Treating pelvic pain – October 30, 2013

My file on vulvar pain stretches back several decades. One thing has not changed: a woman may seek up to 10 medical opinions before getting a correct diagnosis and possible help. In the absence of pathogens or a clear physical ailment, a woman’s concerns tend to be dismissed as being “all in your head.”

At a meeting of the Sexual Health Network of Ontario in September, I was absolutely floored to learn about the use of physiotherapy to treat chronic pelvic pain (CPP). A sex therapist, a physiotherapist and a health advocate talked about pelvic pain, which can include vestibulodynia (pain at the “front porch” of the vagina), vulvodynia (pain in the superficial tissues of the vulva, also used as a general term for vulvar pain), clitordynia (pain at the clitoris) vaginismus, (the inability to have penetration into the vagina) clitoral pain, pain from endometriosis (where uterine tissue grows outside the uterus) and interstitial cystitis (a condition that involves pain, frequency and urgency). (More about these conditions).

I was entirely ignorant that physiotherapists could be rostered by their college to do a manual pelvic exam and treat CPP. According to Pelvic Health Solutions, research has shown that treatments carried out by a physiotherapist for pelvic floor problems are highly successful, and should be the first line of defense for both pelvic pain and incontinence.

Many of us were told that we should do our Kegels (pelvic floor exercises) to prevent some of these issues. But Kegels are not a one-size-fits-all exercise. There are Kegels where you tighten and relax; and reverse Kegels where the goal is to relax and open the pelvic muscles. The prescribed exercise depends on the condition.

Pelvic Health Solutions explains that most practitioners who teach women how to do Kegels no longer do an internal exam to assess these muscles to ensure their proper contraction, which has led to a very poor success rate and significant frustration for women trying to do their best with these exercises.

Pelvic floor muscles attach to the front, back and sides of the pelvic bone and sacrum. They are like a hammock or a sling, and they support the bladder, uterus, prostate (in men) and rectum.  They also wrap around the urethra, rectum, and vagina. This group of muscles assist with bowel function, bladder function and sexual function.

The physiotherapist on the panel explained that these muscles need to be the right length to function correctly; otherwise, they can contribute to pain. They might be tight, or weak and loose.

Weak muscles (hypotonicity) contribute to stress incontinence (peeing when you cough, laugh or exercise), urge incontinence (gotta go, now!), and pelvic organ prolapse (when pelvic organs drop due to weak or stretched muscles). Tight pelvic floor muscles (hypertonicity) contribute to urinary and fecal urgency, urge incontinence, CPP, dyspareunia (painful intercourse), vaginismus, vulvodynia, pudendal neuralgia, Interstitial Cystitis and chronic prostatitis in men, according to Pelvic Health Solutions.

During a pelvic examination, a physiotherapist may also encounter trigger points, possibly caused by surgery, childbirth, chronic pelvic infections, fibroids and even poor posture. They can often be felt as a lump; or there may be a twitch when they push on the suspected spot, causing referred pain to another area to increase. Some trigger points refer into the pelvic floor.

To treat pain and improve bladder function, physiotherapists use manual therapeutic techniques such as normalizing muscle tone, abolishing trigger points, breaking down scar tissue and re-educating pelvic floor muscles through specific exercises.  They can also use behavioural modification, including techniques for dealing with stress and dietary irritants.

Gynecologists who train with physiotherapists specializing in CPP learn how to do a very different pelvic exam, looking for trigger points or problems with connective tissue. In some settings, gynecologists may work as part of a multidisciplinary team in the treatment of pelvic pain.

Sex therapists may also be part of this team. They learn to assess psychological and medical factors. The sex therapist on the panel showed a diagram of a continuum of painful intercourse, from a simple lack of lubrication to nerve damage. She said that women with CPP have higher rates of sexual dysfunction, depression, history of sexual abuse and substance abuse. Even relationship issues may be expressed as physical symptoms.

In her discussion of female sexual response, she referred to the non linear sexual response model. This model is relevant because it takes more factors into consideration than the standard: stimulus, excitement and orgasm.

For example, women who suffer from painful intercourse (dyspareunia) may end up avoiding any sexual touching. A woman who has experienced pain may worry she will feel pain the next time. The result will likely be a lack of interest in setting up a sexual encounter; so she may end up having intercourse without desire, which would again trigger pain. Part of sex therapy may include helping a patient to redefine sex and intimacy; for example, encouraging increased pleasure as a goal rather than increased arousal.

The health advocate on the panel insisted that patients need to be self advocates. When patients initiate a conversation with a health care provider about their pain, what they want to hear, she said is, “That’s very common” and “you’re not alone.” They also want to be told it’s not all in their head. Women also need to learn the language of pain in order to be clear with their practitioner(s).

“Healing begins,” said the advocate on the panel, “the moment you get your diagnosis.” And, clearly, a multidisciplinary approach is the logical next step.

Here is some helpful information on pelvic pain:

When Sex Hurts: A Woman’s Guide to Banishing Sexual Pain by Andrew Goldstein MD and Caroline Pukall Ph.D.

National Vulvodynia Association:  Tutorial: http://learnpatient.nva.org/

Pelvic Health Solutions

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