Postcard From: Expert Panel

Compiled By Fiona McMahon DPT Beyond Basics Physical Therapy recently held its first ever Expert Panel and it was a massive success. We invited some of the City’s/Country’s/ World’s leading clinicians in pelvic health/pain and opened the floor up to our guests to ask questions regarding pelvic pain and its treatment. Let us first introduce you to the guests on our panel. First up is Dr. David Kaufman (DK), urologist and leading expert on interstitial cystitis, a condition affecting the bladder, which can cause severe pain, urinary urgency, retention and frequency. Our next expert speaker is Dr. Dena Harris (DH), a gynecologist and expert in chronic sexual, vulvar, and pelvic pain. Dr. Allyson Shirkhande (ASMD) is a physiatrist specializing in male and female pelvic pain. Dr. Amy Stein (ASPT) is a physical therapist specializing in pelvic floor dysfunction, the author of Heal Pelvic Pain, and founder of Beyond Basics Physical Therapy. The floor was opened to our guests to ask our expert panel whatever questions they wanted. Here is a brief synopsis of the questions asked and our experts’ answers. Question: How can a labral tear effect pelvic pain and vulvodynia? Answer: DH: A labral tear can be related to pelvic floor dysfunction and starting off with a conservative approach is recommended: PT, injections and anti-inflammatory medication if needed. Earlier detection is better and repair of labral tear can help, especially with generalized vulvodynia (non-provoked). . ASPT: Typically we like to see if PT or a more conservative approach can help and in most cases it does! We do a combination of manual work and exercise to take the pressure off of the labrum and to help with proper alignment and body mechanics. ASMD: There is a relationship with obturator, piriformis and other external rotators of hip and vulvuodynia. Typically we do a course of physical therapy first. We very rarely do surgery right away. Follow up question: Can you treat it with physical therapy here , if we are already seeing you for another issue? ASPT: Yes, we are all well trained in treating hip issues, including labral tears. We find that people with premorbid pelvic floor dysfunction present differently than those with just hip pain. Because we have knowledge of the pelvic floor, we can treat your hip without worsening your pelvic floor, which can happen with clinicians who are not well educated in pelvic floor dysfunction. We also treat hip dysfunction with patients that do not have a pelvic floor condition. Question: I have a lot of pulling in my pelvic floor. I do pilates and yoga and I know the importance of strengthening. I have vulvodynia and neuropathy. I sometimes feel like I’m hurting myself. I sometimes get stabbing pain throughout my leg. I’m tight but not too flexible. What should I do? DH: Have you been to physical therapy? ASPT: It sounds like you have tightness in your pelvic floor muscles and other areas of the body and possibly some nerve irritation. ASMD: It sounds like you are spasming because you are unstable. ASPT: We see a lot of foot pain secondary to fascial pulling and nerve irritation. In the brain, , the feet and the genitals are very close together and the nerves get overflow onto the other nerves. I would tell you to stop Pilates if I saw you and then I think you’d need a very specific type of yoga. I have my patients start from 0 and then slowly work up. I then monitor very careful to detect what is aggravating their symptoms. Follow up comment: I have neuropathy too. DH: It may be worth checking it out if you haven’t been to physical therapy in a while. A lot can change and there are constantly advances in medicine and physical therapy. ASPT: Have you had a nerve block? Follow up Question: What type of nerve block? ASMD: That would require an assessment to determine which nerve(s) are irritated. There are a lot of medications to calm it down, injections, medications as well. DK: I find that if you do things piecemeal it doesn’t work as well. You can do all these individual pieces, but the magic is when you do it all together Follow up Question: I see a lot of different doctors, it’s so hard to navigate. DK: That’s why we’re all here, I certainly understand it. ASPT: A fresh set of eyes may be helpful to see what’s changed in the past five years. I am a huge proponent of home exercise programs and so are the physical therapists here. For your situation I’d have you do more relaxation and breathing exercises. You probably need a lot of soft tissue work and sympathetic nervous system down training. DH: A lot of doctors are into meditation in ways to desensitize the pain, acupuncture ASMD: Accupressure as well.

Question: Is there ever a time where it stops? Are you in therapy and the doctor’s office forever? Do you always have to maintain or do a home program? DH: It depends what’s wrong. Some people get completely better ASMD: With our physical therapists, we try to instill lifestyle changes. When you’re done with PT you may want to do something like yoga. DK: You need to find the instigator to find out what’s making the fire that’s making the muscles go nuts. You need to get the fire down. Medicine and physical therapy can help. Follow Up Question: Say you got a massage and then you feel better, but a few days later your back hurts again, is it like that? DK: If you haven’t figured out why your back hurt in the first place your back will cramp again. ASPT: When people are getting ready to be discharged, I warn them to come back if they feel their symptoms coming back even the slightest or to increase their home program. Your home program should work for you. It should help to reduce your symptoms and reset the pain cycle. If not, you need to meet with your PT and adjust it accordingly. I have patients that come in for “check ups” but the majority of our patients we do not see again in our office because they get better. We give them the tools to be independent, monitor their symptoms, make adjustments in their daily routine, etc. Question: What’s the relationship between the gastrointestinal system and vulvodynia? DH: Sometimes the trigger is gluten, constipation, ulcerative colitis, Crohn’s, IBS . Sometimes the treatment for IBS helps with vulvodynia. DK: Sometimes a spastic pelvic floor and abdominal wall can cause constipation and IBS-type symptoms. Follow up Question: What about food? DK: It’s interesting with people that think they have bladder problems because their symptoms are flared with certain types of food. I look at the bladder it’s fine. Sometimes the food is actually exacerbating pelvic floor muscles. Question: If you have pelvic floor dysfunction and nothing else, , is there anything else that could cause it? DK: If you go back in time there is usually something. Like history of infection, a fall on the tailbone or sacrum as a kid. ASPT: Lots of things, alignment. Follow up question: What about scoliosis? All: Definitely. Follow up question: How often is the cause emotional? DK: There is always a component of emotion. It’s devastating. I never think emotions cause the problem. Anxiety can make it worse but not the cause. ASPT: There’s usually trigger like a urinary tract infection but you have to address the emotional component to bring down the activity of the pelvic floor muscles. There are some great mindfulness/mediation options on iTunes. It’s not for everyone. Sometimes people respond better to yoga. Q: I have interstitial cystitis which is well managed, however the interstitial cystitis keeps coming back secondary to bacterial vaginosis. I’m taking meds and suppositories why does it keep coming back? DH: Ureaplasma, it can cause recurrent pain. There may be some underlying infections that aren’t being detected. You need a really good lab to pick up some of the other types of yeast. There’s certain candidiasis that doesn’t respond to typical drugs. DK: I think it’s great that she’s figuring out what the fire is. Just a little bit of bacteria can send someone to the moon. Sex can move a lot of bacteria to the urethra and set off interstitial cystitis. These are the things I recommend that my patients do: 1.) Pee after sex- a little tinkle after sex isn’t going to cut it. If you pee before sex you don’t have enough urine to really flush out the bacteria from the urethra. It needs to be like a water hose! 2.) Bidet- really wash out the vulva- you really need to irrigate it with water before sex: put it on strong. Get a moveable shower head, spread apart the lips of the vulva to get it really clean. Q: What percentage of you patients are male? DK: There is a whole category of men that no one thinks of as pelvic floor dysfunction. It actually is the most common diagnosis in my office. It’s common knowledge that pelvic floor dysfunction can come from untreated prostatitis. 95% of prostatitis is nonbacterial, and the cause, pelvic floor myalgia/spasm.