Case Study: Increased Tension In The Pelvic Floor Muscles

Sonya was referred to WMHP for obstructed defecation and pain with bowel emptying. However, following a thorough biopsychosocial assessment, it emerged that Sonya’s main concern was dyspareunia.  This case study explores the complex inter-relationships of bladder, bowel, and sexual function, and highlights the sequela of increased tension in the pelvic floor muscles (previously termed an “overactive pelvic floor”).

Subjective Assessment

• History:
  • Sonya, a 28-year-old nulliparous female, was referred to WMHP from a colorectal surgeon, with a 12 month worsening history of difficult evacuation and pelvic pain during and after a bowel motion. These symptoms commenced following surgical incision of a perianal abscess. Prior to the abscess, Sonya had no bowel dysfunction or pain.
  • At her initial physio consultation, Sonya reported intense rectal, perineal and gluteal pain with bowel opening, which would last  up to 8 hours each day, and impact her ability to sit and function at work.
  • Her bowel routine consisted of emptying once per day in the morning of a Bristol Stool Scale type 2. She would not wait for a bowel urge, as she ‘wanted to go before she left for work’, so would strain to empty.  She was ‘terrified’ to open her bowels.
• Previous treatment: Botox injection into the external anal sphincter did not alleviate her symptoms, she was then referred to WMHP.
• Bladder: Sonya reported increased urinary frequency and voiding dysfunction with hesitancy and slow flow.  
• Sexual function: Prior to the surgery Sonya was not sexually active. She was married 6 months ago and has not been able to consummate her marriage due to superficial dyspareunia. Sonya has never used tampons before as she ‘doesn’t like the thought of putting anything up there’, and has never had a pap smear.
• Attitudes towards sex: Thorough psychosexual questioning and exploration of Sonya’s thoughts about sex revealed poor libido, and a belief that sex is ‘dirty’. She wants to be able to have sex so she can get pregnant, and please her husband.
• Social history: Sonya is feeling intense family pressure to become pregnant since her wedding 6 months ago. She also reports pressure from her husband who has said ‘she is not a good wife if she can’t have sex’.

Objective Assessment

• Per rectum examination: Spasm of the external anal sphincter, with inability to contract or relax. Unable to complete examination due to pain.
• Per vaginum examination: presence of vaginismus, increased resting tension, pain and an inability to contract or relax the pelvic floor muscles.
• Defaecation dynamics: straining with breath holding and uncoordinated abdominal and pelvic floor muscle pattern.

Impression

Sonya is an interesting case, highlighting the multidimensional nature of dysfunction in the pelvis.  It is probable that Sonya may have had pre-existing pelvic floor muscle dysfunction related to her thoughts and beliefs surrounding penetration of any kind. It is likely that the pain of the perianal abscess and subsequent surgery contributed to spasm of the pelvic floor muscles. This led to obstructed defecation, constipation, pain with bowel emptying, and lower urinary tract symptoms.  Ongoing pain and fear associated with bowel emptying have further contributed to increased muscle tension and central sensitisation.

Sonya’s pelvic floor muscle dysfunction, combined with low libido, and unhelpful thoughts and beliefs about sexuality and intercourse, would have subsequently led to dyspareunia.  

This complex presentation is extremely common amongst our patients, and demonstrates the importance of a thorough assessment, as problems in the pelvis are often not isolated.

The significant psychosocial contributors in Sonya’s history include negative pre-existing beliefs regarding her pelvic anatomy, the pressure by her family to become pregnant, pressure by her husband to have intercourse, her fear of bowel emptying, and unhelpful thoughts and beliefs about her condition.

Treatment Program

Sonya was treated with a biopsychosocial approach to management. Key treatment areas included:

• Education: Sonya had a very poor understanding of her own anatomy.  She was provided with extensive education about her pelvic anatomy and an explanation for why she was experiencing her symptoms.  The simple technique of showing Sonya her vagina and anus in a mirror and explaining the anatomy was a ‘lightbulb’ moment for her, helping her understand why she couldn’t have sex without pain.
• Stool manipulation: following analysis of a bowel diary, Sonya was recommended Movicol to soften the stools, which was effective.
• Retraining in defecation dynamics: Sonya was taught the correct posture and technique for bowel emptying, and taught a morning bowel routine to facilitate a bowel urge after breakfast.
• Pelvic floor re-education: Instruction in pelvic floor muscle downtraining / relaxation including design of a home program to normalise muscle tension, and internal pelvic floor muscle release in-rooms was performed.
• Therapeutic neuroscience education: Education on the role of the brain in pain perception, which helped alleviate her fear associated with bowel emptying and intercourse, and calmed her sensitised nervous system.
• Biofeedback with rectal balloon therapy: Rectal balloon therapy was used to treat Sonya’s obstructed defecation.  In rooms therapy included Sonya practicing relaxing her pelvic floor and external anal sphincter to allow the rectal balloon to be expelled.
• Desensitisation with vaginal trainers: rather than using trainers to “stretch out” the vagina, Sonya was educated that their purpose is to change her response to penetration.  This graded exposure retrains the sensitised nervous system, emotional response and reflex pelvic floor muscle tension.    
• Arousal and desire: Sonya and her husband were educated about the importance of intimacy, arousal, and desire in their relationship, and were referred to a sexual counsellor.

Outcome

After 3 weeks of treatment, Sonya was emptying her bowels regularly without straining or pain.  After 6 months of treatment, Sonya and her husband were able to consummate their marriage.  

Sonya and her husband attended sexual counselling together, which was very helpful in developing intimacy in their relationship and in combination with the management strategies outlined above, led to them enjoying a healthy, pleasurable and pain free sexual relationship.