Upon being introduced to pelvic floor physical therapy via a two-hour lecture in PT school, I remember thinking “how is this even PT” and “no thank you.” Yet here I am, 6 months after graduation, and I cannot believe how fortunate I am to have fallen into this specialty.
As health care providers who care strongly about our patients’ quality of life, we need to start considering the role that pelvic floor dysfunctions can play. Pelvic floor conditions, many of which are treatable, are affecting our patients’ ability to work, drive, garden, and fulfill their roles as family members and significant others. People affected by these conditions can become socially withdrawn, anxious, or sedentary, and this can affect the rest of their lives and health profile.
Research has shown that “nearly one third of Americans ages 30-70 have experienced loss of bladder control symptoms at some point in their lives,” but nearly 64% of those who self reported symptoms are not seeking treatment. Furthermore, in the United States, women wait an average of 6.5 years to seek help for pelvic floor dysfunction, while men wait for an average of 4.2 years (1).
Pelvic floor dysfunction, however, is not just about incontinence, which can be so debilitating that people begin avoiding public areas entirely. It’s not just about sexual dysfunction, which can contribute to the social reservation and deteriorate intimate relationships. It affects your patients with hip pain, with low back pain, with groin pain. Whether you’re in orthopedics or pediatrics, pelvic floor dysfunction can, and likely does, affect many of your patients.
1. Pelvic floor dysfunction is not rare.
Prior to entering this field, I assumed that pelvic floor dysfunction was relatively uncommon. Given my conversations with friends in the field, I was not alone in that assumption.
The National Institute of Health completed a cross-sectional analysis of 1,961 nonpregnant, healthy women over the age of twenty. These women were assessed for urinary and fecal incontinence, and pelvic organ prolapse. 23.7% of these people experienced at least one of these symptoms. These were asymptomatic women, and yet nearly 24% of them still had pelvic dysfunction (2).
Furthermore, those above-listed conditions affected (2):
- 10 percent of women from 20 to 39 years of age
- 27 percent of women ages 40 to 59
- 37 percent of women ages 60 to 79
- ~50 percent of women 80 or older
I am referring a study that focused on women not to skew your impression of these statistics, but rather because research for men is not as widely published. Is anyone else blown away by these numbers?
Additionally, their research found that “almost 10% of women have surgery for urinary incontinence, pelvic organ prolapse, or both during their lifetime, and 30% of those women have two or more surgical procedures.” According to the United States Census Bureau, the population of the United States on Sunday, November 5th at 2:18PM was 326,217,396. According to the US Census Bureau’s report in 2010, 50.8% of the total population of the United States is female. That means there are roughly 166,370,871 women in the United States. If 10% will have surgery for pelvic floor conditions in their lifetime, that’s 16,637,087 surgeries. These numbers are not insignificant, and these conditions are not rare.
2. Incontinence is not a normal part of aging.
According to a study by the Society of Urologic Nurses and Associates, 38% of men and women interviewed thought incontinence is a normal part of aging. This is a major contributor to why people wait so many years between time of onset and seeking care. The most unfortunate thing about this statistic, in my opinion, is that estimates range as high as 80% of those with incontinence being curable, or at the least improvable (1).
While incontinence does become more prevalent as we age, this is not simply because we are getting older. Elderly people may be more likely to experience conditions that contribute to incontinence, such as prostate cancer for men, or menopause and subsequent low estrogen levels in women, but the resulting symptoms are not irreversible.
Incontinence is not a normal part of aging, or childbearing for that matter. Incontinence causes social anxiety, can lead to social withdrawal, anxiety, even sexual dysfunction. Incontinence can wake us up at night, multiple times, severely affecting the quality of our sleep. It’s embarrassing and frustrating and people assume they have to live with it so they don’t seek help.
During my short time as a pelvic floor physical therapist, my patients have told me they’ve stopped going to the gym because of incontinence, stopped walking their dogs, or heck, just stopped walking. Some even stopped going to work. As healthcare practitioners, I urge you to screen your patients for some of these common, treatable pelvic floor conditions, and educate them that there is help available. In fact, there is an entire field dedicated to resolving their symptoms and getting them back to the life they had and want.
3(a). It’s not all about Kegels.
“Isn’t it all about Kegels?” is the question that both patients and therapists ask when I tell them I’m a pelvic floor physical therapist.
In short, no. Let me explain.
What we colloquially refer to as Kegels are also known as pelvic floor muscle contractions. When muscles are weak, we strengthen them; however, do all muscular dysfunction and pain come about as a result of weakness? Of course not. What about muscle shortness? If you excessively contract a muscle that’s already shortened, that’s not going to make pain go away.
A simple way to break down pelvic floor dysfunction is to think of these diagnoses as falling under one of two categories: diagnoses of weakness, and diagnosis of tension. For diagnoses of weakness, pelvic floor contractions may be appropriate. For diagnoses of tension, we have to think stretching, decreasing tone, relaxation.
To complicate this issue even further, in diagnoses of weakness where Kegels are indicated, it turns out that the majority of people don’t do a Kegel correctly. In a study from the American Journal of Obstetrics and Gynecology, Dr. Bump et. al. note that up to 51% of people will do Kegels incorrectly, and that 25% of participants in their study “displayed a Kegel technique that could potentially promote incontinence.”
That’s right: not only do the majority of people do them incorrectly, but as many as a quarter of people may be doing these exercises in a way that directly contributes to worsening their symptoms.4
So, it’s not all about Kegels, and even if it were, most people still need some guidance regarding form. Now let’s dive just a little further into Kegel misconceptions.
3(b). If a person leaks urine, they don’t necessarily need Kegels.
Let’s talk length-tension relationships of skeletal muscles. I’m sure you all remember sarcomeres, with their actin and myosin needing just the right distance for the muscle to achieve a maximal contraction. Skeletal muscle has a normal resting length, a position that the muscle needs to achieve to generate its maximum force.
Well, what if the muscle length is decreased? What if there is a contracture and the muscle is unable to achieve that resting position? When treating an elbow contracture, you first work range of motion, and then you strengthen. There’s no point to begin strengthening if the only range you have access to is 90 to 135 degrees of flexion. The pelvic floor is no different. While contractures may not look the same because we can’t visualize that area, muscle length can still be decreased. Kegel exercises are for strengthening, but we can’t begin strengthening until that length-tension relationship is reestablished.
This is why Kegels are not always the answer. People can leak for two reasons: weakness and tension.
4. We don’t just treat postpartum women and old people.
Pelvic floor physical therapy is generally an unknown for people. It’s a big black hole of physical therapy done behind closed doors. Furthermore, for those who are familiar with the field, it’s a specialty that helps pregnant and postpartum women regain continence after childbirth, and maybe some elderly folk as well. Unfortunately, this misconception leaves many potential patients without care and many practitioners reticent to refer.
Although postpartum and pregnant women do make up a significant percentage of our patient population, we also treat everybody else. That’s right! Everybody! Everybody from pediatrics to geriatrics, from women and men, from cisgendered to transgendered folks. Everybody with a pelvic floor.
I work at a specialty clinic called Sullivan Physical Therapy in Austin, Texas. We have ten pelvic floor physical therapists, seeing upwards of 80 patients a day, and over 300 patients a month. Today, on November 1st, 2017, 30% of our collective 72 patients were men.
What do men come in for, you may ask? A wide variety of diagnoses and treatments, just like in every other specialty of physical therapy. We see men pre- and post-prostatectomy for education and symptom management. We see men with pelvic pain, pain with sitting, pain with sex or orgasm, and a number of other presentations and concerns. We have therapists who specialize in treating men, and we even have a therapist who owns a continuing education company, Alcove Education, who teaches a class specifically regarding men with pelvic pain.
Another misconception I frequent is that we treat primarily older people. On the same day 30% of our patients were men, 38% of our patients were under the age of 40. On that very same day, we had a patient under the age of 10, as well.
Part of the reason our patient demographics are so much wider spread than expected is that we treat a number of diagnoses outside of incontinence. Some of the more widely known include: constipation, fecal incontinence, low back pain, hip pain. But did you know we also treat cesarean and episiotomy scar pain? Or that we also treat dyspareunia, or painful sex? Or that we can treat nighttime enuresis in children?
Additionally, pelvic floor physical therapists can treat postoperative prostatectomy and hysterectomy symptoms, prolapse of the bladder, rectum or uterus, coccyx pain, irritable bowel syndrome, pelvic and genital pain, and those are just the tip of the iceberg. Pelvic floor physical therapists, at my clinic and elsewhere, treat all these diagnoses and more.
So if you have a patient who has complaints or symptoms that you think may be related to “down there,” don’t be afraid to call up your fellow physical therapists who specialize in, well, “down there.”
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1. Muller, Nancy. What Americans Understand and How They Are Affected by Bladder Control Problems: Highlights of Recent Nationwide Consumer Research. Society of Urologic Nurses and Associates. 2005:25(2): 109-115 https://www.suna.org/download/members/unjarticles/2005/05apr/109.pdf
2. Nygaard, I. Barber, M. Burgio, K. Kenton, K. Meikle, S. Schaffer, J, et. al. Prevalence of Symptomatic Pelvic Floor Disorders in US Women. JAMA. 2008:300(11): 1311-1316. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2918416
3. Facts About Incontinence. Illinois Department of Public Health. http://www.idph.state.il.us/about/womenshealth/factsheets/inc.htm
4. Bump, RC. Hurt, WG. Fantl, JA. Wyman, JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gyncecol. 1991:165(2): 322-7. https://www.ncbi.nlm.nih.gov/pubmed/1872333