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Pelvic Floor Case Study – Female

Urinary Urgency and Incontinence 

History

A 76 year old female presenting with urinary urgency and incontinence symptoms for the last year.  She reported that her urge to urinate was too strong and would not make it to the bathroom 3-4 times a day.  She reported the worst urges were in the mornings while walking fast or sudden sprinting, experiencing increased levels of stress, and with breath-holding.  She also reported that dramatic exhales and sitting/lying down decreased her urge intensity and occasionally got rid of the urge completely.  She’s an active retiree and is frustrated that she can’t enjoy long brisk walks.

Patient goal

Control her urinary urges and reach a toilet in time without leaking urine, and return to her favorite activity and fast and brisk long walks.

Evaluation

Upon evaluation, her pelvic floor muscles (with patient consent) were weak and could not contract efficiently upon command. She demonstrated taking consistent quick short and shallow breaths during all her walking trials with “gripped” abdomen muscles. Since walking produced her symptoms, a gait analysis demonstrated absent shoulder and arm movement/swinging, and constantly raised and rigid shoulders.

Treatment

We had three main objectives, one was to make her pelvic floor muscles stronger and better coordinated to hold in her urine until she reached a toilet. The second objective pertained to her walking pattern. There were clear signs of abnormal movements and postures.  The third was to address her abnormal breathing patterns and excessive abdominal use with walking.  I explained that holding her belly in excessively and taking shallow breaths increased pressure on her abdominal organs and bladder. I compared it to sitting on a balloon, that with enough pressure something was going to give. In this case, it was her weak pelvic floor muscles (PFM) that could not hold back that excess pressure. I also explained that walking with her upper body rigid would also increase the pressure in her abdomen and make her breathing mechanics worse.

Outcomes

The patient required 19 visits to reach her goals. We used EMG biofeedback to train her PFM to contract with good coordination in all positions (lying, sitting, standing) and to gradually build the PFM strength. Her PFM contraction quality and breathing mechanics improved during the first 4-6 sessions in a lying and sitting position. Controlling her PFM endurance and demonstrating muscle control in standing and walking were achieved over the next 6-7 sessions. Movement re-education activities during sessions and at home were necessary to adjust her walking pattern. She was given a comprehensive home program to strengthen her PFM and her lower body. Her final 6-7 sessions focused on tying all the pieces together, instead of gripping her abdominals/core tightly, and how to adjust the PFM according to her activity level. She reported she no longer had any urgency or leaking with her desired activities at her discharge, and that her new habits were slowly becoming permanent mechanics.

Pelvic Floor Case Study – Male

Male Frequent Night Urination, Pain with Urination and Intercourse, Urinary Leakage and Groin Pain

History

A 72-year-old male presented with urinary leakage, burning both during and after urination. The patient was experiencing significant sleep disturbance due to his frequency of urination (3 or more times a night). In addition, he reported L groin and testicular pain. All his symptoms worsened with walking, eating spicy food, urination, and both during, after intercourse. Leakage occurred right after urinating. His symptoms lessened with resting and lying down.
Ultrasound imaging demonstrated an enlarged prostate, which is common within his age group.

Patient Goal

Abolish leaking, pain and burning with urination, decrease night time urination episodes, return to pain-free sex, and walking.

Evaluation

Palpation of his pelvic floor muscles revealed poor muscle coordination. His pelvic floor muscles, both hips, and lower abdomen were severely tense and painful to touch. After testing, nerve involvement was ruled out as a cause of his pain and symptoms. Since walking produced his pain, a gait analysis was performed and showed significant left hip stiffness and decreased stability. Muscle strength and length testing showed general L hip muscle weakness and tightness.

Treatment

We had four main objectives:
1. Decrease pain with all activities
2. Improve his pelvic floor muscle coordination and contraction/relaxation pattern
3. Address his Left hip weakness, muscle stiffness and tenderness
4. Correct abnormal gait pattern

We began his treatment program focused on addressing his pain with soft tissue mobilization, patient education, and self-massage. We prescribed a therapeutic stretch and strengthening exercise program to address his pain and improve his gait. In addition, we instructed specific pelvic floor muscle exercises with the goal to eliminate his leaking and pain with urination and sex. We used EMG Biofeedback in lying, sitting, and standing positions to improve his muscle coordination and decrease the muscle tension. Good muscle coordination is necessary to decrease urinary incontinence, frequency of night time voiding, and pain with urination and sex.

Outcomes

By session 4 the patient reported an 80% decrease in urinary pain, burning, and leakage. By session 6 the patient reported a perceived 50% decrease of pain with walking and 75% decrease in urinary leakage. At time of discharge, he reported pain free sex and L groin /testicular pain only with palpation. We feel the patient made very good progress because he consistently attended treatment and adherent to his Home Exercise Program. The patient was seen for a total of 9 sessions.

Case Study: Erectile Dysfunction and Abnormal Urination

History

24 year old cis-gendered, straight male presents with gradually worsening erectile dysfunction (ED) and premature ejaculation (PE) over the last 7 years. The patient reported a pelvic floor muscle (PFM) pain episode (age 14) at the perineum that was significantly painful to the touch. He was given a diagnosis of prostatitis, which was treated with antibiotics, but does not recall a physical or internal rectal exam by his doctor. Symptoms of ED and PE were intermittent until the past year when he began his first job in finance.  At that time, he reported severely high levels of stress as well as prolonged sitting throughout the day. His usual workday was from 8am to 8pm, Monday through Friday, and some work from home during the weekends. The patient was unable to have an erection approximately 80% of the time when aroused, and consistently experienced PE when he did engage in any sexual encounter. He reported that he could not masturbate regularly due to fear of worsening symptoms. He also did not explore any sexual relationships due to his symptoms.

The patient’s current urinary issues (voiding issues) include slow urine stream, a significant delay ( > 5 seconds) when trying to urinate, slow urinary stream, and urinating that stops and starts. He denied any urinary leakage. The abnormal voiding worsens after exercise, weight training, performing sit ups, after orgasm, and after retaining urine for a long time period (had a long meeting, no restrooms available, etc.)  His ED and PE episodes also worsened after the above activities occur.

Goals: Have normal erections, achieve orgasm at an appropriate time, engage in a sexual relationship with a partner, and to urinate normally.

Evaluation

While in standing, he demonstrated excessive weight-bearing in his heels, excessively wide stance width, severe forward pelvic thrust, rounded shoulders and head jutted forward.  His breathing pattern consisted of quick short and shallow breaths, with an immobile ribcage indicative of constant sucking in his belly and gripping his abdominals.  He demonstrated severe muscle tightness and lack of extensibility in his lower abdominals, lower rectus abdominus (“six-pack”) muscles, and groin/inner thigh. When tested for strength and stability, his core and PFM performed poorly. There were significant trigger points at his lower abdominals, six-pack muscles, and groin/inner thigh muscles. He described the discomfort as moderate to severe but stated palpation was tolerable. However, he reported severe PFM sharp pain and could not tolerate anything but light touch. He demonstrated severe PFM tension and tightness along with trigger points at the base of his penis, testicles, and perineum.

Treatment

The patient’s initial treatment plan had three objectives. The first was to address the severe tenderness of his PFM and the genital area. The next objective addressed the severe tissue tightness of his PFM, lower abdominals and groin/inner thigh muscles with a comprehensive stretching program. The third was to address his abnormal breathing pattern.

PFM dysfunction: I explained to the patient that the base of his penis, its “base of operations” is the pelvic floor muscle (PFM) structure. They support the bottom of the pelvis and are directly involved with sexual and urinary/bowel function. When these muscles and associated pelvic bones (pubis and sitting bones) are severely tender and/or tense, they prohibit efficient muscle function, including penile erection and urination quality.  It is necessary to release the muscle tissues and related pelvis areas to enable proper function. These aforementioned areas were extremely sensitive to direct touch.  I determined it would have been initially difficult for the patient to tolerate gentle soft tissue mobilization (STM) on his PFM.  Instead, I started STM with the surrounding areas that are intimately associated to the PFM (lower abdominals, lower rectus abdominus muscles, and groin/inner thigh muscles).  These areas were reported to be less tender upon examination and he tolerated STM.

Comprehensive Stretching Program: Another way to allow the sensitivity of these muscles to decrease was to develop a comprehensive stretching program. His postural and standing habits directly contribute to the severe tension of the PFM and its related muscular areas. He had difficulty correcting into typical posture. Stretching was specifically to address these limitations and allow his PFM to work efficiently. He performed and maintained this activity throughout his treatment period.

Breathing Dysfunction: I explained that holding his “gripping” belly also inadvertently “grips” his PFM and prohibits a natural breathing pattern. The efficient use of the diaphragm correlates with proper PFM function. This continual holding postural pattern can lead to unnecessary PFM overuse and eventual muscle failure (erectile dysfunction and poor urinating quality). We focused on breathing techniques that were meant to deliberately engage his lower, mid, and high trunk/ribcage with mindfulness and intent.

Core strength and stability therapeutic exercises, direct PFM STM, and postural re-education followed.  Postural re-education taught the patient that his normal stance prohibited any form of quality breathing techniques or core activity, which are major factors contributing to his symptoms.  Once he assumed an efficient posture, he was taught to decrease the abdominal/PFM “gripping”. With an increased tolerance to PFM direct touch, he received PFM STM and trigger point releases, along with Kegel exercises to relearn how to properly engage these muscles.

Outcome

After 3-4 sessions the patient reported improved voiding with his delay eliminated and a stronger urinary stream.  He noted an added benefit with slower and deeper breathing which helped to decreased perceived stress levels. His urinary issues were reported to be 50-75% resolved once his core and postural rehabilitation routine began several weeks later.  During this training period, he reports having an erection with more regularity, mild decrease in PE episodes. His core and postural training progressed slowly for several weeks and demonstrated improved PFM coordination and strength. At discharge, his urinary issues were abolished, reported normal erections at the appropriate times (arousal, masturbation, intercourse), and the incidences of PE dropped by half.

References

Davia, J., Welty A. Manual Therapy and Education for Physical Therapy Management of Male Chronic Pelvic Pain Syndrome, Journal of Women’s Health Physical Therapy: January/April 2014 – Volume 38 – Issue 1 – p 3-10

Dorey G, Speakman MJ, Feneley RC, Swinkels A, Dunn CD. Pelvic floor exercises for erectile dysfunction. BJU Int. 2005;96(4):595-597.

Underwood, Dawn; Stolp, Kathryn Differential Diagnosis in a Patient Referred for Pelvic Floor Tension Myalgia, Journal of Women’s Health Physical Therapy: September/December 2011 – Volume 35 – Issue 3 – p 96-102

Case study: S/P Laparoscopic Robotic Prostatectomy

History

The patient is a 57-year-old male status post-Laparoscopic Robotic Prostatectomy secondary to prostate cancer 2 years ago.   He presented with stress urinary incontinence and erectile dysfunction (ED). His leakage worsened with coughing and sneezing, increased exercise (circuit training), upon standing up, lifting heavy objects, fast walking, sudden sprinting, stress, and breath-holding. He also reported intermittent leaking while sleeping. He wore 3-4 pads a day and an overnight diaper. He reported having occasional (1-2x/month) small erections, unable to orgasm, occasional bouts of lower back pain since the surgery (none were severe or more than a week). Back pain was often produced with overexertion or after sudden awkward movements.

Goals:

  • Decrease or abolish urinary leakage with all functional movements and activities.
  • Decrease or eliminate the need for incontinence pads and diapers.
  • Increase the frequency of erections and to normalize orgasm.

Evaluation

Laparoscopic robotic surgery differs from traditional open surgery by making 4-5 small incisions on the anterior abdominal wall as opposed to a single large incision. His post-surgical scars were thick, rigid, immovable, and moderately raised (over 2mm but under 5 mm).  None of the incisions showed signs of inflammation. Further evaluation of his abdomen produced sharp local pain points along the length of his rectus abdominis (six-pack muscles).

With his consent, I assessed pelvic floor muscles (PFM) and found them to be weak (could not contract efficiently). The PFM was severely tight and tense, and there were several exquisitely tender spots (trigger points), more anteriorly (at the level of the base of the penis), than posterior (closer to the perineum and anus). His shallow breathing was with excessive use of the shoulders and upper chest muscles in standing and sitting positions. His spinal posture was rigidly straight. The patient had significantly decreased flexibility on both hips, especially the front and inner thighs.  Both sides of the hips and buttocks were significantly weak during postural and functional movement assessment (squatting, single-leg stance, and gait), and had difficulty efficiently coordinating his pelvis and hips.

Treatment

Due to the complexity of this patient’s case, the first stage of his treatment had three objectives:

  1. Improve his PFM coordination and strength
  2. Decrease the pain intensity and number of trigger points to his PFM and abdominal areas
  3. Adjust his posture for efficient breathing mechanics

Research has shown that abnormal urinary issues and ED may be the result of PFM dysfunction (potentially due to muscle weakness, tension, overwork, or incoordination).  We used EMG biofeedback to gradually re-educate PFM muscle contraction and control. It is also a tool to assist the PFM to contract and relax throughout its full range and decrease muscle tension. Good muscle coordination is necessary to decrease urinary incontinence and improve erection quality. We progressed to PFM EMG biofeedback training in all positions (I.e., lying, sitting, standing). He was given a home program with specific PFM coordination exercises, as well as contraction techniques to prevent urinary leakage.

We worked with this patient to deepen his breathing patterns. Shallow breathing, with a rigidly straight posture, increases pressure on the abdominal organs and bladder. It also decreases the efficiency of abdominal muscles which increases tension and stress on PFM.  Urinary leakage may occur because weak pelvic floor muscles (PFM) are unable to hold back that excess pressure.

The patient received scar mobilization to his incision points. Scar tissue can adhere to tissues and may decrease trunk flexibility and abdominal contraction efficiency. Pain may also be the result of adherent scar tissue and research has shown that pain decreases muscle contraction efficiency. An abnormal breathing pattern and posture may arise from the body’s efforts to avoid discomfort.

The second stage of his treatment program focused on integrating his new postural, breathing, and PFM gains with core, pelvis, and hip strength training. We focused on functional movement exercises, especially those that usually result in urinary incontinence.

Outcomes 

EMG biofeedback improved his PFM muscle control and improved his ability to hold urine with more active movements and with sneezing/coughing. Within 8-10 sessions, he was using 1-2 less pads per day and after a month used a pad rather than a diaper for any unexpected nighttime leaking. Within the first month, the combination of abdominal scar releases, PFM manual trigger point releases, and postural re-education improved his basic functional movements. This allowed the patient to fully catch his breath. These improvements motivated this patient to start a daily brisk walk in addition to his physical therapy home exercise program.

By the end of the second month, the patient reported an 80% decrease in urinary leakage. He reported progressing to 2-3 pads a day (formerly 3-4), and one at night (formerly 1 diaper).  He reported intermittent erections with arousal.

References

Dorey G, Speakman MJ, Feneley RC, Swinkels A, Dunn CD. Pelvic floor exercises for erectile dysfunction. BJU Int. 2005;96(4):595-597.

Hodges, P., Sapsford, R. and Pengel, L. (2007), Postural and respiratory functions of the pelvic floor muscles. Neurourol. Urodyn., 26: 362-371.

Huynh LM, Ahlering TE. Robot-Assisted Radical Prostatectomy: A Step-by-Step Guide. J Endourol. 2018;32(S1):S28-S32.

Shin, T.M. and Bordeaux, J.S. (2012), The Role of Massage in Scar Management: A Literature Review. Dermatol Surg, 38: 414-423.