Finding Good Pelvic Pain PT: It’s a Global Challenge

In Uncategorized by Stephanie Prendergast38 Comments

world

At the First World Congress on Abdominal and Pelvic Pain in Amsterdam last month (WCAPP), I had the opportunity to gain a more vivid understanding of how pelvic pain PT is administered outside of the U.S. And what I realized is: Good pelvic pain PT is hard to find…no matter where in the world you live.

In this blog post, I’m going to discuss some of the obstacles pelvic pain patients and PTs face in countries outside of the U.S., like Great Britain and France. But this is not just a post about PT outside of the U.S. As it turns out, shining a light on pelvic pain PT across the globe actually provided me with some valuable insights into the current and future status of pelvic pain PT right here in the U.S.

First a quick word about why this post is important to me: The major reason I wanted to write this post is that my role in the planning of WCAPP as IPPS president reminded me that the more the medical community works together across borders to solve the problems related to treating pelvic pain, the better hope we have of raising the standard of care and improving outcomes for all patients—the very reason WCAPP was conceived to begin with.

Now, let’s hop across the ocean to take a look at some of the challenges patients and PTs are facing outside of the U.S. when it comes to getting and administering “good pelvic pain PT”.

We’ve already talked quite a bit about the challenges involved in finding appropriate pelvic pain PT, but in case you need a refresher on what I mean when I refer to “good pelvic pain PT,” what I’m talking about is hands-on, manual PT within a multidisciplinary framework that is tailored to each individual patient. (Click here if you’d like a more indepth refresher.)

In learning about the different approaches to pelvic pain PT internationally at WCAPP both from the presentations and in chatting with my international colleagues, the first conclusion I came to was that patients and PTs outside of the U.S. have every bit as difficult a time finding good pelvic pain PT as those in the U.S.

Take England for instance. England has a publicly funded universal healthcare system under the National Health Service (NHS). (Disclaimer! Before I go any further, I feel I need to stress that this blog is by no means meant to be a treatise on the superiority of privatized healthcare over public healthcare. In fact, as I make clear further down in the post, in the U.S., under a private healthcare system, we have our own set of issues surrounding pelvic pain PT. Nor is it my intention to bash the healthcare system in any other country. I am far from an expert on any one country’s healthcare system! My intention here is to simply offer up a discussion of the different challenges faced in the pelvic pain PT arena.)

Now, getting back to pelvic pain PT in England. If a pelvic pain patient is being treated within the NHS, it can take anywhere from 18 to 24 months of waiting before the patient gets in to see a pain specialist who will then provide him or her with a referral for PT.

What I learned from two British PTs who delivered a lecture at WCAPP on the topic is that pelvic pain PT under the NHS umbrella is a very different animal from the standard of care that we offer at PHRC.

Within the NHS model, patients are treated in a group setting (about eight patients per group), and the focus is on delivering treatment in a “cognitive behavioral therapy framework.” Basically, this means that treatment is aimed at improving the quality of life and functionality of patients through strategies that do not involve the musculoskeletal system. The nuts and bolts of treatment are: “goal setting, pacing activity, thought challenging, stretch, communication, exercise/activity, medication management, and sleep.”

The aim of treatment includes:

·      “supporting patients in constructively acknowledging the impact of chronic pain within the context of their own life”;

·      figuring out how to help patients meet their personal goals “alongside pain”;

·      and supporting patients in developing self-management strategies to enable them to continue managing their pain and working towards goals after completion of treatment.

So treatment is not one-one-one, is not hands-on, is not truly multidisciplinary (technically there is a “team,” but they do not work together to adapt treatment plans in the way that we do at PHRC), and does not involve evaluating or treating the pelvic floor musculature or the surrounding areas.

My initial thoughts upon learning of this approach were: What about conducting a pelvic floor evaluation? What about treating trigger points and tight pelvic floor muscles? Connective tissue manipulation, assessment of the pudendal nerve, internal work…where do these important components of pelvic pain PT factor in?

Indeed, all of the things that I most associate with pelvic pain PT were nowhere to be found in this model. As you can imagine, the explanation of this treatment model didn’t sit very well with me. For one thing, the underlying causes of the patient’s pain are not addressed at all. Not to mention that it’s a cookie-cutter approach, and I think most of you already know how I feel about those.

Don’t get me wrong, the model, which is at its heart a cognitive-focused approach to pelvic pain PT, does have its merits and its place, but for the vast majority of patients, that place is as an adjunct to one-on-one, hands-on, manual treatment.

For instance, I recently saw a 27-year-old female patient who is a triathlete. Her pelvic pain symptoms, pain with intercourse and pain with sitting, started about six months ago after a round of UTIs and a few yeast infections. As her PT, if I were to follow the approach laid out by the PTs from Great Britain, I wouldn’t be helping this patient, I’d be setting her up to become a lifelong pelvic pain sufferer. To be sure, this patient has musculoskeletal impairments, hypertonic muscles, trigger points and some connective tissue restriction; all of which I can manually work on and she can work on at home with specific exercises. And more than likely, the end result will be the resolution of her symptoms.

However, as I said before, many of the techniques of the NHS model can be beneficial as an adjunct to manual PT, because at the end of the day, they do have the potential to quiet down the nervous system, which is always a major ringleader in any kind of chronic pain. On top of that, there are certain patients, who have been dealing with pain for so long that, even if they do have musculoskeletal impairments, their central nervous system is so amped up that before their impairments can even be addressed, their nervous system needs to be quieted down.

For example, I have a patient who, after 11 abdominal surgeries and years of constant, daily pain is having a difficult time tolerating manual therapy. She presents with several trigger points, but her tissue is so hypersensitive that before I can apply manual therapy techniques, I first need to work with her to desensitize the tissue. (More on this topic next week!) Plus, this patient is basically bedridden, so again, she would benefit from many of the behavioral techniques within the NHS model that are aimed at improving functionality.

During their presentation, my British colleagues provided ample research to show that a patient’s quality of life improves thanks to their approach. But the fact of the matter is that anyone’s quality of life is going to improve somewhat after this therapy because it teaches positive thinking and coping skills. As a pelvic pain PT, I’m absolutely committed to helping to improve a patient’s quality of life. But my role is to do whatever it takes to diagnose and treat their musculoskeletal impairments in order to lower their pain levels. This is what’s going to have the most impact on their quality of life!

Now, I should point out here that throughout England, there are pelvic floor PTs who work outside of the public health system who do their own thing. Furthermore, the NHS does allow a private health insurance market to operate. But at the end of the day, going outside of the NHS is going to be a much more expensive alternative for patients. Not to mention that the number of private practitioners is few and far between.

Another international example of pelvic pain PT within a public health model that did not sit well with me exists in France. Surprising, right? Considering how advanced France is when it comes to postpartum pelvic floor rehab. A colleague I met described how she treats 35 patients a day by setting up three rooms of patients at a time. These patients are either hooked up to biofeedback or e-stim. The patients are then sent home with various home exercises. For her part, the PT is reimbursed only 8 euros per patient, which explains why she’s under such pressure to see so many patients simultaneously.

One question these two examples brought up for me was whether or not a public healthcare framework makes it all that much more difficult for patients to find good pelvic pain PT—or for PTs to administer it for that matter. At first blush, it does seem that cookie-cutter approaches to pelvic pain PT could become much more firmly entrenched in a public healthcare system versus a private healthcare system; however, I simply do not know the answer to this question. Plus, it must not be overlooked that under a mostly privatized healthcare system, like the one we have here in the U.S., obstacles to good pelvic pain PT also exist.

For instance, the amount of time it takes to treat a pelvic floor patient, the one-on-one component of treatment, and the resources needed to work with health insurance companies can make it financially prohibitive to operate a pelvic floor-focused PT practice. The reality is that orthopedic PTs can see more than one patient at a time and do not have the same struggles with insurers that pelvic pain PTs do.

For that reason, it’s fairly common for pelvic floor PT practices to operate as cash-only practices. And while the majority of insurance companies do reimburse patients for treatment, typically from 50% to 75% of the amount, there are those that will not reimburse any amount if a patient goes outside of network. Plus, when it comes to Medicare, it’s illegal for a pelvic pain PT outside of the Medicare system to treat a patient even if that patient is willing to pay cash.

Now considering the obstacles that exist within a private healthcare system, the question remains: does “good pelvic pain PT” stand a better chance of becoming the standard of care in a private healthcare system versus a public one?

Those that would argue “yes” will say that within a private healthcare framework, because of the more competitive nature of the landscape, there is simply going to be more of a financial incentive for PTs to offer good pelvic pain PT. On the flip side, those who disagree will say that if good PT is ultimately embraced within the umbrella of a public healthcare system then it will become the law of the land and will be accessible to all, similar to how postpartum pelvic floor rehab has flourished in France.

After the Fifth World Congress, I’ll consider the question again, and by then I’m betting that I’ll be able to answer it because I do believe we’ve reached an important tipping point whereby good pelvic pain PT is going to start becoming more readily available across the globe. That’s because two market forces—greater patient awareness (thanks in part to the Internet!) and demand and better access to education for PTs—will result in a higher across-the-board standard of care for pelvic pain PT. And that’s the good news.

International readers, we want to hear from you. If you are a PT or a patient outside of the U.S., please share your experiences with pelvic pain PT with us!

All my best,

Stephanie

 

Comments

    1. Author

      Thank you so much for sharing your experiences Soula!

      All my best,
      Stephanie

  1. Stephanie,
    The justification offered by the UK NHS for not using hands on physiotherapy for pelvic pain patients is that there is no good high quality evidence that it works.
    Can you point us to some studies that show that they are incorrect in this belief-studies, as apposed to anecdotal evidence, that is?

    1. Author

      Hi Alan,

      In the lecture I gave at WCAPP I made it clear that we have TONS of research for hands-on PT. Here are TWO NIH-funded, double-blinded randomized prospective trials stating evidence of M/S findings and the efficacy of physical therapy treatment: All my best, Stephanie

      1. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes.
      Fitzgerald MP, Anderson RU, Potts J, Payne CK, Peters KM, Clemens JQ, Kotarinos R, Fraser L, Cosby A, Fortman C, Neville C, Badillo S, Odabachian L, Sanfield A, O’Dougherty B, Halle-Podell R, Cen L, Chuai S, Landis JR, Mickelberg K, Barrell T, Kusek JW, Nyberg LM; Urological Pelvic Pain Collaborative Research Network.
      J Urol. 2013 Jan;189(1 Suppl):S75-85. doi: 10.1016/j.juro.2012.11.018.

      Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness.
      FitzGerald MP, Payne CK, Lukacz ES, Yang CC, Peters KM, Chai TC, Nickel JC, Hanno PM, Kreder KJ, Burks DA, Mayer R, Kotarinos R, Fortman C, Allen TM, Fraser L, Mason-Cover M, Furey C, Odabachian L, Sanfield A, Chu J, Huestis K, Tata GE, Dugan N, Sheth H, Bewyer K, Anaeme A, Newton K, Featherstone W, Halle-Podell R, Cen L, Landis JR, Propert KJ, Foster HE Jr, Kusek JW, Nyberg LM; Interstitial Cystitis Collaborative Research Network.
      J Urol. 2012 Jun;187(6):2113-8. doi: 10.1016/j.juro.2012.01.123. Epub 2012 Apr 12.
      PMID: 22503015 [PubMed – indexed for MEDLINE] Free PMC Article
      Related citations

  2. Stephanie, thanks again for an excellent article and your advocacy in bringing good pelvic PT to the US and international communities.

    In my personal experience, I opted for PPO instead of an HMO so I could have more flexibility in the care I got for my pelvic pain. However, the PPO did not pay for the pelvic pain urologist specialist I went to as he was out of network. It also didn’t pay for Dr. David Wise’s pelvic pain clinic I attended, which was really beneficial for me. It paid a limited amount for the myofacial release physical therapists I saw before attending Wise’s clinic.

    I realized that to get the care I felt I really needed, I had to be resolved to the fact that I would have to pay out of pocket for it. This included getting mind-body coaching, similar to England’s NHS model. I needed both the hands on physical therapy, the home PT program to treat my own trigger points and the cognitive & behavioral therapy and emotional pieces to get my life back. It was totally worth the money I paid for it!

    1. Author

      Dear Gail,

      Thank you so much for sharing your experience with us!!! It is SO helpful to our readers to hear from folks who have made it out on the other side!

      All my very best,
      Stephanie

  3. Hi Stephanie

    I’m a Womens Health Physiotherapist working in England,I work both within the NHS and privately.I treat both men and women with pelvic floor dysfunction and chronic pelvic pain.I am very much a manual therapist and try to provide individual treatment for this group of patients which includes pelvic floor assessment,internal and external trigger point release,tecniques to release tightness in the pelvic floor and connective tissue therapy.
    I know I still have alot to learn!!! and find the information in your blogs and website really useful.

    The main difficulty here is access to specific training and manual therapy courses aimed at Physios working in this field.(There’s not many of us)I would love to know what training you can access in your part of the world?

    Just wanted to let you know that some physios are treating along the same lines as you and are getting great results for patients with a manual therapy approach here in England.
    However most of my patients are seen at a private clinic and self fund!

    Thankyou again and best wishes,
    Julia.

    1. Hi Julia,

      Having searched extensively for this type of physical therapy in the UK to treat my PNE so I was pleased to read that you are offering this treatment.
      I am about to commence the NHS pain management process but feel I would like access to some more specific treatment.

      Please could I ask you for details of your clinic so that I might contact you for a consultation / treatment if considered appropriate.

      Thanks

      Martin

  4. Hi Stephanie,

    I’m a male currently suffering from pudendal neuralgia. I live in England and my take on this, based on my experience, is that there are two main problems. The first is a general lack of awareness/understanding of pelvic pain among general practitioners (essentially the gatekeepers to specialised secondary care) and a lack of trained pelvic pain physiotherapists. When I presented to my GP with my symptoms, the initial diagnosis was a UTI. I had the urine test, which (after the best part of a week) came back negative. After I presented agains to my GP with worsening symptoms, he said it might be an inflamed prostate and prescribed me some antibiotics which did nothing apart from aggravate my gastro-intestinal system. If I’d left it at that I’m convinced I would have been classified as someone with prostatitis and been counselled to accept the fact I’m just going to have to live with the problem. Fortunately, I didn’t accept this and after researching my symptoms on the internet (and enduring many frightening horror stories on discussion forums) I came to the conclusion that I had pudendal nerve problems. My next problem was finding out how this could be treated. I have the good fortune of being an academic with a familiarity with health care literature and was able to search the academic journals for evidence on effective therapy. Manual PT was the way to go. I then had to find a trained PT. Ater much searching I came across a website listing details on PTs who use manual therapy for pelvic floor dysfunction. In England there were 22 PTs, the majority of whom are in London (i don’t live anywhere near London). Luckily I found one who was relatively close to me and I have been receiving regular treatment which has been of benefit. I have to pay for this, with each session costing me around £50. This is, of course, another barrier as not everyone could afford this.

    Reading your posts along with other information on pelvic pain treatment in the US, it’s clear to me that you’re miles ahead of the rest of the world in this area and I often wished I lived there!

    Thanks for your regular posts – they’re incredibly informative and very helpful.

    Best wishes,

    Phil

    1. Dear Phil,

      Thank you so much for your thoughtful comment! All of your insights are spot on. My hope is that as time goes on, the barriers that you and so many others are up against in their search for proper diagnosis and treatment will fall away. In the meantime, I’m so happy to hear that you were able to advocate for yourself and get into the hands of a manual PT, one that has been able to improve your symptoms. I wish you continued relief! And I’m so glad our blog has been a help to you. Please keep us posted on your progress! We’d love to hear from you again in the future!

      All my best,
      Stephanie

    2. Who have you found outside of London Phil? I’m looking for someone near Manchester but so far can only find London or Edinburgh.

      Jamie

      1. Hi Phil
        good to know…what were your symptoms exactly?
        how long did it take for you to notice a difference and what kind’ve techniques did they use? Did they do internal trigger therapy amd muscle release? And did you have some constipation issues with it? And if so did those clear up?
        many thx

  5. Hi Stephanie,

    Thank you to you and your colleagues for this website, it has been a most useful to me and I think will help me in moving forward.

    I am 28, female and live in Scotland. 20 months ago, I got a horrific stabbing pain in my lower left side approximately where my ovaries are. The pain came on suddenly and intensely, lasted 30 seconds, eased off before coming back just as strong. This process lasted about half an hour and for about 5 days after this event my left side was tender and uncomfortable.

    I presented to the out of hours GP suspecting it was an ovarian cyst however tests have since shown that it was not.

    Each month, about 10 days before my period I get pain in my lower left side that varies month to month. Sometimes it is just a tenderness in my left side and sometimes it is a stabbing pain that runs all the way down to my cervixs/urethra. In addition, sex just before my period can be a little sore at my cervix. I also get a skin irritation, like mild thrush just before my period comes and have to use hydrocortisone cream for a few days to clear it. In addition to this, since the pain has started I have a reduction of mobility, flexibility and strength in my lower left side which I have managed to greatly improve through functional therapy which I paid for privately (at its worst, I struggled to climb stairs, carry heavy shopping bags and walk uphill).

    To date I have had an ultrasound, xray, MRI and laproscopic surgery (hernia, IBS , Pelvic Inflammatory Disease and endometriosis have been ruled out)and no diagnosis.

    My laproscopic surgery was only 3 weeks ago and as everything was clear, the gynacologist said ‘well I have good news and bad news for you. The good news is you don’t have endometriosis and your organs look healthy but the bad news is I can’t tell you what is causing the pain … I don’t need to see you again’ leaving me sitting wondering where I go next?

    The answer is the GP but unless he has any knowledge of nerve pain and treatment I won’t get anywhere and that is the problem with the NHS. You can’t get easy and quick to what you need and if it is not a straight forward diagnosis you are passed around specialist department after specialist department and there is no communication between these departments so the patient’s history is not fully understood or communicated i.e. the next specialist I see will not know that I have had a laparoscopy or the result of that unless I tell them. You also only get short appointments so it is very hard to communicate your history to the doctors and often the doctors are more concerned about the number of people they have waiting to see them before 5pm. Also I visited the gynecologist department three time and not once did I see the same gynecologist, there is just no consistency.

    For me moving forward, I will tell the GP that I suspect that it is nerve pain and will see what specialist he now refers me onto however since finding your website, I have tried to search for specialists in the field of pelvic nerve pain including pelvic PTs to no avail so if you or any reader knows of any specialist operating in Scotland please post a link so I can find them.

    Just to state I do think that the NHS is a fantastic facility and would hate to see it collapse, I just think that it needs to be remodeled to provide a better service to patients and a better working environment for staff that is not focused on keeping costs down and getting patients out the door as soon as possible.

    Kindest regards

    Claire

    1. Author

      Dear Claire,

      Thank you for sharing your story. All of the points that you make are right on target!

      We do know of two PTs in Scotland. Here is there info:

      Campbell Karen PT Edinburgh Scotland Karen.E.Campbell@luht.scot.nhs.uk Western General Hospital
      Taylor Bill PT Edinburgh Scotland physiobil@btinternet.com Taylor Physiotherapy Sports Injury Clinic

      Maria Eliot is a great PT in London, in case traveling for PT is an option for you.

      All my best,
      Stephanie

      Here is her info:

  6. I am stillhurting after two urologists examined me – both have different diagnosis. Will I ever get relief. Tears!!!

    1. Author

      Dear Linda,

      I’m so sorry about the problems you are having. If you would like to provide more detail I can tell you whether or not pelvic floor PT might be an option for you.

      All my best,
      Stephanie

  7. Stephanie,

    Do you know of any PTs in Singapore? Or perhaps the South East Asia reigon or Australia. Seriously considering coming over to see you and possibly attend the Wise-Anderson protocol. Male pelvic pain sufferer with poor treatment options so far. Would love to discuss if traveling would be the best option for me!

    Lee

  8. S — is there anyone you can recommend in Austin TX? (i get consistent PFPT in NYC but will be spending some time there starting next week and don’t want to lapse treatment.) THank you!
    Sharon

    1. Hi does anyone know and PT around the manchester area specialist in Pelvic Floor Pain as I’m struggling to find one!

  9. Hi, can you recommend any PTs in Oxford, UK who offer the kind of manual treatments you describe? Thanks.

  10. Hi Steph
    Great article!
    Can you recommend a few hands on manual
    Pelvic floor therapists in London and LA?
    Preferably female
    Many thx!
    Ashley

      1. thx whats the website for the place in LA and whom would you recommend I see there? thx!
        and anyone else in London?

  11. My husband has been suffering with pelvic pain for the last 5 years. He’s undergone multiple surgeries including an orchiectomy before a chiropractor mentioned possible pudendal neuralgia. Do you have any recommendations for a pelvic floor therapist in the Huntsville, AL area (including Birmingham and Nashville)? Any recommendations would be hugely appreciated!!

    1. Author

      Hello Kate,

      Are you and your husband able to travel? We do not have a recommendation for Huntsville, Birmingham, or Nashville, AL.

      Best,

      Stacey

      1. We are – we can go anywhere at anytime if it means getting some resolution! Thanks so much for the quick response!

  12. Hello!

    thank you for your website and for your dedication to such an important yet under-represented topic of pelvic pain.

    I live in the Czech Republic, struggle with the symptoms associated with the diagnosis of Interstitial Cystitis, and despair at the lack of options available in terms of treatment.

    Are you aware of any good PT closer to my country?

    And what is your experience with helping patients with IC? What kind of therapy should I be looking for?

    Thank you,

    Paula

  13. I am a 32 year old male and developed chronic pelvic pain following discontinuation of an antidepressant.

    The NHS were incredibly unhelpful and told me they believed my symptoms to be part of an anxiety disorder and prescribed me a high dose of Clonazepam which I’m now struggling to taper off, could be considered worse than my pelvic pain itself though the two are now very much intertwined. It was the beginning of what is still a long and painful journey but thanks to the advice I received from your clinic I am now on the right track.

    The NHS were dreadful though they meant well they exacerbated I genuine physical ailment by throwing more drugs at it. They didn’t listen to me and what I believed I was dealing with (I was correct) my belief was disregarded and undermined. The worst part for me personally being that I am now experiencing horrendous withdrawals from the benzodiazepine so readily prescribed (frightening but true) which has only exacerbated my depression which came about as result of this physically and emotionally debilitating condition and the lack of help and apathy I received from our National Health Service.

    I too was given antibiotics for prostatitis without any examination on a whim, subsequently saw a urologist privately who advised me to stop the course immediately. He confirmed no infection and no issue with prostate.

    This eventually led me to Dr David Goldmeier in London, again privately. He was familiar with the condition and had researched it extensively. He has written and published papers on the correlation between antidepressant use and withdrawal and the development of Pudendal Nerve Neuralgia. Finally I had a diagnosis which the NHS could not refute considering he also happens to work for them.

    He wasn’t happy that I was taking Clonazepam given it’s side effects and highly physiologically addictive nature but sadly at this point I had been taking it for some time.

    I was now on the hunt for a physiotherapist at his recommendation for treatment, one of many, the rest being antidepressants ironically. Not an option I was keen on for obvious reasons.

    I saw a physio close to home who hadn’t a clue, nice guy but no experience treating the pelvic floor. He did some acupuncture, in short it was a waste of time. The second physio dealt solely with the pelvic floor. She examined me and confirmed my pelvic floor to be hypertonic and that she could resolve it, remember I’d been suffering with this for close to year. When I left her treatment room I went out to my car and I wept! Finally I have real diagnosis, something tangible that can be treated. Sadly her treatment which consisted only of kegels made matters worse and it was at this point when I contacted your clinic for advice.

    I was advised that the treatment I was receiving was counterproductive and to contact Bill Taylor in Edinburgh.

    I can not speak highly enough of Bill, he is very wise and has been treating my pelvic floor and trigger points internally with measurable results. If I hadn’t found Bill when I did I’d be dead and to put that into perspective I have a wife and three beautiful young children who I adore but I’m only human. There’s only so much pain and disappointment one individual can take, we all sadly have our breaking point and I very nearly reached mine.

    Not only is he an exceptional physiotherapist but he is genuinely one of the most amazing, passionate and compassionate people I’ve ever had the pleasure of meeting all be it under pretty horrendous circumstances. I consider him not just my physio but a true friend.

    I Honestly can’t say enough positive things about Bill.

    From the bottom of my heart I thank you.

    1. Hello Robert,

      Thank you so much for sharing your story! We know that the road to recovery is often confusing, and finding help can often seem uncertain. But much has advanced in the pelvic pain community, and the quality of care that patients deserve is available! There is hope, and we are very glad that you found healing with the help of Bill. We wish you continued success in your recovery.

      Best,

      Steph and Liz

      1. Thank you

        I hope that my testimony will be of some help to someone.

        You’re doing incredibly important work and doing it well, keep it up and thank you again.

        God bless

  14. Anyone in the Cote d azur region of France? I desperately need one but no luck so far.

  15. Hi Admin, Its very helpful blog and yea i agreed its global challege to find best pelvic pain specialist. Thanks for sharing it with us.

Leave a Comment