Touch But Don't Look?

Are you guilty of treating the pelvic floor muscles without inspecting the tissues of the vulvar area or perineal area? A recent posting about clinical pearls by Institute faculty member and Pelvic Guru author Tracy Sher got me thinking about this dilemma. How can we avoid treating pelvic muscle trigger points when the patient has a medical condition requiring immediate intervention, and without which, the trigger points do not stand a chance of resolving? The larger picture is that all pelvic rehabilitation providers must be responsible for an increased awareness of medical issues, pelvic-related pathologies, and how to coordinate referrals.

Experienced therapists tend to have strong skills related to referrals and identifying conditions that require the eyes and ears of a medical provider. Less experienced therapists, in my observation and opinion, have the updated information about medical screening and multiple systems involvement, yet lack the clinical experience to develop an efficient pathway to referral and problem solving. What strategies can improve this issue?

Collaborate

There is much to be gained by the patient when therapists of varying experience level share information, and mentor each other. This requires some humility on the part of both therapists involved, and a huge effort on the part of the employing facility as well as the therapists who aim to find time to review charts, discuss difficult cases, or request that another therapist assess the complex patient. Many sites do not have more than one therapist. What about forming a local study group with the assistance of the the APTA Section on Women's Health, or simply contacting area pelvic rehab providers and doing a quarterly dinner and education session at neighboring clinics? The first response I usually hear is that therapists are in "competition" with these clinics, and that collaboration would be a negative thing. I reject that thought, professionally and personally, as there is plenty of pelvic rehab work to go around, especially with the lack of awareness within the community of our services. Check out this poignant blog post about collaboration.

Consult

Request the opinion of the referring provider whenever possible. Developing a strong relationship with providers is paramount to delivering excellent care. Physicians in this day and age are under severe pressure for being accurate and efficient, and when approached with respect, may develop a habit of seeking your opinion when the patient's condition is perplexing. Likewise, when you have a question or concern, he or she will create time to field the question. Is it possible to invite a referring provider to speak to a group of therapists, or to invite a provider to attend a pelvic rehab lecture with you?

Continue to Learn!

Take a course in medical screening. If you have not taken DPT level courses, what about taking an on-line course in the topic? Or purchase some of the amazing texts from authors including William Boissonnault or Catherine Goodman? Being able to ask the right questions or to communicate effectively about a concern can boost our confidence when contacting providers or when documenting concerns. (I still find myself saying things such as "....there is this odd bump located here and it feels like this...") yet if I can research some options for what that bump would feel like if it were a cyst, a lymph node, a hemorrhoid, etc, then I can discuss with more clarity the true concerns that I have.

Now back to the looking part. Sometimes, looking at the vulvar area or around the male genital area feels uncomfortable for either the therapist, the patient, or for both parties. This issue is the responsibility of the pelvic rehab provider to address. The phrase "fake it 'til you make it" comes to mind, because it is completely acceptable to simply take a deep breath, smile, and pretend to be a little more comfortable than you feel inside; the comfort level will come with practice. If your attitude is "I don't need to see what is going on," well, you are incorrect. What you might find is a lump, a rash, a cut, a bruise, an infection, a suspicious mole, pale skin, or a myriad of other things. A brief and thorough inspection (including under the scrotum or within the vestibular area) are crucial for the patient's wellness. It is possible that the provider has not seen what is going on due to lack of a complete examination or the time between provider examination and your examination.

How do we know what "normal" looks like? This is an area I think we can improve upon in general in pelvic rehabilitation. We are exceptional at education about the muscles, and nerves, and function, yet we might learn how to complete a pelvic muscle examination before learning what lichen sclerosis looks like. The integumentary system is considered to be the largest organ in the body, and if this organ lacks health, certainly the underlying muscles, connective tissues, and nerves can be affected. There are some very helpful resources for us in learning what dermatological conditions look like might affect a patient. Below I have linked some of them for you.

• Blog with link to resources about vulvar skin conditions
• A prior blog post with a link to a terrific article with images of common vulvar skin conditions
• Perianal images including surgical correction
• Images of normal and abnormal anal verge appearances
• Powerpoint available through google scholar with images of vulvar dermatology conditions