kim_vopni (00:02.158)
hello stephanie thank you so much for joining me on this week's episode
stephanie (00:07.12)
hi thanks for having me kim
kim_vopni (00:09.518)
yeah we were just saying we have spoken on the phone before we've known each other virtually for several years but this is the first time we're actually seeing each other face to face so it's nice to see you i really wanted to invite you on to talk about pelvic pain and my understanding or my knowledge and my sort of what i share with people about pelvic pain is there's really so many different
stephanie (00:19.38)
it's so nice to see you too
kim_vopni (00:40.078)
aspects of pelvic pain it's not just you know a pubic joint or a tall bone pain there there are so many different nuances in there and i know that your a lot of your practice focuses on pelvic pain you've written a book pelvic pain explained so that's really a lot of what you focus on yeh
stephanie (01:01.32)
yes so my personal areas of interest are amongst all pelvis female and male all gender pelvic pain disorders my company as a whole does focus on the entire umbrella and spectrum pelvic floridas function which can include a lot more than pelvic pain but the beginning of my career we were really launched into pelvic pain specifically which is how it became my area of interest
kim_vopni (01:28.198)
so maybe if you can talk a little bit about your journey to becoming a pelvic floor of physical therapist and really what led you down that path of wanting to specialize in pain
stephanie (01:37.8)
so i graduated from physical therapy school in two thousand seems like a very long time ago and i started in orthopetics as a lot of people do and not that different from now we didn't have any exposure to pelvic floor dis function when i was in school i was not even aware that this was a discipline during my last rotation of physical therapy school there was a woman who was doing some sort of pelvic floor thing in the corner in a back room by her
kim_vopni (01:43.638)
yeah
stephanie (02:07.76)
i started to become aware that this was something that physical therapist could do but i still didn't have much information on the topic like many i started in orthopetics and i just did not enjoy it and looking back on why i was a new grad i didn't have mentor ship and i just really didn't feel like i would know what i was doing so i thought it was the field versus a lack of you know mentorship and training which i now know was really important for people so went through
or seven jobs in my first year out of school and actually almost left the field all together to be a form of suitocal sales web is not my personality if you know me at all when i responded to an ad in the san francisco chronicle that said pelvic floor physical therapist wanted well train and to me i remembered that woman in the back room and i was wondering what is this and so i went on an interview and this was in a eurology practice where somebody who
kim_vopni (02:44.918)
wow
stephanie (03:07.56)
a little ahead of the curve realized that it wasn't all medications and surgeries there was something else going on that was contributing to irritated bladder symptoms and pelvic pain and i was lucky enough to get the job and once i started it was completely i opening experience i saw patients who were roughly my age who couldn't sit down who couldn't have sex who felt like they had a u t i all the time and
was much more interesting to me than somebody who can't run twenty four miles because their knee hurts and i also of course did not have the skills to know how to treat that athlete with my newer beginnings so i had mentorship and i had a complete practice of men and women suffering from these public pain disorders that was just completely opening to me and fascinating and so it really captivated my interest and now here we are
kim_vopni (04:05.958)
yeah that's amazing that's so interesting i always love hearing people's stories of how they got to where they are now so you wrote a book along the way and you have your practice as you mentioned that is really dedicated to pain for all genders genders pain for all types and we won't have time to explore absolutely every angle here but there's a few that i really wanted to highlighpt um intersticial systitis
i see our painful bladder syndrumis one pudenda neuralgia is another and the overriding sort of sexual pain side of things so wherever you feel best to start and then we can sort of eban flow our way to get all the iras covered
stephanie (04:52.26)
i'm so glad you asked about interstitial sysditis and podental neuralgia and i know we had a little email exchange first but these are two diagnosis that are different but under the umbrella of sexual pain disorders as you just said and so we could start with podental neuralgia because i think it's a little bit more straightforward than intelsisditis podental neuralga is really a mechanical disorder and it's a clinical diagnosis so by clinical diagnosis
kim_vopni (05:12.818)
sure
stephanie (05:22.1)
there are no official diagnostic tests whether it's imaging or electro physiological testing that can confirm or refute the the presence of pudental neuralgia so essentially if somebody has shooting stabbing burning pain in the territory of the podental nerve which i can discuss they meet the diagnosis of podentalralga which is a little unnerving for people when in this day and age we think that we need some sort of confirmation that this is actually the die
kim_vopni (05:44.658)
m
stephanie (05:52.18)
nosis so the podental nerve is an interesting creature it has a very vast innovation so in the sensory distribution meaning this is responsible for bringing sensation into our body it innorvates the clitoris the pets part of the squotumlabia parenneum and nus it innervates part of the urethra part of the rectum and then all of the pelvic floor muscles on the motor control side and so it's very unusual
kim_vopni (06:11.058)
that's a lot
hm
kim_vopni (06:19.978)
wow
stephanie (06:22.12)
to have that vast of a distribution and many preriferal nerves have a sensory component and a motor component but the podental nerve has a third component which is an autonomic feature and this is because the pelvic floor muscles are always active whether or not we think about it i make the analogy is similar to breathing and that we breathe without thinking about it but we have the ability to override our breath so our pelvic floor muscles are active thanks to that autonomic component of the of the
kim_vopni (06:42.878)
hm
stephanie (06:52.12)
and al nerve unless we decide we're in a socially acceptable place to use the rest room or if we decide to do a keggle for example and override it but it's always active so when people start to get symptoms of podental neuralgia it's usually because somewhere along the course of the nerve there is a mechanical interruption that doesn't let the nerves slide glide and move as it should and that can come from various things it follows a very interesting course
kim_vopni (07:00.258)
right
stephanie (07:22.12)
the pelvis it comes out of sacral nerve roots s two three and four it kind of goes underneath the pure forms near the sciatic nerve which could be one point where it gets into trouble it travels through the sacred tuber sacre pinus ligament which is another place it can get into trouble if there's a sacre iliac joints function that's affecting the nerve space then it branches into three different nerves that go to the cliterus the penus the pareneum and then the anus which any time a nerve branches there's
so potential compromise so in order to be symptom free we have to be able to have our nerves slide glide and move normally if there's muscle tightness a joint dis function or some other pathology such as pelvic floridas function or facial changes anywhere along the course of the nerve it's not going to be able to function normally so how does that happen so there's four different general mechanisms that people can develop podental neuralgia one can
compression injuries such as psychlen horseback riding prolonged sitting now many people can do any of those activities and not have podental neuralgia symptoms t's my understanding that i think people mechanically either developed or have a genetic predisposition that they're body just can't do those activities where other people can so that's part of the mystery of pelvic floor physical therapy is figuring out well why can't this person sit without podental pain when somebody else can
there can also be tension injuries such as child birth and constipation so that's when the nerve is under too much tension and there can be inflammation may be without any compression points along the course of those areas i just described there can be surgical trauma from things like pelvic organ prolapse repair prostetecto me other types of pelvic surgeries and sometimes it's an insidious development over time again because usually mechanical considerations may be there's
impression and tension or something that they're doing in their professional or recreational life that just is not making it comfortable for the nerve
kim_vopni (09:23.978)
right
kim_vopni (09:32.198)
that's a lot
stephanie (09:34.04)
i know i could keep let me pause for a moment
kim_vopni (09:37.538)
yeah so so that i mean it's not i guess my first question is given the how like how it travels and how it branches and how many different influences there can be and there's the sensory and the autonomic and the motor like where do you start obviously somebody could come in with symptoms that may give you a clue that an indication that it could be pudenda neuralgia and so how do you go about
exploring and providing that person with that diagnosis so as you said there's no imaging or anything so it's clinical so how do you where do you start and how do you come about that diagnosis
stephanie (10:19.18)
we often start with the patients stories and i'm in a position where podental neuralgia was one of my specialties very early on and so a lot of times people are seeking us out on specifically because of that background and they kind of have figured out a lot of their story most of the time they start to realize their symptoms if they google it quickly they're going to be able to get themselves to a diagnosis probably faster than what you would think a dinachologist gerologist p c p many people don't even know
what this is and so patients are often more resourceful than the general medical community and then it's as i'm sure yure where there's pockets of specialties specialists around the country that that can help but we really start with their history how do you think this happened how did your symptoms begin and once people start telling their story we can usually ask a few more questions to figure out what may have led down this road one of the situations i left out with something called the visrosomatic reflex
and that can occur in people who have disease processes such as anddemetriosis or repetitive infections um sometimes some of those things can also lead into a sensitization of the pudental nerve which is different than the mechanical causes so by listening to someone's history you start to figure out okay what are we going to need to examine during the physical portion of the exam and then the assessment is really what's important where we're linking their history to the objective fine
ans and then making a story for them as to how this probably happened and then a reasonable treatment plan as to how we need to tackle the different impairments that are causing the symptoms so they can get out of it and i will say pudenda or alga is one of the diagnosis that does involve inter disciplinary care a lot of the patients that we see may have been suffering for multiple years at a time if somebody has unprovoked daily burning they usually need some sort of form a suitocal management in conjunction with
addressing the underlying cause and it can be really frustrating for people because people want the one thing that's going to help them but this is one of the diagnoses that we have to be patient and really work together with a coordinated plan of care
kim_vopni (12:33.958)
yeah and i find the people that i've worked with with with pain sin drums i'm always referring to pelvic floor physical therapy for everybody there anyway but definitely with pains and drums and we're sort of working in a collaborative way but a lot of people that i work with who have had this diagnosis or other chronic pelvic pain it's been years before they finally got a diagnosis and there's i'd i see this with both pain and with prolapse there's a desperation to
i need it fixed i will do whatever i can and when you talk about being patient it can sometimes be really challenging when you have chronic pain or potentially i guess at a side bar with prolapse there um so i mean as you say there's potentially a farmasutical position or piece that will come into there as well so working with euroganochologists ginochologists and family practitioners would that be ac here
stephanie (13:34.66)
for the form of sutocal management there's only three classes of drugs that are appropriate for neuropathic pain and so a primary care doctor can typically prescribe those when we're starting to talk about more nuance polly pharmacy plans then a pain management doctor who deals with multiple formasuticles may actually be the best option and we're not talking about opiates the three classes of drugs or trysiclaanti depressns s n r s and then some of the nauromodulators
but there also may be the need for medical procedures which can assist and so podental blocks gangling in par blocks pelvic floor bow tacks are like the top three that may be appropriate for somebody based on various criteria that we used to try to help them get that help but it is frustrating for patients and it's exhausting they don't feel good they can't function normally and they may not have access to some of the things that we're talking about right now which really
be upsetting for people and when they know more than their providers it's it's it's really a challenge
kim_vopni (14:41.218)
yeah i've definitely found and this has kind of been a consistent theme through a lot of the more recent episodes that i've done where there's there has been a significant shift in health care you know kind of in this post covid era where there's been a lot more exposure to other available treatments and practitioners and online health care and some people have recognized that there are solutions and options that could potentially help them that they may not have been introduced
two before which i think is a good thing as we evolve sometimes information is very powerful sometimes that can be overwhelming so it's hard to sort of shift through but so you talked about a few of the treatment i come back to the physical therapy side first and then the treatment like bow tok and those are ones that physical therapy cannot do is that correct okay
stephanie (15:34.52)
correct we have very close relationships with pain management providers that can offer these procedures um and that can vary whether they are a neurologist of physical medicine and we have or an antastesiologist are typically the top three disciplines but those particular people also have to have an interest in public pain and the majority of them do not so we're very lucky and keep these people close when we find those who are interested in taking care of these patients with us
kim_vopni (16:02.638)
yeah interesting okay so i want to talk about your role as a public for physical therapist what can you do and at what point would you refer out for some of those other treatments and then we'll talk about those other treatments and more detail as well
stephanie (16:15.84)
and i'm sure you've encountered this yourself a lot of patients with these symptoms get triggered by exercise though the physical therapy isn't what you would initially think of with regular physical therapy a lot of times it's pretty passive for the first few visits we have to examine the various soft tissue structures and really figure out why our patients can't move in a certain way and so that will involve a manual examination of connective tissue muscles and then a transveginal and or transrectal
examination to see how the pelvic floor muscles are functioning of note in particular the opterator internes muscle holds part of the podendal nerve in a structure called alcoxs canal and if people have hit pathology sciatic something that's going to affect the opterator internes that's really going to have a negative impact on the public floor and so as we described listening to their history is going to help us pin point you know which areas we need to look at first but initially
we have to start with the soft tissue structures and try to figure out points of limitation of the nerve and then we usually address that with manual therapy befor we can have patients start to work on their bi mechanical considerations so a mistake i see is sometimes p ts whether it's or the pic or pelvic and they're very separate even though they shouldn't be they may want to stretch a hamstring because there is post here like pain or try to stretch the pure forms in a pidgen posts all of those
things if there's a mechanical traction somewhere are going to irritate the nerve and flair the patient up these are well intended exercises people really get fear avoided when something that should be good for them all of a sudden is causing this exasperated pain response that could last for days and so we need to basically work it backwards and figure out how functional can our patients be with what they have right now and then make temporary modifications along the way until they're functioning and can move with better range emotion
unless consequence so as a p t it's really different for every person so many people have asked what's my protocol and the most i can say is we start with life style modifications and some passive treatment working towards more activity
kim_vopni (18:30.818)
so when you talk about manual therapy and the more passive that would be i'm putting words out there but correct me if i'm wrong so may be some finding trigger points almost or like palpating certain aspects and applying pressure elsewhere that type of thing is that am i accurate and what you mean by that
stephanie (18:52.74)
a hundred percent yes and so we really are examining all structures from the ribs down and that is manipulation of fascia pal patient of muscle looking for miofasial trigger points and reallyt examining in the pelvic floor the motor control and the ability of people to move their public floor muscles in a way that is functional and most of our patients with pudenaralga cannot do that so it's a really it's an eye opening experience when they feel it for the first time and they
and start to do those things and realize how difficult it was sometimes that can take six visits before we actually have a functioning pelvic floor again and varying degrees of severity you know as as you mentioned some patients have had symptoms for six months the more realistic scenario as probably three to six years and so we have to consider how long their bodies have been functioning in a way that isn't the best for them
kim_vopni (19:31.398)
m hm
kim_vopni (19:48.458)
yeah and what would home so they're with you for a period of time and then obviously in between visits there's i think there're things that they could do at home so what would some of the home care self care practices look like for these types of patients
stephanie (20:04.32)
it's really important because they're in physical therapy basically one hour a week and obviously there's a lot more hours outside of that one hour where their life is happening so we do the life style modifications that we say are temporary at the beginning modified work stations things like that modified exercise routines but the most important is some of the pelvic girdle muscle work that they can do at home as you mentioned there's a lot of tell of health opportunities which podental nouralga is probably the largest
chunk of the tell of health that we do within see the largest i would say and it's not the type of thing where i'm treating somebody over the computer for a series of times and we're just trying to help pin point their story and get them to local providers who can provide more assistance but just having that overall umbrella understanding of how did they get this what do i think is going on based on what they're telling me and let's see who can help you locally with the home program it's also very simi
kim_vopni (20:36.758)
really
wow
stephanie (21:04.12)
or i'd say regardless of what's going on with the patients stretching is usually provocative if they can't relax their pelvic floor muscles course strength can be provocative so those things may need to initially be taken out and replaced with something like film rolling where they're able to actually work on the muscles or there gun without lengthening the nerve around a joint the nerve doesn't cross a joint but with increasing degrees of hipflection and internal rotation that nerve gets triggered and tension and so we really
want to try to help them address the soft tissue issues without irritating the nerve which can be a delicate balance
kim_vopni (21:42.178)
and at what point then would you say you know we need to move to the next level where we're now going to the other three treatment suggestions that you had so you said i'm gonna forget the bow talks and the other two you have to say again ner block
stephanie (21:58.08)
there's denalnerblocks gangin in par blocks some interesting examples i think it's better with with case examples we've had patients with laboral terrors and podental noralga but their podental ga is much more severe to them than the pain with the laboral terror so for example we may try to treat them but week after week the opterator inturnist is very painful and it's irritating the nerve can't tolerate the manual therapy can't tolerate some of the exercises i just described so
erhaps at that point if we touch the nerve it causes shooting stabbing pain that's called a positive tone sign that person may be a good candidate for a podental block if i touch it and it's that reactive and they can't tolerate these things but truthfully at the end of the day multiple people they needed their labor repaired because until that is they're still going to have this aggravating situation going on and so lesson learned that you know sometimes you have to get to the underlying pathology but we can try to make
kim_vopni (22:47.678)
hm
stephanie (22:58.0)
more comfortable along the way air block may give transient relief but then what if it comes right back well the underlying problem is still there so potentially public floor botocks may be a solution to the opturator to try to give that canal a little bit more breathing room that's going to last for somebody for about three months which may be enough time for the nerve to settle down but it may not be either though in general the blocks tend to be more effective if the symptoms are more acute meaning they've been there
kim_vopni (23:00.198)
hm
kim_vopni (23:21.818)
hm
stephanie (23:28.08)
six months to a year and there's the positive pal patient finding the problem is that they're not working with somebody like me who can identify those things and a diagnosis is made based on symptoms we don't know if the nerve is irritated or not someone may get a block it may not help them at all so we really want to try to keep things out of the treatment plan that may not be useful for people as well as putting things in that they may need and so i really think bota has been helpful because if we know that
kim_vopni (23:50.838)
hm
stephanie (23:58.0)
is a muscle impairment that they may be feel better for three days after p t but by the time they hit that week mark everything is right back we can't get it to stabilize despite their compliance at home despite what we're doing then this may be an option for people
kim_vopni (24:11.578)
hm and where so with a pedendal nerve block where what are they in it's an injection where where are they injecting and what are they injecting
stephanie (24:18.9)
it's an injection
stephanie (24:23.04)
they there's some very degrees of opinion on this and so lidacine is always involved and some people want to use straight lieocane they consider it diagnostic for pudental nerve problem other people want to include a steroid whether it's water soluble or non water soluble to try to reduce the inflammation you know which takes me back to the point where if it's sort of touch may benefit from having a little bit of a steroid in there if there's no pro
kim_vopni (24:31.238)
okay
stephanie (24:52.9)
occasion with my finger touching it do we think a steroidis going to help probably not because it's not irritated but you really need that physical exam to know but there is various ways to inject and with various injected bowls and that depends on the experience of the provider
kim_vopni (24:56.678)
right
kim_vopni (25:10.638)
and so injected in in and around the hip does it go through like whereabouts in the body would it go
stephanie (25:18.08)
most the most targeted area is alcock canal and that can be visualized with floroscop c t scans ultra sound and some physicians just do it finger guided the other nerve branches are a little bit more nuance and there are very select few people that can inject the dorsal branch to the clitteras or the inferior rectal branch that's a little bit more specific and not available to most people
kim_vopni (25:22.738)
okay
kim_vopni (25:31.438)
hm
kim_vopni (25:46.218)
okay and how long did you say they last six months four hours
stephanie (25:48.64)
four hours so the yes so the anesthetic lasts about four hours and then that wears off which is why if there's a steroid and there's inflammation the steroid is what's going to be the therapeutic agent but the diagnostic process for some people is to see if there's anesthesia in the territory of the pain in the area of the nerve during those four hour windows and if there is then it's assumed that there's probably a podental nerve problem
location
kim_vopni (26:20.178)
okay so pedendal nerve block is is not a long term treatment is more part of a diagnostic strategy correct
stephanie (26:29.22)
and i'm going to argue about the diagnostic strategy i mean people say that this is the case but before we had epideral they use podental blocks during labor and delivery if you remembering the innervation of what i said this nerve goes everywhere if you put anesthetic in that nerve it's going to eliminate pain that's coming from the muscle pain that's coming from the fascia menapausal pain coming from the vestibule or breast feeding atrophy that's coming from those oval vaginal structure so to me that's not indicative necessarily of a podental nerve
problem i take it with a grain of salt because it's going numb everything downstream now other people will totally disagree with me but to me it makes sense if you numb the entire area we can't say it's a nerve problem and you can just say you numbed the entire area
kim_vopni (27:09.918)
yeah
kim_vopni (27:14.218)
right right right that's interesting okay so then with bow talks this has a longer lasting effect and can be viewed more of a treatment would somebody potentially have a nerve block get an answer and then potentially move right into a bow talk treatment or would they be completely separate days or time that they would do that
stephanie (27:33.6)
if we're aiming for a therapeutic benefit with somebody and we know that there's an opterator problem and pudenda tenderness what we have found in clinical practice is that actually utilizing the bow tox first takes the pressure off the canal and then the north block will have more likely of a chance to provide some relief for that patient whereas it's going back to what i said if we just block the nerve and then the problem is still there the anesthetic wears off someone's back to square one so we
doctors we work with we've played around with this a bit and we've found is that the botas first if it's indicated is better maybe then you won't need a nerve block but if you do it has a better chance of working if the environment is more hospitable for healing
kim_vopni (28:19.158)
and when you say working working a bit more longer term than four hours right okay what's the what would be the potential length of time if best case scenario with bow talks and that alleviates an aspect now we do the block what's the best potential outcome
stephanie (28:22.96)
exactly exactly
stephanie (28:35.08)
time frame i wish i could answer that it really varies per person because once those therapeutic agents are introduced now we've got to get every thing to a better working place so it doesn't come back so i feel it's a race against the clock we've got three months how much can we do to fix the bio mechanical considerations the impairments all of those things and we don't have to repeat this whole process
kim_vopni (28:45.898)
m hm
yeah
kim_vopni (28:59.638)
and then what was the third one that you had mentioned
stephanie (29:01.94)
there's something quilled a ganglion empire block which is a sympathetic structure underneath of the coxics that basically provides a lot of in putting output from the entire public floor and some of the distal public organs and in some cases this also can be effective for patients but the literature is saying a series of those are better sometimes up to five about a month apart in the isolation i don't really recommend any of these procedures just by
kim_vopni (29:04.638)
okay
stephanie (29:31.88)
selves the outcomes won't be as good as if it's part of a comprehensive plan
kim_vopni (29:34.378)
hm
kim_vopni (29:38.018)
and then final kind of wrapping up the podendal neuralga piece i know there's many more fast as we could ask but but if somebody reaches a point can somebody reach a point where it has resolved completely and is this then something they need to manage are they always at risk of it having a recurrence um and what is the in your practice how many people can have a full resolution versus people who just kind of get it to a manageable level
on a kind of a chronic perspective
stephanie (30:08.4)
that's i'd say all of the above unfortunate i mean having practiced this long patients are in a much better situation now than they were when i was really dealing with mostly pudetalneralgia between two thousand and one and two thousand and six sometimes there is a surgery involved as well and that's most likely tied to people who have had the introduction of the diagnosis because of another surgery or severe child birth complication that has evolved into a true
kim_vopni (30:10.998)
yeah
stephanie (30:38.22)
treatment so i would say you know the sooner people get diagnosed the better the prognosis the lesser degree of the severity of the symptoms the better prognosis we have a number of patients who are completely fine they may never think about it again we have a number of patients who want to check in once a year so i know they're fine but they're still nervous it may come back and then we have some people that tend to be re triggered by just ac activities of daily living and then that is a management situation
kim_vopni (31:07.858)
but i guess at least having experience it in the past they can probably get on top of it a little bit quicker and i thought i thought it was done but you mentioned surgery i forgot to ask that piece so there is this a surgery component so that would be nerve and trapment release surgery correct
stephanie (31:12.82)
exactly
stephanie (31:23.12)
correct it's called podental nerve decompression and similar to the diagnosis of podental neuralgia one mechanism could be podental nerve and treatment but there are no diagnostic test that can confirm or refute that so people really have to go into that procedure knowing that we don't know what's going to happen once the surgeon is taking a look at things it's mostly based on history so in my experience the people who i have sent for surgery in the past few years have either
had blunt trauma to the area somebody fell and hit a bar stool while cleaning a fan that went right into the space where the alcoxscanal is other people have had pelvic organ prolapse repair and clearly they did not have pelvic pain before surgery and then developed this vaginal pain that just did not fit the mechanical presentation that i earlier described and then some child birth injuries in hematomas may be okay at first and then over
time you start to develop symptoms of pudental neuralgia that's another very suspicious category for me the development that insidious development is suspicious that it's not entrapment but it may be un managed pain because this can be tough to treat you need the right people doesn't mean lack of resolution of pain does not mean entrapment to me but it can to a lot of people who are suffering they think well it must be this
kim_vopni (32:30.518)
and what
kim_vopni (32:51.878)
yeah and where what is what is the surgery how is it performed or where would they where is the incision made and what are they actually doing
stephanie (32:59.7)
so there's only a handful of surgeons in the united states who actually do this procedure a transgludial incision across most of the surgeries now where they basically are going down to alcox canal and the legamentis area and looking for areas of entrapment now what that looks like to a surgeon means that the nervous gray flattened it visually looks different to them and adjacent to what they would think an entrapment would look like it is a microdistsection
the space is around the two main areas that i just described are main targets but with these other types of trauma surgical injuries what not mesh may need to be removed scar tissue around the hematoma that may not be near alcox canal but somewhere along the course of the nerve may have to be microdisected or if there has been another trauma anywhere along the course of the nerve could be a therapeutic target for the surgeon
kim_vopni (33:57.378)
super interesting and then from a post operacovery again the importance of your role in helping manage the re training of the muscles the scar tissue you know all of that kind of stuff is so important
stephanie (34:11.619)
and it's a long road it is a difficult recovery from the surgery at least a year usually and it's not people learn a lot of pain there's urinary ball sexual dis function and compromise in all those areas usually and so it is a slow it's a slow refabilitative process and people may not have access to a physical therapist that knows how to manage it post op and most people travel to get to the surgeons for the surgery so they don't live near their doctor which
a second problem that is a barrier to care
kim_vopni (34:45.618)
yeah so kind of seguin now into this sexual component there's obviously with any type of pain there can be influence to sexual response the capacity for pleasure with any gender really we're focusing on on females in this in this call mainly so female sexual pain and again i know there are a lot of things that can come under there the one that we're kind of going of focus a little bit more
on his interintersticial sycitisic i can never say that word interstitial systitis i s or also called painful bladder syndrome but maybe talk start with the pelvic pain side of things the sexual pain side of things and then move our way over to i
stephanie (35:33.22)
and i always laugh because i couldn't say interstitial sysditis either when i was interviewing for the job that i got and like he's not going to hire me i can't even see diagnosis i had done my home work it's just you know it can be a tongue twister
kim_vopni (35:39.398)
yeah
kim_vopni (35:48.098)
it's a mouthful he
stephanie (35:50.54)
but under if we talk about sexual disfunction like what does that mean it can mean arousal disorders it can mean orgasm disorders and it can mean pain disorders and in the umbrella of sexual pain people can feel difficulty with penetration hyper sensitivity of their clitoris provoked or unprovoked in any of the genital areas but when you earlier asked about interstitial systitus a lot of patients with provoked pain or unprovoked
pain during penetration also have irritated bladder symptoms and if we take somebody let's let's give a young woman an example of irritative bladder symptoms and penetrative sex pain if she goes to the ginacolegist he is going to be told she has wolvadinia if she goes to the rologist she's going to be told she has interstitial systitus what we've come to realize is that most people have both and they were considered chronic overlapping pain conditions most recently but are they overlapping pain conditions or they really the same thing
and so what research is showing is there's certain fino types of both of those things bulvadinia and interstitial systitis um and that can overlap and so that can include we got to go to the mechanism podental neuralga can cause both of those things and innorvates part of the arethra and innovates the vestibule it can cause either of those symptoms but if we leave the podental crowd out of it there's also the considerations for hormonal deficiencies so that is going to lead to atri
around the arethra and at the vestibule and that can happen with women on oral contraceptives or other hormonal suppressive therapies women who are breast feeding and then as people enter paring menopause and menopause so that is not a small group of people and women are told they have over active bladder but really is it and is it really interstitial systatis which means an inflammation of the lining of the bladder if really the problem is vestibule atrophy
kim_vopni (37:36.718)
no
stephanie (37:50.42)
which often is accompanied by public floor dis function so we really see the biggest subset of people with sexual pain disorders having pelvic floridas function and usually some sort of hormonal compromise with it which is another opportunity for teams to work together to treat both p ts can help the muscle dis function but if there's also atrophy at the vestibule we need medical support to help with that too and so what we're coming to see is some of these peno types hormonal deficiency and
clo skeletal it doesn't matter what we're calling it because it's really just describing the symptom there can be other causes of irritative bldder symptoms or i see such as hunters alters but initially everybody thought that i c was a disease of the bladder and there was something wrong with the lining of the bladder and so many people and now we know from all the research that's only ten per cent of the people that had the symptoms that meet the classification for i c so the movement now is to separate out the people who
kim_vopni (38:44.018)
wow
stephanie (38:50.02)
actually have hunters legions and call that a separate thing because it's interfering with the effect of treatment for everybody else which may have different peno types which now there's eight so i mentioned hormone deficiencies i mentioned public floridas function menopause is considered a hormone deficiency but is considered a separate vino type there can be infectious causes there can be other disease processes such as like in sclerosis like in planes but really under
kim_vopni (39:01.638)
wow
kim_vopni (39:10.898)
category
stephanie (39:20.1)
i mean why somebody has this symptoms is leading to with better care than i've ever seen and this has been really new in the last five years so for me it's really it's really nice to see because we're really being able to better manage these really challenging symptoms just said really several times because it's been great to watch this happen because it was awful at the beginning and you we just didn't know what to do people were putting installations into bladders and maybe that is effective for somebody if there's a
kim_vopni (39:39.578)
yeah yeah
yeah
stephanie (39:50.02)
roblem with the lining of the bladder but what if the lining of the bladder is fine then what does that person do you've got to look at these other causes so i think the therapist really have a good position right now because we have the most time with our patients and we can help them figure out what their peno type is and get them to the right care if somebody only has pain with penetration they're probably not going to respond to a drug that would help somebody with constant daily unprovoked
kim_vopni (39:56.178)
right
so interesting
kim_vopni (40:08.498)
right
stephanie (40:20.08)
pain and so these are also some of the little nuances that are newer in clinical care that are making a better difference we don't want patients on medications if they don't need to be on them picking the people for the right therapy sis key
kim_vopni (40:31.518)
right right
kim_vopni (40:36.578)
there's a couple of things i want to have clarified can you talk about what what does it mean when you say provoked and unprovoked
stephanie (40:43.98)
so provoked pain basically means camp on penetration like some sort of activity that is provoking the pain if we are not inserting a camp on not trying to have sexual contact there's no symptoms whereas other people may have spontaneous urinary pain bull var pain and it's just there all the time or more times than not without doing anything that you think would cause it
kim_vopni (40:56.578)
and there still is pain that would be unprovoked
kim_vopni (41:07.418)
right
kim_vopni (41:12.458)
and the other thing i wanted clarification was it hunters legions or hunters
stephanie (41:16.84)
they're called hunters legions
kim_vopni (41:18.578)
hunters legions i've never heard that term before can you describe or explain what those are
stephanie (41:23.18)
so that is basically a scenario that is diagnosed what's called a systoscapy which is an instrument that's placed in the arethrea to look inside the bladder and they have found that some people actually have lesions on the lining of their bladder and that could attribute for the urinary and irritated bladder sometimes that they feel the majority of people with the diagnosis of interstitial systitis do not have that and because of that
a u a actually that's the american nero logic association revised the gidelines for interest ucialsystitis in twenty fourteen to actually not make systoscapy part of the diagnostic process because in the majority of cases it's not the problem it's not going to help the therapeutic process they did revise guide lines again in twenty twenty two and stated this again but yet some people still do that to rule in er out in her social systitis and that's just not appropriate
kim_vopni (42:19.458)
hm
kim_vopni (42:24.598)
and the menopause has come up a few times and obviously the world is very thankfully there's a lot of conversation happening around menopause which is awesome i think it's indirectly helping the world of pelvic health because suddenly there's a lot more talk about vaguldryness and vaginal atrophy and genetoryarners and menopause so all a sudden all of us who've been preaching pelvic health along the way they're finally getting a little bit more attention because menopause is getting more tention which is amazing so which is that
like could that be a time of life when like you mentioned ifferent penotypes but is that time of life with the hormonal change a trigger almost is it more likely to show up during times of hormonal shift
stephanie (43:06.9)
yes the bladder itself has estrogenreceptors on it and not to mention the vestibule which can sensitized the urethra and then lead into bladder irritation is one mechanism but the other thing that happens that's so crucial and i'm really grateful for the younger female urologists that are carrying the torch and changing guide lines is our vaginal p h changes as our estrogen goes down and it makes it very hospitable to get recurrent urinary tract infections that
may not feel the same as a u t i when your premenpausal where you know you've got a u t i you've got to get to the doctor you've got to get those met especially at four o'clock on a friday when you know all the offices but this may go a little bit undetected may not be as symptomatic but it's causing problems that could go up into a kidney infection and i think one of my biggest pet pies is when menapausal women are given over active bladder medications that are not they're not hormonal and if the underlying cause
kim_vopni (43:47.098)
uh
stephanie (44:06.7)
is a p h issue urethra atrophy you rethroprolaps into the vagina making it more likely to communicate with these pathogens like it doesn't make sense to put women on those types of medications when they need vaginal estrogen and vaginal estrogen is safe and different than systemic hormone therapy so thank goodness there's all this media attention right now because it was believed that menopause hot flashes the genitourinary cyndremameno pause was not even a word until twenty fourteen so look
where we yeah
kim_vopni (44:38.098)
yeah yeah yeah that's so it's so interesting and i agree i hear so many people that i work with who have been put on over active bladder medication and really you know they say well it didn't work and they have the expectation that that's going to solve their problems but really they've had nobody spend the time to hear their story and determine root causes and really understand if that's that's actually what's happening and what needs to be treated so so
once the person again this can be another one that it might be a little bit challenging to reach a diagnosis and once they do what does it look like from how you as a physical therapist can help and do you is there any other reason why you would refer on or the other treatments that are outside of the scope of physical therapy
stephanie (45:28.3)
yes and the reason i get so worked up about the hormone deficiencies is because as i say can ruin my work space if some one man to me with disparonia and irritated bladder symptoms and i see that there's these hormonal problems i can effectively treat them but the symptoms of these things overlap with pelvic floor dis function and so they really go hand in hand and a lot of times when there is any type of pain condition both exist together and so we do need to work very
see with people who are menopause and formed that can help with the just the g s m even i'm not worried about the rest of it even though that is important for people to but if there is volvovaginal atrophy for these various reasons it's only going to continue to get worse because we're getting away from menopause and we are living into our eighties so that is one third of someone's reproductive life where they really could have a compromised quality of life it's very difficult for people and i feel like it doesn't need to be
it really doesn't i think everyone going into menopause and as the field you're in to a working with these women there's always opportunity to improve our public health so we want to improve the muscular skeletal system why do we exercise everywhere else and not deal with the pelvic floor and in the best of circumstance s not even chasing pain just protecting our bodies over time and then we've got to consider the hormone factor because it's just going to hit all of us at some point if left untreated
kim_vopni (46:28.758)
totally agree
kim_vopni (46:56.638)
yeah i'm sure you're familiar with dr rachel reuben who she has been a really incredible voice for not just vaginal ixtrogen but over all hormontherapy is specific to sexual health and women's health and reproductive health like she's she's pioneering a lot so i'm really grateful for the work that she's doing and could not agree more with regards to estrgen and there's the there's the muscles muscle etalpiece and there's also the tiss
you health and support we spend a lot of money in serums and lazers and therapies on our face and we really need to be putting some of those same therapies and serums and care into into our pelvic tissues as well so how do you sorry go ahead
stephanie (47:32.12)
i like
stephanie (47:41.18)
and i now and i really i think doctor rachel reuben is one of the people that we are lucky is out there and taking on the a u a the reason that they're going to include vaginal estrogen as part of menopausaltherapy is because of her and other people on social media so people in social media are realizing these doctors are out here talking about these important things they're taking it to their own doctor who may be told them something completely different but they've got hers that here's a board certified
kim_vopni (47:51.498)
yes
kim_vopni (47:57.158)
yeah
kim_vopni (48:08.598)
yeah yeah
stephanie (48:11.08)
ourologist saying this is actually okay why didn't you tell me really interesting
kim_vopni (48:14.478)
yeah yes yeah yes it is it's an an agaidit's kind of that post covid era where people are becoming more informed from social media from word of mouth whatever it is but i think that that's forcing a shift and people are coming in with now evidence to provide excuse me to their practitioners that will then only in turn hopefully for ther educate the medical providers it's just not part of their training and i'm hoping that it really starts to become it needs to be
um but it is also putting some more information and power into the hands of the actual person themselves to be able to advocate and make the best choice for their situation um so with with your role in interstitial systitis how do you affect change and what would your treatment suggestions be
stephanie (49:06.68)
i'd like to first to neutralize people's fear because they think this is going to be a lifelong diagnosis for them and really help them make sense of why maybe past treatments didn't work because usually by the time they're seeing us sometimes they're referred right away other times they kind of find us after years of struggle so it's really important to help people understand why past treatments didn't work and identify what is their i see and whenever we post about this on social media there tends to be a lot of
conversation in our comments and what not about the causes because this is really a bothersome clinical presentation you feel like you need to urinate all the time urinate you don't feel relief like it's really distracting but there's different reasons it can be central nervous system it can be pelvic floor it can be a hormonal deficiency sometimes there is an infection sometimes there's sub clinical inflammation without infection and it's really trying to help people understand what the
there i see is and then for us we treat the somatic causes which is almost always accompanying these these pain conditions because if you've got that irritation in a visceral structure there's going to be a somatic consequence and so we have to get the symptoms under control and sometimes that's by eliminating the pelvic floor and girdle this function but sometimes we need support in these other areas too
kim_vopni (50:32.878)
and at what point like are there other therapies that exist in in other fields where you would be referring on or collaborating with other health care practitioners
stephanie (50:41.96)
you know it's funny you mentioned vaginal lazars and things because i mean facial lazars because some of those can actually be effective as well to help with some of this that's going on virginally if there's situations too mentioned prolapse earlier that can be really bothersome for people as well and if the reason that they're constantly having some irritation is because of a mechanical things such as prolapse we want to try to reduce the prolapse and physical therapy but sometimes that's a surgical situation where it may need to
kim_vopni (50:52.798)
hm
stephanie (51:11.88)
better addressed with a euroginachologist if we're seeing somebody who has pelvic floridas function but also i'm suspicious there's a true lining of the bladder issue a very basic test people can do is take one of the urinary anesthetics that are available over the counter such as peridium if we know they don't have an infection and pervideum is providing them relief then some of the bladder directed therapy may actually be effected for them whereas a majority of patients at the lining of the bladders
and that's not going to be something that would be part of their therapeutic process
kim_vopni (51:46.218)
interesting so they could ask you said over the counter so they could ask for that from a farm assist
stephanie (51:50.04)
they can just go buy it at wall green and it's a urinary anesthetic and anelgsic basically and it turns your p blue or orange and if it's providing relief in the absence of infection that may be the bladder is contributing to some of their pain um if they have what they call chronic overlapping pain conditions migraine t m g and demetrios is irritable bl vulvidinia and irritable bell then the nervous system is typically in
kim_vopni (51:52.118)
oh
kim_vopni (52:02.458)
hm
kim_vopni (52:05.978)
got it
stephanie (52:19.82)
volved and research has shown this over and over again that in those particular patients their brains are actually different than people who don't have those symptoms on functional m r i scans and so right now one of the easiest ways to target that is with some of the formicologic therapys for neuropathic pain that i mentioned earlier but we're seeing some other technological procedural advances such as trans cranial magnetic stimulation where they're actually targeting these regions of the brain with a
ticular technology to try to help it rewire itself if you will that's already being used effectively for refractory anxiety and depression and now we're seeing it come into pain and some other things that can really i think we're going to be seeing more of that in the future
kim_vopni (53:07.298)
interesting that's cool
stephanie (53:08.4)
and we re one of the studies here in l a u s c and they've identified the region of the brain where there's the problem they've identified connectivity issues in these people's brains and a therapeutic way to target it with t m s this is not available widely yet but i think it's coming their studies showing promising data so
kim_vopni (53:27.478)
so interesting
kim_vopni (53:31.538)
and and do you know of we were talking about the vaginal rejuvenation therapy s there's light therapy there's radio frequency there are ablative and nonoblativ lazer's are there ones that you know of that would be indicated for this provided we found some sort of root cause and we know that this is what we're dealing with
stephanie (53:51.78)
so if fulvoveginal atrophy is present from hormone deficiency the carbon dioxide resurfacing lazars clinically exactly is one of the brand names that they are effective for people they will never be f d approved well i guess i mean they're they're not covered by insurance nor do i think they will be because there's no motivation if people are paying out of pocket for it for them to get classified as a medical de
kim_vopni (54:01.618)
like mona lisa yeah
stephanie (54:21.6)
so it all comes down to insurance but i do see very good outcomes with that especially for people who have very minimal symptoms and atrophy if somebody is in a very severe situation that's not going to be appropriate for them it can be very helpful for patients recovering from various cancers if for some reason the vaginal estrogens are not appropriate they do they do work they're just expensive
kim_vopni (54:50.998)
yeah yeah they are and there's really i think that there's as you say there's lots of advancement and evolution that's happening from a technological perspective that provides us with some hope and some opportunities down the road we'll see we'll see what comes are things like p r p like the shot i know is more for ideally it's supposed to be to enhance sensation or gasmic potential but ice
p r p being used in so many ways and think that there could be some cool other i don't want to say off label per sect right now but some other ways that it could potentially be used is that something that could be indicated for this condition
stephanie (55:34.3)
i would think so i don't have a ton of clinical experience with it because also to me it does the same thing as like a typical hormone but i mean i know it's available and they are using it pre cursing orthopedic surgeries and things like that so i think more data we may be seeing more of that in the future too
kim_vopni (55:43.858)
yeah
kim_vopni (55:56.618)
is there anything that we haven't touched on that you would like to discuss anything that i haven't asked or anything i've missed
stephanie (56:04.78)
with the pain conditions that we talked about i do think pelvic floor physical therapy should be front and center and through the various like life milestones that women do go through post part peri menopause and menopause i think everybody can benefit from a pelvic floor examination just to optimize their pelvic health which is i know something that you help people with all the time i really think it's important to just take the shame out of this conversation and get the help you need if you're not like you what you hear there are other providers
who can help we've really seen a split lately where there's experts now in all of these topics where again even ten years ago there may not have been and so that's i think helping to elevate the general fields of medicine to at least help these people get more informed whether it's a weekend seminar or what not to get the training they need to help people i just don't think it's the fault of the provider if they went to medical school even ten years ago and didn't have training in the things we talked about today
kim_vopni (56:43.878)
yeah
kim_vopni (57:00.838)
yeah
yeah yeah yeah i wholeheartedly agree and pelviclorphysical therapy anybody that knows me as i show from the roof tops all the time and i think that it's the most under use women's health resource we have i think we should be treating our pell is like we should like we do our mouths and see a pelviclorphysical therapist like we see the dentist right we go to the dentist once or twice a year and we go without any toothache or any indication of any problem because we're going to prevent problems from happening and and i think that there's such a missed opportunity right now
stephanie (57:18.62)
that's a good analogy
kim_vopni (57:33.278)
for that to be part of our our annual self care really if you if you think of it so wholeheartedly agree with everythin that you said i'm so grateful for your work and everything you do to help care for people and get your information out there thank you so much for joining me
stephanie (57:49.28)
oh and likewise to you thank you for having me i've been a fanning yours for a long time i think i hunted you down first years ago you had the best graphics i ever saw before they were even a thing thank you
kim_vopni (57:57.778)
thank you so much
yeah thank you i appreciate that
