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Rehabilitation&Therapy Options for Pelvic Floor Pain&Incontinence _ Helping Patients Regain Control

Online Health Chat with Juliet Hou, MD, and Megan Edgehouse, MPT

April 12, 2011


Introduction

Cleveland_Clinic_Host: As many as 20 percent of women age 18 to 50 suffer from chronic pelvic pain. Disorders causing pain in the pelvic floor may be visceral and/or somatic. Gynecological, psychological, gastrointestinal, urological, musculoskeletal, and neurological sources are the major contributors. Common pelvic pain conditions in women include endometriosis, vulvodynia, vestibulitis, pelvic floor tension myalgia, pudendal neuralgia, levator ani syndrome, interstitial cystitis, irritable bowel syndrome, vaginismus, and dyspareunia. A woman’s unique pelvic anatomy and biomechanics place her at increased risk of developing pelvic region pain.

Although the majority of pelvic floor pain patients are women, men can also experience pelvic floor pain due to the pelvic floor muscles becoming weak or tightening, or from spasticity as a result of disuse, surgery, or trauma. This condition can result in pelvic pain, incontinence, or other related symptoms.

Juliet Hou, MD, is a physiatrist with Cleveland Clinic’s Department of Physical Medicine and Rehabilitation. She is board certified in physical medicine and rehabilitation, and electromyography. Her specialty interests include women’s rehabilitation, neurological rehabilitation, non-operative musculoskeletal medicine, and electromyography. Dr. Hou received her undergraduate degree from Sun Yat-sen University of Medical Sciences, Guangdong, China, and her medical degree from Peking Union Medical College, Beijing, China. She completed residency training at New York University School of Medicine, New York, NY, as well as at the University of Washington Medical Center, Seattle, WA.

Megan Edgehouse, MPT, is a physical therapist with Cleveland Clinic Rehabilitation and Sports Therapy, specializing in the treatment of male and female pelvic floor dysfunction. She is the Clinical Team Leader for the women's health, chronic pain, return to work, and aquatic rehabilitation therapy programs. Megan received both her undergraduate degree and Masters of Physical Therapy degree from St. Louis University, St. Louis, MO.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Juliet Hou MD, and Megan Edgehouse, MPT. We are thrilled to have them here today for this chat. Let’s begin with some of your questions.


Pelvic Pain

hardymum: Where does chronic pelvic pain come from?

Dr__Juliet_Hou: It can be caused by urological, gynecological, gastrointestinal (GI), musculoskeletal, or psychological conditions. For instance, gynecological causes could include endometriosis (one of the main causes of pelvic pain) and scar tissue adhesions following surgery. Urological causes include prostate and bladder disorders. Colorectal disorders can cause pelvic pain, as can musculoskeletal disorders, including hip conditions and lumbar spine disorders, as well as coccyx or myofascial disorders. Psychological disorders leading to pelvic pain could include a history of abuse and depression/anxiety.

A physiatrist can also look at neurological causes, such as pudendal neuropathy (a weakening of the nerves that can cause pain and incontinence in the pelvic area). Electro-diagnostic studies can also be performed to assist in the diagnosis.

bc: I have sitting pain that used to be just a nuisance, but now is so bad I cannot sit for even 5 minutes. What could be causing such a bad pain? I have seen several doctors but none of them knows what to do for me?

Dr_Juliet_Hou: Again, the first course of action would be to determine the cause of the pain. It could be caused by a urological, gynecological, gastrointestinal, or musculoskeletal condition. The spine should also be examined to determine if there is local tenderness or coccydynia.

Possible treatment options include medications, local trigger point injections, epidural blocks, and/or physical therapy that could include a sitting evaluation and assessment of the muscles of the pelvic floor, especially around the tailbone. Seat cushions are available over-the-counter or can be custom-made as part of your treatment plan.

blunder: I have pain every time I have intercourse. This started one year ago and is now so bad I cannot have sex at all. What could be causing this pain? Is there medication for this or some other treatment option?

Dr_Juliet_Hou: The causes for this type of pain can vary between urological, gynecological, gastrointestinal, musculoskeletal, or psychological. Before a physician can recommend the type of treatment, a cause must be determined. A variety of medications can be prescribed depending on the cause identified. Physical therapy can also assist in helping patients relax their muscles, and can provide relaxation training and massage. Desensitization can also help.

mommo: Is pelvic pain common in younger girls (age 15)? What could cause this in someone of this age?

Dr_Juliet_Hou: Pelvic pain is not very common under the age of 14. The majority of female patients are often 15 to 75.

We typically see girls under the age of 14 suffering with pelvic pain as a result of high performance dancing or athletic training. Other younger patients often find the cause of their pelvic pain stemming from menstruation.

so_be_it: Is it common to have pelvic pain prior to menstruation (for about one week before), or does this indicate some sort of problem?

Megan_Edgehouse_MPT: Dr Hou could probably better comment on this, but I don't think it’s uncommon to have some cramping or pain prior to menstruation. If you think the pain is very bad or does not get better, then I would suggest seeing someone about it.

rainstorm: How can I tell the difference between my normal menstrual abdominal pains and something possibly more severe?

Megan_Edgehouse_MPT: Something more severe would probably be pain that came and was constant, and was not related to your period. Menstrual cramps are cyclical and are generally not constant over a long period of time.


Physical Therapy

steps: How can physical therapy help my periodic incontinence?

Megan_Edgehouse_MPT: Physical therapy can help patients deal with several types of incontinence. We can teach you how to correctly do a Kegel, which will help strengthen the pelvic muscles and help to prevent stress incontinence, or leakage with coughing, laughing, sneezing, etc. We can also teach you habits and techniques to reduce urgency and urge incontinence (or leaking with a strong urge on the way to the bathroom). Even periodic incontinence is not something you have to deal with. We can help!

Sandra: My physician has decided that I should have physical therapy for my incontinence. What would an appointment involve? What kinds of things are done?

Megan_Edgehouse_MPT: A physical therapy evaluation is generally an hour. We ask a lot of questions in order to fully understand your symptoms (what type of incontinence you have and when you get it). We talk about diet, fluid intake, and controlling urgency. We do a general range of motion screening to look at your flexibility, and to make sure no muscles are too tight and could be contributing to symptoms of incontinence. We also do a vaginal assessment to educate you on how to do a Kegel correctly or make sure you are using the correct muscles. We may do biofeedback, which utilizes electrodes that can "measure" how well and how coordinated your pelvic floor muscle contraction is. The session will involve a lot of education. We'll provide you with a home exercise program and some suggestions related to fluid and diet to combat your incontinence. We usually have you come back for subsequent visits to progress your exercise program and to add in abdominal and lower extremity strengthening and core strengthening. Of course, each person's problem is different, so each session may be a little bit different, but it is tailored to the individual.

time_will_tell: Once you start therapy, how long does it usually take before you start to see results?

Megan_Edgehouse_MPT: Each person is a little bit different, but as an overview, I think people with urgency and urge incontinence see some improvement in two to six weeks (sometimes even faster). For stress incontinence, I think people see results within four to six weeks or sooner.

Sandra: Returning to the question about the PT appointment for incontinence, what is the setting like where the appointment takes place? I ask because it sounds a little embarrassing.

Megan_Edgehouse_MPT: We know this is not the most fun type of therapy that exists. We have individualized treatment rooms where the door can be closed so no one else can hear your problems or symptoms. We maintain modesty as best we can, providing patients with gowns and sheets for covering up. We want to make the experience as comfortable as possible.

extreme: How painful is this type of therapy? I have read that when people do these exercises, they were in a lot of pain the next day (i.e., yoga or Pilates). Does this mean they are doing something wrong or is it just painful, at least to start?

Megan_Edgehouse_MPT: Yoga and Pilates should not be painful. Muscle soreness after a new exercise is to be expected, but pain other than that is not expected.

Physical therapy is generally not painful either. Again, you might have some soreness after a new exercise, and sometimes people are sore after a lot of massage or manual therapy on a painful spot, but that shouldn't last more than 48 hours or so.

break_through: Does therapy alone work, or do you need to mix it with other treatments?

Megan_Edgehouse_MPT: For some types of incontinence, your doctor will prescribe a medication that can also help with your problems. This is most common with overactive bladders and urgency. For stress incontinence, generally therapy is prescribed alone. I think each person is different, but we do see a lot of people who are just getting therapy and do very well. Sometimes with pelvic pain, we incorporate the help of pain management and psychiatry, if needed, to cover all the bases.

jobe: Does the type of therapy suggested depend on the cause of the pain? What if the cause is 'unknown'?

Dr_Juliet_Hou: Even if the cause of the pain is unknown, physical therapy can often be helpful to provide patient education, as well as flexibility, muscle strengthening, and correction of posture and muscle imbalance.

toto: If my chronic pain is from nerve damage, can therapy help at all with my pain?

Megan_Edgehouse_MPT: Potentially. We are able to do a lot of work with neurological problems, including desensitization of overactive nerves in the pelvic region. We can do some manual techniques that help loosen nerves from restricted connective tissues, etc. It’s worth a try. I have personally seen patients with nerve damage/neural issues make great gains in physical therapy.


Incontinence and Frequency

gardens: What causes incontinence and are there different types?

Dr_Juliet_Hou: There are different types of incontinence – the two main types being urinary and fecal incontinence. Different types of urinary incontinence include stress incontinence, urge incontinence or even overflow incontinence. There is also fecal incontinence or leakage of stool.

The causes could be structural or neuropathic/neurogenic. Structural causes mean that the pelvic floor structure has been weakened from surgery, birth, aging, hormones, etc. Actions such as coughing, sneezing or other types of straining activities can trigger this type of incontinence. Neuropathic/neurogenic occurs when an illness or disorder, such as having a stroke or having diabetes, causes the incontinence issues.

A full evaluation is needed to determine the cause, and then a treatment can be recommended based on this cause. Treatments for incontinence can include medication and physical therapy.

fancyface: Are only specific causes of incontinence helped with physical therapy? For instance, I know if there is a physical cause like a fistula post-surgery, this would require surgical repair.

Megan_Edgehouse_MPT: Certain situations may require surgical intervention as you noted. Even with the surgical intervention, it’s not a bad idea to come to therapy to learn how to do Kegels correctly and then continue to do them both before and after surgery for an optimal post-surgical result.

In therapy, we can treat all kinds of incontinence - urinary urgency and urge incontinence, stress incontinence, and fecal incontinence. But, sometimes the patient may require more than therapy if there is something structurally wrong.

michi: I have three children. The first two were born naturally and the third by cesarean. I now have some incontinence, but mostly very frequent urination. I have been told that pregnancy can cause this. How is this? I know that therapy can help with the incontinence, but can it also help with the frequent urination?

Megan_Edgehouse_MPT: Pregnancy does cause frequent urination, but it should end when the child is born. Therapy can help with frequency and urgency. We will try to help you "retrain" your bladder. Sometimes your bladder takes over and it becomes in charge of when you go to the bathroom. We need to teach you some techniques as to how to regain control of your bladder. We will discuss your fluid and diet intake, and make suggestions as needed. We can also see if you have any restrictions near your C-section scar that could be giving your urgency/frequency.


Exercise

operahouse: Can yoga help with my chronic pelvic pain?

Megan_Edgehouse_MPT: Yoga incorporates a lot of deep breathing and relaxation techniques that can have some positive effects on pelvic pain. So, yes it can. We do utilize some yoga positions and techniques in therapy as a way of stretching and mobilizing soft tissues. I also think that the relaxation and deep breathing that is stressed in yoga is very beneficial for patients with pelvic pain. Relaxation helps to decrease the overall muscle tone or guarding, and that can make pain better.

time_will_tell: I have read that yoga and Pilates can be helpful. What are your thoughts? Is it OK to do these on your own or is it better to work with a professional?

Megan_Edgehouse_MPT: Yoga and Pilates are both great schools of exercise. They each have very positive aspects to them. I would say as a general rule of thumb that it is OK to do them on your own as long as you don't have any orthopaedic issues (i.e., osteoporosis or severe arthritis) or as long as you are not having any pain with the exercise. If you are, then it’s best not to do it. I always think it’s a good idea to get some formal training from a certified instructor or leader when starting a new exercise program to make sure you're doing it correctly. Once you feel confident in the routine and the program, then I think it’s OK to continue on your own.


Pain After Surgery

jelser: I have pain in my groin area that has been getting worse since my surgery for an ovarian cyst last year. It is so bad now that I cannot even carry my purse.

Dr_Juliet_Hou: The surgery may not necessarily be the primary cause of your pain. Although it could be caused by scar tissue adhesions from the surgery, it may also be caused by local myofascial pain originating from the hip. In addition, the cause could also stem from the spine, such as upper lumbar radiculopathy, which could be causing this type of pain. Your OB/GYN surgeon should conduct the first evaluation, and -- depending on his or her findings -- a physiatrist might also be consulted. A physiatrist can help to evaluate other causes and provided a recommended course treatment that could include physical therapy.

Physical Therapy techniques can assist with correcting body mechanics and teaching you the proper ways in which to do everyday activities, such as carrying your purse in the proper manner.

kare_package: My mother has chronic pelvic pain. She had a hysterectomy about a year ago. Could this pain be related? What can she do?

Dr_Juliet_Hou: The pain could be related to the hysterectomy, but could potentially be caused by other factors. I would suggest that she first follow-up with her OB/GYN surgeon to discuss this, but she could also be seen by a physiatrist, who may recommend a course of physical therapy as a treatment option.

msn: If I possibly have scar tissue from a number of abdominal surgeries, how can I know if I should see a surgeon, or if physical therapy would help? I guess I just don't know where to start.

Megan_Edgehouse_MPT: Depending on what type of previous surgeries you have had, I would suggest following up with the surgeon first. I would recommend telling him or her about your discomfort, and if your surgeon does not recommend physical therapy, then you can ask for a referral. If the doctor does not see any surgical intervention that is feasible, then he or she could refer you to PT. Physical therapy can definitely work on the soft tissues that were affected from your previous surgeries and teach you how to do exercises at home, as well, for maximum benefit.


Kegels

helpme: Can you explain what Kegel exercises are and how they help with pain?

Megan_Edgehouse_MPT: Kegel exercises are a contraction of a group of muscles collectively called the pelvic floor muscles. This includes the area around the urethral, vaginal, and/or rectal openings. You want to try to tighten and lift this area inward. Some people try to do this by holding in gas or trying to stop the flow of urine. Unfortunately Kegels don't do a lot to help with pelvic pain; in fact, they can make it worse. Kegels are commonly given as a treatment method for incontinence, but less frequently for pelvic pain. In chronic pelvic pain, the pelvic floor muscles are usually too tight, or in spasm. Doing a Kegel would actually increase this tightness and potentially make pain worse. For pelvic pain patients, we concentrate more on relaxing the pelvic floor muscles. A physical therapist can help evaluate whether your muscles are too tight or too guarded and give you the best course of treatment.

wilderland: I do exercises tightening my gluts and stomach muscles, and have seen some improvement in my bladder control. Should I add Kegels? Would that improve bladder control even more?

Megan_Edgehouse_MPT: Yes. You should add Kegels. Your gluts and your stomach are considered "accessory muscles" that work in conjunction with your pelvic floor muscles. So if you contract or tighten them, you may notice some improvement in your bladder control. However, the Kegel is actually contracting the muscles that pinch off the end of the urethra and prevent urine from coming out. You will get the best results from doing Kegels, but the gluts and stomach are a good adjunct. If you are unsure if you are doing Kegels correctly, a physical therapist can help.

jump_up: I have tried doing Kegel exercises, but I do not know if I am doing them correctly. They do not seem to help at all. How do you know if you are doing them correctly?

Megan_Edgehouse_MPT: It’s very important that you contract the right muscles when doing a Kegel to get the best results. It’s hard for me to tell you how to do it correctly over a web chat. The best thing I can tell you is to try to stop your flow of urine. If you can, you are using the right muscles. If the muscles are very weak though, you might not be able to do this. However, you don't want to do this practice a lot, just to see if you are doing the exercises correctly. You could also insert a finger vaginally or rectally and try to contract. If you feel the muscles of the rectum or the vagina move upward then you are using the correct muscles. If those don't work, come to physical therapy, and we will make sure you understand how to do them correctly.

wilderland: Does exercise equipment designed for Kegel really help?

Megan_Edgehouse_MPT: I wouldn't suggest it. A lot of times the equipment utilizes your abdomen and your inner thighs. Just doing a Kegel would probably be most beneficial.

Virginia: I am 85 years old and have periodic bouts with incontinence, both urinary and bowel. My physician basically says to practice Kegels and the incontinence is probably a natural process of aging. Would Kegels alone help, especially when I am already this old?

Megan_Edgehouse_MPT: Kegels can always help. It is true that as we age our muscle tone, strength, and tissue integrity all decrease, which makes it all the more important to do Kegels. What is really important is that you are doing the Kegels correctly. You're never too old to do Kegels and to see some results when doing them on a regular basis. Just like any exercise program, you have to be compliant to see results. You can't just do Kegels once a month and expect results!


Men and Pelvic Pain

january: Can men also suffer from pelvic pain?

Megan_Edgehouse_MPT: Definitely! Men can have pelvic pain just as much as women. It can be just as problematic and debilitating. Pelvic pain in males can be treated the same way as in females. Most male pain patients are referred from their urologist after he or she has ruled out any prostate problems, infection, cancer, etc. They can also be referred from a physiatrist, neurologist, or colorectal doctor. The doctors usually determine that the problem is musculoskeletal in nature and send them to physical therapy for evaluation and treatment. We usually have really good results with treating male pelvic pain.

dfj: I am a male who has chronic pelvic pain that comes and goes for a few months a year. It has been diagnosed as prostatitis. Do you have any idea why it would fluctuate like that and what might cause flare-ups? I would like to prevent it from coming back, so I am assuming it would have to do with my pelvic muscles being very tight. I was wondering if you had any recommended stretches to loosen up those muscles and prevent flare-ups in the future. Thank you!

Megan_Edgehouse_MPT: Unfortunately, pelvic pain can recur and often flare-up due to a potential infection, stress, and/or an aggravating factor (such as an injury). If you have been through therapy in the past, I would suggest continuing with the exercises you were prescribed, as the therapist would have performed a thorough evaluation. If you did not have physical therapy before, see your doctor about a referral.

Also, relaxation and general lower extremity stretching is very important, especially with recurring pain. Deep breathing helps with this as well. When stretching, remember to keep all your muscles nice and relaxed. It’s also important to remember during the day to not clench or hold your pelvic floor and butt muscles tight. Relax! That usually helps patients a lot.


General Questions

get_started: Do relaxation techniques help?

Megan_Edgehouse_MPT: Relaxation techniques definitely help with certain pelvic floor issues. Pelvic pain in particular comes to mind. For all of my pelvic pain patients, I make sure they do some type of relaxation daily. Relaxation means something different for everyone. What makes you relax might not be relaxing for someone else. Relaxation could include meditation, deep breathing, mental imagery, walking, exercising, and/or being in a dark room. Whatever works for you. But yes, relaxation is important in treating pelvic pain.

mayfair: How are pelvic floor issues diagnosed?

Dr_Juliet_Hou: A physician evaluation would include a thorough medical history, such as when the pain started, what may have triggered the pain, etc. A physical exam includes a full musculoskeletal evaluation for scar tissue and a neurological exam, as well as a vaginal and rectal examination.

Depending on the initial findings, blood work and ultrasounds, CT, or MRI may also be ordered.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Juliet Hou MD, and Megan Edgehouse, MPT, is now over. Thank you both again for taking the time to answer our questions about Rehabilitation and Therapy Options for Pelvic Floor Pain and Incontinence.

Megan_Edgehouse_MPT: For any other questions regarding physical therapy and pelvic floor problems, or to schedule an appointment with one of our therapists, please call 216-445-8000.

Cleveland_Clinic_Host: Dr. Hou had to leave a few minutes early but she was thrilled with your questions.


More Information

To schedule an appointment with Juliet Hou, MD, Megan Edgehouse, MPT or any of the clinicians in the Department of Physical Medicine and Rehabilitation at Cleveland Clinic, please call 216.636.5860 or toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/pelvicrehab.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!

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This chat occurred on April 12, 2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition.

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