Patient History
Ted is a 67-year-old male with a primary concern of stress urinary incontinence (SUI) and secondary concerns of erectile dysfunction. Ted reports he was diagnosed with prostate cancer in September 2013 and underwent a “bilateral nerve-sparing radical suprapubic prostatectomy”, a procedure in which the nerves must be cut in order to remove the cancerous tissue, later that fall. He said he did not require radiation or chemotherapy treatment.
Ted complained of an onset of SUI after his surgery, and was referred by his urologist to pelvic floor PT. During his evaluation, Ted said he was wearing two to three pads a day with moderate saturation when changing them. He said he was “fairly” dry at night and was waking once a night to urinate.
Ted’s symptoms of SUI were aggravated with walking, standing, and an increase in intra-abdominal pressure with coughing, laughing, and sneezing. His symptoms interfered with prolonged standing and flying. He said he was “always looking for the nearest restroom”. In addition, he was unable to achieve an erection, but had a moderate erection with medication. His goal for physical therapy was to improve his incontinence.
Assessment
Based on Ted’s history, I chose to evaluate the following:
- Abdominal wall assessment for a diastasis recti, which is a separation of the abdominal muscles.
- Scar tissue assessment for mobility and hypersensitivity.
- Assessment of the transversus abdominis (TrA), the deepest layer of the abdominal muscles.
- Assessment of muscle tone in the pelvic floor musculature.
- Assessment of pelvic floor motor control.
The reason why I chose to assess these specific details was because I wanted to know if Ted’s incontinence was caused by poor integrity of the abdominal wall, scar tissue impairments, and/or pelvic floor dysfunction. These three components can often lead to SUI.
Objective Findings
Here’s what I found upon examination:
Ted had pelvic floor muscle weakness, poor endurance, as well as transverse abdominis (TrA) weakness. He could not contract his pelvic floor with an increase in abdominal pressure. Ted also presented with minimal to moderate scar tissue restrictions over his incision site and a posterior pelvic tilt of the pelvis in standing. A posterior tilt is when the front of the pelvis rises and the back of the pelvis drops due to shortened/tight muscles.
His symptoms of SUI developed due to his weak pelvic floor musculature and TrA. Low tone, or weakness of the pelvic floor muscles, can contribute to SUI with coughing, laughing, and sneezing as well as with dynamic activities such as walking. TrA weakness can also contribute to SUI because the abdominals are poorly supported. Ted’s standing urinary incontinence was due to his poor standing posture, which inhibited the pelvic floor from working properly. Ted did not have a diastasis recti.
Initial Treatment Plan
Ted’s initial treatment plan consisted of scar mobilization, pelvic floor strengthening, postural education, core strengthening, and dynamic strengthening exercises.
I worked on mobilizing the scar to increase the flexibility of Ted’s lower abdomen, and thus allow for proper contraction of TrA. This would then improve the integrity of the abdominal wall.
I gave Ted pelvic floor strengthening and endurance exercises in supine, sitting, and standing in order to increase his pelvic floor strength, and decrease his urinary incontinence. Specifically, I gave Ted the “knack” exercise which taught Ted how to contract his pelvic floor muscles in order to help prevent SUI with a cough, laugh, or sneeze.
I also educated Ted about his posture when sitting and standing in order to help place the pelvis in a neutral position, and allow for good motor control of the pelvic floor muscles. The core stabilization exercises were to help strengthen his TrA, and the dynamic strengthening exercises with pelvic floor contraction were to help decrease any SUI with walking.
Ted’s home program included self-scar mobilization, pelvic floor and TrA strengthening exercises. Lifestyle modifications included bladder retraining in order to allow the bladder to fill instead of frequently voiding to prevent SUI.
Goals
Ted’s goal to “improve incontinence” was within reason and realistic. He understood that he might not achieve complete continence, however he wanted to improve his quality of life. I felt there was room for improvement due to the low tone of his pelvic floor musculature. An increase in strength would help decrease his incontinence and improve his quality of life.
My goals for him were the following:
Short Term Goals (two to three weeks):
- For Ted to demonstrate the “knack” exercise correctly.
- To achieve an increase in his pelvic floor muscle strength and endurance.
- To decrease pad usage, and to have minimal saturation.
Long Term Goals (four to eight weeks):
- For patient to wear only one pad per day.
- To eliminate all SUI with standing and walking.
- No longer avoid prolonged standing and flying.
- No longer look for the nearest restroom and to void within normal limits.
Summary of Treatment
As Ted’s pelvic floor and TrA became stronger, I progressed his exercises to a more advanced level with exercises, such as core stabilization on a foam roller. After seven months of treatment, Ted said he felt like he had plateaued, but did have significant changes.
At the time of his last visit, Ted only wore one pad per day, and was no longer incontinent at night. Ted now voided three to four times per day instead of voiding frequently, and was able to identify the difference between feeling the urge to void, versus not having an urge but still voiding due to a fear of being incontinent. Ted was no longer looking for the nearest restroom, and he was no longer anxious about flying. He also stated that he felt better overall.
However, Ted continued to have urinary incontinence with prolonged standing. We discussed other treatment options, such as a penis clamp. I also referred him back to his doctor to discuss surgical options, i.e. artificial sphincter or sling.
Ted did well with PT. Despite his continued incontinence with prolonged standing, which I believe continued to be caused by poor posture, he reported an overall improvement in his quality of life.
If you have any questions about this case study, please do not hesitate to leave them in the comments section below!
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.
Comments
I just finished treatment for CPPS caused by Chronic non Bacterial Prostatitus. It seemed to work. I just had a real bad flair up two weeks ago and wet myself quite a bit. Once even at the Dr office. My issue is,I get real bad muscle and pelvic spasms when I have these chronic attacks and it causes me to leak prostatic fluid and urine. Any thing you guys know of to help with that. The therapy helped with day to day leakage but this it did not help. I get recurrent attacks at least 7 to 9 times a year. HELP!!!!!
Hello Wilburn,
Did your treatment involve internal manual therapy? I would be happy to recommend a local therapist if possible. Receiving a second opinion may be helpful for you.
Best,
Malinda
Yes, it consisted of both internal and external therapy. It worked as far as my being able to sit for more than an hour in a car. It also helped with the constant ache I always had. I’m asking if there is anything that can be done for the chronic prostititis? Also when I get these occurrences, it causes tension in my pelvic area as well as incontinence and spasms with severe pain.I don’t know if you deal with that or not. My Urologist doesn’t have a clue. I’m about to give up and I guess will just have to live with it.
Hello Wilburn,
Yes, your symptoms can improve. Please read our blog for more information. Again, I encourage you to consult with a different therapist for a second opinion.
https://pelvicpainrehab.com/male-pelvic-pain/1994/shedding-light-on-male-pelvic-pain-and-sexual-dysfunction/
Best,
Malinda
Thanks,I will go to her website and see what she has to say. The CPPS is way better than it used to be before I took therapy that you talked about. It does work. This is the second part of the pain issues that I want to try and fix or get down to manageable. You guys have been a great source of info and help. If you are ever in Memphis TN, look me up and I will treat you to some great southern hospitality.
A therapist local to the Los Angeles area would be helpful. Currently seeing a urologist at a specialist clinic and not satisfied with my results.
Hello Jacob,
We have an office in Los Angeles and would be happy to treat you. Please contact us for more information. (424) 293-2305
Regards,
Casie
My Dad has the same problem from the radiation (he could not have the surgery due to his heart). He has the urge to go all the time and that unfortunately keeps him up all night and he isn’t getting any sleep and that in turn doesn’t help his heart. What are some options for him, he is in Edmonton Alberta Canada. Any referrals there?
thanks,
Lisa – his concerned only daughter in California
Hello Lisa,
We recommend several great therapists in Edmonton. Here’s their information:
Kalinocka Sarah PT Edmonton, Alberta Canada 780-735-4761 [email protected]
MacDonald Dianna PT Edmonton, Alberta Canada 780-735-4761 [email protected]
Wood Mary PT Edmonton, Alberta Canada 780-443-4473 [email protected]
Best,
Stacey
My prostatectomy was done approximately 8 years ago and afterward I continued to have urinary incontinence. More recently I was introduced to Urologist near my former home on Long Island when back there for a family visit. She was very through in her examination and taught me how to strengthen the muscles necessary to minimize leakage. She also recommended Pelvic PT which would enhance my ability to control urination. While my ability to control urination has been greatly enhanced I’m ready to do whatever is necessary to improve it further. I’m 73 years old and physically fit for my age. I’ve just read during my search for more information that ED may also be enhanced during PPT. I live in Delray Beach Florida 33483 and I’m seeking near by treatment. That you for your support, the information has been very helpful. JMc
Hi James,
Please use the link below to find a physical therapy in your area.
https://pelvicguru.com/2016/02/13/find-a-pelvic-health-professional/
Regards,
Admin
Great post! Have nice day ! 🙂 nidvr