A few weeks ago, I connected with Noa Fleischaker, the founder of Tight Lipped. This organization started as a podcast in 2019, and has grown to reach over 3000 people from 58 countries around the world. Tight Lipped is all about supporting people who have been struggling with vulvovaginal pain conditions– problems like vulvodynia, vestibulodynia, pelvic pain, painful sex, and more. They share stories to build community, normalize often very private problems, and advocate for better care. They recently published their first Zine, “Opening Up,” and it is a beautiful compilation of art and stories from people who have dealt with vulvovaginal pain conditions. I received my copy last week, and it is in our waiting room as I type this!
I hope you enjoy this interview and connect with Noa’s message! If you would like to support the work of Tight Lipped, please visit their website! They also have events, meet-ups (with one coming up this week!!), workshops, and book clubs! So check it out and connect with this amazing group!
You all know by now that I’m fairly nerdy. I love reading research articles, trying to understand complex topics, and everything about learning. Honestly, I think that is why I love pelvic health so much! The pelvis is so complicated! There’s so much to know, and the more I learn, the more I truly realize how much more there is to know! As an anatomy nerd, you know I have favorite muscles. I’ve written about the respiratory diaphragm, who is one of my most favorites, but I haven’t spent much time introducing you to my other love~ the obturator internus!
Meet the Obturator Internus
The Obturator Internus (Or OI, as they are known by friends) is a muscle that lives inside your pelvis in the obturator foramen and attaches to the hip via the greater trochanter. You can see it here:
The OI has several major functions for the body. First, it is a deep hip external rotator, and has shown to be active during the movements of hip extension, external rotation and abduction. In fact, this research showed that it was the first muscle to turn on in these motions (which I theorize could be part of it’s connection to the pelvic floor muscles and the anticipatory role the pelvic floor has in movement, pressure management and postural stability). My theory on this makes sense when we look at some of the research on the involvement of the OI in hip stability. This excellent article identifies the obturator internus & externus, quadratus femoris, and gemelli as important synergistic muscles that work together to modulate the position of the femoral head in the acetabulum during movement. This is particularly cool because in many ways, this function is very similar to the pelvic floor muscles! The authors suggest a dynamic stabilizing role for these muscles, making subtle alterations in force to control the femoral head position.
This study also recognizes the stabilizing role the OI can play, particularly when it works as a team with the other deep hip rotators. The authors here highlight that the obturator internus, obturator externus, superior & inferior gemelli (who I affectionately call the gemelli brothers) are essentially fused. And this fusion, actually leads to a decent cross-sectional area and ability for force generation. The orientation of the fibers adds further credence to the view that these muscles are crucial to hip stability.
The OI shares fascial connections and attachments with the pelvic floor muscles, which makes it an even more unique muscle. The iliococcygeus attaches to the arcus tendoneus linea alba, a fascial line that is also an attachment of the obturator internus. Additionally, the pubococcygeus and OI are fascially connected around the pubic bone, and the fascia around the bladder and urethra also is connected to the OI. What does this mean? It means that the OI can be impacted by what happens at the pelvic floor and can impact what happens at the pelvic floor. And research tends to show this. This study showed that the vast majority of people with pelvic girdle pain have obturator internus tenderness. This study found that most people with chronic pelvic pain have obturator internus tenderness with palpation. And here’s another study that found that 45% of people with pelvic pain had tenderness at the obturator internus. Another study found that in people with lumbopelvic pain, experiencing urinary urgency, and central sensitization made them 2x more likely to have concurrent pelvic floor and OI involvement.
Finding the Obturator Internus
One of the cool things about the OI is that it is a muscle that can be palpated both internally via the vagina or rectum, and also externally. The OI is palpated internally with an examining finger angling out toward the hip. You can see the palpation here on my lovely pelvic model.
The OI can also be palpated by examining medial to the ischial tuberosity, then angling in toward the obturator foramen. You can see where palpation would be happening here.
Treating the Obturator Internus
If you think your Obturator Internus is involved in the pain or pelvic floor problems you’re experiencing, the first step is to have it examined. Your PT can palpate these muscles as described above. The muscles should be soft and move well, so they should not be sensitive or painful to touch. If they are, they could potentially be involved in the pelvic problems you are experiencing.
From a treatment standpoint, we can address the OI by first improving the mobility via gentle manual therapy, and then improving the overall hip stability (retraining the anticipatory function through the relationship between the pelvic floor & OI). It usually isn’t the “sole” problem happening. But including it within your treatment can be key to helping you get better!
May is Pelvic Pain Awareness Month, so I thought it was only fitting to write something about pelvic pain before the month is over. Pelvic pain impacts so many people, in fact, the International Pelvic Pain Society estimates that over 25 million women suffer from chronic pelvic pain. While the number is generally lower in men, some studies estimate that around 1 in 10 men experience chronic pelvic pain (often termed chronic prostatitis).
Next week, my clinic is officially re-opening our doors for in-person sessions, after operating completely virtually for the past 2.5 months! During this time, I tried to stay as connected to our patients as I could, and sent out a newsletter each week full of pelvic health tidbits. One of the new things I created was a daily movement sequence for pelvic pain, and I wanted to share it with all of you here!
Before we get started, you should know a few things about pelvic pain. First, each person with pelvic pain is a unique entity. So, while this sequence can feel lovely for many people with pelvic pain, some may not be quite ready for it. For others, they may find that doing it actually increases their pain (clearly, not our goal). For rehabilitation for a person with pelvic pain, it is very important that exercises, movements and activities are done at a threshold that does not increase or aggravate pain or discomfort. This is, as we have spoken about very often, because we want to create positive movement neurotags for the brain. Basically, we don’t want your brain to think that movement is bad or dangerous (because as we all know, it should not be bad or dangerous!). If we do movements that increase our discomfort and make us feel worse, the brain can build a connection between moving that way and bad/pain feelings. Instead, we like to move at a threshold where the body does not guard or protect by pain. So, why am I telling you this? Because, if you start doing these movements and your symptoms worsen, or it doesn’t feel therapeutic to you, you need to stop doing it and see a pelvic floor therapist who can evaluate you comprehensively and help you develop a specific movement plan that IS therapeutic to YOU. And lastly, remember that anything on this blog is not in any way a replacement of in-person care. You need to consult with your interdisciplinary team (your physician, PT, etc!) to determine the best approach for your health! (And if you’re not sure, schedule a virtual consult with a member of my team to help figure out where to go next!)
Daily Movement Sequence for Pelvic Pain
So, let’s break down this sequence.
If I could give any person with pelvic floor problems a single exercise to do, it would be this. The breath is SO powerful, and sync’d with the pelvic floor. For diaphragmatic breathing, you want your breath to move into your belly, expand your ribcage in all directions, then lift your chest. A misconception of diaphragmatic breathing is that the chest should not move at all, and this is FALSE. The chest should lift–but–so should the ribcage and the abdomen. You can do this in sitting or lying down. As you inhale, aim to lengthen and relax your pelvic floor muscles, then exhale, allowing your muscles to return to baseline. Start your sequence with 2-5 minutes of this breathing. (and toss in some focused relaxation of each part of your body while you’re doing it!)
Happy Baby or “the Frog”
This one is a key movement for anyone with pelvic pain! To perform this, lie on your back and bring your knees up to your chest. Reach your arms through your legs to grab your lower shins, support your legs using your arms, and allow your knees to drop open. You can alternatively hold your legs at your thighs, depending on your comfort and your hip mobility. From here, aim to let go of muscle tension. Then, take slow breaths, directing your breath to lengthen and open your pelvic floor muscles. This is a great position for relaxation and lengthening of the pelvic floor!
This is a nice movement to warm up your spine and practice using small amounts of tension to perform a graded movement (you know I love my slow movements!) For this exercise, you will lie on your back with your knees bent. Then inhale in to prepare, exhale and slowly begin to roll up off the mat, lifting your tailbone, then sacrum, then low back, then mid back, then shoulder area. At the end of your exhale, slowly inhale, reversing the movement. You can repeat this 5-15 times, and do 1-3 sets. (Vary this based on what feels healthy and helpful to you!). Sometimes people get back pain when they do this (usually their back muscles are trying to do the job of the glutes). So, if this happens, try to bring your feet closer to your buttocks, and press through your feet while you are lifting. If it still happens, stop the exercise, and talk to your physical therapist.
Reach and Roll
I love this exercise for improving mobility of the upper back (thoracic spine). For this exercise, lie on your side with your knees and hips bent to 90 degrees, arms stacked in front of you at shoulder level. Inhale, reaching your top arm forward, exhale, and slowly roll your hand across your chest, opening to the opposite side. Keep your hips stacked so you don’t rotate through your low back. Pause here and inhale in, letting your ribcage expand, then exhale letting the hand glide across your chest to meet the opposite hand again. Repeat this movement 5-10 times on each side (You can do a few sets if you would like!)
So, this is another one of my top exercises. I love the cat-cow as it promotes segmental mobility of the lumbar and thoracic spine into flexion and extension. It is another great movement to encourage minimal tension, and coordination of breath, so it’s a big favorite for people with pelvic pain. To do this, get into a quadruped position (hands and knees, with hands aligned under shoulder and knees aligned under hips) Inhale, allowing your tailbone to come up and your back to dip down, head looking up. Exhale, dropping your head down, rolling your back up and tucking your tailbone. Perform this movements slowly, using small amounts of tension. Repeat this 10-15 times, 2 sets. You can alternate each set with child’s pose, listed below.
Child’s Pose (Wide-Kneed)
Child’s pose is a beautiful exercise that also encourages opening and lengthening of the pelvic floor muscles. It is nicely performed between sets of Cat-Cow. I like to modify this slightly by bringing the knees into a wide position to further encourage relaxation of the pelvic floor muscles. To perform this, begin in the quadruped (hands/knees) position as above. Open the knees into a wider position, keeping your feet together. Drop your pelvis back toward your feet, reaching your arms forward and relaxing down toward the mat. You can use a pillow (or 2 pillows!) to support your trunk and decrease how deep your child’s pose goes. Hold this position (and make sure you are totally comfortable!) for 60-90 seconds, breathing in long, slow breaths, encouraging lengthening and opening of your pelvic floor. Repeat this 2 times, preferably, interspersed with the Cat-Cow exercise.
And there you have it. My daily sequence for people with pelvic pain to get some movement in!
There are so many other great exercises for people with pelvic pain! Do you have any favorites I didn’t include in this sequence? Any movement challenges you want help solving? Let me know!
If you would have told me two weeks ago that I would have closed the doors to my clinic, Southern Pelvic Health, a week later, and shifted my practice to a virtual one, I would not have believed you. Maybe I was naive (yes, I probably was), but this change came quick to me. It almost happened overnight. And, here we are. I am moving into my second week of working with my patients online. While for many, that seems incredibly scary, I actually think that shifting to an online platform for a while is going to do a lot of good.
Last week, I worked with a few other colleagues to host a webinar on bringing pelvic health online– basically, how do pelvic floor PTs treat most effectively without actually touching their patients? It was a quick production–one built out of necessity–and it sold out in 24 hours because rehab professionals everywhere are trying to figure out how we can still be there for our patients and help them get better during this time. (For my colleagues out there, if you missed it, it’s still available as an on-demand purchase!) I brought together 5 experts from various corners of the country and the world, and we spoke for nearly 2 hours about how we assess the pelvic floor, evaluate patients, and actually help patients get better in a virtual setting. It was full of creative ideas, and also challenged some of the current practice patterns. As you know, I work hard to always question my own practice–learn more–do better– and I’m excited to see what this next period of time does for me as I learn to better and more effectively treat my patients, to be creative with self-care treatments and home strategies, and to use movement to help patients move when my hands are unable to. I will share what I learn with you here, of course.
Pelvic PTs are not the only professionals taking their skills online! Last week, my daughter and I joined a “Frozen Sing-A-long” through a local princess parties company. I have been thrilled to see some incredible resources for people with pelvic floor dysfunction hop online, and I am excited to share some of those with you today!
So, what can you join virtually this week?
Yoga for Pelvic Health
My dear friend and colleague, Patty Schmidt with PLS Yoga, is incredible and specializes in therapeutic yoga for pelvic floor dysfunction. She is bringing several awesome classes online! AND, they are cheap– $15 per class (which honestly, is a HUGE value for the expertise she brings!) So, I do hope you’ll join in:
Gentle Yoga (Via Vista Yoga)– this really could be great for anyone with persistent pain, I think!: Tuesday, March 24th at 12p.m., Thursday, March 26th at 10 a.m.
Patty also is teaching private sessions virtually at $30 for a 30-minute session. This is a steal, believe me!
I also need to share with you all of the FREE yoga resources through another friend and colleague, Shelly Prosko. Shelly has this incredible library of Yoga options for pelvic health, all available right here.
I hope you are able to partake of these awesome resources. Remember, we are in this together my friends! I’ll leave you with a quote from a much-loved movie in my house, Frozen II, “When one can see no future, all one can do is the next right thing.” Let’s all try to do the next right thing amidst this craziness!
I am super excited! I am hosting Dr. Andrew Goldstein at my NEW CLINIC for a one-day intensive course on Vulvar Dermatology on Saturday, November 2nd!!! This course is open to PTs, MDs, PAs, and NPs, and should be absolutely epic!!
Dr. Goldstein is known internationally as a leader in the treatment of vulvar pain disorders, and is very well-published on the topic. It should be an incredible day of learning, and I can’t wait to show you all my new space!!
I hope you will join me for this important class! Pelvic PTs and other HCPs- let’s always keep learning!
Last summer, Sara Sauder asked me to collaborate with her and Amy Stein on a submission to Sexual Medicine Reviews, highlighting the role physical therapy can play in helping men and women with sexual dysfunction. I was thrilled to have the opportunity to collaborate with Amy and Sara, and for the next year or so, we worked together to create “The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment.”
In this article, Amy, Sara and I discuss the role the pelvic floor muscles play in sexual health and common dysfunctions that can occur. We also discuss the process of physical therapy evaluation and treatment for sexual dysfunction, as well as the evidence regarding the efficacy of such treatments. Submitting to a peer-reviewed journal was humbling and exciting, and honestly, gave me much more respect for the process. I have been wanting to get involved with research for some time now, and I hope that this will be a springboard to more involvement and more writing.
The journal gives authors access to full-text of the article for the next 45 days, and I am excited to have the opportunity to share it with all of you!! Please let me know what you think of the article, and enjoy!
Last week, one of my favorite things to happen in the clinic happened again. A sweet patient I had been working with over the past few months came in to her session, and as soon as we closed the door, she exclaimed, “We had sex and it didn’t hurt!” As a pelvic PT, there is nothing better than sharing in the joy of the successes of your patients. Treating sexual pain is close to my heart, particularly because this was one of the reasons I became a pelvic PT to begin with. “Treating Sexual Pain” was actually the focus topic for my small group mentoring program this month, so I thought it would be fitting to highlight a common treatment tool/strategy used in pelvic PT to help people experiencing painful penetration.
What are vaginal trainers?
Vaginal trainers are tools used to help to desensitize the muscles and tissues of the canal. They are often helpful when a person is wanting to participate in penetration activities, and is having difficulty doing so due to pain. Vaginismus is a particular diagnosis that refers to painful vaginal penetration due to muscle spasm. Women experiencing vaginimus in particular can be very good candidates for this type of treatment program. That being said, trainers can also be helpful for people with pelvic pain in performing self-manual treatment to the pelvic floor muscles, or for other vulvar pain conditions. Trainers also come in rectal variations, and some patients benefit from these as well depending on their primary complaints and goals.
Trainers generally come in graded sizes, often ranging from very small (think pinky finger) to large. There are several different companies that make trainers, and I’ll share a few of the different types here:
Silicone Dilators/Trainers: These are smooth silicone, and bend and move very easily, so they are what I consider to be top-of-the-line trainers. Soul Source and Intimate Rose are two companies that sell these trainers. Both are great, but I do really like how smooth and soft the intimate rose dilators are. These are a little pricey, so range from $18-50 per trainer $80-200 for a set. (As an aside, Intimate Rose was actually designed by a pelvic PT, Amanda Olson, DPT, PRPC. Amanda has excellent resources on her website, including this great video providing a breathing exercise for pelvic pain)
Plastic Dilators/Trainers: These are hard plastic, so they do not move and bend the way silicone trainers do. However, they do tend to be on the cheaper side. Vaginismus.com sells a trainer set including 6 sizes with a handle for about $45. The Berman Vibrating Set includes 4 sizes and often sells on amazon for less than $25. Syracuse Medical also makes a set without handles that is solid plastic, and those trainers are sold individually ($10-20 each) or as a set ($45-80).
How do you decide which to pick?
Well, it depends on a lot of things. Some of my patients prefer to go the cheapest route possible, so for them, it makes sense to get the $25 Berman set off of amazon or the $45 Vaginismus.com set. For others, they really like the softness and bendiness of the silicone sets, so they feel comfortable spending a little more for that type of set. Some sets come with varying sizes, so it is important to pick one that has the sizes you (or your patient) needs to accomplish their treatment goals. Usually, I sit down with my patients, show them a few different sets, then allow them to pick the set they feel the most comfortable with.
Wait…Trainer or Dilator? What’s in a name?
So, you’ll see these terms used interchangeably quite a bit, but honestly, I think the name really does matter. The term “dilator” never really settled well with me…because…well…dilation is a fairly strong word. Dilation refers to passive opening. I think pupil dilation. I think cervical dilation (although one could argue that is not totally passive!). Honestly, dilation is not what we are aiming for when it comes to the pelvic floor muscles. Trainer on the other hand, is an active term. It requires participation, focus, involvement. It is not a passive process, but rather, is an active journey. And that, my friends, is what utilizing trainers to improve penetration should be.
Getting started with trainers
A word of advice- please do not try this on your own. I have had so many patients who become discouraged, sore, or get worse from using trainers without the guidance of a pelvic PT. If you are struggling with sexual pain, and you would like to try trainers, please please please make an appointment with a pelvic PT who can evaluate you and guide you in this process.
Once my patients purchase their trainer sets, I have them bring the trainers to the clinic. We then will use them together in the clinic before they begin using them as part of their home program. I have a few rules when it comes to trainers:
We are gently introducing a new stimulus to the vagina; therefore, we do not want to do anything that leads to the body guarding and protecting by pain. So, when people use trainers, all discomfort should be 2/10 or less, and should reduce while we are using the trainer. (Note: Some very well-intending clinicians will give advice to “insert the largest dilator you can tolerate and leave it there for 10-15 min.” Tolerate is a very strong word, and I find this approach tends to lead to a lot of pain as well as fear and anxiety associated with the treatment.)
We cap out at 10-15 minutes. I encourage patients to set a timer when they start, and whenever that timer ends, to go ahead and end their session. This keeps the session reasonable in time commitment, and also avoids over-treating the area.
We avoid setting “goals” for the sessions or the week. The goal of using trainers is to gently provide graded exposure to the muscles and the tissues, to allow relaxation and opening without anything being threatening or painful. Our muscles are impacted by many different things, so many patients will find that the size of trainer they use or the level of insertion that happens can vary based on the day, week, etc. So, for this reason, we avoid setting a goal to accomplish, but rather, just aim to spend time focused on breathing, relaxation, opening, and gentle desensitization.
So, how do we use the trainers?
My approach to using trainers is strongly influenced by my friend and mentor, Darla Cathcart, PT, DPT, WCS, CLT. Darla was my clinical instructor back when I was getting my doctorate 10 years ago, and her approach to using trainers is gentle, progressive, and based in our understandings of muscles and neuroscience. (As an aside, Darla recently started teaching for H&W and I could not be more excited!! We taught our first class together a few months ago, and we will be teaching together again in 2019!! She is the absolute best, and is actually currently doing her PhD research on women with vaginismus. I’ll try to share more as she gives permission to do so in the future!)
Back to trainers, I encourage people to start with the smallest trainer (or for some, I may recommend a different size based on what I noticed with the exam). First, I encourage creating a comfortable environment to use the trainers– this means calm lighting, comfortable space, pillows to support legs and torso so that muscles can relax, and sometimes even a nice candle or soft music. We begin with placing the smallest dilator at the opening of the vagina, then slowly insert until the person feels discomfort (2-3/10) or guarding. When this happens, we stop moving, and they take slow long breaths focusing on relaxing and opening the pelvic floor muscles. They can then gently (like with 25% force) contract and relax the pelvic floor muscles, aiming to completely let go and rest the muscles. If the tenderness/guarding they felt resolves, they continue to slowly insert the trainer and repeat this process until the trainer is completely inserted. If at any point the discomfort does not reduce, we then will back the trainer out a little bit and rest/breathe there for a minute, then try again. If it still does not reduce, then the body is giving a cue that it is ready to take a break from trainers, and we go ahead and stop the session.
Once the trainer is completely inserted, we add movement. This can include turning the trainer side-to-side, or pressing it right, left or down. We avoid turning or pressing the dilator toward the pubic bone as the bladder and urethra live there, and they don’t generally like being mashed on. We can also move the trainer slowly in and out, stopping again during this process if anything is uncomfortable and repeating the steps above.
One that size trainer is completely comfortable, we move on to the next size and repeat the process. This continues until the 10-15 minute session ends, and then wherever we are, we stop for the day. We can add modifications in to trainer sessions, and this will depend on the particular patient. Sometimes this includes partner involvement with trainers or it can include visualizations or imagery to aid in the process.
With this slow, graded, and gentle approach, I find that most patients can do very well and this can be an excellent treatment to help them achieve their goals! I hope this was helpful in better understanding an approach to this treatment! If you are a patient and think you may benefit from using this approach, I would strongly recommend discussing this with your physician and seeking out a pelvic PT to help you guide the process!
If you are a pelvic PT, feel free to share any additional tips or recommendations you have for trainers in the comments below!
This past weekend, I was fortunate to work with an incredible group of practitioners at a Level 1 Pelvic Floor Course in my home city of Atlanta. I always leave these weekends renewed, excited, and yes, somewhat exhausted ;-). Not only do I get to teach with some pretty incredible colleagues (in this case, Sara Reardon– the VAGINA WHISPERER!!, and Darla Cathcart–who literally is the reason why I practice pelvic health!), but I also get the opportunity to see the transformation of clinicians who start the weekend a little nervous about the possibility of seeing a vulva, and end the weekend confident and empowered to start helping people who are experiencing pelvic floor problems. (Ok, some may not be 100% confident–but definitely on the road to confidence! ;-))
One of my favorite research studies of all time (yes, I am that nerdy) is always shared at this course with participants. This study by van der Velde and Everaerd examined the response of the pelvic floor muscles to perceived threat, comparing women who have vaginismus (painful vaginal penetration) compared to women who don’t.
Throughout my clinical career, the concept of stress and threat worsening pelvic floor problems has been a consistent thread. I frequently hear:
“My job has been so incredibly stressful this week. I am in so much pain today.”
“Everything started this past year…during that time, my parents had been very sick and it was a very emotionally and sometimes physical stressful time for me”
“I’ve been having a severe flare-up of my pain. Do you think the stress that I’ve been dealing with in going through a divorce/break-up/job change/move/new baby/new house/etc. etc. etc. could be related to this?”
Honestly, I could go on and on with continued statements like this. Stress is a complicated topic, and there are many factors involved that can contribute to an alteration or increase in symptoms when a person is in a persistent stressful situation. So, back to my favorite study. In this study, the researchers had the participants watch four different film excerpts that were considered to be: neutral, threatening, sexually threatening or erotic. They then recorded the response of the pelvic floor muscles using EMG. The results of this study were fascinating. They found that with both the threatening stimulus(which happened to be an excerpt from the movie Jaws) and the sexually threatening stimulus (which was an excerpt from a TV movie called Without her Consent–which frankly, sounds awful to me!) the pelvic floor muscles demonstrated increased muscle activity. And this was true in both the groups of women who had vaginismus and the groups of women who did not. (side note: they also saw that the upper traps had this same activation pattern! Makes sense, right?)
Fascinating right? So, what does this mean? I always tell patients that the pelvic floor can be like a threat-o-meter. When a person is experiencing a threat–this can be a physical or emotional threat– the pelvic floor will respond. You can imagine then what happens when that stressful situation or threat stays around for a long period of time! This knowledge alone can sometimes be so empowering for people in better understanding why their bodies might be responding the way that they are.
So what can we do about it?
If you are dealing with pelvic floor muscle overactivity problems or pain, and you find yourself in a stressful or threatening period of time in life, try these ideas:
Be mindful of what is happening in your body: I encourage people to do regular “check-ins” or body scans throughout the day to feel how their pelvic floor muscles and other muscles might be activating. If you feel any muscles gripping, try to see if you can consciously soften and let go of tension you might feel. After doing this, try to take a slow long breath in and out thinking of letting tension release.
Drop it like it’s hot: Your pelvic floor, that is. Several times throughout the day, consciously think about letting your pelvic floor drop and lengthen. If you have a hard time feeling what your muscles are doing, you can try performing a small (think 10-25%) activation first and then think about letting go of any muscle activity.
Don’t be an island: Know that there are so many resources to help you if you need them! Working with a skilled psychologist or counselor can be incredibly beneficial to many people! And, if your pelvic floor is giving you some problems, always remember that you can go see a pelvic PT– yes, even if you had worked with one in the past! We are always here to help you get through life’s hurdles! Sometimes people end up needing little “refresher courses” along the way to help when the body needs it.
So, what are your favorite ways to manage stress? Fellow PTs- how do you help patients handle flare-ups that happen when life starts to get stressful?
I love to hear from you, and meet you! Always feel free to reach out to me here! If you would like to take a course with me, check out the schedule listed on my For Professionals page! I hope to meet you in person soon!
Over the past week, and really the past year, the cases of sexual abuse and assault perpetrated by Larry Nassar, a medical doctor with MSU and USA gymnastics, have rocked the nation. The horrific abuse he inflicted on well over 150 young women, under the guise of “appropriate medical intervention” is deplorable, and I know many of us were glad to see him held accountable for his actions with both the verdict and sentencing last week.
In the pelvic PT world, this hit very close to home, and made all of us completely infuriated. For this person to take a completely valid, evidence-based and extremely beneficial treatment technique, and contort it into being an avenue for abuse was unfathomable to those of us who have dedicated our careers to helping men and women with pelvic floor problems. Several colleagues have spoken out about this. Particularly, Lori Mize, the incoming Vice President of the Section on Women’s Health, wrote an excellent post for the Huffington Post, that I would strongly encourage you to read.
Over the next year, I want to highlight a variety of treatment techniques used in pelvic floor physical therapy to help you better understand treatment options, and hopefully alleviate some fear that some of you may have about “the unknown.” In light of these current events, I thought it would be meaningful to start by discussing internal manual therapy techniques for the pelvic floor muscles.
What is it?
Internal manual therapy techniques are a treatment used for someone who has overactive, tender and/or shortened pelvic floor muscles. Before we get started, if you want to better understand the anatomy of the pelvic floor, check out this post by my friend and colleague Tracy Sher. Tender or overactive pelvic floor muscles can occur when someone is experiencing problems like pelvic pain, painful sexual intercourse, tailbone pain, as well as urinary or bowel dysfunction.
These techniques are performed either vaginally or rectally by a skilled medical practitioner who has undergone advanced training to learn to evaluate and treat the pelvic floor muscles. They are only performed once the patient has been thoroughly educated about the treatment techniques and consents to participating in the treatment.
What does treatment involve?
The goal of internal manual therapy is to improve the relaxation, lengthening and tenderness of the pelvic floor muscles. Generally, the patient is first positioned comfortably in either hooklying (on their back with knees bent, sometimes resting on a pillow– yep, no stirrups needed!), sidelying or sometimes on their stomach, depending on what position is preferable to the patient and allows the therapist access to the tissues being treated. The therapist then places one gloved finger within the vaginal or rectal canal and gently presses on the muscles of the pelvic floor to identify (with constant feedback from the patient) where the muscles are tender or uncomfortable. Manual therapy techniques then can be performed to help improve the tenderness of these muscles and promote relaxation and lengthening. These techniques can include:
Holding gentle pressure while the patient focused on relaxing and breathing
Holding gentle pressure while the patient performs a contact/relax of the muscles or a pelvic floor bulge.
Holding gentle pressure while simultaneously pressing with the opposite hand on a point around the pelvis to produce slack in the muscle (a modified strain counter strain technique.
Sweeping stretches over the muscle belly
Different therapists have different approaches, but they all are done in complete collaboration and communication with the patient and are modified based on the patient’s comfort and response to the treatment. Personally, I tend to prefer more gentle approaches while also focusing globally on improving awareness and calming the nervous system. This is not a “no pain no gain” situation– in fact, most often we see the best results when we are able to keep pain at a very minimal level.
What type of training should the therapist have?
It is very important that the person performing this treatment has had specialized training in this technique. At minimum, they should have attended an initial continuing education course that teaches a beginner level evaluation and treatment of the pelvic floor, generally weekend course including at least 24 hrs of instruction. Many training programs now include a 3 or 4 course series, and I strongly encourage clinicians to complete the coursework to learn how to comprehensively care for their patients. At Herman and Wallace Pelvic Rehabilitation Institute, the organization I am a faculty member of, we have a 4-course series which includes a level 1, 2A, 2B and Capstone. The Section on Women’s Health has a 3- course series and there are now several other companies offering varying training programs. Of course, I’m biased as a faculty member of H&W and if you’re reading this and work in healthcare in pelvic rehab, you should definitely come to one of my courses!
Who does this treatment help?
As I mentioned above, manual therapy to the pelvic floor is helpful when a person has overactive, tender and/or shortened pelvic floor muscles that are contributing to the problem they are experiencing. This can occur when a person has pain in and around the pelvis or if the person is experiencing urinary, bowel or sexual dysfunction.
We are producing more and more research about these techniques every day, but here are a few snippets:
In this study, 50% of the men treated to address chronic scrotal pain saw a significant reduction in their pain.
In this study, 93 people were treated with pelvic floor techniques to address coccyx pain (as well as pain after coccyx removal). Overall, they saw an average of 71% improvement.
This study compared comprehensive pelvic PT to cognitive behavioral therapy for women with provoked Vestibulodynia. They found that 80% of the women in the PT group had significant improvements compared to 70% in the CBT group.
This study evaluated the effects of pelvic floor physical therapy techniques on pain reduction in men who had chronic pelvic pain. Treatment included internal and external techniques and over 70% experienced moderate or robust improvements.
This study found that 62% of women experiencing urinary frequency, urgency and/or bladder pain who were treated with physical therapy interventions, including internal manual therapy techniques, reported feeling “much better” or “very much better” following the interventions.
I hope this was helpful and removed some of the fear from this technique! If you think this treatment may be a helpful one for you, talk with your health care provider! As always, I love to answer any questions you may have!
“Ok, TMI…but is everyone having sex again? We tried last night and OMG it was awful! So painful!!”
I clicked on the thread in one of my Facebook moms groups, and slowly looked through the comments, hoping to see words of encouragement, support, and most importantly, solid health advice.
“I know, me too. I just try to avoid it as much as I can.”
“What is sex? LOL”
Then, I began my comment, “Hi, I’m a pelvic PT and also the mom to a 6 month old. I’m so sorry you’re hurting. It’s so important to know that pain is not something you have to live with. There is help out there…”
Why is painful sex after childbirth so overlooked in healthcare? Why do so many women feel like they just have to live with this as a normal “consequence” of having a baby?
This past fall, I went through the craziest initiation process to join one of the most exclusive clubs out there: Motherhood. It has been an incredible and humbling journey for me, especially as a health care provider who specializes in helping women with problems they experience while pregnant and postpartum. Becoming a mother has allowed me to experience and witness first-hand many of the challenges women face after having babies.
Pain during sexual activity is extremely common after childbirth (Note: I said common…NOT normal). In fact, a large study of over 1000 women found that 85% experience pain during their first vaginal intercourse postnatally. At 3 months postpartum, 45% still were experiencing pain and at 18 months postpartum, 23% were still experiencing pain. Let that sink in. When a mother’s baby is 18 months old, 1 in 5 mamas had pain during sex! And the sad thing is that pain during sexual intercourse is SO treatable!! So, let’s get down to business…
Why could sex hurt after a baby?
Perineal Trauma from Childbirth
Spontaneous tearing and episiotomies are very common during vaginal deliveries. In fact, this study looking at 449 women who had at least 1 delivery found that only 3% of them did not have any tearing/episiotomy. Many women are able to heal from tears without problems. However, for some women, these injuries can become sources of pain, especially during sexual intercourse. This is especially true with more severe tears extending into the external anal sphinctor and rectum (grade 3-4 tears). This study found that women who had tears extending into the anal sphinctor were 3-4 times more likely to have pain during intercourse at 1 year postpartum compared to their counterparts. Perineal scars can be very sensitive and move poorly in some women leading to persistent discomfort which can last for years after the baby is born when it is not treated (but guess what? It CAN be treated!)
Anyone who has had a baby can attest to the crazy hormonal fluctuations that happen during pregnancy and postpartum. One of my very best friends warned me about this telling me that she cried every day for the first week after the baby was born. Guess what? So did I. These crazy hormones can also impact what is happening down below, especially in breastfeeding mamas. Basically, the hormonal changes lead to decreased estrogen in the vulvar tissues often causing thinning and dryness. This is why breastfeeding is associated with painful sexual intercourse early on postpartum. Now, if you are reading this and you are a nursing mama like myself, should you stop to fix your sexual discomfort? Not necessarily. This study found that although nursing was associated with dyspareunia at 6 weeks postpartum, the association was eliminated by 6 months. Meaning, stopping nursing won’t necessarily fix the problem (so don’t let this be your deciding factor in the decision to breastfeed your babe).
Tender Pelvic Floor Muscles
The pelvic floor muscles themselves can become big sources of sexual discomfort if they are tender, shortened or irritated after childbirth. Perineal trauma and hormonal changes can lead to tenderness in the pelvic floor muscles, but the muscles can also stand on their own. Many people believe that C-sections protect the pelvic floor muscles from having problems, however, we have to remember that the pelvic floor are one member of a team of muscles (including the deep abdominal muscles, low back muscles and respiratory diaphragm) that work together to provide support and stability to the pelvis. That could be partially why C-section mamas are actually 2-3 times more likely to experience more intense pain during sexual intercourse at 6 months postpartum.
Because Babies are Hard
I had to add this one in. It’s important to remember than normal sexual function should include sexual desire, arousal, and orgasm. New mamas are exhausted, feeding sweet little babies around the clock, settling into a new routine whether they are returning to jobs or caring for their babies at home, sleep-deprived from often waking up multiple times a night, changing diapers, and worrying constantly about helping these little babies survive and thrive. And honestly, it can be really hard for many moms to have the same level of sexual desire and arousal that they had prior to having their babies (at least until life settles down– or I’m told–when the babies go to college LOL). When a woman experiences sexual desire and arousal, there is natural lubrication and lengthening of the vaginal canal, and this step is so important in having enjoyable sexual activity. Sometimes, when this step is skipped, women are more likely to experience discomfort with vaginal penetration.
So, what can be done to help?
Realize it is not normal. Don’t just deal with it. And check-in with your Obstetric provider.
The first step is seeing your OB or midwife to make sure everything is ok medically. She should evaluate you to make sure everything is healing the way that it should be healing and that nothing else is going on that needs to be managed medically. I have had patients who have had difficulties healing after tears and needed some medical help to encourage their tissues to heal the way they needed to. I have also worked with women who had underlying infections contributing to their pain, that of course, needed to be treated to move forward. This is not a step you should skip, so don’t be bashful! Tell your doctor what is going on.
Don’t be afraid to use a little help.
I get it. You never had to use lubricant before, and it’s annoying to have to use it now. But guess what? It can make a HUGE difference in reducing discomfort from thin or dehydrated vulvar tissues after babies! So, if you don’t already have a good one, go pick out a nice water-based lubricant to use. Some of my favorites for my patients are Slippery Stuff and Sliquid. I am also a big fan of coconut oil (but make sure to know that using it with condoms can cause condom breakdown).
If you are having difficulty with sexual arousal and desire since having your baby, and you feel comfortable with it (I know, some women don’t!), try using a small vibrator to help with improving sexual arousal and promoting orgasm. Many sex therapists I work with encourage couples to consider using this on days when they need a little assistance attaining the arousal they need.
Educate your sexual partner and empower them to help you
It can be so helpful to include partners in this process. Show them this blog post, so they can understand what could be going on, and empower them to help you! For some women having difficulties with arousal, having their partner do something like clean up after dinner and put the baby to bed so they can have time for a quiet relaxing shower can be just the ticket to helping them become more sexually aroused to decrease sexual discomfort. If you are having problems with painful perineal scars or pelvic floor muscles, consider including your partner in your medical or physical therapy visits so they can understand what you are experiencing. Many pelvic PTs (like myself) will often educate partners in methods to help with decreasing pain , and even in treating the pelvic floor muscles/scars (if both people feel comfortable and on-board with this!).
Go see a pelvic PT!
If you have tender pelvic floor muscles or painful scars, all the lubricant and sexual arousal in the world is not going to fix the problem. Working with a skilled pelvic floor physical therapist can be hugely beneficial in identifying where and what the problem is, and helping you move forward from pain!
A skilled physical therapist will spend time talking with you the first visit to understand your history (including specifics of your delivery), and will perform a comprehensive examination, head to toe, to see how your body moves, where you might not be moving as well as you could be, and how you transfer force through your body. They will also perform an examination of the abdominal wall (especially important for C-section mamas), and an internal vaginal examination of the pelvic floor muscles. Based on this examination, they will be able to work with you to develop a plan to help you optimize the function of your body and get back to a happy and healthy sex life!
This is first in likely a few series of posts I will be doing on postpartum specific problems. I hope you all enjoy! Please please please reach out if you have any questions at all!