Martha’s orthopedic evaluation revealed an unlevel pelvis, restricted spinal mobility, decreased hip abduction range of motion, a minor right sacroiliac joint dysfunction.  She has no visceral mobility dysfunction, no flexibility limits, no neural tension, and no core or leg weakness.  So, orthopedically speaking, we only have a few things to work on.

The pelvic floor muscle exam revealed dryness of the mons pubis and superior labia majora region, tightness of 2 superficial pelvic floor muscles, introitus tightness, and shortening of all deep pelvic floor muscles.  Her Q-tip test for vestibulodynia was negative.  When attempt was made to examine her internal (deep) pelvic floor muscles, Martha arched her back, clenched her teeth, and closed her legs together.  We used some relaxation techniques and emotional support was provided.  Martha had poor awareness or proprioception of the deep pelvic floor muscles and demonstrated discoordination (contracted the muscles when asked to relax and vice versa).  With instruction she achieved a very strong pelvic floor muscle contraction or Kegel contraction.  She also demonstrated good ability to volitionally relax or lengthen the muscles after instruction.  Martha was gaining some understanding and increased confidence.  By the end of her initial session/evaluation, Martha could tolerate 2-digit vaginal insertion and rated the pain as 2 out of 10.  She was nervous but gave approval to attempt this today! There was also provoked sensitivity with 2-digit insertion involving one area of the posterior fourchette (5 o’clock spot) yet no redness.  Martha is very brave and we commend her for tackling this issue.

Martha’s program will consist of pelvic floor muscle releases and re-education, joint mobilization to align her pelvic joints, sEMG biofeedback to improve her awareness/control, neuromuscular re-education of all her pelvic musculature, therapeutic exercises, behavioral modification, somato-emotional release (craniosacral therapy), integrative manual therapy (IMT), and dilator therapy.  She has been encouraged to continue sex therapy with her psychologist concurrently and to consider dating again.  We have also referred her to a nutritionist and a trainer.  A full recovery is predicted for Martha.  More to come on this case…

Hannah is a lovely 23 year old female referred to physical therapy with a diagnosis of pelvic floor muscle dysfunction and vestibulodynia, bilateral hip pain, and clitoral pain.  Her past medical history includes fatigue, seasonal allergies, nosebleeds, chronic migraines, sciatica, and a hernia repair (age 5).  She is married to a supportive spouse and they had recently moved to NYC from Israel.  Her medications included topical estrace cream, vitamin D and B12, and medication for her migraines.  She has a history of severe constipation, evacuating only twice weekly (normal is 1 – 2 bowel movements per day!).  Hannah also emptied her bladder every 5 hours daily whereas the normal rate is emptying every 2 – 4 hours.  So, she was chronically clenching her pelvic floor muscles causing extreme hypertonicity (shortening).

After Hannah married in June 2009, her first sexual intercourse experience with her husband was unsuccessful and resulted in severe pain and feeling itchy.  She called her gynecologist who prescribed an antifungal cream to be used topically on the vulva and intravaginally.  She returned to the gynecologist one week later due to no improvements.  She was seen by a physical therapist in Israel only twice with some relief yet pain returned three months after.  Trial of intercourse was painful again.  Hannah also complained of hip pain on both sides with walking and constant clitoral pain.  We had a lot of areas to address!

The orthopedic evaluation revealed impaired spinal mobility with lumbar facet joint irritation at L4 – 5 on the right, impaired flexibility bilateral lower quarter, weakness bilateral hip rotation movements, sciatic neural tension on both sides with positive SLR testing right side only.  Hannah tested positive for hip joint arthritis yet x-rays were not performed yet.  She had visceral mobility restrictions of the pelvic girdle and B SI joint pain.

The pelvic exam revealed clitoral phimosis Grade I with poor hygiene (smegma under the prepuce due to not cleaning properly), moderate pelvic floor muscle pain left side more than right, and when her rectum was palpated it reproduced her tailbone pain.  Touching her bladder and urethra referred pain to her clitoris.  She has what is known as “organ cross talk” (when the nerves of one organ cross paths with the nerves of adjacent organs and can mix up pain signals).  Hannah tested positive for localized provoked vestibulodynia and demonstrated weakness in her pelvic floor muscles.

After the evaluation, I recommended Hannah see an orthopedist for further hip diagnostic tests and we implemented a bowel/bladder retraining program.  She was instructed on proper clitoral/vulvar hygiene and care.  Hannah was also not applying the estrace cream correctly, so we discussed this and she was to call her doctor for re-instruction.  Physical therapy treatments focused on manual therapies to her pelvic girdle, hips, and pelvic floor muscles.  Visceral manipulation and massage to her colon and bladder were initiated immediately.  Hannah was given hip and low back exercises for homework and advised to ice her perineum daily with a gel ice pack specifically designed for the perineum.  We saw an immediate change in her hip mobility and significant reduction in pain by her 4th visit.  Her bowel frequency also improved to every other day yet was not everyday yet.  On her 4th visit is when we learned that Hannah was 8 weeks pregnant!  In fact, she had not been able to tolerate any thrusting by her partner.  She had conceived with only having penetration!  Her physical therapy could only be external techniques from here on.

Treatments consisted of external manual therapies to her pelvic girdle, lumbar spine, coccyx, pelvic floor muscles, hips, and sacrum.  Her vestibulodynia has improved to ranging now 3 – 7/10 from 8/10 prior.  She has been seen for only been seen for 6 sessions since learning of her pregnancy.  Hannah reports having no hip or low back pain, and only mild intermittent tailbone pain now.  Her treatment was recently complicated by onset clitoral pain which was determined to be a yeast infection under the prepuce.  Topical antifungal cream prescribed by her gynecologist has provided relief.

Hannah continues with physical therapy here as our goals are to achieve painfree tailbone and painfree clitoris.  An eventual goal at the end of her third trimester will be to prepare her pelvis for an easier birthing experience.

Ivan was self referred to us (after reading the website) due to right sided testicular pain and pelvic pain upon sitting.  He is a 34-year-old male with a supportive wife and a medical history of prostatitis and hemorrhoids.  He is a technology manager, which requires him to sit daily.  His other symptoms of urinary urgency/frequency began 1 year ago.  At that same time, he and his wife were having intercourse very frequently to conceive and he experienced pelvic pain the entire day after intercourse.  Ivan’s urologist referred him to a physiatrist (a doctor of rehabilitation) where he was incorrectly diagnosed as having a “groin strain”.  Hip massage and trigger point needling were not helpful. A pelvic ultrasound revealed varicoceles.  Ivan was seen by another urologist and given a 30-day dose of antibiotics. His symptoms improved a little but later persisted.

Initial intake with us revealed normal urination frequency of every 2 to 4 hours, normal BMI (body mass index), healthy diet and normal bowel habits of 2 daily.  Because he is in a rush at work, he bears down to evacuate his bowels faster.  He rated his stress level as moderate due to his work and inability to conceive with his wife.  Ivan’s pain level was 3 out of 10 and worsened with prolonged sitting and intercourse.  His pain improved with exercise, abstinence and after a bowel movement.

Ivan’s orthopedic evaluation revealed an uneven pelvis (called a pelvic obliquity), decreased flexibility lower quarter muscles, impaired sensation along his hip/thigh region, mild impaired hip range of motion, and mild visceral mobility restrictions.

His pelvic evaluation revealed left-sided superficial pelvic floor muscle pain/tightness, peroneal body tightness/swelling and moderate to severe deep pelvic floor muscle pain.  Palpation of his prostate caused penile tip pain (a reproduction of another symptom).  Ivan had very good strength in his pelvic floor muscles therefore his main issue was pain, shortening or tightness, and perineum swelling.  His sEMG biofeedback testing confirmed hypertonicity at 8.07 uV, whereas normal is considered below 4 uV.  Special nerve tests revealed tension along both pudendal nerves.

We referred Ivan to a top urologist, Dr. David Kaufman, in NYC who also specializes in pelvic floor muscle pain/pelvic pain.  He confirmed the pelvic floor muscle dysfunction but also thought another course of antibiotics was indicated to further treat the ongoing prostatitis.  The frequent intercourse seems to have been a cause or at least a perpetuating factor of the chronic prostatitis issue.

Physical therapy treatment for Ivan has consisted of manual therapies to realign his pelvic gridle and resolve the lower quarter muscle imbalances.  Specific manual techniques to reduce swelling and resolve his pelvic floor muscle dysfunction have proven to be beneficial already.  Neural tension releases have helped ease compression off of the pudendal nerves. After 4 sessions to date (August 31, 2010), Ivan is now able to sit at work!  The intensity of his testicular pain is now 1-2 out of 10 and there are times of the day where his pain abates completely.  Specific manual visceral techniques to his colon and prostate have lessened his penile pain and his sensation of bladder urgency/frequency improved.  A bowel retraining and education program was implemented.  Ivan no longer bears down for bowel movements and has improved his dietary fiber intake.  Ivan is taking daily baths at home to relax the pelvic floor muscles and is performing prescriptive therapeutic exercises and stretching exercises at home. He has been asked to abstain from intimacy for another week or two until his symptoms resolve further.

We are off to a great start!  Stay tuned for a progress update soon…..

Linda is a 55 year old psychiatrist referred to me by a urologist.  Linda’s chief complaints were pain with intercourse, recurrent urinary tract infections, and constipation.  She had a medical history which included anxiety disorder, scoliosis, genital herpes, and a uterine fibroid.  She had 2 prior c-sections, an appendectomy, and a myomectomy.  Her spouse was supportive.  She leads a sedentary lifestyle with no exercise routine.  Her medications included vaginal valium suppositories and macrobid which were recently prescribed by the urologist.  She used Dulcolax, an over-the-counter laxative, to treat her severe constipation.  She only had 1 to 2 bowel movements per week.  Normal bowel habits are 1 to 2 per day!

Some of the clinical orthopedic findings of the PT evaluation included impaired spinal range of motion in all directions, moderately tight hip adductor muscles, mild scoliotic spinal curve, severe tightness of her hamstrings and calf muscles.  She also had bilateral (both sides) sacroiliac joint dysfunction.  Her pelvic floor evaluation revealed moderate abdominal bloating, visceral mobility restrictions of the ascending and descending colon, c-section scar tightness, labia minora resorption, vaginal dryness, clitoral phimosis Grade II (adherence of clitoral prepuce or hood to glans), shortened pelvic floor muscles on the left only, mild pain of the vestibule at the posterior fourchette (4 to 8 o’clock positions), and weakness of her core and pelvic floor muscles.  She also had tightness to the introitus (vaginal opening) only tolerating 2-digit insertion.  So, there was quite a bit to work on! 

The priority for her was to get her the proper medications for the vaginal dryness, clitoral phimosis, and vulvar vestibule pain.  The second priority was to resolve the constipation through a bowel retraining and movement program.  This way we improve the vulvar tissue health and relieve her pelvic bowl of the toxins from stool faster.  Another result would be relieving the pressure on the bladder from having a constantly full rectum.  We wanted her to not have to bear down at all to have a bowel movement as this causes more pelvic floor muscle dysfunction.  She started daily application of estrace cream to the vulvar vestibule and inserted some into the vagina as her gynecologist prescribed and also applied clobetasol cream to the clitoris.  As part of the bowel retraining program, Linda was to begin increased water consumption of 6-8 glasses daily, decrease her cheese intake, and increase her consumption of fruits/vegetables.  For bladder retraining, Linda was asked to decrease her coffee intake, a major bladder irritant.  She was also instructed to perform prescriptive pelvic floor muscle exercises.

Her follow up with me occurred 1 month later. Linda reported having painfree intercourse for the first time in a long time!   She was compliant with her cream application, dietary changes, home exercises, water intake, and decreasing consumption of bladder irritants.  She reduced her coffee begrudgingly but was happy with the results!  She was also placed on a regimen of using Macrobid (an antibiotic) after intercourse to prevent onset of a urinary tract infections.  Her clitoral phimosis was minimally improved, yet this can take a few months to fully resolve.  Her constipation had also improved, yet she still was not having a bowel movement every day which was the goal. 

PT treatment consisted of manual therapies to her hip and pelvic girdle, transvaginal pelvic floor muscle releases, clitoral prepuce stretching, visceral manipulation, stretching, core and pelvic/low back therapeutic exercises.  Linda was treated for 5 sessions altogether over 6 weeks. 

During her 5th sessions it was noted that she had continued labia minora resorption and was referred a vulvar pain specialist to rule out Lichens Sclerosis (LS), a dermatological vulvar disease.  The clitoral phimosis was also unchanged despite cream application and prepuce stretching which can be an indicator of LS.  Orthopedic improvements included increased hip mobility all planes, painfree sacroiliac joints, improved spinal mobility, increased lower quarter flexibility, and decreased abdominal bloating.  Her pelvic re-evaluation revealed increased pelvic floor muscle lengthening and strength by 1.5 grades.  Her introitus became more flexible too, permitting 3-digit insertion.  She no longer had any bladder symptoms and intercourse had remained painfree!  Linda was discharged from physical therapy after meeting all of her rehab goals and is to continue with a home program. She now participates in a yoga DVD at home several times per week.  Linda was a pleasure to work with and it was rewarding seeing her achieve all of her goals.  Her overall compliance expedited her progress.  We wish her well.

Ruth came to me after being seen at another clinic for pelvic rehabilitation. She had suffered from fecal incontinence after undergoing anal sphincter repair surgery. Her surgery was complicated by an infection of the surgical site and scar tissue.

I evaluated her and noted that her pelvic floor strength deep layer (III) was weak on the left side > right and she had trace (barely there) contraction of the anal sphincter. Layer II was also weak but she had a contraction present. She had been performing internal electrical stimulation with her daily pelvic floor muscles exercises (Kegels) and sEMG biofeedback.

Ruth was a determined patient and wanted to leave no stone unturned in trying to regain her fecal continence. During the evaluation, I noted that Ruth had a stronger contraction using her pelvic floor muscles when she focused on contracting the “vaginal” aspect of the muscles. (The pelvic floor muscles surround and support both the vagina and the rectum.) So, we began to have her focus on and perform her electrical stimulation intravaginally, in addition to intrarectally.

This caused a mild improvement in her pelvic floor muscle strength and she began noticing a decrease in her incontinent episodes over the next 2 months. Because she only had trace strength in her anal sphincter, it would take a long time to build up or hypertrophy this area and the surgery had caused her to possibly lose nerve function. So, I was not sure just how much return of function she would get and neither was she.

But we were both determined! Oh, and did I mention that Ruth was a neurologist (a nerve doctor).

Ruth performed her home exercise program which included sEMG biofeedback, electrical stimulation, and specific “overflow exercises”. These are pelvic and hip exercises that encourage and recruit the pelvic floor muscles to contract harder. Ruth would come in for follow up appointments to monitor progress and I would then upgrade the difficulty of the exercises as she improved.

Well, after a few months and some mild improvements I thought that perhaps Ruth had reached a plateau and that I could no longer help her. Ruth would not accept this. I suggested that she try external electrical stimulation to the peri-rectal area and levator ani. External electrodes (stickers) were placed around her anus region and the stimulation unit facilitated a stronger contraction for her. It is called NMES-neuromuscular electrical stimulation. She worked on this unit at home for several weeks and had a follow-up with her colorectal surgeon.

He was thrilled and said that she had gained significant return of anorectal strength and to continue with physical therapy. Ruth returned to me and we tested her. In fact, she had gained about 2 grades of strength in her sphincter and levator ani muscles. Her fecal incontinence had improved significantly although she still was having a few episodes. Ruth works diligently at her home program and I commend her for her hard work. It is a pleasure to be a part of her rehab process.

Tune in soon for another update…….

Nina was such a great success story!  She was one of my younger patients, age 19, with celiac disease and social anxiety disorder.  She was in a long-term relationship and in college.  She had complained of having pain during her first attempt at intercourse and any subsequent attempts with pain at the vaginal entrance.  Digital stimulation was painful but she still participated to have some sort of sexual experience with her boyfriend.  She was orgasmic with clitoral stimulation. She was very bright, very quiet but determined to fix her problem.

Her physical therapy evaluation revealed impaired spinal and hip mobility, shortened deep pelvic floor muscles with trigger points, localized provoked vestibulodynia, and partial vaginismus.  sEMG (surface electromyography) biofeedback of the deep pelvic floor muscles(levator ani) revealed instability and spasms yet she had good resting tone at 1.37uv (2.0uv or below is considered acceptable).  She also had very tight lower extremity muscles.

She was given a home exercise program including stretches, instructed in dilator use and self-pelvic floor releases.  She was in college so she was unable to take warm baths that was also prescribed for her.  Manual therapy to her hips, pubic region, sacroiliac joints and lumbar spine, gluteal region, and pelvic floor muscles occurred each session.

By her fourth PT session, she had pain-free insertion of 1 finger, improved hip mobility, and continued to progress very well with dilator use (up to level 2 now).  By her 10^th visit, I noted that the redness of the vestibule region was not improving and suggested she see a vulvar pain specialist and consider applying topical estrace cream as her long term use of oral contraceptives may also have been a factor.  She did exactly that and was prescribed topical estrace cream compounded in a non-chemical base daily application to the vulvar vestibule.

During her 16^th session, she progressed to tolerating 2-3 finger insertion…on her way!  She still had some pain but significant improved introitus (vaginal opening) flexibility and had moved onto using a medium dilator (level 3).  I found that her hymen tissue was tight…. there was a tight band in the upper left quadrant so we spent some time addressing this issue via manual stretches.

At her 24^th session, she reported breaking up with her current boyfriend and starting a new relationship with a partner that was more supportive and understanding.  By her 26^th session, she tolerated 3 fingers insertion with very little discomfort and by the next session had had intercourse 4-5 times with no pain, using dilators prior. She was discharged on her 28^th session and reported not needing to use dilators before intercourse!!

Update on Nina’s story: