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.