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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