Dr. King is a member of the Cleveland Clinic Section of Minimally Invasive Gynecologic Surgery. She is the Director of Benign Gynecologic Surgery, the Director of Innovation for the Women's Health Institute and the Associate Program Director of the MIGS Fellowship. She served on the Executive Board of AAGL Fellowship Board as well as the SGS Board and is host of their collaborative podcast, Gynecologic Surgeons Unscrubbed. It's great if you're looking for something to listen to. She has so many accolades. We could talk about them all day, and she's an amazing educator. She's earned multiple teaching awards for education endeavors for both medical students and residents, and so we are excited to have her talk about her bread and butter, chronic pelvic pain and vulvodynia. Thanks, Dr. King. Thank you so much. Thanks for inviting me. This is one of my favorite conferences every year. You guys are so hungry, like so hungry. I see it in your eyes that you just want to learn, and Lisa, we go way back. We used to share a nanny, yeah? I was with them last night. Maritza's doing fantastic. Yeah, Aliana's doing great, yeah. All right, so we're going to talk about chronic pelvic pain today and vulvodynia. Who loves chronic pain? Yes, there's always like one, yeah. I'm happy that you guys are here, though, hungry to learn more about it. I think a lot of the reason why we don't like it is it's just really messy. It can be hard to scaffold our minds and how to get our arms around it, so I'm hoping that we can do that today. I'm a consultant from Medtronic. I'm president of the Academy for Surgical Coaching, which will not impact my slides today. So we're going to talk about defining what is chronic pelvic pain, what is vulvodynia, review some causes, talk about how to get a really great history, as well as perform a really thorough and thoughtful pelvic exam. Then we're going to move into medical management and understanding when to refer to a surgeon. So I am a minimally invasive gynecologic surgeon. I'm in the OR pretty much every single day, so it is where my brain goes and it's where my happy place is. But fortunately or unfortunately, most patients with chronic pelvic pain actually don't need surgery. So we have to understand how do we do the right workup and when do we actually refer to surgeons in the right part of your patient's journey. So like I mentioned, I think a lot of the reason that we can be intimidated by chronic pain is because it can be really complex. And so what I'm hoping that we can do for the next 30 to 45 minutes, and I did leave time at the end for questions, so if you guys have complicated patients you want to talk about, please think about them now and you can bring them up at the end. But I want to make a framework of mental scaffolding to understand the steps of what we do when we see these patients. So that's really what I'm hoping I leave you with, because we could talk forever about all of these things, but I want you to leave with a mental model of how to approach these patients in the right way, that when they leave your office that day you feel like something was accomplished and you feel good about it, and maybe you even start liking this population. All right, so what is chronic pain? Chronic pain, there's a lot of definitions out there, but the most common one is going to be non-cyclic pain perceived to be in the pelvic area that has persisted for at least three to six months and is not related to pregnancy. So that's very vague, yeah? Vulvodynia, vulvar pain of at least three months of duration that has no identifiable cause. There's a lot of causes for vulvar pain. We've reviewed a lot of them already. That last presentation was incredible. You see those Kenalog injections, what it did to the vulva? Oh my God, that was amazing. But no identifiable cause, yeah? So like no infection that we can see, et cetera. So this is, we've done in our exam and there's nothing that we can identify, that's considered vulvodynia. Now chronic pain impacts about six to 25% of reproductive age women. Think about that. That's like everybody, not really, one in four, but that's like a lot, right? And 99% of diagnostic laparoscopies for chronic pain in the US are on women or people with uteri, yeah? And vulvodynia is most frequently the cause of dyspnea and premenopausal women with a prevalence of about 12% of all comers into your office. So are you guys seeing chronic pain in your clinics? Like of course you are, right? Like in some capacity, we all are. And what I think the takeaway message from this is that it is very common, it's likely under-measured overall, and it disproportionately impacts women, especially during the reproductive years when we're supposed to be the most productive of our lives. So it's a huge issue. So I wanna really work on a strategy. And we're gonna start with, before you even see the patients, what's our strategy, what's our mental model of how we approach these patients? So you're in clinic tomorrow, you see that one of your patients is a chronic pelvic pain patient. So instead of feeling defeated before you see her, how do you become proactive in that? This really starts before you even see the patient, in my opinion. So utilizing standard questionnaires, I think, can be exceptionally helpful. Are you guys using any standardized questionnaires right now? There's a lot out there, and I think this is actually really helpful in that a lot of the information can happen before you actually see them. Because you can get really, really bogged down with a lot of things that you can actually get in a questionnaire beforehand, so you can target your discussion when you see them a little bit more deliberately. And I know I say gather and view all available data. That may seem like, yeah, obviously, King, I will do that. But I think what I mean by that is creating a team around you when you can to go through a lot of this before the patient gets there. And so some of this is gonna be systemic changes, right? Like actually in your clinic and getting buy-in from the top down to actually create what you need resource-wise to see these patients in the right way. I'm at the Cleveland Clinic, so I'm obviously a high-volume referral center where I'm seeing patients who have seen nine billion other providers and come with a huge stack. And so I fortunately have a nurse coordinator team and a nurse practitioner team that helps do this before they even get there. But if you can create a way to actually go through the data before they get there, again, it's gonna make your visit with them much higher impact versus extending their visit appointment that day and running late. But then also setting expectations. So recognizing that the initial eval, you may require more than one visit. And framing that up front and even informing the patient up front. Like today we may only get through 80% of your story and it's really, really important that we do that. But today may not be the day that we actually even dive into management or treatment options. So I think framing expectations from both ends before we even see the patient can actually go really, really far when you actually get them in your office. Now in regard to different questionnaires, there's a lot of them out there. And IPPS, the International Pelvic Pain Society is an incredible resource for a lot of these things. But they really have a thorough pelvic pain assessment form. It's 11 pages long. So it is quite extensive. But it's a really good place to start. And if you can somehow get this to your patients before you see them or even in the waiting room while you're rooming them, if they can get through this. Again, it can help a lot with the visit itself, diving into things that are really important. All right, I played around a lot with the order of my slides, right? Like I'm like, we'll talk about peri, and then we'll get into history and physical and then causes. I flip things around because my history and my physical is completely based around causes and understanding that. So I think about being like a detective, like a detective ninja in these chronic pelvic pain visits. Yeah? And one thing that I see when I'm teaching my learners, so residents, fellows, medical students, is they'll come in and they'll check the boxes of asking all the right questions, but they're not framing their brains during that history of actually what their end point is, if that makes sense. So I think it's really important to understand the causes before getting into the history, because that's gonna frame how you ask your questions and how you dive into certain avenues. So if I break this up into the biggest scaffolding possible, I think about somatic structures, I think about visceral organs, and I think about central sensitization. So in regard to somatic structures, I'm thinking like muscles and bones. In regard to visceral organs, I'm thinking about uterus, ovaries, bowel, bladder. And what I really love about pelvic pain and the pelvis in general, is there's so much stuff going on. It's like wicked exciting for me, because there's a bowel, there's a bladder, and there's ureters, there's a pelvic floor, and there's uterus, and there's tubes, and there's ovaries, and there's nerves, which is why I love pelvic surgery, because it's so complex, but also makes it a little bit muddy in our heads when we try to navigate through this. So again, zooming way, way out, I think about somatic, visceral, and central. And then my brain breaks everything up into these columns, and I literally think I associate these colors with the organ parts. It's like the way my brain works. So I think about GYN, GI, GU, musculoskeletal, neuro, and the psychogenic, the psychologic part of it. And so when I ask my questions, this is the way my brain kind of goes through the different organ systems. So within GYN, I typically say, I'm a mainly invasive GYN surgeon, gynecology is where my brain oftentimes goes, but our body does not work in silos. Our body has a lot of overlap, so I have to ask about all the other things to understand where your pain is coming from. So from a GYN, we talk about adenomyosis, that's when the lining of the uterus can implant into the muscle wall, endometriosis, when the lining tissue, similar to the lining of the uterus, can implant outside the uterus. This is the primary part of my practice. I'm primarily an endometriosis surgeon of stage three, stage four, so bowel, bladder, ureteral, diaphragm endo is my specialty. I think about adhesive disease, ovarian remnant syndrome. You guys know a lot of these, tubal pathology, fibroids, malignancy. So that's a GYN column. Within GI, we want to think about things like irritable bowel syndrome. Cancer's always on the differential, but lower down. Hernias, I think a lot about hernias when we're thinking about right and left lower quadrant pain. From a GU perspective, I'm thinking about bladder pain syndrome, urethra issues, renal stones, so thinking about back pain that radiates towards the front. Of course, malignancy's on the list. Musculoskeletal, you guys are getting a ton of this with pelvic floor, which is amazing, and I'm gonna talk about that in more detail as well. Coccydynia, SI joint dysfunction, fibromyalgia, et cetera. In regard to neuropathic, I'm thinking about disc disease. I'm also thinking about nerve pathway things, and so that can sometimes be from a surgery that we unfortunately snagged a nerve or it could be more central. Then I think about the psychologic component. You have to be careful how you ask these questions and how you address these questions, right? You never want to make the patient think that it's in their head, because it's not, what their experience is is real, and so acknowledging that when you go down this path I think is really critical, because sometimes if you start talking about depression and anxiety, like of course, I shouldn't say of course, a lot of the patients are feeling this because they can't live the quality of life that they want, but you have to make sure you're separating that. It's not depression that's causing the pain. It can sometimes be the other way, so you need to address that the right way. Now I want to talk a bit about normal sensation versus central sensitization. The main thing I want you to see on this slide is that in normal sensation, so the top path that you see with that nerve is noxious stimuli that's painful, like touching a hot stove. Ideally, that should be a straight line telling your body that you have pain, right? It's not diverging over to that bottom nerve. It's going straight across and saying you're touching a hot stove, 10 out of 10, remove your hand. In the bottom one, that's light touch. That's like someone touching your skin that you notice that's having maybe a full bladder and noticing you have to pee. That's maybe ovulating and being like, ugh, I feel a little bit like I'm ovulating, but I'm not like 10 out of 10. And that should stay on the bottom, the bottom nerve pathway. So there should be two separate tracks between pain and then just light touch or not noxious stimuli. Now with central sensitization, these paths cross. So what happens is that touching a stove, yeah, that goes straight across and tells your body that you're having pain, but there's a crossing of just the light touch and normal sensation. I call this physiologic things that are happening. There's a cross that goes over to the high intensity pain. So the way I describe this to my patients, I've played around with the way I describe this. If you guys have better ways, please let me know because this is not perfect. But I say things like, so again, pain is not in your head. Your pain is real, but your body isn't recognizing the difference between normal physiologic things like a full bladder or you have to poop or you're having intercourse or you're ovulating with things that are 10 out of 10 pain. So it's almost like the wires are crossed. So it's like me going into the bathroom and flipping the light switch and having the toilet flush. It's just not crossed. It's not wired the right way. And this is not in your head. This is real neuropathic changes that happen. I'll sometimes also compare it to like train tracks and a conductor saying which track that the train should go on. And in these patients' spine, the conductor doesn't understand. The conductor isn't keeping the pain on the right path and it's crossing. So things like ovulation are giving you 10 out of 10 pain or full bladder is giving you 10 out of 10 pain. You have to describe these in a way that the patient understands what you're talking about because 90% of this is having patient buy-in, right? Because patients oftentimes are coming, at least to me, very frustrated right off the bat. And so having the patient truly understand and buy-in on the treatment methods are gonna be really important. Okay, so history. So the patient comes in with like a whole mess of stuff. And so what our job is is to sort this out in a way that makes sense in our brains and in a way that we can then communicate that with the patient and create the right care plan. So this is the way my brain works in regard to taking my patient and then kind of putting it into those columns so I can understand what care team we need to put on board and how I counsel my patient in the right way. So history. So again, these aren't just boxes to check. A lot of times I'll have my learner come out and just kind of go through these boxes. But I want you guys to think analytically when you talk to your patients about those different columns that we just saw with causes and how we ask the right question to get to the bottom of that. So I talk about pain, location, and radiation. So I oftentimes, I mean, that's pretty self-explanatory. Right, left, middle, right, does it travel anywhere? Does it travel down your leg? Does it travel into your butt? Does it travel into your vagina? Does it travel into your upper quadrant? I wanna know about quality of that. Is it crampy, sharp, dull, fire-like, throbbing? All these things make a difference. So my brain is thinking, okay, so if it's fire-like, that's more neuropathic. If it's cramping-like, is that more uterine? Is it worse at the end of the day? Is it worse at the beginning of the day? I'm timing all this out to think about pelvic floor, uterus, nerves. Associated factors, so I always ask about things that are associated with their symptoms, which the next slide will break that down. I wanna know about timing, and I wanna know about setting. So timing, what I'm really getting into is, is it cyclic? Is it related to their periods? I'll be worried about a hormonal thing. So again, I do primarily endometriosis, so I wanna know, is this worse during ovulation? Is this worse during your periods? But endo, if you wait long enough, the average delay of endometriosis is seven to 10 years between patients presenting and an actual diagnosis. Isn't that insane? 10 years for a real diagnosis? Think about 10 years of chronic pain. By the time I see them, it's no longer endo. I mean, it's very much endo. But there's like all these other columns that we have to address, or even if I do the most perfect surgery, they're not going to improve. So I wanna know about timing. And I wanna know about setting. I wanna know, when did you first identify your pain? Did you just wake up in the morning and have pain? Was this like a slow onset? And when you talk about setting, oftentimes, I shouldn't say often, sometimes a patient will be like, oh yeah, I was like a cheerleader in high school and I got thrown around and fell on my coccyx and it broke. It did, wow, okay, that may be contributing to it, right? There's like some random thing that they didn't maybe think about. But I ask very much getting into when did this actually start? Was there a trauma? Was this slow, a slow onset? And then you wanna also open up that area of like sexual abuse or trauma or things like that, because that can also trigger a lot of things down the road that you may not realize are associated. All right, so for associated symptoms. These are kind of my big buckets that I dive into. And this order is maybe a little bit off. My sexual symptoms are gonna be last. I wanna make sure that I build good rapport with my patients before I dive into things that are extra sensitive. And so even for my physical exam, I oftentimes, I'll break it down, but I start with very non-private places and then work my way down into the pelvic exam. So I typically start with my urinary symptoms, but for this list, sexual symptoms, the things I wanna know is have you always had pain? Is this pain newer? Is it pain with just initial penetration or is there also pain with deep penetration? Does it get better once you get going? Does the pain actually not start until after you're finished having intercourse? Does the pain get worse with orgasm? Can you orgasm? Like, we get into it. Like, we really get into it for these visits. But like, this is helping your brain understand where the source is. Urinary things, right? So do you have pain with a full bladder? Does it hurt when you actually start your stream? Does it hurt when you're finished with your stream? Can you start your stream when you want to? Can you finish, like when you finish peeing, do you feel like you have to sit there for a while to actually finish emptying? When you sit down, can you pee right when you want or do you have to wait a while to start? Again, this is thinking about pelvic floor things. For bowel movements, I wanna know about bloating, constipation, diarrhea, blood on bowel movements. And if you say, yeah, I have pain with bowel movements, I wanna know more about that. Does it hurt when you just have to poop? Is it actually hurt when you're like passing the bowel movement? I know this sounds crazy how specific we get but it helps my brain understand where the source is from. With deeply infiltrating bowel undo, it oftentimes feels very sharp, almost like spastic-like. And so I'll say things like, when you have a bowel movement does it feel like there's a sharp blade going up your rectum? These are really discrete things but it helps me understand where we're coming from. Myofascial questions are things such as is the pain worse in the morning versus night? Is the pain worse more with physical activity? Is the pain worse after intercourse? Because sometimes that will cause a trigger. And then autonomic things are gonna be more central acting things like bloating, for example. And that helps, again, explain to the patient this is much more than just maybe your bowel but it's a lot more than that from an anatomic standpoint. And we also cannot ignore our biopsychosocial part. So the social support aspect of your patient, abuse history, and sometimes they won't divulge just right off the bat. So opening it up with even the question so they know that it's on your mind. Sometimes the patient will come back in the second, third, fourth visit and then divulge this information. Sleep assessment and sexual habits. So do they even have a libido? Do they have a sex drive? That's also telling you about overall health. So chronology. This happens, I see this a lot when patients are identifying progressively larger areas of pain and thinking that an actual disease process, like something physical is changing within them. I think about this with endometriosis. So I always ask about is the pain getting better, worse, or no change? And a lot of patients will think that their endometriosis is like going throughout their entire body, right? Before it just hurt when I had periods but now I feel like it's everywhere. It's growing into my bladder, it's growing into my bowel. I think I have it on my right eyeball and my lung, right? Like it's freaking endo. It grows rampant for some patients when they come to me. And their pain is real, but I think it's important to understand the central sensitization process. You can have more pain without an actual something like endo doing that. It's the neuropathic part of that, the central sensitization part of that. So understanding progression. Another part of my history that I've incorporated that I think has made a huge difference, honestly, in patient buy-in and for me to understand where they're coming from is what are the patients and family, oftentimes, if they bring their family member in, what are their ideas about the causes of their pain and the future of their pain? So sometimes a patient's idea of what is going on is not even on my differential. Like some patients will come in and think they have cancer and I wouldn't even have that in my differential. But when I ask them, they're like, they maybe will bring that up as an example. And if I didn't ask them and bring that up as part of my counseling, they may have left feeling like I didn't address all the things. So understanding what they think and what they think their future of their pain is, I think is critical. And again, I say family's ideas just because if you have a patient come in with a family member who has an idea and is feeding that idea to your patient and you don't realize what all that is going on outside your room, it's not going to be able, it's not going to offer you the best knowledge to counsel your patient in the right way. Are you guys hanging on? Yeah, yeah, you're hanging on. Okay, cool. All right. So moving into physical exam. All right. So we did our pre-appointment questionnaire. We have an idea why they came in. We have our physical, our history. I sometimes do my history with them dressed to build that rapport, make them not feel like they're already half naked freezing on a table and I'm sure I'm running behind so making sure they're not naked while I'm running behind. So dressed, history. I then have them change and honestly the physical exam starts with just observation of how they move. Like how do they get up from their chair and walk over to the exam table? Like how they walk down the hall when I saw them? Those little slight movements are actually, my brain is working already critically thinking about where their pain could be coming from. And then I look at this as some seeds on the table. Like take a second just to look at their hips and like how they're sitting. Like sometimes you'll see a patient she's leaning like way off on her left hip and you're like man I guarantee her right levator spasming right now. Like you can just see like little shifts of things or sometimes you'll walk into a room, maybe you've walked into a room and the patient's like pacing around. Like they can't sit. You're like why aren't you sitting? Like it hurts for them to sit. Like these little cues actually are you being your ninja detective to know what's going on. And then again half of this is patient buy-in. So when you're counseling, when you say things like when I walked I noticed you couldn't even sit down. That completely fits in with a really significant musculoskeletal skeletal component. And that gives them buy-in that you're actually noticing what they're doing. Then we go to supine. I lied. Take it back. Seated. Okay so as they're seated, next I just look at their back and like their hips and they're and they're and they're like where their hips are when I look at the back of them. So I'm a DO, osteopathic physician. So I was trained in OMM and all that all that stuff. And so my what I'm looking for is evenness of the iliac spines. I'm looking to see if the spine is straight. And so I'm starting with my exam just actually touching their shoulder, touching their back, touching their flank, looking for flank tenderness, looking at the height of their iliac crest. Is it off or is it even? And so and that's also me just touching my patient not straight to their vagina. Yeah like I've seen so many people just jump in and throw a speculum in and like that is the last thing you want to do. So just starting touching your patient in a way that feels comfortable, ask their permission, and in a way that's not intimidating. Okay now they're lying down. So next again you're observing how they lay down. Can they can they fire their abdominal muscles? Can they not? Are they like laying on their side and then laying down? Like what does that look like? And then I just start by looking again at their abdomen. Sometimes for incisions because people somehow forget major surgeries. Like how many times are you like have you had surgery before? No? Okay great. You lift up their shirt and there's like a vertical midline keloid. I'm like ma'am what's that? Oh I had gut malrotation. Yeah yeah they like flipped everything around. Yeah like things like you're like oh my god like that. So look for scars that will tee in about previous surgeries, adhesion disease, things like that. And then after that I just start with very gentle touch. Like very light touch. Because some patients will say things like you know hurts even when my pants rub or my underwear rubs or like the shower hits me and that hurts. Like you know right away there's a central neuropathic process going on. So I start just by light touch. And does my light touch already cause them discomfort? If that's the case again you know there's a central component. Next I touch just bony structures. I touch their iliac crest. I touch their pubic bone. And again that's telling me is there an actual bony issue. Pubic bone I'm looking for any diastasis like separation. Especially if someone's had pregnancy. I've also diagnosed a few endonodules right on the pubic bone. That if I didn't deliberately check. Siri was that UW? Remember that triplet? I had triplets. They all had the same endo. That's crazy. Yeah she followed me to Cleveland. So I found like a little nodule like right on someone's pubic bone. So being very deliberate about that. Yeah ASIS pubic bone. And then from there then you can start palpating a little bit deeper. And I start in the areas that don't hurt. So if all of our pain is in our left lower quadrant I'm starting in the right upper quadrant. So you're gonna start in the area that does not hurt. And then from there I actually always make my patients show me with one finger where the pain is if they can. So can you just show me with one finger where your pain is? And that's gonna help identify it as well. Because some patients have pain everywhere. And if they do mental note that too. But make them try to localize it to see if there's a central spot that radiates out. Once I find that then I have them do a lot of flexion of their muscles. And on the next slide I have a picture of a carnet sign if you're not familiar with what that is. But I'm looking for what I call TTAs tissue texture abnormalities. Where I'm feeling almost like a fascia knot within their abdominal wall. I'm also feeling for any hernias. So I want them to do kind of a half sit up to see there's any hernia formation in that area. And then again endometriomas. Especially if someone's had c-sections. Think about subcutaneous endometriomas. Because that can sometimes happen when they take the uterus out. Some of the endometrium can get into that subcutaneous wall. So sometimes we cause the endo unfortunately. So are you guys familiar with carnet sign? Are you guys doing that at all? So what that is is you're gonna find the area that causes the most discomfort. You're gonna palpate that with them just relaxed. And then you're gonna palpate it again with them flexing. And that either can be their legs lifting or their head lifting. Something like a half sit up. And what that's doing is telling you is that pain supra or infra fascial. So if you touch that spot and they do a half sit up and their pain gets worse. Then it's probably fascial. Musculoskeletal. If they do a half sit up and their pain gets better. It's probably deep roll and more likely visceral. And so that's a good way to kind of differentiate. Would a trigger point work? Would it not work? When you're breaking things down. All right. So that is everything before the pelvic exam. So next we get to the to the pelvic exam itself. So again the very first thing I do is just look. So just take a second and look. And the previous lectures that we've had have dove a lot into the vulvar exam. So I'm not gonna get into a lot of deep detail. Other than don't just run in there with a speculum. Please God. Like if you learn nothing else from today. Please put the speculum down. So for chronic pelvic pain patients. I oftentimes won't even use a speculum depending on what they're coming in for. If I'm worried about weird bleeding or something like that I may. But in general if you just run in there and throw a speculum in. Your physical exam is a wash. Like everything just hurts. And then you it's hard really hard to get a good read of what you need to do next. So just look to start. Next you can you can move to a Q-tip right. And so you want to be very deliberate when you touch. Sometimes you can also break the Q-tip in half and do very light very light like soft like sharp versus dull to understand nerve differences. You can check for anal wink to see if there's neuropathic things going on. So this is you just being very gentle looking and touching. All right next we're getting to our internal exam. Still no speculum. Okay still no speculum. So this is a part where you're getting patients buy-in as well. Because you're gonna take your findings of this physical exam and use it when you start to counsel them at the end. So the first thing I'm gonna do is just use one finger for all of this. So after you do your outside vulvar exam you're gonna take one finger and just put it right at the introitus. You're not even gonna go in. You're just gonna hover it. Just sit it there and say does this cause pain. Because if they're already having pain and you're not even like trying to do anything that gives you a ton of information about where the source could be. Next I go in maybe three centimeters one finger. Do not move. And what I'm feeling for is vaginismus right. So you know sometimes you put a finger in someone's vagina and it's like twitching on your finger. That's telling you that there's a lot of pelvic floor spasm and central central sensitization going on. And with every move I'm asking does this cause pain and is this the pain that you came in to see me with today. Because there's a difference right. If someone has a has pain but it's not why they actually came today. Maybe you put that on the back table for the moment to address the pain that's that's bringing them in today. So it's one finger in just sitting right in the middle checking for vaginismus or pain. I have really small hands so I'm not even near their cervix yet. I can't usually reach cervices with just one finger so I'm not even there yet. Then I go towards the bladder next and say this is gonna feel like you have to pee. That's totally normal sensation but does this cause this does this cause you pain and is that the pain that you came in to see me with today. Next I rotate towards the rectum put pressure towards the rectum. This is gonna make you feel like you have to poop. That's normal but does this cause this pain. Does this cause you pain. From there I'm gonna go laterally. I'm checking the levator and obtrator muscles and I'm sure you guys have had a lot of lectures on this already or you will but the short version is I find that ischial spine above it is obtrator below it is gonna be levator and you're gonna see if that spasming underneath your finger does it feel hypertrophic and does it cause pain. After I've done all of that then I put a second finger in to try to reach their cervix. Is there cervical motion tenderness? Next the uterine sacral ligaments. Is there a uterine sacral ligament nodularity? And then after I've done all of that then I put my hand on their abdomen for the uterine part and I'm checking for fibroids adenomyosis which is pain with the uterus oftentimes ovarian masses things like that and also mobility. So if a patient has a uterus that does not move it makes me worry that there's endometriosis there as well. And then after that I consider a speculum exam but even then oftentimes I don't if I don't feel like I need to. If they're not having abnormal bleeding, they're up to date on their pap smears all those things you may not need a speculum exam that day and so don't just make that your autopilot. Does that make sense? Yeah okay so uterine sacral ligaments yeah these are ligaments that go from your uterus to your sacrum. You can feel those on exam. They're gonna be right to the left and right of the cervix itself. If you don't do a ton of these you may not be able to pick up subtle endometriosis there but what you should be able to feel is if the cervix is deviated. So if you go in and the cervix is like wicked off to the left or wicked off to the right that oftentimes means there's nodularity or shortening of that uterine sacral ligament so you can at least mental note that. And then the pelvic floor muscles right big bowl of muscles that goes from our pubic bones, hips, coccyx keeps everything up and again the main thing you're feeling for is that ischial spine and sweeping up as obturator down as levator and when I do this this is what I wanted to say. When I do this I'm asking them right is this the pain that you came in with today? Patients oftentimes will say yes that's my pain and what I'll say to them during that moment is excellent I'm happy that I found it found it I'm sorry that I'm hurting you right now I'm on your levator muscle I'm nowhere near any of your GYN organs right now when I'm done with my exam I'll talk to you about what that means and what I'm doing is I'm planting the seed because every patient comes in to see me they don't they like what they think it's their ovaries do you guys see that everyone hates their ovaries why do people hate their ovaries it's like the only thing that's working for them oftentimes and so like on everyone's questionnaire they're like I want my right ovary out I'm like ma'am that is like not what we need to do today and so even when patients come in to see me they're like yeah my I'm having right ovary pain I instantly will tell them don't use organs use locations I need to like break the association that they hate their ovary or their uterus I just want location because the more again this is all patient buy-in and so the more you can tell them again this is your pain that like I'm touching your obturator muscle right now I'm nowhere near your GYN organs I'll talk about that in a moment they're thinking like oh my god when you tell when she touched my ovary that actually wasn't painful and it's gonna help you a lot more when you counsel we're playing chess yeah okay so what's our next move so lab testing there's not a ton of labs that can help us man I wish that there was like I wish there was a serum blood draw for endo yes no we're actively working on it but alas we are women and so we have no research dollars so with that being said we're working on it but we don't have any of any of that yet so I mean you want to rule out infectious causes yeah so like sometimes we'll get a CBC to check for a white count but I don't even think that's necessarily needed a sed right yeah I guess maybe cervical cultures yeah like make sure you don't have like a raging gonorrhea infection like that you don't want that going on because that can cause pain you make sure they're not pregnant right so because if they're having pain this much pain and they're pregnant that's an issue maybe a urine cytology if they're having some hematuria if someone has had a bilateral sapingo oophorectomy and they're having a lot of pain sometimes I will get an FSH if I'm and an estradiol if I'm worried about ovarian remnant syndrome so that could be an idea and if someone's had a hysterectomy and they're having periods not good that is not normal so that would also necessitate you to think about endometriosis on their vaginal cuff that could still be residual imaging yes we need some baseline imaging and that's going to help the surgeon figure out if they need surgery or not surgery and so things we're looking for is going to be things like ovarian torsion right is there ovarian cyst that looks like it could be twisted is there an infection like a TOA going on within their adnexa are there big fibroids transvaginal ultrasounds typically our gold standard we can see everything from an ovarian perspective typically with a transvaginal ultrasound this is a picture of an endometrioma that kind of has that we call it glass ground appearance are you guys doing any type of interactive ultrasounds like a slide sign or like mobile ultrasounds where you guys are we're working hard to make that like standard so seeing if the uterus and bowel move freely or if the ovaries move freely but that can also be helpful to see if things are sticky or if they're moving MRI can be helpful at better soft tissue differentiation maybe a colonoscopy and the main thing that you want to make sure is that this isn't an urgent situation right so when you see a patient you have to make sure they're not going to have something urgent happen that night so fevers are never normal you need to address that right away ovarian torsion right so that's like acute rebound guarding febrile nauseous puking not normal you need to address that make sure not worried about something like an intestinal obstruction appendicitis ectopic pregnancy these things cannot wait and chronic pain patients can get these things obviously you have to make sure that you are thinking critically when you see them that there could be something acute going on and making sure that it's not the road is windy yes the road is windy and so again setting the expectations with the patient because a lot of patients come in that day and they are ready to feel better and from in my role they're always like okay I'm ready for surgery take my ovary out and we have to step back in that sometimes the road doesn't look like that right patients expectations are straight up the reality is oftentimes not that straight sometimes we have to say I may not get your pain ever down to a zero out of ten like the best we can do is maybe a four out of ten but I want to make sure we can actually get you back doing the things that are important to you and goal of regaining function so again sometimes just saying we may not be able to find this we may not get you down to a zero and that conversation can be hard but I think it's really important and also thinking about a multimodal approach so for my last bit here I'm going to talk a bit about some medication management things that we can think about and how to incorporate the right multimodal team so again my brain as you can see works in these scaffolding so I think about surgery medications non medication options and then injections so within the area of surgery a lot of these patients don't need it but things we're thinking about are gonna be if there's endometriosis they're excising all of that but framing in a way that excision of endo may not fix everything we may still have to add on other things like pelvic floor PT and injections etc but it could help because we need to get those peripheral nerve generators out ovarian cystectomy versus oophorectomy so there's big ovarian masses if there's big fibroids we may need to operate on those if there's mesh coming through then we may have to think about taking that out if there's an I say nerve release meaning if they've had surgery now they're having pain right after you worry about us and trapping a nerve in our procedure so that may need a repeat surgery to make sure it's not being being pulled down medications we're gonna get into that in a lot a lot of detail shortly non medication things like pelvic floor physical therapy critical all my patients are getting that cognitive therapy right psychoeducational approaches functional medicine consults can be really helpful at anti-inflammatory diet counseling acupuncture I'm a big believer in all of these things but again just overlaying multiple things at once I actually think can be helpful and then injections so that can be sometimes pelvic floor injections trigger point injections abdominally as we as you stated earlier nobody likes a needle to the genitals I have to back that up but it can help so sometimes we recommend it so this is my world it's such a beautiful world I love this world so deeply and I think very rarely give a lecture without videos I'm not giving any videos today but this world is gorgeous but again moving on so here what I want to show is just the ink the ileoinguinal nerve and then they'll hypogastric nerve these can sometimes be snagged when we're doing certain surgeries especially if your surgeons using a 10 port laterally which I never do my 10 port is always super pubic or umbilical but if they're putting lateral 10 ports so this may not mean anything to you guys so 10 millimeter trocar yeah anything over five millimeters needs a fascial stitch so it decreases the risk of hernia so if your surgeons putting a 10 millimeter port or larger laterally that means I have to close the fascia that means they're doing a big whomping fascia bite and you can snag these nerves when they do that or even see sections when they close that fascia so if if they're having fire pain radiating pain especially after a surgery in that area think of that that those two nerves could be potentially incorporated within a fascial stitch this is my typical multi ID team I don't include all these people every single time but we include a lot of these people most of the time so pelvic floor PT my favorite human in the entire world is going to be pelvic floor PT I use them a million times every single day and then again nutrition pain psychology urology if they need them functional medicine gynecology GI and visual anesthesia and I tell our patients we are going to build a tribe around you it's going to take time it's I oftentimes say it's taking you let's say 10 years to see me it's gonna take you a couple years probably to get back to where you want to be which again is just setting the expectation and I also say again I'm always thinking about how to counsel patients please tell me if you have something that works really well I have a time say I think about myself like a janitor with like a million keys yeah and like we're gonna try this key in the door like a few times it may take us a few times to figure out what keys gonna work for you because everybody's journey is so unique but we're gonna build a tribe around you we're gonna make steady and unrelenting progress we have sometimes a few steps back but we can do this together there's something to say about optimism I think that helps the universe in general yeah all right so pelvic rehab calm I'm sure people have talked about this already with you this is the most hit website in my world and so this is a really great way that patients can put in their zip code find somebody close than that does a type of PT that we're talking about in regard to medications right so there's like a medication ladder that we have to think about starting with very simple things over-the-counter and then building to more complex modalities and so you know a lot of times I'll say like NSAIDs and acetaminophen and people laugh and scoff at that I get it like if they were if they had if this work they probably won't be coming to see me but I still bring it up make sure they're dosing themselves correctly make sure they know this is an option you synergistically with other things and so that would be our first tier next is gonna be topical analgesics and so I think it's important to think about getting a little creative in this area and again this isn't like every patient gets all of these things this is like us figuring out what they've tried what symptoms they have what things are realistic for them what things are insurance are covering like a million things but for topical analgesics you can really make whatever you want if you have a compounding pharmacy and so think about the only thing I mentioned is think about what base you're putting these compounded medications in so make sure it's a very neutral base and if you have somebody who's hypersensitive I sometimes will give them just the base alone to make sure that it doesn't bother their skin so sometimes just giving them the base straight up make sure they do okay with it and they're not blaming a medication and saying that they're allergic to that for the rest of their lives when that may not be the case so things like combination amitriptyline and ketamine have been shown to help with some rectal genital and perineal pain you can also compound topical analgesics as you can see, or carpacin. So these are different ideas that you can kind of have in your toolbox of things that you can do in regard to topical analgesics. There was a study looking at baclofen, amitriptyline, and ketamine mixed into one suppository. They used baclofen 10, amitriptyline 40, ketamine 20, and compounded it into a gel. And this seemed to work for some patients, but again, evidence is not great for any of these things. So last presentation, there was a slide that was just white and it had a question mark in the middle. Like, I need that for this one. We don't really know what works. It's like you try things and you see what the patient does well with. I will say I use baclofen alone a fair amount of time. I just compound it as a 10 milligram suppository. My compounding pharmacy does it. I tell them they can place it one to three times a day. I usually have them start placing it at night before bed. Anything that goes in the vagina, if they're up running around, is gonna come out. So side effects are low, but the main complaint is that they have extra vaginal discharge. If it works well for them at night and they wanna use it during the day, then I oftentimes recommend rectal placement because then it's real in there. Yeah, it'll come out when they poop, not like when they're playing pickleball. And so, not that these patients are actually playing pickleball, but it probably would help. So vaginally at night, rectally if they're gonna be running around during the day, up to one to three times a day, I found works really well, especially if they're starting pelvic floor PT. So pelvic floor PT can sometimes spike pain before it gets better. And I oftentimes tell my patients that means we're doing the right thing, even though it might seem counterintuitive. And so giving them some vaginal Baclofen can be helpful. The last comment I wanna make on vaginal Baclofen is that it can sometimes be expensive, depending on what patient's insurance are covering. I used to work at the VA, which was really hard to get things covered. And so what we would sometimes do was take actual Baclofen tablets, crush them, and then put it in KY jelly or coconut oil or something that worked. I would actually have them, I'd give them a handful of gloves to go home with. I'd have them put a dose in the finger of each glove. Do you remember this, Sari? Yeah, we did this a lot. And then put it in the freezer, yeah. And then I'd tell them to cut the finger off the glove and pop it out and slip it in, yeah. I will say, I moved to Cleveland and started doing that. And my pharmacist was like, what are you doing? I was like, we are not covering the things. They don't love it because it's not totally even absorption. I get that. So if you don't do, I would first line try to get a suppository. But if they can't and you're in a bind where it's nothing or maybe that, I do think it's probably helpful. So that's just an idea about getting creative and meeting patients where they are. Muscle relaxants, you have to be a bit careful with, right? Because you don't want to worry about dependency issues. But sometimes five to 10 milligrams at night can be helpful, especially if they're having more cyclic pain. In the next slide, I'll talk about hormonal suppression therapy. But sometimes that can be helpful for spot treatment. It can also improve sleep. So we recommend taking that at night if they're going to take it. Be careful with it, like I said, though, because there can be some dependency issues. And so Keras Prodol is linked to more euphoria than cyclobenzaprine. So in our practice, we rely more on cyclobenzaprine when needed. But again, this is a tiered approach or we would never start with this. In regard to hormonal suppression, if the pain is cyclic, I try to get my patients just to stop their periods. Are your patients against hormone suppression right now? Are you guys having any issues with birth control? Are you guys getting this? So in my world, in the endo world, there's a lot of social media stuff going on that do not go on birth control. If your doctor says birth control, fire them. Are you guys seeing any of that? Yeah, I'm seeing a lot of it. And so it's actually becoming really challenging because patients no longer, they think this is like us putting a Band-Aid on things and that it's messing with them and increasing cancer risk, et cetera. So again, addressing these things in the right way, providing evidence-based information can be really helpful. And again, the way I frame this to my patients is if you have diabetes, you sometimes need insulin. If you have high blood pressure, you sometimes need an antihypertensive. If you have endometriosis, the only treatment now we have is hormonal suppression. This is a treatment. I'm not putting a Band-Aid on things, but I'm helping suppress symptoms. This isn't gonna take your endometriosis away necessarily, but it can actually improve symptoms in a way that we can decrease your central sensitization, we can reset your pelvic floor, et cetera, et cetera, et cetera, right? And so I think incorporating this in the right way is really important. There's estrogen-progestin combination methods, there's progestin-only methods. Again, understand your patient's history. If they have migraines, blood clot disorder, hypertension, smoking over 35, you can't do estrogen components containing hormonal suppression options. Otherwise, you can do progestin-only. Marina IUDs are my favorite thing in the world. And so if you can convince them to do that, that's great. If pregnancy is a priority though, off the table. And so again, understanding pain versus pregnancy, because those are oftentimes directly competing, is going to be important. If you are going to prescribe birth control, I don't even call it birth control anymore, I call it hormonal suppression. It's not really helping me sell it, but I'm trying. Use it continuously. There's no reason to have periods, like ever. Like all of you guys, you shouldn't be having periods, yeah? Like none of us should be having periods. It's like very 1980. So continuous is the way to go. But sometimes if you do it too long continuously, they'll have breakthrough spotting, because it can be, it just gets too atrophic, the lining. And so when they start, if they're doing a combination or a progestin-only, sometimes I'll have them do two or three months continuously and then give themselves a break and have a period and then restart back up. It's not dangerous to go longer, but if you start spotting, it's frustrating for the patient, understandably. So trying to optimize that. All right, so if pain still persists, what do we do? So we're gonna be looking at more specific peripheral pain generators. So again, pelvic floor PT is like my go-to for everybody. Thinking about trigger point injections, are any of you guys doing trigger point injections abdominally or vaginally right now? They're wicked easy. You should learn if you don't do them, unless you don't want to, but they're really easy. So vaginal are a little bit more complex, I get that. But abdominally, you're gonna find a tissue texture abnormality that muscle knot, you can just get 10 cc's, usually a bupivacaine, some people use lidocaine, but I usually use half percent bupivacaine. You just place that needle right down to that fascia, texture, that TTA, that knot, and then you inject it within that area. Patients, oftentimes, if they're going to get relief, they're gonna get relief that day. And then oftentimes, they'll just need a handful of those injections. Again, what you're trying to do is break that nerve pathway. Nerve blocks, that's when I incorporate my regional anesthesiologist. Surgery, that's only if there's actual endonodules or fibroids or something that you can see that's causing the pain. If you have nonspecific sorcel, that's likely from central sensitization. And so to address that, we oftentimes use different types of medications that are addressing the nerves themselves. So in regard to the big buckets of these type of medications, there's the anticonvulsants, the TCAs, the tricyclic antidepressants, or the SNRIs. And so again, I tell my patients, I'm not saying that I'm treating your depression, for example, but I'm actually remodeling the nerves and addressing that. So the way that I typically start these is you're gonna start with one, you choose one class based on, again, patient's history, symptoms, ease of use, because some of these medications do require three times a day dosing, which are hard. You're gonna start low and taper up. And then you're going to adjust when needed. If there's no relief, you're gonna taper off and then attempt to switch to drug class. And then sometimes you can add on those muscle relaxants if needed on a PRN basis, or that vaginal baclofen, which can also be really helpful. So in regard to the anticonvulsants, things that we think about are gonna be the gabapentin or the pregabalin. So gabapentin can work really well, but it can take a little bit of effort to get you to the dose that you need. So typically I recommend starting at 100 or 300 just at night before they go to bed to start. We usually adjust every five to seven days. We taper up until we find good relief of their pain without making them too groggy. So fatigue is oftentimes the number one thing that we see as we get up to the higher dosages. The max dose is gonna be 2,700 milligrams per day. Or actually, it can get up to probably 36. But I typically don't go above 1,800 milligrams a day because above that, I don't see much more relief and I see a lot of fatigue. So again, you kind of have to play around with that and see what that feels like. And then we get into the TCA, so amitriptyline or nortriptyline. This can be helpful just because it's only one time a day dosing. So start at 10 or 25, one dose starting at night, and then you can wean up to a max dose of 150 milligrams. And again, this can be a little bit easier sometimes just because the dosing isn't as high in regard to once a day instead of three times a day. And then the next line is gonna be these SNRIs. And these can be medications such as duloxetine. And the side effects, we have to be careful with these just because they do have more renal and hepatic toxicity, more so than the amitriptyline family. But again, it can be a little bit easier dosing, but we have to be careful about people's underlying comorbidities and make sure we monitor these things. And then we get into the area of antipsychotic medications. Again, we have to be careful of these in that these have more side effects. So every drug class that I'm talking about is gonna have more side effects than the last oftentimes. And so it can be a lot more sedating for patients. And so if they're too sedated and they can't function either, that's not helping. And then the cannabinoids, difficult to know exactly how these are gonna integrate moving forward. I know a lot of physicians are using these. The Canadian Pain Society does recommend as a third line therapy. And so I know these are becoming more commonly used. And so again, this is just kind of the scaffolding of the way you can approach these patients with CPP in regard to understanding the cause of the pain and what medications we should be thinking about, starting with, again, NSAIDs and acetaminophen. If we don't know if there's a disease process that we can treat, if there's a disease process, then treat that first. And then moving into, is there a cyclic component? If there is, stop the cycle, hormone suppression. If there isn't, then moving into these other areas of SSNRIs, different central acting medications. And then again, any of these things can be given transdermally. And so some patients, if they don't want to be taking medications by mouth or they're hypersensitive, you can literally take anything and make it into a transdermal delivery. I think about this a lot with my vulvodynia patients. I've had some really great success in actually compounding these into a cream or a gel and having them place it vaginally. It's a little bit more local. And again, it takes some playing around with, but sometimes you can actually get some really good relief with just transdermal delivery, again, especially from a vulvodynia standpoint. So with that, I'm gonna leave you with some resources. The two main resources that I use for myself, my learners, as well as my patients, are gonna be the Vulval Pain Society. Their QR code is there, but they have some great education videos, great patient Q&A areas on their website, which are really helpful. And then International Pain Society has a pelvic pain education program with tons of helpful websites for, again, people who are training or your patients. Really fantastic videos, patient survey questionnaires. And so if you're looking for ways to really make your practice more robust in this area, this can be a good place to start. So in summary, understand the differential is important. A thoughtful history and physical exam, setting your patient up for the counseling, I think, is gonna be critical. And using a multi-ID management is often required for these more complex patients. Thanks, guys. Did you learn something? Yeah? Your scaffolded brain? Good. I left just a couple minutes for questions. Am I allowed to do that, Lisa? I don't even know. If you guys have difficult patients or questions about anything, let me know. We're gonna open up for questions. If you could come up to the mic, and also, it might be nice to say your name and where you're from, too, just to build a little bit more camaraderie in the group. Be my friend, okay. Oh, yeah, yeah. I think you, yeah. Hi, I'm Sarah Huntington. I'm from Olympia, Washington. I was really interested in your comment about how hormonal suppression can help reset the central sensitization, and in particular, those patients who still think that they might have another baby, so we don't wanna do anything definitive. I'm also interested in whether my fembri might be part of that picture of giving them a break from their pain. Yeah, really great question. You're dead on in that pain and fertility are so directly competing. You have to time this out right. So if someone's 40 and wants more babies, I'm not gonna suppress them. I'm gonna move forward and get them moving, most likely, or incorporate REI in a sooner fashion, but you're right. I did not bring up GNRH antagonists very much, like the Orlissa or the myfembris. They're hard to know when to integrate, but patients are getting some good relief with them. Orlissa, you can start low and taper up, which can be nice, right? GNRH agonists are gonna be things like Lupron for injectables. Antagonists are gonna be things like myfembri, which partners with hormone ADBAC. Yeah, I like this for three to six months. To me, this feels good when they come into me and they can't function, and I know that they have central sensitization, pelvic floor spasm, pain's worse every time they ovulate, pain's worse every time they have their period. Sometimes just stopping their period for six months so we can work on their pelvic floor, maybe do some pelvic floor injections so it'd be Lidocaine, Botox, or sometimes Botox reset, can be helpful. And then at that point, they have a whole new pelvis, work on constipation, like work on all the things, and then see what happens when they have their period again, and sometimes it's a totally different experience. So that's sometimes what I'll do, but with that being said, if you put them on hormonal suppression for six months and their pain is not better at all, or even three months and their pain's not better at all, they need a laparoscopy, in my opinion, to look for endometriosis. So again, endodelay seven to 10 years, that is awful. That needs to be changed. So don't just belittle pain. And if you try hormonal suppression, again, give them three months, if pain's not different, surgeon consult. Yeah. Hey, I'm Brooke from Moultrie, Georgia, and you kind of just answered my question. Perfect, love that. I was gonna ask, when are you pulling the trigger on a lap? Is there something specific on an exam when you're meeting a patient initially that you're like, this patient has to have a lap? Yes, love that question. Yeah, surgery questions, yes. So, great question. If there's something on imaging that's obvious, like a big endometrioma, endometriomas do not live alone. If you see an endometrioma, over 95% chance they have deep endo in the pelvis. So, omas do not live alone. So if you see an oma, then, in my practice, they get, oftentimes, if they have bowel symptoms and an oma, we get an MRI for endomapping and refer to a surgeon. Or if we see big fibroids or a big anexal mass, refer to a surgeon, in my mind. On your exam, so if you go in vaginally and you feel like their cervix is way deviated off to the side, you feel nodularity, have you guys done those exams where nothing moves? Like, maybe you haven't, I don't know. Like, nothing moves, that's a problem, refer them to a surgeon. Or if they've tried a hormonal suppression for three months and no improvement, in my mind, they deserve a laparoscopy, yeah. I'm from Colorado, but I just moved to Naples and I'm back in GYN after 33 years. Welcome home, woo! Lots of personal history, so I guess one in five women have Mayburners and, you know, nutcracker syndromes from there, but pelvic congestion syndrome, they say that it actually causes, like, larger uterus and also ovaries. When are we looking for that? Great question. Because these people have already been in pain and they're suffering for so many years and, you know, that's something simple that we can look for with a doctor and ultrasound to see if they've got some of those. Yeah, I wish I said, yes, order this. I don't, so I'll tell you my thoughts on this, though. Pelvic congestion syndrome is kind of this, like, diagnosis by exclusion, right? Like, you look at everything else, everything else is negative, then we say, maybe pelvic congestion syndrome. There's sometimes on MRI, so we'll get an MRI sometimes to look for deeper endo as well, and sometimes you can see those really dilated vessels, and if there's really dilated vessels going to your uterus or a big dilated ovarian, we call it IP ligament, like ovarian artery and vein, then we think there could be potentially some pelvic congestion as well. But with that being said, I've done some laparoscopies with huge vessels and the patients don't have pain because I'm going in for something else, right? So I can't say, like, a diameter over X millimeters means pelvic congestion, I just don't have that. But with that being said, I think having it on your differential is really important, hormonal suppression to start. If not, then we actually do include our radiologists that can actually embolize those vessels sometimes and see if that helps. And if that doesn't help, then sometimes we will go in and do more major surgeries with removing ovaries or things like, or uterus. We don't do that lightly, but sometimes that's what they need. But there's nothing, like, black or white that I can offer, unfortunately. Like, nutcracker syndrome, right? There's like, you can see it a little bit easier, potentially, but pelvic congestion's not quite like that, unfortunately. Great question. Yes. I'm Candice, I asked a question yesterday, but I'm from Salt Lake City, Utah. I'm new to urogyne. Nice, welcome. So I'm seeing all these things and I'm curious about them. But my question is in regards to post-op pain. Yes. And if you're seeing those patients, in particular, and again, it's related to sacrospinous ligament fixation. Yes. With possibly entrapping that pudendal nerve. Yes. And then having that gluteal pain, and it just persists and persists. Yes. How do you handle that, other than, like, going in and releasing it? That's a great question. I may actually pull my friend in, Lisa, a little bit on that. That's a great question. Because we see that sometimes. We'll do a surgery that we think we're gonna be, like, big ego surgeon, I fix everything. And then they come back and they're like, I feel no better or I feel worse. That's awful. So I think if there is an entrapment, do you guys release that? Like you said, you're saying if you can't release that. So I don't do those procedures. I'm pulling in Dr. Hickman. I just want the online participants to be able to hear. So, I mean, my algorithm with that, if a patient wakes up immediately after surgery and is in severe pain, it's a no-brainer. You have to just take them back to the OR and you have to cut that stitch out. Sometimes it's a little more insidious, and it could be from inflammation around the nerve. And so sometimes we'll try a neuropathic medication, like gabapentin, or even a MedDRAL dose pack to see if using a course of steroids will cool down the inflammation in that area and make patients feel better. You could also do a pudendal nerve block in the office, if that's in your tool set. It's actually not that hard to do. There are pudendal nerve trays. And basically what I do is I inject quarter percent Marcane, usually 10 cc's, and you just move a centimeter over and a centimeter inferior from the ischial spine. Now obviously with post-surgical anatomy, that can be a little bit challenging to feel, especially if the patient is uncomfortable. So I don't want it to sound like it's a very layup thing to do. But the more pelvic exams you do, I would encourage everyone to get comfortable with where the ischial spine is. And I always tell my trainees, you move medial because you can't move lateral, that's bone. And why would you go higher up in the vagina? Like you can get the nerve going distal because it runs superior and inferior behind the spine. So those are two things I would say. And then ultimately, you know, if they get transient relief from a pudendal nerve block, but then the pain comes back, well now that's diagnostic and obviously only transiently therapeutic. You probably need to take that stitch out. And ultimately, yeah, you may end up needing to do an interval, take the patient back to the OR and remove that stitch if their pain continues to persist. Thank you very much. Yeah, great question. And to your point, this is making me think, like my NPs, I've actually brought them to the OR with me a few times just for exams, right? Like exams under anesthesia, because it just takes a few in your head to know what you're feeling for. And so I think even just spending a day buzzing in and out of the OR, just doing exams can actually really change your exam in the office. So good thought.

chronic pelvic pain

vulvodynia

holistic patient care

comprehensive history-taking

multi-disciplinary approach

pelvic floor physical therapy

pharmacological management

central sensitization

personalized care

evidence-based strategies