Pelvic floor dysfunction causes a number of problems: dyspareunia, urinary frequency or incontinence, pain with walking, pain with prolonged sitting, fecal incontinence, constipation or dyschezia. For women suffering from pelvic floor dysfunction, physical therapy can work wonders, says Noor Dasouki Abu-Alnadi, MD, MS, who specializes in chronic pelvic pain at University of North Carolina-Chapel Hill.
The female pelvis is a basket of muscles that help support the bladder, uterus, and rectum. Clinicians caring for women think of these muscles in their roles during pregnancy and delivery, urination, and defecation. However, reminds Abu-Alnadi, they are also critical for day-to-day activities. That is why activities such sitting or walking for prolonged period of time can contribute to pelvic pain. Common presenting conditions in reproductive health care settings are vulvodynia or dyspareunia. In fact, vulvodynia is not just a common condition, it is also a common etiology, as contact with a vulvar irritant causes the patient to contract the muscles of the pelvic floor in attempt to pull away from the irritation. If that contraction from pulling away becomes a learned response and happens frequently enough, the resting tone of the pelvic floor muscles changes from being relaxed, as would be expected during resting phases, to being continually partially contracted.
This partial contraction/partial relaxation results in a decreased blood supply to the muscles and can potentiate nerve damage or the nerve stimuli that causes chronic pain, explained Abu-Alnadi at Contraceptive Technology’s 2020 conference. Clinicians advise Kegels to strengthen these muscles, but they need to remember that these muscles also need to relax, not just contract.
If you suspect pelvic floor dysfunction, it is important to assess whether the muscles engaged during sex are shortened or painful to the touch, and whether any are painful when activated. You can assess the muscles’ resting tone by inserting a finger in the vagina and having the patient perform the Valsalva maneuver and then stop the Valsalva. There should be a noticeable difference in muscle tone, with the muscle group contracting during the Valsalva maneuver and then relaxing after.
In the basic pelvic floor exam, always assess the levator ani muscles, said Abu-Alnadi, because these are usually the ones associated with the pain along the vestibule experienced with vulvodynia. When you insert your finger into the vestibule, at about 2 centimeters you should feel a U-shaped muscle, which is the levator ani complex, situated at about 5:00 o’clock and 7:00 o’clock. Also always assess the deeper muscles of the pelvic diaphragm—the obturator internus and the piriformis. The obturator internus is long and flat. You can feel it when the patient activates the muscle by externally rotating each leg. This muscle inserts into the hip, so frequently patients will complain of hip pain. The thin strip of the piriformis lies along the ischial spine, about a centimeter cephalad, passes through the greater sciatic notch and attaches to the greater trochanter of the femur. Patients can experience pain in the hip and in the butt. In about 25% of patients, the sciatic nerve can run through the piriformis muscle, so the muscle spasm can cause numbness and tingling.
For patients with pelvic floor dysfunction, specialized physical therapy techniques can work wonders, said Abu-Alnadi. Pelvic floor physical therapy has no risk and every benefit. Techniques often include manual massage, trigger point release, application of hot and cold, or dry-needling. Patients learn to perform reverse Kegel exercises, during which the objective is not to tense up the pelvic floor but to instead focus relaxing and releasing the muscles of the pelvic floor. They will also learn pain management techniques, including deep diaphragmatic breathing, and bowel and bladder management.
Physical therapists will have their clients use vibrators along the perineum, which will help massage the superficial muscles but will also help decrease sensitivity. They often recommend that their pelvic pain clients use a pelvic wand for myofascial release and for trigger point release on an area of muscle that is painful but too far back to otherwise reach. A vaginal dilator is a great treatment option for vestibular pain, though less so for pelvic pain. A dilator helps desensitize the area overtime as the patient inserts it gently into the vestibule.
Physical therapy for dyspareunia is a total win, advocated Abu-Alnadi. However, some patients worry about the cost or their embarrassment over having the therapist place their fingers or instruments inside their vagina. If you can alleviate these concerns, and if there is a physical therapist to treat dyspareunia in the area, just know that you are doing your patients “one of the greatest services.”