Dear Diary -

When someone calls my office to set up an appointment for any condition remotely related to pelvic floor problems, I ask them to track behavior in a bladder diary for at least 3 days before the initial consult. I require this of patients with incontinence, pelvic pain, interstitial cystitis, vulvodynia, and urinary frequency. Often the response I get is, “Oh – I don’t need to do that, I don’t leak, and I know how often I go to the bathroom.” This is really good information – but; a bladder diary can tell me so much more.

Different diaries allow for recording of different data. My favorite is from the NIDDK (The National Institute of Diabetes and Digestive and Kidney Diseases). Click here to download a copy in pdf format: Bladder Diary. This diary breaks the day up hourly, with separate sheets for night and day. Each hour you are asked to record what you drank, and how much; how often you urinated, and how much; if you had an accidental leak; if you had a strong urge to urinate; and what activity you were involved in at the time. I know – you think you are going to spend your life filling out a ridiculous form, you already know you go too little, too often, and you don’t drink enough water. But now we have a pattern, and this information will tell me a lot about when you have the most frequency, and maybe some information about why.

For instance: some nights you only have to get up once or twice to urinate, some nights it’s five. Most people are aware that they occasionally have more nocturia (night-time urination), but with a bladder diary we may find out that it happens on nights that they have a glass of wine or soda with dinner. Sometimes the patterns aren’t as easy to see: once a bladder diary showed me that a patient went to the bathroom as often as 4 times in one hour on Monday afternoons – the day her mother-in-law came to visit the grand children. Do you think stress may have been a factor?

Usually the diary is a tool I use to further explore problem areas with the patient. Sometime, just the act of writing things down lets the patient see patterns that they were missing. I had someone schedule for an evaluation because she had severe urge incontinence. While doing her homework before the appointment, she realized that she lost control as she got to her front door after work everyday. She also realized that she worked an 8 hour day without urinating – not even once. She disciplined herself to take potty breaks during the day, and called me to cancel her appointments – complete resolution of the problem.

Even if your healthcare provider has not asked for a bladder diary, it might be a good idea to start one. I only ask for 3 days because I can usually expect some level of compliance in that amount of time; a week would be better, a month would be optimal. Some additional things that you may want to track, especially if this is a problem you have had for a long time, or if you are seeing a new doctor, or just looking for more comprehensive information to give your health care team:

• Bowell patterns. Are you frequently constipated? If so, when? And does it affect your urinary frequency, urgency, or incontinence?


• Menstrual patterns. Do you have more symptoms before, during, or after your period?


• Diet. Some foods irritate the bladder, and most diaries only consider fluids.


• Stress patterns. What is going on in your environment, and in your head? Does any of this have a bearing on your symptoms?

Don’t just write down the bad things; track the simple pleasures in your life. You may find that when you have a really good day – your bladder has a good day, too!

Let's go! Really go!

"The time to relax is when you don't have time for it."
- Sydney J. Harris (1917-1986)

When you have pelvic floor dysfunction, one of the worst things you can do is strain while sitting on the toilet. Normal bladder function includes relaxing the pelvic floor, which sends a message to the bladder muscle (detrussor) to squeeze. When you strain during urination, to force things past the tight, spasming pelvic floor, it confuses the system. Straining during a bowel movement also worsens pelvic floor problems.

I know - you have a life, and sitting on the toilet for 10 minutes every 1/2 hour, hoping to pee, can put a huge rift in that life. As physical therapists, we work on relaxing the pelvic floor muscles (PFM) by down-training with surface emg (biofeedback), I touched on this a little more in the "To Kegel or NOT to Kegel" post. We use manual techniques (see "Trigger Trauma"); we teach you exercises to relax the muscles surrounding the pelvis and pelvic floor; most therapists will either teach some sort of meditation, visualization or "physiological quieting" techniques, or refer you to someone that can.

So here you are, about to learn all of these really great techniques that you know will help you, and you still have to go to the bathroom. NOW! not later, after you have hypnotized your PFM into submission. Now! while your baby is screaming and the phone is ringing and you still haven't loaded the dishwasher or folded the laundry, and what is that weird noise coming out of the cat?

There are a few things you can do while you are sitting there:

• 1st - Breathe! Just take a couple of deep breathes when you first sit down. If you know any of those visualization techniques from your therapist or somewhere else, this is the time to use them.
• Get a stool. A little foot stool to keep in the bathroom to put your feet on while sitting on the toilet. This brings your knees up, similar to a squatting position, relaxing the PFM. This works great - helps with constipation, too.
  
• Passive voiding. This actually works better for people that have trouble emptying, but it can work if the problem is initiating a void: place your fingers just above your pubic bone while sitting up right on the toilet. Press in with your fingers, and lean your body forward over your knees.
• Eat right, with lots of fiber. Avoiding constipation will help to keep the pelvic floor in good shape, and help you avoid the habit of straining.

If any of you have any other tips and ideas - please share. I love comments!

That's so......... Stimulating!

Electrical stimulation in all of its many forms is widely used in physical therapy today. Every therapist has their favorites: favorite machine; favorite treatment parameters; and favorite conditions to treat with it. For this reason, I am not even going to pretend that this post will be a comprehensive guide for you. I will discuss a few standard uses of electrical stimulation with pelvic floor and/or bladder control problems, but be aware that your therapist may be using something completely new and/or cutting edge.

First, let's talk about delivery systems. The Medtronic Interstim device is implanted into your body (by a surgeon, under anesthesia) with a wire that connects directly to your sacral nerve. I’m not going to go into any more detail – that’s a whole different blog subject. There are internal probes that can be used rectally or vaginally. There are superficial pads; these used to be carbon, with sticky gel that we taped or strapped on to people, these days I think most places use self-adhering pads that are patient specific. (That means multiple uses, but only one set per patient). There are point probes, hand held by the therapist while specific spots are stimulated for a short amount of time.

I rarely use the internal probes for electrical stimulation, because for many of my patients, they are cost prohibitive. When I leave it up to my patients, they are often very happy with the disposable pad electrodes, for pain control and calming the detrussor (bladder muscle). If I was treating more incontinence, where strength is an issue, I would use internal probes more often for stimulating the pelvic floor muscles, as it is often difficult for the patient to build the force needed for strengthening. There are some very good home devices out there that use vaginal or rectal probes; all of them require a physician’s prescription.

Reasons to use electrical stimulation:

• Strengthening – really important with weakness of the pelvic floor resulting in incontinence. This is done internally with a probe; the stimulation is turned up until you feel the muscles contract. The therapist will set the times for contraction (on) and relaxation (off).


• Calming the bladder – This works really well for controlling urge incontinence, frequency and urge/frequency disorders. It can be done with pads (placed above the pubis and at the sacrum); internal probes; or Interstim. I am not sure if you actually feel the Interstim – I never thought to ask one of my patients. (Let me know if you are using it, or have used it). With probes and pads, you will feel the electricity like a rhythmic tapping, which will last for the duration of the treatment.

Pain control – This is where we, as therapists, get really creative.

• For vulvodynia, pudendal neuralgia, or vestibulitis I often do something called Interferential electrical stimulation. This requires four pads, out of two channels, the current from each channel interferes with the other. So – If I set the pads up so Channel “A” goes from just above the pubic bone on the Right, to the Left adductor (inner thigh) muscle, and channel “B” does the opposite, then the majority of the electricity is centered on the vestibule. You will typically feel the electricity at the pads, but the treatment is more central. We can do this treatment with different pad placements, but the currents must cross to work properly.


• Constant, pulsed, burst, or modulated waveform settings using TENS (transcutaneous electrical stimulation – often sent home with the patient, looks like a beeper with wires). Each of these waveforms feels a little different, your therapist (hopefully with your input) will make the best decision for you.


• Constant setting with an internal probe.


• Micro-stimulation – I use hand held probes, there are also pad placements for this type of electricity. This is very low-level stim, often sub-threshold, or so minimal you barely feel it. I use it with a combination of acupuncture points, and common trigger point patterns that affect the pelvic floor and bladder.

There are some pain control protocols out there that include stimulating the pelvic floor muscle to fatigue, creating a forced relaxation, that will hopefully carry-over to everyday life. I have never used this method. It hasn’t worked for me with neck, back or shoulder muscles, I have not been willing to try it with the pelvic floor.

I could probably do a 3 hour course on electrical stimulation for pelvic pain syndromes, without even getting into the principals of electricity. This is a very small overview of what is out there. If your doctor or therapist is using something that you don’t understand, ASK! There should be some sort of rationale behind whatever it is.

TMJ Quick Tip

Once in a while I will throw in bits of information that have nothing to do with pelvic floor problems. Tempormandibular Joint Disorder (TMJ, TMD, or TMJD) is another specialty area of mine.

If you have pain or popping in the joint when you yawn, try this:
Put the tip of your tongue on the roof of your mouth, and bend your neck down, chin towards your chest, before you yawn. This limits the opening, but still allows you to get that satisfying oxygen dose your body craves.

"To Kegel, or NOT to Kegel..."

That is the question.

In 1948 Dr. Andrew Kegel noted that the “passage of the fetal head through the vagina during delivery is inevitably attended by muscle injury.” In other words, delivering babies is hard on the pelvic floor muscles. At the time, Dr. Kegel was convinced that having babies caused the lack of muscle tone that led to incontinence. Then he realized that women often became incontinent, even if they never had babies. So what’s going on here?

Well, the theory I like best has to do with cultural norms. We, like most western, industrial nations, use toilets; and sit in chairs when eating; and sit in chairs while working; and socializing. We are a sitting culture. Squatting cultures have very little problems with female incontinence. In pre-WWII Japan, the condition was very rare. Now, as our toileting and sitting habits have been widely adopted by Japanese society, the rate of incontinence there is equal to our own. Interesting, huh? The pelvic floor muscles activate in rising from a full squat, so they are naturally exercised in these cultures just by normal activities of daily living. Since I don’t think our end of the world is going to give up toilets – face it, I’m not even going to give up mine – then we have to come up with another way to keep these muscles strong and healthy.

Dr. Kegel studied the muscle integrity of thousands of women. He developed a system of strengthening these muscles that was three-fold:

• Isolate. Find the muscle, contract it- and try not to let the rest of the body kick in. He had women isolate the muscle by inserting a finger into the vagina, and squeezing around it.


• Resistance. He felt having something to contract against was important. A finger, a penis, a perinometer.


• Feedback. This is where the perinometer comes in. He developed this device so that the women could see how much she was contracting. A pneumatic device (kind of like a partially filled balloon) was inserted into the vagina. As the women contracted the muscles, the pressure in the balloon would make the gauge on the end move. It was the same sort of dial they use on the end of a blood pressure cuff. The woman got instant feedback as to the strength of her contractions.

This probably does not sound a thing like the instructions you were given in your doctor’s office, or the last women’s magazine you read. Mainstream civilization kept the concepts of Dr. Kegel alive, but we lost a lot in translation over the years.

There are many products on the market that provide resistance and feed back: The PMTx, which is very similar to Dr. Kegel's device; MySelf is more high tech, and has an easy to read screen, but; I’m cautious about giving this to my patients with pelvic floor dysfunction, because you lose the visual feedback during the relaxation phase, and the contract/relax timing is cued by the device, so if I want you to relax for longer than you contract, you have to really think about it.

There are lots of products out there that give resistance, without feedback. Vaginal cone weights are common (the link is just one of many examples). I never give these unless the patient is critically weak, and I have evaluated her on EMG (electromyogram) and I am positive that there are no coordination or spasm issues with the pelvic floor. There are also some pretty scary devices out there; some of them show up on the Google ads on this blog. Did I mention that I don’t screen or condone the banner ads that show up here?

So – what about pelvic floor patients? Should they do Kegels (the modified, common ones that every body teaches now), or not? The answer is: maybe.

Before I give strengthening exercise of any kind, I make sure that the person has good control of the muscle. You should be able to isolate the muscle, contract it, and most importantly, relax it. This is true of just about any muscle in the body, not just the pelvic floor muscles (PFM). I use a lot of EMG (biofeedback) training with my patients. It is a very good visual and audio system for learning the difference between a relaxed PFM and a tight one. If the person does not have good control while hooked up to the machine, I will not recommend a series of activities that involve regular contraction of the PFM for a home program. When I am absolutely positive that my patient can tell when her PFM is tight, and can consciously get it to relax and stay relaxed, then we are ready for some strengthening activity. Even at this point I am very cautious. Most of my patients are given programs that include relaxation times that are twice as long as the contraction phase. Even when they don’t present with a pelvic floor dysfunction, I want to make sure they are relaxing appropriately.

The average woman in our society needs to be doing strengthening activities with her pelvic floor muscles. The populations I treat are the exceptions to the rule: people with tight, spasmodic, or uncoordinated muscles; because of this I tend to error on the side of caution. As with any exercise program, before jumping into it, if you feel that you have any problems or medical issues that could be affected by your activities, consult your physician or physical therapist.