Episode 140: Pelvic Floor PT & Hernias | Hernia Talk Live Q&A

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Speaker 1 (00:00:10):

Good evening everyone. It’s Dr. Welcome to Hernia Talk Live. We’re here every week as our session restarts again this Tuesday we call Hernia Talk Tuesdays. My name is Dr. Shirin Towfigh. I am your hernia and laparoscopic surgery specialist. You are joining me, some of you as a Facebook Live and others on Zoom, but you can also follow me on my other social media accounts at Hernia Doc on Twitter and Instagram. And most importantly related to this episode and all prior episodes. You can watch all of them on my YouTube channel at Hernia Doc. So I’ve been wanting to have this amazing guest for many years. We’re both very busy. She’s busier than I am for sure, especially if she can follow her on social media. Dr. Sally Sarrel, she is a doctorate in physical therapy. You can follow her on Instagram at Doctor Sally pt and she’s very well known for the endometriosis summit. So hi Sally.

Speaker 2 (00:01:18):

Hi. How are you?

Speaker 1 (00:01:20):

I’m excellent and thank you so much for making time for this. I am so happy to finally speak with you one-on-one about all of these things. We share a lot of common likes.

Speaker 2 (00:01:33):

It’s exciting to be here. I’m usually a viewer, so to be on the other side of the zoom is very exciting for me.

Speaker 1 (00:01:40):

Same here. I’m a viewer of everything you post. You have some of the most, I would say you have a great combination of information plus entertainment. It’s so high energy. I want to listen to what you’re saying, but I a hundred percent agree with everything you say. So that’s like a great combination.

Speaker 2 (00:02:00):

Well, nobody agrees a hundred percent, but yes, we try to make, my goal as part of the endometriosis summit is to make education accessible to all because it shouldn’t just be the doctors with all the knowledge, a patient should be able to arm themselves with what they need to know.

Speaker 1 (00:02:20):

Absolutely. So we have a bunch of questions that have already been submitted. I’d love to be able to get through some of those Before we begin, perhaps educate my audience. So my audience mostly are people with hernias or concern that they may have hernias or hernia related complications. But that includes people that have been referred to physical therapists. They’ve been told they need pelvic floor physical therapy. They’ve been told maybe it’s not a hernia and it’s something else. Gynecologic or urologic, orthopedic. There’s a lot of overlap in what we do. So maybe you can first explain physical therapy and then specifically pelvic floor physical therapy. If someone gets sent to that, what does that mean?

Speaker 2 (00:03:08):

Physical therapy, especially when you’re dealing with pelvic physical therapy is a discipline, a subspecialty within a musculoskeletal education. So we deal with all things, well, all physical therapists deal with bones, muscles, ligaments, and fascia in a non-surgical way. But the pelvic physical therapist to work in anything between really the belly button and the knees. And so I thought I’d take a minute. I’m not even sure you the story or how I came to be the hernia whisperer as oh as our friends in New York to call me. I

Speaker 1 (00:03:52):

Love it. So

Speaker 2 (00:03:54):

I have endometriosis and of course my endometriosis like many with the disease, took 23 years to diagnose. Even though my entire family’s in medicine and I’m a pelvic pt, it is very hard to diagnose. And the majority of my disease was on the pelvic sidewall. So especially on the left side. And after I had excision, I had a good excision. They were removing calcified endometriosis. They were operating in all sorts of places. I come back within four weeks of the excision and I felt great. You could see the inflammatory effects of the disease were gone. But I kept pointing to one spot. I have a puppy and she has a toy. So I kept pointing to one spot. I kept point that spot that’s like your belly button between and right near the groin crease. And I kept saying my ovary hurts. They kept doing ultrasounds, they kept doing MRIs, they did try this, try that.

Speaker 2 (00:05:02):

And no one said to me, the ilioinguinal nerve is right there. We should look at what that right. And I am a competitive tennis player. And so the answer always was, that’s why you have groin pain. And I had right horrendous pelvic floor spasms in, but really in one place. And I kept saying I had vaginal burning, but I didn’t know at that time if you really break down the nerve, which we can talk about if your burning is in one spot versus another spot, it’s two different nerves. So I end up doubled over on the court, tennis and then I end up having big major surgery. I have a urologist there because I have this insane urgency, which I think comes with hernia as well and

Speaker 1 (00:05:57):

Discuss that.

Speaker 2 (00:05:58):

And I have a bowel surgeon because I have all this rib tip pain and I wake up from the surgery and without my consent, they removed my ovary. They said we didn’t really, this is one of the most, at the time well-known endometriosis surgeons in the world. We didn’t really see anything. I also had umbilical pain. That’s different. That’s a different line. And we didn’t see anything. We took out your ovary, you are all fine now. In addition to that, causing me big time problems because I couldn’t get any eggs out. I went into ovarian failure. It didn’t stop the pain, the pain’s getting worse in the

Speaker 1 (00:06:42):

Region. It was in the area of your pain, but it wasn’t the cause of your pain.

Speaker 2 (00:06:46):

Right. And so it took, then I met a physiatrist and they were like, did you ever hear about these? You don’t really need a bulge for hernia. Well, it took three years for me to find someone who believed me. And I’m like learning how to do all these techniques as a pelvic pt. And then it took, after I found the person, it took me nine months to get him to operate. And I had bilateral inguinal and femoral and an obtuator, which the pelvic. Oh, right. So I

Speaker 1 (00:07:21):

That’s a lot.

Speaker 2 (00:07:23):

I then, yeah. And

Speaker 1 (00:07:25):

You were pelvic floor PT already by that time?

Speaker 2 (00:07:27):

Yeah. Not only pelvic floor pt, but I was already traveling the world talking about pelvic floor PT and endometriosis and presenting research all over the world. So then I switched and I do a lot of work with this hernia. And the first year I was working as a pelvic PT in endometriosis. I really only saw endometriosis patients at that time. I found out of 36 patients, I found 22 hernias. So

Speaker 1 (00:07:58):

Based on your exam or your stor, their

Speaker 2 (00:07:59):

Story, I would do an exam at that time. I could gather the masses. I would do an exam. I then had a different physiatrist who would do a block if she needed to. And then I would have them confirmed by a general surgeon who specializes in this. Wow. Now what I’m always amazed by is the people who come in and my Instagram is filled with that. No, no, I have cysts. It’s really not the cyst because the cyst itself, okay, endometrioma causes pain, but a simple cyst isn’t causing the pain. It’s the inflammatory response around the nerve. And then I also see, oh, I got it over the weekend. Someone got ahold of my cell phone and they were texting me symptoms. This happens all too often. And they’re like, it’s, it’s pudendal. It’s not

Speaker 1 (00:08:54):

Pudendal. Oh God, you’re hitting on all the topics we’re going to be discussing.

Speaker 2 (00:08:58):

And she’s like, my PT says, and I’m like, your PT took out a grease pencil and marked the nerve every ounce of the nerve and then found that, or was it really a different nerve?

Speaker 1 (00:09:11):


Speaker 2 (00:09:12):

Yeah. So this was my story. I also had a massive ventral hernia, but different, cause I had a mother who was a stroke survivor. And so that led a little bit of a passion. There’s obviously a connective tissue.

Speaker 1 (00:09:28):

Yeah, I was going to say tested for connective tissue probably.

Speaker 2 (00:09:31):

So. Yes,

Speaker 1 (00:09:32):

Yes. You double jointed.

Speaker 2 (00:09:34):

I’m not. So before I went through the first hernia surgery, I went to someone, and in those days they used to categorize connective tissue disorder. And he was like, you have something. But it does, it’s not exactly e d s. It’s not this. But now we don’t categorize

Speaker 1 (00:09:55):

Belo syndrome.

Speaker 2 (00:09:56):

And then once I got older, you can really see I have a lot of mast cell responses. So when you put the mast cell together with all the hernias, there’s definitely something on the connective tissue. Great. I have a great speaker for you if you want to talk about EDS. She was amazing.

Speaker 1 (00:10:12):

Yes. Share. Love

Speaker 2 (00:10:13):

It. Yeah, I’ll email

Speaker 1 (00:10:15):

You. Well, okay. So as you’re talking about how your left ovary was kind of considered the reason for your pain, someone actually says the question live. It says, my left ovary hurts. Now it’s always my ovaries. And now I’m thinking maybe it’s a hernia. I feel an elastic band, heavy pulling, weighing down my pelvic area.

Speaker 2 (00:10:36):

Well, I think mean you’re the surgeon, but I think when someone says elastic band, yeah. So I’ve had endometrium. I, I’ve had a seven before that ovary left, I had a seven centimeter so I could feel the difference. Oh wow. And that endometrioma feels like a bomb in one spot. When people say elastic band, that makes you think of a ligament that makes you think of a nerve, doesn’t it?

Speaker 1 (00:11:04):

Yes, for sure. Pulling any pulling since. So I think the history is really important. The area of pain is also obviously important in physical exam. But I often walk in a room already kind of knowing what’s going on based on the story. In fact, my nurse, nurse Bell, who’s great, all she does is hernias. She comes to me because she does the intake first. And based on what they’re saying, she’s like, oh, this is not a hernia. Oh, this is a hernia. Oh, this is a hip. Because the story makes all the sense. So unlike ovarian stuff, the musculoskeletal like hernia stuff, activity related, burning, pinching, pulling, sometimes tearing, radiating pain, those are all kind of hernia related. But because we’re women and people point down, they’re like, oh, it must be your ovary. Or maybe it’s endometriosis. Don’t you think? Well,

Speaker 2 (00:12:03):

I always say to people, maybe it’s endometriosis, but the thing is you can have both. I know we have lots of men watching tonight, so I’ve had a lot of experience with my hernia as well. But I’ll also say just because it hurts at ovulation doesn’t mean it’s ovarian. Because right. Ovulation is a inflammatory experience. And if the nerve that’s sitting next to the ovary is getting irritated because, and it already has a little compression somewhere in there, you’re going to get a response. And I also think one of the issues in endometriosis, nobody’s ever believed. And so they go back to the doc. That was really my issue. I kept going back to the doctor that believed me and back to the doctor that believed me. But he really, it’s, it wasn’t in his wheelhouse. I mean, here, Ernie should be on the radar by now. We’ve done a lot of work. You would me, but it’s not in the wheelhouse. And I think when somebody has that burning groin pain or they have pubic bone pain or they have patients, when you talk about the story, you have have recurrent ingrown. I had a patient who came to me, they would all come in, excuse me, I didn’t get my laser this week. Why? Yeah,

Speaker 1 (00:13:24):

It’s too painful. You

Speaker 2 (00:13:25):

Need to ask why are you getting the laser? Are you getting, oh, I’m getting so many ingrown. Where are you getting these ingrown? Can you point to that? Where’s the nerve that all of that is? Gives information to the picture, I think.

Speaker 1 (00:13:38):

Yeah, I think all, some patients don’t want to give too many details. They think they’re going to overwhelm you. I’m like, no, I need to know. Because those little, for example, they can’t wear certain underwear or

Speaker 2 (00:13:49):

Wear no underwear, but no underwear club.

Speaker 1 (00:13:53):

Or they wear, women wear skirts, they prefer to wear skirts or they wear loose pants, yoga pants or it’s too constrictive for them belts. They can’t, men can’t wear belts. So those, that little bit of detail, very helpful.

Speaker 2 (00:14:09):

And I think we’re a lot of information about, oh, it’s always your labrum, it’s always your lab. It’s not always your labrum. And the other thing which I learned from hernia talk, it’s really the role of femoral hernia in assigned female at birth related pain in fe female hernia. And so that when somebody keeps taking their hand and rubbing it down their thigh

Speaker 1 (00:14:35):

Of their thigh,

Speaker 2 (00:14:37):

Is that the femoral hernia? And it’s interesting, my father has terrible stenosis. And while I was learning the mapping, I’m mapping out his pain and it’s not consistent with where the narrowing is. And he had hernia surgery two weeks later.

Speaker 1 (00:14:55):

Oh boy.

Speaker 2 (00:14:57):

But it helped that pain. So this pain that he always assumed was from the stenosis down the front of his thigh really was hernia related.

Speaker 1 (00:15:07):

And it runs in family. So your father academically, well,

Speaker 2 (00:15:10):

It’s worse because my uncle, the three of us could stand in a row and it definitely runs in families.

Speaker 1 (00:15:18):

So this lady who she is viewing us right now talks about the ovary pain and maybe this elastic band. She also says every step I heard. What does that mean to you when walking or stopping?

Speaker 2 (00:15:30):

Well, I do think about the femoral hernia when people have that sort of pain down the front of the legs when they’re walking. The person that got in touch with me over the weekend, her groin, her the text was, my groin is on fire from running. What I think is when you’re putting compression into the system and you already have maybe a fat pad laying on the nerve, making a tight system tighter.

Speaker 1 (00:16:06):

And don’t you think that also brings in hip problems when people have walking limping issues, then it also brings in hip potential disorders into the differential.

Speaker 2 (00:16:17):

Yeah, I think that that’s the fun part. As a clinician, I know that’s terrible to the patient, but is it hip? Is it this, is it that, is there a little joint disorder? Is it the hernia? Is it, can we block the nerve? Is it the adductor insertion with the pelvic floor? Is it that that’s, and usually I find it’s not just one thing.

Speaker 1 (00:16:43):

Okay. So let’s say I send a patient up for pelvic floor therapy, what should they expect to do? Do they all get internal examinations or No? I know some people that don’t get internal

Speaker 2 (00:16:55):

Examinations. I do a lot, a lot of trauma informed care and I have to meet the patient where they are. And if you are not ready for internal work, we don’t do internal work. And I also do, first of all, well, it’s not usually you that’s sending it to me. It’s usually say the primary care. I get a lot of physiatry recommendations or G Y N who goes, I don’t know what to do. And

Speaker 1 (00:17:26):

Neurologist sometimes,

Speaker 2 (00:17:27):

And maybe it’s muscular skeletal. So if I see that the person comes in, they’re pointing to one or another spot and they’re complaining about burning, I’m going to do a really good interview like you said it, where is your, and they’re going to learn from the start. While it’s trauma in informed care, I do need to know is it the labia or the scrotum that’s burning versus is it somewhere else? Is it I really, that provides me a lot of information. And then I really do take out a grease pencil before I do internal work. And I try to see, I mark on the person. I don’t do the fancy way, the international hernia people do.

Speaker 1 (00:18:16):

I don’t either,

Speaker 2 (00:18:17):

Which is like, but I really do the x’s. And I think that that provides a way for a patient to be looking like, because you can stand up, you can look at a mirror. I should have pulled those pictures. I took at white athletic tape before my big surgery where, not where they removed the ovary. And I marked my whole body and I took photographs of it and I sent it off to the doctor. I sent it to the urologist and I arrived there and I said, before, we’re going to go in the or, I want you to see this is the pain pattern. Great. If you or I looked at that, you’d be like, we’re not going to do a G Y N surgery. We would, but they didn’t know

Speaker 1 (00:19:01):

musculo skeletal.

Speaker 2 (00:19:02):

Right. They didn’t know what they didn’t know. And so looking back, I’m like, then I guess what, I should have hit them in the head. But we didn’t do nerves those days. But I do. And I think when a patient sees it, then they, maybe that’s the moment for them. Then I definitely test out all planes of motion on the hip before I do any internal work. And then if it’s warranted, I’m going to do a gentle pelvic exam. And remember, I’m not looking at ovaries and prostates and I’m looking at the musculoskeletal complex. And so

Speaker 1 (00:19:40):

One of the things that we learn in patients that have hernias, so the typical hernia is like a bulge, right? That’s like common, a bulge. Most people understand that’s a hernia, but it’s everything else that they don’t understand necessarily is due to hernia. So pelvic floor spasm is a poorly understood problem that we see with hernias. And that could include pelvic floor pain, pain with sexual intercourse and penetration, rectal pain, urinary frequency, all of these things. Do you notice pelvic floor tenseness on the side of hernias? Absolutely. And then had you been able to then examine them after her new pair and say, oh, that’s much better.

Speaker 2 (00:20:27):

Yeah, because I used when we were like, I used to do before and afters. So after covid I treat very differently because of my life changed. But I find that you’re going to get spasm in the pelvic floor, particularly not in your superficial pelvic floor muscles. So not in, we have

Speaker 1 (00:20:52):

For those you on YouTube, we have

Speaker 2 (00:20:55):

Not in

Speaker 1 (00:20:56):

A lot of muscles,

Speaker 2 (00:20:58):

Not in your superficial pelvic floor muscles. But in the deeper layer of the pelvic floor, typically one sided. Yes. And I would say, I would almost always say halfway back. Right. Okay. You’re not talking about deep. And when people have that pelvic floor in one spot, right? It’s like a cluster area that you can feel in your fingers. It’s often triggered by hernia. But rarely, I have to say all the hernia that I’ve worked with, maybe one had a bulge. I really don’t see bulge hernia. Right. The men, sometimes I can find that in men. And actually the primary symptom, I hope YouTube loves us tonight. The primary symptom that men is pain with ejaculation when they end up coming to me and we find the yes.

Speaker 1 (00:21:58):

Yeah. Yeah. And then how painful is the examination for the patient

Speaker 2 (00:22:07):

In general? If your pelvic floor, if I have to go banging around in there and you need to take the rest of the day off from work, that’s not working because all it’s doing is upregulating your central nervous system. So it should be, well, I hate the dentist, but it should be equal to or less painful than the dent. I have a lot of dental fear than the dentist. And I think also I do exams in multiple positions.

Speaker 1 (00:22:39):


Speaker 2 (00:22:42):

So this is

Speaker 1 (00:22:42):

A digital exam for men. It’s a rectal exam

Speaker 2 (00:22:46):

For minute, it’s a rectal exam. I do primarily see women and for

Speaker 1 (00:22:54):

Vaginal and rectal or a vaginal only

Speaker 2 (00:22:56):

Exam, I tend not to do a rectal exam on women, on men. To tell you the truth, if you map it and you take a good history, I send them off to the surgeon because it’s much easier to spot that on an MRI. Sure. In a man. And if they can find help, I can never fix a hernia. I can’t fix a hernia. And the surgeons can. And sometimes that’s what people need now after surgery. I think that people still need the muscles balanced. And the other thing is, if you’ve been in pain, some people that we’re seeing have had this pain, you get horrible bloating from hernias. Yeah.

Speaker 1 (00:23:41):

Nausea, bloating for sure. You need

Speaker 2 (00:23:43):

You to know how to reactivate your transverse abdominals and balance your core and train your obliques to provide you the support you need so that I’m not seeing you in a year for hip problems.

Speaker 1 (00:24:01):

I’ve noticed athletes who have hernias, they really feel off balance. It could be smalls hernia and they’re like, I can’t engage my core. And they have a little eat speech hernia. Well, we

Speaker 2 (00:24:12):

Should talk about Rafa one day offline. I think there’s, yes. There’s a lot going on there with Rafael. We have not been divulged.

Speaker 1 (00:24:23):

Well, I’d like to examine Raphael.

Speaker 2 (00:24:25):

I, I’d like to examine,

Speaker 1 (00:24:27):

I want to examine LeBron James too. Can I add that to the list?

Speaker 2 (00:24:31):

Well, what’s interesting is Raphael Nadal’s thing, he says, started with a sewist strain. And I see a lot of, even though he had

Speaker 1 (00:24:41):

A rectus tear

Speaker 2 (00:24:42):

Well before that, first he had the sous, then he had a rectus tear. Now he has groin pain. I mean, we could talk about pubalgia on him, but no one else will. So whatever. But I think I see a lot of people who come into me, even though we don’t typically think of the hip flexor as being in spasm, but they say, my hip flexors are so tight. They’re so tight. They’re so tight. And I do see that with hernia as well because it’s reacting to

Speaker 1 (00:25:13):

The Yeah, it’s all reacting. Yeah. Yeah. Okay. One comment, my audience wants to clone you by the way. It says, can we clone you Dr. Sally? Oh, another question. How can a male recognize if he has pelvic floor spasm? You mentioned the pain with ejaculation, but

Speaker 2 (00:25:33):

Right. I think also constipation and defecation related issues. I also think to some extent, pain sitting. And I always ask when I’m treating men, what is, especially with the peloton, since where are you sitting and how often are you sitting? Because that’s a good way to talk about pelvic floor spasms. Yeah. But let’s not forget pelvic floor in its own way is adductor. Right. Because the adductor inserts on all

Speaker 1 (00:26:05):


Speaker 2 (00:26:07):

And also back pain and urinary Listen with a hernia. My, I had a patient come to me in a diaper.

Speaker 1 (00:26:17):

Oh yeah.

Speaker 2 (00:26:18):

And she said the excision didn’t work because the minute I have to go, I either have to go or that’s it, I’m giving up.

Speaker 1 (00:26:26):

Oh yeah, I have, she would urinate 10 times every night and then she would like 40 times during the day. And then she would have her husband massage her from the inside through the vagina. And I’m like, you’re basically pushing your hernia back in. Right. That’s basically what we’re doing. But yeah, we fix the hernia. All that went away. But severe pelvic floor spasm. Right.

Speaker 2 (00:26:50):

Well, I always fight with the urologist on this one that if you see the hernia on the film and they’re describing this intense urgency, it’s not just frequency. It’s like now yeah, we do something for the hernia before, say you shove a inner stem device in them. Cause if the hernia is easy relatively to fix, not to be then, then to have a device in your body the rest of your life.

Speaker 1 (00:27:21):

Yeah. Yeah. Thank you for that. And hernias are so common. All of the other things are not common. Pudendal Neuralgia is very, very, very uncommon. Well,

Speaker 2 (00:27:32):

True Pudendal Neuralgia, true

Speaker 1 (00:27:34):


Speaker 2 (00:27:34):

Neuralgia Neuralgia. I,

Speaker 1 (00:27:38):

Yeah, you can get pudendal nerve symptoms from pelvic floor spasm, but that doesn’t mean you have to go getting pudendal nerve injections and blocks and surgery for it. Well, I also think people goes

Speaker 2 (00:27:50):

Away. Gynecologists know what the pudendal nerve is. It’s like they know what vulvodynia is. But you don’t all have vulvodynia when you have a pelvic floor spasm. Yeah. It’s not just because your script says that does not mean that is what I think.

Speaker 1 (00:28:04):


Speaker 2 (00:28:04):

I think especially in females, people say, oh, if it’s the clitoris then it’s the pudendal nerve. But what they’re inputting everything in the area, it has to be like smack dab on the clitoris to be pudendal. The rest of it is ilioinguinal or genital femoral. Yeah. Really genital.

Speaker 1 (00:28:26):

Yeah. Tell me more about pudendal nerves, because I see a lot of over diagnosis of pudendal nerves. In fact, one of the questions, I should bring it up because it was kind of nicely worded. One of the questions was that, yeah, let’s do this because this is important. The question is, how often do you find Pudendal Neuralgia diagnosed instead of a hernia? And then the patient’s then taking it down this rabbit hole, down the pudendal Neuralgia pathway with blocks and ablations and so on. And this whole time it was pelvic floor spasm due to a hernia.

Speaker 2 (00:29:06):

Well, I see that. I see the patients nobody wants. So I see that a lot.

Speaker 1 (00:29:12):

I say that patients nobody can help.

Speaker 2 (00:29:14):

No. Well, but I see that I in men almost all the time. Yeah. I don’t know why a urologist or a primary care doesn’t want to talk about other nerves. I see it all the time. Yeah. I see it in women and the doctoral, the script and put Pudendal Neuralgia on it, which then the person’s brain has now grabbed onto that and it almost defines, and so it takes months to explain what all the other nerves are. And the way I go around that is, that’s why I started with the grease pencil. And I had someone who I had been treating a very difficult case, very young woman who by an excellent doctor was told, have a hysterectomy for the adenomyosis. That’s her choice for adenomyosis. And then you should really do a device for the Pudendal Neuralgia. And I had been treating her already for three or four months and I went back and what she said was, the nerve pain is so sharp, I jump when I bend forward to get the remote control. Well, if you’re bending forward, you’re compressing. Think about where the nerve meets the leg. And then I started to evaluate and sure enough, I think within three weeks she had hernia surgery. And it definitely fixed that. It did not fix the adenomyosis. But honestly, I think a nerve doctor hears burning and they think it’s a nerve in the pelvis. Must be.

Speaker 1 (00:30:56):

Yeah. Yeah. And people do just don’t wake up one day and get Pudendal Neuralgia. That’s my argument. a lot of the nerve stuff is you can have nerve pain due to a hernia, but people don’t, don’t just wake up one day and get an injury of their pudendal nerve. That doesn’t happen. So to kind of take them through this very singular adenal nerve diagnosis is just a waste of time. And it could cause damage. Well,

Speaker 2 (00:31:27):

And you could have Pudendal Neuralgia well in men. I see. They recently retired. So a lot of where I live, they’re all on bicycles. Or it’ll be interesting. I, I’m going to develop a pickleball protocol, but that didn’t come yet. Oh, I

Speaker 1 (00:31:44):

Love it.

Speaker 2 (00:31:46):

But I think they never sat on a seat like that until they really, that’s how their nerve got ir. That’s when I see a Pudendal Neuralgia.

Speaker 1 (00:31:56):

Sure. The cycling for sure on the couch. You’re not going to get Pudendal Neuralgia.

Speaker 2 (00:32:01):

Right. I see a lot of, and I have seen pudendal endometriosis. I’m not denying that there can be. And I’ve seen a ton of sciatic endometriosis.

Speaker 1 (00:32:12):


Speaker 2 (00:32:13):

And I see that game more than it. But is it inguinal endometriosis, which I’ve only seen once in 15 years where the piece was literally removed and run through pathology. But I think there’s a lot of mistakes on nerves. And what else? I see the gynecologist went in and they didn’t see anything. So there can’t be a hernia.

Speaker 1 (00:32:41):

Yeah. That’s an incomplete look. But actually this next question talks about that. I was told this is a question. I was told that I had anal hernia during my most recent endometriosis surgery. The endometriosis was removed from the hernia. Would it be common that the hernia may now go away?

Speaker 2 (00:33:02):

Remove. So I also, it sounds like end cases it set you a very similar case.

Speaker 1 (00:33:06):


Speaker 2 (00:33:09):

So I think that first of all, the hernias that I see are not typically seen during endometriosis surgery because there are wads of pre peritoneal fat laying against the nerve. And if that hernia is all the way through the retroperitoneum, you really need a decent specialist in there to fix it. So if you’re taking the endometriosis out of the hernia, if you’ve wrapped it inside the hernia and you do not have a superstar, her not a general, I don’t believe every general surgeon can handle hernia. Maybe mean

Speaker 1 (00:33:46):

They should be able to, but they can’t.

Speaker 2 (00:33:48):

Yeah. Well luckily I’ve taken family members to general surgeons who say, I don’t do it this well go to this, go to my partner, go to. Sometimes they’re becoming aware of that. But I think if you’re doing a repair during an endometriosis surgery and there’s endometriosis in there, how are you repairing because you’re not doing a Mesh repair. And if the hole was that big, do you need Mesh? That’s a good conversation. People ask me that all the time about Mesh. And it would be, I think, unsafe to be doing Mesh while you’re doing an endometriosis surgery until the pelvis is clear. So then how is it repaired? So yes, you could still have it. But the other thing is once you have that compression on the nerve, the nerve is all turned up and aggravated. So it may need something to quiet. It may need some myofascial techniques to the nerve when you’re healed. And you may need a little anti-inflammatory into the nerve and a little low.

Speaker 1 (00:34:50):

Yeah, that’s very true. Another question, can Dr. Sarrel discuss, you mentioned trans versus abdominus and oblique reactivation. How do you reactivate the trans versus abdominus and your obliques?

Speaker 2 (00:35:03):

Well, I start with the breath and understanding how to perform that contraction. And then I go up from there. So first you’re going to do it in supine. Your legs are not going to be moving. Then you’re going to be in supine. But you’re going to use, as you work your breath, you’re going to move your legs from abduction to abduction. From abduction to abduction. I work in standing, I work in is your, and in terms of obliques, I try to do functional. What is the person’s function? Are they lifting groceries? Because then just putting a weight in the hand and going, that’s not how groceries move. And I really have started to do dynamic strengthening of the obliques while you’re moving. Cause that’s when you really need them. So maybe you’re walking And I used to keep groceries in the practice and people. Yes. Yeah. And I like my diagonals. So I’m teaching breathing. So teaching how to stabilize with the belly button in. And you’re moving on a diagonal, which is a little bit of our P N F type working. And I have to say, when somebody’s been in pain a long time, your pelvic floor and your abs, you’re, because when you’re in pain, you’re like this,

Speaker 1 (00:36:39):

You have to

Speaker 2 (00:36:41):

Learn to lengthen. I put the towel on the floor and I teach people sort of reverse downward facing sit ups to control that. Oh sure. Transversus muscle. And it’s really hard

Speaker 1 (00:36:58):

To learn the engagement specifically of a transversus abdominis. But it’s so important because it’s like your inner girdle. And if you look at imaging, most people have a poorly developed trans versus abdominal muscle.

Speaker 2 (00:37:12):

It’s really hard to describe it because I do it by touch. And so when I’m teaching how to do it, I’m touching. But to describe it, I’m like, well, I don’t, it’s very hard to do the news studio. I’ll be able to demo.

Speaker 1 (00:37:27):

Oh really? Are you going to have a green screen or something?

Speaker 2 (00:37:31):

Yeah, have the green screen I would have to buy. So we’re going to hold off for a year or two before we put a bed up there, but I’ll be able to have the lighting and everything. That’ll be really

Speaker 1 (00:37:40):

Nice. Congratulations on that. That’s really cool. Okay, another question. Do Anglo hernias hurt or become tender during ovulation? I noticed that my area hurts to the touch during ovulation. You were talking about that it’s hormonal, right? It’s through the estrogen peak that we get more pain of anything including hernias during menses. I

Speaker 2 (00:38:02):

Guess I feel like I should have brought my diagrams with me, but if you think about, I usually stand up, but if you think about where the ovary sits and where the ilioinguinal and the genital branch of the general femoral nerves are so close together that it’s very possible that with the hormonal fluctuations and with the inflammatory response of ovulation itself, that you’re going to get more pain. And I see that all the time. And I think that’s how people end up at the gynecologist. If you’re saying to me my inner thigh burns during ovulation, unless you have some sort of strange adhesion wrapped around something or other, I definitely suspect hernia.

Speaker 1 (00:38:51):

Yeah, for sure. Yeah, because that’s ileal nerve. So the way I describe it is the ileal nerve runs in the groin and if during normal anatomy, that nerve should be just hanging out where it normally hangs out and it gives sensation to the inner thigh. However, if add content there to compete with space with the nerve, whether it’s fat or intestine, basically a hernia that’s bulging or any of its contents, you’re now competing for space in a very tight area. And any activity can kind of tickle that nerve and cause nerve related symptoms, burning, searing pain, hot poker is a common way to talk about it. And then also it’s in the distribution of the nerve. So radiation of pain to the inner thighs Classic for most anal hernia type symptoms. And women, that canal is much narrower than in men. So you have less room even than men and therefore less hernia and smaller hernia is necessary to spark that nerve pain.

Speaker 2 (00:40:00):

That why I feel like noble hernia is much more common in, I mean, not that it’s like that common in the first place, but yeah, much more common in women.

Speaker 1 (00:40:11):

And this whole idea of occult hernias or smaller hernias being symptomatic is because you don’t see it be large enough yet, but it’s large enough to tickle that nerve. So you get nerve pain and people don’t see their hernias, so they just focus on the nerve pain, not understanding it’s from the hernia. And they take you down this whole nerve pathway and people get nerves cut nerves burn nerves, nerve pain medication, and all they really need is a hernia repair.

Speaker 2 (00:40:38):

I think also I have stood at conferences and shown some of this unscreen in a medical setting and had general surgeon stand up and say, but that’s not a hernia. And so I know you do work with it, I

Speaker 1 (00:40:59):

Ate it.

Speaker 2 (00:41:00):

The radiologist likes to see a big fat hole with something that’s going to kill you. Right. Going before they’re going to call it. Yes. But that doesn’t mean that’s the only type of herniation that’s going to cause pain.

Speaker 1 (00:41:12):

And most general surgeons do not understand that the size of the hernia does not correlate with symptoms. So large hernias may completely no symptoms. Small hernias you can and feel can have symptoms and they deserve to be treated.

Speaker 2 (00:41:29):

Our general, we have a general surgeon, but then we also have a hernia specialist in the clinic that I work with. But the general surgeon will actually say once it’s a big hernia, it could kill you, but it doesn’t really hurt anymore.

Speaker 1 (00:41:42):

Yeah, it doesn’t hurt anymore. Wide open, wide open hole. Not it’s

Speaker 2 (00:41:46):

The guy that comes in and he isn’t complaining. He’s concerned about,

Speaker 1 (00:41:50):

Yeah. Let’s see. A couple more questions coming in from a PT standpoint. Is PT for the rectus abdominals different from general abdominal pt? And how are those different from PT for ventral hernias? If there’s actually a protocol for ventral hernias question too. After you answer that about visceral therapy,

Speaker 2 (00:42:12):

I was going to say I work very differently and I do predominantly manual therapy, whether I’m doing visceral work or I’m doing myofascial work or I’m helping you retrain your musculature. So when somebody says abdominal wall therapy, I think of a orthopedic setting where they treat and round and they hand you some exercises and walk away. Right. When you say rectus abdominal, am I doing rolling of the muscle? Am I don’t forget the rectus has different segments to it. Am I seeing which segment fires? Am I working on your spine and the multifidus? Is there a rotator in the back of the spine that isn’t firing just how we would like it. So that’s going on with your rectus. And in terms of ventral hernias, I do some diastasis rectocele work. Is that the source of the ventral hernias? Sometimes I don’t mess too much with that because those are the ones you can get really sick from. Yeah, yeah. If I really suspect one, I send them off. So I was in a course once, it was supposed to be a course on exercising with dia diastasis, and then the woman was being evaluated and she domed, she really doomed.

Speaker 1 (00:43:41):

Oh, pass that. And

Speaker 2 (00:43:41):

I, I’m watching her and I’m like, should I give her my card so I could give

Speaker 1 (00:43:46):

Her, because I call a pyramid, it comes out like a pyramid.

Speaker 2 (00:43:50):

And the instructor was like, no, no, she could learn to control that. And I was like, under my breath, I’m like, before or after her small, small intestines are in her hand. I don’t, yeah. So I think that

Speaker 1 (00:44:05):

What is visceral therapy?

Speaker 2 (00:44:07):

Visceral therapy works with the organs. Supposedly it’s developed by Jean Pierre Barral and it works with the fascia surrounding the organs to that. Each organ has its own position and rhythm. And as woowoo as that sound, it’s extremely effective.

Speaker 1 (00:44:28):


Speaker 2 (00:44:29):


Speaker 1 (00:44:29):

Yeah, I’ve had a lot of patience with that.

Speaker 2 (00:44:31):

You’re always going to have some sort of myofascial tension and it really works well on that. The other thing I’ll say in terms of ventral hernia and regular and inguinal hernia, femoral hernia, your pelvic floor is going to respond to all that because the body works like a can. And if there’s a weakness in one area, then the floes to provide more of that support. So sometimes to balance the abdominal muscles, you do have to lengthen the pelvic

Speaker 1 (00:45:04):

Floor. Got it. Does Dr. Sarrel believe in pain desensitation desensitization techniques? What is that?

Speaker 2 (00:45:15):

I do believe that there is, that the body remembers pain and that in many people beyond, we know that acute pain is up to three months, but after three months there actually are cortical changes in the brain regarding pain. And so once the nerve has become sensitized, that pain has was what we call centralized central sensitization. So do I believe in desensitization techniques? Yes. But it depends on the person. So is pain neuroscience education going to work for you if you have a compression on the nerve? Probably not. But if you’ve had the hernia fixed and that there’s not any endometriosis there, it is it time to work on the central nervous system to do your nice breathing to understand I’ve done dry brushing with patients so that they begin to feel a different sensation to do all those things. Is that the time to do it? Probably if it’s not always. The example with central sensitization is the guy that was bit by the snake and almost died. And now if he hears a snapping branch, he has all those symptoms. Again, that’s how the right, but we had to treat the snake bite in the first place.

Speaker 2 (00:46:38):

So you have to have, it’s not just about desensitization.

Speaker 1 (00:46:44):

This viewer says I need to use a cushion to sit because of tight pelvic floor muscles. I also get sharp pains in the right side of the groin 99% of the time. And centralized sharp pelvic pain. I was told I have pudendal Neuralgia and I’m getting blocked soon, but I’m not sure how to rule out a hernia.

Speaker 2 (00:47:04):

That’s a good time to talk about diagnosis. Do you want to talk about ruling in or ruling out the ring?

Speaker 1 (00:47:11):

Yeah, yeah, yeah. Well tell me a little bit about sitting being painful on a tight pelvic floor.

Speaker 2 (00:47:17):

Well, I always ask when you say where is the sitting triggering it? So the pudendal nerve, if you are sitting against the sits bones and that’s triggering it, then we think more about the P dental nerve and we put you on a special pillow. And I saw a patient with this last week. Oh no, it’s a sitting, when you sit, your abdomen comes over your groin, you

Speaker 1 (00:47:47):

Crush it a closer colon canal.

Speaker 2 (00:47:50):

And so you are crush, if you’re getting groin pain, usually labia burning or wraparound back pain when you’re sitting, it’s because you’re compressing a whole different set of nerves. And then to me it’s a lot easier to rule in or rule out the hernia than to start with

Speaker 1 (00:48:11):

Dental nerves blocks. Yeah. But there’s so few true specialists of pudendal nerve. So to kind of play around with it, I agree with you. I rule out a hernia. So sitting, bending, all of those close off the inguinal canal. So if you have a hernia in that region, it’ll cause more symptoms. So prolonged sitting, bending, like to tie a shoelace, prolonged standings, another good one. Those are all kind of groin related pains.

Speaker 2 (00:48:41):

I like to watch how they sitting when I

Speaker 1 (00:48:44):

Say again,

Speaker 2 (00:48:45):

I like to watch how they’re sitting when we do the eval. You must do that too, right? They’re sitting up.

Speaker 1 (00:48:50):

Yeah, absolute. Sit to the side.

Speaker 2 (00:48:51):

I was going to say they sit up on their foot, so they’re off to the side and opening the crease a little bit.

Speaker 1 (00:48:57):

So if they’re reclining backwards and especially if one leg, that same leg is put out instead of a in that’s classically a hernia or a hernia related complication from a administrate repair.

Speaker 2 (00:49:11):

Yeah, I think so. It’ll be interesting. There’s new research coming out by Maurice Chung about pain post endometriosis surgery. And in that I, I’ve read it, but he, it’s not published so I can’t, so not only does he do a bladder installation. Right, but he also, if they’re continuing to have pain, he does ilioinguinal and genital branch blocks before he even touches the pudendal nerve.

Speaker 1 (00:49:42):

Yeah. This

Speaker 2 (00:49:43):

Is the guy who, his majority of the career was in pudendal nerve research. But he always does the ilioinguinal blocks first.

Speaker 1 (00:49:51):

It’s easier and it’s less complicated and less complications and it’s more likely to give you the answer.

Speaker 2 (00:49:59):

Yeah. I also had a block. It didn’t help. I don’t think blocks are fail safe, do you?

Speaker 1 (00:50:04):

They’re not. But in some cases, because the nerve is not the issue, it’s the hernia. If you block the nerve, then the hernia pain, it’s like a radio, if you block the volume background noise of the nerve, then the volume or the noise of the hernia pain actually goes up. So if someone gets a nerve block and their pain actually gets worse, I think, oh then there’s definitely a hernia. Cause it’s not the nerve. Yeah. Yeah.

Speaker 2 (00:50:30):

I also think it depends who does the blocks. Yes. So it depends the same way. It depends who reads your MRI.

Speaker 1 (00:50:37):

A hundred percent true. Yeah, absolutely. Question about what else do people need to know about pelvic floor spasm? What symptoms do they usually come with?

Speaker 2 (00:50:51):

Pain with sex, back pain, difficulty urination, constipation, sometimes diarrhea as well. I always say it’s pain with exiting of the stool rather than just that belly pain, but bloating because the pelvic floor serves to sling the whole system. And if the pelvic floor is too tight, you’re going to bulge out somewhere. Not to misuse the word bulge in our conversation. And I also see quite a bit of hamstring pain and adductor pain from pelvic floor.

Speaker 1 (00:51:30):

And do you recommend pelvic floor training, let’s say after hernia repair?

Speaker 2 (00:51:37):

It depends on the person. Yeah. And I’ve seen different seen different from the MDs surgeons as well. Yeah. I think if it’s somebody who was really not functioning that great and they had a lot of spasm to go into the surgery with, then they should definitely have the surgery after. Now I work with someone who does a lot of obturator work and it’s not a, an obturator hernia. It’s like a thickened fat pad basically around the nerve. And I think if you’re going to have that done before you run off in life, you should have maybe six sessions of pelvic pt because that totally changes your pelvic floor.

Speaker 1 (00:52:21):


Speaker 2 (00:52:24):

And if you’re going to go back to I think high end athletics, then there should be some PT involved. But then they send people home, you don’t need it, don’t worry about it. See

Speaker 1 (00:52:37):

Well as hernia surges, were always asked what physical therapy do I need after surgery? And we don’t really have a standardized protocol for physical therapy. There’s a group out of Ohio State that is working on that, but it’s not like like, oh, this would be a good idea to do. Oh, but does your society have any recommendations for postoperative physical therapy?

Speaker 2 (00:53:02):

The society, but I put everybody on a walking program for so many reasons. And really the first four to six weeks, the first day day you’re home, you’re walking five minutes, even if it’s in the house out of every hour that you’re awake for a lot reason. And then it progresses from there so that by week two you’re really doing at least 30 minutes. I think towards the end, I haven’t looked at it in a while, but towards the end of the 14 days. And then I have people doing abductor, abductor like sidewalk I think at about three and a half weeks.

Speaker 1 (00:53:50):

Come on.

Speaker 2 (00:53:52):

I think that I’ve had a lot of anesthesia and I think that it’s important to move to get that out of your, to get the surgery behind you also, to not be a broken, fragile bird anymore. You’re a healing bird and walking is a good time to connect with that concept of healing and leave behind the concept of being sick.

Speaker 1 (00:54:18):

Yeah, that’s good. Be one with nature. Walk outside.

Speaker 2 (00:54:22):

Yeah. Right. But I, I’ve had people mean one surgery, I was walking in malls then I was meeting patients to walk in malls for a long time. And New York people say, everybody walks. I said, then start your timer so that you’re getting the minutes in.

Speaker 1 (00:54:40):

Yeah, that’s really, really great. And then in terms of physical, pelvic floor, physical therapy appointments, my patients also get pelvic floor physical therapy without an internal examination. Is that mostly perineal examination only or pelvic? Not perineal, but just pelvic, lower abdominal.

Speaker 2 (00:55:05):

If somebody, well, it depends on the case. If you need internal work, I actually do a whole technique against, depending where they are, if they’ve had Mesh or no Mesh or whatever in the groin crease. Right. And that’s a manual technique to, I say floss the nerve, but it’s probably not actually flossing the nerve. But I do some work there and some lower abdominal work. I also do a lot of rib cage work because everything that goes on in your Rives and your diaphragm is going to have a reactive to your pelvic floor as well as in the mouth. So your big clenchers definitely have pelvic floor spasms be and that’s well proven right Because embryologically, we, the tissue in the mouth and the tissue in the pelvic floor develop at the same time. But there’s all sorts

Speaker 1 (00:55:59):

Of, so if you’re clenching your teeth, you’re maybe clenching your pelvic floor.

Speaker 2 (00:56:03):

Yeah. Are you a, your teeth grinders, lots of pelvic floor problems usually. Wow.

Speaker 1 (00:56:09):

Yeah, it should Making a tooth how they have the teeth guards that should get a pelvic floor guard.

Speaker 2 (00:56:15):

Yeah. Oh no, I don’t know about that. But there’s a great pelvic floor PT in New York and she started, she was like the world’s leading T M J expert and then she noticed this connection and she founded this. Yeah. Big deal. It was like a big shift.

Speaker 1 (00:56:31):

That’s so interesting.

Speaker 2 (00:56:32):

Yeah, I always want her to come speak, but she’s too busy for us.

Speaker 1 (00:56:37):

How often do you treat men versus women?

Speaker 2 (00:56:40):

Me personally.

Speaker 1 (00:56:42):

Personally? Yeah.

Speaker 2 (00:56:44):

Well, I just don’t mark it that way. Most pelvic PTs will, especially if they’re going to do sports and athletics, will treat men. I specialize in endometriosis and unless I’m treating somebody or who’s trans, I’m not treating a lot of men just because I focus on the endometriosis and the hernia. But once you put up all your hernia stuff, I get a lot of male calls.

Speaker 1 (00:57:13):

Yeah, true. Here’s a question. Is growing pain with prolonged sitting or standing more likely pain of the ilioinguinal nerve or the pudendal nerve? I would say hernia but not nerve. I got five iliohypogastric blocks with my surgeon and those do not help me. The fourth one caused my pelvic floor to be in a lot of pain afterwards, therefore I’m going to try pudendal blocks next with pain management. I don’t understand why you’re not just going to get evaluated for a hernia. Why does all pain have to be nerve pain?

Speaker 2 (00:57:45):

Right. Well let me tell you, I think they don’t get evaluated for a hernia. Shh. That they don’t get evaluated for a hernia because finding somebody who’s really going to go through that MRI, there’s like four or five people in the country

Speaker 1 (00:58:01):

I know.

Speaker 2 (00:58:02):

And so then they end up in this pool of it’s nerve. It’s this, it’s that. Try this block, try that block. First of all, you’re mentioning inguinal nerve pain and you didn’t mention any nerve that goes through the inguinal canal. The ilio hypogastric nerve does not go through the canal and no, the nerve doesn’t either. And what I would do is I would get evaluated by somebody who knows what to do. I think you have the MRI protocol on your website.

Speaker 1 (00:58:34):

Yeah, I do.

Speaker 2 (00:58:36):

And now you can have you do consults also.

Speaker 1 (00:58:41):

Yeah, for sure.

Speaker 2 (00:58:42):

You do remote consults and also map out those nerves. Don’t let somebody inject something that isn’t showing up in the right place.

Speaker 1 (00:58:51):

And we just said if you hit a nerve with a local anesthetic and your pain is worse, that’s by, that’s often almost always a hernia because it’s not a nerve problem. You’re shutting down the nerve related pain and so the hernia related pain becomes louder and so don’t go for the pudendal nerve that the logic isn’t to go from ilio hypogastric nerve to pudendal nerve. Those are like two separate nerves. They cause different symptoms and different, there’s different reasons why get those problems. They’re just two different entities.

Speaker 2 (00:59:25):

So go on my Instagram today, the picture is behind me of the nurse. Yes, yes. Screenshot the reel and take your fingers and enlarge it and trace where your pain is or find any other picture. But ultimately find someone who’s going to do a consult on the hernia because if you rule it in or rule it out a lot easier physically and financially to decide whether or not you’re going to treat it then to just keep doing random nerve blocks. Yeah. Even though I do nerve blocks not cheap.

Speaker 1 (00:59:57):

Yes. Which are not cheap. So I collaborate with you on that story, on that reel on Instagram. So it’s a great one. I collaborate because it was great. I loved it. And guess what we’re done for? Our hour went by so quickly,

Speaker 2 (01:00:11):

So quick. I can’t, you have to come do a Instagram live with us. We’ll set that up.

Speaker 1 (01:00:16):

For sure. For sure. We’ll do that. So much fun. That’s it everyone. That was fantastic. Thank you Sally. I’m so happy that we made this work. I’ve had so many questions to ask you and you answered them all for me. But I’m sorry for those who submitted questions. It didn’t get all those answered, but I think we did a good job getting as much of them answered this area, this one hour as possible. And to all of you, thank you for joining me on Hernia Talk Live. We’ll join me again next Tuesday on Hernia Talk Tuesdays. We’ll have another great guest and I hope you enjoy everything we do. That’s all archived on my YouTube channel at Hernia Doc and we will see you later. Thanks again, Sally.

Speaker 2 (01:00:58):

Take care.

Speaker 1 (01:00:59):


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