By Bryn Zolty, PT
As she described her urinary symptoms to me, I decided to check the fascia located near the urethra for any restrictions or asymmetries. There I palpated a very large round dense mass. It was on the right side and felt as if it was altering the position of the bladder. The most likely cause was a fibroid, and the patient did then confirm that she had a history of a small fibroid. I had concerns that this fibroid had grown and might have been the cause of the urinary symptoms. It was certainly large, and very close to the urethra and bladder. I referred her back to her physician to have the dense mass evaluated. The physician confirmed it was a fibroid and immediately ordered a surgical consult. The fibroid was removed.
We have all been through such moments of anguish where symptoms don't add up. This patient is a reminder that we are not alone in our fear and confusion. She had a fibroid that had been driving many of her symptoms all along. It was through her persistence in getting the right care and her practitioners actually communicating with each other that a solution was found. She was her own advocate with a powerful alliance of team members to help her find an answer. She is an example of how sometimes we have to fight through the anguish and fear to find true healing.
I am so thankful that this patient was kind enough to share her story to help other women continue to search even when they feel at a loss as to where to turn for answers. A pelvic physical therapist is one of the few practitioners that spends each session one-on-one for at least 45 minutes. As a result, we are able to re-evaluate and treat each session. Consider a physical therapist on your treatment team.
By Bryn Zolty, PT
How do men Kegel? In the literature, the phrase that was found to be most associated with stopping urine leakage was, “Shorten the penis.” This simple cueing creates the greatest displacement of the muscles that close the urethra. Other cues like “lift the bladder” were not as effective and increased pressure in the abdomen and pushed down on the pelvic floor. (1) It is important to be aware that you are not contracting other muscles in the legs, buttocks, and abdomen when isolating the pelvic muscles.
Every Kegel or pelvic floor strengthening program should be customized to each person. In the clinic, we work on endurance and quick contractions. For example, a home exercise program may include:
Some men lose large amounts of urine after prostate surgery, which can have a huge impact on normal daily activities. It may take time for kegels to make a difference in symptoms. A penis clamp may be an appropriate option to stop large leaks. The clamp places gentle pressure on the urethra to block urine loss. It may not stop all leakage but can significantly reduce it. When the clamp is removed, the release of pressure allows for normal urination. The amount of time recommended for wearing the clamp is variable between different devices. If you have any interest in a using a clamp, contact your physician or pelvic physical therapist to see if you are a good candidate.
According to the Journal of Neurourology and Urodynamics, men " found the device easy to use, felt more confident wearing the device, and had increased levels of physical activity with device in situ." They had significantly improved urinary incontinence symptoms per the Incontinence Impact Questionnaire. (2)
If you are going to have a prostatectomy or already have, ask your physician for a referral to a pelvic physical therapist. They can guide you through your pre- and post-surgical rehabilitation and reduce urinary incontinence.
(1) Stafford, R. E., Ashton‐Miller, J. A., Constantinou, C. , Coughlin, G. , Lutton, N. J. and Hodges, P. W. (2016), Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourol. Urodynam., 35: 457-463.
(2) Barnard, J. and Westenberg, A. M. (2015), The penile clamp: Medieval pain or makeshift gain? Neurourol. Urodynam., 34: 115-116.
Written by Bryn Zolty, PT
If I just had a baby can I return to running? I’m leaking - can I do exercise that involves jumping? My doctor says I have a prolapse - can I lift weights at the gym? As pelvic physical therapists, we hear these questions every day. It is very common to wonder if after having a baby, a surgery, or if you have pain in the pelvis, if it is okay to engage in activities that can push pressure down into the pelvis.
While more research is needed to better answer these questions, there are a couple of studies available that have measured the pressure in the vagina with functional tasks, yoga poses, and other exercises in attempts to answer these questions. Here is a little of what they found with a group of women ranging in age from 20-51:
These numbers can surprise people. How can a crunch be so bad if the average pressure is 23.8 and a normal daily occurrence like coughing is 98? As a therapist, my focus is drawn to the large ranges within each activity. What is the woman doing differently to crunch at a pressure of 8 compared to the woman at a 75?
As therapists we evaluate how you move and conduct each of these activities. As pelvic physical therapists we look closer at your movement, alignment, breathing, coordination, and muscle tone in relation to the pelvis. All these factors play a role in the pressure your body places on the pelvic floor. This pressure is known as the intra-abdominal pressure. This is how one woman can have very low pressure on her pelvic floor while another woman has high pressure during the same activity. The key is how they complete the task.
Back to the question, can I do a crunch? Can I return to strenuous exercise? Our goal is to teach you how to do movements or activities properly while minimizing the negative impact on the pelvic muscles. A pelvic physical therapist’s job is to evaluate the movement or activity that gives you pain or makes you leak and improve it.
How do we do this? Let’s take a squat for example. If a patient comes in because she leaks urine while squatting, we would explore all the possibilities.
After having babies, surgeries, or injuries our bodies change. Some of these changes can lead to incontinence or pain. A pelvic physical therapist is a great clinician to discuss these changes along with your goals for fitness or everyday activities. Whether it’s cueing on alignment or movement strategies, breathing, releasing or strengthening, it is our goal to help you reach yours.
From the Glottis to the Pelvic Floor: Making Clinical Connections. Julie Wiebe, PT, MPT,BSc, and Susan Clinton, PT,DScPT,OCS,WCS,FAAOMPT.
Cobb WS, Burns JM,Kercher KW, Matthews BD, Norton HJ,Heniford BT. Normal Intra-abdominal Pressure in Healthy Adults. 2005; Journal of Surgical Research 2005; (129):231-235.
O’Dell KK, Morse AN,Crawford SL, Howard A. Vaginal Pressure during lifting, floor exercises, jogging, and use of hydraulic exercise machines. International Urogyneocology Journal, 2007;18: 1481-1489.
Written by former staff physical therapist, Aisling Linehan, PT
Pelvic health therapists are sometimes known as women’s health therapists; however, it’s important to note many of them also treat men. Our pelvic floor therapists treat men as well as women. Pelvic therapy is effective and often life-changing for both genders.
Let’s use male pelvic pain as an example. When pelvic pain strikes, males often wait a few months for it to go away on its own. They finally visit their primary care doctor who commonly refers them to a urologist. Urologists do their best to work up patients for any harmful pathology like infection and cancer. For males with non-bacterial prostatitis, the tests for infection will be negative, and frequently prescribed antibiotics like Cipro may not help. Unfortunately, many men will continue to take it in hopes of future relief all whilst suffering from its many side effects. When urologists have sufficiently ruled out pathology but the pain remains, the patient is left wondering where to turn next. Many males turn to the internet to find that there are other people like them, in pain, alone and suffering but have found relief with pelvic floor therapy. Urologists are so effective at ruling out pathology that almost every male who ends up in a pelvic PTs office is suffering from a musculoskeletal issue.
Pelvic floor tone is assessed digitally through the rectum and electronically with biofeedback. It is important to note that a high tone pelvic floor can cause any combination of the following symptoms: urinary urgency, urinary frequency, constipation, penile pain, and testicular pain/pulling/burning/retraction. Many of these symptoms can be relieved with PT interventions that may include: soft tissue release for pelvis and hips, breath training, rib/diaphragm mobility, internal pelvic floor trigger point and myofascial therapy, perineal mobility, light stretching, and gentle core strengthening.
Pelvic floor therapy is a safe space. It is not scary or threatening. Many patients feel immediate relief knowing that we have treated and helped patients just like them. We are here to educate and make space for the healing to happen. Knowledge is power and the more you know about your body they better you can treat it. If you’re looking for help and education regarding pelvic pain, contact your local pelvic floor physical therapist for an evaluation today.
Written by Becca Ironside, PT. Becca is also a published Author of Fiction.
Theresa came to Connect Physical Therapy in late fall of 2017. She looked like she had it all – dark, glossy hair, olive skin and a neckline without wrinkles that belied her age of 57. Theresa has two children, is married to a man from Ireland and is gainfully employed by the State of New Jersey in Trenton. Theresa has an unmistakable air of confidence. This was surprising, given her reason for seeking help in our office for Pelvic Floor Physical Therapy.
During her first visit, Theresa confided that she had recently begun to experience fecal incontinence. It had come out of the blue, she said. A few months back, Theresa noticed severe urgency with bowel movements. She would feel spasms within her rectum and there was no warning before she would have to defecate. There were times when she could not make it to the toilet in time, and so she was forced to wear disposable pull-ups to manage her “accidents”. She had to plan her commute to work, stopping at least once in the cleanest of public bathrooms she could find, because she could not wait during traffic. Theresa’s problem was worsening. She could no longer go to social outings without scoping out for the nearest restroom. The humiliation was awful, she said.
“After I married my husband, who is from the outskirts of Donegal, Ireland, I traveled overseas to meet his family,” Theresa explained. “They live very simply, these people. They wear the same clothing most days, drive old cars with manual transmissions, and do not have the same access to healthcare that we do.”
“I am so fortunate to live in America,” Theresa continued. “My Irish in-laws call me ‘A spoiled Yank’. I used to love it when they referred to me that way. I have everything a person could want. Except that now I am terrified of being in public and have to wear adult diapers. I do not feel like a spoiled Yank anymore.”
I knew that Theresa was at the end of her tether. She had tried prescription medication, daily Imodium, altering her diet and kept her legs tightly crossed at all times to avoid what still happened. I explained to her what Pelvic Floor Physical Therapy was all about. That in this type of clinic, we would do an internal examination to discern if the muscles of her perineum might be driving the fecal incontinence.
“I have been through so much already. If you have to do an internal examination, so be it,” Theresa declared. After an exam of the musculature of Theresa’s pelvic floor, it felt as though her muscles were in moderate to severe spasm. These muscles control urination and defecation; they were firing so rapidly that she could not contain feces within her colon, and worked incessantly to force it out. The function of the large intestine is to pull water out of our foodstuffs and allow feces to become solid. This was not happening in Theresa’s case, because the food was not in her colon for enough time, and her stool was unformed and messy. This explained her chronic diarrhea.
The treatment plan for Theresa included deep breathing, relaxation of her pelvic floor muscles and some natural over-the-counter additives to bulk up her stool. “This sounds counter-intuitive to me,” Theresa said at first. “If I relax the muscles, then won’t more feces escape unplanned?” I smiled at her and explained that if she wanted to try something new, she would have to trust me.
It took almost three months of once-weekly treatment in our clinic, with a really good home program, for Theresa’s symptoms to subside. But subside, they did. She now has solid bowel movements twice daily and can control them wonderfully. Gone are the pull-ups and the fear of accidents. Her commute to work and social life have been restored to normalcy.
“I cannot believe how this treatment has helped me! I wonder if this would be available to my relatives in Ireland? I hope so. But at any rate, I feel like a ‘spoiled Yank’ once more,” Theresa remarked. Pelvic Floor Physical Therapy is gaining rank, accessibility and respect all over the world. It likely is available to her in-laws in Donegal, Ireland. The trick is to find ways to talk about these issues and overcome the embarrassment surrounding words like rectum, feces, and stool.
This is what we do, as pelvic floor physical therapists. One client at a time. For spoiled Yanks, people from Ireland and every other continent, men and women, young and older, there is help. We live in a time when anything is possible.
Written by Becca Ironside, PT. Becca is also a published Author of Fiction.
I met a woman named Eva* at the Pelvic Floor clinic. She came for physical therapy to address urinary leakage, which she has endured for over ten years. I had to glance at her date of birth to make sure of her age. Eva is 85 years old, and she looks spectacular. “What is your secret to looking so young and vibrant?” I asked her. “Maybe it is having good friends. Wonderful children and grandchildren. Or maybe it is just my good Danish genes,” she replied.
Eva told me that she began leaking urine several years ago, but her condition is getting worse. She told me that she cannot go to the beach anymore at Point Pleasant, which is her favorite thing to do. In her medical history, I learned that Eva had had three pregnancies with vaginal births. She does not drink enough water, mostly in fear of losing even more urine. Based on her age and prior history of childbearing, I was working under the assumption that Eva had weakness in her pelvic floor muscles. Maybe a little prolapse of the bladder.
“A lot of young women come here with complaints of pain with sex,” I told her. Eva’s eyes opened wide. “Do you mean to tell me that there is treatment for that? I had two husbands and sex was awful with both of them. The pain was unbearable. I never understood what the big fuss about sex was all about.”
Here was a woman in her eighties who had lived with pelvic floor dysfunction her entire life. The painful intercourse made sense, given how much tension she was holding in her musculature. I devised a treatment program for Eva to allow the muscles of her pelvic floor to elongate. She was given a home program of self-stretching, diaphragmatic breathing exercises, and an activity known as the pelvic floor drop, which is the opposite of the famed Kegels we have all read about in McCall’s Magazine.
Eva has returned several times to our clinic. She has far less urinary leakage, is drinking more water (she has retrained her bladder to accommodate this), and practices yoga and deep breathing. She is planning a month-long trip to Florida, wherein she will be able to go to the beach in a bathing suit encasing her lithe body without fear.
I learned something wonderful during my treatment of Eva. I rejoice in living in a time when help is now possible for these things that have plagued women for centuries. I also learned that it is never too late to change. Eva is 85. And if she responded so readily to this therapy, then anything is possible.
*The name and some personal details of this patient have been changed, according to the laws of the Health Care Portability and Accountability Act. But the symptoms of Eva and the outcome of her treatment are true. Pelvic Floor Physical Therapy works!
What the research says: effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence
A prospective study by Filocamo and colleagues in 2005 investigated the effectiveness of early pelvic floor muscle training (PFMT) after radical retropubic prostatectomy (RRP). After catheter removal, 300 men were randomized equally into either a structured PFMT group or a control group that did not receive exercise. Incontinence was assessed by the 1-hour and 24-hour pad test, as well as the ICS-Male questionnaire.
By 6 months, almost 95% of the PFMT group achieved continence as compared to 65% of the control group. The authors concluded that an early supportive rehabilitation program like PFMT significantly decreases continence recovery time.
Filocamo M, Marzi VL, Del Popolo G, Cecconi F, Marzocco M, Tosto A, Nicita G. Effectiveness of Early Pelvic Floor Rehabilitation Treatment for Post-Prostatectomy Incontinence. European Urology. 2005 Jun:48(5)734-8.
Patient: 42-year-old female
Chief Complaint: Urine leakage with urgency after vaginal delivery of 2nd child + emergency hysterectomy; 6 night voids
Past Medical/Surgical History: Repair of prolapse the following year + Oxybutynin with 50% decrease in symptoms; history of low back pain, irritable bowel syndrome
Physical Therapy Treatment: proper voiding techniques; lower body stretches; prolapse management; posture and breathing exercises; abdominal scar release
Results: 0 urine leakage with 1.5 hour urinary intervals, 0 night voids, 0 Oxybutynin in 12 visits!
(Constipation in Children. (2013).Retrieved June 9, 2014 from http://digestive.niddk.nih.gov/ddiseases/pubs/constipationchild/#common Urinary Incontinence in Children. (2012). Retrieved June 9, 2014 from http://kidney.niddk.nih.gov/kudiseases/pubs/uichildren/index.aspx)
Written by Michelle Dela Rosa, PT.
Another study from Japan showed that almost half of their 784 elderly participants reported nocturia 2 times or more per night. These individuals were at greater risk for fracture and mortality. (Nakagawa et al, J Urology. 2010 October; 184(4): 1413-18.)
Simple advice like decreasing caffeine, alcohol, or any fluid near bedtime may help improve nocturia. Physical therapists can help patients with other behavioral strategies and techniques after a thorough evaluation. Other factors to consider include: sleep disorders, diabetes, poor bladder storage, kidney dysfunction, or cardiac issues.
Written by Michelle Dela Rosa, PT.
1000 healthy, young women (age 16-30 in Melbourne, Australia were surveyed about continence. 6.2% of women reported urinary leakage with stress, 4.5% with urge, and 1.9% with both stress and urge. Women were also more prone to UI if they reported a history of bedwetting beyond 5 years of age.
Written by Michelle Dela Rosa, PT.
(Hung HC et al., “Effect of pelvic-floor muscle strengthening on bladder neck mobility: a clinical trial”. Phys Ther. 2011 Jul; 91(7): 1030-8.)
These results demonstrate the need to screen patients with IC for pelvic floor dysfunction and painful muscle trigger points, and refer them to specialists like physical therapists who are skilled in treating pelvic pain.
Urinary incontinence exists at higher levels in patients with Type I or II diabetes than in those without diabetes, according to new research. Another article from the National Association for Incontinence (NAFC) website states that 50% of men and women with diabetes have incontinence. It describes how sugar can get into the urine and irritate the bladder. This creates urinary urgency, frequency, and incontinence, symptoms that could be mistaken for a urinary tract infection.
The article also notes that persistent bacteria in the bladder can lead to symptoms of overactive bladder (OAB), which results in the neurologic dysfunction of incomplete bladder emptying. Consequently, the patient becomes more susceptible to urinary incontinence and infections.
In addition, fluid retention can be associated with other conditions of the diabetic patient. Extra fluid in the legs can be moved into the patient’s system when lying down. This often leads to urinary frequency at night, which interrupts sleep and puts patients at risk for falls.
Some easy solutions include having the patient do ankle “pumps” (bending the foot back and forth) before bedtime to move fluids out of the legs earlier. If a diuretic is being taken, altering the dose or timing may also help. The literature suggests that physicians should screen for incontinence in diabetic patients, as they may not share this information by themselves.
Elser D, Diabetes and Urinary Incontinence. Quality Care. 2011 Nov
Phelan S et al., Clinical Research in Diabetes and Incontinence: What We Know and Need to Know. J Urol. 2009 Dec