Special Report: My Quest For Pain-Free Sex, Part II

“Does your pain occur with ‘deep penetration’ or is it more like a ‘ring of fire,’ at the opening?”

This is the kind of question you get upon entering the world of pelvic floor physical therapy. That is, if you’re lucky enough to find out that the therapy even exists.

Recently, I wrote about my experience suffering from pain during sex, and how I found relief from pelvic floor physical therapy, a little-known treatment that is often overlooked by doctors. I got scores of comments from other women with similar problems — some who have lived with their pain for years. Like me, they’d never heard of pelvic floor PT, and they were thrilled to learn that there is an effective alternative to quietly enduring their extreme, often secret, discomfort.

Perhaps pelvic floor therapy might soon gain credibility: last week, a local physical therapist, Jessica McKinney, used my story as part of her Grand Rounds at Massachusetts General Hospital. She spoke to about 16 obstetrician and gynecology residents and medical students. They listened intently to her hour-long talk (edited and posted below) and when it was done, one young man walked over and asked, “What’s a Kegel?”

Pelvic floor PT is far more than Kegel exercises. So, in the spirit of enlightenment, here are a few more details (maybe too many) about my sessions at the Brigham and Women’s Hospital Department of Rehabilitation Services:

The First Visit

After my physical therapist, Rachael Maiocco, talked about the anatomy of the pelvis and relevant organs, she asked many questions about the nature of my pain. Was it deep or superficial? How intense on a 1-10 scale? She asked about my experience giving birth and other medical history. We determined that the initial cause of my pain was probably a particularly bad bladder infection that was left untreated for too long. (I was on the Cape and trying to ignore it, until I developed a fever and rushed off to the clinic in Provincetown.) My body’s reaction to the infection was to tense up into “guard” mode — my pelvic floor muscles tightened and wouldn’t relax. In addition, the nerve endings were hypersensitive, and my skin was irritated: hence the pain. (Ring of fire, since you asked.)

To work out the muscle tension and desensitize the nerve endings and skin, Ms. Maiocco explained she would use “soft tissue mobilization” and a variety of manual techniques. (Note: physical therapists hate the term “massage” because it connotes either being pampered at the spa or engaging in X-rated behavior. Ms. Maiocco and all the therapists I’ve quoted here have doctorates in physical therapy and specialized training in pelvic floor PT, so I will respect their preferences on this point. But just to be clear, she did use her finger inside my vagina to press on various muscles — and I can tell you, the experience was neither spa-like nor X-rated. )

So, using a finger, she pressed along different areas at the vaginal opening and then moved on to other muscle groups. The goal was to improve muscle performance and relax any areas of tension. This physical manipulation also had a mental component: retraining my brain to understand that what it perceived to be “pain” and “irritation” was simply pressure. (This is a complex process — really as complex as sex itself — and involves the dynamic interplay of brain, nerves, muscles and pelvic organs.) After 15-20 minutes of varying types of pressure, my “pain” actually began to shift to a more generic, neutral sensation.

Pelvic Floor Biofeedback

On the second visit, in order to visually track how tense my muscles really were, we did biofeedback. Using an internal sensor, I was able to see on a computer screen how well my muscles were able to contract and relax. “Many people don’t even know they have
muscles inside,” Ms. Maiocco says, “and are unsure how to coordinate movement.”

When I contract, I see the trace spike higher on the screen, but when I try to relax, the line doesn’t return to baseline. I can now clearly see my inability to let go. (Paging Dr. Freud). Ms. Maiocco urges me to repeat this practice at home: contract the muscles until they are moderately tight and then release. Do it again.

Because my problem was relatively straightforward and my pain was only mild to moderate, my body responded quickly to treatment. But for other women who have endured pain for years, sometimes therapy needs to be much more involved for it to be effective. The manual work can go on for 45 minutes per visit, with techniques that focus both inside and outside the vagina, sometimes even on the labia and skin. It can include the buttocks, abdomen and legs — all areas that impact the pelvic region. (By the way, men who suffer from an enlarged prostate, frequent middle-of-the-night bathroom runs and related problems can also benefit greatly from pelvic floor PT, but the internal work can take some getting used to. Think rear entry.)

The Bladder Diary

In addition to my relaxation exercises, I had another assignment: record everything that went into and out of my body.

Admittedly, I was a bit lax on this, and did a bunch of guessing after the fact. But one key point emerged: I peed a lot.

Let me rephrase: I went to the bathroom a lot, but not much always came out. This must be a vestige of all those endless drives from Brooklyn to Wellfleet in my childhood where my mom would make us go “just in case.”

In pelvic floor PT, the “Just In Case” phenomenon, or “JICing” is well known, and it leads to trouble. That’s because it teaches the bladder that if it’s only half full, it gets to void. Over time, the perception of “fullness” changes and your bladder can’t hold as much and it gets “confused.” “You end up asking too much of those muscles,” Ms. Maiocco says. “And it irritates the whole system.”

So, I underwent bladder re-education. I learned about minimizing irritants like coffee, alcohol and chocolate; initiated a “healthy voiding schedule,” about 5-7 times a day; and tried to drink the right amount of water. Finally, I was told, when going to the bathroom, never “push.”

Over the course of five visits (my insurer authorized a total of 8, and I may eventually return for more) my pain did subside.

Yes, the process was time consuming, and surely not as simple as taking a pill. But the combination of “hands-on” therapy, learning about how to properly use my pelvic floor muscles, and (not trivially) discussing my problem with my husband and enlisting his help, made a huge, positive difference.

Dr. Samantha Pulliam, a urogynecologist and pelvic floor surgeon at Massachusetts General Hospital, says there are three main reasons why pelvic floor physical therapy has been largely ignored, even while it is often the the missing link in treating pelvic pain.

First, she says, medical training programs don’t give much, if any, information about the problem or possible solutions (that’s why Dr. Pulliam asked Ms. McKinney, the therapist, to speak to the residents at MGH).

Second, there’s a “huge disconnect” among doctors about what other providers actually do. “If they send a patient to PT, it’s like they’re sending them to a black box,” she says.

Finally, there’s a lot of resistance by patients to the time commitment, and to their perception of the treatment (who wants to see yet another provider for yet another vaginal exam)?

“But I tell them going to PT is like going to the gym,” Dr. Pulliam says. “The first time may not feel that great but over time, it’s good, and almost everyone who goes is thrilled.”

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  • Bannermkr

    My question is will this work with a plethoria of physical disabilities that I was born with. I was born with an undersized bladder and an oversized set of kidneys that lean forward. I have had no trouble in my teen years with tampons in fact I used the supersize ones because I was so heavy during the periods that I did have. I had a hysterectomy when I was 28 years old. I have never been able to complete a gyn exam since the hysterectomy. I have been hit by vehicles that would have nothing to do with it.
    I was able to have intercourse with a man 7 months before I met my husband without a problem now after a date rape I have extreme pain. We have not been able to consummate our marriage, mainly because he is too embarrassed to admit to a doctor that he has never had intercourse. Now I get diagnosed with Vaginal atrophy and sent to PT. They say my vagina is not wide enough. Please tell me how PT is supposed to widen what is a physical abnormality. I am very upset with my gyn for doing this I consider it brushing me off instead of dealing with the issues. Once again just shoved to the side.

  • Guest

    Thank you so much! I have only just learned about this report, and I wish that I had encountered it when it came out. I have the same problem for over two years, and have tried everything that has been suggested to me (oestrogen cream, progesterone cream, acupuncture, anti-depressants)–all to no avail. Thank goodness that there is one physiotherapist here in Hobart, Australia who specialises in Pelvic Floor PT–I’ve just booked an appointment! Thank you again!

  • km

    A great article….really has opened my mind to different kinds of treatments and different ways thinking about pain. This is very pro active. Thank you.

  • Portislisa

    Thank you so much for shedding light on this important issue. I’ve never
    had pain-free sex. I started going to a pelvic floor PT about a year
    ago, and I’m back for round two. My experiences and passion for the
    issue have lead me to consider going into the field myself. There’s such a need for it and so many people are forced to live with this pain that is not only physical, but emotional as well.

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    Thank you for helping increase awareness.

  • http://www.Myofascialrelease.com Valerie McGraw, P.T.

    Pelvic problems affect women of all ages and are often caused by undiagnosed Myofascial restrictions. The standardized tests that are done today such as CAT Scan, MRI, x-ray, EMG, do not show fascial restrictions and therefore this problem often goes undiagnosed. This is why so many women go from specialist to specialist and still suffer with unrelenting pelvic pain and dysfunction. Traditional medicine and therapy treat the symptoms and ignore an entire physiological system of the body, the fascial system.

    Fascia is a tough connective tissue in the body that surrounds every muscle, bone, blood vessel, organ, and nerve of the body, all the way down to the cellular level. Fascia tightens from trauma, inflammation, poor posture, and childbirth resulting in excessive pressure on pain sensitive structures of the body creating pain and dysfunction including painful intercourse.

    As a Physical Therapist who has specialized in John Barnes’ Myofascial Release for Women’s Health problems for the past 23 years, I have seen the benefits of this approach in so many women who suffer with pelvic pain including vulvodynia, pudendal nerve entrapment, endometriosis, painful intercourse, interstitial cystitis, bladder problems, menstrual problems, adhesions, fibrocystic breasts, chronic fatigue and fibromyalgia.

    At John Barnes’ Myofascial Release Treatment Center in suburban Philadelphia and Sedona, Arizona, patients come from across the country and abroad who have suffered for years or decades, have seen numerous specialists and/or have had surgery and have had little or no relief of their symptoms. Often, they have been told that they have to live with the pain or that the pain is in their head. Myofascial Release treats the cause of the problem, fascial restrictions, using gentle, sustained, hands-on pressure into the restriction. Myofascial Release treats the body as a whole because fascia is a whole body system. By treating the cause of the problem in the fascial system, women are able to return to a painfree active lifestyle again.

    Specialized Myofascial Release techniques for Women’s Health problems address fascial restrictions in the pelvic floor using internal techniques with sustained gentle pressure. This helps to free the restrictions that cause painful intercourse, vulvodynia, bladder problems, pudendal neuralgia, and more.

    For additional information on this highly effective approach, visit:

    http://www.Myofascialrelease.com.

    The following links will provide you with some useful articles written by John F. Barnes P.T. who developed the Myofascial Release approach and has trained over 50,000 healthcare professionals to date over the past three decades.

    http://www.massagemag.com/News/massage-news.php?id=7935&catid=62&title=therapeutic-insight-the-myofascial-release-perspectivefemale-problems

    http://www.massagemag.com/News/massage-news.php?id=9186&catid=62&title=therapeutic-insight-the-myofascial-release-perspectivebreast-health

    http://www.myofascialrelease.com/fascia_massage/articles/article_fibro.asp

    http://www.massagemag.com/News/massage-news.php?id=8112&catid=62&title=therapeutic-insight-the-myofascial-release-perspectivefrequency-urgency-andor-incontinence

    Valerie McGraw, P.T. Myofascial Release Treatment Center, Paoli, PA

  • http://www.Myofascialrelease.com Valerie McGraw

    Karen Wiesner wrote…… “Why the medical community cannot find some way to help those of us so afflicted is quite beyond me.”

    Pelvic problems affect women of all ages and are often caused by undiagnosed Myofascial restrictions. The standardized tests that are done today such as CAT Scan, MRI, x-ray, EMG, do not show fascial restrictions and therefore this problem often goes undiagnosed. This is why so many women go from specialist to specialist and still suffer with unrelenting pelvic pain and dysfunction. Traditional medicine and therapy treat the symptoms and ignore an entire physiological system of the body, the fascial system.

    Fascia is a tough connective tissue in the body that surrounds every muscle, bone, blood vessel, organ, and nerve of the body, all the way down to the cellular level. Fascia tightens from trauma, inflammation, poor posture, and childbirth resulting in excessive pressure on pain sensitive structures of the body creating pain and dysfunction including painful intercourse.

    As a Physical Therapist who has specialized in John Barnes’ Myofascial Release for Women’s Health problems for the past 23 years, I have seen the benefits of this approach in so many women who suffer with pelvic pain including vulvodynia, pudendal nerve entrapment, endometriosis, painful intercourse, interstitial cystitis, bladder problems, menstrual problems, adhesions, fibrocystic breasts, chronic fatigue and fibromyalgia.

    At John Barnes’ Myofascial Release Treatment Center in suburban Philadelphia and Sedona, Arizona, patients come from across the country and abroad who have suffered for years or decades, have seen numerous specialists and/or have had surgery and have had little or no relief of their symptoms. Often, they have been told that they have to live with the pain or that the pain is in their head. Myofascial Release treats the cause of the problem, fascial restrictions, using gentle, sustained, hands-on pressure into the restriction. Myofascial Release treats the body as a whole because fascia is a whole body system. By treating the cause of the problem in the fascial system, women are able to return to a painfree active lifestyle again.

    Specialized Myofascial Release techniques for Women’s Health problems address fascial restrictions in the pelvic floor using internal techniques with sustained gentle pressure. This helps to free the restrictions that cause painful intercourse, vulvodynia, bladder problems, pudendal neuralgia, and more.

    For additional information on this highly effective approach, visit:

    http://www.Myofascialrelease.com.

    The following links will provide you with some useful articles written by John F. Barnes P.T. who developed the Myofascial Release approach and has trained over 50,000 healthcare professionals to date over the past three decades.

    http://www.massagemag.com/News/massage-news.php?id=7935&catid=62&title=therapeutic-insight-the-myofascial-release-perspectivefemale-problems

    http://www.massagemag.com/News/massage-news.php?id=9186&catid=62&title=therapeutic-insight-the-myofascial-release-perspectivebreast-health

    http://www.myofascialrelease.com/fascia_massage/articles/article_fibro.asp

    http://www.massagemag.com/News/massage-news.php?id=8112&catid=62&title=therapeutic-insight-the-myofascial-release-perspectivefrequency-urgency-andor-incontinence

    Valerie McGraw, P.T. Myofascial Release Treatment Center, Paoli, PA

  • http://twitter.com/KLHaskamp Karen Wiesner

    I spent four years traveling from doctor to doctor in search of a cure for my chronic pelvic pain. I must have seen 20+ physicians and all of them were as ignorant as anyone might imagine. Finally, in utter desperation I purchased an anatomy text, a neurology text, and painfully sat at my desk and computer and determined, on my own, that the problem was pudendal neuropathy. I found a physician who administered a pudendal block, and all pain disappeared temporarily. Repeated blocks (administration of a corticosteroid & local) allowed me several months of pain free living, but one cannot continue to have corticosteroids pumped into the same area indefinitely. After three blocks on each side I turned my attention to the surgical decompression of the pudendal nerve, traveled to Texas, and underwent the surgery. This took my pain from 8-9-10 down to 5-6-7, which was an improvement, but hardly a cure. So, I then turned my attention to the efficacious application of Botox to the afflicted area. Sure enough, injections of Botox into the bulk of the muscles of the pelvic floor eliminated the vast majority of the discomfort down from 5-6-7 to 2-3-4 (some days even zero!!!) Unfortunately, after years of utilizing Botox PLUS physical floor rehabilitation (PT) I developed antibodies to the Botox rendering it ineffective for my problem. So, now I am left with only P.T. and my pain management doctor who is recommending a stim unit. Please note that during this entire time I avoided opioids, as they induce constipation, and the LAST thing one needs to experience with PN is constipation. I will now endeavor to see if weekly visits to my P.T. will eventually restore normal functionality, but I am not holding my breath, as I have been undergoing P.T. for years without resolution. I am still in horrific pain and this is with Cymbalta, Valium, Prozac, & OTCs. I simply don’t know what to do….I had bladder infections throughout my life as regularly as summer follows spring, I had endometriosis (but that was all excised back in my 30s, well before I developed PN), I had frequent yeast infections following the administrations of antibiotics to treat the bladder infections. Life was just one big circus of one problem after another in the gynecological regions. One birth was problematic, but that was when I was only 28, and my PN symptoms didn’t appear until my 50s. So, what’s a girl to do? Grin and bear it? Anyone who has this condition knows the pain can be so intense that thoughts of suicide become daily experiences. This is not some “discomfort” that you can learn to live with……I coped with the pain of endometriosis cramps for years and they were a “cake walk” compared to this. Why the medical community cannot find some way to help those of us so afflicted is quite beyond me. They have their obnoxious E.D. cures, but then that’s for men! I guess since we’re just females it isn’t of much importance to anyone until they, themselves, become slaves to the misery that this existence evokes…

    Karen in Calif. :(

  • Cecily Sam Legg, RN

    Really excellent. As a birth center nurse I saw women with pain after childbirth, of coourse, but the pain was often still present with the next pregnancy. As a perinatal massage therapist I see women with pelvic pain during pregnancy, when the whole area is already tender and swollen both inside and out—-and am so glad now to have something to offer them for treatment options.
    Thank you for your articulate, woman-friendly, engaging article.

  • Leah

    Excellent and informative! As a person who works with women pre-natally, through birth, and postpartum, I am delighted to have information to give my clients about this often felt but rarely discussed situation. Thank you for covering this!!

  • Guest

    The past two articles have been extremely insightful, thank for the information and sharing your story Rachel. I’m curious to hear if PT can help with going to the bathroom frequently and leaking urine that happens to many when laughing or not getting to the bathroom fast enough. And is insurance paying for visits that are not related to pain?

    • http://www.marathonphysicaltherapy.com Jessica McKinney

      Hi “guest”, this is Jessica McKinney, the PT in the video clip. Thanks for your comments on the article and support for Rachel and CommonHealth in telling this important story! In answer to your question, absolutely! What you describe (in order) are symptoms of urinary frequency, stress urinary incontinence, and urge urinary incontinence, and physical therapy is an excellent resource to address all of these issues. If you haven’t done so already, you may also want to consult a urogynecologist, a specialist physician in pelvic reconstructive surgery and pelvic floor dysfunction. As a general rule, many of them work quite closely with physical therapists and can assist in any investigation and decision-making regarding the nature and cause of your symptoms and any interventions in addition to physical therapy. To find a urogynecologist, visit http://www.augs.com, select “Patient Resources” in the lower right side of the page, and then select “Find a Provider” from the left side menu.
      Lastly, insurance almost always covers physical therapy visits for the urinary symptoms you describe. Best of luck!! Jessica

  • C_schulze

    This is outstanding information on a sensitive and pervasive issue. I had no idea PT was available and am pleased to see the topic getting attention. Cathy S. Childbirth Educator ICEA and Certified Doula (DONA)

  • Doulapaulasanti

    Wow. I am delighted to see this covered in such a human way. I am a doula and when people find out that I work with women in birth, sometimes they trust me with problems they are having sexually. I have known about pelvic floor therapy for years, but it is really good to hear exactly what it is. I hope lots of people see this!

  • Angela

    Any article highlighting Pelvic Floor PT and the need for it, is a HUGE win to women’s health. Thank you, Rachel! As a mother of 2 who has endured one uniquely challenging physical recovery from childbirth, I can speak personally to the massive benefits of pelvic floor PT. In fact, following my personal experience with this type of PT, I found it so exasperating that women’s health and postpartum recovery issues were so little known, so “missed” by not only women themselves but by the overall medical community that I was compelled to start a non-profit to support women in taking ownership of their physical recoveries following pregnancy and childbirth so that they can seek out the immensely valuable treatments that exist but are not well known. Pelvic Floor PT, in my opinion, is the largest of these! Our non-profit (www.womensaction.org) seeks to educate women about physical conditions that are quite common (urinary incontinence, sexual dysfunction, pelvic/back/hip pain, just to name a few) but cannot be viewed as “normal” or as something to be lived with as a typical “price of motherhood” — these issues, and most certainly this one addressed by Ms. Zimmerman (painful intercourse) desperately need focus and attention. Amazing resources like Pelvic Floor PT need to become part of the regular repertoire of options that women know about, talk about with their friends, recommend and reference to others, so that we all can seek out PT as needed. I’m thrilled, THRILLED, to see this coverage and hope that we see much more. Again, THANK YOU, Rachel! (ps: if you need a Pelvic Floor PT, use this great resource to find one: http://www.womenshealthapta.org/plp/locator and if you want to learn more about the highly common physical complaints following pregnancy and childbirth, and how to resolve them, visit http://www.womensaction.org)

  • Guest

    I have been living with the ring of fire sensation for years, much to the great disappointment of my husband. I am sensing relief mentally at this moment to hear there are medical professionals who understand this!!!

  • r.

    You have most effectively addressed and helped demystify a subject of concern to women across the board. In addition to those of childbearing age, many women over the age of 55 dread pap smears, trans vaginal sonograms and routine gyn internal exams due to the varying degrees of discomfort or pain which can accompany these and other internal procedures. Those who have undergone treatment for breast cancer and are taking estrogen depleting medication may also suffer these symptoms. None of us can afford to delay or skip medical exams and screenings recommended by our doctors. Equally important, women of all ages should have the option of pain-free intimacy. In taking us step by step through your personal experience with pelvic floor physical therapy and honestly sharing your reactions and impressions, you have helped open an avenue other women may not have known about or readily considered. Thank you.

  • guest

    Physical therapy…not just antibiotics, cremes or surgery…who knew?
    Now we do. Thank you

  • Kim

    great article! Thank you for helping increase awareness, for sharing your personal story and talking about the alternatives to drugs and surgery!

  • Sharon Goldfarb

    Thank you for the great article and being brave enough to share your story. As a clinician I have heard complaints from patient for years, and often the medical establishment either writes it off or determines it as all psychological. It goes untreated and unstudied, but how many medications are available for men with a sexual dysfunction. Ironic that many insurances pay for Viagra but not oral contraceptives, women are screened for chlamydia during annual gyn exams while men go untested (and hello men would just need to give a urine sample). And how about the HPV vaccine only being given to women. The sexist underpinnings in medicine really lead to serious mortality and morbidity in women.

  • Kamali

    Thank you, thank you, thank you! I am 56 years old and have had this problem for the last 4 years. Nothing I have tried has worked and I have chauked this up to getting old! I can’t wait to give pelvic floor therapy a chance.

  • kristi

    Dr. Pulliam works at both the MGH main campus and in the MGH/North Shore Outpatient Facility in Danvers. She sees patients at both offices.

  • ria

    Thank You for this series of posts. I’ve suffered from pelvic pain off and on over the years. I’m a young woman (27) and I have always believed that my frequent (2-3x year) UTIs have contributed to my pain. My bladder can be very sensitive to the touch. Certain sexual positions are unbearable at times. The main reason my UTI’s go untreated is because most doctors just do a dip-stick test into my urine sample looking for a change in ph which would indicate an infection. My bladder is so oversentive that low levels of bacteria can set off unbearable pain. I’ve been to urologists, had my kidneys scanned, and been chastised by more than a few doctors to just ‘drink more water’. Now, I insist that they send my urine out for a culture…and sure enough it’s always positive. And then I take antibiotics which usually gives me yeast infection, so I treat that. It’s a terrible terrible cycle.

    Thankfully, I’ve found on my own to avoid coffee, chocolate…anything super acidic. My diet and my stress levels play a huge part in how often I get infections. Plus, I’ve learned to listen to my body and to be flexible when it comes to sex. If I’m feeling sensitive, having penetrative sex only makes it worse. It’s better to let my body calm down, and try again tomorrow. Most importantly, I’ve learned to advocate for myself at the doctors office. I don’t fool around with any UTI infection. If I think I have one, I make doctor’s appt THAT day and insist on a culture. I’ve struggled with this since grade school. And only now, 17 years later do I have a good handle on how to take care of myself.

    • guest

      ria…d-mannose is a natural, very effective treatment for UTI’s.

    • Eva

      I used to have painful UTIs decades ago — until a wise woman doctor told me to drink cranberry juice. As a tea drinker (3 times a day), I add cranberry juice to my tea instead of milk. It tastes great, I love it — and haven’t had a UTI in nearly 30 years!

  • Peg

    Really informative, thank you.