By Jennifer Guan, PT, DPT PHRC Los Gatos
André Fenri* is a 28 year old male who was referred to PHRC by his urologist. André reports that three months prior to his initial evaluation, he developed pressure and pain on the left side in his groin region. He reports that he had gone skateboarding prior and his MD suspected a hernia or a pulled muscle. However, test results were inconclusive. He reports that the pain had become so significant that he was bedridden. He was using some groin compression wraps to help the pain but stopped using them as he was worried they were going to make his muscles weaker. He tried to work on some stretching exercises, but worries that he may have overdone it. He reports overall the symptoms are worse at the end of the day. He reports that he feels that walking and movement cause him more strain. It is hard to sleep on his left side as well. After sexual intercourse he feels pain in the left side, but the pain is in his groin and he denies pain in his penis, scrotum, or testicles.
He also reports that for a few weeks, he has had a sensation of urine dribbling which prompted him to seek an appointment with a urologist. He reports that although it was only drops, he was fearful that it would be a full leakage. A urine sample was obtained, and was positive for a UTI. He also received a CT scan to rule out kidney stones. He was prescribed some antibiotics but reports continued groin pain and dribbling. He was provided some gentle stretching exercises by his urologist as well as a referral for pelvic floor physical therapy. When he had his active UTI, he reported using the restroom about three times every two hours. Currently he reports that his urination symptoms have gone back to more normal, other than the dribbling. He does not urinate at night and goes at a more normal interval. He reports that his urine stream is a bit slower when his bladder is full vs prior to these symptoms starting. He was also recommended to perform double voiding to avoid dribbling.
Physical Exam:
Current objective findings:
- External Exam:
- Moderate connective tissue dysfunction in his bony pelvis and inner thighs. Severe connective tissue dysfunction in his abdomen.
- Sensitivity upon palpation of the suprapubic region on the left side.
- Myofascial trigger points in the psoas and iliacus.
- Decreased abdominal deep core (Transverse Abdomnius muscle) and hip stability and strength
- Internal Exam:
- Severe hypertonicity (tightness) throughout the urogenital diaphragm (bulbospongiosus, ischiocavernosus, and transverse perineal muscles) and moderate hypertonicity in the obturator internus, coccygeus and levator ani muscles.
- Poor muscle-length tension relationship of the pelvic floor muscles, with poor ability to lengthen and relax the pelvic floor muscles voluntarily
Assessment:
Overuse, injury, and stress can lead muscles into tightness. Additionally, when an injury occurs, muscles can also tighten as a protective mechanism. Even if the injury is to one specific muscle, the muscles in the surrounding region will be impacted as they will react to the injury. In Andre’s case, it is likely that the injury caused by skateboarding was to his hip flexor muscle group. Inconclusive imaging does not always rule out injury. Following the injury, the connective tissue and muscles in the surrounding abdomen, pelvis, and thigh regions were also affected.
The tight muscles then in turn lead to his reports of dribbling urine. Tight muscles in the pelvic floor can lead to urinary dribbling because when the muscles are so tight, the muscle-length tension relationship changes. This leads to a decreased ability for the muscle to activate as the available length of the muscle has changed. Imagine trying to do a bicep curl, when your elbow is already bent- you are not going to be able to do a full curl. I had a very difficult time inserting my finger during the rectal exam. For Andre, this was exacerbated by his UTI which caused him more pain and urinary function disruptions.
Fortunately in Andre’s case because he had the additional symptom of dribbling, he was working with a urologist and ended up at PHRC to have his pelvic floor evaluated. It is all too common for us to meet patients who report groin pain, and after months or even years of orthopedic treatments, do not feel 100% symptom resolution because there was an important piece of the puzzle missing. The pelvic floor has a very important role to play in pelvic stability as well as spine, hip, and pelvic function. Furthermore, the obturator internus muscle, while a part of the hip, originates quite deep in the pelvis and the majority of the muscle cannot be accessed externally.
Plan:
The plan for André’s treatment sessions include connective tissue manipulation, myofascial release, and myofascial trigger point release to address the dysfunction in the muscles and fascia. His plan also included neuromuscular reeducation, therapeutic exercise and activity, and home exercise program prescription and management to improve his ability to voluntarily lengthen the pelvic floor muscles. After he masters the ability to lengthen his muscles and has improved neuromotor control, he will receive hip and core strengthening and stabilization exercises. These exercises will help him to return to some more high impact activities and prevent future injury to the region.
Goals:
Andre shared with me that his goal is that he is “hoping to get an understanding of what is wrong with my body and get closer to getting back to normal life. Walking/hiking without having to lay down to recover, comfortably at my desk, and sexual intercourse without feeling strain.”
My long term goals for Andre were:
- Patient will normalize pelvic floor tissue tension and connective tissue mobility in order to support proper pelvic floor function in 12 weeks.
- Patient will report 0% pain in his groin for at least one hour during the day in 12 weeks.
- Patient will report no urinary leaking with standing, walking, or transitional activities in 12 weeks.
The Recovery:
Andre’s progression has been slow and steady. He has been conscious about not rushing himself. We began with addressing the pain and providing him with techniques and manual treatments targeted at pain management. Pelvic pain can be challenging as certain triggering activities such as walking, standing, and sitting cannot be 100% avoided. This makes it all the more important for patients to remember to not over-do it and to introduce activity modifications. Andre needed to bring all of his tight muscles into a better resting position and to learn how to voluntarily relax his pelvic floor muscles. After this was achieved, we began strengthening his core and hips to provide him with stability and strength in this new and improved muscular resting state. Andre started with weekly appointments, but after seven appointments, he was showing improvements in his tissue and muscles and he was subsequently able to be seen every two weeks, and then every three weeks.
Two and a half months into his treatments, he was able to attend a music festival which included a significant amount of walking and standing. He reported that he walked on average 20,000 steps per day. He reports that he knows he still needs to be mindful of his groin and not overdo it, but was glad to be able to spend time with his family and friends and not decline social invitations anymore like he had been earlier in the year.
At this time, Andre is able to complete hikes with elevation and has been jogging as well. Last weekend, he went on three hikes and also went kayaking. His dribbling symptoms are not affecting him anymore and he does not need to consciously think about it as he knows he is not going to have an accident.
Andre says “If I could share thoughts to myself in the past or to someone just starting their journey, I’d say: listen to your body. Don’t forget to do your stretches and exercises. Most of all, be patient and stay positive. Healing takes time”.
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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.
Comments
Very well presented. Every quote was awesome and thanks for sharing the content. Keep sharing and keep motivating others.