2. Women’s Health Section
Presentations
× Role of PT in Postpatum Patient
× The When, What, Who, and How of Pain Science
× Hot flashes, low libido, and back fat: Singling the
menopause blues
× Continence, Pelvic Organ Support, Breathing, and
Lumbopelvic Control
× Pregnancy and Parenting in Women
× Low Back Pain and Pelvic Floor Disorders: Neural
Mechanisms of Muscle Synergies
× Is a Perfect PERFECT Perfect?
× Pudendal Neuraligia: Then and Now
× Pelvic and Women’s Health PT: What They do and
How They Got Started
× What You Need to Know about Urogynecological
Surgery
× Section on Women’s Health Complex Patients
× What Does Movement Have to Do with Urgency?
× Boldness, Brass, and Stilettos, Climbing the
Career Ladder
× The Effects of Cervico-thoracic Stiffness on the
Lumbopelivic & Pelvic Floor Region
× Management of Chronic Testicular Pain
× Why Every Patient Treated for Cancer should see a
Pelvic Floor Therapist

3. Is a perfect PERFECT… PERFECT?
× By Dr. V. Norene Christensen, PT, DSc, OCS, CLT1
i. Four Pines Physical Therapy- Jackson, WY
× New PERFECT Assessment2
i. Power- measure of strength of maximum voluntary contraction
ii. Endurance- time in sec that MVC can be help prior to 50% loss
iii. Repitions- # of times MVC can be repeated
iv. Fast- full contraction/relaxation in 10 sec
v. Elevation- lifting of posterior vaginal wall during MVC
vi. Co-contraction- of lower abdominals during MVC
vii. Timing- synchronous involuntary contraction of PFM on coughing

4. Is a perfect PERFECT… PERFECT?
× Allow 4 sec rest break when assessing repetitions
i. Provides weak, easily fatigued muscles time to recover
without allowing excessive rest periods for stronger muscles3
× Allow 1 minute rest break before measuring quick
contractions3

5. 2 sides of Incontinence
× 2 Sides of Incontinence1
i. 5/10/10/10/P/A/A
ii. 0/0/0/0/A/A/A
× 2 Sides of Continence1
× 5/10/10/10/P/P/P
× 2/5/6/6/A/P/P

6. 2 sides of Incontinence
× 2 Sides of Incontinence1
i. 5/10/10/10/P/A/A
ii. 0/0/0/0/A/A/A
× 2 Sides of Continence1
i. 5/10/10/10/P/P/P
ii. 2/5/6/6/A/P/P
× Common Factors1
× Absent co-contraction of
lower abdominals during
MVC
× Absent synchronous
involuntary contraction of
PFM on coughing
× Common Factors1
× Present co-contraction of
lower abdominals during
MVC
× Present synchronous
involuntary contraction of
PFM on coughing

7. Neuromotor reflex system &
co-contraction of TA
× Common Denominator for incontinence vs. continence1
× Teach Knack Reflex if not present2
× Study showed by teaching women to contract PFM before &
during cough, stress urinary loss decreased avg. 73.3% after
week 1 of practice4
i. Aim is to achieve a learned reflex activity2
× Small study showed contraction of TA results in PFM
contraction in healthy subjects5
i. Gross contraction of abdominals, especially RA, leads to
inappropriate increased intra-abdominal pressure5

8. Diaphragm & Internal Pressure System
• Natural co-contraction of diaphragm
& abdominals1
• Inhale, exhale, kegel1
• More upright sitting posture recruits
greater PFM resting activity8
• Strengthening vs. Reflex Training1
* All interconnected in this
internal pressure system and
work together1
* Anticipatory contraction of the
human diaphragm during rapid
postural adjustments6
* PFM component with pre-
programmed anticipatory
postural activity7

9. The Effect of Thoracic and Cervical Stiffness on
Lumbopelvic/ Pelvic Floor Dysfunction
× By Susan C. Clinton PT, DScPT, OCS, WCS, COMT, FAAOMPT9
i. Embody Physiotherapy & Wellness, LLC
ii. University of Pittsburgh
× Address stiff thoracic
i. Diaphragm unable to descend & allow negative pressure in chest to draw air in9
× Cervical & thoracic postural contributions to changing intrabdominal pressure9
I. >20 degrees significantly increases intrabdominal pressure9
I. Clinically significant at 30-45 degrees with decrease of abdominal perfusion9
II. Seated postures
I. Discourage hospital beds from always being at inclined angle9
II. Discourage patients from working on laptop in bed9
III. When eating, bring food to mouth, not mouth to food9
I. Ex. Bring spoon to mouth when eating soup9
III. Forward head posture9
IV. Dysfunction of 1st & 2nd ribs9

10. The Effect of Thoracic and Cervical Stiffness on
Lumbopelvic/ Pelvic Floor Dysfunction
× When you speak/sing at high pitch, PFMs tighten9
i. Difficult to talk high and loud at the same time9
ii. Instruct pts to drop larynx and hyoid, relax toes, talk loud9
iii. Train pelvic floor muscles down scale and octave9
× Clear airway efficiently
i. When patient coughs, patient’s abdominals should go in,
NOT out
ii. Do not hold in sneeze or do “mouse-like” sneeze
× Take Home Message: If you can change things above, don’t
need to work so hard below9

11. Every Patient with Cancer Should
See a Pelvic Floor PT
× By Carina Siracusa, PT, DPT, WCS
i. OhioHealth Oncology Rehabilitation Program Coordinator10
× If you contact squatty potty & say you are a PT, you get free squatty potty10
× Post-prostatectomy can result in decreased blood flow to penis10
i. Improve blood circulation during intercourse by instructing man to be in
dependent position for intercourse10
i. man on top
× Vibration over bladder allows muscles to contraction, can help with urinary
retention10
× Cool water cones10
i. Soft, gel based, refrigerated, for pain relief after radiation
ii. Can also be used as a dilator
iii. Also used post intercourse for relaxation if sore

12. Pudendal Neuralgia: Then and Now
× By Elizabeth H. Akincilar-Rummer, MSPT & Stephanie A. Pendergast, MPT11
i. Pelvic Health: San Francisco, Berkeley, Los Gatos, Los Angeles, Boston
× Diagnostic Criteria for Pudendal Neuralgia by Pudendal Nerve Entrapment (Nantes
Criteria)12
i. Pain in territory of PN
ii. Pain predominantly while sitting
iii. Pain does not wake patient at night
iv. Pain with no sensory impairment
v. Pain relieved by diagnostic pudendal nerve block
vi. Absence of pathognomic imaging, laboratory, & electrophysiologic criteria, remains
primarily clinical
vii. “In fact, only operative finding of nerve entrapment & post-operative pain relief can
formally confirm diagnosis of PN due to PN entrapment, except for a possible placebo
effect of surgery”12
i. How to choose patients for PN surgical decompression
i. Patient meets overall diagnostic criteria
ii. Failed extensive conservative therapy
iii. Neuropathy
iv. No other treatment options in their locality
v. Mechanism of injury acute onset of symptoms (mesh, hematoma, etc..)
vi. Meet the Nantes Criteria, appears to correlate with better surgical outcomes

13. Pudendal Neuralgia: Then and Now
× Who might we not want to operate on11
i. Severe centralization, significant psycho/social component, diagnoses somewhat unclear,
failure to meet Nantes Criteria, drug dependence
× Pudendal Nerve Decompression Surgeries11
i. Trans-ischiorectal (TIR)
i. Dr. Bautrant- France, rare
i. Transglueteal (TG)11
i. Dr. Robert- France, Conway- New Hampshire, Hibner- Arizona, Filler- California
ii. Most common approach
iii. ST ligament can be replaced cadaver tissue
ii. Anterior Approach11
i. Dellon- Maryland
iii. Laproscopic11
i. Erdogru-Turkey
× No data between different approaches11
× PT protocol11
× Begin PT 8-12 weeks post surgery, 12 weeks post for internal
× At 8 weeks, do scar management
× Up to 2 year recovery after surgery

14. References
1. Christensen VN. Is a perfect PERFECT...perfect? Paper presented at: Combined Sections Meeting
2016; February 19; Anaheim, California.
2. Therapeutic management of incontinence and pelvic pain : pelvic organ disorders / J. Haslam and J. Laycock
(eds). 2nd ed: London : Springer; 2008.
3. Laycock J, Jerwood D. Pelvic Floor Muscle Assessment: The PERFECT Scheme. Physiotherapy. 12//
2001;87(12):631-642.
4. Miller JM, Ashton-Miller JA, DeLancey JO. A pelvic muscle precontraction can reduce cough-related
urine loss in selected women with mild SUI. Journal of the American Geriatrics Society. Jul 1998;46(7):
870-874.
5. Sapsford RR, Hodges PW, Richardson CA, Cooper DH, Markwell SJ, Jull GA. Co‐activation of the
abdominal and pelvic floor muscles during voluntary exercises. Neurourology and Urodynamics.
2001;20(1):31.
6. Hodges PW, Butler JE, McKenzie DK, Gandevia SC. Contraction of the human diaphragm during
rapid postural adjustments. The Journal of physiology. Dec 1 1997;505 ( Pt 2):539-548.
7. Hodges PW, Sapsford R, Pengel LH. Postural and respiratory functions of the pelvic floor muscles.
Neurourol Urodyn. 2007;26(3):362-371.
8. Sapsford RR, Richardson CA, Maher CF, Hodges PW. Pelvic floor muscle activity in different sitting
postures in continent and incontinent women. Archives of physical medicine and rehabilitation. Sep
2008;89(9):1741-1747.
9. Clinton SC. The Effect of Thoracic and Cervical Stiffness on Lumbopelvic/ Pelvic Floor Dysfunction.
Paper presented at: Combined Sections Meeting; February 19, 2016; Anaheim, C.A.
10. Siracusa C. Every Patient with Cancer Should See a Pelvic Floor PT. Paper presented at: Combined
Sections Meeting2016; Anaheim California.
11. Akincilar-Rummer EH, Pendergast SA. Pudendal Neuralgia: Then and Now. Paper presented at:
Combined Sections Meeting; February 18, 2016.
12. Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal
neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306-310.