Intercourse Pain

Posted by on Aug 31, 2010 in Dyspareunia


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 pain-free 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, pain-free 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.