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The Case of Female Pelvic Pain, Painful Sex

Posted Apr 19 2013 3:49am
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This week’s post is a case study of a female pelvic pain patient.

Before I get into the specifics of the case, let’s first take a look at female pelvic pain by the numbers:

    10% of all visits to gynecologists are due to chronic pelvic pain. 25% of women will experience chronic vulvar pain at some point in their lives.
  • 60% of sexually active women will suffer from painful sex at some point in their lives.

The good news is that physicians and patients have become more aware of the important role that PT plays in the diagnosis and treatment of female pelvic pain.

Now, let’s focus in on one woman’s experience with pelvic pain, sexual pain and pelvic floor PT.

Patient History

About nine months before her appointment, Meghan, a 30-year-old female, had been diagnosed with a bacterial vaginosis, or BV, infection. (BV is the most common vaginal infection in women of childbearing age.) Her Ob/Gyn gave her a prescription for oral antibiotics to treat the infection.

The antibiotics were successful in clearing up the infection, however Meghan continued to have provoked vulvar pain. She was unable to tolerate vaginal penetration of any kind, including tampon use or a speculum exam. She described the pain as a “burning, raw feeling.” On top of that, she was “tensing up with anticipation of sex” and since the onset of her symptoms, found that although she tried to relax during sex, she could not. Because of her pain, she had completely stopped having intercourse.

To treat her symptoms, Meghan’s doctor gave her a prescription for a topical steroid. However, because she had an allergic reaction to the medication, which exacerbated her symptoms, she stopped using it.

In addition to the steroid, she tried applying lidocaine ointment to her vulva and vestibule during sex. This produced no change in symptoms. Her doctor also advised her to soak a cotton ball in lidocaine, insert into her vaginal opening, and leave overnight. This also did not change her symptoms. Meghan was also taking 25 mgs of amitriptyline for anxiety and Lutera for birth control.

Meghan had also taken the advice of her doctor and eliminated all harsh soaps, dyes, and chemicals from her daily hygiene routine.

Meghan said that before the BV infection she had never had any pain or difficulty with sex or vaginal penetration. In addition, she had no urinary or bowel symptoms. Plus, she could wear jeans, tight pants, and underwear. As far as daily exercise, she attended a “boot camp” exercise class at her gym three to four times a week.

Goals

Before I talk about Meghan’s goals, I’d first like to chat a bit about our goal-setting process at PHRC. Obviously, a patient’s ultimate goal with PT is to get better! But, as both patient and PT embark upon that goal, it’s important to set more specific, attainable goals along the way. This allows both patient and PT to assess progress throughout the course of therapy.

At PHRC, at the beginning of treatment, we work with patients to set both short-term and long-term goals. When we refer to a patient’s “long-term” goals we do not mean his or her ultimate goals for treatment. Rather, long-term goals are set for eight to twelve weeks down the road. Our objective is to set achievable goals for the first round of long-term goals, and then to modify as we go.

As for a patient’s “short-term” goals, it’s understood that the time it will take to achieve these goals will be less than what will be needed to achieve the long-term goals.

Initially, for her long-term goals, Meghan wanted to be able to tolerate full insertion of her partner’s penis with a 50% reduction in pain during and post coitus. In addition, she wanted to be able to tolerate insertion of a speculum with less pain so that she could receive her annual PAP exam.

As for her short-term goals, Meghan wanted to establish a home exercise program, which included work with vaginal dilators. In addition, she wanted to see a decrease in pelvic floor muscle tone and trigger points by 50% to allow for a decrease in her fear and anxiety with vaginal penetration

Findings

Below is an outline of my findings following my initial evaluation of Meghan. I’ve presented my findings in detail as in the past, readers have communicated to us that they actually appreciate this level of detail. However, if you have any questions, please don’t hesitate to ask via the comment section or e-mail!

Structures Evaluated and Objective Findings:

I. External

Connective Tissue Assessment: 

  • Connective tissue of abdomen and suprapubic area: suprapubic: minimum restriction and abdomen: moderate restriction.
  • Connective tissue of bony pelvis, labia, through groin area, ischial tuberosity (IT), and anterior through suprapubic: moderate restriction, minimal traveling up to suprapubic area.
  • Connective tissue medial and lateral thighs: moderate.
  • Connective tissue buttocks: moderate to minimum.
  • Connective tissue post thighs: minimum to moderate restriction as move cranially, closer to IT, dorsal branch territories, tissue close to vaginal opening.
  • Connective tissue low back: minimal restriction.

External Muscular Assessment:

  • Trigger points located in: rectus abdominus on right side, right illicacus, bilateral adductors, superficial transverse perineal/bulbospongiosus from external palpation: trigger points at 5-7 o’clock positions (very tender), right piriformis, left gluteus medius, piriformis, gluteus maximus.

Visual inspection of Vulva/Vestibule/Pelvic Floor Muscles:

  • Mild erythema noted at Hart’s line, reflexive guarding with external palpation, quivering of perineum upon contraction-minimal relaxation on release, could bear down and did have perineal descent.

Q-Tip Test:

  • Tender at 3, 5, 6, 7, and 9 o’clock

II. Internal

Internal Pelvic Floor Muscle Assessment

  • Tone is increased globally.
  • Reflexive guarding present with digital insertion.
  • Connective tissue lateral to urethra and urethral sphincter: normal.
  • Urogenital diaphragm: bilaterally decreased length.
  • Trigger points: located superficial transverse perineal, bulbospongiosus, ischiocavernosus bilaterally.
  • Reproduced burning pain with myofascial release of bulbospongiosus, trigger point release to superficial transverse perineal at 6 o’clock, and vulvar connective tissue mobilization bilaterally.

Deeper Structures: (bilateral obturator internus, pubococcygeus, and illiococcygeus):

  • Control is fair to poor; there is an increased baseline tone.
  • Delayed and incomplete relaxation.
  •  Poor quality of concentric contraction.
  • Normal bearing down
  • Transverse abdominus symmetry noted with minimal voluntary contraction

Assessment

Patient presents with increased pelvic floor muscle tone globally, restricted connective tissue mobility in the above-mentioned structures, poor control, reflexive guarding, and muscular trigger points throughout her pelvic girdle and pelvic floor musculature. She also presents with poor motor control and delayed voluntary relaxation.

These impairments contribute to her symptoms of entry dyspareunia and provoked vulvar pain. I am able to reproduce her pain with penetration upon myofascial release and trigger point release of urogenital diaphragm (specifically bulbospongiosus and superficial transverse perineal muscle), connective tissue mobilization to vulva, and bilateral obturator internus trigger point release.

In addition, the above impairments contribute to patient’s functional limitations of inability to tolerate vaginal penetration, which impacts her ability to have intercourse with her partner, wear tampons, or undergo an annual PAP exam. She is very anxious regarding her condition, and exhibits reflexive guarding and fear avoidance behaviors that contribute to the physical impairments of shortened pelvic floor muscles and active spasms.

Initial Treatment Plan:

  • PT once a week for eight weeks: Treatment to include: manual PT techniques to restricted tissues; connective tissue mobilization to vulva prone and supine, abdomen, bony pelvis prone and supine, medial thighs, buttocks, all planes; and trigger point release to abdomen, hips, adductors, hip extensors, abductors, urogenital diaphragm, levator ani, and obturator internus muscles.
  • Initial home program: Exercise modification, a decrease in boot camp activities; deep breathing; relaxation techniques/pelvic floor drops; and start with vaginal dilators.

Outcome

After eight visits, I assessed the following changes:

  • Vulvar burning was less with vaginal penetration: dilator and finger;
  • was able to insert largest dilator out of five with fifteen seconds of mild burning, and then no pain;
  • Meghan was less afraid of vaginal penetration;
  • and she was able to “relax” her pelvic floor muscles voluntarily.

My assessment:

  • Pelvic floor muscle hypertonicity persists, although is lessened;
  • trigger points in urogenital diaphragm still present, but are decreased to right bulbospongiosus and left ischiocavernosus;
  • increased vulvar connective tissue mobility;
  • improvements in motor control, able to voluntarily relax after contraction;
  • still presents with impairments contributing to entry dyspareunia;
  • Q-Tip: tender at 6 and 7 o’clock positions;
  • erythema (skin redness) no longer present;
  • and reflexive guarding no longer present with digital insertion.

New Plan of Care:

  • Continue PT once a week for another six to eight weeks
  • Increased digital insertion to two fingers to aid in increased myofascial release
  • Continue with manual techniques to restricted tissues, increase time spent internally as external findings are normalizing and primary impairments remain in pelvic floor muscles and vulva.

New Goals:

  • Continue to pursue long-term goals
  • Transition to light aerobic exercise program with no flare ups of symptoms
  • Transition to two digit internal myofascial release with patient reporting no increase in burning or pain to aid in transition to intercourse

After a total of 13 visits (Meghan was able to decrease her number of visits to one every other week at visit number nine), I discharged Meghan with all of her goals met and her symptoms eradicated. After visit number eight she had transitioned to intercourse. In addition, she returned to yoga, running, sex, and tampon use with no pain. She stopped using lidocaine; however, continued taking amitriptyline.

After a total of 13 visits (Meghan was able to decrease her number of visits to one every other week at visit number nine), I discharged Meghan with all of her goals met and her symptoms eradicated. After visit number eight she had transitioned to intercourse. In addition, she returned to yoga, running, sex, and tampon use with no pain. She stopped using lidocaine; however, continued taking amitriptyline.

If you have any questions or comments about this case study or about any of the topics covered in this case study, please leave them in the “Comments” section below or email them to: blog@pelvicpainrehab.com .  We want to hear from you!

All my best,

Marcy

 

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