00:00 – does it hurt when you um write when you start peeing or when you’re wiping or
00:05 – does it hurt when you stand or does it hurt like five minutes after it really matters how we’re asking the questions
00:11 – and it matters how you’re able to feel your body today I’m speaking with Dr mallerie Hopkins and Dr Ali Francis who are both doctors of physical therapy Dr mallerie
00:33 – is also a herbalist their own experiences with pelvic pain began their journey to their current Practice Dr
00:38 – mallerie is passionate about exploring the intricate connections between physical hormonal and emotional health
00:44 – in addressing unexplained chronic pelvic pain Dr Ally has extensive expertise in managing highly intricate pelvic floor
00:50 – dysfunctions including pental neuralgia pelvic organ prolapse and chronic bladder pain we’ve collected a lot of
00:56 – questions for our community for today’s chat but first I wanted to thank you both for sharing your time with
01:01 – us yes thank you so much for having us we love sharing our passion our work with everyone we’d love to start with
01:08 – some more about your own stories and how you ended up in this line of work yeah I’ll go first so I was
01:17 – diagnosed with Interstitial cystitis actually when I was a teenager I was
01:23 – having chronic UT like The Chronic UTI um no explanation why and that
01:31 – carried me honestly up until I got into PT school until my first pelvic Health
01:36 – rotation and honestly that was just luck of the draw and then I was with my
01:42 – clinical instructor and when I got into the clinic CL was like oh this is going to be pregnancy postpartum kind of what
01:49 – we think about pelvic floor PT were treating pelvic pain bladder pain I was
01:55 – like oh my gosh this is me and so I got treated and then
02:00 – I got better and I started to realize I was like wait a lot of this is muscular skeltal a lot of the tension that we’re
02:06 – holding I mean years of pain and so that just put me on a trajectory like
02:12 – straight in into treating pelvic pain in physical
02:17 – therapy yeah I can imagine that would have been quite the journey especially the realization once you got to that
02:23 – point yeah yeah and then on my end I mean pretty similar I had painful periods
02:31 – ever since I started um GI issues constipation stuff like that um but I
02:37 – started to use more of nutrition and more of that row I didn’t know there was
02:43 – a pelvic floor Bill to be honest I was a physical therapist already treating an orthopedic World Sports typical um
02:51 – injuries that we see um it wasn’t until I started reading more books about Hormone Health I was like what in the
02:57 – world and from there I mean my mom has endometriosis and her social cystitis my
03:03 – sister suffered from infertility so it there it was just a mix of woman’s health that we I was experiencing that
03:10 – once I knew there was a field I was like this has to be it I have to do this so I’m drawn into it and we’re so
03:17 – passionate about it yeah a lot of what you mentioned well everything you mentioned are things that we hear from our community so a lot of people with
03:24 – chronic bladder pain or chronic UTI have many other overlapping or comorbidities and so many people mention the gastro
03:31 – symptoms as well as pelvic spasms and different types of pelvic pain and just other symptoms that are never really
03:38 – like officially grouped with UTI but so many of them go together but I think a good way to start the interview would be
03:44 – to for you to provide us with an overview of the muscles that do make up the pelvis so that we can kind of visualize how the bladder sits within
03:51 – that yeah definitely got my pelvic model right here so that way we can have a
03:58 – good reference so if I were sitting down right this is what I would look like I have my two waist bones these waist
04:04 – Bones come meet at the middle of the pubic symphysis and then all of the red are the pelvic floor muscles so these
04:12 – muscles right here that are more superficial they’re right behind the vula they are external and so I often
04:20 – look at these muscles when it comes to frequent um chronic UTI any kind of
04:26 – urinary tract pain because these muscles right here you can see the close relationship with the urethra right
04:33 – there and if these muscles get really tight that can cause restriction with
04:39 – urination um inability to completely urinate even pain around the um around
04:46 – these structures can cause like that clodia which is clitoral pain or
04:51 – vestibul Denia which is right here so if these muscles again are really tight
04:56 – that can affect urination and they’re superficial now we have the more deep pelvic Flor
05:02 – muscles so these are the internal muscles so just for um relationship
05:08 – purposes we have the bladder that sits right behind the pubic symphysis and then the uterus takes a nice bow over
05:16 – the bladder and then the rectum is kind of hard to see and then the rectum sits
05:22 – right behind all of those organs so it’s a really close knit Bowl now we have the
05:29 – pelvic floor muscles again they’re the all of the red so if you see these muscles that attach right behind the
05:36 – pubic bone and they come in and attach to the tailbone I think of those as like the classic keigle muscles so main
05:43 – function storage and elimination of ball and bladder now if there’s dysfunction
05:49 – in those muscles it’s going to make storage elimination difficult painful
05:55 – now we have these muscles back here and they are the part of the pelvic floor
06:01 – and they help lift up the pelvic floor they’re named the levator anite and they are named for exactly what they do they
06:07 – lift the anus and so again if those muscles are tight or dysfunctional or
06:12 – uncoordinated it’s going to kind of throw off that whole bowel bladder system as well so that’s
06:21 – superficial deep and then even that backside posterior view where it’s
06:26 – coming in attaching onto the tailbone attaching onto those bottom aspects of
06:31 – the sacrum which is sometimes why we can get that SI dysfunction coming in with as well and then we have this close
06:38 – relationship to the hip joint as well so that’s kind of how it’s all
06:44 – interconnected as well so we got low back connections hip connections and
06:49 – then all of the visceral organ connections as well it kind of helps
06:54 – explain why it’s often difficult for patients to pinpoint where pelvic pain is coming from it’s all connected did
07:00 – how would you go about establishing where the pain might be coming from the vagina or the bladder area or some other
07:06 – muscles in the pelvis yeah so typically when someone comes in we’re already trying to get
07:13 – that wheel turning with descriptors so they might say something like rawness or
07:18 – Bernie or ay or sharp or deep or they might say clothes bother all that is
07:25 – already making us think oh maybe it’s superficial maybe it’s deep if some someone said it hurts during bow
07:31 – movements and it feels like a knife is shooting up to us it’s like oh okay we have to look back not front
07:38 – first so there’s a lot of different ways to figure out where it is and sometimes
07:44 – it’s hard because when you come in it’s hard for you to even explain what’s going on so from there we kind of guide
07:50 – it’s like okay if they can’t tell us where where it is and they’re like oh it’s kind of like this I can’t really
07:57 – pinpoint it then we’re going to start asking the Deep questions like okay does it hurt when you um write when you start
08:05 – peeing or when you’re wiping or does it hurt when you stand or does it hurt like five minutes after or does it hurt after
08:11 – interourse does it hurt during interourse so it’s it really matters how we’re asking the questions and it
08:18 – matters how you’re able to feel your body and it’s okay if you don’t know how to feel it we teach you how to feel that
08:25 – I think it can be really difficult to differentiate those symptoms if you’ve hadron inflammation because of infection
08:31 – for a long time everything can just feel like it’s in pain and we often get the question how can you tell whether the
08:37 – pain you’re experiencing with urination is because of infection or if it’s because of a pelvic floor issue or
08:43 – ongoing inflammation is there a way that you can differentiate yeah there are ways that
08:50 – we can differentiate too so um can you ask that question again it’s about um
08:57 – how to know whether pain you’re experienc ING with urination is infection or a pelvic FL problem yeah so
09:04 – if people are confused what they’re having I mean I go through this weekly with patients um and I was just having
09:10 – this conversation last week and so if it’s first off I’m I say go get a test
09:18 – you can go to CVS or if you have a good relationship with your urologist Euro gynecologist sometimes they’ll give you
09:23 – samples send that in let’s just get a confirmation however by this point we’ve
09:29 – establish that there are symptoms that are related with the pelvic floor so the first one is are you constipated
09:36 – if the person’s constipated I think well this potentially may not be an infection
09:41 – this may be the bowels that are pressing up on the bladder therefore the pelvic
09:46 – floor muscles are getting tight um there are there’s unique symptoms from person
09:52 – to person but it would be um they’re not having trouble with completely eliminating they’re able to completely
09:59 – eliminate the bladder and maybe it’s a little stingy um whenever like that
10:04 – burning sensation afterwards so I guess to answer your question it’s dependent
10:10 – on the person um but I would say are there symptoms consistent with their
10:16 – more pelvic floor symptoms or with the UTI so when I think UTI I think of like
10:22 – fever um Mala as well but also something is a little like clinical tip for me is
10:30 – if heat does not make it better so if you have a UTI heat will often flare
10:37 – your symptoms and you will not want any heat in this area because it’s a true infection so if I think there’s heat on
10:43 – this area and it’s making it worse probably an infection but if it’s starting to cool things down I would
10:50 – think this is probably more pelvic floor more structurally related that’s interesting
10:56 – because a lot of people do say they like to use a hot water bottle when they have UTI pain does that mean that you think
11:02 – that might actually be more of a pelvic floor or a pelvic Flor reaction to an infection if they do have an infection
11:07 – present yeah I tend to think so like if it’s an acute infection it’s not going
11:13 – to respond all the heat right because if there’s inflammation in that area Heat’s
11:18 – just going to exacerbate it and so your body’s going to want to think cool cool
11:23 – that area down um so that’s like my first I mean that’s my own experience to
11:29 – When U I’m like my body does not want heat in this area at all but if I am
11:35 – having symptoms I’m like he’s kind of like dropping those symptoms down I’m thinking this may not be a UTI yeah to
11:43 – add to that too it’s it’s the intensity so if you get moments of Silence of
11:50 – those pain signals it’s most likely muscle skeletal if you’re not getting
11:55 – any moments like it’s just raging that’s more likely you it will not get better
12:01 – as the days go on it will actually get worse so sometimes I tell people give it
12:06 – 24 hours if it if you feel it like riding a wave then most likely it’s
12:12 – going to be muscular scal hoold but again like you are sleeping by that toilet you’re just like ow what is going
12:19 – on that’s UTI and then the second thing is more like what are your thoughts so
12:24 – if you start to think is this a UTI is it not a UTI most likely not UTI
12:30 – sometimes when it is actually U you can’t think you’re not here you’re just in so much pain that’s another way to
12:37 – kind of think about it on the inner self or like what are your thoughts okay that’s an interesting way
12:43 – to look at it and sometimes the symptoms that people report are not pain it could be an idiopathic itch or tingle or
12:50 – something that they get and and I got a few questions about why that happens and then how you would approach that from a
12:55 – physical therapy point of view yeah okay so this is what I I always say
13:04 – too so we have the pudendal nerve and the pudendal nerve I geek out about this
13:09 – nerve so it has three components it has a visceral component which means it
13:15 – innervates our organs and then it has a sensory component so that gives us
13:21 – Sensations and then it has a motor component and so that means it’s in charge of how um our muscles are
13:27 – Contracting and so so this is what makes pudendal nerve a little tricky because it’s giving off so much input and
13:35 – receiving um so much stimulus as well so if this so the sensations of the
13:43 – pudendal nerve are burning itching arousal right so your pelvic Flor so let
13:51 – me take the organs out so if we
13:56 – have the penal nerve coming in right through here if these muscles get tight
14:04 – it can constrict on the pudendal nerve and it can elicit those organ sensation
14:09 – motor functions but often times it’s the sensation um that can be affected so it
14:16 – may give off that burning feeling it may give off itching or even unwanted
14:21 – arousal and so sometimes that’s where the burning is coming from too but
14:27 – there’s also another branch of the p gal nerve coming in innervating right at the
14:32 – base of the vagina and up at the clitoris and so this is something often I see as well when people are having
14:39 – urethal pain I say point to it and so a lot of the time because the clitoris and
14:44 – urethra are stacked right on top of each other people point right to their clitoris I’m like oh that’s your
14:51 – clitoris that is giving off that burning sensation and like you were saying earlier whenever that those pain signals
14:98 – are so diffus it’s coming in and it’s giving that um
15:03 – general area burning and so I think pudendal nerve itching burning yeah
15:10 – additionally when we think about the vulva it’s lined um or I guess let’s
15:17 – just say estrogen supports these tissues and so also with the Ure estrogen but
15:24 – testosterone as well so if people are saying they’re feeling itchiness other things I’m thinking of is hormonally
15:29 – what’s going on do they have low hormones and then I might ask in that nature but then secondly tissue dryness
15:36 – so if you do have low hormones or maybe you’re just cyclically going through your cycle and towards your ludal phase
15:43 – you start to notice that you get a little bit more itchier a little bit more UTI symptoms then we’re that there
15:48 – might be a hormonal imbalance influencing these tissues and then if there’s dryness we teach mobilization
15:54 – techniques so we can help them soothe that tissue bring more blood flow so the itchiness can quiet down a little bit on
16:02 – that note um when people are wiping a lot or trying to keep that area so clean it’s
16:08 – often which is kind of goes in with what mallerie is saying so looking at tissue
16:14 – nerve as well okay we do have some more questions about nerve pain but first it
16:19 – would be good to have a walk through of what it looks like so if a a patient was to come to your practice with
16:24 – unidentified pain or unexplained or unlocatable and what would would be the steps they could expect to go through in
16:31 – order to get a diagnosis and what might a treatment plan look like so first step
16:36 – is obviously finding that right practitioner um wherever you are there are directories that you can look up um
16:44 – in Europe I don’t know but in here we over here we have
16:50 – Herman and Wallace and pic Guru those are directories that people are registered under and you can look at
16:55 – your locations now when it comes to um when you come into the clinic first
17:03 – thing is we’re going to take a subjective component meaning we’re going to listen to your story think about it as being body detectives we’re here just
17:10 – listening trying to put the pieces together for you so as you’re talking we’re just going to kind of write some
17:15 – things down ask specific questions categories that after that we’re going to do Hands-On maybe we’re going to
17:23 – theorize what’s going on and then look at your body and start putting those pieces together
17:29 – and from there typically I tell people it takes at least six sessions for us to get to know you your body the way it’s
17:36 – responding unfortunately when it comes to P pelvic Health there’s no protocols there’s no um when you come in for
17:43 – shoulder pain right it’s like we have these specific measures we can take you through each series we can tell you when
17:49 – you’re going to get better when it comes to pelvic Health it’s very big on collaboration we’re making sure we’re
17:55 – talking to you we’re communicating with you very transparent and honest and then we’re getting you to the right
18:00 – practitioner because unfortunately we get people who have seen many different
18:06 – providers and everything is you look fine you look normal and when it gets like that I often tell people I’m
18:13 – actually I’m so sorry that you’re experiencing that but I’m happy to hear that because that shows me there’s no
18:19 – disease there’s no damage it could it’s just muscular skeletal and or nervous
18:25 – system hormonal hormonal things that we can’t see and so can’t see that we often
18:30 – are the providers to be able to help them guide them through the medical field and tell them where to go now if
18:36 – we’re thinking about diagnosis it really depends I give people options because sometimes you
18:43 – don’t need the diagnosis in order to get better sometimes you do need the diagnosis so there’s a big thing when it
18:50 – comes to intercal ctis and the biggest thing we want to know is are there Hunter lesions are there actual damage
18:56 – to your bladder if so that’s a whole different whole different case if you
19:01 – don’t have lesions in your bladder then we can take you the conservative route and if you do have those lesions we do
19:08 – have to add more medical route making sure you’re getting that lining nourished and it’s not so inflamed and
19:16 – spiky and just yelling the whole time so there are different paths and so your
19:21 – gynecologists are the people typically we would refer to for that and if
19:26 – someone has an active infection is that inappropriate to get pelvic FL physical therapy at that time and how does that
19:33 – apply to people who have a chronic infection that just never really gives them relief yeah I this is this is how I
19:41 – practice so whenever someone comes in with an active infection I will not do
19:47 – internal PT just because I do not want to cause any more friction um movement
19:53 – into that tissue I really want it to rest and heal um
19:59 – we can still move um so usually I would say um just stay at home I don’t need to
20:06 – see someone during an active infection I want them to rest stay hydrated um take
20:12 – whatever course um their physici has prescribed to them um but when it comes
20:18 – to a chronic UTI I will like see people whether that’s tah Health consultation
20:25 – or they’re in the office because we need a game plan what’s happening what’s going on again like what Dr mallerie was
20:32 – saying we need to look at your tissue we need to look at your abdominal wall what’s going on with bowel movement so
20:39 – there’s a little bit there’s two different courses active UTI um we’re taking a little break until you do not
20:45 – have a UTI it’s a chronic UTI that’s where we have to game plan because something is keeping this going so yeah
20:54 – and that’s kind of the next question was about patients who are on long-term antibi biotics you already mentioned
20:59 – that you work with clinicians and other Specialties to help get different types of treatment that might be necessary how
21:05 – do you think that long-term antibiotic treatment or other chronic hi treatments can complement pelvic flow Physical
21:11 – Therapy yeah so when it comes to long-term antibiotic use I’m not I think the question more so are you asking how
21:19 – does that impact their GI system or maybe their vver tissue or just general
21:25 – are you asking more so um pelvic wise I
21:31 – would go first around yeah the former is quite interesting because people often have the question of how does it affect
21:36 – long-term health for one thing and there’s also often the question of do public for physical therapists even
21:42 – think that antibiotic treatment is necessary but I understand that that’s kind of outside what you you do especially if there is an infection
21:48 – present so what you mentioned is quite an interesting way to answer that yeah so when if someone’s on antibiotic use
21:57 – we always say just confirm get the culture first so people are you know
22:02 – just prescribed antibiotics unknowingly if they do have one or not because they have the
22:07 – symptoms they do the dip test and the test comes back positive inside the clinic and from there um they’re given
22:15 – antibiotics but then they might get a call back three days later saying like hey actually you don’t have um a
22:21 – bacteria present and so they’re prematurely taking antibiotics so in that case I tell people if you can cuz I
22:28 – know it does help wait until you get the confirmation and then start taking it but number two the most important thing
22:35 – is if you’re prescribed it and you don’t want to take it and you do have an infection take it because the worst case
22:42 – scenario it goes up to your kidneys we don’t want that and from there it turns into sepsis so take the antibiotics it’s
22:49 – very important now if you’re long-term use antibiotics I would start going down the herbal route and trying to see like
22:57 – is there any way we can support your tissues um nourish it from a different
23:02 – perspective especially if you’re not in that chronic state of that UTI right now
23:08 – like if the UTI is not active it’s being proactive on the other side of the story
23:13 – that can help nourish the tissues um so yeah that’s kind of how I would look at
23:19 – it I can piggy back to just um from a person who was on long-term antibiotics
23:26 – to which um developed into a bofilm and I know that happens with a lot of
23:32 – chronic UTI right you have that resistance in the bladder and so I feel like what Dr mallerie was saying with
23:39 – the herbalism I feel like the herbalism is absolutely critical at that point to
23:45 – heal the lining of the bladder to help because at that point your body’s not responding to the classic antibiotics
23:52 – and so you have to disrupt that in somewhere um so yeah I fully support
23:57 – herbalism when it comes to Chronic UTI and biofilm presence and when you say holism is that aimed at fighting an
24:05 – infection or inflammation or providing another kind of support it’s support so
24:10 – if you have a an actual UTI herbalism won’t work at least that’s the way I view it I’m sure the take a different
24:17 – approach but to me um herbalism is more of this patience and it takes its time
24:25 – and it works it through and it makes the changes long term again when it comes to antibiotic use that means you have UTI
24:31 – we want immediate things and that’s the beauty of medicine it gives you that very quick experience we don’t have time
24:39 – to nourish but we can do both we can nourish at the same time as you’re
24:44 – taking action of resolving the actual um bacteria that’s involved and then after
24:51 – we can work on how can we prevent the bacteria from building up in the first place so it’s kind of working with and
24:58 – then moving forward to prevent it to happen again but once it happens it’s Switching gears and trusting that your
25:05 – body can take the antibiotic I think it’s important to talk about that kind of support as well because I’m sure
25:11 – you’re aware of the limitations of standard testing for UTI so a lot of people don’t get an answer standard
25:16 – culture has a lot of limitations dipsticks are very inaccurate and so they can often be in this place where they’re sure they have an infection but
25:23 – they cannot get the right treatment we have a lot of other information on our site about that and but that does mean
25:28 – that trying to support overall health of the bladder while they’re trying to find a Better Way Forward becomes even more
25:34 – important and and we do have a couple of questions based on some of the experiences that people have had through
25:40 – their treatment or just through having UTI for such a long period of time one of them was can pelvic floor physical
25:47 – therapy help with a distended bladder can you actually correct something like that over
25:52 – time yeah so the bladder here we got the bladder right here and we can see all
25:57 – those strands on the bladder and that is a muscle it’s the det truser muscle so I
26:04 – will say this not once an organ is distended in other areas like the colon
26:10 – it’s probably going to stay distended however the bladder is a muscle and so
26:16 – we can get that stretch because it’s elastic right so it can come down but really the big thing
26:24 – is from a neuromuscular level is that our bladder is dependent on this
26:30 – threshold and so whenever the bladder fills right to that 700 milliliters
26:37 – where it’s a completely full bladder um that can that can reduce if
26:43 – someone’s having chronic pain or those chronic UTI that threshold can go down so that can also be um help with the
26:51 – distension of the bladder and the sensations that we feel so to answer the
26:56 – question yes um the bladder can we can resolve some of that
27:03 – distension um into that but also from that neurom muscular that coordination level between your brain and bladder we
27:09 – can increase that urinary threshold okay that’s very interesting
27:14 – another um comorbidity that exists a lot in our community is endometriosis or unrelated to endometriosis painful
27:21 – periods can therapy help with painful periods yes 100% um
27:29 – there when we think about period pain many people just think about just hormones and there’s so many connecting
27:35 – factors do you mind if by yeah so like Dr allly was showing the uterus sits
27:42 – right here now what hugs it on either side is a muscle here and on both sides
27:49 – it’s hugging it so that’s called the operator internis so when you think of period
27:55 – pain the first thing I want to ask someone is where is your period pain some people might have um lower
28:00 – abdominal pain some people have pubic bone pain some people have low back sacral
28:06 – pain some people have pain rting into their inner thigh and then some people
28:11 – have bolver pain and bolver spasms so depending on all that is the way we’re
28:17 – going to look and treat it for example if someone’s having lower abdominal pain I want to know what the uterus is doing
28:22 – is the uterus stuck is it sticky so then I look at the uterus and I try moving it
28:27 – it’s like like o it’s a little bit tight here all of our organs are tethered down by ligaments so we want to look at the
28:33 – ligaments the ligaments all attach to the sacrum for the most part and so then
28:39 – I want to look at the sacrum is the sacrum tilted in a way so we look over
28:44 – here is the sacrum tilted in in a way the next thing we want to look at is
28:50 – maybe tailbone if the tailbone is pushed forward uterus is right there so is the
28:56 – tailbone being pulled forward by either the sacrum or the pelvic floor because it’s lifting and it’s tightening that
29:03 – area when you’re on your period your uterus does expand and so when it’s
29:09 – expanding it could feel just tense and tight doesn’t want to feel that next things are nerves nerves can also refer
29:16 – down into the inner thighs so that’s something I’d want to look at too like what’s going on back in this area and
29:23 – it’ll look like this with the muscles back
29:29 – here these muscles can be tight causing irritation to those nerves we have nerves that come to the front this way
29:37 – and so that can become tight and that can be radiating down if people have endometriosis they might have adhesions
29:44 – and so if they have adhesions rather that’s through the enetri andrios lesions and or the surgical component we
29:51 – want to make sure that’s nice and mobile and then lastly constipation constipation is always something we’re thinking about when it
29:58 – comes to any pelvic health issue because they’re just so closely knitted and it
30:03 – can refer everywhere that we’re not thinking like that and when we talk about constipation most people think oh
30:10 – I go all the time I’m not constipated it’s not the frequency it’s the amount so if people are going daily but are
30:18 – only going this much that much I typically tell people if you haven’t looked at your poop look
30:23 – at your poop how long is it and I’m like is it about like six and is about like 12 and people are like oh
30:30 – yeah it’s about like maybe six or like this big I’m like oh you’re not going enough so I wish there was a study I
30:37 – know somewhere in the world in my brain 12 inches came up and I confirm where
30:43 – that came from I am trying to look for that Source but you basically want to be
30:48 – pooping around like this much daily and so you’re not doing that it can be
30:54 – broken up into sessions you can go twice a day that’s totally normal um two six
30:59 – inches that’s full fully eliminated if you’re not going that much that’s
31:04 – constipation if you’re going longer than five minutes right you have to sit and you’re trying you’re trying that’s
31:10 – constipation if you have pain that’s showing pelvic floor muscle tension around there which is constipation so
31:17 – there’s just this series when it comes to period pain that we’re not just looking at the sorce we’re looking at
31:24 – that big picture um and then lastly prostaglandins I mean can keep talking
31:29 – period there’s so many things that could involve in it but our work is to support the tissues the
31:36 – ligaments so that we can increase endorphins and reduce the prostag glandon component so we can help
31:42 – inflammation and pain signals I’m just going to make a little visual image this
31:47 – is the bladder vagina rectum and they are on top of
31:53 – each other right so there’s inflammation back here or constipation you can see
31:59 – there’s like so pocketing right there how it’s going to put pressure right on the uterus therefore it’s going to put
32:06 – pressure on the bladder and even if it’s a little bit of pressure that can go a long
32:11 – way a lots of discomfort yeah I think a lot of people can attest to that in our community
32:18 – before we jump on to more questions about nerve pain there was one specific question about treatment which was that
32:24 – do you utilize Botox in your practice and if do you find that it can be beneficial and in what
32:31 – circumstances yeah definitely so my practice will always go
32:36 – conservative until I have to start to integrate different treatments interventions and so when people are
32:44 – stuck in that chronic state and their pelvic floor cannot get out of that spasmodic or that tightened contracted
32:51 – State um I will refer for Botox um and
32:56 – so what’s really great to is the practitioners that I work with um I will
33:02 – do a pelvic floor mapping assessment and so I map out the muscles that
33:08 – specifically need the Botox and where those muscles need the botox um I’m
33:13 – going to steal that pelvic model really quick so right if there’s those
33:19 – superficial muscles that are having a really hard time relaxing versus these muscles are fine
33:26 – back here a lot of the time people go in for Botox and they’ll get these posterior muscles um and that’s fine
33:33 – because we know that the botox can move and translate forward but what’s really great working
33:39 – with a PT who is specific in mapping out the pelvic floor we can say oh actually
33:45 – it’s STP superficial transverse perennial that needs Botox you actually
33:51 – need some Botox right at the perennial right at the base um and then maybe
33:57 – these more superficial pelvic floor muscles versus the Deep um and so yes I will um
34:04 – recommend BOTOX for the people who are having a lot of difficulty with the coordination of their pelvic floor
34:11 – relaxing their pelvic floor um with that sometimes can come some difficulty
34:18 – holding back urine holding back gas and those first few weeks but um I always
34:24 – say it takes about two to four weeks for Botox to set in and the most important
34:30 – part when it comes to Botox is you receive pelvic floor PT um in clinic or
34:36 – you do it at home because you have to now retrain the muscles you just paid a lot of money to get the botox now we
34:43 – need to make sure that it works you don’t have to keep going back and that’s the point of Botox not to just relax it
34:49 – but now let’s retrain the system yeah that makes sense and you
34:54 – spoke earlier about why the pental nerve is so involved in all of this what’s pudendal neuralgia and what are the
35:01 – causes the common causes of that so pudendal neuralgia so we’ll just break
35:06 – that down the um here’s a fun fact pudendal um and its Latin base is shame
35:14 – so I think that’s telling you a lot right there and then we have nerve which
35:20 – is the ne R and then Alia which means pain so essentially we have a nerve that
35:26 – is pain specifically to the pudendal nerve and so pudendal nerve this is how
35:33 – I think of it because a lot of after working 10 years at this now people are
35:39 – pental neuralgia and they will they look it up and there’s not a lot of great
35:44 – stories um people don’t have a lot of good experience with P neuralia um they
35:50 – think of entrapment and so the way that I like to shift the way that we’re talking about pental neuralgia is
35:57 – there’s a inflammation to the nerve I mean we all have experienced some inflammation to a nerve at some point in
36:03 – our life um and let’s say we pinch a nerve in our neck it takes about six
36:09 – weeks it calms down however when it’s in our pelvis and because there’s so many
36:15 – sensory those nerve receptors and it’s organ related too it feels like it’s a pretty big deal and it is like it can be
36:23 – a big deal when it’s not treated or addressed or you’re kind of getting into that
36:28 – psychosomatic um part too so um essentially I think of pental neuralgia
36:35 – irritation to the nerve it can elicit motor symptoms sensory system visceral symptoms as well um it can be caused by
36:44 – prolonged sitting um cyclists often get it it could be childbirth it could be um
36:52 – sexual trauma it could be physical trauma it could even be emotional trauma thinking about its origin in the name
36:59 – pudendal shame um so we’re kind of dabbling in a lot of mechanisms of in
37:07 – potentiality could a single UTI lead to pental neurala yeah I’m sure because I mean if
37:14 – those muscles are really tight right it’s going to compress um let’s say you
37:19 – get the UTI your body is getting into that hypertonic tightened State and then
37:25 – it doesn’t relax and then the nerve gets irritated there’s not enough slide and glide there’s restriction there’s a loss
37:33 – not loss there’s a lack of blood flow to that area can cause friction and so then
37:38 – someone can develop a pudendal neuralgia it may not be a long term but it could be shortterm just again thinking about
37:45 – that pinch nerve in our shoulders our neck our back it it can go away our body
37:51 – has the ability to heal itself and we just have to support that and kind of get on the same page and education’s
37:58 – huge yeah typically too when it comes to pental neurologia if there wasn’t
38:04 – no actual onset of the symptom like it just kind of came I tell people that
38:11 – especially if you didn’t change anything your body let you want to think of your body
38:18 – as this kind of pillar system so we have the way your body’s posturing so that’s
38:25 – one that’s biomechanics are you slow are you lacking specific restrictions within
38:30 – your Mobility um are some muscles tight then we want to look at your nervous
38:36 – system so are you in a sympathetic response are you in a parasympathetic response that firl rest and digest you
38:43 – want to think about that hormonal system all these things within our body all have pillars so for example when it
38:49 – comes to pendal neuralgia down here this is our pelvic outlet and these are our
38:55 – sitp bones so Dr Alie mentioned about sitting for too long so could one person
39:01 – sit for too long and be okay but then another person not so it’s the active sitting is a contributing factor but
39:07 – it’s the way our body’s posturing that can put us more susceptible to getting things like this for example if these
39:14 – are sit bones this is a pelvic Outlet this is internal rotation so you’ll see
39:19 – that these two body are coming together and then we have external rotation which
39:25 – makes it go away so if someone’s already Laing internal rotation meaning they’re already very compressed in this state
39:31 – pelvic floor is probably a little bit more shortened so now this person sits
39:36 – and let’s say they’re sitting back here they’re not sitting on their sit bones then they’re adding more pressure to the
39:42 – system causing right here pmal nerve is where it exits out of the pelvis and
39:47 – goes into its area that’s when sitting is going to cause the issue of creating pental neuralgia so that’s just like
39:54 – things to think of is your pillar where where are those pillars where are we at when our body um is having these
40:02 – symptoms and those are things to look into right are you having big things happening in your life going back to the
40:07 – emotional component there if we think about Energy Systems if we just think about what is in this area um you can
40:15 – think of it energetically more of like the root chakra sacral chakra right protection U when she was mentioning
40:22 – trauma right so if we feel threatened the this area of our body is going to be very protected very tight but if we
40:29 – think about nervous system that fight ORF flight response our pelvic Flor is very um automatically driven um with the
40:37 – autonomic nervous system so if you are trying if you’re nervous if you’re
40:42 – fearing if you’re worrying right the bladder carries worry and so if you have
40:48 – those emotions so stuck and so stagnant our body is super smart IT protects us
40:53 – it’s not going against you it’s going for you because you’re feeling the those emotions so it’s going to turn on and so
41:00 – that’s where all of those other symptoms arise so other things to think of when it comes to the body I mean there’s so
41:07 – much to think about which is why this is so difficult for people to move forward but what one of the things that people
41:13 – often describe is just the pain is not there and then suddenly it’s there or it’s there and it disappears when they
41:18 – just drink one sip of water like how can we explain it when there doesn’t seem to be any logical explanation for this
41:24 – coming and going of the pelvic pain nervous system when it’s like that if
41:30 – it’s very sporadic it started here now it’s here it was there like this now
41:36 – it’s like this if it’s constantly changing it’s nervous system and not system in a way that we over thinking
41:44 – and it’s all in our head it is not the body is so amazing our nervous system like I said protects us and so if
41:51 – there’s any ounce of worry maybe you even think like this water is like I’m very thirsty I need this water and you
41:57 – drink it our nerve system’s like ah I can kind of like come down now so you are not thinking that but your body is
42:05 – and your body responds so that’s a way to always kind of take a step back if
42:10 – it’s changing for you start working on that nervous system see what’s going on deep in within look look around you
42:17 – what’s going on in your life is it heavy right now but also pain is worrisome and
42:22 – so when we think about pain as physical therapists that is our specialty we are
42:29 – pain experts we work with pain day in and day out and it’s one of the biggest
42:34 – things that you know we take pride in and on my end I love teaching people
42:39 – about pain how to befriend pain how to meet pain and what does pain mean to you and how can we reframe what pain is
42:48 – because again it’s just our body trying to say something and the frustrating part is because you as a person
42:54 – experiencing pain do not know how to read it or hear it or listen so that’s
42:59 – why you seek the providers that can help you interpret it and one of the best things to learn is that once you find a
43:06 – really good provider that you connect with let them hold it for you let’s take
43:11 – the weight off of you and let us hold it for you so that you can actually just do the things instead of have to think
43:17 – about what is going on because we’re going to teach you that so I hope that for everyone that they can find a really
43:23 – good practitioner that they they really connect with and if you don’t there are people out there so it’s like just keep
43:29 – searching I know it’s frustrating um reach out to us we do virtual stuff we
43:35 – can connect we you know it I just feel like you need to find that person that
43:40 – makes you feel and safe too because nervous system it’s part of the
43:45 – treatment yeah it’s so important it really does help when you find that right clinician with whatever treatment
43:50 – you need to move forward but one of the questions that comes up a lot with this is so painful the pelvic pain that
43:56 – people going through with UTI is it normal when you start pelvic floor physical therapy for the pain to get
44:02 – worse or is like how do you know when the pain is not necessary for future Improvement yeah so sometimes it can and
44:10 – so it kind of like is piggybacking with what Dr mallerie was saying because as we’re peeling back these layers we’re
44:17 – really coming up and getting familiar with your pain that can be a really
44:23 – uncomfortable process and there is that aspect of getting familiar with your
44:30 – pain but there also is um what Dr mallerie was saying earlier it takes sessions for us to get to know your body
44:37 – we’re a full body assessment and sometimes we’re making you do things that provoke your pain because we need
44:44 – to see what you’re doing at home that may be contributing to this pain we may
44:49 – be poking on certain structures because we have to find what structures are involved with the pain and once we have
44:56 – that map down then we can start to cool it down so essentially we’re looking at
45:01 – this like a map and we’re pinpointing right Hot Spot Hot Spot oh this is actually a relieving spot and so in an
45:09 – Ideal World we would love for everyone to come in and start to feel better
45:14 – immediately and sometimes that does happen um and sometimes it doesn’t happen but both are good information and
45:23 – data points are what we need to get people to being painfree so it’s kind of
45:29 – part of the um kind of part of the game I mean I think about other injuries as well when you’re rehabbing an ACL when
45:36 – you’re rehabbing a frozen shoulder there’s going to be pain that’s involved and I always say to this is a this is a
45:45 – time that we can actually capitalize like how are you responding to pain right now let’s practice this together
45:51 – you know what are these techniques that we can start to get your pain down in the office versus when you’re at home and you’re and you start to spoil let’s
45:58 – put in those strategies now so I always say actually this is a good thing that
46:04 – we’re provoking pain right now yeah and another thing to acknowledge is how long
46:09 – was the aftermath so someone comes in and they said I left the session I was
46:16 – feeling very achy like it was coming on again and you know when I woke up the
46:21 – next morning it went away I’m like H great that’s exactly how I want it right you don’t want to be agonized but then
46:27 – you know it’s not uncommon that someone would come in and be like I literally and we see them once a week they’re like
46:33 – I literally just got relief yesterday last night I was like oh wow is comfort for a whole week and they’re like yeah
46:39 – I’m like all right we’re g to reel it back this is what we did now this time I’m going to tone it down look at
46:45 – different areas and let’s see how you respond so we’re constantly adjusting with people trying to see like what’s
46:51 – the best touch what’s the best area sometimes like Dr Ally was mentioning if it’s a hot spot or like oh this is
46:57 – actually relieving we might be like okay let’s let let’s let those hot areas calm
47:03 – down on their own we’ll work on the places that you find relief or maybe we start up at the neck I know that sounds
47:08 – like what the heck but you’re having pain down here we can address the nervous system in this area like maybe
47:15 – right now your body cannot get the touch in that area we’ll work our way down we’ll make it that your body receives
47:22 – what we’re trying to do so we’ll keep trying to figure it out um but our goal is to never have someone to be in pain
47:28 – for a week if you’re in pain for a week after the session something we have to think about if they’re in I usually use
47:35 – um you know in exercise science Doms delayed onset muscle soreness um when
47:41 – you go let’s say squat and you PR that day you’re just like working really hard
47:47 – you’re going to be sore for about anywhere from 24 to 72 hours so that’s a time frame I give people on a sore end
47:55 – 24 is great 48 is good 72 is like I just pushed your limit and if it’s past 72
48:02 – that’s way past the limit we need to bring it back and figure out a new route to help you okay so let’s talk a little
48:08 – bit about painful sex which is a big Topic in our community as well how can public FL physical therapy help with
48:15 – that especially if it’s a pain that only comes on after sex so it might not be there when you’re in
48:21 – therapy so so many things um with this
48:26 – another topic love um let’s talk about UTI specifically so people who get UTI
48:32 – like symptoms post interor or post postcoidal we want to think about one of
48:37 – the what positions were you in when did it happen um was it before and then it
48:45 – exacerbated was it during in a specific position was it when you orgasmed was it
48:51 – when they touched you in a away did they put their finger inside of you were they fingering you right did they um did you
49:00 – have it after you peed did you go pee before you had intercourse and then you
49:06 – forc yourself after your 20 minutes of intercourse to go pee again right can trigger it because you’re going pee so
49:13 – close to each other right and then you can think about the actual components of
49:18 – it what which is is it actually UTI do we have to look at your your pH levels
49:24 – and your partner’s pH levels and are are you guys just not connecting on that end right is there actually UTI going on in
49:31 – there chances are it’s probably the the others that we just mentioned versus the
49:38 – actual UTI being caused by intercourse and so when you’re having intercourse
49:43 – just the mechanism if you’re having penis and vaginal intercourse penis goes inside
49:50 – vaginal Canal but as you’re becoming aroused your vaginal Canal lengthens so
49:56 – it’s called vag tenting so it’s going to lengthen and then right here on the back end this is going to be your cervix this
50:03 – is going to be the uterus it’s supposed to lift up and out of the way and then
50:08 – you’re able to penetrate now we’re thinking about remember pel for muscle
50:13 – tension so if those muscles are tight around right if they’re already tight
50:20 – and then it can’t do the mechanism of lengthening and moving well now it’s
50:26 – Crow in there and your partner who’s penetrating and the person that you’re having penetration intercourse with it’s
50:33 – going to be causing more friction in those areas bladder sits right on top so
50:39 – if you’re in missionary your body’s going to look like this and so bladder is right here so what we can think about
50:46 – is if everything’s not moving up and out of the way well then it’s could be irritating the urethra that sits right
50:53 – behind that pubic bone so you’ll see this muscle right there there right on
50:58 – the outside yeah this is what those two muscles look like let me
51:04 – see okay I’m trying to see how I can show you okay so that that’s how the two
51:09 – muscles look like urethra is right in between so is right in between that and
51:15 – those muscles are super tight as you’re having penetrative intercourse it’s basically like there’s so much friction
51:20 – in there and it’s not allowing that kind of gliding motion so when we think of
51:26 – for muscle dysfunction if someone’s saying they’re having pain painful UT or like urination post intercourse we want
51:33 – to look at all those P Flor muscles we want to see can the uterus move back is the cervix moving back um and then
51:41 – getting more detailed like with the orgasms and um different types of ways
51:47 – people have pain right and on the topic of penetrative sex or penetration in
51:53 – general there has been quite a bit of discussion lately about how vaginal penetration is essential to help prevent
51:58 – vaginal atrophy can you provide any insight on why that might be the case yeah so essentially muscles act
52:07 – like any other muscle in our body or our pelvic floor muscles act like any other muscle in our body they contract and
52:14 – they relax and so whenever we are getting movement to that tissue not only are we getting into the actin meios like
52:22 – those contraction filaments will build a stronger pelvic floor but we’re also
52:27 – getting that neuromuscular feedback so our body says oh we are still using this
52:33 – area so let’s continue to feed that area blood flow um more coordination so um
52:41 – that’s essentially how it works um contract relax um is
52:47 – essentially needed for vaginal penetration does that have to be in a
52:53 – state of arousal for the benefit to be gained or can it be penetrating of a p FL device or a sex toy without
53:01 – arousal that’s honestly a really good question I would assume that you could do both like just saying like um a squat
53:09 – is going to be beneficial for building your pelvic floor any like running or
53:16 – any kind of activity is going to be beneficial for the contract relax that full function of the pelvic floor um sex
53:23 – is in functional activity as well so to answer your question you can do both and
53:30 – it will benefit the um quality of the pelvic floor and how frequently is
53:35 – penetration required in order to gain that benefit for the parameters of
53:44 – um yeah when when it comes to I would say frequency it’s more of like what the
53:51 – goal is right what is your if the goal is to open up tissue and if someone was
53:57 – like I love intercourse I’m like beautiful have intercourse do as much as you want right but if someone doesn’t
54:03 – like intercourse especially if they’re having pain yeah it’s typically very
54:09 – hard to prescribe something like that so we often would give them more of like um
54:14 – and have you ever heard of kiwi it’s a it’s by the pelvic people they created
54:20 – like a little um pelvic pain device well it’s it is more of like like a massage
54:27 – onto your vva but can also be inserted so it kind of looks like this it doesn’t go in that deep it’s about this deep
54:35 – works on Entry pain and so we might tell someone do that daily until I see you
54:40 – next time and when I see them next time I’m like okay was there changes did they have pain did that change and if that
54:47 – worked I’m like great let’s do it one more week daily let’s see what happens and then after that I might have them go
54:53 – down to three times and then maybe once a week and then from there I mean I know
54:58 – you’re saying that arousal might not be there but when you’re using these devices arousal could be there and so I
55:06 – typically would guide people into like this is more therapeutic I want you to get into your body feel what it’s
55:11 – feeling like stretch it be cous but if you’re aroused you have options you can
55:17 – be like oh interesting I’m getting aroused okay and then you just kind of do your thing and continue stretching
55:23 – but if you’re like oh I’m actually getting arouse and this feels pretty good then I’m like go for it right
55:30 – arousal and orgasms lead to more blood flow lead to more lubrication it plumps
55:36 – the tissue and so D was mentioned it is an exercise intercourse is one of the
55:42 – biggest kind of events that the vaginal tissue will go through and so if you
55:48 – enjoy those things then it’s it’s no shame it’s it’s therapeutic so
55:54 – definitely something that we encourage I think the question partly comes from this predicament that people in this
55:59 – community are in they avoid sex because it causes a UTI or it causes pain but they also know that vaginal atrophy is a
56:06 – huge contributor to UTI so then they’re told that they need to have penetration in order to benefit or prevent atrophy
56:13 – and then they feel like they can’t so they’re asking what is the minimum amount of penetration they can have to get the benefit without pushing them
56:20 – over that edge so other things so many other things it does not have to be yeah
56:25 – yeah does not have to be intercourse like I was saying squats um zone two
56:31 – exercise um stretching actually moving your vaginal
56:36 – tissue right like outside not inside there there’s so many Alternatives and
56:42 – if you’re worried about infection like just even touching you wear gloves so
56:47 – there’s so many things to do besides vaginal penetration yeah and and can an orgasm benefit the well prevention of
56:54 – vaginal atrophy in the same way that penetrates might or in a similar way without penetration yeah yep so essentially with
57:01 – an orgasm it’s the contract relax of the pelvic floor muscles and so not only are
57:06 – you getting movement of the pelvic floor but you’re getting blood flow and you’re also getting a lymphatic flesh which is
57:13 – great for immune system which is great for the immune health of the vaginal tissue of the bladder of the
57:20 – urethra okay and in terms of things that people can do at home are there any
57:25 – exercises that you consider safe that most people could try yeah so I always lean into first the
57:34 – nervous system so we’ll go into breathing mechanisms which we could talk
57:39 – about that honestly for a good like 10 15 minutes to um um down regulation
57:46 – exercises um because that will help calm the nervous system that is an exercise in its own your body needs restoration
57:55 – as much as it needs Mobility the two go hand in hand um if you can tolerate
58:01 – walking is amazing um or pain in general
58:06 – there’s a lot of research on movement with um people’s pain getting into zone
58:11 – two again if you’re um I would highly recommend working with a physical
58:18 – therapist um someone who knows and is trained in exercise prescription um but just to across the
58:25 – board meditation breathing exercises walking
58:31 – Mobility um stretches at home across the board will be safe yes some some
58:38 – stretches that are pretty General and like generally safe could be um a
58:43 – child’s pose cat Cow adductor rockback um butterfly happy baby happy baby um
58:52 – and then let me see that and then actual touch to your vula so outside externally
58:59 – not internally you can get your labia and you can stretch so we can relieve
59:04 – right here here’s the urethra relieve that area so hold that and stretch for 30 seconds let it go pull Let It Go I
59:12 – usually how people do this in the shower you can open up your labia and then massage on the outside on that muscle
59:20 – that’s where the urethra clitoris you could go in and then just like do
59:26 – circles so it’s kind of like if your neck hurt right people go like this it’s
59:32 – the same thing and I think that we forget that these are muscles and it’s
59:38 – not it’s not wrong to touch your vulva right it’s not saying that you want to
59:43 – be intimate with yourself it’s not saying that you’re trying to arouse yourself these are muscles you’re trying
59:49 – to stretch you’re trying to bring blood flow you’re trying to calm the signals just like we would do with our shoulder
59:54 – just like we would do with our back right we can rub these tissues and oftentimes they feel good and not good
1:00:00 – in a sense that you will get aroused but I mean you can and that’s not wrong
1:00:06 – either so that’s just very important to state that these are muscles just like every other body part yeah I think it is
1:00:12 – really important to make that point I think we could talk about a lot of these topics in a lot more detail but we probably run out of time today so I
1:00:18 – wanted to ask a couple of quick questions about your practice what types of patients do you
1:00:24 – see yeah um we see so I feel like our
1:00:29 – main population is pelvic pain so unexplained pelvic pain chronic pelvic
1:00:36 – pain really is our Niche within the niche um we do see people pregnancy
1:00:43 – birth prep postpartum um other rehab pain with sex
1:00:49 – infertility and their fertility Journeys um male pelvic pain we really we really
1:00:55 – see it all but we really focus in on the pain aspects and where you’re at in your
1:01:04 – journey and where abouts okay sorry go onor I was in pelvic pains like
1:01:09 – endometriosis intertial cytis it could be um chronic bladder syndrome it could
1:01:15 – be on the flip end symptoms so abdominal pain vver pain constipation constipation
1:01:21 – period pain right so we can do symptomology pelvic pain or actual diagnosis pic pain okay that’s great
1:01:28 – tonight and where is your clinic located and how can people get in touch if they’d like to make an appointment yeah
1:01:33 – we’re based in Costa Mesa California and then on our website we have um a bunch
1:01:40 – of just fore education um our websites called tonic and phasic Doc t o n i c a
1:01:47 – n d p h I say that because it’s so like people are like wait what is that yeah I can
1:01:55 – understand we’ll be sh up put their Link in the description as well so they can find it directly perfect and on there we
1:02:01 – have like I was saying um blogs free handouts um our contact and so it’ll go
1:02:07 – to our um patient coordinator and if it’s specifically towards us she’ll give it to us and we can get in communication
1:02:14 – we have online booking so we do do virtual visits for people we call it pelvic Health coaching where we coach
1:02:20 – you through your pelvic experiences and try to navigate the medical field for you so that can get to the right
1:02:26 – providers get the right treatment and then even coach you through the things that we can coach you through great well this is all being
1:02:33 – very insightful and I look forward to sharing it with our audience and thank you so much again yes thank you so much
1:02:39 – for having us yeah thank you for having us it was a lot of fun and a good way to get my brain going right in the morning
1:02:45 – so I love it are any questions I’m here for it thanks so much for watching I hope you found this expert video helpful
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