Chronic pelvic pain and sexual dysfunction

Transcription

1 Sexual Pain Disorders Mind and body treatment of sexual pain disorders Talli Y. Rosenbaum, MSc., PT AASECT Certified Sex Therapist Inner Stability, Ltd Vaginismus: inability to allow any vaginal penetration due to anxiety and fear of pain Dyspareunia: the essential experience of pain with sexual intercourse (deep vs. superficial) Provoked vestibulodynia (PVD)is most common cause of superficial dyspareunia in childbearing age women (Laumann,1999 Danielson,2003 Harlow, 2008) DSM V : genito-pelvic pain/penetration disorder (Binik, et al 2011) Pelvic and sexual pain, QoL and psychological distress Emotional (Lumley, 2011) Associated bowel and bladder symptoms LUTS in men Depression, anxiety, and sleep disturbances (Grace, 2006, Pitts, et al, 2008) Chronic pelvic pain and sexual dysfunction Associated sexual dysfunction (decreased desire and arousal) Painful orgasm Painful intercourse affects over 40% of women with CPP (Ferrero, 2008, Montenegro, 2009) ED and PE in men (Sibert, 2010) Painful arousal and ejaculation in men Classic paradigm CPP, sexual pain, and the biopsychosocial model If organic etiology identified, then the treatment is medical If no organic cause was identified, the pain is in your head and referral to psych or sex therapy In CPP, after myriad of invasive tests No organic cause identified may also be related to inability to allow appropriate examination. Physical factors Medical Adhesions Musculoskeletal dysfunction (Tu, 2005, Montenegro, 2005) Pelvic floor muscle hypertonus conditions (Van der Velde, 2007, Reissing, 2005, Gentilcore-Saulnier, 2010, Butrick, C, 2005) Psychological factors Anxiety/Fear avoidance (Kellner, 1988,Watts & Nettle, 2012, Khandker, et al, 2012, Payne, et al2004) Hypervigilance ² Catastrophizing (Tripp, 2006) ² Aversion/disgust (Borg, 2009) ² Self efficacy (Desrochers, et al 2009) ² Body image/disconnect 1

2 Social factors Social construction of gender and sexuality directly shape the fear and distress of women with sexual pain. (Farrel & Cacchione, 2012) Perception that women must allow vaginal intercourse for satisfactory sex, to please her partner or fulfill his need for sex (Ayling & Ussher, 2008) Guilt/responsibility/lack of autonomy Relationship dynamics Expectations (work, home) Role identity The biopsychosocial model Psychologist Sex therapist CPP Vaginismus Dyspareunia Physician Physiotherapist Designate: the psycho-social aspects including anxiety and aversion, to mental health professionals (MHPs). the physiological aspects of treatment to medical professionals (MPs), Identifying a diagnosis Pain relief Skin care Medical Oral and topical meds Injections: trigger point, Botox, nerve blocks, anxiolytics Surgery Physical Therapy Musculoskeletal aspects and myofascial components Exercise Pelvic floor relaxation Biofeedback Electrical stimulation Dilator therapy Manual therapy Dry needling Sex Therapy Therapy Psycho-education Cognitive behavioral therapy (Bergeron, 2001; 2010; Landry et al., 2008; Masheb et al., 2009) Pain monitoring/coping/cognitive restructuring/ thought monitoring Group therapy Relaxation training Partner communication Increasing sensuality, meaning of sex 2

3 Problem with this model Compartmental Fear avoidance and anxiety are significant characteristics of the patient s response to physical examination, mirroring the sexual setting Disassociation and triggering of trauma are most likely to occur in the MP setting. MPs traditionally receive limited training in mental health counseling skills. The Pelvic Exam So, how do you feel about an examination? Pelvic examinations Negative feelings such as fear, pain, embarrassment and awkwardness (Wendt, 2004) Physical and emotional discomfort correlated with: negatively perceived first pelvic examination (Wijma, 1998), past history of sexual abuse (Swanberg, 2011) PTSD (Weitlaug, 2010) Physician gender, informed communication, positioning, nakedness, and whether physician seemed in a hurry are factors influencing feelings of control and comfort (Yanikkerem, 2009) Pelvic Exam anxiety and pain There is little literature on perceptions of the PE in women with SPD though difficulty with, or inability to undergo an examination are defining features of vaginismus and dyspareunia. Pain and anxiety with PE are significantly greater in women with dyspareunia (Boyer, in press) Sexual Abuse Women may not report due to feelings of shame, lack of perception of safety, repression of painful memories Inquire about trauma and abuse and know how to cope with post-traumatic exacerbations: Disassociative reactions, flashbacks The pelvic floor Hyperactivity of the pelvic floor is not simply an isolated dysfunction, but a physical manifestation of the patient s emotional state. (Rosenbaum, 2012) Trait anxiety/habits affect baseline tone (Anderson, Wise, 1993) 3 or more PF symptoms related to sexual abuse (Beck, et al, 2009) Increased PF activity as a defensive reaction. ( Van der Velde et al.,2001.) 3

4 Pelvic floor EMG (Both, 2012) Models addressing pain/anxiety VPA EMG Neutral Sex Interventions that target psychological variables in women with sexual pain are not widely used by physical therapists to complement traditional physical therapy interventions (Allapatu, 2011 Hartman, 2011) Sexual Threat Anxiety VPA EMG Emotions Thoughts Fear of pain Fear of bleeding Fear of it getting stuck in there or going in to the wrong place or damaging something Disgust, shame and failure Guilt and resonsibility Self pathologize Desire to have it fixed w/ techniques that allow absence I will never be able to have sex I will never be a mother He will leave me. I feel so bad for him. I have to let him inside, or he will feel bad This time, I will be good and it will succeed I have to fix this. I have no other choice. I have to get rid of this pain. This is my fault Beliefs about the hymen The hymen covers the vaginal entry The hymen has to break/bleed during intercourse The hymen disappears after first intercourse My husband should be the first to break the hymen Vaginal exams, tampons, finger insertion will affect my betulim. Cognitive and emotional split Cognitive: I have to allow this exam, I have to get better, if I don t fix this my husband will leave me. Go away, anxiety Emotional: Anxiety Sensory: Heart rate and breathing, feeling in chest, pain in stomach, muscles contracting Behavior: Withdrawal response/disassociation Talli Rosenbaum all rights reserved 4

5 Addressing the conflict Point out discrepancy between cognitions and feelings and ask client to stay present Point out unhelpful, negative or catastrophizing thoughts Focus on feelings, sensations and behaviors Know what NOT to say If I don t fix this, I am never going to be able to have children Its not bad, its just a speculum. Babies come out of there, you know Just Relax! Please, just let me. You know I am not going to hurt you Can you please just try to relax? If I would I could. I am so embarras sed I am outta here Managing Pelvic Exams Techniques Should be performed only when indicated. Discuss options with their patients Prepare in advance when an exam will be needed. Explain everything you are about to do before you do it Always ask permission Allow self inserting the ultrasound transducer Maintain eye contact Be alert for signs of disassociation Stop when asked (Hobbins, 2004) Allow more time than usual. Point out unhelpful thoughts Ask client to recognize and self rate anxiety Explain everything you are about to do before you do it Always ask permission Be alert for signs of dissociation 5

6 Mindfulness Recognized role in the treatment of chronic pain (Kabat-Zinn, et al,1985) and anxiety (Kabat-Zinn et al., 1992) Treatment of sexual dysfunction (Brotto, et al 2008) Addresses perceptions, feelings, attitudes and thoughts Allows clients to recognize how cognitive judgment of their feelings and symptoms, negatively affects their symptoms (Bishop et al., 2004). Allows the client to focus on and accept feelings and perceptions. Rosenbaum, TY,An integrated mindfulness-based approach to the treatment of women with sexual pain and anxiety: promoting autonomy and mind/body connection, Sexual and Relationship Therapy, DOI: / Rosenbaum, TY, Padoa, A.Managing Pregnancy and Delivery in Women with Sexual Pain Disorders. The Journal of Sexual Medicine, 2012;9: Rosenbaum, TY. Addressing Anxiety In-Vivo in Physiotherapy Treatment of Women with Severe Vaginismus: A Clinical Approach (2011) J Sex and Marital Therapy 37(2): Rosenbaum Mindfulness Protocol Tools Psycho-education Cognitive restructuring Deep breathing Visualization Step back/try again Break it down Externalize (put it in a box) Accept Lying on the bed fully dressed, covered with a sheet Bend knees and separate legs Self rate anxiety Increasing exposure: shorts, underwear, no underwear with and without sheet Intervention Intervention Recognizes discrepancy b/w cognitive motivation and anxiety Ability to return or use tools ( go back to prior step, close legs, use sheet, etc ) Discourage cognitive/encourage mindfulness of rise in anxiety Containment vs. ignoring or trying to think away anxious feelings 6

7 Advantages Allows the client to reach the genital examination when she is far more prepared for it and can be both physically and emotionally present during the examination Less likelihood of dissociation. Teaches the client to value her anxiety and be with her pain mindfully. Preparation Genital self examination Genital self touch Practitioner pelvic examination Finger and dilator insertion Sexual intercourse Suited to women from traditional populations (Ribner & Rosenbaum, 2004). Mindful dilator exercises Not just about insertion and containment Stay present Feel the pelvic floor relax and the vagina open Wait until your vagina lets it in Be aware and accept anxious feelings Do not judge the pain Gradual trust Ascribing meaning Use mindfulness to address anxiety as well as pain Suspend judgment and criticism Stay in the moment Appreciate and experience pleasure Not too goal oriented Mirror mirror, on the wall! Facing the monster Addressing aversion Genitals? (Her own, penis?) What senses (looking, touching, smell?) Where? (midline aversion, external, internal, mucosa) What? hair, secretions Mine isn t normal Partner s reaction, past or present Aversion to sex or penetration? Medical interventions? 7

8 Treating Aversion Gentle exposure to pictures or slides Stick pictures without genitals Stick pictures with line for genitals Frontal illustration Vulva illustration Frontal picture Vulva picture Frontal mirror Vulva mirror Conclusions Sexual pain is a multi-factorial problem Medical professionals are often confronted with clients emotional experience in the clinic Mindfulness offers a treatment approach that addresses anxiety in the treatment of sexual pain References Rosenbaum, TY. Addressing Anxiety In-Vivo in Physiotherapy Treatment of Women with Severe Vaginismus: A Clinical Approach (2011) J Sex and Marital Therapy 37(2): Rosenbaum, TY. How well is the multidisciplinary model working? The Journal of Sexual Medicine, 8: Talli Y. Rosenbaum (2013): An integrated mindfulnessbased approach to the treatment of women with sexual pain and anxiety: promoting autonomy and mind/body connection, Sexual and Relationship Therapy, Journal of Sex and Relationship Therapy DOI: /