Pain with sex
Commonly seen in young couples who are virgins.
Commonly seen in religious communities – be they Muslim, Christian or Jewish.
A gentle program of decreasing sensitization and increasing trust and tolerance to touch (Sensate Focus) is advised. We work manually, and use dilators and/or vibrators for home progress and maintenance. Posture or position during sex can make a big difference as to the tension of the pelvic floor muscles – missionary position, with a posterior pelvic tilt, is not your friend!
A good lubricant is an essential tool (for some) for happy bedroom play!!
Thrush and chronic pain
Some women get thrush (candida albicans) more easily than others. Some get it once in a lifetime; others every second month; and some get it every time they have sex – which is very distressing and often impacts negatively on libido. Thrush causes a local irritation, which can make muscles and nerves overactive and hypersensitive.
A red herring of abdomino-pelvic pain in young women. If a woman feels bloated and uncomfortable, she may go into a fetal position, tucking her tailbone under and tightening her pelvic floor muscles. Over time she may develop trigger points in her deep posterior pelvic floor referring pain and aggravating her experience. It is advised to assess the pelvic floor muscles, perform myofascial release if indicated, and exclude persistent pelvic floor tension as a driver of the pain and discomfort associated with endo. Many endo sufferers have moderate to severe adhesions internally and manual techniques of connective tissue mobilization and visceral manipulations can also add value.
Vulvar pain conditions
Dyspareunia, or pain with sex can have many root causes. Vulvodynia and vulvar vestibulitis, whilst having defining characteristics are not caused by any single factor; hence pain associated with penetrative activities should consider a physiotherapeutic pelvic assessment.
Of note: some dermatological conditions (lichen schlerosis and planus) also cause problems. Advice regarding positions, stretching, lubrication, manual stimulation and relaxation techniques can all help.
Recurrent urinary tract infections
There are two main groups of patients:
Younger, just started having sex: tight pelvic floor muscles can mimic a bladder infection with symptoms of frequency, urgency, irritation, pressure. For all suspected infections you should take a urine sample, and send it to the laboratory to culture for an organism (bad bug). If no active infection is identified, antibiotics should NOT BE TAKEN and dysfunction or imbalance of muscles and nerves should be assessed as a cause of the symptoms.
Older patients (see below).
If it is an infection, treat the infection. If it is a recurrent infection, treat the cause of re-infection. This could be due to reflux up the urethra after intercourse, or to an allergenic reaction to certain chemicals and products. Attention should be focused on correcting the imbalance – be it by alkalising the system through diet, or voiding before and after sex. Please complete a bladder chart and bring it with you to your (initial) consult.
Never tell a runner not to run.
What ultra-marathon do you have in your area?
South Africa is home to, among others, the Comrades Marathon – all 92km of it, with alternating up and down runs. It is amazing how many patients crawl out of the woodwork after a down run, complaining about problems from the 60km mark.
Cross fit, as aggressively comprehensive as it is, can be too much for some new mums. For many, they need the stress release of exercise, but if they were giving it horns before they fell pregnant, and now want to get back to pre-pregnancy body ASAP…. Your body needs time to recover. Different bodies need different times. Load should be introduced gradually so that stability and flexibility are developed alongside strength and endurance.
As a general rule:
- Gymnasts, ballet dancers, horse riders and runners leak.
- Pilates, yoga and exercise instructors often have pain (too tight from constantly engaging), as do physios!
An assessment of pelvic floor muscle tone, technique and function, and advice on minor adjustments can improve if not resolve pelvic dysfunction during sporting activity.
High impact and excessive training can lead to a number of overload scenarios; in a woman who has been pregnant, the impact of pregnancy and delivery need to be considered. That said, many elite athletes rapidly return to pre-pregnancy status with all of its demands.
Management of our sportswomen is based on individual presentation and sporting demands. Ultrasound is a very useful tool when trying to break down movements into their component actions.
Which sports are particularly vulnerable?
- Impact sports: Running, ball sports (marathon, triathlon, tennis, squash)
- Loading sports: Weightlifting, body building
- Seated sports: Cycling, rowing
- Excessive training: Better low weights high reps, than high weights low reps
- Changes in training load and conditions
When to consider a pelvic assessment in the management of your current symptoms:
Common in women who have a history of pregnancy related pelvic girdle pain. Non-resolving, or as a consequence of rehabilitating another part of the pelvis e.g. a hamstring or SIJ (buttock) injury.
Non-resolving low back pain
Common in women who deal with load.
- If you have seen physios – bios, chiros – and it helps a bit, but then comes back again….
- If you have had cortisone injections, and they helped, but have worn off….
Buttock pain (non-resolving SIJ or hamstring)
Common in women who have a child on a hip, or engage in repetitive sports where similar movement patterns can aggravate an imbalance e.g. road running and tennis. Very similar to groin and low back pain above – after all the pelvis is a ring and movement, tension or imbalance in one area can be shifted to another area.
Each athlete is different, and although patterns of injury exist due to the demands of their chosen sport, we still assess each on its merits.
Pregnancy (antenatal) and postnatal care
Specific problems include: pregnancy-related pelvic girdle pain (including low back pain); thoracic pain (midback pain); rib pain; incontinence (both urinary and faecal), pelvic organ prolapse and separation of the abdominal muscles (diastasis abdominis rectalis).
Irrespective of your mode of delivery, your body has undergone massive changes. Both vaginal deliveries and caesarian sections can suffer from incontinence, although vaginal deliveries are more prone to pelvic organ prolapse due to stretching of connective tissue. The caesarian section ladies often complain of a lack of sensation above the scar, making it difficult to retrain abdomino-pelvic synergy, or core activation. They often complain of persistent low back pain.
Return to exercise should be graded, with shortening and tightening of all abdomino-pelvic muscles, prior to adding too much load and impact. Realtime ultrasound is an invaluable tool for visualizing the muscles and practicing correct activation. Electromyography and neuromuscular stimulation can help to increase sensory awareness and connection in patients who feel they have less sensation or motor activity post kids. A postnatal check from 6 weeks allows us to assess for abdominal diastasis, ‘clear’ the pelvic floor muscles, and advise regarding the re-integration of abdominopelvic synergy. Rehabilitation is available to those who require assistance with regaining pre-pregnancy function.
Getting fit post kids
Beware the dreaded star jumps!!
Return to exercise should be graded, with shortening and tightening of all abdomino-pelvic muscles, prior to adding too much load and impact. Realtime ultrasound is an invaluable tool for visualizing the muscles and practicing correct activation. Electromyography and neuromuscular stimulation can help to increase sensory awareness and connection in patients who feel they have less sensation or motor activity post kids.
Hypo-pressive technique or low pressure fitness can be of great value in certain cases where they are struggling to control changes of intra-abdominal pressure.
Whilst the role of food (diet) and fluid (water) cannot be underestimated, defaecatory technique (or ‘how to poo’) and tricks to ‘call the poo’ can be very beneficial in getting that gut going again. Visceral manipulations can help to restore appropriate colonic activity, whilst the focus is on establishing a healthy toilet routine. The role of stress and inhibitory behaviours are discussed.
A vulnerable group are post operative patients, specifically those with abdomino-pelvic surgery, high pain relief requirements, low mobility and prior dysfunction. If not well managed, they are at risk of putting too much pressure on the posterior vaginal wall and ‘ballooning’ into the vagina in what is known as a rectocele (or low posterior wall defect).
Pelvic organ prolapse (POP)
If you have been pregnant, you have stretched the abdomino-pelvic cavity. If you have had a vaginal delivery, you have stretched the vaginal walls. That is no cause for panic. You will just have to work your pelvic floor muscles a little harder, and engage your core with increases in intra-abdominal pressure such as lifting and coughing. That said, your behaviours and movements should allow you to cope with the physical demands of life, without aggravating your presentation.
Things invariably get worse around menopause, which may be when some women become aware of prolapse for the first time. Topical vaginal oestrogen and pelvic floor muscle contractions are deemed first line management in the treatment of pelvic organ prolapse.
Anterior vaginal wall defect
- if the stretch was high you can have some bladder prolapse (cystocele)
- if the stretch was low you can have a prolapsed urethra (urethrocele)
Superior and lateral defect
- if the stretch was around the uterus you can have uterovaginal prolapse
Posterior vaginal wall defect
- if the stretch was high you can have some small bowel prolapse (enterocele)
- if the stretch was low you can have some prolapse of the rectum (rectocele)
Another period of change, this time the withdrawal of hormones resulting in an array of weird and wonderful symptoms from night sweats and anxiety, to incontinence, pelvic organ prolapse and vaginal dryness. This is a time when women often need to develop a living relationship with their pelvic floor muscles, if they haven’t yet done so – pelvic floor muscle contractions.
Management of the aging female needs to be considered and compassionate. Are we really expecting 100 Kegels a day, from 85 year old Granny? Is it fair, or practical, given that she no longer carries the grandchildren, or runs (and please, there are exceptions!). Is the aim a tight vagina achieved with surgery, or do we want to keep the insides on the inside (pessary)? And if surgery has resulted in a tight vagina, can we regain sexual function? Each individual has different needs and treatment or management is tailored accordingly.
Pelvic organ prolapse (POP)
Things invariably got worse around menopause, and prolapse may present for the first time, or get worse despite your best efforts. Topical vaginal oestrogen and pelvic floor muscle contractions are deemed first line management in the treatment of pelvic organ prolapse.
If insufficient, we can strengthen a weak pelvic floor – but what if the muscles are strong already? We might suggest the use of a pessary, or in severe cases consider surgery.
Over the past several years, the FDA has seen a significant increase in the number of reported adverse events associated with the use of surgical mesh for trans-vaginal POP repair, and an advisory panel of experts recommended in 2011 that more data is needed to establish the safety of the device.
The FDA has since taken several actions to warn doctors and patients about the use of surgical mesh for trans-vaginal POP repair.
January 4th 2016
Recurrent urinary tract infections
There are two main groups of patients:
Younger patients (see above)….
…and older patients who may have some pelvic organ prolpase: if the bladder isn’t emptied effectively, residual urine can result in an ongoing infection. Management should focus on improving bladder emptying as a way of clearing and resolving a persistent problem.
If it is an infection, treat the infection. If it is a recurrent infection, treat the cause of re-infection. this could be due to emptying properly because of prolapse or poor inner range bladder contractility, or to a susceptibility to certain chemicals and products. Please complete a bladder chart and bring it with you to your (initial) consult.
As our mobility decreases, and we require less food, or suffer from a bladder problem meaning we drink less fluid, our bowels slow down. Our colons also lengthen over our lives – longer colon, slower transit. This may result in a harder stool that desensitizes an already stretched rectum…. Whilst the role of food (diet) and fluid (water) cannot be underestimated, defaecatory technique (or ‘how to poo’) and tricks to ‘call the poo’ can be very beneficial in getting that gut going again. Visceral manipulations can help to restore appropriate colonic activity, whilst the focus is on establishing a healthy toilet routine. The role of stress and inhibitory behaviours are discussed.
A particularly vulnerable group are post operative patients, specifically those with HIP REPLACEMENT SURGERY as they have restricted hip flexion. This dramatically impacts on the position required for defaecation. Use of appropriate aids (laxatives, suppositories, low volume washouts if need be) are highly encouraged. Other vulnerable patients are those with abdomino-pelvic surgery, high pain relief requirements, low mobility and prior dysfunction. If not well managed, you are at risk of putting too much pressure on your anterior rectal wall which is your posterior vaginal wall and ‘ballooning’ into the vagina in what is known as a rectocele (or low posterior wall defect).
Most women with pelvic pain are tormented by it – no longer believing the medical profession, or even themselves.
Pelvic pain and dysfunction can behave strangely: starting as one thing e.g. tight bladder; morphing later in the day e.g. sensation of swollen labia; and culminating in the evening in e.g. stabbing pain in rectum.
Don’t worry if/that your symptoms do not add up – to you, or your medical team to date; we ask very specific probing questions to establish patterns or signatures of physical (and psychological) dysfunction and imbalance. Complaints include vaginismus, vulvar vestibulitis, vulvar pain syndromes, interstitial cystitis, frequency:urgency, anismus, proctalgia fugax, levator ani syndrome, – the list goes on.
Please get assessed by an appropriately trained physiotherapist.