Pelvic Floor Physical Therapists Research Articles

Geographic Access to Urogynecology Care in the United States.

Although access to urogynecologic care is known to influence patient outcomes, less is known regarding geographic access to care and how it may vary by population characteristics. The primary objective of this study was to estimate geographic accessibility of urogynecologic services in terms of drive time and by population demographics. We performed a descriptive study using practice location data by zip code for all board-certified urogynecologists who are American Urogynecologic Society members (n = 497) and pelvic floor physical therapists (n = 985). Drive times from each zip code to the nearest health care professional zip code were calculated. These data were then overlaid onto a map of the continental United States. Race/ethnicity, age, education, poverty status, disability status, health insurance coverage, and rurality were compared across travel times. Of the 31,754 zip codes of the continental United States, 389 (1.23%) had at least 1 urogynecologist, and 785 (2.47%) had at least 1 pelvic floor physical therapist; 92.29 million women older than 35 years were represented in the demographic analyses. Seventy-nine percent of the studied population live within 1 hour of a urogynecologist, and 85% live within 1 hour of a pelvic floor physical therapist. Seven percent and 3% live >2 hours from urogynecologic services, respectively. Values for drive times to all health care professionals indicate that American Indian/Alaska Native individuals have a much greater travel burden than other racial/ethnic groups. There are population groups with limited geographic access to urogynecologic services. Pelvic floor physical therapists are more geographically accessible to the population studied than urogynecologists.

(137) MULTIDISCIPLINARY PERSPECTIVES ON FEMALE SEXUAL HEALTH: HOW CAN WE DO BETTER?

Abstract Introduction Sexual dysfunction is a pervasive yet overlooked concern in the care of women with chronic urological conditions. Objective The purpose of this study is to evaluate the challenges and opportunities that urologists and sex therapists encounter when treating and referring female patients with chronic urological conditions and sexual health concerns. Methods All participants were recruited by email to participate in semi-structured interviews about their current practices, perceived barriers and facilitators, and preferences for further training. The interviews were recorded, transcribed, and inductively coded by two independent researchers. Excerpts were then analyzed using qualitative description to identify themes. Results We conducted 22 interviews involving 6 urologic oncologists, 7 urogynecologists, and 9 sex therapists, and determined themes affecting care for women with chronic urological conditions and sexual concerns: (Table 1). Lack of Training All participants indicated lack of education on the association between female sexual dysfunction and chronic urological conditions. Urologists were hesitant to discuss sexual health, citing a lack of counseling skills and treatment familiarity. Sex therapists, particularly those unaffiliated with academic centers, either did not inquire about or could not identify urological conditions in patients. Participants universally supported more focused training. Insufficient Communication Urologists were unlikely to proactively initiate the conversation about sexual health concerns with patients, primarily due to lack of time, need to focus on primary urological issues, older patient age, or the patient's low priority of sexual health. They saw merit, however, in using standardized questionnaires to facilitate discussions. Urogynecologists avoided treating sexual dysfunction to maintain a balanced surgical and clinical caseload. Sex therapists faced communication challenges with patients who normalized their symptoms or were overwhelmed by the chronicity of their condition. Integrated Care All participants considered multi-disciplinary collaboration with one another, and with gynecologists and pelvic floor physical therapists to be beneficial. Referral Dynamics All participants identified cost, insurance coverage, lack of understanding of each profession's capabilities, and patient reluctance as barriers to referral. Urologists were motivated to refer to sex therapists when they exhausted treatment options, when patients expressed interest in seeing a sex therapist, or when urologists had a trusted list of sex therapists for referrals. Sex therapists were more inclined to refer if they knew the urologist was collaborative, possessed a good bedside manner, showed interest in female sexual medicine, and had good marketing. Conclusions Participants faced personal, professional, and patient-centered obstacles when addressing the sexual concerns of women with chronic urological conditions. Future interventions should aim to mitigate these factors and promote cross-disciplinary partnership to enhance the overall quality of sexual health care. Disclosure No.

Triangulation of a Needs Assessment on High-Tone Pelvic Floor Dysfunction.

High-tone pelvic floor dysfunction is a complex condition that is challenging to manage effectively. Pelvic floor physical therapy (PFPT) is often used in the treatment and relies on a coordinated effort between the physician, patient, and physical therapist. Collaboration is crucial for therapy success, but there is limited research that includes personal perspectives from these individuals. The objective of this qualitative study was to gain further insight from these groups to identify areas for improvement in patient counseling and understanding of the diagnosis of high-tone pelvic floor dysfunction and the role of physical therapy. The following participants were recruited: urogynecologists, pelvic floor physical therapists, and patients. Semistructured interviews were conducted exploring participant experiences with therapy and management of the condition and surrounding phenomena. Participants interviewed included 5 urogynecologists, 5 pelvic floor physical therapists, and 15 patients. Similarities in key themes were identified: (1) the usefulness of pelvic models and illustrations in counseling, (2) appropriate descriptions of therapy, (3) motivating factors for patients, and (4) patient barriers to completing therapy. Several emergent themes revealed a misalignment in perspectives, including (1) patients reporting an unclear understanding of PFPT, (2) patient unawareness of the intimacy of therapy, and (3) reports of unsupportive and unempathetic physician providers. There are both similarities and discrepancies in the perspectives among physicians, pelvic floor physical therapists, and patients regarding high-tone pelvic floor dysfunction and PFPT. Acknowledging these comparisons and adapting practices could facilitate patient-centered care and improve patient understanding of their diagnosis.

Utilization of Rectal Examinations Before Magnetic Resonance Defecography Studies.

More information is needed to guide referring subspecialists on the appropriate patient evaluation before magnetic resonance defecography (MRD). This study aimed to evaluate how often health care providers perform digital rectal examination (DRE) before ordering MRD to investigate causes of bowel and pelvic floor complaints. We conducted a retrospective cohort review, including MRD performed on female patients at an integrated health care system from 2016 through 2020. The primary outcome was the presence or absence of documented rectal examination in the year before defecography by the referring provider or 6 months prior by a primary care physician or pelvic floor physical therapist. We hypothesized that the overall rate of rectal examination would be high and unaffected by the referring provider's subspecialty. Three hundred-four defecography tests were performed, with 209 patients (68.8%) referred by gastroenterology providers and 95 (31.2%) from other specialties. Gastroenterologists performed DRE in 32.8% of patients, in contrast to 84.4% of patients referred by other specialties ( P < 0.001). When comparing subspecialties that most commonly refer patients for MRD (gastroenterology, colorectal surgery and urogynecology), there was a statistically significant difference between gastroenterologists and colorectal surgeons ( P < 0.001) as well as urogynecologists ( P < 0.001) but no difference in the rate of rectal examination between colorectal surgeons and urogynecologists ( P = 1.00). At our single integrated health system, the rate of DRE before MRD testing varied significantly by specialty. Our findings highlight the need for better understanding of DRE utility in the algorithms for evaluation of bowel and pelvic floor disorders.

Interdisciplinary pain rehabilitation and sexual functioning: Treatment outcomes and patient preferences.

Sexual dysfunction is common for patients experiencing chronic pain. Prior research is limited on how treatment for chronic pain affects patients' sexual functioning. This study reports pre-/post-treatment measures of self-reported sexual functioning among individuals presenting for chronic pain treatment at an interdisciplinary pain rehabilitation program (IPRP) and reports patient treatment preferences. This study uses detailed treatment measures across multiple domains of sexual functioning to describe the prevalence and correlates of self-reported sexual functioning among individuals with chronic pain presenting for and discharging from treatment at an IPRP (N = 71). Domains include sexual interest, satisfaction with sexual functioning, vaginal lubrication, vaginal discomfort, and erectile function. Patients also completed a multiple-choice treatment preferences questionnaire created for this study. Results from this study show a high prevalence of sexual dysfunction in chronic pain populations (51.5%) and show no significant difference in sexual functioning after completing outpatient treatment, except for a significant improvement in sexual satisfaction for males only. Results from the patient treatment preferences questionnaire indicate that most patients (83.3%) thought their pain was important to address within the context of an IPRP; however, many patients (58.7%) did not think their treatment addressed sexual functioning. In addition, many patients (34%) would prefer to discuss sexual functioning with their primary care provider or pelvic floor physical therapist. Findings demonstrate that usual multidisciplinary pain management treatment is not sufficient to address patients' concerns with sexual functioning. Additional creative strategies will need to be studied on how to best treat these overlapping problems. Implications and future research directions are discussed.

(065) Let’s Talk about Sex: Resident Run Didactic Curriculum

Abstract Introduction The Council on Resident Education in Obstetrics and Gynecology (CREOG) includes sexual health learning objectives as part of the core education for Ob/Gyn training. Residents are expected to gain understanding of normal sexual function as well as common areas of sexual dysfunction. Unfortunately, several studies have demonstrated a lack of knowledge in this area by Ob/Gyn residents and that educational didactic programs are not standardized on this topic. In 2010, over 90% of post graduate year (PGY)3 and PGY4 residents reported attending fewer than 5 didactic activities on sexual function/dysfunction, with only 50% feeling able to perform a targeted physical exam. Over the past decade, there has not been substantial improvement in this subject matter. In a 2021 survey evaluating the sexual health CREOG objectives showed that more than half of Ob/Gyn residents were not able to describe the disorders of sexual function or list common medications that effect sexual function. This is not isolated to the US, with studies in other countries including Singapore and Brazil, showing residents lack formal training and residents want increased didactic time focused on sexual health. Objective Our hypothesis was that at our institution the baseline knowledge of sexual dysfunction among Ob/Gyn residents would be low. The primary objective was formulating a needs assessment through implementation of a pre/post survey with a curriculum component. The secondary objective was to determine what areas of sexual medicine are most commonly areas of confusion or where residents lack comfort in regard to patient care. Methods The resident-designed curriculum was built with collaboration from a pelvic floor physical therapist. The journal club format was based on American College of Obstetricians and Gynecologists (ACOG) Practice Bulletins, the International Society for the Study of Women’s Sexual Health (ISSWSH) clinical pearls, and the North American Menopausal Society (NAMS) position statements. The pelvic floor physical therapy component focused on pelvic pain, perinatal considerations, and incontinence. The WCG IRB deemed this study exempt. After the pre-curriculum assessment was used to identify knowledge gaps, a month of one-hour weekly sexual health sessions were implemented followed by a post-curriculum survey. Results Due to small sample size, (N=14) there was no way to establish significance in our results. In general, areas that residents were weak and the curriculum focused on were: 1) Pelvic floor/vulvar/vestibular disorders. 2) Genitourinary syndrome of menopause and vasomotor symptoms of menopause. 3) Sexual medicine disorders (hypoactive sexual desire disorder, female sexual arousal disorder, persistent genital arousal disorder, female orgasm disorders, genitopelvic pain penetration dysfunction). Conclusions The baseline knowledge of sexual dysfunction and menopausal concerns among Ob/Gyn residents was low. However, implementation of a structured curriculum after a formal needs assessment improved comfort with these topics. Now that the baseline curriculum is designed it is imperative to expand to further residency programs (in Ob/Gyn as well as other specialties) to disseminate the knowledge to providers in training who require competency in sexual health concerns. Disclosure No

(087) Why Should Pelvic Floor Physical Therapy be Included in Treatment of Vestibulodynia?

Abstract Introduction Vestibulodynia, vulvar pain localized to the vestibule without an identifiable cause, has a multifactorial etiology including neurologic, hormonal, inflammatory, psychologic, and musculoskeletal factors. Key pathophysiologic drivers likely vary from patient to patient. Published studies demonstrate that compared to controls, patients with provoked vestibulodynia are more likely to have pelvic floor hypertonicity and decreased pelvic floor strength, as measured by dynamometric speculum and ultrasound. Further, observational studies describe improvement of vestibulodynia symptoms with pelvic floor physical therapy, suggesting a causal relationship between pelvic floor hypertonicity and vestibulodynia. Objective To describe the pathophysiologic mechanism by which pelvic floor dysfunction and myofascial trigger point development could cause vestibuoldynia, with a focus on pelvic floor anatomy. Methods Literature about vestibulodynia, pelvic floor dysfunction, and pelvic floor anatomy was reviewed and synthesized in conjunction with expert clinical experience of pelvic floor physical therapists and gynecologists. Results The pelvic floor consists of the levator ani muscles (iliococcygeus, pubococcygeus, and puborectalis) and ischiococcygeus, which form a basket to support the pelvic organs. The puborectalis inserts in the posterior vestibule, and hypertonicity can cause allodynia in this region. The levator ani are innervated by the levator ani nerve, which originates from S3-S5 and traverses the visceral surface of the muscles. Some cadaveric studies suggest dual innervation of the levator ani by the pudendal nerve, which originates from S2-S4 and courses over the inferior surface of the muscles. Pelvic floor hypertonicity, increased resting tone of the pelvic floor muscles, can result from many factors including stress, bladder and rectum voiding habits, and painful pelvic processes (i.e. interstitial cystitis, endometriosis). Increased muscle tone can promote sensitization of muscle afferent fibers and neuropathic upregulation. This may be perceived as vestibulodynia because the vestibule contains visceral and somatic sensory nerve fibers, whose signals are integrated at the same spinal levels as those from the levator ani. This anatomy allows for somatovisceral convergence of afferent signals, and thus perception of vestibular pain. Hypertonicity of the pelvic floor muscles decreases circulation creating localized hypoxia that can promote development of myofascial trigger points (tender nodules) in the pelvic floor. These trigger points can cause allodynia, perceived in the vestibule. In some cases, vestibulodynia may develop first and promote pelvic floor hypertonicity. Conclusions As pelvic floor hypertonicity can contribute to the pathogenesis of vestibulodynia, it is imperative for clinicians to include pelvic floor tone evaluation in their assessment of vestibulodynia. If pelvic floor hypertonicity is present, it should be treated concurrently with vestibular pain through a combination of pelvic floor physical therapy, trigger point injections, and botulinum toxin injections as pelvic floor hypertonicity and vestibulodynia may each perpetuate the other. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Johnson &amp; Johnson.

Diagnosis, causes, and treatment of dyspareunia in postmenopausal women.

Evaluation and treatment of dyspareunia remains a significant unmet need despite the availability of safe and effective treatments. The objectives of this review are to consider evaluation techniques, the medical causes, and treatment options for dyspareunia in postmenopausal women. This narrative review used PubMed to search for English-language articles related to postmenopausal dyspareunia. Search terms included, but were not limited to, dyspareunia, genitourinary syndrome of menopause, sexual dysfunction, postmenopausal dyspareunia, posthysterectomy dyspareunia, and postcancer dyspareunia. Many postmenopausal women with dyspareunia do not discuss their symptoms with their physicians. Healthcare clinicians should broach the topic of dyspareunia with their patients using oral or written questionnaires. In addition to a thorough medical history and physical examination, various tools can be used as further assessments, including vaginal pH, vaginal dilators, imaging, vulvar biopsy, vulvoscopy and photography, the cotton swab test, sexually transmitted infection screening, and vaginitis testing. Although dyspareunia in postmenopausal women is often due to the genitourinary syndrome of menopause, other conditions can also cause dyspareunia, including hypertonic pelvic floor, hysterectomy, cancer treatment, lichen conditions, vulvar cancer, vestibulodynia, and pelvic organ prolapse. Some of the treatments discussed include lubricants, moisturizers, vaginal estrogen, ospemifene, dehydroepiandrosterone, local testosterone therapy, cannabidiol, and fractional CO 2 laser treatments. In some cases, dyspareunia may need to be specifically addressed by pelvic floor physical or sex therapists. Dyspareunia is a common issue in postmenopausal women, which remains largely untreated. Women with dyspareunia require a thorough history, targeted physical examination, and coordination of multiple disciplines including medical clinicians, pelvic floor physical therapists, and sex therapists.

To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound

BackgroundAnorectal function tests are helpful for objective investigation of anorectal (dys)function. A variety of tests are available, but there is no recommendation when to perform which test. Furthermore, which test is the most accurate is controversial and the correlation between these tests is not very clear. The aim of our study was to examine the correlation of anal pressures and the possibility to diagnose pelvic floor dyssynergia between digital rectal examination (DRE) and several anorectal function tests.MethodsBetween January 2020 and April 2022, all men and women aged 18 to 80 years, treated at the Proctos Clinic, who were referred for pelvic floor physical therapy (PFPT) by the surgeon and underwent anorectal function tests, were included. DRE was performed to establish the anal pressure at rest and during squeeze and straining. Anorectal function tests included 3D high-resolution anal manometry (3D-HRAM), balloon expulsion test (BET), transperineal ultrasound (TPUS), and surface electromyography (s-EMG).ResultsA total of 50 patients, 37 (74%) females, were included. Median age was 51 years. Twenty-three (62%) females had a history of two or more vaginal deliveries. The most frequent reason for referral for PFPT was fecal incontinence in 27 (54%) patients. The assessed pressures and pelvic floor function measured with DRE by the surgeon and the pelvic floor physical therapist during rest, squeeze, and straining correlated in 78%, 78%, and 84%, respectively. Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures. The correlation between s-EMG and 3D-HRAM was better during squeeze than at rest with an agreement of 59% and 37%, respectively.ConclusionDRE by an experienced investigator is of sufficient value for daily clinical practice to detect dyssynergia and to measure sphincter tone. Commonly performed anorectal function tests correlate poorly with DRE and with other anorectal function tests. When conservative treatment fails, further investigation is warranted; however, these results should be interpreted with caution.What does this paper add to the literature?Anorectal function tests such as the 3D high-resolution anorectal manometry, balloon expulsion test, surface electromyography, and transperineal ultrasound are all frequently performed in the diagnostic workup in patients with defecation disorders. No previous study has compared these tests regarding their outcomes, nor has the interrater agreement been measured regarding the digital rectal examination by two experienced observers. Furthermore, transperineal ultrasound is in all probability not frequently used and therefore underexposed in the diagnostic workup of patients with dyssynergic defecation.

Management of Sexual Dysfunction in Gastrointestinal Disorders.

Patients with gastrointestinal (GI) disorders are at increased risk of sexual dysfunction (SD) due to a combination of biomedical, psychological, social, and interpersonal factors. While most patients desire information on the impact of their GI disorder on sexual function, few providers initiate this conversation. GI providers should routinely assess their patients for SD, validate these concerns, and provide brief education and a referral for evaluation and/or treatment. Treatment of sexual concerns is often multidisciplinary and may involve a sexual medicine physician, pelvic floor physical therapists, and sex therapists.

Sexual Dysfunction in Female Patients with Inflammatory Bowel Disease: An Overview.

Sexual dysfunction is common among females with inflammatory bowel disease and may result in issues involving intimacy, sexual activity, and satisfaction, as well both the formation and preservation of personal relationships. Risk factors for sexual dysfunction include select surgical interventions, medications, mental illnesses, and IBD-related intestinal and extraintestinal comorbidities. In addition, certain demographic factors such as age, disease type and activity may influence the severity of sexual dysfunction. Evaluation of sexual dysfunction may include the use of validated sexual functioning questionnaires, a brief mental health assessment, initial inquiry into vulvovaginal or perineal symptoms, and a gynecologic and GI-focused physical exam. An interdisciplinary care team involving IBD specialists, obstetrician-gynecologists, pelvic floor physical therapists, and primary care physicians may be best suited to provide optimal care and treatment recommendations for patients with sexual dysfunction. Options for management often include pelvic floor physical therapy, biofeedback, and mental health support. Further research is necessary to delineate the impact of IBD activity on sexual dysfunction, to determine if health outcome differences exist depending on surgical approaches utilized during J-pouch operations, and finally to evaluate the care and perceptions of patients with IBD who identify as sexual and gender minorities.

Empiric Pelvic Rehabilitation Delivered by Pelvic Floor Physical Therapists as an Up-Front Treatment for Chronic Constipation

Pelvic rehabilitation therapy is a recognized treatment for chronic constipation that aims to improve defecatory mechanics.1 Unlike treatment refractory patients for whom appropriateness of intensive biofeedback depends on the presence of dyssynergia, we recently reported that outcomes with biofeedback-based pelvic rehabilitation do not appear to depend on dyssynergic defecation in treatment-naive populations seeking gastroenterology care who fail a simple trial of osmotic laxative or soluble fiber.

Medicare Patient Referral Networks to Pelvic Floor Physical Therapy Across the United States.

The purpose of this study is to evaluate the distribution of referrals to pelvic floor physical therapy throughout the United States and to identify specialties with the highest and lowest referral rates. Referral networks to pelvic floor physical therapy were identified, and factors associated with referral connections were determined. This retrospective network analysis of referrals examined U.S. Centers for Medicare and Medicaid Services data from 2009 to 2017. Pelvic floor physical therapists were identified, and their patient-sharing networks were modeled using social network analytics. There were 18,740 Medicare beneficiaries referred to pelvic floor physical therapists between 2009 and 2017. The mean number of referrals to each physical therapy provider or practice was 82 (SD ±46.3). Half of the referrals were made by a general acute care hospital. The remainder were referred by female pelvic medicine and reconstructive surgeons, nurse practitioners, colorectal surgeons, internal medicine, and obstetrician-gynecologists.The number of individual pelvic floor physical therapists, as well as the referrals, increased each year. The geographic representation of the patient referral networks is illustrated. The map reveals that pelvic floor physical therapists often work in groups and treat patients in their geographic vicinity. In this study, we demonstrate intensely fractured referral networks. Our network analysis of pelvic floor physical therapy referrals in Medicare patients across the United States shows fractured networks with dense geographic connections in some areas, whereas sparse in others. Multidisciplinary approaches and early referrals to pelvic floor physical therapy are recommended as some ways to amend these fractured networks.

Multidisciplinary evaluation of chronic pelvic pain patients increases compliance with pelvic floor physical therapy

Pelvic floor physical therapy (PFPT) is widely accepted as a first line therapy for pelvic floor dysfunction. Despite studies demonstrating a 50-90% improvement in pelvic pain in women undergoing PFPT, adherence and follow up with PFPT is poor. The primary aim of this study was to evaluate whether the presence of a pelvic floor physical therapist at the initial consultation for chronic pelvic pain (CPP) resulted in greater compliance with PFPT. Secondary aims evaluated patient characteristics and provider practice patterns. We performed a retrospective chart review of all patients evaluated for CPP from June 2019- June 2020 in both a CPP multidisciplinary center as well as a traditional gynecology office. In both settings, patients were evaluated by fellowship-trained minimally invasive gynecologic surgeon. At the multidisciplinary center, patients were evaluated by the same surgeons, in addition to a pelvic floor physical therapist. Descriptive analyses compared patients who were referred to, attended, and completed PFPT, stratified by whether they saw PFPT the same day as their initial consultation. Kruskal-Wallis test or Pearson's chi-square test were used to determine whether distributions of continuous or categorical variables differed by clinics. 556 patients included in this study, 172 (31%) were seen in the CPP multidisciplinary center and 384 were seen in the traditional gynecology office. A total of 177 (32%) were referred to PFPT. A greater percentage of referrals were made from those patients in the CPP center (n=86;50%) as compared to the traditional office (n=91; 24%). Patients seen by a PFPT at the initial evaluation in the multidisciplinary center were more likely to complete at least one PFPT visit (n=57; 66%) when compared to those seen in a traditional gynecology clinic (n=26;29%, p <0.001). Patients seen in the multidisciplinary center who were also seen by PFPT at the time of referral had more PFPT visits on average as compared to those patients when referred from the traditional office (5.8 vs 2.0 respectively; p<0.001). A multidisciplinary approach to CPP increases the number of patients who establish care with PFPT. Future studies should focus on developing interventions to increase compliance to prescribed physical therapy regimens.

Impact on pelvic floor in post covid–Phase: Review

Background and Introduction: Pelvic floor therapist understands that both respiratory dysfunction and hospitalization can have an impact on pelvic floor function. The long term effects of Covid -19 could affect the pelvic floor as well as some generalized treatment consideration. Stress &anxiety leads to pelvic floor dysfunction. Objective: The aim of this study is to cognize the role of physiotherapy & the impact of COVID-19 on pelvic floor. Methodology: Relevant articles were identified by searching from: PuBMed, Science Direct, Ebsco, SCOPUS, Web of Science, shodhganga, Elsevier, Google Scholar, academia. Four scientific studies were found related to impact on pelvic floor in post covid – phase. Results: More than 10 recent articles are on pelvic floor in which 04 articles are matched with impact on pelvic floor in post covid – phase. Physiotherapy supervision includes exercises which have demonstrated to have a great efficacy on protocol of Pelvic floor – like Keagel & bridging exercise. Conclusion: Pelvic floor muscle has been dramatically affected by the covid-19 outbreak. Because of the pervasive nature of this virus, pelvic floor physical therapist should be a part of the rehabilitation team treating these patients once they have become medically stable.

The effects of a brief mindfulness-based intervention on pain perceptions in patients with chronic pelvic pain: A case series

IntroductionChronic pelvic pain affects 15–20% of women, and patients frequently do not find relief with first-line therapies. Mindfulness-based meditation programs are effective in improving outcomes for patients with chronic pain conditions, but limited data exists for patients with chronic pelvic pain. We describe the effect of a brief mindfulness-based program, incorporated into pelvic-floor physical therapy visits, on perceived pain in patients with chronic pelvic pain.Case seriesPatients being treated for pelvic pain participated in this 8-week program. Pelvic-floor physical therapists delivered a brief mindfulness-based exercise during routine physical therapy visits. Patients reported pain scores and pain catastrophizing scores at the beginning and end of the program. Ten patients completed the program. Paired-samples t-tests showed that pain catastrophizing significantly decreased from baseline to 8 weeks in patients who completed the mindfulness training and increased among patients who withdrew.ConclusionMindfulness-based exercises may be a useful complementary therapy for the treatment of chronic pelvic pain.

Diagnosing Constipation Spectrum Disorders in a Primary Care Setting.

Understanding pathophysiological causes of constipation is worthwhile in directing therapy and improving symptoms. This review aims to identify and fill gaps in the understanding of the pathophysiology of constipation, understand its prevalence, review diagnostic tools available to primary care physicians (PCPs), and highlight patients’ expectations for the management of this common spectrum of disorders. Literature searches conducted via PubMed included terms related to constipation, diagnosis, and patient perceptions. Case studies were developed to highlight the differences between patients who may be appropriately managed in the primary care setting and those requiring specialty consultation. Myriad pathophysiological factors may contribute to constipation, including stool consistency, altered intestinal motility, gut microbiome, anorectal abnormalities, as well as behavioral and psychological factors. Common diagnoses of “primary constipation” include slow-transit constipation, defecation disorders, irritable bowel syndrome with constipation, and chronic idiopathic constipation. A detailed medical history should be conducted to exclude alarm features and PCPs should be familiar with pathophysiological factors that cause constipation, available diagnostic tools, alarm signs, and the various classification criteria for constipation subtypes in order to diagnose and treat patients accordingly. PCPs should understand when a referral to a gastroenterologist, anorectal specialist, pelvic floor physical therapist, and/or mental health specialist is appropriate.

Pelvic Floor Considerations in COVID-19.

Much of the research and clinical commentary on COVID-19 have been focused on respiratory function. Pelvic floor therapists understand that both respiratory dysfunction and hospitalization can have an impact on pelvic floor function. This clinical commentary provides context as to how the long-term effects of COVID-19 could affect the pelvic floor as well as some generalized treatment considerations. The respiratory diaphragm has an impact on the ability of the pelvic floor to contract and relax in a manner that will allow for both continence and elimination. COVID-19 survivors often have disability in this muscle of respiration that can lead to implications for both overactive and underactive pelvic floor. Commonly, this population is hospitalized for long periods of time, which can have long-term consequences on both bladder and bowel functioning including, but not limited to, incontinence, urinary retention, and constipation. Pelvic floor therapists must be prepared to adjust both their evaluation and treatment methods in consideration of this novel treatment population. Because of the pervasive nature of this virus, pelvic floor physical therapists should be a part of the rehabilitation team treating these patients once they have become medically stable.Video abstract with sound available at http://links.lww.com/JWHPT/A36.

Subspecialty care for peripartum pelvic floor disorders

Obstetrical perineal and anal sphincter lacerations can be associated with considerable sequelae. The diagnosis of short-term bowel, bladder, and healing problems can be delayed if patients are not seen until the traditional postpartum visit at 4 to 6 weeks. Specialized peripartum clinics create a unique opportunity to collaborate with obstetrical specialists to provide early, individualized care for patients experiencing a variety of pelvic floor issues during pregnancy and in the postpartum period. Although implementation of these clinics requires thoughtful planning and partnering with care providers at all levels in the obstetrics care system, many of the necessary resources are available in routine gynecologic practice. Using a multidisciplinary approach with pelvic floor physical therapists, nurses, advanced practice providers, and other specialists is important for the success of this service line and enhances the level of care provided. Overall, these clinics provide a structured means by which pregnant and postpartum women with pelvic floor symptoms can receive specialized counseling and treatment.

Novel insight into the coordination between pelvic floor muscles and the glottis through ultrasound imaging: a pilot study.

Pelvic floor physical therapists have long utilized breathing cues with exercises and are beginning to incorporate vocalization tasks. To date, there have been no publications describing pelvic floor displacement during vocalization tasks. This study is a preliminary investigation into the changes in bladder shape distortion as a proxy for pelvic floor muscle displacement during respiratory and phonatory tasks. Bladders were imaged using two-dimensional ultrasound in standing position. Measurement consisted of a diagonal line from the most anterior-superior aspect of the bladder to the most inferior-posterior aspect of the bladder. Length was measured at baseline and maximum distortion for each task. The first two tasks cued pelvic floor muscles to contract and then strain. Subsequent tasks only cued glottis function. A linear regression tested correlation between bladder distortion response to glottis tasks and cued pelvic floor tasks. The hypothesis was that diagonal would shorten with contraction, lengthen with strain, and follow a similar pattern seen in respiration for phonation tasks. Ten asymptomatic participants (5 men, 5 women) showed bladder diagonal shortening when cuing pelvic floor contraction for all participants and lengthening for 7 of the 10 participants when cued to strain the pelvic floor. The response of bladder length change was variable for glottis tasks, trending toward lengthening and significantly different in response to contraction. When cuing pelvic floor to contract, healthy individuals showed shortening of bladder length and most lengthened during strain. When cuing phonation and respiration tasks, there was a tendency toward bladder lengthening.