Treating Female Pelvic Pain Disorders Using a Combination of Pelvic Floor Physical Therapy and Sex Therapy
Manley, Ginger, Odom, K. Lynne, Contemporary Sexuality
Treating Female Pelvic Pain Disorders Using a Combination of Pelvic Floor Physical Therapy and Sex Therapy
Editor's note: Updates of Clinical and Educational Sexology are intended to provide state-of-the-art education for AASECT members and other professionals on matters relevant to the practice of sexuality education, counseling and therapy. At the direction of AASECT's Professional Education Committee, and with the oversight of AASECT's president, executive director and Board of Directors, these Updates will offer readers who fulfill certain designated criteria an opportunity to receive AASECT Continuing Education credits relevant to AASECT certification procedures.
We publish Updates on a bi-monthly basis as a special eature of Contemporary Sexuality.
INTRODUCTION AND PURPOSE OF ARTICLE
When patients present with disorders of pelvic pain they are often met with a variety of circumstances that neither inspire hope nor help to alleviate the disorder. These dysfunctions are typically very difficult to diagnose, and without an adequate etiology, treatment is haphazard at best. Women who present with such disorders are usually scared, angry, and/or frustrated with the conventional methods of evaluating and treating their pain. Often they have been prescribed medications to take orally or apply transdermally, and occasionally they have been directed to have surgical excision of the painful area. These approaches may sometimesactually worsen the problem, leaving a woman feeling completely distraught about ever finding relief. If she is in a relationship, the sexual activity has usually been painful or even intolerable, creating even more tension for the woman and her mate.
Recently, a newer approach, using physical therapy to address the musculoskeletalcomponents of pelvic floor muscle dysfunction and pain combined with the psychoeducationalinterventions of a sex therapist or counselor, has enabled more women with these problems to achieve relief and to resume their sexual lives.
This paper will present an overview of the anatomy and physiology of the pelvic floor structures and a brief description of the physical therapy approach to managing pelvic floor dysfunction. Using traditional and emerging sex therapy methods, the sex therapy approach to teaching a woman to understand her body's sexual functioning and to gradually change the experience of vaginal containment from a negative to neutral to a positive experience will be presented. The authors recognize that either a sex therapist or a sex counselor may provide these interventions. Whenever one provider is mentioned in this paper, the authors assume that the information may pertain to both providers, unless a specific disclaimer is described.
BRIEF REVIEW OF LITERATURE
Pelvic pain disorders can have multiple causes, making them very difficult to accurately diagnose. In general, they can be divided into ones of physical origin or of psychogenic origin or a combination of the two. In reality, the cause is frequently not known. Physical disorders are further classified as arising from dermatologic, infectious, vascular, or neuromuscular causes. Due to brevity, this article will include only a general discussion of the variety of disorders other than those of neuromuscular origin.
Sexual health providers have been describing their interventions for these problems for several years. (Kessler, 1998; Koehler, 2002). Unfortunately, many sex therapists and counselors practice in office settings separate from other potential treatment team members, so it may be difficult to collaborate in person.
Physical therapists are skilled in evaluating and treating a wide variety of musculoskeletal conditions. Recently some physical therapists have undergone additional training in pelvic pain assessment and treatment to be able to better help their clients overcome sexual pain problems using a "hands-on" approach. (Rosenbaum, 2002). Suggested readings are included for further information.
PELVIC FLOOR MUSCLE FUNCTION AND DYSFUNCTION
The pelvic floor muscle group has 3 primary functions: supportive, sphincteric, and sexual. Pelvic floor muscles provide inferior support for pelvic organs, sphincteric function for bowel and bladder control, and assistance with normal sexual arousal response.
Pelvic floor dysfunction may cause disruption in any or all of these bodily functions. Such dysfunctions may have primary or secondary causes and there may or may not be a pain component. For example, someone with urinary or fecal incontinence may or may not also have pain. Someone with vaginismus (increased tone of the pelvic floor muscles) may only have pain with pelvic exams and/or intercourse. Alternately, someone with vulvodynia (vulvar pain) may have pain that does not affect bowel or bladder function.
Musculoskeletal Structures of the Pelvic Floor The pelvis contains a complex system of nerves, arteries, veins, ligaments, muscles, organs, bones, and fascia, all of which must be functioning normally to enable optinormal pelvic floor muscle function. Because of the brevity of this article, only the basic neuromuscular functions of the perineum and the pelvic floor will be described.
The female perineum consists of the vulva/pudendum, urogenital triangle, pelvic diaphragm, urethral sphincters, pelvic and endopelvic fascia, and anal triangle. There are three muscle layers of the perineum: the superficial layer (urogenital triangle); the deeper layer (urogenital diaphragm); and the pelvic diaphragm (also known as the "levator ani"). Each layer consists of a group of muscles. (See Table 1 for details of action/function and innervations.)
Pelvic Floor Dysfunctions
The four types of pelvic floor dysfunctions are: 1) supportive dysfunction; 2) hypertonus dysfunction; 3) incoordination dysfunction; and 4) visceral dysfunction. Supportive dysfunctions occur when there is loss of strength and integrity of the pelvic floor connective tissue and muscle fibers. Hypertonus dysfunction occurs when tension or active spasm of the pelvic floor muscles causes musculoskeletal pain or dysfunction. Incoordination dysfunction occurs when soft tissue trauma or nerve injuries interfere with appropriate use or coordination of the pelvic floor muscles. Visceral dysfunction is the abnormal movement of pelvic organs such as may occur with rectal, uterine or bladder prolapse, fibroids, or tumors.
Causes of Pelvic Floor Dysfunction
Pelvic floor dysfunctions are the result of trauma or injury (old or new), musculoskeletal imbalances or injuries (old or new), nerve entrapments or irritations, pelvic or abdominal prolapse, pain syndromes, vascular disorders/varicosities, inflammations, infections, and gastrointestinal disorders. Trauma or injury can occur with pregnancy/birth, surgeries (hip, trunk, pelvis, lower extremities), sexual/physical abuse, or fractures (pelvic, lower extremities, spine).
Musculoskeletal imbalances of the trunk, pelvis, hips, or lower extremities such as occurs with a leg length difference, pelvic obliquity, or scoliosis may also contribute to pelvic floor dysfunction. Nerve entrapments of the lumbosaccaral nerves and pudendal nerve may facilitate increased tone or atrophy of the the pelvic floor muscles. Pain may also refer from the lumbar spine and/or sacroiliac joints resulting in hypertonic or supportive dysfunction.
Pelvic and abdominal prolapse may also create pelvic floor dysfunction along with pain syndromes such as dyspareunia (painful intercourse), proctalgia, levator ani syndrome, fibromyalgia, and myofascial pain syndrome. Pelvic and abdominal vascular disorders and varicosities, as well as gastrointestinal disorders such as diverticulitis, constipation, hemorrhoids, fissures, irritable bowel syndrome, and Crohn's disease can cause pelvic floor dysfunction. Other causes are inflammation and infections caused by interstitial cystitis, vestibulitis, vulvovestibulitis, and pelvic inflammatory disease.
PHYSICAL THERAPY EVALUATION
The physical therapy history and physical examination includes a detailed subjective history including a review of current and old traumas or surgeries, physical or sexual abuse, pregnancies/births, functional limitations, medications, treatments, special tests, and gynecologic history. The urogenital history also includes bowel and bladder problems, voiding habits, bowel habits, fluid intake, and diet.
The objective evaluation includes a lumbosacral screening for postural deviations, trunk and lower extremity range of motion and strength, and reflex and sensation testing. Special tests for specific lumbar, hip and sacroiliac mobility are included. Joints of the lumbosacral spine, hips, and sacroiliac joint along with the associated soft tissue are palpated for tenderness, tone, and muscle guarding. A pelvic floor muscle assessment is performed to assess pelvic floor muscle tone, tenderness, endurance, and sensation. This is explained in detail to the patient and performed only if the patient is comfortable with it and expresses a good understanding of the assessment. Only physical therapists that have received advanced training in pelvic floor assessment may perform this assessment. Patients are offered the opportunity to have someone else present for this assessment.
Contraindications for a pelvic floor muscle assessment are: lack of cognitive understanding by the patient; lack of training by the practitioner; children/females who have never had a pelvic exam; pregnancy; active infectious lesions; severe atrophic vaginitis (thinning of the vaginal wall); immediate post operative urogynecologic or colorectal surgery (MD approved only); immediate postpartum (wait for 6th week healthMD check up).
Some patients may not tolerate pelvic floor muscle assessment due to increased pelvic floor muscle tone, tenderness, or for emotional reasons. The patient is frequently instructed to communicate with the physical therapist if at any point it becomes uncomfortable in any way and the assessment will be discontinued. Verbal and non- verbal communication are continually monitored. Biofeedback with surface or vaginal or rectal electrodes may be used to assess pelvic floor resting tone, strength, and endurance.
Biofeedback is a diagnostic and treatment tool used to increase a patient's muscle awareness based on psychological conditioning. There are electronic devices, or EMG's, as well as verbal and tactile techniques. An EMG measures in microvolts the activity of a muscle. As the pelvic floor muscles are under voluntary control, it is a very useful assessment tool as well as a treatment modality. It provides a visual or audible feedback mechanism for patients to see or hear how well they are able to contract or relax their pelvic floor muscles.
Surface electrodes or internal vaginal or rectal electrodes may be used. Surface electrodes are placed at the perineum as closely as possible to the vagina with a ground electrode at the ischial tuberosity ("sitting bone"). It is also helpful to have surface electrodes at the transverse abdominus (lower abdominals) to observe potential substitution patterns of muscle recruitment. Resting tone, strength, and endurance measurements are recorded as a baseline.
Biofeedback may also be used as a treatment tool. For example, a patient who has increased pelvic floor muscle tone that contributes to pelvic pain, painful intercourse, or vaginismus (increased tone of the pelvic floor muscles) may measure a high resting tone of greater than 6 microvolts. The patient is able to observe a bar and/or number graph (or hear a tone) which shows this measurement and is instructed in pelvic diaphragmatic breathing exercises or other relaxation techniques as she focuses on relaxing her pelvic floor muscles to achieve a resting measure below 6 microvolts. For someone who may have weak pelvic floor muscles, the goal would be to contract so that she can observe a higher reading on the screen. For example, someone with less than a measure of 8 microvolts upon pelvic floor contraction may observe the screen and attempt to contract her pelvic floor muscles so that a number higher than 8 occurs.
Other forms of biofeedback include tactile or verbal cues from the therapist for sensory and verbal feedback of correct muscle contraction or relaxation. A patient may also be trained to perform her own tactile feedback by self-digital assessment. A mirror to observe the perineum for a perineal lift with a pelvic floor muscle contraction may also provide helpful visual feedback. Some therapists or health-care providers may also use vaginal weighted cones that may enhance a patient's sense of muscle awareness.
The physical therapist attempts to determine through the musculoskeletal assessment the source or contributing factor of the pain and/or reason for the dysfunction. Notice is made of questionable or obvious nerve entrapment, muscle imbalance or incoordination, muscle weakness, surgical adhesions, lumbar or sacroiliac facet irritation, or other. Treatments will include addressing any problems noted in the evaluation, including but not limited to pelvic floor exercises such as Kegel exercises.
Treatments may also include manual therapy (joint mobilization and/or soft tissue mobilization, trigger point and/or myofascial release), therapeutic exercises, biofeedback, and other modalities such as ultrasound (for improved blood flow at deep tissue levels), interferential stimulation (for pain inhibition), electric stimulation (for assisted muscle contraction), moist heat or ice (for pain inhibition), relaxation techniques, and postural training (sitting, sleeping, toileting, and intercourse). Artificial vaginal dilators may also be used. Patients are usually seen 1 or 2 times a week for 8 weeks.
PSYCHO-SEXUAL THERAPY OF PELVIC PAIN DISORDERS
Many of the women who seek help for these disorders have just about lost all hope and patience by the time they reach a sex therapist or counselor who is knowledgeable about their problems. Additionally these women describe themselves as feeling isolated and as if they are "too much" for their health practitioner or their spouses. Therefore, one of the first efforts of the therapist is to establish that this is indeed a complex situation and it requires a complex solution in the form of a team approach. Ideally, all members of the treatment team - the healthcare provider, the physical therapist who specializes in women's health, the sex therapist, and the woman and her significant other - would all meet together' for in-depth evaluation and treatment planning, but in reality this rarely happens. In the place of an onsite treatment team, the sex therapist or counselor can facilitate dialogue among all the providers and can serve as the care coordinator, in the absence of another person having that job.
Creating safety is the primary aim of the sex therapy of such a woman. Usually she is scared and angry and feels completely out of control and powerless. The sex therapist can facilitate her re-empowerment and safety building by: 1) framing the issue as a joint problem, for those women who are in a coupleship; and 2) helping to "buy time" for evaluation and treatment to occur without pressure for sexual activity through creating a pro-active "window of time" for the woman to be sexually abstinent.
By the time they seek sex therapy, many couples have already become sexually abstinent in a reactive posture to the problem. As the sex therapist or counselor reframes the issue from one of adversity to one of partnering, the woman can usually begin to take ownership of her sexuality and with guidance, she can move from a place of negative reactivity to one of neutrality to one of positive thriving sexuality. When the sex therapist or counselor outlines such a progression, there is often softening of anxiety between the couple and an opportunity for each partner to make needed changes. It may be helpful to note that, just as experiences of sexual abuse or trauma have hidden lives, so the problem of pelvic pain disorders and ensuing sexual problems usually exists in secrecy, and the best solution is to treat it with openness.
The sex therapist or counselor's office serves as a "container" for feelings and experiences to be explored, and while the woman may be the "identified patient" in the medical offices, the couple is the "identified patient" in the therapist's office. As the woman signals her readiness to move, the sex therapist provides modeling of sex-positive experiences through prescribed bibliotherapy, audiovisual recommendations, and dialogue between the therapist and the woman and her partner.
Often the sex therapist or counselor will be very helpful in interpreting to the woman the evaluation that is being done by the medical and physical therapy team members. The sex therapist can use a variety of teaching tools to instruct in female anatomy and physiology. One particularly useful tool is the anatomically correct female genital model (see www.jimjacksonanatomymodels.com in the list of recommendeduseful web sites below). Using this teaching aid, the woman and her partner can explore the female anatomy in much more detail than is available just with drawings, and they can do so without the risk of imposing pain. The insight gained by understanding the tremendous complexity of the female pelvic structure is a huge step forward for most women. When such a teaching session is followed with take-home information and opportunities for more questions and answers, most women truly begin to identify as "team members" rather than "victims of circumstances."
Depending on the establishment of the diagnoses and causes for the pain, either the sex therapist or the physical therapist may also teach Kegel exercises and other pelvic floor exercises (Leiblum & Sachs, 2002, p.207) or may suggest breathing or stretching (such as Yoga) measures (Rosenbaum, 2002). The sex therapist or counselor may also offer options for expanding the woman's repertoire of sexual activities, including finding more comfortable positions for sex (Foley, Kope, & Sugrue, 2002, p. 237). The sex therapist may also prescribe or teach the use of artificial vaginal dilators for progressive desensitization and mastery of vaginal containment (Binik, Bergerson, & Khalife, 2000). Several sources for such dilators are included in the references. While some women may have used other forms of dilators that might not be hygienically acceptable, the sex therapist or counselor should guide a woman to use standardized dilators that can be matched to the expected size of her comfort level and her intended partner.
If the woman is in a relationship with a male, it will be helpful to obtain the measurements of the man's erect penis, including length and girth. The man can use a standard fabric tape measure to obtain these measurements, and the results can be relayed to the therapist. Working with the woman, the therapist can help her to practice to accept a dilator equivalent to her mate's erection, and when she can do so without pain and with confidence then she can choose to begin bridging to intercourse. Some gynecologists women's healthcare nurse practitioners, physical therapists, or sex counselors may be able to provide "hands on" guidance for dilator use as a part of their practice. This "hand's on" approach would be outside the appropriate practice boundary for most sex therapists because of the need to protect the emotional boundaries of a vulnerable client or patient and the risk of transference. For an in-depth discussion of the ethical use of touch in the practice of psychotherapy, please see Hunter and Struve (1998). As a woman progresses from containing successively larger dilators, she may also transition to use of her own or her mate's fingers in her vagina, and eventually will be able to comfortably accept her mate's erect penis as it is inserted without thrusting. It is helpful for the woman to sit astride her mate and to be completely in control of when and how to proceed. Most women will need encouragement to do their pelvic relaxation exercises; to find a comfortable tilt of the pelvis; and to use copious amounts of a wetting agent, such as water based lubrication, to minimize any friction. It may take several tries before a woman with a history of pelvic pain disorder can fully envelope her mate's erection, but when this happens it is usually a profound breakthrough for her and her partner.
There are several circumstances in which the sex therapy for pelvic pain disordered women will need to be modified. These include those women whose traumatic histories, especially if there was force or coercion with vaginal penetration, may be triggered by either the evaluation or treatment phases of the above protocols. In these situations, the therapist will communicate this obstacle to the other team members and will assist the woman to participate to whatever degree she is capable, but not to the point where she feels out of control, such as she did in the traumatic experience. Additionally women who are undergoing fertility/infertility treatments or who are pregnant or recovering from pregnancy or pelvic related surgery will need to have modifications in their treatment planning. Working together in regular communication with each other, the team members can be creative in developing alternative methods or approaches to the problem.
Treating pelvic floor dysfunctions and the ensuing sexual problems is a difficult and complex situation. When sex therapists and counselors can partner with physical therapists that specialize in women's healthcare, the outcome is often enhanced for the presenting patient and for the treatment team, which is a far better scenario than many women have previously encountered.
SOURCES FOR VAGINAL DILATORS
Cooper Surgical (formerly Milex Products) - Set of four flexible silicone vaginal dilators, all are pink flesh color-$135. Phone 1-800-621-1278 Customer Service; www.milexproducts.com. Requires prescription from MD or Nurse Practitioner and only ship to health care provider's office.
Soul Source Enterprises - Eight sizes of graduated flexible silicone dilators, each size a different color; prices vary for each dilator; set of four mid-range dilators is $125. Phone 1-503-750-1802; www.soulsourceenterprises.com. Does not require a prescription and can be ordered by clinics, health care providers, and individuals and will ship to patient.
Syracuse Medical Devices - four sizes of white plastic sterilized rod dilators, graduated circumferences, all six inches long with one rounded end, available individually or as a set of four for $38. Phone 1-315-449-0657. Does not require a prescription but will only sell directly to hospitals or physicians/nurse practitioners.
Dilator billing information: Use CPT code 99070 "supplies and materials, except spectacles, provided by the physician over and above those usually included with the office visit or other services rendered." To justify payment, most insurors will request a copy of the office notes or a summary letter linking the diagnosis and the need for the dilators.
The International Pelvic Pain Society (IPPS) - 800-624-9676; www.pelvicpain.org
International Society for the Study of Women's Sexual Health (ISSWSH) - www.isswsh.org
Dr. Howard Glazer's web site - www.vulvodynia.com (chat room)
Talli Rosenbaum's web site - www.physioforwomen.com
Jim Jackson anatomic models - www.jimjacksonanatomymodels.com
American Physical Therapy Association, Section on Women's Health - www.womenshealthapta.org
National Vulvodynia Association - www.nva.org
CONTINUING EDUCATION QUESTIONS
Complete the following questions after reading "Treating Female Pain Disorders."
Photocopy and mail your response and the required fee to: AASECT, P.O. Box 1960, Richmond, VA 23005-1 960.
City, State __________ Zip __________
AASECT Member ___ AASECT Non-member ___
Each Update Aticle = 1 CE hour; Fee is $20 per article for members, $3Q per article for non-members.
Make checks payable to AASECT.
Event Code: CS Update March 2006. Responses must be submitted by March 2008.
Directions: Circle the correct answer to each of the following.
1 . The physical disorders that cause pelvic pain may arise from __________ origins
E. All of the above
2. Some causes of pelvic floor dysfunction that may contribute to pelvic pain are:
A. Recent or old trauma from surgeries, injuries, pregnancy, sexual/physical abuse.
B. Musculoskeletal imbalances or injuries of the trunk, pelvis, lower extremities.
C. Lumbosacral nerve root entrapments or irritations.
C. Pelvic organ prolapse.
E. All of the above
3. The primary aim of sex therapy for the woman with pelvic pain disorder is to
A. Create safety
B. Teach Kegel exercises
C. Instruct her in female anatomy and physiology
D. Direct her to accept her partner's erect penis in her vagina
4. As a woman progresses in accepting vaginal containment, she might practice using all of the following except
A. Artificial vaginal dilators
B. Her own or her mate's fingers
C. A cucumber fresh from the produce section
D. Her mate's erect penis without thrusting.
5. Pelvic floor disorders that disrupt positive sexual experiences are best treated using a team approach, including a healthcare provider trained to specifically evaluate these problems, a physical therapist with specialty training in women's health, and a sex therapist who can facilitate dialogue and practice with the treatment protocol.
Binik, Y. M., Bergeron, S., Khalife, S. (2000). Dyspareunia. In S. R. Leiblum & R. C. Rosen (Eds.) Principles and Practice of Sex Therapy, 3e. NY: Guilford Press
Foley S., Kope S. A., Sugrue, D. P. (2002). Sex matters for women. NY: Guilford Press
Hunter, M., & Struve, J. (1998) The ethical use of touch in psychotherapy. Thousand Oaks, CA :SAGE Publications
Jackson, J. Anatomical teaching models, http://www.jimjacksonanatomymodels.com
Kessler, J. M. (1998). Sexual Issues and Vulvar Pain. The Vulvar Pain Newsletter. No. 15, The Vulvar Pain Foundation
Koehler, J. D. (2002). Vaginismus: Diagnosis, etiology and intervention. Clinical Sexuality Updates. Contemporary Sexuality, 35(8), i-viii
Leiblum S, & Sachs, J. (2002) Getting the sex you want. NY: Crown Publishers
Rosenbaum, T (2002). Physical therapy treatment of vulvodynia: A "hands-on" approach. National Vulvodynia Association Newsletter, 8(1), retrieved at La-briut.org.il
Carnes, P. (1997). Sexual anorexia. Center City, MN: Hazelden
Castleman, M. (2004). Great sex: A man's guide to the secret principles of total body sex. Rodale.
Davis, M. W. (2003). The sex starved marriage: A couple's guide to boosting their marriage libido. New York: Simon & Schuster.
Foley, S., Kope S., Sc Sugrue, D. (2002). Sex matters for women: A complete guide to taking care of your sexual self. New York: Guilford Press.
Glazer, H., & Rodke, K. (2002) The vulvodynia survival guide. Oakland, CA: New Harbinger Publications.
Goldstein, A., & Brandon, M. (2004). Reclaiming desire: 4 keys to finding your lost libido. Rodale.
Katz, D., & Tabisel, R.L. (2002). Private pain. Plainview, NY: Katz-Tabi Publications.
McCarthy, B., & McCarthy, E. (2003). Rekindling desire. New York: Brunner-Routledge.
Sapsford, R, Bullock-Saxton, R, Markwell, S (1998) Women's Health: A Textbook for Physiotherapists WB Saunders Company Ltd, The Bath Press, Avon, UK
Stewart, E. G., & Spencer, P. (2002). The V book: a doctor's guide to complete vulvovaginal health. New York: Bantam Books.
Zoldbrod, A.P. (1998). Sex smart: How your childhood shaped your sexual life and what to do about it. Oakland, CA: New Harbinger Publications.
Ginger Manley, APRN, CST and K. Lynne Odom, PT, MOMT
Ginger Manley, APRN, CST, is a psychiatric nurse practitioner and AASECT Certified Sex Therapist and supervisor in Franklin, Tenn. She is a Clinical Professor of Nursing in the Vanderbilt University School of Nursing in Nashville and has published numerous articles in professional journals.
K. Lynne Odom, PT, MOMT, has practiced physical therapy for over 10 years in Nashville. She received her Masters in Orthopedic Manual Therapy in 1998. In 1999 she furthered her education to include Women's Health and currently addresses pelvic floor dysfunction in her practice.
The authors are colleagues in separate practice settings who frequently collaborate to facilitate care of the same patient. They are co-founders of a monthly roundtable case consultation group for health professionals who are treating sexual health concerns in a variety of settings in the greater Nashville geographic region.…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Treating Female Pelvic Pain Disorders Using a Combination of Pelvic Floor Physical Therapy and Sex Therapy. Contributors: Manley, Ginger - Author, Odom, K. Lynne - Author. Magazine title: Contemporary Sexuality. Volume: 40. Issue: 3 Publication date: March 2006. Page number: 13+. © American Association of Sex Educators, Counselors, & Therapists Mar 2009. Provided by ProQuest LLC. All Rights Reserved.