By Dongfeng Zhou, AP, Dipl.OM

As many as 1 in 3 women will suffer from pelvic floor dysfunction. The more well-known syndrome is hypotonic pelvic floor dysfunction, widely recognized because it causes more common symptoms such as uterine or bladder prolapse, and urinary incontinence. In contrast, hypertonic pelvic floor dysfunction is not a well-known disorder. This syndrome

is classified by tight pelvic floor muscles that cause a variety of symptoms such as pain and difficulty urinating or defecating, and pain during intercourse. Women who suffer with hypertonic pelvic floor dysfunction require therapies which relax the muscles and tendons of the pelvic floor to reclaim their quality of life.

What are the symptoms of hypertonic pelvic floor dysfunction?

• constipation, straining or incomplete emptying of bowels

• pelvic, hip, coccyx or low back pain

• painful sex or vaginismus

• dysuria, urinary incontinence or urgency, and hesitant, slow or incomplete urination

What causes this dysfunction?

Pelvic Floor Hypertonicity is when the muscles become too tight or cannot relax. The muscles of the pelvic floor are directly affected and may cause problems in the piriformis, psoas, hip flexors, hamstrings, obturator internus, and other abdominal and back muscles. While there is no definitive cause of this dysfunction, there may be lifestyle contributions which can make it worse or may precipitate problems.

Activities can contribute to or worsen pelvic floor hypertonicity. Exercises that cause the abdominal muscles to over-tighten or hold for a long time may make pelvic floor hypertonicity worse such as dancing, gymnastics, or extreme workouts or ab work. The muscles are tightened for a long length of time, and then have a difficult time relaxing. Some people are predisposed to being very “tight” or inflexible.

Some people can develop the pelvic floor hypertonicity from holding their bowels or bladder too long. When people do not use the bathroom when they need to, the muscles over tighten to help retain control. This trains the body for tension in the pelvic floor and makes it more difficult to relax. Stress, fear, and anxiety can cause tense muscles that lead to this dysfunction as well.

Physical health conditions can lead to pelvic floor hypertonicity. Endometriosis, scarring or tearing during childbirth, irritable bowel syndrome, interstitial cystitis, vulvodynia, and pudendal neuralgia may contribute to this syndrome. The chronic inflammation, cramping, and pain can cause the muscles in the pelvis to tighten, leading to hypertonicity.

Vaginismus

One syndrome within the hypertonic pelvic floor dysfunction is called vaginismus, which may affect as many as 5-15% of women. This is a tightening or spasm of the muscles surrounding the vagina. The spasms cause pain, burning, and may even make it impossible to have intercourse. The underlying cause of these spasms is the decrease in circulation to the area and buildup of lactic acid due to poor circulation when the pelvic floor muscles tighten.

Treatments for Pelvic Floor Hypertonicity

There are several treatments available for pelvic floor dysfunction. Physical Therapy is a mainstream treatment for hypertonicity. Therapies include breathing exercises to relax the muscles and nervous system responses, physical release of the pelvic floor muscles, and practice relaxing the muscles involved with vaginismus. Kegel exercises are not indicated for hypertonicity issues, but rather hypotonicity. Other helpful therapies are pharmaceuticals such as benzodiazepines, Botox injections, hypnosis, and cognitive behavioral therapy. Acupuncture and herbs are excellent choices to help patients overcome pelvic floor hypertonicity and will be explored in-depth in the following case study.

Case Study:

Female patient, 41 years old, Caucasian, , single, has a boyfriend, no history of sexual abuse. She has had pain in the vagina for 8 months. She has had two previous episodes of pain in the vagina in the past 10 years. The previous two occurrences all resolved without intervention within a month. This time she has been treated for 8 months by another acupuncturist without relief. She was referred to me on 12/13/2018.

First Visit: 12/13/2018

Chief complaint: constant pain in the vagina. She stated that feel like a knife is scraping her vagina. This was triggered by a UTI followed by prolonged antibiotic treatment 8 months ago. Pain level is 6/10 today. The nature of the pain is sharp, stabbing, and constant spasms. She had a few days without pain after her menstruation. She states that her pain severely interferes with her daily life, and sometimes she has to take days off from work.

Secondary complaint: frequent urination and incontinence.

Other Complaints: sluggish bowel movements, occasional lower back pain.

Lab test: All blood tests were normal. All culture studies are normal. Progesterone level is slightly low. Low iron level, slightly anemic, and bruises easily.

Image Study: MRI indicated small bladder.

Gynecology: frequent urination, incontinence of urine occasionally. She stated that she has normal libido, but she is fearful of relationshipsbecause of the possibility of increased pain during intercourse. Moderate PMS that makes her pain worse. Regular menstruation cycle, 28 days, lasts for 4 to 5 days, dark red, small clots, moderate cramping during first day of period. Never been pregnant.

Lifestyle: Stressful life as a nurse in a busy medical office. Stress triggers her anxiety and acerbates her pain. Aversion to cold; pain relieved with warmth. She has a very healthy diet, eating mostly vegetables and trying to stay away from diary and gluten. She is doing yoga 2x a week as her major exercise.

Treatment history: she goes to a physical therapist who specializes in pelvic floor physical therapist twice a week. She also has been seeing other acupuncturist for 8 months who referred to me. She is using a dilator a home to relax her muscles. Warm bath always helps. She is taking Prozac for the anxiety and insomnia.

Medications: Prozac for the anxiety which arises from the hypertonic pelvic floor pain.

Observation: pale complexion, thin, fit, low voice, general nervousness, cold hands and feet. Lower abdomen slightly cold to the touch.

Tongue: dim pink, pale root, purple spots in the back, redder tip, thin gray coat.

Pulse: thin, soggy, moderate; weak right cun and left chi

Assessment:

Western medicine diagnosis: hypertonic pelvic floor syndrome, vaginismus.

TCM diagnosis: Yin Len 阴冷，Yi Niao 遗尿

TCM Pattern: Liver cold with damp accumulation, Liver Qi stagnation with Liver blood deficiency

Treatment principle: warm the Liver, resolve damp, move Liver Qi, and tonify Liver blood.

Treatment plan:

Acupuncture: LV 3, LV 8, SP 6, KD 3, KD 7, RN 3, Tung Point: Fu Ke. Ear Points: Shenmen, Liver, kidney, uterus.

Herbal formula:

Nuan Gan Jian 20g

Dang Gui Shao Yao San 20g

Shao Yao Gan Cao Tang 15g

Wu Ling San 15g

I also suggested that she refrain from consuming cold foods and drinksas well as dairy products.

Second visit 12/20/2018

Progress: Patient states that her pain is 4/10 in general; pain is less sharp and burning but still constant. Her urination is less frequent with better flow. She continues seeing her physical therapist, but reduced visits to once a week.

Tongue: dim pink, pale root, purple spots in the back, thin gray coat.

Pulse: the same as first visit, thin, soggy, moderate; weak right cun and left chi

Acupuncture: LV 3, LV 8, SP 6, KD 3, KD 7, RN 3, Foot Motor Sensory (FMS), DU 20, Tung Point: Fu Ke.

Herbal formula: same as first visit.

Nuan Gan Jian 20g

Dang Gui Shao Yao San 20g

Shao Yao Gan Cao Tang 15g

Wu Ling San 15g

Third visit: 1/04/2019

Progress: Patient states that her pain is 4/10 today; still has some burning pain, but it is more localized and less constant compared to her second visit. She also complains about her anemia and bruising easily. General fatigue due to holiday travel. She has refrained from cold foods and drinks as I instructed. She had sex and with mild discomfort.

Acupuncture: LV 3, LV 8, SP 6, KD 3, KD 7, RN 3, Foot Motor Sensory (FMS), DU 20, Tung Point: Fu Ke.

Herbal formula:

Nuan Gan Jian 20g

Dang Gui Shao Yao San 25g

Shao Yao Gan Cao Tang 15g

Wu Ling San 10g

I suggested that she continue to refrain from cold foods and drinks, and dairy products, and add more iron-rich foods such as beets to her diet.

Forth visit: 1/11/2019

Progress: Patient stated that her pain has been reduced significantly since last visit. Her pain is 3/10; she described she have “tightness” in her vagina at 2 o’clock position. She has more energy and more pain free days. She continues to see her physical therapist, but she is finishing up her sessions with them in two weeks. She has been more sexually active. Her urination is normal without incontinence. Her bowel movements have improved, but still somewhat loose. She is expecting her period in 6 days and experiencing PMS.

Tongue: dim pink, pale root, purple spots in the back, thick coating in the back.

Pulse: thin, soggy, wiry, moderate; weak right cun, wiry left chi

Acupuncture: BL 17, 18, 32, LV 3, SP 6, KD 3, KD 7, DU 20 and FMS

Cupping on the Bladder Channel.

Herbal formulas:

Nuan Gan Jian 15g

Dang Gui Shao Yao San 20g

Shao Yao Gan Cao Tang 15g

Gui Zhi Fu Ling Wan 15g

Fifth visit: 1/19/2019

Progress: Patient states that her pain is 2/10 today with no burning pain. Pain is less constant. She said 70% of her days without pain. She noticed her menstrual cramps are mild compared to last month. She stopped taking prozac and has difficulty falling asleep. She is also stop seeing her pelvic floor therapist last week.

Tongue: dim pink with thin gray coat

Pulse: thin, soggy, moderate; weak both cun

Acupuncture: RN 3, 6, LV 3, SP 6, KD 3, KD 7, DU 20 and FMS, HT 7, Ear seeds: shenmen, uterus, Liver, tranquilize.

Herbal formula:

Nuan Gan Jian 20g

Dang Gui Shao Yao San 20g

Fu Shen 8g

Yuan Zhi 5g

Ye Jiao Teng 7g

He Huan Hua 5g

Da Zao 5g

Sixth visit: 2/03/19

Progress: Patients stated that she has not has any pain recently. She has pain occasionally, but it’s more like “tightness” than pain. She is able to sleep better with less anxiety. Her energy level is increased, and she is able to manage daily tasks. She said she is sexually active without pain. We discussed about reducing the dosage of herbs to half, and just maintaining for another two weeks.

Tongue: dim pink, thin, slight purple in the back, thin white.

Pulse: thin, soggy, wiry, moderate; weak right cun and left chi

Acupuncture: BL 17, 18, 32, LV 3, SP 6, KD 3, KD 7, DU 20 and FMS

Herbal formula:

Dang Gui Shao Yao San 25g

Gui Zhi Fu Ling Wan 20g

Gui Pi Tang 15g

Nuan Gan Jian 10g

Last Visit 11/21/2019

It has been ten months and patient emailed me occasionally, indicating that she is doing well.

Progress: she stated that she has had mild flare-up recently due to high stress at work. She was going to Europe for 2 weeks of vacation and feared that her pain might interfere with her time with her boyfriend. She was experiencing occasional pain and spasms in her vagina with the pain level at 1/10. She has been following mostly dairy-free and a warm foods diet for the last 10 months. She is also actively doing yoga twice a week. No issues with her sleep and urination.

Tongue: dim pink, thin, slight purple in the back, thin white.

Pulse: soggy, moderate: short left chi.

Acupuncture: LV 3, yintang, ST 29, RN 4, SP 6, KD 3, KD 7, DU 20 and FMS

Herbal formula:

Dang Gui Shao Yao San 30g

Gui Zhi Fu Ling Wan 20g

Si Ni San 20g

Last time phone follow-up with the patient on 12/08: she indicated everything was good and she had great time in Europe.

Discussion:

Hypertonic pelvic floor dysfunction is rarely seen compare to hypotonic dysfunctions such as prolapse. There are not many specific TCM diagnoses regarding it as well. The closest terms found through research in TCM are “yin len” 阴冷 pertaining to cold in the genitals, and “yi niao” 遗尿, pertaining to incontinence. The key components to this case are Liver cold and Liver blood deficiency. Once the diagnosis is clear, it helps the practitioner construct the core treatment plan.

The herbal formulas are key in treating this dysfunction. The formula Nuan Gan Jian is used to treat Liver cold related inguinal hernia and testicular torsion, which has some similarities with vaginal spasms. The other key formula is Dang Gui Shao Yao San, a traditional formula for treating various gynecological patterns. It nourishes Liver blood, spreads the Liver Qi, drains dampness, and fortifies the spleen. DGSYS not only releases pain caused by gynecological disorders but also treats threatened miscarriage, abdominal pain during pregnancy, irregular menstruations and painful dysmenorrhoea. The usage of DGSYS in this case is to percolate damp, disperse Liver Qi, nourish Liver blood, and soften the sinews and tendons. Wu Ling San in the initial visits was to warm the lower burner and resolve damp; it addressed her frequent urination and incontinence. Shao Yao Gan Cao Tang is a simple and powerful formula for muscle spasm that mostly involves the gastrocnemius muscle. Research has shown its effectiveness in treating pelvic floor spasms. Gui Zhi Fu Ling Wan is a guiding formula toward the pelvis to resolve damp and break up blood stasis.

Conclusion:

Acupuncture and herbs are effective in conjunction with physical therapy in the treatment of hypertonic pelvic floor dysfunctions. Treatment plans should include both physiological and psychological issues. Patients should be advised that the course of treatment could be up to 3 months to change the “muscle memory.” Lifestyle changes are also an important part of the healing process.

References

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