A recent Johns Hopkins Health Alert reflects a current issue in the family practice and urology clinics. For decades, men who presented to their medical care provider with symptoms of perineal aching and malaise were diagnosed with prostatitis, or inflammation of the prostate gland, and then they were given antibiotics. It is not uncommon to meet men who have been on multiple courses of antibiotics over a period of years. Due to research that has emerged over the past decade, the prescribing of antibiotics has been questioned since most men do not actually have an infection.
Jeanette Potts, urologist, has written several articles and presented research about this issue. You can read an article about prostatitis by Dr. Potts by clicking here. The article describes the importance of classifying patients accurately into true infection versus chronic pain or neuromuscular dysfunction. The general population estimate for prevalence of prostatitis is 5-10%, and the estimated number of patients diagnosed with prostatitis who actually have an infection (bacterial prostatitis) is also 5-10%.
As pointed out in the Johns Hopkins alert, " ...the impact of CPPS on a man's quality of life is often devastating." In addition to pain and discomfort, patients may also suffer from urinary frequency that interferes with work and home activities. This NIH public access article describing the life impact of urologic pain syndromes also lists fatigue, sexual dysfunction, limited social roles and negative emotional changes as concerns for patients.
It can be challenging for physicians (and the patient) to modify the habit of prescribing antibiotics for prostate region pain. Increased awareness about the condition and about the change in focus (from prostate alone to consideration of the pelvic muscles and the neurologic systems as well) can help the pelvic rehab provider to share knowledge with both referral sources and patients. You can learn more information about the treatment of prostatitis in the Institute's Level 2A course as well as in the Male course.
Although hand washing is clearly the easiest, and most effective way to practice preventive health in the clinics, it appears that the act of wearing gloves gives providers a sense of safety that is not healthy. In an article titled "The dirty hand in the latex glove: a study of hand hygiene compliance when gloves are worn", researchers looked within 15 hospitals in England and Wales at 7578 physician interactions with patients. Hand washing occurred 47.7% of the time, and when gloves were used, this number dropped to 40%.
One problem identified in the article is that gloves are not impermeable to pathogens, so having dirty hands inside the gloves can create a contamination issue for patients. Another concern is that doctors, when wearing gloves, failed to wash hands after removing the gloves 40% of the time. The researchers also found that gloves were often worn when not indicated, and forgotten when indicated.
The criticality of this practice certainly increases when medically fragile patients are involved and when conditions such as MRSA are lurking. However, it is best practice to wash (and dry) before donning gloves, and then to wash following glove removal. It becomes very important to have easy access to a sink near patient care, and to choose gloves when appropriate. Options of using non-latex gloves, and at a minimum non-powder latex gloves can reduce risk of developing latex allergies or giving a patient who is allergic to latex a reaction. Many outpatient clinics avoid latex gloves altogether and use alternatives such as gloves made from synthetic latex.
The problem for clinicians when washing so frequently is that soaps can be very drying, and skin can quickly become irritated, cracked, and even further at risk for infection. Having a quality skin care lotion and using this daily can help avoid such breakdown. The bottom line in this study is that when gloves are used, handwashing fequency decreases. Being aware of this tendency that may be related to a psychological protection from the gloves can help pelvic rehab therapists to maximize patient and provider safety practices.
In the patient who presents with urinary incontinence (UI), it is always important to find out what co-morbidities are present in her history. When a patient who has UI is dealing with diabetes, the pelvic rehabilitation provider needs to ask several questions related to the management of diabetes. Some of the questions that I have found to be useful include: "Are your blood sugars well-managed at this time?", and, "If your blood sugars are unstable, what symptoms should I look for?" The second question allows me to be alert to changes in patient behavior that might mean a blood sugar level should be tested or a quick-acting sugar might need to be consumed by the patient. Some patients have very obvious reactions to changes in blood sugar levels and some patients have very subtle reactions. A therapist can also inquire how often the patient tests her blood sugar levels and if she brought a testing kit to the clinic. A "diabetic kit" should be available in every clinic setting so that a patient can have immediate access to readily available sugar such as candy, glucose tablets, or soda.
Urinary incontinence has been found to co-exist at higher levels in patients with diabetes (Type 1 or Type 2) than in patients who do not have diabetes. The reference that discusses this issue also states that physicians need to be aware of and ask questions about incontinence in the patients who have diabetes because patients tend to not bring it up independently. Denise Elser, MD, reports in this article on the National Association for Continence (NAFC) website that over 50% of men and women with diabetes also suffer from UI. She describes issues that occur within the scope of diabetes that can cause incontinence for patients. For example, if blood sugars are not managed well, sugars can get into the urine (glycosuria) and irritate the bladder, creating urinary urgency, frequency, and incontinence. These symptoms can be mistaken for a urinary tract infection, leaving the patient to over-treat with repeat antibiotics.
Dr. Elser also points out that patients who have diabetes are more prone to urinary tract infections, often with chronic bacteria in the bladder that irritates the tissues and creates symptoms of overactive bladder (OAB). The neurologic dysfunction that accompanies diabetes can lead to impaired ability of the bladder to empty well, creating opportunities for urinary leakage as well as urinary tract infection due to poor emptying. Lastly, fluid retention can create urinary issues for the patient who has diabetes, as heart conditions may co-exist. When a patient lies supine, the extra fluid volume in the lower extremities can now more easily be moved through the patient's system to be voided out, usually leading to night time voiding frequency. This can interrupt a patient's sleep, and more alarmingly, create unsafe situations because the tired patient (who may have vision loss due to diabetes) is now frequently walking in darkened surroundings, leading to increased fall risk.
One home program strategy that is taught in the Institute's Level 1 course is to ask the patient to elevate the lower extremities and do ankle pumping towards evening but prior to bedtime so that fluids are encouraged to move out of the legs. This might increase voiding prior to bedtime, but it may allow the patient to have less interruption to her sleep hours. Many patients with increased swelling in the limbs are also taking diuretics, and if taken in the evening, may lead to frequency of voiding at night. The pelvic rehab therapist can encourage the patient to talk to her prescribing medical provider (or the therapist can contact the provider directly) to discuss the option of having the diuretic dose or timing reviewed. Many patients have been taking the same dose for years and, once reviewed by an appropriate medical provider, may be adjusted with improved outcomes for the patient.
When all of these puzzle pieces are put together, it is clear that our patients who have urinary incontinence as well as diabetes may require a very thorough history-taking and an equally comprehensive treatment strategy. If your patient is not managing blood sugars well, it is important to explain the above issues and encourage the patient to be more adherent to her diabetic home management program, or to return to her medical provider for further counseling and required care. The National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK) can be a wonderful resource for patients as well as pelvic rehabilitation providers.
Check out this 8 minute video update on use of topicalsfor pain management on MedScape today. Dr. Charles Argoff, Professor of Neurology at Albany Medical College, shares updates in research from the American Academy of Pain Management meeting that took place in September. In the video, Dr. Argoff discusses various types of topical agents that have been tested for relief of acute and/or chronic pain. A topical agent, he points out, has a more local effect, with less systemic uptake than an oral medication, and ideally less side effects because of the decrease in general uptake.
Some of the topicals are anti-inflammatory, such as Voltarin, which can be used for osteoarthritis. Pennsaid and the Flector patch also have an anti-inflammatory action. Pennsaid has research to support its use for knee osteoarthritis, and the Flector patch is applied for muscle sprain/strain type injuries.The lidocaine patch, which has FDA approval for post-herpetic neuralgia, has also been reported to be useful for chronic musculoskeletal pain or complex regional pain syndrome. The Qutenza patch (with 8% capsaicin, extracted from chili peppers) has been demonstrated to be helpful for reducing pain of post-herpetic neuralgia. This patch works on a specific receptor that is in the skin, thereby reducing local pain. Whereas the lidocaine patch can be applied by the patient, the Qutenza patch must be applied carefully in an office setting.
Dr. Argoff concludes that the skin (and therefore topical, local applications to skin in painful areas) may be "...far more important than we ever thought in helping people control their pain." This is due to the important role that skin (an organ) plays in the initiation, maintenance, and modulation of the pain experience.
So how can topicals be useful to our patients with pelvic pain?When working as a team with medical providers, we can advocate for our patients to have the option of trying some pain patches over tissue that can tolerate such an application. Perhaps coccygeus pain, ischial bursitis pain, or other sites of neuropathic pain in the inguinal area, gluteal regions, or abdominals would respond favorably to the application of topicals. An example of research supporting use of topicals is thisCanadian studythat describes the benefits of a mixture of amitriptyline, ketamine, and lidocaine for neuropathic pain caused by radiation dermatitis. As with most modalities for pelvic pain, we need more research.In the world of pelvic pain, any option that assists the patient in healing the pain experience can be positive.
Vaginal diazepam has been used by patients who have pelvic pain as an "off-label" drug option yet there has been little research to support its use. Recognizing that conditions such as painful bladder syndrome (PBS)/interstitial cystitis (IC) may be complicated by pelvic muscle dysfunction, the use of diazepam (brand names include Valium) aims to target the muscle overactivity.
In the September/October issue of Urologic Nursing, Donna Carrico, MS, WHNP, and Kenneth Peters, MD, report on the effects of vaginal diazepam on 21 women (mean age of 40) who were diagnosed with urogenital pain. Women completed assessment scores at baseline and at one month after being treated with vaginal diazepam. 2-10 mg ("...as needed for symptom relief...") was prescribed to be used up to every 8 hours. Most women started at 5 mg unless they reported high sensitivity to most medications. Although patients had the option to have the medication compounded into a cream or suppository, all patients chose to utilize the oral tablet inserted vaginally. (It was either inserted whole or crushed and mixed with vaginal lubricant to be inserted into the vagina.) The women recorded weekly their dose, usage, and pain score on 0-10 Visual Analog Scale (VAS) as well as any adverse effects that occurred over the month. A serum diazepam level was recorded at the end of the 4 weeks for the 15 women who were using vaginal diazepam at least daily, and these levels were found to be in the normal range.
VAS scores decreased on average from 4.8 to 3.4, average vulvar Q-Tip level decreased from 3.3 to 1.2, and vulvar pain levels decreased at one month follow-up as well. Only 1/3 of the women reported a side effect of drowsiness, otherwise no side effects were reported.Interestingly, some patients found it helpful to insert the medication vaginally 1 hour prior to engaging in intercourse so that pain was reduced.
The authors are quick to point out that this research was not conducted as a controlled trial, and there is no proposed protocol for the use of vaginal diazepam. What this research does assist with is establishing that the off-label use of diazepam vaginally in those suffering with urogenital pain may have few side effects and may offer benefits. Because pelvic pain often does not have a target organ as a cause, and because pelvic muscles are involved in most urogenital pain cases, it makes sense to address the involved muscles. Of course, pelvic rehab practitioners are well-trained to address the muscles via direct releases as well as through the use of other modes, yet having assistance of pharmacology may be a useful tool for the patient.
Research about animated biofeedback and its effects on children who have elimination disorders appears in the December issue of the Journal of Urology. A report by Rueters can be accessed here, the PubMed abstract can be accessed here.
Dr. Kajbafzadeh of the Tehran University of Medical Sciences in Iran led a study that involved a total of 80 children randomly assigned with 40 subjects in either Group A or Group B. The average age group was 8-9 years with more than 75% of the children being female. Group A received 6-12 sessions of animated biofeedback in addition to behavioral modification while Group B received behavioral modification only. The animated biofeedback used a computer program with images of dolphins or monkeys to get children to activate and relax the pelvic floor muscles. This type of training could then help the children understand how to relax the muscles with emptying the bowels or bladder, and to have active, more healthy muscles in general. Behavioral modification included education in hydration, high fiber diet, and scheduled voiding. At baseline, and at 6 and 12 months, data was collected regarding dysfunctional voiding scores, constipation and fecal soiling episodes/week, and uroflowmetry.
The results were very positive, with vesicoureteral reflux resolving in 7 of 9 children. (Vesicoureteral reflux occurs when urine moves from the bladder towards the upper urinary tract instead of flowing out of the urethra. This can create urinary tract infections (UTI), kidney scarring, and in severe cases, kidney failure.) 10 of 14 children did not have a return of UTI within 1 year from the start of the study. Bladder capacity and voided volume did not significantly change. The authors report that PVR (post-void residual, or how much urine is left in the bladder after voiding) improved as did urine flow. Within 12 months after treatment, children who reported fecal soiling at baseline were symptom-free, and 17 of 25 who had constipation were symptom-free. The control group also had improvements in symptoms but these were not as significant as in the group receiving animated biofeedback therapy.
If you have a biofeedback unit (for surface EMG, or sEMG, one type of biofeedback) and know how to use it, you can apply this wonderful skill in the care of children who need your help. Many of the computer programs do have animations included in the software. If you would like to learn more about treating children who have bowel and bladder dysfunction, the Institute offers a course in pediatric pelvic rehabilitation with faculty member Dawn Sandalcidi. The next course is scheduled in May in Texas. Click here to see more information about the class.
Dr. Deborah Coady and Nancy Fish, MSW, MPH, have collaborated to offer a book exclusively for women who have pain with sexual function. The book is called Healing Painful Sex: A Woman's Guide to Confronting, Diagnosing, and Treating Sexual Pain. Dr. Coady and Ms. Fish both work in a practice in New York serving women who have chronic pain. You can read more about them here. Their book explains how prevalent sexual pain is and for our patients who feel isolated in their pain, this concept in itself is a valuable thing to share. Medical treatments available for pelvic pain are included in this book so patients can be better prepared to discuss their concerns with a provider.
Healing Painful Sex is a very patient-centered book and includes many actual patient stories, allowing the reader to gain perspective about the various ways that pelvic pain can interfere with relationships, work, and typical activities. The reader also can gain insight into how to bring support into her life so that healing can take place.
This is a great book to add to your collection so that you can share with patients that there is a new resource available to help increase their knowledge and perhaps their level of hope. If you would like tolisten to an archived radio broadcast of the authors speaking with Dr. Melanie Barton on the Dr. Melanie Show, clickhere. The book is easily available from Amazon and Barnes and Noble and is very reasonably priced.
PT in Motion recently reported on a newfield guidecreated by theJoint Commissionthaturges US health care providers to create a more inclusive and safe environment for LGBT (lesbian, gay, bisexual, and transgender) individuals. The new guide points out that LBGT patients struggle with overall lowered health status, higher rates of substance abuse, higher risk for anxiety or depression, and decreased access to insurance and health care services. Additionally, LGBT patients are not treated equally, facing refusals of care or delayed care, leading to distrust of the health care system.
One of the strategies described in the guide that will help improve communication and inclusion is the use of neutral language on commonly used forms. In a hospital this may include admission forms, in a clinic, all intake forms can use the term "partner", or "parent/guardian" may be substituted for father or mother. Verbal communication should also be free of assumptions. For example, "are you married?" implies heterosexuality to most people. Instead of referring to husband or wife, the guide suggests that you can ask, "Who are the important people in your life?", or, "Who is family to you?" Listening to and reflecting the patient's choice of language can demonstrate inclusion and help your patient feel more able to reply honestly.
Other concepts are shared towards creating a welcoming environment.For example, does your health care setting have a non-discrimination policy? Perhaps it could be more prominently displayed to demonstrate that your work environment does not tolerate discrimination of any type. Images of or descriptions of "family" should include various structures of family, including same sex couples. Your clinic can also display LGBT-friendly symbols such as the rainbow flag, the pink triangle, or a "Safe Zone" sign. Having a unisex or a single stall restroom may also be more comfortable for a patient.
There is an incredible amount of information available in this new guide, it is nearly 100 pages long and can serve as an excellent resource in your work place. The guide summarizes that "...all patients, regardless of social or personal characteristics, should be treated with dignity ad respect...and should feel comfortable providing any information relevant to their care, including information about sexual orientation and gender identity."
According to a research review by senior staff nurse Julie Patrick-Heselton, fecal incontinence in critical illness “…is distressing, unpleasant and frequently socially disruptive to patients.” Because patients who require intensive care often have diarrhea, skin care and avoidance of infection are important for patient health. If bowel care is not made a priority, patients can additionally suffer from abdominal bloating, vomiting, dehydration, urinary issues, and bowel obstruction and perforation according to the article. Skin that is exposed to excess moisture from urine or stool becomes more fragile and at risk for breakdown. If a pressure ulcer occurs due to skin breakdown, infection becomes a major health risk.
If you are working with patients who are at risk for skin breakdown due to urinary or fecal incontinence, it is important to provide education about skin protection including barrier creams. These topics are discussed in the Herman & Wallace course series, and handouts are available in the Urinary Incontinence and the Prolapse and Colorectal Care Manuals. This study refers to Cavilon Durable Barrier Cream, and describes its use with incontinence pads for maximizing protection. For most patients, anything that contains zinc oxide or other water-repelling substance can assist in keeping the skin less moist and therefore less susceptible to breakdown.
Another resource described in this article is the Flexi-Seal FMS (Fecal Management System). It is a device that uses a tube to divert loose or liquid stool into a bag so that skin is protected. Although this is not something that most patients in outpatient rehab would utilize, I can think of a few patients who may have been able to use such a device during periods of diarrhea and skin irritation. (One patient I recall had to periodically go through a medical procedure and take antibiotics, which always increased her fecal incontinence for several weeks. One strategy we also implemented was having her talk to a pharmacist about changing the form of antibiotic that she used from a broad spectrum to a narrow spectrum antibiotic, which was very helpful.)
While fecal incontinence may resolve in patients following a bout of critical care at hospital, I have worked with several patients who suffer from long-term diarrhea or from chronic infection of C. difficile. Diarrhea is not normal, and patients must be sure to be evaluated medically to reveal the cause of the issue. Many patients we meet in the clinic have been suffering from bowel issues for years, some for decades. Patients can routinely be screened by all providers (pelvic rehab providers or not) for bowel and bladder issues so that appropriate referral can be provided. Protecting perianal skin as well as reducing the psychosocial impact of fecal leakage is a goal that we can all work towards for the sake of our patients.
Last weekend Herman and Wallace faculty met in Florida to work on the Pelvic Therapy Practitioner Certification(PTPC) development. The team was led fearlessly by Patricia Young of Kryterion, who assists the Institute in creating a test of the highest quality. Working within the framework of the patient/client management model that appears in the Guide to Physical Therapist Practice (APTA), faculty worked on exhaustive lists of concepts with which a pelvic rehab therapist must be competent. The work completed this past weekend allows Kryterion to create the practice analysis that will be foundational for all other elements of the test development.
The intent of the PTPC is to recognize expertise in treatment of pelvic floor and pelvic girdle dysfunction. Some of the topics that will be included on the certification exam will be pelvic anatomy, pathophysiology, medical and rehabilitative interventions, outcomes measurement, and ethics. If you currently receive the Herman & Wallace newsletter, you will be notified when Certification information is updated. If you are not currently receiving newsletters, click hereif you wish to sign up.
While the faculty worked hour after hour to move the certification process forward, there was also a lot of sharing of knowledge, learning of new vocabulary words such as "criticality" and eating of excellent food such as the kale ceasar salad made by Institute administrator Siv Prince.The letters "BBGOSO" were substituted whenever someone wanted to refer to bowel, bladder, gynecologic, obstetric, sexual, and orthopedic conditions (I even heard a rumor about a t-shirt being created). Theweekend was a great opportunity to spend quality time with other people who are passionate about their work, and who all have unique contributions that he or she is willing to share. The next step of the PTPC process will involve many pelvic rehabilitation providers as a survey involving job tasks will be sent out to those on the Herman & Wallace list. Please consider participating in the survey when you see that e-mail.The Institute looks forward to having the Pelvic Therapy Practitioner Certification available as a means of recognizing the specialized care that you provide to your patients.