Dr. Allyson Shrikhande, a board certified Physical Medicine and Rehabilitation specialist, is the Chief Medical Officer of Pelvic Rehabilitation Medicine. She is also the Chair of the Medical Education Committee for the International Pelvic Pain Society. Dr Shrikhande shares what pelvic floor rehabilitation is and how it helps with feelings of UTI, pain with intercourse, and other women's health-specific conditions.
Georgie: I’d love you to share your background.
Allyson: I am a rehabilitation doctor. Essentially what that means is we treat the muscles, joints and nerves of the pelvis. We typically take more a holistic approach when treating patients with chronic pelvic pain or pelvic muscle dysfunction.
Georgie: what inspired you to start this center?
Allyson: I was a final year resident and pregnant with my first daughter, Ava. I had significant issues and a challenging vaginal delivery. Postpartum I had pelvic floor muscle dysfunction, pain with intercourse, urinary urgency and frequency, a sensation of the UTI that would not go away. I went to my OBGYN at the six week check-up and everything was fine. I went back at 10 weeks and the ultrasound was okay so I was offered painkillers and no other solution. I found an excellent pelvic floor therapist who examined me, explained what was going on and really helped me get better. This field is undertreated and underdiagnosed and so, as I graduated from residency, I moved towards this specialty. I started at Cornell and then another private practice, growing and learning about this world. Then I co-founded Pelvic Rehabilitation Medicine and we’re growing today in multiple cities across the country as we speak. Pretty exciting stuff!
Georgie: I can appreciate that you started this center because of your own personal experience. The passion for this field comes across due to your experience.
Allyson: it’s a great field and we’re recruiting as many medical practitioners as we can.
Georgie: Let’s start with the basics. What is pelvic floor rehabilitation?
Allyson: rehabilitation in general is the concept of resetting and retraining your muscles and nerves, essentially. We are taking this approach and applying it to the pelvis. Conceptually, we talk to patients about: “you’re like an iPhone: we’re turning you off and on and resetting so that the wiring works better.” It improves your muscle function and your nerve function. That is what rehab doctors do. The idea is that there is neuroplasticity where your muscles and nerves CAN heal and can get better.
We are detectives. When male or female patients come to us, we find the primary reason for pain. There are multiple organ systems at work. We look for the primary pain generator as well as treat the muscles, nerves and joint dysfunction.
Georgie: to bring this to life, what if we walk through examples. What sorts of conditions does pelvic floor rehabilitation treat? Walk us through what you do or how this treatment helps specific conditions.
Allyson: the pelvic floor goes from the front to your coxis in the back: it’s a big muscular sling. In the front, it holds the bladder and the male and female organs. In the back you have the descending colon.
Common complaints will be urinary urgency or frequency, feelings of having a UTI, discomfort or pain during and after intercourse, constipation (the enemy of the muscles and nerves of the pelvic floor). Everything along the pelvic floor sling are the chief complaints that we see and hear all day.
Georgie: I had no idea that sexual intercourse challenges could be resolved with pelvic floor rehabilitation. At the recent endometriosis conference, which I know you were on the panel at, I learned about sexual health and pelvic floor. A lot of us are naively taught what intercourse is and is not and don’t learn how to communicate needs or even pain with partners. I was fascinated by all of that.
I’d like for you to talk a little bit more about how you work with couples to support their experiences.
Allyson: it’s not uncommon for the partner to come in and work together to resolve these issues. That open communication and support is a good thing. First, it’s really important to speak up if you are having discomfort. A lot of times it is positional and we talk about different positions that can relieve pain. There are options like lubricants and tools like the O-nut that gives you a barrier. The goal is for open communication while still enjoying this part of an intimate relationship. We’ll often bring in sex therapists as well which is extremely helpful. With our patients, we make a plan so they can have intercourse that feels good. If it is excruciatingly painful, we talk about non-penetrative seasons while treatment is happening to decrease any negative association with intercourse. We are open and honest and make a step-wise plan. Of course, things like penetration are re-introduced when the patient is ready.
Georgie: I’d love to dig into UTIs. Pelvic floor rehabilitation isn’t commonly discussed. When I’ve talked to women about UTIs the general knowledge is, “urinate after intercourse and drink cranberry juice.” Talk to us about that.
Allyson: when I say “the sensation of a UTI,” I’m referring to the fact that it feels like a UTI but it isn’t. Sometimes it’s nerve issues. Essentially what we’re doing in terms of both UTI and intercourse is we’re treating the nerves that are firing inappropriately. Sometimes, when the pelvic floor muscles are in a spastic condition, they squeeze and irritate your nerves. This causes inflammation and the nerves fire when they shouldn’t. There are a variety of symptoms that arise from there. Our protocol reverses that: we increase blood flow, decrease inflammation and provide a better environment for nerve function.
Georgie: how would someone know if they feel they have a UTI and don’t?
Allyson: you go to your primary care doctor or gynecologist and get a simple test. If it’s negative, they’re often referred to people like us. Their OBGYN will realize that if it’s not an infection, it isn’t treatable with antibiotics. The next option is that it is a nerve, which is what we treat.
Georgie: is it common for OBGYNs to know that pelvic floor rehabilitation is an option?
Allyson: that’s a good question. We are a newer field of rehab. Awareness is growing but still not where it needs to be. So, not necessarily. Some OBGYNs are aware but we need to do a better job of letting them know that we are here.
Georgie: so, all of those ladies out there who are listening in: go get a test. Before you drink all of the cranberry juice, make sure that you truly have a UTI.
It is endometriosis awareness month and I want to make sure we cover that. There are a lot of women out there with endometriosis who are undiagnosed. Could you share a bit more about how pelvic floor rehabilitation can help endometriosis specifically?
Allyson: it’s multi-factorial. One, the presence of endometriosis can cause your pelvic floor muscles to spasm. This will lead to a cycle that we mentioned earlier, where the nerves keep squeezing and increase nerve inflammation. This gives off the symptoms of urinary, intercourse, bowel and sometimes even lower abdominal pain.
Second, endometriosis in and of itself is a proinflammatory state. It stimulates the release of proinflammatory cytokines.
Third, endometriosis causes pelvic pain because it can directly invade nerves. It’s not as common but it can do that.
Those would be the reasons that people would come to us. They have these symptoms caused by endometriosis itself.
Lastly, when this happens for a long period of time (more than six months), those signals go to the spinal cord and the brain and something called central sensitization occurs. You get a heightened sense of your nervous system overall. The reason I say that is because when we treat people we address all of it: the peripheral nerve, the central nerve and the myofascial tension.
Georgie: my endometriosis is asymptomatic but certainly impacted my fertility. Talk to us about the pain in surgery. Some women have laparoscopic surgery multiple times, due to the fact that endometriosis comes back. In some cases, it’s suggested that they do a hysterectomy. I’d love to better understand how the pelvic floor rehabilitation support could be looked at as unique or an alternative to surgery. I understand that you yourself are not a surgeon but help us understand the roles of these two approaches when look at the whole picture.
Allyson: most of our patients present without a diagnosis of endometriosis. Our approach is to treat them. If they respond, then we keep going. If they don’t respond enough, endometriosis is high on the list of things they could have. We refer them to an endometriosis specialist in the gynecological world. The way we fit in is twofold:
First, we see patients post-operative after excision surgery (which is important, as opposed to an ablation). After this, patients have persisting symptoms. This is attributable to the cycle we discussed. When the endometriosis has been there for a long time, it needs treatment even after it’s been removed. We treat the muscle spasm and nerve inflammation and patients respond nicely.
Second, we call this pre-hab. We’re trying to get this concept out there. Pre-hab is basically wrapping a patient’s muscles and nerves up in a nice bow to prepare them for surgery. The goal is to decrease flare-ups or pain medications and more. Some surgeons send patients to us before surgery. We get you “less hot” so that you respond better to surgery.
We work closely with surgeons and pelvic floor physical therapists. We take a holistic approach to this, discussing additional things like nutrition and meditation with our patients.
Georgie: talk to me about the difference between a pelvic floor therapist and what you do.
Allyson: when people see us and haven’t tried pelvic floor therapy, we would first send them for about two months to do that therapy. If this doesn’t work or you plateau, you come to us. We are MDs and physicians. Sometimes imaging is required, topical creams or other medical therapies. We perform external ultrasound guided injections. This is non-invasive enough to go on with your day. We’ve published two papers on some of our innovative methods on this so far and are constantly gathering and publishing more data. In addition to medicine, we utilize homeopathic and natural alternatives, things like injectable Arnica for bruising and to promote healing.
Georgie: I don’t want to lose the point about excision being more important than ablation. I’d love your perspective on this.
Allyson: with excision, you’re removing at a deeper level. This gets to layers that are deeper, which promotes less recurrence. With ablation, you’re burning off but it’s the top layers. With ablation, you can have residual cells left behind which promote recurrence. Our surgeon at PRM has an additional two years of experience at the Mayo Clinic above and beyond the typical training, so we understand the highest standards and what’s best.
Georgie: there was an article posted recently about Botox being used for endometriosis pain. In my 10-year fertility journey, I learned so much about women’s health where we mask actual problems with medication. I was curious to get your perspective.
Allyson: it wouldn’t be treating the primary pain generator. It’s treating the muscles and nerves, which could be in spasm. Botox itself isn’t treating endometriosis at all. Conceptually, our protocol is a functional, restorative approach. We rewire, reset, retrain muscles and nerves. It’s a healing approach.
The main issue with Botox is that it can cause weakness in the pelvic floor. We don’t love that. Those muscles need to get stronger. There are also risks of Botox: bladder incontinence and urinary retention. All of the issues increase with higher doses. For Botox, I’m a fan of less is more. The only time we would use it as part of post-op protocol. After a proper endo excision, with persisting symptoms, we would treat your condition and get you 70% better but needed a little more, that could be a case for a little Botox. At a low dosage, it won’t carry as much risk for weakness. We don’t do this very often.
Georgie: four questions were provided by our listeners. First, talk to us about yoni eggs.
Allyson: yoni eggs help you find your pelvic floor. They’re from ancient Asia and have a sacred meaning. It can help women sense their pelvic floor and start to feel comfortable and excited about intercourse. Conceptually, patients usually use them for about 15 minutes at a time but this can increase over time. I usually ask patients to discuss it with their pelvic floor physical therapist as well and start with a size that feels comfortable.
Georgie: so, we shouldn’t go on Amazon and buy yoni eggs and start using them? I think Gwyneth Paltrow is talking a lot about yoni eggs right now and getting a lot of flak for it.
Allyson: this isn’t something that there isn’t any medical data on. In terms of safety, if you are someone who has pelvic floor dysfunction in general, I would seek a physician or specialist out before trying them. If you don’t, try one that’s smaller and see how it feels. If there’s any sort of discomfort, don’t do it. There are no studies so it’s not something we prescribe. However, patients of ours have mentioned that they’re doing it and it’s not contraindicated. It’s okay to try: start small and for a short time.
Georgie: have you found that there have been benefits?
Allyson: I haven’t had enough experience to say that.
Georgie: hopefully they come with detailed instructions.
Another question from Facebook that came up was pelvic floor exercises for about one year postpartum.
Allyson: that’s a bit of a challenge to answer without examination because it depends on how your pelvis responded to birth. There are two different categories: hypertonic and hypotonic. For example, kegels aren’t recommended for hypertonic pelvises. You need an exam.
Georgie: even I’m learning that there are so many other exercises and kegels aren’t always recommended.
The next question is about a prolapsed rectum. This person has that condition. They had a baby 22 years ago and she feels it’s a bulge when she uses the bathroom.
Allyson: I would seek medical care if you’re concerned. If you’re sensing a heavy bulge when having a bowel movement, I would look for a pelvic rehab physician or ask your gynecologist for pelvic floor rehab therapy.
Georgie: maybe she’s in a situation where her OB simply doesn’t know, so that would be something to ask.
There are so many women who live in areas where specialists aren’t as readily available. What would you recommend if this person, or anyone listening, is in a situation where they don’t have that kind of access? Are there other options? Do they have to travel for treatment? Do you have wisdom to share?
Allyson: International Pelvic Pain Society has excellent resources and find a provider link. Check there. That will tell you the closest providers who understand pelvic floor and pelvic pain. I would Google your nearest pelvic floor physical therapist. Sometimes, at this point, there could be a bit of a drive. Pelvic floor rehabilitation has a Facebook group for remote or international members. This provides expert information.
Georgie: the last question is, how does pelvic floor rehabilitation help with fertility?
Allyson: there’s no data on this. We say we can help patients have more comfortable intercourse or have more comfort in bowels. The PRM vertical is about decreasing inflammation. Inflammation of course could compromise your fertility. We don’t directly claim to help with fertility. As far as fertility, we help you have comfortable and enjoyable intercourse.
We can treat women before they have IVF or other fertility treatments to make all of the procedures more comfortable. Decreasing spasms or inflammation around the nerves can make the procedures more comfortable.