Maggie McKay (Host): Women's bodies are complicated. And when we experience pelvic pain, it can be debilitating. So today, we're going to find out about a new treatment for pelvic pain with Dr. Neeraj Kohli in pelvic pain uncovered.

Host: Welcome to Top Docs Podcast. I'm your host, Maggie McKay. What a pleasure to have you here today, Dr. Kohli. Would you please introduce yourself?

Neeraj Kohli, MD: Thank you, Maggie. My name's Neeraj Kohli. I'm a fellowship-trained urogynecologist and currently serves as the Medical Director of Boston Urogyn and Assistant Professor of OB-GYN at Harvard Medical School.

Host: So, what is this new treatment for pelvic pain called SoLá?

Neeraj Kohli, MD: SoLá therapy is a photobiomodulation therapy, which uses light energy to affect a biologic effect on the pelvic floor. And it really stems on this new concept that most conditions of pelvic pain are not related to the uterus, the bladder or the bowel, but they're related to the pelvic floor and the muscles of the pelvic floor, which have tension or spasms causing pelvic pain.

Host: Has SoLá changed the way you manage pelvic pain patients?

Neeraj Kohli, MD: Completely. We typically used to think of all pelvic pain being endometriosis or adenomyosis, or it used to be interstitial cystitis. And now, we're realizing that the vast majority, up to 85% of those women, even with those conditions, really have levator spasms or tight pelvic floor or hypertonic pelvic floor dysfunction.

In addition, a lot of pelvic pain complaints, including vaginismus, interstitial cystitis, pelvic pain with intercourse is all related to tightness of the pelvic floor. Now, that we know that we have a good therapy for it, a safe and effective therapy, we're diagnosing this more frequently and treating it more successfully.

Host: Dr. Kohli, I'm so glad I don't have to say those big words that you just said. I don't know if I could. What symptoms do you find are most responsive to SoLá pelvic therapy?

Neeraj Kohli, MD: So any patient who has pelvic pain, especially pain with urination, pain with intercourse or pain with bowel movements, most likely has a tight pelvic floor. In order to do those things, the pelvic floor has to relax. And anything that can trigger a tight pelvic floor can put patients in this cycle of pelvic floor tightness, which never resolves, and these are the patients we treat.

Host: So, does SoLá pelvic therapy hurt? And what should a patient expect when undergoing SoLá pelvic therapy?

Neeraj Kohli, MD: It doesn't hurt, and a lot of people are very anxious about an exam or as well as treatment, anything that involves in the vagina because they have pain and discomfort with any insertion of a speculum, a tampon, or intercourse. But SoLá therapy has a very small probe. The probe goes in the vagina and there's a very gentle back and forth motion delivering near-infrared light laser energy with a small warming effect. So, very few of our patients say that it's uncomfortable. They'll often say they feel a gentle warming in the vagina, which oftentimes can be soothing.

Host: And it seems as though many different diagnoses, such as endometriosis and IC, are associated with pelvic pain. SoLá does not treat the diagnosis, it treats the pain. So, is there a finding on examination that tells you that a patient may be a good candidate for SoLá pelvic therapy?

Neeraj Kohli, MD: What we're finding is any trigger, a urinary tract infection, a vaginal infection, endometriosis, sexual activity, exercise, trauma, it can cause a spasm of the pelvic floor. And I compare it to my patients, it's like lifting an object. Nine times out of 10, you lift the object and no problem. Every so often, you throw out your back. And once you throw out your back, you have significant pain. Now, you can treat it with pain medications, which is just symptomatic until hopefully the back heals. Or you can do physical therapy or you can treat it with photobiomodulation to the back muscles, and then the spasm goes away and, therefore, the pelvic pain goes away.

SoLá therapy achieves the same exact effect. It is a photobiomodulation therapy specifically indicated for the vagina and we relax the pelvic floor. So, many patients who have interstitial cystitis or vaginismus or endometriosis who aren't getting better, it's probably because they have an underlying pelvic floor condition and the spasms of the muscle is causing pain. Very few doctors will do a comprehensive pelvic exam to look for what we call trigger points. When you put your finger in the vagina and gently press on various aspects of the pelvic floor, in the routine patient, it should not be uncomfortable. In the woman who has a spasm or tight pelvic floor, you'll see pelvic floor trigger points, and those are the patients that are most responsive to SoLá therapy.

Host: And what is myofascial pain and how does it pertain to pelvic pain? And you can correct me if I pronounce that wrong.

Neeraj Kohli, MD: No. Perfect. So, myofascial pain means that the muscles and the ligaments and, as a result, the nerves of any structure can be affected. And when those structures are tight or under tension, they cause pain. We see this a lot in the back. We see this in the extremities. And physical therapists have been using photobiomodulation for over 10 years with very good results. Only now are we realizing that 85% of women who have pelvic pain also have myofascial pain. And the average woman struggles for at least three years and sees over five specialists before a proper diagnosis is made. What's frustrating but rewarding at the same time is that the diagnosis is easily made with a comprehensive pelvic exam if you know what to look for. And once you make the diagnosis of myofascial pain, appropriate treatment can be very effective.

Host: And you said there's an exam. How is myofascial pain diagnosed in the office?

Neeraj Kohli, MD: Again, because the myofascial pain can involve the deep pelvis, it can also radiate to the opening of the vagina and the vulva. So, patients who have vulvar pain or who have pain at the vaginal opening during intercourse will often exhibit tightness of the muscles. So, we always start with a Q-tip test in the vulva and the vaginal opening, gently pressing and seeing whether or not it's tender to the patient. We'll then use a single finger exam, well lubricated, and we'll touch on the various aspects of the pelvic floor muscles on the left and the right side to see if we see those trigger points. And then, finally, we'll assess the pudendal nerve because those nerves go through the tight muscles. If the muscles are tight, the nerve is going to cause pain. And I think that's important because a lot of people will get primary treatment for the nerve. But if you don't treat the tight muscles, that will be short-lived.

Host: And what are the typical treatment options for myofacial pain, and where does SoLá fit in?

Neeraj Kohli, MD: So traditionally, we've always first treated the symptoms of pain, which is ineffective because if you don't treat the root cause or the etiology of pain, the patient will continue to be in pain. So oftentimes, they'll be treated with nonsteroidal medications or narcotics or other pain medications. Sometimes gabapentin and neuroleptics can also be used. Once you make the diagnosis of tight pelvic floor, there are a variety of treatment options, including using suppositories, pelvic floor physical therapy, pelvic floor trigger point injections, Botox and then SoLá therapy. We find that SoLá is very effective, one, because it's very holistic, regenerative medicine; the success rates are higher, the onset of action is better, the treatment lasts longer, and it has minimal to no side effects.

Host: That's amazing. And what about recovery?

Neeraj Kohli, MD: There is no recovery. The SoLá therapy typically is a vaginal probe inserted in the vagina, back and forth. The treatment takes about three to five minutes. It's done three times a week for three weeks. And the vast majority of patients will see over 50% improvement within the first five sessions. By the end of the nine sessions, 80% of patients are seeing improvement. There is no recovery after the procedure. They can then continue doing physical therapy or using a vaginal wand, and they've shown up to 80% success rates lasting as long as six months.

Host: That's amazing. This has been so fascinating and informative. Dr. Kohli, thank you so much for educating us about this. Is there anything else you'd like to add in closing?

Neeraj Kohli, MD: If there's any way we can help our patients, locally or nationally, you can reach us at 617-340-6446 or our website, www.bostonurogyn.com. You can also visit the SoLá website to see local providers.

Host: Thank you so much.

Neeraj Kohli, MD: My pleasure.

Host: Again, that's Dr. Neeraj Kohli. And if you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. This is Top Docs Podcast. Thank you for listening.