Talking to your kids about their pelvic floor

Pain persists without treatment, so be proactive

Around six years ago, I was working in a hospital based outpatient physical therapy clinic. I was specializing in pelvic floor dysfunctions and perinatal physical therapy, but I was also treating individuals with other diagnoses. A woman came into my office with a referral (required at the time) for hip pain. As I spoke with her and completed a full examination of her hip and surrounding joints, I learned that she had received physical therapy multiple times before for these same symptoms. Her symptoms always improved, but returned one to two years later. As I completed my examination of her hip, my clinical tests were telling me that there was no issue with her hip. I was able to recreate minor pain, but not the dysfunction for which she was seeking physical therapy.

Now, as a pelvic floor physical therapist as well, I was well prepared for the next line of questioning. I asked her about incontinence, pain with sex, pain with tampon use, and constipation. It turned out that she had pain with sex, tampon use, and gynecological examinations all her life. She told me that she had always just been tight and had always experienced some pain. I talked to her about pelvic floor physical therapy and she wanted to go forward with an examination that day. Quickly, I was able to determine that my hunch was right as her pelvic floor was overactive and I recreated her hip pain with gentle palpation. When she returned for her next appointment, her pain was much improved. In a few weeks, her symptoms had entirely resolved. She no longer had any incontinence, her hip pain was completely gone this time, and she had no pain with sex. For the first time in her life, she really enjoyed sex!

About three weeks into her treatment plan, she came in for a session and announced that she thought she had figured it out. She asked if it was possible that an injury when she was seven had caused her to tighten up. She explained that she had visited a hospital after falling on a fence.

My answer without question, was…

YES!

Ask questions early to be sure our kids receive the pelvic health care they need

This incident could absolutely be responsible for her pain. Unfortunately, this is an all too common experience.

I have also worked with a 19 year old with painful gynecological examination who had never used a tampon due to it “not fitting”. It turned out she had fallen off a horse many times with one particularly bad injury. She saw multiple chiropractors, physical therapists, and physicians. When she saw me her legs were still different lengths and no one had ever asked her about tampons. It wasn’t until she saw a gynecologist at 18 and experienced pain so excruciating that she could not complete the exam that she was told we pelvic floor physical therapists even exist. When we finished treatment she used tampons for her most recent period, had pain-free gynecological exams, and her legs were no longer different lengths.

The right questions earlier in her life could have given her more options for menstruation, saved her painful exams, and helped her feel more confident in her body.

Before I received training in pelvic floor physical therapy, I saw a client for rehabilitation after hip surgery. Her surgery was mostly to correct a deformity to her labrum that had likely existed since birth. The theory was that her mechanics had changed enough that it was now causing her pain. Initially, she did fantastic and it seemed her pain was successfully resolved, but about eight weeks post surgery her pain returned. She reported her pain as exactly the same as prior to surgery. As I examined her, I found that her obturator internus (a muscle that rotates the hip) was very tender. This particular muscle is mostly within the pelvis and is palpated most accurately on an internal pelvic floor exam, but I was only able to treat the external portion. Every treatment, her pain resolved at the session and returned the next day. We did this for two or three sessions and then made a plan. My treatment was not working. I explained pelvic floor physical therapy to her and she was all for it. The problem was (due to limitations in the law and my previous employer’s policy at the time) she needed a new referral from her physician. Luckily, she had an upcoming visit with her surgeon. I joined her for her visit rather than discussing the option over the phone. When I made my suggestion, he asked how he could make it happen. I was so happy that he was open to the suggestion, but he had never heard of pelvic floor physical therapy. I told him what to write on the referral and he handed it to the patient. Her pelvic floor exam with a different physical therapist at a different clinic was the next week, and she arrived back at my office a few days later to tell me I was right. Her pain was already significantly improved and seemed to be staying better this time. No one will ever know if she needed the surgery, but it appears her pain was due to a muscular issue and not related to her labrum.

Anatomy picture of obturator internus externally. This is how I was able to palpate and treat.

Obturator internus internally. This is how I treat the obturator internus now.

These stories are examples of people who did eventually get access to the care they needed, but they demonstrate the lack of awareness of pelvic health among the community at large and even among medical professionals. They also demonstrate that years of suffering can be saved with proper education and asking the right questions early. Please, remember this article if you have kids in your care who will menstruate in the future. When they start to have periods, talk to them about tampons or menstrual cups. Ask them whether they have pain or difficulty, and if they do, then find them a pelvic floor physical therapist. Sometimes a little knowledge goes a long way. Unfortunately, we cannot rely on our providers to know everything. Hopefully a few readers can save their kids from suffering. Unfortunately, this particular question does not work for all kids, some will never menstruate and therefore will not have this particular early indicator. For all kids, accurate and open communication about sex is helpful. Education such as sex should not be painful, urination should not be painful, defecation should not be painful, and if any of these symptoms occur then find a trusted adult to ask for help finding a pelvic floor physical therapist.

Happy educating and openly conversing with all the kids in your care.