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Be the Detective: Using Differential Diagnosis

Be the Detective: Using Differential Diagnosis
SEXMED THUMBNAIL 1

The following is an excerpt from the short interview between Holly Tanner and Tara Sullivan discussing her course Sexual Medicine in Pelvic Rehab. Watch the full video on the Herman & Wallace YouTube Channel.

Hi Tara, can you introduce yourself and tell us a little bit about your background?

Sure! So I’m Tara. I’ve been a pelvic health rehab therapist for about 10 years now. I started right out of PT school and I got a job at a local hospital where they were looking to grow and build the pelvic rehab program. So of course, I found Herman & Wallace and started taking all of the classes there that I could and just kept learning over the years. Now the program is expanded across the valley, we have nine different locations, and it’s been very successful and fulfilling. It’s my passion.

Recently, I would say the past four to five years of my career, I’ve started getting more into sexual dysfunctions. I was always into pelvic floor dysfunction in general - bowel, bladder, sexual dysfunction, and chronic pelvic pain, but I  didn’t get specifically into the sexual medicine side of it until recently. I did the fellowship with ISSWSH that really pulled all of that information together with what I’ve learned through the years.

Can you explain what ISSWSH is and how that combined with the knowledge base that you already had?

I feel like ISSWSH for me, where I came full circle. I finally was like “I get it.” ISSWSH is the International Society for the Study of Women’s Sexual Health and it’s all the gurus like Dr. Goldstein, Rachel Rubin, and Susan Kellogg that have been around forever doing the research on sexual medicine. I started attending their conferences, became a faculty member, and presented at their annual fall meeting here in Scottsdale. Then I ended up doing their fellowship. Every year I would attend the conference, but it took a couple of years for all of that knowledge to soak in and for me to be able to really apply it.  For example, that patient with that sticky discharge, maybe that is lichen planus – that’s the kind of medical side that you don’t necessarily learn in physical therapy school.

That for me just really helped my differential diagnosis which means that you can get the patient’s care faster. Get them to that resolution faster because you are working with a team of people and we all have our roles. As PTs and rehab practitioners, we have the time to sit with our patients. We are so blessed to have an hour, and the medical doctors don’t, for us to really take that time to figure out the patient’s history and what they’ve been through, and what could be the cause of it. We have the time to be the detective and help them get the care they need. Whether it’s with us, or in conjunction with something else. My goal is to never tell someone that I can’t help them because it’s not muscular.

How has this knowledge helped you in your collaboration with other practitioners in your practice?

I feel like this knowledge was the missing link for me. It brings it all together for the patient. So the patients come here and the urologist says “that’s not my area,” and then the gynecologist says “that’s not my area.” Then they come to you and you’re like “it’s kind of my area, but I can’t prescribe the medication that you need.”

My practice got so much better, just in the sense of the overall quality of care, when I was able to develop those relationships with the doctors. I could pick up the phone and say “Hey, that patient that you sent me – I think they have vestibulodynia, and I think it’s from their long-term use of oral contraceptive pills. I think that they might benefit from some local estrogen testosterone cream.” They would say, I don’t know about that, and I’d respond “let me send you some articles. Let me tell you what I’ve learned.”

Now I can just pick up the phone or send them a text asking them to prescribe so and so. It really helped bridge that gap. The doctors now will say “Ok. I know something’s going on, but I don’t know if it’s muscular or tissue. I don’t have that training, what do you think?” So it’s just been such a collaboration, it’s been so great. Then I’ll go the reverse of that and watch them do a surgery, watch them do a procedure.

For our patients, we need to take that time and work with the physicians and develop that relationship with them, because it’s easy to pass it off as “that’s not my job.” Especially the vestibule! The gynecologist goes right through it and looks into the vaginal canal and then the urologist is like I’m going to look at the urethra but I’m not looking around it, let me just stick that scope in. This knowledge and ability to use differential diagnosis, for me just brings it all together.

Does your course have an online, pre-recorded portion as well as a live component?

Yes. There are about nine lab videos on manual techniques because everyone wants to know what to do. For me, it’s more about what you know. What can you identify and differentiate with the differential diagnosis. Then we have about two hours of just the basic lectures on general pain and overactivity of the pelvic floor so that we can spend our time in the live lecture getting into the very specific conditions that we as PTs are, not necessarily diagnosing, but recognizing and sending for further care. That’s really where I wanted this class to fill the gap between the urologist, the gynecologist, and the PT.

Is your course primarily vulvo-vaginal conditions or are there some penile, scrotal, or other conditions?

It is both male and female dysfunctions, and I have a few transgender cases. I don’t personally treat the transgender population very often so I only have a couple of examples of that. I have a lot of examples where I’m trying to get practitioners to recognize the problem by what the patient is saying and their history, and how to funnel this into their differential diagnosis. Case studies include different types of vestibulodynia and causes, all the different skin conditions…and it’s not necessarily something that they didn’t learn in one of the Pelvic Floor Series courses, but I wanted one class where they could just talk about all the sexual dysfunctions and get into some of the ones that we don’t see as often but are present.

We also talk about PGAD (persistent genital arousal disorder), and with male dysfunctions, we talk about spontaneous ejaculation and urethral discharge, post vasectomy syndrome. All of these things that you might not see every day, but when you see them you’ll recognize them so that you can help patients talk to the doctor and get the proper care. There are a lot of random, not as obvious, conditions that are not as prevalent. Then there are the common conditions that we see every single day like lichens.

What is the biggest takeaway that practitioners have who come into your class?

It is really being able to access and effectively use differential diagnosis. A lot of practitioners in the course are like “I always wondered what that was.” I have a ton of pictures that I share, and I’m like, I know you guys have seen this before. I think a lot of it is the differential diagnosis. The feedback that I get from every class is “I feel like I can go to the clinic on Monday and apply what I learned.” “I’m going to go buy a q-tip and start doing a q-tip test because now I know what to do with that information.” They feel that confidence of really being able to apply it, talk to the patient, talk to the doctors, and figure out that meaningfulness.


Sexual Medicine in Pelvic Rehab - Remote Course
SEXMED NL

2022 Course Dates:
July 16-17 2022 and October 15-16 2022

Sexual Medicine in Pelvic Rehab is designed for pelvic rehab specialists who want to expand their knowledge, experience, and treatment in sexual health and dysfunction. This course provides a thorough introduction to pelvic floor sexual function, dysfunction, and treatment interventions for all people and sexual orientations, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, as well as multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Lecture topics include hymen myths, female squirting, G-spot, prostate gland, female and male sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm, and function and specific dysfunction treated by physical therapy in detail including vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post-prostatectomy, as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus. Upon completion of the course, participants will be able to confidently treat sexual dysfunction related to the pelvic floor as well as refer to medical providers as needed and instruct patients in the proper application of self-treatment and diet/lifestyle modifications.

Audience:
This continuing education course is appropriate for physical therapists, occupational therapists, physical therapist assistants, occupational therapist assistants, registered nurses, nurse midwives, and other rehabilitation professionals of all levels and experience. Content is not intended for use outside the scope of the learner's license or regulation. Physical therapy continuing education courses should not be taken by individuals who are not licensed or otherwise regulated, except, as they are involved in a specific plan of care.

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What about the Clitoris?

What about the Clitoris?

What About the Clitoris

Tara Sullivan, PT, DPT, PRPC, WCS, IF is on faculty with Herman & Wallace. She created Sexual Medicine in Pelvic Rehab and co-created Pain Science for the Chronic Pelvic Pain Population which she instructs alongside co-creator Alyson N Lowrey, PT, DPT, OCS. Tara started in the healthcare field as a massage therapist, practicing over ten years including three years of teaching massage and anatomy and physiology. Tara has specialized exclusively in Pelvic Floor Dysfunction treating bowel, bladder, sexual dysfunctions, and pelvic pain since 2012. She is adjunct faculty speaking at the annual conference for the International Society for the Study of Women’s Sexual Health (ISSWSH) and teaches an elective course at Northern Arizona University (NAU) and Franklin Pierce University on Pelvic Health. Tara is very passionate about creating awareness on Pelvic Floor Dysfunction and recently launched her website pelvicfloorspecialist.com to continue educating the public and other healthcare professionals.

You may have heard of Jessica Pin. She’s been making headlines lately with the unconventional ways she is going about changing what medical texts and schools teach about the clitoris…..which is currently very little. According to Pin, who has a bachelor’s degree in biomedical engineering, the average textbook has over 50 pages more dedicated to the penis than compared to the clitoris. Jessica Pin started her journey to create awareness of clitoral anatomy because at 17 years old she had a labiaplasty leaving her with sensory loss. Jessica’s activism has so far changed 8 medical texts to include detailed anatomy of the clitoris in hopes knowledge of this anatomy is understood well, as it is critical prior to performing surgery near the clitoris.

Loss of clitoral function can also occur after labiaplasty, biopsies, cosmetic surgeries, and repair. As pelvic rehab providers, there is a level of responsibility we have to help shift the narrative. How often have we seen or heard similar stories of young patients undergoing cosmetic surgeries to try to ‘look normal’ or apologize for the way they look? We have such a unique position to spend time educating our patients and treating sexual dysfunctions across the spectrum.

The clitoris is analogous to the penis so what is the cause of this disparity? It could be that, traditionally, the focus has been on penetrative intercourse which largely overlooks that the clitoris is the primary sexual organ of the female sexual response and that 81.6% of women don’t orgasm from intercourse alone (without additional clitoral stimulation). Only 18.4% of women report that intercourse alone is sufficient to orgasm (Herbenick, et al. 2018).

The clitoris has historically been omitted from anatomical textbooks and then ‘rediscovered’ throughout medical history (O’connell, 1998). If you look at the 1948 Grey’s Anatomy textbook you will see that the clitoris was left out. Anatomical information centralized around the medical field has been historically male-dominated, affecting how the world discusses and understands anatomy and their bodies even in the current day. In 2005 Wade, Kremer and Brown ran a study on college students and found that 29% of women and 25% of men could not identify the clitoris on a diagram of the vulva. We need to revolutionize female sexuality in general, change the focus from the linear model where penetrative sex and orgasm are the focus as it’s been traditionally taught. 

JPin Clitoral Anatomy

The full clitoris goes far beyond the crown which is the external tip. The clitoris actually extends several inches into the body where it branches into a shape similar to a wishbone. A description that I love is from Latham Thomas, “It’s all this amazing erectile tissue that wraps around, and it all engorges when it’s stimulated. Pound for pound, if you have a vulva, you actually have the same amount of erectile tissue that people with penises have, but it’s just internal.” These clitoral legs are responsible for the sensations where the front wall of the vagina connects to the paraurethral glands (the G-spot) and for female ejaculation.

I authored the Herman & Wallace Sexual Medicine in Pelvic Rehab course for practitioners to have a platform to learn proper anatomy, identify misconceptions, and understand that sexuality is circular with satisfaction as the focus. With the understanding of ‘normal’ anatomy and function, we can help our patients with sexual dysfunctions return to a healthy sexual lifestyle.

To sign the petition to get the nerves of the clitoris into the American College of OB/GYN curriculum go to:

https://www.change.org/p/american-college-of-ob-gyns-get-nerves-of-the-clitoris-into-american-college-of-ob-gyn-curriculum?utm_content=cl_sharecopy_26277604_en-US%3A3&recruiter=955693637&utm_source=share_petition&utm_medium=copylink&utm_campaign=share_petition


Sexual Medicine in Pelvic Rehab is a two-day, remote continuing education course designed for pelvic rehab specialists who want to expand their knowledge, experience and treatment in sexual health and dysfunction. This course provides a thorough introduction to pelvic floor sexual function, dysfunction, and treatment interventions for the gender and sexual spectrum, as well as an evidence-based perspective on the value of physical therapy interventions for patients with chronic pelvic pain related to sexual conditions, disorders, and multiple approaches for the treatment of sexual dysfunction including understanding medical diagnosis and management.

Lecture topics include hymen myths, female squirting, G-spot, prostate gland, female and male sexual response cycles, hormone influence on sexual function, anatomy and physiology of pelvic floor muscles in sexual arousal, orgasm. As well as the function and specific dysfunction treated by physical therapy in detail including vaginismus, dyspareunia, erectile dysfunction, hard flaccid, prostatitis, post-prostatectomy; as well as recognizing medical conditions such as persistent genital arousal disorder (PGAD), hypoactive sexual desire disorder (HSDD) and dermatological conditions such as lichen sclerosis and lichen planus. Upon completion of the course, participants will be able to confidently treat sexual dysfunction related to the pelvic floor as well as refer to medical providers as needed and instruct patients in the proper application of self-treatment and diet/lifestyle modifications.

Course dates in 2022 include:


Top Homogenous Image: Internal genitalia depicting homology (Carrellas, B. and Sprinkle, A., 2017).

Bottom Clitoral Anatomy Image: Jessica Pin, https://drive.google.com/file/d/1fS1HfBWYqXAEBu_jnAPuiulTE3nqIYYQ/view

O'Connell, H.E., Hutson, J.M., Anderson, C.R. and Plenter, R.J., 1998. Anatomical relationship between urethra and clitoris. The Journal of Urology, 159(6), pp.1892–1897.

Herbenick, D., Tsung, Chieh F., Arter, J. Women's Experiences With Genital Touching, Sexual Pleasure, and Orgasm: Results From a U.S. Probability Sample of Women Ages 18 to 94. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2017.1346530

Wade, L.D., Kremer, E.C. and Brown, J., 2005. The incidental orgasm: The presence of clitoral knowledge and the absence of orgasm for women. Women & Health, 42(1), pp.117–138.

 

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