By Melinda Fontaine, DPT, PHRC Walnut Creek
Symptoms
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- Many families struggle with constipation in children. Maya is a 10 year old who likes to swim, camp, and play with her little brother. She had suffered with constipation and fecal incontinence most of her life. A year ago, an x-ray showed that she had an enlarged colon from chronic constipation, and she had been using daily colonic enemas since then. The most recent imaging a few months ago showed the colon size had returned to normal. She tried taking fiber and senna without using enemas. Her stools without the enemas were large and hard. Her fecal leakage returned, so they increased the laxatives which made her vomit. She stopped the medicine and returned to daily enemas. With the enemas, her stools are soft and mushy. She has fecal incontinence when she has been backed up for days or is on a high dose of senna. She had anorectal manometry which diagnosed her with “pelvic floor dyssynergia type I.” I’ll explain what this means in a few paragraphs 😉
- Goals: Maya was limited in her activities because of her symptoms and the length of time it took her to have a bowel movement. She had a school camping trip coming up. She was going to need help from her mother for enemas there, but she would rather not. She wanted to have more sleepovers with her friends. She often had to leave friends’ houses or events to do her daily enema, and she really wanted to participate in these fun activities without interruption. Maya will be starting junior high next year and would like to have better control over her bowels by then to avoid awkward social situations and having to talk to her multiple teachers about it. Her doctor referred her to pelvic physical therapy.
Assessment
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- After having an enlarged colon for so long, Maya had difficulty identifying the sensation of having to evacuate her bowels. Then, she used daily enemas for a long time, which helped the colon size normalize, but did not allow her to practice recognizing the sensation of having a full bowel. The signals from her bowels to her brain telling her to go poop had not been present for years, and may feel unfamiliar when they return. She also had poor coordination of the pelvic floor muscles, which was preventing her from getting the poop out. “Pelvic floor dyssynergia type I” means that she could create a downward pressure starting from her abdomen to push the stool through her colon, but instead of the anus opening up to let the stool pass out, the anal sphincter squeezed shut and kept the stool inside.
Plan
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- Maya would benefit from skilled PT to practice coordination of the muscles and improve relaxation and dropping of the muscles to improve her ability to pass stool without an enema. Improved muscle coordination and directing her attention to the sensations in her body would help her learn to recognize when her bowels are full. She noticed she felt gassy before and more energetic after a BM. I taught Maya what her pelvic floor does during a bowel movement and how she could see it move with a handheld mirror or feel it by sitting on her hands. At home, Maya was very diligent in her home exercise program. Every day, she practiced diaphragmatic breathing with a stuffie, yoga poses for pelvic floor relaxation, coordination exercises for the pelvic floor, and good bowel habits.
- With her and her family’s permission, I called Maya’s gastroenterologist who prescribed the daily enemas. I told them our plan for physical therapy and our goal for Maya to be able to pass her bowels without enemas. In order to practice pooping, she would need time to try pooping, but she did not often get the urge before her next enema. I asked if the doctor could create a plan for Maya to safely reduce the enemas to allow her time to practice pooping without an enema. The doctor agreed and called Maya and her family to discuss a new plan.
Success
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- Her new plan included a daily oral laxative and reducing the enemas to twice a week. She was relieved to find that she started having an urge to poop almost every afternoon when she stopped the enemas. She started having spontaneous bowel movements six out of the seven days of the week without straining, and her stools were shaped like beautiful smooth logs. Her fecal incontinence was once a week or less with this routine. She continued to practice her exercises to retrain her muscles, and her good bowel habits helped move stool through her intestines and create a recognizable sensation of having to poop. Maya and her family gradually spaced out the enemas until she was only using them when she had not pooped in a few days. Her persistence with the program from her doctor and the physical therapy exercises helped her body relearn how to have a bowel movement. Maya is very happy to be able to play at the neighbors house and not have to come home early to do an enema.
For more on pediatric pelvic floor dysfunction and constipation, check out these links:
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
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.