Pardox - or conundrum?

It is a riddle wrapped in a mystery inside an enigma: but perhaps there is a key.

         -Winston Churchill

 I recently recieved an email from someone with a question about paradoxical contractions of the pelvic floor.  I'd like to apologize to the person that sent the email.  I inadvertantly erased the email while I mused about my reply - so hopefully she will read this (sorry ;-l).

A parodoxical contraction of the pelvic floor happens when the muscles react inappropriately to normal signals from the brain, or reflexively, from the spinal cord.  For instance: during normal bowell movement, the anal sphincter relaxes and is stretched as the stool moves through the opening, when it passes, the sphincter contracts quickly and strongly, ending the movement.  What happens if the sphincter does not relax? or if  it contracts in the middle of the movement? or if relaxation starts to occur, then spasm, then relaxation, then spasm?  or if the normal contraction that occurs at the end of the movement is instead painful and unrelenting like a cramp?

These contractions are "paradoxical." They can interfere with urination, bowell movements and normal sexual function.  They can be painful, or just annoying.  These contractions are one of many forms of pelvic floor dysfunction, and often one of the more difficult to treat.  

When I first started treating pelvic pain, I was emphatic that EVERYONE needed biofeedback (surface EMG).  Over the years, I have found that with a little coaching, most people can learn to sense the difference between relaxation and contraction, even without biofeedback.  However, people suffering with severe paradoxical contraction seem to respond best to biofeedback training.  Often these people feel like things are relaxed, but in reality the contractions may be getting stronger and stronger.  Having visual and audial cues to help sense what the muscles are actually doing is beneficial. 

As with most pelvic floor dysfunctions that result in pain, it is very important to get the muscles to relax.  I have many posts on this: heat, ice, a warm bath, gentle stretching, massage, meditation, whatever it takes.  When relaxation is established, it then becomes the goal to relax during challenging situations (bowell movements, urination, sex).

Everyone is an individual.  Treating paradoxical contractions require diligent effort, patience, creativity and time.   In my opinion, it also requires an experienced biofeedback therapist.

 

If you can add suggestions for things that may help, please do.

Book Review

I have been asked to review “Heal Pelvic Pain” by Amy Stein.  I normally disregard anything that promises to “Heal” conditions, particularly when the scope is as broad as Pelvic Pain.  Amy and her practice, Beyond Basics Physical Therapy in New York City, have an excellent reputation, so I thought I would at least give it a read.

First, let me commend Amy for tackling this project.  The nature of the beast is daunting, and she covers a wide range of pelvic issues, not only pain, but incontinence and other pelvic floor dysfunctions.  Her tone is warm and compassionate, backed up by the knowledge and experience of a veteran pelvic floor therapist. This is the real deal.  

The book gives a simple, easy to grasp overview of pelvic anatomy and the many causes of pelvic pain.  Remember – it is an overview.  Interstitial cystitis patients will be disappointed that the explanations are not specific to them, as will people with endometriosis, irritable bowel, and vulvodynia.  She really gets to the core issues that link all of the problems, and gives really good overviews of each condition, leaving the minutiae to others.  Later chapters discuss different populations, men, children, pregnant and post-partum women.  She even has chapters on healthy eating, relaxing, and better sex (really – this is an achievable goal, and the chapter is worth reading, even if you have given up on having a normal sex-life).

Chapter 3 is my favorite – and most appropriate for my patient population- “End The Pain.”  These are fairly standard exercises for relaxing the pelvic floor, and strengthening and relaxing the muscle that contribute to pelvic pain.  The best part is the easy, direct instructions and the very clear pictures.  Please read this chapter all the way through before implementing the exercises.  There are cautions about causing flares by jumping too quickly into the strengthening portion, and it is a good idea to know where you are going before you begin.  I also like her encouraging tone; exercise is an incredibly important piece of the puzzle, and staying motivated is difficult for all of us.

In “Give Yourself a Massage” Amy discusses how to do self massage: searching for and treating trigger points; abdominal massage; and internal massage.  This is a difficult topic in written format, and there are just not good graphics available to make it easier.  She does an excellent job of explaining the basics, and in a significantly less confusing way than I would have been capable of.  For internal massage I recommend that my patients use the EZ-Magic device, as it makes everything a little easier to reach.  If at all possible, I think it is still optimal to see a physical therapist that can train you on this portion of self treatment directly.  For those that cannot get to a pelvic floor therapist, this book is probably the best available explanation. 

All-in-all, I recommend the book, especially for those that don’t have easy access to a pelvic floor therapist, but also as an adjunct to the treatment you are receiving.

Thanks, Amy!  You’re patients are lucky to have you.