I sometimes see patients state online "PT didn't help me" or "PT doesn't work."    It's vital to know that  physical therapy is not a modality   or a single treatment.  That would be equivalent to someone saying "cardiology doesn't work" or "personal trainers don't help." We know it depends on the individual professional or team of professionals.  A pelvic physical therapist is a  professional who  combines years of academic training with clinical training - and then there are so many other types of skills  or behaviors- listening,  empathy, critical thinking,  and ability to consider full spectrum of care including other professionals.   

Unfortunately, by the time patients see us at Sher Pelvic Health, they have likely seen numerous physicians and physical therapists. I often hear "why didn't anyone else ever check this?" or "why  are you the only person to ask about this or make this connection?" So, why do I bring this up?   Don't give up. If you feel that the pelvic PT you worked with was not able to help you (or any health professionals for that matter), maybe it would help to see another pelvic PT. Or there could be another professional in your area who is trained in pelvic health conditions that knows more than most . 

If you are looking for pelvic health professionals all around the world - check out the  Pelvic Guru global directory that grows daily .  There are 16 types of professionals, including physical therapists.   
​~ Tracy Sher

 Undoubtedly, one of the conditions I am most passionate about treating  is vaginismus. I wish I could scream it out loud: THERE'S HELP AND HOPE with the right treatment! I promise.  I have seen so many women  who suffer in silence for many years and finally get the help they need. They often share their frustrations of feeling isolated and alone in dealing with this. Often times, they don't attempt to have sexual relationships or end up losing relationships.  These women often share that they  also don't always participate in activities because they can't use tampons or  menstrual cups. 

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.

Do you have questions about Kegel exercises after childbirth?  You are not alone.  Most women have heard they should be doing “Kegel” exercises to strengthen their pelvic floor muscles, especially after having a baby in order to reduce urinary leakage and pelvic organ prolapse risks.  However, more often than not, the instructions given by the OB/GYN or childbirth educators are too vague or not specific enough to treat the real problem, and some people should not do Kegel exercises.  If you have pelvic pain, exercising might be making the pain worse.  Seeing a physical therapist who specializes in the pelvis may be the answer to your Kegel questions.
 
How do I know if I am doing them correctly?  How many should I do?  What position should I be in?  Are you supposed to do them when you pee or when you are at a red light-which is it?  Will it help with my urinary leakage?  What about with my sex life? 
 
These are common questions I hear in my practice as a pelvic floor physical therapist.  I specialize in treating the muscular dysfunctions of the pelvic floor.  A group of over 20 separate muscles that lie underneath the pelvic organs (the bladder and the bowels, the uterus and vagina in women, and the prostate in men), the pelvic floor acts to support the organs and gives us voluntary bowel and bladder control. Most people think their bowel, bladder, or genital troubles are due to problems in the organs themselves.  Your bladder problem may really be a muscle problem.
 
The most frequent question I hear is, “What on earth can a physical therapist, of all people, do about my bladder or bowel problem or my pelvic pain?” A lot, actually. 
 
The American Urological Association recently recommended pelvic floor physical therapy as an early treatment option for pelvic floor dysfunction, especially in those with pelvic pain. The pelvic floor muscles are skeletal muscles, which mean they are under your voluntary command.  They are controlled by your thoughts, just like the muscles in your arms and legs, which means they can have the same type of problems as any other muscle.  Weakness, poor endurance, poor coordination, and even painful tender points and scar tissue adhesions can occur in the pelvic floor muscles.  Instead of causing difficulty with walking or lifting, pelvic floor muscle dysfunction can cause incontinence, pelvic organ prolapse, and even pain with intercourse. 
 
So, what does a pelvic PT know?
 
Pelvic PT’s know that most bladder problems are really muscle problems. 
Like pinching a garden hose, the pelvic floor muscles contract around the urethra (your bladder tube) to give us bladder control.  When you have the urge to urinate and “hold it”, your pelvic floor muscles are doing the holding. 
 
If your pelvic floor muscles don’t have adequate strength, they can’t pinch the urethra tight enough to hold urine inside the bladder.  If you have poor endurance in your pelvic floor, you might have trouble making it to the bathroom on time.  If you have poor coordination, your pelvic floor muscles might not squeeze fast enough to counteract that cough or sneeze.  The same can be said for bowel control, too.
 
Your average Kegel program is too simple to address these muscle complexities. Bladder and bowel control is dependent on the pelvic floor muscles working in harmony, not just being “strong”. 
 
Think about it-does it make sense that just doing biceps curls would fix every arm problem?  No, it doesn’t.  Kegels can’t fix every pelvic problem, either.  There are many  types of pelvic exercises.  Kegels are just one type of exercise a pelvic physical therapist might prescribe.
 
 
Pelvic PT’s understand pelvic pain.
To put it simply, pain inhibits normal muscle function.  When we hurt, we don’t move normally. 
It is easy to see if someone has pain in their knee or ankle – they limp!  The pelvic floor is an inside muscle, which makes seeing its dysfunction more difficult. 
 
If your pelvic floor muscles are painful due to an episiotomy scar or other birth trauma, repetitiously contracting the muscles may make your pain worse.  You may need exercises that stretch rather than strengthen your pelvic floor.  Only a trained pelvic floor physical therapist can evaluate your pelvic muscle function and then prescribe the right type of pelvic floor exercise program for you. 
 
 
Pelvic PT’s know how to individualize an exercise program.
A Physical Therapist uses movement to treat the body the same way a doctor uses medicine.  Exercises are prescribed and are individualized to the patient.  A triathlete or cross-fitter should, and will, have a different program compared to someone who has never really exercised.  Your “movement medicine” is designed to fit your life and the demands your lifestyle puts on your body. 
 
The pelvic floor is not an isolated muscle group.  It is anatomically connected to your hips and is a part of your inner core of muscles.  Knowing how connected the pelvic floor is to the spine and legs, it is no surprise that back pain and balance troubles are linked with incontinence. In a recent study, 52% of people with low back pain also reported having some form of pelvic floor dysfunction (voiding dysfunction, urinary incontinence, sexual dysfunction and/or constipation). Over 80% of those with pain said their pelvic floor symptoms began about the same time as their low back or pelvic pain did. 
 
If you have pelvic pain, back pain, tailbone pain, or genital pain, it is very likely your pelvic floor is part of the problem. Seeing a pelvic floor physical therapist who can tailor a program for you can be a part of your solution.

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 [email protected].
 
 
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.

 
​

According to the 2016 study (and previous studies) on postnatal pelvic girdle pain, Response of the muscles in the pelvic floor and the lower lateral abdominal wall during the Active Straight Leg Raise in women with and without pelvic girdle pain: An experimental study  , women with pain activate muscles differently.  There's help for this! 

The important findings are: 
During the subsequent ipsilateral leg lift (lifting  the  leg  on the same side as the painful  pelvic region):
* pre-activation in the pelvic floor muscles was observed in 36% of women with pelvic girdle pain and in 91% of pain-free women
*Compared to pain-free women, women with pelvic girdle pain also showed significantly later onset time in both the pelvic floor muscles and the muscles of the lower lateral abdominal wall

 We know from previous studies (one of many) that  there are many prognostic factors that  can relate to  persistent pelvic girdle pain  such as  age, muscle function, disability, and previous  fitness level/pain  levels . What  does this all mean for patients ? How  can we help  those of you who are dealing with lumbar and pelvic pain , even years after having a  baby? 

The key is to address  each patient individually. There are numerous layers to  the pain experience  - beyond just the location of pain.  It  is likely also simplistic and  erroneous to assume that the pelvis is  "too unstable" or that the  sacroiliac joint  is just hypermobile  (there are certainly cases of  people who have hypermobility as a component such as with Ehler's Danlos Syndrome, but even then, there are other factors). If you find that you have been seeing other healthcare professionals for years telling you that your leg, sacroiliac joint, or pelvis keeps going "out," that's likely not the issue.   From a whole-person perspective, there are  factors to consider such as hormonal, physical, sleep/lifestyle, social, and psychological (not "it's-in-your-head type, but rather effects of anxiety, stress, previous pain, or previous trauma, etc) .  Therefore,  addressing  these factors AND  taking a closer look at  the  pre-activation/motor control of the muscles and general movement patterns  is  an ideal approach.  

If you are a patient dealing with  pelvic  girdle pain,  sacroiliac joint pain, lower back pain  after having a baby (even years later), there's a  lot of hope for getting better!  A pelvic physical therapist  can assess you individually to  facilitate the best plan for your daily life and also provide an optimal exercise plan to  guide you to relatively pain-free  movements! This goes beyond simply giving a list of exercises and  saying good luck!  That's why so many women continue to have pain for years later.  We can also work closely with your pregnancy /postpartum specialists  - there are some incredible ones out there too. 

For professionals - The key is how do we improve/facilitate the proposed disturbed motor activation patterns that influence women's ability to stabilize the pelvis during leg? How much do we train "pre-activation?"
There seem to be distinct professional views: 1. Some say just get patients moving in pain-free ways and this will help with improving neural/motor activation and don't focus on pre-activation and minutia; or 2. Others focus heavily on individual "pre-activation," movement patterns, segmental/"core" strengthening. Couldn't it be the case that we include both of these strategies (and individualize as needed) - not so much thinking we are increasing strength, but rather improving motor patterns and activation on a neural level? 

Another consideration:  EMG testing can be subpar for understanding the underlying issue regarding muscle activation. In other words, patients may not be pre-activating pelvic floor as a result of shortening of the muscles rather than simply not activating due to weakness or other. Therefore, just working on activating the pelvic floor prior to an activity, may not be the best treatment. We still have to look at each individual and assess  all of the  variables.
**  Did you know that Tracy Sher, MPT, CSCS and Alma Bautista, SPT,  at Sher Pelvic Health are both Certified MuTu  Pros™ in  postnatal fitness?  Minal Saraf, MSPT also specializes in  Pelvic PT for pregnancy/postnatal. 

We receive many questions about postnatal exercise concerns and online programs.  We hope you find this information helpful!

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. 

"Had enough of the baby belly? Strengthen your core, improve pelvic floor function + get strong, fit + body confident… however long ago you had your baby!"

Click on the Banner Below to Learn More! 

We recommend this  to  new moms  in conjunction with our  pelvic PT sessions OR  this program can serve as a stepping stone to  more advanced exercise programs (getting back to high-intensity weight lifting classes  and/or aerobic exercises) . Tracy Sher serves as Medical Advisor for  MuTu  and affiliate and fully endorses the program.  The online program also includes access to  a very active  online  support  group. The founder, Wendy  Powell, is very passionate  about this system and  heavily involved in online support. 
* We will soon offer  LIVE MuTu  classes in Orlando starting in  July/August of 2016! 

"Wholesome fitness for the whole family.  You crave modesty, affordability, and accountability." 

Another  program that is always rated with high satisfaction  is Fit2B , by Beth Learn.  The primary feature is a monthly or yearly membership that provides online options such as:  access to over 100  workouts,  a supportive Facebook community, discounts on eCourses , and  a  Fit2B mobile app. 

"Hab-it: Pelvic Floor is a DVD [now digitial download] that gives women suffering from the symptoms of a weakened pelvic floor (urinary incontinence, pelvic prolapse) the experience of working with a physical therapist from the comforts of home. The intent of the DVD is to help, if not eliminate, the symptoms of a weakened pelvic floor...designed with input from physicians, physical therapists, and real patients to ensure that viewers receive expert guidance that addresses the most common mistakes and frustrations of physical therapy"

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. 

We hope this has been helpful!  
If you would  like to set up a  consultation with  one of our Pelvic  PTs , you can fill out the  registration form on our    welcome page HERE or call 407-900-2876

​~  Tracy Sher and the Sher Pelvic Health  team!

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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 (article continues after the picture gallery)

I'll never forget the words of a former patient of mine, who happens to be a Radiologist.  He said "MRIs  can be MR  LIES. Sometimes you can't see things and other times there are false positives "  This is seen  with all sorts of cases of low back pain, for example.  Low back pain is such a common problem and radiologic findings don't always correlate with symptoms .  We know that even if herniated discs or degenerative changes are found on an  MRI, it doesn't mean that it relates to patient symptoms.(2014 MRI  study)      ( Scans  For Back Pain Ineffective) .  I once heard an example that elucidates this point. Someone can have migraine headaches and also have baldness, a "degenerative" change.  But, this does not mean the baldness is causing the headache. If someone has findings of degenerative discs, this does not mean it is the cause of the back pain. The opposite can also happen where important  things are not  seen  and  reported  as well  (Harvard researchers found that 83 percent of radiologists didn't notice the gorilla  in a lung scan).  Also, some results of  MRIs  differ  depending on who's reading  them.  This can be based on experience, knowledge of history,  training  in a specialty area,  potential for  financial gain and so forth. 

I recently saw a patient for an evaluation and a follow-up visit. Her case truly  concerned me. She supports me sharing the initial findings to promote awareness and education.  The  MRI  report  looks potentially daunting (particularly if one does a Google search about it) and  the diagnosis  appears to be incorrect. This  could likely lead to a totally different  path of care than the patient needs , as we unfortunately see far too often with pelvic health  issues.  When evaluating patients, my  goal is to  ensure I get a  complete  patient history,  relevant  physical exam based on my  knowledge and licensure, and  utilize  critical  thinking skills to move forward with a plan of care.  With regard to pelvic pain,  there aren't always  enough  specialists  in this area for patients to see.  As a result,  I often become a primary source for  triage  and case management to ensure patients  are connected with resources and a full team of other medical professionals, if needed.   This is one of those cases where the patient stated  "Had I  not seen you first, I was so desperate, I would have  paid any money to do  a surgery that would have probably been the wrong choice."  I share this  case  to highlight  the importance  of  not  relying on just one test or measure, which may be skewed; and encouraging patients to advocate for themselves and their loved ones.  It is  perfectly acceptable  to  get  several  opinions/evaluations from  qualified  professionals.  

Patient  Evaluation
Based on a 2 hour evaluation  with  extensive  clinical history of symptoms  and onset and  extensive physical exam. 
47  year-old woman  who came  from out of state after  multiple attempts to seek help in her area.  Based  on her symptoms,  she was very concerned that she had pudendal  nerve entrapment after researching on the internet. While waiting to see me in my office, she was sitting  in a special anti-gravity chair  she brought with her and was reclined back.  She reports  she is so miserable with sitting that she can't even drive  her kids  around  town to  activities or work much.  She works  in a reclined position , alternating with standing. Walking and lifting heavy things can also aggravate the symptoms. She has seen numerous  physicians in her area and they have suggested things like  "it seems like a nerve - here's medicine for that" or " just  don't sit up as much,"  or  offering pudendal injections.  But, she has felt hopeless.

Important  history:       
* Patient  had an abdominoplasty (tummy tuck) surgery about 8 months prior to these symptoms happening AND had also started doing intense kickboxing and abdominal crunch exercises.  
* She  had  an oopherectomy (removal of an ovary)  after these symptoms started, as  one GYN  thought this may decrease her pain due to a large cyst on that ovary.  She felt only minor relief, but then the pain returned. 
* History of 2 vaginal births. 

Primary symptoms:  
*  Not able to tolerate sitting upright  at all  (Most  of her  physicians didn't ask for more information)
Important: If she sits up straight, she feels  like she has a "toothache " in  the  lower abdominal/pubic area.  She also feels a distinct  vulvar /clitoral/ and urethral discomfort. As long as she leans back,  the symptoms decrease. If she lies flat, the symptoms usually go away.  Sitting on a toilet seat relieves this pressure too. 

*  With walking ,  the patient  felt some lower  abdominal/pubic pressure  and sometimes gets  the  sharp "fork" pain in her vagina. 
*  Symptoms  increase  when she lifts  things  like a jug of milk. 
* Symptoms worse by the end of the day. 

MR  findings:    
Bilateral (both sides) PUDENDAL  NERVE  ENTRAPMENT  at the area of the piriformis  (located  in the buttock region). 

* The patient has absolutely no  signs or symptoms  of issues  at or near the piriformis on  either side and she doesn't even have symptoms classic of pudendal nerve entrapment. Furthermore, we cannot be sure it is true entrapment just based on this test. The  danger with  this diagnosis, is it may lead  someone down the path of thinking they need some sort of pudendal nerve decompression surgery and/or both of the piriformis muscles resected.  I've seen too many people get these types of surgeries when it is just  NOT the  right treatment at all.   Pain with  sitting does not  have to mean  pudendal neuralgia or entrapment.

Clinical Evaluation - Highlights
Negative for  all cystoscopy,  other urology tests, and spinal MRI.  Negative for abdominal/transvaginal  ultrasound other than  cyst on ovary (and  removal of that ovary  since symptoms started). 

** Absolutely  no pain or reproduction of symptoms with any touch, testing, pressure at the piriformis or surrounding hip or  posterior external pelvic muscles.  No pain or reproduction of symptoms with palpation at ischial tuberosities,  external obturator internus, or along pubic ramus. 
** Able  to reproduce  the  deep "fork" pain in the vagina with direct pressure  into the umbilicus (belly button).  Appears to have  superficial diastasis recti of 1 finger at umbilicus and slighly below (but deeper part is intact)
**  Mild tenderness  and "toothache" feeling with pressure /palpation  at  lower abdomen   and along her scar.  Symptom  reproduction and increased  abdominal  pain with sitting  hours after palpation at abdomen.
*  Mild pelvic organ prolapse - bladder and rectum  (I -II). Not significant. GYN  exam  performed recently indicated the same (I-II).  
*  Some  mild tenderness  of deep internal pelvic floor muscles  (levator ani,  obturator internus)  and near paraurethral/sphincter urethrae area;  and  no tenderness at  bulbocavernosus/ischiocavernosus. Not able to reproduce the deep vaginal pain, sitting pain, or clitoral/urethral/vulvar with palpation at pelvic floor muscles, at cervix (though tender to touch)  or  near ischial spine, alcock's canal, or  deep sacral region B. 
*  Tenderness  directly at/near the clitoris  and near the external urethral meatus that patient reports  feels like the "urethral" discomfort when she sits. This appears to be separate  from the other pain and may  be  a local  tissue  issue  (not primary source of pain).
* Negative  for general  thoracic, lumbar, sacral  musculoskeletal/neural testing. 
* Cutaneous sensation at the abdomen  appears  intact (reports still having sensation at scar - possibly slightly diminished) and no  allodynia or  hyperalgesia. 
*  Long history of urinary frequency and nocturia ; and  urinary leakage with jumping  (prior  to  new onset of symptoms).  History of constipation , but improved now, which seems to help some with her symptoms. 

The evaluation reveals  that the area of most discomfort and also reproduction of symptoms  is at the abdomen, not  at sacrum or  piriformis. She likely has difficulty sitting  due to compressing the abdomen. 
She is likely having nerve irritation  at/near the abdominal/pubic/inguinal region . She likely has adhesions (scar tissue from the surgery) - may or may not be contributory;  She may have some lymphedema (vascular compoent) at the abdomen/inguinal regions; It is possible she may have had  some form of osteitis pubis  due to excessive abdominal crunches and kicking  without proper support or activation of the transversus abdominus.    I'm keeping prolapse and possible enterocele in the diffrentials just in case. There's also a sensitive area to the touch at/near the clitoris that we can easily address as well.  We will continue to see if  conservative management is effective.  We will begin  the treatment plan and  reassess.  

BIG  Difference  Between  MR  Report and  Symptoms /Clinical Findings!
This patient was considering  pudendal surgery on both sides .  Doesn't look like the right diagnosis, right?

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. 

A 59 year-old male, traveling from out of state, presented here to SPHH with the chief complaint of  "penis pain" he's had for 14 years. 

He's already seen physicians at the top  medical centers all over the U.S. He's had pudendal nerve decompression surgery (...because he was told "MAYBE" he had pudendal nerve entrapment. This is NOT the same as pudendal neuralgia; and surgery is a last resort IF the right differentials and treatments are tried), numerous other procedures such as pudenda nerve blocks, pulsed radio frequency ablation and cryoablation to the pudendal nerves. He's had many different types of imaging tests - pelvic MRI and spine MRI. He's tried all sorts of medications. Nothing helped with his discomfort, or if it has, it was fleeting for a few days. Every place he went, they tried their best treat for what was considered a "pudendal issue." Based on his symptoms, I was glad to know he found professionals who even knew about the pudendal nerve and types of treatments. This is not always the case. Often, patients go for years hearing "I deal with the back and hips, not  that  region" or "It must just be in your head, stop worrying about it so much" and so forth. The issue in his case is that it appears that not all of the differentials were properly considered or assessed. THIS is the key. 

When I completed a long, detailed patient history discussion and listened to his story, I realized this is a patient who has been possibly misdiagnosed. The pain is at the pubic region and  base of his penis. He also doesn't like to eat meals during the day because his lower abdomen feels "bloated" and his pain gets worse. He appeared to have an umbilical hernia (at the belly button).  When I pressed on it, that seemed to  reproduce some of his  penile pain.  I could decrease his pain by closing the gap at his  belly button  AND if I lifted his  abdomen  up  or  put a lot of pressure  in an upward direction on his  sit bone area  and perineum.  Typically,  patients with pudendal neuralgia  feel worse with compression  or any type of pressure with sitting. He feels better sitting on a very hard surface and worse on  soft surfaces.  He's also had previous inguinal hernia surgery.

Since our initial visit , he's had a  minor surgery to correct the umbilical hernia and already had relief of some of the symptoms. I placed him on an exercise program to facilitate  improved movement,  better breathing, and  activating  the  "core" muscles in  a way that was supportive vs. too much lower abdominal pressure.  He's also started  a pelvic floor strengthening and coordination program  (usually this is not recommend  with pudendal issues). 

Any guesses what the  likely  correct diagnosis is for this patient?  I helped the patient find the right healthcare professionals for a "virtual team" and we are continuing  treatment  and care  for what appears to be some form of an   ilioinguinal, iliohypogastric and /or genitofemoral  neuralgia or entrapment (and ruling out an enterocele and/or vascular components).  Stay tuned for updates! 

All of the usual treatments  for pudendal nerve, even the  conservative pelvic physical therapy treatments  are not optimal. In fact,  he  does better  with a program for  strengthening and coordinating  better control of  "core" muscles and engaging the pelvic floor and glutes.  

**  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.