Pelvic Rehabilitation Medicine, Author at Pelvic Rehabilitation Medicine

A hysterectomy is the partial or total surgical removal of the uterus. This can also include the removal of the cervix, ovaries, Fallopian tubes, and other surrounding structures. It’s a common procedure for women experiencing uterine fibroids, endometriosis, and cervical or ovarian cancer. Hysterectomies are the second most frequently performed procedure for women of reproductive age in the United States. Over 600,000 hysterectomies are performed every year.

While most hysterectomies are straightforward, hysterectomy recovery can be full of surprises. Here are four surprising things that women may not expect after a hysterectomy.

1- Emotional recovery

Women can be left feeling emotionally vulnerable after a hysterectomy. They can experience feelings of sadness, loss, and grief for their loss of fertility. If a woman’s hope of conceiving has been terminated by a hysterectomy, the aftermath can be even more devastating. Often, a woman’s notion of what it means to be a woman—as a mother and desirable partner—is attached to her physiology. A hysterectomy can feel like a loss of feminine identity. It can also feel like a failure, forced menopause, or a sign of premature aging, to name just a few emotions that may resonate after surgery.

Additionally, hormonal changes after a hysterectomy can contribute to mood swings, irritability, sleeplessness, and depression. If a woman’s ovaries are removed at the same time as the uterus, the immediate onset of menopause can cause even more distinct emotional symptoms. Hormone replacement therapy, nutritional counseling, or other types of supplements and medications can ease these emotional fluctuations.

Women experience a spectrum of feelings after a hysterectomy, which should be normalized. Leaning on loved ones and other women, organized support groups, or quality therapy can go a long way in helping a woman recover emotionally from hysterectomy surgery.

Remember, it is essential for patients to seek the support they need if they are struggling. If emotional disturbances are severe, they should immediately contact their doctor.

2- Sexual recovery

Some women are surprised to find their sex lives disrupted by a hysterectomy. Estrogen is a hormone that helps maintain vaginal health and sexual function and is produced by the uterus and ovaries. When the uterus and ovaries are surgically removed, the sudden drop in estrogen can bring about challenging sexual consequences. Potential side effects such as vaginal dryness, painful intercourse, difficulty orgasming, diminished sensation, and a lower libido can add additional stress to a patient in recovery.

But there are definite solutions. A good-quality vaginal lubricant can boost vaginal moisture and elasticity. Estrogen creams can assist with the hormonal changes that bring about lowered sex drive and decreased sensation. And physical therapy can help a patient regain pelvic muscle tone and strength, which can alleviate pain during intercourse or difficulty achieving orgasm.

3- Bowel and bladder function

After surgery, individuals may experience changes in bowel and bladder function such as difficulty urinating, constipation, and incontinence. These embarrassing symptoms can aggravate a woman’s emotional recovery. Pelvic floor physical therapy can diminish pain and retrain muscles in the pelvis to regain control over these basic functions.

4- Lingering pain after hysterectomy

Women with chronic pelvic pain sometimes opt for a hysterectomy. They can be dismayed to discover that the pain is not gone. In fact, between 25-40% of women report continued pelvic pain after hysterectomy.

Consulting with a pelvic health specialist like Pelvic Rehabilitation Medicine can help ensure that surgery is indeed necessary. And if it is, then they can help alleviate postoperative pelvic pain and optimize healing.

What is the recovery time for a hysterectomy?

Hysterectomy recovery time varies depending on the type of procedure and the individual’s overall health.

For a vaginal hysterectomy, patients can return to normal activities within 2-4 weeks and can return to work within 4-6 weeks.

For a laparoscopic hysterectomy, patients can also return to normal activities within 2-4 weeks and can return to work within 4-6 weeks.

For an abdominal hysterectomy, the recovery time is longer. Patients can return to normal activities within 4-6 weeks and can return to work within 6-8 weeks.

A hysterectomy is major surgery. Even after the recommended hysterectomy recovery time, a woman may still experience discomfort, pain, or fatigue. She should resume activities slowly and thoughtfully. Keep in mind that it’s always important to follow the recommendations provided by the surgeon and medical team.

How can a patient alleviate symptoms after a hysterectomy?

Pelvic Rehabilitation Medicine (PRM) can help with a variety of post-op problems. PRM is a physician practice with offices nationwide that offers a functional and restorative approach to persistent pelvic pain. We have experience treating the repercussions of hysterectomies, both partial and full.

Whenever possible, we use non-pharmacologic and noninvasive interventions that expose patients to less risk than invasive measures or drug therapies. One of the most important of these treatment options is pelvic floor physical therapy.

A multi-modal approach can reduce hysterectomy recovery time

If a patient is experiencing lingering physiological symptoms after a hysterectomy, our team of pelvic pain specialists can help them recover sooner.

Many of our patients come to us 6 months to several years after a hysterectomy and are still experiencing pain. We recommend that if a woman is still enduring extreme discomfort after the three-month mark, she ought to see a specialist. It is simpler to correct certain pelvic issues before they become deeply established in the body.

At PRM, we use a multimodal approach to healing persistent pelvic pain. This can include our pelvic nerve and muscle treatments, managed pelvic floor physical therapy, lifestyle modifications, and medications such as muscle relaxers.

Our unique approach is the first and only of it’s kind in the country and focuses on reversing the inflammation in the pelvic floor, resetting the nerves and muscles, and retraining the pelvic floor.

While hysterectomy recovery can be surprising and sometimes difficult to manage, women do not need to suffer. Please reach out – we can help reduce your symptoms faster and help you regain an optimal quality of life.

It’s a sad truth that endometriosis doesn’t get talked about nearly as much as it should. This often painful disorder – in which tissue similar to the uterine lining grows outside the uterus, causing bleeding, lesions, and other issues – is not particularly rare. As a matter of fact, it affects an estimated one in ten women in the United States. However, endo is often under-discussed, misunderstood, and misdiagnosed, leaving many patients with inadequate care that fails to alleviate their symptoms.

Dr. Allyson Shrikhande and Dr. Lyndsey Harper are well-versed in identifying and treating this illness. Dr. Shrikhande is a board-certified physiatrist and the chief medical officer of Pelvic Rehabilitation Medicine, a dedicated pelvic pain practice with locations in over a dozen cities nationwide. Dr. Harper is a board-certified Ob/Gyn who is also the founder and CEO of Rosy, a new app dedicated to providing community and educational resources that help women overcome sexual health issues and have better sex overall. Here is what they had to say about the key challenges and takeaways from their experience helping patients who have endometriosis.

The path to diagnosing endometriosis may not always be simple and can be different for every woman. What are some indicators you look for when you suspect a patient may have endometriosis?

Dr. Harper: If a patient has a history of painful periods, I would automatically suspect endometriosis. In some other cases, there can be histories that involve painful sex, infertility, and bowel or bladder symptoms during menses. Any of these symptoms can be due to endometriosis, and if a patient reports more than one of these, the suspicion is even higher.

Is there any specific kind of testing you administer or refer out to reach a diagnosis?

Dr. Harper: Diagnosis of endometriosis is extremely challenging and that is a big part of the reason that it takes many women so long to get diagnosed. In some cases, endometriosis can cause cysts on the ovaries that can be seen by ultrasound, but in the vast majority of cases, a woman has to undergo laparoscopic surgery to investigate whether or not endometriosis is the cause of her symptoms. The fact that we do not yet have a reliable non-surgical test is a major frustration for many physicians and their patients.

When would you say is the right time to bring in a physiatrist/referring provider to help treat this patient?

Dr. Harper: If a patient has persistent pain due to endometriosis (and many other causes) that is not well controlled with medication or after surgery, I would definitely start involving other providers in the plan of care. Whenever pain is involved, we want to address it in as many ways as possible in order to avoid all of the negative effects that pain can have on our body and on our mental health.

Is there any kind of supplemental testing you administer/perform that could be different from an OB/GYN to help solidify a diagnosis?

Dr. Shrikhande: Pelvic floor spasm symptoms often overlap with endometriosis symptoms – these include pain with/post intercourse, constipation, abdominal bloating, abdominal pain, and urinary urgency, frequency, or pain with urination. Therefore the best tool that we have to diagnose endometriosis is a thoughtful history looking for specific details such as onset of pain, family history, autoimmune disease, and infertility.

As a physiatrist, what is your treatment protocol when treating a patient with endometriosis?

Dr. Shrikhande: As endometriosis is a systemic inflammatory disease process, we take a holistic approach. Endometriosis often upregulates the nervous system and causes chronic pelvic floor muscle guarding. Therefore, we use modalities which address the nerve inflammation and muscle spasms. These often include pelvic floor physical therapy, muscle relaxer suppositories, mindfulness/meditation, and a series of external ultrasound guided peripheral nerve blocks with trigger point injections to the pelvic floor.

Sometimes, depending on the severity and chronicity of the patient, we will use an oral medication to treat the central nervous system. Together, this multimodal outpatient treatment protocol works to reset and retrain the nerves and the muscles to a more calm state with less inflammation and more blood flow. We also focus on nutrition, optimizing bladder and bowel function, as well as exercise and sleep.

How do you both consistently work together on the path to helping the patient find relief?

Dr. Harper: In my experience, communication is key. This is important between the patient and all providers taking care of her. One of us may have one understanding of the issue and processes involved, while the others of us can add our own experience and expertise. When there is open communication among all involved, the best outcomes are achieved for the patient.

Dr. Shrikhande: Physiatry and gynecology use a team approach to treating Endometriosis. Typically a GYN is in charge of the initial work up for a patient’s pelvic pain symptoms: imaging, cultures, blood work, etc. A GYN is an expert in the female organs and is essential to the process, particularly for the surgical excision of endometriosis. A GYN is also extremely knowledgeable about the hormonal aspect of endometriosis and can recommend hormonal treatments.

A pelvic physiatrist is an expert on diagnosing and treating nerve and muscle pain and inflammation that comes with endometriosis. The nerve and muscle dysfunction are directly related to a patient’s symptoms of pelvic pain, as healthy pelvic nerves and muscles are required to have pain-free intercourse and healthy bladder and bowel function.

Resources:

To learn more about Rosy, visit their website here: https://meetrosy.com/

You can download the Rosy app here:

Our Chief Medical Officer, Dr. Allyson Shrikhande discusses pelvic floor physical therapy with Dr. Laura Meihofer PT, DPT, ATC, RYT 200 and how it is a critical part of the PRM treatment plan for helping patients find relief.

To learn more about Dr. Laura Meihofer, visit her website: https://laurameihofer.com/

Follow her on social channels:
Instagram: https://www.instagram.com/laurameihofer/
Facebook: https://www.facebook.com/laurameihofer/
LinkedIn: https://www.linkedin.com/in/laura-meihofer
YouTube: https://www.youtube.com/channel/UCcTgM_qYmkZVMS1548I7eFA

Title: Working with Physiatry for Pelvic Pain Webinar

Date: Monday, September 13th

Time: 7 p.m. to 8 p.m. EST

Price: $35. Receive 1 CE credit.

About: This course overviews the core elements, including diagnosis and non-operative treatment options, for a successful pelvic floor physical therapy and pelvic physiatry relationship for non-operative management of men and women with Chronic Pelvic Pain (CPPS). This course aims to describe the synergistic nature of pelvic physiatry with pelvic floor physical therapy, in hopes of promoting collaboration for the care of male and female chronic pelvic pain patients.

Registration: Click the link below to register

In this episode, we discuss pelvic health from the lens of physiatry with Dr. Allyson Shrikhande, MD. She is the medical director and founder of Pelvic Rehabilitation Medicine (PMR), offering true multidisciplinary care for people with pelvic floor dysfunction.

Allyson shares what a pelvic health physiatrist does, saying “we’re trained really to look at the interplay between the organ systems with each other, as well as the organ systems with the fascia, the muscles, and the nervous system.” Physiatrists can serve as the quarterback for people with pelvic floor dysfunction, referring them to the various specialties. She also shares how all of us pelvic providers can work together and how the mind-body connection affects pelvic pain

Learn more about The Conscious Clinician Podcast by going here.

Advanced Urology’s Dr. Marc Greenstein and Pelvic Rehabilitation Medicine’s Dr. Yogita Tailor discuss pelvic floor injections for pelvic pain in this webinar.

Dr. Marc Greenstein specializes in all aspects of Urology including kidney stones, men’s health, female and male pelvic pain syndromes, interstitial cystitis, urologic cancers and minimally invasive procedures.

He treats his patients with a holistic, integrative approach. Learn more about Dr. Marc Greenstein by visiting the Advanced Urology website.

Dr. Allyson Shrikhande had a blog published in Rosy discussing Pelvic Pain Gender Affirmation Surgery.

Excerpt:

What is gender affirmation surgery?

Gender affirmation surgery is a surgery for transgender individuals with a goal of alleviating gender dysphoria by providing the physical appearance and functional abilities which match their inner self. While this is a medically necessary procedure for many who are trans, it also significantly changes the anatomy of the pelvic region and can cause pain and a range of other side effects. It is typical to feel some pain or discomfort immediately after major surgery, but pain that does not subside or even worsens over time is not normal and should be treated.

How can gender affirmation surgery affect the pelvic floor?

Bottom surgery can have a major impact on the structures of the pelvic floor. Invasive surgery and other trauma to the area can cause the pelvic floor muscles to shorten, resulting in weakness and spasticity. Surgery can also cause the formation of scar tissue and pelvic adhesions which may affect blood flow and exacerbate pain.

To learn more about Rosy, visit their website at: https://meetrosy.com

Read the full blog here.

Dr. Allyson Shrikhande speaks with Herman & Wallace Pelvic Rehabilitation Institute about Physiatry

Excerpt from the interview:

Q: What is a physiatrist?

A: A physiatrist is an MD or DO with a specialty in Physical Medicine and Rehabilitation. This non-operative medical discipline involves focusing on the neuromusculoskeletal system to help patients recover their functional well-being and quality of life. We describe physiatry as an extension of physical therapy because a physiatrist diagnoses, manages, and treats pain from injury, illness, or medical conditions, incorporating other methods in concert with physical therapy to rehabilitate the body. Physiatrists are trained not solely in one organ system – rather, they take a holistic, full-body approach that accounts for the interplay of different organ systems, both with each other and with the neuromuscular and myofascial systems.

Q: What does a physiatrist do?

A: Physiatrists work with physical therapy to rehabilitate the neuromuscular system. A core underlying theme in physiatry is the concept of Neuroplasticity. This is the understanding that the nervous system has the ability to form and reorganize synaptic connections, especially in response to experience or learning following injury.

Read the full interview here.

Join Dr. Carolyn Moyers as she chats with Dr. Rucha Kapadia, physical medicine and rehabilitation (PM&R) specialist at Pelvic Rehabilitation in Dallas. She is a pelvic pain specialist with experience in treating both male and female patients who experience chronic pelvic pain, core muscular and pelvic floor dysfunction, and musculoskeletal-related issues.

It’s exciting to know there are a variety of options for the treatment of pelvic pain. The answer isn’t always surgical.

Learn more about Dr. Moyers by going to her website: https://skywomenshealth.com

Dr. Allyson Shrikhande had a blog published in Rosy discussing the effects of stress on pelvic pain.

Excerpt:

April is Stress Awareness Month, although I’m going to go out on a limb and say stress is something that we’ve all been pretty keenly aware of for most of the past year. Stress and anxiety are fully understandable responses to the way that 2020 and the start of 2021 have unfolded, but that doesn’t change how unpleasant they can be, or the negative impact that these feelings can have on your health.

It’s important to have strategies in place for coping with stress not only for the sake of your mood and emotional state, but also because of the very real relationship that that stress has with your physical health. This is particularly true of people with chronic pain issues. Emotional duress and physical pain very frequently go hand in hand, and it’s critical to treat both sides of this equation.

To learn more about Rosy, visit their website at: https://meetrosy.com

Read the full blog here.

Dr. Allyson Shrikhande had a blog published in Rosy discussing endometriosis.

Excerpt:

March is Endometriosis Awareness Month, dedicated to shining a spotlight on a serious chronic illness that affects one in ten women in the United States. While endometriosis has been gaining in visibility over recent years, with more organizations emerging to promote awareness and some celebrities like Chrissy Teigen and Padma Lakshmi coming forward to share their personal experiences with endo, we still have a long way to go in building a greater understanding of this disorder among patients and healthcare providers alike. It’s so important to recognize the very real impact that this invisible illness has on people’s lives and promote awareness of the ways that it can be treated.

To learn more about Rosy, visit their website at: https://meetrosy.com

Here is a description of that show:

Dr. Allyson Shrikhande speaks with Patricia Ladis PT, CBBA, founder of Wise Body PT and author of Wise Woman’s Guide to Your Healthiest Pregnancy & Birth about pelvic health.

Learn more about Patricia Ladis by visiting her website: https://www.patricialadis.com/

Instagram – https://www.instagram.com/patricialadis/

More information on her book – https://www.patricialadis.com/wise-woman-s-guide

Dr. Shrikhande had a blog published in Rosy discussing painful sex after a hysterectomy.

Painful sex can be a difficult thing to talk about. The millions of women who experience pain during intercourse, or dyspareunia, can have feelings of frustration and embarrassment. It can be particularly frightening for those who experience these symptoms after undergoing a total hysterectomy. Surgical removal of the uterus is sometimes a necessary procedure – hysterectomies are the second-most common surgery for women – but the post-surgery effect on the body can be distressing and disorienting.

While painful sex in the aftermath of a hysterectomy is not entirely uncommon, it is also not something that should be ignored. Some pain and discomfort while recovering from surgery is to be expected, but debilitating pain that prevents you from having a fulfilling and enjoyable sex life is a medical issue. It’s important to know what to expect from sex after your procedure, and to be aware of the signs that something is wrong.

To learn more about Rosy, visit their website at meetrosy.com

To read the full article click HERE.

Here is a description of that show:

Men Feel It Too: The Scoop On Male Pelvic Pain

About 10% of males in the US experience some form of pelvic pain. Nonbacterial Prostatitis tends to be one of the most common diagnoses. However, many men are seen by multiple urologists, receive extensive medical work up, find that none of the medications works, and end up feeling helpless. When they are finally seen by a pelvic specialist, they can begin to have the confidence they need to regain control of their life.

Dr. T. R. Christian Reutter from Pelvic Rehabilitation, explains to us why seeing a pelvic pain specialist should be the first line of defense in the absence of bacterial/viral infection. Other than being set up with pelvic floor physical therapy, specific medications, trigger point injections, peripheral nerve hydrodissection injections, and other minimally invasive procedures can help men who experience pelvic pain.

Dr. Reutter attended medical school at the University of Health Sciences College of Osteopathic Medicine in Kansas City Missouri and then completed his residency in Physical Medicine and Rehabilitation at the University of Texas Health Science Center in San Antonio, Texas. He practiced for almost 17 years as a sports medicine and spine specialist in San Francisco, California before joining the Pelvic Rehabilitation Medicine team in New York.

He took an interest in pelvic pain and realized that there were limited resources with regard to addressing pelvic pain conditions. He joined the Pelvic Rehabilitation Medicine Team in order to further pursue his interests. As a physiatrist, he feels that he brings a unique approach to patient care with the goal of pain reduction/resolution, improvement in the quality of life, and allowing the patient to return to the activities that they enjoy.

Learn more about Dr. Sneha Gazi by going to her website:

https://www.snehaphysicaltherapy.com/

Abstract:

Endometriosis is the abnormal growth of uterine tissue outside the uterine cavity that can cause chronic pain, dysmenorrhea, and dyspareunia. Although the disease is common and nonmalignant in nature, the symptoms can severely impact function and quality of life. Treatment options for endometriosis are limited and not well understood despite a growing need.

Research is done by: Dr. Allyson Shrikhande, Dr. Tayyaba Ahmed, Dr. Charity Hill

Read the full article here.

Abstract:

Urological chronic pelvic pain syndrome (UCPPS) represents a group of pain symptoms relating to patients with pelvic pain for which treatment is largely unsatisfactory. The objective of this study is to analyze the effects of a novel treatment strategy in males suffering from UCPPS.

Research is done by: Dr. Allyson Shrikhande, Dr. Gautam Shrikhande, Dr. Tayyaba Ahmed, Dr. Christian Reutter, Dr. Charity Hill

Read the full article here.

Estimates reveal that anywhere from 11-40% of adults in the U.S. have chronic pain, which is linked to disability, opioid addiction, anxiety, depression, and increased medical costs. More specifically, chronic pelvic pain affects up to nearly a quarter of all women worldwide.

Dr. Jana Scrivani, a clinical psychologist specializing in pelvic pain, joins us for a lively conversation today to answer the question – “What is Pain?” She discusses how pain is real and is mediated by the brain by various pathways in the nervous system. Dr. Scrivani created a behavioral health program for Pelvic Rehabilitation Medicine called Retrain Your Brain where she guides clients through virtual group sessions to understand their pain. Her goal is to empower her patients to help them change the way they act, think and approach their bodies.

Learn more about Dr. Sneha Gazi by going to her website:
https://www.snehaphysicaltherapy.com/

Call 713-487-1580 to set up a 10-min free consultation to see if the Retrain Your Brain Course is right for you.

Dr. Allyson Shrikhande had a blog published in Rosy discussing PGAD.

Sexual pleasure under appropriate circumstances is normal and natural, something that we should be able to talk about openly without shame or stigma. However, for some, feelings of sexual arousal may be constant and intense, occurring in unwanted situations. For these people, this can be embarrassing, uncomfortable, and even painful. This is known as Persistent Genital Arousal Disorder, or PGAD. It’s a real medical condition with real medical causes, and its symptoms are not normal, but they can be treated.

What is Persistent Genital Arousal Disorder?

Persistent Genital Arousal Disorder, also known as restless genital syndrome or persistent sexual arousal syndrome, is a condition that causes uncontrollable, unwanted spontaneous sexual arousal without any sexual stimulation with or without orgasm. While most common in women, it can also affect males. Persistent arousal can last days and even weeks, causing pain, discomfort, and disruptions in your day to day life.

What are the symptoms of PGAD?

The disorder is generally marked by ongoing feelings of sexual arousal that become uncomfortable and disruptive. In women, this can involve unprompted swelling of the clitoris and labia, as well as wetness, itching, and burning. Men with PGAD often report penile pain or erections that do not go away even after several hours. When symptoms first emerge, the disorder is often mistaken for a urinary tract infection because of similar feelings of itching and burning. UTIs, if untreated, can also cause Persistent Genital Arousal Disorder symptoms.

To learn more about Rosy, visit their website at: https://meetrosy.com/
Read the full blog here.

Abstract:

We published a manuscript entitled “A Novel, Non-opioid Treatment for Chronic Pelvic Pain in Women with Previously Treated Endometriosis Utilizing Pelvic-Floor Musculature Trigger-Point Injections and Peripheral Nerve Hydrodissection”. There is little consensus in the literature on the underlying etiology of endometriosis. There is even less evidence on effective treatment options for endometriosis and its associated chronic pelvic pain. Although there is no cure, traditionally endometriosis symptoms are managed with a combination of hormonal and surgical treatments. This manuscript is a commentary on a unique outpatient neuromusculoskeletal protocol to add to the traditional hormonal and surgical approaches to help improve pain and function in patients with endometriosis. This commentary takes a gastrointestinal and colorectal slant as to how the complex disease process of endometriosis can affect these organ systems and the symptoms that arise when this happens.

Research done by: Dr. Allyson Shrikhande

Read the full article here.

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Dr. Shrikhande was featured on the Living A Better Life podcast to talk about the PRM protocol for Endometriosis that they use at Pelvic Rehabilitation Medicine.

Here is a description of that show:

In this episode, I interview Dr. Allyson Shrikhande about endometriosis. We dive into prevalence, symptoms of endometriosis that you may not have considered as a typical sign, why diagnosis is challenging, how endometriosis is linked to pelvic floor dysfunction and nerve sensitivity and what you can do about it. Dr. Shrikhande takes us through the PRM protocol they use at her clinic.

For more information on Dr. Madelaine Golec and Ecophysio, visit their website:

https://www.ecophysio.com/

Follow their social channels…

ECO Physiotherapy:
Facebook – https://www.facebook.com/ECOPhysiotherapy/
Instagram – https://www.instagram.com/ecophysiotherapy/

Living A Better Life Podcast:
Facebook – https://www.facebook.com/livingabetterlifepodcast/
Instagram – https://www.instagram.com/livingabetterlifepodcast/

Our very own, Dr Charity Hill, is joined by Dr. Linda Kiley of Palm Beach Center for Pelvic Health and PT Gail O’Neill of Pelvic Health Solutions where they discuss the journey a pelvic pain patient takes to find relief.

For more information on Palm Beach Center for Pelvic Health, visit their website at:

https://www.drlindakiley.com/

Follow their social channels:

Facebook – https://www.facebook.com/urogynecologypalmbeach/

For more information on Pelvic Health Solutions, visit their website:

https://phsfl.com/

Follow their social channels:

Facebook – https://www.facebook.com/Pelvichealthsolutionsfl/

Instagram – https://www.instagram.com/pelvichealthsolutionsflorida/

LinkedIn – https://www.linkedin.com/company/pelvic-health-solutions-florida/

Pelvic Rehabilitation Medicine’s, pelvic pain specialist, Dr. Christian Reutter speaks to Men’s Health about pelvic pain in men.

He is quoted saying:

According to Dr. Reutter, the pelvic floor consists of a network of muscles that act as a “sling” to support the pelvic floor organs (the prostate, bladder, rectum and seminal vesicles), stabilize the connecting joints and assist in bladder, bowel and sexual function. Unlike the muscles you see when you hit the gym, these muscles are mostly internal and (hopefully) not visible to the general public. But they are critical to your everyday function and easily affected by stress, sleep, and other lifestyle factors.

Dr. Reutter adds that working from home, stress, uncertainty, sitting, lack of exercise, and lack of social connection contribute to any of these symptoms.

In addition to breath work, Dr. Reutter suggests you take warm baths, increase aerobic activity (which increases endorphin levels, the body’s natural painkiller) and avoid prolonged sitting on hard surfaces to help relax the pelvic floor and mitigate symptoms.

Dr. Reutter and Dr. Weber go deep on a few common conditions below. If you are experiencing the symptoms described here, reach out to one of these experts to help determine the true cause of your symptoms and whether or not there is more you can do. If not addressed, your pelvic pain could have a large range of effects, from reducing your ability to produce power during your workout to impacting you emotionally and socially.

Prostatitis

The prostate is a small gland located directly below the bladder that enlarges over time. According to Dr. Reutter, prostatitis consists of swelling and inflammation of the prostate gland. This gland secretes a fluid that helps constitute semen or seminal fluid. Prostatitis can be bacterial or non-bacterial. Non-bacterial prostatitis is more common form and can be due to nerve irritation, chemical irritation, stress, and often a weak or spastic pelvic floor. Symptoms normally include painful urination, pain w ejaculation, and pain in the groin, genitals, and pelvic floor.

Levator Ani Syndrome

The levator ani is one of the muscles of your pelvic floor. It is primarily responsible for preventing urinary incontinence and supporting the pelvic organs. Dr. Reutter explains that this syndrome can be due to chronically contracted pelvic floor muscles.

Symptoms often present as pain in the rectum resulting in an “achy” feeling during and after intercourse, pain with bowel movements, constipation, and/or a feeling of rectal “fullness” or pain. Dr. Reutter notes: “Patients often describe a feeling of a ‘golf ball’ or similar in the rectum.” He adds that stress, anxiety, chronic constipation, a history of hemorrhoids, anal fissure, and prior colorectal surgery are all causes of levator ani syndrome.

View the original piece placement on Men’s Health.

Helpful video from PRM’s Dr. Jana Scrivani

Social-distancing can be hard for some people. Watch this video of Dr. Scrivani sharing some tips for remaining calm and relieving stress during this difficult time.

A full transcript of the Managing The Stress of Social Distancing can be found below:

Hi, everybody! I’m Dr. Jani, a licensed psychologist, and I’m here to talk to you today about a very timely subject: managing stress in the age of social distancing and home quarantine.

So, if anyone out there is like me, given the area of the country that I live in, I have not really left my house since Friday, with short breaks to take walks and get some fresh air, and things like that. So, what I’d like to do is offer you some tips that you can use to manage the absolutely expected stress and anxiety that all of this is no doubt bringing up, and then how to manage it when you’re stuck in your house or your apartment.

Number one… This is my top 10 list. So, number one: limit your news exposure. I cannot stress this enough. So, if you find yourself stuck at home, and you’re just watching endless news, and constantly reading, and looking for updates, what that’s doing is ratcheting up your stress and anxiety without actually providing you with a lot of useful information. So, how I like to do this is pick one reputable news source, check it no more than one time per day. That will be enough so that you’ll get the accurate information that you need without increasing your stress levels.

Number two: give yourself a smell right now. A little sniff. When was the last time you took a shower? Create a regular routine. So, it can be really tempting to just have a free flow day, but routine and structure are things that we as human beings thrive on. So, create a routine for yourself, including showering, getting dressed, eating regular meals. Definitely will help to keep that stress in check.

Number three: try and get some fresh air at least one time per day. So, of course there are a lot of us who are either strongly suggested or perhaps even under mandate to stay in our homes. But social distancing doesn’t mean that you can’t, let’s say, take a bike ride where you don’t come within six feet of other people. Or take a socially distanced hike. Or a walk. If you happen to be lucky enough to live in New York City, folks are telling me that Central Park, everyone’s being very respectful of maintaining social distance, and is a great place to go and get some of that fresh air.

Number four: prepare to get aggravated like you have never been before at the people with whom you live. So, whether that’s your kids, your partner, your parents, friends. And you want to prepare yourself for this. The more time we spend under stressful circumstances, in close proximity with each other, the more stressful things get, and the more likely we are to have conflict with people.

So, an interesting exercise: take a moment, write down a list of five things you love about the people who you’re living with right now, and take that out when you have the urge to snap at them or respond in a way that you won’t feel proud of later. Remind yourself of why you love these people and why you care about them. Practice assertive conflict resolution.

Number five: there are lots of memes going around about “quarantinis” and other creative ways to spend your time in isolation. You really want to limit your use of alcohol and other substances right now. And there’s a great acronym to help yourself ask, “Okay, why am I having an urge to drink or use a drug right now?” And the acronym is HALT. H-A-L-T. It stands for “Am I hungry? Am I angry? Am I lonely? Am I tired?” And I’m going to add also bored. So, when you’re having an urge to take a drink, ask yourself that question. And if you are hungry, angry, lonely, tired, or bored, take steps to try and resolve that.

Okay, number six, maybe the most important one: take a moment, be kind and gentle with yourself. You are not going to be the perfect homeschooling parent. You’re not going to be the perfect partner. You’re not going to be the perfect friend, the perfect employee. Remind yourself that at any given moment you are doing the absolute best that you can, and that is all you can expect of yourself.

Number seven: social distancing does not have to mean social isolation. Humans are social creatures, and this is one of the reasons that people are struggling with this particular viral outbreak so much right now, is because all of the structures of our society that we go to as humans, right now they’ve pretty much stopped functioning. So, if you live alone, this is going to be even more important. Plan times to do FaceTime dates with people in your life. Set up online meetings, phone calls. Reach out to people you know who live by themselves and who may need extra support right now. So, you might have to find that it takes a little bit of extra effort to get that social interaction that you need, but it is so incredibly important right now.

Number eight: something that helps me, because let’s face it, I’m scared, you’re scared. I think everybody right now is feeling scared, and anxious, and worried about the future. And something that I like to do is remind myself of everything that we’ve gotten through together as a society. Whether it was a World War, or the Swine Flu epidemic, September 11th, we have witnessed, and some of us in our lifetimes, catastrophic events; and as a society, we have never failed to emerge from them and get through them. And we will get through this one too.

Number nine: it is completely normal right now to feel increased stress and anxiety. As I just mentioned, everybody is feeling it. We’re feeling it because we’re human, and we’re living through a time of unprecedented uncertainty, and that is the perfect storm for anxiety and stress. Ride those feelings like a wave. Don’t stuff them down and don’t suppress them. Allow yourself to feel. Allow yourself to experience anxiety and sadness about what’s going on. It doesn’t make you a weak or bad person. It makes you a human. No feeling is final, and no feeling is fatal. Remind yourself of that. It’s completely impossible for these feelings to last forever, but likely they will come and go like waves. And just like a surfer, we have to ride those waves of emotion until then eventually crash.

Number ten: it is more important than ever to reach out for assistance if you need it. And I’m going to post all of these resources that I’m sharing with you right now underneath this Facebook Live once it gets saved to my page.

If you live in New York and you need assistance with food, housing, rent, dial 211. That is your resource for New York City.

There is a friendship line specifically created for older adults who might be feeling particularly socially isolated right now, and that number is 1-800-971-0016.

The National Crisis Hotline: 1-800-273-8255.

The National Crisis Text Line: so text “Home”, that’s H-O-M-E, to 741-741 to initiate a chat with a crisis counselor.

And finally, the National Domestic Violence Hotline. They provide services to people in 200 different languages. They’re open 24/7, and can be reached at 1-800-799-7233.

If you’re already receiving psychotherapy or psychiatric care, check in with your providers. A lot of providers are offering video sessions right now. I’ve been offering video sessions for years, and so have many practitioners, and a lot of practitioners are starting to offer them now so that you can continue receiving therapy during this time of increased stress.

If you’re currently under psychiatric care, now is a good time to call your psychiatrist and make a plan to make sure that you don’t run out of your psychiatric medications.

So, all of those things are some proactive things that you can do now. And if you do not have a therapist and you’re looking for one, tons of therapists across the country are currently offering video sessions to folks in need. So, reach out for help if you need it. There are a couple of organizations that can help you find a therapist, and I will also post those at the bottom of this Facebook Live once it gets posted to my professional page.

Thank you for coming and listening. Stay safe out there, take good care of yourself, take good care of each other, and I’ll probably be back with more Facebook Lives soon. If there’s any topic that you’re interested in hearing me speak about, just leave a comment on this Facebook Live, and I’ll do my best.

All right, everybody, take care.

Pelvic Pain with Sitting and Intercourse Patient Testimonial Transcript

So my name is Jason. I’m from Montreal. About a year ago, started having pain in my pelvic area. The longer I sat, the more I would feel a discomfort or burning, same thing for walking. And it would also limit my ability to be intimate with my partner because of the discomfort and it sort of lead me to question what was going on. And I saw a few different doctors, nobody could really come up with an answer. And then I just went online and I Googled Pelvic Rehabilitation and up came Doctor Ahmed’s name and her practice.

The staff was extremely friendly upon my first arrival. It’s a very comfortable setting. And, of course, when I met Doctor Ahmed, she really put my mind at ease that this problem is correctable, that with the right treatment and the right health regimens that things could go back to normal or as close to normal as possible. The treatments consisted of injections and they were guided by ultrasound, so Doctor Ahmed was able to target the muscles that were in a contracted state and the source of the pain ultimately. And those injections really helped kind of relax the muscles and enable the discomfort to slowly go away.

I would definitely recommend them. They’ve definitely taken me from a place where I was in a lot of pain to significantly less pain. And I would definitely recommend them to anyone in a similar situation.

Pain During Intercourse Patient Testimonial Transcript

My name is Mike and I’m from Cliffside Park, New Jersey. In July of 2011, I was 24 years old and I was introduced to this woman through a mutual friend of mine and on our first date we had sex. I felt the worst pain of my entire life, like a snapping in my penis, and I instantly knew something was wrong.

A couple of days later, the pain had not subsided. I sought out a urologist. I was given all these courses of treatment that were horrible. I mean, I’ve been poked, I’ve been prodded. I was told I couldn’t have ketchup, I couldn’t eat pepper. I work in television and I was told that I couldn’t drink coffee. This wasn’t like an erectile dysfunction. This was literally a loss of sensation. I would have sex and literally not feel anything. I literally suffered with this for six years and I had countless girlfriends in between.

Now we’re in 2017. This problem started July of 2011 and I still don’t feel anything during sex. I made an appointment with Dr. Ahmed in January of 2018. I get an email with the name, Pelvic Rehabilitation Medicine and it was like music to my ears. There was a doctor named Dr. Ahmed who actually dealt with this.

Dr. Ahmed put me on a treatment plan that actually helped and not for nothing, this is an emotional rollercoaster. Dr. Ahmed didn’t give up on me, even when I wanted to give up on myself. She started putting me on a plan that included seeing a sex therapist, going to physical therapy and seeing her, and she would call me and just be like, hey, how’s everything going? I have never had a provider do that for me.

I am so happy to say that I had sex recently and it felt awesome. I hope that somebody out there listening who is suffering will take a stand, will go to the doctor, will be seen, will come here to Pelvic Rehabilitation Medicine. Please call Dr. Ahmed. If I help somebody out there, if I help just one person, then I know I’ve done the right thing.

Urinary Urgency and Frequency Patient Testimonial Transcript

My name is Genie. I’m from upstate New York. Kind of started about five years ago. I started feeling this constant urgency to urinate. I didn’t have incontinence. I didn’t have issues urinating. It was just a constant urge to, but it was beyond feeling the urge. It was painful. It would be at least a few times per hour some days. A ridiculous amount. And sometimes I would be able to actually urinate and other times I wasn’t able to and in the moments when I could, it was just such a relief, but then shortly after the urgency would just come back.

As you can imagine, every doctor said, “Oh, it’s probably a chronic UTI,” and I hadn’t really had many UTIs in the past, but every single test I would take would come back negative. But they still would say, “Oh, well, maybe it’s a false negative. We’ll treat you anyway.”

Finally, that led me here to Dr. Shrikhande and the first appointment I had with her, she gave me a pelvic exam. She sat there, she looked at me, she listened to me, I finally felt heard. That was the moment that like my life completely changed. I wouldn’t say that it immediately fixed things and Dr. Shrikhande was very open about this is going to be a journey. I never felt that she was pushing treatment on me and she was really taking a holistic view on this and was like, “There’s a lot of factors here.”

I’ve done another round of injections and we plan to do more and I’m continuing to see a physical therapist weekly. That has just become a part of my routine. I just am in such a better place, or just such a different place than I was last year. Both how I’m feeling physically and how I’m feeling mentally. Just recently I’ve started feeling like I can actually live my life again and do normal things.

It’s just a shame that there are so many people out there that I guess aren’t educated in this area, so many medical professionals. And it just feels like this is something that’s not talked about. I mean, it’s not a really comfortable subject to talk about. This isn’t in your head. It is real and there are people out there that can help.

One of our pelvic pain and board-certified Physical Medicine and Rehabilitation specialists, Allyson Augusta Shrikhande, MD, was quoted in a Women’s Health Magazine article talking about life after pregnancy.

She was quoted saying:

Before I had a baby, I never imagined that my recovery would take longer than a couple of months. But the time it takes to get back to normal after experiencing fecal incontinence can vary greatly, says Allyson Shrikhande, M.D., a physical medicine and rehabilitation specialist at Pelvic Rehabilitation Medicine.

“The first part is re-setting those muscles, which would take about six to eight weeks—and then we have to do a proper neuromuscular re-education for another eight to 10 weeks,” she explains. “It’s about a three- to six-month process.”

Read the original article placement on Women’s Health Magazine.

Dr. Allyson Shrikhande and Dr. Tayyaba Ahmed were featured on How Cum Podcast with Remy Kassimir. Here is the description of that show:

In this week’s episode, we have two brilliant doctors of physical medicine and rehabilitation, Dr. Allyson Shrikhande and Dr. Tayyaba Ahmed, who specialize in pelvic pain. They teach us about a very gender neutral organ; the pelvic floor, and many different causes of pelvic pain. We learn about endometriosis, the seriousness of pudendal nerve/ pudendal entrapment, and why Kegels aren’t always the answer. The doctors answer questions from the Cumpanions and talk thrush, anorgasmia, penis burn, clitoral adhesions, and more. Ahmed and Shrikhande also share their personal experiences as women, mothers, and students during medical school, as well as their first-time stories!

Medical Assistant Position

Full Time – Bethesda, MD / Washington, DC Area

Job Description

We are looking for a motivated, team player to join our growing, specialty medical practice. Some of the skills and characteristics you must possess are:

Develops and maintains a high level of customer service
Strong organizational, multi-tasking and time management skills
Oral and written communication skills; planning and organization; teamwork
Demonstrates flexibility with job duties
Maintains an applicable, medical knowledge base.
Prepares patients for examination by Provider
Assists with Ultrasound Guided Injections
Excellent Patient Follow Through
Knowledge of Insurances
Clerical Duties
Experience with electronic health record systems

Associates Degree preferred but not required.

Job Type: Full-time

To be considered, please send your resume with a short written account of why you would be best suited for this position to:

[email protected]

Medical Assistant Position – Full Time

Job Description

We are looking for a motivated, team player to join our growing, specialty medical practice. Some of the skills and characteristics you must possess are:

Develops and maintains a high level of customer service
Strong organizational, multi-tasking and time management skills
Oral and written communication skills; planning and organization; teamwork
Demonstrates flexibility with job duties
Maintains an applicable, medical knowledge base.
Prepares patients for examination by Provider
Assists with Ultrasound Guided Injections
Excellent Patient Follow Through
Knowledge of Insurances
Clerical Duties
Experience with electronic health record systems

Associates Degree preferred but not required.

Job Type: Full-time

Locations:
Manhattan, NY
Long Island, NY
New Jersey, Bergen County
Miami, FL
Bethesda, MD

To be considered, please send your resume with a short written account of why you would be best suited for this position to:

[email protected]

A physiatrist’s view on pelvic pain: an interview with Allyson Shrikande, MD

Below is the transcript of an interview with Allyson Shrikhande, MD and Michelle Dela Rosa, PT.

Michelle: I’m here with Dr. Allyson Shrikande, founder of Pelvic Rehabilitation Medicine in New York and recently Hoboken, NJ. Thank you for speaking with me.

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.

Allyson: 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?

Allyson: 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?

Allyson: 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?

Allyson: 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?

Allyson: 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?

Allyson: 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.

Allyson: 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, which is 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?

Allyson: 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?

Allyson: 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.

Allyson: We have to work together.

Abigail Bayer−Mertens Human, Charity Hill MD, Tayyaba Ahmed DO, Gautam Shrikhande MD FACS, Allyson Shrikhande MD

Pelvic Rehabilitation Medicine, New York, NY

Objective.
Endometriosis is a disorder characterized by the abnormal growth of uterine tissue outside of the uterus. Its symptoms are known to be painful and debilitating to patient functionality. Treatment options for these symptoms are not well understood despite a growing need. The objective of this study is to determine the effectiveness of pelvic floor musculature trigger point injections and peripheral nerve hydrodissection in treating endometriosis symptoms, associated pain and pelvic functionality.

Study Design and Outcomes.
The participants in our study consisted of 16 female patients, aged 21-67, with endometriosis. Pre-treatment, all patients were evaluated with a detailed history and physical exam. This included an internal pelvic floor evaluation. Each patient took part in physical therapy before and throughout the treatment process, with individualized pelvic floor physical therapy programs.

Methods.
Treatment consisted of ultrasound guided pelvic floor trigger point injections to the iliococcygeus, pubococcygeus, and puborectalis. The first two injections combined 1% lidocaine with dexamethasone, while the next 4 injections consisted of 1% lidocaine. Nerve hydrodissection allows the nerves to reset, decreasing hypersensitivity. These treatments were performed once a week for 6 weeks, and were all office based and ultrasound guided. Patients were evaluated using two scales to quantify their pain and functionality before treatment and 3 months after treatment; the 0−10 Visual Analogue Scale (VAS) and the Functional Pelvic Pain Scale (FPPS). The FPPS rates pelvic functionality in 8 categories: bladder, bowel, intercourse, walking, sleeping, working, running, and lifting. The patient rates each category from 0 to 4, with 0 being normal functionality, and 4 being severe debilitation. Thus, each patient can be given a total score from 0 to 32.

Results.
The mean age of patients was 32.4. Pre-treatment, the mean VAS score was 6.00 (SD 2.68) and post-treatment the mean VAS score was 2.94 (SD 2.59); P<.05, 95% CI 1.16-4.97. The mean total FPPS score before treatment was 14.44 (SD 5.24) and post-treatment it was 9.13 (SD 5.75); P<.05, 95% CI 1.34-9.28. Analysis of the subcategories within the FPPS indicated the improvement was statistically significant in the categories of intercourse, sleeping, and working. In the category of intercourse the mean score before treatment was 3.07 (SD 1.14) and post-treatment it was 1.79 (SD 1.48); P<.05, 95% CI 0.26-2.31 . In the category of sleeping the mean score before treatment was 2.00(SD 1.22) and post-treatment it was 0.85(SD 0.8); P<.05, 95% CI 0.32 -1.99. In the category of working, the mean score before treatment was 2.00 (SD 0.96) and post-treatment it was 1.14 (SD 0.77); P<.05, 95% CI 0.18-1.53 .

Conclusions.
This study set out to determine the effectiveness of pelvic floor musculature trigger point injections and peripheral nerve hydrodissection as a treatment option for endometriosis related symptoms. Analysis suggests the treatment was effective at relieving pain related to endometriosis; it also reflected promise in improving overall pelvic functionality, particularly in relation to intercourse, working and sleeping. This study provides the foundation for future research with larger sample size and longer follow up.

Abigail Bayer-Mertens Human, Tayyaba Ahmed DO, Charity Hill MD, Gautam Shrikhande MD FACS, Allyson Shrikhande MD

Pelvic Rehabilitation Medicine, New York, NY

Patients with chronic pelvic pain syndrome (CPPS) often have debilitating symptoms and decreased functionality related to their pelvic organs and pelvic floor musculature. CPPS is underdiagnosed and treatment options are not well researched. The objective of this study is to determine the effectiveness of alpha-2 macroglobulin therapy in patients with CPPS.

One promising CPPS treatment is the usage of alpha-2 macroglobulin as a protease inhibitor to mitigate inflammation and pain. Alpha-2 macroglobulin, a regenerative, non-opioid treatment option, is a plasma glycoprotein which occurs naturally in humans. This retrospective study analyzed the effectiveness of alpha-2 macroglobulin in eleven patients, seven male and four female, with CPPS. Patients were aged 31-59, and additionally had diagnoses ranging from central pain syndrome, interstitial cystitis, and endometriosis. Patients were initially evaluated with a detailed history and physical exam, including internal pelvic floor evaluation. All patients had unsuccessfully attempted other treatments for their pain in the past. Patient’s scores on the Visual Analogue Scale (VAS) and Functional Pelvic Pain Scale (FPPS) were collected pre-treatment and 12 weeks post-treatment. The FPPS is a scale which measures 8 categories (bladder, bowel, intercourse, walking, sleeping, working, running and lifting) to determine a patient’s functionality in relation to their pelvis. The scale rates each category from 0 to 4, with 0 being normal and 4 being most debilitating. The patient can thus be given a total score from 0 to 32.

Patients all continuously underwent weekly physical therapy. Approximately 90 milliliters of the patient’s blood was drawn and centrifuged with the APIC system to separate its components. The alpha-2 macroglobulin concentrate (8-10 milliliters) was thereby isolated and then injected locally under ultrasound guidance in the region of the iliococcygeus, pubococcygeus, and puborectalis muscles. Pudendal nerve hydrodissection was also performed.

The mean age of the patients was 42.9. Pre-treatment, the mean VAS score was 5.18 (SD 2.48) and post-treatment the mean VAS score was 3.18 (SD 1.54); P<.05, 95% CI 0.16-3.84. Pre-treatment, the mean overall FPPS score was 12.36 (SD 5.80) and post-treatment, the mean overall FPPS score was 5.55 (SD 4.27); P<.05, 95% CI 2.29-11.35. Analysis of the subcategories within the FPPS indicated the improvement was statistically significant in the categories of bowel, intercourse, walking, sleeping, working and lifting. Pre-treatment, the mean FPPS bowel score was 1.36 (SD 0.67) and post-treatment it was 0.45 (SD 0.52); P<.05, 95% CI 0.37-1.45. For intercourse, the mean FPPS score pre-treatment was 2.56 (SD 1.24) and post-treatment it was 1.00 (SD 1.50); P<.05, 95% CI 0.18-2.93. Pre-treatment, the mean FPPS walking score was 1.88 (SD 0.83) and post-treatment it was 0.88 (SD 0.83); P<.05, 95% CI 0.11-1.89. For sleeping, the mean FPPS score pre-treatment was 1.67 (SD 0.71) and post-treatment it was 0.67 (SD 0.50); P<.05, 95% CI 0.39-1.61. Pre-treatment, the mean FPPS working score was 2.5 (SD 0.71) and post-treatment it was 1.5 (SD 0.85); P<.05, 95% CI . For lifting, the mean FPPS score pre-treatment was 2.25 (SD 1.16) and post-treatment it was 0.38 (SD 0.74); P<.05, 95% CI 0.83- 2.92.

This study has promising results in regards to the usage of localized alpha-2 macroglobulin as a novel, regenerative, non-opioid treatment option for patients with CPPS. This study also provides the foundation for further research into this topic, which will involve larger sample sizes and longer follow-up.

Sports Hernia: Causes, Treatments, and Symptoms at Pelvic Rehabilitation Medicine located in New York City

Sports Hernia Video Transcription

Very often, we have patients who present with abdominal tenderness which likely is a sports hernia. A sports hernia is a weakness in the soft tissue and muscle area around their pubic symphysis and their lower abdomen. This is important because these muscles are their core muscles, and the core muscles are part of your pelvic floor as well. So if you have a weakness there, you will have a weakness in your pelvic floor and thus causing the pelvic pain. Having a sports hernia can now result into pelvic pain because of their weakness in their abdominal muscles and their core. Then patients may present with pain in their groin, they may present with pain going down their leg, pain in their hip. Pelvic pain does radiate, and it does not just stay in one location, so it can mimic other things like lower back pain.

Patients with sports hernias can attribute this from being very active. Oftentimes, they are athletes or have active lifestyles. We’re evaluating their lumbar spine, we’re evaluating their hips, we’re evaluating their abdomen and checking to see if they could have a potential hernia. When patients have sports hernias, we also have to treat the underlying pelvic floor dysfunction that they may have.

Typically, we do that with pelvic floor physical therapists, possibly some Valium suppositories, maybe a nerve medication for any neurogenic inflammation, if they need, we may do hydrodissection nerve blocks and trigger point injections to their pelvic floor. And at the same time, we’re hopefully working with a hernia surgeon to evaluate if there is a need for repair of the sports hernia. When patients present with pelvic pain, we’re trying to understand where their pelvic pain is coming from and why they have it. Until we figure out what’s causing the issue, the pain won’t resolve.

Causes of Vaginismus: Causes, Treatments, and Symptoms at Pelvic Rehabilitation Medicine located in New York City

Causes of Vaginismus Video Transcription

Vaginismus is a tightness of the muscles around the vagina. Primary vaginismus can be caused by when they are trying to have intercourse for the first time, or they’re trying to use a tampon for the first time. It’s now like this trauma that is causing them to tighten up. We do evaluate them and try to figure out where is this coming from.

Secondary vaginismus is typically when patients who previously could have intercourse and previously could use tampons are now unable to do this. Other causes for vaginismus are postpartum changes in their hormones, recurrent yeast infections.

Vaginismus can be relieved by a multi-modal approach. Often we will prescribe patients with Valium suppositories to relax their pelvic floor muscles. They can use dilators under the supervision of a pelvic floor physical therapist. They can also be treated with hydrodissection nerve blocks and trigger point injections to their pelvic floor muscles.

Chronic Pelvic Pain Endometriosis: Treatment and Relief Options at Pelvic Rehabilitation Medicine located in New York City

Chronic Pelvic Pain Endometriosis Video Transcription

Endometriosis is a chronic inflammatory condition where you have lesions that are like plaques that can grow anywhere in the abdominal cavity. And so typically people say that it grows just on the outside of the uterus instead of inside of the uterus. But it can actually grow anywhere on the abdominal wall, sometimes on the bowel and sometimes on the diaphragm. And then oftentimes on the pelvic floor, which can lead to other pelvic pain syndromes that we treat, specifically pelvic floor dysfunction, as those lesions can cause direct inflammation into the muscles and nerves of the pelvic floor. It can start affecting the quality of the muscle tissue, it can affect the blood flow, it can affect the nerves in the area and create neurogenic inflammation. And it can also start affecting the central nervous system or the way the brain processes pain.

A lot of patients come into us nervous because they’ve all heard there’s no cure for endometriosis. But we really look at the whole system to try to relieve the pain of endometriosis by treating all the other systems that can be affected by it. We really work best in conjunction with other providers like the endometriosis surgeons. Sometimes we need to refer to an orthopedic surgeon if people start having other issues with their hips get involved. There really is hope for pain relief from endometriosis. A lot of times it’s just finding the right providers and treatments to give you that relief. I find that it’s very helpful for me having gone through the pain and suffering of endometriosis. I understand because I’ve felt those same strange sensations before that no one else has been able to understand. And I’m able to give that affirmation back to the patient and say, “No, I’ve dealt with this too. What you’re experiencing is real and that’s a symptom that goes along with endometriosis.” I just think of how much my quality of life would have improved if I was able to seek these treatments sooner. And that’s why we’re trying to reach out to people at a younger age to try to prevent these things going on for years and years and causing mental anguish that really we could help prevent.

Male Pelvic Pain: Types, Conditions, and Causes for Men at Pelvic Rehabilitation Medicine located in New York City.

Male Pelvic Pain Video Transcription

We always laugh when people ask us if we are women’s health, because when we first started we thought we would only have women patients, but the men just showed up. I have very young patients in their 20s, late teens, up until their 60s or 70s.

The symptomology of male pelvic pain can differ from females because of the difference in genitalia. The number one chronic pelvic pain symptom that a male usually presents to us is with pain with sitting. Males will present with testicular pain, testicular numbness, rectal pain, rectal numbness, pain in their perineal region, urinary frequency, urgency, burning, chronic constipation, diarrhea, abdominal tenderness, or abdominal pressure, bladder pain, coccyx pain, and not being able to have pleasurable intercourse.

Some potential causes of pelvic pain in men are IBS, Crohn’s disease, ulcerative colitis, interstitial cystitis, or abacterial prostatitis, inguinal hernia or a sports hernia, hemorrhoids. If you have a tailbone injury, that can cause pelvic pain. Athletic injuries, especially if it relates to your hip. Most males do not talk about their pelvic pain issues to anybody, and if they do, it may be to a spouse or partner. This is a very private issue and a lot of people are not speaking about it. Most of our male patients which encompass about 30% of our practice find us by Google. They are concerned with their livelihood. We understand that. We want them to be able to enjoy the things that they used to be able to enjoy.

The most important thing for male patients to understand is that although this is a very sensitive topic, we are very experienced in what we’re doing. We understand what you’re going through regardless of the fact that we’re females. We see this so often and we have great success with our treatment protocol.

Dr. Tayyaba Ahmed was featured on The Period Party Podcast with Nicole Jardim and Nat Kringoudis. Here is the description of that show:

Dr. Tayyaba Ahmed is an osteopathic physician who is board certified in Physical Medicine and Rehabilitation. She is also a contributing author to the textbook Pelvic Pain, Essentials of Physical Medicine and Rehabilitation, and a collaborator in the Northwell ROSE Study for endometriosis research.

In this episode, we talk about common causes and symptoms of pelvic pain, the relationship between endometriosis and pelvic pain, the issues surrounding endometriosis surgery, the impactful goal for the ROSE study, how you can participate in the ROSE study, and so much more!

Here are the highlights of what we cover during this episode:

What is pelvic pain?
Misconceptions about physical medicine and rehabilitation (PM&R) physicians, also known as physiatrists
The most common types of pelvic pain and associated symptoms
What is endometriosis?
The relationship between endometriosis and pelvic pain
Symptoms of endometriosis and how they usually present
Why endometriosis tends to remain undiagnosed for so long
The importance of early diagnosis for women with endometriosis
The questions to ask yourself to determine if your symptoms point to endometriosis
Other conditions associated with pelvic floor dysfunction
Ahmed’s observations about post-partum pelvic pain
Nat shares her experience with pelvic pain
What to look out for if you’re considering surgery for endometriosis
The reason ablation surgery remains so widely used
How the success of the ROSE study would impact women’s health
How to be a part of the ROSE study

Resources & Recommendations:

Ahmed’s Practice: Pelvic Rehabilitation
Ahmed on Instagram
Nancy’s Nook Endometriosis Education
The ROSE Study
Endometriosis Foundation of America
Endo What
The Endometriosis Coalition
For a free consultation with Dr. Ahmed over the phone, feel free to call 646-481-4998

Female Pelvic Pain Video Transcription

Female pelvic pain is a complex multifaceted condition. For women, it can be felt in their vagina, in the lower abdomen, in the lumbar, in the sacral region, the buttocks, and then, of course, the entire pelvic region where it can be felt in something called the perineal area. It can go down their leg, it can radiate up towards the thoracic spine, quite often it can be felt in the bladder, and the urethra, and/or the rectum.

Some things that are unique to females are vulvodynia and/or vaginismus, underlying gynecological disorders such as endometriosis, polycystic ovarian syndrome, uterine fibroids, and/or ovarian cysts that can cause pelvic pain, vaginal delivery. There is a strong hormonal component to pelvic pain with females. You can have something called pubic symphysis dysfunction or pain in your pubic symphysis, sacroiliac joint dysfunction, this can happen with pregnancy itself with or without a vaginal delivery.

What is Pelvic Pain? Transcription

Dr. Shrikhande: Pelvic pain is a complex multifaceted condition, mainly because in the area of the pelvis, there really is quite a bit going on. Issues in the bladder can actually crosstalk and cause issues in the pelvic floor and so on. Pelvic pain can be felt in the lower abdomen, in the lumbar, in the sacral region, the buttocks, and then, of course, the entire pelvic region where it can be felt in something called the perineal area, it can go down their leg, it can radiate up towards the thoracic spine. For men, it can be felt in their penis, in their testicles. For women, it can be felt in their vagina, quite often it can be felt in the bladder, and the urethra, and/or the rectum.

Patients with chronic pelvic pain have sensitization of their nervous system. Their nerves are hyperexcitable or hyperactive, and essentially firing too much. We always start with pelvic floor physical therapy, in addition, we always add daily diaphragmatic breathing, meditation of some patients, we’ll add some craniosacral work, some acupuncture, some medical massage or connective tissue work, and some yoga, depending on the patient. We have patients that come in to see us who have high-stress level jobs and have type A personality and often are sitting the majority of the day.

Dr. Ahmed: Oftentimes, we see a lot of patients who are professional athletes who developed pain from repetitive microtraumas to their pelvic floor.

Dr. Hill: I try to get them out of that state of despair that it’s so easy to get sucked into when you’re suffering day-to-day.

Dr. Ahmed: When they talk to me, they’re usually very tearful and upset because they don’t have anyone to talk to. For those patients, I try to see if I can connect them with another patient with their permission. I also encourage them to find different outlets like Facebook, different organizations.

Dr. Hill: Sometimes it’s just helpful to talk to people who understand and who’ve had the same conditions as you have, and kind of troubleshoot with them things that have worked and to get support.

Dr. Ahmed: I think the most important thing is that patients with pelvic pain should know that they are not alone and that they can find help and support.

Dr. Tayyaba Ahmed was featured on RUSK Insights on Rehabilitation Medicine podcast. This is part 2 of 2. Here is the description of that show:

Dr. Tayyaba Ahmed is a doctor of physical medicine and rehabilitation. A native of New York City, after spending five years honing her skills in outpatient care, Dr. Ahmed focuses on her passion for treating pelvic pain, believing that concentrating on a specific field creates the greatest expertise. A board-certified Physical Medicine and Rehabilitation physician, Dr. Ahmed also is a fellow of the Academy of Physical Medicine and Rehabilitation and a member of the International Pelvic Pain Society. She completed the BS/Doctor of Osteopathic Medicine program at New York Institute of Technology and was trained at the New York College of Osteopathic Medicine, Northwell Health Plainview Hospital, and the NYU Langone Medical Center/RUSK Institute for Rehabilitation.

In Part 1 of this two-part interview, Dr. Ahmed discusses: kinds of interventions involved in pelvic rehabilitation; types of health problems that necessitate pelvic rehabilitation; roles played by factors such as age and gender in determining which patients are candidates for pelvic rehabilitation services, and biofeedback as an effective technique to enhance positive outcomes and how it is used.

Dr. Tayyaba Ahmed was featured on The Women’s Pelvic Pain Podcast podcast. Here is the description of that show:

In this episode, I sat down with Dr. Tayyaba Ahmed, a pelvic pain specialist at Pelvic Rehabilitation Medicine in NYC. Dr. Ahmed is an osteopathic physician, board certified in physical medicine and rehabilitation. We discuss many components of pelvic pain, including the mind-body connection, the stigma against pelvic pain, what Dr. Ahmed’s practice entails and how she treats her patients.

Dr. Tayyaba Ahmed was featured on RUSK Insights on Rehabilitation Medicine podcast. This is part 1 of 2. Here is the description of that show:

Dr. Allyson Shrikhande Bigraphy Video Transcription

My name is Dr. Allyson Shrikhande. I am a Doctor of Physical Medicine and Rehabilitation. I went to medical school at the Royal College of Surgeons in Dublin, Ireland, and then went on to do my internship in general surgery in Boston at Harvard Medical School, then did my residency at NYU and Physical Medicine and Rehabilitation. Now, I’m a practicing physiatrist or physical medicine rehabilitation doc who treats male and female pelvic pain.

The main society that I’m involved with is the International Pelvic Pain Society, otherwise known as IPPS. I am the Chair of Medical Education Committee. I am board certified in physical medicine and rehabilitation. I am a member of the National Vulvodynia Association, giving patients with vulvodynia options for treatment. I am also a member of the New York City PM&R Society, also am member of pudendal.org. I got interested in the field of pelvic pain when I was first pregnant. I had difficulty walking and couldn’t figure out what it was at first, ended up being sacroiliac joint pain and dysfunction and pelvic floor muscle dysfunction.

At the time, had trouble finding someone to help me, and that made me realize that there’s a large need in this field for medical practitioners. The passion for pelvic medicine really started when I met a patient that flown to New York City from L.A. She was in her mid-20s and had been complaining about pelvic pain symptoms for over 10 years. After 10 years of being sent from psychiatrist to psychiatrist, she arrived in our office extremely frustrated and very concerned for why there was not a diagnosis. She was eventually diagnosed with endometriosis, however, it was late stage endometriosis, and I really feel that if we can educate both the medical professions and patients that, we can catch things earlier and allow people to suffer less and not feel that they’re alone and/or crazy.

Pelvic Pain Endometriosis Patient Testimonial Transcription

Ever since I was younger, I would get stomachaches a lot and have kind of different stomach pain. And it wasn’t terrible. And then when I got to college it got a little bit worse. I would say it would get sometimes like very full after meals and I guess bloated, and also would get really strong lower pelvic pain. So it almost felt like I had like a band on my lower abdomen. And then it was post-college when it got so bothersome that I kind of started seeing doctors more proactively.

A lot of times specialists only know their specific area. So, you know, the gynecologist, was like, “It’s not a gynecological issue, go to a urologist.” Urologists like, “Go to a GI doctor.” The GI doctor’s like, “Go to this other doctor.” And then finally I got referred to Dr. Shrikhande. And lo and behold after seeing Dr. Shrikhande for a full year, she figured out I had Endometriosis. You know, it’s a disease that affects a lot of women but all these in 10 years of seeing doctors, no one had ever figured it out, and I think because Dr. Shrikhande is one, so caring, but two, so holistic and looks at everything. She was able to kind of listen to all my symptoms and look at the bigger picture, and I think really helped get to the root of what was causing my pain.

You know, she’s so 24/7 if you ever have questions, responds within 24 hours. And I think that was really helpful and made me want to keep going back to her. She was very helpful in having the right procedures done. So I had CAT scans done and MRIs done, and before we actually realized I had endometriosis, she also did a lot of things that help with just general pain management. I did a course of the different nerve injections with her, which was really helpful and I think kind of temporarily helped to numb and some of the pain I was having. She not only was a great doctor herself, but also referred me to kind of a network of other people then who were very helpful. When you go on Yelp and look at the best doctor, you know, you don’t really know actually is this like a good doctor you’re going to. She referred me ultimately to the surgeon I ended up using and was in constant communication with him.

Going to so many doctors, it’s so frustrating not to share your story over and over again. She’s able to give all my background and honestly took a lot of pressure off of me because I had been doing for the year acupuncture and physical therapy, it made it so that I was actually able to recover much more seamlessly. I would recommend Dr. Shrikhande to anyone. She’s an excellent doctor and really cares about her patients and takes full ownership and goes above and beyond, outside of just being with her patients during the session. She thinks about you, sends updates, asks how you’re doing. She gets to know the other doctors in your network and makes sure that everyone’s working together to help manage her patient’s pain. She’s just wonderful.

Pudendal Neuralgia Video Transcription

Pudendal Neuralgia is pain in the distribution of the pudendal nerve and its branches. Pudendal neuralgia can be felt along the sit bones, along the rectum, along the perineum, and along the vaginal area, as well as the testicles and penis in males. Symptoms of pudendal neuralgia are achy, burning, stabbing, sharp, knife-like pains in the distribution of the pudendal nerve, which includes from the sit bones and buttocks, out to the rectum, or perineum, and/or the vaginal area, or the testes and penile area in the men. It’s often worse with sitting, as sitting does put pressure on the pudendal nerve, and it can be associated with pain with bowel movements. It is not associated with any sensory loss or sensory deficits.

Potential causes of pudendal neuralgia are anything that can put pressure along the pudendal nerve, from its course from the lower sacral nerve roots, down to the rectum and the vagina. Vaginal childbirth could put pressure on the nerve during delivery. A bladder sling operation can put pressure on the nerve and any other surgery that could cause scar tissue. Entrapment of the pudendal nerve which can come from higher up, from the lumbar sacral plexus, and injuries to the ligaments, where the pudendal nerve courses under.

The pudendal nerve can be injured. The most common way would be a stretch injury. However, the pudendal nerve, in most cases, can heal with time.

Persistent Genital Arousal Disorder (PGAD) Video Transcription

PGAD, or Persistent Genital Arousal Disorder, also goes by “restless genital syndrome” or “persistent sexual arousal syndrome.” PGAD symptoms, which are often extremely distressing to the patient, are unwanted, unpleasant sensation of arousal and/or orgasms, that the patient is unable to control. Women who come in to Pelvic Rehabilitation Medicine with symptoms of PGAD often feel that they don’t have control over their life, as it’s very challenging to have this unwanted, unpleasant sensation throughout the day, and extremely disturbing to their quality of life, their ability to function, at work and at home, and in relationships, and, often, their ability to get quality sleep.

The underlying cause of Persistent Genital Arousal Disorder is unknown. There are multiple theories, some including lumbar sacral causes, where there could be lumbar spine pathology, or something called a Tarlov cyst, that could be contributing and causing compression of the nerves that are related to arousal. There could be some hormonal contributions to Persistent Genital Arousal Disorder. There can be some causes associated with descending modulation from the brain, and that could potentially upregulate the nerves that lead to arousal and orgasm, and there could be some pressure from an underlying gynecological disorder. And there could be some role in the pelvic floor muscles itself putting tension on the nerves, that can increase arousal and orgasm in a patient. So we will evaluate a patient, try and find the cause, and then essentially try to relieve pressure on the nerve itself, and also try and calm patients down from chronically tensing their muscles and from activating their nervous system via either high levels of anxiety and/or depression.

There is debate in the medical community if PGAD can go away. We have had success in treating it here with our protocol. However, the longevity of the treatment is still yet to be determined.

Allyson Shrikhande, MD, founder of Pelvic Rehabilitation Medicine, has submitted an abstract for the International Continence Society’s Annual Meeting. The International Continence Society (ICS) has over 3,000 members and is a thriving society of Urologists, Uro-gynaecologists, Physiotherapists, Nurses, Basic Scientists and Researchers with a focus on continence and pelvic floor disorders. We are growing every day and welcome you to join our Society.

Here’s the link to the presentation abstract: https://www.ics.org/2018/abstract/306

International Continence Society Abstract:

A Novel, Non-Opioid Based Treatment Approach for Men with Urologic Chronic Pelvic Pain Syndrome (UCPPS) Using Ultrasound-Guided Nerve Hydrodissection and Pelvic Floor Musculature Trigger Point Injections

Urological Chronic Pelvic Pain Syndrome (UCPPS) represents a group of pain symptoms relating to patients with pelvic pain that are poorly understood and for which treatment is largely unsatisfactory. Newer nomenclature has combined Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS) and Interstitial Cystitis/Painful Bladder Syndrome (IC/PBS) into a single classification of UCPPS. The objective of this study is to analyze the effects of a novel treatment strategy in males suffering from UCPPS.

This retrospective, institutional review board approved study analyzed eight male patients aged 24-61 with UCPPS. All patients had a trial of antibiotic therapy, and had pelvic floor physical therapy pre and post taking part in the study. Patient’s scores on the Visual Analogue Scale (VAS) and Functional Pelvic Pain Scale (FPPS) were collected pre-treatment (Figure 1). While continuing physical therapy, patients underwent ultrasound-guided pelvic floor trigger point injections to the iliococcygeus, pubococcygeus, and puborectalis. The first two injections combined 1% lidocaine with dexamethasone, while the next 4 injections consisted of 1%lidocaine, and a plant-derived anti-inflammatory medication. Concomitantly, patients received peripheral nerve hydrodissection performed on the pudendal nerve and the posterior femoral cutaneous nerve. These treatments allow the nerves to reset, decreasing hypersensitivity. These treatments lasted for 6 weeks. After completion of treatment, each patient retook the VAS and FPPS.

The mean age of our patients was 31.8 years and the average duration of symptoms of the UCPPS was 21 months. Pre−treatment, the mean VAS was 3.3 (STD 1.7) and the mean VAS post-treatment was 1.8 (STD 1.4); P<0.05, 95% CI 0.73-2.27. The mean FPPS pre-treatment was 11.0 (STD 8.0) and the mean FPPS post-treatment was 6.3 (STD 5.3); P<0.05, 95% CI 0.03-9.22.

Our results show promise for a novel, non-opioid based treatment for UCPPS by using ultrasound-guided pelvic floor trigger point injections combined with peripheral nerve hydrodissection with lidocaine and dexamethasone along with a pelvic floor physical therapy program.

Uncovering the Black Box of Pelvic Pain: Understanding the Role of the Pelvic Floor

Presented By: Allyson Shrikhande, MD

PATIENT AWARENESS DAY 2018:
LIVING YOUR BEST LIFE WITH ENDO

Pain with Bowel Movement Video Transcription

Pain with bowel movement can happen when you have underlying pelvic floor hypertonia or pelvic floor muscle dysfunction. It can also happen when you have irritation of your pudendal nerves which often come with pelvic floor muscle dysfunction.

A risk factor for having a pain with bowel movements is constipation. So, chronic constipation can ultimately irritate the muscles and nerves of the pelvic floor and cause secondary pelvic floor muscle spasm. And that can spread to both the perineum and the testicles and the base of the penis in men, and for females, it can spread to the vaginal area and the bladder in both men and women, and ultimately lead to Chronic Pelvic Pain Syndrome.

It’s important to address your constipation and let your healthcare professional know about it so that we can address it with both lifestyle and nutrition. Particularly with lifestyle, we have patients do the breathing exercises to help release the spasm in the pelvic floor muscles because often, even just the mechanical restriction of the pelvic floor muscles near the rectum can cause constipation. So it’s important to release the tension in that mechanical restriction.

In addition, diet modification is important. We recommend supplements. Quite often, we use something called magnesium, which can gently promote normal bowel movements daily. Also, we recommend patients to prevent constipation to get the Squatty Potty. It’s a simple maneuver that can really relax the muscles of the puborectalis and pubococcygeus and help the mechanical inhibition of bowel movements.

Pain with Sitting Video Transcription

Pain with sitting presents to us with pain in the sit bone area, and the rectum, and sometimes out to the buttocks, when patients sit down, particularly on hard surfaces.

Quite often, patients who have pain with sitting have a high-stress lifestyle, high-stress job, and sometimes they’re holding their tension throughout the day in their pelvic floor muscles.

It’s important to make sure to get up once every hour, and to do proper breathing. This can help drop the pelvic floor, reset the muscles, and relieve tension in the area.

Something as simple as evaluating a patient’s chair at work, and their lumbar support, and their support for their pelvis, can really help alleviate a patient’s pain with sitting.

Prostate Pain (Prostatitis) Video Transcription

The subset of prostatitis that we would treat is abacterial or non-bacterial prostatitis. Meaning, there was tenderness on the prostate in exam, however, the workup was negative for any prior infection. So the symptoms that we would see here in patients with abacterial prostatitis would often be testicular pain or burning, perineal discomfort or burning in the perineum, penile pain, pain with erection or ejaculation or post-intercourse, as well as urinary symptoms such as burning during urination or frequency or urgency.

Some potential causes is inflammation in the genitourinary system. From when there’s chronic pelvic floor tension and muscle dysfunction, you essentially get release of proinflammatory cytokines from the pelvic nerves. In addition, there’s been some recent research that has shown the importance of the descending modulation from the brain going down the spinal cord to the genitourinary system that can modulate pain and prostatitis itself and the overall urological chronic pelvic pain syndrome.

Therefore, when we do treat patients particularly with urologic chronic pelvic pain syndrome, we not only treat the peripheral nervous system and the muscles of the pelvis and the surrounding soft tissue, but we also treat the descending modulating signals from the brain. Here at Pelvic Rehabilitation Medicine, we work to relieve the symptoms of abacterial prostatitis as they’re intimately connected to tension in the pelvic floor muscles. And we work to relieve that tension and increase blood flow and decrease inflammation around the nerves that can ultimately help with the pain and inflammation associated with the prostatitis.

Charity Hill, MD Biography Video Transcription

I’m Dr. Charity Hill. I am a medical doctor. I trained at Temple University for medical school and did my residency at NYU. I got involved in Sports & Spine Medicine because I was a competitive athlete. When I decided to focus on pelvic pain, that became really helpful as a lot of the structures we treat are very deep and can only be properly imaged using a lot of the techniques that I developed in my orthopedic training.

I joined the International Pelvic Pain Society, and that’s a group of physicians in multiple specialties that all work together to try to tackle the complicated aspects of pelvic pain. So, when I first began having pelvic pain, I registered it as a sports injury just because I was playing sports around 30, 40 hours a week. Went to multiple orthopedic surgeons and our team doctor in college and they just weren’t able to really figure it out.

When I was on my OBGYN rotation in medical school, we had a pelvic pain patient coming into the clinic. My attending said, “Ah, it’s these pelvic pain patients, you know? It’s just all in their head, there’s nothing we can do for them.” I myself had pelvic pain, and I remember just thinking to myself, “Oh my gosh, am I just crazy?” For a couple years I just kept my mouth shut and actually didn’t seek any medical care, and I thought I could maybe make it go away if I just ignored it. At one point I knew I really needed help when my medical assistant came in to get me for a patient, and I was laying on the floor of my office and that was kind of my rock-bottom when I was like, “No, I really need to treat myself as well as treating other patients.”

Finally, gotten to a doctor who was able to figure it out that I had endometriosis, and I was really grateful I eventually found someone. Though I figured if I had that hard a time finding care, even though I was already in the medical field, I figured it must be so much more difficult from people who are coming from outside that field to get care. And I decided I wanted to focus my career on educating people on the realities of pelvic pain and giving treatment to those kind of patients. I’m very grateful that I am able to use all the information that I’ve gathered over the years in order to help treat these patients who are suffering so badly.

So, there was a quote I heard once, “Pain is inevitable, but suffering is optional.” For a while I didn’t have much hope that I was ever gonna get to a place where I was going to be able to function like a normal person, but it’s wonderful to have hope for the future and have hope that you’re able to be who you really are and not let the pain rule your life.

Tailbone Pain (Coccydynia) Video Transcription

Coccydynia is pain in your coccyx or tailbone area. Coccydynia or tailbone pain is felt directly in the coccyx area. It is typically worse with sitting, particularly on hard surfaces.

Potential causes of coccydynia would be pregnancy and particularly vaginal delivery, certain athletic activities such as horseback riding or bike riding, a history of a fall on a patient’s coccyx or trauma to the coccyx such as a fracture, as well as pelvic floor muscle dysfunction or pelvic floor spasm, where the muscles are pulling on the coccyx, and that will irritate the nerves around the coccyx. Part of the treatment for coccyx pain is to have a proper cushion when you sit down, to relieve pressure on the coccyx.

You Can Help Us Learn More About Endometriosis

Pelvic Rehabilitation Medicine has partnered with Northwell Health in the Research OutSmarts Endometriosis (ROSE) Study to help discover an early detection test for endometriosis. The research and participant selection is being done through the Feinstein Institute for Medical Research at Northwell Health in partnership with the Endometriosis Foundation of America and Pelvic Rehabilitation Medicine.

If you’re a woman living with endometriosis, or you suspect you might have it and are scheduled to have surgical treatment, you may be eligible to participate in the ROSE Study. Your immediate family (siblings, parents, and children), if they do not have endometriosis, may also be eligible to join the study. ROSE Study researchers are exploring what causes endometriosis and if a better treatment can be developed. To participate in the study, you will be asked to:

1. Older than 18 years
2. Not pregnant or breastfeeding

To participate in the study, you must be:

1. Share medical/demographic information
2. Answer questions about how endometriosis affects her life
3. Provide a blood sample (from the arm)
4. Offer a sample of menstrual flow that can be collected at home using a simple procedure; this collection is optional
5. Allow ROSE Study researchers to collect excess endometrial tissue samples from a past or future surgery

Participants will be compensated for their participation.

If you would like to learn more about how you may play a part in improving the understanding of endometriosis, please contact a research nurse at 516-562-ENDO (3636), email [email protected], or visit us at ResearchOutSmartsEndo.org.

Download the research participation flyer HERE.

Rectal Pain (Levator Ani Syndrome) Video Transcription

Rectal pain is also known as Levator Ani Syndrome. What it is is spontaneous episodic pains in the rectum that are secondary to spasms in the pelvic floor musculature. These pains are said to last at least 20 minutes at a time, and as they do progress they can last longer. Patients often say that it’s a sensation of a golf ball in their rectum. Patients say that they have a dull ache in their rectum, or a burning, itchy sensation in their rectum. Risk factors for Levator Ani Syndrome include a history of hemorrhoids or hemorrhoid surgery, history of an anal fissure, history of prolonged sitting, particularly sitting on a hard surface and with poor posture, or chronically holding your stress in your pelvic floor muscles, and it can be aggravated with intercourse. It may be relieved with bowel movements. It is important to let your doctor know that you’re experiencing these symptoms, because research has shown that the earlier that we catch and diagnose and treat it, the easier it is for us to make patients better. The longer things persist, the more challenging it is for us to make it go away. Really because it starts to become your new normal, both in the way your muscles are set, the way your muscle spindles are, as well as the way your nerves are trained and the way they function. So if we catch it early, we can retrain the muscles and the nerves faster, and with a better prognosis.

Painful Erection / Painful Ejaculation Video Transcription

Male patients can experience pain during erection or ejaculation or pain post erection or ejaculation. Painful erection and painful ejaculation quite often comes from inflammation around the nerves that are involved in the process. There are multiple reasons they could be inflamed. Sometimes there is scar tissue around where the nerves flow from a previous surgery, such as an inguinal hernia repair or sometimes it’s purely from the persistent pelvic floor muscle spasms that ultimately lead to inflammation around those nerves involved in the erection and ejaculation process that causes the pain. We do see quite a bit of erectile dysfunction when patients do present with pain with intercourse to us. Trigger points in the muscles are nodules in the muscle fibers and these nodules can restrict the blood flow, essentially, in the surrounding tissue. And this restriction of blood flow ultimately proliferates in inflammatory cascade, which can lead to inflammation around the nerves and pain with erection and ejaculation.

Tayyaba Ahmed, DO Biography Video Transcription

My name is Dr.Tayyaba Ahmed. I am an osteopathic physician. I went to school at NYIT, which was a program with New York College of Osteopathic Medicine, and then I went to NYU where I met Dr. Hill and Dr. Shrikhande. I pursued sports medicine for a few years, and now doing pelvic rehab primarily. I had two kids, one in residency and one after residency. And most women will tell you that when you go back to working out and exercising you may have a little bit of leakage doing jumping jacks. And a lot of doctors and women think it’s normal to have that, you can actually improve the muscles of their pelvic floor, and doing that can prevent that leakage.

When I first got introduced to the pelvic pain world, a colleague had offered me an opportunity to edit a chapter for the Frontera textbook, the chapter was the pelvic pain chapter which I thought was a great opportunity to learn about pelvic pain and use what I’ve learned from Dr. Shrikhande. Since starting with Dr. Shrikhande, I have done many talks, one for the NYU health professionals, and one for Beyond Basics. I have also done some community talks, and at the National College of Osteopathic Surgeons Conference, I spoke about non-surgical treatment options for pelvic pain.

Pelvic Pain During Sex (Dyspareunia) Video Transcription

Dyspareunia is pain with intercourse or pain post intercourse. Pain with intercourse itself can have a strong emotional impact. Quite often, it can lead to avoidance of intercourse with your partner. It can lead to relationship issues with your partner. It can lead to a fear of intercourse and this fear can lead to something we call Vaginismus. When patients are in fear of intercourse, the muscles surrounding the vaginal opening can clamp down, so to speak. It can also lead to emotional distress, anxiety, as well as sleep disturbances, all secondary to the pain with intercourse. We do always ask, is it more of a superficial burning sensation? Which can often be associated with entrance pain or Vulvodynia symptoms, and at that point, it’s important to evaluate any underlying hormonal cause or underlying infection such as a yeast infection. Or is it more of a deep, penetrating pain? The pelvic floor muscles are important in evaluating and treating as well as any underlying organ disorders potentially within the female system such as ovarian cyst or a fibroid.

Audio: Pelvic Floor Dysfunction

Vulvar Pain (Vulvodynia) Video Transcription

Vulvodynia is vulvar pain. For vulvodynia to be labeled chronic, it has to be going on for over six months. Symptoms of vulvodynia include a sensation of throbbing or burning, or some patients say a rawness in the area, that can be heightened with intercourse specifically, or for some patients it’s heightened with prolonged sitting. There could be an underlying hormonal imbalance that leads to vulvodynia. There could be an allergic reaction, it could be secondary to pelvic floor muscle dysfunction, there also could be a potential injury or damage to a nerve that innervates the vulva area. An additional cause of vulvodynia could be recurrent vaginal infections.

Vulvodynia can either be constant or intermittent. It can be described as provoked or unprovoked. Provoked meaning when you touch the area there’s pain, but if you’re not touching the area there is not pain. Vulvodynia can be generalized where the entire vulvar hurts a patient, or it could be localized to a specific area in the vulva. So the pelvic floor musculature, which is a sling of muscles, can have trigger points just like any other muscle in the body. It can benefit from a release of the trigger point. Sometimes it’s myofascial release from a physical therapist and sometimes it can be from a trigger point injection performed by a physician, where you would like to break up the trigger point and release the tension, ultimately increasing blood flow to the area. And blood flow is healing and provides oxygenation and will overall make the muscles feel better.

Audio: Pelvic Floor Dysfunction

Pelvic Floor Dysfunction Video Transcription

Pelvic floor muscle dysfunction is dysfunction in the muscles of the pelvic floor. It can be something called hypotonic, where the muscles are extremely lax. And there is something called hypertonic. Pelvic floor hypertonia is where the muscles are short, spastic, and weaker, and essentially there’s reduced capacity for the muscles to lengthen. Therefore, they are not supporting the above structures as well as we would like them to be, including the bladder, the uterus, and the colon, as well as the hips and the lower spine and sacrum.

In addition, when the muscles are short, spastic, and weaker, there is less blood flow to the area. And when there’s less blood flow, there’s less oxygenation, and this can lead to a drop in the pH levels. And this essentially is what stimulates something called an inflammatory cascade. And when this whole inflammatory cascade is stimulated, you get release of these pro-inflammatory cytokines that we describe as an inflammatory seep, and this is what ultimately leads to neurogenic inflammation, where the nerves of the pelvis then start to fire inappropriately.

So the symptoms that can come with this are: rectal burning, rectal pain, pain with sitting, burning with intercourse, pain with bowel movements, urinary urgency, frequency, and burning with urination, all related to both the muscle dysfunction, where the muscles are in spasm and weaker, and then, eventually, over time, causing inflammation in the peripheral nervous system.

Audio: Pelvic Floor Nerve Hydrodissection

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Pelvic Floor Nerve Hydrodissection Video Transcription

Peripheral hydrodissection nerve blocks under ultrasound guidance are a simple day procedure that is not surgery. Patients go back to work the same day. In the nervous system, you have the central nervous system which is the spinal cord and the brain, and then you have the peripheral nervous system which is everything else that comes out of the spinal cord. In the pelvis, there are multiple nerves that come from the lumbosacral plexus to innervate the pelvis.

The goal of the peripheral hydrodissection nerve blocks is to create space in the fascial planes where the peripheral nerves flow, so there’s less restriction and ultimately more blood flow. In addition, the goal is to reset or retrain hyperactive peripheral nerves and also to decrease any inflammation that can occur around these peripheral nerves that all these things contribute to pain in the pelvis.

We treat an array of extremely complex, chronic pain symptoms, and we have a Triplex approach that is extremely safe and minimally invasive and effective.

Audio: Chronic Pelvic Pain Syndrome

Chronic Pelvic Pain Syndrome Video Transcription

Chronic Pelvic Pain Syndrome can originate for the male, it can originate from the prostate, in the testicles, from the epididymis. For the female, it can originate from the ovaries, or the uterus, or the vagina. It can originate from the intestines, or the muscular-skeletal system, or the neurological system, or colorectal system.

In terms of that, we would evaluate any system that we feel is necessary, and that requires an additional workup to see the cause of Chronic Pelvic Pain Syndrome. In addition to an underlying cause within the organ systems, lifestyle plays a large role with chronic pelvic pain, and by that we mean stress and how patients deal with stress, as well as their athletic ability and what they’re doing for athletics, whether it’s putting a lot of pressure on their pelvis in terms of microtraumas, or pressure on their coccyx, or pudendal nerve.

Nutrition plays a large role with chronic pelvic pain patients. Nutrition can help decrease inflammation in the body. Nutrition can help decrease different hormonal levels such as estrogen in the body, as some issues with pelvic pain are estrogen-dependent pathologies. Nutrition can also help affect the bladder. And there’s something called interstitial cystitis diet that can help calm down the bladder and stop irritating the bladder.

So those would be the lifestyle options for instigating and/or proliferating underlying pelvic floor muscle dysfunction and Chronic Pelvic Pain Syndrome.

Audio: Painful Bladder Syndrome

Painful Bladder Syndrome Video Transcription

Interstitial cystitis is also called chronic bladder pain syndrome, because essentially you’re constantly having pain in the bladder. It’s very common in people with endometriosis, and in fibromyalgia. And it can just be something that cripples people, in addition to having chronic pain in the pelvis and other places in the body.

The bladder rests right along the pelvic floor muscles, which wrap from the pubic bone in the front, to the tailbone in the back. And so, when the bladder is inflamed or irritated, it can irritate the muscles underneath, as well as some of the nerves and blood vessels that run close to it.

Painful bladder syndrome can often be misinterpreted as a urinary tract infection. The biggest difference is, on testing at the doctor’s office, you’ll get negative tests and negative cultures which can be really frustrating for both the patient and the doctor, as they’re trying to figure out what’s going on. And it’s very disabling, interrupts sleep, and can be very misunderstood by other providers on the medical community, who will again, often think that it’s a psychiatric issue or something else going on with the patient, that it has nothing to do with an actual physiological problem.

The potential signs and symptoms of painful bladder can be: frequent urination, only urinating in small amounts, burning with urination, feeling like the bladder’s full when its not. A lot of people would notice tenderness in the bladder.

There is a correlation in patients who have painful bladder syndrome and pelvic floor dysfunction. And sometimes we’re not sure which one came first, because we’re seeing patients so far down the road. But, the general belief is that if you have painful bladder syndrome it can cause pelvic floor dysfunction, and if you have pelvic floor dysfunction it can cause painful bladder syndrome. So typically, by the time we see patients they’re suffering from both at the same time, and so we work on treating both simultaneously.

There are many treatments for painful bladder syndrome and some of those may be medications or injections that can help release the pressure on the pelvic floor, which then relieves the pressure on the bladder that may be contributing to the frequency of urination and to the pain symptoms involved.

The road to relief from endometriosis and its related pain can be long and confusing. Listen to a patients journey over a decade period finding bringing her to a position of comfort. Endometriosis pain can manifest in many different ways, one being chronic pelvic pain and numerous other associated conditions.

Video: Endometriosis Pain Patient Testimonial

Audio: Endometriosis Pain Patient Testimonial

Endometriosis Pain Video Transcription:

My pain started even before, like, my menstrual cycle, so I was very young. At, like, 13, I had this, like, weird pain. And I remember my dad brought me to, like, the store before soccer practice, and he was like, “Get some Icy Hot. Maybe you tore a muscle.” And then once I had my menstrual cycle, it kinda evened out, but I was just, like, bedridden during my periods and everything. And I just thought that was normal. My mom said that she had bad periods, so I kinda just dealt with it.

And then I dropped to the floor one day because I had really sharp pain. I had, like, a cyst on my ovary that was the size of a grapefruit. So I had to have surgery for that, and they questioned endometriosis then. I didn’t know what endometriosis was. I was young still. I thought I would get better after the surgery just for the cyst. And then it would just get, like, worse and worse as the years went by.

So I had a partial hysterectomy when I was 17 or 18. No one should have to have a hysterectomy at 17, and that’s the whole reason why my endometriosis was never excised properly. And it’s common for it to resurface the worst ever after a hysterectomy. You get a few good years, amazing years, but then it comes back, and it hits you just like a tsunami, nothing like I ever felt before.

When I was in law school, I started bringing my heating pad to lectures, and I was, like, losing the battle. And that was the first time I had to, like, put my hands up. And I had to leave school, and couldn’t work, couldn’t even go to the store. I couldn’t eat. I was throwing up from the pain. That was the first time where I felt like, “This is the end.” I was like, “Is this gonna be the rest of my life?” And I was so, like, driven and stayed in school, so then people couldn’t understand socially, like, “Why can’t you just get better? You’ve had surgery.” You know? But they don’t understand, you know?

Some doctors feel like they’ve done all they can do, and they think that you don’t have it anymore. And he told me it was impossible that I had any endo again, and that’s a common theme. You’ll hear that a lot from specialists. I met Dr. Shrikhande through a mutual friend. She was wonderful and kind and warm. And this field is so dominated with males, and it was just so nice to have females to come to, and it was just a different atmosphere. The injections that she did, like, doing it how she did it and following her plan, finally, now, I’m feeling like my old self. So I call it “my flare of a lifetime.”

I feel like everything that occurred and happened to me was just creating, like, “the perfect storm” I like to call it. Even my family members were saying my personality was coming back. I was feeling better because the pain wasn’t at the forefront of my mind all the time. There’s no cure, and I’ll always have issues with the pelvic floor, but that’s why you see a specialist like Dr. Shrikhande.

She makes something that can be very awkward not awkward at all. She’s just very bright and warm, and no matter what state you come in seeing her, you leave feeling happy. And she’s very nurturing, and she makes you feel like it’s gonna be okay. She’s inspired me and has inspired me in how much she’s helped me. I wanna be able to help someone like that because I know what it feels like, and I wanna be able to help change someone’s life. She definitely gave me something back that I lost, and I’m so grateful for it, and I just can’t wait to see what the future holds.

So I’m excited for all the people that are going to benefit from this and feel like me and feel like they’re getting control back over their bodies and their life and have a say in it again. So yeah. I can’t put it into words. I love her, and the whole office is amazing.

Video: Pelvic Health and Rehabilitation Center

Learn about the leading Pelvic Health and Rehabilitation Center treating men and women with an array of pelvic health concerns. Dr. Allyson Shrikhande explains the new treatments they are designing and what to expect as a patient at Pelvic Rehabilitation Medicine.

Pelvic Health Rehabilitation Center Video Transcript:

Pelvic rehabilitation medicine is a practice that helps treat men and women who have pelvic pain from all conditions, from all the etiologies. And we are able to evaluate and help diagnose and treat the underlying cause. One of our goals is to bring exposure to a very misunderstood and misdiagnosed condition in the medical world. It can be very frustrating for patients with pelvic pain because often the imaging is normal, the blood work can be normal, all the cultures are normal.

When you come in into our office here at PRM, you’re greeted by a friendly welcoming staff who is empathetic and understanding that you are in pain and discomfort. We treat pelvic pain, but we understand and are aware of how chronic pain interacts with the rest of your body. And we listen to patients and really focus on them as a whole beyond their pelvis. Pelvic Rehabilitation Medicine was created really to end patients’ suffering and silence and to really let patients know that there are treatment options out there for them.

I really feel that if we can educate both the medical professions and patients that we can catch things earlier and allow people to suffer less and not feel that they’re alone and/or crazy. We’re lucky enough to work with some of the most amazing specialists in pelvic pain so we can help patients get better via teamwork. Being in New York City, we do treat patients from all over the country and really, all over the world. It’s not uncommon that people are flying in for consultations and then for their treatment protocol.

They are able to fly the same day as the treatment. So quite often patients will fly in, have the treatment and then be flying out later on that day, and that’s not a problem at all. At Pelvic Rehabilitation Medicine, we aim to create a calming and healing environment and help patients understand their pain, hopefully, find a diagnosis and then get them on the road to recovery.

Around 16 percent of the female population suffers silently with vulvar pain, yet there are some treatment options that provide efficacy and relief. A challenge of treating vulvar pain or vulvodynia is that patients are embarrassed to report their issue to providers — and it may also be difficult to convey and track symptoms of sporadic, intermittent episodes that are an indicator of this medical condition.

Talk to your provider or practitioner today, and get answers to common questions surrounding vulvar pain:

What is vulvodynia?

Vulvodynia is classified as chronic vulvar pain with no obvious cause, and only recently has it been identified as a chronic pain syndrome. Vulvodynia strikes women of all ages, with no predisposition for any race or ethnicity. There are basically two different types of vulvodynia, localized which impacts a specific area and generalized which may be indicated by roaming or inconsistent pain.

Where is vulvar pain felt?

Vulvodynia can be difficult to talk about, but there are options available from providers. Vulvodynia pain impacts the external female genitals, the vulva, including the labia, vaginal opening, and clitoris. Pain may target a specific spot, or as mentioned, could affect the entire vulva at different times, frequency and severity. The pain of vulvodynia has been described as burning or stabbing, which can make it difficult to diagnose.

How and when is vulvar pain felt?

The defining difference between chronic vulvodynia and other genital pain is the underlying cause: vulvodynia is a condition that lacks a concrete cause or reason. Women of all ages are at risk, and a genetic link has not yet been established. It is difficult to estimate the exact number of women impacted by chronic vulvar pain due to the sensitivity of the topic and reticence for many afflicted to seek treatment, however, it ranges from at least 200,000 to millions of women affected.

What are the risk factors?

While there is no known cause for vulvodynia, there are some factors that can increase or aggravate the condition. These risk factors make you more at risk of contracting chronic vulvar pain and that could increase the severity of vulvodynia symptoms during an outbreak. Some things that contribute to developing vulvodynia include trauma or injury to the vulvar, weak pelvic-floor muscles, nerve abnormalities or injury or a genetic predisposition that affects the body’s response to inflammation. Some other conditions that seem to correlate with chronic vulvar pain and vulvodynia include muscle spasms, frequent use of antibiotics, allergies, hormones or a history of sexual abuse.

What are your treatment options?

While treatment may not “cure” you of vulvodynia, it may reduce the frequency of symptoms and decrease the severity of the discomfort. Some recommended interventions include physical therapy, and potentially nerve injections, in some instances related to cases of nerve injury or physical trauma. Some other effective approaches to treatment include holistic methods like stress-reduction, meditation, and acupuncture. Some effective ways to reduce discomfort are to avoid irritants (hygiene products, tight clothing), relieve pressure (limit sitting, use cushions, loose-fitting underwear), and manage your pain, with medications or homeopathic options.

Severe cases of vulvodynia merit ultrasounds by your hip and pelvis specialist. They may also utilize trigger-point injections to reduce inflammation, reduce pain, and treat your vulvar pain.

Chronic pain can impact your mood, cause depression and deteriorate your overall quality of life; why suffer from vulvar pain any longer? Talk to your provider about treatment options for vulvodynia or seek the specialized attention and expertise in Pelvic Rehabilitation Medicine.

Chronic pain can throw your entire life into upheaval: Injuries incur hardship and cost money and time. Furthermore, pain cuts into your normal routine and lifestyle, often making activities, work and family time difficult and uncomfortable. Sometimes you can injure or pull a muscle, such as the piriformis muscle, which is located near your buttocks, that later impacts your mobility and causing chronic discomfort.

What Is Piriformis Syndrome?

Piriformis syndrome is a condition in which spasms occur in the piriformis muscle, creating pain in your buttocks. This muscle’s close proximity to the sciatic nerve also can contribute to the issue, causing nerve pain, tingling, and numbness in your foot and along the back of your leg. Piriformis targets the hip and pelvis area, which is what contributes to chronic pain and limited range of motion.

What Causes Piriformis Syndrome?

The causes of piriformis syndrome are unknown, though spasms in this area of the body and injury to the nearby joints and hip can contribute to the problem. Swelling can occur in the piriformis muscles, causing further irritation and tightening, which could exacerbate your symptoms and pain level.

Symptoms of Piriformis Syndrome

The symptoms of piriformis syndrome are hard to ignore. You may experience a dull pain in the buttock and increased discomfort when you climb stairs or walk up hills. Another common complaint of sufferers is discomfort when sitting or after extended periods of sitting. The symptoms also include decreased range of motion in your hip, which can impact overall mobility and movement, particularly for active individuals. Walking, jogging and running may worsen symptoms, and comfort might be found lying flat on your back.

The best way to determine if the pain you are experiencing is Piriformis Syndrome is to have an examination by a hip and pelvis specialist. They will be able to diagnose the condition before symptoms exacerbate.

Risk Factors of Piriformis Syndrome

The risk factors of piriformis syndrome are straight forward and can be common based on your lifestyle.

Childbirth
Deviated Coccyx
Pelvic Hypertonia
Trauma
Working Lifestyle

Relieve Symptoms and Treat Piriformis Syndrome

Treatment options vary depending on the severity of piriformis syndrome symptoms and can be noninvasive to quite aggressive. Catching this condition early and beginning treatment is key to preventing complex pelvic issues later on. Stretching exercises have shown efficacy in the piriformis muscle, also impacting the hips and hamstrings favorably. Physical therapy may be a useful recovery tool that educates the patient on how to properly do stretching exercises to bring comfort and promote healing.

Some practitioners may choose pharmacological interventions to help in the healing and recovery of the piriformis muscle. Anti-inflammatory medications can alleviate the swelling that co-occurs with this condition and could provide some pain relief. Some have found relief with deep-tissue massage therapy.

For more severe cases, steroidal and anesthetic injections may be a practical approach. The goal of treating with injections is to relieve pain long enough for the patient to participate in physical therapy, which will have more long-lasting repercussions. Botox is another injectable option that has been found effective at relieving pressure from the sciatic nerve, which may reduce overall pain in patients with piriformis syndrome.

Don’t live with the pain of piriformis syndrome one more day; look into Pelvic Rehabilitation Medicine to relieve your painful symptoms and regain your mobility. The longer you delay assessment and treatment, the more at risk you become for pelvic complications that could require more invasive procedures to alleviate, such as surgery or injections. Get help today and regain your range of motion pain-free with the help of professionals who have experience in this and other chronic pain conditions.

Relevant Publications/Citations

Shrikhande A, Ahmed T, Shrikhande G, Hill C. A Novel, Non-Opiod Based Treatment Approach to Men with Urologic Chronic Pelvic Pain Syndrome (UCPPS) Using Ultrasound Guided Nerve Hydrodissection and Pelvic Floor Musculature Trigger Point Injections. The International Continence Society. 2018 Aug. Link to Article.

Allyson Augusta Shrikhande, MD. Interviewee on Pelvic Health Summit – CPPS. Pelvic Health Summit. 2018 May. Link to Interview.

Allyson Shrikhande, MD sits as the chair of the Medical Education Committee for the International Pelvic Pain Society. Link to Medical Committee.

What is Complex Regional Pain Syndrome?

Complex regional pain syndrome (CRPS) is a chronic pain condition that most often affects one limb usually after a trauma. CRPS is characterized by prolonged or excessive pain and changes in skin color, temperature, and/or swelling in the affected area. CRPS is believed to be caused by malfunction of the nervous system. CRPS represents an abnormal response in the nervous system that amplifies the effects of an injury. As pelvic pain and health specialists, we treat many patients that have CRPS affecting the pelvic region. Whether from trauma or prolonged injury, we can help alleviate chronic pelvic pain.

What Are The Symptoms of Complex Regional Pain Syndrome?

Prolonged Severe Pain
May be described as burning or a “pins and needles” feeling
Spreads throughout entire limb
Allodynia, where normal contact with the skin such as soft cotton is experienced as extremely painful
Changes in skin color, temperature, or swelling
Changes in hair growth or nail growth patterns
Abnormal sweating
Stiffness in joints
Abnormal movements in the affected limb

Reflex Sympathetic Dystrophy Syndrome Risk Factors

We do not know why some people develop CRPS after trauma or injury and other’s do not. A prolonged injury or delayed treatment is the same way, some people develop CRPS while other’s do not.

What Are Some Options For Treatment of CRPS?

Physical Therapy: A physical therapy program to promote range of motion and movement of the affected body part can improve blood flow. Additionally, exercise can help improve the affected limb’s flexibility, strength, and function. Rehabilitating the affected limb also can help to prevent or reverse the secondary brain changes that are associated with chronic pain. Pelvic floor physical therapy is a key piece in the comprehensive treatment protocol we require of our patients.

Occupational Therapy: Occupational therapy can help the individual learn new ways to work and perform daily tasks.

Psychotherapy: People with CRPS may develop depression, anxiety, or post-traumatic stress disorder, all of which heighten the perception of pain and make rehabilitation efforts more difficult. Treating these secondary conditions is important for helping people cope and recover from CRPS.

Medications: Several different classes of medication have been reported to be effective for CRPS, particularly when used early in the course of the disease. However, no drug is approved by the U.S. Food and Drug Administration specifically for CRPS, and no single drug or combination of drugs is guaranteed to be effective in every person. Drugs used to treat CRPS include:

Bisphosphonates
Corticosteroids (in early stages)
medications used to treat neuropathic pain, such as gabapentin, pregabalin, amitriptyline, nortriptyline, and duloxetine
topical local anesthetic creams and patches such as lidocaine.

All drugs or combination of drugs can have various side effects such as drowsiness, dizziness, increased heartbeat, and impaired memory. Inform a healthcare professional of any changes once drug therapy begins.

Sympathetic nerve block: Some individuals report temporary pain relief from sympathetic nerve blocks, but there is no published evidence of long-term benefit. Sympathetic blocks involve injecting an anesthetic next to the spine to directly block the activity of sympathetic nerves and improve blood flow.

Additional Treatments Options:

Behavior Modification
Acupuncture
Relaxation techniques (such as biofeedback, progressive muscle relaxation, and guided motion therapy)

Emerging Treatments for CRPS Include:

Intravenous immunoglobulin (IVIG): Researchers in Great Britain report low-dose IVIG reduced pain intensity in a small trial of 13 patients with CRPS for 6 to 30 months who did not respond well to other treatments. Those who received IVIG had a greater decrease in pain scores than those receiving saline during the following 14 days after infusion.

Graded Motor imagery: Several studies have demonstrated the benefits of graded motor imagery therapy for CRPS pain. Individuals do mental exercises including identifying left and right painful body parts while looking into a mirror and visualizing moving those painful body parts without actually moving them.

If you are suffering from any pelvic health or pain concerns please contact Pelvic Rehabilitation Medicine today to get you on the path to finding relief.

Relevant Publications/Citations

Norman J. Marcus, MD Allyson Augusta Shrikhande, MD Bill McCarberg, MD Edward Gracely, PhD. A Preliminary Study to Determine if a Muscle Pain Protocol Can Produce Long-Term Relief in Chronic Back Pain Patients. Pain Medicine. 2013 Aug; 14(8): 1212–1221. Link to Article.

Allyson Augusta Shrikhande, MD, Robert A. Schulman, Brian S. Lerner, Alex Moroz. Acupuncture for Treatment of Chronic Low-Back Pain Caused by Lumbar Spinal Stenosis: A Case Series. Medical Acupuncture. 2011 Sep; 23(3). Link to Article.

Dr. Tayyaba Ahmed was featured on Carly Snyder, MD’s MD for MOM radio show. Here is the description of that show:

This week on MD for Moms, I’ll be interviewing Dr. Tayyaba Ahmed about pelvic pain. Having a baby can cause pelvic discomfort or even pain, but is rarely permanent. What happens when the pain does not go away? How about pelvic pain not associated with pregnancy? Learn the causes and types of pelvic pain and also ways to treat it on this week’s MD for Moms.

LEARN MORE ABOUT MY GUEST, DR. TAYYABA AHMED:

Dr. Tayyaba Ahmed is a doctor of physical medicine and rehabilitation who was born and raised in New York. She completed the BS/DO program at New York Institute of Technology and was trained at the New York College of Osteopathic Medicine, Northwell Health Plainview Hospital and the NYU Langone Medical Center/RUSK Institute for Rehabilitation.

A board certified Physical Medicine and Rehabilitation physician, Dr. Ahmed is also a fellow of the Academy of Physical Medicine and Rehabilitation and a member of the International Pelvic Pain Society.

Dr. Ahmed is a contributing author to a textbook which is considered a staple during every Physiatrist’s training. The fourth edition is currently in press and scheduled to publish in the spring of 2019. This full title reference is: Ahmed T, Chan I: “Pelvic Pain”, Essentials of Physical Medicine and Rehabilitation, 4th edition by Frontera W, Silver J, Rizzo T; Elsevier, Philadelphia, In Press.

After spending the last five years honing her skills in outpatient care, Dr. Ahmed is ready to focus on her passion for treating pelvic pain. Dr. Ahmed has chosen a focused practice, because she believes concentrating on a specific field creates the greatest expertise. Chasing that greatness has been her consistent driving force.

How is a Pelvic Pain Doctor Different From Other Specialists?

If you’ve experienced pelvic pain before, you understand how debilitating it can be. It’s especially common in women, but can also occur in men. Pelvic pain can be acute (lasting for a short period of time) or chronic (lasting six months and more). Learning how a pelvic pain doctor is different that other specialists may help you find the care you are looking for.

While your gynecologist or personal doctor can treat acute pelvic pain with medication, chronic pelvic pain is better dealt with by a pelvic pain specialist. Unfortunately, there’s a lot of misinformation out there about pelvic specialists, which can lead to a series of misdiagnoses and worsening pain.

If you’re dealing with pelvic pain, or know someone who does, this article will explore pelvic pain and how a pelvic doctor differs from your local specialist.

Understanding Chronic Pelvic Pain (CPP)

Chronic pelvic pain generally lasts for more than six months. It can be very difficult to pinpoint the exact cause because it’s often the result of many things happening at the same time. And with this type of pelvic pain, it’s entirely possible that the original source of pain may have been dealt with (or healed on its own), yet the pain remains.

Unlike cancer or heart disease diagnosis, tests by your doctor may not result in an accurate diagnosis for your pelvic pain. Even a pelvic pain specialist will need to understand your medical history to get a bearing on what the problem might be. And whatever cause, your pelvic doctor identifies could be just one in a series of problems.

In short, CPP is often unexplained severe pain that can directly affect your muscles and nerves. This condition is often characterized by four levels of increasing pain:

Original injury – CPP can be as a result of a current or previous injury resulting from endometriosis, appendicitis, adenomyosis, Crohn’s disease, colon cancer, bladder or bowel infections, cysts, scar tissue or other complications.
Transferred pain – This level of pain occurs when the original injury pain lasts a long time. As a result, the visceral nervous system comes into contact with the somatic nervous system, transferring the pain back to the pelvis and abdomen. For instance, if you have a resolved uterine problem but the pain remains, you’re at this pain level.
Trigger points on the abdominal wall – After the pain is transferred to the pelvic area, the muscle wall of the abdomen experiences tenderness in specific areas. These are trigger points and explain the pain when you or a pelvic specialist pushes down on an affected area. This could be a major source of pain. One of your treatments is directly aimed at relieving the pain and tension caused by trigger points.
Psychological pain – If your pelvic doctor tells you that your severe pain may be more psychological than physical (often called psychosomatic), don’t take offense. Since your nerves and brain are connected to the spinal cord, the state of your mind could lead to increased pain. In such a case, your pelvic doctor may recommend psychological counseling or physiotherapy.

How a Pelvic Doctor Differs From Other Specialists

With an understanding of how chronic pain can vary dramatically from person to person and between men and women, let’s take a look at how pelvic doctors are uniquely equipped to help treat and manage pelvic pain:

1. A Pelvic Doctor Understands All Possible Complexities

Going to your primary care provider for CPP is like visiting your local dentist to get a root canal. You believe they’re qualified to help, but in reality, they lack the necessary specialized training. To have a root canal, you’d need an endodontist and not a regular dentist.

In the same way, if you experience pelvic pain for more than six months straight, you’ll want to see a pelvic specialist. A pelvic doctor understands exactly how to deal with any problems related to pelvic pain, including musculoskeletal pain, endometriosis, vulvar pain disorders, painful bladder syndrome, and peripheral neuralgias, among others.

2. Primary Physicians May Not Know How to Control the Pain

A primary physician will almost always focus on the most probable causes of your pain, ignoring psychological factors. But managing psychosomatic pain plays a big part in reducing pelvic pain and improving your quality of life.

According to the International Pelvic Pain Society, CPP can lead to depression, trouble sleeping, lack of appetite, anxiety, and general changes in behavior. A pelvic pain doctor is trained to look for these symptoms and recommend suitable treatment immediately.

3. A Pelvic Doctor Will Avoid Unnecessary Surgery

If you look at the common diagnosis of CPP, endometriosis leads the list for women. This is a condition where the lining of the uterus or similar tissue grows in other parts of the body. Research shows that at least 176 million women around the world suffer from this condition.

To treat this condition, surgery is required to remove the tissue. Unfortunately, only a third of these surgeries result in relief. In addition, CPP is the reason for up to 12% of all hysterectomies. Yet 22% of post-hysterectomy patients still report pelvic pain.

For men the pain can be just as prevalent, but less understood and treated. It is estimated that 10-12% of the male population suffers from chronic pelvic pain. But because of the sensitive nature of the issues, there are only 2 million outpatient visits a year. That is less than 1% of the male population suffering from chronic pelvic pain.

These stats demonstrate the elusiveness, sensitivity and misunderstanding around CPP. If you or your doctor are unsure or have been unsuccessful in treating your pelvic pain it is best to contact a specialist.

Always Look Out For Yourself as a Whole

Treating CPP is “like peeling the layers of an onion”. With one solution often comes another problem. This is because the pain can stem from multiple sources or one distinct source, but it’s often nearly impossible to tell the difference.

That’s why you should always consider seeing a pelvic doctor, even if just for a second opinion. These specialists are equipped to help you manage pelvic pain in the best way possible while working towards a long-term treatment plan.

We Are Doctors Who Specialize Pelvic Pain

At Pelvic Rehabilitation Medicine, we only treat pelvic pain and pelvic related conditions. All of our doctors are pelvic specialists, and more importantly, pelvic pain specialists. We treat a wide range of male pelvic pain and female pelvic pain conditions, including Hypertonic Pelvic Floor, Levator Ani Syndrome, Vulvar Pain and Vulvodynia, PGAD, Pudendal Nerve Entrapment, Fibromyalgia and Pelvic Pain, and many others.

Women with Persistent Genital Arousal Disorder typically develop symptoms of spontaneous arousal suddenly. Often times they are confused and unsure of what is going on. They typically try to see their primary care doctor or make an urgent care appointment soon after the onset, to figure out what is happening to them. More times than not, the doctor or nurse practitioner they see, has no idea what is going on based on their description. If they see a general internist they may be referred to a Gynecologist or even a psychiatrist.
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Treat Persistent Genital Arousal Disorder, Not Its Symptoms

Sometimes they are given lidocaine cream to numb their symptoms, which does not treat the problem, but only mask it. Most medical professionals we speak to, have no idea what it is and often think it is a hyper-sexuality disorder or laugh and say how that sounds like a “good problem”. Unfortunately, with the little literature out there, patients often feel helpless and discouraged. The truth of the matter is, persistent genital arousal disorder is unwanted, unpleasant and disruptive for every single woman that has it.
[/et_pb_text][et_pb_text _builder_version=”3.9″]A quick google search of PGAD, brings up limited articles, most of which do not give any hope for treatment. The reality is most women who do have this condition, do not want to talk about it, out of fear of what others may think. Women with PGAD may not realize the causes which could be pudendal neuralgia, repetitive stress to the groin area, weening off anti-depressants, or a Tarlov cyst. Women suffering with PGAD have no support groups or outlets to discuss their condition and often leads to anxiety and depression.

Pudendal Neuralgia Repetitive Stress to Groin Area Weening off Anti Depressant – Tarlov Cyst

Treatment options for Persistent Genital Arousal Disorder

However, there is treatment for PGAD, and we have had success with treating our patients with PGAD depending on the chronicity of their symptoms. It is important for women with persistent genital arousal disorder to know that there are treatments options and that research is being done on this disorder, so they know that this condition isn’t hopeless. Our treatment protocols can range from yoga routines to ultrasound guided trigger point injections but all aim at releasing the compression in the pelvic floor muscles. If you have been diagnosed with PGAD or suffering from its symptoms contact Pelvic Rehabilitation Medicine today.

Relevant Publications/Citations

Walter Frontera, Julie Silver, Thomas Rizzo,Tayyaba Ahmed, Isabel Chan. Musculoskeletal Disorders, Pain, and Rehabilitation. Essentials of Physical Medicine and Rehabilitation. 2018 Nov; 4(107): 587-595. Link to Article.

Ahmed T. Interviewee on Pelvic Health Summit – Pelvic Pain and Sexual Health. Pelvic Health Summit. 2018 May. Link to Interview.

How does chronic prostatitis and pelvic pain overlap?

Chronic nonbacterial prostatitis or chronic abacterial prostatitis is a common condition that causes pain and inflammation in the prostate and the lower urinary tract in men. The prostate gland is located right below the bladder in men. It produces fluid that helps transport sperm.

In chronic abacterial prostatitis the condition is ongoing and not due to a bacterial infection. Often times patients are seen by their urologists and worked up for an infection, but despite treatment, they continue to have stomach and pelvic pain.

Many causes of chronic abacterial prostatitis include nerve irritation, chemical irritation, stress and often a weak and spastic pelvic floor. When the muscles are in constant spasm the pain has little chance of improving as the ureter travels through the pelvic floor muscles.

Some symptoms patients with chronic abacterial prostatitis present with are:

Urinary urgency painful urination
burning upon urination, urinary frequency
difficulty starting urination, weak urinary stream
frequent need to urinate at night
low back pain
painful ejaculation
pain in the perineum ( the area between anus and scrotum)
pain in the testicles
pain in the penis
pain in the groin

We at Pelvic Rehabilitation Medicine work hand in hand with the best urologists and urogynecologists in the tri-state area to evaluate and work up our patients for the cause of their chronic pelvic pain. Once our imaging and any testing that is required is complete, we can make a treatment plan with all the members of our team, including the pelvic floor physical therapist, urologist, and any other providers.

Relevant Publications/Citations

Allyson Augusta Shrikhande, MD. Interviewee on Pelvic Health Summit – CPPS. Pelvic Health Summit. 2018 May. Link to Interview.

Allyson Shrikhande, MD sits as the chair of the Medical Education Committee for the International Pelvic Pain Society. Link to Medical Committee.

Can Your Pelvic Floor Muscles Be Contributing To Erectile Dysfunction Pain?

Erectile dysfunction is defined by the National Institute of Health as the “inability to achieve or maintain an erection sufficient for satisfactory sexual performance”.

It may affect 10% of healthy men and an increasing number of men with co-morbidities such as high blood pressure, diabetes and heart disease.

Pelvic Floor and Erectile Dysfunction

Trigger points and subsequent weakness in the pelvic floor muscles can play a role in the venogenic form of erectile problems. The bulbocavernosus muscle of the pelvic floor compresses the deep dorsal vein of the penis to prevent the outflow of blood from an enlarged penis. If there is a weakness in the pelvic floor and in particular the bulbocavernosus muscle outflow of blood may not be prevented as well, leading to erectile dysfunction.

Due to the fact that the pelvic floor muscles play a role in sexual activity, the British Journal of internal medicine published a study in 2005 suggesting pelvic floor physical therapy as a first line agent in treating erectile dysfunction. A full urological workup should first be performed in patients with erectile issues, a referral to a pelvic floor specialist may be the next step.

Erectile Dysfunction Causes

The underlying causes of ED are commonly classified as neurogenic, arteriogenic, venogenic, or psychogenic.

Erectile Dysfunction Risk Factors

The risk factors for erectile dysfunction are:

Pelvic floor muscle spasms
Decreased blood flow
Age
Stress
Gender
Sedentary lifestyle

At Pelvic Rehabilitation Medicine we center ourselves as the guide with your pelvic floor pain and conditions. If you are having erectile dysfunction and/or pelvic floor concerns please contact our office. We can assist in setting up urological work or provide additional insight if you have already seen other specialists.

Relevant Publications/Citations

[/et_pb_text][et_pb_blurb url=”https://www.ics.org/2018/abstract/306″ url_new_window=”on” image=”https://www.pelvicrehabilitation.com/wp-content/uploads/2019/02/ics-logo.jpeg” icon_placement=”left” image_max_width=”65px” content_max_width=”100%” admin_label=”T1 – TA – Nerve Hydrodissection and Pelvic Floor Musculature Trigger Point Injections” _builder_version=”3.26.6″ global_module=”9740″ saved_tabs=”all”]

Ahmed T. Interviewee on Pelvic Health Summit – Pelvic Pain and Sexual Health. Pelvic Health Summit. 2018 May. Link to Interview.

Can Pain With Intercourse Come From Your Pelvic Floor Muscles?

Dyspareunia, painful sexual intercourse has been shown to affect between 8-21% of women. There are numerous physical, psychological, and social causes of pain with intercourse. A gynecological exam is the first place to start if a person is experiencing pain with intercourse. If the gynecological examination and work up are normal the pain with intercourse may be attributed to spasm in the muscles of the pelvic floor.

What Causes Pain During Intercourse?

Pelvic pain, in particular, can result from:

Pelvic Inflammatory Disease

Scarring of ligaments from childbirth or pelvic surgery

Tightening of the pelvic floor muscles

Pain during intercourse may also point to other pelvic conditions, including:

Chronic Pelvic Pain Syndrome (CPPS): A condition that involves regular pain in the pelvic region

Pudendal neuralgia (PN) or pudendal nerve entrapment (PNE): Both involve stress on the pudendal nerve which runs between the anus and the genitals

Piriformis Syndrome: The compression of the piriformis muscle and sciatic nerve in the buttock

Pain During Intercourse Can Be Due To Conditions/Symptoms:

Vulvodynia: chronic vulvar pain with no discernable cause that may be the result of sex-related nerve injury or irritation

Vaginismus: painful vaginal contractions that may be a result of performance anxiety, often treated with Kegel exercises

Levator Ani Syndrome: a type of chronic proctalgia (or recurrent rectal pain) in which a muscle in the pelvis is often sensitive and sore\

Dyspareunia Risk Factors:

Gynecologic Disorders
Endometriosis
Chronic Prostatitis
History of STD
Pelvic Floor Spasm/Hypertonia
Hermia

Pelvic Floor Pain Specialists

Pelvic floor physical therapy and a physiatrist who specializes in the treatment of the pelvic floor may be able to help relax the spasms. The involuntary spasm during penetration, whether it is intercourse, a gynecological exam or the use of a tampon can restrict penetration and be painful. Relaxation of the pelvic floor muscles is obtained by teaching proper breath

ing techniques, improving posture and biomechanics of the pelvis, myofascial release of muscle trigger points, muscle relaxers in both the oral and suppository form, as well as trigger point injections to specific tight muscles that are no responding to manual release.

Approach To Pelvic Floor Pain During Intercourse

A team approach is important in treating patients with dyspareunia, addressing stress management, nutrition, exercise, relationship, and psychological health are important in obtaining a global picture of a patients overall wellbeing in order to get them on the path to recovery.

Relevant Publications/Citations

Ahmed T. Interviewee on Pelvic Health Summit – Pelvic Pain and Sexual Health. Pelvic Health Summit. 2018 May. Link to Interview.

Medical Education Committee

Visit the International Pelvic Pain Society site »

Why is Endometriosis Painful?

Some patient’s with endometriosis have pain. The theory is that patients who have endometriosis that is infiltrative in nature can stimulate nociceptors directly and stimulate the inflammatory cascade causing pain. While pain is often associated with endometriosis, the exact reason why endometriosis is painful is not always talked about.

Infiltrative endometriosis is considered a noxious stimuli, an event that is or can be damaging to the tissues in the body. Physiatrist, Dr. Allyson Shrikhande, describes the tissue damage that occurs from endometriosis as a trauma to the body. It causes the nervous system to be in an excitable state and also starts an inflammatory cascade.

Anesthesiologist, Dr. Gerard DeGregoris, compares the direct invasion of very sensitive structures by endometriosis and the ensuing inflammatory response to getting hit with a hammer. When you get hit with a hammer, inflammation, a complex biological response of tissues to harmful stimuli, occurs in the form of heat, redness, swelling and an uncomfortable sensation. When a trauma occurs to tissues in the body, there is a direct stimulation of nerve fibers called nociceptors. When these nerve fibers are stimulated they transmit a pain impulse to the brain. Dr. DeGregoris explains that we developed these pain filled inflammatory responses so that we can be aware that tissue damage has occurred in order to try and protect our bodies from harm.

Types of Pain

Dr. DeGregoris explains how there are two types of pain associated with endometriosis, nociceptor pain and neuropathic pain. Nociceptor pain is caused by the direct damage of tissue from endometriosis. The sensations associated with this type of pain are usually sharp, aching or throbbing pains. Neuropathic pain is another type of pain that endometriosis patients often experience. This pain can occur even after excision of the disease, as neuropathic pain can last even after inflammation and the direct trauma to the body is gone. The sensations associated with neuropathic pain are heavy, stabbing or burning feelings.

How does Endometriosis Excision Help Pain?

Endometriosis excision surgery by an expert doctor is considered the gold standard of treatment for patients suffering from the disease. Excision works to remove the disease, or the noxious stimuli, from the body. Dr. Shrikhande works with many endometriosis patients in her practice in New York City, “I have seen patient’s pre and post operatively, after a proper excision treatment. A proper excision surgery gets rid of the noxious stimuli and stops the persistent inflammatory response.”

It should be noted that some patients are told that a hysterectomy can cure their endometriosis. If the uterus and ovaries are removed, but if endometrial implants are left in the pelvis, these noxious stimuli will continue to cause pain in patients.

Reasons for Pain Post Excision

Unfortunately, some patients who have endometriosis excision, with even the most expert surgeon, may still experience pain. This can be devastating and confusing to patients. While persistent disease and adhesions from surgery are possible causes for pain that should be explored, there are also many other reasons endometriosis patients may experience pain after complete excision.

Patients need to assess whether or not they could have other common co-current conditions that cause pain. Adenomyosis, interstitial cystitis and pudendal neuralgia are examples of conditions which can be found in endometriosis patients that often mimic endometriosis pain.

In her practice, Dr. Shrikhande sees how pelvic floor muscles are intimately involved with the suffering endometriosis patients endure. Dr. Shrikhande explains to patients how muscles contract in a linear pattern, similar to the pattern of a railroad track. When a patient has a trigger point, the pattern is no longer linear and is in disarray. A trigger point is a palpable taut band of muscle. When you touch the trigger point you get a twitch response and you also may get a referred pain pattern. Physiatrists work in conjunction with pelvic floor therapists to identify trigger points and which muscles in the pelvic floor are causing pain.

Dr. Sallie Sarrel is a pelvic floor therapist that focuses on pelvic pain, “The cause of pelvic pain is multi-faceted. Even after disease has been removed pain may remain.” Dr. Sarrel talks about studies that demonstrate how endometriosis causes higher tone throughout the pelvic floor. High tone increases the likelihood of painful spasms. She also addresses how the average diagnostic delay of 8-10 years warps the body and adversely impacts the way the pelvic floor functions. The body forms reactive adaptations to the inflammation, peritoneal insults, adhesions and constant pain signals caused by endometriosis. Dr. Sarrel has found in her practice that surgery alone cannot always fix these adaptions.

A diagnostic delay and a delay in having complete excision of endometriosis can transform the acute pain patients experience to chronic pain. Dr. DeGregoris explains that when inflammation goes from acute to chronic, prostaglandins tend to be overproduced by tissue and an up regulation of estrogen then maintains chronic inflammation and chronic pain. Dr. Shrikhande discusses how chronic pain can cause allodynia, a condition in which a stimuli that is not usually painful, becomes painful. Chronic pain can also cause hyperalgesia, a condition in which patients experience stimuli as extremely painful that most others find mildly painful. Once pain moves from acute to chronic, this pain state gets stored in the brain and becomes the patients new normal.

Treatment Options for Pain

An Anesthesiologist Perspective: Dr. DeGregoris uses different medications to help both the nociceptor pain and the neuropathic pain that endometriosis patients feel. Most doctors treat patients who present with painful periods with different hormonal treatments, as well as over the counter pain medicines. Anti-inflammatory NSAIDs block the conversion and liberation of prostaglandins. Working within 1-2 hours, NSAIDS are well absorbed, but too many can cause gastrointestinal issues. Naproxen is also well absorbed but is easier on the stomach. Acetaminophen is the safest pain medication for those patients who are trying to conceive.

Dr. DeGregoris also recommends pain agents such as Gabapentin and Lyrica which can help patients with neuropathic pain. Side effects of the medications can include dizziness, sedation, clouded-thinking and weight gain. Giving patients tricyclic anti-depressants, in a dosage far below what is used to treat depression, can also be effective for pain with the occasional side effects of sedation, dry mouth and confusion. SNRI (Cymbalta) was also designed primarily as anti-depressant but has been found to decrease the amount of pain impulses that make it up to the brain. One possible risk of SNRI’s is that this medication can cause serotonin syndrome. SSRI’s are another class of medications that are used primarily as anti-depressants, but are also effective in treating chronic pain.

Opioids are often seen as a controversial drug to treat pain. Dr. DeGregoris believes that if opiates are used with the guidance of a physician, they can be used safely. He believes they are ideal for postsurgical pain and episodic pain. He stresses that opioids are not ideal for long term relief because the more a patient takes them, the less pain relief she will get from them. When you take opioids chronically, your body becomes less receptive to their benefits. There are also significant side effects to these drugs such as respiratory depression, hormonal imbalance, opioid induced constipation and urinary retention. For some patients who are having worsening pain after opiates, or pain that does not improve, it is worth a try to decrease the dose to see if pain decreases or remains the same.

A Physiatrist Perspective: Dr. Shrikhande uses many different techniques to help endometriosis patients reduce their pain. She finds muscle relaxers (oral or suppository) helpful for patients. For patients with pelvic floor pain, Dr. Shrikhande starts with a suppository made of combined valium and baclofen. She also utilizes ultrasound guided trigger point injections such as Lidocaine. Topical medications made by compounding pharmacies can be quite beneficial to treat patients. Mixtures using Gabapentin or Lyrica, mixed with lidocaine or baclofen or even a NSAID’s are quite helpful for patients. For patients with vulvodynia, mixing compounds in olive oil reduces irritation.

Dr. Shrikhande not only utilizes medications, but encourages patients to engage in cognitive behavioral therapy, guided imagery, meditation and lifestyle modification to reduce pain and inflammation. She encourages patients to go to acupuncture to help desensitize the nervous system. She feels that learning the proper breathing technique can relieve the pressure and pain caused by tensions in the pelvic floor and may be the fastest way to help. Dr. Shrikhande works hand in hand with pelvic floor physical therapists to help patients with their lingering pain after surgery.

A Pelvic Floor Therapist Perspective: Dr. Sallie Sarrel states that “Pain is the sign that something in our bodies is wrong. When you have endometriosis, you have been sending that signal for so many years that your brain has gotten simply overwhelmed. You need to send a different signal and you need to use something to send a different signal. Pelvic Physical Therapy is one of the things that can mediate that pain signal.” She stresses that therapists need to have advanced and specialized training beyond doctoral education to evaluate and treat dysfunction of the pelvic floor muscles. Pelvic floor therapists should teach patients postural re-education, muscle relaxation, education for bowel and bladder issues, strengthening exercises and how to use the body to empower oneself over pain. Treatment may include deep tissue massage, internal or external, mobilization, joint manipulation, soft tissue mobilization, sensory, motor and sympathetic and parasympathetic nerve re-training.

The Cause and Cure for Pain

Endometriosis is a complex disease to treat. While endometriosis excision surgery is the gold standard of treatment and does relieve a significant amount of pain, sometimes pain still lingers. There seems to be many reasons why patients are in pain and an equal amount of possible solutions to reduce pain. Dr. Shrikhande concludes by saying, “Pain is so complex. When managing pain, it is really important to draw in a multispecialty group and work in collaboration. So many different factors are involved in a patient’s perception of pain. Regulation of stress, nutrition, diet and exercise all play a strong role in a patient’s quality of life and the perception of their pain.”

These lectures were presented at the annual Endometriosis Foundation of America Patient Awareness Day. For more lectures and more information about the work the EFA does and how to support it go to www.Endofound.org.

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British researchers used Dysport to bring long-term relief for common ailment of physically active people

Please note: This article was published more than one year ago. The facts and conclusions presented may have since changed and may no longer be accurate. And “More information” links may no longer work. Questions about personal health should always be referred to a physician or other health care professional.

MONDAY, Feb. 22, 2016 (HealthDay News) — A Botox-like injection, added to physical therapy, may relieve a type of knee pain that’s common in runners, cyclists and other active people, a new study suggests.

The condition — called lateral patellofemoral overload syndrome (LPOS) — affects more than one in eight people who regularly exercise, the British research team explained. The condition causes pain in the front and side of the knee joint, and healing can be a challenge, experts said.

“Knee pain in runners and cyclists is often difficult to treat,” said Dr. Victor Khabie, chief of sports medicine at Northern Westchester Hospital in Mount Kisco, N.Y. “Most will respond well to traditional therapy, but some will continue to have pain.”

According to the study authors, prior research has shown that 80 percent of people with LPOS have ongoing symptoms after undergoing conventional treatment, and 74 percent have reduced activity levels. Current methods of treatment include physical therapy, anti-inflammatory drugs and steroid injections. If these therapies fail, patients may opt for surgery, according to the investigators.

The new study was led by researchers at Imperial College London and included 45 patients. Each received an injection of a type of botulinum toxin called Dysport to relax a muscle at the front and outside of the hip, followed by physical therapy sessions.

The hip was targeted because, in prior research, the researchers had noted that people with LPOS tended to overuse this particular hip muscle, instead of using the gluteal muscles in the buttocks.

According to the investigators, two-thirds (69 percent) of the patients required no further treatment and were free of pain when assessed five years after the injection into the hip muscle.

“It can be incredibly frustrating to run out of treatment options for patients with this painful condition,” said study co-author Jo Stephen, a physiotherapist at Imperial College London and Fortius Clinic.

In a college news release, she said that “many athletes who took part in this study had exhausted all other treatment options and this was their last resort. We are really excited that our approach is showing positive results for patients, which could have implications for active people around the world.”

Khabie agreed. “This is a very important finding, because in the past surgery was the only other option [for these patients],” he said.

The Dysport injection “relaxes a very tight muscle/tendon unit on the outer aspect of the leg, which is often very tight in runners and cyclists,” Khabie explained. “Physical therapy aims to relax this muscle, but when therapy is not enough, this study shows that [the] injections are an option.”

Dr. Allyson Shrikande is a physiatrist (rehabilitation specialist) at Lenox Hill Hospital in New York City. She believes that use of the injection “offers a wonderful solution to aid in those who have failed a course of physical therapy.”

But, Shrikande also cautioned that the injected toxin may “spread” to adjacent tissue and so the “optimum dose” needs to be determined for each patient.

The study was funded by the Fortius Clinic and Chelsea and Westminster Hospital in London.

SOURCES: Victor Khabie, M.D., chief, department of surgery, and chief of sports medicine, Northern Westchester Hospital, Mount Kisco, N.Y.; Allyson Shrikhande, M.D., physiatrist, Lenox Hill Hospital, New York City; Imperial College London, news release, Feb. 22, 2016

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Suffering from back pain on the left? Or is the pain on the right? The location of your pain can help identify its cause and help determine the best treatment.

Up to 80 percent of U.S. adults suffer from back pain at some point in their lives, according to the American Chiropractic Association. And when your back hurts, the first thing on your mind is how to feel better fast.

Pinpointing the exact location of your back pain can help you work out the cause, because different types of pain can affect different parts of the back. And determining the culprit can lead you to the right treatment and feeling better sooner.

Common Types of Back Pain

When you overdo it —whether during everyday activities, vigorous exercise, or playing sports —your back can suffer. It’s possible to sprain or strain your back, or even cause a disk (one of the cushions between your vertebrae) to pop out of place and press on a nerve, a condition known as a herniated or bulging disk.

Depending on the mechanics of the activity that caused your injury, any part of your back can be affected, causing left back pain, right back pain, upper back pain, or lower back pain. And sometimes it’s not just your back that hurts —your groin or legs and feet can feel the pain, too. Classic types of back pain include:

Back strains and sprains. While a sprain or strain can affect any part of the back, this type of injury typically causes pain that gets worse with movement. Other symptoms include muscle cramping, sudden uncontrollable muscle spasms, and difficulty standing, walking, or bending forward or sideways. According to the Association of Neurological Surgeons, muscle strains and sprains are the most common causes of low back pain. This type of pain usually lasts no longer than two weeks.
Acute back pain. This is short-term pain that’s usually caused by some sort of injury to the back — from playing sports or working around the house, or from a sudden jolt such as a fall or a car accident. Arthritis also can cause acute back pain. Symptoms typically last from a few days to a few weeks. The most common kind of acute back pain is mechanical, which means it begins in the bones, ligaments, disks, membranes, or joints of the back. As with sprains and strains, you can feel this type of pain throughout your back, depending on where the injury occurs. If you have mechanical back pain, you may also experience muscle spasms in your lower back when you try to lift something heavy or move your back more than usual.
Sciatica. The sciatic nerve runs down the backs of both your legs. Sometimes, parts of the sciatic nerve can get irritated or compressed, causing a type of pain known as sciatica. Sciatica typically begins in your lower spine and radiates down to your buttocks and the back of one of your legs. “The most common reason for this is a bulging or herniated disk,” says Allyson Shrikhande, MD, a physiatrist at New York Bone and Joint Specialists in New York City. Sciatica can cause a range of other symptoms, from a mild ache to extreme discomfort. Coughing or sneezing can make sciatica symptoms worse, as can sitting in one position for a long time. Other symptoms, like numbness, muscle weakness, or a tingling sensation in the leg or foot are also common with sciatica. A review of scientific studies published in 2014 in the American Journal of Epidemiology found that being overweight or obese were risk factors for developing this type of back pain.

When to See Your Doctor About Back Pain

Some back pain symptoms—and the location of these symptoms —are cause for greater concern. Although rare, back pain can be a symptom of a more serious medical condition, and you should seek medical attention promptly if:

You have back pain that spreads down your legs, especially if it spreads below your knee. This could be a sign that you have a bulging or herniated disk.
Your legs are weak, numb, or tingling. This means that there is involvement of the nerves and requires immediate attention.
You have new bowel or bladder problems. This could signal a serious problem called cauda equina syndrome, a rare disorder that affects the bundle of nerves at the base of your spine and requires emergency medical attention.
You have blood in your urine. This may be a sign of kidney stones. Kidney stones can cause sharp back pain that may become worse during urination. The pain is usually on one side.
You have a fever or abdominal pain. This could be a sign of an infection or a condition that requires surgery, such as appendicitis. Infections of the vertebrae, disks, or even the pelvis or bladder can also cause back pain.
You have had a fall or an injury to your back. Your doctor should evaluate you after any new injuries.
You have been losing weight and can’t explain why. This could be a sign of cancer of the colon, rectum, or ovaries.
The pain is a deep, dull ache in one specific spot over a bone, or it is continuous, even when you lie down and at night. These could be a sign of a tumor in the bone.

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Manipulating the spine can help people with lower back pain — but it doesn’t work for everyone, according to a new study.

Spinal manipulation, or applying force to the joints of the spine, is a technique commonly used by chiropractors and physical therapists, according to the National Center for Complementary and Integrative Health. However, there is conflicting evidence about whether the treatment actually helps people, the researchers wrote in their study.

In the new study, the researchers found that spinal manipulation therapy (SMT) provided relief for some patients with lower back pain, but not for others.

“The big finding is that both sides have been right all along,” said Greg Kawchuk, a professor of rehabilitation medicine at the University of Alberta and co-author of the study. It’s not a matter of whether the treatment works or doesn’t work, but rather, figuring out the best way to care for each patient, he said.

In the study, 32 people with lower back pain received two spinal manipulation treatments over the course of a week. They told researchers how much pain they felt, and the researchers also looked at objective measures of improvement, including measurements of muscle activity, disc hydration and spinal stiffness. A control group of 16 people underwent similar physical examinations, but did not receive treatment. A third group, of 59 people who did not have back pain, was also included, to provide another comparison.

Among the participants who underwent the spinal manipulation treatments, 15 said that they felt better, and the researchers found that their physical measurements all improved as well, Kawchuk told Live Science. For example, their measurements of disc hydration and spinal stiffness were nearing those of the people without any back pain at the end of the study, he said.

The people who said they did not feel any better did not have those physical changes, Kawchuk said.

It’s unclear why the treatment worked for some patients but not others, but one idea is that the people who felt that the treatment worked have different spinal characteristics, Kawchuk said. The researchers need to do a much larger study to see whether that may be the case, he added.

The new study “is the beginning of an attempt to understand why some patients respond to SMT and others do not,” said Dr. Allyson Shrikhande, a rehabilitation physician at Lenox Hill Hospital in New York City, who was not involved with the study.

Previous studies have looked at how SMT can affect people’s pain levels and degree of disability, but they didn’t include the physical measurements, Shrikhande told Live Science in an email.

She added that it would have also been beneficial if the researchers had examined how the treatment affected patient’s hamstring flexibility, because this can significantly affect people’s bodies.

For the people who were not helped by the spinal manipulation treatments, it’s not all bad news.

Future research will be aimed at figuring out what does work for these people, such as massage or surgery, Kawchuk said. The ultimate goal is to be able to match patients with the treatments that work best for them, he said.

“Back pain is not one problem — it’s a group of problems,” so there won’t be one treatment that works for everyone, Kawchuk said.

The study was published on Aug. 31 in the journal Spine.

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Most patients who have endometriosis struggle with the breathtaking pain that characterizes the disease. While pain is often associated with endometriosis, the exact reason why endometriosis is painful is not always talked about.

Endometriosis is considered a noxious stimuli, an event that is or can be damaging to the tissues in the body. Physiatrist, Dr. Allyson Shrikhande, describes the tissue damage that occurs from endometriosis as a trauma to the body. It causes the nervous system to be in an excitable state and also starts an inflammatory cascade.

Anesthesiologist, Dr. Gerard DeGregoris, compares the direct invasion of very sensitive structures by endometriosis and the ensuing inflammatory response to getting hit with a hammer. When you get hit with a hammer, inflammation, a complex biological response of tissues to harmful stimuli, occurs in the form of heat, redness, swelling and an uncomfortable sensation. When a trauma occurs to tissues in the body, there is a direct stimulation of nerve fibers called nociceptors. When these nerve fibers are stimulated they transmit a pain impulse to brain. Dr. DeGregoris explains that we developed these pain filled inflammatory responses so that we can be aware tissue damage has occurred in order to try and protect our bodies from harm.

Types of Pain

How does Endometriosis Excision Help Pain?

Endometriosis excision surgery by an expert doctor is considered the gold standard of treatment for patients suffering from the disease. Excision works to remove the disease, or the noxious stimuli, from the body. Dr. Shrikhande works with many endometriosis patients in her practice in New York City, “I have seen patients pre and post op of a proper excision treatment. A proper excision surgery gets rid of the noxious stimuli and stops the persistent inflammatory response.”

It should be noted that some patients are told that a hysterectomy can cure their endometriosis. If the uterus and ovaries are removed, but endometrial implants are left in the pelvis, these noxious stimuli will continue to cause pain in patients.

Reasons for Pain Post Excision

In her practice, Dr. Shrikhande sees how pelvic floor muscles are intimately involved with the suffering endometriosis patients endure. Dr. Shrikhande explains to patients how muscles contract in a linear pattern, kind of like a railroad track. When a patient has a trigger point, the pattern is no longer linear and is in disarray. A trigger point is a palpable taut band of muscle. When you touch the trigger point you get a twitch response and you also may get a referred pain pattern. Physiatrists work in conjunction with pelvic floor therapists to identify trigger points or which muscles in the pelvic floor are causing pain.

Treatment Options for Pain

A Physiatrist Perspective: Dr. Shrikhande uses many different techniques to help endometriosis patients reduce their pain. She finds muscle relaxers (oral or suppository) helpful for patients. For patients with pelvic floor pain, Dr. Shrikhande starts with a suppository made of combined valium and baclofen. She also utilizes ultrasound guided trigger point injections such as Lidocaine. Topical medications made by compounding pharmacies can be quite beneficial to treat patients. Mixtures using Gabapentin or Lyrica, mixed with lidocaine or baclofen or even a NSAID are quite helpful to patients. For patients with vulvadinia, mixing compounds in olive oil reduces irritation.

Dr. Shrikhande not only utilizes medications, but encourages patients to engage in cognitive behavioral therapy, guided imagery, meditation and lifestyle modification to reduce pain and inflammation. She encourages patients to go to acupuncture to help desensitize the nervous system. She feels that proper breathing technique can relieve the pressure and pain through the pelvic floor and may be the fastest way to help. Dr. Shrikhande works hand in hand with pelvic floor therapists to help patients with their lingering pain after surgery.

The Cause and Cure for Pain

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Tylenol and other products containing acetaminophen do little or nothing to help lower back pain or arthritis, a new report finds.

Patients might do better with stretching and exercise, the Australian researchers report. They don’t recommend that people move on to stronger drugs such as opioids.

It’s sure to be a controversial finding. Most expert groups advise that people try acetaminophen first — even though the pills can cause liver damage, if people take too much. They’re also far safer than drugs such as ibuprofen or naproxen, known as non-steroidal anti-inflammatory drugs or NSAIDS. NSAIDS can sometimes cause deadly gastric bleeding.

And the dangers of opioids are even worse — dependence, addiction and overdose.

For the study, Gustavo Machado from The George Institute for Global Health at the University of Sydney in Australia and colleagues reviewed 13 different studies that looked directly at which treatments helped lower back pain and arthritis.

Ten of the trials included 3,541 patients with osteoarthritis of the hip or knee, and three trials included 1,825 patients with lower back pain.

“There was ‘high quality’ evidence that (acetaminophen) is ineffective for reducing pain intensity and disability or improving quality of life in the short term in people with low back pain,” they wrote in the online version of the British Medical Journal, called The BMJ.

“For hip or knee osteoarthritis there was ‘high quality’ evidence that (acetaminophen) provides a significant, although not clinically important, effect on pain in the short term,” they added.

“(Acetaminophen) is ineffective in the treatment of low back pain and provides minimal short term benefit for people with osteoarthritis.”

It might be better to tell people to manage pain with exercise and stretching, the team recommended.

That’s what Susan Fox of Cambridge, Massachusetts, will do from now on.

Fox, who is 59, takes acetaminophen for back pain that followed back surgery.

“If I kind of have acute back pain, then I will be taking it every day, extra strength as a way to not make it any worse because I’m worried about permanently injuring my back and not being able to make it better,” she told NBC News. “And that’s pretty much what I have been told to do.”

But Fox says she also exercises five days a week. “I go to the gym,” she said. “I go running,” she added. Stretching is important.

“It helps in an enormous amount, because not only has it made me a lot stronger (but it helps) in all kinds of ways.”

Fox, a computer programmer, was disappointed by the study’s findings.

“I was really surprised to hear that it really didn’t have any effect on acute back pain, because that’s what’s really offered to you,” she said.

“Tylenol is supposed to be the thing you do to relieve it.”

Dr. Allyson Shrikhande, who specializes in physical rehabilitation and pain at New York Bone and Joint Specialists, says it’s unlikely doctors will change their recommendations just yet.

“The study does make me question the use of acetaminophen,” she told NBC News.

“My experience is the Tylenol is just controlling symptoms while not fixing the problem,” she added.

“However, given other options it will remain the first-line treatment as oral pain medication.”

The makers of Tylenol didn’t directly challenge the study.

“The safety and efficacy profile of acetaminophen is supported by more than 150 studies over the past 50 years,” McNeil Consumer Healthcare said in a statement.

Jane Derenowski and Judy Silverman contributed to this report.

This article was originally published Mar. 31, 2015 at 6:30 p.m. ET.

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THURSDAY, July 9, 2015 (HealthDay News) — For people with chronic back pain who also have depression or anxiety, narcotic painkillers may not be the best therapy for their pain, a new study finds.

“A lot of patients have depression and anxiety on top of their back pain,” said lead researcher Dr. Ajay Wasan, a professor of anesthesiology and psychiatry at the University of Pittsburgh School of Medicine. Pain can make depression and anxiety worse and depression and anxiety can make pain worse, Wasan said. “It’s a two-way street.”

But, he added, people with depression or anxiety may get a lot less pain relief from narcotic painkillers and have a higher rate of misuse of their medications.

Wasan said misuse includes taking too many pills and running out of medication early, doctor shopping — getting prescriptions for the same drug from several doctors — and using marijuana or cocaine along with narcotic painkillers.

Doctors should know whether someone has depression or anxiety before prescribing a narcotic painkiller, Wasan said.

“That needs to be assessed and needs to be treated,” he said. “Treating these conditions improves pain by itself,” he added.

Wasan also thinks doctors should prescribe alternatives, such as non-narcotic pain medicines and physical rehabilitation.

The report was published July 9 online in the journal Anesthesiology.

The study included 55 people with chronic lower back pain and low to high levels of depression or anxiety. They were randomly assigned to receive morphine, oxycodone (Oxycontin) or a placebo for six months. Patients reported their pain levels and daily drug doses to the researchers.

People with high levels of depression and anxiety had less pain relief — about 21 percent pain improvement compared to 39 percent for the group with less depression and anxiety, the study found.

In addition, patients who had high levels of depression or anxiety showed far more painkiller abuse than those with lower levels of depression or anxiety — 39 percent versus 8 percent.

They also had more side effects from the narcotic medications, the study found. Side effects common to this class of medication include constipation, nausea, fatigue and confusion, according to the American Academy of Family Physicians.

Dr. Allyson Shrikhande, a physiatrist at Lenox Hill Hospital in New York City, said, “Using narcotics to treat chronic back pain in patients with a history of a psychiatric disorder may not be effective in decreasing the pain.”

In addition, patients with a history of anxiety or depression can have an increased risk of addiction to pain medication versus a person without a psychiatric history, she said.

“This is due to the effect of narcotic medications on the neurohormonal balance. It is important for physicians treating back pain to inquire about a patient’s psychiatric history prior to initiating treatment. A team approach is also vital, using experts such as psychiatrists and psychologists to assist in managing the patient,” Shrikhande said.

Dr. Scott Krakower is the assistant unit chief of psychiatry at Zucker Hillside Hospital in Glen Oaks, N.Y. He said, “Narcotic painkillers are a temporary ‘band-aid’ and often exacerbate the problem.”

With the rates of narcotic addiction on the rise, doctors should be mindful of other treatments available to patients for chronic back pain, he said. In addition, conditions such as depression and anxiety should themselves be treated, which in turn will make relieving back pain more effective, he added.

“This study reinforces the importance of screening for coexisting conditions and treating them effectively,” Krakower said. “If the anxiety and mood symptoms diminish, then there is a better chance of relieving pain in the long run.”

SOURCES: Ajay Wasan, M.D., professor, anesthesiology and psychiatry, University of Pittsburgh School of Medicine, Pennsylvania; Allyson Shrikhande, M.D., physiatrist, Lenox Hill Hospital, New York City; Scott Krakower, D.O., assistant unit chief, psychiatry, Zucker Hillside Hospital, Glen Oaks, N.Y.;July 9, 2015, Anesthesiology, online

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Olympic swimmer Amy Van Dyken-Rouen’s recovery from a spinal cord injury, including the use of a new high-tech “exoskeleton” that has enabled her to walk again, spotlights how broad, rapid advances in paralysis treatments are allowing patients to regain their independence and live on their own.

Remote-controlled exoskeletons are just one of several new biomedical developments that are helping paralysis patients stand and move without the use of wheelchairs. Microchips implanted in paraplegics’ brains are allowing them to reclaim the use their arms and hands. New neurological devices are helping quadriplegics operate “bionic limbs” using only their thoughts. And new developments in stem cell research and the regrowth of nerve cells are offering new hope to the hundreds of thousands of American patients paralyzed by accidents and illnesses.

Allyson Shrikhande, M.D., a spinal cord injury specialist, tells Newsmax Health that Van Dyken-Rouen’s decision to go public with her inspiring experience spotlights the progress being made in the field.

“Amy’s story is amazing,” says Dr. Shrikhande, in an interview on Newsmax TV’s Meet the Doctors program. “And her dedication as an athlete and her athleticism has really allowed her to progress much more quickly than the average American would.”

Psychotherapist Jeffrey Gardere, M,D., tells Newsmax Health the new advances are not only providing paralyzed individuals greater independence, but also a positive outlook for the future.

“What we see with a lot of these new innovations is it gives a lot of hope to these patients,” he says.

“So it’s important that they’re able to … have the freedom to take care of themselves and not only rely on other people….

“It’s about being a complete human being even if parts of your body are not working as they once were. And that is the battle and that’s where they win because they know that they can be respected as a whole person again and see themselves as a whole person.”

Van Dyken-Rouen, 41, severed her spine in a June 6 all-terrain vehicle crash. But she recently began walking again, thanks to a specialized exoskeleton device called Indego. She told reporters last month that she began using it as part of a Food and Drug Administration study that its manufacturers hope will lead federal approval for wider use.

The six-time Olympic gold medalist says she has come a long way since being brought to the hospital on a stretcher after her accident, paralyzed from the waist down.

Since she began using the device, which she operates with hand controls that help her stand and walk, she has learned to dress herself and pick up things up from the floor. She has also gone boating and kayaking.

Throughout her ordeal, she has shared her experiences via social media.

“What a day,” she tweeted recently. “Went swimming, then rode the hand bike for a while. I’ve done a duathalon today. Is that a Paralympic sport? Lol #Imkidding.”

Dr. Shrikhande notes that an exoskeleton, like the device Van Dyken-Rouen is using, is designed for people who still retain use of their arms.

“For patients who have incomplete spinal cord injuries and have a strong prognosis and chance of recovery,” she says. “It helps teach them to walk again, it really teaches their nerves … [and] stimulates the neurons and really teaches them [how] to walk again.”

Exoskeletons are just one of the many developments designed to help the estimated 250,000 Americans who are either paraplegic (paralyzed below the waist), or quadriplegic (without the ability to move their arms or legs). Most cases are due to an injury to the brain or spinal cord from an accident, a fall, a sports injury, violence, or a disease that affects mobility.

Nearly 40 percent of all injuries that leave people with at least some paralysis are due to car accidents, but a growing proportion are tied to violent acts, which now account for nearly one in three of the 11,000 new spinal cord injuries reported each year, federal health statistics show.

In most cases, treatment involves physical therapy to maximize mobility, which is critical right after an injury. Many individuals are able to regain at least some movement with therapy. But for those who don’t benefit from therapy, a number of new treatments are under development.

For instance, earlier this year Ohio state researchers implanted a first-of-its-kind microchip in the brain of a young man who was paralyzed in a diving accident that essentially allowed him to move his fingers and hand using only his thoughts.

The so-called Neurobridge chip decodes the user’s brain activity and uses a high-tech muscle stimulation sleeve to translate impulses from the brain into movement in the paralyzed limb. The technology has been in the works for nearly a decade.

Scientists are also working on materials that can interact with human nerves and tissues that could eventually lead to prosthetics that are fused with the body and controlled directly by the nervous system or the user’s own thoughts.

In addition to these technological developments, medical researchers are testing a variety of new treatments that involve regrowing spinal cord tissues and nerve cells, as well as new adult stem cell techniques that hold a great deal of promise.

“It’s very exciting,” says Dr. Shrikhande, of the new technologies under development. “And I think the hope is that [they] can complement the traditional therapies that we’ve been doing for 20 plus years and then also complement the research that’s going on with stem cells so everything will work together.”

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A popular over-the-counter pain medicine doesn’t pass muster when it comes to easing pain and improving movement in people with osteoarthritis, a new study shows.

The study, published in The Lancet, found that paracetamol — sold as acetaminophen in the U.S., under the brand name Tylenol and as a generic — was not effective at reducing pain or improving movement in patients with osteoarthritis of the knee and hip. Osteoarthritis, the most common form of arthritis, involves wear-and-tear damage to cartilage protecting the joints.

Researchers conducted the study — the largest of its kind to date — to learn more about the effectiveness of different types and doses of pain relievers for treating osteoarthritis pain. Their meta-analysis included a review of 74 randomized trials published between 1980 and 2015, totaling 58,556 patients with osteoarthritis. The studies looked at 22 treatments including several different dose levels of paracetamol (acetaminophen) and seven different non-steroidal anti-inflammatory drugs (NSAIDs), a class of drugs that includes aspirin and ibuprofen. The length of follow-up in most of the trials was three months or less.

Acetaminophen did beat out the placebo by a hair, but when taken alone, the researchers said it was not clinically significant.

“We see no role for single-agent paracetamol [acetaminophen] for the treatment of patients with osteoarthritis irrespective of dose,” they concluded.

The Lancet study found that the NSAID diclofenac, at a dose of 150 milligrams per day, is the most effective NSAID available. Diclofenac is sold by prescription in the U.S.

Taking any NSAID long term carries risks, such as serious gastrointestinal and cardiovascular side effects, that doctors and patients need to consider carefully, the researchers warned.

“NSAIDs are usually only used to treat short-term episodes of pain in osteoarthritis, because the side effects are thought to outweigh the benefits when used longer term. Because of this, paracetamol is often prescribed to manage long-term pain instead of NSAIDs. However, our results suggest that paracetamol at any dose is not effective in managing pain in osteoarthritis, but that certain NSAIDs are effective and can be used intermittently without paracetamol,” study co-author Dr. Sven Trelle, from the University of Bern, in Switzerland, said in a statement.

Trelle noted that NSAIDs are some of the most widely used drugs for patients with osteoarthritis, but patients often switch between the different options. “We hope our study can help better inform doctors about how best to manage pain in this population,” he said.

Arthritis expert Dr. Bashir Zikria, an assistant professor of orthopaedic surgery at the Johns Hopkins University School of Medicine, said there’s been limited research comparing acetaminophen against a placebo.

“It is a pain reliever and may relieve some arthritic pain, but not enough to make a significant difference,” he said.

Doctors recommend it to patients with osteoarthritis because it’s generally safe. “Tylenol is publicized as being the safest one. It doesn’t bother your kidneys and stomach,” Zikria explained, although, in very high doses, acetaminophen can have liver side effects.

McNeil Consumer Healthcare, the makers of Tylenol, told CBS News it provides an essential option for patients, especially those who can’t take NSAIDs.

The company said in a statement: “We disagree with the authors’ interpretation of this meta-analysis and believe acetaminophen remains an important pain relief option for millions of consumers, particularly those with certain conditions for which nonsteroidal anti-inflammatory drugs (NSAIDs) may not be appropriate (including cardiovascular disease, gastrointestinal bleeding, and renal disease). The safety and efficacy profile of acetaminophen is supported by more than 150 studies over the past 50 years and we are committed to furthering research and education to ensure consumers can make informed choices about their medications based on individual health needs.”

The study, while “excellent,” had limitations, Prof. Nicholas Moore and colleagues from the University of Bordeaux wrote in an accompanying comment in The Lancet. They point out that some popular NSAIDs weren’t part of the study, “probably because no recent trials have been done of these drugs or because any recent trials that did assess them were too small.”

“The most remarkable result is that paracetamol does not seem to confer any demonstrable effect or benefit in osteoarthritis, at any dose,” they write. Even though the drug “has been on the market for as long as most of us remember,” they add, “its efficacy has never been properly established or quantified in chronic diseases, and is probably not as great as many would believe.”

It’s estimated that 26.9 million adults in the U.S. have osteoarthritis, a degenerative joint disease and the leading cause of pain in older people. About a third of adults over 65 suffer from the condition, according to the CDC.

Pain management expert Dr. Allyson Shrikhande, a physiatrist at Lenox Hill Hospital in New York City, said doctors may need to rethink their recommendations for many of these patients. “The classic teaching in residency in medical school for first line treatment of osteoarthritis is to start with Tylenol. At this point physicians are starting to see that it may be outdated,” she said.

She said that while acetaminophen can help decrease pain, it does not have an effect on inflammation. “This may be reason why NSAIDs technically work better to decrease pain and improve function,” she explained.

Shrikhande said NSAIDs should not be used for more than two weeks to a month. “In short doses, preferably two week courses, NSAIDs are preferable, however for long term chronic pain, there really is no good oral medication at this point.”

There are non-drug options to help manage osteoarthritis pain, too, Zikria said, including physical therapy, acupuncture, and weight management, which people with osteoarthritis should talk about with their doctors.

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NEW YORK (FOX 5 NEWS) – Opioid painkillers — like OxyContin (oxycodone) and Vicodin — have become the most widely prescribed drugs in the country and they have contributed greatly to the heroin epidemic. Many heroin addicts turn to heroin after getting hooked on opioids.

The Centers for Disease Control and Prevention has issued the first national standards that doctors should follow in prescribing the highly addictive painkillers.

Dr. Allyson Shrikhande specializes in pain management and rehabilitation at Lenox Hill Hospital. She supports the CDC’s recommendations, which include prescribing pain relievers like ibuprofen before prescribing opiates for pain. And when doctors do prescribe opiates, give patients a low dosage enough to last a few days — not weeks and months. Plus the doctor says opioids aren’t even an effective treatment for chronic pain.

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NEW YORK — Dr. Andrew Kolodny rattled off the startling statistics that grow with every passing year: More than 200,000 Americans dead from opioid overdoses since 1999 — a 900 percent increase in opioid addiction since 1999.

For those not familiar with the term “opioid” — it’s a class of drug common in the painkillers that thousands of Americans have come to rely on—Percocet, Vicodin, and OxyContin pills. And when the pills are no longer available, those who’ve become addicted often turn to heroin, a cheaper opiate that causes a similar high.

Kolodny, Chief Medical Officer for the Phoenix House treatment center, has been warning the public about prescription painkillers for years.

“We shouldn’t be putting patients on them for conditions like lower back pain or chronic headache,” Kolodny told us, after the Centers for Disease Control issued new guidelines to primary care doctors. The CDC recommended that physicians try pain relievers like ibuprofen before rushing to prescribe the highly addictive opioids.

Dr. Thomas Frieden, director of the CDC, told reporters this week “We lose sight of the fact that the prescription opioids are just as addictive as heroin.”

Back in the mid-1990s, pharmaceutical companies successfully convinced doctors that drugs like OxyContin could be safely prescribed for patients with chronic pain issues.

But Kolodny’s research illustrated to PIX11 how opioid addiction started cropping up in the late 90s, with pretty much every state in the nation facing a crisis by 2009, a decade later.

Young people who experimented with painkillers in their parents’ medicine cabinets often gravitated to heroin use, after they became addicted to the pills. Heroin was much cheaper to buy, at $5 or $10 a hit.

But Doctor Kolodny—who started a group called Physicians for Responsible Opioid Prescribing—said more people were dying from overdoses in an older demographic.

“The overdose rate is actually much higher in that older group that’s getting pills from doctors for a chronic pain problem,” Kolodny told PIX11. “The age group with the highest rate of drug overdose deaths in the U.S. is 45 to 54 years old.”

Dr. Allyson Shrikhande, who works with the New York Bone and Joint Specialists—an affiliate of Lenox Hill Hospital—told us she stopped prescribing opioids about a year ago.

Although Dr. Shrikhande acknowledges opioids can be effective in acute pain situations—used three to five days post-surgery—she told PIX11 they’re not very effective long-term.

She pointed out that “anti-inflammatories, Aleve or ibuprofen” can be very helpful in pain management. She added, “Also, there are many medications that can help calm down the nerves.”

“Advil works very well for dental pain,” Dr. Kolodny pointed out, “but unfortunately, dentists are giving patients who have their wisdom teeth out Vicodin, which isn’t a very good idea.”

Doctors are also being encouraged to look at acupuncture and physical therapy as alternatives to opioid prescribing.

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Acupuncture may help ease pain and improve quality of life for people with fibromyalgia, a new study suggests.

Ten weeks after treatment, the pain scores of patients given acupuncture dropped an average of 41 percent, compared with an average drop of 27 percent for those given a simulated acupuncture treatment. The benefits were still seen after a year.

“Individualized acupuncture is a safe and good therapeutic option for the treatment of patients with fibromyalgia,” said lead researcher Dr. Jorge Vas of the pain treatment unit at Dona Mercedes Primary Health Center in Seville, Spain.

Fibromyalgia patients — mostly women — have chronic widespread pain, which is associated with fatigue, poor sleep patterns and depression. The condition affects up to 5 percent of the population, Vas said.

“Both acupuncture and traditional medicine have a place in treating fibromyalgia,” said Dr. Alexander Rances, an acupuncturist, pain management specialist and attending physician at North Shore University Hospital in Manhasset, N.Y. “A combination of Western as well as traditional Chinese medicine probably offers these patients the best possible therapy.”

With acupuncture, extremely thin needles are inserted through the skin at strategic body points to treat pain.

Fibromyalgia treatment usually starts with medications such as the nerve pain medication Lyrica (pregabalin), and if that fails or is only partly effective, doctors might add acupuncture to the mix, Rances said.

For the study, Vas and colleagues randomly assigned 153 patients diagnosed with fibromyalgia to individually tailored acupuncture or simulated acupuncture. Patients had nine weekly treatments, each session lasting 20 minutes.

“Although it was allowed for the participants to continue with the pharmacological [drug] treatment they were taking beforehand, when the study was finished, the patients who received individualized acupuncture were taking less medication than the group on sham acupuncture,” Vas said.

One year after treatment, acupuncture patients had an average 20 percent drop in their pain score, compared with a little more than 6 percent among those who had simulated therapy, the researchers found.

Scores on the Fibromyalgia Impact Questionnaire, which measures how the condition affects patients’ lives, also differed between groups. Reductions were seen of 35 percent at 10 weeks, and just over 22 percent at one year, for those given real acupuncture, compared with 24.5 percent and 5 percent, respectively, for those given sham acupuncture, the researchers said.

Pressure pain and the number of tender points also improved more in patients given real acupuncture after 10 weeks, as did measures of fatigue, anxiety and depression, Vas said.

However, although taking less pain medication, acupuncture patients were using higher levels of antidepressants after one year, which may have artificially boosted the positive results, he said.

The report was published online Feb. 15 in the journal Acupuncture in Medicine.

Dr. Allyson Shrikhande is a physiatrist — a doctor who specializes in physical medicine and rehabilitation — at Lenox Hill Hospital in New York City. She agreed that antidepressant use could have been a “significant contributing factor to their continued improvement.”

Still, Shrikhande said, “the findings in this study help demonstrate that acupuncture is a safe and effective treatment for chronic pain patients.”

Many patients with fibromyalgia have a central nervous system that is unregulated, meaning an abundance of pain signals are sent to the brain, Shrikhande said.

“Acupuncture can calm or quiet the nervous system and help slow down the pain signals to the brain,” she said.

Some insurance companies cover acupuncture, which costs about $125 a session, according to the University of California at San Diego Center for Integrative Medicine.

Copyright © 2017, Chicago Tribune
A version of this article appeared in print on March 02, 2016, in the Health & Family section of the Chicago Tribune with the headline “Acupuncture may have place in treating fibromyalgia pain”

Patient Awareness Day
The Lifecycle of Endometriosis: From Diagnosis to Coping with Disease
Sunday April 17, 2016
Lenox Hill Hospital, Einhorn Auditorium

Good afternoon. I am a physiatrist. Essentially we treat the muscles, bones and nerves of the body. I focus on the pelvis. As physiatrists we work very closely with physical therapists. We really are an extension of a patient’s physical therapy program.

I was asked to speak about why do patients still have musculoskeletal pain after endometriosis was removed. A recent study done by the NIH published in the Journal of OBGYN in 2015 suggested a comprehensive nerve muscle and skeletal exam to identify pain sensitivity and trigger points post operatively for patients who have undergone excision of endometriosis. Essentially what they did was examine patients pre-operatively, particularly for muscle sensitivity and trigger points internally throughout the pelvic floor. The patient underwent surgery and then was examined again post-operatively. What they found was those trigger points remained. What they did then was treat the patients with physical therapy and then a physiatrist. I will go on to discuss what we do but really they were saying that could be a source of the pain persisting post-operatively.

This slide really discusses a lot of what has already been talked about today with the hormonal aspects of pain and then with inflammation contributing the inflammatory cascade to the persistence of pain.

My talk today will focus really on pelvic floor myofascial pain as well as sensitization. We have both peripheral nerve sensitization and central sensitization. The pelvic floor muscles: there is a sling of muscles going from the pubic symphysis in front to the coccyx in the posterior aspect. As you can see from the picture they are holding up the bladder, the uterus and the descending colon. Endometriosis can really be found throughout. The pelvic floor muscles really are intimately involved with patients who suffer from endometriosis.

This is a more detailed look at the sling. Really, the basic concept is a sling of muscles. This is the detailed look at the different aspects where as a physiatrist working in conjunction with the pelvic floor physical therapist we are trying to really identify which muscles are causing the problem and the pain.

Muscles, how do they contract? You have actin and myosin and they contract in a linear pattern. I explain to my patients it is like railroad tracks. This linear pattern really allows for the small arterials that come off the larger arteries to infiltrate.
When you have a trigger point the pattern becomes a disarray, and why is that a problem? Why does that disarray cause pain? Really, it is a neural ischemia. The railroad tracks are no longer available so those small arterials have difficulty really ascending down to where they are supposed to and there is a neural ischemia going on. Essentially there is a hypoxia drop in the pH balance of the tissue, and that drop in the pH is what stimulates the inflammatory cascade that we addressed about ten minutes ago. But really the idea is, it is a disarray. A trigger point by definition it is a palpable taut band of muscles so you can feel the top band. It is almost like cords. When you touch the trigger point you get something we call a twitch response. You can feel a twitch when you touch a trigger point. You also get this referred pain pattern. So, you touch a trigger point and you have referred pain to elsewhere in the body. Lastly, with trigger points at times you can get an associated dysautonomia as well when you touch a trigger point. Or there is referred heat or sweating or some sort of dysautonomia can occur as well.

How do we treat this muscular pain of the pelvic floor? The gold standard really is pelvic floor physical therapy, which will be addressed in more detail. Proper breathing technique; a recent study done out of the University of Chicago really took patients with pelvic pain and high tone pelvic floor and taught them how to breathe where they put manometry inside the pelvic floor and had them breathe improperly and then taught them the proper diaphragmatic breathing. The pressure dropped over 50 percent immediately and they had a statistically significant change in their pain. I think that is the fastest way, really, is with proper breathing. It seems so simple but really that is important to always teach to all the patients.

Muscle relaxers; I use both oral and suppository forms of muscle relaxers. Quite often for specifically pelvic floor I will start with suppository options. Usually I combine the Valium with Baclofen. Lastly, ultrasound guided trigger point injections using lidocaine, which is the gold standard, into the muscles.

This is an example of going in to a trigger point injection going into myofascial trigger point. The whole idea is to break up the disarray and really get blood flow. Going back to my point earlier, why does a muscle trigger point even cause pain? It is because it is a neural ischemia. The idea behind trigger point injections is getting blood flow. Blood will bring oxygen. That is the concept and the theory behind it.

Now we are going to talk a bit about peripheral sensitization and central sensitization it was alluded to in the prior talk. But with peripheral sensitization really when there is that trauma, as we were talking about before, which really is the endometriosis you get this sensitizing soup where you have this release of neurotransmitters that stimulate the inflammatory cascade. Really what it is is there is extracellular calcium and nitric oxide that move intracellular and they release this substance P as well as glutamate. This can happen both, again, peripherally at the nociceptors and then centrally at the spinal cord going up to the brain. You get this hyper-excitability of the membranes. They start to depolarize, the sodium potassium channels start to depolarize when they really should not. They get hyper-excitability.

This is another picture talking about the inflammation, which again, really is the inflammation released from the tissue damage of endometriosis, release of the inflammatory mediators and then you get this hyper-excitability state. There are more ascending signals from the spinal cord to the brain and there is a lack of what we call descending inhibition. So, your nervous system is excited. Then you get this chronic pain state with allodynia and hyperalgesia. Allodynia means something that should not be painful so you touching a patient even with a cotton swab is painful. Hyperalgesia is exaggerated painful state as we talked about earlier, where you pinch somebody and it should be mildly painful but a patient who is in a chronic pain state could jump out of their seat.

With central sensitization you get this abnormal pain signaling as we were discussing before. Once this becomes chronic – it goes from acute to chronic – really this pain state you start to get stored in you mid-brain, so it becomes the patient’s new normal. Then you have this sensitizing soup as we were discussing with high levels of substance P and glutamate travelling throughout your body.

Now we will talk about treatment of neuropathic pain. The idea is to desensitize both the central nervous system and the peripheral nervous system, calm things down. How do we do that? Again, physical therapy can desensitize in their way working with their patients, particularly myofascial release can help. Acupuncture can help to desensitize by working really on the central nervous system. I quite often will refer for acupuncture and I always ask my patients really on the second visit a good acupuncturist should have you falling asleep on the table. That is what I would like them doing, calming things down and desensitizing your central nervous system. Guided imagery and meditation – we always talk about lifestyle modifications with patients. Cognitive behavioural therapy is excellent. On my end what I use are medications targeted at the nerves which we really already discussed in the prior talk and a series of peripheral nerve blocks. Those are the two things that I do.

Medications targeted at patient’s nerves; I use quite a bit of topical medications where you can use specific compounding pharmacies using gabapentin, Lyrica that we talked about earlier and you can mix them. A lot of times mixing with the lidocaine or you can mix them with a muscle relaxer, such as Baclofen and ketoprofen which is a NSAID. You can do a lot of things topically as well. For my patients who have associated vulvodynia with their endometriosis I recently have started doing this is in olive oil too so it does not irritate. You can use the medications as we have talked about. You have the anticonvulsants, which include the pregabalin, Neurontin and Topamax and then the antidepressants. These all help to calm down the nervous system – those hyper-excited.
Peripheral nerve blocks; the most commons ones that I will do, pudendal, ilioinguinal/iliohypogastric, the genital branch of the genitofemoral, posterior femoral cutaneous nerve and the lateral femoral cutaneous nerve.

These are just some pictures and you can see how everything is connected and you have the pudendal nerve running medially, the posterior femoral cutaneous nerve and then the muscles of the pelvic floor, particularly the piriformis, obturator and quadratus femoris. These are pictures of other nerves. You have the lateral femoral cutaneous nerve, iliohypogastric and their innervations. This is just an ultrasound picture which essentially everything I am doing into the pelvic floor is under ultrasound and you are using a lot of times the bony structures to really identify the muscles and the nerves. You have your piriformis specifically here, which is common with endometriosis patients because the piriformis really supports the pelvis and is an external rotator of the hip and part of the pelvic floor. Quite often endometriosis patients do have the piriformis spasm, which a lot of times they present to me as hip pain.

Another ultrasound image describing the proximity of the sciatic nerve and pudendal nerve related to the ischial spine. A picture of the guided needle going in.

This really shows how complex pain is and how important it is when you are managing pain to really draw in a multispecialty group and work in collaboration. Really, so many different factors are involved in a patient’s perception of pain and regulation of stress is extremely important, nutrition, diet, exercise really all play a strong role in the patient’s quality of life and their perception of their pain.

Lastly this picture, the noxious stimuli really is endometriosis. It is interesting to see for me I have seen patients pre and post-op a proper excision treatment, again, as we really hit home today it needs to be a proper excision treatment, but you can really see the difference even just touching them. Before surgery you will either swipe with cotton or you will do a gentle touch and they literally are often jumping off the table. Post-op, a couple of months, you will touch and you will notice the difference – much more calm. Really the why is you are getting rid of that noxious stimuli, it is important to really get rid of the noxious stimuli and stop the persistent inflammation.
Thank you.

FDA cleared device could be an innovative way to help control chronic pain for sufferers.

Manipulating the spine can help people with lower back pain — but it doesn’t work for everyone, according to a new study.

In the new study, the researchers found that spinal manipulation therapy (SMT) provided relief for some patients with lower back pain, but not for others. [5 Surprising Facts About Pain]

The people who said they did not feel any better did not have those physical changes, Kawchuk said.

Previous studies have looked at how SMT can affect people’s pain levels and degree of disability, but they didn’t include the physical measurements, Shrikhande told Live Science in an email.

For the people who were not helped by the spinal manipulation treatments, it’s not all bad news.

“Back pain is not one problem — it’s a group of problems,” so there won’t be one treatment that works for everyone, Kawchuk said.

The study was published on Aug. 31 in the journal Spine.

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For some patients, a simple change in diet might reduce medical costs and even eliminate the need for medication. Dr. Allyson Shrikhande, a physiatrist at Lenox Hill Hospital, explains why food is instrumental in both preventing and alleviating illness.

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