After treatment: Physical therapy options for pelvic floor pain and incontinence

By Jill Ehrmantraut Dec 06, 2016


In the wake of diagnosis and treatment, cancer patients may think that issues like pelvic floor pain and incontinence are problems they just have to live with. Patients alongside Sanford Health physical therapists can work toward improving their quality of life through a variety of pelvic floor physical therapy treatments.

Cancer treatment can have a number of effects of the pelvic floor — a group of muscles at the base of the pelvis responsible for supporting the organs, control of the bladder and bowel and sexual function. Two primary effects physical therapy can treat are pain and urinary incontinence.

Pelvic Floor Pain

Scarring and muscle problems like adhesion, thinning and increased tension can lead to pelvic floor pain with physical activity or sexual intercourse. The pain can then manifest in the pelvic area as well as the:

  • Buttocks
  • Groin
  • Hips
  • Lower abdomen
  • Lower back

Muscle coordination also tends to diminish with pain, leading to a cycle of discomfort as muscles have difficulty relaxing, tense up further and cause more pain. Many patients find pelvic floor muscles a hard area for coordination in the first place. When patients squeeze other muscles, they can usually see movement of different body parts. But when they squeeze their pelvic floor, they generally don’t, so it’s just a feeling. It’s particularly hard for these patients to feel that.

Pelvic floor physical therapy patients are typically seen two times per week, for four to eight weeks. Treatment is usually multi-modal, starting with manual therapy and including therapeutic exercise and biofeedback. Hands-on treatment is the focus during clinical time, as patients are expected to focus on exercises they learn during clinic visits when they are home. We do exercises and review them in the clinic as needed, but not during every visit because we have other things we want to work on.

Along with reducing pain, treatment goals include restoration of muscle extensibility and coordination, while decreasing muscle tension.

Manual is the first line of therapy, as we gauge the level of pain a patient is experiencing. We do let patients know they might be sore after the first session, not everybody is, but it is pretty normal.

Therapeutic exercise aims to restore muscle extensibility, essentially stretching what is tight. Stretches are the first exercises I will give to these patients. Along with stretching, we also perform relaxation exercises, which include deep breathing, visualization of the muscles and body awareness — anything we can do to get the body to relax. These exercises are good for pain anywhere in the body.

Biofeedback is a tool we use quite a bit to restore pelvic floor muscle coordination. Via electrodes, biofeedback reads the electrical output of the muscles, providing a visual representation of muscle coordination and how to relax muscles. Once patients are able to do that, they’re able to sustain that relaxation.

After therapy discharge, patients are strongly encouraged to continue with their home exercises to maintain the improvement gained while in physical therapy.

Patients can always return for a second round of physical therapy, if needed. A second round typically doesn’t take as long as the first round did. Before a patient comes back, I usually recommend they first go back to their exercises for a week or two. Not always, but we usually find that they start feeling pretty good again, if they have stopped doing them.

Urinary Incontinence

Urinary incontinence, the involuntary leaking of urine, comes in three main types: stress incontinence, urge incontinence and mixed incontinence, which is a combination of stress and urge.

With stress incontinence, urine leaks when coughing, sneezing, laughing or other sudden movements. Physical activities — even walking or standing up from a seated position — can cause an increase in abdominal pressure that in turn puts pressure on the bladder. When this pressure is greater than what the surrounding pelvic floor structures can exert to keep the urethra closed, a leak occurs. A leak of this nature tends to be smaller.

Urge incontinence encompasses a strong need to go to the bathroom really badly, as if a person won’t be able to make it in time. Facing this strong urge, the nervous system ramps up, and the bladder of a person moving to go to the bathroom squeezes. In this case, leaks tend to be larger, if not the full bladder.

Treatment of urinary incontinence revolves around strengthening, and the number one strengthening exercise we use is the Kegel. The top verbal cue I use when teaching patients Kegels is: trying to stop the flow of urine.

While this is a key verbal cue, it is also important to note that we don’t want patients to actually stop their flow while urinating. Doing it can cause bad bladder habits that we don’t want as well as backflow of urine into the bladder.

I like to have patients practice Kegels lying down, sitting or standing, whatever is appropriate for their strength level. We can advance as needed.

First, we learn correct technique, then we test endurance. We try quick ones, hold five seconds, five in a set, three to four times a day. Depending on strength and endurance, patients are doing 30 to 60 or 80. We want those three to four times daily spaced out throughout the day. Muscles need a chance to recuperate after becoming fatigued.

It is best to work these exercises into the day. Most people have a cellphone or computer that they’re close to during the day where they can set an alarm. That seems to work pretty well. Another cue to use to remember to do the exercises: once the bladder is empty, do a set.

We also work to strengthen the lumbopelvic system. This is very important and includes strengthening of the hips, core and pelvic floor. The exact types of exercise won’t be the same for every patient, depending on the strength level they come in with and other factors, but in some form, almost all of my incontinence patients are doing these exercises.

I encourage diet modification — decreasing intake of bladder irritants like caffeine, carbonation and spicy and acidic foods — for everybody. I have patients who have done just diet modification and made a huge difference in their incontinence. In turn, I have patients who have done just diet modification, and it made no difference. Everybody’s body is different in sensitivity to these things.

Behavior modification methods in the form of bladder retraining and urge suppression work to retrain the brain and body to recognize bladder levels as well as identify actual versus perceived urgency to urinate.

Urinary incontinence treatment is not quite as intensive as treatment for pelvic pain. Most patients are seen three to five times in total. The biggest goal of mine with urinary incontinence patients is to have them be independent with their exercises. Maximum improvement in bladder control and urinary incontinence doesn’t typically occur until after three months of being consistent with the exercises.

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