Constipated? Can’t Poo? GI Issues? Yes, There Are Special Tests to Investigate This.

There are many causes of constipation or difficulty evacuating stool  even when it is “locked and loaded” in the rectum. Sometimes, the solution is as easy as changing diet and other lifestyle habits. Other times, there are medical causes involving colonic transit, tight pelvic floor muscles, rectal wall prolapse or a combination of all of these. It can be complicated and frustrating to figure out how to poo regularly!

There are a variety of medical tests used to assess this (and other GI issues) further. Patients are often nervous and not sure what to expect. Here’s some general information about the tests. In the future, we’ll cover some of these tests in depth with pros and cons.

From Cake Hour Cackle

From Cake Hour Cackle



(per NDDIC) Flexible sigmoidoscopy is a procedure used to see inside the sigmoid colon and rectum. Flexible sigmoidoscopy can detect inflamed tissue, abnormal growths, and ulcers. The procedure is used to look for early signs of cancer and can help doctors diagnose unexplained changes in bowel habits, abdominal pain, bleeding from the anus, and weight loss


More extensive than above. Examines the entire colon with a flexible four foot long, flexible tube about the thickness of a finger with a camera and a source of light at its tip. The tip of the colonoscope is inserted into the anus and then is advanced slowly, under visual control, into the rectum and through the colon usually as far as the cecum.

“Colonoscopy may be done for a variety of reasons. Most often it is done to investigate the cause of blood in the stoolabdominal paindiarrhea, a change in bowel habit, or an abnormality found on colonic X-rays or a computerized axial tomography (CT) scan. Individuals with a previous history of polyps or colon cancer and certain individuals with a family history of some types of non-colonic cancers or colonic problems that may be associated with colon cancer (such as ulcerative colitisand colonic polyps) may be advised to have periodic colonoscopies because their risks are greater for polyps or colon cancer” (MedicineNet.com)

Sitzmark Studies (Colon Transit Study):

In this procedure, a capsule is swallowed containing markers that show up on X-rays taken over several days. Looking for signs of intestinal muscle dysfunction and how well food moves through your colon.

There are modifications to the original testing, but here are sample directions given to patients:

The colon transit study will take 6 days to complete. You will begin the test after you have a bowel movement. You will take 1 Sitzmark capsule every day for 5 days. On the sixth day you will come to National Jewish Health for an x-ray of your abdomen”

SitzMark Test Results  via ucl.ac.uk link

SitzMark Test Results via ucl.ac.uk link


Colon Transit Test: Pelvic Floor Dysfunction All radio-opaque markers were sitting in the rectum 6 days after ingestion.

Colon Transit Test: Pelvic Floor Dysfunction
All radio-opaque markers were sitting in the rectum 6 days after ingestion.

Anorectal Manometry and Balloon Expulsion Test:

Manometry is a test used to measure and assess pressure, reflexes and sensation in the rectum. The test also evaluates the efficiency of the anal sphincter.  Balloon Expulsion can be done during the same testing period: a measurement of the time it takes to expel a balloon from the rectum.

Patient information: “While lying on your left side, a thin flexible catheter with a small uninflated balloon at the tip is passed through the anus and into the rectum. The catheter is slowly withdrawn while numerous pressure measurements are recorded. You will also be asked to push and squeeze your anal muscles at certain times. You will also be asked to indicate when you experience a feeling of fullness or distension in the rectum, upon inflation of a small balloon at the end of the catheter.”

CME (March 2007) Monthly Self-Study Series Management of Constipation Dr. Wong Sau Wai, Grace

CME (March 2007)
Monthly Self-Study Series
Management of Constipation
Dr. Wong Sau Wai, Grace


Anal Sphincter Electromyography:

Anal sphincter EMG is recorded with a small sponge electrode in the anal canal. The person relaxes, squeezes and pushes. A computer records sphincter muscle electrical activity.

Anal sphincter electromyography confirms the proper muscle contractions during squeeze and muscle relaxation during push. In people with non-relaxing puborectalis, the tracing of electrical activity gets bigger, instead of smaller, during a push.

** The exact testing procedure for EMG can be different in a physician vs. pelvic floor physical therapist office.


Defecograms (also known as fluoroscopic or xray proctograms, evacuation proctograms and defecating proctograms) can differentiate between anterior and posterior rectocele. Also, in external rectal prolapse that was not directly visualized during examination, this radiographic projection will demonstrate its presence. The position is relatively functional, with the patient sitting on a toilet.

“The technique itself involves insertion of a caulk gun device into the rectum with subsequent manual infusion of barium paste…. The patient is then transferred to a portable plastic commode which is situated next to a fluoroscope which records the defecation. Positioning of the x-ray camera is of paramount importance as visualization of the buttocks, rectal vault, and lower pelvis is critical.”

** Full article about myths of defecography coming up soon!

rectocoele trapping WM

Dynamic MRI Defecography (Dynamic Pelvic MRI)

For optimal MRI evaluation in the sagittal plane, the patient is placed in the supine position. Static images are frst obtained, with subsequent series of images performed during resting and straining in the midsagittal plane. Selected midline sagittal T2W images at rest and on the Valsalva maneuver and/or sagittal 2D GRE images in real-time at rest and on Valsalva are used to assess the degree of pelvic floor descent and pelvic organ prolapse. Some authors advocate the use of intraluminal contrast”


1. “the development of fast MRI sequences has allowed for the quick evaluation of pelvic organ prolapse and pelvic floor relaxation with increased patient comfort, decreased complexity, and decreased invasiveness and radiation exposure. The intrinsic soft tissue contrast capability of MRI allows for detailed visualization of the pelvic floor, and the faster techniques now allow for dynamic evaluation of pelvic support structures. Studies have shown that dynamic MRI has greater sensitivity than physical examination and has led to changes in the initial surgical plan in 41% of patients. It has become clear that MRI has an important role in the preoperative planning in patients with pelvic floor dysfunction” (Imaging the Female Pelvis: When Should MRI be Considered?)

2. The test also reveals anterior prolapses (not just rectocele, enterocele, rectal prolpase) such as cysteceles (bladder), uterine prolapse, vaginal vault.

Disadvantage: Expensive test and not functional (lying down), but still valuable.

My favorite dynamic pelvic MRI showing a rectocele:


Additonal website Citations: 

The Evaluation of Constipation - PubMed Central

Diseases and Conditions – Constipation: Tests and Diagnoses – Mayo Clinic

Tracy Sher, MPT, CSCS  Private Practice Owner in Orlando, FL; International Speaker/Faculty. Passionate about treating pelvic pain and all pelvic floor disorders – bowel, bladder, sexual function. Secretly hoping to be a circus clown or rock, paper, scissors champion some day. Connect with Tracy on LinkedinCheck out Pelvic Guru on Facebook or Twitter @pelvicguru1


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Kegels and Comedy? Meet Gusset Grippers.

Meet Gusset Grippers.

Stand-up comedy about ‘wee’, ‘pish’, and ‘banging on’.

The 1st Pelvic Professional Spotlight


Who is Elaine Miller,

A.K.A Gussie Grips, Gusset Grippers?

Usually, discussing matters of urinary incontinence and pelvic organ prolapse is NO laughing matter. However, there’s a fabulous, hilarious physiotherapist in the UK (Edinburgh, Scotland) who’s found a unique way to bring these topics to the comedy stage with grace. Her timing and comedic knack are special qualities; and so is her ability to educate about very important pelvic health topics at the same time. She is one of a kind. Who is this crusading comedienne in Scotland? Her name is Elaine Miller, also known as Gusset Grippers or Gussie Grips.

Watch this! Comedic Genius.

“I brought you a pelvic floor to look at. Truth be told I brought two, but you are only seeing one”

“I don’t mind a bit of premature ejaculation because I’ve got 3 children and a laundry basket”

“Imagine you are on a date and you can feel a fart brewing…”

Now, THIS is a way to decrease embarrassment about these important topics.

How Was Gusset Grippers Discovered?

Twitter: @GussieGrips

“I tweet you twitch your twinkle” – Twitter motto to educate about the pelvic floor.

Many of us discovered “Gussie” on Twitter.  She is a regular contributor to the #pelvicmafia tweets on Twitter (great way to find other pelvic PTs and pelvic health professionals). She has a way of bringing humor to any and all pelvic health topics. Here’s a peak:

Other Tweets:




Gussie Grips incontinence image / Twitter pic
Click to follow Gussie Grips on Twitter! Gussie Grips incontinence image

tweet 3

Did you know Gusset Grippers also organizes parties: Coffees, Cake, and Clench?!

Clever, right?

“Kegel” Tupperware party, anyone? On her website she informs: “The chat lasts an hour, £10 a head which includes coffee, cake and the chat/advice/laugh.  Supply your own clench.”

My Interview with Elaine:

Stand-up comedy with Elaine

Stand-up comedy with Elaine

1. Tell me about you – professionally and personally.

So, my background’s in sports, but, I’m training to become a pelvic physio.   My interest in continence  started because I was left more than a little leaky after having my kids.  It really amazed me that three wee exercises could change my life.  Wish I’d done them earlier…
I do see patients, I’m self employed.  But, it’s very small – my three kids don’t seem to be self managing yet.
The parties were designed really to trial the comedy.  I was sure that an irreverent approach would work, and they gave me the confidence to try the Fringe show.  They are good fun, women are initially very quiet and then, once they realise I’m not going to pick on them or ask them any questions, they relax and get really quite ribald!
The comedy only works because the joke is always on me. I turn myself into a characature of a woman living with incontinence, pain and prolapse.  It’s ludicrous to think that I could possibly have experience of ALL the conditions, but, I’ve used anecdotes from patients as tools to illustrate the problems and solutions.  There’s humour in everything.
The men like it, I was surprised by that.  There’s not a man on the face of the planet who’s not interested in being “stronger for longer” and they are, generally speaking, even less aware of pelvic floors than women are.  I like men, I get on with blokes, and, that seems to come through on stage – female comedians have a (slightly unfair) reputation of being unkind to men, but, I seem to be able to get them to warm to me.  Probably talking about their willies helps that.
I live in deepest darkest suburbia in Edinburgh, you can see the castle from the end of my road.
I’m married to Stevie and we have three kids (10, 8, 6) and an ever increasing menagerie.  Stevie’s very supportive of my comedy, but, wearies of me “going on about vaginas” to anyone and everyone.  Seems I’m a little disinhibited. Och well.
2. How did you get involved in the comedy tour and what comedy shows have you done?
I got into comedy by accident.  There was a bunch of us at the school gate, all turning 40, and we set “bucket list” goals.  One was going to run a marathon, one was going to finish her degree, one was going to get divorced (!) and I didn’t fancy any of those options at all.  But, when I was in my 20s I was telling a story at a party about a really dreadful date I’d been on the night before, it was so bad it was funny.  Someone there ran the Comedy Store in London, and he offered me 5 mins on stage.  Naturally, I refused.  And, so I’ve spent 20 years watching comedy thinking “I could do that”.  So, I did.  I entered a “newcomers competition”, naively not realising that you are supposed to be Quite Good in order to enter a competition.  And, I got through a couple of rounds, and, really loved it.
I’ve performed at most of the comedy clubs in Scotland.  Last year I did a run at the Edinburgh Festival Fringe with “Gusset Grippers” which was stand up about pelvic floors and continence.  It was awarded “Weirdest show of the Fringe” which is, apparently, a compliment.  Reviewers liked it, comedians liked it, professional peers liked it, but, most importantly, the audience liked it.  Bit of a relief, really.
flyer for Elaine final
I like the straight stand up, my stuff’s mostly about living with young kids and the exasperations that come with being married to someone that you love dearly, but, who bemuses you most days.
3. What’s your ultimate goal? 
To break down the taboo that surrounds incontinence.  It really bothers me that women are too embarrassed to seek help.  Living with less bladder control than your toddler has won’t kill you, but, it does interfere with every single thing that you want to do.  Women are disempowered by this condition and I don’t understand why we put up with it, especially when most cases of simple stress incontinence are completely curable with exercise and basic lifestyle changes.
So, I’m writing a book, imaginatively entitled “Gusset Grippers”.  It’s like the show, evidence based practice disguised as scatological humour.
“I truly believe that comedy is the way to evangelise about pelvic floor exercises.  If you can make them laugh, they’ll talk, if they talk they can get educated.”
Menstruation was embarrassing 30 years ago.  We now have adverts on the telly and girls are no longer taught to be ashamed by their normal bodily functions in sex ed classes.  I’d like to do the same for incontinence.  It’s so common, every woman understands or has had personal experience, so, there’s no need to be trapped by shame and miserable.
I’d REALLY like to get our government to listen to me.  They waste so much money by not managing incontinence.  I’d like to get them to force continence pad manufacturers to put health promotion information on the packaging, they are making huge profits out of people’s misery and I think they should be obliged to print basic information on every pack of pads.  Anything that prompts people to seek help is a good thing, and, if you saw #doyerblardyexercises printed on every incontinence pad, well, it’d improve compliance.
I’d like to see articles about incontinence in the media.  Not just in preganancy magazines, but, in running forums, fashion articles and the Sunday Supplements.  It’s not a thing to be ashamed of, and it’s not a thing to put up with <gavel>
AND, I’d like to get medics understanding that most of these people can be self managing or cured with simple education.  There’s really no need for gynaecologists to be snowed under with so many prolapses, or for the endless number of TVT surgeries.
Women want a “quick fix”.  That’s our fault.  If the evidence says that 1:3 women are incontinent and 70-80% of that is curable, then we need physios helping these women!
Why isn’t incontinence discussed on orthopaedic wards?  Why is it acceptable that elderly people in residential care are padded up rather than toileted regularly?  Why is most of the focus on continence around maternity services and not in schools – if we teach 16 year old kids wht the exercises are, and that they improve  your sex life and that you should do them when you brush your teeth, well, the randy wee rascals will do them!  And, who knows what effect that could have on their pelvic floors once they get into their 50s and beyond.
Sorry, I know I’m preaching to the converted.  I’ll just hop off my soap box.

 Who wants to see Gussie Grips on tour? Let’s bring her comedy all over the world!! 

If you loved what you saw, please write a comment (and share this link with others) in support of Elaine (Gusset Grippers)!

Twitter again: @GussieGrips. Gusset Grippers also has a Facebook page and website.


Do you want to nominate anyone for the next Pelvic Professional Spotlight?

If yes, who and why? (This can be a physician, physical therapist, fitness professional, midwife, sex therapist and more!)


Tracy Sher, MPT, CSCS  Private Practice Owner in Orlando, FL; International Speaker/Faculty. Passionate about treating pelvic pain and all pelvic floor disorders – bowel, bladder, sexual function. Secretly hoping to be a circus clown or rock, paper, scissors champion some day. Connect with Tracy on LinkedinCheck out Pelvic Guru on Facebook or Twitter @pelvicguru1


The Ultimate Pelvic Anatomy Resource: Articles, Links, and Videos, Oh My!

Pelvic Guru:

The Ultimate Pelvic Anatomy Resource post has been updated again! I’m excited to share the additional resources. I hope you find this helpful. If there are other links, videos, or research articles you’d like to see on here, place that information in the comments section.

Originally posted on Pelvic Guru ™:

Ever wanted a resource with articles, pictures and videos of pelvic anatomy all in the same place? Here it is!  I’ve been putting this together for a while and am very excited to share this with you! This resource will  evolve and update as new, exciting links are found. The content ranges from basic articles to in-depth anatomical reviews. Please leave a comment if you think other links or articles should be included in this resource. As always, thanks for all of the support. If you are a self-proclaimed Pelvic Nerd or just want to learn more about pelvic anatomy, I hope you enjoy! ~ Tracy Sher, MPT, CSCS

pelvic floor

Female Pelvic Anatomy:

Basic Information -

 Diane Lee PDF: Understanding Back and Pelvic Girdle Pain – with basic anatomy

Interactive Anatomy: The 3D Vulva

***New Addition (2/17/13) 360 Degree View of the Pelvis – Muscles, Nerves, Arteries and more!

A funny…

View original 452 more words


What IS Pelvic Physical Therapy and Why Doesn’t EVERYONE Know About It?

True story -

During graduate school (Northwestern shout out) for physical therapy over 15 years ago, I distinctly remember turning to a friend in class and stating emphatically,

“Mark my words, I will NEVER EVER do what the therapist is doing in that video. NEVER. Why are we even seeing this in class?”.

You may wonder what happened in that video that lead to my bold statement. Why was I so shocked at the time? Well, that was essentially my first exposure to learning about pelvic physical therapy. [The video demonstrated an internal rectal coccyx (tailbone) technique]. I had no idea there were highly skilled specialists who performed internal vaginal and rectal musculoskeletal evaluations and treatments for women and men.  I didn’t know at that time that the scope was even larger than that. And I certainly didn’t know I would end up spending my career focusing in this area and embracing it with such enthusiasm. After a wonderful clinical internship in women’s health and the professional influence of great mentors (thank you!), it was clear that this was the right path for me; and the need for this type of therapy was very evident. I tell my patients about the video story sometimes and we laugh about ‘never say never’, right!?










PELVIC FLOOR BIOFEEDBACK THERAPY (but oh, so much more than that)

Here I stand (because sitting is bad) today, stating without hesitation, that this type of specialized work, is very rewarding, challenging, and vitally important to people all over the world.  Pelvic physical therapists are musculoskeletal experts in the areas associated with the pelvis (sacrum, sacroiliac joints, coccyx), including vulvar and vaginal, penile and scrotum, colorectal regions. Most importantly, as physical therapists, we are trained to assess the musculoskeletal system and body as a whole as well (not just small bits and parts). We can still treat necks, shoulders, knees, etc., but some of us have such a high volume of patients needing pelvic health care that we focus in this area exclusively (and still treat the person as a WHOLE).  It is also common for pelvic physical therapists to take post-graduate advanced classes to study GI, reproductive/sexual, orthopedic, neurologic and dermatologic “systems” (and more) to understand the complexity of how this all impacts an individual’s function and movement. We are interested in how systems operate together. Many of us are lucky to work with a network of specialized physicians, midwives, sex therapists and educators, fitness professionals and others in associated fields.

A patient once told me:

“Having endometriosis, painful intercourse, and constipation at the same time is tough. I feel crazy having to go to so many doctors for each thing  - GYN, GI, and Colorectal.  This is the first time I’ve been to someone who’s looked at all of these issues in a bigger picture at the same time, connecting the dots, and coordinating care with these doctors”

Depending on the type of physical therapy practice, the assessments styles and environments can vary. There are some fantastic therapists who focus on orthopedics and sports and do assessments without touching the pelvic floor internally; or some who focus on chronic pain conditions;  while others focus heavily on assessing the pelvic floor muscles and associated areas in private treatment rooms first and then transition to daily functional activities or athletic moves later. There are lots of options. The exciting part is that we can offer hope with conservative treatment! You may see us in private clinics, outpatient hospital facilities, nursing homes, gyms, and other settings.

Here’s a sampling of the types of conditions we treat (from my clinical website) The list shows some conditions for women and men and we also treat pediatric bowel and bladder issues:

pelvic PT conditions

Sample of some of the conditions treated by Pelvic PT. From http://www.sherpelvic.com/services.html

Here’s a great 3D video by biodigitalhuman.com and anatomyzone.com about the pelvic floor anatomy and bony landmarks. We love this stuff! “The BioDigital Human Platform simplifies complex health concepts through the power of visualization. Our platform reveals anatomy, health conditions, and treatments in interactive 3D, demystifying what goes on below the skin through friendly visuals” Anatomyzone.com has a fantastic female reproductive tutorial (and male) on their website.

Want to see more about pelvic anatomy?

Best Articles on Pelvic Physical Therapy. All in One Place!Thanks to My Wonderful Colleagues for These Contributions!

Great article by my colleagues, Sarah Talley and Emily Wegmann at Carolina Pelvic Health Center, Inc.: You Do WHAT? 

Elle Magazine explains treatment for pelvic pain:  Let WHO Put WHAT WHERE? Finding a cure for pelvic pain

Pelvic Guru blog post by Proaxis PT, Jessica Powley:  Misconceptions of Pelvic Physical Therapy

Excellent Article by my colleagues, Stephanie Prendergast and Liz Rummer, at Pelvic Health and Rehabilitation Center What’s the Patient’s Role During Pelvic PT?

Beyond Kegels: When Do Gynecologic Problems Call for Physical Therapy?

The French Government Wants to Tone My Vagina

Even Oprah’s talking about it: Physical Therapy for Your Lady Parts.

Pelvic Physical Therapy for Men with Pelvic Pain – 2 Case Studies, APTA

Another great one by Pelvic Health and Rehabilitation Center: The Role of the PT in Treating PN (Pudendal Neuralgia)

Here are some great articles about how physical therapy can help with urinary leakage during workouts: 

Side note: If a doctor’s office has an employee doing pelvic floor biofeedback (and/or electrical stimulation) as the ONLY treatment to every patient, regardless of the condition  (painful intercourse, urinary leakage, bladder pain), you may not be getting the full spectrum of care.

Where Does a Licensced Physical Therapist (Masters/Doctorate level) Go For Specialized Pelvic PT Training?

When physical therapy graduate students ask me how to get into this specialized area of work, I direct them to two main educational tracks of postgraduate study (and there are other organizations and groups to discover):

American Physical Therapy Association – Section on Women’s Health

Herman and Wallace Pelvic Rehabilitation Institute

Why Doesn’t Everyone Know What Pelvic Physical Therapy is and How Can We Change This!?

To Physicians, PAs, Nurses, Fitness Professionals – please consider referring your patients and clients to a licensed physical therapist who understands this specialty field and can complement your care.

To Physical Therapists and patients, please share this with friends, family, and your healthcare providers so that there’s awareness of this conservative type of care.

Here’s a Women’s Health Physical Therapist locator by the APTA Section on Women’s Health (under temporary construction)

You can also follow the #pelvicmafia hashtag on Twitter- many great pelvic health specialists sharing information and research.

primal image

primal image

**If I missed anything, please let me know! 


  Tracy Sher, MPT, CSCS  Private Practice Owner in Orlando, FL; International Speaker/Faculty. Passionate about treating pelvic pain and all pelvic floor disorders – bowel, bladder, sexual function. Secretly hoping to be a circus clown or rock, paper, scissors champion some day. Connect with Tracy on LinkedinCheck out Pelvic Guru on Facebook or Twitter @pelvicguru1

Pelvic Guru 2013: Most Popular Posts of the Year

Pelvic Guru 2013 – Most Popular Rankings

What a fantastic 2013 ! Thank you all so much for viewing, supporting and sharing at Pelvic Guru – the blog website and social media sites. The positive feedback rocks. The mission is basic: share valuable (and sometimes just funny) information and promote the work of colleagues regarding pelvic health across disciplines. At the end of the year, I like to see what posts generated the most interest. It’s quite fascinating!  * There are numerous articles that did not make this list, but are still worth checking out at Pelvic Guru on Facebook. Sometimes the best, nerdiest info doesn’t get pop-culture fabulous viewing ratings, but should.

Much love to all of your during this holiday season.

Best in Health,

Tracy Sher, MPT, CSCS, Founder of Pelvic Guru

Here’s how this post is organized:

I. Most Viewed and Shared Funny Pictures

II. Top Viewed and Shared Blog Articles and Scientific Pictures

III. Top Viewed and Shared Social Media Quotes, Question,and Announcements

The results below are based on the TOP viewed and shared posts on all Pelvic Guru sites – www.pelvicguru.com, @pelvicguru1 on Twitter, Pelvic Guru page on Facebook, and Pelvic Guru on Pinterest. All of these pictures and posts reached views in the thousands. They are in order of how they ranked. So, #1 in each category was the HIGHEST VIEWED and had the most interest or “buzz”. Enjoy! 

Most Viewed and Shared Funny


1. Funny pic helmet/penis

* Google image

* Google image

2. Do these pants make my…

* Google image

* Google image

3. Vagina Onesie

This picture was a hit on our Facebook and Twitter pages. There were also spin-offs seen later that read: “Made in VaChina”. You can purchase these at various sites such as here.

Made in Vagina Onesie Pic. Can purchase at: http://www.cafepress.com.au/mf/55150231/made-in-vagina_bodysuit?productId=542172810

Made in Vagina Onesie Pic. Can purchase at this link.

4. GYN Restaurant

Would you go to this "Gynecology Restaurant"?  LOL *Pic found on Google at KulFoto.com

Would you go to this “Gynecology Restaurant”? LOL *Pic found on Google at KulFoto.com

5. Giggles and…

Popular saying gone wild. This is now available as a t-shirt logo. *Available Google Image Search - ecards

Popular saying gone wild. This is now available as a t-shirt logo. *Available Google Image Search – ecards

6. Easter Peeps

* Google image

* Google image

Top Viewed and Shared Blog

Articles and Scientific Pictures

1. Dear CrossFit and “CrossFit Gynecologist,” I’m Appalled. There’s Help For ‘Peeing’ During Workouts!

By far, this original Pelvic Guru article went “viral” in terms of usual views at Pelvic Guru – with 10,000 + views a day on some days (and almost 3K shares on Facebook). Part of this was due to this article showing up in a major article on Crossfit’s Dirty Little Secret at Huffington Post by Eric Robertson.  If you have not seen the video posted in this Pelvic Guru article, it’s worth checking out to see why it was so controversial. Although the video was quite alarming to many, it provided a fantastic opportunity for many physical therapists, exercise specialists, OB/GYNs and more to provide solid education about the topic of “peeing during workouts”.

There’s lots of help if you want it!


2. Gluteus Medius Activation

Here’s the Facebook post that had the MOST interest, views, and shares this year (Want more?There’s a follow-up series with more of this stuff for 2014).

Pelvic Guru Facebook Post Glut Med

Original research article here

The incredible chart Adam Meakins created (Here’s Adam’s blog: The Sports Physio):

Screen Shot 2013-12-18 at 1.14.09 AM

3. The Diaphragm-Psoas Connection by The Daily Bandha

* Image from www.dailybandha.com

4. Is There an Orthopedic Test for Hip Labral Tear?

Who knew this is such a popular question and topic!?  This was viewed thousands of times and had 16 Facebook shares.  This is part of a powerpoint presentation for a Pudendal Neuralgia differential diagnosis course (yup…my course). Here’s the link to the study abstract: Concurrent criterion-related validity of physical examination tests for hip labral lesions: a systematic review.

* Posted on Facebook on 9/23/13

* Posted on Facebook on 9/23/13

5. Elle Magazine Article Pelvic PT Screen Shot 2013-12-19 at 10.11.32 AM


This is a fantastic article about pelvic physical therapy and pelvic pain. The best part – it was featured in a major, mainstream media publication, Elle Magazine! Please share this!

6. a. Pregnancy and Crossfit Heavy Lifting: During Pregnancy Controversy 

* Picture on Public Facebook page and featured in Huffington Post article

* Picture on Public Facebook page and featured in Huffington Post article

The picture that sparked lots of debate! *Picture is posted on Facebook and was featured in Huffington Post article.

The picture that sparked lots of debate! *Picture is posted on Facebook and was featured in Huffington Post article.

6b. Pregnancy and Crossfit Heavy Lifting: After Baby


7. Men Experience Labor

You’ll have to watch these videos to believe it!

8. Invisible Injuries of Vag Delivery

A very popular Pelvic Guru Facebook and link from an excellent website and resource regarding the pelvic floor and vaginal delivery.

Facebook post - Vaginal Delivery Tears

9. 10 Common Misconceptions of Pelvic Physical Therapy

This is wonderful article about Pelvic PT by Jessica Powley,  that Pelvic Guru featured on the blog site. Check it out!! There’s another great article about pelvic physical therapy written by Sarah Talley, You do WHAT?.

10. Pelvic and Upper Thigh CT 

Thousands tried to guess what the structures were.

11. Anatomic connections of the diaphragm: influence of respiration on the body system

This was a popular article posted at Pelvic Guru via social media. Of course there’s a relationship between the diaphragm and pelvic floor!

12. Vaginal Dilator Guide for Patients: Part 1

This is a Pelvic Guru blog article. “There are different reasons to use vaginal dilators. This particular post focuses on providing dilator information for women facing fear, anxiety, and/or pain with regard to vaginal touch, finger insertion, gynecology exams, use of tampons, and intercourse.”

Thanks for all of the positive feedback about this dilator information! It’s wonderful to know that individuals all over the world are receiving this as a reference and benefiting from it. Part II will be out in 2014.

Top Shared and Viewed Social

Media Quotes, Question,and


1. “Curious to Know Who You All Are Out There!”

When I inquired about who was viewing the Pelvic Guru Facebook page, I was pleasantly surprised to see 78 comments from all over the world. This post also had one of the highest viewing rates. I love promoting wonderful pelvic health professionals and connecting with individuals who love to learn from the best in the world. This is GREAT!

Curious to Know Who's Out there - Pelvic Guru

Some of the responses and introductions on this post (though a public post, I left names off):

Was a nurse midwife ” back in the day” and now working as a Birth Doula; Extension work in Women’s Health and Wellness 

Adult boutique owner

Banker seeking knowledge to self treat PN. I can’t find a pelvic PT anywhere near me”

Former dancer and now a fitness professional/studio owner teaching many styles of fitness and not long ago I became involved in pelvic floor fitness”

2-1/2 years status post daVinci Robotically Assisted vaginal hysterectomy/BSO followed by postop hemorrhage 2 weeks later resulting in confirmed severe bilateral PNE and complex pelvic and hip instability

Physical therapist in Lisbon, Portugal Women’s Health lover

OT who had a wonderful pelvic floor PT following a difficult delivery. Now very interested in maintaining pelvic floor health!! Love your site!!

stage 4 endometriosis and Pelvic Organ Prolapse…just had surgery for POP just over 3 months ago…still dealing with the pelvic floor dysfunction so I am on here to learn to heal myself

 I’m a Pelvic Floor Strength Instructor. I have designed over 20 internal moves that cannot be seen externally. I authored the worlds first compendium on internal weight lifting in 2010 “Enchantress” I’m also a Hypnotist focused on embodiment and passionate about empowering the global sisterhood. I love your work Pelvic Guru.

Nutritionist specializing in pelvic pain and former pelvic floor physical therapist… my practice is global. I work with women all over the world via phone/ skype and online programs.

I’m from Ontario and suffer from Pelvic Floor Dysfunction & SIJD. I am seeing a wonderful Pelvic Health PT and love all the info and articles you share, it’s nice to understand what’s happening in my body!

Sex therapist/ psychotherapist/ licensed social worker.

Women’s health NP run a chronic pelvic pain clinic at a university and public hospital.

Woman’s Health and Continence PT. Migrated to Mumbai last week from London. Love this page. Well done you.

I’m a somatic sexologist, author, and educational filmmaker.


2.  Quote from Explain Pain by Moseley and Butler – posted on Facebook. 

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3. Medicare G-Code charts available.

This was the first major project Pelvic Guru rolled out to help out physical therapists and occupational therapists in the U.S. Heather Edwards did a fabulous job with these G-Code tables and we provided the Pelvic tables for free. We then published full G-code tables for other disciplines – the charge is for all that hard work and to put back into other PG projects in the future. We received incredible support for this project and look forward to many others.


* …and the best commercial of the year goes to: Poo-Pourri. This is really well done! It’s a REAL product. Really.

** I’m not quite sure how a “Pain and Brain” article or video did not make the top posts this year. I’ll have to keep sharing this information because it is so important. Here’s a great video by Lorimer Moseley.

Thanks for all of the support! Looking forward to a great 2014!!

If you liked this, please share with others. Comments are always welcome too!

Here’s last year’s top posts: Pelvic Guru 2012


Bladder Pain and Bowel Issues – Oy! IPPS Conference Highlight Series, Part 1

Bladder Pain and Bowel Issues – Oy!

Highlights on these topics from the International Pelvic Pain Society Conference in Orlando, FL, October 17-20, 2013.

The 2013 International Pelvic Pain Society (IPPS) Conference was highly anticipated and with great reason! We were impressed by the excellent clinical information for first-time and return attendees to the conference. It is exciting to see how far we have come in pelvic pain diagnosis and treatment and the direction we are heading in applying current research to clinical practice. A broad variety of diagnoses and treatment strategies were presented, and it’s hard to choose just a few to showcase.  This is the latest and greatest info! The Twitter hashtag was #IPPS13 

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We chose to share highlights over a series of posts, as to not overwhelm you with too much incredible information at once! You will see that this info is cutting-edge. 

Bladder pain and bowel issues – Most people don’t enjoy discussing this topic, but let’s face it: when you have bowel and/or bladder problems (and they tend to co-exist quite a bit), they will have a huge effect on daily function AND your mood. Right!? 

good bowel movement

Google image

Urinary Highlights:

Diagnosis and Treatment of Urological Causes of CPP – Amanda Yunker, DO, MSCR (Vanderbilt Medical Center, Dept. of OB/GYN)

Great review of female-associated pain: UTI, Urethritis/ Urtheral Diverticulum, Bladder-related – stones, tumors, bladder pain/IC , post-mesh pain.

  • One diagnosis that can be missed – Urethral Diverticulum - localized out pouching of urethral mucosa. The best way to detect this is with an MRI  (best test) specifically looking at this area (sometimes can be seen visually and correlated with symptoms but not always). Some of the symptoms and signs a patient may have are recurrent/chronic UTIs, painful intercourse, stone formations, urinary incontinence; and sometimes this can lead to urethral malignancy.
  • Urinary Tract Infection: Some antibiotics have an anti-inflammatory effect. This explains what happens with those patients that are assumed to have a bladder infection, the pain is resolved while on the antibiotic, the pain returns as soon as the antibiotic is done, and the urine is negative for any infection.
  • Bladder Pain Syndrom (PBS) / IC : Prevalence is 4-5%. Some symptoms – painful urination, frequency, urgency, incomplete emptying, night time voiding, and pelvic pain.
  • There is a 3-13% risk of dyspareunia after vaginal mesh placement for pelvic organ prolapse, as well as risk for Chronic Pelvic Pain (CPP). Potential risk factors include too much tension on the graft and proximity to nerve (also discussed by Dr. Hibner). Early detection is critical for ease of removal if suspected to be the source of pain.
  • CPP/ Prostatitis prevalence is 2-10% of adult men with a peak in 40’s
  • Ever heard of Retroperitoneal Fibrosis (you aren’t the only one). This is rare, but may be a cause of pelvic pain in males more than females (2:1).
  • Prevalence of post-vasectomy pain is 1-15%-so much for a simple procedure and an ice pack. Pain is suspected to be due to backflow of sperm and testicular fluid into the epididymis, causing swelling and chronic congestive epididymitis and is asymptomatic in most men.  Pain may be worse during ejaculation and may also be related to nerve entrapment or adverse tension.  Treatment may range from NSAIDS to nerve blocks to surgery.

“A warm bath is used to treat EVERYTHING. We should tell Congress to take a warm bath” – Dr. Yunker

Contemporary Management of Pelvic Pain – (focus on the bladder), Robert Evans, MD, FACS (Associate Professor of Urology, Wake Forest School of Medicine)

“IC may be a common and major cause of chronic pelvic pain in women”

Dr. Bob Evans rocked a mean bowtie and shared some of the current treatments available for patients with Interstitial Cystitis (IC)/ BPS. 

Not the actual bowtie Dr. Evans wore, but pretty impressive, huh?

Not the actual bowtie Dr. Evans wore, but pretty impressive, huh?

  • 79% of women with persistent pelvic pain were diagnosed with bladder dysfunction consistent with IC/ BPS
  • Prevalence of CPPS is 9%- similar to heart disease and diabetes and 90-95% of CPPS patients have a negative urine culture.
  • Among IC/ BPS patients, the most common previous diagnosis was UTI
  • IC/ BPS and vulvodynia may have overlapping symptoms due to similar etiologies
  • Treatments: Include Elmiron or less expensive OTC herbal options like Cysta Q and Prosta Q if there are financial limitations.
    • Medications like Singulair and antihistamines like Hydroxyzine, Cetirizine, and Cimetidine may help IC/ BPS symptoms. Those containing pseudoephedrine (labeled –D) may cause retention and are not recommended.  (Isn’t this interesting that we are now seeing Singulair and Cymbalta used for bladder or pelvic pain!?)
    • Vaginal valium suppositories may also be helpful but more expensive.  An alternative is placing a valium tablet vaginally. (as an aside- this is a bit controversial because some medical experts state that this does not work vaginally – read here from Dr. Gunter)

“Beware- this may result in a ‘Smurf vagina’ due to the blue coating on the tablet. It’s harmless but good to know” Dr. Evans

  • Learning self-instillations for home pain management gives patient some control over pain management for general activities as well as intimacy.
  • Dr. Evans advocates for conservative measures, including physical therapy. Here was the quote of the weekend. We know it’s not all about manual therapy, but it got everyone’s attention!

“If your therapist doesn’t have a finger in your vagina by the second visit, find another therapist.”

Mechanisms Underlying Urogenital Pain Syndromes in Women, Ursula Wesselmann, MD, PhD (Professor of Anesthesiology and Neurology, University of Alabama School of Medicine)

Dr. Wesselmann rocks! That is all. Actually, we will post more about her research in the future. Here are just a few highlights:

  • We know that there is a huge overlap between gynecological, urological, and gastrointestinal pain in the same patient (IC, Vulvodynia, Dysmenorrhea, IBS, Endometriosis).
  • We must keep a global picture in mind [and consider the cross-talk between visceral organs, the pelvic floor muscles, and the neural system] – rather than chasing a single symptom! 
  • There are differences between different urogenital pain syndromes, indicating that different pathophysiological mechanisms might be involved.
  • Interesting point on a fantastic slide presentation available to the public on PDF. Here it is! 

“There is a more than 4-fold higher risk of panic disorder (PD) in patients with IC compared to controls. First degree relatives of patients with IC are significantly more likely to have PD and urologic problems, suggesting that there might be a familial, possibly pleiotropic syndrome that may include IC and PD.”

  • She highly recommends CONSERVATIVE management first or only (not immediate surgery); and supports and individualized approach that may include: pelvic physical therapy, psychological therapy, pharmacology approach (that does not include long-term antibiotics, BCG or RTX instillations, acupuncture) and more – refer to slide presentation.
  • If you have a chance to read her research, it’s quite fascinating! 

judging diagnosing

Bowel Highlights:

Functional Bowel Disorders:  Patients often presents with a history of irritable bowel syndrome (IBS) or constipation even when bowel symptoms are not their primary complaint. We are gaining a better understanding and classification of functional bowel disorders in order to treat these patients more effectively, and were fortunate enough to have 2 separate presentations on IBS and constipation at this year’s conference.

Irritable bowel

Irritable Bowel Syndrome – Maryam Kashi, M.D. (Central Florida Hepatology and Gastroenterolgoy, Orlando, FL) -

Dr. Maryam Kashi broke down the essential elements of classification, diagnosis and treatment of IBS.  It is the most commonly diagnosed GI condition and affects over 13 million people, females more than males at a ratio of 2:1.  

Many of our patients may report IBS in their medical history, but it is important to clarify that this is an actual diagnosis rather than a self-diagnosis.   If their symptoms include weight loss, nighttime symptoms, worsening symptoms, rectal bleeding or abnormal blood work, it is not IBS and should be further evaluated.

Rome III Criteria definition of IBS:

Recurrent abdominal pain or discomfort at least 3 days/ month in the last 3 months with at least 2 of the following:

  1. Relief after bowel movement
  2. Onset associated with change of frequency of stool,  or
  3. Onset associated with change in form of stool.
  • May have subcategories of diarrhea, constipation or mixed.  Be aware that some patients experiencing diarrhea are actually constipated and are experiencing overflow around the blockage.
  • Dietary changes are essential for determining triggers and managing IBS symptoms (same goes for constipation).  It is not enough for patients to ‘try to eat better for a couple of days.’Dr. Kashi recommends:
    • Two (yes 2!) weeks of dairy avoidance (no cheating).
    • Elimination of gas producing foods- this includes usual suspects like beans, onions and celery but also more surprising foods like bananas, raisins, carrots, apricots, prunes, wheat germ, pretzels and bagels.  Yes- pretzels and bagels are on this list.  There goes my college diet.
    • Consider gluten sensitivity if celiac tests are negative.
    • And if you are still reading this list with intention to try these changes, there is also a FODMAPS diet (click here for excellent information on FODMAPS from Stanford) to assist those with carbohydrate malabsorption. This is EXCELLENT information because we see patients trying to do all sorts of diets for IBS or going completely gluten free, when they may actually respond to this specific type of plan! 
    • Fiber (we will talk more about this when we review constipation)

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Evaluation of the Patient with Constipation, Sergio Larach, M.D.  (Center for Colon and Rectal Surgery, Orlando, FL)

Dr. Larach at the head of the table with Drs. Feranec, Colimon, and Hoover (and 2 fellows). Colorectal and GYN surgeons.

Dr. Larach at the head of the table with Drs. Feranec, Colimon, and Hoover (and 2 fellows). Colorectal and GYN surgeons.

A few Constipation facts:

  • Most common digestive complaint
  • Affects 4 million people with female: male ratio of 3:1.
  • Incidence increases greatly after age 65.
  • Evaluation includes assessment of intestinal transit, evaluation of pelvic floor via manometry, invasive or non-invasive EMG, Sitz marker testing, manual exam and defecography.  You may also see a patient who has had a pelvic floor dynamic MRI, but it’s not as likely- it’s not done as often as defecography (although the pictures are pretty amazing!).
  • CHECK out this video of a Dynamic Pelvic Floor MRI of a rectocele!
  • You may be more familiar with a diagnosis of rectocele and pelvic floor dyssynergia, but what about internal rectal prolapse, known as intussusception? Symptoms that may be reported are sensation of incomplete emptying and the need standing and walk between evacuation attempts before emptying completely.
  • Non-surgical treatment includes (you guessed it) dietary changes- 30 grams of fiber/ day, plenty of liquids and exercise are all recommended aspects of care. Different laxatives may also be indicated to improve frequency, and biofeedback is indicated for short term response and may need to be repeated annually to continue positive effects.
  • Just remember: There can be one or several factors contributing to constipation. It likely requires a multi-modal approach. Is it just a rectocele issue? Is it also a tightness/spasm of the pelvic floor leading to difficulty emptying? Is it a dietary issue? Much to consider.
  • Surgical interventions are dictated by the differential diagnosis and severity of symptoms.
  • Future direction is looking at sacral plexus stimulation for patients with true colonic inertia. In this patient group, very few dietary changes are effective.

*Here’s a bonus – nice article describing medical evaluation of constipation.

* We are always open to receiving highlights and blog posts from other pelvic health conferences such as AUGS, Section on Women’s Health, SSSS, etc. If you’d like to share highlights in a blog post, please send an email to pelvicguru1@gmail.com

* Text in italics was information added to enhance the presenter’s content (but not directly expressed). Furthermore, the links are added for educational purposes, but not directly recommended by the presenters.

Here’s a great PDF handout explaining chronic pelvic pain (CPP) from IPPS

Sarah TalleyPrimary Contributing Author, Sarah Pinneo Talley, PT, DPT, has over 17 years of experience as a physical therapist and has devoted most of her practice to treating men and women with pelvic dysfunction.  Sarah is co-owner of Carolina Pelvic Health Center, Inc. in Raleigh, North Carolina and has extensive training in the treatment of a range of pelvic symptoms, including bowel and bladder dysfunction, orthopedic back, hip and tailbone injuries, and complex pelvic pain syndromes.  Sarah’s passion is to help her patients surpass their expectations by empowering them to learn the tools necessary to build a better life through improved movement and decreased pain. 
Sarah earned her combined BS/ MS of Physical Therapy from D’Youville College and her transitional Doctorate of Physical Therapy from Northeastern University.  She is a member of the Women’s Health and Private Practice Sections of the APTA and the International Pelvic Pain Society.  
Sarah is currently a lab assistant at Elon University and has been a guest speaker at University of North Carolina at Chapel Hill, the 2010 Advances in Gynecology and Pelvic Pain Symposium and the 2011 International Pelvic Pain Society annual meeting.
Loretta and Tracy at IPPS

Loretta and Tracy at IPPS

Editor-in-Chief (not my day job) and Contributing Author:  Tracy Sher, MPT, CSCS  Passionate about treating pelvic pain and all pelvic floor disorders – bowel, bladder, sexual function. Secretly hoping to be a circus clown some day.  Check out Pelvic Guru on Facebook or Twitter @pelvicguru1
 Another fabulous contributor: Loretta Robertson, PT,MS  An awesome person and pelvic PT. More from Loretta in future posts.
Loretta, Sarah, and Victoria
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Pelvic Pain Research: What’s Happening and Who’s Recruiting?

Pelvic pain research “nerd alert”.

You have been warned!

Here’s a sampling of some of the great research projects and trials (primarily pelvic pain with some others sprinkled in) listed as CURRENTLY recruiting subjects in the United States and Canada.  Who else hopes the funding dollars are there to support these (crossing fingers)!? Let’s face it: pelvic pain is complex and there’s still a lot to learn from research regarding how to treat these conditions with a multimodal approach.

This does not include all of the research going on worldwide…yet!  Please feel free to share (in the comments section) any other research trials. 


Google Image - Gary Larson comic

Google Image – Gary Larson comic

Pharmacology Trials

There are currently a few major studies recruiting patients from all over the United States:

Interstitial Cystitis / Bladder Pain (Multiple locations across the U.S.) This research study is designed to see how well an investigational study medicine works at reducing moderate-to-severe IC/BPS pain.This interstitial cystitis/bladder pain syndrome (IC/BPS) study is enrolling women 18 years and older with IC/BPS. Up to 150 women with IC/BPS across the United States will participate. 

Chronic Pelvic Pain  University of Maryland, Baltimore, Maryland. Patients are needed to participate in a clinical research study evaluating Duloxetine and Sugar Pill for the treatment of Pelvis Pain Chronic.

A Trial of Gabapentin in Vulvodynia: Biological Correlates of Response  The Specific aims of this project are to (1) test the prediction that pain from tampon insertion (primary outcome measure) is lower in PVD patients when treated with gabapentin compared to when treated with placebo. Secondary outcome measures include intercourse pain and 24-hour pain and (2)perform a mechanism-based analysis of gabapentin effectiveness, and to gain insight into the underlying pathophysiology of subtypes of PVD that may lead to more specific treatment options.

*Pharmacology trials provide an opportunity for breakthroughs in finding new ways of managing complex pelvic health conditions. We hope that the pharmacology companies are ethical in their use of data and publish all outcomes. Here’s info on the controversy. 

Epidemiology, Phenotypes, Neural Pathways

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Multi-Disciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) **Excellent, collaborative research network. Recruiting link!

To help better understand the underlying causes of the two most prominent chronic urological pain syndromes—interstitial cystitis/painful bladder syndrome (IC/PBS) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS)—the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) of the National Institutes of Health (NIH), has launched a new and novel research study.

The NIDDK’s Multidisciplinary Approach to the Study of Chronic Pelvic Pain (MAPP) Research Network embraces a systemic—or whole-body—approach in the study of IC/PBS and CP/CPPS.

A Trial of Intravesical Therapy for Interstitial Cystitis in Patients With Generalized Vulvodynia (VV/IC)

In order to investigate whether the pain in women with vulvodynia may represent bladder origin pain, we will be performing a diagnostic test for interstitial cystitis (IC) in women with generalizedvulvodynia. Those women with a positive test for IC, we will be performing a series of bladder treatments (instillations) for IC and checking symptoms throughout the trial to see if significant relief of vulvar pain can be obtained through treatment for IC.

Prospective Data Bank Creation to Study Vaginal Conditions  The purpose of this study is to identify and elucidate the pattern and perhaps role of atypical proteins, cytokines and vaginal microbial flora in the pathogenic mechanisms involved in the development ofvulvodynia, recurrent fungal and bacterial vaginosis and preterm labor.

Brain Imaging/ Mapping

Multi Modal Imaging: An MRI Study to Investigate Differences in the Structure and the Function of the Brain at Rest. (MMI)

UCLA study currently recruiting: The overall goal is to identify structural and functional brain abnormalities in patients with chronic pain conditions, such as Irritable Bowel Syndrome (IBS), Functional Dyspepsia (FD), Cyclical Vomiting Syndrome (CVs), Non Cardiac Chest Pain (NCCP) or Inflammatory Bowel Disease (IBD), and comparing those differences between conditions; and matched healthy control subjects.

Irritable Bowel Syndrome
Non Cardiac Chest Pain
Cyclical Vomiting Syndrome
Functional Dyspepsia
Ulcerative Colitis
Crohn’s Disease

Surgical Trials

Functional Status in Older Women Undergoing Surgery for Pelvic Organ Prolapse

(U. Penn) This prospective longitudinal observational study will assess the functional status of women over the age of 60 undergoing surgical treatment for pelvic organ prolapse. All women will complete questionnaires regarding functional status, co-morbidities, and frailty at a baseline visit. Surgery for pelvic organ prolapse will be performed by the treating surgeon. Women will then report for post-operative follow-up visits at 6 and 12 weeks following surgery. Questionnaires measuring functional status will be completed at these visits as well. Principle Investigator: Lily Arya, MD

*More in this section upcoming.

Behavioral Trials

Validation of Instruments for Pragmatic Clinical Trials for Overactive Bladder

(U. Penn) The purpose of the study is to assess your urinary symptoms, their impact on your quality of life, and the effect of treating these symptoms.  We also want to measure your willingness to stay on medication (adherence).  This study will last for 3 months past the screening visit.  Visits include screening (physical exam and urine testing); baseline visit (bladder diary; questionnaires; medication); 2 week follow-up phone call; 8 week follow-up visit (in office: bladder diary; questionnaires) and 3 month follow-up visit (identical to 8 wk. visit). Principal Investigator: Lily A. Arya, MD

For more information about our clinical trials in urogynecology, please call 215-662-7727 or send an email toreproresearch@obgyn.upenn.edu

Integrated Mindfulness-based Cognitive Behaviour Therapy Versus Cognitive Behaviour Therapy for Provoked Vestibulodynia (COMFORT)

University of British Columbia (Currently Recruiting):  This randomized trial, nicknamed the COMFORT (Cognitive therapy or Mindfulness FOR Treatment of pvd) study, will compare the effects of an 8-session group Mindfulness-based Cognitive Therapy (MBCT) to an 8-session group Cognitive Behavioural Therapy (CBT) for women with provoked vestibulodynia (PVD).

Pelvic Physical Therapy / Manual Therapy

Physiotherapy Intervention for Provoked Vulvar Vestibulodynia

University of British Columbia (Currently Recruiting):  This study will look at specific physiotherapy treatment interventions to see if they decrease pain, improve pelvic floor motor control, increase self efficacy, improve sexual function and decrease pain catastophizing behaviour. Participants will fill out a questionnaire on their pain symptoms and complete standardized scales prior to starting treatment and after 4 sessions to determine change due to interventions.

Efficacy of a Physiotherapy Treatment in Women Suffering From Provoked Vestibulodynia

Université de Sherbrooke (Canada – Currently Recruiting): This study aims at better understanding and treating gynaecological pain. The focus of the study will be provoked vestibulodynia, pain at the entry of the vagina. The efficacy of specialized pelvic floor physiotherapy will be compared to a topical cream (lidocaine) applied to the vulva.


Refractory Overactive Bladder: Sacral Neuromudulation v. Botulinum Toxin Assessment (ROSETTA)

(U. Penn) The purpose of this randomized, open label, active-control trial is to compare the effectiveness of an experimental treatment, botulinum toxin A (BOTOX) versus standard of care sacral neuromodulation (INTERSTIM) for the treatment of urge urinary incontinence (UUI). This study will look at women with refractory and severe UUI i.e. women who have failed conservative management and have at least 6 episodes of UUI on the bladder diary.  Effectiveness data will be collected at 3, 6, 12, and 24 months after the intervention.Principal Investigator: Lily A. Arya, MD

For more information about our clinical trials in urogynecology, please call 215-662-7727 or send an email toreproresearch@obgyn.upenn.edu

Clinical Efficacy of Changing the InterStim® Parameters in Patients With Interstitial Cystitis/Painful Bladder Syndrome


  1. To demonstrate better symptoms control (pain, urinary urgency and frequency) with sacral neuromodulation (SNM) in patients with interstitial cystitis /painful bladder syndrome (IC/PBS) using a stimulation frequency of 40 hertz (experimental) compared to a frequency of 14 hertz (standard).
  2. The evaluate the efficacy of the two frequency settings on the other associated conditions that often coexist in patients with IC/PBS, such as female sexual dysfunction (FSD), bowel dysfunction, high tone pelvic floor dysfunction (HTPFD, painful spasm of the pelvic floor muscles), Vulvodynia (pain at the opening of the vagina).

Additional Clinical Trials:

Interstitial Cystitis – Clinical Trials

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Endometriosis Clinical Trials across the U.S.  



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