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?
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@
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.