The Agency for Healthcare Research and Quality (AHRQ) Julyfeature story is one of hope for improving care for women who suffer from issues of urinary incontinence or pelvic pain. The AHRQ publishes reviews of literature on various topics and then prepares documents for both the clinician and the consumer summarizing the findings of the research. Reviews pertaining to female urinary incontinence and female pelvic pain were updated this year, and the evidence, according the the summaries, is encouraging of pelvic rehabilitation therapies as opposed to medications and surgical approaches.

The AHRQ is the research arm of the US Department of Health and Human Services, looking at issues within health care quality, costs, outcomes, and patient safety. In preparing the evidence summary for urinary incontinence, 889 research articles were reviewed. The report states that 25% of young women, 44-57% of middle-aged and postmenopausal women, and 75% of older women in nursing homes report urinary incontinence (UI). Age, pregnancy, childbirth, menopause, hysterectomy, and obesity are all recognized as risk factors for UI, and when we consider how many women within our patient populations (or community populations) present with such risk factors, we can begin to understand the scope of the problem. The report notes that pelvic floor muscle training (PFMT) alone is as effective for stress and mixed UI as when adding biofeedback, bladder training, or electrical stimulation. For urgency UI, bladder training alone is as effective as bladder training with PMFT. Also according to the report, 19.5 billion dollars annually are spent for treatment of UI. To access the clinician summary regarding the non-surgical treatments for urinary incontinence, click here, for the patient summary, click here. The patient, or "consumer" file is also available in an audio version on the AHRQ website.

In the March 2012 research activity update, the AHRQ issued a statement that evidence is lacking to support surgery for pelvic pain. Based on the review of pelvic pain treatment options, there is a recommendation for further studies not only related to surgery, but also for conservative options for treating pelvic pain. In the comparative effectiveness review summary for patients, that can be accessed here, it is recognized that irritable bowel syndrome, endometriosis, painful bladder, tense pelvic floor muscles, or scar tissue can all create pelvic pain. It is also noted that a provider may refer a patient for physical therapy. In the clinician summary of the effectiveness review it is stated that there is not enough evidence to conclude that pelvic muscle therapy is effective for treating pelvic pain. This leads us to a common conclusion in health care: we need more clinical research that helps us answer questions about effective approaches for treating pelvic pain.

If you are interested in creating an opportunity to participate in clinical research, contact a local university physical therapy program to inquire about options. If you feel that you lacked training in research methods or concepts of evidence-based medicine, try taking a local or on-line course in one of the above topics. You do not need to be enrolled in any particular program to take a course, and you may even be able to audit a class if you contact a nearby educational facility.

The value of being aware of these documents created by the AHRQ is that we are often in a role of educating patients about treatment options. It is important that we represent the accuracy of the research as evaluated by government committees, and stay abreast of updates and additions to the body of knowledge. It is also helpful to direct patients to these websites when we know our patients are able to further empower their own lives by having more information.

On at least a weekly basis, most pelvic rehabilitation providers hear "I didn't know there was therapy for my condition." We also have to field questions about why the medical provider did not refer to rehabilitation before recommending surgery or drugs. One of the best ways for us to improve the lack of awareness in our communities is to go out and speak to them. While we have opportunities throughout our work and personal time to share information about what we do in practice, we can maximize the sharing of information by preparing a more formal option than simply giving our "elevator speech" from time to time.

A community presentation takes a little preparation and possibly a few tools. Fortunately there are many resources available for you to utilize when giving a talk to the public. Here is a look at what you might consider:

1. The audience- to whom are you going to present information? Find out exactly who, how many, and what the goals of the audience is ahead of time. Showing up to give a talk about urinary incontinence when the group thinks you are speaking about arthritis could be awkward. It is also helpful to make sure there is enough space for those in attendance so you are not distracted by trying to add more chairs, move tables, etc.
2. The topic- sometimes it is helpful to keep the topic broad, for example, "what does a pelvic rehabilitation provider do?" may be a generally interesting presentation. However, if you are speaking to a bladder pain/interstitial cystitis support group, you may want to me more specific in addressing bladder dysfunction and pain.
3. The length- community members (and potential patients) want to ask questions. Inquire how much time you will have to speak, and then if there is time allowed for questions and answers. If there is not time allocated for answering questions, leave 10-15 minutes at the end of your presentation (and possibly plan to stick around a few minutes more if needed.)
4. The presentation- unless you are speaking to medical residents or another professional group, skip the powerpoint. If you can bring a pelvic model, bring a prop like you may have seen an instructor use during a demonstration, or bring a chart or other visual aid, this may allow to you speak more naturally, tell a few stories. It also avoids the inconvenience of dealing with IT issues at the last minute.
5. The giveaways- always bring with you some business cards and some brochures if you have them. Attendees will want to walk away with something tangible so they can contact you or tell a friend or loved one about your services. There are also sites that allow you to download and print handouts for patients. National sites such as the NIDDK have patient information about urinary incontinence in men or women (click on either word to access the document) and you can see that the handout is not copyrighted. You will also see that the handout is available in both Spanish and English versions. Other giveaways might include a water bottle, a stress-ball to squeeze, or a pen with your clinic name on it.
6. Where to present- the options are endless, especially if you are willing to be creative and think outside of the doctor's office. Check with your local health clubs, they often allow presenters to come in and share information. Assisted care facilities are used to organizing activities for residents, and local hospitals may allow you to speak. Look on your newspaper community activity page or hospital website and see what support groups are meeting- perhaps a prostate cancer group, bladder pain group, fibromyalgia group, pregnancy class. Contact key educators at a local university, is there a classroom where you can provide a short lecture?

An article appearing in The Journal of Sexual Medicine asks the following question: do bicycle seats damage the female pelvic floor? The authors studied the affects of bicycle set up on genital sensation and saddle pressures among female cyclists. Subjects included were premenopausal, non-pregnant women who rode at least 10 miles/week, and the women used their own bicycles and saddles for the study. Genital sensation was determined with use of a biosthesiometer, a research device that measures thresholds of vibration in the body. A pressure map was used to record perineal and total saddle pressures. When the bike handlebars were positioned lower than the saddle, increased perineal pressure and decreased anterior vaginal and left labial genital sensation was noted.

Prior research published in the same journal reported that female cyclists can suffer from genital pain, numbness, and swelling, and that debate exists regarding best bike seat/saddle design. 48 cyclists were included in this research, and more than half of them used traditional saddles versus "cut-out" or narrow saddles with portions of the seat removed to avoid pressures on the perineum. Although there was an association of decreased lower mean perineal pressure with use of traditional saddles, these differences were not statistically significant. Overall, cut-out and narrower bike seats were found to have increased saddle pressures measured by a specially designed pressure sensor.

When educating our patients about pelvic health and biking, the most important factor to consider is overall fit. Many therapists are trained in the evaluation of bike fit, if you are not, consider adding those skills to your tool box, or get in touch with an expert for referrals. By contacting a local bike shop, you can get names of bike experts or therapists who specialize in fitting. To learn more about bike seats and posts, click hereand you can find an entire website devoted to concepts of bike fit, including classes that you can attend to become certified in bike fitting.

Authors of each study mentioned state that more research is needed to determine if bike saddle pressures affect pudendal nerve health, sexual function, and pain. To determine if bike fit is a part of your patient's issues, ask her detailed questions about how much time is spent on the bike, what kind of bike (mountain bike versus road bike), what position she is in most of the time (in the "drops" or lowered handle position versus upright), what kind of terrain she rides (bumps that can jar the pelvis versus smooth roads), and what kind of symptoms that she has on and off the bike. Female runners were found in one study to have improved perineal vibratory sensation thresholds when compared to competitive cyclists, indicating that biking can impact genital sensation and potentially create other pelvic dysfunctions.

Your Pace Yoga is a home yoga program that was designed by Dustienne Miller MSPT, WCS, CYT,who is a board certified women’s clinical health specialist in physical therapy and Kripalu Yoga teacher.

This program is intended for men and women who are healing chronic pelvic pain. The DVD video weaves together breath work, meditation, body awareness, and gentle yoga postures. This stress relieving program can be practiced in as little as twenty minutes, making it possible for the patient to fit into daily life.

The DVD can be purchased HERE

Dustienne also has a blog, Your Pace Yoga, which provides resources and information about yoga, pelvic pain and wellness.

Keep up the great work, Dustienne! The Institute is proud to endorse these excellent clinical and patient resources!

Recent research in The Journal of Pediatric and Adolescent Gynecology points to the alarming number of young women who present with pelvic pain who in fact also have endometriosis. Dr. Opoku-Anane and Dr. Laufer report that prevalence rates of endometriosis in an adolescent gynecology population have likely been underestimated (reported range of 25-47%) and that with advanced surgical methods the rates have been estimated to be as high as 73% in those who have pelvic pain. In their retrospective study, 117 subjects ages 12-21 completed laparoscopic examination for endometriosis. These subjects did not previously respond to non-steroidal anti-inflammatories or to oral contraceptives, and they were all referred for evaluation of chronic pelvic pain. In addition to collecting data about patient symptoms, the stage and descriptions of any endometrial lesions were documented.

A remarkable 115 of the 117 subjects (98%) presented with Stage I or II endometriosis as defined by the American Society for Reproductive Medicine guidelines. (Click here for the link to a detailed patient education document from the ASRM that describes endometriosis as well as staging.) The median age for onset of menarche in this population was 12 years old, and the median age of first symptoms reported occurred at age 13. Nearly 16% of the subjects also reported gastrointestinal complaints, menstrual irregularity in nearly 8%, and 76% of the participants reported a family history that included endometriosis, severe dysmenorrhea, and/or infertility. The authors of this research point out that advances made in surgical technique, both from a technological standpoint and a physician skill level, may be contributing factors in the increased rates of diagnosis of endometriosis.The authors also point out that it is yet unknown if early diagnosis and treatment will lead to improved outcomes in this population.

If you are interested in learning more about endometriosis in general, click here to follow the link to a free, full text article in PubMed Central. The article was first published in 2008, and even though advances in surgical diagnosis have been made, most of the information related to symptoms, medical treatment, and related risks remain significantly unchanged. In relation to etiology of endometriosis, one study that has set forth an environmental risk for endometriosis can be accessed here. Dr. C. Matthew Peterson, one of the researchers involved with the ENDO study, presented at the 2011 International Pelvic Pain Society meeting, and he encouraged all present to consider implementing strategies to minimize risks from chemicals in our daily lives. The Environmental Protection Agency offers advice towards protecting our health that can be accessed here. If environmental hazards are influencing the onset or progression of conditions such as endometriosis, it is in our best interest to reduce these risks. Consider not only the product exposure at home, but also at the workplace, and request less toxic products including cleaners when able.

In relation to pelvic rehabilitation, patients who present with pelvic pain or other pelvic health issues due to endometriosis often find relief when working with pelvic rehab providers. While surgery may be critical in reducing severe adhesions, maximizing tissue health and patient mobility and function is a job in which we can all actively participate. The evaluation and treatment of pelvic pain is instructed at various levels of depth in all of the main series courses as well as in many other courses offered at the Herman & Wallace Pelvic Rehabilitation Institute.

Pelvic floor muscle training has been found to be an effective approach for treating fecal incontinence in children following surgical correction for Hirschprung disease. This disease can cause severe constipation or intestinal blockage due to a lack of nerve cells in the large intestine that are responsible for creating contractions in the smooth muscles of the bowels.Most of the time, Hirschprung disease is identified and corrected in infancy, but it can also be treated in childhood and sometimes in the adult patient. Thereare several different types of "pull-through' surgical procedures that can be used to remove the diseased portion of the large intestine and attach a functioning portion of bowel to the anus. This type of procedure can injure tissues including the internal anal sphincter, creating the issue of fecal leakage or incontinence.

A case series appears in the European Journal of Pediatric Surgery that reports on 24 cases of children who became incontinent following a Soave pull-through procedure for Hirschprung disease. 16 of the children were treated with 2 weeks of biofeedback training in the hospital followed by home program for pelvic muscle exercises, while 8 children served as a control group, receiving no therapy following the surgery. At baseline and at one year follow-up, measures were taken via anorectal manometry for resting anal canal pressure, squeeze pressure, and for rectal sensation. At one year post-surgery, the children in the treatment group were found to have significantly increased resting rectal pressure as well as squeeze pressure. Rates of fecal incontinence were significantly reduced with only 3 of the 16 children reporting occasional soiling after completing the pelvic muscle training.

This research is encouraging as biofeedback therapy is a non-invasive, inexpensive option for patients who have already been through a surgical procedure to correct a biological dysfunction. The International Foundation for Functional Gastrointestinal Disorders (www.iffgd.org) has a wonderful website with more information for rehabilitation providers and for patients, and they also have a website designed for kids and teens who have functional gastrointestinal issues. That website can be accessed at www.aboutkidsGI.org.

Just published in the June edition of the Journal of Obstetrics and Gynecology, evidence points to post-traumatic stress disorder (PTSD) among female military veterans as a cause of urinary incontinence. 968 women ages 20-52 completed surveys addressing gynecologic, medical, and mental health. 19.7% of the women reported urgency/mixed urinary incontinence (UI), and 18.9% reported symptoms of stress UI. PTSD was associated with urinary urgency or mixed UI, but not with stress incontinence. Symptoms of depression did not correlate with stress or urgency/mixed incontinence. The authors concluded that for a female veteran having symptoms of urge or mixed UI, there is an increased likelihood that she also suffers from PTSD and an associated poorer mental health/quality of life. The authors also state that increased research is needed to better understand the neurobiology of continence.

A report in the Journal of Psychiatric Research suggests that women who have served in the military need to be screened for PTSD and prior trauma or stress events, as regular duty and reservist personnel serving in Canada were found to commonly deal with symptoms of PTSD. Other issues found to be clinically significant for female veterans include depression, sleep difficulties, and chronic pain. In 135 patients studied by Kelly et al. and reported in the journal Research in Nursing and Health, military sexual trauma is reported by 20-40% of female veterans.

All of the above issues are relevant to the pelvic rehabilitation provider. It makes sense that post-traumatic stress disorder has an effect on the nervous system that can then affect bladder function. Our treatments often include strategies to calm the nervous system, and for those patients who have PTSD, relaxation strategies may be extremely important as a treatment tool. In addition to urinary complaints, a female veteran presenting to our care may also have pelvic pain manifesting as various functional limitations including sexual dysfunction. It is appropriate to ask about all domains of pelvic health when working with a patient who has served, or who is currently serving in the military. The impact of serving in the military is gaining increased awareness, resulting in research that identifies various symptoms and proposed treatments. Overall, this improves our ability to provide more comprehensive care through increased physician awareness and through referrals to pelvic rehabilitation.

Research presented recently at theannual Scientific Meeting of the American Urological Association (AUA) addresses the increased risk for urinary and sexual dysfunction among men who have served in the military.In a press release issued by UroToday, it is noted that men who have prior military service have up to 3 times the risk for developing urinary incontinence. Data was collected on nearly 5300 men and the results were categorized into 3 age groups: < 55, 55-59, and > 70 years of age. 23% of the men in this general population sample reported military exposure, and the rate of urinary incontinence (UI) was 18.8% in the military group versus in the men without military experience (10.4%). Interestingly, it was the age group of < 55 years that had the most significant increase in risk for UI, as the men older than 55 did not have a significant difference in rates of incontinence.

Not only has prior military service been found to be an independent risk factor for men under age 55 developing urinary incontinence, but the diagnosis of posttraumatic stress syndrome (PTSD) in male Iraq and Afghanistan veterans is linked with a higher rate of lower urinary tract symptoms as well as sexual dysfunction. Male veterans who suffer from PTSD are more likely to suffer lower urinary tract symptoms (LUTS) than men without PTSD, even when medications for the syndrome are taken into consideration. In other research presented at the AUA meeting, the prevalence of sexual dysfunction in men who have PTSD was discussed. Conditions including erectile dysfunction and premature ejaculation were analyzed in health histories of men with and without PTSD. The rate of sexual dysfunction in men with PTSD was nearly 10%, while in men without PTSD, the rate was 3.3%. The authors concluded that while certain medications taken for PTSD can cause sexual dysfunction, medications alone are not responsible for all cases of sexual dysfunction in men with a military service history. Issues of avoidance, emotional numbing, and hyperarousal (all symptoms of PTSD) were found to be important factors in the dysfunction.

Increased awareness of these issues may lead to better identification of the conditions as well as improved emphasis on effective treatments. In my role as faculty for the Herman & Wallace Pelvic Rehabilitation Institute, I have met several pelvic rehab providers who work within the VA system, providing care for the men and women who have served in the military. There is increased awareness of and interest in integrating pelvic rehabilitation programs for veterans, and this is a trend that will hopefully expand into comprehensive pelvic rehab care. With Memorial Day so recently behind us, it is timely to have increased light shed on these significant issues so that care may be directed to treat these sensitive issues that can impair quality of life.

The American Urological Association (AUA) issued new guidelines today for the treatment of overactive bladder. Overactive bladder (OAB) is described by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) as having to void or empty the bladder more than 8 times in a day or more than 2-3 times/night. Strong, sudden urges occur with OAB and may or may not be accompanied by urinary leakage. The first line of treatment recommended by the AUA includes behavioral therapy as well as possible combining of anti-muscarinic therapy (the only FDA-approved medication for overactive bladder.)

Behavioral therapy for bladder dysfunction is commonly instructed as part of a symptom management strategy by pelvic rehabilitation providers. Patients are instructed in normal bladder function, dietary factors that influence the bladder, bladder habits, the influence of medications on bladder function, in addition to pelvic muscle training. Behavioral therapy is one component, and a very important one at that, of the comprehensive care for the patient with bladder dysfunction.

Second line treatments discussed in the updated guideline all relate to medications and their potential uses and risks. Recommended third line treatments suggest more invasive options including tibial nerve stimulation and sacral nerve stimulation, which are both FDA-approved options. The guidelines are based on expert opinion as well as on research. As reported in prior posts about overactive bladder, more research is required to better define the symptom complex and more consistency within the research is needed in regards to definitions throughout the research.The AUA also has guidelines for other male and female urologic conditions such as urinary incontinence, erectile dysfunction, female surgeries, and interstitial cystitis/bladder pain syndrome. You can access the page with links to these documents by clicking here. To access the new AUA guidelines for overactive bladder only, please click here.

The value of seeing behavioral training listed as the number one treatment that providers should offer the patient is to be celebrated in a world when pharmacology and surgeries is the typical go-to medical suggestion. What a wonderful document to discuss with your urologists, urogynecologists, family practice providers, and fellow party-goers as we head into the Memorial Day weekend.

Recent research has confirmed prior work that suggests the use of boric acid is an effective treatment for vaginal yeast irritation. Chronic yeast irritation, commonly caused by Candida albicans, is a troubling condition that can cause symptoms of vulvar itching and burning, abnormal discharge, painful urination or intercourse, and vulvar swelling. Triggers for yeast imbalance include antibiotics use, pregnancy, changes in glucose metabolism, and use of certain oral birth control pills. Tight clothing and use of plastic pantiliners can also create an environment in which yeast growth can cause symptoms.

The availability of over-the-counter yeast treatment has led to patients misdiagnosing and often over-treating with such medications. The ingredients in many of the available creams or suppositories can cause allergic reactions, vaginal burning, irritation, or itching. Many of our patients who complain of pelvic pain may be dealing with a history of or a current case of low grade (non-acute), recurrent yeast overgrowth and subsequent tissue irritation that can create a chronic pain condition. There are several intravaginal treatments that have been used by patients including boric acid tablets. Knowing that I worked with a high population of women's health patients, I recall my naturopath handing me an article over a decade ago that described the superior results of boric acid over nystatin. Some providers recommend the use of boric acid in the evening, followed by intravaginal probiotics in the morning. Boric acid can cause local skin irritation as a side effect, but no other significant side effects have been reported when used vaginally.

In a reviewby Iavazzo and colleagues about recurrent vulvovaginal candidiasis, the use of boric acid is presented. The studies included in the review reported a 40-100% cure rate with minimal side effects. The authors conclude that boric acid is an economic, safe option for women who have non-albicans Candida strains of yeast overgrowth or for those who have azole-resistant strains. The National Institutes of Health recommends avoiding vaginal douching or feminine hygiene sprays, rinsing with water only (no soap), use of condoms to prevent spread of sexually transmitted infections, wearing cotton underwear and avoiding tight, non-breathing clothing, and keeping blood sugars in check.

We can keep this information in mind when working with patients who complain of pelvic pain, vaginal or vulvar burning. Of course, these symptoms can also be attributed to neuromuscular pain, referred symptoms, or a chronic pain cycle. The above information about boric acid can be presented to the patient if she reports a history of chronic yeast irritation and she can then discuss the option with her medical provider. According to Donders, patients often feel misunderstood, guilty, and feel sexually inferior due to chronic candidosis, requiring that medical providers consider this issue as one to be taken seriously. Having the information about options such as boric acid appear in medical journals helps to highlight the importance of managing this condition that is often recurrent and sometimes difficult to treat.