All About Testicles

tennis ball isolated

By Fiona McMahon, PT, DPT

Testicles have long held a special place in our society.  In fact, the word testis means “witness of virility” in Latin. They help produce the hormones that spark puberty. They are responsible for body hair, the growth of the penis, and sex drive.

Testicles are gonads. Gonads are sex organs that produce sex cells.  People with male anatomy produce sperm and  people with female anatomy produce ova (eggs). Testicles also produce the hormone testosterone, which as stated earlier is responsible for people with male anatomy’s secondary sex characteristics, like body hair, muscle bulk, and sex drive.

Testicles are housed in the scrotum, a sack of skin just behind the penis. Within the scrotum, the testicles are covered by a fibrous sheath called the tunica vaginalis and tunica albuginea. The testicles are composed of many tightly bound tubules called the seminiferous tubules. These tubules give the testicles their uneven feel. Each testicle is held in the scrotum by the spermatic cord, which is composed of the vas deferens, blood vessels, and lymph vessels.

Anyone who has watched an Adam Sandler movie knows that testicles are delicate and sensitive creatures. Even just a jostle can be enough to double one over in pain. But sometimes your testicles may hurt for no apparent reason.  Acute scrotum is the technical name given to sudden onset testicular pain without swelling. There are many medical reasons your testicles may hurt.  Testicular pain can be a serious condition and should not be ignored.

Testicular torsion is a medical emergency that requires immediate treatment in order to save the testicle.  Testicular torsion is most common in people with male anatomy under the age of 25. It occurs when the spermatic cord twists cutting off blood supply to the testes. Usually testicular torsion is spontaneous and cause pain great enough to wake a one out of sleep and induce vomiting.

In some people testicular torsion is contributed to by what is known as a bell clapper deformity. A bell clapper deformity occurs when there is a lack of fixation in the tunica vaginalis. Because of this lack of fixation, the testis is free to rotate around on itself and obstruct blood flow. Bell clapper deformities are present in 12% of males and in males with bell clapper deformity 40% have bilateral derformity. In neonates, extravaginal torsion can occur when the tunica vaginalis and the testes both twist in the inguinal canal. Any case of sudden and severe testicular pain should be considered testicular torsion until proven otherwise and treated as a medical emergency.

Testicular cancer is usually painless but in 20% of cases pain can be a symptom. The pain caused by testicular cancer is typically due to hemorrhage. In the overall population testicular cancer is relatively rare, however it is the most common form of cancer in young males between the ages of 15 and 35. Signs of testicular cancer include a dull ache in the abdomen and groin, heaviness in the scrotum, lump in the testicle, enlargement of the breast tissue, or back pain. Any of these symptoms warrant a visit to your general practitioner.

So what about testicular pain that is not cancer or testicular torsion? Testicular pain can also be caused by other medical conditions like epididymitis, orchitis, urinary reflux, urinary tract infection, or sexually transmitted infection. Again as stated before, any acute testicular pain that occurs out of the blue warrants immediate medical attention.

There are some people however who suffer from acute and recurrent testicular pain for which a medical cause has not been established. For these people, not having concrete answers for what is going on can be especially distressing. In a paper by Anderson and colleagues, trigger points elsewhere in the body have been found to cause pain in the testicles, shaft of the penis, and other areas in the genital region.

Trigger points are defined as areas of hypersensitive and painful spots within the muscle that can be felt as a tough or tight band. In their study, Anderson and colleagues found that testicular pain could be elicited in 80% of men with testicular pain with no other medical cause, when trigger points in the external obliques were palpated. The study also found other trigger points referring to the shaft of the penis, and the perineum (the bicycle seat area of the body). Myofascial restrictions can refer pain to testicles as well as reduce blood flow to the genitals, making erections difficult or painful.

Irritated nerves can also be the cause of testicular and penile pain. The pudendal nerve is most commonly associated with male pelvic pain. The pudendal nerve supplies sensation to many of the pelvic structures including the penis, scrotum, and anorecatal region. This nerve can become inflamed or strained for a variety of different reasons. Straining with constipation, boney alignment that stresses the nerve, as well as tight ligaments and muscles that surround the area can all stress the pudendal nerve and cause scrotal, anal, or penile pain.

Other nerves such as the Iliohypogastric can cause suprapubic and gluteal pain. The inguinal nerve can cause pain in the inner thigh, and lateral scrotal skin. The genital femoral is also associated with the skin of the scrotum and thigh.

If you find yourself with testicular or penile pain that has not been resolved with medical intervention, it may be time to find your way to a licensed pelvic floor physical therapist. Physical therapists can work with you to break up your trigger points, provide postural education to correct alignment, reduce constipation with bowel training, and incorporate relaxation and postural changes to prevent your pain from coming back. At Beyond Basics, we have a great team of therapists who treat pelvic floor disorders who can help treat your testicular pain.

Sources:
Anatomy and physiology of the testicle. Canadian Cancer Society. http://www.cancer.ca/en/cancer-information/cancer-type/testicular/anatomy-and-physiology/?region=on. Accessed June 10, 2015
Anderson R, Sawyer T, Wise D, Morey A. Painful myofascial trigger points and pain sites in men with chronic prostatitis/ chronic pelvis pain syndrome. The Journal of Urology, 182;6 2753-58
Jefferies M, Cox A, Gupta A et al. The management of acute testicular pain in children and adolescents. BMJ. 2015
Mayo Clinic Staff. Testicle Pain. Accessed June 8, 2015. http://www.mayoclinic.org/symptoms/testicle-pain/basics/causes/sym-20050942
Mayo Clinic Staff. Testicular Cancer. http://www.mayoclinic.org/diseases-conditions/testicular-cancer/basics/definition/con-20043068. Accessed June 10, 2015

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

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: Pain and Sexuality: is it all in my head?

 

By Fiona McMahon, DPT

Sex should feel good… really, really good. But when it doesn’t, you may start to wonder, what’s wrong with me? Am I broken? Am I a prude? Am I frigid? Painful sex isn’t something we talk about. No one would look at you twice if you walked into work complaining of pain in your elbow, but if you walk into work complaining about pain in you vagina or penis, you may end up having a meeting with HR.

On October 18th, 2017 we at Beyond Basics are breaking down those taboos and having an educational seminar, followed by an optional question and answer session at the end. We will discuss the many causes of sexual pain and how physical therapy can help.  The event will be hosted by one of our therapists, Stephanie Stamas, DPT, ATC. Stephanie will give a detailed seminar about pelvic health and take time to clear up some common misconceptions many people have concerning their bodies and sexual function.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes

Pelvic Health 101 Fall 2017

PH 101 Something’s Wrong with my What?

 

You’ve waited and waited, now finally Pelvic Health 101 is BACK!

On September 20th, 2017 at 7pm we will be kicking off our fall semester of pelvic health education classes. We have a lot planned this year, so get pumped. In our first class we will be introducing you to the pelvic floor muscles, where they are, what they do, and how they relate to the health as well as the function of your bowel, bladder, and sexual muscles and organs. We will also be covering how things such as alignment, posture, muscle tone, and nerves can affect your symptoms. This course is a great starting point to help you understand your pelvic floor and pelvic floor symptoms.

Please join us at our office at:

110 East 42nd Street, Suite 1504

New York, NY 10017
Register at: pelvichealth101.eventbrite.com

Here is our line up of this and future classes:

Pelvic Health 101 Fall 2017

Navigating Life with Chronic Pain: Part 1

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Fiona McMahon, PT, DPT

Why Should Everyone Care About Chronic Pain

Chronic pain is the in vogue topic of the day. It is a subject that has pushed its way into American’s awareness for very good reason. According to the American Academy of Pain Medicine, chronic pain currently affects more than 1.5 billion Americans, affecting work, sleep, and quality of life. Most importantly chronic pain has become dangerous as the opioid crisis has come to a head. Out of the 28,000 people who died of accidental drug overdose, nearly 12,000 died from pain killers, three times as many in 1999, according to the American Academy of Pain Medicine.

What Is Chronic Pain

Chronic pain is classically defined as pain that persists more than 3 months, but it is so much more than that. When pain becomes chronic, it is actually processed in the brain differently than acute pain. This is one of the reasons chronic pain has proven to be so difficult to treat using traditional means.

Pain serves a vital function and is something we need to survive. Pain alerts us to danger like a hot stove or broken bone and compels you to take action. This “take action now” pain is acute pain. Chronic pain lingers and can be totally independent of what is actually going on in the tissue. In fact, the tissue may have healed completely and still pain persists. There are a lot of thoughts as to why pain becomes chronic. It can seem like there is nothing left to treat, and all we can do is blunt it with analgesics and painkillers. But there is more to do. All pain, whether it is acute or chronic is processed by pain receptors, the spinal cord, and finally the brain. By addressing pain at the level of the nervous systems, we can change the way stimuli are perceived in the brain, and hopefully reduce pain.

The book, Explain Pain, by David Butler and Lorimer Moseley does a really superb job explaining this concept. In the book, they explain chronic pain is the body’s response to prolonged exposure to noxious stimuli. (In non medical person terms: basically if you have pain for a long time, the body becomes much more sensitive to things that may or may not be painful or damaging). In states of chronic pain, your body can actually lower the threshold for something to become considered painful in the brain. Meaning, that simple stimuli like tight fitting clothing, or sitting can feel very painful. Your body is doing this, because it is on guard for anything that might hurt it. Chronic pain is your body’s way of looking out for you, but has gone way too far.

This blog is not long enough to dig into all of the varied nuances of how and why chronic pain occurs, but if your interest is peaked, I would highly recommend taking a look at Explain Pain or The Explain Pain Protectometer in order to dig down into the deep and fascinating science behind chronic pain.

False Leads and Dead Ends In Pain

Opiods, Addiction, and Efficacy

The nature of chronic pain has proven to be elusive for patients and healthcare practitioners alike. In the 1990’s, in an effort to finally address chronic pain, opiods became much more widely used. At the time, drugs like Oxycontin were marketed as a safe way to treat chronic pain. The manufacturer of Oxycotin, Purdue Pharmaceuticals, instructed their drug representatives to tell doctors that the rate of addiction for long term Oxycotin users was 1%, according to pharma who help fund these studies. Although one study did indeed find these numbers many other found addiction rates in excess of 40%.

Probably one of the most unfortunate aspects of the push by pharma to prescribe opioids more freely, is despite marketing to the contrary, there have been more and more studies supporting the theory that opioids may in fact be ineffective for the treatment of chronic pain. Studies of worker’s compensation patients being treated for chronic pain indicate that patients on higher opioid dose, return to work more slowly than those on lower doses. Additionally, patients with back pain, who are being treated with long term opiod therapy report greater disability than those who are not on opioids.

Opiods have their place, especially in the treatment of cancer, procedural, and end of life pain, however it is becoming more and more clear that opiods are not the miracle drug we once thought they were in the treatment of long term chronic pain. The increased risks of addiction, accidental overdose, falls and fractures, depression, and severe constipation (which can indeed worsen the pain for which the opiod was prescribed in the first place), make it clear that as a medical community, we need to find a safer and more effective way to reduce chronic pain symptoms.

First steps

If you can find a cause, but at the same time don’t get hung up on it.

This is easier said than done. Often times, by the time patients reach us here at Beyond Basics Physical Therapy, they have folders that are stuffed to the brim with expensive diagnostic tests that read “unremarkable”. This can be incredibly frustrating for someone suffering with very real pain. My first word of advice is, If something doesn’t feel right with your body, don’t stop looking for help, until you find someone who can truly help you. There are many pain conditions like, chronic prostatitis and endometriosis. Which are poorly understood by many providers, that require treatment and or consultation by a specialist. This isn’t to say that the clinicians that are unfamiliar with chronic pain conditions aren’t fabulous providers, but these chronic pain conditions often require a clinician who spends his or her career treating and managing these type of pain syndromes. Basically, don’t allow yourself to be written off by any clinician who tries to tell you your pain isn’t real. It is, but most importantly there are things to be done. At Beyond Basics, we have extensive training on chronic pain conditions, additionally we have multiple connections with physicians, nurse practitioners, and other clinicians who treat chronic pain, that we will often refer too if we feel additional intervention beyond physical therapy is necessary.

I am warning you, before you read this paragraph, I am about to say something that on its face will seem mind numbingly contradictory. Bear with me please, and read the entire passage. If you do get a diagnosis, do not expect an immediate cure of pain. Chronic pain has gone past the point of solely being about tissue damage. A chronic undiagnosed infection, muscle spasm, or injury should be treated to remove the fire or proximate cause of the pain. Just because the pain is gone, does not mean the nervous system will immediately calm down. In chronic pain, treating the proximate cause enables the nervous system to begin to down regulate (or less threat sensitive) with further treatment, but does not always guarantee immediate cure.

This brings me to the problem with imaging. Imaging is a great tool and advances in the ubiquity and affordability of imaging techniques like ultrasound and magnetic resonance imaging (MRI), are allowing more and more people glimpses inside their body. If you have ever looked at an MRI of yourself the feeling is profound. I have been fortunate enough to see both my brain and right hip in mind blowing detail on MRI. It’s amazing, but sometimes knowing where every tear, herniation, and bit of swelling is not only unhelpful, but downright dangerous to some patients.

I am not being hyperbolic simply to drive a point home. Early and unindicated MRI in cases of low back pain has been shown to result in increased time spent on disability and increased cost of care ranging between $8,000-13,000 according to the article by Webster, cited in the sources. The fact is with imaging as powerful as MRI, we get to see almost EVERYTHING and because MRIs are getting slightly cheaper and more common, we are identifying structural changes like disc herniation in people, who might not have had a reason to suspect that there was something wrong in their spine in the first place. Sometimes knowing there is a structural abnormality in your body can cause pain and hypervigilance, when prior to knowing, you may not have had the same quality or as much pain in the first place.. Reports indicate that disc herniation and narrowing of the spinal cord can be seen in up to 57% of people who have no symptoms at all. It’s not a far leap to imagine someone with pain hanging all of their problems on a slipped disc if the MRI shows it. What’s worse, is MRI results are alluring and can often lead practitioners down the wrong path of treatment, because it is an easy answer.

In physical therapy school, my professors drilled into us, with almost religious fervor, treat what you find. A fabulous Physician’s Assistant of mine also told me 90% of what you need to know is in a patient’s history of their present illness. It is so true. You can tell a lot about the origin of the pain by asking questions like, how long has it been around, what makes it worse, what makes it better, and what does it feel like. Imaging can sometimes be a bit of a red herring, rushing well intentioned clinicians towards what they think is a cure, while skipping some crucial information through gathering steps that would aid in a more accurate diagnosis.

MRI’s aren’t all bad. They can be life saving and life improving when they are used appropriately. There are many clinical practice guidelines that guide providers on when it may be beneficial to order MRI or other imaging, however, research has certainly borne out that early imaging is actually counter productive in the treatment of chronic pain.

 

If you find a cause, great. If you don’t, or still feel bad don’t despair

We place so much of our hopes on diagnosis. It seems logical that if there is a cause, there must be a cure. Unfortunately, it is not alway so simple. We went over in the opening paragraphs about how chronic pain is more than what’s going on in a specific body part, it also involves the brain. Sometimes simply curing the tissues is not enough. Sometimes we never know what the cause is. This can be so frustrating for patients. As a pelvic pain specialist, I treat a lot of patients with pelvic floor pain and spasm, who have not yet figured out what specific incident brought the pain on. Rarely, in these cases, is there the “oh, crap” moment, when you realize you have injured yourself. Sometimes the development of chronic pain is like having a water glass. We are all born with water glasses of different sizes. We pour a little water in for something like poor posture, genetics, injury, diet, stress, etc., and when our water glass has overflowed, we develop chronic pain. There is no one definitive cause in cases of the overflowing water glass. Many factors have contributed, and many factors must be addressed in order to treat it properly. That’s why the holistic, mind-body approach is really where it’s at, when we treat chronic pain.

Now that you have a grasp on pain science and how chronic pain can behave differently from acute pain, you can begin to approach treating and dealing with it in a different way. In part two of this blog we will discuss different treatments for chronic pain, including yoga, acupuncture, meditation, of course, physical therapy, and many more. Please stay tuned.

Sources:

AAPM Facts and Figures on Pain. The American Academy of Pain Medicine. http://www.painmed.org/patientcenter/facts_on_pain.aspx. [Accessed June 25, 2017]

Butler, David S, and G L. Moseley. Explain Pain. Adelaide: Noigroup Publications, 2003. Print.

Zee A. The Promotion and Marketing of Oxycotin: Commercial Triumph, Public Health Tragedy. Am J Public Health. 2009;99(2):221-227

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

Von Korff M. Long-term use of opiods for complex chronic pain. Best Pract Clin Rheumatol. 2013 Oct 27(5):663-72

Webster B, Bauer A, Choi Y, et al. Iatrogenic Consequences of Early Magnetic Resonance Imaging in Acute, Work Related Low Back Pain. Spine. 2013. 38(22) 1939-46