By Molly Bachmann PT, DPT, PHRC San Francisco
“Penile numbness, perineum pain, post void dribble . . . oh my!”
*All names and other identifying information has been changed.
Symptom Presentation:
Frank began to have pain in his perineum seemingly out of the blue. The only connection he could make was an instance of loose stool that triggered the need to urinate every 45 minutes. As these symptoms developed over the course of several weeks, Frank developed tingling in his urethra and at the tip of his penis, and pain in his perineum that was an eight out of ten at its worst which prompted a visit to his urologist. The urologist tested his psa levels, which were normal, and prescribed an antibiotic. Halfway through the course of antibiotics, Frank developed pain in his rectum and upper gluteal muscles.
When Frank came into Pelvic Health and Rehabilitation Center, he had just finished his course of antibiotics and continued to experience tingling at the tip of his penis (specifically worsened just after urination), was urinating every hour, post void dribble, was unable to sit more than five to ten minutes without perineum pain, decreased libido, increased reports of tension with orgasm . . . and to make matters worse, Frank was losing weight intermittently without trying, causing much distress.
All of these changes were challenging for Frank to navigate as he had been a cyclist riding at a high intensity multiple times a week and considered himself to be a healthy guy. It was starting to impact his ability to work and even commute to work which really worried him.
Assessment:
When I evaluated Frank, we wanted to first rule out anything that we would consider to be a red flag. For Frank, this meant further investigating his unexplained weight loss. After multiple doctor’s appointments, red flag testing was cleared and they determined there was nothing to fear and that it was likely due to loss of appetite when symptoms flared.
Frank’s exam included assessing hip range of motion and hip muscle flexibility, connective tissue restrictions, trigger points, nerve mobility, as well as assessing the deepest layer of pelvic floor muscles via a rectal examination. Franks presented with significant tightness in his hamstrings, gluteal muscles, pelvic floor muscle tightness, sensitivity along the pudendal nerve, pelvic floor muscle weakness, poor coordination of these muscles with other core muscle groups as well as an inability to release or let go of the tension in these muscles. It became clear that the tension from these muscles and inflammation caused by that tension was impacting his nerve function causing his symptoms of urinary frequency, urgency, and pudendal nerve pain with sitting, and sexual function.
Plan:
When symptoms involve irritation to the pudendal nerve in any of its branches, it can be challenging to reduce muscle tension and address tissue restrictions when the nerve has very clear boundaries of how far it will tolerate a stretch. For Frank, we were able to quickly identify five key stretches and modify them so as not to irritate his pudendal nerves. As his tissue tension released and numbness and tingling diminished, Frank was able to tolerate more advanced stretches closer to end range without exacerbation of his symptoms. Frank worked diligently every day at home on these stretches. We also incorporated foam rolling to his adductors and glutes to improve blood flow. This really helped progress Frank’s tolerance to hip flexion and soon he was able to tolerate walking up hills at a moderate pace with his dog.
While in PT sessions, we worked intensively to release connective tissue restrictions, muscle tension and address trigger points that were making it difficult for his pudendal nerve to slide and glide properly. Within a couple weeks, we were able to trial cupping with various movements as well as nerve glides to improve tissue length and nerve mobility. As his tissues continued to heal, we were able to add in some therapeutic movements to strengthen his gluteal muscles which he had a lot of difficulty isolating. Throughout our sessions and continued evaluation, it was clear that one of the driving factors for his persistent pelvic floor muscle tightness and residual symptoms was weakness in his glutes causing compensatory persistent contraction of his pelvic floor muscles in attempts to better stabilize himself.
At the time this is written, Frank is now able to commute an hour each way to work without symptoms. He is urinating every three hours with the occasional exception, no longer has pain in his perineum or numbness and tingling at the tip of his penis. He even has been able to put on some weight with healthy dietary changes and reduced stress! I am still working with Frank to address residual irritation in his urethra and intermittent urinary frequency. At this time, he reports 80% improvement overall and I expect that he will continue to make a full recovery.
Patient perspective: “I think of myself as a fairly typical guy – work hard, exercise, have fun, enjoy the outdoors, etc. Everything in life was going quite well – or, at least that’s what I thought – until one sudden moment when, out of the blue, I found that I was unable to sit down without intense pain. I also had very strange sensations shooting through my pelvis and needed to urinate very frequently.
When my life flipped upside down with pelvic pain, I visited numerous doctors, urologists and gastroenterologists looking for a solution – and, while they all had suggestions, none of these specialists ever mentioned pelvic floor PT.
Just as I was ready to head out to yet another doctor, one of my friends mentioned pelvic floor physical therapy – and I am so thankful they did. From day 1 at PHRC my life finally began to turn around. It was absolutely amazing to have someone that could truly understand my pain and relate to what I was going through – words cannot state how valuable this was. My therapist offered support that was relevant and effective, both physically and mentally. Prior to pelvic floor PT I was in a very dark space. The lack of answers from the medical community led me to overthink my illness and travel into a very unhealthy place. Once I began PT I could finally begin to see a path forward. With my mind reassured, my body could finally begin to relax and heal.
It’s been a long and challenging journey and I’m still on the path to recovery. I still hit occasional rough patches – but I’ve learned how to cope and, with the help of my physical therapist, I’ve come up with strategies to calm down, focus on the basics and get through the tough moments.
I feel so fortunate to have found pelvic floor physical therapy. I’m now able to put in a full day of work, sit down for an extended period, and take long walks around my neighborhood.
If you find yourself experiencing pelvic pain be sure to check out this avenue. It is worth educating yourself on all the options and – in the least, it is absolutely worth having a conversation about your pain with someone who can truly comprehend what you are experiencing.”
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Are you unable to come see us in person? We offer virtual physical therapy appointments too!
Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.