Episode 96: Who Can Treat My Pelvic Pain? | Hernia Talk Live Q&A

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Speaker 1 (00:00:00):

Hi everyone. It’s Dr. Towfigh, your hernia and laparoscopic surgery specialist. Welcome to another episode of Hernia Talk Live Q&A. Many of you are joining me on Facebook Live at Dr. Towfigh and some of you on our Zoom channel. Thanks to everyone who also follows me on Twitter and Instagram at Hernia doc. Today we have an amazing guest, Dr. Sonia Bahlani. She is in New York. She is a urogynecologist, highly specialized in pelvic pain, which is what we will be dedicating our hour to. She can follow her at Pelvic pain Doc, I’m hernia doc. She’s pelvic pain Doc is kind of works out really well. So please welcome Dr. Bahlani.

Speaker 2 (00:00:43):

Thank you so much for having me.

Speaker 1 (00:00:45):

Thanks for having for your time. I’m always so appreciative of everyone who’s on the East Coast or it’s later in the evening, and so thanks for your time. We won’t abuse it, I guarantee.

Speaker 2 (00:00:57):

No, it’s an honor. Honestly, it is. I love working with physicians like yourself who kind of have the same philosophy of care, so I think I do. It’d be great.

Speaker 1 (00:01:06):

Yeah, we do. So I believe you’re my first urogynecologist. We’ve had gynecologists and we’ve had urologists, multiple of each, but we’ve never had a urogynecologist. So maybe you can start to just explain what makes you a little bit of both and we can move on to all the questions we have. Tons of questions have been submitted and hopefully in the chat we’ll hear some as well.

Speaker 2 (00:01:33):

So it’s interesting because my kind of path to doing this is very non-traditional. So I did my residency in OB/GYN, actually at New York Presbyterian in Cornell, right up on the Upper East Side. And when I did my GYN residency, I worked with this physician named Dr. Ledger, and he’s one of the kind of pioneers in pelvic pain work. He did a lot of work with vulvodynia and when I would work with him in the clinic, I would say, Dr. Ledger, you’re referring a lot to urology. That’s kind of interesting. And he was like, oh yes, well, there’s a specialist in interstitial cystitis because many patients who suffer from vulvodynia have all these other and started naming other pelvic pain disorders. So it just so happened that my chief at Cornell at that time was doing her urology, urogyn rotation with Rob Baldwin, who’s one of the pioneers in the field of interstitial cystitis, and she brought up my name. She said, I have this resident who’s super interested in this field. Do you want to meet her? And so I was graduating my chief year and I met and I met, went, I met with him and he said, I think it would be great if you were my fellow. And so I went on and did a fellowship with him, and then I stayed on in the Department of Urology for about eight years until I started my own private practice. How

Speaker 1 (00:02:51):


Speaker 2 (00:02:52):

So it was really interesting because I’m a GYN by training, but then I did all of these years in urology. So it’s like, and pure, actually the department of urology, not urogynecology. So it’s an interesting mix, I guess.

Speaker 1 (00:03:05):

That is interesting because, so gynecology is what, five years,

Speaker 2 (00:03:10):


Speaker 1 (00:03:11):

Years of residency after medical school. And then you did how many years for the urology?

Speaker 2 (00:03:17):

One year fellow fellowship. One

Speaker 1 (00:03:19):

Year. And were you with other urologists that were like what we call female urology? Yes. Oh, okay.

Speaker 2 (00:03:26):

I was with other, exactly, female urologists, neuro urologists. I mean, there was cancer surgeons there too. It was a department, actually 24 men. I was one of the only women in the department first you were. And my fellowship, I loved it. And they actually said it was interesting because they actually said, you bring this component of G Y N that we don’t know about, but there’s such an overlap, so stay on and be faculty. And so then I often ended up seeing a lot of the patients with things like recurrent UTIs and continents, recurrent BV, pelvic floor dysfunction, interstitial cystitis, Pudendal Neuralgia. And that’s really how this niche came to play for me.

Speaker 1 (00:04:10):

But other urogyn, there’s like a gynecology fellowship within gynecology,

Speaker 2 (00:04:16):

Right, than gynecology that’s more focused on things like incontinence, like incontinence issues, slings. But my clinical focus was more on pelvic pain and pelvic floor disorders. And I think it’s interesting because there’s not an overlap there, you know, would think that many urogynecologists are trained in the field of pelvic pain, but they’re oftentimes trained in incontinence and things like reconstruction. So it was so yes, narrow. It’s very narrow. So by definition, yes, I do urology and gynecology, but am I tr that three year fellowship with urogyn? No.

Speaker 1 (00:04:57):

So you’re more skilled in, you can do cystoscopy, whereas most gynecologists don’t really do cystoscopy. Okay.

Speaker 2 (00:05:03):

Cystoscopy, bladder biopsies, talks to the bladder, that kind of thing.

Speaker 1 (00:05:07):

Cool. And just out of curiosity, does that, when you get hospital privileges, does that freak them out that you’re board certified gynecologists that’s wants to do a bladder biopsy? No, no.

Speaker 2 (00:05:20):

There’s tons. I think that UroGyn can actually do bladder biopsies. They just don’t do it at the amount that you end up doing when you work in urology. Yeah. You know what I mean? I think at the end of the day it’s covered under the same malpractice, so to speak. But I think that the volume, I always tell my patients, I say, you want to go to someone that can do this in their sleep. You want, yes. You want to go to someone who does hernia surgery in their sleep.

Speaker 1 (00:05:43):

I dream about hernias. Yeah,

Speaker 2 (00:05:45):

Exactly. And so in the same respect, it’s like if I’m doing it all day every day, then it gives you a little bit of wiggle room.

Speaker 1 (00:05:56):

But what makes you different is you do not see men or do you ever so often also see men?

Speaker 2 (00:06:01):

So because I was in the Department of urology and because there’s so few people that are specialized in things like chronic prostatitis, pelvic cord dysfunction, and men, I do see men,

Speaker 1 (00:06:11):

Oh, how great

Speaker 2 (00:06:13):

Testicular pain, it falls under the same umbrella. And the hard part is that men who suffer from this are just as marginalized as women are. You know what I mean? And there’s not enough specialists out there who knows. So yeah, when I was in urology, they were like, please do. And then I went on in my private practice to continue to see men

Speaker 1 (00:06:36):

So much pelvic pain or what’s called chronic pelvic pain or C P P is female focused. And I feel that this is one of the few areas where there’s much more avenues and special available for the women and not as much for the men. It’s so true. I just saw a patient today actually, and he shared with me his medical records records and he went to pelvic floor, I think Pelvic floor physical therapist or I don’t think it was a physician. And he’s shown me the, well, as part of the medical records, I saw his questionnaire and it was, when you press into your vagina, do you feel a bulge? I’m thinking that’s not the right question for a male.

Speaker 2 (00:07:17):

Right? You

Speaker 1 (00:07:18):

Must have felt so out of place trying to get help and care from this specialist.

Speaker 2 (00:07:24):

So I love that you said that because it’s interesting, when I talk to men, I’m set. So if we delve a little bit into the concept of chronic prostatitis or C P C P P S and pelvic function, essentially the same entity. We call them different names, but yes, in men it’s CPCPPs, but in men, some of the highlighted symptoms are things like pain at the tip of the penis pain that can radiate into the testicles. You know what I mean? And so if we don’t almost ask these questions, you’re really not assessing for the appropriate things. Yes. But I find it often interesting because you’re so right in intake forms, it’s all focused on

Speaker 1 (00:08:05):

Vagina, vagina

Speaker 2 (00:08:06):

Or frequency and urgency and not really focused on specific anatomical symptoms.

Speaker 1 (00:08:14):

Before we move on, this pain, the tip of penis, a very specific pain, very specific, and there’s very few things that cause it. Can you just briefly review when someone specifically has that symptom, what it can be or what you think about?

Speaker 2 (00:08:32):

Yeah, so when someone has that specific symptom pain at the tip of the penis, yes. It always makes me think about CPC P P S or pelvic floor dysfunction,

Speaker 1 (00:08:43):

Which is chronic prostatitis, chronic pelvic syndrome.

Speaker 2 (00:08:46):

Right, exactly. Now there are different categories of this. So there’s acute bacterial, I’m talking about category 3B, which is non chronic prostatitis, chronic pelvic pain syndrome. And this is really important because many men are placed on long-term antibiotics with little no avail in their symptoms, and they come into the office and they say, look, I can’t sit every time I sit, I have pain that it hurts. I have pain that radiates to the tip of my penis and I have testicular pain and it’s all morphed. And I was treated for things for things like orchialgia and I was given long-term antibiotics and nothing is working and that should be key. You know what I mean? Always thinking about the fact that there is likely pelvic floor involvement. Men also tend to focus, also tend to present with things like constipation, urgency, frequency, a lot of urological symptoms. That’s often mistaken for BPH, you know?

Speaker 1 (00:09:45):

Yes, that’s so

Speaker 2 (00:09:46):

True. I think that the

Speaker 1 (00:09:49):

Pelvic floor spasm, right, the urgency and pain with Yeah,

Speaker 2 (00:09:53):

Exactly. Because the bladder contracts, the pelvic floor doesn’t fully relax. They don’t completely empty. They go to the bathroom, go to the bathroom, go to the bathroom, and then we also see it can affect erections. We also see people that will say, I have pain after ejaculation. I have hard flaccid. All of these things can occur in men with category 3B, non bacterial C P C P P S.

Speaker 1 (00:10:16):

Yeah. And there’s a lot of that that happens with hernias too. So inguinal hernias, I know, right? Inguinal hernias can often be a cult or you can have a obvious inguinal hernia, but people don’t associate inguinal hernias with pelvic floor spasm. But we’ve noticed a correlation. So if you have an inguinal hernia, you can have secondary pelvic floor spasm. You fix the hernia, the pelvic floor spasm goes away. So you may not present with a groin pain or groin bulge, but you have the symptoms of pelvic floor spasm. So pain with intercourse, pain with ejaculation pain or urinary frequency. It’s like extreme 10 times, wake up 10 times at night or something crazy like that. And those are, or even perianal pain, those are all pelvic floor. And so they’re sent to pelvic floor physical therapy. But until you fix a primary problem, which in my situation with my patients is a groin hernia, it’s actually quite painful to have pelvic floor PT because you’re constantly in spasm. So they hate it. You fix a hernia goes away. It’s kind of this fascinating overlap of what I do, what you do, what urologists do, what gynecologists do. Yeah, the physical therapists do. Yeah. But I do see that P point tip of penis pain and it always throws me off because I know it’s not like it’s not STD related. Usually it’s not a penile thing, but is it a prostatitis thing or is it a pelvic floor problem? That’s what I don’t understand.

Speaker 2 (00:11:53):

I think it arises more from the contract, the spasming of the pelvic floor musculature. Oh, okay. And that kind of neuromuscular response that radiates to the tip of the penis. You know what I mean?

Speaker 1 (00:12:02):


Speaker 2 (00:12:03):

It. But I find that so interesting, the inguinal hernia stuff that you’re talking about. Because for me, as physicians, we can get pigeonholed into Yes, we see what we see because we know it. You know? I mean, that’s

Speaker 1 (00:12:16):

Why I do this because I get to learn from all your specialists.

Speaker 2 (00:12:19):

And so I guess a question on my end would be, when I’m seeing these patients, when should I be thinking, wait a minute, this might not just be pure pelvic floor. Is there a certain symptom or sign I should be looking for that can more towards an inguinal hernia?

Speaker 1 (00:12:35):

Yeah, so inguinal hernias, the small, these are the smalls. These are not the obvious big ones, but the small ones that are harder to kind of think about, they often are activity related pain. So when they’re up and about, or if they’re doing anything that’s involving hip flexion, so sitting or bending kind of crunches or squishes that hernia, it causes more pain. But if they lie flat in bed, their pain goes away. But also you have other things you don’t see with prostatitis or other kind of pelvic floor stuff, which is you get radiating pain around the back to the lower back and men they get testicular pain rating, testicular pain or inner thigh. That’s another good one to ask. Does that go to inner thigh? And sometimes nausea or bloating. So it’s a little bit, if you categorize all these symptoms, they overlap when some but not in others, and it’s the other ones that don’t overlap that help you figure out if it’s a hernia or not.

Speaker 2 (00:13:35):

Yeah, that’s so interesting. I actually have a patient that I’m thinking about, which is why I’m asking. That’s great

Speaker 1 (00:13:40):

To hear. Yeah, absolutely. So we have a question for you. It says, hi doctor. 18 months ago I had a small asymptomatic inguinal hernia repaired with Mesh via open procedure. I’ve had pain in my penis and burning when urinating ever since. I also have interstitial cystitis. I tried gabapentin with no success and switched to Lyrica for a year, but that did not help either. I’m recently talking with my doctor to let me try L D N, which I think is low dose naltrexone, working up to the four and a half dose slowly in hopes of getting help. I have had physiotherapy and acupuncture. What are your thoughts? So maybe you can explain interstitial cystitis first. What is that? Why do you get it? What are the symptoms?

Speaker 2 (00:14:25):

I love this. So interstitial cystitis, which is also commonly underdiagnosed in men, and there’s a few reasons why is when there’s a degradation in what’s called the gag layer of the bladder or the glycosaminoglycan layer, you can think of this layer as the bladder as a protective layer. So many people will compare it to things like leaky gut of the bladder. All right? Okay. And so oftentimes patients present. And so in terms of there’s a map, N I D D K criteria. And so in terms of how patients present, the biggest symptom that is often heard is pain with bladder filling. Okay? You have persistent urgency frequency pain with bladder filling. And this is really important because interstitial cystitis has been renamed so many times in its existence, painful bladder, bladder pain. But the whole concept being that phenotypically, it’s bladder centric, it’s revolved beyond the bladder. 80% of patients, both men or women with interstitial cystitis have concomitant pelvic floor dysfunction.

Speaker 1 (00:15:29):

Oh, that’s why it’s so complicated. Got it.

Speaker 2 (00:15:32):

That’s why it’s so complicated. And so everyone asks what came first, the chicken or the egg? Is it because there’s pain in the bladder, tend to hold tension within the pelvic floor as a guardian system. So now the pelvic floor exacerbates the frequency, urgency leads to pain at the tip of the penis, that kind of thing. Or just in terms of inflammation? It is, we both, we don’t know what causes interstitial cystitis. There’s thoughts that it’s due to autoimmune processes or things like inflammation. So is there just chronic inflammation throughout the body that degrades this gag layer of the bladder that ultimately also causes things like trigger or tender points within the pelvic

Speaker 1 (00:16:07):

Floor? So this patient has pain in the penis and burning when urinating, is that a consequence of interstitial cystitis or can it be?

Speaker 2 (00:16:15):

So I think the thing here that we have to be cognizant of is that with interstitial cystitis, and I make a clear distinction of it, one of the biggest symptoms that we talk about is pain with bladder filling. And that would be something that you always want to ask a patient like, okay, it burns when you urinate, but burning when you urinate can also be stemming from the pelvic floor, that neuromuscular response, the spasming of the muscles around the urethra. So I think that symptom in and of itself can kind of fall in. And I don’t know if it can fall in the inguinal hernia realm, but it can definitely fall both in interstitial cystitis or in pelvic floor dysfunction. I think the biggest thing is that number one, things like gabapentin, Neurontin, Lyrica, amitriptyline, great medications, but rafts, right? What are they doing? It’s essentially downward. They’re

Speaker 1 (00:17:09):

Like nerve medications. Her

Speaker 2 (00:17:10):

Nerve medications, they’re turning the volume down on whatever neuropathic sensation is occurring. So ultimately we’re you and I are kind of discussing, it’s not our biggest passion, which is treating root cause essentially assessing for root cause. Right? So I think part of this is understanding be because if it’s intrinsically coming from the bladder, Neurontin and amitriptyline are not going to fix that bladder lining, right? They’re simply just turning the volume down on the bladder. So is

Speaker 1 (00:17:41):

There treatment for interstitial cystitis?

Speaker 2 (00:17:43):

There are many treatment, there are many treatments just kind of depending on where. So when you break down interstitial cystitis, you can break it down into two patient groups. They’re patients with hunter’s lesions and patients without hunter’s lesions. 80% of patients with interstitial cystitis do not have hunter’s lesions. That,

Speaker 1 (00:18:02):

And that’s something you see on cystoscopy,

Speaker 2 (00:18:04):

That’s something you see on cystoscopy.

Speaker 1 (00:18:06):

80%. Okay.

Speaker 2 (00:18:07):

80%. And this is important because phenotypically, you treat these patients very differently.

Speaker 1 (00:18:12):

And hunters is that when you do the bladder insuflation the pressure and see if there’s bleeding.

Speaker 2 (00:18:19):

So that’s what we used to do. So the whole concept of so and AOA guidelines for interstitial cystitis have changed dramatically. Okay. So back in the day what they used to do was they used to essentially do a hydrodistention to the bladder. Yes. They’d overfill the bladder and then they would look for glimmer. The problem that they started to see was that if you hydrodistend any bladder, you can cause glomerulations. Oh,

Speaker 1 (00:18:44):

So glimmer, they used to do cystoscopy and then they hang a IV bag or something that’s fill the bladder and then they see if it bleeds after certain

Speaker 2 (00:18:53):

Pressure and then, right, exactly. So there’s two problems with that. One is like, okay, so how is that indicative? We now know glom or not specific to interstitial cystitis.

Speaker 1 (00:19:03):

Okay, I didn’t know that. Okay,

Speaker 2 (00:19:04):

Great. And then secondarily, the concept of using hydrodistention as a therapy was to cause a neurapraxia Oh, overdistend the bladder

Speaker 1 (00:19:14):

Patients got better reset.

Speaker 2 (00:19:15):

Yes. But then guess what happens? They noticed that after three months after hydrodistention patients ended up recurring currently having their bladder pain and it becomes harder to treat. Oh, so hydrodistention is not something, it is not first line. I will say people do use it for interstitial cystitis, but it’s not first line anymore for treating interstitial cystitis. Okay. And so that’s how medications like Amrip and gabapentin came into vogue. Right. Okay. neuropraxia, I guess the neuro proliferation around the bladder essentially. Okay. But that still intrinsically didn’t fix what we believe causes interstitial cystitis, which is that degradation in

Speaker 1 (00:20:01):

The obturator. Okay. Yeah.

Speaker 2 (00:20:03):

And so that’s when people came up with things like bladder installations where we put medications into the bladder, usually medications, combinations of things like lidocaine, Marcaine, heparin, gentamycin, like heparin being a coating agent. That’s also how medications came into vogue. Although now we don’t use that much anymore.

Speaker 1 (00:20:24):

So what do you do? You do and you kind of let the bladder simmer in this cocktail.

Speaker 2 (00:20:29):

Exactly. Well, and you don’t how long every single time you can do just a straight catheterization. We ask patients to keep it for at least 30 minutes to an hour.

Speaker 1 (00:20:38):

Oh, that’s it.

Speaker 2 (00:20:38):

Okay. And so you can do a regular installation. Some people, if there’s levels to this, you can add a sodium bi carb to the installation to increase bladder penetration. Some people will argue that you can do D M S O. Now we’re doing a lot of things like Botox into the trigone of the bladder for patients with interstitial cystitis. If patients have hunter’s lesions, you can do things like a ration of the hunter’s lesion. You could do triamcinolone injection of the hunter’s lesion. So there’s so many different ways we could go to treat this that really looks directly at the bladder.

Speaker 1 (00:21:09):

So it sounds like this patient needs more than just medication because the medication alone didn’t work. And just doing low dose naltrexone is not the right, assuming all this is due to interstitial cystitis.

Speaker 2 (00:21:23):

I think this patient would benefit from number one in an evaluation of the pelvic floor because potentially there could be an aspect of it that’s coming from the pelvic floor, which oftentimes can be really helped not just with pelvic floor physiotherapy, but things like Valium suppositories, Botox of the pelvic floor, pudendal nerve blocks, that kind of thing. And then I think evaluation of the bladder would be key. And then ultimately, even the concept of doing an installation, if you put a medication to numb the bladder in and decrease inflammation into the bladder and a patient subsequently feels better, then some of that pain is coming from the bladder. Do you know what I mean? Ok, that’s very good. A guide that’s

Speaker 1 (00:22:02):

Not really invasive

Speaker 2 (00:22:03):

And it’s not really invasive. And then I think you are able to peel the onion a little bit more. You know what I mean? How much of it is this? How much of it is that? Because the vast majority of the time, it’s not just simply this one thing that’s going to go away with low gabapentin or low-dose naltrexone or whatever.

Speaker 1 (00:22:22):

And the follow-up question is, can you clarify what you mean by proliferation? Is this mean that the innervation number of nerves can increase or what increases it?

Speaker 2 (00:22:32):

So it it’s that, and that’s the question that occurs. Is there some sort of central sensitization that’s occurring? Is there actual neuro proliferation where there’s more nerves going? We don’t know the answer to that. Do you see what I’m saying? But the concept being that when there is some sort of irritation or aggravation internally in the bladder, our neuromuscular systems rev up essentially the pain gate theory central sensitization. So then thereby you have this neuropathic response, right? Because now the nerves are firing

Speaker 1 (00:23:03):

That much hyperactive

Speaker 2 (00:23:04):

Nerves. Exactly. And so then we use things like these medications to down-regulate those nerves. So I think it’s more of a central sensitization kind of a thing. But when we talk about things like vulvodynia, we do talk about neuro proliferation. So we do talk about there being more nerve endings in that area than in other places. So I think that in terms of the specific, is it central sensitization? Is it neuro proliferation? That question can’t be answered via a simple conversation. You know

Speaker 1 (00:23:33):

What I mean? So the best specialist for this is someone like you who’s done the pelvic pain urology fellowship or a urologist, but not a typical urologist. It should be like, is it a bladder specialist or a female urology? Probably bladder specialist, right? I

Speaker 2 (00:23:49):

Think, yeah. I mean

Speaker 1 (00:23:49):

Urologist who’s a bladder specialist,

Speaker 2 (00:23:51):

I would do a urologist, a pelvic floor or a pelvic pain specialist or a bladder specialist. I think that would be best for this person. They could completely be evaluated.

Speaker 1 (00:24:02):

Okay. Ready for the next question? Hello? I’ve had three failed angular hernia repairs open via tissue repair. I don’t usually have menstrual cramps, but since having had the Anglo hernia, I’ve started to have an increase in pelvic and groin pain and bladder irritation during my period. The menstrual type pain is only on my left side, which is the same location as my hernia. What could be causing this flare up during my period? I’ve been told that. So okay. 25% of women that have called al hernias will have pain during their menses. And so then they’re like, oh, endometriosis, ovarian cyst. But it’s not, it’s really their hernia. So I was told that kind of estrogen bump or whatever during menses increases all pain. And that’s why let’s say this patient has groin pain, maybe it’s hernia pain and worse during her menses, but it’s not really menses or menstrual related pain. Is that correct? What I was told,

Speaker 2 (00:25:06):

It’s interesting because so patients with interstitial cystitis, for example, will get an increase in their pain right before their period. And so the same concept came into play. So is it hormonal then? Yeah. Is this fluctuate? But what we believe, at least in the pelvic pain world, is that it’s due to changes in inflammation and inflammatory cytokines during that time. It’s not necessarily formal. So because the real question is postmenopausal women, it’s not like they’re pain free. Do you know what I mean? Right, right. And so I think these types of questions are so interesting, and I think that more often than not, there’s a low lying level of inflammation that can often be exacerbated during these time periods. And then people always ask, can I get on birth control? Well, getting on birth control helped me, at least in my world, we don’t really see it makes that much of a difference. I don’t know if patients ever ask you that in your field, but in terms of putting a patient on OCPs, they don’t generally now stop having pain by any means. And that’s right. Yeah, that’s

Speaker 1 (00:26:15):

Right. It’s that whole, it’s worse during my period type thing that takes that away, that it is just always, they just have pain. They don’t just get the peaks during their menses. So it’s very possible that these, it’s weird that it had been three attempts at tissue repairs. Usually we move to a different technique once one technique fails. But the fact that the pain is worse with menses does not imply its hormonal or endometriosis or something. Usually because it’s growing pain, it can just be a complication from the hernia per lets, so you have a recurrence or something similar. That said it’s incumbent on whoever’s evaluating you to develop, make sure you don’t have endometriosis or something else that could be on top of your growing pain. Right.

Speaker 2 (00:27:08):

Exact. I absolutely agree with that. Yeah. Yeah. I mean, I think it’s just a tough question to answer because could it be this, could it be that? Sure. But we won’t, wouldn’t know unless we actually evaluate that. I try to think back, and I think endometriosis is one of the most interesting diagnoses. And I don’t know if you see this in your specific niche, but I often find that patients are told everything is endometriosis. I mean like urgency. It’s endo.

Speaker 1 (00:27:34):


Speaker 2 (00:27:35):

It’s endo. And what I see in my practice,

Speaker 1 (00:27:37):

Every time I cough, I get groin pain. Oh, endometriosis, really?

Speaker 2 (00:27:43):

And then I get patients who undergo these huge excision surgeries and then they’re hyster

Speaker 1 (00:27:48):

Hysterectomy, ectomy hysterectomy for a groin hernia,

Speaker 2 (00:27:53):

Right? And then they’re back in your office and they’re like, but nothing changed. And yeah, 35 and they weren’t. And then you’re like, oh my gosh. So I don’t call endo endo unless I’m a hundred percent sure it’s endo. Oh. Simply. Cause I think that we can get lost in that diagnosis.

Speaker 1 (00:28:12):

I agree. I agree. And I tell everyone, get a second opinion. Surgery. Surgery. Even the small surgery, even if they see you or me or whatever, I say, go see a second opinion. It’ll bring up new questions and give you more insight into your surgery. Surgery is serious stuff, no matter how big or how small

Speaker 2 (00:28:33):

We are. So cut from the same cloth. I absolutely believe that. I always tell patients, I’m like, please seek a second. If you have a question about something and you don’t feel like it’s fully don’t understand it, please, I want you to, you know what I mean? Because I think it’s good to be able to have this kind of back and forth discussion with patients, actually how some doctors will say, oh, Dr. Google, I don’t mind when my patients Google. I like it. You know what I mean? I’m like,

Speaker 1 (00:28:59):

See my desk right now, I’ve got all this paperwork from people. Yeah.

Speaker 2 (00:29:03):

I’m like, good. You know what you’re talking about. You’re having, we have questions and let’s get them answered. Yeah. But I agree,

Speaker 1 (00:29:09):

Totally agree. This patient we were just talking about mentioned that she does have endometriosis, but it’s been in remission. But in remission, these, it could always come back. You have scar tissue and other injuries from endometriosis that maybe have not been addressed. So it’s good to make sure that you see an endometriosis specialist that can help figure that that out. Right?

Speaker 2 (00:29:34):

Absolutely. Out. Absolutely.

Speaker 1 (00:29:36):

Let’s see, another question. I’m not sure if it’s the same patient, but urologists first recommend cystoscopy, but now recommends laparoscopic surgery for potential adhesion issues. I’ve had multiple abdominal surgeries, so that’s a whole adhesion issue, including its left me with no belly button and abdominal wall. So what are your thoughts on this approach? So bladder’s usually not involved in adhesions, right?

Speaker 2 (00:30:03):

I mean,

Speaker 1 (00:30:04):

It’s very uncommon,

Speaker 2 (00:30:05):

So it’s so hard to say. Yeah, no, I mean I don’t see it commonly, but I also don’t know if there’s something else that a physician would’ve recommended that for. Do you know? I mean, I think

Speaker 1 (00:30:19):

Can adhesions cause pelvic floor problems? I don’t think so.

Speaker 2 (00:30:24):


Speaker 1 (00:30:24):

In inguinal problems, no.

Speaker 2 (00:30:26):

In some women, at least we do see after C-sections, if there’s abdominal scarred tissue, there can be some tethering of the pelvic floor to things like parts of the hip, the lower abdomen, suprapubic, and you know, think about it in our bodies or essentially like a poly lever system. Yes. So if there’s tension in a certain area, you can have spasming of the pelvic floor muscles before.

Speaker 1 (00:30:47):


Speaker 2 (00:30:47):

Right. So I it’s Do we see it commonly? No. Is there a potential for it? Sure. How can I tell that they switched from a cystoscopy to a laparoscopy? I don’t know. Yeah. That I’m not sure about.

Speaker 1 (00:31:03):

This was provided earlier. What types of disorders or diseases cause groin or pelvic pain that’s worse with prolonged sitting.

Speaker 2 (00:31:12):

So pelvic floor dysfunction is one of them. Lyse really is another one. So with pelvic floor dysfunction, we see this a lot. It often occurs in patients who sit for long periods of time. So I get it a lot in my computer programmers, I get it a lot. My doctors who tend to hold their bladder for long periods of time, oh

Speaker 1 (00:31:31):

Yeah, I’m there.

Speaker 2 (00:31:32):

Yeah. They tend to see it a lot even in desk jobs. And so oftentimes in terms of lifestyle modifications, what do we recommend? Things like a standing desk, you know what I mean? And then of course, Pudendal Neuralgia, which is this interesting term that people tend to throw around that oftentimes people have difficulty deciphering Pudendal Neuralgia from pelvic floor dysfunction. Do you see what I’m

Speaker 1 (00:31:55):

Saying? Yes, yes, yes. Often. Cause one it could it’s chicken or versus egg, right?

Speaker 2 (00:31:59):

Oh, exactly. And do they often, is the pudendal nerve often inflamed or irritated with pelvic floor dysfunction? Sure. But with pudendal neuralgia specifically, is their injury to the nerve, do you know what I mean? Right. Do they respond to a pudendal nerve block? These are all questions that we have to be asking ourselves. Because even when you do things like a pal nerve ablation and things like that, campaign recur, can nerves, regrow, like these are all the things that we have to be thinking about.

Speaker 1 (00:32:29):

So with hernias, that can cause pelvic floor spasm. The pelvic floor spasm can be spasming, whatever goes through the pelvic floor muscle, which includes the pudendal nerves. Every so often you see someone with pudendal Neuralgia symptoms, but people don’t really wake up with pudendal neurology. You can’t just like Right. Can people like walking normally? And then up now I have pudendal Neuralgia. There needs to be trauma and injury, some lifestyle thing. Right.

Speaker 2 (00:32:55):


Speaker 1 (00:32:56):

Tissue from something.

Speaker 2 (00:32:57):

I agree wholeheartedly because I think the word pudendal Neuralgia to me is inflammation. Okay, where is this coming from? Do you know what I mean? It’s like, yes. Is there irritation or inflammation of the pudendal nerve? Okay, but is it related to some sort of trauma in that nerve? Is it coming from some spasming? You see what I’m saying? Yeah. So I think that that’s the key. That term throws my patients off a lot because they’re often told they have pudendal Neuralgia, they don’t quite understand what that means. Correct. They don’t respond to pudendal nerve blocks. You know what I mean? Exactly. It’s

Speaker 1 (00:33:35):

Such a tough, I see a lot of people that are like, oh, and I have pudendal neurology. I’m like, okay, how was that diagnosed? And it’s something else, whether it’s the hernia or something else, but it’s so complicated for people to hear testicular pain or pain with intercourse or intravaginal pain, which you can get with inguinal hernias. The automatically, oh, pudendal Neuralgia, that’s must be what it is. Sorry. Sucks to be you, that type of thing. And all they need was a hernia repair or something else that’s unrelated to the nerve. But it causes a pelvic floor spasm.

Speaker 2 (00:34:19):

And I absolutely agree with you we’re so on the same page. And what else we can see, and I’m sure you see this too, or patients that are put on chronic gabapentin get relief for a few months because it again puts, turns the volume down. But then there is essentially a hernia or pelvic floor, something that we’re missing that rears its ugly head again. So now they’re on 900 of gabapentin. And why are there symptoms recurring? Because we’re not treating root cause, we’re simply just, you know what I mean?

Speaker 1 (00:34:43):

Yeah. You’re just asking it. Yeah, absolutely. Yeah. There was a question submitted about pudendal Neuralgia, and the question is, how can the doctor and patient recognize pain that’s caused by pudendal Neuralgia and pudendal nerve entrapment?

Speaker 2 (00:34:57):

So you know, and I were kind of talking about this before with the criteria that people use to define pudendal Neuralgia, and essentially it’s pain in the distribution of the pudendal nerve, which by the way is a huge distribution. So in women, the pudendal nerve has the clitoral branch, the vaginal branch, and the perineal branch. So whoa. So where along those branches are we talking

Speaker 1 (00:35:24):

Front back?

Speaker 2 (00:35:26):

So pain in the distribution of the nerve worsens with sitting, doesn’t awake you at, doesn’t wake you up at night. What’s the other part of this criteria or the worsens with sitting’s? The most interesting part of it though, and it responds to a pudendal nerve block. Yeah. I think the biggest problem that I have with pudendal nerve blocks, and I do them all the time, so I’m saying this with a grain of salt, is that blocks are short-lived. So how do you know if you got relief with the pudendal nerve block? Do you know what I mean? Sometimes people are just like, I was numb for a little bit. I think I might’ve felt better, but I’m not sure.

Speaker 1 (00:36:03):

Yeah. Is it always,

Speaker 2 (00:36:05):

And yes. Yes. And so that’s another thing that’s such a great point is that when people talk about bilateral Pudendal Neuralgia, I’m like, generally, if you didn’t want to,

Speaker 1 (00:36:16):

Hell, does that happen?

Speaker 2 (00:36:17):

Yeah. I mean, even with tailbone injuries, it would be unclear to me how you can have that bilaterally. So yes, absolutely. And it’s often unilateral,

Speaker 1 (00:36:29):

Often unilateral, and there needs to be a instigator. You don’t just wake up one day with it. The same is true for anal hernias. So again, another patient I saw today was diagnosed with genital femoral nerve pain, and of course that’s a hernia until proven otherwise. Same with ilio inguinal nerve pain. So her inguinal hernia until proven otherwise, because you don’t just wake up one day and have your nerve entrapped or impinged or something, peripheral nerve. So it kind of really bugs me because I have one patient that actually literally was going to be scheduled for a spermatic, sorry, a spinal cord stimulator for their it chronic ilio, inguinal Neuralgia. And it was all from a hernia, never had surgery before, never had trauma before. I mean, it just drives me nuts. The patient knew not to do it, but actually the patient’s in your town,

Speaker 2 (00:37:27):

I was just going to say this story sounds yearly familiar simply because I see it all the time. Yeah. And you have me thinking now I’m literally diagnosing hernias left and right now.

Speaker 1 (00:37:41):

Yeah. I mean it’s complicated what hernias

Speaker 2 (00:37:43):

Are common. I’m like, like this person probably hasn’t that person, probably hernia. But what we do see is a lot of that is a lot of, okay, I can’t tell where the pain is coming from. Let’s do a block. Sure, let’s do a P dental block. That didn’t work. Let’s do an block that didn’t work. Let’s do a hypo. We keep going up and up epidurals. You know what I mean? And at some point patients get benefit. They say, oh, okay, I did remember. I’m better

Speaker 1 (00:38:11):

Keeps coming back though.

Speaker 2 (00:38:13):

Right. Oddly, oddly. Or they get things like nerve ablations and their pain comes back likely, often. I think that we’re missing hernias. I think that people left and right are missing hernias.

Speaker 1 (00:38:25):

Yeah. Someone’s asking, do you know any hernia specialists in Nebraska? Omaha, Dr. Robert Fitzgibbons at Creighton University will be one of our guests in a couple weeks. So he’s a great hernia specialist and author of many of the watchful waiting trials. So we’re going to be discussing that in a couple weeks. The other question also kind of related to the first one, can isolated groin pain in the pubic bone region caused by pudendal nerve problem without any perineal scrotal or vaginal or bladder symptoms. So can you just get one branch?

Speaker 2 (00:39:02):

I think it’s you can, but I think it’s less likely unlikely. You know what I mean? I agree. So I love doing this with you because I’m learning at the same time and I like hearing other people’s opinions on this. Stuff’s

Speaker 1 (00:39:16):

Mutual. The learning is mutual,

Speaker 2 (00:39:18):

But I think it’s pretty rare. And I think that that kind of part of what we see with this groin pain in general, and I see it a lot in my office too, is, and I don’t know if you see this in your specialty, but more often than not, people automatically get an ilio inguinal nerve block, like groin pain or hypogastric done, you know what I mean? And without any other symptoms associated with it. So I think that

Speaker 1 (00:39:45):

Because they know how to do it, it’s often not general thermal that’s more difficult. Everyone gets ilio on their blood,

Speaker 2 (00:39:51):

Everyone gets and hypogastric like those two are like, but I think it would be exceedingly rare. And then on top of that, the question always, I always ask the question then what’s, what are you going to do? So now you are going to get nerve blocks all the time. You’re going to get on gabapentin

Speaker 1 (00:40:07):

Spinal stimulator,

Speaker 2 (00:40:08):

Final thing. Right, exactly. So it’s so crazy. I think you should go searching for another cause if that was the

Speaker 1 (00:40:14):

Case. That’s again, second opinion. Always good to get a second opinion. Yeah, exactly. Someone on here says, pal nerve pain is humbling and excruciating pain, which is true. You do not want to have that diagnosis. And I feel like it’s thrown out so often, but it’s a horrible diagnosis.

Speaker 2 (00:40:34):

It is very

Speaker 1 (00:40:34):


Speaker 2 (00:40:35):

It’s very difficult and it impacts quality of life so significantly. I think that it builds a cycle almost. And I think that’s oftentimes why you see pudendal Neuralgia occur with things like pelvic floor dysfunction, a lot of guarding maneuvers, a lot of pain, a lot of discomfort, and then it really become, and then quality of life gets worse because then urological symptoms develop or other type of pain symptoms develop. And then teasing that out can be really difficult. But I do agree dental neurology is a really tough diagnosis. And I think that in general, it’s why I think it’s so important to be very specific before you give it out so that patients aren’t pigeonholed. And it’s ultimate,

Speaker 1 (00:41:19):

Do you do pudendal blocks?

Speaker 2 (00:41:22):

I do.

Speaker 1 (00:41:23):

And anterior or posterior?

Speaker 2 (00:41:28):

I actually do anterior. So I do it the old school way, go inferior and medial to the issue tuberosity and just get that pudendal nerve that blindly. And ultimately that’s how old school obs used to do it for pain control. But I find that in terms of needing ultrasound and stuff, I find that it works really well. So I tend to do it in the office, especially if there’s a question of it just so that diagnosis for diagnostic reasons.

Speaker 1 (00:41:57):

And do some people do ablation, like alcohol ablation of that nerve? Is that safe to do?

Speaker 2 (00:42:03):

I don’t do

Speaker 1 (00:42:03):

That. The distal.

Speaker 2 (00:42:04):

Oh, okay. I don’t do that. But there are physicians in New York who do that. I think the hardest part with ablations, I feel, is that oftentimes I find that patients recur.

Speaker 1 (00:42:16):

Yeah, that’s what I’ve seen. Yeah. No, I think, or maybe I only see the recurred ones, but they’re actually worse off in some ways

Speaker 2 (00:42:23):

I think. So I do see that. And so I am, it’s rare for me to recommend it unless I really think it.

Speaker 1 (00:42:29):

Got it. We have some geniuses as our viewers. So the question is what is a nantes, I think it’s a French word, nantes criteria for and other algorithms for diagnosing pudendal nerve pain.

Speaker 2 (00:42:47):

And this is kind of what we were discussing before this. So a nantes criteria is the five pronged criteria, the first of which being pain in the distribution of the pudendal nerve, the second being worsened by sitting, the third being responding to a pudendal nerve block. The fourth being no sensory loss, I believe. And the fifth being that it does not wake you up at night. And I think that that’s really interesting. I often find with a lot of pelvic floor patients, at least their pain worsens at night oftentimes because they’re up on their feet all day, they’re contracting the pelvic floor muscles all day. So I guess that’s part of why they use that delineation to diagnose pudendal nerve pain. But at the end of the day, I think it takes a good exam too, because I think a lot of these symptoms can go either way.

Speaker 1 (00:43:48):

Yeah. Very difficult disorder.

Speaker 2 (00:43:53):

No question. I’m sorry. I’m going to ask

Speaker 1 (00:43:54):

You. Yeah, yeah.

Speaker 2 (00:43:55):

Tell me, do you ever notice changes in patients symptoms during the nighttime with hernias? Is there a change in terms of time of day at all?

Speaker 1 (00:44:08):

Yeah, so classically they wake up with no pain and by, as the day goes on, they, it’s worse because they’re upright, more active. And then every so often, some people say they are, they’re woken up by their pain. That’s not common. But it can go either way. Not specific either way. And there’s other hernias like obturator hernias and kind of weirder rare hernias where they prefer not to sleep in fetal position. It’s more like frog lagged, and that’s to open up that space more. So yeah, everything is, there’s a wide variety, but classically they’re better in the morning and worse towards the end of the day.

Speaker 2 (00:44:53):

Interesting. Okay.

Speaker 1 (00:44:55):

Okay. Here’s another one. I’m six and six and nine months status post bilateral FAI. So that’s femoral acetabular impingement and labrum repairs. That’s for the hip with multiple years of, and a long history of peroneal pain, labial itching, pain of the introitus. That’s something we haven’t discussed is labial symptoms. Amitriptyline, which is a nerve pain medication did not help, nor did Valium suppositories, which is a muscle relaxant. Recent pelvic physical therapy seems to flare it up. Pelvic floor issues or hernia issues or both. Question mark.

Speaker 2 (00:45:35):

This is awesome. That’s a lot. So that, that’s a lot. So I’m looking at the question right now as I’m kind of thinking about it, but a couple of things come. Yeah, come out at me. Number one, labial itching. Not all itching is infectious. And this is something for the general GYNs out there, because oftentimes these patients are being swabbed for things like recurrent BV, recurrent yeast, and this is itching can often be a neuromuscular symptom. So I like the A

Speaker 1 (00:45:59):

Nerve pain. It could be nerve,

Speaker 2 (00:46:01):

Right? Exactly. Exactly. And pain at the introitus. So there appears to be a

Speaker 1 (00:46:07):

Neuromuscular, what’s the introitus?

Speaker 2 (00:46:09):

Where is the introitus

Speaker 1 (00:46:11):

Of the vagina?

Speaker 2 (00:46:12):

Yeah, the little V. Yeah. Right. So the intro and almost like your vestibule, right? Yeah. So it’s the vestibule of the vagina. And so part of what we do in our exams in the office is we take a Q-tip and we go all around the vestibule and I say, is this pain? Is this pressure? Is this stinging? Is this burning? Because ultimately itching and burning can be signs of proliferation or nerves. Okay.

Speaker 1 (00:46:39):

So yeah, burning is very classic nerve type itching less common, but both can be nerve.

Speaker 2 (00:46:46):

Both can be nerve, absolutely. The fact that Amitriptyline didn’t help, I mean, again, in general, when we talk about medications, I always tell patients, it’s like me having a tennis racket and Andre Agassi having a tennis racket, he plays a lot better than I do. We have the same tools, it’s just how you use them. So were you on 10 milligrams of amitriptyline? Were you on 25? Were you on 50? I mean, in terms of things like vulvodynia, the therapeutic dose of amitriptyline is somewhere around 25 milligram. And that can vary per patient.

Speaker 1 (00:47:14):

So vulvodynia is labral, technically labral as well in

Speaker 2 (00:47:20):

Introital pain, vestibular. And it can be divided up into different groups. So it can be divided into proliferate, neuroproliferative, vestibular, it could be divided up hormonally mediated. It can maybe divided up into inflammatory with pelvic floor dysfunction. And that’s really contingent on how it looks, how the vestibule looks on exam under colposcopy. And so with this, there’s a few different issues because even with Valium suppositories, I often see Valium suppositories or simply a mask. And sometimes if you, depending on where you put them vaginally, do you put them lyse? Patients can respond very differently. I never have patients on Valium suppositories for more than somewhere around six to eight weeks. And I think the response to a Valium suppository doesn’t determine whether it’s pelvic floor or not. So I don’t think that that really helps in general. But

Speaker 1 (00:48:13):

The purpose is it’s a muscle relaxant directly adjacent to the pelvic floor muscles. So it should technically relax those muscles

Speaker 2 (00:48:23):

Technically. But when placed vaginally, the absorption rates are really not thick. Great. When they directly, they are a little bit better, but in addition, they don’t work overnight. So patients like they’re not going to put in one Valium expository and feel relief. Generally it can take anywhere around six to eight weeks. And all the data suggests doing pelvic floor PT at the same time.

Speaker 1 (00:48:43):

So the way I’m looking at this, she’s got a hip, she’s got perineal labial intro. So hernias for sure don’t give intro as pain that we can take that out of the picture. It should not give labial itching or burning. But you can have hypersensitivity of the labum only on one side unless you have bilateral hernias. But the issue is hip pain and hernia pain are very overlap a lot. So I see a lot of orthopedic patients too. And you can get an MRI and show F A I and labral tears and a lot of people. And the question is, is that really the reason for their symptoms? And one of the key questions is, do you have buttock pain or is it all in the front? And if they have buttock pain, that’s usually hip. If it’s only pain in the front groin and not also in the buttock, then it’s usually then it can be either hip or hernia. The other question I ask is the pain better when you lay flat? So with a hip problem, it’s not necessarily better when you lay flat doesn’t go away. Whereas with a hernia pain, it should get better when you lay flat. Of course there’s exceptions, but that’s the general rule. So I’m going to say I don’t think this is going to be hernia related.

Speaker 1 (00:50:03):

It’s always worth getting an imaging to rule that out. But hip problems can cause pelvic floor spasm. Right?

Speaker 2 (00:50:12):

Absolutely. It was just good. Say that. Yep. Labral tears can absolutely call PE cause pelvic floor issues. Okay. And pelvic floor issues can absolutely call, cause things like labial itching and can often cause literal stimulation can cause things like, is that

Speaker 1 (00:50:29):

The pudendal again? Yes,

Speaker 2 (00:50:31):

It’s, yep. And things like introital burning. So I think that this patient would definitely benefit from a further evaluation of their pelvic floor and their vestibule, just the vestibule of the vagina essentially, to see what’s happening there. What we see a lot of too, with, which a lot of people don’t recognize is with things like pelvic floor dysfunction, especially when there is a significant amount of it, you decrease capillary blood flow to the vestibule. Combine that with patients who are either postmenopausal or on long-term OCPs, you alter the pH of the vagina, you alter the pH of the vagina, which can often cause things like micro tears, a lot of pain with sex. And that can also cause things like recurrent BV, recurrent yeast. So again, there’s many different ways that this can affect both vestibular and labral function. And yet, so I don’t like to talk it all up to the pelvic floor, but there definitely seems to be a pelvic floor issue and beyond potentially. So

Speaker 1 (00:51:30):

If the hip is causing pelvic floor or then you have to go back and fix hip problems or physical therapy or something. Right?

Speaker 2 (00:51:37):

Yeah, I mean there is actually, at Cornell Strong Coleman is someone that’s, it’s really big on doing hip labral surgery for patients with pelvic floor dysfunction. It’s a pretty big surgery. So oftentimes patients, and again, the hard part is in my opinion, I don’t know if you see this muscles have muscle memory, so whatever came first, the chicken or the egg, yeah, I don’t really know. But ultimately I see a lot of patients post labral surgery that continue to have their symptoms. You know what I mean? And so I think they

Speaker 1 (00:52:10):

Have a hernia, but Okay,

Speaker 2 (00:52:12):

A hernia too, with common things being common. You treat patients, they’re your families. Yeah. You would want to do the least invasive to start with, you know what I mean? Which would mean either hernia surgery or evaluating their pelvic floor,

Speaker 1 (00:52:26):

You Botox injections into the pelvic floor. Sure.

Speaker 2 (00:52:30):

Yeah. Yep.

Speaker 1 (00:52:31):

And how does that work? Do they end up in incontinent or

Speaker 2 (00:52:35):

Never? No, never. Okay. And of course, it’s always a theoretical risk and there’s a difference theoretical and actual risks. But what I always tell patients is, number one, I’m not going to make you the patients walking around New York with a ton of Botox in their face where they can’t move their head less, more, less. Yeah. Yeah. You only need small amount to really release and relax those muscles. Ok. You know what I mean? And then number two, it works in conjunction with pelvic floor physical therapy. So if you want longevity to it, if you want to not have Botox again, then you have to do it at the same time. You know what I mean? Because that internal myofascial release is really key to keeping the muscles released and relaxed.

Speaker 1 (00:53:15):

So you do the Botox first and then they do the physical therapy to follow, or

Speaker 2 (00:53:20):

I usually have patients meet with the physical therapist prior to doing Botox, and that way they have, and oftentimes they will report that PT flares their symptoms. Right. Because if you’re pushing on an actual trigger point,

Speaker 1 (00:53:35):

Can’t tolerate it, yeah,

Speaker 2 (00:53:36):

It’s going to spasm right back at you. And then I do Botox, and then I have them continue to see the pelvic floor physical

Speaker 1 (00:53:45):

Therapist. And is Botox is not covered by insurance for this purpose, correct?

Speaker 2 (00:53:50):

No, it’s not. It’s an off-label use for Botox, but not rightfully so because I will Oh, no, tell you there’s tons of data on it for the pelvic floor. Yeah. It’s simply one of these, dare I say, political issues where it’s just not it. I mean, it absolutely should be something that’s that’s FDA approved for. I mean, it’s FDA approved for migraines. For TMJ, that’s the same neuromuscular response. You’re dealing with pelvic cord function. It’s kind of not,

Speaker 1 (00:54:21):

Yeah. Yeah. It is nuts because I use it for abdominal wall in preparation for a massive abdominal reconstruction, or some people have really tight repairs and you have to loosen up for them to help get over the pain hump. And fortunately, I live in Beverly Hills, so there’s Botox at every corner. It’s

Speaker 2 (00:54:43):

Not hard to find Botox.

Speaker 1 (00:54:46):

But that said, yeah, the patients have to pay out of pocket for it. It’s not fair.

Speaker 2 (00:54:50):

It’s not not fair. And I think that oftentimes that can pertain to so many aspects of both our fields. It’s because often what we deal with is so nuanced and requires such diligence on the details that insurances will say, I’ll cover tramadol or a muscle relaxer before I’ll actually actual evaluation of the initiating cause. So it’s really

Speaker 1 (00:55:18):

So crazy. Yeah. Yeah. There’s a question about adhesions. I know in gynecology a he or considered a part of the pelvic pain kind of workup, can adhesions by themselves cause pain? What are your thoughts on that? And do you think that these are nerves involved or just vascular?

Speaker 2 (00:55:38):

So can adhesions by themselves cause pain? I think adhesions alone in certain circumstance don’t always have to cause pain. For example, when I have my C-section scar, I have a keloid that’s an adhesion in and of itself, right? It’s scar tissue. It doesn’t cause me pain. Does it not look pretty? Sure, but it’s there, right? Yeah. So adhesions themselves are not, I think, what’s super pathologic, but adhesions can cause pulling and tugging of the muscles in certain places. It’s almost like our body’s response to say something’s wrong, which can often cause this pain gate central sensitization issue. So then you start to feel pain in that area. So of course they can be innervated in that sense, but I think that not all that adhesions are pathologic, so to speak.

Speaker 1 (00:56:27):

Yeah, I agree. That’s very true. Although that said, I’ve had a handful of patients who were like, there’s no way this adhesion caused pain. You get rid of it and they’re like, oh, I’m so much better. Yeah, you do. Like I did very little, but that’s great. Every patient’s different. The thing

Speaker 2 (00:56:46):

I worry about adhesions is them recurring, you know what I mean? I think for when you put much, it’s much nicer and much more nuanced. But in terms of like GYN surgery can be pretty like it. Yeah.

Speaker 1 (00:56:57):

I mean bloody,

Speaker 2 (00:56:58):

Yeah, bloody.

Speaker 1 (00:56:58):

And you guys deal with big blood vessels. Yeah. This is a question that I love your input on. I’m glad a patient asked it. Is it true that people with preexisting pain before surgery are more likely or at greater odds of developing chronic pain after surgery? And why is that? This is something that in the hernia world, they talk about all the time, oh, you operate on pain, you’ll get pain. And I’m like, I don’t agree with that. I think you’re just maybe doing the wrong operation or something. And so a lot of patients in general surgery are not operated on because like, oh, you already have so much pain, you’re going to have chronic pain after surgery. And yeah, there’s so much pain because someone needs to fix their freaking hernia or something like that. And I don’t see that. I’m also a optimist, and I try and I operate on patients that have pain all the time. But what’s your thought? Is this a myth or is this something that is taught to you guys too?

Speaker 2 (00:58:01):

It’s interesting. I have similar viewpoints in the sense that I only treat pain patients, right? So to me, not treating a pain patient is

Speaker 1 (00:58:11):


Speaker 2 (00:58:12):

It’s nuts. No, this is the patient that deserves some sort of intervention to help alleviate their pain. Correct. But I think that the way that this occurs, number one is, I mean, twofold. Number one, I think in general pain patients are highly stigmatized and it’s part of the problem in seeking care just in general. They don’t know to come to me, to you to come to anyone, because most of the time they’re just told, well, you’re going to have to learn to live with this, and that’s the way that you have to go. I think number two, this concept of the pain gate theory is really interesting. So when you develop pain in a certain area and you rev up these nerves and you rev them up, and then you get a tiny little cut that tiny little cut doesn’t feel like a tiny little cut. Now that tiny little cut feels like a huge cut, right? It feels like a big thing and that that’s not the patient’s fault. You know what I mean? That’s by virtue the pain gate theory. That is why. But I also think if we don’t assess that root cause by means of whether hernia, pelvic floor, whatever, then ultimately these patients are just told to get on pain management medication.

Speaker 1 (00:59:19):

Yeah, I agree. I agree. I think the art and the beauty of medicine is lost in many practitioners and so they just don’t want to deal and that it’s such a great way to say, you operate on pain, you’ll get pain and just I hate that. I hate it when they say that. Oh my God, we are done. That one done so bad. Nice tell you. That went so fast. I enjoyed every moment of it. Me too. And lemme tell you, so for those of you that don’t know, I hope you do follow Dr. Bani at Pelvic Pain Doc on all the different Social Media Pro platform. She is funny and she is fun, and it’s just very entertaining. And at the same time, you learn a lot from her social media. So I hope you all follow her. And if they want to see you, can they see you in person in

Speaker 2 (01:00:11):

Just Yeah, where they can see me in person. We do still do virtual appointments as long as they’re going to come to New York if they need to. But yeah, I would be honored to take care of. And anyone who you take care of in general?

Speaker 1 (01:00:26):

Yeah, I think I do the same. So with the whole pandemic, we’ve just learned that virtual appointments or what I call online consults too, and people that are out of state or whatever, happy to at least tell you. And then I’ll be like, yeah, then go to Dr. Bahlani afterwards. I think this is something that she can handle. So yeah. Love it.

Speaker 2 (01:00:47):

Thank you.

Speaker 1 (01:00:48):

Okay, everyone, thanks for joining me on another Hernia Talk Tuesday. This was a great, great hour. As you know, this will be posted on my YouTube channel, Dr. Bahlani. You can share it with anyone you want afterwards. It’ll be up on the YouTube channel and Facebook Live at Dr. Towfigh. Thanks everyone. See you next week. We have another amazing guest and I love doing these every week, and I’m so happy that so many people also enjoy talking about hernias and hernia related topics, pelvic pain, et cetera. Thank you very much for your time and help you enjoy your time with your family. Thank them for me for borrowing you for the full hour.

Speaker 2 (01:01:28):

Thank you. That was awesome.

Speaker 1 (01:01:30):

Okay, take care. We’ll see you. Okay, bye Bye.