Pelvic Pain and the Pelvic Floor - Diagnosis and Treatment

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Dr. Stones: "We're at the meeting of the International Pelvic Pain Society here in Connecticut, and I'd like to introduce my colleague, Dr. Jerome Weiss, who is the Director of the Pacific Center for Pelvic Pain and Dysfunction at San Francisco. I'm William Stones, I'm a British gynecologist in academic practice at the University of Southampton, and I've come over to see what my American colleagues are up to in the field of pelvic pain. So it's, as you can imagine, quite an interesting experience for me because they do have some very different perspectives on these things. One of the features I'm really appreciating at this meeting, Dr. Weiss, is the interdisciplinary nature of the meeting; we're hearing from colleagues from different specialties that are giving a different angle, and also really learning about some of the different patient groups that we get to see. I wonder, if you could share with us what kind of patients tend to make up your practice."

Dr. Weiss: "First, I want to mention how the meeting has been developing over the years that I've been coming, and how all the groups are coming together and starting to see things a little bit more similarly. It's been very exciting to see the blending of ideas, not just separate ideas, but people are really blending them. I come from an area looking at pelvic floor dysfunction as an underlying cause for many of the pelvic complaints that we see that are many times looked at separately but I think can be tied together under one underlying etiology of pelvic floor hypertonerism spasm. We see people in my office that have interstitial cystitis or urinary urgency or frequency, vaginal pain, vulvodynia, anal pain, low back pain, or suprapubic pain, and they may all be treated separately because the shelf/shallow pelvic floor muscle spasm trigger points behave in a very sound fashion. Instead of speaking out, they send their increased tension or muscle and muscle nerve reflexes to the various organs that penetrate them - such as the urethra, vagina, and the rectum. Because they insert on the same route, there can be low back problems, and because of trigger point referral patterns, they can be felt in many other areas. So as a consequence, patients could go to a gynecologist, urologist, and proctologist, and they all seem to be looked at separately but rather not seeing the whole picture."

Dr. Stones: "Yes, so you're a urologist. What was it that led you to start thinking in a slightly wider way or how did this way, when you see patients with primarily bladder symptoms - what was it that led you to start asking them about their pelvic floor or examining their pelvic floor?"

Dr. Weiss: "There have been studies - years of medical studies - that show that urine urgency and frequency, severe urgency and frequency, was the cause of increased tension of urinary sphincter. I was aware of that, and many standard urologic procedures do not attend to give any long-term success as urethra dilations, antispasmodics, and so on - because it's the muscles surrounding the urethra that are involved and dilations can help. So as a consequence, I started to investigate other means; I started doing acupuncture, and I was doing acupuncture for, maybe, several years before I realized that it really wasn't the answer either, and since acupuncture currents and manufactured trigger points are one and the same - I started to explore the possibility of working on those in another manner."

Dr. Stones: "So we're really talking about patients who've been through, perhaps, a routine work-up with an absolute suppositive finding. Is that the sort of patient group that we're really talking about?"

Dr. Weiss: "And that's a suppositive findings or a finding that is thought to be the cause but isn't and, therefore, receive surgical treatment and so on."

Dr. Stones: "So that would be individuals who've had medical or surgical treatments or both or...?"

Dr. Weiss: "Yes, they would have had medical treatments generally or surgical treatments. I usually see them after they've failed the methods."

Dr. Stones: "So women who've been through that sort of process already, and they've had failure treatment, they must be pretty angry and hostile individuals when they get to your office."

Dr. Weiss: "I would say in general, they're pretty agitated, upset, depressed, and pretty hopeless a lot of times."

Dr. Stones: "Yes, are there any tips that you can give us as to how you would actually get through and establish a rapport with somebody who's really had that previous negative experience with investigation and treatments?"

Dr. Weiss: "I would say - first of all listen, because most doctors will hear them, but not really hear them. I think if you really listen to the patient and spend time - I think that's how I usually get through the first day."

Dr. Stones: "Right, that sounds like going back to basics in medical practice. Were there any very specific features that you would be looking for in the history that would most take you in the direction of thinking about a pelvic floor dysfunction or point you in the direction of wanting to identify trigger points?"

Dr. Weiss: "Many times, as I mentioned, there's a whole complex that goes together with the pelvic floor trans-for-nee. They complain of urinary symptoms, some difficulty starting a stream or some other dysfunction of voiding, frequency or urgency, or they'll have the vulvar symptoms etc., or they'll have back problems. What I start doing is going over their history to find out what might have set off some of these problems because myofascial trigger points, active points, are usually the result of accumulation of traumas, not necessarily one trauma. When we look at this…."

Dr. Stones: "So you'll be delving into the history of specific episodes that could have led to an inacerbation"

Dr. Weiss: "Exactly, and if we go way back into childhood, and we're going to try to because you can find early in childhood there can be issues that have set off a tension holding pattern and maintained through life that have been added to the other traumas."

Dr. Stones: "Would those most prominently be issues of the family life or issues like sexual abuse?"

Dr. Weiss: "There could be sexual abuse, but there could be problems even with dance and gymnastics. Children that are taught ballet are taught to hold their center core very tight and to keep their pelvic floor tight, and in gymnastics the same. It could be abnormal problems with bad training, there's a lot of problems occasionally that surround that, or could simply be a lot of stress during childhood, and that's an area that they hold their stress. It could be urinary infections as children, and so on - there's a whole list of things that could occur."

Dr. Stones: "In your own practice, do you find that sometimes this can be difficult in a consultation to really start to uncover these issues or is this kind of information that patients are, in a way, waiting to share with you?"

Dr. Weiss: "It's a variable thing, some people share immediately, and other people with tears in their eyes - they don't have to say anything, you can just mention some of the possibilities. I don't say - "did you" - I just mention - "these are some of the things" - and you can tell sometimes what the story is."

Dr. Stones: "That why it's good. Could you take us through your approach of the physical examination in one of these patients who has a chronic condition with a number of organ systems involved, some bladder symptoms, perhaps some vulva pain. How would you approach this examination?"

Dr. Weiss: "Because some of the surrounding muscles groups can affect the pelvic floor, I first look at the way they walk and their posture just taking them into the examining room, have them stand up, look at their back, look for a lordotic position or tilt, pelvis tilt, or weaknesses of abdominal wall. Then I will lie them down and check the abdominal wall muscles, the rectus abdominis for trigger points, the ileococcygeus muscle, the gluteal muscles, the abductors, the piriformis, and so on, and just look for any areas that might be abnormal with tenderness or trigger points. Then we'll usually put them in a lithotomy position and inspect the pelvic floor - usually by compression - externally to see if there's any tenderness and many times it's real tight and tender just on external compression. I'll look at the vulvar area and the vestibule, and generally I use the Q-tip test to check for sensitivity developed in the vestibular area and see if there's any other abnormalities. I check the strength of pubococcygeus muscle, though it can contract or relax many times; if they've lost complete control of that there is so much pain or weakness from trigger points that they have no connection at all. Then I'll assess various muscles groups internally with my finger, looking at the levator groups, the coccygeus, piriformis, the urinary sphincter etc.; the obturator internus is a very important one as well. Once I've established the pattern, then I'll go ahead and start working on these muscles to try to relax them using standard manufobic techniques."

Dr. Stones: "In terms of your diagnostic findings on examination, do you tend to find that one particular muscle group is involved or do your patients tend to have some degree of tenderness or spasm associated with many of the muscles?"

Dr. Weiss: "Yes, muscles will kind of work together, when there's a lot of tension most of the muscles will get tense, but there are specific areas that I find will relate to the complaint. If they have urinary symptoms there usually will be tightness around the urinary sphincter, the puborectalis. If they have clitoral pain behind that same area to be involved, you constantly nick the pudendal extension if you tend to work into that area into the clitoris, so when they come in complaining about that, I find that's really a very tender area. I also find that priformis muscle to be extremely important, vaginal symptoms, and then so on, around the anus, and so on for symptoms back there."

Dr. Stones: "Then your findings on examination do tend to relate quite reasonably to a particular pattern of complaint?"

Dr. Weiss: "In general, but many times I'm surprised that the referral can be quite so erratic, but in general, I suppose."

Dr. Stones: "So can you outline the main approaches to treatment when you've identified the muscle groups that you think are mainly the problem?"

Dr. Weiss: "What I do with treatment would be using manual therapy techniques of stretching, compression, and sometimes injections - trigger point injections using an anesthetic agent. We'll try to eradicate the tender spots, but we also need to re-educate the muscles to be sure the muscles are stretched to the full range and contracted. It's a re-training process because these muscles have not known full range of motion for a long time."

Dr. Stones: "So in practical terms, is this something that you would need to repeat on a - what sort of frequency?"

Dr. Weiss: "I would need to repeat it ideally twice a week but generally on patients, how difficult is it coming in that often, so I do it once a week. That depends upon the condition on how long it's lasted, we may have to do with, maybe, 10 or 12 treatments fairly close together then start spreading them out according to their improvement. This is only part of the treatment because we have to work on the external muscle groups as well, so a physical therapist will use stretching, manual therapy and instructions as well, and then we do biofeedback, re-education, pelvic form for strengthening, relaxation, so that's many arms of it."

Dr. Stones: "Just recently I've had some experience of using biofeedback. It does seem to be encouraging - is that your perception that that's a useful modality?"

Dr. Weiss: "I think it's essential, it gives the patients a connecture of the pelvic floor. A lot of times they just don't know what to do with it, they just have no energy, and they just completely don't want to have anything to do with the tightening or relaxing. It's a matter of re-training them and reprocessing them so they can connect. I think it's extremely important that they say it's a help that can be done on a daily basis at home, and it reinforces what we've been doing. In addition to the biofeedback, we also many times teach the spouse how to do some of the work internally because that also will be a more constant, even penile, will be a more constant therapy."

Dr. Stones: "In a patient who is responding to this sort of personal treatment, over what sort of time frame will you get a response? Is it fairly immediately or do you fail to see a particular individual is going to benefit or is it something that will only become apparent later on in a series of treatment?"

Dr. Weiss: "There's a variation on that too, again, depending on how long it is and what other elements there are. Many patients will feel better when they get off the table for the first time because everything feels lighter and it feels different. I think to get sustained improvement, it may take months, it could even take up to a year depending on what circumstances there are, to really get sustained improvement. Vestibulitis patients, I'd say, take a good eight-to-nine months or so; interstitial cystatic patients may take one or two years, but it's an ongoing process of re-education."

Dr. Stones: "Do you think that the approach that you are taking in this group of women - do you think this is something that all gynecologists or urologists should be trying to extend to their practice or is this something which is really quite specialized and applies to a very definite group of, if you like, difficult patients that really should be seen by somebody with a very special interest in that area?"

Dr. Weiss: "I think that all gynecologists and urologists should be aware of this because I think as we discussed in the meeting today, it's better to try to head off something in the early stages than to let it go too long for central sensitization to occur. I think that it should be a preliminary to any kind of surgical or invasive procedures. I think from that standpoint, they should be aware of it, and I think it could be learned; it's not that hard basically."

Dr. Stones: "So you feel this is something that every gynecologist or urologist should be having in their mind during their initial assessment of patients with pain?"

Dr. Weiss: "I definitely think so, it's very important."

Dr. Stones: "Do you have any pearls of wisdom that you can share with us in this field with regards to diagnosis or treatment approaches?"

Dr. Weiss: "I think basically, as what you said, a pearl is a sudden awareness realizing that this does exist as an entity, that through various nerve reflexes it can create all kinds of symptoms. And that if it's not brought up and examined, a lot of future patients will treat it improperly. What we really need to do is just pay attention."

Dr. Stones: "Dr. Weiss, thank you very much."

Dr. Weiss: "Thank you."