Pelvic pain is a common physical and emotional barrier to intimacy
Not long ago, the words “impotence” and “incontinence” would never have been mentioned in polite company.
Now because of drug company marketing campaigns, erectile dysfunction and overactive bladder are the subject of nightly TV commercials and even party talk.
Here’s another taboo topic some physical therapists and doctors – and their female patients – would like to bring into the open: pelvic pain during sexual intercourse.
An Indiana University survey found that 30 percent of women reported difficulty with pain during their most recent sexual encounter. Estimates are that pelvic pain affects 70 percent of women over age 40, interfering with urinary continence as well as sex.
But many women just live with it. They’re embarrassed. They don’t know there’s help.
Physical therapists have known for decades that pelvic pain can stem from spasms in the muscles of the pelvic floor. Exercise and stretching can restore flexibility and relieve pain in the pelvic floor, as they do with other muscles.
“Most people don’t even know they have a muscle there,” said Barbara Green, a Charlotte physical therapist who specializes in women’s health. “They don’t know that it’s too tight, and they don’t know how to relax it.”
Green and other physical therapists say they help women recover the ability to have pain-free sex – or have it for the first time – by massaging the pelvic muscles to help them relax and by teaching women to relax and contract those muscles themselves.
In movies, books and among friends, everyone seems to be having sex and having fun. No one talks about the possible pain.
“I want to assure them,” Figuers said, “it is not at all uncommon, and it’s very treatable.”
Physical therapy can help
Only in recent years have medical schools taught gynecologists about using physical therapy to treat pelvic pain.
“I’ve been out of residency for 10 years, and I never heard a thing about this,” said Dr. Chris Morris with Providence OB/GYN in Charlotte.
For years, Morris said he sometimes felt helpless when patients complained of painful intercourse. Several years ago, he learned about the use of physical therapy at a lecture. “It made such sense,” he said.
Patients and doctors may have a hard time believing pelvic pain can be a muscle problem, Morris said. Maybe it doesn’t start that way, he said, but at some point, women “get a contracted pelvic floor that they are unable to relax. They have sort of accepted that ‘This is life, and I’ll never be able to enjoy sex again.'”
When Morris began referring patients to Green, he was impressed by the results.
“I can think of probably five patients who say it has changed their life,” Morris said. “[One] had not had sex with her husband for more than five years. Now, she says, ‘I’m having pleasurable, comfortable sex in a way that I never thought I would.'”
Dr. Alyse Kelly-Jones, co-founder of The Center for Sexual Health and Education in Ballantyne, said doctors should refer women to a physical therapist as part of the evaluation of any pelvic pain disorder.
“What often happens is women hurt below their belly button, and their gynecologist doesn’t really find anything, but says, ‘Maybe we should do some surgery to look around.’… Some women get surgery that’s unnecessary.”
Today, gynecologists can specialize in pelvic medicine through fellowships in urogynecology. Most academic medical centers now have pelvic pain clinics, where patients can get treatment and professionals learn about physical therapy.
At Duke, Figuers teaches doctors, physician assistants and physical therapists during their training.
Charlotte has several urogynecology specialists and about a dozen physical therapists who can treat women for pelvic pain.
“This is truly an accepted therapy and should not be overlooked,” said urogynecologist Dr. Kevin Stepp, who joined Carolinas Medical Center-Mercy last summer. But he said some patients are skeptical because they think of physical therapy as “a room full of guys with sports injuries.”
“This isn’t the physical therapy you think of. It can be very intimate. It also can be done at home.”
Holly Herman, co-founder of Herman & Wallace Pelvic Rehabilitation Institute in New York, has been using physical therapy to treat pelvic pain for 34 years. She teaches courses for health professionals around the country.
Still, among some doctors, she said, “There’s this whole mentality of ‘Have a glass of wine and everything will be fine.'”
As more people get training, Herman said, “Doctors are finding out that it’s not just women being frigid.”
Cause is hard to find
Pelvic pain that makes intercourse difficult is described in the medical world as dyspareunia (dis-par-OO-nee-ah).
There are many causes. But muscle tension and tightness in the pelvic floor is a major factor, and that type of dyspareunia is called vaginismus (vaj-in-ISS-muss).
For some women, vaginismus can occur early in life, making it impossible for them to insert a tampon or have a gynecological exam before they even think of having sex. Others can have normal sex lives and develop pelvic pain later.
The cause of the pain may be hard to identify. It can be related to scarring after surgery, such as episiotomies, C-sections and hysterectomies, or to vaginal dryness with menopause. It can also be a response to stress.
“Some people hold tension in their neck,” said Green, the Charlotte physical therapist. “Some people hold tension in the muscles in their pelvis.”
Physical therapists follow a step-by-step approach to calm the tension and stretch surrounding muscles of the back, hips, buttocks and thighs.
Therapy includes massage, with the therapist helping to release tension by touching pelvic muscles, ligaments or scar tissue with a gloved finger.
“It’s like a gynecological exam, but we’re working with muscles, just like we work with any other muscles in the body,” she said.
Green identifies the muscles as she touches them, and she can tell when a muscle is tight or when it’s relaxed. But many of her patients can’t tell whether the muscles are relaxing or contracting.
That’s why therapists also use biofeedback, with electrodes attached to the pelvic region. Patients can see on a monitor whether their muscles respond when they consciously try to relax and tighten.
Other exercises are recommended to stretch or strengthen abdominal and hip muscles. Therapists also use dilators, inserting them into the vagina to stretch and relax muscles; patients also use the devices at home.
Both Figuers and Green said patients should first have a checkup with a gynecologist to rule out a serious medical problem. They also refer patients to psychotherapists for treatment of emotional issues.
Blog opens discussion
Rachel Zimmerman, a reporter for public radio station WBUR in Boston, recently blogged about her own experience with pelvic pain and physical therapy. Although she’s an educated health-care consumer, Zimmerman said she had never heard of the treatment until she complained to her gynecologist about pain during intercourse.
The blog attracted many readers grateful to her for letting them in on the secret.
One wrote: “Physical therapy … not just antibiotics, cremes or surgery…who knew? Now we do. Thank you.”
Karen Davis of York County, S.C., just south of Charlotte, found out about the treatment after she’d been married for 18 years without having intercourse. She married as a teenager and hadn’t been able to use a tampon or have a pelvic exam because the pain felt like “a razor blade cut.”
Davis said she and her husband found other ways to have sex – she called it “outercourse.” And the years went by. “We had a very satisfying sex life until we wanted to have children.”
Tension over that issue led to their divorce. Only later did Davis learn physical therapy could treat her condition – vaginismus.
On the Internet, she found Barbara Green and started physical therapy. In less than four months, she was able to have intercourse, without pain, for the first time.
“It’s changed my life,” she said. “I just wish I could have found her a long time ago.”
Davis’ ex-husband is now remarried, with children. Talking about it makes her cry. She had wanted children too.
“I battled with it my entire life,” Davis said. “Now I’m 46 and treated, but it’s too late.”
Today, she tells other women about physical therapy for pelvic pain through an Internet support group.
“That’s my salvation,” she said, “being able to help other people.”
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