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Herman & Wallace Blog

Talking about sexual health...

Appearing in Medscape this week is an important message from the Centers for Disease Control and Prevention (CDC). Gail Bolan, MD, of the Division of Sexually Transmitted Disease (STD) Prevention, speaks about the importance of skilled sexual health interviewing and teaching on the part of the medical provider. Her message is directed towards a provider interviewing an adolescent, however, her points are very relevant for all of us in health care who wish to ask respectful and meaningful questions regarding a patient's sexual health.

Dr. Bolan recommends that we avoid assumptions about the patient's sexual orientation, behaviors, or number of partners. Using gender-neutral language may be important, and you can take cues from the patient in order to use consistent language. Being nonjudgmental and supportive is also important, and we may need to become more comfortable ourselves with topics related to sexual function.

The article continues to recommend using the "5 Ps" when taking a sexual history. The "Ps" stand for: partners (learning the number, sex, and current sex partner history), practices (does the patient engage in anal, vaginal, or oral sex), protection from STD's (condom use or use of other forms of birth control), past STD history (the patient's or the partner's history of STD), pregnancy prevention (is the patient trying to get pregnant or needing to discuss birth control).

The above description of sexual history may be most relevant for a medical provider for the purposes of ruling out disease risk and need for further care. However, many of these questions are very important for the pelvic rehab therapist to be able to ask. For example, although we use standard precautions, if a patient is dealing with a current STD, internal treatment may be inappropriate for both the patient and for the therapist. If a female patient is trying to get pregnant, certain therapies are contraindicated, so it is helpful for us to know that we should check in with patient status.

It is always appropriate to use language the helps a patient feel most comfortable, and this includes avoiding assumptions about marital status, gender of a patient's partner, and sexual behaviors in which a patient engages. Many of us were not prepared for having such intimate discussions with our patients, and it can challenge our own belief systems and create feelings of discomfort or uncertainty. It is helpful to have resources including mentors or colleagues to discuss these issues with when they do occur.

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Looking at IBS from more than one angle...

In the world of pelvic rehabilitation, it is rare that we meet a patient who has an isolated issue. More often we hear complaints about not only bladder dysfunction, but also about bowel dysfunction, sexual health issues, and pain. Irritable bowel syndrome (IBS) is one diagnosis that shows up on many of our patient intake forms and will be identified as constipation-dominant, diarrhea-dominant, or as having both conditions. Much of the recent research regarding IBS reiterates the fact that the cause of IBS us unknown, that it is a functional gastrointestinal disorder, and that the diagnosis is made based on clinical symptoms rather than a test. Some patients have responded favorably to trials of certain antibiotics, but the medical community continues to struggle with a cure for this painful, distressing condition.

I was very pleased to see an article that proposes a biopsychosocial model for IBS. There is increasing interest in and awareness of the relationships between the brain and the gut. In this article, the authors discuss issues of life stress, history of abuse, parental patterns of "illness behavior", coping mechanisms, in addition to gut physiology. Although the authors do not recognize the role of physical therapy in treating IBS, it is stressed that providers must develop strong rapport with patients so that clear communication is available. It is then much easier for some of these challenging topics to be discussed and for strategies to be put in place. In addition to pharmacology, the authors suggest that psychotherapy may play a larger role in helping patients with IBS to heal.

Many of our patients do recognize that stress is a major factor that worsens pain and bowel dysfunction. Pelvic rehabilitation specialists are equipped with tools to help teach patients how to decrease the physiological sequelae of stress through skills such as breathing, contract-relax, physiologic quieting, and other means. If you are interesting in learning more about treatment of bowel conditions such as IBS, that information is covered in the Level 2A courses.

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Are you Suffering From Compassion Fatigue?

After reading a Medscape article about compassion fatigue and cancer care, it seemed appropriate to bring up the topic for pelvic rehab therapists and providers. In the article, burnout is described with phrases such as overwhelming exhaustion, detachment from job, and a sense of ineffectiveness. Compassion fatigue, while being associated with burnout, is related more directly to being in a role of helper to those in distress, thereby creating tension and distress for the one giving care. Health care workers are believed to be a vulnerable group for this compassion fatigue.

Many of the pelvic rehab therapists I have met over the last decade describe the challenges of working with this rewarding, yet challenging population. Patients with chronic pelvic pain are particularly in need of a listening ear and also require a significant amount of case management, hands-on rehabilitation, and encouragement. All of these factors can lead to increased work task burden for the therapist as well as psychological burden from carrying the weight of the patient's suffering. It then becomes important to "heal the healer" as described in this family practice article.

There are some resources in place at various work sites, such as employee assistance programs that provide a few visits to a counselor, and these should be used readily as the visits are usually free to an employee. The life skill of self-care does become the responsibility of the care provider, however, and in order to take care of ourselves the basic (but difficult to achieve) balance can be maintained by good nutrition, breaks from work (not documenting through lunch), having our own social support, and getting sleep and exercise.

You can take a Compassion Fatigue self- test, or the Professional Quality of Life (ProQOL) testhere.There are resources to combat burnout, one of the latest that I've seen is a book by Joan Borysenko, PhD. Check out her book Fried: Why You Burn Out and How To Revive.Another book that is clear in practical suggestions is The Art of Extreme Self-Care by Cheryl Richardson. You may also find support within the pelvic rehab community, as the therapists who have similar jobs truly understand some of the challenges as well as the rewards of our meaningful work. It is the hope of the Pelvic Rehab Institute that therapists continue to look towards the Institute to provide such support and a sense of community.

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Irritable Bowel Syndrome Correlated to Decreased Quality of Life and Increased Pelvic Floor Disorders

In a study that was originally published in Alimentary Pharmacology and Therapeutics, researchers correlated self-reported irritable bowel syndrome (IBS) with symptoms of urinary incontinence, pelvic organ prolapse (POP), sexual function, and quality of life (QOL.)

In a population of more than 2100 female patients, the reported incidence of IBS was nearly 10%. Within these women, an increased risk of bother from prolapse and sexual dysfunction was reported as well as a decrease in quality of life scores. The authors point out the hypothesis that frequent bouts of constipation may lead to weak pelvic floor muscles, and therefore increased pelvic prolapse, but this remains to be proven in the literature.

This study is meaningful not only because it evaluates information about a large group of women, but also because the population is a diverse group between the ages of 40 and 69. As IBS according to the ROME III can be further divided into constipation-dominant, diarrhea-dominant, or both, it makes sense that pelvic floor dysfunction is correlated to the diagnosis. Many patients who experience loose stool with IBS may unknowingly tighten the pelvic floor chronically to avoid leakage, and this in itself could lead to pelvic muscle tension and dysco-ordination as we see in many of our patients. Those patients who experience constipation and straining may also interfere with healthy muscle activity and create prolonged stress on the supporting tissues in the pelvis and pelvic floor.

The relationships pointed out in this study remind rehabilitation experts that it is important to ask detailed questions about all aspects of a patient's pelvic health, from sexual function to bladder or bowel function. This study is now available in PubMed Central, where you can find free, full-access articles.


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New research supports visceral mobilization to reduce post-operative adhesions.

Abdominal adhesions following surgeries can lead to pain with bowel function or general movement. This study aimed to assess whether or not a specific manual therapy approach could reduce the prevalence of such painful adhesions.

Researchers using an experimental animal model did in fact report benefits from applying post-operative visceral mobilization (VM). 3 groups of 10 rats were examined post-mortem at 7 days following an adhesion-producing surgery. The rats in the Lysis group were treated (unsedated) on day 7 only, while the Preventive group animals were treated daily beginning the day after surgery.

The severity and the number of adhesions were significantly lower in the Preventive group. Clear signs of disrupted adhesions were noted in both the Preventive and Lysis groups. The authors in this study conclude that pending further studies, “…visceral mobilization could readily be implemented into post-surgical care and patient education.” They propose that VM could aid in preventing and/or treating abdominal adhesions.

This is a very well cited study that describes the available literature in reference to abdominal surgery and adhesions. Although an animal model was utilized, the authors believe that the assessment and treatment to the animals creates an environment that encourages tissue mobility and discourages fibroblast invasion of the peritoneal tissues in the same manner as human tissues would react.

You can check out coursework that the Institute offers that focuses on visceral mobilization for patients with pelvic issues.

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How Bothersome is Urinary Incontinence?

In an effort to answer this question, 15,000 enrollees in AARP Medicare supplement plans (insured by United Healthcare) were asked this question in the form of a survey. Of the more than 5000 members who responded, over 35% of them described urinary incontinence as a condition that affected not only physical, but mental health as well.The researchers in this study also found that urinary incontinence affected perceived quality of life more than diabetes, arthritis, and some forms of cancer.



AsBurgio et alreported previously, many adults do not report incontinence to their medical providers, so the likelihood of incontinence creating significant bother is high when the chances of acquiring treatment are decreased. If health care providers and the insurance companies can help patients identify impairments caused by urinary leakage early on, send the patients to the most appropriate conservative care versus surgeries, perhaps patients will report enhanced quality of life as well as save health care dollars."

As reported onEnhanced Online News, Dr. Richard Migliori of the Business Initiatives and Clinical Affairs at UnitedHealth Group describes an "...opportunity for the health care system to develop treatment programs that can enhance not [the patients] physical health, but their mental and emotional health as well." We as rehab professionals can continue to educate the public and the health care system regarding our role in treating bladder issues so that fewer patients suffer decreased life quality due to urinary incontinence.
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Can Patients Use Internal Trigger Point Devices Safely?

The team associated with what was formerly called "The Stanford Protocol" for pelvic pain has evaluated the use of an internal wand by patients. This trigger point wand was designed to help the patient apply appropriate amounts of pressure as it has in its design an algometer for measuring pressure. 113 of 157 enrolled (mostly male) patients completed 6 months of wand use, the authors point out that those who dropped out of the study did not withdraw due to adverse affects from using the wand. Patients were instructed in use of the wand and carefully supervised prior to using the device on their own. They were instructed to use the wand several times per week. Visual analog scale measurements were taken at baseline and at 6 months. The baseline median sensitivity was 7.5 and decreased to 4 at 6 months. Over 95% of the patients reported that the wand was very or moderately effective in relieving pain.

This pilot study addresses some very important concerns. Although it is a pilot study, this work addresses the need for research to support aspects of pelvic pain therapy programs. Very importantly, it addresses the issue of how much pressure patients are using when applying self-trigger point releases with a device. We have all met patients who, despite our best coaching, apply so much pressure with any self-treatment that the symptoms meant to be alleviated are worsened, usually accompanied by the phrase, "I don't know what you did last time, but..."

Until such a device used in this study is available to clinicians, it will be difficult to gauge how much pressure a patient is applying with a device such as a wand. As in this study, patients who wish to use a trigger point tool should be carefully instructed in safe techniques for use of such a device. These trigger point tools may continue to be helpful in self-care and home program participation by the patient.

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Improving Urinary Continence Improves Sexual Function

As reported in Female Pelvic Medicine & Reconstructive Surgery, women who were successfully treated for stress urinary incontinence also noted improvements in sexual function. Women in the study were treated with a pessary, with behavioral therapy for incontinence,  or with a combination of these treatments. Behavioral therapy included pelvic muscle strengthening and continence strategies. At 3 months, sexual function was assessed using short forms of both the Pelvic Organ Prolapse-Urinary Incontinence Sexual Function Questionnaire (PISQ-12) and the Personal Experiences Questionnaire (SPEQ).

The researchers found that in those women who experienced improved urinary continence, sexual activity was one of the activities in which a reduction of urinary leakage occurred. Patients also reported less restricted sexual function due to fear of leakage.

Interestingly, patients who experienced both urge incontinence and stress incontinence (versus stress incontinence alone) reported a lower level of sexual function at baseline.
It is well documented in the literature that urinary incontinence impairs quality of life in women, and this includes sexual health. The American Urological Association (AUA) recommends that medical providers ask questions about urinary incontinence and about level of bother of symptoms. The AUA also recommends that providers use validated surveys to assess a patient's function. As physical therapists, we can include screening questions on our intake forms, provide more detailed continence questionnaires, and discuss these sensitive issues with our patients to ensure that we are getting the best information about our patient's function.

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Leaking? Drink more green tea

Behavioral modification training for patients who have urinary issues commonly involves education about dietary triggers. The IC-Network lists green tea as "probably problematic" for triggering increased symptoms. Researchers in Japan, however, have reported an inverse relationship between urinary incontinence and drinking green tea.

Researchers at Curtin University in Western Australia and at the University of Tokyo completed dietary intake questionnaires for 300 Japanese community dwelling women aged 40-75 years. A urinary continence questionnaire was also completed (International Consultation on Incontinence Questionnaire- Short Form).

In the 27.5% of women who experienced urinary incontinence, less green tea was consumed on a daily basis versus those who did not leak. Average consumption of green tea for those who did not report incontinence was over 3 cups (757 ml). This relationship was not identified to be in effect for coffee, black or oolong tea.

Perhaps an important message to take from this research is that in our clinical experiences patients rarely respond equally to the same dietary factors. Some of our patients cannot, despite vigorous logging of food and beverage intake, find a consistent association between certain foods or fluids and their bladder symptoms. Even though some of our patients may benefit from reducing coffee and teas, we can appreciate that at least in Japan, where this information was gathered, a diet that includes green tea may not necessarily contribute to bladder issues.
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Recently published JAMA article on the effectiveness of physical therapy and Biofeedback in treating post-radical prostatectomy male urinary incontinence

In a study from the Center for Aging at the University of Alabama, Birmingham and the Birmingham/Atlanta Veterans Affairs Geriatric Research, Education, and Clinical Center, researchers determine that physical therapy, bladder control strategies, and biofeedback significantly reduced the incidence of urinary incontinence in post-radical prostatectomy males when compared to a control group.

Check out the abstract of the study here.

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