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Q&A: Kegel Confusion, Penile Pain, Pregnancy after PN, and More

Posted Mar 29 2013 6:11pm

qa In today’s Q&A post, we tackle some important pelvic floor issues, including whether Kegels are appropriate to do in preparation for childbirth; penile pain, and pregnancy after PN.

Should I do Kegels to Prep for Childbirth?

Dear Marcy,

I’m 23 weeks pregnant and have been told that Kegels are absolutely beneficial. Plus, I read on Web MD that “Kegel exercises help to strengthen the muscles that support the bladder, uterus and bowels.”  However, I’ve also read that not ALL women should be doing Kegels, only women with weak pelvic floors, and that doing Kegels could actually cause more harm than good for women with tight pelvic floors. So now I doubt the advice to “do Kegels.”

Is it bunk?

I mean how do I know whether my pelvic floor is weak or tight, or just normal? Would doing Kegels be helpful for birth if my pelvic floor is normal to begin with?


—Signed,

Kegel Confused

Dear Kegel Confused,

There’s so much information out there, it is difficult to know what is best for you. Being pregnant puts extra demand on the pelvic floor, simply because there is more weight that needs to be supported, among other things. During labor and birth, the muscles relax and stretch to accommodate the baby. Kegels are a “shortening” exercise, so when you voluntarily recruit them and do a Kegel, the muscles contract and therefore build strength (similar to a bicep curl).

The tricky thing about the pelvic floor is that it is on all the time to support us, maintain continence, and aid in sexual function. It’s working now to hold in urine and stool, and support your uterus and growing baby. As the demand increases on the muscles, they must be strong enough to continue to work properly and accommodate the new demands. Kegels will help strengthen the pelvic floor, not necessarily “relax” it, if you will. And, yes, it can be helpful in pregnancy if the muscles are beginning to tire out and become weak. Usually signs of weakness include stress incontinence, for example. But, it’s hard to tease that out in late pregnancy because the baby is also tap dancing on your bladder!

To really tell what state your pelvic floor is in, it is best to have an evaluation by a qualified physical therapist. She can evaluate your muscles and assess whether they are weak, short, or strong, and if you should be doing Kegels or not. To answer specifically if they would be helpful in birth, my personal opinion is that they are more helpful in the recovery of birth (if you are on the weaker side going into delivery).

If you are strong going into labor, and you are able to relax your pelvic floor and bear down appropriately, you may have a little easier recovery. Again, this is all woman-specific, and there are a lot of variables to take into consideration.

So…should you do Kegels while pregnant? It depends on where you are now, and what state your pelvic floor is in. Remember, your pelvic floor muscles are working all the time, so your pelvic floor may be perfectly strong and may be accommodating the pregnancy and added demand on them just fine, so you may not need to take any action, it really just depends on the woman.

So touching on the WebMD comment, it’s not completely bunk, because yes those muscles help support all those structures mentioned, but like I mentioned above, Kegels don’t help relax or lengthen the muscles, and that’s what you really need for birth. It’s all about balance. You want the muscles to be strong to continue to support you and the baby, and also decrease the risk of urinary incontinence after birth, but at the same time, you need to be able to relax them and control them appropriately.

The best way to learn how to do all those things is to have an evaluation by a qualified pelvic floor physical therapist. I believe the overall message here is that this is an issue that’s complicated with many variables. So an across the board edict to either “do Kegels” or “don’t do Kegels” is just not appropriate.

All my best,

Marcy

Looking for Answers for Penile Pain

Dear Liz,

I have had a mild pain at the head of my penis for almost a year now, mostly constant.  I have seen four urologists, one said he didn’t know what was wrong, while the others suggested prostatitis. All urine cultures were negative. All blood tests negative. The last urologist had me take a months’ worth of Cipro, and when nothing changed he told me he was stumped and could no longer help me. He then recommended another doctor. I contacted his assistant; she then told me they could not help me. I have seen naturopathic doctors as well and have taken months’ worth of homeopathic medicine with no changes.

Is this condition anything you are familiar with and if so has your practice helped such individuals?

 —Signed,

Looking for Answers

Dear Looking for Answers,

Unfortunately we hear stories like yours all the time. In many cases, when testing is negative and pain persists, the pain may be tied to the pelvic floor and surrounding pelvic girdle muscles and connective tissue. It will be beneficial to have an evaluation with a pelvic floor physical therapist. If there are no pelvic floor PTs in your area, I would be happy to evaluate you at our clinic. We have a program for Out-of-Town patients that you can view on our website. I recommend that you read this past blog post about male pelvic pain. Hang in there, things can get better!

All my best,

Liz

Central Sensitization versus Myofascial Pain

Dear Stephanie,

My question is, what is the difference between central sensitization pain and myofascial pain?

 —Signed,

CS Pain or MF Pain

Dear CS Pain or MF Pain,

This is a fantastic question. We have increasing evidence that central sensitization plays a large role in chronic pelvic pain states. We also know that myofascial impaiments are highly associated with pelvic pain. Most patients likely have a combination of both issues occurring if they have been in pain for a long time. Generally speaking, myofascial pain is usually specific and often manipulation or palpation of an involved structure can reproduce symptoms.

For example, if your burning was partially or completely caused by an inflamed nerve a PT should be able to palpate that nerve and reproduce that symptom. Pain that is more central in origin tends to be diffuse and bilateral. People with central sensitization also tend to have severe pain reactions to non-harmful stimuli. For example, if a patient sits for 15 minutes and then has severe pain causing him to lie down for three hours there is likely a central component.

However, these guidelines are only general examples to help you get the picture. Pelvic floor PT will use more specific guidelines, questionnaires, and criteria to determine what is happening with your symptoms. Myofascial pain and central pain are both young fields. There is still a lot we do not know and I do not think the two are as separate as we would like them to be. We will be posting a blog about central sensitization soon, so stay tuned!

All my best,

Stephanie

The Best Treatment for Vulvodynia, IC

Dear Liz,

What are the most effective treatments for vulvodynia and interstitial cystitis?

This is a very heavy question because there are no gold standards in the treatment of either vulvodynia or interstitial cystitis. There are many recommended treatments, of which some will be very effective for some people, but not effective at all for others. I think a good place to start is with a correct diagnosis. For example, I find that myofascial pelvic pain is often misdiagnosed as IC, a situation which will alter the treatment strategy considerably. Therefore, be sure that you’re being diagnosed by a physician that has considerable experience with these diagnoses.

As far as treatment goes, I think a multidisciplinary treatment approach is always best. That includes medical treatment (typically from a physician to treat any pathology that may exist), a physical therapist to treat the musculoskeletal system, a pain management specialist to perform any necessary interventional pain treatments and/or manage medications, and psychological support. Each patient is going to require a different combination of each of these components, but it’s important to consider all necessary disciplines when developing a treatment plan.

PN and Pregnancy: Is it Possible?

Dear Liz,

I am curious about your experience with your female patients with Pudendal Neuralgia who are of childbearing age.  Have any of your patients become pregnant after being diagnosed with PN?  I ask because I suffered an acute right pudendal nerve injury from childbirth.

 

Signed,

Pregnancy after PN?

Dear Pregnancy after PN,

Pregnancy can absolutely occur after a PN injury. It may take a little while to resume sex comfortably, but it does not affect fertility. PN injuries during childbirth do happen, but you can work with a PT to minimize symptoms during your pregnancy. Nerve irritation is common during pregnancy due to physiologic changes, swelling, and postural changes, however common is different than “normal,” and a pelvic floor PT can generally reduce some of the symptoms with manual physical therapy techniques, postural re-education, proper positioning, and use of a belt or cushion if appropriate. Your qualified PT can also educate you in birth positions that decrease strain on the pelvic floor if you are planning a vaginal delivery.

All my best,

Liz

If you have a question of your own, please take the opportunity to post it in the “comments” section of this blog, email it to us at  blog@pelvicpainrehab.com , post it on our  Facebook  page or  tweet  it to us. We want to hear from you!

All our best,

Marcy, Liz and Stephanie

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