SAUGA NEWSLETTER SEPTEMBER 2017
Welcome

Message from the Editor:

We face a glorius New Spring, albeit a dry one, given the lack of rain in these areas of the Western Cape.
This newsletter has two great papers, both of importance that promise to enlighten
the readership, save the date in your diaries 1 & 2 November for the next Pelvic Academy workshop in Cape Town.
See you there!
Dr Peter De Jong

Message from the President:

In August this year, SAUGA hosted its 11th biennial congress at Inkosi Albert Lethuli Central Hospital. It was indeed an academically stimulating meeting which included 3/ 4 dimensional pelvic floor ultrasound and laparoscopic surgery. Professor Giulio Santoro highlighted the clinical relevance of ultrasound assessment of the pelvic floor with special attention to methodology. This was followed by a live demonstration of a 4th degree perineal tear repair illustrating anatomy and technique. Dr Hafeez Rahman elegantly performed a laparoscopic neovagina using peritoneum from the pouch of Douglas in a patient with Rokitansky syndrome amongst other urogynaecological procedures. Delegates enjoyed a number of interesting talks, interaction with industry and great Indian food to mention the least! A special thank you to Dr Suran Ramphal and his team and to our members who attended and supported this meeting.

-“Action without vision is only passing time. Vision without action is merely day dreaming. But vision with action can change the world’’- Nelson Mandela

Yours sincerely
Dr Zeelha Abdool
SAUGA President

PELVIC ORGAN PROLAPSE: APPROACHING IT FROM A NEURO-MUSCULOSKELETAL PERSPECTIVE…

INTRODUCTION
Pelvic organ prolapse (POP) has a multifactorial pathophysiology and a complex etiology that is still poorly understood. Levator ani muscle defects play a major role in the pathophysiology of POP, but does not account for all POP.

Adverse changes in the levator ani muscle function have been associated with early presentation and also recurrence of prolapse after surgery (Bo et al. 2007). The problem is, however, that etiology and management does not always focus on all neuro-musculoskeletal aspects, in what is actually a very complex and integrated mechanism of pelvic support (Grewar and McLean 2011) and motor control (Figure 1).

Multiple aspects of the neuro-musculoskeletal and other systemic systems can contribute to failure of pelvic support.

Coordinated interaction of the articular, myofascial, neural and connective tissue systems of the body, as well as other autonomic systems, together with environmental and personal factors, is necessary for prevention of symptoms, disability, and dysfunction (Comerford et al. 2005). Disturbance of any of these systems may lead to poorly coordinated PFM contraction, or increased demands on the other sub-systems, and consequently failure of a component, resulting in urinary and/or faecal incontinence, prolapse of the anterior and posterior vaginal wall, the vaginal apex and uterus, or pain and sexual dysfunction (Bo 2004).





Figure 1. The neuro-muskuloskeletal control system (Adapted from Grewar & McLean 2011, Comerford et al. 2005).

THE ACTIVE (MUSCULAR) SUBSYSTEM

The PFM function in an interrelationship with other muscles, such as the transversus abdominus muscle, the diaphragm, and the multifidus muscle, as part of the core musculature. If these muscles function in good coordination, it will lead to a decreased intra-abdominal pressure (IAP) which is an important factor to consider with POP.
However, if any one of these core muscles are affected or inhibited by factors such as pain (which include pain from the lower back, pelvis or viscera), or trauma due to surgery or labour, it will affect the function of the other muscles in order to compensate for the loss of function. It is usually the PFM and abdominal muscles which are affected/inhibited. The compensation may lead to an increased tone/overactivity in the other muscles. For example, if the abdominal muscles are weak or inhibited due to pain after abdominal surgery, it may affect the PFM to increase its activity, leading to pelvic pain. However, overactivity of the PFM leads to weak PFM function, therefore contributing to POP.

It has also been indicated that weak PFM contraction is actually substituted by increased activation of the global rather than the local abdominal stabilisers. This strategy may lead to increased stress on the ligaments and fascia and worsen symptoms of prolapse and incontinence by increasing IAP and causing PFM descent.

It is also important to consider that dysfunction of the core muscles and increased IAP is one of the important factors that causes lower back and pelvic pain. The opposite should also be considered (as explained above): namely, that pain from these joints may cause inhibition of the core musculature and therefore contribute to loss of pelvic organ support.



THE PASSIVE (ARTICULAR) SUBSYSTEM

Weakness of the PFM, whether it is due to primary or secondary reasons, may lead to decreased support of the pelvic organs, and increased tension on the ligaments. Lengthening of connective tissue in the muscles and ligaments due to the traction forces of prolapsed pelvic organs, leads to increased tension up to a point where failure might even occur in these structures. The problem is however, that all connective tissue/fascia is continuous, from the muscles to the pelvic organs. Failure/disruption at any point in this continuation of fascia and ligaments, whether it is due to surgery or the consequence of the POP itself, will contribute to the dysfunction in all of the other components (muscle, viscera, and ligaments).

NEURAL SUBSYSTEM

The fascia, muscle and ligaments are richly supplied by afferent and efferent nerve endings which are affected by any trauma or change in muscle tone/length leading to alteration in the neural input and output mechanisms.

It is however not only the peripheral nervous system that should be considered, but also the central nervous system where the processing mechanisms can be affected by cognitive and affective factors related to POP, or by associated chronic pelvic or lower back pain.

Pelvic floor muscle dysfunction (PFD) may be socially embarrassing and may cause the patient to avoid certain social situations, for example to withdraw from participating in leisure, sport and physical activities. This may eventually lead to a life-long avoidance of health and fitness activities, a lower activity level, and thus an increase in mortality and morbidity (Bo 2004).



CONCLUSION

POP, from a neuro-musculoskeletal perspective, is related to a complex interaction of muscle, articular and neural function in the lower back and pelvic area, but also to other types of PFD. It should therefore be recommended that the neuro-musculoskeletal components in the pelvic and lower back areas, as well as its underlying structures, be assessed when managing patients with POP or any other form of PFD.

Some take home messages

The muscles, such as the levator ani, can contribute to dynamic as well as static support of the pelvic organs. The dynamic support is provided by means of muscle activity, and the static support by means of the effect of the muscle activity on the connective tissue (such as ligaments and fascia) to which it is connected.


Similar to the case of pelvic floor dysfunction and pain, the stabiliser muscles exhibit disturbed motor control patterns and changed physiological properties, in individuals with low back pain (Hodges & Richardson 1996). On the other hand, altered postural activity and morphological changes in these muscles, are related to the development and the recurrence of low back pain (Cholewicki et al. 2005). Pain may cause inhibition of the stabiliser muscles, and therefore contribute to PFM dysfunction such as POP and even incontinence (Comerford & Mottram 2001).


Dysfunction of the TrA muscle may lead to either increased tone of the PFM, or weakness due to failure in response to sustained overload and compensation.


REFERENCES

Bo, K. (2004). Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Medicine, 34(7):451-464. DOI:0112-1642/04/0007-0451.

Bo, K., Berghmans, B., Morkved, S. & Van Kampen, M. (2007). Evidence-based physical therapy for the pelvic floor. London: Churchill-Livingstone.

Comerford, M.J. & Mottram, S.L. (2001). Movement and stability dysfunction – contemporary developments. Manual Therapy, 6(1):15-26. DOI:10.1054/math.2000.0388.

Comerford, M.J., Mottram, S.L. & Gibbons, G.T. (2005). Understanding movement and function. Kinetic Control. Course manual. United Kingdom.

Cholewicki, J., Silfies, S., Shah, S., Greene, H., Reeves, N., Alvi, K. & Goldberg, B. (2005). Delayed trunk muscle reflex responses increase the risk of low back injuries. Spine, 30:2614-2620. DOI:10.1097/01.brs.0000188273.27463.bc.

Grewar, H. & McLean, L. (2008). The integrated continence system: A manual therapy approach to the treatment of stress urinary incontinence. Manual Therapy, 13:375-386. DOI:10.1016/j.math.2008.01.003.

Hodges, P. & Richardson, C. (1996). Inefficient muscular stabilization of the lumbar spine assosciated with low back pain. A motor control evaluation of transversus abdominis. Spine, 21:2640-2650. DOI:10.1097/00007632-199611150-00014.

  
CANCER AND SEXUAL DYSFUNCTION - Corina Avni

Co-morbidity in the pelvis is common. Not only can dysfunction in one compartment effect function in another, but systemic diseases and their treatments may also impact on pelvic function. When that disease is cancer, and indicated management includes surgery, chemotherapy and/or radiotherapy, the impact can be profound. Many pelvic or androgen-specific cancer patients and survivors suffer from sexual dysfunction, ranging from mild to debilitating.

Whilst individuals differ, certain patterns can be identified. This is relevant to the cancer e.g. vaginal dryness / atrophy post breast cancer, or erectile dysfunction post prostate cancer; and treatment e.g. vaginal shortening and tightness post surgery or radiotherapy.

As a general rule women usually complain of pain due to tightness and decreased lubrication, although some may present with a lack of sensation. This is true for gynae, bowel and breast cancers. Treatment includes gentle stretching and release of focal tight spots. Initially this is done by the physiotherapist, but soon the patient learns to identify areas of restriction or holding, and starts to self-release or dilate. Breath-work, awareness, and the ability to ‘let go’ are essential components in managing the bracing reaction with initial discomfort, which aggravates tightness causing pain. If scarring involves nerves, connective tissue mobilisations can help to improve circulation, normalising neural function and decreasing pain. Usually, a few sessions of pelvic physiotherapy are enough to loosen things up adequately; maintenance happens at home with dilators or vibrators, and can be incorporated into foreplay and sex.

Sexual dysfunction may begin during cancer treatment or it may present later. A recent study on the baseline characteristics and concerns of female cancer patients/survivors seeking treatment at a Female Sexual Medicine Program (Carter et al. 2015) reported on data from 509 women of whom 97% completed a patient-reported outcomes questionnaire, and 50% received a pelvic examination. The majority had a history of breast (51%), gynae (36%), or colorectal/anal (7%) cancer. As many as 44% experienced pain during their exam (23% mild, 11% moderate, 1.5% severe, 8.5% not indicated). Approximately half had moderate/severe dryness (51%) and dyspareunia (46 %). In a follow-up study they advised the use of vaginal moisturizers and lubricants, pelvic floor exercises, and dilator therapy, in addition to psychosexual education regarding sexual changes associated with cancer treatment and reported “significant changes were observed in women using treatment strategies, with improvement in vulvovaginal symptoms, a decrease in elevated vaginal pH and pain with exams, enhanced sexual function, and increased intimacy confidence” (Carter et al. 2017). A clinical guide to the management of genitourinary symptoms in breast cancer survivors on endocrine therapy advises conservative treatment options that include behavioural therapy, electrical stimulation, pelvic floor muscle training, watchful waiting therapy and anti-incontinence/vaginal supporting devices (Sousa et al. 2017). Quality of life after cancer becomes the clinical challenge.

A systematic review of treatment of female sexual pain disorders shared the following critical review of physiotherapeutic modalities - “this category comprised a heterogeneous group of therapies, and the methodological quality of the studies was similarly quite mixed. There were three controlled studies identified but all of the other studies used uncontrolled prospective designs. Some of the studies reviewed also had very small sample sizes and few involved any long-term follow-up”. (Al-Abbadey et al. 2016). They went on to conclude that a multidisciplinary team with active patient involvement may be needed to optimize treatment outcomes in these complex chronic patients.

It is essential to acknowledge the complexity of female sexual dysfunction, best managed by a multidisciplinary team including doctor, psychologist/sexologist and pelvic physiotherapist. One hundred and forty-three of the 188 (general) pain clinics currently in existence within the United Kingdom and Republic of Ireland responded to a 2015 survey (response rate - 76%), of which 84% reported to use a multidisciplinary approach, whilst 16% did not. They acknowledge that “much progress has been made within this sphere in comparison to the 1980s; however, this may have stalled to a degree over the last decade or so and it is hard to see this improving given the precarious financial and political position of the NHS in general” (Kailainathan et al. 2017). It is not surprising that South Africa lacks the resources to support similar initiatives, given our financial and political situation. Another 2015 report from the UK on radiotherapy for pelvic cancers (prostate, ano-rectal, cervical and endometrial) stated that “Macmillan Cancer Support estimate as many as 350 000 people in the UK experience sexual consequences of cancer and its treatment, an aspect of survivorship and rehabilitation that receives relatively scant attention in service provision, policy development and research terms” (White 2015). South African numbers are unknown, and most patients do not receive the care they should.

Men face different challenges; they seldom have pain per se, but erectile dysfunction is reported in a variety of patient groups. Jo Milios , an Australian Men’s Health physiotherapist, has treated over 3000 prostatectomy patients in the last 10 years and advocates a strict program of pelvic floor exercises (to get the muscles going) and an erection pump (to maintain penile mobility, as the normal nightly ‘housekeeping’ erections are lost for a few months after surgery). She reports that most men are dry and sexually functional around 3 months post operatively, if they start the program a month before surgery. Penile rehabilitation plays an integral role in male recovery. The Vacuret , a proudly South African vacuum erection device, offers an acceptable self-management option to regain and maintain erectile function post radical prostatectomy, and has sold more than 200 000 devices worldwide in countries such as the USA, UK, Europe, Australia, India and other Southern African countries. Conquering Incontinence by Peter Dornan is a useful tool for those men who refuse to give-up on being dry, but an assessment by an appropriately trained physiotherapist should be standard.

That is not to say that men don’t get pelvic pain post cancer, it’s just not sexually relevant. We are more likely to see pain elsewhere in the pelvis and presenting at different times e.g. before, during or after a bowel motion, or a constant sense of bladder urgency. Also, men do get pain related to sex, but not necessarily because of cancer; more likely to be prolonged exposure to sitting, or high levels of anxiety.

Of course, sexual dysfunction after cancer in the pelvis is understandable – there are many people for whom simply having had cancer (anywhere) has a profound effect on their sexual being. Please email womenshealth@saphysio.co.za for a list of appropriately trained physiotherapists in your area – both Women’s Health and Men’s Health. Note: it is an uncommon special interest and there is no guarantee that you will have easy access to a trained therapist, but clinicians are encouraged to identify referral sources, and make use of the multidisciplinary team at their disposal.


The exhaustion of the clinical journey is etched on many patients’ faces. Sumintha Gokool , a Durban physiotherapist with a special interest in oncology and women’s and men’s health, says “we see a lot of cancer survivors who deal with the diagnosis, surgery, and radio- or chemotherapy as if they were on autopilot. However, when faced with the debilitating effects that the disease and treatment have on their endurance, strength and function, they are neither mentally nor physically prepared for it.

Physiotherapy rehabilitation (especially early intervention) includes assessment, exercises to improve endurance and strength, manual techniques as well as individualised education to help maintain and improve their functional abilities." Those who embark on rehabilitation are not assured of success, but many will experience an improvement in their sense of wellbeing, both physically and psychologically. The multidisciplinary team has a great deal to offer this vulnerable group of suffers and survivors.

Bio:

Corina Avni is devoted to pelvic function as a Women’s and Men’s Health Physiotherapist, with special interests in chronic pelvic pain and gait. She sees men, women and children in rooms at Kingsbury Hospital.

Mugshot:


References available on request.
Picture Gallery
  

Thank you to Professor H Cronje for the stunning images

SAUGA NEWSLETTER September 2017