Pudendal Neuralgia and Complex Pelvic Pain: An Interview with Tracy Sher

Complex pelvic pain… that’s often a tough one to treat. Especially for those of us who work in clinics as the only pelvic PT! I remember feeling like I just needed another set of eyeballs and more ideas as well as some nudging into perspective shifts to get a better idea of what was going on with some of my more complex patients. I took Tracy’s pudendal neuralgia course back in 2013 and LOVED it. I really learned a ton and it’s been one of those courses that became really foundational in the way I treat pelvic pain (with better results!). It was fantastic to get to talk to her a bit about her course and what lights her up about teaching. ~Heather Edwards (PG Course Coordinator)

Here’s the interview: 

PG: What is the thing you love most about teaching Pudendal Neuralgia and Complex Pain Solutions (a.k.a. Pudendal Palooza)?  

Tracy: Patients all over the world are desperately seeking clinicians who understand how to treat those with pelvic pain. I feel very strongly that anyone treating patients with pelvic pain should attend a course like this because it is practical and full of case studies and ways to immediately enhance one’s clinical knowledge. 

I love seeing the big lightbulb moments that participants have when I explain the continuum of care from assessment to treatments as well as ideas for the language around all of it. Big learning moments also happen when I demonstrate approaches that they’ve never learned about before – even the seasoned clinicians. Each time we go over the “positions lab” (all sorts of positions!), the “male anatomy” lab, or manual therapy demos, someone has come up to me to say something like “THAT alone was worth the price of admission.” 

My favorite quote I use in this course is “we are drowning in information while starving for wisdom.” I use that as a guide for this course – provide VALUE and solid clinical pearls rather than just throwing information out. I love the interaction and I keep it approachable and fun too! 

PG: What are some of the biggest misconceptions about treating pelvic pain/ pudendal neuralgia that you see in pelvic physical therapy? 

Tracy: One misconception is: “If you’ve learned about the basics of pelvic pain you can treat anyone with pelvic pain”. Pelvic pain is a large umbrella with so many considerations and diagnoses. Having a label such as “pelvic pain” or “pudendal neuralgia” does nothing for creating a full plan for patients. I’m shocked at how often well-meaning clinicians do the same exact treatments for their pelvic pain patients, regardless of symptoms or history. 

PG: What do you think of the following assertion? “If you keep treating the pelvic floor muscles and helping patients breathe better, each person will get better”.  

Tracy: Not exactly. So many other differential diagnoses are missed or mismanaged. Yes, pelvic floor muscles are important but are we truly ruling in/out other comorbidities and are we considering the full person. 

PG: What about this statement: “If someone has been diagnosed with pudendal neuralgia or is sure they have pudendal neuralgia, they must have it.”

Tracy: No. Sigh. I’ve had patients labeled with that diagnosis for 10-15 years and it was completely wrong. They had unnecessary pudendal decompression surgeries and so many unnecessary injections or procedures. Or many patients self diagnose it as pudendal neuralgia when it may be something similar, but requires different considerations and treatments. On the flip side, many patients are labeled with diagnoses such as IC, but they actually have a pudendal nerve irritation that does not require all sorts of bladder treatments and extensive tests. 

PG: What about this statement: “Most GYNs have been trained to treat complex pelvic pain patients.”

Tracy:  Not true, sadly. As health professionals, we must work and learn together to help patients. Additional training in pelvic pain is needed for all pelvic health professionals! 

PG: What are some of the biggest barriers to getting pelvic pain patients into our clinics?

Tracy: There simply aren’t enough of us trained to treat pelvic pain. Many of my patients have shared similar stories that begin with “well, I went to a pelvic PT who said they mostly treat incontinence but would try to help with my pelvic pain” or “My gynecologist said they can give me medicine but they don’t know a lot about my diagnosis.” 

There are still too few of us in the fields of pelvic physical therapy and occupational therapy. I truly hope we continue to train more people and empower them to feel super confident treating pelvic pain. People all over the world need this. At Pelvic Guru, we get messages and emails weekly from patients all over the world seeking help.

Also, patients around the world simply don’t know that pelvic PTs and OTs treat pelvic pain. We are on a mission to change this with a variety of campaigns at Pelvic Guru. I see pelvic pain message boards with questions regularly about what urologists or neurologists can help with pelvic pain. Many people don’t even know that there’s direct access to pelvic PT or that pelvic PTs/OTs often have more extensive training in pelvic pain than other professionals. 

Much of the lack of knowledge is a marketing issue. This is why I am SO excited that we have launched the largest global pelvic health directory. Over time, more people will know to go there to find pelvic health clinicians trained in all specialty areas. 

PG: What have been some of your “aha moments” when working with complex pelvic pain patients? 

Tracy: Often times, even complex cases can be simple in the sense that if you provide them with good education, movement ideas, and facilitate ways to improve quality of life, their condition improves. That’s not always the case, though. I thrive on assessing the complex cases that typically need BOTH a myopic, local assessment and overall global considerations. Sometimes it becomes clear that a full evaluation has not been completed. Patients will see an expert in pelvic floor, pain science or BPS, but symptoms don’t resolve. Here are some examples:

Example 1: A patient in his 20s (who came from another state) with penile pain, ED, and cold scrotum was being treated for pudendal neuralgia but actually had a tumor in that area. I recognized he needed imaging STAT. Why was this missed? 

Example 2: A patient who was treated for pudendal nerve entrapment for 13 years actually was found to have gluteal atrophy, weak pelvic floor, diastasis recti, and multiple hernias causing symptoms. He was being treated for hypertonic muscles and pudendal nerve issues – totally wrong! Resolved 90% of symptoms in 1 year with a totally new approach when no changes happened for 13 prior. 

Example 3: A patient with severe sitting pain who came to my clinic on a mattress in the back of a van was misdiagnosed by MRN with bilateral piriformis dysfunction causing pudendal nerve entrapment. We determined the severe symptoms were actually from an abdominal surgery that was not being assessed. The recommended bilateral decompression surgery would have been a WRONG move. 

Example 4A patient was treated for 2 years for pelvic floor dysfunction for severe pelvic pain. It was missed that her cervix was significantly painful to the touch. No one assessed this. She had adenomyosis and improved after the appropriate treatment. .

I could go on and on. It’s vital to listen to patient histories and then complete thorough assessment and reassessments. 

PG: What is your ideal audience for this course? 

Tracy: The ideal audiences are pelvic PTs and OTs, physicians, PAs, nurse practitioners who see pelvic health patients and realize that they would benefit from a deeper dive in knowledge about pudendal neuralgia and all sorts of complex pelvic pain cases. It’s ideal for those who’ve taken at least a basic pelvic floor course all the way through the advanced. 

The biggest reason why I continue to teach this course is that there seems to be a HUGE gap between what pelvic health professionals learn in basic courses – even ones that highlight pelvic pain- and the types of cases and questions that present in the real world! 

Patients with pelvic pain have become very savvy with knowledge and will travel for help. I’m shocked by how many people fly to see me in Orlando and say comments such as “I’ve seen 9 physicians and 4 pelvic PTs in my area, why are you the first person to check this or the first person to identify this plan so clearly?” The gap is real. 

PG: Do pelvic pain patients seem to fit into basic types or categories? 

Tracy: There seem to be 3 types of patients seeking help for pudendal neuralgia and/or a variety of complex pelvic pain symptoms:

Type 1: People who are super knowledgeable and have identified that they definitely have pudendal nerve (and/or other nerve) involvement and are seeking specific advice on plans such as: 

1. Should I get a pudendal nerve block or a ganglion impar block?
2. What imaging should I get or does it matter?
3. Is it worth it to get an MR Neurography?
4. Should I seek cryoablation?
5. Does it matter that I have a Tarlov’s cyst?

These patients want to work with a clinician that is fully up to date with all of the latest research and treatment plans for someone in their situation. They have had basic pelvic floor therapy and that didn’t help them or provide answers to the wide array of questions they have. 

Type 2: People who have been treated for pudendal neuralgia, posterior femoral cutaneous neuralgia, etc. for YEARS by many of the top pelvic pain specialists – but, in fact, that is NOT their diagnosis. They haven’t received a full and comprehensive evaluation and critical thinking approach because they were stuck with that label from the onset. 

Type 3: People with significant pelvic pain issues and are confused about what conditions they may have. They get labeled with something general like “pelvic floor dysfunction” or “pudendal neuralgia” or “pelvic pain,” but they are seeking specific guidance about what the actual condition is (or multiple conditions are) and the best plan of care to help.

Type 4: People who are simply desperate and need local help and can’t travel. They are turned away because they seem complex or the local practitioner simply doesn’t have the comprehensive experience or knowledge to consider differential diagnoses or a complete plan of care. 

PG: What do you hope is your takeaway from your Pudendal Neuralgia course? 

Tracy: My goal by the end of this course is that each clinician feels empowered and full of ideas about how to critically think about and treat patients with pelvic pain using the latest pain science research and biopsychosocial considerations. It provides a way to consider clinical cases and even the best language to use to facilitate autonomy and decrease nocebic information. 

PG: Fantastic! I know that so many feel the way I do about your course and I’m so excited those who will be catching this course in the future!

More information about Tracy Sher, MPT, CSCS 

To find Tracy’s Pudendal Neuralgia course, go HERE. 

As the owner/clinician of the private practice, Sher Pelvic Health and Healing, and the global online platform, Pelvic Guru, ­­­­Tracy Sher has built a strong following of patients and practitioners in Orlando, FL and around the world.  Orlando Family Magazine named Tracy “Readers’ Choice for Best Doctor for Women 2016” in the area of female pelvic medicine – the only physical therapist on the list. She travels the country and the world sharing her expertise, teaching courses and speaking to professionals and women’s health groups. She taught Pelvic Floor Level 1 and Pudendal courses with Herman and Wallace Pelvic Rehabilitation Institute for four years and has subsequently started Pelvic Guru Academy where she teaches a variety of professional courses. 

Tracy served on the Board of Directors for the International Pelvic Pain Society and was a main speaker at the Third World Congress for Abdominal and Pelvic Pain Conference hosted by IPPS.   Tracy has a passion for treating complex pelvic pain, sexual pain and pudendal neuralgias and is committed to improving women’s health care across the lifespan – pregnancy, postpartum, and beyond.