12 and not “jump in” and work in isolation. This is best done with mindfulness training. A high degree of interoception (a lesser known sense that enables understanding and feeling what is happening inside the body), is required to change these unconscious patterns. The multiple functions assigned to the PFM include: 1. Holding the pelvic organs in place in an upright posture, under the force of gravity. 2. Closing the circle of integrity and providing stability to the pelvis and the lower quarter, by making up its oor. 3. Working as an integral stabilizer of the body as a bipedal organism. 4. Allow for urination, defecation, and birth in the female. And facilitate urinary, fecal and atal continence. 5. Allow for sexual arousal, and contract during orgasm to provide sexual appreciation. 6. Support penile function in the male and allow for penetration. With so many different functions, it is easy for things to go wrong. The list is long, but just for the sake of completeness, they include: Anterior dysfunctions Urologic: • Difcult urination: hesitancy, delay in the urinary stream • Cystocoele: bulging or herniation of the bladder into the vagina • Urethrocele (urethral prolapse): bulging of the urethra into the vagina • Urinary incontinence: involuntary leakage of urine. Gynecologic: • Dyspareunia: pain with or following sexual intercourse. • Uterine prolapse (herniation of the uterus beyond the introitus of the vagina) • Vaginal prolapse (herniation of the vaginal apex beyond the introitus) • Enterocoele (bulging of the intestines into the vagina) • Rectocoele (bulging of the rectum into the vagina) Colorectal: • Constipation: dyssynergic defecation (inadequate relaxation of the PFM) • Fecal incontinence (involuntary leakage of stools) • Rectal prolapse • PPP (chronic pain unrelated to other conditions) • Levator ani spasm (which may cause PPP) • Proctalgia fugax (sporadic or momentary LA pain) • Perineal descent (bulging of the perineum below the pelvic outlet). For PFM function to be optimal, the “conductor” needs to know precisely where the muscles ligaments and fascia are in space and in the motor sensory cortex. The brain’s internal somatic represenentation, perceived in the sensory homunculus needs to be accurate and clear. This builds good body awareness, and is crucial to generating functional ring of the core muscles and accurate proprioception and motor control of the pelvic region. This forms accurate interoceptive awareness. Interoception is often called the seventh sense. This interoception may be interrupted in victims of sexual abuse or in patients suffering PPP, PFD or in people suffering from sexual dysfunction. It is best trained and restored with mindfulness techniques and mindful movement practice. Conclusion Successful rehabilitation of any aspect of the pelvic region or the pelvic girdle requires intervention on the multidimensional level. Resolution of PFD and restoration of pelvic health and wellbeing demands input into the mind, body and lifestyle simultaneously. Lifestyle interventions need to include diet, weight, gut health, mindful eating, sleep hygiene, stress interventions, self-efcacy coaching as well as selfawareness training. In addition, developing agency in the presence of pain and dysfunction is essential. Where exhaustion overwhelms or an internal message of being unsafe and unsupported exists, this needs to be changed, through mindfulness-type interventions and where needed psychotherapy. Unconscious holding patterns (non-relaxing PFD) need to be brought conscious and using mindfulness training and active relaxation, they need to be re-wired. This allows a new default pattern to set in. Core muscles need training in a global context so that the mindset that underlies posture and muscle tone can be altered, making change sustainable and not short lived. In addition, the body awareness capacity of the brain must be enhanced, which requires motion control rehabilitation. Medical practitioners need to work together in a multidisciplinary-team-style-approach to enable patients to get the results they deserve. Every member of the team is integral, but the role of the pelvic health trained physiotherapist must not be overlooked and wherever possible mindfulness training as well as mindfulness based cognitive behavioural therapy (MBCBT) must be introduced to facilitate enhanced awareness and therefore agency for the patient. UROLOGY, URO-ONCOLOGY AND SEXOLOGY UPDATE
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