Pelvic Floor Dysfunction Is Not One Diagnosis | Dr. Adam Gvili

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when I was going through it, I would have killed to see someone explain their symptoms and that they got through it. And so we started out with urologists because anything in the in your nether regions, there's no one else to really go to, right? Um, and what I found is that many urologists and are still kind of practicing 1970s medicine. Hi, I'm Dr. Jason Seafferman and welcome to Care Beyond the Pain. In each episode, I will sit down with a provider, a person with pain, or a supporter to explore their experience and share their perspective on the pain journey.

Together, we will navigate care beyond the pain. Hey, I'm Dr. Adam Gilli. I'm a pelvic floor therapist and founder of Pelvis NYC here in New York City. Adam, thank you for joining us. It's a pleasure to meet you and I'm eager to learn more about what you do. Can you tell us how as a physical therapist you got into pelvic pain? Sure. Um, I went through my own journey with pelvic floor dysfunction for about six years. Um, and then, uh, it took me a long time to finally get good care and, uh, ultimately it took me about four pelvic floor therapists until I can get better and we found that there was a need in this space for pelvic floor physical therapy.

So, you actually went to physical therapy school to become a pelvic floor physical therapist? Uh, no. So when you when you get your doctorate for physical therapy, you're considered a generalist. And so everything in regards to pelvic floor is post-dopate work. So tell us more about So was it your experience with pelvic pain that drove you to become a physical therapist? Oh, absolutely. Yeah. I I realized there was a a big need for pelvic floor therapists that knew how to treat men with um with the dysfunction and um the gap in knowledge was was immense.

So ultimately I knew nothing about pelvic floor therapy. I just knew that it kind of needed to get done. So, you learned a lot from the experience as a patient that informed your practice as a provider. Yeah, without a question. Can you tell us a little bit more about that? Sure. Um, once I found the right pelvic floor therapist who was phenomenal, um, I kind of guided her through treatment because she was also taking theory that she learned for, um, pelvic floor for females and kind of attributing it to men.

Um and she was open to kind of like collaborating in that in that respect. Um and then once we once we kind of figured out some way where um I decreased symptoms at some point uh we knew we were on the right track. M can we go back in time a little bit just to hear about your patient journey because certainly a lot of people we work with they're still learning what it means to be a patient and what this arc looks like.

A lot of patients haven't found the right provider or the right team yet. Uh they've bounced around. They've been around the block and they still don't have answers. Did did you go through any of that? Yeah. Um six years of that. Um so I started out with urologists then um functional medicine doctors um you know we did the I had it first of all we can go through what I what my issue was um only if you're willing to share I don't yeah it's pretty important I think um when I was going through it I would have killed to see someone explain their symptoms and that they got through it um so I had urinary urgency hesitancy some form of ED um hard flaccid which is a new diagnosis that we is didn't exist 20 years ago didn't exist 20 years ago So actually I believe that Reddit has been able to coin the term hard flaccid and now it's in medical journals.

Yeah. Um constipation um and some a little bit of pain. And so we started out with urologists cuz anything in the in your nether regions there's no one else to really go to, right? Um and what I found is that many urologists and are still kind of practicing 1970s medicine. And so even in the absence of finding a bacteria, I was still prescribed antibiotics just in case. Just in case. Um now I know that prophylactic antibiotic use is a thing.

I'm not a physician of course so I don't know to what scope but um you know when you're using fuoricquinolones which have blackbox warnings and stuff like that. Yeah. I don't know if like the riskto-reward ratios there. Um and uh we've done semen cultures and even in that case we found back uh interocus ficalis which is a very common bacteria to find in your semen. Uh we treated that that didn't work. So um Doppler ultrasounds penile doppler I've been through it right cystoscopy when you're 19 years old is not funny either.

Uh but my whole point to say is uh none of it came up with anything. We I mean we didn't find anything but um the only thing that worked was pelvic floor therapy. So in that discovery phase of your journey where you're really trying to figure out what's going on like before you even get to a point of considering what treatments might make sense. What was it like going through that? Right. So given that we have such a fragmented medical system right where you kind of have to bring all your info from one practitioner to the other.

And remember I'm not in medicine at that especially at that point right so I don't even understand the medical jargon involved here to bring it from practitioner to practitioner and I find that this is common for most of the chronic pain patients that I treat is that you have to be your own advocate and then you almost have to in this anxious moment of meeting with the provider which you have probably have white coat syndrome and all that you then have to explain that oh wait there's this one other thing that the provider said that maybe you can make sense of and we can all put together and then we'll have this eureka moment.

That's the hope. Um, and what's common is that a lot of these people leave my office or maybe the urologist's office and then they forget. They're like, "Oh, wait. I I forgot to tell them that one thing." But that's just part of the anxiety of of going through this um and grasping at straws, so to speak. Right. No, there's a hypervigilance that without question, right? Which which increases that sympathetic dominance and all like the the buzzwords that we like to throw around.

Yeah. Um yeah and and it was it was very difficult to navigate. How do you approach patients now as a provider especially new patients who maybe are just starting this journey? How do you approach them to let them know that you get it? I think for starters, I want to be the the person that encourages them and and offers hope because up until that point, they what used to be the case is that up until that point, they would if they came in to see me or any one of my staff is they probably have seen five to 10 providers before me.

Yeah. And so in most cases, which you probably get this a lot with chronic pain patients, is they tend to be dismissed. Yeah. And they they tend to fall by the wayside, right? Um, a lot of a lot of practitioners, whether it be physicians or physical therapists, they tend to exaggerate. Um, they think their their patients are exaggerating when it comes to pain or the scales that we use, 0 to 10 or these arbitrary numbers that mean nothing. How do you describe hard flaccid on a scale of 0 to 10?

You can't, right? Um, and so just take more of a I can say biocschosocial. Again, that means nothing. Just take more of a human approach. Yeah. empathetic, right? Um, just them understanding that I know I've been through this, but not only that, understanding where they they the journey that they've they've been through. Um, maybe even mentioning some sort of symptom that they can relate that they know that I understand them or some sort of psyche component, something that connects me with them.

And I think a lot a lot more providers need to do more of that so that they can connect to their patients. With pelvic pain especially, it it's often multiffactorial. It's rarely just one thing. And when it is, of course, it's the easiest to treat. But I feel like that's so rarely happens. Or at least the patients I end up seeing, it's so rarely one thing. It it's often one thing that was the straw that broke the camel's back, right?

But that was only in the setting of uh an unstable pelvic ring or hip impingement or a lumbar disc or something else that kind of set the stage for that one thing to be a problem. Sure. Uh do you see this a lot? Yeah. Yeah. I a big fan of John Sarno's work and Howard Schubiner. Okay. Talk a lot about the mind body syndrome um and no plastic pain, right? what we would call a central sensitization. And so at some point um whatever it is that broke the str the camel's back as you say um there is this sympathetic dominance hypervigilance that keeps the body to increase hypertenity and causes pelvic pain and so our goal is to really decrease that so the best way possible and it's different for each patient.

So we just spoke about John Zarno with a psychiatrist that was on the podcast. You know, John Sardo was very much it's all in your head. There's no physical problem. If you see any practitioner who works on your bodygu is is that are you really a psychologist in the physical therapy suit or do you actually perform manual therapy and treat patients physically? So I I do but I I don't pathize patients meaning I'm not going to tell you you're broken so that you could come three times a week for the next 12 months.

Right? So but if you identify opportunities for physical improvement 100%. But I think what's important is so for instance someone might come up uh someone might come to me for they call it erectile dysfunction but then when speaking to them you're like okay you could get erections at times maybe when you're less anxious or maybe when you masturbate you don't have an erectile issue. So is it really a dysfunction? Right. So I I I tr I I want to make sure not to pathize the patient so that they know that they can get better and that's what I took from John Sardo and Howard Schuber.

I I'm I'm just very cautious with with his name because there's a lot of pathizing associated with his name, telling patients it's all in their head. Uh sending patients to uh rehab programs that are basically conversion therapies for pain. Right? I've had many suicidal patients deep self-blame uh when they do actually have physical anatomical sources of pain but are told to convince themselves that it really is just in their head when it's not right. What what I'm hearing you say is that can the brain amplify things?

Can psychological dysfunction cause physical dysfunction? I 100% agree with that. Uh, anytime there's a black or white approach to it, I become a little cagey. I I'm always open to the possibility that both can be true at the same time. And I certainly don't want to be in the position of missing a physical cause, right? And we are heavy manually manual therapy focused because I do believe in in touch and uh and we do get great outcomes with it, right?

And and it's incredibly subjective in many times and but but it works and um there's a theory as to why it works because we could take a top down approach through education and have the body relax or we take a bottom up approach and teach the body how to relax. Then the brain's able to register what that relaxation feels like and what the the lack of pain and so hopefully it stays that way. And that's really kind of like shooting the dice so to speak.

Well, no. Every tool has its utility, right? Uh physical touch is the one way we and our patients share a moment of confidence, right? Like how else does a patient know that I understand that something hurts other than I can reproduce that pain on exam, of course, right? Like when you find that spot and they say that's the spot, you know that's the spot. They know they know that you know that that pain is real and they have some confidence that you're going to figure out what to do because you found it, right?

I I feel like that's a pivotal moment when establishing with a patient. Yeah. Yeah. Um and in many cases like for instance if you get a patient with proctal fujax right that's a pretty debilitating diagnosis right which is shooting pain into the rectum or any pudendal nerve involvement because it's really what it what it is. Um, am I really decompressing the pod? No, no, I'm not sure. But I do know that we have some sort of effect where the the patient's pain scale does go down.

And to me, that's the most important thing. Yeah, I I generally approach those with the question of what's happening, why is it happening, what is actually causing that? Uh, and of course, there can be psychological causes, there can be physical causes. uh if there's some pudendal nerve enttrapment there's a variety of ways a pudendal nerve can be involved sure and so I mean just to share with you my approach because we're meeting for the first time of course uh I generally try to reverse engineer that situation as much as possible before I start down any one treatment path I really want us to understand what's happening why it's happening how it came to be why it's not getting better what else is going on in the area like I said I'm looking at the back and the hips and every just to really fully understand uh I mean maybe pitch conic constipation, right?

And and I might get a pelvic x-ray to look at the hips and I see that they're full of stool. My first move is to decompress the bowel. Sure. Right. And and if that's all that it is, that's the easiest whenever. So, you know, start with something easy. But, uh I I generally very much like to understand why things are happening. And I feel I mean in general when when I have a patient that's been around the block with providers rather than jump to a treatment without that full understanding I want to take that journey with the patient of of discovery to really figure out what is happening with their body and because ultimately long term if they don't understand what's going on and why it came to happen even if I do provide them some short-term relief it's not going to be durable like they they really have to learn themselves how to manage their body otherwise I'll just be in business forever and I don't want that.

I want to retire at some point. Yeah. You don't want patients dependent on your care, right? At some point you do want to discharge them and that's what makes good providers. Yeah. Specifically in um in an environment where everyone's trying to make money from their patients right here in New York City. So that's the other thing with you know first of all finding a patient that believes you and will listen to you but then also someone who's invested in helping you figure out what's going on with your body so you can manage it yourself for the rest of your life.

just like graduating school and moving on. Yeah. Can you share with me how you cuz you you work with your hands and you work with the physical body. What is the diagnostic process look like between you and a patient? Yeah. So, um obviously we're going to have the subjective portion where we're speaking to the patient and that's generally the most important. I'm going to get the most information to them. um before the patient comes in, I would love to have um I would say 80% of our patients, we do a discovery call before they come in.

I want to know if they're appropriate for therapy. If not, I probably would refer them out or tell them they should probably refer see another practitioner before they see us. Um and then at some point, um again, they would come in, we do the subjective, then depending on what's going on, like you said, you'd want to clear the joint above and below. I'd want to clear the lumbar spine, thoracic spine. Um, I would do different muscle testing, see what's going on in around the pelvis.

Um, and then at some point it's a bit of trial and error. So, I would start, it's kind of like you're diagnosing and treating in the same session because I'll start the manual therapy. Um, you can give me any sort of diagnosis, but I might work on their lower abdomen, the abdominal viscera, the perennium, uh, bulb spongiosis, issueosis. Um, and then do an internal and see if we get a change. And my goal is see do we get a change between the first one to three sessions.

If yes, let's just keep doing that. And also, you're learning as you examine the body, as you're working with body, as you see how it responds. I mean, this is something that I end up explaining to patients a lot. Guarding muscles feel different than distonic muscles, which feel different than trigger points. Uh, so you're very much gaining and understanding and and probably a lot of it's second nature for you at this point, but really just that that diagnostic process is iterative, right?

It it comes in snapshots because each time we see the patient, they're in a different state and we learn a little bit more about what's going on with their body each time we see them, right? Yeah. What what are home exercise like for for your patients? Um Okay. So, majority of the time, depending on We see a lot of hyperenicity cases. It's like majority of the men that we see. Um and so a lot of breath work if I can get them to my two favorite exercises.

is I get them to lie on a foam roll right on the lower abdominal visceral and do deep diaphragmatic breaths because if we can introduce a stimulus to the body that would otherwise make you contract but you're learning how to relax around that stimulus then we're reverse engineering this whole thing. Yeah. The same thing with a deep squat. This this would work for like majority of our diagnosis. um they're in a deep squat and they're doing deep diaphragmatic breaths because as the diaphragm distends increases intraabdominal pressure which increases the pressure in your pelvic floor thereby stretching it and so you could also kind of take it as a meditation 20 deep breaths twice a day do both otherwise you don't think about your symptoms the whole day yeah so there's a lot of learned disenergia between the abdominal wall the core muscles and the pelvic floor over time yes of course a lot of guarding a lot of guarding and and I don't know if that's the case for most men.

I don't know why we're seeing that now in from 2010 to 2026. I don't know if this has been around for x amount of years. It's the age-old question. It's absolutely been around just no one knew, no one gave it a name. What do you think they would diagnose people with? I mean, levatory syndrome was popular. I mean, I went to med school. I graduated in 2007, right? So I I saw a number of these cases and it it levator was the typical diagnosis with just the pelvic floor was too tight and then some patients couldn't urinate, they couldn't have bowel movements.

Uh and you know at that time like Botox was sort of the introductory treatment. Um there and then the other thing that was common was chronic prostatitis, right? And whether it was bacterial or not bacterial just irritation of the prostate, right? Things like pelvic congestion syndrome were not in the vernacular, right? um thinking about lumbar discs causing pelvic floor dysfunction were not thought of. You know, it's it's since been proven that the pelvic nerve can be affected by an L45 disc, right?

And sometimes those patients with a diagnostic epidural will find relief, which really localizes the source of the problem, right? Doesn't mean you have to treat it that way, but of course it helps you understand where it's coming from. Uh and and then of course there's been a lot of evolution on on all of these fronts. And then even more recently the role of hypermobility has come into view and I I think that really happened after COVID when a lot of people developed longco or postcoid syndrome with massel activation syndrome or small fiber neuropathies or a lot of the the vascular congestion symptoms got worse postcoid as well.

um that that brought a lot more light to the people with hypermobility. Sure. Because they were also more likely to have these issues and that's when we start picking up on all of the associated disorders of hypermobility. And of course, pelvic ring hypermobility, hip hypermobility, hip impingement, hernas, these will all cause pelvic floor guarding, pelvic floor uh and in some cases it develops into donia. Yeah, we actually just did a study to validate a a scoring tool for pelvic donia uh to to distinguish it from pelvic floor dysfunction.

I mean, pelvic floor dysfunction is like an overall big win, you know, umbrella that kind of covers everything like fibromyalgia, right? Right. But pelvic floor dysfunction can be donia, it can be trigger points, it can be guarding, uh it can be an actual bacteria, prostatitis, right? It can be pelvic congestion syndrome, can be a whole heck of a lot of things. Uh so our job is really figuring out what that thing actually is and when it is pelvic donia that is actually appropriate for something like Botox but the rest of them are not.

It's interesting you say that because chronic prostatitis which as we know 96 or 97% of all cases are aacterial um was the umbrella diagnosis for so long for anything going on with a man with a man right thank god we're going away from that because it's much easier. Well, but that that also bounces the other way because chronic prostatitis is a real diagnosis. Sure. And I've seen more than one male who's been to three or four urologists who said, "Oh, it's just pelvic floor dysfunction."

But then I hear their story. I mean, we can go into the nitty-gritty of what chronic bacterial prostatitis presents like, but my my next step is to give them a trial of an antibiotic, something like nitrofure to a macro, right? which is like pretty inert but it kills most of the like the inner caucus that you mentioned right so like if that inner caucus is causing a problem if I give them two weeks of a macro and they feel better it's bacterial or it's placebo but hold on we do know that antibiotics de they have a decreased cytoin activity effect correct not all of them not all not all okay because I found through my obviously go doxycyc absolutely but then how would you know if it's truly bacterial or not using doxic obvious So that that's when I use the macro bit, right?

I I would generally put them on cranberry and macro bit like two weeks just to see what happens. And if they feel better, that's suspicious to me. That really makes me double down. And now, of course, we can do the the uh the PCR testing for bacteria. So rather than doing a semen culture, which is really unreliable, right? Uh you can actually do the PCR and identify if there's something there. Uh and again, and have you had success? I mean, yes.

someone with chronic pro prostitis in like x amount of years. Yes. Wow. So this doesn't happen often, right? Like these are the patients that fall through the cracks who have been to the urologist who get blown off by the urologist and and of course it it gets tricky too because they often did get the course of cypro and that definitely will alter the localization of the bacteria because you know the prostate just it's a perfect home for bacteria to just live there.

And I also I don't know I have beliefs because we don't have science to give me better information than a belief. But I have a belief that a lot of people live with a colonized prostate. So if if if I have a man come in and tell me that after he ejaculates, if he doesn't urinate, he develops urethritis. Yeah. And that urethritis just kind of persists until he takes an antibiotic and then it goes away and he's good until he ejaculates again.

That to me is a story of a colonized prostate. And of course this doesn't happen often. This doesn't come up much. Right. Sure. But the same thing if I give someone a trial, you know, but they're not distinguishing this. They come in with a prostatitis. If it sounds like a bacterial prostatitis enough or if at least like it started, if somebody tells me they had unprotected anal sex and they didn't shower or clean or urinate afterwards and then they developed urethritis that ascended into a prostatitis, that's a good story.

Yeah. Right. And can it persist? Can they have colonization in the prostate for years and years and years? that that's where you know they may have been on courses of bacteria of antibiotics that really didn't kill it off because they can live in the prostate for a long time. This is a topic that I really get into because a lot of patients find themselves in this very little nook where they've been down the road with the urologist, they've been told it's nothing, but then actually sometimes it is.

So anyway, I I do the antibiotic test and I see and then if it is, I'll treat them and then they'll often get better. Wow. And I mean does it last or No, no, but then they have to be careful because they're they're still colonized. You can't get rid of the colonization in the prostate. And of course, there there are urologists now injecting sephilosporins directly into the prostate, which I don't even know that that actually takes care of the problem, right?

But you know, generally in that case, if every time they ejaculate, they urinate or they clear the path immediately or they use some cranberry or something that prevents adhesion of the bacteria, you know, that they can manage it. They can live with it. Anyway, it's better than the functional medicine doctors injecting the protoid methyl blue. I'm just Oh my gosh, talk about lack of science. [gasps] Uh but but then to to what you're speaking about, if there was a bacter a chronic prostatitis, regardless of whether it's bacterial or venus congestion, right?

There's going to be a pelvic floor reaction to that and that doesn't just go away. I mean, it's the same thing we see if somebody has back pain or hip pain or shoulder issues, right? Just because you treat the primary issue, the muscle guarding doesn't automatically reset. They still have to go to PT. They still have response. They still have to rehab those muscles and correct the postural adaptations. So, there's still a lot of pelvic work to do even if the primary source is treated.

That's right. It's a learned response. It's habitual. So, over time, if you're in pain for that long, you're going to develop some sort of uh u you're going to need to get out of it best way that you can, right? And this is where that mind body awareness is super important. BOF feedback is do you do any pelvic floor bio feedback? Yeah. So um on that cuz it's very important um a lot of physicians love to refer to you and say do bio feedback and I think it's one of the reasons is because that's that's what they learned correlates to getting better.

Now I don't disagree. I'm just saying that when I was a patient I would get stuck in a room um where they would stick a probe on my butt and be like we'll be back in 30 minutes and like um okay great thank you very much. So I don't do that because I I I we do it digitally. So when we're in there, we're able to give feedback, real-time feedback to the patient, and I'm able to intuitively feel what's going on, as in my staff is as well.

And I think that's more important because you're you're along that journey with the patient. Well, but that's also therapeutic. You're probably doing some contract, relax, you're probably doing some stretch. You're probably pressing on focal structures to see what hurts, what doesn't hurts. You're assessing everything. Yeah. And you can recognize the constellations of what's going on. That helps you pinpoint, you know, that root source. Right. Exactly. I also wanted to um comment on what you said earlier and what we're getting with when 2026 which we didn't get 20 years ago I'm assuming with pelvic pain and maybe with even medicine in general is I'm getting patients coming in like do you think it's uh I think it's believe May Turner syndrome yes like I'm like I'm not sure but no patient would ever come in and ask these difficult questions right well they didn't have claude correct helps and I love it too because it really helps patients process and consider a lot of the opportunities right and And I'll even say go ask Claude if they want to know the side effects for a medication when the side effect list is you know 20 items long like just Google it.

Yeah. Uh but sorry to to to your point like Mayer you know it's it's compression of the iliac vein on the left side from from it can be the right two but it's usually just the left um from from the iliac artery and it'll generally cause swelling and that swelling may backflow into the pelvis and I mentioned pelvic congestion syndrome earlier. That's one way pelvic congestion syndrome can occur, right? But of course, a lot of people have make their own without pelvic congestion syndrome.

A lot of people have, not a lot of people, but some people have nutcracker syndrome, right? Which is renal vein compression, which will affect the left gonatal vein. So, you know, if you ever see a man who has hernia type symptoms or on the left side only, correct? Uh, or testicular pain on the left side only. Um, that's a consideration. I mean, fortunately, the diagnosis is pretty easy, right? I can whip out the ultrasound. I can look at the gonatal vein and if it's dilated on the left side and not on the right, you know, that's pretty suspicious, right?

So, we work and that, you know, our practice is heavy on hypermobility spectrum disorders. So, we're working with a lot of vascular specialists who treat pelvic congestion, not cracker, that kind of stuff. Wow. But, but anytime I'm considering one of those things, you know, it broadens my consideration like what else is going on with their body, right? Um, so we know things like recticils are more common, right? uh constipation is more common uh you know a hip hypermobility and SI joint dysfunction or you know in terms of what I see with pelvic pain those are the two major drivers of pelvic dysfunction the hips and the SI joint.

Yeah. Um we I don't get much pain around the hips for like a hip impingement. That's more orthopedics. Yes. Of course, that's going to that's going to indicate how we treat of course. But um generally it's we get a mostly hypertenicity cases, believe it or not. And it skews 25 to 40 our age group. Yeah. And and with hypermobility, there doesn't have to be pain. No. It can just be the guarding of the instability that engages the pelvic muscles or the optator or internist.

Correct. And then that's that's the tricky part for patients to understand. It's it's a tough cell for me as a doctor to say your hip's the problem when the hip doesn't hurt, right? But it's the guarding of the hip. Yeah. Um even we what we get is a lot is people think, well, it does tight mean weak? Does weak mean tight? And then I'm I'm like, well, if you go into physics and then you have the lead tension relationship and like technically in order for a muscle to produce force, it's able to fully relax and then also fully contract.

Yes. But if I can only if this is full relaxation, this is contraction, I can only relax to here and I can only produce force from here to here. Yeah. I'm not going to get that much force in the muscle function. Correct. Yeah. Right. So explaining some of this stuff is is pretty difficult to some patients, especially if there's no medical background. As you're going along the diagnostic process, what tools do you reach for outside of your practice?

Uh, do do you refer to anyone for pedental nerve blocks? Do you refer for any special imaging studies? Do you work with hernia doctors? Um, yeah, I think it's important for everyone to say within their own scope and then take a collaborative approach. So, um, we used to refer to anyone and everyone when we first started and thank God we have a good list of practitioners that we see as almost an extension of our care and we see ourselves an extension of their care that I think that's very important.

Um so yeah uh pain specialists um colurectal specialists proctologists gastro interologists um I refer I find that I try and refer to um mental health specialists but I find that it it's either a money thing or they don't really know how to treat the patient with chronic pain. Um and so it's difficult. I I try and do what's right for my patient, but I also remember at that point as we said earlier, um they've seen x amount of practitioners. So to me now to refer to a psychiatrist is just one more thing for them to be like again and I I find this was this was very this was this is what happened with me when I was a patient is that I went to the uh I saw a female as a pelvic floor that was a pelvic floor practitioner and she was like, "Well, if you have anxiety around this, you should see a mental health therapist."

I was like, "Yeah, but if I get rid of this problem, I don't have anxiety." Right. Um, and yes, I appreciate you helping me manage this, but this is just another practitioner that I have to see. Yeah. Right. And so, that was an added stress. I keep that in mind when speaking to patients. But we also have to get to the the root cause of the issue, right? And that's important. The good news is pelvic floor uh therapy is now is now a thing and people are getting to know this a lot faster.

So it used to be that I would have to see a patient after four or five doctors that they saw and now patients are coming to see me first. Now that can be good and bad, right? Because they should probably be screened in most cases by a urologist or a primary care physician. Um, but if we find that there is potentially a physical cause to their pain and maybe in one session because we do have direct access in New York City in New York State and we're able to get their pain better, then you know I'll still have them check up with their physician of course but we are seeing patients faster and I think that's great for the patients psyche and for everyone involved and that's that's a been a huge blessing.

Yeah. As someone who went through it, it's incredibly lonely. don't really understand it. Um, and for a doctor to be your advocate as your doctor, I mean, that's huge. We don't see that in medicine anymore, especially in a time where we just don't trust doctors anymore, right? Um, the RFKs or the peptide situation or whatever it may be, but I think people want to be their own doctor. And to have a doctor that's on your side is I don't know.

Most of my patients don't want to be their own doctor. That's great. So you want a doctor who really like is their advocate, their educator. I mean, I do my best to like understand what's happening and then explain what I see. I do a lot of talking out loud as I'm processing what I'm finding. Right. I get a lot of patients that talk about the profit motive in regards to medicine. And um and so a lot of them question whether their doctor actually wants to help them or just is another um insurance to bill, so to speak.

And that's that goes for physical therapists alike. That goes for everyone, right? And so there's a distrust in the medical system. Um I mean the focus has to be on what we're doing for the patient, right? Like and and you know when patients ask how do they know who who to go to? Like what doctor is good? How do you tell a good I mean everyone generally has their own ideas how they figure out who's a good doctor and who's a bad doctor.

But there should be some some endeavor to understand what's happening, right? Some endeavor to understand what the underlying process is. not just a magical cure that oh you're going to do three sessions of this and then you'll be fixed, right? Not not a preset program, not a singular tool and that's all they have to offer. U especially if there's not a clear diagnosis, right? If they've been around the block, it's generally because there isn't diagnostic precision. And and you know, with the diagnosis, it's not just a name like pelvic floor dysfunction or chronic prostatitis.

It's really understanding at the most fundamental anatomic level what's actually not what what's happening right why is it happening how did it come to happen why is it not getting better on its own right like if we don't understand that if we can't reverse engineer what they come in with we're not going to make them any better right like we can't even begin like sure I can throw some medications their way and see what happens and that'll give me some ideas as to what's going on but that's not the highest level of medicine right I I would much rather have a firm or at least a well-formed hypothesis as to what's going on and then go take some steps to confirm that hypothesis and then you know it's the same process you describe, right?

Because that's the only way that we really know what's going on and we really only know what's going on in hindsight after it gets better and we can say well that's actually what it was because this worked and it's that's why it was happening because we fixed this and then that stopped coming back. So I I feel like if patients find a provider who engages in this journey with them, that's that's the value worth investing in. Yeah. And the the big question comes up where how do you set expectations without killing their hope, you know, and that's the tough part.

You also want to be realistic with patients. A lot of times the hope is shot. I tell them I don't need their hope. You know what? Let's let's work on this. I'm going to do my best to figure out what's going on. Save your hope. I don't need it. Right. Let me do my stuff. Right. Yeah. We'll we'll figure it out. That's what I mean. And that's great because as a patient that where I was and it's kind of what I tell my patients like let me do the dirty work.

You just come right. You do the stuff I tell you to do at home. Yeah. And just let your shoulders down. We have a plan. That it's exactly what I say. Like cuz we'll we'll have patients of course coming in sympathetic elevation. They've been everywhere. They're frustrated. They don't know who to they've been told it's all in their head, right? They're so activated and so desperate and and so much in need of care. I sometimes have to lend them a little bit of my confidence.

Like, of course, I can only do that when I have some reasonable confidence as to what's going on. And it's great to get that at that first visit, but you know, it's just like, I've seen this before. Bear with me for just a moment. We can get this better. It's going to take a minute. We can work through it, but we'll get there. It's great. I'm glad I'm glad we met. No, likewise. I really appreciate you joining us.

Yeah. Thank you. Thank you for having me. Thank you so much. Thank you for joining us on another episode of Care Beyond the Pain. The pain journey is rarely a straight line. To learn more about how to navigate it, you may visit our website, manhattanpain medicine.com, or read our book, Pain Answered, found on Amazon. Until next time.