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Pelvic Floor Therapy

Why see a pelvic floor therapist?

Many pelvic floor conditions can be managed and healed without surgery. Seeing a physical therapist (PT) or an occupational therapist (OT) who is trained as a pelvic floor therapist may help you better understand your symptoms and design a personalized program to help alleviate your pelvic discomfort or pain through retraining and strengthening your muscles. Some people will see a pelvic floor therapist just once or twice to assess their strength and flexibility, to get assistance with learning a specialized exercise and self-care program (which may include learning to do Kegel exercise correctly), assist with learning to do Kegel exercises correctly, and receive personalized guidance for maintaining pelvic floor health. Others may need more sessions for their condition(s) to be sufficiently treated.

 

Pelvic floor issues are rarely isolated—it is common for symptoms to emerge together or for one problem to cause a cascading effect. Some conditions treated by a pelvic rehabilitation therapist include:

 

  • Bladder and bowel issues
  • Incontinence
  • Prolapse
  • Painful sex or an inability to have penetrative sex
  • Vaginismus
  • Vulvodynia (pain of vulva) and genital skin conditions
  • Musculoskeletal aches and pains (involving the back, hips, SI joint, groin, abdomen and sometimes limbs)
  • Pregnancy & postpartum recovery

 

You might need to seek care from multiple specialists to address related issues such as back pain and skin issues. Sometimes putting together an integrated treatment plan including a PT/OT, other specialists, and complementary medicine services such massage, yoga, bodywork, and nutritional guidance is the best approach. Your primary care provider or OB/GYN may be able to help you with this.

 

How to find a pelvic floor therapist

Most major hospitals and large clinics have PTs or OTs on staff who have been trained to offer pelvic floor therapy services. Providers will have a range of focus and experience; it’s worth asking around for recommendations, interviewing different people, and looking for someone who has some knowledge of and experience in treating your condition. You might need a referral from your primary care provider or OB/GYN to make an appointment, though some physical therapists offer direct access or self-referral. Either way, talking to you primary care provider about your pelvic pain or discomfort is a good first step to understanding your situation and determining the best treatment plan.

 

However, if your physician does not give you a referral or does not provide you with specialized help or resources, this does not necessarily mean that pelvic floor therapy wouldn’t be appropriate for you. Not all health care providers are trained or knowledgeable about pelvic floor health and related resources.

 

Sometimes getting a second opinion and/or bring in any information or articles you have about pelvic floor health to your next appointment can be helpful.

Depending on where you live, some private physical therapy clinics and practitioners may offer pelvic floor therapy services as well. In some cases these option can be more expensive, but it is worth some research to get the care you need.

 

What to expect during appointments

 The first appointment should include a careful interview and discussion about your experience, including an account of symptoms as well as medical history and lifestyle. Pelvic floor therapists are trained to be sensitive to how personal and intimate these topics and this part of your body can be. The therapist will then evaluate your posture, back, and hips, and they should also explain along the way what they are noticing and how physical therapy can help.

 

To complete the assessment, your PT/OT may need to conduct an internal exam. Internal examination helps a PT/OT get a full sense of the strength and flexibility of your pelvic floor muscles, ligaments and fascia. For women, this will be through the vagina (though not with a speculum like a standard pelvic exam). For men and some women, the exam is done rectally.  In some cases an internal exam is not necessary or possible, such as when your condition involves pain during penetration. 

 

Often a biofeedback examination will be part of the complete evaluation. The therapist will use an internal sensor in your vagina or rectum or external sensors over your skin. These sensors do not do anything to you; they read the electrical activity in your muscles so that you and your therapist can see your pelvic floor muscles at work on a monitor.

 

If you are on your period or not comfortable doing this part during your first visit, the internal exam can wait until the second appointment. The PT/OT should be sensitive to any pain or discomfort that arises. Be sure to speak up and know that you are in control–nothing should happen without your full consent.

 

 

The Take-away: Treatment plan, goals, and timeline

During the first appointment, you may receive some initial advice and education. After the second appointment, you should have a more complete treatment plan. This plan may change based on how your body responds, and may include internal soft tissue work and exercises to do at home. Below are some things that your PT/OT might recommend. Some may require the purchase of a tool and/or lubricant for use.

 

  • Pelvic floor exercises to do at home with or without a biofeedback tool (egg or wand)
  • Trigger point massage to release muscle tension
  • Insertion and use of a silicone dilator or vibrating wand
  • Massage of other parts of the body
  • Stretching and yoga
  • Other gentle strength-building exercises
  • Nutrition and lifestyle
  • Mindfulness, breathing techniques and other pain management methods

 

You may need to have frequent appointments, especially at first, depending on your condition. Your PT/OT should be able to give you an approximate timeline, though rehabilitation and healing is not always predictable. We recommend collaborating with your therapist to set specific treatment goals, such as having comfortable sex, alleviating back pain, managing incontinence, etc.

 

Other resources:

Heal Pelvic Pain by Amy Stein, MPT

 

The Better Bladder Book by Wendy Cohen (for folks with Painful Bladder Syndrome)

 

The information above was adapted from the following sources:

Heal Pelvic Pain by Amy Stein, MPT

 

http://womenshealthfoundation.org/2010/04/28/womens-health-pt-what-to-expect/

 

http://www.pelvicphysicaltherapist.com/

 

Special thanks to Jane Walter for reviewing and contributing input from her experience as a PT. 

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Best intercourse positions for avoiding back pain

I am 61 years old and still sexually active with my partner who has some back problems.  During intercourse he is usually on top but occasionally wants me to be on top. I try but it seems like it’s not a comfortable fit and I don’t have the flexibility in my spine.  So that only lasts about a minute.  I of course want to give him a break sometimes and wondered in there’s a position aide/prop that might be helpful or any advice you may have.

There are a variety of positions that work well for people who have back or knee pain and want to avoid pressure on those.

“Spooning” where you both lie on your sides and your partner enters from behind is a good choice, and allows you or him to reach down and provide direct clitoral stimulation. You can move back and forth toward him, or him forward and back toward you.

Sitting up on a chair, with his feet on the ground and you either sitting facing toward or away him is another good choice. If you are not too heavy for him, you can wrap your legs around him and rock back and forth (or try this in a rocking chair and let the chair do the work for you).

Another one we like a lot is to have him lie on his side and then you lie at a 90 degree angle to him, with your legs over his hip. This is great for looking into each other’s eyes, and again offers the opportunity for direct clitoral stimulation using fingers or a vibrator during intercourse.

If you like penetration from behind, you can lie on your stomach on a table (put a pillow or folded towel under your belly for comfort) so that you are at waist height, and he can penetrate you while standing.

Enjoy!

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Rheumatoid Arthritis and Sexuality

Q: Dear Sex Educator,

I am living with rheumatoid arthritis, and the pain and fatigue that I experience can make sexual intimacy difficult or impossible. Is there anything I can do to improve my sex life?

__________________________________________________________________

Chronic pain and fatigue can make you feel like your sex life is over, but this does not have to be the case.

Some of the tips to consider  include talking to your rheumatologist about medications and side effects, communicating with your partner about what feels good and when you might have more energy, and combining soothing activities that bring relief and relaxation (like a bath) with gentle massage and touch that might be sexual.  For some people the feel-good chemicals released by the brain during intimacy and sex play can provide a welcome respite from pain.

I encourage you to consider scheduling intimate play times for when you might have more energy rather than expecting your play to be spontaneous or to happen at the end of the day before sleep. When we have conditions that affect our energy and comfort it is useful to be more intentional about when you engage in intimate or sexual plaY.

Our brochure Othercourse also contains some helpful ideas for connecting creatively with a partner. Turning the focus to any activities that bring you pleasure–rather than the goals of intercourse and/or orgasm–liberates you to be in the moment and enjoy more satisfying intimacy for a lifetime.

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Vaginal Renewal™

Download a free PDF version of this brochure

I am a cancer survivor in menopause. I don’t want to use estrogen but I am dry and sex is getting more painful. What can I do?


At A Woman’s Touch, we developed a program (beginning in 1997) for people with vaginas who are  experiencing dryness and discomfort or pain during vaginal penetration that is either diffused throughout the vagina or burning or tearing at the vaginal opening. Although originally developed for people who have had radiation therapy to the pelvis to treat different forms of cancer, people with less aggressive symptoms related to menopause also benefit from the Vaginal Renewal™ program.

We also helped manufacture vibrating wands for use in this program, which you can find by clicking on this link.

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Vaginal atrophy, dryness, and lack of flexibility

I am postmenopausal – I have vaginal penetration issues that are severe, tearing and extreme dryness as well as progressive desensitization. I am looking for ways to renew vaginal tissue and increase elasticity. Where do I begin…massage vibrator? moisturizer? kegel exerciser? estriol creams?


Begin with reading through the Vaginal Renewal program.

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Premature or Eager Ejaculation

After several months as friends, my dance partner and I have decided to fulfill each other’s desires. We have had a very strong sexual tension from the moment we met. Just recently we started becoming more touchy, and she has made it clear that she is ready for us to act on our desires. My fear is that when the time comes I will not be able to please her. I enjoy orally and manually pleasing women, but I am very doubtful about my abilities when it comes to penetration (I believe I have a premature ejaculation problem.) Can you please give me any advice to help the premature ejaculation and make her experience unforgettable? Thanks.


Learn more by downloading this free brochure.

Did you know that most women do not have orgasms through vaginal penetration? Oral and manual stimulation are the most pleasurable forms of stimulation for most women, and are most likely to produce orgasms, although some women prefer to have fingers or a dildo in their vagina while having their clitoris orally or manually stimulated. Since the clitoris and labia are the most sensitive parts of a woman’s sexual anatomy, and therefore the most pleasurable areas for a woman to have stimulated, getting maximum pleasure from penetration is difficult. In fact, the penis going in and out of the vagina is not enough stimulation to produce an orgasm in up to 75 percent of women.

That said, my recommendation for you is as follows:

  1. Change your mindset about what sex “needs” to be. If intercourse is not your strong suit, then redefine sex to be that which you feel comfortable with. Take the pressure to perform and try to transform it into the notion that pleasure is the goal, rather than making a “good performance” on your part the goal.
  2. Talk with your new partner about what you like to do and what your fears are, and ask her how she likes to be stimulated. I know this is difficult to do; most of us like to just roll into bed with a new partner and let lust and our own desires steer our sexual encounter. Unfortunately, though lust is powerful, it is not enough to produce full satisfaction. Eighty percent of women report that they have faked an orgasm during intercourse, and 79 percent of women do not ever experience orgasms during intercourse without some additional clitoral stimulation!Rather than being part of the statistics, I suggest a very sexy conversation to start things off. There is no reason for you to think that your partner expects a particular performance from you, and sex is very much a mutual dance, with both of you taking responsibility for your own and your partner’s pleasure. Tell her what you like, ask her what she likes, and then slowly and luxuriously start exploring. Performance “anxiety” is often the cause of premature ejaculation, so taking this anxiety out of the picture will make for a more pleasurable experience for both of you.
  3. Consider having her orally or manually bring you to an orgasm first, then allow yourself and her to explore her body fully with hands and mouth. Bring her to orgasm one or several times. After a while you may become aroused again, she has had a lot of pleasure already, and you may be able to have intercourse slowly and pleasurably, without any expectations or performance pressures. If, after taking the pressure off yourself, you find that premature ejaculation is still an issue that you feel needs addressing, you might want to look at our information on Eager Ejaculation and what to do about it.

Hopefully you will be able to relax and enjoy the wide range of sexual activities available to both of you that don’t depend on your penis to be performing in any particular manner. This way, you can enjoy the pleasure rather than worry about expectations.

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Blood pressure medications, erectile function, and alternatives to intercourse

Dear Sex Educator,

About six years ago, I developed high blood pressure. My physician put me on beta blockers. You know what they do to a man’s virility. Anyhow, over the first three years, I saw a steadily decreasing ability to have sex with my wife. At the end of three years, I was so frustrated and embarrassed at my attempts that I quit trying. For three years, we had absolutely no sex. She did not complain. Then, last year, I turned 60, and my physician suggested I include a urological exam as part of my physical. He is a male. When he found I was on beta blockers, he was quite shocked. He asked me about sex and I told him about my situation. He immediately took me off the beta blockers.

Now, three questions: First, will my ability to have intercourse come back? He says “to a degree” it will. I get erections during the night, so I am encouraged. Second, I would like to try a dildo with my wife to take performance pressure off me. What size and shape is preferable? There are dozens to choose from. Third, should I just not worry about intercourse until I “think” I can function? I mean, if I get all this started after all this time and can’t perform, will I be worse off? I love my wife and miss our intimacy very much.

While I am not qualified to answer your first question (and it sounds as though your physicians have already answered the question to the best of their knowledge) I will address the other two questions.

First, this is the time when you need to have a frank conversation with your wife. Many women enjoy penetration during sex, and many women enjoy sex without any penetration. She may be happy to have other contact with you, including oral sex, manual stimulation with your fingers, and more extended full-body contact. If she says she misses penetration, then you have several options. One, you can use your fingers and/or a dildo during oral or manual stimulation, moving your fingers or dildo as she indicates she likes it. Some women like the feeling of thrusting; others like the feeling of just being filled up. Having something in the vagina during orgasm can increase the orgasm’s intensity, but many women will say it’s not necessary.

If you wife says she misses actual intercourse, then you can purchase a harness and dildo and penetrate her as you used to. We generally suggest the “two-strap” style for men (the Orion Harness might be a good choice for you). In choosing a dildo, you need to consider how many fingers she enjoys having inside of her when she is aroused (when I say aroused I mean swollen vaginal lips and clitoris). You then choose a dildo that is about as wide as the fingers are. We give finger-width equivalents in the descriptions of our dildos, as well as actual widths. Length is less important, as you can control how deeply you penetrate your wife.

You also may want to talk with her about whether she enjoys G-Spot stimulation. If you and she don’t know where her G-Spot is, then you can start by exploring together with your fingers in her vagina (after she has become aroused). As she becomes more aroused you will feel a ridge of tissue at the top of her vagina (if she is on her back) about 1-1/2 to 2 inches inside the opening. Stroke that tissue, and ask if she likes that feeling. If she does, then you may want to choose a dildo with a slight curve that will stroke her g-spot as it moves in and out.
Another thing you two can do is explore what kinds of touch and contact you enjoy. While you may not be able to obtain an erection that is hard enough for deep penetration, you still can enjoy oral and manual stimulation, and can still have orgasms. Invest in a good personal lubricant (try a sample pack or read how to choose)and begin by exploring by yourself what feels good. Then invite her to learn with you about what kinds of touch feel best to you. Sex can be much more than just intercourse, and the connection many couples create when they begin exploring beyond intercourse can be very rewarding.

So I don’t think you need to wait; instead, I suggest you start exploring and finding the wide range of ways to pleasure each other. If you are able to have intercourse later, that’s great. If not, you won’t have lost anything, and in fact you may have gained a much wider repertoire of pleasurable activities that you both can enjoy. If you are looking for suggestions on what you can do, you might look for The New Good Vibrations Guide to Sex or Red Hot Touch as wonderful resources for the world of sexual possibilities.

The Sex Educator

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Painful anal sex

I have some questions about painful anal sex.We took a big leap the other night with a rather large butt plug. It hurt, and I bled a fair amount. I don’t even really like anal stimulation, but my partner enjoys it a great deal. Is there anything you can suggest that will make this more pleasant for me?


First, if anything hurts, ever, with anal play, STOP! Pain is not a part of anal massage or penetration, and is your signal that something is wrong, either with the technique or your body.

Each of us has only one anus. Pain is NOT a part of anal massage and penetration, and is a signal that your actions are damaging skin, muscles, tissue of the anus and/or anal canal. So, if you are not enjoying yourself, stop. Sexual pleasure is about consent for all involved, and you are not obligated to provide pleasure for someone else when it is hurting you. I encourage you to stop and get more information, no matter how much your partner enjoys it. You need to advocate for yourself in this situation. It is a difficult life to live with a less-than-healthy anus. You rely on the comfortable functioning of your anus every day for the rest of your life, and no one’s pleasure is more important than your health.

Bleeding is also important to pay attention to. Beyond an infection risk, anal bleeding means that something has been ripped (anal fissure), torn (a hemorrhoid has broken open), or abraded (the surface friction was too much). In short, it means that some part of you has been damaged. The scarring can lead to prolonged pain and discomfort, and this type of touch has no place in your sessions. Serious rectal bleeding can be an emergency, and you might need medical attention to evaluate the cause of the bleeding.

You need more information about anal play. For example, the anus doesn’t require “bigger is better” for pleasure. The many nerve endings in your rectum/anus/perineal (around the anus) area means that the area is exquisitely sensitive to both touch and arousal. A little sensation and pressure can go a long way. Very small strokes, latex- or polyurethane-covered fingers, air puffs, small dildos, etc. can be quite arousing. Very satisfying anal-play experiences can be achieved through prolonged anal massage with fingers, gloves and lube. Stroking the outer anal muscle ring with firm massage strokes will enhance sensation and blood flow, increasing your sexual arousal.

There are some great references specifically on anal play for you to read up on: J. Morin’s book Anal Pleasure and Health and T. Taormino’s book The Ultimate Guide to Anal Sex for Women. You deserve – and need – information about anal play so that you can make informed decisions about your body and the bodies you love. Above all else, take care of your tushie.

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Vulvodynia and Vulvar Pain

Why is my vulva so sensitive? I’ve been told I may have vulvodynia. What is vulvodynia? What can be done to treat it?


There are many potential causes for pain in the vulvar region, and the term “vulvodynia” is a word that describes a variety of conditions. Vulvodyina, or chronic vulvar discomfort, is characterized by burning, stinging, irritation or rawness of the vulva. Three different sub-types have been described, and have different treatment approaches:

  1. skin disease,
  2. inflammation of the vulvar opening, and
  3. irritation of the nerves that serve the vulva.

Vulvodynia is a diagnosis made after other diagnoses, such as vaginal infections, neuropathies, sexually transmitted infections, and other dermatological conditions are tested for and found not to be the cause. If you have an actual sore or scab patch on your vulva, you very likely need a series of biopsies to diagnose the problem. (One biopsy isn’t enough: it usually takes three biopsies minimum to determine a diagnosis.) Even when health care providers have extensive genital dermatological experience, the good providers will get a biopsy to confirm the diagnosis.

For skin-related vulvodynia, steroid ointments are used, often successfully, for treatment. (NOTE: Steroid creams, by definition, have alcohol in them, and should be avoided.) Although it is true that we need to be careful of using steroid ointments on the skin of the body (because it causes thinning), the vulva is relatively steroid insensitive, and use of steroids on the vulva does not cause the same problems that it can elsewhere.

Having said that, one should only use the very smallest amount prescribed, and ONLY on the areas where directed. Using more doesn’t make something better, and can cause it’s own problem if you become irritated by the base that the medication is in. Also, make sure to completely avoid the anal area unless your health care provider has instructed you to use the steroid there. The anus is very SENSITIVE to steroid ointments, and thinning can cause fissures and other skin problems you don’t need to add.

For women who experience inflammation of the vulvar opening, good attention to vaginal health may help. The skin at the opening of the vagina is just more sensitive than that of the lips, and often needs some healthy conditioning to help vaginal penetration be more comfortable. Look at the AWT Vaginal Renewal posts, and consider whether that may work for you.

We also find that strict attention to a low inflammation diet (see the AWT Good Sex Diet) helps dramatically with many types of skin inflammation disorders. Some women find relief with alpha-interferon injections, and others choose to pursue a surgical operation (vaginal advancement) when vestibular glands are infected or impacted for a long period of time.

The most severe cases of vulvodynia are those with neurologic irritation. Pain occurs wherever the nerves in the region receive too much sensation: the clitoris, vestibule (vaginal opening), urethra, perineum (skin between the vaginal and anal openings), and down the inner thighs. As in other cases of sensory neuropathies (diseases of the nerves), antidepressants and anticonvulsants may ease the pain in some cases by “resting the nerve” and allowing it to heal.

Other people may need an evaulation by a pelvic floor Physical Therapist, to determine whether a muscle spasm is causing compression on a nerve that you then feel as pain.

Vulvodynia can be a difficult condition. For many of the conditions, the cause is unknown, and the cure elusive. For some women, it’s a big breakthrough to know the name of this condition, and that this is not something “in their head”, or something to be ignored.

For more information, visit the website vulvodyniasupport or contact the National Vulvodynia Association (online at www.nva.org and ask for a referral for a gynecologist or genital dermatologist in your area who is familiar with vulvodynia.