By Tiffany Yuen, DPT, PHRC Los Gatos
The History of Kevin’s Symptoms and How He Found PHRC
“Tiffany did an excellent job helping to loosen the muscles in my pelvic area; I experienced minimal discomfort during our sessions but saw marked improvement in urgency and frequency as long as I showed up and did the basic exercises she prescribed for me to do at home. I would recommend pelvic physical therapy for others who are looking for relief from interstitial cystitis or other bladder-related issues.”
Kevin is a 28 year old male who referred himself to PHRC with severe urinary urgency and frequency that started when he was 14 years old. He was urinating every five to ten minutes (normal is every three to four hours) during the day, especially after increasing his fluid intake, as well as waking up four to five times a night to do so. He was also experiencing difficulty initiating his urine stream (also known as urinary hesitancy), which takes 10 minutes, and difficulty voiding completely, reporting that “he feels as if he can’t get all the urine out.” In addition, he continued to have urgency even after voiding. As a result, he was avoiding any liquid consumption, including water, to manage his condition. He has seen multiple urologists over the past decade, who diagnosed him with interstitial cystitis (IC) after he underwent a cystoscopy, which showed no signs of bladder lesions. However, the American Urologic Association Interstitial Cystitis Guidelines state that a cystoscopy cannot confirm nor refute an IC diagnosis. Furthermore, this study shows that only about 12.3% of those diagnosed with IC have Hunner lesions in the bladder. He also underwent urodynamic testing, which revealed completely normal bladder function. One urologist prescribed Elmiron (a medication that is FDA approved for IC), which he took for eight years. Despite taking Elmiron, his symptoms persisted and he wanted to stop relying on it as it was very expensive. Kevin considered pelvic floor physical therapy after he learned about PHRC through his girlfriend, who was currently receiving treatment at the time, and found out that we also treat men with pelvic pain and symptoms.
Physical Exam and Assessment
During his physical exam, I noted the following objective findings:
- Moderate connective tissue dysfunction at his abdomen, inner thighs, suprapubic region, and bony pelvis.
- Myofascial trigger points along the rectus abdominis, iliopsoas, adductors, and obturator internus.
- Hypertonicity (tightness) throughout the urogenital diaphragm (bulbospongiosus, ischiocavernosus, and transverse perineal muscles), obturator internus, and levator ani, which were all tender to touch.
- Decreased pelvic floor range of motion along with poor ability to lengthen and relax the pelvic floor muscles voluntarily.
- External anal sphincter tension and paradoxical contractions (contracting pelvic floor muscles when asked to relax).
My assessment was that Kevin was experiencing urinary dysfunction secondary to having a hypertonic pelvic floor. During the internal assessment on our first day, I had difficulty inserting my finger to assess the deeper pelvic floor muscles because the superficial muscles were so tight. His muscles were in spasm and there was involuntary clenching against and around my finger.
This makes sense when one thinks about the hypertonicity of his muscles in relation to his symptoms. The urogenital diaphragm makes up the superficial layer of the pelvic floor, consisting of the bulbospongiosus, ischiocavernosus, and transverse perineal muscles, and is important for both urinary function and sexual pleasure. These muscles have to be able to relax in order to let urine pass through the urethra. Since the superficial pelvic floor musculature surrounds the urethra, tightness in these muscles could cause compression against the urethra and mimic symptoms of urinary urgency and frequency.
The tension in Kevin’s pelvic floor was not necessarily due to a specific incident, accident, or injury, but built up over time due to various reasons. During his first visit, Kevin reported a history of generalized anxiety disorder, weightlifting at the gym, and excessive sitting due to working from home as a result of the pandemic. It is possible that he had a tendency to hold tension in his buttocks and pelvis whenever he was experiencing episodes of anxiety. In addition, if he was weightlifting with poor breathing mechanics and holding his breath during every or even some of the reps, this could also lead to increased pressure in the abdomen and resulting tension in the pelvic floor. Furthermore, decreased physical activity and excessive sitting is another factor that could have created additional tightness in his pelvic floor muscles. Overall, these could all be possible contributors to Kevin’s hypertonic pelvic floor. Read more about the causes of pelvic floor tightness via our website.
My Plan and Goals for Kevin
Kevin’s goals were the following:
- Alleviate symptoms of urinary urgency and frequency.
- Alleviate symptoms of difficulty voiding.
Based on Kevin’s report of negative cultures, normal cystoscopy, and urodynamics tests, it was clear to me that the cause of Kevin’s symptoms was musculoskeletal. My plan for him was physical therapy one time a week for the next eight visits. In order to monitor his progress in every visit, I set both short-term and long-term goals for Kevin.
My short-term goals were:
- The patient will normalize connective tissue mobility to improve blood flow and tissue function.
- The patient will demonstrate good motor control for pelvic floor drop to improve pelvic floor tone.
My long-term goals were:
- The patient will void no more than six to eight times in a 24-hour period.
- The patient will be able to initiate a urine stream in less than five seconds.
- The patient will reduce nocturia (urinating at night) to zero to two times/night.
During his initial evaluation, I acknowledged that he has been experiencing his symptoms for the past ~14 years and we discussed how chronic pain can affect the nervous system as well as how increased stress and anxiety can play a role in exacerbating his symptoms. We also talked about the importance of staying hydrated and drinking sufficient amounts of water (half your body weight in ounces) to decrease the concentration of urine. Otherwise, increased concentration of urine may actually irritate his bladder and urethral lining. Furthermore, I educated him about how the bladder is really trainable and the importance of urge suppression. Otherwise, succumbing to the urge and urinating every five to ten minutes will continue to feed signals to his brain, telling it that the bladder is full when it’s not. Foam rolling exercises were given as the first part of his home exercise program to address restrictions in his connective tissues and muscles.
My plan for future treatment sessions involved connective tissue manipulation, myofascial release, myofascial trigger point release, neuromuscular reeducation, therapeutic exercise and activity, and home exercise program prescription and management. There was going to be an emphasis on improving the range of his pelvic floor by teaching him how to voluntarily lengthen the muscles through doing pelvic floor drops. In addition, my plan included combining diaphragmatic breathing with the pelvic floor drops, which would help to address and mitigate his episodes of anxiety since this activates the parasympathetic nervous system.
The Course of Kevin’s Recovery
At Kevin’s first follow-up visit, he reported that his inner thighs and buttocks feel less tight than before. He also reported some soreness in those areas secondary to the manual therapy after our evaluation visit and the foam rolling exercises he has been doing at home. However, he stated an increase in urinary frequency secondary to increasing his water intake. I assured him that this is normal, but feel free to read more about how drinking water throughout the day may actually improve urinary urgency and frequency. During this session, we continued to work on improving connective tissue mobility and addressing myofascial impairments, such as trigger points present in his abdomen, adductors, and bony pelvis. We also continued to practice pelvic floor motor control and relaxation techniques. However, he continued to demonstrate external anal sphincter tightening and paradoxical contractions during internal treatment.
At his second follow-up visit, Kevin reported that he notices a decrease in urinary urgency after having practiced urge suppression that week. He also stated that he has less difficulty initiating his urine stream, which improved from 10 minutes to 30 seconds. During this session, he demonstrated mild pelvic floor motion with diaphragmatic breathing. In addition to manual therapy, stretching exercises were initiated as a progression of his home exercise program. I instructed him to do the diaphragmatic breathing and pelvic floor drops concurrently with the stretches to further promote pelvic floor lengthening and relaxation.
At Kevin’s third follow-up visit, he reported that his urinary frequency has reduced from every five to ten minutes to every hour even when his fluid intake has been increased. He stated that he was waking up in the night to urinate three times compared to four to five times in the past. At this point in time, he reported that it took about 15 to 20 seconds to initiate urination, which is an improvement as well. During this session, he presented with increased tension and myofascial trigger points in his abdominal muscles and iliopsoas. However, he demonstrated less external anal sphincter tightening and moderate pelvic floor motion with diaphragmatic breathing.
At his last two visits, Kevin reported that he has been urinating five to seven times during the day and that he has some nights where he does not need to wake up in the middle of the night to urinate while he may awaken up to twice a night on some other nights, which was his baseline before his symptoms started. He also stated that it takes five to ten seconds to initiate urination and is able to void completely after every bathroom visit, reporting no sensation of urgency afterwards. By his last visit, he presented minimal restrictions in his connective tissues and elimination of most myofascial trigger points in his abdomen, inner thighs, and gluteal muscles. He also reported no tenderness to palpation of both external and internal musculature. Kevin demonstrated excellent ability to achieve global pelvic floor relaxation and lengthening as well as improved motor control.
With the correct treatments and interventions, Kevin’s pain and symptoms resolved very quickly within approximately one and a half months given the amount of time he has been experiencing these symptoms, which was 14 years. He did not feel the need to come in after six visits as he stated that he feels he is back to his normal. Therefore, he was provided with a thorough home exercise program to manage his condition, which consisted of diaphragmatic breathing, pelvic floor drops, foam rolling, stretches, and purchase of the pelvic wand for self-internal massage. I hope that those of you who are reading this are able to see that alleviating and managing chronic pain is very possible given the right guidance, resources, and mentality. You can read more about how pelvic floor physical therapy can help with patients with interstitial cystitis (including resources), on our blog.
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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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.