Chad P. Hubsher, MD
■ Aimee Rogers, MD
■ Stanley Zaslau, MD, MBA, FACS
■ Introduction
■ Noninvasive therapies encompass a wide range of modalities used to treat women with sexual problems.
■ Due to the complex nature of female sexual dysfunction, each patient must be individually assessed to determine the best treatment methods to pursue.
■ Examples of noninvasive therapy to treat sexual problems in women include:
• Psychotherapeutic interventions and counseling
• Lifestyle changes
• Physical therapy that specifically addresses the pelvic anatomy and function, stimulation devices, sacral neuromodulation, and lubricants and moisturizers.
■ Furthermore, it is often beneficial to the patient to be referred to a sex therapist or physical therapist who is specifically trained in educating and treating the patient in various noninvasive therapies.
■ Psychotherapeutic Interventions
■ Female sexual problems are generally the result of a complex interaction of biological and psychosocial factors.
■ First-line treatment of female sexual dysfunction involves patient education and psychotherapeutic interventions that include:
• Basic counseling
• Cognitive behavioral therapy
• Interventions for the individual woman
• Couple therapy
■ The goal of a psychotherapeutic treatment program is to assist the woman in understanding her own physiology, feelings, and emotions, and in communicating with her partner.
Basic Counseling and Education
■ The initial treatment strategy of psychotherapeutic intervention, basic counseling, starts with the physician’s readiness to give the patient time to talk about her sexuality and sexual problems. This was previously described in Chapter 10.
Sex Therapy
■ Women with sexual dysfunction may additionally benefit from a referral to a sex therapist.
■ Sex therapists can educate a woman about the normal sexual response and effectively deal with cultural or religious concerns regarding sexuality.
■ Prior to referral, the clinician should reassure the patient that a therapist is a professional who deals with psychological issues regarding female sexual dysfunction, as there are many misconceptions about sex therapy. These range from sexual surrogacy to performing sexual acts in front of the therapist.
■ One of the most popular models used by sex therapists in treating female sexual dysfunction is the P-LI-SS-IT model, described by Annon in “Behavioral treatment of sexual problems: Brief therapy,” which encompasses four levels of intervention.1
• The first level involves the practitioner creating a comfortable atmosphere, introducing the topic of sexuality, and giving permission (P) to discuss sexual concerns and enter into a dialogue with the clinician.
• The therapist then proceeds to address specific concerns, attempts to correct myths, and provides limited information (LI) about the human sexual response, differences between men and women, the frequency of sexual problems, and the relationship of sexual problems with different life phases.
• The next level of intervention involves specific suggestions (SS), in which specific advice or treatment is given.
• For a majority of patients, these three steps should provide sufficient treatment; however, a small proportion of patients will need intensive therapy (IT) with frequent sessions of longer duration in order to improve their sexual complaints.
■ These patients’ sexual dysfunction is often complicated by the coexistence of complex life issues, including psychiatric illnesses, interpersonal or intrapersonal conflict, or substance abuse.
■ The sex therapist is trained to identify situations that require intensive therapy and make the appropriate medical referrals when deemed necessary.2-4
Cognitive Behavioral Therapy (CBT)
■ In CBT, sexual dysfunction is looked upon as a learned behavior, either via classical conditioning, operant conditioning, or model learning.5
■ The result is a behavior sequence characterized by a specific sexual stimuli, response, and contingency. This was discussed previously in Chapter 10.
Interventions Focusing on the Individual Female
■ Therapeutic interventions that focus solely on the woman, such as a psychoanalytic approach or general body awareness exercises, have demonstrated some efficacy in improving female sexual dysfunction. This has been previously discussed in Chapter 10.
Couple Therapy
■ Sexual desire is often directed toward another person and, thus, sexual interaction becomes an issue of communication and exchange. Partners frequently have difficulty listening to each other and accepting the views, feelings, or thoughts of the other person. Partner counseling can teach basic listening skills, as well as the importance of respecting the partner and understanding how to express criticism without hurting the other. This therapy was discussed in detail in Chapter 10.6-8
Lifestyle Changes
■ Life events that cause an increase in fatigue or stress are frequently closely associated with sexual problems and a low libido.
■ Reducing stress, either by applying better planning, organization, and time management skills or by attending stress-reducing activities, such as yoga or exercise classes, will likely improve sexual interest and satisfaction.
■ Furthermore, getting help with child-care responsibilities and housework may also help to improve stress and daily fatigue, thereby improving sexual function.
■ Also, encouraging couples to establish a regular “date night” that allows them to spend an occasional night away from family responsibilities may lead to significant improvements in sexual interest.
■ In addition to minimizing stressful events and daily fatigue, there are a number of lifestyle changes that can be made to maximize one’s potential for sexual satisfaction. Known risks factors of female sexual dysfunction include:
• Hypertension
• Hyperlipidemia
• Diabetes
• Cigarette smoking
• Drug and alcohol abuse
■ Reducing these risk factors and implementing a healthy diet, adequate nightly sleep, and daily exercise will promote physical and sexual well-being.
Pelvic Floor Rehabilitation
■ Pelvic floor rehabilitation, a specialized field within the scope and practice of physical therapy, has clearly demonstrated effectiveness in the treatment of urinary and fecal incontinence.
■ However, the pelvic floor is also a significant component of sexual function. It has been proposed that the pelvic
floor muscles are active in female genital arousal and orgasm, and that hypotonus may be a significant component of sexual pain disorders in women.
■ Additionally, conditions related to pelvic floor dysfunction, such as organ prolapse, lower urinary tract symptoms, and pelvic pain, are correlated with sexual dysfunction and therefore pelvic floor rehabilitation may aid in the treatment of female sexual dysfunction.
Role of Pelvic Floor in Female Sexual Function
■ In addition to maintaining pelvic support and bowel and bladder continence, the muscles of the pelvic floor play an important role in female sexual function.
■ For example, as described by Chambless and colleagues, a strong ischiocavernosus muscle that attaches to the cli- toral hood is crucial for adequate genital arousal and attainment of orgasm in the female.9,10
■ Additionally, Shafik proposed that during sexual activity, sexual pleasure is enhanced, for both the male and female, by contraction of the levator ani muscles.11
■ Furthermore, Graber and associates explained that weak or deconditioned muscles may provide insufficient activity necessary for vaginal friction or blood flow, resulting in an inhibited orgasmic potential.12
■ Also, syndromes that cause pelvic floor dysfunction and affect the urological system frequently have an effect on sexual function as well.
• In fact, due to the relationship between urological and sexual problems, women with urinary problems should also be questioned about their sexual function.
■ According to Handa and colleagues, women with urinary incontinence also reported low libido, vaginal dryness, painful intercourse, decreased orgasm rates and intensity, and decreased overall sexual satisfaction.13
■ Similarly, Barber and associates determined that one- third of patients with prolapse reported that their pelvic floor condition affected their ability to have sexual relations.14
Pelvic Floor Hypotonus
■ Pelvic floor muscle weakness has been reported as a source of urinary and sexual dysfunction.
■ Often concomitant with pelvic floor hypotonus is a lack of sphincter control, which may lead to symptoms during intercourse of flatus and urinary or bowel leakage, and negatively impact sexual function.
■ As described by Rosenbaum, in cases of prolapse of the posterior vaginal vault (rectocele), penile thrusting may put pressure on structures, causing bowel urgency and expelling of gas, and in more severe cases, fecal incontinence during sex.15
■ According to Moran and associates, the pathophysiology leading to urinary incontinence during penetration may have to do with displacement of the anterior vaginal wall and bladder neck, or an increase in intra-abdominal pressure.16
• It is thus reasonable to anticipate improvement with pelvic floor exercise.
Pelvic Floor Strengthening
■ According to Kegel, patients should become aware of the different elements of the pelvic floor, the movements of this part of the body, and the relationship between it and their respiration.17
■ Physiotherapists and biofeedback instruments can promote this awareness, and women can learn to train their pelvic floor muscles and to use them to increase proprioception of their vagina and vulva.
■ Pelvic floor surface electromyography biofeedback involves insertion of a probe into the vagina, which measures the activity of the pelvic floor muscles, displaying them in graph form on a computer monitor.
• The muscles can thus be visualized by the patient, who is given additional training to learn to relax, strengthen, stabilize, and coordinate them.
• The goal of biofeedback is to normalize the pelvic floor muscle tone and improve contractile and resting stability.
■ Exercises to increase pelvic floor awareness and strength include interrupting the flow of urine, core exercises, and personal massage.
■ Additionally, as described by Mahoney, patients may be taught techniques to inhibit bladder contractions by using active pelvic floor contraction and providing reflex inhibition of the detrusor muscle via Mahoney’s reflex.18
Mechanical Devices
■ One nonpharmacological approach to the treatment of female sexual dysfunction is to use a mechanical device designed to increase blood flow to the clitoris and vagina.
■ This device causes engorgement of the clitoris and a resultant improvement in:
• Vaginal lubrication
• Genital swelling and sensation
• Orgasm
• Overall sexual satisfaction
■ There are two categories of mechanical devices that currently exist:
• Mechanical vibrators
• Clitoral vacuum engorgement devices
Mechanical Vibrators
■ Mechanical vibrators have been used for decades to treat primary and secondary anorgasmia.
■ Vibratory stimulation of the dorsal nerves in the clitoris induces clitoral engorgement, with consequent improvement of vaginal lubrication and enhancement of the female sexual response.
■ However, vibratory stimulation may only be effective when these nerves are well vascularized. If the female sexual dysfunction is a result of diminished blood flow to the clitoris, labia, and vagina, stimulation with a mechanical vibrator may not achieve adequate engorgement because of poor blood flow to these diseased genital vessels.
Eros Clitoral Therapy Device
■ The Eros Clitoral Therapy Device, the first FDA- approved nonpharmacological device for the treatment of female sexual dysfunction, is a battery-operated, handheld apparatus that is placed over the clitoris to provide a gentle adjustable vacuum suction and a low-level vibratory sensation (Urometrics, Inc).
■ The advantage of this device compared to a mechanical vibrator is that the vacuum suction allows engorgement of the clitoris even in the presence of diminished genital blood flow, as is seen with vascular disease.
■ This device is designed to be used three or more times a week, for approximately five minutes at a time.
■ Studies by Billups and colleagues and Wilson and associates both used patient questionnaires to show significant improvements in genital sensation, vaginal lubrication, orgasm, and sexual satisfaction after use of the Eros Clitoral Therapy Device in women with female sexual dysfunction.19,20
■ Additionally, Munarriz and colleagues used duplex Doppler ultrasound to quantitatively measure clitoral blood flow before and after 10 minutes of stimulation with the Eros Clitoral Therapy Device.21
• They determined that there was a significant increase in peak systolic velocity from 7.1 cm/sec to 26.2 cm/ sec with use of the device in women with female sexual arousal disorder.
• Similar significant increases were also observed in measurements of labial blood velocity.
■ The Eros Clitoral Therapy Device provides an adequate alternative for patients who want to avoid use of pharmacological or hormonal agents for the treatment of female sexual dysfunction, particularly arousal and orgasm disorders.
Neuromodulation
■ Over the past few years, neuromodulation has become an established treatment option for lower urinary tract symptoms.
■ However, recently observations have been made of benefits beyond voiding disorders.
■ This next section will describe various forms of neuromodulation and their effects on sexual function.
Sacral Neuromodulation (SNM)
■ SNM is a relatively new therapy that is FDA-approved for the treatment of urinary urgency/frequency, urge incontinence, and nonobstructive urinary retention.
■ The mechanism of action is largely unknown; however, it is thought to occur via alteration of the nerves that supply the bladder.
■ Generally, a lead is implanted at the S3 foramen, while a pulse generator is placed permanently in a subcutaneous pocket over the buttocks.
■ The pelvic, pudendal, and posterior femoral cutaneous nerves arise from S3, resulting in modulation of the motor innervation of the muscles of the perineum via the pudendal nerve and function of bowel and bladder via the pelvic nerve and its distal inferior hypogastric plexus.
■ According to Bernstein and Peters, SNM may have added benefits, including:
• Re-establishment of pelvic floor muscle awareness
• Decrease in vestibulitis, vulvadynia, and bladder pain
• Normalization of bowel function
• Possible improvement of sexual dysfunction
■ Little is known about the complex neural pathways that control female sexual function, but it has been hypothesized that SNM may have a direct impact on the female sexual response through the stimulation of the pelvic and pudendal nerves at the sacral roots, which are responsible for supplying the sensory innervation to the clitoris and pelvic musculature.
■ However, at this time it is not definitively known whether the improvement of sexual function can be solely attributed to SNM, or possibly explained in part by the clinically significant enhancement of urinary symptoms.
■ Additional studies examining the relationship between sacral and pudendal neuromodulation and sexual function are needed to further evaluate the influence neuromodulation therapy has in women with sexual problems.
• These studies would optimally incorporate a large number of women who have sexual problems but no lower urinary tract dysfunction.
Transvaginal Electrical Stimulation (TES)
■ TES is a conservative treatment option for urinary incontinence that was described over 45 years ago. It is used to stimulate nerve fibers and muscles by modifying the frequency of the conduction velocity of various nerve types.
■ For example, at 5—10 Hz, TES affects the detrusor muscle by reflex inhibition with a pudendal to pelvic nerve reflex activation, and at 35—40 Hz, the pelvic floor muscles are stimulated through a pudendal nerve reflex loop.
• As described by Berghmans and colleagues, randomized clinical trials involving TES advocate the use of 50 Hz for stress urinary incontinence and 10—20 Hz for urge urinary incontinence.22
■ Recently, in addition to treating urinary incontinence, TES has been proposed in the treatment of female sexual dysfunction.
• In a study by Giuseppe and colleagues, TES showed a significant improvement on urinary incontinence as well as sexual problems in women.23
• Using questionnaires, it was noted that electrical stimulation significantly improved painful sexual disorders and orgasmic disorders, while also reducing the number of leakage incidents during intercourse.
• However, these positive sexual function results correlated with a decrease in urinary dysfunction. Thus, at this time, the impact of TES on sexual function, independent of urinary incontinence, cannot be determined.
Percutaneous Tibial Nerve Stimulation (PTNS)
■ PTNS has recently been introduced for managing lower urinary tract dysfunction.
■ It was first described by McGuire and associates in 1983 and was based on the traditional Chinese practice of using acupuncture points over the common peroneal or posterior tibial nerves to affect bladder activity.24
■ However, details concerning its exact mechanism of action have yet to be elicited.
■ Currently, this technique involves a 34-gauge needle inserted between the posterior margin of the tibia and soleus muscles, approximately 3—4 cm cephalad to the medial malleolus, and a stick-on electrode that is applied near the arch of the foot on the same leg.
■ The needle and electrode are connected to a low-voltage Urosurge stimulator (Urosurge, Coralville, Iowa) that contains an adjustable pulse intensity of 0—10 mA, fixed pulse width of 200 ^s, and a frequency of 20 Hz.
■ Patients undergo weekly 30-minute treatment sessions for several weeks. If a benefit is perceived by the patient, often chronic maintenance treatment is continued.
■ Similarly to TES, PTNS has also been recently proposed to treat female sexual dysfunction in addition to lower urinary tract dysfunction.
• Van Balken conducted research using questionnaires to evaluate the effects of PTNS on sexual function in patients with lower urinary tract dysfunction.25
• The study determined that sexual life, including overall satisfaction, libido, and frequency of sexual activities, were most likely to improve in women and patients with an overactive bladder undergoing PTNS therapy.
• However, as with the previously described neuromodulation techniques, further studies are needed to examine the effects PTNS has on sexual function, independent of lower urinary tract dysfunction.
Lubricants and Moisturizers
■ During intercourse, lubricants and nonhormonal vaginal moisturizers can be useful in both pre- and postmenopausal women with vaginal dryness and dyspareunia.
■ Although these agents may improve comfort during coitus and increase vaginal moisture, they do not reverse any atrophic vaginal changes that may be present.
■ Water-soluble lubricants, such as K-Y Personal Lubricant and Astroglide, or silicone-based lubricants, including Eros and ID Millennium, are applied at the time of intercourse to decrease irritation.
■ In contrast to lubricants that are applied at the time of coitus, Replens is a long-acting moisturizer that lasts up to three days and should be used on a regular schedule, being applied to the vaginal mucosa two to three times a week.
• It works by binding to the vaginal epithelium, releasing purified water, and producing a moist film over the vaginal tissue.
• In a randomized study by Bygdeman and Swahn comparing Replens to a vaginal estrogen preparation, di- enoestrol, both agents significantly improved vaginal dryness, itching, irritation, and dyspareunia.26
• Furthermore, when compared with each other, no difference was observed between the two agents Replens and dienoestrol.
■ Conclusions
■ Sexual dysfunction in women is a complex process that can lend itself to many treatment options.
■ Prior to beginning any treatment modality, it is important to thoroughly evaluate the patient and discuss with the patient the various options that may be pursued, including referring the patient to a physical or sex therapist.
■ Furthermore, it is important for the patient to understand that when it comes to female sexual dysfunction, there is no quick-fix solution, and both the patient and the clinician must work together and be patient in order to obtain desirable results.
■ References
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