Dr. Lauren Peterson, PT, DPT
Physical therapy for pelvic pain
The most vivid memory from the Pre-Cana class I took with my husband was the teaching that in a Catholic marriage it is imperative to be open to life and to be committed to raising your children in the Church. Having and raising children is a joy and pleasure which most Catholic couples look forward to and see as the next natural step in life, if the sacrament of marriage is where we have been called. Not to mention that the holy scriptures tell us that man and woman are to be one - that our union in marriage is consummated through intercourse, and part of the love from God is shown in the birth of a child.
When sex with your spouse isn’t straightforward
But what if you can't consummate your marriage? What if intercourse is not the pleasure that society describes, but instead a barrier to your marriage and children? What if intercourse is so painful that your partner feels coercive or abusive when trying to initiate sexual relations or you start to feel yourself tense up at the mere thought of attempting intimacy again? It can make you feel less than, it can put a strain on your marriage, it can be a barrier to having children, it can make you feel incomplete as a woman and a married Catholic, but it shouldn’t.
If intercourse is not pleasurable for you, if intercourse is painful for you, you are not alone.
Pelvic pain disorders
Millions of women suffer from a variety of pelvic pain disorders. They are characterized by intermittent or constant pain anywhere in your groin (including your low abdomen). If your pain is so severe that it is preventing you from engaging in sex with your husband, that is certainly going to have an impact on your ability to be a mother.
Pelvic pain manifests in a variety of ways. Two of the most common pelvic pain conditions are known as vaginismus and dyspareunia. Vaginismus is an involuntary tightening of pelvic muscles. Whereas, dyspareunia means very specifically painful intercourse. But maybe you experience a constant, raw feeling of pain, a condition known as vulvodynia. Or maybe you feel pain only when your genitals are touched, a condition known as vestibulodynia. Or maybe your pain started with the insertion of a tampon.
No matter how your pain started or when it occurs, if pain is preventing you from participating fully in your marriage, if it is preventing you from engaging in sexual intercourse, your pain is a problem and one that you shouldn’t feel embarrassed about. And you shouldn’t feel like you have to deal with it silently or alone.
Don’t suffer in silence
Pelvic pain may be something you have suffered from for a long time. Or it may be relatively new for you, which can make it that much more frustrating to your partner and put an even bigger strain on your relationship. Oftentimes women have suffered in silence, not knowing that treatment options exist, or who even to talk to. It is all too common that I hear that a woman reached out to her Ob/Gyn, only to have her concerns dismissed. Or being told to “relax”, “take a bubble bath” or “drink a glass of wine”.
I want you to know that treatment options do exist, that you are normal, and that you are perfectly created in the image of God. That you were created in the image of God, just as were Adam and Eve, means that you are made of muscle and bone and connective tissue. Being human means that you can suffer bodily and emotional wounds, which can present themselves in a variety of ways.
What do you do in pelvic floor physical therapy for pelvic pain?
If you have never heard of pelvic floor physical therapy before, you can be forgiven. While the field itself is well studied, and has strong evidence-based practice, most women and even many Ob/Gyns are unfamiliar with what a pelvic floor physical therapist does or how they can help. Remember that your body is made up of muscle, bone, and connective tissue. So just like your leg or your arm, your pelvic floor can be injured, unhealthy or weak. It is the foundation of your core, made up primarily of your hip bones, sacrum and pelvic floor muscles. As the foundation of your core, pelvic floor muscles are responsible for, or take part in, some really important functions of daily life including holding in your organs, coordinating your breathing, standing, sitting, walking and, most importantly, urogenital functioning (that is sex, urination and defecation).
While each of us is made in the image of God, each of us is unique. When it comes to pelvic pain, we are unique in our anatomy, and unique in when and how our pain occurs. That means that a cookie-cutter approach to pelvic pain might help you improve, but to get the best outcome you need to see a pelvic floor physical therapist who can develop your personal plan of care. When it comes to the women I help with their pelvic pain, there are six treatment elements I used in varied combinations to help my patients get the most from treatment.
1. Getting your husband on board
In 1 Corinthians 7:4, we hear “A wife does not have authority over her own body, but rather her husband, and similarly a husband does not have authority over his own body, but rather his wife.” If we read that to believe that we must be subservient in dealing with pain, then we overlook the immediately preceding verse, “The husband should fulfill his duty toward his wife…” (1 Corinthians 7:3).
We can look to these verses to acknowledge that pelvic pain is 1) not something you should have to handle alone, and 2) that your husband is going to be key in getting you the treatment you deserve. When you suffer from pelvic pain, having relations might be the last thing you want to do but this can be confusing and isolating for your partner. I like to encourage my patients to bring their husbands with them because your husband needs to know that the pain you are dealing with is not his fault any more than it is yours. And you both need to know that through the treatment of pelvic pain you can improve the physical and emotional aspects of your relationship.
(Note: While the focus of this article is on pelvic pain in women, I would be remiss not to point out that men can have pelvic pain as well. And that pain can be just as embarrassing and just as debilitating in a relationship. If your husband seems not to want to engage in sexual intercourse because of pain, pelvic floor physical therapy is a treatment option available to him as well.)
2. Coordinated breathing
Healthy muscles are both strong and flexible. When you are dealing with pelvic pain, your muscles are not as healthy as they could be, which usually means they are too tight and lack flexibility. For this reason I have found coordinated breathing to be one of the most effective techniques I can share with you, and it’s usually the first technique I consider teaching my patients. Remember that your pelvic floor is intimately associated with breathing because of the pelvic floor connection to your diaphragm. Poor, shallow breaths up in our chest can make the tension in our pelvic floor far worse. Poor breathing is also linked to stress, anxiety and pain. If we can get you to breathe properly, we can get you to relax. If we can get you to relax, we can get your pelvic floor to release tension. And if your pelvic floor has less tension, you may start to enjoy intercourse.
Because your pelvic floor is the foundation to your core, it interacts with your hips, low back, abdominals, and legs. There is evidence to suggest that pain and tightness in these other areas is correlated with underlying pelvic floor dysfunction including pelvic pain. Learning how to properly stretch all of these tight muscle groups produces multiple benefits, not the least of which is reducing stress and improving muscle health. Healthy accessory muscle groups are only going to better support your pelvic floor taking less strain and pressure off of these muscles.
4. Targeted exercises
You cannot just look at a woman and know she has a strong, healthy pelvic floor. I have seen elite athletes with unhealthy pelvic floors and I’ve seen out-of-shape women who had great pelvic floors. The requirement that healthy muscles are both strong and flexible, means that a “tight” pelvic floor is not necessarily healthy (and it may not even be that strong). However, most providers’ go-to for pelvic floor dysfunction is the pelvic floor muscle contraction, or “Kegel.” In the case of pelvic pain, this is likely to make things worse. You need to learn to relax your pelvic floor muscles first.
There are some other muscle groups that may need strengthening, or that can support your pelvic floor as you learn to properly relax. Learning to use your abdominal muscles, inner thighs, and gluteals (butt muscles) separately from your pelvic floor muscles can go a long way in allowing your pelvic floor to relax and relieve built-up tension. If you are unsure about what you are doing or you have increased pain, stop your strengthening exercises. You need to speak with a pelvic floor physical therapist who can properly evaluate your pain. Until then, stick with stretching and breathing.
5. Manual muscle manipulations
Pelvic pain syndromes are medical conditions and, just like an Ob/Gyn, I take my responsibility to my patients very seriously. But that doesn’t mean that everything is extremely comfortable. You need to know that a good pelvic floor physical therapist is highly trained and is going to work with you at the level at which you are comfortable but I would encourage you to be open to all available treatments. One such treatment is manual muscle manipulation. Whether your pelvic floor physical therapist calls it "pelvic floor releasing" or "manual therapy", manual muscle manipulations are one of the most important tools we have in treating pelvic pain. Manual therapy allows your physical therapist to manually release tightened muscles.
If you have ever had a massage with a trigger point released, you have experienced manual therapy. Trigger point release can be achieved with a finger (“digital”), pelvic dilators or a pelvic wand. Regardless of the tool used, manual muscle manipulation is meant to reduce the tension, pressure and pain caused by vaginal muscle trigger points. You can be taught to perform manual therapy techniques on yourself; they work really well when you have a partner helping to relieve your pain. By this point in treatment, we really hope your partner is on-board.
When it comes to your body and your healthcare, it is your choice; you have to be comfortable with your body and be an active participant in your treatment. If you're not ready for manual therapy, biofeedback is another option that can be used. (It is also really great in combination for those who are comfortable). Because biofeedback is more personal than stretching or breathing, but less invasive than internal muscle work, I use it for many of my patients being treated for pelvic pain.
Biofeedback shows you a visual representation of how well you contract and relax the muscles of your pelvic floor. Using a handheld unit with real-time feedback, we can better teach you how to coordinate your breathing with a Kegel, how to downregulate your nervous system, and how to relax your pelvic floor for maximum benefit.
Living without pelvic pain
By incorporating properly coordinated breathing, stretching, targeted exercises, manual muscle manipulations and biofeedback into a plan that fits your unique needs, you can enjoy a healthy pelvic floor and you can live your life without pelvic pain. Fertility is already a challenging journey for so many women; pelvic pain shouldn’t have to be a burden you carry on that journey. If you are having difficulty conceiving because of pain during intercourse, you owe it to yourself to speak with a pelvic floor physical therapist about this highly effective approach to treating pelvic pain.
Dr. Lauren Peterson, PT, DPT is the clinical director and co-owner of FYZICAL Therapy & Balance Centers of Oklahoma City. She specializes in pelvic floor, vestibular and orthopedic physical therapy. Dr. Peterson is one of four CAPP* certified practitioners in the state of Oklahoma. She wants you to know that there are treatment options for your pain and pelvic floor dysfunction, and that you don't have to go it alone. If you are unsure about your pelvic health, or you want to see the FYZICAL Difference for yourself, schedule a free consultation today.
*Certificate of Achievement in Pelvic Physical Therapy from the American Physical Therapy Association