#PTonICE Daily Show – Monday, November 13th, 2023 – Varicosities and varicoceles

In today’s episode of the PT on ICE Daily Show, #ICEPelvic faculty member Rachel Moore describes pelvic varicosities & varicoceles. Rachel breaks down the difference in how these present in both male and female pelvic physical therapy patients as well as how to conceptualize treatment in the clinic. 

Take a listen to learn how to better serve this population of patients & athletes.

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All right, good morning PT on ICE Daily Show my name is Dr. Rachel Moore I am here this morning. It is Monday morning. That means it is our pelvic day here on this podcast So I’m here with the pelvic division and I am super excited to talk to you guys this morning We’re gonna be kind of diving into varicoceles and varicosities, vulvar varicosities, and the way that those are actually incredibly similar in our treatment approach, whether we realize it or not. Before we dive into that though, if you missed it, we’ve officially rolled out all of our certifications here at ICE. So we have certifications, we’ve had them before in the clinical management of the fitness athlete division and an MMOA, but now we have new ones. So we have orthopedic, we’ve got dry needling, we’ve got an endurance athlete, and then what we are super excited about in the pelvic division is we have our pelvic cert as well. So this is three courses, two online, a level one and a level two, and then one live course. If you’re looking to get in on that certification, our upcoming courses, we actually have one this weekend in Bear, Delaware. That’s going to be with myself and Alexis Morgan. So super excited about that. Still, time to hop into that if you want to buy yourself a plane ticket and get out there. And then we also have one on December 2nd. If you are north of the US border in Canada and Halifax, Nova Scotia, Christina is bringing those live courses to Canada. So we’re super excited about that. Our next L1 cohort kicks off January 9th, and then our L2 you can already sign up for. So if you want to be in that first cohort of that L2, it kicks off April 30th. So if you’re interested in getting that cert, all of the options are out there. Hop into one of those courses. We’re excited to see you in them.

Let’s dive into our topic for the day. So a lot of times those of us in the pelvic space if we are maybe majority see women a lot of us tend to maybe start there and then maybe branch off into seeing men but if we are in this kind of blinders-on situation where we’re like no no I only see women sometimes we may be uncomfortable or unsure if somebody gives you a call and asks about a certain diagnosis or maybe you have a friend or somebody that you know that is struggling with something and asks for advice on the pelvic space and you’re trying to figure out how to get them into your clinic. And so I wanted to draw a parallel this morning between two diagnoses that we see as fairly common that actually are very similar in the way that we treat them. So that is going to be varicoceles and varicosities. So in utero, the reproductive tissues of males and females begin developing similarly. If you guys remember that from PT school, when we were learning about the brief amount that we cover these types of topics, once testosterone starts being released, that’s when the reproductive organs shift and either develop into male organs or continue on the path of female organs. And so if the testosterone is there, then the tissue that is becoming the scrotum becomes the scrotum. But if the testosterone is not there, then that tissue continues on to turn into the labia. So when we think about our tissues and our anatomy, we often talk about how male and female anatomy really aren’t that different. It is similar parts arranged differently and maybe to different sizes and proportions. But when we look back all the way in utero, we can see that developmentally these things start the same and there’s a certain point where things branch, but we have these kind of analogous, um, uh, tissues within males and females. So, We know that the tissues are similar between the scrotum and between labia. When we’re talking about varicosities, this is important for us to know because these are two diagnoses that we tend to see come up fairly frequently.

So before we dive into the specifics of varicose veins in the pelvic area, let’s talk about what varicose veins are. Varicose veins, if you’re not familiar with them, are enlarged twisted veins. So oftentimes this comes from damage to the valves in the veins. So our veins have one-way valves that help push blood up and prevent backflow back down. If there is damage to the inside of the vein and the valves are damaged somehow or maybe are not operating at the capacity that they need to be operating, we can see kind of a backlog of blood and that can lead to this kind of inflamed or swollen look to the veins and that blood just kind of pulls in there. The causes of the damage, quote-unquote, Inside of the vein can be known. So this can be something like high blood pressure or it can be unknown Things that increase your risk for developing varicosities are gonna be things like being female So that’s always fun when gender is one of the top things can’t control for that genetic predisposition so if you have a family history of varicosities then this might be something that you’re really keeping an eye on and older age as we get older maybe those valves within the vein become a little bit less competent increased body mass and then in pregnancy we’ll dive into that here in just a second and then also interestingly having a history of blood clot that’s really important to kind of keep in mind on our radars not only in our post-surgical patients but we’re starting to see blood clots kind of popping up more and more um and so if you have somebody who might be not hitting any of these other risk factors but has a history of blood clots it’s still something that we want to kind of keep on our radar varicose veins aren’t a medical emergency by any means but they can cause some like uncomfortable unpleasant symptoms like heaviness aching pain and then swelling.

Let’s dive a little bit deeper into varicosities of the pelvic region so in our biologically female counterparts we see vulvar varicosities this is varicosity that develops on the vulva so anywhere along the outside of the vagina so that tissue of the vulva It can happen on labia majora, labia minora. It can be going towards the inner thigh, more into that groin area. Really just kind of depends on the area that is affected. The risk factor for this specifically is pregnancy. So we see this come up in pregnancy for a few different reasons. One reason is that we have an increase in blood volume during pregnancy in order to support the baby. So that increase in blood volume means that our veins have to work harder to push more blood up. we also know that we see relaxin circulating and that does have an effect on all tissues and then we have an increase in pressure so we have increased pressure from both the weight coming down of baby placenta amniotic fluid and all the things but then if we also think about like the anatomy of a pregnant belly as people progress through pregnancy get into this maybe anterior pelvic tilt their belly maybe drops low it can cause some congestion or some backup within that system which then leads to less efficient drainage. This is something that we see pretty often in the clinic really and you might be familiar with this if you’re in the pelvic space. but what we tend to not really think about is how this parallels varicose seals. So a lot of times we’re pretty confident and comfortable with vulvar varicosities, but then somebody comes in with a little bit different anatomy, and we kind of get thrown for a loop. So a varicose seal is a varicose vein that’s located within the scrotal sac. This can actually develop during puberty because blood flow to the genitals increases during puberty. As those tissues are maturing things can just get a little thrown off, but it can also happen as a result of surgeries So think about vasectomies even though those are like minor office procedures surgeries vasectomies or trauma to the scrotum They’re surprisingly common, especially in the adolescent puberty side of things. And just because you have a varicocele doesn’t necessarily mean you’ll even know it, aside from feeling it, potentially. So the biggest way or hallmark of this is called the bag of worms. because within the skirt sack that varicocele feels like a thick ropey worm and so as people are feeling around checking testicles for different things then you might feel that bag of worms type sensation or that that feeling with your fingers and other than that you may not have any idea However if you have a varicose seal that is causing problems We can see swelling pain and heaviness as I talked about earlier and if this is left alone and becomes severe it can actually impact fertility in men because it can lead to decreased sperm in the ejaculate and so it can be something that if it happens in adolescence and somebody is trying to conceive later on in life with their partner and they’re struggling, it’s an area to look at. Just like vulvar varicosities, we see an increase in symptoms when we’re standing for prolonged periods, but uniquely to this population, we can see potential pain with ejaculation. So with vulvar varicosities, we might see pain with intercourse because of the pressure on the outside of the vulva during intercourse. But with this population, it’s going to be more so during ejaculation that there is pain.

We have our person in front of us, male or female, who comes into your clinic, some varicosity of some sort going on. What are we supposed to do? Jess actually did a really fabulous episode on this topic. It’s episode 1198, so if you want to go back and listen to that, she talks specifically about varicosities during pregnancy, and those same concepts can be applied to varicoceles in men. So I highly recommend giving that a listen. We’re going to dive in just really briefly touch on some of those topics and then I’ll let you guys really dive into justice. External support can be a game changer for these folks, especially those with varicose heels whose anatomy is already putting things in a gravity, um, disadvantageous position for drainage. So giving some type of support, whether that is like when you’re getting up and moving using your hand to support or getting some type of support garment. There are specific support garments that are made both for males and females for varicosities. soft tissue massage and when we think about this we’re really thinking like mimicking lymphatic drainage I talk about this all the time with breast tissue and engorgement but the same thing we’re thinking about this like congestion within the pelvic region and so we want to think about clearing more proximally up Towards the iliac vein so that we can kind of promote that drainage and then work our way down Rather than coming down to the bottom and just shoving everything up and causing more congestion Superiorly, so we’re starting closer to the midline Draining quote-unquote that area. So if you’re watching on Instagram, we’re saying we’ve got a guy in and he’s got varicose heels maybe we’re starting here and then we’re working lower and then working lower and until we get to that most distal tissue. From an exercise intervention standpoint, the pelvic floor muscles, of their functions are a sump pump. So when they contract and relax, they push fluid out of areas. So teaching our patients how to do pelvic floor contractions, how to lift up and contract into the attic, relax down and go into the basement, get that pumping mechanism going, and then teaching them belly breathing on top of that to help facilitate that as well. Finally, from a positional standpoint, we can have our patients if at the end of the day, they’re super symptomatic and they’re feeling rough after being on their feet, laying on their back, propping their legs up on the couch, or on a wall to get some passive decrease in gravity pressure on the pelvic region, and we can even take that a step further, have them plant those feet on that surface and do some bridging where they’re squeezing their glutes, maybe adding in that pelvic floor contraction, layering that in, so we’ve got gravity coming down, we’ve got our muscles contracting and relaxing, really everything helping to push that fluid up and out into the drainage system to go bring that blood back to the heart. So, if you have somebody come in your clinic tomorrow, and you are a pelvic floor PT who traditionally treats females, and a guy walks in and he’s like, I have a varicose seal, I don’t know what to do. I hope that you can put your cap on, thinking cap on, and realize like, you got this, you know what to do. At the end of the day, we have to remember that our males and our females, although the anatomy is arranged a little bit differently, and proportions are a little bit different, they are similar tissue. So keep that in mind. You guys are rocking it out there. Have a happy Monday. Thanks for having me. Bye.

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