By Elizabeth Akincilar-Rummer
I am happy to say that in March we celebrated our one year anniversary in our Boston area office!! It has been a crazy year, but I’ve truly enjoyed getting to know new colleagues and being another resource for the many people suffering from pelvic pain in New England.  

During the past year there has been one glaring difference between my practice in San Francisco and here in the Boston area. Men! I have a larger percentage of male patients in this office than I ever had in San Francisco. So, I thought it would only be fitting to share a recent success story about one of my male patients, Steve (his name has been changed for anonymity). His journey with pelvic pain is unfortunately not an uncommon one, but fortunately has a happy ending!

 
“I suffered with great pain and restricted activities for more than five years, and no doctor ever mentioned the possibility of physical and occupational therapy. I found out about it online. What the doctors and specialists said was incurable was entirely curable! Before consenting to surgeries (I had two) and all sorts of pills, you really owe it to yourself check out physical and occupational therapy.”    Steve, age 40

Steve is a 40 year old man that drove 1 ½ hours in desperation of finding some help for his 6 year history of pelvic pain. Here’s his story: In 2007 he noticed blood when he ejaculated. He was prescribed antibiotics and his symptoms resolved. In 2009 the same thing happened, noticeable blood when he ejaculated, but in addition, this time he also experienced pelvic pain. Again, he was prescribed antibiotics and the blood in his ejaculate resolved, but the the pain did not. Since 2009, his pain has been consistently sharp pain in his right lower abdomen, and radiating pain to the right side of his penis and perineum. He noted that any friction to the right side of his lower abdomen (i.e. when wearing a belt) would increase his pain. He reported that his pain was the most severe after ejaculating, lasting up to 36 hours. He had basically given up on even trying to ejaculate because the resulting pain was so intense and debilitating. He also noted that he was unable to walk fast because the friction caused by swinging his arms would flare up his pain.
During these 6 years he attempted several treatment interventions. He saw several urologists and pain management specialists. At no point did any medical provider recommend physical and occupational therapy.  In 2012 he was diagnosed with a right inguinal hernia which was surgically corrected. He reported one month of relief and then the pain returned as before. In 2013 he underwent a partial orchiectomy during which his right spermatic cord and right testicle were surgically removed. Again, he reported one month of relief only. Later in 2013 he had a series of 3 right ilioinguinal nerve blocks. He reported the first nerve block gave him approximately 20% pain relief, but the latter two had no effect. Virtually coming to the conclusion that this was just something he was going to have to live with, he found PHRC during extensive online research.

When I evaluated him in early 2015 he reported the same pain symptoms: sharp right lower abdominal pain and hypersensitivity, radiating sharp pain to his perineum and right side of his penis, inability to ejaculate without 1-2 days of severe pain, and an inability to walk fast without causing an increase in pain. He reported urinary frequency only if his pain was very severe and denied any bowel dysfunction. He was currently taking 3600 mg/day of gabapentin (neurontin) which he thought was helpful. He was able to work from home as a musician and composer.

During his initial evaluation I noted the following:

• • moderate connective tissue dysfunction in his abdomen, lower abdomen and along his bony pelvis on the right side
  • Hypertonus (tightness) in his right psoas, adductors, and abdominal musculature
  • inguinal hernia scar restriction
  • right bulbospongiosus, ischiocavernosus, and transverse perineum hypertonus

 

My assessment was that the infection in 2009 caused changes in the surrounding somatic tissues via the visceral-somatic reflex. In other words, the infection initiated dysfunction in the muscles, nerves and connective tissue in the pelvis.  The initial infection in 2007 likely caused some of these same changes, but at that time the changes in the muscles, tissue, and nerves weren’t significant enough to cause pain. When the second infection occurred, the dysfunctional changes were then enough to cause symptoms of pain. Another possible factor was that the inguinal hernia that was later diagnosed was also contributing by irritating the ilioinguinal nerve, which would be consistent with his symptoms of lower abdominal and penile pain. The partial relief of pain with the ilioinguinal nerve block also supports this theory.  

 

Steve’s goals were the following:

1. No pain during or after sexual activity
2. Able to walk at desired speed
3. Stop taking gabapentin

I recommended treatment 1x/week for 8 visits. My treatment plan included scar mobilization, connective tissue manipulation, myofascial release, myofascial trigger point release, pain physiology education, and home exercise program development. During his initial evaluation, we began discussing pain physiology and the impact chronic pain can have on one’s nervous system. I gave him the book, Explain Pain, to read prior to his next appointment.

At his first follow-up visit he reported that he thought many of the concepts in Explain Pain applied to him and his history of chronic pelvic pain. We continued our discussion about these concepts and how he could apply them in his life. I continued the manual therapy on the myofascial impairments, including the inguinal scar, the abdominal and adductor trigger points, connective tissue restrictions and the pelvic floor hypertonus.

At his second visit, he reported that clothes were now less irritating and he had less pain with walking. He was now able to walk slightly faster and swing his arms more without aggravating his pain. At this point he also started to decrease his gabapentin. Upon exam, I noted that the scar mobility was improved, he had less skin hypersensitivity, and the connective tissue mobility was improved. He continued to have urogenital diaphragm hypertonus.

 

At his third visit, he reported that he was now able to wear a belt without pain. During the last week he ejaculated one time and had minimal discomfort, but then tried to ejaculate a second time that week and had significant pain afterward. He also decreased his gabapentin again. I noted the connective tissue restrictions continued to decrease and the urogenital diaphragm muscles had less hypertonus. I taught him self myofascial release techniques to utilize after ejaculation.
At his fourth visit, he reported that he was able to walk even faster without pain and was able to ejaculate without any pain or limitations in activity the following day. I noted minimal connective tissue restrictions and minimal scar restrictions. The primary remaining impairments were hypertonus in his right ischiocavernosus, bulbospongiosus, proximal adductors, and right lower abdominal muscles.

By his sixth visit, he reported he had no limitations in walking and was able to have sex in the evening multiple times during the week without pain or any limitations the following day. He had also completely stopped taking gabapentin by this point. I noted minimal hypertonus in his ischiocavernosus, bulbospongiosus, and lower abdominals. I decreased the frequency of treatments to 1x/2 weeks.

 

By his eighth visit, he reported that he felt 90% better. I noted minimal myofascial impairments. At this point I recommended we decrease the frequency of treatment to 1x/month.

 

After 2 additional visits, once per month, he reported no restrictions or pain with exercise/walking or sexual activity. After a total of 11 visits over 5 months, I discharged him with his home exercise program of self myofascial release as needed.   

As you can see, with the correct treatment interventions, Steve’s symptoms resolved relatively quickly given the amount of time he had been suffering. He underwent at least one major surgical procedure that was completely unnecessary and possibly two. This is an excellent example of the importance to educate the medical community about pelvic pain and the role physical and occupational therapy can play in recovery. Had his medical providers been better educated about treatment options for pelvic pain, Steve’s pain could have been resolved years earlier. Those of us who treat pelvic pain need to take on the challenge of educating our colleagues to prevent situations like Steve’s from happening.

 

All my best,

Elizabeth Akincilar-Rummer, MSPT

 

 

 

 

Sitting on the toilet!! Actually sitting, skin to porcelain. No more hovering! Even in public restrooms. I know, it’s going to be a tough paradigm shift since this issue is ubiquitous; one study, done in the UK, surveyed 528 women at a gynecology clinic and found that 85% reported that they crouched over public toilets while urinating. 12% said that they used a paper toilet seat cover and 2% reported that they sat all the way down1. Only 2%! So, I decided to make a point to ask every woman that I’ve seen recently in my office what their preference is regarding toilet seats.The answer: overwhelmingly in favor of squatting over the pot (especially when in public).

This week, my goal is to try to dispel some of the myths about public toilet seats and try to convince you, the readers, that sitting on the toilet is more important to urinary/bowel function and health than the germs you might find hanging out on the john.

 

First, let me back up and explain how our urinary and bowel systems work from a musculoskeletal standpoint. A typical urinary system works like this: liquid waste (urine) that has already been filtered by the kidneys, empties into the bladder. As the bladder fills, it stretches to accommodate the extra volume. Once it starts getting somewhat close to full, (about 300 cc or about 1 ¼ cup) it sends a message to the brain, which then sends a message to the pelvic floor muscles to say “Hey, we need to pee, let’s get to an appropriate place (in this case we are going to call ‘that place’ the toilet).” We get to the toilet, we sit, our brain tells our pelvic floor muscles and the urinary sphincters to relax and we empty our bladder. In an adult with typical or “normal” urinary function, we expect close to full emptying of the urine in the bladder.

 

The bowel system works similarly: The colon fills with solid waste, it moves by peristalsis through the ascending, transverse, and descending colon. Once it arrives in the rectum, a signal is sent to the brain, that says it’s time to go. We get to a toilet, we sit, the sphincters relax, we empty. Voila.

 

Hovering over a toilet seat can become seriously problematic, especially if it is a habit that you have been practicing for many years. Even if all of the events leading up to voiding may be normal,when we hover, we are engaging so many muscle groups to support us in that position! Think about doing a squat and holding it for 45 seconds. Better yet-try it. If you do, you can feel the core engage, as well as the quadriceps, hamstrings, gluteals, and pelvic floor muscles. They are all on! So the mechanisms to empty the bladder/bowel engage, but the sphincters CANNOT fully relax here. It becomes an uphill battle.

 

The sphincters cannot fully relax, which means that the bladder and/or rectum could not fully empty, meaning that now we are getting a backup of residual waste left in the body. If this becomes a regular occurrence we can begin to see issues arise within the bowel/bladder systems. We can begin to see increased risk for bladder stones, infections, hesitancy, urgency and frequency, constipation, prolapse, and incontinence.  

 

In the same study that I mentioned above, the researchers found that there was a 21% decrease in average urine flow rate and a 149% increase in residual urine volume in women that voided in a crouching position. They went on to conclude that women found with any abnormal bladder voiding/retention symptoms may benefit from being encouraged to sit comfortably on the toilet whenever possible1.

 

Still not convinced? Ok let me try a different route. In 2014, an article came out in the journal of Applied and Environmental Microbiology. In this study researchers found that “while enteric bacteria would be dispersed rapidly due to toilet flushing, they would not survive long, as most are not good competitors in cold, dry, oxygen-rich environments.”2 In other words, although germs are present in and on all toilets, they don’t last long. In an interview for The Huffington Post, Dr. William Schaffner, a professor of preventive medicine at Vanderbilt University Medical Center commented, “toilet seats are not a vehicle for the transmission of any infectious agents — you won’t catch anything.”3

 

Intact skin is generally thought of as an effective germ barrier, and the skin of the buttocks and legs is relatively thick. If you have very thin or cracked skin on the buttock or thigh, or have any open wounds in that area consider wiping the seat down. The American Society for Microbiology (ASM) published a study which found that after a porcelain surface had been wiped one time with either water, liquid soap, or an antibacterial wipe,* the amount of germs was decreased 10,000 times. A second wipe further reduced any remaining germs 1,000 times.4

 

A study published by the Public Library of Science swabbed flushers, door latches, faucet handles, and towel dispensers and found they are as dirty as, or dirtier, than the toilet seats themselves.5 In fact, many other places far from toilets are colonized by microbes. The main culprits include kitchen sponges, playground equipment, gym mats, and computer keyboards.5 And don’t get me started on your cell phone; cell phones carry 10 times more bacteria than most toilet seats, according to Charles Gerba, a microbiologist at the University of Arizona.6

 

Have I totally freaked you out? Don’t worry! Germs ARE everywhere. But if your immune system is healthy, and if you adopt simple hygienic measures like hand washing, you should have no problem kicking those pathogens to the curb. So let’s do it! Let’s all just start wiping the toilet seat off with a preliminary toilet paper wipe and sit yourself right down. And enjoy the full pee/poop that comes to follow**. Get the word out-let’s make 2016 the year we start sitting down on those seats and put our “germ-phobia” to rest!

 

*Remember not to flush antiseptic wipes because they are detrimental to our oceans. Instead, throw them in the trash.

 

**That being said, we have found that it is also important to increase the hip flexion angle for best pee/poop success. See this blog for more info.

 

References:

 

1. Moore KH, Richmond DH, et al. Crouching over the toilet seat: prevalence among British gynaecological outpatients and its effect upon micturition. Br J Obstet Gynaecol. 1991 Jun;98(6):569-72.
2. Gibbons S. M., Schwartz T., et al. Ecological succession and viability of human-associated microbiota on restroom surfaces. Appl. Environ. Microbiol. Online. Ahead of print 14 November 2014; doi:10.1128/AEM.03117-14 .
3. “Why Using Toilet Seat Liners Is Basically Pointless.” Interview by Amanda L. Chan. Huffington Post 17 June 2014: n. pag. Web.
4. Tuladhar, E, Hazeleger, W, et al. Residual Viral and Bacterial Contamination of Surfaces after Cleaning and Disinfection. Appl. Environ. Microbiol. November 2012 vol. 78 no. 217769-7775.
5. Flores GE, Bates ST, Knights D, Lauber CL, Stombaugh J, Knight R, et al. (2011) Microbial Biogeography of Public Restroom Surfaces. PLoS ONE 6(11): e28132. doi:10.1371/journal.pone.0028132
6. Gerba, Charles. “Why Your Cellphone Has More Germs than a Toilet.” Interview. Https://cals.arizona.edu/spotlight/why-your-cellphone-has-more-germs-toilet. The University of Arizona, College of Agriculture and Life Sciences, 15 Sept. 2012. Web. 29 Mar. 2016.

By Admin

Disclaimer: I’m a PT and a Pilates instructor.  Often, patients ask if Pilates is the answer for their pelvic floor dysfunction.  You know that old saying, “Kegel-ing all day, keeps the urine at bay.”  Well, unfortunately, this is not always true.  At times Kegel-ing can make actually make your symptoms worse, be it urinary urgency, frequency, incontinence or pain!  Sometimes these type of symptoms are due to the pelvic floor muscles being too contracted.  Since a Kegel is a contraction of your pelvic floor muscles, you can see how contracting muscles that are already too contracted may exacerbate symptoms.  Take a look at Liz’s post to get a little more info. 

 

So, since that’s a bit more settled let’s get to the purpose of this post: Pilates exercises for the short/tight, or in other words, too contracted pelvic floor.  Pilates provides a breadth of repertoire that focuses primarily on contracting or “up-training” pelvic floor muscles along with the rest of the “core” to do certain movements.  However, even though all of pilates repertoire may not be appropriate for all people, there are some helpful themes and sequences that can be beneficial when performed safely and precisely.

 

Since most of pilates is uptraining, i.e. tightening your pelvic floor muscles, I’m going to first introduce some downtraining exercises, i.e. lengthening/relaxing your pelvic floor, as a baseline for movement.  I found in teaching that starting from this baseline actually improves students understanding of the pelvic floor and success in the practice.  Also, it challenges the assumption that most of us have loose/weak pelvic floors that we need to strengthen, when the actual problem is lack of awareness (*more on this later blogs).

 

Please note: Although these exercises are primarily directed towards those with tight or hypertonic pelvic floor musculature they can provide awareness training for any pelvic floor, big or small, tight or loose, weak or strong.

 

Disclaimer:  None of these exercises should increase pain or symptoms.  Feel free to limit the range of motion/movement to what is tolerable and outside of pain.  If you are unsure please seek advice from your physical and occupational therapists or a rehabilitation pilates professional who has experience with pelvic pain.

 

Since most of us don’t have pilates studio in our house I’ll be going through some exercises that can be done at home on a yoga mat and with small props as necessary.  Considering setting aside ~ 10 minutes to give yourself the time to focus and experience the exercises.

 

Breathing

Purpose: improve awareness of breath and mobility of the body when breathing

Start lying on your back with your knees bent feet flat on the floor with shoulders broad and palms turned up.

 

Feel the weight of your body on the floor and sense your breath moving in your body.  As you inhale feel the rise and as you exhale feel the fall.  Where does the breath go?  Just observe this for a few moments…for many people this movement happens at the collar bone and upper chest, for others it’s softly in the belly or sometimes even shared between both areas.  Now we are going to send the breath into other areas.

 

Do you know how big your lungs are?  Do you know they are not only in the front but in the back too?  They are actually longer on the sides and in the back then they are in the front.   

 

See if you can breathe wide, try putting your hands on the sides of your rib cage and feel the movement, wide and down into your fingers.  Try this for a bit…

 

 

Now see if you can breathe back, try putting your hands or a small folded towel behind your midback to feel the movement of your back ribcage.  Some imagery that can be helpful here: Imagine you are creating deep groves in the sand with the expansion of your rib cage and it washes away as you exhale…or the imagine your back ribs are like the wings of a lady bug that are lifting and lowering.

 

 

Get the idea, there is so much movement in the rib cage that we barely even use.

Now we are going to try some belly breathing.  Same start position.  But place your hands on belly.

 

Inhale wide and easy.  Just follow where the breath goes.  Which hand moves more?… See if you can allow the bottom hand to fill up a little more, like a big Buddah belly.  Try this for a couple breaths…as you feel like you can fill up your belly, can you send the breath a little lower, just down to your pubic bone.  Allow the breath to flow all the way down to your belly and pelvis then back up again.  Easy inhale, easy exhale.  Now you may feel some movement in your low pelvis.  With your inhale, feel an easy stretch of your pelvic bowl (i.e. your anus, or vagina or scrotal area), and with you exhale, feel an easy recession.  No problem if you don’t sense anything right away, just keep breathing.  If you do feel this easy stretch then see if you can start sending you breath down and wide towards your perineum between your sit bones.  You can try sending it more towards the front- vagina/ base of the penis, or towards the back- anus.  Just allow it to be easy.  Continue for 5 minutes or so.

 

Take a moment just to feel if the ease or tension has changed in your body and specifically in your hips and pelvic floor area.

 

Pelvic Clocks

Purpose- to improve awareness and mobility of the pelvis, hips, lower back and related muscles, i.e. pelvic floor muscles.

 

Pelvic clocks are used in many exercise regimens, whether you know it or not.  You can do this exercise on your back with your feet flat on the ground, broad shoulders, palms on your hips.

 

NEUTRAL

Essentially the idea is to move you pelvis in a full circle, or through all the numbers of the clock.  Let’s get started.  Feel your pelvis resting on the ground beneath you.  Feel the heaviness of the right back pelvis and the left back pelvis.  Feel where you pelvis starts to make contact at the base of your sacrum, and where it curves away, at your tailbone.  Generally you want to be in your “neutral” or “neutral zone” where you are evenly balanced right to left and forward to back.

Now see if you can start rocking your pelvis easily forward and backward.  Slowly rock your tail under, feel your low spine press into the ground and your tail lift a little.  This position in Pilates is called an “imprint” or “flat back.”

 

 

EASY ROCK BACKWARDS, “IMPRINT”

DON’T SQUEEZE BOTTOM, KEEP IT EASY AND SOFT

Slowly start to rock you pelvis the other direction, past your start position, you may feel your low back pull off the floor even more. Go slow and easy.

 

 

STICK BOOTY OUT A LITTLE, PELVIS WILL TIP FORWARD, LOW BACK WILL COME OFF FLOOR

Continue to go slowly and easily between these two positions, ideally your legs, feet and buttocks are relaxed and you feel as if your bones are just rocking back and forward.  Let’s call the “imprinted” spine 12 o’clock, and the booty out position 6 o’clock.  So now you’re rolling easy between 12 and 6 slowly and comfortably.  Start with only doing about 5 or so.

Now pause in the middle of 12 and 6, so you’re back to your start position, or perhaps at the center dial of your clock.

 

Slowly tip your pelvis over to the left, your 3 o’clock.  You should feel weight come off of the back right pelvis, and become heavy on the back left pelvis.

 

Then slowly come back to the center.  Now, tip your pelvis slowly over to the right, to your 9 o’clock.  You should feel weight come off of the back left pelvis, and become heavy on the back right pelvis.

Now you’ve got your clock 12, 6, 9, 3.  Try going slowly and easily up and down and side to side, don’t be too forceful with it, just imagine your bones are moving and your muscles are easy and quiet.  See if you can let your legs and feet relax so you’re only moving your pelvis.

 

If your still not sure take a look at this video.

 

Once you try this 4-5 times you can now try doing a full circle, or going around the clock.  Start at 12, tip over to 3, then 6, then 9, then 12 again.  Return back to neutral, then go the other direction or “counterclockwise”, from 12 to 9 to 6 to 3 to 12.  Try this 4-5 times keeping your legs relaxed and muscles relaxed.  You can take a look at this video if you are completely lost.  When in doubt keep it easy and smooth.

 

 

Bridging on Wall

Purpose- To integrate your legs and back into pelvic movement to move and massage the pelvic floor muscles.

 

Start with your feet on the wall, legs bent to ~ 90 degrees.  Feel how heavy your pelvis is on the ground and how you can allow your pelvis can sink deeper into the ground and settle.

 

 

Now slowly start to tip your pelvis backwards, as if just the bones were moving. Press firmly but softly into your feet and start to roll your pelvis and low back off the ground so your pelvis can hover just off the ground.  Let your pelvic floor and hips feel loose, relaxed and easy.

 

Take a breath there at your top of the movment and slowly start to roll down one vertebra at a time towards the ground. Once one vertebra presses into the ground see if you can lengthen your hips away towards the wall and drop the next one down, and so on and so on.  Keep it easy.  Try this ~5 times.

Take a look at the video with some additional cueing.  Remember, only go as high as is easy and comfortable.

 

Mermaid

Purpose- To stretch the side body, hips and pelvis and improve expansion of the rib cage and pelvic floor muscles with breathing.

Sitting with your legs in a mermaid position- one leg turned out in front one leg turned in behind.

 

Or, if this is not comfortable at your hips or your knees you can sit cross legged or on a blanket so your pelvis is above your legs.

 

 

 

 

Settle into this position for one or two breaths just allowing your jaw, shoulders and pelvic floor muscles to let go.  Slowly reach your right arm up to the ceiling, keeping the shoulder easy.  Let your left hand provide some support on the ground as you reach up and over to the left.  Think about creating more length in the spine then just compressing the left side of your spine. Take a breath intoour right side body and rib cage.

 

You can play with going to either side, left and right.

 

You can also try rotating your trunk slightly towards the ceiling or towards the ground to move the stretch and find more ease.  As long as it feels good.

Slow return to your start postion.  Once you have completely on side, switch your legs and repeat right to left.  If you are in sitting in a criss-crossed position you can switch which leg is on top and repeat the stretch again either side if you’d like.

*You can try these poses daily.  You should always feel better or no change in your symptoms. Though you may feel some stretching these exercises should never create more pain. When in doubt talk to your Pilates rehabiliatation professional or physical and occupational therapists. For more great exercises to improve pelvic floor mobility check out Casie’s blog on Yoga Poses for Pelvic Pain!

 

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Are you unable to come see us in person? We offer virtual physical and occupational therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical and occupational therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical and occupational therapistss committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical and occupational therapistss via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical and occupational therapistss, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical and occupational therapists 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. 

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical and occupational therapists at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836