By Stephanie Prendergast, MPT, Cofounder, PHRC Los Angeles
In 2021, a panel of experts published a consensus and management of care paper on Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) in the Journal of Sexual Medicine. The paper describes a treatment algorithm involving five different therapeutic targets for PGAD/PGD! The paper describes how clinicians newer to treating this diagnosis can conduct a history, examination, lab work and imaging to help guide effective treatment combinations based on a person’s underlying factors.
Region 1: End Organ In this care, the term ‘end organ’ refers to visceral structures such as the clitoris, vestibule, urethra/bladder, vulva or vagina. Repetitive infections, hormone deficiencies, vulvar disease and clinical clitoral pathology can cause or contribute to PGAD symptoms. All of these situations are treatable with appropriate medical management which in turn can help alleviate or completely resolve symptoms.
Region 2: Pelvis/Perineum Pelvic floor dysfunction, pudendal neuralgia (compression, tension, entrapment, neuroma), and vascular pelvic pathologies (pelvic congestion syndrome, arteriovenous malformation) also can cause PGAD/GPD. Pelvic floor dysfunction and pudendal neuralgia are effectively managed with pelvic floor physical therapy and medical management. Vascular pathologies can effectively be treated with medical management and may involve surgery. Treating the underlying pathology will result in symptom improvement!
Below, we will explain the central nervous system impairments that can be factors to consider.
Region 3: Cauda Equina
The Cauda Equina is the bundle of lumbar and sacral nerve roots located at the lower end of the spinal cord. These nerve roots innervate the pelvic floor and the genitals. If the nerve roots become inflamed they can cause a host of symptoms, including PGAD/GPD. Examples of dysfunction include Tarlov or other cysts and lumbar spine or disc pathology. Imaging such as a lumbar MRI and /or CT scan may aid in the diagnosis. Symptoms and impairments can be treated with a combination of physical therapy, neuromodulation, cauda equina injections, pharmaceuticals, and in some cases, surgery.
Region 4: Spinal Cord
The spinal cord plays a role in sensory, motor, and autonomic pelvic function. If there is an injury anywhere in the cervical, thoracic or lumbar spine PGAD/GPD may result. Withdrawal symptoms from SSRIs and/or trazodone can impact spinal cord function and should be considered when taking a patient’s history. Neurologic and Imaging studies and physical examination can be helpful for the diagnosis. Treatment involves treating the underlying impairment with a combination of pharmaceuticals, physical therapy, and surgery.
Region 5: Brain
Functional MRI (fMRI) studies of the brain have confirmed that some people with PGAD/GPD demonstrate alterations in certain parts of their brain associated with sensation, motor function, and autonomic function of structures in the genital region. Withdrawal from SSRIs and/or can be a contributing factor to these changes. Most people with anytype of persistent pain will have changes in their brain and spinal cord, but the good news is our nervous system can change and change back. Treatment for fMRI brain changes involve treating all the underlying factors causing symptoms and they can be helped with certain neuromodulating pharmaceutics. A promising new technology called Transcranial Magnetic Stimulation (TMS) is effectively used for refractory cases of anxiety and depression and is being studied with promising results for chronic overlapping pain conditions.
We understand that many people may not have access to experts to help them with their diagnosis. The article we reference in these posts is an excellent tool for clinicians wanting to learn more. We commend the authors of this paper for their work. If you are a medical professional wanting to learn more, consider joining ISSWSH and attending virtual and in-person conferences on numerous sexual health topics!
Reference: International Society for the Study ofWomen’s Sexual Health (ISSWSH)
Review of Epidemiology and Pathophysiology, and a Consensus
Nomenclature and Process of Care for the Management of Persistent
Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) published in The Journal of Sexual Medicine in 2021
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
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.
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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.