Condition: chronic pelvic pain syndrome, pain with sitting

Patient Described:34 year old male with 16 year history of pain with sitting, rectal spasms, straining with BMs, and difficulty maintaining erection, pain with ejaculation. Has a labor intensive job that requires prolonged standing and history of repetitive riding of ATV and tractors with repetitive trauma to the lower back/pelvic floor.

Patient Journey:Patient was seen by ortho who did S1 nerve injection with minimal relief to his symptoms. We discussed that although S1 nerve was compressed on imaging, his symptoms are likely attributed to pudendal nerve involvement leading to an upregulated nervous system and sensitization with chronic pain.

Conditions/Complaint: Pudendal Neuralgia Pain with Sitting, Rectal Spasms, Straining with bowel movements, Difficulty Maintaining Erections/Ejaculation

PRM treatment approach: We discussed that chronic pain was leading to his muscles and nerves remaining tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: He was sent to pelvic floor PT and underwent our protocol with rectal suppositories, magnesium citrate, and hydrodissection injections.After treatment, he has improvement in standing and sitting tolerance and notes he sustains his erections for a longer period of time. His rectal spasms have subsided and he is able to pass bowel movements without straining or pain.

Condition: Chronic pelvic pain syndrome and PGAD

Patient Described: 41 year old female presented with uncontrolled clitoral hyperarousal, inability to orgasm with intercourse, uncontrolled orgasms when not engaging in sexual activity, vaginal pain.

Patient Journey: Her quality of life was impaired due to uncontrolled sexual arousal, vaginal throbbing and inability to sit for prolonged periods of time. We discussed her diagnosis of PGAD and PFM hypertonia, which was causing her muscles to remain tense and her nervous system upregulated and hypersensitized.

Conditions/complaint: PGAD, Clitoral Hyperarousal/Swelling Inability to Orgasm, Vaginal Pain with Penetration, Pain/Clitoral Arousal with Sitting

PRM Treatment Approach: We discussed that chronic pain and her diagnosis was leading to her vaginal muscles remaining tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: She was referred to PFPT and started on a vaginal suppository & Duloxetine to help with muscular relaxation and nervous system desensitization. She underwent our injection protocol and the retrain your brain course as well and after several months, she was no longer having clitoral arousal. She was able to have painless penetrative intercourse and began to have small orgasms during intercourse which were enjoyable for her. She no longer felt fear of being in social environments as her clitoral hyperarousal had subsided and her nervous system was in a relaxed state with controlled pain.

Condition: Chronic Pelvic Pain Syndrome

Patient described: A 22-year old female presented with chronic vaginal and pelvic pain over 1 year despite several visits to the emergency room, laboratory and imaging testing being non-diagnostic.

Patient Journey: This patient was experiencing symptoms for years. She reported a history of recurrent bacterial vaginosis and yeast infections that had been treated. Constant pelvic pain and heightened sense of arousal were impairing her ability to sleep and work.

Conditions/Complaint: Benign hypermobility syndrome, Ilioinguinal Neuralgia, Pain and increased genital arousal after intercourse, Chronic, Urinary Frequency, without infection

PRM Treatment Approach: We discussed that chronic pain was leading to her vaginal muscles to remain tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: She underwent the injection series in combination with pelvic physical therapy, non-opioid pharmacological therapies, and nutrition changes with near complete resolution of symptoms.She no longer was experiencing constant pelvic pain or urinary symptoms.

Condition: pain with sitting, chronic pelvic pain syndrome

Patient Described: A 55- year old female with sitting pain, urinary urgency/frequency and lower abdominal pain x 2 years. Sitting pain was interfering with her ability to participate in professional and social activities.

Patient Journey:This patient was experiencing symptoms for years prior to coming to PRM. She worked with a pelvic floor physical therapist with some improvement; however still was unable to sit for more than 15 minutes intervals.

Conditions/Complaint: pain with sitting and chronic pelvic pain syndrome

PRM treatment approach: We discussed that chronic pain was leading to her pelvic muscles remaining tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: We started her on suppository medications and our injection protocol along with pelvic floor PT. We believe in a multi-modal approach to healing faster.She noted resolution of urinary symptoms and abdominal pain. Sitting pain improved significantly and was able to participate in activities with minimal pain.

Condition:Chronic pelvic pain syndrome, dyspareunia

Patient Described: 17 year old female presents with pain upon penetration – unable to tolerate tampon, internal exam, etc.

Patient Journey: Initially, this patient wanted to take it slow. She prescribed PFPT, dilator therapy, and muscle relaxation suppository. At three month follow up appointment patient exhibited more urgency as she was non compliant with treatment protocol and made no improvements. She just tried doing dilator therapy alone, with no therapist and had no success but was now ready to be compliant.

Conditions/Complaint:Chronic Pelvic Pain Syndrome, Dyspareunia, Painful Penetration

PRM Treatment Approach: We discussed that chronic pain was leading to her vaginal muscles remaining tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: She was treated with our injection protocol, along with pelvic floor physical therapy, suppositories to relax the muscles, and dilator therapy.therapy. Each week following our treatment protocol, she would see improvements and after six injections, with Pelvic PT, suppositories and she moved up five dilator sizes – reporting pain free penetration.

Condition:chronic pelvic pain syndrome, interstitial cystitis

Patient Described: 51- year old patient with symptoms for 4-years and diagnosed interstitial cystitis after cystoscopy showed bladder wall scarring.

Patient Journey: This patient was experiencing symptoms for years prior to diagnosis. She has tried PRP injections to the bladder without relief. Her main exacerbating factor was anxiety and concern about a new treatment protocol.

Conditions/Complaint: Interstitial Cystitis Urinary Urgency, Urinary Frequency, Nocturia, Sensation of Retention, Dysuria, Dyschezia

PRM Treatment Approach: We discussed that postpartum pain and chronic pain was leading to her vaginal muscles remaining tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: She was treated with our injection protocol, along with pelvic floor physical therapy,suppositories to relax the muscles and calm nerves for a 3mo, Myrbetriq for 3 months, and avoiding trigger foods. At 3 month post-injection follow-up all her symptoms have resolved and she felt like “a brand new woman.”

Patient Described: 31 year old female high level athlete presented 8 months postpartum, after vaginal delivery that was complicated by shoulder dystocia.

Patient Journey: She was experiencing pelvic pain and pain during intercourse with her main goal to have a second baby.

Conditions/Complaint: Dyspareunia Chronic Pelvic Pain Syndrome, Postpartum Pelvic Pain, Pain with Intercourse

PRM Treatment Approach: We discussed that postpartum pain and chronic pain was leading to her vaginal muscles remaining tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: After working on relaxing and lengthening her pelvic floor with a pelvic floor therapist and undergoing our hydrodissection peripheral nerve blocks and trigger point injections to treat the inflammation of her pelvic nerves and spastic pelvic floor muscles. Several months later, she is now pain free and back to high interval running and looking to expand her family even more.

Condition: Endometriosis

Patient Described: 40-year old woman presents with history of painful periods since age 11. Prescribed OCP, Birth control, history of painful intercourse, At 25 years old diagnosed with endo and laparoscopy ablation performed to remove endo.

Patient Journey: Following first surgery, prescribed Lupron, helped with pain but had many unpleasant side effects. Second surgery 10 years later, and was now struggling with infertility, underwent multiple fertility treatments, failed pregnancy, miscarriages, etc. Referred to PRM seeking pain relief and expert excision.

Conditions/Complaint: Dyspareunia, Endometriosis, Infertility, chronic pelvic pain

PRM Treatment Approach: We discussed that though endometriosis surgery had been performed, her pain was related to persistent spasms of her muscles and inflammation of her nerves, and that her nervous system remained upregulated and sensitized to pain as her “normal state”. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after surgery.

Treatment Result: PT was prescribed suppositories, muscle relaxers, topical pain relief. She was also referred to Dr. Lora Liu for consult/excision surgery.Prior to surgery, treatment protocol consisted of injections coupled with medications. Pain level went down from 8 to 5 by third injection and by injection 6, a 3 out of 10.Dr Liu performed excision surgery and at, 6 week follow up. Patient pain significantly reduced and feels like the beginning of a new life.

Condition: Chronic pelvic pain syndrome, vulvodynia, pain with intercourse

Patient Described: 26 year old female presented with 8-year history of pain with penetrative intercourse, inability to tolerate intercourse, urinary urgency, and dysmenorrhea. On exam, she displayed vulvodynia with positive Qtip test.

Patient Journey:Recent flare up of these symptoms in last 1 year. Pain was further exacerbated after placement of IUD per patient, leading to burning and tearing during penetrative intercourse.

Conditions/Complaint: Dyspareunia, Chronic Pelvic Pain Syndrome, Vulvodynia, Pain with Intercourse, Urinary Frequency,Persistent Pelvic Pain, Urinary Urgency, Inability to Tolerate Intercourse

PRM Treatment Approach: We discussed that vulvodynia and chronic pain was leading to her vaginal muscles remaining tense which in turn was causing an upregulated and sensitized nervous system. Muscle tightness and pelvic nerve inflammation and irritation contribute to chronic pain even after multiple treatments.

Treatment Result: She was sent to PFPT where we recommended dilator use, myofascial release, and neuromuscular reeducation. She underwent PRM treatment protocol with suppositories and injections as well. By the end of the series of six injections, she was having painless penetrative intercourse. Her urinary symptoms had resolved and on repeat exam, her qtip test for vulvodynia was negative.