Treatments

PELVIC FLOOR THERAPY TREATMENT

Manual assessment, Ultrasound Imaging, Anorectal Manometry and EMG assessment are the main tests that proved information about the health of your pelvic floor. These are not scary tests, but rather quick and painless. The results of these tests give us information from which decisions can be made about the course of your therapy and track your progress over time.

IS PELVIC FLOOR REHABILITATION RIGHT FOR ME?

If you are a male and think you have issues related to being too tight or too loose in or around your ass, causing pain, any problems with sex, aesthetic issues, bowel or bladder issues, constipation, or leakage, you will benefit from Pelvic Floor assessment and treatment.

WHAT ARE THE BENEFITS OF PELVIC FLOOR REHABILITATION?

As we age our pelvic floor muscles weaken over time. Certain activities or stressors compound that decline. Pelvic floor dysfunction causing symptoms such as incontinence of feces or urine, constipation, urinary hesitancy, pain, defecation disorders such as paradoxical contraction, uncontrolled gas can lead to depression, anxiety and social isolation.

WHAT ARE THE PROCEDURES USED FOR PELVIC FLOOR EVALUATION?

Evaluating a pelvic floor involves looking at a person holistically and completely. The comprehensive assessment is vital so we know how to help you in the best way possible and includes:
  • Postural and spinal assessment
  • Muscle strength and length testing
  • Internal and external manual pelvic examination
  • Surface Electromyography testing to assess the electrical activity in your pelvic region
  • Real-Time Ultrasound Imaging of your pelvic floor position and excursion during contraction, relaxation, and symmetry
  • Anorectal Manometry: a test of anal and rectal pressures, sensations and responses

WHAT TO EXPECT DURING MALE PELVIC FLOOR THERAPY?

There are a number of techniques designed to help with pelvic floor disorders. The main aim of treatment, no matter what the issues are, is to relax the muscles to an acceptable baseline level. After achieving an appropriate baseline of muscle activity and resting tone, the goal is to create control through the range of muscle activation. So, to put it another way, pelvic floor muscle action is controlled by you, from relaxation to contraction and back again.
Treatment Techniques can include:
  • Education about your condition, treatment, and home program (including Kegel exercises)
  • Postural realignment and re-education
  • Manual therapy internal and external when appropriate
  • External muscle mobilization, strengthening and lengthening as needed
  • Surface EMG Biofeedback training
  • Ultrasound imaging Biofeedback
  • Manometric Biofeedback
  • Manual scarring and fibrosis treatment.
  • Bladder and bowel training
  • Relaxation Training
  • Dietary education and changes
  • Core Strengthening
  • Cognitive-Behavioural Strategies

HOW LONG DOES A COURSE OF PELVIC FLOOR REHABILITATION USUALLY TAKE TO WORK?

It takes between 6 to 8 weeks to see a physiological change in a muscle or skin after therapy has started. However, is it not uncommon to see changes in coordination and muscle control well before this time due to a reinforcement of the existing neural pathways.

IS THERE ANY SPECIAL PREPARATION I NEED TO DO BEFORE HAVING A PELVIC FLOOR EVALUATION?

The answer depends on how well you know your bowels and at what time of the day your appointment is. Most likely, if you have had your normal bowel movement for the day before arriving for assessment or treatment, you should be fine.

External Manual Therapy

External muscle strengthening and lengthening as needed. External manual therapy techniques include nerve release, trigger point therapy, deep tissue massage (myofascial release), skin rolling, and joint mobilization.

WHAT IS NERVE RELEASE THERAPY?

A frequently used technique is nerve release therapy in which your therapist finds a trigger point by feeling a twitch in the muscle underneath, exercising it using a circular motion, and then putting pressure on it to help relax it, repeating the process until the muscle starts to release. Internal massage can also help release nerves.

WHAT IS TRIGGER POINT THERAPY?

One of the goals of nerve release therapy is to eradicate myofascial trigger points. A “trigger point” can be described as pain related to a discrete, irritable point in skeletal muscle or fascia, not caused by acute local trauma, inflammation, degeneration, neoplasm or infection. The painful point can be felt as a tumor or band in the muscle, and a twitch response can be elicited on stimulation of the trigger point. Palpation of the trigger point reproduces the patient’s complaint of pain, and the pain radiates in a distribution typical of the specific muscle harboring the trigger point. The pain cannot be explained by findings on neurological examination.

WHAT IS DEEP TISSUE MASSAGE?

For internal massage, your PT may insert a finger into the rectum and massage the muscles and connective tissue directly. If the tissues are restricted there will be a decrease in blood flow, muscle atrophy, and thickening of the subcutaneous tissue. Physical therapists will utilize a technique called connective tissue manipulation and is performed with minimal pressure as the therapist pushes through the subcutaneous tissue. The goal of CTM is to restore connective tissue integrity, improve circulation and decrease general water retention.

WHAT IS SKIN ROLLING?

Skin rolling is a form of myofascial release. It is used to identify and treat areas of restriction or abnormal cross-linking of fascia or connective tissue in a painful area in the body. When trauma, infection, surgery, or inflammation occurs in an area of the body, fascia loses its pliability and can become “sticky” causing abnormal links between areas that are normally not attached or linked. This results in pain, loss of motion, and pressure in the area of abnormal cross-linking. Skin rolling can break up the abnormal cross links or adherences and restore normal fascia mobility. The therapist pinches the skin between their fingers (picking it up) and pulls the skin away from the underlying structures. Their fingers move along the surface of the skin continuously picking the skin up to stretch the subcutaneous fascia, break cross links, and make the tissue more mobile. The areas that do have restrictions or cross-links can be painful or sore as the technique is performed. Areas that were tight or restricted and released through skin rolling may turn red or release heat. This is a good response. Decreased pain, improved lymphatic flow, decreased swelling, improved nerve function, improved range of motion, and improved mobility and posture usually result.

WHAT IS JOINT MOBILIZATION?

Joint mobilization treatment is where you lie face-down and force is placed into the sacrum or pelvic bone gently but firm, the bone is moved an extremely small distance, and the end position of mobilization should be held for less than a second. This mobilization is usually repeated for a set of three to five oscillations; and anywhere from one to three sets of oscillations are usually done, or for 10, 15, or 20 seconds. As with all manual therapy techniques, the determinant for how long to apply a technique should be based on the response of the tissues on your body.

Internal Manual Therapy

WHAT IS INTERNAL MANUAL THERAPY?

Internal manual therapy techniques are a treatment used for someone who has overactive, tender and/or shortened pelvic floor muscles. Techniques include manual therapy to mobilize restricted skin and pelvic floor structures, including the anus.

WHAT IS THE GOAL OF INTERNAL MANUAL THERAPY?

The goal of internal manual therapy is to improve the relaxation, lengthening and tenderness of the pelvic floor muscles.

HOW DOES THE THERAPIST APPLY INTERNAL MANUAL THERAPY TECHNIQUES?

Generally, the patient is first positioned comfortably in either hooklying (on their back with knees bent, sometimes resting on a pillow– yep, no stirrups needed!), side lying or sometimes on their stomach, depending on what position is preferable to the patient and allows the therapist access to the tissues being treated. The therapist then places one gloved finger within the rectal canal and gently presses on the muscles of the pelvic floor to identify (with constant feedback from the patient) where the muscles are tender or uncomfortable. Manual therapy techniques then can be performed to help improve the tenderness of these muscles and promote relaxation and lengthening.
These techniques can include:
  • Holding gentle pressure while the patient focused on relaxing and breathing
  • Holding gentle pressure while the patient performs a contact/relaxing of the muscles or a pelvic floor bulge.
  • Holding gentle pressure while simultaneously pressing with the opposite hand on a point around the pelvis to produce slack in the muscle (a modified strain counter strain technique.
  • Sweeping stretches over the muscle belly

WILL I FEEL COMFORTABLE DURING TREATMENT?

Different therapists have different approaches, but they all are done in complete collaboration and communication with the patient and are modified based on the patient’s comfort and response to the treatment.

Surface EMG biofeedback training

WHAT IS SURFACE EMG BIOFEEDBACK TRAINING?

Biofeedback is a self regulation training technique derived from well established principles of human learning. Biofeedback is a technique, not a stand alone treatment, which is one component of a behavioral training program to facilitate acquisition of pelvic floor muscle control and other continence skills.

HOW DOES SURFACE EMG BIOFEEDBACK WORK?

With the use of biofeedback, physiological change can be achieved by means of operant conditioning, a type of learning which occurs as a result of feedback, or the experience and awareness of the consequences of one’s behavior. For example, the core behavioral treatment of urinary incontinence is pelvic muscle re-education. The pelvic floor refers to the complex of connective tissues and muscles that close off the pelvic outlet and act as a “floor” to the abdominopelvic cavity. Biofeedback “takes the guesswork out of pelvic muscle training” because it enables the patient to improve pelvic muscle function through muscle awareness, which, when combined with a home exercise program, leads to increased muscle strength and improved coordination. In a review of several studies using biofeedback to teach pelvic muscle exercises (Kegel’s exercises) for the treatment of incontinence patients benefit from biofeedback by developing a greater sense of control and mastery of bladder and bowel control significantly reducing their fear, anxiety, isolation and hopelessness.

HOW CAN YOU SET GOALS USING SURFACE EMG BIOFEEDBACK?

The first step in using biofeedback as a therapeutic tool is to understand the anatomy and physiology underlying the symptomatic dysfunction. This allows the selection and measurement, and ultimately voluntary control, of a physiological response.

WHAT CAN I EXPECT DURING THE PROCEDURE?

Prior to being admitted to the biofeedback program, patients must be evaluated by a physician with expertise in this field. Some forms of incontinence, even genuine stress incontinence, could be secondary to a general disease or to a local specific disease for which biofeedback treatment may not be appropriate. However, in those cases, although biofeedback does not ameliorate the underlying condition, it may improve the incontinence.
A daily bladder or bowel diary should be kept for one week prior to beginning a behavioral program. This should include the number of incontinent accidents, activity associated with the accidents, times of regular voiding and fluid intake. The evaluation will include a review of the patient’s medical history, a rectal examination, an assessment of bladder and urethral prolapse, rectal prolapse, muscle strength and of the patient’s ability to control his or her pelvic muscles. Usually, only urinalysis and culture and post void residuals are necessary. Depending on history and physical examination findings, urodynamic testing, cystometrogram, abdominal leak point pressure, and/or bladder leak point pressure, x-rays and cystoscopy could be useful.  
During the pre-treatment visit, our physical therapist will provide educational information and explain the use of the equipment, including the sensor and its placement.
“T” shaped sensors are used, the patient may insert themselves, taking care that the large end remains outside of the rectum. The “T” allows the patient to sit without any sense of discomfort and has the advantage of having the patient start training in a functional position making it easy to progress from sit to stand.
The patient is seated on a firm chair. This position allows for easy progression to a more functional standing position and further increases the patient’s proprioception of the target muscles due to contact with the firm surface. The sensor is then connected to the EMG instrumentation.Electrodes, monitoring accessory muscles, usually the abdominals, are attached by the clinician. These surface patch electrodes can be placed above the pubic symphysis and to the right of the umbilicus, 3-4 centimeters apart, to monitor muscle activity. After connecting to the EMG instrument, the assessment can begin. First, baseline information is gathered for the resting EMG levels of the pelvic floor muscles. The resting EMG levels should be acquired over a 1-3 minute interval.
The patient is then asked to tighten the pelvic muscles and to hold the contraction for 10 seconds. The amplitude of the contraction will vary from patient to patient and is dependent on a variety of factors, including prior nerve or muscle damage to the pelvic floor as a result of childbirth or surgical trauma, genetic makeup of the individual, as well as placement of the electrodes and instrumental bandwidth. There is no “magic” number for signal amplitude during contraction and no evidence has been found to support any specific amplitude necessary to attain continence. Patients must be monitored on an individual basis. After the pelvic muscle contraction, a period of relaxation should follow, typically ten seconds. It is important that the pelvic muscles are isolated and that the accessory muscles of the legs, abdomen and buttocks are not contractedю
Our physical therapist will instruct the patient to contract and relax the pelvic muscles four to six times, allowing for ten second rest periods between each contraction. These voluntary contractions should be observed for maximal amplitude, the average amplitude of the ten seconds, recruitment and fatigue. The resting levels should be observed for any evidence of muscle spasm, such as abnormally high resting tone, or even excessive activity at lower amplitudes. A response time, or measure of “latency”, can be determined by recording the length of time it takes for the EMG signal to make the transition from rest to work and work to rest. A series of five rapid, forceful contractions, sometimes called “quick flicks”, are a good measure of the fast twitch fibers of the pelvic floor. The ability to perform 5 such rapid contractions in a ten second period is a goal in training patients to be able to use their muscles in a functional manner.

Ultrasound Imaging biofeedback

WHAT IS ULTRASOUND IMAGING BIOFEEDBACK?

Ultrasound imaging is a tool that has been used to evaluate the morphology and certain components of the function of pelvic floor muscles.

HOW DOES IT WORK?

Dynamic rehabilitative ultrasound is used to image function and dysfunction of musculo-skeletal and pelvic floor disorders. This is one of the many ways our pelvic therapists can assess pelvic floor muscle functions. The aim is to directly evaluate the effect of muscle contraction and relaxation. The rehabilitative ultrasound uses a small sound head placed over the muscle group allowing us to look at the structure, size, and activation patterns of the muscles during different activities. This technology has given us one of the most advanced ways of observing the muscle activation patterns in all positions. It also allows us to give patients real-time feedback based on observations and help them improve function and meet their physical therapy goals.

Manometric biofeedback

WHAT IS MANOMETRIC BIOFEEDBACK?

This test measures the pressures of the anal sphincter muscles, the sensation in the rectum, and the neural reflexes that are needed for normal bowel movements. It is used as a tool to help patients learn how to perform muscle exercise training. Manometric Biofeedback is an instrument-based learning technique wherein an instrument such as a manometry probe is placed inside the body to provide visual or auditory information to the patient regarding their anorectal muscle function.

WHAT IS BIOFEEDBACK?

During anal manometry special exercises of the pelvic muscles can strengthen the muscle, retrain the coordinated relaxation of the anal sphincter and improve rectal sensation via sensory/ visual conditioning techniques.

HOW CAN YOU PREPARE FOR THE PROCEDURE?

You should not eat anything during the two hours prior to the procedure. If you are diabetic, this may involve adjusting your diabetic medications. You may take regular medications with small sips of water at least 2 hours prior to the study. If you have heart disease, kidney disease, or electrolyte abnormalities, contact your physician prior to beginning preparation.

WHAT CAN I EXPECT DURING THE PROCEDURE?

The test takes approximately 30 minutes. You will be asked to change into a hospital gown. A technician or nurse will explain the procedure to you, take a brief health history, and answer any questions you may have. The patient then lies on his or her left side. A small, flexible tube, about the size of a thermometer, with a balloon at the end is inserted into the rectum.
The catheter is connected to a machine that measures the pressure. During the test, the small balloon attached to the catheter may be inflated in the rectum to assess the normal reflex pathways. The nurse or technician may also ask the person to squeeze, relax, and push at various times. The anal sphincter muscle pressures are measured during each of these maneuvers. To squeeze, the patient tightens the sphincter muscles as if trying to prevent anything from coming out. To push or bear down, the patient strains down as if trying to have a bowel movement. One other test may also be done: Balloon expulsion test; a measurement of the time it takes to expel a balloon from the rectum.

WHAT CAN I EXPECT AFTER THE TEST?

After the examination, you may drive yourself home and go about your normal activities. You can make an appointment with your physician in 2 weeks to discuss the test results

Bladder and bowel training

WHAT IS BLADDER OR BOWEL TRAINING?

Pelvic floor muscle training exercises can help strengthen the muscles under the uterus, bladder, and bowel (large intestine). They can help men who have problems with urine leakage or bowel control. A pelvic floor muscle training exercise is like pretending that you have to urinate, and then holding it. Bladder retraining is a simple and effective method used to try and overcome bladder problems including, urgency, frequency and incontinence.

HOW DOES BLADDER RETRAINING WORK?

Bladder retraining helps you to begin to hold more urine for longer periods of time. It is possible to train your bladder to do this by gradually increasing the time between each visit to the toilet. This method sounds simple, however bladder retraining takes time and determination and will not work overnight. To have a chance of successful bladder retraining you must try and ignore the feeling that you need to go to the toilet for as long as possible. If you can learn to ignore the feeling that you need to go straight away your bladder will begin to relax and will become less irritable. It is possible for you to be in control of your bladder and not the other way round.

HOW DO YOU BEGIN TO RETRAIN THE BLADDER?

You must try and resist the messages that your bladder sends to you telling you that you need to go to the toilet. If you continue to respond to those messages and go to the toilet each time you feel the urge to go, your feelings of urgency or frequency will continue and possibly get worse.
Resisting messages from your bladder will not be easy. When you listen to the messages and relieve yourself, you find immediate relief – but of course it is only temporary because you will start feeling uncomfortable again after only a very short time. This cycle of discomfort, even panic, followed by brief relief is very hard to break. You need to be strong and focused. Try and empty your bladder after you experience feelings of urgency. Gradually increase the amount of time you wait before you empty your bladder again. You will need to be patient and not be put off if you have accidents and failures, especially at first. You will feel rather silly, living your voiding schedule by a stopwatch, but very often this method works and can make your life easier.
Some things you should remember while retraining your bladder:
  • Plan your retraining schedule clearly with realistic and achievable goals.
  • Focus on success – not on setbacks.
  • Be patient; bladder retraining will not be a success overnight. You will need to work hard at it for some weeks.
  • Be aware of any fears or worries associated with your bladder problem. In some cases these fears or worries will need to be tackled before long-lasting success is possible.

Relaxation training

The daily practice of pelvic floor relaxation is important for teaching tight and painful pelvic floor muscles to relax.

WHAT KIND OF EXERCISES BENEFIT RELAXATION?

Make sure you are in a quiet environment
Get into a comfortable position, possibly lying down or sitting in a supported position. Turn down the lights so you feel calm and composed. Once you’ve mastered relaxing in a quiet environment, learn how to relax in a less quiet environment. Our bodies have the ability to relax even while we are walking; it just takes practice.
Diaphragmatic Breathing
This is a type of “deep breathing” to practice during all your pelvic relaxation exercises. First, take a slow, gentle breath in through your nose, and allow your belly and ribs to flare out to the sides. “Open” your pelvic floor with your inhale breath. Exhale slowly and gently through your mouth, allowing your belly to fall. Let the air out of your upper lungs, relax your ribs, belly and pelvic floor. The diaphragm works in synergy with the pelvic floor and helps to promote muscle relaxation. This is important for decreasing pain and promoting optimal muscle function.
Practice Visualization
Close your eyes and imagine you are in a quiet place that makes you feel relaxed. Picture a place in your mind that makes you feel most relaxed, such as a beach, mountain, or meadow — whatever picture works best for you. Imagine what you would see, hear, feel, and smell in this specific place.
Find your Pelvic Floor Muscles, learn how to make them contract and relax.
First, look at the diagram of the pelvic floor muscles. The muscles sit like a hammock inside your pelvis. In the front, they start at the pubic bone, surround the penis and rectum, and attach in the back to your coccyx (tailbone). Picture the muscles in your mind. Imagine the muscles relaxing, contracting, and relaxing. Imagine how they would feel without pain or problems. Picture the muscles sagging down now, with your rectum (as a circle) getting larger, and your sitting bones (the bones in your pelvis) separating.
Pay attention to other areas of your body for signs of tension.
Tension in other parts of your body may be making the tension in the pelvic floor muscles worse. Check various body parts (head, neck, shoulders, eyes, cheeks, jaw, arms, hands, legs, feet, ribs, belly, and buttocks) for tension. Now, gently release any area that feels tense. Allow yourself to entirely relax.

Find support for handling stress.
Set some time for yourself.
Be the manager of your care.
Stretch frequently throughout the day.
Do not overexert yourself.

Dietary education and changes

WHAT KIND OF DIETARY EDUCATION IS NEEDED FOR PELVIC HEALTH?

It’s helpful to implement a dietary education about which foods are either anti-inflammatory (will cause less pain in the pelvic floor region) or foods that will aid in digestion. It is also important to understand which foods to avoid as these can cause the bladder and other areas of the pelvic floor to become irritated.

WHAT KIND OF DIETARY CHANGES DO I NEED TO MAKE?

Our suggestion is to consume a high-fiber diet or take fiber supplements so that when you do go to the bathroom, your stool is collected together in one smooth, bulky mass and/or one is able to expel all colon contents in a single movement. When you consciously make fiber a part of your daily regimen, you’ll reach a point where the most important step of your cleaning regimen is simply using the bathroom and quickly rinsing off. Your body will get rid of mostly everything in a very natural way, without disrupting the pH balance of your rectum. In terms of how to incorporate fiber into your diet, fresh fruits, vegetables, leafy greens, whole grains, and unprocessed bran are important sources of natural fiber. It is quite difficult to naturally ingest the daily recommended dosage of fiber, so it may be fruitful to take a hybrid approach of both increasing fiber-rich food intake, but also supplementing with fiber pills or powders.  

WHAT OF FOODS WILL HELP AID IN DIGESTION?

  • Drink plenty of water
  • Herbal/Caffeine-free teas
  • Low-acidic fruits and veggies: apricots, melons, bananas, and carrots
  • Certain spices: turmeric, garlic, ginger, lemon zest, and parsley
  • Fish high in Omega-3 fatty acids
  • Healthy fats from olive oil, coconut oil, avocados, ghee, and nut oils
  • Sweet potatoes
  • Mushrooms

WHAT FOODS SHOULD I AVOID?

Many of these foods can cause the bladder and other areas of the pelvic floor to become irritated.
  • Caffeinated beverages
  • Alcohol
  • Highly acidic fruits and veggies: tomatoes, cranberries, and oranges
  • Carbonated beverages: soda
  • Spicy foods
  • Artificial sugars and sweeteners

Core strengthening

Your pelvic floor muscles contract simultaneously with the deep muscles of your back and abdomen to provide strength, support, and stability to your spine and organs whenever you move. Strengthening the core can reduce or eliminate urinary incontinence by restoring support to the pelvic organs and helping to control against leakage.

WHAT ARE THE BENEFITS OF CORE STRENGTHENING EXERCISES?

  • Coordinating abdominal and pelvic floor muscles
  • Your innermost layer of abdominal muscles should contract with your pelvic floor muscles to help with bladder and bowel control.
  • Protecting and supporting your abdominal organs
  • Your abdominal muscles protect your abdominal organs and help to hold them in position.
  • Stabilizing your joints
  • Toning your abdomen
  • Train your spinal, pelvic floor and trunk muscles
  • Reduce your risk or pelvic floor overload

WHAT ARE SOME COMMON MISTAKES MADE WITH CORE STRENGTHENING EXERCISES?

Over Bracing
Some over brace their abdominal muscles which means they contract these muscles too strongly. Over bracing your core abdominal muscles increases downward pressure onto your pelvic floor. If you over brace your abdominal muscles you may need to learn how to relax your core muscles.
Holding your Breath
Holding your breath during core abdominal exercises doesn’t train your deep abdominal muscles to work normally during everyday tasks. Try to breathe normally during core abdominal exercises. Practicing deep breathing exercises can also help you relax your core abdominal muscles.
Poor Posture
Good upright posture is important for your core muscles to work well. Try to use good upright posture when you’re sitting and standing to encourage your core muscles to work as they should.

Stretching

There are simple stretches that are designed to loosen the muscles inside and around the pelvis. These exercises work best when done daily.

Happy Baby Pose
Lie on your back and open your knees out wider than your chest and bring them towards your armpits. Try to keep your ankles over your knees. You can either hold this position or gently rock on your back from side to side.
Child’s Pose
Start on your hands and knees and spread your knees wide apart while keeping your toes touching. Gently bow forward, moving your torso downwards, between your thighs. Keep your arms stretched out in front of you.
Adductor Stretches
Lie on your back with the soles of your feet together and knees spread out to the sides. This should be a relaxing position. If you feel a strain or pulling of your inner thighs or in your pubic bones, place pillows under your knees for support.  
Piriformis Stretching
Lie on your back with your knees bent. Place your left ankle over your right knee, like a figure four. Pull your right thigh towards your chest to feel a stretch on the outside of your left hip. Hold for 30 seconds and then repeat on the other side.