Welcome to the 11 th Meeting of Pelvic Floor Sexual Medicine Healthcare Providers

1. Welcome to the 11th Meeting ofPelvic Floor Sexual Medicine Healthcare Providers Redondo Beach, CAMay 20, 2013

2. Patient Case Vickie

3. PT Evaluation and Treatment ofVulvodynia Secondary to Adverse Chemical Response Jenni Gabelsberg DPT, MSc, MTC, WCS, BCIA-PMDB Owner/Director Women’s Advantage, Inc. Torrance, CA

4. PT Evaluation: December 22, 2011Subjective Summary • History of hysterectomy and bladder sling with mesh 4 years prior • History of mild urinary frequency and nocturia 2x/night • 4 months before eval, self treated a yeast infection with Monistat

5. Subjective Summary • At eval: pt could not sit or walk prolonged, wear tight clothing/jeans, or tolerate intercourse • Urethral pressure with sitting • Severe pain at vestibule, worsened by touch, and worst at night • Pain rated as 10/10 without neurontin and 3/10 with meds (300 mg TID)

6. Objective Findings • Red irritated vestibule at 4 and 8 o’clock positions, mild tenderness with Q Tip test • Thinning and pale labia • PFM MMT 2/5 (poor) with a 2-3 second hold

7. Objective Findings Hypertonus and pain found with palpation of: • Bulbocavernosus, ischiocavernosus, STP (severe) • Urogenital diaphragm ms (mild) • Pubococcygeus, iliococcygeus, coccygeus and OI (moderate)

8. Objective Findings • Tightness found in bilateral hamstrings, adductors, iliopsoas, piriformis and gluteal muscles (with poor connective tissue mobility) • Weak abdominal, lumbar and pelvic girdle stabilizers

9. Beginning Physical Therapy Treatments: • Intravaginal Manual Therapy • LE and trunk stretching • Biofeedback evaluation – modified Glazers protocol given for HEP • Cold laser

10. Beginning Physical Therapy Treatments: • Connective Tissue Mobilization: Adductors Anterior thigh and inguinal region Labia Abdomen Posterior thigh Gluteals

11. Layer 1

12. Layer 2

13. Layer 3

14. Pelvic Wall Muscles: Superior View Piriformis ObturatorInternus

15. CTM Adductors

16. CTM Labia

17. MyoFascial release Labia

18. Cold Laser Treatments: Also known as low level light therapy, NON thermal Effects: • Increase ATP at cellular level • Stimulation of mitochondria, cellular enzymes, macrophage activation, collagen synthesis, increase in granulation tissue, increased serotonin and endorphin with decreased c fiber (pain) activity. • Uses: inflammatory conditions, wound care and tissue repair, pain control

19. Progress Assessment – Two Months: • 30-40% improvement in vulvar pain • Able to sit 20-40 minutes depending on the surface • Still unable to wear tight clothing • Decreased external vestibular pain by 95% • Able to tolerate orgasm but pain/”tingling” continued for 24 hours after • Zero penetration

20. Progress Assessment – Three Months: • Zero pain at vestibule with touch • Brief shooting pains at anterior vulva • Tingling nerve pain remains 80% of the time, worsens with sitting • Can put on jeans and zip up, but has not tried sitting or wearing out • Still wearing sweat pants all the time • 30-40 min sitting tolerance – better on soft surfaces • Describes feelings of pelvic “congestion” and “heaviness”

21. Treatment additions: • Began neural glides of the pudendal nerve • Added sacrotuberous ligament release

22. Pudendal Nerve Route It will cross under the piriformis, leaves the pelvis through greater sciatic foramen, then back through lesser sciatic foramen, over the sacrospinous ligament, under the sacrotuberous ligament

23. Pudendal Nerve - Branches • Dorsal nerve of the clitoris or penis • The perineal branch • Urethral sphincter • Perineal muscles and sensation • The inferior rectal or hemorrhoid nerve • External anal sphincter (EAS) • Perianal sensation

24. Neural gliding for PN

25. Ligament and Muscle Relationships • ObturatorInternus • Sacrotuberous Ligament • Sacrospinous Ligament

26. SACroTub Ligament Release

27. Progress Assessment – Six to Seven Months: • 75% overall improvement, pain rated 4-5/10 • Now able to wear jeans 5-6 hours, able to wear underwear • Able to sit through dinner with her family • Able to sit on a hard surface 5-10 minutes, soft surface for 2 hours • Able to have intercourse with no vulvar or vaginal pain during

28. Progress Assessment – Ten to Eleven Months: • 80-85% improvement, pain rated 2-3/10 • Sitting is still her most pain provoking activity • Now able to walk up and down hills, stairs and do pilates • Able to sit 3 hours at hairdresser • Meds – Estrace 3x/wk, Neurontin increased to 2400 mg/day

29. Treatment additions: • Thoracic and lumbar joint mobilizations • Heat and Interferential electrical stimulation to thoracic spine • Given a TENS unit to do EMS at home • Postural education/core training

30. Progress Assessment – One Year: • 90% improved • Sitting still limited by vulvar and buttock/posterior thigh pain • Able to walk 7 miles at beach with zero exacerbation in symptoms • External vulva healthy • Pain free standing tolerance • Able to wear jeans and underwear all day

31. Treatment additions: • Increased external manual therapy to levatorani ms, adductor attachment onto pubic rami, ObturatorInternus ms, coccygeus • Focused internal MT to iliococcygeus, coccygeus and OI

32. Recent Changes: • April 11, 2013 had first caudal nerve block with significant improvement in nerve pain, zero radiating buttock pain, scheduled for weekly injections Pt treatments focus on: • External MT to levatorani, adductors • CTM to adductors

33. Recent Changes: • Intravaginal MT to urogenital diaphragm and levatorani ms • ART to proximal hamstrings • Hip mobilizations with neuromuscular re-ed, glut strengthening • Heat with IFC/EMS to gluteals and lumbosacral spine • Neural Glides to Pudendal nerve • Cold laser

34. ART Hamstrings

35. Current Status • 90% improved • Pain continues to “move around pelvis” • Most consistent pain is buttock pain with any prolonged sitting • Able to participate in family activities, camping, exercise