Managing a medical crisis such as a cancer diagnosis can be overwhelming for an individual. Faced with choices about medical options, dealing with disruptions in work, home and family life often leaves little energy left to consider sexual health and intimacy. Maintaining closeness, however, is often a goal within a partnership and can aid in sustaining a relationship through such a crisis. The research is clear about cancer treatment being disruptive to sexual health, yet intimacy is a larger concept that may be fostered even when sexual activity is impaired or interrupted. Last year, when I was asked to speak to the Pacific NW Prostate Cancer Conference about intimacy, I was pleasantly surprised to find a rich body of literature about maintaining intimacy despite a diagnosis of prostate cancer.

Sexual health and sexuality is a social construct affected by many factors including mood, stress, depression, self-image, physiology, psychology, culture, relational and spiritual factors ^{(Beck et al., 2009; Weiner & Avery-Clark, 2017)} Prostate cancer treatment can change relational roles, finances, work life, independence, and other factors including hormone levels.^{(Beck et al., 2009)} Exhaustion (on the part of the patient and the caregiver), role changes, changes in libido and performance anxiety can create further challenges. ^{(Beck et al., 2009; Hawkins et al., 2009; Higano et al., 2012)} Recovery of intimacy is possible, and reframing of sexual health may need to take place. Most importantly, these issues need to be talked about, as renegotiation of intimacy may need to take place after a diagnosis or treatment of prostate cancer. ^{(Gilbert et al., 2010)}

If the patient brings up sexual health, or we encourage the conversation, there are many research-based suggestions we can provide to encourage recovery of intimacy, several are listed below.

- Manage general health, fitness, nutrition, sleep, anxiety and stress
- Redefine sex as being beyond penetration, consider other sexual practices such as massage/touch, cuddling, talking, use of vibrators, medication, aids such as pumps ^{(Usher et al., 2013)}
- Participate in couples therapy to understand partners’ needs, address loss, be educated about sexual function ^{(Wittman et al., 2014; Wittman et al., 2015)}
- Participate in “sensate focus” activities (developed by Masters & Johnson in 1970’s as “touch opportunities”) with appropriate guidance ^{(Weiner & Avery-Clark 2017)}

Within the context of this information, there is opportunity to refer the patient to a provider who specializes in sexual health and function. While some rehabilitation professionals are taking additional training to be able to provide a level of sexual health education and counseling, most pelvic health providers do not have the breadth and depth of training required to provide counseling techniques related to sexual health- we can, however, get the conversation started, which in the end may be most important.

In the men’s health course, we further discuss sexual anatomy and physiology, prostate issues, and look at the research describing models of intimacy and what worked for couples who did learn to renegotiate intimacy after prostate cancer.

Beck, A. M., Robinson, J. W., & Carlson, L. E. (2009, April). Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn. In Urologic oncology: seminars and original investigations (Vol. 27, No. 2, pp. 137-143). Elsevier.
Beck, A. M., Robinson, J. W., & Carlson, L. E. (2013). Sexual Values as the Key to Maintaining Satisfying Sex After Prostate Cancer Treatment : The Physical Pleasure–Relational Intimacy Model of Sexual Motivation. Archives of sexual behavior, 42(8), 1637-1647.
Gilbert, E., Ussher, J. M., & Perz, J. (2010). Renegotiating sexuality and intimacy in the context of cancer: the experiences of carers. Archives of Sexual Behavior, 39(4), 998-1009.
Hawkins, Y., Ussher, J., Gilbert, E., Perz, J., Sandoval, M., & Sundquist, K. (2009). Changes in sexuality and intimacy after the diagnosis and treatment of cancer: the experience of partners in a sexual relationship with a person with cancer. Cancer nursing, 32(4), 271-280.
Higano, C. S. (2012). Sexuality and intimacy after definitive treatment and subsequent androgen deprivation therapy for prostate cancer. Journal of Clinical Oncology, 30(30), 3720-3725.
Ussher, J. M., Perz, J., Gilbert, E., Wong, W. T., & Hobbs, K. (2013). Renegotiating sex and intimacy after cancer: resisting the coital imperative. Cancer Nursing, 36(6), 454-462.
Weiner, L., Avery-Clark, C. (2017). Sensate Focus in Sex Therapy: The Illustrated Manual. Routledge, New York.
Wittmann, D., Carolan, M., Given, B., Skolarus, T. A., An, L., Palapattu, G., & Montie, J. E. (2014). Exploring the role of the partner in couples’ sexual recovery after surgery for prostate cancer. Supportive Care in Cancer, 22(9), 2509-2515.
Wittmann, D., Carolan, M., Given, B., Skolarus, T. A., Crossley, H., An, L., ... & Montie, J. E. (2015). What couples say about their recovery of sexual intimacy after prostatectomy: toward the development of a conceptual model of couples' sexual recovery after surgery for prostate cancer. The journal of sexual medicine, 12(2), 494-504.

Men who present with chronic pelvic pain frequently have symptoms referred along the penis and into the tip of the penis, or glans. Symptoms may include numbness, tingling, aching, pain, or other sensitivity and discomfort. The tip of the penis, or glans, is a sensory structure, which allows for sexual stimulation and appreciation. This same capacity for valuable sensation can create severe discomfort when signals related to the glans are overactive or irritating. One of the most common complaints with this symptom is a level of annoyance and distraction, with level of bother worsening when a person is less active or not as mentally engaged with tasks. Wearing clothing that touches the tip of the penis (such as underwear, jock straps, jeans, or snug pants) may be limited and may worsen symptoms. When uncovering from where the symptoms originate, the culprit is often the dorsal nerve of the penis, which is sensible given that the glans is innervated by this branch of the pudendal nerve. If we consider this possibility (because certainly there are other potential causes) we find that there are many potential sites of pudendal nerve irritation to consider. First, let’s visualize the anatomy of the nerve.

Following the usually accepted descriptions of the dorsal nerve, we know that it is a terminal branch of the pudendal nerve that primarily is created from the mid-sacral nerves. This can lead us to include the lumbosacral region in our examination and treatment, yet in my clinical experience, there are other sites that more often reproduce pain in the glans. As the dorsal nerve branches off of the pudendal, usually after the location of the sacrotuberous ligament, it passes through and among the urogenital triangle layers of fascia where compression or irritation may generate symptoms.

As the nerve travels towards the pubic bone, it will pass inferior to the pubic bone, a location where suspensory ligaments of the penis can be found as well as pudendal vessels and fascia. This is also a site of potential compression and irritation, and palpation to this region may provide information about tissue health. Below is a cross-section of the proximal penis, allowing us to see where the pudendal nerve and vessels would travel inferior to the pubic bone.

As the dorsal nerve extends along either side of the penis, giving smaller branches along its path towards the glans, the nerve may also be experiencing soft tissue irritation along the length of the penis or even locally at the termination in the glans.

Palpation internally (via rectum) or externally may be a part of the assessment as well as treatment of this condition. Oftentimes, tip of the penis pain can be reproduced with palpation internally and directed towards the anterior levator ani and the connective tissues just inferior to the pubic bone. It may be difficult to know if the muscle is providing referred pain, or if the nerve is being tensioned and reproducing symptoms, however gentle soft tissue work applied to this area is often successful in reducing or resolving symptoms regardless of the tissue involved. In my experience, these symptoms of referred pain at the tip of the penis is often one of the last to resolve, and the use of topical lidocaine may be helpful in managing symptoms while healing takes place. Home program self-care including scar massage if needed, nerve mobilizations, trunk and pelvic mobility and strengthening, and advice for returning to meaningful activities can play a large role in resolution of pain in the glans.

If you would like to learn more about treating genital pain in men, consider joining me in Male Pelvic Floor: Function, Dysfunction, & Treatment. The 2018 courses will be in Freehold, NJ this June, and Houston, TX in September.

In 2007, after only speaking on the phone and never meeting in person, my new friend and colleague Stacey Futterman and I presented at the APTA National Conference on the topic of male pelvic pain. It was a 3 hour lecture that Stacey had been asked to give, and she invited me to assist her upon recommendation of one of her dear friends who had heard me lecture. I still recall the frequent glances I made to match the person behind the voice I had heard for so many long phone calls.

Upon recommendation of Holly Herman, we took this presentation and developed it into a 2 day continuing education course, creating lectures in male anatomy (we definitely did not learn about the epididymis in my graduate training), post-prostatectomy urinary incontinence, pelvic pain, and a bit about sexual health and dysfunction. Although it truly seems like the worst imaginable question, we asked each other “should we allow men to attend?” As strange as this question now seems, it speaks volumes about the world of pelvic health at that time; mostly female instructors taught mostly female participants about mostly female conditions.

Make no mistake- women’s health topics were and are deserving of much attention in our typically male-centered world of medicine and research. Maternal health in the US is dreadful, and gone are the days when providers should allow urinary incontinence or painful sexual health to be “normal”, yet it is often described as such to women who are brave enough to ask for help. Times have changed for the better for us all.

The Male Pelvic Floor Course was first taught in 2008, and so far, 22 events have taken place in 18 different cities. 73 men have attended the course to date, with increasing numbers represented at each course. Rather than 20-25 attendees, the Institute is seeing more of the men’s health course filling up with 35-40 participants. In my observations, the men who attend the course are often very experienced, have excellent orthopedic and manual therapy skills, and have personalities that fit very well into the sensitive work that is pelvic rehabilitation.

The course was expanded to include 3 days of lectures and labs, and this expansion allowed more time for hands-on skills in examination and treatment. The schedule still covers bladder, prostate, sexual health and pelvic pain, and further discusses special topics like post-vasectomy syndrome, circumcision, and Peyronie’s disease. In my own clinical practice, learning to address penile injuries has allowed me to provide healing for conditions that are yet to appear in our journals and textbooks. As I often say in the course, we are creating male pelvic rehabilitation in real time.

Because the course often has providers in attendance who have not completed prior pelvic health training, instruction in basic techniques are included. For the experienced therapists, there are multiple lab “tracks” that offer intermediate to advanced skills that can be practiced in addition to the basic skills. Adaptations and models are used when needed to allow for draping, palpation, and education when working with partners in lab, and space is created for those therapists who want to learn genital palpation more thoroughly versus those who are deciding where their comfort zone is at the time. One of the more valuable conversations that we have in the course is how to create comfort and ease in when for most us, we were raised in a culture (and medical training) where palpation of the pelvis was not made comfortable. Hearing from the male participants about their bodies, how they are affected by cultural expectations, adds significant value as well.

We need to continue to create more coursework, more clinical training opportunities so that the representation of those treating male patients improves. If you feel ready to take your training to the next level in caring for male pelvic dysfunction, this year there are three opportunities to study. I hope you will join me in Male Pelvic Floor Function, Dysfunction and Treatment.

As someone who has spent nearly two decades marketing myself, my practice, or practices for employers, I have learned a lot of skills by trial and error. One of my favorite strategies to expand my professional network is to “Follow the Patient.” By this I mean to follow the patient to a specialist consult, to a procedure, or to a referral that you helped to coordinate. This must be done with the patient in mind, first and foremost, and then also the provider and their practice environment, so as not to have that practice shut the door on you in the future. Of course, this process can look different if you are in a health network because as an insider, you will likely be more welcome and have all the right credentials in order to simply attend a patient’s provider visit. If you are in a private practice, there are sometimes more hoops and permissions to negotiate. Following are some tips I have learned about this strategy of nurturing referral sources.

Offer the idea to the patient and see if they are open to it. It might sound like this: “If you are interested, I may be able to accompany you to your upcoming appointment. Does that interest you?” It’s very important that the patient is consenting to you being in attendance at their appointment, as the visit is for them. It may be best to not promise that you can clear your schedule, or coordinate the visit, but finding out if the patient is open to the idea is the first step.

2. Check in with the provider’s office. This can be accomplished by you or by the patient. This might sound like this: “I’d like to be sure that your provider would welcome me at your appointment. Would you prefer to contact the provider’s office or shall I?” In my experience, the provider’s office will say “if it’s ok with the patient, it’s fine with us!” Typically, a patient can bring whomever they like to an appointment, so that’s not much of an issue, unless there is close quarters or some other limiting scenario. The good thing about giving a heads up is it allows the provider’s office the opportunity to know that you may be joining your patient. I was able to follow a patient into a hernia repair surgery, and the nurses were so surprised that a physical therapist was in the prep room, they asked me “does the doctor know you are here?” in which case I was able to affirm that I indeed had permission from the surgeon.

3. When you attend the visit, allow the patient to introduce you or politely introduce yourself. Then listen. This is not the time to tell the medical provider all of the wonderful things you have been doing, or all of the things you have to offer their patients. Sometimes when reporting their history, the patient will look questioningly at me to recall details, and unless I am needed to give a brief response, I like to be quiet and stay out of the story until later. This is the time for the patient and the provider to get to know each other, establish rapport, and fewer interruptions are best.

4. Be prepared to summarize your thoughts when given the opportunity to share. Typically I have found that a medical provider will at some point turn and ask me a few questions, or simply state, “Do you have anything to add?” at which point I try to make concise yet thoughtful statements about the patient’s progress, continued challenges, and the reasoning behind the referral if I was the one to coordinate it. The summary might sound like this: “The original severe pain locations have eased, function has improved in this way, and the symptom or issue that is persisting is this. I was interested in knowing if there is potentially something else going on, or if you have a recommendation towards furthering their progress.” At this point, it’s best to not get too far ahead of yourself, or put expectations in front of the patient beyond a brief summary. In other words, don’t request specific imaging or suggest a particular procedure, as this may create an imbalance in the patient’s expectations and the reality of what takes place. If the provider wants more details or thoughts from you, they are likely to ask directly. (You can also send a progress report or summary letter prior to your visit if you have specific thoughts or concerns about what is going on.)

5. Allow the visit to unfold, listen carefully and take mental or written notes. I have often found that I recall details of anatomy, medications, or suggested interventions easily and the patient may ask about the details in a follow-up visit. This type of partnership allows the patient to have “another pair of ears” and can serve as a valuable part of the rehabilitation care planning. For example, perhaps the provider said, “Let’s try this imaging, if nothing of interest shows up, continue rehabilitation for 6 weeks. If no significant progress, I’d like to see you back here within a couple of months from today.” This allows the therapist to note that a provider visit was requested at 6 weeks following the appointment.

Marketing our services, in the long run, and especially in pelvic health, is critical in sharing awareness of the role of pelvic rehabilitation. Marketing is about relationships, and the easiest way to create a relationship is face to face. “Following” a patient along their healing journey, while it may take time out of the clinic for you, is a valuable way of engaging with providers and of being part of a collaborative process. When another provider or therapist requests that I see their patient to offer another view, I find it helpful to welcome the referring therapist to join the patient as well. This can lead to valuable discussions, sharing of information, and ultimately the patient may experience more efficient care that is directed to optimal strategies.

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.

Once we discuss the usual functions of these muscles, we can then imagine the dysfunctions potentially created by less than optimal activity. Consider the difficulty that these muscles will create in contracting or relaxing if they are either too weak, or too tense. These issues can create difficulty emptying well the urethra, often leading to post-void dribble. Blood flow and therefore penile rigidity with erections may be negatively impacted by inability of these muscles to contract or stay contracted, and blood flow leaving the penis may be impaired if the muscles cannot relax. When we work with patients who have genital pain, pelvic floor muscle weakness, dyscoordination, or tension, we can often improve sexual function, bladder emptying, and tasks that might otherwise be affected by pain.

If you are interested in learning more about how to assess and treat these muscles, you have one more opportunity this year to attend the 3-day Male Course instructed by Holly Tanner. Holly has been teaching this course for over 10 years when she co-wrote the first course with colleague and faculty member Stacey Futterman. The course has been updated and turned into a 3-day course to include more manual therapy techniques. Hurry to grab one of the remaining spots in the October 27-29 course in Grand Rapids!

Preterm birth can have deleterious health effects not only for the child, but also for the mother. A child may be born so early that various health systems are not matured, leading to susceptibility and delay in development and growth. Maternal health may also be severely impacted, with conditions such as anxiety and psychological stress. Managing the prevention of a pre-term delivery can be stressful and challenging for a pregnant woman, and authors Ha & McDonald (2016) report that this issue is not well studied. A cross-sectional survey was completed to find out not only what a woman’s preferences and concerns are, but also to find out which recommendations were likely to be followed by the patient. This is important, the authors state, because women who are actively involved in medical decisions are more likely to feel satisfied with their childbirth experience.

The survey was completed by 311 women at a median of 32 weeks gestation. Mean age was 30.9, and the majority of them identified as European/White-Caucasian. Most of them were married or in a common-law relationship and had received some level of post-secondary education. The majority of women who were told they were at increased risk of preterm labor (PTL) preferred close-monitoring rather then PTL prevention. Of interest is that the majority of women reported they would use other sources of information besides their primary provider, with the most reported source being the internet or family and friends. This point begs the question of how high is the quality level or accuracy of the available information on the internet or in the general public? Common available options for prevention included progesterone, cerclage, and pessary use. If a woman is not interested in using recommended prevention strategies, the goal of the rehabilitation clinician should be to, on a constant basis, monitor for symptoms and signs of early labor, and encourage the patient to keep any recommended provider appointments, and stay in close contact with her provider so that close-monitoring may be carried out.

An additional goal for rehabilitation is to provide the mother with strategies that may assist her in managing her anxiety, stress, movement dysfunctions, sleep, and other activities. Prior research has validated the benefits of relaxation training in pre-term labor: a cost-effective, low risk and easily implemented strategy. Training women in such a tool during pregnancy fits well into the rehab provider’s scope, and can be instructed in the clinic (or home!) for home program implementation. Larger newborns, longer gestations, and higher rates of prolonged gestations have been recorded when using relaxation training training for pre-term labor.^{Janke et al., 1999)} Chuang et al. (2012) have documented fewer admissions to neonatal intensive care unit, decreased rates of extreme pre-term birth, and shorter stays in hospital with use of relaxation training. Meditation, mindfulness, deep breathing, visualization, and movement within recommend medical limits may all be valuable tools that make up a part of a patient’s rehabilitation experience. In an article describing how prenatal meditation influences infant behaviors, yoga, singing, and massage therapy are all cited methods for improving maternal and/or fetal health.^{Chan, 2014}

The Herman & Wallace Institute offers a three part series on pregnancy and postpartum. Get started by attending either Care of the Pregnant Patient or Care of the Postpartum Patient. You may also be interested in any of the Mindfulness & Meditation courses, including Holistic Interventions and Meditation, Mindfulness-Based Pain Treatment, and Mindfulness for Rehabilitation Professionals.

Chan, K. P. (2014). Prenatal meditation influences infant behaviors. Infant Behavior and Development, 37(4), 556-561.
Chuang, L.-L., Lin, L.-C., Cheng, P.-J., Chen, C.-H., Wu, S.-C., & Chang, C.-L. (2012). The effectiveness of a relaxation training program for women with preterm labour on pregnancy outcomes: A controlled clinical trial. [Article]. International Journal of Nursing Studies, 49, 257-264. doi: 10.1016/j.ijnurstu.2011.09.007
Ha, V., & McDonald, S. D. (2017). Pregnant women’s preferences for and concerns about preterm birth prevention: a cross-sectional survey. BMC pregnancy and childbirth, 17(1), 49.
Janke, J. (1999). The effect of relaxation therapy on preterm labor outcomes. Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN / NAACOG, 28(3), 255-263.

“To me it felt like I was just sitting on bed rest, waiting to have a seizure, you know, waiting to start circling the drain.” “Every time I went to the doctor I had this…anxiety attack.” These are the words of pregnant women diagnosed with preeclampsia and on bed rest. Other phrases reported by the authors who interviewed women on bedrest included “…an impending doom…”,  “…meltdown…”, “nervous wreck.” A few of the major themes that emerged in the interviews was that of negative thoughts and feelings, family stressors, and not being heard. And while using the term “crazy” is not truly appropriate, women who are forced to abruptly stop interacting and participating in their typical life activities must be regarded as being very high risk for more than just physical issues. ^{Kehler et al., 2016}

In an ideal situation, bed rest during pregnancy is prescribed to help keep the mother and fetus healthy. Unfortunately, bed rest in itself is associated with potentially negative consequences in physical and mental health, and providers are not always up-to-date on changing recommendations for bedrest. Perhaps the cautious attitude of providers towards minimizing risk guides some choices. In addition, many women describe frustration about lack of clear guidelines, difficulty managing their stressful feelings, and varying degrees of support from medical providers.

During pregnancy-related bed rest, research has described how the entire family is affected. Physically, the mother may have changes in her circadian rhythms, increased anxiety, depression, and hostility. The rest of the family can also experience and demonstrate stress. Other children may act out, partners may be more stressed and worried, and financial strain may be a concern. ^{Bigelow & Stone, 2011} Although we as rehab professionals may not have solutions for every issue, we may be able to facilitate accessing resources and at a minimum hear what a woman is dealing with during this stressful time.  Many women, even when on bedrest, are allowed to attend medical appointments such as physical therapy, and should be provided with appropriate physical and mental activities to help minimize muscle atrophy and stress. Home health or hospital-based providers are also in a perfect position to educate providers on the value of referrals while the patient is at home or in the hospital.

We should keep these issues in mind during pregnancy as well as in the postpartum period. Maloni & Park (2005) measured postpartum symptoms in women who were on bedrest during pregnancy, and at 6 weeks postpartum, 40% of the 106 women (high-risk, singleton) complained of mood changes, difficulty concentrating, and other physical issues. Women who had a c-section had worsened symptoms, and the length of time on bed rest was highly correlated with the number of symptoms.

Bed rest affects a woman’s cognition, creates fear, a sense of lack of control, powerlessness, and even anger. “Because of this, Rodrigues and colleagues (Rodrigues et al., 2016) suggest that “…mental disorders should be routinely investigated during high-risk pregnancy, whenever possible with the use of specific instruments so that they can be detected early and so that interventions can be made in due time.” If you are interested in discussing this issue and many others, check out the Institute’s continuing education choices in peripartum health. The next Care of the Postpartum Patient course is taking place on September 16-17, 2017 in Nashville, TN.

Bigelow, C., & Stone, J. (2011). Bed rest in pregnancy. The Mount Sinai Journal Of Medicine, New York, 78(2), 291-302. doi: 10.1002/msj.20243
Kehler, S., Ashford, K., Cho, M., & Dekker, R. L. (2016). Experience of Preeclampsia and Bed Rest: Mental Health Implications. Issues in Mental Health Nursing, 37(9), 674-681.
Maloni, J. A., & Park, S. (2005). Postpartum Symptoms After Antepartum Bed Rest. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 34(2).
Meher, S., Abalos, E., & Carroli, G. (2005). Bed rest with or without hospitalisation for hypertension during pregnancy. Cochrane Database of Systematic Reviews, 4.
Rodrigues, P. B., Zambaldi, C. F., Cantilino, A., & Sougey, E. B. (2016). Special features of high-risk pregnancies as factors in development of mental distress: a review. Trends in psychiatry and psychotherapy, 38(3), 136-140.

Polycystic ovarian disease (PCOS), also known as Stein-Leventhal syndrome, is an endocrine system disorder that affects women of reproductive age. The disease is associated with some major adverse health issues including infertility, diabetes, metabolic syndrome (a cluster of conditions that increase risk for heart disease, stroke and diabetes), cardiovascular issues and endometrial carcinoma. Because, according to Okamura et al., those with PCOS share risk factors for endometrial cancer and atypical endometrial hyperplasia, early detection and treatment are critical for optimal health outcomes. Some of the primary shared risk factors include obesity, not bearing any children (nulliparity), infertility, hypertension, diabetes, chronic anovulation, and unopposed estrogen supplementation.

One study (Malcolm²⁰¹⁷) that addressed reproductive health comparisons among young women with and without PCOS found that although women diagnosed with PCOS had significant concerns about their reproductive health, they were found to be as sexually active as young women without PCOS. Unfortunately, women with PCOS were more likely to have pelvic inflammatory disease (PID), which could increase the risk of infertility. In this study, the importance of counseling in safe sex practices such as condom use and sexually transmitted infection screening was highlighted.

As weight loss in women diagnosed with PCOS has been shown to improve blood sugar levels, exercise and healthy weight management strategies can also be keystones of care. Vasheghani-Farahani et al report on a home-based exercise program with positive outcomes in health for women with PCOS. The women in this study were ages 15-40, with 16 patients in the exercise group and 14 in the control group. Blood pressure, waist to hip ratio, BMI, blood tests for insulin factors, sex hormones, and markers of inflammation made up outcomes measures at baseline and again at 12 weeks following intervention. The active group completed aerobic and strengthening exercises and were found to have an improved waist to hip ratio as well as reductions in cardiovascular risk profiles.

The exercise instructed as home program is as follows: 30 minute walk at least 5 days per week at medium intensity (64%-76% max heart rate), strengthening exercises of biceps curl, wall push up, chair push up, single arm row, seated lower leg lift, seated straight leg lift, stair step and chair squat 10 times each. The participants were instructed to increase the exercise bouts per day from 1 to 3 by the end of the study. Participants were guided through the exercises at the beginning of the study, and exercise logs as well as phone calls were used to track progress, answer questions.

This study is an encouraging example of simple yet effective strategies to guide women diagnosed with PCOS. Although there are other equally valuable aspects of care that a pelvic health therapist can be involved in for women managing this challenging disease, the research presented reminds us that basic information on healthy sexual practices and provider follow-up, strengthening and aerobic exercise can have meaningful impact on quality of life. If you are interested in learning more about PCOS and other endocrine conditions, and ways to help manage pelvic pain, adhesions, and other symptoms, join us in Pelvic Floor Series Capstone: Advanced Topics in Pelvic Rehab, available twice more in 2017.

Malcolm, S., Tuchman, L., Cheng, Y. I., Wang, J., & Gomez-Lobo, V. (2017). Differences in Reproductive Health Issues in Adolescent Females With Polycystic Ovarian Syndrome Compared to Controls. Journal of Pediatric and Adolescent Gynecology, 30(2), 330-331.
Okamura, Y., Saito, F., Takaishi, K., Motohara, T., Honda, R., Ohba, T., & Katabuchi, H. (2017). Polycystic ovary syndrome: early diagnosis and intervention are necessary for fertility preservation in young women with endometrial cancer under 35 years of age. Reproductive Medicine and Biology, 16(1), 67-71.
Vasheghani-Farahani, F., Khosravi, S., Yekta, A. H. A., Rostami, M., & Mansournia, M. A. (2017). The Effect of Home based Exercise on Treatment of Women with Poly Cystic Ovary Syndrome; a single-Blind Randomized Controlled Trial. Novelty in Biomedicine, 5(1), 8-15.

In the world of pelvic health, we are constantly meeting patients who are surprised to learn about the scope of what we do. Oftentimes, it is because we mention the pelvic muscles’ roles in sexual health that a patient will offer up symptoms with their sexual health, or ask a few more questions. Outside of pelvic health professionals asking about sexual function, do men bring up these issues with anyone? Not usually. In Fisher and colleagues 2-part “Strike up a conversation” study (2005), the authors reported that men who have erectile dysfunction (ED) are worried about their partner’s reaction, don’t want to admit to having a chronic problem, and frankly, just don’t even know where to start. Unfortunately, the partners of men who have ED have the same concerns. In addition, partners are worried about bringing it up and “making their partners feel worse about it.” When men did bring up sexual concerns with their physician, although they reported feeling nervous and embarrassed, they also reported feeling hopeful and relieved.

This issue was highlighted in a recent interview and article published on National Public Radio. The article shares that for war veterans, sexual intimacy is often affected, and yet, is often ignored. A Marine who suffered PTSD after a head injury and shrapnel to the head and neck describes how he had to go to the doctor several times just to work up the nerve to ask for help for his sexual dysfunction. He also shared how it was difficult to talk about “…because it contradicts a self-image so many Marines have.” Apparently you don’t have to be a Marine to feel the same intense pressure related to talking about sexual issues. I have spent more time in the past year trying to better understand why men don’t discuss these issues, with a best friend or partner, and each time, my question of “what would that be like if you brought it up?” is met with near bewilderment, as if revealing this issue were akin to revealing your deepest, darkest secret. Apparently, it is. Telling a buddy you have erectile dysfunction, for men, seems to be like showing your enemy where the chink in your armor is, or like setting yourself up to be the center of every “getting it up” joke for the remainder of your life.

The bottom line is that we can be part of the solution to this problem, because men must be certain that their medical provider knows about any emerging or worsening erectile dysfunction. Loss of libido, or changes in erectile function can be associated with heart issues, with diabetes, or with other major medical concerns. Research such as the referenced “strike up a conversation study” has demonstrated that health care providers or partners may positively influence a patient’s access to care. Once medical evaluation has been completed, the role of the pelvic health provider is critical in improving sexual health for men with dysfunction. If you are interested in learning more about the role of the pelvic health provider for erectile dysfunction or pain related to sexual function, the Male Pelvic Health continuing education course will be offered 3 times this year through the Herman & Wallace Pelvic Rehabilitation Institute. Your next opportunity to learn about urinary and prostate conditions, male pelvic pain, sexual health and dysfunction is next month in Portland, Oregon.

Chang, A. (2016). For veterans, trauma of war can persist in struggles with sexual intimacy. Retrieved from http://www.npr.org/sections/health-shots/2017/01/01/507749611/for-veterans-trauma-of-war-can-persist-in-struggles-with-sexual-intimacy
Fisher, W. A., Meryn, S., Sand, M., Brandenburg, U., Buvat, J., Mendive, J., ... & Strike Up a Conversation Study Team. (2005). Communication about erectile dysfunction among men with ED, partners of men with ED, and physicians: The Strike Up a Conversation Study (Part I). The journal of men's health & gender, 2(1), 64-78.
Fisher, W. A., Meryn, S., Sand, M., & Strike up a Conversation Study Team. (2005). Communication about erectile dysfunction among men with ED, partners of men with ED, and physicians: the Strike Up a Conversation study (Part II). The journal of men's health & gender, 2(3), 309-e1.

With menopause and the hormonal shifts that take place, some women suffer more than others with symptoms such as hot flashes. If you have ever been near someone during a hot flash, you know that this curious condition is more than feeling a little hot under the collar. During a hot flash, women will suddenly disrobe, wake from a deep sleep covered in sweat (so much so that they have to change the sheets!), or otherwise appear distressed and oftentimes suffer interference in whatever activity in which they were engaging. As we reported in an earlier post, women on average may have hot flashes for 5 years after the date of her last period. Some women (up to 1/3 in the referenced study) will report hot flashes for 10 or more years after menopause.

Hot flashes and night sweats also significantly disrupt sleep, according to research by Baker and colleagues. Menopausal women with insomnia may also have higher levels of psychologic, somatic, vasomotor symptoms, and score lower on the Beck Depression Inventory, and sleep efficiency and duration scores. Poor sleep can be associated with morbidity such as hypertension, stroke, diabetes and depression, so interrupted sleep is more than an inconvenience, but potentially a serious health issue.

A more recent study linked anxiety as a potential risk factor for menopausal hot flashes. In 233 women who are premenopausal at baseline and who were followed for at least a year after their final menstrual cycle, anxiety symptoms, hormone levels, hot flashes and other psychosocial variables were assessed. During the 14 year follow-up 72% of the women reported having moderate to severe hot flashes, and the researchers correlated somatic anxiety as a potential predictive association with anxiety. Somatic anxiety refers to the physical symptoms of anxiety, such as stomach ache, increased heart rate, sweating, muscle aches.

In order to help a woman support her wellness during menopausal transitions, being able to address somatic anxiety and conditions like hot flashes is imperative. Teaching skills such as breathing, relaxation training, meditation, or mindfulness may positively impact the anxiety, and therefore have the potential to reduce hot flashes and other adverse symptoms. Herman & Wallace's Menopause Rehabilitation and Symptom Management course is an excellent opportunity to learn some of these valuable skills.

Baker, F. C., Willoughby, A. R., Sassoon, S. A., Colrain, I. M., & de Zambotti, M. (2015). Insomnia in women approaching menopause: beyond perception. Psychoneuroendocrinology, 60, 96-104.
Freeman, E. W., & Sammel, M. D. (2016). Anxiety as a risk factor for menopausal hot flashes: evidence from the Penn Ovarian Aging cohort. Menopause, 23(9), 942-949.
Freeman, E. W., Sammel, M. D., & Sanders, R. J. (2014). Risk of long term hot flashes after natural menopause: Evidence from the Penn Ovarian Aging Cohort. Menopause (New York, NY), 21(9), 924.