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Pelvic Health FAQs

Answers to your frequently asked questions from the team at the Program for Abdominal and Pelvic Health at Rush University Medical Center in Chicago.

General abdominal and pelvic health concerns and symptoms

What are common causes of pelvic pain?

Pelvic pain is pain that occurs in the lower abdomen below the belly button. It is a symptom and not a disease. It is more common in women but occurs in both men and women.

In women, the vast majority is attributable to gynecologic causes but during the initial evaluation all causes must be considered. Common gynecological causes of pelvic pain include endometriosis, chronic pelvic inflammatory disease, and fibroids (non-cancerous tumors of the uterus).

Gastrointestinal causes are the next most common reason for pelvic pain. Diseases of the colon and rectum such as colitis, diverticulosis and diverticulitis may cause discomfort in the lower abdomen. Irritable bowel syndrome is another gastrointestinal disorder that is often associated with pelvic pain. This pain is often relieved with passing gas or a bowel movement and may occur in conjunction with altered bowel habits.

The bladder and urinary tract also are located in the pelvis. Interstitial cystitis is inflammation of the urinary bladder and may cause urinary urgency or pelvic pain. Fibromyalgia is a chronic pain disorder that involves muscles, ligaments and tendons and may also lead to pelvic pain. Depression is also often linked with chronic pelvic pain although a cause and effect has not been established.

A careful history and physical will direct your doctor towards appropriate diagnostic tests. There is no single test which can identify the cause of pelvic pain in patients.

How do I know if I have chronic pelvic pain?

While it is not unusual to have discomfort related to your period, chronic pelvic pain is defined by the American College of Obstetrics and Gynecology as non-cyclic pain (not related to ones menstrual cycle) of three months duration or significant cyclic pain of six months duration, either of which interfere with normal activities.

What types of tests are used to evaluate patients with pelvic and abdominal pain?

The most common test the gastroenterologists perform is colonoscopies. A colonoscopy is a procedure that enables your gastroenterologist to examine the lining of the lower part of the GI tract (colon — sometimes referred to as the lower intestine) using a flexible tube with its own lens and light source. It is performed to evaluate abdominal pain and problems with constipation or diarrhea. In most circumstances the doctor can inform you of your results on the day of the procedure. The results of any biopsies however may take several days.

If you doctor wants you to have this test you will be given instructions on how to prepare for the test with a special diet and preparation to be given the day before the test.

Bowel problems and concerns

Why do I have difficulty moving my bowels?

The process of having a bowel movement is complex requiring a number of coordinated functions. The colon must contract and propel fecal material towards the rectum. The muscles of the pelvis then must relax and contract in a coordinated fashion to eliminate stool. Bowel movements may be affected by poor colonic muscle tone (colonic inertia or "lazy" colon), disorganized pelvic muscle activity (pelvic floor dysfunction), and functional bowel diseases (such as irritable bowel syndrome — IBS).

More commonly, bowel movements are affected by diet, medications, and other medical problems (low thyroid, high or low calcium absorption, etc.). A careful history and physical exam guides your doctors to order the most appropriate tests to establish a cause for your altered bowel movements.

What range of frequency of bowel movement is considered normal and how do you define constipation?

Constipation is a disorder that defined by changes in either the frequency or the character of a person’s bowel movement. A normal range of bowel movement is from 3 bowel movements a day to a bowel movement every three days — 95 percent of the normal population is in this range. People can also be characterized as constipated if their bowel movements are difficult to pass or are hard. The biggest distinction with constipation is whether there is any pain or discomfort with the bowel movements. The presence of pain indicates the need for a medical evaluation.

What is "lazy" colon or colonic inertia?

Colonic inertia is also known as a "lazy" colon or slow transit constipation. The colon is a muscular organ which plays an important role in the absorption of water and some electrolytes, storing stool, and propelling feces towards the rectum. It has its own nervous system as well as being innervated by the spinal cord. When the colon function is slow it is called colonic inertia. It is characterized by very infrequent bowel movements. The diagnosis is based on an x-ray exam known as a transit study. This test is performed by having the patient ingest a capsule which contains 20 markers (which will show up on x-ray) on each of three days. In the days preceding and during the study, patients need to be off any laxatives. An x-ray is then taken on day four (or whatever the protocol for a given hospital) in order to follow the transit of markers through the colon.

A high number of markers left in the colon at the time of x-ray is an abnormal test and helps to establish the diagnosis. The treatment of colonic inertia is varied and must be tailored to the patient. Rarely surgery is needed to remove the poorly functioning colon.

What is irritable bowel syndrome (IBS)?

Irritable bowel syndrome (IBS) is one of the most common chronic gastrointestinal disorders. Patients may experience constipation, diarrhea, abdominal pain, bloating and gas. It can also cause difficulty swallowing, heartburn, acid reflux, nausea and an uncomfortable sense of fullness.

IBS is a disease characterized by symptoms of abdominal pain associated with a change in bowel frequency or stool characteristics. It is very common affecting 25 to 55 million people in the United States alone. The diagnosis is based on symptoms and the exclusions of other medical problems.

The cause of IBS is unknown although there is much ongoing research in this area. Theories include abnormal contractions of the small and large bowel, food intolerances and irritability following gastrointestinal infections. Some studies suggest it is caused by heightened sensitivity of the intestines to normal bowel function and sensation.

IBS is also linked to intolerance to certain foods. Patients are often asked to keep a food and symptom diary to identify foods which consistently trigger symptoms. A diagnosis can often be established by history and physical alone, although your doctor may perform additional testing to rule out other conditions.

Although it is not a psychological problem, it can be triggered by stress. IBS is not life threatening, but untreatable this problem can have devastating effects on people’s quality of life.

There are many treatments available for IBS to allow most patients to live normal lives. Treatment is often based on establishing a healthy, high-fiber diet, regular physical activity and eliminating foods that trigger your symptoms. Depending upon your symptoms, treatment may include anti-spasmodics, anti-depressants, anti-diarrheals and/or natural supplements.

What is fecal incontinence?

Fecal incontinence or anal incontinence is involuntary loss of stool. If you have this problem you are not alone. Somewhere between three to seven percent of the population and 10 percent of elderly individuals have this condition? Many are embarrassed to talk about this to their physician. Fecal Incontinence can almost always be improved or cured.

What is pelvic floor muscle dysfunction?

The pelvic floor muscles play an important role in the process of having a bowel movement. The muscles of the pelvis must relax and contract in a coordinated fashion to eliminate stool. People with pelvic floor dysfunction often report the need to strain or assume different positions in order to achieve a bowel movement. Some patients may also need to manually remove stool or actually splint the rectum in order to eliminate stool.

Anal rectal manometry and defecography are important tools in the diagnosis of pelvic floor dysfunction. Anal rectal manometry involves inserting a balloon in the rectum that measures pressure in the muscles at rest and during a squeeze. Defecography is performed by inserting x-ray paste into the rectum and taking a series of x-rays while the patient is going through the act of having a bowel movement on a specially designed toilet or commode. This gives import information about the function of the muscles in the pelvis.

The best treatment available for pelvic floor muscle dysfunction is physical therapy focusing on pelvic floor retraining. This physical therapy is aimed at coordinating abdominal and pelvic floor muscle activity.

Urinary problems and concerns

What are some warning signs of bladder problems?

Consult with your physician or a specialist, if you are experiencing any of the signs below.

I leak urine when I sneeze, cough, lift heavy objects, exercise. Why did I develop it? Can this be helped or cured?

These symptoms are classic signs of stress urinary incontinence. It is a most common type of urinary incontinence and is caused by weakening of muscles that control urinary leakage and weakening of the support for the urethra (the channel that carries urine from the bladder to outside your body). It most commonly occurs as a consequence of vaginal delivery of the baby during childbirth and also has a genetic component (you may be predisposed to the condition because of hereditary). If untreated, it may get worse. It is initially treated with non-surgical means: Kegel exercises and medications, but complete cure in serious cases often requires a minimally invasive surgery. This surgery involves placement of a small piece of a tape-like material "sling" in the vaginal area using less than a half-inch incision. The surgery is performed on an out-patient basis, takes 30 minutes to perform, and has reported cure rates of 85 percent.

I have frequent urges to urinate, and sometimes I leak urine if I cannot get to the bathroom on time. Can this condition be helped? Will I need surgery?

This conditions is called urge incontinence. It is also a common type of urinary incontinence. It is mostly treated with non-surgical approaches. These approaches include behavioral changes (urinating on schedule, rather than on demand, and curbing fluid intake before periods of prolonged activity in order to prevent incontinence episodes), physical therapy and medications. Combination of these measures is most effective. For patients who have failed more conservative approaches, a surgery that involves placement of a "bladder pacemaker" — Interstim is offered.

What can I do to help to control my urinary incontinence?

The first and most important thing is to find out what type of urinary incontinence you are having, and then to determine what the cause of that incontinence is. There are many causes of urinary incontinence, but, in general, intermittent daytime wetness that women have falls into two general categories: urge incontinence and stress incontinence.

Urge incontinence is caused by an overactive bladder, which sends a strong, uncontrollable urge signal with bladder filling. Stress incontinence is caused by damage to the pelvic muscles and ligaments, which prevents the urethra and bladder control mechanism from working when the bladder is exposed to increased pressures such as coughing, laughing or lifting.

Because an overactive bladder and weakness to the pelvic muscles and ligaments can occur simultaneously, some women have mixed stress and urge incontinence.

How can I tell what type of incontinence I have?

Your doctor can perform an exam to determine the support to the bladder control mechanism and urethra and whether the bladder is moving out of position with straining. In addition, a voiding diary is very helpful in determining your pattern of voiding, when incontinence occurs, and what other symptoms may be associated with your urinary incontinence.

A urinalysis and a targeted pelvic and general physical examination can help to determine if there are other causes of the incontinence. Additional testing may be necessary to help sort out the cause, and to rule out other more serious problems in some patients.

What can I do myself to help improve my urinary control?

If the primary complaint is stress incontinence (again, a leakage of a small amount of urine with straining — laughing, a sudden sneeze, lifting, etc.) there are a number of things you can do to control it. You can do pelvic floor exercises (Kegel’s exercises), reduce your weight, if your overweight and you can try some timed voiding and fluid management. These can help to reduce the severity and bother of the urinary stress incontinence.

If urge incontinence is the primary problem, then eliminating dietary irritants (coffee, carbonated beverages, spicy foods, concentrated citrus, etc.) and maintaining a dilute urine by drinking more water (even though this may seem counterintuitive) is often helpful. In addition, certain relaxation response exercises to the urge symptoms can help to re-train an overactive bladder — sort of self-administered biofeedback.

Do Kegel’s exercises help, and how should I do them?

First, for patients who have severe damage to the pelvic muscles and ligaments, from pregnancy childbirth, trauma, radiation or prior surgery, Kegel’s exercises probably won’t have a major impact. However, many patients with mild stress urinary incontinence will find that they can gain significant improvement in their leakage through Kegel exercises. Unfortunately, most women who fall in this category don’t may not do the exercises correctly, may not do them consistently enough or long enough, to see the benefits.

Like any exercise program, it takes time before one sees the improvement in strength or endurance. And, when we don’t see immediate results, we may get annoyed with the inconvenience, or simply forget about doing them. In addition, even when we see improvement, we will rapidly lose the benefit if we stop doing the exercises. Kegel’s exercises are best implemented as part of a general fitness and exercise program along with diet and weight control. They should be performed three to four times a day at a convenient time, and only take a few minutes for each exercise.

To perform the exercises, the pelvic muscles (muscles between anus and sex organs) are firmly lifted and squeezed and then relaxed. This is repeated in a fairly rapid sequence 10 times. After the 10th squeeze the muscles are contracted and held for 10 seconds. The exercise may be increased after a week by repetitions of five (15 squeezes followed by a 15 second contraction) building up to a 20 repetition — 20 sec — exercise. To find the proper muscle group, one should think of squeezing the anus closed and lifting the anus towards the belly button, or may place a finger in the vagina and squeeze the muscles around the finger to find the proper muscle groups.

If I have urinary incontinence will I need to have cystoscopy?

Not necessarily. For most patients with uncomplicated, straightforward stress urinary incontinence, a treatment program may be initiated without the need for cystoscopy. There are some patents, however, where cystoscopy should seriously be considered. These are patients with irritable voiding complaints or urgency incontinence, who have a history of tobacco use, have blood in the urine (seen under the microscope on urinalysis) or fail to respond to initial therapy. In addition, patients who have sudden, acute onset of symptoms (in the absence of a urinary tract infection) additional testing is usually helpful. Finally, for patients who are not responding to our initial efforts to treat either the uncomplicated stress incontinence or urgency symptoms, then further evaluation is warranted.

I feel (or was told by my doctor) that I have a "dropped" or "fallen" bladder. Is it dangerous? Is it treatable?

This condition is called pelvic prolapse and involves a hernia-like protrusion of vaginal walls. If anterior wall of the vagina is weakened, than this protrusion usually involves the bladder and is termed "cystocele," "dropped" or "fallen" bladder. Other types of hernia-like protrusions occur resulting in prolapse of the posterior wall. These are referred to as "rectocele" or "uterine prolapse" or in women who have had a hysterectomy — "enterocele." All of these types of vaginal wall prolapses usually are not related to significant health risks (unless prolapse is very advanced and than function of the bladder or bowel may be compromised). Nonetheless, these conditions are very uncomfortable creating feelings of mass or pulling in the vagina, urinary frequency or retention or difficulty emptying the bowel. These conditions can be treated with a pessary (vaginal ring-like insert) or can be cured by a surgery. A thorough evaluation by a proper specialist is essential in order to accurately diagnose and treat pelvic prolapse.

Physical therapy for pelvic health

What can I expect during my initial physical therapy session?

Your physical therapist will first ask you several questions, gathering a history of your problem. A physical therapy examination will follow and include the following:

Biofeedback is painless and will allow the therapist to gather further information regarding the pelvic floor muscles. Treatment often begins during the initial session and your therapist may instruct you in a home exercise program and offer advice regarding self care of your problem.

How is a physical therapist able to help me?

A physical therapist treating pelvic floor dysfunctions has had specific training regarding the pelvic floor and has taken educational courses in this area sponsored by the American Physical Therapy Association. A physical therapist is the ideal health professional to assess and treat muscle dysfunctions, as she has been trained to assess the musculoskeletal system and determine a treatment plan.

Could I be doing something that is making my problem worse?

Yes. For example, if your problem is urinary incontinence due to muscles that are weak and not supporting your bladder, you may be worsening your incontinence if you are often constipated and straining hard during bowel movements. Chronic straining may further weaken you pelvic floor muscles. In another example, rectal pain may worsen with prolonged, frequent sitting, jogging, and repetitive heavy lifting.

How long will I need to have physical therapy?

This is very difficult to answer, as treatment duration will vary depending on your specific problem. Also, your response to treatment may differ from someone with a similar problem. This question may be better answered by your therapist after your physical therapy evaluation and following several treatment sessions, as she will be able to assess your response to treatment.

What are Kegels?

Kegel exercises were name after Dr. A. H. Kegel, a gynecologist who developed them. Tightening or contracting your pelvic floor muscles as if you are stopping urine flow or holding back gas is a Kegel contraction. Strengthening your pelvic floor muscles most likely will be part of your rehabilitation program. Your therapist will make sure that you are contracting the appropriate muscles and performing a correct muscle contraction. Frequently, additional exercises will be necessary to strengthen other important muscles in your pelvis. Your specific exercise program will depend on your therapist’s assessment of your condition.

Will physical therapy hurt?

When a physical therapist evaluates your muscles and joints for tenderness, abnormal tone, and tissue texture, the patient may experience some tenderness, discomfort, or pain if a muscle is dysfunctional. Normal muscles are not painful. The therapist is trying to determine which, if any, muscles are dysfunctional so that these muscles can be treated appropriately. Treatment techniques are used to normalize muscles, but at times the patient may experience some discomfort during treatment. The patient needs to communicate to the therapist that pain is being provoked, as the therapist can often modify her treatment to minimize any pain.

Why can’t I go to any physical therapist for treatment?

A pelvic floor physical therapist has had specific education and training in treating this area. The American Physical Therapy Association offers continuing education seminars involving the evaluation and treatment of pelvic floor disorders.

Why can’t my doctor just give me some exercises to perform on my own at home?

Assessing and treating pelvic floor dysfunctions can be very complicated. There are other muscles that may become painful and dysfunctional such as the abdominal, hip, and low back muscles. Also, postural and bony alignment problems may be contributing or causing the dysfunction. Your physical therapist needs to assess and address your specific needs. Even doing simple Kegel contractions may require initial instruction and supervision by a therapist, as oftentimes patients perform Kegel contractions incorrectly.

For how long will I need to perform my home exercise program?

At the time you are discharged from physical therapy you therapist will advise you on you home exercise program. There are usually some exercises that the therapist will advise that you always incorporate into your daily routine.

Will my problem be resolved with therapy?

This is a difficult question to answer, as patients present to therapy with individual problems. Many patients are markedly improved with physical therapy. However, there are patients who do not respond favorably to physical therapy. Your therapist will continual assess your response to treatment.

Mental health issues related to abdominal and pelvic health

How do I know if I am depressed?

Depression can occur for a variety of reasons including chemical abnormalities, a loss of a loved one or other life stressors. Many times symptoms of depression develop gradually and it is hard to identify a specific cause. Common symptoms of depression include low mood, tearfulness, irritability, reduced interest in activities that you used to enjoy, low energy, changes in sleep or appetite and/or feelings of hopelessness. Depression is different from everyday ups and downs. Depression is something that occurs more days than not for a period of at least one week or more.

What can I do about depression?

Depression is a serious condition that can significantly impact your relationships, ability to parent, work or do other important life activities. It can also slow healing time and impair recovery in certain cases. Thus, recognizing and treating depression as soon as possible is critical. Currently, the recommended treatment for depression is a combination of medication and psychotherapy. Health psychologists are uniquely equipped to treat depression as it relates to chronic health problems and can work with your physicians to improve your quality of life as you adjust to your health.

Why are behavioral interventions used for treatment of health problems?

Most of us are aware that the mind and body are connected in many different ways. Often, physical symptoms are affected by your thoughts and feelings, even though your thoughts and feelings did not cause your health problem. For example, feeling anxious about your health can sometimes interfere with your ability to make important medical decisions or interact with others. Anxiety and depression associated with health conditions can reduce your sense of confidence or desire to live. Further, many people suffering from health problems experience significant reductions in their quality of life and relationships as a result of being sick. They may also experience financial strain or excessive worry about the future. Health psychologists are trained to help people cope with the effects of physical health problems and use behavioral techniques such as relaxation training and stress management or cognitive techniques to help you change your thoughts and feelings about your condition. They can also provide a listening ear and help you effectively communicate with your treatment team. Health psychologists are also helpful in working with patients’ families and loved ones.

What is hypnotherapy and how does it work?

Hypnotherapy is a well-established intervention for several health conditions including irritable bowel syndrome (IBS) and related gastrointestinal problems (for more information on hypnotherapy for IBS see, chronic pelvic and rectal pain and even in preparation for surgery. It is also commonly used for smoking cessation and weight loss.

Broadly speaking, hypnosis is a heightened state of physical relaxation and mental concentration. During the hypnotic state, the brain is more capable of processing information, which allows a hypnotherapist to reinforce and/or change perceptions about symptoms through imagery and metaphor. From this perspective, hypnosis can be used much like other psychological techniques to facilitate increased control over symptoms and improve wellbeing. Hypnotherapists are licensed, trained professionals who will work with you in the context of a therapeutic relationship to identify your needs in a comfortable and safe environment. Contrary to popular belief, at no point in time does someone undergoing hypnosis "lose control" to the therapist or engage in any behaviors that they would normally not engage in if they were not in the hypnotic state. Hypnosis is often used in conjunction with other medical interventions to achieve maximum effect. Side effects of hypnosis are rare and include drowsiness, tingling especially in the fingers or hands. These side effects usually last no more than 15 to 30 minutes.

Does my insurance cover hypnotherapy for the treatment of IBS?

There are a couple of different ways in which you can receive behavioral health services through your insurance company. Depending on your plan, it is possible to use your medical insurance for these services rather than the more traditional route of mental health benefits. Prior to scheduling your first appointment, you should speak with the therapist to find out more details regarding your benefits and eligibility. You can also call your insurance company to find out whether they cover "health and behavior interventions" for your specific medical condition.