IUGA Brisbane, Australia 4 September Workshop: MULTIDISCIPLINARY APPROACH TO FEMALE SEXUALITY BASED ON O PRACTICAL CONCEPTS

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1 IUGA 2012 Brisbane, Australia 4 September 2012 Workshop: MULTIDISCIPLINARY APPROACH TO FEMALE SEXUALITY BASED ON O PRACTICAL CONCEPTS Current physical therapy for sexual dysfunctions, what is the evidence? Bary Berghmans, PhD MSc RPT clinical epidemiologist, health scientist, pelvic physiotherapist Pelvic care Center Maastricht Maastricht University Medical Centre,, the Netherlands

2 sex response circle Basson 2001 PT?

3 objective sex investigation catheterisation clisma penetration of the pelvic floor positive effect pleasure clarification emptying bladder & colon negative effect pain fear

4 sexual dysfunctions DSM-IV criteria: - continu, repetetive - causes suffering - no better explanation by other Axis 1 disorder sexual disorders, dysfunctions related to: sexual desire sexual arousal orgasm sexual pain vaginism dyspareunia sexual disorders caused by medical complaint/ remedy paraphilia exhibitionism fetisjism pedophilia sado-masochism masochism,, etc. gender identity disorders types: - primary/secundary - generalised/ situative

5 sexual abuse unsafe situations at home education incest violence undesirable intimidation at school at work unequal situation undesirable penetration partner (desired( desired/undesired) health care provider (desired/undesired) perpetrator

6 sexual abuse and PFD psychosomatic dysfunction fear, depressive complaints, cognitive problems,, sleep disturbance, social PT? cognitive problems, personal social problems urological dysfunction dysfunctional voiding, chronic pelvic pain syndrome (CPPS), enuresis, incontinence, gynaecological dysfunction CPPS, dyspareunia, vaginismus, focal vulvitis sexual dysfunction

7 sexual abuse & pelvic floor muscle dysfunction complaints PT!!!!

8 prevalence & incidence sexual dysfunction prevalence dyspareunia, vaginism 8%-16%: mostly vulvar vestibulitis, vulvodynia,, overlap Engman et al 2004 vaginism,, for example, has been reported to affect up to 21% of women younger than 30 years Laumann et al 1999 cumulative incidence inability sexual intercourse because of pain 10%

9 sexual dysfunctions subtypes: lifetime versus acquired generalised versus situative psychological factors versus combined factors

10 sexual dysfunctions sexual pain disorders: vaginism dyspareunia (chronic) pelvic pain Tu et al 2008 sexual dysfunction with somatic origine sexual dysfunction caused by a remedy sexual dysfunction not specified

11 dyspareunia DSM-IV : contineously recurrent or persisting genital pain in women related to coïtus and not solely caused by vaginism or deminished lubrication and not solely a consequence of a somatic health problem prevalence: globally 3-18%???!!! Dutch outpatient sexology 37%

12 vaginism DSM-IV / ICD-10 vaginism = involuntary contraction of muscles in outer third vagina and often pelvic floor, which limits or prevents intercourse or vaginal penetration

13 sexual problems DSM always 2 aspects: dysfunction significant suffering

14 sexual dysfunctions lack operational definitions in current chronic pelvic pain research Williams et al 2004 in studies: location pain not specified in 93% duration pain not specified in 44% pathology not specified in 74% co-morbidities not specified in 95% additional inclusion/exclusion criteria not specified in 65% So, PT difficult, often not enough information!!

15 PFM dysfunctions hypotone pelvic floor overactive (hypertone) pelvic floor disorder co-ordination ordination pelvic floor

16 PFM overactivity vaginism compared with normal subjects in women with vaginism elevated electromyographic readings in m. levator ani, puborectalis and bulbocavernosus,, both at rest and with induced vaginism (attempted insertion of a dilator) Shafik & El-Sibai 2002

17 PFM overactivity sexual activity effect overactive pelvic floor (OAPF) on urinary tract is dynamic pain associated with sexual activity may be either dyspareunia or vaginism or non-coital sexual pain Basson et al 2000 dyspareunia varies from localized introital tenderness to diffuse deep soreness often sustained for 3 days after sexual activity Salonia et al % with OAPF report dyspareunia related to stretching of shortened pelvic floor, stimulation painful regions or organ dysfunction/adhesions Meadows 1999, Munarriz et al 2002, Beji 2003, FitzGerald & Kotarinos 2003 Beji et al

18 Basson 2001 Copyright 2005 CMA Media Inc. Basson, R. CMAJ 2005;172:

19 managing sexual dysfunction "ALLOW" algorithm: : a sample management plan the body work of sexual therapy Cacchioni 2010

20 assessment: history taking overview of findings explanation nature, causes, severity analysis & evaluation available treatment options benefits and disadvantages or risks treatment option encouragement patient to participate actively in the decision- making process Hatzichristou 2004

21 assessment: history taking thorough pain history: site of pain confirmed by pain diagram duration of pain nature of onset or precipitating event pain characteristics response of pain to activity and associated symptoms Hopwood 2000

22 physical assessment key elements of the physical examination in sexual dysfunction complete genital exam secondary sexual characteristics (e.g., gynecomastia) body hair,, fat distribution BP, heart rate, peripheral pulses, edema vibratory sensation lower extremity strength and co-ordination ordination Hatzichristou 2001

23 physical assessment physical assessment visually inspect perineum at rest. Genital hiatus may appear small and perineal body displaced anteriorly,, especially if shortened position PFM observe PFM contraction, relaxation and bearing down. check sensation/neurological integrity: the anal wink reflex may be absent due to an already contracted PFM. watch out: be aware of body work in relation to patient s intimacy and reaction Cacchioni 2010

24 evaluation of palpate internal vagina/rectum presence of pain. pelvic floor muscle tone (lack validity and/or reliability testing Devreese et al 2004, Reissing et al 2004 relaxation of the PFM (e.g., absent, partial, full Messelink al 2003) spasm muscle contractile activity as measured by Messelink et digital palpation (PFM contractility, symmetry and co-ordination) ordination) surface electromyography (manometry) (transperineal and transabdominal ultrasound)

25 information & education relaxation exercises respiration exercises PFMT massage triggerpoints Anderson et al 2009 biofeedback electrical stimulation Tu et al 2005 balloons pelots multidisciplinary: change of cognitions scoring fear using VAS-scale interventions

26 PFMT find / feel / force / follow through: 4 Fs co-contraction contraction m. transversus abdominis lordosis/contract PF, kyphosis/ / contract PF contract abdominals-contract PF-relax PF-relax abdominals different levels PFME in combination with respiration review: pelvic floor physiotherapy for women with urogenital dysfunction: indications and methods Minerva Urologica e Nefrologica 2011 March;63(1):101-7 Rosenbaum 2011 management of female pelvic and sexual pain disorders

27 PFMT objective:evaluate evaluate effect PFMT on female sexual dysfunctions methods: no RCT,, n=26, sexual dysfunction (sexual desire, arousal, orgasmic disorders and/or dyspareunia), ten sessions, two-digit palpation (assessment of pelvic floor muscle, PFM, strength), intravaginal electromyography (EMG) Female Sexual Function Index (FSFI), once or twice a week Piassarolli 2010

28 PFMT results: all parameters sign. improvement 69% of the women presenting grade 4 or 5 conclusions: : PFMT improved muscle strength and electromyography, contraction amplitudes, with improved sexual function, indicating that this physiotherapy approach may be successfully used for treatment female sexual dysfunctions Piassarolli 2010

29 PFMT involvement pelvic floor in sexual function and dysfunction is examined,, as well as potential role of pelvic floor rehabilitation in treatment. Further research validating physical therapy intervention is necessary Rosenbaum 2007 no RCT,, n=3!!!! biofeedback, functional electrical stimulation, pelvic floor muscle exercises,, and vaginal cones complete rehabilitation can provide beneficial effect on sexual function larger trial, on more extended female population,, is currently in progress,, in order to confirm findings effectiveness of complete PFR scheme, together with lack of side effects, makes it suitable approach to sexual dysfunction that is associated with UI Rivalta 2009

30 evidence interventions Cochrane database systematic reviews was searched for evidence of effectiveness interventions PFM pain or abnormal muscle tone results: no reviews regarding PFMT, nor use adjunctive therapies, nor lifestyle modifications for PFM pain.

31 evidence interventions PEDro database two papers: - systematic review of Chronic Pelvic Pain in Women Kirste et al RCT Peters et al 1991 flexible biopsychosocial approach seems most promising cognitive-behavioural stress management intervention aimed at improving coping with pain and strategies for stressful life events may be indicated in sub-sample sample patients

32 evidence interventions objective: evaluate the effects of early pelvic floor muscle training after vaginal delivery on sexual function methods: : RCT PFMT VS controls, n=75 primipara,, start 4th postpartum month,, end 7 th, sexual function and PFM strength scores results: all scores sign higher, BUT only within group results conclusions: : PFM training improves PFM function,, and starting after the puerperal period, exercise appears to have positive effects on female sexual function Citak 2010

33 evidence interventions most promising treatment PFM pain / abnormal PFM tone seems - manual therapy techniques for reducing muscle tension - PFMT exercises to reinforce normal muscle contraction & relaxation, coordination - supplementary use of semg - possibly electrical stimulation for pain relief and assisted muscle activation and release - patient advice, education regarding recognition aggravating factors and encouragement to adhere to home exercise programs seem important element in success therapy Bo, Berghmans et al, 2007

34 questions? questions?