Why seek out a physical therapist with advanced orthopedic training? The case for CFMT and OCS

Pelvic 3By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT

If you have perused our website, you might have noticed that here at Beyond Basics, we have many physical therapists who have a CFMT certification, or are in the process of completing one. Now the question lies, what is a CFMT? How is this approach unique? How can this approach be of benefit to me?

The acronym CFMT stands for Certified Functional Manual Therapist. This certification is through the Institute of Physical Art (IPA), which is an organization founded by two physical therapists, Gregg and Vicky Johnson.

With the CFMT approach, we evaluate and treat every individual’s mechanical capacity (how your tissues and joints move), neuromuscular function (how your system stabilizes itself, and the coordination of muscle activation), and motor control (how an individual moves and performs daily tasks). Furthermore, we assess and retrain how these three individual components interact to ensure each person can return to the tasks/activities they need and love to do.

What this means is, when a new patient walks through our door, we don’t just focus on one small area, such as only the knee in which you report pain. Instead, we will look at the big picture by assessing your strength, amount of limb and segmental motion available to you, posture and alignment, and movement, which can be as simple as getting out of a chair, or a higher level activity such as running, weight lifting or other sport-related activity. This will allow us to get a thorough impression of what impairments you might have, and will help us determine what the cause of your symptoms and functional limitations is (what is the driver?). From here we can figure out the most effective approach to your treatment, and will apply progressive interventions that help to ensure continued benefits from each session. We have found that this approach commonly gets you back to your activity or sport faster!

Now you may be asking yourself, “Well this sounds interesting, but why does it matter?” Looking at the whole person and treating your system overall, allows us to make lasting changes, not only to a specific body part that is causing problems for you, but also with your habits of how you hold yourself and move. By becoming more aware of your body and moving with more efficiency, you will find day-to-day activities, and even sporting activities, are easier for you to perform. Furthermore, and most importantly, if you are able to move and live in a more efficient way, you are decreasing the risk of future injury.

So whether you are experiencing incontinence, pelvic pain, low back pain, or a shoulder injury, having a knowledgeable therapist work with you, can make a significant impact on your function and quality of life. While many therapists have gone through the certification process, most of the therapists at Beyond Basics have had training in this approach, so we are all in a strong position to help address your needs. Feel free to contact our office at 212-354-2622 or at our website, or visit the IPA  for more information

 

Pediatric Bowel Part II: How to Make Pooping Easier for your Kiddo

poop

Fiona L McMahon, PT, DPT

Hey everyone! We are resuming our conversation about potty issues with kiddos. In our last blog, we discussed how issues with pooping can occur with kiddos and how often times it is easy to overlook long standing constipation in kiddos with fecal and urinary accidents. We learned that although it can seem like someone is doing something wrong, potty issues are no one’s fault. Even though poo problems are no ones fault, they are problems that families can work on together to be solved.

In this blog, we are going to discuss right here and right now what you can do today to help your child poop easier. Some of the changes are astonishingly simple while some may require a bit more work and change from the whole family. Keep in mind in order for anyone’s bowel to change ( not just kids), you must be consistent, and these changes may take a very long time to occur. Be patient, you and your child will get there. Let’s go over ways to get back on the right track now.

STEPS to help with bowel issues:

Step 1: Allow your kiddo enough time to poop

Ever have to catch an early morning flight and noticed that you skip pooping that day, or even worse, you get a little bound up in the following week? Getting up early and rushing in the morning can constipate anyone and the thing is that’s what most kids are having to do. Many children have between half an hour to an hour to scarf down their food, dress, and brush their teeth before rolling out to school, leaving very little time to sit on the toilet and have an effective bowel movement. Kids then often find themselves at school with public bathrooms or single bathrooms within the classroom that don’t lock, making it hard to be comfortable enough to have a bowel movement. Then they usually must rush to extracurriculars and complete homework before bed. There simply is not enough time to poop.

Allowing your child 10-15 minutes to sit on the toilet 10-20 minutes after they eat can allow them to use what’s called the gastrocolic reflex. Basically what that means is when you eat, the body makes room for the new food by moving everything down further in the digestive canal. Therefore, after meals is the time when we are most likely to have a poop.

Allowing more time in the morning is the most easily modifiable part of your routine to start with when trying to improve your kiddos pooping habits. Get up about 30 minutes earlier to allow your child time to eat and to sit on the toilet. Follow with sitting on the toilet after lunch and after dinner.

Step 2: Fit the toilet to you child; don’t fit your child to the toilet

Studies show that toilet posture is imperative to good poops. My colleague, Sarah Paplanus, DPT, explains in detail the importance of having your knees above your hips while pooping in her blog on the squatty potty. Step stools will help your child get their knees above their hips, just remember to make sure that they keep their legs somewhat separated. Also, for the little littles, a child size toilet seat will help make sitting on the toilet more comfortable for kiddos with little tushes.

Also, check out this video on potty posture, with fellow peds therapist, Victoria LaManna PT, DPT, CLT

Step 3: Improve Diet

Most adults are aware that diet is important, but diet is equally as important with children. Making sure your child is getting enough fruits and veggies (approximately 5 servings daily), skipping sugary and refined foods like white bread, pastries, candy, and chips, and getting enough water (about half their weight in ounces) is so important to keep their stool soft and moving.

Step 3: Recognize Progress and Hard Work

Bowel issues are hard work for all involved. Make a sticker chart to track how often your child is compliant at sitting on the toilet, eating well, and having bowel movements. Make a goal for how many stickers your child will earn and celebrate when they achieve their goal. It is a long process so make sure to recognize even the smallest of victories.

Step 4: Get Help from Professionals

There is help out there. Make sure you go to a knowledgeable doctor and physical therapist to ensure your child gets the best chance at improving their bowel issues as quickly as possible. Do not accept any medical professional telling you it is normal for children to have accidents past potty training age, (age 5), or that it is your fault as a parent, or it is the child’s fault. It’s not. A knowledgeable doctor will run appropriate tests to rule out dietary allergies that could be contributing as well as starting your child on medicine or supplements to help improve bowel movements.

Pelvic floor physical therapy is a mainstay of care for kids with bowel issues, Skilled pediatric physical therapists will help your child re-learn how to use their pelvic muscles to better hold in waste as well as eliminate it when appropriate. We will teach you how to use techniques to help stool move more effectively, and we can perform hands on work to reduce pain and discomfort associated with bowel dysfunction. In addition to our clinical skills, we will help you to find doctors to help compliment the treatment your child is receiving in PT. If your child is suffering from bowel problems, don’t waste another day, call our front desk to make an appointment today!

The Scoop When Kids Have Trouble with Poop

 

Kiddo

Fiona McMahon PT, DPT

I spend a lot of my time at work talking about poop. In fact, poop discussions run in my family. My great grandmother, a nurse in the 1920’s, would always inquire about her charges and her children’s movements when they’d complain of any ailment. This scatological interest was passed to my grandfather, a civil engineer, designing and working in wastewater treatment plants, to my mother who was a nurse practitioner, who dealt with digestive issues and famously asked a guest at her parents’ dinner party when she was a child, “how are your bowel movements, lately?” This familial interest in the distal end of the alimentary canal was bequeathed unto me and I now spend much of my working life trying to help people of all ages with issues defecating to live more comfortable and full lives when it comes to bowel movements.

Anyone who has had any issues concerning their ability to poop, or to hold it, can attest to how much havoc issues with bowel movements can cause in one’s life. This is especially true when it comes to children. Children often have continence requirements to attend school, camp, and other activities. Not to mention other children may not always be very kind to another child who is experiencing difficulty with their bowels. Aside from the obvious issues of constipation and incontinence, kids with bowel issues can experience other symptoms like pain in their belly or with defecation, foul body odor, problems with their bladder, including incontinence, as well as skidmarks in their underwear or itchy bums. It really does all come down to poop.

The largest driver of bowel problems in kids is constipation. Constipation is surprisingly common and occurs in 4-36% of children. It accounts for 3% of visits to the pediatrician and 30% of visits to pediatric gastroenterologists. Constipation can be tricky to diagnose and many people who have children who are constipated, do not identify constipation as the culprit for issues like bowel and urinary incontinence, and pain. According to Afzar and colleagues, constipation would be missed nearly 50% of the time in children, if infrequent bowel movements was the only criteria used in assessing constipation in children.

So what criteria do we use to assess constipation in kiddos? We obviously look at how often a child is defecating. Two or less bowel movements a week is considered constipation, but it is important to keep in mind that a child with difficulty evacuating may move one or two small pellets multiple times a day and still be severely constipated.  Check out the Bristol Stool Chart here to determine if your child’s BM’s are normal. Types one and 2 indicated constipation. Bowel incontinence is also an indicator of constipation in children. In fact, 90% of children with constipation experience fecal soiling. Kiddos with large fecal masses felt in the rectum by a doctor or through the abdomen, those with history of painful bowel movements, and those who produce large toilet clogging poops are exhibiting symptoms of constipation. Children with constipation may also exhibit retentive posture in an effort to prevent painful bowel movements. They may go up on their toes, squeeze their butt cheeks and thighs together, cry, and rock back and forth. Retentive postures can trick parents into thinking their child is trying to defecate when in fact they are working hard to keep everything inside. If you see any of these symptoms in a child under 4 years lasting for a month, and over 2 months in kids over 4, you are dealing with constipation

Constipation can be divided into two different types, functional and constipation due to an organic or pathological cause. Around 95% of constipation in both adults and children is considered functional. Functional constipation can occur for a variety of different reasons in children. One of the most common reasons is that children can get in the habit of delaying or trying to prevent defecation. Children are often just as busy as the rest of us. They may simply be too busy in the morning to have a full bowel movement. Once they arrive at school, they are faced with bathrooms that have doors that may or may not lock, or they may have to contend with intimidating multi-stalled public toilets. Either way both are not conducive to pooping. After school is usually filled with activities and a mad dash to do homework. You can see that it may be very difficult to schedule in a good time to use the toilet. Kids also delay going to the bathroom because it hurts or may be uncomfortable to go. The more they delay their bowel movements, the more uncomfortable it can be to go. Thus creating a negative feedback loop that just feeds back on itself and worsens the constipation symptoms.

Weeks of delay whether it be secondary to pain, scheduling, or plain old distraction, can cause a big build up of poo in the very end of the digestive system, the rectum.  The accumulated fecal matter may be backed up through the  entire length of the colon. This big build up of feces in the rectum causes it to  stretch out.  A stretched out rectum is not good at holding feces in, or sensing that it is time to go to the bathroom, making the problem even worse. Furthermore, soft poo will easily slide by the hard fecal blockage and create smears or “skidmarks” in the underwear, or even more severe incontinence mistakenly labeled diarrhea. Chronic fecal impaction, and fecal withholding can alter how the muscles that control continence work (the pelvic floor), which may further worsen this constipation syndrome. Skidmarks, constipation and fecal incontinence are not anyone’s fault, especially the child’s, but it is a problem that can be solved.

So what to do about all of this? Is it too late if your child has been constipated for a long time? Tackling poo problems in kids is daunting for both parents/guardians alike. The first step is educating yourself, your doctor, and your child. My motto for the kiddos that I treat is, “Accidents are not your fault, but it is your problem to solve.” Letting children know what is happening in their body can help them further internalize this message and become more invested in the process to remedy their symptoms.

Next you have to tackle the poo situation inside of your child’s tummy, This is where a two pronged approach is key. Both physical therapy and your doctor will get you on the right track. Your doctor will screen your child for that 5% of constipation cases that are caused by organic causes like Hirshprung’s disease, thyroid issues, and notably cow’s milk allergies and gluten intolerance/ celiac disease. It is important to be screened for these allergies and food intolerance as they represent a large portion of organic constipation cases. Once organic causes are ruled out, your doctor will start medication to help clean out the bowels. Miralax (Polyethylene glycol), is a mainstay of pediatric constipation treatment and is generally best tolerated. Miralax may be first given in large amounts to clean out the bowel, and then followed with smaller maintenance and then slowly tapered off as the rectum reduces from it’s stretched out size. It is important to remember that when starting miralax, especially at “clean out”, doses will likely increase episodes of incontinence at first, so prepare both yourself and your child. Make sure to consult your doctor before attempting any sort of clean out on your own.

Next up is physical therapy. Our main goal is to keep poo moving and avoid buildups so your child’s body can heal. We will teach you ways to massage the colon through the belly to keep poo exiting and to reduce back ups and the need for laxatives. We also work to teach your child to sit on the toilet in a way that will help the poo as easily and painlessly as possible. More often than not, kiddos with constipation have pretty weak cores that make defecating difficult. As pediatric physical therapists, I humbly assert that we are the masters at dreaming up fun ways to gain a little core strength in session and at home to help make bathroom trips easier.

What Beyond Basics does that is truly unique from non pelvic floor physical therapists, is we train the muscles of the pelvic floor (the muscles that control both the the anal and urethral opening to better open and close). Kiddos with chronic constipation tend to have pelvic floors that are tight and uncoordinated. Paradoxical contraction occurs when a child tries to open their anal canal, and they truly believe they are doing so, however they are I n fact clamping it shut. We can treat this problem at Beyond Basics.

If your child would benefit from physical therapy, or an evaluation, to make pooping a bit easier, give us a call. Stay tuned for our next blog, where we will go over some practical at home tips for improving both you and your child’s pooping situation!

 

Sources

Afzal N, Tighe M, Thomson M. Constipation in Children. Ital J Pediatr. 2011; 37

 

Poddar U. Approach to constipation in children. Indian Pediatri. 2016;53(4) 319-27

 

 

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

rainbow flag

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

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