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You, Me and E.D.: 3 Ways to Fight Erectile Dysfunction

1/14/2018

Men, your partner lies before you in a dimly lit room, completely enticed by your pre-mating seduction ritual. Marvin Gaye, just barely audible in the background, whispers “Let’s get it on.” Following a trail of rose petals littered across the floor, you advance to the silk-covered bed where your lover awaits. Minds and spirits already entwined, the time comes for bodily connection when, as though pressing a soft gummy worm against the keyhole of the doorway to your love life, you find yourself locked out … and no one can let you in.

There are over 600,000 new cases of erectile dysfunction in the United States annually.{1} Erectile dysfunction is defined as the consistent or recurrent inability of a man to attain or maintain an erection sufficient for sexual intercourse and is considered a symptom, not a disease.{2} This article will identify the physiology of penile erections, risk factors of erectile dysfunction, and ways to maintain a healthy erection.

So, what do you know about how the male erection works? Engorgement of the penis with blood appears to be common knowledge, but how does that blood get to your “tower of power”? Does one just “will it” to the penis?

To start, there are three types of erections: those that occur during deep sleep, those caused by direct physical genital stimulation, and those caused by any of the other four senses or by mental imagery.

Let’s pretend for a second that you are with a partner and the erection process has been initiated. For the first phase of your erection, varied hormones will begin to circulate in the penis. The hormones stimulate relaxation of penile arteries and smooth muscle—a type of muscle similar to that found in the stomach lining- which will increase blood flow to the penis. Simultaneously, penile veins contract, preventing that blood from leaving the penis. For increased rigidity (hardness) of the penis and ejaculation, the ischiocavernosus and bulbospongiosus muscles—similar in composition to muscles that move your arm or leg—contract around the bottommost portion of the penis and “sit bones.”{3} Now that you know how erections are supposed to work, let’s look at the risk factors of erectile dysfunction.

The risk of developing erectile dysfunction has been shown to increase sharply beyond the age of 40.{4} There is not much we can do to combat Father Time, and accident or illness can happen unexpectedly at any age; however, more manageable risk factors of erectile dysfunction for those over 40 include heart disease, high cholesterol, and high blood pressure.{5} For those under 40, psychological risk factors such as anxiety and depression have been shown to be the most prevalent.{6} Regardless of age, I think many of us will agree that a healthy erection is ideal. Here are some ways to keep your flag at full staff through the ages.

Unrestricted passage of blood to the penis is ideal for a healthy erection; thus, decreased fat accumulation along arterial walls is essential. Brisk walking for an average of an hour a day has been shown to promote healthy arteries and significantly decrease the onset of erectile dysfunction.{7} In addition, people following a Mediterranean-based food pyramid have been found to demonstrate a lower onset of erectile dysfunction.{8}

Sustained occlusion of blood flow to the penis for more than three hours per week (common in cyclers) has also been shown to have a negative impact on erectile function.{9} While more research is required to identify the best bike seat cushion for the prevention of erectile dysfunction, pressure mapping studies have shown that gel-padded and air seat cushions provide the most even weight distribution.{11}

Finally, performance anxiety may be avoided through positive and open communication with your partner. From the start, try to incorporate phrasing such as “it would feel better if you…” versus “I do not like it when you….” {11}

These are all great ways to address risk factors before they become evident. But what if you want to put a little more “pep” in your pepperoni?

In The 40-Year-Old Virgin, Steve Carell’s character asked, “Is it true that if you don’t use it, you lose it?” We all laughed at his droll question, but he may have been onto something. Remember, the rigidity of a penis during arousal is increased and maintained by two pelvic floor muscles similar to the muscles in your arms and legs. Just like those muscles, the pelvic floor muscles may increase and decrease in size and strength with exercise.{12}

To maintain a healthy erection, it may help to lie on your back with hips and knees bent so you can comfortably keep your feet in full contact with the floor. Place your dominant hand on the buttock muscle on the same side (for example, if you are right-handed, put your right hand on your right buttock). From here, contract your pelvic floor the same way you might contract to stop or slow the flow of urine. The dominant hand’s role during the contraction is to make sure that the buttock muscle stays relaxed. For increased resistance to the muscles at play, perform the exercise with an erection.{13}

It is paramount that the pelvic floor muscle is engaged in isolation. If you are having a difficult time isolating the pelvic floor muscle, another way people think of engaging it is by trying to make the penis “jump.” However, if you use this cue, be careful that the penis does not jump too far away because then we have a whole other issue.

Earlier I mentioned that erectile dysfunction is a symptom rather than a disease; this means it is a finding that results from another condition.{14} Erectile dysfunction in younger men has often been shown to improve spontaneously, and in older men pelvic floor physical therapy has proven to be very effective.{15} But it may be appropriate to consult a primary care physician to rule out other serious conditions prior to initiating physical therapy.{16}

References:

{1} Catherine B. Johannes et al., “Incidence of Erectile Dysfunction in Men 40 to 69 Years Old: Longitudinal Results from the Massachusetts Male Aging Study,” Journal of Urology 163, no. 2 (February 2000): 460–3, https://doi.org/10.1016/s0022-5347(05)67900-1.
{2} Ian Eardley, “The Incidence, Prevalence, and Natural History of Erectile Dysfunction,” Sexual Medicine Reviews 1, no. 1 (May 2013): 3–16, https://doi.org/10.1002/smrj.2.
{3} Ernst R. Schwarz, Erectile Dysfunction (New York: Oxford University Press, 2013); Pierre Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation in Erectile Dysfunction and Premature Ejaculation,” Physical Therapy 94, no. 12 (December 1, 2014): 1731–43, https://doi.org/10.2522/ptj.20130354; Rany Shamloul and Hussein Ghanem, “Erectile Dysfunction,” Lancet 381, no. 9861 (January 12, 2013): 153–65, https://doi.org/10.1016/s0140-6736(12)60520-0.
{4} Ronald W. Lewis et al., “Definitions/Epidemiology/Risk Factors for Sexual Dysfunction,” Journal of Sexual Medicine 7, no. 4 (April 2010): 1598–607, https://doi.org/10.1111/j.1743-6109.2010.01778.x.
{5} Allen D. Seftel, Peter Sun, and Ralph Swindle, “The Prevalence of Hypertension, Hyperlipidemia, Diabetes Mellitus and Depression in Men with Erectile Dysfunction,” Journal of Urology 171, no. 6 (June 2004): 2341–45, https://doi.org/10.1097/01.ju.0000125198.32936.38; Wesley Ludwig and Michael Phillips, “Organic Causes of Erectile Dysfunction in Men Under 40,” Urologia Internationalis 92, no. 1 (January 2014): 1–6, https://doi.org/10.1159/000354931; Lewis, “Sexual Dysfunction,” 1598–607.
{6} Eardley, “Erectile Dysfunction,” 3–16; Ludwig and Phillips, “Organic Causes of Erectile Dysfunction,” 1–6.
{7} Sidney Glina, Ira D. Sharlip, and Wayne J.G. Hellstrom, “Modifying Risk Factors to Prevent and Treat Erectile Dysfunction,” Journal of Sexual Medicine 10, no. 1 (January 2013): 115–9, https://doi.org/10.1111/j.1743-6109.2012.02816.x.
{8} Glina, Sharlip, and Hellstrom, “Modifying Risk Factors,” 115–9.
{9} Glina, Sharlip, and Hellstrom, “Modifying Risk Factors,” 115–9.
{10} Hirosuke Takechi and Akihiro Tokuhiro, “Evaluation of Wheelchair Cushions By Means of Pressure Distribution Mapping,” Acta Medica Okayama 52, no. 5 (October 1, 1998): 245–54, https://doi.org/10.18926/AMO/31321.
{11} John P. Wincze and Risa B. Weisberg, Sexual Dysfunction: A Guide for Assessment and Treatment (New York: The Guilford Press, 2015).
{12} Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation,” 1731–43.
{13} Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation,” 1731–43.
{14} Shamloul and Ghanem, “Erectile Dysfunction,” 153–65; Michel Millodot, Dictionary of Optometry and Visual Science, 7th ed., s.v. “symptom,” retrieved January 7, 2018, from https://medical-dictionary.thefreedictionary.com/symptom.
{15} Johannes et al., “Incidence of Erectile Dysfunction,” 460–3; Lavoisier et al., “Pelvic-Floor Muscle Rehabilitation,” 1731–43.
{16} Shamloul and Ghanem, “Erectile Dysfunction,” 153–65; Giorgio Gandaglia et al., “A Systematic Review of the Association Between Erectile Dysfunction and Cardiovascular Disease,” European Urology 65, no. 5 (May 2014): 968–78, https://doi.org/10.1016/j.eururo.2013.08.023.

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CrossFit: 3 ways fitness crosses female pelvic health

12/14/2017

Many of us are acquainted with CrossFit through advertisements, television, participation, etc. I have traveled across the internet and back, and during that journey—as well as throughout my clinical experience—the developing connection between CrossFit and pelvic hefalth has become evident. Stress urinary incontinence (involuntary loss of urine during physical exertion) and pelvic organ prolapse (falling, slipping, or downward displacement of an organ originating in the pelvis) are the pelvic conditions that appear to have the greatest correlation with CrossFit.[1]

There is no shame in experiencing incontinence or prolapse, but neither condition is required to prove competitive effort in CrossFit (or any other sport). This article shows how CrossFit and pelvic health cross paths by looking at what CrossFit entails and defining stress urinary incontinence and pelvic organ prolapse. It also discusses how to know when it is time to see a healthcare professional, and how to maintain good pelvic health.

CrossFit is a fitness regimen developed by Greg Glassman in which varied functional movements are conducted with high intensity. The goal is to generate maximum power by doing the most work in the least time.[2] To increase work, a greater distance must be traveled; thus, CrossFit exercises typically encompass larger movements such as deadlifts, push-presses, box jumps, and burpees (not to be confused with the less flattering “fartee”).[3] To produce more power, CrossFit routines are intensified by adding time limits—to the full workout, or to repetitions of a given exercise.

CrossFit sure sounds like fun, and maybe it is something you want to pick up, but first let’s connect the dots between this trendy fitness regimen and pelvic health by exploring stress urinary incontinence and pelvic organ prolapse.

The loss of fluid associated with stress urinary incontinence occurs when bladder pressure exceeds urethral closure pressure.[4] To illustrate this, think of your bladder as a full water balloon you are pinching closed (urethral closing pressure). While you are trying to keep the water in the balloon, someone comes along and tries to squeeze the water out (bladder pressure). If your summer-break bully squeezes hard enough, the pressure created by your fingers will be overcome and water will leak out. Increased bladder pressure to the point of incontinence can be caused by levels of exertion ranging from a cough to lifting a car off a trapped child. Risk factors for stress urinary incontinence include decreased estrogen, heavy exertion, and pelvic organ prolapse.[5]

Pelvic organ prolapse happens when pelvic organs fall into the vaginal canal. It is classified by which organs are falling, how far they fall, and which vaginal wall they contact.[6] Symptoms of pelvic organ prolapse may include the sensation of pressure or heaviness in the vagina, pain in the pelvis or lower back, difficulty starting or maintaining the flow of urine, more frequent desire to urinate, and stress urinary incontinence.[7] Risk factors associated with pelvic organ prolapse include increased intra-abdominal pressure, high-intensity exercise, and decreased estrogen.[8]

By now you may have realized that risk factors of stress urinary incontinence and pelvic organ prolapse coincide with some components of CrossFit, but is there really a significant connection?

Due to the timed component, CrossFit tasks require a lot of exertion; a novice may not have the strength and endurance required to complete the tasks. For each CrossFit task, there is a “standard of movement” outlining how to begin and end an exercise, but not necessarily what to do in between.[9] Without that guidance, a participant does the best they can (as fast as they can), leaving their anatomy to compensate however it deems necessary. This subjects the participant to injury.

When a task is put in front of someone whose body is tired, the body may begin recruiting muscles and using strategies that typically would not be used for the task at hand. A common compensation is breath holding during heavy lifting, which increases intra-abdominal pressure. Of the risk factors surrounding stress urinary incontinence and pelvic organ prolapse, I find that heavy exertion, high-intensity exercise, and increased intra-abdominal pressure are where pelvic dysfunction crosses CrossFit.

Despite these risk factors, a 2016 study of twenty-minute “typical” CrossFit sessions showed an insignificant increase of prolapse from beginning to end of participation when compared to people who walked for twenty minutes.[10] However, in my clinical experience, I find CrossFit has a more direct impact on pelvic health than reflected by current research. So if you decide to participate in this high-intensity functional movement program, consider ways to maintain good pelvic health.

An effective way to decrease intra-abdominal pressure caused by breath holding is to exhale through pursed lips, as if blowing out birthday candles, during the exertion phase of an exercise. For example, when performing a box jump, inhale as you bend your hips and knees and exhale as you leap onto the box. To address the risk factor of decreased estrogen, warming up prior to your competition with the clock during a CrossFit class may increase the levels of estrogen in your blood.[11] (However, a good warm-up is not a substitute for prescribed estrogen therapies.)

Regardless of the internet portrayal of incontinence and prolapse as a rite of passage in the CrossFit world, there is little empirical data supporting the notion that this strenuous fitness routine is any more related to pelvic dysfunction than its nonstrenuous counterparts. However, in spite of the evidence, you should see a healthcare provider if you notice any of the symptoms affiliated with stress urinary incontinence and pelvic organ prolapse (leakage with exertion, pressure or heaviness in the vagina, pelvic or low back pain, difficulty starting or maintaining the flow of urine, or more frequent desire to urinate). As long as you are seeing a gynecologist regularly, consulting a physical therapist specializing in pelvic health may be appropriate; he or she should be able to accurately diagnose and treat the conditions mentioned in this article. If a physical therapist is not available near you, speak with your local urogynecologist, gynecologist, or urologist for assistance opening the door to a healthier pelvic floor.

References:

[1] Haylen, B.T., “An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction,” Neurology and Urodynamics 29, no. 1 (2010): 116, https://doi.org/10.1002/nau.20798; Ren, Shuang et al., “Biomechanics of Pelvic Organ Prolapse,” Science China Life Sciences, 58, no. 2 (February 2015): 218–220, https://doi.org/10.1007/s11427-014-4767-2.

[2] “What is CrossFit?” CrossFit, retrieved August 22, 2017, https://www.crossfit.com/what-is-crossfit.

[3] Middlekauff, Monique L. et al., “The Impact of Acute and Chronic Strenuous Exercise on Pelvic Floor Muscle Strength and Support in Nulliparous Healthy Women,” American Journal of Obstetrics and Gynecology 215, no. 3 (September 2016), https://doi.org/10.1016/j.ajog.2016.02.031.

[4] Swenson, Carolyn W. et al., “Obesity and Stress Urinary Incontinence in Women: Compromised Continence Mechanism or Excess Bladder Pressure During Cough?” International Urogynecology Journal (February 1, 2017), https://doi.org/10.1007/s00192-017-3279-6. See also Haylen, “Female Pelvic Floor Dysfunction.”

[5] Luber, Karl M., “The Definition, Prevalence, and Risk Factors for Stress Urinary Incontinence,” Reviews in Urology 6, supplement 3 (2004): S3–S9, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472862/.

[6] Jelovsek, J. Erik, Christopher Maher, and Matthew D. Barber, “Pelvic Organ Prolapse,” The Lancet 369, no. 9566 (March 24, 2007): 1027–1038, retrieved August 22, 2017. http://dx.doi.org/10.1016/S0140-6736(07)60462-0.

[7] Jelovsek, “Pelvic Organ Prolapse.”

[8] Word, R. Ann, Sujatha Pathi, and Joseph I. Schaffer, “Pathophysiology of Pelvic Organ Prolapse,” Obstetrics and Gynecology Clinics of North America 36, no. 3 (September 2009). https://doi.org/10.1016/j.ogc.2009.09.001; Braekken, I.H. et al., “Pelvic Floor Function Is Independently Associated with Pelvic Organ Prolapse,” BJOG: An International Journal of Obstetrics & Gynaecology 116, no. 13 (December 2009): 1706–1714, http://doi.org/10.1111/j.1471-0528.2009.02379.x; Lang, J.H. et al., “Estrogen Levels and Estrogen Receptors in Patients with Stress Urinary Incontinence and Pelvic Organ Prolapse,” International Journal of Gynecology & Obstetrics 80, no. 1 (January 2003): 35–39, https://doi.org/10.1016/s0020-7292(02)00232-1.

[9] See, for example, the movement standards from the CrossFit website for this workout in February and March of 2017: https://games.crossfit.com/workouts/open/2017#workoutDescription.

[10] Middlekauff, “Impact of Acute and Chronic Strenuous Exercise.”

[11] Casto, Kathleen V. and David A. Edwards, “Before, During, and After: How Phases of Competition Differentially Affect Testosterone, Cortisol, and Estradiol Levels in Women Athletes,” Adaptive Human Behavior and Physiology 2, no. 1 (March 2016): 11–25, retrieved August 22, 2017, https://doi.org/10.1007/s40750-015-0028-2.

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Vaginismus: 3 ways to dilate without dilators

11/14/2017

Here we are: the next stop on your search engine tour in the hope of finding out why you or someone you know is having pain when intimate. Likely, somewhere along your journey the words vaginismus and dilation therapy popped up before you stumbled upon my blog. Let’s look further into what vaginismus and dilation therapy are.

The accepted classifications and definitions of vaginismus change from time to time as research and trials generate new findings. But generally, vaginismus is known as a penetration disorder in which any form of vaginal penetration is often painful, difficult, or impossible despite the desire to do so.[1] As the definition of vaginismus is ever-evolving, so is the accepted treatment. This is where dilation therapy comes in … figuratively speaking of course.

Dilation therapy is a treatment typically used for penetrative pain disorders such as vaginismus. Much of what is described to me when I speak with practitioners and recipients of dilation therapy is something that resembles gauging an infected ear piercing (ouch). Rest assured, dilation therapy is not intended to be painful and should not cause a great deal of discomfort when conducted by an experienced healthcare professional.

Let’s take a look at how the experienced pelvic health practitioner deals with vaginismus pragmatically when increased pelvic floor muscle tension and sympathetic (“fight or flight”) nervous system activity are present upon examination.

A dilator (similar in composition and structure to the sex toy commonly referred to as a “dildo”) is inserted vaginally while the patient is lying on her back, and remains in position for between five and fifteen minutes. At the beginning of therapy, patients can typically expect to use something smaller in diameter than a pinky finger, increasing in diameter every week or two. As one becomes more comfortable with dilation therapy in the initial position, new positions may be introduced (for example, standing).

Like some of the dilation-less dilation techniques we will discuss, dilation therapy is intended to promote pelvic floor muscle relaxation in order to decrease pain during intercourse. Despite its good intentions, some patients are still reluctant to attempt dilation therapy, however, there are less invasive alternatives that can help in some cases. Here are three ways to dilate without dilators.

Everyday life is full of stress. The constant stressors may inadvertently increase use of the sympathetic nervous system, which often will manifest physically as tension in pelvic musculature.[2] Short-term meditation (approximately twenty minutes) has been shown to increase utilization of the parasympathetic (“stay and play”) nervous system.[3] Increased activation of the parasympathetic nervous system permits the release of tension in muscles connected to vaginal penetrative pain.[4]

The studies suggesting meditation as a way to regulate nervous system activity do not specify what parameters were used. However, I found anecdotally that guided meditative recordings online, which encourage users to focus on breathing and staying alert, as opposed to falling asleep, evoked favorable outcomes. But why would breathing be important to nervous system control?

While the reason is not clear, there is no shortage of studies linking respiration to parasympathetic nervous system response.[5] To decrease sympathetic nervous system activation in daily life, control studies almost literally propose taking a minute, or thirty, to stop and smell the roses. Slow prānāyāma breathing—a practice focusing on the inhalation, retention, and exhalation of a breath—has been shown to increase parasympathetic nervous system activation and decrease sympathetic nervous system activation when used in increments of eight to ten minutes for thirty minutes a day.[6] As discussed earlier, decreased sympathetic nervous system activation is a key factor in successfully decreasing tension in the pelvic floor musculature and further reducing vaginal penetrative pain.[7]

Along with slow prānāyāma breathing, there is evidence emerging that the respiratory diaphragm (breathing muscle) has ties to regulating nervous system activation. The picture being painted by emerging evidence regarding the role of breathing and muscles involved is great and all, but they may have another responsibility paramount to the battle against vaginismus and dilation therapy.

Shallow, chest-dominant breathing may deny our pelvic floor muscles the rest and stretch they deserve; deep, belly-dominant breathing may provide that rest and stretch. Pistoning is a term coined by Julie Wiebe to describe the dynamic interaction between the pelvic floor musculature and respiratory diaphragm. When the respiratory diaphragm is used for breathing, the pelvic floor muscles lengthen to accommodate the change in position of the abdominal and organs; larger respiratory diaphragm contraction (deeper breaths) should equate to larger pelvic floor muscle lengthening. There are studies showing a link between activity in the respiratory diaphragm and pelvic floor musculature, which lends some validity to the notion of “pistoning.”[8]

You are not a car, so why should you care about this whole piston thing? The vaginal canal passes through an opening in the pelvic floor musculature called the levator hiatus. As the pelvic floor muscles lengthen, the width of the levator hiatus increases, permitting less restricted passage of anatomical structures out of it and, for intimate purposes, into it.[9]

The pistoning effect can be demonstrated with a simple exercise for those who desire a healthier pelvic floor. Try lying on your back with hips and knees resting at approximately 90 degrees and knees separated slightly further than feet; this puts the muscles of the pelvic floor in a relaxed position. From here, place your dominant hand just below the rib cage and non-dominant hand on your chest. During inhalation, allow your stomach to push the dominant hand outward with as little chest movement as possible. As you exhale, let your belly fall to the floor; remain in this position and repeat.

Candidates for dilation therapy who are not comfortable with that form of treatment may discuss the alternatives offered by this blog with a healthcare professional. The goal of these three treatment suggestions is to relax the muscles making up the pelvic floor. With vaginismus, be sure to seek professional medical advice. Unlike patients suffering from stress urinary incontinence due to the female athlete triad (discussed in my previous blog), and assuming you are already being seen regularly by a gynecologist, you may want to start by visiting a physical therapist who specializes in pelvic health to avoid any unnecessary pain from a gynecologic exam.[10]

The most difficult portion of getting past vaginismus is staying positive. Try finding one thing you can look forward to every day. It can range from kicking back with a bubble bath to rocking out to your favorite ’90s boy band like I do (NSYNC). A happy, positive state of mind can help you get one step closer to pain-free intercourse and one step further from dilation therapy.

References:

[1] Rosemary Basson et al., “Summary of the Recommendations on Sexual Dysfunctions in Women.” The Journal of Sexual Medicine 1, no. 1 (July 2004): 24–34, https://doi.org/10.1111/j.1743–6109.2004.10105.x; APA (American Psychiatric Association), Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed. (Washington: American Psychiatric Publishing, 2014); Yitzchak M. Binik, “The DSM Diagnostic Criteria for Vaginismus.” Archives of Sexual Behavior 39 no. 2 (April 2010), 278–291. https://doi.org/10.1007/s10508-009-9560-0. Retrieved July 31, 2017.

[2] David Wise and Rodney Anderson, A Headache in the Pelvis. (National Center for Pelvic Pain, 2012).

[3] Yi-Yuan Tang et al., “Central and Autonomic Nervous System Interaction Is Altered by Short-Term Meditation,” Proceedings of the National Academy of Sciences 106, no. 22 (June 2, 2009), 8865–8870. https://doi.org/10.1073/pnas.0904031106.

[4] Wise, A Headache in the Pelvis; Tang, “Central and Autonomic Nervous System Interaction.”

[5] Ravinder Jerath, “Physiology of Long Pranayamic Breathing: Neural respiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system,” Journal of Yoga & Physical Therapy 6, 252 (July 12, 2016), http://doi.org/ 10.4172/2157-7595.1000252.

[6] Mussadiq Shah et al., “Modulation of Cardiac Vagal Tone During Breathing at 0.1Hz in Fully Conscious Human Volunteers,” Autonomic Neuroscience 192 (November 2015), 76, http://dx.doi.org/10.1016/j.autneu.2015.07.073.

[7] Wise, A Headache in the Pelvis; Tang, “Central and Autonomic Nervous System Interaction.”

[8] Ruth R. Sapsford et al., “The Effect of Abdominal and Pelvic Floor Muscle Activation Patterns on Urethral Pressure,” World Journal of Urology 31, no. 3 (November 2012), 639–644, https://doi.org/10.1007/s00345-012-0995-x; Ruth R. Sapsford and Paul W. Hodges, “Contraction of the Pelvic Floor Muscles during Abdominal Maneuvers,” Archives of Physical Medicine and Rehabilitation 82, no. 8 (August 2001), 1081–1088, https://doi.org10.1053/apmr.2001.24297; Lia Ferla et al., “Synergism between Abdominal and Pelvic Floor Muscles in Healthy Women: A systematic review of observational studies,” Fisioterapia em Movimento 29, no. 2 (June 2016), 399–410 https://doi.org/ 10.1590/0103-5150.029.002.AO19.

[9] H. P. Dietz et al., “Biometry of the Pubovisceral Muscle and Levator Hiatus by Three-Dimensional Pelvic Floor Ultrasound,” Ultrasound in Obstetrics and Gynecology 25, no. 6 (June 2005), 580–585, https://doi.org/10.1002/uog.1899.

[10] Elke D. Reissing et al., “Vaginal Spasm, Pain, and Behavior: An empirical investigation of the diagnosis of vaginismus,” Archives of Sexual Behavior 33, no. 1 (February 2004), 5–17, https://doi.org/10.1023/b:aseb.0000007458.32852.c8.

Additional References:

Larysa Sydorchuk and M. H. Tryniak, “Effect of Voluntary Regulation of the Respiration on the Functional State of the Autonomic Nervous System,” Likars’ka Sprava, (1–2), 65–68. Retrieved August 1, 2017. (Sydorchuk and Tryniak 2005)

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The Female Athlete Triad: winning competitions but losing bladder control

10/15/2017

It is the last leg of the race. Victory is in sight. Just have to kick it to the finish and ... What just dribbled down my leg?

The female athlete triad is described by the Women’s Task Force as a collection of three separate but interrelated conditions (Nazem and Ackerman 2012). Separately, the conditions in the female athlete triad are serious; combined, they become substantially more dangerous. One of the less frequently discussed conditions stemming from the triad is stress urinary incontinence. This article will review the female athlete triad and stress urinary incontinence, their relationship to one another, how to recognize the signs and symptoms, and how to intervene.

The female athlete triad is the union of disordered eating, amenorrhea, and osteoporosis in an athlete who has two “X” chromosomes. Disordered eating is a non-psychiatric condition (not to be confused with an eating disorder) in which a person either restricts or binges food—typically, specific macronutrients such as carbohydrates (Hinton and Beck 2005). Most of us have been disordered eaters at some point without realizing it. As a broke college student, you may recall binging ramen noodles when pulling an all-nighter.

In an athlete with disordered eating, the low nutrient intake relative to the high energy demand may result in amenorrhea—the absence of a period for longer than three months (Eguiguren and Ackerman 2016). Athletes with disordered eating are at higher risk for functional hypothalamic amenorrhea due to decreased leptin—a hormone found in fat tissue. A disrupted menstrual cycle leads to decreased levels of estrogen—a hormone heavily involved in regulating bone mineral density, which is related to bone strength. Maintaining uninterrupted bone mineral regulation in the young female athlete is crucial since a majority of bone mineral content is achieved by 18 years of age. Decreased bone mineral density, osteoporosis, leaves athletes prone to injury (Eguiguren and Ackerman 2016).

The cycle of the female athlete triad is now complete. But what about that urine dribble? Stress urinary incontinence is the involuntary loss of urine during physical exertion (Petrou 2010). How can two conditions that are so vastly different be related?

There is a dearth of research into the connection between the female athlete triad and stress urinary incontinence. So I decided to connect the risk factors for stress urinary incontinence that coincide with aspects related to the female athlete triad: female gender, decreased estrogen, amenorrhea, high impact-sports and weight-class sports, and heavy exertion (Luber 2004). Two risk factors of stress urinary incontinence are uniquely associated with female athlete triad patients compared to their eumenorrheic (regularly menstruating) counterparts: decreased estrogen and amenorrhea. Due to the aligning risk factors, someone fitting the criteria of the female athlete triad is more likely to develop stress urinary incontinence.

Now that we know what the female athlete triad and stress urinary incontinence are and understand their relationship to one another, let’s look at how we identify that any of this is happening in an athlete.

None of us has X-ray vision to see an athlete’s bone composition, nor psychic powers to tell us she is wetting herself. (If you do please contact me immediately.) Fortunately there are other identifiable factors. Parents and coaches will be surprised at how much information they can get about an athlete’s eating habits from the athlete herself. I have found that athletes of any gender and age are often willing to openly discuss eating habits when asked. To recognize malnourishment in athletes taking part in weight-class sports, be alert to alterations in energy level and demeanor outside of their sporting activities.

As for identifying amenorrhea, it is time for the dreaded period talk. Not all parents are comfortable speaking to their children about topics related to sexual development, and the children are often uncomfortable too. It is beneficial for the female athlete to understand what to expect past menarche (the first period) so she can recognize when something is not right. But more important than recognizing a problem is seeking help.

If I suspect one of my younger patients has a problem they may not want to disclose to me personally, I encourage them to tell an adult they are comfortable with—perhaps a parent, guardian, teacher, or coach. Physical therapists can use outcome measures such as the Pre-Participation Gynecological Examination (PPGE) and Eating Attitudes Test (EAT). The PPGE is a validated questionnaire that can be used for the recognition of physical alterations often underestimated by the athletes themselves; this information permits referral to the appropriate practitioner (Parmigiano et al. 2014). The EAT is an acceptably reliable questionnaire for the identification of potential disordered eating in adolescents (Gleaves et al. 2014). Once the three-headed beast known as female athlete triad is identified, how can you intervene as a coach, parent, or practitioner?

In the Disney movie Hercules, you may recall a mythical creature called the hydra. Hercules had a particularly difficult time defeating the hydra as its number of heads increased. Eventually our hero was overcome and swallowed whole. Had Hercules intervened before the hydra’s heads multiplied, defeating the beast would have been significantly easier. Stress urinary incontinence and the female athlete triad are very similar in that way.

Early intervention for the female athlete triad and stress urinary incontinence is imperative due to the increased likelihood of bladder dysfunction occurring again in adulthood (Heron et al. 2017). Thankfully, Our mighty heroes and heroines at Canadian Sport for Life proposes a multidisciplinary approach using the “Attention to Prevention” protocol from the beginning of an athlete’s career to ensure positive long-term athlete development (Harber). Well-educated coaches, school counselors, and physical education teachers make a winning combination to keep the female athlete triad at bay. Teaching and implementation of positive eating habits should begin in infancy and continue into early childhood. Beyond 8 years of age, child athletes should begin learning specific nutritional fueling practices when preparing for, during, and after sport. Female athletes should also be taught about the connection between menstrual function, energy intake, and bone health.

Athletes can begin learning technique as soon as age 6, such as batting stance in baseball or foot position for kicking in soccer. Between the ages of 11 and 15 years it is considered safe to initiate strength and agility training. Should the female athlete triad show any of its three heads, it is imperative to refer the athlete to a primary care or sports physician (Eguiguren and Ackerman 2016). I suggest physical therapists make the same referral if stress urinary incontinence becomes apparent in a pubescent female athlete, before treating the incontinence as its own entity.

As parents, coaches, and physical therapists, it is our duty to diligently combat all components of the female athlete triad in our athletes before any become a reality. Should disordered eating, amenorrhea, and osteoporosis evolve into the three-headed opponent known as the female athlete triad, remember that it can be defeated. Keep your wits about you, and do not be afraid to refer out so the multidisciplinary attack on the female athlete triad can begin.

References:
{1} Nazem, Taraneh Gharib, and Kathryn E. Ackerman. (2012) “The Female Athlete Triad.” Sports Health 4 (4), 302–311. http://doi.org/10.1177/1941738112439685. (Nazem and Ackerman 2012) {2} Hinton, Pamela S. and Niels C. Beck. (2005). “Nutrient Intakes of Men and Women Collegiate Athletes with Disordered Eating.” Sports Science and Medicine, 4 (3), 253–262. Retrieved September 6, 2017. (Hinton and Beck 2005) {3} Duffy-Paiement, Christy. 2009. Disordered Eating Among Collegiate Female Athletes: The Role of Athletic Seasonal Status and Self-objectification. In PsycEXTRA Dataset. Albany: ProQuest Dissertations Publishing. https://doi.org/10.1037/e627862010-001. (Duffy-Paiement 2009) {4} Eguiguren, Maria L., and Kathryn E. Ackerman. 2016. “The Female Athlete Triad.” In The Young Female Athlete, edited by Cynthia J. Stein et al., 57–71. Contemporary Pediatric and Adolescent Sports Medicine. Cham: Springer. https://doi.org/10.1007/978-3-319-21632-4_5. (Eguiguren and Ackerman 2016) {5} Petrou, Steven P. 2010. “An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction.” International Brazilian Journal of Urology, 36 (1), 116. https://doi.org/10.1590/s1677-55382010000100032. (Petrou 2010) {6} Luber, Karl M. 2004. “The Definition, Prevalence, and Risk Factors for Stress Urinary Incontinence.” Reviews in Urology, 6 (Supplement 3), S3–S9. (Luber 2004)
{7} Miller, Michael G., Christopher C. Cheatham, and Neil D. Patel. 2010. “Resistance Training for Adolescents.” Pediatric Clinics of North America, 57 (3), 671–682. https://doi.org/10.1016/j.pcl.2010.02.009. (Miller et al. 2010) {8} Parmigiano, Tathiana Rebizzi, Eliana Viana Monteiro Zucchi, Maíta Poli de Araujo, Camila Santa Cruz Guindalini, Rodrigo de Aquino Castro, Zsuzsanna Ilona Katalin de Jármy Di Bella, Manoel João Batista Castello Girão, Moisés Cohen, Marair Gracio Ferreira Sartori. 2014. “Pre-participation gynecological evaluation of female athletes: a new proposal.” Einstein (São Paulo), 12 (4), 459–466. https://doi.org/10.1590/s1679-45082014ao3205. (Parmigiano et al. 2014) {9} Gleaves, David H., Crystal A. Pearson, Suman Ambwani, and Leslie C. Morey. 2014. “Measuring eating disorder attitudes and behaviors: a reliability generalization study.” Journal of Eating Disorders, 2 (1), 6. https://doi.org/10.1186/2050-2974-2-6. (Gleaves et al. 2014) {10} Harber, Vicki. (n.d.). The Female Athlete Perspective. Canadian Sport for Life. Retrieved June 11, 2017, from http://sportforlife.ca/portfolio-view/the-female-athlete-perspective/. (Harber) {11}Heron, Jon, Mariusz T. Grzeda, Alexander Von Gontard, Anne Wright, and Carol Joinson. "Trajectories of urinary incontinence in childhood and bladder and bowel symptoms in adolescence: prospective cohort study." BMJ Open 7, no. 3 (2017). doi:10.1136/bmjopen-2016-014238. (Heron et al. 2017)

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