4.4 Treatment of Sexual and Pelvic Floor Dysfunctions

Mieke Raadgers
Marjo J Ramakers
Rik H. W. van Lunsen

Introduction

The pelvic floor is an active sexual organ in women and men, in addition to its supportive function, its role lies in the mechanism of urinary and fecal storage and emptying, and its function in parturition (see also section 4.2, pp. 343–373). Voluntary contractions of the pelvic floor increase vasocongestion and physical sensations in both men and women during the early phases of sexual arousal [Messe and Geer 1985, Colpi et al. 1999]. A low pelvic floor tone results in a lax pelvis, associated with impaired sexual feelings [Graziottin 2000]. The physical sensations of orgasm are induced by a series of involuntary pelvic floor contractions at an interval of 8 ms. They were described long ago by Masters and Johnson [1966] as the contractions in the “orgasmic platform”—the congested perineal body— occurring in women as well as in the second phase of ejaculation—the expulsion phase—in men. Dynamic contractions of the pelvic floor muscles then reduce the extent of vasocongestion, gradually causing it to disappear [Rosen and Beck 1988]. These mechanisms indicate that hyperactivity of the pelvic floor can reduce vasocongestion and cause erectile dysfunction in men and sexual arousal disorders in women (female sexual arousal disorder, FSAD), and may decrease the orgasmic capacity [Shafik 2000]. Moreover, these mechanisms may explain why, in patients with hyperactive pelvic floor muscles, pelvic floor contractions occurring during orgasm can lead to clonic contractions with discomfort and pain, as reported by a number of patients [personal observation].

A certain degree of relaxation of the pelvic floor is necessary to allow coital penetration. Pelvic floor hypertonicity can both cause and maintain dyspareunia. Hypertonicity can cause difficulties and pain during intercourse, while in turn dyspareunia can lead to increased pelvic floor activity as a reflex defense against pain. In classic vaginismus, the perivaginal muscles contract to the point at which sexual intercourse becomes impossible.

In patients with urologic and gastrointestinal symptoms accompanying dyspareunia, the possibility of a generalized outlet obstruction due to hypertonicity of the muscles of the pelvic floor should be considered—the hyperactive pelvic floor syndrome [van Lunsen and Ramakers 2002].

Vulvar Vestibulitis Syndrome

Dyspareunia is recurrent or persistent genital pain occurring before, during, or after intercourse [American Psychiatric Association 1994, Kaplan et al. 1994]. It is much more common in women than in men. It may be felt at the introitus, the entrance to the vagina (superficial dyspareunia), or deeper in the vagina (deep dyspareunia).

Vulvar vestibulitis syndrome (VVS) is thought to be the most frequent cause of dyspareunia in premenopausal women [Bergeron et. al. 1997]. Although physicians who are not familiar with the features of VVS may easily miss the characteristic symptoms, the diagnosis of VVS is not difficult.

Most patients are between 20 and 30 years of age; most of them are nulliparous.

Women suffering from VVS have a history of at least 6 months of severe pain on vestibular touch or attempted vaginal entry [Friedrich 1987]. Typically, the complaints are fairly mild at the onset—superficial dyspareunia on penetration, which disappears during intercourse, with some vulvar burning and soreness after intercourse. Gradually, intercourse becomes more painful or even impossible. Vulvar burning and soreness become more lasting. There is a burning sensation when the vulva is touched during common activities such as riding a bike, horseback riding, wearing tight jeans, swimming in chlorinated water, etc. The same burning sensation is often felt when voiding.

In this condition, there is a history of primary or secondary pelvic floor dysfunction [van Lunsen 1995, 1996, Ramakers and van Lunsen 1997]. This may include vaginismus, problems with inserting tampons, etc. Often, there are symptoms of permanent hypertonia of the pelvic floor musculature, such as voiding problems (urethral syndrome, interstitial cystitis) and irritable bowel syndrome (IBS).

Sexual dysfunction is part of the syndrome. When the sexual history is thoroughly explored, most women admit that at the time of onset of the symptoms, there was a stressful period during which they had intercourse without arousal, either due to lack of sexual desire or because the partners– desires and expectations did not match. Women with VVS often continue to have intercourse over months or even years despite pain and despite a lack of sexual desire and/or arousal and lubrication. Many women try to hide the pain from their partner and continue to have intercourse due to feelings of guilt towards their partner, because they feel inadequate [van Lunsen 1996].

Vaginismus is an involuntary muscle contraction of the outer third of the vagina that interferes with penile insertion and intercourse [American Psychiatric Association 1994, Kaplan et al. 1994]. A woman suffering from classic vaginismus may consciously wish to have coitus, but unconsciously wishes to keep the penis from entering her body. Most of these women have a normal sexual response: they enjoy lovemaking and experience orgasm as long as intercourse does not take place. Some of these couples only seek medical intervention when they want to have children, despite the fact that coitus is not strictly necessary for conception.

More generalized and persistent hypertonia leads to a symptom complex in both women and men that is known as hyperactive pelvic floor syndrome (HPFS) [van Lunsen and Ramakers 2002] (see also section 1.7, pp. 120–121). This syndrome is accompanied by disease symptoms in the area of gastrointestinal, urogenital, and sexual function. Hypotheses regarding its etiology have resulted in a multifaceted multidisciplinary clinical approach to the diagnosis and treatment of the complex symptomatology. These patients often have long histories of unsuccessful medical, surgical, and psychiatric treatments. These usually do not take into account the fact that muscle tension derives from various combinations of psychological, psychosocial, and psychosexual distress that tend to consolidate in a vicious cycle of pain, anxiety, and muscle tension [van Lunsen and Ramakers 2002]. The symptoms are listed in Tables 1.16 and 1.17 in section 1.7 (p. 121).

Treatment of Women with Pelvic Floor Dysfunction and Sexual Dysfunction by a Specialist Physiotherapist

In the Netherlands, physical therapists can take an advanced qualification in physical therapy of the pelvic floor. In the United States, a physical therapist can take an advanced training course in pelvic floor rehabilitation through continuing education programs. A specialized physical therapist who treats women with pelvic floor and sexual dysfunctions always works in conjunction with, and after referral from, the treating physician—who may be a general practitioner, sexologist, psychologist, psychotherapist, psychiatrist, physiatrist, gynecologist, urologist, urogynecologist, gastroenterologist, or colorectal surgeon.

When examining the pelvic floor, the physician tries to gain as precise an impression of pelvic functioning as possible by external—and, if this can be done painlessly—internal palpation of the perineum. Van der Velde and Everaerd [2001] developed a “pelvic floor score” that was designed to correlate precisely with the history taken by an expert and laboratory measurements. It depended on an examination that took into account time, rest, and safety. The score is the sum of points (0, 1 or 2) allotted to the following items:

Physical therapy proceeds according to the treatment plan summarized in Table 4.22. In this physiotherapeutic treatment plan, diagnosis and treatment go hand in hand. This means that each part of the treatment has a diagnostic function and may be a point at which treatment can be initiated. The sequence in which the various segments are applied varies and is determined as treatment develops.

Relaxation is an important part of treatment. To be able to relax, the patient must feel safe and that she is keeping control over the situation. The physiotherapist can create this feeling of safety and control by:

• Making a note of what the patient considers “safe” and taking this into account [van der Hart and Friedman 1989, Herman 1992, Nicolai and Bartels 1997, Nicolai 1998]. For instance, she may allow the patient to choose a safe starting posture: sitting instead of lying, keeping the door open or closed.
  
• Telling the patient beforehand what she wants to examine, and asking for permission.
  
• Telling the patient exactly what she is doing and observing her reactions (for example: “I’m now going to put my hand on your stomach”).
  
• Explaining to the patient that she can always indicate when something feels uncomfortable or unsafe, so that the therapist can react. The physiotherapist must be alert for possible signs that the patient feels unsafe, such as looking away, faster breathing, and changes in facial expression.
  
• Watching for possible dissociation and re-experiencing of a trauma. Dissociation is a defense mechanism designed to cope with trauma. Repressed memories may come to the surface when the patient turns her attention to the pelvic floor and works on relaxation. Signs of dissociation may include, among others: the patient is unable to make good eye contact, gives vague answers to questions, cannot discuss adequately, changes her breathing unexpectedly, and displays some degree of altered consciousness. If a woman dissociates, it is important for the physiotherapist to talk to her clearly and calmly and to bring her thoughts back to the here and now as quickly as possible. It is realistic at that point to terminate the exercises and to inform the attending sexologist or psychologist—of course, only with the patient’s consent.

Preferably, the work should not include internal manipulations, since those suffering from dysfunctions of this type will probably include a number of patients who have been abused [van Lunsen and Ramakers 2002]. These patients have considerable difficulty in recognizing and indicating their limits. They will often say “yes” when they mean “no.” Thus, they will rarely object when the therapist asks to work internally. Despite this, internal work can cause repeat trauma in such patients. This must be avoided in treatment, since every repetition of the trauma or of an event associated with the trauma reinforces it [Herman 1992].

Internal work can also irritate the skin. Since the function of the pelvic floor can be examined equally well by history and by external rather than internal examination, perineometry or electromyography [van der Velde 1999, B⊘ et al. 1990], the physiotherapist who wants to examine the pelvic floor can use specific external palpation (see Table 4.22).

History

The impression made by the patient begins at the first contact. The physiotherapist notes posture, movement, breathing, eye contact, voice, and other body language.

To begin with, the physiotherapist explains what the patient can expect during the first session: the duration of the session, history-taking, and patient education. The physiotherapist assures the patient that she does not have to expose her lower body. The patient therefore does not need to wonder if and when “it” is going to happen, and she can concentrate on the history.

The history is the first part of the treatment plan, from which it will be possible to predict with a considerable degree of certainty if the patient’s pelvic floor muscles are overactive or hypertonic [van der Velde 2001]. To establish the diagnosis of hyperactive pelvic floor syndrome (HPFS), the presence of three or more physical complaints related to gastrointestinal, urogenital, and sexual functions associated with pelvic floor dysfunction must be established [van Lunsen and Ramakers 2002, Draijer 1988, Jamieson 1997] (Table 1.16, p. 121).

For the treatment to be successful, the patient has to have confidence in the therapist. Confidence is determined to a great extent by the patient’s belief that the physiotherapist is listening to her [Alewijnse 2000], so that she feels that she is being heard, accepted, and respected. Active listening is best initiated by beginning the history-taking with an open question. Examples might be: “Tell me about … ” or “Your referring doctor says you have pain during intercourse. Can you tell me more about that?” “What are your symptoms?” Using open-ended questions (the counseling model), the therapist can listen actively, ask follow-up questions, comment, and summarize. In this way, objective findings can be supplemented with impressions of the patient’s emotional state actively, ask follow-up questions, comment, and summarize. In this way, objective findings can be supplemented with impressions of the patient’s emotional state.

The sequence of questions is not rigid. It is advisable to ask exhaustive questions about one subject before proceeding to the next. The history consists of several parts: general, urologic, gynecologic, sexual, and gastrointestinal (Table 4.23). A number of indications in the history can point to an overactive and/or hypertonic pelvic floor musculature. These are summarized in Table 4.24.

Patient Education

Patient education includes—if possible, during the first session:

• Anatomy and physiology of the pelvic floor
  
• Function and dysfunction of the pelvic floor
  
• Possible causes of dysfunction

Education can be supplemented with illustrations, anatomic plates, and models. It is best if the physiotherapist is present when the patient views the models or plates, to help with the patient’s understanding. Moreover, it is necessary to anticipate that looking at illustrations may increase the patient’s anxiety, and this must of course be prevented. Hence, illustrations and models should only be shown to the patient after their use has been explained.

Good education can clarify for the patient why she has been referred to a physiotherapist and what the connection between the complaints is. This better understanding usually has a motivating effect [Alewijnse 2000].

Improving Awareness

The patient must be aware of the muscles of the pelvic floor in order to be able to work with them. Becoming aware is not a separate exercise, but is embedded in the whole treatment. Attention is directed to perception and experience of the pelvic floor through every segment of the treatment. At first, the physiotherapist provides constant feedback during the exercises. When the patient herself becomes aware of her pelvic floor, the physiotherapist tries to link this awareness to everyday activities (see also “application to daily life” below).

Related posts:

Psychosocial Influences Training and Functional Exercises for the Muscles of the Pelvic Floor Pediatric Therapy Diagnosis, Evaluation, and Treatment of Reflex Incontinence Musculoskeletal Chronic Pelvic Pain Strain and Counterstrain for Pelvic Pain

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