Demystifying Persistant Genital Arousal Disorder (PGAD)

PGAD photo

Fiona McMahon PT, DPT

Hello, everyone. Today I want to discuss a condition called Persistent Genital Arousal Disorder (PGAD). PGAD is an often sensationalized, painful, and disruptive condition that causes unwanted genital arousal, which doesn’t typically get better with orgasm and if it does, orgasm only brings relief for a short period of time. The key feature of this disorder is the genital arousal is unwanted and can cause deep psychological distress.

Typically when I write blogs, I will spend the lion’s share of my time sifting through scholarly articles, general health articles targeted at the general public, and maybe I will read one or two essays or editorials written by people with that particular condition. The process for writing this blog went a bit differently.

I was researching a condition that had only been first classified in 2001. There really was a small pool of articles from which to pull. I also had to sift through a lot of garbage. There were titles like “ Woman has 100 orgasms a day”, click bait, on click bait, on click bait. I thought of my patients and women and men, who are just starting their journey, not knowing where to start. Frankly, I was sad. I can’t think of a more eloquent way to say it: the web can be a real garbage pit sometimes. I can imagine how hopeless it might feel scouring the Internet for answers.

The good news is, I did not end my research sad. I ended up finding some great articles, but most importantly I listened to a fabulous Pelvic Messenger podcast with our very own Stephanie Stamas PT, DPT with guest Dr. Irwin Goldstein, MD, on PGAD. I ended my research feeling empowered, and it is my hope through this blog and additional resources I have provided, that you will too. If you have found your way here because you have or think you may have PGAD, please, do yourself a massive favor and give this podcast a listen. I will be breaking down so me of its points in this blog, but what the podcast does so well, is give hope.

Let’s go ahead and read on, and learn more about PGAD and how to manage it.

What Causes this Condition?

PGAD can affect people with both male and female anatomy. As Dr. Goldstein explains in the pelvic messenger podcast, It is more common in individuals with female anatomy, secondary to the fact the people with female anatomy have a shorter refractory period. The term refractory period refers to the interval of time that is required between an individual’s first orgasm and when they are able to become sexually aroused again. People with male anatomy tend to have longer refractory periods, allowing them some relief between bouts of arousal.

There are many factors that are thought to contribute to PGAD. It used to be considered more of a psychological disorder. Over the past 16 years, researchers have found that the development of PGAD can be influenced by stress, but there usually is some sort of anatomical or physiological factor contributing to the development of this condition.

The Role of the Brain

Like we discussed before, stress is a contributor and trigger to PGAD symptoms. Additionally, one of the criteria in diagnosing PGAD is that the genital arousal causes distress. Examining stress triggers and managing the stress of the disorder itself is paramount to effectively managing PGAD, especially if it is taking time to determine what physiological intervention will help treat the symptoms.

There also is some discussion that the sensations that trigger PGAD are processed differently in the brain. Disruptions in the vulvar, penile, or scrotal tissue, nerve compressions, pelvic congestion, etc may be processed in the “action” areas of the brain and may be interpreted as or cause arousal, when in fact, there is a physical condition irritating that delicate tissue that must be addressed.

Studies have also found a connection with PGAD suffers and individuals with restless leg syndrome. In a 2008 study PGAD and restless leg syndrome were found to be correlated. Restless leg syndrome bears some similarities to PGAD in that sufferers often feel they need to take action, like moving their legs, adjusting their position, and in individuals with PGAD, obtain orgasm for momentary relief. These findings amongst others support the theory that the brains of individuals with PGAD may interpret sensory signals differently that those without the condition.

Medication, Pearls, Back Problems, and Cysts

Now that we have talked about a potential explanation for persistent genital arousal as it relates to the brain, let’s talk about some of the physiologic contributors. The first factor found to be correlated with PGAD has to do with what we put in our mouths. There had been some evidence to support that increased soy intake may affect the development of PGAD. Also certain medications and withdrawal from them may also contribute to PGAD. Trazadone has been found to contribute to priapism (persistent and painful erection of the penis) in individuals with male anatomy and may also contribute to PGAD in individuals with female anatomy. There also has been a correlation with sudden withdrawal from selective serotonin reuptake inhibitors, (SSRI’s), a form of antidepressant, and the development of PGAD. We always have to remember the old adage that is familiar to anyone who has been taught to consume scientific literature that, “Correlation does not equal causation”. It’s really important to remember that phrase with PGAD, because there are many correctable physiological conditions that also contribute to PGAD.

Keratin pearls, sounds lovely, right? Not so much, and these bad boys are a big factor in the development of PGAD and other pelvic pain syndromes. Keratin pearls develop when the normal products of the vulvar tissue collect and harden under the clitoral hood. As you can imagine, having a keratin pearl is super irritating to this extremely sensitive tissue, not unlike having a piece of sand caught in your eye. This constant stimulation can certainly contribute to PGAD symptoms. Keratin pearls can be removed by an experienced doctor and bring relief for PGAD.

In pelvic floor physical therapy land we think a lot about the pudendal nerve. The pudendal nerve transmits sensory information from our genitals to our brain and gives our pelvic floor muscles instruction from the brain. The pudendal nerve comes off the sacral nerve roots, S2, S3, and S4, (remember this for later). This nerve can become compressed from tight muscles and fascia and can cause PGAD symptoms.

Physical therapists and other clinicians also think about the various “dynias”. Dynia is the Greek word for pain. In relation to PGAD we often think of clitorodynia, vulvodyina, and vestibulodynia referring to pain in the clitoris, vulva, and vestibule respectively. These “dynias” can be caused by irritated nerves, hormonal conditions and overactive pelvic floor muscles and should be addressed in order to help treat PGAD. Additionally, other pelvic syndromes like pelvic congestion can contribute to PGAD.

Do you remember the nerve roots for the pudendal nerve? It’s okay if you don’t. They are the sacral nerve roots S2, S3, S4. Your sacrum is part of your spine and problems in your back like a slipped disc, irritable facet joint, stenosis can all be culprits in irritating these very important nerve roots.

There are these things called Tarlov’s Cysts which recently have been found to be huge in the development of PGAD. Tarlov’s cysts are little sacs filled with cerebrospinal fluid and they can irritate those important nerve roots, S2, S3, and S4. In 2012, it was found that the rate of Tarlov’s cysts is exceptionally high in individuals with PGAD. Management of these cysts can help with this disorder.

Treatment Options and Finding the Correct Practitioner to Connect you to Those Options

So there is a lot of stuff to sort through when trying to figure out where your PGAD is coming from. It requires a skilled clinician to separate the signal from the noise. At Beyond Basics Physical Therapy, we are especially poised to help you get started on the correct treatment path.

Unlike many other clinicians, we are comfortable assessing things like the mobility of the clitoral hood, mobility of the structures surrounding the pudendal nerve and other pelvic nerves, as well as being able to treat issues involving the back and tailbone. We also have strong and robust connections to physicians who are pioneers in the treatment of PGAD and can help facilitate access to complementary medical treatment.

The most important part of treating PGAD is finding the cause, or the driver. Once the driver or drivers are found, you can begin the process of treating them and reducing PGAD symptoms. Dynias, clitoral adhesions, pelvic floor congestion, back issues and irritation to a pelvic nerve can be treated by physical therapy or a combination of physical therapy and medical intervention. Tarlov’s cysts may require surgery to correct. Additionally medication to reduce the symptoms, mental health therapy and relaxation techniques can be helpful.

PGAD used to be such a mystery and in some respects, it still is; however we are in a very exciting time, where knowledge about PGAD is growing as well as our ability to diagnose and treat this disorder. The internet is a very scary place to research PGAD and it can be hard to find almost anything hopeful or positive, but there is hope. Give the Pelvic Messenger Podcast a listen and make an appointment to see us here at BBPT today.

Charitable Giving Options to Support Research and Treatment

Like many pelvic pain conditions, PGAD is under researched. Research is an essential weapon to help us fight PGAD and improve individual’s lives. Please consider donating to the following organizations to fund the development of diagnosis and treatment protocols for PGAD and other pelvic conditions. Also, consider having your company or a friend’s company match you donation.

Donate to support pelvic pain research here:

International Pelvic Pain Society : IPPS https://wjweis.association-service.org/securesite/ipps/donations.aspx

International Society for the Study of Women’s Sexual Health ISSWSH; http://www.isswsh.org/about/endowment-fund

Sources

Aswath M. Pandit L, Kashyap K. et al. Persistent Genital Arousal Disorder. Indian J Pyschol Med. 2016; 38(4)

Jewell T, Legg T. What is persistent genital arousal disorder (PGAD?). Healthline. 2017 [Accessed: November 13, 2017]

Komisaruk B, Lee H. Prevalence of Sacral Spinal (Tarlov) Cysts in Persistent Genital Arousal Disorder. J Sex Med. 2012 Aug;9(8):2047-56.

Stamas, Stephanie. “ Dr. Irwin Goldstein: Treating Persistent Genital Arousal Disorder (PGAD).” Audio Blog Post. Pelvic Messenger Podcast. Blog Talk Radio. March 2017

Waldinger M, Schweitzer D. Persistent Genital Arousal Disorder in 18 Dutch Women: Part II- A Syndrome Clustered with Restless Legs and Overactive Bladder. J Sex Med. 2008

The Special Care Needs of the LGBTQ+ Community

Amy Stein PT, DPT and Fiona McMahon PT, DPT

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Who are LGBTQ+ individuals?

At Beyond Basics Physical Therapy, we have been meeting and studying with experts about the LGBTQ + community. LGBTQ+ refers to individuals who do not identify as heterosexual or do not identify as cis- gendered (although these two categories are not mutually exclusive). Cis-gender means you identify with the genital anatomy you were born with. People who belong to the LGBTQ+ community can be cis-gendered (meaning they identify with the genital anatomy that they were born with) and be gay/lesbian/ bisexual/ questioning etc.  They can be trans-gender and heterosexual or some combination thereof. Basically LGBTQ+ is a term that includes people who are not both cis-gender and heterosexual. LGBTQ+ is an acronym for lesbian, gay, bisexual, transgender, queer/questioning, and other individuals.  

Never Assume. Listen, Ask.

We were excited to understand and learn more about how we can help, specifically with patients experiencing pain or weakness in the pelvic floor. We met with an LGBTQ + advocate and he recommended the following when it comes to treating patients both within and outside the LGBTQ+ community.  First rule of thumb:  with all patients, don’t assume and be open to any questions or discussion. Ask if your patient would like you to stay away from certain terms regarding their anatomy, as well as their preferred gender pronoun. Use language that they want us to use.

 As with all patients, we need to use a biopsychosocial approach. With any patient, Richard Green at Bellevue hospital says that we always want to know exactly what is going on with our patient. We must subjectively understand why they are visiting us.  Has there been trauma, surgery, complications, or anything that has worsened their symptoms? What hormones and medications are they on? Don’t single anyone out. These questions are important for every patient.  

We want to get the medical and surgical history during or prior to the visit. There is no standard one surgical procedure or hormonal protocol in Trans care. Hormones, either testosterone, estrogen, Lupron, puberty blocking, GNRH can be used in many patients, but are also used specifically to aid in transition in Transgender patients. Many hormones have consequences or side effects and our patients need be educated on the various options.  There is research on hormones and bodily changes, however there is no good research on how the hormones affect the pelvic region. Anti-estrogen hormones may result in vaginal drying and atrophy, more tissue tearing, and pain with penetration.  Endometriosis can be worsened with testosterone hormones.  Hormones can be administered via injection, pellets, patches, creams, gels, and pill form.  It’s important to realize side effects and risks of hormones for each patient. Dosage depends on body type, weight, previous surgeries, etc.  Hormone therapy can be given by a primary care provider or endocrinologist; however, many are not familiar with a specific protocol but at the same time each person may have different goals.  Progression of hormones can be monitored for each patient and according to patients wants and needs.  

For those who opt for surgical transition, it can result in pelvic pain and or weakness as organs are moved and or removed. Like we mentioned before, there is no one surgical protocol and it will vary from surgeon to surgeon, from changes in hormones from the removal of certain organs.  Knowing what tissues have been removed or moved and or where scar tissue could have been formed, is important to addressing a patient’s complaints. Also, it’s important to ask if the patient was having these symptoms or pain prior to any of the surgeries or hormonal medications. Surgical transition can take a long time with various surgeries and various symptoms that arise throughout. Some issues that  can occur are fistulas or fissures and when dealing with nerve implants there could be nerve damage and restrictions.

 

How is care for the LGBTQ+ community funded and regulated?

Medical coverage for the LGBTQ + community is non-regulated and different in each state. The Affordable Care Act, (ACA) covers some therapies and surgeries. You can try to appeal with each insurance which have their own policies on gender affirming care.

How can physical therapy help?

At Beyond Basics Physical Therapy, we specialize in abdomino-pelvic disorders, including pain, weakness, bladder, bowel and sexual dysfunction.  We also specialize in orthopedics and functional manual therapy.  We treat the LGBTQ+ community and we welcome any questions at desk@beyondbasicspt.com or call 212-354-2622. We are happy to help and look forward to hearing from you!
Resources: Center of excellence for transgender health.

WPATH center for care Endocrine Society

  • speaks on hormone therapy (however some information may be out of date).

 Adolescent Health Center

World AIDS Day

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Today, December 1st 2017, is World AIDS Day. World Aids Day has been held on the first of every December since 1988. World AIDS Day works to spread awareness of the disease and to remind the general public that AIDS and HIV still must be taken seriously and that there is still a lot of work to do in order to prevent the transmission of new cases, as well as to better care for those who are infected with the disease.

What is AIDS/HIV?

AIDS (acquired immunodeficiency syndrome), is caused by a virus called human immunodeficiency virus (HIV). HIV can be treated in order to prevent AIDS, however there is currently no cure for HIV.

HIV causes AIDS by attacking the immune cells of a person’s body, which can leave a person vulnerable to infections that otherwise would not have made them sick. These infections are referred to as opportunistic infections, an opportunistic infection is a signal that someone’s HIV may have progressed into AIDS.

As said earlier, HIV doesn’t always have to progress to AIDS. Antiretroviral therapy (ART)  can work to help keep the immune system healthy, as well as lower the risk of transmitting the virus to others. People on ART have dramatically improved lifespans. It is imperative to get on ART as soon as possible to lessen the effects the HIV virus has on your immune system.

HIV Testing

1 in 7 people infected with HIV do not know they have the virus. Testing is necessary to start treatment and reduce harm done to your immune system as well as risk of transmission to others.

According to AIDS.gov, you should be tested if:

  • You have had sex with someone who is HIV positive, or someone whose status you were unsure of since your last test
  • Had tuberculosis or hepatitis
  • Used shared needles
  • Been diagnosed with another type of sexually transmitted disease

HIV/ AIDS and Physical Therapy

Physical Therapists do not treat AIDS or HIV, rather, they treat the symptoms of AIDS/HIV and HIV/AIDS treatment to allow patients to live as fully and independently as possible. Both the disease itself and the treatment for it have effects like increasing fatigue, decreasing strength and endurance, and increased pain. Physical therapy can help by tailoring programs to help with pain, ability to perform everyday tasks, improve heart health, balance, endurance, strength and flexibility.

You can mark today by doing a number of things:

Wear a red ribbon to spread awareness

Donate to groups that work to help people living with AIDS and help to prevent its transmission:

United Nations (UN AIDS)

https://donations.unaids.org/

UNICEF

https://www.unicefusa.org/donate/support-unicefs-hivaids-programs

Sources:

AIDS.gov

Resources:

HIV/Screening:

National HIV Testing database: https://gettested.cdc.gov/

Marathon Update: Shaving Time off my Race with Physical Therapy and Doing Good in the Name of Multiple Sclerosis Research

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Fiona McMahon PT, DPT

Hi everyone! It’s Fiona from BBPT. I am writing the day after the 2017 NYC Marathon sore, tired, but happy. It was a great training season, in which I pushed myself harder than I had before and had a great physical therapist, Jessica Babich PT, DPT looking after me the whole way.

Let’s not bury the lead any further. As of today, we managed to raise over $3,500 to support research for multiple sclerosis (MS) through NYC Team Tisch MS and as a group Team Tisch raised over $100,000 dollars to further the goal of making TISCH MS history.

finish timeALSO…. physical therapy definitely payed off. I shaved over 17 minutes my last NYC marathon in 2013, going from a time of 4 hours 0 minutes and 4 seconds, to 3 hours 43 minutes and 2 seconds. Not only was it a personal record for the course, but it was 8 minutes faster than my previous all time best at Sugarloaf in 2011.

This was my first time getting physical therapy during training for a race, rather than having to turn to it when some type of disaster struck, be it a rolled ankle, irritable knee, etc. This is the first time I’ve had someone care not only about my core, but whether or not it engaged when it was supposed to.

I would advise anyone who is considering engaging in an athletic endeavor, especially a new one, or when competing in a sport for time, to strongly consider getting an experienced physical therapist with expert skills in manual therapy and a keen eye for function. They can evaluate problem spots from head to toe (literally, in my case, Jessica worked on both my neck and ankles). They can help you tailor your training to get the most out of your exercises to allow you to perform at higher levels. Jessica kept me healthy and motivated, and her work allowed me to train safely and effectively at an intensity I hadn’t yet explored independently.

Thank you all for your support. If you still care to donate you still can here.

If you think you would benefit from PT at Beyond Basics, click here or call today.

Navigating Life with Chronic Pain: Part II

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Fiona McMahon, PT, DPT

Welcome back to our discussion on chronic pain. In our last blog we discussed why one might experience chronic pain and some common missteps and pitfalls that have occurred in our understanding of chronic pain. If you haven’t yet read part one of this blog, I highly recommend checking it out first so you can get the most out of this post. Click here to read it now.

For chronic pain we have drugs, surgery, mental health therapy, physical therapy, and what is called complementary alternative medicine (CAM), which includes modalities like yoga, acupuncture, and mindfulness meditation. We discussed earlier about how some opiods may actually be harmful in treating chronic pain. Unnecessary surgery can also have risks of actually increasing pain post surgically, because it can change the brain’s sensitivity to pain. Because, for most musculoskeletal conditions, a course of conservative treatment is recommended for a period of time before turning to surgery, we will focus on non-surgical, and non medical approaches to chronic pain.

Before we dive into specific treatments, let’s talk about what puts a person at risk for chronic pain. We can divide these risks into modifiable and non modifiable risks. Non modifiable risks are situations or characteristics about ourselves that we can not change. They include socioeconomic status, where you live or have lived, cultural background and genetic factors. Unfortunately, we can’t change these things, but things like alcohol intake, nutrition, and obesity are all things we can change and have been generally understood as modifiable risk factors for chronic pain. Now that we have that in mind, let’s explore different approaches for the management of chronic pain.

 

Mindfulness Practice as Pain Management

Have you tried mindfulness practice? I ask this question a lot. When I ask it, I am careful to frame it in a way that does not give the patient the impression that I think their pain is all in their head, but rather, I try and present it as part of an adjunct to the current physical therapy treatment they are receiving from myself or any of the other PT’s at Beyond Basics Physical Therapy, and any other medical intervention they may be receiving.

Mindfulness and mindfulness meditation are somewhat based on eastern meditation practices.  Not all mindfulness programs are the same, but the basic premise is to allow  the participant to to observe their thoughts, feelings, sensations, and attitudes without judgement. Giving them the opportunity to reframe their thoughts in a positive manner.

It may sound like a small change, but research is really starting to bear out that changing your frame of mind about pain can have some very real results. In a meta-analysis done by Hilton  and colleagues, mindfulness programs were found to have statistically significant positive results on pain, depression, and quality of life.

There are a lot of ways you can incorporate mindfulness into your day to day life. Apps for your phone are really helpful. I recommend both Calm and Headspace. I personally like Calm a bit better, but both are excellent. Headspace is a good starter because it breaks up meditation into more digestible nuggets, which can be a good way to start your meditation practice. Calm, as the name implies, is more soothing.  There are also guided classes you can attend in your area if that’s more up to your speed.

Be patient with mindfulness, I definitely suggest giving it the old college try. Stick with it for a week or two. If it isn’t for you, that’s perfectly okay. It’s not a moral failing, or a psychological one it’s definitely a case of different strokes for different folks.

Psychological Intervention

In a study performed by Macrae and colleagues, it was found that patients who engaged in catastrophizing type behaviors experience post surgical pain at a significantly higher rate. Catastrophizing is envisioning a situation to be far worse than it actually is. A good example for this blog would be a patient with low back pain, jumping to the conclusion that her back pain will prevent her from being able to work and she would end up on the street, secondary to her her lack of ability to secure an income. Although this is a possibility, it really isn’t a realistic one and it fails to entertain the possibility of the back pain remaining stable or getting better.

Mindfulness meditation can help with catastrophizing behaviors, but sometimes you need a little extra help. Psychological interventions, like talk therapy and cognitive behavioral therapy, can help you get a handle on these thoughts and address your current loss of function, secondary to pain in a more productive manner. Cognitive behavioral therapy as well as other forms of therapy have shown improvement in pain symptoms and quality of life in adults, and has shown even more robust effects in children.

Acupuncture

Acupuncture is an ancient form of eastern medicine that is gaining a stronger and stronger foothold in the States. It has been shown to be effective in managing a number of conditions, and chronic pain is no different. Reviews of acupuncture in the scientific literature have found that acupuncture can improve pain and function. The same review found that electroacupuncture had even more robust results for pain and stiffness.

Yoga

Yoga is super hip right now. In fact it now has its own international day on June 21st of each year. It does for good reason. A consistent and solid yoga program has been shown to improve conditions such as low back pain, myofascial pain syndrome, fibromyalgia syndrome, osteo- and rheumatoid arthritis. It can be a great option to continue to add consistent exercise and pain management into your life.

Physical Therapy and Exercise

Exercise is good for you, even if you have chronic pain. The old way of thinking was to put someone on days of bedrest when they have chronic pain. No more. Evidence has shown gentle movement progressing into more functional training can really help with chronic pain. In fact the National Institute for Healthcare Excellence’s (NICE)  osteoarthritis  guideline is  “exercise should be a core treatment… irrespective of age, comorbidity, pain severity and disability. Exercise should include: local muscle strengthening [and] general aerobic fitness”(NICE 2014) . Geneen and colleagues found in their review and meta-analysis of the current literature that just receiving the advice to exercise alone, is not sufficient to produce improvements in pain scales. That’s where the professionals like physical therapists come in, PTs have the knowledge and expertise to prescribe exercise that is not only safe and functional, but hopefully kind of fun. PTs also can diagnose and treat issues such as tissues with reduced mobility and poor alignment to ensure you get the most out of your exercise.

Data show that a prescribed and monitored exercise program by a physical therapist can have good effects on pain symptoms and can help facilitate the production of your body’s own natural painkillers.  Additionally exercise can help individuals lose weight, which can reduce the pressure on one’s  joints and further improve pain.

Aside from exercise and hands on work, we can use modalities like kinesio tape at physical therapy. Kinesiotape has been shown to improve not only pain, but decrease trigger points, improve range of motion and improve disability rates in individuals suffering with myofascial pain syndrome.

Conclusion

Chronic pain is complex. Rarely is there a silver bullet that will cure it. Treatment requires a multidisciplinary approach, which has been shown to be more effective than traditional treatment alone. Start small, where you feel comfortable when adding something new into your treatment approach. You will find what works best for you. A good place to start is here at Beyond Basics. Our staff not only has the expertise to treat you from a physical therapy perspective, they also have the ability to guide you towards other traditional and complementary treatments/practitioners that can help you reach your goal. Your treatment for chronic pain does not have to be and should not be passive, please call and make an appointment today to start your journey.  

 

Sources:

 

Achilefu A, Joshi K, Meier M. et al. Yoga and other meditative movement therapies to reduce chronic pain. J Okla State Med Assoc. 2017;110(1):14-16

 

Andersen T, Vægter H. A 13-Weeks Mindfulness Based Pain Management Program Improves Psychological Distress in Patients with Chronic Pain Compared with Waiting List Controls. Clin Pract Epidemiol Ment Health. 2016;12: 49-58

 

Ay S, Konak H, Evick D, et al. The effectiveness of kinesio taping on pain and disability in cervical myofascial pain syndrome. Rev Bras Reumatol. 2017; 57(2) 93-9

 

Eccleston C, Crombez G. Advancing psychological therapies for chronic pain [version 1]; referees: 2 approved]. F1000 Faculty Rev. 2017

 

Geneen L, Moore R, Clarke C, et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews ( Review).  Cochrane Database Syst Rev 2017; 4

 

Hilton, L, Hempe; S, Ewing B. Mindfulness Meditation for Chronic Pain: Systematic review and meta-analysis. Ann Behav Med. 2017. 51:199-213

 

Kamper S, Apeldoorn A, Chiarotto A, et Al. Multidisciplinary biopsychosocial rehabilitation for chronic pain ( review). Cochrane Database Syst Rev. 2014; 9.

 

Macrae W. Chronic post-surgical pain: 10 years on. Br J Anaesth 2008;101: 77-86

 

Mayer F, Scharhag-Rosenberger F, Carlsohn A. The intensity and effects of strength training in the elderly.  Dtsch Arztebl Int 2011; 108(21):359-64

 

Neira S, Marques A, Pérez I. Effectiveness of aquatic therapy vs land based therapy for balance and pain in women with fibromyalgia: a study protocol for a randomized trial. BMC Musculoskelet Disord. 2017; 18(22)

 

Perry R, Leach V, Davies P, et al. An overview of systematic reviews of complementary and alternative therapies for fibromyalgia using both AMSTAR and ROBIS as quality assessment tools. Sytematic Reviews. 2017. 6(97)

 

Saxena R, Gupta M, Shankar N, et al. Effect of yogic intervention on pain scores and quality of life in females with chronic pelvic pain. Int J Yoga. 2017. 10(1): 9-15

 

Singh P, Chaturvedi A. Complementary and Alternative Medicine in Cancer Pain Management: A Systematic Review. Indian J Palliat Care. 2015. 21(1): 105-15

 

     

 

How to Improve Bladder Health

Bladder

Fiona McMahon, DPT

The bladder, not super complex right? Just a tupperware for pee, holding your urine until an opportune time to go. The bladder is so much more than that, integrating information from the brain, muscles of the pelvic floor, and responding to stretch to efficiently serve its purpose. We never think of the bladder until something goes wrong with it.

In honor of bladder health month, we will be exploring the anatomy of the bladder, what is normal for the bladder, what can go wrong with the bladder, and how to best take care of your precious and hard working bladder.

Bladder Anatomy/ Physiology

 

Male or female, we all have the same basic structure of the bladder, with a few exceptions. Here’s what everyone has in their lower urinary tract.

  • Detrusor Muscle: Forms the body of the bladder and is responsible for squeezing the bladder to empty its contents. It spends most of its time relaxed in order to allow for bladder filling.
  • Trigone Muscle: Forms the neck of the bladder, and is a powerful sensory organ. When the trigone stretches in response to the filling of the bladder, it sends a message to the brain that it’s time to pee.
  • Internal Urethral Sphincter: Smooth muscle (involuntary) which seals off the exit of the bladder and allows for continence.
  • External Urethral Sphincter: Striated or voluntary muscles which also seals the exit of the bladder.
  • Urethra: This is the tube that leads out of the bladder and is the pathway for urine into the outside world.

Sex differences:

Men have a prostate. The prostate is a sex organ and is responsible for keeping the semen at the right pH to fertilize a waiting egg. It wraps around the urethra and lives just under the bladder. It also provides a mechanical buttress or support for the bladder, lessening the load on the pelvic floor.  Because of its proximity to the urethra, problems with the prostate can cause problems with the bladder.  An enlarged prostate, which can be a benign part of aging, cancer, or infection, will restrict the flow of urine out of the urethra, resulting in weak stream, painful, burning urination, and difficulty urinating (the same thing happens with tight pelvic floor muscles). A prostate that has been surgically removed, most often has occurred for treatment of prostate cancer can reduce support for the bladder and lead to leaking. For more information on prostate cancer click here  and for more info on prostatitis, click here!

Another important difference between people with female and male anatomy are the respective length of their urethras. Male urethras are a lot longer than female urethras. This is one of the reasons people with female anatomy are more prone to bladder infections. In a female, bacteria have a lot easier time making the trek to the bladder because of the shorter urethra.

Conditions of the Bladder

Incontinence

Incontinence is the involuntary leakage of urine. There are many causes of incontinence. It’s important to know why you are leaking in order to know how to appropriately remedy it. It is possible to have more than one type of incontinence, and when that occurs we call it mixed incontinence.  Let’s go through the types together.

  • Urge incontinence occurs when you leak urine  after a sudden urge to urinate. We call it, lock in key syndrome, because certain events like unlocking the door to your home can cause urge incontinence.  This is the type of incontinence, which should be treated first in cases of mixed urge/stress incontinence.
  • Stress incontinence is the result of pelvic floor weakness that prevents the closure of the external urethral sphincter with activities that increase the pressure on the bladder, like coughing, laughing, lifting or sneezing. Pelvic floor weakness can occur if the muscles and or connective tissues are too loose to create an efficient contraction and more commonly, especially with athletes, too tight or imbalanced, to fully close the external urethral sphincter. Read more about incontinence in athletes here.
  • Functional incontinence occurs when you physically can not get to the bathroom in time to urinate. This is common in the elderly or disabled, who may have trouble ambulating to the bathroom, removing clothing, or transferring from a chair into standing. It is imperative that this type of incontinence is treated aggressively by a physical therapist or occupational therapist as it increases the risk of potentially fatal or disabling falls.

Incomplete voiding

Incomplete voiding is when the bladder does not fully empty.

In a normally functioning patient, volitional effort should not be required to empty the bladder.  A pelvic floor that is unable to relax, will have a smaller opening for urine to pass through or the voluntary muscles involuntarily contract because of muscle spasming, resulting in hesitancy, or incomplete bladder emptying.

Bladder Pain

Pain is our body’s way of telling us there is something wrong. With a new onset of bladder pain, it is important to rule out infection or an organic condition. Often times musculoskeletal conditions or general bladder irritation can mimic bladder infections.  In our practice, we often see patients who had been convinced they had an infection only to find out all of their tests for infection, where in fact, negative and the source of their pain was a tight or shortened pelvic floor.

It is important to understand the character of your bladder pain. Does your bladder hurt as it fills with urine and then feels better only shortly after voiding? If your answer is yes, you may have bladder irritation from urine that isn’t dilute enough (you are not drinking enough water), or you are consuming something irritating like spicy food, caffeine or alcohol. You may also have a condition known as painful bladder syndrome/interstitial cystitis which is contributing to your symptoms. It is important to get a handle on bladder filling pain right away, because it is the first step in treating other conditions such as frequency, urgency, incomplete emptying and retention.

If you have pain and burning during urination with no infection, it is likely the pelvic floor muscles and tissues cannot relax enough to allow urine to flow out without burning, (the pelvic floor also plays a role in bladder filling pain as well). Burning with urination that is not caused by an infection, is treatable with pelvic floor PT.

Frequency:

Everytime I hear someone say “I have a small bladder”, I have the uncontrollable urge to say, “No, you have a sensitive bladder, which can be trained to be better”. Saying you have a small bladder is 95% of the time fatalistic and just untrue. Most bladders, with few exceptions can hold 400-600 mL. Holding capacity can be diminished in cases of constipation, pregnancy and some neurological conditions, but most everyone is working with similarly sized equipment (the exception, being growing children).

Average intervoid interval, aka times between pees, is 2-3 hours, unless you chug a liter of fluid or cups of caffeine in one sitting. An example is being able to make it through James Cameron’s, Titanic, without having to excuse yourself. The trick with the bladder is it’s antsy. It informs you with the first urge to urinate when it is approximately 40% full. Over time, if you listen at that first urge, the bladder will begin to inform you earlier and earlier until you are going once every 20 minutes. Training your bladder to hold more is achieved with ignoring the urge or practicing various behavioral strategies, like deep diaphragmatic breathing with pelvic floor drops, to allow for longer intervals until your bladder capacity is within normal limits. This can be a longer process for those with a more sensitive bladder.

Bladder training is complicated by pain. Pain usually must be treated simultaneously in order to truly get the most benefit from bladder retraining. It is also important to realize that substances like caffeine and alcohol increase urgency and make bladder training more difficult.

How to Manage Bladder Issues:

Fortunately, there is a lot you can do, RIGHT now to manage your bladder symptoms. I find that in my practice and everyday life, there is a certain fatalism about bladder conditions. I can’t count how many times I’ve heard phrases like, “ I just have a small bladder”, “Women my age after babies just leak”, “I am older so I pee more at night” and “it’s always been like this”. The bladder is a trainable organ and the muscles influencing it can be stretched and strengthened like any other muscle in the body. The best part is there is so much you can do for yourself at home. It’s totally worth trying and in many cases is a life changer.

Diet and fluid intake:

It may sound counter intuitive, but drinking plenty of water is good for almost all bladder conditions. Yes I am talking about leaking, urgency, incomplete emptying and frequency. Drinking lots of water keeps your urine nice and dilute, minimizing the irritation of the bladder wall as well as the reactive spasm of the detrusor muscle. You should drink approximately half your bodyweight in ounces of water a day. For example: a 150 lbs person should consume 75 ounces of water a day. You should increase this amount if you are exercising, or experience a lot of sweating or drink a lot of caffeine and or alcohol, which are both dehydrating. It is also important to be mindful of bladder irritants which can worsen bladder issues. Big irritant culprits are alcohol, caffeine, citrus, and spicy food. In children, dairy milk is a common bladder irritant.  Keep in mind that one person’s bladder irritant may not be your bladder irritant. It’s easy to look at lists of bladder irritants and get overwhelmed. Try eliminating a suspected offender for two to three days. If you feel better when you aren’t consuming that item and worse when you add it back in, consider eliminating that item from your diet.  It is also important to eat in a way that prevents constipation, as this worsens bladder symptoms and puts extra pressure on the bladder.

Posture

If you are having problems fully emptying your bladder or you have post void leakage ( dribbles following going to the bathroom) consider your toileting posture. People with bladder issues should sit on the toilet ( even dudes), to allow the pelvic floor muscles to relax and allow the bladder to fully empty.

Bladder Training

If you have bladder frequency or leakage  now is the time to try and train your bladder to hold more urine. Keep in mind you should start treatment to address pain with physical therapy and in certain cases, with medication, to allow you to be successful with bladder training. I always tell my patients to start their bladder retraining at home, where a bathroom is available to take the stress out of possible leaks or not being able to find a bathroom. Start by simply waiting to go to the bathroom 5-10 minutes past your first urge to urinate. Use behavioral strategies, such as deep breathing and pelvic floor drops, mindfulness, distraction and others.  If you don’t have to go after 5-10 minutes, Great! If you do, go to the bathroom. As waiting 10 minutes becomes easy, stretch your time to 20 minutes and so on until you are able to go 2-3 hours in between urination.

Physical Therapy

Physical therapy is considered a mainstay and top treatment for musculoskeletal causes of bladder disorders and bladder pain.  Expert pelvic floor physical therapists are clinicians who can find the cause of your bladder issues and provide you with a customized plan that will provide you with the best results possible. PT’s can work to relax spasmed muscles, treat constipation contributing to bladder issues, improve your toilet posture, reduce tightness around the bladder, abdominal and thigh region that can contribute to bladder dysfunction, as well as strengthen weak muscles. If you are experiencing bladder issues, please come see us.  There is so much we can do to help!

Sources:

Berghmans L, Hendriks H, Van Waalwijk, et al. Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU Int. 2000; 85: 254-63

Chancellor, M, Yoshimura N. Neurophysiology of stress incontinence. Rev Urol. 2004; 6(Suppl3)S19-S28

Chang H, Lynm C, Glass R, et al. Urinary incontinence in older women. JAMA, 2010; 303(21): 2208

FitzGerald M, Brensinger C, Brubaker L, et al. What is the pain of interstitial cystitis like?. International Urogynecology Journal Including Pelvic Floor Dysfunction. 2005

Shafik A, Shafik I. Overactive bladder inhibition in response to pelvic floor muscle exercises. World J Urol. 2003 May; 20(6):347-7. Epib. Apr 4

PH101: Potty Issues with Kiddos

happy kid play superhero , boy power concept

Fiona McMahon PT, DPT

Did you know kids can suffer from pelvic floor dysfunction too? Pelvic floor dysfunction in children can result in pain, bladder holding or constipation, embarrassing soiling accidents, frequent nighttime accidents, as well as trouble going potty. For most kids, there is an underlying physical component that needs to be addressed by an expert pediatric pelvic floor physical therapist.

It is very upsetting for a parent, guardian or caregiver to see a child suffer with pain or embarrassment, but there is so much that can be done to help out children with these issues. We use positive charts to develop short term and achievable goals to reinforce  behaviors and steps towards healthy toileting. Simple techniques like using the improving toilet posture, practicing deep breathing with bubbles, using a timer to assist in times voiding, educating the parent/guardian/caregiver on the colon massage, developing a core stability and stretching program, and more can go a long way towards improving bowel and bladder symptoms.

If your child is suffering from urinary or fecal accidents, bed wetting, skidmarks, or painful defecation, join me on November 15, at 7pm , to discuss pelvic floor dysfunction in children, common conditions affecting pottying, and practical tips you can use to make potty time easier.

This is our last Pelvic Health 101 class of the spring series. We want to thank for an awesome season! Keep your eyes on the blog for the Fall’s PH101 classes!

RSVP: pelvichealth101.eventbrite.com