Pelvic Floor Dysfunction and Interstitial Cystitis
Like many things connected in some way to Interstitial Cystitis, Pelvic Floor Dysfunction or “PFD” (which is occasionally also referred to as vaginismus, and prostatodynia in men) is difficult to readily define, or to find agreeable epidemiological statistics for. Even more intricate though is living with this (frequently) chronic condition.
Background
Pelvic Floor Dysfunction is believed to affect at least 70 percent of the Interstitial Cystitis population, though some experts in this area believe that all IC patients have PFD to some extent. Pelvic Floor Dysfunction is not limited to IC patients, it can occur separately from any other (seemingly) relevant conditions. As well PFD can often accompany many other conditions such as Vulvodynia and Irritable Bowel Syndrome. PFD can also occur as a result of an injury or trauma to the pelvic floor muscles themselves (such as child birth, surgery like a appendectomy, laparoscopy or hysterectomy) or due to an accident such involving a car wreck, horseback riding, fall, impact injury, sports injury or bicycle mishap.
The question as to which came first PFD or IC is something that will likely be debated well into the future, as there seems to be many cases of both (IC first or PFD first, with a later development of the other). As well it is possible that both IC and PFD started at the same time for some patients. IC expert and author Doctor Robert Moldwin wisely points out that, “often some of the most pronounced symptoms of IC derive from abnormal muscle activity in this (the pelvic muscle) region, rather than the bladder”. That is an amazing statement if you think about it because it gives way to the idea that muscle activity is playing a profound role in the behaviour of IC symptoms.
Symptoms
Coincidently (or perhaps not) if we look at the hallmark symptoms of Pelvic Floor Dysfunction many of them are remarkably similar to those of Interstitial Cystitis. Key PFD symptoms include lower back pain, urinary frequency, urinary urgency, a sense of incomplete urination (feeling like even after you void there is still “more to come out” yet you cannot pass any more urine at that time), pelvic pain, pelvic pain during sex, pain in the vagina (often the back), pain in the penis and testicles, constipation and or other bowel symptoms (especially in IC patients with Irritable Bowel Syndrome), decreased urine flow, an inability to pass urine (urinary retention, which if prolonged requires immediate medical attention), and a sense of tight or twitchy pelvic floor muscles. For males with pelvic floor problems some of the main symptoms are a feeling of pain or burning in the perineum, pain upon ejaculation, lower back pain, decreased urine flow and urgency. It is immediately evident that many, if not all of those symptoms are ones that are frequently described by Interstitial Cystitis patients. Is this a coincidence, or is it that all those with IC really do all have PFD to some extent? It’s hard to guess, given that an exact cause of IC is thus far unknown. But if you are experiencing any of these symptoms it is worth investigating them further.
Not only do the pelvic floor muscles play a role in IC, they can also be a factor in (or be responsible) for a myriad of other serious medical conditions such as urinary incontinence. In short urinary incontinence is superfluous urine leakage, over which the person experiencing incontinence has little or no control. Incontinence is in many ways the opposite of what happens when the majority of IC patients have pelvic floor muscle problems. With incontinence the pelvic muscles become too “relaxed”. Yet in the type of PFD most often associated with IC the pelvic muscles are too tight or tense and constricted. Frustratingly some ICers even experience both over-activity and under-activity of their pelvic muscles. Other conditions that can occur due to pelvic floor muscles problems are rectocoele (a condition wherein a portion of the rectum protrudes into the vagina, this may go completely unnoticed by the patient, with constipation being one of the only telltale signs), cystocoele (similar to rectocoele, except that in this instance it is the bladder which drops or slides into the vagina), and both rectal and vaginal prolapse. In a rectal prolapse the rectum itself actually protrudes from the anus, generally a very painful condition. Vaginal prolapse is where the interior of the vagina actually protrudes from the vaginal opening; both require medical attention.
A very common sign of Pelvic Floor Dysfunction is having a poor or weak urine stream. The flow of urine may be slower or weaker than what is usual for the patient. Or it may stop and start, puttering out in little amounts until the bladder is (seemingly) empty (the pelvic floor muscles are supposed to relax while the bladder contracts and voids). Thusly a vicious cycle is born. Instinctually the ICer feels that he or she has to push in order to void entirely, yet at the same time the pelvic floor muscles are trying to hold in the urine (contracting and tightening in order to keep the urine from escaping as it should). This “war” between the bladder and the pelvic floor muscles then results in a poor stream, skittish urine flow (it stops and starts) and in some cases a lag time between when the ICer attempts to void and when they actually begin to pass urine.
This can be nerve wracking for the patient, and leave them wondering if in fact they really did void completely. Consequently they may return to the washroom shortly (or repeatedly) in an attempt to try and void out the last little bit that they feel is still inside their bladder. It is possible that due to pelvic floor muscle problems they are in fact retaining some urine, and that this is what they feel instead of a “phantom” amount of urine that does not really exist (yet feels as though it does). There again straining and pushing excessively in order to try and strain out a few drops of urine occurs. Experts agree that this is one of the worst things you can possible do (excessive straining or pushing) as it can lead to even more spasticity in of the pelvic muscles, as well as often causing highly increased levels of associated pain. Yet it can become almost unavoidable for those with pelvic floor muscle problems if they are to void at all in a semi-normal manner. Interestingly some ICers who experience these symptoms find that if they are catheterized (thusly bypassing the conscious effort of urinating) these symptoms all but vanish. (For others catheterization is almost impossible due to associated pain.) This gives weight to the evidence that the pelvic floor muscles are in fact causing the weak urine stream and other related PFD complications.
An interesting factor that is seen in some cases is that the symptoms of Pelvic Floor Dysfunction began after a urinary tract, urethral or bladder infection (or a series of infections, known as recurrent infections). This may result from the fact when these sorts of infects set in the patient is more prone to push and strain in order to void, as they are voiding significantly more than their normal level, and as it may feel like they are not emptying their bladder. Even when the infection has been treated and appears on tests to be gone, the patient may still have what is referred to as dysfunctional voiding. In essence abnormal/dysfunctional voiding means that you are no longer (for whatever reason) voiding in a normal way (wherein you would not have to strain to void, not be voiding more than the usual number of time per day, not feel pain before, during or after urination, etc).
When this occurs the patient may push and strain to void or void all the time (frequency) as it feels that their bladder is not emptying entirely. These affects can lead to tightening of the pelvic floor muscles. Dysfunctional voiding can start a downward spiral of both IC symptoms and/or PFD symptoms. Yet in many cases it seems to be almost unavoidable as it is difficult to predict the way in which each person’s pelvic floor will react to an UTI (and/or the development of IC which almost always causes some level of abnormal voiding due to the sheer nature of its symptoms). What helps little is that these two things (UTIs and/or subsequent PFD symptoms) may precede the onset of IC entirely, or may occur after the first symptoms and or diagnosis of IC. However in the non-IC general population urinary tract infections are thought to be a leading cause behind the development of pelvic floor dysfunction.
Other reasons for pelvic pain
It is important to point out that not all pelvic pain is a result of Pelvic Floor Dysfunction. In fact dozens of different medical conditions, diseases and injuries can cause serious and often chronic pelvic pain. Pelvic pain is not a normal thing to feel at any time, and should always be brought to the attention of your doctor (and/or gynaecologist or urologist).
While at the same time it’s wise to know that muscles are not the only part of the body that can contribute to some types of pelvic pain and pelvic floor problems. For example misalignment of the sacroiliac joint (which is made up of the sacral bone encompassed by two iliac bones) can inhibit the normal function of the pelvic floor muscles. Joint alignment can occur if the soft tissue (such as the anterior muscle) surrounding the sacroiliac joint has caused one of the iliac bones to move forward. In turn this causes the posterior muscles to grow weak and may cause pain. Only proper testing can determine if the soft tissues are at fault for sacroiliac joint pain. Treatment of this problem is often geared towards hands on therapy that aims to help stretch and lengthen the short, weak muscles.
What is Pelvic Floor Dysfunction?
So what exactly is this somewhat mysterious condition that so many are affected by? Again there appears to be a bit of leeway in this description depending on whom you are talking with or what you are reading, but in short PFD means that you are experiencing spasms (spasticity) in you pelvic floor muscles. This likely comes from the fact that your pelvic floor muscles are some of the only skeletal muscles where you have electrical activity at all times. This is because the electrical activity helps to keep us from being incontinent (both fecal and urinary).
PFD may occur as a result of too much electrical activity in your pelvic floor region. In order to combat the affects of excess electrical activity many physicians recommend that the patient try a procedure call biofeedback, which we will discuss later on in this article. What this technique and others like Kegel exercises aim to accomplish is a marked reduction in excess electrical activity in your pelvic (muscle) region. (Pelvic Floor Dysfunction is considered a non-neurogenic condition. In other words it is not like multiple sclerosis or Parkinson’s Disease. With PFD the person has no (obvious) related neurological condition.)
The role of pelvic floor muscles
The pelvic floor muscles are an integral part of our structure. They are attached to the back, sides and front of sacrum and spine. On top of the lay the bladder and other organs (rectum, prostate, uterus) located in the pelvis. They pelvic muscles work like a hammock or sling to support the bladder and pelvic contents. In addition the pelvic floor muscles enfold the vagina, rectum and urethra.
They are highly complex muscles that we often take for granted. Yet without them we would not be able to control our bowels or bladder, and have what we would consider normal sexual activity. They help us to control our urine stream, empty the bladder, control urinary urgency and frequency, ward off constipation, and have pain-free sex (assuming one does not have any other medical issues that would cause painful sex). When the normal function of the pelvic floor muscles are impaired many of the symptoms mentioned above can occur. Bladder and bowel functioning is directly controlled by how our pelvic floor muscles are working. When they become distressed (injured, etc) we can have trouble having a bowel movement (so hence the common PFD symptom of constipation), properly voiding and having comfortable intercourse.
Instead of being “soft” and tender (almost malleable, if you will) PFD muscles are usually very tight, stiff and compact (short), this is clinically referred to as “hypertonus”. Bands of taught muscle can be felt running through the muscles in some cases; these have been likened to the strings on a guitar. Examination of the pelvic floor muscles is often very painful (for both sexes). The patient may feel many different forms of pain such as a stabbing, jolt-like or burning feeling when certain areas of their pelvic floor muscles are touched or stimulated. Areas that are more prone to sensitivity (pain) are referred to as “tender points”, a term that is also used in a number of other muscular skeletal conditions like fibromyalgia. While some doctors and physiotherapists aim to treat PFD through muscle control (such as with physiotherapy, biofeedback and at home pelvic floor exercises), others believe that (firstly) you have to locate and try to help heal the specific pelvic muscle tender points. This may be done through tender point specific treatments (muscle relaxants, tender point injections, physical therapy, etc).
When and where these pelvic floor muscle changes began to happen to a patient’s pelvic floor muscles also seems to be a variable. In some they appear to stretch back to childhood, for others it may have started with an infection, injury, trauma, giving birth, related medical condition(s) or surgery, pelvic inflammation, and for others (just as with IC) they can not per se pinpoint when their PFD problems arose or what may have triggered them.
The pelvic floor muscles are comprised of a diverse group of different muscles, each one with it’s own purpose, yet they also work together as a collective. The main muscular trigger points in PFD patients are the coccygeus muscles, the levator ani and the sphincter ani. As well the pelvic muscles primarily belong to two groups, one relating to hip-joint muscles and one to pelvic muscles. Key muscles in your pelvic region, hip and buttock region are:
-Sphincter ani (also known as internal anal sphincter): This is the muscle that encases the anus; it is the sphincter muscle of the anus/rectum. This muscle helps in the normal expulsion of stool. Damage (typically serve damage) to this muscle can lead to anal incontinence.
-Levator ani: A broad, thin muscle that increases the amount of intra-abdominal and pelvic pressure when you are having a bowel movement or staining your pelvic muscles in general (such as whilst making love). It is attached to the inner surface of the “lesser” pelvis, and joins up with the same muscle on the other side of the body to form the vast majority of the floor of the pelvic cavity. The Levator ani is supplied by a division from the fourth sacral nerve and by a branch that is sometimes derived from the perineal, and sometimes from the inferior hemorrhoidal division of the pudendal nerve. Problems with this muscle in particular may lead back to why so many with PFD experience bowel/constipation related problems, as well as related pudendal nerve issues.
-Coccygeus (also known as the pubococcygeus muscle or PC muscle): A primary muscle that is connected to the tailbone. It helps to form the pelvic floor and support the pelvic organs. As well it is critical in the control of urine, and aids in childbirth for women. Some people feel that a “well toned” PC muscle can aid in better sex. Perhaps because of the range of control you have over the muscle.
-Piriformis: A muscle that lies partially in the pelvis and partially at the back of the hip joint, under the buttock and connects to the top of the thigh and the bottom of the sacrum (a triangular shaped bone at the back of the pelvis). It helps to rotate the hips and support the pelvic floor muscles. (A neat fact, in Latin Piriformis means, “pear shaped”.)
-Oburator internus: another hip rotation muscle located partially in at the back of the hip joint and partially in the pelvis, it helps to stabilise the hip while rotating and to help turn the femur bone.
-Gluteus medius: Buttock muscles (the gluteus medius is one of three muscles in each of the buttocks, with its origins in the ilium) that help to control (“work”) the hip joint, and rotation of the thigh (femur). They are largely responsible for keeping you stable while walking and moving your legs (running, swimming, etc).
-Gluteus maximus: Probably the most well known muscle in the pelvic region (having become something of an acronym for one’s bottom side). This critical muscle ties into the ilium, the sitz bone, and the top of the thigh (the “trochanter”), the sacrum, the coccyx and the hip rotators. It relates largely to proper body posture, climbing and running. It is the largest of the three gluteus muscles (the gluteus minimus and gluteus medius being the other two). These muscles can be strengthened as such as through some types of weight training, though in the case of PFD this is not usually a good way to go. As excessively harsh exercises may do far more harm then good to the surrounding and adjacent pelvic floor muscles.
-Iliospoas (also known as the psoas muscle): This long muscle extends from the bottom rib to the lumbar (loin) region of the spine to the sacroiliac joint, as well as running along the edge of the pelvic region and attaching to the front of the hip and the pubic bone. The psoas muscle helps the body to raise up from any position that is not one where you are standing erect.
With so many muscles, serving so many purposes it is understandable that one or more can easily become affected by PDS. Whether this is (PFD) purely the result of trigger/tender points or an excess of electrical activity – or both – remains something of a mystery at this point in time. However, there are treatments, both low key and involved that may bring some relief.
Pelvic muscle trigger points
The tender points that occur in Pelvic Floor Dysfunction are very similar to those found in fibromyalgia (FMS) patients and myofascial patients. “Tender points” are areas of the skin (surface level/external) or internal locations that when pressed or stimulated in a way that would not normally hurt someone causes the patient to feel discomfort, but not out-and-out pain (this is referred to as hypersensitivity). Trigger points are the same except that they are areas where the discomfort level rises to painful, if not down right agonizing. Again when and how these points developed can vary greatly. It has been found that if one tender point (say an arm muscle) is worked too hard it can lead to subsequent trigger or tender points. In the case of FMS these often spread through out the entire body, causing high levels of pain, fatigue and other symptoms. The same thing can happen on a smaller level to the pelvis floor muscles, in other words the entire pelvic muscular region can become littered with trigger and tender points.
Interestingly (and somewhat bafflingly for doctors and researchers, not to mention the patients themselves) trigger and tender points can be active or dormant. An active trigger point is painful to some degree pretty much all the time as the pain comes from a distal site. Wherein a dormant trigger point (which can become active over time) is not sensitive until it is touched/pressure is applied, and it is these points which often lead to pelvic floor muscle (and other muscular in the case of FMS, etc) shortening. These tender points are thought to be entirely responsible for PFD by some clinicians and partly to blame by others. Thusly whom you see for treatment can have a lot to do with what sort of PFD treatment you are started with.
Diagnosing Pelvic Floor Dysfunction
In order to properly diagnosis pelvic floor dysfunction the patient needs to be examined physically, ideally by someone who is an expert in the field of PFD. The examiner should look at your medical history. For example do you have IC or IBS? And/or a history of reoccurring urinary tract infections? Have you had children? Do you have pain with intercourse? Where is your pain located? By gently using hands-on techniques the assessor will try to evaluate the functionality of the pelvic floor muscles and (often) try to locate tender points. As well muscle control can be assessed with certain devices, some of which may include internal probes or parts (that are placed in the rectum or vagina) – things that many with IC, vulva/vaginal conditions, gastrointestinal problems such as IBS and PFD in general may find excruciatingly painful. When internal examination is out of the question electrodes can be placed on the sacrum and/or perineum. A device then attached to the electrodes than sends signals to a machine that records your ability (or lack of ability) to contract and relax your pelvic floor muscles.
Some physicians also perform an uroflow test that determines the mechanics of a person’s urine flow (how fast is the stream, how much is voided, what the strength of the urine stream is, etc). Depending on what is found the doctor may subsequently (after voiding is complete) perform a type of ultrasound called a bladder scan that goes over the top of the pubic bone. This neat test shows how much urine is in truth residually left in the bladder after the patient voids. This is a critical point, as many with PFD do not actually empty their bladders entirely when they void (the remaining volume can vary from a few drops to more than a hundred millilitres).
If the patient is found to have pelvic floor muscle problems than it is critical that attention be placed on to those symptoms. As well as treating your bladder (in other words focusing on the IC aspect of the equation), you will need to begin some form of pelvic floor muscle therapy.
Pelvic Floor Dysfunction treatment options
Before treatment commences though it is crucial that the patient (ICer) has been fully evaluated, and examined. Things like constipation, and bladder pain/symptoms need to be equally addressed. Pelvic floor treatments are not (usually) a singular substitute for IC treatments like oral and instilled medications, diet modification, life style changes and stress reduction, and other important treatment options. On the contrary, assuming that one or more of these sorts of treatment options is working for someone, they will be like a boost towards helping the pelvic floor treatment, because the bladder may be less agitated (hypersensitive) and in a somewhat healthier state.
As well it’s important to know that just as with IC alone, PFD can seem to wax and wane in terms of pain and symptoms. ICers may even experience Pelvic Floor Dysfunction flares, brought on by so many of the things that trigger IC (sex, sitting for extensive amounts of time, certain physical activities, etc). How much of the flare is IC and how much is PFD is hard to say, what we do know is that a PFD flare can revert the pelvic floor muscles back to a rougher shape, and require starting PFD treatment, if it has been stopped due to positive results. This is usually only temporary though, and the lost ground can be recovered. Many with PFD use ongoing forms of treatment, even after their symptoms lessen (if this occurs), as both a preventative measure and a way to help their bladders (IC), and potentially other overlapping conditions too (like IBS).
Almost universally the first key point on the road to treatment is to stop straining when you urinate. But this can be so much easier said than done. Relaxing the pelvic floor muscles (assuming that they are too tight/stiff) in IC patients is critical. You want to begin to relax the muscles and reduce putting undo stress on them. Methods by which to do this can start at home and/or (often) incorporate treatment in a clinical setting.
(Please note that the majority of experts unanimously agree that you should not stop and start the flow of your urine - a technique that is some times recommended in bladder retraining procedures and to help locate your Kegel muscles - by conscious choice, as this can do further damage to your pelvic floor muscles.)
Clinical methods of treating Pelvic Floor Dysfunction
-Physical therapy. In terms of PFD and physical therapy the aim is to help stabilize (steady) the bones and muscles of the pelvic floor as well as the hips, sacroiliac joint, and lower back. A psychical therapist should check for things like tender/trigger points, muscle spasming, muscle weakness or stiffness and joint misalignment. Three types of physical therapy treatment options are as follows:
-Lengthen and stretch the pelvic floor muscles through manual therapy. In order to work properly the pelvic floor muscles need to be a proper length (this will vary from a patient to patient). Procedures like internal manual therapy can aid in releasing trigger points, connective tissue tension and even neural tension.
Internal massage involves have a trained physical therapist gently massage the perineum or vaginal area internally, he or she may be looking for trigger points which can be felt as the muscle in the area(s) that are affected by trigger points will be twitching or contracting abnormally. If trigger spots are located the therapist may gently apply pressure to the area after messaging the spot in a circle, this is called “Thiele stripping”. This is done vaginally for women and anally for men (though in theory a woman could undergo anal internal massage as well). Sessions are often frequent, especially during the initial stages of treatment, and then taper off slowly as progress is achieved. If manual therapy is not possible initially than the therapist may start with external muscular massage. In both cases it may take time to se results but they will usually always occur to some helpful degree.
-Stimulating the pelvic floor muscles electronically. By inserting a small (dildo-like) probe internally (anally for men, vaginally for women) the therapist administers electrical current to the muscles. This kind of therapy is helpful in calming muscles spasms, and reducing and relaxing associated pain. However electronic stimulation cannot cause the pelvic floor muscles to involuntarily contract and relax. For some people this type of treatment is too painful, and in these cases a home unit like a TENS device (see below) may be more beneficial as it uses electrical current that is delivered externally rather than internally. Some home units also come with a probe device so that patients can administer internal therapy themselves, outside of the physical therapists office.
-Eliminating pelvic floor muscle trigger points and connective (pelvic and adjacent) tissue problems. This is typically done via hands on tissue and trigger (and/or tender) manipulation (massage) and release, also known as pelvic floor tissue release. As well some employee the use of specific acupuncture methods and trigger point injections (such as the drug Marcaine). As with internal manual therapy pain should not arise after the treatment session, you want to feel better not worse off then when you began the treatment session. If pain is occurring post session this needs to be brought to the attention of the physical therapist who is performing these techniques.
- Specific musculoskeletal treatments like chiropractic work and myofascial physiotherapy.
-Biofeedback is one of the most commonly used forms of pelvic floor therapy. Biofeedback is essentially a technique wherein patients can monitor their own muscle activity. Biofeedback is done by inserting a probe vaginally or anally, or places electrodes on the sacrum (or perineum). The probe or electrodes are connected to a computer monitor or are heard through an audio device (this is becoming less common in an office setting, and is now often used just for home biofeedback devices). The visual and/or audio patterns that are seen/felt help the patient to learn which regions (areas) of their muscles are being affected by PFD. By locating and learning which muscles are responsible the patient can (ideally) begin to learn how to contract and relax these trouble areas on a conscious level. In doing this they can decrease PFD symptoms because they learn to relax taught and hypersensitive muscles. This usually has far-reaching, positive benefits on the person’s IC as well, and in some cases Vulvodynia and IBS too, if applicable. It usually takes between one and three months before improvement begins to be seen.
Biofeedback units can also be used at home with a portable version, however these can be costly, and few insurance companies will pick up the tab. If you are interested in this it is a good idea to first undergo some biofeedback work with a therapist and then (or in conjunction with) more on to a home unit.
The theory behind biofeedback (and to a certain extent other techniques) is to reduce the amount of excess electrical activity going on in the pelvic floor area. It is thought that through understanding and targeting muscle contraction you can ultimately (best) relax the pelvic floor muscles. Relaxation will in turn lead to less PFD symptoms, as the muscles will no longer be tightening and stiffing unduly, as you know know (recognize) how to stop them from doing so (via biofeedback).
Interestingly some doctors and therapists feel that biofeedback alone will not “cure” a patient of biofeedback, as they feel trigger points (especially lower back trigger and tender points) would still exist and need to be appropriately dealt with.
Home methods of treating Pelvic Floor Dysfunction
-Taking warm baths. It is recommended that patients take short, warm baths (1-2 a day usually) in order to help relax their pelvic floor muscles. Think of this much like applying heat to a sore or strained muscle. Not only will this help the pelvic floor muscles but it can also aid in reducing accompanying inflammation of the bladder/pelvic/lower abdominal area. It may take a while for any improvement to be noticed but after a few weeks the majority of PFD patients begin to see a difference.
If a full bath is not possible (say for example if you do not have a tub) a sitz bath may help. However showers are not considered to be as affective as either sitz or full tub bathes, as they do not immerse the pelvic region directly in warm water.
It is worth noting that for some with vulva conditions baths may provoke and irritate their symptoms to a level that makes bathing impossible. In cases such as this it is probably best to forgo the use of warm baths. One tip that may help though, is to use a small amount of colloidal oatmeal in your bath water.
-Addressing constipation issues. If a patient has overlapping constipation issues they must be addressed. The constipation may be coming from the PFD itself, IBS or other gastrointestinal problems, as a resulting side affect of certain medications, improper or altered diet, or other for other reasons. Chronic constipation alone can lead to pelvic floor problems.
If the rectum (lower intestine) contains a large amount of stool it imposes distension and pressure on the bladder and the pelvic floor muscles. The choice of laxatives seems to vary but if the patient does not have IBS (which can be very sensitive to certain laxatives) common choices are Senokot and Milk of Magnesia. Before starting any laxative please discus them with your doctor.
-Attempting to maintain a good (“proper”) posture. This will help to take some of the pressure off your pelvic floor muscles.
-Sitting in the most comfortable chair you can find (have), and for some people who experience an increase in IC and/or PFD symptoms only sitting for short periods of time. Try to sit on firm, but comfortable cushions and chairs with even surfaces. You want the chair to support you as best as possible and therefore take some of the pressure of your pelvic floor muscles.
-Try “safe” exercises, for most people these can include walking, jogging, or running, swimming and bike riding (with the use of a recumbent seat bike seat). However many of these activities can cause IC symptoms to flare so it is best to proceed with caution and start with short intervals of exercise. For those with vulvodynia bike riding and swimming in particular may be too painful. Less aggressive forms of exercise are gentle stretching (usually it is best to start of with stretching exercises and then proceed to ones that will strength the trouble areas over time) and gentle yoga that does not contain positions that will put undo stress on the pelvic floor muscles and/or bladder and/or lower abdominal muscles.
The aim of home exercises is to help the person with PFD to control, and relax the pelvic floor muscles. Stretching techniques that involve relaxing the back and legs, and exercises that are similar to Kegels but which focus on relaxing the pelvic muscles, but not intentionally strengthening them may be used. These are usually variants of exercise that your physical therapist use in their office, and which he or she will teach you how to perform at home.
-Bladder training exercises/techniques that help to strength the bladder muscles for more on this please see the article, To pee or not to pee
-Daily stress reduction. Stress, while not the root cause of the problems themselves, is known to significantly impact both IC and IBS (as well as many related conditions like IBS and FMS). Again the double-edged sword of stress and health problems raises its head here, as the pain/symptoms of PFD and/or IC can cause stress unto themselves. Many different beneficial ways exist to reduce daily and medically related stress. It is a good idea to talk to your doctors and physical therapist about these. Simple things can include establishing a good sleep pattern (going to bed and rising at essentially the same time each day, for more info on IC and sleep see the article, I just want some sleep ), making dietary changes which will benefit your bladder and in term help your PFD (following an IC friendly diet , avoiding dehydration, addressing IBS and constipation issues through diet), and seeking support so that you are not fighting these battles alone.
-Using a TENS unit. A TENS or Transcutaneous Electrical Nerve Stimulation unit is a device that uses low levels of electrical stimulation to manage pain. TENS uses electrodes that are attached to wires connected to a monitoring device (the body of the TENS machine which is battery powered and worn externally) in order to pass electrical stimulation to the patient, through their skin and in turn into the affected muscles. TENS has shown to be very helpful in treating chronic pain and in some IC cases, especially where pelvic floor muscles are especially damaged or constricted. Some types of TENS can typically be purchased by the patient themselves from a pharmacy or medial supply shop, and it is recommended that you discus this option with your doctor before commencing any self-treatment, as too strong of a stimulation my cause further injury or strain to the affected muscles.
In the case of PFD TENS is often applied to the lower back and/or hip joints, instead of the front of the torso. TENS aims to help increase blood flow, strengthen and heal weak and/or damaged muscles and to block pain by interrupting the electrical nerve stimulation. This point in particular may explain why many with PFD benefit from TENS therapy as it is thought that PFD may be caused by or affected by an excess amount of electrical activity in the pelvic floor region.
-Using medications to combat pain, PFD and IC symptoms. In the case of PFD itself drugs such as muscle relaxants (some doctors use very low doses of Valium), antidepressants, analgesics and anti-inflammatories. However a contradictory problem arises in that some people find some types of IC (and PFD) treatment drugs actually exasperate and increase their symptoms. Culprits may include tricyclic antidepressants (Tofranil, Elavil) and drugs like Detrol and Ditropan.
-Using pelvic floor specific exercises at home.
There is an ongoing debate as to the effectiveness of Kegel exercises in helping IC patients with PFD. This conflict largely arises from the fact that the majority of ICers have pelvic floor muscles that are too taught and stiff, wherein Kegel exercises aim to tighten and strengthen pelvic floor muscles that are too relaxed or “lose” (so hence why it is often the first line of defence for incontinence, wherein the pelvic floor muscles have actually become to relaxed). While strengthening alone can be beneficial, tightening muscles that are already too taught to begin with can cause a further increase in PFD symptoms. Before commencing Kegel exercise sit is wise to consult with your doctor and/or physical therapist for more on Kegel exercises see the IC encyclopedia
Pelvic Floor Dysfunction and sex
One area where both males and females run into trouble in particular when it comes to Pelvic Floor Dysfunction is love making, involving (in the case of females) penetration in particular, where pain is the biggest culprit (pain with sex is called dyspareunia). For many this ties directly back to their Interstitial Cystitis.
Many of the techniques and tips applied to sex and IC can be applied to PFD and sex as well. Position, relaxation, and lubrication may all offer some relief. As with IC some people also note that their PFD does not flare during sex but afterwards. Sometimes this may occur as many as 24-48 hours after sex. Problems largely arise because you clench and tighten your pelvic muscles (we all do) while making love. This is normal, but for someone with pelvic floor muscle problems it can exasperate their symptoms and lead to further pain and a sharp increase in symptoms. Taking a mild muscle relaxant prior to sex may help your muscles to relax, as will having your partner thrust gently while you contract and relax your muscles around his penis. If you are on top, then gently thrust or rock on your partner, also contracting and relaxing your pelvic floor muscles while you do so. If sex hurts too much, stop! It may not be possible at that point in time, and carrying out the act may cause you hours or days worth of severe pain and discomfort. When making love go slowly, talk to your partner (to let them know how you feel, what hurts, etc) and try not too put undo stress on yourself regarding performance or completion. As adults we know that sex is so much more than just penetration, so it is not the end of the world if you find other means by which to please each other sometimes. Issues surrounding painful sex (and/or an inability to tolerate having sex at all due to associated pain) are all things that must be addressed with your doctors, physical therapist, and partner.
Don’t fight PFD alone
Pelvic Floor Dysfunction is not something that can be merely swept under the rug, so to speak. It requires aggressive, continual treatment and attention. Once you have been formally diagnosed with PFD your doctor(s) should start you on some form of treatment, or multiple types of treatment. He or she may also refer you to a physical therapist, or you may need to locate one in your area who has extensive expertise in the area of pelvic floor treatment. Physical therapy be it biofeedback, electronic stimulation, hands on massage, trigger point work or whichever technique, will likely take time to work. It took months or years (for some even decades) for our pelvic floor muscles to reach this wounded state. Sadly, they will not be cured (helped) over night. Encouragingly some people do find that with efficient treatment they stop feeling PFD symptoms, and many notice a wonderfully marked improvement in their IC. If you believe you may be experience Pelvic Floor Dysfunction please talk to your doctor. You do not need to, and should never suffer in pain and discomfort alone.