Hello and welcome back everyone. I am with one of my favorite people in the world, Dr. Tracy Sher Welcome.

Dr. Tracy Sher, DPT, CSCS (00:07)

Hello, hello.

Dr. Ginger Garner PT, DPT (00:08)

I just had to drop that straight in because I’m so excited that you’re here. There’s so many important things that I want to talk with you about today and this is just one of many topics. So everybody kind of put your seatbelt on and get ready. I always do a little bio first so I’m going to jump into that. Dr. Tracy Sher is the founder and CEO of the Global Pelvic Health Education Platform and Community.

pelvic group guru, LLC, Pelvic Global, and the Pelvic Global membership. She’s also the owner and clinical director of Sher Pelvic Health and Healing in Orlando. Tracy is a pelvic PT, sex counselor, and strength and conditioning specialist with over 25 years of experience in pelvic health. Orlando Family Magazine named Tracy as one of the readers choice for best doctors for women by community votes in the area of female pelvic medicine. Yes.

She has a passion for treating complex pelvic health cases relating to pelvic pain, sexual pain, and postpartum changes. She’s known for her critical thinking skills and the ability to get to the root of tough cases, because that’s what matters. She has dedicated a large part of her career to the specialty areas of pudendal neuralgia, pelvic neuralges, vaginismus, and associated pelvic pain conditions, some of which we are gonna talk about today.

As a leader in pelvic health therapy with a biopsychosocial approach, and we’ll talk a little bit about what that means and why it’s so important, Tracy travels all over the place, y’all, sharing her experience, her expertise, her teaching courses, and speaking to the community and professionals. And she thrives on being a connector who brings people together and improves the way healthcare providers learn, which ultimately helps everyone.

And she often sees patients who’ve been dealing with pelvic health issues for years without having answers, the answers they need. And that is why we’re here. So welcome, Tracy.

Dr. Tracy Sher, DPT, CSCS (02:12)

Thank you so much. love any opportunity to speak about this stuff and get it out there. So I appreciate this opportunity.

Dr. Ginger Garner PT, DPT (02:19)

Yeah, absolutely. ⁓ I’ve been wanting to talk to you about this for a long time and I know we kind of meet ships, not passing in the night, because we’ll hang out and do stuff at conferences, but it’s always at a conference where we’ll meet and see other and then, so it’s just nice to have a dedicated conversation here. So first of all, I want to tackle the very complex and kind of deep well of pudendal neuralgia and the things that can be associated with that.

Can you define that for our listener and how it is different from other conditions?

Dr. Tracy Sher, DPT, CSCS (02:55)

Yes. So a lot of people hear, you know, we hear sciatic nerve a lot. That’s something you hear a lot of people, if I were to pull people go out to the communities and say, do you know what the sciatic nerve? Many people say, wow, yes, I have a sciatic nerve problem or I know it or my mother does or someone does. But if you say, what is pudendal nerve crickets, right? And you think it’s actually just in the community. But if you actually were to talk with a variety of physicians, they say, well,

Dr. Ginger Garner PT, DPT (03:15)

Yeah.

Dr. Tracy Sher, DPT, CSCS (03:22)

I didn’t really, I don’t know much about the pudendal nerve. So it’s this kind of enigmatic, ⁓ mysterious nerve, but it’s actually, believe the most important nerve because it controls bowel, bladder, and sexual function. So the pudendal nerve is super important. Okay. So if you can imagine if someone has pain in the distribution of the sciatic nerve, they can also have pain and dysfunction and problems with distribution in the pudendal nerve.

So the biggest way to say when we talk about pudendal neuralgia is basically pain in the distribution of that nerve. And when I say distribution of nerve, that means basically the genitals. So when you think about the genitals, and this is in both, ⁓ in all genders essentially, if you have pain in that area of the genitals, it’s potentially the pudendal nerve. So that’s the area. Now what gets confusing is how, where does that stop? And if someone’s sitting, they also talk about pudendal neuralgia being there.

So it’s basically towards the genitals, but can also be near the sit bones as well. So anywhere in that area is considered potentially pudendal nerve.

Dr. Ginger Garner PT, DPT (04:30)

That’s super important because I think that A, ⁓ if people have pain in that area, they wouldn’t know where it was coming from. And B, if they have pain in that area, they’re not talking to people about it, right? And we’re gonna get a little bit later on in this episode of why that becomes more and more complex, like the further you dig, like literally into the pelvis.

Dr. Tracy Sher, DPT, CSCS (04:44)

Yes.

Yes.

Dr. Ginger Garner PT, DPT (04:59)

You know, for the listener again, ⁓ talk a little bit about the most common signs and symptoms that might suggest someone has that because, you know, if you’re listening and you’re, you know, in the realm of women’s health, it’s important to be aware of, maybe you’re midwifery or whatever that is, but if you’re also the person, ⁓ you’d want to know exactly what those signs and symptoms are.

Dr. Tracy Sher, DPT, CSCS (05:20)

Yeah, so I’m actually going to show one diagram. It’s very basic. It’s an entry point into understanding the pudendal nerve. I sometimes call it, if you look at those, three primary branches. So essentially ⁓ when it comes, comes from the spine. So it’s coming from the sacral nerve roots S two, three, four. Okay. And as it comes down, it goes inside the pelvis and essentially emerges where we have, we have one dorsal branch that goes to the clitoris or penis.

We have another branch, the middle branch is perineal branch that goes to that perineum area. And then we have an inferior rectal branch that goes to the rectal area in that area. So essentially it’s not just the skin and the tissue, it actually goes deep into the pelvic floor and all the layers of the pelvic floor as well. So if someone, we can actually see if someone has clitoral types of pain, there’s a chance that that dorsal nerve part, sorry, dorsal aspect of that pudendal nerve is affected.

If it goes more in that perineal or vulvar area or scrotal area, it’s actually going to be more perineal branch potentially. And if it goes somewhere in the area where it’s the anal sphincter opening there or any kind of rectal discomfort, it could be there. So the other thing to know is that there are other nerves that cross over that can be part of this as well. So we don’t always say it could be another nerve. It’s not always pudendal, but we have to consider that the pudendal nerve is affected

if you’re having any of these types of discomfort in this genital area in one of those branches there. So that’s a good starting point just to know. So also the other thing that gets missed and it’s hard to see exactly in this diagram, there’s something called the alcox canal, okay? And the alcox canal sits right where that sit bone is, but it’s on the inside part of it. And you can feel it actually on the outside, but you can also go in internally vaginally and also feel where the alcox canal is inside as well.

And that area when someone sits and they have pain, that’s potentially affecting the pudendal nerve there as well. So when we talk about symptoms, it’s going to be when someone has pain in the pudendal distribution, they might have any of the pain we just described in the general area in those three regions, or they might have a sitting pain. But also keep in mind, there could be other reasons to have sitting pain. but those are the typical symptoms. Pain with sitting, better when lying down or sleeping.

and pain in the genital areas. So that’s the general idea. There can be some bowel and bladder and sexual dysfunction along with it as well. But when we’re talking about pain, that’s the area we’re talking about.

Dr. Ginger Garner PT, DPT (07:59)

Yeah,

and can you describe the range of symptoms that people have? Because it might be like pain with sitting, but then people, might swing and be on that pendulum of can’t wear pants anymore, you know.

Dr. Tracy Sher, DPT, CSCS (08:10)

Yeah,

absolutely. there’s definitely an in the course I teach, we talk about the spectrum. We have patients who just feel like a little irritated, they sit too long, they might say, I feel some general discomfort and they can get up and once they start walking, they’re fine. But that bothers them. It’s still something that I just want that to go away. I don’t want to have that discomfort. Or only when I wear tight underwear or certain kinds of things, I might feel it. Whereas on the other part of the spectrum, we have someone that is basically bed bound, I see patients that basically

have trouble even getting to my clinic because they’re in bed and they basically don’t have much of a quality of life. And they’re desperate for answers because the pain, the clitoral pain, the perineal pain, the genital pain is so bad, they’re not able to tolerate sitting even for one minute. And so we deal with such a large spectrum. And I think it’s so important to understand what could be the causes of that to get to this point. And I think sometimes people are just so misguided and it’s so frustrating because…

Dr. Ginger Garner PT, DPT (09:07)

Yeah.

Dr. Tracy Sher, DPT, CSCS (09:07)

Sometimes, you know, they just didn’t get the right help, but there can be that much of a spectrum. We’re talking from mild to significant life function changes. Yeah.

Dr. Ginger Garner PT, DPT (09:17)

Yeah,

it’s just, my heart goes out to people who’ve had to take that long journey because it’s not just, especially when we’re talking about women’s pelvic health, because statistically we know that women are going to be dismissed, and men can be dismissed with pelvic pain as well. I know you and I have both seen that.

Dr. Tracy Sher, DPT, CSCS (09:36)

Yes.

Dr. Ginger Garner PT, DPT (09:39)

However, statistically speaking, women are more likely to be dismissed. So it’s not just that they might be misdiagnosed, they might actually be sent to psych instead of biomechanical or otherwise medical management. So when we come to talk about pudendal neuralgia, where do you see, because I’m sure you have seen it all.

Like where do you see that it’s most often misdiagnosed or just missed altogether?

Dr. Tracy Sher, DPT, CSCS (10:10)

Yeah, I think what happens is there’s different entry points. So there are people, and this is so important to understand that the reason why I call myself a pudendal neuralgia expert at this point, or someone that really specializes in it, is one entry point into getting help is when people think I do in fact have pudendal neuralgia, or they’ve been told by a provider or someone, I think you have pudendal neuralgia. Now there’s…

a whole other entry point of people who had been told they have vulvodynia or endometriosis or other kinds of diagnoses that technically they do have a form of pudendal neuralgia because they do have pain in that distribution. We treat them sometimes still we’re trying to figure out what the root causes and we’re still trying to treat them. The similar treatments might appear, but there’s this pathway and this is why it’s so important. There are people who have gone their whole lives or many years having this problem.

and they finally feel like, my gosh, I finally figured out, think it’s a pudendal nerve issue. And sometimes it turns out it’s not, by the way, it’s something close or similar, but it’s not. I call it a pudendal tour because then what happens when they go into groups and they start learning more, there are people that specialize in this in the US as well as across the world, but it’s a very specific route they might go on. And I try my best to facilitate that because sometimes there are stops they shouldn’t be making, sometimes they…

kind of go in circuitous routes where they shouldn’t be. So I’m not sure if I mentioned your question exactly, but what’s important is that when someone has pain in that area, they might find that they think they have pudendal neuralgia and that’s when they start trying to go on this path to get help. And unfortunately, some things like they might say, okay, I need to get a pudendal nerve block, or I need an MRI or an MRN specifically, because that’s what they’ve been told. Maybe they need a…

MR Neurography, not necessarily just a three Tesla MRI. But then they might be told, well, now we should try an ablation on you, or we should do some other kind of cryoablation, or we should do… So there’s variety of things I’ve seen people do. We need a neurostimulator now, but have we even figured out what’s going on? Or are we just doing PRP? Are we just doing stem cells? Are we doing all the things that have been told that people can do? And my frustration is, but what’s actually going on, right?

Dr. Ginger Garner PT, DPT (12:20)

Mm-hmm.

Yeah.

Dr. Tracy Sher, DPT, CSCS (12:24)

Yes, you might have this pudendal nerve irritation somewhere, but we need to figure out what’s going on instead of just trying a bunch of things, you know, and that’s part of the gas lighting It’s like, well, the pudendal nerve block didn’t work. So I guess you just don’t have pudendal neuralgia or pudendal nerve entrapment, but that’s just a piece or a part of this puzzle. so patients feel so frustrated when they go down this path. And I’m telling you, like you said, I’ve seen it all and I’ve been there with so many patients at this point.

Dr. Ginger Garner PT, DPT (12:31)

Mm-hmm.

Dr. Tracy Sher, DPT, CSCS (12:51)

And it’s become my mission to really figure out how we help navigate this better for patients. ⁓

Dr. Ginger Garner PT, DPT (12:56)

Yeah,

yeah. So.

it’s impossible to explain, because a lot of people ask this question, right? This is the question. Well, what kind of tests do you do? What kind of assessment do you do? How do you diagnose it accurately? And it’s like, well, okay, that’s why we go to school for years, and then you don’t learn anything that you, you don’t learn enough in school, then you go for continuing for 20 years. So obviously we can’t answer that question, but to get people…

Dr. Tracy Sher, DPT, CSCS (13:05)

Yes.

Dr. Ginger Garner PT, DPT (13:27)

you know, going in the right direction, what are some of the early things that would be done or that should be done for them?

Dr. Tracy Sher, DPT, CSCS (13:33)

Yeah.

So I would say, I would say this because there are, the tests can be helpful at times. So I want to back up and say, it’s not that you should never do testing or it’s all just not, not helpful. It’s really a lot of times ruling out things. So for example, if you feel like, I’d like to just know what’s going on inside my pelvis and someone offers you an opportunity to have an MRI or an MRN.

It’s not necessarily bad in the sense I tell patients that it might rule out something big. What if there’s a tumor? What if there’s something else going on that can be caught? But it also matters who reads it because it’s really hard to see the pudendal nerve. So it has to be at a place that where they actually specialize or know how to read the pudendal nerve. And to be honest, there’s only a few places in the U.S. that I’m aware of that are very strong with that. So just having it read doesn’t necessarily mean just like endometriosis, it doesn’t mean that it’s gonna give you the information you’re looking for.

So it’s good to keep the records and have it on file for whoever you see in the future. But so it’s more of a diagnosis of sometimes exclusion of just making sure there aren’t major things going on inside the pelvis that are affecting things. A block, if every time they did a block, they find that it does really help them, then that does guide us to know, it is happening somewhere near the pudendal nerve or at the pudendal nerve. So it can be helpful to know that, but.

Dr. Ginger Garner PT, DPT (14:24)

Yeah.

Dr. Tracy Sher, DPT, CSCS (14:51)

If it’s a negative, it can be a false negative where they didn’t have the right guidance or it didn’t go in the right place. So then they say, it wasn’t pudendal nerve area. And then it turns out that in fact it maybe is. So there’s tests along the way can be helpful. What I find super helpful and what I would say from my perspective, and I wish more people do this, and this is why I train so many people. This is why I’m a big advocate for understanding anatomy and understanding how to look for these things is palpation.

and provocation of symptoms. So if I’m touching all around the anatomy there and every time I touch somewhere, they say, that’s my pain. To me, that’s huge indicator of what’s happening in that anatomy. Okay, let’s test and retest. Let’s figure out, is this something going on just at the tissue level? Is this something deeper on the muscle? Is this something going on only with sitting and compression? Is this happening only with standing? So I’m trying to figure out what provocates the symptoms.

how I can actually sometimes increase that or decrease it. Is there something I can do manually? Is there something we can positionally do that immediately takes the symptoms into a better position that they just feel a lot better? So to me, I think that that’s a lost art sometimes because we’re doing all these testings and all these things when actually we can do a lot with testing, with provocation testing, trying to figure out with our hands and our anatomy knowledge what we can do to get a better sense of what’s happening with each patient.

Dr. Ginger Garner PT, DPT (16:18)

Yeah.

Dr. Tracy Sher, DPT, CSCS (16:18)

And

then when I have patients that have seen all the different places, they’ve gone all around the country, all around the world, I’ll say, I’m just going to do a really thorough anatomy, palpation and provocation testing. And they say, you know, you’re the first person to ever do this, to actually touch in these places. And I’m always shocked because I firmly believe we all should be doing this. We should be testing this stuff. So when I do it, they say, wow, I’m learning more than I ever did before because I now actually understand what’s happening. And then we can go with the next layer. Okay. In your case,

Dr. Ginger Garner PT, DPT (16:37)

Mm-hmm.

Yeah.

Dr. Tracy Sher, DPT, CSCS (16:48)

based on what I’m finding, you may actually benefit from this specific kind of MRI looking to see if you have a hernia. Or based on the testing, it might mean that you are someone that we might need to look more at your hips, or we might need to look into endometriosis might be a leading factor for you. So if we’re not looking at the anatomy and provocation and hearing symptoms and history, we’re missing a lot of the pieces. And we’re just kind of stabbing at things. just saying, let’s try this, let’s try that. And so patients come to me a lot and say,

Dr. Ginger Garner PT, DPT (17:14)

Yeah.

Dr. Tracy Sher, DPT, CSCS (17:16)

By the way, I was offered an opportunity to get this kind of surgery or to get this kind of ablation. I say, well, let’s back up a little bit. Let’s figure out what’s going on with your symptoms first. Let’s see what we can provocate. And then we can see, that make sense in your case? So it’s a lot of case management instead of just trying things, just to try them.

Dr. Ginger Garner PT, DPT (17:31)

Mm-hmm.

Yeah, and I think that’s so true and it’s one thing that I think we’re deeply missing in our healthcare system is the time and the effort of listening to someone’s story and then being able to discern what variables are most important to be able to then do a physical exam. that’s why I think pelvic.

Dr. Tracy Sher, DPT, CSCS (17:52)

Yes.

Dr. Ginger Garner PT, DPT (18:03)

PTs and OTs are really ideally suited to be doing this work because we do get more time. And of course, if you’re in the insurance system, you have a certain amount of time, those of us in the cash-based system can do whatever we want and however long it takes to solve the case is however long we’re on it. But that is something that I think for the listener’s sake is like you really need to look for in a practitioner is someone that has the time and you feel listened to because if you don’t feel listened to, you’re right.

Dr. Tracy Sher, DPT, CSCS (18:19)

Yeah.

Yes.

Dr. Ginger Garner PT, DPT (18:32)

like you weren’t listened to, you know.

Dr. Tracy Sher, DPT, CSCS (18:35)

And also I’ll say on top of that, I think there’s a lot of well-meaning clinicians out there that do listen, but they also need more training on understanding where to palpate and what to provocate. Because what will happen is they just go and start doing more pelvic floor sweeping. And I’ll say, okay, but in your case, you’re complaining about a urethral pain here. Has someone touched in that area? And they’ll say, no, I’ve had the nicest, most wonderful people work with me, but they just kind of do the same thing each time. They just kind of stay in this area. And so it’s like, you know,

Dr. Ginger Garner PT, DPT (18:54)

right.

Yeah.

Dr. Tracy Sher, DPT, CSCS (19:04)

We’re getting there, we’re getting close to the places, but we have to continue to figure out ways to empower clinicians as well as patients to feel, know, like, hey, we can do that, we can continue to find things and we can continue to work on this. And the other thing that comes up a lot in the pudendal world, which is really important, is the distinction between pudendal neuralgia and pudendal nerve entrapment.

Dr. Ginger Garner PT, DPT (19:18)

Yeah.

Dr. Tracy Sher, DPT, CSCS (19:27)

It’s a scary place. you go online and you start looking at pudendal nerve entrapment, it looks so scary. You know, they see these cases where the nerve is entrapped and it’ll never get better. Most cases are actually more, if they are involving the pudendal nerve or that area, it’s more an irritation of the nerve in that area, more like it could be a sciatic nerve irritation. It’s not necessarily that it’s entrapped. So that’s important people. I want people to know that too, to be empowered to know most of the time it’s not entrapment. And we can find lots of ways to help patients.

There are cases that are entrapment and you know in 25 years of doing this and really specializing in this for many years now I found there are several cases I’ve seen over years that I really think were fully entrapped and and they received the right treatments, but It’s not necessarily you’re gonna see most patients have that and I will say that because I think this is very very important ⁓ There the one time where there’s a few times and it can be entrapment and one time I really like to highlight if someone goes into a surgery. This is so important

whether it’s a surgery for, they go in for a hysterectomy, they go in for a prolapse surgery, or they go in for any other kind of pelvic abdominal surgery, and they wake up from the surgery, and or maybe the next day or two, and they immediately have a severe genital pain that they didn’t have prior to the surgery, that’s the time when they may have had some form of entrapment or suture closure over the nerves or something like that happening.

Dr. Ginger Garner PT, DPT (20:53)

Mm-hmm.

Dr. Tracy Sher, DPT, CSCS (20:53)

And sometimes

when you talk about gaslighting, they’re told, don’t worry, it’ll improve over the next few days. And then months and months go by and they feel helpless. And I think that that’s so important, whether it’s a mesh involvement or suture involvement or some sort of other problem with where they had the surgery, that’s a potential entrapment that needs to be addressed. Typically it might not even be the same surgeon that does it, but that’s something that is potentially a red flag.

Dr. Ginger Garner PT, DPT (21:20)

Yeah, absolutely. I think that’s part of the driver of, ⁓ hip arthroscopy, is changing post types in surgery because before it was just a post right at the perineal area. so that was one of the risk factors was injury to the pudendal nerve. And certainly it did happen. I’ve seen several patients with it. So talk

Dr. Tracy Sher, DPT, CSCS (21:40)

Yeah.

Dr. Ginger Garner PT, DPT (21:43)

a little bit about ⁓ the difference between, because we were talking about diagnosis and misdiagnosis and what can happen. So there are several things that if we have the misdiagnosis bucket that we could talk about. So talk to us a little bit about that, about conditions, whether it’s a pelvic floor dysfunction or interstitial cystitis, painful bladder syndrome, and the one that we’re getting to, endometriosis. Like talk a little bit about, that’s a big bucket of stuff that you’re trying to sift through and figure out.

Dr. Tracy Sher, DPT, CSCS (21:55)

Yeah.

Thank

Dr. Ginger Garner PT, DPT (22:13)

⁓ which is which.

Dr. Tracy Sher, DPT, CSCS (22:15)

Some of the ways that I first talk about, because some people say, yeah, you deal with pudendal neuralgia. Basically you just treat pelvic pain. I’m like, yes, technically it’s under that umbrella. But again, you’re to have very specific symptoms and people are going to come with specific questions about that nerve. So you really want to be well versed in that. ⁓ But when patients come to us, I think of it as a lot of overlapping conditions.

So I look at pudendal neuralgia symptoms as exactly that, a label ⁓ and symptoms. So for example, if someone came in, I use this a lot when I teach, if someone came in and said, man, I have a terrible headache here, we wouldn’t automatically say, my gosh, you have a tumor, you need to get it removed immediately. We would have to figure out, okay, tell me your symptoms, what happens with your headache? We’d wanna go through a lot of lists of symptoms, we might start to narrow it down, there could be two or three diagnoses. And some of them might actually overlap.

Right, someone could have some sort of autoimmune issue that’s increasing their symptoms, but they might also have another diagnosis as well. So it’s similar to pudendal neuralgia. Pudendal neuralgia is a label and a symptom. It’s essentially pain in the distribution of the nerve. So now we have to figure out, and this is again, a lot to do with the history and propagation testing and a lot of questions, is that, you know, did they have a surgery or something that is the primary reason they have the pudendal neuralgia symptoms? So then we got to look at what can be done with that.

Two, if there’s something underlying, let’s say for example, if they have bladder pain or discomfort and it’s also causing other genital pain, that’s a perfect example where sometimes they just get labeled with another thing. They’re told they have, this happens very often by the way, they’ll say, well, my physician said I have interstitial cystitis, vulvodynia, pudendal neuralgia, and know, something, one other thing. And I’ll ask the physician sometimes, well, why did you say that? say, well, just not as well, just throw all of them at them just in case, just to cover it.

But what it does, it can create this feeling of, my gosh, I’ve got so many diagnoses now, I feel overwhelmed. When really it might be that there’s one underlying problem. For example, we know that bladder pain can be specifically from endometriosis. So is endometriosis the actual driver of the pudendal neuralgia itself? And some people say, no one even asked me these questions. I didn’t even realize that it could be tied to something like endometriosis.

Dr. Ginger Garner PT, DPT (24:12)

Mm-hmm.

Mm-hmm.

Dr. Tracy Sher, DPT, CSCS (24:33)

So it can be that there is an actual disease process that is the cause of the symptoms of pudendal neuralgia. If someone has vulvar pain and it’s a hormonal regulatory thing, let’s say that they just need more hormone in that area, some sort of estradiol cream. I’ve had patients think that they have pudendal neuralgia for 20 years and it turns out you get them three months on vaginal estrogen, estradiol and they’re like, this is like a miracle. I no longer have pudendal neuralgia.

Dr. Ginger Garner PT, DPT (24:52)

Vaginal estrogen. Wow, this is amazing.

Dr. Tracy Sher, DPT, CSCS (25:01)

That’s why it’s important that there’s overlapping conditions with this where we’re not saying you only have pudendal neuralgia we’re saying that’s a symptom or a problem. Now we have to figure out, it truly that, like you said, the muscles might be the issue. So for example, someone might have a tight obturator internus muscle, which by the way, the fascia is where the pudendal nerve goes through the obturator internus fascia there. So it could be that there’s truly just a local tightness of an obturator internus muscle, thereby,

in like irritating the pudendal nerve. And then they have pudendal neuralgia symptoms. And it could be as simple as let’s just get this muscle, calm down a little bit, strengthen around it, get it to move better and not get as tight anymore. And that might be the solution. So it can be as simple as just a tight pelvic floor muscle, deep muscle there. It could be something like a disease process we’re looking at.

⁓ Anytime I hear interstitial cystitis, I immediately think, okay, let’s look and see, are we looking at a local urethral problem? Are we looking at dorsal aspect of the pudendal nerve at that anterior vaginal wall? So the top part of the vaginal wall, is that a problem? Giving the feeling of interstitial cystitis, but it’s actually coming from something that we can change. We can move that tissue at the top of the vagina basically, and that can be life-changing for some people to have that.

Dr. Ginger Garner PT, DPT (26:02)

Mm-hmm.

Dr. Tracy Sher, DPT, CSCS (26:24)

To answer your question, there are overlapping conditions that can be contributing to symptoms of pudendal neuralgia. And that’s always my goal is to figure out to case manage this and say, okay, what are we looking at in this particular case? Everyone’s a little different. So it’s figuring out what that looks like. And again, sometimes it’s super simple. It’s just that a local tissue issue or a pelvic floor muscle issue. And other times it is more complex and there’s multiple diagnoses that we figure out need to be managed.

Dr. Ginger Garner PT, DPT (26:51)

Yeah, and I think that kind of messaging

is part of the empowerment. It lands in a very good place for women to hear this because they, like you said, they could come saddled, preloaded with a half a dozen diagnoses that may or may not actually be true. And it doesn’t take a lot of that interaction with the medical establishment to already be, you’ve pathologized yourself.

So you’ve gaslit yourself. You’re like, I am not fixable. This is not an easy solution. But our medical education system has been so set up to offer drugs and surgery first that I think that as patients in the system, your brain will automatically go there. And to know that a lot of the

tissue issues that we have can be treated either by self-management techniques that you’re teaching them or with a few visits of doing manual therapy or whatever that is, is incredibly hopeful. So I just wanted to pull that thread out and go there’s a lot of hope and empowerment in that message.

Dr. Tracy Sher, DPT, CSCS (28:00)

That’s, we speak the same language. I know we always do. It’s the empowerment and knowing that there’s hope. So many patients tell me that whether I’ve done telehealth or they say it finally makes sense that there’s hope and it’s not false hope. I don’t give false hope. It’s really more just, there are all these ways we can look at this and how about considering this. It just opens your mind to different ways that this can be treated. ⁓

in the system you get put in sometimes it’s like, well, if this doesn’t work, then the last thing we have to offer you is pudendal nerve decompression surgery. And I always tell patients it’s not necessarily, that’s not the last stop. That’s an option certainly, but that might not even make sense, right? So we have to figure out. And I want to tell you, there’s one case, gosh, think of many cases, one case that I saw recently that I was just in tears and it really affected me a lot because this is a person that basically

had no function in life. She was not able to do anything, walk, sit, ⁓ very limited in function. And this happened after a prolapse surgery where she woke up with that kind of pain. And then she had ended up having mesh removal and still continue to have these same problems. Okay. And there’s multi there’s layers to this that we’re still looking at, but I want to tell you one of the things that was really interesting in her case, she said the only time she’s felt better is when she’s in a pool.

Dr. Ginger Garner PT, DPT (29:07)

Mm.

Dr. Tracy Sher, DPT, CSCS (29:23)

and she’s got some sort of buoyancy and she doesn’t have to worry. That’s the only time she actually feels like she’s herself again. And other than that, as soon as she gets on land, as soon as she sits, as soon as she stands and walks, she’s immediately having this problem. So I started thinking out of the box a little bit with her. And I said, do you mind if I just do something? This is kind of like, she’s coming from a different state and I didn’t have a lot of time to say, let me just try something. ⁓ And a lot of times, by the way, when I share this, someone’s like, of course, I would have done that too. I’m like, well, she’s single.

Dr. Ginger Garner PT, DPT (29:51)

Yeah. ⁓

Dr. Tracy Sher, DPT, CSCS (29:52)

She’s

been dealing with this for years and she’s gone to many, many practitioners. So she said she was so thrilled that I tried this. I took McConnell taping. So I did some taping and essentially lifted different tissue. was basically pulling her abdominal wall. And then I put her in one of those B support types of things to lift up her gluteals and essentially did a variety of things that were pulling up the tissue and the amount like the seeing her face and her husband’s face and seeing her walk.

Dr. Ginger Garner PT, DPT (30:06)

Mm-hmm.

Dr. Tracy Sher, DPT, CSCS (30:22)

for the first time she said, it’s the first time I’ve been able to walk in, I think it was two years, three years. She’s like, you have just that restored my function. She goes, I know we still have to figure out some other things, why and what, but like just to walk out of there. she’s, mean, she was, I’m in tears just thinking about it because it’s sometimes we don’t know why they’re having the padenorhagic symptoms and the problems yet. We’re still gonna be looking at this, but.

Dr. Ginger Garner PT, DPT (30:26)

Mm.

Dr. Tracy Sher, DPT, CSCS (30:47)

sometimes it does take again provocation and or the opposite trying to figure out is there anything we can do positionally or in some way to help that person and she said and she’s been gone she’s gone to the top experts in the world and she’s I mean she’s been in France she’s been all over everywhere you can think of and no one actually touched and took the time to really see what we could do with tissue and that sort of thing and she messaged me later to say that still this has been you know

Dr. Ginger Garner PT, DPT (31:09)

Yeah.

Dr. Tracy Sher, DPT, CSCS (31:13)

miraculous for her in terms of just giving her function back right now while we continue to look for more answers. so it matters what we do. And I want to give the hope to patients that even though you think you’ve tried everything, there are ways to continue to look for things.

Dr. Ginger Garner PT, DPT (31:29)

Yeah,

that’s kind of a solid definition of what a biopsychosocial approach is because you’re also impacting, she’s coming in with all these, well, no quality of life. So when you talk about lifestyle habits, she doesn’t get to have any because she can’t move. And so when we think about the multifaceted aspect of what you did there from a functional perspective, like looking at ⁓ how changing length, tension, relationship of tissue,

Dr. Tracy Sher, DPT, CSCS (31:44)

Thanks.

Dr. Ginger Garner PT, DPT (31:57)

just with something like taping could profoundly shift her experience of how she’s experiencing things in her body. It speaks really loudly to looking at all those lifestyle factors like causes and risk factors like, how is someone sitting? What is their posture? What happened during childbirth? Has anyone asked them about trauma? Because I think that aspect of the trauma informed piece too, which you alluded to.

is so incredibly important and it is not gonna be standard on someone’s intake to ask about that. And patients are not gonna offer that information, you know, to. And speaking of this case, she just experienced trauma being in the system, whether or not she had trauma outside of the system. She was.

Dr. Tracy Sher, DPT, CSCS (32:45)

She had

one of those moments where she said, she goes, I think about all the time, all the places I’ve been, and they were just telling me, you know, there’s nothing you can do, or you should be better now, or she’s tried every kind of treatment you can imagine. So it’s feeling defeated through the system. just, yes.

Dr. Ginger Garner PT, DPT (33:02)

Yeah, which makes it worse because

it’s hard to then trust yourself. one of the most important aspects about someone getting better is them feeling like they have a sense of control over the situation and that they have that self-efficacy, like something can help, I can help. And what she does can make her more effective in her own journey towards healing as well.

And when you’ve been betrayed by the system that’s supposed to be helping you, it is hard to go into a situation, ⁓ another therapy situation and go, okay, all right, I’m gonna believe this is gonna help and then it can shift me for the better. And so that’s an incredible story. Thanks for sharing that.

Dr. Tracy Sher, DPT, CSCS (33:40)

Yes. Yes.

And

yeah, there’s another story to go on top of that, just I feel like because there’s all these nuances and it’s not that now everyone’s going to come to me and I’m just going to be taping them up. It just really depends on the scenario and what’s happening. But there’s another case where I think, again, this highlights understanding where to send people and having good case management, where there’s someone that was told there’s nothing more they could do. And every time I saw her, you could just see that she’s not even able to function with moving her leg, walking, sitting, nothing. ⁓

Dr. Ginger Garner PT, DPT (33:56)

Yeah.

Dr. Tracy Sher, DPT, CSCS (34:16)

not able to even flex, you know, move the leg up and down. I mean, it is just consistently severely painful. And to be told by many people in the system, there’s nothing wrong, there’s nothing more. Let’s just do some injections. There’s nothing more that can be done. And to keep hearing that and for me to say to her, you know, I don’t know yet what’s wrong, but I know that this isn’t functioning just like we just need to do some injections and it’ll be better. We just need to push through some therapy. This will be better.

So I specifically knew we needed to do a specific kind of imaging and get her to the right person to read it. And sure enough, they were discovered specific things they were able to find that just made sense in this case that had been missing for years again, where once that was revealed, it was like, wow, there is still some mesh there. There is still this other issue going on. And I don’t want to the specifics yet, but the idea is this is a person who was told,

Dr. Ginger Garner PT, DPT (35:06)

Mm-hmm.

Dr. Tracy Sher, DPT, CSCS (35:13)

there’s nothing more that can be done. you’ve reached the end of it and just do more therapy. And I’m as, you know, the pelvic therapist saying this doesn’t feel right to me. I feel like there’s more we need to dig. So sometimes just having someone champion that for you or figure out where to go next. So that’s where again, this hope and empowerment comes in. Keep looking for the people that specialize in this that can help you. It’s sometimes, it is a circuitous right route sometimes, but there are people out there that really have made this their

passion and their dream to make sure that they’re helping people with this. And I know you’re one of them. So Ginger, so, you know, when you find people like this, it’s, really helpful to get you on the right track. So. ⁓

Dr. Ginger Garner PT, DPT (35:47)

⁓ well, thanks.

Yeah,

it’s the definition of an advocate because they may come to you and if we take our role as an advocate seriously, that means they actually may not be in your clinic for treatment. They may actually be referred to the right person and that really at the end of the day is our job. It’s again, why…

pelvic PTs and OTs are really ideally suited to take on these complex cases because we do have the time to do that. And you made another point that I think, I just want to reemphasize it because when people go to get diagnostic imaging, and this also speaks to endometriosis, which you’re kind of going to fall forward into that. Next is that everyone makes an assumption. We can do this. If it’s not our area of specialty, we can do the same thing of thinking that

just because you get the imaging, it’s gonna be read correctly by the right person, right? And we know, especially in this area, that is so not true. Can you elaborate a little bit on that just to let people know? Because oftentimes they’ll close the door. I had the MRI. I had the thing. Well, wait, wait, wait, wait. Who actually read that information? ⁓

Dr. Tracy Sher, DPT, CSCS (37:12)

us.

Dr. Ginger Garner PT, DPT (37:14)

I know you can speak a lot on this, so I’m just gonna let you go with it because I want to make sure that everybody understands that just because you had imaging doesn’t mean that the door is shut on it.

Dr. Tracy Sher, DPT, CSCS (37:16)

Thank you.

Yes, it is so true. I have two things I need to say. think there are distinctions. Hopefully I’ll get to the second one and I don’t lose my train of thought. But the first one is that I’ll never forget. I was working with a hernia surgeon locally who moved sadly, but there were people that would come in repeatedly and say, I know I don’t have hernias. I’ve already had it checked. I’ve already had this checked, especially by the way women get missed a lot. And Dr. Toffey’s work has changed that a lot from my perspective, just seeing how many women are being missed with that. So, ⁓

They would come in and say, I’ve already been checked. I already know I’ve been to hernia surgeons. They’ve already looked at my imaging. And so this surgeon, would put up the, you’d see her put up the CAT scan or the MRI, whichever one it was at the time. She’d say, that was missed, that was missed. Ooh, look at that, that was missed. And sometimes the hernia would go into the pelvic floor. So the symptoms they were having, they were treated for a long time for pelvic floor, but I kept thinking something is missing. And sure enough, she’s like, so it does matter who reads it.

And even if you’ve gone to a center that says they do this, it sometimes can be helpful to get another, second or third or fourth opinion. Even though it seems painful at the time, like again, I have to go and do this, it does matter who reads the imaging, right? That makes a huge, huge difference. And I want to also say on the flip side, sometimes there are people reading the imaging that get it wrong. And I have this case where I’ve talked about this before in my courses.

⁓ It was an important case because she was told very specifically from an MRN and so an MR Neurography that she had bilateral pudendal nerve entrapment via piriformis muscles Okay, and she had with no ability to sit she had severe vaginal pain She came to me from another state basically on the mattress in the back of the van and she could just was miserable Okay, could not sit at all soon as she sat up. She had severe problems

Dr. Ginger Garner PT, DPT (39:14)

Hmm.

Dr. Tracy Sher, DPT, CSCS (39:20)

So she was scheduled for a bilateral pudendal nerve entrapment decompression via some form of, they were going to cut the piriformis muscles. And she was scheduled for the surgery and she came to see me first. And I said, will you do me a favor? Can you hold off on that surgery? Because I was doing the testing, was doing provocation testing. I was looking at the imaging myself. I was looking at things and I just didn’t understand where they were getting that from because her symptoms, had no provocation at the piriformis at all.

Dr. Ginger Garner PT, DPT (39:50)

Hmm.

Dr. Tracy Sher, DPT, CSCS (39:50)

However,

when I went to her abdominal scar, where she had an abdominal plasty years before, that lit up all of her symptoms. And so I said, if you can just be patient with me, has anyone ever touched you here? She said, no, in all the time I’ve been dealing with this problem, no one has ever thought to touch there. They thought I had a pudendal nerve issue, so they were going in the back. They were doing everything. And even the imaging said I have piriformis compression causing pudendal nerve entrapment.

And so we worked on her abdominal wall, vaginal walls, vaginal everything pelvic floor in that area. And sure enough, she was able to start driving down herself to see me and ultimately getting back to work and all of her life things. And she avoided this major surgery by, and this was a physician who said that she had this entrapment problem via imaging. So we also have to be careful again, getting second and third opinions to make sure that you’re not jumping into a significant surgery.

Dr. Ginger Garner PT, DPT (40:39)

Mm-hmm.

Yeah, yeah, absolutely.

Dr. Tracy Sher, DPT, CSCS (40:49)

That’s an important story.

Dr. Ginger Garner PT, DPT (40:51)

Totally, I

mean, it speaks a lot to the treatment and management, because really that was kind of the next question in. And you’ve alluded to this or mentioned this already about having multiple conditions. And while everybody accepts that, yes, you can have multiple diagnoses going on, how do you see pudendal neuralgia presenting itself in cases like endometriosis, which we know as a whole body, like systems experience?

Dr. Tracy Sher, DPT, CSCS (41:07)

Yeah.

us.

Dr. Ginger Garner PT, DPT (41:20)

and it can be anywhere. so if listener, if this is your first time podcast is dropping into pudendal neuralgia, roll it back to some of the previous episodes where we go through all of the definitions and where it can land and how it manifests itself, because we won’t rehash that right now, but we’ll go into just how, when you see people with endometriosis, what’s the range of presentation that you see when it comes to ⁓ pudendal neuralgia?

Dr. Tracy Sher, DPT, CSCS (41:48)

Yeah, so I think that that’s so important. And that’s why when you are a pelvic health specialist, the more you can understand about so many different diagnoses and ⁓ conditions, it will help you tremendously with figuring out how to put the pieces together. Because I know people who start out doing more postpartum and they’re doing a little dabbling a little bit in it. And so someone presents with pudendal around you and they start treating more pelvic floor around the area where the pudendal nerve is. But we’re not necessarily getting to the root.

issue, is this person has endometriosis that’s causing a lot of these issues. someone that has an, this is another thing too. Someone might have endometriosis symptoms. might even have surgery. get ⁓ a really good excision surgery done and they still have lingering pudendal neuralgia. So what I say is they, sometimes the pressure from changes, inflammatory, all things we think about autoimmune responses, all the things that happen with endometriosis, you can therefore have

pressure on the nerves. So they would, cause pressure on the pudendal nerves. So someone could have genital pain. Then they get incision surgery and they actually say, wow, I just don’t have that bogginess down there anymore. I don’t have that genital pain. So it can be specifically that getting treatment of the endometriosis can significantly affect pudendal neuralgia symptoms. So we know that can be the case, but there can be cases where we see this a lot, right? Where

Someone has endometriosis, but then they develop a pelvic floor disorder and tightness of the pelvic floor around the pudendal nerve there. So therefore, even when you get excision surgery and other kinds of treatments, you’re still left with some things like pelvic floor dysfunction and or tightness, irritation of the pudendal nerve itself. So there can be still a local irritation of the pudendal nerve and or that alcox canal that sits near that sit bone that can still be very irritated just locally, the local tissue there.

So it doesn’t have to be that it’s only, well, know, miraculously everything will go away once we start really working on the endometriosis. There might be a secondary dysfunction. And then I’ve seen some cases where actually that was the primary dysfunction. Someone didn’t even have any, they found out later they had endometriosis, but that wasn’t even the driver of their symptoms. It really was a local issue all along. And again, it could be that they also have a hormonal where they get help with some hormonal treatment, again, estradiol or something vaginally plus pelvic floor treatment.

Dr. Ginger Garner PT, DPT (44:03)

Yeah.

Dr. Tracy Sher, DPT, CSCS (44:13)

And that works well. So I’ve seen it both where there’s a true driver that’s coming from endometriosis or another diagnosis like that. But then also it can be a local issue that is totally separate.

Dr. Ginger Garner PT, DPT (44:26)

And I think that, yeah, I think that, I think that’s important because if someone comes out of excision surgery, and there’s not a brochure on this, We don’t have enough ⁓ surgeons, we don’t have enough therapists specializing in this. It is hard to find and build the team that you need. So it’s not like you’re gonna get the definitive,

Dr. Tracy Sher, DPT, CSCS (44:27)

or secondary.

Mm-hmm.

Dr. Ginger Garner PT, DPT (44:54)

brochure when you have surgery that’s gonna tell you what to expect. So I think it’s important to emphasize that when someone comes out of excision surgery, things could magically get better. Not magically, it’s excision. They’re cleaning it up. It should get better. But I also don’t want women to feel incredibly discouraged or even fearful when they come out of surgery and it’s not gone yet.

Dr. Tracy Sher, DPT, CSCS (45:23)

Right.

Dr. Ginger Garner PT, DPT (45:23)

it’s not

resolved yet. The hope is, the message of hope is, well, there’s a lot of healing going on for a massive surgery with tiny incisions and that it shouldn’t all immediately go away. And that if it doesn’t, it’s kind of part of the healing process and can be part of the normal journey. And yeah.

Dr. Tracy Sher, DPT, CSCS (45:37)

Yes.

Yes. And that’s where pelvic therapy can help so much

is we’re going to help with any kind of lymphatic stuff after and pelvic floor function. And there’s going to be changes in the structure and the way things move. we’re basically facilitating healing. I look at it as I’m this, I’m a guide, right? And we talk about biopsychosocial again, I’m guiding them with emotional stuff, with support, with,

Dr. Ginger Garner PT, DPT (45:59)

Yeah.

Dr. Tracy Sher, DPT, CSCS (46:08)

hands-on treatments, we’re trying to get things to really start to heal. The body wants to heal, it wants to do things, and so you’re facilitating that, that’s how I look at

Dr. Ginger Garner PT, DPT (46:15)

Yeah,

you know, one thing that I just thought of that might be really great for the listener too is, you know, we’re joking about there not being a brochure, but we could actually kind of map a little brochure for them when it comes to pudendal neuralgia because what are the factors, right? Okay, so we’ve got acute healing, they just come out of surgery, you’ve just gotten, your whole belly’s blown up, you’ve got, you know, the gas pain and oxycodone constipation and all of these things.

So here’s the map. Okay, they come out acute from excision surgery. What are the reasons that they would feel a pudendal neuralgia type symptom, or presentation there, versus subacute when they’re moving into that four to six week timeframe, versus beyond that? How are the different ways in which it could still present and in which they can be helped by pelvic therapy?

Dr. Tracy Sher, DPT, CSCS (47:09)

Yeah, that’s great. We could do handouts, by the way, as you know, we can talk about this. ⁓ The other thing too, is that sometimes, and this is also a touchy subject in the area of endometriosis, as we know, there are patients who have more of a sciatic nerve involvement or other types of nerve involvements, where, it could be by the way, actually around pudendal nerve, and it depends also on who’s doing the surgery and their experience in that way as well. So it might be that

Dr. Ginger Garner PT, DPT (47:11)

I know, we should. That’s right.

Dr. Tracy Sher, DPT, CSCS (47:38)

we’re getting, you know, there’s a huge part of the endometriosis that’s been taken care of, but there might be some other aspects to look at. again, I, I don’t want to gaslight someone and say, now it should be better. We’re just going to work on your pelvic floor because it might be that there are other elements of endometriosis still there or still to consider. And not again, not to make you feel also concerned. no, did they not get it all, but just to be mindful that it’s trying to make sure that nothing’s being missed and, looking at the whole picture. But yeah, that’s a great point about.

Dr. Ginger Garner PT, DPT (48:02)

Yeah.

Dr. Tracy Sher, DPT, CSCS (48:07)

there really could be some phases to look for and how to help after.

Dr. Ginger Garner PT, DPT (48:11)

Yeah, because when you first come out, there’s

just natural inflammation. They have just pissed off every layer of tissue trying to be very thorough about the excision. You’re not coming out of there without a great deal of inflammation. And so, as you mentioned earlier, that heaviness that they feel, the shifting and dissection of tissue, et cetera, the reaction of the local tissue and having that inflammatory response could just give you

Dr. Tracy Sher, DPT, CSCS (48:16)

Yeah.

Dr. Ginger Garner PT, DPT (48:41)

a nice case of pudendal neuralgia just because of the healing process, you know, that’s happening.

Dr. Tracy Sher, DPT, CSCS (48:45)

Yes, yes.

And again, there’s a difference between pudendal neuralgia nerve irritation where it just things feel a little bit tender or you have some discomfort there. But if there’s significant I’m talking, you know, massive genital pain, then bring it up sooner rather than later. You know, we want to make sure that you’re not being told just, don’t worry about it. You know, that is another factor to consider. But yeah.

Dr. Ginger Garner PT, DPT (49:00)

Right.

Yeah, totally.

Yeah, if you’re having those symptoms, is to bring it up because you’ll have that two day, three day follow up before you go anywhere where you can mention if that is severe. ⁓ And then as we move into subacute, ⁓ well, we know that endometriosis can be closely associated, not that every person that has endo is going to be hypermobile, but if you have tissue issues with hypermobility, it could be that that’s where again, pelvic, you know,

Dr. Tracy Sher, DPT, CSCS (49:20)

Yeah.

Dr. Ginger Garner PT, DPT (49:34)

therapy comes in because you could have a pelvic organ prolapse issue or another tissue that’s then in the subacute phase creating the same type of symptoms.

Dr. Tracy Sher, DPT, CSCS (49:44)

Yes, and that’s an important distinction is that we’re just looking to see if there’s anything else that can be irritating the nerve. There could be a variety of factors. So it’s just making sure to be thorough and looking at the whole picture and not saying, it was just endo that now that’s done, you know, we want to just make sure that nothing’s being missed.

Dr. Ginger Garner PT, DPT (50:01)

Yeah, all the parts and the pieces are in the right place.

Dr. Tracy Sher, DPT, CSCS (50:05)

Yeah,

that’s why knowing the anatomy and understanding the testing of all that really can help.

Dr. Ginger Garner PT, DPT (50:09)

Yeah, it also tamps down fear. If you know that you could expect some of these symptoms to continue, but that pelvic therapy is going to help with that and potentially entirely resolve them, you’re less afraid that, my gosh, something was missed, right? Or, my gosh, something went wrong in the surgery, or, my gosh, I’ve done something wrong.

Dr. Tracy Sher, DPT, CSCS (50:26)

Yes.

and you have support and you have another teammate in this to help you navigate it. So that’s where pelvic therapy can be really, really powerful is to know that you’re now having someone else say, okay, this is what’s been done. Now I’m going to take it from here and help again, facilitate the healing for and helping you work together as a team for sure.

Dr. Ginger Garner PT, DPT (50:48)

Yeah,

absolutely. can’t ⁓ sing the praises enough of having that contact with your team member. ⁓ I’ve had patients come out of ⁓ excision and they’re messaging me in the portal. I tell them that, I’m not sure if that’s a good patient or not, but they’re messaging me in the portal. As soon as they get to the hospital room, I feel really good. This is already better. These symptoms are better and these symptoms, I’m like, that’s wonderful.

I’m so glad that you’re not feeling afraid, right? That you’re feeling empowered, that we’ve been through this information and you know what to expect and you know if something ⁓ doesn’t feel right, that it’s a safe space to mention it. And it should be to the surgeon, it should be to your whole team. Yeah. So you can technically have these overlapping ⁓ conditions, particularly speaking with endometriosis. And then when we move into this,

Dr. Tracy Sher, DPT, CSCS (51:18)

Yes. Yes.

Yes.

Dr. Ginger Garner PT, DPT (51:45)

Hopefully restorative phase that it’s not a chronic or persistent pain phase. I think that’s where if someone still has lingering issues after excision with struggles with pudendal neuralgia, that’s again where you’re going back to the beginning. What was missed? What wasn’t listened to in their story? Did they do a new activity? Are they wanting to do something that they couldn’t do before that maybe their body’s not quite ready for yet?

And then it’s your job, you know, it’s our job to build them back up into, you know, that activity, which is where strength and conditioning and everything else comes in. ⁓ Again, to tamp down that fear so they’re not worried, I can never do those activities again. It’s that I think patients are too often told, this happens postpartum, let’s get on our soapbox for a second, Tracy. This whole one six week visit thing where they’re told you can go back to sex and running and whatever you wanna do.

Dr. Tracy Sher, DPT, CSCS (52:36)

Yeah.

everything happens

at that six, yeah, six week visit.

Dr. Ginger Garner PT, DPT (52:46)

Right, it’s like magically, your

conditions, you have the strength, you can just go and do those things. It’s like, where did that come from? Same thing is true, you know, with endo. So if you’re listening and you’ve had excision surgery and you’re still having pain and it’s been six months or it’s been a year and you’re worried that you can never do those activities again, if no one has specifically walked you through these steps that you have to get to for strength and conditioning and for more pelvic.

Dr. Tracy Sher, DPT, CSCS (53:09)

stuff.

Dr. Ginger Garner PT, DPT (53:14)

you know, health, you might need more therapy, ⁓ then that’s probably what was missed. It’s not that you necessarily can’t do what you want to get back to doing.

Dr. Tracy Sher, DPT, CSCS (53:15)

Mm-hmm.

And also just to advocate to that, I think that I can help a lot of patients, but sometimes it matters to try someone different, to see if there’s someone else that just has a different lens that might specialize more in strength and conditioning or might specialize more in post-endo surgeries, things like that. So if you’re with someone and you feel like they, you’ve gotten to a point where you’re not sure that they’re helping you, it’s not necessarily a look at that person and them specifically, it just might be that

there’s other skills that you can turn to. So that’s why I keep advocating finding people that, you know, in your area or sometimes even telehealth or working with people that can help you that might just know a little different angle instead of feeling like that’s the end of the road for treatment. There’s lots of different ways to keep navigating.

Dr. Ginger Garner PT, DPT (53:55)

Right.

Yeah.

Such an important point because

everyone has, ⁓ I love that clinicians will have laser-like focus where they’re specialized in one area. I think that is one of our strengths. But from the patient perspective, I think it’s important, we can’t overemphasize that we aren’t specialists of everything, like just in pelvic health alone. ⁓

Dr. Tracy Sher, DPT, CSCS (54:32)

Thank

Dr. Ginger Garner PT, DPT (54:34)

I

would refer to so many different people for different conditions because I don’t treat absolutely everything and none of us do. So when patients know that and we have the humility to say that, then it opens the door for them to pick up a piece of wisdom from this therapist or that therapist or whatever it may be and that might be what completes the circle for them. So they’re done.

Dr. Tracy Sher, DPT, CSCS (54:57)

Yes, I love

it when I, as you said in my bio, I love being a connector. I love it when I can connect different people and say, this is a really good match. You know, it doesn’t have to all sit on me. It’s like, there’s so many ways we can match patients to make sure they’re getting the right help.

Dr. Ginger Garner PT, DPT (55:10)

Yeah,

yeah. So talking about patient support, I think that’s really important, especially in both those areas in pudendal neuralgia and endometriosis, because there can be so much medical gaslighting, and you’re just given the runaround. And then, like I said earlier, you learn to gaslight yourself. When we talk about support and advocacy, what advice do you have for patients in navigating this health care system that

Dr. Tracy Sher, DPT, CSCS (55:21)

nothing.

Dr. Ginger Garner PT, DPT (55:38)

may not understand pudendal neuralgia that well.

Dr. Tracy Sher, DPT, CSCS (55:43)

Yeah, think, gosh, I wish I could tell you there was an easy way. There are support groups and things out there and they do have people listed as people who really specialize and understand pudendal. That can be helpful. I think, again, it’s important to see what they specialize in because some people primarily specialize in pudendal nerve surgeries. So you might not need that or you might not even need to consider that yet. ⁓ I would say people who specialize in pelvic pain

and or if they have in their bios that they specifically do something to Pudendal Neuralgia look for that, ask, call and say, do you specialize in pelvic pain? Do you specialize in Pudendal Neuralgia? Ask those questions, I think can be really helpful because there are many people that simply just don’t, haven’t taken the courses or don’t understand a lot about that. And they specialize more in urinary incontinence and those kinds of things. So it matters. They’ll certainly try to help you, particularly in rural areas where there might be the only person there that does pelvic therapy.

And so I’m a big advocate of at least trying and seeing what they can help with. But the more that you can see, ⁓ belong to, I’ve been a board member and I’ve belonged to International Pelvic Pain Society for many, many years now, probably gosh, going on 20 years. And I would say that group is heavily dedicated to pelvic pain and pudendal neuralgia types of symptoms. So if you find in, you if you go to International Pelvic Pain Society, that website and see the practitioners there.

Dr. Ginger Garner PT, DPT (56:39)

Right.

Yeah.

Dr. Tracy Sher, DPT, CSCS (57:04)

⁓ There’s certain organizations that really, and Nancy’s Nook is another great one as we know for endometriosis. And again, some of those practitioners really help and understand pudendal neuralgia. And again, just keep looking, searching and asking. ⁓ And if you need, I sometimes just say, can reach out to me, see if there’s anyone in your area too.

We do have a directory in at pelvicglobal.com and we try to tell people to put in their bios as well if they really specialize in pelvic pain or pudendal neuralgia or other kinds of things like endometriosis, really put that there so that people can find you. So we’re really trying to do our part in a global directory that crosses the world in terms of pelvic specialists.

Dr. Ginger Garner PT, DPT (57:38)

Yeah.

Yeah, that’s so important

and ⁓ I know so many people use that, so I’m glad that you actually started that. That’s been super helpful because although APTA and other like IPPS will have their find a therapist ⁓ search engines, we need more than one or two or three. We need a lot because it can be very difficult as the listener knows. It can be very difficult to find what you need.

Dr. Tracy Sher, DPT, CSCS (58:03)

Yeah.

Yes.

Dr. Ginger Garner PT, DPT (58:15)

What would you say to family members and partners who trying to support someone living with this? How can they best support them?

Dr. Tracy Sher, DPT, CSCS (58:24)

I think it’s just to know that ⁓ the person dealing with genital pain already feels a lot of shame. And a lot of times there’s a lot of dysfunction, whether it’s bowel, bladder, or sexual dysfunction, or feeling that they’re less than. So many of my patients say things like, I just don’t feel like myself anymore. I feel like I’m less than. I feel like I need so much more support. it’s one of those things that I would just, and by the way, I would say that the nice thing is that many of the patients I see when they come in with a spouse or partner,

or family member, those family members are so supportive for the most part. I I’m so, I feel so happy for a person to have that support. So I would just encourage you just to keep trying to support and just like we were talking about earlier, being an advocate for them and seeing if you can help navigate the system a little bit. In fact, a lot of times I ask, well, how did you find me? For example, you know, I’m always curious to know where people have come from. I have people that come from India and Japan and all over the world.

And I’ll say, how did you find me? they say, well, I listened to, for example, a podcast of my family. You know, my family member told them they need to go see you. So these, you can become such a huge advocate by getting the right people and listening to people and finding, finding those, those people that can help your, your loved one. So I think that’s really beautiful when you see them really advocating and just knowing that the system is stacked against you in a lot of ways, when you have pudendal neuralgia and other kinds of pelvic pain disorders.

Dr. Ginger Garner PT, DPT (59:42)

Yeah.

Dr. Tracy Sher, DPT, CSCS (59:49)

It really feels like, you I will never forget another story where someone said they waited for, I think it was six months to see a specific urologist and they were so excited. They finally walked into the urology office and she said she was shocked. She walked in, he grabbed the paper and looked at the diagnosis, pudendal neuralgia and something else that was on it. And he said, Oh, why are you even here? I don’t even, I can’t help you. I don’t even know what pudendal neuralgia is. Like, why are you even here? And put the paper down.

Dr. Ginger Garner PT, DPT (1:00:16)

goodness.

Dr. Tracy Sher, DPT, CSCS (1:00:19)

And I mean, she just immediately started crying because she had been waiting and waiting to finally get some answers and thought that this person would be able to help. So the more that we can keep guiding people to those that really have advocacy and really care about pelvic pain, pudendal neuralgia, endometriosis, all those kinds of issues and conditions that will be really helpful. So I wish I could tell you there’s an exact specific way, but keep looking.

Dr. Ginger Garner PT, DPT (1:00:26)

Hmm.

Yeah, well,

and I think that speaks to the broader impact and it also speaks to clinical education and the way healthcare providers are educated that those are the ways in which things can be improved in recognizing and treating pudendal neuralgia because if someone is in neurology, they should know that. They should know they don’t know necessarily or they might know of some, but they should have a list of resources instead of.

Dr. Tracy Sher, DPT, CSCS (1:01:11)

Yes.

Dr. Ginger Garner PT, DPT (1:01:12)

doing what they did to that patient, which was just absolutely horrible.

Dr. Tracy Sher, DPT, CSCS (1:01:16)

And that’s how that

patient back months. I they said they gave up months. mean, it breaks my heart on a daily basis when I see these cases because they feel like, like you said, they’re either a gaslit or just such nocebic negative stuff that they feel like they just aren’t heard. And that’s why it’s so beautiful to have different practitioners, whether it’s a pelvic floor therapist, whether it’s physicians, nurse practitioners.

Dr. Ginger Garner PT, DPT (1:01:19)

Yeah, right.

Dr. Tracy Sher, DPT, CSCS (1:01:43)

There’s variety of different paths. So that’s where it doesn’t just have to only come through pelvic therapy first. It can be an amazing physician. It can be a nurse practitioner, but it’s just finding people that are helpers that are really willing to help.

Dr. Ginger Garner PT, DPT (1:01:55)

Yeah, yeah. Are there any emerging research areas, treatments, et

cetera, that are giving you hope?

Dr. Tracy Sher, DPT, CSCS (1:02:02)

⁓ that’s a good question. ⁓ I think, gosh, I’m trying to think if there’s anything that it’s, tricky because it’s more of the training. So for example, I have been really encouraged by IPPS doing more training on symptoms and looking at, they have a really nice, history taking process they go through that you can access online there for that, for them. And so I feel like there are, we’re getting better at asking the right questions about pelvic pain and really trying to delineate more.

of what could be going on. In terms of emerging treatments, interestingly, something like a shockwave treatment, it’s ⁓ interesting because there used to only be one or two people up in Canada, this was 10 to 13 years ago. And I would always say be really leery of it because it’s just, it would be painful for patients and it was terrible at the time and they didn’t necessarily get better. Well, now we have new shockwave types of units out there that seem to be really promising for people with these kinds of pains.

So again, I haven’t dealt with it too much yet. I’ve just started looking into it and they can be expensive for a practitioner to get. So not everyone has them yet, but it seems like an interesting emerging in terms of local tissue issue. And someone has pudendal types of symptoms. This could be an, as you said, maybe some emerging stuff there.

Dr. Ginger Garner PT, DPT (1:03:05)

Definitely, yeah.

It does.

It does. I just had a demo in my office the other week. And yes, you’re right. Those machines are very expensive, but they’ve evolved so much. And I actually had just demo treatments done. A, it’s not painful. ⁓ It’s ⁓ very tolerable. ⁓ the emerging research on red light therapy and different things like that and CBD. ⁓

Dr. Tracy Sher, DPT, CSCS (1:03:20)

Yeah.

Yes.

Dr. Ginger Garner PT, DPT (1:03:45)

And also technologies that weren’t available to us even over five years ago that many of us are utilizing in clinic like musculoskeletal ultrasound imaging that is more affordable and super relevant to pelvic health so it is easier to do imaging in the office ⁓ for therapy. So many cool things.

Dr. Tracy Sher, DPT, CSCS (1:04:02)

Yes,

yes, it’s true. And so we’ll see what happens with the there’s, you know, pain simulators, all the the DRGs and some of the other kinds of dorsal root ganglion types of stimulators and things. I’ve been watching that for a while and I can’t say it’s a home run just yet. But there’s some patients that do find the stimulators are really good. So neurostimulators are still something on my radar to see is there’s something that can help some of these patients. But again, a lot of times I find there’s another root cause before they even need to get that. But you know,

Dr. Ginger Garner PT, DPT (1:04:26)

Yeah.

Dr. Tracy Sher, DPT, CSCS (1:04:31)

they’re really desperate that could be a potential steal.

Dr. Ginger Garner PT, DPT (1:04:31)

Mm-hmm.

Yeah, yeah, absolutely. Thank you so much for this discussion. It has been so full and I just really appreciate your insight and wisdom on everything. If you would share ⁓ with everyone where they can find you.

Dr. Tracy Sher, DPT, CSCS (1:04:38)

You’re welcome.

Okay. ⁓ Yes. So ⁓ my, so the best way to find me on social media is pelvic guru 1 which is on Instagram. So pelvic guru 1 P E L V I C G U R U 1 the number 1 And that’s on Instagram. We do have a professional one to pelvic global. And then my practice is a sher pelvic.com. So S H E R P E L V I C.com.

That’s where I my private practice. ⁓ Unfortunately, I’m only one person in the practice at the moment. So it’s been, you know, ⁓ long waits to get in and I apologize and I try my best with telehealth and other ways to help. ⁓ And that’s why I love doing this because I love to be able to impart information to as many people as possible so that you can feel empowered and not have to only rely on one person. But ⁓ yeah, so those are some of the ways you can find me.

And ⁓ yeah, reach out if you want to try and, and then again, pelvicglobal.com, if you want to find the directory of all the pelvic health professionals. We have it across multidisciplinary and we have it really where it’s across the globe on purpose so that if you’re looking for someone in Paris or someone in Indonesia, there’s a chance that they’re in the directory, but we’re trying to grow that as much as we can.

Dr. Ginger Garner PT, DPT (1:06:10)

which is fantastic. Thank you so much.

Thank you so much for being here, Tracy.

Dr. Tracy Sher, DPT, CSCS (1:06:13)

You’re welcome. I love

talking about this and I appreciate the opportunity. Thank you, Ginger.