A Physiatric Approach to Pelvic Rehabilitation Medicine with Dr. Kelly Scott
By Julie Hastings, MD
Kelly M. Scott, MD is an Associate Professor in the Department of PM&R at the UT Southwestern Medical Center where she is the Medical Director of the PM&R Department’s Comprehensive Pelvic Rehabilitation Program. Dr. Scott is one of a very small number of PM&R physicians who specialize in the diagnosis, treatment and rehabilitation of pelvic floor disorders. I sat down with Dr. Scott to learn more about her approach to pelvic floor disorders and what residents should know about this PM&R subspecialty.
What led you towards your specialization in Pelvic Rehabilitation Medicine?
The short answer is that I tried it out in residency and liked it. The long answer is that it fit into what I was looking for in a practice. I liked the abstract concept of pain management — helping to alleviate suffering. But I just wasn’t seeing much improvement in most of the typical chronic pain patients. And then when I tried out pelvic clinic, I found that the patients were getting better in much larger numbers than the chronic back or neck pain patients, and it was very gratifying to be a part of that. Moreover, what drew me to PM&R was the focus on improving quality of life. To me, there is nothing more inherent to “quality of life” than being able to urinate, defecate, have sex, and sit without having genital pain. My patients are totally miserable — some of them void every 15 minutes, some cannot leave the house because it takes 4–6 hours in the bathroom to defecate daily. I see relationships falling apart because people cannot engage in sexual intercourse and people going on disability because they cannot sit. Helping patients with these most intimate of functions is truly life-changing for them. I also like that I am doing something that very few people are doing, and it has been relatively easy to make a name for myself because I am doing such a niche thing that is at the same time something that has the potential to help so many people who are suffering. The prevalence of pelvic floor disorders in the general population are extremely high (5–25% women have chronic pelvic pain, 2–16% of men have chronic pelvic pain, 20% of women have dyspareunia, 50% of women have urinary incontinence, 14% of men have urinary incontinence, 20% of people have constipation, etc.)
What is unique about the physiatric approach to pelvic disorders?
Most of the doctors who try to help people with pelvic disorders are surgeons. They don’t have the understanding of muscles, nerves, and joints that we have as physiatrists. They tend to look at the organs as the cause of all pelvic problems. But pelvic muscle, nerve, and joint pathology can cause pelvic pain, urinary/fecal incontinence, urinary urgency/frequency syndrome, constipation, dyspareunia, and a slew of other pelvic complaints. As a physiatrist, I can do a detailed pelvic muscle, nerve, and joint examination to elucidate the causes of their dysfunction and pain. Moreover, with my PM&R training, I can put the pelvic exam findings in the context of the whole body — both physically and psychologically. Perhaps their pelvic floor muscles are dysfunctional because they have signs on their neurologic examination that point to a central process like Parkinson’s disease? Maybe they have constipation because of lower motor neuron neurogenic bowel via chronic cauda equina arachnoiditis caused by a dural tear in a prior lumbar surgery? Perhaps their anxiety and bipolar disorder are causing upregulation of their sympathetic nervous system, resulting in high tone pelvic floor dysfunction? I get a very thorough history, including a focusing on their life stressors and prior abuse histories, as well as a full neuro exam as well as lumbar spine and hip exam in addition to the pelvic floor exam — it is very helpful to put everything in context.
What advice would you give to residents interested in treating pelvic disorders?
I would advise residents to keep an open mind — I never thought I would be doing this. I didn’t even like my OB-GYN rotation in medical school! But if you think you might have an interest, try to get in contact with some of us in PM&R who are doing pelvic rehabilitation, go to our lectures (we speak on pelvic topics almost every year at AAPMR), and try to spend some time in the clinics with us. See if your residency will allow an away rotation, or if not, come and spend a week or two while on vacation. You can also check out the International Pelvic Pain Society website and conferences. We have chapters in Braddom about the Rehabilitation of Pelvic Floor Disorders and Sexual Dysfunction in Disability which are worth checking out, and a recent PM&R Clinics of North America edition on pelvic pain which is excellent.
What do you find most rewarding and challenging about your current work?
I think the most rewarding thing is being able to truly help people who are suffering. I feel like my patients suffer more than many of the more classically disabled patients I encountered in residency. Being able to help them understand themselves better and improve their quality of life is a great blessing — that’s what I went into medical school wanting to do. I like that the work is always challenging — I have to use my brain, rely on excellent physical examination skills, and be a great communicator in order to get through every patient encounter. I cannot just coast through my day. I also really enjoy the team approach to patient care that we have in our pelvic rehabilitation program — the pelvic PTs and I practice in the same space, meet weekly to discuss patients, and have a very collaborative and supportive relationship that I don’t always see in outpatient physiatry practices, but which I feel is essential when you are a pelvic rehabilitation physiatrist. The main challenge of practicing pelvic rehabilitation medicine is that the patients tend to have a lot of anxiety and sometimes other psychiatric disorders. The work is never boring, but the amount of suffering combined with the psychiatric co-morbidities can be overwhelming at times. There are other logistic challenges — having long enough appointment times to properly evaluate these complex patients, making enough RVUs when the role for procedures is more limited than in other PM&R subspecialties, managing long waiting lists due to the large number of patient referrals. But it is definitely worth it.
