By Fiona McMahon and Amy Stein
Imagine if you will, Sheila. Sheila is an active 30-something who has just come into her own. She is moving up the ranks at work, she is in a stable and loving relationship, and is even thinking about having kids one day. Imagine Sheila begins developing pain in and around her vagina that makes it painful for her to have sex with her partner, sit for long periods of time, or even wear tight pants. Sheila begins missing work because she can’t bear to sit for eight hours a day, she stops working out, and her relationship with her partner has become increasingly strained. Sheila feels increasing shame that she is not the sexual person she once was and is hesitant to bring her pain up to her doctor because she fears there is nothing he can do, or even worse, he might think her pain was all in her head.
Now imagine Sheila’s pain isn’t in her vagina, but rather it is in her back. You could imagine that the version of Sheila, with the back pain ends up faring much better than the version of Sheila with the vaginal pain. Sheila with the back pain isn’t embarrassed to bring her pain up to her doctor. She may even talk to her friends about their back pain and treatments and practitioners that have helped them. Sheila is given all the tools, resources, and support of the healthcare community and her friends to help treat her back pain and return to the person she was before. The version of Sheila with the vaginal pain remains unsure of where to start. She is embarrassed and feels alone in her journey. She has bounced back and forth to doctors, urologists, gynecologists and even psychologists but has found no cause or relief in her pain.
We at Beyond Basics see it as one of our key missions to open a dialogue about the millions of women (and men!) who suffer with pelvic pain and provide them with treatment options to help them return to their former selves. We recognize for many women and men, pelvic pain is a profoundly sensitive subject that can be difficult to talk about. We also recognize that the consequences of letting pelvic pain go unchecked can deeply affect an individual’s, and their family, friends and colleagues’ quality of life.
Let’s start our conversation with the type of pain Sheila was experiencing. Someone like Sheila might start her journey thinking she has a urinary tract infection or a sexually transmitted disease, but when the results of her medical tests come back negative, she and her healthcare practitioner may not be aware that her pain could be caused by musculoskeletal dysfunction, which can be treated by a trained pelvic floor physical therapist.
Patients who lack a clear cause of their pelvic pain may have muscle spasm or nerve irritation, in their pelvic floor muscles, weakness, or bony misalignments. We refer to these problems in the pelvic floor as pelvic floor muscle dysfunction (PFMD). PFMD can occur from a variety of different causes, a fall while skiing, stress, chronic illness, or previous acute infection.
PFMD can occur in men, women and children, of whom may experience pelvic, abdominal, hip, back and/or lower extremity pain. In addition, men may experience pain in their testicles, groin, tip of the penis, or perineum. Women, like Sheila, may experience vaginal pain with penetration (superficial or deep), burning in the vulvar area, or pain in their clitoris. PFMD can significantly impair one’s ability to enjoy sex, causing painful penetration in women, and post ejaculatory pain, premature ejaculation, difficulty reaching climax, and erectile dysfunction in men. Patients with PFMD may also experience urinary and gastrointestinal issues and/or incontinence.
A pelvic floor physical therapist can diagnose PFMD by performing a specialized pelvic exam, where the therapist will test the strength of the pelvic floor muscles, their ability to relax, and whether or not the pelvic floor muscles are in spasm or are shortened. A pelvic floor physical therapist will also examine the skeletal alignment, the strength and range of motion of the hip and core muscles, and the muscles and fascia of the abdomen, back, lower extremities and perineum to assess for other possible biomechanical contributors to the patient’s pain and symptoms.
Based on what the physical therapist finds, he or she will develop a specialized course of treatment for the patient. Sometimes scarring is the culprit in PFD. Conditions like endometriosis, episiotomies, and abdominal and pelvic surgeries can all cause scarring. Scarring can lead to tissue adhesions, which don’t allow the tissues of the abdomen, trunk and pelvic area to move freely. Tissues that can’t move freely, whether from shortened muscles or from scarring, can impair motor control, visceral function (i.e. intestines) and contribute to pain. Tissue restrictions and shortening can be effectively treated in physical therapy by using manual techniques to mobilize the restrictions both internally and externally. In addition, the pelvic floor physical therapist will correct bony misalignments that may be found upon exam.
Weakness is a common contributor in PFMD. Weakness can cause the organs of the pelvic cavity to drop lower in the pelvis due to a lack of muscular and connective tissue support. The dropping of these organs can cause discomfort that worsens over the course of the day. A patient with weak pelvic floor muscles can be guided through an exercise program to strengthen his or her pelvic floor.
Pelvic floor physical therapists may also use different tools besides their manual skills to address PFMD. Some women experience pain during penetration because the skin and muscles of their vagina and/or perineum are too tight. In this case, a physical therapist may use vaginal dilators to gently stretch these tissues allowing the patient to comfortably be able to accommodate her partner’s penis or a sex toy during penetration.
Biofeedback is a tool that can help improve a patient’s awareness of his or her pelvic floor muscles. Biofeedback is used to show the muscle activity of a patient’s pelvic floor as a display on a computer, allowing the patient to see the action of his or her pelvic floor in real time. For a patient who is experiencing pain, a physical therapist can use biofeedback to teach a patient how to properly relax his or her pelvic floor muscles allowing for better pelvic floor function.
Having pain is hard. Having pelvic pain is arguably even harder. We as a society attach so much shame to this area of our body that sometimes we end up closing ourselves off from possible treatments when something goes wrong with our pelvic floor. We at Beyond Basics hope you have found this article helpful and encourage you to seek help from a pelvic floor physical therapist if Sheila’s problems seemed at all similar to your own. We hope this post has helped you to reconsider pelvic pain and the options that exist to help you return to your old self.