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Pelvic Floor Physical Therapy: What It Is and Why You May Need It
Excerpted from Slip Sliding Away: Turning Back the Clock on Your Vagina – A Gynecologist’s Guide to Eliminating Post-Menopause Dryness and Pain
By Lauren Streicher, MD
It’s not unusual to successfully treat dry thin tissues yet still have pain with intercourse. Muscle memory does not know that vaginal tissues are now well lubricated and that whatever originally caused the pain has been eliminated. Your vagina, in fact your entire pelvis, has been in protective “keep out mode” for so long that pelvic and vaginal muscles will continue to contract involuntarily to keep out a penis that could potentially cause pain. Muscles that are contracted not only keep the penis out, which at its extreme is a condition known as vaginismus, but also are painful. So, you need to repair not only the vaginal tissue, but also the muscles that support and surround the vagina.
And that is where pelvic floor physical therapy comes in.
The pelvic floor is made up of multiple muscle groups that support and surround all the good stuff — your clitoris, vagina, bladder and bowels.
If you imagine a woman in a standing position, these muscle groups function as a strong trampoline that supports not only the bladder but also the uterus and rectum.
When all the muscles work together, the “trampoline” is able to contract and relax in a coordinated fashion. Pelvic floor muscles are responsible for bladder control, bowel control and vagina control. When it comes to pain-free intercourse, the ability for the muscles to relax is the important part.
Normally, when a woman becomes aroused, her body prepares to let a penis in, the biological purpose of sex. In preparation, pelvic floor muscles relax, causing the vagina to lengthen and expand. The muscles around the opening of the vagina also relax, which is your vagina’s way of saying, “I’m ready, come on in.”
But, if your past sexual attempts resulted in pain, your vagina goes into “Are you kidding? You are not coming in here just to cause me more pain” mode. Your pelvic muscles will involuntarily contract to keep the penis out.
A Personal Trainer for Your Pelvis
I’ve heard it a million times. When discussing solutions for vaginal dryness, my patients expect me to bring up lubricants, moisturizers, medications. It’s when I introduce the topic of pelvic floor physical therapy that I get reactions like:
“You’re kidding, right?”
“She’s not going to put her hands in there!” (This is accompanied by a horrified look.)
“Do I really need that? Can’t you just give me a different medicine?”
Well, no, I’m not kidding. Yes, she is going to put her hands in there. Yes, you do need that, and no, I can’t just give you a different medicine.
Consider if you broke your leg. Once the cast comes off, working with a physical therapist is a standard part of rehabilitation and restoration of normal function. After a break or serious injury, your muscles don’t function properly because of trauma and disuse.
The same goes for the muscles that support your pelvic organs. If your vagina or pelvis has been traumatized by painful sex, physical therapy is a key component to your recovery.
Pelvic floor physical therapists have done additional, very specialized training in the treatment of pelvic disorders, including gynecologic, urologic, muscular and neurologic problems. Many women are skeptical when advised to seek the help of a physical therapist. These same women usually become the greatest advocates of the treatment. As a gynecologist, I can almost always fix the problem that initially caused the pain, but the physical therapist is the only person who can erase the muscle memory, eliminate pelvic floor muscle tension, strengthen atrophied muscles, and restore normal, healthy functioning. In my practice, I rely so much on my team of pelvic physical therapists that I refer to them as my “magicians.”
Painful intercourse is not the only thing pelvic floor physical therapists treat.
The list also includes:
Working With a Pelvic Floor Physical Therapist
Since it is a mystery to most women what a pelvic floor physical therapist does, it helps to know what to expect when signing up.
In the first part of the physical exam, the physical therapist will evaluate things like your posture, abdominal strength and general physical fitness. The pelvic exam is kind of like a gynecologic exam without the speculum; however, it’s likely to include several elements that are unfamiliar to you.
It starts with a thorough visual evaluation of the vulvar skin and vestibule. The therapist uses a cotton swab to touch each zone to see which areas are painful. She then gently introduces a gloved, lubricated finger into the vagina to systematically touch specific muscle groups that make up the pelvic floor. By gently applying pressure on various pelvic floor muscle groups, the therapist determines whether the problem is due to tight muscles, known as a hypertonic pelvic floor. She feels for inappropriate knots, contractions and inflammation of not only the muscles but the connective tissue as well. She may identify a specific, isolated tender spot, known as a trigger point, that when touched reproduces the pain felt during intercourse.
The physical therapist also evaluates your overall muscle strength and coordination by asking you to squeeze her finger using your pelvic muscles. This is like the maneuver you do when performing a Kegel exercise.
The experienced pelvic floor physical therapist not only treats the problem but also plays an important role in helping us determine the source of the problem in the first place. In performing a thorough musculoskeletal evaluation of the pelvis, spine and hips, she often finds pelvic asymmetry and muscle imbalances in women with pelvic and sexual pain.
Often the location of the pain is not where the pelvic pain originates. For example, tight hip flexor muscles tilt the pelvis and cause tension in the pelvic floor muscles, which contributes, in turn, to pelvic pain and dysfunction.
Once the source of the pain is identified, the therapist uses several modalities for treatment, including techniques such as myofascial (tissue) release and joint mobilization. Muscle spasms are eliminated using manual soft tissue work and trigger point release directly on the pelvic floor muscles through the vagina and occasionally the rectum. (This is a hands-on treatment!)
Ultimately, pelvic physical therapy allows a woman to improve function and also allows her to engage in intercourse without the vaginal and pelvic floor muscles painfully and inappropriately contracting.