Hello, everyone. Welcome to what's going to be probably the best session of the meeting, I have to say, in part probably because I'm not speaking. I'm just going to introduce some people and sit down. Please remember to silence your cell phones, and also that there will be no – please don't videotape, but this particular session is being live-streamed, so we really ask that at the end, if you have some questions, please make sure you come up to the microphone so that the people live-streaming at home can hear what you said. The evaluation forms are going to be available in the mobile app in the online agenda. Please complete individual session evaluations. Search for the desired session in the mobile app or online agenda and click CME and Evaluations to open the evaluations. Lastly, please remember, although the pavilion closes at 1.30 a.m., please do remember to go down there and check it out if you haven't already, and there are several free-to-attendee symposiums down there. We have a distinguished group of speakers today. I'm going to go from right to left. We have Dr. Scott, who is Professor and Program Director at UT Southwestern, Dr. Kumar, who is an Assistant Professor at UT Southwestern. We have Dr. Nakamura is – oh, I have you guys backwards. I'm so sorry. Dr. Marcotte is from University of Michigan, and Dr. Nakamura is from the University of Washington. I have you guys switched, I'm sorry, Michigan and Washington, and they all are experts in pelvic pain, which is what's really great about what we're doing today is talking about something that has not much research and not many, very many clinicians who are treating it, but fortunately, we have experts who have been doing it for a long time. Great. Okay, so I'm going to start off by talking about inguinal disruption. A lot of you might be familiar with this condition more as athletic pubalgia, and so just first to start off, I would like to point out that inguinal disruption, which is what I call it, it actually has many synonyms, one of them being core muscle injury, which is actually not on this list that you're going to be – that you see here. However, if you actually look it up in PubMed, you're going to see core muscle injury as describing what we have – we know of as athletic pubalgia or sports hernia in the more orthopedic or sports literature. So experts in this area believe that inguinal disruption is the preferred term for the constellation of symptoms that involve the inguinal region and the core. So in my sports-trained experience, this condition, as I said, is commonly known as athletic pubalgia, which I must admit, it is nonspecific, as well as being a misnomer because there is no hernia in this condition. In addition to that, it is also seen in patients who are nonathletes. So – and to top it all off, there's also controversy as to the origin of the pain, if this is a groin problem, if this is abductor, or is it inguinal-related. So we're going to start off with the case. 22-year-old male ice dancer with four weeks of right groin pain with radiation to the lower abdomen and the proximal inner thigh, and this also sometimes radiates into the testicles. The pain occurs only with lifting, lifting his partner, as well as with spread eagles, and you can see the spread eagle position displayed very nicely here in the picture with Yuzuru Hanyu. So I would say in terms of history, this is what you're going to be hearing from your patients. They're going to say, I have pain in the groin. Typically, they're going to feel it also in the lower abdomen, also in their groin area. And in my case, because in my practice I have a subset of patients that I see who have chronic pelvic pain, they tend to tell me that they have pain radiating into the perineum, into the pelvic floor, or into their testes. On physical exam, he was tender at the right adductor longus, as well as the insertion of the tendon, the rectus abdominis insertion, and the pubic tubercle at the insertion of the adductor and rectus aponeurosis. There was pain with resisted sit-ups and resisted adduction, and he also had a positive bilateral adduction test, and I'll show you what that positive test is in a little bit. And again, in terms of physical exam, this is very typical of what you're going to see with inguinal disruption. They do most 100% are going to have pain at that pubic tubercle, sometimes a little bit more at the adductor or the rectus, depending on which one is more involved. And the special tests, as I said, I'll review in a little bit. So let's go over the anatomy. So anatomy of the groin region is complex and involves a confluence of structures. So before inserting at the midline, the superior fibers of the internal oblique aponeurosis is going to split around the rectus abdominis, with the external oblique being fully anterior and the transversus abdominis being fully posterior. Now, while the more inferior fibers of the internal oblique aponeurosis goes fully anterior to the rectus, and the transversus abdominis also inserts only anterior to the rexus. And so this means that behind the rectus abdominis, there is an area that only has the transversalis fascia, which is potentially an area of vulnerability. And the inguinal canal passes just superior and parallel to the inguinal ligament, and it contains the spermatic cord in men and the round ligament in women. The canal extends from the deep inguinal ring to the superficial inguinal ring in the aponeurosis of the external oblique muscle, which is just superior and lateral to the pubic tubercle. So right next to where patients with inguinal disruption are going to be complaining of pain. So the pubic aponeurosis complex, this is formed by a confluence of fibers from the rectus abdominis, the conjoined tendon, and the external oblique. The pubic aponeurosis is in continuity with the origin of the adductor muscles and the gracilis, and is referred to as the rectus abdominis adductor aponeurosis. The pubic symphysis here acts as a fulcrum for the forces that are generated at the anterior pelvis, and the structures that are involved in the pathogenesis of inguinal disruption are all associated with this fulcrum. So athletes who undergo repetitive hyperextension, kicking, sprinting, cutting sports, such as soccer or ice hockey, are especially prone to inguinal disruption. However, as I mentioned, this is also seen in non-athletes. And most of the literature, but most of the literature does come from the athletic population, and so understanding in the non-athlete is limited. So the prevalence and management in non-athletes is not very well described in the literature. I personally treat them in the same way. As associated with pregnancy, you're going to find this in the literature as a osteitis pubis. So in general, concerning the etiology, it is not completely clear, and it's still being debated. However, a muscle imbalance between the abdominal and the hip adductor muscle is currently considered to be an important factor in the development of inguinal disruption. Other factors include a defect or weakness of the posterior inguinal canal and or that weakness that causes compression of the genital branch of the general femoral nerve, which causes that neuropathic pain that radiates down into the perineum or the testes. So experts do agree in terms of pathological findings that you will see, that there is always a weak posterior wall of the inguinal canal, although pathology may not always be evident until surgery. These include disruption or tears of the external oblique aponeurosis and or inguinal ligament disruption or tears. Other pathology may also be present, including dilation of the external ring, conjoined tendon tears, inguinal ligament dehiscence, and at adductor longus and rectus abdominis aponeurosis, injury, or tears. And so to diagnose a patient with inguinal disruption, it is considered that they should have at least three out of five findings. And this is based on this sort of expert consensus that came out in 2014. So pinpoint tenderness over the pubic tubercle at the point of the insertion of the conjoined tendon, palpable tenderness over the deep inguinal ring, pain and or dilation of the external ring with no obvious hernia, pain at the origin of adductor longus insertion, and then finally a dull, diffused pain in the groin that often radiates into the perineum and inner thigh or across the midline. So but, you know, we're physiatrists and we like special tests, right? We do this in our practice. And so I wanted to bring up a few special tests that are actually excellent for inguinal disruption. And so you can see of the three tests, so the single adductor is SA, the squeeze test is SQ, and BA is the bilateral adductor test. The bilateral adductor test has the highest metrics in terms of correlation with what we're going to find in terms of chronic groin pain and then MRI findings. And then when you look at the specificity and the positive predictive value, again, you see that the bilateral adductor test has the highest metrics. And so if you're going to do a special test, I would recommend doing that bilateral adductor test in your patients. In my experience, patients who really are involved, they can't even get up into that position. So for imaging, you know, we get x-rays. The x-rays really is to rule out other sources of groin pain. So we're going to be looking at the hip. There's a lot of times concomitant femoral acetabule impingement for patients. And so sometimes it becomes important to figure out if it really is that FAI or if it is that inguinal disruption that is causing their pain. And a diagnostic anesthetic injection may be very reasonable to do either into the hip or to the aponeurosis to determine that, you know, primary source of pain. If you're concerned about symphysis, pubis instability, you may want to also get flamingo views. And so that means you're going to get an AP view of the pelvis. And it's going to be single leg stance on the right and then on the left. And you're going to be looking for that movement at that pubic symphysis. MRI is considered the modality of choice. In an estimated, though, one-third of patients may not demonstrate any significant finding of MRI. So be aware of that, that you might not even see anything when you get that MRI. And then finally, ultrasound is also an option. So for ultrasound, you know, because of my sports training, I'm going to be looking at the adductor longus tendon or the aponeurosis or the rectus abdominis. But there is also a dynamic ultrasound evaluation that you can do that looks at that posterior inguinal canal with a valve salvo and looking for a bulge in that posterior inguinal canal, which will be considered a positive finding as well. That would be very operator dependent and dependent on really your, you know, radiology colleagues if they're going to be able to do that on their techs or trained to do that or not. And so looking at MRIs, we have, you know, findings that are typically seen at the symphysis pubis as well as the inguinal canal. And it really depends on the age group of the patients you're going to be seeing. I personally see more older patients. I don't really see younger, you know, younger patients less than 18. So for the younger patients at the symphysis pubis, it is generally, you know, believed that they have bone marrow edema of both pubic bodies and they may also include a high signal fluid in the pubic symphysis, a diffuse symmetric soft tissue edema also that extends to the surrounding tendon or muscle. However, in older patients, you're going to see something that's likely a little bit different. And so you'll see more focal pubic bone marrow edema. And in addition to that, they may also have edema of the anterior capsule or capsular ligaments. And the enthesis of the common aponeurosis of the adductor longus and rectus abdominis may show some tears or edema. And then finally, also, you know, we do expect to see, well, we would hope that we would have inguinal canal findings. But really, when you look at an MRI, the MRI usually does not show any edema or any structural disruption of that inguinal canal. And so here is a MRI image of our ice dancer. And so the picture on the left here is going to show edema of that, you know, the pubic bodies. And then the picture on the right is going to show, again, edema of that pubic body. And then he actually has a partial tear of that aponeurosis. And in addition to that, he actually has a small avulsion as well, a partial avulsion. Now, this image is an MRI of a different patient. She is a 29-year-old postpartum woman. This is one year out from delivery. She had persistent groin pain following delivery one year out, had already gone through physical therapy. And this is what the MRI came back with. Now, you know, you should be aware, postpartum, if you take an MRI of a woman, you know, who's delivered, three out of the four patients are going to find you're going to see bone marrow edema. The important thing is that you're going to have to correlate that with the patient's symptoms. You know, same with your athletes, right? A lot of athletes are doing soccer players. They also have bone marrow edema. It doesn't necessarily mean that they're symptomatic. So, but in her case, this is one year out, you know, it's, we expect edema or natural edema to fully subside by the time at least six months comes along. And so I just wanted to show this MRI just to say that, hey, like, this is something that we can also see in pregnancy and we can see in patients who are non-athletes as well. So for treatments, the, you know, the range of success for non-operative treatment, it's very wide. We'll start with, you know, usual sort of MSK treatment, sports injury treatments, arrests and analgesics, and then we start a physical therapy program. And so for, you know, physical therapy, we start off slow. We really work more on postural education, muscle recruitment, gentle stretching. We don't directly go for strengthening any of those muscles that are directly attached to that pubic tubercle. And then gradually we work through phases in advancing patients. And so generally speaking, these PT programs are about two months in terms of advancing patients through their recovery and then returning to either sport or returning them to regular activity. And, you know, this is an example here of exercises that can be done for the early stages of conservative treatment. I just want to throw out there that in my experience, physical therapists are not very well trained in treating patients with inguinal disruption. And so if they're at a loss, I would highly recommend forwarding either this article or some examples to your physical therapist so that they can start working with your patients. The other piece that I want to mention is that I've had a lot of patients come to me with inguinal disruption who have worked extensively with pelvic floor physical therapists, but they're not getting better. Pelvic floor PTs are not very good at treating this. Like this is more of a, it really is more of a sports PT, ortho PT skill set. And so I would highly recommend, you know, recommend that you refer them more towards the sports ortho PTs rather than the pelvic PTs. And then in terms of treatments, we have options for injections. So there are studies on both steroid as well as prolotherapy. You know, both do relatively well, you know, and they're back to sport and activity at eight weeks and nine weeks. It seems to be that, you know, prolotherapy has a little bit higher rate of, you know, lower rate of non-responders. And then finally PRP is also a reasonable option. Just know that there are only like two case reports out there in terms of PRP for treating inguinal disruption. And then finally, for those who fail conservative management, surgery is an option. And so the role of surgery is to release abdominal tension, abnormal tension in the inguinal canal and reconstruct the weakness in the posterior wall with a mesh. There are both open and laparoscopic approaches. And, you know, the laparoscopic seems to have faster recovery in experienced hands. There are although no studies showing superiority of open versus the laparoscopic surgeries. So this is all I got. So I'm going to pass on to our next speaker here. So here are my references. And so, you know, like I said, some of these articles I think are very helpful to pass on to your physical therapist if you do see these patients in your practice. All right. Hello. I'm Rupali Kumar. I'm going to be talking about pelvic floor dysfunction and deep hip rotator as a source of pelvic pain. I don't have any disclosures. So today we're going to focus on the anatomy and function of pelvic floor muscles and the deep hip rotators and understand how this type of pain would present and how it's diagnosed and how we would manage it. So starting off with a case. So this is a pretty typical patient that I will see in my clinic, which is purely pelvic rehabilitation. A 45-year-old woman with a history of endometriosis who's had laparoscopy and excision of the endometriosis presenting now with left lower abdominal groin pain, also dyspareunia, both entry and deep, and urinary urgency and frequency, but not a UTI, negative UA and cultures. She has been through multiple docs to try to find an answer for her pain. She's seen PCP, her OB-GYN, urology. She's had full workup. It's been negative. And it's kind of unclear what the reason for her pain is, as oftentimes pelvic pain is assumed to be related to a visceral origin many times, and the musculoskeletal or neurological parts can be neglected. So talking about more about pelvic floor dysfunction background. So I'll say that pain in the pelvic floor muscles and the connective tissue in the surrounding fascia, as well as the deep hip rotators that are very closely associated with the pelvic floor is what we're discussing. This is characterized by having muscular pain, taut bands of muscle, trigger points in the muscles, and it can be the primary source of pain, or it can be secondary to another source of pain within the pelvis that's caused reflexive muscle contraction. There are no labs or clear imaging tests that will help you diagnose this as well as history and physical exam. Those are the mainstay. This is one of the areas of medicine where I think physical exam is still of primary importance to diagnose. This is a very under-recognized source of pain. It's often presumed, like I was saying before, that it must be visceral pain, especially when people are having these urinary type of symptoms, or dyspareunia. They think it's more in the gyne or urology world, but oftentimes not. So the most common cause of chronic pelvic pain when you rule out the visceral sources of pain is myofascial pain from overactive pelvic floor muscle dysfunction. It often coexists with these other visceral sources of pain as well. So in a study of women with chronic pelvic pain, 89% of them had levator ani tenderness, 50.8% had piriformis tenderness, 31.7% had obturator internus tenderness. So oftentimes we can reproduce the pain with myofascial sources, even if the visceral part has been treated. And 59% of women who are evaluated for chronic pelvic pain will have musculoskeletal dysfunction of pelvic floor. So to go into more of the anatomy here, we can break it down into superficial and deep muscles. So the superficial pelvic floor muscles, you could call urogenital diaphragm, involves bulbospongiosis, ischiocavernosis, and superficial transverse perineal, as well as external urethral sphincter, and I didn't think I put it here, but anal sphincter, and then superficial perineal fascia and perineal membrane. And then the deep pelvic floor muscles and hip rotators, and we would call this the pelvic diaphragm, it involves levator ani, so puborectalis, pubococcygeus, and iliococcygeus, the coccygeus, or ischiococcygeus, inferior pelvic fascia, piriformis, and obturator internus. So here's to visualize in a female, we're looking at the superficial pelvic floor muscles, so. My mouse? Okay, so immediately there's, I didn't practice this, yeah. Immediately you'll have, thank you. Oh, very nice. Okay, so immediately you have bulbospongiosis, and laterally ischiocavernosis, and then running across the perineum is the superficial transverse perineal, and in the male, similar location at the muscles, bulbospongiosis immediately, ischiocavernosis out here, and transverse perineal is over here. Okay, and then looking at the deep pelvic floor muscles. So we're pointing out the levator ani muscles, so puberectalis, pubococcygeus, and iliococcygeus. And then back here, connected to the tailbone is coccygeus, and then behind that, piriformis. Deep hip rotators, here's obturator internus, but again, piriformis, both highlighted here. And then here's another view looking at those deep hip rotators, so you're all probably quite familiar with this deep gluteal muscles view. So you've got piriformis, and then obturator. So you've got the obturator internus sandwiched between the gemelli, and then quadratus femoris below that. Okay, so the role of the pelvic floor, the function of the pelvic floor, it's essential for supporting the pelvic abdominal viscera, preventing prolapse. It's an essential part of the core, which resists the increases in intra-abdominal pressure, without which everything would just fall out the bottom. So it allows you to perform forced expiration, coughing, vomiting, and fixation of the trunk for activities like weight lifting, maintaining balance, stability. And then it's essential for controlling the outlets of the pelvis. So for urination and defecation, these muscles control the ability to do those actions. And then pelvic floor is responsible for being able to have sexual intercourse and have it be pain-free. It supports the fetus in pregnancy and has a huge capacity beyond any other muscle group in the body to stretch during delivery. And then the deep hip rotators provide essential stability to the hips and the pelvis. Okay, so here is one way of visualizing the core, where you've got the multifidus and transversus abdominis core muscles. You can consider like the walls of a soup can, the top being the diaphragm, and the bottom being the pelvic floor, essential of importance for the integrity of the core. And as far as pathophysiology, the pelvic floor muscles can become overactive or tightened in response to direct injury. So childbirth, trauma, surgery, radiation, and people who have pelvic, GU, or gyne cancers. Microtrauma, so overstretch, overuse, poor posture, maladaptive voiding and defectory patterns, like a lot of straining. And then there can be reflexive pelvic muscle overactivity in response to visceral pain. That's kind of what we were referring to. So the concept of viscerosomatic convergence is reflexive muscle spasm from visceral pathology. So you can think of it as a driver and a passenger. So it could be that the patient has some conditions such as endometriosis that initially is the driver of their pain. Then this causes reflexive pelvic muscle guarding response. So in this case, endometriosis is the driver and the muscle spasm is passenger. The patient gets treatment for the endometriosis. So let's say they had hysterectomy and the ovaries removed, and now the endometriosis is essentially gone. Response to the surgery, there's pain, the muscles are tensing up. And now the patient still comes to us with severe pelvic pain and it's unclear why because we thought we've treated the endometriosis. So at this point, we can assume that muscles have taken over as the primary pain generator in the situation, now have become the driver of the pain car where they were previously the passenger. There are many correlations with psychological causes of pelvic floor muscle spasms. So chronic stress anxiety will lead to muscular tension anywhere in the body. The pelvic floor is a very susceptible region. We often also see this with tension type headaches, TMJ. Pelvic floor, you can consider very similar. People with disordered eating, people who may not have a specific psychiatric diagnosis, but they will self-describe themselves as being a worrier, having a high stress lifestyle. We see it often in people who are pilots or surgeons or things like that. Type A personality, all those different ways you can get at whether there could be some other contributor to why they're having so much muscular tension. History of abuse and trauma is very important to elicit. A large proportion of the patients that I see with pelvic pain have a history of sexual abuse or some type of abuse in their past. And when we do our evaluation, we're starting with a very comprehensive history. So getting all the pain descriptors, getting a full sexual history, psychological history, asking in detail about the bowel bladder symptoms. And then these are some of the things that would give us a high suspicion for pelvic floor overactivity. So they're describing pain in the right areas. So anywhere from lower abdomen, suprapubic groin, low back, tailbone, thigh, perineum, genitals, I should have put on there as well. Also pain with sitting. Urinary symptoms, so urgency frequency or the obstructive voiding kind of symptoms like hesitancy or feeling like they can't completely empty. Dyspareunia, constipation or feeling like you can't fully empty the rectum, that defecatory dysfunction kind of thing. Pain in the tailbone. They note that their pain's better with relaxation, with heat, with stretching. That anxiety and stress seem to trigger their pain. And if they've got the history of abuse. So our examination has to be very thorough. It starts with a basic examination of the spine and hips. And then when we're specifically looking at the pelvic floor start by observing the movements of the muscles. So having the patient usually in a hook-lying position and sitting at the foot of the bed so you can visualize. We're asking the patient to make movements of the pelvic floor muscles. So asking them to voluntarily contract. You can say how you would stop the flow of urine or stop a bowel movement. Not that we encourage them to ever do that. You should see ascent and contraction. And then when you ask them to let go, watch if those muscles return back to baseline. Then ask them to reproduce the motion that they would make to urinate or defecate. And we're observing for a downward descent and relaxation which is the reverse Kegel motion. So oftentimes people are fixated on Kegel when it comes to pelvic floor but there's a full range of motion that needs to be present. Contraction and the downward-outward descent reverse Kegel. And then you can observe if there's any pelvic organ prolapse going on. When you're having them do these motions you can often see whether there's cysticeal or recticeal or especially if there's some external prolapse occurring. You can also have them cough or valsalva to help you determine that. Then the next part of the exam would be palpation. So we're palpating the superficial pelvic floor muscles first. Determine if you notice spasm in the muscle and if they are tender. Palpate the bony landmarks as well, pubic symphysis, PSIS, coccyx, and ischial tuberosities. And then the internal examination to evaluate the deep pelvic floor muscles. So here you would be doing a one-finger exam internally, vaginally, or rectally. So insert a lubricated finger and then start to palpate internally. And you can envision the clock to understand where you're palpating. So at 12 o'clock, pubic symphysis, at six o'clock is the coccyx. So palpating all of the levators circumferentially and feeling for tight spasm muscles, feeling for taut bands of muscle, evaluating where they have tenderness, seeing if their pain is being reproduced, all those things. And then on rectal exams, easier to palpate coccygeus. Here's just another image of how you would perform this exam. And then to evaluate the obturator internus from the pelvic exam. So you have the inserted digit. You have looking for at the three o'clock or nine o'clock position, palpating that archus tendineus where the pelvic floor muscles attach. And above that is where the obturator internus is going to be located. So often, like we're saying, they're laying in hook line, have them externally rotate the hip and provide some resistance, and you'll feel that obturator internus bulge, and then you can palpate it and determine if that is a source of their pain. Theoretically, you can also palpate the piriformis similarly. It's a little bit hard to get to from this position, but you could do so, more likely rectally. And so there's OI here and piriformis. As far as treating these conditions, so we'll go over the conservative measures, the importance of treating the underlying contributing factors to the pelvic floor dysfunction, and then pelvic floor physical therapy and the role of medications and injections. So as far as conservative measures, patients often feel relief with topical heat or cold, specifically heat when we're talking about these muscle tension type of conditions, so hot pads or sitz pads. Behavioral modifications, so avoiding straining, avoiding doing kegels. A lot of times, patients will come to us being like, well, I thought there might be a problem with my pelvic floor, so I've just been doing constant kegels, and she's like, okay, we need to stop. And then teaching them some techniques and strategies for bowel and bladder management in terms of not going to the bathroom very, very frequently, or again, not pushing a straining to avoid those kinds of things. And then treating the underlying contributing factors is essential. So if there's some raging infection or they have really horrible endometriosis or IBD or something else that's driving pain within the pelvis, then that needs to be treated before the muscles will be able to relax. So that's important. And then controlling, again, one of the major contributors to this will be anxiety, stress, so controlling those factors that are leading to more muscular tension. And when we go into this, it's just a lot of explaining to the patient that these are the things that drive your pain. So these are the things to be cognizant of. And then pelvic floor physical therapy is really the mainstay of how to treat pelvic floor dysfunction. The main most important thing that the pelvic floor physical therapist is providing is education, teaching the patient behavioral modification. They're doing some neuromuscular re-education so people to get a better kinesthetic awareness of what their pelvic floor is doing and how to move the muscles. And some down-training techniques, so diaphragmatic breathing, reverse K goals, stretches for including piriformis and OI. We use biofeedback so they can see what degree their muscles are contracting and be able to use that as a gauge for controlling their muscles. A lot of manual work, so myofascial release, soft tissue visceral mobilization, which pelvic PTs have excellent skills in. Vaginal and or anal dilators, which is a way of patients being able to carry forward the home program and be able to continue to make change in the muscle. Pelvic wand for trigger point release as well. Medications can have some use here. So basic over-the-counter meds, sometimes muscle relaxants. People will use vaginal or rectal suppository forms of diazepam or baclofen. There's mixed evidence on efficacy, but sometimes can be useful. And then injections can be used. The trigger point injections can be done either intravaginally or you can do ultrasound guided injections of some of those hip rotators. And some people benefit from Botox injections. So that would more likely be in more refractory cases where they're not able to participate in the therapy as well. And this would help facilitate that. So coming back to our patient, basically what I described here is a pretty common presentation for pelvic floor and octrode internist myofascial pain. So I would start here with a really detailed history exam and then educate the patient and have them start with some pelvic PT. That's it, thank you. Hi everybody, I'm going to be talking about neuropathic pelvic pain today. And if you're like me, I have no disclosures, you know, 100% of your patients who come in with any kind of pain say it's nerve pain, I know it, right? But then the question is, sometimes it is, sometimes it isn't. So how do we know, right? So I'm going to do a couple of cases side by side to try and illustrate. So let's say we have a 34-year-old woman with severe pelvic pain of six months duration. And so patient number one has a really pretty focal pain. It's just in the right posterior labia and the medial ischial region, has no pain on the left side. It started one day after doing weighted squats and lunges in the gym, burning, tingling, excruciating pain, aggravated by sitting on hard surfaces or defecation, and alleviated by sitting on a toilet seat or standing. And this lady's pain is usually intermittent. So some days there's not too much pain and some days it is terrible and she can't get out of bed. In contrast, our other patient has pain located more diffusely through the pelvis, especially more deep, like vaginal and groin regions, insidious onset during a time of stress at work, history of painful menses, kind of aching, tight, cramping, sickening type of pain, and aggravated by stress as well as sitting activity and made better by lying down in heat. And really, constant pain much more compared to the other one. Can vary in intensity, but this patient's going to say, I always have pain. OK, so which one is neuropathic, A or B? It's A. A. OK, this is classic, right? More focal, unilateral, intermittent pain, OK? Much more common with neuropathic. And so I'm going to briefly talk about some neuroanatomy first of some of these nerves that can cause neuropathic pelvic pain. And then we'll go into some of the syndromes after that. So our iliohypogastric, ilioinguinal, and genitofemoral nerves, we'll talk about those first. A lot of times we group those together and call it border neuralgia, because it's like the border of the thigh. So iliohypogastric is the one here that is orange. And so coming off an L1 predominantly, and just remember, in addition to doing that sort of region right above the inguinal or into the inguinal area and upper pubis, it also does the lateral butt. I think a lot of times we forget about that one. Ilioinguinal, coming out right next to iliohypogastric and coursing around, that's going to be your pink. OK? So ilioinguinal, doing kind of that pubis region, and also upper inner thigh. Do not forget that. A lot of times we think of that as obturator, but it is not. Upper upper inner thigh is ilioinguinal. And then obturator, right, is more like mid-inner thigh, right? Ilioinguinal, obturator, femoral. OK? And then, did you guys hear that? I don't know. Ilioinguinal's at the top, obturator's in the middle, femoral's distal medial thigh. Genital femoral is going to be blue and green here. So it splits into the genital branch and the femoral branch really high, actually. And so a lot of times one of these two branches is injured without the other, specifically usually the genital branch, and the femoral branch is kind of left unscathed in a lot of these syndromes that involve these nerves. And so the genital branch is going to the anterior portion of the scrotal skin, controls the cremaster muscle as well, and is responsible for the cremasteric reflex. In women, the genital branch of the genital femoral is doing the upper one-third of the labia. OK? And then the femoral branch is just kind of a patch of the anterior upper thigh. Pudendal, coming out at S2, 3, and 4. And then it takes a really crazy course. So it comes out of the greater sciatic notch alongside of the sciatic nerve and the PFCN. And then it immediately, so it's in the butt, actually. It doesn't stay intrapelvic. It's in the butt. Do I have that little cursor? All right. So right here, it's in the butt. OK? And then it dives back in through the lesser sciatic foramen, and then that is between our sacrospinous, sacrotuberous ligaments. And then it runs on a canal on the inside of the meal issue tuberosity that we call Alcox canal. And then splitting at this point into our three terminal branches. In the alcox canal, it is encased in obturator fascia, obturator internus fascia, so that's why that muscle is so important for pudendal neuralgia. And three terminal branches, you have your inferior rectal, sometimes called inferior hemorrhoidal branch, which usually comes off in most people before alcox canal, going to the anal sphincter, and then your perineal branch, that includes your urethral sphincter and the dorsal branch, which goes to the penis or the clitoris. The posterior femorocutaneous nerve is going to be this little thin one that's right next to the sciatic nerve, also coming out there in that greater sciatic foramen. And it does this green sensory region here of the posterior thigh, and in the past ten years or so, people in the pelvic pain world have really come to an understanding that this can be a huge source of pelvic pain, and that is because of the inferior clunial and perineal branches. And so here you see the inferior clunial branches coming off of the posterior femorocutaneous and going right to that ischial region and medial ischial region, okay, so these a lot of times can present similar to an ischial bursitis or something like that. The perineal branch, what this is showing, is it can come off of either the PFCN proper or the inferior clunial. And then the perineal branch going to that lower portion of the labia. So there's a lot of overlap between the pudendal and the inferior clunial and perineal nerves. And in fact, there's a lot of overlap with all of these nerves. So one of the hallmarks of pelvic neuralgia or pelvic neuropathy is that there is almost never any numbness, and that's because there's so many nerves that are all going to this tiny region, and they're all overlapping each other. They don't have distinct regions, okay? So let's talk a little bit about border neuralgia, and again, that would be iliohypogastric, ilioinguinal, and genitofemoral. And we kind of lump them together because they are so close together in that groin region, and they tend to be injured together often. So the most common way that these are injured is during surgery, okay, or after surgery with entrapment and scar or mesh, okay? So the numbers are actually not rare at all. Inguinal hernia repair, estimate around 10% of all inguinal hernia repairs end up with chronic pain from border neuralgia, and that's one quarter of men in their lifetime that would need this surgery. So these are huge numbers. Closure of a laparoscopic incision in the lower abdomen, okay, you can get these nerves with like a C-section incision that's pulled too laterally, other things like that. And then other, and then the laparoscopic as well. Sometimes just they puncture right in the spot where the nerves are for laparoscopic. So these present with groin pain, and sometimes it can be hard to tell the difference between this and an athletic pubalgia until you start looking at some more of the fine details of the presentation, right? These tend to have more pain, not necessarily with using their adductors, although it can, but more with compression. So if they're flexed for a long period of time, or overextension. So they tend to want to stay like this guy in this sort of semi-flexed but not super flexed position. When they're sitting down, a lot of times these guys, and it's, it can happen in women, but it's much more common that we see this in men because of the ideology with the surgery. They sit with one leg extended and leaning like slightly back when they're sitting in their chair, because they're just trying to take the pressure off, okay? Walking with a slightly flexed trunk as well, because they don't want to be totally straight. And they really tend to have very severe burning symptoms a lot of times. So how do you diagnose? You could use something called MR neurography. We're doing this a fair amount at our institution. So this would be an example of a genital femoral neuropathy at an inguinal surgery site, or a nerve block. So, you know, a diagnostic, right, nerve block. They're not the easiest to see on ultrasound. You can see the plane, but to see the actual nerves, especially in the patients who have these neuropathies, tend to have mesh and a lot of scarring. And I would say at our institution, even really experienced sonographers are sending the genital femoral blocks to be done with CT guidance, not the ilioinguinal and iliohypogastric necessarily, but the genital femoral is hard to see with ultrasound. Do you agree? We'll talk. Okay. So this is a picture of CT guided injection there of the genital femoral. And I would say most commonly what we see with the men who had the hernia repairs is that the most common is ilioinguinal and genital femoral that are the genital branch, specifically of the genital femoral with the ilioinguinal are the two that are the most affected. So treatment, neuropathic pain medication is often very helpful. You can do nerve blocks, radiofrequency ablation, continuous or pulsed, peripheral nerve stimulators, and cryoablation would be more experimental, but are out there. I sort of think of the best thing, once you prove that they have this, is usually surgery. If you have a surgeon who knows how to do this, and it's often plastic surgery who are doing these surgeries. And so it's called a triple neurectomy with re-implantation, because none of these nerves are nerves that you need very badly. They mostly just do sensation. And so you can cut them above the area where they're entrapped in all that scar and bury the cut end into the muscle. And then these patients do pretty well, actually, with that surgery. Only a retroperitoneal neurectomy is needed if the initial neurectomy fails, and that's obviously much, much more difficult surgery to do. For pudendal neuralgia, we have no idea how common this is. It's probably way more common than what our estimates would be, which is sort of 1% of the population or 4% of chronic pelvic pain. It's probably a lot more than that. It was first described in the medical literature in 1991, which is so recent, right? So we just don't know a lot about these pelvic pain conditions. There's a lot of different etiologies for pudendal neuralgia. Certainly pelvic surgery, things like the vaginal mesh kits that luckily are no longer being used, but they were in use between 2003 and 2011, and that caused a lot of terrible disability for our female patients. Sacrospinous ligament fixation is still being used, and they go right next to the pudendal nerve, and they can injure it. Vaginal childbirth, so there's studies that show up to 85% of women who deliver vaginally have pudendal nerve injury. Heels in most of those women, but it is definitely a factor. And then prolonged sitting, prolonged cycling has been associated, positions of stretch for a prolonged period of time, endometriosis, radiation fibrosis. I see a decent number of patients who cause themselves a pudendal issue with squats, especially weighted squats and lunges, and we also think that prolonged pelvic floor dysfunction, so just having tightness of the pelvic floor muscles due to stress for long periods of time can lead to pudendal neuralgia because that obturator internus muscle is controlling the alcox canal, okay, the fascia of that muscle. So there's four primary sites of pudendal entrapment or compression, and, you know, your patient will look on the internet and they'll say, PNE, pudendal nerve entrapment. It's very rarely actually entrapped. It's usually much more about dynamic factors. So the first is at number one here, the exit of the pudendal nerve right underneath the piriformis, and we tend to see this alongside piriformis syndrome. So they're going to have sort of unilateral, usually buttock pain, kind of can shoot down to the mid-posterior thigh and then coming over into the labia or into the perineum for that one. Second is right at the level of the ischial spine in the lesser sciatic notch area. This would be a very common location because it looks like a big wide open space, but it's not. The third is at the entrance of the alcox canal, and this would be very common in association with obturator internus muscle spasm. And then the fourth would be something going on with just like the terminal branches, like maybe just one of the terminal branches, like an episiotomy. Maybe that scar got one of those terminal branches. And so the hallmark of this is chronic pain of perineal, penile, scrotal, labial, anorectal, most often unilateral, debilitating, horrible pain. And so, you know, patients will say things like, there's a hot poker in my labia. They might also describe a foreign body sensation, so like a golf ball in the rectum is very, very common. That's a key to you. If they're saying there's something in there, there's something in my vagina, like check again, that is usually neuropathic because there's nothing in there, but it feels like there's a baseball in there, okay? Patients tend to develop pelvic floor dysfunction once the nerve is injured, and so then the pain spreads to the contralateral side. And it's associated with urinary and defecatory sexual issues, and usually they say it's better when they sit on a toilet seat. Like I said before, usually no numbness on the exam. You can do a TINELS internally on rectal or vaginal exam right over the ischial spine, which is where that nerve is passing, and that can reproduce symptoms. There's something called a nonce criteria, and the nonce criteria is supposed to look for pudendal neuralgia. These are them, but just know it applies equally well to pelvic floor dysfunction, including a positive response to a pudendal block can just be from pelvic floor dysfunction. So these aren't very sensitive. We don't have a huge role for nerve conduction EMG, especially since so many women have had a pudendal injury in the past when they deliver. And so MRN, we did a retrospective, but showed that they did not correlate with blocks, actually. So it just seems like not very accurate. And blocks then would be the gold standard, but just remember, if you get pain relief after the block, it could just be that you're also blocking from the superficial pelvic floor muscles and the sphincters, right? So they could feel better just with pelvic floor dysfunction from a block. If you do a block and it doesn't relieve their pain, it would rule out pudendal neuralgia. But doing a block and taking away their pain doesn't mean it's from the pudendal nerve. Different ways of doing blocks, you know, treatment, it's tough. Pudendal's really tough. Conservative is best. We want to avoid pissing it off. So cut out cushions, avoiding prolonged sitting on hard surfaces, neuropathic pain medications. CPT can play a role, especially if those tight pelvic muscles are contributing to the compression or traction on that nerve. Dr. Kumar talked about suppositories already. I'll just say, you know, we have no known mechanism for vaginal valium, right? It's centrally acting. We have two randomized controlled trials that show it doesn't help. So just think, you know, if I wouldn't give valium orally, I shouldn't be giving it in a suppository, okay? Different types of treatments, you know, nerve blocks, pulsed radiofrequency. We're not going to do continuous. We can't destroy this nerve. It's really important. We need it. Different types of neuromodulation and maybe chemodenervation, although not covered by insurance. But again, the goal would be to maybe take some of the pressure off of the nerve. There are very few surgeons in the world doing surgery to try and relieve this, and they don't have great success rates all the time. And Roger Robert is kind of the prenatal expert of the world, out of France, out of Nantes. And I was at a lecture where he was at, and he said that if patients have proven entrapment, however, also central sensitization, he won't operate because they don't get better anyways. So it's just very interesting to think about. And then quickly at the end here, I'm going to talk about clenialgia. So you know, we don't know how common this is. We call it bleacher butt because it happens often with sitting on a hard surface for a prolonged period of time because the nerve is so superficial right under the ischial tuberosity, so soccer moms and stuff. And so they're going to have pain in the kind of green area here, and they usually don't have bladder, bowel, or sexual problems unless they get secondary pelvic floor dysfunction. And if the PFCN proper is involved, sometimes you can detect a subtle numbness in the posterior thigh, but not usually. And a nerve block, you know, would be the gold standard for diagnosis, treatment for this, pain medications, blocks. And you can do neurectomy and re-implantation for this nerve because it's sensory. Thank you. Good morning, everyone. I'm Marissa Marcotte. I'm an assistant professor at the University of Washington Medical Center, and I'm going to talk a little bit about clenialgia. So clenialgia is a type of nerve block. And it's a type of nerve block that's very common in the brain. Good morning, everyone. I'm Marissa Marcotte. I'm an assistant professor at the University of Washington Medical Center, and I will be discussing spinal causes of pelvic pain, mainly focusing on arachnoiditis, tarlovus, and cauda equina syndrome. I don't have any disclosures. Three objectives for you all today. I want you to be able to know the nerve roots responsible for innervating the pelvic floor, understand how arachnoiditis and tarlovus can lead to chronic cauda equina syndrome, and start naming management strategies for tarlovus. So for a little briefcase, 56-year-old female reports intractable pelvic pain, urinary and fecal incontinence. This has been progressive over the past year. A year ago, she had a discectomy. She's also reporting radiating pain down the legs, worse on the right. She's having an altered sensation when she's wearing her underwear now, and she's most recently started to use a rolling walker to help her walk some further distances. So for that first objective, we went over some peripheral cutaneous nerves with Dr. Scott. Big picture, S2 through 4. You know, we have that medical school mnemonic, keeps your stuff off the floor. That's going to be your pelvic floor. Opterator internus is more L5, S1, and again, these same regions are what's going to be causing neurogenic bowel and bladder, lower motor neuron dysfunction if they're involved. You're going to get your sexual dysfunction in these regions as well. Brief overview of the cauda equina, the nerve roots start at the L1, L2 level in adults. You can see the schematic. They should kind of be nicely displayed dependently in the axial cut in the cerebrospinal fluid in the spinal canal. As you go lower in the spine, you should have less nerve roots because they're going to be exiting and going more laterally to exit under that vertebral body. And cauda equina syndrome, you want to think of the trifecta. You're going to have the saddle anesthesia. You're going to have bowel and bladder dysfunction and that motor weakness. Again, it can also present with some sciatica, low back, and pelvic pain being more neuropathic pelvic pain. Etiologies, most commonly when we think of cauda equina syndrome and what we learn about is that acute presentation. You're going to get that central disc herniation. It needs to be emergently identified and treated, IV steroids, decompression to prevent long-lasting sequela. But we do get chronic cauda equina symptoms and we want to be able to identify that so we can educate and help our patients manage appropriately. Some of those etiologies, again, the focus of this talk, arachnoiditis, sacrolar toleralopsis, tethered cord syndrome. So our second objective is how these things cause our chronic cauda equina syndrome. So what is arachnoiditis? It's going to be that inflammation of the lining, the arachnoid lines, the brain, and the spinal cord lines, the cauda equina nerve roots, itis inflammation. But most of the pathology that you see is coming from the dysfunction in the nerve roots. You're going to get abnormal clumping. They're going to, you can have adhesive arachnoiditis. There's a spectrum. So arachnoiditis can happen anywhere in the spine. The more severe cases are going to be, again, with the cauda equina involvement and that abnormal kind of layering that you'll see. It's a progressive neuroinflammatory disease, as I said. Some etiologies, it's difficult to say because you can get acute presentations. You can get presentations that come on at a later onset. There's a lot of different factors that may overlap in the patient's history. So again, we'll kind of go over diagnosis and how that's important, teasing everything out. These are just pictures trying to demonstrate, again, in comparison to that normal anatomy that I showed where everything's kind of nicely dispersed throughout the canal. The nerve roots are towards the side. They're starting to clump onto the lining. They don't always have to clump. The bottom, the right picture is a little bit more easy to see. That's like very abnormal. There's that big bunch of nerve roots down on that canal. So when you're looking for these abnormalities, again, the nerve roots, you want to look for displacement. You want to look for enlargement. They're going to be enlarged due to edema and that abnormal clumping. Transitioning into tarlov cysts, similar to arachnoiditis, etiology is unclear. There's a lot of proposed mechanisms. Some include increased hydrostatic pressure and the sacral part of the spinal cord kind of pushing, making these cysts form. It's between the layers of the perineurum, which is the lining around nerve fascicles, and the endoneurium, which is lining our individual nerve fibers, and they happen more towards the dorsal root ganglion, so you're going to get more of that sensory involvement. There's on the bottom picture, you can kind of see when they form, you might have a communicating cyst where the CSF can kind of come in and out, they aren't growing as much, and again, one of the proposed mechanisms is this valve mechanism that eventually the scarring happens in such a way that once the CSF is going in, it's not coming back out again, and it's growing. An important feature of Tarlov cysts is that the nerve roots must be contained within the cyst itself, so within the walls or in kind of that fluid collection, and it's the stretching or the, if it's pressing against something, that's going to generate more of that neuropathic pain and the symptoms that you'll see with patients potentially. If it is greater than 1.5 centimeters in diameter, that's considered large, similar to the arachnoid itis, again, Tarlov cysts can present anywhere in the spinal canal, but again, for what I mentioned earlier, they're going to be more often in that S1, S2, S3 region. They can get so large that they can erode away at the bone in the sacrum as well. So our clinical presentation for Tarlov cysts, they're going to be more common and symptomatic in women. They can be associated with those connective tissue disorders such as Marfan syndrome, Ehlers-Danlos. Again, dorsal root ganglion in proximity is going to have more sensory than motor symptoms, and I talked about, again, how you can have that neuropathic pain presenting in different regions of the body, including the pelvis. It's worse with activity, valsalva, sitting, standing, bending. Patients report feeling better lying on their side. It can cause PGAD or persistent genital arousal disorder, infertility, retrograde ejaculation, and again, just thinking about that S2 through 4 where we just discussed how everything's kind of involved helps you understand why they're having this clinical presentation. And again, we want to look for those red flags of the Caudate Aquinas syndrome. Are they having the leg weakness, the bowel bladder dysfunction, sexual dysfunction? That we need to kind of think about that. Diagnosis is going to be the same approach when you're looking at Tarlov cysts or arachniditis. You want a detailed neuro exam looking at the dermatomes, light touch, pinprick, looking at the perineum and the lower limbs. You want to assess if they have any lower motor neuron signs, hyporeflexia, decreased anal and pelvic floor tone, sensory loss, motor weakness. Your imaging of choice for both is going to be MRI lumbosacral spine with and without contrast. You want to get the contrast as well just in case you have those other etiologies, malignancy, epidural abscess infection. Other options can include CT myelogram, MRN lumbosacral plexus as Dr. Scott mentioned can also be used in this setting and can help be advantageous identifying if you have a Tarlov cyst and is it actually responsible for the patient's symptoms or not or is it just going to be an incidental finding and I'll show you a picture of that later on. The MRN lumbosacral plexus, although you can see the signs of the different changes in the nerve roots that I talked about with arachnoiditis, it has been shown it's easier to visualize for the radiologist to identify and call out that that can be a potential etiology of the patient's symptoms. And again, similar to what Dr. Scott said, electrodiagnostics are difficult to help in this situation just given the location and the sensory predominance of the symptoms. And this is just another presentation of innervation. So Tarlov cyst and MRN, focusing on panels C and E. A and B is normal sagittal T2 MRI. Again, you can see that the Tarlov cyst is there, but again, how do we know if it's being a problem or if it's just an incidental finding? If you look at E, you can see a hyper-intense signal at the nerve roots, L5, S1, S2, showing that edema and how the nerve roots are involved, which would lead you to believe that, okay, we can lead this as what is causing the symptoms versus we don't need to intervene on it. Arachnoiditis, these pictures are MRN findings showing the nerve clumping and abnormalities. And in C, this is an MRI view. Again, you don't necessarily need the MRN to diagnose that arachnoiditis is happening. This is in the same patient, by the way, but they can't, like I said, it can be helpful if there's a confusion. A recommendation is if you have the clinical suspicion of a cauda equina syndrome with your patient and asking the radiologist to reread the MRI, again, if you don't have MRN at your institution, giving them the clinical scenario and to go back and look again. Is there this abnormal clumping? Is there any edema in the nerve roots? Transitioning to our third objective, management-wise, conservative management includes our normal pain, oral regimen, Tylenol NSAIDs. It is neuropathic, so using those, like amitriptyline, anticonvulsants, gabapentin, and pregabalin to help with that. Oral steroids have been shown to be effective. Pelvic physical therapy for any of the other symptoms that may be secondary pain generators from the nerve dysfunction procedures, epidural steroid injections, especially if they're having pelvic pain or radiculopathy symptoms, targeting those regions. Steroids have shown that if you use a higher amount of the triansimolone, like 8 milliliter CCs compared to 3 CCs, there are better outcomes. You can use spinal cord stimulation, again, with the neuropathic pain. Some interventional procedures is you can try and target the cyst, aspirate it. You can insert either like fiber and glue or gel to try and block off any more CSF going into that cyst and causing it to grow again. You can use aneurysm clips. Surgical techniques that can be options include intervening on cysts larger than 1 1⁄2 centimeters in diameter. And it would be preferred before you move on to seeking surgical intervention, trying some of those other interventional procedures. Was there relief when you did that block with the epidural steroid injection? Otherwise, that might not be this patient's primary pain generator. So you would want to kind of avoid the more aggressive surgical techniques. Arachnoiditis and chronic caudate quina syndrome, again, same kind of picture. Using the medications for that neuropathic pain, if they have the lower motor neuron bladder and bowel program, if it is that more advanced picture of the adhesive arachnoiditis with more symptom involvement, we might need to educate them on our lower motor neuron bladder and bowel program. Because of the neurogenic process of the bladder and bowel compared to, for example, the myofascial dysfunction that we saw with Dr. Kumar's portion of the talk, the pelvic floor PT may not be as efficacious getting improved results because you can't overcome the nerve dysfunction. Giving assistive devices as appropriate for our patients, again, spinal cord stimulators. If there is any signs of elevated intracranial pressure, they might intervene with a shunt. Physical removal of the scar, again, arachnoiditis can have etiologies with interventions, procedures, surgery. So is it worth going in, again, when they already have this finding and potentially disturbing and causing more damage to the nerves and more scar tissue formation? So going back to our case, just kind of picking out all of those findings that you would want to dissect in your history. We're seeing that trifecta of the Cauda Equina syndrome, the etiology might be from arachnoiditis because of that discectomy intervention that they had. And overall, just wrapping up some key points, tarlopsis and arachnoiditis can cause pelvic pain and that neuropathic pelvic pain. You want to review your MRI imaging to see if there is any signs of the adhesive arachnoiditis if your patient is coming in with clinical signs of Cauda Equina syndrome. There are asymptomatic tarlopsis, so again, differentiating if you do need to treat them or not. And again, because I said, depending on the presentation of where you're finding the tarlopsis or where the arachnoiditis, how many of the nerves are involved, it doesn't always have to cause Cauda Equina syndrome, but if it is a more advanced and more involved picture, it could. So you want to be on the lookout for that. Thank you. All right. We have some time for some questions if anybody wants to come up to the microphone. If I have, I have a few questions if, if, oh, do you have a question, sir? Great. It was a great, great symposium, really comprehensive. I have a question. Do any of the panel members have any experience with botulinum toxin for chronic myofascial pain, pelvic floor dysfunction? And if so, what's been the experience? Those mics are on, correct? So my experience is, A, it can be a challenge to get Botox approved by insurance, right? Because we are treating myofascial pain. We're not treating spasticity. So that's the first thing. So it is insurance-dependent. I have done Botox injections to the pelvic floor on a few of my patients using the trigger point technique that I would for trigger point injections, generally on patients who've responded to the trigger point injection, but it didn't last long. And I would say my experience has been 50-50, so very similar to sort of the studies I think that are out there that are saying that do show that, or at least the little literature that we do have doesn't necessarily support Botox as like a silver bullet for chronic pelvic pain. Okay. Can I ask one more? I'll just add real quick to that. I think pelvic muscle contraction is almost always going to be a fight or flight response, right? It's a anxiety manifestation. So you can Botox them, but they haven't learned anything about their body or about themselves or how to control that response, that muscle contraction response. So if you're going to use it and if your patient can afford it, it would be best to combine it with pelvic physical therapy so that when you have a period of time where the muscles are less tight potentially that they're learning how to manage it for when it wears off. We have had some more success with anal sphincter Botox for people with chronic fissures and anismus combined with pelvic therapy, and that is for most insurance companies an approved indication for Botox as anal sphincter, but not pelvic therapy. To be clear, just since this is a CME talk, we're talking about botulinum toxins in general, not just Botox. Chemo-denervation. Yeah. Okay. Second one, if I can ask another. For chronic pedendal neuralgia, negative MR neurography, positive response to blocks. Blocks were at the ischial spine. No definite entrapment. It was an endometriosis patient who had it prior to the surgical excision and after, and it's continued, and that's the main symptomatology. Any experience with a nerve stimulator? You mentioned it in the talk. Yeah. There are definitely people doing this. Ken Peters out of Michigan, I believe you're up there with him, right? It was one of the first ones to do that, and he gets good success. What I've read, nobody's doing it at our institution yet, although we've had some talks. I think what I've read is that other people have maybe a harder time reproducing his results. I don't know if you've heard of that, like when other people try and do these stimulators, but it makes sense that it might be helpful, right? It's just the place where the nerve is and how to situate that stimulator and everything is, it's not easy. Nothing in the pelvis is easy, anatomy-wise. Okay. Thank you. Yes. Hi. Thank you for the really interesting talk. My name is Sophia, and I'm a medical student. I have two questions also. Going off of what Dr. Scott said about anxiety being a cause or very closely tied to pelvic floor dysfunction, and what one of the other doctors said about treating that as an important component of treating pelvic floor dysfunction, what, in your experience, is the role of physiatrists in treating or addressing the anxiety of patients with pelvic floor dysfunction? That's obviously not, you know, part of formal training, but. I think it's essential. I think, as physiatrists, we do take into account a really broad picture of the patient psychosocial, biopsychosocial picture. And so we do really have to take into account, especially because we know this is one of the main drivers. So we do have to take on a little bit of a role of, you know, overlap with psych in terms of at least eliciting the symptoms or what could be the driving factors. Like I was saying, maybe they don't have a diagnosis of anxiety, but they might have some of these other tendencies that they can describe to you. And then talking them through what are the options for managing this, and oftentimes we will start them on something, especially if there's a pain concurrent with anxiety, we might start them on an SNRI like Cymbalta. And then very, very often, most of the time, we'll encourage counseling therapy, getting in with psychotherapy, and often putting in a referral. I think an ideal pelvic pain program would incorporate psych as a part of the treatment, but we are working on that. Thank you so much. And second question, what's your approach to treating patients or, you know, even diagnosing patients with pelvic floor dysfunction and like a history or cause of sexual assault? Because obviously these exams are, you know, invasive. It's extremely difficult, and you have to tread very lightly. I think we work a lot to build a trusting relationship with the patient, make sure that they understand that we can take things very gradually, we can even do the exam, you know, partially, and then, you know, at any point they want to stop or we try again later, that's totally fine. So they should understand that they're in the driver's seat for that. I have to give a ton of credit to the pelvic PTs, like if you have great pelvic PTs near you that they're able to help introduce all the techniques that they'll be working on in a very gradual way, just responding to how the patient is able to accept those different interventions. So it's very slow and gradual and keeping in mind the patient's response to things. Yeah, and I'll just add, so some of the literature shows that in chronic pelvic pain, like 40 to 60% of those patients have a history of abuse. It doesn't have to be sexual abuse. Physical abuse as a child also can manifest as pelvic pain as adult, right? Because they learn that fight or flight response. They learn to tense and then they just do it in the pelvis. They tense in the pelvis as an adult, so they get pelvic pain. But that's not 100% either. And so I've definitely had patients who said, well, my counselor says I must have been abused as a child. I just don't remember it because I have all this pelvic pain. No, you know, it doesn't have to be like that. So I think we have time for one more question. Not so much a question, but just an observation or a comment. A lot of times, particularly when these women have had a history of sexual abuse, that's just part of the issue. The other issue is that they have been repeatedly invalidated and been told that they're hysterical or crazy or it's in their head. And it's kind of almost like a iatrogenic trauma. That's kind of built by the healthcare system that doesn't understand them. So I think as physiatrists, we have like a really important role in doing that. And I've had patients come in and I don't market myself as a pelvic floor, but they come because I'm one of the only women pain management physicians in my area. And so just listening to them and like letting them tell their story and have empathy for them and validating them, they walk out of there with 50% less pain, just from my one hour new patient consultation. Also for those that do see pelvic floor pain or pelvic pain, really try to take the time to know who your pelvic floor therapists are in the area. A lot of them in my area don't take insurance. They're cash based in Austin, which has a high socioeconomic potential for patients to be able to pay cash. And so the accessibility is a little bit hard there, but just getting to know and then really getting the patients to buy into it and say, listen, this is worth the investment and kind of work with them on that is really helpful. Thank you so much for that. And I totally agree. And I think to your point, anxiety and abuse, they cause pelvic floor dysfunction via an organic mechanism, right? I mean, those muscles are tight. So it's not that we would ever say to the patient, oh, you were sexually abused as a child, so that's just your problem, go only do psych stuff. It's about explaining to the patient the fight or flight response, explaining like, you know how dogs tuck their tail between their legs when they're stressed out? So do we. And then I show them a model and I say, if a bear was chasing you and then you stopped to pee or poo, you would die. Like the bear would eat you, right? So that's why we shut it all down in the pelvic floor with stress. But to explain to the patient, to help them to understand that this is an organic thing that you have going on right now. It's just that the anxiety or the abuse could have fed into that in a way. And then they really get on board with what you're saying if they understand it. But you can't just say, oh, you have anxiety, so you have pelvic pain. Then they're going to walk out of there like, they dismiss me. Thank you all very much. Don't forget to fill out your evaluations. We can definitely stay up here if you guys have other questions.

pelvic pain

diagnosis

multidisciplinary treatment

pelvic floor anatomy

deep hip rotators

physical examination

conservative measures

pelvic floor physical therapy

neuropathic pain

myofascial pain

neuroanatomy

spinal causes