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.
What we Discuss
What is pelvic floor rehabilitation?
What happens at pelvic floor physio?
How can pelvic floor therapy help with UTIs or feelings of one?
How can pelvic floor physio help with pelvic floor pain during intercourse?
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.