Episode 1711 - Pain in the vagina: a case study

Dr. April Dominick // #ICEPelvic // www.ptonice.com

In today's episode of the PT on ICE Daily Show, #ICEPelvic faculty member April Dominick discusses ideas for further treatment for an individual experiencing vaginismus.

Take a listen to learn how to better serve this population of patients & athletes or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

INTROHey everybody, Alan here. Currently I have the pleasure of serving as the Chief Operating Officer here at ICE. Before we jump into today's episode of the PT on ICE Daily Show, let's give a shout out to our sponsor Jane, a clinic management software and EMR. Whether you're just starting to do your research or you've been contemplating switching your software for a while now, the Jane team understands that this process can feel intimidating. That's why their goal is to provide you with the onboarding resources you need to make your switch as smooth as possible. Jane offers personalized calls to set up your account, a free date import, and a variety of online resources to get you up and running quickly once you switch. And if you need a helping hand along the way, you'll have access to unlimited phone, email, and chat support included in your Jane subscription. If you're interested in learning more, you want to book a one-on-one demo, you can head on over to jane.app.com. And if you decide to make the switch, don't forget to use the code icePT1MO at sign up to receive a one month free grace period on your new Jane account. APRIL DOMINICKGood morning, everyone, and welcome to Pelvic Monday on the PT on Ice Daily Show. My name is April Dominick. I'm here to talk to you today about pain in the vag, a case study. This case study was brought to us by some of our students in our level one pelvic cohort, and they just had some questions about a case on vaginismus and where to go since they were feeling a little bit stuck. So I wanted to hop on here and provide some in-depth guidance on how to continue with what they have already started for their treatment. Particularly, they are interested in how to improve their patient's pelvic floor hypertonicity, as that's where they're feeling a little stuck. So here are some details of the case that the treating therapists have already shared with us. The subject is a 19-year-old female who's diagnosed with vaginismus. Her aggravating factors are history of difficulty and pelvic pain with insertion of a tampon. She more recently was on her menstrual cycle, got a chance to try putting the tampon in. and had another failed attempt. She also has reported pain at her inner thighs after horseback riding, and she is an avid horseback rider. Easing factors so far, the therapist had provided the patient with adductor stretching, strengthening, foam rolling, and that seems to have eased the adductor pain, not necessarily helped with her pelvic floor situation just yet. And from a physical activity standpoint, I don't know much, but again, she is an avid horseback rider. And she also reported history of sexual trauma from a horse camp instructor who is now in jail. And thankfully she is currently working with a trauma therapist as well. In terms of objective findings, again, they found some tightness and pain with adductor palpation. as well as when attempting the internal pelvic floor exam, they were limited by the patient reporting pain. Current treatment, they have done some dilator work that has improved since the start of PT. So a few weeks ago, the dilator itself was shooting out upon insertion, and now the patient is able to maintain a dilator inside the vaginal canal for a few minutes. And if you all are unfamiliar with what a dilator is, it is essentially a phallic-like structure, that can be inserted into the vaginal canal. I like to call it a space holder for the vagina. And there are different variations of it. And some of them have a longer length while others are wider. And so it allows someone to be able to progressively overload the vaginal space or the vaginal canal. And after horseback riding, the general adductor exercises that the therapist provided have helped, again, reduced the patient's adductor discomfort. So their biggest question, again, is how do we address the pelvic floor hypertendency? It doesn't seem to be that we are making progress with this. So initial thoughts. First off, the therapists are doing just wonderfully with the direction of treatment. I love that they zoomed out from that pelvic space and addressed structures that indirectly impact the pelvic floor. And I love that they did attempt an internal exam, but again, didn't find that to be helpful given that the pain was present and the patient needed to stop the exam. I also appreciate that they talked about any previous trauma, as that is extremely important in this case in particular, and that they asked about, hey, are you getting help for this? And yes, the patient is again seeing a trauma therapist. So I'll discuss some of the considerations that I am thinking about, and I wanna talk about some things like working from the outside in, with external manual therapy of the pelvic floor, of the hips, as well as mobility and active strengthening that I would suggest as well, and some thoughts on, hey, what is going on with her nervous system and working together with the trauma therapist. So let's start with the internal external pelvic floor work first. Given that pain was a limiting factor in the internal pelvic floor muscle exam, That's a sign to me that the patient is not currently ready for or would benefit from continued internal exam attempts at this time. As she works with her trauma therapist from the inside out, she can simultaneously work with her physical therapist to treat the outside in. And what do I mean by that? External work on the pelvic floor, that can be simply a visual exam. And the vulva, no palpation, just guiding the individual on how to relax the pelvic floor. This is your pelvic floor. Using mirror feedback or even imagery work, like imagining that she, the patient, is inserting something into the vaginal canal and see if she responds better just from that imagery versus any sort of palpation. And then gentle, moving on towards a gentle external pelvic floor soft tissue mobilization. So techniques like sustained pressure or contract relax on the superficial pelvic floor muscles, like the bulbospongiosis, ischiocavernosis, and near the outer labia, as well as near the perineum. And also tackling the obturator internus, given that it is a hip rotator. So the hip, the obturator internus shares some fascia with the levator ani, and if we can work on the obturator internus externally, then it's very possible that we can just help decrease some of that upregulation in the pelvic floor, no matter where we are tackling the pelvic floor. Another piece is working on hey, can I do some cupping in that posterior pelvic floor region? I've been known to cup that area. And for some of my clients who have just a lot of tension and pain in that pelvic floor region, I will again offload the backside of the pelvic floor. in hopes to also decrease some of that hypertonicity in the anterior side or near that vaginal opening. So I pair the cupping with some child's pose or some quadruped rocking just to get some gentle movement, active movement in as well. And then if there is some progress with those techniques, but then we're running into a roadblock again, and maybe we're still not ready for any sort of internal work, then considering some dry needling plus electrical stimulation, maybe with some neuromodulation to the pelvic floor, and that's gonna directly tap into the cortex, create a nice chemical pump to the pelvic floor, and really help downregulate. Now, if this will work the best, if the patient has really responded well to dry needling in the past and is game to have it done in that region, it can be extremely beneficial. And then after doing all those manual therapy interventions, what are some things that she can do herself? She can do some self palpation externally with diaphragmatic breathing and some pelvic drops or pelvic lengthening to release some of that tension. I want to suggest that she try using her own digit, her own finger, to do some external self palpation. while she gradually moves towards internal insertion of her own digit into the vaginal canal. As this can be often more approachable and less painful for someone who has a history of trauma, for them to do it themselves, rather than inserting something external like a tampon or a dilator, or having someone else do the insertion. This way, if she's using her own finger, then she's remaining in control. Then having the client follow up on self-palpation with the dilator practice. It sounds like this person was already doing some dilator practice. So having her try it in varied positions of comfort, coupled with the diaphragmatic breathing. And then in terms of when someone is ready to trial vaginal insertion, I generally prefer them to be able to insert an object that's the same size or larger to what they're wanting to insert. In this case, having the individual aim for comfortably tolerating a dilator that is the same size or larger than a tampon is a great rule of thumb for test-retest with that tampon insertion. Traditionally, many individuals insert a tampon seated or maybe in a mini squat over the toilet. While this client is building up her confidence in getting those positions and doing this in public, I believe that she can try some more comfortable positions for tampon insertion like semi-reclined, maybe having her legs supported by walls or a pillow in her own home. Again, not traditional, but a great place to start.So attacking the hip from the joint side of things. We can do some manual therapy in the sense of doing some joint mobility. The therapist can do some joint mobilizations. And then that can be followed up by the client getting in some active hip mobility exercises. Gotta love the seated hip 90-90s. or seated banded hip IR and ER, banded hip capsule mobilizations, and I really love the long axis distraction just to get some nice general chemical pumping blood flow to that area to address chemically induced stiffness. Then we have hip mobility via muscle. Given that the adductor's origin is the ischiocubic ramus, I like to say the adductors are the long driveway to the pelvic floor. Dry needling plus e-stem for the adductors to reduce tone and increase blood flow is a beautiful option. Only always follow whatever kind of manual therapy to the adductors with standing banded and loaded lateral lunge sliders, sumo deadlifts or Copenhagen variations. We love the holds for 45 seconds. times five rounds for those Copenhagans, just to really tap into the analgesics from an isometric hold perspective. Also of note, if we're continuing the house analogy, and the adductors are the driveway, I like to think about the abdominals as the chimney. So the abdominals, if they are showing signs of hypertonicity and gripping, then we wanna do some of those same techniques, soft tissue manual therapy, to the abdominals followed by stretching and loading of that area. And then the nervous system, given that the individual has that history of trauma, we have to treat her from a holistic standpoint. Addressing that elevated centrally sensitized nervous system by ramping up the parasympathetic side. So doing vagus nerve stimulation exercises to increase calm, What are those examples of? Having her chew her food at least 10 times. This taps right into the vagus nerve. Humming, gargling, having her do one to three physiologic sighs. And that is two inhales followed by one long exhale. It sounds like this. So making sure that first inhale is longer than the second. or having her create a mantra like, I'm in control of my body right here, right now. Doing any of those vagus nerve stimulation exercises before and during her attempts to insert a finger, a dilator or a tampon in. This is going to really help address that tenacity. And then a time expectation. How long have you been working together? If it's only been a few sessions or if the client has dealt with vaginosis for a long time, rest assured it can take time for that physical side to catch up with the emotional or vice versa. especially given that trauma link and reminding her, hey, progress may not be linear, but here's what you've already improved on and showing her what she's made some progress with in terms of a couple of weeks ago, you weren't even able to have that dilator remain in the vaginal canal. And then I love that she's seeing a trauma therapist. This is so vital in this scenario and asking the patient, hey, can you tell me what you all talk about in your sessions? Or are you okay with me contacting your therapist so that we can do some integrative work? So I can bring in maybe some things that you all are talking about and we can practice that from the physical space. So given I don't have all the details, I'd also be curious of, hey, has she been able to insert a tampon in pain-free previously? And if so, we can lean on those positive instances that she does have the capacity to do so. And then I'd also be curious about some of the previous hip, low back, abdominal surgeries or injuries that she's had. Does she have any associated bowel, bladder? issues, urinary urgency, difficulty completely emptying, as these may be conditions that contribute to that pelvic floor holding tension. And then if she's sexually active, understanding what that means and what that experience is like for her. So hopefully those tips help y'all with the case or if you're someone who has someone like this on your caseload. To summarize, when we're treating someone with vaginismus, we really wanna lean into treating from the outside in, with external pelvic or abdominal or hip manual therapy, whether that's soft tissue, joint mobilization, cupping, dry needling, plus stem, all followed by some active mobility and stretching as well. And know with some of these patients, you may never get to the internal exam, and that is totally okay. The internal pelvic floor exam. Remember, the adductors are the driveway to the pelvic floor. The abdominals are the chimneys, so down-regulating those structures and then eventually loading that is going to be helpful. And then tapping into the nervous system via the vagus nerve just before and during insertion attempts in positions of comfort. Timing can have a huge impact on healing trajectory, and working side-by-side with their mental health or trauma-informed provider to reiterate concepts of the mind and body connection. Okay, so if you all want to learn more about some of those external techniques I was discussing, like the external pelvic floor exam, or if you do want to learn more about the internal exam, our next live courses are Kearney, Missouri, May 18th and 19th, and we have a double hitter of a weekend, June 1st and 2nd, with one course going down in Anchorage, Alaska, and the other in Highland, Michigan. So definitely sign up for those courses, or if you're interested in our online courses, we have two available. Head over to btonice.com and hop in. Thank y'all so much for listening, and I'll see you next time.

OUTRO Hey, thanks for tuning in to the PT on Ice daily show. If you enjoyed this content, head on over to iTunes and leave us a review, and be sure to check us out on Facebook and Instagram at the Institute of Clinical Excellence. If you're interested in getting plugged into more ice content on a weekly basis while earning CEUs from home, check out our virtual ice online mentorship program at ptonice.com. While you're there, sign up for our Hump Day Hustling newsletter for a free email every Wednesday morning with our top five research articles and social media posts that we think are worth reading. Head over to ptonice.com and scroll to the bottom of the page to sign up.