Welcome back to the Healing Pain Podcast with Dr. Amy Stein.
This is a podcast where practitioners as well as patients gather to discuss natural strategies for healing chronic pain of all types. This week, I have a really exciting guest. We’re going to be talking about the chronic pain that is associated with pelvic floor dysfunction.
My guest is Dr. Amy Stein. She is a doctor of physical therapy and a leading expert at treating pelvic floor dysfunction, pelvic pain, women’s health and men’s pelvic health. She’s the founder of Beyond Basics, a physical therapy practice in New York City. As well as the author of the book called, Heal Pelvic Pain, and the creator of the video called, Healing Pelvic and Abdominal Pain: The Ultimate Home Program For Patients And A Guide For Practitioners.
Amy is the founder of the Alliance for Pelvic Pain and serves as the president of the International Pelvic Pain Society. She lectures both nationally and internationally on television, has been featured on shows such as Dr. Oz, ABC’s 20/20 and magazines such as Prevention.
Women’s Health and Pelvic Pain with Amy Stein
Dr. Amy Stein, welcome to the Healing Pain Podcast. It’s great to have you here.
Thank you so much for having me. I’m excited to be here.
It’s always wonderful to have a therapist who’s in my home hood of New York City. Obviously you have a great thriving practice here in New York City that treats pelvic pain. You’re an author, which is wonderful. I always like to go back a little bit with professionals and ask them about their journey and their discovery as to how they became a specialist in pelvic health.
My story goes back to the very beginning. When I was in grad school, I had a friend, she had a hysterectomy and she ended up with severe pelvic pain. They’ve ruled out the back, she thought it was coming from her back, the doctors thought it was coming from her back, but they had ruled it out. She didn’t have any significant findings. They ruled out urinary tract infection. She was having pain in the genital region. She ended up with bowel issues. A couple of years later, she ended up with diverticulitis. But it all started with the hysterectomy. I opened up my textbooks. I tried to figure out what’s going on if it’s not in the back. I went to my professors. At that time, they didn’t really know what was going on.
I started doing my own research and I looked further down on the chain of the lumbar spine and I went to the sacral spine, sacral nerves and I realized maybe it’s coming from some of these nerves. Lo and behold, it’s now a finding with hysterectomy, as they’d become much more careful, but sometimes they knick the femoral nerve and it creates bladder, bowel, sexual dysfunction. She was in disabling pain that she couldn’t even work. Years later, she’s doing much better. She did go through pelvic floor physical therapy, as well as other relaxation techniques. It was definitely a full body approach for her. She was out of work for a couple of years because of this. It took some nutrition, meditation, mindfulness meditation, eventually going back to yoga class and also the pelvic floor physical therapy. That’s how I got interested. Then it just started from there and it just kept going. I was so interested and realized there was such a need for this field and this area, that I was really intrigued by learning more and I still am.
There’s always new information to be learned especially in the area of pain. What year was this? Because I know you’ve been in practice for quite a long time. Women’s health now has really solidified itself as a specialty and solidified itself as a much needed service for women and men. I think we’re now getting a lot of insight into men’s pelvic heath as well, which maybe we can talk about as well. What year was this when you had this initial patient and this discovery?
This was in ’97, a while ago. I’ve seen the field evolve and it has been great. When I first started out of school, all the training is post graduate. In school, we went over an hour of incontinence and incontinence is the other spectrum of what my friend was experiencing. All we did was an hour. Now they have post graduate classes. It’s very systematic, where they have a level one, a level two, a level three and then all these other classes that you can take. Prior to that, when I was learning, there was one class and I just went to various parts of the country. I trained with a physician. I was learning more about pelvic pain doing pudendal blocks, as well as other blocks, doing trigger point injections for his patient, who’s a neurologist. Then I went to other PTs that were the pioneers of pelvic pain. That’s where my training came from.
The majority of my training came from my patients actually, because as I would do things and work on things with patients, I realize, “This isn’t working. Let’s go back. Let’s try something else.” Now, definitely there are so many more resources and it’s really wonderful to see. We still have a long way to go, but it still is wonderful to see. An actress just came out all over the internet about her vaginal pain and what she’s feeling in her vaginal area. She said that pelvic floor physical therapy has helped her significantly. It’s great to be hearing that it’s getting out there.
It’s wonderful that an actress comes out and talks about it, because for a long time, that type of pain really was not spoke about publicly. It was a place that maybe a patient spoke about it to their OB-GYN. They probably didn’t mention it much to their primary care physician. Then once they arrive at a physical therapist office, oftentimes, after a couple of weeks, they feel like, “Now, I can forge a healing relationship and a bond with someone who understands what I’m feeling and who could help me heal.” I think it’s important that people talk about it more as well, correct?
Yes. I’ve had other actors and actresses in the practice. It’s a tough thing to talk about, and I understand that and I respect that. It’s wonderful when someone is willing to speak publicly about it. I have many patients that have and are willing to speak publicly about their condition, male and female.
I want to put my practitioner hat on for a minute. You said something earlier in our discussion that this initial patient, your friend who had pelvic pain, initially they were looking at her lumbar spine. They were looking for musculoskeletal pain in the lumbar spine area. What’s fascinating to me is that the evolution of pelvic pain, let’s just call it pelvic health for the moment, the evolution of pelvic health really started with women and women’s health. But now we see that obviously men have pelvic health as well. We’ve watched the evolution of women’s health and this whole pelvic floor dysfunction transition to now where we’re bringing men into the equation and we’re just looking at pelvic dysfunction.
My question for you as a physical therapist, as a practitioner, is should we stop calling it women’s health and call it something else? Does it actually belong in the realm of orthopedic physical therapy since we know that the pelvic floor has so many different functions throughout respiration, through stability and pelvic pain, through GI dysfunction? There are so many different areas it relates to, so maybe you can talk to that for a couple of moments.
I do know that the American Physical Therapy Association, which is an organization that supports physical therapists, it’s a great resource, they have a section, it’s a women’s health section, I believe that they’ve been trying to figure out how to rename it and they’re having a hard time because there’s already so many people and so many resources within women’s health and they’re not sure which direction to go. I do know that now there are different certifications. There is the WCS, which is the Women’s Certification Specialist. Now there’s also Pelvic Floor Certification which encompasses men, women and children, I believe. We see children in our practice, typically more with bladder, bowel issues, not so much the pain aspect. They do get the abdominal pain from constipation, but we do see them as young as four, sometimes even younger, the babies with the constipation. If you address that sooner in life rather than later, then I think it helps to not have so many issues when they are older. But I think it’s just hard. They’re trying to figure how to call it more a pelvic health section versus a women’s health section or divide it. I don’t know if there’s a consensus yet.
My next question to that would be, the average, let’s say, musculoskeletal practitioner, because we have physical therapists listening to the podcast. We have chiropractors, we have massage therapists. If they’re treating musculoskeletal pain, let’s say back pain or hip pain, is it wise for them to start to incorporate aspects of pelvic dysfunction into their rehab program? That may or may not be an internal treatment approach. Obviously, sometimes you can treat things externally, which have an impact on the pelvic floor.
There are definitely some techniques that you could do externally for sure. I have a couple physical therapists that work at Beyond Basics and they have worked in the orthopedic setting, where they didn’t have the private rooms. One thing that they said coming here to work here was that they now feel like they can treat the patient as a whole, meaning that they may need to do some internal work with a gloved hand, with lubrication when needed. It is definitely in the musculoskeletal realm. From what you were asking before, yes, it does fall into musculoskeletal dysfunction, but it’s definitely more specialized.
I wouldn’t feel comfortable having a PT, with having only taken one class, treat my patients. I have very high standards for our patient care because we do have a lot of chronic pain patients. A lot have been suffering for a long, long time, decades. I think the statistics show that most of the chronic pelvic pain patients see seven or so practitioners prior to coming to a final diagnosis. Even this actress that had all of this exposure and everything at her fingertips, she was misdiagnosed and mistreated many times and for many years. That’s goes to show, we still have a long way to go, but we are slowly getting there.
Let’s talk to someone who may be struggling with pelvic pain or pelvic floor pain. Tell us what exactly is pelvic floor dysfunction? That’s a really good place just to start.
I have a model here. Here’s the pelvis. There’s the part of the lumbar spine, sacroiliac area. If you tilt the pelvis this way, all of this pink or red, whatever you want to call it, is all muscle. There are a lot of muscles going on. Again, some of them you can address externally, but most of them you do have to address internally. This is obviously the female version. The male version, they have the same muscles. It’s the same exact muscles, it’s just different organs. They have the urogenital triangle, which has the three more superficial muscles, men and women have it. Bulbo and ischiocavernosus in the transverse perineum, which is down here. Then you have the deeper levator ani muscles, which is the deeper muscles that connect to the bowel and the rectum. But you can have dysfunction in one of these muscles. You can have dysfunction in all of these muscles.
My friend that I mentioned earlier, she had nerve irritation which caused her to have bladder, bowel and sexual dysfunction, as well as pain in the whole area. The pudendal nerve comes from S2, S3 and S4 nerve roots. When I was new to the field, it was all pudendal nerve. Now they’re realizing that the posterior femoral cutaneous nerve, which runs alongside of the pudendal nerve, can also play a factor in pelvic pain as well as a ton of other nerves that are higher up, the iliohypogastric, the genital femoral, all these nerves have different distributions, which you can learn about and try to figure out from where the patients are experiencing pain, numbness, tingling.
Just to go back to the pudendal nerve, basically almost everyone is familiar with the sciatic nerve. They basically come out like this, so sciatic is more lateral. The posterior femoral cutaneous nerve comes right next to and in between the sciatic, and then the pudendal nerve. The posterior femoral cutaneous nerve can have some of the same symptoms as the pudendal nerve, such as burning, itching, sharp shooting pain that goes into the perineum area. The posterior femoral cutaneous can go a little bit down the legs, so then you get confused, is this sciatica or is it posterior femoral cutaneous pain?
Then the pudendal nerve interestingly also has an autonomic function, so it also can cause sweating and increased respiration and heart rate, so that’s a whole separate component. It’s clear just from talking about this for twenty minutes that it requires a lot of post graduate training for pelvic pain. Not just from the pelvic floor physical therapy standpoint, there are a lot of mental health challenges that these patients that are experiencing, as well as nutrition. It could start where the muscles are tightening and then they’re just not able to empty the bowel as well. They’re not able to empty the bladder well. Then they start getting constipation, irritable bowel syndrome. It can cause a cascade of symptoms. It can be complicated, but we are learning more and more from our patients and as a community, a pelvic health community.
I think it’s wonderful, because I think the layman version of pelvic floor dysfunction, which you see this every once in a while in a magazine, that it’s just Kegel exercise. That all you have to do is just do some Kegel exercises and squeeze your pelvic floor and retain the flow of urine for about five seconds. Repeat that ten times a day and your pelvic floor will just be fine and healthy. But when you start mentioning that nerves have a motor function, nerves have a sensory function and there are nerves that have an autonomic function. It’s linked to all parts of your nervous system. Tell us about the muscles down there. Generally, what are their functions? Do they always need tightening? Or is it something else that is needed for someone to heal?
I think over the years, we’ve definitely learned more and we’re finally starting to narrow things down. A while ago, it was called hypertonic pelvic floor muscles, which meant more tightening, shortening of the muscle, more restrictions, trigger points, connective tissue restrictions, etc. Now, they are calling that overactive pelvic floor dysfunction, so hypertonic and overactive are really meaning the same thing. Some diagnoses that you’ll hear under that category are vulvodynia, provoked/unprovoked vestibulodynia. For the men, the non-bacterial prostatitis is very common. 40% of our patients in our practice are male patients. By the way, everyone thinks it’s a problem when you’re older. It’s not a problem when you’re older. We have kids in this office, but we also have a lot of young population, 20’s and 30’s that may start with a bladder issue of frequency, urgency, retention. These are all more of the overactive syndromes and symptoms.
Then there’s the underactive or the hypotonic pelvic floor dysfunction. That’s when you would use Kegels. That is when the muscles are weak and they don’t have the strength to help support the abdominal pelvic contents and they don’t have enough control or strength to help with continence, as well as core stability. That’s when you do more of the pelvic floor exercises and you do those Kegels. There are two different types of muscle fibers, which are also throughout the body. There’s the slow twitch, which makes up 80% of the pelvic floor, and then there’s the fast twitch, which makes up 20% of the pelvic floor. When you are doing pelvic floor exercises, you do need to focus on both strengthening the slow twitch and the fast twitch. It’s just like any other exercise of the muscle. When you have bicep weakness, you want to strengthen the muscles but you want to go through the full range of motion.
There’s basically the overactive, which I mentioned. Then the underactive is more the diagnosis of incontinence, prolapse. Prolapse is when the organ is actually starting to descend. That could be strictly from weakness, it could also be from connective tissue laxity. Then there’s the whole musculoskeletal component, the skeletal component, if there’s malalignment in the hip region, it can throw off the muscles of the pelvic floor. If there’s malalignment in the SI region, it can also throw it off. If there’s weakness on one side, tightening or shortening on the other, it can also throw off the pelvic floor, whether it’s more of a weakness issue or underactive issue or more of the overactive or hypertonic muscle issues.
That’s a wonderful explanation for anyone who has any type of pelvic pain or pelvic dysfunction. I’d like to hear a little bit about your book, it’s called Heal Pelvic Pain. Every time I go on Amazon and I look, your book is always up there on the top five or top ten. I think it’s wonderful because there are not too many pelvic pain or pelvic dysfunction books written for the consumers, but you really have a great book that hits both consumers as well as practitioners. Tell us about your book and what inspired you to write it and what’s really come out of that?
I’m not a writer, but I had a patient that came to me and she was a literary agent and she said, “You have to write a book on this. It’s essential. We need it. We need your help with it.” This is definitely geared for more the patient population, but I’ve had practitioners that are just learning about pelvic floor dysfunction buy it and say that it’s very helpful as a beginning practitioner to learn the overactive versus the underactive, the different descriptions of each so that they can go to their patient and say, “Do you have leaking with coughing, sneezing, lifting, laughing?” That’s more of an underactive condition where the muscles just can’t support the abdominal and pelvic contents.
Or do you have urinary or bowel urgency, frequency, retention, incomplete emptying? Because those muscles aren’t allowed to relax. They’re so tight or shorted in hypertonic or overactive that they have difficulty emptying the bladder. They have difficulty emptying the bowel. They have pain with sexual activity, male or female. We do see a lot of males with genital pain, tip of the penis pain, testicular pain, and that could be a muscle issue. It can also be a nerve issue. The genital femoral nerve runs right through the iliopsoas. If the iliopsoas, which is the hip flexor muscle, it that’s tight, irritated, it can also irritate the genital femoral nerve. The male could complain of testicular pain. The female could complain of pain in their vaginal area. Like I said before, it’s complicated but we’re getting better at the diagnosis.
Back to the book. The book does have massages. It separates into the overactive, underactive population. For the overactive, it would be more relaxation techniques, massages, genital stretches. For the underactive population where they need more strengthening, I go through how to do the slow twitch, fast twitch exercises, then adding exercises like abdominal exercise, bridging to help recruit more muscles. Then with the underactive population, you want to go into functional training too. Once they get all that together and they’re doing that well, then you want to have them do squats with the pelvic floor exercise.
Again, just like any other exercise, you repeat it ten times or twenty times. You take breaks in between. I’ve had patients, we use a biofeedback machine. I’ve had patients where I’ve hooked them up to the biofeedback for the underactive weakness patients and I had them do jumps in the room because they said they leak while they jump. You shouldn’t leak while you jump. I’ve had moms come to me and say, “When I go to this CrossFit, I start leaking.” I’m like, “No, we need to fix that and fix it now before you get older and it gets harder.”
I think a lot of women may think, because I think this has been spread around culture, that after a baby it’s normal to leak, and as you get older, it’s normal to leak. The truth is, we know as physical therapists that that’s not normal and there can be treatment for it.
Our male patients too, the post prostatectomy patients, it’s a common finding that we find. A lot of them when they come to us, they’re not doing the exercises correctly. Then they feel like they failed the treatment, they failed the exercises, but in fact they’re recruiting their adaptors too much. They’re recruiting their glutes too much instead of isolating the pelvic floor. That population as well can be helped through pelvic floor physical therapy. The sooner they get the treatment, the better. Because the longer you wait, just like with any other condition, the harder it is to treat the condition.
What I love about your book is, I think especially for the pelvic floor population, is a book can be a really nice way and people ask me this whole time, “Why did you write a book on chronic pain?” I said, “Because obviously there are many people who struggle with chronic pain. They have, at times, been caught up in the medical system. They’ve not been able to find a solution when the truth is there are natural ways to heal.”
I think that when you’ve been to see many practitioners, like those with chronic pain, like those with pelvic pain and dysfunction, sometimes you get a little cautious, you say, “I’m really not ready to go see someone again because I’ve been through this once or twice or ten times.” I think a book, whether it’s your book or my book, can be a really nice way for someone to read and start to educate themselves. As you educate yourself, you empower yourself. Then when you feel more empowered, you feel like, “Now I can take a step and look to forging a relationship with someone who can now take this book and really take me on the next phase of the journey and take me deeper into the work.”
I think especially with pelvic floor dysfunction, that’s very important because there is that sense of fear. There is that sense of insecurity at times. There is that sense of, “I’ve been to see all these physicians but nothing has really helped me.” Thank you for the book. Tell me, you’re the president of the International Pelvic Pain Society. What do you have coming up? What’s new on your list?
We have the World Congress on Abdominal and Pelvic Pain, which is three organizations doing a meeting together. That started about seven years ago where an organization from France and then IASP, which is the International Association of the Society of Pain. They have a special interest group on pelvic pain specifically, pelvic and abdominal pain. We merged together seven years ago and we are doing the World Congress on Abdominal and Pelvic Pain.
The International Pelvic Pain Society which has been around since 1995, it was started by just a group of gynecologists that got together trying to figure out what’s going on with this patient population. We are sponsoring the congress this year and it will be in Washington DC in October. Save the date, sign up soon. We’re opening registrations soon. Fortunately, we were able to get a lot of international speakers. We’ve got Lorimer Moseley from Australia. We’ve got Paul Hodges from Australia, Diane Lee. Those are the physical therapist and PHDs that are studying pain. Then we have gynecologists also, there’s one woman from New York, Katy Vincent. She’s big on endometriosis.
We basically broke it down into nine clusters this year. One cluster is endometriosis. One cluster is musculoskeletal, sexual dysfunction. I could go on and on, but if you just go to PelvicPain.org, you can see more about the conference. It’s really going to be exciting. Paul Hodges and Lorimer Moseley are doing a post-conference one day on explaining pain and the most recent findings of how to treat chronic pain syndromes. This meeting, it’s really exciting. It started again in ’95 with I think six gynecologists, it’s now 800 and some practitioners. It’s all types of practitioners, lots of gynecologists, lots of pelvic floor physical therapists. But we really try to encompass pelvic pain as a whole, looking at the body as a whole and how do we treat it as a whole.
Dr. Amy Stein, it’s been great having you on the Healing Pain Podcast and talking about pelvic floor dysfunction. If people are interested to learn more about you, your work, where can they find you? Where is the best place to find you?
We have a website, BeyondBasicsPhysicalTherapy.com and that has a lot of information on pelvic health for men, women and children. We are also in Midtown, 110 east 42nd street, suite 1504. There are nine of us here. We are all very much orthopedically trained with pelvic health training on top of it, so we do approach the body as a whole because it’s needed. Because we have the patients, like you said earlier, they actually have restrictions in their diaphragm and their whole ribcage is compressed or it’s uneven on one side and the diaphragm is supposed to move with the pelvic floor, they’re supposed to move in unison. If the diaphragm is stuck, then the pelvic floor could be stuck.
It’s really important to know the orthopedics of pelvic health as well from pretty much head to toe. We see even foot issues that are either caused from a pelvic floor issue or a contributor to. It’s hard always to know which came first, the chicken or the egg, but we know how to fix these things and we get the patients better.
I want to thank Dr. Amy Stein for being on the Healing Pain Podcast this week. You can check her out. Of course, if you’re in New York City and you need any kind of physical therapy, check her out at Beyond Basics Physical Therapy, that’s her practice. You can also check out her book called Heal Pelvic Pain. Make sure each week you stay connected to DrJoeTatta.com/podcasts. I want to thank you for being on the Healing Pain Podcast. We’ll see all of you next time. Thank you.
About Amy Stein, DPT
Amy Stein, DPT, is a leading expert and at the forefront of treating pelvic floor dysfunction, pelvic pain, women’s health, and functional manual therapy for men, women, and children. She is the founder of, and a premier practitioner at Beyond Basics Physical Therapy in NYC. She is the author of Heal Pelvic Pain, an easy-read, self-help book and created a video called Healing Pelvic and Abdominal Pain: The ultimate home program for patients and a guide for practitioners. Amy is one of the founder’s of the Alliance for Pelvic Pain, a patient-oriented educational retreat, and she serves as the President of the International Pelvic Pain Society. Amy is a co-editor of Healing in Urology and an author in many medical textbooks, including Pelvic Pain Management, Female Sexual Pain Disorders: Evaluation and Management, Management of Sexual Dysfunction in Men and Women, and The Overactive Pelvic Floor. She lectures internationally, is featured in the Endo What? documentary, and has been interviewed in media outlets ranging from the medical segments of popular TV shows, like Dr. Oz, ABC’s 20/20, to such magazines as Elle, Prevention and More magazine and newspapers such as the New York Daily News. She is a member of ISSWSH, the NVA, ISSVD, ICA, and the APTA Women’s Health section. Amy received her Masters in Physical Therapy from Nova Southeastern University in 1999, and her Doctorate in Physical Therapy in 2013.
Amy Stein, PT, DPT, BCB-PMD, IF
110 E 42nd St Suite #1504
NY, NY 10017
- www.healingpelvicandabdominalpain.com (Book and Video website)
- www.pelvicpain.org (International Pelvic Pain Society)
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