By: Melinda Fontaine, DPT, PHRC Walnut Creek
Darnell took a trip to Europe a few months ago with his spouse. They had planned a wonderful vacation, but what they didn’t plan for was Darnell not being able to urinate or have a bowel movement (BM) for nine days! He took magnesium citrate which helped him produce partial BMs. When I met him and his wife two months later, he just had a urinary catheter removed. He was emptying his bladder three times per day using an intermittent catheter (a soft thin tube inserted in the urethra to drain the bladder). The doctor had recommended Miralax (an osmotic laxative) and Citrucel (a fiber supplement) twice a day, and he could evacuate stools with only a little bit of straining if they were lucky enough to make it all the way through his system to the rectum (the final part of the colon where a stool collects until it is pushed out of the body). He was still having significant difficulty emptying his bowels and bladder. Darnell was also a survivor of anal cancer which was treated about 10 years prior with radiation only. He was told the radiation would cause some symptoms 10-20 years later, so he wondered if this was what they meant.
What he experienced:
Over the last two years, Darnell had been experiencing elevated heart rate and blood pressure when he stood or walked. He had seen his doctors about it, and they recommended more consistent exercise. However, he had not done much exercise in the past two years because standing and walking caused his heart rate and blood pressure to rise. He also retired from working retail about two years prior when the pandemic hit. He drank about 2400cc of sparkling water per day, and his goal was to avoid a colostomy. His gastroenterologist referred him to physical therapy.
What the PT found:
When I evaluated Darnell, he held his breath with each activity and when he tried to bear down as when having a bowel movement. He accredited this to many years of swimming and having to time his breaths with his strokes. However, holding one’s breath prevents the pelvic floor from fully relaxing and opening to allow the urine and stool to come out. Fun Fact: holding one’s breath while bearing down can also cause a temporary change in heart rate and blood pressure. When I reminded him to breathe, he had limited expansion of his ribcage. Darnell’s deep abdominal muscles were also weak. Strong abdominal muscles are needed to help food move through the digestive system and create the downward force that pushes urine and stool out. Lastly, when he told his pelvic floor muscles to push out, sometimes they squeezed instead. This is known as paradoxical movement and it leads to straining on the toilet often without passing any stool. Darnell also had thickened tissue at the anus and the left lower quadrant of his abdomen due to the radiation. These thickened areas create speed bumps that are difficult for the stool to pass. He also had some restricted connective tissue at his sits bones and inner thighs which contribute to more tension and difficulty relaxing around the anus.
Why is this happening and What can be done about it?
Darnell’s difficulty emptying his bowels and bladder were likely due to multiple factors. The lack of coordination of his pelvic muscles and holding his breath made it so he could not open the sphincter enough to get all the stool out of his colon. The change in his fitness level when he stopped exercising regularly slowed down his digestion and weak core muscles led to ineffective straining on the toilet.
Darnell and his wife learned about all of the above physiology in the first appointment. His wife was eager to help and he wanted to include her, so she learned to do a massage to his abdomen to help move stool through his bowels. My goals for his first few visits were that Darnell would learn and become proficient at an exercise program to improve his breathing, core strength, and pelvic floor coordination. He also increased his exercise in multiple short bouts to avoid sustained tachycardia. During sessions, we continued education on the physiology, visceral mobilization of the colon, myofascial release of the connective tissue, and muscle retraining. We also reviewed healthy bowel habits, such as chewing food well, drinking plenty of water, and leaning forward on the toilet when moving bowels. He came in every other week for six visits.
Progress Towards Goals:
On the second visit, he reported that he tried to clean out his bowels with a high dose of Miralax/osmotic laxative, but he only produced small amounts and he felt like the stool was not getting to the end of the colon unless it was the exact right consistency. We continued to work on breathing, core strengthening, and abdominal massage. By the fifth visit, he reported that he was not having daily bowel movements with much less straining, and he felt confident he could avoid a colostomy. He also noticed that he was able to empty his bladder without using the catheter since his bowel issues cleared up. Reducing the pressure from the colon also took pressure off his bladder, so he could urinate. At the sixth visit, he met his two main goals:
#1 Daily bowel movements without straining and
#2 Able to urinate without a catheter.
Many people suffer from constipation and urinary symptoms that can be helped by pelvic physical therapy. Schedule an appointment with us if you would like better bathroom habits!
Check out these links for more information:
Bowel Dysfunction – Pelvic Health & Rehabilitation Center
How PT can help with Anal Cancer Treatment
How Pelvic Floor Physical Therapy Helps Bowel Dysfunction
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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.
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