Pelvic Pain Awareness Month: Part 2: Hope for Chronic Pelvic Pain

Mayis PelvicPainAwarenessmonth

Welcome back! In part 1 of this blog we discussed how pelvic pain can affect anyone, regardless of their age or gender. We also discussed that pelvic pain can feel many different ways and may occur in different body locations and be triggered by different activities. Now that we have the basics under our belt, we can march forward and start to explore different ways to manage and treat pelvic pain.

First steps

Now that you have a name for what you are experiencing, it is important to get a handle on the various characteristics of the pain you are experiencing. This information will provide valuable insights to the clinicians who are treating you. Some questions to think about include:

  • How long has this pain been going on?
    • Chronic pelvic pain is classified as pain that has gone on for 3 or more months, this type of pain likely has musculoskeletal involvement and will likely require the help of a pelvic floor physical therapist in addition to medical intervention
    • Also try and think if there were any significant events around the time of your symptoms onset; these events may be physical like spraining an ankle or emotional, like moving or starting a new job
  • What makes it worse and what makes it better?
    • Sometimes you won’t know and that’s ok too.
  • Where is the pain?
  • What does the pain feel like?
    • Describing the character of pain can be really tricky. Here are some words we hear a lot
      • Burning
      • Itching
      • Stabbing
      • Buzzingwork
      • Aching
      • Gnawing
      • Sharp, Shooting
      • Dull
      • Tingling/numbness

Now that you have this information, it’s time to make an appointment with a doctor, who ideally has experience in treating pelvic pain. Your doctor will work to determine if there are any immediate medical concerns that require treatment. It is important to be patient when starting this step. Usually it is not immediately clear on exactly what is causing your pain, especially if it has been going on for some time. Usually chronic pelvic pain is caused by more than one system (i.e it could be a bit digestive and also a bit musculoskeletal). That is why your first visit with a clinician is typically just a jumping off point.

Next Steps

After your initial appointment you may have a referral in hand to see a specialist. Specialities that treat pelvic pain include:

  • Colorectal
  • Gastroenterology
  • Gynecology
  • Physical therapy
  • Physiatry
  • Psychiatry
  • Psychology
  • Neurology
  • Urology
  • Urogynecology

It is important to visit a clinician who specializes in pelvic pain, considering it is a very specialized topic, and unless a clinician has an interest in it, their exposure to pelvic pain may be limited.

The next two pieces of advice I am about to give may seem mutually exclusive, but hear me out. Trust your gut, but also be patient with the process. For chronic pelvic pain, it takes some time to see improvement. Think about it, you’ve had this pain for a very long time, it will take a while to improve. In physical therapy, we expect our patients to see some improvement in 4-6 weeks, and similar timeframes can be expected for other types of interventions. That said, if you feel like the clinician you are seeing is dismissing you or not taking your complaints seriously, that is important. A colleague of mine, who I adore, tells her patients “who knows your body better than you?”. The answer is no one. If you think something is wrong, it is your right to be taken seriously.

First Steps in Treatment

There are steps you can take to start addressing your pain almost immediately. I discuss some of them in this blog. Getting a handle on your stress is really important when dealing with chronic pelvic pain ( I am currently writing this during a global pandemic, so I do recognize this is much easier said than done). This is important because chronic stress can cause the pelvic floor to tighten which can exacerbate pain issues. It is important also to recognize that despite anxiety and stress being strong contributors, pelvic pain is not in your head and your symptoms are real.

It also may be worth your while to experiment with gentle heat or cold. A warm bath or hot pack or cold pack can be helpful. Just make sure to put plenty of layers between you and the cold/ hot pack.

Professional Interventions

Address your muscles. Yes, we are a PT clinic and we will always say muscles are important, but the truth is, with chronic pelvic pain, muscles spasm/tightness is involved in most cases of pain. For those of us on lockdown, physical therapy is still accessible and considered essential. Beyond Basics offers both in person and telehealth appointments to guide you on your way.

A trained pelvic floor physical therapist can help to teach you exercises to do on your own to manage pain, release muscle tightness, and correct poor postures and overuse patterns that may have contributed to your pain in the first place.

Depending on your diagnosis you may see other medical specialities who will prescribe medicine, injections, or surgery in some cases, like endometriosis. You may also be referred to a nutritionist, acupuncturist, or mental health therapist as well. Like I mentioned earlier, typically pelvic pain can have many different contributing factors so it is really important to have a team and to make sure your team is communicating well together.

Although pelvic pain can be massively disruptive and upsetting, that fact is people can get better. Have hope, trust your gut, and reach out if you need us.

Beyond Basics Physical Therapy

212-354-2622

How to find a physician familiar with pelvic pain:

International Pelvic Pain Society, Interstitial Cystitis Association

Bonder J, Chi M, Rispoli L. Myofascial pelvic pain disorders. Phys Med Rehabil Clin N Am

. 2017 28(3), 501-15

Speer L, Mushkbar S, Erbele T. Chronic pain in women. Am Fam Physician. 2016 1;93(5):380-7

Van der Velde J, Laan E, Everaerd W. Vaginismus, a component of a general defensive reaction. An investigation of pelvic floor muscle activity during exposure to emotion- inducing film excerpts in women with and without vaginismus. Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12 (5) 328-31

Pelvic Pain Awareness Month Part 1: What is Pelvic Pain

Beyond Basics remains open and is offering both in person and telehealth appointments. Call 212-354-2622 for our midtown office and 212-267-0240 for our downtown office to learn more

Mayis PelvicPainAwarenessmonth

Fiona McMahon PT, DPT

I don’t need to write it out. You’ve already heard it. But I will write it anyway. These are uncertain times. This May, much like March and April, is shaping up to be a May that is very different than ones we’ve ever experienced before. That said, life still marches on. May is Pelvic Pain Awareness month and it seems appropriate to take some time to recognize those who are dealing with pelvic pain as well as spread awareness to what it is and how we can make it better… even in these uncertain times.

What is Pelvic Pain?

Pelvic pain can sound really simple, it’s pain in your pelvis, but let’s explore what that really means. The pelvis is a bowl shaped set of bones, the innominate (literally meaning no name), the sacrum, and the ischium, that connect your abdomen to your legs. Within this bowl lives your reproductive organs, your bladder, and rectum. Surrounding these bones and organs you have this nifty stuff called fascia. Fascia is the organ of shape and helps to both give structures within our body form as well as help them to slide and glide past each other. Like I said, nifty. Also within the pelvis we have muscles, nerves, and blood vessels! It gets really busy down there!

Because there is so much going on in the pelvis, pelvic pain can feel a lot of different ways depending on what structures are involved and even individual differences in how the body feels pain. Pelvic pain can have the feel of a dull ache, which you can feel in your pelvic bones, genitals, and or abdomen. It could also feel sharp and “stabby”, hot and burning, itching,and/or like a bunch of pressure. It can come and go or be a constant sensation. It can be what we call provoked, meaning certain triggers elicit it, or it could come and go seemingly without any obvious cause.

Pelvic pain can come in a lot of different varieties and it can affect everyone, regardless of gender or age. Many people who hear that I am a pelvic floor physical therapist, assume that I only treat postpartum women. The truth is postpartum women are not the only ones who can experience pelvic pain.

People with male anatomy can experience pelvic pain. They may feel burning with urination or climax, pain in the tip of the penis, in the testicles, or in their rectum. Sometimes this pain limits the ability of its sufferer to sit, wear tight clothing, or have pain free sexual experiences Often these symptoms get confused as a bladder, prostate or yeast infection. Although infections can certainly cause these symptoms, many times tight and spasmed muscles within the pelvis can be the culprit. We will discuss this further in part two of this blog.

People with female genitalia can experience many of the same symptoms listed above with obvious anatomical differences. Instead of the tip of the penis, a person with female anatomy may feel pain in their clitoris, or labia. They also may have pain with sexual penetration or arousal. Patients may also experience burning urination similar to the sensation of having a bladder infection. For people who menstruate, the cramps may be so debilitating that they are unable to work or go to school through the pain. All of these different presentations fall into the category of pelvic pain.

Children can also experience pelvic pain. Oftentimes this is caused because of prolonged constipation, but it can also be caused by muscle tightness, and gynecological conditions like endometriosis or lichens planus/ sclerosis.

People with pelvic pain, regardless of age or gender may also experience pain with voiding, either urine or feces, abdominal bloating, and or difficulty sitting.

What Causes Pelvic Pain?

So now that you know what pelvic pain is, what causes it? Many, many, many different things can cause pelvic pain. As we spoke about earlier in the blog, infections can cause pelvic pain. That is why it is important to get yourself in to see a doctor if you are experiencing this type of pain. She will be able to rule out or rule in infections or other medical causes for your pain. Often the problem causing your pain may be musculoskeletal. People with this cause of pelvic pain may not feel relief with traditional medical intervention. The muscles of your pelvis include the muscles of your abdominal wall, your bottom, and the muscles that live between your pubic bone in front and your tail bone in the back, also known as your pelvic floor. These muscles may be in spasm causing the types of pain I described earlier, (yes even the burning urination pain). It may also be that a muscle group in the pelvis itself or supporting the pelvis may be too weak to do its job properly. When this is the case, it is important to get yourself in to see a pelvic floor physical therapist, who can figure out exactly why your muscles are causing your pain.

Although pelvic pain can seem really bleak, there is a lot that can be done to treat it. It’s all about finding the right qualified professional to treat it. At Beyond Basics Physical Therapy we are the experts in pelvic pain and we treat patients from all over the world. We not only treat musculoskeletal causes of pelvic pain, but also work to connect our patients with other professionals who can help to holistically treat pelvic pain. If you have pelvic pain, please remember that there is hope for you.

Alright readers, that’s the basics on what pelvic pain is and what it looks like in different people. Next week we will go Beyond the Basics (see what I did there?) and discuss how to treat pelvic pain, especially pelvic pain caused by muscle dysfunction, in the clinic and even at home.

For more reading on pelvic floor dysfunction please check out these blogs as well as Amy’s books books on pelvic pain

Treatment

How to Deal with Pelvic Floor Pain From Home

What is Pelvic Floor Physical Therapy

What is Myofascial Release and Why do We Always Talk About it So Much?!

For People with Female Anatomy

Endo Awareness Month: How Endo can Affect your Tummy

Endo Awareness Month: Understanding Endo

Endo Awareness Month ( Part 2 of 4) : How Endo can Affect your Bladder

When it Feels Impossible to Have Sex

For people with male anatomy

All About Testicles

What’s Neater Than Your Peter? Burning Urination

Prostatitis What it is and What to do About it

Bladder Health

Pelvic Floor MythBusters! Don’t eat lemon to avoid bladder pain, true or false?

How to Improve Bladder Health

Books By Dr. Amy Stein PT DPT

Heal Pelvic Pain : available here

Beating Endo: available here

The International Pelvic Pain Society (IPPS) is a multidisciplinary group working to promote awareness and education of pelvic pain, if you care to donate, click here

How to Deal with Pelvic Floor Pain From Home

woman-in-grey-jacket-sits-on-bed-uses-grey-laptop-935743

Dear reader, 

As I sit down to write this, New York City is on PAUSE, many other cities around the world are on various forms of lock-down. As a planet, we are working to slow the spread of COVID-19, the condition caused by the novel coronavirus. Those of you who are working from and staying at home, your efforts are noble and life saving. We thank you. For those of you in pain, we see you and feel for how tough it can be to feel like you have to wait to get help. Hopefully in a short period of time this virus will have passed . Follow these simple tricks to get started on tackling your pelvic pain. 

 

Check In With Your Seat

Work from home setups can leave a lot to be desired. Designed for portability, but not ergonomics, our laptop computers can leave us curled up like little cashews or “c’s”. This position tucks our pelvis underneath us and can cause us to put extra pressure and compression through our pelvic floors, not to mention putting extra pressure on our spinal discs. Even if you only have a laptop, you can remedy this c position by imagining you are a puppy dog with a tail. You want to sit so you could wag your tail like a happy puppy. Now for some people this may actually feel a little worse, if it does, this is not the trick for you. Don’t worry I have more. 

If you can, use a portable mouse and keyboard to discourage your cashew sitting tendencies. Arrange your setup so your eye line falls just about in the middle of the monitor by elevating it on some books.  You should be able to access your keyboard with your elbows bent at 90 degrees.

Now it’s time to think about what you are sitting on. I recognize that those of us living in teeny tiny NYC apartments may not have a lot of options to think about. But keep in mind that pelvic floor pain can be counterintuitive and an overstuffed couch, may not be the best thing if your pelvic floor is overworking to stabilize your body while you are sitting. Likewise, your kitchen chair may be too firm. Play around, how does the couch cushion feel on the chair? Is a firmer seat better or worse? You may have to trial and error your way into a solution.

Move

This one is so important. Depending on where you are geographically, you may be allowed different degrees of movement. If you are currently allowed to leave your home for exercise, go for a walk. Besides breaking up the day, walking can decrease the pressure from all the sitting you have been doing, as well as increase blood flow to the pelvic floor. While the requirements for social distancing remain, ensure that you maintain a distance of 6 feet (about 2 meters) between yourself and other people and wear a homemade mask.

If you cannot walk outside, and even if you can, get up periodically throughout the day. Stretch out, do some gentle air squats if they feel good. Look for some free restorative virtual yoga classes. Movement is medicine. 

Just be Happy… Like a Happy Baby

I love this pose so much that I could write a love song to it. Honestly. It works to stretch not only your pelvic floor, but your entire posterior chain  (back of the body). 

The most traditional way to do it, is to lie on your back, bend at your hips and knees, so that your feet are in the air, and grab the outside of your feet. As you stretch bring your knees towards your armpits. Hold this pose for 10 deep, beautiful breaths.

Feel free to modify this pose. Grab on the back of your calves or behind your knees if you have tight hammies. Put a pillow between your abdomen and thighs to prevent any pinching in your hip. It’s honestly all good.

Breathe

Another super important tool in your toolbox. Deep slow breathing can calm your nervous system, which can help to decrease pelvic floor spasm and guarding. In fact, in a study by Van der Velde, it was found that stressful stimuli do cause an increase in pelvic floor tightening. Try 10 deep slow breaths throughout the day and note how you feel from both a pain and stress perspective.

We are OPEN and also offering Telehealth

For those of you who are ready to get started NOW. You can. We are currently offering office evaluations and treatments, and telehealth services. Both Corey Hazama PT, DPT and Amy Stein PT, DPT are doing in person visits and telehealth visits are available with Sarah Paplanus PT, DPT.  For more information contact Beyond Basics Physical Therapy at 212- 354-2622 or check out our website: http://www.beyondbasicspt.com

 

Van der Velde J, Laan E, Everaerd W. Vaginismus, a component of a general defensive reaction. An investigation of pelvic floor muscle activity during exposure to emotion- inducing film excerpts in women with and without vaginismus. Int Urogynecol J Pelvic Floor Dysfunct. 2001; 12 (5) 328-31

 

Pelvic Health 101: Running to the Bathroom Again?

***In light of current events, and in an effort to keep our community as healthy as possible, we have moved our Pelvic Health 101 (PH 101) seminars from in person to online.  Although we regret not being able to meet everyone in person, we are excited for the opportunity to broadcast information about pelvic floor disorders and how to treat them fair and wide. Please keep an eye on our social media as well as the blog to find out how you can learn more about the pelvic floor.****

Warmly,

The Team at Beyond Basics

By Fiona McMahon, DPT

Do you find yourself with a full map of every public restroom along your daily commute in your head? Do you find yourself competing for the aisle seat at movies so you can sneak away to the bathroom? Does it hurt to go? Do you get up multiple times a night? If you answered yes to any of these questions, this week’s Pelvic Health 101 is for you.

On Thursday, March 26 join us at Beyond Basics Physical Therapy, for all of the ins and outs of bladder health. Learn how the bladder works, common bladder disorders, and practical tips for helping your bladder symptoms. Light snacks and wine will be served.

Register at PelvicHealth101.eventbrite.com today.

ph101 sp 20

 

Pelvic Health 101 is back!

Pelvis Drawing

***In light of current events, and in an effort to keep our community as healthy as possible, we have moved our Pelvic Health 101 (PH 101) seminars from in person to online.  Although we regret not being able to meet everyone in person, we are excited for the opportunity to broadcast information about pelvic floor disorders and how to treat them fair and wide. Please keep an eye on our social media as well as the blog to find out how you can learn more about the pelvic floor.****

Warmly,

The Team at Beyond Basics

 

On March 19th, at 7pm we will be kicking off our spring semester of pelvic health education class, we call Pelvic Health 101 (PH101). 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 and function of your bowel, bladder, and sexual functioning. 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.

 

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

Here is our line up of this and future classes

ph101 sp 20

 

 

Endo Awareness Month: Understanding Endo

Amy Stein and Fiona McMahon

Beating Endo Cover

March Is Endometriosis Awareness Month. Treating endometriosis and improving the lives of people with endometriosis, has long been a passion of Dr. Amy Stein, founder of Beyond Basics Physical Therapy, so much so, that she teamed up with Dr. Iris Orbuch and wrote a book about it! This month we are reviewing some of the major talking points in their book, Beating Endo. Available here.  For more on endometriosis, check out our past blogs as well as Beating Endo.

Endometriosis is a condition that affects people born with female anatomy. It occurs when a tissue similar to that of lining of the uterus (known as the endometrium) grows outside of the uterus. Seems like a pretty simple definition, but it can cause a whole host of symptoms.

When something that doesn’t “belong” in the body is detected by the body, inflammation will occur. It is this inflammation that is believed to cause the myriad symptoms someone with endometriosis may experience. These symptoms can include

  • Irritable bowel syndrome (IBS)
  • Painful bladder syndrome
  • Pelvic floor dysfunction

One of the confusing things is, you don’t have to have all of these symptoms to have endo and the severity can range. This is Fiona writing, and I’m sure Amy would agree, no two endo patients are alike, and your pain is valid even if your symptoms do not necessarily look like someone else’s’ who is suffering with endo. It is this variability in presentation along with poor awareness within the medical field and public, leading to an average of 7 to 12 years to get a diagnosis.

Endometriosis can only be diagnosed by analyzing the suspected endometrial lesions removed during an excision surgery. There is no other test to confirm it, which can make diagnosis obviously, very difficult.

There is another condition that is called Adenomyosis. Similar to endo, adeno occurs when cells similar to the lining of the uterus occur within the muscular wall of the uterus. Most people with adeno have endo, but it is not always true that most people with endo have adeno. Adeno can show up as heavy periods, low back pain, and pelvic pressure.

Endometriosis is a chronic illness that affects millions of people. There is still a lot to figure out about endo and because of that fact there are many truths, half-truths, and myths floating around out there about endo. Check out some of the myths Amy and Iris busted together in Beating Endo.

Common Endo Myths

The abdominal and pelvic floor muscles are rarely affected by endometriosis.

False: Constipation, frequent urination or retention, pain with vaginal penetration from endometriosis causes tightening of the abdominal and pelvic floor muscles; So too does assuming the fetal position which is our go to pose when we are in pain. Both contribute to tight abdominal and pelvic floor muscles which causes pain.

The pelvic floor and abdominal muscles do not cause bladder, bowel, sexual dysfunction or abdominal-pelvic pain in patients with endometriosis.

False: Tight pelvic floor muscles caused by years of straining or reflexive tightening due to pain, often cause a severe amount of pain which results in further tightening and shortening of the pelvic floor muscles. Good news is that pelvic floor physical therapy benefits most people who have been experiencing abdomino-pelvic or sexual pain and/or are straining due to ongoing bladder and bowel symptoms.

Hysterectomy is a cure for endometriosis.

False: Hysterectomy is neither a treatment nor a cure. By definition endometriosis consists of cells similar to those in the lining of the uterus but found outside the uterus. Only surgical ‘excision’ removes endometriosis cells.

Medical menopause is a cure for endometriosis.

False: Just because your medicines give you hot flashes doesn’t mean your endometriosis is going away. The best treatment approach is to meet with an endo specialist to discuss options, and in most cases PT management. As well surgical excision has much better results than ablation of Endometriosis.

There is no correlation between quantity of endometriosis and severity of disease.

Truth: Even if you have a minimal amount of endometriosis, you can be in debilitating pain with lots of symptoms and in most cases dietary changes, physical therapy and mindfulness practices can help manage a lot of your symptoms.

Teenagers are too young to have endometriosis.

False: Teenagers can have endometriosis and their endometriosis can cause debilitating symptoms.

Pregnancy is a cure for endometriosis.

False: Just plain no. Pregnancy does not cure endometriosis.

Ablation surgery is the same as excision surgery.

False: Not even close. Excision surgery is the proper treatment for endometriosis. Ablation surgery, burns the surface of the endometriosis lesion but leaves the bulk of endometrial implants behind.

Surprising Endo Facts:

Fact: Physical therapy (pelvic PT) can help many suffering from the many pains and symptoms of Endo, including back, abdominal and pelvic pain, bladder, bowel and sexual function.

Fact: The majority of patients with Endometriosis require pelvic floor physical therapy. Pelvic floor PT can be instrumental in the healing process and can help abdominal-pelvic pain, bladder and bowel urgency, frequency, retention, incomplete emptying, and any sexual pain related to the musculoskeletal system.

Truth: Painful bowel movements, constipation, diarrhea and bloating are symptoms of endometriosis as well as symptoms of pelvic floor dysfunction .

Truth: Painful sex is a symptom of endometriosis as well as a symptom of pelvic floor dysfunction.

Truth: 40 to 50% of women with unexplained infertility is caused by Endometriosis.

Truth: Teens with endometriosis often have acyclic pain, that is, pain at other times of the month rather than only during their period, in addition to cyclic pain.

Truth: Back pain is a symptom of endometriosis.

Truth: If your ultrasound is normal you can still have endometriosis.

Truth: roughly 10% of women have endometriosis. That’s close to 200 million women worldwide. Endometriosis is much more than just bad period pain. 1 in 4 women have pelvic floor dysfunction.

Truth: Endometriosis commonly affects the musculoskeletal system, and in many cases can be a primary contributor to one’s pain and symptoms.

 

Orbuch I, Stein A. Beating Endo. New York. Harper Collins. 2019

What is Pelvic Floor Physical Therapy

marigold-2117436_960_720By Amy Stein, DPT and Fiona McMahon, DPT

As physical therapists who specialize in abdomino-pelvic pain disorders, one of the toughest parts of the job is meeting men and women who have suffered with pelvic pain for years, only to be told by their doctors/healthcare providers that there is no help for them. It is not uncommon to meet a patient who has suffered for 5- 10 years without help before finding us. Musculoskeletal causes of abdomino-pelvic pain are treatable conditions and often times we can start to improve a patient’s symptoms within just a few visits. Please read on to see how we can help you with your pain.

What do pelvic floor physical therapists actually do? Why do they do what they do? What can you expect from your first physical therapy visit?

Physical therapists (PTs) are experts in movement and function, which sounds like a pretty broad topic to be an expert in, and it is. After physical therapists graduate PT school (now-a-days at the doctoral level), they find their niche and specialize. You can find PTs working with high-level athletes, children, infants, people who are recovering from injuries, people with neurological conditions, and many other types of clients.

Pelvic floor physical therapists specialize in the muscles, nerves and connective tissues that live between your legs, also known as the pelvic floor. They gain their expertise through a series of post-graduate continuing education classes, certifications, and training. Their training allows them to perform both internal and external pelvic exams, and broadens their knowledge of conditions which affect the pelvic floor. Sometimes, people who specialize in modalities like biofeedback or dilator therapy, advertise themselves as pelvic floor therapists, but don’t have any hands on experience treating the sensitive and often reactive muscles of the pelvic floor. If you are seeking pelvic floor physical therapy, it is important to inquire about the experience and level of training your potential physical therapist has had in this specialty.

What is the pelvic floor and what is pelvic floor dysfunction?

Who needs pelvic floor PT? The pelvis performs many important functions of the body. The muscles, nerves, connective tissues and skeletal structures of the pelvic floor help to keep us continent, aid in sexual performance and function, and assist in core stability.

When some or all of these structures of the pelvic floor are not functioning properly, they can cause a multitude of different symptoms. People who are suffering from bowel, bladder, and or sexual problems, as well as those who are suffering from pain in the pelvis, upper legs, abdomen or buttocks most likely have pelvic floor impairments contributing to their pain.

Issues with the pelvic floor can arise from a multitude of reasons. Infections, previous surgeries, childbirth, postural and lifting problems, and trips and falls can all bring on pelvic floor dysfunction. Pelvic floor pain can persist well after the cause of it has been removed. So it is entirely possible to feel the effects of an old infection, surgery or injury, days to years after it occurred. Anyone who has had long standing abdomino-pelvic pain, or pain that they can’t seem to get rid of after seeking the help of medical doctors or other healthcare providers is a good candidate for a pelvic floor physical therapy evaluation and possible curative treatment.

What is Pelvic Floor Physical therapy?

Physical therapy is a practice of healing that restores function and reduces pain through the use of techniques to improve bony alignment, reduce trigger points, and improve muscle coordination and strength. Pelvic floor physical therapy is a branch of physical therapy and is built upon these same principles.

What sets pelvic floor physical therapists apart is their in depth understanding of the muscles and surrounding structures of the pelvic floor, beyond what was taught in physical therapy graduate school. What that means for a patient who is seeking the help of a pelvic floor physical therapist, is that his or her pelvic floor issues will be examined and treated comprehensively with both internal and external treatment, they will be provided  with lifestyle modifications to help remove any triggers, and receive specific exercises and treatment to help prevent the reoccurrence of pain once he or she has been successfully treated.

What exactly do Pelvic Floor Physical Therapists Do?

The elephant in the room with pelvic floor physical therapy is the internal exam/ treatment. It can seem a little daunting, especially if you have pelvic floor pain, but pelvic floor therapists are trained to be as thorough as possible while minimizing discomfort.

During the internal exam, your physical therapist will place a gloved finger into your vagina or rectum to assess the tone, strength, and irritability of your pelvic floor muscles and tissues. Internal exams and internal treatment are invaluable tools that are taught to pelvic floor physical therapists. It can tell us if there are trigger points (painful spots, with a referral pattern or local); muscle/tissue shortening; nerve irritation and/or bony malalignment that could be causing your pain directly or inhibiting the full function of your pelvic floor muscles. We can also determine if your pelvic floor has good coordination during the exam. A pelvic floor without good coordination, may not open and close appropriately for activities such as going to the bathroom, supporting our pelvis and trunk, sexual activity, and keeping us continent.

It is essential that we, as pelvic floor physical therapists, also include other assessments when we are examining our patients for the very first time. We employ the tried and true physical therapy exam practices to determine if there is an underlying condition elsewhere in your body, such as a strength deficit or alignment issue that could be affecting your pelvic floor. It’s wild to think of it, but something as seemingly unrelated as a flat foot or a hip injury can be enough to set off pelvic and abdominal pain!

Some pelvic floor physical therapists may have the opportunity of getting a lot of time to speak one-on-one with a patient to determine possible causes of his or her symptoms, educate the patient and to guide them to other practitioners who may optimize their physical therapy results if necessary. We truly can find out so much by just listening to what our patients have to say. A fall, or infection can be significant as well as a patient’s feelings and knowledge about their current condition.

Once we determine the cause of our patient’s pelvic floor dysfunction, we design a plan tailored to the patient’s needs. At Beyond Basics, we have a diverse crew of physical therapists who bring their own training and background into each treatment. What is really beautiful about that, is that all teach and help each other grow as practitioners. It will be difficult to go over every single type of treatment in one blog post, but we will review some of the main staples of pelvic floor rehab.

Manual Techniques

As physical therapists, are our hands are amazing gifts and phenomenal diagnostic tools that we can use to assess restrictions, tender points, swelling, muscle guarding, atrophy, nerve irritation and skeletal malalignment. We also use our hands to treat out these problems, provide feedback to the muscles, and facilitate the activation of certain muscle groups. There have been a great number of manual techniques that have evolved over the course of physical therapy’s history. Let’s go over a few.

Myofascial Release

Myofascial release was developed by John Barnes to evaluate and treat the myo-fascia throughout the body. The myofascial system is the connective tissue that coats our muscles, nerves, blood vessels, and bones, and runs throughout our bodies. Any tightness or dysfunction in the myofascial system can affect the aforementioned structures and result in pain and or movement dysfunction. By treating the fascia directly, therapists can improve their patient’s range of motion, reduce pain, and improve a patient’s structure and movement patterns.

Myofascial release is a more gentle technique that can be useful in cases where a patient is already experiencing a great deal of pain. The therapist will hold gentle pressure at the barrier of the tissue (the point where resistance is felt) for a short period of time, usually less than 2 minutes until the therapist feels the tissue release on its own. The therapist does not force the barrier.

Scar Tissue Manipulation

Scars are almost always a fact of life. From surgeries, to accidents, to conditions like endometriosis, or certain STI’s, almost everybody has one. What doesn’t have to be a fact of life are the muscle, nerve and skin restrictions and overactivity that they can cause. By releasing scar tissue in physical therapy, it has been shown that the surrounding restrictions also decrease their resistance and adherence to the deeper tissues and surrounding organs.

Myofascial Trigger Point Release

Discussed extensively in Travel and Simon’s two volume series, trigger points are taut (firm) points in the muscle that have a consistent referral pattern (they transmit pain to the another part of the body). Trigger points are not only important because they cause pain, they also can affect how the muscle works. This is one of the main reasons our therapists at Beyond Basics are fastidious about ensuring all trigger points are released in the abdomen, back, legs and pelvic floor before transitioning to any core stabiltiy or strengthening exercises that can re activate a trigger point.

People with trigger points in their pelvic floor and surrounding areas can experience pain in the rectum, anus, coccyx, sacrum, abdomen, groin and back and can cause bladder, bowel, and sexual dysfunction. When physical therapists find a trigger point they work to eliminate it and lengthen it through a myriad of techniques. Recent literature has found that trigger point release alone can achieve an 83% reduction in symptoms.

Connective Tissue Manipulation

Skin rolling, ie. rolling of the skin over another layer helps to improve the movement of those two layers and reduce the tension and pulling between them. It feels like a scratch or ‘nails’, and in cases where a patient has more restrictions, the sensation may be more amplified.

One of the great benefits to skin rolling is it increases the circulation in the area to which it was applied. Often times, areas that are tight or restricted are receiving reduced blood flow and oxygen. By bringing blood flow to the area, toxins can be cleared and the healing contents of the blood are brought to the injured area. Skin rolling can also restore the mobility of surrounding joints and nerves, which can help to restore normal function. By allowing the skin to move more freely, pelvic congestion, heaviness and aching can be effectively treated.

Neural, Visceral, and Joint Mobilization

Nerves, organs, and joints can lose their natural mobility over time and cause a whole host of symptoms from pain, to loss of range of motion, and poor functioning of the bodily symptoms. Skilled and specialized therapists can use a variety of active techniques (patient assisted) and passive techniques to free up restrictions in these tissues and organs and improve overall function.

Neural mobilization as the name implies, involves the restoration of neural structures back to their normal mobility: to glide and slide. Neural structures that cannot move properly can cause pain that can radiate down an extremity or into the trunk and can give the sensation of burning, zinging, and stabbing. Some orthopedic therapists practice this type of mobilization; common examples include the sciatic nerve in the leg and the ulnar nerve in the arm. Pelvic floor PTs focus on these nerves when they cause issues, but they also pay attention to nerves that innervate the perineum and genital region (bicycle seat area), such as the pudendal, iliohypogastric, obturator, ilioinguinal, genitofemoral and the femoral cutaneous nerves. By allowing these nerves to move freely, symptoms such as vulvovaginal, penile, rectal, clitoral and testicular pain, itching and burning can be greatly improved.

Visceral mobilization restores movement to the viscera or organs. As elucidated earlier in our blog, the viscera can affect a host of things even including how well the abdominal muscles reunite following pregnancy or any abdominal surgery. Visceral mobilization aids in relieving constipation/IBS symptoms, bladder symptoms, digestive issues like reflux, as well as sexual pain. Visceral mobilization can facilitate blood supply to aid in their function, allow organs to do their job by ensuring they have the mobility to move in the way they are required to perform their function, and to allow them to reside in the correct place in their body cavity. Evidence is beginning to emerge to demonstrate how visceral mobilization can even aid in fertility problems.

Joint mobilization is a common and favorite tool of most orthopedic physical therapists. We love it so much because it can have so many different benefits depending on the type of technique used. Maitland describes types of joint mobilization on a scale between 1 and 5. Grade 1 and 2 mobilizations are applied to a joint to help to lessen pain and spasm. These types of mobilizations are typically used when a patient is in a lot of pain and to help break the pain cycle. On a non-painful joint, grade 3, 4, and 5 (grade 5 requires post graduate training) mobilizations can be used to help restore full range of motion. By restoring full range of motion within a restricted joint, it is possible to lessen the burden on that and surrounding joints, thereby alleviating pain and improving function.

Neuro-education of the Pelvic Floor and Surrounding Structures

The muscles of the pelvic floor must work together and in coordination to perform specific tasks. The pelvic floor has to contract, elongate and relax in very precise ways to perform basic functions like urination, defecation, support the pelvis and organs, and sexual function and pleasure. If your pelvic floor muscles and/or nerves fail to do what they are supposed to do at the right time, problems like painful sex, erectile dysfunction, constipation, and incontinence can occur.

Biofeedback is a modality that allows you to learn how to better control your muscles for optimal function. Biofeedback shows you what your muscles are doing in-real time. It is helpful to teach patients to lengthen and relax the pelvic floor for issues like general pelvic pain, painful sexual activity and constipation or to contract the pelvic floor in order to prevent leakage with activities like coughing, laughing, lifting, running or moving heavy objects. However, biofeedback does not demonstrate shortened muscles and tissues; therefore, in certain cases the biofeedback may seem to be within normal limits but yet the patient has 10/10 pain. In these incidences, manual palpation is more appropriate to identify restricted and shortened tissues and muscles, and myofascial trigger points.

HEP: Home Exercise Program

 

Home exercise programs are essential for each patient. In the case of weakness, a patient will require more pelvic floor, core and functional strengthening and stability exercises. For overactive and pain conditions, the HEP typically consists of relaxation techniques, self-massages (both external and internal), gentle stretching, cardiovascular fitness as tolerated, and eventually pain-free core stability exercises. Both require postural and behavioral modifications and self-care strategies. For more information and detail, check out the book: Heal Pelvic Pain, by Amy Stein or her DVD: Healing Pelvic and Abdominal Pain here.

Conclusion

As you can now see, there is so much out there that can be done for people suffering with pelvic floor dysfunction. This blog is by no means extensive, and there are even more options you and your physical therapist can explore to help manage your pain or other pelvic issues. Pelvic floor dysfunction requires a multidisciplinary approach for most of our patients. Hopefully, this blog helped to paint a picture of what you will experience with a pelvic floor physical therapist. We advise that you seek out an expert and experienced pelvic floor physical therapist in order to help better your life and improve your function.

Sources

FitzGerald M, Kotarinos R. Rehabilitation of the short pelvic floor I. Background and patient evaluation.

Padoa A, Rosenbaum T. The Overactive Pelvic Floor. Springer. 2016

Simons DG, Travell JG, Simons LS. Travell and Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual. Volume 1 Upper Half of Body. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999.

Stein, Amy. Heal Pelvic Pain. McGraw-Hill. 2008

Stein, Amy. Healing Pelvic and Abdominal Pain. Video: www.healingpelvicandabdominalpain.com 2013

Travell, Janet G. and Simons, David G., MYOFASCIAL PAIN AND DYSFUNCTION. THE TRIGGER POINT MANUAL, Volume 2, The Lower Extremities, Williams & Wilkins, Baltimore, 1992.

Valovska A. Pelvic Pain Management. Oxford University Press. 2016

Weiss J. Chronic pelvic pain and myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001; 166(6) 2226-31

Pelvic Floor Mythbusters: Is kegeling the one true way to a healthy pelvic floor?

Pelvis Drawing

Fiona McMahon PT, DPT.

Is kegeling the one true way to a healthy pelvic floor? Not always. We can end the blog here. Just kidding, of course there is nuance to be considered here. But as pelvic floor physical therapists, nothing is more cringe inducing than hearing the phrase “just do your kegels” thrown around for myriads of ailments from low libido, to pain, incontinence, and erectile dysfunction. While it is true the pelvic floor muscles can be involved in all of these conditions and in some cases kegels may help, there are many cases where kegels are the EXACT opposite of how you should be treating these muscles.

Physiology

To understand kegels we must first understand the pelvic floor. To understand the pelvic floor we must also explain the muscles at a very basic level. Bare with me readers, this will help us as we bust through this myth. Muscles, all muscles do what they do, by contracting and getting shorter to produce force. This is easy to see on a bodybuilder doing a bicep curl. As she curls her hand up you can see these muscles shortening into a little ball. Not only is this a great way to show off your gains in the gym, the shortening of these muscles are providing the strength to perform this task. We call this shortening a concentric contraction. Kegels are concentric contractions too! A good kegel will cause the pelvic floor to shorten and provide strength. Let’s go back to our body builder for a second. She has done her lift now she needs to lower her dumbbell back to the floor. In order to lower that dumbbell back to the floor in a controlled way, she needs what’s called an eccentric contraction, which is the controlled lengthening of the muscle. If she did not have a good eccentric contraction she may not be able to lower that weight effectively after she curled it. What if she couldn’t lower her bicep at all or just very slowly after her bicep curl? Maybe her weightlifting wouldn’t be as effective, she’d tire more easily, or she could develop pain. Would you tell this woman that more bicep curls would help? Or might you suggest a program of stretching first? Telling someone to do kegels, when you don’t know the status of their pelvic floor and how well it can relax is similar to telling the bodybuilder with the non relaxing bicep to just do more bicep curls. At best it certainly won’t help the situation and at worst it could cause more pain and dysfunction.

“But Fiona, I have incontinence, so that definitely means I have weaknesses, so it’s good for me to do kegels, right?”. Maybe… but in my experience, probably not. Let’s agree on one thing, it’s completely intuitive that people would think that kegels would help incontinence. The muscles of the pelvic floor are responsible for continence… so they must be weak if one is experiencing incontinence. You are right! When we think weak with muscles, we often think weak and loose, which is one form of weakness, but we rarely think weak and tight. Let’s go back to our body builder lady. She deserves a name at this point. Let’s call her Kendra. If Kendra has a tough time moving her lifting her arm from fully straight to a full bicep curl, we could guess she is weak and loose. But if Kendra could not fully straighten her arm out she would be considered weak and tight. Both of these versions of Kendra would have trouble curling heavy weight. One Kendra due to frank weakness another Kendra because she simply does not have enough room or range of motion to generate enough force to curl that dumbell.

Tight and weak pelvic floors are a lot like second Kendra with the poor ability to lengthen her arm. Tight pelvic floors have less range of motion to generate force. You need a good amount of force from the pelvic floor to counteract the pressure of activities like lifting, coughing, laughing and sneezing and stay continent. Over loose and over tight pelvic floors can’t really do that.

If you have pain in your pelvis not from a medical condition, (although tight pelvic floors present with many medical conditions), your pelvic floor is probably tight. A tight pelvic floor may also have trigger points which can send pain to various locations in your genitals, back, legs, and abdomen. Continuing to tighten can cause this pain to get worse.

Treatments

So how do you know what to do? This is where a skilled pelvic floor physical therapist can come in handy. They can assess the muscles by touching them either externally or internally to determine what course of action is right for you. If you are loose and weak, HAPPY DAYS! Strengthening can help them get better. If you have tight and weak muscles, HAPPY DAYS again! Gentle lengthening, stretching and down training of the muscles can help them get better. Did you know, because a tight pelvic floor can cause weakness itself, returning the proper length to the muscles can restore strength, without actually needing to kegel?! Wild! Regardless of the situation happy days can be ahead.

Skilled PT

Really knowing the pelvic floor is a skill and requires advanced expertise.  Kegels should not be initiated, unless the physical therapist has carefully examined your pelvic floor. Not all therapists are trained to do that technique so it is important to inquire about their background before starting pelvic floor PT. There are a lot of different ways to treat the pelvic floor, to read more What is Pelvic Floor Physical Therapy . If you are interested in learning more give us a call at 212- 354-2622 for a free consult if you live in the greater NY/NJ/CT area.

PH101: Ladies Session

By: Fiona McMahon, DPT
Hey Ladies!!! In the next installment of our Pelvic Health 101 course, we are hosting a ladies’ session to allow for a safe and non-threatening place to discuss many issues that can affect the health of your pelvic floor. This class one of Stephanie Stamas’s (the founder of PH101’s ) favorites and is definitely not to be missed. Hear more about it in her video below! Join us at 7pm on October 30th . Please register at pelvichealth101.eventbrite.com

 

Location

110 East 42nd Street, Suite 1504

New York, NY

10017

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Ph101 Men’s Only Seminar

Fiona McMahon PT, DPT

On October 23rd at 7pm we will be hosting our  “Men’s Only Seminar”. Join us as we discuss how pelvic floor dysfunction affects the male pelvic floor. Learn how your sex life can be improved by pelvic floor treatment, how to regain function after prostatectomy, and how to rid yourself of the pain of prostatitis, and avoid antibiotics for the most common type of prostatitis. This seminar is not to be missed!

For more reading on male pelvic health topics, check out:

All About Testicles

Navigating Life with Chronic Pain: Part 1

Navigating Life with Chronic Pain: Part II

Prostatitis What it is and What to do About it

Location:

110 East 42nd Street

Suite 1504

NY NY

10017

Pelvic Health 101 Flyer-jpeg