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Course Title: Men’s Health Issues: An Introduction from Front to Rear
Presenters:
Daniel J. Kirages, DPT, OCS, FAAOMPT
Jason J. Kutch, PhD
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With 6-12% of men suffering from chronic pelvic pain and 4-21% of men experiencing
incontinence the role of physical therapy for men’s health issues has never been more important.
Whether the symptoms are pelvic region pain in a younger group or bladder control problems in
an older group, either way we as physical therapists play a large part in their recovery. Please
join us so we can guide you through several clinical presentations of men’s health issues
throughout the lifespan. You will see both low-tech and high-tech methods of investigation and
intervention to assist with proper clinical decision making. This population needs you and this
presentation will be a link towards adding them into your daily appointment schedule.
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Note: Registration fee does not include special events or preconference course fees.
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DEADLINE 12/21/12
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SPECIAL EVENTS (OPTIONAL)
Course Objectives: Participants will learn about:
PT-PAC’s 40th Anniversary Celebration at the House of Blues | Wednesday, January 23, 2013 |
Fee: $40. Fee is nonrefundable. If a registrant cancels, this fee is not refunded.
Catch the Buzz Networking Coffee | Wednesday, January 23, 2013 | 6:30 am – 8:30 am | Tickets
Sponsored by the Foundation for Physical Therapy and the Home Health Section
PRECONFERENCE COURSES AND FEES (OPTIONAL)
1. Common concepts of men’s health issues:
a. Bladder and bowel dysfunctions including post-prostatectomy incontinence
b. Pelvic region pain syndromes
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outstanding dues will be charged the nonmember registration fee.
2. Anatomical and physiological mechanisms that potentially contribute to male pelvic floor
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3. Principles of examination, evaluation, and intervention of common male pelvic floor muscle
dysfunctions using sEMG, 2D and 3D sonographic imaging, manual therapy, behavioral
techniques, and therapeutic exercise.
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5. Existence of men’s health issues within a typical outpatient musculoskeletal setting and why
we should embrace learning more about this population.
6. Ongoing research efforts to determine useful screening tools via sonographic imaging, sEMG
and fMRI to enhance the effectiveness of physical therapy evaluation and intervention.
Topic #1 – Physical Therapy for Post-Prostatectomy Incontinence - (D. Kirages)
Assist in answering some very common questions:
• Why does incontinence occur?
• What is the pelvic floor muscle?
• What can be done to help me regain control?
• How long will it take?
Prostate Cancer (CaP)
• Surgical Options
• Robotic assisted
• Open procedure
Continence Recovery Timeline
Exp Date
Behavioral / Conservative Management
• Scheduled voiding
• prompting person to urinate at designated time
• Usually every 2 hours
• maintain dryness
•
Fluid/Food Education
• caffeine (coffee, tea, soda, chocolate)
• citric acid (orange, grapefruit, lemon juice)
• carbonated drinks (soda, ginger ale, tonic)
• alcohol
Pelvic Floor Exercises
• Retraining the Pelvic Floor Muscle
• exercises
• biofeedback
• electrical stimulation
Pelvic Floor Muscle Awareness Training
• Verbal cues / responses
• holding back gas expulsion
• holding urine in during urge
• stopping urine stream
• “clearing the line”
• penis wiggle
• contraction during ejaculation
•
Common errors
• holding the breath
• bearing down (Valsalva Maneuvor)
• tightening abdominals
• tightening buttocks
Effective conditioning requires proper:
• isolated muscle group
• sufficient load intensity
• duration of exercise
• training within specific activity
• adherence to maintenance program (Johnson, 2001)
Exercise Progression
• Phases 1-2 – Supine (Week 1-5)
• Phases 3-4 – Sitting (Week 6-12)
• Phases 5 – Functional (Week 13-16)
Motor Plan Development
• Anticipatory contraction
• Repetition
Topic #2 – Physical Therapy for Voiding Dysfunction - (D. Kirages)
Chief Complaints
• Urinary difficulties
• Fecal difficulties
• Ejaculate difficulties
• Incontinence
Symptoms
• Frequency / Urge
• Nocturia
• Hesitancy
• Weak stream
• Split stream
• Not emptying
• Straining
• Post-void dribble
• Fragmented stools
• Thin stools
• Fullness in rectum
• Low ejaculate force
Bladder Retraining
• Gradually increase of voiding interval (2-4 hrs)
• Delay of voiding
• Urge Suppression
• detrusor inhibition with PFM relaxation
• parasympathetic quieting
• cognitive distraction
Lifestyle Modification
• Improvements in posture
• Increase LE exercise frequency
• Stress reduction
• Diaphragmatic breathing
• Avoid aggravating factors
Topic #3 – Physical Therapy for Male Pelvic Pain - (D. Kirages)
Typical referred medical diagnoses
• chronic prostatitis
• levator ani syndrome
• coccygodynia
• pudendal neuralgia
Descriptions of Pain
• “It feels like a knot between my legs.”
• “I feel like I am sitting on a golf ball.”
• “The tip of my penis burns.”
• “My testicles ache after ejaculation.”
• “Burning feeling in my groin area.”
Aggravating Factors
• Prolonged sitting
• Running
• Lifting heavy items
• Holding back urge to urinate
• Ejaculation
• Riding a cycle
Easing Factors
• Standing up
• Sitting on toilet
• Warm bath
• Post - bowel movement
• Post - urination
What will a physical therapist do?
• Perform an examination to look for body structure and function deficits in:
o Mobility – contributions from lumbar spine, SIJ, hips
o Flexibility – contributions from intra and extra-pelvic region musculature and
tissues (PFM,adductors,abdominals,gluteals,etc)
o Power/Endurance – pelvic floor muslce (muscle performance – awareness,
concentric, eccentric loading)
o Motor Coordination – proper synergy during voiding, evacuation strategy for BM,
selective relaxation and activation when needed, with respiration
How will a physical therapist intervene?
A typical interventional skill set will include:
Manual therapy
• Joint mobilization (lumbar spine, sacro-iliac joint, hip, thoracic spine)
• Soft tissue mobilization (stretching, trigger point release, skin rolling, etc.)
Neuromuscular reeducation
• Pelvic floor awareness training
• Respiration training (relaxation, autonomic nervous system adjustment)
• Biofeedback / down-training
Therapeutic exercise
• Stretching
• General activity – walking program
Patient education / counseling
• Condition / behavioral modification / fear reduction / positive thinking / biologise
Topic #4 – Male chronic pelvic pain: the state of the science (J. Kutch - ampl.usc.edu)
The diagnosis of chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is most commonly
used in the research literature.
Current critical research questions:
• Chronicity of symptoms: problem in the pelvis, problem in the brain, or both?
• Initiation of symptoms: how does a person transition from acute to chronic?
• Most effective paradigms for inducing neuroplasticity and returning patient to health?
Recent findings:
• Heightened pelvic floor EMG predictive of CP/CPPS symptoms [1].
• Brain activity associated with CP/CPPS symptoms [2].
• Stress markers elevated in CP/CPPS patients [3].
• Uncontrolled trial: CP/CPPS patients reduce EMG with biofeedback [4].
Relevant neuromuscular research tools:
• Intra-rectal electromyography (EMG).
• Trans-perineal sonographic imaging (ultrasound).
• Functional magnetic resonance imaging (fMRI).
Research challenges and new approaches:
• Is brain activity in CP/CPPS patients a marker of altered brain function or normal?
• Randomized controlled trials of EMG biofeedback needed.
• What are the optimal conditions for biofeedback: stress or no stress?
Course objectives:
• Understand current objective biomarkers of CP/CPPS.
• Interpret brain imaging data in CP/CPPS and understand need for careful controls.
• Conceptualize different models for CP/CPPS pathogenesis.
References (DK):
1. Anderson RU, Wise D, Sawyer T, Chan C. Integration of myofascial trigger point
release and paradoxical relaxation training treatment of chronic pelvic pain
in men. J Urol. 2005 Jul;174(1):155-60.
2. Parekh AR, Feng MI, Kirages D, Bremner H, Kaswick J, Aboseif S. The role of pelvic
floor exercises on post-prostatectomy incontinence. J Urol. 2003 Jul;170(1):130-3.
3. Berger R.E.,. Ciol M.A,. Rothman I, and. Turner J.A. Pelvic tenderness is not limited to
the prostate in chronic prostatitis/chronic pelvic pain syndrome (cpps) type iiia and iiib:
comparison of men with and without cp/cpps. BMC Urology, 7(1):1–7, 2007.
4. Anderson RU, Wise D, Sawyer T, Chan CA. Sexual dysfunction in men with chronic
prostatitis/chronic pelvic pain syndrome: improvement after trigger point release and
paradoxical relaxation training. J Urol. 2006 Oct;176(4 Pt 1):1534-8; discussion 1538-9.
5. MacDonald R., Fink H.A., Huckabay C., Monga M., Wilt T.J. Pelvic Floor Muscle
Training to Improve Urinary Incontinence After Radical Prostatectomy: A Systematic
Review of Effectiveness. British Journal of Urology International (2007); 100:76–81
6. Weiss J. Pelvic floor myofascial trigger points: Manual therapy for interstitial cystitis and
the urgency-frequency syndrome. The Journal of Urology 2001: 166:2226-2231
7. Campbell SE, Glazener CM, Hunter KF, Cody JD, Moore KN. Conservative
management for postprostatectomy urinary incontinence. Cochrane Database Syst Rev.
2012 Jan 18;1:CD001843. Review.
8. Goode PS, Burgio KL, Johnson TM, Clay OJ, Roth DL, Markland AD, Burkhardt JH,
Issa MM, Lloyd LK. Behavioral Therapy With or Without Biofeedback and Pelvic Floor
Electrical Stimulation for Persistent Postprostatectomy Incontinence. JAMA.
2011;305(2):151-159. doi:10.1001/jama.2010.1972
References (JK):
1. Hetrick DC, Glazer H, Liu YW, Turner JA, Frest M, et al. (2006) Pelvic floor
electromyography in men with chronic pelvic pain syndrome: A case-control study.
Neurourol Urodyn 25: 46-49.
2. Farmer MA, Chanda ML, Parks EL, Baliki MN, Apkarian AV, et al. (2011) Brain
functional and anatomical changes in chronic prostatitis/chronic pelvic pain syndrome. J
Urol.
3. Anderson RU, Orenberg EK, Chan CA, Morey A, Flores V (2008) Psychometric profiles
and hpa axis function in men with chronic prostatitis/chronic pelvic pain syndrome
(cp/cpps). J Urol 179: 956.
4. Cornel EB, van Haarst EP, Schaarsberg RWM, Geels J (2005) The effect of biofeedback
physical therapy in men with chronic pelvic pain syndrome type iii. European urology 47:
607-611.
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