By Sara K. Sauder
In preparing the curriculum for my class on vestibulodynia (yes I will start talking about this class over and over because I am discovering so much and learning a lot while in the process of creating and teaching the curriculum and this is a blog that I write using real life experiences so why wouldn’t I write about something that I’m doing and learning from in my real life experience)…what was I saying?
Oh yes.
In preparing the curriculum for my class on vestibulodynia, I think made some pretty refreshing connections between pain at the vestibule and clitoral pain. I’d like to share some of this information because, while it doesn’t exactly completely challenge the thought that the dorsal branch of the pudendal nerve could be the culprit for this pain, it certainly does give some options for a different approach in tackling clitoral pain. I said “tackling” clitoral pain. I guess we just need to “resolve” clitoral pain. No need for aggression or sport references, I guess.
So there is the classic hypothesis that it is the dorsal branch of the pudendal nerve that is responsible for clitoral sensation. I’m sure that it is indeed responsible for clitoral sensation, but I am not positive that the dorsal branch is the only nerve responsible for clitoral sensation.
The ilioinguinal nerve could refer painful sensations to the clitoris. The ilioinguinal comes from L1 spinal level. Do you have back pain? Had a hernia repair or abdominal surgery? Maybe, just maybe your clitoral pain is coming from or contributed to by the ilioinguinal nerve.
Could the genitofemoral nerve from the L1,L2 spinal level possibly extend down the padded area above the clitoris (the mons pubis) to the clitoris on some patients? I think so. Think about this too if you had a hernia repair or abdominal surgery.
So, I’m basically asking…did you have a hernia or abdominal surgery before you started having clitoral pain? Well, if so…think ilioinguinal or genitofemoral nerve.
Think “WHAT?” though? Good question.
Consider these three options…the dorsal branch of the pudendal nerve, the ilioinguinal nerve and the genitofemoral nerve…you could block one of these nerves to see if it eliminates your clitoral pain. Then, you know what nerve is problematic. You can then, or instead, have your physical therapist do several things to attempt to improve the mobility and the health of that specific nerve.
Your pelvic floor physical therapist could:
1. Do skin rolling or connective tissue manipulation or trigger point work along where the nerve runs. This will attempt to improve the mobility and health of the nerve by bringing more blood and oxygen to it. Nerves require 20% of the body’s oxygen, but only make up 2% of the body.
2. Correct your pelvic alignment. This will improve the function of the muscles and nerves in your pelvis. The bones of the pelvis are the foundation that the nerves and muscles in the pelvis lie on. If the foundation is asymmetrical, how can you expect the muscles and nerves to operate correctly? Potentially, tight muscles can pinch around a nerve and cause that nerve to basically “choke”. Being out of pelvic alignment can be a quiet thing, it’s trying to get your attention, but it sometimes can’t get your attention until shit hits the fan and it’s blue in the face waving its arms around and throwing things trying to get anyone to help. It isn’t getting oxygen, it’s not getting enough blood supply…so the output is pain along where the rest of that nerve runs. Consider pelvic alignment corrections a way of performing the Heimlich on your nerves. They will thank you for it once they can breathe again. And then they’ll go sky diving and travel the world and finally write that memoir they have been putting off. They will title it “Too Nervous to Try: One Nerve’s Journey to the Hood and Back” <— Please acknowledge “hood”, just please.
3. Go to your spine. Do you have back pain? Do you have hip pain? Something really cool about our bodies is that when we have pain in location A, it is sometimes stemming from a problem in location B. So, you could have hip pain or pelvic pain or specifically clitoral pain that is actually stemming from an issue at one or several levels of the spine. It’s like humans are a computer. Or, it’s like computers are human. Whatever helps you sleep better at night. The entire lumbar and sacral spine could be contributing to clitoral pain by effecting the performance of firing, mobility and health of nerves that exit the spine and can give your brain information about sensations at the clitoris. If the sacrum is tilted to a side, flexed forward or extended backward or rotated, or any combination of these movements, it can also effect the lumbar spine (which sits on top of the sacrum) because ligaments do attach the two last segments of the lumbar spine to the sacrum. (Yet another reason to always check and correct pelvic alignment.)
But, your physical therapist could also…
- Look at your clitoris. Is there a dermatological issue here? Do you need a referral to a dermatologist for a specific medication to clear up a skin condition that could be creating clitoral pain?
2. Look at your clitoris…again. Is the skin really fragile? Is it no longer supple healthy? Is the clitoris really small? Is the hood over the clitoris really stuck? These could be signs that your therapist needs to actually start moving the hood of the clitoris gently so that it is not adhered to the clitoris itself. You can also do this yourself gently at home, like while in the shower or on the toilet. If the clitoris is really small, this could be one of many signs that you need some estrogen placed on your clitoris, your vulva and your vagina.
3. Check out your vagina. Are the vaginal muscles really tight? Do you need to focus on relaxing the pelvic floor? Have you just gone through a stressful experience and now you don’t know how to calm down the pelvic floor? Have you always been high stress or high anxiety and you’ve never been able to calm the pelvic floor? This can cause clitoral pain too.
There are so many ideas, so many doors to open and close, so many ways to develop clitoral pain…and therefore different ways to treat pelvic pain. There is no one cure for clitoral pain because there is no one cause for clitoral pain.
If you have any questions or comments, please leave them anonymously in the comment section below or email me atSara@
www.blogaboutpelvicpain.com
www.sullivanphysicaltherapy.com
Best,
Sara K. Sauder PT, DPT
Sara is a pelvic floor physical therapist from Sullivan Physical Therapy in Austin, Texas. Sara’s primary interest is pelvic pain. She is consistently learning about new treatment techniques, reading about complex pain treatment approaches and pursues opportunities to learn from pelvic pain specialists across the country. Her goal is to help people living with chronic pain learn how to manage, improve and abolish their symptoms. She feels patient education is vital to recovery and she works to have open communication with each patient’s medical team. Sara believes that the mind and the body work together to both create and eliminate pelvic pain.
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.
Comments
Great article!! I actually have small cuts under the hood and near the clitorus area that have not been healing for nearly 3 months causing tremendous pain ( this is most likely due to repeat yeast infections).
I know my flora is off since I have been on many medications to try and clear this up for months so I am now just working on correcting this with putting some good bacteria (over counter prebiotic creams) but otherwise I will mention this to my PT as I was not aware that there was anything she could help with in regard to the clitorus. I am interested in the estrogen approach since my clitorus is small and wondering if that would speed the healing?
Hello Susan,
Great questions. However, in order to know for sure, you will need to have a therapist evaluate you.
Best,
Sara
Are there any known trigger points, either internally or externally – eg, back, hips, ribs – that impact these specific nerves or the clitoris?
Thanks for the post!
Hello Hoodie,
Great question! Yes, there are several possibilities, but in order to know which is contributing to a patient’s symptoms, an evaluation with a pelvic floor therapist is required.
Best,
Sara
I’ve been experiencing right sided clitoral nerve pain for the past several weeks from sitting too long and shortly thereafter sustaining a sports injury that possibly changed my alignment and re flared it worse. (I thought I recovered from the initial flare of sitting because I could have intercourse enjoyably two weeks later) If my PT adjusts my pelvic alignment–if that’s the culprit, will the pain diminish immediately or is there a recovery time for the pudendal nerve to heal since it’s been in pain? Your website is the first one to provide some hope and well being about PN. Best wishes.
Hello Loralie,
“Adjusting a pelvic alignment” is not the same as manual therapy. Internal and external manual therapy release by a pelvic floor therapist, along with patient education are the main contributors to a patient’s improvement. I am happy to recommend a local therapist if possible. Where are you located?
Best,
Sara
Can you locate a local therapist for me? I live in Michigan.
Hi Jules,
Please use the link below to locate one.
https://pelvicguru.com/2016/02/13/find-a-pelvic-health-professional/
Regards,
Admin