Hypertonic vs. Hypotonic Pelvic Floor Dysfunction: Vaginismus, Pelvic Organ Prolapse, & More

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Pelvic floor dysfunction (PFD) isn’t a single diagnosis: it’s a spectrum. PFD ranges from hypertonic (pelvic floor muscles that are too tight) to hypotonic (pelvic floor muscles that are too weak). And within those categories lie subcategories — diagnoses like vaginismus, pelvic organ prolapse, and urinary incontinence — each with their own point along the spectrum.

Unfortunately, many doctors still view PFD as one diagnosis. They prescribe Kegel exercises for incontinence, or “more lube” for sexual pain, then send you on your merry way… only you don’t feel very merry, do you? You feel confused and disappointed, wondering if you will ever find a cure for your pain.

The problem with treating PFD as a single diagnosis is that it overlooks the spectrum of dysfunction that exists within our pelvic floor muscles. Without pinpointing the exact problem, your pelvic floor PT (or whatever provider is treating you) won’t know the right exercises to help you overcome your specific complaints.

Most pelvic floor PTs can determine whether you have hypertonic or hypotonic PFD upon an initial evaluation. My pelvic floor was so tight at my first PT appointment, there was no way my provider could have missed it! Yet the hard work doesn’t end there: it’s also important to understand the spectrum of pain and where your personal experience lies on that spectrum.

The spectrum of pelvic pain encompasses disorders ranging from vaginismus, the tightest pelvic floor possible, to pelvic organ prolapse, the weakest pelvic floor possible. Treatments for pelvic floor conditions vary widely, making it important to get the right diagnosis.

In this blog post, I’ll share my personal experience with hypertonic pelvic floor dysfunction and vaginismus, as well as explore the different types of PFD that often affect people with vaginas, to help you better understand your pain and what you and your providers can do to treat it.

As always, I’d like to warn that I am not a health expert — just a patient. I cannot diagnose or treat you, so please consult with your doctor before making any important decisions about your health!

Types of Pelvic Floor Dysfunction

The pelvic floor is a bowl-shaped group of muscles that supports your reproductive organs, your bladder, your bowel, and more. Problems can occur with any of these organ systems when the pelvic floor muscles are too tight or too weak.

Exercising your pelvic floor after the birth of your baby

Many people wrongfully assume that pelvic floor dysfunction occurs only in women and only affects reproductive organs like the vagina and uterus. In reality, people of all genders deal with PFD, and PFD can affect any organ supported by the pelvic floor muscles.

You probably remember from high school biology that the prefix “hyper-” means too much and the prefix “hypo-” means too little. From that, we can deduce that hypertonic means too much tone and hypotonic means too little tone — muscle tone, that is.

Rather than separate groups of conditions, I like to think of PFD as a spectrum. If hypertonic PFD and hypotonic PFD are the two extreme points on a line, the ideal pelvic floor is the midpoint of that line. Like Goldilocks, you don’t want a pelvic floor that’s too weak or too tight, but “just right!”

Hypertonic Pelvic Floor Dysfunction

Hypertonic pelvic floor dysfunction occurs when your pelvic floor muscles are too tight…. and yes, there is such a thing as your vagina being too tight. As someone with hypertonic PFD, I find it incredibly ironic that straight men have conditioned us to strive for a “tight vagina.” Thanks, porn!

This problem can develop in a number of ways, but it is often a response to chronic pelvic pain (CPP). When our body is in pain, it learns to clench the muscles surrounding the painful area to protect itself. As a result of this chronic clenching, people with CPP can develop hypertonic PFD.

Signs and symptoms of hypertonic PFD can include:

  • Constipation
  • Dyspareunia (painful sex)
  • Chronic pelvic pain
  • Muscle spasms
  • Urinary frequency
  • Trouble starting the stream of urine
  • Straining to empty the bladder

Unsurprisingly, hypertonic PFD is also linked to chronic pain conditions like endometriosis and irritable bowel syndrome. Having one of these conditions does not guarantee you will develop hypertonic PFD, but it does make it more likely.

Treatment for hypertonic pelvic floor dysfunction involves retraining the pelvic floor musles to relax. This can involve pelvic floor physical therapy and, for people with vaginas, dilator therapy. In severe cases, trigger point injections and even surgery can help alleviate the symptoms of hypertonic PFD.

What is vaginismus?

In people with vaginas, hypertonic pelvic floor dysfunction is often used interchangeably with the term “vaginismus.” Vaginismus involves involuntary contractions of the pelvic floor muscles, paired with intense anxiety and pain surrounding penetration, whether with a partner, a speculum, a tampon, or even a finger.

Like all types of PFD, vaginismus is a spectrum, ranging from “true” vaginismus (where the patient can’t insert so much as a Q-tip comfortably) to milder forms, like the one I suffer from. It frequently develops in conjunction with other pain conditions, like vulvodynia and vestibulitis. Sometimes, vaginismus is linked to sexual trauma and shame, making it especially prevalent in religious communities and among survivors of sexual assault.

Hypotonic Pelvic Floor Dysfunction

Hypotonic pelvic floor dysfunction occurs when, you guessed it, the pelvic floor muscles are too weak. This problem can stem from underuse of the pelvic floor muscles, radiation treatment, pelvic surgery, pregnancy, or delivery.

Signs and symptoms of hypotonic PFD can include:

  • Urinary or anal incontinence (“leaking”)
  • Passing gas when bending or lifting
  • Pain or pressure in the pelvis
  • A feeling of something bulging into or falling out of the vagina
  • Decreased sensation during sex

The most serious consequence of hypotonic PFD is a condition known as pelvic organ prolapse. A prolapse occurs when the muscles surrounding the organs are so weak that they can no longer hold the organs in their proper place.

People with pelvic organ prolapse may experience uterine prolapse, where the uterus inverts or comes out through the vaginal opening; vaginal prolapse, where the top of the vagina drops through the vaginal opening; or rectal prolapse, where the rectum bulges into the vagina.

Treatments for Pelvic Floor Dysfunction

Pelvic floor dysfunction is common, affecting one in five people over the course of their lifetime and about a quarter of women. But just because PFD is common does not mean you have to accept it as normal.

Thankfully, pelvic floor disorders are highly treatable. Many cases resolve with minor treatment, like pelvic floor physical therapy and lifestyle changes, while more severe cases may require medications or surgery.

Treatments for Hypertonic Pelvic Floor Dysfunction

Treating hypertonic PFD involves learning to relax and lengthen the pelvic floor muscles. There are a number of ways to accomplish this, both with medical treatment and self-help strategies at home.

Pelvic Floor Physical Therapy

Pelvic floor physical therapy is the most important thing you can do for hypertonic PFD. As my doctor put it, the first, second, and third recommendations for treating hypertonic PFD are physical therapy! Working with a pelvic floor physical therapist, you can learn to actively relax and lengthen your pelvic floor muscles until it becomes second nature. This process of developing greater control over the pelvic floor is known as biofeedback.

Dilator Therapy

Silicone or plastic dilators can help you stretch and relax the pelvic floor muscles. They are graduated in size and used progressively to rehabilitate your pelvic floor. Traditionally, dilator therapy was developed for the treatment of vaginismus. However, dilators can also be used as tools for the myofascial release of tight pelvic floor muscles.

My favorite dilators are made by Soul Source Therapeutics. All of their products are body safe, latex-free, and soft in texture for gentle dilator therapy. I use the Medium Set of silicone dilators. Best of all, you can use my affiliate code ENDOSTRONG to get 15% off your purchase from Soul Source! Click here to shop.

Soul Source Silicone Vaginal Dilators, Medium Set

Trigger Point Injections

Trigger points are areas where the pelvic floor muscles or fascia are especially tight. Trigger point injections can aid in myofascial release of the pelvic floor by getting medication directly into painful areas. Usually, numbing agents like lidocaine are used. Sometimes, Botox can also be injected to treat pelvic floor muscle spasms. These are not a first-line treatment option but may be used for severe cases.

Estrogen Therapy

Diminished hormone reserves may contribute to pelvic floor pain in some people, especially in people who are taking hormonal birth control or who are menopausal. Topical estrogen cream is an effective solution for some of these patients and may relieve symptoms like dyspareunia. Estrogen therapy starts at very low doses to minimize the associated risks, such as endometrial or ovarian cancers. You may be unable to use topical estrogen if you have had an estrogen-related cancer in the past.

Self-Help

Self-help strategies aren’t a replacement for the medical treatment of hypertonic PFD, but they are effective when used in conjunction with other treatment options, such as pelvic floor physical therapy. Some self-help tips for hypertonic PFD include:

  • Building relaxation into your day with activities like yoga, meditation, or even adult coloring
  • Trying some gentle pelvic floor stretches one to two times per day
  • Modifying your core workouts to avoid sit-ups and crunches
  • Using only 100% cotton, bleach- and chlorine-free menstrual products (or a soft menstrual cup)
  • Cutting out irritants by wearing only 100% cotton underwear and only washing the vulva with fragrance-free soap
  • Avoiding urinary continence, or holding in your pee; instead, try to go before the need to pee becomes urgent
  • Applying an ice pack wrapped in a washcloth or towel to the vulva to relieve pain after sex — or Honey Pot Co.’s cooling Lavender Vulva Cream with mint and coconut oil

Treatments for Hypotonic Pelvic Floor Dysfunction

Treatment for hypotonic PFD involves strengthening the weak pelvic floor muscles through exercise and physical therapy. Occasionally, more invasive treatment — such as surgery — is required.

Pelvic Floor Physical Therapy

Again, pelvic floor physical therapy is the most important step you can take to strengthen your pelvic floor. Many people who suffer from hypotonic pelvic floor dysfunction don’t even know how to locate the pelvic floor muscles. During treatment, a pelvic floor physical therapist will walk you through contracting and relaxing your pelvic floor muscles in an exercise known as Kegels. If you are not sure if you have hypotonic PFD, you should not start doing Kegels without first seeing a physical therapist, as you could have another type of PFD. Kegels can actually make hypertonic PFD worse.

Catheterization

Urinary incontinence — or involuntarily leaking urine when you cough, laugh, sneeze, or exercise — is a common sign of hypotonic PFD. Sometimes, doctors recommend a urinary catheter for the treatment of urinary incontinence, especially in older adults. Catheters are devices that help collect urine without you needing to go to the bathroom to pee. Foley catheters can be used for up to two years and are inserted into the urethra. For long-term treatment longer than two years, doctors use indwelling subrapubic catheters, which are surgically inserted into an incision in the pelvis. Catheters aren’t the first line treatment for hypotonic PFD because they come with a high risk of infection, but they are an option for severe cases of urinary incontinence.

Pessaries

A pessary is a supportive device inserted non-surgically into the vagina to support the pelvic organs. It is used to treat pelvic organ prolapse. Some pessaries can be removed and reinserted at home, while others must be placed by a doctor. If your pessary needs to be inserted and removed by a doctor, you will need to have it replaced at least every three months to prevent infection.

Surgery

Surgery may be necessary if you are experiencing pelvic organ prolapse, especially in the rectum. A specific condition known as a rectocele can form when the rectum bulges into the vagina due to prolapse. Rectoceles often require surgical repair. The two types of surgery for pelvic organ prolapse are obliterative and reconstructive surgery. Obliterative surgery narrows the vagina to provide support for pelvic organs; however, penetrative intercourse is no longer possible after this procedure. Reconstructive surgery is an alternative that aims to restore the organs to their original position. Like endometriosis surgery, it can be done laparoscopically.

Self-Help

You can’t replace medical treatment for hypotonic pelvic floor dysfunction with self-help strategies, but they can improve your quality of life with PFD. Some self-help tips for hypotonic PFD include:

  • Practicing biofeedback using a smart device like the Elvie Trainer
  • Performing Kegels when you sneeze, cough, or laugh to help hold in urine
  • Trying Pilates or yoga to strengthen the pelvic floor
  • Modifying your core workouts to avoid sit-ups and crunches
  • Avoiding dietary triggers like alcohol, artificial sweeteners, caffeine, and carbonated beverages
  • Training yourself to pee on a schedule, gradually increasing the amount of time between urination
  • Wearing pee-proof panties to collect urinary leakage throughout the day

More Resources

Vaginal Dilator Exercises for Psychosexual Therapy

Oxford University Hospitals

Pelvic Floor Exercises with Breathing

Dr. Beth Shelly, PT, DPT

Easy Stretches to Relax the Pelvic Floor

VuVa Tech

Dilating is Doable Series

The Vaginismus Network Blog

Self-Help Tips

National Vulvodynia Association

Effective Kegel Exercises: A Full Workout Plan for Beginners

Ruby Cup

How to Do Pelvic Floor Exercises

Always Discreet

Finding Bladder-Friendly Foods

Interstitial Cystitis Network

Heal Pelvic Pain (Book)

Amy Stein, DPT

Sex Without Pain (Book)

Heather Jeffcoat, DPT

*Use my affiliate code ENDOSTRONG for 15% off your purchase at Soul Source!

Ohnut

A set of four protective, stackable rings worn around the base of the penis to limit the depth of penetration for people with vaginas who experience deep dyspareunia.

*Use my affiliate code ENDOSTRONG for 15% off your purchase at Soul Source!

Wild Flower Sex Shop

A sexual wellness boutique for people of all genders. I include this link because Wildflower sells flexible dildos that are a great “next step” after completing dilator therapy for vaginismus.

Getting Started with Pelvic Floor Physical Therapy (featuring Soul Source!)

Disclaimer: This post represents a paid partnership with the brand Soul Source.

Thank you so much to Soul Source for sponsoring Endo Strong!

When I first suspected I might have endometriosis, I expected to be told I needed surgery. I had done enough research to know that the only way to definitively diagnose endometriosis is by diagnostic laparoscopy. But what I didn’t expect was to hear that my pelvic floor muscles had become dysfunctional. Now, I was going to need to do internal work with a pelvic floor physical therapist in order to retrain my body to release its muscles and relieve its pain. I’m pretty sure my first thought was, Um, what?!

Beginning pelvic floor physical therapy shook my world, in more ways than one. In case the experience of a stranger poking around my most intimate body parts was not jarring enough, I quickly discovered how painfully slow the process of pelvic floor physical therapy can be. It’s important not to progress through the exercises too quickly, as moving forward before you’re ready can actually make things worse. And, if pelvic floor PT wasn’t slow enough already, the coronavirus quickly put a stopper in my plans for pelvic floor physical therapy.

If I’m being honest, it didn’t take me long to fall behind on my at-home exercises. During the first months of the coronavirus, I spent more time grieving for my missed appointments and canceled surgery than actually working toward my recovery. And that’s okay — I needed that time to feel sorry for myself. I think we all did at that point. Between canceled surgeries, weddings, graduations, sports tournaments…there’s not a single person I know who hasn’t lost something to this pandemic.

But now, as cities begin to reopen, it’s no longer time to feel sorry for myself. It’s time to get back on the pelvic floor PT bandwagon! Admittedly, after not doing it for so long, pelvic floor PT feels hard. In some ways, it feels just as difficult as when I started. But then I remember how frightened and uncertain I felt when I first got started. Not only did that shift my perspective, but it also inspired me to write this article.

If I felt that scared and unsure when I was being guided by a pelvic floor physical therapist, I can’t imagine how people must feel when they are starting their pelvic pain journeys in the middle of a global pandemic. Sure, now that states are reopening, some of us, like me, are willing and able to risk ourselves to visit a physical therapist in person. Yet I recognize that it is a privilege to be able to do so.

That brings me to the purpose of today’s post. Today, I’m teaming up with Soul Source — yep, the original silicone dilator company! — to share a comprehensive resource for all my endo friends who are getting started with pelvic floor PT at home. To be honest, I’m a little starstruck about this collaboration, since Soul Source was one of the first resources I found on my pelvic floor PT journey. I’ve been keeping it quiet for about a month now, and I’m so glad to finally be able to share it with you all!

Why Pelvic Floor Physical Therapy?

As an endo patient, you may have already heard of pelvic floor PT. However, it’s important to note that pelvic floor PT addresses a specific type of pain caused by a disorder known as pelvic floor dysfunction (PFD), rather than pain directly caused by endometriosis.

Chronically tight pelvic floor muscles cause a type of pelvic pain called myofascial pain, which is just one form of PFD. This pain can cause areas of tenderness in the abdomen, pelvis, and vagina, called trigger points.

Over time, pelvic floor physical therapy can promote myofascial release through gentle trigger point massage. For people with vaginas, this usually means your physical therapist will perform internal work — which is why it’s crucial to find a physical therapist you feel comfortable with.

Endometriosis does not directly cause PFD, but PFD often develops in patients with endometriosis. When we experience pain, our body’s instinct is to protect itself by contracting the muscles surrounding that painful area. As a result, people with chronic pelvic pain (like endo patients) may develop tight pelvic floor muscles.

While it’s true that laparoscopic excision surgery is the only viable treatment for endometriosis, many patients continue to experience pain after surgery. As my pelvic pain specialist back in Cleveland stressed to me, surgery can fix the pain caused by your endo, but it will not fix the added pain caused by your tight pelvic floor muscles.

Unfortunately, PFD does not go away when the endometriosis pain does, so removing endometriosis lesions will not cure PFD. The only way to fix PFD is to retrain your muscles through physical therapy.

Getting Started with Pelvic Floor Physical Therapy

To help you feel less overwhelmed, I’ll break getting started with pelvic floor physical therapy into three easy steps:

  1. Finding a pelvic floor physical therapist near you.
  2. Learning about pelvic floor physical therapy.
  3. Stocking up on pelvic floor PT essentials.

Step One: Finding a Pelvic Floor Physical Therapist

Oftentimes, reaching out to a pelvic floor physical therapist is scarier than starting the PT itself. As a sexual assault survivor, I definitely found this to be true. I knew if I was going to have internal massage done, I wanted my PT to be someone I could trust — but it’s difficult to know who you can trust simply by reading someone’s biography on a website.

You can approach finding a pelvic floor physical therapist in one of two ways. Your pelvic pain specialist or endometriosis expert might recommend a colleague who is a pelvic floor physical therapist. Or, you can search for a pelvic floor physical therapist on your own.

If it’s possible for you, I recommend, at the very least, visiting your endo doc before starting pelvic floor PT. Pelvic floor PT won’t help if your problem isn’t actually PFD, and your doctor can confirm the diagnosis of PFD through a pelvic exam.

You should always look for a pelvic floor physical therapist who is board-certified. There are a few types of board certification you might come across in your search for the right PT. All the abbreviations that are thrown around can make physical therapy seem like a foreign language — so allow me to translate two of the most common certifications you’ll see:

  • Women’s Clinical Specialist (WCS). The American Physical Therapy Association (APTA) represents more than 100,000 physical therapists in the United States. APTA delegates the supervision of its Women’s Clinical Specialist (WCS) board certification to the American Board of Physical Therapy Specialties (ABPTS). This means ABPTS administers the certification exam and governs who is eligible for certification. In order to call themself a WCS, a physical therapist must be licensed to practice PT in the United States, have completed at least 2,000 hours of direct patient care in the women’s health specialty, and submit an application for certification that includes a case reflection. After their application is accepted, they must sit for the certification exam. PTs can only use the WCS credential once they pass this exam.
  • Pelvic Rehabilitation Practitioner Certification (PRPC). The Pelvic Rehabilitation Practitioner Certification (PRPC) is overseen by Herman & Wallace Pelvic Rehabilitation Institute. The Institute primarily provides continuing education courses for current PTs, but also offers the PRPC. PRPC applicants do not need to be PTs to earn this certification; they may also be doctors of osteopathic medicine (DOs), physical therapist assistants (PTAs), registered nurses (RNs), and other medical practitioners with a valid U.S. license. In order to sit for the PRPC exam, professionals must document 2,000 hours of clinical experience in the women’s health specialty, but only 500 of those hours need to include direct patient care.

Search engines can help you locate a pelvic floor physical therapist, but they aren’t always reliable. Google won’t always tell you whether or not a pelvic floor PT has the right credentials or what those credentials mean. I recommend turning to sources like the International Pelvic Pain Society (IPPS), which has its own search engine to help you find a trustworthy provider specializing in pelvic pain. Other recommended sources include:

  • APTA Pelvic Health Academy, the APTA’s membership community of pelvic and abdominal physical therapists.
  • Global Pelvic Health Alliance, a global directory dedicated to helping you find pelvic health professionals.
  • Herman and Wallace, a continuing education resource in pelvic floor PT for physical therapists, whose website includes a directory of pelvic floor PTs. .

Step Two: Learning About Pelvic Floor PT

Making an appointment with a pelvic floor PT is an important first step that should be celebrated, but you might be itching to get started right away — I felt the same way! After all, when you’ve already waited 10 years for an endometriosis diagnosis, waiting a month for an initial PT appointment can feel like the straw that broke the camel’s back.

In the meantime, one of the most important things you can do, both for your physical health and your mental health, is to learn everything you can about the pelvic floor. Educating yourself through reading will help you understand your treatment plan better, converse more clearly with your pelvic floor PT, and become a more active participant in your PT experience.

There are so many great books and resources out there that have been recommended to me by doctors and patients alike. Here are a few of my favorites:

  • Heal Pelvic Pain by Amy Stein, DPT was the first chronic pelvic pain book ever recommended to me. I recommend buying your own copy of this book rather than borrowing it from the library, because you’ll definitely want to look back on it during your pelvic pain journey. It contains a week-by-week stretching and strengthening program for PFD and directions for performing internal massage at home.
  • The Chronic Pain Research Alliance offers a comprehensive patient guide to chronic overlapping pain conditions (COPCs), which include endometriosis, vulvodynia, and interstitial cystitis. As you may already know from reading my blog, many of these disorders go hand-in-hand — hence the term “overlapping.” The CPRA patient guide explains the mechanisms behind chronic pain, as well as things you can do at home to relieve the symptoms of COPCs.
  • The V Hive women’s health podcast, hosted by Hannah Matluck (a pelvic pain patient), is amazing on so many levels. In addition to covering everything from nutrition for endometriosis to the importance of periods in girls’ global access to education, the V Hive has tons of episodes related to chronic pelvic pain. Try listening to episode #57, Diagnosing and Treating Pelvic Pain, or episode #66, Why Our Pelvis is the Core of Our Well-Being.

Step Three: Stocking Up On Pelvic Floor PT Essentials

At some point in your pelvic floor PT journey, your provider is probably going to ask you to perform maintenance exercises between appointments, including internal trigger point massage. While doing exercises on your own can be intimidating at first, it definitely helps if you already have the right tools for the job.

Enter Soul Source. I first discovered Soul Source at the recommendation of my own pelvic floor PT, and quickly fell in love. I mean, there’s a lot of things to love about this company: their products are made in the United States, they were designed by a sex therapist and a gynecologist, and Soul Source performs global outreach to help women all over the world, to name just a few.

Soul Source makes and sells both rigid and silicone vaginal dilators, including the only vaginal dilators specific for transgender anatomy. Personally, I use their silicone dilators — in particular, the size #4 — to perform internal massage at home. (Please note that I exclusively use my Soul Source dilators under the guidance of my PT. Soul Source recommends that you consult a pelvic pain practitioner before use in order to get the most benefit from their products!)

The silicone dilators are especially great for people like me who suffer from vulvodynia in addition to PFD. Because I suffer from vulvodynia at the vestibule, penetration with a rigid dilator would be much more painful than using the silicone ones from Soul Source. I also know that their silicone dilators are often recommended to patients with vaginismus, a different sexual pain disorder characterized by painful contractions of the vaginal wall upon attempted penetration. Soul Source also makes rigid dilators that are recommended for trigger point release by many pelvic floor physical therapists.

All of Soul Source’s vaginal dilators are body-safe and easy to clean. They are widely used by the medical community (including my own doctors!), so you can trust that their products are legit. As someone with vulvodynia and chronic vaginal infections, it’s definitely important to me to be conscious of what I put into my body. I’ve never felt any hesitation about using Soul Source’s products — and if you prefer an extra layer of protection, they are condom-compatible.

While browsing the dilators at Soul Source, you can also stock up on other pelvic floor PT essentials. A quality lubricant is a must-have for internal work. I swear by Good Clean Love’s BioNude lubricant, which was formulated especially for extra-sensitive skin.

You can find this lube at Soul Source, as well as one of my other favorite pelvic pain buddies: the Ohnut! The Ohnut is a set of four flexible silicone rings worn on the penis to help partners explore comfortable penetration depths. If you don’t want to compromise intimacy as you work toward pain-free sex in PT (and if your provider gives it the okay), then the Ohnut is for you.

Want 15% off your purchase at Soul Source? Use the code ENDOSTRONG at checkout! Click here to shop.