00:00 – Dr. Kumar: We find that actually working with a pelvic floor physical therapist is more beneficial
00:05 – and treating that hypertonic pelvic floor is helping their symptoms finally.
00:25 – Melissa: Let’s move on to talk a little bit about pelvic floor dysfunction. So everyone always asks us
00:31 – the question, how do you know if the pelvic floor dysfunction caused the UTI or if the infection
00:36 – caused the pelvic floor dysfunction? And is it important to know or do you just have to get to the bottom of both?
00:43 – Dr. Kumar: I think it is important to know. There are women
00:51 – who I’ve seen who’ve had UTIs and I think the pain has caused them to have pelvic floor dysfunction.
00:58 – And then they still feel like they have a urinary tract infection but when we
01:06 – say, okay maybe it’s an untreated UTI and they get more antibiotics, their symptoms don’t
01:11 – change, and on exam you can really feel that those muscles are contracted and
01:18 – they’re not relaxing, and then we find that actually working with a pelvic
01:24 – floor physical therapist is more beneficial. And treating that hypertonic pelvic floor
01:31 – is helping their symptoms finally. So I think that unless the pelvic floor dysfunction
01:39 – is causing urinary retention which is then causing a urinary tract infection, it’s more likely
01:46 – the opposite, where the urinary tract infection, a painful stimulus is then causing
01:52 – a very reactive pelvic floor. And some people do have pelvic floor dysfunction and
01:57 – hypertonicity in the absence of a UTI. I’ve seen it happen just from women who have
02:05 – vaginal dryness or vestibulodynia and like having any sort of sexual activity is
02:12 – so painful that it then puts their pelvic floor into a very spastic state. So pelvic
02:18 – floor dysfunction doesn’t necessarily have to be from a UTI. I think it can come from
02:23 – many different causes but I don’t think that pelvic floor dysfunction
02:30 – causes UTIs unless it contributes to incomplete bladder emptying.
02:35 – Melissa: What about a pelvic floor that is too loose rather than too tight? Could that contribute to infection or vice versa?
02:44 – Dr. Kumar: Pelvic floor laxity, if it results in a prolapse, like if there’s a dropped bladder
02:52 – and a woman is not emptying her bladder completely then it can contribute to infection,
03:01 – but I think the mere sort of laxity of the pelvic floor is not an integral step
03:08 – in how women get infections, unless it’s they develop a prolapse.
03:13 – Melissa: And is treatment in most cases physical therapy, or is surgery sometimes involved?
03:18 – Dr. Kumar: For pelvic floor laxity…So for hypertonic pelvic floor muscles, or dysfunctional voiding
03:31 – where the pelvic floor sort of paradoxically contracts when a person wants to urinate,
03:38 – there’s not really a good surgical treatment, that’s really physical therapy, you know
03:44 – relaxation. Sometimes we use topical, sometimes we use intravaginal valium or baclofen or gabapentin.
03:50 – Stress reduction is really important for that.
03:55 – For pelvic floor laxity, if a woman has a symptomatic dropped bladder where she feels
04:02 – a bulge, she’s not emptying her bladder completely, she’s uncomfortable she feels a heavy pressure
04:08 – from the descent of the pelvic organs, then surgery is an option, yes.
04:18 – But pelvic floor physical therapy is usually the first option and then if that’s not
04:24 – effective then surgery would be the next option. And there are also devices like
04:28 – pessaries for example, which women can use to reduce the prolapse without
04:35 – having to have surgery and those are often pretty effective. But that’s of course also a matter of personal preference.
04:43 – Melissa: Something like a pessary, do you need to use that
04:46 – 24 hours a day or only when you’re not sleeping? And I imagine that’s also an object that
04:52 – could contribute to infection of some kind as it’s a foreign object. What are the risks around that?
04:57 – Dr. Kumar: So if I have a woman who has a pessary who’s getting recurrent UTIs I do usually advise
05:05 – that we try to leave it out for the duration that we’re treating the UTIs. And then if she wants
05:11 – to start wearing it again I usually recommend that it gets changed more frequently.
05:17 – Some women are able to manage their pessary on their own which is optimal because then,
05:24 – what I will usually tell my patients is wear it during the day, take it out at night,
05:28 – wash it with soap and water, put it wherever you want to keep it and then you
05:33 – can put it back in the next morning. Some women do not feel comfortable managing their pessary on
05:39 – their own and so they need to come to the doctor’s office for pessary
05:45 – care visits. And those are typically once every three months. So once every three months
05:52 – they’ll come in and either the doctor or the nurse practitioner or the PA will take the
05:58 – pessary out, clean it and then reinsert it. And I think, I’ve had a lot of patients who
06:05 – are managing their pessary like that and they don’t get urinary tract infections.
06:09 – And I think that’s fine if you’re not someone who’s prone to UTIs and that regimen
06:14 – works for you that’s fine. But in the women who are doing that who do get UTIs, yes I usually will
06:20 – say let’s leave this out for a little while or if three months is too long for you
06:27 – and we need to change it sooner that makes sense.
06:33 – Melissa: And with the pelvic floor physical therapists, are there particular professionals that you work with and refer
06:38 – patients to, or is that something patients have to find on their own?
06:45 – Dr. Kumar: No, we definitely refer in our practice. We have a list of pelvic floor physical therapists, most of whom we know personally and
06:54 – pelvic floor physical therapists who I know to be very good. So these are the ones who
06:58 – I recommend. I usually give my patients a list of therapists and then they need a referral as
07:06 – well. Sometimes their insurance, depending on their plan, sometimes their insurance will cover
07:10 – it and sometimes they won’t. And I think a big thing with pelvic floor physical therapists
07:15 – is that most of them are very good at helping women do strengthening exercises
07:22 – for things like urinary leakage or overactive bladder, but I think it’s much more difficult
07:30 – to work with women who need to do pelvic floor muscle down training and how to relax
07:36 – those muscles. And certain stretching techniques, and they do like myofascial release and massage.
07:42 – So it takes a really good pelvic floor physical therapist to know that and I know this
07:49 – because when I first started practicing I had a patient who did have pelvic floor dysfunction and
07:54 – I sent her to a pelvic floor physical therapist and when she came back she said, I’ve
07:58 – been doing these kegels and I’m like, no you’re not supposed to be doing kegels. So
08:06 – I then became sort of very selective about the therapist that I send my patients to.
08:12 – Melissa: We’ve actually heard from a few people in that situation as well where they’ve gotten worse
08:16 – because they’ve been given strengthening exercises when that was the issue in the first place.
08:21 – Dr. Kumar: Right. Or the therapist is not attuned to the degree of pain the patient is having from the therapy
08:30 – and then if it’s painful I think that can also make things worse because when something
08:37 – is painful you clamp down and when you clamp down in those muscles you build lactic
08:42 – acid and it’s like a muscle cramp and then it’s more painful. And so it’s a vicious cycle.
08:48 – So yeah, I’m very selective about the therapist that I send those patients to.
08:55 – Melissa: Do you see patients with hypertonic pelvic floor actually getting to the point over time where they
08:59 – no longer need therapy or does it often end up being a long-term issue?
09:06 – Dr. Kumar: I do. I’ve seen, I have a few young patients who have been in this cycle where like for example they’ve
09:14 – been on a birth control pill and then they develop some dysuria or hormonally mediated
09:21 – vestibulodynia, which can happen on the pill. And then intercourse becomes really painful
09:28 – and then they develop pelvic floor hypertonicity because of all the discomfort. And then in addition,
09:34 – you know it’s like plus or minus UTIs. Some of them are also getting UTIs,
09:39 – and some aren’t and in the same way that that sexual activity can be
09:44 – a risk factor for UTIs, if you’re doing pelvic floor physical therapy with
09:50 – dilators and myofascial release, it’s actually the same type of risk because it’s
09:57 – that vaginal penetration and that manipulation of bacteria in the area that can also make you more
10:04 – prone to getting a UTI. So what I find is that we get into these vicious cycles.
10:11 – And I tend to follow those patients really closely and in addition to using
10:19 – things like topical estrogen and testosterone, if they’re going to be using dilators or
10:25 – doing their physical therapy and they’re prone to urinary tract infections, I’ll say,
10:30 – we have to treat that like sexual activity and you take a nitrofurantoin after. Because
10:35 – if you’re doing physical therapy and it’s helping your pelvic floor but then you’re getting a UTI
10:40 – it’s difficult. So we have to be aggressive about UTI prevention.
10:46 – Make sure that the physical therapy, that they’re actually progressing and that they’re
10:50 – not just lost in sort of this, yeah I’m going every week but I don’t know, sometimes
10:56 – my symptoms are a little better or sometimes they’re not. I think you have to follow patients really closely
11:00 – because if it’s not working you really want to identify why. What’s going
11:08 – on that can potentially be changed, or that you can improve to get them to benefit from the
11:13 – physical therapy more. And I think when you do it with those other strategies like UTI
11:19 – prevention, treating the vestibulodynia, you know the patient’s going to derive greater
11:26 – benefit from the physical therapy as well. So you often have to use a multimodal approach.
11:32 – Melissa: That’s really helpful information. I think a lot of people do get into that place where they’re just
11:36 – not progressing and they’re not getting the support that they need to progress. So it’s good to look at it from that perspective.
11:44 – Dr. Kumar: Right. That’s when I bring you in close.