the 11th Meeting of Pelvic Floor Sexual Medicine Healthcare

Report
Redondo Beach, CA
May 20, 2013
Vickie
Jenni Gabelsberg DPT, MSc, MTC, WCS, BCIA-PMDB
Owner/Director Women’s Advantage, Inc.
Torrance, CA
Subjective Summary
 History
of hysterectomy and bladder sling
with mesh 4 years prior
 History
of mild urinary frequency and
nocturia 2x/night
4
months before eval, self treated a yeast
infection with Monistat
Subjective Summary
 At
eval: pt could not sit or walk prolonged,
wear tight clothing/jeans, or tolerate
intercourse
 Urethral
pressure with sitting
 Severe
pain at vestibule, worsened by touch,
and worst at night
 Pain
rated as 10/10 without neurontin and
3/10 with meds (300 mg TID)
Objective Findings
 Red
irritated vestibule at 4 and 8 o’clock
positions, mild tenderness with Q Tip test
 Thinning
 PFM
and pale labia
MMT 2/5 (poor) with a 2-3 second hold
Objective Findings
Hypertonus and pain found with palpation of:
 Bulbocavernosus, ischiocavernosus, STP
(severe)
 Urogenital
diaphragm ms (mild)
 Pubococcygeus,
OI (moderate)
iliococcygeus, coccygeus and
Objective Findings
 Tightness
found in bilateral hamstrings,
adductors, iliopsoas, piriformis and gluteal
muscles (with poor connective tissue
mobility)
 Weak
abdominal, lumbar and pelvic girdle
stabilizers
Beginning Physical Therapy Treatments:
 Intravaginal
 LE
Manual Therapy
and trunk stretching
 Biofeedback
evaluation – modified Glazers
protocol given for HEP
 Cold
laser
Beginning Physical Therapy Treatments:
 Connective
Tissue Mobilization:
Adductors
Anterior thigh and inguinal region
Labia
Abdomen
Posterior thigh
Gluteals
Piriformis
Obturator
Internus
Cold Laser Treatments:
Also known as low level light therapy, NON thermal
Effects:
 Increase ATP at cellular level

Stimulation of mitochondria, cellular enzymes,
macrophage activation, collagen synthesis, increase
in granulation tissue, increased serotonin and
endorphin with decreased c fiber (pain) activity.

Uses: inflammatory conditions, wound care and tissue
repair, pain control
Progress Assessment – Two Months:

30-40% improvement in vulvar pain

Able to sit 20-40 minutes depending on the surface

Still unable to wear tight clothing

Decreased external vestibular pain by 95%

Able to tolerate orgasm but pain/”tingling”
continued for 24 hours after

Zero penetration
Progress Assessment – Three Months:

Zero pain at vestibule with touch

Brief shooting pains at anterior vulva

Tingling nerve pain remains 80% of the time, worsens with
sitting

Can put on jeans and zip up, but has not tried sitting or
wearing out

Still wearing sweat pants all the time

30-40 min sitting tolerance – better on soft surfaces

Describes feelings of pelvic “congestion” and “heaviness”
Treatment additions:
 Began
neural glides of the pudendal nerve
 Added
sacrotuberous ligament release
It will cross under the
piriformis, leaves the
pelvis through greater
sciatic foramen, then
back through lesser
sciatic foramen, over
the sacrospinous
ligament, under the
sacrotuberous
ligament
Dorsal nerve of the
clitoris or penis
2. The perineal branch
 Urethral sphincter
 Perineal muscles
and sensation
3. The inferior rectal or
hemorrhoid nerve
 External anal
sphincter (EAS)
 Perianal sensation
1.
Obturator
Internus
Sacrotuberous
Ligament
Sacrospinous
Ligament
Progress Assessment – Six to Seven Months:
 75%
overall improvement, pain rated 4-5/10
 Now
able to wear jeans 5-6 hours, able to wear
underwear
 Able
to sit through dinner with her family
 Able
to sit on a hard surface 5-10 minutes, soft
surface for 2 hours
 Able
to have intercourse with no vulvar or
vaginal pain during
Progress Assessment – Ten to Eleven Months:
 80-85%
improvement, pain rated 2-3/10
 Sitting
is still her most pain provoking activity
 Now
able to walk up and down hills, stairs and
do pilates
 Able
 Meds
to sit 3 hours at hairdresser
– Estrace 3x/wk, Neurontin increased to
2400 mg/day
Treatment additions:
 Thoracic
and lumbar joint mobilizations
 Heat
and Interferential electrical stimulation to
thoracic spine
 Given
a TENS unit to do EMS at home
 Postural
education/core training
Progress Assessment – One Year:

90% improved

Sitting still limited by vulvar and buttock/posterior
thigh pain

Able to walk 7 miles at beach with zero exacerbation
in symptoms

External vulva healthy

Pain free standing tolerance

Able to wear jeans and underwear all day
Treatment additions:
 Increased
external manual therapy to levator ani
ms, adductor attachment onto pubic rami,
Obturator Internus ms, coccygeus
 Focused
and OI
internal MT to iliococcygeus, coccygeus
Recent Changes:
 April
11, 2013 had first caudal nerve block with
significant improvement in nerve pain, zero
radiating buttock pain, scheduled for weekly
injections
Pt treatments focus on:
 External MT to levator ani, adductors
 CTM to adductors
Recent Changes:
 Intravaginal
MT to urogenital diaphragm and
levator ani ms
 ART to proximal hamstrings
 Hip mobilizations with neuromuscular re-ed, glut
strengthening
 Heat with IFC/EMS to gluteals and lumbosacral
spine
 Neural Glides to Pudendal nerve
 Cold laser
Current Status
 90%
improved
 Pain
continues to “move around pelvis”
 Most
consistent pain is buttock pain with any
prolonged sitting
 Able
to participate in family activities, camping,
exercise

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