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Herman & Wallace Blog

Intravaginal estriol plus pelvic floor rehab recommended for postmenopausal women.

In a study completed at the University of Sassari in Italy, physicians addressed post-menopausal pelvic floor changes such as stress urinary incontinence (UI), urogenital atrophy, and recurrent urinary tract infections. Half of the 206 post-menopausal women in this study were treated with intravaginal estriol (1 mg treatment daily for 2 weeks then 2 treatments/week for a total of 6 months). The other half was treated with estriol in addition to pelvic floor rehabilitation.

The outcomes measured at beginning and 6 months after start of treatment included urine cultures, urogenital symptomatology, and urethral pressure profiles, among other measures. At 6 months, urogenital atrophy was improved in both treatment groups. While in the control group (estriol only) patients reported a 9.71% improvement in urinary incontinence, 73.49% of the patients who were treated with estriol plus pelvic floor rehabilitation reported improvements in UI. Urethral closure pressures were also significantly improved in the estriol plus rehab group.

The authors conclude that pelvic floor rehabilitation in addition to estriol should be considered as first-line therapy for symptoms of urogenital aging in postmenopausal women.

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Pelvic Rehabilitation Recommended as First Line of Defense for Female Stress Incontinence

Dr. G. Willy Davila of the Cleveland Clinic Florida has published an article in Advances in Urology that describes non-surgical management of female stress urinary incontinence. He reviewed the literature for prospective clinical trials and included only those studies that had a minimum 12 months of follow-up. Interestingly, most of the studies involving pelvic floor rehab only had follow-up for 6 months.

This article confirms prior research reviews in identifying pelvic floor rehabilitation as a low cost, low risk treatment that has well-proven short term benefits with 60-77% of patients benefiting from conservative treatment. Dr. Davila points out that level one evidence (randomized, controlled trials) are difficult to complete for this population as blinding is difficult when varied treatments are needed to compare conservative management techniques.

Also described and reviewed in this full-access article are the non-surgical techniques of urethral bulking and transurethral radiofrequency collagen denaturation used for urethral hypermobility. Urethral bulking involves an injection that is designed to augment the urethral sphincter. While many patients report benefit from this treatment, the collagen injections usually have to be repeated within a year. The radiofrequency treatment, as pointed out in the article, is not the same as transvaginal radiofrequency tissue ablation because the newer technique requires no incision and uses a much lower temperature that avoids tissue necrosis and shrinking. The radiofrequency collagen denaturation instead creates tissue remodeling. In a 3 year follow up study using this technique, Appell et al reported a 50% or more reduction in stress incontinence for 56% of women in the study.

While patient adherence has been found to be understandably necessary for pelvic floor therapy to assist in patient recovery from stress incontinence, it is recommended as the first line of treatment. This review of available research is helpful towards understanding what literature is available to support pelvic rehab, and it is also useful in pointing out what needs remain: namely, more long-term follow-up (at least 12 months), and more standardized terminology and methodology.

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Chronic Pain Following Hernia Repair

Chronic pain following hernia repair has been estimated in the literature to be as high as 54% for inguinal hernia repair. Pain is often categorized as neuropathic or non-neuropathic. Recent research appearing in the Annals of Surgery and reported on in Medscape Today discusses nerve management in relation to post herniorrhaphy pain. (You can register with the Medscape site to receive weekly updates.)

The authors designed a prospective cohort study and they report on 781 elective hernia operations that were performed on 736 patients in a hernia center. The preoperative pain rate was 41%. At 6 months assessment, chronic pain was reported by 16.5%, sensory disorders (such as numbness or dysesthesia) were reported in almost 16% of patients. At 5 years following surgery, 571 men and 74 women were re-evaluated (follow-up rate of 82.6%) with chronic pain rate of 16.1% , sensory disorder of 20.3%. Independent predictors of post-surgical pain included pre-operative pain and a groin sensory disorder.

The authors make recommendations for surgical approaches, and they discuss the likelihood that nerve contact with surgical mesh or nerve tissue that is surrounded by fibrosis can create significant pain. While there is very little in the literature to support physical therapy and post-herniorrhaphy pain, this pain pattern may be very well treated post-surgically. The nerves that are most involved with a hernia repair (ilioinguinal, iliohypogastric, and the genital branch of the genitofemoral) can be assessed and may be treated with neurodynamics techniques, well described by David Butler and colleagues of the Neuro Orthopedic Institute. Patients with pain or dysesthesia stemming from these nerves may arrive in the clinic of the pelvic rehab practitioner as these nerves travel distally to the groin area.

For more information about current management of post-herniorraphy groin pain, click here for a recent update.

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Behavioral therapy for incontinence in patients with Parkinson disease.

A pilot study addressing urinary incontinence (UI) in patients who have Parkinson Disease (PD) appeared in the journal Neurology. The studyutilized biofeedback training of pelvic floor muscles and urge suppression techniques along with use of a bladder diary in a series of 5 visits over an 8 week period.

17 of 20 patients (90% male) who were recruited from movement disorders clinics completed the study. Mean age of the patients was 66 years and the mean length of time diagnosed with PD was nearly 7 years. At the time of entry to the study the participants had a median of 9 episodes of urinary leakage per week.

Following the intervention, weekly episodes of UI recorded by bladder diary was reduced to 1 time per week. Quality of life scores on the ICIQ-OAB were also significantly reduced. The authors note that following this pilot study, randomized controlled trials are needed to further validate the benefits of exercise-based behavioral intervention for urinary incontinence reduction in patients who have Parkinson Disease.

It has been recognized in the literature that additional burden is placed on patients and on caregivers when those who have PD. Reducing such comorbidities can thereby hope to reduce such burden.

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Warning About Surgical Mesh

Today the US Food and Drug Administration (FDA) issued an alert about mesh used in transvaginal placement for pelvic organ prolapse (POP). This mesh which can be made from synthetic or biologic material is placed permanently to repair weakened tissues.

Serious complications have been reported due to surgical mesh, the most common one is that of mesh erosion through the vaginal tissue. The mesh can also shrink and create vaginal tightening and pain, thereby limiting sexual function. This is not only known to be problematic for women, but men can experience pain during intercourse with a female partner due to mesh. This was identified in the literature as "hispareunia."

So, what does this mean for the pelvic rehab professional? Inquiring about surgical histories including the placement of mesh is very important. If a patient has mesh erosion, there may be no amount of relief to be gained until the mesh issue is resolved. You may feel the mesh yourself as a sharp or non-tissue like structure along the vagina. If you have any doubt that mesh erosion has occurred, or if your patient is dealing with significant stenosis or canal narrowing after their procedure, request that the patient return to the provider.

The alert contains recommendations for surgeons as well as for patients so that patients can make informed decisions with respect to the risk mesh placement can pose. A prior warning was issued by the FDA in 2008 stating that severe mesh complications were rare; the update on their website today indicates that the issue remains one of serious concern that is no longer considered to be rare. Watch for further updates from the FDA as they continue to meet and evaluate the research related to this topic.

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Scrabble Anyone?

I used to think that supercalifragilisticexpialidocious was a very cool word to know. (Ok, when I was 12 it seemed cool.) I found a new word that will perhaps light a fire for you, too, especially if your inner anatomy nerd is needing some attention during the heat of summer. While reading an original article by Yabuki et al in Female Pelvic Medicine & Reconstructive Surgery (2011;17: 60-66) I came across this word: sacrorectogenitovesicopubic. It was followed by the phrase lamina of Farabeuf.

The authors of this article lament the fact that anatomy terms are challenging to work with because the surgical anatomy is described differently from clinical anatomy. They set out to redefine pelvic connective tissue through cadaver dissection as well as through histology studies. A figure in the article divides the pelvic connective tissues into a "supporting system" and a "suspensory system" with various ligaments and named fascia.

This article highlights a few things in my opinion. One, anatomy is a living science, and it continues to be researched and redefined as surgeons and other disciplines find needs for sharing information and for shaping best practices. It is also important to remember that surgeons are amazing resources, and one can really "get" anatomy while observing a surgery and listening to a surgeon describe layers of fascia or muscles as they pertain to the procedure. Lastly, we can continue to be engaged in learning and re-learning anatomy, as it sets the foundation for the stories that bodies tell.

If you are inspired to study a bit of cadaver anatomy, here is an interesting link that will take you to an on-line education program's anatomy. Scroll down once you open the link to get to pelvis and perineum.

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Improving Sexual Function in Women with Breast Cancer

An intervention study involving physical therapy was included as an abstract and poster presentation at the American Society of Clinical Oncology (ASCO). Female breast cancer survivors have significant complaints of sexual dysfunction including vaginal dryness and dyspareunia. 37 women were enrolled in this study and were instructed to apply Replens( a vaginal moisturizer) 3 times per week, perform pelvic floor muscle exercises 2 times per day, and to utilize olive oil during intercourse.

A pelvic physiotherapist instructed the patient in the pelvic muscle intervention at 0, 4, 12 and 26 weeks, measuring pelvic muscle function with manometry and with surface EMG.

The women who participated in this study reported significant improvement in overall sexual function and in dyspareunia. Maximal benefits were reported at 12 weeks, with additional follow-up occurring at 26 weeks. Quality of life measures improved as well.

Because sexual dysfunction is reported in such high numbers in the literature (up to 50% as referenced in this study), there are clearly more women in our communities who need our assistance. Whether a patient needs more muscle activity or less is best determined by the physical therapist who can be a part of a cancer care multidisciplinary team. Are there oncologists in your area who would love to meet you and find out more about what you have to share?

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Prevalence and Trends of US Adult Urinary Incontinence

In the Journal of Urology, data was presented by Markland et al following data analysis of nearly 18,000 adults (age 20 or older) participating in the National Health and Nutrition Examination Surveys between 2001 and 2008.


In the combined surveys the prevalence of urinary incontinence (UI) in women was 51.1%, in men it was 13.9%.In the combined surveys the prevalence of urinary incontinence (UI) in women was 51.1%, in men it was 13.9%. Factors that the authors associated with UI included "...age, race/athnicity, obesity, diabetes and chronic medical conditions (prostate disease in men.)" After standardization for age, it was noted that prevalence of UI increased in both men and women over the time during which the surveys were completed.


The authors point out that especially for women, decreasing obesity and diabetes may contribute to lower rates of urinary incontinence. Prior research has concurred that even a 5-10% loss of body weight in obese women can improve urinary symptoms. Although weight loss may feel like a sensitive subjective to discuss with our patients, it seems an appropriate topic to share when our patients are inquiring about prognosis and interventions.


It is remarkable that the prevalence of UI is so high, and it is imperative that the field of pelvic rehabilitation continues to grow so that we can best serve our patients.

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Myofascial Trigger Points

It seems safe to say that if you are currently working with patients who have pelvic pain, you are familiar with the phrase "trigger point." Yet, what is a trigger point? This question has proved elusive for quite some time, given that there is not always a palpable structure or a visible change in the tissue that produces the pain.

Travell and Simons, in their 2 volume classic work on myofascial paindescribe the concepts of active and latent trigger points, with an active trigger point being a location in the tissue that when palpated, reproduces the patient's symptoms, often at a site distant to the one being palpated.

In a very interesting article, Hong-You Ge, MD, PhD, and colleagues describe a possible mechanism for a local pain site (trigger point) creating more global and chronic pain via central sensitization. The authors explain the concepts of spontaneous electrical activity (SEA) at the myofascial trigger point (MTP) via research over the last decade. Some of the article (which you can read full-text thanks to PubMed Central access) will bring you back to physiology class as you do your best to recall gamma motor units within the muscle spindles or extrafusal motor endplate potential (yeesh).

While the authors admit that the "how" in formation of a taut band in a muscle is still under debate, the evidence they cite as explanation to many of the tissue responses is very enlightening and interesting. Dr. Ge also describes how motor control strategies are impaired by active trigger points. We may observe this in the clinic through the patient who reports that her urinary leakage control improves following muscle tension release techniques to the pelvic floor that were administered due to pelvic pain.

As the scientific community continues to give attention to the physiology behind connective tissue dysfunction, we should hope to better explain why some of our interventions are helpful in alleviating impairments. If you feel like nerding out and catching up on some of the interesting research related to trigger points, read this article. And then, be sure to use the phrase "membrane depolarization" in your next conversation.

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A new questionnaire is available to assess women with pelvic girdle pain.

Pregnancy related pelvic girdle pain is a considerable issue for women that creates significant loss of function. An update on pelvic girdle dysfunction from Kanakaris et alcan be found here by opening the link to the free full access text to the right of the Pubmed abstract. They report that the incidence of pregnancy pelvic girdle pain ranges from 4-76% in the literature depending on the definition utilized.

Britt Stuge, PhD, PT, of Norway and colleagues recently published an article in the Physical Therapy Journal. The article includes a new tool that physical therapists can utilize to assess function in female patients who have pelvic girdle pain.

The tool is called the "PGP" for "pelvic girdle pain" and was designed for use in the pregnancy and post-partum period.20 of the questions refer specifically to activities and 5 questions are about symptoms. This is a rather specific tool and it was designed for use in the clinic or for research.

You can access this tool on the Herman Wallace website and you can use it in your practice. This is very valuable to therapists as not all tools can be used freely in the clinic or in research without specific permissions or fees paid.

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