Too much of a good thing
With all of the focus on strengthening the pelvic floor, there seems to be a silent epidemic of inflexibly tight pelvic floor muscles. You’ll see advice (which I don’t agree with) to ”do 100 kegels in the car on the way to work”, but with no relaxation component. Active relaxation is as important as muscle strengthening. Tight or spasmed pelvic floor muscles are as dysfunctional as weak pelvic floor muscles, and can be lead to intense pain during vaginal penetration, orgasm and even difficulty with comfortable bowel movements. Some women who spend a great deal of effort strengthening their “core muscles” through gymnastics, dance, pilates, or other athletic pursuits create a very strong and dysfunctional pelvic floor.
This is not the same as Vaginismus. Vaginismus is a sexual disorder that is characterized by the pelvic floor muscles tightening involuntarily, often painfully. However, to be diagnosed as Vaginismus, the guarding muscle conditioned response must be due to psychological factors or a combination of psychological and medical factors, but not to medical factors alone.
In contrast, high-tone pelvic floor muscle dysfunction is a physical muscle dysfunction related to chronic muscle strain, misguided training practices, or as a consequence of pelvic floor muscle trauma from surgery, sexual activity, or chronic muscle stress. While there could be overlap in some situations, features of high-tone dysfunction (trigger points on muscle bodies) are often not present in Vaginismus, where muscles are functioning normally except with certain situational cues (attempted sexual intercourse).
High-tone pelvic floor muscle (PFM) dysfunction
Strength does not equal function. Pelvic floor muscles (PFMs) function best when they are both strong and flexible. Poor function occurs when one of these aspects is deficient. For example:
- When PFMs are weak and flexible, they have Low-tone dysfunction. Symptoms of low-tone are weak or absent orgasm muscle contractions, stress urine incontinence, and for some, a loosening of the ligaments which hold pelvic structures (uterus, bladder) in place, which can proceed to prolapsed organs.
- When PFMs are strong but inflexible, they have High-tone dysfunction. Symptoms of high-tone dysfunction are pain with vaginal penetration, pain with building sexual arousal or only at orgasm, and pain with bowel movements. Many other medical conditions may be mis-diagnosed as, or associated with, high-tone dysfunction (see partial diagnosis list below).
Of course, body function isn’t simple: there is a spectrum of “sort-of weak” with “sort-of inflexible”, etc.
Pelvic floor muscles that are chronically tight pull and strain against other muscle bundles and ligaments, and those bones that support them. Chronic strain can also put unrelenting pressure on nearby structures, preventing proper function and blood flow (bladder, rectum, prostate). Additionally, because the PFMs contract as a group during orgasm, both women and men can experience a building then pulsating pain sensation as the muscles strain against themselves during orgasm.
Figure 1. The muscles nearest the tail bone are most susceptible to fatigue and muscle cramps.
How do I fix High-tone dysfunction?
Before you can fix a problem, you need to be sure you know what the problem is, and that’s not always easy. There are many structures which are related to, or function with the pelvic floor muscles. This article can’t be used for diagnostic purposes for exactly this reason–you need a comprehensive physical exam, and sometimes special diagnostic tests to completely understand what is–and isn’t–involved in your pain.
To give you an idea of how many different things need to be considered, diagnoses related to and/or confused with high-tone pelvic floor muscle dysfunction are:
- Interstitial cystitis (internal inflammation of the trigone of the urinary bladder, without infection)
- Chronic urinary tract infection (infection of the urinary bladder wall)
- Chronic Prostatitis (infection and/or inflammation of the male prostate)
- Proctalgia (pain of the anus or anal canal)
- Coccygodynia (pain of the tailbone)
- Vulvodynia, not otherwise specified (pain of the vulva)
- Orgasmodynia (pain with orgasm, not otherwise specified)
- Introital dyspareunia (pain at vaginal penetration 2-3 inches in canal, cause undetermined)
- Chronic Pelvic Pain Syndrome
Bones and connective tissue of the pelvic bone
- Pudendal Nerve Entrapment (pain only with sitting, never standing, better in am)
- Piriformis Syndrome (spasm of the piriformis muscle(s)
- Sacro-iliac syndrome (loose or over-rotation of the SI bone in the pelvis)
- Obturator Internus Syndrome (spasm of the Obturator Int.)
Figure 2. View looking down on pelvic floor inside the pelvis.
My Pelvic Floor physical therapist/health care provider has diagnosed High-tone pelvic floor dysfunction.
Many people need several sessions with pelvic floor physical therapists before they can attempt any home-based therapy. It is very difficult for some people to do the initial relaxation/trigger point massage on their own. The book Headache in the Pelvis is actually a guide for the type of therapy done at Stanford, CA, not a self-help book. It is very useful in describing the scope of the problem, methods of treatment, and levels of progress, however.
Generally, the best route of action is to first gain/regain flexibility of the muscle structures, and then work on strength of the muscles. Incorrectly trying to strengthen inflexible muscle easily leads to more trouble, since the portion of muscle that is tight will pull uncomfortably against other healthy sections, possibly causing more damage and pain. Ask your pelvic floor physical therapist about which, if any, of the following exercises are right for you.
There are three main home-therapy approaches to working on the health and flexibility of the pelvic floor muscles:
- Active stretch and breathing/relaxation with external perineal pressure.
- Active trigger point pressure/release with internal vaginal or anal massage. Some people will work on #1 and #2 simultaneously.
- For those past involuntary spasm, vibration with focused mental relaxation.
External Perineal Pressure
One way to begin generalized, non-specific, pressure release of the PFMs as a whole is to apply external pressure to the perineum, while using deep internal abdominal breathing. This exercise is best done by sitting on a chair with/or without a pillow and a small ball. Use a small, soft, partially flexible ball (racquetball or tennis ball); an exercise ball is too big to provide adequate perineal pressure.
Figure 4. Cross-section of tennis ball external pressure on perineum.
The idea is to gently break the tension of the PFM group by sitting on a ball located on the perineum, while sitting on a pillow. It isn’t comfortable, but take a very deep breath, and let your belly button gently blow away from your body as you inhale. Begin with two minutes (between 15-25 gentle deep breaths), and imagine your perineum melting around the ball. If this is too painful, stop and call your PF therapist, find a softer ball or add a larger softer pillow.
Gradually work up, adding one minute to the total time, until you can sit and breathe for 10 minutes. After this, remove a pillow and shorten the time back to 2 minutes. When you can build this time, minute by minute, up to 10 minutes and have no pillows, try this same exercise sitting cross legged on the floor, and use a pillow again if you need to soften the pressure again.
This process takes months of time, but remember, it took months (or years) to develop the muscle spasm in the first place. You will notice a gradual improvement, and will notice that you are able to breathe into your abdomen more comfortably over time.
Internal Trigger Point Massage
Here you will be using gentle physical pressure to mechanically unlock the spasmed muscles. Once you’ve identified where your pelvic floor trigger points are (with your therapist), there are several tools designed specifically to allow you to apply pressure against the trigger point for 15-30 seconds, then release. You will need to experiment whether any side to side movement of the tool is beneficial (a la Thiel Massage), or whether the pressure alone without movement is sufficient. You may want to take your new tool to your next physical therapy appointment and work with your therapist to find the ideal angles. Don’t forget the lube, since you’ll need this for comfortable penetration and manipulation of the tool.
Figure 5. Using the flexibility of the vaginal wall to put pressure against a trigger point of the pelvic floor muscles.
There is no point mashing the trigger point–excessive pressure can cause more muscle trauma–so don’t be tempted to “really work it out”. Dr. Jeannette Tries in Milwaukee feels that sometimes the lightest of touches is beneficial. Healing doesn’t have to hurt.
There is no one schedule that is best for every person. Some feel that working the points (vaginally or anally or both or alternating) two times per week, 15-30 minutes per session is best, depending on the amount of work you need to do. Every day is overdoing it for almost everyone, since muscles need a chance to readjust to their new un-cramped state.
Vibration has several benefits for muscle relaxation, because it helps bring new blood to muscle, and gently disengages muscle fibers from one another. It has one major disadvantage worth remembering: if vibration (like any excessive stretch) increases the guarding reflex (light tension across the muscle intended to protect the muscle), vibration may therefore increase the involuntary spasm that some people experience.
Therefore, vibration massage of the PFMs can only be done when the person is past involuntary spasm of the muscles. It is not useful to increase the guarding reflex, since this overall tension of the PFMs will work against any relaxation techniques you try.
If you’re not sure whether you’re past the reflex spasm point (won’t let anything in), begin here:
- Choose the smallest diameter shaft-shaped vibrator that you can use. (For example, if you can comfortably insert one lubricated finger, but not two, try a one-finger sized vibe.) Some people prefer the sensation of buzzy vibration (penetrates less deeply) while others prefer the deeper relaxation of throbby vibrators (penetrates more deeply). You are the only one who can make that decision of what will feel best to you.
- Remove all batteries from the vibrator.
- Lubricate yourself (outside of vulva and vaginal entry), and the vibrator.
- Take a deep breath, and as you exhale, gently insert the vibrator into your vagina.
- Allow the vibrator to rest there, and continue breathing for 1 minute.
- Gently remove the vibrator.
If no spasm occurred, and you can increase the time to 5 minutes, then you are ready to try vibration. Go through the same procedure above, but this time turn the vibrator on after the vibrator is in place. You might notice a gentle tightening right as the vibration begins, but this is normal. Relax and breathe deep abdominal breaths. If you notice that you experience sexual arousal, this is also normal. Notice what this feels like, and work your breathing into this awareness too.
Some people let the vibration relaxation proceed for 15-30 minutes. Some people read a book, while others just concentrate on relaxing their deep pelvis. If you experience any pain, turn the vibration off, but leave the vibrator in place and refocus your relaxation/breathing to unclenching the muscles again. This is not a step backwards; the blood flow will continue to help the muscles relax as long as you maintain abdominal breathing from the inside. Just don’t continue to vibrate through pain since the pain is giving you important messages about the tension in the muscles.
It takes time
These muscle spasms didn’t develop over night, so we can take some time to undo them. Some people want them “GONE!” but that isn’t very realistic. Learning to work with your pelvic muscles as you learn to relax them during or AFTER your pilates class exercises is the key to long term health. You’ll benefit from the strength of the muscles (stronger, pleasurable orgasms) when you learn how to maintain your PFM flexibility.