Scott’s Journey: Overcoming Pelvic Floor Dysfunction

The holiday season tends to be a stressful time for many people. It’s not uncommon for people to feel their bodies tense up as the levels of stress and anxiety rise – and every year we see an increase in patient numbers as a result. In December, I had the opportunity to evaluate a male patient, who I’ll call Scott, who is no stranger to stress and anxiety. What brought Scott in to pelvic floor PT was a recommendation by his orthopedic physical therapist. As you’ll see, Scott’s is a success story; however the success wasn’t in my treatment skills, but rather in his referring PT’s knowledge.

Scott is in his early 70’s and he has for most of his life been experiencing anxiety and stress. His body is quite tense, and for many years he has been in and out of orthopedic PT for different injuries. One day, Scott opened up to his orthopedic PT about his urinary symptoms. He had been seeing a urologist for an occasional weak urine stream and occasional urinary urgency. He had been experiencing these symptoms for many years and thought it was due to his prostate and age. A urological exam revealed his prostate was “slightly enlarged” and Scott was prescribed medication. After a course of medication and seeing a few urologists who specialize in prostate symptoms, a “TURP” was recommended to Scott. TURP is an abbreviation for transurethral resection of the prostate, which is a surgery used to treat an enlarged prostate. You can read more about TURP here. Scott knew from past experience that his body does not do well with surgery, and he wanted to avoid it. He started researching other treatment options for his symptoms, and decided to try acupuncture for his anxiety. He noticed that his urinary symptoms were better after the treatment. He found that lying on the acupuncturist’s table for an hour forced him to relax, and later that day his urinary symptoms would be nonexistent. However, he noticed that his urinary symptoms would return as his anxiety set in again. He continued to do online research for his urinary symptoms and he came across an article on kegels. He thought it would be a good idea to start kegel exercises and brought this up to his orthopedic PT. Thankfully, Scott’s PT knew that kegels are not always the best remedy, and that it’s best to be examined by a pelvic floor PT before starting on a pelvic floor strengthening regime. His PT referred him to us here at PHRC and I had the pleasure to evaluate him.

Given everything Scott has said, would kegels be appropriate? I know the medical professionals reading this blog will be asking, “What were your physical exam findings?” and I’ll get to that in a moment. However, I want to first appreciate all the information Scott provided us with his subjective history. Listening to patients provides us with a lot of information, and Scott was a good historian. We know that he experiences anxiety often, his body tends to be on the tighter side, that lying on the acupuncture table for an hour forces him to relax, that relaxation and acupuncture help his symptoms, and that he doesn’t do well recovering from surgery. From this we can already tell that kegels are going to be unlikely to help Scott (at least not at first), and in fact they might well make his symptoms worse. From what he says, Scott’s pelvic floor muscles are likely to be tense, such that if he was to put additional strain on them by doing kegels, he could put them into spasm and cause more discomfort.

Now let’s look at his physical exam results. Scott presented with minimal myofascial restrictions over the somatic structures superficial to his bladder, and his pelvic floor muscle contraction, relaxation, and bulge were all normal – but he did have some over-recruitment of the pubococcygeus muscle bilaterally. Since kegels are designed to strengthen this exact muscle, we need to go carefully. First we need to relax his pubococcygeus muscle, and only then work on strengthening it with exercises.

I discussed with Scott why kegels were not appropriate for him at this point, and how they can lead to an over-recruitment of his pelvic floor muscles, potentially causing him more symptoms. Instead, we talked about the importance of relaxation and the management of anxiety. Scott is currently managing his anxiety with medical care and I encouraged him to continue with that treatment, but I also gave him some helpful tips on how to manage his urinary symptoms, such as relaxation techniques to help calm his bladder for when he experiences urinary urgency.

There are many treatment techniques we pelvic floor physical therapists use to address urinary impairments and all of them have their uses, we just need to choose the right tool for each job. Scott’s main concern, was whether or not he should initiate kegels, and to answer that question we needed to know the current state of his pelvic floor muscles. Scott’s orthopedic physical therapist made a good call referring Scott to pelvic floor PT; once we knew the exact state of his muscles, we were able to avoid exercise that would have led to an increase in his symptoms, and instead guide him in the right direction for managing his anxiety and urinary symptoms.

It’s not everyday I get to evaluate a patient who is thinking about initiating kegel exercises. Most of the time I see patients after they have done months of kegels, and are experiencing more discomfort as a result! Thank you to all the orthopedic physical therapists and other practitioners we work with that know the importance of a pelvic floor assessment. We appreciate collaborating with you!

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.