My interview with pelvic floor physical therapist Dr. Julie Sarton, PT, DPT, WCS, was filled with so much great information, I couldn’t fit it all into one post. Here is part 2!
4. What could someone dealing with painful sex gain from seeing a pelvic floor physical therapist like yourself?
I think that we are just touching the tip of the iceberg in terms of people who suffer from painful sex. It’s an intimate condition, and is underdiagnosed—some studies suggest that as many as 40% of women suffer from painful intercourse! When we look at sexual pain there are multiple potential causes, but the musculoskeletal system is one of them that I think is routinely missed. I would guess maybe less than 10-20% of physicians (OBGYNs) out there, during the time of the annual exam, ask patients about their sexual life and screen for potential pain. If the musculoskeletal system is found as a driver, a pelvic floor physical therapist is critical in helping that patient achieve a pain free state.
We become one of the primary care practitioners that help. I think it’s important to remember that almost any problem, whether it’s pelvic pain or sexual pain, usually requires multi-modal therapies. So we are one piece of it, rarely working in isolation. You need a village—a team. We need to be working hand in hand with a physician that can help with the medical management, a good psychologist or sex therapist that can deal with the psychological elements that come, and some people need a pain management doctor, or a guided imagery therapist (like we’ve recently integrated), acupuncturist, etc. There is a different team for different patients, but I would say that the physical therapist for many patients becomes one of the mainstays.
5. What should a new patient expect at their first physical therapy session?
The first session—the evaluation—is always going to be the longest. It’s always going to start with an extensive time period to go through the patient’s history. So many of the patients have been bounced from doctor to doctor and never truly been heard. So our goal with that first visit is to hear the entire story. We want not only for them to be heard, but we need to pull all those pieces out from the past that have set the stage and connect the dots to come up with why they’re presenting the way they do. The next piece is the anatomy and we thoroughly explain to the patient because it can be scary and intimidating, so we go through the anatomy with a 3-dimensional model, thoroughly explaining—this is where the pelvic floor is, these are where the muscles go, this is the nerve innervation, these are the functions—so the patient is comfortable with the exam.
At that point we exit and the patient will get undressed and underneath a sheet. But we start externally because you can’t look at the pelvic floor in isolation. We start with the patient’s posture, looking at the pelvic alignment, the external muscles, and the tendons and ligaments. A major portion of the evaluation is actually an external evaluation that you would get with an orthopedic physical therapist, though more in depth because of our training and length of treatment. The final component, if necessary, is an internal exam. This is somewhat similar to an OBGYN exam for women or a prostate exam for men, but we are going to be examining in detail the musculoskeletal system. If we need to, we keep the model on top of the patient’s belly as we’re doing the internal work. We always tell them they are totally in control and we are communicating the entire time. Among other things, we are looking for “trigger spots” that can reproduce the pain or the symptom of the patient.
Knowledge is power, so once a patient understands the anatomy and we can reproduce their symptoms, we usually hear “I got it, wow…how come no one else could figure this out?” It’s validating for the patient, especially when we can reproduce the patient’s pain symptoms, whether it’s sexual pain or pelvic pain. Unfortunately, patients are often told the wrong thing from general practitioners. Many of our patients have been misdiagnosed three or more times before they reach our office. We are working with local practitioners and schools to increase awareness and knowledge, and are slowly seeing an improvement.
I’ve heard terrible things over the years of what patients have been told by practitioners. Often, if the cause of the pain isn’t apparent, a doctor can be quick to dismiss it as “all in your head” and try and refer the patient to a psychologist. Other times patients can undergo “exploratory surgery” to look for problems that aren’t there at all. One patient, with one of the most severe cases of vulvodynia I have seen, was told by her doctor “you’re taking too much time in my office. I have patients I have to deal with that are worrying about dying.” And she looked at him and said, “Do you know that my pain is so bad that it makes me want to die?” I don’t think you can underscore the importance of how much this truly does impact people’s lives. Doctors and insurance companies need to take this seriously—we all do.
6. Do you have any recommendations or words of advice for someone who is looking for or trying to choose a pelvic floor physical therapist?
This is a good and important question because a lot of people can go take a weekend course and hang their shingle and claim that they’re a pelvic floor physical therapist. With how complicated and complex these pelvic floor conditions are, years of experience and training are often necessary before a physical therapist is truly qualified.
So as a patient when you’re looking, you really need to look deeper into the credentials of the physical therapist. You will want to know how long they’ve been doing this type of work, and what truly their training and coursework is. The American Physical Therapy Association now has advanced board certification for pelvic floor physical therapists and it’s called the Womens Clinical Specialty, or WCS (it should be in general pelvic floor clinical specialists because we treat men too who have the same issues). This board-certification requires at least three years of practice, thousands of hours, the preparation of a case study, and the passing of a comprehensive, half-day exam. Don’t be afraid to ask! This is your health, and no good physical therapist will ever resent being asked these kinds of questions—we want you to ask us, and take an active role in your own healing.
The WCS certification is a great place to start, though you may want to look into their subspecialty (pregnancy, incontinence, pelvic pain, lymphedema) if they have one. Have a phone conference with the physical therapist before you go into the office if you need to. Do some background research and then beyond the credentialing, make sure it’s a good fit for you—not just personality style but treatment style and approach. Additionally, you need a physical therapist that is plugged in with a good solid network of providers, because the pelvic floor physical therapist ends up becoming almost like the case manager for the patient. They should be able to recommend doctors, surgeons, psychologists, or other practitioners that may be able to help. And again, a lot of these patients see multiple doctors, so the physical therapist starts to help coordinate and synthesize all the information coming from these various physicians. It is also important to find a physical therapist that will be equally yoked with you in terms of also pursuing treatment and respecting what you want. I believe the patient knows her or his body better than anyone, so a physical therapist should be your partner in healing, working with you towards your goals.
*For more advice on finding a pelvic floor physical therapist, check out Finding a Pelvic PT by fellow blogger and physical therapist Dr. Jessica Reale, DPT, WCS.
7. Why do you think someone suffering from pelvic pain and painful sex who could benefit from pelvic floor physical therapy never actually starts therapy?
There are many different stumbling blocks for patients in their road to recovery. Many patients are misdiagnosed by their doctor. Or, even if they are correctly diagnosed, they are referred to the closest clinic to where they live instead of to the best treatment. In some places, it’s very difficult to even find a pelvic floor physical therapist. We are lucky here in California, but fewer than 150 board-certified therapists are available in the entire country! We get patients who come in from across the country, or even internationally, who stay for the week in order to take advantage of the treatment at our clinic and the local network of great doctors and specialists.
Sometimes a patient may not have an understanding of their condition, or may be embarrassed by the personal nature of their problems. We let all of our patients know that just about everyone will struggle with a pelvic floor condition at some point in their lives. Like all of us, pelvic floor patients sometimes just hope that their condition will get better all by itself, but this rarely happens. Fortunately, people like you, Sarah, are working to get the word out about these conditions and the possibilities for hope and healing for pelvic floor patients.
For more information about Dr. Julie Sarton and Sarton Physical Therapy, check out their website at PelvicHealing.com. You can also contact the clinic directly at (714) 770-8222.