Pelvic Pain and

About Pelvic Pain

For many people, dysfunction and pain in the pelvic region are uncomfortable to talk about, even with a doctor. For that reason, people often wait until mild discomfort and minor symptoms escalate into unbearable pain with embarrassing and unmanageable symptoms before seeking help.

Because of the complex anatomy of the pelvic region, many things can be at the root of pelvic pain and dysfunction, and until the cause is identified, the issue cannot be resolved. Treatment with internal manual therapy, drugs and steroid injections may dull the pain and mask the symptoms, but the condition often remains unresolved, relegating patients to a vicious cycle of pain and therapy.

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Dr. Lev Kalika

Clinical director & DC RMSK

Dr. Escudero

Manual Physical Therapist

Dr. Tatyana Kapustina

Acupuncture specialist

About the Pelvic Pain Team at NYDNRehab

Dr. Lev Kalika has been an active member of the International Society of Medical Shockwave (ISMST ) since 2007, and has performed over 3000 ESWT procedures. He is a world-renowned expert in ultrasound guided dry needling and has published multiple peer-reviewed articles about ultrasound guided procedures. Dr.Kalika is also a member of International Society of Neuromodulation, and has published multiple research articles about use of neuromodulation under a variety of conditions. As an active contributor and participant in the International Continence Society (ISC), as well as a member and contributor to the International Neuromodulation Society (INS). As Dr.Kalika’s knowledge and expertise about pelvic pain and dysfunction has evolved, he has developed his own unique approach to pelvic pain physical therapy that produces exceptional results. Dr. Daniela Escudero, DPT is a Certified Manual Physical Therapist who specializes in pelvic floor health, with an emphasis on functional movement and manual therapy. Dr. Escudero is dedicated to improving the quality of life of her patients, so they can pursue their full potential without pain or dysfunction. Dr. Tatyana Kapustina, our acupuncture specialist, earned her Master’s Degree in Acupuncture from the Pacific College of Oriental Medicine. She uses dry needling to target myofascial trigger points affecting the pelvic floor with highly effective results. Her treatment approach includes:
  • Dry needling of the pelvic floor and hip muscles and fascia
  • Balancing of the autonomic nervous system
  • Pudendal nerve acupuncture
  • Tibial nerve stimulation to downregulate pelvic pain

How Treatment at NYDNRehab Differs from
Conventional Pelvic Floor Physical Therapy

Most traditional approaches to pelvic pain fail to get at the root cause of pelvic floor dysfunction and correct it. Instead, we see an excessive amount of internal, intravaginal, intrarectal myofascial work, which does not address the true underlying cause of pelvic problems. Patients are subjected to years of “specialized” pelvic physical therapy and multiple injections, without making any significant progress.

Conventional methods merely treat the symptoms without fixing the problem, and fail to succeed in over 80% of patients with pelvic pain. In the course of treating pelvic pain patients for over 20 years, Dr.Kalika has found that manual internal trigger point release therapy should not be performed initially for the majority of patients with pelvic pain, as it tends to make the condition chronic, and makes patients dependent on the therapist without seeing any progress.

In some cases, people see a urologist for pelvic pain, even though most urologists are unfamiliar with pelvic pain and address it as a prostatitis, prescribing different antibiotics over the course of many months of treatment, only to tell the patient that the treatment failed and they will have to live with pelvic pain. Meanwhile, the patient’s gut health has been destroyed and the nerves become hypersensitized, resulting in chronic pain.

Dr.Kalika believes that pelvic pain and dysfunction are rarely caused by trigger points alone, and recent research has shown that, in the majority of pelvic patients, pelvic floor trigger points are secondary to the dysregulation of peripheral and autonomic nerves within the sacral plexus. The peripheral sensitization of sacral nerves causes dormant trigger points to become activated and resistant to myofascial therapies. Pudendal nerve compression is also rarely the problem, as it is rarely proven by MRI or ultrasound.

Given the failure of conventional pelvic therapy over the past 20 years, Dr. Kalika believes it is critical to identify the underlying cause prior to addressing the trigger point component of pelvic pain.

Ignoring the following external components is a key reason why pelvic pain is often mismanaged:
  • Dysregulation of forces within the intra-abdominal and intrapelvic cavities.
  • Inability of the motor system to cope with external forces to the spine, and shifting lumbar stabilization from group activation to overuse of the pelvic floor muscles, to compensate for the failure of other spinal stabilizers.
  • Incoherent interplay of spinal stabilizers and breathing apparatus.
  • Habitual abnormalities of sexual and excretory functions.
  • Hip muscle dysfunction caused by excessive sitting and improper walking gait mechanics
  • Unhealthy lifestyle habits
  • Stress, emotional issues, and poor coping strategies

Pelvic pain is a multifactorial condition. When a patient’s chronic pain is caused by multiple factors, more than one treatment approach may be required. When we consider secondary causes, it is important to note that many of those factors also exist in people who never develop pelvic pain. Secondary factors should only be considered once dysregulation of the nervous system has been addressed. When exposed to stressful events, disease, surgery, or physical or emotional trauma, trigger points and myofascial pain may arise, but they should be considered secondary to sacral nerve dysregulation.

What sets treatment at NYDNRehab apart from conventional pelvic physical therapy:
  • We use different types of neuromodulation technology such as NESA microcurrent and high energy inductive therapy to calm the central, peripheral, and autonomic nervous systems.
  • We use focused shockwave therapy and ultrasound guided dry needling to desensitize pain receptors, small nerves, trigger points and fascia within the pelvic floor.
  • We use radio frequency microcurrents to produce a global thermal intracellular effect on the pelvic floor muscles.
  • If patients still have some residual pain, only then do we begin a combination of internal and external physical therapy.

We believe that performing internal physical therapy when the patient is experiencing acute pain is counterproductive and merely leads to chronicity. This has been our experience with a large number of patients who have come to us after receiving unsuccessful internal physical therapy elsewhere.

Watch this video to learn more about NYDNRehab’s unique approach to pelvic pain treatment.

Symptoms, Causes and Risk Factors of
Pelvic Dysfunction


  • Pain in the genital area
  • Pain in the perineum
  • Rectal pain
  • Pain in the pelvis
  • Pain during sexual intercourse
  • Urine leakage during intercourse
  • Urine leakage during exercise
  • Leakage when coughing, sneezing or laughing
  • Difficulty emptying your bladder or bowels
  • Prolapsed uterus or internal organs
  • Low back or hip pain


  • Postural issues affecting the pelvis and low back
  • Trauma
  • High-impact physical activities
  • Surgery
  • Obesity
  • Sedentary lifestyle
  • Pregnancy and childbirth

Risk Factors

  • Pregnancy and childbirth
  • Advanced age
  • Obesity
  • Chronic constipation
  • Chronic coughing
  • Pelvic muscle atrophy post-menopause
  • Radiation or pelvic surgery
  • Smoking
  • Enlarged prostate

Accurate Diagnosis of Pelvic Floor Dysfunction Means Successful Treatment

Diagnosis begins with a medical history and physical exam of the pelvic floor, low back, hips and pelvis. Gait analysis may be performed as well. Your clinician will ask for detailed information about pregnancies and childbirth, and any difficulties or abnormalities you experienced associated with childbearing.

At NYDNRehab, we use high resolution dynamic ultrasound to visualize the structures of the pelvic floor with the patient in motion. Since the pelvic region is closely related to the low back and hips, we perform diagnostic and functional sonography to rule out hip and low back issues.

During a diagnostic ultrasound session, both patient and clinician can view the muscles of the pelvis and abdominal wall in motion, to assess for muscular deficits, excessive force production (pressure) and trigger points.

With real-time ultrasound imaging, we are able to diagnose and treat a number of issues related to pelvic dysfunction, including:

  • Low back pain
  • Chronic pelvic pain
  • Hip and groin pain
  • Postpartum issues
  • Urinary and bowel incontinence
  • Post-surgical issue

Pelvic Fascial Manipulation – the Missing Link in
Pelvic Pain Treatment

The superficial fascia of the pelvic floor is a thin fibrous layer of connective tissue embedded with adipocytes – specialized fat cells – along with a complex network of lymphatic and blood vessels. The pelvic fascia plays an important role in exteroception – sensory awareness of stimuli outside the body.

Fascia tissue has a high percentage of elastic fibers and a slippery coating of hyaluronan that facilitates the gliding of nerves and blood vessels. The pelvic fascia works together with the transversus abdominis, diaphragm and pelvic floor muscles to optimize abdominal pressure, providing spinal stability. Its autonomic innervation makes the pelvic fascia sensitive to stress and changes in temperature, and it is intricately connected to the genitalia.

Pelvic fascia manipulation is often the missing link in pelvic pain treatment. Pelvic pain is mostly generated from hyperactive nerves embedded in the deep fascia of the pelvis. These include peripheral nerves like the pudendal, gluteal and cluneal nerves that glide between the pelvic floor muscles and can be released from entrapment by manipulation of the endomysium and perimysium.

Other sensory nerves and their endings inhabit the superficial fascia, such as the ilioinguinal, iliohypogastric and genitofemoral nerves. When your parasympathetic nerves are entrapped in the superficial fascia they become hyperactivated, generating pelvic pain.

The intimate connection between the deep and superficial fascia layers has been largely overlooked in conventional treatment of pelvic pain. Most doctors and therapists focus on injections to block the pudendal nerve, and on manual release of trigger points.

According to evidence-based research, pelvic fascia manipulation therapy not only releases densified layers of superficial and deep fascia, but also calms hyperactivated nerves. Other therapies, such as ultrasound-guided electro acupuncture, are often used in conjunction with fascial manipulation for the neuromodulation of hyperactive pelvic nerves.


Regenerative Technologies for Pelvic Floor
Physical Therapy

The human body has its own innate healing mechanisms, but it sometimes needs a nudge to accelerate the healing process. Regenerative technologies help to jump-start healing by stimulating tissue repair at the cellular level. Our outpatient regenerative therapies expedite recovery with minimal discomfort for the patient.

Focused Shockwave Therapy (ESWT)

Focused Extracorporeal Shock Wave Therapy (ESWT)

Focused ESWT produces high frequency sound waves to stimulate the body’s own reparative mechanisms. In patients with chronic pelvic pain, ESWT works by interrupting hypersensitized nerve impulses, helping to reduce muscle spasms. It also reduces inflammation to free up entrapped nerves, allowing them to glide among other structures. We use ultrasound guidance to ensure that shockwaves reach the targeted nerves and tissues. Shockwave also helps to release myofascial trigger points and fascia adhesions that contribute to pelvic pain. ESWT is considered to be a top-tier, evidence-based treatment approach for pelvic pain.

Extracorporeal Magnetic Transduction Therapy (EMTT)

EMTT is a fairly new technology that transmits high energy magnetic pulses to targeted tissues. The magnetic waves synchronize with the body’s own magnetic fields, causing a disturbance that triggers a regenerative response. EMTT waves can penetrate deep tissues up to 18 cm beneath the skin’s surface, to target difficult-to-reach tendons, muscles, bones and nerves.

Electromagnetic Transduction Therapy (EMTT)

Extracorporeal Pulse Activation Technology (EPAT)

Extracorporeal Pulse Activation Technology (EPAT)

EPAT, also known as defocused shock wave therapy, uses acoustic pressure waves to enhance blood circulation to targeted tissues. This speeds up the delivery of oxygen and nutrients to damaged tissues and stimulates cellular metabolism, to accelerate the healing process.

High Energy Inductive Therapy (HEIT) – aka Electromagnetic Therapy

HEIT uses electromagnetic fields to penetrate cells, tissues, organs and bones, to reactivate the electrochemical function of cells and cell membranes. HEIT generates a magnetic field 600 times stronger than the field of a normal magnet, to stimulate healing of nerves, muscles and blood vessels. *It is important to note that the technology behind HEIT is identical to EMSELA (electromagnetic pelvic floor therapy). EMSELA is a rebranded version of HEIT, promoted by some clinics at more than double the price.


Pelvic Conditions Successfully Treated with Regenerative Therapy

Growing evidence indicates that regenerative therapies like ESWT are especially effective in treating the following pelvic conditions:
  • Pelvic pain of unknown origins
  • Pelvic floor muscle pain from myofascial trigger points and spasms
  • Pudendal neuralgia (damage to or irritation of the pudendal nerve)
  • Vulvodynia
  • Urinary incontinence
  • Dyspareunia (painful intercourse)

Ultrasound Guided Injection Therapies

Injection therapies use natural/neutral solutions that stimulate cellular repair by either nourishing or irritating the targeted cells. Guidance by ultrasound ensures that the injected substances hit their mark, for maximum effectiveness.

Platelet Rich Plasma (PRP)

PRP therapy uses a sample of the patient’s own whole blood, which is spun in a centrifuge to extract a high concentration of platelets. When injected into damaged tissues, PRP initiates tissue repair by releasing biologically active factors such as growth factors, cytokines, lysosomes and adhesion proteins. The injected solution stimulates the synthesis of new connective tissues and blood vessels. PRP can help to jump-start healing in chronic injuries and accelerate repair in acute injuries.


Proliferation Therapy, aka Prolotherapy

Prolotherapy uses a biologically neutral solution, often containing dextrose, saline or lidocaine. The solution irritates the affected connective tissue, stimulating the body’s own natural healing mechanisms to encourage growth of new normal ligament or tendon fibers.

Ultrasound Guided Dry Needling

Myofascial trigger points often contribute to knee pain. The dry needling procedure inserts non-medicated needles into trigger points to evoke a twitch response, releasing the trigger point and immediately relieving pain. Ultrasound guidance eliminates the need for multiple insertions, reducing pain and discomfort for the patient.

More Treatment Options

Acute Pelvic Pain

Sudden onset pelvic pain should not be ignored. It is essential to immediately rule out visceral pathology (organ dysfunction).

Treatments for acute pelvic pain include:
  • Pudendal or genitofemoral nerve blocks followed by tibial nerve neuromodulation.

Chronic Pelvic Pain

Ongoing or intermittent pelvic pain that lingers for weeks or months can often be eliminated with non-invasive conservative treatment.

Treatment options for chronic pelvic pain include:

  • Extracorporeal shockwave therapy ( eswt)
  • Extracorporeal magnetic transduction therapy (EMTT)
  • Ultrasound guided dry needling
  • Comprehensive Pelvic floor physical therapy

Home treatment options for pain management and restoration include:

  • Sitz bath
  • Foam rolling on the painful region
  • Physical therapy exercises
  • Meditation with focus on your pelvic floor

Get Personalized Pelvic Pain Physical
Therapy Designed Just for You

At NYDNRehab, we take a one-on-one approach to patient care. We understand that every patient has a unique anatomy, and that each condition has unique characteristics. We tailor our treatment plans to the individual, and never use cookie cutter approaches.

Our experience using innovative treatment methods and advanced technologies makes NYDNRehab the number one choice for pelvic floor physical therapy and rehabilitation in NYC.

Benefit from Our Innovative Non-Invasive Therapies

The muscles and connective tissues that make up your pelvic floor form a hammock that spans from your tailbone to your pubic bone, creating a wall of separation between your perineal region and your pelvic bowl. The pelvic floor provides support for your intestines, bladder and uterus, and its muscles govern bladder, bowel and sexual function.

Signs that your pelvic floor may not be doing its job often begin with bladder and bowel leakage, urinary hesitancy or urgency, or constipation.

High-impact sports like gymnastics, basketball and running create downward pressure on the pelvic floor muscles, putting athletes in those sports at risk for dysfunction. Pregnancy and childbirth may also lead to pelvic pain and dysfunction.

Pain that persists for six months or longer is categorized as chronic pelvic pain (CPP) which can seriously interfere with normal daily activities. CPP is common in women, accounting for about 10% of all visits to the gynecologist. It is also a common urologic complaint among men under age 50.

We strongly believe that the pelvic floor muscles are not the underlying cause of pain. Experience tells us that pelvic pain originates in walking gait deficits and imbalances in the hips and low back, interfering with the body’s ability to balance intrapelvic and intra abdominal pressure. While ESWT, EMTT, and USGDN are effective in relieving pain, restorative pelvic floor physical therapy provides the ultimate solution to pelvic pain and dysfunction.

Preventing Pelvic Pain and Dysfunction

Lifestyle factors play a key role in pelvic dysfunction. Eating whole organic foods and drinking plenty of plain filtered water can help you avoid urinary and bowel issues that lead to pelvic pain. Regular exercise that targets muscles throughout the entire body helps to strengthen the pelvic and core muscles and promote healthy function. Managing your weight, avoiding smoking, and stress management are all important lifestyle factors that help to prevent pelvic issues. Staying fit and active throughout your pregnancy can reduce your risk of developing pelvic floor issues.

In addition, you should rule out visceral pathologies by consulting your healthcare provider. If you suffer from hip or back pain, you should seek treatment, as untreated pain in those areas can affect the pelvic region. A 3D gait analysis can help to identify and correct asymmetrical gait patterns. Try to remain aware of your pelvic floor, and do not clench your pelvic muscles when stressed. Be sure to void your bladder and bowels when you feel the urge – do not hold your urine. Eating an organic whole foods diet and drinking plenty of purified water will help you avoid constipation.


Get Pain-Free Pelvic Floor Treatment
That Really Works!

Pelvic floor physical therapy helps your body heal itself, to eliminate pelvic floor dysfunction for good. However, not all physical therapy is effective. Conventional therapy uses manual intra vaginal or intrrectal release techniques to target the internal pelvic floor muscles. In our experience, this type of treatment only provides temporary relief with no significant progress, making patients dependent on ongoing therapy to relieve pain.

At NYDNRehab, we help our patients get long-term relief using a combination of extracorporeal shock wave therapy (ESWT), extracorporeal magnetic transduction therapy (EMTT) and ultrasound guided dry needling (UGDN). Our treatment approach goes beyond pain management, to actually regenerating damaged tissues and promoting healing. We are the top rated physical therapy clinic for pelvic pain in NYC.

Clinical Case Studies

Case Study: Male Pelvic Pain and Erectile Dysfunction

Our Patient A male cyclist came to us with erectile dysfunction and pelvic pain. He was being treated elsewhere with manual therapy, with no signs of improvement. The Challenge The therapist who had been treating the patient was using internal manual therapy to address tight pelvic floor muscles, when in fact the muscle tension was […]

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Case Study: Pelvic Pain Demystified in Female Patient

Our Patient A 33-year-old female came to us complaining of persistent left groin pain and painful intercourse. She had been seeing a physical therapist for hip pain that extended to her groin and pelvis. The Challenge In addition to physical therapy, the patient was treated with manual internal pelvic floor massage. When her condition did […]

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    Range of Available Unique Physical Therapy
    Treatments at Nydnrehab


    In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.

    Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.

    The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.

    Dynamic ultrasonography examination demonstrating
    the full thickness tear and already occurring muscle atrophy
    due to misdiagnosis and not referring the patient
    to proper diagnostic workup

    Demonstration of how very small muscle defect is made and revealed
    to be a complete tear with muscle contraction
    under diagnostic sonography (not possible with MRI)


    Complete tear of rectus femoris
    with large hematoma (blood)


    Separation of muscle ends due to tear elicited
    on dynamic sonography examination

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