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Conservative Management of Female Patients With Pelvic Pain.

Female patients with hypertonus of the pelvic musculature can experience pain; burning in the clitoris, urethra, vagina, or anus; constipation; urinary frequency and urgency; and dyspareunia. Physical therapy techniques are effective in treating female patients with pelvic pain, and can successfully reduce the major symptoms associated with it. Using a treatment plan individualized for each patient's symptoms, these techniques can provide considerable relief to patients with debilitating pelvic pain.

The primary symptoms of hypertonus of the pelvic musculature in female patients include pain; burning in the clitoris, urethra, vagina or anus; constipation; urinary frequency and urgency; and dyspareunia (DeFranca, 1996). There are many names for hypertonus diagnoses involving these symptoms including: levatores ani syndrome (Nicosia, 1985; Salvanti, 1987; Sohn, 1982), tension myalgia (Sinaki, 1977), proctalgia fugax (Swain, 1987), coccygodynia (Dittrich, 1951; Thiele, 1937; 1963; Waters, 1992), dyspareunia (Glatt, 1990), vaginismus (Hall, 1952), animus, vulvodynia (MacLean, 1995; Marinoff & Turner, 1992; Reid, 1993; Secor, 1992), vulvar vestibulitis (deJong, 1995; Spadt, 1995), interstitial cystitis, pudendal neuralgia (Turner, 1991), pelvic pain (Baker, 1993), and urethral syndrome (Steege, Metzger, & Levy 1998).

The objective findings in patients with hypertonus include pain on palpation to the genitalia, pain on palpation of the perineal region from 3 to 9 o'clock, or pain in the urethra, perineal body, perianal area, posterior thigh, gluteal, and abdominal areas (Costello, 1998). Sacroiliac, coccyx, symphysis pubis, lumbosacral joint malalignment and instability are present (Lee, 1999). Patients have functional impairment with sitting, walking, urination, and defecation (DeFranca, 1996), and with household and community activities of daily living. A high resting baseline, excessive signal variability, and a low net rise on surface EMG (sEMG) is commonly recorded. Muscle hypertonus can be palpated on external and internal pelvic floor muscle examination. Muscle weakness is measured in the levatores ani, obturator internus, gluteus medius, iliopsoas, adductor, and lateral hip rotator muscles. Some degree of dyspareunia is usually reported.

Dyspareunia

Dyspareunia is better defined as painful penetration rather than painful intercourse, as many patients report painful gynecologic examinations using speculums or a gloved examining digit. Causes for dyspareunia can include: abscess, fissure, adhesions from prior surgery, adhesions causing conditions such as endometriosis (Blackwell & Olive, 1998), vaginal pH alteration, dermatological disease, cancerous vulvar disease, episiotomy, laceration, birthing trauma with forceps or vacuum extraction, vaginal infection, urinary tract infection, inflammation, skin irritation from chemicals, nerve irritation from entrapment, neurohormonal alteration particularly estrogen deficiency (Glazer, Romanzi, & Polaneczky, 1999), psychiatric disorders, instability of the pelvis (Lee, 1999), prolapse, vasocongestion, and sexual trauma. Physical therapy treatment coverage of dyspareunia may be denied under its primary ICD-9 code if viewed as a psychiatric or sexual dysfunction rather than an anatomic or physiologic dysfunction.

Marinoff and Turner (1992) defined three levels of dyspareunia (see Table 1). Burning, stinging, irritation, rawness, tearing, and searing pain are the most common complaints with penetration during and afterward. If these symptoms are felt at the introitus, superficial structures such as the genitalia, perineal body, posterior fourchette, episiotomy site, and superficial muscle layer may be implicated. If deeper pain occurs, adhesion of the vaginal canal, adhesive disease, cervix and uterine dysfunction, levatores ani muscle trigger points, or sacroiliac and symphysis pubis joint dysfunction may be involved.

When evaluating patients with dyspareunia, it is important to first rule out any medical conditions. Differential diagnosis to establish that the cause is musculoskeletal rather than fungal, bacterial, viral, or otherwise infectious is essential for effective physical therapy treatment. Once the diagnosis is established that pelvic pain is of musculoskeletal origin, treatment may include the steps listed in Table 2. Following office treatment to correct the joint malalignment, the patient can continue with self-corrections at home.

Pelvic Floor Muscle Exercises

Using sEMG with pelvic pain patients, Glazer, Rodke, and Swencionis (1995) demonstrated unstable and abnormally high resting baselines (tension). Unstable and weak amplitudes were recorded during phasic, tonic, and endurance voluntary contractions. The use of sEMG was proposed as an objective method for forming a differential diagnosis between functional (musculoskeletal) vulvovaginal pain syndromes and other sources of vulvovaginal pain such as infections. Stabilizing muscle variability overall and predominantly at rest was a major factor in effective treatment, rather than focusing on increases in the contractile amplitude. Glazer and MacConkey (1996) proposed simultaneous use of different muscle combinations to enhance the pelvic floor muscles contraction, in order to "break" the resting tension level and reduce pain. Thus, the "Glazer protocol" (see Table 3) consists of two 20-minute exercise sessions per day. Each session is 60 repetitions of 10-second contractions alternating with 10-second relaxation phases. Patients are asked to contract the pelvic floor muscles maximally with all other surrounding muscles. They are required to use home sEMG training devices with intravaginal sensors.

Over time the clinician may observe increased contractile amplitudes, decreased variability of the contraction and relaxation amplitude, and faster rise and recovery times with subjective reports of less pain.

According to Glazer, after treatment the sEMG demonstrates a reduction in the hypertonicity and instability associated with chronic uncoordinated discharge of fast twitch fibers seen in the resting sEMG of vulvovaginal pain patients. Variations on "Glazer's protocol" that have had equally significant treatment results are two 15-minute rather than two 20-minute sessions.

Perianal external surface sensors can be used initially, progressing to a small intravaginal sensor the size of a tampon for those with level 3 dyspareunia. There are reasonably priced rental programs throughout the country that offer month-long home use of a single channel sEMG unit, allowing most patients the opportunity to use this treatment (see Table 4).

Constipation

Tension in the pelvic floor muscles, poor intake of fiber and fluid, and lack of activity may cause constipation (Whitehead, 1998). This condition may contribute to pelvic pain. Relaxation of the pelvic floor muscles during defecation is necessary to allow the canal to open and the anorectal angle to increase. Evaluation of the activity of the puborectalis muscle can be assessed using sEMG. Two channels of sEMG should be used, the first with surface external sensors placed at a 3 and 9 o'clock position around the anal rim. A second channel for monitoring abdominal muscle use in a sitting position can demonstrate the patient's ability to use the abdominals while relaxing the puborectalis muscle. Lack of ability to allow relaxation is termed a paradoxical contraction and would make it necessary to strain to try and evacuate through a closed tube. Patients can be taught proper relaxation of the puborectalis in coordination with the abdominal muscles using sEMG. Improved sitting positions with hip flexion past 90 degrees can promote muscle relaxation of the puborectalis for easier defecation.

Straining to defecate is necessary when there is a lack of tone in the rectal walls from a rectocele. When a significant rectocele is present, fecal material is pocketed into the prolapse (into the vaginal canal) despite efforts to push it out. Insertion of a gloved digit into the vaginal canal, with pressure posteriorly on the back wall will give missing foundation to the rectal wall and allow for easier defecation.

Thiele's massage (see Table 5) is a technique to directly address the soft tissue hypertonus surrounding the rectal canal by using a sweeping massage stroke while inside the canal. Soft tissue friction massage to an anal fissure, where scar tissue is less pliable, may free the tissue mobility and allow less painful stretching with defecation.

Evaluation of the thoracolumbar junction for vertebral malalignment may prove helpful to reduce irritation at the innervation of the rectal canal. Visceral mobilization to free organ immobility may promote pain-free defecation. Intestinal massage clockwise staffing from the right lower abdominal quadrant, up under the ribs, across the abdomen to the left descending colon, on to the left sigmoid colon and then looping out will stimulate peristalsis action for gas elimination.

Finally, proper sacral joint alignment is vital to the function of the sacral micturition center. When sacral joint malalignment is present, manual therapy techniques such as sacral decompression, springing, rocking, strain counter-strain, and myofascial release may be beneficial (see Table 6).

Nerve Supply

The nerve supply to the vulva includes branches of the ilioinguinal nerve (L1), the genital branch of the genitofemoral nerve (Li-L2), the perineal branch of the femoral cutaneous nerve (L2-L3), and the perineal nerve (one of the branches of the pudendal nerve). The symphysis pubis is innervated by branches of the iliohypogastric nerve (T12) and branches of the genitofemoral nerve (L1-L2).

Entrapment of nerves may contribute to pelvic pain (Baker, 1993).

Potential Pudendal Nerve Entrapment Sites

The lesser sciatic foramen is a potential hot spot for entrapment of the pudendal nerve. It has firm unyielding boundaries with the bony ischium on one side and the sacrotuberous/sacrospinous ligaments on the other. These two ligaments fuse as they pass one another, creating a tight fit for the pudendal nerve, internal pudendal vessels, and obturator internus muscle with its tendon passing through (Alevizon & Finan, 1996). Hypertonus of the obturator internus muscle may compress the pudendal nerve and vessels.

A second site for entrapment of the pudendal nerve is under the sacrotuberous ligament just before it enters into Alcock's canal.

A third site for entrapment is in Alcock's canal as the pudendal nerve makes its way toward the pubic bone, branching into the inferior rectal nerve, then the perineal nerve, and finally into the dorsal nerve. These branches lie over the belly of the obturator internus muscle. Entrapment of the pudendal nerve and its branches can generate burning, prickling, irritation, hypersensitivity, lack of sensation, and other sensory disturbances.

Physical therapy manual techniques such as myofascial release, trigger point release, strain counter-strain, ischemic pressure, friction massage, trigger point release, muscle energy techniques, and joint mobilization may reduce the pressure on the nerve and lessen the symptoms. Addressing hypertonus in the levatores ani, particularly the pubococcygeus and iliococcygeus (DeFranca, 1996), iliopsoas (Headley, 1997; Lee, 1999), piriformis, adductors (Costello, 1998), quadratus lumborum, hamstrings, obturator internus, coccygeus, and gluteus medius (Lee, 1999) are essential for complete treatment of this region (see Tables 7, 8, & 9).

Other Nerve Entrapments

The ilioinguinal nerve arises from the first lumbar root and accompanies the iliohypogastric nerve, though caudal and parallel to it. It crosses the internal oblique aponeurosis in the direction of the symphysis pubis along with the round ligament. The sensory distribution is the inguinal area including labia majora and inner thigh. Entrapment has been described as a complication of Pfannenstiel incision, appendectomy, herniorrhaphy, or needle suspension for stress incontinence (Challis & Bennett, 1994; Miyazaki & Shook, 1992). Correct diagnosis after onset of symptoms is often as long as 20 months.

The iliohypogastric nerve arises from the first lumbar of the 12th thoracic nerve and passes through the psoas muscle diagonally along the surface of the quadratus lumborum. It passes caudally toward the crest of the ilium, laterally through the transversus muscle and the internal oblique, medially to the ASIS, then runs horizontally under the aponeurosis of the external oblique where its anterior cutaneous branch can be trapped during surgery. It supplies the skin of the groin and symphysis pubis. Entrapment of the iliohypogastric nerve can occur from the same surgical procedures listed for entrapment of the ilioinguinal nerve. Entrapment may also result from placement in the lithotomy position for vaginal deliveries, laparoscopies, and vaginal hysterectomies (Goh, 1994).

The genitofemoral nerve arises from the first and second lumbar nerves, passes through the psoas muscle, through the transversalis where it splits into the genital branch, which continues along the psoas muscle to the inguinal ligament. In the female it accompanies the round ligament to the labia. The femoral branch lies lateral to the genital branch in the psoas muscle, passing under the inguinal ligament with the external iliac artery, entering the femoral sheath. It supplies the skin of the proximal anterior thigh. Problems may arise from an incision that injures the nerve, or from hypertonus of the psoas muscle and malalignment of the symphysis pubis joint.

Treatment for these nerve entrapments may include myofascial release, friction massage, strain counter-strain, trigger point release, stretching exercises, joint mobilization, and muscle energy techniques to realign the joints and promote increased tissue mobility.

Urinary Frequency and Urgency

Female patients with pelvic pain often report feelings of urgency and frequency with a strong urge to void but little significant output. Voiding patterns can be as frequent as three times per hour, causing severe lifestyle changes. Musculoskeletal limitations are found in the lateral rotators and lower-extremity adductors. Weakness in the abductor and rotator muscles is common. Trigger points from the adductors, rotators, and levatores ani muscles can elicit referred pain elsewhere (Costello, 1998; Travell & Simons, 1992). sEMG evaluation reveals a high resting baseline and poor muscle awareness. A possible mechanism for the constant voiding sensation may be hypertonic tissue connections from the inside of the pelvic brim to the urethra, creating a stretch on the canal with a subsequent feeling of the need to void (Raz, 1996).

Patients respond well to soft tissue techniques that increase tissue mobility and lessen the stretch on the urethra. Manual work to the adductors, levatores ani, obturator internus, and bulbocavernosus muscles reduces the referred pain. The symptoms are reduced by a voiding schedule that increases the interval between voids to the recommended 2 to 4 hours, and also by submaximal pelvic floor muscle exercises, visualization, distraction, breathing, and mental exercises.

A TENS unit placed over the sacral micturition center at S2-S4 with conventional settings may help. Down training to relax the muscles is the heart of the program.

Summary

Physical therapy techniques are effective in treating female patients with pelvic pain, and can successfully reduce the major symptoms associated with it - dyspareunia, constipation, urinary frequency and urgency, and nerve entrapment syndromes. Pelvic floor exercises, well known to nurses treating urinary incontinence, are a major component of physical therapy techniques for pelvic pain though they are performed in a slightly different manner. Other exercises assist in eliminating trigger points, stabilizing joints, and down training (or relaxing) affected muscles. Using a treatment plan individualized for each patient's symptoms, these techniques can provide considerable relief to patients with debilitating pelvic pain.

Hollis Herman, MS, PT Ocs, is a Physical Therapist in Private Practice in Cambridge, MA.

References

Alevizon, S., & Finan, M. (1996). Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment. Obstetrics and Gynecology, 8(4), 713.

Baker, P.K. (1993). Musculoskeletal origins of chronic pelvic pain: Diagnosis and treatment. Obstetrics and Gynecology Clinics of North America, 20(4), 719-742.

Blackwell, R., & Olive, D. (1998). Chronic pelvic pain: evaluation and management. New York: Springer-Verlag.

Challis, D., & Bennett, M., (1994). Nerve entrapment- An important complication of transverse lower abdominal incisions. Australia/New Zealand Journal of Obstetrics and Gynaecology, 34(5), 594.

Costello, K. (1998). Chronic pelvic pain: An integrated approach. In J. Steege, D. Metzger, & B. Levy (Eds.), Myofascial syndromes (pp. 251-266). Philadelphia: W.B. Saunders Co.

DeFranca, G. (1996). Pelvic locomotor dysfunction. Gaithersburg, MD: Aspen Pubishers.

deJong, 1. (1995). Focal vulvitis: A psychosocial problem for which surgery is not the answer. Journal of Psychosomatic Obstetrics and Gynecology, 16, 85-91.

Dittrich, R.J. (1951). Coccygodynia as referred pain. Journal of Bone & Joint Surgery, 33A(3), 715.

Glatt, A. (1990). The prevalence of dyspareunia. Obstetrics and Gynecology, 75, 433.

Glazer, H., Romanzi, L., & Polaneczky, M. (1999). Pelvic floor muscle surface electromyography: Reliability and clinical predictive validity. Journalof Reproductive Medicine, 44(9), 779-782.

Glazer, H., Rodke, G., & Swencionis, C. (1995). Vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. Journal of Reproductive Medicine, 40. 283-290.

Glazer, H., & MacConkey, D. (1996). Functional rehabilitation of pelvic floor muscles: A challenge to tradition. Urologic Nursing, 16(1), 68-69.

Goh, J, (1994). Lithotomy position-induced femoral neuropathy. Austalian/New Zealand Journal of Obstetrics and Gynaecology, 34(5), 571.

Hall, S. (1952). Vaginismus as a cause of dyspareunia. World Journal of Surgery, Obstetrics, and Gynecology, 117-120.

Headley, B. (1997). When movement hurts. Boulder, CO: Innovative Systems of Rehabilitation, Inc.

Kuijpers, H. (1985). The spastic pelvic floor syndrome. Diseases of the Colon and Rectum, 28, 669-672.

Lee, D. (1999). The pelvic girdle. London: Churchill Livingstone.

MacLean, A. (1995). Benign and premalignant dieases of the vulva. British Journal of Obstetrics and Gynoecology, 102, 359-363.

Marinoff, S., & Turner, M. (1992). Vulvar vestibulitis syndrome. Dermatolagic Clinics, 10, 435-444.

Miyazaki, F., & Shook, G. (1992). Ilioinguinal nerve entrapment during needle suspension for stress incontinence. Obstetrics and Gynecology, 80, 246.

Nicosia, J. (1985). Levator syndrome: A treatment that works. Diseases of the Colon and Rectum, 28, 406-408.

Raz, S. (1996), Female urology. Philadelphia: W.B. Saunders Co.

Reid, R. (1993, September). Vulvodynia: What is it and how can we break the pain loop? Presentation to the Intnational Society for the Study of Vulvar Disease. Quebec.

Salvanti, E.(1987). The levator syndrome and its variant. Gastroenterology Clinics of North America, 16(1), 71.

Secor, M.(1992). Vulvar vestibulitis syndrome. Nurse Pracititioner Forum. 3(3), 161-168.

Sinaki, M. (1977). Tension myalgia of the pelvic floor. Mayo Clinic Proceedings, 52, 717-722.

Sohn, N. (1982). The levator syndrome and its treatment with high-voltage electrogalvanic stimulation. American Journal of Surgery 144, 580-582.

Spadt, S. (1995. November/December). Suffering in silence: Managing vulvar pain patients. Contemporary Nurse Practioners.

Steege, J., Metzger, D., & Levy, B. (1998). Chronic pelvic pain an integrated approach. Philadelphia: W.B. Saunders Co.

Swain, R. (1987). Oral clonidine for proctalgia fugax. Gut, 28, 1039-1040.

Thiele, G.H. (1963). Coccygodynia: Cause and treatment. Diseases of the Colon and Rectum, 6, 422-436.

Thiele, G.H. (1937). Coccygodynia and pain in the superior gluteal region. Journal of the American Medical Association, 109, 1271-1275.

Travell, J., & Simons, D. (1992). The lower extremities. In Myofascial pain and dysfunction: The trigger point manual (Vol. 2). Baltimore: Williams & Wilkins.

Turner, M. (1991). Pudendal neuralgia. American Journal of Obstetrics and Gynecology 165, 1223-1226.

Waters, E. (1992). A consideration of the types and treatment of coccygodynia. American Journal of Obstetrics and Gynaecology 166, 437.

Whitehead, W. (1998). Gastrointestinal disorders. In J. Steege, D. Metzger, & D. Levy (Eds.), Chronic pelvic pain: An integrated approach (pp. 205-224). Philadelphia: W.B. Saunders Co.

Table 1.

Three Levels of Dyspareunia

Level 1: Painful intercourse not severe enough to prevent the activity.

Level 2: Painful intercourse which limits frequency of the activity.

Level 3: Abstinence from intercourse because of severe pain.

Table 2.

Treatment for Dyspareunia of Musculoskeletal Origin

1. Correct any joint(s) malalignment to promote pain-free joint(s) mobility.

2. Teach the patient self-correction joint(s) techniques (see Tables 3, 4, & 5).

3. Stabilize the joint(s) with muscle stabilization exercises.

4. Eliminate trigger points in all of the muscles.

5. Eliminate or reduce scar adhesions and tissue restrictions (see Table 6).

6. Teach pelvic floor muscle awareness using a biofeedback device (see Table 7).

7. Correct muscle imbalances by down training (relaxation) and up training (strengthening).

8. Re-educate the pelvic floor muscles to be relaxed upon penetration.

9. Combine down training with dilators (see Table 8).

10. Educate about positions for intimacy.

11. Educate about lubricants.

Table 3.

Glazer's Protocol

Patient is supine, semi-reclining, sitting, or standing.

Contract the pelvic floor muscles up and in as hard as possible.

You may contract any other muscles along with the pelvic floor muscles.

Hold the contraction for 10 seconds.

Relax for 10 seconds.

Repeat 60 times twice a day.

Table 4.

Protocol for Using sEMG and Dilators

1. Identify the pelvic floor muscles using biofeedback. Practice contracting and relaxing the muscles to achieve a resting baseline that is normative for that equipment. Use any biofeedback equipment available from mirrors to computerized sEMG. If using sEMG use a continuous mode for the resting baseline while inserting the dilator.

2. Wash dilator with soap and water prior to insertion. Dilators are for single patient use only.

3. Position the patient in supine or semi-hook lying with knees up and apart. For home use the patient can try this procedure while in the bathtub as she is submerged in warm water; the sides of the bathtub support her knees and often it is the most private room in the house.

4. Lubricate the end of dilator with a water-soluble lubricant.

5. Separate the labia. Tense pelvic floor muscles then relax; while relaxing, slide lubricated dilator into the vagina or rectum a little. Tense muscles again while holding the dilator so it does not get pushed out; relax, and slide it in a little further. Try blowing out as if filling a balloon; this may relax the muscles and allow penetration. Repeat blowing out to insert dilator further.

a. Maintain low resting readings once dilator is inserted for 10 minutes to allow stretching of the muscles around the canal.

b. If 10 minutes of stretching is comfortable, progress to inserting and removing the dilator several times for 10 minutes while maintaining a low resting sEMG baseline and maintaining relaxed muscles.

c. If step b is comfortable, angle the dilator to the different quadrants of the canal to locate trigger points; keep pressure on these points until they soften and recede.

d. Insert the dilator and practice pelvic floor muscle exercises with it in place.

6. Never force the dilator into the canal.

7. Progress to the next size dilator and repeat steps 5a-5d.

8. Progress to having the partner participate in stretching with the dilator, with careful penetration into the patient.

9. If the patient is not able to insert the dilator without pain, try modalities such as ultrasound, soft tissue mobilization, joint mobilization, or insertion of a digit to promote muscle relaxation.

Therapists have tried use of procedure code 97112 (neuromuscular reeducation), 97530 (therapeutic activities), and 99070 for supplies for reimbursement.

Flexible silicone dilators are available in a set of 4 in 3 sizes (vaginal-hymeneal, rectal, or pediatric) from Milex, Chicago, IL 60631. They are packaged with a tube of Trimo-San (ph4) to restore normal acidity within the canal and help prevent abnormal growth of organisms. Contraindications for use are listed as infection of any type. They are cleaned with mild soap and water. If your department's infection control policy allows for intra-patient use, dilators can be sterilized in an autoclave at 250 F for 15 minutes, or boiled for 15 minutes, or submersed for 10 hours in Cidex solution.

Syracuse Medical Devices has individual dilators in XS-1/2 inch, S-7/8 inch, M-1/18 inch, L-1 3/8 inch sizes (214 Hurlburt Road, Syracuse, NY 13224; [315] 449-0657; Fax: [315] 449-0756).

Table 5. Thiele's Masseage

* Patient lies on left side.

* Therapist is behind patient, left hand on right hip (ASIS), right hand performs massage in the rectal canal.

* Orientation of the perineum:

Perineal body = 12 o'clock

Left side = 1, 2, 3, 4, 5 o'clock

Coccyx = 6 o'clock

Right side = 7, 8, 9,10,11 o'clock

* Orientation in the canal from deep structures to superficial:

Piriformis

Coccygeus

Sacrospinous ligament

Iliococcygeus

Pubococcygeus

Sphincter

Thiele's Massage

* Firm sweep from 3 - 9 o'clock with index gloved finger.

* Repeated 10 to 15 times in one session, fewer if severe spasm.

* Patient is asked to strain down during the massage and the muscles relax.

* Amount of pressure is determined by patient tolerance.

* Likened to sharpening a razor on a strap in the one direction.

Thiele recommended daily treatment for 5-6 days; then every other day for 7-10 days, then less often until the pain has disappeared. Improvement should be noted in 7-10 days.

Table 6.

Self-Correction for Right Anterior Ilium Sacroiliac Joint Malalignment

Step I

Ankles together.

Knees 18 inches apart.

Squeeze knees for 6 seconds.

Repeat 3 times.

Step 2

Right leg pulls down.

Left leg pushes up for 6 seconds.

Repeat 3 times.

Step 3

Lift buttocks up for 30 to 120 seconds.

Tighten all muscles around the buttocks and hips.

Step 4

Lie on the floor with bent leg up on the couch. Position the leg to turn off the tender point found on the front of the hip so it is in flexion, abduction, external rotation. Stay there for 90 seconds, then slowly come out of it.

Table 7. Perineal Massage

Trim fingernails.

Wash hands.

Semi-sitting with back supported against pillows.

Knees bent up and open.

Hold mirror for viewing.

Use water-soluble lubricant if preferred: Slippery Stuff, Astroglide, KY Jelly

Procedure 1

Practice a lifting contraction of the pelvic floor muscles, then relax.

View in the mirror to see that the perineal body is pulled inward with the lift.

While relaxed, slowly insert thumb fully into the vagina.

Pull down with the thumb.

Stretch the bottom wall of the vagina toward the anus.

Hold for 1-2 minutes.

A feeling of burning in the stretched tissues usually subsides after a little while.

Pull the thumb down and to the right and stretch those tissues for 1-2 minutes.

Pull the thumb down and to the left and stretch those tissues for 1-2 minutes.

Combine stretching down and stretching to the sides in a sweeping motion.

Procedure 2

Insert your thumb partially into the vagina.

Place your index finger on the outside of the vagina over the perineal body.

Roll the posterior wall of the vagina between the thumb and index finger.

Roll the tissues for 3-5 minutes.

Procedure 3

Place the index and middle finger on the outside of the vagina over the permeal body.

Massage the tissues sideways to free up tissue mobility and scar adhesions.

Massage for 3-5 minutes.

Table 8.

Self-Correction for a Right Inferior Pubic Bone

Lie on your back, knees bent, feet flat on the floor.

Bend your left leg up to your chest while trying to push it down with your left hand.

Push your right foot down into the floor at the same time.

Lift up your head and right shoulder and twist to the left.

Hold the partial sit-up and leg lifts for a count of 6.

Relax.

Repeat 3 times.

Table 9.

Self-Correction for a Forward Bent Coccyx

To relax the coccygeus muscle that may be tight and holding the coccyx forward.

Procedure 1

Sit on a firm chair.

Place a lipstick canister, pencil, or magic marker to one side of the tailbone where the muscle meets the bone and roll your full weight onto it for 30 seconds to 5 minutes.

Imagine that your muscles are melting over the cylinder and softening up.

Repeat for the other side of the tailbone.

Procedure 2

Lie on your side with the painful side up.

Reach around to the side of your tailbone and press firmly on the sore muscle.

Hold your pressure for 30 seconds to 5 minutes.

Repeat for the other side by rolling over.

Procedure 3

Lie on your side.

Place your finger over your tailbone.

Contract your muscles around your anus and vagina and lift up and in.

Press your tailbone in with your finger and hold it in for 6 seconds, then relax your muscles.

Repeat the sequence 3 times.
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Date:Dec 1, 2000
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