Pelvic Floor Therapy

I was checking out the ICN (Interstitial Cystitis Network) message board, and was surprised at the different experiences people have with pelvic floor therapy. The same day a friend e-mailed me a question from the message board and asked me to address it in this blog.

This is the question:
“How often do you guys have PFT appointments? Mine are only once every other week. They just use the probe and it only takes about 20 minutes. I do not feel like it is doing anything at all. Any advice? Also, they tell me to do kegels in the meantime, and I was under the impression that those are bad for IC? Just checking.”

I can only answer from my perspective. I know nothing about this patient, and have not evaluated her, so my answer may not even apply to her situation. During the initial evaluation there is a lot of history taking and discussion. I review their bladder diary, which tells me patterns of frequency; consumption of bladder irritants; incidences of incontinence (rare with IC, but it happens). We discuss life habits, previous and current treatment attempts, and general health history.

Then we assess posture and general musculoskeletal structure – is the pelvis and low back in alignment and working together? Are the muscles of the thigh and hip particularly tight? Weak? Balanced? We then assess the pelvic floor muscles (PFM), visually at first: I have the patient try to contract the PFM, I observe the pelvic floor during coughing or laughing, I look for irritation, discoloration or scarring. I then palpate (gently) the external region for tenderness. Internal exam consists of looking for trigger points in the muscles of the pelvic floor, assessing tone of the muscles and having the patient contract and relax the pelvic floor. This part is especially important for detecting pelvic floor dysfunction. Most IC patients can contract, the question is: do you relax appropriately, quickly and completely? If a patient cannot tolerate intervaginal palpation, I will evaluate by palpating rectally. Often on a first visit, I will not have time to do a complete evaluation, and will leave internal palpation for the next appointment.

The next part has to do with surface EMG (electro-myogram) we call this biofeedback, but it is really just assessment of neurological output of the muscle. On the initial visit I do this superficially, with small round electrodes on either side of the anal sphincter. I do this because the probes are often cost prohibitive for my patients, and I don’t recommend the purchase of them unless I feel it is medically necessary.

All of this information makes up my side of the conversation when determining schedule with a patient. Then comes the patient side of the process. How much is cost a factor? How much will insurance pay? How far do you have to drive? Will travel be detrimental to the process? A 30 minute drive for someone that has to go to the bathroom every 10 minutes will probably make physical therapy (PT) much less effective. How motivated are you toward self-treatment? How ill are you? If you literally cannot get up for more than a few minutes a day, weekly or bi-weekly PT appointments are probably not a good idea.

When all of these factors come together, we determine a schedule. Often I want to see someone more than once a week for the first 2 or 3 weeks. As I teach you more home treatments, you get to see me less. If you need lots of biofeedback training, then I suggest a home unit. It is you alone with the machine' you don’t need to be in my office with unfamiliar surroundings trying to teach yourself to relax. Plus, at home you can do 3 5-minute sessions in a day, rather than 1 20-minute session every 2 weeks. Much more effective!

Evaluation is on-going. If you have increased symptoms the day after treatment, I want to know about it. It sometimes takes a few sessions before we find out how much you can tolerate, without a rebound. We also need to figure out what works for you. I have done visceral massage to the bladder on a patient that absolutely stopped her nocturia (getting up to pee at night), and the same technique on another patient left her in horrible pain and increased frequency for 3 days. Feedback during the session is also very important. The things I do may be slightly more painful than what you are currently experiencing, but if it is so excruciating that you tighten the muscles or cannot breathe, well, expect a really bad day tomorrow. By the end of the 4th or 5th session you and your therapist should have established some pretty clear communication about what works and what doesn’t. Most patients have significant improvement after several weeks of therapy. Remember that keeping open lines of communication is very important. Give your therapist feedback, let her know what you experienced after each session (good and bad), and be sure to talk about your reactions during the session also. If there has been no change (worsening symptoms are actually better than NO change, at least we know we are affecting something), then it’s time to try something new. There are lots of options for treatment, and chances are, after 5 sessions, your therapist hasn’t tried ½ of her tricks.

Next time I'll address the infamous "Kegel."

Sex, Lies, and Dyspar....WHO?

Dysapreunia, or painful sex, affects most, if not all sufferers of chronic pelvic pain. For some, it is the only symptom; for others, it is one of many aggravating factors. Vestibulitis is characterized by burning pain at or around the opening to the vagina, sometimes the entire labia minora is affected. Vulvodynia is often characterized as pain in the introitus (the muscular entrance to the vagina), or may encompass a larger area of pain. Interstitial Cystitis sufferers may have pain only with deep penetration that puts pressure on the bladder. Vaginismus is an involuntary spasm of the pelvic floor, which can be painful in itself, but contributes to other types of pain. Any combination of these symptoms is common.

Some women have pain at arousal, partially because of the blood flow to the area, which increases congestion of the tissues. Sometimes the pain is anticipatory, knowing it is going to hurt, causes tightness and pain. Sometimes the pain is only during penetration, and many women will tolerate very little. Some women cannot tolerate penetration of any kind. Sometimes the pain is during orgasm, when the pain of involuntary muscle contraction overrides the natural endorphins that make sex so pleasurable for most people. Sometimes the pain kicks in the next day, sometimes during sex, sometimes immediately after. Regardless of how or when the pain presents itself, the loss of a pleasurable sex life is an issue that should not be minimized.

Communication is key to having a fulfilling sex-life, regardless of limitations. Remember, the problem is in your body, not in your relationship. Talk to your partner. Open lines of communication, even if it is difficult and painful. Many women are more concerned with the effect that their pain has on the partner's sex life than their own. Chances are, your partner is just as concerned about you. You may need to modify how you define sex, at least when you are having an acute flare-up, or while you are seeking treatment. Sex isn't all about penetration, and it isn't all about direct stimulation. Be creative, and be gentle. If all of this sounds foreign, and maybe scary, consult an expert. Clinical Sexologists, or Sex Therapists, are available in every major city in the US. do your home work. Most states have very strict licensing laws about Sex Therapists. be sure whoever you talk to is appropriately certified.
Some things a Sex Therapist will NOT do:

• Ask you to have sex in front of them to "observe"
• Offer to "demonstrate" with you or your partner
• Belittle your concerns and fears

Sexology is a branch of psychotherapy. Sex Therapists are there to teach you and your partner how to communicate, and explore a fulfilling sex-life. They aren't scary, and they aren't weirdos. They are trained, compassionate professionals.

What else? Well, relaxation is huge. In physical therapy, we do alot of things to help you relax. We use biofeedback (surface emg), so you can tell when the muscles are tightening, even if you can't feel it. We do manual techniques to reduce the muscle spasm (see the Trigger Trauma post dated 1/30/2006). We recommend meditation and relaxation tapes.

Things you can do to help relax the pelvic floor before intercourse:

• Take a warm bath
• Use a moist heat pack on your back and lower abdomen
• Gently warm a safe device that can be placed inside the vagina for 5-10 minutes prior to intercourse. I often recommend the EZ-Fit.
• Apply topical Lidocaine, to numb the tissues. Be very careful with this recommendation, and consult your physician about safety for you. If the surrounding tissue is very fragile or sensitive, there may be tearing with intercourse that you won't be able to feel until it's too late. If the majority of the pain is from muscle spasm or interstitial cystitis, lidocaine will be less helpful. Be aware that for a man, the topical lidocaine that you use will limit his sensitivity, making it difficult for him to achieve orgasm.
• Use a lubricant, but be very particular about what you use. Many of the commercial lubricants irritate vestibulitis and vulvodynia. I have had very good luck with pure aloe vera gel, but even that has irritated at least one of my patients. Some of my patients prefer emu oil, but oils will break down the latex in condoms, making them less effective.

After intercourse try:

• Internal cold. Use a device that will hold the cold for 2-5 minutes. Again, the EZ-Fit works great. I have had patients try to fill a condom with water and freeze it, but they stretch to an enormous size. The finger of a rubber glove will work better for most patients. When using a frozen device remember that the vaginal wall is composed of very delicate tissue, and an ice-cold object may be damaging, so limit the time accordingly.
• Cold packs on the lower abdomen, low back, and/or between the legs to cover the external genitalia
• Another warm bath.

I hope some of these suggestions help. Please comment, with additional ideas, or e-mail me with questions.

Sole Mates

My shoes are special shoes for discerning feet. -
Manolo Blahnik

All of my patients, and friends, and aquaintances know this about me: I am very concerned about posture. It is wierdly satisfying to walk into a business meeting and have the whole room sit up straight in their chairs. It is a little disconcerting when my patients walk in bare-foot, to avoid the lecture about high heeled shoes.

A former patient sent me an abstract concerning ankle position and pelvic floor muscle activity. The authors are Charles Vega, MD and Laurie Barclay, MD. As I only have the abstract, I'm not sure about the details of the study, but apparently the information was intended for continuing education credits. The gist of the article is: When your feet are in dorsiflexion (toes pointing up), there is more activity in your pelvic floor muscles (pfm), and it is easier to build a strong contraction. When your feet are in plantar flexion (heels up, toes down), there is less activity and it is harder to build an effective muscle contraction.

Before we jumped to the conclusion that if you have tight pelvic floor muscles you should wear high heels, lets look at the details. The study was conducted on women that had stress urinary incontinence. Although not specifically mentioned, we can assume that many of these women had weak pfm. The women were tested in neutral standing, 15 degrees of dorsiflexion and 15 degrees of plantar flexion. They stood in these positions for 5 minutes prior to testing. Resting muscle activity and maximal contraction were recorded. The results show that the plantar flexion position (toes down) had less muscle activity at rest than neutral and dorsiflexion. A stronger contraction is possible with the toes up.

So what does this mean for you? The only specific conclusion drawn by the authors was that pfm exercise in conjunction with raising your toes will be helpful in training women with stress urinary incontinence. We get into trouble in medicine when we take information from a study and apply it to a different population without really researching the details. We have no idea what ankle placement will do with a pathologically tight pelvic floor. Even if 15 degrees of plantarflexion will relax the pelvic floor, realize that 15 degrees is not much, perhaps only a 3/4" - 1" heel. This will come as a shock to some of my patients, but I don't have too much of a problem with 1" heels, as long as it doesn't go any higher and they spend some or most of their day in good, supportive shoes. Also, this study only measures the pfm activity, and does not take into consideration the rest of the body. We know that pelvic pain problems can be exacerbated by mechanical imbalances in the spine and pelvis, and wearing heels all day can be very hard on the back, neck and jaw.

I'm still not endorsing high-heels for pelvic pain patients, but picking up your toes when you cough or sneeze (don't fall over) will apparently help to prevent leakage.