case study

Tony’s Case Study: What Pelvic Pain?!

Case study: 33 year old male

29 yr old athletic male. Reported attempting to do a handstand 3 months ago and had ‘pinching’ pain in the lower abdominal and belly button region. The pain was brought on by sudden movements or when arching back. PCP ruled out hernia and diagnosed patient with an abdominal strain.

Patient stopped exercising for one month, no change. Went to see 2 sports medicine physician at Stanford, negative for hernias. Pt again diagnosed with abdominal strain and was instructed to begin core-strengthening exercises, which exacerbated the condition. Stopped physical therapy and returned to MD who informed him he had an entrapped nerve. Began to notice L pain when sitting at the sit bones and perineum and tip of penis, and noticed he always leans to the right when sitting. Sitting for long periods of time also caused burning at the tip of the penis. This symptom may have been there for years.

Patient also reported burning in the L groin and penis burning after physical activity.

Patient called Pudendal nerve surgeon after 4 physicians visit informed him of abdominal nerve entrapment

History of performing 200 crunches 4-5 times per week and this resulted in increased burning around penis and occasionally a sharp pain in the anus.

History of chronic constipation since childhood, hard bowel movements and history of hemorrhoids.

When active cycling, patient would notice urinary frequency for next 1-2 days and a decreased stream when voiding at night.

Patient occasionally experienced post-ejaculatory burning.

Pt has a history of LBP for 7 years and was diagnosed with L5 disc bulge per MRI. Treated with physical therapy and chiropractic care. Pt reports still experiencing a low level of pain and episodic acute flare-ups several times a year. Occasional R buttock pain.

Objective Findings

Upon examination with doctor, 2 active MTrPs were identified in the abdominal wall in the rectus abdominus muscle. These trigger points were the source of the abdominal wall burning and pinching and were likely a result of excessive abdominal crunches over a long period of time.

Upon internal examination, doctor also found the patient to have a shortened, tight pelvic floor in all of the major muscle groups.

The pudendal nerve on the right side did not present with any tenderness to palpation. On the left side, the patient presented with severe tenderness at alcock’s canal and the ischial spine. The shortened pelvic floor and inflamed pudendal nerve were the likely sources of the penile burning and shooting rectal pain.

Stephanie continued the evaluation and found the patient to have connective tissue restrictions around the ischial tuberosities, in the abdomen, gluteal muscles, LB and lower extremities. The left psoas, iliacus, and rectus abdominus were tighter than the right and palpation reproduced penile and abdominal burning. The patient also presented with sacroiliac dysfunction and pelvic obliquity.


We diagnosed this patient with pudendal neuralgia and myofascial pelvic pain, including active trigger points in the abdominal wall, and scaroiliac joint dysfunction.

We recommended that the patient undergo a PNTLT. At the time, we relied on this test to determine if the patient’s symptoms were caused by a pudendal nerve entrapment. We also recommended that the patient begin weekly physical therapy.

We referred the patient to our physiatrist, Irene Minkowsky, for further scaroiliac joint and low back work-up and evaluation.

We also recommended that he begin a stress reduction program.

Treatment- the first two sessions

During the first visit with doctor, the patient underwent trigger point injections to the abdominal wall and subsequent spray and stretch therapy

During the first physical therapy visit, the patient underwent CTM to the left LQ, MFR at the RA, psoas, and iliacus, muscle energy techniques for the scaroiliac joint and internal pelvic floor stretching and neural mobilization.

We discussed lifestyle modification. It was important for this patient to minimize any activity that caused an increase in abdominal, LB, buttock, or pelvic pain while we were treating his problems. This involved sitting on a cushion and standing when the symptoms increased as a result of sitting. We requested that he stop all direct abdominal exercises until we resolved the trigger points and the muscle hypertonicity. We discussed stopped exercise that exacerbated his symptoms: biking (caused further compression of the comprised tissues and irritated the PN0, running (unilateral impact through a dysfunctional SI joint led to further dysfunction). It is important for the patient to remain active; he could do this through swimming, walking, pull-ups and push-ups. We discussed diet modification to normalize the bowel habits and avoid starining to have a bowel movement, which can cause further neural inflammation and muscular dysfunction.

Very importantly, we discussed his habit of ‘puckering up’…essentially clenching his pelvic floor muscles together all day. He was informed this would help him prevent hemrrhoids and had been using these faulty holding patterns most of his life, which could have contributed to the short pelvic floor and the inability to relax the muscles to have a normal bowel movement.

During the second visit the patient reported a complete resolution of abdominal symptoms following the trigger point injections and physical therapy to the abdominal wall. Between his first and second appointment he had undergone the recommended electrophysiological testing. The results of the PNLT were 1.48ms on the R and 2.96 ms on the L. His left pudendal latency was slightly prolonged.

The patient’s main complaint was now the burning inside the sit bones and at the tip of the penis. Doctor performed a finger-guided pudendal nerve block at the ischial spine and Alcock’s Canal.

The patient reported his pain was eliminated during the period the anesthetic was in effect from the nerve block. His symptoms were reduced but he pelvic burning was still present. Upon examination, the pudendal nerve was no longer tender to palpation. His symptoms were present, at this point with minimal pudendal inflammation we began to address the other findings that were likely the sources of the remaining problems: the sacroiliac joint, hypertonic abdominal and pelvic floor muscles, trunk and LE connective tissue dysfunction, and peripheral nerve adverse neural tension.

The patient continued with weekly physical therapy and also under a series of 6 proliferative therapy injections with Irene Minkowsky to treat his SIJ hypermobility.

We continued to make weekly gains in physical therapy; however the patient remained concerned that his symptoms were caused by a nerve entrapment that would require a surgical decompression. He contacted 2 US surgeons who recommended a surgical consult and did not support conservative management both informed our patient if he did not get surgery as soon as possible his outcome would be worse,

The patient continued weekly appointments with SAP and monthly appointments with doctor.

About four months after the patient began consistent treatment, his symptoms were almost completely eradicated- no abdominal burning, LBP, or groin pain, the penile pain was 90% resolved and he could sit for several hours on a cushion. On a weekly basis, he would experience a transient symptom of burning or pain that would last for a few seconds.

The patient continued weekly therapy and monthly dry needling into the abdomen or medial to the ischial tuberosity. He did not require any further injections.

Approximately one year and a half later, as his sitting tolerance increased and the transient remaining symptoms completely minimized, the patient decreased his frequency of PT visits to two times per month.

Four months later, the patient had returned to all previously limited activities and could sit limitlessly on a cushion and for 2 hours without a cushion. He had been on several plane trips, rode trips, and was hunting without a problem. He was able to surf, ski, and exercise. We decreased his visits to one time per month.

The patient had persistent connective tissue restrictions at the bony pelvis and inside his sit bones. The tissue was improving slowly and the patient had not had pudendal nerve sensitivity upon examination since January of 2004. The connective tissue dysfunction was the reason the patient could not yet sit without a cushion limitlessly. Because of this, his monthly sessions consisted of emphasis on this tissue: for the entire hour we performed CTM at the bony pelvis, internally and externally, to the restricted tissues.

Two years after beginning treatment, the patient was sitting without a cushion, doing all previously limited activities, and was entirely symptom free. We continue to see him one time per month for follow-up.

Three years after beginning treatment, he is about to have his third child, he no longer uses a cushion ever and had resumed all activity.

July 2012–still great. What pelvic pain?


case study

Case Study: PT for a Vulvodynia Diagnosis

The patient was a 41-year-old female who came to PHRC with a five month history of constant vulvar pain described as red hot, itchy, and stinging. In addition, the patient had suprapubic and abdominal pain.

The patient’s pain increased with sitting, tight clothing, including underwear, exercise, and any kind of touch. As a result of the pain, sexual activity was not possible.

Upon interviewing the patient for her history, it was uncovered that: five months prior to the onset of her pain, she had had a vaginal culture taken that had tested positive for bacterial vaginosis. The infection had been treated with antibiotics; however, even after her follow up culture came back negative for infection, her symptoms continued.

In addition, the patient was involved in a motor vehicle accident four months prior to the onset of her pain, which resulted in TMJ pain that was being well-managed. The patient also suffered with migraines.

The medication the patient was taking was Sanctura, a medication used to treat an overactive bladder, nortriptyline, a tricyclic antidepressant that had been prescribed to her as treatment for her migraines, and a 5% lidocaine ointment for her vulvar pain.

The patient was receiving weekly acupuncture treatments and bi-monthly massages.

The patient was evaluated and treated by Liz, whose objective findings were:

  • moderate to severe connective tissues restrictions along bony pelvis, medial to ischial tuberosities, and in suprapubic and abdominal tissue,
  • moderate to severe pelvic floor muscle hypertonus,
  • myofascial trigger points left greater than right bulbospongiosus,
  • and poor pelvic floor motor control.

Liz’s treatment plan included:

  • connective tissue manipulation,
  • myofascial release per vagina,
  • myofasical trigger point release,
  • and a home exercise program of regular pelvic floor drops.

After four hour-long treatment sessions, the patient had no vaginal burning, no pain with sitting, and was able to wear pants without pain.

After five hour-long treatment sessions, she was able to have pain-free intercourse; however with some itching and burning afterward.

After six hour-long treatment sessions, she was able to have pain-free sex with no pain afterward.

After six weeks of treatment, Liz’s objective findings found an improvement in the patient’s connective tissue mobility; a minimum to moderate improvement in her pelvic floor muscle hypertonus; and a significant decrease in the trigger points in her bulbospongiosus muscles.

After six weeks of treatment, the patient believed she was having a relapse of the bacterial vaginosis. In addition, there was a significant increase in her stress levels. As a result, her symptoms flared for about three weeks.

After two appointments, the patient was again back to a symptom-free state. She continued PT every two to three weeks for three months until she was able to resume her regular exercises routine without vulvar irritation.

In total, she was released pain-free after 16 treatments with instructions to continue her home exercise program of pelvic floor drops.


Case Study: The Case of PT for Urge Incontinence

Patient History

The patient, who we will call “Joan” for the purposes of this case study, is a 44-year-old female with a 14-year history of urge incontinence. Joan has no children.

Also called “overactive bladder,” urge incontinence is a sudden, intense urge to urinate, followed by an involuntary loss of urine. Patients with urge incontinence typically have only a few seconds to a minute to reach a toilet. Plus, they urinate often, including throughout the night.

For her part, Joan experienced leakage on the way to the toilet at least once a week, and she suffered with urinary frequency, urinating two times every hour. These incontinence issues greatly impacted Joan’s functioning and quality of life. She couldn’t sit through meetings at work and she avoided social activities and long walks due to a fear of leaking. By the time she sought out PT, she had come to feel as though her bladder was holding her hostage and preventing her from living her life to the fullest.


Joan’s initial goals for pelvic floor PT were twofold: one, to eliminate leaking on the way to the bathroom, and two, to decrease her urinary frequency from twice per hour to once every two hours.


I evaluated Joan’s bilateral inner thighs, her abdomen, pelvic floor, hips and low back.


  • trigger points in her bilateral adductor muscles,
  • trigger points in her rectus abdominus muscles, which reproduced her urinary urge,
  • trigger points in her urogenital diaphragm (trigger points in the urogenital diaphragm can actually create urinary urge!),
  • hypomobile (too tight) connective tissue around urethra,
  • some tightness within her pelvic floor,
  • poor pelvic floor muscle control and awareness (in other words, she had difficulty relaxing her pelvic floor muscles.)

Treatment Plan

Urge incontinence often involves both myofascial pelvic floor impairments, such as the ones mentioned above, and behavioral impairments. Both were at play in Joan’s case.

When it comes to urge incontinence, it’s common for there to be specific triggers for the leakage. For some, it could be as basic as putting the key in the door when they get home. But in Joan’s case, she had developed fear and anxiety around the possibility of leaking.

Joan’s issues actually began when she was in grad school and was drinking several cups of coffee a day. All that caffeine, which can be a bladder irritant, initially kicked off her urgency and frequency, but it was the anxiety that she began to have about making it to the bathroom on time that likely set things off in full force.

Let me explain. You see when Joan had a situation where she didn’t think she would make it to the toilet on time, many areas in her brain were activated (fear, emotion, and anxiety centers to name a few), which then lead to muscle guarding and tightness. So whenever Joan felt that urge to urinate, her brain clicked into panic mode, which in turn caused her pelvic floor muscles to tighten. Ultimately, this tightness and guarding contributed to her leakage problem.

It seems counter intuitive to blame Joan’s inability to hold her urine on too tight muscles because it would seem that “tight” muscles would help hold everything in.

However, the tightness becomes the baseline meaning there is much less muscle range to move through if you need to further tighten to prevent possible leakage. Think about a bicep muscle in your arm when you’re lifting something. If you have the full range of the muscle, you can lift something easier than if you only have a portion of the range.

So in Joan’s case, there was actually a vicious cycle at play that involved both physical impairments and behavioral issues. Physical impairments had kicked off behavior that had in turn kicked off further physical impairments, and around the cycle went.

Now back to my plan. So I planned to treat the myofascial findings with manual, hands-on PT both internally and externally. This work included trigger point release (the trigger points that Joan had in her pelvic floor likely played a role in both her urgency and her frequency), lengthening of the connective tissue around the urethra, general lengthening of too tight pelvic floor muscles, and working with Joan on a pelvic floor muscle relaxation program. (Pelvic floor drops are one exercise that is helpful in this area.)

Now my plan for the behavioral impairments.

In order to help Joan retrain her brain to let go of her anxiety and fear, and thus put the brakes on the muscle tightening, I worked with her on a “bladder retraining program.”

I instructed her that when she felt the urge to urinate, she was to take a deep breath, and reassure herself by saying something like: “Hey, it’s okay, I’ve got this.” She was then to walk slowly and purposefully to the bathroom as opposed to running to the toilet in a panicked dash.

The point of this was to make it a calm experience every single time she felt the need to urinate. Bladder retraining takes patience and commitment—patience because it’s not going to work every time and commitment because repetition is important for laying down new pathways in the brain, which ultimately will serve to retrain the brain.

Progress Report:

After two months of pelvic floor PT consisting of both the above mentioned myofascial work and the bladder retraining program, Joan was leak-free. However, she did continue to feel anxious when she was in an unfamiliar setting, so we continued to work the “brain retraining” program.

Ultimately, with weekly PT sessions of one-hour, and a solid commitment from Joan (she never missed an appointment and was completely committed to the brain retraining program) both of her treatment goals were met!


Case Study: The Case of Female Pelvic Pain, Painful Sex

This week’s post is a case study of a female pelvic pain patient.

Before I get into the specifics of the case, let’s first take a look at female pelvic pain by the numbers:

  • 10% of all visits to gynecologists are due to chronic pelvic pain.
  • 25% of women will experience chronic vulvar pain at some point in their lives.
  • 60% of sexually active women will suffer from painful sex at some point in their lives.

The good news is that physicians and patients have become more aware of the important role that PT plays in the diagnosis and treatment of female pelvic pain.

Now, let’s focus in on one woman’s experience with pelvic pain, sexual pain and pelvic floor PT.

Patient History

About nine months before her appointment, Meghan, a 30-year-old female, had been diagnosed with a bacterial vaginosis, or BV, infection. (BV is the most common vaginal infection in women of childbearing age.) Her Ob/Gyn gave her a prescription for oral antibiotics to treat the infection.

The antibiotics were successful in clearing up the infection, however Meghan continued to have provoked vulvar pain. She was unable to tolerate vaginal penetration of any kind, including tampon use or a speculum exam. She described the pain as a “burning, raw feeling.” On top of that, she was “tensing up with anticipation of sex” and since the onset of her symptoms, found that although she tried to relax during sex, she could not. Because of her pain, she had completely stopped having intercourse.

To treat her symptoms, Meghan’s doctor gave her a prescription for a topical steroid. However, because she had an allergic reaction to the medication, which exacerbated her symptoms, she stopped using it.

In addition to the steroid, she tried applying lidocaine ointment to her vulva and vestibule during sex. This produced no change in symptoms. Her doctor also advised her to soak a cotton ball in lidocaine, insert into her vaginal opening, and leave overnight. This also did not change her symptoms. Meghan was also taking 25 mgs of amitriptyline for anxiety and Lutera for birth control.

Meghan had also taken the advice of her doctor and eliminated all harsh soaps, dyes, and chemicals from her daily hygiene routine.

Meghan said that before the BV infection she had never had any pain or difficulty with sex or vaginal penetration. In addition, she had no urinary or bowel symptoms. Plus, she could wear jeans, tight pants, and underwear. As far as daily exercise, she attended a “boot camp” exercise class at her gym three to four times a week.


Before I talk about Meghan’s goals, I’d first like to chat a bit about our goal-setting process at PHRC. Obviously, a patient’s ultimate goal with PT is to get better! But, as both patient and PT embark upon that goal, it’s important to set more specific, attainable goals along the way. This allows both patient and PT to assess progress throughout the course of therapy.

At PHRC, at the beginning of treatment, we work with patients to set both short-term and long-termgoals. When we refer to a patient’s “long-term” goals we do not mean his or her ultimate goals for treatment. Rather, long-term goals are set for eight to twelve weeks down the road. Our objective is to set achievable goals for the first round of long-term goals, and then to modify as we go.

As for a patient’s “short-term” goals, it’s understood that the time it will take to achieve these goals will be less than what will be needed to achieve the long-term goals.

Initially, for her long-term goals, Meghan wanted to be able to tolerate full insertion of her partner’s penis with a 50% reduction in pain during and post coitus. In addition, she wanted to be able to tolerate insertion of a speculum with less pain so that she could receive her annual PAP exam.

As for her short-term goals, Meghan wanted to establish a home exercise program, which included work with vaginal dilators. In addition, she wanted to see a decrease in pelvic floor muscle tone and trigger points by 50% to allow for a decrease in her fear and anxiety with vaginal penetration


Below is an outline of my findings following my initial evaluation of Meghan. I’ve presented my findings in detail as in the past, readers have communicated to us that they actually appreciate this level of detail. However, if you have any questions, please don’t hesitate to ask via the comment section or e-mail!

Structures Evaluated and Objective Findings:

I. External

Connective Tissue Assessment:

  • Connective tissue of abdomen and suprapubic area: suprapubic: minimum restriction and abdomen: moderate restriction.
  • Connective tissue of bony pelvis, labia, through groin area, ischial tuberosity (IT), and anterior through suprapubic: moderate restriction, minimal traveling up to suprapubic area.
  • Connective tissue medial and lateral thighs: moderate.
  • Connective tissue buttocks: moderate to minimum.
  • Connective tissue post thighs: minimum to moderate restriction as move cranially, closer to IT, dorsal branch territories, tissue close to vaginal opening.
  • Connective tissue low back: minimal restriction.

External Muscular Assessment:

  • Trigger points located in: rectus abdominus on right side, right illicacus, bilateral adductors, superficial transverse perineal/bulbospongiosus from external palpation: trigger points at 5-7 o’clock positions (very tender), right piriformis, left gluteus medius, piriformis, gluteus maximus.

Visual inspection of Vulva/Vestibule/Pelvic Floor Muscle:

  • Mild erythema noted at Hart’s line, reflexive guarding with external palpation, quivering of perineum upon contraction-minimal relaxation on release, could bear down and did have perineal descent.

Q-Tip Test:

  • Tender at 3, 5, 6, 7, and 9 o’clock

II. Internal

Internal Pelvic Floor Muscle Assessment

  • Tone is increased globally.
  • Reflexive guarding present with digital insertion.
  • Connective tissue lateral to urethra and urethral sphincter: normal.
  • Urogenital diaphragm: bilaterally decreased length.
  • Trigger points: located superficial transverse perineal, bulbospongiosus, ischiocavernosus bilaterally.
  • Reproduced burning pain with myofascial release of bulbospongiosus, trigger point release to superficial transverse perineal at 6 o’clock, and vulvar connective tissue mobilization bilaterally.

Deeper Structures: (bilateral obturator internus, pubococcygeus, and illiococcygeus):

  • Control is fair to poor; there is an increased baseline tone.
  • Delayed and incomplete relaxation.
  • Poor quality of concentric contraction.
  • Normal bearing down
  • Transverse abdominus symmetry noted with minimal voluntary contraction


Patient presents with increased pelvic floor muscle tone globally, restricted connective tissue mobility in the above-mentioned structures, poor control, reflexive guarding, and muscular trigger points throughout her pelvic girdle and pelvic floor musculature. She also presents with poor motor control and delayed voluntary relaxation.

These impairments contribute to her symptoms of entry dyspareunia and provoked vulvar pain. I am able to reproduce her pain with penetration upon myofascial release and trigger point release of urogenital diaphragm (specifically bulbospongiosus and superficial transverse perineal muscle), connective tissue mobilization to vulva, and bilateral obturator internus trigger point release.

In addition, the above impairments contribute to patient’s functional limitations of inability to tolerate vaginal penetration, which impacts her ability to have intercourse with her partner, wear tampons, or undergo an annual PAP exam. She is very anxious regarding her condition, and exhibits reflexive guarding and fear avoidance behaviors that contribute to the physical impairments of shortened pelvic floor muscles and active spasms.

Initial Treatment Plan:

  • PT once a week for eight weeks: Treatment to include: manual PT techniques to restricted tissues; connective tissue mobilization to vulva prone and supine, abdomen, bony pelvis prone and supine, medial thighs, buttocks, all planes; and trigger point release to abdomen, hips, adductors, hip extensors, abductors, urogenital diaphragm, levator ani, and obturator internus muscles.
  • Initial home program: Exercise modification, a decrease in boot camp activities; deep breathing; relaxation techniques/pelvic floor drops; and start with vaginal dilators.


After eight visits, I assessed the following changes:

  • Vulvar burning was less with vaginal penetration: dilator and finger;
  • was able to insert largest dilator out of five with fifteen seconds of mild burning, and then no pain;
  • Meghan was less afraid of vaginal penetration;
  • and she was able to “relax” her pelvic floor muscles voluntarily.

My assessment:

  • Pelvic floor muscle hypertonicity persists, although is lessened;
  • trigger points in urogenital diaphragm still present, but are decreased to right bulbospongiosus and left ischiocavernosus;
  • increased vulvar connective tissue mobility;
  • improvements in motor control, able to voluntarily relax after contraction;
  • still presents with impairments contributing to entry dyspareunia;
  • Q-Tip: tender at 6 and 7 o’clock positions;
  • erythema (skin redness) no longer present;
  • and reflexive guarding no longer present with digital insertion.

New Plan of Care:

  • Continue PT once a week for another six to eight weeks
  • Increased digital insertion to two fingers to aid in increased myofascial release
  • Continue with manual techniques to restricted tissues, increase time spent internally as external findings are normalizing and primary impairments remain in pelvic floor muscles and vulva.

New Goals:

  • Continue to pursue long-term goals
  • Transition to light aerobic exercise program with no flare ups of symptoms
  • Transition to two digit internal myofascial release with patient reporting no increase in burning or pain to aid in transition to intercourse

After a total of 13 visits (Meghan was able to decrease her number of visits to one every other week at visit number nine), I discharged Meghan with all of her goals met and her symptoms eradicated. After visit number eight she had transitioned to intercourse. In addition, she returned to yoga, running, sex, and tampon use with no pain. She stopped using lidocaine; however, continued taking amitriptyline.

After a total of 13 visits (Meghan was able to decrease her number of visits to one every other week at visit number nine), I discharged Meghan with all of her goals met and her symptoms eradicated. After visit number eight she had transitioned to intercourse. In addition, she returned to yoga, running, sex, and tampon use with no pain. She stopped using lidocaine; however, continued taking amitriptyline.


  1. Hi I have been diagnosed with fluid in my pelvis. I don’t even know how it go there but been in pain for a year now with no sign improving after lots of Physio an doctors. Reading online I’m looking at steroid injections or prolotherapy to rid I this severe pain. What would u recommend to get rid of this fluid?? Please help I’m getting so down with this

    1. Dear Wesley,

      I’m sorry, but I’m really not sure what exactly you have. I’m not really sure what ‘fluid in your pelvis’ means. Are you talking about pelvic congestion syndrome or inflammation? Steroid injections are utilized to decrease inflammation and prolotherapy is used to create more joint stability. I’m not sure if either of those treatment modalities makes sense for your particular situation, but then again, I’m not sure what you’re dealing with. Sorry I can’t be of more help.

      All my best,

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