment related to physical activity as ways to minimize physical disability. Certainly with the challenges a new mother faces, decreasing any potential physical limitations and improving social functioning would help in encouraging a healthier postpartum period.

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