What is pelvic floor physical therapy?

Pelvic floor physical therapy is an important part of treatment for most women with vulvodynia. A pelvic floor physiotherapist is trained to treat muscles, nerves, and structural impairments. In many cases, the primary physician can determine that a woman has pelvic floor dysfunction and can immediately refer her to physical therapy. Alternatively, a woman may see a physical therapist first, or if she has not gotten better with other treatments.

The goals of physical therapy will be specific to each patient, and will determine the purpose and specific therapies used. For example, the ability to have intercourse may be a goal for some women, but not others.

A physiotherapist can also help with accurate diagnosis. Similar to a visit with a sexual medicine specialist, a physiotherapist will also start with a detailed history. It is important to collect as much information as possible about all types of pain and when they occur. This will help give the therapist some initial ideas about what to look at first. A therapist can makes connections among symptoms that may seem unrelated, but may be indicative of a certain problem. I’ll use myself as an example. I did not think that my constipation, urinary frequency, hip pain, and lower back pain were severe enough to worry a lot about, and never thought they may be connected to my sexual pain issue. It turns out that these are all symptoms of hypertonic pelvic floor dysfunction!

Pelvic Floor Anatomy

The muscles of the pelvic floor form a bowl that supports the pelvic organs. The vagina, urethra, and rectum all pass through these muscles. Dysfunction in individual muscles can lead to certain symptoms, and these are the kinds of connections a pelvic floor physiotherapist can make.

The pelvic floor muscles are innervated by the pudendal nerve. The pudendal nerve has three branches: the dorsal clitoral, posterior labial / perineal, and inferior rectal. A physiotherapist may be able to map pain to an individual nerve or branch, which would indicate and underlying nervous issue. The Pelvic Guru’s has an Ultimate Pelvic Anatomy Resource that includes a map of nerve branches.

A pelvic floor physiotherapist will also check alignment and mobility. Innate structural problems may be the cause of muscular dysfunction, as surrounding muscles try to compensate for a defect. Limited joint mobility can perpetuate dysfunction and is important to consider. Mechanical issues can also lead to nerve pinching (or entrapment) between structures and cause pain.

What does a pelvic floor physical therapist do?

There a number of techniques that a pelvic floor physiotherapist may use, depending on the particular issues and goals of each patient.

• Myofascial Release & Trigger Point Release - The fascia is a system of connective tissue that surrounds all muscles and bones; dysfunction can lead to trigger points and shortening of tissues. Chronically tensed muscles tend to collect knots / trigger points, which are particularly painful. These can be released by applying pressure to the knots to temporarily block blood flow and act as a “reset.” This can be done both externally (e.g. hips, thighs) and internally (vaginal, rectal).

• Joint Mobilization - If certain joints are painful or have reduced range of motion, a physiotherapist may work on stretching and strengthening.

• Neural Mobilization - If nerves cannot move properly through surrounding structures or are pinched, a physiotherapist will work on fixing the mechanical causes of the restriction.

• Scar Tissue Mobilization - If a woman has scars, perhaps from childbirth or surgery, lack of mobility of these tissues may be the cause of pain. A physiotherapist can work on gently moving the scar to treat adhesions of the tissue to the surrounding tissues, and improve mobility.

• Vestibule Desensitization - In combination with cognitive behavioral therapy, a physiotherapist may use a process of vestibule desensitization to help with the fear of and response to pain. Gradually increasing pressure is applied to the vestibule with a q-tip, and, over time, the patient accommodates until it is no longer painful.

• Bowel & Bladder Retraining - Pelvic floor muscle dysfunction can cause issues with bowel and bladder function. Oftentimes, these issues are exacerbated by certain behaviors; a physiotherapist may educate a patient on new best practices for improving function.

• Breathing Practices - Deep diaphragmatic breathing relaxes the pelvic floor muscles and is crucial for both improving awareness of the pelvic floor and reducing pain. This may be done in conjunction with mind-body practice.
  

There are a few more techniques/ tools that can be used, but are adjunct to the main techniques above:

• Biofeedback - Electromyography (EMG) biofeedback displays muscle activity in a digital feedback. It can be helpful for assessing muscle activity and helping women know when muscle activation / relaxation is being performed successfully, as this takes time to learn how to feel.

• Vaginal Dilators - Dilators are made from various materials (silicone, plastic, glass, etc.) are are used for desensitization, stretching, and even internal trigger point release. Often, dilator therapy is part of a home therapy program.

• Dry Needling - In most states (currently 45), physiotherapists can perform dry needling of trigger points using thin needles (as used in acupuncture). Insertion of the needle into the trigger point facilitates a muscle twitch and subsequent release of the knot. Note that this is different from trigger point injection.

• Mind-Body Practices - Deep diaphragmatic breathing, progressive relaxation, guided imagery, and other mid-body practices may be helpful, especially in reducing muscle tension.

I have been in pelvic floor physical therapy for over a year now. I went for eight months before my vestibulectomy; during that time I made minimal progress in relieving my severe muscle tension, likely because the vestibule pain was so severe. Most women with vestibulodynia also have hypertonic pelvic floor dysfunction because the initial pain leads to constant (unknowing) muscle contraction. It is thought that this is a guarding technique in response to pain.

I started therapy again about six weeks after my surgery. My muscles have been more responsive to treatment than before, and I’ve made much more progress. Also, we have been working through the scar tissue (fortunately minimal) from the surgery and that mild pain resolved quickly.

In my appointments, my physiotherapist usually spends the first ~10 minutes checking my alignment and working on tension in my abs, hips, and thighs. The next ~10 minutes working on the pelvic floor muscles externally, and another ~20 minutes on the pelvic floor muscles internally (one finger in the vagina). The last ~10 minutes are spent on my lower back and buttocks, stretches, and rechecking alignment. At the start of an appointment, my hips are usually tilted to the right and twisted, but much straighter at the end. I have had dry needling of trigger points in my thighs, hips, and buttocks, but I prefer manual release when possible, as I find it less painful.

Reference

Irwin Goldstein, Anita H. Clayton, Andrew T. Goldstein, Noel N. Kim, and Sheryl A. Kingsberg. 2018. Textbook of Female Sexual Function and Dysfunction, Diagnosis and Treatment. John Wiley & Sons Ltd., Hoboken, NJ. https://onlinelibrary.wiley.com/doi/book/10.1002/9781119266136

The Pelvic Guru’s website is full of fantastic information about pelvic floor physical therapy!