The second chapter on men's pelvic stories is a more specific look at how men (and those who love them) can work through pelvic challenges, focusing on prostate cancer, surgery and treatment.  The first chapter talked about the pelvic problems that a man may face.  The good news is that with pelvic physiotherapy and a solid commitment to follow through with the work at home both before and after surgery and treatment, complete resolution of both leakage and impotence is possible.  Each man will have varying severity and duration of these physical side effects and they can lead to a much reduced quality of life.  You can rewrite your story with help.

The protocol that is described here leans heavily on the brilliant work of Jo Milios in Australia, a pelvic physio devoted to men's pelvic health and aided by over 3000 men who have had radical prostatectomies.  Men who followed this protocol had much less leakage, much reduced duration of leakage and a much improved quality of life throughout their recovery time.  Even more convincing is the statistic that 1 in 6 men had no leakage whatsoever!

For 4 - 6 weeks prior to surgery and resuming immediately after surgery, men are taught the following protocol:  six times daily, in a standing position, two exercises are performed.  The first is 10 fast twitch (or speed 'ems) maximal (full on!) contractions and releases.  These are followed by 10 slow twitch (endurance building or hold 'ems) contractions, holding each for 10 seconds with a 10 second relaxation time between each contraction.  It's important to find "the right muscles".  Try this:  squeeze the front passage as if you're stopping the flow of urine, then lift your testes and retract the penis.  Doing these exercises in standing is important as this is the position in which most men leak.  With your pelvic physio, you'll learn awareness of which muscles activate correctly, then how to release fully and more!  The importance of "pre-hab" or beginning training prior to surgery can't be reinforced enough.  The time between biopsy/diagnosis and surgery is a time to begin learning about your pelvic function, strengthening and releasing.  Bladder control (voiding with control and fully 6 - 8 x daily or learning to do so) and a happy bowel really make a difference as you head into the choppy waters of surgery and treatment.  Jo's research has shown that men respond very well to the improved physical control of their waterworks and sexual function with this help, but additionally they are emotionally and relationally so much stronger!  Her goal is to improve the quality of life for all undergoing prostate cancer diagnosis, surgery and treatment.

Let's get specific....one appointment for assessment/training is sufficient to help you begin.  Palpation can be done externally in most cases.  Your important three muscles that control your urine, the trio that you need to learn to turn on and off and strengthen are called the external urethral sphincter + bulbocavernosus + puborectalis.  Sometimes that pesky external anal sphincter gets dominant and you need to learn to teach it to quiet down.  Once you've found these muscles, you'll move onto working in synergies, becoming powerful (for coughing and sneezing), strong (for sit to stand and lifting), having endurance (for standing and walking), improving the quality of contraction/lifting of the pelvic floor as well as improving release/relaxation in order to support the next contraction.

The toughest bit?  Fatigue.  Standing upright will fatigue the system and that fatigue may worsen as the day progresses, causing leakage to occur.  Many men will have overactive muscles that need to learn to release and NOT exercise at first (called pelvic downtraining), some men will vary

When I write about women's health, oncology (cancer related) and pelvic physio, it's a logical to assume that it's only women that we pelvic physios assess, treat and talk about.  This is the first in a series of articles that will introduce you to the challenges that men face in their pelvic region, despite "being absolutely mortified to be discussing their private parts" (to quote Dr. Jo Milios, our lead teacher, a brilliant physio who had set up a non-profit organization in 2012 in Australia called PROST! Exercise for Prostate Cancer Inc.).  Her passion is to educate all of us so that the everyday man on the street has better health outcomes and a much longer life.

Pelvic physiotherapy for men addresses loss of function in the pelvic region including prostate cancer pre-hab (prior to surgery and other treatments) and rehab, pelvic floor muscle dysfunction, urinary incontinence, painful urination, recurrent bladder infections, urinary frequency, bowel dysfunction, erectile dysfunction, chronic pelvic pain syndrome and Peyronie's Disease (a crooked or bent penis).

Let's begin with the prostate.  The prostate gland is a walnut sized donut shaped gland found right under the bladder and wrapped around the urethra (urine tube).  Its job is to produce most of the fluid that makes up semen.  The prostate can become inflamed (prostatitis, acute or nonbacterial) or enlarged (benign prostatic hyperplasia).  Enlargement of the prostate doesn't mean it's cancerous and is usually noticed after age 40 during a regular doctor's visit.  Prostate cancer is the most common cancer in North America and accounts for 11% of all cancer diagnoses in BC men; 1 in 9 males is expected to develop prostate cancer in their lifetime with 89% of them being over the age of 60 when they are diagnosed.  There are some well known correlations (not causes) that may raise a man's risk of developing prostate cancer, including aging, family history, high levels of testosterone, being overweight, not exercising regularly and a poor diet.  Large studies have shown that there is no correlation between having a vasectomy and prostate cancer.  Yet again, Grandma's sage advice to exercise regularly, eat real good and maintain a healthy weight (for all cancers!) are actions that you can take to reduce your risk of developing prostate cancer.  Your doctor (GP or urologist) or nurse practitioner may do a DRE (digital rectal examination) to palpate your prostate or you may have a PSA (blood test) to measure how much of a specific antigen is in your system.  If you notice changes in your urination (stuttering flow, slow stream, painful, frequent, dribbling/double voiding, feeling the urge to bear down to start or finish, urge or loss of control, increased night time voiding or blood in your urine and/or painful ejaculation), please tell your doctor.  Even though it's difficult or embarrassing to open up these conversations, your healthcare professional will want to know, will have had these conversations before and will make you comfortable sharing your story.  Tell them!

We pelvic physios become involved with men going through prostate surgery because most men (99%) will experience incontinence and erectile dysfunction.  One of the prostate's secondary jobs it to support the bladder and to give neurological support of continence through the autonomic (involuntary) nervous system.  The Cavernosal Nerves, responsible for erections, are wrapped around the prostate and they're usually damaged or removed in the process of the surgery.  Each man will have varying degrees or severity and/or duration of physical side-effects of the surgery but please know that each man will generally improve over time.  With pelvic pre-hab and rehab, complete resolution of both continence and sexual function is possible.  It's all about restoring wonderful function and quality of life while reducing anxiety and depression, penile fibrosis and shrinkage and stopping the development of Peyronie's disease.

Most importantly, men and partners who love men, talk with your doc if your experiencing pelvic dysfunction.  In part 2 of this series, I'll share Dr. Milios' well researched brilliance after seeing >3000 men with radical prostatectomies, showing that, by using her protocol, men had less leakage (in amount and duration) with 1 in 6 men having no incontinence at all!

Each week as I prepare to teach the Yoga for People with Cancer class, I seek some inspirational words.  I'd decided that we'd visit and revisit Tree pose in all its iterations, from lying to long sitting to static tree to moving tree to a pre-savasana resting tree, each time finding a new kind of balance.  This poem, written by Ilan Shamir, really struck a chord with me and so here's playful blog to share with you.  As we transition into spring, let's celebrate the catkins on the hazelnuts, the swelling buds on the maples and our own roots and growth!

Advice from a Tree

Dear Friend
Stand Tall and Proud
Sink your roots deeply into the Earth
Reflect the light of your true nature
Think long term
Go out on a limb
Remember your place among all living beings
Embrace with joy the changing seasons
For each yields its own abundance
The Energy and Birth of Spring
The Growth and Contentment of Summer
The Wisdom to let go like leaves in the Fall
The Rest and Quiet renewal of Winter.

Feel the wind and the sun
And delight in their presence
Look up at the moon that shines down upon you
And the mystery of the stars at night
Seek nourishment from the good things in life
Simple pleasures
Earth, fresh air, light
Be content with your natural beauty
Drink plenty of water
Let your limbs sway and dance in the breezes
Be flexible
Remember your roots
Enjoy the view!

Menopause.  Hot Flashes.  Uncomfortable, disturbing, nauseating, fuzzy brain, disturbed sleep....hot flashes are listed as one of the most negative aspects of our peri to post menopausal years.  We begin to feel like Goldilocks, desperately seeking a "not too hot, not too cold, just right" kind of world.

75% of women have hot flashes during their menopausal transition.  Moderate to severe hot flashes typically last 7 to 10 years on average and less frequent or severe (either end of the spectrum) can last even longer.  Let's talk about how you can influence the frequency and intensity of hot flashes, sleep and feel better!

We enjoy a breadth of temperatures in our lives before surgical (full hysterectomy), chemical (induced by medication) or natural menopause....we can be too warm or too cold and simply put on or remove a layer of clothing and stay comfortable.  This is due to our clever hypothalamus, the part of our brain noticing and controlling thermoregulation.  When it sense that we're becoming too warm or cold, it send signals to our organs, muscles and hormonal systems.  They collectively respond to bring our internal core temperature back to normal.  With menopause, the range of acceptable fore body temperature is drastically narrowed.  We become more sensitive to external temperatures so much that we experience a sense of panicking with crisis messages zipping around, causing blood vessel dilation, sweating, wakefulness, peeling off of clothing/blankets....the list is long!

Why now?  There are a number of theories including declining estrogen theory, elevated noradrenergic activation (stress) theory, east vs. west (consumption of phytoestrogens) theory, stress-coping theory, perception of menopause theory and thyroid dysfunction masquerading as menopause symptom theory.  Estrogen does 400 jobs in our premenopausal body each and every day.  We have declining estrogen with menopause, reducing support to our hypothalamus, making our threshold to heating much more sensitive.  Simply adding estrogen sounds logical, but isn't an answer for women who are sensitive to estrogen (a history of estrogen related cancers), nor for those who are estrogen dominant (actually have low progesterone in relation to their estrogen).  This is a condition that is more common in recent decades due to chronically high stress hormones that creates chronically low progesterone in relation to our declining estrogen.  It's all in the balance.

We need stress hormones in our lives in order to wake up each morning, but again, not too much stress. With our reducing estrogen, we handle stress less well after menopause due to altering of our neurotransmitter activity.  Rather than thinking that we've become wimpy, we now know that our stress response is more sensitive through menopause due to physiological changes!  Those of us who dread menopause or fear aging, those who are stressed by daily life (financially, physically, relationally, emotionally), those who have suffered trauma and those who smoke and/or are obese are likely to experience more frequent, intense and long lasting hot flashes.

Triggers for hot flashes include caffeine, dehydration, alcohol, smoking, sugar, hot foods (spicy and temperature), stressful situations, stressful thoughts, sleeping in a hot/unventilated room, wearing too many clothes/blankets, focusing on/worrying about hot flashes/aging and not prioritizing restoration time (like quietude, meditation, prayer or nature walks).  Hmmmm......notice any patterns for you?

Begin by keeping a hot flash diary for a week.  When do they come?  How severe are they?  How long do they last?  Which of the triggers can you align with your hot flashes?  Each woman is unique and it's up to you to sort yourself out.  Be your own personal sleuth.

Some general guidelines are:  Address one personal trigger per week from your list, beginning with your toughest personal challenge.  Stop and congratulate yourself, knowing that the balance of the list will be easier.  Learn and practice calm breathing by doing the following:  breathe in for a count of four and out for a count of four.  Keep going for 5 minutes, building up to 10 minutes, repeating 2 - 4x/day.  Lose 5 pounds; repeat if needed.  Begin a gratitude journal, noting 3 items each day that you're grateful for.  Controlling your controllables is your first step!  You'll sleep better, fell better and enjoy life more.

 
Constipation. If your back passage (bowel release and anorectal action) isn't working well, nothing else in your pelvis (bladder, intimacy, pelvic organ support and core strength) will be working well.  So, brace yourself, let's talk constipation!
 
Do you enjoy a consistent, full, complete and satisfying bowel movement every morning?  BMs should be a minimum of every 2 - 3 days and a maximum of twice daily.  You should never need to rush, have skidmarks in your undies or lose stool without you knowing or before you're ready.  Ever.  The stool should be firm but not dry or very cracked, smooth but not sticky and medium sized to pass with comfort.  It should be brownish, of a consistent smell and without mucous or blood.  It shouldn't be painful to release your stool nor should you bear down.  Hemorrhoids can come with pregnancy or stress, but shouldn't be persistent.  You should be able to travel or change your routine without upsetting your BMs.  Your bowels are meant to digest your food and drink, transfer nutrition to your body, then get rid of the waste.  It's a beautiful system!
 
How does it actually work?  When you take that first warm drink in the morning, the sphincter between the esophagus (food tube) and the stomach sends a signal to the rectum that today's food is en route.  Yesterday's waste is nudged along the colon, down the digestive tract and into the rectum.  The sphincter at the end of the rectum opens up.  Counterintuitive?  Stool has just landed and it opens up to take a sample.  It checks if it's gas, liquid or solid. If it's gas, it nudges you. If it's liquid, it slams shut and gives you to signal that you need to move!  If it's solid, it shuts firmly and gives you the message, "Time to go to the toilet".  Don't delay.  It nudges, you calmly go.
 
Toileting habits are important. Sit comfortably and relax.  Your knees should be slightly higher than your hips, supported on a stool or block. Breathe into your belly and sense your pelvic floor softening, descending, and the sphincters opening up to let stool pass.  If you have the urge to push, don't!  Just breathe into your belly and do a bass hum, low growl or pursed lip outbreath to protect your pelvic floor.  Keep allowing your system to release and let go.  Don't stop the stool until your body says you're done.  Then belly breathe again, rock your pelvis and enjoy a few moments of quiet.  When you're sure you're done, do a few gentle pelvic floor squeezes to help clear the anus so that wiping is gentler and more complete.
 
You can support your digestive system.  Keep hydrated, drink mostly water, and enjoy a drink of warm water with tooth-brushing to help your stool stay hydrated overnight.  Be cautious with fibre, adding a little at a time.  Pay attention to the foods that your body finds a problem - what makes your stool too solid and/or what makes it too loose?   What gives you gas?  You're unique, so learn about you.  Support your system with a heated wheat bag and a massage.  Help your system release its waste products after all the work it's done for you.  Depending on your issues, there are specific techniques, stretches, breathing patterns and habit changes that will help you enjoy lovely BMs that support your health.
 
If you have specific problems with your bowel release, a pelvic physiotherapist provide you with with an internal and external assessment and treatment plan just for you.  Your digestion, bladder, pelvic organ support and intimate life will thank you!

 
Pelvic pain is complex and has many faces.  We've talked about Painful Periods, Endometriosis and now we're going to tackle Bladder Pain Syndrome.
 
Bladder Pain Syndrome may have begun like this:  You had a urinary tract infection that just didn't go away.  You felt urgency to void.  You felt pain just above your pubic bones (where your bladder lives), in your perineum and/or in the urethra (the tube from the bladder to the outer world). When urinary tract infections became chronic, the old thinking was that the interstitium (bladder lining) was inflamed, ergo the outdated name "Interstitial Cystitis". Bladder Pain Syndrome is far more complex, the name far more descriptive. 
 
In 2018, we know the onset of BPS is more like this:  Your bladder thinks that it's under threat…..a grizzly is at its door.  Your bladder may have suffered at some point in your life, perhaps when you were a child (Chronic infections? Withholding voiding? Difficulty with bedwetting?).  The part of your brain that worked with your bladder remembered this sense of distress.  Later on in life (with puberty, onset of intimate relations, stressful situations, baby having, an accident or menopause), your bladder had "flashbacks" and kicked into that difficult memory.  Your immune system pitched in, bringing on an immune response and inflammation.  Your bladder nerve endings and the nerve pathways to the brain were woken up.  Your tendons, muscles and fascia tightened up in order to protect the area. 
 
The outcome?  You may develop a hypersensitive, overactive, inflamed bladder.  As your bladder fills, it naturally stretches.  That tight and inflamed bladder isn't so keen on stretching, sending a threat message to the brain.  Your bladder naturally fills to 500-ish mls., but with BPS it can become painful at only 100 mls..  The bladder may also not welcome urine due to the inflamed lining, so you may feel a sense of urge to get rid of it…now!  If you experience these feelings for more than three months, your brain begins to focus on the bladder, becoming attentive to all bladder sensations from a little urine to moderately full to urgency to pain!  The natural voiding reflex and habits become distorted over time and your bladder forgets how to feel the "Oh, I'm getting full…..I'll have to go to the loo soonish, but no rush" sensation.  The rising tension in the pelvic floor creates more problems.  Toilet time naturally involves releasing the pelvic floor along with opening of your sphincters in a lovely dance.  With a tight pelvic floor, your urine stream may become slow, interrupted, painful and incomplete.  Intimacy may become painful.  You may have an accompanying challenge with bowel release (not constipation….it's the letting it go part that becomes slow and/or painful).  Your stress system and brain become alerted over time and this increases your perception of pain; it attaches it to your emotional state.  If you haven't slept, are having a bad day or have stress, you'll feel BPS more than you would have otherwise.  It's just all so connected.
 
What can you do about it?
 
Find a pelvic certified physio.  You'll be asked about how your bladder functions, how often you void, how it feels before, during and after voiding, how your bowel works (loading, comfort, movement, frequency), pelvic floor function, deep core function and how your life is working (your nutrition, sleep, understanding of pain, pelvic systems and stress management).  Your internal and external pelvis and deep core will be assessed.  Research has shown us that your pelvic floor needs to be calmed down in its hypertonicity (tension), pain and function or the dysfunction and pain in your bladder won't change. You will be taught pelvic floor releases with breathing patterns, general and specific stretches and perhaps the use of a wand (a pelvic trigger point tool for you to use). An elimination diet is helpful, but no two women with BPS have the same dietary triggers.  Eat food that agrees with you.  Get good sleep and downtime.  Find and manage your stressors.  Bladder Pain Syndrome can be managed well.  You can experience a cascade of wonderful changes when you take charge of your own health.

"That time of the month" may bring on cramps, bloating, food cravings, unpleasant moods, loss of energy for some women.  Consistently painful periods are NOT normal, so please ask for help if that is your experience and learn some ways to ease your discomfort!
 
Deep Breathing
 
Stress can increase period pain, make you skip or lose your periods altogether.  When you're stressed or in pain, your breathe at the top of your lungs, just under your collarbones.  Breathing deeply and fully into your low lungs creates rhythmic abdominal and pelvic movement.  It's a natural massage, moving your organs like seaweed dances in the ocean in response to waves.  Slow, relaxed deep breathing promotes relaxation, enhances your mood, improves your concentration and simply feels wonderful!  Use your breath to make a simple, accessible and lovely change. 
 
Here's how:  Ly on your bed with a pillow under your head and another under your knees.  Let you body release and relax.  Place one hand on your chest and the other on your low belly, making sure your elbows are supported on the bed.  No effort!  Now, breathe in slowly through your nose.  Let your belly lift, your low back arch, your pubic bones descend towards your feet and your hips release.  Your lower hand will have lifted and your upper hand will stay quiet on your upper chest.  Now just let the air seep out of your nose, exhaling without effort.  Let is be as slow as you're comfortable enjoying.  Count a slow 4 counts in and at least 4 or more (to 5 or 6?) out.  Repeat.  Enjoy.
 
Release Your Pelvic Floor
 
When our body experiences pain, it may respond by tightening up and holding back.  Periods, when completed with ease, are about letting go!  Our pelvic floor can get in the way of releasing our flow by becoming tight in response to pain.  Begin practicing release of your pelvic floor by sitting on a big ball or over an upholstered sofa/chair arm.  Breathe into your low belly, feel your pelvic floor open and release…….use this technique when you're in your painful cycle and you will find more ease with your flow.
 
Abdominal Massage
 
Start with a hot water bottle or heated wheat bag for 15 - 20 minutes in a restful position and quiet place.  Cover yourself with a blanket.  When you're all warmed up, remove the heat and, with the heel of your hand, massage your own belly, picturing a clock.  Find the "time" on the clock that needs special attention, keeping the massage gentle, slow and consistent.  You might need 10 - 15 minutes to massage, then 5 more minutes to repeat heat.  This stimulates blood flow, mobilizes your fascia and organs and distracts the pain nerves from being cranky.
 
Yoga
Yoga is a way of learning to breathe, release, strengthen, move and approach life with ease.  Some of the yoga poses that relieve period pain are Child's Pose, Knees to Chest, Forward Fold, Cat-Cow, Windshield Washer Spinal Twist and Savasana.
 
An experiment of one:  Try by adding 2 yoga "classes" (at home or in a class) per week for 3 months.  Employ low belly breaths, releasing your pelvic floor, heated tummy massage.  Keep track of your periods for 3 months.  Benefits may include:  reduced cramping intensity and length of time, less moodiness, more regular periods, lighter bleeding, less bloating, less tender breasts, better sleep, improved concentration and a more relaxed experience.  Find ease in your monthly cycles……they'll be a monthly experience for most of your life, so find what works for you!

POP, Not the Fizzy Kind!
 
POP, Pelvic Organ Prolapse, is experienced by almost 70% of women, yet fewer than 28% of us know what it is!  Let's define it, unravel its causes and Most Importantly, learn how to assess, stabilize, prevent and reverse POP. 
 
What is Pelvic Organ Prolapse?  The International Uro-gynecological Association defines POP as "the bulging/herniation of one or more of the pelvic organs (uterus, vagina, bowel and bladder) into or out of the vagina."  POP occurs when the muscles, ligaments and fascia (a network of supporting tissue) that hold these organs in their correct position become weakened.  POP is common because its causes are so common:  pregnancy, labour and childbirth, aging and menopause, genetics and family history, obesity, chronic cough, chronic constipation, heavy lifting (work or play), hypermobility (naturally stretchy people) and pelvic surgeries (especially hysterectomies).  Often the impact on supportive structures earlier in life (i.e. pregnancy) that create prolapse will not be functionally obvious until menopause.  That's why being assessed for POP at any time in a woman's life is so helpful…..it is usually preventable!
 
How would you guess that you have POP?  Women describe heaviness or a dragging sensation in the vagina or pelvic floor, a lump or bulge in the vagina, aching discomfort in the pelvic region, urinary or bowel problems, a dull backache or sexual problems.  These symptoms often worsen with activity or simply as the day goes on.  Bladder and bowel problems involve incomplete emptying, feeling the need to bear down or use manual help to finish the job on the toilet.  If the bladder prolapses on its own, it can create chronic bladder infections. This is due to kinking of the bladder neck before you've completely emptied leaving just enough urine behind to brew up another infection.  POP must be assessed functionally, graded, on repeated testing and with an understanding of the deep core system and breathing patterns.  Our bodies are supremely clever at recruiting "help", but often those patterns of recruitment cause further dysfunction. 
 
What can you do about POP?  Reversing POP is a new and exciting world in Pelvic Physiotherapy.  We used to think that surgery was the only option…….a challenging surgery and one that is oft repeated due to structural failure as life's activities challenge the repaired structures.  In a recent study in Vancouver, 79% of prolapse surgeries were cancelled after 8 weeks of pelvic physiotherapy, thereby avoiding the risks inherent in surgical intervention.
 
Creston has a bounty of options for you:

Pelvic physiotherapy will help you to make the changes necessary including:  integrated pelvic floor and deep core muscle training, establishing healthy bladder, bowel and lifestyle habits, and learning healthy ergonomics for coughing, toileting, lifting, sport/exercise and sitting/standing/resting your body through the day.  Pelvic Physiotherapy is available at Full Circle Health Centre with Joanne Gailius.  An assessment and a few follow-up sessions are usually all that you'll need.  Hypopressive training is available locally at Spitfire Fitness with Jenn.  Group and individual Pelvic Yoga Therapy is at The Yoga Room with Barb.  With your gynecologist, you may be fitted for a pessary, a ring that is inserted in the vagina to hold up the organs.  After trying all conservative options, you may need surgery.  You'll be ready and able to employ all the skills that you've learned already and you'll have greater benefit from the surgery!
 
Pelvic Organ Prolapse is common but not normal.  Learn about your pelvis, your deep core strength and a strong and healthy body through life's seasons.