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Pelvic Floor Dysfunction and Problem Trigger Points in Other Areas of the Body

Symptoms of pelvic floor dysfunction (PFD) include urinary urgency and frequency, a feeling of incomplete urination, decreased urine flow and constipation, pelvic pain with intercourse, pain in the back of the vagina, pain in the testicles (and/or penis), and pain in the lower back. Sound familiar? If you read our last column you will understand that there is a debate between doctors, whether IC is caused by PFD, or whether PFD can cause IC. Are both theories right? There are doctors who believe that IC is caused by different things in different people. No one really knows yet.

What we do know is that about 70% of IC patients don't have a normal cooperation of parts in their pelvic floor muscles. Urination depends on muscle coordination between the bladder and the pelvic floor muscles. The muscles of the pelvic floor are meant to relax while the bladder contracts. However, in PFD, the pelvic floor muscles continue to tighten when the bladder contracts. The result is poor urine flow. Experts in PFD believe that straining and pushing to get the last drop of urine out, further aggravates the muscles of the pelvic floor. Thus, a vicious cycle develops.

A Case Study - Mary Jo

When Mary Jo came to our last support group meeting she told us that she was feeling much better. Mary Jo had been to see Susan Guynes, a physical therapist who specializes in PFD, at Louisiana State University Medical Center. Mary Jo was diagnosed with IC only a few months ago and has had other health problems for many years. She has learned to be proactive with her health-care, so getting a handle on her IC seems to come naturally.

Along with her medication, Mary Jo practices pelvic floor relaxation exercise every day, several times a day. As a matter of fact, she brings a mat to work so she can practice during work hours. Mary Jo's exercise focuses on relaxing the muscles of her pelvic floor, especially the urethral sphincter (refer to the graphic of the pelvic floor in our May column). In order to first locate the area of her urethral sphincter and the surrounding tissue, Mary Jo had to stop her urine flow during urination. This allowed her to locate her muscles and feel how they work. Mary Jo's relaxation exercise works by tightening specific muscles in her pelvic floor before relaxing them.

When Mary Jo tried amitriptyline she couldn't empty her bladder completely. Her doctor explained that her bladder was quite large and didn't drain well, and the amitriptyline didn't help because it caused her bladder to over-relax. Mary Jo's doctor prescribed a medication to help her to empty her bladder and she has been taking Elmiron. Mary Jo's physical therapist also uses pelvic floor tissue release. This is an external rather than internal massage (or hands-on release) of the tissue around the ramus (refer to our graphic of the pelvic floor in our May column). I have found this soft tissue work to be extremely helpful. I have actually experienced very bad bladder pain subside with the release of this tissue. However, when the work was too close to the urethra it set off my bladder symptoms.

Prevention & Other strategies for Pelvic Floor Dysfunction

There are a variety of techniques that can be used to address pelvic floor dysfunction, including:
  • bladder training (to strengthen the bladder muscles)
  • internal massage to address the perineum (the area between the anus and vagina in women, and between the anus and base of the penis in men)
  • biofeedback
  • trigger point therapy (anesthetic agents are sometimes injected into tender points in the pelvic floor)
  • TENS unit (transcutaneous electrical nerve stimulation to block pain, increase blood flow and strengthen the problem muscles)
  • musculoskeletal treatment (myofascial therapy and chiropractic adjustments)
  • acupuncture
  • dietary modifications (to prevent bladder spasms, constipation and dehydration)
  • warm sitz baths
  • stress reduction (to reduce symptoms)
  • gentle exercise (to promote healthy digestion and elimination, and fight the pain pattern)
  • postural education
  • sitting for only short periods of time
  • sitting only on firm and even chair cushions (muscles shift bones and are compromised on uneven surfaces.)· medications, such as anti-inflammatory agents, muscle relaxants, low dose antidepressants and analgesics.

Tender Points & Trigger Points

PFD is thought to be caused by trigger points or tender points in the pelvic floor. What are these? Tender points are most commonly found in fibromyalgia patients. FMS is defined as a widespread musculoskeletal pain and fatigue disorder that involves sensitivity to pressure on specific areas of the body. These sensitive areas are called tender points. When pressed, tender points cause great discomfort, but not referred pain. A diagnosis for FMS requires patients to have at least 11 of the 18 tender points.

Another condition that often occurs with FMS is myofascial pain syndrome (MPS). MPS is caused by myofascial trigger points. Trigger points are tender points that refer pain to other areas when pressed. They present as contracted knots or tight bands. Trigger points can be caused by surgeries and injuries (such as repetitive motion trauma), joint problems, viral infections and the cold. When a muscle with a trigger point is worked too hard, a secondary trigger point can develop. When trigger points spread throughout the body, MPS may become chronic.

Trigger points can be active or latent. Active trigger points may be sensitive to palpation, but the pain is felt at a distal site (referred pain). Active trigger points hurt when the involved muscle is used, and very active trigger points can hurt when the muscle is at rest. Only when pressed, do latent trigger points hurt. Latent trigger points can contribute to muscle shortening and weakness, causing restricted movement. Latent trigger points can also become active when the involved muscles are overstretched or overused. Devin Starlanyl, M. D., in her Fibromyalgia/Myofascial Pain Syndrome Handout (1994), says that muscles with latent trigger points give out when stressed.

Treatment for trigger points includes most of the treatments listed for PFD . Trigger point therapy, injections of numbing agents such as lidocaine or procaine into the site, are often used. Anesthetics make it possible for a therapist to stretch the sore muscle or group of muscles without hurting the patient. Muscles are also loosened with a technique called "spray and stretch." The cold spray numbs the muscles and allows them to be painlessly stretched in order to regain their range of motion. These treatments are offered at physical therapy clinics that work with FMS patients. Improvement can last for weeks, or even months. However, IC patients who suffer with chemical sensitivity may be sensitive to the cold spray. IC patients should also probably avoid numbing injections that contain epinephrine, which can set off bladder spasms.

Which Muscles Are Most Effected?

The postural muscles of the body are most affected by trigger points, which occur in the neck, the scapula (the wing bone), the soft tissue of the thoracic and lumbar spine (the ribs and low back) and the sacroiliac joint (where the sacrum, the triangular composite bone at the bottom of the spine, meets the ilium, the hip bone).

THE NECK AND SHOULDERS (see the graphics below)

The sternocleidomastoid is an important muscle for rotation, flexion and extension of the head. According to Dr. Starlanyl, trigger points in the sternocleidomastoid muscle can cause FMS patients to suffer with chronic runny noses and sinus infections. Dr. Starlanyl theorizes that this is a mechanical problem that happens during sleep, when stuffiness in the nose moves from side to side while rolling side to side. As a result, the post-nasal drip runs down the back of the throat and makes patients susceptible to sinus infections.

Other symptoms caused by trigger points in the sternocleidomastoid muscle are deep ear pain and/or stuffiness in the ear, and migraine headaches. Cold drafts can cause trigger points to occur in this muscle.

The trapezius rotates the scapula upward during shoulder and arm movements, such as lifting with the hands or holding an object overhead. This large muscle covers the area up and down, and between the spine of the scapula and the spinal column. The trapezius originates at the base of the skull. Trigger points for migraines are located in the upper trapezius.

The infraspinatus muscle attaches the scapula with the arm. Like the trapezius, it is a leverage muscle. It is effective in fixing the scapula when bringing the arm from a position straight out in front of
the body to a position straight out to the side. It is also used when drawing the arm from a position straight out in front of the body down to the side of the body.


The splenius cervicis arises with the semispinalis from the thoracic spine, and is one of the "bandage muscles" that extends and rotates the head in concert with the opposite sternocleidomastoid muscle.

The semispinalis capitus is also a deep muscle of the back that extends and rotates the head (side to side) and the spinal column. Both the splenius cervicis and the semispinalis capitus serve to stabilize the bones of the spinal column. They influence posture, flexion and extension of the spine.


*The neck area is vulnerable for sympathetic nerve injury and trauma. Injury (such as whiplash) and trauma to the neck can lead to FMS and trigger points.

THE LOWER TRUNK

The quadratus is a deep muscle that attaches the back of the iliac crest (where your thumbs rest when you put your hands on your hips) to the bottom back rib. This muscle is used when bending over forward, or to the side to lift an object or scrub a tub. If the 12th rib (bottom rib) is tender from trigger points it may contribute to pleuretic symptoms. Muscle pain in the quadratus is sometimes confused with kidney pain, abdominal or lung problems.

For information on the gluteus medius see our May column.


 

About The Authors:
Gaye is an author and IC patient & support group leader who has been involved in IC work for years. In 1990 she published "Stretch Into a Better Shape" and produced a stretching and exercise video for IC patients in 1993. She is a specialist in Aston-Patterning movement and muscle re-education.

Andrew has over ten years of clinical and health care management position. He is currently the Administrator of Maison Hospitaliere, located in New Orleans. Andrew holds a Ph.D. in Special Education, a M.A. of Health Adminstration, M.A. of Clinical Psychology.

They welcome your comments and feedback on their articles at: The Sandlers


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