Menopause is more than just hot flushes, night sweats and mood changes! Even though 50% of the population goes through menopause the majority of people and healthcare providers are under-informed about menopause and safe and effective treatments. Too many people are suffering unnecessarily. Perimenopause, the precursor to menopause begins in the 40’s for most people and most women will be in menopause by their early 50’s. Beyond the systemic symptoms of menopause people will start to experience more subtle genitourinary symptoms that will continue to worsen over time if untreated. Painful sex, urinary urgency, frequency, leaking and burning, recurrent vaginal and urinary tract infections and vaginal dryness are symptoms of the Genitourinary Syndrome of Menopause (GSM). The symptoms of GSM are also symptoms of pelvic floor dysfunction, which almost 50% of women suffer by the time they are in their 50s.
Systemic menopause symptoms are often treated with systemic hormonal therapy. This may not be sufficient for people developing GSM symptoms. The North American Menopause Society recommends vaginal estrogen for women in menopause to help counter GSM symptoms.
Menopause is more than just hot flushes, night sweats and mood changes! Even though 50% of the population goes through menopause the majority of people and healthcare providers are under-informed about menopause and safe and effective treatments. Too many people are suffering unnecessarily. Perimenopause, the precursor to menopause begins in the 40’s for most people and most women will be in menopause by their early 50’s. Beyond the systemic symptoms of menopause people will start to experience more subtle genitourinary symptoms that will continue to worsen over time if untreated. Painful sex, urinary urgency, frequency, leaking and burning, recurrent vaginal and urinary tract infections and vaginal dryness are symptoms of the Genitourinary Syndrome of Menopause (GSM). The symptoms of GSM are also symptoms of pelvic floor dysfunction, which almost 50% of women suffer by the time they are in their 50s.
Systemic menopause symptoms are often treated with systemic hormonal therapy. This may not be sufficient for people developing GSM symptoms. The North American Menopause Society recommends vaginal estrogen for women in menopause to help counter GSM symptoms.
Differential Diagnosis:
GSM or Pelvic Floor Dysfunction
Symptoms of pelvic floor dysfunction and GSM include:
- Urinary urgency, frequency, burning, nocturia
- Feelings of bladder or pelvic pressure
- Painful sex
- Diminished or absent orgasm
- Difficulty evacuating stool
- Vulvovaginal pain and burning
- Pain with sitting
An informed healthcare provider – whether a pelvic floor physical and occupational therapists or medical doctor – can do a vulvovaginal visual examination, a q-tip test to establish pain areas, and a digital manual examination to identify pelvic floor dysfunction, hormonal deficiencies, and pelvic organ prolapse. All women will experience GSM if enough time passes without appropriate medical management. The majority of people do not realize that menopausal women can benefit from a pelvic floor physical and occupational therapy examination to address the musculoskeletal factors that are also making them uncomfortable. The combination of pelvic floor physical and occupational therapy and medical management is key to help restore pleasurable sex and eliminate urinary and bowel concerns!
FACTS
From: https://www.letstalkmenopause.org/further-reading
- 6000 women enter menopause everyday
- 50 million women are currently menopausal in the US
- 84% of women struggle with genital, sexual and urinary discomfort that will not resolve on its own, and less than 25% seek help
- 80% of OBGYN residents admit to being ill-prepared to discuss menopause
- GSM is clinically detected in 90% of postmenopausal women, only ⅓ report symptoms when surveyed.
- Barriers to treatment: women often have to initiate the conversation, believe that the symptoms are just part of aging, women fail to link their symptoms with menopause.
- Only 13% of providers asked their patients about menopause symptoms.
- Even after diagnosis, the majority of women with GSM go untreated despite studies demonstrating a negative impact on quality of life. Hesitation to prescribe treatment by providers as well as patient-perceived concerns over safety profiles limit the use of topical vaginal therapies.
Hormone insufficiency can result in interlabial and vaginal itching. Other dermatologic issues such as Lichen Sclerosus and cutaneous yeast infections are just two of the many factors to also be considered.
Unfortunately people are vulnerable to recurrent vaginal and urinary tract infections in menopause due to:
- pH and tissue changes
- incomplete bladder emptying
- pelvic organ prolapse compromising urinary function
Recurrent infections are a leading cause of pelvic floor dysfunction! They must be stopped or the noxious visceral-somatic input can cause further pain and dysfunction after the infection is cleared. Furthermore, if the infections are left untreated without hormone therapy infections continue to occur and the consequences can be severe. Women can develop unprovoked pain, sex may be impossible, and undetected UTIs can lead to kidney problems and more sinister issues.
We encourage people to work with a menopause expert to monitor, prevent, and treat these issues as they are serious and treatable! We need to normalize the conversation about what happens during GSM, it is nothing to be embarrassed about and with the right care vulva owners can live their best lives! Pelvic floor physical and occupational therapy and medical management go hand in hand.
Treatment:
How We Can Help You
If you are having issues with your sexual function, it is in your best interest to get evaluated by a therapist for pelvic floor therapy, so they can establish what part, if any, of your pelvic floor may be contributing to the symptoms you are experiencing. During the course of the examination, the physical and occupational therapists will talk to you about your medical history and symptoms, including what you have been previously diagnosed with, the treatments or therapies you have had, and how effective or ineffective these therapies have been for you. It is significant to mention that we fully comprehend what you’ve been dealing with and that the majority of individuals are angry by the time they make it to see us. The physical and occupational therapists will conduct an evaluation of the patient’s nerves, muscles, joints, tissues, and movement patterns while doing the physical examination. After the examination is finished, your therapist will go over the results of the assessment with you. The physical and occupational therapists will conduct an evaluation to determine the cause of your symptoms and will establish both short-term and long-term therapy goals based on the results of the evaluation. Physical therapy treatments are typically administered between once and twice each week for a period of around 12 weeks. Your physical and occupational therapists will assist you in coordinating your recovery with all the other experts on your treatment team. They will provide you with an exercise regimen to complete at home and the sessions you attend in person. We are here to assist you in getting better and living the best life possible.
For more information about IC/PBS please check out our IC/PBS Resource List.
Treatment:
How We Can Help You
If you are having issues with your sexual function, it is in your best interest to get evaluated by a therapist for pelvic floor therapy, so they can establish what part, if any, of your pelvic floor may be contributing to the symptoms you are experiencing. During the course of the examination, the physical and occupational therapists will talk to you about your medical history and symptoms, including what you have been previously diagnosed with, the treatments or therapies you have had, and how effective or ineffective these therapies have been for you. It is significant to mention that we fully comprehend what you’ve been dealing with and that the majority of individuals are angry by the time they make it to see us. The physical and occupational therapists will conduct an evaluation of the patient’s nerves, muscles, joints, tissues, and movement patterns while doing the physical examination. After the examination is finished, your therapist will go over the results of the assessment with you. The physical and occupational therapists will conduct an evaluation to determine the cause of your symptoms and will establish both short-term and long-term therapy goals based on the results of the evaluation. Physical therapy treatments are typically administered between once and twice each week for a period of around 12 weeks. Your physical and occupational therapists will assist you in coordinating your recovery with all the other experts on your treatment team. They will provide you with an exercise regimen to complete at home and the sessions you attend in person. We are here to assist you in getting better and living the best life possible.
For more information about IC/PBS please check out our IC/PBS Resource List.
Hemorrhoids. About 75% of us will have one at some point in our lives,1 and half of us will have had one before the age of 50.2 Surprised? It’s not the kind of thing we like to discuss with our friends – until you actually have one, that is. Then you find out your buddy has had one too. Americans spend over $250 million annually on over-the-counter products, and 5 million Americans seek medical treatment yearly for their hemorrhoids.3 That’s a whole lot of Preparation H! At PHRC we see patients with hemorrhoids all the time. Fortunately, most of the time they don’t linger, and there are steps you can take to avoid them coming back.
So what exactly is a hemorrhoid? Here’s what the National Institute of Diabetes and Digestive and Kidney Diseases has to say:
“Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. The rectum is the last part of the large intestine leading to the anus. The anus is the opening at the end of the digestive tract where bowel contents leave the body. External hemorrhoids are located under the skin around the anus. Internal hemorrhoids develop in the lower rectum.”
So, hemorrhoids are basically varicose veins in the anus.
Internal hemorrhoids may protrude, or prolapse, through the anus. Most prolapsed hemorrhoids shrink back inside the rectum on their own, but severely prolapsed hemorrhoids may protrude permanently and require treatment. Hemorrhoids look a bit like little balls, and are sometimes known as “piles” after a Latin word for ball. You might have noticed them when wiping.
Those of you sitting uncomfortably through this anatomy lesson are probably itching to hear about the treatment of hemorrhoids. Good news! There are a number of treatments. Starting with the things you can do at home, avoid constipation by keeping your stool soft and easy to pass. (Check out Put Your Constipation Woes Behind You) You can do this by eating a diet high in fiber, such as leafy greens and vegetables, drinking six to eight 8-ounce glasses of water per a day, and exercising 30 minutes per a day. Another thing you can do at home to treat hemorrhoids is use over-the-counter creams, ointments, and suppositories to help with the pain, itching, and swelling. A Sitz bath, or sitting in warm water for 10 minutes, will also help ease the discomfort and itching. An ice pack can help with any swelling.
If they don’t clear up on their own, you’ll want to consult with your doctor. Medical treatment options include rubber band ligation (also know as “banding”), sclerotherapy, stapling, and a hemorrhoidectomy, which is a medical word for surgically removing the hemorrhoid. Please see informedhealth.org for more information on what these treatments are.
For those of you who continue to have anal pain after the hemorrhoid has resolved, pelvic floor physical and occupational therapy can help. The continued pain may be due to muscle spasms in the pelvic floor musculature, and/or scar tissue hypersensitivity from where the hemorrhoid was. Please check out our blog on What Is A “Good” Pelvic Pain PT Session Like?
So, what causes hemorrhoids? How can we avoid them? There is no single cause, however, there are many factors. Straining with bowel movements is a common one. Sitting on the toilet seat for greater than 10 minutes can also cause them, because when we sit on the toilet and relax the anus, the veins pool with blood and this puts more pressure the veins themselves. Fellas (and ladies, too), I recommend keeping the smartphone and magazines out of the bathroom. Also, you might like to check out Shayna’s blog on What’s The Right Way To Poop. Other factors that can cause hemorrhoids are frequent constipation and/or diarrhea, obesity, frequent heavy lifting, poor diet, lack of exercise, and pregnancy.
The occurrence of hemorrhoids during pregnancy is quite common. The body circulates more blood as the uterus grows. This puts pressure on the veins, especially in the last trimester when the uterus is largest. The veins in the rectum become dilated and the increased blood and pressure can lead to hemorrhoids. Hormones, specifically progesterone, can also contribute. Progesterone increases during pregnancy and relaxes the smooth muscles in the body; including the walls of the veins allowing them to swell. Progesterone can also slow down the intestinal tract causing constipation. As we know from earlier, constipation and straining are one of the main contributors towards hemorrhoids. Straining and prolonged pushing during labor can also cause them. The good news is, hemorrhoids tend to disappear after the baby is born.
Hemorrhoids. They can happen to anyone, and often do. They’re a pain in the butt, but they’re easily treated, and with a few small changes in your daily routine, you can prevent them from coming back.
Warmly,
Malinda Wright, PT, MPT
References:
- National Institute of Diabetes and Digestive and Kidney Diseases https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/hemorrhoids/Pages/facts.aspx
- Health Line: Hemorrhoids
http://www.healthline.com/health/hemorrhoids#Overview1 - Hemorrhoid Information Center: Digestive Health http://www.hemorrhoidinformationcenter.com/category/hemorrhoids/
- Hemorrhoid Information Center: Hemorrhoids During Pregnancy http://www.hemorrhoidinformationcenter.com/pregnancy-and-hemorrhoids/
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 and occupational therapy?
Pelvic floor physical and occupational therapy is a specialized area of physical and occupational therapy. Currently, physical and occupational therapistss 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 and occupational therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical and occupational therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical and occupational therapists will take a detailed history. Following the history the physical and occupational therapists will leave the room to allow the patient to change and drape themselves. The physical and occupational therapists 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 and occupational therapists 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 and occupational therapists 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 and occupational therapists 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 and occupational therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical and occupational therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical and occupational 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 and occupational therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical and occupational 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 and occupational therapistss who work at PHRC have undergone more training than the majority of pelvic floor physical and occupational therapistss 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 and occupational therapistss 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 and occupational 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.
We live in a different time. I remember when chat rooms and meeting people from the internet was the plot line for a Lifetime movie. Now, we get in cars driven by strangers and fall in love via sophisticated algorithms and profile pictures. What a time to be alive! It is pretty apparent that technology plays a huge role in our lives. Since I live in the tech mecca of San Francisco, I am surrounded by techies and have connected with several start-ups that specialize in a field that I hold very near and dear to my heart: sex! At first, I thought that I had discovered a small niche in the tech community; now I know that technology and sexual health have quite the relationship, one that is more extensive than you might guess.
These days, the role of technology in sex is so much more than online pornography, although that market is still booming (or so I’ve heard). First, there is a whole wide world of alluring apps. There are apps, such as Kindu and Undercovers, that allow you and your partner to find new sexy things to try together. Think R-rated truth or dare, but sans slumber party with the added bonus of being able to potentially play on your commute! There are apps that give you ideas for new sex positions to try or even places to try them in. Finally, there are the obvious hook-up dating apps, including some that help you find a third (or fourth) should you be in the mood for some late night company.
Then there are some apps with not-so-carnal intentions, such as Tabú, a start-up that I have recently become involved with as a “sexpert.” And yes, my parents are “so proud.” Tabú helps promote sexual education via an app that allows its users to post questions and receive answers from their peers, as well as “sexperts,” who have been approved by Tabú as being knowledgeable in the field of sexual health. Tabú also has a college ambassador program to allow college students to provide quality sex education via campus workshops . Per Mia Davis, the founder of Tabú, “the goal of Tabú is to empower ‘millennials’ to take control of their sexual health. We understand that misinformation is rife in sexuality, and to truly break down the myths and taboos, we need to provide young people with answers. We believe that to open up a dialogue, we need to approach young people where they are – their phones, social media, and for college students, on their campuses.” With more and more people using smartphones and apps to interact, having resources to provide solid education to people is crucial. And education can be as simple as knowing about your own body. As you know, I am a big advocate for getting to know yourself, which I discussed at length in this post. Luckily, there are many apps that allow people to learn all about their sexual health and health in general. Certain apps, such as Clue and Glow, allow people to track their menstrual cycle, ovulation and other details relating to fertility. Some, such as Pelvic Track, even allow individuals to track symptoms related to pelvic floor dysfunction, such as pain and incontinence.
Some apps even connect with other devices to help improve pelvic floor motor control ( like a fitbit for your vagina). Here is one example. Another company, Lioness, has developed a “smart” vibrator that helps users to better understand how they experience sexual pleasure. The vibrator pairs with an app that provides biometric data about how quickly the user becomes aroused and how long it takes to orgasm. The app allows the users to share this information with their partner. Some other vibrators on the market even allow your partner to control the device from afar via their cell phone! This can be useful for long distance relationships or for patients with pelvic pain who cannot tolerate penetration but still want sexual intimacy with their partner.
Intimacy is a key word. Smartphones and laptops have almost become a silent partner for most of us. It brings us information from other people that makes us feel like we are in constant contact without having any real contact at all. This brings me to one of the downsides of the internet and technology in general: everyone has access to it and can therefore contribute content. I frequently see patients who — terrified after reading about someone who was bed bound with pelvic pain for five years — ask, “Will that happen to me?” The thing I remind my patients is that it is impossible to know who your new internet “friend” really is. The person writing could be a thirteen year old teen who thinks it is hilarious to post in forums for people with chronic pain. Why? We may never know. Just like Pokemon-Go’s popularity, some things may never make sense. Just like the person who posted that he cured himself with some wonder-herb and is living the pain-free dream. Maybe he did, and that is great, but that doesn’t mean he has a medical background or any knowledge about your unique history and symptoms. In other words, Basically why should internet user #10065 be trusted to give you advice? The internet is not the end-all, be-all of information. I mean, Dr. Google didn’t even go to medical school! However, you can find a lot of well researched information online. Please refer to Liz’s post on determining what articles are legitimate. Yes, the internet can create great communities as a way to form support groups of people who share similar experiences, but remember to, always take information with a grain of salt.
Now, if you think the present world of sex and tech is amazing, wait till you hear what the future holds. Love and sex with robots may be here sooner than we think. I wonder, will the legalization of robot marriage be a future debate topic? Will 3-D printed robot babies be the new norm? The ethical and philosophical questions that go along with a robotic romance are endless, and if I am brave enough, I may explore it in a later post (or while watching Westworld). Sex-bots may still be in the future, but this sweet virtual reality sex jumpsuit is currently available in — surprise — Japan! While these developments make me question what this means for the future of intimacy and relationships, virtual reality and robots may have a positive impact on controlling STD/STIs and unplanned pregnancies. Furthermore, this type of technology may let you discover your own wants and needs without the pressure of a (human) partner being present.
As a provider, I find the potential future impact of technology on sexual health both fascinating and at times frightening. Someday, will I be treating patients who can’t have sex with their robot husbands? Or will I be treating robots which have such advanced Artificial Intelligence that they have chronic pelvic pain and are unable to function as “human beings?” But what scares me is this: what if I already am?
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 and occupational therapy?
Pelvic floor physical and occupational therapy is a specialized area of physical and occupational therapy. Currently, physical and occupational therapistss 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 and occupational therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical and occupational therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical and occupational therapists will take a detailed history. Following the history the physical and occupational therapists will leave the room to allow the patient to change and drape themselves. The physical and occupational therapists 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 and occupational therapists 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 and occupational therapists 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 and occupational therapists 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 and occupational therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical and occupational therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical and occupational 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 and occupational therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical and occupational 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 and occupational therapistss who work at PHRC have undergone more training than the majority of pelvic floor physical and occupational therapistss 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 and occupational therapistss 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 and occupational 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.
By Admin
During pregnancy and the postpartum period, many women suffer from both functional and cosmetic issues caused from the widening of the abdominal wall from stretch and pressure generated from the growing uterus. This stretching can result in a separation of the rectus abdominis muscle, known as a diastasis recti (DR). Diastasis recti occur in approximately 66% of women in their third trimester of pregnancy 1, many of which continue to suffer even 1-year postpartum, despite physical and occupational therapy or exercise programs designed to close this gap. In addition to the pregnant/postpartum population, others can suffer from this as well, including athletes, babies, and even patients who have undergone laparoscopic surgery such as hysterectomy, endometriosis, and prostatectomy.
Malinda wrote a great blog all about DR that you can read here that discusses functional limitations a DR could impose, how to check for it, and some basics on how to close it. This blog will focus on the ongoing debate of what researchers and clinicians believe is the best way to rehabilitate diastasis recti.
Is it really important that there is a wider gap than before pregnancy or surgery? Should we focus on crunches, abdominal bracing, or surgery? What should be done when exercise is not enough? And ultimately, how does one know when someone may require surgical intervention?
Anatomy of diastasis recti
The rectus abdominis is what we commonly think of as our six-pack muscle that connects from our sternum all the way to our pubic bone. We have two of them, one on the right and one on the left, that are separated by a dense band of connective tissue known as the linea alba. The linea alba is made from a continuation of our internal obliques, external obliques, and the transverse abdominal muscles.
What is the function of our abdominal muscles?
The function of the abdominal musculature is to resist changes in intra-abdominal pressure (IAP), and transfer forces between our right and left sides during movement such as lifting our legs, twisting, etc. When there is a widening of these muscles and the linea alba becomes lax, we lose this ability, and it is possible that we may experience low back pain, weakness, pelvic girdle pain, urinary incontinence, and in time, even pelvic organ prolapse may occur.
What is normal?
In general, there is debate about how wide the inter-rectus distance (IRD) can be, and researchers have performed imaging in cadavers, as well as in women who have not had children (nulliparous), to determine what is “normal.” How wide and at which points to measure vary in the literature, and currently there is no international consensus in the best way to measure. Most recently, there was a study performed on nulliparous women that suggested a normal linea alba should be less than 15mm at the xiphoid level, 33mm at 3 cm above the umbilicus and 16mm at 2 cm below the umbilicus.3
The Debate
Most physical and occupational therapistss, trainers, and exercise programs that currently exist tend to focus on closing the gap between the rectus abdominis muscle bellies. At PHRC and many other clinics, we teach patients to pull the bellybutton to the spine (a draw-in maneuver that activates our transverse abdominis muscle also called a TrA contraction) and then with a towel wrapped around the widest part of the gap, do a mini abdominal crunch which activates the rectus abdominis muscle bellies and pulls them closer together. It has generally been thought that the TrA contraction will draw the muscle bellies of the rectus abdominis together and improve stability of the core, while abdominal crunches alone have been considered a risk for the development of DR. 4
The Research
There was a recent journal article released from the Journal of Orthopedic and Sport Physical and Occupational Therapy (JOSPT) that actually looked at the effect of a drawing-in maneuver (or TrA contraction) and the abdominal crunch in its ability to decrease the IRD. Surprisingly, it showed that doing a draw-in maneuver caused a slight widening of the IRD, while the abdominal crunch in both the gestational period (during pregnancy) and postpartum periods showed a narrowing of the IRD 2 – which has been the focus of rehab!
This was interesting because like I said before, abdominal crunches tend to not be the exercise of choice and have been thought to be a risk factor for DR. This also led to the question – does closing the gap really matter as much as we previously thought?
Technically, we do not just have patients do a draw-in maneuver, nor do we have them just do crunches or sit ups to correct the DR, we actually teach them a very specific way to do this correction exercise, and it involves a combination of the two exercises. In a very recent study by Diane Lee and Paul Hodges, they did look at what happens at the IRD with an abdominal crunch alone, and an abdominal crunch with pre-activation of the transverse abdominis muscle or a “draw-in” maneuver. What they found was that doing a draw-in maneuver with a crunch decreased the narrowing of the IRD compared to what would occur with an abdominal crunch alone. This still technically does not close the DR as well as we’d like, but it does increase the tension on the linea alba, which they propose is necessary to support the abdominal contents and to transfer force between the two sides of the abdominal wall.5
Currently, the goal of rehabilitating a DR is to reduce the IRD. This is based on the assumption that closing the gap will restore the function of the core and improve cosmetic appearance. Lee and Hodges showed the opposite in their study, and demonstrated that while we are closing the gap, we are creating more laxity or distortion on the linea alba, which makes us less likely to restore the function of our abdominal wall; this will lead to potentially poorer cosmesis of the abdominal wall.
What to do now?
It seems that closing the gap may not matter as much as we previously thought, and instead of focusing on the width of the gap, we should be focusing on optimizing the functional ability of our abdominal wall to generate enough tension to stabilize us in order to perform the activities we do on a regular basis and this will vary individually.
If you suffer from a DR and have not been assessed by a physical and occupational therapists, start there! During their evaluation, the physical and occupational therapists will be able to identify functional and structural impairments that may be contributing to ongoing symptoms, and can either help you to continue to improve your function, or have the resources to refer you to a surgeon if conservative approaches have been exhausted.
Below is a list of criteria that would identify a good surgical candidate, your physical and occupational therapists can help determine if you would benefit from a surgical consult. To find out more about pregnancy and postpartum physical and occupational therapy, visit our website or our Pinterest page.
Who actually needs surgical intervention?
According to Dianne Lee, the criteria for referral to a surgeon are summarized below:
- The woman should be at least 1 year postpartum and has failed appropriate therapeutic approaches to restore function, resolve lumbopelvic pain and/or urinary incontinence.
- The inter-recti distance is greater than mean values, and the abdominal contents are easily palpated through the midline fascia.
- Multiple vertical loading tasks reveal failed load transfer through the lumbopelvis.
- The active straight leg raise test is positive, and the effort to lift the leg improves with both approximation of the pelvis anteriorly, as well as approximation of the lateral fascial edges of rectus abdominis.
- The articular system tests for passive integrity of the joint of the low back and/or pelvis (mobility and stability) are normal.
References:
- Diastasis Rectus Abdominis & Postpartum Health Consideration for Exercise training: http://dianelee.ca/article-diastasis-rectus-abdominis.php
- Mota P, Pascoal AG, Carita AI, Bo K. The immediate effects on inter-rectus difference of abdominal crunch and drawing-in exercises and during pregnancy and the postpartum period. J Orthop Sport PhysTher. 2015; 45(10):781-788.
- Beer GM, Schuster A, Seifert B, Manestar M, Mihic-Probst D, Weber SA. The normal width of the linea alba in nulliparous women. Clin Anat. 2009;22:706-711. http://dx.doi.org/10.1002/ ca.20836
- Blanchard PD. Diastasis recti abdominis in HIV-infected men with lipodystrophy. HIV Med. 2005;6:54-56. http://dx.doi. org/10.1111/j.1468-1293.2005.00264.x
- Lee D, Hodges PW. Behavior of the linea alba during a curl-up task in diastasis rectus abdominis: an observational study. J Orthop Sports Phys Ther. 2016;46(7):580-589.
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 and occupational therapy?
Pelvic floor physical and occupational therapy is a specialized area of physical and occupational therapy. Currently, physical and occupational therapistss 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 and occupational therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical and occupational therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical and occupational therapists will take a detailed history. Following the history the physical and occupational therapists will leave the room to allow the patient to change and drape themselves. The physical and occupational therapists 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 and occupational therapists 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 and occupational therapists 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 and occupational therapists 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 and occupational therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical and occupational therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical and occupational 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 and occupational therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical and occupational 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 and occupational therapistss who work at PHRC have undergone more training than the majority of pelvic floor physical and occupational therapistss 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 and occupational therapistss 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 and occupational 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.