Introduction
Historically, many have incorrectly defined yoga as a tool used solely to benefit one’s spiritual, religious and psychological health. Cautious exploration over recent decades has brought to light the benefits yoga positions (asanas) and deep breathing (pranayama), when used as a light to moderate exercise program, have on those afflicted with chronic disorders. However, while one can safely claim that yoga is no longer seen as “quackery,” the full beneficial effect yoga can have on those suffering from chronic disorders has yet to be accepted or fully explored.

The psychological benefits of yoga have been documented in a recent study comparing two groups of females: one group practicing yoga, the other group remaining in a relaxed state of reading. Those practicing yoga were found to show higher scores on life satisfaction, and lower scores in excitability, aggressiveness, openness, emotionality and somatic complaints.[1]

There are also physiological benefits to patients using yoga as light to moderate exercise including increased aerobic capacity[2] and increased muscle strength.[3] In addition, with over 200 individual exercises with multiple variations[4], yoga is highly adaptable to the individual patient’s medical situation. It is starting to be used by medical professionals in very targeted recovery programs such as recovery from back surgery[5] and as one part in comprehensive health management programs such as heart disease management programs by Dr. Dean Ornish (em, I know this is not quite right; all my references are packed away. Can you fix?). While not claiming that yoga should be an alternative to conventional medicine, yoga should be accepted as a tool that speeds the recovery of the patient by strengthening the physiology and psychological health of the afflicted.

Hatha Yoga and Health
Considering chronic disorders frequently causes the patient psychological/emotional pain stemming from an unnecessary sense of embarrassment, one must stress the analogous proof yoga has on correcting levels of stress.In our experience, asanas have been a great self-help method to teach patients. These techniques provide the patient with a sense of independence which is often lacking in those suffering from chronic disorders. Interestingly, recent studies have been conducted which demonstrate increased endorphin[6], and dopamine[7] release in people practicing yoga. Changes in EEG patterns have also been observed, thus making yoga a useful modality for seizure control[8].

Dr. Karen Koffler, working with inverted asana postures believes that, ‘If there is increased blood flow to the area, there will be increased bioavailability of oxygen and glucose—the two most important metabolic substrates for the brain. It follows, then, that those cells bathed in a solution that is rich in the building blocks required for the creation of neurotransmitters like norepinephrine, dopamine, and serotonin, will be better able to produce these chemicals.” [9]In further studies, Dr. Don Glassey theorizes that since the practice of yoga places a great emphasis on the health of the spine, it is natural that proper spine function will increase the flow of cerebrospinal fluid.[10] In addition to the psychoemotional benefits and neurotransmitter changes, yoga has been linked to improve physiological changes of the cardiopulmonary systems. In a study of two groups of cardiac patients, both of which modified risk factors and diet, reductions in the levels of serum total cholesterol, LDL cholesterol, and triglycride levels were noted in those practicing yoga, as well as a reduction in angiographic lesions.[11]In another study of 287 patients practicing yoga, a statistically significant (p<.001)increase in vital capacity was observed[12]. Further studies have shown improvements in lung function (FEV1, and PEFR) as well as improvement in dyspnea.[13]

In these few instances, yoga has been linked to benefit both the psychoemotional and physiological health of the patient.

Hatha Yoga in Urology
Urological disorders of chronic nature, such as: interstitial cystitis, vulvadynia, prostadynia, orchalgia, epididimalgia and incontinence are associated and aggravated by poor musculoskeletal, neural and myofascial function of the back and/or pelvis. At this point it is difficult to separate the exact etiology of these conditions, since often time these conditions are multifactorial.

Pelvic floor dysfunction contributes to many urological conditions. The two major categories are pelvic floor hypertonicity and hypotonicity. Pelvic floor hypotonicity is often associated with urinary incontinence and can be addressed by asanas which strengthen both muscular layers of the pelvic floor (deep layer or levator ani and the superficial layer of the urethral and anal sphincters). Pelvic floor hypertonicity is addressed with asanas that will relax both layers of the pelvic floor. More importantly, many of these asanas will help bring muscle awareness to the patient and help them learn to self correct.

Because the pelvic floor is not working in isolation, any rotation or dysfunction of the lower back, bony pelvis, and its joints will also result in pathology, so yoga programs have to be designed to maintain balance of the major muscles which influence the pelvic structure and the lower back. Either sacroiliac joint dysfunction or symphesis pubis dysfunction can both result in pelvic floor hypertonicity and can aggravate the chronic conditions mentioned above.

Thus, improving muskuloskeletal alignment and myofascial function through yoga practice can greatly improve standard western medical treatment results.

Program Design
As with any other therapeutic physical exercise program yoga must always address the medical history of the patient. Prior to starting, the physician and the yoga professional should take into consideration patient factors such as body type/weight, age, health, overall physical fitness of the patient and pre-existing surgical condition such as: traumatic deliveries, bladder suspensions, hysterectomies, prostrate surgery, etc. In cases of chronic disorders, one should not blindly start a therapeutic yoga program and should structure a program that addresses a patient’s physical and emotional limitations.

Once a patient’s basic physical condition has been addressed, a yoga program can be structured which affords the patient the ability to reduce symptoms in the privacy of their homes. Since yoga does not require special machinery, heavy lifting, and very little expense, our experience has been that many patients report a high degree of satisfaction with yoga as exercise. 

Sample Program
A good basic yoga program follows the basics of any good program; warm-up exercises, main exercises, cool down exercises. It differs in that it includes deep breathing exercises. These are essential as they help reduce stress while improving oxigenation that will aid in the release of endorphins and they help improve cardiopulmonary function.

Example Warm-up Exercises
1. Resting Pose, Lying on Back
2. Neck Rolls, Lying on Back
3. Ankle Circles, Lying on Back, Leg Extended Upwards
4. Side-to-Side Back Rocks
5. Cat Pose
6. Cat-Cow Pose
7. Shoulder Circles

Example Main Exercises
1. Bird Pose
2. Bridge Pose
3. Cow Pose
4. Cobra Pose
5. Crocodile Pose
6. Downward Facing Dog Pose
7. Frog Pose (with or without Kegels)
8. Half-Shoulder Stand/Fish Pose set
9. Locust Pose
10. Plank Pose
11. Seated Twists
12. Shoulder Stand/Fish Pose set
13. Sitting Forward Bends
14. Squating Pose
15. Wind Reliving Pose

Example Cool Down Exercises
1. Resting Pose, Lying Flat on Back
2. Resting Pose, Lying on Back with Lower Legs Resting on Chair

Example Deep Breathing Exercises
1. Basic Deep Breathing, Lying Flat on Back
2. Alternate Nostril Breath, Sitting

Table 1

Clinical presentation and sample beneficial postures for Urologic conditions[14],[15]

Condition	Posture	Benefits
Stress Urinary Incontenance Cystocele Rectocele Vaginal Prolapse Uterine Prolapse	Frog Pose (with kegels)	Strengthen Pelvic Floor Realignment of coccyx and Sacroiliac joint, loosens tight pelvic muscles
	Sitting Forward Bend	Improves back muscle strength, increases back flexibility, increases flexibility in hips
	Shoulder Stand/Fish Pose set	Strenghtens pelvic floor muscles, increases neuro-transmitter production, decreases muscle tension in back, greatly increases torso muscle strength
	Locust Pose	Increases upper body strength and back flexibility
	Plank Pose	Increases upper body strength, especially good for patients who are very weak in their upper body
	Bird Pose	Improves hip and shoulder flexibility
	Seated Twist	Improves hip and spine flexibility
	Basic Deep Breathing, Lying Flat on Back	Provides cool down, helps reduce tension
	Resting Pose, Lying Flat on Back	Provides cool down, helps reduce tension
Condition	Posture	Benefits
Prostadynia Vulvadynia Epidimalgia Orchlalgia Interstitial Cystitis	Bridge Pose	Restore flexibility in hips, strengthen torso and leg muscles
	Cobra Pose	Reduce muscle tension in back
	Cow Pose	Relax tension in hips, back and shoulders
	Crocodile Pose	Increase upper body and back strength
	Downward Facing Dog	Improve sacroiliac joint function, strengthen upper body
	Frog Pose	Realign of sacroiliac and coccyx, stretch and relieve tension in pelvic floor muscles
	Half-Shoulder Stand/Fish Pose set	Teaches pelvic floor muscle awareness, decreases tension in lower back and pelvic floor muscles, strengthens torso muscles
	Kegels (very gentle version)	Decrease muscle tension in hips/pelvis
	Locust Pose	Increases upper body strength and back flexibility
	Side Leg Lifts	Reduces side hip and waist muscle tension, strengthens side hip and waist muscles, stretches pelvic floor muscles
	Squatting Pose	Greatly increase hip, pelvic, and leg strength and flexibility
	Twist (seated)	Improves hip and spine flexibility
	Wind Reliving Pose	Improves leg, hip and pelvic flexibility
	Alternate Nostril Breathing, Sitting	Aids in concentrative abilities, helps reduce stress
	Resting Pose, Lying on Back with Lower Legs Resting on a Chair	Cool down, helps reduce stress, releases tension in lower back and pelvic muscles

Summary
Hatha Yoga is not an alternative to traditional treatments. Rather, it should accompany long-standing methods, providing the patient with another potential tool to benefit their overall health. Yoga is a useful complimentary therapy in the treatment of chronic urological conditions. Regular practice of yoga has been shown to increase endorphin release, resulting in improved pain control and stress reduction. Since reduced levels of stress have been noted, often, the patient practicing yoga changes their perception of stress, which results in an increased sense of well being. Often, the practitioner of yoga feels a sense of accomplishment and control over their chronic pain, which, until they began practicing yoga was absent in their lives. Improved musculoskeletal function has also been linked to the practice of yoga providing the patient a legitimate exercise format to regain or keep muscle strength and aerobic capacity.

References
1.    Schell FJ, Allolio B, Schonecke OW (1994) Int. J Psychosom 1994; 41 (1-4): 46-52

2.    Ray US, Sinha B, Tomer OS, Pathak A, Dasgupta T, Selvamurthy W., Aerobic capacity & perceived exertion after practice of Hatha yogic exercises, Exercise Physiology Laboratory, Defense Institute of Physiology & Allied Sciences, Lucknow Road, Timarpur, Delhi 110054, India., Indian J Med Res. 2001 Dec;114:215-21

3.     Tran MD, Holly RG, Lashbrook J, Amsterdam EA., Effects of Hatha Yoga Practice on the Health-Related Aspects of Physical Fitness., Department of Exercise Science, University of California at Davis, Davis, CA 95616., Prev Cardiol. 2001 Autumn;4(4):165-170.
PMID: 11832673 [PubMed - as supplied by publisher]

4.    B. K. S. Iyengar, 1979, Light on Yoga, Schoken Books, a Division of Random House, NY, NY, pages 61-4485.    M. P. Schatz, M.D., 1992, Back Care Basics, A Doctor’s Gentle Yoga Program for Back and Neck Pain Relief, Rodmell Press, Berkely, CA, pages 21-36

6.     Hartle JL , Eifert GH, Smith R(1995) Biol Psychol 1995 Jun; 40 (3):251-65 7.     Kjaer TW, Bertlesen C, Piccini P, Brooks D, Alving G, Lou HC (2002) Brain Res Cogn Brain Res 2002 Apr;13(2):255-98.     Yadri N (2001) Seizure 2001 Jan;10(1):7-129.     Arambula P, Peper E, Kawakami M, Gibney KH (2001) Appl Psychophysiol Biofeedback 2001 Jun;26(2):147-5310.  Weintraub Amy, The Natural Prozac http://www.yogajournal.com/health/133_5.cfm11.  Glassey, Don Dr. “Why Yoga Works” http://www.healtough.com/csft/yoga.html12.  Manchanda SC, Narang R, Reddy KS, Sachdeva U, Prabhakaren D, Dharmanand S, Rajani M, Bijlani R(2001) J Assoc Physicians India 2000 Jul;48:687-9413.  Birkel DA, Edgren L (2000) Altern Ther Health Med 2000 Nov;6(6):53-6314.  Behera D (1998) J Assoc Physicians India 1998 Feb;46(2):207-815.  Ripoll, E, Mahowald D (2000) Hatha Yoga for People With Cystitis (2000 Kriya Yoga Publications, Eastman, Quebec, Canada)

16.  Mahowald D, Ripoll E (2000) Application of Hatha Yoga Asanas to Chronic Cystitis Using Western Medical, Chinese Acupressure and Aryuvedic Points of View (2000 Int. J. of Yoga Therapy)

Footnotes