Success Story: Tessa’s Triumph Over Painful Sex

By Shannon Pacella, DPT, PHRC Lexington

Do you remember the first time you tried using tampons? Did you have anyone help guide you or were you trying to follow the little paper instructions from inside the box? Once you mustered up the courage to try and insert it, was it painful? Maybe you were not able to get it inserted at all. You may have been afraid to ask for help or thought there was something wrong with you since your friends seemed to have no problem with them. What about gyn exams? Do you loathe the thought of having a speculum inserted due to pain? If any of this sounds familiar to you, keep reading to learn about Tessa’s story of triumph over pelvic pain.

Tessa is a 22 year old cis female who was referred to pelvic floor physical therapy by her gynecologist with the diagnosis of vaginismus. She is a recent college graduate and is in a long-distance relationship. Tessa reported excruciating pain with any vaginal penetration, which has prevented her from ever being able to use tampons. She experiences pain with speculum insertion during gynecological exams, and she has not been able to have sex with her partner due to this pain. She described the pain as a sharp stinging around the vaginal opening with initial attempt of penetration, and then she can feel her pelvic floor muscles tensing and tightening, preventing further penetration. She had previously read a book about vaginismus and tried to use dilators on her own, but was unsuccessful. Tessa also reported occasional constipation and urinary frequency prior to falling asleep. Tessa’s goals for physical therapy were to gain control of her pelvic floor muscles, be able to comfortably insert a tampon, and eventually have sex.

What is Vaginismus?

Vaginismus is characterized by involuntary contractions of the pelvic floor muscles, interfering with vaginal penetration. Vaginismus is often revealed during penetration attempts such as those made by inserting a tampon or a speculum during a gynecological exam.

There are two types of vaginismus, primary and secondary.

Primary vaginismus: have always had pain with vaginal penetration.
Secondary vaginismus: have had pain-free vaginal penetration in the past.

To learn more, we have a blog that offers a rough guide to vaginismus.

Tessa has been an athlete and has always been very active, but reports never being flexible and often feeling stiff in her hips and back. She also recently discontinued taking oral birth control pills (three months prior to our evaluation), and reports that she had been taking them for approximately six years.

These were Tessa’s objective findings upon physical examination:

Connective tissue restrictions in the abdomen, medial thighs, posterior thighs, bony pelvis, suprapubic region and buttocks.
Myofascial trigger points in bilateral adductors, piriformis, and obturator internus.
Erythema (redness) around the vaginal opening at the vulvar vestibule.
Tessa reported pain when I touched the vulvar vestibule with a cotton swab.
Significant guarding of gluteal muscles when my finger was nearing introitus for insertion.
Tessa reported pain with palpation of pelvic floor muscles.
Pelvic floor muscle hypertonus: increased muscular tension, thickening, overactivation and myalgia present throughout the levator ani and urogenital diaphragm.
Impaired motor control: difficulty with pelvic floor relaxation and minimal pelvic floor movement with breathing.

To learn more about pelvic physical therapy evaluations, check out What to Expect From A Pelvic Floor Physical Therapy Appointment, What is a Good Pelvic PT Session Like and Part 2.

My clinical assessment of Tessa was that her connective tissue tension, myofascial trigger points, and pelvic floor muscle hypertonus, along with hypersensitivity throughout the vestibule, and difficulty relaxing her pelvic floor, were making it painful for her to tolerate things (tampon, dilator, speculum, etc.) touching her vulva and vagina, let alone having any of those inside her vagina without pain. These findings are consistent with primary vaginismus. Also, due to her history of taking oral birth control pills and the redness and hypersensitivity of the vestibule, as it appears Tessa may have OCP induced vulvar vestibulitis and also have hormonally mediated vestibulodynia. I recommended that Tessa discuss this with her gynecologist who could prescribe a topical hormonal cream.

With all this in mind here are the goals Tessa and I discussed:

To decrease the hypersensitivity of the vaginal opening/vestibule, in order to not have pain with touch to the vaginal opening.
To improve pelvic floor motor control in order to be able to voluntarily relax the pelvic floor muscles.
To be able to insert and use tampons without pain.
To become independent with at home dilator use and be able to insert the largest dilator without pain in order to prepare for eventually having sex with her partner.

The plan to get Tessa to reach these goals included weekly pelvic floor physical therapy sessions that included manual therapy to reduce the connective tissue restrictions, myofascial trigger points, and pelvic floor muscle hypertonus, pelvic floor motor control exercises to allow her to voluntarily relax her pelvic floor muscles, and teaching her an at home exercise program.

Home Exercise Program (HEP)

Diaphragmatic breathing exercises with focus on relaxing the pelvic floor
Self myofascial release of her hips and thighs using a foam roller
Positions that facilitate pelvic floor muscle relaxation (child’s pose)
Self abdominal massage to reduce constipation
Dilator exercises*

*Dilator exercises: At her third appointment, Tessa was able to insert the smallest dilator without pain. At her next visit, Tessa was able to rotate the smallest dilator clockwise/counterclockwise, and gently press the dilator along the sides of the vagina helping to release pelvic floor muscle tension. Tessa then progressed to the next size, and once that became pain-free, she moved on to the next size, and so on.

Tessa’s gynecologist prescribed a topical hormonal cream which she applied around the vestibule twice a day.

At Tessa’s sixth appointment she had big news to announce: she was able to insert a tampon comfortably, without pain for the first time ever!

Tessa has gained tremendous confidence in knowing that she was able to control her pelvic floor muscles. She was able to get her first pap smear which requires speculum insertion, and had a good experience with that as well.

Tessa continues to follow her home exercise program and is able to use the largest dilator in her set without pain. She feels much more comfortable for when the time comes to have sex with her partner.

Take Home Points:

Tessa’s difficulty with insertion was caused by pelvic floor dysfunction
Tessa’a difficulty with insertion was also caused by hormonal insufficiencies from birth control pills
Pelvic floor physical therapy and dilators alleviated the muscle pain
Topical hormone therapy alleviated the pain in Tessa’s vestibule
Both PT and MD management helped her achieve her goals!

Many women present with muscular and hormonally causes of difficulty with insertion. Learn more about the causes in this video and this podcast!

If you can relate to Tessa’s story, our website has a section where you can learn more about physical therapy for pelvic pain.

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Are you unable to come see us in person? We offer virtual physical therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online.

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.

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

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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.