Good morning, everybody. Thanks for showing up to the early morning session. We have somewhat of a tight day or tight morning with the slides, so we're going to get moving early. A few announcements. Welcome. Thank you for coming. Make sure cell phones are off, airplane mode, no audio or video recording while it's going on. It's live streamed. You'll be able to get it online if you miss our faces at any point. Business forms, the app, online platform or the learning portal, make sure you access that. That will also help with your CME. Don't forget to visit the PM&R Pavilion. I hear there's dogs there, so you can pet dogs if you like them with other stuff. For the sake of moving with time and saving enough for our expert panel here, today we'll start with one session about pelvic pain, but really the day with all our experts coming through throughout the day, we'll be focusing on pelvic pain, pelvic floor-related management. A lot of us in cancer rehab, we have seen a lot of different patients for a lot of different reasons, but I think a lot of us probably do not have a significant amount of expertise in this area. Some of us may have more comfort with certain parts than others. I would say probably in the PM&R world, we're comfortable with bowel and bladder from a neurologic perspective, but I think understanding the really musculoskeletal perspective or other interventions to do, I think unless we have specialists or partners around, a lot of us are missing some of that expertise. My role is the simple cancer rehab doc that has no understanding and rely on my colleagues here to help explain that process, but the best way to go through it is talk about a few cases. Initially, to start off, no disclosures, and I'll talk about a few cases. These are actually real cases that I've seen in clinic with maybe a little modification for the sake of patient privacy, to go through it of generally what I get patients for and how I would approach them, and I think maybe you guys would disagree how I look through my assessments. I don't think I did anything wrong, but I'm probably missing some things without getting that full assessment. When we're talking about pelvic pain or pelvic floor issues or pelvic dysfunction, oftentimes what comes in mind, and I think when I actually started, our pelvic floor therapists were under women's health, so if I wanted to send a male or non-binary person to pelvic floor therapy, I had to put in a women's health order, and so even in our own culture, it was stuck of it's a women's related issue, but prostate cancer is a large population that requires support and intervention, and I'll talk about just a case of someone I've seen in clinic and highlight a few things and highlighted just a few pieces with this individual. This is a person I saw fairly recently, a 61-year-old male. They had prostate adenocarcinoma. They came to me for lymphedema. It's a pretty common referral. Long history of cancer, going back to April of 2019. They had a high PSA, biopsy-proven cancer, ended up having a radical prostatectomy with bilateral lymph node dissection. You can see the pathology there. Nothing abnormal through here. They were monitored, salvage RT with concurrent androgen deprivation therapy, which is basically moving forward and I think pretty much standard of care probably for most people that are seeing this population, and then the PSA remained undetectable with the last check around the time they had seen me. Some important past medical history. This person has diabetes hypertension. They had an inguinal hernia, some lower extremity knee injuries. Important for me as I'm assessing for lymphedema and mobility and function. We want to get our psychosocial history. They were single. They lived in Chicago. He's had some caregiving duties. Obviously, we pay attention to some of that as we're gauging in terms of activity. Still a working individual, standing, carrying equipment, keeping active. Their lower extremity swelling history. They noticed initially it started after a DVT and an infected lymphocele. And so they had a drain. They were treated. Saw them. They were diagnosed on my exam. They had left greater than right lymphedema, considered those multiple factors in the history given the prior musculoskeletal injuries and surgery, the radiation, and then they started after the lymphocele and the DVT. So we recommended compression. He was actually doing pretty good with his current status. And then we, because he was busy and he was caregiving, we talked about therapy. He really was almost too busy to go to therapy. He just really wanted guidance on what to do. So we talked about issues. We talked about compression. If we still had issues, we go forward. Does anyone have any concerns about that evaluation? I'm sure probably many people in the room have seen someone that you feel like, hey, I did my job. I came here for lymphedema. Yeah, me. Cancer rehab, right? But as we'll find out, there's more parts that probably we kind of dig deeper as we want to do an overall comprehensive assessment. Going through to the next case, you know, the gynecologic cancers, obviously this is a little bit of a broad-based term. Lots of things encompass this, but we'll talk about one particular case that may give some thoughts and process as we start thinking through. As we go through the days, the other speakers will talk about probably some different examples and cases that may be more relevant to whatever your practice may be, depending on what your patient population is. Another 60-something-year-old female came in with metastatic endometrial cancer, and again came for lymphedema. I would say functional issues, quote-unquote, meaning their functional decline or lymphedema are probably two of my most common referral, at least in my practice. I think depending on what your referral base is, I think most people in this population, that will be the case. I think Dr. Wong is here with me. I would say a lot of the gynoncs, that's what they refer over to. I don't think we had a lot of progress historically of them thinking in terms of functional-related issues or MSK-related issues. We may treat them when they come over to us, but that's really the aspect. This person, again, diagnosed some years ago, had a robotic total laparoscopic hysterectomy, had their ovaries in fallopian tubes with pelvic node dissection and pelvic washings. They had brachytherapy of the vaginal cuff, unfortunately had metastatic disease subsequently, and they enrolled in a trial. You'll see there's immunotherapy with Pembro as well as paplitaxel and carboplatinum. Initial response, although peripheral neuropathy limited their ability to continue to progress forward in certain treatments, their plan was to do nine cycles of chemotherapy followed by that ongoing placebo versus immunotherapy. Some other aspects in the history, obesity, gout, the usual hypertension, diabetes. This individual also had TVTs in the past. Neighborhood, two children, home accessibility, Logan Square is a neighborhood in Chicago. They're working from home. This person started working from home during COVID and ended up staying here. So they were really just kind of computer desk work. We talked about the swelling when it started. After surgery on and off for years, persistence in starting chemotherapy, they tried some exercises online without improvement. Again, this kind of started during the COVID times. They improved with elevation, but it got worse. They had difficulties wearing shoes, and they do wear some compression socks they get from Amazon or some podiatrist, but just when it's bad. The neuropathy, there was tingling in the bilateral fingers, uncomfortable. They had some stabbing pains. It got a little bit better with some decreasing the chemo dose, and they felt a little off balance. What we discussed is lymphedema therapy, and then again, for a lot of these people, and I don't know if you guys have a similar end, but we sometimes triage what's the most important piece because of life, other aspects, they can't kind of devote their time to just therapy. So we said, we'll start with lymphedema, depending on your progress, maybe with the swelling and progress as you're moving farther away, we'll start some PT for your balance. But as I mentioned, are we really done? So we hopefully pride ourselves in doing a comprehensive assessment. We may get sent for one thing, but one of the pieces that makes us good cancer rehab or physiatrists is making sure we have that global view of patients and individuals, and I think we can always build on that and see where we add in. I think some of the sessions on the other day, I think they talked about palliative care and other things. So I think more skill sets that we have, more things we can offer and help the patients. But I am now going to pass it along to Dr. Wong, who will talk about other things we can talk about. Hey, everyone. My name is Sarah. I am not a cancer rehab doc, but I am a public health doctor. And so I'm going to talk a little bit about history in these patients. So as Sam said, we're not quite done here, because in this patient population, we see a lot of pelvic health concerns. So when we talk about pelvic floor dysfunction, what does that mean? There's kind of two areas that we typically see overactive muscles, which we often call high tone muscles, or weak muscles. And often what we see is a combination of the two. And when patients have pelvic floor dysfunction, they can present with bowel and bladder issues, sexual dysfunction, or pain. And so that's kind of what we're going to talk about today, and how to assess these patients a little bit further. And we know that in the cancer rehab population, this can happen as a result of radiation, surgery, chemotherapy. But especially, well, in both populations, but more so in women than men, they might have premorbid pelvic floor dysfunction that was never treated as well. So sometimes part of it is kind of distinguishing when this all started. Was this a problem before? And that kind of helps us in evaluating and treating them as well. So bladder complaints. Patients can have urinary frequency urgency, trouble emptying the bladder, nocturia, or painful urination. Generally, when we see those kind of symptoms, we're thinking more tight muscles, high tone. And I'm going to tell you kind of a little bit of just like, when I see some, what I'm thinking I'm going to find on exam, what we often find is that that's not right. But urinary incontinence and frequency, urinary incontinence is generally what we expect to see more with weak muscles. But we definitely see it with patients that have high tone as well. And when we're asking them about urinary incontinence, we want to know how bad it is, right? Is it just a little bit of a dribble? Are they having to use pads? How many pads are they using a day? In the cancer rehab population, probably the most common things we see are urinary urgency and then urinary incontinence. And studies have shown that in women that had cervical cancer that underwent hysterectomy and radiation had like a three to six greater odds of having urinary incontinence than general population. And four to 12 greater odds of having fecal incontinence, which I'll also talk about. And then we know in the prostate cancer population, about 70% of men will experience urinary incontinence and urinary symptoms. We also see bowel complaints. So generally, again, when we're thinking high tone, we're thinking things like constipation, the patient may have straining or trouble emptying the bowel. And then if the muscles are weak, we might be thinking more that we're going to see fecal urgency, incontinence, trouble holding back gas. And then obviously, again, with the incontinence, we're always wanting to know how bad this is when it's happening. So I've had, especially in my prostate cancer patients, where they're having this issue all the time. And to patients where it's like, oh, when I'm golfing, it's the only time it happens. So we kind of want to know what we're dealing with. And that will help then our physical therapists kind of guide and help us guide treatment a little bit better. We can also see pain in this population. So when I trained, we always talked about the pelvis is like this basket, right? So there's the basket, and then there's the fruit. So all the internal organs, you can have visceral pain. That's the fruit. We're dealing more with the basket generally. So the muscles, the bones, and those types of things. But again, we see a lot of these patients come in and say, well, yeah, I did have cancer. I've been through treatment, but I've had pain for 20 years, right? So we want to know a little bit more about the pain, how long that's been going on. And then just a typical kind of the same pain evaluation that you would do for anyone, right? Location, description. I mentioned in here foreign body sensation, because one thing we're always thinking about is could there be a pudendal nerve component to the pain? And that's always a trigger in my head. I always tell my residents, if a patient tells you they feel a golf ball in the rectum, or they feel a sensation of something being in the vaginal canal, we should be at least thinking about pudendal neuralgia. And we're going to treat those patients a little bit differently, and some of the, especially the interventional options that we have, will change a little bit in that patient population, which we'll get into more later today. And then sexual health, which is an important part of this, and something that not everyone's necessarily comfortable talking to patients about. But sexual health's a key component to life, right? Linked to physical and emotional well-being and quality of life. And sexual challenges can come about in these patients from many things. It can be the impact of the cancer, from their treatments, other physical conditions that they may have, as well as just something that's happened to them pre-morbidly, right? Psychosocial, mental health, the history of trauma, and then even cultural histories. So we want to make sure that when we're talking to patients about this, we're getting that full kind of picture of where they've been even prior to their cancer treatment, to better understand where the sexual dysfunction might be coming from. So sadly, we as physicians don't do a great job talking about sexual health. So if you look on the American Cancer Society website, this is what they tell you. Don't assume your doctor or nurse will ask you about these and other concerns about sexuality. You have to bring it up, which is really kind of sad, because honestly, are patients going to bring this up? No, right? It's as hard for the patient to talk about, probably harder than it is for us to bring up and ask about. So I think, you know, with our focus on function, this should be a question we're asking every day, right? There's been studies that have looked at how often these questions are getting asked. Only getting asked in about 27, 28% of the cancer rehab population, or cancer patient population. Generally asked, males are asked more about sexual health than women, 53 to 22%, and that was statistically significant. What they found is that a few, you know, some people will utilize these like standardized kind of sexual health questionnaires, and men about 30% of the time, and women about 5% of the time. But what they also found is that patients actually liked this as a bridge to talking about it, right? Because they see these questionnaires, and they think, oh, someone, they're actually asking me these questions. And it kind of prepares them for that conversation a little bit better. So when we look at sexual health in female cancer survivors, in gyne cancer, it's about 78% from what the studies have shown us. Breast cancer is 65%, colorectal cancer also about 65%. So this is happening to a lot of patients, right? And what do we see in female cancer survivors? Women with intercourse, they might have arousal difficulties, vaginal dryness and atrophy is very common, decreased orgasm intensity or frequency, and then loss of desire. And oftentimes that loss of desire can come, again, from cancer treatments and kind of changes of body image and self-esteem, but that could also be pre-morbid, right? So we want to make sure that we're talking about that. And again, like I said before, we know that surgery can lead to these sexual dysfunction. We know radiation can, chemotherapy can. And then menopause, so if we have early induced menopause because of treatment, a lot of those patients are going to have sexual dysfunction as well. Studies have shown that anywhere between 33% and 98% of prostate cancer survivors have sexual dysfunction. So again, most of these patients, right? So we want to make sure we're asking these questions in both populations. What we see most commonly is erectile dysfunction that can happen from surgery. What the studies have shown is that about 50% of men that did not have erectile dysfunction prior to surgery will continue as that not being an issue. So about 50% of men that didn't have erectile dysfunction will develop it after surgery. And then obviously the more advanced the cancer and the more complicated the surgery, the more likely we're going to see these things. But like the nerve sparing treatments have been helpful. That's just not always the case in all patients. Loss of libido, difficulty with orgasm, obviously loss of ejaculation, and then sexual bother, which is kind of just the like psycho and emotional kind of aspect of all these things happening. So I think when we're talking about taking a sexual history or just asking our patients about sexual health, the most important thing we can do is create a safe space for that conversation. So starting with thinking about ourselves and the biases that we might have and making sure we're addressing those before we start asking questions. Make sure it's a welcoming environment. I think just like normalizing that we talk about it. I often have patients that say, this is really uncomfortable to talk about. I was like, I talk about this all day, every day. It's fine, this is normal. This is part of your life. It's an important part of your life. I think the further along I've gotten in my career, I've been in practice like 12 years now, it's becoming easier for patients to talk to. And I think they, especially for me, because they know they're going to a pelvic health doctor, the conversations have gotten easier, but they don't necessarily expect to be having that conversation when they're coming to see you. Make sure you're using sensitive terminology, correct pronouns, and then never make any assumptions about what the patient is doing, or what they might ask you. Always make sure that you're considering a history of trauma, thinking about their beliefs, and then their education. So, and I think I have a slide on this later, but a large number of patients that we see, not necessarily in the canceria population, but that have pelvic pain will have a history of trauma. And that can really be important when we're thinking about examining the patient, sending them to physical therapy. So we ask every patient about a history of trauma. It's easy for me because I'm going to do a pelvic exam. So I just say, this is a question I ask everyone before I do an exam. Do you have any history of trauma or abuse? And then if they say yes, I'll just say, do you mind sharing a little bit more with me, or can you talk to me a little bit more about that? And then, because again, I'm doing a pelvic exam, I'll ask them, how do you tolerate exams? Can you, you know, can we do a pelvic exam? We can stop at any point. I tell them exactly what I'm gonna do, and we'll go over this a little bit more in the next section, but kind of setting them up and knowing what to expect, what they're expecting, and what they've had happen in the past can be helpful. Similarly, if you're gonna send them to a physical therapist, it's helpful to know that and communicate that with your physical therapist. Like, hey, we're probably not gonna wanna do internal pelvic floor physical therapy right away. Let's do, let's focus on some spine things that might be going on and get to know the patient a little bit better, and we'll progress to this. And then, I always try to keep very, I tell myself all the time, there's no bad questions. The questions that you're gonna get asked might be surprising at first, but just, you know, being ready, because everyone has, like we said, different education, different beliefs. Everybody's been raised differently, and look at sex and relationships in a different way. And so, I often get questions that I maybe don't expect to have from patients, and that could happen to you, too, if you're starting to bring up these topics. And then, I think it's important to remember that if you're uncomfortable talking about sex, that your patients are probably gonna be uncomfortable talking to you about it, so trying to manage that and be more comfortable. When we're talking about what questions we need to ask, think about those slides where I told you what we're seeing the most. So, we wanna know about pain, dysorgasmia in women, pain with arousal, men, pain, erectile dysfunction, loss of libido, and then, again, how is this impacting them? So, is that sexual bother kind of a part of this, and how can we address that? And again, this is in a non-cancer population, but we know that 45% of people that have pelvic pain have a history of abuse or trauma, and the great majority of those patients, it's sexual trauma. So, when a patient shares with me that they have that history, I always ask about, have you seen a therapist? Is that something you've done before? Are you in therapy now? Sometimes, getting them into therapy, even if they're like, yeah, I've seen a therapist in the past, if you know you're gonna send them to pelvic floor therapy, sometimes it's helpful to have a therapist on board, so if this does bring up concerns, or they do have negative feelings about therapy, we can work on that as a team. So, I'm gonna circle back to the cases that Sam presented. In our prostate cancer patient, he had some comorbid conditions that put him at a higher risk for erectile dysfunction, so he had hypertension, diabetes, hyperlipidemia, so I'm already kind of thinking about that being a confounding factor to this erectile dysfunction, in addition to, obviously, his treatments. He had a more advanced surgery, he had radiation, plus years of hormonal treatment, so I'm expecting him to present with incontinence, and then probably sexual dysfunction, most likely erectile dysfunction. After treatment, he could be high tone or weak, so there was actually a study done by a physiatrist, Kelly Scott, in Texas, who, she looked at, again, I said, when we think of incontinence, we're thinking weak muscles, but what we found in patients with prostate cancer is that, actually, we see a lot of men that have high tone after treatment as well, and then will still present with urinary incontinence, so making sure that if you're not assessing that, you're at least sending to PT and that they're assessing it. Okay, and then going back to the endometrial cancer case, risk factors for pelvic floor dysfunction in this patient, just the fact that she's a female predisposes her to having pelvic floor dysfunction. She was also obese and had children, so we're thinking already that there could be some premorbid pelvic floor dysfunction that could have been there. She had surgery, break therapy, chemo, so we're thinking, I'm thinking when I see her before I go in the room, probably we're thinking about sexual dysfunction and then likely bowel or bladder symptoms, so those are the things I wanna make sure I'm gonna ask about. And then I would say, if you guys do nothing else, if you're like, I don't wanna talk about all this, I think if you start with a questionnaire and just have pelvic pain, sexual dysfunction, urinary symptoms, or bowel symptoms on that questionnaire, it's like a good starting point, and hopefully then, if you have these on the questionnaire, then you could at least ask a little bit more about them in your encounter. Or send to someone else, like me, or physical therapy. Okay, that's all I got. And Dr. Flores is gonna come up next and talk about what the pelvic physical exam looks like. Thank you. Good morning, everyone. My name is Maddie Flores. I am a new faculty at UT Health San Antonio. I'm excited to share with you a little bit about the pelvic physical exam and bring these skills to our patients down in South Texas. So what is the pelvic floor? The pelvic floor comprises the muscles, including the external sphincters, sacral and pubic ligaments, fascia, and neurovascular bundles that lie within the pelvic cavity. It is bounded anteriorly by the pubic symphysis and ischial tuberosities, and posteriorly by the coccyx and sacrotuberous ligaments. The pelvic floor has several different functions, including supporting our pelvic organs, helping with maintaining continence, aiding with voiding, defecation, sexual activity, pregnancy and childbirth, as well as being a key component of postural stability. In order to accurately assess and treat patients with pelvic floor dysfunction, it's really important to have a good, strong understanding of anatomy. So I'm gonna take a few minutes to go through the different layers of the pelvic floor musculature. I think one thing that's important to highlight here is we have both male and female bodies here, just as a reminder that pelvic health is not just women's health, but health for all. So the first layer, the superficial layer of the pelvic floor, is made up of three muscles, the ischiocavernosus, the bulbospongiosus, and the superficial transverse peroneal muscle. The intermediate layer, also known as the urogenital diaphragm, is comprised of the different sphincters, as well as the deep transverse peroneal muscle, which lies in a similar plane as a superficial transverse peroneal muscle, with fibers running medial to laterally, and lies just deep to that muscle. The deep layer of the pelvic floor really includes two main muscles, levator ani and coccygeus. Levator ani is composed of three muscles, the puborectalis, the pubococcygeus, and the iliococcygeus. And these muscles run anterior to posterior, and they attach from the pubic bone to the coccyx. The other muscle here, the coccygeus, is a little bit more posterior, originates from the ischial spine, and attaches to the sacrum and coccyx bilaterally. Now, I wanna take a moment to highlight different muscles that are closely connected to the pelvic floor. So, while these are not true pelvic floor muscles, we know that muscles in this area lie in close proximity, and can be closely associated with dysfunction, along with our pelvic floor muscles. So, the muscles that we think about here are really our external rotators. So, our obturator internus, originating from the obturator foramen, and attaching onto the greater trochanter, as well as the piriformis, which originates from different areas within the pelvis, and attaches, again, to the greater trochanter, these helping with external rotation and abduction, as well as the glute muscles, particularly the glute medius and glute minimus. These muscles, as we know, help with hip abduction and internal rotation. So, now getting a little bit more into the external physical exam. As we see commonly in areas of musculoskeletal medicine, any dysfunction in one area can lead to compensation and impairments in adjacent areas, and that's the same thing here with the pelvic floor. Overactivity in the pelvic floor muscles can refer pain to the hips, the spine, the back, and the glutes, and dysfunction within all of those areas can also contribute to, or cause pain within the pelvic floor muscle groups. So, it's really important to do a generalized musculoskeletal screening exam, assessing these patients for lower extremity strength, sensation, reflexes, checking the range of motion at the spine and hips, and doing more provocative maneuvers when appropriate. Common conditions and diagnoses and impairments that we see in association with pelvic floor dysfunction include hip girdle pain, glute weakness, adductor tightness, as well as true interarticular hip and spine pathology. Now, understanding the sensitivity of this exam is almost equally, if not equally important, if not more important than the actual assessment itself. So, starting the pelvic floor exam, consent is always, we must always begin with informed consent for our patients, as well as a true, detailed description of the different components of the assessment. Any increased emotion, any stress, anxiety can cause elevation in pelvic floor tone and can alter our assessment, so we wanna make sure patients feel comfortable and they really know all the different aspects of the exam. If patients are uncomfortable and they wanna defer the pelvic floor assessment on our first evaluation, we can push it to subsequent follow-up visits, but I do try to counsel patients that we really do need a full assessment in order to be able to have a full, accurate picture of what's going on. The proper positioning for our patients, we have our patients lying supine with their hips and knees flexed about hip-width apart. In our practice, we don't use any stirrups or speculums, so we just do this as a digital assessment. So, first, starting off with inspection. Really, here, we wanna inspect all the tissue here, looking for any areas, any masses, any cysts, any scars or lesions, looking at the skin integrity and architecture here. And oftentimes, we use this clock as a landmark in order to guide a little bit more clear picture of different anatomic structures. With this clock, the clitoris represents 12 o'clock, the ischial tuberosities representing three and nine o'clock and the anus representing six o'clock. Oftentimes, you'll see this listed in the different pelvic floor PT notes as well, using the clock as guidance for their assessments too. Next, thinking about the sensory exam. So, it's important to remember our different sacral dermatomes, but I think almost more commonly, thinking about the different border nerves and the territories of where they lie. Oftentimes, some of these nerves can have overlapping territories, but if we've referred patients to therapy, tried different medications, and they're still having local areas of numbness or tingling, then we can refer them for different interventions based on their border pathology. Next is the Q-tip test. So, this is not something that I assess in every patient, but really patients that are presenting with any hypersensitivity or really any pain, particularly with insertion, then we'll move to the Q-tip test. And this is, the goal of this test is really to assess for any vulvodynia. Vulvodynia is defined as a genital chronic pain that is described as being any burning, any irritation or sensitivity in the absence of any other skin or scuff tissue or neurologic disease. And the Q-tip test can help us assess for that. So, oftentimes, I'll take the Q-tip and I'll allow the patient to test the sensation in a neutral area, like their hand, to give them a baseline. And then I'll move to testing areas along the inner thigh, and then I'll move closer to the mons pubis, and then really looking at that superficial layer of the pelvic floor, ischiocavernosis and bulbospongiosis, and then I'll test really right at the introitus. Commonly, that introitus is the area of the most pain for patients with vulvodynia. This is the area that's most commonly causes some dysfunction. This test should not be painful. So, any abnormal, at any point, if there's any pain or any abnormalities in their sensation, it would be considered a positive test. As with any other muscle group in the body, it's important to assess the muscle's ability to fully contract and relax. So, when we think about the pelvic floor muscles, it's often times described as the floor of the core. So, you can see in this photo on the left here, it really works in conjunction with our diaphragm, our transversus abdominis, and our multifidi muscles, really to all contribute to core support. When we're thinking about a true pelvic floor contraction, or a Kegel, as it's commonly known, we want to see the pelvic muscles lift. So, you can see this ultrasound video here. This is an abdominal ultrasound with a probe located over the bladder. So, the hypocoic area is the bladder, and you can see those muscles deep to the bladder rise with a pelvic floor contraction. Sometimes it's difficult for these patients to actually perform this when we're doing our assessment. So, some cues that we've used is try to pull your pelvic floor muscles upward and inwards, or squeeze, like you're trying to pull in fluid through a straw, and that can sometimes help with cueing. Another thing that's important to be mindful of for our pelvic floor muscles is sometimes in patients with overactive tight muscles, they can have a hard time relaxing. So, I think after assessing for a contraction, assessing how long it takes those muscles to relax can also help clue you in to abnormalities there as well. So, now I'm moving into the internal pelvic exam. When we're assessing the different muscle layers, one thing that's important to know is any tightness in the superficial layer can limit your ability to assess the deep layer. So, if you're having a difficulty time getting to the muscles of the deep layer, it might clue you in that there might be some abnormal tightness or high tone in those superficial muscles. When we're assessing for the deep muscles, the main muscle that we're really able to assess in our female patients is the levator ani, and it's often difficult to say what portion of the levator ani we're on when we're doing that assessment. So, that's oftentimes another example of when we're using that clock to really help identify any areas of pathology. Normal pelvic floor muscles should feel soft and should not be painful. Any overactive muscles can feel bulky, they can feel thicker, and it typically creates discomfort in our patients or can refer pain to different areas as well. One muscle that can be a helpful landmark is obturator internus. So, this muscle lies lateral to a thick fibrous fascia called the archus tendinus. So, in patients with healthy tissue, if you can feel for that fibrous fascia, the archus tendinus, you can assess that, or you can know that obturator internus is just lateral to that. And one thing that I will do sometimes is place a hand on the lateral portion of their knee and have them externally rotate so I can feel obturator internus more clearly, and then that can help me identify that, you know, where I am in my exam. For our male patients, we assess this using a digital rectal exam, and you, again, are feeling for levator ani, and you have a much higher likelihood of being able to assess coccygeus in our male patients. Now, two main ways to grade the pelvic floor muscles, there's two main grading scales, the Modified Oxford Scale and the International Continent Society. The Modified Oxford Scale is what I've seen most commonly. It's a scale of 0 to 5, with 0 being nothing, 1 being a flicker, 3 really being that squeeze with a lift, and then 4 and 5 being stronger squeeze and lifts. Technically, to qualify as a 5, the patient should be able to hold that contraction for 10 seconds, so that can be helpful as a way to help differentiate the strength there as well. The International Continent Society Scale, a little bit more general, just grading from absent, weak, normal, to strong. I've seen this used more often with urologists or urogynecologists. And now, lastly, just to give one quick slide, talking about pelvic floor dysfunction, like Dr. Wang has already highlighted for us, really we think about them in the two categories of hypertonic or being overactive or being hypotonic or underactive muscles. Again, the same complaints that you would likely see in our overactive muscles, including dyspareunia, any pelvic pain, constipation. In our low tone or our underactive muscles, we commonly see incontinence or prolapse. But again, to really highlight that a lot of our patients present with this mixed picture of muscles that are tight and overactive, but are also weak. So again, presenting with any urinary incontinence, difficulty emptying, or pain. And with that, I will turn it over to Dr. Nelson. Good morning, everybody. Usually I'm dealing with a taller platform, so I'm so excited today. So I am a faculty member at UofL, Fraser Rehab, but I spend most of my time at the Academic Cancer Center, Brown Cancer Center. So no financial disclosures, but I do have some very graphic photos, so just forewarning. So we have two cases today, the endometrial cancer patient and the prostate cancer patient. But my content really extends to other gynecologic cancers as well. A lot of the side effects from cancer and treatments for endometrial cancer you can see in other gynecologic cancer populations. For prostate cancer patients, as you can see, that prostate is really close to your bladder and your rectum. So side effects can hit some of those nearby structures and cause side effects as well. And then even thinking beyond the gynecologic and the genitourinary cancer patients, we've got to think about our anorectal cancer patients or colorectal cancer patients who can have pelvic pain. Let's think about the bony pelvic tumors like sarcoma patients that can have pelvic pain. Melanoma patients, I have a patient right now who has lymphadenopathy due to spread to the lymph nodes in the groin as well as dermal mets creating pelvic pain. Even our neurofibroma patients can have neurofibromas creating pain in the pelvis. And then any cancer patient that may have metastases to the lymph nodes or bone in the pelvis. So really this content extends beyond our endometrial and prostate cancer patient. So they've hit kind of on the incidence of pelvic pain. For prostate cancer, like looking through the literature, it's really hard to find an exact percentage of how many of those patients have pelvic pain. There's reports, at least in the gyne world, that patients report much higher pain levels and dysfunction than we physicians do. So I've talked to some urology colleagues and they say, oh, I think about 5 to 10% of prostate cancer patients have pelvic pain. It always makes me think that's probably an underestimation. For rectal cancer, about 30% may be an underestimation too. So what causes pelvic pain in our cancer patients? The first thing we think about is, where is the location of the cancer? Imaging is super helpful. You may see, you know, documented in the oncology notes, this is endometrial cancer, this is prostate cancer, and it's stage four, it's stage three, or it's stage whatever it is. And sometimes it's so helpful just to pull up those images and see from a rehab mindset what muscles nearby, what nerves nearby could be impacted to cause pain dysfunction. And then moving on to the next several slides are, what are treatments that can impact pelvic pain? There's so many different cancer treatments now and it's always evolving. So I feel like I'm learning all the time and Googling what side effects does this cancer treatment have? But we'll start with surgery and just kind of go through surgery, radiation, and chemo, and what sort of things we should be considering when we're seeing oncology patients. So operative reports are really helpful. Sometimes it's just a straightforward hysterectomy, laparoscopic, no big deal, we kind of can grasp that in our mind. Or it's a straightforward robotic-assisted laparoscopic resection of the prostate. That's kind of easy to think about. But what was the extent of the disease once they got in there with the laparoscopes? What all did they have to take out to make sure they got all the cancer? What other organs and tissues nearby got impacted? And that's where the operative report can really help you. Because sometimes our oncology notes don't include that if we're researching the chart, right? So an operative report also tells you the lymph nodes, how many lymph nodes, what lymph nodes. And then also, were there any peripheral nerves that had to be sacrificed or transected because of where that tumor was located to help you think about pelvic pain, dysfunction. Prostate cancer patients can have the obturator nerve injured. And then we're gonna see that on a physical exam, for example, or pudendal nerve branches had to be sacrificed. And then using our exam techniques that Dr. Flores just mentioned. This next slide is a hard one to see. But sometimes patients with much more extensive disease obviously have to have much more extensive surgical resections. This is courtesy of a gynecologic surgeon at my institution and a patient with vulvar cancer that required a complete pelvic exoneration. And on that top left photo, you see rectum at the top kind of, it almost looks like a uterus, but it's the rectum, the sigmoid rectum. In the middle is the uterus. And then you have the bladder and you have the ovaries and the complete vulva resected. And then they tend to use a VRAM flap, the rectus abdominis muscles to then create a flap. That bottom left picture is using a VRAM flap. The other lady who has the vulva intact was a cervical cancer patient. And then they use bilateral gracilis muscles to create a new vagina. And these patients have urostomies and colostomies. So operative reports, extent of surgical resection before you even see this patient is really helpful to know going in. Moving on to radiation and happy birthday to Marie Curie yesterday. I just learned that yesterday, so I threw that in there. But radiation, as we well know, has lots of side effects. A lot of times we think about the external being like lay on a table, get radiation, pelvic radiation, and we can kind of imagine what that looks like. Brachytherapy as a whole, another thing to think about, more of a internal radiation application. It depends upon the diagnosis what kind of brachytherapy they use. So understanding if the patient says, yeah, I had radiation, what does that really mean? What kind of radiation? Do they have one type? Or a lot of times they'll have both, external beam and brachytherapy. And so this is just an example of a treatment regimen for actually a cervical cancer patient. In the blue bars, it's daily external beam radiation therapy, Monday through Friday. The yellow dot is concurrent chemo with a platinum agent. And then in week six and week seven, they have brachytherapy. So a picture of like, for example, our patient who has a hysterectomy and then vaginal cuff brachytherapy, that's an applicator, that's kind of the middle of the top slide, what that looks like. And it's inserted into the vagina and it gets connected to a radiation machine and that allows radiation to the direct tissues. If they have still their uterus intact, they may have an additional extension to go into the uterus for radiation there. And the pictures on the right kind of just show you, our radiation oncology colleagues have come a long way in order to maximize dose of radiation to certain structures and try to protect those neighboring healthy tissues, but still you can't help but get some of the scatter effect. And so some of those surrounding healthy tissues become unhealthy with radiation fibrosis. So keeping the other surrounding structures in mind from pelvic pain is really helpful too. This is another disturbing slide. This is another type of brachytherapy that patients may use for cervical and endometrial cancer. And this is actually placed in the OR. Patients are put under general anesthesia and they insert certain needles and using imagery guidance with CT and ultrasound all at the same time. It's a big endeavor in the OR, multiple people just to get this brachytherapy implanted. I got to watch this about a year ago and I left the room thinking that's the most barbaric thing I've ever seen. These patients then have to stay in the hospital supine and flat for two to three days and they go down to radiation, get hooked up to the machine, get 10 to 20 minutes of radiation twice a day. And so if you can't figure out in the chart like what kind of radiation did this patient have? There's like a bazillion notes. If you just ask, were you inpatient? Were you hospitalized for your radiation? Or did you do it outpatient? That's really enlightening because if they're inpatient, this is what they've had. And again, they may have had both, both external beam and brachytherapy combined. So we've heard about some of the percentages of radiation induced pelvic pain. And again, it was about 40% for cervical cancer. But again, I'm curious if that's an underestimation. What does prostate cancer brachytherapy look like? Again, this is an operating room, typically and under general anesthesia and they place these radioactive seeds go through the perineal region and insert these seeds that stay lifelong. And eventually their radiation capacity kind of dwindles away and they're no longer active. And those little tiny seeds are in the palm of his hand just so you can see how tiny these things are. And on the bottom right of this shows again how many needles are placed just to put those seeds in. It seems like more and more commonly they're getting more external beam radiation rather than brachytherapy for our prostate cancer patients anymore. So again, if you don't know the answer, did you have to go to the OR? They tend to have an outpatient procedure though. That's not like the cervical cancer or the endometrial cancer patients that have to stay for two to three days. They go into the OR, have these placed. The external beam is a picture at the top. And again, just kind of showing us if we get the chance to look at the radiation plans, the extent of involvement of surrounding tissues. And thinking about the rectum, thinking about the bladder, for acute radiation-induced proctitis and acute radiation-induced cystitis, about half of our patients are gonna experience that within three to six months after the radiation. Good thing is late radiation inflammation continues only in five to 10% of those patients. So that's good. It's good to hear that hopefully if they get past the three to six month mark, some of those side effects will decrease. So moving on to chemo. And both of our patients, I believe it was both had diabetes, right? So a diabetic going into chemo, especially for a lot of your gynecologic cancer patients, they're gonna have the platinum-based agents, the taxane-based agents, sometimes even the vincristine agents. A lot of times our brains goes to peripheral neuropathy. The hands and the feet, we're asking about that. It's good to think about, go a step further if you can, and ask about genitalia sensitivity. We don't have a lot of studies on this at this point. I saw a small self-report study, and several of the patients had either hypersensitivity and the genitalia lubrication disorder. And this article was like, how much is chemo? How much is the hormone therapy? It's hard to know which one causes what, but using our exam, using our history first is helpful to think. Was the surgery impact? Was it radiation impact? Was it chemo impact? A lot of times it's a combo of all of them. So since we're talking about the oncology patient population, I wanna have all of us aware of some precautions to think about as you see these oncology patients. We've heard a patient have lymphedema, right? Let's not forget to also think about, could it be a DBT at any point during their journey, because cancer patients have such a higher risk of clots. So don't forget about that. Also think about obstructive lymphedema possibility, including your metastatic patients who may have large involved lymph nodes that are causing obstructive lymphedema. So we gotta be cautious to just not say, oh, this is lymphedema, they had a cancer history, it all matches up. Think about what else could be causing swelling. Looking at the skin on exam, is this just radiation-induced skin changes? Do they have any overlying infection, fungal infection, or are we dealing with recurrence or even infection in a recurrence lesion? And this poor lady on the right, you can see the impact of radiation-induced fibrosis, and she unfortunately had recurrence and she since has passed. She was young with cervical cancer. And also think about radiation-induced insufficiency fractures with pelvic pain. It's estimated, estimated to be about 10 to 30% of patients with pelvic cancers who have had pelvic beam external radiation to have insufficiency fractures. That seems like a high number to me, but it's something just to keep in our minds. And again, looking at the radiation exposure and those pelvic bones included in getting some hit from radiation. Fortunately, not as much as the cancer territory, but still get exposed. And then also keep in mind any side opinions that could be involved, especially if we're gonna do an exam even. If the platelets are low, you don't wanna cause any trauma, especially if you're dealing with already traumatized tissue and radiation fibrosis tissue. If the platelets are below 50, you may wanna take a second thought and delay an exam. If you're gonna do an injection, you definitely wanna delay an exam with low platelets or even low white count. If they're in the midst of treatment, delay because of the risk of infection too. So paying attention to what chemo agents they have, what's the trend of their blood counts recently, because that may help you decide whether you proceed with an exam or injection as well. And then also think about immunotherapy, which is becoming more and more utilized. That immunotherapy helps stimulate our immune system, revs it up, gets it ready to fight off that cancer. The last thing we wanna do is throw steroids, especially oral steroids at a patient on immunotherapy for any reason, because then we just ding the effect of immunotherapy. So talking with your oncology providers, if you're gonna use even an injectable steroid, it's nice to just, hey, are you okay with this? I mean, using a steroid injection, especially if it's an injection, usually they're fine with it. And if the pain is so problematic, they're happy to have help. But just think, double check before you do any steroids if they're on immunotherapy. So just kinda in conclusion on my part, just keep in consideration with your oncology patients and pelvic issues, look at operative reports, they're super helpful. Think about each treatment that the patient endured. Think about the surrounding tissues, not just that uterus, not just that prostate. And look at imaging, that can be super enlightening. And even if it's months ago, imaging, a bone scan, a PET scan from months ago can be enlightening. And don't forget about labs and their trends. So I think we're ending with about four minutes to spare. So I think we can take some questions, or what do you think? Yeah, we got time for questions. Yeah. Thank you. Any questions from the group? Okay, perfect. Yeah, I can start. I did my residency at a program that had a women's health or pelvic health program. And so I, and there are no fellowships for pelvic health, so I kind of learned everything in residency. And then I've been out of practice about 12 years. I have been at two institutions, and kind of at one started a pelvic health program, at the other kind of came back and revitalized an older program. As far as other training, when I was starting out, I worked really closely with physical therapists. The program that I started after residency didn't actually have any physical therapists in the area that were doing pelvic floor. So we identified a couple of orthotherapists that were interested, and they went through training. I actually went to one of their courses just to kind of see what they were learning. They did a different course than the therapist that I had worked with as a resident took, and so I thought it would be helpful. That course is open to physicians. It's through a company called Herman and Wallace. It really focused on the exam. So I think if you want to learn the pelvic exam, and you don't necessarily have a physical therapist in your area or something like that that you could team up with to get more education, or another physician that does it, that course might be an option. I think the nice thing about it is that it doesn't, it's really not going into a lot of the treatment part of, you know, the physical therapy part of it. So it actually is a good way to learn the exam if you've never done it. I'm going to let everyone else answer, and then we'll get to your question for sure. So I did my residency at Northwestern Shirley Ryan Ability Lab. I trained with Dr. Wong, and so I got a good solid understanding of how to do this exam. I spent time with different pelvic floor PTs just to learn what they did, their different assessments. And, you know, we've had different simulations at like a formal pelvic health lab where we, those of us who were more comfortable got to teach our other residents in the program a little bit about it. So that's been my background. And I got interested actually, thank you to AAPMNR, two years ago, when there were some great pelvic floor lectures and on-site, like using obviously not live models, but fake models. And honestly, since then, I've been kind of just digging into it myself more. And thank you, Dr. Wong, for letting me travel up to Chicago one day and learn in person with her and then being an ongoing mentor, so to speak. So mine, I definitely did not have any residency training and in fellowship, I didn't get exposure to this either in cancer rehab. So it's just been self-driven a bit, but AAPMNR is awesome to have this day today too. I'm not an expert, but I do think what, I think what Dr. Nelson was mentioning, I think finding partners and colleagues. So as Dr. Wong mentioned, she was with us, left, came back. We were a little lost for a while, honestly. I think some of the people that had trained before, I got some training in residency, and then we kind of had a partner with some physical therapists. So I think for most people it's finding a partner in the community. I think I am not, I'm going to, a lot of these parts of screening, I self-admit, I am not good at screening all these at times. I do. And then when you're focused on your problem and you get your visit time and those sort of things, I think the questionnaires and other things, as I sit through the talks, as much as I'm part of the talks, we think of other things, how we can improve as you're sitting and thinking through that. But I think I'm also aware of, we've talked about trauma and comfort level, my appearance versus how a patient wants to talk to me versus a therapist, understanding where those are and kind of having that kind of read the room ability. So a screening question, you can see I have that, you can gauge that process. And I often, luckily, refer to therapists or other people to kind of delve in more and then maybe have a partner. And sometimes I'll even, after the visit, I'll pick their brains and say, hey, I had this person, like, do you think we can get you over there? And we'll, like the next visit, the same thing of kind of building some connection with that. But I think partners are probably really important. As someone who is not an expert, I think you kind of build your expertise and kind of understanding how to read the therapy notes and things like that is, then you can start having actual conversations just like you do for any other diagnosis with your therapist. I have one more thing to add. So one thing that can be helpful is there's a website called www.apta.com, and you can put in your zip code and your location, and you can see what public floor therapists are certified in your area. And if they've done like formal training, it'll actually mention that under their bios. And that can just be really helpful when kind of figuring out what the different therapy backgrounds are in your general area. So oftentimes when we see patients, we'll ask them like what their public floor PT experience was like and like what they actually did in those assessments and whether they strictly did external, you know, hip girdle strengthening, or if they did like formal internal assessments, and kind of knowing their background and like the PTs in your area can be really helpful to learn who to partner with. We've got a question for you, sir. Steroids. What about topical steroids? They can certainly influence diabetic control. Are they contraindicated in the cancer treatment? Topical steroids? Do you mean topical steroids for pelvic pain? For pelvic, you said don't do any steroid injections. So what about topical steroids and the type, any difference, let's say, between hydrocortisone versus Lidex, which is apparently the strongest? Any issues on that? I have not used topical steroids for pelvic pain, but that's a great question. I'm trying to think of a topical steroid patient I've utilized on, but that is much less systemically absorbed, so you'd be much better, it'd be better tolerated by patients. I don't know if anybody else has used topical steroids before? I mean, we, you know, I see like a lot of vulvar pain, and we, like in sclerosis, some of those diagnoses will use steroids, and we will use them in, you know, diabetic patients and other patients that you may have concerns on. Yeah, I mean, when we're using it, when we're using the steroids on the vulva, then we're, you know, mindful of how often we're using it and things like that because of tissue thinning and those types of things. Just for the online audience, there was a, they wanted to repeat the question, so the question was, is it okay to use topical steroids in this patient population? So just to repeat the question, for patients with decreased libido on antidepressants or SSRIs, at what point do we talk about medications and what other medications may be used to help with libido? So that's a conversation that I think it's a risk-benefit conversation with the patient. I'm generally not prescribing those medications. I work part-time in gynecology in a sexual medicine and menopause clinic. And so a lot of times I'll send to my colleagues to start any medications like that. But I will start these conversations of, you're on these medications. This could be contributing to the loss of libido. But obviously, we're using these medications for a reason. So it's something to think about. But honestly, generally, for treatment, that's something I'm sending to the gynecologist that I work with. I think I'll repeat that, sorry, the question. Yes, the question was, in patients with history of trauma, basically, what are we changing, how we're examining the patient or thinking about treatment? I would say, in the patients that have a history of trauma, I tell them what I'm going to do multiple times and continually check in and make sure that they know that we can stop at any point. And so I'll tell them my whole exam. Sometimes I'll do it twice. Sometimes I'll do it before I leave the room, before they change. I always see my patients first fully clothed, and then I'll leave the room and let them change. So I'll go over the exam with them before they get changed. I'll go over it again when I come in the room. And then as I'm doing it, I walk them through each step. And oftentimes, we'll just check in and say, are you OK with this? Is this OK? I think leaning on mental health therapists in those patient populations, and especially for sending them on to physical therapy and things like that, is really important. And I also, and I kind of mentioned this, but I also, before I do the exam, ask them what exams are like for them. Some patients will say, I have a history of sexual trauma. And I say, how do you tolerate gynecologic exams? And they're like, yeah, it's totally fine. I still go over everything multiple times with them. Where other patients say, no, I have a really hard time tolerating the exam, and a lot of times in those patients, I'll say, we don't have to do that today. Let's just talk and get to know each other a little bit better. And while it's an important part of my treatment plan is having that exam, there's a lot of times things that we can start. And even if that's just getting them to a therapist initially, that's a good first step. And then we can work towards doing the exam. Yeah, so we can use ultrasound as a form of biofeedback as well, as many other forms of biofeedback, obviously. My therapist recently started using ultrasound, but didn't for, I mean, I would say in the last six months, they've started incorporating that into their practice. We actually have a physical therapist who's going to talk this afternoon, so we can get an idea from you, you know, what you do in your practice. Do you, do your... Yeah, ours do not. I think it's a great way for patients to see and be able to kind of connect to those muscles, but the pelvic floor therapists I have in Louisville do not use ultrasound at this time. I will just, a quick kind of overview of physical therapy. So, you know, when we're referring to pelvic floor therapists, I think it's important to remember that that class that I went and took that is essentially taught me how to do an exam or teaches physical therapists how to do an exam. They could take that course and then say, I'm a pelvic floor therapist, and we, and I see this a lot, and this is why I mention it. I think it's really important to get to know the therapist that you're sending patients to because I was at that course and I, that is, that's not enough to know how to treat the problems that we're seeing. So it's important to develop those relationships, know who you're sending people to, know what they, what their limitations are and what they're able to do. And I think some of the websites, you know, we can, we see the therapist, but we don't necessarily know them. So when I moved to, you know, a place that I didn't know, I would call them and, hey, how would you treat this patient? They're like, who is this person? Right. So it gave me a little bit of an idea. And then I would always check back in with my patients and say, like, what were you doing in physical therapy? Right. Because I have patients that go to pelvic floor therapy. And when I say, well, did they do like an internal assessment of your muscles? Oh no, that's not at all what they did. Right. So just knowing, and in some cases that's fine and not everyone has to have internal pelvic floor therapy, but you just want to make sure that if that's what you want for the patient, that that's what they're getting. I think that's the challenge. Like, we have that acceptance with any other type of therapy. You kind of say, well, what do they do for your back? What kind of things do they do for your, like, we have an understanding. I think we need to kind of probably build up our, for when we're not the specialists to end up seeing. So we're not just like, oh, they went to pelvic floor therapy, it didn't work or it worked or what their approach was. So there is a question online that I will share. It said, thank you for the insightful discussion of pelvic floor rehabilitation. Could you recommend any essential readings, articles, or books that would help us future physiatrists learn about and integrate trauma-informed care in our practice? Yeah, so specifically to trauma-informed care, there's a lot of courses that I know about. I don't have a necessarily a specific book reference that I know off the top of my head. We have, in the gynecology clinic that I work with, one of my colleagues has done extensive training and does teaching on trauma-informed care. So it's, I've kind of been lucky in that I've gotten most of that education from there. If you're interested in learning more just about pelvic floor, like a good starting place, there's a chapter in Bradham that's like a good kind of basic overview of pelvic floor and what kind of, you know, conditions we might see related to pelvic floor. Any other questions from the audience? Is there anything else there? Do you use any of the injections or suppositories in patients who aren't cancer? Yeah, the question was if we use injections or suppositories in any of these patients. I do. I, in the, in patients that have like high tone pelvic floor that are in physical therapy, if that's not improving, things that I would consider utilizing are things like baclofen suppositories. That's probably one of the most common things I prescribe. I do, in my practice, pelvic floor trigger point injections and pelvic floor Botox injections. So again, like, I'm working, I'm constantly working with my physical therapist to say, like, we, I almost, almost always, very rare exceptions will start with physical therapy and then see how they're doing. And again, it's nice to have that close relationship. My PTs are right in the same office. They come down the hall and say, well, I've done, you know, three, four sessions with this patient and they're not responding as I would hope. Can we get them back in and start to talk about next steps? So I usually bring those things up in the first visit. Sometimes I will start the baclofen suppositories right away. But that's something I'm thinking about later on. And then they both do the injections as well. And then other injections I'm sending to my colleagues. So, you know, I, we, Maddie mentioned, like, obturator internus is a muscle that we're evaluating often. So that's often a muscle that I'll do a trigger point injection in. And then I have a colleague who is a sports medicine and she, you know, obturator internus is a long muscle. And so sometimes I'll do an internal obturator internus injection and she'll actually do a posterior approach to obturator internus. And we've had really good success with kind of doing those two injections together to get more the length of the entire muscle. So are there courses offered to patients that aren't, you know, what doses and techniques? Because I know in a non-cancer patient, but I mean. Yeah. I mean, pretty similar doses and things in the non-cancer patient as in the cancer patient. I don't, the medication dosing I use is the same. And injections to Botox I usually, I generally use 100 units. There's not really courses. And there's not a lot of us that do these injections, honestly. So most of us are either self-taught, worked with someone who is self-taught, or there's some urogynecologists that do the injections. So we are at time. Dr. Wong is going to have to run to our next thing, so I want to keep her. We will actually, later talks we'll have actually more discussions on interventional aspects. So we got more therapy discussion, interventional. We are actually going to try to bring a bunch of the speakers back in that last session to have a little bit more of a panel discussion. So invite your friends, think of questions, more discussions about some of those blocks Dr. Wong talked about. So thank you for everyone for coming. Bring more questions. Bring your friends for the afternoon. Thanks.

pelvic pain management

cancer rehabilitation

pelvic dysfunction

prostate adenocarcinoma

endometrial cancer

lymphedema

psychosocial history

pelvic floor dysfunction

trauma-informed care

sexual health concerns

PM&R resources