Lifelong vaginismus is a condition where a person experiences pain or difficulty with vaginal insertion from the first attempt. This could include the insertion of a tampon, gynecologic speculum, finger, penis, or sex toy. Many patients report, "I always had trouble with tampons" and may avoid using them altogether. They might also avoid pelvic exams and face significant challenges with receptive sexual activity.

Pelvic trainers, also known as dilators, vaginal trainers, or accommodators, can be effective tools for addressing lifelong vaginismus. However, as a pelvic health clinician, you may have noticed that some patients reach a plateau, getting "stuck" at a certain size trainer. Lifelong vaginismus is believed to be due to uncontrolled spasms of the pelvic floor muscles surrounding the vaginal opening. These spasms can hinder the insertion of progressively larger trainers and are not easily managed through passive stretching alone.

Instead, combining passive stretching with techniques like breathing and contract-relax exercises can be beneficial. Using muscle contractions may seem counterintuitive, but they can effectively promote muscle relaxation and control. Let's explore four scientific perspectives on how this works.

1. Physiology of Skeletal Muscle

Skeletal muscle, which includes the pelvic floor muscles, responds to isometric contractions by activating Golgi Tendon Organs (GTOs) embedded in the muscle fibers. When GTOs are activated, they send signals to the spinal cord, triggering a reflex that inhibits the same muscle. Essentially, an isometric contraction causes the muscle to inhibit itself. This technique, known as "hold-relax" in Proprioceptive Neuromuscular Facilitation (PNF) stretching, may increase flexibility in the pelvic floor muscles when performed around the trainers.

2. Neurological Effects

Repeated, sub-maximal contractions followed by gentle stretching and intentional relaxation can increase corticospinal excitability, promoting motor learning and performance (Christiansen et al., 2018). Over time, practicing voluntary contraction and relaxation, along with breathing exercises, helps patients gain more control over the muscles surrounding the vagina.

3. Pain Science Perspective

Voluntary contractions activate the motor cortex in the brain, which has two effects on inhibiting pain (Lopes et al., 2019):

1. Inhibition of the thalamic nuclei (lateral spinothalamic tract), limiting nociceptive messages.
2. Activation of the periaqueductal gray, which contains enkephalin-producing cells that release endogenous opioids to suppress pain.

These effects reduce pain and facilitate the progressive insertion of vaginal trainers.

4. Graded Exposure

Graded exposure involves gradually increasing exposure to an activity that causes fear or anxiety. Starting with the smallest size, trainers are inserted to the "just the start of discomfort" point (not to pain). This is followed by breathing exercises and gentle voluntary contractions and relaxations ("hold-relax" technique) along with passive stretching. As discomfort lessens, the trainer can be inserted further, repeating the steps. This process, over several sessions, allows progression to larger trainer sizes, reducing fear and anxiety while increasing functional insertion and decreasing pain.

Practical Application

During a session, a patient may insert a trainer just to the point of discomfort. The clinician can then guide them through the hold-relax routine:

1. Take a breath in.
2. Exhale and gently squeeze the pelvic floor muscles around the trainer – hold, hold, hold (through the full exhale).
3. Release the muscles while inhaling again.

Repeat for 3-5 repetitions. After the last hold-relax, keep the muscles relaxed while gently pressing the trainer to stretch along the vaginal wall for 30-60 seconds, maintaining the same insertion depth. Repeat these steps for the posterior, left, and right vaginal walls (avoiding the anterior wall to prevent irritation of the urethra). These instructions can be adapted based on the individual patient.

In the Vaginismus and Vulvovaginal Dyspareunia course, participants learn and practice these steps, along with other techniques for addressing painful vaginal intercourse. The course covers selecting trainers, using lubricants, sexual positions, props and aids, perineal scar massage, and specific manual therapy treatments. It also provides guidance on discussing sexual activity with patients, including when to pause or continue, and how to involve partners. A rehabilitative treatment decision-making algorithm based on examination findings helps clinicians determine the most effective treatment combinations for each patient. Join us in the next Vaginismus and Vulvovaginal Dyspareunia course, scheduled for September 14, 2024.

For patients struggling with vaginal trainer progression, try these breathing, hold-relax, and gentle stretching techniques in your clinic this week. It may transform trainers from a frustrating obstacle into a useful and functional tool.

References:

Christiansen, L., Madsen, M. J., Bojsen-Møller, E., Thomas, R., Nielsen, J. B., & Lundbye-Jensen, J. (2018). Progressive practice promotes motor learning and repeated transient increases in corticospinal excitability across multiple days. Brain stimulation, 11(2), 346-357.

Lopes, P. S. S., Campos, A. C. P., Fonoff, E. T., Britto, L. R. G., & Pagano, R. L. (2019). Motor cortex and pain control: exploring the descending relay analgesic pathways and spinal nociceptive neurons in healthy conscious rats. Behavioral and Brain Functions, 15(1), 1-13.

AUTHOR BIO

Darla Cathcart, PT, DPT, PhD, WCS, CLT

Darla graduated from Louisiana State University (Shreveport, LA) with her physical therapy degree, performed residency training in Women’s Health PT at Duke University, and completed a Ph.D. at the University of Arkansas Medical Sciences. Her dissertation research focused on using non-invasive brain stimulation to augment behavioral interventions for women with lifelong vaginismus, and her ongoing line of research focuses on painful intercourse and post-Cesarean rehabilitation.

Darla’s certifications and training include Women’s Health Certified Specialist (WCS, board certification through the American Board of Physical Therapy Specialties). Certificate of Achievement in Pelvic Physical Therapy (CAPP-Pelvic). Certificate of Achievement in Pregnancy & Postpartum Physical Therapy (CAPP-OB). Certified Lymphedema Therapist (CLT).

Darla began her women’s health physical therapy career in her first job while working with pregnant women with musculoskeletal problems in a private outpatient therapy clinic in Shreveport, LA (with a focus on spine rehab). While there, she developed and hosted an exercise class for pregnant women. She would go on to develop a mom-and-baby postpartum exercise class while in her Duke residency in Durham, NC. She went on to develop the pelvic, pregnancy, and post-breast cancer/lymphedema PT program at Christus-Schumpert Health System in Shreveport, LA. During this time, she participated in educating women in the labor and birth preparatory classes hosted by the hospital; she also taught the women’s health course for physical therapy students at LSU-Shreveport. Darla went on to serve as a full-time faculty member in the physical therapy program at the University of Central Arkansas in Conway, AR, where she taught women’s health topics, documentation, therapeutic exercise, professional development, and human physiology. She recently owned a private PT practice that is dedicated to pelvic (bowel, bladder, and pelvic pain) and pregnancy/postpartum conditions in Conway, AR. Darla now is a full-time faculty member in the entry-level Physical Therapy program at Graceland University.

Darla currently serves as the President of the Academy of Pelvic Health of the American Physical Therapy Association. She has several peer-reviewed and non-peer-reviewed scientific publications. Amongst some of these, she co-authored “Clinical Summary: Urinary Incontinence” for PTNow.org in April 2015. She authored the chapter titled “The Female Hip and Pelvis” in Orthopedic Management of the Hip and Pelvis (S Cheatham, M Kolber, Elsevier, 2015). She chaired the committee for and participated heavily in the development of the Certificate of Achievement in Pregnancy/Postpartum (CAPP-OB) course series for the Section on Women’s Health of the American Physical Therapy Association. Darla has spoken and instructed many courses in local, national, and international settings on a variety of pelvic, pregnancy/postpartum, and other women’s health physical therapy topics. Darla has served as the Director of Education (2011-2014) and as Vice President (2015-2016) for the Section on Women’s Health, American Physical Therapy Association. She also served as a technical expert panel member on Treatments for Fecal Incontinence, Agency for Healthcare Research and Quality in 2014-2015. She also volunteered as a Women’s Health Certified Specialist Exam Standardization Task Force member in May 2013. Darla received several awards from the Section on Women’s Health: CAPP-OB Instructor of the Year (2017); Course Site Hostess of the Year (2018); and Volunteer of the Year (2015). She also received Clinical Instructor of the Year while serving as a clinical instructor a pelvic health physical therapy student from Elon University in 2011.