Thinking Beyond the Dilators: How Vicki Beat Vaginismus

By Morgan Conner, DPT, PHRC Los Gatos

Sadly, the starting point of this success story is not novel to me as a pelvic floor physical therapist or for many who struggle with primary vaginismus. However, this story has a happy ending (pun very much intended!) as well as an interesting middle. When Vicki (not her real name) married her husband three years ago, they attempted to have intercourse for the first time and they “hit a wall.” Being the resourceful couple that they are, they promptly went to see a gynecologist who recommended she start using dilators and sent them on their way. Vicki then got dilators and started using them. She found that her progress was slow; it took her a year to even be able to fully insert the smallest dilator. Three years later she was able to get the third dilator inserted but moving it around was incredibly painful and she was still not able to have sex with her husband. Vicki and her husband told me that at this point they were not sure what to do. However, when they first got her diagnosis they found the r/vaginismus subreddit, so they went back there and not only found out about pelvic floor physical therapy, they also found a recommendation for PHRC! They decided that she should go back to the gynecologist and get a pelvic exam before coming to pelvic floor PT. (She was able to get the exam BUT it was under anesthesia.) After the exam, she was told that her pelvic floor muscles were very tight and she needed to get them to relax. Cue pelvic floor physical therapy music please!

When Vicki came in for her initial evaluation, her husband came too. They tag-teamed the interview portion of the visit where they told me the above story and were eager to get her the help she needed. They also told me that when Vicki was quite young she fell and landed on a bar between her legs (ouch!). After the interview, we proceeded to the physical exam where I found the following:

Connective tissue restrictions in the abdomen, medial thighs, bony pelvis, suprapubic region and buttocks and myofascial trigger points in bilateral adductors and obturator internus
PT (me) was unable to spread labia to visualize vulva and perform internal exam due to guarding, Vicki had to spread her own labia
During the exam, mobility of the clitoral hood was impaired with touch resulting in guarding. She also presented with mild clitomegly. (Normal clitoral size is about the size of a pencil eraser.)
Vicki reported pain when I touched the vestibule with a cotton swab
Significant guarding with gluteals and lower extremities when my finger was nearing introitus for insertion
Tolerated vaginal insertion of full index finger
Increased muscular tension, thickening, overactivation and myalgia present throughout the levator ani and urogenital diaphragm.
Impaired motor control: difficulty with pelvic floor relaxation and bulging and minimal pelvic floor movement with breathing.

While that might make perfect sense to me and many of PTs who read this blog, I want to make sure we are all on the same page. If you want a detailed walk-through of my examination of Vicki, or want to know what yours might look like if you were to see a pelvic floor physical therapist for vaginismus, scroll down to the bottom of this article.

My clinical assessment of Vicki was that the muscle and connective tissue tension, along with hypersensitivity throughout the vulva and difficulty relaxing her pelvic floor, were making it uncomfortable for her to tolerate things (finger, dilator, penis, etc.) touching her vulva and vagina, let alone having any of those inside her vagina without pain. While I have seen sensitivity in the vulva before, I had a suspicion that her childhood accident may have contributed to her clitoral and vulvar hypersensitivity. While there is no way to know this for sure, I appreciated knowing this piece of her medical history as it certainly informed my plan of care. With all this in mind here are the goals Vicki and I discussed were to: 1) decrease the hypersensitivity of the vulva and clitoris, 2) be able to relax the pelvic floor, 3) be able to use the largest dilator without pain and with ease, and 4) be able to have intercourse with her husband.

The plan to get her there included weekly pelvic floor physical therapy sessions that included manual therapy to improve the connective tissue restrictions and muscle tension and a daily home program. Her home program included: 1) dilator training, 2) vulvar desensitization, and 3) manual pelvic floor releases to be performed by both the patient and her husband. With the dilator training, I backed her down to the smallest size dilator and had her start pressing the dilator into the sides of the vagina to help stretch out the pelvic floor, then to rotate the dilator and finally once those felt okay, to start moving the dilator in and out. Once she was able to do all of these with the smallest size she could move to the next size up and so on with each size. With the vulvar desensitization, I had her start by just touching and stroking the inner side of the labia majora with a good water-based lubrication. For the final part of her home program, I had described to her and her husband how to do the manual internal releases. With her home program in place, we concluded her first visit and she got to work on her home program.

After a few sessions, she had made some good progress and had been working on her dilators daily, and her husband was working on her pelvic floor every one to two days as well. However, she told me that what he was doing was not the same as what I was doing in our sessions. So, I had her bring him to her next session where I taught him how to find the tight muscles in her pelvic floor. I used our 3D pelvic model to help him visualize where his finger was. I find that this helps people to better understand what is going on in the pelvis and pelvic floor.

After this first tweak to her home program, Vicki started making progress with leaps and bounds every session. Both she and I would get excited (I love hearing that my patients are getting better!) as she told me about how she was having less pain with touching this or that part of her vulva. Eventually after about six sessions, I was able to separate her labia without her flinching, she was no longer guarding during the insertion of my finger into her vagina, and there was no burning pain when I moved around while palpating her pelvic floor. However, she was still fairly guarded and tender around the clitoris and just lateral to the introitus and despite good progress with the dilators, the third dilator (her end goal) was still uncomfortable to move around and she was still unable to have intercourse (they tried once and it didn’t work). She also told me at this time that she and her husband were wanting to try to get pregnant in the next year.

With this in mind we adjusted her home program again. In addition to her husband doing the pelvic floor massage, he would also start using the dilators with her. This is an important step as intercourse, similar to any other group activity, is not solely controlled by one person so getting used to having someone else move the dilator around can be a good addition to a program. Next we progressed her desensitization program by having her start desensitizing the tissues around the clitoris by moving the clitoral hood up and down. And in the clinic, I started working more intensely to mobilize the skin and fascia around her suprapubic region. Lastly, we added in desensitization to the posterior labial tissues next to the vaginal opening and a foam rolling routine for her legs.

After 13 sessions, she was really close to successful intercourse. She reported that she and her husband had been able to incorporate stimulation of the clitoris and labia into their physical intimacy. This was a huge step for her as prior to starting PT she was barely able to touch these places let alone include them into physical intimacy. She was also not having any difficulties with the third dilator. They had attempted intercourse again and while it was not nearly as uncomfortable as before with contact to the vulva, they were still “hitting a wall.” As she and I discussed what might have been going on, we figured out that it may have been related to their position and some lingering tension in her perineum. So that day we focused on stretching out her perineum and talked about what positions would allow her pelvic floor to be the most relaxed.

The next session she came in and reported that she had been able to have intercourse not only once, but twice! She had needed to use a bunch of pillows, be in a specific position, and dilate beforehand but nonetheless she had been able to do it! As we discussed this huge win for her, she mentioned that she understood now why the vulvar and clitoral desensitization was so important. We had talked about it before, that while the dilators are a stand in for the penis, her husband was attached to the other end of the real thing and he would probably end up touching the area around her vagina during intercourse. If she was still hypersensitive, this might lead to her guarding again which in turn might lead to her tightening her pelvic floor and cause them to keep hitting that wall. This was also an “Aha” moment for me because it reminded me of two things: 1) how important it is to treat the whole patient and the whole condition and 2) how important it is to explain why we as physical therapists are assigning a specific activity or exercise to a patient.

Here is what I believe were the keys to Vicki’s success: Her dedication to and diligence with her dilator program, incorporating the desensitization of the entire vulva, and help and support from her partner. While what we did in the clinic during her pelvic floor physical therapy sessions was important, what I did was not nearly as important as the work that Vicki did outside of the clinic. I like to say to my patients “You are the driver, you have control of your therapy. I’m just the navigator pointing you in the right direction. YOU are in control.” Vicki is the real rockstar and hero of her story, she was the driver.

Here is what Vicki had to say about her PT experience:

“Since vaginismus is a lesser known condition, I didn’t have good luck finding help from regular ob-gyn and primary care doctors. I was pleasantly surprised when I came across a testimonial for PHRC on reddit. Within the first few sessions with Morgan I was sure that I was in the right hands and that this was the treatment I was looking for. Morgan had a holistic approach in helping me both physiologically and psychologically. She custom curated the sessions based on my progress which helped me immensely. I would strongly recommend others who are facing this condition to consult PHRC.”

You can find other blogs on vaginismus here:

And more resources here:

Blog about what a good pelvic floor PT session is like: https://pelvicpainrehab.com/pelvic-health/5974/part-1-of-2-what-is-a-good-pelvic-pt-session-like/
Webinar on Vulvodynia: https://www.youtube.com/watch?v=dxPCCDejedY&feature=youtu.be and https://pelvicpainrehab.com/female-pelvic-pain/6694/pelvic-pain-explained-vulvodynia/
Podcast on vestibulodynia, vulvodynia and Vaginismus: https://podcasts.apple.com/us/podcast/episode-21-stephanie-prendergast-dpt-pelvic-floor-pt/id1379107302?i=1000427642085&mt=2

Epilogue:

While Vicki was able to achieve her initial goal of intercourse and desensitization, we didn’t feel like she had reached her full potential so we set a few new goals: to be able to change positions during intercourse and be able to have intercourse without dilating first. After one more session and with these new goals in mind, she decided that she wanted to try working on her own and would reach out to me if she felt like she needed my help again. At this point, I asked for her permission to tell her success story and she agreed hoping that her story could help someone else with vaginismus to get help.

Physical exam walk-through:

I almost always start my physical exam by checking for restrictions in the skin and fascia, for example when I drag my fingers across the skin on the top of your thigh, does it move easily or get stuck? In this case, it was getting stuck and pretty much everywhere I checked. Next we checked for any trigger points, spots where the muscles felt like they were knotted up; she had a few in the legs and hips. Next we moved towards the internal portion of the exam. I like to start by looking at the vulva in order to check the skin for any abnormalities. In order to do this, I have to use my fingers to separate the labia majora. From there, I check the clitoral hood mobility by placing a finger above the clitoris on the top part of the clitoral hood and gentle pull up, does it move easily and without any pain? With Vicki, that first step, the separation of the labia, was painful and triggered muscle guarding in her glutes and legs. So we adjusted, she held her labia slightly apart so that I could test the clitoral hood mobility (it wasn’t moving as much as it should and looked like it was almost glued down to the clitoris). Next, I performed a Q-tip test. This test is where the PT gently taps a Q-tip around the vestibule (the area inside the labia minora) and introitus (the vaginal entrance) to check for any spots of tenderness. Vicki had tenderness throughout the vestibule. This test helps PTs know where in the vestibule a patient has pain with light touch and can help you know where you might need to avoid. Since Vicki was sensitive everywhere, I proceeded very carefully and slowly. I started my internal exam by applying gentle pressure to the perineum (the area just behind the vagina). There is a muscle here that is often very tight and I have found that if I apply pressure here I can help this muscle relax while my patient gets used to having my finger near their vagina. While doing this with Vicki, she had difficulty keeping her legs relaxed and I could feel her tightening her pelvic floor. (This is not uncommon for those with vaginismus.) However, I was able to slowly insert my finger into her vagina where I found that the muscles all around her vaginal walls and pelvis were very tight and she had quite a bit of difficulty relaxing and lengthening these muscles. After testing her muscle control I slowly removed my finger and concluded my physical exam. I then let her get dressed before we started talking about the plan moving forward.

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.