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Episode 25 Transcript

Post-Op Pelvic Floor Pain with Dr. Allyson Shirkhande

Introducing Dr. Allyson Shrikhande

Erin Everett: Hey, welcome back everybody to Exclusively Inclusive. I’m your host Erin Everett nurse practitioner. On today’s episode, we’ll be taking time to talk to Dr. Allyson Shrikhande. Dr. Allyson Shrikhande is a board certified physical medicine and rehabilitation specialist. She’s also the chief medical officer at Pelvic Rehabilitation Medicine. In addition to that, she’s the Chair of the Medical Education Committee for the International Pelvic Pain Society. The Public Rehabilitation Medicine is a clinic that offers services, including treatment for chronic prostatitis, endometriosis, interstitial cystitis, urinary incontinence, painful intercourse, and many other conditions. They have multiple locations and offer services in most major cities, including Atlanta.

Erin Everett: On today’s episode, we’ll be focusing on a special subject, post-op pain after gender affirming surgeries, but we’ll also be briefly touching on other causes for chronic pelvic floor dysfunction and pain. So without any further delay, I would love to welcome Dr. Allyson Shrikhande to the show.

Erin Everett: Welcome to the show. We really appreciate having you here. If you wouldn’t mind telling us a little bit about yourself, a fun fact, and then also what your pronouns are before we get started.

Allyson Shrikhande: Sure. Thank you, Erin. Thanks so much for having me.

Erin Everett: Of course.

Allyson Shrikhande: My name is Allyson Shrikhande. Fun fact, would be I have a ten-year-old daughter and we love to play Monopoly together, we are big fans of Monopoly. My pronouns are she and her.

Erin Everett: Excellent. So one of the things that we got connected with is not only your expertise in pelvic rehabilitation and medicine, but also in the fact that your clinics are offering services to people in the transgender community. Could you expand a little bit on that and how you all got into it and what kind of treatment options you have for those people?

Allyson Shrikhande: Sure, happy to. We saw our first transgender patient about seven months ago, and really we treat a lot of classically post-op abdominal, pelvic surgeries. So it is in our wheelhouse. We’re really treating any post-op nerve and muscle dysfunction and pelvic pain, as well as pain with intercourse that can happen. Urinary urgency sensation of UTI is common in any bowel, constipation, bowel movement, all those things can happen either before or after a surgery. So we’re treating that for rehabbing the pelvis, getting the muscles and nerves, everything firing and having everybody return to pain-free life with functioning in terms of the pelvis.

Erin Everett: Excellent. so just to expand a little bit on that, you mentioned post-operative pain. I wanted to just be a little bit more clear, are there services available to those who’ve received vaginoplasty and metoidioplasty or phalloplasty?

Allyson Shrikhande: Yes. So any gender affirmation surgery. We really have seen all of it and yes, it’s available to everybody and we’re honored and excited to try and help this patient population, the best we can, any residual issues after surgery in terms of pain, discomfort, or pelvic function, that is what we’re doing. Because you’re rehabbing the pelvis and that includes muscle and nerve dysfunction.

Erin Everett: Excellent. So with that too, a lot of people who have a vaginoplasty won’t actually have removal of the prostate, are those services too, when you’re talking about chronic pain, and inflammation, and pelvic pain, is that considered as maybe a source of that as well when you’re working up a patient?

Allyson Shrikhande: Possibly, yes. I mean yes, multiple patients we have seen, the prostate was not removed, correct. But potentially there might’ve been some mild pelvic floor, muscle dysfunction preoperatively, hard to say. That can get a little bit worse with surgery, right? Because of the trauma or an insult to the body. So if you’re teetering and had a little bit, it could have gotten a little bit worse. But yes, that would be the classic patients that we have treated thus far. The prostate was not removed during vaginoplasty.

Erin Everett: Right. So I guess that would vary a lot too for a case by case basis. But for a lot of people who go on to have vaginoplasty, if they’re a little bit older, say age greater than 50, have already had issues with their prostate, I imagine that would come more into play because their pelvic floor is already tightened, and as you’ve mentioned before, has these walls or blockades up. Is there anything that you could think of or would it be of any benefit do you think for those particular patients to come and see a provider at your clinic prior to having surgery?

Allyson Shrikhande: 100%. That would be ideal. We love that. We call it prehab. In our world of rehab, we do it before spine surgery, before hip, before knee surgery quite often actually, to get them in the best shape they can for surgery. But we haven’t really gotten, we’re trying to get people to do it before any abdominal pelvic surgery. I think they’d do much better honestly, if we can really get the muscles and nerves in the best shape they can be, wrap them up in a nice bow and present them for surgery, that would be ideal. Yes, I definitely think that would be best. But it’s hard, that’s life. So sometimes patients, like I said, are teetering and then surgery is really the thing that throws them over the edge, and then no problem we can help them after as well.

Erin Everett: Right. Right. Absolutely. I think that too is going to be important. Hopefully for people listening will take those steps too, but also to connect with more primary care providers because we’re often the coordinators of care. So now that I’m aware of your services and everything too, I’ll also be way more apt to be able to refer patients to get treatment prior to surgery. Because usually once they go through their surgical workup, they end up on a waiting list with a lot of affirming surgeons. So there’s plenty of time to work on those things in preparation for surgery.

Allyson Shrikhande: I think that would be great, working with our physiatrists and pelvic floor physical therapy, I really think would help their post-op recovery go more smoothly.

Erin Everett: Yeah, absolutely. When you’re talking about offering trans services and the post-operative complications and pain, one of the conditions that you mentioned on your website that may increase pain was interstitial cystitis. I don’t see a ton of it, but I see enough of it to where this definitely caught my attention and wanted to ask you a little bit more about that. Because a lot of patients are concerned that having interstitial cystitis would ruin their chances of having gender affirming surgery. Could you speak a little bit more about interstitial cystitis and how maybe successful your treatments are? Just to give those patients a little bit more hope that they would have a better opportunity with surgery.

Allyson Shrikhande: 100%. Yeah. So with interstitial cystitis, essentially they’re Hunner’s lesions or these lesions in the bladder that really cause a lot of bladder symptoms, a lot of urgency, frequency, sometimes burning with urination. In addition to that, they cause their pelvic floor muscles to go into spasm. Again, it’s another condition that causes that pelvic floor hypertonia, which then irritates the nerves. It’s a vicious cycle where everything’s up regulated and that’s really what happens. So what we’re treating is we’re calming down the muscle nerve dysfunction that almost always happens with IC. That really helps patients for two reasons, the nerves aren’t so sensitized and hyper, so they’re not irritating the bladder as much. In addition, the bladder is now sitting on a pelvic floor that’s not so spastic. So when the bladder sits in the pelvic floor that’s more calm and relaxed, you don’t have to pee as much, essentially. You don’t have to go to the bathroom as often.

Allyson Shrikhande: That’s what we’re doing with our IC patients, which works nicely. One caveat is actually a lot of, you definitely want to make sure you get a diagnosis of IC with a urologist, taking a camera and looking inside the bladder. Because often it’s the camera, when they take a look it’s normal, we call it then it’s bladder pain syndrome. A lot of bladder pain syndrome is just pelvic floor muscle dysfunction, muscle nerve dysfunction, which is definitely can be treated very well with pelvic floor physical therapy and PRM. Because we can treat that muscle nerve dysfunction, particularly if they don’t have the lesions inside the bladder when the camera goes in there. A lot of patients don’t really know, but it is important to get the IC versus bladder pain syndrome really nailed down.

Allyson Shrikhande:
Then yeah, either way we can really treat that muscle nerve dysfunction and then pre or post-operatively that can contribute. But I would say it would be very sad to think that it would inhibit patients from getting the gender affirmation surgery with IC. I mean, I would definitely see us in our PRM and a pelvic floor, physical therapist and see what we can do 100% to get your symptoms under control.

Erin Everett: YES, Absolutely. I mean it is. I mean, I think most of the time it’s not necessarily the surgeons limiting it. I think it’s the fear of increased pain. They already have such a terrible relationship with their pelvic floor area and then there’s the dysphoria and there’s chronic pain. So I think it’s mostly fear that’s blocking them from proceeding with that. Of course, that’s a sweeping statement, not everybody’s going to feel that way, but I think a lot of people do. So that’s really a great resource to have, to be able to send prior to surgery to decrease any of that pain and those fears.

Allyson Shrikhande: 100%. Yes. I mean, again, I submitted our peak of almost 200 patients with IC and bladder pain syndrome undergoing our treatment protocol.

Erin Everett: That awesome.

Allyson Shrikhande: Because we do see once the muscles and nerves dysfunction goes away, a lot of the symptoms get better.

Erin Everett: Yeah. Yeah. That’s awesome. Some of the other questions too, I had about your transgender services is, and it’s not specifically listed on here, but others conditions like it are, so I’m sure that you guys are open to it. Is I have a lot of trans males or trans masculine patients, so they were assigned female at birth, they identify as male, and they may or may not be on hormones. But once they are on testosterone, it creates a condition very similar to post-menopause, and so they often have similar issues. But some of them will even prior to hormones have terrible vaginismus and pain. Often it’s really hard for them to find a safe space to get treatment for that. Have you all dealt with anything in that arena at all, or anyone in the treated anybody in the gender community for something like that?

Allyson Shrikhande: Yes, one of our patients who’s trans male, vaginismus was presenting complaint. So yeah, we do address it in terms of, again, working with us and pelvic floor physical therapy, really to treat the underlying nerve muscle dysfunction, and then a lot of it’s also some muscle relaxation techniques. There is a strong connection between certain areas of the brain and the pelvic floor to just teach patients how to drop their pelvic floor and relax their pelvic floor. Also, the topical hormones can help, particularly if they have entrance issues to topical hormones, really sometimes combining estrogen and testosterone can help with with vaginismus symptoms, as well as sometimes adding either a topical nerve or muscle relaxer as well can help.

Erin Everett:
That’s interesting, I didn’t think about that.

Allyson Shrikhande:
Sometimes topical ketamine. We’ll do 10% ketamine around really does help while we treat the muscle nerve dysfunction. So yes. No, we have seen that. A lot of it is, I think it’s important the entire sling needs work, not the anterior compartment. Patients do much better when the entire sling is released.

Erin Everett: Yeah. That’s really fascinating because I mean, often I’m left to treat this stuff by myself. Because again, it’s really hard to find inclusive providers who are going to offer safe care. So again, I really appreciate you guys. But I often lean on the topical estrogen gels because obviously those tissues are super estrogen dependent and do better with the estrogen dominant environment, but you don’t want to give them something that’s going to create higher level systemically because it would go against their goals for transition. But I never had considered, and not that I would necessarily write for this, the benefits of a topical muscle relaxer or the ketamine. That’s fascinating.

Allyson Shrikhande: Yeah, yeah, it does, it helps and the topical nature of it too, it’s safer and less absorption, but yes, we do use it. We’ll combine it with the muscle relaxer as well.

Erin Everett: Yeah. So does you find insurance typically pays for this type of treatment?

Allyson Shrikhande: For our treatment? We are out of network, so most of our patients, it is insurance, not the cash pay. It is insurance, but we are out of network.

Erin Everett: Okay. So for someone say in the Atlanta area where the majority of my listeners are, but there are a lot in Florida too, in the Northeast area, what kind of costs could be associated with it or is it just up to the compounding pharmacy that makes the medication?

Allyson Shrikhande: Oh, for the topical cream?

Erin Everett: Yeah.

Allyson Shrikhande: The cost of the topicals? That would really depend on the patient’s plan because if the plan covers compounding pharmacy, so it really just depends on the individual plan.

Erin Everett: Okay. Excellent.

Allyson Shrikhande: Yeah.

Erin Everett: Yeah. Well, thank you for that information. It’s something that your office actually compounds or did they do get sent out to a pharmacy?

Allyson Shrikhande: No, we use our own pharmacy. Certain cities use a local pharmacy. There’s a pharmacy in the New York area that we’ve been working with for many years now. Who essentially, when you’re doing topicals in that area, you can’t have any propylene glycol because that will irritate. So you have to make sure they know what they’re doing, so no propylene glycol. Classically we’ll sometimes have them try different bases, send the patient a couple bases and see, but classically olive oil is good or coconut oil. They can do it in those bases are great for that area as well. But yeah, we do work with pharmacies that are familiar with vaginismus, vulvodynia, and also we’re trying to also find the best price for our patients. So that’s the balance we’re trying to find, honestly. We’ve been lucky, we found several throughout the US who’ve really worked with us to create the best products for our patients. It’s been great.

Erin Everett: That’s awesome. I know we’ve talked about this briefly before, but a lot of people complain about pain with intercourse, what is your clinic’s approach to assessing that and helping people deal with that?

Allyson Shrikhande: Yeah, Erin, I’d say that’s our most common chief complaint, so we do see that all day every day. Yeah, I mean our approach is, first of all, we help diagnose any underlying issues that may coincide as to why they have pain with intercourse. Number two, we devise a treatment plan to work with pelvic floor physical therapy, where we have patients that go to pelvic floor physical therapy once a week, and they see us at PRM once a week. We do external ultrasound guided selective peripheral nerve blocks as well as trigger point injections to the levator ani sling, so the pelvic floor sling. There’s no downtime, patients see us in the morning at 8:30 and there’ll be at their 10:00 AM meeting. So they go straight to work, you go on with your day. But it’s three times on each side.

Allyson Shrikhande: So it’s once a week for six weeks with PRM and pelvic floor PT. What we’re treating is that muscle nerve dysfunction, because the pain with intercourse, those are the two culprits that are causing it, right? So the nerve dysfunction and the muscle spasm. That’s why patients are having this pain. So we just treat them both, we believe concomitantly. You can’t just treat the muscles or just the nerves, we use to treat them both concomitantly, and then with pelvic floor physical therapy. Quite often, we’ll also prescribe about six to eight weeks of a suppository to take at night that will help also relax the muscles. So all that really it’s that multimodal multidisciplinary team approach that really helps patients get better. There’s nothing better than when a patient, we feel honored that they trust us and are able to open up and it’s such a private area, right?

Erin Everett: Right.

Allyson Shrikhande: Then they undergo our protocol working with an amazing pelvic floor, physical therapist. Then when they come back after, six weeks post and they’re walking in saying, “Dr. Shrikhande, I had intercourse. I had sex last night, it was the best thing ever.”

Erin Everett: That is amazing.

Allyson Shrikhande: That’s why we show up for work every day. I mean, that’s really what we do. It makes us feel so good and honored really that they trusted us. When they feel better, it’s the best thing in the world.

Erin Everett: That’s all part of that patient centered approach that you guys have, and I really just value that so much. It makes me more comfortable to referring to your clinic because I know that when my patients go there, they’re going to get individualized treatment plans. While some of the treatment options may be the same for everybody, it sounds like you’re going to be evaluating them on a case by case basis, and I really enjoy that.

Allyson Shrikhande: 100%. Because everybody’s reasons for getting there are different. That is the key, we can’t just blindly treat. Of course, we treat the muscle nerve dysfunction 100%, very important, but we really need to understand why in order to prevent any flaring or reccurrence. In addition to the muscle nerve dysfunction, we need to understand what team we need to build. Is it gynecology? Is it GI? Or is there something else? But if we don’t understand deeply the origins and do a root cause analysis, then we’re not doing our patients, the service that they need.

Erin Everett: Right. Right. Absolutely. I know we touched on endometriosis before and how your team is really going to help identify those symptoms and then refer out for an actual diagnosis. But you mentioned how it can impact the colorectal area. I meant to ask you for more details on that, because I don’t think a lot of people really understand that.

Allyson Shrikhande: Yeah, sure. Yeah. Actually that is one of the most common chief complaints for endometriosis is constipation, pain with bowel movements, bloating, straining on the toilet. Because you can have an endometriosis really in the sac right near the rectum. That really can cause a lot of, we call it bowel dysfunction. One classic thing to look for is if there’s any blood in your stool during your period, I always ask patients that. Then it’s only during your period, right? While you’re bleeding, there’s blood in your stool, that’s something to think of endometriosis. So yeah, I mean, definitely, most of my patients who have endo started off with the GI workup, right? Because they’re like, “I don’t know my pain with bowel movement, I’m bloated all the time.” So they get upper and lower scope. They get scoped from above and below and it’s classically normal. The scope won’t show it, so then they see the next doctor. But yeah, very common bowel complaints because all the endometriosis plaques, there can be scar tissue around the rectum, they can really just deposit right in that sac and irritate the bowel.

Erin Everett: Okay. So a lot of the patients too, with the endometriosis, they’re also going to be some of the patients that you see too, for pain with intercourse?

Allyson Shrikhande: 100%. Yeah. So we always show pictures when you come in, we have a lot of pictures and anatomy. But it’s a sling, right? So it’s bowel, bladder, intercourse is what we see and treat at Pelvic Rehabilitation Medicine. That’s what endo would also present with bowel, bladder, intercourse. Those are really your classic. We saw a lot of abdominal bloating as well.

Erin Everett: Okay. Like we touched on before, and that’s going to be similar too, for the patients with polycystic ovarian syndrome or PCOS.

Allyson Shrikhande: Yes. It is similar. Well, number one PCOS we do can come with endo and PCOS and come together. But so PCOS is more of a secondary pelvic floor guarding that causes this bowel, bladder, intercourse, dysfunction in PCOS, right? For endometriosis, it’s both, that’s why the secondary guarding, but also endo itself, the endometriosis plaques can be around the bladder. They can be on the bladder. They can be right around the rectum. So it’s more of a direct cause with endometriosis. PCOS, it’s indirect, it’s your pelvic floor. It’s really your pelvic floor muscles. Which is why PCOS patients respond very well to our protocol because we’re not fighting those endometriosis plaques if they don’t have it. So we can just reset their muscles and nerves and they can go on their way. So they do respond very well because this is secondary, right? It’s the muscles are guarding because of the PCOS.

Erin Everett: I know, I’m sorry, I’m asking you a lot of questions about this, but I just want to make sure that my listeners understand, because sometimes these medical conditions can be complex and hard to decipher. So of course, when people are listening to this, they should always consult their primary care providers for more information about it. But for them listening, the main differences, then what you’re saying is endometriosis, there’s pieces of tissues that can be causing the pain, you’re referring to those as plaques. Whereas with PCOS, it is more just hormones and actual pelvic guarding, but there are no scar tissue or plaques being adhered to other areas of the system, right?

Allyson Shrikhande: That’s exactly right Erin.

Erin Everett: Excellent. While the two may go hand in hand, you often see those separately. But they’re treated somewhat similarly, it sounds like.

Allyson Shrikhande: From the muscle nerve standpoint, 100%. Yes. We treat them similar.

Erin Everett: Excellent. Awesome. Hey everyone, I have a quick favor to ask. If you wouldn’t mind taking a moment and just clicking the subscribe button on whichever platform you use to listen to my show, that would be wonderful. Not only does it allow you to get notified every time I publish an episode, but it also helps with my ratings and reviews. What that means in podcast world is that I’m able to climb up in the rating scale and reach other listeners. The whole reason why I started the show is to access people who needed the information. So please just go ahead and click subscribe. Then we can all be happy and continue to listen to this good quality free information. Thank you so much.

Erin Everett: When I was looking earlier before we started chatting, one of the things that I was surprised to find, and I don’t really know why I was surprised to find this because it makes perfect sense was your emphasis on treating cis-gendered men for chronic prostatitis symptoms. That is something that we treated our clinics so often. I liked that you mentioned that it’s not always attributed to bacterial infections. Would you mind explaining a little bit about that?

Allyson Shrikhande: Sure. Yes. For chronic prostatitis, exactly, so patients who essentially, their pathophysiology is there’s nerve muscle dysfunction that’s actually causing the symptoms of chronic prostatitis. When the pelvic floor is guarding state, it really is squeezing those nerves and causing the nerves to have less blood flow. When that happens, they get inflamed essentially. You get the release of what we call pro-inflammatory cytokines and neurogenic inflammation, so inflammation around the nerves. That inflammation then can cause the symptoms of chronic prostatitis. So that is really the connection that could cause pain with erection, pain with sitting, pain in the paraniem, urinary urgency, burning, all nerve dysfunction correlated to the spasm in the pelvic floor. So we are really reversing that process with chronic prostatitis in terms of decreasing all that inflammation around the nerves and then releasing the spasm in the pelvic floor. Once that goes away, the nerves can reset, and heal, and return to normal and stop causing these symptoms where they shouldn’t. They’re firing when they shouldn’t fire, essentially. So that’s really what we’re doing, is treating that.

Erin Everett: That’s awesome. It’s great to know too, for me as a provider. Because sometimes it just feels like we’re just throwing antibiotics and medications at patients and they don’t always improve. So it’s nice to know that there’s another option for that.

Allyson Shrikhande: 100%. Yes. I mean, classically the patients tried multiple courses of antibiotics and multiple courses of inseds, both of which you don’t want to take too much of, right? Antibiotics and inseds honestly, both of them, so yeah. So that is what we know where we are treating chronic prostatitis, we use something called the chronic prostatitis symptom index pre treatment. When we first meet you, we get it, and then post our protocol showing that basically chronic prostatitis, it does improve with our treatment protocol. So that is the data we’re collecting.

Erin Everett: Wow that’s awesome. I’m wondering if a low sugar, a low inflammatory diet is helpful for endometriosis and PCOS, have you noticed that any dietary changes for those experiencing chronic prostatitis is helpful?

Allyson Shrikhande: That’s a great question, there’s not as much data out there for the men. From the muscle nerve standpoint and male and female, it’s very similar overall, so we still stick with the anti-inflammatory approach. We were using any data for nutrition, honestly, in chronic pain. That’s what we’re doing. So sometimes fish oils and anything…also we’ll use the interstitial cystitis diet where anything that we find can be irritating to the bladder may also irritate the entire urological system. So we’ll say is coffee irritating you, alcohol, classically acidic foods, chocolate, but it’s not everyone. Again, it’s you try it, if you stop coffee for a week, do you feel better? So a lot of it’s trial and error because some people are fine with coffee, but not great with acidic food. So it is individualized as well. But those are the two approaches we take, is really anything that can irritate the bladder, we think, may irritate the entire urological system. Then also the anti-inflammatory approach because anti-inflammatory approach has been studied with just chronic pain in general.

Erin Everett: Excellent. Well, thank you so much for your time today. I feel like I have thoroughly picked your brain. I’m sure there’s 1,000,001 of the questions I could ask you and your expertise, but I have found it so fascinating to chat with you today, and I really appreciate you taking the time.

Allyson Shrikhande: Thank you, Erin. Thank you for having me and thank you for all the amazing work you’re doing. I mean, this is really important work.

Erin Everett: It really is.

Allyson Shrikhande: So congratulations and keep going.

Erin Everett: Yeah, congratulations to you and your clinic for being so open and inclusive. I mean, I am so excited to connect you too with other experts. You mentioned you’re in the South Florida area, right?

Allyson Shrikhande: Yes. We’re currently in the Miami area and we’re opening up soon in Palm Beach gardens.

Erin Everett: Awesome. Yeah. I actually have some other specialists in that area that I should connect you with, who would probably just love being able to refer to you as well. So we can chat later about that too. But before we wrap up, is there anything that you want to make sure my listeners know about you, or your clinic, or any other tidbits you want to add?

Allyson Shrikhande: No, we feel honestly honored that our patients trust us and are really brave enough to speak up about their pelvic issues. So please speak up, tell your friends to speak up and to come see us.

Erin Everett: Excellent. Thank you so much. Remember everybody, stay fierce and live your truth.