Today, September 21, 2010, I evaluated a classic case of vaginismus. Martha is a 40-year-old female referred to physical therapy by a sex therapist/psychologist. Martha had undergone psychotherapy for the past 6 months to deal with her inability to tolerate sexual intercourse. Penile penetration into her vagina since age 18 was impossible and her partners in the past have told her that they feel “a wall” at her vaginal opening. Any repeated attempt at penetration resulted in pain. Martha’s medical history includes obesity, heart murmur, gallstones, and uterine fibroids. The fibroids were removed surgically in 2006. Prior traumas included death of her mother when she was 21 years old and she reported being beaten as a child for chronic bed-wetting from age 4 to 11 years old. Martha had a “normal” diet yet admitted to eating lots of chocolate, meats, and cheese daily. She exercised 4 days per week consisting of slow walking for 45 minutes or a low-level exercise DVD. She has normal voiding (urination) of every 2 to 4 hours and 2 bowel movements daily. She only drinks water, more than 8 glasses per day. She only sleeps 5 – 6 hours per night. So although Martha has some healthy habits, her eating and sleeping habits likely contribute to her inability to lose weight. She denied thyroid problems and previous blood work had been done. Martha did report having performed dilator therapy with her sex therapist in 2002 successfully and had one partner that she could have non-pleasurable sexual intercourse with in the past. However, Martha could never tolerate the speculum insertion for gynecological exams, even the pediatric-sized one. Additionally, Martha reported being able to achieve orgasms using a magic wand to stimulate her clitoris in the past. Overuse of the device and using it incorrectly caused her to have persistent clitoral numbness. Her goal of physical therapy was to have pleasurable sexual intercourse. Martha’s pain level was rated at 10 out of 10 upon attempted penetration.
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…