By Stephanie A. Prendergast, MPT, Cofounder, PHRC Los Angeles
There are a number of treatable causes of clitoral pain, yet often patients are misdiagnosed and this distressing symptom can persist.
Hormonal deficiencies associated with birth control pills, acne medications, and age can lead to thinning of hormonally sensitive structures, such as the clitoris and clitoral hood. This can lead to micro tears, inflammation, pain and a few other symptoms described below.
Clitoral phimosis occurs when the clitoral hood fuses together. This can compress the clitoris and trap discharge under the hood and cause pain. Hormone deficiencies and vulvar diseases such as Lichen Sclerosus can lead to this type of architecture change.
Vaginal infections and vulvar infections can lead to inflammatory and infectious discharge that can accumulate under the clitoral hood and cause pain. It is important to note that vaginal swabs may be negative for infection but there can still be an infection on the vulva. Treatment for vaginal and vulvar infections are different.
Surgical scars in the suprapubic or vulvar area can lead to fascial restrictions, pelvic floor dysfunction, and/or peripheral neuralgias which can cause clitoral pain. Understanding what the cause is leads to effective treatment, which is often a combination of medical management and pelvic floor physical therapy.
Vulvar Lichen Sclerosus and other dermatologic diseases can cause clitoral pain. These diseases are thought to be autoimmune and are diagnosed via a biopsy and can be successfully treated with medical management.
Our bodies have right and left pudendal nerves with dorsal branches that are responsible for sensory information to and from the clitoris. If either of these branches become irritated, people may feel unilateral or bilateral clitoral pain. A diagnosis of pudendal neuralgia is made by history and physical examination. Pelvic floor dysfunction is associated with most pelvic pain diagnoses. Dysfunctional pelvic floor muscles can refer to pain in multiple places, including the bladder, urethra, clitoris, vulva, and vestibule. A diagnosis of pelvic floor dysfunction is made by a physical examination.
Clitoral pain is scary. The good news is that it is treatable when the underlying causes are identified and treated. There can be various reasons people suffer from clitoral pain.
Treatments include:
- Identifying and addressing the underlying cause
- Pelvic floor physical therapy
- Home exercises for tissue mobility
- Proper hygiene
If pudendal neuralgia is the cause, it needs to be treated. If a disease such as lichen sclerosus is the cause, it needs to be identified and treated. This is the case for everything on our list. Many providers may not understand all the causes of clitoral pain, if you are not getting the answers you need we recommend consulting with a vulvar health expert.
Resources
How to find informed medical providers
International Pelvic Pain Society Find a Provider
American Physical Therapy Association’s Section on Women’s Health PT Locator
Herman and Wallace Find a Provider
Pelvic Guru Provider Directory
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Are you unable to come see us in person in the Bay Area, Southern California or New England? We offer virtual physical therapy appointments too!
Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. For more information and to schedule, please visit our digital healthcare page.
In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page.
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FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.