Why Pelvic Physical Therapist should get loud about the clit

The pelvic floor is the biggest fan of your clitoris, constantly cheering it on and supporting it’s success. 

Quite literally, if the pelvic floor is oprah-then the clitoris is gayle because the pelvic floor is here to see the clitoris come up (no pun intended.) According to literature, one specific pelvic floor muscle which I’ll specify below attaches into the body of the clitoris. Additional research reveals that blood flow into the clitoris then depends on the activity of the pelvic floor because they restrict the outflow of clitoral venous blood back to the heart. So if the pelvic floor is what propels the swelling and arousal of women and those with vulvas, why don't Pelvic Physical Therapist have a seat at the table when it comes to pleasure problems for the female sex population? Pelvic Physical Therapist are the trained experts on the pelvic floor (in addition to urogynecologist) so we need to be the front line workers for clitoral dysfunction like inability to orgasm, difficulty achieving orgasm, and painful orgasm. The pelvic floor muscles include the bulbocavernosus which wraps around the opening of the vagina and acts as a vaginal sphincter. This particular muscle is the dramatic family member to blame for conditions like vaginismus (a painful sex disorder that makes vaginal insertion extremely painful or in some cases impossible). Because of one of the major jobs of this muscle, to constrict the vagina, It's important for this muscle to relax in cases of vaginismus. But generally speaking, even when the pelvic floor is working optimally, this muscle (bulbocavernosus) attaches directly into the clitoris corpora cavernosa, as the very name of this muscle suggest: bulbo-CAVERNOSUS. As Pelvic Physical Thysical we know that when a skeletal muscle attaches itself onto a bony landmark or fascial landmark, that it directly controls the function and action of that body part. For example, because the quads on our thighs insert onto the knee joint, we know that contracting our thighs extends our knees. This means that any type of dysfunction within the pelvic floor muscles, specifically the bulbocavernosus, will impact clitoral function. Clitoral function is our primary physical driver of sexual satisfaction but if we have absolutely no experts in treating the muscles that control and enhance clitoral function or worse— have experts that treat the pelvic floor but exclude clitoral function from the plan of care, where does that leave women and all people with clitoral anatomy? We won’t think to ask about orgasm potential, orgasm frequency, painful orgasm, time to orgasm, and strength of orgasm. This information on the connection between the pelvic rloor and the clitoris may seem completely intellectual and biomechanically arousing for us as health professionals, but this information is knowledge that should become mainstream for the general public. It starts with us as Pelvic Physical Therapist.

 Not only does the pelvic floor muscle group attach into the clitoral tissue but this attachment point directly impacts it's ability to enable sustained arousal.
 
We’re assured with literature to know that the pelvic floor muscles constrict the tissue of the clitoral fascia, which compresses the deep dorsal vein of the clitoris, enabling clitoral engorgement, similar to a penile erecrion. And just as men and those with a penis who generally need an erection to be able to reach orgasm, we as as women and vagina owners need that genital swelling and erection too which is why forwplay is not to be under-valued.

 Foreplay is essentially the reserved time it takes to fill the clitoris, inner labia, and vaginal walls with maximum blood volume to make our tissues more pleasurably sensitive.

 So the entire time that sexual activity is taking place, bulbocavernosus in addition to the ishiocavernosus muscle has to be strong enough to sufficiently constrict the clitoris but also have sufficient muscular endurance to maintain these sustained neuromuscular and involuntary contractions through out the phases of sexual activity. A pelvic floor muscle group that is either too tense, too weak, or lacks muscular endurance (which incorrectly tends to take the back seat to pelvic floor strength) will impact one's ability to achieve sufficient arousal, clitoral engorgement, and nerve sensitivity to reach orgasm. And surprisingly, this article reveals that pelvic floor muscle endurance was more associated with orgasm than pelvic floor muscle strength! It is only after these pelvic floor muscles constrict the clitoral veins and are able to maintain this constriction for sufficient time- that more blood can be rushed into the clitoral erectile tissues and remain there long enough to lead to orgasm. This engorgement of blood presses on our nerves and then makes the sensation more pleasurable and therefore more likely to facilitate an orgasm which is contraction of these very muscles, in addition to chemical activity in the brain. 

 As pelvic physical therapist, the pelvic floor muscle group is our terrain. It’s ours. So we must take accountability for the patients we have seen and will see who struggle with clitoral dysfunction or difficulty with orgasm.

Nonetheless, it is vitally important to note that orgasm is a complex dichotomy and can be slowed or stagnated by several factors like: high stress or anxiety levels, relationship dis-satisfaction, poor communication with partner, poor partner sexual performance, medical conditions, pain conditions, and use of medications like birth control or anti-depressants. However, this does not liberate us from the fact that there still remains physical barriers to sexual arousal and orgasm, which most definitely includes the function of the pelvic floor. So when you sit down for brunch, the lunch room at work, or when you're in the group chat with your friends, the discussion of pleasure problems should include the possibility of pelvic physical therapy as a treatment option. 

No one wins when we shrink from the role we play in the world of pleasure.

Our patients don't win, nor do we win when we overlook a potential community of people who would easily support the therapy we can provide to them. I personally believe that this is enough reason for us to interrupt the sexual dis-satisfaction that many experience. However, it does not end there. The orgasm phase itself is a intermingling of neurological, vascular, and muscular pathways converging to a common place. But for most who actually achieve orgasm, it consist of a rhythmic contraction of the pelvic floor muscles which in combination with the fireworks happening in the brain, releases an intense feeling of pleasure, release, and satisfaction. The neurological and autonomic activation of the bulbocavernosus muscle is actually used to determine spinal cord integrity and brain integrity needed to initiate a vaginal or clitoral orgasm. By checking for a reflex called the bulbocavernosus reflex, we can clinically assess whether our patients have the neurological potential to achieve orgasm. This reflex is maintained by the S2-S4 nerve roots within our parasympathetic nervous system. This is a completely reflexogenic pathway for arousal and orgasm that we must have in tact. While even those with spinal cord injury can still orgasm, it can only be from direct cervix stimulation or paychogenic stimulation for those with SCI. While those without spinal cord injury may be more inclined to seek orgasm from clitoral stimulation alone or primarily. This BCR reflex an be elicited by squeezing the glans of the clitoris and then observing for a reflexive contraction of the perineum. The absence, presence, and strength of this reflex could tell us a lot clinically about whether our patients have great potential to achieve orgasm-because according to the current literature we have about anorgasmia and this reflex, it is this autonomic neurological pathway that is essential for the beginning of the pelvic floor rhythmic contractions that we know and identify as orgasm. It's important to note that someone can have a highly functional and healthy pelvic floor but yet still not achieve orgasm. This could be due to any of the factors already mentioned above. This means we are not redeemed from our job to think critically and know when to refer out to a different specialist. But also we need to know that we as pelvic physical therapist have to take up more space in the pleasure and sex conversation. Let's put our thinking caps on and a cape on our backs as we seek to pay more attention to the complaints, barriers, and frustrations of our patients regarding their sex life. By looking at reflexive functions, pelvic floor muscle endurance as priority, PFM speed, PFM relaxation, PFM coordination, and PFM strength-we can be sure that we are covering much of the muscular grounds necessary and crucial for sexual fulfillment, enjoyment and satisfaction. And by doing this we can swell with a little more pride as a pelvic physical therapist, knowing for sure that this aspect of the pelvis greatly contributes to the quality of life and mental health of the community we seek to know, serv, and heal.