Let’s talk about sex-things I learned at the ‘International Society for the Study of Women’s Sexual Health’ annual conference

At the recent ISSWSH www.isswsh.org conference in San Diego there was a lot of talk about sex. Psychologists, physical therapists, researchers, sexual medicine doctors and a spine surgeon presented on insights and medical advances to improve women’s sex drive (hypoarousal no more!); reducing pain during/following sex; balancing hormones (estrogen is good!); post menopause in the bedroom (women in their 60-70’s have sex!) transgender information (3% of highschool students in a major US city say they are transgender). Today’s blog is about the big insights in treating vaginal pain.

Many women still think that it’s normal to have vaginal pain during and following intercourse.  Some experience vaginal burning, itching, pain and feel raw in this area 24/7 and sex increases their pain.

Women may be embarrassed, think this experience is normal, some even feel guilty so they don’t tell their doctors. Unfortunately, many doctors do not ask 3 important questions:

  1. Do you feel pain during/after intercourse?
  2. Are you happy with your sex drive?
  3. Can you achieve orgasm and if yes, are you satisfied with the quality?

 

 

Women with persistent pain can get stuck in a cycle of pain. Vaginal pain causes tension of the pelvic floor/abdominal muscles which can lead to depression, anxiety and catastrophizing behavior. If not treated effectively, they can develop a hypersensitive central nervous system and overprotective brain which worsens pain.  To break this cycle, it’s crucial to find out what type of vaginal pain she has, as each requires a completely different medical approach.

 

The following is a general information guide – see your doctor to get your specific diagnosis!

 

After taking a good history and listening to your symptoms, your doctor that specializes in sexual medicine will do a physical exam, using a Q-tip to gently press against each point of the Vestibule (see image below)

The vestibule is divided like a clock, the top portion, 9 to 3 o’clock is considered the “anterior vestibule” and contains Skenes glands.  The lower 4 to 8 o’clock are considered the “posterior vestibule” contains Bartholin glands and reflect how tense or relaxed are the pelvic floor muscles. Redness of the vestibule is not always an easy way to determine pain because it’s naturally red due to lots of blood vessels.

Complete Vestibulodynia

The whole vestibule, anterior and posterior portions are super sensitive to the Q-tip touch.

This is due to a dominance of estrogen (the pill, acne medicine, facial hair medicine all contains estrogen). These women are not getting enough androgen and testosterone, male hormones that the vestibule needs to be balanced.  Treating this type of vaginal pain is challenging because the woman on the pill has to discontinue and find alternate birth control methods. Teenagers being treated for acne will have it return, so coming off estrogen is a challenge yet once done, this type of vaginal pain will completely heal.  The time it takes to heal – in 6 months she is 50% better and in a year, she is  100% better.  While waiting for the body to balance, doing some healthy mental and physical exercises from the relieve program (link) can also help.

Inflammatory Vestibulitis.

If a woman has a history of chronic infections or if she is one of the 3-4% of American woman who is allergic to propylene glycol which is found in all vaginal gels, yeast creams, steroid creams such as the over the counter Monistat.  Woman may have been incorrectly diagnosed with a yeast infection and given creams (that contains propylene glycol) which causes more sensation of rawness, burning and cutting. What’s happening is that the inflammatory cells, called Mast cells, actually signal nerve endings to grow into the vaginal tissue which makes women feel more pain.

How to treat? If women can be seen within 6 months of symptom onset, they’ll be started on Interferon, a medicine which stops the production of mast cells.

If the woman is seen after 6 months, then treatment is more challenging. Either they use of a capsaicin crème (hot pepper component which removes “Substance P” of the nerve ending or desensitizes the nerve). Treatment is for 12 weeks of use of nightly cream – doable, but painful. Other option is surgery (vestibulectomy) to remove the affected tissue.

Congenital Neuroproliferation.

There is an increased amount of nerve fibers in the vestibule since birth.  These women could never use a tampon. A quick test is to touch your inner belly button and gently press inward. If you feel increase pain/sensitivity in your vagina, then this may be the cause for your pain. How can this be? The umbilicus shares the same embryonic tissue as the vestibule – so they are connected and have the same increased nerve fiber growth.

Treatment is surgical removal of the vestibular tissue (which healthily heals without the extra dense nerve fibers) resulting in no pain.

Overactive Pelvic Floor

Women who experience vaginal pain and have pain with the Q-tip test at the 4-8o’clock region, the posterior vestibule, with no sensitivity in the anterior vestibule. These women have overly tense pelvic floor muscles and this is the most common cause for vaginal pain.  Women can also experience symptoms of urinary frequency, urgency, sensation of incomplete emptying, constipation, rectal fissures, hemorrhoids.

This condition can be effectively treated by pelvic physical therapy. Pelvic PT includes releasing tension in the muscles of the lower back, sacrum, inner thighs, pelvic floor, teaching breathing techniques to relax the pelvic floor muscle, biofeedback, use of dilators and bladder and bowel retraining exercises.

Biopsychosocial Approach for Chronic Pain

Over the last 10 years, we also are now understanding why people stay in chronic pain for months, years, even decades.  Once an injured or chronically inflamed tissue has healed, why is there pain?

 

The answer is that they have developed an overprotective brain and hypersensitive nervous system. Without being aware of their habits developed due to social norms, family history, past experiences with pain, some people learn to be in a pattern of pain. Once the tissue issue has been healed, yet there is still pain, pain is the brain’s way to protect your body.   Ongoing negative experiences like a fight with your partner, stress at work, abuse at home, loss of a pet, saying non-loving, fear-based statements to yourself all day, not having or doing something that gives you joy  (even for a few minutes) can make the brain feel you are always in danger and send pain to protect you.

 

The Doctors of Physical Therapy at EMH are well versed in helping women heal from chronic pain using the biopsychosocial approach as well as our pelvic floor physical therapy for vaginal tissue based pain.  Our e-Book, re.lieve Solutions for Chronic Pain can help you learn self-help techniques to lower chronic pain.  Here’s the link: http://emhphysicaltherapy.com/product/re-lieve-solutions/

 

In summary, women can have a healthy fulfilling sex life – to find a provider, go to isswsh.org.

 

Painful sex? Check out our helpful tips about what you can do to help!

If you’re having pain during sex, try the following tips:

You should have a consult with a pelvic floor physical therapist for training on positioning and how to use a set of vaginal dilators:

They are used to stretch the vaginal tissue, facilitate pelvic muscle relaxation and prepare for intercourse.

If you are able to have penetrative sex:

  • Practice breathing techniques or stretching prior to intercourse
  • You may want to begin with clitoral stimulation to increase natural lubrication and vaginal expansion prior to insertion
  • You can use the dilator with your partner if you feel comfortable as a way to transition from medical to sexual use of dilator. This practice can help prepare you for engaging in sexual intercourse and help you both come to understand the challenge of the healing process and develop skills for working together as a team
  • The transition from plastic dilators to a partner’s penis is often an exciting step for a couple. To make the transition, your partner has to learn a passive role, letting you control the insertion and then just resting inside the vagina for a while. In time you can expand this exercise to permit insertion by the male of his own penis, clitoral stimulation, some thrusting and experimentation with different positions.
  • Use plenty of lubricant and use one that is water soluble
  • Apply ice or frozen blue gel pack wrapped in one layer of a hand towel to relieve burning after intercourse. Frozen peas or corn in a small sealed plastic bag mold comfortably to vulvar anatomy.

Keep in mind that intercourse isn’t always 100% comfortable. Temporary tugs and pressures are often just part of getting started. If some minor discomfort exists, try moving ahead anyway – but if obvious pain persists, don’t ignore it, stop. If you encounter unexpected difficulty, you may want to practice with the dilators some more before attempting intercourse again. Continued dilator use may be necessary from time to time, to keep the vaginal area relaxed and comfortable.

Pooping 102

Here’s the second part of  Poop 101

What should my poop look like?

Have you ever heard the expression ‘you are what you eat’? Well, it’s true! What we put into our bodies affects the health of our gut, which has more neurons than is in our brains! Say what? So, it’s helpful to occasionally take a peek at the color, shape and size of your poop.

The chart above reflects this. Imagine if you’ve barely had any water all day, as you are busy rushing from place to place. Maybe you grabbed a sandwich or pizza for lunch. Your stool may end up looking like Type 1, separate hard lumps, difficult to pass because you are dehydrated. The stool is hard because the intestines have absorbed all of your fluid, leaving nothing behind but what looks like rabbit pellets.

If you’ve ever had a stomach virus, you may have had type 7 or diarrhea. Your body also may have trouble digesting certain types of foods such as products with lactose or artificial sweeteners. Generally, softer stools are associated with inflammation.

Normal, healthy stool is type 3 or 4, sausage shaped which is not too lumpy and stays together as one solid mass.

If your stool is not diarrhea, but comes out in soft blobs with clear-cut edges, you may be lacking fiber in your diet. Fiber can prevent and relieve both constipation and diarrhea. Insoluble fiber moves bulk through the intestines and balances the intestinal pH, whereas soluble fiber binds with fatty acids and slows transit time. The best form of fiber is from natural sources, such as fruits and vegetables.

How frequent should I go?

The frequency of a bowel movement (BM) varies frequently from once a day to every 3 days and that can be completely normal. Again, you do not need to poop every day to be normal and healthy. Remember, it takes up to 72 hours for the stool to pass through the large intestine alone. Everyone has their own version of normal. Now, what is abnormal?

Diarrhea is defined as loose stool more than 3 times per day. Constipation is defined as straining to pass stool or a feeling of incomplete emptying with a frequency of bowel movements less than 2 times per week.

As a general rule of thumb, the longer digestive contents are in the intestines, the harder the stool and greater chance of constipation. The opposite is true of diarrhea. In other words, if the intestines don’t have time to absorb fluid, the feces are more likely to be soft or liquid. Remember, the intestines absorb 1000 – 1500 mL of liquid leaving just 100- 150 mL for the stool. If the body doesn’t have time to absorb this liquid, diarrhea can occur.

What factors affect intestinal motility?

  • Amount of feces
  • Chemical makeup of feces
  • Intestinal hormones
  • Nervous input to intestines
  • Female hormones
  • Emotions
  • Visual and olfactory input
  • Time of eating, schedule
  • Systemic diseases – anorexia, diabetes myelitis, hypothyroidism
  • Activity level

What Can I Do To Poop Better?

 

You can improve bowel regularity through exercise;  find out the side effects of medications, especially beta-blockers and opioids; learn some easy ways to relieve your stress and eat regular meals.

Other helpful tips to stimulate a BM:

  • drinking warm water w/ lemon in the AM to stimulate the bowels
  • do an “ILU massage” or self-intestinal abdominal massage
  • taking a morning walk or do some yoga poses

An example of a self-intestinal massage is shown above. Provide light strokes in the direction in a clockwise direction as shown for 1-3 minutes or until you hear a “gurgling” of your stomach.

References

Doughty, D. (2002). “When Fiber is Not Enough: Current Thinking on Constipation Management.” Ostomy Wound Management 48(12):30-41

Force, A. (2005). “An Evidence-Based Approach to the Management of Chronic Constipation in North America.” American Journal of Gastroenterology 100(S1):S1-S22.

Hawkey, C.J., Bosch, J., Richter, J.E., Garcia-Tsao, G., &Chan, F.K. (Eds.). (2012). Textbook of clinical gastroenterology and hepatology. John Wiley & Sons.

 

POOPING 101 – Part 1

What is one thing we all have in common? What brings us all together? We all poop!  How much do you know about your bowel movements? What does it mean when your stool is a different color, shape, texture? What leads to constipation or diarrhea? How can we have a healthy bowel movement and how often should we have a bowel movement?

 

I am writing this blog in two parts to help you have a better understanding of the mysterious #2, because pooping is an integral part of our daily life and can tell us a lot about our health.

DIGESTION

Lets start from the beginning, how food travels from entry to exit:

1. ORAL CAVITY & ESOPHAGUS Digestion begins in the mouth, as saliva helps break down starches. The esophagus is the portal to which the contents travel to our stomach. No digestion occurs here, but “heart burn” can occur when there is backflow from the stomach up into the esophagus through the cardiac orifice seen above.

2. STOMACH Now that the food has made it to the stomach, acids break down proteins. Food spends approximately 2-4 hours here before traveling to the small intestine through the pyloric sphincter

3. SMALL INTESTINE  In the small intestine, over the course of 4-6 hours, our body continues to break down starches and proteins and tackle a new molecular compound called carbohydrates. Juices secreted from the pancreas and liver help break down starches, fats and proteins.

4. LARGE INTESTINE What’s next? You guessed it, the large intestine, which absorbs 1000- 1500 mL per day, leaving 100-150 mL along as hardened feces to the rectum. Digestive contents spend the longest time here, approximately 24-72 hours. It travels through the ileocecal valve up the right side of the abdomen through the ascending colon, across the transverse colon and down the left side into the descending colon.

5. RECTUM Using strong peristaltic waves, our bodies push stool into the rectum. That’s when we have our first urge to defecate. We have stretch receptors which tell our bodies to relax an involuntary muscle called the internal anal sphincter while we close our external anal sphincter (EAS) to keep feces from coming out until we are ready.When we sit on the toilet, our EAS relaxes along with our puborectalis muscle. This relaxation combined with a gentle increase in intra-abdominal pressure pushes fecal matter out. Placing our knees higher than our hips, via a squatty potty or stool, helps relax the puborectalis muscle even more, allowing from easier elimination as shown below. The external anal sphincter (EAS) changes its tone based on what it senses. If it senses liquid, such as diarrhea, the EAS increases its tone. If it senses, gas, it allows that to be selectively released. If it senses solid stool, our body can override our urge to defecate until we are at a toilet, so we can hold it in when necessary.

When we sit on the toilet, our EAS relaxes along with our puborectalis muscle which surrounds the rectum tightly at rest creating the “anorectal angle”. When the puborectalis relaxes it allows the rectum to have easier passage. This combined with a gentle increase in intra-abdominal pressure pushes fecal matter out. Placing our knees higher than our hips, via a squatty potty or stool, helps relax the puborectalis muscle even more, allowing  easier elimination.

GOOD DEFECATION TECHNIQUE

A healthy bowel movement (BM) should not involve straining or pushing. The action of defecation is a part of the parasympathetic nervous system, which helps the body soften and relax. The first step to a good BM is making sure you are in a comfortable, safe place. Have you ever noticed it’s easier “to go” at home versus in an unfamiliar place?

If we lose our ability to properly relax with a bowel movement we may start to strain with defecation, which over time is injurious to our body.

Here are some quick, easy tips for a healthy BM.

  • Sit with your knees above your hips, feet resting on  a child’s step stool or “Squatty Potty”
  • Place both hands on your abdomen, or, if you have jaw tension, support your head in your hands
  • Draw up or contract your pelvic floor muscles as though you are trying to hold back gas
  • Relax your pelvic floor muscles as though you are trying to release gas
  • Note how the stomach muscles relax and bulge forward
  • Relax the pelvic floor muscles and think of widening the rectal opening
  • Imagining your body is a tube of toothpaste, pushing from the top down, brace and breathe out
  • You can use certain sounds such as “grrr” and “shhh” to help gently increase intra-abdominal pressure to pass stool

If you feel like you are unable to perform an easy BM even with taking fiber, drinking water, or are spending too much time in the bathroom, straining often, or experience frequent constipation and bloating, consult a pelvic floor physical therapist.  We’ll assess if restricted pelvic floor, abdominal muscles are hindering your function. We perform gentle manual therapies to restricted muscles/fascia of both internal and external pelvic areas, visceral mobilization  to help the organs move optimally and “do their thing”,  use biofeedback to retrain the pelvic floor muscles so they don’t contract when they are supposed to relax, teach breathing techniques and other home exercises.

Stay Tuned for “Pooping 101 – Part 2”!

 

 

 

Multi-Disciplinary Approach is best for relieving Chronic Pelvic Pain

Evelyn and her DPT staff traveled to Chicago for the International Pelvic Pain Society conference to learn about the evolving sciences and evidence based treatment for pelvic pain.

Pelvic pain is typically located in the lower part of your abdomen & pelvis and can stem from the reproductive, urinary or musculoskeletal systems. The cause of pelvic pain can be complicated, involving interactions between gastro-intestinal, genito-urinary, musculoskeletal, nervous, endocrine systems and can include socio-cultural factors.

So it’s important to have a medical team working with you. Your team can include a urologist, pelvic physical therapist, gynecologist, gastroenterologist, psychologist, radiologist acupuncturist and sex therapist.

In our experience we find that patients just need 2-3 team members such as a medical doctor well versed in pelvic pain to guide on medications and general health, an experienced pelvic physical therapist who provides education, manual and movement therapy, and a talk therapist to address underlying emotional traumas. 

UPOINT  helps MD’s find best treatments for Male pelvic pain

Most men with symptoms of chronic pelvic pain syndrome (CPPS), such as penile pain or discomfort, urinary urgency/frequency, inability to sit, testicular pain and/or ED, have been given a diagnosis of “Non Bacterial Prostatitis” and prescribed antibiotics. I often hear from my patients that the medicine didn’t help, as their prostate gland was not infected, which is what antibiotics target. Many men were not getting pain/symptom relief from antibiotics and doctors needed a better system to determine the cause of CPPS.  UPOINT was developed to help.

 

UPOINT is a classification system to determine the specific diagnosis and treatment for male CPPS. The white boxes below represent the cause of symptoms, which in the case of CPPS, can be multiple. The higher the number of causes, the more severe the symptoms.  The gray boxes show the appropriate treatment options depending on the cause(s).1

 

 

A study of 100 men assessed and treated with the UPOINT system saw an 84% reduction in pain and disability. 2 CPPS can have multiple classifications including Psychosocial, Neurologic/Systemic and Tenderness of Skeletal Muscles.  These men healed with a combination of pelvic floor physical therapy, medication that targets nerves and talk therapy. By using the UPOINT system doctors can prevent the natural increased anxiety and pain escalation that these patients experience the longer they experience pain.  

Women with Endometriosis benefit by a team of providers

The BC Women’s Centre for Pelvic Pain and Endometriosis utilizes an interdisciplinary approach to treat women with endometriosis which resulted in 45% of their patients feeling “much better” in regards to pain and quality of life. Twenty three percent (23%) reported feeing “somewhat better” and only 20% reported feeling the “same”. These results were seen at the completion and at the 1 year follow up of the program.3

 

What does this interdisciplinary approach look like?

BC’s approach included education in the recent science of pain – how the brain is involved in sending pain signals as a form of protecting the body and how the brain can be retrained to lower or stop sending those signals. BC clients received pelvic physical therapy which involved manual therapy to release adhesions of muscles, fascia & intestines and movement/exercise prescription. They were also assessed by a gynecologist, received counseling (stress management), nursing care management and  BC’s team would meet to discuss their patients to ensure great outcome.

Create Your Medical Team

Women may not have access to nor can afford an extensive program like BC’s, however they can use the same approach with their own care. An experienced pelvic physical therapist can be the liaison between the medical doctor and all other healthcare providers as we tend to spend dedicated 45 minutes to an hour of interrupted time with our patients.  Being open to explore other treatment options such as cognitive behavioral therapy, acupuncture and nutritional guidance as this can also lower symptoms of endometriosis.

 

 

Pelvic Physical Therapy helps Cervical Cancer Survivors

 After being diagnosed and successfully completing cervical cancer treatment, we learned that 66% of cervical cancer survivors suffer from urinary issues such as leaking. Thirty three (33)% percent have a “storage dysfunction” which means the bladder sends the “Gotta Go” signal when it is only a quarter or half full, making women go to the bathroom too many times a day. Fifty (50) % have voiding dysfunction, which means there is left over urine in the bladder or the time it takes to pee is markedly increased.4

Pelvic physical therapy is an accepted treatment option for these women. Gentle manual release of the lower abdominal, inner thigh and pelvic floor/perineal regions and pelvic floor muscle training using biofeedback can significantly improve urinary incontinence, sexual function and quality of life for women who survived cervical cancer. Progressive use of vaginal dilators can help promote optimal healing of vaginal tissues after radiation.5

We want all women to feel good and confident about their body after cancer treatments and are thrilled to see this research.

  1. Nickel JC. C. Paul Perry Memorial Lecture “Clinical Approach to Male CPPS”. 2016.
  2. Shoskes DA, Nickel JC, Kattan MW. Phenotypically directed multimodal therapy for chronic prostatitis/chronic pelvic pain syndrome: a prospective study using UPOINT. J Urol. 2010;75(6).
  3. Allaire C. Innovations in the Evaluation and Care of Women with Endometriosis. 2016.
  4. Katepratoom C, Manchana T, Amornwichet N. Lower urinary tract dysfunction and quality of life in cervical cancer survivors after concurrent chemoradiation versus radical hysterectomy. Int Urogyn J. 2014;5(1).
  5. Lyons M. Women, Cancer and Pelvic Pain. 2016.