Foye: I think that the biggest problem is that the vast majority of physicians unfortunately have a huge blind spot when it comes to understanding coccyx [tailbone] pain. We learned almost nothing about the coccyx in medical school. This leads to four main problems.
Dela Rosa: Your book Tailbone Pain Relief Now! describes the many reasons why people end up with tailbone pain. Are there 1 or 2 causes of tailbone pain that are more common than others?
Foye: Great question! By far the most common cause coccyx pain is when there is an unstable joint between the bones of the coccyx. Many medical textbooks and websites incorrectly state that the coccyx is a single fused bone. But that is rarely true. In the vast majority of humans, there are 3 to 5 individual coccygeal bones, with variability in whether there is fusion between any of those bones. Most people have at least a few coccygeal joints. And most people with coccyx pain have joint hypermobility (excessive movement) as the source of their pain.
The second most common cause of coccyx pain is a "bone spur"; extending from the lowest tip of the coccyx. When this happens at the bottom of the coccyx, there is thickening of the bone that projects backwards, often coming to a sharp focal point. It’s almost like a tiny icicle made of bone. This bone spur pinches the skin between the spur and the chair where the patient sits, and especially when they sit leaning partly backwards.
Dela Rosa: Thank you for clarifying the common causes of tailbone pain. In your book, you detail some of the seat cushions and medications that may help. People ask about injections for pain. As a pain management doctor, would injections be helpful for these causes and if so, could you describe how and what kind?
Foye: Sure it's a great question. Medications by mouth have a couple of big problems with them, which is why a lot of times medication given focally by a small local injection could be superior.
When medications are given by mouth, number one they go through multiple places throughout the body. If you're taking medication by mouth, they can cause side effects in the stomach, the intestines, the liver, and the kidneys, so the side effects can be quite limiting.
The second problem with medications by mouth is that because the medicine travels throughout the entire body, it gets diluted out. So only a minuscule amount of the medication actually makes it to the tailbone where the patient needs it the most. Many of these patients do respond to medication given locally at the site. Typically, that's done under fluoroscopic guidance. Fluoroscopy is like x-ray up on a computer screen, and using fluoroscopy we can target a specific location at the tailbone. I'm generally opposed to blind injections, which is where injections are done without any image guidance because 1) you can't guarantee where the medication is going to go and whether it's actually given at a place where it's going to be helpful, and 2) you also can get into problems if it's given in the wrong place - it can cause side effects.
So back to your question, which was about the diagnoses like hypermobility or a bone spur... Absolutely those can respond very, very well to placing medication locally at the spot under image guidance. Often that's a combination of steroid which helps to fight inflammation, and also local anesthetic which can be given as a nerve block and can be very helpful when there's hyperactivity or hyperirritability of the nerves.
Dela Rosa: How is the x-ray your center performs different than how many other facilities perform the test?
Foye: Here at the Coccyx Pain Center, the biggest difference is that we take coccyx x-rays while the patient is sitting down, since that is when tailbone pain hurts the most. I have trained the radiology technicians here regarding how to properly perform this technique, which was first developed in France. Very few places in the United States have ever heard of this approach and even fewer are experienced at doing these x-rays properly. We have evaluated and treated thousands of patients with tailbone pain, many of whom fly in from around the country and internationally. And it is extremely common that patients had previous imaging studies that were read as being normal. But then they come here and our seated x-rays show that when the person sits down and leans backwards (putting their body weight onto the coccyx) they often have very dramatic dislocations or other abnormalities that would be completely undetected if the x-rays had not been done while the patient was sitting. It is a huge relief for patients to finally have an answer as to what is causing their pain. Then, when we have identified a specific cause for their pain, we can provide treatments for that specific cause, which is much more likely to be helpful than generic treatments done blindly without a diagnosis.
Foye: A lot of this goes back to and starts with the general lack of awareness that physicians, radiologists and radiology technicians have about tailbone pain. Frequently, they lump it all in with low back pain. Lumbosacral pain is thousands of times more common than tailbone pain. A lot of the automatic checkoff boxes that people have on their radiology x-ray or MRI forms will have a box to check off for lumbar spine or lumbosacral spine, but they will not have a box to check off for the coccyx or tailbone just because it is thousands of times less common. So what happens is that the primary care doctor, or the orthopedic surgeon, or the pain management doctor, will check off the box and order lumbar or lumbosacral x-rays or MRI, and then that doesn't even include the tailbone at all.
The next problem then is that the study gets done and the patient is told that there's nothing wrong, and that there's no explanation for their pain when really the images did not even include the symptomatic area, or worse yet, it shows an incidental finding of the lumbar spine that may not be causing any symptoms at all. But now they start down the treatment path of epidural injections, and even spine surgery and other things for a part of the body that wasn't even causing the problem. So basically back to your question about what the patient can do: 1) look at the orders, look at the x-ray or MRI orders, make sure that the ordering physician has specifically explicitly requested imaging of the coccyx, and 2) when you go into the radiology center, make a point of talking to the radiology technician and being crystal clear with them that this is not your lumbar spine, that this is not up in the small of your back at the belt line, that the pain is specifically down at the coccyx, and make sure that the radiology technician is going to include that part of the anatomy within the study. It really does require a certain amount of self-advocacy by the patient unfortunately to fight this uphill battle against the ignorance that's out there.
Dela Rosa: I'm just curious, have people come to you from outside of the US? Or are you mostly seeing people domestically?
Foye: Most of my patients travel in from out-of-state and about a third of my patients fly in. It's maybe 5% or less that are international. Within the last six to 12 months, I've had patients from Japan, Sweden, Africa, the UK, New Zealand, and I think two from Australia. Which really just gets back to that there's this unmet need out there and patients who are not able to find local clinicians who will either take them seriously or that know the appropriate testing and treatments to provide.
Dela Rosa: How do you work with pelvic floor physical therapists in the treatment of tailbone pain?
Foye: As a physician specializing in Physical Medicine and Rehabilitation (PM&R), I'm a strong advocate for the role of physical therapists in treating patients who are suffering from painful musculoskeletal conditions. Historically, a big problem was that very few physical therapists were comfortable or experienced in treating pelvic floor problems. Fortunately, that has been improving in recent years.
The pelvic floor is often described as being like a muscular sling, or hammock, which supports and holds up the pelvic organs. The back end of that sling has attachments to the coccyx. Pelvic floor physical therapists and I often collaborate on figuring out the "chicken and the egg" phenomenon. By that I mean that we assess whether a patient is having tailbone pain due to pulling and tugging onto the tailbone caused by tightness and spasms of the muscles that attach to the coccyx. Or, sometimes it could be just the reverse: a painful condition at the coccyx itself might be causing reactive muscle spasm and guarding of the pelvic floor. If evaluation and treatment at one location is not providing adequate relief, then it often makes sense to collaborate and to consult each other, to help the patients find the answers and relief that they deserve.
By Bryn Zolty, PT, DPT
*This article is based on Return to running postnatal-guidelines for medical, health and fitness professionals managing this population. Tom Groom, Grainne Donnelly and Emma Brockwell
Most orthopedic injuries have protocols after surgery for rehabilitation prior to returning to sport. However, there is not a set protocol for women after giving birth to return to their prior level of activity safely. Many women have very limited knowledge of their pelvic floor or ability to strengthen the muscles to support their organs and keep them from leaking urine or bowel movements. Very frequently, women are not even aware of pelvic organ prolapse (POP). POP occurs when the pelvic floor muscles are weakened and the bladder, uterus, or rectum can start to press into or drop out of the vagina.
The research shows that women should wait until 3-6 months postpartum to return to running. For women anxious to return to running, that seems forever! The reason to wait is based on healing time. For vaginal births, the pelvic floor muscles are stretched greatly, and the levator hiatus (pictured below) can take as long as 12 months to become closer to baseline. In addition, the pelvic floor muscles, connective tissue and nerve healing is maximized by 4-6 months (Staer-Jensen et al. 2015). That means that women should seek a pelvic floor physical therapist after vaginal births as soon as they are cleared in order to maximize their ability to heal these tissues.
In both cases, vaginal or cesarean, the recommendation is to have a pelvic health physical therapist evaluate the pelvic floor and abdomen prior to returning to high impact exercise. High impact exercise in female athletes was found to have a 4.59 fold increase in risk of developing pelvic floor dysfunction compared to low impact (De Mattos Lorenco et al 2018). Running has been associated with a rise in intra-abdominal pressure and increased ground reaction force between 1.6 and 2.5 times bodyweight when running at a moderate pace (Gottschall and Kram 2005). These statistics are not to show that women should avoid high impact exercise, but should make sure women are physically prepared to return to sport.
The article concluded that return to running should occur 3-6 months postpartum in the absence of the following symptoms:
Other symptoms in addition to those listed above, that if experienced a woman should seek out a physical therapist include:
In addition, there are recommendations on the amount of strength and endurance in the pelvic floor and fascial support that should be present for running to prevent pelvic floor dysfunction. These measurements can be evaluated by a pelvic floor physical therapist.
The full article can be found for free here.
Goom, Tom & Donnelly, Grainne & Brockwell, Emma. (2019). Returning to running postnatal – guideline for medical, health and fitness professionals managing this population.
Recent studies support the benefits of mindfulness for bowel health. A 2014 study of 53 patients reported that mindfulness-based stress reduction (MBSR) “had a significant positive impact on the quality of life…” on people diagnosed with ulcerative colitis compared to a control group (1).
Another study the same year examined 24 people with irritable bowel syndrome (IBS) and compared them to a control group. Authors concluded that mindfulness-based therapy was more effective than cognitive behavioral therapy (CBT) to decrease symptoms in those with IBS at a 2-month follow-up. (2)
Is what you are eating contributing to your pain? Can the choice of food you eat actually help to relieve pain? Can nutritional interventions ease your pain? The answer is that nutritional interventions are often effective in reversing chronic pain. Simple dietary changes that remove inflammatory foods and replace it with better choices can help to reverse chronic pain conditions. Pain conditions are often due to an imbalance in the body’s chemistry. This can be due to many factors, such as a lack of nutrients in your diet, stress overload, lack of exercise, increased inflammation, insulin resistance and environmental factors. Nutritional interventions can be one element for shifting the chronic pain response.
In the links below, Joe Tatta, PT, DPT, addresses components of various anti-inflammatory diets and their benefits. Dr. Tatta is a physical therapist and Founder of the Integrative Pain Science Institute, an education company that supports practitioners as they explore integrative models for pain. In these blogs, there is a review of the current literature of the types of foods and diet that can ease the pain associated with various health conditions.
These are some general guidelines. There is not a “one-size fits all” eating plan as you are unique and complex. Start by making a few changes in your diet and notice how you feel. For example, you can eliminate sugar and processed foods. Making limited changes will assist in recognizing how those particular foods impact you. Is there a relationship between food and pain? Going slowly and changing one or two things at a time is recommended so that you can identify whether a particular modification had an effect.
What happens if you eat a dessert or two, have some alcohol or coffee, or eat some other food that is generally considered inflammation provoking? By all means - enjoy it and savor the experience! There will be more on that in an upcoming blog. Resume the low inflammation regimen when you can and just move forward.
What you choose to eat has an influence on your overall health and resolving pain. Nutrition and diet affect both the physical and psychological processes that impact chronic pain, and good nutrition can be a pivotal component to attain and sustain optimal function and quality of life.
Making delicious and nutritious meals and desserts can be simple. Here is a simple 3 ingredient treat to get you started.
Blueberry Banana Muffins
For reference, check out the Integrative Pain Science Institute.
Question from Marc: I have premature ejaculation. It has been part of my life since I was sexually active at 16 years old and I am now 33. Is this something that can be helped by pelvic floor physical therapy?
Answer from Becca: Marc, I would imagine that you may have been treated by psychotherapists for your issue. In the last century, many specialists have placed premature ejaculation into the category of a problem of the brain. However, pelvic floor physical therapists now treat your particular diagnosis in an entirely different manner. What we have discovered in treating men like you, is that those who experience early climax often have tight musculature in their saddle muscles (the muscles of your body that would be in contact with the saddle of a horse, were you seated upon one). In the ideal situation of arousal, these saddle muscles should expand and allow blood to flow into the penis and testicles. This blood should be retained in this saddle area to allow for an adequate time span during arousal and penetrative sex before ejaculation. In the case of premature ejaculation, the muscles of this saddle region are taut and cannot allow accumulation of blood to pool in the testicles and penis, which then creates an emergency expulsion of the seminal fluid from the penis.
This condition of premature ejaculation is treated in pelvic floor physical therapy. We assist men in reaching longer time durations of their erections by teaching them to lengthen their pelvic floor (saddle) muscles. We also instruct patients and their partners to increase the time of arousal and defer climax, thereby encouraging the blood flow necessary to prolong the sexual experience. In answer to your question, Marc, you can find help with a pelvic floor physical therapist.
Question from Steve: I suffer from chronic constipation. While that is terrible by itself, I also find that I cannot get fully hard during sex when I am constipated. Am I imagining this, or is there a correlation between constipation and erectile dysfunction?
Answer from Becca: Steve, I wish that more of our patients made this connection between the bowel and sexual function. The organs that sit within the relatively small cavern of the bony pelvis in men are the bladder, prostate, and the end of the colon (rectum). These organs are crammed into a very tight space. Which means that when one of these organ systems is a little bit off, the other systems invariably feel askew as well!
When the bowel is impacted with stool, as it is with constipation, this organ presses on the prostate and then the bladder. Also, the pressure on the perineum (the saddle region we discussed in Marc’s case), is created by too much fecal matter accumulating in the bowel. This excess pressure inhibits a full sexual response and limits full erections in men. The long-term discomfort associated in prolonged constipation can also distance a man from wanting to engage in sex.
The solution: pelvic floor physical therapists treat bowel dysfunction. We educate our patients in how to improve bowel regularity with stretches, exercise and lengthening of the pelvic floor muscles. What we find in treating patients like Steve is that when regular bowel movements are achieved, more satisfactory sex follows!
Question from Chen: I have trouble urinating from time to time. Sometimes, I think I am done peeing, I pull up my pants, and then I dribble urine. I am only 25 years old. Why is this happening and what can help?
Answer from Becca: Chen, I wish that you would start an online social media feed about your problem! Because it is so common and so very easily addressed. Many men come to pelvic floor physical therapy with complaints of leaking after peeing, or what we refer to in our line of work as “the post-void dribble.” Guys think there is something terribly wrong when this occurs, and because they won’t talk about it, they don’t know that many other guys have exactly the same problem!
Many men stand up to pee in urinals. This is the cultural norm in our society. But for men with tight pelvic floor muscles, or even men with moderate anxiety in a public restroom, the bladder cannot completely empty when a guy is in a standing position or when there are other men around him. What happens in this case is that the bladder cannot fully relax and the urine within it will not completely drain from the pelvis. Many guys shake their penises to try to get excess pee out of it. But this technique doesn’t always work to sufficiently drain the bladder. Hence, the dribble occurs after you think you are done peeing, Chen, and so many other men like you leave the bathroom to return to the tavern or sports arena, because they never allowed their bladders to fully empty.
Here is what a pelvic floor physical therapist may tell you, Chen.
Finally, for Chen and the vast number of guys like him, view this PDF for the technique on how to avoid the post-void dribble.
Question from Don:
“I am 32 years old and have no difficulty with sex. I do find that it is hard for me to pee after ejaculation. Is this normal? And should I be forcing out pee after sex?”
Answer from Becca:
“What you are describing is very normal. The muscles of your pelvic floor that allow you to maintain an erection and expel semen during ejaculation are in a shortened position during sex. These same muscles must be completely relaxed and elongated to allow urine to exit the urethra. Asking your body to pee immediately after having sex is like decelerating a car from 90 mph to a full stop. The pelvic floor muscles are too revved up after climax to stretch and relax. Instead of ‘forcing out pee after sex’, try sitting on the toilet and taking some deep breaths. This will allow whatever is within the bladder to naturally come out of your penis. And if you do not have the urge to pee after sex, you needn’t try this at all.”
Question from Gary:
“I am 53 years old and in pretty good shape. I have diabetes and my erections are not as strong as they used to be. My doctor has tried to give me Cialis; it works only some of the time, and it is very expensive. Are there any tips that you could offer as a pelvic floor physical therapist to improve my erections?”
Answer from Becca:
“Erectile dysfunction and diabetes are often linked. This is because having high blood sugar in the body alters circulation of blood and leads to nerve damage over time. The good news is that this type of erectile dysfunction can be reversed with good lifestyle choices. Maintaining a good diet for stable blood sugar, regular exercise and stress reduction can all help to improve your sexual response. From a physical therapy perspective, we can teach you how to isolate and contract your pelvic floor muscles during sex (also known as Kegel exercises), and improve your core strength. This will allow for increased rigidity of erections. You are one of so many men with exactly the same problem; there is help in pelvic floor physical therapy for a better sex life.”
Question from Pedro:
“I am 28 and began having groin pain over one year ago. I have penile pain along my shaft and up towards the tip, both during and after sex. It helps when I masturbate versus have sex with someone else, because I can avoid the tip of my penis and ejaculate with much less pain. I am not having sex with anyone at the moment, but I am worried because I used to get morning erections and now I don’t. Is this normal? I can’t exactly ask my friends.”
Answer from Becca:
“This is a multi-pronged question, so I want to be careful that I address each part of it. First, a great place for you to start if you have penile pain would be to go to a physician. There may be an infection under your foreskin (known as Balanitis), certain cancers or scar tissue development within the penis (also named Peyronie’s disease. You may have seen commercials on television about this diagnosis). Once your physician has ruled out any medical cause for the pain in your penis, a pelvic floor physical therapist can assess the musculature of your pelvis to determine if there are any imbalances or muscle tension that may be driving your pain.
“Second, having pain in the penis is one of the symptoms of Chronic Male Pelvic Pain Syndrome. That is not to say you have this diagnosis, Pedro. But this description of your problem is more common than you know. In pelvic floor physical therapy, we treat many men with penile, testicular, perineal and rectal pain. The causation of this pain is often tight musculature in the saddle area. Relaxation of these muscles can do wonders, but it is often difficult for guys to learn how to relax this region of the body without some guidance.
“Thirdly, many men with such symptoms tend to prefer masturbation to sex with a partner, especially when they are having a flare-up of pain. This is because, just as you mentioned, only you know what hurts and how to avoid pain during sex. Your partner will have a more challenging time working around your specific pain. That said, once your symptoms are decreasing in severity, the reintroduction of sex with a partner can be a creative and exciting learning curve. Physical therapists can help with this area of problem-solving with both partners.
“Lastly, morning erections are the body’s natural response from overflow of the parasympathetic nerves in your spine. In other words, the nerves are sending calming signals to the pelvis during sleep. This explains why having erections in the middle of the night or first thing in the morning is not a result of having erotic dreams or a person feeling aroused, per se; rather, the body is in a calm state and the testicles and penis become engorged with blood during sleep. Your lack of morning erections is consistent with your penile pain. This is because your pelvis is not relaxing appropriately during the sleep cycle to facilitate those erections. Many men with pelvic pain find that their morning erections return once their symptoms of pain are better managed. This is a good sign that the muscles of the pelvis are relaxing and allowing the return of painfree arousal and improved sex.”
by Karen Bruno, PT, DPT
Adapted from The Gabriel Method.
By Karen Bruno, PT, DPT
According to a recent article published in the American Journal of Physical Therapy, “Research continues to reveal that sleep is not a period of physiologic inactivity; rather, it represents a critical period of recovery that supports cardiovascular, neurologic, and other life functions. Sleep is a basic human need, and recent attention on sleep by researchers and media are changing sleep attitudes and behaviors. Sufficient sleep was often viewed as a luxury, and reduced sleep time was often equated with increased productivity; however, attitudes are shifting to prioritize sufficient quality sleep. Quality sleep is recognized as a positive health behavior, and it has been recommended to consider sleep as another vital sign, as sleep can give insight into the functioning and health of the body (3)."
You may have noticed that getting a good night’s sleep helps you to feel better both physically and mentally and this helps you function better during your waking hours. Basically, getting a good night’s sleep is a game changer that enhances the quality of your life. “Sleep is critical for the proper functioning of the body, including immune function, tissue healing, pain modulation, cardiovascular health, cognitive function, and learning and memory. Impaired sleep can lead to obesity, mood disorders, constipation and heart disease” (3).
Tips for Healthy Sleep
There is good news! There are many natural ways to improve the quality of your sleep and restore your sleep health. Scroll through the list below and try one or more of the tips, and see how they work for you.
Energy medicine is a safe and natural way to manage your energies to meet the stresses and anxieties in your life by optimizing your energies to help your body and mind function at their best. This approach acknowledges your unique complex nature and how your whole body is connected. From the energy medicine perspective, sleep problems are seen as an energetic imbalance that can be resolved by activating the body’s natural healing ability to restore balance.
I hope you will join me on Wednesday, March 20, 2019 at 6 pm in our Hamilton office to learn some of these easy and gentle self-care Energy Medicine techniques. Get a jump start and sign-up by calling 609-584-4770 for this free presentation.
By Bryn Zolty, PT, DPT
However, there is research that suggests that women who have painful penetration and have not yet had children, three maximum Kegels can significantly lower vaginal resting pressure and surface EMG(1). Lower resting pressure and surface EMG, or biofeedback, translates to lower muscle tension, improved function, and less pain.
Biofeedback can be a very helpful tool to determine if this type of treatment is right for you. Small electrodes (stickers) are placed on either side of the anus. These electrodes connect to a computer that measures the muscle activity in the pelvic floor. As you watch the computer, a therapist will guide you through how to contract and relax your pelvic floor and try the three maximal contractions. If the tension in the pelvis is reduced, the therapist will provide you with your home exercise program that includes the three maximal contractions.
Can maximal voluntary pelvic floor muscle contraction reduce vaginal resting pressure and resting EMG activity? Naess, I. & Bø, K. Int Urogynecol J (2018) 29: 1623.
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?
By Karen Bruno, PT
Mini-relaxation exercises are focused breathing techniques which help reduce anxiety and tension immediately. You can informally cultivate mindfulness by focusing your attention on the moment to moment sensation during ordinary activities. You can simply do this by single tasking - the art of doing one thing at a time and giving it your full attention. As you wash your hands, pet the dog or eat a meal, slow down the process and be fully present, using all of your senses.
Mini Version 1: count very slowly to yourself from ten to zero, one number for each breath. With the first breath you say “ten” to yourself, with the next breath, you say “nine, etc.
Mini version 2: as you inhale, count very slowly up to four; as you exhale, count slowly back down to one.
Mini version 3: after each inhalation, pause for a few seconds; after each exhalation, pause again for a few seconds. Do this for several breaths.
By Becca Ironside, PT
Matt was a regular guy. At 36 years old, he had a successful career in IT and was newly married. Matt had been playing ice hockey from the time he was in grade school and had no intention of stopping in adulthood. Every Tuesday and Thursday night, Matt went to a local ice rink and laced up his skates to play with a men’s league. This was the release from the grind of his job and he felt like a young kid as the blade of his stick hit the puck away from the opponent’s net.
Matt always wore a mouth guard and a jock strap. They were as necessary as the shoulder pads under the jersey. Anything could happen on the ice, and Matt was taking every precaution necessary, while having the best release of adrenaline he ever felt during the workweek. Until one day when all of this hockey armor failed to protect Matt. He will never forget it, he said. How could he? One evening, as Matt was playing defense, the puck flew into the air and hit him just to the left of his groin. The trajectory of the puck was like a sharp-shooter, it got that very tender spot between his jock strap and
testicle. The pain was excruciating.
The only choice was surgery. The urologist made an incision down the seam in the middle of the scrotum and removed the damaged tissue. There was pain after the surgery, Matt said, but nothing as severe as the pain which brought him to the hospital after the puck’s errant contact with his groin. This surgical pain settled down, healing took place, and all seemed to return to normal.
It was not until three months later when Matt noticed that he was having difficulty with sex. He had developed premature ejaculation. There was also a strange sensation of fullness and tenderness in his testicles after climax. How had this happened, Matt wondered? And what could be done? Was there treatment for this?
It was Matt’s wife who found our clinic. This was not surprising, as women typically have a more visceral connection with their pelvic floors; we have periods as teenagers, we get examined internally when most men do not until later years and we often have pregnancies which put this area of our bodies in the spotlight. Matt came to Pelvic Floor physical therapy with his wife, Maria.
Maria explained that she was concerned about her husband’s premature ejaculation and discomfort after sex. Not only did Maria and Matt want to return to their very robust sex life, they also wanted to conceive a child. It was helpful to have both partners attend this initial session.
Matt returned for several physical therapy appointments by himself after that first evaluation. He learned methods to relax the muscles of his perineum. It was the scar adhesions of his testicular surgery that caused his muscles to go into spasm; this was driving the premature ejaculation and pain after intercourse he was experiencing. He learned techniques to release the scarring and relax his muscles and taught his wife how to help him. Together, this couple worked to recover Matt’s sexual and
It was nothing short of wonderful to get a letter from Matt a few months after he stopped attending PT. The letter read as follows:
“It was not easy to come to a physical therapy office and talk about erections. But I am so glad that I did it. Since then, Maria and I are able to have the kind of sex that we did before the injury. I am also back to playing hockey, but only one night a week. This is because we are expecting a baby girl in a few months and I need to be at home more to get ready for the baby.”
What was so successful about the outcome of this story, you might ask? Firstly, Matt had a traumatic injury to his groin and developed symptoms immediately thereafter, so the causation of the problem was easy to determine. Secondly, Matt was open to this type of therapy and it was readily available to him in the area in which he lived. Finally, and what is most important about this story, is that Matt and his wife Maria tackled the problem together. They both had to adjust their expectations, lifestyles and learn to overcome something which might have driven them apart. Instead, it brought them closer together.
Pelvic Floor physical therapy helped to make this happen. With a baby girl to reinforce the story! There is great power in looking at life’s problems and seeking help. It requires staring down our opponent on the ice. We need the shoulder pads and the mouth guards, but the puck might still hit us in the worst possible spot. With a team approach, we can recover. We cannot allow the fear of the puck to keep us out of the ice rink. Just like Matt and Maria, we have to keep skating.
Many patients have visited their pelvic floor physical therapist and wondered, “Why are you looking at my feet when I’m here for pelvic pain?” The answer is the alignment in your feet, and how you walk affects the muscles, joints, ligaments, and bones in your pelvis.
The foot is complicated. It contains 26 bones, 33 joints, and over 100 muscles, tendons and ligaments. But let’s keep this explanation simple. Its main functions are to soften, absorb shock and accommodate to the surface on which your foot lands, then become rigid to help you push off and take a step.
Here are two examples of how your foot alignment can affect your pelvis:
There are many more considerations in evaluating the foot than the two examples provided, but they all have a profound effect on the rest of the body. They can cause instability at joints, pain, strained muscles, overworked muscles, and much more. In pelvic health physical therapy, your therapist is not only treating the symptoms in the pelvis, but always looking for possible causes of the symptoms such as your feet!
By Michelle Dela Rosa, PT
Hesselman S, Högberg U, Råssjö E‐B, Schytt E, Löfgren M, Jonsson M. Abdominal adhesions in gynaecologic surgery after caesarean section: a longitudinal population‐based register study. BJOG 2018; 125:597–603.