Amy Stein1
(1)
Beyond Basics Physical Therapy, LLC, 110 E 42nd St Suite #1504, New York, NY 10017, USA
Amy Stein
Email: amy@beyondbasicspt.com
Keywords
Pelvic floor physical therapyTreatmentSexual dysfunctionsPhysical therapy
Sexual dysfunction and the pelvic pain that typically accompanies it can profoundly affect the lives of the many men and women who suffer from these disorders. This is a prevalent issue: In a study of 112 women with genital pain, 78 of them—67.8 % (p < 0.0001)—suffered some form of female sexual dysfunction (FSD) . The most prevalent form of FSD, affecting 58 of the 78, or 74.3 %, was dyspareunia [1]. Similarly, in a study of men with pelvic pain, 88.3 % suffered pelvic floor myalgia and pelvic floor dysfunction [2]. The consequences for these individuals can be far reaching. Loving relationships are strained, and the individual’s sense of self-worth as a fully functioning human and sexual being can be severely impaired. Yet this is an issue that rarely gets attention from either clinicians or the public at large.
Perhaps even more significantly, little consideration is given to the musculoskeletal impairments that commonly cause sexual dysfunction and pelvic pain. Rather, when we do think about sexual dysfunction, we typically mean yeast, urinary tract, and sexually transmitted infections, and when we think about sexual inactivity, we typically refer to a decreased sexual response. While sexual inactivity and infections certainly contribute to pelvic pain and sexual dysfunction, we often forget about the underlying joints, bones, and muscles of the pelvis as potential generators of pain or weakness. As a result, when laboratory tests and other diagnostic procedures reveal neither disease nor infection, patients’ symptoms are too often written off as purely psychogenic. Yet their pain and dysfunction persist.
In the absence of a clear medical cause, it is likely that these patients are suffering from pelvic floor musculoskeletal dysfunction—PFD. The potential causes of such dysfunction can reach as far back as childhood and may result from such insults as abdominopelvic surgery, trauma, parturition, or bony misalignment. PFD may also appear insidiously such as with endometriosis or scoliosis. Whatever the original cause, patients with PFD who present with musculoskeletal dysfunction and who have not found relief from their symptoms through traditional medical means are perfect candidates for pelvic floor physical therapy.
Pelvic floor physical therapy is the practice of a growing number of physical therapists. Extensively schooled in the body’s musculoskeletal and neuromuscular systems, these physical therapists have often pursued specialized postgraduate study in musculoskeletal dysfunctions of the pelvic floor. They are uniquely suited to diagnose and treat patients whose pelvic dysfunction may stem from disorders of the pelvic floor muscles and surrounding structures. Although the dysfunction may manifest as a complex of impairments, these can be categorized as due to either (1) pelvic floor muscle underactivity or weakness with no pain and no muscle shortening/tightness, resulting in decreased sexual response, prolapse, or leakage, or (2) pelvic floor muscle overactivity with or without pain but with concomitant muscle and tissue shortening and possible trigger points. Some patients may suffer both categories of dysfunction.
17.1 Anatomy
The pelvic floor muscles and fascia) surround the urethra, anorectal region, and genitals (Figs. 17.1 and 17.2). They assist with voluntary sphincteric control and sexual arousal and performance [3]. Dysfunction of the neuromuscular system can negatively affect bowel, bladder, and sexual function [4] and can contribute to abdominopelvic pain and possible peripheral or central sensitization [5]. The muscles and fascia also function structurally to support the abdominopelvic organs and to assist in lumbo-pelvic stability (Figs. 17.3 and 17.4). Pelvic floor muscles are 80 % slow-twitch (type I) skeletal fibers and 20 % fast-twitch (type II) skeletal fibers [6].
Fig. 17.1
Female pelvic floor anatomy
Fig. 17.2
Male pelvic floor anatomy
Fig. 17.3
Female urogenital system (midsagittal section)
Fig. 17.4
Male urogenital system (midsagittal section)
The skeletal structures surrounding the pelvic floor help to keep the entire musculoskeletal and neuromuscular system in alignment [3].
17.2 Common Symptoms
Both men and women may present with a variety of subjective complaints, and both may be treated by pelvic floor physical therapists. Men with pelvic pain and sexual dysfunction typically complain of pain in the testicles, groin, rectum, tip of the penis, and abdomen. They may also complain of inability to achieve an erection, premature ejaculation, and/or post-ejaculatory pain [7]. Often these symptoms are misdiagnosed or confused with prostatitis.
Women typically complain of symptoms ranging from vulvar burning, pain in the clitoris, introital dyspareunia, pain in the introitus, pain deep within the vagina to pelvic pain. In both male and female patients suffering from pelvic floor weakness, the first of the two categories of dysfunction, decreased sexual response (i.e., difficulty reaching climax or orgasm), may be an additional complaint.
Both men and women may also complain of symptoms not related to sexual function—for example, urinary or fecal incontinence and/or urinary and/or bowel frequency, urgency, the sensation of incomplete emptying, or constipation.
17.3 Evaluation
A physical therapist or healthcare provider specializing in pelvic floor issues typically performs a manual examination to evaluate the muscles, tissues, and nerves of the pelvic floor. The aim is to gauge pelvic nerve involvement and to identify muscles and fascial tissue that may be either shortened, tender when palpated, and weak or lengthened with diminished tissue elasticity, making it difficult to support the pelvic contents or to achieve a positive sexual response.
The evaluation will also include a medical history and a pain diary in which the patient notes increases or decreases in pain; instances of bladder, bowel, and sexual dysfunction; and previous treatments and whether they helped or worsened the condition. The patient’s gait patterns, posture, alignment, joint mobility, range of motion, and strength levels are all evaluated, as all may affect the dysfunction.
To assess the patient’s musculoskeletal system, the practitioner will also evaluate for any physiological and biomechanical changes in the pelvis, trunk, lower extremities, and pelvic floor muscles, probing for overactive, underactive, and/or shortened muscles, increased or decreased sensation, skin and tissue changes, and pain patterns. These conditions may be caused by myofascial trigger points, altered nerve sensitivity, and/or increased fascial/connective tissue restrictions [6, 8, 9].
In women, trigger points in the urogenital triangle and pubococcygeus muscle may result in superficial introital pain and pain at the vestibule (see Fig. 17.2). Trigger points in the deep levator ani, obturator internus, coccygeus, and piriformis muscles, however, can cause deep, penetrating pain [6]. Trigger points in either area can result in postorgasmic and post-ejaculatory pain. Neville et al. [10] found that women with chronic pelvic and genital pain presented with significantly more abnormal muscle findings than pain-free women.
Specific nerves that innervate the genital and pelvic region—the pudendal, the posterior and lateral femoral cutaneous, iliohypogastric, ilioinguinal, levator ani, and genitofemoral nerves—should be evaluated for unfavorable neural tension, which may result in hyposensitivity, dysesthesia, or hyperalgesia, and for changes in neurodynamics that could result in underactive muscles and weakness, or in overactive muscles and increased pain [11, 12]. Either condition may result from connective tissue restrictions in and around the pelvic floor and genital region or around nerves and can leave the pelvic floor muscle dysfunctional [8]. In addition, nerve irritation or injury may be a result of such biomechanical abnormalities as foraminal narrowing, scarring of a nerve canal, or myofascial trigger points. Patients may describe the resulting muscle tension and/or neuropathic pain as burning, itching, tingling, cold, sharp, and shooting pain or, in the case of decreased sexual response, as weakness and incontinence [6, 8, 13]. The variety of responses is just one reason why it is so important to assess the body from head to toe to discover all impairments that could be affecting a patient’s symptoms and function.
17.4 Treatment
Physical therapy for pelvic floor and sexual dysfunction will of course be based on what the therapist has found in the examination and evaluation process. The therapist’s arsenal includes neural and visceral mobilization and mobilization of connective tissue, internal and external myofascial trigger point release [6], pelvic and core mobilization and stabilization, and such modalities as biofeedback and electrical stimulation [14]. All of these practices reduce tender points and decrease tissue restrictions while also strengthening and stabilizing any weakened muscles or joints; they therefore apply primarily to dysfunctions in the category of pelvic floor weakness and are aimed at restoring the proper length of the pelvic floor muscles and tissues and at reducing neural tension and sexual dysfunction [8, 15–17].
Where such events as scarring from endometriosis, prostatectomy, vaginal childbirth with perineal laceration or episiotomy, or caesarean section have caused abdominal and pelvic scarring, the goal of physical therapy is to enable the structures of the pelvis to move more freely and to increase blood circulation; the therapist therefore applies manual techniques to loosen areas of restriction. Internal and external massage can reduce the amount of tension and restrictions in the sensitive structures of the abdomen and pelvis and thereby alleviate pain.
Many category-one patients—those evaluated for pelvic floor weakness—may present with underactive pelvic floor muscles unable to support the pelvic organs and assist in sphincteric control. They are unable or less able to contract the pelvic floor muscles, which can result in incontinence and decreased sexual response. The lack of support may also make the patient feel heaviness and discomfort in the pelvic area, which worsens over the course of the day. In these cases, the physical therapist will guide the patient in ways to strengthen the pelvic core while maintaining proper bodily alignment to ensure that the pelvic muscles are in their optimal positions for proper functioning.
For category-two patients—both males and females with pelvic and/or sexual dysfunction—physical examination typically shows pelvic floor muscles and tissues that are overly tight or have gone into spasm. In this case, the physical therapist may choose manually to correct any bony misalignments, then stretch, and lengthen the muscles out of spasm and tightness [18, 19]. The American Urological Association (AUA) guidelines for the management of this kind of pelvic pain recommend manual physical therapy by clinicians appropriately trained in treating pelvic floor overactivity, and they suggest that patients avoid such improper pelvic floor strengthening exercises such as Kegels [20].
In addition to their manual skills, pelvic floor physical therapists have at their disposal a number of effective tools for treating patients’ pain and dysfunction. Among them is biofeedback, a highly effective technique for “teaching” patients how to relax and contract the muscles of the pelvic floor. Electrodes are placed either at the rectal opening or inside the vagina or anus and are connected to a computer; the computer translates patients’ responses into graphic measurements on the computer screen so patients are able to view their own pelvic floor muscle activity in real time. As the physical therapist guides the patient through relaxation and strengthening techniques, the patient can thus “see” how his or her pelvic floor muscles function and how the techniques affect that function and their own pain levels. It is a form of reeducation of the muscles that helps category-two patients coordinate and down-train overactive muscles [8] or category-one patients to coordinate, uptrain, and strengthen the pelvic floor muscles [21–23].
In addition, in extreme cases of pelvic floor weakness, such as those caused by a neurological pathology like multiple sclerosis or by postsurgical weakness, a physical therapist might use neuromuscular stimulation (NMES) to help the patient gain muscle strength. Using a setup similar to that of biofeedback, NMES works by sending electricity directly to the muscles of the pelvic floor. The electrical stimulation causes the muscle fibers of the pelvic floor to contract; this assists in gradually strengthening the pelvic floor to allow for greater muscle function.
Adding a home program that is specific to the objective findings from the pelvic floor, physical therapy evaluation is also essential to the patient’s recovery, as is monitoring of the home treatment plan. For example, for women who are experiencing painful penetration secondary to tight vaginal muscles and tissues, a physical therapist might teach the patient to use dilators or a massage wand in her home program as a way to stretch the vaginal tissues or to address trigger points and so tolerate her partner’s penis or other sexual activity. This will require the monitoring and supervision of the treating physical therapist to ensure proper guidance of the home program.
The pelvis is an extremely complex area of the human body in which a lot can go wrong. When treating individuals who suffer from chronic pain and sexual dysfunction, it is therefore essential to consider all of the systems of the body in the process of evaluation and diagnosis, including the musculoskeletal system. Where traditional methods have failed, physical therapists addressing that system—and attending to the patient’s mental state as well—have helped alleviate the suffering of numerous patients and have advanced their rehabilitation [15, 16, 24, 25]. It is important for the patient and the prescribing healthcare provider to understand that “flare-ups” are not unusual and that pelvic floor rehabilitation is not usually a quick fix. With persistence and proper guidance, however, such rehabilitation can be extremely effective for patients suffering from pelvic floor and sexual dysfunction.
References
1.
Verit FF, Verit A, Yeni E. The prevalence of sexual dysfunction and associated risk factors in women with chronic pelvic pain: a cross-sectional study. Arch Gynecol Obstet. 2006;274(5):297–302.CrossRefPubMed
2.
Schmidt R. Male pelvic pain syndrome. J Urol. 1999;161:903–8.CrossRefPubMed
3.
Irion JM, Irion GL. Women’s health in physical therapy. Philadelphia: Lippincott Williams and Wilkins; 2010.
4.
Haylen BT, de Ridder D, Freeman RM, et al. An International urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4–20. doi:10.1002/nau.20798.PubMed
5.
Hilton S, Vandyken C. The puzzle of pelvic pain – a rehabilitation framework for balancing tissue dysfunction and central sensitization. I: Pain physiology and evaluation for the physical therapist. J Womens Health Phys Ther. 2011;35:103–11.CrossRef
6.
Simons DG, Travell JG. Myofascial origins of low back pain. 3. Pelvic and lower extremity muscles. Postgrad Med. 1983;73(2):99–105. 2.CrossRefPubMed
7.
Anderson, et al. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174:155–60.CrossRefPubMed
8.
FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. I: Background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14(4):261–8 (Epub 2003 Aug 2. Review).CrossRefPubMed
9.
Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC, Nogueira AA, Dos Reis FJ, Poli Neto OB. Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain. Pain Med. 2010;11(2):224–8.CrossRefPubMed
10.
Neville CE, Fitzgerald CM, Mallinson T, Badillo S, Hynes C, Tu F. A preliminary report of musculoskeletal dysfunction in female chronic pelvic pain: a blinded study of examination findings. J Bodyw Mov Ther. 2012;16(1):50–6.CrossRefPubMed
11.
Darnis B, Robert R, Labat JJ, Riant T, Gaudin C, Hamel A, Hamel O. Perineal pain and inferior cluneal nerves: anatomy and surgery. Surg Radiol Anat. 2008;30(3):177–83.CrossRefPubMed
12.
Jamieson DJ, Steege JF. The prevalence of dysmenorrheal, dyspareunia, pelvic pain and irritable bowel syndrome in primary care practices. Obstet Gynecol. 1996;87(1):55–8.CrossRefPubMed
13.
Weiss J, Prendergast S. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol. 2003;46:773–82.CrossRefPubMed
14.
Hartmann E. The perceived effectiveness of physical therapy treatment on women complaining of chronic vulvar pain and diagnosed with either vulvar vestibulitis syndrome or dysesthetic vulvodynia. J Women’s Health Phy Ther, APTA. 2001;25:13–8.
15.
Prendergast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol. 2003;46(4):773–82.CrossRefPubMed
16.
FitzGerald MP, Payne CK, Lukacz ES, et al. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. J Urol. 2012;187(6):2113–8.CrossRefPubMedPubMedCentral
17.
FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol. 2009;182(2):570–80.CrossRefPubMedPubMedCentral
18.
Oyama IA, Rejba A, Lukban JC, Fletcher E, Kellogg-Spadt S, Holzberg AS, Whitmore KE. Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology. 2004;64(5):862–5.CrossRefPubMed
19.
Weiss JM. Pelvic floor myofascial trigger points: Manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol. 2001;166:2226–31.CrossRefPubMed
20.
Winters JC, Dmochowski RR, Goldman HB, et al. Urodynamic studies in adults: AUA/SUFU guideline. J Urol. 2012;188 Suppl 6:2464–72.CrossRefPubMed
21.
Glazer HI, Rodke G, Swencionis C, Hertz R, Young AW. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med. 1995;40(4):283–90.PubMed
22.
Glazer HI, Jantos M, Hartmann EH, Swencionis C. Vulvodynia and asymptomatic women. J Reprod Med. 1998;43(11):959–62.PubMed
23.
McKay E, Kaufman RH, Doctor U, Berkova Z, Glazer H, Redko V. Treating vulvar vestibulitis with electromyographic biofeedback of pelvic floor musculature. J Reprod Med. 2001;46(4):337–42.PubMed
24.
Ree ML, Nygaard I, Bø K. Muscular fatigue in the pelvic floor muscles after strenuous physical activity. Acta Obstet Gynecol Scand. 2007;86(7):870–6.CrossRefPubMed
25.
Gyang A, Hartman M, Lamvu G. Musculoskeletal causes of chronic pelvic pain: what a gynecologist should know. Obstet Gynecol. 2013;121(3):645–50.CrossRefPubMed
Additional Reading
Baker P. Contemporary Management of Chronic Pelvic Pain. 1993;20(4):719–42.
Bergeron S, Lord MJ. The integration of pelvi-perineal reeducation and cognitive-behavioral therapy in the multidisciplinary treatment of the sexual pain disorders. Br Assoc Sex Relationship Ther. 2003;18:135–41.CrossRef
King R, et al. Increasing orgasm and decreasing dyspareunia by a manual physical therapy technique. Medscape Gen Med. 2004;6(4):47.
Nygaard et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008;300(11):1312.
Schultz et al. Women’s sexual pain and its management. J Sex Med. 2005;2:302.