I am a regular reader of your column and my wife and I have a problem I hope you can give some advice on.

From the birth of our daughter, my wife ended up with a pelvic floor injury. Since then, she saw various specialists that performed internal massages, she had surgery, E-stim, googled and searched all over the internet for solutions, and was shown various methods to relieve the pain but nothing seems to help. Generally when she has her period she is in so much pain that she is up all night. I'm not trying to sound gross but her sphincter muscles constrict so tight that she cannot go to the bathroom and she is in pain to the point where she can't sleep.

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In addition to this affecting her, it greatly affects us, me, and our sex life. This has been going on for seven years and we feel like there are no options for her. I am hoping that with your worldly knowledge you can point us in the right direction. We want to resolve her problem and get back on track to a fun filled life that once again includes mind-blowing sex. Any help that you can offer is greatly appreciated.

Basically Off Balance


My response after the jump...

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My worldly knowledge of pelvic-floor injury and vaginal pain is pretty limited, BOB. Two bottoms wondering how to make their relationship work? That question I can field on my own. But your question—and your poor wife's medical issues—are above my pay grade. So I passed your letter along to Dr. Lori Brotto, a clinical psychologist and a sex researcher at the University of British Columbia in Vancouver. (Dr. Brotto was also a guest on the live taping of the "Savage Lovecast" in Vancouver last month.)

Dr. Brotto founded the first clinic in North America dedicated to treating genital pain in women. You can read about Dr. Brotto's clinic here. You can follow Dr. Brotto on twitter @DrLoriBrotto. You can volunteer to take part in her studies here. You can hear her chat about cultivating sexual satisfaction here.

And here's Dr. Brotto's advice for you, BOB...

Dear BOB,

As you know, the pelvic floor is a collection of muscles that support the bowels, the bladder, and neighboring organs, and is important for preventing urinary incontinence (leakage of urine or feeling an uncontrollable urgency to urinate), fecal incontinence (like urinary but regarding fecal material), and pelvic organ prolapse (when pelvic organs such as the bladder, bowel, uterus, etc.) droop down into the vagina or rectum. It is well known that pelvic floor disorders (including the ones listed above) are more common among women who have delivered at least one child than women who have not, and the risk increases with each successive pregnancy. You don't mention the mode of delivery for your daughter, but vaginal operative procedures, like the use of forceps during delivery, significantly increase the risk of these and other pelvic floor problems. Even in the case of a cesarean section if the woman has not labored, pregnancy itself can place an enormous strain on the pelvic floor muscles and lead to pelvic floor injury.

Your wife has seen a number of specialists and tried many different treatments with no improvement in her pain (I’m going to say more about the pain in a moment). It is not clear what type of surgery she has had. If her surgery was to repair the pelvic floor muscles because of incontinence, we know that this procedure may improve the leaking of urine or feces but may not improve pain. If she has not already seen a urogynaecologist (a gynaecologist who has received extra training and expertise in the pelvic floor muscles), I strongly suggest that you ask for a referral to one. The International Urogynecological Association (http://www.iuga.org) keeps a list of all these specialists by country. Surgery is only one of their tools; they also provide education that itself can be therapeutic.

E-stim (electrical stimulation of the pelvic floor), which your wife also received, is typically done by a pelvic floor physiotherapist—this provider plays a crucial role in the recovery of individuals with pelvic floor injury or dysfunction. (For readers, don't see the physiotherapist who is treating you for your pulled hamstring. Pelvic floor physiotherapists have received specialized training in rehabilitating the pelvic floor and their work involves “hands on” exercises with the muscles of the vagina and anus). After consulting with local pelvic floor physiotherapy experts in Vancouver, I was informed that E-stim tends to be effective for grade 1 muscle contraction to improve strength, but it is not likely to help in your wife’s situation. That said, there are other methods used by pelvic floor physiotherapists that can improve symptoms of pelvic floor dysfunction, including pain. A sizable part of their work involves teaching women how to gain control over their pelvic floor: to relax it when it is overly tense, and to tense it when needed to prevent incontinence!

Now what about the pain itself? Pain at or near the entrance to the vagina is known as vulvodynia—a chronic pain condition that affects about 15% of women. Women with vulvodynia will say that intercourse or other types of vaginal penetration will feel as if there are tiny cuts at the opening of the vagina, and it has a stinging, cutting, and burning quality. Pelvic floor dysfunction is a major contributor to vaginal pain, and pelvic floor physiotherapy can reduce vaginal pain significantly, though it is not a perfect cure for all women. If the pain is felt further down the reproductive tract, it may be felt deeper, or internally. Deep penetration can trigger this type of chronic pelvic pain. Women with dysmenorrhea, or painful periods, can have a spike in their vaginal and/or pelvic pain given the interconnections of the organs and nerves in the area.

After seven years of this pain, your wife is now experiencing a chronic pain condition. What that means is that what originally triggered the pain (pelvic floor damage, possibly even the surgery scar) may not be what is maintaining the pain. This has two important consequences: (1) the “injury site” may have totally healed, even though pain might be felt in that area. Trying to improve the pain by focusing only on the injury site will only provide limited relief, and (2) in addition to the nerves at the injury site being affected, the pain centers in the brain are likely involved. This is a process called “central sensitization” whereby pain nerves in the brain become much more sensitive to any type of touch such that a less intense touch is sufficient to trigger a sensation in the brain, and a touch sensation can be misperceived as pain. Or as my colleague Marcy Dayan puts it (www.dayanphysio.com), it’s like your home alarm going off when the cat walks across the floor at night instead of when a burglar breaks in. In many chronic pain conditions, including vulvovaginal and chronic pelvic pain, there is strong evidence for central sensitization, or changes in brain nerve cells.

Continuing to look for tissue damage and treat the “local” area will not be very effective at this point, seven years later. There is very good evidence that working with a behavioral pain specialist (imagine a psychologist with expertise in managing pain) can be critical to management and recovery from chronic pain, including vulvodynia. Even though the pain was not triggered by psychological factors (though you do not mention this, either way), pain-management psychologists can teach women skills in tracking and understanding the triggers and reducers of pain, examining the (strong) impact of mood and thoughts on pain, teach skills in challenging irrational pain-related thoughts, and also in mindfulness meditation skills, which can potently affect how we anticipate and therefore experience pain.

An excellent book that discusses some of these mechanisms is “A Headache in the Pelvis” by David Wise. You can also read Marcy Dayan’s website for valuable pelvic floor physiotherapy education at www.dayanphysio.com.

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Now what about your sex life? You don't ask for advice here, but I’m going to give you some, based on the countless couples I’ve seen who can relate entirely to your situation. When sex hurts, you should stop. That seems like obvious advice, but I’ve seen many couples who barrel through excruciating pain because they think that any sex, including painfully torturous sex, is better than no sex. This is a myth. Pain can actually contribute to ongoing changes in the local nerves to make the area more and more sensitive to pain. I do encourage the two of you to resume (or discover!) any kind of sexual activity that is not painful or minimally painful. Other women with similar pains to your wife’s will often say that oral sex, manual (non-vaginal) stimulation, and masturbation can be pain-free activities. For some women, anal sex is also an option for pain-free pleasure. If you can, enlist the help of a local, qualified sex therapist to guide you in the right direction, address and dispel your anxieties, and provide support and education. Instead of striving for "mind-blowing sex,” strive for pleasurable, pain-free sexual activity that helps her to feel comfortable, safe, and "in the moment."

Good luck!

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