Re-capturing Sensual Pleasure After Resolution of Pelvic Pain: CSM Presentation

The female sexual response cycle is more than physical stimulation. As pelvic therapists, we frequently find ourselves treating pelvic pain that has interrupted a woman’s ability to enjoy her sexuality and sensuality. As physical therapists, we focus on the physical limitations and pain generators as a way of helping patients overcome their functional limitations. However, many of us find that once many of the physical symptoms have cleared with pelvic floor and fascial stretching, our patients are still apprehensive to engage physically, or they are not able to derive pleasure. There is clearly a gap that needs to be bridged that goes beyond pain.

Last year I taught my class, Lumbar Nerve Manual Assessment and Treatment. I was honored and astounded to have Dee Hartmann, PT in my class. For those of you who do not know Dee, she has been a champion of our field for a long time, and she has been instrumental in elevating physical therapy as a first line of treatment in pelvic pain through her work, international leadership, and representation in multiple organizations, including APTA SOWH, ISSVD, IPPS, NVA, ISSWSH, and as an editor for the Journal of Sexual Medicine.

In this manual nerve class, I was teaching how to treat the path of the genitofemoral nerve, which affects the peri-clitoral tissues and sensation. We also covered manual therapy approaches to decrease restriction in the clitoral complex and improve the blood flow response in this region. Dee was fascinated and looped me into what she had been working on for the past several years. She has been working as part of a company called Vulvalove with her partner, sex therapist, Elizabeth Wood on studying and teaching women how to recapture their sensuality. Immediately, we wanted to combine forces in some way to present a way to approach these issues. So, when Dee invited me to present with Elizabeth and her at the Combined Sections Meeting of the American Physical Therapy Association (CSM) this year, I was humbled and excited to jump on board.

With improved tissue mobility in the clitoral and vaginal area, blood flow is able to improve through any previously restricted tissues. With any manual therapy or soft tissue work, it is expected that cutaneous circulation of blood and lymph will alter. In studies, a measure of this blood flow, VPA (Vaginal Pulse Amplitude) is higher in the arousal than the non-arousal state in women.⁴ “The first measurable sign of sexual arousal is an increase in the blood flow. This creates the engorged condition, elevates the luminal oxygen tension and stimulates the production of surface vaginal fluid by increased plasma”.⁵ Manual therapy can likely affect this.^1,2. During our CSM talk, I will discuss the neurovascular anatomy and will have a brief video of manual techniques to enhance these pathways in my portion of the presentation.

In the 19th century, female orgasm and sensuality was believed to be more vaginal, but as the 20th century unfolded, understanding of the clitoral tissues improved. More recent research reveals the origin of female pleasure is more complex, involving the clitoris, vulva, vagina, and uterus.³ However, female response is more complicated than just anatomy below the waist.

Heart Rate Variability (HRV) is a measure of autonomic nervous system health and the ability to flux between sympathetic and parasympathetic states. Autogenic training and meditation or mindfulness have been shown in multiple studies to improve HRV. A study by Stanton in 2017 demonstrated that even one session of autogenic training can increase HRV and VPA (Vaginal Pulse Amplitude, a measure of arousal). In our talk at CSM, Dee will cover the role of autogenics and how to specifically and practically use our autonomic state to influence our perception and feeling of pleasure. Dee will also cover extensive clitoral anatomy to have a better understanding of how this intricate complex functions and is structured in women.

Elizabeth Wood, a former sex therapist who is now a sex educator, will then present on the arousal cycle and what can be done physiologically to prepare the arousal network for climax. Elizabeth will help us to better define and understand the roles of arousal, calibration, and exploring sensuality, including exercises to help a patient have a more fulfilling experience once the physical pain is resolved. As Elizabeth says, “Knowledge is an antidote to shame and an invitation to pleasure”.

If you will be at CSM, please come join us at the opening session, Thursday February 13 from 8am-10am (PH2540), “Now That The Pain Is Gone, Where’s the Pleasure”.

If you can’t make it to CSM, I hope to see you at one of my nerve classes, “Lumbar Nerve Manual Therapy and Assessment” this year in Madison, WI April 24-26 or Seattle, WA October 16-18 to further explore manual therapies to improve sensation and neural feedback loops and to continue this conversation!

1. Portillo-Soto, A., Eberman, L. E., Demchak, T. J., & Peebles, C. (2014). Comparison of blood flow changes with soft tissue mobilization and massage therapy. The Journal of Alternative and Complementary Medicine, 20(12), 932-936.
2. Ramos-González, E., Moreno-Lorenzo, C., Matarán-Peñarrocha, G. A., Guisado-Barrilao, R., Aguilar-Ferrándiz, M. E., & Castro-Sánchez, A. M. (2012). Comparative study on the effectiveness of myofascial release manual therapy and physical therapy for venous insufficiency in postmenopausal women. Complementary therapies in medicine, 20(5), 291-298.
3. Colson, M. H. (2010). Female orgasm: Myths, facts and controversies. Sexologies, 19(1), 8-14.
4. Rogers, G. S., Van de Castle, R. L., Evans, W. S., & Critelli, J. W. (1985). Vaginal pulse amplitude response patterns during erotic conditions and sleep. Archives of sexual behavior, 14(4), 327-342.
5. Stanton, A., & Meston, C. (2017). A single session of autogenic training increases acute subjective and physiological sexual arousal in sexually functional women. Journal of sex & marital therapy, 43(7), 601-617.