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Painful Bladder Syndrome/ Interstitial Cystitis(I.C.)/ Bladder Pain and Physical Therapy

Introduction 

Painful Bladder Syndrome (P.B.S.) is bladder pain, know to affect women primarily but this can affect men and children too. This presents with the classic symptoms of urinary frequency, urinary urgency, and bladder pain. In this post all of this is addressed, along with helpful tips to manage painful bladder syndrome ( P.B.S.) and physical therapy for this condition. This is also called Interstitial Cystitis /I.C. There are about 12 million with the diagnosis of Painful Bladder Syndrome/ Interstitial Cystitis/I.C. don’t feel alone, there is help and hope and its a matter of finding it .

Definition :Over sensitivity of bladder weather or not inflammation is present  PBS/Interstitial cystitis/ I.C.

Symptoms that are found in Interstitial Cystitis/I.C.(+ ve symptoms) Symptoms that are not found ( -ve symptoms)
Urinary frequency
Urinary Urgency 
Pelvic pain
Urethral symptoms – dysuria pain with urination		-ve UTI
-ve Bladder cancer 
-ve Endometriosis-Urine analysis (no pus cells , no blood cells)
  • Other conditions that can coexist with Interstitial Cystitis/I.C.

Allergies

Migraines

Vulvodynia

Fibromyalgia

Sensitive skin

Bladder Anatomy :  

The bladder is a muscular bag that stores urine until ready to be expelled from body .The triangular lower end of the bladder is called the Trigone.Trigone of the bladder is estrogen dependent.So what occurs in the vagina, the trigone of the bladder will experience the same, like an  infection or irritation. This is the part of the bladder that is sensitive to pain.To know more of the bladder anatomy click here 

The Diagnosis of Painful Bladder Syndrome is based on 

Presence of bladder pain , urinary frequency and urgency

Rule out other diseases that could cause the same symptoms.

APF biomarker .This is a test to detect APF in the urine but this is in the preliminary stages of development.

Amino acid marker : People with Painful Bladder Syndrome /I.C. process the amino acid Tryptophan differently from those that do not have P.B.S. / I.C .This is also in the developmental stages .

Possible wrong Diagnoses of the Interstitial Cystitis/I.C.are

  1. UTI
  2. Overactive bladder
  3. Hemorrhagic Cystitis
  4. Pudendal Neuralgia
  5. Prostatitis
  6. Endometriosis

Homeopathic remedies for UTI  

6 Steps of Painful Bladder Syndrome / I.C. Treatment according to American Association of Urology

Step 1

Drinking water recommended
  1. Drink water: Drink enough water to keep the urine not too concentrated. If the color of the urine is yellow its too concentrated , if its clear you are probably drinking too much water.
  2. Diet modification : IC diet
  3. Muscle relaxation : to improve the blood flow to the pelvic muscles ,or a relaxation class
  4. OTC supplements : Acid neutralising/ reducing products such as Prelife,Acid Zap, Javacid, Cysto Renew , Cysto Protek,,Cysta Q, Desert Harvest Q (consult you Dr before taking any medications)

Step 2 

  1. Oral medication : 
  • Elmiron : has side effects such as hair loss, diarrhea , change in liver enzymes .
  • Antihistamine
  • Low dose antidepressant : may help to calm the nerves, may have some side effects 

        2. Bladder instillations :Rescue installations,coats your bladder and helps to numb the bladder.

       3. Pelvic floor Physical Therapy: A study in 2008 found Pelvic PT to be very effective in reducing the symptoms of Interstitial Cystitis I.C. A vast majority of patient’s with IC have PFD ( pelvic floor dysfunction ) ie the pelvic floor muscles get spastic and are not functioning properly.

Step 3 

  1. Treatment of Hunner lesions :Hunners Ulcer,, associated with gross inflammatory response of the bladder and it is usually not missed to diagnose and it  is generally  biopsied to rule out any bladder cancer.Very small % of patients actually  have these lesions.Treatment can include 
  1. Fulguration
  2. Laser Therapy
  3. Steroid Injection.
  4. LiRIS /LiNKA
  1. Hydrodistention with Cystoscopy : currently done as a diagnosis and not as a treatment option but can vary based on the Dr’s school of thought.

Step 4

  1. Neuromodulation that targets nerves: Reregulation of those nerves can help with pain.

                 2 Types

  1. Sacral/Pudendal ( Surgical)
  2. Post Tibial nerve ( Non surgical) known as Urgent PC .PTNS: PercutaneousTibial  nerve stimulation to decrease the pain memory in chronic pain to down regulate the pain in the conscious and subconscious level .Success rate of 70 %, treated twice a week for 6 weeks and reevaluate with a gradual weaning off of the treatment as per  the patient’s response.

        2). BoTox: Helps numb and calm the nerves

Step 5 

  1. Experimental procedures: Strong steroid and immuno suppressant medications

Step 6

 Surgery: Bladder removal .Surgical option is the last option and most people with IC respond well to options listed prior to step 6.There are different surgical procedures.

Women and Painful Bladder Syndrome / Interstitial Cystitis

P.B.S./I.C. during Pregnancy:

There is limited scientific data on the subject of pregnancy and IC.In the study conducted in 1989 it was found that the IC symptoms did not change much until the 3rd trimester and even in the last semester showed a small change in symptoms.Closely coordinate you plan of treatment during pregnancy with your ObGyn.

P.B.S./I.C. and Genetics:

IC was found to have a small genetic component, meaning you could pass it on to your baby. Research shows environmental influences to be greater than genetic predisposition towards IC.

P.B.S./I.C. and Conception:

IC dose not seem to influence the ability of a woman to conceive. Bladder pain from IC can interfere with sexual activity but IC was not found to interfere with the actual conception when able to engage in sexual activity.Timing inter course to when most fertile or during ovulation  could be one way to cope with pain and plan conceiving a baby.

Painful bladder Syndrome /I.C. and lovemaking /Intimacy : 

As per reports an estimated 85% of women with Interstitial cystitis suffer from Vulvodynia. The aspect of sexuality is not generally addressed, Dr’s do not talk much  about this with their patients. Interstitial cystitis can affect all aspects of sex.Many may have pain with intercourse and an I.C. flare up following intercourse.This can lead to a viscous cycle of avoidance,decreased desire, guilt, depression and relational stress.Men may have the same complaints coupled with erectile dysfunction and painful ejaculation.

Tips  for Intimacy: 

  1. Try to plan intimacy when you feel your best, for eg after receiving some  I.C. treatments that can help with pain.
  2. Try out some products out before you use them with your partner, such as any sex toys or a particular lubricant.A successful trial by your self can be boost your confidence and interest in lovemaking.
  3. Think outside the box. Is there anything else you can do other than the traditional penetrative intercourse ? How about outercourse?
  4. Work with a psychologist/counselor, if you are getting depressed, or even a sex therapist or a sexual medicine specialist. 

Painful bladder Syndrome and Men 

  1. The diagnosis of I.C. in men can be missed due to the fact that I/C. is not as common in men, and the symptoms mimic other conditions, such as prostatitis,chronic pelvic pain, prostate enlargement and  urinary tract infection or prostate infection.
  2. One of the factors that has been found in men with IC is the urine marker for APF(antiproliferative factor ).
  3. Men are less likely to report and seek out help for pelvic pain.
  4. Pelvic floor dysfunction is prevalent in male population with I.C. as well.Internal massage of the pelvic floor muscles is done through the rectum and a good % of my male patient population are reluctant for therapy via this route. Hence pain management may continue to be an issue.

Painful Bladder Syndrome and Children

  1. Very little is known about I.C. in children.
  2. Many adults who are diagnosed with I.C. recollect symptoms since their childhood.
  3. Symptoms are similar to adults with urinary urgency, frequency and pelvic pain.
  4. Diagnosis in children is difficult and is made on exclusion i.e. ruling out all other possible causes.
  5. Treatment options may be the same as adults but in low doses/ pediatric doses of medicine and at the discretion of the medical team.

Physical Therapy and Painful Bladder Syndrome /Interstitial Cystitis

Painful Bladder Syndrome effectively manged with Pelvic Physical Therapy
  1. Most of my patient’s who see me following a diagnosis of P.B.S./ I.C. are in pain and also have pelvic floor dysfunction, meaning the muscles of the pelvic floor are not relaxed and tight and upon exam I may even find trigger points in the pelvic floor muscles.
  2. My therapy sessions are customized and tailor made to my patients needs. I treat what I find during my initial assessment. If I find tightness I include stretching and relaxation techniques. I instruct my patients to perform this every day as home exercises to maintain the work I do with them when they see me for their session.Other Manual techniques  may include
  3. Trigger points release.
  4. Joint mobilization.
  5. Nerve flossing / Nerve releases
  6. Biofeedback to help down regulate and relax the muscles or help train the muscle coordination .
  7. Breathing can play a key role in helping manage pelvic pain.To learn about this you may visit my post on Diaphragmatic breathing.

Conclusion

To summarise 

  1. There is help and hope even after the diagnosis of Interstitial Cystitis or Painful Bladder Syndrome.
  2. There are 6 specific steps suggested by American Association of Urology when followed closely can be effective to manage I.C.
  3. I.C. can be seen in men, women and children.
  4. Physical Therapy has been found to be very effective in conjunction with other treatments to manage I.C.

Refrences:

www.auanet.org

www.ichelp.org

IC & Pelvic Pain Network – Interstitial Cystitis, Bladder Pain Syndrome, Pelvic Pain, Hunner’s Lesions

www.https://www.youtube.com/user/icnjill/featured

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Painful sex or Dyspareunia

Painful Sex or Dyspareunia

Introduction to Painful sex or Dyspareunia

Definition: This is pain during sexual intercourse or pain with sexual activity that involves penetration.

Dyspareunia can occur in men and women who are sexually active regardless of their age. The majority of dyspareunia or painful sex is seen in women but men also can be suffering with this diagnosis.

Physiology of Painful sex or Dyspareunia

When intercourse is painful (dyspareunia) our muscles naturally contract to protect from the pain. and in anticipation of pain. This anticipation of pain can lead your nervous system to react with a cascade of events leading to even tighter muscles, vaginal dryness and loss of lubrication.  When this happens, intercourse becomes even less comfortable, resulting in more pain. Hence this becomes a viscous cycle that need to be broken and can be done with Pelvic Physical therapy.

Types of painful sex or dyspareunia ( in women)

1.Superficial Dyspareunia

2.Deep Dyspareunia

1. Superficial Dyspareunia : 

 Pain at the entrance of vagina during attempted penetration is superficial dyspareunia.

Causes of Dyspareunia

This type of dyspareunia can occur due to any of the following

Dryness of the vagina due to 

Inadequate foreplay

Hormonal imbalance as in perimenopausal women and in women who are breastfeeding.

UTI

Injuries to the Genital area

Vaginismus 

Vulvodynia – involuntary contraction of the vaginal muscles

Surgery : anything that narrows the vaginal opening such as episiotomy and it’s repair post child birth.

Congenital tight hymen 

Dyspareunia can cause relational issues

2.Deep Dyspareunia

Pain post penetration during the thrusting movement is Deep Dyspareunia

Causes :

Retroverted Uterus : Normally the uterus is tilted forward on the bladder, but it can be tilted back in retroverted uterus and this can cause dyspareunia.This can be surgically corrected if severe.

Vaginismus

P.I.D. ( Pelvic Inflammatory diseases) infection of cervix , uterus or vagina .

Endometriosis

Gynecological cancers : Ovarian, Uterine cancers  and Fallopian tubes.

Scarring from radiation and Chemotherapy or surgical scars.

A through exam is the start to the solution of dyspareunia

Diagnosis for painful sex or dyspareunia

Subjective History:The diagnosis depends on the symptoms the patient reports such as when does the pain occur and where is the pain.For ex.

1.When do you have pain during intercourse ? Is it at the entrance of the vaginal opening or during thrusting?.

2. How long does the pain last ?

3.Was there ever a time when intercourse was not painful?

4. Any history of sexual abuse or genital trauma?

5.Any History of sexually transmitted diseases?

Pelvic  Exam :This may be followed by a gentle but through pelvic exam to assess hypersensitivity to touch and any increased inflammation.The pelvic area may be touched by a cotton swab to assess the area of pain and sensitivity externally.The pelvic muscles may be assessed internally  by gently inserting a gloved and lubricated finger through the vagina.

Pelvic Physical Therapy for painful sex or dyspareunia :

Physical Therapy: Intervention will include

Massage techniques/ Myofascial release.

Relaxation training , with Diaphragmatic breathing and Reverse Kegels.

Stretching.

Strengthening of weak muscles.

Postural training and coordination of the muscles that support your core. 

I evaluate the back, hips and possibly the rib cage region to see if there are any imbalances in those regions contributing to your pain.   I also be teach self-care techniques for you to utilize at home and possibly with your partner. PT is a process with which one has to have patience if you wonder about the duration of PT before you see results check this article I wrote on that subject matter.

Painful sex or Dyspareunia in Men

Painful sex or dyspareunia defined by ICS : It is Penile discomfort occurring during intercourse , may be caused by penile diseases ,altered vaginal anatomy( vaginal tightening and scarring) or various positions during intercourse, that causes impingement of the uterine cervix.

Chronic Dyspareunia : is recurrent or continuous pain that occurs in the pelvic and genital area that occurs during and after sexual intercourse, for 3 months or more pain may in the penis may be accompanied by a burning sensation. 

Causes: 

Psychological Causes:

Sexual Abuse 

Anxiety 

Stress

Fear  

Medical Causes:

Phimosis : Tight foreskin

STD

Testicular Cancer

It can also be due to tears in the foreskin or  Peyronie’s diseases.

Infections of bladder, UTI can cause painful ejaculation.

Conclusion

Painful sex is a common occurrence but not normal .

This is treatable and there is a solution to the problem.

Pelvic Physical Therapy can effectively treat this condition in most cases with success.

Please leave your questions and comments below .

References:

  1. www.practo.com
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Rectocele : What is it and its Medical and Physical Therapy Treatment

Introduction : What is Rectocele?

Rectocele happens when the supportive tissues between the vagina and rectum weakens and  that causes the front of the rectum to bulge into the back wall of the vagina. The other articles in this series were Vaginal prolapse, Cystocele and Uterine Prolapse .

Rectocele is not the same as Rectal prolapse.In rectal prolapse, the rectum bulges through the rectum and not through the vaginal wall.

Women are more likely to have a rectocele than men. A small % of men can develop Recocele following the removal of prostate, as a  treatment for  prostate cancer.Rectocele  is usually seen in older women, after multiple vaginal births.

When it’s a small rectocele people do not have symptoms and it does not need any treatment. Certain lifestyle modifications can help maintain and slow down the progression of the rectocele.See the table of do’s and don’ts to manage pelvic organ prolapse at the end of this article. Rectoceles need treatment only when they start to interfere with the quality of life, and lifestyle.

Definition: It is the bulging of the rectum into  the posterior (back wall ) of the vagina.

Causes :

  • Traumatic Vaginal Delivery : The tears/ episiotomy ( surgical incision ) that can occur can reach to the rectum.
  • Weak pelvic floor muscles and weakening of the tissues b/w the rectum and the vagina. 
  • History of constipation involving chronic straining.
  • Rectal surgeries 
  • Pelvic surgeries( Hysterectomy )

Symptoms : Can be divided into Rectal and Vaginal Symptoms

Rectal SymptomsVaginal symptoms
Rectal PainPainful Intercourse (dyspareunia)
Difficulty emptying the bladder , and feeling of  “stool getting stuck”.Feeling of vaginal fullness
Feeling the need to splint (using the finger)  through the vagina to evacuate the bowel.
Constipation.
Urge to defecate frequently

Diagnosis :

Rectocele  can be detected in a physical pelvic exam by a gynecologist, colorectal surgeon , or urogynecologist .Further tests may also be done to assess the severity more accurately.

Tests :

Defecography :Special  X-ray that shows the changes in rectum and anal canal during defecation. This test can be very specific about the degree of prolapse and the extent of bowel emptying.

Treatment :

Treatment can be both surgical and non surgical treatment depending on the severity of the Rectocele.

  • Non Surgical Treatments :Mild cases can be treated without any surgical methods with remedies like bowel retraining.
  • Surgical Treatments : Surgical options considered when non surgical treatments do not resolve the symptoms and continue to interfere with the quality of life.Surgery aims to strengthen the wall between the vagina and the rectum to fix the rectocele. Posterior Colporrhaphy is the surgical way to fix rectocele.

Physical Therapy :

Pelvic floor exercises are an effective way to strengthen the Pelvic floor muscles and to help maintain and prevent further worsening of rectocele.

When a pelvic organ prolapse is noted depending on the degree of prolapse it can be managed at home with the below listed Do’s and Don’t .For effectiveness regular, consistent practice is required .

When knees higher than hip helps in easier defecation.This can be done using a “Squaty potty” Google image no intention of copy write violation.
Do’s Don’ts
Bowel Movements: Do avoid constipation.
Do eat a well balanced diet by increasing your fiber intake  and develop regular bowel habits .		Don’t  strain to have a bowel movement.
Sitting on the toilet :
Do sit correctly on the toilet. When having a bowel movement do  sit on the toilet with the knees higher than the hips which can be achieved by placing your feet on a stool.Lean forward from your hips and keep your spine straight.With Diaphragmatic breathing (I have  an article  in my previous post on the blog) relax the Pelvic floor muscles to have an easy bowel movement.		Don’t hover over the toilet to urinate.
Don’t try to push out or force urine out
 Don’t not bear down to evacuate the bowels , just once instance of bearing down can also worsen the prolapse if you already have it.
Don’t hold your breath as you are bearing down.This is called the Valsalva breathing .
Lifting :Do breath out when doing the lifting.
Pelvic Floor Exercises:
Do definitely do your pelvic floor exercises.
Do practice “ the knack”( Out lined in my previous blog post titled how to avoid urinary Incontinence)
Don’t engage in high impact exercises and exercises that require heavy repetitive lifting such as crossfit workout.

Treat Chronic Cough:Do treat the cause of Chronic cough, it will help avoid repeated increase of intra abdominal pressure that in turn puts pressure on the pelvic floor muscles.

Conclusion

  • Rectocele is when rectum budges thought the posterior wall of the vagina.
  • This can be treated successfully non surgically in mild case of prolapse.
  • Pelvic Physical Therapy can be an effective way to manage mild degrees of prolapse.
  • Any question or comments are welcome .
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Uterine Prolapse,Medical and Physical Therapy Treatment

Introduction 

In this post I will be talking about  the uterine prolapse /prolapse of the uterus,its symptoms treatment with both Medical / Surgical  and Physical Therapy.

It is a common condition in women, statistically it is said that nearly half of the women b/w age 50 to 79 have some degree of uterine  prolapse.This is not medically dangerous or an emergency condition.People can engage in sexual activity following the diagnosis of prolapse , intercourse may feel uncomfortable.

Anatomy :

The uterus is located in the pelvis supported by ligaments and pelvic floor muscles which form a hammock .When one or both the pelvic floor muscles and ligaments get weak the organs are no longer are held up in place and may sag to be out of place through the vagina.

Causes

Damage to the supporting structures of uterus  can occur 

Avoid constipation
  • During Childbirth ( usually the most significant cause )
  • Chronic constipation 
  • Chronic coughing 
  • Genetically weak connective tissue 
  • Aging process.
  • More causes from my previous post

Diagnosis and Degree of Prolapse:

The degree of prolapse depends upon how far down the vagina the protrusion of uterus has occurred.Your Dr. will determine the degree of prolapse on pelvic exam. If you have symptoms of incomplete bladder emptying the Dr made do a Cystoscopy to look inside the bladder.

MRI may also be done to accurately assess the internal organs.

Uterine Prolapse and Infertility 

Uterine prolapse can reduce the chance of a couple getting pregnant  since the uterus is not positioned properly to receive and keep the sperm alive.Sperm dies when exposed to air.This can be corrected surgically  by hysteropexy.

Uterus Prolapse and Pregnancy

Women with mild to moderate prolapse can get pregnancy .During the pregnancy progression of the prolapse can be minimized by adapting the lifestyle modifications mentioned below. Learning to relax the pelvic floor is very important to all for a smooth vaginal  birth and not further increase the prolapse.Pelvic floor relaxation can be done through diaphragmatic breathing .Recommended to discuss with Dr. regarding the type of birth Vaginal vs C section keeping the prolapse in mind.

Uterus Prolapse and Running 

Running is high impact activity which can put a lot of stain on a pelvic floor and the uterine prolapse  has a potential of getting worse with running Somethings that can be done to prevent the prolapse from getting worse are as follows .

  • Decrease the speed of running 
  • Decrease the running distance. Long distance running put prolonged pressure on the pelvic floor.
  • Run on a level surface , avoid running on concrete. 
  • Avoid running uphill. The posture of leaning forward as one goes uphill can increase the intra abdominal pressure and in turn affect the pelvic floor.

Symptoms specific to Uterine Prolapse: It time to see a Dr, when you experience these symptoms

  • Heaviness or pulling feeling/pain  in the vagina .My patient generally describes their symptoms as  “I feel like something is falling out of my vagina.”
  • Progressively increased heaviness in the vagina as the day progresses.When the prolapse is of an advanced degree a pink bulge can be noticed at the vaginal entrance  (with use of a mirror to look ), in standing or with coughing and straining. 
  • Pain with sexual intercourse 
  • Urine leakage during sex.
  • Difficulty or inability to have an orgasm.
  • Stress ( with coughing, sneezing and laughing ) urinary incontinence.
  • Difficulty with bowel movement 
  • Patients may have to use the finger through the vagina to help empty the bladder or have a bowel movement.

Treatment :

Lifestyle Modifications:Control what you are able to control .

Adopt a good sitting posture
  • Proper Biomechanics of lifting/pushing or pulling  : Do not hold your breath , but exhale with exertion and lift from the legs and not your back. 
  • Sitting posture .Avoid slouching when sitting on a couch or at the desk working ,to decrease the pressure put on the pelvic floor.
  • Standing posture.Try to maintain a neutral spine to avoid slouching, this does not have the core muscles firing effectively and the pelvic floor and core muscles need to be working together in sync.
  • Wt.management 

Most prolapses once they  become symptomatic need some degree of intervention.

Mild to Moderate degrees of prolapse can be treated and some cases reversed with Physical therapy with Kegel exercises.This can adequately strengthen your muscles to prevent further progression of the prolapse.

Severe Degrees of prolapse will still benefit from skilled PT as a preoperative intervention to strengthen the muscles as I always tell my patient’s “You go into surgery stronger you come out stronger and the recovery is faster.”Once the prolapse is of a severe degree it will need surgery since that will continue to get worse .

Surgical Repair of prolapse – Vaginal Hysterectomy

Vgainal Hysterectomy is the common surgery done to address Uterine Prolapse.This is a procedure where the Uterus is removed via the vagina.This method has better recovery and has no abdominal or laparoscopic incisions.

The surgery is performed in a hospital setting under general or spinal anesthesia. 

The surgeon makes an incision around  the cervix, the bladder and rectum are carefully moved and all the major blood vessels clamped and then the uterus is removed and the top of the vagina is sutured and this is called the vaginal vault.

Success rate after Surgery 

85 % of women who have a Vaginal Hysterectomy are cured of uterine prolapse.About 15% may  develop a vaginal vault prolapse in the months or years later.

Complications of Surgery:

As with any surgery there are some possible complications.

  • Infection , Surgical site ,or urinary tract infection.
  • Blood clots 
  • Urinary retention
  • Injury to any of the adjacent organs during surgery

Recovery after Surgery 

Patients are usually recommended  to “take it easy ” for about 6 weeks and avoid any heavy lifting.Sexual activity may be resumed after discussion with Dr. after 6 weeks.

Conclusion 

  • Treatment of uterine prolapse depends on the degree of prolapse 
  • Pelvic PT and lifestyle modification  is an effective way to manage mild to moderate prolapse
  • Surgical option for the advanced stages of prolapse.
When there is a problem there is a solution it just needs to be found !

References

www.iuag.org

Pelvic Floor Function,Dysfunction and Treatment( Level 1) Herman and Wallace

www.acog.org

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All you need to know about Bladder Prolapse/Cystocele.

Introduction 

Question about bladder prolapse

Do you want answers to your questions of badder prolapse or cystocele ? I have answers to all your questions such as is bladder prolapse curable? If so how? and is it dangerous? What will happen if I do not get  any treatment? Can it be fixed with Physical therapy? What is surgery like? Will I need surgery? These and many more will be answered as you read this blog post.

Prevalence 

This is the most common of the 3 kinds of organ prolapse seen in associated with urinary incontinence seen in the older female population 60 years and older.

Anatomy 

The 3 main functions of the pelvic floor are  

The 2nd image is Bladder Prolapse .Image obtained from Google mages , no intention of copyright violation.
  • Bladder 
  • Bowel
  • Sexual function

The associated organ systems of the above listed functions are located in the pelvic floor. The bladder, the rectum and  the uterus are supported by tissues called the ligaments.Most of the time, these organs are held in place by a combination of strong ligament and pelvic floor muscles.When the supportive ligaments and muscles get weak the organs start slide from their places  to bulge  through the vagina.When there is a bladder prolapse the bladder starts to protrude through the front ( anterior ) vaginal opening.

Degrees of Bladder Prolapse : The degree of prolapse is measured in the extent of prolapse relative to the hymen.

  • 1st degree
  • 2nd degree
  • 3rd degree 

Symptoms of Bladder Prolapse:

Recurrent UTI and pain
  1. Urinary Incontinence- 
  2. Stress Incontinence : urinary leakage with coughing sneezing and laughing 
  3. Urge Incontinence :  Decreased ability to control and subside the urge to  urinate is felt.
  4. Incomplete bladder emptying 
  5. Recurrent urinary tract infections 
  6. Difficulty inserting a tampon and difficulty with keeping the tampon in during menstruation. Common patient statements are “ the tampon doesn’t stay inside for long or I have trouble inserting the tampon.“
  7. Difficulty initiating the urine steam.
  8. A feeling of bladder fullness which increases as the end of the day usually feels better when patient is laying down .
  9. A bulge can be seen and felt at the vaginal opening. Can be seen during  straining/ coughing in  lying down and  seen and felt in standing as well (in severe cases).
  10. Pain and discomfort with intercourse.

Causes /Risk Factors of Bladder prolapse

Chronic coughing and sneezing can be a risk factor for bladder prolapse
  • Childbirth( Vaginal delivery , especially instrument assisted )
  • Constipation
  • Chronic coughing as in C.O.P.D.( lung diseases)
  • Repetitive heavy lifting and strenuous exercises such as crossfit  
  • Postmenopausal. Estrogen is responsible to keep the vaginal tissues supple and in good tone hence post menopause the tissues (ligaments ) loose elasticity and are prone to bladder prolapse.
  • Any pelvic Surgery
  • Genetic factors 
  • Caucasian Ethnicity

Diagnosis of Bladder Prolapse

  • A Through History and Physical Exam to assess the degree of prolapse
  1. Test for Bladder prolapse : 
  • Urodynamics : to know the type of incontinence.
  • Urine test to check for UTI ( urinary tract infection )
Bridges with Kegel exercises

Treatment for Bladder prolapse

  • The treatment depends on the degree of prolapse. 
  • No treatment may be required if it’s not interfering with your daily activities or causing urinary issues.
  • Prolapse can remain asymptomatic until the organ descent has reached a certain point and hence it may not be recognized until advanced. In some women the prolapse progresses rapidly and some it remains stable for years .Handa et al ( 2004 ) found that spontaneous regression was seen in cases of mild prolapse.
  • Miedel et al (2011) found that only small % of women with POP worsen over 5 years. 
  • Bladder prolapse is not dangerous in mild cases. It’s an inconvenience interfering with daily activities  and in most of the less severe degrees of prolapse can be treated effectively with a combination of lifestyle change, pelvic floor therapy and medications.The severe degree of prolapse may require surgery.

1. Lifestyle changes :

  • Wt. loss ( if overweight )
  • Treating Chronic Cough
  • Avoiding straining and managing constipation
  • Pelvic floor muscle exercises Kegel exercises
  • Pessary .May require some practice to insert the Pessary.May require regular follow up with Dr .

A. Pelvic Floor Exercises :

A,PFMT ( Pelvic floor muscle training ) has been concluded to have a positive effect on POP (pelvic organ prolapse ) due to the following hypothesized reasons (Bo, 2004)

  1. Women learn to contract the pelvic floor before and with any increase in the intra abdominal pressure , such as bearing down when lifting heavy wts .
  2. Regular strengthening exercises build up the strength of the Pelvic floor and the structural support overtime .

      B.  The Knack

Squeeze before you sneeze
  1. The Knack is a technique that we pelvic PT’s call instruction to consciously contract the PFM before an activity that requires an increase in the intra abdominal pressure for eg lifting something heavy or before a cough or a sneeze (if you can predict it).
  2. I instruct my patients “ Squeeze before you sneeze “.
  3. This will take some practise but will prove to be effective, as reported by my patients about 3 to 4 weeks of regular pelvic floor exercises.

3. Medications:

    Estrogen Replacement Therapy

4.Surgery 

Surgical options may be considered as a means of treatment usually in severe degree of prolapse and when conservative management was not effective. Prolapse recurs in 70% of the women who had surgery.(Iglesia et al 2010) and 1/3rd of the operated women undergo one further surgical procedure for prolapse (Olsen et al 1997) 

  1. Types of Surgery 
  1. Reconstructive Surgery – restores organs to their original place.Normal activities can be resumed after recovery from surgery. 
  2. Obliterative Surgery -which narrows and closes off the vaginal to support the prolapse, sexual intercourse is not possible after this surgery. 

This can be done in one of the following ways.

Open Surgery

Laparoscopic Surgery

Robotic assisted surgery

Recovery time : Depends on the type of Surgery but the Dr usually recommends no heavy lifting, straining , and sexual activity for 6 weeks post surgery. 

Conclusion 

  1. Bladder prolapse is a treatable condition and patients can return to a good quality of life after the diagnosis of a bladder prolapse.
  2. Mild degrees of Prolapse, can be treated effectively and successful most of the time with Physical therapy , Pessary and lifestyle modification .
  3. Surgery is an option in advanced prolapse.

References :

1.www.urologyhealth.com

2.www.acog.org

3.Evidenced based Physical Therapy for Pelvic Floor 2nd edition

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Guide to Pudendal Neuralgia and Physical Therapy

Introduction

Are you suffering with pain in the butt( pudendal neurlagia ) or is it siatica? How do you know? Pudendal Neuralgia is chronic pain in  the innervation of the pudendal nerve, which is in the perineum( genital area). This can be found in men and women but 2/3rd of the patients are women. Pudendal nerve is the main nerve of the pelvis. it is formed in the low back in the pelvis near the tailbone, its travel  in the pelvis is  tortuous as it weaves its way in and out of the pelvis giving branches of nerves on its way to different pelvic floor muscles.

It is particularly vulnerable for compression in 2 anatomical areas  1. the Alcock’s canal and  2.  in the “clamp” the nerve course between sacrotuberous and sacrospinous ligament.The cure of pudendal neuralgia will depend on targeting the cause of the symptoms, this is discussed more in the physical therapy section of this post.

Other names for Pudendal Neuralgia:

  • Pudendal canal syndrome 
  • Cyclist’s Syndrome 
  • AlCock’s Syndrome 

Causes of Pudendal neuralgia 

  • Nerve compression  as in ligamentous or fascial entrapment (cyclist, childbirth injury and scarring)
  • Change of bony alignment as in sports injury. 
  • Increased pelvic  muscle tone ( fear or due to pain ) can compress the nerve.
  • Decreased pelvic and hip flexibility.
  • Any surgeries and resulting scars in the pelvic area.
  • Chronic Constipation ( lots of repetitive small trauma)
  • Recent loss of wt,decreasing the cushioning and causing compression of the nerve.

When nerves get irritated chronically pain is perceived at a lower level and the pain response is greater.

Is it Pudendal Neuralgia? If your answer is yes to the following it might be PN.

  • Do you have pain with sitting but reduced when sitting on the toilet?
  • Did your problems begin after biking for a long time? 
  • Did your problems begin after a fall on your tailbone (coccyx)
  • Do you have incontinence of stool, gas or urine ?
  • Did you have  pain during intercourse ?
  • Do you have pain after ejaculation?
  • Do you suffer from sexual impotency ?

Symptoms: 

  • Pain is the main symptom, pain which progressively gets worse as the day goes on and pain with sitting but relieved by sitting on the toilet.
  • Symptoms may also be experienced as bladder. bowel and sexual dysfunction.
  • Symptoms may start suddenly or be of a gradual progression.
  • Symptoms may be on one side or both sides of the perineum.
  • Skin of the perineum may be sensitive to touch. 

Location of pain: Perineum sometimes can be the hip and pelvis as well.

  • In the labia
  • Vulva
  • Clitoris ( Penis and Scrotum in men) 
  • Urethra
  • Rectum and Anus

Diagnosis:

 Pudendal nerve neuralgia is rare and is difficult to diagnose, it usually coexists with Pelvic floor dysfunction and is hard to diagnose.The most common misdiagnosis  in men of PN is nonbacterial prostatitis. The Dr. who treat PN are Neurologists pain management Drs.. Some of the tests used to diagnose Pudendal neuropathy are as follows

  • Pudendal nerve motor latency test (PNMLT)
  • EMG ( Electromygraphy )
  • 3T MRI
  • MRN ( Magnetic resonance neurography may give clear enough images to see nerve entrapment )
  • Diagnostic nerve blocks (CT guided)

To summarise the Conclusive diagnosis depends on the following 

  • Symptoms consistent with PN.
  • An abnormal test, ( any of the above listed )
  • Pain along the pathway of the nerve.
  • Ruled out all other possible causes and diseases, such as infection , prostatitis (in men). Vaginal infections or STD’s to name a few .

Treatment for Pudendal Neuralgia:

PN is more likely to respond well to treatment when caught early . 

The treatment can be divided into 

  1. Conservative Treatment 
  2. Surgical  Treatment
  1. Conservative Treatment:
  • A through Physical exam and understanding the symptoms 
  • Ruling out all other causes of the pain, such as coccyxdynia ,interstitial cystitis and prostatitis
  • Tests to rule in Pudendal neuralgia 
  • Physical Therapy
  • Pudendal nerve block
  • Medications,( Antidepressants )
  • Lifestyle modifications – Avoiding the prolonged pressure on the buttocks by limiting sitting, avoiding strenuous exercises
  • Perennial suspension pads to help relieve pressure when sitting.
  1.  Surgical Treatment :

Surgery includes relasingthe entrapped pudendal  nerve, which can be 3 approaches 

  • Trans-perenial
  • Trans-rectal
  • Trans-ischiorectal

Physical therapy for Pudendal Neuralgia 

Physical Therapy is a very important part of conservative treatment of the PN. Treatment is most effective in a team approach. PT, plan of care is going to depend on the findings during the Initial evaluation, after taking a thorough history and a physical exam, I prepare a custom tailored plan for the patient depending on the patients goals and the impairments I found.

  1. When increased tone of the pelvic floor muscles and Trigger points are found (a trigger point is a hyperirritable spot in the muscle fibers which is painful with compression.)Trigger point release can be done manually when trigger points are identified. A more aggressive trigger point treatment would be trigger point injections ( injections are usually done by a Dr.)
  2. When Pelvic floor dysfunction is noted, relaxing and lengthening the tight or shortened pelvic floor provides relief. Kegels is not appropriate to be done in this case.
  3. Pudendal nerve gliding is done  when abnormal neural tension is noted.
  4. When Biomechanical and structural abnormalities are  found in the SI joint, hips, low back, and joint hypermobility, exercises to improve stability and restore function are taught.
DosDon’ts
Do Stretching to  lengthen the pelvic floor.
Do seek myofascial release and trigger point release.
Do Diaphragmatic breathing to coordinate relaxing the pelvic floor muscles 		Don’t do pelvic floor strengthening exercises such as Kegels.
Do not do Valsalva breathing 

Conclusion:

1.Pudendal neuralgia is a rare peripheral nerve disorder, that can be very distressing .

2. Can be cured depending on the severity of nerve involvement

3.Most PN generally responds well to conservative treatment with Physical therapy.

References:

1. http://www.spuninfo.org

2. http://pudendalhope.org

3. http://www.tipna.org

4. http://www.pudendalhelp.com

5. http://www.pnfdn.org

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Symptoms of Vaginal Prolapse, Medical and Physical Therapy Treatment

Introduction

Pelvic Organ Prolapse (P.O.P.)  is  very common and seen in 43% to 76% of women. This can be seen in young and older women. In younger populations childbirth related, Pelvic floor muscle trauma, this can occur after prolonged and hard labor and giving birth to a “big baby” (more than 9 to 10 lbs). In the older population this can occur due to the stretching out of supportive ligaments.

Picture from Google images ,No intention of copy write infringement.

P.O.P. or simply prolapse is the downward descent of the female pelvic organs, (Vagina,Uterus,Bladder and Rectum) . 

Prolapse Terminology:

Cystocele or Urethrocele :Bladder prolapse

Rectoclele or Enterocele: Rectum prolapse .Rectal prolapse is not the same as hemorrhoids.

Uterine Prolapse : The vaginal vault prolapse.

Urodynamics:Bladder function test that evaluates urinary incontinence or difficulty urinating.

Cystoscopy: A procedure that uses a camera to look and assess for any anatomical abnormalities that contribute to urinary symptoms.

Defecography: A radiological study that looks at  bowel function and prolapse symptoms. .

Risk factors for developing Prolapse:

  • The loss of uterine and bladder support, connective tissue lax and weak.Some women are genetically predisposed to lax tissues.
  • Chronic constipation.
  • Systemic disease, Ehlers-Danlos syndrome
  • Chronic coughing 
  • Obesity
  • Menopause
  • Heavy lifting and repetitive intense activities such as CrossFit
  • Smoking 

Degrees of Prolapse:

P.O.P. is said to be of 3 degrees  mild , moderate and severe.The degree of prolapse is graded by the organs descent in relation to the hymen.  

  1. Mild P.O.P. : Most women are asymptomatic , no complaints of symptoms are expressed until the organ be it uterus , bladder or rectum has prolapsed past the hymen.
  • In mild P.O.P. loss of this support results in urethral hypermobility and cystocele(bladder prolapse) which is thought to cause stress urinary incontinence (DeLancy 1994) hence these 2 ( ie bladder prolapse and stress incontinence) usually coexist especially with mild prolapse.
  1. Severe  P.O.P. : symptoms include vaginal bulge that can be seen and felt, and can be the uterus, bladder or rectum that can be causing it.
  • Urinary urgency, frequency and incontinence are common coexisting complaints along with Pelvic floor dysfunction and possibly  with constipation as well .The anterior vaginal wall supports the bladder and urethra.

When the prolapse is of a more severe degree P.O.P ,women complain of urinary hesitancy , intermittent flow , weak or prolonged stream , and also feeling difficulty with emptying or feeling the need to manually splint the prolapse to urinate.Possibly changing  the sitting position on the toilet  to facilitate completion or to start urination.

  • Symptoms of moderate and severe degree  are usually worse at the end of the day or with standing and exercises and improve with laying down .
  • Prolapse symptoms primarily impact the quality of life and symptoms are not “dangerous” to life or medically but symptoms gradually and usually progressively get worse.Prolapse generally does not heal itself.
  • Symptoms are usually better in gravity eliminated positions
  • Symptoms more prominent with straining ..

Symptoms can be divided into 

VaginalUrinary Bowel Sexual
Sensation of heaviness and pressure and Bulgein the vagina which may be visible when and or palpable.In mild prolapse urinary incontinence of stress ,urgency and frequency.In moderate prolapse Weak urine stream, incomplete emptying of bladder and urinary retention in severe prolapseFeeling incomplete emptying of bowel. 
Feeling an obstruction to defecation.		Dyspareunia (Painful sexual intercourse) 

Adapted from Jalovesk et al, 2007

Treatment for Prolapse:   

Conservative Treatment:

  • “Wait and Watch”(depending on the degree of prolapse)
  • Pessary
  • Physical Therapy.                         

Surgical Repair of Prolapse :Surgical repair of prolapse is performed by a Urogynecologist.

What can one expect when seen by the Dr.(Urogynecologist)

  • The Dr  would examine the symptoms to evaluate the degree of organ prolapse based on the prolapse grading system.
  • A vaginal exam will be performed and the patient asked to strain to produce the maximum extent of prolapse.Various instruments may be used.
  • Depending on the degree of prolapse and if weakness is found in the pelvic floor muscles, the patient may be referred to the pelvic floor therapist. A pelvic floor therapist is a physical therapist who undergoes additional specialised  training and board testing to treat patients with issues of the pelvic region related diagnosis.
  • When appropriate the patient may be fitted with a Pessary.

Pessary: 

  • A Pessary is an intravaginal device used to support the vaginal wall in women with P.O.P.
  • A Pessary is generally prescribed by the urogynecologist and they are made in various shapes and sizes.
  • They are mostly made of silicone.
  • Pessary is used as a safe alternative to surgery when appropriate.
  • There has been no high-level research based evidence of the effectiveness of pessaries to manage P.O.P.
  • Pessary seems to be effective in  improving the pelvic floor symptoms as evidenced by clinical trials  that showed significant symptom relief and improvement in the quality of life, satisfaction and sexual function.
  • Women fitted with pessaries are advised to remove and reinsert periodically to avoid complications of pessary use like, vaginal bleeding erosion and infection.Regular follow up with Dr. is recommended.
Pelvic Physical Therapy is the one of the effective way of management conservatively .

Physical Therapy and  Prolapse :

  • Women cannot change their genetic predisposition but can certainly do what can be done what is in their control which is exercise. Pelvic floor muscle strengthening exercises, Kegels  have been proven to help prevent the symptoms and even to improve the symptoms of urinary urgency frequency  if present.
  • Regular Pelvic floor muscle strengthening helps to strengthen and retain the muscles and nerves of the Pelvis.
  • Download my helpful instructions on Kegel Exercises.
  • If you suspect you have prolapse or have any questions please comment or contact me via email .I will be happy to answer your questions or point you in the right direction, if possible .

Resources :

Association for Pelvic organ Prolapse Support (APOPS)

Private Facebook Groups for Pelvic organ Prolapse

References :

Evidence-based Physical Therapy for Pelvic floor  2nd Edition.

Pelvic Floor Dysfunction and Treatment , Level 1 Herman and Wallace Pelvic Rehabilitation Institute

Declancy,J.O. 1994 Structural support of urethra as it relates to stress incontinence, the hammock hypothesis .AM. J .Obstet. Gynecol. 170 ,1713 to 1720

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Physical Therapy for Prostate Cancer and Male Urinary Incontinence

Introduction:

June is Male Pelvic Health awareness month. Hence I thought I would write about some of the most common diagnoses that affect men and I have treated successfully. As a pelvic therapist I am well  trained, comfortable  and experienced in treating men.

Prostate Cancer 

According to CDC prostate cancer is one of the most common types of male cancers and according to the American Cancer Society 1 in 7 men will receive this diagnosis.

The diagnosis is usually  made by 

  • Medical exam -Rectal exam 
  • Prostate -Specific Antigen (PSA) levels
  • Biopsy
  • Transrectal Ultrasound ( as deemed appropriate by MD)
Prostate Cancer Treatment Options

Depending on the stage of cancer it can include

General Pelvic PT includes the following.
  • For Urge Incontinence (UI)  behavioural intervention is utilised .The individual is instructed in contracting the PFM (Pelvic floor muscles) to inhibit bladder contractions and suppress the urgency to urinate (urge control technique).
  • The individual is instructed in proper engagement and isolation of the PFM contraction, using verbal and tactile cues and biofeedback is used if appropriate, and the individual is cautioned against using Valsalva maneuver.
  • The individual is instructed in using “ the knack” ,which is contracting the PFM prior to coughing sneezing or changing positions such as sit to stand or any physical exertion that increases the intra abdominal pressure.
  • Education on Bladder training and lifestyle modification ,for eg  avoiding bladder irritants.https://www.hopkinsmedicine.org/johns_hopkins_bayview/_docs/medical_services/gynecology_obstetrics/bladder_irritants.pdf
  • Abdominal exercises focusing on Transverse Abdominus because of the role of core strength in PFM . 
  • Home exercise program of PFM contractions of Quick contractions and slow contractions as deemed appropriate based on the findings during the pelvic therapy evaluation.

A case report of the article in the reference and a article on the blog of Herman Wallace, Physical Therapy Interventions for Male Urinary Incontinence Post Radical Prostatectomy  reported an interesting fact .The patient saw an improvement in Urinary incontinence , of frequency and urgency even after attempting Pelvic PT 10 years post Radical Prostatectomy

Conclusion

Pelvic Physical Therapy is effective in improving Urinary Incontinence in men after radical prostatectomy. The patient saw an improvement in Urinary incontinence, of frequency and urgency even after attempting Pelvic PT 10 years post Radical Prostatectomy.

Pelvic PT works !!!

Refences

Physical Therapy Interventions for Male Urinary Incontinence Post Radical Prostatectomy  by Rachel Kilgore DPT, COMT,OCS ,Herman and Wallace Blog .

Pelvic Floor Function, Dysfunction and Treatment (2A ) Manual , Herman and Wallace Pelvic Institute
Roscow, A. S., & Borello-France, D. (2016). Treatment of Male Urinary Incontinence Post–Radical Prostatectomy Using Physical Therapy Interventions. Journal of Women’s Health Physical Therapy, 40(3), 129-138.

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Suffering from Chronic Pelvic Pain?

Introduction

Any  pelvic pain that lasts more than 6 months or more is categorized as Chronic Pelvic Pain. Many times this can be even after the original cause of pain is treated the pain persists. This is known as Chronic Pelvic  Pain (CPP) Syndrome. You are probably thinking “Why does this happen and how can I get relief?”. Keep reading to find out !

Mechanism for Chronic pain 

Photo by PublicDomainPictures
  • The pain signals are handled differently in the brain of people with chronic pain.
  • There is an  increased nerve sensitivity upregulation of nerve signals transmitted to the brain, stress and anxiety can further add  to this dysfunction.
  • The pain signals travel through specific pathways to the brain via the spinal cord ,parts of the spinal cord  act like a gate, these gates can block the pain and thereby decrease or weaken the pain signals.
  • In people suffering from chronic pain, this part of the spinal cord may be malfunctioning, with the pain gate remaining open longer and even after the injured tissue is healing. This is when pain is experienced despite treating the original cause of pain.   

A Dr. will diagnose a person with the diagnosis of CPP , following a thorough physical exam and any lab tests and scans as deemed appropriate in the medical opinion of the Dr.

How can CPP be treated ?

Chronic pain affects all aspects of physical and emotional life. Pain includes both the body and the mind hence the effective treatment is one that treats the body and the mind .The multidisciplinary  team can include a Dr, PT, Counselor, Cognitive Behavioral Therapy ,and Psychotherapy  .

Photo by VSRao
  • Pain Medications : Early treatment can be started with pain medications that make the symptoms more bearable, and a combination of medications that can be used to interrupt excessive pain signaling.
  • Physical Therapy : CPP can cause tension in the muscles of the pelvis causing bladder bowel and sexual dysfunction .Tension can result in trigger points that can be addressed by Physical therapy, and relaxation therapy.
  • Psychotherapy : psychological symptoms seen with CCP are anxiety ,depression, behavioral changes resulting in relational difficulties.These can be addressed in a counseling session or in psychotherapy.

How soon can one expect to see pain relief ?

Patience is a virtue

Chronic pain was a long time in the making resulting in physiological changes that have to be reversed and help decrease the pain , so what am I saying ? Please be patient. Yes patience is a big part of your healing journey !

Follow all instructions given by each one of your team members. It may take 3 to 6 weeks or more to start seeing results, I know that sounds like a long time , but remember it was a long time in the making and relearning has to take place.

Conclusion:

  • CPP is the most common, (25% of the population in women) and disabling medical issues.
  • CPP can be due to improperly functioning pain gate pathway in the spinal cord.
  • Multidisciplinary team approach is best to address the symptoms psychosomatic in nature.
  • Treatment requires patience and doing your part that is required by the multidisciplinary team.

Any Questions and Comments are Welcome https://bewholecreations.com/contact-page/

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What is Wholeness and Why Pursue Wholeness ?

Definition of Wholeness :A thing complete in itself, or comprising all its parts or elements.

This is the first and an introduction  in the series to explore the deeper meaning of  wholeness, the practical aspects of it and the importance of wholeness. I started to become sensitive of what wholeness is the older I got and started to focus on the deeper things of life, you know  the things of lasting value and things that really matter. Whatever you see is temporal but what you cannot see is eternal. 2Cor 4:18

Have you ever been in pain ? Be it physical or emotional ? I have more times than I would like to. I hated that season of pain, oh how I wished that the pain would go away and my tears would stop! but in hindsight I see my greatest growth came in this season of pain. Growth, be it my  faith or new heights of emotional fortitude, was birthed  because and in spite of pain. The next time painful season rolled around  I sought to seek the life lesson hidden in that for me. 

It is impossible to avoid pain.especially emotional pain in this  life, so my response to that has been to be  a whole me, the highest and best version of myself, content in who I am and in my purpose on this planet. Thus started my journey of pursuing wholeness and helping people in my circle of influence to in turn also be whole and this is the reason my blog is  named  be whole creations. I desire to help people be whole in all their being , not just the physical body but mind and soul as well.

Brokenness is the opposite of wholeness and is rampant in our  current society, Brokenness leads to sabotage of relationships, careers and ultimately a dissatisfied and unfulfilling life. 

Seek and ye shall find

The turn around to seek wholeness comes when 

  • One has reached the end of themselves.
  • Desires to live a life that is different from their current  and seeks to improve their lives.Seek and ye shall find .Mt.7:7

In the next post I will discuss some practical steps towards wholeness. I would love to hear from you, your life experience and your thoughts on being whole. Please share in the comments below.