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."