Pelvic inflammatory disease (PID), involves inflammation and infection of the upper female genital tract, and according to Dr. Jonathon Ross, Professor of Sexual Health and HIV, is associated with infertility, ectopic pregnancy, abscess formation, and with pelvic pain. PID one of the most common infections in women of child-bearing age, and PID is the most common gynecological reason for admission to hospital in the US. Statistics from this systematic review (you can access the full article here) include that about 20% of women with PID develop infertility, 40% develop chronic pelvic pain, and 1% will have an ectopic pregnancy. Risk factors for acquiring pelvic inflammatory disease include young age, reduced socioeconomic status, and new sexual partner. It is also not uncommon for a patient to have a recurrence of PID, and this increases the risk of infertility significantly.
Dr. Ross cites a case control study that demonstrates that a delay in care of 3 days can significantly increase the risk of infertility in women, therefore it is very important to screen the patient who may be at risk for pelvic inflammatory disease. The most important factor to consider is whether or not the patient (who may be seeing you for her pelvic pain) has been seen by a medical provider. In the medical office, the patient may have testing completed to rule out sexually transmitted diseases (STD's), or have a pelvic examination done to check for typical tenderness in the pelvic organs. Unfortunately, pelvic inflammatory disease can be a "silent" disease, according to the literature, so it is important to keep in mind that even if a patient has seen a medical provider, a return visit may be warranted if the patient's condition is worsening, is failing to improve, or if you learn more information about the patient's history that makes you more concerned about the possibility of PID. This might include finding out that the patient does have a history of an STD, has multiple partners, or has had a recent history of a change in sexual partners.More obvious signs and symptoms of pelvic inflammatory disease according to the Center for Disease Controlcan include fever, vaginal discharge with odor, painful intercourse, painful urination, irregular periods, and possibly right upper quadrant abdominal pain.
The fact that pelvic inflammatory disease can have such profound consequences on a woman's health should keep the pelvic rehabilitation provider alert to the possibility of such infections in our patients. While we rely upon the medical provider to screen for such disease, we are responsible to listen well, ask relevant questions (often asking them again on repeat visits) so that we can get a patient to medical evaluation quickly if we suspect that a patient could have an active infection requiring medical intervention.
Over the years, I have met many patients who choose not to wear underwear due to perineal irritation, severe pelvic pain, or perhaps recurrent infections. Patients who have hypersensitive scars on the abdomen, bladder pain, allergies or reactions to fabric cleaners, or who simply cannot wear underwear comfortably now have another option that is easily available. Check out COMMANDOS, a single-use cotton patch that sticks to the inside of your clothing so that the only thing touching the vulvar area is a very soft, non-chafing fabric. These can be worn everyday, as a substitute for underwear, or to replace going completely commando because the seams of clothing can rub and irritate.
Check out the website with the above link for detailed information about product materials used (great attention is given to the materials in the adhesive, for example) as well as for the variety of testimonials from happy customers. From patients with pelvic pain to fitness professionals wearing exercise pants all day to equestrians wearing riding pants, people seem to really be grateful to avoid the irritation of thongs or the added bulk of underwear that may not always stay in place.
Keep this product in mind for your patients when you are discussing the functional limitations posed by pelvic pain including restrictions in clothing choices and potential for irritation from seams in clothing. COMMANDOS wishes to support pelvic rehabilitation providers by giving a discount for you and your patients. You or your patients can enter Promo Code EVYMED for a 15% discount. A 4-pack assortment costs $10 plus shipping , and packs of 8 are $16 (or $18 for organic cotton patches.) Try them out yourself, order a pack for the clinic to show patients, or give them away as door prizes at your next staff meeting or community presentation! And be sure to give COMMANDOS some feedback if you find the product is helpful for your patients.
What is the role of the pelvic rehabilitation provider when a patient fails to follow-through on your recommendations? This issue is addressed in the medical literature, particularly for compliance with medications or medical office follow-up appointments, and it is in the medical literature where we can find a very useful articleabout the subject. Dr. Kleinsinger, MD, writes from a clinically practical point of view, and his suggestions for dialog and re-framing a patient's compliance issues can be put into use immediately. You can access the full article here.
The term "non-compliance" has been previously criticized as sounding judgmental towards a patient who is not following orders from a physician. The term "non-adherence" has been suggested as an alternative and is one that you may see in the research as well. Dr. Kleinsinger states that "non-compliance" can be utilized as long as the patient's plan of care involves both the provider and the patient in decision-making. In pelvic rehabilitation, we may not be dealing with life-threatening issues such as a patient not taking cardiac medications, however, we are required to utilize a patient's rehabilitation resources wisely and to continuously assess the response that our treatment has on the patient's health. This is challenging when a patient chooses not to complete self-care, avoid injurious activities, or take part in an instructed home program.
The suggestions in this article are directed primarily towards medication compliance, yet the principles of communication and shared decision-making can be immediately applied to the rehab clinic as well. Dr. Kleinsinger states that trust is paramount in encouraging compliance, and the clinician must recognize the power differential between the patient and the provider. Following are some guidelines adapted from the article:
1. Pose your questions in a non-judmental manner and with a problem-solving approach. Example: "I see that you have not been completing your exercises properly. Are you having difficulty with the written program I gave you?"
2. Ensure that there is a common understanding regarding the importance of the problem, the available and effective treatments, and the risks of under-treating the condition. Example: "If your body is not moved in these first weeks after surgery, you may develop a significant loss of motion that can be very painful to recover. Do you have concerns or questions for me about your treatment?"
3. Develop a shared understanding that compliance is critical to improvement.Example: "It seems that what we are trying is not working for you, and we both want you to benefit from rehabilitation. What do you think will be more helpful?"
4. Build a more effective therapeutic partnership with your patient by being open, non-accusatory, and focused on problem-solving. Example: "What could I do differently to help you? What obstacles are we facing? How could we tackle this more effectively?"
Dr. Kleinsinger offers further, useful suggestions towards effective communication, such as using physical mirroring, using "I" statements, and reinforcing that the patient can take positive action towards health. Choosing one issue at a time or asking family or friends to help out can also be meaningful for the patient. This article offers further approaches to specific causes of non-compliant behavior that you might find beneficial for your practice. Perhaps this article could be a simple tool (for a complex problem) to share with colleagues at a meeting or inservice. The author includes a checklist of tools for working with a non-compliant patient that may also be of use. He emphasizes the importance of using non-judgmental, open language when establishing a trusting relationship with the patient. It is difficult to "listen" to ourselves when we dialog with patients, yet if you can pause to think about how you are framing your discussions, it may be helpful for maximizing patient compliance. Another strategy that I have found useful is to seek out those around you who are very effective at carrying out the behaviors described in this article and modeling those behaviors. If we based our need for improved communication on all the available relationship self-help books, we can be assured that maximizing our use of communication in the clinic and in our personal lives is something that we will be refining for years to come.
As we head into the New Year, we commonly reflect on the past year and plan for the next 12 months. I wanted to share with you a tool that I have found to be useful not only in my personal life, but also in assisting patients with choices. This is a tool that I first read about in a book about neurolinguistic programming, and one that I understand many life coaches use when assisting people who want to assess various aspects of self or of life categories.
First, make a large circle on a piece of paper. Then divide it into "pie pieces" and label each piece of pie with a category. For example, if you wanted to get a sense of your personal satisfaction with your life, you might choose: spiritual practice, fitness, primary relationship, work, finances, and home improvement. List numbers from the center of the circle outward along the lines separating the category, you can use any range of numbers such as 1-5 or 0-10. Then score your rating for each category with the higher number being a positive rating. Let's say you self-score at least an 8 on all categories except for finances. If that is the case, you can then list a few tangible goals that relate to financial health with dates for achieving those goals. This type of wheel can be completed very quickly and in my experience it does not take much thought to score your sense of happiness within the various categories. If you focused this wheel on work/career, you might label the pieces as various aspects of evaluation, treatment, perhaps body parts, or even categories such as managerial tasks versus documentation. We are often balancing so many domains in our life that it is challenging to stay at a "10" with any one category for long; we are often giving of our energies to patients, to employers, to our families and children, and this leaves little time for our own self-care.
Many patients who present to our clinics our facing similar challenges. You may have met the patient who reports he or she is "falling apart" and does not know where to start, or who suffers from pain that limits sleep, work, and self-care, making it difficult to complete the 3 exercises we instructed last session. Perhaps your patient can be given a wheel of life assignment for a home activity, or it can be completed in the clinic. Once areas of dissatisfaction are identified, the patient can set goals towards improvement. If the wheel was designed to represent various environments that support or impair a patient's healing process, perhaps it could be sorted out that the work environment is where the patient feels resistance to follow-through with therapy concepts. This would allow you to help develop strategies towards improving that work environment in relation to rehab (such as an ergonomic eval, for example.) It may give another patient the opportunity to identify that her primary relationship is really struggling, therefore she does not truly want to return to intercourse with her partner due to these issues. If your home program of self-stretching or breathing, etc, is aligned towards physical intimacy with her partner, she may sabotage her home program and fail to progress. If she is able to make these connections as part of her pelvic rehabilitation, perhaps she will recognize that she wants to attend some counseling before continuing the physical rehabilitation process. My example is hypothetical, yet most of you could share similar stories about patients who are either overwhelmed by their life, or who are subconsciously resistant to your best efforts at rehabilitation because they are struggling with other more important issues.
I hope that you find this exercise useful in your own life. Sometimes I simply share the idea verbally with a patient, friend, or colleague and it is simple enough that the person can make a mental note to try it at a later time. I have found it very valuable to save the wheels in a notebook, re-assess and then see where progress has been made. Of course, the progress is usually made because goals were identified and efforts were made towards completing the goals. On behalf of the Herman & Wallace Pelvic Rehabilitation Institute, I wish you a very Happy New Year, and happy goal setting as well.
Can you list the three components of the female athlete triad? In an article published in a physical therapy sports journal 205 physical therapists were asked this same question, and only 21% of the therapists could list all components. These components are disordered eating (not to be confused with "eating disorder" because that is a more narrow description), menstrual dysfunction, and lowered bone density. The study further describes the strategies that surveyed physical therapists utilize to treat and/or prevent the female athlete triad.
Pantano, the author of this study, points out that "...therapists must be responsible for recognizing, treating and preventing the female athlete triad." Nearly 25% of the respondents surveyed described involvement in treatment via education (to include the patient, family, physician, or coach) or referral of the athlete, screening of the athlete, and nearly 50% reported efforts at prevention of the disorder. It is interesting to note that the surveys were sent to members of either the Orthopedic or the Sports Physical Therapy Specialty groups of the American Physical Therapy Association (APTA), and many of the PT's who participated in the study were also certified in athletic training and interfaced often with female athletes.
Regardless of how often we work with athletes, it is crucial for pelvic rehabilitation providers to be globally aware of the signs, risks, and treatments for female athlete triad. In the National Athletic Trainers' Association (NATA) position statement on the management of disordered eating in athletes, it is pointed out that disordered eating (DE) can not only impair health and function, but DE can be fatal. This article that you can access in full text contains excellent screening tools, advice for referrals to nutrition experts, and information about current treatment.
At a minimum, we must be aware that adolescent females can suffer from disordered eating that leads to poor energy availability in the body, with increased risk of menstrual dysfunction, and decreased bone density and risk for fractures in athletes. Knowing how to ask the right questions, provide education and communicate with a team of providers can improve the lives of athletes who are at risk for female athlete triad symptoms. The NATA guidelines suggest that female athletes should be evaluated within the first 3 months of amenorrhea so that aggressive screening and treatment can be implemented. It is common for an athlete to have one or two of the components, such as disordered eating and amenorrhea without bone loss. The guidelines also point out that males can suffer equally from disordered eating and a high suspicion should be in place for male athletes who are reluctant to discuss their eating patterns, regardless of the sport in which he participates.
Most of us, regardless of treatment setting, can make use of this information to maximize our awareness of the profound affects that athletics and improper diet can have on our female patients. Opportunities are available in our communities as well as in the clinical setting for educating others about the risks and about the available treatments.
The Bladder and Bowel Foundation (B&BF), a non-profit organization in the UK, has recently published an educational brochure for teenagers that teaches them about the pelvic floor muscles. The publication was also written in part by teenagers, and it has a look and feel that is appropriately "younger." If you click here, and then scroll through the announcement about the leaflet, you can view it on-line. You will note that many topics are covered, such as the where and why of pelvic floor muscles, and even the how to contract and exercise them. Conditions or habits that can interfere with pelvic floor health are described, including childbirth, smoking, coughing, and underactive abdominal and pelvic muscles.
Teenagers are struggling with pelvic pain, bladder, bowel, and sexual dysfunctions, and may feel uncertain about with whom they can discuss the issues. We know from the adult pelvic floor literature that in general, physicians don't ask and the patient is embarrassed to tell. What would make a teenager any more likely to share such private information? Teenagers may experience painful sexual encounters, bowel issues such as constipation or fecal incontinence, and bladder issues including urgency, pain, or leakage. (Have you noticed how many teens stop at Starbucks on the way to school now? Who is educating them about bladder irritants?) Athletes may also have increased risk of leakage, especially when engaged in high-impact sports.
I have often wondered how we can better impact the health of children and young adults if we discussed their pelvic floor as well as bowel, bladder, and sexual health beginning at younger ages. In this country, we certainly come up against the controversy of discussing the pelvic floor as it relates to sexual health, as well as the challenge of speaking about bodily functions that are not typically discussed. It may not be possible at this time to have pelvic floor education taught throughout middle and high schools, but it may be possible for pelvic rehab providers to improve the knowledge of parents and teens in our own communities. Perhaps offering a program at a local community center, with a session for adults and one just for teenagers would work. To better inform the parents, each adult could be given a detailed outline of what will and will not be included in the teen session. Better yet, the adults could be instructed in the same information so that the chances of dialog between parent and child may be more likely.
You may find the new teen pelvic floor resource useful in designing a brochure or a handout that could be offered in your own clinic or at a local event. As we continue to educate our colleagues, referral sources, and patients about pelvic floor health and function, we may be able to broaden the age base and improve the help that is offered to teenagers.
Researchers in the UK recently asked this question: For women in the UK who have given birth, what is the risk for pelvic floor surgery and for repeat surgery? Surgery for pelvic organ prolapse (POP), urinary incontinence (UI), and rectal prolapse or fecal incontinence (RP-FI) were included in the study. The research also addressed re-operation rates and the length of time between repeat surgery for prolapse and incontinence.
From the national registry in Scotland, 34,630 health records of women were accessed. The lifetime risk for women (up to age 80) having pelvic floor surgery was just over 12%. Re-operation rate was 19%; women who had a mid-urethral sling (MUR) versus a retropubic operation had reduced rates of re-operation.The average time between repeat surgeries for prolapse or incontinence was 2.8-3 years. A woman who gave birth to a first child when she was less than 20 years old, or women who had all births via c-section had reduced lifetime rates of surgery. Conversely, increased body mass index (BMI), having one perineal laceration, or having 1 birth that involved forceps for delivery increased rate of surgery. (Sustaining a third degree perineal tear was a risk factor for rectal prolapse-fecal incontinence.)
The bottom line: in the UK, more than 1 in 10 parous women will undergo pelvic floor surgery. This is a general population study, therefore the authors express confidence that these rates should hold true for the general UK or for the European communities. The authors also compare their findings to several other epidemiological studies completed in the US, Australia, and France, and it is interesting to read the discussion related to comparison of populations in these studies. As in all the studies addressing pelvic floor surgery rates, the numbers are sufficiently high to warrant increased national attention towards prevention, including pelvic rehabilitation. The average time interval between surgeries struck me as being relatively short, and it would be valuable to have more research that compares repeat surgeries in those patients who have had pelvic rehabilitation versus those who have not been educated about pelvic floor functional use and/or strengthening. If you are interested in reading the full, free-access article, please click here.
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.