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 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]

Treating the Iliopsoas.

I think it’s important to treat the iliopsoas for a variety of pelvic floor dysfunctions.  Last post explained how you can tell if your iliopsoas is tight.  I also explained how you can stretch it.  I also mentioned that you really should make sure your pelvis is aligned when doing this.

I want to talk about this some more because I firmly believe in correcting pelvic alignment and re-correcting pelvic alignment and correcting your own pelvic alignment and correcting your friend’s pelvic alignment and correcting your doctor’s pelvic alignment.  I also, as an aside, really want to see OB/Gyn’s correcting pelvic alignment.  It’s so simple to do and such a powerful treatment that it’s disappointing to see so few providers employing this treatment.

Think about this.  If your iliopsoas is tight, then, when you get into the Modified Thomas Stretch (as I suggested in the last post), your thigh is going to be really far away from being parallel to the table or the ground.  If one attachment site of the iliopsoas is the front of the low back and you’ve got this attachment site stapled down to the ground, the mat or the bed, then the other attachment site is attching to the hip bone.  Because the iliopsoas is tight and stapled down on one end, it’s going to rotate the pelvis so that your pubic bones are trying to point towards your face (and not the ceiling like they should).  This rotation of the pelvis will force your thigh upwards towards the ceiling.

If you have a tight iliopsoas…and one side is tighter than the other, it will pull our pelvis out of alignment.  Your whole pelvis might be tilted forward, giving you that excessive curve in your low back and making your butt stick out, but if the tightness is unequal, then one side of the pelvis is going to be tilted anteriorly more.  So, if you don’t correct this before doing your stretching, then you are going to be stretching inefficiently.  You are going to have further to go in your stretch than if you were stretching with an aligned pelvis.

But, almost more than that, you really shouldn’t do anything healthy for your body without an aligned pelvis.  This makes all your other body parts compensate for what’s going wrong in your pelvis.  This upsets your muscles, bones, nerves, bowels, bladder, etc.  You don’t drive with your tires out of alignment, why do you live your life with your pelvis is out of alignment…especially if you already have pelvic pain???

I work on my patient’s iliopsoas by digging my hands into their abdomen and attempting to reach my fingertips deep into where I think the iliopsoas runs.  I try to feel the spine of the patient by going through their abdomen and then I work my way down the diagonal that the iliopsoas runs and then I dig into the iliacus.  Am I actually touching the patient’s spine through their abdomen?  Sometimes I really, really think I am because I think I can really, really feel it.  Other times I really can’t get very deep.  But, truly, am I touching the iliopsoas ever?  I don’t know.  There’s a lot of stuff in the abdomen and I do my best – whatever I am doing is just incredibly helpful.  If I’m just messing with really superficial abdominal trigger points, but I think I’m on the iliopsoas…it’s still helping.  If I am just moving intestines a bit, it seems to be helping!  I say it helps not because I believe it helps, but because my patients really improve after I do this work.

Sometimes I hold trigger points on what I think is the iliopsoas while I have my patients move their leg slowly on that same side.  I have them bend their knee, but angle their hip so that the knee isn’t facing the ceiling, but also isn’t facing the wall on their side.  The knee is angled just between these two extremes.  I have them slowly flex their knee all the way and then slowly straighten their knee all the way – all the while I am holding pressure on a part of the iliopsoas.  I’ll do this while running pressure all along the iliopsoas.  It takes some time, but it does a lot of good.  I make sure not to forget the iliacus.  Working the iliacus, as I always like to say, is like scooping out the meat of an avocado.  I view the iliacus as a shell filled with iliacus meat and I use my fingers to knead into it, scooping, holding singular pressure, massaging.  This can be done with the leg still or moving.


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

Twelve Angry Americans

The abdomen is the area between the rib cage and the pelvic bones.  It’s responsible for holding a lot of organs.   A really important muscle called the psoas runs through the abdomen.  It attaches from the front of the spine.  The front of the spine is the front of the back.  This part is internal and you cannot reach it.  It attaches from this spot and goes diagonally through the abdominal cavity to attach the inside of each pelvis to join a muscle called the iliacus.  The iliacus and psoas joined together make the muscle that we call the iliopsoas.  The iliopsoas then finally attaches to the top of the hip bone.  That is the iliopsoas.  The iliopsoas is on each side of the body, so you have two.

There are a lot of cool things about the iliopsoas.  One is that it is responsible from lifting the thigh.  It also is responsible for bending the trunk over the pelvis.  The iliopsoas, as a whole, crosses over a lot of territory.  So, let’s think of it as a connector of two points.  Point A is the front of the lumbar spine (the low back that sits on top of the sacrum and below the thoracic spine).  I’m going to call Point A “Canada” now.  Note that at Canada, the psoas has an attachment point to each individual lumbar vertebrae, like it’s sewn in to each vertebrae individually.  Point B is the hip.  Let’s call this “Mexico”  Ok, so between Canada and Mexico we’ve got a whole lot of stuff (like the United States of America).  There’s all the intestines, the bladder, the connective tissue and abdominal muscles, the pelvis and the pelvic floor muscles.  So, there’s that idea.  That idea will sit for now.

Here’s another idea.  Humans sit a lot.  We sit for work, we sit to commute, we sit to eat, we sit to poop, we sit to read, we sit to watch TV, we sit to write blogs, we sit to visit with friends, etc.  We sit a lot.  When we sit, your hips are flexed, that’s the only way we can sit in a chair or on the floor.  When we sit sometimes our trunks are flexed forward too, like if we are really into a conversation or we can’t see the computer screen well – we flex trunk the trunk for whatever reason.  So, the two end points of the iliopsoas are closer together, essentially in a contracted state for much of our lives.  There’s that idea too now.

Bring the two ideas together…

For much of our lives, we are basically squeezing Canada and Mexico together.

So, pretty much everyone in the United States is going to get pissed off, right?

You never know what you’re going to get with a pissed off American.  If you piss off America, you could get symptoms that you never expected…because Americans are very creative….  When you piss off America, you should expect some or all of the following symptoms (at a minimum):

  1. Low back pain
  2. Thigh pain
  3. Hip pain
  4. Sacroiliac joint pain
  5. Bladder pain
  6. Urinary urgency
  7. Urinary frequency
  8. Incomplete bladder emptying
  9. Burning with urination
  10. Constipation
  11. Vaginal pain
  12. Rectal pain

12 angry Americans.

In the next post I will discuss these symptoms, how you can tell if your iliopsoas is a problem and what you can do about it with a therapist or on your own.


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

What Are You Doing on September 26th?


The Pudendal Neuralgia Association is a new group for people with sitting pain.  The organization began in 2013 and it’s goal is to be a resource for patients and their providers.  Yes – for their providers.  So…if you’ve got a doctor that wants to help you, but doesn’t know where to begin – this is where they begin.  Their website has a list of resources to help a patient find a doctor, a therapist, a counselor, etc.  There is even a number for a suicide hotline.

Last year they held their first Pudendal Neuralgia conference intended to teach medical providers.  This year will be the second conference.  The Second Annual Pudendal Neuralgia Conference will be held in Annapolis, Maryland on September 26th.  Any provider that’s interested, whether it’s your doctor, therapist or counselor or even your nurse practitioner will get the chance to learn from Dr. Hibner and Dr. Conway and Stephanie Prendergast and other specialists.  Where else will your doctor learn?  Seriously.  Where?  That one paragraph in their medical school textbook and the complete absence of any physician continuing education courses over pudendal neuralgia clearly isn’t cutting it.

Ah – but then there’s this!  And “this” is what I’m really excited to tell you about:  On September 26th, there is a Pudendal Neuralgia Patient Web Conference.  What???  Who said that???  An educational seminar for patients?  On the web?  Because people with sitting pain can’t sit on a fucking plane???  Genius!  Or…common sense!  Some of the speakers are Amy Stein (of Heal Pelvic Pain), the sassy Dr. Deborah Coady (of Healing Painful Sex) and Dr. Hibner (talking to patients!) among other names.  I only wish I could be part of the web conference (hint hint).  If I was part of it, I’d be screaming and fuming and pulling my hair out and pointing at the camera a lot saying “You deserve better!  You deserve better!  As God as my witness, we are going to do better!!!”

This is the number one thing I hear from patients – they want to learn more about their pain – from people who know about their pain.  My patients would love to attend conferences that I attend, but they’re not allowed to attend – which is silly and wasteful in a lot of ways.  But here we have a mighty opportunity that I’m excited to share with ya’ll.  A web conference from the specialists to the patients.  From them to you.  For you.

So…if on September 26th you don’t have any plans – you’ve got plans now.


Click on the underlined phrases to go to the registration site.

The Pudendal Neuralgia Association and they will indeed be selling DVD’s of both the provider and the patient conferences.  They will be available several weeks after the conferences, so please check their website after the conference for more information.


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

NEW NOTE ADDED 8/1/15:  Unfortunately, today I found out that this conference has been postponed until September 2016 due to lack of registrants.  So disappointing.

That Scar Will Take You Far

Working scar tissue can work wonders for pelvic floor problems.  It’s awesome because it’s simple and it’s awesome because it’s awe-vious.   So, why are you never told to work the scar?  Why are you never told that if you work the scar it will take you far?

The thing with scar tissue is that it’s tough, it’s super fibrous and it grows like the roots of a thick weed down into your fascia and even to your muscles.  If your connective tissue is like a leotard connecting your whole body from head to toe, then imagine that leotard had a hole in it and someone grabbed an excessive amount of tissue all around that hole and sewed it back together – really tight.  All the edges around that patched hole would be puckered.  There would be tension at a distance away from the patchwork and even as far as inches and feet away, there would be a tug toward the patchwork.  That’s basically what a scar can do to your fascia and your muscles if it’s allowed to take over without proper treatment.

Because of what’s demonstrated in the above analogy, it’s really important to search your body for scars in the effort to treat pelvic pain.  I’ve got a patient that has a scar on his low back, but it affects his bladder and perineal symptoms.  This is not rare.  Cesarean scars on women can affect bladder symptoms and painful sex.  Then there are the more obvious scars – scars that affect nerves directly.  Scars need to be respected, not ignored.  They are powerful and can be damaging, but they don’t have to be.

Physical therapists are skilled in releasing scars, but I do not think we are skilled in appreciating that a scar at Point A can be related to pain at Point B.  I say this because I am at fault for this too.  It took me a really long time to care about scars. that were not directly on top of a painful area.

If you do not have a physical therapist, but you want to address your scar, you are not out of luck.  You can work on your scar for yourself.  See if it moves like the rest of the skin around it.  If it does not move like the skin around it, then that scar is kind of stuck.  You can tug the scar (and the scar-free tissue around the scar) in different directions, in all planes (left, right, up, down and all around).  You can pick it up, you can marble it between your finger like a booger, you can press downward into it.  It might burn, it might feel sharp, it might reproduce a weird symptom like an urge to pee.  The more you address your scar with this kind of hands on work, the less that scar will create those weird symptoms.  Your goal is to have a pain-free, symptom-free scar that moves freely with the rest of your skin.

Using any plain lotion will do.  If you have sensitive skin, try to avoid lotion with special chemicals or scents.  You don’t need a lot of lotion either.  You want some friction so that your scar moves.  You don’t want your fingers slipping right over it.  Sometimes I do scar lotion without any lubrication.  I like that best.

You can spend a few minutes a day working on your scar.  I would advise that if you are working on a post-operative scar and you recently had surgery, then you need to ask your doctor when you can start working on the scar.  They may tell you that you never need to address the scar.  In that case, just ignore that comment and get a straight answer.

Scars are like cars.  If you tend to them, they’ll take you far.


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

The Puborectalis – My Favorite Backdoor Location

Ya’ll – I have a favorite pelvic floor muscle.  I talk about it all the time.  It’s got the coolest name.  You can’t totally access it through any door.  It’s responsible for so much, but is so under appreciated.

It’s the puborectalis.

The pube…oh…wreck…tAl…iss.  The puborectalis.  It’s the figure eight around the vagina and the rectum, it’s the infinity that keeps us connected, it’s the wedding band to our pelvic floors.

So it’s into looping – right?  The figure eight, infinity, a ring…it loops.  It’s two connected circles.  It’s a lasso (if you will) around the vagina and it’s a lasso (if you will again) around the rectum.  This is what’s so cool about the puborectalis – it’s role in looping around the rectum is kind of magical/awesome/fantastic/sexy (sexy???)  Hear me out – please – hear me out.

What It Does

The puborectalis lassos around the rectum and holds kind of taught, just hugging the rectum enough to keep stool from plopping out of your rectum and right onto the anal sphincter.  See, there’s two exits for shit.  (I find it freeing to say “shit”.  Call me anal expulsive.)  It’s got to get past the bouncer that is the puborectalis, then it has to get past the anal sphincter.  So, when you sit on the toilet and do that little bulge, that little tiny push that starts the bowel movement, that’s you actually releasing/relaxing/widening the puborectalis so that stool can slide down the rectum and past a relaxed external anal sphincter out of your body and into the toilet.

So, why the Hell did I use the word “sexy” to describe the puborectalis?  Because I’m weird.

I am.  I’m weird.  But, you know when you’re a girl starring in a movie and there’s this plain looking guy also starring in the movie and he all of a sudden, but very casually solves an impossible math problem that saves the world?  Something a little tiny bit like the plot of Good Will Hunting – well, that’s kind of sexy.  I don’t know how else to describe it.

The puborectalis is also kind of like a John Wayne.  Just saves the day, no big deal, all while smoking a toxic cigarette and leaning on his horse.  No need to talk fast.  No need to over explain anything.  Just gets the job done, no complaints, no extras necessary.  The puborectalis is just really cool and it doesn’t even know it!  And that’s sexy, right???

Things I Think I Know and Things I Know I Don’t Know

While it’s no doubt that if you have constipation or tailbone pain, a physical therapist is going to check out the puborectalis for appropriate or inappropriate tension, I really think he puborectalis needs to be looked at for other symptoms as well.

So this is one is easy for me.  The “simple” form of painful sex – just feeling pain with actual sex, without pain at the vestibule, without spasming that does not allow penetration – just plain old “sex hurts” sex – that symptom responds well to puborectalis work through the rectum . I can actually explain this one.  When someone has the simplest form of painful sex it is usually because the pelvic floor muscles are not relaxed enough.  If all the muscles are relaxed vaginally, the tone seems pretty good, but sex still hurts (and the vestibule is pain-free and there is not visible evidence of spasming), then you should consider having the rectal muscles checked out too.  In my book, the vagina is doing what the anus is doing and the anus is doing what the vagina is doing.  I know for a fact that some therapists teach trying to relax the vagina and the not anus or vice versa or they try to teach squeezing the vaginal muscles, but not the anorectal muscles – but I do not see how that is possible.  I think it’s all really wired together.  So, if you still have painful sex (without vestibule pain and without visible spasms of the pelvic floor muscles), consider asking your therapist to that the pelvic floor muscles through the rectum.  While the muscles are the same, the way they are accessed is difference and this could be the key in changing your symptoms.

I know a  little bit, but I don’t know everything.  I don’t know the “why” or even the “how” sometimes of the role of the puborectalis in effecting other symptoms, but I know it needs to be looked at with these symptoms.

Urinary urgency and frequency – yeah, urinary urgency and frequency…while the puborectalis (via rectal access) isn’t the first muscle you’d think of, it certainly plays a role in treatment of these symptoms.  When you feel like you’ve got a nagging urge to urinate that is intense and comes out of nowhere, then you’ve got urinary urgency.  It doesn’t matter if you actually eliminate much or any urine.  If you get an urge to urinate frequently, like, you have to go often enough that it is annoying or other people comment on how much you go to the bathroom, then you’ve got urinary frequency.  Some people have both.  A lot of people have both. Classically physical therapists will look more at the front of the body for issues that could be feeding into these symptoms.  And, they are right to do so.  But, sometimes I get that patient that improves with classical work, but that work isn’t enough to eliminate the symptoms.  In that case, I start to look at the puborectalis through the rectum.  For some patients, this is what ends up halting the urgency and frequency.

But why?  Why does rectal puborectalis work change the symptoms?  I don’t actually know why.  I just have theories.  I wonder if the puborectalis is so tight that somehow this ends up sending a message to the nervous system and effects the parts of the system that control the message to the brain about the bladder.  (Vague response – I know.)  But, then there’s an obvious hypothesis – these people with urinary urgency and frequency are actually constipated.  The puborectalis is holding the rectum too tight which isn’t allowing the stool to move through with a natural bulge to poop and so the mass of the full rectum is placing pressure on the bladder creating a sense of urgency and frequency.  

Clitoral pain/hypersensitivity…I think these things are effected by the puborectalis as well.  I have some women with clitoral complaints.  Some of them feel better when they feel stool in their rectum.  I wonder if it’s because the puborectalis is being stretched because there is an increase in the rectum – which the puborectalis is lasso’d around.  Some of these women feel better after a bowel movement.  I wonder if it’s because the puborectalis was relaxed during the act of defecation.  See?  I don’t know the answers, I only have theories.  All I do know is that the puborectalis matters and can and has made a massive impact on my patient’s clitoral pain/hypersensitivity experience.  Is it because I’m actually working on the puborectalis via the rectum or is it because my finger is in the rectum at all and that it is somehow effecting the pudendal nerve some way because of that.  The inferior rectal branch of the pudendal nerve is effected when I slide my finger passed the external anal sphincter, but does the inferior rectal branch of the pudendal nerve have anything to do with the clitoris?  It doesn’t seem so, but somehow I might be effecting the other branches of the pudendal nerve – perhaps by a big of traction???  I don’t know.  

The same thing goes for erectile function…the penis is a lot like the clitoris.  Men complaining of premature ejaculation or other erectile dysfunction or penile pain or sensitivity, they seem to do really well when the puborectalis is treated.  My theories for this are the same as my theory for how it effects the clitoris.

Do any of you have answers?

Do any of you have more theories?

Do any of you love the puborectalis as much as I do?


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

Books Worth Drinking and Eating

Up until last week*, I sent out a blog post once a week, at a minimum.  The only way I’ve been capable of doing that is by continuing to learn.  I learn by treating my patients, hounding physicians with questions, observing physicians and therapists and by reading.  I learn so much by reading.

I want to share the books that I’ve learned the most from so far.  I haven’t read it all and I will never have read it all, but there are a handful of titles that need to be shared.

In no particular order, these are the books that have answered questions and inspired me to move in new directions with my practice.  So get a cup of hot tea, put on an oversized cashmere sweater, pull the sleeves down past your hands, sit on the couch with one knee propped under your chin and drink the tea with two hands.  Oh, that’s not for you?  Ok, get on the couch in the same position, hold a bowl of salad in one hand, take a bite and hold the fork up by your left ear, tilt your head back and laugh.  Like a maniac eating a salad.**  Then dive into these reads:


healingpainfulsexHealing Painful Sex by Deborah Coady and Nancy Fish

This one sat on my clinic bookshelf for some time.  I saw other therapists reading it and thought “Eh, what is this book going to tell me that I don’t already know?” But, my, what a lovely cover that book has? That’s actually a common mistake we therapists make – judging a book by its cover.  We think we know everything about painful sex – specifically.  We will admit we don’t know everything about sitting pain, but painful sex – I for one was guilty in thinking I knew it all.  Coady and Fish really impressed me.  I almost felt frustrated that my co-workers who read this didn’t share the information with me.

Dr. Coady no longer practices in the clinic, but she is doing research.   I interviewed her about a year ago and nothing in the interview was really in the book! A second edition is long overdue because Dr. Coady has a lot more to share. She is always learning, always researching, getting better and now she needs to sit down at a keyboard and type.  Right?  Dr. Coady – if you’re reading this:  Thank you!  Thank you!  Thank you!  You keep moving and you keep shaking and you keep speaking your mind.  You’re a superhero in a white coat.


when_sex_hurts_coverWhen Sex Hurts by Andrew Goldstein, Caroline Pukall and Irwin Goldstein

I do have to admit, the cover of this book is nice, but it’s not as beautiful as Healing Painful Sex.  I’m sorry, I had to say it!

The authors of this book are incredibly passionate clinicians devoted to treating sexual issues.  They work together a lot, though they are on different coasts.  I have either interviewed or spent time with both Dr.’s Goldstein (Andrew and Irwin), but I have only listened to Caroline Pukall speak at a conference.  (She supported a very aggressive comment I made once so I feel a special kinship to her.  She doesn’t even know it!  She doesn’t know how I feel!)  Listen, when you’re passionate about something, it makes you a little crazy – good crazy – crazy good.  Dr. Andrew Goldstein is very direct and very clear about his ideas.  If he were to sit on a couch with a salad, I imagine he would stab each leaf very methodically, look at it under a vulvoscope and determine it is good enough to eat.  If Dr. Irwin Goldstein were to sit on that same couch with a salad, I guarantee you he would toss the whole damn bowl up in the air, open his mouth and see what happened.  These specialists are very unique and they come together to figure out the upsetting dilemma of sexual dysfunction.  You want minds to be different, you want thoughts from here and there and you want passion.  That’s one thing that makes this read is so perfect.


About Healing Painful Sex and When Sex Hurts…

Read them both.  One doesn’t replace the other, however they are very ying and yang – reinforcing a lot of concepts.  Both books share a world of information  to help patients navigate the medical community in getting the right treatment for painful sex.  They give advice on how to speak with your physicians.  They empower patients in taking control of the situation.

Should a guy read these books?  Yeah, why not?  Men drink tea and eat salads, right?  I think that men would get a lot of use out of reading the first third to a half of both books.  Men need to know how to broach topics with their doctors and they need to know when to switch providers.

But, it’s not all about navigation through doctors and appointments.  Healing Painful Sex and When Sex Hurts do a great job of giving treatment interventions and substitutes for those interventions.  They give lots of ways you can improve the quality of your tissues with and without hormones.  This is powerful because improving tissue quality is half of the game.

One thing I don’t like.  I know for sure that When Sex Hurts mentions this and I think Healing Painful Sex mentions this – but biofeedback is brought up as one possible treatment option with physical therapy.  I don’t like biofeedback for most of my patients who deal with pain.  I can’t remember the last time I used biofeedback for pain.  If you want to know what I have against biofeedback, you can read it here.

Another aspect of both books that I really appreciated, as a physical therapist, is how the books dive into the the “why” of certain symptom manifestations.  I read these books not too long after I interviewed Dr. Andrew Goldstein, so the fact that the vestibule is made up of the same tissue as the urethra and the lining of the bladder – that hit home to me and changed my practice.  This concept is described in both reads.  (“Changing my practice” means that it changed my suggestions to patients, my conversations with local physicians and the way I thought about my patients’ symptoms and the underlying cause of the symptoms.  You could read it as “Changing my life” because my job is incredibly important to me.)

Please, read this again:  One book doesn’t replace the other.  They’re different.  They’re like siblings – a little similarity of course, but not the person and with different things to offer.


*Did you notice?  There was no post.  I was on vacation and knew I didn’t have a post.  I let it slide and I felt so free and guilty at the same time.  I felt free because I wasn’t on a deadline.  I felt guilty because I thought I might have let people down.  But, I was on vacation and learning so it was an investment into future posts.  Please forgive me.

**There’s nothing I hate more than women trying to be adorable while drinking tea or eating a salad.  In my book (he he) doing things makes you adorable.  Saying things makes you adorable.  Being nice makes you adorable.  Tea and salad are not adorable.


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

Where Do We Begin? or How Did We Get So Far (away)?

This is how it started:  It’s April.  A lot of my friend’s have April birthdays.  Thank God for Facebook, it is my new friend calendar reminding me of all the birthday’s I’ve forgotten.  I start posting “Happy Birthday” on friends’ Facebook pages, but instead of a happy face or a picture of a cute animal, I post reality.  I post the reason they have a birthday at all.  I post a vulva.  But, it’s not just any vulva – it’s a handrawn picture of a vulva with all the anatomical landmarks labeled.  It’s the vulva I use in treatment when I identify the details of the vulva to my patients.

The first friend loved it.  She said it was perfect and made her laugh.

The second friend (who is a physical therapist) removed it and told me that her patients are friends with her on Facebook.

The third friend…was my boss.  She did not remove it.  She did not even see it because before she had the chance to, someone else who read her page reported the post to Facebook “authorities” for “nudity”.  This is what did me in, kind of down to my core – no, down to my vulva.  Can I go so far as to say my vulva felt disrespected???


I posted on my own page – I said something like “The vulva is so birthday appropriate.” and “What is nudity anyways?”.  Several of my friends, and even a former professor of mine were quite supportive of my stance and empathetic with my frustration.  That was cool.  Makes me think that maybe, just maybe my friends read this blog and “get it”.  So many “quotes”, I “know”!

But then this happened – and this is the kicker – the kick in my vulva, metaphorically…I posted the same frustrations on a very popular, closed professional pelvic floor physical therapy Facebook page and there was little to no likeminded thought.  I was shocked.  Everyone was kind, but a few people admitted that they would have removed the post had it been on their own page – they would not want to make any of their Facebook viewers uncomfortable and they did not immediately see the link between a vulva and a birthday.  And that – that right there – that is what gets me down to my vulva.

That’s how that situation started.


But, how did this entire concept of genital shame start?  How and when did the vulva become indecent and inappropriate?

I have to say that, yes, I’m totally aware that I’m knee deep in this pelvic floor stuff.  I’m fully committed and I have the opportunity to do what I love for a living.  This makes me a person who is completely comfortable using pretty much any genital/sex/taboo word or phrase known to man without batting an eye.  I get that and I know that I cannot expect that from others.  However, it must be noted that, well, we aren’t afraid of talking about the bottom of our feet.  The bottom of the foot can be dirty, unattractive and most of the time it’s very rightfully hidden!  But, you need the bottom of your feet.  If you didn’t have the bottom of your feet, you could not walk.  This is a very useful part of the body.  If I posted a picture of the bottom of someone’s foot on a friend’s Facebook page, no one would call that “nudity”.  So how did society become so repelled by the vulva – a very useful part of the body that is responsible for bowel and bladder function – oh yeah, and that one function of bringing life into the world.  We forget that one a lot.  Especially when wishing someone “Happy Birthday”.


But, oh!  This isn’t just another rant!  I promise, it’s not!  I’d like to connect this vulva-shame to pelvic pain.  I believe genital embarrassment/discomfort is…now I’m about to make a bold statement here, but…I believe it is the reason that pelvic floor dysfunction does not get addressed with the same general interest and efficiency as knee pain (or foot pain for that matter).

I have heard a lot of people with pelvic pain say that they don’t bring up a lot of their pelvic complaints to their doctor because their doctor doesn’t ask.  I hear that some patients don’t want to make their doctors uncomfortable by talking about pelvic floor issues.

I think the patients are right.  Their doctors don’t always ask about the pelvic floor and even if the patient did bring it put, it would indeed make the doctor uncomfortable.  One of my own patients was brave enough to go to pain management to talk about her clitoral pain and the doctor said “Isn’t it weird that you’re talking to me about this?”.

Medical schools don’t really get into pelvic floor dysfunction.  They just don’t.  I hear this from doctors and residents.  I’d love to be part of this change.  I just wish I could get an hour in front of a class of residents.  I’m rubbing my hands together and drooling a little bit just thinking of the first words I would say.  It’s like thinking you have an amazing singing voice and seeing a music producer on the street.  Obviously you’d think about going up to them, but what would you say?  What would your first words be?  Would you just stand there and sing and see what he says?  Do I stand at the podium and say “Fuck, Shit, Balls, Ass” to get the shock factor of what I’m about to say out of the way or do I go another route and make a bold statement like “If you truly listen this hour, you could give people life again – the very thing you intend to do as a physician.”  The latter is just so heavy and a little too Presidential, the former opener is much more my style.

So there’s that problem – medical schools don’t teach pelvic floor dysfunction diagnosis or treatment.

But, you have to go back even further.  How did we get so far away from the genitals?  Why don’t medical schools teach this?  That’s where I get stuck.  That’s where we use the word “society” a lot.  “Society” isn’t okay with the pelvic floor.  “Society” has made the pelvic floor all about unrealistic sex.  “Society” doesn’t acknowledge urination and bowel movements – it’s not polite to do these things.  But we all do these things.  When I was single, I used to go up to men I wanted to talk to.  One of the ways I built up the courage was by thinking about what we had in common; pooping.  We all poop.  It’s the great equalizer and the vision of a highly attractive man on the toilet passing a bowel movement, well, it brought them, in my eyes, down to my level.  I then would have the confidence to approach them.

Where do we begin to change this?  When I think of practical movements, I think of a lot of things.  For example, when I went to the urgent care clinic for my sinus infection yesterday morning, I thought of asking if they get a lot of women with recurrent UTI’s or UTI-symptoms.  I wanted to explain that there is a place to refer these patients.  But, I didn’t do that.  I didn’t feel well enough to talk, really.  But, I should have done it.  I was in the perfect place talking to the perfect person.

When I talk to my cousin, the urologist in Florida whom I have subscribed to my blog but whom does not open my posting notifications, (he confirmed this on the phone with me last week) when I talk to him – I always bring up what I do and what symptoms I treat.  I do this.  I gladly do this.

When I meet a resident, I tell them about my specialty and how they can screen patients for appropriate referrals.  I tell them they can see what I do in the clinic and that they can contact me with any questions.  I tell them that it would be so wonderful to have another physician I could refer my patients to because the work they could do with this population is truly life changing.

But, what else can I do?  What can you do?  What can every person do in small bits that will make the genitals less offensive?  How do we make it okay to say that the vulva needs medical attention?  How do we remind ourselves that a picture of a vulva with identifying parts is just anatomy, not “nudity”?  I hear complaints about putting the Christ back in Christmas, but good golly Miss Molly, what about putting the birth back in birthday?


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