TODAY'S GUEST: Stephanie Prendergast, sex surrogate and sexuality expert

I'm extremely happy to welcome Stephanie Prendergast to Hard Conversations!

Stephanie Prendergast is cofounder of the Pelvic Health and Rehabilitation Center (PHRC) which has 9 locations in the United States. She currently treats patients in their Los Angeles location. Stephanie has has been treating women, men, transgender and gender non-conforming persons suffering from pelvic floor disorders since 2000.

Within the field of pelvic health, Stephanie’s subspeciality is management of complex pelvic pain disorders, including pudendal neuralgia, vulvodynia, interstitial cystitis and male pelvic pain/chronic pelvic pain syndrome. In 2013 Stephanie was the first physical therapist to become president of the International Pelvic Pain Society. Stephanie teaches courses, is coauthor of the popular book Pelvic Pain Explained, and is published in a number of peer-reviewed journals and textbooks. Stephanie is internationally recognized as an advocate for pelvic floor physical therapy and improving interdisciplinary patient care.

In addition to her local patients, PHRC offers an out-of-town program for patients and she treats people from all over the world. The entire team at PHRC is known for helping patients manage their treatment team and plan, they understand that patients often need medical or other management in addition to physical therapy. They work hard for their patients, offering complete case management until their patients achieve their goals. All of the physical therapists are active in their local communities lecturing, attending medical courses and lectures, and building relationships with other providers. PHRC publishes an award-winning blog, As The Pelvis Turns, every Thursday. You can find Stephanie on Twitter as @pelvichealth and the Pelvic Health and Rehabilitation Center on Instagram, Facebook, and Pinterest.

• WEBSITE:

  https://pelvicpainrehab.com/

• book:

• https://www.amazon.com/Pelvic-Pain-Explained-Prendergast-Stephanie/dp/B014I7U3FW

YOU'LL LEARN

• The penis can experience pain and discomfort in a variety of ways

• The difference between functional problems and pain problems

• What the experience of working with a pelvic pain medical practitioner is like

• The importance of being able to relax one’s pelvic floor

• How the pelvic floor functions

• The importance of noticing the pelvic floor

• The similarities between breathing and pelvic floor muscles

• Practical exercises you can do at home

• All about pelvic floor physical therapists

• Male pelvic pain expertise

• Different terms like interstitial cystitis, chronic pelvic pain syndrome

• The impact of pelvic issues on sex

• And more!

THANK YOU FOR LISTENING to my male sexuality and sex therapy podcast!

To get more hard conversations sent directly to your device as episodes become available, you can subscribe on iTunes or Stitcher!

Also, reviews on iTunes are extremely helpful and greatly appreciated! I read each and every one of them, and feel free to share your URL there so I can contact you later on and say thanks!

And lastly, if you have any questions (or would like answers to previously submitted voicemail questions!), head on over to Tim’s website.

About the Show

Introducing Hard Conversations, a podcast about male sexuality, and all things erectile, from the latest natural erectile dysfunction treatment to the best ed medical treatment. Therapist Tim Norton expands the conversation about male sexuality, adds context to why we struggle as a society to have hard conversations and breaks down how in a sex-positive environment there really is no room for taboos, judgment, or shame when it comes to penises.

YOUR online sex therapy and couple’s therapy HOST:

Tim Norton is a sex positive sex therapist working in private practice. He offers online therapy, online sex therapy, online sex coaching, and therapy and coaching for somatic symptom disorder.

Tim obtained his bachelor’s and master’s degrees from the University of Southern California. Tim is a proud member of American Association of Sex Counselors, Educators, and Therapists (AASECT), the Los Angeles Sexological Association, and works part-time with the Pain Psychology Center in Beverly Hills.

Hard Conversations Podcast Transcript

Tim Norton: Welcome to Hard Conversations. My next guest I'm very excited about - Stephanie Prendergast is a pelvic floor, physical therapist and the co-founder and co-owner of the pelvic health and rehabilitate patient center. The largest multicenter clinic in the United States dedicated solely to the management of pelvic floor disorders, helping women, men, children, transgender, and gender non-conforming persons optimize their pelvic health.

Stephanie was elected to the international pelvic pain society's board of directors in [00:01:00] 2002. And in 2013, she was the first physical therapist to be president of the society. In 2013 and 2015, she served on the program committee of the world, Congress of abdominal and pelvic pain, and 2017 served as the scientific program chair, bringing the world Congress to the United States.

She's authored numerous publications in peer reviewed journals and textbooks and regularly lectures at medical conferences and in the community on pelvic health related topics. She is an advocate for people with pelvic pain, pelvic floor, physical therapists, and the field of pelvic health. She is a coauthor of the popular book.

Pelvic pain explained in 2016. PHRC publishes an award-winning blog as the pelvis turns every Thursday. Thank you, Stephanie, for joining me. Thank you very much.  what is CPPs? What does that even [00:02:00] stand for? And what's the difference between CPPs prostatitis about pelvic floor disorder. 

Stephanie Prendergast: Coming out hard.

Let's get into it. CPPs stands for chronic pelvic pain syndrome,  which is a term that I don't necessarily enjoy because it implies that this is a problem. That's chronic meaning it's going to be with a person for the long haul.  what it refers to is a musculoskeletal condition where the pelvic floor muscles become hypertonic.

Okay. And can cause symptoms of urinary urgency, frequency, penile pain, Squirtle pain, perinatal, or anal pain posted dilatory symptoms and erectile dysfunction in men. Okay. So it is different than prostatitis in that those terms were overlapping only used interchangeably and incorrectly for a period of time.

The term prostatitis implies that there's inflammation and [00:03:00] infection of the prostate, and while the symptoms of an actual prostate infection mimic. The ones I just described. It actually happens in the absence of infection. So commonly men with these symptoms are often misdiagnosed with prostatitis and being prescribed antibiotics.

When in fact it's actually a musculoskel disorder. 

Tim Norton: Okay. And that's, prostatitis now. What's pelvic floor 

Stephanie Prendergast: disorder. So the pelvic your muscles run from the pubic bone to the tailbone. Most people think of them in terms of childbirth and in women and have do your kegels, but obviously men have pelvic floors too.

So it's responsible for helping with urinary function, sexual function and bowel function. And once things become dysfunctional, as we just mentioned with CPPs, then you can have a whole host of symptoms in any of those areas. The muscles are very important to support our organs and to help keep our body functioning normally.

Okay. 

[00:04:00] Tim Norton: So let's, let's talk about those symptoms because I suppose I should mention that in therapy I'll occasionally see somebody who's been diagnosed with any of these things and the symptoms that I hear. Are burning numbness, dripping, leaking, painful urination, painful ejaculation, tingling, aches, and, and then the state of being hard flacid.

So which, which symptoms correspond to which, or how do, can we even delineate 

Stephanie Prendergast: that way? So CPPs encompasses all of what you just said. So it's this really broad umbrella term that is. F it's defining a syndrome more than a specific disease. And that's important to make a note of that. This is a cluster of symptoms that can manifest with some of the symptoms you just mentioned, or unfortunately, in some cases, all of them.

And so the symptoms can range from dollar achy to severe stabbing shooting, debilitating [00:05:00] pain. 

Tim Norton: Wow. And there's a difference between something that is a functional problem versus a pain 

Stephanie Prendergast: problem. Correct. So functional problems often precede the pain issues. So men may start to notice all of a sudden.

There urinary stream is a little bit different, or if they try to start their stream, they may have hesitancy where they didn't before they may notice their stream diverts to one side or the other, they could have terrible evacuating stool.  and then sometimes as that goes on long enough on checked, then it can proceed into a pain issue where then they start to develop pain again in the penis, paranoia marinas as well.

Okay. 

Tim Norton: And yeah, I love 'em. The formality of the language evacuating,

so pooping trouble pooping.  but, but I [00:06:00] suppose that in that situation where we're talking about these very intimate areas, that it helps to stay very formal and, and clinical. And unmedical about all of these things. Cause it's it, not many people get to see guys in that state. 

Stephanie Prendergast: We have different language, for sure.

Tim Norton: Yeah. And so tell, tell me about that state. Tell me,  when somebody comes in and they they're. They're trying to figure out what what's wrong. Why, you know, why do I have this burning? Or why w what's wrong with my poop?  what do they actually go through? So 

Stephanie Prendergast: it's unfortunate because most men have been through at least five to seven providers before they typically get into our office and actually understand what's wrong, which can come with a fair amount of trauma, because people are saying, you just need to take this antibiotic, or there's actually nothing wrong with you.

When in fact they don't feel like anything is normal. So by the time sometimes they get to our office, they are extremely distressed. And at least the first day, [00:07:00] hopefully we can do is normalize their symptoms and they are not alone. These symptoms affect one in 10 men.  symptoms start as early as the twenties and thirties, they can progress into the forties and fifties and sixties as well.

But there's a whole host of issues that can affect men from the time they're 20 til the time they're 70. And it just isn't. As talked about in the mainstream as female pelvic health issues, 

Tim Norton: one in 

Stephanie Prendergast: 10 men, one in 10 men studies have shown have the symptoms of CPPs. Wow. 

Tim Norton: You know, if you think of something like schizophrenia effects about.

1% of the population, maybe two, maybe, maybe, you know, depending on how you count it. This is five to 10 times more common than that yet until I started to get into this work, I never had heard of that. And I still, I think I told you one of the times where I was talking to you about this, that I met a nurse who dealt with female [00:08:00] pelvic pain.

I think she worked in a, in a urologist office and didn't know men had this. So it's really just really not talked about much. 

Stephanie Prendergast: It, it hasn't been in the past. So it's great that you're doing podcasts like this to help get them information out there because men may be listening to this and thinking, Oh, I I've noticed that I have these symptoms.

And in a lot of people, it can be a very insidious onset. So as I mentioned, you may start to notice it's hard to start the urinary stream, or you notice you have a little bit of post-void dribble. There's another word, another medical term, like you're still dribbling a little after you urinate.  and then all of a sudden, you start to notice, you may have tingling at the tip of your penis after you ejaculate or something, more significant.

And men, a lot of times, some of these things can be triggered and exacerbated by things like exercise such as cycling or certain workouts. So they may notice that after they go to the gym, they have trouble with urination, but if they don't go to the gym, they. They don't have those issues. So [00:09:00] it's starting to show that there is a functional problem.

That's tied to their musculoskeletal health. That's creating these symptoms. So 

Tim Norton: another word that I've heard thrown around or no, let me back up. So what I was asking. What's it like when they get to your 

Stephanie Prendergast: clinic. So Wednesday arrive at our clinic. We will go through a comprehensive history to understand how the symptoms started.

And a lot of times we may be asking questions that they may not even realize are tied to their symptoms.  a lot of times people do think it's an infection or an STD. So once they've been cleared for that, It usually is left in the musculoskeletal department. After we go through the history and answer any questions that they may have is the physical examination.

At that point in time, we will examine the muscles connective tissue and joints, basically between the ribs and the knees. Depending on the etiology and also do an internal pelvic floor exam, which has done transiently. At that point, we are checking for motor control. Can people can track [00:10:00] their muscles.

Can they relax their muscles? We're looking for pain, tenderness, nerve sensitivity. Yeah. As well as just overall function of the pelvic floor. That's the passive part. If there is a biomechanical cause for people's symptoms, which is often the case with male pelvic pain, then we also need to see how they're moving.

What happens during various movements, during various exercises, things that will normally provoke their symptoms. Okay. 

Tim Norton: And let's, let's get into some of that. There's a limitation for this being a podcast and we can't. Show people a diagram of that area, but can you describe, like, let's say a listener at home is going to try to figure out their pelvic floor and where everything is.

Can you give us the geography of, of, of these areas? 

Stephanie Prendergast: So a simple thing that people can do is when you cough, [00:11:00] reflexively your pelvic floor muscles contract, otherwise you would leak urine you. And if you think about trying to pay attention to the area between the scrotum and the anus, when you cough, you may feel that.

 so those are the muscles that do compromise. I heard that our pelvic floor, 

Tim Norton: okay. Right there that, that. It should be, what should it do when you cough? 

Stephanie Prendergast: When you cough, you should feel a small contraction. Okay. And when you orgasm, that's a rapid muscle contraction, which is also a pelvic floor muscle function in the, in the 

Tim Norton: same 

Stephanie Prendergast: area, same area.

Okay, great bowel movement. You're relaxing your pelvic floor muscles. So that's the opposite of the cough. Everything has to relax to be able to evacuate stool. Okay. You never think about it. Cause I never do. 

Tim Norton: And the other day somebody told me, you know, We were talking about relating their anxiety to these issues.

And so, and she said the moment she had some breakthrough about one of the major sources [00:12:00] of her anxiety, that the moment that she had that realization, her pelvic floor relaxed. And I thought, how do you know, how do you tell? But, but, okay. So it's kind of like having just avoided stool. 

Stephanie Prendergast: Right? Okay. But if you just, like you mentioned, if you don't think about it, These muscles are going to function on their own, right?

And that is what makes them different than other parts of the body. You couldn't make a fist without voluntarily thinking to do so, but your pelvic floor always maintained some tone, cause it's a little bit different than every other skeletal muscle in your body, because it has some autonomic function.

It's the same thing. As your diaphragm, you can choose to breathe and you can choose to breathe faster or to hold your breath. Just like you can choose to squeeze your pelvic floor. Or relax it, or if you don't think about it, it's going to do what it normally needs to do without your consciousness. 

Tim Norton: Hmm.

Okay. And so. You're examining somebody from the knees to the ribs, [00:13:00]  where, and, and who are these people 

Stephanie Prendergast: and what are we doing exactly what you're doing? Yeah. Passive part of the exam is palpation and we are literally touching each of the muscles that attach to the pelvic girdle, the connective tissue, as well as.

Peripheral nerves looking for tenderness pain. If the muscles can contract, if people can control them. And the same thing happens internally. So the first part of the exam, people are laying on the table. And that may be the first few appointments, especially if they have pelvic pain until we can do the manual therapy, which kind of mirrors the evaluation to help the muscles get back down to normal tone.

Okay. 

Tim Norton: And then as you said, manual evaluation, you gestured. So can you describe the manual evaluation? 

Stephanie Prendergast:  I guess you could think, I mean, it's hard, it's not as general as a massage, but it looks somewhat similar to that in terms of evaluation and [00:14:00] treatment. Okay. Okay. 

Tim Norton: And so how invasive is it? 

Stephanie Prendergast: In my world.

I don't think it's invasive as all, but in other people who may not be used to a physical therapist using a gloved finger to examine the muscles of the pelvic floor through the anus that may be considered invasive.  but that's what's, but that's how we have to get their 

Tim Norton: finger lubricant 

Stephanie Prendergast: lubricant one finger, right.

While people are lying down. So it's different than a prostate exam where. Men envisioned bending over the table, turn your head and cough. That's not what we do. Right, 

Tim Norton: right. Cause you're not even necessarily getting to the prostate. 

Stephanie Prendergast: We can access the prostate, but it's not necessary for the evaluation that we're doing.

 we were examining the muscles, which actually surround the prostate. 

Tim Norton: Okay. And I have heard of this thing called a wand used and. Treatment. Do you use a wand? 

Stephanie Prendergast: Not really. [00:15:00] Okay. So a wand is a therapeutic tool that people can use at home for therapy to try to mirror what may go on in pelvic floor, physical therapy.

I have very mixed feelings about them. I find it's difficult for patients to actually use them on their selves in a way that's effective. I would rather have them spend their time at home, doing something that we know is going to help there. Problems such as meditation or things like that. Whereas using a wand is I think rather difficult to access some muscles and successfully treat them.

Tim Norton: I feel like I've heard of, of a wand gone wrong story or two that you can hurt 

Stephanie Prendergast: yourself. The anus is a vacuum too. People need to know that. So if they're using something that isn't long enough in length, yes, we've had. It bet stories where people have. Accidentally sucked up the wand and has needed surgery to get it back out.

 and also [00:16:00] people can press on structures that are sensitive, that you shouldn't be pressing on with a wand. And I feel like the lay person really has a hard time telling the difference even with instruction. 

Tim Norton: Okay. So you use at your own discretion using 

Stephanie Prendergast: your own discretion or maybe just don't use.

Okay. 

Tim Norton:  I've heard of well. Okay. And the other question that I had was pelvic floor therapists. What kind of training do they have? And, and, you know, what's their background, pelvic 

Stephanie Prendergast: floor, physical therapists have their physical therapy degrees. They are state and. Federal certifications,  beyond that it gets a little dicey.

So there's a varied amount of educational experience between pelvic floor PTs, typically, because this is not yet taught in graduate schools. It's all post-graduate education. Which means that the person people may be going to see for pelvic floor PT has really sought out additional advanced [00:17:00] training on their own to be able to treat this patient population.

And that can come. There's really no standard of care at this point in time, because it's a fairly new field. So there can be a range of experience among providers. 

Tim Norton: Okay. And you guys train. 

Stephanie Prendergast: Yes. So we, I mean, as a company, all we do is pelvic health. So we obviously train our employees and we teach classes to other pelvic floor, physical therapist to be able to do the same thing.

Tim Norton: Okay. And I. Do you feel like the, so we didn't say this. This is mine and seventies. Second, take this interview. I had my first hard conversations and possible conversation. I had a major technical malfunction, but the last time that we talked about this, we, we somehow stumbled upon the fact that it's difficult to train this.

Cause there aren't that many men in the field and they're practicing on each other.  

[00:18:00] Stephanie Prendergast: so the training that pelvic floor PTs undergo is in, as I mentioned, postgraduate classes. So what that consists of is a two to three-day course where they usually have to travel and learn the didactic information, but also there's a lab portion where.

People practice on one another. And there's very few men as providers that are in this field, which means often women are trained by practicing on other women, which is clearly not the same thing, which is why I'm glad this podcast is happening because a lot of men may not have access to people who can help them.

And it really does requires specific training to be able to do so. Right. And 

Tim Norton: so. In those classes, weren't you saying that they'll actually hire not actors, but people to come in to be subjects for that 

Stephanie Prendergast: training? They actually do not in most cases. And I think they need to, because as a female physical therapist, who's about to treat this patient population.

It's very [00:19:00] difficult to take. Book knowledge and then translated into the clinic and know what you're doing with manual therapy and treatment plan progressions and those types of things. 

Tim Norton: Yeah, definitely. Yeah. You would, you would want to know. I mean, you're asking the question. So how many, how many men's butts have your fingers actually been 

Stephanie Prendergast: in mine?

A lot, 18 years of a lie, 10 years out, I actually was trained by a urologist on. Actual male patients. So my experience was quite different than, 

Tim Norton: okay. So. Another word that I've heard thrown in the gamut is pudendal neuralgia. Where does that fit into all of this 

Stephanie Prendergast: carpal tunnel of the button? Penis. Okay. So that basically means tingling, shooting, stabbing pains, just like you think of in carpal tunnel of the wrist, but that can occur again in all the territory of the pudendal nerve, which is.

The penis, the parent IOM and the anus, the majority of the pelvic floor muscles, part of [00:20:00] the urethra and part of the rect 

Tim Norton: I guess you just have to go to you to keep all of these things straight. 

Stephanie Prendergast: Well, if you notice that you have those symptoms, I think men primarily go to the urologist first. If they're not familiar with the diagnosis, I would seek a second opinion.

I can provide resources for medical providers across the country who are, are trained.  but I don't. Want patients to feel discouraged if their doctor doesn't actually understand what's wrong with them at first, because it is. Physical therapists need specialized training in this. So do physicians, right?

And unless they're seeking this information out on their own, they're probably not exposed to these syndromes or the fact that they can even happen. So it's pretty easy to diagnose the clinical symptoms are what we just said.  there's no further diagnostic testing that can confirm or refute that that's a problem it's completely based on symptoms.

Yeah. And that 

Tim Norton: that's a challenging factor as well. And I got to imagine there are other. Diagnoses that [00:21:00] trickle into this, this diagnosing process. 

Stephanie Prendergast: So CPPs technically encompasses pudendal neuralgia and pudendal neuralgia. Encompasses CPPs, which again is chronic pelvic pain syndrome. It overlaps with what's called prostatitis and basically they'll umbrella male, pelvic pain.

Okay. But 

Tim Norton: are there other disorders that are thrown out there? Other names of other disorders that you're hearing that other urologists have? 

Stephanie Prendergast: Sometimes they will say interstitial cystitis, which is technically a. What was originally thought to be a bladder syndrome, but we now know that bladder is the victim, not the cause in overlapping musculoskeletal condition.

Tim Norton: Okay. And interstitial cystitis for all of those of you Googling all these things out there or just, I see I'm among friends.  so. Let's let's segue into sex here. So how does C [00:22:00] PPS affect sex? 

Stephanie Prendergast: So it's, it's unfortunate. Cause one of the primary symptoms of, of CPPs can be posted Jackie dilatory pain, erectile dysfunction, just genital pain in general.

And when people have pain, it can affect desire obviously, but also if. What it's supposed to be pleasurable is associated with pain. It's very difficult for our male patients and they're just uncomfortable and they're upset and they're stressed about it. Understandably. 

Tim Norton: Yeah. And then they come in and they talk to you about their sex 

Stephanie Prendergast: lives, right.

And often relieved that their partner isn't having an affair as unfortunately, men may think because it feels like an STD and it's not. Yeah, 

Tim Norton: as I suppose we should say that there's a, there's a good chance that it's not an STD guys or not an STI. So,  get this checked out or you get tested for the STI first and then when that's ruled out, you're, you're really in this territory.

So. You mentioned erectile [00:23:00] dysfunction. And for those of you who listened to every single episode and, and memorize my words,  I'm, I'm pretty careful about when I say erectile dysfunction. And when I'm talking about erectile issues, because we don't want to call. Like anxiety, a dysfunction, because if you essentially, if your body's in a state of fear, it's not as functioning.

It shouldn't be hard. Your peanut shouldn't be hard, but we're actually talking about something that's physically wrong. And so I would put that under the umbrella of dysfunction. So what exactly is happening to your pelvic floor? That, that makes it so that the penis isn't retaining blood? 

Stephanie Prendergast: And I think you did bring up a good point too, about the words and the language.

Like, it's easy for me to say erectile dysfunction, but I think it'd be better to say transient erectile changes. Just like I don't like chronic pelvic pain. It should be persisting right now because I don't want people to feel limited that this is stuck with them for a long time. But what transient 

Tim Norton: erectile 

Stephanie Prendergast: change?

[00:24:00] Changes and 

Tim Norton: erectile issues or issues.  what's the best,  acronym, T a S T 

Stephanie Prendergast: a Thai. I just want people to know it's a, it's a transient thing like this, just as quickly as it showed up, it can also be treated. And that's where I think people are. They're just not informed enough with what you read online.

This looks like a pretty. Dim situation. But as we mentioned, the pelvic floor muscles are responsible for orgasm function. And as we discussed last time, they're also responsible for maintaining interaction. So they help to close the blood vessels to keep blood in the penis during erectile function. And if the muscles are too tight to effectively do that, which happens in pain syndromes.

Or if they're weak, which can happen in older gentlemen after things like prostatectomy surgeries, thinking of the whole gamut here,  it's going to be a challenge to maintain the erection that isn't just the vasodilation factor and things that people think of when they take Viagra [00:25:00] and Cialis. Right.

Tim Norton: So if they're they're too tight, Then blood's not going to get there and then get in there in the first place 

Stephanie Prendergast: where it's harder for the muscles to effectively contract to keep those vessels closed. It's like trying to clench your fist when you're already in a tight fisted position, you can't go any further.

So they're just not functioning efficiently as they 

Tim Norton: could. Okay. Yeah. And you can help with that. 

Stephanie Prendergast: And we can help with that. So we we'll examine if the muscles are too tight, which again is usually the case in pelvic pain, syndromes manually lengthened the muscles through weekly physical therapy sessions.

Typically eight to 12 visits is standard for shorter term duration problems, and then teaching the patients how to actually regain control of the muscles themselves to maintain what we did in the clinic. Okay on the latter end of the spectrum. If they have weakness or issues [00:26:00] following prostatectomy procedures, and it's the opposite, we're actually teaching them how to strengthen and again, teaching them control.

But the treatment is exactly the opposite. We're trying to up train everything. 

Tim Norton: Okay. And that's, that's a huge 

Stephanie Prendergast: difference. Huge difference. It's important to know the difference as well. Yeah. 

Tim Norton: Is there another. Version of a cough test that they could do at home right now to have an idea. If it's, if it's strengthening or relaxing, 

Stephanie Prendergast: if, if men try to squeeze their muscles or hold back gas, if you will, and you feel like you actually can't do that, you might be weak.

Tim Norton: Okay. Oh, okay. So if you can't hold it in your fart, then you've got, you might have,  some,  condition that. Could improve 

Stephanie Prendergast: treatment and in the later decades of life, and especially after prostatectomy, pelvic floor dysfunction affects about 80 to 90% of men. Okay. Okay. 

Tim Norton: Did you work on those with older gentlemen as well?

And can they [00:27:00] see improvement? 

Stephanie Prendergast: Yeah. So research has actually shown that if you are undergoing a prostatectomy surgery, men have less chance of stress incontinence and erectile dysfunction. If you go through pelvic floor physical therapy before and after. So I think a lot of people aren't prepared for.

Exactly what I just said, stress incontinence, leaking urine and erectile dysfunction. And as people live longer and the age where these surgeries are happening remains the same, people want to preserve their sexual function. So it is an easy, low risk thing that should be part of every man's treatment plan.

And it isn't always, which still surprises me now. Right. 

Tim Norton: And then as you mentioned earlier, Viagra, isn't going to fix this situation. Even an older man. If the blood has no way of holding itself in, or being held in, then the bagger can't help. Correct. Okay. So yeah, that is surprising. What 

Stephanie Prendergast: about you surgeries, knee [00:28:00] surgeries.

You have to do physical therapy afterwards. Think of how much more complicated that pelvis is. Like the fact this isn't integrated into some of these things really does surprise me at this point in time. 

Tim Norton: Did I hear. At one of your lectures on all these issues and women that there are countries that mandate physical therapy before and after pregnancy.

Yes. 

Stephanie Prendergast: Yes, absolutely. And I prostatectomy as well, but our insurance system runs a little bit differently here in America and 

Tim Norton: as well. Yes. Do 

Stephanie Prendergast: you remember which countries?  mostly all of them that have socialized medicine because the rate, the cost of people continuing to go to the doctor and continuing to need another surgery or another procedure.

Far exceeds the amount of pelvic floor physical therapy. So if you think about it that way, it actually lowers costs in these other countries where medicine is socialized. Whereas in the United States, it's almost viewed by insurance companies as one more [00:29:00] thing they don't want to pay for. So it's a little bit of a political situation 

Tim Norton: there.

Then yeah, that could be a whole other conversation about the medical. Yeah, don't get me started. Okay. That physical therapy has actually taken place. What are, what are guys telling you about how their sex lives have changed? They're 

Stephanie Prendergast: actually quite happy with a few visits and learning how to control their muscles and regained function.

There can be quite a dramatic change, especially for example, if you're leaking urine, you may not want to leave the house. You may feel socially isolated. And again, these aren't. And these people are in their fifties and sixties. This is a problem that this is happening at this point in their life. And that they can also maintain intimacy with their wives.

So there can be things like Viagra and Cialis. There can be injections that they have to administer themselves into the penis, but if the pelvic floor muscle function makes up at least 50 to 60% of that, it makes sense to maximize that, [00:30:00] to reduce these other interventions. 

Tim Norton: Right. And what, what about the other symptoms?

 When somebody had a burning for a while or, or the one I've heard a few times is the sensation of a golf ball on your butt. 

Stephanie Prendergast: So switching back to the more younger end of the spectr right?  obviously if those sensations are there, it's unpleasant. And so over the course of time, we're able to help reduce them.

Doesn't feel like there's a golf ball in the butt anymore, which can be a sign of pudendal nerve issues or pelvic floor, muscle dysfunction. 

Tim Norton: Okay. And then they come in and they say, gosh, I'm feeling a lot better. 

Stephanie Prendergast: They can. And it's often if the symptoms are very severe, cause we're talking about a whole range of things.

So on the pelvic pain end of the spectr it is an interdisciplinary approach. That's the most helpful for our patients with severe pelvic pain. So that involves medical management, which may include some pharmaceuticals that are not antibiotics. Okay. More [00:31:00] neuropathic drugs.  there could be various procedures such as Botox or nerve blocks.

It can be therapeutic in conjunction with physical therapy. 

Tim Norton: Okay. And once you said interdisciplinary, 

Stephanie Prendergast: that means doctors and physical therapists, psychologists are all involved to help people function better in the face of their issues. 

Tim Norton: And so when would you involve a psychologist or a mental health therapist 

Stephanie Prendergast: at this point?

I mean for me in my career, I feel like we can kind of assess how distressed people are about their symptoms. I mean, obviously this is unpleasant for everybody, but you can kind of gauge how people are coping or not coping. And at the point that we. Obviously suggest people like you, we want to have them establish a relationship with us.

So we're not offensive, which some people can take this as I'm only upset because I have a physical issue, but that's okay. You're just not coping well while you have [00:32:00] it. And maybe we can help you make this. Less sufferable as you're going through the process. So I think in an ideal world, mental health specialists would be involved from the beginning.

Our society doesn't totally work that way. And some people definitely need it more than others. Right. 

Tim Norton: And then what I find is that,  The anxiety, the stress, the lack of coping exacerbates the 

Stephanie Prendergast: symptoms. So they, of course it does. So people think they're doing this to themselves because stress makes all musculoskeletal pain worse.

 and that's just not the case, especially if you've been told by five, six, seven doctors that there's nothing wrong with you or the medications that are prescribing it, working, you Google your symptoms. You read online that you're going to have this chronic condition that affects. Your sex life for the rest of your life.

You're not going to be happy and that's okay. We have to sometimes undo all of that misinformation because treatment is available. It is effective. It's just not readily available to every provider across the country. 

[00:33:00] Tim Norton: Right. And I bet some of your interventions are actually pretty similar to some of mine.

I'm like stop Googling. Yes. And,  sometimes stop. The examining your penis once an hour. And,    Dr. Gonzalez actually was, was saying some of those things, like he, we would get continual calls from people,  about just put the same questions over and over again, and clearly. Way too in their heads about it and read thus increasing their stress and thus leading to probably be more tension and the area more attention throughout their body and worse symptoms.

Hmm. 

Stephanie Prendergast: It sounds like you're in this situation and you're going to be here for the next 40 years and people often think, Oh my gosh, if I feel this bad now, how bad is it going to be then? And we do want to stop that thinking because that's just not how it has to go. 

Tim Norton: Right. And you're sitting there and telling them, okay, stop thinking like that.

Yeah. That's where we see a lot of results. We [00:34:00] see a lot of progress in this area and I know you've gotten mixed messages, bots. This is something that we're really good at treating. And I bet that you have to have a pretty good bedside manner as you talk to these guys. 

Stephanie Prendergast: Yes. I mean, I mean, I understand if I Googled the same symptoms and I thought I had this, I would be probably in the same boat.

So I understand, 

Tim Norton: but you could also read your book 

Stephanie Prendergast: began and they also it's so funny how often men see so many men coming in and out. Of our office. And one thing they say is everyone here looks so normal. I'm not sure what they thought, but of course they looked normal and there's so many men in here which is true.

I mean, this is not a women's issue. Yeah. Yeah. 

Tim Norton: Should they buy your book? What's in your book is everything that we just talked about in your book. 

Stephanie Prendergast: Yes. The book contains,  a more detailed explanation about the specific musculoskeletal issues that happen, but more importantly, my book isn't [00:35:00] do this stretch, do that stretch cause everybody's symptoms are totally different.

And so are the reasons for it. It's more teaching people how to understand how they develop the symptoms and how to navigate the treatment process because some people may need physical therapy and pudendal nerve. Blocks. And some people may not even need physical therapy. They may be, they need psychology.

So it's really important to understand where the person is and how to troubleshoot things if they plateau or if they can't tolerate certain treatments or medications. It's really about teaching people how to think through this issue versus just go stretch your hamstring. Cause that's very rarely effective.

Tim Norton: Is there a. Do this stretch, do that stretch book. 

Stephanie Prendergast: Well books. Yes. No, there's a ton of books saying stretch, this, do that. And I don't find them very effective. I went for strata. 

Tim Norton: Right, right, right. Okay. Cause yeah, I, there, there are a lot of pelvic pain books out there, but you don't have one that you love.

No. [00:36:00] Okay. All right. You heard it here first. Now we have talked a little bit about medications and that's another thing that I've, I've heard. Well, here's the typical story is, you know, somebody told me I had prostatitis and they, it was a urologist, gave me an antibiotic. Everything was working well for a few days and everything came back and now they want to give me another antibiotic.

And then I've found you. 

Stephanie Prendergast: So, I'm glad you brought up the antibiotics situation. This is important, and everyone needs to know this, that there are analgesics in a number of animal Biotics. Analgesic. Analgesic is a it's Tylenol. Yeah. Pain numbing medication, because oftentimes people with infections have pain associated with infections.

Infections are unpleasant. They usually hurt. And so people can erroneously think that the antibiotic is killing the bacteria because they feel better on it. When in fact they're taking a pretty high dose of Tylenol [00:37:00] with the Cipro, for example. And so they may feel better. And then they think their infection came back when they go off of it.

When in fact they're just not taking that much. Of the Tylenol anymore. So many people don't realize that. And that's important to know, especially if they're given antibiotics without proper testing to diagnose prostatitis you have to undergo a full semen analysis, not a urine culture, but a full semen analysis and many people who are diagnosed with that have not been through that process.

Tim Norton: You're right. I'm telling you you're right. That the few times I have worked with somebody who said. They have prostatitis I asked that question and then a semen analysis. Isn't that common, 

Stephanie Prendergast: right? And that's because it's, it's difficult to do. And there are issues with the labs. It's just not always a clear cut in a straightforward test is we want it to be, there can be false positives.

There can be false negatives. It can get contaminated quite easily. So. People don't bother. They [00:38:00] just give the antibiotics, but that's actually not right. Especially time and time. Again, it can cause gastrointestinal distress and a whole host of other problems for men, 

Tim Norton: antibiotics are not the only medications I've heard prescribed in this arena.

What else is being given to these patients? So, 

Stephanie Prendergast: because this is a. Pain syndrome. They're often given the same medications that are used for any type of pain, whether it be a migraine or back pain or things like that. And there's three classes of drugs that could possibly be effective. Those are either tricyclic, antidepressants that are used at a dose lower than treating depression to treat pain.

 there's SNRI such as Cymbalta. Have been shown to have musculoskeletal pain reduction effects. And the third class of drugs are the neuromodulators, which are Lyrica and Gabapentin.  so those drugs may be prescribed for this just as they are for any other pain syndrome. And depending on how involved the nervous [00:39:00] system is, or isn't in somebody issues, they can be effective or not effective.

Tim Norton: That's interesting because when I took my licensing exam, I learned about all three of those medications and yeah. So those must be secondary benefits to those medications. Does SNRI wasn't designed for pain? 

Stephanie Prendergast: No, but it has been FDA approved for pain. Whereas the tricyclic antidepressants and the neuromodulators are off-label uses.

Those are off-label use actually the tricyclics may be on label at this point, but Lyrica and Gabapentin are off label for pain, but really commonly prescribed commonly prescribed. 

Tim Norton: Okay. And how do you feel about all three of those drugs? 

Stephanie Prendergast: I think for certain patients, some of them have been quite effective.

I think. The side effects can sometimes outweigh the benefits. The most important thing with the medications is that patients often don't understand why they're taking them and they have unrealistic expectations as to what they should do. So if [00:40:00] you take these medications and you have. Daily unprovoked pain.

It's not going to take it away, but it may take it down a few notches. So if you can't sit for more than 10 minutes without getting severe parallel burning, maybe instead you get perinatal aching at 15 minutes instead of 10, and that actually is considered effective for what it's intended to do, but people think it's just going to completely take away their symptoms.

And that's just not how it works. 

Tim Norton: Right. Cause I'm thinking about the way that that study would be designed is study the efficacy of that medication and that isn't right. Improvement. 

Stephanie Prendergast: That is an improvement, but this may be why it's not FDA approved for pain. It's very difficult to quantify. Right, 

Tim Norton: right.

Okay. Yeah. Cause I would imagine. I'm prescribed a tricyclic and I go home and I Google that. I'm like, wait a second. I'm not depressed. I'm not bulb. Am I depressed? Because I'm certainly very distressed about this, or are they saying that if my depression goes [00:41:00] away, that this pain is going to go away?

Stephanie Prendergast: Right. So I think, again, people think that they're given it because they're being told it's all in their head or things like that because often physicians may not have time to explain why we're giving, why they're giving patients these drugs. So they are meant. To treat pain at different doses. And for depression, it's important to know for the tricyclics.

 Cymbalta is the same for anxiety, pain and depression, and that can be an effective medication to help people go through the treatment process. 

Tim Norton: Okay. So I'm trying to imagine the guy who has some of these symptoms, who's kind of a long way from deciding, okay. I'm going to come in. Okay. What can you say to him, or is there a video where he could look online and say, okay, I just want to see what this is like, or is there something that might kind of make it hasn't been in a [00:42:00] movie?

Not yet. 

Stephanie Prendergast: It's creeping into movies for female, pelvic pain and TV shows and all kinds of IX right now. Now it hasn't been in a movie.  I think doing some Google searches, the lecture that you attended at USC is amazing online,  where people talk about the whole spectrum of things. And I think for men, not sure if this is.

What they need or not. I think an evaluation is warranted and at least get a little bit more information. If you have these symptoms, I think you should rule in or out the pelvic floor as a source of them. So, you know, 

Tim Norton: and they could come in and get a decent evaluation without getting a finger on the button.

Nope. Nope. Okay. So that's going to be a part of it. So it's just going to be part of it. I don't, I don't want us, I don't want to say man up, but I guess I'm 

Stephanie Prendergast: kind of saying that well, and as the symptoms get. Severe enough. They rarely, once you get to a symptomatic point, they may not resolve on their own.

And I think that motivates people to seek appropriate attention because they can see that things [00:43:00] are changing and progressing and often not in the right direction. Okay. 

Tim Norton: Is there anything that. People could be doing in the meantime that they're mulling over this decision of whether or not to come to your center.

Are there stretches, you already mentioned, maybe ease back on the cycling. 

Stephanie Prendergast: Well, and again, it's all about someone's anatomy, plenty of people cycle and have absolutely no problems. And certain people may ride their bike a mile. And all of a sudden have penile numbness for two days. It really depends on your anatomy.

And if your body can do the activity in question and so listen to your body, if you do feel symptoms after certain exercises you do at the gym or riding your bike or sitting for 18 hours, you know, listen to your body, get up, move. And if the symptoms repetitively, keep coming back, that activity may not be okay for you, but you also may have a treatable.

Condition 

Tim Norton: are [00:44:00] there yoga poses guys could do to help this condition? 

Stephanie Prendergast: If. The in general, the child's pose will help relax the pelvic floor muscles.  however, if you have symptoms of pudendal neuralgia or there is nerve symptoms, burning shooting, stabbing, tingling, things that stretch muscles. Will also stretch the nerve and provoke the symptoms nerves do not like to be stretched.

So it's really important to distinguish patients with nerve issues from muscle, because what you think could be therapeutic could actually be less useful. Same thing with a lot of people with low back pain, they want to strengthen their core. That's actually going to provoke your pelvic floor muscles to tighten.

If your muscles are tight enough that they can't relax things that are well-intended to help your back are actually going to cause pelvic pain or exacerbate your pelvic pain. So strengthening is not always the answer in these cases until the muscles are in a [00:45:00] position that they can do. So. Okay. 

Tim Norton: I think that's a really good rule to live by.

You say things that stretch the muscles, stretch the nerves. Yeah. Yeah. 

Stephanie Prendergast: So it can be provocative instead of therapeutic and you'll know, it may not happen right away. It may be a delayed onset, like two to three hours, but people usually can start to tie provoking activities to their symptoms. Once we start asking them more specific questions.

Hmm. 

Tim Norton: Yeah. And that would happen over the course of treatment. They'd start to piece things together. I bet a lot of guys will say things like. But I've been cycling my whole life or something like that though, or all of the exercises.  

Stephanie Prendergast: what's your response. Maybe they'd been cycling their whole life, but recently they had a bad sciatica.

And so now things are different, the sciatica resolved, but maybe their hip muscles are still tight or there's still some sort of tissue change that is now. [00:46:00] Causing symptoms during the same activities they've always done. And I also say your body changes over time. Like we can not do the same things in our thirties necessarily that we did in our twenties, as much as we all want to, things are different as you age.

And it doesn't mean it's not correctable, but you may need to focus your attention on addressing impairments. Hmm. 

Tim Norton: You keep mentioning. Studies is there, is there, has there been a really good meta analysis or maybe your book would just be a collection of those? Or what, where should a guy start reading? So he's just not Googling blindly about this stuff.

Stephanie Prendergast: That's a good question. I think our blog is a good patient friendly resource and we referenced that to go to other places. Most people don't want to read medical journal articles. However, I would say. Yes. I would say that this year,  just in August,  Rodney Anderson published in the journal of urology,  a [00:47:00] huge meta analysis on CPPs.

And instead of calling it a prostate dysfunction, they're finally acknowledging it as a psycho neuromuscular disorder. So effecting the mine, the body. And the nervous system. And they went through all of the literature on this. And again, showing that the majority of men never have an infection, they don't respond to any Biotics.

They don't respond to a lot of medications cause it's not that type of a problem. And I think that's a big step forward because most urologists get the journal of urology. So even if they're not seeking out additional knowledge for these patients, this came to their doorstep. So hopefully they read it.

Tim Norton: Awesome. So yeah, if, if guys, if your urologist doesn't seem to know what's going on, get the August journal of urology, find the article by Anderson. And this is Google-able,  obviously, and you probably have to pay the 40 bucks for the article, or there are ways around that we won't go into on this podcast.

[00:48:00]  but yeah, and. Forward it to your I'll just hopefully he or she will read it. And this is why these studies,  take place in a big meta analysis. And that, so that was just a couple months 

Stephanie Prendergast: ago. That was recent. Yeah. Big step forward. I'd 

Tim Norton: say that's great. And you're reading your journal of urology 

Stephanie Prendergast: must stay on top of it.

Yes, you 

Tim Norton: do. Okay. So. What just in general, what, what would you like to say to the guys out there who have some of these symptoms? Like what words of hope can 

Stephanie Prendergast: you give to them? Canon will get better. There's usually room for improvement.  if you have these symptoms and people are telling you there isn't anything wrong or.

Certain treatments that they're prescribing are not working. I always recommend getting a second opinion.  I can direct you to resources where they can find providers that are skilled in treating this. And I think that they [00:49:00] should. Move forward and try to get the issues taken care of. Don't ignore them.

Great. 

Tim Norton: And their sex lives can improve. 

Stephanie Prendergast: Sex lives can improve. Erections can improve. Anxiety can go down. You can return to the exercises that normally provoked your symptoms. All of this can get 

Tim Norton: better. Okay, good. And what about for, for you? What's going on in your world? You have how many centers. Nine. 

Stephanie Prendergast: Wow.

Now we just opened one more. Yeah, just open 

Tim Norton: one more. And those are not all in 

Stephanie Prendergast: California. So we're in new England, Northern California and Southern California. Okay. 

Tim Norton: What kinds of things do you have on the horizon? 

Stephanie Prendergast: What's on the horizon.  that's a good question right now. We're trying to hold down the Fort right now.

We're pretty busy in the clinic and it looks like in 2019, we're going to start teaching again and locally.  I have a larger space now, so things will [00:50:00] be changing a little bit on that front. Basically just keeping the clinics running at this point. Yeah. 

Tim Norton: Yeah. That's a lot to oversee and it was,  You, you are very busy.

Absolutely. We, it took us a while to get this rescheduled after I blew it on the first episode, but you you're at the top of your field and you're doing really great work. And every time somebody named drops you, they're saying really wonderful things. So I know I said it at the beginning of this episode that I was excited, but I am,  you know, I think that you're doing really.

Really important work. And I'm so grateful to have you on here and helping us have these hard conversations.  where can we find you on the 

Stephanie Prendergast: internet?  our website is pelvic pain, rehab.com. A book is on Amazon. It's called pelvic pain explained, and that's where we are. I practice in our Los Angeles location.

Right. You're on Twitter. I'm on Twitter at pelvic health. I'm also [00:51:00] on Instagram. The same at pelvic health and Facebook is pelvic pain, physical therapy 

Tim Norton: kinds of pictures. Do you put on Instagram? Yeah, that's a good question. 

Stephanie Prendergast: Yeah. Check us out. It's a challenge. All right, Stephanie. 

Tim Norton: Well, thank you so much.

Thank 

Stephanie Prendergast: you. Bye-bye.

Shout outs to the sex positive community, including sex educators, sex therapists, sex coaches, other fellow sex, podcasters, sex, surrogates, academics, sexual health, medical community, sex workers, the tantric community, and everybody else involved with having hard conversations. Bye-bye.