Posted on

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

Posted on

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.

Posted on

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/