Pelvic pain and pain with sexual activity is a pervasive issue that profoundly effects the lives of many males and females and can strain loving relationships and severely impair one’s self-worth as a fully functioning sexual being. Although pelvic pain and pain with sexual activity can have severe and far-reaching consequences, it rarely gets enough attention from both general clinicians as well as the public at large.

When we do think about sexual pain, our minds typically jump to infectious causes such as yeast infections, urinary tract infections, and sexually transmitted infections (STIs). While these infections certainly do contribute to pelvic pain, we often forget about the underlying joints, bones, and muscles of the pelvis as potential pain generators. Too often patients’ symptoms are written off as purely psychogenic when their lab tests and other diagnostic procedures reveal that they are free of disease, yet their sexual pain persists.

Patients whose sexual pain persists or who appear with no clear medical cause, may be suffering from pelvic floor dysfunction. Pelvic floor dysfunction can appear after an insult such as psychological stress, infection, or boney misalignment. It also can appear idiopathically or be contributed to by a chronic illness, such as endometriosis. These patients, who present with musculoskeletal dysfunction and have not found relief from their pelvic pain symptoms through traditional medical means, are perfect candidates for pelvic floor physical therapy.

Physical therapists are educated extensively on the musculoskeletal system. We often think of physical therapists as the people we see after we sprain an ankle or hurt a shoulder, but there is a small but growing cohort of physical therapists who choose to specialize in musculoskeletal dysfunctions of the pelvic floor.

A physical therapy practitioner who becomes specialized in the field of pelvic floor health has a unique ability to diagnose and treat patients whose pelvic pain stems from disorders of the pelvic floor muscles and surrounding structures. Patients who are treated by pelvic floor physical therapists are both males and females and present with a variety of subjective complaints. Males with pelvic floor dysfunction may complain of pain in their testicles, groin, tip of the penis, and abdomen. They may also complain of the inability to achieve an erection, premature ejaculation, difficulty reaching climax, and or post-ejaculatory pain. Females may complain of symptoms ranging from burning around the vulvar area, pain in the clitoris, pain deep within the vagina, and/or pain in the superficial opening of the vagina (introitus). Both malesand females who suffer from pelvic floor dysfunction may also complain of non-sexual function related symptoms, such as urinary or fecal incontinence and/or frequency, urgency, incomplete emptying, or constipation.

Pelvic floor dysfunction can be discovered by a specialized pelvic floor physical therapist or healthcare provider who performs a manual exam to test the muscles, tissues, and nerves of the pelvic floor to identify muscles that may be in spasm, tender to palpation, or too weak to support the pelvic contents. The therapist will also incorporate strength testing of the muscles of the hip and core, as well as check boney alignment and external soft tissue mobility to determine what other factors may be contributing to pain in the pelvic floor muscles.

Treatment of the pelvic floor by a physical therapist varies largely based on what he or she finds in examination. In some cases of pelvic pain, like those contributed to by a condition that causes abdominal and pelvic scarring like endometriosis, prostatectomy, and child birth (both vaginal with tearing or episiotomy and caesarian births), the goal of physical therapy may be to allow the structures of the pelvis to move more freely by using manual techniques to break down areas of restriction. By breaking down scar tissue through both internal and external massage, a physical therapist can alleviate pain by reducing the amount of tension of the sensitive structures of the abdomen and pelvis.

In both males and females, physical examination may reveal pelvic floor muscles that are overly tight or have gone into spasm. In this case, the physical therapist may choose to manually correct any boney misalignments, then stretch and massage the muscles out of spasm and tightness.

On the opposite end of the spectrum, a patient may present with loose pelvic floor muscles, which are unable to support the pelvic viscera. This lack of support may make the patient feel heaviness in and discomfort in the pelvic area, which worsens over the course of the day. In these cases, the physical therapist will guide the patient in pelvic strengthening while maintaining proper bodily alignment of the patient to ensure that the pelvic muscles are in their optimal positions to function properly.

Pelvic floor physical therapists have many tools besides manual skills at their disposal to help treat patients. For females who are experiencing painful penetration secondary to tight vaginal muscles and tissue, a physical therapist may teach the patient to use dilators or a massaging wand to stretch the vaginal tissues to allow the patient to tolerate her partner’s penis or sex toy during intercourse.

Physical therapists also use a technique called EMG-biofeedback to help patients learn how to both properly relax and contract the muscles of the pelvic floor. Patients who are experiencing pelvic floor weakness, as well as those who are experiencing pelvic floor over-activity, can benefit from biofeedback. Biofeedback works by translating the activity of the pelvic floor muscles from electrodes placed either by the rectal opening or inside the vagina or anus to a computer screen, allowing the patient to see their own pelvic floor muscle activity in real time. The physical therapist will guide the patient through relaxation and strengthening techniques allowing the patient to gain awareness of his or her pelvic floor muscles and use them in a functional way.

In extreme cases of pelvic floor weakness, such as cases caused by neurological pathology, such as multiple sclerosis, a physical therapist can use neuromuscular stimulation (NMES) to gain muscle strength. NMES works by sending electricity directly to the muscles of the pelvic floor using a set up similar to that of biofeedback. The electrical stimulation will cause the muscle fibers of the pelvic floor to contract and over time, gradually strengthen the pelvic floor to allow for greater muscle function.

The pelvis is an extremely complex area of the human body and, unfortunately, it is an area in which much can go wrong. When treating individuals who suffer from chronic pain, we must consider all of the systems of the body in our diagnosis, including the musculoskeletal system. In careful consideration of the musculoskeletal system, we can help alleviate the suffering of patients whom traditional methods have failed.