In the world of pelvic rehab, fiber is a big deal. Regardless of the diagnosis that brings the patient in to our clinic, bowel dysfunction is often a complaint that can aggravate or complicate any other diagnosis. Most of us are familiar with dietary fiber basics, but what do we know beyond those basics?

Put simply, there are 2 types of fiber: soluble and insoluble. According to Medline Plus, the average American eats 10-15 grams of fiber per day, when the recommended intake for older children, adolescents, and adults is 20-35 grams. (A high fiber fruit, a medium apple has 4.4 grams of fiber, just for perspective.) Soluble fiber, such as oat bran, nuts, seeds, beans, attract water and turn to gel during digestion. This helps to slow digestion, whereas insoluble fiber, found in wheat bran, vegetables, and while grains, speeds passage of food through the stomach and adds bulk to stools.

According to Eswaran & colleagues (2012), fiber is a crucial part of the digestive process. Any undigested carbohydrate that reaches the colon can be completely or partially fermented by the gut bacteria. Fiber fermentation can indirectly increase fecal bulking, and water retention (influenced by fiber type) can also affect bulk of stool. A potential negative aspect of fermentation is gas production that can cause bloating, discomfort, and flatus.The level of fermentation and solubility of different types of fiber varies based on chemical composition. For more details about the benefits of fiber related to fermenting and non-fermenting properties, click here for a full text article describing these processes.

In the article by Eswaran et al., the authors describe how insoluble fiber can have a laxative effect through mechanical stimulation/irritation if the fiber particles are sufficiently course and large. Soluble, viscous fibers can soften hard stool OR firm loose stool via its water-holding and gel-forming capabilities. While the authors point out varied types of fiber and the research about potential risks and benefits of each in patients with irritable bowel syndrome (IBS), the results of the research are often "mixed." This same phenomena can be seen in our patient populations: each person may need to tailor the amount and type of dietary fiber to her own body.

In relation to dietary fiber supplements, the highest level evidence(Level IIB)cited in the same article is for psyllium/ispaghula. While some patients consume psyllium that is recommended by a medical provider such as Metamucil, many patients choose to purchase the same product (minus the added preservatives) and add psyllium to their diet. While there are many studies that examine the effects of adding a fiber supplement, few actually study the effects of whole foods as the treatment.

One of the most important concepts to teach patients when they are adding fiber to their diet is to do so gradually, as a sudden increase can cause bloating, abdominal gas, and discomfort. If you are interested in learning more about pelvic rehabilitation for functional gastrointestinal disorders, come to PF2A, or attend the new-this-year Bowel Course happening next in November in California. Sign up early for the next 2A course, as the remaining 2013 courses have sold out!

Many therapists who are interested in the use of dry needling for patients who have pelvic pain are faced with the following questions:

• is dry needling in my scope of practice?
• how do I get trained in the technique?
• how do I bill for the intervention?
• is there research to support use of dry needling?

Most pelvic rehabilitation providers begin working with female patients. Regardless of a therapist's interest in or comfort level with working with male pelvic rehabilitation issues, these same therapists find themselves sitting across from a male patient who is desperate for relief from symptoms. What happens next? The therapist extrapolates what she has learned about female pelvic floor dysfunction, applies that information, and is often successful in offering effective solutions. The concern with that approach is this: while there are similarities in anatomy and function, the differences require knowledge and skills specific to the male population.

Most pelvic rehab providers have taken several courses specific to female pelvic dysfunction, and can easily discuss diagnoses such as vaginismus, dyspareunia, dysmenorrhea, or surgeries for prolapse. Thinking back to our schooling, we commonly had not learned evaluation or intervention strategies specific to those conditions. If we apply the same thinking to male patients, what were you taught about hernia repair, scrotal pain, ejaculatory dysfunction? While applying what we know about female conditions when treating men is a good start, filling in the gaps in knowledge and adding tools to our ever-growing toolbox is critical in providing expert care.

One way to fill in the gaps is to attend the Male Pelvic Floor course offered by the Pelvic Rehabilitation Institute. The course offers detailed information about urinary incontinence (including post-prostatectomy rehabilitation), sexual dysfunction, and many topics related to male pelvic pain. Conditions you can learn about include epididymitis, testalgia, benign prostatic hypertrophy, transurethral resection of the prostate, erectile dysfunction, and many more. The lectures include several anatomy lectures to help providers understand the functional relationships of the structures to urinary, bowel, and sexual health. The next opportunity to take the course is next month in Minneapolis. I just noticed the leaves starting to change this morning- September in Minnesota is beautiful, and we would love to see you there!

A recent article examines the relationship between sexual dysfunction and body image. The authors note that little is known about the relationship between dyspareunia (painful intercourse) and body image and genital self-image. Could it be that body image issues link to the fact that women who report dyspareunia also complain of overall sexual impairment, anxiety, and feelings of sexual inadequacy?

The research included an on-line survey of 330 premenopausal women, and 58% reported dyspareunia, 42% were pain-free controls. The women with dyspareunia reported more distress about their body image and more negative genital self-image. This study presents an excellent literature review related to the myriad of challenges a woman faces when dealing with pain limiting intercourse. Such examples include decreased sexual desire, feelings of guilt, shame, failure, and a sense of being incomplete. Women will frequently describe their genital area as a "dead" part of the body. These intense thoughts and feelings are rarely addressed in studies of dyspareunia, and in the treatment of the condition, according to the authors. In studies using the Female Genital Self-Image Scale (FGSIS) in a sample of young college women, women reporting impaired sexual function also reported negative genital self image.

How do we help? In addition to providing caring pelvic rehabilitation, how can the medical community offer a more comprehensive approach that encompasses body image? As discussed in the article, if health care providers view dyspareunia as a chronic pain syndrome rather than only as a sexual dysfunction, patients may benefit from addressing how their "sense of self" becomes negative in relation to the pain. Interestingly, body image and sexuality are intertwined, as a positive body image may "...facilitate the subjective experience of sexuality..." while a negative body image can inhibit sexual health.

In our role as pelvic rehabilitation providers, we can discuss the potentially negative relationship between a woman's sexual dysfunction and her body image. As a minimal level of intervention, instructing in awareness of the problem, in use of positive self-talk, and in ways to evaluate self-worth as a "whole" person despite sexual health issues. Ideally, rehabilitation and medical management can alleviate sexual dysfunction, yet the patient may continue to struggle with anxiety, fears, and self-doubt. Through education, encouragement, rehabilitation, and further research, patients may continue to address issues of sexual health as well as body image. We may not know if decreased genital self-image causes decreased sexual dysfunction, or if having sexual dysfunction causes the poor body image, but this research creates an excellent, well-cited platform from which we can launch meaningful discussions with our patients. Referring providers can also be consulted when the patient may benefit from a consult with an expert in psychological health or counseling.

Inflammatory bowel disease (IBD) is an idiopathic disease estimated to affect 1.4 million people in the United States. The two main types of IBD are Chrohn's disease and ulcerative colitis (UC). Chronic inflammation occurs in all or part of the digestive tract. Symptoms related to chronic bowel inflammation include diarrhea, rectal bleeding, bowel urgency, abdominal pain, constipation and incomplete emptying of the bowels. Constitutional symptoms such as fever, weight loss, fatigue, night sweats, and changes in menstrual cycle can also be reported. To read more about the symptoms, treatment, and research updates about IBD, the Crohn's and Colitis Foundation of America (CCFA) is an excellent resource. The CCFA has a variety of events aimed towards support, education, and fundraising, and you can look for events in your part of the world by going to this page on their website.

Other resources for increasing your own knowledge and awareness and for patient education purposes are listed below.

• IBD Fact Sheet from womenshealth.gov that can be printed and shared.
• Mayo Clinic pages with information on diagnosis, treatment and management.
• Terrific collection of IBD endoscopic images from Atlanta South Gastroenterology.
• American Gastroenterological Association IBD pages.
• Patient brochures from the American Society of Colon and Rectal Surgeons
• Information for parents, kids and teens about bowel disease at kids health.org
• American Academy of Pediatrics information about bowel disorders.

These conditions are different from Irritable Bowel Syndrome primarily due to the inflammation that occurs. While the etiology of IBD is still unclear, what is known is that the body's immune system response is abnormal. The condition is more common in patients who are caucasian, and there is also a familial link. Structural abnormalities including inflammation, lesions, ulcers or tearing are common. While Crohn's can affect any part of the gastrointestinal tract, ulcerative colitis affects the lining of the colon. If a patient of any age presents with symptoms of bowel dysfunction, a worsening of or lack of improvement of bowel complaints, he or she should be referred to an appropriate medical provider to rule out inflammatory conditions of the bowel. In children, IBD can affect growth and development, so the sooner the condition is managed, the better for overall health. The presentation of IBD can be cyclical, with flare-ups that occur, and while pelvic rehabilitation providers are a valuable part of the team treating the symptoms and functional bowel dysfunction related to IBD, we also must be astute in recognizing when a patient requires the evaluation of a medical provider.

While on a walk with my son recently, as he was collecting sticks, he casually repeated the phrase "sticks and stones may break my bones, but words can never hurt me..." and it allowed us to have a brief discussion about how words can, and do, hurt people. Parents today are armed with terrific tools to learn about emotional intelligence, and how the power of language can, for example, help preserve a child's self-esteem while the parent still sets up boundaries. How often are we trained as adults to pay attention to the phrases, gestures, or words that we use during adult interactions, or in patient care interactions? Think about a mentor, supervisor, or friend who you admire- who you aim to emulate. What is it about the person's interactions you find inspiring? Is it the command of the situation she has, the compassion she exudes, or the intelligent way she can say things to a patient? Regardless of the trait you are admiring, communication is likely a key factor in the interactions you find pleasing.

A recent MedScape article asks doctors to share words they let fly, only to wish they could take them back. We have all spoken in haste, in frustration, or in jest, only to realize that we have offended a patient, a family member, or a colleague. The most important thing in that situation may be the actions that follow the indiscretion. And as many martial arts traditions teach, the highest form of self-defense is to avoid conflict in the first place, so how can we best position ourselves to avoid using phrases, gestures, or other communications that offend and create barriers between ourselves and the patient? The most critical part of the solution is awareness. We all use phrases that are so commonly part of our everyday life we don't even know we are using them. It could be "cool" or "is that right?" Do you really mean that a patient's response to your intervention is "cool?" And do you really want the person to clarify if what they are saying is true? What if we took the world as literally as some of the children in our lives do? What would our day look like? Looking at some typical, and lazy ways that we talk, is is accurate to say the following?

• I'm starving
• I wanted to die
• He is so worthless
• You'll be fine
How many of us are truly starving in our communities? Is someone worthless simply because you did not get a return phone call? Will the patient be fine, or do you need to say so because you want to feel less worried?
And how do you feel about the person who begins a discussion with these?
Let me be honest with you
Here's what you need to do
I hope this doesn't offend you
I realize this might seem like micromanagement of every single word out of the mouth. I encourage you to try sometime being truly, excruciatingly aware of what you say, even for an hour. If you invite the kind of honesty required to make habit changes, you could ask a colleague if there are any phrases you often say that are annoying, or not useful. You could ask a student to write down phrases you use in patient care and then compare those phrases to more inspiring language you could employ. The next time you give a presentation, ask a trusted colleague how your use of language was perceived. You may be unpleasantly surprised to find out that you used the word "like" as if it were going out of style (and it did...) When we are really comfortable with our patients, perhaps we have treated them off and on for a few years, or they simply are a person we get along well with, dropping into casual conversation, dropping an f-bomb, or confiding personal details can happen. If you find yourself in this situation, you might simply apologize with a smile, and state that you forgot your manners, and request the patient forgive your casual attitude. We are always in a power situation with our patients, and can never assume that a casual attitude is not misconstrued.
Another habit that can cost you a patient, or a promotion for that matter, is using phrases that come across as callous, or using gestures that indicate a lack of sensitivity. Are you someone who holds the imaginary gun to your head and pulls the trigger when you want to express how maddening a situation was? What do you know about the person to whom you are talking? Did a loved one commit suicide? Again, intention does not really matter once you have completed an act that hurts or offends, and only by improving our awareness of every word, every hand gesture, can we work towards always saying what we mean, and being careful with other people's trust. Hand gestures outside of our own cultural awareness is another topic fraught with the potential to make a wrong move. When in doubt, check in with what your hands are doing: hold on tight to your pen, clipboard, or theraband, and avoiding pointing, thumbs up sign, and other common gestures that may not mean what you think it means.
While sensitivity of language and gestures takes effort, awareness, and being able to take feedback with openness, everyone wins in the end.

Fecal transplants have been in the medical news lately as the Food and Drug Administration attempts to standardize the procedure. The procedure is also known as a fecal microbiota transplantation, or FMT. If this is a new topic to you, here's how it works:  a patient who has bowel dysfunction transfers stool from another personinto their own body. The burning question most people have when they first hear about this is: "How?"  The transplantation can be completed, according to this Mayo clinic article, through a nasogastric tube, nasojejunal tube, upper tract endoscopy, colonoscopy, or a retention enema. Before you think you would never choose this procedure, consider the evidence and the dire consequences of severe bowel dysfunction. The evidence for cure or recovery from bowel dysfunction requiring hospitalization is as high as 90%. The potential consequences of severe infection or conditions such as colitis can include disability, colon removal, progression to cancer, or even death.

The most common indication in the literature at this time for a fecal transplant is chronic c-difficile infection, described in this MedScape article. People have even figured ways to DIY (do-it-yourself) when it comes to stool sharing. There is a website called the "Power of Poo" that is dedicated to increasing public awareness of the procedure. Clearly this is a topic that, if you have not yet heard about it from your patients or friends, you soon will. If you would like to learn more about the procedure, check out the links provided within this report, or click here for a great Q & A with Dr. Brandt about fecal transplants.

Herman & Wallace has also put together a comprehensive Prolapse/Colorectal Care resource for therapists treating fecal incontinence patients, complete with evaluation forms, patient questionnaires, and education materials.

Are you guilty of treating the pelvic floor muscles without inspecting the tissues of the vulvar area or perineal area? A recent posting about clinical pearls by Institute faculty member and Pelvic Guru author Tracy Sher got me thinking about this dilemma. How can we avoid treating pelvic muscle trigger points when the patient has a medical condition requiring immediate intervention, and without which, the trigger points do not stand a chance of resolving? The larger picture is that all pelvic rehabilitation providers must be responsible for an increased awareness of medical issues, pelvic-related pathologies, and how to coordinate referrals.

Experienced therapists tend to have strong skills related to referrals and identifying conditions that require the eyes and ears of a medical provider. Less experienced therapists, in my observation and opinion, have the updated information about medical screening and multiple systems involvement, yet lack the clinical experience to develop an efficient pathway to referral and problem solving. What strategies can improve this issue?

Collaborate

There is much to be gained by the patient when therapists of varying experience level share information, and mentor each other. This requires some humility on the part of both therapists involved, and a huge effort on the part of the employing facility as well as the therapists who aim to find time to review charts, discuss difficult cases, or request that another therapist assess the complex patient. Many sites do not have more than one therapist. What about forming a local study group with the assistance of the the APTA Section on Women's Health, or simply contacting area pelvic rehab providers and doing a quarterly dinner and education session at neighboring clinics? The first response I usually hear is that therapists are in "competition" with these clinics, and that collaboration would be a negative thing. I reject that thought, professionally and personally, as there is plenty of pelvic rehab work to go around, especially with the lack of awareness within the community of our services. Check out this poignant blog post about collaboration.

Consult

Request the opinion of the referring provider whenever possible. Developing a strong relationship with providers is paramount to delivering excellent care. Physicians in this day and age are under severe pressure for being accurate and efficient, and when approached with respect, may develop a habit of seeking your opinion when the patient's condition is perplexing. Likewise, when you have a question or concern, he or she will create time to field the question. Is it possible to invite a referring provider to speak to a group of therapists, or to invite a provider to attend a pelvic rehab lecture with you?

Continue to Learn!

Take a course in medical screening. If you have not taken DPT level courses, what about taking an on-line course in the topic? Or purchase some of the amazing texts from authors including William Boissonnault or Catherine Goodman? Being able to ask the right questions or to communicate effectively about a concern can boost our confidence when contacting providers or when documenting concerns. (I still find myself saying things such as "....there is this odd bump located here and it feels like this...") yet if I can research some options for what that bump would feel like if it were a cyst, a lymph node, a hemorrhoid, etc, then I can discuss with more clarity the true concerns that I have.

Now back to the looking part. Sometimes, looking at the vulvar area or around the male genital area feels uncomfortable for either the therapist, the patient, or for both parties. This issue is the responsibility of the pelvic rehab provider to address. The phrase "fake it 'til you make it" comes to mind, because it is completely acceptable to simply take a deep breath, smile, and pretend to be a little more comfortable than you feel inside; the comfort level will come with practice. If your attitude is "I don't need to see what is going on," well, you are incorrect. What you might find is a lump, a rash, a cut, a bruise, an infection, a suspicious mole, pale skin, or a myriad of other things. A brief and thorough inspection (including under the scrotum or within the vestibular area) are crucial for the patient's wellness. It is possible that the provider has not seen what is going on due to lack of a complete examination or the time between provider examination and your examination.

How do we know what "normal" looks like? This is an area I think we can improve upon in general in pelvic rehabilitation. We are exceptional at education about the muscles, and nerves, and function, yet we might learn how to complete a pelvic muscle examination before learning what lichen sclerosis looks like. The integumentary system is considered to be the largest organ in the body, and if this organ lacks health, certainly the underlying muscles, connective tissues, and nerves can be affected. There are some very helpful resources for us in learning what dermatological conditions look like might affect a patient. Below I have linked some of them for you.

• Blog with link to resources about vulvar skin conditions
• A prior blog post with a link to a terrific article with images of common vulvar skin conditions
• Perianal images including surgical correction
• Images of normal and abnormal anal verge appearances
• Powerpoint available through google scholar with images of vulvar dermatology conditions

In this article titled "Too Posh to Push?"the value of elective cesarean (or "c-section") deliveries for childbirth is revisited. Statistics in Britain are referenced, as rates for the procedure have increased from 4.5% in 1970 to nearly 25% today. This trend is stated to have occurred without a corresponding obstetric need for the the procedure. The US has experienced a similar debate, with stories of women demanding an elective surgery, sometimes for the preservation of the pelvic floor, other times because she is interested in avoiding the pain of pushing. Some providers also promote elective cesareans for birth, perhaps due to their own beliefs about potential benefits, or for the value of having more control over a schedule. Regardless of the motivations and beliefs of the patients or providers, pelvic rehabilitation providers can land in the middle of such an important discussion.

The choice about desired birth practices is between a mother, her family, and her providers. At no time is it appropriate for a pelvic rehab therapist to impose an opinion upon a woman who is pregnant. It is, however, most appropriate to answer questions that may arise in relation to musculoskeletal health and about discussions the patient may be hearing or reading about elective cesareans. The literature in the past decade has been decidedly in favor of avoiding vaginal births in order to avoid pelvic floor injuries. The other half of the story is that birth is not the only factor in pelvic floor health and injury, and that cesarean deliveries also carry risks- some of those risks are lessened in a vaginal birth.

Basic information about a cesarean delivery are available on many sites, including the National Institute of Health's MedLinePlus. While c-sections are always described as a "safe" surgery, all surgeries carry risks. Personally, I have been amazed at the nonchalance of surgeons who give an air of "no-big-deal" for common surgeries that is contrasted with the informed consent waiver a person is asked to sign before entering the operating room. All surgeries have risks. While it is acknowledged that vaginal deliveries are associated with increased incontinence, the actual cause of the pelvic floor injuries cannot be directly correlated with the delivery itself.

A recent study from Brazilevaluated the use of 3D perineal ultrasound to measure pelvic floor injuries at the second postpartum day. 35 patients were allocated to groups according to delivery type: elective cesarean (10), vaginal delivery (16), and forceps delivery (9), with episiotomy performed in 3 of the deliveries. The urogenital hiatus was found to be significantly increased from the cesarean group, at 12.4 cm, to 17 cm in the vaginal delivery group and 20.1 cm in the forceps delivery group. 3 of the 25 women in the non-cesarean groups had a tear of the levator ani. The authors recommend routine assessment of pelvic floor integrity following childbirth. While vaginal birth may be correlated with increased rates of incontinence and prolapse, a recentstudy that evaluated 84 women (grouped by mode of delivery) did not find any correlation between mode of delivery and return to sexual function.

The controversy is far from over, as we continue to see research that aims to answer questions about long-term benefits for pelvic floor health in relation to cesarean versus vaginal deliveries. As is often the case, the swinging pendulum that headed towards recommending elective cesareans will likely swing back towards the middle ground when more research comes in, and when more providers and women understand the total implications of various birth practices on not only the mother and child, but on families and communities as well. In the meanwhile, pelvic rehabilitation providers will continue to support a woman regardless of birth history, focusing instead on patient presentation, goals, and examination findings when applying best practices.

Pelvic rehabilitation providers tend to have personalities that inspire patients to share intimate concerns and issues. One issue that we can play a part in bringing to light is that of medication usage for male sexual performance. Viagra, or the generic version, sildenafil, is a drug that improves blood flow to the penis. It is also one of the the most counterfeited drugs in the world, according to this report. The issue has been in the media for several reasons in recent weeks, with counterfeit manufacturing as one of the concerns.

The United States Food and Drug Administration recently issued a warning about a recall for an over-the-counter male sexual enhancement supplement, "Lighthening Rod," because the supplement contained an undeclared amount of the medication sildenafil. What's the harm? Drugs.com lists 34 major drug reactions for sildenafil, including blood pressure changes (hypotension) or other cardiac effects when taken with nitroglycerines. A national study completed in Australia reports that erectile dysfunction may be a clinically relevant predictive tool for cardiovascular risk, and it may be that men are not sharing information about their sexual function with providers due to embarrassment. In fact, in a news report about a presentation at the American Urologic Association, research presented found that only 25% of men with erectile dysfunction seek treatment.In what has been described as an unprecedented move, Viagra has now made the drug available for purchase on its website, issuing a warning about acquiring the drug without a prescription or ordering a counterfeit drug. While this approach may help to avoid black market purchases of the medication, it also may allow men who don't feel comfortable filling prescriptions for the drug to purchase it in the privacy of their own home.

In terms of our role in helping men avoid the pitfalls of the diagnosis of erectile dysfunction as well as the potential harm from medication available without a prescription, we can start by asking more questions. A good question to start with is "Are there any other supplements or medications that are not on your medication list?" or "Are there any medications or supplements that you purchase from the internet or from a local store?" We can also be sure to include questions about sexual function and health on patient intake forms, and include such verbal questions in our history taking. Because the patient may not feel comfortable on a first visit discussing intimate issues such as erectile dysfunction, in our education of the patient we can provide anatomy and physiology lessons related to sexual function. For any patient who admits to purchasing sexual enhancement drugs that have questionable contents, the patient should be referred to his medical provider to discuss the issue immediately, and the patient can be instructed in the potential adverse effects and in the need to discontinue such medications.

Many pelvic rehabilitation providers are more comfortable discussing sexual health with female patients than with male patients. This topic may be an excellent place to start when it comes to ensuring that our male patients have a place where they can feel safe discussing such sensitive issues, and where they can receive the most current information about their issues. To learn more about erectile dysfunction in general, you can visit sites such as Medline where interactive educational modules can be found.