By Jandra Mueller, DPT, MS, PHRC Encinitas and Jennifer Guan, DPT, PHRC Los Gatos
Happy Endo Awareness Month!
Tracy is a 35 year old patient who was referred to PHRC by her doctor. This is her story:
“I was diagnosed with stage four endometriosis through a laparoscopy and excision surgery in 2017. Sadly, my first surgeon didn’t refer me to pelvic floor PT until six months post-op, but I ended up seeing a handful of pelvic floor therapists over the next one and a half years. Unfortunately, I had to take more than a two year break from pelvic floor PT after being diagnosed with bilateral hip dysplasia and undergoing two reconstructive hip surgeries.
During my recovery from hip surgeries, I started seeing a new endometriosis specialist (Dr. Lum at Stanford) and a GI who works with the Pelvic Health Center at Stanford. The tests that my GI ordered showed that some of my digestion and bowel issues were due to pelvic floor dysfunction and suggested that I would benefit from pelvic floor PT again. Thankfully, I found PHRC and began seeing Jennifer, who set up a treatment plan based on my complicated medical history. She also referred me to Jandra, her colleague specializing in nutrition and endometriosis, who has been so helpful in finding targeted treatments instead of just recommending elimination diets. My GI and bowel symptoms started improving after a few months of manual treatment in-clinic, at-home exercises, as well as supplements and dietary changes.
In the middle of our initial treatment plan, an MRI showed that my uterus and bowels were potentially tethered together and I decided with the help of Dr. Lum and Jennifer to move forward with a second laparoscopy given that my first surgeon wasn’t able to remove all of the endometriosis and I’d tried many other non-surgical interventions.
I had a successful laparoscopy in late January 2022 and feel much more confident about recovery this time thanks to Dr. Lum and my amazing PHRC care team, Jennifer and Jandra, who have given me invaluable knowledge and tools to treat my GI and endometriosis symptoms moving forward.”
I (Jennifer) first saw Tracy when she was referred by her GI doctor for symptoms of constipation, frequent but small bowel movements throughout the day, as well as some occasional emptying issues. She also shared that she has a history of hip pain and had a B PAO (Bilateral Periacetabular Osteotomy procedure) due to suspected congenital hip dysplasia. She was diagnosed with endo and received excision surgery in 2017 and reports pain in her R abdomen as well as in her perineum currently.The pelvic pain and bowel symptoms started around 2016, though she has experienced painful periods since she was much younger. She got PFPT in the past for her endo, but paused due to her hip surgeries. It was helpful for her endo pain; however, her bowel symptoms remained.
She has tried a low fodmap diet, cutting out dairy and sugar, neither of which alleviated her symptoms. She was also placed on a progestin only pill continuously to stop her period altogether.
Her current complaints at the time of her evaluation were the following:
- Frequent small bowel movements throughout the day
- Occasional emptying issues, some straining/pushing although this is less
- Anorectal manometry on 8/31/2021 revealed dyssynergic defecation and abnormal balloon expulsion test (showing that her pelvic floor was not responding as it should while emptying her bowels)
- Dyspareunia (painful sex); both initial penetration and deep penetration which she describes as a burning pain
- Decreased desire
- Dilators – somewhat helpful
- Position changes during sex – somewhat helpful but limited by hip dysfunction
- Using pads vs tampons when she was getting her period – helpful
- Magnesium at night for constipation – helpful
- Squatty potty – helpful for improving bowel movements
- Birth control
- Tried ones in the past, currently on Aygestin
- Stopped due to migraines
- Was placed during surgery but had spotting for four months so they removed it
- Appendectomy (2013)
- Laparoscopy for endometriosis w/ excision (2017)
- Lipoma removal (2018)
- RPAO (2019)
- LPAO + hardware removal (2020)
- Hardware removal from left hip (2020)
- Shoulder labrum repair and debridement (2021)
Current objective findings:
- Bristol Stool Scale – Typically she is between a type four to six (normal to loose/diarrhea), especially variable when she was menstruating
- Frequency of bowel movements – four times per day on average
- External Exam:
- Moderate connective tissue dysfunction at her abdomen, inner thighs, suprapubic region, and bony pelvis, with patient reports of discomfort on the R.
- Myofascial trigger points along the rectus abdominis, iliopsoas
- Decreased abdominal deep core (Transverse Abdomnius muscle) which was likely contributing to non-optimal bowel movement biomechanics
- Internal Exam:
- Mild hypertonicity (tightness) throughout the urogenital diaphragm (bulbospongiosus, ischiocavernosus, and transverse perineal muscles) and moderate hypertonicity in the obturator internus 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: My assessment was that Tracy was experiencing bowel dysfunction secondary to her pelvic floor hypertonicity as well as poor muscle-length tension relationship and decreased neuromotor control of the pelvic floor muscles. When muscles are tight in their resting state, this decreases the ability for the muscle to respond as the available length of the muscle has changed. Additionally, increased tightness in the pelvic floor can affect the rectum and vagina both. Imagine moving an object through a smaller cylinder- whether it is allowing stool to move out or to accept penetrative intercourse in, the decreased space will make it more challenging. These findings are often commonly seen in individuals with a history of endometriosis and bowel dysfunction.
Plan: My plan for Tracy’s treatment sessions included connective tissue manipulation, myofascial release, and myofascial trigger point release to address the dysfunction in her muscles and fascia. Her plan also included neuromuscular reeducation, therapeutic exercise and activity, and home exercise program prescription and management to improve her ability to voluntarily lengthen the pelvic floor muscles, and to improve her deep core strength as these muscles get engaged during bowel movements.
Goals: Tracy reports that her goal is: “to improve bowel symptoms and other pelvic pain issues that are related to either endo or hip dysplasia/surgeries; improve pain with sex”
Progress and next steps:
Tracy started to make great progress with her pelvic floor. By visit six, she was able to relax her pelvic floor muscles voluntarily 90% of the time. Her core muscle strength improved, and she was able to demonstrate improvements to her bowel mechanics. However, she continued to have “ups and downs” with her bowel movements, and the abdominal pain was still present. Earlier in the month, Dr. Lum, an endometriosis specialist at Stanford, performed a pelvic MRI which revealed the bowel seemed tethered to the ovaries and uterus, which could be a sign of endometriosis or adhesions from previous surgery. At this point, we discussed referral to Jandra Mueller to further discuss her digestive system symptoms.
Nutritional Evaluation with Tracy
When Jennifer discussed Tracy’s situation, one aspect that had not been addressed was the function of her GI system. Functional digestive issues are very common in those with endometriosis. Functional disorders simply mean that there is nothing “wrong” with your bowels – no structural issues, no evidence of inflammatory bowel disease, no polyps, nothing that can be “seen” with imaging or other testing. That being said, there may be nothing “wrong” or “serious” going on, but your digestive system may not be adequately digesting and absorbing nutrients in the way that it should, and there can be changes in the microbiome that can further cause dysfunction. This is very common in endometriosis and it is becoming an area of focus in research in this population.
During the evaluation, we focused on her primary digestive symptoms which where the following: :
- Alternating constipation/loose stools – variable consistency
- Early satiety
- Incomplete emptying
Previous interventions she had tried were different types of diets, low FODMAP, anti-inflammatory and elimination diets all of which weren’t helpful. She also had been placed on proton pump inhibitors (PPIs) for some burning she experienced for a short time. She noted in her intake forms that she was sensitive to garlic, onions, and some dairy and she would experience heartburn, bloating, and diarrhea as a result. When we got more detailed during the initial evaluation, she provided more detail from doing a stool diary Jennifer had recommended. Some of the key factors she noticed are summarized below:
- Stools varied in consistency
- Constipation was worse with a change in routine and without magnesium citrate at night
- Stool color
- Almost all were lighter in color, occasional clay
- Noticed floating stools
- Bloating was frequent with both normal size meals as well as large meals
After going through her history, we reviewed her food intake and eating behaviors and I used her symptom questionnaire to give me better insight into various nutrients she may be missing, or how her overall system was working. Overall, she ate a balanced diet, ate adequate fruit and vegetables, protein, and starches, and slightly low in her fiber intake. Her fiber intake was an area she could optimize and I was interested in how that would change her bowel movements, or create any unwanted symptoms like bloating. Her symptom questionnaire identified several areas that could be optimized and that she may not , there were several areas that were marked that were consistent with the potential of inadequate stomach acid, reduced essential fatty acids, and possible histamine sensitivities. Because her diet was not void of any major nutrient, my hypothesis was that there were issues with how her digestive system was functioning and breaking down her nutrients.
- Food tracking for three to five days with a focus on how specific foods/nutrients are related to her symptoms
- Increasing fiber to 25g/day (gave suggestions)
- Mindful eating techniques to optimize digestive function, activating “rest and digest” to help with production of gastric secretions
- Vit D3 + K
- Multivitamin focused on mitochondrial health
- Digestive enzymes with meals
- Comprehensive stool test
Rationale for suggestions:
Her dietary intake did not reflect any obvious reasons for her symptoms and the appropriate dietary recommendations such as low FODMAP and elimination diets did not change her symptoms, so we decided to focus on very specific observations. For example, when she eats meals higher in protein, which was the case for her dinner choices, does she notice upper GI bloating shortly after meals, or does she find herself getting very full after eating smaller meals where the protein content is high. We also discussed foods that are high in histamine which she had not looked into previously.
Implementing mindful eating techniques such as eating slower, taking deep breaths and time to eat your meals, can help to increase your vagus nerve which helps to promote “rest and digest” by activating the parasympathetic nervous system and getting out of “flight, fight, freeze” thus helping your digestive symptom to produce the necessary secretions to aide in emptying, digesting, and absorbing nutrients.
Based on several findings, I recommended her to take a higher dose vitamin D supplement, a specific multivitamin mineral that has specific forms of a vitamin to help with any methylation issues as this is commonly seen in endometriosis, and a digestive enzyme with meals to help her with breaking down and absorbing nutrients.
We also decided to do a comprehensive stool test right away because other than a few areas, there wasn’t anything very obvious in her diet causing these issues. Additionally, in this population, more evidence is available discussing the role of dysbiosis (an imbalance in the gut bacteria) in this population and would give us more direct information about the function of her digestive system.
- Understand the function of the GI tract regarding digestion, absorption, dysbiosis status, metabolites, pathogens, etc. with using comprehensive stool test
- Understand how various foods/beverages relate to symptoms – histamine, GI, constipation, etc.
- Meet recommended fiber intake (25g/day) with food.
- Optimize dietary intake to include variety and blend of macronutrients without an increase in symptoms.
- Maintain improvements in gut health based on findings supported in the GI test.
- Able to self-assess and manage symptoms when/if triggered
- Complete BM emptying, avg type four stool, with normal coloring.
After a few weeks on the digestive enzyme, Tracy reported that her stools were more solid and darker in color and she did notice this would change with the addition of dairy or foods higher in fat. Her stool test confirmed many of my initial thoughts about her ability to digest and properly absorb nutrients and some other findings consistent with what is stated in the research regarding digestive health and endometriosis. The summary of findings with short explanations are below:
- Normal load of overall bacteria
- High proteobacteria – this is a group of bacteria that when out of balance, can produce lipopolysaccharides (LPS) which is an endotoxin and in theory, can be a driver for endometriosis progression due to its inflammatory effects
- Low pancreatic elastase – indicating a need for digestive enzymes
- Low short chain fatty acids – these are fuel sources for the gut cells, and when low, inhibit various cells and bacteria from being able to perform their job
- Additional bacteria was found including a bacteria called Klebsiella Oxytoca, which can contribute to diarrhea and systemic illness and has been found to be involved with urinary tract issues
Based on these findings, we were able to further tailor her dietary recommendations and supplement recommendations to address the above.
- Focus on limiting red meat and meat higher in fat and increase lean meats such as turkey, chicken, and fish
- Continue to introduce higher fiber foods, prebiotic rich foods and fermented foods as tolerated to help maintain microbiome balance
- Continue to practice mindful eating techniques (which she had started to do already)
- Added in additional enzyme more specific to bile and fats
- Antimicrobial herbs that would be used after her surgery to address the elevated bacteria and potential pathogen as these were likely contributing to her symptoms
- Use of elemental heal diet around surgery to minimize GI symptoms while recovering and still obtaining proper nutrition
Tracy had her surgery shortly after this, we had only met three times at this point. Her report post-surgery regarding her digestive system was that she was having loose stools again, she was forgetting her enzymes, and stool consistency was all over the place. I suggested she try to take psyllium husk which solved the problem of the loose stools. We continued focusing on foods that would optimize the findings of her test, mainly resistant starches, fiber, and fermented foods as she was eating more and feeling better. She had noticed that one of her incisions opened and suspected an infection, which was confirmed.
Tracy will be resuming both physical therapy and working on her digestive issues likely for the next few months; although, she was able to improve many of her symptoms in a relatively short time. With the removal of endometriosis lesions, we will continue to monitor how she is able to handle a variety of food. In theory, working on areas of inflammation as well as the nervous system, in addition to addressing the physical lesions themselves, hopefully reduces the need for future surgeries and a better quality of life.
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.
Melissa Patrick is a certified yoga instructor and meditation teacher and is also available virtually to help, for more information please visit our therapeutic yoga page.
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