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’ve been pregnant before, you know the feeling of going out and having everyone comment on your beautiful belly. Of course, we all get the occasional, “wow, are you sure you’re not having twins?” “When are you due? You’re not going to make it there!” (And can we collectively just tell those people to leave us alone!!) BUT, the majority of the comments are, “you look amazing!” “Wow, she is really growing!” “How are you feeling? Congratulations on your baby!” Honestly, my own body self confidence was at a high during pregnancy. But then, our sweet little love muffins are born. And society expects us to very quickly bounce back to our pre-baby state (and I have so many thoughts on that…because we just went through this transformative, incredible experience, that took nearly 10 months to build! And often times mamas are left alone to figure things out after birth).
As an aside, this was one of the BIG reasons that my friend and colleague, Sara Reardon, and I decided to partner together to create live & on-demand classes! We recognized that soooo many people are struggling with pelvic health problems. While individualized pelvic PT is so beneficial, it’s not always possible for people at the time they need it. For one…ummm…coronavirus/social distancing. But also, some people prefer trying to learn and work independently, may feel too nervous to discuss their problems with a provider, or may have a schedule/time constraints/financial constraints/geographical constraints that just don’t allow individualized care at the time they are wanting it. SO, these are our classes.We have 2 LIVE postpartum classes coming up– TOMORROW 4/14 is our “Postpartum Recovery After a Vaginal Birth” Class, and the following Wednesday 4/22 is our “Postpartum Recovery After a Cesarean Birth” Class (SO excited about this one as a mama of 2 Cesarean babies!). These classes are built for the consumer—BUT, if you are a health care provider, I can guarantee that you’ll learn a bunch also! We sold out before the start of our “Pelvic Floor Prep for Birth” class, so if you’re on the fence, register soon and reserve your spot!
Anyways…back to our topic at hand: Diastasis Rectus Abdominis.
The abdominal wall is stretched during pregnancy to accommodate the sweet growing munchkin, and in some cases (most cases, according to some research!), this leads to a stretching at a structure called the linea alba- the connection between the two sides of the rectus abdominis or “6-pack” muscle group. When this becomes larger than about 2 fingers in width, it is known as diastasis rectus abdominis (DRA). This is what it looks like:
The two “+” marks indicate each side of the lines alba, and you can see that it is wider than it likely was previously. Note, this is an ultrasound image of a 38 year old mom who had diastasis after her pregnancy. DRA is different than a hernia. When a hernia occurs, there is a defect that allows an organ or tissue to protrude through the muscle/tissue that normally contains it. So, someone could have a DRA and not a hernia. Or, they could have a DRA and a hernia. Make sense?
Diastasis rectus abdominis is common during and after pregnancy, and varies in severity. For some moms, they may not really realize it’s even there. Others may feel a complete lack of support at their belly, notice a bulge, or even worry that they still look pregnant. A recent study published in 2016 found that among 300 women who were pregnant and gave birth, 33.1% had a DRA at 21 weeks gestation. At 6 weeks postpartum, 60.0% had a DRA. This decreased to 45.4% at 6 months postpartum and 32.6% at 12 months postpartum. So, basically, many pregnant folk get this, and while for some it gradually improves over time, for others it can persist.
The link between DRA and musculoskeletal dysfunction is not confirmed. A recent systematic review published in 2019 found “weak evidence that DRAM presence may be associated with pelvic organ prolapse, and DRAM severity with impaired health-related quality of life, impaired abdominal muscle strength and low back pain severity.” This makes a lot of sense to me. Conditions like pelvic organ prolapse and low back pain are complicated, but in some cases do have components related to pressure management. The abdominal wall is very crucial in helping to modulate intraabdominal pressure, so it makes sense that when it is not functioning optimally, a person could struggle with managing pressure well.
The intra-abdominal pressure system involves coordination between the respiratory diaphragm, low back muscles, transverse abdominis, and pelvic floor muscles. These muscles need to work together to control pressures through to abdomen and pelvis and create dynamic postural stability. When the abdominal wall has a loss of support, this system can be impacted and contribute to pressure problems like prolapse and low back pain. However, those diagnoses are complicated. There are many other factors involved (like connective tissue support, amongst other things), so this is why a comprehensive examination is often very beneficial. This is also why not everyone who has DRA has pain.
I think it’s important to note here, that for some people, their DRA may not be contributing to things like back pain or prolapse, but it may still be a huge problem for them. People can feel guilty about caring about the cosmetic component involved in some instances of DRA…you know…the pooch. But, you know what– if this matters to you, then it matters! Feeling confident and strong is so important! So, don’t let anyone tell you what is or isn’t important for you to care about!
So, how do you find out if you have a diastasis?
The best thing to do if this is sounding like you is to see a pelvic PT to be evaluated comprehensively. There are many different things that can contribute to a loss of support at the abdomen, so looking at the complete picture is the best option. We’re going to talk about some of those pieces and how we as pelvic PTs evaluate DRA in Part 2 of this blog series. However, there are ways you can examine yourself and find out if you have a diastasis rectus. First, lie down on your back with your knees bent.
Start by placing two of your fingers at your belly button. Next, lift your head and your shoulders up (like doing an abdominal crunch) and sink your fingers in, gently moving them back and forth to feel the sides of your rectus abdominis. Notice if your fingers sink in, and if you feel a gap between your muscles. Repeat this a few inches above your belly button, and again a few inches below your belly button. Also notice how you feel as you do this– do you feel tension at your fingers? Do your muscles feel strong? When you lift up, are your fingers pushed out or do they sink in? What do you notice? (This is great information for you to understand how much force you can generate through your “gap” and will be important as we start discussing how we treat this!)
How can you help a diastasis?
Well, the good news is that there is so much we can do to help improve diastasis, make your belly stronger, and help you feel better. In part two of this series, we’ll discuss the ways pelvic PTs can best evaluate someone who has a diastasis, and the methodology we use to treat this problem. The method of treating this has changed over time, so I’m going to give you my best understanding of the research as it’s available today! Stay tuned to learn more!
Stay healthy during this time my friends– and wash your hands!
A few weeks ago, my husband returned from spending a few days at Barnsley Gardens Resort, where he helped with a fundraising event for the Atlanta Area Boy Scouts of America. Upon his happy return (for all parties involved– single moms: you are rockstars!), he gifted me with a bottle of my favorite relaxing lotion, scented with lavender and peppermint. It is heavenly, and we both adore it! It has become a tradition that he brings me a bottle every time he helps with the event in November. Why do we both love it so much? Well, 3 years ago, we spent 2 wonderful nights at Barnsley Gardens for a mini babymoon. It was our last getaway as a family of two. I was super pregnant, but we ate delicious food, relaxed in the pool, went on evening walks, and slept in. We had an incredible couples massage also, and this lotion was the smell of the spa. We bought a bottle then, and even now, 3 years later, using the lotion evokes feeling of peacefulness, joy, love, and overall relaxation.
So, what happened there? How do brain-smell associations work? (And I know some of you are sitting there thinking…what does this have to do with the pelvis?)
We’ve all been there, right? When I hear the song “Kiss me” by Sixpence None the Richer, I’m transported back to the middle of the summer working as a lifeguard. I smell sunscreen and chlorine and feel the warmth of the sunshine. When I smell a certain blend of middle eastern herbal tea, I’m transported back to Cairo, Egypt where I studied abroad in college, walking through the busy streets at the downtown market. Our brains are incredible like that. Certain memories impact us, and cause our brains to form neurotags– specific patterns of neural activation based on that single input. This is why all of the pieces of the memory come flooding back to you when you have the evoked stimulus (in my case recently, amazing lavender mint lotion).
Now let’s jump into pelvic health, and particularly, chronic pain. What if the brain forms neurotags about pain? For example, what if a person began having pain with sitting, and let’s say, for this example, they experienced a few situations where they needed to sit for a long period of time, and the pain was just awful. As we have discussed many many times, we know that all pain is produced by the brain, that the brain can play tricks on us, and that the brain does change over time due to pain and many other factors. The brain could then, build a neurotag about sitting. Basically, when the person in the above example goes to sit, the brain will activate the neural pathways to remember pain, negativity, perhaps anxiety/stress about the situation, etc. and instead of amplifying the feelings of peace and love (like my lotion!), the brain will amplify the feelings of distress and pain. What about a painful medical examination? A negative sexual experience?
Fascinating, right? So, what can we do about it?
First, recognize a negative neurotag for what it is– your brain recognizing familiarity. And what it is not– a true interpretation of the current situation.
Next, change up the pattern to trick your brain. If you have pain when bending forward to pick something up, can you try the bending motion while lying down (ie pulling your knees up to your chest)? If you had a negative medical exam and start feeling anxious about your appointment, could you see a different provider at a different office? Perhaps request a different position for the exam? If you have pain with sex, could you alter the experience? Maybe this means a different position, different location, different warm-up?
After that, aim to build new, positive neurotags for your brain. How do we build positive neurotags? It can start by building a positive association for your brain. So, this could mean diffusing a calming oil blend while listening to a guided relaxation track. Once this association builds for the brain, you could then try using the same scent within a typically negative situation (assuming you have also removed the negative stimulus!). For people with pelvic floor pain, we often use gentle manual treatment (either with a finger or vaginal trainers) to provide a safe input to the tissues in a way that the brain will not guard and protect by pain. Now, envision pairing that calming scent with gentle pelvic floor muscle desensitization? The options are endless for creativity in building positive neurotags! Movement can also be great to build positive neurotags! If you find that pain limits what you can do, working with a physical therapist to develop movements you can do, that keep you at minimal to no discomfort can help your brain build neurotags for safety with movement again!
If this is fascinating to you (as you know it is to me!), here are a few other resources to check out:
These amazing Vlogs by Jilly Bond, one of my favorite physios across the pond (You may recognize a certain someone in the second video!):
Agency is defined as, “the capacity of individuals to act independently and to make their own free choices.” What does this mean for healthcare? How does the healthcare consumer maintain and create agency while also navigating the complexities of medicine?
A few weeks ago, I traveled to Washington DC to teach a group of 40+ physical therapists and occupational therapists about working with people who are dealing with various types of pelvic pain. Over this 3-day course, we covered topics related to diagnosis, medical management, manual therapies, movement interventions, and much more. On the third day of the course, I gave a lecture on “trauma-informed care.” What is trauma-informed care? Trauma-informed care means the “adoption of principles and practices that promote a culture of safety, empowerment and healing.” While we do focus on how widespread trauma is, the varying ways people experience trauma, and strategies to develop sensitivity, respect and consideration for the needs of our patients, we also strongly emphasize the importance of treating all patients in this way. One of the key pieces in doing this is helping a person develop a strong sense of agency– the ability to make their own educated decisions and partner alongside their healthcare professionals, instead of being the recipient of directed care.
The idea of agency can seem fairly basic. Shouldn’t every patient feel like they can make their own decisions? Shouldn’t they feel like their healthcare providers are all members of the same team? But, that is often not the case. When a person loses this agency, they can end up in situations where things start happening to them, instead of with them, and this can create difficult and sometimes traumatic experiences. This could be a mother who feels pressured to have a birth intervention she was really not comfortable with having. This could be a person being scolded for not being “compliant” with their recommended home exercise program (as opposed to their clinician understanding what happened and partnering with them to fit exercise in their lives). Or, it could be feeling pressured to continue a painful examination that they otherwise would choose to stop.
There are many reasons why losing one’s agency is detrimental. Remember, the pelvic floor muscles respond to threat. So when a person is in a situation where they feel threat (whether that is due to stress, a difficult situation, or other circumstance), the pelvic floor will activate. When someone is dealing with something like pelvic pain, sexual pain, and other diagnoses, this can lead to a problem becoming worse. So, how can you maintain your agency as a patient?
Ask Questions. All the Questions. “The only stupid questions are the ones that are not asked.” If you aren’t understanding what is being recommended to you, ask more questions for clarification. Your healthcare provider should always be happy to answer any questions you may have to help you make the best decisions for your care. This also applies to times when you are in the middle of a treatment/procedure/etc. Ask away. Try saying:
“Would you mind explaining my options again?”
“Can you clarify what the benefits and risks would be to…”
“Are there any risks in not moving forward with that treatment?”
“What are the reasons you think I need to…”
“I’m sure you have a busy day, but it would really help me if you could answer a few questions.”
Don’t be afraid to slow things down. If your treatment session or medical appointment is going a direction you are uncomfortable with, or if something is happening that you don’t feel like you understand, feel free to take a break. Try saying:
“I need some time to think about that.”
“I would like to take a few minutes to consider my options.”
“I would prefer not to move forward with that today.”
“Can you explain _______ to me again?”
“I’m not sure I understand all of my options.”
“I’d like to go home and think about all of this. I’ll let you know what I think at our next visit.”
Bring a friend. If you know that you tend to get overwhelmed at your appointments and have difficulty expressing your needs or how you feel, consider bringing a friend/partner/spouse who will have your back! Tell them in advance what you want their role to be and how they can help you! This could be stepping in to ask for some time to consider options, asking a provider to slow down and repeat their explanation, or simply being a person to be present with you during a difficult appointment.
I hope these tips have been helpful in helping you develop strategies to create agency as a patient. If you are a healthcare provider, I urge you to reflect on your own practices. Do your words and actions support your patients in maintaining autonomy? support agency? Do you unintentionally pressure patients into participating in treatments or exams that they may not feel comfortable with? Do you shame patients when they don’t follow your recommendations? None of us are perfect. I truly believe that most health care providers have the best of intentions. But, we can all do better. Reflect on our own words, habits, body language, and be better partners for our patients!
What other strategies have you found to help you improve your agency as a patient?
Happy Pelvic Pain Awareness Month! I do plan to post a few blogs on pelvic pain over the course of this month, I promise, but I wanted to quickly share with you a few events I am going to be a part of over the next month!
First, next Wednesday, May 15th, I will be the special guest at a FREE pelvic health education event hosted by PLS Yoga and Wholeheart Psychotherapy, “Women’s Pelvic Health: Key Considerations for Health and Wellbeing for Women Living with Pelvic Pain” The event will run 7-9 pm at 6 Lenox Pt NE in Atlanta! If you are struggling with pelvic pain, please join us for this incredible evening!
Next, on Sunday June 2nd my colleagues and I will have a booth at the Mama Bear Fair, hosted by Dr. Jamie Michael’s chiropractic clinic in Smyrna! Fitting, as this is just 2 weeks before my due date (I did tell you all I was expecting another baby girl, didn’t I?) Stop in between 3-6pm to chat with me about prenatal/postpartum care and pelvic health! RSVP for the event via Facebook!
I hope to see some of you at these events! Please feel free to be in touch if you have any questions!
I was interviewed for an article that was featured this month in Men’s Health! I wanted to share with all of you here! Excited to bring information on male chronic pelvic pain and pelvic floor physical therapy to such a big platform!
In the article, we discussed the scope of the problem, treatment recommendations, and even some details on what good pelvic PT should look like! I hope you all enjoy!
Did you know that Endometriosis affects more people that inflammatory bowel disease?
Did you know that 10-15% of women (and some men too!!) suffer with endometriosis?
Did you know that they often see 7+ physicians before being diagnosed with the condition?
Endometriosis is so common, and often can be a very life-impacting condition. As a pelvic PT, I often treat individuals with endometriosis, helping them with the musculoskeletal and neuromuscular sequelae of the condition. I have also helped many patients navigate the healthcare system to ultimately receive the appropriate care they so desperately have needed.
In honor of Endometriosis Awareness Month, I asked Dr. Ken Sinervo, the medical director for the Center for Endometriosis Care in Atlanta, GA to spend some time with me discussing this important diagnosis. Dr. Sinervo is an expert in treating endometriosis, and I can’t tell you how lucky I am that his office is about 20 minutes from mine! He is also a kind and humble person and a compassionate physician, and I was so excited to interview him for this post!
In the video below, we discuss:
What is endometriosis and where does it occur?
What are the current theories on the causes of endo?
How can it be treated?
Excision vs. Ablation surgery
How to find an Endo expert
For pelvic PTs: How do you identify patients who may have endo?
And, as an extra bonus, cherry on top, Dr. Sinervo describes the research he is involving in trying to identify potential markers to actually test for endometriosis!!
I hope you enjoy the video as much as I enjoyed interviewing him! I apologize in advance if our video cuts out a little bit, but I don’t think it impacts the incredible content (Our weather in Atlanta was a little struggly, so I think my internet had some difficulties!).
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!