As I was working with a patient recently, she remarked to me that she was surprised that our sessions were not painful for her like they had been with a prior pelvic PT in another town previously. And yes, she is making wonderful progress!
She had also noted that some internal pelvic floor sessions with another pelvic PT had been quite aggressive and felt like the therapist was focused on “working out” some of her tight muscles just as one would work out a tight shoulder muscle. This did make sense to her, so she was willing to tolerate this discomfort if it meant relief in the future.
I of course was glad to hear her confirm to me that she didn’t find any part of our sessions to be painful, because that is the ONLY way that we feel sessions for a pelvic pain sufferer should be.
Why? Let me explain.
Our brain and body are designed to be quite protective of the pelvic area as it houses 3 crucial organs, is the base of the spine and legs, and is the center for sexual intimacy, pleasure, and creating and having babies for women. As a result, pain can be a tool the brain uses to make sure that this area is protected.
Pelvic pain patients that we see have often been struggling with pain for months and or years and their nervous systems have been “on guard” or in protect mode, ready to send down more pain signals to keep threats at bay. This can be a vicious cycle to the point where even very light touch to the pelvic floor outside of clothing can be felt by the body and nervous system as pain.
The LAST thing this person’s pelvic floor and nervous system need is more reasons to stay “on guard”. In fact, I am frequently describing a patient’s pelvic floor area to them as a narcissist where everything needs to be it’s idea. With any hands on techniques, wand or dilator use, the patient or the therapist needs to be incredibly sensitive to how the pelvic floor muscles are responding (pain sensation and/or increased tension) and act accordingly. Here are a couple examples:
With initial contact or slight penetration with a therapist’s gloved index finger or patient’s wand or dilator… if the pelvic floor muscles tense in response or patient reports increased pain, we do not progress further, focus on the patient taking slow belly breaths, and only proceed once the initial pain sensation dies down which it will 95% of the time within 10-30 seconds.
If we are internally cuing the pelvic floor muscles to release with or without inhale, we cannot use a gloved finger or wand to be the boss. We have to go WITH the pelvic floor muscles and focus on letting the pelvic floor muscle lead (which is hard to do for the patient at first). While this can be frustrating and take some time over a few sessions, the patient will be much less likely to have a pain flare and we will make progress more quickly.
With choosing and using a particular sized dilator, it is crucial to use the size that causes some discomfort, but not pain. The goal is to collect non-painful experiences so that the nervous system feels more and more safe and is less likely to respond with pain.
I am very used to hearing patients initially report pain levels of 5-7/10 at first contact with internal pelvic floor muscles then report 1-3/10 after some slow belly breathing and focused active release of the pelvic floor muscles with verbal and very light tactile cues within the span of 5-8 minutes. This is more because we calmed their nervous system down in a non threatening way and their brain no longer felt that protection-inducing pain signals were necessary.
The same goals should be continued at home with any self internal pelvic floor work with their own finger, a dilator, or wand. Their body will still respond protectively if the pelvic floor area or muscles are touched aggressively. Patients often come to learn this on their own as it is sometimes just too tempting to try and speed things along and “mind over matter” the issue.
Pelvic floor pain can be a complex condition to resolve and will always require patience, reverence and respect for the pelvic floor, and a do-no-harm approach.
If you are struggling with pelvic pain, know that you are most certainly not alone in this and there are passionate pelvic physical therapists including our PTs at Pinnacle that GET IT and have years of experience in helping women get to the pain free place again. Know that therapy should never be a pain inducing experience as there are so many wonderful ways that we can help with pain that don’t even include internal pelvic floor work!
Contact us if you have questions or would like to work with us. We can’t wait to help you resolve your pain for good!