Did you know that spinal health could hold the key to resolving pelvic pain and certain types of sexual dysfunction? Join me as we delve into groundbreaking insights with Dr. Choll Kim, a leading expert bridging the gap between spine health and sexual wellness.

Dr. Choll Kim, a pioneering spine surgeon whose work is challenging the traditional boundaries of pain management and sexual medicine. Dr. Kim shares his journey from orthopedic surgery to collaborating with specialists in sexual health, uncovering the unexpected links between spinal conditions and pelvic pain disorders like PGAD (Persistent Genital Arousal Disorder). 

Together, we discuss how this understanding could reshape treatment options for those who’ve been told their conditions are “all in their heads.” Dr. Kim explains how seemingly routine spinal issues, such as annular tears or Tarlov cysts, may trigger chronic pain that extends beyond the back, affecting intimate areas in ways that are often overlooked by conventional medicine.

He also shares the innovative diagnostic techniques he uses to distinguish spinal-related sexual dysfunction from other causes, which has opened doors to effective, minimally invasive treatments.

In addition, we discuss the challenges of bringing these ideas to the broader medical community. Dr. Kim has faced resistance from peers who view the spine as an unlikely source of sexual pain, yet his patient successes speak volumes. This episode is packed with insights for both patients and practitioners who want to explore a more holistic approach to pain management and sexual health.

Dr. Kim’s dedication to helping patients find relief from life-disrupting symptoms is nothing short of inspiring. By listening, you'll gain a new perspective on the interconnectedness of the body and why keeping an open mind is crucial in healthcare.

Episode Highlights:

• The surprising role of the spine in conditions like PGAD and pelvic pain disorders.
• How Dr. Kim uses targeted spinal injections to identify the source of sexual dysfunction.
• The anatomy of annular tears and why they’re a common cause of persistent pain.
• Challenges and breakthroughs in advocating for spinal evaluations in sexual health cases.
• Practical advice for both patients and clinicians on considering spinal health in treatment plans.

Dr. Kim’s Bio:

Dr. Choll Kim, a Harvard cum laude graduate, completed advanced training in complex spine surgery at the Mayo Clinic. Dr. Kim is a pioneer in minimally invasive spine surgery techniques including Laser Endoscopic Spine Surgery (LESS) which has transformed treatment for herniated discs, radiculopathy,and sciatica.

In addition to spine surgery, Dr. Kim is also recognized for his knowledge in sexual dysfunction related to spinal conditions, such as Tarlov cysts. His integrated approach ensures comprehensive care for patients facing spinal and sexual concerns. 

Dr. Kim is a renowned global educator, training specialists around the world in advanced, computer-assisted minimally invasive techniques such as LESS. As the founder and past president of SMISS and MIS-COE, he has played a pivotal role in the advancement of spine surgery. With over 200 publications and active involvement in organizations such as ISASS, NASS, AAOS, and KASS, Dr. Kim has made significant contributions to the field, shaping the future of minimally invasive spine surgery.Beyond the operating room, he enjoys kickboxing, golfing with his mom, and family vacations.

Don’t miss future episodes! Subscribe now to stay informed on the latest in health insights and patient advocacy. If you found this episode valuable, please take a moment to share, rate, and review—it helps us reach more listeners and spread awareness.

Get in Touch with Dr. Kim:

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Hi everyone, welcome back to another episode of Gyno Girl Presents Sex, Drugs and Hormones. You guys are in for a big treat today. I'm super excited to have an amazing, this is my second orthopedic surgeon on this podcast actually. An amazing, amazing surgeon who I have a lot of respect for and he's just like the coolest guy ever.

You guys heard my intro. This is welcome. Dr. Chol Kim. I'm trying to be like Oprah now Welcome Chol so happy to have you here I met Chol actually, you know, you guys hear me talk about Ishwish all the time I met him at the International Society for the Study of Women's Sexual Health probably Do we meet in Dallas or did we meet in St. Louis? I don't know. It was years ago and

I love that.

you know, there aren't that many surgeons that come like I guess orthopedic and neurosurgeons that would come to the Ishwish conference and he's trailblazing man. He's leading the way here. So we're gonna talk to Dr. Chol Kim today about how what brought him into the world of orthopedics and then more importantly, what brought him into the world of sex medicine that we wanna hear about. But I've talked actually about how the spine is so important in our evaluation with some, you guys have heard my.

Discussion what some of my patients will come on that have spinal injuries and and I had April on the podcast too when she talked about her annular tear and she talked about you at that time with her p-gad symptoms, but First told tell me about Right. yeah, there you go. See so and that actually that podcast like I had so many people reach out to me about because the You p-gad isn't often, you know discussed enough and the fact that she was so forthcoming about her own journey

She was one of my very first patients.

And then she's now like someone that treats it, you know, in the pelvic floor area.

You know, what's interesting is that I did a survey of my regular spine patients, not the patients that are referred to me through our sexual medicine program and Dr. Goldstein. And probably almost 10 % of patients have some degree of significant sexual dysfunction. But had I not administered this questionnaire and kind of like a kind of private setting, we probably would have never known.

or once it's.

Yeah.

Mm-hmm. Yeah. Isn't that amazing? Yeah.

but 10%, it was actually 8%, but that's a lot.

It's a lot. think, think maybe I told you this story before, but you know, when I started my practice 10 years ago, my husband's interventional pain supports medicine through PMR, PMNR, but he does all the, you know, injections in the spine. And so he was like, I got to teach you a little spine so that you know who to refer to me. And then I'll know that I can refer, you know, to you as a gynecologist, you know, I know what you do. And so he taught me how to do like a brief spine evaluation and question the patients about other ridiculous symptoms.

And in the beginning, I had all these patients that had like either interstitial cystitis or, know, weird vulvar pain. And they also had this ridiculous symptoms. I was like, well, they also have this spine stuff happen. Other ridiculous symptoms, I should say, you know, whether or not it was like tingling or numbness down their legs or like weakness or whatever. And, you know, I would send them for an MRI and then send it to my husband. And then he would treat them with, you know, whatever caudal epidural, whatever thing he did. And they would these the symptoms would improve like, and it was like, so like.

That was my first epiphany before like having I should have published it back then

You know, it's okay. You know, what's funny is that I had a very similar experience. I did a surgery on a patient with back pain, shooting down their leg. This person happened to work in Dr. Goldstein's office. She had a facet cyst and severe radiculopathy and back pain. I did her surgery and she got better in terms of back pain and radiculopathy, which I fully expected. But you know what she said after that? She said, Dr. Goldstein.

Yeah. What?

I've never told anybody this, but I have pelvic dysesthesia, it's like a form of PGA D. And I didn't really say anything about it, but that's better now after Dr. Kim's surgery. And that's probably what really motivated, Erwin and me to like go after this in earnest, because until then we kept just going back and forth. Yeah, maybe we should do this. Maybe we should do that. After that, we started having weekly meetings.

Yeah.

I love it.

Yeah. Yeah. Yeah.

going through MRIs and it's a very interesting story of how I became a part of this community, which by the way, the Ishwish and sexual medicine community, I'm around a lot of physicians, but this is the most dedicated, the most caring and the most energized and cooperative group of physicians I've ever seen.

That's my idea.

That's fine.

Me too.

together, when I go to Ishwish, I'm just energized because the effort is like, there's the whole like, you know, energy going in the same direction. Everyone is just focused on taking care of this really bad problem. And I've, I've thought about this myself. If I had to decide between a sexual disorder and a drop foot or radiculopathy, it wouldn't even be close. I'd be like, give me the drop foot. Never think about it until you really seriously think about it. It's a huge deal.

Yeah.

Sorry. Yeah, no kidding. Yeah.

It's a huge deal. Yeah.

so I get it and I'm really lucky. I became into that. I came into this world, but had it not been for Dr. Goldstein being on the same campus as me and him badgering me. for anyone that knows who Dr. Erwin Goldstein is probably one of the most, the father of sexual medicine in this country. He is relentless. Once he decides on something, he's not going to let it go. And yeah. And.

father,

And he keeps going. He keeps going. Well tell me how you met him and then tell, because you kind of already described one of the patients, the first patients you had, but tell me how you guys met and like when that...

Well, I knew about him because I got recruited in part by the owner of the hospital that he was at away from UCSD to Alvarado, which is a small community hospital. And I was thinking about leaving and my two practice partners back in the back at that time was also recruiting me, but the owner of the hospital, I was at UCSD at the university. I've been, I've been in academics for the vast,

Okay. The Alvarado one. Yeah.

ever.

majority of my career, but the last 15 years I've been in private practice. And by the way, being in private practice and being academic is not necessarily mutually exclusive. In some ways you can be more academic in private practice. Anyway, they recruited me and, and Erwin had this kind of the same obstacles and challenges doing what he's doing in sexual medicine as I was in mineral invasive surgery. I started society. I was doing stuff that no one else is doing and he was doing the same thing. So

Okay.

reaches a decent grade.

I agree.

Yeah.

He recruited me there so I knew about him and every time I saw him I'd say, hi Dr Goldstein and one day he said, Chol I need to meet with you because I think some of my patients that have PGAD and he told me what it was and I thought wow that's I choked around probably I think it's coming from the spine and I said what almost all spine surgeons probably have said to a multitude of our mutual patients That's crazy. I've never heard of such a thing and he kept badgering me and badgering me and badgering me

Yeah.

of course.

Yes. Right.

Then he sent me his employee, this patient has, you know, one of my employees can barely stand and sit to work. And so I did her surgery and she got better. And then he came to my office with a stack of MRIs. He waited in my waiting room while I finished clinic. I told him I'd be done at six. I'm never done on time. He waited till like 7.30 and we went through imaging studies and we went, maybe we have something here.

Yeah, wow.

Wow. Amazing.

And little by little, we started very carefully selecting specific patients, doing targeted injections, and then doing the most minimum based surgery possible. And guess what happened? Patients that have seen multiple doctors have had multiple surgeries, multiple treatments without success. They got better. was, it was life changing for both the patient and for me.

I got better.

Absolutely. Right.

And we've kept this up. There's still a very challenging group of patients, but that is, this is absolutely real. It just requires a lot of work identifying the correct patient that has an actual spine related sexual difficulty of some type. If you think about it, it makes perfect sense. mean, it's all about sensations, experiences, all that goes, it has to go through a nerve and then the small.

Yeah. And I think a lot of work.

Right.

Right. Yeah.

The nerve. Yes. And the nerve. Yeah. Yeah.

there's going to be a group of patients where that problem is because there's something wrong with the nerves in the lumbar spine. I'm sure it goes all the way up even to the brain, but the lumbar spine is the easiest thing to work on first. we've had some of my happiest patients are my patients that I get from people like you and Dr. Goldstein.

Yeah. Yeah.

Yeah, I think what's amazing is it really changed the paradigm of how we look at genital pelvic pain, right? Like, at that point, it was all like, okay, just look at the vagina, the vestibule, the clitoris, maybe you look at the pelvic floor a little bit. But, know, the spine, that region three and four, and you know, the brain, obviously, we always kind of knew was involved, but three and four, like that was huge, actually. And to now have a paradigm, like this is like, now we have an algorithm to kind of think about

how to identify what patients might benefit from the things that you're describing. And you're totally true in saying that not every patient with a Tarlov cyst is gonna have sexual disorders or PGAID, but there are those subsets that benefit. Can you tell us a little bit about that, like how we can differentiate those?

Yeah. So, so one of the, one of the ways that, all this happened is that Dr. Goldstein saw a study by Dr. Barry Komisarac, neurophysiologist at Rutgers also in his own right, a sexual medicine expert, but he's a PhD neuroscientist. And he noticed that in a high proportion of patients with PGAD, persistent genital arousal disorder, you know,

Thank

which is probably constellation of things, but anything related to like sexual dysfunction and orgasmic dysfunction, he'd noticed that an unusually high number of his patients had Tarloff cysts on their pelvic MRIs. So he made the correlation, maybe patients that some of these are due to Tarloff cysts. And when Dr. Goldstein saw this paper, they talked and that's what motivated Dr. Goldstein to reach out to me. And our initial

Right.

Mm.

look at all this was specifically look to look for patients with Tarloff cysts. But in the process of doing so, we saw that a lot of them did not have Tarloff cysts, but they had all these like annular tears and disc herniations and degenerative changes in stenosis in the lumbar spine. Cause you often get the same images. You get those images on the same sequence. So we thought, okay, if Tarloff cysts can cause a neurologic disorder,

Mm-hmm.

up for it.

Right.

Right.

Maybe the disc can cause a neurologic disorder. Either way, we have to figure out if it's true or not. Because here's what's weird about the spine. You could have an annular tear. You can have a herniated disc. You can have a tarloff cyst and not even know it. In other words, a lot of abnormal findings on an MRI without symptoms. That probably happens a lot in other areas of medicine, but in the spine, it is really common. So somebody in my age group in their 50s,

Right.

No.

Right. Yeah. Yes.

Yeah.

If we just took a hundred people in their fifties and sixties and offered them a free MRI, half of them will have stenosis, herniated disc, annular tears, and they don't even have any symptoms. But saying that is not the same thing as saying all abnormalities are asymptomatic because in a sea of asymptomatic abnormalities, there's going to be that one or that one patient that has a symptomatic problem. And so if we have a way to identify.

Mm-hmm.

a symptomatic abnormality from an asymptomatic abnormality, which look identical on MRI, then we have something and there's a way. If you do a targeted injection at that disc and you bathe it with an anesthetic and a steroid and ask the patient, do they get temporarily better? That is pretty good insight as to whether or not it's symptomatic. And a patient that says, I didn't notice any difference. We decide they're probably not.

Yes, absolutely.

Mm-hmm.

as good as it. Yeah.

they probably don't have a problem due to the spine. But in patients that say, I got temporarily better, that's never happened before. That's a positive diagnostic response. And then those patients, if we operate on them, they get a lot better. So I would say that there's a multitude of steps to take a huge sea of patients that you don't know exactly what's going on and whittle them down to that one, that few patients, the few remaining patients that actually have a spine problem.

Yeah. Yeah. Yes.

that if you treat it will get better. And that starts with an initial assessment by a sexual medicine expert because I don't know how to do it. And it's pretty clear to me that most of these problems are not due to the spine. Most of them are due to other things. We call it region one, like local. It could be hormonal. It could be a variety of like anatomic things in the pelvis. And you treat those patients with the most common causes and you just keep willing them down to the patients that don't get better.

Right. Yes. Right. Yeah.

Mm-hmm.

Yes.

And we have a very kind of regimented program. So somebody like you or Dr. Goldstein, they do the first pass. They treat the patients with the non-operative treatments that are the most obvious. And the ones that get better, great. The ones that don't, they get more testing. And we even do something called neurogenital testing. That's what Dr. Goldstein does. And it has, it's like three different exam tests with like temperature probes, like little pins, vibration sensors.

Mm-hmm.

Yes. Yeah.

Yeah.

cold temperature monitors. He even puts like a balloon inside crevices and inflates them up to see if you can notice these things. And he creates like a map of where he thinks the abnormality is. And he can kind of whittle it down to like region three. And he sends me the region three patients. And then I take a crack at it. I talked to the patient, I talked to them about all their other symptoms.

Yeah. Yeah. Right.

And then I decide whether or not it's reasonable to do a targeted injection. And order that and I see the patient afterwards and interrogate them about the response. And every one of those steps, at least for now, I wouldn't know which ones to take out. You just have to go through all those steps. And with that, success, our surgical success has been on par with some of my happiest patients, like my discectomy patients. So it's been...

So sick.

Absolutely. those listeners that might not have listened to my other podcast around PGAN and Tarlarsis, can you explain what causes a Tarlarsis or how do people get these spinal anatomic issues that might come up? As if we knew. As if we knew the answer. It's true.

Well, no one really knows why you get a Tarlov cyst. I'm embarrassed to say it's one of those things like we just don't know. There's probably a genetic predisposition. There's probably a little bit of serendipity and bad luck, but no one really knows why these cysts pop up, but it's probably related to some subtle collagen disorder because there are cases of patients that have multiple Tarlov cysts all throughout their spine.

Yeah.

Right.

And it's very likely that patients with like Marfan like syndrome, like Marfan syndrome is a very specific genetic disorder of collagen type one. Yeah. Like a specific genetic defect, but there's probably like all these variants and patients like that have really loose connective tissue. They can hyper, hyper extend their elbows. Some people can like push their thumb all the way down to their forearm. can you do that?

Yeah.

Mm-hmm.

No, I cannot. But I always ask for the patients and then they show me.

and it's likely that it's a combination of those two things. What's interesting though is, is what makes an asymptomatic tarloff cyst symptomatic. And it's probably two things. The most obvious thing is that they grow and grow and grow and they get so huge that something's wrong. Like, like a nerve gets stretched out or,

Right.

The hydrostatic pressure inside the nerve sheath is so high that it affects the nerve, just the size. But I would say that the majority of symptomatic Tarlov cysts start becoming symptomatic way, way before them. So probably what happens is some bad luck event triggers an inflammatory response. And then that inflammatory response turns on. And for most people, it turns back off again because it's things

Yeah. All right.

get abnormal in the body, the body tries to heal it. And every healing response goes through at least inflammation. So most cases it turns on and turns off, but every once in a while it turns on. It does not turn off. It just stays chronically on. And by the way, that happens all the time. Anybody that's had tennis elbow, golfer's elbow, plantar fasciitis, shin splints, rotator cuff tendonitis, those are all chronic inflammatory conditions that,

Yeah. Yeah.

On imaging studies, barely have any, like it barely looks like anything, but it is really, really painful and it lasts forever. So that's probably what happens. A little bit more complicated than that because when I do tarlof cyst surgery, the amount of inflammation is like visibly obvious. Everything's stuck down. And then I can even see like a nerve sheath right next to a tarlof cyst and it's red right there.

Yes, yeah. Forever. had pleasure. So was awesome.

Yeah.

really? And you do all your through scope, right? Minimally invasive. Can you talk about a little bit how you approach these trial systems?

because of increased vascularity. So I think.

all the surgeries that I do, I try to use some type of middle invasive techniques. So the most extreme one is when I use the endoscope, like using the shoulder or the knee, but for Tarloff cysts, it's not ready for endoscopic treatment. So I still have to make a little small incision and I make that incision as small as possible by using navigation so that, even before I make the skin incision, like, like in my car, I know exactly where everything is in three dimensional space. And as I go down, I know exactly where I am. So.

Yeah. Yeah.

using mat and specialized retractors and treating the cyst earlier rather than waiting until it's way too big or waiting until a patient's incontinent by doing these targeted diagnostic blocks. You can do the surgery with the minimum amount of trauma, minimum amount of like reconstruction. So sometimes when the cysts get really big, you have to like deal with the bone erosion and you have to wrap the cyst and like a membrane and do a lot more.

you.

Yeah.

Yeah.

extra stuff that makes the surgery much bigger and much more difficult to recover from. So MIS is like a combination of early detection, using intraoperative computer navigation and imaging to know exactly where you are at all times without having to like look down anatomically and then using all the specialized kind of retractors and instruments in the operating microscope to try to be as gentle as possible and minimize collateral damage. When you do that, so far,

Mm-hmm.

That's cool.

Every patient goes home the same day and the complication rate has been zero and the recurrence rate has been zero. I'm sure at some point I'm going to have a complication because you just, it's not possible to avoid it at some point, but it's vastly different than what I expected because the literature on Tarloff's cyst surgery is filled with horror stories because traditionally Tarloff's cyst surgery was done way too late, like way, way too late.

Yeah.

Right.

Yeah. Yeah. Yeah.

Either they're so huge that they erode into the bone or the patients show up incontinent of urine. And urinary incontinence is one of those really sensitive markers. Once that happens, it's really difficult to go backwards. So you want to catch patients well before that.

Right. Right.

Yes. And I think that's the challenge. it also is part of that detective work that we do, is trying to identify. Because I think you may remember one of my students presented on a case of that huge Tarlopsis that was in the lumbar sacral spine. she had been to so and she's like, I can't believe my gynecologist diagnosed me with this back issue. She did have vulvar dysesthesia and that's why we went down that path.

Well...

I mean, she's lucky to have somebody like you because it's really fascinating to me how the human mind works because when I look back on it, it is obvious that this would be the case. You know why? Patients with spinal cord injury, they have sexual dysfunction as well as incontinence and inability to control their bowel and bladder. If you ask them, they have sexual dysfunction. And then patients with an entity called Cata-Equina Syndrome.

Yes. Yeah. Right. Yes.

So that's like a medical emergency. It's usually when somebody has a huge sudden herniated disc, like an acute sudden event. And you go from being normal to like all of a sudden, all your nerves are squashed. You show up to the ER with severe back pain, saddle anesthesia, like your butt area, your perineum is numb. You have burning pain down your legs. and you have either urinary retention or urinary incontinence or some type of urinary dysfunction. It's a surgical emergency.

Right.

Yeah.

Yep.

on.

I spoke with a neurosurgeon that takes call to deal with those patients and she just happens to like, I see so many Cotty Quina patients. We're the referral center for Cotty Quina syndrome. And I asked her what proportion of those patients have sexual dysfunction. She didn't even hesitate. She answered immediately. 100%. She goes like this a hundred percent. So Cotty Quina patients have sexual dysfunction and I bet you.

Yeah.

The Tarlov cyst patients had sexual dysfunction before urinary dysfunction. And then there's a really prominent Tarlov cyst surgeon in Texas. He reported on his group of patients. and by the way, a bunch of them had sexual dysfunction that got better. So when you go back and look at it, it is not a mystery that there's the neurologic cause. One of the causes of sexual dysfunction is going to be neurologic. Why it took this much effort.

Mm-hmm.

Yeah.

mystery. We just didn't communicate.

Yeah.

convince somebody like me. And by the way, I've not been able to convince my colleagues yet. I'm slowly chipping away at the stone.

I was going to ask you, didn't you present at one of your conferences? How did that go?

Yes, so I presented at a Japanese Spine Association Conference. They specifically asked me to give that talk and I have no idea how it went over because it was... But I just submitted an abstract to ORS. It's like a really academic society called Orthopedic Research Society. These are like hardcore scientists on the TAR-LAF-SYS report. But before that, I have a lot of colleagues.

Okay.

Yeah, yeah.

And I mentioned that to them. I also have posts and none of my colleagues will even acknowledge it. When I bring it up, they immediately divert the topic to something else. It's really clear. They are not ready to hear this, but I'm just slowly chipping away at the stone because we've been at this for eight years now. This is real. So now I'm like starting to submit or writing up another paper, and another two more papers and submitting it to journals. So hopefully.

Yeah. Yeah.

my god. That's sad. Uh-uh, they're not ready. Yeah.

Yeah, this is so good.

we will slowly start getting a few other spine surgeons to accept this, to start looking at this so that, you know, lot of my patients on the East coast, they really have a hard time because they have to schlep all the way over to San Diego for me to do their surgery because they cannot find a surgeon that's willing to do it. You can't even find a surgeon that's willing to like see them and talk to them about this. I was like that, I get it.

Yes.

Totally.

Yeah.

Right, entertain it, yeah, exactly. Yeah, no, it's true. I think, you know, because my husband is an interventional pain doctor, like I've convinced him enough, but I think that like when he tries to convince the orthopods and the neurosurgeons he works with, it's always like, he's like, I don't know, I can't do anything. He's like, tell him that your wife is Your wife is crazy.

It's like everything at first they ignore you, then they fight you like it's offensive and then they act like everyone. It's always been like that. What are those three or four phases like?

Yeah.

Yeah.

But I guess if you publish it enough, then eventually people will start believing that this exists. This is it. Yeah.

It, this is, this is real. It's going to happen. We just have to, it's just going to take time to convince people. I went through something and I'm going through something really similar because before this, I was at the forefront of a male invasive surgery called endoscopic disc endoscopic spine surgery. Same thing. People think I'm crazy. What do you think we do in the knee and the shoulder and the abdomen? We don't do open surgery anymore. So for us to think like.

Yeah.

Yeah. Right.

That's not going happen in the spine. It's like, hello, that's not reasonable. It's going to happen. So it's just, took me 20 years to convince people, but now there's like this little army of young spine surgeons that, that are so into endoscopic surgery. They treat me like Obi-Wan Kenobi. And I bet you in another 20 years, there's going to be a small cadre of, you know, spine sexual medicine experts that will be looking at me like,

Hello. Get with it. Right. Yeah, absolutely.

Mm-hmm.

I love it.

I remember when you told us about this 20 years ago and I thought you were crazy, but it's going to happen.

Yeah, yeah, yeah. it's just sad because the PGAID patients and the pelvic, the Cisticia patients are the ones that really like, know, because it's hard enough for that. Like I have patients that will like literally cry that there's even a word to describe what they've been experiencing their whole life, right? Like this is such, know, just, wow, this actually is something that's not something that is in my head because women are told so long that everything is in their head, you know? And it's just like,

you know, if you're continuously being told this and you're actually believing it after a while. And then of course the brain does get involved, you know, there's like that fifth aspect where it gets involved and it gets centralized and all this stuff.

If I had, if I had PGAD, I would go crazy and my life would be literally upside down right now. I probably wouldn't be able to be the person that I am now. Not even close. I thought about it. could, if I was that like, you know, sciatica, I mean, I could do a lot with a typical spine problem, but PGAD or something similar to that, it would be.

Go crazy for sure.

Right. I like, you know,

Yeah, you can continue with it. Yeah.

Yeah.

exceedingly disruptive and it would have a huge effect on my quality of life. I had to think about it for a while and now I can, know, my heart goes, and I think everyone at Ishwish have come to the same conclusion and that's why everyone at Ishwish is so motivated because they realize what a huge deal this is.

Totally.

Absolutely.

Mm-hmm.

Yeah. Yeah.

Yeah.

Huge, I remember talking to April and just how it was such a transformative experience. And it happens to a lot of former athletes, right? Because she was like a former soccer player and like all these people who like gymnast, all these people who have all these athletic histories and no one actually looks in that. remember, and I told April, I like, remember when you came to the conference and you were presented as one of the patients.

And she actually came to one of the conferences to tell her story as a patient and her husband was there. Your first one, right? Yeah. And just to see how, I mean, now she's like a warrior. She's doing all the pelvic floor stuff for all these people. I send her so many pelvic floor.

I remember that. That was probably one of my very first conferences too.

She helps so many of our mutual patients. It's crazy. Because the pelvis is complicated. It's not like your foot or your ankle. mean, that's like checkers. The stuff that goes inside your pelvis, it's like chest. Yeah, there's a lot of things are autonomic. Whereas your foot, it's mostly somatic. I can tell it to go up and down. I can't tell my bladder to contract.

Yeah, but it's

Yes. I mean, it's like everything. Yeah. Yeah.

Yeah, no.

kind of knows on its own. mean, I think I have control over my sphincter, but besides that, everything else is kind of automatic. And so you can imagine how complicated things are in there and how hard it is to treat those conditions. And by the way, at least most of the patients that I take care of, by the time they get to me, they're like the most unfortunate group of patients that have not just one thing. It's not just the spine.

It's on autopilot. Yeah.

Yeah. Right.

They usually have something else. They almost all have pelvic floor dysfunction because I think you just get pelvic floor dysfunction after a while. Sort of like I probably have some kind of problem with my leg muscles if my ankle is constantly bothersome. And they may have a little bit of hormonal problems. They may have a little bit of like local problems. So it's multifactorial. then, yeah, and then they get very anxious that and anybody that doesn't think

Yeah.

Then they have anxiety on top of that. Right. And then they develop anxiety.

The mind has an effect on your physiology. They haven't thought about it enough. And then two, your mind on your sexual function. I can have one random thought and it'll affect me in a big way. So it's all, it's, it is both fascinating and challenging at the same time, because it's so complicated.

Yeah, go back. Right.

Yeah.

Yeah,

Yeah.

Do you see, do you, because I mean, I only treat women, but I know, you know, Erwin treats both sexes obviously. Do you see a lot of men with this as well?

Yes, but PGAD sense seems to be more common in women. It's definitely true. And then men have like, yeah, they have a few other weird neurologic disorders that we're not really sure how to best treat them yet. But one of them is these really painful nighttime erections that we can't figure out. And then something called heart flaccid syndrome. And then there are a group of patients with, it's not erectile dysfunction exactly. It's

Yeah. Yeah.

the hard flaccid and.

Mm.

like orgasmic dysfunction where it's a little bit of both. So they have a little bit of erectile dysfunction, which is not the same thing as orgasmic dysfunction, but they have a little bit of both. So we're struggling through those patients. I would say that our greatest successes have been in our women patients. And they seem to be the most distressed anyways, so it works out well, but we have so much work to do in this field. It's crazy.

Right. Right.

Right. Yeah.

Absolutely. Do you want to talk a little bit about how the annular tears came into the equation? mean, in terms of like what it is, how it might present and how you went about treating that.

The annular tears are by the way, the most common cause of PGD in my group of patients. So I've probably done well over a hundred, probably 150 surgeries on the disc and 20 or 25 surgeries on Tarloff cysts. So the majority of the problems that we find are in the discs. So an annular tear is probably the first thing that happens to a disc as it starts to wear out and degenerate.

Yeah.

Right.

before you have a Frank disc herniation. So the disc has two parts. It has the central core called the nucleus, it's gelatinous and it's in some ways kind of like the shock absorber. It's surrounded by a thick ring of crisscrossing collagen fibers called the annulus. And that kind of holds everything in, but it's really thick. And it also has weight bearing support too. It rings it sort of like seal belted radial tire. But over time with cyclic loading and gravity and bad luck and genetic predisposition,

can start developing fissures and cracks and the nucleus can start like migrating in and getting trapped inside those fissures. And if any of that either leaks out a little crack to the outside world, or it stretches the outer part of the annulus because it's, you know, with the fissures, it gets weak because it gets pressurized. It activates these nerve sensors on the outside and tells the body something's wrong and initiates a healing response. And when you develop an annular tear, you probably have that

Right.

Yes.

I think I overdid it. I have a really stiff back and it lasts for like two weeks and then it gets better.

When the annular tear heals, you're better, but if you get an MRI a month or two later, guess what? It looks exactly the same. It looks like, wow, that looks really bad, but it's asymptomatic. So most annular tears we see on MRI imaging are asymptomatic because most patients have gone through the healing process. But there's a small proportion of patients where that annular tear did not go through the normal healing process and the inflammatory process never turned off. It just stayed turned on.

Yeah. Yeah.

And that's what a symptomatic anulary tear is. The majority of those patients, by the way, have back pain going down their leg. That's my normal practice. Patients with back pain going down their leg. By the way, even to this day, I don't routinely ask them about their sexual function. Because it's still awkward. Even for me.

goes on. Yeah.

Yeah.

So for me to ask my colleagues to start asking their patients about such dysfunction, that's just not going to happen. And then the patients don't feel comfortable asking about it. I had to administer a written survey and go, here you go, just fill it out. I'm going to leave now. And I'm not going to even ask about it. Just don't even write your name. Just put your initials and your date in case I have any questions, but I'm not going even try to, that's how I had to do this survey to confirm that people didn't.

and it just...

Bye.

Right.

So that's interesting.

get defensive and go, I don't have any sex. I wanted to really think about it. didn't, I didn't, and I didn't just ask them to be habit or not habit. It was like a little questionnaire with threshold. Anyway,

Right. Exactly. Yeah.

Yeah.

Finding that group of patients that have a symptomatic aneurysm from an asymptomatic one is no different than trying to figure out a symptomatic Tarlov cyst from an asymptomatic Tarlov cyst. In fact, it's even easier because we can do an injection. I'm sure everyone knows the spine sits like this, right? This is a front view. If you look at the side, those are the discs right here, right? There's a natural opening called the neuroframing. So the central canal is right here.

Yep. Yep.

that goes all like straight up and down. And then at each level, a nerve root comes out and goes to different parts of your body, right? So in your pelvis, it's like a little bit of S1, a little bit of S2, a lot of S3, some of S4, right? But they all go down and then they exit at each places. Now, if you have an annular tear there and it's like a little inflammatory storm, then two things happen. One, the nerve gets stuck down and just, if you put a piece of tape on your neck,

Yes.

Mm-hmm.

By the end of the day, the skin underneath that tape will be so irritated because it just gets pulled on. So the nerve gets irritated just from being sucked down to the inflammation. And then the inflammation just has like, it turns things on just like how plantar fasciitis hurts. And so any nerve going by any of these discs can be irritated. And if it just happens to be the S2 and S3 nerves, guess what? Your experience will be in your pelvis. If it's irritating the S1 nerve root or the L5 nerve root, it'll be in your leg. That's the sciatic.

Mm-hmm.

Yes.

No.

Right. Right.

it's S2 or S3, it's in your upper thigh. And so turns out a lot of our patients, they don't have both back pain, leg pain, and pelvic problems. Majority of the patients have one or the other and not both, just because of serendipity. And so the injection can be done right at that level to bathe the annulus and bathe the annular tear. And if the patient gets better, then I have the most

Right. Yes.

Right. That's interesting.

Right. Yep. And they get temporary relief.

awesome most middle invasive surgery, the laser endoscopic surgery, which is even way less invasive than a Tarlath cyst surgery. So that's been the best part of this whole process that I've been able to use the most middle invasive surgery that I have to identify a really common group of patients that historically people didn't know how to treat.

That's wonderful. I mean, I this is like the best story ever. this in terms of, mean, I have to tell a side story. When I was after my pregnancy, my second child, I started doing CrossFit. So do you see a lot of CrossFitters? My husband's like, CrossFitters keep me in business. But like the reality, yeah, you you do one bad deadlift and that's it, right? Like that's how I herniated my L5S1. And I had all these crazy symptoms, which were awful. And, but.

But you know, I think the reality is like your disc doesn't always just go back to normal either, right? Like that's just so.

No, once you injure a desk, it's forever injured.

It's a forever injury. So like if I have a five pound weight gain, that's it. Like I'm feeling all the pain. And so I think that's something to remember too is like, take care of your back because you know, once you start doing some of that stuff, it's never going to get never going to be the same.

That is so true. And unfortunately, it's, it's something that is readily doable, but it's at the same time, the most difficult thing to do. You know what that is? Getting really healthy and fit and exercising on a regular and consistent basis. It is so obvious that that's all you have to do, but it is impossible to get people to do it. And I'm one of them. I've been having such back problems for six months.

What's that?

yeah, but doing the right exercise.

Yeah.

Yeah, yeah, no, it's hard. It's hard to keep it going.

Yeah.

And I keep telling myself, I gotta get back to my exercise program and I just keep on making excuses.

That's what it is. Yes, because it is. It's just that one bad movement. I mean, I can still remember that deadlift. I don't do deadlifts anymore, but I still remember like trying to. And yeah, I just feel like, you we have to be cognizant of our movements because, you know, that's why I went.

I like to think of CrossFit not as exercise, but as a sport. Cause it's like a sport. You can get injured if you're healthy, it's a great sport, but it's not a great sport to be fit. You need to do other stuff so that you don't get injured during CrossFit. So that's how I tell people. I say, that's not a good exercise regimen. That's a sport.

Yeah,

Yeah. Just to start off with.

So true. Yeah. Yeah. Yeah, it's actually true because I tried to do it postpartum like, you know, it's like six, 12 weeks postpartum. It's like, no, that was I don't ever recommend start with Pilates. Yeah. Right. Totally. Yeah. Yeah, because one bad swing and it's like.

If you're, if you're not injured, it's like the best way to get really, really fit and be a warrior, but it is a high risk sport. It's kind of like golf.

Yeah, one bad luck swing or you hit the ground too hard or something or is that what bad day? Weird stance.

Yeah. Yes, absolutely. So, so tell us what advice do you have to, number one, clinicians that are listening here to say like, you know, in terms of evaluating, like what are some basic techniques of evaluating the spine that you would tell someone like me, a gynecologist who learned from my husband, like, but just so we know, because again, this is how we know like the back might be involved.

awkward.

You know what I would say? It's really simple. Probably the simplest thing is to have a lower threshold on getting a lumbar spine MRI. Because in the lumbar spine MRI, you can get most of the sacrum. And it's not like the olden days where these MRIs cost thousands of dollars. They're really inexpensive. It's really get authorized. if you go through the whole process of trying to assess somebody for their pelvic problem, and you kind of are at the end of the road of thinking of

Mm-hmm.

Yes.

No, yeah. Yeah.

anything else, I just get an MRI. And by looking at the MRI, if there's any abnormalities, then it may be an avenue for treatment because there's no physical exam finding, no consolation of symptoms that would be pathognomonic or even suggestive of the diagnosis. It almost always comes down to like an index of suspicion and having ruled out all other more obvious potential causes. And you're kind of at the end of the road.

You can tell.

Mm-hmm.

Yeah.

Now, if you're like 30 or younger, the likelihood that the MRI will be abnormal is lot lower, but anybody that's 30 or older, they're gonna have abnormalities in the MRI that's worthwhile looking.

Sure, that makes sense. so what I can say is for some patients who, you know, they're trying to use their insurance to get their lumbar, you know, sacral MRI, like just if you use like any other sexual dysfunction code, it's not gonna get covered. Yeah. Yes.

Yeah, I can see how that is because you know, it's a whole nother huge topic of discussion on how we take care of patients. It's almost like our parents are the insurance companies. It's like we can't do anything without asking our parents first. Like any decision we make, it's like, is it going to be okay with the parents? It's really distressing actually. It's really distressing. So you have to talk in parent language. The parent languages, they have to have some kind of dysesthesia.

Yeah. Breath.

That's so true! That's so true! And then you have to pay, you need to pay someone to get money from...

I like it about yes

So I would say pelvic dyssusthesias. Because by that point, you're probably thinking like, this seems neurological because it's not hormonal, it's not local, it's not purely psychological. So try pelvic dyssusthesias.

Yep. Yes.

Right, exactly. Yeah, and sometimes you can, I mean, because pelvic dysesthesia is our form of lumbar radiculopathy, you we think at least, right? So you just have to say that. I say lumbar radiculopathy.

Yeah, absolutely. And then if a patient has back pain, which a lot of people just do, that's reasonable too.

Yeah. Right. So I think that's something important to say.

I think that's probably the easiest thing that that makes things easier. Having to focus on symptomatology and things like that.

Make it difficult, yeah. Yes.

It's a lot more complicated. And it turns out, at least now, we don't have a good answer for that.

Yeah, that's true. And then one piece of advice for the listeners, like if you if you're a patient that's struggling for this, how do you go about getting someone to listen to your I would ask this to all my all the people I interview, like how would you go about getting telling a patient how to advocate for themselves when they're with someone that's not going to believe them? I know it's different for you because

Well, we are so lucky to live right now and having discussion right now. And the fact that we're not in the same room right now having this awesome discussion is probably the single best thing. Use the internet to identify people that are experts in the field and seek them out. And it's worthwhile.

Yeah.

getting an initial evaluation by somebody that knows about this. In the olden days, it would be hit or miss because we didn't have a way to like research. But now you just go on to Google and you type in a bunch of stuff. You can set up a Zoom appointment. I do like over half my patients appointments are by Zoom and people like from all over the place. And even though they don't have surgery with me, at least they can get a lay of the land. And we do a lot of things locally, like all the injections tend to be by the local pain doctors.

Right. Yeah. Yeah.

Right. Yeah.

Absolutely.

And through this mechanism, we could do two things. utilize technology to get the word out and increase awareness. But like on a grassroots basis, the local doctors are going to find out about it because they have a patient in front of them asking them like, there's a Dr. Chol Kim in San Diego that wants me to do this injection for this problem. Here's a letter. And if you're bored, go on the internet and check out his YouTube channel. That doctor will probably...

Yeah. Yeah.

Yeah.

Yeah.

be much more likely to be convinced than a doctor sitting at some conference is my guess. And I've had many doctors reach out to me and go, Dr. Kim, this is fascinating. And so little by little, I have like little pockets of colleagues, pain doctors and primary care doctors that like I save their information because if a patient comes from their region, I send them to them. So it's slowly growing. So I encourage patients to

Right.

Yeah.

Yeah. Yeah.

Yeah, yeah, we're chipping away. Yes.

Not give up, utilize the internet and connect with people like you and demand better because it's out there. And it just takes a long time for medicine to catch up. It's not necessarily a bad thing. We don't want medicine to be this fly by night. try every crazy little idea and everyone jumps on board only to find out that it was a bad idea. We want things to be slow and cumbersome in some things like government and medicine.

It does. Yeah.

Yeah.

Thank

Yeah. Right.

so it's not necessarily a bad thing, but at same time, is a little distressing, but luckily the internet helps that a lot because it kind of makes the world way smaller.

Yeah. It's frustrating.

Absolutely. Brings the world together. Absolutely. All right, awesome. Well, thank you, Dr. Chol Kim, for being on my podcast today. I'm so excited for everyone to listen to this. Thank you guys for listening. My name is Dr. Samina Rahman, Gyno Girl. I'm here for my podcast, Gyno Girl Presents Sex, Drugs, and Hormones. Remember, I'm here to educate so you could advocate for yourself. Please join me next week for my next episode. Yay.