Outline. Down Under: What every sex therapist should know about the pelvic floor

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1 Down Under: What every sex therapist should know about the pelvic floor Talli Y. Rosenbaum, MSc. AASECT Certified Sex Therapist Outline Review anatomy and basic function of the pelvic floor Review basic of pelvic floor rehabilitation Discuss symptoms of pelvic floor dysfunction Explain how PF symptoms affect sex Review literature regarding role of PF in sexual activity Discuss PF over-activity and painful sex 6 1

2 Muscles of the Pelvic Floor Figure 10.12c What affects the pelvic floor? Pregnancy Childbirth Obesity Heavy Work Chronic Cough Surgery Smoking Aging Menopause/Hormones Lack Of Fitness Neurological Conditions Radiotherapy The Pelvic Floor Maintains continence (bladder and bowel) Supports pelvic organs Some evidence the PF plays a role in breathing, posture and lumbo-pelvic stability 2

3 What affects the pelvic floor? Pregnancy Childbirth Obesity Heavy Work Chronic Cough Surgery Smoking Aging Menopause/Hormones Lack Of Fitness Neurological Conditions Radiotherapy Indications Stress Urinary Incontinence (SUI) and mixed incontinence Overactive bladder (OAB) Pelvic Organ Prolapse (POP) The overactive pelvic floor/pelvic and genital pain syndromes Post-surgical rehabilitation Other indications What do pelvic floor PTs do? 15 Pelvic floor rehabilitation aims To increase PFM strength and function in conditions of weakness contributing to SUI, mixed incontinence and prolapse (Doumolin, 2010) To reduce and normalize increased PF activity associated with conditions such as vulvodynia and vaginismus (Rosenbaum, 2005) and IC/PBS (Lukban, 2000) The complicated pelvic floor Physiotherapists as PF rehab specialists PF as part of an integrated unit Breathing, posture, joint mobility, trunk and extremity strength and length may affect IAP, continence, prolapse and pelvic pain. 3

4 The PT Exam History Observation of gait and movement patterns Musculoskeletal/ postural evaluation Vulvar and vaginal exam Pelvic floor assessment EMG assessment The PT Exam History Observation of gait and movement patterns Musculoskeletal/ postural evaluation Vulvar and vaginal exam Pelvic floor assessment Measuring the Pelvic Floor Most scales measure PF symptoms (van Lunsen, 2002, Laan, in prep) Visual and digital assessment semg Dynamometric speculum (Morin, 2006) Ultrasound (Braaken, 2009, ) Measurement problems Valid and reliable tools are lacking Manual examination is subjective and difficult to standardize particularly with high tone and anxiety semg unreliable: Contact mucosa, degree of lubrication and thickness of the vaginal tissue can all greatly affect signal detection (Merletti, 2004) Pelvic Floor Manual Examination: gold standard Awareness and ability to isolate muscles Balance and symmetry Muscle tension/ muscle stiffness Presence of trigger points Dysenergy Strength: force, lift, no., duration Hartman, D 2010 Talli Rosenbaum

5 Breathing Relaxation Local desensitization Methods General and Pelvic Floor Exercise Manual Therapy Dilator therapy Surface EMG (semg) biofeedback Electrical Stimulation. Talli Rosenbaum What does the pelvic floor have to do with SEX? Pelvic floor and sex Pelvic floor symptoms interfere with sex Pelvic floor muscles play an important role in sexual function (arousal and orgasm) Pelvic floor over-activity is related to painful sex (or inability to allow intercourse) Pelvic floor symptoms Bladder and bowel symptoms: retention, frequency, urgency, and constipation and IC/PBS (Tripoli TM, 2010, Peters, KM 2007, Zaslau, S 2008, Ottem, DP, 2007) Bother, distress and decreased QoL (Gil, 2009) Affect social, recreational and physical activities Negative impact on mental health.(melville 2005) Affects sexuality and relationships Fear of coital leakage (Knoepp, 2010, Pons, 2008, Achtari, 2005) POP alters body image perception (Loewenstien, 2009) Pelvic and genital pain syndromes, IC/PBS dyspareunia, decreased arousal and lubrication and orgasm (Tripoli TM, 2010, Peters, KM 2007, Zaslau, S 2008, Ottem, DP, 2007) 5

6 Incontinence during sexual activity Sexual response and function is negatively impacted when lack of sphincter control leads to incontinence during sex Urinary leakage can occur during arousal penetration,during orgasm, or both. Flatulence, fecal loss Education and reassurance re: female ejaculation Urogenital conditions and sexual function 40-46% of women with LUTS suffer from impairment in their sex lives (Salonia. 2004). 1/3 of patients with prolapse reported their ability to have sexual relations was affected (Barber, et al. 2002) Low libido, vaginal dryness, painful intercourse, decreased orgasm rates and intensity. and decreased sexual satisfaction reported in women with UI (Handa et al. 2004). LUTS, pain, and men Male chronic pelvic pain (CPPS) is associated with sexual dysfunction, including ED, PE and painful erection and orgasm. (Potts, 2003) Pelvic floor syndromes should be considered as a possible factor in this co-morbid symptomatology which may respond to pelvic floor treatment The Pelvic Floor and Sex Pelvic floor symptoms negatively affect sex Pelvic floor rehabilitation (PFR) improves symptoms So, does PFR improve sexual outcomes? Pelvic floor rehabilitation aims To increase PFM strength and function in conditions of weakness contributing to SUI, mixed incontinence and prolapse (Doumolin, 2010) To reduce and normalize increased PF activity associated with conditions such as vulvodynia and vaginismus (Rosenbaum, 2005) and IC/PBS (Lukban, 2000) The complicated pelvic floor Effective in treating SUI (Doumolin, 2010, Neumann, 2007) Sexual function improves with pelvic floor training Improves qol and sexual function in women with SUI in RCT. N=59 (Bo, 2000) Improvement in sexual desire, arousal and orgasm reported in women (n=42) who received PFM rehabilitation. N=42 (Beji, 2003). Electrical stimulation improved sexual function and decreased SUI symptoms N=37(Giuseppe, 2007) 6

7 Sexual function improves with pelvic floor training PFMT improves sexual function of women with SUI (n=70).(zahariou,2007) The effectiveness of a complete PFR scheme, makes it a suitable approach to sexual dysfunction that is associated with UI. (Rivalta, 2009) Paula and PFMT improved QOL and sexual functioning (Liebergall, 2012) Role of PF in arousal and orgasm PF contractions are used during early arousal to increase vasocongestion and physical sensations (Messe and Geer, 1985, Colpi, et al, 1999) Initiation of orgasm is characterized by PF contractions with an interval of 8 ms (Masters and Johnson, 1966, Masters, 1994) Orgasm is a spinal reflex triggered by firing of stretch receptors in the PF muscles caused by vasocongestion ( Sherfey, 1974) During orgasm rhythmic contraction of the PF muscles is perceived as pleasurable. Studies supporting PF exercise for ED and PE Treatment of ED by perineal exercise, EMG biofeedback, and FES 42% improvement (n=150) (Van Kampen et al. 2003). 47% regained erection with PFE alone (n=51) (Claes, 1993) RCT of PFM exercises and BF for ED (n=51) (Dorey et al. 2004). Early PFME can help men post prostatectomy (Sighinolfi, et al, 2000 Lin, Y., 2012 ) Studies supporting PF exercise for PE 61% of patients (n=11) with PE were better able to control the ejaculatory reflex after the first 20 sessions(la Pera et al. 1996) 11/19 (57%) were able to control the ejaculation reflex, optimizing the latency time to ejaculation from the start of intravaginal intercourse. (Pastore, 2012) By what mechanism? What do we know about the role of the PF muscles in sex? PFR is effective in improving PF symptoms, increasing Qol and improving sexual function. Does this mean that better PF muscles improves sex, or less SUI symptoms? Does that mean strengthening the PF can treat sexual dysfunction in women without SUI? 7

8 What do we know about the role of the PF muscles in sex? Part of ancient Chinese Taoist teachings (Chang, 1984) Lack of arousal and frigidity due to weak pelvic floor and laxity is associated with decreased sexual sensation (Kegel, 1952) Weak muscles provide insufficient activity necessary for vaginal friction or blood flow. (Graber, Kline-Graber. 1979) Role of PF in arousal and orgasm PF contractions are used during early arousal to increase vasocongestion and physical sensations (Messe and Geer, 1985, Colpi, et al, 1999) Initiation of orgasm is characterized by PF contractions with an interval of 8 ms (Masters and Johnson, 1966, Masters, 1994) Orgasm is triggered by firing of stretch receptors in the PF muscles caused by vasocongestion ( Sherfey, 1974) During orgasm rhythmic contraction of the PF muscles is perceived as pleasurable. Bulbocavernous Arises from PB and inserts into clitoris Surrounds opening of vagina narrows vaginal entrance Compress DDV Continuous with EAS which is closed during arousal and orgasm (Shafik,2000) Covers the surface of crura which contributes to clitoral swelling Works together with deep transverse perineal and sphincter urethrae Ischiocavernous Erection and ejaculation PFM function enhances BF to the penis. Contraction of the IC,BC muscles compresses the deep dorsal vein of the penis. (Dorey, 2004) During orgasm rhythmic contraction of the PF muscles is perceived as pleasurable. Pelvic floor muscles are active during ejaculation (Shafik, 2000) Role of Levator Ani During Sexual Intercourse Penetration triggers vagino-levator reflex Levator plate elevates and laterally retracts pulling on hiatal ligament Lifts uterus and elongates and balloons vagina (Shafik, 1995) 8

9 Female genital anatomy Anatomy of the clitoris Clitoral shaft and glans. Clitoral crura (9 cm into pelvis) Vestibular bulbs sponge-like tissue around the urethra Copyright Talli Rosenbaum Female Arousal/Erectile tissue Copyright Talli Rosenbaum O connell, Clitoral anatomy in nulliparous, healthy, premenopausal volunteers using unenhanced magnetic resonance imaging J Urol Pelvic floor and vaginal orgasm: Sonographic studies Penetration triggered reflex vaginal contraction or voluntary contraction dispaces clitoral root closer to vagina facilitating vaginal orgasm. This is the G-spot. Foldes, et al JSM

10 PF muscles and sexual function So, the PF muscles are involved in sexual function, but, Are stronger pelvic floor muscles necessarily correlated with better sexual function? N=176 PFM strength was ranked from 0 (weak) to 2 (strong) Women with strong or moderate PFM scored higher on the FSFI orgasmic and arousal domains than women with weak PFM The duration of PFM contraction was correlated with FSFI orgasmic domain and sexual arousal (Loewenstein, et al, 2010) So, improving the strength of the pelvic floor should enhance sexual function, right? PFM strength not correlated with arousal/orgasm Chambless et al found no correlation between PFM strength and sexual function. No difference in orgasmic outcome in 3 treatment groups. (n=46) (Roughan, 1981) PF differences in strength but NOT to sexual function. (Batyur, 2005) Women who had C-sections had better vaginal tone, but did not score higher on sexual function domains (Dean, 2008) Is Is the Sexual Satisfaction of Postmenopausal Women Enhanced by Physical Exercise and PFMT? Medical History Women s sexual response is multi-factorial Psychological Well-being Family Beliefs N=32 Implementation reduced anxiety and improved PFM strength in sedentary and continent postmenopausal women. However, did not improve sexual function. (da Silva Lara, 2012) Illness/ Medications External Stressors Sexual Response Cognitions/Beliefs Early Sexual Experiences Partner Relationship 10

11 What about the overactive pelvic floor? Pelvic and genital pain PF overactivity is a component of pelvic and genital pain in men and women (Tu, 2008, Reissing, 2005 Engman, 2004) The overactive pelvic floor and painful sex Causal or reactive/baseline or response Affects blood supply to the vulva affecting genital arousal and lubrication Increased friction with intercourse/mechanical trauma Inadequate lubrication, fissures, and more pain Pain and anxiety Pain and anxiety are understood to be salient components of both vaginismus and provoked vestibulodynia (PVD) (Watts & Nettle,2012, Khandker, et al, 2012) Increase in pelvic floor hyperactivity is component of both conditions (Van der Velde, 2007, Reissing, 2005, Gentilcore-Saulnier, 2010, Rosenbaum, 2007) Persistent and unwanted feelings of genital arousal in the absence of desire, not generally relieved by orgasm. Peripheral and central mechanisms have been suggested. Affect of PFM hypertonus? The pelvic floor and PGAD Physical Therapy Treatment of PGAD During Pregnancy: A Case Report Trigger point release of OI relieved symptoms. Over activity of the OI may restrict available space in Alcock's canal impinging or entrapping the pudendal nerve The treatment provided decreased the hypertonicity of the OI muscles, increased available space in the Alcock's canal, and released excess pressure on the pudendal nerve. (Rosenbaum, 2010) 11

12 Conclusions References The pelvic floor has an important role in sexual health Treating PF symptoms improves Qol and sexual function Awareness of the PF helps overall body awareness, which helps sex An overactive PF is often a physical expression of an emotional state We don t really know yet how the PF functions in sexual arousal and orgasm Rosenbaum, TY. Pelvic Floor Rehabilitation: Indications and Methods. Minerva Urologica e Nefrologica, 2011 March;63(1): PMID: Rosenbaum,TY. Physical Therapy Treatment of Persistent Genital Arousal Disorder in Pregnancy: A Case Report. J Sex Med Volume 7, Issue 3, Date: March 2010, PMID: Rosenbaum, T., The Role of Physical Therapy in Female Sexual Dysfunction. Current Sexual Health Reports 2008, 5: Rosenbaum, T. Owens, A The Role of Pelvic Floor Physical Therapy in the Treatment of Pelvic and Genital Pain Related Sexual Dysfunction. J Sex Med Mar;5(3):513-23; quiz Rosenbaum TY, Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: A literature review. J Sex Med Jan;4(1):4-13. Review.PMID: