Meet Dr. David Prologo

Have you heard of him?  I had not until just a few weeks ago.  I heard a rumor that he is doing some great stuff with pudendal neuralgia.  He is an interventional radiologist located at Emory in Atlanta, Georgia.  He is doing cryoablation to the pudendal nerve with use of CT-guidance.

See, interventional radiologists are the guys that are doing pudendal blocks with CT-guidance in the first place.  They are also the vein guys.  They treat pelvic congestion.  So, how perfect that Dr. Prologo treats both.  Makes sense, right?  Especially if  pelvic congestion created your pudendal neuralgia.  (The varicose veins can distend so much that it puts pressure on your pudendal nerve – or other nerves.)  If you don’t know much about pelvic congestion, then check out my post on it.  Click here.

So I hear about Dr. Prologo, I google him and the first image that pops up is the face of a very cheerful man.  I think, “Oh. He is happy.  Good.  I will email this happy doctor.”  And I do.  And he writes back.  Right away.  He allows me to basically interrogate him.  Here is a bit of our conversation:

  1. Sara: Is your technique for treating pudendal neuralgia called cryoablation or is it different from cryoablation?

Prologo_DavidDr. Prologo: This technique is indeed cryoablation. The unique thing about what we are doing, though – is the implementation of image guidance. We are using our interventional radiology training and evolving image guidance techniques to access nerves that are deep in the body and otherwise inaccessible for injections or ablations, in this case the pudendal canal.

2. Sara: How is your technique different from pulsed radiofrequency ablation?

Dr. Prologo: Radiofrequency ablation is heat mediated tissue destruction. Cryoablation creates shifts in osmotic gradients and intracellular ice crystals that ultimately results in the shutting off of nerve signals, more like turning down the volume of the stereo vs. blowing it up with a bomb.

3.  Sara: Why do you prefer freezing versus burning?

Dr. Prologo: 1) Cryoablation is great for pain procedures because it is not painful 2) Cryoablation creates an “ice ball” that we can see on CT. Therefore there is no guesswork involved with where we ablated 3) Cryoablation initiates a unique immune response that a) results in longer lasting results and b) stops neuroma formation (vs. radiofrequency ablation or surgery)

4.  Sara: What are the results you are getting?

Dr. Prologo: Our results have been largely durable and positive. That is, the great majority of our patients experience complete relief from their symptoms. That said, pain can be complicated and outcome depends heavily on patient selection.

5.  Sara: Have you followed your patients from four years ago?

Dr. Prologo: I am in touch with most of the patients that were done and they are still doing well.

6.  Sara: What are the side effects?

Dr. Prologo: We have not seen any side effects to date.

7.  Sara: Any long term issues?

Dr. Prologo: Not that we are aware of at this point.

8.  Sara: Is it possible that you are inadvertently treating the posterior femoral cutaneous nerve as well?

Dr. Prologo: No. The ablation zone and CT scanning are both exquisitely precise. This is actually the epicenter of the new therapies and innovation. That is, it isn’t really the cryo that is new, it’s the advanced imaging guidance to treat pain. The techniques are so precise that we can literally treat 2mm nerves in the skull base.

9.  Sara: Who is an appropriate referral?

Dr. Prologo: This is key. Patients who have been diagnosed with pudendal neuralgia are most likely to benefit. That said, many patients come with a wide variety of backgrounds and symptom descriptions. As a result, we can get everyone to the same starting point by performing a diagnostic “test injection.” Again, because we have CT, we can see with 100% certainty where our injection ends up. As a result, there is not guess work. If the patients symptoms improve with the test injection, then they will do well with the cryo. If not, then they don’t have pudendal neuralgia and some other therapy is warranted. That said, interventional radiologists also treat pelvic congestion syndrome, which can be misdiagnosed as pudendal neuralgia.

10.  Sara: Explain the process.  Do patients fly in for an evaluation and receive treatment or do they have to fly back for treatment?

Dr. Prologo: No. We have developed a system in which patients who have stories reflecting underlying pudendal neuralgia – or some close variant – come in for a consultation and injection on the same day. Usually, we also schedule the cryo for the following day so everything can be done in one trip. If the patient fails the injection, we just cancel the cryo.

11.  Sara: What does treatment consist of?

Dr. Prologo: We place a needle in CT in the pudendal canal. The needle is configured to create a 3cm x 2cm ablation zone about its center. We freeze for 8 minutes, thaw for 4 minutes, freeze for 8 minutes, and thaw for a final 4 minutes – after which we pull the needle/probe.

12.  Sara:  How long do patients stay in town after the treatment for pudendal neuralgia?

Dr. Prologo: I encourage patients to at least stay the night of the procedure. That way, if there happens to be a complication (bleed, for example) we can take care of them here.

13.  Sara:  Do you freeze the whole nerve or different branches of the nerve?

Dr. Prologo:  We freeze the portion that runs in Alcocks’s canal (the pudendal canal).

14.  Sara:  Are you doing a pelvic exam to confirm your diagnosis of pudendal neuralgia or are you going by verbal report of symptoms alone?

Dr. Prologo:  No. It is all about the injection. We have the luxury of being able to make the diagnosis based on the injection because of precision imaging. We shut down the nerve with 100% certainty in order to make or exclude the diagnosis of pudendal neuralgia.

15.  Sara:  Are you familiar with Interstitial Cystitis?

Dr. Prologo:  Yes.

16.  Sara: Are you seeing your patients’ Interstitial Cystitis symptoms resolve?

Dr. Prologo:  We usually don’t treat this condition with this procedure. I think it may be helpful for folks to understand the larger picture. We have been lucky enough to be able to treat many conditions by accessing nerves with image guidance (phantom limb pain, occipital neuralgia, cancer pain, and more). Pudendal neuralgia is one of these subsets.

17.  Sara:  Does insurance cover treatment?

Dr. Prologo:  So far >90% of cases have been covered without incident. Sometimes we need to call or write a letter if the patient is out of network.

18.  Sara:  Will you be presenting your treatment at any pelvic pain conferences?

Dr. Prologo:  I have thought about this, but have not pursued it. I presented a few years back at our conference (Society of Interventional Radiology) but I think more interested parties may be at the pelvic pain conferences.  

I would like to add that 1) I didn’t invent this. I was trying to help patients with cancer pain using cryoablation and God put these patients with nerve pain in my path (pudendal, greater occipital, phantom limb, etc) so I feel like it is my responsibility to do the best I can to help them. I have been so fortunate and blessed to have met so many beautiful people because of the way this thing has worked out. In the end, my only motivation for continuing to do this is to help folks.  2) as I mentioned earlier, the therapy is one application in a much larger picture – the use of image guidance for the treatment of pain. As data emerges regarding the safety and efficacy of these procedures, we will continue to grow and hopefully help even more patients. We appreciate the privilege to participate in each and everyone of these patients’ lives, hopefully toward the better. 

Thank you Dr. Prologo for metaphorically sitting down with me, letting me shine a super bright light in your eyes and continuing to answer my questions despite my Cheetoh breath and complete lack of etiquette.  You are patient.  I am a salivating, rabid dog hungry for some answers.

If you have any questions or comments please leave them anonymously in the comment section below or email me at [email protected]

What to Do After a Hernia Repair Makes You Nervous


I’m going to go out on a limb and say that probably one quarter to one third of my male patients have pelvic pain because of a hernia repair gone imperfect.  (Don’t confuse that to my guess that 80-90% of my male patients have pelvic pain because of something related to a hernia.) When this happens, there are options out there.  I have to honestly say that those patients who have pelvic pain because of a hernia repair only go so far with physical therapy treatment alone.  They may improve a lot, a little or not at all until they get the right kind of medical management.  I’m considering medical management to be care that I cannot provide as a physical therapist – something a physician might do.

According to the article that I reference often called :  Current trends in the diagnosis of and management of post-herniorraphy chronic groin pain which can be found in the World Journal of Gastrointestinal Surgery (try googling it – the full length article is available)…there are a number of treatment options for those with pelvic pain after hernia repair.

There are surgical and non-surgical options.  Let’s start with the non-surgical:

  1.  Lifestyle modifications:  This means that you just change things.  Sit less.  Avoid pain.  Use heat or ice to calm the pain down.  In general, I think this is a dumb idea (and so do the authors of the article, but they say this much more professionally).  So, forget this option.

2.  Use analgesics:  Numb the pain with creams and gels.  This is a Band-Aid and it isn’t a Band-Aid.  It’s a Band-Aid because you are masking the pain to an extent, but you are not resolving the core issue of scarring, fibrosis, a lumpy mesh or nerve irritation.  However, what you are doing is chilling out the constant painful signal to your brain.  This might allow your fascia and muscles to calm down for a bit and for your brain to get a break.  Constant pain signals to the brain actually change the brain and essentially make you more sensitive to less pain.  It’s exhausting for your nervous system and it’s a downward spiral for your quality of life.  So, in this respect, it isn’t a Band-Aid.  Get it?

3.  Physical therapy:  Ya’ll, this article lumps physical therapy in with massage and acupuncture.  Nothing against those that practice massage and acupuncture, but when you lump us all together, it tells me that the authors of this article have no clue what pelvic floor physical therapists do.  It says that physical therapy can reduce the pain, but cannot prevent pain recurrence.  I agree and disagree.  It just depends on the reason one has pain after their hernia repair in the first place.  We cannot treat all the symptoms with the same interventions.  Cookie-cutter, cookie-cutter, cookie-cutter!

4.  Nerve blocks:  The article says that this can reduce the pain signal to the brain and there needs to be more research on nerve blocks for post-hernia repair pain.  After what I’ve seen in my own practice, I think that it really depends on why one has post-hernia repair pain in the first place, who is doing your nerve block, which nerve the physician decides to block, how they block it and what combinations of nerve blocks (if they are doing more than one) they decide to do and what they are injecting into the nerve.  Nothing is simple, everything is complex, but if the nerve is a big issue and there isn’t a neuroma growth and the nerve is purely just irritated and a patient gets the right kind of physical therapy from a therapist that doesn’t provide cookie-cutter treatment, then I believe that nerve blocks are a viable option to resolve some patients’ pain.  It’s about why the patient has their post-hernia pain.

Surgical options:

  1.  Mesh removal: This article says that just removing the mesh alone won’t resolve the pain because an inflammatory process has taken place and nerves have become irritated.  Because of this, many physicians will remove the mesh and then remove parts of the irritated nerve as well.  Partial removal of the nerve is called a neurectomy.  This can result in numbness.

2.  Ablation:  So they discuss radio-frequency ablation which is the use of heat to burn the nerve.  This article looked at doing ablations for inguinal nerves at the spinal level and found that 4 out of 5 patients found that this completely resolved their pain months later.  Now, don’t go thinking this is the golden ticket.  Remember that patient selection is really important here, so after careful assessment of a patient the ablation was performed.  When you do the right treatment for the right cause of symptoms, that’s when you get good results.  In my next post, I will discuss cryoablation which is the use of cold to treat a nerve.  Heat vs. cold.  Cool, huh?  <— Wait, I swear I didn’t write that intentionally, but will you look at that…”Cool” – I just kill myself!  Ah…me.

So, that’s that.  These are the options listed in ONE article about post-hernia repair pelvic pain.  Again, I want to stress that for anything in medicine, you will only get better if you get treated for the root cause of your pain.  Too many providers out there are throwing only apples at pelvic pain.  Instead, they need to look at the pelvic pain and determine if that patient needs to be treated with an apple, banana, orange, kiwi or a cantaloupe.  We cannot only have apples in our pockets because apples don’t really fit in a pocket to begin with.

If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

When a Hernia Repair Makes You Nervous

In the last post I discussed the importance of getting hernias checked.  This is really serious as the effect of the hernia on nerves can cause a lot of what might seem to be unrelated pain.  Meaning, you can have pelvic pain as a result of hernias at your abdominal or inguinal areas.  Like I said before, I only truly opened my eyes to this a few years ago thanks to my detective patients.

Before jumping into surgery to repair a hernia, it’s important to understand what can happen as a result of hernia repair.  Let me preface this with one statement.  I have not had any patients start with pelvic pain and then get a hernia repair to end up with more pelvic pain.  I say this because of the next statement.

Hernia repairs can cause pelvic pain.

Let me repeat much of what I just said, but in a different way.

Hernias can cause pelvic pain. I’ve had patients get a hernia repair in order to reduce/eliminate their pelvic pain.  I have never had a patient get a hernia repair in order to reduce/eliminate their pelvic pain and end up in more pelvic pain.

Hernia repairs can cause pelvic pain.  Depending on where the hernia is located, it is very possible to develop pelvic pain as a result of the repair.  

Here is why:

  1.  During the incisions, it is possible to nick, damage or irritate a nerve that extends down to the pelvis.  This can happen with any incision at any part of the body.  It also happens with Cesarean scars when women deliver.  A small (or large) nerve gets a little more action than it was meant to have and that nerve gets pissed.  It can develop a reactionary neuroma which is like a little flower bud along the nerve now that is constantly and unnecessarily sending signals to all the remaining highways of that nerve – potentially the clitoris, penis, scrotum, testicles, close to the sit bones and anus.  It just depends on which nerve gets mad.  It could be the ilioinguinal, iliohypogastric or genitofemoral nerve.
  2. When mesh is placed, scar tissue can develop over the mesh and the surrounding nerves that can extend down to the pelvis.  Scarring of the nerves reduces their oxygen intake, blood flow and their mobility.  Without enough oxygen and blood the nerve has essentially become ischemic.  This means the blood supply (and oxygen carried in the blood) is cut off from the nerve.  This is really bad for the health of the nerve.  Nerves are a small percentage of the human body, but they require an oxygen supply that is proportionately quite hefty.  Without this and without proper mobility, you are going to feel pain in the pelvis.
  3. When mesh is placed, it can roll up a bit and irritate nerves that extend down to the pelvis.  This causes all the same symptoms as reasons 1 and 2 because of the same reasons as reasons 1 and 2.

Essentially, you could have a variety of different pelvic pain symptoms resulting from a hernia repair.  Person A and Person B could have drastically different symptoms depending on which nerve is mad and what part of that nerve is mad, but it’s possible that their symptoms are all a result of an imperfect hernia repair.

There are options for those dealing with pelvic pain from hernia repair and those will be discussed in the next post.

If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

When a Hernia Makes You Nervous

Please appreciate my attempted pun.

Hernias can make your nerves hurt.  It’s true.  Read about it here.  <— click there

I only started opening my eyes to this about two years ago.  It was two patients that really turned my focus onto hernias.  I have lots of patients with diagnosed small hernias.  I’m very suspicious of the role of hernias in pelvic pain.  It can mimic pelvic pain that one might think comes from the pudendal nerve.  The issue I face as a therapist is getting these hernias repaired.  Many physicians acknowledge a small hernia, but feel that if a hernia doesn’t create bulging then it doesn’t need to be repaired.  But if you read Dr. Shirin Towfigh’s post that I linked to above, you’ll understand that this isn’t always the case.  (On a side note – if you aren’t going to clink on that link, please know that she highly recommends checking for hernias while standing.)

If I hit a plateau with a patient and the doctor’s have tried everything they’ve thought of or everything I’ve suggested and we know that a patient has a small hernia, at that point I’m pushing for that hernia repair.  Very few local physicians agree with me.  It’s a sad, sad thing.  It makes me a highly unlikeable advocate for my patients.  I’m unlikeable to the physician, not the patient.

Outside of the immense pressure that a small hernia creates through the abdomen and then pelvic cavity, it is my hypothesis that ignored hernias can create nerve pain.  Specifically, I’m thinking that the ilioinguinal, iliohypogastric and genitofemoral nerves can be affected with hernias – whether they be big or small.

Hear me out.  I’m guessing the following.

There are some common sites for hernias.  One is at the belly button.  This is called an umbilical hernia.  These types of hernias occur often in babies, perhaps because of the placental attachment.  I’m assuming that often this hernia closes on its own, but when it doesn’t and the belly button appears normal then perhaps these babies become adults with small umbilical hernias.

Another common hernia site is the inguinal area.  This is that crease where your abdomen meets your leg.  It folds in when you sit and straightens out when you stand.  There is something called a pubic tubercle that rests in this inguinal space.  This space carries blood vessels and nerves.  Many men get inguinal hernias after lifting heavy objects, though women can get inguinal hernias too.

Some hernias bulge out and can be pushed back in.  Some don’t bulge at all.  Some hernias hurt, others are completely pain-free.  Sometimes a person has one badass hernia that looks like an animal is trying to free itself from the human’s abdominal cavity.  Other times a person has several teeny tiny hernias that they are unaware of.

So – let’s talk about this.

If a person has a hernia, then any and all the nerves around that hernia site could be aggravated by the hernia alone or by movement such as bending, lifting, stretching, pressure from pooping, eating a lot of food and stretching out the abdomen, etc.  Think of something that moves the abdominal tissue around that hernia and that could irritate nerves in that area.

This is why if I plateau out with a patient, I really push searching for a hernia.  Sometimes I can say, I think your hernia is at the left inguinal area or at the belly button.  I’ll tell the patient to tell their doctor that I’m super suspicious of this undiagnosed hernia.  However, like I said before, there is so much push back from my local physicians.  I don’t know if this is a regional problem or a blanket problem across the board.

Something is causing your pain.  I believe all people can heal.  So if you have reached a plateau, getting checked for a hernia isn’t a bad idea.  You just have to know what to expect in a good screen.  You also need to know the downsides of hernia repair which will be in my next post.

If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

Predicting the Future – My Free Crystal Ball Session (Rocks not included)

This is what I cannot understand:  Providers can be really short-sited.  But, why?

Think of the wrist surgeon who says you have carpal tunnel, but they ignore your complaints of elbow, shoulder and neck pain.  Your wrist pain is coming from the neck!  So you need your posture corrected, your spine and shoulder mobilized, your shoulder blades re-educated and your nerves flossed.  The wrist is attached to the rest of the body, we cannot be wrist-centric in this case.

Think of the colorectal surgeon who will surgically remove your hemorrhoids, but won’t look in your vagina to see if you have a prolapse ultimately causing you to strain when you poop.  You need a prolapse assessment, treatment for the prolapse and the factors causing the prolapse so that you stop straining and don’t create further hemorrhoids.  The anus is centimeters from the vagina, we cannot be anal-focused in this case.

So then there is the person with pelvic pain.  Many people with pelvic pain end up complaining of foot pain.  They’ll go to a podiatrist and are told that they have plantar fasciitis.  This just kills me!  Patients start to think that they are falling apart, one part of their body at a time.  But, they’re not falling apart.  It all makes sense.  Hear me out:

I’m going to predict the course of events of someone in pelvic pain.  If I take a simple case, it would look like this:

  1.  You go through a period of high stress for work.  You sit a lot for this job.  You think about this job when you are at home.  You continue this high stress situation for weeks, months, years.
  2. You start to notice a dull ache in your rectum.  You’re like “I feel that, that’s weird, huh.”  You shake it off.  No big deal.  You decide not to do anything about it because it’s too weird a thing to bring up to anyone.
  3. The dull ache in your rectum becomes an actual pain in your ass.  You start to freak out because it’s starting to flare up sometimes when you sit for a while.

This person thinks that this pain is one thing.  But, then this happens:

4.  You start to notice that you have trouble getting all the pee out and when you are done, sometimes you dribble a little bit.  You kind of feel like an annoying nagging sensation to pee, even though you just went.  You realize that you need to pee a little more at night than you used to.

So now you think that you have rectal pain and now a bladder problem.  You must be just getting old, right?  But, there’s more:

5.  For some reason you start to feel a little sore after you orgasm.  You get a lingering discomfort in your genitals.

Eh, not a huge deal, just a little weird.  Until…

6.  Now you really dread pooping because you notice that you really hurt after pooping.  You notice that pooping makes your bladder hurt and your rectum flare up.  You don’t understand why this is happening since you’ve always pooped without issue before.

You’re starting to get freaked out at this point.  You decide to go to the doctor and they give you antibiotics for an infection that they cannot find.  You feel better for a while, but then…

7.  Your rectum hurts again, your bladder is still messed up, sex doesn’t feel the same and you still hurt more after pooping.  And now your feet hurt.  What the fuck?  Your feet?

This is when panic sets in.  You.  Are.  Falling.  Apart.  You go to the podiatrist and they tell you you have plantar fasciitis.  Can you catch a break already?  You do some foot stretches and massage your feet, the pain gets a little better, but it’s still there and it’s still bugging you.

8.  Now you can’t stand and you can’t sit.  You prefer to lie down.  What has become of you?  How will you work?  How will you play?  How did this happen all of a sudden?  You used to run marathons and you have two kids and you need to keep your job.  Now you’re anxious, really, really anxious, but the doctor tells you that nothing is wrong since you’ve been on several antibiotics already.  They’re now telling you to relax and seeing a psychiatrist.  So you go to the psychiatrist and they say you need to relax and get on anxiety meds.  So you get on anxiety meds and they help a little, but you are still in Hell!!!

That’s my guess.  That’s my prediction about the beginnings and the ends of my imaginary person’s pelvic pain.  Does it sound familiar at all?

What I’d like to see is a little more thought go into this situation.  You are paying your providers for their unique thoughts which are supposed to be better versed in the body than yours – that is why they are medical providers and you are not, right?  I’d like this thought to go in the direction of the whole body and not just the body part.

What I’m saying is, I want the podiatrist to know a lot about the back.  I want them to know when to send a patient with foot pain to a spinal specialist.  The sensations from the foot stem from the low back.  If the podiatrist could be less foot-centric and more whole-body centric, I think that the world would be a less pained place.  Really, I mean it.

Now, there are, of course, times when foot pain is stemming from the foot.  But, sometimes it’s stemming from the ankle, knee, hip, pelvis, back or all of the above.  Expert judgment should determine this.  Expert judgment is really necessary and should be expected, but most of the time I don’t see this happening.

So…what I’m saying to you is this:  If your feet start to hurt, please consider that your foot and pelvic pain could be coming from your back.  Don’t let anyone tell you otherwise.  Get treated for the core of why you are hurting, not just the symptoms alone.

And then there is the homunculus.  This is your brain’s map of your body.  Except, your body is Picasso’d in this map.  The parts of your body with more sensation are drawn larger and the parts of your body that are more “connected” are drawn together.  It looks like this:


As you can see with a magnifying glass, on the left side of the picture, in the middle part of the brain (because that is one half of a brain), the feet and toes and genitals are next to each other.  Hence the theory why people with pelvic pain also develop foot pain.

What’s the answer?  I think the answer is that you should get your back screened very well before doing anything to your feet.  I think that’s the only thing you can take action on.  This homunculus thing is cool – but what do I do with that information?  How can I help you with that other than just getting you to understand the potential link?  It does make a cool picture and there is truth to it, so maybe you can frame it.  I would.

If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

All Your Psychosocial Issues


All ya’ll.

Listen up.

I just had a manic OCD episode and washed my hands way too many times so this soap box is empty!  What should I do with it?  Any suggestions?

I don’t quite feel like recycling it yet so I think I might…just…stand on it.

Is that cool?

You’ve got psychosocial issues.

Have you heard that before?  Of course you have because you have pelvic pain.  The first few medical thoughts you pay for are that you need counseling or maybe even sex therapy.  You might have been told that you need counseling before you were told that you needed pelvic floor physical therapy.

The truth is that there is truth in this.  You do have psychosocial issues if you have pelvic pain.  How could you not?  But, the other truth is that we all have psychosocial issues.  How could we all not?  I’m compelled to stand on this now empty box that was once filled with unscented, white Dove soap because I’m hearing this phrase far too much in my professional life.

Allow me to explain.

What is real, what is necessary, what is evolving is this construct of explaining pain to patients.  There is really good research to back up the idea that if you explain what happens to the nervous system once someone has been in pain, anxiety, fear, etc long enough, then real physiological changes happen to the body.   These changes can create an exaggerated interpretation of stimulus.  That means a light stroke on the back of the hand can be truly interpreted by the brain as a razor splitting the skin on the back of the hand.  The observer’s reality of that act is different from the reciever’s reality of that act.  The brain connected to that hand, in the case of a person with chronic pain, truly believes that someone tried to shave their hand open.  And that’s scary.  Like, really, really scary in so many ways.  Can we count them?

  1.  Why the fuck would someone shave your hand open?
  2.  Truth is that there was no razor, but it’s hard to constantly remind your brain of that.  One part of your brain says “calm down” while the other part says “calm down, whaaaat?!?”
  3. If there is this much difference between the brain’s truth and the rest of the world’s truth, then is this person in chronic pain crazy?  Is all of this pain truly in their head?

It gets so sticky.  It gets hairy.  It gets confusing and lonely to be in this much pain for so long.  The only good part of this all is that there is true science to demonstrate that this is happening to the brain and the body.  The nervous system is re-wired.  The collective “we” of healthcare providers doesn’t know a whole lot about how to change this, but “we” are really interested in changing this and “we” are implementing new practices to do our best to change the chronic pain nervous system.

The names that pop up are Lorimer Moseley and David Butler.  They do tons of work on chronic pain – also known as central sensitization.  One example of this that many people are familiar with is the concept of phantom limb pain.  This is when someone has had a body part amputated, but their brain still interprets sensations of pain in that body part that is no longer there.  These amputees are not crazy people, they are sane, frustrated people living with significant alterations to their nervous system.  The same thing happens with pelvic pain.  You can get to a place where there is no intrusive injustice taking place in or on your body, but your brain perceives that there is still a body threat and therefore your body feels pain.  Remember – pain has a purpose.  Pain is to protect you from harm.  It’s just that with central sensitization aka chronic pain aka an altered nervous system, the nervous system gets stuck in a loop.  It just plays the same “pain” message”.

Ideally, patients are given tools via reading material, actual body movement homework programs and body calming techniques to retrain the nervous system.  Counseling can also be very helpful in reprogramming the negative through process that can take place when you are in chronic pain.  So, how much am I using all this in my practice?  Not enough.

I don’t use this enough.  I don’t educate on chronic pain nervous system changes enough.  I don’t harp enough because I have so much difficulty with my patient “buy in”.  I struggle to be consistent with my body movement retraining programs because if a patient gets stuck, I get stuck.  I don’t know how to proceed or alter my advice well enough to help the patient.  I need more education to help me be a better educator.

So…can we say that is kind of the “psych” part of “psychosocial”?

What about the “social” part.  What does that mean?

I think it means that, regardless of whether someone with pelvic pain is aware of it, being in pain changes their social roles.  It might mean that they do less housework, it might mean they switch some of their responsibilities at work, it might mean they are having less sex with their partner, it might mean they need to ask for some help from a friend.  Things are just a little or a lot different.  This difference can impact a person’s identity, their relationships, etc.  It can be a drastic thing where a person has taken on “pelvic pain” as their new identity, or it can be smaller like “Oh, I just don’t go to the movies anymore.”

I think that’s the “social” part of “psychosocial”.  I could be wrong and if I am…it doesn’t really matter because my angst isn’t about the definition of the word, but the use of the word.

The medical community uses the term “psychosocial” as a scape goat when they do not know what to do with a patient.  The pain doctor says “Oh, they say they had more pain after my nerve block, they have a lot of psychosocial issues to take care of.”  The physical therapist says “The patient complains when I have them do clamshells.  They say it makes their anus hurt.  That doesn’t make any sense.  I don’t think they want to get better.”  The psychologist says “I think that the pain is serving a role in their lives.  They are not ready to get better.”

My truth is that sometimes it’s true.  Sometimes, and it’s rare, sometimes I do think a person has psychosocial issues and the pain might be serving a role.  But…most of the time, MOST of the time, it’s just bullshit to blame a patient’s lack of progress on psychosocial issues.  In most of those cases, it’s the provider that doesn’t know how to best treat that patient.  Why do I say this?  I say this because I’m usually the second, third or fourth physical therapist that a patient has seen and I often hear from their former providers that the patient has “psychosocial” issues.  I even once asked an orthopedic surgeon to do a diagnostic procedure and he responded “Well…has the patient seen a psychiatrist?”  Kudos to you, sir, for thinking about the patient’s emotional well-being, but I take that Kudos bar back because you have forgotten to do your actual job.

The psychosocial scape goat.  We blame the patient – behind their backs.  Should we be blaming ourselves?  Eh.  No.  I don’t think it has to be binary.  I think that it’s okay to tell a patient that we’ve taken them as far as we know how to take them at this time.  I can’t tell you how many patients I want to find and pull back into my treatment room because on this day I know how to best treat them, but three months ago, one year ago, five years ago…I did not.  I truly believe that all of my patients can get better with the right care.  Sometimes I’m not the one that can give that right care.  In that case, I believe that I need to refer to another provider.  I think that’s the right thing to do and the honest thing to do.  I hate to hear discharge stories of patients who were essentially “laid off” by their therapists.  They didn’t do anything “wrong”, they just didn’t get better fast enough or at all.

There is the argument that as providers we can’t fix everyone.  It’s true.  I cannot heal all my patients.  But, I do firmly believe that if I cannot help someone, then someone else can.  I want to have options A, B and C available to them.

psychosocial issues

If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

Extra! Extra! New courses for your pelvic floor physical therapist! Spread the news! Spread the love! (Don’t spread disease.)

Learn from the author of Blog About Pelvic Pain.

Vestibulodynia:  A Pelvic Floor and Orthopedic Approach.

Course Dates: 

Austin, Texas August 19-20, 2016

San Diego, California September 17-18, 2016

Course is approved for 16 contact hours through the TPTA and CPTA.

Click here for registration form.

Click here for course schedule.

More information at

Book Review! Pelvic Pain Explained

Pelvic Pain ExplainedThis book has no rainbows.

But I still love it!

Pelvic Pain Explained, ironically, does what it’s title tells us it’s going to do.  It explains pelvic pain.  For some reason, I was expecting something different.  I’ve taken Stephanie and Liz’s class before and I remember really enjoying it, but I can’t remember commenting on how good they are at actually breaking down the “why’s” of pelvic pain.  Am I only now paying attention?

Ya’ll, this is better than Headache in the Pelvis.  It explains things more simply and more efficiently.  My favorite example of how pelvic pain can develop is this one:  A guy works as a cashier.  His conveyor belt is on the left side of his body, he constantly stands with planted feet facing forward and rotates to the left.  Day in and day out, left rotations.  So now he has a left lumbar rotation (Ok, they didn’t say that, but I’m saying it) and the muscles on the left side of his back/pelvis, etc. become tighter and the muscles on the right become looser.  Then the patient goes skiing and does a bunch of jumping and falling and uses a lot of his back, hip and pelvic floor muscles doing so.  The left side muscles were already chronically tight and now they were asked to do a bit more work and BAM! now this guy has pain.  He thinks “Why do I have pain after skiing?”  Well – because I just explained the build up, you all now know.  I love this example because it’s super common.  Think about the woman who is driving with her toddler in the backseat.  She constantly reaches to the right behind her to give her daughter something or take something away (because she is driving in America and her driver’s seat is on the left).  Think about the guy that works as a dishwasher.  The dishwasher is on one side of his body and he makes constant, repetitive motions in the same direction.

I like how user-friendly the book is.  It helps patients navigate the medical community and offers questions to ask providers.  I think going to a provider with a list of questions is important.  It’s even more helpful when the list comes from pelvic floor physical therapists that know how to treat pelvic pain.

The first thing I noticed when flipping through Pelvic Pain Explained was that they mention that patient’s can get a lot of good information from blogs.  Blogs like…mine!  I got the book as a birthday present from my sister.  The best birthday present was seeing Blog About Pelvic Pain referenced in the appendix.  That’s me! In print!  (Every birthday and Christmas she asks me what I want and every birthday and Christmas I ask for a book about pelvic pain.  She hates it.  She’s bought me The Better Bladder Book, Screaming to Be Heard, Mind Over Medicine and Pelvic Pain Explained.  I recommend all of them.  Embarrassing shout out to my sister Aryana Khanzadeh.  She will truly hate that I have said this much about her and that is why I just keep going….Hopefully now anytime someone googles her they will find my blog muwahahaha!)

Then there are the kegels.  They talk about kegels.  Not everyone should do kegels and just because you shouldn’t do kegels now doesn’t mean you can’t do kegels later.  Just because you once did kegels, doesn’t mean you should still be doing them.  I was actually a kegeler for some time before I really let this concept settle in.  I came from an orthopedic background so it made sense to me that if you did kegels it could only improve your pelvic floor dysfunction.  I was starting to hear buzzings that doing kegels wasn’t for everyone so I just shoo’d those mosquitoes out of my ear.  I continued to make my patients kegel left and right until I started to really pick up that my patients were coming back feeling worse.  They would have more pain or they would have more of an urge to pee than before.  I had to come to terms with the fact that I might be wrong.  It was turning out that somewhere around 50% of my patients who had short pelvic floor muscles who were instructed in doing kegels (by me) were feeling worse because of it.  That was my fault.  Kudos to the therapist’s out there that started practicing in pelvic floor after this kegel situation was being addressed – I had to learn the hard way.  It’s kind of embarrassing to make your patients worse because you are stubborn.

My only regret about this book is that they didn’t go into a whole chapter of detail about how powerful a role connective tissue plays in pelvic pain.  I wanted the explanation of the reasons for connective tissue manipulation to be more expansive.  I do want everyone to skin roll appropriately.  I want everyone to understand the purpose and the benefits of skin rolling.  I also want to eat Toblerone for every meal without gaining weight.


If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

Trusting Estrogen Part 4

I said the blog would be back.  So now the blog has returned.

Why the abrupt, unexplained halt?  Well…I was trying to get knocked up and it wasn’t happening.  There was a lot on my plate.  Something had to give and this gave.  I think I’ve got my ducks in a row now and on we go.

Do you remember months and months ago how we were talking about estrogen?  No?  Well…go back and read the past few posts and you’ll be caught up.


But what about the fear?  Let’s talk about the fear.

Does estrogen cause cancer?

I’m going to keep what I know simple.

Estrogen applied to vulvovaginal tissue is not supposed to be absorbed throughout the body.  The simple truth that I do know is that it can be absorbed systemically – just a bit.  But, it’s not the same as using systemic estrogen via a patch or a pill or a gel.  Estrogen that is only absorbed at the vulvovaginal tissue should not cause cancer because it should not have large body wide effects.

Some women are super sensitive and their nervous systems absorb, absorb, absorb.  I have patients who use vaginal estrogen and they’ll notice mood changes and breast changes.  This is because of the systemic absorption that they are receiving because their systems are bit more spongy – they take in everything quite intensely.  I’ve asked these patients to try to just place a dot of estrogen on their urethral openings or just at the vestibule.  This way they are getting benefit without putting the hormones in the pelvis pocket – otherwise known as the vagina.

Estrogen in itself, regardless of where it is applied, does have the ability to increase cell growth.  This is what cancer is – it’s crazy, uncontrolled cell growth.  Estrogen in itself, regardless of where it is applied, increases the body’s metabolism.  For example, when a man takes estrogen therapy to perhaps transition to become a woman or at least to make their physical appearance align more with what a classical woman looks like, their fat redeposits on their face making their cheek bones more noticeable and their waist thins because of the increased metabolism in these areas.  Because of this increased metabolism, many physicians say that estrogen bodywide is considered breast protectant.  It’s increased metabolism counteracts it’s own increased cell growth.

The other important piece of information to add is that the study that emphasized the connection between estrogen and cancer was a study that used Premarin and only Premarin.  That is worth consideration.

This is one reason I am glad I’m not a doctor.  I don’t have to make these decisions for patients.  What I do do, though, is ask my patients to have these conversations with their doctors or I have these conversations with their doctors.  It is the doctor’s decision to determine whether or not estrogen body wide vs. locally is appropriate for a patient.  Each individual must consider their own  unique medical history.

Can you see it now?  The hurricane is coming.  I’m the hitchhiker from way back.  You are in a car with gas and you have pelvic pain.   You’ve got pain…but you’ve got gas.  Will you pick me up?  I’m a pelvic floor physical therapist and I can help your pelvic pain – but you don’t even know it because you are programmed to be scared of all hitchhikers.  You are programmed to be scared of estrogen.  But, what if this is what you need to make a huge difference in your pain?  In your life?  Something so simple?  It could make all the difference in the world.  So, arm yourself to identify someone or something that can help and ask the right questions to determine with your physician if you should pick up this hitchhiker or if you should drive on by.  Do your own homework and present it to your doctor.  Have these conversations.  Have intelligent conversations and ask more questions.  Don’t take a blanket statement as truth.  The truth isn’t black or white, it isn’t even gray.  It’s all colors, so figure out the truth for you.


Oh, am I pregnant now?  Like, right now?  I don’t know.

If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

Alliance for Pelvic Pain Retreat


(I’m not back.)

Alliance for Pelvic Pain Retreat: Interview with Amy Stein

Have ya’ll heard of this?  It’s an annual retreat for those with pelvic pain.  This is not my interview, but I did want to spread the message.  Please note:  There is a minimum attendance required to put on this retreat, so without that, the retreat cannot be held.  (Just a heads up!)

The Alliance for Pelvic Pain on May 20-22, 2016 at Honors Haven, Ellenville, NY.

Read more about a previous retreat, which was a huge success!  Please enjoy the following interview with Amy Stein regarding the retreat…

  1. What was the goal in creating the Alliance?

The goal was to create a safe learning environment where participants feel comfortable expressing their thoughts and feelings.  In addition, we wanted to help women meet other women suffering from chronic pelvic pain (CPP) and to teach them self- healing and self-care techniques that they could practice at home.  Furthermore, we wanted to help participants learn about the medical physical therapy approach and mental health approach to treating CPP and  to learn about how bowel, bladder, and sexual function can be compromised due to CPP.

  1. What were the highlights of the weekend in your opinion?

The highlights were the ability for these women to realize that they were not alone and they were able to bond with each other.  We were also pleased with the teamwork of the interdisciplinary health care providers. CPP is a complex condition that affects multiple aspects of life and which requires the participation of several disciplines to account for all areas affected.  The Alliance team all worked very well together and we felt huge reward and accomplishment by offering this to these women.

  1. What was some of the feedback you received from participants?

Some of the comments that we heard were, “This was a life changing experience!” “This was the best weekend of my life!” “This was a monumental event and I’m glad that I was a part of it.” “I felt so relieved to meet so many women with my same condition and to know that I am not alone.” ”I learned a lot this weekend from a medical approach, a self-care approach, and about the mind-body connection.”

  1. How did the Yoga sessions complement the lectures and workshops?

It helped with more mind-body awareness as well as educating the participants on relaxation breathing and relaxation poses.  It complemented the mental health care providers in educating patients on how to calm the nervous system and de-activate the fight or flight (sympathetic nervous system) response.  It also gave patients more options for various stretching positions.

  1. Would you do this again? What do you look forward to incorporating into future Alliance retreats?

YES!  I would love to do this again, assuming we have as good of an organizer as Alex. From a physical therapy perspective, I would like to incorporate more self-care techniques.  We look forward to providing more support groups related specifically to their condition.  We would also like to have male patients in the future.


For almost two years, Blog About Pelvic Pain has provided weekly posts.  (Well, there were a few weeks there where I failed you…but for the most part…weekly posts. )

The blog is now on an immediate and unexpected break.


But, the blog will return because it has to return.

Trusting Estrogen Part 3

So let’s back up.  Way up.


People are scared of estrogen.  People don’t understand estrogen.  People hate estrogen.  People love estrogen.

We have a lot of emotions towards estrogen.

Estrogen can help with vulvovaginal issues.  So how do you know what kind of estrogen to use?  That is a really big question.  Estrogens can be given orally, via a gel, with a patch or topically.

Oral, gel and patch estrogens are meant to be absorbed throughout your whole body.  That is considered “systemic” absorption.  That is body system wide.  Topical estrogens are to be applied to the vulvovaginal tissue.  They are typically only absorbed “locally”.  This means that the estrogen isn’t going to affect your body outside of the vulvovaginal tissue.  The tricky thing is that there are some women who have sensitive nervous systems.  These women do notice more systemic absorption of topical estrogens.  They might notice mood irritability, breast tenderness among other body changes.

One thing you must know:  Just because you are using systemic estrogen does NOT mean you are getting an adequate amount at your vulvovaginal tissue.  Many, many women need topical hormones on their vulvovaginal tissue IN ADDITION TO the systemic estrogen they are using.  Most doctors don’t understand this.

To review…

Orals, gels and patch estrogen = systemic estrogen = changes body wide

Topical creams applied to the vulvovaginal tissue = localized estrogen = changes in vulvovaginal tissue (but can be body wide for some)

So, there’s that.

Now if we look just at localized estrogen we can answer some more questions.  There are lots of different companies making localized estrogen.  You may have heard of names like:  Estrace, Premarin, Vagifem and now there is an oral pill called Osphena that is supposed to target only vulvovaginal tissue.   And there are more names that I’ve not listed.  There are three different types of estrogen found in the human body.  The type of estrogen used in these creams can differ.  Each estrogen, regardless of type, needs to be transmitted to vulvovaginal tissue through a base.  So, all estrogens are mixed with a base.  What we’ve got here now is different types of estrogens and different bases.  We’ve got a confusing situation.  We’ve almost got too many options.

Too many options.  It’s true.  But, when you go to your doctor, it might not seem that way.  It might seem as if there is only one or two options and those are called Estrace and Premarin.  Doctors get lots of free samples of Estrace and Premarin.  I’m going to talk about only three topical options because if I talked about any more I might type forever and have to rename this entire blog Blog About Pelvic Pain and Also A Lot About Topical Hormones – But, Men, I Have Stuff For You Too, I Promise and oddly enough – that url was taken….  Who knew?

Let’s talk about Estrace.

Estrace is estradiol + propylene glycol.

Estradiol is the estrogen and propylene glycol is the base.

Estradiol is is bio-synthetic.  It is very much like what our own body produces.  It is a very helpful estrogen.  It is a very powerful estrogen.  It is my favorite type of estrogen for women to apply topically to the vulvovaginal tissue.

Propylene glycol is an alcohol base.  So…if you already have issues at the vulvovaginal tissue – say you already have pain and are seeing your doctor to resolve this pain, then applying alcohol (albeit with a good estrogen) to your vulvovaginal tissue might actually burn.

When it burns…ah, let’s talk about when you’ve been prescribed Estrace and it burns.  Oy.  A lot of times a doctor will tell you to keep using the Estrace if it burns, but a lot of times patients just give up.  Because it burns.  Because they went to the doctor to get relief from the burning in their vulvovaginal tissue and were prescribed a topical hormone that created more burning in their vulvovaginal tissue.  Doctors will often say, well, if you’re really deprived of estrogen at the vulvovaginal tissue, then the estrogen alone will burn.  And, they are right – if your vulvovaginal tissue is super duper incredibly out of this world unbelievably deprived of estrogen.  Just touching it to apply anything at all can hurt.  But, for the most part, if your vulvovaginal tissue is super deprived of estrogen and you give it estrogen (without also introducing alcohol), then it will feel pretty decent to good to really nice a lot of the time.  I think that doctors think that the estrogen is burning because they are largely unaware that they are issuing estrogen with an alcohol base.  I think that, honestly, is the main problem.

The way you get around that is by compounding the estradiol in a very gentle base.  There are tons of bases out there with really exciting names.  But, I like to keep it simple.  I like plain old coconut oil as a base.  It’s good for your, it’s anti-microbial and I haven’t met anyone that it irritates.  (Actually, one person was irritated by it and they ended up using Slippery Stuff as their base.)  The point is, there is a base option out there for the very sensitive vulvovaginal tissue.  The downside of this option is that insurance doesn’t pay for compounded topical hormones.  Insurance doesn’t get it.  The other thing is – you have to advocate for yourself and ask your doctor for this.  They aren’t going to jump right to it most of the time, but they have probably heard of the idea of a compounded topical hormone.

Let’s talk about Premarin.

Premarin is made from pregnant horse’s urine.

Pre(gnant) + Mar(e) + (Ur)in(e) = Premarin

This is not bio-synthetic…because it’s from a horse.  It’s considered a conjugated equine estrogen (CEE).  This means that it is a horse estrogen that has been converted to a form that can be used by the human body.  The implications of this are that the estrogen sticks to your body’s estrogen receptors very aggressively and it’s affects last for a really long time.  The other part of this is that our body doesn’t metabolize these estrogens in the same way that it would metabolize something that is more bio-synthetic.  For some women, this has been really problematic.  You can google it and find lots of crazy stories.

Nevertheless, Premarin is heavily marketed to physicians and it is heavily used by physicians.  It’s not my first choice, by any means, but it’s one choice and for some people it’s better than nothing at all – if they can tolerate it.

That’s the basics.  The basics of the basics.


If you have questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

Trusting Estrogen Part 2

Remember a week ago where I left off?  I was being compared to Adam.  If you can’t remember -you’ll have to read it again, because that right there…that name-calling.  Well, that brings me back to estrogen.

Estrogen is in the male and female body.  But, when a woman goes through menopause (or when she is young and on specific medication(s)), she has a sharp drop in estrogen.  One of those places in her body that loses a lot of estrogen (and testosterone) is the vagina and the vulva.  Remember – the vagina is the cave inside the body and the vulva is the genitals that you can see with your eyes (it’s on the outside of the body).  Both of these locations have a decrease in estrogen (and testosterone) during pre, peri- and good old menopause.  This affects the body in a lot of ways.  In a global sense, the body gets drier.  Skin loses it’s rebound and elasticity, the mouth dries, the eyes feel drier.  Memory can be affected.  Hair on the vulva might start shedding.  More plaque might start forming on blood vessels.  Specifically in the vulvovaginal tissue, you might see that you are getting more actual infections, more symptoms of fake infections, dry sex, dryness without sex, lower sex drive, painful sex and a slew of bladder issues.

Let’s break these apart.

Estrogen helps plump up all of your vulvovaginal tissue.  If you have a drop in estrogen (and testosterone), then your tissue is more fragile.  This means that if you have friction at the vulvovaginal tissue, its more likely to form microscopic tears.  It means it can form larger tears – tears that don’t require a microscope to see.  Let’s call these eyescopic tears.  And I mean tears like a rip in paper, not a tear from crying.  I’m getting less and less unequivocal.  (Did you get all that?  I walked myself deep into a word maze.  Puns and using a stupidly long word that means “to be clear”, yet ironically is the most unclear word of all.  Public education.  That’s all I have to say.)  So these tears of skin – they can hurt.  They can burn.  They can also allow bacteria that would normally just bounce around and off closed tissue to then incept that broken tissue and create an infection.

Estrogen helps bring blood and oxygen to vulvovaginal tissue.  When you’ve got blood and oxygen, everything works better.  Your tissues are more plump.  Your tissues will hurt less.  Your tissues will be more pliable to a penetrating item (penis, dilator, vibrator, speculum, finger, toy) and respond to physical therapy treatment better.  When you don’t have enough blood and oxygen in your body, then you can develop tightness in your tissue making stretching painful.  This can keep your muscles in the vagina and the rectum short.  So if the muscles are short because stretching is painful, then when your muscles need to stretch to let items in or out of the pelvic area, then it will hurt.  Also, short pelvic floor muscles can give bad information to your brain.  It can create false senses of urinary urgency and frequency and can make urinating burn.  This can feel like an infection.  The confusion comes in when you get tested for an infection and there is none.  Then what? Then your doctor puts you on an antibiotic anyways.  Maybe long-term.  Maybe every time you have sex.  But, still, you’re on an antibiotic that is fighting off something that isn’t there.   The antibiotic is like a dumb Jedi with a light saber fighting off…nothing…just air…just fighting in your body…just wreaking blind havoc to your gastrointestinal system.  Just because it’s got nothing else to contest with.

Then there’s the dry sex.  Estrogen helps your vulvovaginal tissue lubricate and it helps your vagina stay at a healthy pH.  So when you take the combination of lack of natural vulvovaginal lubrication, possible change in pH and possible miscroscopic tears, then it makes sense that sex might be dry and painful.  And then there’s the added thing of a drop (or plummet) in libido because of a potential drop in estrogen (and testosterone).  Or – perhaps the drop in libido is a result of recurrent dry, painful sex.  Chicken or egg, chicken or egg.

Ok, so now take sex out of the equation.  With a lack of natural vulvovaginal lubrication, possible change in pH and possible microscopic tears and lack of estrogen and oxygen to plump the vulvovaginal tissue – you’re just going to feel dry.  Even when you’re not having sex.

But then there’s the bladder stuff.  This is one of my favorites.  See, it makes sense that if the vulvovaginal muscles are tight and making the nervous system send false signals to the brain about urinary urgency and frequency and if these tight muscles are causing painful urination that you would think there is a problem with your bladder.  (And that a doctor would jump to thinking you have Interstitial Cystitis.)  But, it’s not always the bladder that’s the problem, right?  Because you just read this paragraph.  The vulvovaginal tissues are the culprit and they are too cowardly to tell you that they are the trouble makers, so they are mimicking bladder symptoms so that you will look to get bladder treatments.  The vulvovaginal tissues are very tricky, they are liars and they have no conscience, I swear!  They put all the blame on the bladder and never admit to what they have done.  Shame on them!

What you must know, is that there is a part of the vulva (the external genitalia) that is called the vestibule.  The vestibule is embryologically the same tissue as the urethra and parts of the bladder.  What that means to you is that if the vestibule has a problem, then it can feel like your urethra and bladder also have that same problem.  They can feel one and the same.  The vestibule is super dependent on estrogen (and testosterone), so if your vestibule has reduced estrogen (and testosterone) you can start to feel like your bladder is acting up (among many, many other things).

Part 3 of this trilogy – err, no, it’s going to be longer than that… and Blog About Pelvic Pain’s 100th post is next!


If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

Trusting Estrogen Part 1

As a physical therapist in the United States, I’m not legally allowed to discuss certain topics with my patients.  I take classes on specific topics in school, but many of these topics are off-limits when educating patients.  This is ironic and puts me in a predicament that I refuse to let stress me.

Medications.  Yeah, I’m not legally allowed to give any advice on medications.  I need to ask what medications a patient is on, I’m expected to be knowledgeable on what the medications do and at what dosages I should expect to see different things happen…but I can’t give any suggestions on medications.  I can only go so far as to say “Discuss this with your doctor.”  and “Take your medication as prescribed by your physician.”  For the most part, I’m cool with this because I really don’t know a lot about meds and their interactions with other meds in the body.  The aforementioned predicament arises, however, when I know what a therapeutic off-label dosage is for a specific drug and the doctor does not.  Or, for example, the predicament arises when I know a certain medication is going to take the person from living in a state of agony to completely pain-free – but the doctor is unaware of how to treat this patient.  Doesn’t know where to start.

What gets me in a pinch the most is topical hormones.  Let’s talk about this.  I love topical hormones.  I love, love, love them because they are game-changers.  They are, however, shrouded in mystery and cancer.  What I mean is that many physicians are not well-educated on the proper uses of topical hormones for vulvovaginal symptoms, specifically.  The cancer comes in because many physicians believe that estrogen causes cancer – period.

I want to share what I know.

But first – a story….

There was once a hurricane in a city that many loved.  It was huge.  It destroyed everything in its path.  It was a monstrous tragedy.

Days later there was an announcement of a coming hurricane in my city.  Because of the devastation of the prior hurricane, my city evacuated.  I decided that in order to beat the mad rush out of town, I’d play it smart.  I’d get in a car and leave in the middle of the night – when no one is on the road – ever.  Because, people don’t drive cars at night.

I realized that I was as bright as everyone else in that city.  At three in the morning there was maddening gridlock traffic – with a potentially deadly hurricane on the move.

When you’re in a situation like that…you realize that you’ve been given the answer to a question you didn’t realize you had ever asked yourself.  I said to myself,  “Oh, ok…so this is how I die.  In traffic.  In a hurricane.”  And I threw my hands in the air.  I was in pajamas. I cannot remember why.  Hours past and the cars never moved so we all ran out of gas.  The cars on the highway – just idling – run out of gas.  So now it’s permanent traffic.  It’s just stupidity.

Those people who were way smarter than me – they didn’t leave their homes at three in the morning.  They left their homes at practical times like…first thing in the morning times.  They drove around the traffic.  They drove in emergency lanes.  They had gas and they were passing me by.  I thought “I literally having nothing to lose.  I’m in pajamas in the middle of nowhere about to die in a motherfucking hurricane.”  So, I got out of the car and put my thumb in the air.  There was a man standing next to me.  He wasn’t hitchhiking – he was just standing there thinking.  He turned to me and said “No one’s going to pick you up.  They don’t know you from Adam.”

That was the first time I had heard that phrase.  It struck me that if I was being compared to the first human – Adam of (Adam and Eve fame) – then why wouldn’t they pick me up?  I mean – I hope they didn’t think I was Adam because I was clearly a girl in pajamas.  Just looking for some sleep (and a private piece of grass to take a shit).  But in the context within which that random thinking man to my left said the comment – I knew it wasn’t a good thing.  It had to mean that the drivers with gas, the ones whizzing by to safety and a clean toilet didn’t know me from someone else named Adam.  And for some reason, they didn’t trust this other Adam.  And they were confusing me.  With him.  They were confusing me with the Adam that they didn’t trust.


How to Release Your Inner Diva

Releasing the diaphragm is so important in diva-hood.  Without the ability to properly use your diaphragm, you will never sing like Otis.  Not ever.  In order to assist my patient’s in becoming the divas they deserve to be, I use a few different techniques, but I do have a favorite.

I think that you can’t be a one trick pony because what works for one patient doesn’t always work for the next patient with the same symptoms.  There are several visceral techniques that directly or indirectly release the diaphragm.  I’m not going to go over those techniques because I’m not about to try to explain how to do visceral techniques.  I’m not there now and I won’t be there for a long, long time.  But, I can explain my caveman technique.

That doesn’t sound nice, does it?  Caveman. It is a caveman technique, though.  It’s just brute force-ish.  It’s straight to the point and it’s super duper effective. If you are like my toddler, you are asking “How it work?” Well…this is how it work:

  1.  I have my patients lie down on my plinth with their hands resting behind their heads.  This opens up the diaphragm a bit and it elongates the torso.  The patient’s legs are also straight to increase the abdominal and diaphragm stretch.  (Remember, if you are lying down, the diaphragm goes right through you from front to back.  It’s like when a magician takes a lady in a box and “slices” right down her middle and then she is in two parts?  That’s how the diaphragm runs, like the magician’s “slicer”).
  2. I stand up towards the patient’s chest and I take my extremely short-nailed fingers and gently dig them under the rib cage on one side.  I’m using two hands for this.  I get a good grasp of that one side of the rib cage.  It’s like getting the firm grip of a handle bar.  It’s a good grip.  It’s a firm grip.  It’s a caveman grip.
  3. I have my patient do really slow, deliberate, dramatic, perfect diaphragmatic breaths.  I let my caveman grip move as the rib cage moves up and down.  Up and down means it’s moving towards the ceiling and down to the floor that I’m standing on with my own caveman feet.  Then, out of nowhere…when the patient is at the height of their diaphragmatic inhalation (which is when the bottom of the rib cage is closest to the ceiling) I freeze.  I keep the rib cage at that height and I let the patient exhale.  That means that their diaphragm goes to its shorter length, it is no longer expanding at this point . But, the rib cage is where still in the “exhale” position.  Does that make sense?  The rib cage is in proper “inhale” position and the diaphragm is in proper “exhale” position.  And the patient – the patient is like “What the fuck are you doing?  Your hands aren’t supposed to be there – ever!”  It’s a crazy feeling when you get your diaphragm released this way.  The best way I describe it is “impolite”.  When I’ve had this done, I’ve thought “This is just not a polite thing to do.”
  4. And now, the patient continues their diaphragmatic breathing.  All the while I am holding the bottom of the rib cage in the “inhale” position, which is towards the ceiling.  I am doing this while the diaphragm moves through it’s range of motion.  After a few breaths, then I move my hand placement to another part of the lower rib cage and repeat the process.  I make sure I cover all the attachment areas of the diaphragm to the rib cage and then continue this process on the other side of the body.

This is a powerful technique.  It really releases the diaphragm well.  Even my most physically and nervous system(ly)-sensitive patients can handle this, as long as I adjust the brute force of my caveman hands appropriately.  Sometimes I have to do some deep diaphragmatic massage-like work first.  Sometimes I have to taper the lift of the rib cage with the diaphragmatic breathing.  But, either way, my patients handle it well as long as I handle it well.  Sometimes they get up and say “you got to…you got to…you got to got to got to got to got to do that again next treatment!“.  So, I do.

Now, my patients can sing.  Their diaphragm can perform its job going through the full range of stretch and release that it is meant to go through in order to breathe.  My patients then can get in more oxygen, promote more blood flow through the body, get more (or the first) pelvic floor expansion with diaphragm inhalation and can start or enhance their journey to improving bowel, bladder and sexual health and improvement of their pelvic pain.  Aaahh – to be a caveman.


If you have any questions or comments, you can leave them anonymously in the comment section below or email me at [email protected]

Release Your Inner Diva

I talked about diaphragmatic breathing before.  It’s so important.  It’s so, so, so important that I want to go back to it.

The thing is, I’m learning that breathing with your diaphragm is not enough.  You’ve got to breathe with your diaphragm when you are in pain.  You’ve got to breathe with your diaphragm when you are stressed.  You’ve got to breathe with your diaphragm when you are not in pain.  You’ve got to breathe with your diaphragm all the live long day.

Have you heard that Otis Redding song with that little part where he goes into a singing seizure? “You got to…You got to…You got to got to got to got to got to got to ARGH!”  At that moment he becomes possessed with the ghosts of stuttering singers past.  And that’s fine with me because it sounds really good and I wish I was so taken with my own singing that I could just one day sing and lose all of my own senses, possibly even pee on myself while delivering a moving and beautiful melody – a melody that essentially tells people what to do – controls the world – you know, let’s me be bossy.  But, that will never happen…not in that way.  I mean, yeah, I can make myself lose my senses and pee on myself, but no one will ever be moved by any melody that comes out of my mouth.  But, for a moment, can you pretend to hear the sound of my voice and be moved?  You’ll do that for me?  You’ll grant me that one kindness?  Okay, thank you.  Then, let’s try it again.

“You got to, you got to, you got to breathe with your diaphragm when you are in pain!  You got to, you got to got to got to got to got to got to breathe with your diaphragm when you got to got to got to be stressed! You got to breathe with your…you got to got to breathe with your…you got to got to…you got to breathe with your…ARGH!…you got to breathe with your…ARGH!…you got to breathe with your diaphragm when you are not in pain!”

But I’ve already said that.  I said that months and months ago.  What I haven’t said is that breathing with your diaphragm is no longer good enough in my books.  My book has been re-written.  Now I write that your diaphragm really needs to be released.  If you are a person who is alive and has eyes in the front of your head and hands in front of your body and tend to any task at all during the day that needs to be performed while sitting in a chair or if you wash dishes, do laundry, drive a car, type on a computer, write on your phone, watch TV, look at things ahead of you or even shave your own legs…then what I’m about to say is for you.  If you don’t fall into any of these categories, go ahead and skip this post.  It’s going to be a waste of your time.

So, if you are in any way remotely like the person I described above, then it’s not enough to breathe with your diaphragm all the time.  The person described above needs to have their diaphragm “released” because it will be “functionally” “short”.  I made up that phrase.  A lot of times we use the word “functional” in front of an undesired medical description to indicate that even though this part of the body is doing a bad, bad thing, it has to actually do that bad, bad thing in order for the body to keep working because there is something else in that body that is not doing it’s job because it’s too lazy to or because it really wants to do it’s job right but for one reason or another it is incapable of doing so.  But, I’m erasing that definition and making my own.  I’m saying that a “functionally” “short” diaphragm is one that is shorter than it should be because it has no other choice.  We sit.  We do things in front of us.  So, if the diaphragm attaches from the rib cage and slices through the body to attach to our back…then when we allow ourselves to slide into normalcy and and imperfection via sub par posture, then the front of the ribs and the back get closer together.  The diaphragm therefore hangs out in a shorter position.  When it is asked to allow for a good inhalation requiring it to expand, it will only give a percentage of the true length it was intended to give.  This is a problem for a lot of reasons.  One big reason is that your diaphragm work synergistically with your pelvic floor muscles.  Your pelvic floor does what your diaphragm does.

Putting it another way:  If your diaphragm is tight, then you won’t be able to breathe well.

If you can’t breathe well, you won’t be able to relax your pelvic floor muscles well.

If you can’t relax your pelvic floor muscles well, you will continue to be in pelvic pain.


Let’s talk about another point succinctly.

If your diaphragm is tight, then you won’t be able to breathe well.

If you can’t breathe well, you won’t be able to sleep well.

If you can’t sleep well, you won’t be able to produce hormones and cell repair in order to heal your body and calm your nervous system.

If you can’t sleep well, you will continue to be in pain.

If you can’t sleep well, you will be tired.

Are you tired of me? (Then release your diaphragm, breathe better and get good sleep.)   Okay, I’ll post the how’s next week.


If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

For the Physical Therapists Out There…All the Physical Therapists Out There….

Sullivan Physical Therapy…one of the most amazing pelvic floor physical therapy clinics in the United States…is hiring.  We are looking for our eighth therapist.  We are all under one roof.  Yes.  All.  Under.  One.  Roof.


What does that mean to you?  That means that if you are a therapist that wants to treat pelvic floor dysfunction as a career, not a “job”, then you have an chance to do so here.  Patients get better here because we all brainstorm together, we all teach each other and we have excellent communication with providers.


So…for the physical therapists out there…if you want to dive in, like, really dive into the pelvic floor world and make some good change, one patient at a time, the opportunity awaits you here.

Just shoot me an email at [email protected]

Voodoo Doo Doo Work Part 2

The voodoo doo doo continues… one long, healthy, completely connected, fully formed piece of crap.  Actually – no, it doesn’t continue.  It stops here.  Because here is where I explain how I turned a hard corner. Like a precision driver.  Like Clark Gable’s grandson.  (That is a story for another post.)

Time to wipe….

Last month I ventured out into the cold air of Salt Lake City to follow Ramona Horton to her Level 1 visceral course. The greatest thing that I learned taking my first visceral course with Ramona Horton was that skin rolling is working a different layer of fascia than visceral work.  What that means to the person in pain is that there are still more options out there.  What that means to me as someone who treats people in pain is that there are still more options out there.  It’s just up to me to identify when I need to be using visceral work.  And it’s up to me to get good at the visceral work I have learned.

What Ramona did for me was take all the voodoo doo doo out of visceral work.  She made it a very “normal” way to treat patients.  She took the time to convince me that my hands don’t have to be stupid and that I can actually feel things with them.  I wasn’t told that I had to put my hands on a patient’s head, I didn’t have to connect with their third eye and I didn’t have to fake anything until I made anything.

Visceral work is working on the deepest layer of fascia.  If fascia has an incredibly supply of nerve endings, which it does, then I need to address all of it, not just some of it.  Just like I need to address the whole person, not just one part of the person.  What I learned about paying attention to the deepest layer of fascia is that there are parts of patients’ pain stories that now make sense when they didn’t before.  For example, the symptoms of feeling unexplained nausea after eating seemed so crazy and a bit psychological when I first heard it.  But now, a little more sense has been made of it.  I now understand that the vagus nerve could be part of this symptom and by working on the deepest layer of fascia over the diaphragm, I can most likely affect the vagus nerve and this once seemingly delusional symptom.

I now have ideas for patients that stumped me.  I find that incredible.  I have an immediate game plan for what seemed to be the trickiest patients.  It’s just so refreshing and exciting.  I have a dear patient that came to me after having plateau’d with physical therapy with another therapist.  We did move forward and saw excellent results.  But, I couldn’t sustain those improvements consistently.  She boggled my mind.  I thought of her often.  I emailed several amazing pelvic pain physicians across the country about her case.  I talked about her in all the classes and conferences I attended.  I kept this patient in my back pocket at all times.  She made sense to no one.  I brought her case to Ramona Horton and instantly Ramona tells me what to do.  I’m thinking: What?  Who ARE you?  WHAT are you?  Ramona is like a backwards voodoo worker gypsy good witch outfitted in white lace and a kind smile.  I get back to Austin and do what Ramona told me to do.  And…the patient feels better.  Not 100%, but significantly better.  The best she has felt in a long time.  Now, I attribute this to two things.  First – Ramona knew what was up.  Second – the patient might have better results if I was more skilled in visceral work, but unfortunately that will only come with time.

Now, I’m not saying that I’m going to use visceral work all the time.  I’m not saying I’m going to use skin rolling any less.  I’m saying that I’ve got another piece of this puzzle figured out.  Is that cocky?  No,I don’t think so.  I think as pelvic floor physical therapists we are detectives.  It is our job to figure out your pelvic pain puzzle…because the way our healthcare system and education is set up…it is a puzzle.

Yet again, my practice is changed.  That is such an amazing feeling.  To experience the view from a higher floor.  If this inspires me, it should certainly inspire anyone with pelvic pain.  You are not out of hope, you are not out of answers, you are not out of your mind.  You just need to find the right care.  And that is the battle, the expensive, tedious battle.  Just keep asking questions.  Keep writing emails.  Keep being your own advocate.

If you want to find someone who does visceral work, you need to ask.  In your vetting of your potential pelvic floor physical therapist you need to ask if your patient performs visceral work or if they know someone who does.  Just like anything else, we are not all good at the things we say we can do.  My skin rolling is a hell of a lot different than the next person’s skin rolling.  Same thing goes for anything else in medicine.  Vet, vet, vet and then vet again.


If you have any questions or comments, please leave them anonymously in the comment section below or email me at [email protected]

Voodoo Doo Doo Work

About a year ago a blog reader emailed me to notify me that I’d do well to improve my website and consider practicing some visceral mobilization.  He said that visceral mobilization provided by his physical therapist was the only type of treatment that created long-lasting maintenance of his improvement.  I worded that really oddly.  Let me say that a new way.  Visceral mobilizations helped him eliminate his symptoms and it kept things that way – eliminated.

I want to be clear that my goal in treating patients is to, when possible, correct the core issue driving their symptoms.  But, if a patient is dealing with something that I cannot change, then my next goal is to eliminate most all of their symptoms.  If I can’t eliminate symptoms, then my third goal, my lowest rung goal, my saddest goal, is to improve their symptoms, even if for just a few days.  Sometimes that is enough to get a person through the week.  Sometimes physical therapy does just enough to keep a person functioning – like Advil for a headache.  We can be like a short-acting medicine in times when a person is going through something that we cannot change.  (And, for the record, there are few times I’m treating someone for something that I cannot change.)

So, this blog reader connected me with his physical therapist.  She had a lot of great things to say about visceral mobilizations as part of a comprehensive treatment for pelvic floor dysfunction (among other issues).  After our conversation, I decided that this therapist had a level head on her shoulders and that maybe I ought to give this type of work a second chance.

A second chance.  I already gave the “visceral” world a first chance and it was a horrible experience.  There is a body of school that teaches visceral work to all types of “body workers” – physical therapists included.  I took a four day course in visceral mobilization.  It was a beginner course.  It involved lots of crazy stuff and at the time I was not in the mood for crazy.  I was in the mood for science-based effective treatment to help my pelvic pain patients.  I spent four days listening to an extremely young instructor tell me to put my hands on people’s heads to figure out where their bodily dysfunction was.  This novice instructor wanted me to put my finger on patients’ “third eye”.  I felt like this asshole was selling me snake oil.

For example, he had me stand behind a patient and gently push them forward.  I was then supposed to know where they had a problem in the body.  Guess what?  I knew.  I said “Oh, the right side of your low back hurts.”  The patient was completely amazed.  The instructor said “See? This works.”  I said “No.  This is a basic core stability test that I learned in orthopedic fellowship training.  You just give a little nudge and see where the back looks most unstable – it will move a little.”  It’s just common sense.

Then, he had a patient stand with their feet together and their eyes closed.  He wanted me to note how the patient’s body waivered.  He placed his index finger in the middle of their forehead and instantly the patient stopped wobbling.  The instructor explained that he had connected with their “third eye”.  Crazy, right?  Except…it’s not crazy.  When you give someone feedback from an outside source, they instantly are able to understand where their body is in space better, so they stop swaying.  It’s the opposite of crazy.  It’s actually kind of boring.

I thought I’d have a heart to heart with the instructor…the guy that repeatedly said “Don’t be mad at me!” when he couldn’t answer the students’ questions.  I told him I was really having trouble feeling all the things he expected us to feel with our hands.  He leaned in and looked me in the eyes and said “Fake it ’till you make it.”  That phrase is my “off” switch.  I fake nothing.  I don’t know how.  I can’t fake nice.  I can’t fake mean.  I can’t fake shit.  Can anyone fake shit?  If you could…what would you do with this skill?

After those four days tested all civility in me, I returned to my patients and practiced zero of what I witnessed in the class.  Yeah, I was too proud.  I basically wasted my time and money by not even attempting to use any of the concepts I was exposed to.  The worst part is, and I don’t know who to blame for this, but I feel that blame is necessary because I have a strong index finger and constantly want to point it at someone…the worst part is that the basic tenant of visceral work was completely lost on me.  And that is a shame because there is a lot of good in visceral work.  I don’t have to act voodoo, fortune-tellerish if I don’t want to.  I can actually make changes in the body using visceral work.

So what is this work I speak of?  Could it help your pelvic pain?  Who does this work?

Ah…stay tuned.

Those Who Can, Do. Those Who “Can’t Even”, Teach.

I’m teaching YA’LL!!!  But, it’s not because I can’t “do”, because I think I can “do”.  I’m teaching because I want to “do” and “teach”.  I want my cake and I want to eat it too.  It’s cuz I did make my bed and I think I will lie in it…thank you very much.

I hate the new young jargon where we destroy the English language by talking in half words and half sentences.  You know what I’m talking about…

“Oh my grd” for “Oh my God”.

“Because [insert any noun at all]” for describing the strength or power of that inserted noun as in “Because [cupcakes].

And my favorite phrase to hate…

“I can’t even” for “This bothers me a lot”.

The middle of the road treatment, the average treatment, the “classical?”, “conservative?”, “historical?” way of treating vestibulodynia “bothers me a lot”.

I can’t even.

So, I will teach.

I want to introduce my new vestibulodynia class titled Vestibulodynia:  A Pelvic Floor and Orthopedic Approach.  Vestibulodynia is defined as pain at the vestibule.  The vestibule is the opening of the vagina.   Typically, people with pain at the vestibule have pain with sitting, sex, pain with wearing tight clothes, sweating, wearing tampons and can also feel like they get urinary tract infections a lot or they feel like have a lot of issues with their bladder.

The goal of the course is to educate physical therapists in how to critically assess each patient so that the treatment of the patient addresses the true cause of the patient’s symptoms.  I’d like to see physical therapists grow more comfortable in identifying the cause of a person’s vestibulodynia symptoms so that they can better treat it.  And, if they can’t treat the symptoms themselves, I’d like to see physical therapists confidently discuss the patient’s case with the right physicians.  There are many times when the physical therapist will need to educate the physician…and there is nothing wrong with that.

I’m tired of patient’s having their symptoms managed, their symptoms masked, their symptoms tackled.  The goal is to take care of the root of the problem.  The root of the problem is the reason why the symptoms exist in the first place.

The other reason I wanted to teach was because I think the pelvic floor physical therapist should have really strong orthopedic skills.  Orthopedic skills are what you think of when you get physical therapy for your hip or your knee in a big open gym.  Pelvic floor physical therapists truly focus on the pelvic floor, but we also need to be really good at assessing and treating the back and hips as well.  My co-teacher in the course is Kelli Wilson.  She is a highly trained physical therapist with amazing orthopedic skills as a result of her years and years of tedious fellowship training.

Together, we want to teach physical therapists to be true detectives who look at the whole picture when treating patients with vestibulodynia.

Share this information with your physical therapist if you think they are open minded and hungry to learn.

More information can be found at our website: