By Sigourney Cross, DPT, PHRC Walnut Creek
Vaginismus is characterized as an involuntary spasm or contraction of the muscles around the vagina. This makes it very difficult for women to insert tampons, receive pelvic exams by their doctors and can also make sexual intercourse nearly impossible and painful. It can affect women anywhere from their teenage years to later in life. Vaginismus can be caused by physical factors, emotional factors or most frequently a combination of both. Because of the varying forms of vaginismus, symptoms can vary widely among individuals. As previously mentioned, vaginismus can lead to painful intercourse or dyspareunia. Dyspareunia is defined as persistent or recurrent genital pain that occurs just before, during, and/or after intercourse. Just like vaginismus, dyspareunia can affect women of all ages and can occur for physical and or psychological reasons. The symptoms of dyspareunia also varies between individuals. It’s not uncommon for both of these diagnoses to occur simultaneously.
For the purposes of privacy and confidentiality, I’ll refer to the patient in this case study as Martha. Martha is a woman in her late 30’s who was referred to PHRC by her primary care physician with the diagnosis of both vaginismus and dyspareunia. Martha and her husband of almost two years really wanted to start a family so started trying to conceive shortly after their wedding?r. Martha had never attempted intercourse before her marriage. Whenever her and her husband attempted intercourse they had to stop because it was too painful for her. She reports at first they attempted more frequently, however, after many failed attempts at penetration they gave up and stopped trying altogether. Her PCP attempted a pelvic exam, however, was unsuccessful due to Martha’s pain, fear and anxiety. Martha also stated she has never been able to wear tampons. She said she had previously tried pelvic floor physical therapy without success. With further questioning, she admitted to the fact that she was very inconsistent with going to her treatment sessions and that her prior physical therapy treatments consisted of mostly breathing and stretching exercises. She was also given dilators, however reports she was scared of them because she was never really shown how to use them. Martha had some difficulty describing the nature of her pain as she and her husband were never really able to get past her introitus or the entryway leading to the vagina. She stated everything felt extremely tight, sharp, achy and burning all at once. Martha denied any significant medical or surgical history and had never been on any form of birth control. She did report a history of occasional urinary tract infections. After a year had gone by with her and her husband only making one attempt at intercourse, Martha realized the lack of intimacy was taking a major toll on her marriage. Her and her husband started seeing a marriage counselor which was helpful emotionally, however still wasn’t helping them become physically intimate. With her marriage on the line and the realization that her goal of having kids before she turned forty was getting further from her reach, Martha had a new fire lit under her and knew she needed more help. Her primary goal for therapy was to have pain free intercourse with her husband so that they could start a family.
Examination and Assessment
I knew that with Martha’s failed gynecological exam attempt and fear and anxiety surrounding her pelvic floor, I was going to have to take things very slow and explain everything I was doing along the way. After hearing her history I felt the cause of her symptoms had both physical and psycho-social /emotional factors. In cases like this, patient education is key. Before I initiated the exam I used a model of our pelvis and went over in detail the anatomy and function of the pelvic floor and explained all the structures I would be assessing and how they could be contributing to her pain. Upon examination I found the following myofascial impairments:
- Moderate connective tissue restrictions throughout her bony pelvis and bilateral adductors
- Severe myofascial trigger points in her bilateral adductors, and both her superficial and deep pelvic floor muscles
- Hypertonicity (Increased tone/tightness) throughout her pelvic floor
- Vulvar tissue dryness and erythema
- Poor pelvic floor range of motion with inability to drop or bulge her pelvic floor
As explained earlier, it can be difficult to pinpoint one direct cause of vaginismus, however given Martha’s history and physical findings, it is plausible that her pelvic floor dysfunction started with her history of chronic uti’s and poor vulvar hygiene, which led to vulvar tissue dryness and sensitivity, which would then make it more uncomfortable when she started attempting intercourse. Once she had the first sign of pain while trying to achieve penetration, she likely went into protective mode and started muscle guarding which led to more tightness and trigger points, which then leads to more pelvic pain and the cycle continues! Her strained marital relationship was also in the backdrop of all of this happening which likely had an even further impact on her symptoms.
After listening to Martha’s story I knew the primary thing I needed to figure out was why her first bout of pelvic floor physical therapy was unsuccessful, as I didn’t want to repeat things that were not helpful to her. The biggest thing that stuck out to me was the lack of consistency of her physical therapy treatments as well as lack of patient education and guidance through an appropriate home exercise and dilator program. I started with tons of patient education with Martha. Educating Martha on the emotional and physical causes of her symptoms really helped a lot with her fear and anxiety surrounding intercourse as it helped de-mystify what was happening to her “down there.” I recommended Martha be seen by me 1x/week for 8-12 weeks. I stressed the importance of her being consistent if she wanted to see a significant change in her symptoms. Throughout her treatment sessions, I continued to educate her about her external and internal myofascial impairments so she always knew why we were performing certain interventions and how those interventions addressed her specific impairments. She also had extensive education regarding proper vulvar hygiene and topical recommendations to improve her vulvar tissue health, which was another important factor in making the manual therapy more tolerable. The first few treatments with Martha I focused on more of her external myofascial restrictions to gain her trust and allow her time to feel safe and comfortable with therapy. I gradually added in longer periods of manual therapy to her pelvic floor muscle restrictions. I also assigned her a home exercise program including pelvic floor relaxation exercises to improve her range of motion and ability to relax her pelvic floor muscles. By session four, Martha felt ready to try dilators again. Instead of just telling her to buy some dilators and use them, we went over different dilator options, the pros and cons of each and I went over dilator exercises for her to practice at home. Over the next few weeks she became more and more confident and slowly progressed herself from dilator size one to dilator size five! By week nine, she was able to tolerate this size with little to no pain and felt ready to try again with her husband.
By our 10th session Martha was elated and so proud to tell me her and her husband had intercourse for the first time! She said it wasn’t all stars and fireworks, however she was able to tolerate penetration without any pain. I saw Martha a total of 13 treatment sessions. By her 13th session she and her husband had successfully had intercourse on four different occasions, for longer periods of time and still pain free. She was ready to progress her goals. After accomplishing her goal of being able to have pain free sex, she now wanted to have great sex and achieve orgasm!
There were a few things that I think made the biggest difference during this bout of therapy that helped Martha achieve her goal.
- The first and most important thing was patient education. Before coming to the Pelvic Health and Rehabilitation Center, Martha never had a clear understanding of her impairments, how they contributed to her symptoms, and how exercise, manual therapy and a consistent dilator program would help her achieve her goals.
- The second most important thing was consistency. Her prior PT sessions were few and far in between. I made sure she understood the importance of consistency as it takes time to change her connective tissue restrictions and myofascial trigger points that she had been living with all these years.
- Another thing that helped make a big difference was setting smaller, more attainable goals. We discussed at length how it can feel overwhelming to see the path from no intercourse to pain free intercourse. We worked on attaining smaller goals, which included first being able to tolerate internal soft tissue mobilization and trigger point release during treatment sessions, then being able to tolerate a size one dilator by this week, size two by this week, etc. Accomplishing these smaller milestones, made her more motivated to keep going.
- Finally, the help of her marriage counselor was crucial. As we progressed through her physical impairments her and her husband were able to make progress in their marriage and regain emotional and other forms of physical intimacy, which was imperative to their success.
I’m happy Martha has achieved her goal of having pain free intercourse with her husband. As far as Martha’s new goal of having great sex and achieving orgasm, this is out of the scope of physical therapist practice. Her and her husband plan to continue their marriage counseling and I have referred them to a sex therapist to take their intimate relationship to the next level.
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