Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Physical therapy for female sexual dysfunction

Hollis Herman

Introduction

Musculoskeletal dysfunctions are factors in the etiology and clinical manifestations of female sexual dysfunction. Gynecologists, urogynecologists, urologists, colorectal specialists, internists, family practice physicians, endocrinologists, sexual counselors, nurse practitioners, and physician assistants will benefit from consultation with practitioners skilled in examination and treatment of musculoskeletal dysfunction to decrease pain, increase muscle strength and improve function in their patients with female sexual dysfunction (see Chapters 4.4 and 6.5 of this book).

Complaints of sexual pain (see Chapters 12.1, 12.2, and 12.4-12.6) are common among women with thoracic, lumbar, pelvic, and lower extremity joint dysfunction.1 Sexual pain is common in women with hypoactive and hyperactive pelvic floor disorders.2-4 Low libido, vaginal dryness, dyspareunia and decreased sexual satisfaction are reported in women with urinary incontinence.2 Inadequate lubrication, arousal, and orgasmic ability are present when there is pelvic floor muscle weakness.5-7 Intolerance to introital penetration, pain during or after sex, fear of pain, and behavioral avoidance of intercourse occur when pelvic floor muscles are adaptively shortened, hypertonic, and weak,8-11 pelvic nerves are inflamed, irritated, and injured or pelvic joints are hypomobile or hypermobile. White and Jantos12 studied the changes in normal sexual behavior that accompany vulvar vestibulitis and found that subjects had no loss of sexual desire. Instead they experienced pain in the vulva tissues with contact, reducing their interest in intercourse and generating negative feelings toward it. In a study of vulvar vestibulitis patients, seven sessions of physical therapy for treatment of dyspareu- nia enabled participants to experience a significant decrease in pain during intercourse and gynecologic examinations. Up to 44 months later, levels of sexual desire and arousal and frequency of intercourse increased as a result of physical therapy intervention.13

This chapter addresses the musculoskeletal dysfunctions commonly associated with female sexual pain. It is written to help referring practitioners understand the role of musculoskeletal dysfunction in sexual pain and treatment options available.

The primary musculoskeletal findings in female sexual pain dysfunction are painful and restricted joints, hypertonic, short and weak pelvic floor muscles and irritated and inflamed nerves. Women complain of burning, stabbing, prickling, searing, knifelike pain in their vulva, clitoris, urethra, vagina, anus or rectum (see Chapters 9.2-9.5). They frequently suffer from constipation, urinary incontinence, or urinary frequency and urgency. They have histories of abdominal, perineal, or lumbar surgeries with scars that restrict tissue mobility or blood flow. They all have functional limitations in performing sexual intercourse and have pain during or after sexual activity.

The screening for musculoskeletal dysfunction involves many components listed in Table 12.3.1, including evaluation of the bony structure to assess static and dynamic alignment, symmetry, joint mobility, range of motion, and function. The evaluation proceeds to soft tissue assessment of sensation, muscle strength, length, recruitment, and function, which are often overlooked in the pelvic floor, leading to misdiagnoses of psychogenic pain.14,15 Musculoskeletal structures of the abdomen, back, perineum, and lower extremities share segmental innervations with many urogenital structures. Referred pain from these musculoskeletal structures can mimic urogenital, gynecologic, and colorectal pain and interfere with the ability to participate in pain-free sexual activity (Table 12.3.2).

Table 12.3.1. Physical therapy components of evaluation and treatment for female sexual dysfunction

Evaluate and treat for postural changes in cervical, thoracic, lumbar, and pelvic regions

Evaluate and treat weakness, hypertonicity, and trigger points in the abdominal muscles

Evaluate and treat for diastasis recti

Evaluate and treat for weakness, hypertonicity, and trigger points in all muscles of the pelvic floor

Evaluate and treat for muscular restrictions to vaginal penetration

Evaluate and treat for vaginal canal movement restrictions

Evaluate for sensory disturbances of the perineum

Evaluate with surface electromyography for perineal muscle hyperactivity

Evaluate and treat for episiotomy and perineal laceration scar tissue restrictions

Evaluate and treat for psoas, iliacus, obturator internus, piriformis, adductor longus, adductor magnus, gluteal, abdominal, paraspinal, hamstring, and multifidus muscle weakness, strain, hypertonicity, and tender and trigger points

Evaluate and treat for pubic symphysis, coccyx, sacroiliac, lumbosacral, lumbar, thoracic, cervical , hip, knee, and ankle joint alignment dysfunctions

Evaluate and treat for pubic symphysis separation, upslip, downslip, anterior displacement, posterior displacement, coccyx hypermobility in flexion or extension, sacroiliac upslip, downslip, rotation, outflare, and inflare

Evaluate and treat muscles affected by spondylolythesis, spondylosis, sacralizations, and lumbarizations

Evaluate and treat for cesarean section scar tissue restrictions

Evaluate and treat for leg and vulvar varicosities with massage, compression, and exercise

Evaluate and treat for lumbar disk herniation, muscle strain, and supports

Evaluate and treat for functional impairment patterns, including poor trunk stability, increased spinal segmental flexibility, decreased proximal and distal limb joint flexibility, and inappropriate compensatory movements

Evaluate and treat for proper body mechanics during functional activities

Evaluate and treat for diminished thoracic and rib cage expansion

Evaluate and treat for first rib mobility restrictions

Evaluate and treat for musculoskeletal restrictions from ilioinguinal, iliohypogastric, genitofemoral, lateral femoral cutaneous, femoral, obturator, pudendal, and brachial plexus nerve entrapments

Evaluate and prescribe an individualized aerobic exercise program

Bony structure

Articulations of the lumbopelvic complex are the sacrum with the fifth lumbar vertebrae, two sacroiliac joints joining the ilium and the sacrum, the pubic symphysis joint, sacrococcygeal joints, intercoccygeal joints, and the femur with the innominate. All of these joints have established normal range of motion measured by goniometric devices, passive range of motion tests, and specific static and active mobility tests. Range of motion values less or significantly greater than expected during these passive and active motion tests are indicative of dysfunction predisposing the joint to abnormal biomechanics, which is a potential source of pain and functional limitation.

Observation of posture from front, back, and side views ideally aligns the joints to a plumb line. Palpation of bony landmarks for symmetry in standing, sitting, and supine, prone, and side lying provides information that alignment may be altered and a potential source of dysfunction. Passive joint testing for proper end feel and mobility can reproduce and isolate painful restrictions. Baker16 lists a typical pattern of faulty posture in patients with musculoskeletal chronic pelvic pain, including anterior tilt of the pelvis with anterior rotation of the innominate and increased nutation of the sacrum, increased lumbar lordosis and hypomobility of the lumbar spine joints, hyperextension of the knees, anterior displacement of line of gravity in the pelvis and lower extremities, adaptive shortening and hypertonus of the iliopsoas and hip external rotators, lengthening of the iliofemoral ligament, loss of hip capsular extensibility, degenerative joint disease of the hips, loss of hip range of motion into internal rotation, weakness of the abdominal muscles, abdominal trigger points, hypermobility of the thoracolumbar facets, and degenerative joint disease of the thoracolumbar facets.

Soft tissue evaluation

The soft tissues of the lumbopelvic and abdominopelvic region are assessed by palpation for sensation, length, tension, strength, quality of contraction, and tender and trigger points. Muscles attaching to the pelvis are the pelvic floor muscles, including the levator ani (pelvic diaphragm), deep urogenital layer (perineal membrane), the superficial layer of muscles of the urogenital diaphragm, the abdominals, hip flexors, hip extensors, hip internal and external rotators, hip adductors and abductors and flexors and extensors of the spine (see Chapter 4.4).

Specific external assessment of the genitalia and superficial perineal structures begins with observation of skin integrity for redness, swelling, lesions, discoloration, hair loss, and discharge. Pelvic floor muscle contraction, relaxation, and lengthening are informative regarding the patient’s awareness, voluntary control, and general resting state of her muscles. If the patient is unaware of the pelvic floor muscles, the excursion of the perineal body from the resting position to the shortened contracted position will be minimal, and lengthening of the tissues by gentle bulging will be absent. Often, patients who do not know how to lengthen the muscles suffer constipation or strain with defecation (see Chapters 9.5, 12.1, and 12.2).

Table 12.3.2. Referred pain sites

Structures

Innervation

Referred pain sites

Common disorders

Hip

T12-S1

Lower abdomen, anterior Medial thigh, knee

DJD, bursitis, inflammation, fracture

Lumbar facets, disks

T12-S1

Low back, lateral buttock posterior thigh

Instability, herniation capsular entrapment fracture

Sacroiliac

joints

L4-S3

Posterior thigh, pelvic floor, buttock

Strain, laxity, malalignment

Symphysis pubis joint

L1-L5

Lower abdomen, anteromedial thigh, pelvic floor, hip

Strain, separation, laxity, fracture

Abdominal

muscles

T5-L1

Abdomen, anteromedial thigh, pelvic floor

Weakness, strain, diastasis recti, TrP

Pelvic floor Muscles

S1-S4

Vagina, rectum, urethra coccyx, clitoris, labia

Adaptive shortening, TrP, protective guarding

Piriformis

L5-S3

Low back, buttock, pelvic

Adaptive shortening, TrP, protective guarding, weakness

Obturator

Internus/externus

L3-S2

Pelvic floor, buttock, anterior thigh, clitoris, vagina, coccyx

Adaptive shortening, TrP, protective guarding

DJD: degenerative joint disease; TrP: trigger points. Modified from Baker’8 and Travel! and Simons.’0

External palpation of the pelvic floor muscles will reveal tender and trigger points, pain, and altered sensation and tone. A muscle trigger point will evoke a local twitch response in the taut muscle fibers upon palpation and produce specific referred autonomic phenomena in a pain reference zone. An active trigger point is always tender, prevents full lengthening of the muscle, weakens the muscle, and refers pain on direct compres- sion.17 Travell and Simons referenced pain zones in the coccyx, anus, rectum, buttock, and posterior thigh from trigger points in the levator ani, obturator internus, and gluteal, abdominal, lumbar, and lower extremity muscles.18 Pelvic floor myofascial trigger points are a source of pain for voiding symptoms and a potential trigger for neurogenic bladder inflammation.19 A muscle tender point produces a visible wince when palpated, and tenderness at the site of palpation. Figure 12.3.1 demonstrates a systematic method for documentation of tenderness, pain, and trigger points in the superficial transverse perineal, bulbocavernosus, ischiocavernosus, pubococcygeus, iliococ- cygeus, and ischicoccygeus muscles.

Midline episiotomies cause perineal trauma. There is a 50 times greater risk of grades three and four lacerations into the anal canal, more pain, more blood loss and slower healing than with spontaneous tears. Mediolateral episiotomies are associated with more pain and weaker pelvic floor muscles that provide less satisfactory cosmetic results and cause more painful intercourse than midline episiotomy or spontaneous tears.20,21 Tissue restriction from the episiotomy scar may be a cause of pain during vaginal penetration. It may be a source of discomfort when sitting, painful defecation, urinary and fecal incontinence, constipation, altered sexual response and sensation, bleeding, and fissure. Tissue mobility of the episiotomy scar can be graded 1/3, 2/3, or 3/3 when palpated, depending on the amount of restriction present when compared with tissue mobility elsewhere in the body. Palpation of the scar may refer pain to the vaginal introitus, vaginal canal, rectum, and labia. Perineal massage (Table 12.3.3), heat, stretching with dilators or pediatric speculums, muscle re-education by surface electromyography biofeedback, and pelvic floor muscle exercises will increase tissue mobility, and decrease perineal pain and functional limitations. If not, surgical scar revision and reconstruction should be considered.

Muscle strength

Reissing et al.8 reported higher vaginal and pelvic muscle tone and lower muscle strength in women with vaginismus and dyspareunia. Muscle testing for strength and endurance is performed manually according to established criteria and graded on the 0-5 Oxford scale. The muscles of the pelvic floor can be similarly tested by digital internal examination. The pelvic floor muscles: superficial, perineal membrane, and levator ani can be assessed independently to isolate muscle weakness at the different layers and the discrepancies between right and left sides that are common, particularly when there is concurrent sacroiliac, pubic symphysis, hip, or lumbosacral joint dysfunction. In an attempt to standardize global pelvic floor muscle measurement, the International Continence Society Pelvic Floor Assessment Group has recommended a simpler grading system for the pelvic floor muscles of absent, weak, and strong.22

Figure 12.3.1. A systematic method for the documentation of tenderness, pain, and trigger points in the superficial transverse perineal, bulbocavernosus, ischiocavernosus, pubococcygeus, iliococcygeus and ischiococcygeus muscles.

Treatment

Vaginismus is an involuntary vaginal muscle contraction making sexual intercourse difficult or impossible. Dyspareunia is defined as painful intercourse. Binik et al.9 propose a reconceptualization of vaginismus and dyspareunia as sexual disorders characterized by pain, to pain disorders that interfere with sexuality. Physical therapy treatment coverage of dyspareunia may be denied under its primary International Classification of Diseases, ninth revision, code (625.9) if viewed as a psychiatric or sexual dysfunction rather than an anatomic or physiologic dysfunction. Graziottin23 suggests that there are solid biologic factors causing vaginismus and dyspareunia, including muscular, neurologic, and vascular factors.

Possible musculoskeletal causes of dyspareunia are as follows: fissure, adhesion from prior surgery, endometriosis,24 episiotomy, laceration, birthing trauma with forceps or vacuum extraction, vaginal infection, urinary tract infection, inflammation, skin irritation from chemicals, nerve irritation from entrapment, neurohormonal alteration (particularly estrogen deficiency),25 instability of the pelvis,26 prolapse, vasocongestion, and sexual trauma.

Marinoff and Turner27 define three levels of dyspareunia. Level 1 refers to painful intercourse not severe enough to prevent the activity. Level 2 is painful intercourse that limits the frequency of the activity. Level 3 represents severe painful intercourse that causes abstinence.

Burning, stinging, irritation, rawness, tearing, and searing pain are the most common complaints reported during and after vaginal penetration. If these symptoms are felt at the vaginal introitus, superficial structures such as the vulva, perineal body, posterior fourchette, episiotomy site, and superficial muscle layer are implicated. If deeper vaginal pain occurs, restriction of the vaginal canal, levator ani, and obturator internus muscle trigger points, or sacroiliac, symphysis pubis, hip, or lumbosacral joint dysfunction may be implicated.

Once the musculoskeletal diagnosis for vaginismus and dyspareunia has been established, treatment should include the following steps:28

1. Correct any joint malalignment to promote pain-free joint mobility.

2. Teach the patient self-correction joint techniques.

3. Inform about positions for sexual intimacy.

4. Eliminate tender and trigger points in all of the muscles.

5. Eliminate or reduce scar adhesions and tissue restrictions.

6. Teach pelvic floor muscle awareness with a biofeedback device.

7. Re-educate the pelvic floor muscles to be relaxed upon penetration.

8. Stretch the muscles surrounding the vagina by combining down-training with dilators.

9. Stretch the muscles surrounding the vagina by manual tissue techniques.

10. Correct muscle imbalances by down-training (relaxation) and up-training (strengthening).

11. Correct muscle imbalances by teaching correct muscle timing and recruitment.

12. Educate about lubricants.

___

Table 12.3.3. Perineal massage

Procedure 1

Practice lifting up and contracting the pelvic floor muscles, followed by relaxation

View in the mirror to see that the perineal body is pulled inward with the lift

While relaxed, slowly insert thumb fully into the vagina 1-1.5 inches (3-4 cm)

Pull down with the thumb

Stretch the bottom wall of the vagina toward the anus.

Hold steadily for 1-2 min

A feeling of burning in the stretched tissues usually subsides after 1-2 min

Pull the thumb down and to the right and stretch those tissues for 1-2 min

Pull the thumb down and to the left and stretch those tissues for 1-2 min

Combine stretching down and stretching to the sides in a sweeping motion

Slowly and gently massage back and forth over the lower half of the vagina, working the lubricant into the tissues for 3-5 min

Procedure 2

Insert your thumb partially into the vagina

Place your index finger outside the vagina on the perineal body

Roll the posterior wall of the vagina between the thumb and index finger

Roll the tissues for 3-5 min

Procedure 3

Place the index and middle finger on the perineal body without lubricant

Massage the tissues sideways back and forth to free up tissue mobility and scar adhesions

Massage for 3-5 min

For all procedures:

Trim fingernails

Wash hands

Semi-sitting with back supported against pillows

Knees bent up and open

Hold mirror for viewing

Cautions: Avoid the urinary opening to prevent urinary tract infections

Do not do this perineal massage if you have an active herpes lesion; it may spread the infection

Hints: Take a warm bath or place warm compresses on the perineum for 5-10 min before massage

Use K-Y jelly, Slippery Stuff, Astroglide, cocoa butter, vitamin E oil or pure vegetable oil, or none at all

Do this massage once a day

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Positions for sexual activity

Patients with orthopedic dysfunctions are often limited in the positions they can tolerate for intercourse, genital-manual manipulation, or genital-oral stimulation. A total of 46% of patients with chronic low back pain have reduced frequency of intercourse, marked discomfort during intercourse, and greater interference with all aspects of their sexual lives. Female patients with back pain prefer the supine to the prone position for intercourse,29 although modifications may be required to place the lumbar spine in a neutral position for better comfort.

Dahm et al.30 surveyed 254 members of the American Association of Hip and Knee Surgeons and found that 80% of surgeons do not discuss sexual positions with their hip artho- plasty patients. A total of 96% of surgeons who discussed postoperative sexual activity with patients spent 5 min or less on the topic. There are five positions for men and three positions for women that are considered acceptable by 90% of the surgeons to protect the hip replacement from dislocation. The most comfortable position reported by women is side-lying on the nonoperative hip. Patients should be instructed in the use of wedges, cushions, and pillows to prevent the operated hip from falling into excessive adduction or flexion past 90°.

Hip dysplasia or symphysis pubis joint separation may limit comfortable lower extremity abduction, external rotation, and flexion. The typical missionary position will be too uncomfortable unless modifications are made by placing pillows and wedges lateral to the knees or placing the legs closer together to relax the hyperactive adductor longus and adductor magnus muscles and maintain joint alignment.

Patients with ilial rotation may prefer to straddle their supine partner or sit atop for intercourse. This musculoskeletal dysfunction is common in pregnant patients, early postpartum, and the luteal phase of the menstrual cycle.

Patients diagnosed with dyspareunia, vaginismus, vulvo- dynia, vestibulodynia, and pelvic floor muscle disorders need to find preferred sexual positions, because each position affords a different contact with the external vulva and internal pelvic organs.31 Having tried one position unsuccessfully, patients and their partners will erroneously believe that all positions will hurt. Not all vaginal canals are at the same angle to the introitus. Patients and their partners benefit from instruction about female anatomy and how different positions may change the “fit” when attempting penetration. Depending on the shape and size of the pelvic outlet, penetration can be compromised. Patients are surprised to learn that limb and body positioning may increase or decrease the dimensions of the outlet. External perineal examination of the bony landmarks, muscle tone, and muscle tender and trigger point pain sites, and scar tissue mobility assessment offer specific information regarding factors that limit penetration and movement during intercourse. The external examination should be followed by an internal pelvic floor muscle examination without a speculum to determine which position is most suited for the patient and her partner. Digital examination inside the vaginal canal to determine elasticity of the tissues will contribute to an estimation of the circumferential dimensions the vagina can comfortably accommodate. Too often, patients are told, “just do it”, or given a set of dilators without specific instruction about which one to start with and then how to progress through the sizes. Fear, pain, and lack of knowledge about how to use the dilators will prevent the patient from using these tools effectively. Simply suggesting that patients attempt vaginal penetration after orgasm by digital or oral stimulation may permit entry and a slower second time around.

In the missionary position, the erect penis reaches the anterior fornix and has contact with the anterior vaginal wall. The posterior bladder wall is pushed forward and upward, and the uterus pushed upward and backward. Patients with painful anterior wall tenderness, interstitial cystitis, painful bladder syndrome, endometriosis, or postsurgical tissue restrictions may find straddling their partner facing away, side lying, on hands and knees, or prone over a wedge more comfortable. In the rear entry position, the erect penis reaches the posterior fornix with contact of the posterior vaginal wall, and the bladder and uterus are pushed forward. Alternate positions are suggested in Table 12.3.4.

All patients should be instructed in self-correction of the lumbar vertebrae, symphysis pubis, hip, sacrum, and ilium by simple effective muscle energy techniques. After office treatment to correct the joint malalignment, the patient can continue with self-corrections at home, with the example of an anterior right ilial correction in Fig. 12.3.2.

Intravaginal manual therapy

Treating the myofascial trigger points in the pelvic floor, abdominal, gluteal, piriformis, and obturator internus muscles resolves or improves symptoms of chronic pelvic pain, sacroiliac joint dysfunction, interstitial cystitis, and irritative voiding.32 Modified Thiele’s massage, intravaginal manual therapy massage of the pelvic floor muscles, two times a week for 5 weeks, improved irritative bladder symptoms in patients with interstitial cystitis and decreased pelvic floor muscle tone.33 In another study, similar intravaginal manual therapy massage to hypertonic pelvic floor muscles two times per week for 12 weeks effectively eliminated the symptoms of urinary urgency and frequency syndrome and interstitial cystitis.17 To correct “short” painful pelvic floor muscles, Fitzgerald and Kotarinos10,11 recommend external connective tissue massage to the lower extremities, abdomen, and pelvis, correction of the abdominal diastasis recti if present, muscle inhibition by proprioceptive neuromuscular facilitation antagonistic muscle patterns, and intravaginal manual therapy muscle massage and stretching. Treating the pelvic floor muscle trigger points by injections or dry needling in combination with intravaginal manual therapy massage techniques can be effective.34

Intrarectal manual therapy

Hypertonus in the pelvic floor muscles, poor intake of the correct fiber and fluid, and lack of activity may cause constipation.35 This condition may contribute to pelvic and sexual pain through altered tone in the pelvic floor muscles. Relaxation of the pelvic floor muscles, specifically the puborectalis, during defecation is necessary to allow the canal to open and the anorectal angle to increase. Inability to relax the puborectalis muscle is termed a paradoxical contraction and necessitates straining during evacuation. Excessive straining can traction the pudendal nerve and alter perineal sensation. The electrical activity of the puborectalis muscle can be assessed by surface electromyography. In sitting, external surface sensors of one channel placed at the 3 and 9 o’clock positions around the anal rim, with the other channel monitoring the abdominal muscles, can demonstrate the patient’s inability to relax the puborectalis muscle while teaching proper use of the abdominals. Re-education of both muscle groups is facilitated by surface electromyography, and proper muscle functioning reduces straining.

Table 12.3.4. Positions for intercourse

Restrictions

Supine -

supported

knees

Supine -

legs

adducted

Prone - with pillow

All fours

Side-lying

Sitting

Straddling

Back pain

+

+

+

+

+

+

 

Anterior ilium SIJ

       

+

+

+

Posterior ilium SIJ

+

     

+

   

Herniated disk

   

+

 

+

 

+

Hip external rotation

+

+

     

+ facing away

 

Neck pain

       

+

+

+

Prolapsed uterus

+ use a

+ use a

 

+

+

   
 

wedge

wedge

         

SIJ = sacroiliac joint.

Figure 12.3.2. Anterior right ilial correction.

Thiele’s massage Fig. 12.3.3 is a technique to address coccydy- nia directly by intrarectal manual therapy massage of the hypertonic piriformis, obturator internus, puborectalis, ischiococcygeus, and iliococcygeus muscles. Massage strokes are in the direction of the fibers or perpendicular to the muscle fibers. Intrarectal translation and traction mobilizations of the intracoccygeal and sacrococcygeal joints are effective 25% of the time to treat coccydynia. Intravaginal and intrarectal levator ani massage and muscle stretching were more effective in reducing pain than mobilization.29

External and internal soft tissue friction massage to a restricted anal fissure scar may reduce painful defecation or painful anal intercourse. Manual therapy techniques of sacral decompression, springing, rocking, strain-counterstrain, positional release, and myofascial release to the sacrum, ilium, connecting ligaments, and muscles will improve joint mechanics and reduce rectal pain.

Surface electromyography and pelvic floor muscle exercises

Surface electromyography was proposed36 as an objective method of differential diagnosis between functional (musculoskeletal) vulvovaginal pain syndromes and other sources of vulvovaginal pain such as infections. Battaglia et al.37 proposed this as an effective therapeutic technique for patients with pelvic floor dyssyn- ergia and slow-transit constipation. Bergeron et al.38 compared the effects of cognitive-behavioral therapy, surface electromyography, and vestibulectomy in the treatment of dyspareunia and found all techniques significantly helped subjects in psychologic adjustment and sexual function from pretreatment to 6-month follow-up. Using surface electromyography with pelvic pain patients, Glazer et al.36 demonstrated unstable and abnormally high resting baseline values. Unstable and weak amplitudes were recorded during phasic, tonic and endurance voluntary contractions. Shafik and El-Sibai39 found that patients with vaginismus exhibited increased electromyography activity at rest and upon penetration when monitoring the levator ani, puborectalis and bulbocavernosus. Stabilizing muscle variability overall and predominantly at rest was a major factor in effective treatment rather than focus on increases in the contractile amplitude.

Glazer and MacConkey40 proposed simultaneous use of different muscle combinations to enhance the pelvic floor muscles in order to “break” the resting tension level and reduce pain. The “Glazer protocol” (Table 12.3.5) consists of two 20-min exercise sessions per day. Each one is 60 repetitions of 10-s contractions alternating with 10-s relaxation phases. Patients are asked to contract the pelvic floor muscles maximally with all other surrounding muscles. They are required to use home surface electromyography training devices with intravaginal sensors. Gradually, the clinician may observe increased contractile amplitudes, decreased variability of the contraction and relaxation amplitude, and faster rise and recovery times with subjective reports of less pain. According to Glazer, the surface electromyography changes demonstrate a reduction of the hypertonicity and instability associated with chronic uncoordinated discharge of fast twitch fibers seen in the resting surface electromyography of vulvovaginal pain patients. Variations on “Glazer’s protocol” that have had equally significant treatment results are two 15- rather than 20-min sessions. Perianal external surface sensors can be used initially, progressing to a small intravaginal sensor the size of a tampon for those with Marinoff level 3 dyspareunia. McKay et al.41 reported that 90% of patients with vulvar vestibulitis treated with home trainers, surface electromyography, and pelvic floor muscle exercises demonstrated decreased introital tenderness and the resumption of pain-free sexual activity within 6 months of the start of therapy. There are reasonably priced rental programs throughout the USA that offer month-long home use of a single-channel, surface electromyography unit, allowing most patients the opportunity to utilize this treatment. Tries42 encourages standardization in protocols of biofeedback techniques using two or more channels of information to reinforce stable abdominal and bladder pressures concurrently with pelvic floor muscle contractions lasting up to 30 s. Patients should be instructed in at least four training sessions before home programs are used exclusively.

Figure 12.3.3. Theile's massage.

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Table 12.3.5. Glazer's protocol and modified Glazer's protocol

Testing

1-min rest, pre-baseline

Five rapid contractions (flicks) with 10-s rest between each

Five 10-s contractions with 10-s rests between each

A single endurance contraction of 60 s

1-min rest post-baseline

Findings

The typical sEMG findings for pain patients are an elevated resting baseline, instability of the signal during resting measured by changes in standard deviation, and instability of the signal during the contraction

Home program

A home program is two 20-min exercise sessions per day

Patient is supine, semi-reclining, sitting, or standing

The patient contracts (shortens) the pelvic floor muscles up and in as

hard as possible along with any other muscles

Hold the contraction for 10 s

Relax for 10 s

Repeat 60 times twice a day

Modifications

External surface sensors placed perianal (either side of the anal rim) rather than an internal surface sensor

Contractions can be performed by isolated pelvic floor muscles or in combination with accessory muscles

One session per day rather than two or two 15-min sessions

Daily

Use a one- or two-channel home rental sEMG unit for daily practice in varied positions of sitting, supine, and standing

Frequent self-monitoring of the pelvic floor muscles during daily activities is possible with focus concentration followed by pelvic floor muscle contractions

Gentle bulging to release and lengthen the pelvic floor muscles six times a day for 6 s

The goal is increased relaxation of the pelvic floor muscles most of the time when not activated for stability, posture, or activities

sEMG: surface electromyography.

___

Fitzgerald and Kotarinos10,11 suggest that hypertonic painful pelvic floor muscles are too short and need lengthening. They propose an alternative to the typical shortening contraction of pelvic floor muscles with pelvic floor muscles by “squat and drop” exercises to lengthen the muscles. Intravaginal manual therapy muscle stretching techniques are followed by active squatting coupled with gentle bulging and voluntary muscle relaxation.

After patients have learned to relax and lengthen the pelvic floor muscles, they can proceed with vaginal or rectal penetration, using progressively larger dilators and surface electromyography for muscle awareness and re-education. Step-by-step patient instructions are outlined in Table 12.3.6.

___

Table 12.3.6. Dilator instructions with sEMG

Now that you are able to contract and relax the muscles around the vagina and the rectum at will, it is time to use that knowledge to re-educate your muscles to stay relaxed while having penetration.

The thought of having penetration (intercourse) can be enough to contract your muscles in anticipation of the pain. So, even before attempting penetration with the dilator, try these steps (also the idea of these exercises is to retrain your muscles to stay relaxed during penetration so that there is less discomfort). Under no circumstances should these exercises cause pain (some stretching feelings or slight tingling are acceptable), but not pain.

1. While connected to the sEMG machine, try to imagine the steps leading up to penetration (intercourse) and see if you can keep your muscles relaxed and the activity of your muscles quiet. Have 1 mv or less as your goal. If the muscles are more active, try squeezing them for 10 s and then relaxing for 10 s to get the baseline down.

2. Once you feel comfortable with that step, try bringing your hand down to your perineum and placing it on your labia. There may be a bit of movement in the graph or lights on the machine from the movement of your hand, but if the muscles are relaxed, the baseline should soon return to a low resting of 1 mv or less.

3. Then, try placing your hand on your labia and separating the labia. See if you can control the muscle activity to remain quiet.

4. You may find that having your legs in an open position is causing a strain on the inside (adductor) muscles and you may want to try positioning your knees on pillows so that they do not need to be held so far apart. Some women find that placing a pillow under the buttocks also can help the pelvic floor muscles relax.

5. Take the dilator, place water soluble lubricant on it, try a 10-s pelvic floor muscle squeeze, and then, while relaxing, slide the dilator into the vaginal canal for 2 inches. Remember, the canal usually angles down slightly toward the rectum, and for some women the canal can angle to the left or to the right. Try to relax with it in place for a few minutes (do not think you have to insert the dilator in all the way).

6. If the insertion of that dilator was comfortable and you wish to proceed with the next size, repeat step no. 5.

7. If that size was comfortable, try the next size until you feel that it is enough of a stretch.

8. Some women, try doing their Kegel exercises (pelvic floor muscle contractions) with the dilator in place inside the canal, but for some women it is too uncomfortable.

9. After removing the dilator, most women find that their resting baseline of muscle activity is practically zero because of the gentle stretching that occurred. Close your eyes and feel that muscle relaxation, for this is the muscle feeling you want to reproduce.

10. Take the dilator out of the vaginal canal, wash your perineum thoroughly with cold water, and wash the dilator with soap and water.

11. If you feel slight tingling or irritation around the opening of the vagina, rinse yourself with cold water, after urinating, for the next couple of hours, or place a bag of frozen peas to your perineum on the outside of your underwear to cool off the area.

12. Variations on this exercise using dilators can include placing the dilator into the vaginal canal when standing in the shower (like placing a tampon into the vagina), inserting the dilator while in the bathtub, having your partner carefully insert the dilator into your vagina with your instructions, moving the dilator in and out to mimic thrusting, pressing the tip of the dilator against a specific pain spot in the vagina and waiting for the muscle to relax, or using the dilator as an internal massage tool for a specific muscle trigger point.

13. Painfree insertion of the largest dilator is not an automatic indicator that penetration (intercourse) with your partner will be painfree and easy every time, but it helps to stretch out the tissues, re-educate the muscles to do what you want them to, break the anticipated pain response to penetration, and offer understanding and awareness as to what sexual positions might work best for you.

sEMG: surface electromyography.

___

Electrical stimulation

Patients experiencing dyspareunia and vaginismus benefited from electrical stimulation one time a week for 10 weeks by increasing their ability to contract the pelvic floor muscles. They had decreased pain measured on a visual analog scale and resumed sexual intercourse.43 A 50-Hz setting utilizes the pudendal to pudendal nerve pathway to stimulate muscle contraction, and settings up to 250 Hz have been effective in reducing pelvic floor muscle pain.44

Ultrasound

A review of randomized, controlled studies on the application of ultrasound for perineal pain and dyspareunia is inconclusive based on minimal studies. Reduction of edema and inflammation through pulsed current, or increased tissue elasticity and mobility through continuous current have been documented. Standardization of settings for intensity and optimal duration have not been established.

Lubrication

Although aging results in changes in anatomy and physiology of the genitals, and many women have lubrication difficulty,46,47 postmenopausal women preserve their genital responsivity when sufficiently sexually stimulated by viewing erotic imagery.48 Vaginal dryness and dyspareunia experienced by some postmenopausal women may result from long-standing lack of arousal and diminished estrogen. The need for lubricant, the proper application of a lubricant, the benefits of a lubricant without propylene glycol if the vulva is hypersensitive, and the importance of foreplay to generate lubrication are topics to discuss with patients in preparation for pain-free penetration.

Transcutaneous electrical nerve stimulation

Transcutaneous electrical nerve stimulation is a noninvasive, affordable method for reducing perineal pain sensations. It has been used effectively to reduce pelvic pain during labor and delivery, and has been recommended for use in gynecologic pain conditions.49 A two-channel unit costs under $60 to purchase, and transcutaneous electrical nerve stimulation can be self- administered with external electrodes placed over the L4-L5 and S2-S4 regions to address perineal pain.50

Nerve supply

The cutaneous nerve supply to the vulva includes the ilioinguinal nerve (Lj), the genital branch of the genitofemoral nerve (L1—L2), the perineal branch of the femoral cutaneous nerve (L2-L3), and the perineal nerve. The symphysis pubis is innervated by the iliohypogastric nerve (T12) and branches of the genitofemoral nerve (L1—L2). Compression, traction, or entrapment of the nerves from abdominal surgeries, injury, or muscle hypertonus may contribute to sensory changes.1 The perineum has sensory and motor innervation from the sacral plexus L4-S4 (Table 12.3.7). Patients with sexual pain often have histories ofherniated or bulging lumbar disks with or without laminectomy. Mobilizing the scar tissue or palpating lumbar or pelvic muscle trigger points will reproduce vulvar pain, vaginal pain, and coccyx, rectal, or even clitoral pain. Sensation of the perineum can be objectively assessed by Symmes-Weinstein monofilaments along established dermatomes.

Table 12.3.7. Abdominal and pelvic neurophathies

Nerve

Symptoms-referred pain sites

Etiology

Ilioinguinal

L1

Sensory-burning pain below inguinal ligament radiating to medial superior thigh and lateral scrotum or Labia majora Motor-weakness of transversus abdominus and internal oblique Bulging of anterior abdominal wall Ambulates with a flexed trunk

Blow to abdominal wall or incision (appendectomy, cesarean section, hysterectomy, inguinal hernia repair, sling suspension), trauma, pubis symphysis joint separation, ilial upslip

Iliohypogastric

T12-L1

Sensory-iliac branch-posterior superior gluteals

Hypogastric branch-anterior suprapubic

Motor-weakness of transversus abdominus and internal oblique

Bulging of anterior abdominal wall

Ambulates with a flexed trunk

Blow to abdominal wall or incision (appendectomy, cesarean section, hysterectomy, inguinal hernia repair, sling suspension), trauma, pubic symphysis joint separation, ilial upslip

Genitofemoral

L1-2

Sensory-femoral branch-proximal anterior thigh Genital branch- with round ligament to labia majora Motor-portion of the lateral bulbocavernous

Blow to abdominal wall or incision (appendectomy, cesarean section, hysterectomy, inguinal hernia repair, sling suspension), trauma, pubis symphysis joint separation, ilial upslip

Sciatic

L4-S2

Sensory-radiating pain posterior thigh Paraesthesia posterior leg to foot Motor-weakness and atrophy of hamstring Gait instablity

Piriformis entrapment, disc injury Retroperitoneal or pelvic bleeding post-lower abdominal while on anticoagulant therapy, post hip surgery/trauma, lithotomy position

Femoral

L2-4

Sensory-middle cutaneous-anterior thigh to above knee medial cutaneous - medial thigh, medial leg w/ saphenous nerve decreased patellar DTR

Motor-weakness in quadriceps and iliacus and hip flexors

Lesions, tumors, trauma, childbirth lithotomy position, laceration or puncture at inguinal ligament retroperitoneal hematoma, pelvic surgery

Oburator

T12-L1

Sensory-medial proximal thigh to inner knee often accompanied

by femoral nerve deficit

Motor-hip abductors and flexors

Groin or medial thigh pain

Wide based gait

Tumor, mass, lesion within pelvic girdle and psoas, childbirth, lower abdominal or gynecological surgery, trauma to pelvis, hip, ischial tuberosity, pelvic fracture, surgical positioning with prolonged hip flexion

Lateral femoral cutaneous L2-3

Sensory-lateral superior thigh with increased symptoms when standing, walking, - relieved when sitting

Injury to inguinal ligament (upper and lateral aspect), hernia repair, pregnancy

Posterior femoral cutaneous S2-3

Sensory-medial posterior buttock, posterior labia and posterior thigh

 

Pudendal

S2-4

Sensory-dermatomes S2-4, perineum, perianal

Motor-anal sphincter, perineal muscles, periurethral skeletal muscles

Childbirth injury, entrapment, compression, traction injuries, pelvic fracture, joint malalignment

Modified from: Cindy Feldt PT-CSM Pelvic Girdle Preconference Course 2000. DTR = deep tendon reflex.

The lesser sciatic foramen, the ischial spine, the sacrotuber- ous ligament, the ischial tuberositity, and Alcock’s canal are potential sites for nerve entrapment or irritation. Physical or manual therapy techniques such as myofascial release, trigger point release, strain-counterstrain or positional release, ischemic pressure, friction massage, muscle energy techniques, and joint mobilization may alter tissue mobility or realign bony structures, thus reducing the pressure on the nerve and decreasing the symptoms. Addressing hypertonus in the levator ani, particularly the pubococcygeus and iliococcygeus,51 iliopsoas,27,52 piriformis, adductors,19 quadratus lumborum, hamstrings, obturator internus, coccygeus, and gluteus medius27 muscles is essential for complete treatment of this region.

Summary

The objective musculoskeletal findings in patients with sexual pain are: abnormal sensations and allodynia upon palpation of the vulva; burning, stinging, prickling, searing or pain in the clitoris, urethra, vagina, perineal body, anus, posterior thigh, and gluteal and abdominal areas;19 lumbar, sacroiliac, coccyx, symphysis pubis, and hip joint restriction, and malalignment and instability of the pelvis;27 functional impairment of sitting, walking, urination, defecation, sexual activity,51 and household and community activities of daily living; high resting baseline on surface electromyography, excessive signal variability, and low net rise;36 muscle hypertonus and trigger points external and internal to the urethral, vaginal, and rectal canals; and muscle weakness in the urogenital triangle muscles, levator ani, obturator internus, gluteals, iliopsoas, hip adductors, and internal and external hip rotator muscles. The commonality of all these findings results in restriction or inability to participate fully in pleasurable sexual activities.

Physical therapists specializing in women’s health who have pelvic floor muscle training are skilled and knowledgeable in joint mechanics, muscle function, nerve innervation, tissue mobility, and functional application. They can assess and treat many of the mechanical joint, muscle, and nerve problems and train patients to work through the pain and fear and avoidance behaviors by demonstration of anatomy and functional anatomy, hands-on manual therapy techniques53,54, biofeedback instruction, electrical modalities, and exercise prescriptions. They are vital participants in the interdisciplinary team to evaluate and treat female sexual dysfunction.

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