To the Man that Yelled at Me

I need to thank you.  If you hadn’t yelled, I would have killed you. I was driving, slowly, mind you, but that makes things even worse.  A slow death is worse than a fast death, right?  You were in the bike lane. I wanted to veer right.  Not turn.  Just…veer.  But, my children were in the car and they were insisting on changing the music.  I was looking down at my phone desperately trying to type in “toddler tunes”.  It’s a lot of letters, you see?  And, I don’t usually listen to that on my phone so it didn’t just pop up.  I had to type in twelve letters.  That wasn’t worth your life.  And you knew it.  That’s why you yelled.  You probably have several children and lots of grandchildren.  You looked really fit. You were gray, but fit.  You looked like the kind of guy that kept up with younger folks easily.  You kept yourself alive and you kept me out of prison. 

My first thoughts were not of gratitude.  My first thoughts were, “You don’t have to be a maniac about it!”.  But you did!   You did have to be a maniac!  You did have to sit up tall and wield your arm around and throw your voice and spittle at me.  I would never had known, otherwise!  So, thank you! 

I only appreciated what you did minutes later.  It was then that I realized that I need to pay more attention.  I was just going about my day doing things the way I’ve always done them.  Paying attention as much as I’ve always needed to pay attention.  Not more, not less.  Just – the same.  But, sometimes “the same” isn’t ok.  We never know when “the same” is ok. Which means that “the same” is actually never ok. 

I think about that moment in the car with my children, the music and the cyclist often. 

I’ve always held a high standard for my care with patients.  I try to be responsive in emails, I try to communicate with the other providers on their team . I try to explain things in a way that patients understand.  When it comes to the actual treatments I provide, I try to make sure that I’m better every six months.  My patients should get better faster because I should be better and more efficient and more knowledgeable every six month.  If I’m not, then I’m stuck in a pattern of “the same”.  Because “the same” isn’t ok.  Because “the same” is actually never ok.  When I find myself doing “the same” I don’t grow and my patients don’t improve. 

It’s the patient presenting me with a clinical challenge that is actually that grandfather yelling at me on the bike.  This is what wakes me up and jolts me into reality.  I need to do better.  It’s these patients that force me to grow and challenge my beliefs about what I know and what I don’t know.  It is these patients that pull me out of a sticky, but safe place and shove me into a new reality that is uncomfortable for me.   Growing does not feel good.  Growing is necessary for me and for my patients. 

Some of the things I’ve been forced to learn is that the whole body is connected to the rest of the body.  I always knew that, but I am guilty of becoming complacent.  I have to consider the upper back, the neck, the ankles. 

I’ve always incorporated the hip into my practice, but with more and more actual practice, my appreciation of the hip is evolving. 

I have never wanted to respect nutrition.  Not my own and not my patients’.  To me, that is boring.  I want to do only exciting things.  But, maybe nutrition isn’t exciting because I don’t understand its role entirely, but I need to.

Then there are times I’m trying to pull up toddler tunes while I’m missing something happening that I shouldn’t be missing.  I’ve been in someone’s case so deep that I cannot see the obvious.  Like, check your blind spot when you change lanes.  I might stupidly make the assumption that someone’s severe pain couldn’t possibly be related to something basic like a leg length issue.  So I don’t check it.  Or, I forgot to check it.  I get embarrassed when I miss this.  I don’t miss this often, but when I do, I do not feel very interesting.

As a human I make mistakes.  As a woman I make mistakes.  As a friend I make mistakes.  As a wife I make mistakes.  As a mom I make mistakes.  As a provider I make mistakes.  The only thing I can do, the one thing I try to do is figure out how they happened and how to learn from them. 

All healthcare professionals are doing the best in every moment.  No healthcare professional wants to mess up.  But, we are human and sometimes we forget to check our blindspot because we are doing something stupid. 

So when we do this, when we make our human mistakes, if we can own up to them to you, please forgive us and let us all move on.  From this we have grown and we thank you for yelling at us. 

After Your Prostatectomy

Catheters are the worst.  It’s out.  And now you have incontinence.

The post-operative prostatectomy appointments are interesting from a PT’s perspective.  I get to witness an evolution.  Patients go from fearful to angry to frustrated to hopeful to grateful.  This is now the first time I see the patient after surgery and the majority of patients are now cancer-free.  While that is a relief, they are not truly relieved because they are dealing with urinary incontinence.  This can be extensive leakage or just moderate leakage from time to time.  Results vary based on several things: what needed to be done in surgery, the length of a specific portion of the urethra, whether or not the patient got pre-operative physical therapy and whether or not the patient adhered to the pre-operative physical therapy recommendations.

Many patients cannot remember what they were told in the pre-operative physical therapy appointment.  Pre-surgery is a stressful time.  You get the diagnosis of cancer and you dive into a world of questions and search for answers.  You are ushered through several appointments posthaste and now have to absorb all of this before your surgery date.  Sometimes you cannot hear what people are saying, as much as you try – the fear is too great.  The stress, the fear, the anxiety can take over.  In these cases we review some information.  Others have posted all their pre-operative information on their refrigerator and reflect on it daily.  Meditatively.  (In a meditative manner.)

At the post-operative appointment, guys want to know how long the indignity of urinary leakage will last.  In general, most of my patients say that by three months post-operatively the urinary leakage has improved 90% since the removal of the catheter.  This requires that you do your exercises…the kegels…the exercise men didn’t know that they could do. 

In the first physical therapy appointment after surgery, I will ask about what sort of protection patients are using.  This gives me a baseline to compare improvement to.  I want to know how much protection patients are using in 24 hours and I can compare that picture to what patients say in future appointments.  It’s true that I’m not getting a quantitative picture of the true volume of daily leakage, but that would require patients measuring their incontinence on a scale.  Isn’t the leakage bad enough, already?  I don’t want to make you weigh your leakage unless we really need to parse things out and get super specific. 

I’m going to ask about what you are eating and drinking to see if this is contributing to your leakage.  The food and drink that you consume can affect the volume of your leakage, but the food and drink you are consuming will not damage you.  I always explain that this is a quality of life issue.  You will not die from urinary leakage.  So, enjoy life.  But, know that you have some control in the leakage.  If you want to socialize and not worry about leakage, we go over the food and drink that will help you avoid leaking more.  But, if you want to socialize and enjoy the food and drink that is available to you, you learn that you will need to bring super protection.  Maybe you need a Depends undergarment with a pad in it.  I once knew a physical therapist that would not work with men after surgery if they did not strictly adhere to her dietary advice in regards to leakage.  I’m a bit much, but that right there is a bit too much, don’t you think? 

At this first physical therapy appointment after your prostatectomy, I’m going to ask to look at your anus, again.  Yup, I am.  I’m looking to make sure your skin is intact.  I’m looking for irritation.  I’m looking to see if I need to make any recommendations to change your padding more often or protect your skin with a cream or both.  I’m also looking at the anus to determine if you are still performing kegels the right way.  I cannot do an internal exam through the rectum until you are at least six weeks out of surgery, so until then a visual exam has to suffice. 

If you are still doing a kegel correctly, then I can advise you on whether you should continue the same kegels you were issued before your appointment or if you need to be doing a harder home program.  From that appointment on, I become your pelvic floor athletic trainer.  You are expected to do your kegel home program every day exactly as I recommend.  This means that I want you to respect the hold times, the rest times and the repetitions that we request of you.  Every program is tailored specifically for you.  If you have buddies going through physical therapy for prostate removal, you cannot compare your home program to theirs. Once I get you going on a kegel home program, I start seeing you less and less.  I may see you two weeks after this first post-operative appointment, then I might ask you to return somewhere between every 2-6 weeks, depending on your specific situation.

 Once you are at least six weeks out of surgery, I will then start discussing what I call “penile rehabilitation”.  Think of lifting weights with your penis.  Did you do it? Is that thought completed?  Ok, good.  Cuz that’s not what this is.  Penile rehabilitation is when I start talking about things you can do to improve the blood flow to the penis, improve your ability to get erections in the future and optimize the environment for improved penile length.  I discuss a recommended frequency for self-stimulation (otherwise known as masturbation) and the expectations while masturbating.  I discuss ways to improve the blood flow to the penis to improve health, function and urinary leakage.  The reality of erections after surgery is that many, many men have to use a device and/or pills and/or injections for some time or for a long time or permanently.  The other reality is that it can take up to a few years to see your erections at their full potential.  Pun intended?  You’ll never know.

Q: What if you had a prostatectomy one year ago?  Or five years ago?  Or 20 years ago?  Will post-physical therapy help you? 

A:  Most likely.

Now there are some cases where you improve your continence with pelvic floor physical therapy, but you cannot eliminate it.  In these cases, we go over procedures that could help you.  If you decide that you are not satisfied with what the remaining urinary incontinence, we advise you talk to your physician about these procedures.  Additionally, if you are overweight, we then ask you to really try to lose weight.  This will reduce pressure on your bladder and can make a dramatic difference.

Before Your Prostatectomy

I have worked at large urology practices. This means that I have had the opportunity to work with a lot of doctors doing prostatectomies. Most men are getting a prostatectomy because they have prostate cancer. Some men get a prostatectomy for other reasons. But, I can assure you that no man gets a prostatectomy to lose a few pounds.

The idea of doing “prehab” - “pre” surgical “rehabilitation” - is really catching on. This means that before prostate removal, men see a pelvic floor physical therapist. In my practice, I see men once before surgery. There are several goals in this appointment. After the prostatectomy, I see men a handful of times. At that point, I’m acting as an athletic trainer and a fortune teller. Imagine me spotting a man’s pelvic floor. Just imagine.

Are you done imagining? So what are these goals I mentioned above? The pre-operative physical therapy appointment is intended to tell you what to expect after your prostate is removed and how to best prepare yourself for optimal outcomes.

I tell men what the spectrum of “normal” leakage looks like after the catheter is removed. I warn them that they might not truly comprehend the volume of leakage until it happens, but hopefully they will look back and think “Ah, Sara told me about this. I choose not to worry. She said this would happen. She knew. That girl…she knew.” I give it to men straight. You might leak like a faucet, even when you are not moving. It could be that bad. Or, you might just leak with coughing and sneezing. Either way, both extremes are “normal”.

I teach men about what makes the bladder spasm. Bladder spasms create urinary leakage after prostate removal. They might make some men feel like they have an urge to constantly urinate or the bladder spasm might cause straight leakage without any message to the brain. Again, both are “normal”. I get guys who say they never get urges to urinate because their bladder doesn’t get the chance to fill. It all just falls out.

I talk about protection. It’s important to protect the skin from constant dampness. It’s important to feel confident when you are out and about. Knowing what kind of incontinence padding to use is important.

I talk about the fact that they won’t be wearing protection. Meaning…there will be no need to use a condom* because there will be very little likelihood for unadulterated erections for quite some time. Can we just stop and appreciate what I just did words right there? I used the word “unadulterated” to describe erections. Unadulterated means that something is basically pure. I’m saying that for quite some time you won’t be able to get a meaningful erection without assistance from a device or medication. Can we stop one more time and appreciate that in the midst of being in awe of my own writing, I did something again that left me in awe. I double-awed myself. “Meaningful erection”. So many things in those two words added together. If you double-awe yourself, does that mean you are no longer in awe of yourself? Does it negate everything?

And what exactly do I mean by “quite some time”, right? I was being pretty vague there, but I know most men want me to be very specific about when erections will return. The reality is, some men get awesome erections back in 1-2 or even 3 years. Some men get awesome erections earlier. Some men get awesome erections only with medications or use of an assistive device. Not like a walker, not that kind of assistive device, but something like a penis vacuum that forces blood into the shaft. Or - less conservatively - a penile pump or prosthesis.

In this appointment, I let guys know that their penis will appear shorter after surgery. I’ve heard this described as an “outie” belly button. I sometimes use the phrase “turtle head”. This length can be regained. We help with that in physical therapy, but even those who don’t go to a physical therapist can see length come back over time.

Finally and arguably most importantly, this pre-operative appointment is supposed to teach you how to properly active your pelvic floor muscles so you can go home with a pelvic floor work out. The point of working out the pelvic floor before surgery is to beef up the muscles, make them more supple, make them better at restricting urine from completely falling out. When the pelvic floor muscles are in their best shape you are hypothetically likely to return to continence and erections faster. How do I teach proper pelvic floor muscle activation? I personally opt to put my finger in the rectum. I do use gloves. I do use lubrication. I do use care. I do use a lot of time. I give several different verbal cues to see which one gives the best contraction. I make sure the patient isn’t cheating with non-pelvic floor muscles and I make sure the patient is still breathing…during the contraction. No one has stopped breathing all together in my appointments. I mean…except when my knowledge and professionalism has taken their breath away. But, I mean, that just can’t be helped and it happens. No one’s fault. I digress. I then have patients contract non-pelvic floor muscles to see which of them enhance the pelvic floor muscle contraction by default. This is a form of cheating, but I mix it up. I teach how to isolate the pelvic floor muscles, but I also bump it up a notch by involving other muscle groups that are wired with the pelvic floor muscles.

While tons of men are getting “prehab”, there are multitudes more who never got the opportunity. All is not lost for these men. I will discuss what post-operative appointments are like in the next post.

*I do have to say that I am not advocating unprotected sex unless you are in a consensual relationship where all parties want to have unprotected sex and have been fully informed of each other’s health history. I was merely telling a joke. Some men can actually still penetrate soon after a prostatectomy either because they are extremely lucky or because they are using medication or a vacuum device.

Probing Your Genitals

It doesn’t happen nearly as often as it used to, thank goodness, but it still happens.  Patients come to me wanting “that thing that reads what I’m doing, like a video game or something”.  That thing is called a biofeedback machine. 

There are two types used in the pelvic floor world.  One type is called surface electromyography (sEMG) and the other type is EMG using a vaginal or rectal probe.  Some people call it a “sensor” because it sounds better.  Let’s not be cute – it’s a probe.  It looks like a probe.  It feels like a probe.  It probably even smells like a probe.  It’s a probe.

If you can’t tell from my sarcasm – and if you can’t tell, Lord help you – I’m not a fan of this equipment for my pelvic floor patients.  I have really good reasons.  I’m someone who was taught to use biofeedback.  I’m someone who used biofeedback.  I’m someone who read research on biofeedback.  I’m someone who stopped using biofeedback.  And I’m someone who evaluated whether or not I really needed to use biofeedback anymore.  I think that’s a thorough analysis, don’t you?

The point of using biofeedback at all is to give the patient “feedback” on what their body (“bio”) is doing.  This can truly be used on any part of the body, but we will focus on the pelvic floor.  Some patients with tight pelvic floors want to learn how to calm the muscles down.  Biofeedback, theoretically, should be able to show the patients when the pelvic floor is tight and when it is relaxed.  Some patients with lax pelvic floors want to learn how to tighten the muscles.  Again, biofeedback should be able to give patients a visual of when this is happening.

In reality – things don’t always go as planned.  Sometimes a patient has a really tight pelvic floor.  Sometimes the pelvic floor is so tight that it actually psyches out the biofeedback machine.  It will give a reading as if the muscles are completely relaxed.  How am I supposed to work with that?

Sometimes a patient is lax and just cannot get their pelvic floor muscles to squeeze, so they are now substituting with other muscles groups like their buttocks or thighs or abdomen.  These muscle groups are wired with the pelvic floor muscles so when these substitute muscle groups tense, the biofeedback machine gives a reading as if the patient is doing a correct pelvic floor squeeze – when in fact it is not.  For example, if I were connected to a biofeedback machine and did only a contraction of my abdomen (not my pelvic floor) – the biofeedback machine would read that I did a pelvic floor contraction.  There is even research that has come out to support this obvious and frequent finding.  In this case, it’s not the biofeedback machine’s fault.  It’s the responsibility of the physical therapist to make sure the patient isn’t compensating with other muscles. 

And then there’s tapping.  If a patient just cannot find their pelvic floor muscles, it is often necessary to use a finger in the vaginal or rectal canal and place pressure in it to activate the part of the brain that captures body part awareness. 

Biofeedback machines take a few minutes to set up and a few minutes to put away and a few minutes to clean.  Those minutes add up and are minutes taken away from one on one care with you.  And then don’t get me started on when biofeedback machines just stop working correctly.  When I used them, this was a weekly occurrence.  It was an infuriating situation that always made me look bad. 

Physiologically speaking, if a muscle or muscle group has been tight for years, technically the little muscle fibers will not lengthen no matter how much the brain asks it to.  These muscles literally do not have that capability.  The only thing that will change teeny tiny short, tight, anxious, frigid muscle fibers is mechanical pressure.  This involves a therapist placing their finger on the actual pelvic floor muscle and creating a stretch to the muscles.

So if I’m not a fan of using biofeedback machines, what do I use instead?

The answer:  Biofeedback. 

I place my skinny little gloved and lubricated finger into a vaginal canal or a rectum and ask a patient to squeeze or relax and then I tell the patient that they are or are not squeezing or relaxing.  “Bio” “Feedback”.  Boom.  What’s more is that my finger is smaller than a probe.  What’s more is I am looking at the patient and determining if they are using cheater muscles.  What’s more is my finger doesn’t take minutes to glove and lubricate, my finger doesn’t take minutes to doff a glove, my finger doesn’t take minutes to clean.  What’s more is that in my entire career, my finger has never, ever malfunctioned.  What’s the most is that if I need to use my finger to tap on the muscles to wake up the brain that controls the pelvic floor or if I need to apply mechanical pressure then my finger is already there.  It’s test, wake up the muscles and re-test.  Easy peasy lemon squeezy.

I’ve done a lot of talk about the probe, but the sEMG which uses basically sticker-like electrodes to get a reading aren’t any better.  They can also provide obscure readings or not read at all and still take time to apply, take off and clean. 

The Internet is full of references to using biofeedback for what seems like every pelvic floor diagnosis.  Trust the Internet sometimes, but not always.  Like, when you use the Internet to read a random blog from a random physical therapist.  Trust it then. 

Ripping Your Skin Off

There is a huge disagreement in the pelvic pain world.  Some people say that you should cause no pain to patients who come to you for treatment of pelvic pain.  The others believe that you should address what is causing the root of pelvic pain in as efficient a manner as possible.  These two viewpoints don’t have to be at odds, except the latter might involve pain.  And that, for the first camp, is a “no-no”. 

You know how when you rip the skin off of raw chicken, you see that iridescent, thin layer over the meat of the chicken?  That’s called fascia.  That thin layer runs all throughout the chicken.  It also runs all throughout…us.  There are four layers of fascia and the most superficial of our layers – the one you see on the chicken – is the pannicular layer.  This layer is so impactful in treating body pain, not just pelvic pain.  This is like a full body suit from head to toe and everything in between.  When one part of this pannicular layer of fascia isn’t sliding and gliding with ease and abandon, then you start to feel weird, ambiguous, though…sometimes extremely specific pain.  The ambiguous pain can feel like “I just feel a spreading ache” or the specific pain can feel like “I am so aware of the opening of my urethra, I cannot stand it!”.  This layer of fascia that we are talking about is found under skin, under fat and on top of muscle.  As physical therapists, we can access this and affect it.  We can make parts of it that are “stuck”, get “unstuck”.  We can make it glide and slide without abandon.  We can make it loosey and goosey and everything in between.  And this, for many people, eliminates their pain.

So, what’s the problem? 

The problem is this:  This treatment hurts.  It feels like I am ripping your skin off.  But, that’s kind of because…I am ripping your skin off. 

I’m doing something unique.  I’m trying to create space between skin and fat and fascia and muscle.  I’m picking skin and fat up and away from the body.  Most everything else we do to try to treat body discomfort does the opposite.  If you are a foam roller, then you are smashing everything together.  If you like massage, then you are enjoying a compression of skin, fat and fascia – though it does provide some gliding.  If you like trigger point releases, then you are pushing things together.  This idea of “ripping the skin off”, is completely opposite, and hurts in a different way.  I’m not taking pride in the pain.  I’m not showing off about the pain.  I just think that this discomfort is a necessary and efficient way to treat so much that stems from fascia, but talks like an organ.  Fascia knows the language of the bladder, the rectum, the penis, the prostate, the urethra.  The fascia knows a lot of languages and it is a capricious, arrogant party guest.  It just keeps showing off. 

This work, this connective tissue manipulation, it’s also called “skin rolling”.  Doesn’t that sound pleasant – maybe even…bucolic?  Well, it’s just not.  It hurts.  It hurts so much that I give every patient a “safe” word.  And it’s not pineapple.  It’s a four letter word:  S-T-O-P.  It hurts so much that I’ve seen many a tear escape from a man’s eye.  They’re not crying – no…this is involuntary.  This is a visceral reaction to a pannicular treatment.  It may cause bruising the first few times it’s done.  You might have fingerprints all over your body.  It might look like tiger stripes. It leaves you sore.  You will feel your clothes touching your body for a few days.  But then, it doesn’t bruise.  And it doesn’t leave you sore.  Eventually, it energizes you with an influx of adrenaline and a burst of joy.  Truly.  Connective tissue work affects the nervous system – that’s how it changes how you perceive calls from the bladder, bowel, genitals, etc..  And finally, this “skin rolling”…it starts to feel good.  And then you start to feel good.  And then you are just that – good.  Good to go.  Good to get out of here without worry and without pain.

This right here, it’s a massive source of contention.  Some therapists refuse to allow their patients any discomfort.  It’s sweet.  It’s kind.  I. Am. Not. That.  But, I do all things with informed consent, intention to serve you well and get results quickly.  We are as varied as the stars in the sky.  Not really – but it sounds good.  So, you might have had a pelvic floor therapist that talked to you a lot, or one that only corrected your posture, or one that only did internal work, or one that never did internal work, one that always made you hurt, one that never made you hurt, one that really, really helped, one that didn’t touch your symptoms…this is all possible. 

But, one thing that is true across the board is that you should not have to live with dissatisfaction with bowel, bladder, sexual function or pelvic pain. 

You Must Drink Water Correctly

I was once at a gas station paying for a bag of beef jerky.  It was some organic super left-wing, not really meat, more like a meat imposter edible– it was horrible.  Don’t ever buy those.  If you want something that feels and smells like meat, then I suggest…meat.  So anyways, I am paying for this faux-meat when a man walks in and says to the cashier, “Hey! Your sign outside says $1.59 a gallon (I don’t know what year this was or what oil prices were doing) and your pump just charged me $1.75 a gallon!  What gives?!?”.  The cashier looked up from my bag of desiccated tofu and made eye contact with the man.  He was probably wondering why he stocked that crap. He paused, then slowly opened his mouth and said “You must read the sign correctly.”  Turns out there was fine print with several exclusions.  The angry customer didn’t qualify for the $0.16 discount and he stormed off.  Ever since then, I like to tell people to do things…correctly.  You must plant the flowers…correctly.  You must take a bath…correctly.  You must do the dishes….correctly.  

In light of this story, it took me very few seconds to come up with the title “You Must Drink Water Correctly”.  Seriously.  This is a real problem. Can you imagine being bad at drinking water?  You might be.  Stop imagining, you might be living it.

So here’s the thing.  Here’s the “deal”. We get a lot of information about drinking water.  We know it’s healthy for our organs.  We know it affects how we feel.  We know it tampers with energy levels.  We know what happens when we don’t get enough. 

But, how does one drink water incorrectly and what happens when one does this?

Everything in moderation, man (or WOman). 

I’m getting a lot of patients who care about how much water they consume.  Nice! But, they don’t care when they consume it.  Not nice.  They will down 40 ounces of water in one hour and then ask me why they pee all the time.  If you drink a ton of water at once and then have to pee a lot, then you are what I call a “normal person”.  You bumrushed a balloon (your bladder) with water.  It wants to pop.  So, unless you go to the bathroom to relieve the pressure, it will burst!  A bursting of the bladder is basically urinary leakage.  You pee yourself.   If I did the same thing, I’d be peeing constantly too.   To avoid this, you just drink in moderation.  A gulp here.  A gulp there.  A bathroom break here.  A bathroom break there.  But, not, a bathroom break everywhere. 

Drink during the day and sleep at night.

Then I have some patients who don’t drink much water during the day, but they get thirsty at night and drink a lot – all.  through.  the.  night.  So what happens to them?  They pee – all.  through.  the.  night.  A strong sensation to pee wakes them up and they don’t sleep well.  But, they don’t attribute the need to pee with drinking at night.  They attribute it to old age or a big prostate or their diuretics or being “bad” sleepers.  They think they don’t know how to sleep correctly, but really they don’t know how to drink water correctly.  This isn’t to say that people don’t have sleep apnea, really do have to wake up because of diuretic use, etc., but it does mean that drinking water at night is making them wake up to pee more often than they would otherwise.  

Water is boring, get over it!

Water is just water.  There is no flavor.  There is no fizz.  There is no trick to it.  It’s just wet stuff in your mouth.  When you “don’t like the taste” of water, it’s like saying “I don’t like the feel of “air” or I don’t like the “sensation” of breathing.  Your body needs unadulterated water.  Plain and simple!  Dr. Pepper does not substitute for water.  Coffee does not substitute for water.  Carbonated water does not substitute for water.  Flavored water does not substitute for water.  Only water is water.  Let me repeat that:  only water is water.  Without old fashioned, unassuming water you are more susceptible to the following: 

1.     Kidney stones

2.     Infections

3.     Green hands.

4.     Burning with urination

5.     Intense urges to urinate

6.     Speaking in a British accent.

7.     Urinating all the time

8.     Bladder pain

9.     Constipation

10.  Lower energy levels

Truly, truly, I say to thee, if you don’t drink water correctly and then you start to drink water correctly – your life will change. 

You’ll be able to actually sit through a car drive without needing to stop.

You’ll wake up less at night.

You will probably leak less.

Your urine stream will get better.

You will become more attractive.  The list goes on and on and it doesn’t stop until the early dawn.

So, follow my man’s advice…”You must read the sign…correctly.”

Why You Hurt

People have issues in their back, hips, pelvis, bladder, urethra, genitals, vagina and rectum for a handful of reasons.  It doesn’t get that wild.  What is actually wild is the depths some patients have to go through to get referred to the appropriate care.  

I’ve listed super common reasons why people have pelvic issues. 

Muscle Tightness: The word “tightness” is frowned upon in academic circles, but I don’t know if it’s for good reason.  The only reason I’d frown upon that word is because I don’t think it is actually a word.  But, if we write to communicate, then I’m going to use communicate by using a non-word that communicates what I need to communicate!  Despite it’s lack of existence, everyone knows what I’m saying when I say muscle “tightness”.  When the pelvic floor muscles are tight, this causing pain.  It might not cause pain with fleeting tightness, but it will, inevitably, cause pain with muscles that stay tight.  This is true for my any muscle in the body, but it is especially true for pelvic floor muscles.

Tight muscles have reduced blood flow and oxygen.  Blood flow and oxygen are necessary for muscle and nerve health.  When any muscle is tight, it cannot perform it’s job because it is weak.  A tight muscle is not strong.  A tight muscle is weak.  This is a fact.  A muscle that never rests at a normal length is not going to be able to contract powerfully.  When a muscle isn’t strong enough to do it’s own job, then other muscles have to step in and take over.  This compensation creates a slew of new problems and new pains.  So, tight muscles cause pain because they are not healthy.  And, tight muscles cause pain because they force other muscles to do too much and move other body parts in a weird, unintentioned way.  <—Yet another non-word from a girl that likes to write.  If Shakespeare did it, Sara Sauder can do it too.

Back Problems: The spine is like a generator that helps everything else in the body light up.  The brain creates a signal to the spine and the spine has all these wires that light up different muscles and then the body appears to respond to the brain’s command.  The spine has all these levels.  It’s like a high rise with a ton of floors.  Imagine that each floor has a window has a zip line connecting it to one body part.  For example, the first floor zipline connects to the toes.  The 10th floor zip line connects to the pelvis.  The 22nd floor zip line connects to the fingers.  The occupant of each floor glides down their own zip line and tell their corresponding body part what to do.  The first floor occupant, her name is Betty and she glides to the toes and says “give me a wiggle”.  Wilma glides from the 10th floor to the abdomen and says “give me a jiggle” and Herb glides down from the 22nd floor super slowly and carefully (he is actually afraid of heights) and tells the fingers to “give me a sniggle” – it rhymed.  But, when these windows to open correctly, the occupants get frustrated.  They push and they pull and they shell out money for a cocky and overpriced maintenance guy to come in, charge a $95 service fee to apply a little 50 cent grease and watch the window slide open on command.  The occupant, now frustrated, humiliated and desperate for fresh air now buck and cuss their way down the zip line.  The zip line frays a bit under the jolted movement of the unhappy campers.  The high rise occupants are now so annoyed and disoriented that they no longer ask for a “wiggle” a “jiggle” or a “sniggle”.  Now they give a garbled mutter of a command.  And this, my friends, is confusing.  It’s not the clear, energetic signal that the toes, pelvis and fingers are used to getting and this confusion equates to pain. 

 Was that the worst analogy of all time?  Possibly.

Nerves come out of your spine and if your spine isn’t moving nicely in all directions, it can cause a pinched nerve.  If that pinched nerve goes to your pelvis, this can cause pelvic pain.  Boom.

Connective Tissue Restriction: You know how when you rip the skin off of raw chicken, you see that iridescent, thin layer over the meat of the chicken?  That’s called fascia.  That thin layer runs all throughout the chicken.  It also runs all throughout…us.  There are four layers of fascia and the most superficial of our layers – the one you see on the chicken – is the pannicular layer.  This layer is so impactful in treating body pain, not just pelvic pain.  This is like a full body suit from head to toe and everything in between.  When one part of this pannicular layer of fascia isn’t sliding and gliding with ease and abandon, then you start to feel weird, ambiguous, though…sometimes extremely specific pain.  The ambiguous pain could feel like “I just feel a spreading ache” or the specific pain could feel like “I am so aware of the opening of my urethra, I cannot stand it!”.  This layer of fascia that we are talking about is found under skin, under fat and on top of muscle.  As physical therapists, we can access this and affect it.  We can make parts of it that are “stuck”, get “unstuck”.  We can make it glide and slide without abandon.  We can make it loosey and goosey and everything in between.  And this, for many people, eliminates their pain. 

Trigger Points: In all honestly, I don’t know what a trigger point is.  Sometimes I feel these little bundles on my patient’s skin and it’s tender when I push on it.  Then I kind of hold my pressure and the tenderness goes away.  That’s a trigger point.  But, what is it?  Some say it is a small area of bundled muscle fibers, bundled fascia fibers, bundled something….  Others say that trigger points are nothing.  All I know is that sometimes I can feel these spots, but most of the time I cannot.  I also think that trigger points are given way too much attention.  I feel uneasy talking about trigger points.  I feel like I’m talking about something mystical, some soft science.  But, I use the term “trigger point”, because there are many times I don’t have another phrase to use to describe a tender spot on a person that becomes untender once I hold pressure on it.  Is something wrong with me?  Likely.  Does this haziness stop me from treating “trigger points”?  Not really.  I can’t explain everything.  I can explain some things. But, I’m really comfortable explaining that I can’t explain things.  Understand? 

 Trigger points are weird.  Sometimes I hit a spot on someone’s thigh and they feel it in their tailbone.  Sometimes I hit a trigger point in the rectum and they feel it in their stomach.  If it works, I do it.  If it doesn’t, I don’t.

Diaphragmatic Breathing

This is the one common denominator that I give all patients.  If you cannot breathe using your diaphragm correctly, then your body is not using all cylinders.  Diaphragmatic breathing allows more oxygen to pump through your body, it allows your nervous system to calm down and it relaxes the pelvic floor muscles.

I was sitting in a counseling session re-telling the story of a recent argument.  I didn’t think I was getting worked up, but my counselor did.  She put a pulse oximeter on my finger and told me to take deep breaths.  I did.  She stopped me.  She said “No, no, you are not breathing.  I don’t see your chest rising.”  I thought, “Lady, stay in your lane.”  I was sitting there looking at my pulse oximeter.  I was getting 99% oxygen saturation (totally normal) and I was diaphragmatic breathing.  Your chest isn’t really going to rise with diaphragmatic breathing.  That’s when I realized that the pulse oximeter must have been her new toy so she couldn’t wait to use it and I must have been her first patient that day.  To appease her, I sat there and breathed incorrectly.  I didn’t want to go down a rabbit hole of how she was incorrect.  She was a counselor.  She would have thought I had control issues (which…maybe I do, so what?). 

My point is that we are told left and right that chest breathing is correct breathing.  I hear that message everywhere.  I’ve heard that message yoga classes, doctor’s appointments, you name it. 

When you use your diaphragm to breathe correctly, you allow your pelvic floor muscles to relax with every single inhalation.  When you do not use your diaphragm to breathe correctly, your pelvic floor muscles tighten with every breath. 

 Two things to look at here:  Excessive pressure and Pain.

 Excessive Pressure:

If too much pressure is being forced on your internal organs, especially the pelvic organs, then your body has to find room for that excessive pressure.  Like a soda can that you shake, the carbonation goes wild and you hear the bubbles inside the can.  You might see a little fizzing start at the opening of the can if there is any weakness at the top OR if it’s a soda bottle and the cap has been unscrewed ever so slightly you will see the bubbles start to leak out the top.  Basically, if there is too much pressure inside and any weakness whatsoever in the body, then the pressure will want to escape.  Something has to give.  In the human body, this escape can look like a hernia, a diastasis recti (appearance of a separation at the midline of the belly) or a prolapse.  Learning to breathe diaphragmatically will reduce the constant pressure being forced on areas of weakness with every breath.

Pain:

There is no good reason for the pelvic floor muscles to be too tight.  There is no good reason or the pelvic floor muscles to be too loose.  No good can come of these extremes.  Plain old normal tension is perfect.  Normal is good.  Normal is perfect.  Normal is normal.  When you breathe using your diaphragm, every inhale helps make the pelvic floor muscles more “normal”.  Every inhale relaxes the pelvic floor muscles.  If literally every breath you take, every move you make, every bond you break…wait.  If literally every breath you take can assist in reducing the excessive tension in the pelvic floor, then it is important to use your diaphragm the way it is supposed to be used. 

Our daily habits contribute to why we do or do not use your diaphragm optimally.  The diaphragm attaches from the lowest ribs to the spine.  This spans the front to the back of the body.  It is like a trampoline.  Imagine there is nothing else in our body but the diaphragm.  If you swallowed a grape, the grape would fall onto the diaphragm and bounce up and down.  The trampoline would catch it.  Now, stop imagining that there is nothing else in your body.  Because that is weird. 

 If we know that the diaphragm spans our body from front to back, then our posture will really affect how our diaphragm functions.  If we constantly put yourselves in positions where our front is closer to our back, then our diaphragm will get shortened.  What brings your front closer to your back?  Bad posture.  Sit in a chair and then slouch.  Your ribs are now collapsed back much closer to your spine than if you were sitting up with good posture.  When we drive in a car with poor posture, when we sit at the computer with poor posture, when we watch TV with poor posture, even when we exercise with poor posture (and I see this a lot at the gym) we are shortening out diaphragm.  This makes our diaphragm much less efficient.  This makes effectively makes your pelvic floor tighten.

 How to Breathe with Your Diaphragm

This is very easy to do.  This is very hard to do. 

 When you inhale, you want to imagine that you are making your belly a little bigger.  When you exhale, your belly should naturally collapse back down.  When your belly gets bigger, you might notice that your whole rib cage expands.  The expansion is lateral (left to right).  But, don’t focus on just that.  If you are able to make your belly slightly bigger because of your inhale, then the rib cage should naturally expand – without any extra attention.  If you want to get nit picky, then focus on your rib cage, but I get scared to ask people to get nit picky.  Nit pickiness is sometimes the reason pelvic pain begins.  Truly. 

 Breathing with your diaphragm means your chest is not rising with the inhale.  That is backwards breathing, formally known as “paradoxical breathing”.  You don’t want to see your chest rise and fall with diaphragmatic breathing.

 And, just so you know, there is only one correct way to breathe:  diaphragmatically. 

The Vestibule

This is an extremely important part of the female anatomy.  It is the reason 50% of women with painful sex have painful sex.  The vestibule is a very specific tissue at the opening of the vagina.  It is made of the same kind of tissue as the lining of the urethra and the bladder.  That is why about 50% of women with painful sex also complain about frequent urinary tract infections (UTI’s) and needing to urinate often or very intensely or even complain of urinary leakage.

 Anatomy

Lots of people, providers and patients alike, do not know use the correct words when describing female genitals. Let’s start from the outside and go in.  When a woman lies down naked and you look at her genitals, that is her vulva.  The clitoris, the labias, even the opening of the vagina – though you are unlikely to see this without spreading the labias – it’s all vulva. 

The tissue at the opening of the vagina is the vestibule.  Vestibule means hallway or entry way.  The vestibule is the path to the vagina.  The vestibule covers the the opening of the vagina and extends past that into vagina just a bit.  “Just a bit” is a medical term.  I argue with a lot of textbooks that say the vestibule tissue ends at the remnants of the original hymen.  Women who have discomfort at the vestibule will say that a penetrating item going into the vagina hurts at the opening and then there is a spot where the pain subsides.  My huge theory is that this is where the sidewalk, err, the vestibule ends. 

The vagina is the dark cave inside the body.  You cannot actually see the vagina unless you are using a medical device to spread the opening of the vagina and look inside.  You can put a finger inside the vagina and feel it, but you cannot actually see it. 

The human body is made up of three different types of tissue when in the mother’s womb.  These are called germ cells.  The study of these tissues is called embryology.  Embryologically, the three layers are ectoderm, endoderm and mesoderm.  When speaking about the female genitals, the vulva is ectoderm, the vestibule is endoderm and the vagina is mesoderm.  It’s all different!  It’s a world of difference right there at the genitals!  It is exciting!  It requires understanding.  I’m essentially saying it’s like the vulva is made up of cotton, the vestibule is made up of rayon and the vagina is made up of silk.  Three different materials.  We cannot treat it all the same.  What that vestibule rayon can feel like if not well tended to by appropriate sex hormones (and even diet for some) is sand paper.  Or fire.  The vestibule must stay healthy to feel like rayon.  Because that things gets pissed really easily.

Here’s where it’s just not fair:  When I give lectures or talks, I often compare the female and male anatomies.  There is nothing like the vestibule on a man.  (Though, men do have pelvic pain.)

I do the same analogy because it creates a lasting impression.  I tell the audience to look at the wall.  I then have them imagine a massive penis coming out of the wall.  I then move way back and have them imagine that I am at the tip of the penis – the glans.  At the glans of the penis is the hole called the urethal meatus.  This is where urine and ejaculate come out.  I then have the audience imagine that I am crawling into the urethral meatus – I am crawling into the hole that urine and ejaculate come out of.  Lining that hole is the urethra.  That urethral tissue (that endodermal tissue), I then tell the audience, is what I grab and as I work my way back out of the urethra and outside of the penis and I then take that tissue and fold it back over the tip of the penis.  Now the tip of the penis (the glans) is covered with urethral tissue.  Completely exposed to the elements.  Now the male is much more likely to feel urinary symptoms and much more likely to potentially have discomfort with sex.  But, in real life, in a world where I do not crawl into a massive penis attached to a wall and pull the urethra out…the man’s urethral tissue is never exposed.  But it is exposed on a woman.  And that is why it is not fair. 

How the vestibule gets irritated

The vestibule likes a lot of things, but I don’t think it’s asking for too much.  All it wants is food, room to move and gentle touch.  This translates to appropriate sex hormones and appropriate bacteria, normal muscle tension and avoidance of scrubbing.  Isn’t that what we all need in life?  Who can blame it?

The vestibule needs a decent environment to thrive.  When it thrives, you don’t even know it is there.  It requires decent levels of estrogen and testosterone.  It requires normal levels of good bacteria.  Bacteria levels and estrogen are quite connected.  If good bacteria is removed, then you are likely to have lower estrogen levels in the vulvovaginal area.  Good bacteria is removed with use of antibiotics and by using soap at the genitals.  Appropriate sex hormones and flora also help create the vagina acidic.  This helps to fight off infection and keep tissue healthy.  When you become more basic because of the change in sex hormones and flora, you start to become symptomatic. You cannot always see that the vestibule is lacking estrogen and testosterone or good bacteria.

When the pelvic floor muscles are too tight and stay too tight all the time, then they don’t create good blood flow.  This is called ischemia.  Muscles that attach towards the vestibule can tug on the vestibule.  This creates more ischemia.  And now the vestibule is irritated.  You cannot always see that the vestibule is ischemic. 

Then there is this:  when the vestibule doesn’t have appropriate sex hormones and good bacteria, then it is likely to cause pelvic floor muscle tension which causes ischemia.  Once will cause the other!  Ridiculous, I say! 

When you don’t have appropriate sex hormones and good bacteria and/or your pelvic floor muscles are tense, you are more likely to develop a true urinary tract infection (UTI) or just symptoms of a UTI.  You might get prescribed antibiotics more often and now you are killing whatever good bacteria you may have had left.  Now you are really stuck in a loop.  And then you know that some docs will prescribe antibiotics even if you don’t actually have an infection or if you don’t know if you actually have an infection.  This snowball keeps getting bigger and bigger.  You cannot always see that you have an infection.

And then, you might be someone who keeps getting true UTI’s over and over again or maybe a yeast infection over and over again.  Now your vestibule is pissed off.  It’s super irritated and inflamed.  Now it’s sitting in the house of rising inflammation and you do not know how to get out of it.  Get the hell out of New Orleans!  You cannot always see that you have inflammation.

Washing the genitals with something rough…like a loofah, even if no soap is used is too abrasive.  The vestibule needs to be handled like a rose petal.  You wouldn’t scrub a rose petal, would you?  You usually can see if the vestibule has small cuts and tears, but it requires knowing what the vestibule is and looking at it with light and at times with magnification.  If your physician is looking at your vestibule with use of a speculum – they are not looking at your vestibule at all.  They are probably tearing your vestibule a bit more and causing you excruciating amounts of pain. 

Symptoms of an irritated vestibule

·      Painful urination

·      Frequent urination

·      Intense urges to urinate

·      Waking frequently at night to urinate

·      Not feeling empty after urinating

·      Urinary leakage

·      Bladder pain

·      Urethral pain

·      Vaginal pain

·      Vestibule pain

·      Painful sex

·      Pain with sitting

·      Pain with wearing underwear or pants

What to do with Sex Hormones

What Now?

If you are lucky enough to have a provider or an advocate that understands that your thyroid levels are appropriate, but your SHBG is too high and we know that this is a number’s game, then you can start considering systemic options.

Systemic hormones are the hormones that can be assessed when you do blood work.  These are the hormones going through your whole body system.  Supplementing with systemic hormones (of any kind) means that when you use that supplementary hormone long enough, you should see that the levels of that hormone change when you do blood work. 

For example, with high SHBG, you can counteract that by increasing your systemic testosterone.

Note that you can increase hormones locally too.  This would not act on your whole body system.  This would not create change on your blood work.

Ways to get more estrogen and testosterone systemically: creams, patches, pellets

There are several different ways to increase sex hormones systemically:  This is hormone replacement therapy (HRT).

 Estrogen can be increased systemically using a patch or an oral pill. 

 Testosterone can be increased systemically using a cream, pellets inserted into the fat of the buttock or an injection. 

Risks of supplementing estrogen and testosterone systemically

If you are a woman of reproductive age and want to consider using systemic testosterone, you must consider that this might affect your fertility options in the future.  This isn’t the case for everyone, but it is something that must be weighed heavily.

If you are a woman with a family history of estrogen dependent breast cancer, you will want to have serious conversations with your physicians about whether systemic estrogen benefits outweigh the possible risks.  While systemic estrogen does not cause breast cancer, those with a family history of estrogen-dependent breast cancer should still consult with their doctors. 

The key is to truly understanding if systemic or local estrogen use is what you need.  Local estrogen can be used mindfully even with women who have active estrogen-dependent or a history of estrogen-dependent cancer.  Local and systemic use are extremely different so a good understanding is vital to your quality of life.

But sex hormones aren’t just for sex.  They are for a healthy urinary experience too!  This is the part that is exciting to me.  This is the part that more people need to understand.  See, the lower part of the urinary system relies on having adequate amounts of estrogen and testosterone.  The parts we are talking about are the vestibule, the lining of the urethra and bladder.   Without proper sex hormones acting locally here, you might start experiencing urinary symptoms.

 These symptoms can be:

·      Urinating often day or night

·      Strong urges to urinate

·      Leaking urine

·      Burning with urination

·      Constant awareness of a need to urinate

·      Constant awareness of your bladder or urethra

·      Frequent urinary tract infections (UTI’s)

·      Frequent symptoms of a UTI, without having a real infection

·      Symptoms similar to Interstitial Cystitis (IC)

 The trick in this situation is that you will not necessarily be able to capture a local drop in sex hormones affecting the lower urinary tract via blood work.  Sometimes the drop in sex hormones is truly just a local drop. 

There are a few things that might create this situation:

·      Using soap to clean the vulva and/or the vagina

·      Frequent use of antibiotics

·      Vulvar skin issues

·      A basic diet

When I examine patients, I look at the vulva and I check everything that could be affected by a drop in sex hormones.  This top to bottom check helps me draw a complete picture.  There is no way to determine via any sort of lab testing if the lower urinary tract and vulva could use more sex hormones – this is done purely by a physical exam looking at the vulva and consideration of a patient’s report of their medical history.  The problem with this is that it takes an educated provider to know what to look for. 

Many physicians do not understand that using estrogen and testosterone locally will not affect blood levels.  Many physicians do not understand that sex hormones can affect lower urinary tract symptoms.  Many physicians do not understand what to even prescribe to supplement your local sex hormones.  This is a problem.  It’s one of the big Kahuna problems.  It’s why so many people have pelvic pain and feel so hopeless about it.  But this ain’t hopeless.

Sex Hormone Background

Your main sex hormones are estrogen and testosterone.  These are extremely important for women to have interest in sex, typical function in sex and typical experiences in sex. 

 In order to best understand what happens with sex hormones in the body, you have to back up and understand a few concepts first. 

 “Normal” Functions

 The thyroid gland must be working properly.  Estrogen and testosterone production will not be ideal unless the thyroid gland is sending correct messages to other organs.  Strictly focusing on sex hormones here, when normal signals are sent to organs, the ovaries produce estrogen and testosterone and the liver produces a hormone called sex hormone binding globulin (SHBG).  Estrogen and testosterone float in the blood stream.  However, hormones do not do any work floating in the blood stream.  They only begin to work once they find a site to connect to.  If you’ve ever taken a biology class in high school or college, you may have heard of the “lock and key” concept.  The estrogen or testosterone floating around is the “key”.  It finds a receptor site and that site is the “lock”.  Now the estrogen or testosterone can do its job.  Only now is it doing something at all. 

You can think of this like a bunch of people on the highway driving to work.  You’ve got a teacher driving in her Camry to get to school.  You’ve got a plumber driving in her (<— notice that?) F-150 driving to a client’s house.  The teacher and the plumber.  They are on the road.  They want to go to work.  But, if they haven’t reached their destination and actually parked in the parking lot and walked into school and the client’s house, then they aren’t actually working yet.  The teacher isn’t teaching until she is in front of her students.  The plumber isn’t actually “plumbing” until she is working on the pipes.  That’s a lot like these hormones.  They may be on the highway driving to work, but they are useless just driving to work.  They are only useful once they have found their receptor site.

Sex Hormone Binding Globulin: SHBG

SHBG is a protein from the liver.  It gets produced and it ends up finding sex hormones and binding to them.  Like a glob.  It sounds like a big fat nuisance.  I imagine it like a big amorphous blob with globous arms looking for estrogen and testosterone.  It finds the sex hormones and hugs them like a complete idiot and never lets them go.  But, if you they aren’t let go, they cannot bind to their receptor sites and do any work.

It’s like SHBG is a complete idiot driver that asks the teacher and the plumber to pull over on the side of the road and it just sits there and hugs the teacher and the plumber because it is so thankful for their services to the community.  But, SHBG is a fool because in hugging the teacher and plumber and never letting them go, the teacher and the plumber cannot actually go to work.  They are annoyed and stressed about being late to work while clutched in the amorphous arms of a blubbering fool.  This blubbering fool never ever lets them go.  So the principal calls the teacher and the foreman calls the plumber and they both answer their phones and say “Listen!  I’m on the highway.  I’m on my way to work!  But, I am stuck in the embrace of this insanely friendly, but highly socially inappropriate and inept blob!”.  The employers tell the teacher and the plumber that they get no credit for attempting to go to work.  They never made it in and the teaching and the plumbing never got done. 

Blood Work

So…who cares that the teacher and the plumber are on the highway? 

If a tree falls in the woods and no one is there to hear it, does it actually make a sound?

This is the dilemma with blood work and our understanding of blood work. 

Often physicians will do blood work to check estrogen and testosterone levels.  This is only helpful if:

1.      We know thyroid levels are normal

2.      SHBG is also checked

Without checking SHBG, then all we know is that the teacher and the plumber are on the highway, we don’t know if they are actually able to get to work.  If SHBG levels are too high, then we know that the teacher and the plumber are on the highway, but the odds of them being snatched up for a gooey hug by SHBG are quite high.  This tells us a lot.  You might look like you’ve got plenty of estrogen and testosterone, but if the odds of them not making it to work are pretty good, then we need to consider how much estrogen and testosterone is truly being activated in your body.

It’s a ratio game.  It truly is.

Guess what.  In reality, SHBG is rarely checked.  You get told your hormones are fine and you and the physician are left with fewer answers, fewer treatment options and a lot more frustration. 

The Dilator Program

The goal of the dilator program is to run through four types of movements with each dilator size until you are able to use a dilator the girth of your erect partner or desired penetrating item.  Start with the smallest girth dilator.

 Movement One:  Insertion.  Can you get the dilator in without more than 2 out of 10 discomfort?  If you can only get it in a little bit and start to feel more than a 2, then you must stop and do your diaphragmatic breathing and anal relaxation. With your ten-minute time limit, this realistically means that you may not be able to insert a dilator in completely for a few days or even a few weeks.  But, no one is judging you but you (or maybe a partner – but that isn’t supportive and that in itself is indicative of one or several issues).  I’m not judging you.  I’m telling you that slow and steady wins the race.  Be patient with yourself and you will be much more successful. Once you’ve gotten your first dilator in all the way, you will notice that a portion of the dilator doesn’t go into the vaginal canal.  This is the part for you to hold.  You will also likely notice that if you don’t hold the end of the dilator, your own vaginal muscles will slowly start pushing the dilator out – not all the way out, but you will see some slow movement.  That is also to be expected and natural. 

 Movement Two:  Rotation.  We want to teach the tissue at the opening of the vagina and inside the vagina (and we want to teach your brain) that movement in all directions is okay.  Not just okay, but not worthy of worry or anxiety.  So now the dilator is completely in the vaginal canal and you can slowly turn it like a dial.  Slowly turn it all the way to the left and then all the way to the right.  The same rules apply:  no more than 2 out of 10 discomfort is allowed and the whole process from insertion to removal cannot take more than ten minutes.  Once this is no big deal to your body and brain, you can move on.

Movement Three: Pressure.  With the dilator inserted completely, take the end that is sticking out of the vaginal canal and put pressure at the vaginal opening.  You will take turns putting gentle pressure all around the opening of the vagina.  Imagine that the vaginal opening is the face of a clock.  12 o’clock is correlated to the direction of the clitoris.  6 o’clock is correlated to the direction of the anus.  Gently place pressure at all the “hours” of the clock, but it is not necessary to do this at 12 o’clock.  The urethra sits there so it won’t be comfortable to put isolated pressure right under the urethra. 

 Movement Four: This is the last step of the progressions used with one dilator size before moving to the next size.  With the dilator inserted completely, remove the dilator halfway out of the vaginal canal and then re-insert completely.  This can be done slowly.  Again, the 2 out of 10 discomfort rule applies.  This is a different direction of movement and simulates penetrative directions.  With this last movement, the opening of the vagina and the vaginal canal have now experienced a slow stretch and different directions of movement.  This takes the nerve endings and gives them gentle and tolerable input that re-trains the brain.  This very benign pressure tells the brain “something is there, I feel it, but this isn’t ‘damage’ so I don’t interpret this as pain”. 

 Once these four movements have been accomplished without more than 2 out of 10 discomfort and in under 10 minutes, then you are ready to move forward with the next dilator size.  

There are a lot of dilator companies. I like dilator companies that create half sizes, so I often recommend Syracuse dilators.  They are cheaper, firm and do have half-sizes.  If someone is having penetrative sex that hurts, I will typically start them on a small or small plus.  However, is someone cannot have penetration yet, then that is a different ball game.  I might start them on a long-stemmed Q-tip.  This is still truly a dilator and you can go through all the movements with it before moving onto a dilator that you order.  Syracuse dilators makes sizes as small as XXS.  I love that and if that’s where you are at, you will love it too.  I progress people to dilator sizes that are either as big as their partner’s or their penetrating item’s firmest girth. 

Medications Affecting Hormones

When I get a patient’s history, I’m trying to figure out why they are hurting.  I’m not interested in why they have their current symptoms, I’m interested in why this whole spectacle of pain started in the first place.  Questions that I ask most all women are:

1.     Have you ever been on birth control? 

2.     Have you ever been on Spironolactone?

3.     Have you ever been on fertility drugs?

4.     Have you ever been diagnosed with endometriosis?

5.     Have you had a hysterectomy? 

6.     Have you ever breastfed?

 All of these scenarios can affect the level of sex hormones in the body. Sex hormones in the body affect so much more than your ability to have sex. The main sex hormones I discuss are estrogens and testosterone.  Birth control, Spironolactone, fertility drugs and hysterectomies can affect sex hormones, though this isn’t a complete list, it gets the big hitters.

Birth Control

Combined hormonal contraceptives (CHC’s) are primarily prescribed as a form of birth control, but sometimes prescribed to clear up skin, change the menstruation experience or help with cramping.  They can be very beneficial for a lot of women.  However, there are effects that happen with every person that takes these medications.  It is a fact that in all women, CHC’s reduce the ovaries’ production of estrogen and testosterone.  It is a fact that in all women, CHC’s increase a protein from the liver called sex-hormone binding globulin (SHBG).  A drop in estrogen and testosterone and an increase in SHBG will actually create an environment ripe for several symptoms, one of which is painful sex.  Not all women experience symptoms from having CHC’s, but they do all experience changes in sex hormones. Sometimes this is reversed when getting off the CHC’s, but sometimes it is not.  That is why I always ask about any history of birth control use.  Even if birth control is used for six months, it still makes changes in the sex hormones.  I do understand that not all birth control involves a CHC.  “Pulling out” is a form of birth control.  Using a condom is a form of birth control.  Not having sex is a form of birth control (am I right or am I right?).

Spironolactone

This is typically prescribed for acne or excessive facial hair.  And it affects the sex hormones.  Again, not all people who use Spironolactone end up with symptoms of painful sex or other vulvovaginal issues, but there is a relationship.

 Endometriosis

It is extremely common to get a prescription for CHC’s in order to reduce the discomfort of endometriosis.  However, it is not lost on me that endometriosis and Interstitial Cystitis are called “The Evil Twins” in much of literature.  I’m highly suspicious that the CHC’s used to help the experience of endometriosis actually help cause Interstitial Cystitis symptoms because of the way they affect sex hormones and SHBG.  When you alter sex hormones directly or indirectly, it is not uncommon to develop bladder symptoms.  This can be confusing because patients usually think that their newfound bladder issues have nothing to do with any other symptoms they have.  Patients start to think they are just falling apart.  But, they are not falling apart.  They are actually wholly making sense. 

Hysterectomy

Without a doubt, removal of the uterus affects the function of the sex hormones, regardless of whether or not the ovaries are intact.  If the one or both ovaries are intact, the blood supply to the ovaries is diminished with removal of the uterus.  This ends up affecting estrogen and testosterone production from the ovaries.  With less blood supply, there is less output.  So many doctors tell patients that removing the uterus, but leaving in the ovaries doesn’t affect hormones, but it absolutely does.  

 Breastfeeding

It’s extremely common for sex to feel drier and less comfortable after childbirth.  One part of this picture is actually from the hormone changes that take place during lactation.  Lactating does cause a drop in sex hormones at the genitals.  It can take a while for sex hormones to level off after stopping breastfeeding. 

Learning to Stop Anticipating Pain

If you’ve been stressed for a long time, you’ve had a rough month, semester, year or if you’ve had a rough marriage or childhood, your pelvic floor muscles will stay in a chronic state of tension.  Without getting treatment of some sort for this, the muscles will likely stay this way.  Having sex with a pelvic floor that is always tight can make sex uncomfortable.  When sex is consistently uncomfortable, then the anticipation that sex will be uncomfortable will feed into this mental loop.  Then you are stuck in a pattern of A) I’m not really enjoying sex  B) I should probably have sex to maintain this relationship/please my partner/out of obligation/etc. C) Penetration is about to happen and I know this is going to hurt E) The anticipation of the pain causes an additional reflexive tightening of the pelvic floor muscles F) Sex hurts again.  This cycle can be broken.  But, your brain has to be part of the process of unwinding the pelvic floor muscles.   

One of the biggest exercises to get out of this catch-22 uses a dilator.  This is a long tube shaped item of varying materials with varying girths.  Some are bendable, some are hard.  The girth is what matters the most because girth is the issue that can cause the most discomfort with penetration. 

Dilators have a really bad wrap.  When people tell me they’ve used a dilator before it makes me want to roll my eyes.  Rarely do I think dilators are used correctly.  95% of the time, dilators have one roll for me.  And that role focuses on the brain.

 My personal story is that I got married when I was 22.  I was a virgin.  I had sex and it hurt.  It hurt way more than I thought it would.  It hurt more than my friends say it did.  It hurt more than fiction and non-fiction said it would.  It hurt more than it should have.  Now, I was definitely dreading sex.  At my wedding friends came up and said “You are going to have sex tonight!”.  I was not looking forward to it.  I anticipated the socially acceptable amount of pain that apparently most women experience the first time they have sex and I was nervous about it.  My anticipation was not only met, but exceeded.  Yes, the first time I had sex it certainly exceeded my expectations with life-altering and mind-numbing pain.  Allow me to get graphic.  I bled.  I bled everywhere.  The next day I got on a 10-hour plane ride to Hawaii.  I bled on the plane.  Sitting was painful.  I bled all over Hawaii.  I wasn’t comfortable going in the ocean because I was bleeding.  I couldn’t have sex on my honeymoon because of the pain and the blood.  I bled for seven full days.  My first time having sex wasn’t beautiful.  It was traumatic, painful, unexpected and I never wanted to repeat that process again. 

Then real married life began.  I moved to a new city away from friends and family.  I attempted sex a few more times, but the experience was still really difficult for me.  When I got to the gynecologist’s office to figure out why I was hurting so much with sex, he did an exam.  He was an Asian man of about 45 (at that time, more than twice my age).  After his exam he looked up at me and said “There is nothing wrong with you.  There is plenty of space for a penis.  If you want to keep that ring on your finger, I suggest you try to put this dilator in every day.  I have no doubts you can get this whole thing in.”  The dilator was massive.

Yeah, he was callous.  But, he did have dilators in his office which looking back, is pretty unique. 

Every day at four I would turn on Oprah (I still love Oprah – get over it) and lie on the ground to insert the dilator.  It felt like a big, slow stretch, deep inside.  A weird feeling.  An unnerving sensation, but not painful.  Mind you, I didn’t really have a relationship with my genitals at that time.  I grew up being told not to have sex before marriage and not to use a tampon because it would mean I was no longer a virgin.  I first used a tampon at the age of 20 (and didn’t know I could urinate with a tampon in).  So, this sensation of a slow stretch in my vagina was weird.

Guess what.  Sex still hurt.  It hurt a lot.  We weren’t even technically to have penetration – there was too much pain.  And…I didn’t keep that ring on my finger.  But, that wasn’t because of the sex or lack thereof.

Enough about me, let’s talk about how dilators should be used.  They should be used with guidance, with strict rules and with results.  I am extremely firm about how I issue a dilator program.  Sometimes the first “dilator” I issue is just a long-stemmed q-tip.  I never hand someone a massive dilator and say “get this in”.  I know that it will never translate to enjoyable sex. 

Rule One: Start with a very doable girth.  If you are already having truly penetrative sex then I usually go with a dilator size that is considerably smaller than their partner’s size.  I start with a size that isn’t intimidating to the naked eye.  What we are trying to do is build confidence and calm and success. 

Rule Two: Use lubrication.  Use a lubrication that doesn’t cause irritation.  I typically recommend using coconut oil because it is anti-microbial, gets the job done great and it is easy to purchase. 

Rule Three: Make sure that you are in a comfortable location without worry of someone walking in.  Make sure that you are mentally relaxed.  Make sure that you are not sexually aroused.  This one is really important.  It might seem that the process of using a dilator may be easier if you are aroused, but the reality is that this would completely defeat the point.  The dilator program is the work.  This is the work that re-trains your brain that vaginal penetration does not equate to discomfort.  If you can experience that inserting a dilator when you are not aroused is completely manageable and doesn’t solicit discomfort, then when you are sexually aroused you will have even that much more confidence that the experience will be enjoyable and not painful.  The dilator program is a rehabilitation program, not a sexual activity.  It is a rehabilitation program for improving later sexual activity. 

Rule Four: If discomfort is quantified on a scale of 0 through 10, then 0 would mean no discomfort and 10 would mean that you would go to the hospital.  Never allow this discomfort to go beyond a 2 out of 10.  Once discomfort exceeds a 2, then you must not move the dilator anymore.  Keep the dilator exactly where it is and start doing diaphragmatic breathing and relax your anus.  2 is the magic number. 

Rule Five: Ten minutes, three times a week.  Use of your dilator from beginning to end should not take more than ten minutes and it is very successful when done three times a week.  While there may be some research that suggests using the dilator for much longer than this and using it every day, the reality is that research doesn’t always sit nicely in real life.  If doing the dilator program takes longer than ten minutes and you have to do it every day, it is much more likely that you will not regularly do your dilator program.  Carving out ten minutes is achievable three times a week.  Carving out 30 minutes every day is not.  Using the dilator doesn’t just require that you insert the dilator, it requires that you find the time to be alone without children screaming in the background, without feeling rushed because you have to start cooking a meal, without worry that someone is about to walk in. 

That leaves us with 2: 10: 3

Never more than 2 discomfort, never more than 10 minutes a day and never more than 3 times a week.

Was that a long prologue to the whole program?  Maybe.  But, if you don’t understand the background of the program, it won’t be nearly as effective.

Painful Sex

There are lots of reasons why sex can hurt.  There are lots of different times in your life that sex can hurt. 

 Sex can hurt because:

1.     You don’t actually want to have sex

2.     You are stressed

3.     Your pelvic floor is too tight

4.     You are constipated

5.     You are going through hormonal changes

6.     You have allergic reactions to products

7.     You need to use lubrication

8.     You have an infection

9.     You are too clean

10.  You are getting on your own nerves

1. You don’t actually want to have 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. 

2.  You are stressed: Your brain is so intimately involved with the functions of your body and sex is no exception.  When you are stressed out, so many things happen.  Your stress hormone levels change.  Your blood pressure changes.  Your muscles tense.  Many people are familiar with how stress creates tension in the neck and can contribute to headaches.  Well, the same thing goes for the vagina and the rectum.  It’s true. 

When you experience a heightened state of stress, fear, anxiety, anticipation of something unlike (like pain), your pelvic floor muscles in the vagina and rectal area will become tense.  This means they become a little tighter.  They become a little shorter.  When they should be relaxed and at a normal length, they are not.  They stay a little contracted.  So when something penetrates the vaginal canal, it is not very comfortable.  The shortened length of the vaginal canal makes insertion a little less comfortable (or altogether uncomfortable) and the movement of thrusting in the vaginal canal can feel more like friction than pleasure. 

 3.  Your pelvic floor is too tight: If you’ve been stressed for a long time, you’ve had a rough month, semester, year or if you’ve had a rough marriage or childhood, your pelvic floor muscles will stay in a chronic state of tension.  Without getting treatment of some sort for this, the muscles will likely stay this way.  Having sex with a pelvic floor that is always tight can make sex uncomfortable.  When sex is consistently uncomfortable, then the anticipation that sex will be uncomfortable will feed into this mental loop.  Then you are stuck in a pattern of A) I’m not really enjoying sex  B) I should probably have sex to maintain this relationship/please my partner/out of obligation/etc. C) Penetration is about to happen and I know this is going to hurt E) The anticipation of the pain causes an additional reflexive tightening of the pelvic floor muscles F) Sex hurts again.  This cycle can be broken. But, your brain has to be part of the process of unwinding the pelvic floor muscles. 

4.  Constipation: There is only so much space in your pelvic cavity.  If you are constipated, then you probably have some stool in the rectum.  The rectum sits just behind the vaginal canal.  If you place a finger in the vagina and push that finger towards the direction of the buttocks, then you are pressing on the rectum.  Now imagine the rectum isn’t quite collapsed, but instead has stool in it.  Then that stool is kind of collapsing the vagina a little.  There is limited space here so if something is going to penetrate the vaginal canal, it’s a whole lot more comfortable if there isn’t something already in the rectum. 

 5.  Hormonal Changes: Sex hormones play a huge role in the sexual experience.  Estrogen and testosterone are the primary sex hormones.  These levels change in the body during different parts of the reproductive cycle each month and throughout the life span.  They also change during pregnancy and with lactation.  This means that the sexual experience will change too.  Some people experience more pleasurable sex during certain stages of pregnancy.  Some people experience more discomfort with during and just after lactation.  Some people experience discomfort with sex because of medications that have affected sex hormones. Some people experience more discomfort just before, during and after menopause.  Not only can these hormonal changes affect the sexual experience, but they can cause a lot of seemingly unrelated issues like urinary leakage, symptoms of urinary tract infections and the need to urinate intensely or really often.

 6.  Allergies: If your body is allergic to certain products you use, materials in your clothes or foods that you eat, you will release mast cells and histamine. These create inflammation in your body.  You may notice a rash or bumps on your skin or watery eyes or swelling.  What you typically do not notice, however, is what happens to your genitals.  There is a part of the vulva that is very sensitive to inflammation.  This is called your vestibule.  Inflammation at this tissue can look like redness, but sometimes it looks like nothing at all.  Instead, you feel symptoms.  One of these symptoms can be discomfort with sex. 

 7.  Lubrication: Lubrication is just going to make the sexual experience more comfortable and for some, more satisfying.  The use of lubrication has nothing to do with your interest in your partner or your partner’s ability to perform sexually.  It has nothing to do with pride or shame.  It has everything to do with common sense.  Using the right lubrication will always enhance the vaginal penetration experience.  Period.  But, you read that right.  The right lubrication is key. 

 8.  Infections: Most of the time a urinary infection or a vaginal infection is pretty symptomatic.  You know you have an infection or you are at least suspicious that you have one.  But, sometimes it’s not so obvious.  Some people don’t know they have an infection until they start to really aggravate the urinary or vaginal tissues with pressure and friction, ie. penetration.  Inflamed tissue does not like this pressure and friction and at this point it is reasonable to be suspicious of a possible infection.  However, self-diagnosing and self-treating an infection isn’t a good idea.  You can actually make your symptoms feel worse or you can make them last longer if you try to medicate yourself without knowing exactly what is going on.  The same thing goes for seeing a doctor.  If they are treating you based on what you tell them, it would be wise to ask for actual testing to make sure that you are being treated for an infection that you actually have.

 9.  You are too clean: A lot of people use soap to clean their genitals.  In general, we think of the vulva as a potentially smelly place.  We think that smelly places like the armpit and the foot need to be washed so they smell less, right?  So, why wouldn’t the same apply to the vulva?  Or…to the vagina?  It’s because your vulvovaginal area was made pretty efficiently.  For many, issues actually start because you are using soap.  Soap – even the kind marketed to women – actually gets rid of everything.  There is good bacteria in the vulva and inside the vagina that needs to stay around.  Soap gets rid of this.  Without the good bacteria, you cannot actually fight off infection well.  Additionally, you get rid of food for some of the sex hormones that you need in this tissue.  So, you are actually far more likely to develop genital order when you use soap!  Odor could be the least of your worries because using soap makes you much more vulnerable to infections, tissue damage and pain with sex.

 10.  You are getting on your own nerves: One of the coolest nerves in the body is located really close to the vagina.  This nerve has three jobs.  This is the only nerve in the body with three jobs.  This nerve is the pudendal nerve and it is responsible for what your genitals feel, what your genitals do and your ability to control the muscles at the genitals. When this muscle gets injured, it gets angry.  When it gets angry, it starts to talk.  The “talk” can feel like so many things because this nerve is responsible for so many things.  The pudendal nerve can get irritated from a trauma like an accident or surgery.  It can also get irritated from the muscles surrounding it being too tight for too long.  It’s like if I’m the owner of a cat shop and I decide what music is played in the shop, what the cats get fed and whether or not they get their claws filed.  If I’m super irritated because the building owner wants to raise the rent, I’m really going to be feeling the pressure and make some odd choices under the stress.  In this state, I’m going to not operate normally.  I’m going to probably play really loud ‘80’s hair rock, I’ll feed the cats only brussels sprouts and everyone that picks up a cat will get scratched.  When you walk into my cat shop, if the music doesn’t kill you, the noxious brussels sprout cat farts and the shredding of your arms will.  My once successful cat shop will no longer be the pride and joy of Main street. This is what happens with the pudendal nerve and your genitals.  Crazy stuff can happen and none of it has to make sense. So, when you go to the doctor reporting that your genitals have gone awry, your doctor typically doesn’t know what to make of it. They look at you as if you really did let loose a brussels sprout fart…in their exam room. 

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.