What is Vaginismus?  
Vaginismus is characterized by fear, pain and vaginal spasm in anticipation of gyn exam, tampon or menstrual cup insertion, or vaginal penetration with sexual activity (finger, toys, penis). They typical definition describes vaginal muscles (pelvic floor muscles) that involuntarily or persistently contract when women attempt vaginal penetration. The condition can be caused by physical or psychological factors or a combination.  Some describe vaginismus and the reaction of the pelvic  floor muscles as a similar response to when  an object is brought close to someone's eye and there's a reflexive blink and  protection/closure.  

Primary vaginismus usually refers to the experience of vaginismus with first-time intercourse or other vaginal penetrative attempts.  Secondary vaginismus usually refers to the experience of developing vaginismus a little later in life, after a period of pain-free intercourse, gyn exams or tampon insertion.  This can relate to changes after  giving birth, medical conditions that may have even resolved, trauma or abuse, surgery, or having painful  penetration (dyspareunia)  for years that has now  transitioned to  a full vaginismus response. 

How  prevalent is it?  
Reports vary widely because many women don't share they have this treatable condition and suffer in silence. It  ranges from 1 in 1,000 to 16 in 100 women. 

What  types of treatments are available? 
The most important first step is to find  a healthcare provider (GYN specialist, UroGynecologist, or a Pelvic PT) who regularly sees patients with  pelvic pain conditions and vaginismus. Believe it or not, many  OB/GYNs do  not get specialized training in this area.  

In some cases, women still have  hymenal tissue that is completely or partially blocking the entrance to the vagina. I have had many patient cases over the years where the issue was not about the vaginal pelvic floor muscles or pyschological, but a true  block from hymenal tissue (sometimes hidden and farther back than  the entrance).  The treatment may include a very minor procedure (hymenectomy) to  cut some of that tissue away.  There are also  other medical conditions or hormonal deficiencies that should be considered as well. 

Once other medical conditions are ruled out, the ideal treatment  for vaginismus is  specialized pelvic physical therapy. That's what we do!  This is done in a private room and only one on one with someone who completely understands how to address this condition.  In some cases, it  may benefit you to  also see a counselor  who understands  how to address pain and anxiety, as this combination of treatment works very well. 

During pelvic physical  therapy sessions, we assess you as a whole person, not simply  as having vaginismus.  We  want to know about your experience and journey with this first.  There's no rush with examinations.  We  make a plan based on your current status and what your individual goals are.  Your primary goal may only be to have a  GYN exam for the first time, while other women who have been married for years may want to  have penetrative sexual activity for the first time.  We  provide treatments in the clinic (sometimes only 2-6 visits are needed) and also create a home program  for you to do that may include vaginal dilators.  Some women try vaginal dilators at home on their own, which may be enough. We often find that combining the full  range of therapies and home management recommendations  is usually much more effective.  In some cases,  you may also benefit from medications or topical creams  provided by a physician as well. 

We will be happy to share any other information  you'd like about what to expect during treatments. 

Is it ever too late to seek treatment?  
No.  Though  this may start early in life, we  see women  in their 40s-60s who finally decided to get help for this. It's never too late.  We encourage you to  reach out early if you can  (even in your teens). If any health provider tells you "it's just in your head" or " just relax more" or "drink wine," look for a new one.  We hear this all too often and it is not helpful advice. 

​What if I've tried treatment and it hasn't worked in the past? 
There's  not an exact standard of care for the treatment of vaginismus.  Over the years, I've heard  patients share all sorts of stories about  treatments and "potions" they  received. Many of our patients have seen 10-15 healthcare providers before finding us. The most important piece of advice is  DON'T GIVE UP.  There's hope and there are people who can help you.  (Refer to the directory below for healthcare providers in your area).

Here's an article I wrote that explains ways  that physical therapy and dilators can help.  Physical Therapy and Dilators. What's the  Connection?    ~ Tracy Sher

Some  more information and resources for you:

Vaginal Dilator Guide for Patients.  Pain, Fear,  and Anxiety

Vaginismus  Website  - How Many Women Have Vaginismus?

​Listing of Pelvic Health Professionals All Over the World. Ultimate Directory.

Pelvic PT’s know a lot about Kegel exercises. 
 
A short history lesson
There was a Dr. Kegel.  He was a Mayo-trained surgeon who became interested in finding non-surgical treatment options for incontinence in post-partum women in the 1930’s.  He did not “invent” the exercises. Therapists in England had been teaching pelvic and pelvic floor exercises since the late 1800’s to new mothers in the maternity wards.  He was, however, the first to apply the scientific method to prove pelvic exercises actually worked to reduce urinary incontinence.  After decades of research on the best methods on how to teach the exercises, he published his results in 1948. His approach was 84% effective in curing incontinence symptoms. 
 
So what happened?  
The methods Dr. Kegel developed in the lab just didn’t translate well into modern medical practice Unfortunately, in today’s post-partum healthcare world, Dr. Kegel’s methods of teaching pelvic exercises have been replaced with a brochure that new moms are handed as they leave the OB/GYN’s office.  Most well-meaning doctors didn’t have the time or resources to duplicate Dr. Kegel’s methods in their clinics. Over the years, the verbal or written description of how to “squeeze down there” started to replace the individualized approach Dr. Kegel was able to take in his research.  
 
Dr. Kegel advocated that without one-on-one instruction physical instruction by a trained practitioner, most women would not be able identify the right muscle, therefore making the exercises ineffective.  Decades after this assertion was published, multiple studies now support Dr. Kegel’s early observations.  One study found that in women who were given only verbal and written instructions on Kegel exercises in an OB/GYN’s office, less than half could demonstrate a correct pelvic floor contraction.
 
How would Dr. Kegel teach you how to do Kegel exercises?  First, he would look at and palpate your pelvic floor to make sure you were using the right muscle group.  He would then use an internal vaginal pressure sensor called a perineometer, an early type of biofeedback, allowing you to “see” your internal pelvic floor muscles working.  He would progress your exercises as you became stronger.  You would be instructed several times over the course of weeks or even months.
 
If you have tried Kegels on your own and not gotten the results you wanted, maybe you need a “Kegel coach” – a pelvic physical therapist who has the time (our appointment are an hour long), the equipment (we use modernized biofeedback methods), and the knowledge (it’s our specialty) to evaluate your Kegel skills and then develop an exercise plan especially for you.
 
***
 
Dr. Heather S. Rader, PT, DPT, PRPC, BCB-PMD   was a former pelvic physical therapist at Sher Pelvic Health and Healing.  She holds certifications in pelvic rehabilitation and biofeedback for pelvic muscle dysfunction.  She has been a pelvic specialist for over 15 years and is a pelvic floor rehab educator. 

Have questions or want to make an appointment? Call (407) 900-2876 or email info@sherpelvic.com.
 
 
References:
1.Bump R, Hurt WG, Fantl JA, Wyman JF. Assessment of Kegel exercise performance after brief verbal instruction. . ;:–329.

1. Hanno, Philip M., et al. "AUA guideline for the diagnosis and treatment of interstitial cystitis/bladder pain syndrome." The Journal of Urology 185.6 (2011): 2162-2170.
2. Kegel, Arnold H. "Progressive resistance exercise in the functional restoration of the perineal muscles." American journal of obstetrics and gynecology 56.2 (1948): 238-248.

1. Pool-Goudzwaard, A. (2003). Biomechanics of the sacroiliac joints and the pelvic floor.

 
​

The  American College of  Obstetricians and  Gynecologists has general guidelines on this topic.

In addition to those general guidelines, it is important to remember that  having a baby  via  C-section or vaginal delivery is a  big deal! Your body is incredible, strong and beautiful. Honor your body during this time and allow the tissues to heal  ( vaginal delivery as an extreme sport  and  returning to exercise after a C-section). 
​Movement is very beneficial to healing  such as  walking, breathing  exercises and pelvic floor exercises.  Generally, after 4-8 weeks (based on  your  medical  visits), you can  increase to higher intensity aerobic exercise and weights.  If you try to go back to  the same exact exercises that you were  doing during pregnancy or  before, you may  realize you have changes affecting the way you move and feel such as: scar tissue  adhesions at your abdomen,  a prolapse starting, separation of the abdominal muscles,  leaking with jumping.

 Once you are cleared by your OB medically,  we highly recommend you see a  Pelvic  Physical Therapist  (Women's Health Physical Therapist). This is exactly what we do! We help you maximize your pelvic, abdominal, and back health to be able to return fully to your daily activities, including exercise programs. We  can do postnatal screenings to  identify  these conditions  and provide individualized  treatment and home programs for you. 

There are numerous  postnatal exercise programs out there,  which is why we want to highlight the very best!  The programs  listed here are  ones that specifically take  pelvic health into consideration. They are  developed by  fitness trainers  or PTs we trust.
**  These exercise programs are  not just for  up to 1  year postnatal. They are safe for  most people at any age because they are meant to  facilitate proper form  and optimal pelvic/core health. 
** Concern: Classes that focus on the  BOOT  CAMP mentality . Some of the exercises can be okay, but often women  are pushed to do crunches, planks,  high-intensity jogging and jumping with the motto "get your body back into shape quickly." These  exercises  are typically not appropriate  for many women  in the first year after baby.  Many women go to  countless exercise classes  for their abdominals  only to learn that it was making the diastasis recti and pelvic floor issues worse.  
**  We receive questions about the Tupler  Technique often.  It involves using  a splint  for a certain period of time while doing specific exercises. It can work for some, but we find that it is not  applicable to  daily function and many women have difficulty adhering to the program.  We  didn't feel comfortable putting it on our "best" list. 
 * We will  continue to  modify and add to this list. 

Click on the Banner Below to Learn More! 

The website features  a  series of  digital  download exercise programs:  Hab-It  Pelvic Floor Exercises,  7 Day Advanced Stabilization Program,  Interval  Cardio Workout,  Interval Plyometric  Workout. 
We  heard a lot about  this from patients. They enjoyed the program, but  were looking for more individualized programs as well. 

"The pelvic floor has long been the only muscle targeted in the battle against incontinence, and yet ignored in our pursuit of a strong ‘core’. New research has helped us understand that the pelvic floor is actually a critical part of the ‘core’ team and collectively that team works together to keep your center anchored and dry. Integrated teamwork, linked to the up and down pistoning action of our breath, provides a sturdy foundation that supports our joints and movement, accelerates fitness, and keeps us dry.  Also recommended for minimal to moderate prolapse, diastasis, and pelvic pain."

Physical Therapist Julie Wiebe is a leading clinician and educator on the topics of returning to high-level athletics after changes at the pelvic floor and core.  Foundation for Fitness is your first step toward resolving leaks and restoring a strong foundation for your movement and fitness.
* This is an educational online course rather than an exercise system.  Highly recommended to understand the pressure system of the core.  You can view  this as a great complement to the full programs listed above. 

Most people think of physical therapy in terms of therapeutic treatment for orthopedic or neurological conditions – things such as back pain, knee pain, and strokes. Did you know, though, that there are pelvic health specialty-trained physical therapists who help women and men with very private conditions? The terms often used are: pelvic health physical therapists, women’s health physical therapists, or pelvic PTs.
 
So, how are vaginal dilators utilized for pelvic physical therapy?
 
Vaginal dilators are most effective when used for conditions that prevent the patient from having a desired body part (finger or penis) or object (tampon, speculum for GYN exam, vibrator, etc.) pass the vaginal opening and into the vaginal canal. Some examples of these types of conditions are:

1. Vaginismus
2. Dysparuenia (painful sex)
3. Vulvodynia, Vestibulodynia
4. Dermatological conditions such as: Lichens Sclerosis, Lichens Planus, Dermatitis
5. Hormonal changes at the vulva
6. Vulvar cancer
7. Post Radiation treatments for gynecologic cancers – particularly in the vaginal canal.
8. Vulvar or vaginal traumas/injuries

 
It is important to note that most of the conditions listed need a team approach to treatment, including the medical management component first. For example, if someone has a dermatologic condition, prior to or during the pelvic PT treatment timeframe and use of dilators, they may need a topical ointment applied to the vulvar tissue. Essentially, the use of dilators does not replace optimal medical and physical therapy management. Rather, it is an excellent adjunct to the appropriate treatment plan.
 
As a pelvic PT since 2000, I can attest that many patients over the years arrived for their evaluations with bags of various dilators and frustrated looks. A typical comment is “My doctor told me to get these, but didn’t provide any additional instruction” or “I ordered these online” followed by “but, I have no clue if I am using them the right way and I’m not even sure they are right for me.” Most of the time, the patients have the wrong sizes and/or the wrong product for their condition all-together. I’ve even heard physicians and pelvic PTs say, “I just don’t use them with patients because they aren’t really that effective.” I wholeheartedly disagree and have been on a mission to show the wonders of the dilator! When the appropriate dilators are selected and the patient is instructed properly on how to use them, there’s excellent potential for a successful outcome.  It can make a significant  difference to have a skilled pelvic physical therapy help guide you with dilators! 
 
When selecting dilators:

1. I make sure that the sizes are appropriate for the patient. For a patient who’s never been able to have a GYN exam or use a tampon their starting size may be different than a woman who’s having intercourse regularly and can use tampons, but she has some increased pain initially. Some dilator sets start out at a size that is already too big for the patients to comfortably handle. Soul source has one of the smallest starting sizes.
2. Another consideration is the type of material used. There are numerous sets out there that are made of plastic or other harder synthetic materials. This can be very painful for patients. The silicone material of the Soul Source dilators is softer and has more movement. Hands-down, most patients find this most comfortable.

 
In an ideal world, pelvic PTs should help the patient initially with a demo on how to properly use the dilators. This includes the best way to insert the dilators (many people are unaware of this aspect), lubricants to use, how to properly progress the dilators, and tips on how to facilitate the desired outcome and transition to the ultimate goal.
 
This is where pelvic PT has a large role in a successful outcome for a patient. In most educational manuals I’ve seen, the primary focus of dilators is just to stretch the vaginal canal and muscles enough over time to get a desired outcome. That’s just a part of what is happening and if only that aspect is addressed, it may be why some patients do not progress well.  The way I instruct dilators has to do with 3 primary factors.

1. Desensitization/Neural System Effect: The primary way I believe dilators are helpful is the most neglected part of how they are explained to patients typically. We can use our professional education here in a way that can make a large impact. When someone has pain with attempts at inserting a finger, penis or object into the vagina, there’s more going on than the patient’s end result of the pain experience. Pain is an output of the brain. There can be an increase in someone’s perception of pain when the nervous system is in “alert” mode. So, if someone is already anxious or fearful of using dilators or being touched in this area, their nervous system is essentially “ramped up.” I teach extensively on how to do the exact opposite – how to utilize what we know about the brain/nervous system and anxious responses as a way to set up the potential for a decreased pain experience. Here’s an extensive guide to this approach
2. “Stretch” Effect: This is the usually the most discussed method to use with dilators. We can utilize dilators as a tool to gently and slowly allow the vaginal canal and pelvic floor muscles to stretch or relax. This can be done just via insertion or there are ways to educate patients on how to provide more pressure and a static stretch to the muscles.
3. “Functional” Effect: We often hear patients ask, “how will I know when I’m ready to try intercourse again?” When I explain that dilators are, in essence, a way to gauge that readiness. I explain often that “dilators are the bridge between not tolerating any touch or insertion in that area to tolerating full penetration.” We teach strategies on how to slowly transition from smaller sizes to larger sizes; from no movement to simulating insertion and in/out movements; and from staying in one position to simulating a variety of positions (this can apply to how one puts in a tampon, varying sexual positions, etc).

 
Once the patient feels comfortable with the education and demonstrations, I often recommend dilators as part of a home program. It is a highly effective way for patients to feel proactive in their medical care versus waiting for a medical practitioner to do something to or for them. Moreover, it is a way to facilitate improvements consistently because patients can use them regularly and at times that work for their schedules.
 
* This post was initially  written for  the Soul Source dilator company. 

 I volunteered to write this blog post for three reasons:
1.  To provide  honest feedback about  the  first Pelvic PT Boot Camp Clinical Skills Course 
2.  I am Pelvic Guru Fan
3.  Because I wanted a free toy chicken! ...(more on that later)
 
If you are a  physical therapist treating pelvic floor muscle dysfunctions, most likely the majority of your training in this subspecialty has come from postgraduate continuing education classes.  Likely your academic curriculum in PT school had little to no information on pelvic floor treatment.  Because let's face it, we are a small percentage (but growing percentage) of therapists that choose this path.  However, once you're  immersed in it,  you begin to see the great need of service for this population and if you're like me, you crave for MORE information!   
 
As a "beta test" course, taught Tracy Sher, it was advertised to be "geared towards improving your hands-on clinical skills and critical thinking".
 
         ...Tracy Sher delivered  on those words! 
 
This class was unique in so many ways and here are some highlights:
 
The Pelvic Guru and "clinical pearls" 
1. You get the clinical knowledge and expertise of Tracy Sher up front and center for a whole two days! Tracy, in my opinion, successfully juggles many hats.  She is an international speaker,  educator, business owner, and compassionate clinician who provides valuable information and  service  to her patients and colleagues.  Tracy delivers  evidenced based research and shares her clinical experiences while revealing those "clinical pearls"  you don't want to miss. She may even throw in a little humor  or show off her juggling skills during a break. :) She covers a variety of topics such as:  treatment plan guidelines for pelvic pain, painful intercourse, urinary incontinence,  vestibulodynia/vulvodynia, and  constipation.... just to name a few.  Rarely do you get to cover  an  array of subject matter in one class. In addition, Tracy did a great job gauging the needs of the class and spent more time in areas the group preferred to cover.  
 
Small group
2.  The class size was purposefully confined to a small-group setting.  It allowed for participants to take part in active discussion throughout the course and accommodated for a comfortable environment to expand on concepts that may not otherwise take place in a larger group. For example, the class that I attended had less than 15 students.
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Important Pudendal Information: :  
(For more details, please view  the article,  The 5  Things  We  Wish You  Knew About Pudendal  Neuralgia) 
*  There is not one single diagnostic test that can reliably  diagnose pudendal  nerve entrapment.   
*  The clinical history and location of the symptoms  are very important. 
*    It is  NOT pudendal nerve  entrapment  OR  pudendal neuralgia  just because one has pain with sitting and improves when  sitting on a toilet.  (You cannot rely on the vague symptom lists on the internet or Nantes  criteria). 
*  Pudendal Neuralgia (pain along the nerve distribution)  is NOT Pudendal Nerve Entrapment  (may  have  neuralgia,  but  in this case the nerve is  actually "trapped"  - due   to a surgery , trauma in that exact area, etc. MOST people are NOT entrapped). 
*  There are other nerves  that can mimic some of the same  symptoms of pudendal neuralgia.

Some final thoughts: 
1. Don't  decide to have a  major surgery based on  just  MRI or other radiology findings alone.  
2. Make sure you get  a few opinions, if possible.  This is particularly true if the  same person who reads the MRI  is  going to perform the surgery.
3. Go to  specialists  who actually specialize in THE issue.  I have some wonderful  Urology, GYN, and Colorectal  physician colleagues  who admit they  are  happy  to help patients, but just don't have the training for complex pelvic pain.  Even if  someone  has a website claiming to treat pelvic pain and pudendal issues , make sure you investigate this  further; and still possibly get another  medical opinion.  I  never  mind if patients seek other  opinions . 
4. Try  the best conservative measures first  such as pelvic  physical therapy.  Make sure it is someone who  treats and understands pelvic pain. Not just incontinence and weakness. 

**  This is merely one case. Just remember that each and every case is so different and the  assessment and plan must be individualized. I find that so often  people go online and see similar symptoms  and run out and have  unnecessary procedures. Find someone who  understands  this. Most  physicians, nurses, and physical therapists do not get specialized training in pelvic neuralgias and pelvic pain .  ~ Tracy Sher, MPT, CSCS

Tracy Sher, MPT, CSCS and Loretta J. Robertson , MS , PT  teach  a  pudendal neuralgia and differential pelvic pain course for MDs and Physical Therapists  internationally. The  next courses are in Salt Lake City , April 18/19, 2015 and Orlando May 30/31, 2015.

Check out  our article : The 5 Things We Wish You Knew About Pudendal Neuralgia.