New Explanation for Women's Pelvic Pain?

What causes pelvic floor dysfunction? Stein: Unfortunately, half the time we don't know. Sometimes it is evident, such as a traumatic childbirth where a nerve got damaged or stretched, or a fall onto the sacrum, back or coccyx, which is at the bottom of the spinal column. People may also have weakness and/or tension in the hip, back or pelvic floor. A lot of patients have had recurrent urinary tract infections (UTIs). These patients complain that they still feel like they have a UTI because the muscles are still in spasm, remembering what it's like to be in that pain.

Kavaler: Pelvic floor dysfunction is just like having a back spasm. It can come from the way you hold your body. If you have an injury, for example, you may compensate by putting stress on other muscles.

How is pelvic floor dysfunction treated? Kavaler: One option is for the patient to just wait it out. A lot of times, urinary problems occur after recurrent urinary infections, or if there is something stressful going on in people's lives. The more tense people are, the more they tend to clench and hold abnormally. They can try lifestyle changes, such as exercising regularly, eating well, and getting a good night's sleep.

If people are urinating frequently at night, then I may give them a muscle relaxant because that will help both the spasm and the sleeping. That often will be the first step in breaking the cycle. But you can't give muscle relaxants during the day because patients will fall asleep at work. I also sometimes give medications that act like bladder anesthetics by coating the bladder wall to make it feel better.

If lifestyle changes don't help, the real mainstay of treatment is physical therapy, which is the same treatment that you would have for a back spasm.

What does physical therapy involve? Stein: I do an extensive evaluation, with a lot of questioning, because everyone has different symptoms. Once I figure out what the problems are, I treat the symptoms. One of the things that I do is deep tissue massage and myofascial release. Fascia is connective tissue. If the fascia is very tight, which I see in most of my patients, it can pull and cause tightness in certain muscles. Physical therapy techniques can adjust the tight muscles and the trigger points, which are the tender spots.

I also teach deep breathing exercise with relaxation techniques, Kegel exercise to strengthen the pelvic floor muscles, and strengthening of the core area. The core area is the abdominal area, the back, the internal/external obliques and the transverse abdominus. I also teach stretching. I do biofeedback if people are having a hard time strengthening or relaxing the muscles. Additionally, patients have to take an active role in their healing and do exercises and stretching at home.

Behavioral changes are also part of the reeducation. For example, the average person should go to the bathroom once every three or four hours. If patients go to the bathroom every half hour, I tell them to stretch it out to 45 minutes, and then once they hit 45 minutes, they stretch it out to an hour, until they get to the norm.

What is the average length of time a patient needs physical therapy? Stein: The average length of time usually varies from two months to a year. It depends on how severe the symptoms are and how long the patients have had them. It's estimated that most patients have had their symptoms for at least five years before they actually get some help.

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