Pelvic Floor Dysfunction

What are the symptoms of pelvic floor dysfunction?

They can be numerous in nature but have been described as follows:

     •   pain with, during or after sexual relations
     •   genital pain
     •   urinary urgency and frequency
     •   deep pain in the lower back radiating to the legs, thighs, groin and hips
     •   lower abdominal pain
     •   vaginal or rectal pain
     •   pain with urination or defecation
     •   pelvic pressure of falling-out feeling
     •   involuntary loss of urine or stool
     •   pain with daily activities; sitting, walking, standing
     •   burning, itching, stinging of the vulva and outer vagina
     •   difficulty initiating a urinary stream

What causes pelvic floor dysfunction?

The cause of pelvic floor dysfunction is unknown but is likely a combination of events. A wise colleague of mine once described it as a glass being filled with water that eventually overflows. There are numerous traumatic events that contribute to the filling of water in the glass. The event that causes the water to overflow can be as simple as a cough or a urinary tract infection. This overflow is recognized as the breaking point in the system that leads to the development of pain or dysfunction. Events that have been correlated with the development of pelvic floor dysfunction include:
     •   direct physical trauma; surgical procedures, sports injuries, fractures, sudden severe muscle strain, car accident, pregnancy or complicated delivery
     •   repetitive minor trauma, chronic cough, constipation, straining to void
     •   chronic tense holding patterns that develop in childhood as a result of sexual abuse, traumatic toilet training, abnormal bowel patterns, stress or sports training.
     •   chronic hip and back pain and causing compensation patterns of the pelvic floor
     •   inflammation of the pelvic organs such as urethritis, cystitis, vaginitis, prostatitis and endometriosis.
     •   Chronic faulty posture and weak core musculature

Where are the pelvic floor muscles and what do they do?

The pelvic floor is a hammock-like web of muscle and connective tissue that covers the pelvic bones and supports the rectum, bladder and vagina. A functioning pelvic floor is integral to increases in intra-abdominal pressure, provides rectal support during defecation, has in inhibitory effect of bladder activity, helps support pelvic organs, and assists in lumbopelvic stability. Coordinated release of the sphincters within a supporting extensible levator ani allows complete and effortless emptying. The pelvic floor muscles also contribute to one's sexual appreciation.

Who develops chronic pelvic pain?

Chronic pelvic pain (CPP) is one of the most common medical problems affecting women today. It is estimated that 14.7% of women in their reproductive ages reported chronic pelvic pain. Extrapolating to the total female population gave an estimate of 9.2 million women suffering from CPP in the United States alone. The diagnosis and treatment of CPP accounts for 10% of all outpatient gynecological visit and 40% of all laproscopic surgeries. Chronic pelvic pain is listed as the indication for 12-16% of hysterectomies performed in the United States, accounting for 80,000 procedures annually.

Chronic prostatitis is the most common urological diagnosis in men older than 50 years and is the third most common diagnosis in men younger than 50 years. This diagnosis results in at least 2 million office visits per year. The average urologist sees approximately 10 prostatitis patients per month, 30% of whom are new patients. Specific urinary pathogens are detected infrequently after culture. The vast majority of these patients are categorized as having chronic nonbacterial prostatitis or prostatodynia, otherwise known as Chronic Pelvic Pain Syndrome (CPPS) in the male.

How is chronic pelvic pain related to pelvic floor dysfunction?

Dysfunctional muscles of the pelvic floor are frequently overlooked as a contributor to chronic pelvic pain. Unfortunately, not all doctors are aware of pelvic floor dysfunction, and others simply don't believe that it exists. Thanks to the experts in our field, it has been well documented in the literature that many urogynecologic symptoms arise from the presence of a short, painful hypertonic pelvic floor.

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Chronic Pelvic Pain

Chronic Pelvic Pain (CPP) can encompass a variety of medical conditions and physical therapy diagnoses. To assist you in understanding the services we provide, we have divided them up into symptoms that can be orthopedic related (see Low Back Pain) and those that can be caused by Pelvic Floor Dysfunction. Please note that symptoms can be a combination of orthopedic and pelvic floor causes.

Abdominal pain can also come from a variety of sources. Possible sources of pain include: referred from the sacroiliac joint (SIJ), ilioinguinal neuropathies, pubis symphysis dysfunction, scar tissue from surgeries, trigger points from the pelvic floor, connective tissue restrictions or referred pain from abdominal viscera.

The diagnosis of chronic pelvic pain is often given to patients when the physician is unable to find a medical diagnosis to explain the severity of the symptoms. Under these circumstances, it is not unusual to find a musculoskeletal component. Many medical diagnoses have been documented to have a musculoskeletal component. It is very important to be thoroughly screened by your physician for any medical diagnosis that requires medical intervention. If you continue to have symptoms after the medical intervention, we feel that an evaluation by a physical therapist trained in treating chronic pelvic pain may be indicated.

Common medical diagnosis that may have a musculoskeletal component include, but not limited to:

     •   Vulvodynia
     •   vaginismus
     •   dyspareunia
     •   interstitial cystitis
     •   prostatitis
     •   orchidynia
     •   vulvar vestibulitis

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Orthopedic Component to Chronic Pelvic Pain

The orthopedic component to chronic pelvic pain usually comes from sacroiliac dysfunction, low back pain, leg length discrepancies or rotated segments of the cervical-thoracic-lumbar spine.

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Low Back Pain

It is estimated that 8 out of 10 Americans will develop low back pain at some time in their life. Low back pain can be localized to the back or it can spread down into the buttocks, legs, groin or abdomen. Patients frequently obtain x-rays or MRI's from their treating physicians to find a cause for the pain. Many of our patients have been diagnosed with degenerative disc disease, herniated discs or "pinched" nerves. Some of our patients have negative findings with special tests. Regardless of the diagnosis, our treatment approach will significantly decrease your pain and increase the quality of your life.

It is our experience that sacroiliac dysfunction (SIJ) is a common diagnosis that is frequently missed. The signs and symptoms of an SIJ can mimic other conditions. Please see the common patterns of distribution that has been documented by the following authors.

We have also noted that many of our chronic pelvic and back pain patients have been participating in strength training that actually makes their condition worse. Ironically, many patients do not even realize that the exercise's are making their condition worse. The pain does not always occur during the exercise itself. We promote a healthy lifestyle that includes a routine exercise program. We have found that our patients are participating in exercises that do not correctly isolate important muscle groups. Once a muscle imbalance has been created, the stronger muscles get stronger and the weaker muscles get weaker. We help our patients identify these weaknesses and give them tools to create balance and stability in their muscles and joints.

Spine/Core Stability

"Core" is a common phrase used with fitness and rehabilitation professionals. The concept of core stability is to be able to optimize forces through the spine to decrease stresses to the joint and optimize functional strength. The body has many different layers of muscles. The "core" is the deepest layer of muscles. It is ideal to be able to effectively isolate these deepest layers and then progressively learn to recruit additional layers in a particular pattern for optimal function.

Core strength training has very many levels and applications. It is our experience that patients are taught too advanced level of core exercises for their current abilities. When an exercise is too advanced, patients lose their neutral spine, hold their breath or mass contract by using compensatory muscles as a strategy to perform the desired movements. These strategies would be inappropriate and the goal for "core stability" is lost. Inappropriate activation of these muscles can actually make your condition worse. Advanced level exercises often involve the use of pilates machines, balls, foam rollers, and weights. Our beginning level exercises start with correct isolation of muscles and then progress to the use of the arms and legs as a lever arm of force to the inner core muscles. We then progress the level of difficulty using different positions, resistance, and changing the stability of the surface.

Our core stability program is personalized to your abilities and conditions. Modifications may be required based on your diagnosis, age, level of activity and personal goals. A thorough evaluation of your personal needs will be determined on your first visit. This program is intended to be done at home with minimal use of equipment and when appropriate we can transition back to the gym.

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Stress Incontinence

Stress incontinence is the involuntary leaking of urine with activities such as coughing, laughing, changing positions, or exercising. Stress incontinence is usually the result of muscular weakness and incoordination.

Most people are led to believe that the pelvic floor (known as the "kegel" muscle) is the only muscle that needs strength training, this is not true. Incontinence is often a coordination dysfunction. It is the correct isolation of the transverse abdominus (deep abdominal muscles) and the pelvic floor muscles during an increase in intra-abdominal pressure.

Literature has shown a strong correlation with low back pain, incontinence and paradoxical breathing patterns. People with breathing dysfunction are frequently unable to perform a correct isolation of the muscles without holding their breath or mass contracting the wrong muscles.

Pelvic floor muscle weakness can be the result of childbirth, a tear or episiotomy, hormonal changes, high impact activities, organ prolapse, surgeries, chronic low back pain, hip pain/sacroiliac joint pain or general muscle deconditioning. Physical therapy treatment may include:

     •   Core stability program (Inner corset includes: the pelvic floor and transverse abdominals)
     •   Bladder Diary
     •   Patient education and behavior modification
     •   Manual therapy treatment for co-existing pain conditions
     •   Progressive home exercise program
     •   Range of motion exercises
     •   Gentle electrical stimulation if needed (performed with internal rectal electrode)
     •   Biofeedback if needed (computerized device that teaches you to contract & relax your pelvic floor muscles)

Urge Incontinence

Urge incontinence is the involuntary loss of bladder control due to an overwhelming and sudden urge to urinate. It is often difficult to get to the bathroom before having an accident. Physical therapy treatment may include:

     •   Bladder diary
     •   Bladder retraining (learning to hold larger volumes of urine and increase time between
         bathroom trips)
     •   Dietary modifications
     •   Biofeedback
     •   Therapeutic exercises
     •   Gentle electrical stimulation if needed
     •   Relaxation techniques
     •   Manual therapy treatment for co-existing pain conditions

Fecal Incontinence

Fecal incontinence is the inability to control your bowel movements, causing stool (feces) to leak unexpectedly from your rectum. Also called bowel incontinence, fecal incontinence ranges from an occasional leakage of stool while passing gas to a complete loss of bowel control.

Muscle damage is involved in most cases of fecal incontinence. In women, this damage commonly occurs during childbirth. It's especially likely to happen in a difficult delivery that uses forceps or an episiotomy. An episiotomy is when a cut is made to enlarge the opening to the vagina before delivery. Muscle damage can also occur during rectal surgery such as surgery for hemorrhoids. It may also occur in people with inflammatory bowel disease, constipation or diarrhea.

People can often compensate for muscle weakness. Typically, incontinence develops later in life when muscles are growing weaker and the supporting structures in the pelvis are becoming loose.

Damage to the nerves that control the anal muscle or regulate rectal sensation is also a common cause of fecal incontinence. Nerve injury can occur in the following situations:

     •   During childbirth.
     •   With severe and prolonged straining for stool.
     •   With diseases such as diabetes, spinal cord tumors and multiple sclerosis.

Fecal incontinence may also be caused by a reduction in the elasticity of the rectum, which shortens the time between the sensation of the stool and the urgent need to have a bowel movement. Surgery or radiation injury can scar and stiffen the rectum. Inflammatory bowel disease can also make the rectum less elastic.

Because diarrhea is more difficult to control than formed stool, it is an added stress that can lead to fecal incontinence. Physical therapy treatment may include:

     •   Manual therapy treatment for co-existing pain conditions
     •   Bowel diary
     •   Biofeedback (computerized device that teaches you to contract & relax your pelvic floor
     •   Core stability program
     •   Relaxation techniques
     •   Patient education
     •   Progressive exercise home program
     •   Gentle electrical stimulation as needed (performed with internal vaginal electrode)
     •   Dietary modifications

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Pregnancy and new motherhood should be times of joy and promise - not pain. Fortunately, times have changed since your mother was pregnant: you don't have to live with pain or other problems related to pregnancy, delivery or recovery after the birth of your child.

That's because physical therapy has changed. Treatment is no longer just for joint problems; it's also a safe, proven, and widely prescribed treatment for pregnant women and new mothers. It promotes a far healthier, less stressful, more comfortable pregnancy that pays lasting dividends: an easier labor, a speedier recovery, and less likelihood of postpartum pain or incontinence (urine leakage).

There are a variety of pains that can arise during your pregnancy. Low back pain (LBP) is a common complaint that can easily and safely be treated by physical therapists that specialize in the care of pregnant women. It is well documented that the pelvic ligaments and joints have more laxity because of increased hormone secretion with pregnancy. We have seen at least a 50-70% decrease in pain within 3-5 physical therapy visits for sacroiliac joint dysfunction (SIJ). SIJ is a condition that is commonly mistaken for Low back pain (LBP).

Our postpartum rehabilitation program can be effective for those that have developed:
     •   Pain with intercourse because of a difficult delivery, episiotomy or tear
     •   Urinary or fecal incontinence
     •   Lingering low back/hip/groin pain, especially with carrying, lifting, holding your baby or with
         simple household chores
     •   Weak stomach muscles (abdominals) or when traditional situps or strength training don’t feel
         as effective as they used to
     •   Painful c-section scar
     •   Feeling of pelvic heaviness or your insides are going to fall out
     •   Abnormal feelings or sensations of the vulvar area
     •   On and off pains they do not seem to go away after 6-8 weeks.

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