All right, quick break, but we're going to come back with our last session, go through our basic announcements, cell phones, silence, airplane off, no audio, video, you can take pictures. These people are pretty smiley still. Evaluation forms, online, app, the portal, and has anyone seen the puppies in the pavilion? I know I keep referencing the puppies, I missed them. Is it worth a visit? Everyone should go to the pavilion. I am not Sonal Oza, I don't think we look alike, unfortunately we had to pull an audible, she was not able to attend, and so we changed up this a little bit with kind of keeping the focus on that, and so I'm kind of jumping in to help kind of moderate and guide a little bit. Dr. Wong, who's been a pleasure to sit with us most of the day as she's doing many of her other duties with the Program Planning Committee as she's one of the pelvic floor experts in our field, will help kind of fill in some gaps, and then we have Rajiv Reddy, who is actually like one of my, now I'm thinking back, one of my first residents, and making me feel old as I moved along, but he is currently Associate Professor at UCSD, as well as the Fellowship Director for Pain Management. I haven't seen him in a long time, but it's good to see him and having his expertise here, and so we'll kind of focus this, at the end actually, one of the audibles are, we have some of our other speakers here that I think if people thought to have more questions, because I do have more questions, to ask more of the group as we kind of piece things together since there's a lot of overlap. So that being said, we'll welcome Dr. Wong back for her brief break. Thank you. You guys get to look at me all day, okay. So we're going to start with a case, and we'll kind of talk about this case and build off of this case for this entire session. So this patient is a 69-year-old female with cervical cancer, status post TAHBSO. She underwent chemo with carboplatin and Taxol, and had vaginal cuff radiotherapy, and she presents about 12 months after treatment with radiating lower extremity pain and pelvic pain. And the goals, kind of why she's here today, wants to have less pain with pelvic exams, wants to start having sex again, and return to work. So just to go over the case just a little bit more, when she presents, the pain she describes is stiff and achy, has paresthesias in the leg that go up to the thigh. She has a sharp shooting pain, even with walking just a few steps, and then pain with prolonged sitting. The pelvic pain that she describes, she has pain at the introitus, and then deep vaginal pain as well, no pain at rest. She describes this as a tight, tender pain, and then has a sharp stinging pain with a speculum exam. All of the pelvic pain got worse after radiation. She was deferring sexual activity due to these symptoms. So not really, when you ask about, you know, do you have any pain with sexual activity, the answer is, I'm just avoiding it because I'm afraid it hurts. And this particular patient has no history of sexual trauma or prior pelvic pain. And as we talked about this morning, and just a little while ago, we know that when we're thinking about the pelvic floor, the things we're thinking about are sexual dysfunction, bowel dysfunction, bladder dysfunction. So we ask her those questions as well. She has some urinary urgency, as well as urge incontinence, and some urinary frequency. And she does occasionally strain to have a bowel movement. So all of these things are starting to make us think there's probably a pelvic floor component to her symptoms. Some key points from the physical exam, so she has a sensory length-dependent neuropathy, asymmetric hip weakness, she has myofascial low back pain, and SI joint pain. Her right lower extremity, she does have radicular pain, and she has pelvic floor myofascial pain. And her pelvic floor is both hypertonic and weak, which as we talked about this morning is what we very commonly see in these patients, is a combination of those two. She does also have an EMG, and has a right lumbar plexopathy with subacute denervation and bilateral length-dependent axonal sensory more than motor peripheral neuropathy. So we're going to talk a little bit about some more conservative management, and then we'll get more into the interventions. Just kind of to start off with, vaginal stenosis and dryness are the two most common symptoms after cancer therapies, and we know this especially among cervical cancer patients. According to the latest reports, in the first three years after pelvic radiotherapy for endometrial, cervical, and anal rectal cancer, the estimated rates of vaginal stenosis are 50% after the first year, 60% after the second year, and 80% after the third year. Overall, the studies that we have show rates up to 88% of these patients have vaginal stenosis. This complication mostly occurs after combined treatment with brachytherapy and external beam radiotherapy. And what's happening in the vaginal tissue is that that tissue is shortening, it's becoming drier, and losing elasticity. And if we're trying to think about is this something we're going to see in the patient, I mean, obviously the answer is most of the time yes, but weak predictors for vaginal stenosis include active treatment length and then shorter duration of dilator use. So vaginal pain is reported in about 40% of gynecologic cancer patients, and we treat this pain differently kind of depending on where we think the pain is coming from. But patients can describe the pain in many different ways. They can have more of these like nerve pain symptoms that they describe, in which case we may use more oral neuropathic pain medications or compounded creams, and I'll talk a little bit more about both of these. Or they might describe more muscular pain symptoms, like feeling like the muscle, like the pelvis is tightening up or spasming, throbbing or locking, in which case we may lean more towards something like a muscle relaxant. So I'm going to talk a little bit about all of these. You guys all know about oral neuropathic pain medications, but just like in any other type of neuropathic pain, we use these medications commonly in pelvic pain. In chronic pelvic pain, we see a lot of patients that have central sensitization as a component of that, and so it's a very common treatment that we're utilizing in pelvic pain in general. Some things that you may not use in your clinic, we in the pelvic pain world, especially if a patient has vulvar pain and sometimes even vaginal pain, we will sometimes use compounded medications, topical, that can be helpful. Historically, I guess when I kind of started my career, we would utilize gabapentin with amitriptyline and then sometimes put like a muscle relaxant in that cream as well. I've kind of gotten away from using the amitriptyline because most of my patients felt like they would use the cream and then they say it burns every time I use it. And so when I started taking the amitriptyline out, the gabapentin wasn't doing that as much and the results seemed to be equally as good. We don't have a lot of data on any of this. This is just like all my clinical experience. If we do the pelvic floor exam, which you guys learned about this morning if you were here, and we find that in addition to this kind of neuropathic pain that they might be describing, there's also a component of muscle pain, then we can put a medication like baclofen in the cream, especially if that pain is like vulvar or right at the introitus and especially if those superficial muscle tightness is kind of part of the picture that we're seeing. And the other, I guess, topical medication that we use, which people can actually buy over the counter is lidocaine. So if a patient is having trouble tolerating physical therapy, having trouble with pain with initial penetration during sex, we can use lidocaine in those cases. One kind of thing to remember when you're counseling patients, lidocaine does burn when you put it on the mucosa. So putting it like at the vaginal opening or intravaginally, what I usually tell people is you're going to feel burning and it doesn't happen to everyone, but most people, 30 seconds to a minute and then it should get better. If you don't warn them, what happens is they try it, they feel burning and they try to get it all off and they never get the benefit from it. But if they know that they're going to expect that it's going to burn, they usually are like, okay, it's going to go away, it's okay. And then that will wear off and then they feel the numbing effect from it. And I use those medications when I'm doing injections as well, which I'll talk about in a little while. If we're looking at more, that we think this is more muscle component, so this patient, you do an exam, they have high tone pelvic floor dysfunction, maybe they're already in therapy or you're planning to send them to therapy. Sometimes we will use compounded vaginal suppositories. So I, again, this has kind of changed throughout my career. When I was a resident, my mentor used a lot of vaginal diazepam, which I used early in my career as well. And I kind of probably, I don't know, eight years ago or so, kind of switched over to using vaginal baclofen. We don't really have any studies on vag, any good, any studies on vaginal baclofen. There have been some studies on vaginal valium. Most of them are small studies. So some of the initial studies were just that they looked at patients that had pain with sexual activity, especially sexual penetration during sexual intercourse. And using that vaginal diazepam did help with that pain in some patients. There was a randomized control study done looking at vaginal diazepam. It was actually done at the institution that I was at. I was not involved in it because I think there were some flaws to the study, is maybe my way to put it. So I would take all this with a grain of salt, but it showed essentially zero benefit of using vaginal diazepam suppositories in these patients. We don't have those studies in baclofen, but what I can tell you clinically is that my patients do think it helps. The physical therapists think it helps. And so we do utilize this. It's not something that I necessarily started the first visit, but especially if they've been to three or four sessions of therapy and they're not getting, they're not kind of progressing as we would expect them to, then a lot of times the PTs will send them back to me and say, you know, is there anything else we could be doing? So that's when I might start to think about it. So you guys kind of heard a little bit about dilators and wands or dilators. We used to use these like hard plastic dilators that you see on the left side. Now they've gotten better. The middle dilators and then the wand are both the ones in this picture from a company called Intimate Rose. If this is a patient population that you think you will be seeing and you want to kind of help prepare your patients for, you know, I'm going to send you to physical therapy, you may, they may, you know, talk to you about using a dilator or a wand. This company will actually, if you go on their website, you can like register with them as a healthcare provider and they will send you all of these. I find it really helpful to have these in my clinic so that when I'm telling them what to expect, I can have them sitting there and say, this is what it looks like, you know, we'll use this or we may utilize this in physical therapy. It's also helpful when they come back and we're talking about, you know, the progress that they've made. So if they started with that pink dilator, they, you know, it's easier to remember the colors a lot of times than, or, you know, than the number necessarily. And they may say, well, now I'm on the green, the first green of the dilator. So it's easier for us to communicate about them, to have them sitting there. You guys heard about the wand in the last session as well. We find these really helpful for usually when we're looking at trying to do myofascial release of the more deep muscles. This company does also make rectal dilator sets, which we utilize in our patients as well. And there's other companies out there too. There's a company called SoulSource, which we have in one of, in the gynecology clinic that I work in, those are really expensive dilators. So I, that's not usually what I'm asking the patients to get. This company is like, I would say kind of on average with cost of most others. There are companies out there that will also send you samples of lubricants. So whether you, usually I don't use those in my clinic, but they're nice to have for patients, especially if you're trying to have them, if they, if you want to try a different lubricant with them, you can have those. And I'll usually just like, can't, you know, say here, take a couple of these and try them. But I can always get you guys the names later if anyone's interested in getting that stuff. As I said, in additional to the vaginal stenosis, we also see vaginal dryness. There are several ways that we can treat this anywhere, you know, like you heard before from using coconut oil to using medications, estrogen. As you heard before, there were studies in the past that kind of made providers kind of go away from using. What we know now is that maybe those studies, the dosing of the medication wasn't what we use and those studies were probably not the best. And more recent studies are showing us that it is okay to use topical estrogen. So we do use this in patients. Usually in the patients that I see that are cancer survivors, I'm, you know, generally there are other providers are ordering this. It's not me giving it to them. But a lot of times they'll come in and say, well, my doctor told me to use this, but I'm really nervous to do so. And so educating them on use. And I do prescribe this in some of my other patient populations more commonly. And then pelvic floor injections is something that I do in my clinic. And we briefly mentioned this this morning. But I do both trigger point injections and botulinum toxin injections to the pelvic floor muscles. I put some pictures on here just to give you guys a little better idea of what I use. So I use this pudendal nerve block kit that you see at the top there. So it's a, the one that I have in the office is a 20 gauge needle. It's a six inch spinal needle. And then there's this trumpet, which you see kind of in the middle of that picture. And it, that's like helping me get it intravaginally to where I need to get the needle. Because obviously a long needle going in vaginally without that is not ideal. I do not use a speculum for this. I'm using just this kit. I do Botox injections with the same setup. The picture on the bottom is actually a picture of a pudendal nerve block. So historically, a lot of gynecologists especially would do these injections blind in the office. And this is what it looked like. We really, I've, I have, we really try to stay away from this now. We obviously like image guided is better. But I do like this picture in, for me to describe you these injections, because this is essentially what I'm doing for the injection. So I'm doing it intravaginally with that kit. To a little bit different location than what you're seeing here. But I inject the pelvic floor muscles, both the superficial layers, the deep transverse peroneal muscle, levator ani, coxigious, obtrator internus. And then if I'm doing, those are kind of the typical muscles that I'm injecting, otherwise I would send to one of my partners. If I'm, like piriformis is really not a muscle that I can reach very well to do an injection on from a pelvic floor standpoint. All right. So just to summarize, gyne-onc patients, especially after your radiotherapy at risk for pelvic for myofascial neuropathic pain, vaginal dryness, vaginal stenosis. And then in addition to pelvic PT, we can utilize oral medications, topical medications, injections, and then psychological resources. And then I think it's important, again, as we talked about this morning, we're always focused on function and sexual function, bowel function, bladder function are important parts of that. So those are definitely things that we should be at least trying to get the patient asking them about and then getting them to the right providers if it's not something that you're comfortable treating. And then, you know, if those more conservative interventions that we're doing, physical therapy, medications aren't helping, then we can lean on some of our interventional providers and refer over to them for next steps. So that's what we're going to talk about next. Great. Just adjust this. Hi, everybody. Rajiv Reddy. Thank you so much for that lead in. And I think this slide is great to just leave up there for a moment as we conceptualize how interventionalists can play a role in the care team. So here in the picture, we have interventional techniques at the bottom far right as most invasive. But that doesn't necessarily mean that it needs to exist only at the end of treatment. But certainly it shouldn't exist in isolation, meaning rarely are we seeing or treating patients for acute pelvic pain, chronic pelvic pain, and they have not established with any of the aforementioned services or things that you've heard about today. And if that is the case and we do get a referral, we're generally making sure that they're still getting looped back in to these other care teams. We don't, generally speaking, want to be doing interventions or procedures in patients that don't have a good support system. It tends not to work as well, and we'll get into that in a little bit. And then in terms of some broad statements that I'll start off with, not to malign my own field, but for a lot of the procedures that I'm going to talk about, we do not have a large body of evidence. A lot of it is comparative studies or case series. And to add on to that, the mechanisms of how some of these procedures work or why they should work is not always fully understood. We're looking at the anatomy, and by blocking X target should provide relief, but it doesn't always work out that way. And part of it is because of how complex treating these pain symptoms are. So just that broad generalization. The other one is that we don't have a well-published, if anybody wants to work on that, let me know, algorithm for managing, with interventions, these different pain conditions. So a lot of it is anecdotal and whoever the patient ends up seeing what they think works or does not work. And so somebody had mentioned earlier getting to know the providers that you're referring to or working with, depending on who that interventionalist is, you're going to get very different approaches potentially. And so going back to this case and highlighting different aspects of their pain and what we might do for it. And I'm also going to pause here just for a moment, another broad generalization when managing these patients. Certainly pain patients in general are a vulnerable population. The distress associated with living with chronic pain will have patients asking for treatments potentially more than you're willing to offer. And then you add on the complexities of pelvic pain and the distress associated with that. And then add on potentially the distress of cancer. So adding all these aspects together for a patient is a very vulnerable population. So patients will come in at times, not certainly everybody, but come in and want more than you're willing to offer or you think is reasonable to try. And so it can be a very nuanced discussion with the patient of what you think is reasonable to try, especially if they've already worked through that algorithm before they've seen you or with you. And now what left can you offer them? And we'll get into that as well. So going to this patient, we're focusing at this point on their myofascial back pain and the radiating right lower extremity pain. Although this isn't specific to the pelvic pain symptoms, it is something that we'll see, as was mentioned before, you can get these central sensitization syndromes, peripheral sensitization, or the dysfunction in the pelvic floor muscles are gonna lead to issues like persistent back pain. And then whether it's related to radiation treatment or mass effect from the tumor, or patients can have more than one thing going on where on top of their cancer-related pain, they are also dealing with herniated discs and those things don't exist in isolation. So when thinking about what to do for myofascial back pain, was already mentioned can be done intravaginally. Most of the procedurals that you're gonna find are gonna avoid doing anything intravaginally or rectally, but for their back pain, easy to do in the office, trigger point injections, I'm sure most of you are familiar with those. Just some points to make, injectate as far as been studied is not important. You're gonna find people choosing all sorts of different things to add to the trigger points. The only one thing that has been found to be the most significant contributor to relief is the dry needling itself. But still you'll find us adding lidocaine, bupivacaine, other options. The big caveat to that is, if you're gonna add botulinum toxin, chemogenervation, there is evidence for that working differently. And for obvious reasons, is it can force relaxation of those muscles. And then also in its own ways, we're learning more and more about botulinum toxin can provide pain relief through some complex mechanisms. We look for the local twitch response, so that's when we see the muscle fire on its own while being needled can indicate some more immediate benefit. So those are options that we'll offer patients if we notice that they're having pain in their mid or low back. Then for this patient specifically, just refreshing your memory, during the case and presentation, they had an EMG that was positive for plexopathy and also length dependent polyneuropathy. Plexopathy pain is very difficult to treat. Unfortunately, there's minimal evidence for interventional options. These are things that have all been looked at in the literature, again, mostly on case report levels or case series. Multi-level transferaminopteral serine injections trying to target the proximal aspect of where that plexopathy is occurring. Plexosympathetic blocks to try to manage any sympathetic contribution to that pain. And then of course, neuromodulation is very popular and there's been some talks here through the conference on the different utilization of neuromodulation. Dorsal column stimulation or dorsal root ganglion stimulation. Again, not a lot of evidence for it, but it is something that could be considered. And when I was just mentioning earlier, patients that are desperate for relief and are asking you to walk past the usual treatments, this is something that you could consider, especially after a nuanced discussion in terms of the evidence and patients understanding that, well, you can get it approved through insurance that there's not a lot of evidence for that. And then for their length-dependent neuropathic pain, neuromodulation is an option, but Q-TENSA treatment actually has pretty robust evidence in terms of talking about things that evidence, more so for diabetic peripheral neuropathy and post-herpetic neuralgia, but it can be used in chemotherapy-induced peripheral neuropathy or peripheral neuropathy from other etiologies. And so that is something to consider if that wasn't on your radar before. It is potentially expensive, very expensive, if not covered by insurance and even with insurance can have significant co-pay. And you also need to have a little bit of a setup for it because it's in-office administered. You wrap the patient's feet, potentially numbing them up beforehand, potentially giving them some pain medication or sedative during the treatment, but can work very well. We utilize it very frequently at UCSD for all the aforementioned pain conditions. And so here, we've now ventured very far away from pelvic pain. I know we're looking at the feet, but to somebody's earlier point, when you're seeing these patients that have pelvic pain, cancer etiology within the uroguide, their treatments, including chemotherapeutics, can present with length-dependent neuropathies where they're complaining of burning pain in their feet. And so just thinking about what else you might suggest for that patient, since you may be their main point of contact for management of their symptoms, and so just putting this on your radar that there are treatment options for downstream effects of their cancer treatments. And even if you're seeing them specifically for pelvic pain, to know that these options exist and that you could consider referring them to a pain specialist. And so, Q-TENZA treatment, some of you may be familiar with capsaicin. Topical capsaicin, for a long time, was thought to work by depleting substance P. That's potentially some part of the mechanism, but specifically with Q-TENZA, which is an 8% extremely concentrated capsaicin patch, you are essentially inducing a loss of function to the TRPV1 receptors, which again are responsible for heat perception, which is a large part of that neuropathic pain experience. And so these dying back of the TRPV1 receptors at the surface of the skin generally last for about 12 weeks before they get regenerated. But the nice thing about, again, capsaicin is it's specifically for TRPV1, and so proprioception, vibration, light touch, is all gonna remain intact. We mentioned how it can be expensive. And then, of course, limited surface area in terms of the patches that you're able to apply. So at most, it's generally four patches. And then this slide applies to this patient in this scenario, but for everything that we're gonna go over and for all patients that have otherwise, you're going to encounter that are having true refractory pain, whether it's active terminal cancer or cancer that is in remission or even curative, and they're still having significant pain, is intrathecal pump. And that's kind of a catch-all, so I'm just putting it there so it's something that you're aware of. You may have seen patients with that or had patients where they were going down that route. And so again, this is implantable where the patient has a reservoir generally and their abdomen could be placed in the back. That contains medication that is going directly into the intrathecal space. The main options, if we're gonna talk about on-label, FDA-approved is morphine as an opioid. And then zirconatide, which is consineltoxin pre-alt, and that is an N-type calcium channel, voltage-gated calcium channel and can work very well for neuropathic pain. Off-label, you may have seen patients with all sorts of things in their pump. Essentially, it's your imagination of what you want to put in there, but to make it clear, these are off-label options such as bupivacaine, clonidine, and other opioids. Baclofen, obviously, is FDA-approved, but is generally not used unless there's a spasticity component. So going back to this patient once more and now thinking about a different aspect of their pain. So the deep pelvic pain they're experiencing and the rectal pain opens up a different route of procedure options. As has already been touched on before, we think of visceral pain as being extremely complex. Still being elucidated in terms of the sensation of pain, the wind-up mechanisms, is not as clearly understood as somatotopically-mediated areas of pain like the extremities. And so to have an understanding of why we target certain structures, just writing this out here, the innervation for viscera is through the sympathetic outflow. That does not mean that it is the sympathetic tone that mediates pain, but rather it's almost, you can think of a two-way road or highway where the afferent, meaning coming back towards the spine and brain, central nervous system, is traveling through these sympathetic fibers. But that is important to know that it is the sympathetic fibers that it travels along in the opposite direction because when you do procedures that target these sympathetic outflows, you are also, while trying to block the afferents, you are also affecting the sympathetic outflow tracts, and that can have downstream effects, unintended or undesirable outcomes. And this applies for the sympathetic outflow ganglions that you may be familiar with from just your anatomy or other cancer conditions that include celiac plexus or the splenic nerves, hypogastric plexus, superior and inferior, and then the ganglion impar. And when we think about breaking down where we would want to target the pain, we think about where those afferents converge, and for pain above the umbilicus, so above the belly button, generally reaching for the celiac plexus or splenic nerve blocks or neuralysis. When pain is below the umbilicus, we're thinking about superior hypogastric plexus or neuralysis, and when thinking about pain in the low aspects of the pelvic floor or rectal area, we're thinking about the inferior hypogastric or ganglion impar. And then that last point there about viscerosomatic convergence is a concept that is definitely germane to everything that's already been described today, where you can have injury or pathology to the viscera and then develop pain along the abdominal wall, along the back, and even into the lower extremities. And part of that is thought to be due to the fact that these afferents synapse in the central nervous system and converge onto similar areas that are somatotopically mapped, like the abdominal wall or into the inner groin, inner thigh region, or even perhaps the back. And so these patients, while they don't have any specific pathology in the abdominal muscle wall or the lower extremities or their back, that is where they feel pain and then they can develop myofascial pain syndromes far away from where their true pathology is, deep into the abdominal region. So we think of patients that have had intra-abdominal malignancies, perhaps surgeries, and they are now complaining of severe back pain, severe abdominal wall pain when there was not actually any trauma or pathology in that area. So again, the concept of viscerosomatic convergence. And then there's also the concept of visceral hyperalgesia. So organs that, whether it's from surgery, whether it's from a malignancy, have been sensitized, similar to you can have sensitization in extremities. And things that otherwise would not be painful present as painful. These patients' organs now are sensitized. And so things like eating or having peristalsis normally would not trigger pain, is extremely painful to these patients. And so going back to their very first point, it is complex, but utilizing these sympathetic chains is how we try to tone down the pain syndromes, whether it's from visceral hyperalgesia or just true malignancy that's causing tumor-related pain. And so this slide is just orienting again where those sympathetic outflows are coming from. We have in the lower thoracic upper lumbar, the celiac plexus or the splanchnic nerves. In the lower lumbar and, sorry, in the upper lumbar, we have the lumbar sympathetic chain. And then the lower lumbar upper sacral, we have the hypogastric plexus. And then between those two, we have the inferior hypogastric plexus. And at the very bottom, essentially the end of the sympathetic chain, we have the ganglion and par. And so thinking about treatment options, I was just alluding to this on the original slide or the slide before this of blocks versus neurolysis is a fairly nuanced discussion with patients. And we have a consideration of where they are in their disease state. Is it terminal active cancer undergoing treatment? Or are they in that remission phase or perhaps even curative? And this also applies to patients that have never had cancer and they have a chronic non-terminal illness but persistent pelvic pain. And so the options we generally start with are colloquially known as blocks, generally meaning with local anesthetic. And that can be with or without steroid, multiple studies have been done just like studies have been done looking at nerve blocks with and without steroid. Mixed results, the general thought is that steroid does prolong the duration of the effect, but certainly can be done without steroid. Blocks tend to not last as long. They can last longer than you would think, which is a whole area of research and can be a whole separate discussion. But even just by putting numbing medication over a group of nerves and that duration of that anesthetic is only several hours, you can get some tone down of the firing of that nerve and therefore the pain symptoms. But why would we choose a block in somebody that has active cancer or is actively undergoing treatment? There are essentially three reasons we would choose a block. One is instead of neurolysis, which we'll get into, one is a patient that has a pain presentation that you're not entirely sure would respond to blocking that group. So I was saying pain below the umbilicus is where we might think of the superior hypogastric. If it was above the umbilicus, you would think about celiac or the splenic nerves. But what if it was in between? Or what if they were saying it was in a far corner and then radiating to the back, kind of hovering around the umbilicus? You're not sure which block might be more helpful. We have patients where, yes, they have pelvic pain, but they're really feeling it into their inner thighs. So just essentially going over atypical presentations. And so before you commit to neurolysis, which has its own risks we'll get into, you want to essentially test whether or not this treatment is going to reliably give them relief, you would choose a block. Another one is a patient that has active terminal cancer and they may not have long to live. So why would you do a block first and not just give them more definitive relief? The patient, when you go over the risks, may be risk-averse and not want to undergo a treatment without knowing with some degree of certainty that it would give them some relief. And so you might choose a block in that case. And then lastly, for most providers, again, I can't speak for everybody, for non-terminal illness, you're generally not going to choose neurolysis and you'd choose blocks, which can get into a whole other discussion because you will find some providers are willing to offer neurolysis for non-terminal disease and pain. So going in terms of neurolysis, there are two agents we utilize most frequently, that's alcohol and phenol. The end result of placing both of these near neural tissue is denaturation of the protein and cell death, leading to valerian degeneration, if we're going deep into some of the neurophysiology of that. But the effects of both of them are a little bit different. For most providers, they're essentially equivalent and that's borne out in the research that they, for, again, most intensive purposes, are similar. Alcohol, dehydrated alcohol, is perhaps a little bit more of a robust response in terms of cell death and destruction of neural tissue, but is more expensive and more uncomfortable. As you can imagine, alcohol is an irritant, and so these procedures can be, alcohol neurolysis can be pretty uncomfortable. Phenol, at low concentrations, can actually act as an anesthetic, and so you generally don't need to numb up the patients and still does cause cell death and protein denaturation. But there are significant risks, and so in terms of talking about predictable side effects, we'll call it, with doing these injections, and then complications that arise. So when you put these medications into a space, you're just relying on them to stay in that area. Unfortunately, even under best circumstances, the fluid can take whatever path it wants, and so injecting the alcohol or phenol near these neural structures, it can leak away from them, it can destroy local tissue, muscle, it can track back and go towards the spinal cord or the exiting nerve roots, obviously causing traumatic issues there. It can also track the blood flow and causing issues there. It can also track more distally along the plexus, and then you can end up with plexopathies, which can be devastating. And then of course you're trying to make sure that you're not intravascular, but you can inject these intravascularly, and those can also lead to significant morbidity. In terms of thinking about the predictable adverse effects, like we were talking about earlier, the sympathetic outflow is important for a lot of different reasons. One is it helps to maintain vascular tone, peristalsis, some of the internal sphincters, and getting rid of these is usually acceptable of somebody's terminal, but if they are not, or at least a pronounced sympathetic or sympathectomy, patients can have persistent diarrhea, orthostatic hypotension, difficulty with urination, and so these are things to consider more predictable and not necessarily seen as complications. And so that's, going back to the earlier point, why we generally, speaking as a field, don't offer neuralysis for non-terminal patients, because we don't want them to be dealing with those adverse effects going forward. This is an area just I'm gonna touch on briefly. There's not nearly enough evidence to do it routinely, but it is a bridge between a block and a neuralysis, and this is radiofrequency ablation. We essentially use a radiofrequency cannula, place it roughly close to the sympathetic chain, and then using these different modalities that I'm not gonna get into any more than you all would like to know about, but pulsed, cooled, conventional, high-temperature ablation, we offer these in our group for patients that are non-terminal illness, but perhaps are not getting long relief with blocks, and so again, a bridge between neuralysis, which we see as more destructive, but is hopefully longer-lasting than a block. And then cryoablation, actually, this is becoming more and more popular, and I saw a couple of different discussions on cryoablation here at the conference. Cooled is sometimes misunderstood to be cryoablation. Cooled is water cooling a radiofrequency cannula to keep the tip cool, but is still a thermal ablation, whereas cryoablation uses different agents to create rapidly lower temperatures in an ice ball at the needle tip, which leads to destruction of tissue in a different way than high-temperature thermal, and is favorable because it is generally seen as not as destructive, and so you can place it on mixed motor nerves and not get as much motor impairment. Difficult to get covered by insurance, and still very much in its infancy in terms of being studied for some of these procedures that we're just going over. And so going through these procedures, again, in fairly general detail, but the reason why I think it's important, especially in this type of talk, is if you are seeing, you're not doing these procedures yourself, but you are seeing these patients, to have an understanding of what you're referring them to, or if they ask you, what does it entail, you can at least give them a basic response, and I found that to be really helpful. A lot of these patients have, have already been over-proceduralized, and so there can be a lot of hesitancy, anxiety, and fear in terms of doing more injections, and so I find that when they've at least had some prep from the referring source on what we're going to discuss, it's a little bit less jarring to say we're going to stick long needles into your spine to help treat your pain symptoms. And so looking again at the superior hypogastric plexus, it is a very common symptom, hypogastric plexus, it is crossing over, generally accepted to be in the L5-S1 ventral border, the vertebral body, just below the bifurcation of the aorta, and so there are a lot of different approaches to get to it, again, this talk is not designed to teach you how to do it, anybody that does these, this talk is certainly below your understanding, and I also don't want to talk above anybody's interest level or understanding of how we approach these, but for the patient side of things, for the most part, it is going to be kind of like an epidural is how I describe it, the patient's going to be laying on their stomach, and we use fairly long needles to access that ventral border. Now you can go through the disc, again, this picture that we're looking at is looking into the pelvis itself, but we're actually going to be coming posterior, so you can go through the disc, called the transdiscal approach, less popular just because of the issues that can arise when you go through discs, and more popular and better studied overall is the sub-particular below the transverse process. So, this is an AP view, and then a lateral view. In the AP view, you can see on the far side a needle crossing underneath the L5 transverse process, and then reaching to the ventral border. Obviously, one view is no view, as we like to say, so it's hard to see what's happening when you just look at the AP, so we look at the lateral, and hopefully you can see it's a little bit faint, but that line coming across in that lateral view is the needle ending up in that ventral border, and when you put both together, you can see that it's roughly reaching, going back here to that ventral area. Now, the transdiscal approach is nice because it's a single injection, as that, those fibers kind of coalesce in the center, whereas if you do the transpedical, or transverse process, inferior transverse process approach, then you have to do both sides. This is just an example of one side. Rarely do we do it unilateral, even if a patient's pain is unilateral, just because of, going back to this picture here, that convergence of those fibers, it's not reliable, generally speaking, to just block one side, so most of us, even if there's a side preference for the patient's pain will block both sides. Going forward, again, the superior hypogastric is if they have pain from the umbilicus to the pelvic region. If it's really in the lower pelvis and deep rectal, we'll think about the ganglion impar, which is the inferior aspect, most inferior aspect of the sympathetic outflow. And this can be accessed in many, many ways. It's at the, essentially, the end of the tailbone or the coccyx. Most often is through the sacrococcygeal discs. And while the procedure is extremely safe, the main risk is venturing too far. As you can see in this picture, bowel gas. So, essentially, the rectum is past the needle tip, whereas that ganglion impar is going to be just on that ventral border of the tailbone or the inferior aspect of the sacrum. So, moving forward, thinking about if the patient had more external pain, genital pain, perineal pain, what we would offer. Some of these pain syndromes have already been presented, and some of the treatments were already described, including with Dr. Wang's in-office option. So, we'll talk about how we would approach that through image guidance. In this picture, obviously, just a gross depiction of the innervation or coverage of the different parts, in this case, female genitalia. Overlap is significant with male, and so it doesn't really change our approach for targets. But just pointing out that if there is pain in the upper portion or in the inguinal region, we would think more about genitofemoral, ilial, inguinal, and iliopigastric. But in this case, we're going to say the patient's pain is primarily encompassed in the light green region, which is covered by the pedundal nerve. And so, thinking about the pedundal nerve blocks, we generally prefer to access it as it loops around before it dives deep into the pelvis and it passes near the ischial spine. It can be difficult to visualize, and so here, just on that AP view, we've dotted it and outlined it with a needle marker showing the tip of that. The pedundal nerve is crossing just medial to that, and so we touch down on that ischial spine and walk off just slightly, being mindful that there are a lot of blood vessels and being mindful that there are a lot of other important targets in that area, structures that we're aiming to avoid, including the sciatic nerve, the nerve to the obturator internus. You also have the posterior femoral cutaneous nerve. And then, of course, in terms of vasculature, you have the pedundal artery traveling with that nerve. And so, the procedure, the patient is, you can let them know they're also going to be laying on their stomach, kind of like an epidural injection, but we'll be going through the gluteal area, and so it's called a transgluteal approach, which is a little bit different, obviously, than going transvaginally. And I have these two pictures up. These are real procedure images from our clinic. One shows you on the side how difficult it can be at times to see that ischial spine, whereas sometimes it's fairly clear where you can see that triangular appearance. You touch down and then walk off medially to target that nerve. And then also, and this can be done in office without the use of fluoro, you can do ultrasound-guided approach, and this is the preference of some practitioners. It's easy to visualize. If the nerve isn't easy to visualize, the pudendal artery that travels with it is, and so it's a pretty quick approach that can be done in office for these patients and potentially give them a lot of relief. I also want to pause and just take a moment to explain how we provide this information to patients. When you talk about doing nerve blocks, at times patients can be confused and think that you're saying there's something wrong with their nerves, whereas we're oftentimes using it for its downstream effects. I only bring that up because if we're talking, if you tell a patient that we're going to do a pudendal nerve block or a hypogastric nerve block, they'll ask about, do I have an injury to my nerve? And we try to reframe it as the nerve is not so much the issue, but we're utilizing it as a tool to block the pain that the nerves travel to or innervate. And so taking a step back, there's so many different procedures that I didn't go over. Again, the further down we venture, the less and less evidence. During the Q&A, I'm happy to go over other things that perhaps you've heard of, and I can weigh in on the utilization of that. But taking it back to earlier discussion where we really started, chronic pelvic pain can be very distressful and in a different way than other pain conditions. I thought that was a really good way of putting it. People will come in complaining of their knee pain or their back pain, but they're not gonna be talking, even with their doctors, certainly not their colleagues and maybe not their family members, about the pelvic pain and the distress it can cause, not just because of the pain symptoms, but the sexual dysfunction associated with that. And it can become very, very distressing. And so that's evidence borne out in the literature that specifically chronic pelvic pain has its own unique biopsychosocial profile that should be considered. And so we try to get our patients, just like I started the talk with the fact that we don't do these procedures in isolation. We try to get these patients involved in some sort of mental health support. We are fortunate enough to have pain psychology within our group, and that is extremely helpful, but it is not always available and can be expensive when not covered by insurance. So even just linking these patients up with psychiatry and psychology to make sure that everything else is being optimized. Generally speaking, these pain procedures do not work well if things have not been optimized, meaning you, and this is pain procedures in general, but you have a target, you expect it to work well, but really the patient is the one that tells you if it works well or not. And these factors, we know, can lead to decreased efficacy of what we would otherwise consider should be a successful intervention. And so optimizing that is really important for us. Part of it is also patient buy-in. Patients, as some of you may have experienced when you talk about pain, and then also parlay that into mental health and what they're doing aside from their pain symptoms, they think that you're telling them that it's all in their head, which, of course, all pain is in the head because that's where we perceive it, but getting patient buy-in is really important moving forward. And so just some take-home points. Lower abdominal pain and pelvic pain is extremely complex. The interventions for it are helpful for appropriate selected patients, but evidence is overall pretty limited. The evidence that is there definitely favors a multimodal and multidisciplinary approach, and that's what we see anecdotally as well. And I'm just gonna put this up here, and certainly we can discuss them more based off Q&A, but things that we all think about as a group, and I think about quite a bit when offering procedures for these patients is at what point do you start offering these procedures? And then an even tougher question to ask and answer, as I was alluding to, especially these patients that are desperate for relief, is at what point do you stop proceduralizing these patients and go back to other modalities? Can be a really difficult discussion. And I will end that there, and feel free to reach out for me if you want any references or anything else. Thank you. So, I am going to ask some of our other speakers to come up because we'll have questions for these guys, but then we'll also kind of panel it up. We'll start with the crowd and see any questions initially for Dr. Reddy or Dr. Wong regarding this last one. I know we have some that I've discussed with prior audience members, if you'd like to ask, and then I will repeat for the group. Yeah, really good question. The question was, when would you offer something like the Q-TENSA, which is the high-dose capsaicin patches, and what quality of pain are you looking for or expecting a response? So for the first part of that, I would say it depends on who you ask. For most of us, because it is expensive and it does take time to get approved, and I glossed over, to some extent, the adverse effects from the Q-TENSA patches, but some patients can have increased pain, so you have an opposite effect, and so that's always something to talk about before you actually apply the patches. But for most of us, to give you a simple answer, should have tried the oral antineuropathic pain medications and potentially even some over-the-counter topicals before we would consider offering that. And then it also should be an area that's reasonable to treat. We were talking about the feet, since that's a common area for chemotherapy-induced peripheral neuropathy, but if they have neuropathic pain somewhere else, you could consider it. Since we're talking about pelvic pain, the warning label is to not apply it near any mucosal surfaces, so I would not recommend, even if they have burning pain near any of the mucosal regions, whether we're talking about perineal or vaginal, would not apply it in that area. And then in terms of the quality of pain symptoms, definitely that burning. Numbness is not going to be a reliable response. They may have some improvement, but that is mediated through a different pathway. We're mostly talking about TRPV1, which is that burning sensation. Any other questions to start from the crowd? We've got a few. This one will kind of go with Dr. Wong and maybe go into our sex therapists and pelvic PT. You had mentioned some of the more conservative oral neuropathic pain agents and topical agents, even like dosing or other things to end up. Is there a typical dose you start at and potentially want to titrate to, whether you figure out what's efficacious or not? And then I think in relation to if we're giving guidance on sexual activity or even pelvic time, you mentioned a study about there was one with the diazepam that may help decrease symptoms. Do we dose them a certain time before therapy or before some of this activity? So I think hearing from the group with that. Yeah. Generally when I am starting, like we'll say the back up in suppositories, I do 10 milligrams at night. And I usually tell patients that I don't look at this as a forever med necessarily, but that we usually do it while they're doing physical therapy for a month or two and see how things are going. After that time, if things are improving, obviously if it's not helping, we would stop the medication. If it is helping and their muscles are getting better, then we may stop the medication. We may go to as needed. So we can use it before physical therapy. I usually say 30 minutes to an hour before therapy. You can also use it if they're having pain with penetration. You can use it 30 to 60 minutes before. Obviously that takes a little of the spontaneity out of things, but if it's pain and I can't have sex or I have to plan a little bit, usually patients are okay with the planning. The topicals that I use when I'm using gabapentin, 6% is generally where I go. If I compound baclofen in that, if it's a cream, baclofen 2%. When I used to use amitriptyline, that I think was also 2%. Was there one other? I think some of them maybe relate to therapy of how we utilize some of these topicals versus in relation to that and home exercise. Yeah, so I'm a pelvic floor physical therapist for anyone who wasn't here in the last talk. Of course, I'm making sure patients are taking their medication as prescribed by their provider, which also has some of this dosing usually in it. So this is going to be that collaborative care. But sometimes I have patients who they're supposed to be taking it every night and then also as needed for PT, but they're not sure if they want to take it before PT and these other things. So I'm certainly guiding patients within what has been prescribed. Sometimes I'm sending patients to PM&R physicians to get this kind of thing, and I try to explain it to patients as almost like a speed-up from a video game. Like, we're going to get where we're going in pelvic PT, or usually that's what I'm saying if I'm sending out for something like this. But this will kind of speed us up and help us to get there better and a little bit more quickly. We'll get where we're going either way. But this is why I think that it can be really important because it will really help us to reach your goals by making you tolerate therapy a little bit better. And then the other thing I would say is, I mentioned that we use these vaginally, but we also use them rectally, so we can use this medication in men or women. And then... I thought there was one other thing I was going to say. Oh, that's good. Okay. And then for the sex therapy, do you incorporate any of that, the topical or the oral stuff when you're talking about, especially with the sensate things, that progresses towards that? Sure. So for the sensate therapy, we're talking about the effects of certain types. So certainly we'll have lotions as a part of that or even feathers in some ways, and just kind of getting creative with those pieces. Obviously, we would refer to provider colleagues for dosing any kind of medication parts. But I think that's a great comment about loss of spontaneity there. So what I oftentimes have patients do is schedule sexual encounters as a way to also build desire. And so I'll have patients and partners, you know, have maybe a shared calendar and have this, you know, several times or however many times that they decided. And so, yes, there's that loss of spontaneity, but also we can kind of work on that from a psychological perspective to build desire, too. So that's kind of a great integration of those tools. I know what I was going to say, too. The cream, especially... I use this a lot in patients with vulvodynia. So if they have pain, especially like at the introitus, you have to remember that all of our patients are going to have a different education and a different knowledge on their own anatomy. So I also confirm with the patient that they know where they're putting the medication. Oftentimes in follow-ups, I'll check with them, and then my physical... I rely on my physical therapist as well to kind of talk about that. I have, like, pictures that I give them, and I use a highlighter and say, this is where you should put it. I have mirrors in the room so they can look, and I'll, you know, I'll show them, have them put their finger on it so they know exactly where it's going. I often will say, like, you know, the idea is that this should be where the pain is. So if the pain is at the introitus and that's where we want this, so, you know, you might feel discomfort when you're putting it on, but then we're also getting that desensitization from using the medication. And the cream, I usually have them use twice a day or three times a day if they're working from home because it's not easy to put on if you're in a bathroom at work. Back to Dr. Reddy real quick. Obviously, some of the procedures you were talking about seem relatively specialized. I think most of us, we probably have pain physicians around us, whether or not they are specialized in it. So is there... should we have an expectation that certain ones would have knowledge to do these procedures or not? Is there certain questions we should be asking from our pain colleagues if we refer whether what kind of approaches or otherwise, what's kind of the standard versus someone with a specialist approach to it? I don't need to repeat the question, right? That is a really good question. We were just talking about that before we started the talk, and patients with pelvic pain can be complicated for multiple reasons. And so even within the pain community and even if the provider had the basic training, they may not be interested in providing these services or attracting those patients. So I would say trying to establish that relationship and asking if they manage abdominal pain and pelvic pain, sometimes that gets wrapped up into the same kind of collective group of procedures or interests. Academic institutions are probably your best bet you're going to see less of an interest in that in general. Again, this is a generalization in the community. I think my name is somewhere in these Reddits somebody mentioned where there's like groups, support groups where they have patients putting in doctors' names that are willing to do... manage their conditions or provide certain services. And so sometimes we have patients if they're moving to a new area and I don't know somebody there, we'll point them towards those resources. And whether the doctor knows or not their name might be on a list because they've done those interventions. But yeah, academic institutions are usually the best option. Sometimes when I have patients who are maybe moving out of the area and they're like looking for physician providers to take over from the physician providers that they have in my area, I usually actually tell them to find their pelvic PT first because the pelvic PT is going to know all of these different providers, especially when they're looking for maybe specific blocks and things like that. Like I know some providers do some things and not others and I can kind of help people through that. So also it's helpful. Did we just find out you're Reddit famous, Dr. Reddy? I hope not. This is one for the whole group a little bit and people can jump in. We as a specialist in cancer rehab have spent a lot of time trying to teach oncologists of our value and when to refer to us. This is obviously a very unique subset and I know experience-wise, like radiation oncology or gynocs, sometimes they keep their arms around them and don't refer out. Have you found that they have a knowledge in understanding this or where their gaps are? Because as we hopefully develop support for referrals and try to build our practice up, what are the ways maybe they have a good knowledge or not in terms of your experience? I know I think in our institution, radiation oncology does a lot of that, but I can tell you I have a lot of patients that don't tolerate the dilator progression the way they do it and I don't really think they do much intervention other than like keep trying. But just curious because obviously everyone in the group has dealt with some of that. So whoever would like to jump in. I'll just stand up here. I find that the gynecologic providers, whether they're radiation oncology, surgeons, they are ecstatic to have somebody interested in helping with pelvic pain. Actually, when I first went to UofL and I went to all the different providers, right on, gynecologists, surgeons, medical oncologists, especially the gynecologists, they were like, so do you treat pelvic pain? That was like the first thing. They are so excited to have somebody. In the beginning, I did not. So going back now that I've gotten into this interest, they really want somebody helping and they are really excited to have PM&R involved. I think what I have to do even more is probably go and see patients with them and actually be able to say, yep, that's a patient I want to see. Gynecologist sometimes sees non-cancer patients and I really want to focus just on cancer patients. So they were like, if you're going in to start doing some of these transvaginal injections, will you take some non-cancer patients? I was like, no. So I've got to like create my own barriers on who I can take on because I think if you go into pelvic, floor, PM&R, you could get an onslaught. So really figuring out what kind of patients you want to treat and then for me, I'm going to go into clinic with Gynonc. I'm going to go into clinic with Radonc and help steer patients to me. Yeah, that's mine. Anybody else? I mean sex therapy since I think a lot of places don't. I think most people are probably relatively ignorant about your skill sets. Right, so I think there's a huge educational piece about what the scope is, what the role is, when to refer. I think we had a question earlier about early intervention is always best, so getting those patients in before there's a significant area of distress. But a lot of that is actually screening. So if we don't know our patients are having concerns with sexual function, we're not going to refer them. So I think it's absolutely educating providers but also letting them know that we have an available resource. And Dr. Nelson and I are both at UofL, so I think at this point we're kind of setting those boundaries of we can only have so many patients. That's been great to see kind of the explosion of focus on pelvic health recently. But again, a lot of that's come from education. I think in the pelvic PT world too, I mentioned this a little bit earlier, that sometimes I'm getting patients from like Gyn, Gynonc, urology, GI, and then they also need to be in the PM&R space and kind of vice versa sometimes. It depends on what providers people come in with. But I do a lot of emailing a physician related to the patient's care, and I'll be like, thank you so much for your referral, even though they definitely don't know who I am. And just trying to get everybody on board with what's going on in PT, give them an update, that kind of thing, and just try to get everybody on the same team as best as I can because it can be really hard. But interdisciplinary care is really the way to go. So I find it's really helpful. So I do my best. Is there someone who had their hand up over there? Go ahead. For the online group, the question was, how do you get botulinum toxin approved? Is there any special magic powers that you have? I wish. You know, earlier in my career, I feel like it got approved a lot more around the time of COVID, Blue Cross Blue Shield stopped approving it almost completely. And so, you know, I, I actually, and people that have worked with me in clinic know, I'll look at the insurance before I even bring it up as a treatment option. Because if it's Blue Cross Blue Shield, the chances are basically zero, right? And so people can self pay for it, but it's expensive. And it's usually limiting on who can get it. We do have some insurance companies that are a little bit better about it, or at least worth trying. I'll usually my actually my in my guy in clinic, it's so bad with Blue Cross Blue Shield, they will submit the prior off, but they will they they've, we've made a policy that we won't appeal, the patient can appeal, but we won't just because it's a lot of paperwork. And it's we've never had one that's been overturned. I've done so many peer to peers, and they've, I finally just said, is, is there any reason to even do this anymore? And they're like, no, what, like, it's a waste of your time, it's a waste of our time. We cannot approve it. I don't know if you're having any better luck. There are some urinary symptoms that some of those codes will work. I'm not 100% sure that the insurance company knows the difference if I'm doing it in the bladder versus the pelvic floor. So you know, but sometimes, I will definitely put like urinary or bowel symptoms in in there as well. And that has rarely helped. I just know I although I don't do the injections, I do have patients that get the injections at times and some of the especially if they have neurologic related like chemo induced of a neurogenic bladder and those related stuff, having those diagnosis of get some of those patients and especially if they have incontinence related issues that you can kind of gauge and from that and I have one or two right now that are getting it from their their providers. Yeah, I would echo that it's become more and more difficult in general medicine to get things approved but specifically Botox has remained expensive. Not encouraging anybody to commit medical fraud but other acquired dystonia is often covered if you can document and truly feel like the patient has acquired a dystonia related to their cancer treatment and it's presenting in their back or their flank that often gets approved. So other acquired dystonia. Is there any other questions before I there's one last question I want to share with the group before we get going. Go ahead. Okay, so I have a question for for Laura about like particularly with Sunstate focus like what sorts of guidance do you give for patients with either impaired mobility or impaired dexterity? Yes, that's a great that's a great question. So that would be something that we would talk about in the initial assessment and educational piece. What is within your toolbox to do. And so a lot of those for working with a lot of those patients it's positioning changes. So again there's there's so many modifications. So if we have patients that do not have strength to even do kind of touch focus it may just be laying next to each other unclothed right. And so that that can be very impactful and that that is more rare in the patient population that I do see. But it's certainly talking about again what's what's within your capacity in terms of physical you know intimacy but also what are those goals. And so some of that may be redefining goals and if there are significant deficits and function status it's you know this is not going to look like what this did 20 years ago. And so again we're doing a lot of grief work surrounding that with both the individual and the couple. But setting those expectations and then working within what's allowable or what's feasible to find exciting pieces. So we get very creative with again I mentioned like feathers and I mean there's all kinds of ways to increase that tactile intimacy and those interactions that you know go go a long way. If you're interested in more of the modifications for some say focus Linda Weiner is fabulous and her book has a lot of illustrations that really kind of cover different abled bodies and how to incorporate. And that's in the list of resources that are on the PowerPoint too. But that's that's a great text if you're interested in kind of what would that look like for different type bodies or different able bodies. Thank you. The last question I have that maybe take home points. So although it would be nice if we can put you guys on a bubble and you would be a pelvic health center that we can have for everyone around the country with all these talents. But I think we have people who maybe live in different areas and an HMO world here in California or somewhere else or early career that public health may be part of their care but just a mix. Is there kind of like hey I don't have a lot of expertise by me like a list of things. Is it the survey of a review of systems is a partnership with a therapist. Is it is there kind of a first step thing that we would say hey just to get things going if I'm not an expert in that but I want to make sure I'm appropriately screening or doing something and not just having this patient ignored. And I think that's a question for the group just to order my work and I get started. I mean I think the resources that were shared today like the PG lookup I think having if you're treating pelvic pain and you think there's a public floor component you the patient is going to have to see a physical therapist right. That has to be part of the treatment. And if that's not a resource that's in the area. I mean I I'm after residency moved to a more rural area and started a practice. There weren't there weren't really public floor therapists there. But when I was going there to interview and and telling them about what I wanted to do. I was very clear that like this will not be successful if we don't have public floor therapists that I can send to. There's nothing that I'm going to be able to do for these patients that's actually going to like fix the problem in the long run without the therapist there. And so you know we were able to identify some orthopedic therapists that were like oh I'm I have an interest in that. And then the university said if you come here we will put them through the training we'll do whatever you know whatever you suggest and what we need to do. So I think if it doesn't exist there's ways to make that happen. The I mean I use the psychology today. You can you know put in location you can put in insurance. You can see people's bios you can see if they're like ASIC certified all those kinds of things. And the ASIC website also has has that resource to look up therapists. Because again if you have patients with history of trauma or history of continued pain with sexual activity that portion of it you can only get so far without having bringing on you know the sex therapist into that you know into that group as well. Anyone else have a. And with that ASIC which stands for the American Association of Sexuality Educators Counselors and Therapists. So that counselor piece encompasses medical providers and physicians who do this work as well. So that's a great resource and the referral directory includes again pelvic floor PTs physicians and psychotherapists that can work with patients. And I will say you know addressing our rural patient needs telemedicine has been great and of course you know obviously there are some things that you just cannot do via telemedicine but our telehealth but being able to incorporate that on some level has been very helpful especially post-COVID. So the grand scheme an interdisciplinary team with the focus is probably the best bet to get started. The other thing I would say is like if you're not comfortable with necessarily treating all aspects of this as a physician you know finding a gynecologist urogynecologist something you know someone like that in the area that does treat pelvic pain that's another would be another good resource to have. I think you were all patient and made it past time. Thank you for hanging with us. Any last questions concerns. Thank you for everyone making it. I didn't even see anyone sleep and it was good post-launch. We made it through. All right. Go find some puppies to pet. Right. Pavilion.

pelvic pain management

cancer treatment

multidisciplinary approach

vaginal stenosis

myofascial pain

nerve blocks

biopsychosocial aspects

interventional procedures

pelvic floor therapists

telemedicine

patient-centered care