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: