Although urinary tract infections almost always affect women, men can get them, too. These infections are not usually serious, but in the acute stage massage is systemically contraindicated. Dysmenorrhea (severe menstrual pain) is another condition that is not dangerous, but it can indicate a more serious underlying condition. 
Some clients are more willing to share health concerns with their massage therapists than they are with their own doctors. We have been surprised at how severe symptoms must get before some people will seek help, which puts us in a position to strongly encourage our clients to see their physician for an examination, even though they may be reluctant to do so.

Urinary Tract Infection

What is it? This is an infection of the urethra, and sometimes the bladder, which results in inflammation. 

Demographics: Who gets it? UTIs are the cause of about 8 million visits to the doctor every year; one in five women will have an episode at least once in their lifetime. It is almost always a woman's disorder because the female urethra is so short, and located close to the anus where bacteria that are harmless in the digestive tract can cause havoc if they gain access to the urinary tract. Urinary tract infections are not unheard of in men, however, and are sometimes the warning sign of something quite serious, like prostate problems.
 

Etiology: What happens? Under normal circumstances, the environment in the bladder is sterile. The urine contains waste products to be expelled from the body, but there should be no living microorganisms in it. Furthermore, the bladder is lined with a protective layer that works to prevent infectious agents from infiltrating the bladder walls. 

Sometimes, however, foreign microorganisms are introduced into the urethra. If the circumstances are right, they can set up an infection that may stay localized, or may travel further into the urinary system.

Another type of inflammation of the urinary tract is not an infectious condition, but rather one of chronic irritation-"honeymoon cystitis."
Causes: Most UTIs are caused by E. coli and are not sexually transmitted. But in some cases infection by chlamydia or mycoplasma organisms can cause infections in the urinary tract. These need to be diagnosed carefully, as they don't respond to the same treatments as more typical bacterial infections.

There is probably a sympathetic nervous system component in the development of UTIs; there is a lot of anecdotal evidence about stress and bladder infections. Living in a sympathetic state may cause reduced blood flow to this internal organ that, in turn, may make it more susceptible to infection. However, clinical evidence to date shows that while stress may aggravate symptoms of UTIs, it has not been proven to cause them.

Risk factors: Some women have been found to be more susceptible to UTIs than others, although the reasons for this are not completely clear. There are some factors, however, that can reliably predict the chance of contracting a UTI:

• Blood types: Some blood types are more prone to this disorder than others; slight differences in internal chemistry seem to make it easier for invading bacteria to cling to the bladder walls.

• Spermicides: Spermicide foams have been shown to raise the risk of UTIs in some women.

• Diaphragm use: Women who use diaphragms show statistically higher rates of UTIs than women who don't.

• Pregnancy: Pregnant women have reduced immune activity (to prevent a reaction against the new tissue they're growing), and this, along with changes in the architecture of the pelvic cavity, makes them prone to UTIs.

• Diabetes: Elevated sugar levels in the urine make a hospitable environment for bacteria to grow in the bladder.

• Neurogenic bladder: If a bladder has lost motor function, it doesn't empty as completely as a normal one. This raises the potential for infection, as does the presence of catheter tubes, which are often used for people with limited bladder function.

• Menopause: Lower levels of estrogen will also decrease lactobacillus, which will increase susceptibility to UTIs.

• Antibiotics: Being on long courses of antibiotics can raise the risk of contracting this disease. Long-term antibiotic use will kill off protective bacteria and can lead to the birth of new, more resistant strains of bacteria.

Signs and symptoms: The symptoms of UTIs are a painful, burning urination; a feeling of frequency; a reduced bladder capacity; urgency; blood-tinged or cloudy urine; back pain; fever and achiness. Men suffering from UTIs may also experience pain in the penis or scrotum.
Complications: Almost all cases of UTIs are caused by microorganisms that live in the digestive tract and have easy access into the short female urethra, where the infection usually begins as urethritis. If the bacteria are able to travel up the system, they may set up an infection in the bladder. If the infection remains unchecked, it may move all the way up the ureters into the kidneys, causing pyelonephritis.

Treatment: The first step in self-treatment of a UTI is to drown it: Radically increasing fluid intake will give the body the much-needed opportunity to fully and frequently empty the bladder, not only of urine, but of bacteria as well. Drinking highly acidic liquids, like orange or cranberry juice, is helpful for many women, as an acidic environment inhibits bacterial growth. For subacute situations, hydrotherapy in the form of hot and cold sitz baths may be recommended.
A short course of antibiotics is frequently prescribed for UTIs. In this case, three to five days' worth of medication is more appropriate than two weeks' worth because the body concentrates antibiotics in the urine, and the risks of long-term antibiotic use have already been discussed. 
The exceptions to this rule are women who experience low-grade chronic UTIs that don't clear up with normal treatments; they are sometimes successfully treated with long-term low doses of antibiotics.

Prevention: There are some basic precautions that can help prevent UTIs, especially for women who are vulnerable to them. These include drinking lots of water and acidic juices; urinating whenever necessary rather than holding it for a more convenient time; wiping from front to back after a bowel movement to prevent the introduction of digestive bacteria into the urethra; taking showers rather than baths; emptying the bladder after sex; and avoiding feminine hygiene sprays and douches that can aggravate the urethra.

Massage? Acute cystitis will sometimes be accompanied by a fever, a systemic contraindication. There is also a small but significant risk of spreading the infection to the kidneys. Even in the postacute stage (after signs of acute infection have subsided), the lower abdomen is a local contraindication until all signs of infection have been eradicated. 

Dysmenorrhea 

What is it? Dysmen-orrhea is a technical term for painful menstrual periods. Generally, a woman is said to have dysmenorrhea if she has to limit her regular activities or requires medication in order to function for one day or more every month. 
Demographics: Most women will have severe menstrual pain at least once in their lifetime. It is estimated that 42 million women suffer from regular painful periods in the United States, and dysmenorrhea is the leading cause of lost time from school or work for women of childbearing age. It usually affects women in their late teens or early 20s and subsides as a woman grows older; childbearing does generally not change it.

Etiology: Dysmenorrhea can be primary; that is, it starts within the first three years of menstruation in an otherwise healthy woman; or secondary to some underlying pathology. 
There are several different factors that can contribute to primary dysmenorrhea. At the top of the list are prostaglandins-chemicals produced all over the body, and especially in the uterus. They cause smooth muscle contractions, but they also sensitize the body to pain.

Prostaglandins are found in higher concentrations in women who have menstrual pain than in women who do not. Progesterone, a hormone involved in the menstrual cycle, inhibits the action of prostaglandins, but just before menstruation begins, progesterone levels plummet, leaving the prostaglandins to do their work unchecked. Also, when the uterus is in sustained contraction, oxygen cannot easily supply the muscle, so ischemia will contribute to the pain-spasm-pain cycle. And finally, the uterine ligament, which anchors the uterus to the pelvic wall, can get pulled and irritated when the uterus is in spasm. 

It is easy to see how physical or emotional stress fits into the picture of menstrual pain. Sympathetic reactions in the body will exacerbate uterine ischemia, leading to pain, which reinforces spasm. The emotional state of dreading the pain and discomfort of menstrual periods can then become a self-fulfilling prophecy: The stress of anticipating an unpleasant event works to make that event even more unpleasant.

Secondary dysmenorrhea is a complication of some other reproductive disorder, such as endometriosis, pelvic inflammatory disease (PID), fibroid tumors, ovarian cysts or irritation from an IUD.

Signs and symptoms: Symptoms of dysmenorrhea vary. They can include dull aches in the abdomen and lower back, or sharp pains and cramping in the pelvis and abdomen. Headaches, nausea, vomiting, diarrhea and constipation are all possibilities, along with a frequent need to urinate.

Diagnosis: Ongoing severe menstrual pain is important to investigate because it could be indicative of serious underlying problems. Diagnosis will often involve a laparoscopy to check for endometriosis, which is the leading cause of secondary dysmenorrhea, and ultrasounds to look for fibriod tumors may be performed. Cultures of vaginal secretions may also be examined to look for signs of PID, chlamydia, syphilis or gonorrhea. In the absence of these conditions, painful periods can be treated without fear of ignoring some important underlying causes.
Treatment: For most cases of dysmenorrhea, painkillers, such as ibuprofen and naproxen, will work by inhibiting the secretion of prostaglandins. A thorough nutritional analysis also will often reveal strategies for dealing with menstrual pain; this is a useful course for many women, but no specific nutritional supplements have been found to alleviate all cases of dysmenorrhea. Certain exercises and stretches can also relieve pain caused by the irritated uterine ligament, which is tugged on by a spasming uterus.

For more serious situations where painkillers, heat and stretching don't affect the pain, more aggressive interventions may be considered. Taking low-dose birth control pills will prohibit ovulation, which in turn prohibits the secretion of prostaglandins in the uterus. If there is a mechanical problem like fibroid tumors, surgery may be an option. Medications or laparascopic surgery for endometriosis may also alleviate symptoms.

Massage? Deep abdominal massage is a local contraindication for the first two days of a painful period, but reflexive work to relax the uterus is perfectly appropriate, as is work done anywhere else on the body. 

Ben E. Benjamin, PhD in sports medicine and education, is the founder and president of the Muscular Therapy Institute in Cambridge, Massachusetts. In private practice for more than 35 years, he is the author of dozens of articles.

Ruth Werner, teacher and massage therapist, has taught every aspect of the massage therapy curriculum at the Brian Utting School of Massage in Seattle, Washington.

Adapted from A Massage Therapist's Guide to Pathology by Ruth Werner and Ben E. Benjamin, published by Williams and Wilkins, Baltimore, Maryland.