You’re hurting and you’ve heard that PT can help. A doctor, friend, co-worker, chiropractor, etc may have recommended you see one. OK – now it’s time to choose. Who should you see? Let’s face it – there are literally thousands of physical therapists. In the US, you have about a quarter-million therapists to choose from, although only a small percentage of those are fully trained in pelvic care. How will you know you’ve got the right one?
There are a few questions to answer here…
First of all, do you go in-network versus out-of-network? Should you stick with the general in-network PT you found on the insurance website? You’ve heard good things about seeing a therapist with the out-of-network option, but is it really worth it? Cost of therapy can vary greatly, as can the quality of therapy you’ll receive. I’m not saying the most expensive is always the best. However, insurance restrictions make it very difficult for even the best PT to provide really good care, much less great care.
Secondly, do you need an expert or specialist pelvic PT? Since cost is THE number one barrier to people seeking the help they need from a specialist PT, knowing what you will get for your money is so important.
So what is the difference? What makes a PT a specialist or expert level? Here are a few ways to narrow it down.
A ring of fire. That’s what it can feel like.
You have pain with inserting a tampon. You’ve always dreaded pelvic exams because they hurt. Every time you try to have sex it burns and stings. Sound familiar? Pain with sex may be due to a lot of reasons – one of those may be vulvodynia.
A bit of history – pain with sex has always been an issue, but the cause has not always been well-known. It’s really only the past 20-30 years that our current understanding of it as a condition has been truly recognized, labeled, studied and appropriately treated. Knowing the true cause of the burning is critical in successfully treating it.
What is “Pelvic rehab” anyway? Basically we help the pelvis work right. It may be defined generally as physical therapy to restore the pelvic region to a more functional and/or less painful state. Pelvic rehab treats anything from pain to leakage to lack of coordination. Treatment of bladder, genital, abdominal, pelvic girdle and bowel dysfunction with physical therapy is well-studied and proven effective (especially incontinence, prolapse, urgency and frequency). It is thrilling to know we can regain control over our bodies, in many cases without surgery and medication. Physical therapy is one of the least invasive and most beneficial methods for treating functional abdominal, bowel, bladder and sexual dysfunctions.
Do you just treat the pelvis? The pelvic region encompasses the areas from the abdomen/mid-back to the upper thighs (this includes all of the organs, muscles, nerves, joints/bones, connective tissue and lymphatics). Evaluation and treatment for pelvic conditions should include more than just the pelvis. Complete treatment must address issues from head to toe since all areas of the body affect each other. Effective treatment also may include more disciplines than physical therapy alone. A good PT will address all aspects of care required for a client’s full recovery, including working closely with other providers (physicians, performance specialists, counselors, chiropractors, massage therapists, nutritionists, etc).
As much as we would like to avoid the topic, poop happens. Or in many uncomfortable cases, it doesn’t. According to the statistics, approximately 20% of adults between 40-75 have constipation. And those numbers are just the base level, run-of-the-mill, stopped-up versions. The actual numbers increase significantly with additional factors:
- Older > Younger
- Female > Male
- Psychologic factors – stress or anxiety
So are you constipated? Many consider themselves not to be constipated if anything at all is coming out. However, the actual Rome IV definition (most recent consensus of the medical community – May 2016) might surprise you.
Why do I pee all the time? Why does almost nothing come out when I go?
Urgency, frequency and hesitancy – these are some of the biggest issues that may be separate from or in addition to leakage. Although they may seem to be contradictory, frequent voiding and urinary hesitancy may actually drive each other.
Regarding urgency/frequency: When the bladder is emptied too often (or not enough), the bladder muscle walls may become less compliant. That compliance, or flexibility within the bladder walls, helps define when the body senses urgency. Basically, the bladder is a small muscular sack that stretches as it fills with urine. It needs to be stretched to a certain point to trigger urgency (correlating with bladder contraction). If the bladder is emptied too often (or not enough), then the ability of the bladder to register that “critical point” is changed. The body will send signals that it is “time to go” by starting bladder contractions at inappropriate times, either before necessary or way too late. The result may become frequent urinary urges.
Regarding hesitancy: Just as the bladder can contract when it shouldn’t, it can also relax inappropriately. Then the bladder will fill past that critical point, leading to urinary hesitancy and retention. With hesitancy, the bladder starts to release the urine, but then the urethra closes and/or the bladder stops contracting to push the urine out. Included in this scenario may be contractions within the urethra itself, at the bladder neck or ineffective bladder contractions – all preventing full release of urine. One danger of retention is that some urine may remain in the bladder which can cause an increased risk of bladder infections.
The good news? Notice that nerves and muscles are involved in much of this process. Even though most of these are smooth muscles (ie, not under voluntary control), they can still be retrained! That’s where physical therapy can help. A trained pelvic PT will consider how everything in the trunk, hips and pelvis may be contributing to this altered bladder-urethra-pelvic floor pattern and give you the tools to regain control over voiding again.
Physical therapy can help to reduce urinary urgency, frequency and leakage.
What should you expect at your initial PT evaluation? It will include a thorough history followed by an orthopedic and pelvic examination that determine what factors may be driving your particular issue.
In treating urinary incontinence, physical therapy interventions can be directed toward the pelvic floor muscles, but should also include a full-body assessment and treatment program. Appropriate coordination of the pelvic muscles with everything around and attached to them is required to reduce bladder symptoms, regardless of the cause.
Subsequent physical therapy treatments will likely include some combination of the following:
- Instruction in urgency control techniques. There are simple, effective methods for getting those sudden, strong urges under control (often without surgery)!
- Pressure regulation, including breath work, postural / positional training, and core work.
- More local training of pelvic floor muscles (those muscles that surround the urethral/vaginal openings). This may include manual training, biofeedback, vaginal weights, and modalities to increase coordination and strength.
- Instruction in bladder health, dietary considerations, and lifestyle modifications to reduce urinary frequency. It is impossible to treat a condition by only addressing the muscles – dietary influences and years of habitual training may need to be addressed for full success in bladder retraining.
- Training in body mechanics to reduce strain on the pelvic muscles and organs. Increased strain on the pelvic organs and pelvic muscles due to inappropriate body positioning or movements may reduce the body’s ability to maintain continence and increase prolapse.
- Instruction in techniques to reduce nighttime frequency, urgency and leakage. Decreased leakage at night is often one of the first areas of improvement noted with conservative measures.
The most common types of UI are “stress,” which involves increased abdominal pressure (sneeze, cough, laugh, etc) and “urge,” which is accompanied by urgency and/or bladder contractions. Mixed incontinence has both stress and urge components. This is the most common form of UI, and people will exhibit a higher percentage of one component over the other. For example, you may have frequent, sudden strong urges with leakage most of the time but occasionally also leak with a strong cough. That would be considered mixed UI with urge dominance.
Urinary Leakage, Urgency and Frequency – A Physical Therapy Perspective
Some feel that if urinary leakage is infrequent or only happens a few drops at a time, then it’s not considered incontinence. In fact, urinary incontinence (UI) is defined as experiencing involuntary loss of any amount of urine, at any frequency. Leakage does not result from “just getting older” and should not be regarded as inevitable. It is a physical condition that is treatable. If you find that you are going to the bathroom all the time just to avoid leakage/urgency then you likely fall in the UI category as well.
The list of websites below is not meant to be exhaustive, but they are each reliable sources of information and support.
- PopUp Lifting is an amazing online exercise program designed for women with prolapse. It’s run by Haley Shevener and Annemarie Everett, PT. It’s an amazing, informative program – lots of options!
- Intimate Rose is a company that helps all-things-pelvic. It includes resources for education, supplies, and many other pelvc-related. Using this link gives you $5 off too!
General Men’s / Women’s Health:
Pelvic and Abdominal Pain:
- www.nafc.org – National Association for Continence – information regarding products, treatments, professional listings.
- www.aboutincontinence.org – website spin-off from IFFGD for urinary dysfunction.
- www.iffgd.org – International Foundation of Functional Gastrointestinal Disorders website for information regarding bowel, colo-rectal, abdominal dysfunction.
- www.awomanstouchonline.com – Website for sexual health – books, supplies, information.
- http://tallirosenbaum.com/en/blog – Great website, blog, information source for all things sexual health. AASECT certified sex therapist – leader in national and international education regarding sexual health.