S1E8 - When Pelvic Pain Comes From the Veins | Dr. Yosef Golowa | Care Beyond the Pain

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And when you can sort of replicate that, okay, this is causing the pain, it's like that eureka moment like, oh, now I now I know at least I know where it's coming from. Let's figure out how to treat it, you know, let's figure out the best way to treat it. 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. Hi, my name is Dr. uh Joe Gallow and I'm an intervention radiologist here in uh in New York City. Dr. Galawa, thank you so much for joining us today. It's a pleasure to have you. We've shared many patients and tackled a lot of the same problems. As an interventional radiologist, can you tell us how you approach pain? Sure. Well, I mean, that's that's a that's a good question. So pain is is um you know very common.

It's it's very it's a common thing that a lot of people have and and um and it can be sometimes difficult to parse out really what what's causing pain for different people and there's really um you know a lot of different co yeah potential causes for pain. Um, for me a lot of it I think is sort of uh talking to the patient, listening to the patient, and really trying to parse out where what the source of this pain is or or sort of where it's coming from.

Um, and it just really requires a you know, I think a fair amount of of time and and attention at least that's the that's the beginning and then you sort of move on to some more of the diagnostic uh diagnostic tests and diagnostic work. So it it leads with the patient's story. That's for sure. Yeah, I mean that's that's probably one of the most important parts of it on once you understand the patient's story and and what they're feeling. Uh there's a specific set of conditions that you really specialize in.

Can you tell us about those? Correct. Well, a lot of it is, you know, it really varies, but a lot of it has to do with pelvic pain for probably both men and women. probably a little bit more common in um in women, but um uh specifically I I would say in in women uh we're treating a lot of women with um uh fibroid disease or or adenomiiosis or or uh or what's called pelvic pain of venus origin, which has to do with sort of stretched out or enlarged veins um in the pelvis.

um or just sometimes I'll I'll see women with with pelvic pain in general. It's a little hard to tell where that's coming from, but that's sort of the treatments that I that I uh that I offer. Um for men also, men with chronic pelvic pain um uh whether it's related to chronic prostatitis or also men could also have um uh Venus disease as well, issues with veins probably again more common in um in women. And then lastly, I I do a lot of or at least more recently, I've been doing a lot of uh uh procedure for chronic muscularkeeletal pain and some new and interesting um uh innovative treatments as well.

And that's really uh um something that that I'm kind of excited about, too. Let's talk about those. Yeah, sure. Um well, this is what what what these treatments are. It's called um trans arterial micro embleization or tame and this was really described or really pioneered by um by a doctor in Japan his name is Yuji Okuno who's really um an interesting guy really innovative and what he what the idea is is that a lot of the the a lot of the the pain involved in muscularkeeletal um either chronic arthritis or or chronic tendinopathy A lot of it's driven by this by inflammatory processes and you know and that's sort of what a lot of these like when you're taking on steroidal anti-inflammatories you're trying to sort of decrease the inflammation systemically when you are doing um steroid injections you're maybe that's a little bit more localized form of reducing inflammation.

um his idea was to try to treat the blood vessels that are bringing these inflammatory mediators into the joint or into the um uh uh the area of inflammation. So what he did was he would do or what what we do is we'll do an angagram and we you see this really abnormal um very small blood vessels or very small vasculature within the area of inflammation and it really looks striking when when you see this inflammation and you you get right up to it with a very small catheter.

So sorry. So this is from inside the blood vessel. You'll do a needle puncture. You'll put a very small tube or a catheter into the um the blood vessel that goes to the joint. You'll inject X-ray dye and under X-ray you'll you'll do this angiogram and you see these really abnormal blood vessels and he he would describe it like a like a puff of smoke. It really just looks like this fuzz. Um and we would essentially emolize it or block off some of these really small micro vessels typically with a temporary um empolic.

So we're we're not blocking any large blood vessels or or permanently blocking blood vessels, but by take by getting rid of some of these small blood vessels, it sort of breaks that cycle of in of these inflammatory mediators or these um you know the these cytoines that are going into that that that joint space and you know really seeing great results from it. So it's really exciting. We've been treating a lot of um patients with chronic uh knee refractory knee osteoarthritis, plantar fasciitis, frozen shoulder.

So this is really I mean I think that this is going to be a very um uh exciting space for for pain and and for for patients with chronic um joint pain. So it sounds like you're targeting the microvascular changes that occur with chronic tenonopathy or chronic overuse injuries. Correct. So that's that's interesting because that's exactly what we'll identify in ultrasound. Really? Yes. Wow. So when when we are approaching a target considering regenerative medicine. Okay. That's one of the hallmarks of teninopathy or bersopathy or a lot of these overuse injuries.

And as you know when a tendonous structures or any kind of fascial structure is strained and overused, you know, there there's a maladaptive healing pattern which includes this neovascularization. And that's just it's a hallmark on ultrasound and it's also uh one of the presumed effects of uh prolotherapy is actually causing some sclerosis of this microvascular adjacent which will similarly stimulate a healing effect. So that's great. Yeah. And so it's essentially it's it's a it's a it's a little bit of a different approach, but we're we're both treating the same the same target.

Yeah. That's that's really cool. Great. Uh let's take a step back. Can you tell me what an interventional radiologist is? Yeah, for sure. So, intervention radiology, it's it's a relatively young field. I would say it kind of it's been around since the 60s. So, it's I guess about 60 years old. So, it's not a very uh um uh old field of medicine, but what it is is it's it's the idea of using image guidance or imaging technologies to to perform minimally invasive procedures.

So, I mean, and I think that's really the way a lot of medicine is going. people really, you know, don't want big surgeries anymore. Uh, ideally if you don't have to. And the idea is is that we're able to using image guidance, we're able to do uh a lot of procedures or treatments really through uh a very small needle stick often um and you know effective effective treatments safer and and less recovery time. Um overall it's it's a it's a pretty rapidly evolving field and I think we sort of have the or I think intervention radiologists kind of have this reputation of you know being sort of innovative thinkers really you know changing a lot of treatments and and sort of early adopters and the technology is constantly evolving the technolog is constantly evolving and um and uh you know it's it's it's really amazing I think it's a very exciting field.

Yeah. Uh can you tell us the breadth of interventional radiology practice is quite wide, right? Like you may be placing drains uh you may be imolizing tumors. Uh can you tell us about your practice? Is there a limited scope within interventional radiology in which you specialize? Yeah, so that's a really good question, a really good point that you brought up. So I mean my background I you know I spent about 12 years in a in a busy tertiary care hospital.

So really this was a practice that had like you said a large breath of of treatments. I was treating cancer patients. I was treating um babies with liver transplants. I was doing drains on people with appendicial abscesses. So it was really everything. And um about four years ago, I I um ended up leaving my hospital practice to really work in an in an outpatient um setting and really sort of narrow my scope of practice a little bit. Um and I think a lot of what I'm doing now is really again treating sort of a lot of this uh sort of this pelvic pain or or or um treating men's health.

So a lot of it has to do it's not it's not all pain. I'm doing a lot of um uh treatment for for prostates. Um so prostate embilization or to shrink prostates for men with large prostates. I'm doing a lot of um treatments for for um for venus work. Um let's talk about that a little bit. H how did you get into the pelvic pain field? Yeah. So, well, I I think a a lot of the pelvic pain or a lot of the the the the pain generators that we see in the pelvis or at least what I what I see has to do with um with Venus disease and a lot of it's just it's it's a it's a disease of veins in the pelvis.

What is Venus disease? So, that's another good question. So vetus I guess veins are veins are uh the blood vessels that are supposed to bring the blood back into the uh back to the heart and they're passive. It's passive flow. The blood is um basically sort of pushed up by by contraction of muscles or or movement. Um but sometimes if if um if the ve drains are excuse me if the veins are not draining well these veins can get stretched out they can get congested and that can cause pain and we it's and it's very interesting because you'll have some patients who do have these veins that are stretched out that really you you'll see it on imaging or you'll see it um on exam and they they'll say it doesn't really hurt them.

And then you'll have some patients where it just maybe I think it has to be where if it's in the right space or or perhaps near a nerve or whatever it is, but it can really cause a lot of pain and really be uh debilitating. Um so that's that's sort of a lot of the Venus uh uh disease that I see. Patients have it. I mean you you you'll see it in the legs in patients with large varicose veins and that could be painful and that's very obvious when you see it on the outside of the patient's uh body but patients have basically similar um similar problems on the inside of their body where the they have essentially varicose veins in the pelvis.

They'll have varicose veins in the well for men they could have varicose veins in the scrotum or whatever it is and and um the idea is to try to decompress them. How might somebody know if they have varicose veins in the pelvis? Um, a lot of times you can't see it. Um, at least not not to the to the naked eye. Sometimes, specifically in women, they'll have um, you know, some veins that they'll see sort of around their their pelvis or bulging veins.

They could have veins in um in the vulvver area also which can be indicative of uh um decompression of uh veins higher up. But a lot of times it requires just some you know imaging or or advanced testing to to really see that or to really um understand how the the the blood is flowing and how those veins are are draining. What are some of the common symptoms of venus congestion disease? Um common Common symptoms of venus congestion disease specifically in women.

Um they'll feel pelvic heaviness especially as the day goes on uh for a long time. Um they'll feel a lot more a and and the these these symptoms or this aching can get worse often during their menstrual cycle. Um if you could imagine during patients menstrual cycle there's more blood flow to that area. So these wings are getting more stressed and more stressed out. Um something that's very common that we see uh that we hear from women is that they get pain uh after intimacy.

Um so again that that's more blood flow to the area and then that'll cause these veins to stretch out more. But specifically uh women will describe pain that'll last for a few hours or even till the next day afterwards. And that's very common um in in really women with with pelleted venus disease. So when I hear that that sort of makes my convers. Yes. So that's something really common. Um and then there are other sort of uh you know I guess like other other issues that can cause it.

I guess when in women that are very severe pelvic venus disease they can have something that's called POTS which is positional orthostatic orthostatic ticardia which is essentially when they'll when they'll stand up very quickly or or get up from lying position uh they'll feel their heart flutter or their heartbeat will go very fast blood doesn't get back fast enough so the heart kicks in. Exactly. So, so then what's happening is a lot of the blood is pooling in the pelvis and it could kind of take a little time for the body to equilibrate.

Um, women will complain of of frequent urination. Also, some of these veins can sort of irritate the bladder as well. Um, so again, it's sort of like what you were describing earlier as far as like what's causing this pain. you really have to talk to the patient, sort of try to understand are they having these symptoms and sort of put the put the whole piece of the puzzle together and then to try to direct your your imaging or your diagnostic workup. A lot of these symptoms you're describing are fairly they cover a lot of different possible diagnoses.

Uh so, you know, if you think of urinary frequency, the list is long. When you think of pelvic heaviness or menstrual pain, the list is long. uh when you're meeting a patient for the first time, how do you begin to parse these possibilities? Well, that's that's exactly it. You really have to try to um you know, hey, listen to the patient. You know, I usually just try to let the patient talk and let me let them tell me uh their story.

Um but correct you know if someone comes in with urinary frequency alone this is you know the the first thing is not going to be pelvic uh venus disease. Um but I think with enough of sort of symptoms and sort of understanding um uh what their presentation is along with with uh with imaging findings or a diagnostic workup then you could sort of um try to point yourself in in in the right direction. what what imaging do you typically use? Um I typically start with uh with an ultrasound and you know the ultrasound is a little can help in a in a in a number of ways.

First of all is very easy to do in the office. Um it's um and it and it gives a real-time imaging. And one of the one of the issues that we want to see with veins or blood flow is we want to see real- time imaging um to see if these veins are are you know are stretching out during um when there's high venus pressure or to see where the which way the blood flow is going. um you know a lot of times I'll do what's called cross-sectional imaging like a cat scan or or MRI but when it's very severe it could be very helpful or it could be helpful in in looking for other things or other causes of pain but it's also just a snapshot in time and you don't always get the full picture.

So patient comes in with complaints that sound like pelvic venus congestion. You do a dynamic ultrasound in the office. You determine that they do have evidence of of venus disease. What what's the next step? Correct. Very often the next step would be uh what's called a a venagram. So a venagram is it's it's it's a diagnostic study, but it's a little bit more invasive than say an ultrasound. And what it involves is uh a needle stick into a blood vessel.

usually uh at the top of the leg um into one of the the larger veins. But the needle stick is probably about the size of an IV line. Through this needle uh stick, we'll be able to slide a very thin tube into um into the blood vessel. And then under X-ray, we'll direct it into different blood vessels in the pelvis or in the abdomen. And we'll inject X-ray dye uh in certain places in these veins. And what we'll look over there is to see which way the blood is flowing and to get a really um uh more dynamic and physiologic idea of how these veins are filling.

So we'll be able to really get a lot more information like that. And also sometimes we'll have patients sort of replicate the the the movements or or positions or or to push down that replicate when they get pain and to really parse out um is this the cause or is this the same type of pain that they're feeling. Uh, and the other thing that we're able to do also is we have miniaturaturized ultrasound probes that we can um put into the veins and also look for areas of narrowing and really get it get really uh fascinating.

Great detail. Yeah. No, it's it's it's really amazing. I think really So there is some diagnostic pain confirming value with the venagram. That's Yeah, that's correct. That's that's really interesting. Can you tell us what that's like for the patient? Um well sometime again it's we like for example if you're in if you're in a vein that and and you let's say you inject that vein and they feel oh that's it that's and sorry when you inject it that you can stretch that vein a little bit sometimes and sometimes that's exactly where they'll feel uh the pain or it could sort of replicate that that's somewhat similar to the pain that so so the veins themselves can be sensitized.

Oh, they are when when you when when we inject a vein itself, if you inject it um enough to stretch a little bit and it's not I'm not injecting with full full force, but you are, you know, increasing the pressure in a small vein and it it's painful. Patients feel it. I you know, it's not excruciatingly painful, but they'll they'll feel it and sometimes that's that's somewhat that must be very meaningful. Yeah. Yeah. It really is. And if you look, you know, you have you you know as well as anyone that it's hard sometimes to really figure out where the you know where these where this pain is coming from, you know, what's causing the symptoms.

And when you can sort of replicate that, okay, this is causing the pain. It's like that Eureka moment like, oh, now I now I know at least I know where it's coming from. Let's figure out how to treat it. You know, let's figure out the best way to treat it. Let let's talk about that for just a second because I think that's the number one message that people miss about pain is that the diagnosis has to come first. If we don't understand what's causing the pain, why that's happening, how that came to happen, we have little success.

Right? So, you're describing a situation where you hear a story that makes sense. You do a diagnostic test that confirms that. that gives you the basis to then choose the most appropriate treatment in that exact situation. How do you walk through treatment options with patients? Um, again, you have to you have to really discuss with them. I at least I the way I approach is I sort of just walk through with them what I'm thinking. You know, I actually just saw a patient um today in the office who, you know, she had a friend that had a treatment for a fibroid embleization.

And you know, look, I I think um you know, a lot of patients will also work with uh with AI or GPT, which I think honestly I think patients come in a lot more educated than they used to. And I a lot of times Yeah. No, a lot of times it's it's very helpful and but you know, I think I think what we are a lot of it is that we we are sort of consultants or or you know, we have to sort of guide patients along.

Yeah. you know, with all this information and try to help them um through this path and a lot of the stuff that she found on on AI sort of did make sense that the fibroids were causing her symptoms. You know, reviewed the imaging and and sort of went through a lot of what was going on. And, you know, again, I I actually thought that this was more of a Venus problem, but I'm not I wasn't sure. you know, it's it's it it wasn't a clear picture overall, but I you know, I sat down and I I spent a fair amount of time just sort of talking about what I thought, what my what my reasoning was and how I was sort of thinking about this.

And I think I think that's what you sort of have to do, you know. I I personally am not very dogmatic a lot of times. I because it's it's hard to be dogmatic. You don't you don't know. Yeah. It's not our job, right? It's not our job. And and and you know it is an art body too. Right. Yeah. Yeah. I think we approach that similarly. I I tell patients I'm the chef behind the buffet.

Right. Right. These are your options. This is what I see and this is what I can provide for you. Right. Ask me if the chicken's any good. I'll tell you. This is what I recommend. Yeah. Yeah. Exactly. But um but I you know but I can't I you know I can't tell you 100% that this is going to be the fix always. I can tell you I think it is and I'm pretty sure you know what I the other thing is I you know luckily I think a lot of the procedures that we're doing um are these aren't risky procedures.

These aren't um they're procedures. I'm not trying to minimize them, but overall um you know, if this can help somebody with pain, it's it's usually, you know, something that I can offer with with a low risk and if it works, you know, they're very helpful. Yeah. Can you tell us a little bit about the patients that do come to see you? Where are they in the pain journey? What have they been through? Yeah. So, I I'm I'm certainly not the first typically not the first um physician they're seeing, but you know, I what I would say is that specifically for patients with with pelvic venus disease, um I I do find a lot of them are have sort of been dealing with this for a long time and sometimes can float around.

um you know a lot of times they they will go to um their gynecologist and and I and I think it's changing and I think a lot of um gynecologists are recognizing this more and being educated more but it is a Venus disease. I think it's a it's a vascular problem. It's not so much a gynecologic problem. So they're sort of, you know, haven't really necessarily been treated adequately and until they sort of just come across somebody that's like, "Oh, that's what this is."

And again, you know, I actually just saw another patient today who, you know, she had a a couple of endometriosis uh surgeries. She had some endometriosis, but really probably not enough to be causing um this pain. And then she ended up going to uh uh um another surgeon uh for a second opinion who was pretty astute and she said, you know, I I I don't want to operate on you again. I I don't think I could help you, but this is what you have.

And once she got on the right sort of that right pathway, um you know, we were able to find it, you know, we were able to treat it and she's just like life changer, you know. And that's to me that's that's amazing. But I guess to answer your question, where on the on the pathway am I? It's you know, a lot of times it's a little bit um of a circle. You know, I I uh you know, a lot of patients have been through a lot until they sort of end up um in my office.

My treatment or my what I can offer is just is just a part of this treatment for pain. You know, I wouldn't say that I'm certainly not the quarterback in this in this um sort of journey. And again, these patients that end up seeing me, it's it's because they have this specific um pain generator or whatever it is. But you're right, you know, when when they see me, there's other there are other factors that that need to be um that may need to be treated.

for example, pelvic venus disease, you know, they're they're getting other, you know, pelvic floor tightening and compensatory um issues that may need to be treated by by, you know, someone such as yourself or or um and most of them are with physical therapy and treated already. Let's talk specifically about some of the complications or or maybe even before that, let's talk about the treatments. Yeah. So here I'll I'll try to like go back and just stick to the nuts and bolts of specific treatment because then we'll have a nice story arc.

Yeah. For that. So if if we're considering the treatment of pelvic venus disease, what treatments do you have available? Um well, pelvic venus disease essentially is or this pelvic pain of Venus origin is essentially when the veins get congested and and and stretched out. And there's sort of um two two factors that that um that can cause this. So you'll have what's called reflux or basically some of the veins the the valves are not working well. So the blood sort of backs up and gets congested and that just brings more blood into that uh area.

So the blood there's just too much blood sort of going into that area. And there's another there's [clears throat] another um aspect of it where some of the veins could be compressed. Um so this is that it's just not draining well. So there's blood going in too much and then there's blood that's not draining adequately enough. Um so based on really what's causing the problem is sort of where you you'll guide the treatment. So, if there's too much blood going in, what you would do is try to close these veins or block these faulty veins that are a not working correctly and b not needed because they're not they're not um they're not doing this job of bringing blood away.

Um that's done by what's called an embleization. So, what what's done is a a needle puncture into the blood vessel. you'll guide a very small uh catheter into that blood vessel, a very small tube into the blood vessel and from inside the vein you can close um you can close that vein uh so that it's not it's not bringing that extra blood in. Um the the other thing that can be uh and then as far as the the venus compression or the blockage of the vein, there's uh there are some tight spaces where there's a lot of traffic in in the pelvis or or tight spaces in the pelvis where one of the veins can be uh compressed by a by the artery or the other blood vessel where it crosses.

If that's causing too much compression, the blood is not able to leave the pelvis. Um, and in that case, it's a that's a little bit more involved, but that would sometimes we'll have to put in what's called a stent, which is a a sort of a a a scaffold or a little mesh that goes in and props that vein open to allow the blood to drain adequately. I think the third thing that can be done and this is a little bit more targeted and again we sort of alluded to it before when a certain vein gets stretched or um or uh and that's what's causing the pain.

If you could sort of find that area or get to that that vein itself, you can try to close that vein that that vein that's causing the pain and sort of just I guess it's called more like flow redirection. So try to keep the blood away from that vessel. If it's really just one little area or one part that's really still causing the pain, you can you if you can find that you can close that that vessel itself. So, a little little complicated, but so if the valves aren't working, then you can imilize those veins to keep the blood from flowing back.

Correct? If there's a reason the blood isn't leaving the area, such as compression, you can open that site of compression. And then if there's a particularly sensitive area, you can close that down so the blood has to find another path. That's that's exactly right. And and often often with the first with the the first two, in other words, the the the the vein that's bringing the blood in, will we usually also try to get into the what what we call the nitis or those those vessels themselves and and close them at the same time.

Okay. And I think typically really I mean it the the way I the way I pro the way I I approach these I'm always trying to get those veins that I think are causing the pain at the same time that I'm treating the the blood that's going in or or overloading the system. So really treating because it's going to be a complex problem. If there if there's compression upstream that's keeping the blood from going it will pull and stretch and backflow. Right.

So you're you're talking about getting it all in one go. Uh well I'm I'm trying to to keep the to to treat the blood going in and to treat the actual nitis or the stretched out veins themselves. the the compression part um sometimes the reason why the compression is a little tricky because it's something that you'll see in a lot of women if you look if you look at almost all women you'll see some component of compression and you don't necessarily I you know I don't always want to over treat that and I think a lot of it has to do with there's just too much blood going into the into that um into those blood vessels once you you decrease the amount of blood going into the blood vessels, a little bit of compression maybe um not so uh the body's able to compensate for that.

So I guess what I'm what I'm saying is typically if if I if I see both if I see too much blood going in and compression I'll treat the blood going in first and and most of the patients do better that way. If if they if they're not doing better after that after a few months then we'll sort of address the compression or look at that afterwards. So it's are are you saying it's more of a dynamic compression because the the venus pressure is too low to prop the vein open the well I think there's too when there's too much blood going in I think there's more blood flow that has to go across this narrowing I see and by decreasing the amount of flow or decreasing amount of blood that needs to cross the narrowing um the compression may not be as clinically um interesting significant.

So one of the more frequent questions I get, you know, we have a number of patients with pelvic congestion syndrome, a thinner, nutcracker. Their question is, how do I know this will treat the pain? You know, and and we have a lot of young people, a lot of hyper mobile people, you know, they may be, you know, in their 20s. Yeah. and committing to a stent at a young age is something they're leerary of and something many of them have had other doctors tell them not to do mostly because they're not familiar with Venus compression disease and high mobility and all of the the the necessity in treating compression syndromes.

Um how how do you approach that question of you know how do we know will this work or not before we actually put the stat in? So that's a really good question and that's sort of what I was, you know, I guess alluding a little bit to before is that I would try to treat if if I can treat the the the veins or the vein it I if it's if I see that it's it's veins that are bringing too much blood in. To me, that's easier to to treat in a young patient, probably less of an issue going down um going down the road for many years.

you know, a patient that's 20 years old, you know, I tell them, I hope hopefully you're going to have another 80 80 100 years ahead of you. Um, uh, you know, the the the stances that we use, we know they're safe. Um, you know, they they've been shown to last a long time, but we don't know, you know, we haven't seen these stances last, you know, 50, 60 years. They haven't been around that long. So it certainly, you know, requires a discussion with patients before you put in um uh this device into someone that they're going to own for for a very long time.

uh to me. So, specifically in younger patients, um I really want to sort of rule out other um other causes of pain and really understand that this is really what's really looks like it's causing uh this problem. Um, you know, I really am very careful that putting a stent in someone that and and if if they really don't get better, it's it's difficult. And, you know, for me, the patient is going to own this stent forever and I'm going to own this stent forever.

This is something that I put in and I'm going to have to really watch watch this patient and honor them and see them and make sure that they don't have any issues uh with the stent. Um, specifically with the stent, uh, again, the the the patencies, meaning they stay open for a long time, and we really don't see a lot of complications with them, but one of the risks is is that they can they can clog or clot and and that's something that we really have to uh watch these patients for for a long time.

I guess I'd like to hear from, you know, I I I talk to interventional radiologists and vascular specialists all day and I know how they think of pelvic pain or to some extent, but I'd like to hear from from you sort of how and you know, you have a very uh interesting uh um I think patient population and a lot of the patients with hyper uh the hyper mobility and and and like you said and and and EDS and and all that and and so how do you approach these patients uh with pelvic pain and um that's really hard you know you're again I I see you as more of the quarterback and sort of you get them you get patients coming in you know as a you know first line and you you have to be the one to really you know work on diagnosis and really try to understand where this is coming from and you know multiffactorial and is this pain is this anxiety is, you know, sort of what's going on.

So, yeah, we we start broadly. Yeah. So, when I'm meeting a patient for the first time, yes, I want to hear the story. I need to understand what they're feeling, how this came to happen, how it's evolved over time. You know, there's lots of clues in that information, but really, we're looking top down. I'm I'm looking at whole body processes and big picture, is there evidence of neurologic sensitization? Meaning, is their nervous system throughout their body upregulated? Are they sensitized?

Um, you know, this can happen with small fiber neuropathy, chronic migraine, complex regional pain syndrome. There's a lot of ways the body can be neurologically sensitized. And if that's happening, of course, it affects pain everywhere and everything will be amplified. Uh, the second category I look for is any inflammatory uh process. So if they have an autoimmune inflammatory process, maybe postcoid, maybe mass cell activation syndrome, any any inflammatory dysregulation that can affect the whole body, it it's going to affect the presentation of pain in any one place.

And you know, if they're coming in specifically for pelvic pain and I don't understand that they also have inflammatory sacralitis, you know, I'm going to miss a lot. Uh so I really need to understand what's affecting them. And and you know the other piece to this is most people don't have pain in just one area. There's usually other places usually uh and it it's just really understanding everything that's going on with their body so that we can understand most deeply uh how they need to be treated and what we need to target.

And you mentioned anxiety. It it's really psychological sensitization. And the way I explain it to patients is you know pain takes its toll. Uh it often diverts your life course. You may not be able to work to the same capacity, engage with friends, family, social activities. Uh you may not be able to do the things that you had planned on doing. And in addition to that, you have all these doctor's offices, you have all these treatments. Uh you may have financial expense.

Uh these things add up and you will have feelings about them likely some anger, maybe some sadness, you know, resentment, maybe some guilt, who knows? Uh but there's a whole host of feelings that get tied to the pain and it happens subconsciously. So that every time you feel that pain again, you may be triggered. uh and if you are psychologically sensitized it's important that we identify that consciously uh because it's something that also requires separate treatment uh and if we ignore that part of the treatment I'm doing the patient a great disservice so uh we really look broadly are they neurologically sensitized inflammatory sensitization and psychological sensitization um from there we we try to get those things identified and treated first because then it's easier to look at focal anatomic structures and trust that what we're seeing on exam is what's actually happening.

It's not an amplification. It's not so much of a referral. And that's where we'll go in pinpoint areas. Okay, your shoulder hurts, your hip hurts, your low back hurts. And from there, try to understand is it a primary process? Is it a secondary process? And and of course, you know this, somebody with shoulder pain may actually have a cervical ridiculopathy in the neck, right? How many things cause pelvic pain, right? The list is not short. So, I really do a broad survey of the region to see, you know, is there something in the back?

Is there something with the pelvis? Is there hypermobility of the pelvic ring? Is there something with the hip? Something with the sacraliac joint? Is there chronic constipation? Is there another bowel issue? Is there a bladder issue? Right? Uh is there a primary myofascial issue? A lot of patients get diagnosed with pelvic floor dysfunction, but in my experience, that's rarely a primary diagnosis. Usually that's secondary to something else, right? uh and identifying what's causing pain and then looking backwards, you know, reverse engineering that to understand what's driving that is the core of my work.

Uh and that that's how I try to build the story of what's happening, understand how it came to happen and then identify an entry point for treatment that will have the the broadest effect with, you know, hopefully the least side effects. It's a tough job. I I enjoy it right now, but it sounds rewarding. Yeah. But it's, you know, and you brought up an interesting point actually. I was just and it kind of clicked in my mind about um this hypersensitization that patients have.

And you know, one of the things that, you know, one of the challenges that that we have specifically, you know, again, I keep talking about pelvic venus disease, but we'll see patients with findings on ultrasound or MRI and very large veins in the pelvis and they're asymptomatic. And then you'll have patients that really don't have, you know, not so convincing or, you know, they'll have mild more mild disease and very symptomatic. And and that's what that's what I think a lot of people have trouble with and they'll say, well, you know, this is not, you know, this is not really the cause of pain and and that's what a lot of people are trying to study and and get better data.

But I think it probably has to do with a lot that some patients do have this hyper sensitization um and they're just more sensitive to to these to these changes or to these stretching of the veins and some patients don't have it. And it's I, you know, I think it's pretty interesting. And you have a very precise diagnostic tool. With the venagram, you can go in and test those vessels and see if they are a source of pain. Yeah. Which is tremendously helpful.

That's not a tool that I have. Yeah. You know, when when I see a patient with pelvic venus disease on imaging, you know, the question is, is it causing pain or not? I have no good diagnostic injection for that. You know, lumbar sympathetic superagastric plexus blocks do not adequately cover the venus pain. So it's it's really challenging because I don't have good guidance for this. So it's good that you do. It's absolutely essential. So how do I guess in your in your workup where when do you start thinking of of Venus?

Um so generally you know we see it with hypermobility and as you say many people have it. Generally anyone with hypermobility has some degree of Venus congestion someplace in their body unless they're very young. Right. Um but even we've had 17 year olds need stances uh just because it can be quite present and you know in those patients my general process is to go after the lowhanging fruit first. Anything that we can identify and treat and take off the table as a pain generator I try to do that first.

And the things I can't treat, we save that for last. So things like tethered cord, right? It can be very difficult to diagnose. Some patients it's obvious and they have clear imaging and it clearly meets the symptoms. Great. Go see a surgeon, have that addressed, that's cleancut. But in many cases it may be an adult an occult tethered cord where it's not so clear on imaging and they have symptoms that are vague and maybe related but maybe not. So before sending them to a spine surgeon for a tethered cord decompression, let's consider, you know, is it the hip?

Is it the SI joint? Is it something else in the low back? And you know we see this with a number of difficult to diagnose conditions. So um tarov cysts are often blamed for pain but we know statistically they're rarely responsible for pain. So just sort of working through the things that we can treat diagnostically testing those seeing if they're involved and if they're not then we move on. And if the only thing that we're left with is Venus congestion or if this story so obviously fits Venus congestion, right?

I have a number of patients who have left leg greater than right leg swelling, right? Varicusils in the left leg more than the right. It's worse with sitting. A lot of very typical pelvic congestion may ther type symptoms and they have it on imaging, right? And if they also happen to have a clot, you know, even more, please go see about getting this treated. Right? Like sometimes these things declare themselves. And that's the other thing I'll explain to patients, right?

Like I I see you as a snapshot in time. And you mentioned this, right? Like I'm just seeing one snapshot. uh as we work together, as we go through the diagnostic process, we will get more snapshots and we'll start to see lines connect and then we can make sense of things and that will give us more data to make a decision with. Yeah, that's very uh really great. Yeah. In other words, I guess how and your patients typically are patients that you're following with them for for I guess a long period of time as well until we figure it out.

Yeah. Which sometimes it's quick, right? So sometimes it's quick and we get a nice clean answer and that's amazing and sometimes we think we know what's going on but you know we go down one path that we think is correct and it turns out that's not the correct path. And so I mean one one thing about the pain journey that I try to explain to patients up front is that it's an iterative process. Meaning it's very much a step by step.

And we may think we have a good idea as to what's going on. But we don't actually know until we have success with treatment. Right? Only then can we look back and say yes that was happening. I know that's happening because I did this to fix that and it worked. And even then there's the maintenance. Right? It may not last forever. There may be some recurrence. it may rear its head in another part of the body depending on what the process is.

Uh so it's it's it's very much important to have some diagnostic rigor to understand the why behind the pain and then we use that you know hypothesis we build it uh and then the patient can carry that forward for the rest of their life. So Dr. Gala thank you so much for joining us today. How can patients find you? Um, so they could patients could find me on drgalawa.com or on uh on Google. Look me up. I'm happy to um to help.

That's amazing. Thank you so much for joining us. Thank you for having me. It's been a pleasure. Pleasure is mine. Thank you. 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.