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Pelvic Floor Dysfunction

Pelvic Floor Dysfunction (PFD), or vaginismus, is a common condition in IC patients. PFD causes the pelvic floor muscles to involuntarily spasm in response to an irritant. In IC patients, it seems to be the irritation in the bladder. In some IC patients it may be the irritation in both the bladder and the vulva, such as with vulvodynia. It is believed that the pelvic floor muscles of IC patients can't always contract and expand as they should during urination, elimination and sex, so they become irritated and spasm. However, doctors who specialize in PFD have different theories about the cause. Some believe that PFD can cause IC and others believe that IC can cause PFD. Some doctors believe that all IC patients have PFD, and some believe that IC and PFD are separate problems. What is agreed upon is that one condition can affect the other, and PFD can definitely cause terrible IC symptoms.

A few weeks ago I interviewed Betty Sound, a physical therapist who specializes in pelvic floor therapy at Touro Hospital in New Orleans. She was very compassionate about her work and I was touched by her concern. Although Betty hasn't had much experience with IC patients, she has worked with a number of vulvodynia patients, as well as patients with incontinence and painful sex. She does not use electrical stimulation therapy (EST) on patients with pain. Instead, she teaches female patients how to self-massage the tight areas in their vaginas by applying gentle pressure with their fingertips.

I decided to ask Jill Osborne (your IC network creator) about pelvic floor therapy. From our conversation, I got the impression that EST helps some IC patients, but it is not always the best therapy for every patient. I know that EST is not the right therapy for me.

When we moved back to New Orleans six years ago I went into a terrible bladder flare-up. Each morning, after I'd drink my dark roast coffee and eat my breakfast, I would experience horrible "make me cry" pain. (The pain in my bladder later subsided when I switched brands of local bottled water.) So, I called the urologist, who originally diagnosed me, to set up an appointment for a DMSO treatment. DMSO has always helped, but this time it didn't. My urologist suggested that I go to a clinic for pelvic floor treatment.

The doctor at the clinic examined me first to confirm a diagnosis of abnormal contraction of the pelvic floor. During the pelvic exam he palpated point tenderness, which are areas of tenderness referred to as "trigger points." (He would have palpated these points in the rectum in a male.) When he palpated my very tight, weak and sensitive pubococcygeal (PC) muscles I almost kicked him. I felt referred pain in my bladder, hips, low back and legs. The pain in one of my hips lasted about two weeks. (I had actually experienced the same lingering hip pain after trying a treadmill for about 10 seconds.) Since I still needed to get rid of my bladder flare-up, I followed his prescription for pelvic floor therapy.

During my therapy session the nurse had me insert and hold a probe in my vagina. The probe, which was four inches long and about three and a half inches in diameter, was hooked up to a biofeedback machine. The nurse asked me to let her know if I felt uncomfortable with the amount of electrical stimulation being used. I didn't feel discomfort at all, until after the session.

On the way to my car I became very nauseated. After I began driving, I started experiencing pelvic floor spasms. When I called the nurse to tell her why I would not be returning for more treatments, she told me that she had never heard of such a thing. Then, when I returned to my urologist for another DMSO treatment she left my records in the room while I was holding in the DMSO. I decided to take a peak because I knew that she wouldn't mind. She had written that the probe was too long for me. Well, I certainly never felt nauseated after sex, and the probe wasn't that big!

I decided that my uncomfortable symptoms were from the muscle stimulation, which makes a lot of sense to me. As with the other muscles of the body, it is best to stretch, lengthen and relax weak and tight pelvic floor muscles before strengthening them. Once again, I had to learn through "trial by error."

According to Jerome Weiss MD, biofeedback will not get rid of tender points. Dr. Weiss said in his 1999 ICN Chat Transcript that biofeedback lowers muscle tension but "it would be very difficult for it to lower muscle tension where trigger points remain." He believes that biofeedback works better when the trigger points are gone. The following illustrations depict trigger points in the pelvic floor, hips and buttocks, as well as the areas of referred pain caused by these trigger points.

GRAPHIC OF PELVIC FLOOR AND REFERRED PAIN

The muscles of the pelvic floor support and raise the pelvic organs. The trigger points in the pelvic floor are in the sphincter ani, levator ani and coccygeus muscles. The sphincter ani surrounds the margin of the anus. The levator ani's contraction increases intraabdominal and pelvic pressure for defecating and straining in general. The coccygeus muscle is attached to the coccyx (the tail bone). It relates to the levator ani and the piriformis muscle (see the illustration of the piriformis).

GRAPHIC OF PIRIFORMIS

The muscles of the pelvis are made of two groups, the pelvic floor muscles and the hip-joint muscles. The piriformis muscle, which is located partly in the pelvis and partly at the back of the hip joint, is a hip rotator muscle as well as a support muscle of the pelvic floor. The piriformis is under the gluteus (buttock), and attaches the lower part of the sacrum (the triangular composite bone in the back of the pelvis) to the great trochanter (the top of the thigh). The graphic below of the piriformis illustrates the location, trigger points, and areas of referred pain. (Stars or X's represent the trigger points. The shaded areas represent the referred pain caused by the trigger points.)

GRAPHIC OF OBURATOR INTERNUS

The piriformis often blends with the tendon of the oburator internus muscle. The oburator internus, like the piriformis muscle is a hip rotator located partly in the pelvis and partly at the back of the hip joint. It is attached to the ramus (see the illustration of the pelvic floor for location of the ramus). The anatomical graphic below illustrates the inside of the pelvic girdle at a three quarter front view. Locate the thigh bones and spine to understand the illustration. Refer to the trigger points and affected areas.

GRAPHIC OF THE GLUTEUS MEDIUS

The muscles of the buttocks work the hip joint. The gluteus medius is an important hip stabilizer, as well as a postural muscle. This muscle keeps the hips stable while walking and running. The gluteus medius is partly covered by the large buttock's muscle, the gluteus maximus. Refer to the following illustration to understand this muscle's role in pain.

GRAPHIC OF GLUTEUS MAXIMUS

The gluteus maximus is a large buttocks muscle that relates to many of the joints and muscles of the pelvis, including the ilium, sacrum, coccyx, ischial tuberosity (sitz bone), great trochanter (top of the thigh bone), the hip rotators mentioned above, as well as some of the muscles of the thigh. The gluteus maximus assists the trunk in an erect posture. It's function helps mostly with running and climbing.

GRAPHIC OF ILIOSPOAS MUSCLE

The psoas muscle runs from the 12th rib (the last rib) down along the lumbar spine to the sacroiliac joint (sometimes including the sacrum and buttock). It then follows the border of the pelvic brim and attaches to the front of the hip joint. The psoas tendon attaches to the pubic bone. The psoas muscle is a powerful hip flexor and postural muscle that assists the body when rising to a sitting position from a lying position.

Our next column will cover the therapy to treat trigger points and areas of referred pain.