Female Veterans and Urinary Incontinence

Just published in the June edition of the Journal of Obstetrics and Gynecology, evidence points to post-traumatic stress disorder (PTSD) among female military veterans as a cause of urinary incontinence. 968 women ages 20-52 completed surveys addressing gynecologic, medical, and mental health. 19.7% of the women reported urgency/mixed urinary incontinence (UI), and 18.9% reported symptoms of stress UI. PTSD was associated with urinary urgency or mixed UI, but not with stress incontinence. Symptoms of depression did not correlate with stress or urgency/mixed incontinence. The authors concluded that for a female veteran having symptoms of urge or mixed UI, there is an increased likelihood that she also suffers from PTSD and an associated poorer mental health/quality of life. The authors also state that increased research is needed to better understand the neurobiology of continence.

A report in the Journal of Psychiatric Research suggests that women who have served in the military need to be screened for PTSD and prior trauma or stress events, as regular duty and reservist personnel serving in Canada were found to commonly deal with symptoms of PTSD. Other issues found to be clinically significant for female veterans include depression, sleep difficulties, and chronic pain. In 135 patients studied by Kelly et al. and reported in the journal Research in Nursing and Health, military sexual trauma is reported by 20-40% of female veterans.

All of the above issues are relevant to the pelvic rehabilitation provider. It makes sense that post-traumatic stress disorder has an effect on the nervous system that can then affect bladder function. Our treatments often include strategies to calm the nervous system, and for those patients who have PTSD, relaxation strategies may be extremely important as a treatment tool. In addition to urinary complaints, a female veteran presenting to our care may also have pelvic pain manifesting as various functional limitations including sexual dysfunction. It is appropriate to ask about all domains of pelvic health when working with a patient who has served, or who is currently serving in the military. The impact of serving in the military is gaining increased awareness, resulting in research that identifies various symptoms and proposed treatments. Overall, this improves our ability to provide more comprehensive care through increased physician awareness and through referrals to pelvic rehabilitation.

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Military service and risks for urinary, sexual dysfunction

Research presented recently at theannual Scientific Meeting of the American Urological Association (AUA) addresses the increased risk for urinary and sexual dysfunction among men who have served in the military.In a press release issued by UroToday, it is noted that men who have prior military service have up to 3 times the risk for developing urinary incontinence. Data was collected on nearly 5300 men and the results were categorized into 3 age groups: < 55, 55-59, and > 70 years of age. 23% of the men in this general population sample reported military exposure, and the rate of urinary incontinence (UI) was 18.8% in the military group versus in the men without military experience (10.4%). Interestingly, it was the age group of < 55 years that had the most significant increase in risk for UI, as the men older than 55 did not have a significant difference in rates of incontinence.

Not only has prior military service been found to be an independent risk factor for men under age 55 developing urinary incontinence, but the diagnosis of posttraumatic stress syndrome (PTSD) in male Iraq and Afghanistan veterans is linked with a higher rate of lower urinary tract symptoms as well as sexual dysfunction. Male veterans who suffer from PTSD are more likely to suffer lower urinary tract symptoms (LUTS) than men without PTSD, even when medications for the syndrome are taken into consideration. In other research presented at the AUA meeting, the prevalence of sexual dysfunction in men who have PTSD was discussed. Conditions including erectile dysfunction and premature ejaculation were analyzed in health histories of men with and without PTSD. The rate of sexual dysfunction in men with PTSD was nearly 10%, while in men without PTSD, the rate was 3.3%. The authors concluded that while certain medications taken for PTSD can cause sexual dysfunction, medications alone are not responsible for all cases of sexual dysfunction in men with a military service history. Issues of avoidance, emotional numbing, and hyperarousal (all symptoms of PTSD) were found to be important factors in the dysfunction.

Increased awareness of these issues may lead to better identification of the conditions as well as improved emphasis on effective treatments. In my role as faculty for the Herman & Wallace Pelvic Rehabilitation Institute, I have met several pelvic rehab providers who work within the VA system, providing care for the men and women who have served in the military. There is increased awareness of and interest in integrating pelvic rehabilitation programs for veterans, and this is a trend that will hopefully expand into comprehensive pelvic rehab care. With Memorial Day so recently behind us, it is timely to have increased light shed on these significant issues so that care may be directed to treat these sensitive issues that can impair quality of life.

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New Clinical Practice Guidelines for Overactive Bladder

The American Urological Association (AUA) issued new guidelines today for the treatment of overactive bladder. Overactive bladder (OAB) is described by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) as having to void or empty the bladder more than 8 times in a day or more than 2-3 times/night. Strong, sudden urges occur with OAB and may or may not be accompanied by urinary leakage. The first line of treatment recommended by the AUA includes behavioral therapy as well as possible combining of anti-muscarinic therapy (the only FDA-approved medication for overactive bladder.)

Behavioral therapy for bladder dysfunction is commonly instructed as part of a symptom management strategy by pelvic rehabilitation providers. Patients are instructed in normal bladder function, dietary factors that influence the bladder, bladder habits, the influence of medications on bladder function, in addition to pelvic muscle training. Behavioral therapy is one component, and a very important one at that, of the comprehensive care for the patient with bladder dysfunction.

Second line treatments discussed in the updated guideline all relate to medications and their potential uses and risks. Recommended third line treatments suggest more invasive options including tibial nerve stimulation and sacral nerve stimulation, which are both FDA-approved options. The guidelines are based on expert opinion as well as on research. As reported in prior posts about overactive bladder, more research is required to better define the symptom complex and more consistency within the research is needed in regards to definitions throughout the research.The AUA also has guidelines for other male and female urologic conditions such as urinary incontinence, erectile dysfunction, female surgeries, and interstitial cystitis/bladder pain syndrome. You can access the page with links to these documents by clicking here. To access the new AUA guidelines for overactive bladder only, please click here.

The value of seeing behavioral training listed as the number one treatment that providers should offer the patient is to be celebrated in a world when pharmacology and surgeries is the typical go-to medical suggestion. What a wonderful document to discuss with your urologists, urogynecologists, family practice providers, and fellow party-goers as we head into the Memorial Day weekend.

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Chronic Yeast Infections and Boric Acid

Recent research has confirmed prior work that suggests the use of boric acid is an effective treatment for vaginal yeast irritation. Chronic yeast irritation, commonly caused by Candida albicans, is a troubling condition that can cause symptoms of vulvar itching and burning, abnormal discharge, painful urination or intercourse, and vulvar swelling. Triggers for yeast imbalance include antibiotics use, pregnancy, changes in glucose metabolism, and use of certain oral birth control pills. Tight clothing and use of plastic pantiliners can also create an environment in which yeast growth can cause symptoms.

The availability of over-the-counter yeast treatment has led to patients misdiagnosing and often over-treating with such medications. The ingredients in many of the available creams or suppositories can cause allergic reactions, vaginal burning, irritation, or itching. Many of our patients who complain of pelvic pain may be dealing with a history of or a current case of low grade (non-acute), recurrent yeast overgrowth and subsequent tissue irritation that can create a chronic pain condition. There are several intravaginal treatments that have been used by patients including boric acid tablets. Knowing that I worked with a high population of women's health patients, I recall my naturopath handing me an article over a decade ago that described the superior results of boric acid over nystatin. Some providers recommend the use of boric acid in the evening, followed by intravaginal probiotics in the morning. Boric acid can cause local skin irritation as a side effect, but no other significant side effects have been reported when used vaginally.

In a reviewby Iavazzo and colleagues about recurrent vulvovaginal candidiasis, the use of boric acid is presented. The studies included in the review reported a 40-100% cure rate with minimal side effects. The authors conclude that boric acid is an economic, safe option for women who have non-albicans Candida strains of yeast overgrowth or for those who have azole-resistant strains. The National Institutes of Health recommends avoiding vaginal douching or feminine hygiene sprays, rinsing with water only (no soap), use of condoms to prevent spread of sexually transmitted infections, wearing cotton underwear and avoiding tight, non-breathing clothing, and keeping blood sugars in check.

We can keep this information in mind when working with patients who complain of pelvic pain, vaginal or vulvar burning. Of course, these symptoms can also be attributed to neuromuscular pain, referred symptoms, or a chronic pain cycle. The above information about boric acid can be presented to the patient if she reports a history of chronic yeast irritation and she can then discuss the option with her medical provider. According to Donders, patients often feel misunderstood, guilty, and feel sexually inferior due to chronic candidosis, requiring that medical providers consider this issue as one to be taken seriously. Having the information about options such as boric acid appear in medical journals helps to highlight the importance of managing this condition that is often recurrent and sometimes difficult to treat.

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PTPC Development Update

A big thanks to everyone who completed our PTPC Job Task Analysis Survey over the past few weeks. We received over 400 responses, which is more than enough data that we will need to perform the necessary analysis.

On May 2nd, we drew the names of our two lucky participants, who will each received a free course registration of their choosing. Congratulations to Christy Kline, PT and Kate Middleton, PT on winning the drawing!

Over the next few weeks, our subject matter experts and test development partner, Kryterion, will work together to finalize the quantitative blue print. This blue print will determine the relative amount of exam items that will be devoted to various sub-topics within pelvic rehabilitation. While not a "study guide", those interested inpursuing PTPC could use this test blue print to determine the topicson which to focus their studying efforts.

Our test developers will also use this test blue print to begin writing exam items. Similar to the JTA survey, we will need to beta test exam items in order to measure their validity for the actual exam.

Thanks again to everyone who participated, and please stay tuned for updates as we continue to work towards offering the PTPC exam for the first time. Also, if you completed the JTA survey, and have yet to redeem your $50 credit, let us know when you are ready to apply your credit to an upcoming course that you'd like to attend.

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Nonrelaxing pelvic floor dysfunction

In the February 2012 issue Mayo Clinic Proceedings, Dr. Faubion and colleagues discuss the symptoms and management of nonrelaxing pelvic floor issues. In this clinical review, the authors differentiate between conditions that involve relaxed pelvic floor muscles (pelvic organ prolapse, urinary incontinence) with conditions in which non-relaxing pelvic floor muscles play a key role. When the muscles of the pelvic floor have difficulty in relaxing, this can impair the person’s function with defecation, urination, and sexual activity. The review focuses on the symptom complex called “nonrelaxing pelvic floor” so that care providers can manage the condition effectively, and in the words of the authors, provide early referral to physical therapy that can address the muscle dysfunction.

When learning about the various diagnoses for pelvic floor pain conditions, medical providers and pelvic rehab therapists are faced with a long list of terms that have overlapping symptoms. Some of the terms listed in this article include coccygodynia, levator ani syndrome, piriformis syndrome, and puborectalis dyssynergia. It is pointed out that using the description of non-relaxing pelvic floor has the ability to encompass many of these other terms without inaccuracy in diagnosis. Dr. Faubion suggests that medical providers look for the cluster of symptoms that tend to accompany non-relaxing pelvic floor conditions, including voiding dysfunctions, constipation, dyspareunia, low back pain and pelvic pain.

What is so exciting about this article from the Mayo clinic is that physical therapy is identified as a “cornerstone of management.” Oftentimes, when we read clinical practice guidelines for various dysfunctions involving the pelvic floor, physical therapy or pelvic rehabilitation rarely gets an honorable mention. To read about the recognition of PT as such an important element of healing pelvic dysfunction can help improve awareness among the medical profession and expedite referrals to pelvic rehabilitation providers. Only time will tell if "nonrelaxing pelvic floor" will catch on as a replacement for the diagnostic terms that name single muscles. In the meanwhile, this article will hopefully serve as an educational tool to increase awareness of the evaluation and treatment options available to medical providers.

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Yoga for Menstrual Pain

In the Journal of Adolescent and Pediatric Gynecology, Rakhshaee reports on the evaluation of 3 yoga poses used to treat primary dysmenorrhea. Primary dysmenorrhea occurs in otherwise healthy young women around the time that the menstrual cycle begins. It has been reported byProctor in 2007that as many as 75% of adolescents have painful periods, and that up to 20% of them limit activities because of the pain. An article by Wilson and Keye report that premenstrual syndrome and dysmenorrhea are reported as a leading cause of missed school and as problems that affected academic performance.

In the study by Rakhshaee, 92 female students (ages 18-22) were randomly assigned to a treatment group (n=50) and to a control group (n=42). Over a period of 3 menstrual cycles, participants recorded pain using a Visual Analog Scale and reported pain duration in terms of hours. During the first menstrual cycle, symptoms were recorded, and then during the second and third cycles, the treatment group was asked to complete 3 yoga poses during the luteal phase. The control group received no intervention. Yoga poses instructed include the Cat, Fish, and Cobra. You can search the Yoga Journal website to view each of the poses by clicking here if you are interested.

In the experimental group, both the pain intensity and the pain duration showed significant differences with the participants who completed yoga poses having less pain intensity and pain duration. The authors conclude that yoga is a safe and simple treatment for primary dysmenorrhea. Oftentimes, patients who complain of dysmenorrhea lack access to care for this other than medications that might include pain medication or birth control pills. Instructing a patient in basic yoga postures presented in this research may be a simple alternative to such medications.There are several websites that offer free access not only to images of poses, but also to free classes. I often hear from patients that they enjoy taking advantage of free fitness classes including yoga on various television stations. This may be another "tool in the toolbox" that we can offer to patients who have pain related to the menstrual cycle.

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Botox for Overactive Bladder

Overactive bladder (OAB) is defined by the International Continence Society as urinary urgency, with or without urinary leakage, that is commonly associated with urinary frequency and nocturia (waking one or more times at night to void.) According to the ICS, this combination of symptoms suggest that detrusor instability is present, meaning that the bladder muscle is overactive. In the absence of proven infection or other pathology, overactive bladder, urge syndrome, or urge-frequency syndrome are terms used to describe the condition.

A double-blind placebo-controlled randomized trial was completed in the United Kingdom for 240 women who experienced "refractory" detrusor overactivity. 122 women with urodynamically proven detrusor overactivity were treated with onabotulinumtoxinA (onaBoNTA), and 118 women served as the placebo group. The medication is injected into the wall of the bladder during a cystoscope procedure. (The women in the placebo group received injections as well, only with 0.9% sodium chloride in saline solution.) The median voiding frequency within a 24 hour period was reduced from 9.67 voids to 8.33. Urgency episodes reduced from 6.33 to 3.83, and leakage episodes from 6.00 to 1.67. To summarize, urinary urgency and incontinence improved more than urinary frequency in this study. The authors conclude that, based on such a large, randomized study, the use of botulinum toxin is both safe and effective for women who have detrusor overactivity.

In reviewing this article, it also seems important to look beyond these recommendations, as clearly the use of this treatment is not safe for all involved, nor is it effective.

  1. The authors defined a "refractory" condition as one that did not respond to an 8 week trial of an anticholinergic medication. Was behavioral training implemented? Could these women have benefited significantly from education in dietary and behavioral strategies? The authors admit that their definition was chosen arbitrarily.
  2. 24.6% of the women in the treatment group did not report any significant improvement.
  3. One third of the women who received the onaBoNTA reported urinary tract infections (UTI) while in the placebo group one tenth of the women reported UTI.
  4. 16% of the women in the onaBoNTA group had voiding difficulties requiring intermittent catheterization compared to 4% of the placebo group.
It is important as pelvic rehabilitation providers that we are aware of options beyond rehabilitation, including procedures such as the onaBoNTA treatment described in this research. The potential risks of such procedures should be taken into consideration, and hopefully patients are given the option to trial the most conservative methods available. In relation to medications for OAB and their negative side effects, it may be helpful for the patient to discuss a change in dosage or a change in medication prior to abandoning use of such medications. You can find out what the standard practice is in your community, or if botulinum toxin is offered to your patients.Use of this medication often has to be repeated,so while there may be gains in function, it is not without risk.

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Laparoscopies and pelvic pain

In an article published in the Journal of Obstetrics and Gynaecology, the authors ask the following question: “How can we reduce negative laparoscopies for pelvic pain?” A retrospective audit of women receiving a laparoscopy (76 charts) was completed to determine how thoroughly the subjective examination was completed for women who complained of pelvic pain. Physical exam, the results of any ultrasound examination, reported usage of hormonal therapy, and the recommendation for multidisciplinary care was also assessed retrospectively. This study also aimed to determine if recommended guidelines for the initial assessment of chronic pelvic pain were followed by the physicians. These guidelines were developed by the Royal College of Obstetrics and Gynaecologists (RCOG) and can be accessed by clicking here.

Outcomes of the chart reviews indicated that history-taking was “deficient” and an integrated approach was not utilized much of the time, leading to a poor initial evaluation of the patient. 13% of the charts had no documentation of duration of symptoms. Only 21% of charts noted if the pain was cyclical or non-cyclical and this lead to failure to recognize the option of a trial of hormone therapy. Complaints of dyspareunia were documented for 31.5% of the women, and this, according to the authors, is less than expected based on general population studies and is likely due to poor history taking.

In this study, laparoscopy contributed to diagnosing and treating disease or other significant findings in 45% of the patients. Endometriosis and adhesions were the main findings reported following the procedure. I found it interesting that 50% of the patients who had negative ultrasound studies were found to have positive laparoscopy results. And despite the fact that the RCOG guidelines suggest psychology and physiotherapy referral for women who complain of dyspareunia, only 1 referral for psychosexual counseling was made.

The authors conclude that in order to reduce the number of negative laparoscopies for pelvic pain, a “…structured initial assessment and targeted selection of patients for laparoscopies…” is needed. It also appears that pelvic rehabilitation specialists must continue to address the lack of awareness of potential referral for chronic pelvic pain. Most medical providers and patients are unaware of the scope of the pelvic rehab therapist, and this study certainly highlights the need for more interdisciplinary communication and care provided to the patient who suffers from pelvic pain.

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New Hormone Therapy Position Statement

The North American Menopause Society (NAMS) has issued a new position statement related to recommendations for hormone therapy (HT) use in women. This topic has been debated intensely over the last decade since the publication of the Women's Health Initiative (WHI) research that was funded by the National Institutes of Health (NIH). Following this research, many women were instructed by their physician to stop taking their hormone therapy medication due to the increased risk of cardiovascular events. For more information about the background of the WHI, please click here.

This information is particularly relevant for the pelvic rehabilitation provider as many women in their perimenopausal years will experience pelvic symptoms related to a decline in hormone levels. The updated NAMS guidelines state that estrogen therapy (ET) is "...the most effective treatment of moderate to severe symptoms of vulvar and vaginal atrophy..." that may include vaginal dryness, pain with penetration, and atrophic vaginitis.Although the guidelines do not recommended hormone therapy for improving libido, use of local estrogen therapy may contribute to improvement in sexual function through improved lubrication, increased blood flow and increased sensation to vaginal tissues. Local estrogen has also been demonstrated to help some women who have overactive bladder or urinary tract infections, however, systemic hormone therapy may worsen symptoms of stress incontinence.

There are other important women's health topics in this position statement including potential benefits of hormone therapy for women who have or who are at risk for osteoporosis. The authors conclude that in healthy women ages 50-59 years old the absolute risks of HT are low. Older women who initiate use of HT or who use long-term HT are at higher risk for adverse effects. Successful implementation of hormone therapy for women depends on the route of administration, formulation of the hormones, and timing of the therapy. "Constructing an individual benefit-risk profile is essential..." when creating a plan of care for women according to the authors.

Unless it is within your scope of practice to prescribe medications such as hormones, the above choices will be made through patient discussions with the appropriate medical provider. We can alert a physician or medical provider if there is concern about the vaginal tissue health of a woman presenting to the clinic. We can also direct patients to these new guidelines developed by the NAMS group. It is helpful to note that many women do not have a medical provider who is actively managing her hormone issues, and simply asking her about HT can lead her to communicate more effectively with her medical providers.

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