(A mural near United Nations in NYC)

I'm so excited that it's that time of the year again! Spring is my most favorite season :) As the days start to get longer, my body begins to thaw and emerge from the shadows of dark and cold winter. I notice this newfound vigor to engage with life once again.

I think spring could be a great time to finally implement all the self-reflections we go through during our hibernation in winter. And in this blog post, I wanna talk specifically about how we can use this change in weather to make some meaningful changes in our lives as well.

Someone wise once said "Self-care beings with self-awareness", (I am pretty sure I came up with this quote but don't wanna run the risk of plagiarism so will go with someone wise :P) and to make any meaningful changes in our lives we must first understand and accept who we really are (self-awareness)!

I don’t think I would be taking any liberties if I said that most of us are not aware of what is going on with us or our bodies and when we do realize that something is off, we are very quick to find excuses/rationalizations for our behavior = hence no real change occurs. Most of us who have some type of chronic condition are very well aware of how lifestyle factors impact our health; however, we can find ourselves saying things like:

• I can’t exercise because I don’t have time or ⁣

• I don’t have access to a gym

• It hurts if I attempt any exercises (not my intention to dismiss anyone’s pain) etc.⁣

• I have too much on my plate and can’t really find time to prepare a healthy meal

And at the risk of sounding preachy, you’ll find me saying things like:

• Self-awareness is everything ⁣

• No one can know your body/mind better than yourself⁣

• 𝘗𝘢𝘺 𝘢𝘵𝘵𝘦𝘯𝘵𝘪𝘰𝘯 and find what works and what doesn’t for your unique body instead of following my instructions to the ‘T’⁣

• I am here to guide you and aid in the recovery process, not to 𝘧𝘪𝘹 𝘺𝘰𝘶. ⁣

And I can assure you that you will find yourself much more empowered if you take an active role in your recovery and pay attention to not just your body but also the circumstances that affect it and the excuses your brain comes up with that keep you from making successful changes.

I recently had this ‘Aha’ moment when I realized that I am looking for excuses only because I didn’t want that thing ENOUGH! Although I’ve been trying to make some changes in my life, they didn’t really happen until I became aware of my brain’s tricks and finally rid myself of these excuses and really decided from deep within that was what I wanted to do. ⁣

Trust me, all the pressures lifted off and I feel so much clearer about my decisions. And since then, I feel more aware of the excuses I make (to myself) that act as my 𝘣𝘢𝘳𝘳𝘪𝘦𝘳𝘴 and this awareness alone has enabled me to work with a lot more 𝘤𝘭𝘢𝘳𝘪𝘵𝘺. ⁣

What are the barriers that are keeping you from recovery?

Xx

Mukta

March is Endometriosis Awareness Month.

This gives us the perfect opportunity to talk about IBS (Irritable Bowel Syndrome). IBS can either co-exist with endometriosis or worse, mask it, further delaying its diagnosis. At present, endometriosis is diagnosed anywhere from 7 to 12 years after the onset of its symptoms.

But what is endometriosis? Endometriosis is characterized by the presence of tissue that is similar to, but not the same as, endometrial tissue. However, unlike endometrial tissue which is present inside the uterus, this tissue is disseminated outside the uterine cavity. Endometriosis is frequently present with painful and heavy menstruation and is therefore often misrepresented as a reproductive disease. However, many studies have found its presence outside of the pelvis, in the colon, lungs, diaphragm, eyes, and even in the brain - in other words, quite far away from the reproductive system.

Endometriosis, when present in the colon (the most common site outside of the pelvis), can give rise to symptoms very similar to IBS. 

Symptoms like abdominal pain, bloating, distention, diarrhea & constipation sound like something must be wrong with the gut, so it is quite common to summarily implicate the GI system and arrive at a diagnosis of IBS. However, inflammation caused by endo lesions can cause similar gut symptoms in the absence of IBS.

Let’s see how IBS is usually diagnosed, particularly since it doesn’t have a gold standard test, and colonoscopy is inadequate to correctly diagnose it.

IBS is diagnosed based on:⁣

❗️your symptoms⁣ 

❗️detailed history⁣

❗️ruling out red 🚩 such as unexplained anemia, blood in stool, family history of colorectal cancer, or IBD⁣ (irritable bowel disease)

❗️Physical exam - should be normal⁣

❗️and most importantly— the Rome IV criteria⁣

According to the 𝗥𝗼𝗺𝗲 𝗜𝗩 𝗰𝗿𝗶𝘁𝗲𝗿𝗶𝗮 :⁣

IBS is a functional bowel disorder, in which recurrent abdominal pain is associated with defecation or change in bowel habits.⁣

🔹 Disordered bowel habit should be present - constipation, diarrhea, or a mix⁣

🔹 Symptoms onset should occur at least 6 months prior to the diagnosis & symptoms should be present for the last 3 months.⁣

🔹 Abdominal pain should last for at least 1 day per week  in the last 3 months ⁣

 ➕⁣

🔹 Should be associated with 2 or more of⁣

- Related to defecation⁣

- Change in frequency of bowel movement⁣

- Change in the form of stool⁣

Endometriosis, on the other hand, can only be effectively diagnosed with laparoscopic surgery, which unfortunately is not readily accessible for a majority of the world population. Advances are being made in the use of ultrasound and MRI (Magnetic Resonance Imaging) for the diagnosis of endometriosis, but these tools are still unable to detect all types of lesions, and the success rate is heavily dependent on the skill of the radiologist studying the imaging. 

❌ Colonoscopy is not a great diagnostic tool for Endo either, as it only picks up the bigger lesions invading the lining of the colon.

✅ Rome IV criteria are essential to properly rule out IBS. However, a thorough history & review of other systems are also important as fluctuation in symptoms can really complicate things & confuse the clinician.⁣

⁣✅ Similarly, to rule out Endo, a detailed history & seeing an Endo specialist are super important, especially if regular IBS treatment is not addressing your IBS symptoms, and you notice fluctuations in your symptoms in relation to your menstrual cycle.

⁣

Was Endometriosis properly ruled out for your IBS-like symptoms? 

References:

Endometriosis and irritable bowel syndrome: A systematic review and meta-analyses. PMID: 35957857

Intestinal endometriosis: the great masquerader. PMID: 15341718

What would be your first reaction if I told you that working on your hip mobility could help fix your constipation? 

Surprise? Disbelief? Mistrust?

I am not kidding about it AT ALL, and I promise there is no voodoo involved in this relationship!

“Everything in a human body is connected” is a phrase we have heard often from our healthcare providers. We often remind ourselves of it too, as we try to make sense of the pain that travels from one region to another. But oddly enough, we seldom pay attention to other bodily functions that run on auto-pilot or wonder how they get affected by other systems of the body. Take digestion as an example. We often assume that as long as we eat healthy, it will work smoothly. But, while it is super-important to control what we ingest, there is a lot more to good digestion than just food intake.

Now, getting down to brass tacks— let’s see how our hip and gut go hand-in-hand.

1. Impacting the Pelvic Floor: 

Let’s start with the most obvious relationship. The Rectum, which is the end of the GI tract, ends in the pelvic region, where it is well-supported by the pelvic floor. In fact, the muscle Puborectalis creates a kind of sling around the rectum to keep it closed, thus preventing leakage!! The pelvic floor is essentially a group of muscles located inside the pelvis and connected to the hip muscles on either side. In fact, two of the hip muscles, the Obturator internus, and Piriformis, link directly to the pelvic floor. A lack of mobility in the hip, tightness in hip muscles, or poor stability, can create tension or overactivity in the pelvic floor muscles. And if you remember, we need a pelvic floor that is able to expand and relax well to have good bowel movements. Tightness in the pelvic floor can give rise to puborectalis dyssynergia (outlet obstruction), which can cause difficulty in voiding, the need for excessive strain, ribbon-like bowel movement, and eventually constipation.

2. Impacting the Cecum and the Sigmoid Colon: 

As we know, the colon or large intestine begins at the cecum and ends in the rectum. It is responsible for propelling feces along the colonic plumbing with the help of the smooth muscular contractions happening on the inside of the colonic tube. This smooth muscle contraction is what is called the peristaltic movement. Although the smooth muscles are pretty independent and mostly function under the influence of the autonomic nervous system, the skeletal muscles present around the gut also have the ability to influence this motility through fascial connections. 

Two such connections exist, one on each side of the pelvis: one on the right side of it, between the cecum and the hip muscle Iliacus, and another on the left side, between the sigmoid and the Iliacus. The movement of the hip towards the body, referred to as hip flexion, not only creates movement on the right side of the pelvis, but the resulting contraction of the Iliacus directly stimulates the cecum as well, both aiding the peristalsis.

3. Impacting the Ascending and Descending Colons: 

Another important hip muscle, the Psoas Major, originates from the front part of the T12 to L5 spinal vertebrae in the abdomen, passing behind the ascending colon on the right side and the descending colon on the left before connecting to the femur (the hip bone). Psoas influences the peristalsis in the ascending and descending colon the same way as Iliacus does through muscular contractions and hip movement.

4. Impacting the diaphragm:

It is no mystery that the diaphragm plays an important role in stimulating gut motility by directly influencing the GI organs as it moves up and down with each breath. The Psoas is also fascially connected to the diaphragm and influences the dynamics of respiratory function, thus contributing indirectly to gut motility.

Still not convinced? Did you know that some people experience fecal urgency during a run — most likely due to an excessive movement of the cecum/ascending Colon in relation to the rhythmically contracting and lengthening Psoas Major muscle?!

So, if this muscle is capable of giving some people Runner’s Trots, why not use this capability to your advantage and cure your constipation?

So what are you waiting for? Get those hips moving!

References:

Marco A. Siccardi; Muhammad Ali Tariq; Cristina ValleAnatomy, Bony Pelvis and Lower Limb, Psoas Major. https://www.ncbi.nlm.nih.gov/books/NBK535418/

Scott Mawer; Ali F. Alhawaj.Physiology,Defecation.

https://www.ncbi.nlm.nih.gov/books/NBK539732/

Have you ever wondered what’s common between hemorrhoids, anal fissures, and rectal prolapse?  Yes, you are right, all these conditions affect the rectum and the anus, but there’s more to it than that! 

Did you know that chronic constipation can cause all these issues if not addressed in a timely manner?

Chronic constipation brings along the problem of chronic straining, which increases the pressure on all the pelvic organs, blood vessels in the pelvic region, as well as the pelvic floor muscles. 

This increase in pressure on the veins in the lower part of the rectum and the anus causes swelling and inflammation, which ultimately gives rise to hemorrhoids. Increase in pressure on these veins is also the reason hemorrhoids are so common during pregnancy. 

The straining to force a bowel movement can also cause overactivity or tightness in the pelvic floor, as these muscles have to work harder to combat/offset the pressure coming from the top. This affects the pelvic floor muscles’ ability to effectively contract and relax, rendering them dysfunctional. This pelvic floor dysfunction is responsible for what is clinically referred to as outlet obstruction or puborectalis dyssynergia, which further perpetuates the vicious cycle

Trying to force a hard bowel movement through tight pelvic floor muscles can really stretch out the mucosal lining of the anal canal beyond its capacity, resulting in tearing, aka anal fissures.

Last but not least, chronic straining due to constipation can also cause rectal prolapse. Rectal prolapse is a downward displacement of the rectum in the anal canal or a forward protrusion towards the vaginal canal. Generally, this is triggered by reduced support to the rectum or the thinning of the wall between the V@gina & the rectum. The prevalence of constipation is as high as 67% in people with rectal prolapse. 

Rectal prolapse can create two issues:

1. Pocketing of feces, and feeling of incomplete voiding— Reduced support of the rectum can affect its ability to push the feces out effectively. The protrusion of the rectum through the vaginal wall (Rectocele) creates a small pouch where the hard feces can get stuck leading to incomplete voiding.

2. Anal incontinence. This refers to the condition where the anus loses its ability to control the feces, resulting in leakage.

To avoid all these issues, Type 4 smooth sausage-like bowel movement is the most desirable! However, we have to be careful about the straining. 

Treating the root cause is obviously the most important thing here! Constant straining increases the pressure on the pelvic organs, and creates tension in the pelvic floor muscles, ultimately causing pelvic floor dysfunction. The overactivity in the pelvic floor can make things worse, perpetuating the vicious cycle.

Along with the dietary changes & improving the hydration to address constipation, you should also:

•  Address the straining: Do not hold your breath and push with all your might. Instead, use the sound 'Moo’ for poo. 

•  Use a squatty potty or a step stool to position your pelvic floor in a more relaxed state.

•  Address your hypertonic muscles through pelvic floor physiotherapy

•  Learn to manage pressure while lifting— again avoid straining and breath-holding. Try exhaling while lifting or use the cue “blow before you go!”

•  Engage in regular exercises to improve gut motility.

Hope this was helpful!

Xx

Mukta

I am sure if you’ve been in the constipation business long enough, you must have heard of the Bristol Stool Chart and how it helps to track your day-to-day affairs!

Although normal bowel frequency has a wide range from 3 times per day to 3 times per week, it all boils down to the quality of the poop and that’s where the Bristol stool chart comes into the picture.

And it’s no mystery that with poop, as with life, consistency is everything (both with frequency and quality)😏.

This regular monitoring not only alerts us to take appropriate steps to prevent constipation before it becomes a full-blown 🤢 problem but also helps us keep track of our progress in resolving constipation and improving our overall gut health.

There is a lot of truth to Hippocrates' statement: "All disease begins in the gut”!! Good poop is usually considered a sign of good sleep, healthy digestion, a balanced nervous system, and a resilient & healthy pelvic floor.

As you can see in the picture, 𝗧𝘆𝗽𝗲 𝟰 is a clear WINNER 👑!! But, don’t be too relieved 😅 (pun intended) if you are having a 𝗧𝘆𝗽𝗲 𝟲 or 𝟳, thinking you are having diarrhea and therefore don’t have constipation ❌. 

⁣In chronic constipation, the stool gets impacted, meaning it gets stuck in the colon and the rectum gets distended. It becomes impossible to push it out 😥!!

The newly formed waste material (as a result of digestion) therefore, is eliminated by the body in form of loose stool (diarrhea), as the colon loses its optimal function of crafting a fully formed stool by absorbing excess water.

Sometimes, it can even lead to losing the ability to hold the feces, known as fecal incontinence. Not because the sphincter becomes weak all of a sudden and loses its ability to control the bowel movement, but more because this liquid stool comes gushing down so powerfully (fecal urgency) that even the sphincter muscle gives up, resulting in leakage.

The impacted stool is usually diagnosed with a flat-plate X-ray and can be treated with an enema or colon prep. However, please do not attempt it without discussing it with your doctor first. (Will discuss colonics in a future blog post).

Therefore, learning the signals of our body in the form of our poop by following the Bristol stool chart can help uncover different lifestyle factors that affect our gut health! ✅.

And if you’ve come this far, keep on reading to learn what you can actually do to ensure a good poop on a consistent basis. I wanted to give you a 360-degree perspective on improving your gut health, which is frequently and very quickly blamed on the food we eat. Don't get me wrong… what we eat is important! But, just like with many other systems in the body, gut health also depends on multiple factors, not just food and fiber! This food blaming has actually created an unprecedented amount of fear around food resulting in a disordered relationship with it, negatively impacting mental health as a consequence.

So here are a few (non-food related) things for you to consider and follow to maintain good gut health.

GI system functions like a clockwork ⏰ and is actually a ‘creature of habit. Taming it is not really that hard as long as you follow these habits:

⁣💩 1. Practicing sleep hygiene and waking up at the same time every day.⁣ 

💩 2.  Learning to notice the urge— it usually comes shortly after waking up.⁣ It could look different for different people. Some people feel pelvic pressure, some would feel lower belly pressure and some may even feel cramping/ pressure in their upper belly. Ignoring the urge is when the problem of constipation usually begins or gets worse!

💩 3. Establishing a time for using the bathroom, and try to stick to the same time every day. Using the bathroom ONLY per your convenience interferes with the communication between your brain and your rectum. If you ignore the urge to use the bathroom later between your meetings, the poop will get pushed back up and your brain probably won’t alert you again, thinking probably it’s not something of importance.

💩 4. Calling gastrocolic reflex to action. If your urge is not very reliable for some reason, you could take advantage of this cool reflex of the GI (gastrointestinal) system. The gastrocolic reflex gets activated 30-40 min after having breakfast in the morning and stimulates the rectum to empty itself to make room for the incoming traffic (newly ingested food). So please don’t miss your breakfast!

💩 5. Calling into action the parasympathetic nervous system by having a more relaxed morning, practicing breathing exercises, or meditation. Digestion and elimination are parasympathetic nervous system activities-- meaning rushing in the morning to get out the door will most likely turn off the parasympathetic drive and hence that Nature’s Call!

💩 5. Practicing movement- some form of exercise in the morning is a wonderful way to help stimulate the gut which can help you go. 

Check out this video to learn an exercise sequence for this.

PS: My little secret that cured my own constipation was really taking my time in the morning to eat my breakfast.

I hope you find these tips helpful :-) 

XX

Mukta

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I love feet. And not because I have some kind of foot fetish. Well ok, maybe a little! But my “fetish” is purely clinical: I am truly mindblown by what I consider one of the most marvelously-built parts of the human body. Yet, for some reason they are often maligned. They are called ugly, and are taken for regular pedicures to make them look acceptable. They are called weak, and are supported with arch supports, soft soles or shoes with the latest technology.

Feet don’t just exist to take us from Point A to Point B. They are also inherently linked to the pelvic floor, and thus our pelvic health. Keep reading to learn more about this connection. 

Let’s first learn about the intricate beauty that our feet possess:

They aren’t the rigid block they are often treated as, but host 28 bones, 33 joints, and over 100 muscles & ligaments!! All these structures come together to give them flexibility, strength, and resilience to keep this exquisite machinery running!

We all know about the arch in the foot, but how many of you know that there are not one but two arches in the foot?

🔹The longitudinal arch: Runs from the heel to the big toe and helps in transmitting the weight from the back of the foot (heel) to the front (toes). It also acts as a shock absorber to shield the impact of running/walking/jumping etc.

🔹The transverse arch: Spans across the ball of the foot from the 1st to the 5th toe.⁣ This acts like a springboard for the toes to push from. But that is not all it does – it also helps distribute our weight evenly.

In summary, these arches provide rigidity/stability to our feet, which is critical to bearing our body weight and propelling our bodies forward for locomotion. But this is not all they do! They also provide the flexibility we need by acting both as springs (storing and releasing energy that further helps locomotion) and as shock absorbers (absorbing the shock from the impact of our feet with the ground).

Now, let’s talk about why you might still be reading this post: What is the connection between your feet and your pelvic floor? Why do I often tell my patients to take good care of their feet in order to keep their pelvic floors happy? And by “care”, I don’t just mean weekly spas and pedicures (though those are great as well!) but actually making sure that your feet are getting the nourishment they need from the strengthening and flexibility exercises. 

Let’s look at a few interesting facts about why you need to take special care of your feet, especially if you are someone with pelvic floor dysfunction:

• GPS coordinates of the foot and our genitals are right next to each other on the ‘Somato-sensory Homunculus’. For the uninitiated, Somato-sensory Homunculus is the part of the brain that receives sensory information from different parts of the body, with the feet and genitals sitting right next to each other on it.  So, it’s hardly surprising that these two regions talk to each other. It’s like accidentally receiving mail that belongs to your neighbor - the issues in the feet can be felt on the pelvic floor, and vice-versa. I often find overactivity in the pelvic floors of people with chronic ankle instability (multiple ankle sprains).

  

• Both of these regions are also supplied by nerves with overlapping nerve roots (origins) from the spinal cord. The pelvic floor is supplied by the S2, S3, and S4 nerve roots, whereas the feet are supplied by L4, L5, S1, S2, S3, and S4. This makes them prone to cross-talk. 

• Both the pelvic floor and the feet function as shock absorbers during walking/running/jumping. Therefore, if the feet don’t do their job well, the pelvic floor may have to work extra hard, and can get overactive as a result. A study showed a statistically significant association between decreased foot flexibility and urinary incontinence.

A recent study also showed that the ankle position influences pelvic floor strength – whereas dorsiflexion positively influences strength, the plantar flexion influences it negatively. Attention high-heel wearers: you may experience low resting tone (reduced strength)  in the front of the pelvic floor that supports the urethra, and as a result, you may be at a higher risk of urinary leakage, especially if you already have stress incontinence.

⁣

Majority of my patients tell me that they were told that they have flat feet, and they have used everything from arch supports to the best shoes in the market,  but I often wonder how different their experiences would have been had they been told to train their feet just like any other body part.

The problem is usually not the flatness of the foot as many people claim, but rather poor flexibility and strength in the small joints and the muscles of the foot… how many did we say? 33 joints and over a 100 muscles & ligaments!! This issue becomes even worse as we provide them with more and more support in the form of arch supports etc., and never bother to train them with the right combination of strength and flexibility workouts. 

I’m curious: when exactly did we decide to be so overly protective of the one body part that’s supposed to do all our dirty work? When did our feet go from being probably the strongest part of our bodies in our hunter-gatherer days, to such small and rigid parts that can barely support the weight of a fully-grown human today? And why would we want to cage this beautiful creation from a very early age? Evolution developed the arch by walking barefoot and now we need arch supports to protect them?  how did we regress this far?⁣

⁣

I appeal to all of you to be kind to your feet… they don’t need to be pampered with a pedicure or new shoes as much as they simply need to touch the ground. Free ‘em! 😇⁣

Further reading:

1. Nygaard IE, Glowacki C, Saltzman CL. “Relationship between foot flexibility and urinary incontinence in nulliparous varsity athletes.”, Obstet Gynecol. 1996 Jun;87(6):1049-51. doi: 10.1016/0029-7844(96)00079-8. PMID: 8649689.

2. Kannan P, Winser S, Goonetilleke R, Cheing G. “Ankle positions potentially facilitating greater maximal contraction of pelvic floor muscles: a systematic review and meta-analysis.”, Disabil Rehabil. 2019 Oct;41(21):2483-2491. doi: 10.1080/09638288.2018.1468934. Epub 2018 May 7. PMID: 29733699.

3. Tang A, Bordoni B. Anatomy, “Bony Pelvis and Lower Limb, Foot Nerves.”, [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537292/

Are you someone who started experiencing pain with intercourse after getting diagnosed with a labral tear?

Or feel a deep pain in the groin after every run that you can’t tell if it’s coming from your hip or the pelvic floor?

And what about the deep buttock pain? Is it your piriformis (hip muscle) or coccygeus (pelvic floor muscle) that sits right next to the piriformis?

What is this mystery here? And what is the connection between the pelvis and the hip?

Well, we all know that the pelvis and hips sit next to each other in our bodies; so, it shouldn’t be a huge surprise that they impact each other in some manner (in fact, the hip bone femur connects to the pelvis to form the hip joint). Even though we can see that these two regions are connected, most healthcare providers do not ask questions about pelvic health when a patient walks in with a complaint of hip pain or vice versa.

Understanding how exactly the hip and pelvis support each other and which anatomical structures they share can really help assess a variety of pelvic conditions, ranging from pelvic floor dysfunction to urinary urgency and frequency, and from dyspareunia (painful sex) to even constipation. Unfortunately, if this assessment isn’t done thoroughly, the root cause can be easily missed and the problem can eventually turn chronic. 😥

So, let’s learn about some of the structures that are shared by these two neighbors:

MUSCLES:

Most hip muscles connect to at least some part of the pelvis. So, pelvic movement/mobility can definitely affect the length-tension relationship of these muscles. For example, all the adductor muscles connect to the inferior pubic ramus and ischial ramus (both are a part of the pelvis). But let’s look at two specific muscles that lie very close to the pelvic floor muscles and can affect their function:

1. Obturator internus (OI): a deep stabilizer of the hip joint; it is also considered a part of the pelvic floor and forms its sidewalls. OI is an external rotator of the hip and its fascia produces a sheath that forms Alcock’s Canal in the pelvis, through which the pudendal nerve, artery, and vein pass through, after crossing the ischial spine. OI can be confused with hip labral pain and can create symptoms of urinary urgency/frequency. Alcock’s canal is one of the common areas where the pudendal nerve can get entrapped and cause issues such as burning, and stabbing pelvic pain.

   

2. Piriformis: a deep hip stabilizer that also rotates the hip externally. It isn’t considered a part of the pelvic floor but sits right next to the Coccygeus muscle in the pelvic outlet. When overactive/tense, it can cause deep buttock pain and can also trap the pudendal nerve. Compression of the pudendal nerve can then create overactivity in the pelvic floor muscles along with burning and stabbing pelvic pain. 

3. Hypermobility of the hip joint: Pelvic floor dysfunction is quite commonly seen in people with hypermobility of the hip joint. Due to either weakness in the hip musculature or a lack of stability of the joint itself, pelvic floor muscles often end up taking up the slack of its not-so-strong neighbor. This additional work of providing stability to the hip joint, therefore, sometimes leads to pelvic floor dysfunction.

NERVES:

The pelvic region is richly supplied by a web of nerves owing to its multiple life-sustaining functions. The nerves ilioinguinal, genitofemoral, and posterior cutaneous femoral nerve provide an overlapping supply to both the hip and the pelvic region, such as the groin, inner thigh, external genitals, and the perineum region, which could be easily confused with the pudendal nerve, and therefore, often times gets misdiagnosed.

1. Genitofemoral Nerve: primarily a sensory nerve that arises from the L1 and L2 nerve roots of the spinal cord:

• Provides sensation to:

  • Upper thigh region

  • Front of the scrotum

  • Mons pubis and outer labia

• Provides motor function to:

  • The Cremaster muscle and helps retract the testes and is responsible for the ‘Cremaster Reflex’ 

2. Ilioinguinal nerve: primarily a sensory nerve that arises from the T12 and L1 nerve roots of the spinal cord:

• Provides sensation to:

  • Pubic symphysis

  • The top inner part of the thigh

  • Outer labia 

  • The root of the penis and the front of the scrotum

• Provides motor function to:

  • Trasnverse abdominis and Internal oblique⁣ muscles (in the abdomen)

3. Posterior Cutaneous Femoral nerve: primarily a sensory nerve that arises from the sacral plexus with nerve roots S1-3. Different branches provide sensations to different areas:

• Provides sensation to:

  •  Inferior cluneal nerve: outer and lower parts of the buttock

  •  Perineal branch: supplies the back of the outer labia and the scrotum

  • Cutaneous branch: supplies the skin of the back of the thigh, inside of the thigh all the way to the popliteal fossa (back of the knee).

4. Pudendal Nerve: is a mixed nerve with both sensory (provides sensation) and motor function (supplies muscles). It arises from the sacral nerve roots (S2, S3, S4) of the spinal cord.

• Provides sensation to:

  • Perineal skin⁣

  • Inner & outer labia, back of the scrotum

  • clitoris and penis⁣

• Provides motor function to:

  • Pelvic floor muscles ⁣

  • Urethral Sphincter ⁣

  • External anal sphincter ⁣

    And thus helps us stay continent

LIGAMENTS:

1. Sacrotuberous Ligament: originates from the sacroiliac (SI) joint capsule, sacrum, and coccyx and attaches to the ischial tuberosity (sit bone), where it blends with the fibers of the biceps femoris Tendon (part of the hamstring muscle) and provides an extensive base for the gluteus max insertion. Any change in the mechanics of the pelvis can create tension in these muscles (or vice versa), commonly resulting in pain with sitting.⁣

2. Sacrospinous Ligament: connects the sacrum to the ischial spine in the pelvis and creates the greater sciatic notch through which the sciatic nerve passes. Should be carefully differentiated from the pudendal nerve.

The pudendal nerve passes in between these two ligaments near the ischial spine, which is one of the most common sites for the entrapment of the nerve. Entrapment of the pudendal nerve at this level can cause pain all the way from the anus to the clitoris/ tip of the penis. All pudendal neuralgia is not caused by entrapment of the nerve and should be carefully examined for the appropriate medical treatment.

So, as you can see these regions share more than just a handful of structures and need to be in total harmony in order to support one another. 

It might sound weird, at first, when your healthcare provider asks questions about bladder, bowel, or sexual history during an exam for your hip pain. But I now hope that you have a better understanding of how intricately these two systems are interconnected 🔗.

References:

Ali A, Andrzejowski P, Kanakaris NK, Giannoudis PV. Pelvic Girdle Pain, “Hypermobility Spectrum Disorder and Hypermobility-Type Ehlers-Danlos Syndrome: A Narrative Literature Review.” J Clin Med. 2020 Dec 9;9(12):3992. doi: 10.3390/jcm9123992. PMID: 33317183; PMCID: PMC7764306.

Kaur J, Leslie SW, Singh P. “Pudendal Nerve Entrapment Syndrome.” [Updated 2022 Nov 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544272/

Chaudhry SR, Imonugo O, Jozsa F, et al. “Anatomy, Abdomen and Pelvis, Ligaments.” [Updated 2022 Nov 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493215/

Before we delve deeper into the role of Central Sensitization in chronic pain, let’s first understand what Central Sensitization really is.

Central sensitization signifies slowly developing, plastic changes in the brain because of:

• the long-standing inflammation/disease state in the body AND/OR

• a feeling of a lack of safety in the psycho-social context (our environment)

Thus, making the brain act like an overprotective helicopter parent, who wants to know everything happening in the body, as well as outside of it (the environment). This makes us hyper-vigilant, making things even edgier as we go through a difficult pain flare.

👉 In contrast, let’s understand how the body communicates with the brain when things are calm and safe. Each level of the spinal cord is responsible for getting information from a specific region to the body. For example, the S2 level of the spinal cord is going to receive information from the specific nerves from the pelvic region, the information that must be, then, relayed to the brain.

There are several different types of nerve fibers, each performing a unique function:

⁣

✅ The 𝗔-𝗯𝗲𝘁𝗮 nerves bring info of light touch, for example, wearing an underwear or just stroking the skin over the genitals.

✅ The 𝗖 𝗻𝗲𝗿𝘃𝗲𝘀 bring information about unpleasant sensations called nociception i.e. unpleasant pressure, touch, temperature and chemical changes (inflammation). Contrary to popular belief, the body doesn’t have any pain receptors, only nociceptors. It may not sound like a huge deal, but when we label every unpleasant sensation as pain, it becomes easier for the brain to see those sensations AS pain. The degree of nociception is what is termed a threat/danger signal raised by the body.

✅ S2 level also gets information from the other levels above and below it, i.e. S1, L5, S3, etc. ⁣

👉 All this information enters the dorsal horn of the spinal cord, where it gets blocked by the interneurons present there, acting as a spam filter so that the brain doesn’t get bothered unnecessarily and only receives relevant and important information. This allows the brain to keep everything in an orderly fashion and take action in a very specific, measured way.

👉 To further ensure that this order is maintained, the brain also releases dampening chemicals such as dopamine, serotonin, and endorphins to suppress this information overload. These hormones are the body’s endogenous happy chemicals.

⁣⁣

However, what happens in central sensitization is that the C nerves release inflammatory chemicals that kill the interneurons in the spinal cord. And without the interneurons to block the excessive information, the brain starts to get bombarded with every tiny detail, which the brain perceives as dangerous. As the brain goes into overdrive, it also stops making the dampening chemicals, as it seeks more info to thwart the next imminent danger. It’s wartime!! 🥷⁣

This results in:

1. A never-ending vicious cycle of unnecessary info from A-beta fibers entering the brain. The more the brain is flooded with information, the more it perceives it as a threat, making us ever more hyper-vigilant and resulting in worsening pain. An example could be: ⁣the underwear touching the vulva or the scrotum is perceived as extremely uncomfortable/painful with a burning sensation. This is called Allodynia, meaning pain due to a stimulus that normally does not provoke pain.

2. The unpleasant information is relentless and the brain constantly feels that the injury to the tissue is ‘persisting’ and the body is under threat. As long as the brain keeps sensing the threat, it would keep dialing up the pain dial.

3. The other levels above and below the S2 level in the spinal cord i.e. L4, L5, S1 and S3, S4 will bombard S2 with info from other body parts, such as the lower back, buttocks, inner thighs (which would be blocked earlier by the interneurons), giving a feeling of pain spreading to the other areas of the body.

This is Central Sensitization in a nutshell! Reading about it, you might think that this nociplastic change in the brain is impossible to reverse. However, the research has found various strategies to be effective in controlling Central Sensitization. If you find this intriguing, then do read the ‘top and bottom up approaches’ blog post to understand this in even greater detail.

Hope you find this helpful!

Xx

Mukta

Pelvic conditions, especially pelvic pain, can be quite disorienting to figure out! The pelvis is this central region in the body, which is the converging point for many different and diverse systems, all supported by the pelvic floor. All these systems not only share the pelvic floor but also share the nerves and the vascular complex and can, therefore, impact one another… Let’s understand these systems one at a time:

1. GI system: Your plumbing (intestines) ends in the pelvic region (rectum). The rectum and pelvic floor muscles share the nerves and the blood vessels; so, common gut issues (constipation, Irritable Bowel Syndrome (IBS), bloating, etc.) can directly affect pelvic pain. The pelvic floor muscle, Puborectalis plays a special role in keeping the rectum closed, so we don’t end up leaking the bowel movement! The Puborectalis hooks around the rectum at rest and when it’s time to go, it expands to allow the rectum to open up and eliminate the bowel movement. If this muscle does not work properly, you can either experience ribbon-like bowel movements or constipation. Inflammation in the gut due to IBS can also irritate the pelvic floor muscles, causing overactivity in the muscles that can aggravate your pain.

➔ Digestion is a tell-tale sign of your gut health and paying attention to your bowel movements is the best way to check whether your gut’s working optimally.

2. Urinary System: Your bladder CAN’T function without the pelvic floor muscles. It’s like they are engaged in constant chatter like two best friends (via pelvic/pudendal nerves). Ensuring that your bladder stays happy and healthy is the surest way to calm pelvic pain and vice versa. Pelvic floor muscles hold the tension around the urethra to prevent leakage at rest and allow the bladder to keep filling. Once the bladder reaches its full capacity and is ready to void, the pelvic floor muscles need to fully relax, so that the urethra can open and help empty the bladder. To maintain a healthy bladder, be sure to:

1. Hydrate well consistently during the day

2. Try to stay away from known bladder irritants (caffeine, alcohol and acidic foods)

3. Use the toilet every 2-4 hours (recommended). Remember that either holding the urine too long or urinating too frequently isn’t considered healthy bladder behavior

4. If you find yourself waking more than once at night, try to avoid drinking water for 2 hours before going to bed.

3. Reproductive System: Sex hormones (estrogen, testosterone, and progesterone) run the show here, controlling lubrication, pelvic floor muscles’ strength, expandability & quality of the tissue in the vulva & the vagina.

➔ Research has shown that the long-term use of combined birth control pills can affect the hormonal availability locally (reduced levels of estrogen &testosterone), making some people more prone to pelvic pain (you can read about more in another blog post [insert hyperlink])

➔ The decline in estrogen levels during early postpartum and menopause is also responsible for reduced lubrication, dryness, itching sensation and in some cases even pelvic pain

4. Nervous System: The brain is the ‘supreme boss’... ALWAYS; so, even a minor stressor can trigger existing pelvic pain during a fight or flight state. We know that all pain is processed and created by the brain (the pain is always real!). Our brains take in our past and present beliefs, memories, culture, thoughts, and social environment, while processing a danger signal coming from a body to produce pain. Therefore, it is imperative that you:

➔ Identify your stressors

➔ Find activities that help calm the nervous system

This can be achieved by either top-down or bottom-up approaches. If you want to understand this at length, then do check out my blog post on top-down and bottom-up approaches.

5. Musculoskeletal System: Pelvic Floor is a part of the core, along with the deep abdominal muscle, diaphragm, and spinal stabilizers. It also shares muscles and ligaments with the hips, spine, and abdomen (do read the blog post [placeholder] to understand this in greater detail). It is important to remember that:

➔ Weakness or injury in these areas can affect the pelvic region

➔ Keeping the neighbors strong and healthy also helps reduce the strain on the pelvic region

The pelvic floor also communicates with the foot, with both performing the function of shock absorbers while walking, running, and jumping. A lack of effort from one means that the other has to work extra hard to compensate. Feet and genitals also sit next to each other in the somatosensory cortex (the region of the brain responsible for receiving sensory information from the entire body), and for that reason, the two have a reason to cross-talk and influence each other.

The human body is so intricately and beautifully designed that we often find ourselves marveling at its interconnectedness. But despite that realization, when it comes to assessing the effect of various systems on one another, we tend to miss out on basic details. The pelvis acting as the point of confluence for diverse systems is the perfect reminder that the optimal way to achieve well-being is when all the systems are working in unison. This might seem like a lot to wrap your head around and I understand that the mere thought of making so many sweeping changes might feel intimidating at first, but trust me once you start seeing the benefits right in front of your eyes, none of this would feel like drudgery!

I often find people (and often catch myself too) from time to time using the term vagina as a catch-all to describe anything that is happening with the genitals. People oftentimes confuse the vagina with the vulva, labia, or perineum… and that mostly happens because everything down there is labeled as the vagina. But this seemingly harmless confusion can backfire when people find themselves not being able to describe their symptoms correctly when they see their gynecologist, urologist, and/or their pelvic health PT.

So, first, tell me:

Did you know that it’s not all VAGINA down there 👇?!😵‍💫⁣

⁣👉 Do you know what are different parts of your genitals called? ⁣

👉 Can you recognize them? 🧐⁣

👉 Have you ever taken the time to look down there using a mirror 🪞?⁣

👉 Have you ever experienced genital pain with or without sex and did not know where it was coming from? 🤨⁣

If you answered NO to any of these questions, this is for YOU… keep reading!

⁣Female genitalia is a complex collection of various structures that includes:⁣

1. 𝗩𝗨𝗟𝗩𝗔: the external genitalia, including the outer and inner lip. The outer lip is the hairy fold of the skin. The inner lip usually doesn’t have any hair on it. The vulva includes everything from the Clitoris, the Vestibule, Bartholin, and Skene glands (produce lubrication) and the opening of the Vagina (yes, 𝘫𝘶𝘴𝘵 the opening— called the Introitus). ⁣

2. 𝗩𝗘𝗦𝗧𝗜𝗕𝗨𝗟𝗘: the innermost (and most overlooked) part of the Vulva that surrounds the Urethral opening at the top and the Vaginal opening at the bottom. It also contains both the Skene glands at 10 and 2’o clock positions and the Bartholin glands at 4 and 8’o clock positions. The vestibule region could be one of the sites of pain (clinically referred to as Vestibulodynia) with insertion and should be carefully differentiated from other reasons for painful insertion such as Vaginismus. It is usually examined with a Q tip (cotton bud) to precisely locate the area of the pain.

3. 𝗩𝗔𝗚𝗜𝗡𝗔: the vagina is a fibromuscular tube that connects the Introitus to the Cervix (most of it is internal). The vaginal tissue looks like the inside of a HEALTHY MOUTH! 👄 Nice and pink and supple! ⁣

4. 𝗖𝗟𝗜𝗧𝗢𝗥𝗜𝗦: is the pleasure house of our body and hosts more than 10000 nerve endings, and is located at the top of the vulva (12’o clock). However, we still can only locate a teeny tiny part of the clitoris externally. Most of it is located internally going alongside the urethra and the vaginal tube. Embryologically, it is derived from the same tissue as the penis. The external part of the clitoris has 2 parts– the glans and the hood. The hood of the clitoris retracts back upon arousal. The hood sometimes can get adhered secondary to infections, Keratin Pearls, etc., and can create pain around the clitoris called Clitorodynia.

5. 𝗨𝗥𝗘𝗧𝗛𝗥𝗔𝗟 opening: lies at the top part of the Vestibule as a teeny-tiny hole, and no, people with vulva DO NOT pee through their vagina. 

6. 𝗣𝗘𝗥𝗜𝗡𝗘𝗨𝗠: The space between the lower end of the Introitus and the upper end of the Anus. Usually feels like a taut band, as all pelvic floor muscles attach to this region via. a central tendon. Episiotomy is performed here. 

⁣I cannot emphasize enough how important it is to know our bodies down there and NOTICE any unusual redness, heavy discharge (note the color too), dryness, bumps, unusual white patches, or the fusion of the labia.

⁣Getting to know each part of our genitals using a mirror is the first step towards accepting, learning, and understanding more about our bodies. Body literacy empowers us and can help us stay out of trouble, help us seek care at the right time, and improve our communication with care providers.

⁣𝘕𝘖𝘛𝘏𝘐𝘕𝘎 𝘐𝘚 𝘛𝘔𝘐 when it comes to your health! Do share any unusual findings with your medical provider without hesitation, no matter how silly it may sound to you!!

References

Sexual Medicine Society of North America, Peters B, et al "How many nerve fibers innervate the human clitoris? A histomorphometric evaluation of the dorsal nerve of the clitoris”, SMSNA 2022; Abstract 1.

Descriptors of Vulvodynia: A Multisocietal Definition Consensus (International Society for the Study of Vulvovaginal Disease, the International Society for the Study of Women Sexual Health, and the International Pelvic Pain Society), Jacob Bornstein, MD, et al, and on behalf of the International Society for the Study of Vulvovaginal Disease (ISSVD), the International Society for the Study of Women's Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS)⁣

⁣