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Treatment Options

Treatment Options

Bowels and Digestion

Digestion is something that you don’t think about, when it’s going right. But, when it’s going wrong, it can really be preoccupying. Here is the gamut of digestive stuff we can help with.

Irritable Bowel: Irritable bowel can be caused by foods, which most people have seen a GI and worked out prior to seeing us. We can help you identify common irritants, but where we can really help is with visceral manipulation for the small intestine and sphincters. Yes, we can also help you learn how to breathe better and bowel mechanics, and relaxation techniques. One common cause of irritable bowel and bloat is SIBO, and all of these are made worse when there is restriction or some adhesion along the bowels from prior surgery or endo. We can help with that (usually by 6 sessions, we will know if we can help).

Constipation: We can help you learn habit modification, do visceral (organ) work to help the movement of the sigmoid, cecum, and rectum. We can carefully assess if pelvic floor tone or the puborectalis is a part of the issue and can treat the pelvic floor and help stretch and relax muscles. Additionally, we can give you biofeedback training in the clinic and then have you practice at your commode at home to learn how to relax the sphincter and anal outlet to allow stool to pass.

Fecal Incontinence: Leaking stool or being unable to hold gas is a problem that makes people’s lives smaller and smaller. But, it doesn’t have to be that way. It will all begin with a very thorough assessment of your pelvic floor and anal outlet muscles, a review of diet and commonly irritating food and highly prescriptive strengthening and manual therapy on any scarring or tightness. We can also employ very specific electrical stimulation, targeted on the parts of your muscle that can be bulked to help. Often with manipulating these variables and forming some new habits, people can get their life back.

Rectal pain: Please see pelvic pain page.

Male care

Men have pelvis, and those pelvises can have similar problems women have. This is not one of those clinics where we just give men exercises and perhaps a little internal stretching. We use as much specificity as we do for women for the following conditions:

Digestive Issues: These are treated for men the same way they are for women, so refer to the the digestive issues tab.

Genital Pain: men can have testes pain from the inguinal canal and the ilioinguinal nerve and spermatic cord getting restricted . We can treat that, often with good success rates. Most men feel improvement by the 6th visit. Penile pain is a bit more complicated: we can address the suspensory structres, the nerves that might be creating pain, and decompress any scar. Honestly, I’d say there is around a 50% success rate at 6 visits, as an estimate.

Bladder issues: Urgency and frequency often respond well to strengthening and manual therapy. Post prostatectomy urinary incontinence often depends on the resection: how much of the bladder neck was compromised, how good was the pelvic floor strength ahead of time, how much is the patient willing to eliminate bladder irritants. It varies, but please note, I can not see Medicare patients of any kind because of their laws for physical therapists in cash practices. I am happy to refer out.

Erectile Function: My personal experience is that patents who have a pain component have responded to care well, as the pain abates. But ED without pain is not something I have had greater than 25% success treating, unless there is scarring in the hip, or changes from spinal surgery or hernia repair, etc. If there is a mechanical/scar tissue component, it responds well. But if it is a chemical or vascular (blood supply) issue, I have not found PT to be helpful beyond 1-2 visits to teach home program to see if kegels will help in the long run.

Post hernia repair or post vasectomy: With scarring from surgery and the sequella of issues, patients with these two diagnoses seem to respond well to a 6 visit course of therapy.

Sexual Pain

Your sex life is deeply personal to you. We are happy to help you with your pain, whether you are CIS, Vanilla, Straight, LGBTQIA, sexually active, asexual, a solo practitioner (self stim), poly, or any combination or none of the above.

The bottom line is your preferences and identity should determine the flavor and pleasure of your sex life, not the pain in your body.

Our bodies are meant to experience sex without pain, and we can help you with that.

All genders and identities are happily treated here, and some diagnoses respond better than others. Feel free to inquire. Please see “male conditions” page or gender care page as applicable.

Dyspareunia: Dyspareunia is the medical term for painful sex, most typically used for CIS women. I like to think of it as painful intimacy, because people can have many kinds of sex lives, and it can limit any of those, including self pleasure. It usually does not go away by ignoring it, and it can be very isolating and hard to talk about. There can be many components to dyspareunia. Sometimes it is a cutaneous/superficial irritation (see vulvadynia and vulvar vestibulitis above).

When it is due to spasm at the opening of the vagina causing a small opening (which is actually a SMALL percentage of dyspareunia), it is referred to as vaginismus. When the deeper muscles in the vagina or the pelvic floor are tight and painful, it may be referred to as levator ani syndrome.

Patients may report they have had pain since a vaginal birth injury or an episiotomy. Many patients also report pain after a pelvic floor repair or hysterectomy. Similarly, patients who are cancer survivors also have vaginal pain after radiation or hormone therapy.

  • Common patient descriptors are as follows: “It feels like a too tight fit with my partner”, “ It feels like my partner is hitting something”, “I have cramping when I have sex”, I have a tearing sensation when I try to have sex”, “I have burning with sex”, "it feels like period cramps during and after sex, touch is not comfortable, I have pain after external stimulation for orgasm.

  • Regardless of the cause, it is not your fault or something you did wrong. There are many reasons for pain, and there are now many therapy options to heal it. Often very specific manual therapy that goes far more specific than stretching internal pelvic floor muscles can be helpful, as can working small fascial restrictions all around the vulvar or penile.

Endometriosis

Endometriosis can create a host of issues: irritable bowel, growing days of pain per month, painful intercourse, painful bowels, bladder pain. It’s not a fair disease, and it needs to be treated aggressively.

Patients dealing with endometriosis and post-surgical pain have a common condition. Normally, within the body, the different layers of tissue glide across one another. With scarring from surgery or adhesions from endometriosis, the body forms adhesions or connections between organs or layers of tissues that are not normally there. We can help treat after surgery to decrease the pain and restriction of tissues that develop most in the first year post op.

With organ mobilization and fascial work, we can optimize the movement between structures, thus reducing the amount of pain receptors.

In the US, 6 of the 10 most commonly performed surgeries are abdominal. These all can create adhesion in time. The 11th most common surgery is removal of adhesions from prior surgery, so common is the side effect. We can help reduce the cumulative sequella. Patients who have had multiple surgeries are frequently pleasantly surprised at how much gentle manual work can do, when it is highly specific in the abdomen, not just the pelvic floor. Visceral mobilization is incredible to help this.

Effective manual therapy can help reduce pain until it is an ideal time to have the endo treated by a skilled excision specialist. After surgery, skilled manual therapy is imperative to reduce pain numbers. We work in tandem with your physician to help manage pain.

Endo used to be treated with scope after scope. This is no longer what the grassroots patient movement supports, and resent research supports excision by a specialist for superior patient outcomes. If you have endo, please educate yourself on the difference between partial ablation and full excision for permanent management of the disease.

Good sources to learn from: Website for Center for Endo in Atlanta

On Facebook, there is a wonderful private group: Nancy’s Nook Endometriosis Education

Pelvic Pain

Pelvic Pain has many names and causes, only a few of which are the pelvic floor: Treating pelvic pain is what we are known for and excel at. By using incredibly specific manual techniques such as visceral manipulation, neural manipulation, fascial work, internal (rectal and vaginal) and external pelvic muscle treatment, vascular enhancing techniques, bony alignment, we can change the structures that cause pain. Pelvic pain will rarely respond to exercise alone. It takes very specific manual treatment, which will be different each session, to change the pattern in the tissues. 

  • Pelvic Floor Dysfunction

The pelvic floor is a wondrous structure: 4 superficial muscles, 4 mid-layer muscles, 4 pelvic floor muscles, and 2 pelvic wall muscles. Each can be reached and treated a bit differently. One can be tight and another weak, depending on the person. Each muscle has its own function, and after a baby comes through, they may be quite different side to side. When they are working well they control the appropriate flow and discharge of urine or feces, help us orgasm, support our pelvis, help with blood flow out of the pelvis after intercourse, and are generally pretty amazing. But when the nerve to them is overactive, they stay a bit tight, and sometimes after an incident, such as birth, they may need a bit of help learning to work again.

  • Pudendal (or other) Neuralgia

The pudendal nerve is amazing in function. It helps us feel sensations of pleasure, helps pelvic floor muscles to contract, and helps us to have control of our bladder and bowels. But this special structure has a somewhat tortured pathway: out the greater sciatic foramen, under the piriforms, wrapping around the sacrospinous ligament, back in through a hole called the lesser sciatic foramen, traveling in a tunnel between a pelvic floor and wall muscle (alcock’s canal), while under an incredibly dense ligament (the sacrotuberous ligament), then exiting the internal pelvis just inside the sitting bone (ischial tuberosity), where it is easily irritated by a bike seat, to travel in 3 branches (one to genitals, one to perineum, and one to anus). It can be entrapped anywhere along that pathway or pinched between the sacrospinous and sacrotuberous ligament. As if that is not enough, the plexus it comes from (sacral plexus) shares so many fibers with the sciatic nerve, that if

there is a history of sciatica, it can keep that pain alive. We treat every one of those structures, to give the nerve more room, less compression. Infact, I teach a class Iwrote with Herman Wallace that specifically teaches how to treat the pudendal and sacral plexus nerves. II have never seen a pudendal nerve calm down with pelvic floor stretching alone….it’s too non-specific for the problem. And the nerve will get irritated if you stretch and glide it without decompressing it. I’d love to help you get over this pain!

  • Coccyxdynia (tailbone pain)

The coccyx is wonderous structure. All of the pelvic floor muscles connect with it, it is the attachment site for the two most stabilizing ligaments in the pelvis, and it should have 30 degrees of motion and move with pelvic floor motion. The problem is when someone has a fall onto their behind (particularly on steps), or perhaps with birth, the tailbone can heal. Or, sometimes after surgical fixation to one of those ligaments after a hysterectomy, it can get pulled over to the side. If the pelvic floor muscles are firing unequally, it can get out of alignment. And then, the small coccygeal nerves, anococcygeal ligament, or the coccygeus muscle can get very tender. We can adjust this and treat all the attaching structures, so it does not have to hurt you.

  • SI joint pain

The Sacroilliac joint connects the bottom of the spine with the base of the spine. It has very few degrees of motion. But, it can get inflamed. Often, this pain is kept alive with the uterosacral ligaments that are attaching to the front side, so doing visceral (organ) work, can often help resolve those cases that keep needing “realignment” that have not responded to other types of PT. Also, the coccyx should always be treated with the sacrum as well as dural tension throughout the nervous system. We can address all of that for you.

  • Vulvadynia or Vulvar Vestibulitis

Vulvadynia is just the medical way of stating the vulva has pain. It’s a bit of a nonspecific diagnosis. Vulvar pain in the absence of other known pathology.

Common complaints are: a burning sensation in the vaginal region, simple touch feeling like burning or scraping, or poking. Patients may have an inability to wear tight or fittend slacks or tolerate the feel of underwear or sensation of tampons. Sometimes patients report an unrelenting itching that does not have a dermatologic or infection origin.

The reason? Well, that is not so well understood. There are literally dozens of possible reasons. In some cases, there is a link with autoimmunity or other inflammatory conditions in the body. Sometimes there are abnormal c-fibers in the tissue, sometimes it is a pudendal nerve issue. 

Often tight pelvic floor muscles are involved (either a precursor or a result of the pain). The honest truth is that we often don't know the exact cause, but we have treatments which often help. Part of the reason for our 2 hour initial visit is to assess several possible factors: entrapped genitofemoral or dorsal or perineal branches of the pudendal nerve, carefully assessing the integrity of the skin, evaluating the pelvic floor muscle and wall tension, assessing the deep fascia in the abdominopelvic cavity, and getting a clear treatment plan. The truth is that the pain is often multifactorial, and it takes a bit of detective work to assess the system as a whole. We often find that treating the pathway of the genitofemoral, ilioinguinal and pudendal nerves and doing

very specific fascial work in the areas of the labia, mons, and peri clitoral tissues free up enough small and large nerve endings to help the pain reduce.

Vulvar vestibulitis is a specific form of vulvadynia, in which the tissues at the entry to the opening of the vaginal canal are hypersensitive. Vulvar vestibulitis patients often have increased c-fibers or pain sensitive fibers in the tissues in this small area. Sometimes the area just at the opening of the vagina is red and inflamed.

· Please know that whether you are vulvadynia or vestibulitis sufferer, you are not alone, and you are definitely NOT crazy. Many therapies are available to help reduce or eliminate this pain. Often many manual techniques internally and externally, including visceral mobilization, myofasical techniques and direct muscle release techniques (internal and external ) are helpful. We may contact your referring physician regarding topical agents we may suggest as prescriptions to assist the treatment. We may refer you to a vulvar pain specialist to help us. Additionally, extensive lifestyle modification tips, from self care to diet to meditation or yoga technique may be utilized.

  • Dyspareunia

Dyspareunia is the medical term for painful sex. I like to think of it as painful intimacy, because people can have many kinds of sex lives, and it can limit any of those, including self pleasure. It usually does not go away by ignoring it, and it can be very isolating and hard to talk about. There can be many components to dyspareunia. Sometimes it is a cutaneous/superficial irritation (see vulvadynia and vulvar vestibulitis above).

When it is due to spasm at the opening of the vagina causing a small opening (which is actually a SMALL percentage of dyspareunia), it is referred to as vaginismus. When the deeper muscles in the vagina or the pelvic floor are tight and painful, it may be referred to as levator ani syndrome. Men can also have dyspareunia, see male pain section.

Patients may report they have had pain since a vaginal birth injury or an episiotomy. Many patients also report pain after a pelvic floor repair or hysterectomy. Similarly, patients who are cancer survivors also have vaginal pain after radiation or hormone therapy.

· Common patient descriptors are as follows: “It feels like a too tight fit with my partner”, “ It feels like my partner is hitting something”, “I have cramping when I have sex”, I have a tearing sensation when I try to have sex”, “I have burning with sex”, "it feels like period cramps during and after sex," among many others.

· Regardless of the cause, it is not your fault or something you did wrong. There are many reasons for dyspareunia, and there are now many therapy options to heal it. Often very specific manual therapy that goes far more specific than stretching internal pelvic floor muscles can be helpful, as can working small fascial restrictions all around the vulvar (or penile) region.

  • Rectal Pain

The rectum is the end of the colon, before it exits the body at the anal canal.

· Patients may report pain with bowel movements that can last for hours. Sometimes it is before, sometimes after. It may or may not be related to when one has their menses, or perhaps when attempting to enjoy anal intercourse.

· When fleeting and intense, it can be called procticalgia fugax. At times it can cause a patient to awaken in the night or can come on with no rhyme or reason. Patients sometimes report a pain so severe that it stops them from leaving the house or working.

· At times it is more of a minor annoyance.

· Some people have a persistent ache or a pain that grows with sitting.

· The patient may state they have a pain deep in the buttock that is difficult to define.

· We can help stop the suffering! A muscle spasm by any other name is still a muscle spasm. It often responds well to direct stretching. Additionally, by releasing other structures in the region with visceral manipulation or neural manipulation or learning muscle retraining with biofeedback, patients can learn to break this cycle of pain. We do offer intrarectal as well as intravaginal manual therapies at our clinic, so we can get to the source of the problem

  • Post birth pain (csection or vaginal)

Growing a baby is a lot of work. Getting it out is one of the most difficult things your body will have to do.

With vaginal birth, muscles can get stretched or torn. In almost 30 percent of births, women can have an avulsion (disconnection from bone) of the pubococcygeus muscle, and most may never know. Babies do not come through symmetrically, left and right sides may need to be retrained and rehabbed differently. It’s rare for every muscle to be tight or every muscle to be weak. Starting with a most excellent and thorough evaluation will allow us to make a plan and to understand how to care for your pelvis the rest of your life. The pelvis is meant to birth, but the US is one of the few developed countries that neglects the need for post vaginal birth care.

C-sections are necessary to preserve the health of the baby in many cases. It makes me sad when women feel like they somehow failed or were less than for this. The truth is, c-sections leave a more intact pelvic floor, and the safest birth for all parties is the best outcome. Usually the scar will benefit from care and manual therapy to help mobilize it and decrease adhesive or restricted motion issues around the bladder and the small intestine. Sometimes people come to me 3 or 9 years after a c-section with pain in the area or bladder leakage, and working the fascia, viscera, and scar almost always helps the issue

we can begin care as soon as 6 weeks after birth or as far out as a couple of decades. There is no expiration for care.

  • Male Pelvic Pain 

Yes, men have pelvises, so yes, men can have pelvic pain. Whether it is testes pain from the spermatic cord and ilioinguinal nerve, or penile base pain from fascial restriction, or deep pelvic pain from levator tightness, we treat men’s pelvises with the same level of attention and specificity as women (not just rectal work or avoiding treating the pelvis). We treat post hernia repair pain, post vasectomy pain.

Somatic Trauma Reduction

Our bodies are very kind to us. When we have too much trauma for our mind to process, or when hard things happen, they hold the memories in little pockets. Sometimes we may feel like we have done a lot of counseling and mental reframing, but when it comes to it, we still have a body memory of the event.

So often patients say, “You will think I’m crazy, but this pain started when _____ happened in my life.”

Nope, not crazy.

In time the fear of the memory can be stronger than the memory itself. Our bodies hold it until (I think) we are ready to address it. Then, it may come up as a growing pain, or a growing stiffness.

We don’t go chasing trauma in the body. Meaning, I don’t assume every problem in the body is energetic or emotional. But there is no line in our body demarcating where feelings end and structure start. They go hand in hand.

By using intuitive listening to the body, we can line up tissues where memories are stored away from the conscious mind, and as I hold presence, your body can let go of things it has been holding.

Sometimes that is all physical.

Sometimes it comes with tears, crying, or memories.

It’s all good to let go of, and it’s all welcomed here.

I am happy to support your whole being.

Often, patients who have already worked on things with counseling and meditation or yoga and movement therapy will have rapid resolution of stiffnesses or restrictions that have been held for a long time, when we add incredibly specific bodywork.

Gender/Trans Care

We are happy to help treat any pelvis.

Some issues that I see particular to transgender persons:

  1. Post surgical care: after surgery: top, bottom, or facial feminization, scar tissue and fascial restriction can create pain, loss of function, or decreased mobility. I am happy to help address any tissues that need care and a caring manual therapy touch. Also, I can help with strengthening and regaining muscle control after surgery, going far beyond kegels. Good manual therapy early is helpful. Also, I can help you to safely and effectively progress a dilation program.

  2. Trauma reduction and re-embodying your tissues. Sometimes after trauma or difficulty, people have a hard time coming home to their bodies…any part of their bodies. I am happy to hold presence for you, as we work on your tissues, helping you come home to your body. We work on areas of the body that feel safe for touch on day one and carefully dialogue about what feels safe over time.

Prolapse Page

First, a rant… Prolapse care for women and the narratives around it, quite frankly, frustrate me. I got into this work after significant damage from a birth, and I was given so many scary stories about the future of my pelvis. Women are told to stop strengthening their abs, stop their fitness programs, not given excellent evaluations that really tell them what happened and how to care for their pelvis in particular (not the same kegels for all), and then so many women stop exercising and limit their activity out of fear of further damage or leakage. I’m saying enough! ENOUGH!!! Yes, that’s me lifting a heck of a lot of weight, and I want you to feel that fearless doing the bada** activities you love also!!!!! You can bet I strengthen my abs!

Ok, but back to education….let’s understand prolapse…

Pelvic organ prolapse is common in women who have had vaginal births or patients who have had chronic constipation. No, that doesn’t mean you are destined for a life of sitting around.

True vaginal vault prolapse is a shortening of the vagina, and uterine prolapse is the uterus moving downward, towards the vaginal opening.

In addition, there can be conditions where another organ starts intruding into the vaginal canal. A cystocele is the bladder sagging backward and down into the vaginal space. A rectocele is the rectum pressing forward into the vaginal space. An enterocele is the small intestine moving downward into the vaginal space.

Patients describe this condition as feeling like something is, “falling out”. Other patients report a low back heaviness or pressure that increases as the day goes on. Sometimes they can see a bulge coming out from the vaginal or anal canal. Sometimes birthing a big baby or some other birth trauma has changed positioning of organs, and the patient reports feeling something soft moving into the vaginal canal.

Part of conservative non-surgical management for includes pelvic therapy to support the involved organs and to restore normal mobility and function to related structures. We also educate on how to prevent future damage and treat whatever symptoms the prolapse is causing. 

It all starts with an incredibly detailed eval. 

  • Did you have muscle tearing?

  • What is your current fascial support? 

  • Do you have equal strength on both sides? 

  • Are you weak by the bladder but overcompensating by the rectum (creating eventual constipation issues), what can we expect from your muscles? 

  • How can we strengthen the muscles that are not strong enough to contract? 

  • What position is best for you? 

  • How deep did you tear? 

  • What is the integrity of the perineum and anal sphincter?? 

From there we make a plan. We do manual therapy on the scarring and organ positioning (visceral manipulation), we apply external support or strengthening assistance in graded progression, until we have you living your fullest life, without symptoms, once again.

Urinary Issues

Many urinary disorders occur in combination with other problems. Sometimes it is weak or tight muscles, many times it has to do with the mechanics of the bladder itself, whether that is the position of the bladder, restriction from a c-section scar, endometriosis, a problem with the lining of the bladder, or habits of diet or emptying.

Patients may present with one or many of the issues below.

  • Stress Incontinence: Urinary stress incontinence is urinary leakage with sneezing, or exercise. Leakage can vary from a few drops to full bladder emptying. Basically, as the pressure in the abdomen increases from these activities, the corresponding structural support in the pelvis is not enough. Often, pelvic floor strengthening coupled with hands on technique to the bladder itself and pelvic floor and some habit modification can take care of the problem. Many patients needlessly wear pads or pantiliners for years, when a short course of therapy (often 6-12 visits) may have corrected their problem.

  • Urinary Frequency: Our bladder is meant to hold around 16 ounces of fluid and only to be emptied 5-8 times a day. Patients often think they have a small bladder or that they just need to empty often because of drinking fluids throughout the day. Patients may find themselves knowing where the bathroom is every place they visit or making “just in case” trips to the bathroom before changing locations or getting in the car. This is not normal, and it is often easily corrected with a bladder retraining program and visceral or manual therapy to the bladder, fascia, and scarring in the region.

  • Urinary Urgency: Urinary urgency is an overly-strong sensation of the need to urinate. Often patients will report leaking as soon as they pull into their garage or leaking once they are on the way to the bathroom. Urgency and Frequency often go hand in hand, but they can be separate. Bladder and habit retraining, manual visceral and internal pelvic floor techniques often resolve this program.

  • Urinary retention: Urinary retention leaves patients feeling like they can not fully empty their bladder or they have difficulty starting a stream. Sometimes patients report they urinate, only to feel the need to try again in 15 minutes. Retention can result from overactive pelvic floor muscles that we can teach to relax.

  • Interstitial cystitis: IC or interstitial cystitis is a painful or urgent bladder condition. IC is now classified as painful bladder syndrome to include patients who may or may not have lesions in the bladder when viewed under a scope. The international continence society now lists relaxation training and physical therapy in the top two tiers of the recommended treatment sequence. In addition, diet can contribute. Treating IC is often a trial and error situation, as each case is very individual. We try every possible modality and approach with our patients, addressing one at a time to see which combination of modalities will leave our patients most able to lead a full life. We will work in tandem with your urologist.

  • Post prostatectomy urinary leakage: Often as men hit middle aged, they start to notice changes in their urination habits, most often due to an enlarging prostate. Non-cancerous, benign prostate hypetrophy (BPH) can be treated surgically. Sometimes these men are left with leakage of urine. This leakage is often improved with physical therapy, including internal work to decrease scarring in tissue, pelvic muscle retraining, and lifestyle modification. However, since this clinic cannot work with Medicare, we are happy to refer to Medicare providers.

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