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Herman & Wallace Blog

Some Physicians Still Haven't Caught On

The following post comes to us from Dee Hartmann, PT, DPT who is the author and instructor of Vulvodynia: Assessment and Treatment. To learn evaluation and treatment techniques for vulvar pain, join Dee in in Houston, TX this March 12-13. Early registration pricing expires soon!

I recently heard a young, vivacious urologist present treatment options for overactive bladder to a group of nursing professionals (SUNA). To my delight as the only PT in the audience, I was pleased that physical therapy was her first line of treatment for this difficult population of chronic pelvic pain patients. As a women’s health PT, we know that chronic vulvar pain suffers experience many of the same dysfunctions, including pelvic floor muscle over-activity.

The physician’s presentation included two very emphatic statements—“physical therapy always hurts” and “no one in this group of patients should ever do Kegel exercises”. She went on to explain that anyone with pelvic floor muscle over activity should only be taught to relax; that “if they were seeing a practitioner who was telling them to do Kegels, they needed to find another PT”. As she’s not a PT, I challenged her on her second comment. I was too annoyed to address the first.

I appreciate that, as a urologist, she may not know that we learned some time ago that rest for chronic muscle tension, like chronic low back, has been proven ineffective[1]. Rather, research suggests that increased mobility and strengthening prove more effective in the long term to decrease pain by restoring normal muscle function. As pelvic floor muscles are voluntary, striated muscles, it only makes sense that the same findings apply. Those who oppose active pelvic floor muscle active exercise suggest that the over-active state of the pelvic floor muscles causes vulvar pain. I agree. However, simply relaxing dysfunctional pelvic floor muscles and expecting them to work effectively seems a bit short-sighted. Normal pelvic floor muscle function is integral to efficient core stability as well as sphincteric control, pelvic visceral support, and sexual function. Why not begin rehab for these ladies with an active exercise program, directed at renewing pelvic floor muscle motor control, with resulting decreased introital pain, improved function (sphincteric , supportive, and sexual), and improved core support?

As for the urologist’s first statement, mark me down as totally opposed. My professional experience suggests the need to replicate familiar vulvar pain and then find abnormal physical findings in the trunk, hips, viscera, and pelvis that are contributory. Rather than utilizing any treatment that causes additional pain, addressing associated abnormal findings that immediately decrease pelvic floor muscle resting tone and palpated vulvar pain, seems much more productive.


[1] Waddell G. "Simple low back pain: rest or active exercise?" Ann Rheum Dis 1993;52:317.

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What's Sex Got to Do with It?

Dee Hartmann

This post was written by H&W instructor Dee Hartmann PT, DPT. This year, H&W is thrilled to be offering a brand new coure instructed by Dee, Assessing and Treating Women with Vulvodynia.This course will be offered in September in Waterford, CT.

What's love (and sex) got to do, got to do with it?

Tina Turner said it well. (Obviously I’m taking a little liberty here.) Some think that love and sex go together, you know, like bread and butter. Others? Not so much. Many think that love thrives even though the sex may slow down because of things like babies, work, stress, dinner with friends, and cleaning the bathroom…you name it. A lot can come between you and a good bedroom romp. But what if those bedroom romps had NEVER been good? What if the only fireworks you remember when earning your womanhood badge were akin to hot, searing sparklers—held way too close for comfort above your knees and between your legs. What’s with that, right?

Tina goes on “…that the touch of your hand/makes my pulse react…”. We all remember that feeling, that first titillation. It was there “…It’s physical/Only logical/You must try to ignore/That it means more than that”.

Boy meets girl. Hugging. Touching. Kissing. All that normal stuff that’s so good. Further progression might be awkward and clumsy but ‘it’ usually works nonetheless. But not always. Sometimes, the sex afterglow is more like, “Wow. That was way overrated…and who lit the fire in my vagina?” That burning pain lingers for days and celibacy, though considered, doesn’t really seem like a good alternative. You try again and again and along with more failed attempts, the pain gets worse. Your brain begins to think that any time anything comes too close to your vagina – like a tampon, fingers, a vibrator, the doctor, or a bicycle seat – it needs to shut the doors for business. As we say in the business, the pelvic floor muscles go into overdrive. Everything can get a bit goofy. You become all too familiar with your work bathroom as your bladder doesn’t seem to want to hold as much as it used to. Emptying your bowels becomes an effort. And those tampons that wouldn’t go in? Now you know why. There’s no room for anything down there! Armed with the sparkler analogy, the only help you get from most medical providers is “just relax, honey” or “have a glass of wine first” or “maybe your boyfriend/husband is just too big for you.” That stinks. And it’s not normal. Sex and reproduction (remember we’re the only mammals—besides dolphins—who do it for fun) are built in to our primitive brain, just like breathing and eating. “It may seem to you/That I'm acting confused/When you're close to me/If I tend to look dazed.” After the whole relaxing and drinking things fail and you kind of like your partner’s parts, what’s a girl to do?

“I've been taking on a new direction/But I have to say/I've been thinking about my own protection/It scares me to feel this way.” Once pain and fear have taken the place of excitement and arousal, your sexual future may appear less and less clear. As you and your partner begin experiencing nothing but frustration, there are my tips for making it through this tough stage.

1) Your best tool is always communication, communication, communication. First and foremost, sex should never hurt. Never. Ever. Discuss it with your partner long before you’re in bed, the lights are out, and you’re pretending to be asleep to dodge foreplay. Desire and arousal go together to create increased blood flow and lubrication, but no one can deny that it’s pretty hard to get excited about a hot stick in the eye (my analogy). Fear of impending pain can throw a wet blanket on the whole idea of sex unless you’ve agreed first to work together.

2) You may have learned to fear touching because of where it might lead, but avoiding hugging, touching, cuddling, and kissing is the first step in the wrong direction. Enjoying your partner’s touch—sexual or not—is a prerequisite for good love-making and will make you both happier in the long run.

3) Make a deal that there will be no sexual contact until you’re ready and will help you to begin dealing with the pain. Keeping your love alive matters for your relationship. Holding back in resentment and fear of the next sexual move chips away at the trust you’ve built.

4) As you begin to regain control, try to be the intimacy initiator at least once a week (or some predetermined time frame). Getting yourself mentally prepared goes a long way to gently urge arousal. Often it takes putting a sticky note on the fridge or work computer screen to remind you to think about it during the day (we women have so many other more important things to think about; sex, even in the best of times, usually doesn’t make the top five). Partners love it as they’ve usually shut down their advances to avoid yet more frustration, rejection, and heartache.

5) Once you’re ready to go for it, remember that your body that might not be too excited about entertaining an extended stay visitor. By agreeing to short visits in the beginning, the brain catches on and doesn’t shut down into protection mode. Go for more foreplay rather than less. Then, once his climax is close at hand, actual penetration time is kept at a minimum. You’ll be happier. He’ll be happier. And your vulva will appreciate the plan.

And here’s where Tina and I part ways. She may have gotten to go on singing (and making millions), but I get to gently guide women to their desired sexuality. Incredible women fill my office every day and continue to amaze me with what they’re able to do with and for their bodies. I don’t fix anyone. Instead, I help them find the power they need to fix themselves. “What's love got to do, got to do with it/What's love but a sweet old fashioned notion.” Call me old fashioned but I can’t think of a greater gift as women’s health PTs than to be able to help women feel more comfortable as women. And to think they call this work!

Want more from Dee? Consider joining us for the Septmber course!

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Upcoming Continuing Education Courses

Pregnancy Rehabilitation - Seattle, WA (SOLD OUT)

Feb 22, 2020 - Feb 23, 2020
Location: Pacific Medical Centers

Manual Therapy Techniques for the Pelvic Rehab Therapist - Pasadena, CA

Feb 22, 2020 - Feb 23, 2020
Location: Huntington Hospital

Pelvic Floor Level 2B - Alexandria, VA (SOLD OUT)

Feb 28, 2020 - Mar 1, 2020
Location: Inova Physical Therapy Center

Pelvic Floor Level 2B - Fort Worth, TX (SOLD OUT)

Feb 28, 2020 - Mar 1, 2020
Location: University of North Texas Health Science Center

Pediatric Functional Gastrointestinal Disorders - Charlotte, NC

Feb 28, 2020 - Mar 1, 2020
Location: Novant Health

Rehabilitative Ultrasound Imaging: Orthopedic Topics - Raleigh, NC

Feb 28, 2020 - Feb 29, 2020
Location: Rex Hospital

Pelvic Floor Series Capstone - Phoenix, AZ (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: 360 Sports Medicine & Aquatic Rehabilitation Centers

Pelvic Floor Level 1 - Salida, CO (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: Heart of the Rockies Regional Medical Center

Pelvic Floor Level 1 - Columbia, MO

Mar 6, 2020 - Mar 8, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Pelvic Floor Level 1 - Princeton, NJ (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: Princeton Healthcare System

Pelvic Floor Level 1 - New Orleans, LA (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: Ochsner Health System

Mobilization of the Myofascial layer: Pelvis and Lower Extremity- Grand Rapids, MI

Mar 6, 2020 - Mar 8, 2020
Location: Spectrum Health System

Bowel Pathology and Function -Salt Lake City, UT

Mar 7, 2020 - Mar 8, 2020
Location: Veterans Administration - Salt Lake City

Postpartum Rehabilitation - Washington, DC (SOLD OUT)

Mar 7, 2020 - Mar 8, 2020
Location: GWUH Outpatient Rehabilitation Center

Pelvic Floor Level 1 - Virginia Beach, VA (SOLD OUT)

Mar 13, 2020 - Mar 15, 2020
Location: Sentara Therapy Center - Princess Anne

Pelvic Floor Level 2A - Philadelphia, PA (SOLD OUT)

Mar 13, 2020 - Mar 15, 2020
Location: Thomas Jefferson University

Pelvic Floor Level 1 - Manchester, NH (SOLD OUT)

Mar 13, 2020 - Mar 15, 2020
Location: Franklin Pierce University

Meeks Method for Osteoporosis - Minneapolis, MN

Mar 14, 2020 - Mar 15, 2020
Location: Park Nicollet Clinic--St. Louis Park

Pelvic Floor Level 2A - Minneapolis, MN (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: Allina Hospitals and Clinics

Nutrition Perspectives for the Pelvic Rehab Therapist - San Diego, CA

Mar 20, 2020 - Mar 22, 2020
Location: Comprehensive Therapy Services

Pelvic Floor Level 1 - Birmingham, AL (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: Shelby Baptist Medical Center

Mobilization of Visceral Fascia: The Urinary System - Carlsbad, CA

Mar 20, 2020 - Mar 22, 2020
Location: Tri-City Medical Center

Pelvic Floor Level 1 - Bellingham, WA (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: PeaceHealth- St. Joseph Medical Center

Pelvic Floor Level 1 - Los Angeles, CA (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: Mount Saint Mary’s University

Breastfeeding Conditions - Phoenix, AZ

Mar 21, 2020 - Mar 22, 2020
Location: Banner Physical Therapy and Rehabilitation

Breathing and the Diaphragm: Orthopedic Therapists - Sterling Heights, MI

Mar 27, 2020 - Mar 29, 2020
Location: Henry Ford Macomb Hospital

Breathing and the Diaphragm: Pelvic and Orthopedic Therapists - Sterling Heights, MI

Mar 27, 2020 - Mar 29, 2020
Location: Henry Ford Macomb Hospital

Pelvic Floor Level 1 - Corvallis, OR (SOLD OUT)

Mar 27, 2020 - Mar 29, 2020
Location: Albany Sport & Spine Physical Therapy

Breast Cancer Rehabilitation - Alexandria, VA

Mar 28, 2020 - Mar 29, 2020
Location: Inova Physical Therapy Center