By Emily Eckmann, DPT, PHRC West Los Angeles
Stacy’s History
Stacy is a woman in her 60s who came to PHRC seeking help for her urinary incontinence that had progressively gotten worse over the last five years. She was eight years into menopause and had seen several gynecologists who did not find ‘anything wrong with her bladder.’ She was told she potentially had a prolapse of her bladder and may require surgery. She came in wanting to get ahead of the issue remembering that her mother had also struggled with incontinence for many years.
At the time of her initial exam she was using one pad/day and was having most of her leakage symptoms with coughing, laughing or sneezing. She had two UTIs in the past year that were treated with antibiotics and noted periodic yeast infections that manifested as “itching.” She also had a history of endometriosis that was treated with oral birth control for 30+ years to control her symptoms until she went into menopause.
She had tried doing Kegel exercises on her own, but generally did not know what to do to resolve her symptoms. How many kegels? Am I doing them correctly? How many do I need to do per day to stop leaking? Stacey googled pelvic floor treatment and found PHRC.
Medical Implications
The first thing we discussed was Stacy’s history of repeated UTIs and yeast infections in the past year. It had been eight years since Stacy’s last period and she had not used vaginal estrogen or hormone therapy.
This history combined with her symptoms pointed to an issue of hypo-estrogenization of the tissues in her vestibule (the area around the entrance of the vagina), including her urethra. These tissues are vulnerable to compromise as hormones decline. During hormone decline the vaginal microbiome changes, we produce less lactobacillus, the vaginal pH rises and so does the rate of vaginal and urinary tract infections.
What is often needed is pelvic floor physical therapy and vaginal and potentially systemic hormone treatment. This helps prevent recurring UTIs and yeast infections, helps restore tissue integrity and women can move on with their lives.
Physical Exam:
With Stacy’s physical exam I found that she had significant weakness in her pelvic floor and that she actually put more pressure down on her pelvic muscles with coughing, laughing and sneezing, when ideally we want to feel a quick contraction to prevent leakage from happening.
She also had some sensitivity in her vestibule and paleness in her tissues with lack of tissue integrity around her urethra; these are clinical signs of decreased estrogen. All of these things were likely contributing to her leakage symptoms. We also found some “itchy” spots in her labia that can be indicative of potential lichen sclerosus, which is a skin disorder that can cause itching and pain and lead to other more serious issues if left untreated.
Unfortunately this is common to find in the menopausal population. To learn more about this cluster of symptoms (and others) visit our blog on the Genitourinary Syndrome of Menopause (GSM) and how this can present and be treated.
Plan and outcome:
Stacy’s physical exam findings showed that she required both medical treatment and physical therapy interventions. I referred Stacy to a gynecologist who specializes in the specific dermatologic issues we found in Stacy’s vestibule.
In the meantime, in physical therapy we found that Stacy’s pelvic floor muscles were both tight and weak, and that her neuromuscular control was not intact, therefore resulting in impairments managing the balance between intra abdominal pressure and pelvic floor control. We worked on pelvic floor lengthening first with manual therapy and improving general pelvic floor mobility and control via exercises. Stacy, like so many other patients with leakage symptoms, had a hard time relaxing her pelvic floor and releasing her pelvic floor muscles after initially contracting. Once she had improved control over her pelvic floor, we began to work on pressure management and coordinating her pelvic contractions with the triggering events that cause her leakage. This included a quick “squeeze” just before a cough or sneeze. We also worked on strengthening her hip muscles to improve the overall stability in her pelvis so her pelvic floor wouldn’t have to work so hard and tighten back up to stabilize her pelvis.
As the weeks progressed, Stacy was using the vaginal topicals that she got from her new gynecologist to address the hormonal changes that were leaving her prone to infections, and performing her exercises at home and in her PT sessions. Within about four weeks her symptoms were over 50% improved and in two more weeks she was only wearing small panty liners that often were not wet at all. We started practicing more balance and jumping/landing exercises to further challenge and load her pelvic floor muscles.
After a little over three months, Stacy was no longer having leakage and the quality of her periurethral tissue was significantly improved due to the hormonal topicals she was using to help support her bladder. The combination of her persistence and commitment to physical therapy and getting access to the proper medical management helped her gain more confidence and freedom to do the things she enjoys in life without hesitation.
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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.