After posting my first two blogs How'd I End Up Here? and How'd I End Up Here Part 2, I now see how important it is to connect to community through story. My story spurred not only an outpouring of support for me and my journey, but it empowered others to share their stories with me. It provided a safe space for people to identify and openly discuss a variety of "pelvic floor secrets" with me and it created a container for many of these stories to be heard for the first time.
This is powerful stuff so I'm going to keep rolling with it... this week I'll share one of my favorite case study stories. This patient is one of the first patients whom I purposefully treated with a more holistic/integrative approach- incorporating manual therapy, mediation/yoga, and lifestyle management education. It's a perfect example of the power of the mind-body connection especially related to pelvic pain.
Let's jump into Amy's story... this will be another 2 part blog. The content will be a bit more clinical than what you might have read previously, however Part I will be a peek into what my evaluation and treatment techniques consist of. Part II will discuss the mind/body interventions in more depth so keep reading!
- Amy was a 37 year old woman who presented to pelvic floor PT with a 2 year history of pelvic pain and gastrointestinal (GI) problems. Her chief complaints at evaluation were:
- Vaginal and vulvar soreness with tightness and sensitivity around her pubic bone.
- Deep pelvic ache up to 9 out of 10, could radiate to her lower extremities.
- Sensation of arousal with increased pain and sensitivity around her vulva.
Amy reported an onset of digestive problems that began two years prior to our evaluation, after spending two years traveling as a musician with a grueling schedule. Her initial symptoms were severe bloating and GI related pain related to small intestinal bacterial overgrowth (SIBO). She reported high levels of stress around this time including a death in the family and a transition in her career. Amy's vulvar pain started one year after the onset of her GI symptoms with pain she identified like a yeast infection. Amy reported vaginal soreness, pubic bone sensitivity, low abdominal/bladder pain, and vaginal discharge. By the time she found my office she had worked extensively with a nutritionist which had eliminated most of her GI symptoms, but had done very little to change her pelvic/vulvar symptoms. Triggers for Amy's pain included heavy meals and decreased sleep (she reported a long history of insomnia which she believed influenced her pain). Her symptoms worsened at night and the week after her menstrual cycle. At our evaluation Amy reported functional limitations including:
- Constant daily pain which could feel stimulating and embarrassing.
- Avoiding intercourse due to fear of pain.
- Limiting full meals due to triggering pain.
- Amy's goal for physical therapy was to eliminate her pain.
After listening to Amy's story I performed the objective portion of the evaluation. Here were my tests, the rationale for these assessments, and what my actual findings were. (This section may be most useful for clinicians given the “PT jargon”, but could be helpful for patients when discussing their own PT’s findings).
Connective Tissue Mobility- I hypothesized significant restrictions throughout her abdomen and suprapubic region due to her GI history and the viscero-somatic reflexes often present with prolonged infection. I wanted to note areas of fascial restrictions and potentially decreased blood flow which could potentially contribute to her pain. I found:
- Severe restrictions in her bony pelvis region anteriorly and posteriorly. Moderate restrictions in her anterior thighs, medial thighs, abdomen and suprapubic regions.
- I concluded that impairments in her connective tissue were contributing to her constant bladder/pelvic pressure. Restrictions in her bony pelvis region and lower extremities were likely contributing to compression of the pudendal nerve branches and causing a sense of arousal.
Myofascial Trigger Points- I suspected trigger points in her abdomen due GI history (with episodes of straining, severe diarrhea, heaving etc). I also suspected internal trigger points causing her deep vaginal pain. I found:
- Adductors, rectus abdominis, and pelvic floor trigger points (right levator ani, right obturator internus, right bulbocavernosus/ transverse perineal muscles).
- General hypertonus was also present throughout her pelvic floor.
- I concluded that these trigger points were likely culprits for her pelvic, vaginal, and radiating lower body pain.
Nerve Sensitivity- Due to Amy's arousal symptoms I suspected anterior pudendal nerve branch sensitivity, however no specific nerve sensitivity was detected.
Skin Integrity- I wanted to examine Amy's vulvar tissue for bulk, erythema, or signs of infection, inflammation, or de-estrogenized tissue. I found:
- Thin and pale intra-labial and vestibular tissue.
- I suspected chronic decreased blood flow associated with connective tissue impairments and/or hormonal changes could be the cause of her thin and pale tissue.
Motor Control- I suspected guarding and difficulty with full pelvic floor mobility given her pain complaints and GI history. I was most interested in the ability for her to be able to "drop" and lengthen her pelvic floor. I surprisingly found:
- Good pelvic floor motor control with 100% normal range of motion.
- Amy’s good pelvic floor control was a good prognostic sign in that she could purposefully relax her pelvic floor throughout her day to help manage pain.
I let you all ponder Amy's story and my objective assessment for now. Perhaps you identify with her story in some way or maybe you've seen patients just like her and are now thinking about different ways to evaluate someone like this? Next week I will reveal my full assessment, our treatment plan including mind/body therapies, and our outcomes... stay tuned!