This week Tim talks to Stephanie Prendergast, an internationally-acclaimed pelvic floor physical therapist and author of “Pelvic Pain Explained." It can be hard identify the causes of pelvic pain, so they talk through types of pelvic discomfort and various treatment options for these chronic conditions. Stephanie also outlines the overlap between pelvic floor disorders and erectile issues, and explains the differences, providing hope and answers for people who suffer from this understudied condition.

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00:00:02hello and welcome to hard conversations about male sexuality intimacy and sex where we have packed the taboo topic of erectile issues in a safe non judgmental and now here's your host sex there welcome to heart conversation my next guest I'm very excited about Stephanie Prendergast is a public
00:00:32floor physical therapist and a co founder and co owner of the pelvic health and rehabilitation center the largest multi center clinic in the United States dedicated solely to the management of public for disorders helping women men children trans gender and gender non conforming persons optimize their pelvic health
00:00:54Stephanie was elected to the international public pain society's board of directors in two thousand two and a two thousand thirteen she was the first physical therapist to be president of the society in two thousand thirteen and two thousand fifteen she served on the program committee of the World
00:01:11Congress of a domino and pelvic pain and two thousand seventeen served as the scientific program chair bringing the World Congress to the United States she's authored numerous publications in peer review journals and textbooks and regularly lectures at medical conferences and in the community on public health related topics
00:01:32she is an advocate for people with pelvic pain pelvic floor physical therapists and the field of public health she is a co author of the popular book pelvic pain explained in two thousand sixteen P. H. R. C. Rick publishes an award winning blog as the pelvis turns every
00:01:49Thursday thank you Stephanie for joining me thank you very much arm what is C. P. P. S. what does that even stand for and what's the difference between C. PPS prostatitis and public for disorder coming out hard does get into it CP PS stands for chronic pelvic pain
00:02:11syndrome %HESITATION which is a term that I don't necessarily enjoy it because it implies that this is a problem that's chronic meaning it's going to be with a person for the long haul and what it refers to is a muscular skeletal condition where the pelvic floor muscles become
00:02:28hypertonic and can cause symptoms of urinary urgency frequency penile pain scrotal pain perineal or anal pain posted Jack in the Tory symptoms and erectile dysfunction in men okay so it is different than prostatitis in that those terms were overlapping Lee used interchangeably and incorrectly for a period of
00:02:54time the term prostatitis implies that there is inflammation and infection of the prostate and while the symptoms of an actual prostate infection mimic the ones I just described it actually happens in the absence of infection so commonly man with the symptoms are often misdiagnosed with prostatitis in being
00:03:16prescribed antibiotics when in fact it's actually a muscular skeletal disorder okay that's prostatitis now what's pelvic floor disorder so the pelvic floor muscles run it from the pubic bone to the telephone most people think of them in terms of childbirth and in women and empty your cables but
00:03:36obviously men have pelvic floors too so it's responsible for helping with urinary function sexual function and malfunction and once things become dysfunctional as we just mentioned with C. P. P. S. then you can have a whole host of symptoms and any of those areas the muscles are very
00:03:54important to support our organs and to help keep your body functioning normally okayed so let's let's talk about those symptoms because I I suppose I should mention that in therapy I'll occasionally if see somebody who's been diagnosed with any of these things and the symptoms and I hear
00:04:14are burning numbness tripping leaking painful urination painful **** tingling aches and and then the state of being hard flaccid so which which symptoms correspond to which her how to do can we even delineate that way so see PPS encompasses all of what you just said okay so it's
00:04:37is really broad on Bella term that is deaf it's defining a syndrome more than a specific disease and that's important to make a note of that this is a cluster of symptoms that can manifest with some of the symptoms you just mentioned or unfortunately in some cases all
00:04:53of them and so the symptoms can range from dollar achy test severe stabbing shooting debilitating pain mount and there's a difference between something that is a functional problem verses a pain problem correct okay so functional problems often precede the pain issues some men may start to notice all
00:05:16of a sudden they're urinary stream is a little bit different or if they try to start their stream they may have hesitancy where they did it before they may notice there stream diverts to one side or the other if they could have trouble evacuating stool %HESITATION and then
00:05:32sometimes as actors on long enough unchecked then it can proceed into a pain issue where then they start to develop pain again in the **** **** perineum arenas as well okay and yeah I I love %HESITATION the formality of the language evacuating store okay so you have a
00:05:55problem %HESITATION being shoveled hoping %HESITATION but but I suppose that in that situation where we're talking about these very intimate areas that it helps to stay very formal and and clinical and medical about all of these things because it's it's not many people get to see guys in
00:06:14that state we have different language for sure yeah and so tell tell me about that state tell me %HESITATION when somebody comes in and they're they're they're trying to figure out what what's wrong way you know what I have this burning or why it will what's wrong with
00:06:30my poop in %HESITATION what are they actually go through so it's unfortunate because most men have been through at least five to seven providers before they typically get into our office and actually understand what's wrong which can come with a fair amount of trauma because people are saying
00:06:47you just need to take this antibiotic or there's actually nothing wrong with you when in fact they don't feel like anything is normal so by the time sometimes they get to our office they are extremely distressed and at least the first day hopefully we can do is normalizer
00:07:01symptoms and they're not alone these symptoms affect one in ten men %HESITATION symptoms start as early as the twenties and thirties they can progress into the forties and fifties and sixties as well but there's a whole host of issues that can affect men from the time they're twenty
00:07:17to the time they're seventy and it just isn't as talked about in the mainstream as female public health issues one in ten men one in ten men studies have shown have the symptoms of C. PPS while you know if you think of something like schizophrenia affects about one
00:07:38percent of the population maybe two maybe it'll make you know depending on how you count it this is five to ten times more common than that yet until I started to get into this work I never heard of that and I still I think I told you one
00:07:52of times where I was talking to you about this that I met a nurse who dealt with female pelvic pain I think she worked in a in a religious office and didn't know men had this so it's really just really not talked about much it hasn't been in
00:08:11the past so it's great that you're doing podcasts like this to help get the information out there because men may be listening to this and thinking oh I I've noticed that I have these symptoms and then a lot of people it can be a very insidious onset so
00:08:25as I mentioned you may start to notice it's hard to start the urinary stream or you know if you have a little bit of post Floyd trouble there soon word another medical term like yours still drivel in a little after you urinate %HESITATION and then all of a
00:08:38sudden you start to notice it you may have tingling at the tip of your **** after you **** or something more significant and man a lot of times some of these things can be triggered an exacerbated by things like exercise such as site clean or certain work out
00:08:52so they may notice that after they go to the gym they have trouble with urination but if they don't go to the gym they they don't have those issues so it's starting to show that there is a functional problem that's tied to their muscular skeletal health that's creating
00:09:05the symptoms so another word that I've heard thrown around no let me back up so I was asking what's it like when they get to your clinic so when she arrived at our clinic we will go through a comprehensive history to understand how the symptoms started knowledge has
00:09:23we may be asking questions that they may not even realize are tied to their symptoms %HESITATION a lot of times people do think it's an infection or an S. T. D. someone say been cleared for that it usually is left in the muscular skeletal department after we go
00:09:37through the history and answer any questions that they may have is the physical examination at that point in time we will examine the muscles connective tissue and joints basically between the ribs and unease depending on the ideology and also do an internal pelvic floor exam which is done
00:09:55trance in only at that point we are checking for motor control can people contract their muscles can they relax her muscles were looking for pain tenderness nerve sensitivity as well as just overall function of the pelvic floor that's the passive part and if there is a by mechanical
00:10:14because for people sometimes which is often the case with male public pain then we also need to see how they're moving what happens during various movements during various exercises things that will normally provoke their symptoms okay then let's let's get into some of that right there is a
00:10:30limitation for this bang a podcast and we cannot show people a diagram of of that area but can you describe like let's say listener at home is going to try to figure out their pelvic floor and hands where everything is can you give us the geography of of
00:10:54of these areas so a simple thing that people can do is when you cough reflexively or public floor muscles contract otherwise you would leak urine you and if you think about trying to pay attention to the area between the **** and the **** when you cough you may
00:11:10feel that I'm so those are the muscles that do compromise %HESITATION that our public floor okay right there that that it should be what should I do when you cough when you cough you should feel a small contraction okay and when you orgasm that's a rapid muscle contraction
00:11:27which is also a pelvic floor muscle function in the in the same area same area okay great and when you have a bow movement you're relaxing your public for muscle so that's the opposite of the cough everything has to relax to be able to evacuate still okay you
00:11:43never think about it because I I never did us el al right and the other day somebody told me you know we're talking about relating their anxiety to these issues and so and she said the moment she had some break through about one of the major sources hiring
00:12:00of her anxiety that the moment that she had that realization her pelvic floor relaxed and I thought how do you know how do you tell but it but okay so it's kind of like having just avoided stool right now but if you'd just like you mentioned if you
00:12:17don't think about it these muscles are gonna function on their own and that is what makes them different than other parts of the body you couldn't make a fast without voluntarily thinking to do so but your pelvic floor always being teens some tone because it's a little bit
00:12:31different than every other skeletal muscle in your body because it has some autonomic function it's the same thing as your diaphragm you can choose to breeze and you can choose to breathe faster or to hold your breath just like you can choose to squeeze your pelvic floor or
00:12:46relax it or if you don't think about it it's going to do what it normally needs to do without your conscious attention okay and so you're examining somebody from the knees to the ribs where and and who are these people and what are we doing what you're doing
00:13:05yeah so I mean it didn't pass of part of the exam is palpation and we are literally touching each of the muscles that attach to the pelvic girdle the connective tissue as well as per from nurse looking for tenderness pain if the muscles can contract if people can
00:13:22control them and the same thing happens internally so the first part of the exam people are laying on the table and that may be the first few appointments especially if they have pelvic pain until we can do the manual therapy which kind of mirrors the evaluation to help
00:13:37the muscles get back down to normal Tom okay and then as you said manual valuation you gestured so can you describe the manual valuation %HESITATION I guess you could think I mean it's hard it's not as general as a massage but it looks somewhat similar to that in
00:13:58terms of evaluation and treatment okay and so %HESITATION how invasive is it in my world I don't think it's invasive is all but in other people who may not be used to a physical therapist using a gloved finger to examine the muscles of the pelvic floor through the
00:14:15**** if he considered invasive %HESITATION but that's what's that that is how we have to get there loved finger lubricants lubricants and one finger right while people are lying down so it's different than a prostate exam where men envision bending over the table turn your head and cough
00:14:33that's not what we do right break as you're not even necessarily getting to the prostate we actually can access a prostate but it's not necessary for the evaluation that we're doing %HESITATION we're examining the muscles which actually surround the prostate okay and I have heard of this thing
00:14:53called a wand used and treatment to to use a wand not really okay so will want as a therapeutic tool that people can use at home for therapy to try to me or let me go on and pelvic floor physical therapy I I have very mixed feelings about
00:15:11them I find it's difficult for patients to actually use them on their cells in a way that's effective I would rather have them spend their time at home doing something that we know is going to help their problems such as meditation or things like that wears using a
00:15:26wand is I think rather difficult to access the muscles and successfully treat them I feel like I've heard of of of a wind gone wrong story or two you can hurt yourself Amos is a vacuum to people team to know that so if they're using something that isn't
00:15:46long enough in line think yes we've had a bet stories where people have accidentally sucked up the wand and has needed surgery to get it back out with %HESITATION and also people can press on structures that are sensitive that you shouldn't be pressing on with a wand and
00:16:05I feel like a lay person really has a hard time telling the difference even with instruction okay so use at your own discretion using your own discretion or maybe just don't use or maybe don't okay %HESITATION I've heard of well okay the other question that I had was
00:16:24pelvic floor therapists what kind of training do they have in and you know what's there background so pelvic floor physical therapists have their physical therapy degrees they are state and federal certifications %HESITATION beyond that it gets a little dicey so there's a very amount of educational experience between
00:16:45public for PT's typically because this is not yet taught in graduate schools it's all postgraduate education which means that the person people may be going to see for public for P. T. has really sought out additional advanced training on their own to be able to treat this patient
00:17:02population and that can come there's really no standard of care at this point in time because it's a fairly new field so there can be a range of experience among providers okay when you guys train yes so we I mean as a company all we do is public
00:17:22health so we obviously trainer employees and we teach classes to other public for physical therapist to be able to do the same thing Kay and I feel like the so we didn't say this this is mine and seventies second today this interview I had my first hard conversations
00:17:42impossible conversation I had a major technical malfunction but the last time that we talked about this we we somehow stumbled upon the fact that it's difficult to train this because there aren't that many men in the field and they're practicing on each other so the training then public
00:18:02floor PT's undergo is and as I mentioned post graduate classes so what that consists of is a two to three day course where they usually have to travel and learn the didactic information but also there's a lap portion where people practice on one another and there's very few
00:18:20men as providers that are in this field which means often women are trained by practicing on other women which is clearly not the same thing which is why I'm glad this podcast is happening because a lot of men may not have access to people who can help them
00:18:35and it really does require specific training to be able to do sell rated so in those classes were you saying that they'll actually higher not actors but people to comment to be subjects for that training they actually do not in most cases and I think they need to
00:18:53okay because as a female physical therapist who's about to treat this patient population it's very difficult to take book knowledge right and then translated into the clinic and know what you're doing with manual therapy and treatment plan progressions and those types of things yeah definitely yeah you would
00:19:13be would wanna now I mean you're asking the question so how many how many men's but save your fingers actually been in mine a lot eighteen years of a life is here's what I actually was trained by a urologist on actual male patients so my experience was quite
00:19:29different than than money and time so another word that I've heard thrown in the gamma is pudendal neuralgia is where does that fit into all of this carpal tunnel of the button **** okay so that basically means tingling shootings stabbing pains just like you think of an carpal
00:19:49tunnel of the rest but that can occur again in all the territory is up to date on our forges the **** the perineum and the **** the majority of the pelvic floor muscles part of the urethra and part of the **** Hey I guess you just have to
00:20:03go to you to keep all of these things straight well I have if you notice that you have those symptoms I think men primarily go to the urologist first if they're not familiar with the diagnosis I would seek a second opinion I can provide resources for medical providers
00:20:19across the country who are trained %HESITATION but I don't want patients to feel discouraged if their doctor doesn't actually understand what's wrong with them at first because as physical therapist need specialized training in this sort of physicians and unless they're seeking this information out on their own they're
00:20:36probably not exposed to these syndromes are the fact they can even happen so it's pretty easy to diagnose the clinical symptoms are what we just said %HESITATION there's no further diagnostic testing that can confirm or refute that that's a problem it's completely based on symptoms and that that's
00:20:53a challenging factor as well and I got to imagine there are other diagnoses that trickle into this this diagnosing speak process Siouxsie PPS technically encompasses pudendal neuralgia and pudendal neuralgia encompasses C. PPS which again is chronic pelvic pain syndrome it overlaps with what's called prostatitis and basically the
00:21:17whole umbrella of male public pain okay but are there other disorders that are thrown out there other names of other disorders that you're hearing that other urologists have said sometimes they will say interstitial cystitis which is technically a what was originally thought to be a bladder syndrome but
00:21:37we now know the plotters the victim not the cause an overlapping muscular skeletal condition okay and interstitial cystitis for all of those of you go going all these things out there or just I see among friends %HESITATION so let's let's segue into sacks here so how how does
00:21:59C. P. P. S. affect sex so it's it's unfortunate because one of the primary symptoms of of C. PPS can be posted Jack in the Tory pain erectile dysfunction just general pain in general and when people have pain it can affect desire obviously but also if what it's
00:22:19supposed to be pleasurable is associated with pain it's very difficult for our male patients and they're just uncomfortable and they're upset and they're stressed about that understandably yeah and then they come in and they talk to you about their sex lives right an often relieved that their partner
00:22:35isn't having an affair as unfortunately man may think because it feels like an STD and it's not yes I suppose we should say that there's a there's a good chance that it's not an STD guys are not a nasty ours so %HESITATION get this checked out her he
00:22:51get tested for the STI first and then when that's ruled out you're you're really in this territory so you mentioned erectile dysfunction and for those of you who listen to every single episode and I memorized my words %HESITATION I'm I'm pretty careful about when I say a rectal
00:23:08dysfunction am when I'm talking about erectile issues because we don't want to call like anxiety at this function because reviewed decision everybody's in a state of of fear it's not as function it it shouldn't be hard your pension BR but we're actually talking about something that's physically wrong
00:23:26and so I would put that under the umbrella of dysfunction so what exactly is happening to your pelvic floor that that makes it so that the **** isn't retaining blood and I think you did bring up a good point too about the words in the language think it's
00:23:43easy for me to say a wreck tile dysfunction but I think it be better to say transit erectile changes just like I don't like chronic pelvic pain it should be persisting right now because I don't want people to feel the minute that this is stuck with them for
00:23:56a long time but what transient erectile change change the anorectal issues issues %HESITATION what's the best acronym T. A. C. C. A. time I just want to know it's a it's a transient things like this just as quickly as it showed up it can also be treated right
00:24:13and that's where I think people are they're just not informed enough it was what you read online this looks like a pretty damn situation but as we mentioned the public for muscles are responsible for orgasm function and as we discussed last time and they're also responsible for maintaining
00:24:30interaction so they help to close the blood vessels to keep blood in the **** during erectile function and if the muscles are too tight to effectively do that which happens in pain syndromes or if they're weak which can happen in older gentlemen after things like prostatectomy surgeries thinking
00:24:50of the whole gamut here %HESITATION it's going to be a challenge to maintain the erection that isn't just the visa dilation factor and things that people think of when they take **** and Cialis right so if they're there to tie then let's not gonna get there and get
00:25:07in there in the first place where it's harder for the muscles to effectively contract to keep those vessels close to keep them it's like trying to to clincher fest when your %HESITATION D. in a tight fisted position you can't go any further so they're just not functioning efficiently
00:25:23as a cut okay and you can help with that and we can help with that so we will examine if the muscles are too tight which again is usually the case and pelvic pain syndromes manually length in the muscles through weekly physical therapy sessions typically eight to twelve
00:25:41visits is standard for shorter term duration problems and then teaching the patients how to actually regain control of the muscles themselves to maintain what we did in the clinic on the latter end of the spectrum if they have weakness or issues following prostatectomy procedures and it's the opposite
00:26:02were actually teaching them how to strengthen and again teaching them control but the treatment is exactly the opposite we're trying to up train everything okay and that's that's a huge difference huge difference it's important to know the difference as well yeah is there another version of a cough
00:26:22tests that they could do it all right now to have an idea if it's if it's strengthening our relaxing if if men try to squeeze their muscles or hold back gas if you will and you feel like you actually can't do that you might be weak okay okay
00:26:38city Catelyn your fart right and you've got here you might have ons some a condition that could improve when this kind of treatment and in the later decades of life and especially after prostatectomy public for dysfunction affects about eighty to ninety percent of men okay you work on
00:26:56this with older gentleman as well and can they see improvement yes so research is actually shown that if you are undergoing a prostatectomy surgery men have less chance of stress incontinence and erectile dysfunction if you go through public for physical therapy before and after so I think a
00:27:14lot of people aren't prepared for exactly what I just said stressing contents leaking urine and erectile dysfunction and as people live longer and the age where the surgeries are happening remains the same people want to preserve their sexual function so it is an easy at low risk thing
00:27:32that should be part of every man's treatment plan and it isn't always which still surprises me now right and as you mentioned earlier **** isn't going to fix the situation even an older man if if the blood has no way of holding itself enter it being held in
00:27:51the back or can't help cracked okay so yeah that is surprising when and if you think about about you ankle surgeries knee surgeries you have to do physical therapy afterwards think of how much more complicated the purposes thank the fact this is an integrated into some of these
00:28:07things really does surprise me at this point in time and did I hear at one of your lectures on all these issues in and women and that there are countries that mandate physical therapy before and after pregnancy yes yes absolutely and I'm prostatectomy as well but our insurance
00:28:29system runs a little bit differently here in America prostatectomy as well yes do you remember which countries are mostly all of them that socialized medicine because the rate the cost of people continuing to go to the doctor and continuing to need another surgery or another procedure far exceeds
00:28:47the amount of public for physical therapy so if you think about it that way in actually lowers cost in these other countries were medicine is socialized whereas in the United States it's almost viewed by insurance companies as one more thing they don't want to pay for so it's
00:29:02a little bit of a political situation there that yeah that could be a whole other conversation about the medical staff don't get me started okay when that physical therapy is actually taking place what are what are guys telling you about how their sex lives have changed they're actually
00:29:21quite happy with a few visits and learning how to control their muscles and regain function and there can be quite a dramatic change especially for example if your leaking urine you may not want to leave the house you may feel socially isolated again these aren't at these people
00:29:37are in their fifties and sixties this is a problem that this is happening at this point in their life and that they can also mean teen intimacy with their wives so there can be things like **** and Cialis there can be injections that they have to administer themselves
00:29:52into the **** but if the public for muscle function makes up at least fifty to sixty percent of that it makes sense to maximize that to reduce these other interventions and and what what about the other symptoms arm when somebody's had a burning for awhile or orders the
00:30:10one I've heard a few times as the sensation of a golf ball in your **** so switching back to the the more younger end of the spectrum right %HESITATION obviously if those sensations are there it's on pleasant and so over the course of time were able to help
00:30:24reduce them doesn't feel like there's a golf ball in the **** anymore which can be a sign of pudendal nerve issues or pelvic floor muscle dysfunction okay and then they they come in and they say gosh I'm feeling a lot better they can and it's often if the
00:30:41symptoms are very severe because we're talking about a whole range of things sauna pelvic pain and to the spectrum it is an interdisciplinary approach that's the most helpful for our patients with severe public pain so that involves medical management which may include some pharmaceuticals that are not any
00:30:58biotics more neuropathic drugs %HESITATION there can be various procedures such as botox or nerve blocks it can be therapeutic in conjunction with physical therapy okay and once you said interdisciplinary denied his doctors and physical therapists psychologists are all involved to help people function better in the face of
00:31:20their issues and so when would you involve %HESITATION psychologist or mental health therapist sex so it's this point I mean for me in my career I feel like we can kind of assess how distressed people are about their symptoms I mean obviously this is unpleasant for everybody but
00:31:39you can kind of gauge how people are coping or not coping and at the point that we obviously suggest people like you we want to have them establish a relationship with us so we're not offensive which some people can take this as I'm only upset because I have
00:31:55a physical issue but that's okay the you're just not coping well while you have it and maybe we can help you make this less suffer boys you're going to the process so I think in an ideal world mental health specialists would be involved from the beginning in our
00:32:10society doesn't totally work that way and some people definitely need it more than others right and then what I find is that %HESITATION D. anxiety the stress that the lack of coping exacerbates the symptoms there of course it does so people think they're doing this to themselves because
00:32:27stress makes all musculoskeletal pain worse I'm and that's just not the case especially if you've been told by five six seven doctors that there's nothing wrong with you or the medications are prescribing isn't working you Google your symptoms you read online that you're gonna have this chronic condition
00:32:43that affects your sex life for the rest of your life you're not gonna be happy that's okay what we have to sometimes undo all of that misinformation because treatment is available it is effective it's just not readily available to every provider across the country right and I bet
00:33:00some of your interventions are actually pretty similar to some of mine %HESITATION like stop googling yes and %HESITATION sometimes stop examining your **** ones in our hands %HESITATION at the doctor Gonzales actually was was saying some of those things like a we we get continual calls from people
00:33:22%HESITATION about just but the same questions over and over again and clearly way to in their heads about it and read thus increasing their stress and lasts waiting to be more tension and the area more tension throughout their body and we're symptoms it sounds like you're in the
00:33:40situation you're going to be here for the next forty years and people often think all my gosh if I feel this bad now how bad is it going to be then and we do want to stop that thinking because that's just not how it has to go right
00:33:53and you're sitting there telling them okay stop thinking like that in this we see a lot of results we see a lot of progress in this area and I know you've gotten mixed messages bites something that we're really good at treating and and I about the you have
00:34:09to have a pretty good bedside manner as you talk to these guys yes I mean I mean I understand if I Google the same symptoms and I thought I had this I would be probably in the same boat yeah I understand you could also read your book again
00:34:27and also it's so funny how often it man see so many men coming in and out of our office and one thing they say is everyone here looks so normal not sure what they thought it but of course it look normal and there's so many men in here
00:34:41which is true I mean this is not a women's issue yeah yeah sure they buy a book what's in your book is everything that we just talked about in your book there's yes the book contains a more detailed explanation about the specific muscular skeletal issues that happened but
00:34:58more importantly my book isn't due to stretch do that stretch because everybody's symptoms are totally different and so were the reasons for it is more teaching people how to understand how they develop the symptoms and how to navigate the treatment process because some people may need physical therapy
00:35:15and pudendal nerve blocks and some people may not even need physical therapy they maybe they need psychology so it's really important to understand where the person is and how to troubleshoot things if they plateau or if they can't tolerate certain treatments or medications it's really about teaching people
00:35:33how to think through this issue verses just go structure hamstring because that's very rarely effective in is there a do this stretch do that stretch book wall books yes no there's a ton of books St stretch this do that and I don't find them very effective okay I
00:35:49went for strategy right right right okay because yeah I there there are a lot of public pain books out there but you don't have one that you love now okay all right and he heard it here first now we have talked a little bit about medications and that's
00:36:07another thing that I've I've heard well here's a typical story is you know somebody told me I had prostatitis and name it was a urologist gave me an antibiotic everything was working well for a few days and everything came back and now they want to give me another
00:36:22antibiotic and then I found you so I'm glad you brought up the antibiotic situation this is important and everyone needs to know this that there are analgesics in a number of antibiotics what's indulges a analgesic is a it's Tylenol okay pain numbing medication because often times people with
00:36:44infections have pain associated with infections infections are unpleasant they usually hurt and so people can a Roni Asli think that the antibiotic is killing the bacteria because they feel better on it when in fact they're taking a pretty high dose of Tylenol with the super %HESITATION for example
00:37:01and so they may feel better and then they think they're infection came back when they go off of it when in fact they're just not taking that much of the town on anymore so many people don't realize that and that's important to know especially if they're given antibiotics
00:37:16without proper testing to diagnose prostatitis you have to undergo a full semen analysis not a urine culture but a full semen analysis and many people who are diagnosed with that have not been through that process you're right %HESITATION telling you you're right that the few times I have
00:37:35worked with somebody who said they have prostatitis I asked that question and then %HESITATION semen analysis isn't that common right and that's because it's it's difficult to do and there are issues with the labs it's just not always a clear cut in a straight forward test as we
00:37:52wanted to be there can be false positives there can be false negatives you can get contaminated quite easily so people don't bother they just give the antibiotics but that's actually not right especially time and time again it can cause gastrointestinal distress and a whole host of other problems
00:38:08for men antibiotics are not the only medications I've her prescribed in this arena what else is being given to these patients so it because this is a pain syndrome they're often given the same medications that are used for any type of pain whether it be a migraine or
00:38:25back pain or things like that and there's three classes of drugs that could possibly be effective those are either tricyclic antidepressants that are used at a dose lower than treating depression to treat pain %HESITATION does SNRIs such as simple to have been shown to have muscular skeletal pain
00:38:45reduction of facts and the third class of drugs are the norm modulators which are Lyrica and gather Penton I'm so those drugs may be prescribed for this just as they are for any other pain syndrome and depending on how involved the nervous system is or isn't in somebody's
00:39:01issues they can be effective or not effective that's interesting because when I took my licensing exam I learned about all three of those medications and to those must be secondary benefits to those medications that those SNR I wasn't designed for pain no but it has been FDA approved
00:39:21for pain okay wears a tricyclic antidepressants and then %HESITATION modulators are off label uses those are off label use actually the tricyclics may be on label at this point okay that lyric and gather Penton are off label for pain but really commonly prescribed commonly prescribed okay and how
00:39:39do you feel about all three of those drugs I think for certain patients some of them have been quite effective I think the side effects can sometimes outweigh the benefits the most important thing with the medications is that patients often don't understand why they're taking them and they
00:39:56have unrealistic expectations as to what they should do so if you take these medications and you have daily unprovoked pain it's not going to take it away but it may take it down a few notches so if you can't set for more than ten minutes without getting severe
00:40:12perineal burning maybe instead you get perineal eighteen at fifteen minutes instead of ten and that actually is considered effective for what it's intended to do but people think it's just gonna completely take away their symptoms and that's just not how it works man right because I'm thinking about
00:40:32the way that that study would be designed to study the efficacy of that medication and that is an improvement that is an improvement but that's maybe why it's not FDA approved for pain it's very difficult to quantify right right okay because I I would imagine I am prescribed
00:40:48a tricyclic and I go home and I Google that wait a second I'm not depressed about bold and my depressed because I've certainly very distressed about this store they saying that my depression goes away that those pants gonna go away right so I think that again people think
00:41:05that they're given it because they're being told it's all in their head or things like that because often physicians may not have time to explain why we're giving why they're giving patients these drugs so they are meant to treat pain and different %HESITATION says send for depression it's
00:41:20important to know for the tricyclics %HESITATION Cymbalta is the same for anxiety pain and depression and that can be an effective medication to help people go through the treatment process okay so I'm trying to imagine the guy who has some of these symptoms who is kind of a
00:41:42long way from deciding okay I'm gonna come in what can you say to him ever is there a video where he can look online and say okay I just want to see what this is why a car is there something that my kind of make it has been
00:41:59in a movie not yet okay it's creeping into movies for female pelvic pain and TV shows and Hawkeye suffix right now does a bit in a movie I think doing some Google searches the lecture that you attended at USC is available online and more people talk about the
00:42:16whole spectrum of things and I think for men not sure if this is what they need or not I think an evaluation is warranted and at least get a little bit more information if you have these symptoms I think you should rule in or out the public floor
00:42:30as a source of them so you know and they could come in and get a decent evaluation without getting a finger on the but nope help okay so that's gonna be a part of it so that is going to be part of it and I don't want us
00:42:43I don't want to say man up but I guess some kind of saying that well in as his symptoms get severe enough they rarely once you get to a symptomatic point they may not resolve on their own and I think that motivates people to seek appropriate attention because
00:42:59they can see that things are changing in progress in an off and on in the right direction okay is there anything that people could be doing in the meantime the that there mulling over this decision of whether or not to come to our center there stretches you already
00:43:16mentioned maybe ease back on the psych laying well and again it's all about someone's anatomy plenty of people cycle and have absolutely no problems and certain people may ride their bike a mile and all of a sudden have penile numbness for two days it really depends on your
00:43:33anatomy and if your body can do the activity in question and so listen to your body if you do feel symptoms after certain exercises you do at the gym or riding your bike or sitting for eighteen hours you listen to your body get up move and if the
00:43:50symptoms repetitively keep coming back that activity may not be okay for you but you also may have a treatable condition are there yoga poses guys could do to help this condition if the DA in general the child's pose will help relax a pelvic floor muscles %HESITATION however if
00:44:12you have symptoms of pudendal neuralgia or there is nerve symptoms burning shootings stabbing tangling things that stretch muscles will also stretch the nerve and provoke the symptoms nerves do not like to be stretched in so it's really important to distinguish patients with nerve issues from muscle because what
00:44:32you think could be therapeutic could actually be less useful same thing with a lot of people with low back pain they want to strengthen their core that's actually going to provoke your pelvic floor muscles to tie in if your muscles are tight enough that they can't relax things
00:44:49that are well intended to help your backer actually gonna because public pain were exacerbate your pelvic pain so strengthening is not always the answer in these cases and told the muscles are in a position that they can do sell okay I think that's a really good a rule
00:45:06to live by you say things that stretch the muscles stretch the nerves yeah yeah cancer can be provocative instead of therapeutic right and you'll know it may not happen right away it may be a delayed onset like two to three hours but people usually constructed tie provoking activities
00:45:25to their symptoms once we start asking them more specific questions in there and that would happen over the course of treatment they'd start to piece things together I bet a lot of guys will say things like but I've been cycling my whole life or something like that or
00:45:43all the exercises and what's your response will maybe they've been cycling their whole life but recently they had about a sciatica and so now things are different the sciatica resolved the maybe there have muscles are still tight or there's still some sort of tissue change that is now
00:46:00causing symptoms during the same activities they've always done I also say your body changes over time like we cannot do the same things in our thirties necessarily that we did in our twenties as much as we all want to things are different as you age and it doesn't
00:46:14mean it's not correctable but you may need to focus your attention on addressing impairments you keep mentioning studies is there is there has there been a really good meta analysis or maybe your book would just be a collection of those are is what partially guy start reading stories
00:46:35just nine grueling blindly about the stuff %HESITATION that's a good question I think our blog is a good patient friendly resource and we reference site to go to other places most people don't wanna read medical journal articles however I would say yes I would say that this year
00:46:52%HESITATION just in August of Rodney Anderson published in the journal of urology %HESITATION a huge meta analysis on C. PPS and instead of calling it a prostate dysfunction they're finally acknowledging it as a psycho neuro muscular disorder so affecting that the mind the body and the nervous system
00:47:14and they went through all of the literature on this and again showing that the majority of men never have an infection they don't respond to antibiotics you don't respond to a lot of medications because it's not that type of a problem and I think that's a big step
00:47:27forward because most urologists get the journal of urology so even if they're not seeking out additional knowledge for these patients this came to their doorstep so hopefully they read it awesome so yeah I've if guys if your urologist doesn't seem to know what's going on get the August
00:47:46journal of urology find the article by Anderson and this is Google a ball %HESITATION obviously and you probably have to pay the forty Bucks for the article or there are ways around that we won't go into on this bike has but yeah and for it to clear all
00:48:04just hopefully he or she will read it and this is why these studies take place and a big mat analysis and those are just a couple months ago that was recent yeah big step forward I'd say that's great Angie you're reading your general of urology must stay on
00:48:22top of it yes you do okay so what would just in general what what would you like to say to the guys out there who have some of these symptoms like what words of hope can you give to them if they can and will get better there's usually
00:48:39room for improvement %HESITATION if you have these symptoms and people are telling you there isn't anything wrong or certain treatments that they're prescribing or not working I always recommend getting a second opinion %HESITATION I can direct you to resources where they can find providers that are skilled in
00:48:57treating this and I think that they should move forward and try to get the issues taking care of don't ignore them great then and their sex life can improve sex life can improve erections can improve anxiety can go down you can return to the exercises and normally provokes
00:49:15your symptoms all of this can get better okay god and what about for %HESITATION for you what's going on in your world you have how many centers nine wow now we just opened one more just over one more and those are not all in California so we're in
00:49:32New England northern California and southern California okay and what kinds of things do you have on the horizon what's on the horizon %HESITATION that's a good question running the four right now we're we're pretty busy in the clinic and it looks like in twenty nineteen we're gonna start
00:49:55teaching again and locally %HESITATION I have a larger space now so things will be changing a little bit on that front basically just keeping the clinics running at this point yeah yeah that's a lot to oversee and it was %HESITATION get you be you are very busy absolutely
00:50:11we it took us awhile to get this rescheduled after I blew it on the first episode but you you're at the top of your field and doing really great work and every time somebody name drops you there's saying really wonderful things so I know I said at the
00:50:27beginning this episode that I was excited but I am %HESITATION you know I I think that you're doing really really important work and time so grateful to have you on here and helping us have is hard conversations %HESITATION where can we find you on the internet %HESITATION our
00:50:44website is pelvic pain rehab dot com a book is on Amazon it's called pelvic pain explained and that's where we are I practice in our Los Angeles location right there on Twitter I'm on Twitter at public health okay %HESITATION also on Instagram the same at public health and
00:51:03Facebook is public pain physical therapy kinds of pictures you put on Instagram yeah that's a good thing we have to find out I have to check this out and challenge the right Stephanie will thank you so much thank you bye bye thanks for the show's executive producer Robert
00:51:25Morris thanks to cap director of social media thanks to team scrub for the music thanks to the sound engineer Robert Brian we for thanks to Alex pets for the intro thanks to our long distance on local you can find the hard conversation or wherever you get your part
00:51:47you can locate me on Twitter Tim Norton LCSW were on my website from my private practice Tim Norton therapy dot com you can also email us at our conversations podcast at G. mail dot com or call into our hotline at six six two six two six four two
00:52:06seven six that's six six two man hard thanks to all my friends and family for brainstorming the show with me shut out the sex positive community including sex educators sex therapist sex coaches other fellow sex podcasters sex circuits academics sexual health medical community sex workers potential community and
00:52:27everybody else involved with having hard conversation

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