Sara Chan Reardon, DPT, WCS, BCB-PMD is a pelvic floor dysfunction specialist practicing in New Orleans, LA. Sara was named the 2008 Section on Women’s Health Research Scholar for her published research on pelvic floor dyssynergia related constipation. She was recognized as an Emerging Leader in 2013 by the American Physical Therapy Association. She served as Treasurer of the APTA’s Section on Women's Health and sat on their Executive Board of Directors from 2012-2015. Today she was kind enough to share a bit about her course Post-Prostatectomy Patient Rehabilitation, which is taking place twice in 2018.
My name is Sara Reardon, and I teach the Post-Prostatectomy Patient Rehabilitation course, which I wrote and developed in the year 2015. At the time, I had been a pelvic health Physical Therapist for over 10 years. Earlier in my career, I had taken the Pelvic Floor 2A course by Herman and Wallace Institute, which was a fantastic and thorough introduction to treating a male patient.
Over the years, I started seeing more and more men with post-prostatectomy urinary incontinence and erectile dysfunction in my clinic. Urinary incontinence is the most common and costly complication in men following prostate removal surgery, and their quality of life is directly related to their duration of experiencing those symptoms. Evidence supports that pelvic floor muscle training started as soon as possible after surgery can help decrease incontinence and improve quality of life. I enjoyed being able to help men decrease their incontinence and improve their other symptoms after all they had been through following a cancer diagnosis and treatment.
A 2016 study by Kaori et al examined the effect of self administered perineal stimulation for nocturia in elderly women. A prior study using rodents found a soft roller used decreased overactive bladder syndrome (OAB), but a hard roller did not produce the same results. Kaori et al performed a similar study for elderly women in a randomized, placebo controlled, double blind crossover. Participants were 79-89 years old women who applied simulation to perineal skin for 1 minute at bedtime, using either active (soft, sticky elastomer) roller or a placebo (hard polylestrene roller). Participants did a 3-day baseline, followed by 3-day stimulation, then 4 days rest, then other stimuli for 3 days. There were 24 participants, 22 completed the study: 9 with OAB, 13 without OAB. The placement of the roller was not on the skin of the perineal body, but rather on the general peri-anal area with the diagram from the study showing an area just medial to the gluteal crease—where one would find the ischial tuberosity-- and anterior and lateral to the anal sphincter.
Across the subjects with OAB, change with the elastomer roller (soft and sticky feel) was more statistically significant than with the hard roller. Baseline micturition for the participants was 3.2+/- 1.2 times per night, measured as the number of urination between going to bed and arising. The group as a whole did not have a statistically significant difference, measured by at least one less time arising per night. However, in the OAB group, the difference was significant. The researchers theorized that the soft and sticky texture may induce more firing of somatic afferents nerve fibers.
The most commonly prescribed treatment for overactive bladder is anticholinergic therapy, but the side effects, including cognitive changes and lack of significant difference from controls, as well as the drying effect of these drugs in a post-menopausal-low-estrogen-pelvis, bring up questions of whether this is the best option in the elderly.(6)
The following is the first in a series of posts by Erica Vitek, MOT, OTR, BCB-PMD, PRPC. Erica joined the Herman & Wallace faculty in 2018 and is the author of Neurologic Conditions and Pelvic Floor Rehab.
A well-respected colleague of mine brought something to my attention. My desire to learn everything possible about Parkinson disease and pelvic health was a unique passion, a combination of expertise not seen in many rehabilitation clinics.
Looking back, being passionate about how to physically exercise a person with Parkinson disease to produce the best functional outcome actually became a passion of mine when I was offered my first job. I was thrown into treating people with Parkinson disease in an acute care setting. I had very limited knowledge about Parkinson disease at the time, but I learned quickly from the vast opportunity that was offered to me through my place of work, which was the regions sought after Parkinson disease center of excellence. At the same time, I was eager to further advance my skills as a pelvic floor therapist, which I developed a substantial interest in when I was in college.
Interstitial cystitis is a chronic pain condition characterized by both pelvic pain and urinary symptoms. It’s diagnosed by unexplained pain or pressure that is perceived to be related to the bladder, and affects more than 12 million Americans. It’s often described as the sensation of a urinary tract infection, but without any bacterial infection. Many patients report severe pain, often more intense than that associated with bladder cancer, and up to 85% of patients have accompanying pelvic floor dysfunction.
Pelvic floor physical therapy is the most proven treatment for interstitial cystitis. It’s recommended by the American Urological Association (AUA) as a first-line medical treatment in their IC Guidelines, and is the only treatment given an evidence grade of ‘A’. Furthermore, it’s the sole intervention that provides sustained relief; bladder treatments and oral medications must be continued indefinitely to provide benefit, if they work at all.
Research has demonstrated that at least 85% of patients with interstitial cystitis also have pelvic floor dysfunction. In fact, many of the symptoms of IC can only be explained by the pelvic floor. The majority of patients report painful intercourse, low back pain, hip pain, or constipation accompanying the condition; symptoms that have nothing to do with the bladder.
The new year is here and with it, lots of motivational posting about exercise and weight loss…but how is this desire for ‘new year, new you’ affecting peri-menopausal women with urinary dysfunction? It has been established that the lower urinary tract is sensitive to the effects of estrogen, sharing a common embryological origin with the female genital tract, the urogenital sinus. Urge urinary incontinence is more prevalent after the menopause, and the peak prevalence of stress incontinence occurs around the time of the menopause (Quinn et al 2009). Zhu et al looked at the risk factors for urinary incontinence in women and found that some of the main contributors include peri/post-menopausal status, constipation and central obesity (women's waist circumference, >/=80 cm) along with vaginal delivery/multiparity.
Could weight loss directly impact urinary incontinence in menopausal women? In a word – yes. ‘Weight reduction is an effective treatment for overweight and obese women with UI. Weight loss of 5% to 10% has an efficacy similar to that of other nonsurgical treatments and should be considered a first line therapy for incontinence’ (Subak et al 2005) But do these benefits last? Again – yes! ‘Weight loss intervention reduced the frequency of stress incontinence episodes through 12 months and improved patient satisfaction with changes in incontinence through 18 months. Improving weight loss maintenance may provide longer term benefits for urinary incontinence.’ (Wing et al 2010)
The other major health issues facing women at midlife include an increased risk for cardiovascular disease, Type 2 Diabetes and Bone Health problems – all of which are responsive to lifestyle interventions, particularly exercise and stress management. In their paper looking at lifestyle weight loss interventions, Franz et al found that ‘…a weight loss of >5% appears necessary for beneficial effects on HbA1c, lipids, and blood pressure. Achieving this level of weight loss requires intense interventions, including energy restriction, regular physical activity, and frequent contact with health professionals’. 5% weight loss is the same amount of weight loss necessary to provide significant benefits for urinary incontinence at midlife.
When I work prn in inpatient rehabilitation, I have access to each patient’s chart and can really focus on the systems review and past medical history, which often gives me ample reasons to ask about pelvic floor dysfunction. So, of course, I do. I have yet to find a gynecological cancer survivor who does not report an ongoing struggle with urinary incontinence. And sadly, they all report that they just deal with it.
Bretschneider et al.2016 researched the presence of pelvic floor disorders in females with presumed gynecological malignancy prior to surgical intervention. Baseline assessments were completed by 152 of the 186 women scheduled for surgery. The rate of urinary incontinence (UI) at baseline was 40.9% for the subjects, all of whom had uterine, ovarian, or cervical cancer. Stress urinary incontinence (SUI) was reported by 33.3% of the women, urge incontinence (UI) by 25%, fecal incontinence (FI) by 3.9%, abdominal pain by 47.4%, constipation by 37.7%, and diarrhea by 20.1%. The authors concluded pelvic floor disorders are prevalent among women with suspected gynecologic cancer and should be noted prior to surgery in order to provide more thorough rehabilitation for these women post-operatively.
Ramaseshan et al.2017 performed a systematic review of 31 articles to study pelvic floor disorder prevalence among women with gynecologic malignant cancers. Before treatment of cervical cancer, the prevalence of SUI was 24-29% (4-76% post-treatment), UI was 8-18% (4-59% post-treatment), and FI was 6% (2-34% post- treatment). Cervical cancer treatment also caused urinary retention (0.4-39%), fecal urge (3-49%), dyspareunia (12-58%), and vaginal dryness (15-47%). Uterine cancer showed a pre-treatment prevalence of SUI (29-36%), UUI (15-25%), and FI (3%) and post-treatment prevalence of UI (2-44%) and dyspareunia (7-39%). Vulvar cancer survivors had post-treatment prevalence of UI (4-32%), SUI (6-20%), and FI (1-20%). Ovarian cancer survivors had prevalence of SUI (32-42%), UUI (15-39%), prolapse (17%) and sexual dysfunction (62-75%). The authors concluded pelvic floor dysfunction is prevalent among gynecologic cancer survivors and needs to be addressed.
Many therapists transition to treating men with the knowledge and training from female patients. When therapists apply this knowledge, for the most part, it works. When we spend some attention on learning what is a bit different, we might be drawn to the superficial muscles of the perineum. This old anatomy image does a wonderful job of "calling it like it is" or using anatomical terms that describe an action versus naming only the structure. In the image we are looking from below (inferior view) at the perineum and genitals. Just anterior to the anus we can see the anterior muscles within the urogenital triangle, with the base of the shaft of the penis located just anterior to (above in this image) the anus and perineal body. Notice that at the midline, we see muscle names the "accelerator urine". Modern textbooks refer to this muscle as the bulbocavernosus, or bulbospongiosus. Taking the name of accelerator urine, we can understand that this muscle will have an effect on aiding the body in emptying urine. It does this through rhythmic contractions, most often noted towards the end of urination, when the typical spurts of urine follow a more steady stream. This assistance with emptying can take place because the urethra is located within the lower part of the penis, the portion known as the corpus spongiosum. Because the bulbocavernosus muscle covers this part of the penis, and the inferior and lateral parts of the urethra are virtually wrapped within the bulbocavernosus, the muscle can have an effect on emptying the urine in the urethra.
Notice that if you follow the fibers of the accelerator urine muscle towards the top of the image, where the penis continues, you will notice fibers of the muscle wrapping around the sides of the penis. These fibers will continue as a fascial band that travels over the dorsal vessels of the penis. This allows the muscle to also have a significant action during sexual activity, in which blood flow (getting blood into, keeping blood in, and letting blood out of the penis) is paramount.
On either side of the penis we can see what is labeled the erector penis. As these muscles cover the legs, or crura which form the two upper parts of the penis, when the muscles contract, blood is shunted towards the main body of the penis. This of course helps with penile rigidity, as the smooth muscles in the artery walls of the penis allow blood to fill the spongy chambers.
At the peak of my racing career I won awards in all my races from 5k to marathon. While warming up I would scope out my competition, intimidated by muscular females wearing outfits to accentuate their physiques. Many times, appearance out-weighed running capacity. In a similar manner, one strong pelvic floor contraction produced by a female athlete does not always mean she has the endurance to stay dry in the long run.
Brennand et al. (2017) researched urinary leakage during exercise in Canadian women. A summary of their findings concluded that skipping, trampoline, jumping jacks, and running/jogging were most likely to cause leakage. To combat the problem, 93.2% emptied their bladder just before exercise, 62.7% required voiding breaks during exercise, and 37.3% actually restricted their fluid intake to minimize leakage. While 90.3% of women who reported leakage impacted their activity just decreased their intensity, 80.7% avoided the activity entirely. Many women used pads (49.2%). Interest in pelvic floor physiotherapy to improve their UI was high (84.6%), but 63.5% of women still sought pessary or surgical management. Unfortunately, 35.6% of the women had no idea treatment was even an option.
Nygaard & Shaw (2016) reviewed and summarized the cross-sectional studies regarding the association between physical activity and pelvic floor disorders. Trampolinists, especially those in the 3rd tertile of competition, even those who were nulliparous, experienced greater leakage. Competitive athletes in the highest quartile of time exercising were found to have 2.5 times the amount of urinary incontinence (UI) as the lowest inactive quartile; however, 2nd and 3rd quartile recreational athletes had no difference in UI compared to inactive women. Type and dosage of exercise were both factors in UI risk. Various studies showed habitual walking decreased UI in older women, moderate exercise decreased the risk of UI, and no exercise increased the risk of UI. The incidence of UI being related to having performed strenuous exercise early in life has been limited and variable, with one study of Norwegian athletes and US Olympians not having any greater UI later in life, while another showed middle-aged women who used to exercise 7.5 hours per week had a higher incidence of UI. This review also reported athletes had a 20% greater cross sectional area of the levator ani muscle and a greater pubovisceral muscle mean diameter; however, the pelvic floor strength recorded was lower than non-athletes.
The first time I experienced the effects of Post-Traumatic Stress Disorder (PTSD) was when my patient dissociated during a treatment session and relived the rape that had occurred when she was ten years old. It was devastating. I didn’t know what to do. She was unresponsive to my intervention. Her eyes didn’t see me, alternating between wide-eyed, horrified panic and clenched-closed, lip biting excruciating pain. It was my late night and I was alone in the clinic. I sat helplessly next to my sweet patient hoping and praying that her torture would end quickly. When she finally stopped writhing, she slept. Deep and hard. Finally she woke up disoriented and scared. She grabbed her things and left. For me, this experience was my initiation into the world of trauma.
Approximately 5-6 % of men and 10-12% of women will suffer from PTSD at some point in their lives. Researchers believe that 10% of people exposed to trauma will go on to develop PTSD. The expression of PTSD symptoms can present differently in men and women. Men may have more externalizing disorders progressing along a scale that includes vigilance, resistance, defiance, aggression and homicidal thoughts. Women tend to present with internalizing disorders such as depression, anxiety, exaggerated startle responses, dissociation, and suicidal thoughts. The research is clear that both men and women with PTSD display changes in brain function. The mid brain (amygdala, basal ganglia and hippocampus) tends to be overactive in sounding alarm signals while the prefrontal cortex fails to turn off the mid brain when a threat is no longer present. Since the prefrontal cortex is not always functioning correctly, traditional talk therapy may not be as effective for treating PTSD. Instead, say many researchers, breath and movement exercises may help regulate brain functioning. Yoga, Tai Chi, and meditation have been shown to have a positive impact on down regulating the mid brain and improving cerebral output. As pelvic floor therapists we deal with trauma on a daily basis, whether we know it or not. Although we are not trained in psychology, understanding PTSD and equipping ourselves with tools to support our patients is imperative for both our patients and ourselves.
You might be wondering what happened after that frightful night in the clinic? My patient was determined to get better. She had a non-relaxing pelvic floor. She was a teacher and was plagued by urinary distress. She either had terrible urgency or would go for hours and not be able to empty her bladder. So we met with her therapist to learn strategies to help us to be able to work together without triggering dissociation. It was a slow road, but the three of us working together helped my patient not only reach her goals but to be able to be skillful enough to maintain her gains using a dilator for self-treatment.
While running on my treadmill, I watched a commercial advertising specially designed pads as “the solution” for women athletes who “leak” during their sport. Before my introduction to Herman and Wallace Rehabilitation Institute, I would have rushed to the nearest store to buy a case of them. When we don’t know how to fix a problem, we tend to cling to bandages to cover them, allowing us to ignore them. With 29 years of running and racing and 2 natural childbirths under my belt, leaks have happened, and it is common. However, leaks due to urinary stress incontinence are not normal and do not stop simply because you place a contoured, sporty, sanitary pad in the lining of your shorts.
A 2016 cross-sectional study by Ameida et al. investigated urinary incontinence (UI) and pelvic floor dysfunctions (PFD) such as constipation, anal incontinence, pelvic organ prolapse, vaginal laxity, and dyspareunia in female athletes who participate in high-impact sports. The 67 amateur athletes and 96 non-athletes completed an ad hoc survey to determine PFD symptoms. Artistic gymnasts, trampolinists, swimmers, and judo participants were among the athletes with the highest risk of urinary incontinence. Although the athletes had a higher risk of UI, they reported less constipation, less straining to relieve themselves, and less manual assistance for defecation than the non-athletes. The authors were able to conclude that high impact sports or sports requiring a strong effort put athletes at risk for UI, uncontrolled gas expulsion, and even sexual dysfunction. They emphasize a need for attention to be given to pelvic floor training for rehabilitation as well as preventative strategies and education for high risk yet asymptomatic athletes.
In 2015, DaRoza et al. performed a cross-sectional cohort study to determine the urinary leakage in 22 young female trampolinists based on the volume of their training and level of ranking. Leakage was assessed by the International Consultation on Incontinence Questionnaire Short-Form (ICIQ-UI-SF), and another questionnaire determined each athlete’s championship ranking and training volume. An astounding 72.7% of girls reported urine leakage since starting to perform on the trampoline, and the greatest severity was significantly associated with the highest training volume. The impact of UI on the athlete’s quality of life was greatest in this 3rd tertile. The authors recommended these athletes with a high frequency of UI be educated on the impact of their sport on their pelvic floor muscles and proposed they get treated by pelvic health professionals to minimize or resolve the incontinence.