Hannah
Hannah is a lovely 23 year old female referred to physical therapy with a diagnosis of pelvic floor muscle dysfunction and vestibulodynia, bilateral hip pain, and clitoral pain. Her past medical history includes fatigue, seasonal allergies, nosebleeds, chronic migraines, sciatica, and a hernia repair (age 5). She is married to a supportive spouse and they had recently moved to NYC from Israel. Her medications included topical estrace cream, vitamin D and B12, and medication for her migraines. She has a history of severe constipation, evacuating only twice weekly (normal is 1 – 2 bowel movements per day!). Hannah also emptied her bladder every 5 hours daily whereas the normal rate is emptying every 2 – 4 hours. So, she was chronically clenching her pelvic floor muscles causing extreme hypertonicity (shortening).
After Hannah married in June 2009, her first sexual intercourse experience with her husband was unsuccessful and resulted in severe pain and feeling itchy. She called her gynecologist who prescribed an antifungal cream to be used topically on the vulva and intravaginally. She returned to the gynecologist one week later due to no improvements. She was seen by a physical therapist in Israel only twice with some relief yet pain returned three months after. Trial of intercourse was painful again. Hannah also complained of hip pain on both sides with walking and constant clitoral pain. We had a lot of areas to address!
The orthopedic evaluation revealed impaired spinal mobility with lumbar facet joint irritation at L4 – 5 on the right, impaired flexibility bilateral lower quarter, weakness bilateral hip rotation movements, sciatic neural tension on both sides with positive SLR testing right side only. Hannah tested positive for hip joint arthritis yet x-rays were not performed yet. She had visceral mobility restrictions of the pelvic girdle and B SI joint pain.
The pelvic exam revealed clitoral phimosis Grade I with poor hygiene (smegma under the prepuce due to not cleaning properly), moderate pelvic floor muscle pain left side more than right, and when her rectum was palpated it reproduced her tailbone pain. Touching her bladder and urethra referred pain to her clitoris. She has what is known as “organ cross talk” (when the nerves of one organ cross paths with the nerves of adjacent organs and can mix up pain signals). Hannah tested positive for localized provoked vestibulodynia and demonstrated weakness in her pelvic floor muscles.
After the evaluation, I recommended Hannah see an orthopedist for further hip diagnostic tests and we implemented a bowel/bladder retraining program. She was instructed on proper clitoral/vulvar hygiene and care. Hannah was also not applying the estrace cream correctly, so we discussed this and she was to call her doctor for re-instruction. Physical therapy treatments focused on manual therapies to her pelvic girdle, hips, and pelvic floor muscles. Visceral manipulation and massage to her colon and bladder were initiated immediately. Hannah was given hip and low back exercises for homework and advised to ice her perineum daily with a gel ice pack specifically designed for the perineum. We saw an immediate change in her hip mobility and significant reduction in pain by her 4th visit. Her bowel frequency also improved to every other day yet was not everyday yet. On her 4th visit is when we learned that Hannah was 8 weeks pregnant! In fact, she had not been able to tolerate any thrusting by her partner. She had conceived with only having penetration! Her physical therapy could only be external techniques from here on.
Treatments consisted of external manual therapies to her pelvic girdle, lumbar spine, coccyx, pelvic floor muscles, hips, and sacrum. Her vestibulodynia has improved to ranging now 3 – 7/10 from 8/10 prior. She has been seen for only been seen for 6 sessions since learning of her pregnancy. Hannah reports having no hip or low back pain, and only mild intermittent tailbone pain now. Her treatment was recently complicated by onset clitoral pain which was determined to be a yeast infection under the prepuce. Topical antifungal cream prescribed by her gynecologist has provided relief.
Hannah continues with physical therapy here as our goals are to achieve pain-free tailbone and pain-free clitoris. An eventual goal at the end of her third trimester will be to prepare her pelvis for an easier birthing experience.
