The Evaluation

Don’t wear work out pants.  They’re just going to come off.  That should put the “what do I wear” question to rest.  Pelvic floor physical therapy is unlike any other physical therapy you have been exposed to.  This is a much more invasive and intimate type of physical therapy.  On your first visit, I sit down with you and get to know your story.  What’s going on?  What do you want to get out of this course of treatment?  In understanding your symptoms, their source and how to intervene, I need to ask all sorts of socially inappropriate questions.  I need to know about your bladder, your bowels and your sexual function.  These three things go hand in hand.  Often when someone is constipated, they also have issues with urinary leakage.  When someone has painful sex, they might also feel the need to urinate all the time. 

Within the first 60 seconds of meeting me, I’m going to get right to it. 

I’m going to ask the following questions about your bladder:

·      Does it hurt to pee?

·      Does it hurt before or after you pee?

·      Do you pee too often?

·      Do you get intense sensations to pee?

·      Do you leak urine?

·      Do you wake up too much to pee?

·      Does your urine spray all over the place?

·      Does your bladder or urethra hurt? 

·      Do you even know where your bladder and urethra are? 

I’m going to ask the following questions about your bowels:

·      Does it hurt to poop?

·      Does it hurt before or after you poop?

·      Do you poop too much? Not enough?

·      Do you have to wipe forever?

·      Do you get intense sensations to poop?

·      Do you leak poop?

·      Does your anus or your rectum hurt?

·      Does your tailbone hurt?

I’m going to ask the following questions about sex:

·      Does sex hurt?

·      Do you have weird symptoms or pain after sex?

·      Can you orgasm?

·      Does it take forever to orgasm?

·      Are your orgasms like “pfff” or are they like “oooooh yeah!” or are they non-existent?

I am going to ask random questions like:

·      Do you have any itching around your genitals, anus or in your rectum?

·      Do you get a lot of infections?  Real infections or “fake” infections?

·      Does it bother you to wear certain types of clothes or underwear?

·      Does it hurt to sit?

·      Do certain food or drink make your symptoms worse?

·      What is your political affiliation?

·      What medications have you been on?

·      Do you like Harry Potter?  If so, why? 

·      Do you have any hernias or hernia repairs?

All of this helps me to get an idea of the root of your symptoms.  I want to figure out not just how to quiet the symptoms that bother you, but also how to squash the problem that is creating the symptoms in the first place.  After this painless interrogation…I ask for consent to do a pelvic exam. 

This is unlike a gynecological exam and unlike a prostate exam.  This exam is done with primarily your comfort in mind.  If I were to impose pain during an exam, I would get misinformation.  For example, when you are in pain, your pelvic floor muscles tense.  This is a primitive and reflexive reaction to pain.  I want to know how your muscles behave when they are as relaxed as possible…that is, as relaxed as possible while you are getting a pelvic exam. 

So, what is the pelvic exam? 

For a female, this is an exam of either the genitals and/or the tension in the vagina and/or the rectum.  If only the genitals are being examined, then a thorough screening with light and magnification is performed from the top down.  Checking out the hood of the clitoris, the clitoris itself, the flaps of the labia and the appearance and tenderness of the tissue at the opening of the vagina all tells a story.  What exactly is the story?  It’s different for everyone.  For some, it’s a story of how time has gone by and now perhaps some supplementary hormones could be helpful.  For others, it’s a story of how using soap on the genitals is cleaning too much, the good and the bad.  One of my favorite things to do is to guess the story before I see it.  It is one of the most exciting parts of my day.  I kid you not.

For a female vaginal exam or a rectal exam for either a female or a male, one gloved, lubricated, warm-hearted finger is gently inserted into the orifice most likely corresponding to your symptoms.  Orifice.  That’s right.  It’s not a beautiful word, but, it does encompass the body parts I need it to encompass, so…orifice it is.  The pelvic floor muscles of the vagina and rectum are the same muscles.  They are just different aspects of the same muscles.  If I were to put pressure in the vagina or rectum and that created some discomfort, I would know that that is a problem.  A pressure on the muscles should feel like exactly that – a pressure, not a pain.  A pain means there is too much tension in the pelvic floor muscles.  Too much tension means not enough movement.  Not enough movement means not enough blood flow.  Not enough blood flow means not enough oxygen.  Not enough oxygen means too much lactic acid build up.  I’ll stop there.  Sometimes, this pain is actually the pain that you are seeking medical treatment for.  Sometimes the pain isn’t a “pain”, but it is your symptom, ie. your intense urge to urinate or your tailbone ache.  I might be figurative miles away from the bladder, urethra or the tailbone, and yet the muscle I am putting pressure on feels as if it is your actual bladder, urethra or tailbone.  And this, my reader, is where the magic begins.  The call is not always coming from the body part that talks the most.  And on this thought, I will leave you to think….

Senses and Arousal

Discovering what helps your body gets the most aroused can be helpful.  We have five senses and some of them are more linked to arousal than others.  Everyone is a bit different and that is why exploration might be necessary.

 1.     Sight: Some people know that their strongest arousal sense is sight.  People who might do well with sight might enjoy visual stimulation.  This could be video, this could be seeing their partner right in front of them, this could be using a mirror to see everything that is happening.

 2.      Sound: This can be a certain type of music.  It could also be the sound of everything happening in that intimate moment.  It could also be hearing the sound of breath or words spoken in the ear.  It could be something crazy like hearing someone talk in a British accent or hearing statements that are usually out of place, like “dirty talk”. 

 3.      Smell: Smells can link to memories.  Some of those memories can be pleasurable memories.  If you don’t have one of those smell connections, you can explore and see if smell does anything for your arousal.  It doesn’t have to be an odor that everyone likes.  It could be an odor that you secretly like or that you didn’t even know you liked…until now. 

 4.      Touch: This might seem the most obvious, but sometimes it is not.  You would think that touching parts of the body that seem the most intimately related to sex would create the most arousal.  However, sometimes these classically considered reproductive parts of the body have painful memories associated with them.  This could start the anticipation of pain process to begin.  Or, it could start the process of remembering negative experiences. 

 This is really a partner project. The reproductive parts of the body are not the only parts that can activate arousal with touch.  It is worth your time to experiment with touch at all parts of the body.  Experimenting with touch involves touching the skin in different areas, but also with different items.  You can use a finger, a feather, a satin sheet, you can get creative.  Places to touch are the face, the neck, ears, back of neck, shoulders, different parts of the arms and hands, fingers, back, belly, hips, all parts of the legs and even the feet.  No skin left behind.  Even massaging the scalp is a good idea. 

 The key to doing this right is to agree that no penetration will take place during this exploration.  You are like a pioneer on new lands you don’t quite know what those lands will bring.  So, no expectations here.  You will get a most accurate picture of what brings on arousal if penetration is taken off the table.  If penetrative sex can cause discomfort at times, then there should be no anticipation of this possible discomfort while trying to figure out how to improve arousal. 

 5.      Taste: Tastes can bring on memories, much like smells can.  If this doesn’t ring true for you, it could be that you haven’t paid enough attention to taste or that yeah, it’s just not an arousal sense for you.  But at a minimum, it should be tested.  Edible sex products sell because they can make sex more fun and exciting and silly, but also because some flavors can arouse people.  Or, the flavors can be linked to positive memories.  Play with the taste of your partner’s skin.  The taste of your partner’s sweat.  The taste of your partner.  If this doesn’t work for you, then play with enjoyable tasting foods during intimate moments.  This can be an intimate conversation, an intimate dinner or a cuddle session on the couch.

 6.      The Sixth Sense: If you see dead people…No.  I can’t go there.

 There is a sixth component to arousal and I do not know if it’s considered a sense.  It’s your imagination.  You can wield this with reading.  You can read something erotic or something romantic.  You can daydream.  You can daydream.  There is, I have to say it, no end to your imagination.  Getting out of the expected, the traditional, the predictable can be rewarding and refreshing. 

Interest in Sex

There are natural steps that take place for someone who wants to have penetrative sex. The steps I will be outlining pertain to vaginal penetration.  Very simply, the steps are desire, then physical arousal, then production of natural lubrication and lengthening of the vaginal canal.  Without all of these steps, it is likely that penetrative sex will be a little or a lot uncomfortable.

Desire:  You decide in your mind that you would like to have sex.  This isn’t “ok, I should have sex tonight because it’s been a while”, this isn’t “I want to want to have sex”, it’s actually “oh, I’m liking what I’m seeing over there and would like to get my hands on that”.  See the difference?  Desire is natural, it’s carnal, it’s not an appointment on your schedule.  Some people call desire the feeling of being, forgive me, “horny”.  This all starts in your mind.  If desire isn’t there on its own, you can try to instigate it in a lot of different ways.   Sometimes it takes exploration to determine the best way to activate your arousal.  The key is to experiment with your five senses and with your brain. This can be a really fun project for you to do alone or with a partner.  The bottom line is, if you do not have the true desire to have sex, then changes in the body will not take place.

Physical Arousal: Once you have the true desire to have sex, then the body starts to respond.  These changes include pupil dilation in the eyes and changes in heart rate and breathing pattern.  Desire also causes a move of blood flow to the breasts and the genitals.  This causes the nipples to become erect and the genitals to become puffier.  The clitoris and labias will actually enlarge a little.  The muscles in the vagina and in the rectum will actually relax quite a bit.

Lubrication:  There are two sets of glands at the genitals that help create secretions.   The Bartholin’s glands are located towards the bottom part of the vaginal opening and creates mucous-like secretions to reduce friction with penetrative sex.  The Skene’s glands are located on the sides of the urethral opening (where urine comes out). These can swell during sex and pinch the urethra a bit closed.  Additionally, they create a secretion to lubricate the urethral opening.  It is thought that the secretions are also anti-microbial and act as a defense against infections.  These two glands are very helpful in reducing discomfort with sex.  These secretions will only come out if physical arousal has occurred.  And remember, physical arousal only takes place if desire is present.  There is a method to this madness. 

 Lengthening:  In my mind, this is the coolest step.  This is also the step where people go “ooooooh, that makes seeeeeeeeense!”.  So, the vaginal canal is where the penetrating item goes.  Let’s take that vaginal canal out of the body and imagine just a canal in front of you.  Now, make that vaginal canal an accordion.  Give it the ability to stretch out and get longer and reduce its ends together to make it shorter.  The vaginal canal actually has accordion-like components that allows for change in length.  Those structures are called rugae.  When nothing is happening, like, you are buying carrots at the grocery store, the rugae are compressed together and create little ridges in the vaginal canal.  But, when you have desire to have sex, then physical arousal follows and then you get production of secretions, then your little ridges start to stretch out and this creates a lengthening of the vaginal canal.  And, to top it off, guess what happens!  If you have a cervix (the bottom of the uterus), the cervix actually moves up towards the direction of your head to create more room for something to penetrate!  It’s like your vagina has a mind of its own, but it doesn’t!  It’s just connected to your own mind!  This is why sometimes it feels like a penetrating item can hurt when it feels like it’s hitting a “wall” inside the vagina and other times you feel like your vaginal canal can accept a penetrating item going really, really deep.  It’s all about whether or not the chain of events took place and…that chain starts in your brain.

Pelvic Floor Dysfuction

What is your pelvic floor?

The pelvic floor is the floor of your pelvis.  Your pelvis is a group of bones at the center of your body that connect to the bottom of the spine and the hip bones.  There are muscles all around the pelvic bones.  There are nerves extending into this area.  There are blood vessels here.  Inside the pelvis sit organs like the bladder, uterus, prostate and rectum.  On the outside of this area sit the genitals and the anus.  All of this is the pelvic floor.  It’s not a good name.  The pelvic floor isn’t just the “floor” of the pelvis.  It is everything in and around the pelvis. 

What is a shiny, happy pelvic floor?

This is when all the contents of the pelvis do what they ought to do.  Urine is held as long as you need to hold it.  Bowel movements are satisfying and complete.  Your brain isn’t constantly being made aware of the presence of your genitals or your anus or your tailbone.  A shiny, happy pelvic floor is once that lets you live life unaware of its existence.

What does it mean to have pelvic floor dysfunction?

Pelvic floor dysfunction is when your pelvis and it’s contents are misbehaving.  They are being rude and socially inappropriate.  They aren’t listening to your requests.  You say “pee” and your pelvis refuses.  You say “don’t leak” and your pelvis leaks.  You say “I do not give consent to this fart!” and your pelvis could care less.  You say “I don’t want to be aware of your presence constantly” and your pelvis says “I’m here! I’m here! I’m here! Can you feel me? Huh? Huh? Huh?  Can you feel me now?”  Pelvic floor dysfunction is when your pelvis needs to learn some manners.  

Physiologically, pelvic floor dysfunction is when the muscles, nerves and bones of the pelvic area are not resting or moving as they should.  This could be because they are staying too tight or too loose or because they are getting too much movement or not enough movement.  The cause of this could be learned patterns that you are contributing to or surgical insult “Like a scalpel told your pelvis that it’s butt looked big in those jeans” or poor circulation.

How can pelvic floor physical therapy help?

The role of the pelvic floor physical therapist is to teach the pelvic floor to know their own role.  It’s to slow their role.  It’s to whip the pelvic floor into shape and take no prisoners.  It’s to say “You’re not the boss!”  It’s to command obedience. 

And how is this done?  Much to people’s surprise, it’s not done over coffee.  It’s done on a plinth with a lot of hands on work to the abdomen, legs, genitals, anal area and internally.  Yes, internally.  The call is usually coming from inside the house so I’d be wasting a lot of time staring at the front door. 

If muscles are too lax, then we work on strengthening them.  If muscles are too tight, then we work on making them longer.  If the pelvis has been insulted by surgery, we work on building up it’s confidence.  We tell it stories and remind them that it too is destined for greatness.  If the pelvis has poor blood flow and oxygen, we do hands on techniques to encourage more blood flow and oxygen.

But what does this really, really look like?  If I were to take a snapshot of a treatment, it would look like this:

Patient is lying on table with a drape over their lower body.  I am gloved with my hands working on their abdomen or legs, or any other external body part.  Or, I am gloved with a finger working in the vagina or the anus.  Yeah, it sounds weird.  But, that’s because it is weird.  It’s evidence-based medicine, but weird.  I get it.  Truth be told, most people’s voices raise a few octaves as they ask “So…how exactly did you get into this field?”.  That question comes out as I put the gloves on.  And, if I don’t hear the question, I’ll offer “Now’s about the time you’re wondering how I got into this work, right?”.  I’m always right.