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Incontinence, Pelvic Pain, and Sexual Dysfunction

Learn about the causes, treatments, and contributing factors of urinary incontinence, pelvic pain, and sexual dysfunction. Discover techniques and technologies to manage these conditions effectively.

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Incontinence, Pelvic Pain, and Sexual Dysfunction

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  1. Incontinence, Pelvic Pain, and Sexual Dysfunction Answers to questions no one asks Melinda Fontaine, DPT, PT

  2. Objectives • Identify causes of the different types of incontinence in adult populations • Identify appropriate treatments for the various types of incontinence • Be comfortable discussing common contributing factors for pelvic pain and sexual dysfunction

  3. Types of Urinary Incontinence Stress Urinary Incontinence With activities that increase abdominal pressure, ie. cough, laugh, sneeze Urge Urinary Incontinence With a strong urge to urinate, ie. “key in the door” Mixed Urinary Incontinence Stress and Urge Functional Urinary Incontinence Cannot get self to the toilet or commode Passive Urinary Incontinence Leaks urine all day and night, cannot hold urine in the bladder

  4. Stress Urinary Incontinence “With activities that increase abdominal pressure, ie. cough, laugh, sneeze” Objective: Strength, endurance, quality of contraction, using correct muscles

  5. Stress Urinary Incontinence Weak vs Short pelvic floor muscles Treatment: To Kegel or not to Kegel

  6. Stress Urinary Incontinence 51% of people cannot perform appropriate pelvic floor contraction with verbal instruction alone 25% are doing something can can actually make it worse! Bump R, Hurt WG, Fantl JA, Wyman JF. Assessment of Kegel exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991;165:322–329.

  7. My Verbal Cues for Kegels Females with SUI: Imagine there is a straw in your vagina. Pull up and in. For superficial muscles: Quickly squeeze the front muscles only, nod the clitoris Males with SUI: Pull penis in. Pull scrotum up All genders with fecal incontinence: You are in a crowded elevator. Hold back gas.

  8. Incontinence and Technology Biofeedback Neuromuscular Electrical Stimulation (NMES) Percutaneous Tibial Nerve Stimulation (PTNS)

  9. Urge Urinary Incontinence “With a strong urge to urinate” Key in the door Sympathetic nervous system/fight or flight Treatment: Urge drill, diaphragmatic breathing, myofascial release

  10. Myofascial Release FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor I: Background and patient evaluation. Int Urogynecol J. 2003; 14:261-8

  11. Mixed Urinary Incontinence “Stress and Urge Urinary Incontinence”

  12. Functional Incontinence “Cannot get to the toilet in time” Is not primarily a pelvic floor issue Treatment: Make it easier to get to the toilet, improve functional mobility, and get help

  13. Passive Urinary Incontinence “Leaks urine all day and night, cannot hold urine in the bladder” May not have the sensation of needing to urinate Poorer prognosis for PT Treatment: Can try to increase muscle bulk to minimize leakage Watch out for skin irritation: use barrier cream and change pads/underwear often May refer for surgical consultation

  14. Other factors in incontinence Hormones Constipation Core strength Prolapse Prostate surgery Diuretics Diabetes

  15. Hormones Low estrogen due to history of oral contraceptives, postpartum, oopherectomy, menopause, breast cancer treatment Estrogen plumps up the supportive tissues Testosterone receptors are in the lining of urethra Treatment: Doctors may prescribe topical creams

  16. Constipation “Full bowels press on the bladder” Stay hydrated Eat plenty of fiber Stay active Stool under feet Breathe on the toilet Massage bowels Chew your food well Eat or drink warm things Medications are constipating www.bedwettingandaccidents.com

  17. Core Strength Diastasis Recti Abdominus Especially after pregnancy, laparoscopic surgery, or abdominal weight gain Transversus Abdominus Shares a fascia with the pelvis Treatment: Core Strengthening

  18. Pelvic Organ Prolapse Cystocele, urethrocele, uterine prolapse, rectocele, rectal prolapse, enterocele

  19. Pelvic Organ Prolapse Cystocele, urethrocele, uterine prolapse, rectocele, rectal prolapse, enterocele Changes in the position and support of bladder lead to poorer ability to stop the flow of urine and the possibility for post-void dribble Rectocele can lead to constipation Treatment: Strengthening, pessary, surgery

  20. Prostate Surgery If some or all of the prostate is removed, it decreases stability of the urethra The pelvic floor muscles can hypertrophy enough to increase urethral stability Patients who are dry at night have the best prognosis with PT Can take a year to get dry Treatment: Pelvic floor strengthening

  21. Diuretics and Diabetes The body makes more urine Patients can still be continent, but will urinate more

  22. Fecal or Gas Incontinence Constipation! Changes in sensation Weakness Trauma or procedure Tear, fissure, hemorrhoid, etc. Loose stools

  23. Pelvic Pain Causes Myofascial restrictions and trigger points Surgery/Trauma/Infections Scar tissue Neuralgia Hormones Central Sensitization

  24. Myofascial Restrictions and Trigger Points Decreased blood flow Irritates nerves Causes: repetitive use, trauma, etc. Treatments: Manual therapy, dry needling

  25. Surgery/Trauma/Infections Body responds by hugging itself, guarding, compensating Leads to myofascial restrictions As little as one infection can trigger this reaction

  26. Scar Tissue Initially, plenty of fibers are laid in various orientations Painful when touched or stretched Scar tissue rebuilds itself quickest in the first 6-12 months Treatment: Mobilization

  27. Neuralgia “Pain in the territory of the nerve” Treatment: Physical therapy, nerve blocks Entrapment: nerve ablation, surgical decompression

  28. Hormones Low estrogen or testosterone can lead to pain and decreased tolerance for pain Treatment: Doctors may prescribe topical creams

  29. Central Sensitization Body creates more in number and more sensitive nerve endings Neural plasticity

  30. Sexual Dysfunction Hormones: changes in desire, lubrication, tissue integrity, pH Pain: inhibits desire and muscle function Prostatectomy: nerves injured, no ejaculation Diabetes: decreases clitoral sensitivity and erection quality

  31. Post-Prostatectomy Rehabilitation Erections can take two years to return to as close to pre-op state as possible Intimacy is encouraged in patient's relationship, even if it means something different Immediately post-op is the most important time to restore blood flow and prevent erectile dysfunction from becoming permanent Ways to restore blood flow: PDE5 inhibitors, pump, injectables, arousal and orgasm

  32. References Bump R, Hurt WG, Fantl JA, Wyman JF. Assessment of Kegel exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991;165:322–329 Price N, Dawood R, Jackson SR. Pelvic floor exercise for urinary incontinence: A systematic literature review. Maturitas. 2010; 67: 309-315 Capobianco G et al. Management of female stress urinary incontinence: A care pathway and update. Maturitas 2018;109:32-38. Onwude JL. Stress incontinence. BMJ Clinical Evidence. 2009;04:808 Balk EM, Rofeberg VN, et al Pharmacologic and nonpharmacologic treatments for urinary incontinence in women. Annals of Internal Medicine. 2019. doi:10.7326/M18-3227. Lee DM, Tetley J, Pendleton N. Urinary incontinence and sexual health in a population sample of older people. BJU Int 2018. doi:10.1111/bju.14177.

  33. References Monga AK, Tracey MR, Subbarovan J A systematic review of clinical studies of electrical stimulation for treatment of lower urinary tract dysfunction. Int Urogynecol J 2012; 23:993-1005. American Urogynecologic Society Guidelines and Statements Committee. American urogynecologic Society Best Practice Statement: Evaluation and counseling of patients with pelvic organ prolapse. Female Pelvic Med Reconstr Surg 2017; 23:281-7. Simon JA, Goldstein I, et al. The role of androgens in the treatment of genitourinary syndrome of menopause (GSM): International society for the study of women’s sexual health (ISSWSH) expert consensus panel review. Menopause. 2018; 25:7 Sikirov D. Comparison of straining during defecation in three positions: results and implications for human health. Digestive Diseases and Sciences 2003; 45:1201-5. Bodner-Adler B, Alarab M, et al. Effectiveness of hormones in postmenopausal pelvic floor dysfunction-International Urogynecology Association research and development-committee opinion. International Urogynecology Journal. https://doi.org/10.1007/s00192-019-04070-0

  34. References Hickey F, FInch JG, Khanna A. A systematic review on the outcomes of correction of diastasis of the recti. Hernia. DOI 10.1007/s10029-011-0839-4 Moseley GL. A pain neuromatrix approach to patients with chronic pain. Manual Therapy 2003;8:130-140. Tienforti D, Sacco E, et al. Efficacy of an assisted low-intensity programme of perioperative pelvic floor muscle training in improving the recovery of continence after radical prostatectomy: a randomized controlled trial. BJU International 2012;110:1004-1011. Overgard M, Angelsen A, et al. Does physiotherapist guided pelvic floor muscle training reduce urinary incontinence after radical prostatectomy: A randomized controlled trial. European Urology 54;2008:438-448. Messelink B, Benson T, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: Report from the pelvic floor clinical assessment group of the international continence society. Neuroulogy and Urodynamics 2005;24:374-380.

  35. STAY CONNECTED! Blog: pelvicpainrehab.com Facebook: facebook.com/pelvicpainphysicaltherapy Instagram: @PelvicHealthEastBay Twitter: @MelindaDPT THANK-YOU!

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