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Herman & Wallace Blog

Psychological Factors in Female Pelvic Pain

An article addressing the fear-avoidance model (FAM) of chronic pain as it relates to female pelvic pain appears in the October issue of Physical Therapy. The FAM, in simple terms, aims to aid understanding of why some people recover from an injury, whereas others may respond with "exaggerated pain perception." Patients who develop chronic pain, according to the model, are in a state of fearful avoidance of the pain which leads to decreased mobility and further challenges in perceiving the pain appropriately. Fear, anxiety, and catastrophizing of the pain can lead the patient to thoughts and behaviors that reduce the patient's ability to recover from the injury.

The authors cite a recent survey of physical therapists who treat pelvic pain and it was noted that these therapists did not employ any specific coping strategies for pain. The authors further recommend that therapists who work with women who have chronic pelvic pain should offer patients education about the psychological components of the pain. This can include teaching the patient that hypervigilance of pain response is not a helpful coping strategy, and that the fear and anxiety related to the pain are important pieces of the therapeutic puzzle. Options for helping the patient reduce anxiety can include relaxation training and helping the patient modulate the return to potentially painful activities.

Screening tools can be utilized as part of the pelvic rehab professionals intake forms, and referral to the appropriate provider for psychological support can be made if needed. The pelvic rehab provider can also include in her treatment plan strategies such as education, relaxation training, activity modification, and coping skills (components also included in cognitive behavioral therapy per the authors.) The study concludes that physical therapists can provide valuable screening of women who have chronic pelvic pain who may also present with fear and avoidance of the pain. This may lead the therapist to modify her treatment plan to include strategies to help the patient reduce the fear-anxiety-avoidance and/or to refer the patient to an appropriate professional for psychological support.

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Common Vulvar Skin Conditions

A recent blog post discussed the importance of looking for skin dysfunctions near the vulva during pelvic muscle examinations. The logical question might be, "what would it look like if the tissue was unhealthy?" I was able to locate a very helpful article for illustrating some variances in tissues. Catherine Drummond, Australian dermatologist, has written a succinct article that includes excellent images to help the reader understand the various clinical presentations of vulvar skin disorders. (The article can be found by clicking here.) Specifically the article discusses inflammatory vulval dermatoses that present as rashes.

Presentations of vulvar dermatoses discussed include those that are erythematous, those with pallor, and those presenting as erosions or ulcers. Hopefully we are not the first person to notice an ulceration or disease process, yet many patients are referred for "pelvic pain" without having a thorough assessment or pelvic examination. In this article there is a chart listing common vulval irritants such as detergents, urinary or fecal discharge, hair removal, lubricants or condoms, pads, tight clothing (including thong underwear), cycling, and swimming. You will also find a list of common corticosteroids used for vulvar care. I found this list helpful as I had a patient last week asking me if she should be applying hydrocortisone cream to her vulvar area. (I deferred the question to her provider.) Keep in mind that unless you ask, you might not know what a patient is applying to the tissues. This same patient found another topical recommended "on the internet" that she started using, without first checking with her medical care providers.

Although some of the article is most relevant for the practicing gynecologist or dermatologist, much of the information is very helpful to us in our role of pelvic rehabilitation provider. The bottom line is that if we do not look, we won't see it. And if we do see something of concern, the more information that we can document, or provide to the provider and to the patient, the more we can be of value when working as part of a team.

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2011 AUA Guidelines for IC/Bladder Pain Syndrome

Physical therapy is listed as a "second line" treatment for interstitial cystitis/bladder pain syndrome (IC/BPS) in the updated guidelines from the American Urological Association (AUA). These guidelines aim to "provide a clinical framework for the diagnosis and treatment of..." IC/BPS. Under diagnosis, tests such as urodynamics and cystoscopy (once considered the gold standard for diagnosis) are listed as tests that are not necessary yet they can be used as an aid for diagnosis.

First-line treatments include education about normal bladder function as well as about the condition, behavioral modifications, and stress management. Recommended physical therapy components of treatment include manual therapy techniques and the avoidance of pelvic muscle strengthening exercises. Also listed under second-line treatments are medications, both intravesical (inside the bladder) and oral.

The treatment of IC/BPS continues to change as researchers and clinicians continue to collaborate to understand the condition. This paper is 41 pages in length and the authors utilize 192 references on which they based these guidelines. It is worth reading if you currently have patients that you are treating for bladder pain. It is also a useful tool for understanding the basis of changes in recommended medications for IC/BPS.

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Hysterectomy: What are the risks?

In a recent article by Forsgren et al., researchers assessed the risk for women in having pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery following a vaginal hysterectomy. They looked at histories of over 118,000 women in Sweden who had experienced a vaginal hysterectomy versus over 579,ooo women who had not had a hysterectomy. The research concludes that having a vaginal hysterectomy, for purposes of a prolapse correction or otherwise, significantly increases the risk of having POP or SUI surgery.

The same primary researcher, Dr. Forsgren, has authored other articles addressing risk factors for hysterectomy. In 2010, this article looked at the increased risk of developing pelvic organ fistula following a hysterectomy surgery. Risk factors for developing a fistula after hysterectomy include smoking, increased age, diverticulitis, and pelvic adhesions. In another article investigating the incidence of bowel dysfunction following hysterectomy, Forsgren et al found that in women who had a hysterectomy with sacral colpopexy performed, the women had a higher risk of defecation issues including incomplete emptying, use of enemas, and having to assist digitally with rectal emptying.

What message does this give to us or to our patients? Some patients are quick to sign up for surgery with the notion that hysterectomies are common and without significant risk, yet we must also help caution the patient against some of the potential risk factors towards pelvic dysfunction. I still occasionally hear that a provider has stated to a patient something on the order of "well, you've had children, you are not using your uterus anymore." Clearly, most providers do not have such a cavalier attitude about a major surgery, and some patients really have surgery as their best option, but information such as the above articles can help inform the pelvic rehab provider as well as our patients about some of the potential risks of hysterectomies.

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Vulvar Skin Conditions

There are many causes of skin irritation in the female vulvar tissues. Bacterial or yeast infections, skin pH imbalances, diseases, contact dermatitis, and many others. How often are we as pelvic rehabilitation providers really looking for these issues? Do you take extra care to gently open the labia so that you can view the vulvar area including the vestibular tissues? It was impressed upon me while I listened to a lecture by Holly Herman, one of the founders of the Herman & Wallace Pelvic Rehabilitation Institute, that I could do a much better job of really investigating these tissues.

During lectures Holly describes her methods of examination that include use of a bright light along with careful inspection of the perineal skin and tissues leading into the vaginal opening. A proper referral may then be made if it appears that some medical intervention is warranted. So how do we know what is "normal?" As a physical therapist, how did I learn what a "normal" knee joint ligament felt like? You have to test a lot of knees to build the experience of learning a range of knee joints. Similarly, you have to begin inspecting the area to develop your own database of healthy-appearing skin versus tissue that leads you to be concerned. In addition, I have included in this post some resources that I found informational.

Do you have a dermatologist to whom you can refer a patient with pelvic pain? I found this "Skin Therapy Letter" helpful in identifying the role of the dermatologist in pelvic rehabilitation. Vulvar lichen planus and vulvar lichen sclerosus are 2 conditions that a provider needs to be looking for, here is an image from a family practice article of a patient who has lichen sclerosus. The International Society for the Study of Vulvovaginal Disease (ISSVD) is also a helpful resource for some basic information about lichen sclerosus and lichen planus. There are many skin conditions other than these that a patient may seek treatment for, yet these are conditions about which I often hear questions from students and therapists. The message to take to the clinic is that it is very important to inspect for healthy, pink, uniform-appearing tissues that are pliable and non-painful to touch or stretch. The more we are aware of the possibility of such skin conditions, the better we can serve as part of a team in caring for our patients.

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Sexuality and the Older Patient

Within the walls of the pelvic rehabilitation clinics, we often hear more intimate details than we ever imagined we would, could, or perhaps should. With increasing patient care experiences, most therapists demonstrate increased knowledge, awareness, and with some practice, increased skill at discussing sensitive issues such as sexuality. Because every person and then every person's relationship is unique, we are sometimes asked questions by our patients such as this: "Should I be having more sex?" "Am I normal?"

I have sometimes been surprised when a patient reports that he or she is "not having sex often enough" and for that patient it means that daily sexual activity is no longer happening. Other patients are quite satisfied with their sexual activity occurring 2-3x/month. And of course we meet patients who have gone for "years" without engaging in sexual activity, perhaps because of pain, or lack of intimate partnership, or medical issues with a partner. It is very useful to avoid having expectations for what we as therapists think a patient should or should not be doing, whether that pertains to a particular sexual practice or to a level of involvement with a partner.

Having said all of the above, let's talk about sexual health in the older patient. Most of us have met patients who are in the seventh, eighth, or ninth decade of life and who are hopeful to continue engaging in sexual activities. I recall working with a couple in their eighties who wanted to improve their sexual health: the woman reported she had not had an orgasm "since her 5th child was born." Needless to say, that had been a long time. Within a few weeks of therapy (and her partner learning to help her with pelvic muscle tender point releases) the patient reported joyfully that she again was able to achieve orgasm and increased sexual satisfaction.

To read more about this topic, please check out this link to the article, "Sexuality in Older Age: Essential Considerations for Healthcare Professionals." The article discusses omissions in national healthcare policies related to sexuality and the older patient (this study refers to the UK) as well as the prejudice that the older person becomes "asexual." This issue is compounded by not only the older patient being uncomfortable talking about sex with the medical provider, but also by the fact that the provider may be uncomfortable bringing up the topic. In the section titled "Recommendations" there is a list of helpful questions for the provider listed as "Box 1." These are great questions to add to your dialogue with older patients.

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You don't have to birth children to have incontinence!

In an article shared on the MONASH University website, the incidence of urinary leakage in young women is discussed. This study concludes that up to 1 out of every 8 healthy women who have not carried or birthed children have urinary incontinence. 1000 healthy, young women (age 16-30) in Melbourne, Australia were surveyed regarding continence status. The results not only concluded that as many as 12.6% of the 1000 women experienced urinary incontinence (UI), it also suggests that UI significantly affects quality of life for these women.

Most studies correlate UI with childbirth history, therefore this study is unique in its look at such a large population of young women who do not have pregnancy and childbirth as a risk factor. Researchers found that 6.2% of the women reported stress urinary incontinence, 4.5% reported urge incontinence, and 1.9% of the women reported experiencing both stress and urge leakage. Women were more likely to experience UI if they reported bedwetting history beyond the age of 5.

This research is being presented this weekend at the 15th Australasian Menopause Society Congress. This study brings to light the importance of sharing these statistics with younger populations of people and with the healthcare providers who reach these young women. It may also be helpful to reach out to your local coaches, coaching educators, associations, or high school and college athletic trainers, college athletic directors, school nurses, high school health education teachers, or to life fitness programs at colleges. What better place to start than with the people who are working with our younger women? Through creative education strategies on our part we can continue to increase the public's awareness so that fewer people have to suffer these issues in silence.

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Smoking and Bladder Symptoms

Ah, the dreaded smoking soapbox. In the orthopedic world, we know that smoking has been correlated in many studies with impaired healing following spinal surgery. Urinary urgency and incontinence has also been linked to the habit of smoking. Women who smoke are three times more likely to have urinary urgency and frequency than women who have never smoked according to a study in Obstetrics and Gynecology.

Researchers received completed surveys from over 2000 women in Finland ages 18-79. Urinary frequency was reported by 7.1% of the women, nocturia by 12.6%, stress urinary incontinence (SUI) by 11.2%, urinary urgency by 9.%, and urinary urge by 3.1%. In the analyses, smoking was correlated with both urinary urgency and with urinary frequency. Smoking did not correlate in this study with SUI or with nocturia (excessive urination at night.)

As mentioned in prior posts, sometimes having research make a point feels less confrontational to a patient or provider versus asking a question such as, "So when are you going to quit smoking?" Some ways to share this issue with a patient may include the following: post this abstract on your bulletin board, include the question on your intake forms, or create an informational brochure that is sent with the patient's pre-visit paperwork. Once you have gained some rapport with a patient, you might say, "Research does suggest that smoking can aggravate the bladder symptoms you have. Is quitting smoking something you are actively working on right now?" Recall that many patients have tried to quit smoking multiple times, and that research shows it takes many attempts before most people are able to quit. Your patient may be quite understandably defensive about this issue, yet it is very valuable to discuss as a part of bladder health education.

This study suggests a dose-response relationship between smoking and bladder symptoms. We can point out to a patient that a decrease in the amount of smoking may influence the bladder positively. Also keep in mind that each person's body and behaviors are different; maybe it's the seven diet sodas, or the poor hydration, or a familial factor in genetics that is the causative factor for her. I know spinal surgeons who refuse to perform surgery on patients who are currently smoking. They basically say, "come back when you have quit smoking." Most pelvic rehabilitation providers who I know would never take this approach because of our kind nature and our desire to have the patient return. It is important, however, for us to continue to acknowledge the research and educate our patients in all strategies for maximizing bladder health.

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Exposure

Last week my patient walked into the office and proceeded to pull a magazine out of a brown paper bag. She proudly displayed her copy of “Women’s Health” and flipped to an article, saying “They mention you in here a couple of times.” My mind searched for the last time that I was interviewed by a national magazine with a readership of over a million women, and then I realized that by saying “you” she meant “us.” As in pelvic rehabilitation therapists.

The article that she referred to, “When Sex Hurts: How to turn the ouch back into ahh”, is a great read for the public learning basic information about pain during sex. Topics such as lubrication, using positions of comfort, increasing time of foreplay, post-partum hormonal shifts, and vaginismus are discussed. Physical therapy is listed specifically for the treatment of vulvodynia and for vaginismus. Although not all pelvic rehab specialists are physical therapists, the majority of the providers at Institute courses are PT’s. Any increase in public awareness is good for medical providers, for patients, and for us.

You might have seen the post on Oprah’s website about pelvic floor therapy. While I find myself cringing a bit when I read terms such as “ladyparts” (mostly because we work so diligently at normalizing anatomy terms including vagina, clitoris, penis) the truth is that the first thing to normalize is the fact that men and women need to share what is happening in their bodies. I meet so many patients who apologize for telling me what they are experiencing, and I wish each patient knew how often I have heard the same stories in the clinic.

Helping patients understand just how prevalent pelvic floor dysfunction is can be very encouraging for them. Take articles like this or opportunities when pelvic dysfunction makes it to Oprah to expose patients to the commonplace diagnoses that we hear about every day. Reach out to a local magazine, newspaper, or other media to share what you know and to educate your public about the opportunities that are available.

PS In the same issue of Women’s Health (September) there is an interesting article about male sexual health. You will find recommendations for Kegel exercises in it!

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Pessaries: A Review

A review addressing pessary use and quality of life is available in PubMed central. Pelvic rehabilitation providers are often in a role of educating patients in what a pessary is, in finding a provider to fit a pessary, or in discussing with the patient the potential benefit of such a device for reducing symptoms of pelvic organ prolapse. If you are unfamiliar with a pessary, click here for information from WebMD.

The history is pessaries is impressive, and this article begins with a reference to Hippocrates who used a pessary made of a halved pomegranate soaked in wine. They are now usually made of silicone, and come in many shapes such as a ring or a donut. In terms of which patients benefit from a pessary, the authors point out that from the literature, this appears to be mainly a subjective experience on the part of the patient related to perceived benefit of pessary use. Some patients have difficulty keeping the pessary in, especially with Valsalva, and then choose to stop using it.

In terms of measured outcomes of pessary use, the authors are critical of the lack of standardized gynecologic outcomes scores used in patients who are successfully fit with a pessary. One study by Abdool (2010) that is referenced, however, suggests that outcomes of pessary use match those of surgery. Factors influencing a successful fit may include use of local hormone supplement such as estrogen cream to improve tissue health and avoid vaginal irritation. An unsuccessful fitting may occur with a "...short vaginal length, a large genital hiatus, prior history of hysterectomy and prior repairs of POP [pelvic organ prolapse]."

Because there are known potential medical complications from use of a pessary, the Pelvic Rehabilitation Institute does not encourage physical therapists to fit for or manage a patient's use of a pessary. It may be incredibly helpful to a patient, however, if you can provide education about what a pessary may offer a patient. This might mean that you have to make phone calls and find out what providers in your community are fitting pessaries. Some providers discourage the patient from its use because of the challenges of getting the right fit. I encourage patients to follow-up readily with the provider doing the fitting so that this can be corrected. I found it to be a very useful option for many patients as it provides a conservative choice prior to surgery. Following one of my patients to her provider's office during a pessary fitting also helped me to better understand the procedure. What a wonderful way to demonstrate to your patient and to providers that you are engaged in a patient's care.


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