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."