Susan Kellogg-Spadt, Kristene E Whitmore
Today, more than ever in the specialties of urology and urogynecology, comprehensive sexual health care is available for women. Sexual medicine centers devoted to the diagnosis and treatment of sexual disorders are opening across the USA, many of which are comprised of multidisciplinary teams (see Chapter 17.6 of this book). Women in these centers are typically seen by a team of specialty clinicians, advanced practice nurses, sexologists, psychologists, and physical therapists, under the direction of a female urologist or urogynecologist.
Historically, recognition and treatment of female sexual health issues mirrored the recognition and treatment of female urologic disorders. Both were poorly understood, and therefore, underdiagnosed and undertreated. This was due, in part, to the absence of accurate definitions and controlled research. Topics including female pelvic anatomy (see Chapters 4.1-4.3) and muscular support (see Chapter 4.4) were given little attention in traditional urologic texts. Women’s anatomy was simply considered to be a duplication of the male pelvic anatomy. Then, in the 1980s, several key urologists, including Raz, McGuire, and Kursh, began studying the effects of female sex hormones on urinary tract smooth muscle as well as delineating the function of the female pelvic floor and its surgical management.1-3 In 1983, the first edition of the textbook Female Urology was published.4
In a similar fashion, the field of urology dealt with sexual concerns as they related to men only. Textbooks contained chapters on “sexual dysfunction” which pertained exclusively to erectile and ejaculatory dysfunction related to vascular and/or sensory insufficiency. In 1998, investigators examined the physiology of female engorgement during arousal and identified vasculogenic sexual dysfunction in females5 (see Chapters 5.4—5.6). These researchers were also members of the American Foundation for Urologic Diseases international consensus conference convened in 1999 to define and formally classify female sexual dysfunction (see Chapter 9.1). Internationally recognized diagnostic criteria for female desire, arousal, orgasm, and pain disorders, as well as for hypersensitivity disorders and pelvic floor dysfunction, all prime causes of sexual dysfunction in women, were established at this conference. These assist a more scientific approach to therapeutics and research in female sexual dysfunction.6
Unlike urologists of the past, today’s resident and attending urogynecologists understand the specialized anatomy and physiology of the female pelvic floor, in terms of muscular support, physiology, restoration of function, affects of pharmacology, and relationship to sexual function.7-10 In the last 20 years, there has been a redefinition of urogynecology as a specialty that excels in the diagnosis and treatment of women with disorders that affect any aspect of the female pelvic floor. Those disorders may involve the “front” compartment, e.g., bladder dysfunction; the “middle” compartment, e.g., genital/sexual dysfunction; or the “rear” compartment, e.g., bowel dysfunction.
Pelvic floor dysfunction
Normal function of the pelvic floor musculature is essential in maintaining appropriate function of the pelvic organs, as well as appropriate sexual function. Abnormal function of this musculature is seen in an estimated 70% of women with genitourinary, bowel, and sexual disorders.9-11 Pelvic floor dysfunction refers to conditions in which the pelvic floor muscular support system is functioning suboptimally. Disorders of abnormal pelvic floor laxity, termed “low-tone pelvic floor dysfunction”, or disorders that cause spasticity and tightness of the pelvic floor, termed “high-tone pelvic floor muscle dysfunction”, may be closely associated with sexual dysfunction.10-12
Hypotonus of the pelvic floor is a familiar disorder in urologic literature because of the relationship of the pelvic floor muscles to incontinence and pelvic organ prolapse. Low-tone pelvic floor dysfunction can result from childbirth, trauma, and/or senescence, and it can contribute to pelvic organ prolapse, transurethral urinary incontinence during orgasm, vaginal laxity, thrusting dyspareunia, and fecal incontinence related to or not related to sexual intercourse.11,12
“Hypertonus or spasm of the pelvic floor” is a newer term, although the concept has been used extensively in the colorectal literature by Thiele and others, referred to as “tension myalgia of the pelvic floor” and “levator ani syndrome”.13,14 High-tone pelvic floor dysfunction can result from childbirth, postural stressors, microtrauma, infection, adhesions, and surgical trauma, and can contribute to symptoms of frequency, urgency, dysuria, urinary retention, fecal retention, penetrative dyspareunia, and/or vaginismus.8-12
Assessment of tone in the pelvic floor is performed to determine a woman’s ability to isolate, contract, and relax the pelvic floor muscles. When the clinician conducts a digital examination exerting light pressure on the inferior lateral walls of the vagina, the woman is asked to squeeze the examining finger and to “lift” the pelvic floor, without simultaneously tightening the abdominal, gluteal, or adductor muscle groups. If the patient is unable to produce sufficient muscle strength to “squeeze” the finger or to sustain that squeeze for a period of 5 s, she may be exhibiting the low-tone pelvic floor dysfunction pattern. If, conversely, the woman experiences muscle tenderness or pain when pressure is applied to the lateral vaginal wall or during an attempted squeeze against resistance, she may be exhibiting the spastic or high-tone pelvic floor dysfunction pattern. Results of the simple digital examination can be verified by the placement of a measurement tool, such as a perineometer or an electromyography probe, designed to measure muscle activity.11-12,14
Conservative therapy for pelvic floor dysfunction is aimed at muscle reeducation. A physical therapist who specializes in the pelvic floor can be a valuable asset to the female sexual dysfunction team in designing a pelvic floor rehabilitation program aimed at facilitating sexual comfort and pleasure for patients. Such a program might involve directed sling massage of the pelvic floor to elongate shortened muscles and decrease high-tone spasm for a woman with involuntary spasm of the pelvic floor muscles or vaginismus.11-13 Thiele reported a case series of 31 patients with pelvic floor related pain, in which 19 (61.3%) were “cured” and 17 (35.5%) were “improved” after a series of directed transrectal massage of the pelvic floor muscles.14 Pelvic floor massage can precede and facilitate the gradual introduction of dilators and movement toward sexual penetration for vaginismus patients.12,13
For a woman with low-tone pelvic floor dysfunction, which can manifest as incontinence with sex, decreased sensation, or poor orgasm amplitude, the physical therapist may design a program focusing on pelvic floor muscle strengthening with Kegel exercises, augmented with biofeedback and/or electrical stimulation of the pelvic floor.10-12,15
The concepts of pelvic floor dysfunction and muscle reeducation will appear throughout the remainder of this chapter as specific disorders and therapeutic regimens are discussed.
Hypersensitivity disorders associated with high-tone pelvic floor dysfunction
Hypersensitivity or sensory disorders of the lower urinary tract represent a spectrum of symptoms and conditions that includes chronic bacterial cystitis, urgency and frequency syndrome, sensory urgency, urethral syndrome, and interstitial cystitis. These entities, as well as vulvar pain, vaginal pain, and perineal and pelvic pain, are associated with spasm or hypertonus of the pelvic floor musculature.16,17 They are classified by the International Continence Society as “genitourinary pain syndromes” and account for a large percentage of the concerns of female patients who present to urogynecologic and sexual medicine practices.8
During assessment of any genitourinary complaints in women, the undeniable link between the hormonal status, sexual activity, and development or exacerbation of urinary symptoms becomes apparent.
Sexual activity can cause direct pressure on vulvovaginal structures as well as a displacement of the bladder neck, creating an uncomfortable coital experience for some women, and potentially resulting in urinary trauma. Frequent and painful voiding, as well as anticipation of genital pain during sex play, can result in pelvic floor muscle guarding, which, over time, can become a spastic or high-tone pelvic floor.
The situation can be further complicated by any relative estrogen deficiency. Up to 40% of women experience atrophic urogenital symptoms at some time during the life cycle, whether during the periand postmenopausal years, during lactation, or while using low- or non-estrogen contraceptive alternatives. Discomfort during sex play, due to trauma or increased fragility of the urogenital tissues, can alter arousal and lubrication. In an evaluation of 90 peri- and postmenopausal women, Sarrell noted marked dyspareunia, burning, penetrative pain, and decreased sexual satisfaction in women whose serum estradiol levels were less than 50 pg/ml when compared with women whose serum estradiol levels were greater than 50 pg/ml.15 Estrogen-deficiency symptoms include dryness, itching, burning, penetrative pain, irritative leukorrhea, urethral pressure, urinary urgency, and fissures associated with loss of tissue elasticity. In addition, poor estrogen binding in genitourinary tissues leads to ischemia, a decreased urethral mucosal cushion, and increased susceptibility of the bladder to bacterial adherence. The result is potential exposure of the neurovascular elements of the bladder wall to urinary toxins and infectious agents, the ramifications of which may be the development of recurrent urinary tract infection and/or a lower urinary tract hypersensitivity syndrome.8,17 Of the 8.5 million women with urinary incontinence, up to 40% have detrusor instability and/or sensory urgency. Symptoms include urinary frequency (greater than eight episodes per 24 h) and uncomfortable urgency with or without leakage. Women with sensory urgency often name sexual intercourse as an inciting event for their symptoms, and report hypoactive sexual desire as a result of this association.17,18 An estimated 5 million women are diagnosed with urinary tract infections each year. Among the 15% of these women who are classified as recurrent urinary tract infection sufferers (more than two episodes in 6 months or three in 1 year), coitus is cited as a major contributing factor for their symptoms17 (see Chapter 7.7).
Interstitial cystitis is one of the most severe and challenging hypersensitivity disorders. Symptoms of interstitial cystitis can be greatly exacerbated by sexual activity, and the disorder can severely disrupt a couple’s satisfying sexual relations over time.
Interstitial cystitis is a chronic bladder condition characterized by urgency, frequency and pain; it affects as many as 1 million Americans, the majority of whom are women.19,20 Although the term “interstitial cystitis” was first suggested in 1887 by Skene, the exact etiology of the disorder remains unclear.21 In 1915, Hunner reported the presence of ulcers on congested bladder mucosa associated with a contracted fibrotic bladder that hemorrhaged after bladder hydrodistention.22 In 1987, the US National Institutes of Health established the following diagnostic criteria for interstitial cystitis: urinary frequency (more than eight times while awake; more than two times at night) and/or pain associated with the bladder, as well as diffuse glomerulations in three quadrants of the bladder and/or a classic Hunner ulcer on cystoscopy.23
Although the exact etiology of interstitial cystitis is currently unknown, most authors believe that it is multifactorial. Proposed causes include infectious agents; quantitative glycosaminoglycan layer deficiency; and ultrastructural abnormality of the lamina propria, interstitium, and/or mast cells of the bladder with neurogenic inflammation.24
Interstitial cystitis, like all hypersensitivity disorders of the lower urinary tract, is a diagnosis of exclusion. Infections such as vaginitis, urethritis, ureaplasm, or herpes cannot be present. In addition, carcinoma, diverticulum or stricture of the urethra, radiation exposure, allergic reactions, and tuberculosis must be excluded. Physical examination yields many typical signs of interstitial cystitis. During a bimanual examination, a woman with interstitial cystitis will often have tenderness just under the posterior bladder wall and/or behind and above the pubic bone. This feature will markedly differ from the condition of a woman who expresses only mild pressure during palpation of her urethra and bladder. The typical experience of a woman with interstitial cystitis is pain rather than light pressure. In addition, a rigid or spastic state of the pelvic floor muscles is often present. Conclusive diagnosis of interstitial cystitis is made in conjunction with other diagnostic procedures.11,17,25
Several office and/or operating room procedures can suggest a diagnosis of interstitial cystitis. Findings on a 24-h voiding diary quantify voiding as over eight times per day and/or over two times per night. Urodynamic testing can verify low volume at first sensation of bladder filling, first and strong desires to void at low volume, increased bladder sensation, presence of detrusor overactivity, and reproduction of the patient’s symptoms during filling. Cystoscopy with hydrodistention can verify the presence of Hunner’s ulcers, linear scarring, hypervascularity, bloody effluent, and glomerulations after hydrodistention. Potassium sensitivity testing can verify increased epithelial permeability when the instillation of a mild potassium chloride solution exacerbates a woman’s symptoms of urgency and pain.2”0
Although no treatment is considered curative for interstitial cystitis, multimodal management includes behavioral, pharmacologic, and surgical therapies. Behavioral therapies include dietary modification, bladder training, and pelvic floor physical therapy. Pharmacologic therapy begins with pentsosan polysulfate. Antihistamines, tricyclic antidepressants, anticholinergics, antiepileptics, muscle relaxants, anti-inflammatory agents, and narcotics are employed for symptom relief. Intravesical instillations are used for symptom flare. Surgical therapy includes hydrodistention and sacral nerve stimulation. Rarely, augmentation cystoplasty or urinary diversion, with or without cystectomy, is performed11,20,23,25,28-30 (see Chapter 14.2).
Frequently, the discomfort experienced by women with hypersensitivity disorders of the bladder is compounded by vulvar vestibulitis syndrome. Vulvar vestibulitis syndrome, also referred to as vulvar adenitis, focal vulvitis, vestibulodynia, or vulvodynia, affects up to 15% of women in the general population and up to 40% of women with interstitial cystitis.18,31 Vulvar vestibulitis syndrome is characterized by focal erythema and hypersensitivity of the vulvar vestibule, dyspareunia, and dyses- thesia31-33 (see Chapters 12.1-12.6).
Definitive causes of vulvar vestibulitis syndrome have not been identified; research suggests that neurogenic inflammation of the vulvar vestibule can occur in response to a variety of noxious environmental stimuli, including mechanical or chemical trauma, infections, viral exposure, and localized allergic responses.31-34
A key factor in managing vulvar vestibulitis syndrome is competent and early diagnosis. In the “touch test”, vulvar structures such as the labia, interlabial sulci, and periclitoral and perirectal areas are touched firmly with a saline-moistened cotton swab, and the patient is asked to respond if she feels discomfort. As the openings of the Skene’s and vestibular glands are tested, women with vulvar vestibulitis syndrome will respond that these touches are painful. If the diagnosis is in doubt, the procedure can be repeated after application of 5% lidocaine to the glandular ostia. If the touch test becomes negative after this application, a diagnosis of vulvar vestibulitis syndrome is likely. Touch testing should be performed in conjunction with a thorough pelvic and vaginal examination, including cultures for bacteria and fungi. Vulvar colposcopy often reveals inflammatory vascular ectasia in gland areas, and can be a useful adjunct to diagnosis.34,35
At present, no treatment for vulvar vestibulitis syndrome is considered “curative”. Traditional management includes anti-irritant hygiene regimens, low oxalate diets, tricyclic antidepressant therapy, topical cortico or hormone steroids, antifungal therapy, intradermal interferon, pelvic muscle biofeedback, and/or vestibulectomy. Newer investigational approaches include use of topical creams containing capsaicin, cromolyn, atropine, or nitroglycerin; pelvic floor physical therapy; and acupuncture.33-41
Irritable bowel syndrome
Hypersensitivity disorders of the bladder and genitals are often accompanied by bowel symptoms. Irritable bowel syndrome affects more than 5 million people and is characterized as a hypersensitivity syndrome. Symptoms include abdominal bloating and cramping, painful diarrhea and/or constipation, mucoid stools, and sensations of incomplete emptying. Symptoms can be incited by ingestion of large meals, certain foods (milk products; fatty foods; or alcoholic, caffeinated, or carbonated beverages), gaseous overdistention, hormonal fluctuations, exercise, and sexual activity. Treatments include dietary modifications, stress management, antispasmotics, and antidepressants.42
Strategies for managing sexuality with hypersensitivity disorders
Sexuality is adversely affected in up to 80% of women with hypersensitivity disorders of the bladder, bowel, and vulva and accompanying high-tone pelvic floor dysfunction. Those that are able to tolerate coitus often suffer a flare of their symptoms for days as a result of sexual activity, which then becomes a negative reinforcement for future sexual activity, and research has documented “avoidance of intimacy most of the time”.25,35,45 Avoidance can result in negative outcomes for both the woman and her partner. As the result of a Western cultural “script” that equates penile-vaginal sex with adequate sexual function, women who avoid contact may feel “abnormal” and inadequate from a cultural standpoint. Lack of physical intimacy can also result in generalized loss of interest in sex, decreased ability to respond sexually, and feelings of depression.16,25,44
An important intervention when working with women who have hypersensitivity-related sexual dysfunction is to introduce the concept of sexual “rescripting”. Encourage the woman and her partner to develop a unique definition of adequate pleasuring (which may or may not involve genital contact) and to make a commitment to pleasure each other with agreed-upon regularity. A way to reframe pleasuring for a couple is by introducing the concept of “his and hers intimacy”. Explain that intimacy, for one partner, might involve a quiet dinner out or going to a movie, while, for the other partner, intimacy might be defined as oral or genital sex play that leads to orgasm. With this technique, intimacy needs are met through activities that are appropriate to physical limitations. Encourage couples to follow their own sexual script, not one that the culture has written for them.43-46
Consistent with the concept of rescripting is the premise of noncoital pleasuring. Since many women with hypersensitivity are unable to engage in pain-free penile-vaginal sex, they may turn to their health-care provider to suggest alternate strategies. For some, oral and manual pleasuring of the clitoris and/or penis (without penetration) are viable options, but others may be unwilling or unable to consider these. Many women find the option of “outercourse” appealing and pain free. In this technique, a man mounts a woman in a traditional intercourse fashion, but instead of thrusting his penis inside of her vagina, he thrusts on the “outside”. Rubbing against her lubricated lower abdomen and pubic bone area, or between a woman’s inner thighs, often creates friction sufficient to result in both male and female orgasm.43,45
For other women with hypersensitivity, sexual intercourse can be accomplished on a limited basis. Comfort measures (Table 17.4.1) that facilitate intimate expression may include applying 2-5% lidocaine jelly to the vaginal introitus 20 min before stimulation to decrease the hypersensitivity of the urethra and vestibular gland areas; applying liberal amounts of a water-soluble lubricant or small amounts of estrogen-based vaginal cream to aid penetration; premedicating with a sublingual smooth muscle relaxer and/or an anticholinergic to decrease sensory urinary or fecal urgency; premedicating with a skeletal muscle relaxant 1 h before sex play to decrease pelvic floor spasm; or inserting a belladonna rectal suppository 1 h before sex play to calm both the bladder and pelvic floor. In addition, many women find that precoital pelvic floor massage, pre- and postcoital voiding, and postcoital application of an ice pack to the genital/suprapubic area enhance comfort.11,25,43,45
Choosing coital positions that are least likely to affect the pelvic floor include having the woman lying on her side or inferior with raised hips. Thrusting in a circular movement and limiting thrusting time to 5-10 min helps to minimize discomfort.45
A couples’ sexual therapist or psychologist can often help the woman and her partner deal with the “long-term prospect” of altered comfort with sexual intercourse and may suggest alternative pleasuring strategies.
Laxity disorders associated with lowtone pelvic floor dysfunction
A second major class of disorders encountered in the urogynecologic setting is disorders associated with weakness and laxity of the pelvic floor muscles. Predominant symptoms among this group of patients are pelvic organ prolapse with or without urinary or fecal incontinence.
Table 17.4.1. Medications that facilitate comfortable sexual relations
Lidocaine gel Prilocaine gel
Blocks pain and hypersensitivity of vulvar tissues
Apply to introitus and/or urethra 5-20 min before lovemaking
Decreases sensory urgency; smooth muscle relaxer
Dosed 10-60 min before sex play, decreases urinary and/or fecal urgency, urethral spasms, and/or urge incontinence that can interfere with sexual expression
Central skeletal muscle relaxant/alpha adrenergic agonist
Decreases involuntary pelvic floor muscle guarding and spasm
Dosed 60 min before sex play, inhibits painful muscle spasms that can interfere with penetration and thrusting
Enhances elasticity and moisture in vulvar tissues
Applied nightly and/or just before sex play, enhances comfort with penetration, and decreases introital microfissures
An incidence of involuntary loss of urine is experienced by an estimated 95% of women during their lifetime, with an estimated one in four women leaking before the age of 59. Approximately 50% of female residents in nursing homes are incontinent.47 Urinary incontinence can be broadly classified as urge incontinence, related to sensory urgency (see previous section on hypersensitivity disorders); stress incontinence, which occurs with increased intra-abdominal pressure and maneuvers such as sneezing, coughing, and straining; or mixed incontinence. Abnormalities in urethral closure and poor pelvic muscle support are the primary mechanisms underlying stress incontinence.17,23
Factors predisposing a woman to stress incontinence include age; heredity; vaginal birth trauma; previous pelvic/vaginal surgery; history of radiation therapy; menopausal status; lifestyle factors, such as strenuous lifting; and chronic medical conditions, including obstructive pulmonary disease, obesity, and constipation. Assessment strategies for incontinence include evaluation of voiding diaries, urinalysis, cytology, and urodynamic testing.47
Incontinence can be improved in 8 of 10 women by treatment options that include nonsurgical and surgical strategies. Nonsurgical strategies include behavioral bladder retraining, pelvic floor strengthening (Kegel exercises), pessary placement, urethral plugs, and implants. Surgical procedures, including sling and tension-free vaginal tape placement, provide cure rates as high as 95% when performed in appropriate candidates.8,47
Fecal incontinence, or involuntary leakage of solid, liquid, or gaseous stool from the rectum, affects as many as 5.5 million Americans. It is more common in women and in the elderly.47,48
Muscle damage is involved in most cases of fecal incontinence. In women, this damage commonly occurs during childbirth, especially after a difficult vaginal delivery that involves forceps and/or episiotomy. Studies suggest that 3-25% of woman experience some degree of fecal incontinence after childbirth.47 Damage to the nerves that control the anal muscle or that are responsible for rectal sensation is also a common cause of fecal incontinence. Nerve injury can occur during childbirth, with severe and prolonged straining for stool, or in association with chronic medical conditions such as diabetes, spinal cord tumors, and multiple sclerosis. Muscle damage can also occur during rectal surgery, as well as in people with inflammatory bowel disease or a history of abscess in the perirectal area.
Fecal incontinence is often associated with reduction in the elasticity of the rectum, which shortens the time between the sensation of the stool and the urge for a bowel movement. Surgery, radiation injury, and history of inflammatory bowel disease are associated with poor elasticity of the rectum. Medical evaluation may include physical examination, ultrasonography, defacography, and anorectal manometry, which tests anal pressures, rectal elasticity, and rectal sensation.48
The treatment of fecal incontinence varies, depending upon its etiology. Behavioral strategies include dietary modifications that eliminate irritants and add fiber, bowel-retraining strategies to prevent diarrhea and enhance formation of a regular bowel movement pattern, Kegel exercises, and anorectal biofeedback. Pelvic floor reconstructive surgery can be an effective treatment for structural defects.47
Strategies for managing sexuality with incontinence
Data from several recent studies suggest that women with mild to moderate incontinence self-report commensurate levels of sexual activity, comfort, and enjoyment with sex as women without incontinence. Mild to moderate prolapse did not usually interfere with sex, as the herniated tissues tended to be pushed into the vagina with penile penetration and thrusting. Prolapse pressure was considered less bothersome during intercourse because of being in a recumbent position. Studies indicate that when incontinence and prolapse are severe, symptoms are a source of anxiety and interfere with the overall sense of sexual satisfaction. Interestingly, studies suggest that women under age 65 report being incontinent during intercourse at a higher rate than women over age 65. The reasons for the findings are unclear and may be related to more frequent and/or more vigorous sex play among the younger age group. The younger women may have had greater urge incontinence, which is harder to control during sex play than stress incontinence, a more common finding among older women.49-52
Women who experience incontinence during intercourse express concern about feeling unclean, undesirable, and “unsexy”. They fear embarrassment, rejection, and possible infection of themselves or their partner. Encouraging a woman to be open and communicative with her partner about incontinence will often decrease anxiety by bringing the issue into the forefront rather than being veiled in secrecy. Instructing the woman with urinary leakage that urine is sterile and poses no health threats will often decrease the fear associated with unavoidable leakage.47,49 Other strategies for women who experience any type of incontinence during sexual activity include daily performance of 30-60 Kegel exercises (taught by a healthcare provider with a return demonstration in the office), emptying the bladder or colon before sexual activity, avoiding ingestion of food or fluids for 1 h before lovemaking, and coital positioning to decrease leakage (e.g., female in superior or side- lying position). Use of a water-soluable lubricant or vaginal estrogen before penetration will decrease urethral trauma and facilitate comfortable entry.47-51,53
When managing female sexual dysfunction patients, it is important that the urogynecology team be confident in their diagnostic and therapeutic capabilities, or be able to triage the patient for optimal care. The adage, “if the treatment isn’t working, reconsider the diagnosis”, should always be kept in mind.
Showing empathy for the patient with sexual concerns is paramount, because of the quality-of-life threats that this problem poses. Advising the patient that if sexual dysfunction has begun to make her feel aversive to intimacy, she should abstain for several weeks (while medical testing and treatment are conducted) may provide a much needed “break” from the stress and discomfort and a chance to re-establish healthy sexual feelings between partners.
A woman’s sense of well-being is closely tied to the quality of her relationships, including her intimate physical relationships. By taking the time to assess and address patients’ sexual concerns, health-care providers can assist women with chronic genitourinary disorders reclaim a sense of themselves as competent women capable of intimacy, rather than “sexually dysfunctional”.
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