With an average of 300 referrals to the Comprehensive Pelvic Rehabilitation Program each month, UT Southwestern is experiencing a significant expansion in this once niche subspecialty. What was once a small field, characterized by only a handful of trained specialists, has evolved into a rapidly growing area of medicine and research. This surge reflects a heightened recognition of the profound impact pelvic health issues – often underrecognized, debilitating, and deeply personal – can have on patients’ lives. As awareness and expertise in this area continue to advance, the program is positioned to address and alleviate these challenging conditions.
Restoring dignity and hope
Rupali Kumar, M.D.
Rupali Kumar, M.D., Assistant Professor of Physical Medicine and Rehabilitation at UT Southwestern and Associate Medical Director of the Comprehensive Pelvic Rehabilitation Program, emphasizes the program’s importance, “Pelvic rehab addresses some of the most vital aspects of quality of life, yet to this day is still a taboo subject. Many people hesitate to discuss issues like urination, bowel movements, and sexual function, even with their doctors. But these are critical aspects of health that deserve attention and care, as they significantly affect a person’s daily life and sense of normalcy.”
In fact, pelvic health is an often underserved, yet crucial area of medicine. Traditionally, medical focus tends to center on organ-related issues within the pelvis, such as problems with the bladder, uterus, or colon. However, this narrow perspective can miss significant musculoskeletal components, including the muscles, nerves, and joints that play a critical role in pelvic function. As a result, when symptoms arise, they are frequently attributed to organ-related issues. If these are ruled out, the underlying cause remains elusive, leading many patients to a prolonged journey before receiving a comprehensive evaluation that addresses these often-overlooked issues.
The case for a new approach
Kelly Scott, M.D.
During her residency, Kelly Scott, M.D., Professor of Physical Medicine and Rehabilitation at UT Southwestern and Medical Director of the Comprehensive Pelvic Rehabilitation Program, recognized a critical need for a specialized program in pelvic rehabilitation. Under the guidance of pioneering physical medicine and rehabilitation experts who were instrumental in the development of this field, she became deeply engaged with pelvic rehab. Driven by her passion, Dr. Scott made a compelling case for the program at UT Southwestern, demonstrating its critical value and the unique benefits it could provide to patients. Her advocacy resulted in the establishment of the groundbreaking program in 2008. To this day, it stands out for its innovative approach, setting a new standard that is rare within other institutions.
Navigating complex discussions and collaborating with various stakeholders fills a vital gap that significantly enhances patient care. With a strong mutual understanding and respect among the various specialties – urology, urogynecology, gynecology, colorectal surgery, and gastroenterology – each group acknowledges the advantages of a multidisciplinary approach and is dedicated to the program’s services.
A new frontier in patient care
Initially starting with a small team, including one pelvic physical therapist, the program quickly grew as word spread about the positive outcomes and the types of issues it could address. It quickly emerged as a resource for pelvic pain – encompassing abdominal, low back, groin, tailbone, and genital pain – urinary and bowel dysfunction, incontinence, painful intercourse, recovery after major abdomino-pelvic surgery and complications related to pregnancy and postpartum.
As more patients experienced the benefits, referrals steadily increased, necessitating the expansion of the team. Over the years, more therapists and additional positions were added. Extensive collaboration both within and outside the program continues and there are regular meetings, including a multidisciplinary conference every two months, where patient cases are shared and representatives from the respective fields contribute insights. This allows the team to discuss challenging or unique cases and learn from other qualified perspectives. Presenters rotate, providing a valuable opportunity to deepen the understanding of different specialties and apply this knowledge to patient care.
From evaluation to breakthroughs
Patient evaluations are thorough and comprehensive to understand the presenting symptoms and assess all functions within the pelvis. This includes detailed inquiries about urinary, bowel, and sexual functions, as well as the psychiatric and psychosocial aspects, which often play significant roles. Many patients with chronic pelvic pain have a history of abuse or trauma, which can be a major factor. Background information, including surgical, obstetrical and other medical histories, allow the team to get a holistic view of the patient's condition.
The physical examination is equally detailed, focusing on the musculoskeletal and neurological aspects from the abdomen to the lower buttocks. A spine examination with particular attention to the lumbar and sacral regions assess the hips and abdominal wall. Sensation, strength, and reflexes in the lower extremities and pelvic region are assessed to evaluate all pelvic nerve distributions. Additionally, pelvic floor muscles are checked for tone, tenderness, coordination, strength, and endurance, while also looking for scar tissue or any obvious defects.
Promising new treatments
Each case combined with research and multidisciplinary collaboration has prompted breakthroughs for patients and doctors seeking answers. One such example is the use of pelvic floor Botox implemented in collaboration with colleagues in urogynecology in patients with refractory, high-tone pelvic floor dysfunction who have not responded well to physical therapy. These patients often experience severe discomfort or minimal improvement, despite adhering to recommended treatments. By using Botox to relax the overactive and tense muscles, it can create a window for more effective physical therapy. This combined approach is being used with promising results.
Chronic pelvic pain shares more similarities with chronic pain in other body parts than with acute pain specific to the pelvis and is another key area of exploration. Chronic pain is a distinct condition, and conventional treatments like medications and injections often prove less effective. Notably, there has been significant promise in mind-body strategies where a pilot study investigated the effectiveness of Qigong – a practice similar to Tai Chi – for patients with chronic pelvic pain. This study explores whether gentle movement, breath control, and body awareness can alleviate pain symptoms by addressing heightened nervous system signaling and the fear of movement associated with chronic pain. The results have been encouraging, offering new avenues for treatment.
Future outlook
With every new discovery and patient encounter, the Comprehensive Pelvic Rehabilitation Program at UT Southwestern represents groundbreaking advancements in a previously underserved area of medicine. This unique program offers a fascinating glimpse into the evolving field of pelvic health, while also providing essential care to patients who might otherwise resign themselves to a life of pain and embarrassment without answers. By addressing complex and often overlooked issues, the program empowers patients to reclaim their quality of life and dignity.