Beyond Kegels: What Real Pelvic Pain Care Looks Like with Elizabeth Akincilar & Stephanie Prendergast

Pelvic pain is one of the most common, most misunderstood, most dismissed categories of pain in healthcare. People are told their pain is normal. They’re told it’s anxiety. They’re told to relax. They’re told to wait. They’re told to try again. But pelvic pain is not just in your head, air quotes, and painful sex,

vulvar pain, pudendal, neuralgia, vaginismus, bladder, bowel pain, the list is long. Basically persistent pelvic symptoms are not things that people should just have to live with. And today’s guests have spent decades changing that conversation. Elizabeth Liz Akincilar and Stephanie Prendergast are co-founders of the Pelvic Health and Rehabilitation Center.

They’re also co-authors of Pelvic Pain Explained. They’re global educators, researchers, clinicians, and advocates who have really helped shape the field of pelvic physical therapy as we know it. And in this episode, we’ll talk about what still gets missed in pelvic pain care, how sexual pain deserves a more informed and compassionate clinical response, and why that’s not happening.

and why advocacy matters and what the next generation of pelvic health providers need to understand.

Welcome back to the pelvic floor, everyone. Where this season we are exploring pelvic health, sexual wellness, advocacy, and whole body healing through the lens of, of course, science, as well as story and clinical truth.

Today I’m honored to welcome two leaders whose work has deeply shaped the pelvic health field, Elizabeth Akincilar aka Liz, and Stephanie Prendergast. Let’s start with Liz. First of all, welcome. I’m so excited, I wanna like jump right in, but I wanna say welcome first, so welcome.

Liz Akincilar (02:03)

Thank

you so much. Glad to be here.

Dr. Ginger Garner PT, DPT (02:07)

Yeah, I’m so glad you guys are here. ⁓ All right, everybody knows that I do a little bragging before we kind of jump into the interview. So I want to start with Liz first. Liz, you earned your Master of Science in PT from the University of Miami Miller School of Medicine. ⁓ She’s the co-founder of Pelvic Health and Rehabilitation Center, which is a multi-location practice specializing in pelvic health for adults and also pediatrics.

She’s also the co-director of a two-year advanced physical therapy diploma in pelvic health at MREF International University in Nairobi, Kenya. And we will definitely be touching on that. Liz is the co-author of Pelvic Pain Explained and has educated clinicians around the world on PT management of pelvic pain syndromes. Stephanie is also co-founder of the Pelvic Health and Rehabilitation Center, which she and Liz opened in 2006, which seems like yesterday, but.

That was a few minutes ago. And they’ve grown into one of the most recognized pelvic health practices in the country. Stephanie has been a major force in pelvic pain education, advocacy and research, and has served as president of IPPS, International Pelvic Pain Society, chaired the World Congress of Abdominal and Pelvic Pain Scientific Program, and is currently an associate editor for the Journal of Sexual Medicine and Sexual Medicine Reviews. She and Elizabeth co-authored

Pelvic Pain Explained together and recently published an ebook on vulvodynia, vestibulodynia, and vaginismus. Again, Liz and Stephanie, welcome to the vocal pelvic floor.

Stephanie Prendergast (03:41)

Thank you for having us.

Liz Akincilar (03:43)

Thank

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

All right, let’s just dive right in. Let’s talk about how pelvic pain gets missed because that’s the thing that frankly, it just pisses me off. It makes me so mad. By the way, if you need to, you can swear on the podcast, just putting that out there. But I just want to begin with the big picture because that’s where the problem is. And between the two of you, you’ve seen thousands of patients with pelvic pain, sexual pain, bowel, bladder symptoms.

Liz Akincilar (03:55)

You

Stephanie Prendergast (03:56)

You

Dr. Ginger Garner PT, DPT (04:13)

pudendal nerve issues, vulvar pain, and complex presentations that can take years to be properly understood. So when someone with pelvic pain finally gets to your clinic, what are some of the most common things that have already been missed?

Stephanie Prendergast (04:32)

No, I know. I’m like, we can start. ⁓ I think it’s also about how patients enter the healthcare system. So being in practice, as long as we have, we have patients that are referred by providers who are experts. We have patients who are referred by general gynecologists and neurologists and may have been given misinformation. And then we have people coming in and they find us on their own. And so it’s a pretty broad question.

Liz Akincilar (04:33)

Go ahead, Steph.

Stephanie Prendergast (05:02)

⁓ And unless they’re coming directly from an expert, there’s a lot of back-end work that we have to do as rehab professionals to really understand what’s happening with their healthcare. And sometimes, even if they were referred, instead of by Google or now CHAT GPT, or it came from a gynecologist or urologist, they could have been given completely the wrong information. ⁓ Men are told that they have prostatitis, there is no infection. Women are told they have vaginismus, it’s vestibulodynia.

not the same thing, not the same treatment plan. And so even though there’s been a lot of advancement, I feel like there’s still a lot of work to do.

Dr. Ginger Garner PT, DPT (05:39)

Yeah, so true. Liz, do you have anything to add to that?

Liz Akincilar (05:44)

Yeah, I think even just in the last few years, there’s been so much more information online about education about hormones and the perimenopause and menopause state. So I think so many women come to our office with various pelvic pain complaints when there is a hormonal insufficiency at heart. So I think that’s a big, I mean, it’s always.

happened clearly in Steph and I’s first year treating pelvic health, but it’s become, thankfully, more of a conversation point and more gynecologists and even just general practitioners are more aware of the needs of ⁓ perimenopausal and menopausal women. So I think that’s a big, big thing. ⁓ I mean, there are so many reasons why pelvic pain is missed, to be honest. think clinicians don’t ask the right questions.

either, you know, starting at the very beginning, you know, if you’re not asked about your sexual health, if you’re not asked about your bowel health, then many people are not going to come forward with that information because they may not see it as problematic, right? I mean, I talk about constipation probably too much. ⁓ But I think it’s like the cornerstone, you know, of so many pelvic health issues. And many people don’t even understand what that means.

Dr. Ginger Garner PT, DPT (06:41)

True. Yeah.

Mm-hmm

Liz Akincilar (07:09)

So if they’re not being asked the right questions, then they’re never going to get a diagnosis, let alone get on the right treatment plan.

Stephanie Prendergast (07:17)

Mm-hmm.

Dr. Ginger Garner PT, DPT (07:18)

And that brings up another really important point. I think that the reason people come in, thank goodness they finally get in the door, right? I mean, that’s one thing. And they may, you may shift into a different mode or education or dispelling misinformation or they’re an entirely different diagnosis altogether than what they were referred for. But I think the overarching theme, it needs to be said out loud and that’s that pelvic pain is still often minimized or misunderstood.

⁓ and people, whether it’s inadvertent or otherwise, end up being medically gaslit.

Liz Akincilar (07:55)

Sure. But it’s also hard to treat, right? I mean, it’s not something that, I should say, it’s difficult as a clinician to treat it. So you don’t always get an easy win, you know, as a clinician. And I think a lot of clinicians are afraid of that. You can’t just throw a medication at it necessarily, or even a surgical procedure. Obviously, sometimes surgical procedures are very… ⁓

important and needed, but not always. And so I think a lot of clinicians are scared of pelvic pain. I mean pain in general, but even more so with pelvic pain.

Dr. Ginger Garner PT, DPT (08:32)

You know, Liz, with your work educating clinicians, know, globally, and we’ll circle back to that in a little bit more depth in a minute, but what gaps have you seen in how pelvic pain is taught or not taught in physical therapy and medical training?

Stephanie Prendergast (08:46)

Mm-mm. ⁓

Liz Akincilar (08:46)

It’s just not taught.

Dr. Ginger Garner PT, DPT (08:47)

Ha

Liz Akincilar (08:48)

It’s

Dr. Ginger Garner PT, DPT (08:48)

ha ha ha ha ha.

Liz Akincilar (08:48)

just not taught. I mean, you can start right there, right? There’s, mean, you know, the work that I do in East Africa is the first of its kind. You know, it’s the first program to teach PT’s, but I mean, Steph and I have done a lot of teaching in Europe or speaking. I mean, the education is really lacking there too. And not just with physios or physical therapists, like it’s from the top, gynecologists and neurologists and… ⁓

know, pain management clinicians. It’s everywhere. It’s just, there’s a huge gap.

Dr. Ginger Garner PT, DPT (09:22)

Yeah, so what do you think, Stephanie, about healthcare systems failure to understand pelvic floor dysfunction, especially with your space and time in advocacy, and also with IPPS?

Stephanie Prendergast (09:39)

Yeah, it’s if I can work backwards from most recent to back in the day, 2025 really changed me when I started teaching at the residency’s via tight lipped who worked very hard to get me into these academic institutions. It all happened around last year at this time, and there were residents fourth year about to graduate who literally delivered babies the day before.

but hands were shaking when I was teaching them how to do a transvaginal exam on models because they didn’t have any of that type of training on how to insert a speculum without hurting the vestibule, what the vestibule even was. And they were about to be doctors in a few months and already are doctors and were already in the field. So that was really surprising to me to also see how nervous.

some of the people were, both in the classes that I was teaching that was the didactic part and the hands-on. There are people too. And if they’re not taught, I wouldn’t want to see these patients either. If you sent me out to try to teach little league right now, I would be a disaster. And so it really, most recently that was really eye-opening to me. And if this is happening in OB-GYN residencies, the urology residents have even less training.

with the male diagnoses. And then going back to the International Pelvic Pain Society and my work at Ishwish, the reason these societies are growing is because the providers who are interested are finding their web. And there’s only a handful of them. At the most recent Ishwish, I have watched it triple in size, but there was still about a thousand people there and this was a global conference and this was in February. And so if we’re looking at those people who are trying to become experts or want to treat the patients,

Think about how many other physicians are available who don’t know how. And so I think Ishwish and IPPS are both working very hard, but coming to a conference is not making you a competent provider. And me teaching how to do a hands-on exam is mostly for the sake of, please don’t gaslight the patients, because I can teach them how to do this in under 30 seconds in a clinical setting, just so you can at least identify it and not tell them there’s not something wrong.

when it’s very obvious there is. And so that’s the work we’re trying to do, but that is only the first step, is to stop the gas lighting.

Dr. Ginger Garner PT, DPT (12:10)

Yeah, yeah, that’s a real mic drop moment, you know, sharing the responses to these physicians who are out to be, you know, about to be out the door and still not literate in some ways, you know, that we need to correct. That’s a big undertaking.

Stephanie Prendergast (12:30)

We have to not be frustrated with them. They really don’t know, is my big takeaway because at times I have been frustrated and the best we can do is educate one person at a time until we make a more broad change, which I don’t see happening to be honest. It’s too hard. They have to get this into the curricula and I don’t see how that’s going to happen when we’re banging down the doors to get me into the residencies.

Dr. Ginger Garner PT, DPT (12:49)

Yeah.

Right, right, exactly. And I think that one of the things that we all hear as pelvic PTs is a patient comes in and sits down and says, I’ve been told everything looks normal, right? Whether it’s a lab or in a standard pelvic exam. And so what’s one of the first things, what’s the first step, right? What’s the next thing that comes out of your mouth in terms of when a patient says that because there are thousands, right?

There are so many people that are saying that and I  know that you’ve heard that story again and again.

Stephanie Prendergast (13:27)

Yeah, go ahead, Liz.

Liz Akincilar (13:30)

Yeah, I think…

Gosh, so many different things, right? I think one of the things I start with is, well, hopefully, or maybe not hopefully, if this is their first time with someone like me, a pelvic health therapist, then I said, well, we’re kind of starting from scratch, right? We’re gonna do a different exam. We’re gonna do some of the same things maybe that have been done. We’re gonna do a pelvic exam, obviously. Most women have not had a adequate vulvar exam.

you know, even though they’ve been to a gynecologist or maybe six gynecologists, they may still have not had a, you know, adequate vulvar exam. ⁓ So we’re going to do that if it’s a male patient or female or male patient. ⁓ Most of them have not had a really sufficient pelvic floor exam to include things like pudendal nerve palpation, ⁓ let alone, you know, all the muscle palpation. So, you know, we do something totally different.

So I think as I’m speaking to those patients who are coming in with those reports that everything came back normal, my doctor said everything’s fine, but well, we’re probably going to expand that evaluation because I think Steph touched on this a minute ago. There have been many times in our career that we’ve been frustrated with the medical community for reason, but at the same time, we have to understand that

Physicians, their training is different. Their training doesn’t include what we do. It’s not their fault. And we have to have some patience, I think, with them because at the end of the day, in order to get these folks better, we have to all work together, right? We can’t do it alone. We need our medical colleagues. So I’d never try to throw their doctor under the bus necessarily, right? know, I just say, well, you know, they just might not be aware we’re going to work together with them, et cetera.

Dr. Ginger Garner PT, DPT (15:19)

Right.

Liz Akincilar (15:27)

to help you reach whatever goals you’re aiming to reach. I think it’s, I think I’ve softened over the years with that, which is, I don’t know. I think we just realized like, you know, it’s hard, right? There are not many people who are interested in this little field of ours, but we all have to work together because we really do need to have the cooperation of that interdisciplinary team to get many of our patients better. So it only behooves us to have a, you know.

Stephanie Prendergast (15:35)

Mm-hmm.

Liz Akincilar (15:57)

collegial  relationship with our other providers.

Dr. Ginger Garner PT, DPT (16:04)

Yeah, yeah. What are some of the red flags you think that a person with pelvic pain

Let’s see, how is the easiest way to put this? In so much of how the current medical system operates, there’s this idea of single provider model. You go to the GYN and they handle everything. Okay, we know that’s not true, right? And they need a more interdisciplinary, multimodal approach almost every time.

especially as things get more complex, like if it’s endometriosis or something like that, which has been a big focus of the podcast in the last season. So what are some of the red flags that that patient or that person may not be, ⁓ that they may need that approach, right, and they haven’t been getting that? Does that make sense? Like if the person,

Liz Akincilar (16:59)

You mean?

Dr. Ginger Garner PT, DPT (17:00)

Like at the GYN, if they go to the GYN and they’re like, no, it’s kind of like an I alone can handle this, right? That is a red flag if someone says, you know, there’s no one else that can help you and I say there’s nothing else that can be done. But in a more nuanced way because you don’t always have to deal with that necessarily, you know, the patient or the provider having that kind of, ⁓ you know, attitude or ego. ⁓ But what are some of the nuanced ways that maybe yellow flags that maybe a provider might not be lining up for a patient?

Stephanie Prendergast (17:07)

Yeah.

Dr. Ginger Garner PT, DPT (17:30)

and they need to seek someone else for help.

Stephanie Prendergast (17:34)

I think one of the biggest things is anybody who has complaints of sexual pain, irritated bladder symptoms, bowel issues, or somatic body pain in their pelvis should be referred. I think the biggest problem is they’re not always getting referred, which I think is part of the advocacy work that we’re all doing. But we also have to say what we mean by pelvic pain, because it does mean different things to different people. To a gynecologist,

dysmenorrhea is pelvic pain and may not be considered pelvic floor dysfunction. To our sexual medicine colleagues, pelvic pain is dyspareunia. So I think also taking out and narrowing down the descriptors as best we can, which patients are figuring out themselves now, especially with AI and all the tools that are available, they’re getting the answers before they’re getting the providers.

Dr. Ginger Garner PT, DPT (18:04)

Mm-hmm.

Stephanie Prendergast (18:28)

And they’re being able, Liz, please speak to this too. I feel like the patients are coming in even without a provider with way better information than I’ve ever seen and a better understanding of what they think they have. And they still may went, they may have gone to four doctors who didn’t know, but they know, and then they come to us and we know, and now we can move forward to get them to the right place.

Liz Akincilar (18:52)

Yeah, I attribute a lot of that to things like what we’re doing right now. know, social media has changed the ⁓ landscape. know, it’s, mean, there’s obviously there’s good things on social media, there’s okay things and there’s bad things, right? ⁓ But that’s really changed, I think, you know, how people are educated and how people are informed. ⁓ Going back to your other question though,

Stephanie Prendergast (18:56)

Mm-hmm.

Liz Akincilar (19:21)

I think there’s a few things that stick out to me when a patient comes about their providers, right? With men, if their provider is consistently prescribing them antibiotics when there’s never been any sort of, know, they’ve never looked at the prosthetic secretions to see if there’s an actual bacterial infection. That’s when I usually intervene and say, let me refer you to someone who might be a better fit for you. Right? The same thing with hormones and women.

someone’s, you know, if you have a woman who’s maybe 25 years old, so clearly not perimenopausal, but has been taking, you know, oral birth control pills and is exhibiting signs of hormonal insufficiency and their physician just may not be really up to speed on how that can happen, then I might intervene to and say, let me refer you to a gynecologist who may be a better fit for you. So there’s definitely points where I refer.

different people, right? If they come in with, well, my physician says, you know, this, that, and the other. I’m like, okay, let’s get you to someone else.

Dr. Ginger Garner PT, DPT (20:26)

Yeah.

One thing I appreciate about this conversation is that you’re helping give language to conditions and experiences that patients are often just struggling in silence. And I think you’re right, too, that AI is doing its job in many ways. And yes, there’s pros and cons to it, but people are increasingly more informed.

⁓ that brings us to a better place in terms of talking about things that already hold such a stigma that we’re trying to constantly dispel in our field. And one of those is sexual pain and sexual dysfunction. And that’s been on this season of ⁓ the show has been very heavily focused in that direction because I think that’s where people…

hold such, they’re most likely to feel shame or confusion and to get dismissal too because practitioners may not know the right questions to ask or maybe they’re frankly uncomfortable with diving that deep or time limitations. I mean, there’s so many different reasons why they don’t. But I think what I want to help the listener with today is distinguishing between some of those things. Like when a person comes in and reports,

painful sex, what are some of the key clinical distinctions that you’re thinking about that providers need to be making early on? Because this also helps our listener to go, ⁓ here’s the green flags if my practitioners are talking about this stuff.

Liz Akincilar (22:06)

Yeah, I think some of the biggest things are you know, what led up to it, right? Is this been always the case since the first let’s just say the female pelvis they have pain with intercourse You know with this from first attempt at putting anything into the vagina whether that’s a tampon a finger a penis or whatever ⁓ Is this something new is this something after starting medications and what medications those are? I mean, there’s a lot of information I feel like you know, we do so much training and

I always tell like newer therapists that are new to this field is the more questions you ask, right, is really going to give you so much information before you even put your hands on that patient. So I think those are some of the biggest things because ⁓ Steph mentioned before, you know, are we talking about, you know, vaginismus or are we really talking about vestibulodynia? And if we’re talking about the vestibulodynia, are we talking about something congenital?

something that’s acquired and why is it acquired, what happened? So really asking all of those questions because that’s going to obviously gear what we’re gonna do or maybe, you know, we’re not the appropriate providers in the first place. Maybe really they need to be on a more, you know, pharmacological treatment versus, you know, a physical therapy treatment. So I think it’s really just asking all those questions because chances are no one’s asked them.

Stephanie Prendergast (23:17)

Mm-hmm.

Dr. Ginger Garner PT, DPT (23:17)

Mm-hmm.

Liz Akincilar (23:31)

those specific questions.

Dr. Ginger Garner PT, DPT (23:32)

Yeah.

Well, the other thing that I would love, and Stephanie, you can chime in on this, ⁓ is in a way that patients can, and people can really understand, is explaining the difference between those things that we kind of kicked off with, like the difference between vulvodynia, vaginismus, vestibulodynia, pelvic floor overactivity in general. What’s kind of rapid fire way that patients begin, people can begin to understand that?

Stephanie Prendergast (24:03)

Yeah, there’s a lot that goes into that. And the physical exam and the history, as Liz just pointed out, is really going to tell us the difference. And I want to add in that some of the newer people to the rehab field, physical therapist, occupational therapist, if they start using dilators and things on somebody with tearing vestibulodynia and lichen sclerosis, they are going to hurt that patient and not know the difference. And one of the things that we’ve learned from teaching so many physical therapists

and occupational therapist is they may not be taught either. And so then they’re trying to immediately do homework and things that are exactly the opposite that you would do for somebody with vaginismus and vestibulodynia that may need medical management first. So the vulvar exam, obviously we know vulvodynia is the broad umbrella term. The vestibule is a very specific part of the anatomy that we can do a visual exam with.

as well as a Q-tip exam if I don’t think it’s gonna be too provocative. If my eyes are telling me this patient is already lit up, there is no reason why I should poke that patient with a Q-tip. And I may not proceed to a transvaginal exam until we figure out if they need medical management for the vestibule because it could be provocative and not therapeutic. And I do get a little worked up about the dilator conversation because anytime I post about it on social media or I’ve made some comments, everybody gets all upset.

But then if you think about a patient who’s actually harming their tissue every time they use it, it’s one more thing that is psychologically traumatizing. It’s not therapeutic. And then they get upset with themselves for feeling like they’re not being compliant when all these people want to do is get better. So we need to know the difference. And it is not hard in a physical exam to tell the difference. Now the treatment part, as Liz alluded to earlier, that’s a whole nother story.

Dr. Ginger Garner PT, DPT (25:56)

Right, right.

Stephanie Prendergast (25:56)

getting the cream on the right

way, the creams may hurt, they may not be compliant, they’re missing the area, but identification is key.

Dr. Ginger Garner PT, DPT (26:05)

So then to help the patient understand what the definitions of those are and what the difference is, because I think that empowering them with that information will at least get them pointed in the right direction to find the right provider.

Stephanie Prendergast (26:19)

I think most patients experience the fact that they can’t have pleasurable penetration. And I think it’s really hard for the patients to feel the difference because all of these things can burn. And we didn’t even get pudendal neuralgia thrown in here yet, but we really have, I know we’ve got, but I mean, these things can burn. They think they have an infection. So I think from the patient perspective, they just know something hurts and it really needs to be with a skilled provider to make the differential diagnosis.

Dr. Ginger Garner PT, DPT (26:32)

That’s next. Yeah.

Stephanie Prendergast (26:48)

They can’t figure this out themselves necessarily.

Dr. Ginger Garner PT, DPT (26:52)

Right, right, but it helps if they understand, I think, what the actual ⁓ distinction is for you when you’re looking at it so that they understand these terms even exist as separate ⁓ things when they come in. Not so much that they’re gonna self-diagnose.

Stephanie Prendergast (27:11)

Yeah, yeah, no,

Liz Akincilar (27:12)

I think, yeah,

Stephanie Prendergast (27:14)

no, go ahead.

Liz Akincilar (27:14)

I mean, I think even just starting with a simple anatomy lesson. So most people just don’t even know the difference or how to distinguish between the vulva and the vestibule and what the vestibule entails. So I think giving that anatomy and then having the patient tell us, this is what hurts, right? Okay, so that’s specifically the vestibulodynia or it’s the whole vulva.

Dr. Ginger Garner PT, DPT (27:19)

Mm-hmm.

Liz Akincilar (27:40)

that is vulvodynia. It doesn’t tell us why, right? And it doesn’t necessarily tell us what we’re going to do to treat it, but at least this is what you’re experiencing. know, with dyspareunia, you know, is it penetrative dyspareunia? Is it deep dyspareunia? Because obviously those things, ⁓ the treatment can be different and the causes can be different. ⁓ First, Steph had mentioned something like lichensclerosis, right? Lichensclerosis can definitely cause vulvodynia or vestibulodynia, right? ⁓ But

Dr. Ginger Garner PT, DPT (27:43)

Right.

Liz Akincilar (28:10)

for completely different reasons. So I think for trying to educate patients on what they’re experiencing, I would say start with your anatomy and see what hurts, right? And then that’s going to dictate probably what the diagnosis is. Again, not saying what it’s from or what the treatment’s going to be, but differentiating between the vestibulodynia and ⁓ vulvodinia. Vaginismus, I vaginismus, I…

I hardly use that term because I think there’s usually something else behind it. ⁓ I think very rarely do we have straight vaginismus, which is just the inability to insert something vaginally. Usually when you go a little bit deeper with the questioning, you find that it’s more like vestibulodynia. So I think starting with that, right? Starting with anatomy. ⁓

Dr. Ginger Garner PT, DPT (28:46)

Mm-hmm.

Liz Akincilar (29:03)

just understanding what vulvodynia means, that it’s the entire vulva versus vestibulodynia mean much more specific and vaginismus meaning just not able to insert something vaginally. And Steph can speak to this better because she was involved in all this kind of more, the more recent change and nomenclature around all of this is, we’re really trying to get away from diagnoses or diagnoses that are just

⁓ discussing like the place where it hurts, right? And trying to go more towards why, right? So it can actually lead towards a more effective treatment plan. ⁓ So that’s going a little bit off topic, but I think that’s really important when talking and trying to differentiate, you know, ⁓ if you have any sort of female pelvic pain.

Dr. Ginger Garner PT, DPT (29:59)

Yeah, I think the point in my question isn’t a diagnosis. The point in the question is to let people know what the anatomy is. And that also is very empowering point, case in point. I had a patient sit down, young, in her 20s, and was clearly uncomfortable with talking about the pieces and the parts. But as soon as you take out the anatomy, right, my model’s behind me if we need to pull that out for our YouTube watchers, right?

and say, well, this is the vulva, right? Is it here? And this is actually a vaginal canal. Then they can say, well, it’s here. It’s there, it’s here. So it’s not like then we saddle them with, ⁓ you have vaginismus, congratulations. That doesn’t really get mentioned. But for them to know the terms exist from an anatomical perspective really does empower them with.

I’m not a unicorn with a special problem no one else has. Like there are names for this stuff, Root cause, yeah, that’s a whole nother issue to dig down into what is actually, you know, the driver for it. But I’ve just found that, and I’d love to hear you guys, you know, perspective on that because I think an average, well, gosh, it doesn’t matter how old they are. They can be 65 and trying to talk about sex, right? Or they could be 25 and talking about sex.

and can have the exact same level of, this is awkward, this is weird, I’m not comfortable with this type of experience. And I think what we all want for people is for them to just walk in and sit down and go, well, I understand my anatomy, so I’m just gonna use those terms and tell you what’s wrong. I think that a lot of times, and I know you’ve probably found this to be true too, is that while we’re educating kind of the top-down system, educating the

the people, the individuals from the ground up is oftentimes what generates the real change in the system. Because they’re more willing to then call the representative about a piece of legislation if they’re aware of that. So I think that was the point and the question really was to empower them with that anatomical knowledge so that they know that exists. Which leads to the next bigger question of

I think pudendal neuralgia gets thrown around in the same way, right? That’s hugely problematic. So we can kind of wrap that up into the next question because you guys developed one of the first kind of CE courses on that. And there’s still a of things that get wrong, know, that I think clinicians are getting wrong about that and patients are getting saddled with diagnoses that A, may not matter at all and B, don’t indicate anything about root cause.

So the question then would be, what would be your next step then in empowering those patients about, ⁓ what are clinicians still getting wrong about whatever that may be, Saddling someone with vaginismus, saddling someone saying they have vulvodynia, saddling someone with a diagnosis and saying they have pudendal neuralgia, when what purpose does that serve, right? We’re really looking for root cause.

Stephanie Prendergast (33:20)

I do feel as rehab providers, we’re best prepared to help with that root cause and the differential diagnosis. That is not going to happen in a quick visit unless they’re seeing one of the experts. And again, we’re seeing this like huge divide right now where there are some experts and then a lot of people are just not aware enough. ⁓ Liz can really talk to a lot of the pudendal too. I think over the last, that’s where we really got started. When we started that course,

Pelvic floor physical therapists were not really involved in pelvic pain yet. I don’t think Liz and I realized at the time how unusual our situation was to be in an interdisciplinary practice. This is before we started our own with medical providers seeing nothing but pelvic pain all day long. We didn’t do incontinence, pregnancy and prolapse first. We went the opposite direction. And

I think there, because of that, we have to really look at our field as only being about like 26 years old with the pain part of it. And Liz, speak to that. was so, we had no idea at the time how unusual our situation was. I don’t even think I realized it until even five years ago.

Liz Akincilar (34:29)

Yeah, I think, you know, ⁓ I may be getting away from your original question. So Ginger, feel free to to know. mean, I’m almost forgetting. Yeah, circling back. ⁓ You know, I find myself often when patients come in, you know, whether they’ve gotten a diagnosis from another clinician or whether they’ve gone online and diagnosed themselves.

Stephanie Prendergast (34:38)

I hope I didn’t, I’m sorry.

Dr. Ginger Garner PT, DPT (34:41)

We’ll circle back, but no, go ahead.

Liz Akincilar (34:57)

I often find myself saying, okay, let’s just put your diagnosis to the side and let’s just see, you know, let’s go through your history, right? And all that. And then I’m to do an exam, right? Because, and I think, you this is so interesting from, you know, treating so many patients with pudendal neuralgia and that being a diagnosis that’s very intimidating to so many therapists and other providers, it’s really not that difficult to diagnose, right? There are certain, you know,

objective findings that either you have or you don’t, right? And if you don’t have it, you don’t have pudendal neuralgia. And that’s, it’s really that simple. And patients are often surprised, wait, you can diagnose me today? Yeah, yeah, I can, because I’m just going to do an exam. And if I, you know, palpate your pudendal nerve, and you’re really not bothered by it, well, then guess what, that’s not your diagnosis, something else is happening, right? Indeed, you have pelvic pain, but it’s not coming from your pudendal nerve. So I think

Breaking it down into simple digestible parts for patients is really helpful for them. I think it decreases anxiety and fear around these diagnoses that have so much fear. I mean, and understandably so. And I think the same goes with providers, right? It doesn’t have to be that complicated. ⁓ You know, just because you have burning pain in the vagina does not mean you have pudendal neuralgia. It also doesn’t rule it out, right? So I think breaking it down,

getting away from the specific diagnosis and just doing an exam and then putting the pieces together. For both patients and other providers as you train them, it doesn’t have to be complicated, but you do have to get all the information, right? Or you won’t figure it out. So I think, that’s, when we’re talking about these complex pain conditions, I think that’s what’s helped me over the years figure stuff out.

Dr. Ginger Garner PT, DPT (36:57)

So when you’re teaching, and this question really is for either one of you. I know Liz, you just got back from teaching recently. ⁓ How do you help pelvic health clinicians from moving beyond just a purely muscle-based model of sexual pain?

Liz Akincilar (37:23)

and there’s a lot of things. ⁓ So I think really looking at the pelvis in its entirety, and I always talk so much about you have to know the anatomy, right? And the anatomy doesn’t stop at the muscles. You really need to know all of ⁓ the muscular, you know, the muscle anatomy, but also the, you know, the nerve anatomy. The pelvis is not just

innervated by the pudendal nerve too, right? There’s a lot of other pelvic nerves that are involved and can contribute to pain. And you, so you really need to A, know that anatomy and B, and understand how the nerves travel through the pelvis. Because when you’re treating neuropathic pain, you have to know, well, what are the surrounding structures doing to that nerve and how is it affecting? How is it creating adverse neural tension? Where is their compression? When they do this movement, what’s happening to that nerve? So

When I’m teaching I really go back to you have to really understand the anatomy, right? ⁓ You know, you know as physical therapists occupational therapists treating the pelvis, know We’re really focused on motor control and muscle but gosh, there’s so much more and then that’s just that’s just when you’re doing your kind of pelvic exam. Then you have to consider all the influence from all the organs, right? You have to consider the rest of the gynecological ⁓

reproductive system, have to consider the urological, you have to consider, I mean, gastrointestinal, which is a huge component, the nervous system. So, ⁓ you know, there are so many things that impact the pelvis that, A, makes our job really challenging at times, but also, I think, really interesting, because when you put all those components together,

Dr. Ginger Garner PT, DPT (38:48)

or tend to.

Liz Akincilar (39:08)

and you have those moments of like, ⁓ so this is affecting this and this is affecting, and then you start to make sense of it and the patients don’t feel crazy, right? Because often patients come in and they feel like they’re going nuts. mean, so many times patients have come to me and said, sometimes I think I’m making this up. It sounds so strange. And so by considering, yeah, yeah, I mean, and it’s understandable, right? Because they’re not getting any help from other people or from other providers. So I think

Dr. Ginger Garner PT, DPT (39:29)

they start gaslighting themselves.

Liz Akincilar (39:38)

for clinicians, that was your question, really going beyond the muscles, right? And you have to get into the visceral ⁓ impact and you have to get in, mean, the neuropathic thing is something that is so often missed, right? ⁓ So I think just expanding, expanding your, you know, what you’re evaluating, what you’re considering.

Dr. Ginger Garner PT, DPT (39:59)

And that to me is, you what you ⁓ highlighted is what listeners should be looking for as green flags. If you go to a practitioner and they say they do pelvic health, PT or OT, and they’re only talking about strength-based models of, know, kegels or whatnot, okay, that does not constitute pelvic health at all. And yet that’s a lot of what’s happening because…

Let’s face it, this is also a highly, it’s a hot topic, right? It’s a very trendy thing to be doing right now. It’s just to pick up that torch and run with it. So I want our listeners to be able to really understand if they had the kind of pelvic PT that’s going to look for the things that you’re talking about instead of saying, ⁓ I had pelvic PT or OT, it didn’t work, right? That I think is one of the greatest. If someone has gone to the length,

Stephanie Prendergast (40:51)

Mm-hmm.

Dr. Ginger Garner PT, DPT (40:57)

right, has traveled that far into the system that they finally get to see us. And then they quickly had a few visits that were just focused on muscle model and that was it. That, ⁓ that makes me, that upsets me because there’s so much more than that, yeah. ⁓ And go ahead.

Liz Akincilar (41:11)

Sure. Absolutely.

Stephanie Prendergast (41:15)

And then

the other direction too, sometimes pelvic health has become very focused on pain science versus manual therapy too. And then patients can feel gaslit because they think they’re going to a visit where they’re gonna get a physical exam and instead they don’t. So that’s another thing that’s been a hot topic.

Dr. Ginger Garner PT, DPT (41:24)

yeah.

Yes.

yes. I just had a patient last week come in and sit down. This individual has been to many, many, ⁓ pelvic health professionals, therapists, and I really hate to say it, but this person was not overtly gaslit, but they were just told the P &E model was used, pain neuroscience education was used. That was not indicated in that case that he had a

he had a specific problem that was identifiable. It was objective. It was measurable. Because I used ultrasound imaging and I was like, oh my goodness gracious. Did anybody see that yet? And they’re like, no, I mean, you know, I was just told it was, I just needed to do some deep breathing and calm down and that I was centrally sensitized and that it was just, it was just a pain perception problem. It like, this is probably, you know, you have to handle it very diplomatically, but

Stephanie Prendergast (42:31)

Cheers.

Dr. Ginger Garner PT, DPT (42:34)

I think these stories are important for the listener to hear if they have been told, ⁓ just pelvic PT or OT didn’t work for you. Yeah, but what were they doing? What were they doing in those sessions with you? Were they really investigating it? Yeah. So that brings up other things like the entire last 20 years of women’s hormonal needs being overlooked, right?

Liz Akincilar (42:49)

Hmm.

Stephanie Prendergast (42:49)

Mm-hmm.

Dr. Ginger Garner PT, DPT (43:03)

So for the listener, okay, hormonal changes, super important. Tissue sensitivity, really important. It’s not just about nervous system sensitization, like Stephanie said. Orthopedic contributors, that’s another thing that I see a lot of new pelvic PTs who will come out of school, go straight into pelvic health and not have any ortho background at all. And a lot of things are being missed that way.

Liz Akincilar (43:29)

Mm-hmm.

Dr. Ginger Garner PT, DPT (43:31)

And of course pelvic floor dysfunction as well. All this intersects in sexual pain and dysfunction and problems. So I think so many patients are uncomfortable about talking about it to begin with. How would you or how do you maybe this could be in how you’re talking to your patients, right? Cause ultimately we’re talking directly to the listeners here who

Stephanie Prendergast (43:37)

Mm-hmm.

Dr. Ginger Garner PT, DPT (43:59)

everybody wants to thrive sexually, how do we talk to them about reducing fear around intimacy, around pelvic exams, not just around penetration, right?

Liz Akincilar (44:12)

Well, I think first identifying why they’re having pain with sexual activity is first and foremost. Is it actually something muscular or is it neuropathic or is it hormonal? I think identifying that first reduces anxiety, just understanding and going back to the pain science stuff, that’s all really valid things to teach our patients.

Dr. Ginger Garner PT, DPT (44:38)

Totally. Yeah.

Liz Akincilar (44:42)

One of the things that their research has shown us is just educating the patients tends to decrease some pain. So I think starting with that, educating, ⁓ figuring out why there is that pain, ⁓ but then getting back into sexual activity or trying to prepare for say a GYN exam. I tend, this is probably the only time I do use dilators to be honest with you.

⁓ is to try to decrease that anxiety to use something, you know, on your own to try to insert and maybe do practice some mindfulness, deep breathing, whatever it is that helps you down regulate your nervous system while trying to put something into the vagina for talking about ⁓ female pelvis. ⁓ I think I, you know, I try to incorporate things with patients that

they’re in control, right? They’re able to ⁓ progress themselves, you know, speed, depth, time, before you bring in a partner or before you bring in a GYN exam. And to try to build that confidence, decrease anxiety and figure out also what sorts of things help to decrease your anxiety in those situations, whether it is something like diaphragmatic breathing, or maybe it is some sort of a mindfulness, or maybe you do put in, you know, some sort of

you know, AirPods and listen to something as you’re preparing for such an exam or activity. ⁓ So yeah, I think ⁓ those are the things that I’ve found most effective. I mean, just, you know, what we’ve been kind of talking about too is empowering the patient, with tools to ⁓ enable them to get through those types of things.

Stephanie Prendergast (46:30)

And I think it’s important to add in too, if they want to have sexual pleasure un- partnered and with themselves and asking about that, because when people go through these pain situations, they may stop any type of sexual contact and masturbation and any of that because they’re afraid. And so helping them figure out within their comfort what their bodies can do while we’re working on the rehab has been helpful.

I have to laugh because, sorry, two cool things had happened though. I was part of the Materna project when they were designing the Milly. And at that point, which is a, it’s a dilator that they put a vibration device in. And when we did the trial of the first 500 patients, so many people that were not having any sexual pleasure started using the vibration feature to masturbate, which improved their overall quality of life, even though the pain was still there.

Dr. Ginger Garner PT, DPT (46:57)

Yeah

Stephanie Prendergast (47:23)

And then the Kiwi came out. And again, not to mention products, but it’s a very effective tool and a vibration tool, which so many of my patients were using that for muscle work, but then achieving orgasm. And I think these are important things to help our patients navigate. And maybe they don’t want to do that, but maybe they do. They just need to be told.

Dr. Ginger Garner PT, DPT (47:41)

Yeah, that’s perfect. Yeah,

Liz Akincilar (47:42)

Hehehehe

Dr. Ginger Garner PT, DPT (47:46)

I think that that is a mic drop moment that they just need to be told. And it’s not like you’re giving them permission to do that, but in a way they have to give themselves permission to do that. Like, this is part of my therapy, but I also deserve quality of life too. Because you’re reading my mind, that’s like my next question was, okay, so the listener has avoided relationships, they avoided sex, they are avoiding masturbation, they are…

avoiding pelvic exams, they’re avoiding everything, maybe even fertility care because pelvic pain has made those experiences feel impossible. So that’s such a critical piece of that. ⁓ And I love the evidence base on vibration and how that’s changing things and that’s so cool. And yeah, it’s hard not to product drop. There’s a lot of things that are thankfully out there now, but, and we’ll include some of these links in the… ⁓

in the show notes as well because you can never have too many resources when it comes to this because it seems like we’ve only had these resources available for about five and a half minutes given that the field is so new anyway. So I think that what I hear coming out of this part of the conversation that’s important is that the pelvic pain care that someone receives and that…

We deliver, it’s really never about one structure. Yep, pain science is important. Yeah, the tissues are important, manual therapy is important. It’s all important, their story, their medical history, how we listen, what questions we ask is so important. And that’s why I also love what you’re doing and advocacy because we wouldn’t have anything if we didn’t advocate. ⁓ And you’ve not only treated patients, but you’ve built systems.

You’ve built clinics, courses, books, e-books, professional education, advocacy pathways, and now international training programs. And that’s a much larger contribution than clinical care alone. And I don’t know, I’d love to hear your stories and brief for each of you about what made you realize that treating patients one by one was not enough, that you also needed to educate providers and advocate for systemic change.

Liz Akincilar (50:08)

⁓ I think for me…

I think it’s just treating patients all these years and having so many patients come in with negative experiences with other providers and just having providers not understanding what to do or how to treat them or even questions to ask. it made it very apparent to me that, you know, through…

luck or I don’t know, like Steph mentioned, like we really started our careers in a very unusual way, treating mostly pain. But at the end of the day, we have a really unique skill set and a unique experience as therapists treating pain. And so I felt like it really is my responsibility to try to spread that information as much as possible. ⁓ You know, there’s…

So many more pelvic therapists in the United States now than there were 20 years ago or 25 years ago, so many more. But man, when you get out of this country, there are so few. And then when you get to countries that, you know, just women’s health in general is really a largely ignored part of medicine, man, those people really appreciate any information that you can give them. So.

I felt like it was really important for me to do what I could to spread my experience and my knowledge to as many people as

Dr. Ginger Garner PT, DPT (51:37)

And you just got back, which we didn’t get to talk about yet. Let’s touch on that a little bit. I mean, you just got back from Kenya like last week. Aren’t you still jet lagged? No? Tell us a little bit about that.

Liz Akincilar (51:45)

Kenya. Yeah, a week ago. Yeah, no, it’s all right. It’s all right. Yeah, yeah, it’s all right.

Yeah, so I got involved with the Jackson Foundation. So Richard Jackson is a physical therapist. had, when he was practicing many clinics in the Virginia area, he back in the seventies did some work with, oh gosh, I’m blanking on the word here. Thanks menopause. Anyway, he did some philanthropic work and then about

15 years ago, he started a program in East Africa where he was teaching specialized or doing specialized courses and he was doing orthopedics, was doing cardiopulmonary. These were like advanced diplomas in these specialties within PT and then in 2019, I came on and to start the pelvic health component. So over the last few years, we’ve created a two year program that teaches physical therapists.

or that gives them an advanced diploma in pelvic health. So I co-direct that program with another physical therapist and we might go and teach like an in-person lab portion once a year. All the didactic is now online, but we’ve had four cohorts now since 2019. And yeah, the pelvic health field is growing. We’ve expanded into Uganda now.

And so it’s really thriving and the therapists are really, really proud, you know, to be able to serve their community in this way. Cause you know, some of them are in cities, many of them are in very rural areas where there’s very little care. ⁓ so it’s, it’s been interesting. And one more thing, and then I’ll, I’ll, I’ll stop. When I started this program, I said, well, we’re going to obviously talk about male pelvic pain too. And Richard, the, the, ⁓

director of the whole program was like, well, we can’t talk about male pelvic pain in Africa. I was like, well, we can, it’ll be fine. And so was like, well, I’m just gonna teach it anyway, whether these therapists ever see a man or not. And they do, they see men and it is really difficult for the, because it’s such a, there’s such stigma around it, right? ⁓ But as we all know here, half my patient population here are men.

Right? They, you know, they have plenty of pelvic issues. So that’s been a surprising but really exciting component too, that it’s reaching a population that, you know, would be really unlikely that those men would ever come forth until, you know, these women started doing some community, you know, outreach and community education about it. So yeah, it’s really exciting stuff. I’m really pleased to be part of it.

Dr. Ginger Garner PT, DPT (54:43)

So fantastic, thank you for doing that. It’s so needed. I remember being at World Congress and talking about ⁓ the global maternal mortality issue. That was when it was in South Africa. Were you guys there then?

Liz Akincilar (54:57)

I taught in South Africa. No, no, not that conference, but yeah, we’ve, yeah.

Dr. Ginger Garner PT, DPT (55:00)

⁓ not that one. Yeah.

And just the feedback ⁓ was just incredible. I know from the therapist there. So thank you so much for being there and doing that. And Stephanie, what’s your story? ⁓

Stephanie Prendergast (55:12)

⁓ I think I went the other direction. I think because

Liz and I did have a lot of pelvic pain experience very early on, what changed me was I think one of the first classes we taught. And again, looking back, who did we think we were? Just starting our own Con Ed course, marketing and we were sending mailers, like what were we doing? ⁓ But getting the feedback from the clinicians in the course made us keep going.

Dr. Ginger Garner PT, DPT (55:29)

⁓ my gosh.

No.

Stephanie Prendergast (55:40)

And I mean, that was really powerful early. And because I was working with a urologist, Liz and I both, that’s where we met and started. He was involved in the International Pelvic Pain Society. And this was before Liz had come on, but he was starting to take me to my first medical conferences where I was the only physical therapist. Maybe there were two of us in a room full of doctors. And when I say a room full of doctors, it was like 50. This was in 2002 was my first IPPS.

And so then I got escalated to the board position because they really wanted to have more representation because the people who were experts then knew physical therapists needed to get more involved. And so I stayed on longer than I should all the way through 2018 because we started bringing the World Congress to the United States, at which point then I started teaching for the International Society for the Study of Women’s Sexual Health. So I think my role has been kind of like the token PT at the medical conferences and really trying to bring

physical therapy voice to medical providers. ⁓ And it’s not, I mean, it’s work, obviously, and it’s time. But because we are so ingrained in this inside and out, we teach within the company, we teach in the community, and we’re doing our different projects. I mean, it does feel like what Liz said, it’s necessary. And it’s not ⁓ technically hard, it just takes up a lot of time.

But we know how to do it after all these years. So I feel like it is our responsibility to keep going.

Dr. Ginger Garner PT, DPT (57:06)

Yeah.

well, you’ve done so much work in that arena and just, and forwarding that conversation and ⁓ in a broad way because you’re involved in so many different aspects. So I think one of the questions the listeners would really benefit from is hearing your input on what you think patients should expect. What should the listener expect from a well-trained pelvic health provider? So pelvic health PT, pelvic health OT.

Liz Akincilar (57:42)

Mm-hmm.

Stephanie Prendergast (57:42)

I think,

Dr. Ginger Garner PT, DPT (57:42)

Small question.

Stephanie Prendergast (57:43)

well, think, you know what I think is really important when we’re teaching our people coming on our short-term and long-term goals. What is our assessment is something Liz and I have always focused on and making sure that we know what we’re doing every week and why. And if, what do we expect to change after four weeks, after eight weeks, who else do we need involved? And I think if we stick to the basics of that and not lose sight and don’t.

get in a rut and start doing the same things and making sure we’re advancing. I feel like it keeps everybody on track.

Dr. Ginger Garner PT, DPT (58:17)

Yeah, that’s a good point.

Liz Akincilar (58:19)

I also tell patients when they see a new provider, this may not be nice to the providers, but I tell them, ask them, especially for my male patients, like ask your therapist, how many male patients do you see? Do you see one in a quarter or do you see 10 or 20 in a week? You know, how many patients with pudendal neuralgia have you seen? Again, is it once in a quarter? Because if that’s the case, chances are that’s probably not the right provider for you. If that’s what you’re…

Stephanie Prendergast (58:23)

Mm-hmm

Liz Akincilar (58:48)

dealing with. You you really do want someone that not just has the experience, I guess needs the skill set, but also has seen enough patients through an entire treatment cycle to know, going back to what Steph just said, to know how to troubleshoot when things don’t go as expected, right? When you get to week eight and you’re like, we’re not really making, you know, we’re not really not hitting the goals that we were hoping for. You got to know how to pivot, right? You have to know

do I bring in another provider, meaning maybe a pain physician or a gynecologist or urologist or whatever that is, you really have to have that experience to know. Because if you don’t, it’s hard to manage those patients, right? This isn’t just your stress, your neuro-incot. And it’s to say that that’s not a big symptom. can be really hard to deal with, but there are some protocols for…

for treating incontinence, then there’s just really not for most of the complex pelvic pain.

Dr. Ginger Garner PT, DPT (59:50)

Yeah, yeah, that’s very true. We have a long way to go there. ⁓ One more question too, I think this would really benefit ⁓ the listener from differentiating between, you know, for clinicians listening who are newer to pelvic health, ⁓ what would you say the non-negotiables are in terms of becoming safe, effective, you know, et cetera, in the field? Because that’s a big question.

but it also informs what the listener would be looking for as well.

Liz Akincilar (1:00:25)

You gotta have a mentor.

Stephanie Prendergast (1:00:26)

I was going to say that I knew you would too. You have to.

Dr. Ginger Garner PT, DPT (1:00:29)

No.

Liz Akincilar (1:00:29)

Yeah,

you have to. You can’t just, you know, be right out of school and have taken a few weekend courses and get a job that you’re going to head up the pelvic department in whatever hospital or clinic or you have to have a mentor. You have to have a group of, if it’s not within wherever you’re working, you have to create a community of having people to go to, to help you talk about cases.

think about cases. And also you can’t just treat a little bit of pelvic health, right? You can’t be in an orthopedic outpatient clinic and be treating 70, 75 % ortho, know, straight ortho, right? I know what we do, there’s an ortho involved, but you know, you have like total knees and total hips and all this stuff, and then you’ve got like 20, 25 % of pelvic. If that’s what you’re gonna do, it’s gonna take a really long time to get good at what you do.

So that would be my, that’s always my suggestion or my recommendations when I talk to young therapists, like get yourself a mentor or get into a clinic that has a good training program. And really, if this is what you want to do, then do it. Don’t just dabble, do

Dr. Ginger Garner PT, DPT (1:01:40)

Yeah.

So let’s translate that into, okay, so if a new clinician’s listening, we know what they need to be moving towards. But let’s translate that into terms that the listener, if you’re a listener and you’re searching out pelvic health for the first time, PT or OT, what should they then be looking for? I think one of the examples you’ve already given.

is if you’re going into ⁓ orthopedic practice and 70 % of what that therapist does is just ortho, might not be the actual provider you need to be looking for if you have a complex situation. ⁓ So if that makes sense, help us translate what that looks like in terms of when a person is seeking out pelvic health, what are the green flags in finding a clinician?

Stephanie Prendergast (1:02:32)

think sometimes a lot of patients may not have a choice. So let’s say they call one of the larger hospital systems. They’re going to be assigned a therapist and really not know, or maybe even have access to a profile that’s going to let them know if this person actually has tremendous experience or no experience or is brand new and had no training. So I think we have to be careful with what we’re telling people because it’s not widely available. We have an accessibility problem.

⁓ So I think that’s why I go back to the goals. What did they go in hoping to get out of it? What is the treatment plan? What is the assessment? Did they come out with like an understanding? And if they didn’t, they may have to leave and go to someone else. And I think a lot of people just do not have training. They may have taken a few weekend courses. They haven’t had the mentorship. One of the pivots Liz and I made in the company, I think about five years ago was because we grew so much.

We started doing these individual mentoring groups on the alternate staff meeting weeks where it was one of us who was what’s considered leadership and then three juniors. And I feel like that really changed what happened for us internally. It’s been very rewarding for us to be in those positions, but to also hear other people’s questions, even though they’ve been through our training program. And I don’t know how people can continue to advance their skills if they’re not getting that feedback. And it’s going to be very difficult for a patient.

to see who is getting that feedback. It’s just not widely available. But Liz, please add to that. Yeah.

Liz Akincilar (1:04:08)

Yeah, I think, you know, from a, from your listener’s perspective, like if you go, if you go see, see, to see a PT or OT a pelvic health specialist, and you walk out of there, kind of piggybacking on what Steph said, without an understanding of what are some of the primary causes of whatever symptoms you’re, you’re experiencing and, or, or, and, you know, what your treatment plan is and what to expect.

then you really have to think if you’re with the right person. Because after that first initial assessment, you should at least have an idea. You’re that therapist should have educated you enough that you have an idea of these are the primary things that are contributing to whatever symptoms and this is our plan going forward and hopefully within four to six treatments or whatever, I should at least start to see some changes in ABC.

That’s pretty basic stuff, you know, because we see a lot of patients that have failed, you know, at other practices. And when I ask, you know, as we should, you know, well, what did you do? You know, what did your treatment entail? And if they’re like, I don’t know, she like inserted a finger vaginally and pressed on some stuff. You know, that’s horrifying to me. Like, well, did you know, did your therapist explain, you know, blah, blah.

Well, no, you know, well, what was the plan? And they really can’t really verbalize that. I find that really problematic. And so I think for your listener, if that’s what you’re experiencing, you’re probably not with the right practitioner. You should probably search for another. But then, as Steph mentioned, we do have an accessibility problem. So I understand that depending on where you live in this country or in the world, there may not be very

many options for you. But if you have options and you’re not getting those answers, you know, with your treatments, then you should, you should.

Dr. Ginger Garner PT, DPT (1:06:14)

Yeah, and think that’s, you know, speaking globally, yes, and in the United States, we don’t have enough practitioners. But ⁓ for those who do have those options, I think it’s important for them to be able to understand the green and yellow flags. Otherwise, it’s easy to consider… It’s too easy for people to consider themselves having failed pelvic therapy when in fact they just didn’t get what they needed, you know, from it.

Stephanie Prendergast (1:06:36)

Mm-hmm.

Liz Akincilar (1:06:42)

Absolutely. Yep.

Dr. Ginger Garner PT, DPT (1:06:44)

⁓

And I think that brings up a really important point too. know things pelvic health looks so much different than it did in 2006 and when you guys wasn’t that when you opened in PHRC? Yes in 2006 and and people know pelvic PT existed now exists now and OT Thank goodness, but again access quality interdisciplinary collaboration all of that is a Still kind of even and fractured and you know that kind of thing. So I guess

What would be awesome in kind of closing is, you what do you wish that everybody knew, like physician, surgeon, midwife, sex therapist, psychologist, physical therapist, occupational therapist, what is like something that you wish that they knew? What do you wish would shift faster than it has? Because for those of us who’ve been doing this, right, three decades plus, ⁓ there’s…

Change is happening, but it also seems quite slow. So I have two questions really, maybe one for each of you is, what do you wish things, how do you wish things would shift a little bit quicker, ⁓ And how do you see collaboration improving? How can we improve collaboration for patients between sexual medicine, gynecology, urology, colorectal, psych, GI, pain medicine, right? All of the different things. ⁓

You know, basically, what’s the message of hope? What do you take forward?

Liz Akincilar (1:08:17)

Go for it, Steph.

Stephanie Prendergast (1:08:18)

That’s a hard question.

have a few things. I mean, I feel there has been advancement with endometriosis, menopause, perimenopause, a lot. That’s been a seismic shift. I don’t think we’re getting far enough with men’s pelvic health. I have seen no progression in that department. ⁓ That’s a problem. But the reason why there isn’t better collaboration is because people are overtaxed and overburdened. And I cannot say this enough. I tell my patients,

Dr. Ginger Garner PT, DPT (1:08:20)

⁓

Stephanie Prendergast (1:08:47)

to call their congressmen because this is a healthcare crisis that’s happening and we are not being treated fairly as pelvic floor physical therapists, as healthcare providers in general, and people are burnt out and they are tired. So we have to give the providers grace, but we also probably should take the higher institutions accountable. This is not a PHRC problem. It’s not, know, patients did not used to have out of network deductibles that were $10,000.

This has been a huge shift. And so it’s not their fault, but it is a systemic problem that I don’t think people understand.

Dr. Ginger Garner PT, DPT (1:09:18)

Yeah.

Yeah, absolutely. It’s why there’s a lot of hope. Like two weeks ago, we were on Capitol Hill advocating for these bills. We’ve been advocating for the same bill of multiple sessions in a row, each time and giving a different number. And whether or not they will move this ⁓ session remains to be seen.

However, you have to keep going and you have to keep doing it and you have to keep calling. And I think that’s just an incredibly important point. It’s hopeful, but it’s also frustrating because those big wheels move incredibly slowly, but don’t quit, right?

Stephanie Prendergast (1:09:52)

Hmm.

Mm-hmm.

And thank you for the work you’re doing around that. It’s so important.

Dr. Ginger Garner PT, DPT (1:10:08)

⁓ yeah.

Well, I think we all have, you know, kind of that built in passion because we may have not directly chosen it right out of school, but the more you stay in it, the more you realize it was something you couldn’t turn away from. You just couldn’t, you had to move in the direction for advocacy. Yeah, Liz, what’s your hopeful piece? That’s a good advocacy point. So listeners,

Stephanie Prendergast (1:10:30)

Liz?

Liz Akincilar (1:10:35)

Yeah.

Dr. Ginger Garner PT, DPT (1:10:36)

It takes

Stephanie Prendergast (1:10:36)

you

Dr. Ginger Garner PT, DPT (1:10:36)

two seconds to pick up the phone and two seconds to send an email. And if you follow Stephanie, follow Liz, follow myself, you will see that in the flavor of what we were doing is how to call and how to be involved. And you’d be amazed if they get a certain number of calls, they will pick up the, ⁓ whether it’s the bill or co-sponsorship or whatever it is they’re voting on, they will pick it up and look at it. But it does take those phone calls to make a difference.

Liz Akincilar (1:11:03)

Yeah, and this is kind of why I asked Steph to go first, because I think we are absolutely, we have a healthcare crisis and patients can’t afford the type of care that they need. We can’t afford to, you know, to pay decent wages to our therapists because of reimbursement rates. I mean,

It’s the trickle down effect of this healthcare crisis is so severe that ⁓ it’s hard. It’s hard to be hopeful on that aspect. ⁓ But, you know, if that, if we can make some headway in that arena, then I think there’s the desire, right? There’s definitely passionate providers. There’s people that want to advance this field that are interested in doing that.

We just have to be given the ⁓ time, the financial support in order to do so. So I see it as a ⁓ real barrier, right? And we have seen this in the 25 years that we’ve had the company, the economic challenges have just gotten greater and greater. And I know there’s other economic, clearly other economic challenges in our lives, but healthcare is a big one.

And so I think for such a niche part of medicine that requires, it’s very labor and time intensive for a lot of these complex people. We as providers or as the medical world, we have to be given the ability, the time, the money to be able to help these folks. So I’m hopeful that the next generation ⁓ will use their voices, will use.

you know, their passion to put pressure on those that they need to put pressure on to make those changes. But I think that’s, that’s, that’s, that’s, think number one for me, ⁓ moving forward is, yeah, we have to remove some of those barriers or at least make them ⁓ less, less severe.

Stephanie Prendergast (1:13:20)

Can we do a whole podcast about this, Ginger? And let’s, the menopause activated the United States. Why can’t we for this? I mean, why not? It’s time. This is not fair for people’s quality of life.

Dr. Ginger Garner PT, DPT (1:13:21)

Yes, that’s what I was about to say.

Liz Akincilar (1:13:23)

Yeah

Dr. Ginger Garner PT, DPT (1:13:30)

Exactly.

Liz Akincilar (1:13:34)

Yeah.

Dr. Ginger Garner PT, DPT (1:13:37)

Yeah, you brought up something that’s so incredibly important and it’s definitely struck multiple nerves, I think, to kind of shore up and come full circle about what we were talking about because there is a message of hope in it in spite of people being exhausted, dismissed, not able to access it, not able to afford it. The wheels of Congress are moving too slow in terms of legislation. We need things to happen faster. But there’s…

action moving forward. There are bills with names attached to this that will help improve access to, you know, to pelvic health specifically that we were circulating, you know, just two weeks ago. So there’s a lot of reasons to be hopeful, but Stephanie brought up a really important point, and that is we might have to do a part two because there is such ⁓ a much stronger message that needs to come forward about advocacy. ⁓

because people want better explanations, they want better care, they want better language for pain that’s often invisible to others, that’s creating disability that they can’t go to work, that they can’t do what they want. ⁓ And that brings up some other issues too of preventing our profession from becoming overly protocol-driven when patients with pelvic pain are complex and things need to be individualized.

I think there’s a lot more things that the listener wants to hear about that of course we didn’t touch on. And this is like, I won’t say it’s our record breaking length podcast because the next one I film could be even longer, but there’s just been so many good points that I’m sorry for keeping you so long and thank you so much for staying and hanging in this conversation for that long because it’s that important. And for listeners, I want to just ask one more question of you.

Obviously at the end, I always say, where can people find you? Please let us know. We will put everything in the show notes that you feel is relevant so that ⁓ people do not have to search for that. And I think the other question in addition to that would be, what do you want patients to know? What do you want clinicians to know to remember from this conversation? What would it be?

Liz Akincilar (1:15:52)

So I’ll take the second question, Steph, and you can talk for where to find us since that’s where you’re arena. So what do want people to know? I think the most important thing is, and this sounds a little cheesy, but it really is true, that there actually is hope past pelvic pain, that there are people out there that can help you. There are resources. You just need to find one clinician that can get you on a path.

And there is life after pelvic pain and that includes, know, petechondrial neuralgia, that includes interstitial cystitis. These things, when you look them up online, you think that your life is going to be forever changed. And with the right team, with the right treatment, you can really get back to doing all those things that you want to do, to your passions too.

take care of your family, being able to work, et cetera. So I think that’s the most important thing for your listeners and for providers that want to get involved in this space. think going back to what we said before, find yourself a good mentor and just jump in, jump into pelvic health and get as much experience as you can with the guidance from a good mentor.

Stephanie Prendergast (1:17:14)

No, I agree with all of that. And all of our links will be below. I mean, we’re active on social media, our website. Liz and I also do telehealth for patients who may be in some of the pelvic health deserts, or if they’re trying to get to the right people. Because of our teaching and advocacy work, we know everybody everywhere almost. And so sometimes patients can use that visit just to…

get on the right track and we get them to the right provider. We’re not doing ongoing telehealth, but we can offer our knowledge to at least get the process started unless they’re really, really stuck. We do see patients from out of town as well. They travel to see us in both of our clinics. I’m in Pasadena, Liz is in New Hampshire, but we’re also in the Bay Area in Massachusetts.

Dr. Ginger Garner PT, DPT (1:18:04)

Awesome. You’ve got so many resources. Again, we will be including all of those in the show notes from your book, educational resources, YouTube channel, links to the Jackson Clinics Foundation. Can we throw that in there too? All right, awesome. Thank you so much, Stephanie and Liz, for being here today, for all the extra time that you have given us. And listeners, if this episode has helped you, please share it with

Liz Akincilar (1:18:19)

Mm-hmm. Yep. Yep, absolutely.

Dr. Ginger Garner PT, DPT (1:18:33)

a patient, a provider, a friend, someone you love who needs to know that pelvic pain is real and help is possible and no one should have to navigate it alone.

Stephanie Prendergast (1:18:42)

Thank you.

Liz Akincilar (1:18:43)

Thank you.