Kitsap Physical Therapy and Sports Clinics

Pelvic Health Services

What To Expect In Pelvic Therapy

Given the nature of pelvic health, a strong emphasis of treatment is focused on motivation, encouragement, and creating a safe environment for patients to progress therapy. In addition to patient education, evaluation and treatment may include:
• Biofeedback
• Bladder log
• Modalities (e.g. ultrasound, TENS)
• External and internal exams for the abdominal wall, low back, pelvis, hips, and genitalia • Prescribed home program

Importance of Treatment

Pelvic Floor Dysfunction (PFD) can be a socially embarrassing condition, causing withdrawal from community situations and reduced quality of life.
• Pelvic Floor Dysfunction symptoms are divided into 5 groups: Lower urinary tract, bowel, vaginal, sexual, and pain.1
• Pelvic Floor Dysfunction is present in 1 in 4 women and 1 in 5 men.2
• One third of men and women ages 30-70 have at least some loss of bladder control. Fifty to seventy percent of those adults fail to seek medical evaluation and treatment because of social stigma.3 4
• One third of women with sexual pain never seek help from healthcare professionals when most women can resume or begin satisfying sexual lives after diagnosis and up to date treatment.5
• Eighty percent of PFD cases have improvement with education and conservative pelvic health physical therapy.6 7 8

The 5 S’s of Pelvic Health Treatment

1. Support

Diagnoses: Pelvic Organ Prolapse, Diastasis Recti Abdominis.
Considerations: Pelvic floor muscle insufficiency can occur as a result of pain, poor movement patterns, or trauma (surgery or childbirth) and does not recover spontaneously. The result can be low back pain, pelvic girdle pain, or hip pain.
Treatment: Focuses on functional movement retraining and posture, strengthening for pelvic floor and abdominal wall, and manual therapy techniques for restrictions or spasms.

2. Stability

Diagnoses: Low back pain, pelvic pain, coccydynia, SIJ pain, pubic symphysis/groin pain.
Considerations: Pelvic health therapists provide a unique perspective in identifying disorders of breathing, continence, and increased pelvic floor activity which have higher associations with back pain, SIJ pain, and hip pain than obesity and physical activity.9 Common misconceptions are that pain is associated with a “weak core” or that core means only abdominal muscles. Current evidence indicates that retraining (the strategy of co-activating the deep muscle system) is more important than strength to improve support for the spine and pelvis.16
Treatment: Not all pain is created equal. Therefore, physical therapists will use an evidence-based treatment classification approach for lumbo pelvic disorders to determine appropriateness of care and treatments specific to individual patient presentations.

3. Sphincteric

Diagnoses: urinary incontinence, fecal incontinence, excessive flatulence.
Considerations: Urinary or fecal incontinence is multifactorial in nature, because no one specific cause exists.10
Treatment: A basic evaluation that includes discussing duration, severity, quantity and frequency of symptoms as well as triggering factors/events of incontinence helps identify which of the 5 types of incontinence a patient may be presenting with. Then successful treatment of incontinence must be tailored to the specific type of incontinence and its cause. 1 in 3 adults perform a pelvic floor contraction wrong, emphasizing that strategy plays a bigger role than strength.17

4. Sexual Function

Diagnoses: Desire disorders, arousal disorders, orgasm disorders, and sexual pain disorders: vaginismus, dyspareunia-provoked, unprovoked or mixed, vulvodynia, and pudendal neuralgia.
Considerations: Sexual dysfunction of some degree affects up to 25-60% of women and 40% of men by the age of 40; despite increasing cultural openness about sexuality,11 12 only 1 in 3 adults with sexual pain or dysfunction will seek help from healthcare professionals.5
Treatment: Importantly, psychologic and physical factors may contribute to sexual dysfunction.13 Therefore education in the physiology of intercourse, vulvar care or hormone replacement therapy, mindfulness-cognitive behavioral therapy, manual therapy to decrease spasm or restrictions, breathing exercises, and pelvic floor muscle relaxation and/or exercises, may be used.

5. Sump/Pump

Diagnoses: Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS), chronic prostatitis, endometriosis, constipation, irritable bowel syndrome, diarrhea, and mastitis*.
Considerations: Persistent muscle contraction of the pelvic floor related to noxious visceral stimulation can cause splinting and pain with reduction of normal pelvic floor muscle function.14 Understandably, one third of sump and pump-related symptoms result from pelvic floor dysfunction.15
Treatment: First line of treatment for patients should be education and stress management practices to improve coping techniques and manage stress-induced symptom exacerbations. Second line of treatment is appropriate manual therapy to resolve abdominal, pelvic floor, and groin trigger points, lengthen muscle contractures, visceral mobilizations to release scars and connective tissue restrictions, manual lymphatic drainage to improve gastrointestinal motility and deep abdominal lymphatic/venous drainage, and AVOID Kegels depending on stage of pelvic floor sump and pump-related symptoms.8

*Can be treated by those who are also Certified Lymphedema Therapists (CLT).

References:
1. Messelink, Bert et al. Stardization of Terminology of Pelvic Floor Muscle Function and Dysfunction: Report From the Pelvic Floor Clinical Assessment Group of the International Continence Society. Neurourology and Urodynamics. (2005) 24:374-380.
2. (NIH 2013)
3. (National Association for Continence 2006 survey,
4. http://emedicine.medscape.com/article/452289-overview
5. http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn
6. www.natc.org
7. Dr. Phillip Hanno-AUA 2014 Take Aways-Painful Bladder Syndromeand
8. Hanno, P., D. Burks, et al. (2011). “AUA Guideline for the Diagnosis and Treatment of Interstitial Cystitis/Bladder Pain Syndrome.” The Journal of Urology 185(6): 2162-2170.
9. Pool-Goudzwaard, A. L. (2005). “Relations Between Pregnancy-related Low Back Pain, Pelvic Floor Activity, and Pelvic Floor Dysfunction.” International Urogynecology Journal 16: 468-474.
10. http:/emedicine.medsapce.com/article/452289-overview
11. http://www.medscape.com/viewarticle/705592_4
12. http://www.webmd.com/erectile-dysfunction/ss/slideshow-erectile-dysfunction
13. Rosemary Basson, MD. “Overview of Female Sexual Dysfunction. April 2013. http://www.merckmanuals.com/professional/gynecology-and-obstetrics/sexual- dysfunction-in-women/overview-of-female-sexual-function-and-dysfunction)
14. Prather H et al. “Recognizing and Treating Pelvic Pain and Pelvic Floor Dysfunction: Phys Med Rehabil Clin N Am. 2007 18:477-496.
15. American College of Gastroenterology Chronic Constipation Task Force. “An Evidenced-Based Approach to the management of Chronic Constipation in North America.” American Journal of Gastroenterology.Vol. 100, No. S1, 2005.
16. Key, J. “The core: Understanding it, and retraining it’s dysfunction.” Journal of Bodywork and Movement Therapies. (2013) 17, 541-559.
17. Devreese, A, Staes, F, Janssens, L, Penninckx, F, Vereecken, R, & De Weerdt, W (2007). Incontinent women have altered pelvic floor muscle contraction patterns. The Journal of Urology, 178(2), 558-562.

Re-gain range of motion, strength and function!