Urinary leakage, pelvic pain or dysfunction may be embarrassing to discuss with your physician. However, many symptoms are common and can be helped with physical therapy.
Kim Fletcher, Physical Therapist and specialist in Women's Health Physical Therapy with Summit Therapy, discusses how physical therapy can improve these conditions.
Selected Podcast
What is Pelvic Health
Featuring:
Kim Fletcher, DPT
Kim Fletcher has a Doctorate of Physical Therapy from Eastern Washington University with Special Interests in Women’s Health, Pelvic Dysfunction, Pregnancy, Post-Natal, Orthopedic physical therapy. She works at Summit Therapy & Health Services at Pullman Regional Hospital. Transcription:
Melanie Cole (Host): If you experience urinary leakage, pelvic pain or dysfunction; you are not alone. You may be a little too uncomfortable talking about your symptoms with your physician or think it’s just a normal part of aging. But that’s not necessarily the case. My guest today is Kim Fletcher. She’s a physical therapist and specialist in women’s health physical therapy with Summit Therapy at Pullman Regional Hospital. Kim tell us what is pelvic health as a specialty and what’s the clinical expertise required to be a woman’s health physical therapist?
Kim Fletcher, DPT (Guest): So, pelvic health or pelvic rehabilitation in the profession of physical therapy is a specialized area of practice. A pelvic physical therapist has advanced training in the assessment and treatment of pelvic dysfunction and understands the relationship that the pelvic floor muscles have with respect to the urinary, bowel and reproductive systems. Our physical therapy assessment and treatment focuses on the muscles and soft tissue and bony structures of the spine, pelvis and hip. And pelvic physical therapists can treat men, women, children and transgender patients. Typically, these skills are not taught as part of a physical therapist’s initial education. So, to be able to practice in this area; additional training is required.
Melanie : Can you share some statistics as to who is affected with pelvic issues? You mentioned men, so it’s not just women that are affected by this, even men who might be going through prostate issues could be affected.
Kim: Yeah so, the research on the prevalence of conditions that a physical therapist can treat are really interesting. The numbers are actually quite higher than one might think. So, starting with the men; men following prostate surgery have up to 50% chance of reporting leakage due to stress urinary incontinence after their surgery. And then as far as urinary incontinence in women; one in four women over the age of 18 experience episodes of involuntary urine leakage. But when we look at women who have bared a child, urinary incontinence will affect up to 30-50% of these women by the age of 40. It’s really interesting that only one in twelve people affected with incontinence will actually seek help and on average it takes seven years for a woman to speak to her medical provider about her symptoms of incontinence.
Melanie : Wow, you know women might be as I said in the intro, a little bit uncomfortable discussing these things. So, speak about what conditions might be related to the pelvic floor muscles. What do you treat and are they a normal part of aging Kim?
Kim: So, urinary incontinence, pelvic pain, bowel dysfunction and when I say bowel dysfunction, I mean constipation and fecal incontinence; those are never a normal part of aging. So, in my practice I work with patients who have a variety of conditions. Urinary incontinence is one of the most common conditions that I treat. However, I also work with people who suffer from bowel dysfunction as I mentioned, pelvic pain, coccyx or tailbone pain and then I’m starting to see more and more women who are being referred specifically to our practice prior to rectal or bladder prolapse repair surgery; which is an ideal time to work on muscle strength and coordination going into the surgery. And then on occasion, I will also get referrals with patients who have low back or hip pain that have been treated in standard outpatient physical therapy and they haven’t had complete resolution of symptoms and so they are referred to me if some sort of pelvic floor muscle function is thought to be a contributing factor in their ongoing symptoms.
Melanie : You stated that some women wait up to seven years. And as many women know who have had babies or have some of these issues, we kind of just pass it off and say oh you know, okay, I can deal with this. When do you feel it’s important that someone seek help for their pelvic floor disorders?
Kim: Anytime that it certainly affects their day-to-day activities. The women that I work with who are pregnant leading up to their delivery, I always discuss what is normal and should be expected postpartum versus what’s not. If these symptoms continue on past the six, eight, ten, twelve weeks, certainly by the six-month mark; it’s important to speak to their provider and get in to physical therapy as soon as possible. The sooner that somebody gets in, the quicker we can help resolve any of these issues.
Melanie : So, tell us about some of the common treatments, because people worry that it’s going to be uncomfortable or that they are going to be a little bit insecure about having a physical therapist helping them with those kinds of disorders. What are some of the treatments like Kim?
Kim: So, the treatments will vary depending on the diagnosis. We always start with a thorough evaluation and then following the evaluation; we come up with a plan of care. And so, in the case of urinary incontinence, those women might need more strengthening which can include some strength exercises of the hip, of the core musculature and then of the pelvic floor muscles. In the case of pelvic pain; sometimes those muscles in the pelvic floor area are too tight and so we can do manual techniques to help relax or stretch the muscle much like a tight muscle anywhere else in the body. We do down training, breathing exercises for those, and then also we have the use of biofeedback where we use little sticky electrodes. This does not put electrical activity into the body. It monitors the muscle activity and it comes up onto a screen. I always explain to my patients that the pelvic floor muscles are a little bit harder to rehab because we can’t see them. And they are really hard to visualize in our own body and so, by using our biofeedback program; it’s really helpful that a woman can compare what they are seeing on the computer screen to what they are sensing and what’s actually happening in their body. And then as we progress through therapy and as symptoms improve; we try to progress those exercises to match whatever physical activities the specific person is involved in or whatever specific activities they might experience leakage during. So, if that be skiing or they want to go jump on the trampoline with their kids; whatever they are trying to do, we try to closely match their functional activities with our rehab.
Melanie : So, we have all heard of the Kegel exercises and some people have heard of cones and all of these different kinds of ways. What would you like women to know about things that they might be able to do on their own to maintain their pelvic health and to work with the physical therapist as they go through therapy to help speed the process along? Tell us about Kegels.
Kim: So, Kegels were developed kind of in the early 1900s by Dr. Kegel and they started off as just a pelvic floor contraction and what I will tell you is that a lot of women – and I get told this a lot by women that they have done Kegels for years and it has never helped their symptoms. And oftentimes when we do our thorough assessment and we assess the pelvic floor; we find that they are either not doing their pelvic floor muscle contraction correctly or they have some sort of coordination dysfunction. And so, that’s where it’s really important to seek help of a physical therapist who is specifically trained in pelvic muscle dysfunction and then from there, we will give you activities to do at home. But Kegels are also not for everybody and in certain diagnoses or certain cases, performing repetitive pelvic floor muscle contractions or repetitive Kegels can make symptoms worse. And so, it’s really important to get guidance from a – somebody who has been trained in the area of pelvic muscle rehab.
Melanie : One of the things I have heard as well about treatments that can make it worse is when women try and start and stop their urine stream, so that they can see if they can hold it in as it were. And that’s not always a great idea is it?
Kim: No, that is not a good idea. A couple of things can happen with that. We always worry about reflux of urine back into the bladder and possibly into the kidneys and we don’t want to set anybody up for a urinary tract infection. And then number two, it confuses the system and so, our bodies are really smart, and our muscles know that when we sit down to urinate, that the pelvic floor should relax and the muscle on the bladder needs to squeeze. And then when we are not voiding, and we are going through our day; our pelvic floor muscles need to maintain a certain amount of tone and the muscle on the bladder needs to stay relaxed and so when we start doing Kegels on the toilet; that’s going to confuse the whole physiological process of voiding and we never want to cause more problems with that.
Melanie : Thank you for clearing that up. What can someone expect from their first visit with a pelvic physical therapist?
Kim: So, I am really happy that you asked this question, and this is probably one of the most common questions that I get asked. And oftentimes women who come into my office have a certain amount of anxiety or they are nervous or scared about what to expect during their first visit. So, during the first visit with a pelvic physical therapist, your general medical health history will be discussed and there will be specific questions about prior injuries, illnesses and any chronic conditions such as diabetes that you might have. And then we will ask about prior surgeries and as a pelvic physical therapist; I am specifically interested in prior abdominal surgeries, gynecological surgeries such as prolapse repair, C-sections, perineal tearing during childbirth. And then we will go into some more detailed questions related to your current symptoms.
And then after gathering the thorough history; I personally spend a lot of time with patients providing education regarding the pelvic anatomy and function as well as basic physiology related to the urinary and bowel systems. We spend time discussing how pelvic floor muscles can play a contributing role in pelvic dysfunction whether that be incontinence, pelvic pain or bowel dysfunction. And then next a physical assessment is performed and I kind of like to think of this in two different parts.
First a general orthopedic based assessment will be performed, and this will include assessing – looking at how your spine moves, the alignment of the pelvis, strength testing of the hip muscles and looking for general coordination and stabilization stability throughout the trunk and the pelvis. And then the second part of the physical exam can be an internal pelvic floor muscle assessment and this internal exam can be performed either vaginally or rectally depending on the symptoms that are present. And I think it’s just important to note that this exam is different from a medical pelvic exam performed by a physician and we don’t use a speculum. And basically, what happens with this exam is it’s completed by inserting one finger either vaginally or rectally and then we assess each muscle layer of the pelvic floor. And what we are assessing for is general tone of the pelvic floor muscles, painful areas and then assessing for strength, endurance and motor control and coordination of the pelvic floor. And then we also look for soft tissue restrictions that might be present due to previous soft tissue injuries and the internal exam – it will only be performed if it is appropriate for the patient’s specific case and only if the patient provides consent prior to the exam. And then depending on the findings from the evaluation, a home exercise will be given. So, this might include a bladder diary, patient specific stretches, breathing exercises. The diaphragm and the pelvic floor work really closely to one another. Strengthening exercises. So, that’s kind of what to expect at the first visit. It’s just really patient dependent.
Melanie : How are you working with the Pullman OB-GYN practice?
Kim: Yeah so, we are really excited to be collaborating with the physicians at Moscow Pullman OB-GYN to provide care to their patients in need of pelvic physical therapy at their office in Pullman two mornings a week. Our hope is to provide a one-stop care experience for their patients. And this will allow care to start and continue in one location making it much more convenient and manageable for our patients and we are also hoping that this improves access to pelvic physical therapy. Patients will be able to get in a little bit quicker. I know my practice included and all over the country; there’s not a lot of pelvic physical therapists out there and so oftentimes women will have to wait two, three, five months before they can even get in to a pelvic floor physical therapist.
Melanie : Do you need a referral for this type of pelvic health visit?
Kim: At our clinic and to be seen by one of Pullman Regional Hospital’s pelvic physical therapists a referral is required. We feel very strongly that your referring physician be closely involved in your care and have the opportunity to assess for and rule out any more serious conditions related to the patient’s specific complaints prior to having the initial physical therapy appointment.
Melanie : So, wrap it up for us Kim with what you would like the take home message to be about pelvic health, pelvic floor disorders, and pelvic physical therapy. Your best advice for maintaining a healthy pelvic floor.
Kim: If there’s any problems at all, if there are any concerns, don’t wait seven years to talk to your medical provider about it and just know that you are not alone. There are many women out there who suffer from these types of problems that severely affect their lives and their ability to participate in activities with their family and their kids. And there is help for it and help doesn’t necessarily mean straight to surgery. It’s always good to try conservative treatment first and so that’s what a pelvic floor physical therapist is here for is to help you work through these issues and get you functioning as well as possible, so you can go on and enjoy life with your family and friends without worrying about urinary incontinence or being debilitated by pelvic pain.
Melanie : Thank you Kim so much for joining us today and for sharing your expertise on what could be considered a sensitive topic and you have cleared it up so very well for us. Thank you again for being with us. You’re listening to The Health Podcast with Pullman Regional Hospital. And to learn more about pelvic physical therapy services at Pullman Regional Hospital please visit www.pullmanregional.org, that’s www.pullmanregional.org. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): If you experience urinary leakage, pelvic pain or dysfunction; you are not alone. You may be a little too uncomfortable talking about your symptoms with your physician or think it’s just a normal part of aging. But that’s not necessarily the case. My guest today is Kim Fletcher. She’s a physical therapist and specialist in women’s health physical therapy with Summit Therapy at Pullman Regional Hospital. Kim tell us what is pelvic health as a specialty and what’s the clinical expertise required to be a woman’s health physical therapist?
Kim Fletcher, DPT (Guest): So, pelvic health or pelvic rehabilitation in the profession of physical therapy is a specialized area of practice. A pelvic physical therapist has advanced training in the assessment and treatment of pelvic dysfunction and understands the relationship that the pelvic floor muscles have with respect to the urinary, bowel and reproductive systems. Our physical therapy assessment and treatment focuses on the muscles and soft tissue and bony structures of the spine, pelvis and hip. And pelvic physical therapists can treat men, women, children and transgender patients. Typically, these skills are not taught as part of a physical therapist’s initial education. So, to be able to practice in this area; additional training is required.
Melanie : Can you share some statistics as to who is affected with pelvic issues? You mentioned men, so it’s not just women that are affected by this, even men who might be going through prostate issues could be affected.
Kim: Yeah so, the research on the prevalence of conditions that a physical therapist can treat are really interesting. The numbers are actually quite higher than one might think. So, starting with the men; men following prostate surgery have up to 50% chance of reporting leakage due to stress urinary incontinence after their surgery. And then as far as urinary incontinence in women; one in four women over the age of 18 experience episodes of involuntary urine leakage. But when we look at women who have bared a child, urinary incontinence will affect up to 30-50% of these women by the age of 40. It’s really interesting that only one in twelve people affected with incontinence will actually seek help and on average it takes seven years for a woman to speak to her medical provider about her symptoms of incontinence.
Melanie : Wow, you know women might be as I said in the intro, a little bit uncomfortable discussing these things. So, speak about what conditions might be related to the pelvic floor muscles. What do you treat and are they a normal part of aging Kim?
Kim: So, urinary incontinence, pelvic pain, bowel dysfunction and when I say bowel dysfunction, I mean constipation and fecal incontinence; those are never a normal part of aging. So, in my practice I work with patients who have a variety of conditions. Urinary incontinence is one of the most common conditions that I treat. However, I also work with people who suffer from bowel dysfunction as I mentioned, pelvic pain, coccyx or tailbone pain and then I’m starting to see more and more women who are being referred specifically to our practice prior to rectal or bladder prolapse repair surgery; which is an ideal time to work on muscle strength and coordination going into the surgery. And then on occasion, I will also get referrals with patients who have low back or hip pain that have been treated in standard outpatient physical therapy and they haven’t had complete resolution of symptoms and so they are referred to me if some sort of pelvic floor muscle function is thought to be a contributing factor in their ongoing symptoms.
Melanie : You stated that some women wait up to seven years. And as many women know who have had babies or have some of these issues, we kind of just pass it off and say oh you know, okay, I can deal with this. When do you feel it’s important that someone seek help for their pelvic floor disorders?
Kim: Anytime that it certainly affects their day-to-day activities. The women that I work with who are pregnant leading up to their delivery, I always discuss what is normal and should be expected postpartum versus what’s not. If these symptoms continue on past the six, eight, ten, twelve weeks, certainly by the six-month mark; it’s important to speak to their provider and get in to physical therapy as soon as possible. The sooner that somebody gets in, the quicker we can help resolve any of these issues.
Melanie : So, tell us about some of the common treatments, because people worry that it’s going to be uncomfortable or that they are going to be a little bit insecure about having a physical therapist helping them with those kinds of disorders. What are some of the treatments like Kim?
Kim: So, the treatments will vary depending on the diagnosis. We always start with a thorough evaluation and then following the evaluation; we come up with a plan of care. And so, in the case of urinary incontinence, those women might need more strengthening which can include some strength exercises of the hip, of the core musculature and then of the pelvic floor muscles. In the case of pelvic pain; sometimes those muscles in the pelvic floor area are too tight and so we can do manual techniques to help relax or stretch the muscle much like a tight muscle anywhere else in the body. We do down training, breathing exercises for those, and then also we have the use of biofeedback where we use little sticky electrodes. This does not put electrical activity into the body. It monitors the muscle activity and it comes up onto a screen. I always explain to my patients that the pelvic floor muscles are a little bit harder to rehab because we can’t see them. And they are really hard to visualize in our own body and so, by using our biofeedback program; it’s really helpful that a woman can compare what they are seeing on the computer screen to what they are sensing and what’s actually happening in their body. And then as we progress through therapy and as symptoms improve; we try to progress those exercises to match whatever physical activities the specific person is involved in or whatever specific activities they might experience leakage during. So, if that be skiing or they want to go jump on the trampoline with their kids; whatever they are trying to do, we try to closely match their functional activities with our rehab.
Melanie : So, we have all heard of the Kegel exercises and some people have heard of cones and all of these different kinds of ways. What would you like women to know about things that they might be able to do on their own to maintain their pelvic health and to work with the physical therapist as they go through therapy to help speed the process along? Tell us about Kegels.
Kim: So, Kegels were developed kind of in the early 1900s by Dr. Kegel and they started off as just a pelvic floor contraction and what I will tell you is that a lot of women – and I get told this a lot by women that they have done Kegels for years and it has never helped their symptoms. And oftentimes when we do our thorough assessment and we assess the pelvic floor; we find that they are either not doing their pelvic floor muscle contraction correctly or they have some sort of coordination dysfunction. And so, that’s where it’s really important to seek help of a physical therapist who is specifically trained in pelvic muscle dysfunction and then from there, we will give you activities to do at home. But Kegels are also not for everybody and in certain diagnoses or certain cases, performing repetitive pelvic floor muscle contractions or repetitive Kegels can make symptoms worse. And so, it’s really important to get guidance from a – somebody who has been trained in the area of pelvic muscle rehab.
Melanie : One of the things I have heard as well about treatments that can make it worse is when women try and start and stop their urine stream, so that they can see if they can hold it in as it were. And that’s not always a great idea is it?
Kim: No, that is not a good idea. A couple of things can happen with that. We always worry about reflux of urine back into the bladder and possibly into the kidneys and we don’t want to set anybody up for a urinary tract infection. And then number two, it confuses the system and so, our bodies are really smart, and our muscles know that when we sit down to urinate, that the pelvic floor should relax and the muscle on the bladder needs to squeeze. And then when we are not voiding, and we are going through our day; our pelvic floor muscles need to maintain a certain amount of tone and the muscle on the bladder needs to stay relaxed and so when we start doing Kegels on the toilet; that’s going to confuse the whole physiological process of voiding and we never want to cause more problems with that.
Melanie : Thank you for clearing that up. What can someone expect from their first visit with a pelvic physical therapist?
Kim: So, I am really happy that you asked this question, and this is probably one of the most common questions that I get asked. And oftentimes women who come into my office have a certain amount of anxiety or they are nervous or scared about what to expect during their first visit. So, during the first visit with a pelvic physical therapist, your general medical health history will be discussed and there will be specific questions about prior injuries, illnesses and any chronic conditions such as diabetes that you might have. And then we will ask about prior surgeries and as a pelvic physical therapist; I am specifically interested in prior abdominal surgeries, gynecological surgeries such as prolapse repair, C-sections, perineal tearing during childbirth. And then we will go into some more detailed questions related to your current symptoms.
And then after gathering the thorough history; I personally spend a lot of time with patients providing education regarding the pelvic anatomy and function as well as basic physiology related to the urinary and bowel systems. We spend time discussing how pelvic floor muscles can play a contributing role in pelvic dysfunction whether that be incontinence, pelvic pain or bowel dysfunction. And then next a physical assessment is performed and I kind of like to think of this in two different parts.
First a general orthopedic based assessment will be performed, and this will include assessing – looking at how your spine moves, the alignment of the pelvis, strength testing of the hip muscles and looking for general coordination and stabilization stability throughout the trunk and the pelvis. And then the second part of the physical exam can be an internal pelvic floor muscle assessment and this internal exam can be performed either vaginally or rectally depending on the symptoms that are present. And I think it’s just important to note that this exam is different from a medical pelvic exam performed by a physician and we don’t use a speculum. And basically, what happens with this exam is it’s completed by inserting one finger either vaginally or rectally and then we assess each muscle layer of the pelvic floor. And what we are assessing for is general tone of the pelvic floor muscles, painful areas and then assessing for strength, endurance and motor control and coordination of the pelvic floor. And then we also look for soft tissue restrictions that might be present due to previous soft tissue injuries and the internal exam – it will only be performed if it is appropriate for the patient’s specific case and only if the patient provides consent prior to the exam. And then depending on the findings from the evaluation, a home exercise will be given. So, this might include a bladder diary, patient specific stretches, breathing exercises. The diaphragm and the pelvic floor work really closely to one another. Strengthening exercises. So, that’s kind of what to expect at the first visit. It’s just really patient dependent.
Melanie : How are you working with the Pullman OB-GYN practice?
Kim: Yeah so, we are really excited to be collaborating with the physicians at Moscow Pullman OB-GYN to provide care to their patients in need of pelvic physical therapy at their office in Pullman two mornings a week. Our hope is to provide a one-stop care experience for their patients. And this will allow care to start and continue in one location making it much more convenient and manageable for our patients and we are also hoping that this improves access to pelvic physical therapy. Patients will be able to get in a little bit quicker. I know my practice included and all over the country; there’s not a lot of pelvic physical therapists out there and so oftentimes women will have to wait two, three, five months before they can even get in to a pelvic floor physical therapist.
Melanie : Do you need a referral for this type of pelvic health visit?
Kim: At our clinic and to be seen by one of Pullman Regional Hospital’s pelvic physical therapists a referral is required. We feel very strongly that your referring physician be closely involved in your care and have the opportunity to assess for and rule out any more serious conditions related to the patient’s specific complaints prior to having the initial physical therapy appointment.
Melanie : So, wrap it up for us Kim with what you would like the take home message to be about pelvic health, pelvic floor disorders, and pelvic physical therapy. Your best advice for maintaining a healthy pelvic floor.
Kim: If there’s any problems at all, if there are any concerns, don’t wait seven years to talk to your medical provider about it and just know that you are not alone. There are many women out there who suffer from these types of problems that severely affect their lives and their ability to participate in activities with their family and their kids. And there is help for it and help doesn’t necessarily mean straight to surgery. It’s always good to try conservative treatment first and so that’s what a pelvic floor physical therapist is here for is to help you work through these issues and get you functioning as well as possible, so you can go on and enjoy life with your family and friends without worrying about urinary incontinence or being debilitated by pelvic pain.
Melanie : Thank you Kim so much for joining us today and for sharing your expertise on what could be considered a sensitive topic and you have cleared it up so very well for us. Thank you again for being with us. You’re listening to The Health Podcast with Pullman Regional Hospital. And to learn more about pelvic physical therapy services at Pullman Regional Hospital please visit www.pullmanregional.org, that’s www.pullmanregional.org. This is Melanie Cole. Thanks so much for listening.