A lot of people ask us about the practice of physiatry. Some people know how it's pain management, but they don't really know how it's different than seeing their gynecologist or their urologist in the way they would treat their pelvic pain. So, can you give me a general overview to describe physiatry and how it treats pelvic pain differently than their gynecologist or their urologist.
Dr. Shrikande: Sure, thank you so much for having me, Michelle, this is great. For a physiatrist treating pelvic pain, we help the other doctors treat the muscles, the nerves, and the joints of the pelvis in a non-operative approach.
Michelle: How would that be different--can you give me examples of treatments that people may not see with their doctor that they're already seeing?
Dr. Shrikande: Essentially, we want to look at it from more of a sports medicine approach, seeing if the pelvic pain is coming from the pelvic floor musculature. Are the muscles in spasm and potentially irritating the nerves of the pelvis, causing some pain? So that's where we would come in when we're evaluating patients. Is there a pelvic floor muscle spasm, which we call pelvic floor hypertonia and can cause pain in patients. And we're really trying to evaluate why this is happening and is there anything from the sports medicine standpoint where we can identify a cause and help to find a proper diagnosis and treatment.
Michelle: I was lucky enough to be able to shadow you for an afternoon and I noticed that while you were treating patients, you were interested in not just recognizing that there was spasm, but like you said, what else could be contributing to it. So what other things do you look for that could be contributing to pelvic spasm?
Dr. Shrikande: From the musculoskeletal or the sports medicine standpoint, you want to see if there's anything going on in the lumbar spine that can cause pelvic floor dysfunction. Or is there anything going on in the sacroiliac joint? Or you want to consider the hips--are the hips working, functioning well? And is there any underlying pathology in the hips as well as what we call the pubic symphysis, which is the joint in the anterior aspect of the pelvis. In addition, is there anything going on from the other specialties as well that could be causing this secondary guarding of the pelvic floor muscles? So is there a gynecological reason if it's a female, or urological reason if you're male or female, or maybe from the GI system, etc? But you really want to say, 'Is there anything else going on here that's causing these muscles to go into this guarding state where it's really not letting go very well?'
Michelle: This is interesting because so many of my patients say they've gotten a diagnosis of pelvic spasm, but they didn't really get checked out. As a physiatrist, you are doing a pelvic exam?
Dr. Shrikande: When you see us, we would do a full exam--again looking at your back, your hips, etc--but we do end the exam evaluating your pelvic floor both externally and internally. So we do an internal exam. I always tell our patients that we're not gynecologists, so we're really looking at the muscles and distribution of the nerves internally. But we would do an internal exam and it does not require a speculum. It would be similar to an internal exam of a pelvic floor physical therapist--we really look at the tone of the muscles, the strength, and the lift of the pelvic floor, and follow the nerve distribution internally to see if there's any increased sensitivity or pain internally.
Michelle: Wonderful, we have such a growing population of men coming to see us for pelvic pain as well. And they're always curious how your exam would be different or how you would be able to help them because they're hearing that a lot of these treatments are for women. Would they be able to access you and what would you be able to offer them?
Dr. Shrikande: We see a lot of men here at Pelvic Rehabilitation Medicine, about equal amounts of men and women. From the muscle, nerve and joint standpoint, the anatomy is actually the same. For us, evaluating men and women, it is a similar approach. For the men, we do look at your lumbar spine, hips, and abdomen, any concern for underlying hernias that could have been missed. But then we do an internal pelvic floor exam as well--it would be internal rectally, also evaluating the muscle's tone and lift and any nerve tenderness internally. With men it would be a similar approach trying to see if there is any possible underlying cause for pelvic floor guarding. And then it's a full body treatment approach where we really can--we call it down-regulate--or calm down the nerves, of both the central and peripheral nervous system and increase blood flow to your muscles, and get the muscles longer and stronger to rehabilitate the pelvic floor.
Michelle: Many of our patients have been seeing multiple providers. And I noticed that in your practice, you seem to be a gateway to many of the other providers, sort of--coordinating care. Is that part of your model of care and how would you say your practice runs differently than other practices that treat pelvic pain?
Dr. Shrikande: Definitely. We see ourselves as the quarterback here, because as rehabilitation doctors, we really are trained from the beginning to look at the whole body and the interplay between multiple organ systems. So quite often, we are talking to a patient, and in our minds, thinking if there's any other specialist that we would need to bring into the picture to help us get this patient better. We work closely with specialists who are excellent in treating the pelvic pain from their angle. But we do see ourselves as the quarterback kind of sending as needed, as well as working closely with pelvic floor physical therapy, to figure out how to get our patients better and what other specialty is needed to calm down their muscles and their nerves.
Michelle: Some of our patients have been getting injections for their pelvic floor and they've been given an option for steroid. I know that you have other options, and also, can you touch upon the imaging that you use to guide you through the injections--if injections are necessary.
Dr. Shrikande: The way we do our injections, or treatments as we like to say…everything is external, nothing is internal. So it's all external, along the sling of the pelvic floor, and they're ultrasound guided. Patients call them their butt injections, that's kind of what it feels like--it's not internal, it's external. The idea behind the guidance is like internal eyes so you can see where you're going. And in addition, it allows us to do a hydrodissection technique, where we can really open up the fascial planes and create space where there is restriction, particularly where the nerves want to flow. What we're using to supplement for a steroid, is something called Traumeel, which is a homeopathic medicine, so it's derived from plants. The main ingredient is arnica--a lot of people have heard of arnica cream like topical arnica--but this is an injectable form of arnica and in combination with echinacea. So it's a nice way to promote healing in addition to decreasing inflammation, which is why we love it. I really used it more in my plastic surgery rotation. Post-operatively we would give it out after a surgery so that patients wouldn't become as bruised and swollen. It would decrease inflammation and promote a faster healing topically. So that's where the idea kind of came from.
Michelle: I know that one of the positions that you hold is that you're the Chair of the Medical Education Committee for the International Pelvic Pain Society. How do you feel that the position helps to shape what you do in your practice and helps shape how pelvic medicine is moving for the future?
Dr. Shrikande: We're actually lucky enough to be surrounded by amazing, intelligent, pelvic health practitioners who constantly push me to really think about things and learn more. The mission of what we do is educate the future of pelvic health from the medical practitioner standpoint--from both the residency program and urology, as well as gynecology and physiatry and any pelvic floor physical therapist who's had training there--just to try and increase awareness for the people who are training, that the pelvic floor itself is its own distinct entity. And although it does not show up in imaging, we really should not ignore it, particularly when the workup is normal and the patient symptoms persist. So we're really trying to raise awareness and at an earlier stage in physician's medical careers, in hopes of getting all our patients recognition earlier and treatment earlier. Because we really believe that is the key--early recognition and early treatment, to squashing it early and getting patients better.
Michelle: What's the range of people that you see in terms of how long patients have had pelvic pain for prior to seeing you? Is there a range?
Dr. Shrikande: It's getting better by the day. But still at this point, the average is six months to 25/30 years worth of symptoms. Even six months is rarest. It's really along the lines of 1.5 years to 25 years.
Michelle: Hmm, yeah. So, both of us are working on that.
Dr. Shrikande: We have to work together.
By Karen Bruno, PT
As we sink deeper into autumn, the leaves are changing colors, the daytime light is decreasing and the temperature is getting cooler. This can be a difficult time for many people. In addition, there is much to do in preparation for the upcoming holidays. Here is a quick "go to" exercise to restore coherence and calm.
Place one or both hands over your heart.
Begin to take some deep breaths in and out through your nose. One to three breaths is sufficient.
Shift your attention to your heart. Imagine breathing in and out through your heart.
Imagine breathing in love, and as you exhale, let that love expand in, through and around you. Surround yourself in a field of loving and compassionate, heart-centered energy. Take it in. Allow yourself to receive this gift.
For extra-credit: put a smile on your face.
For double extra credit: Smile into your heart.
Use this exercise anytime you want! Here are some suggestions for convenient uses:
As you awaken in the morning.
When you to go to bed.
Anytime you need or want a boost of energy, nourishment or connection to yourself or others.
When you are driving.
Anytime you are feeling upset or stress.
The overarching benefit of heart-centered practice is to live a fuller, healthier and happier life, even in the midst of the day to day demands.
My intention for each of you is to have a happy, peaceful, joyful and healthy holiday season.
By Bryn Zolty, PT
How do men Kegel? In the literature, the phrase that was found to be most associated with stopping urine leakage was, “Shorten the penis.” This simple cueing creates the greatest displacement of the muscles that close the urethra. Other cues like “lift the bladder” were not as effective and increased pressure in the abdomen and pushed down on the pelvic floor. (1) It is important to be aware that you are not contracting other muscles in the legs, buttocks, and abdomen when isolating the pelvic muscles.
Every Kegel or pelvic floor strengthening program should be customized to each person. In the clinic, we work on endurance and quick contractions. For example, a home exercise program may include:
Some men lose large amounts of urine after prostate surgery, which can have a huge impact on normal daily activities. It may take time for kegels to make a difference in symptoms. A penis clamp may be an appropriate option to stop large leaks. The clamp places gentle pressure on the urethra to block urine loss. It may not stop all leakage but can significantly reduce it. When the clamp is removed, the release of pressure allows for normal urination. The amount of time recommended for wearing the clamp is variable between different devices. If you have any interest in a using a clamp, contact your physician or pelvic physical therapist to see if you are a good candidate.
According to the Journal of Neurourology and Urodynamics, men " found the device easy to use, felt more confident wearing the device, and had increased levels of physical activity with device in situ." They had significantly improved urinary incontinence symptoms per the Incontinence Impact Questionnaire. (2)
If you are going to have a prostatectomy or already have, ask your physician for a referral to a pelvic physical therapist. They can guide you through your pre- and post-surgical rehabilitation and reduce urinary incontinence.
(1) Stafford, R. E., Ashton‐Miller, J. A., Constantinou, C. , Coughlin, G. , Lutton, N. J. and Hodges, P. W. (2016), Pattern of activation of pelvic floor muscles in men differs with verbal instructions. Neurourol. Urodynam., 35: 457-463.
(2) Barnard, J. and Westenberg, A. M. (2015), The penile clamp: Medieval pain or makeshift gain? Neurourol. Urodynam., 34: 115-116.
By Becca Ironside, PT
I have been working as a pelvic floor physical therapist for a few years now. As with many people with hold this job title, we were often met with confused looks, raised eyebrows and a generalized misunderstanding as to what physical therapy of the pelvic floor could possibly entail. This is entirely understandable, as I had been a physical therapist for sixteen years before taking the dive into getting my pelvic floor specialty.
Why did I change paths and redirect my craft towards the pelvis? In part, because I had become a little bored with the other facets of physical therapy I had worked within and wanted a new challenge. But the larger reason why I felt compelled to undergo this very specific training for the pelvic floor is because I suffered from pelvic pain. It was unpredictable pain, which manifested itself in odd and various ways. I went to so many different physicians, yet none of these specialists I went to for treatment could help me with my symptoms.
Fast forward, five years later: I have a very gratifying job treating the pelvic floor muscles of both women and men. The demand for this work is enormous, as there are not enough pelvic floor therapists to treat the vast number of people who have discovered its importance. Women come to our clinic and the ability to help others who have the nebulous and seemingly inexplicable symptoms that I once did is a splendid feeling. Secondly, I no longer experience pelvic pain. This is because I can utilize the techniques and knowledge that I use with my patients on myself; I also have a great bunch of coworkers who can treat me when I cannot fix the problem and need another mind or another set of eyes and hands to brainstorm and palpate the causation of it. Lastly, there is a show featured on HBO which is all about a woman with pelvic floor dysfunction. Finally, the world is being educated on a grand scale about the importance of pelvic health! The show is entitled Camping.
In watching the show Camping, we learn that Kathryn has undergone a hysterectomy. The loss of her uterus and ovaries has led to other losses. For instance, Kathryn and her husband have not had sex in two years. We are led to the conclusion, by her husband’s discussion with his fishing buddies, and Kathryn’s own overt disgust and refusal of sex, that it is chronic pelvic pain that seems to be driving the boat in their marriage.
Let’s go back to what pelvic floor dysfunction really means. Some women, like Kathryn, have had pelvic surgeries which can lead to scar tissue formation. Other women have constant burning and discomfort with urination, all due to muscular imbalances. What will that lead to? Sex can often become painful and many women brace themselves before each sexual encounter, in fear of the discomfort that will ensue.
The show Camping does a fair job in unveiling how a relationship can be eroded by pelvic pain and the lack of intimacy that often accompanies it. This is a finding often seen in the pelvic pain population. Pain alters how the brain processes information. It effects our ability to be active listeners, to take care of others, either in the bedroom or out of it. But when the pain is so directed in the perineum, sex is often one of the first leisure activities to take a backseat in the relationship. That makes sense, right?
There are other manifestations to having this condition. Many people with chronic pain find themselves more withdrawn than they might have been without it and more apt to find solitude. Their threshold for chaos can often run thin. And because women are often called upon in society to act “motherly” and to be “nurturers”, many of them living with chronic pain will simply put their chins up and bear it. Even though depression and anxiety might be creeping up their backs like a snake. Lots of them soldier on, push down the pain and are reluctant to make their diagnosis public.
Obviously, this does not represent all women with chronic pelvic pain. When we are introduced to Kathryn, the main character in Camping, we get quite a different profile of how this pain can affect people. The actress Jennifer Garner plays the role of Kathryn, and Ms.Garner uses her elan in this performance to show us a woman who is highly obsessive, erratic in thought and speech and has great difficulty maintaining relationships with others. Kathryn is described as “bitter” and “angry” behind her back and she hits her husband when he attempts to initiate sex.
This characterization of a woman with pelvic pain may be what the writer of the series felt if she had similar pain. Or the character may be based on a Type A Helicopter Mom to make the series more amusing, as this series is a sitcom. But the reality of this portrayal of Kathryn as a woman suffering from pelvic floor dysfunction is that she does not represent the typical sufferer. Because this is the first exposure that the general public has had in mainstream television to the pelvic floor, it may render women less willing to acknowledge or seek help for their diagnosis, as they may not want to align themselves with the behaviors of Kathryn.
In fact, the portrayal of women in this light can seem reminiscent of the 1950’s. The term “hysterical” was used in the past as an actual psychiatric diagnosis used to label women for being overly dramatic and prone to bouts of insane behavior. The medical operation known as a hysterectomy was named because it was believed that if a physician removed a woman’s female parts, he would eradicate her insanity.
I am reluctant to bring these facts from the past for women into the cold light of today. This is what the world of pelvic floor physical therapy is trying to reverse – the notion that women with feminine troubles are irrational and unable to be around without great unpleasantness. While it is encouraging that a cable network has named pelvic floor dysfunction, it would be far more helpful in the future if women were represented as emboldened by the power to take back their own pelvic health. Because that is precisely the image of the women who come to us: bold, unashamed and ready to use available resources to uproot outmoded theories of how they should feel and who they should be.
So, where do we go from here?