Physical Therapy: Sexual Pain

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Physical Therapy Sexual Pain Sexual Health

• PASSAGES PHYSICAL THERAPY
• Pat Salin Huston, MSPT

www.passagespt.com
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The Floor of Your Core

• The pelvic floor support team functions together
  with your abdominal, spinal and diaphragm
  muscles.
• These muscles can have all of the problems which
  other muscles in the body exhibit. All muscles
  can be influenced by adjoining structures, and
  respond to pain, pressure, and stretch.
• Pelvic floor muscles can have injury, weakness,
  spasm and restriction in any combination. This
  can result in a variety of symptoms, including
  sexual pain.

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Life Events Can Influence Pelvic Pain, Pelvic
Floor Response and Sexual Function

• Abdominal Surgery including Hysterectomy
• Abuse
• Breast Cancer , Lymphedema
• Hormone changes/Menopause
• Orthopedic Injuries, Osteoporosis
• Endometriosis, Dyspareunia, Vulvodynia, Vulvar
  Vestibulitis
• Pregnancy and Childbirth C-Section
• Urinary Stress and Urge Incontinence

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The pelvic floor consists of several layers
of muscle and fascia. For
practical and exercise purposes the muscles can
be thought of containing both a superficial
(surface or exterior) and deep (inside or
interior) layers.
Surface Muscles
Deep Inside Muscles

A normal contraction of the pelvic floor can be
felt both in the surface layer (urogenital and
anal sphincter muscles) and deeper inside layer
(levator ani muscles) during a contraction.

It can voluntarily contract, relax and even bulge
or expand to deliver a
child or have a bowel movement.

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Dr. Arnold Kegel, 1948

• For the past fifteen years I have
  experimented with various means of exercising the
  perineal muscles. Any active exercise must be
  directed primarily toward drawing in the
  perineum.
• Only the exceptional woman, however, will
  continue the exercise long enough to produce
  results on mere instruction to do this.

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Dr. Kegel 1948

• Many women, in addition, have no awareness
  of function and, unless provided with some way
  of knowing whether or not they are being
  successful, soon become discouraged or are
  unwilling to make even an initial attempt at
  exercise.
• Am. J. Obst. Gynec. Aug 1948 Progressive
  Resistance Exercise in the Functional Restoration
  of the Perineal Muscles. Dr. Arnold H. Kegel, MD
  FACS

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Physical Therapy Initial Evaluation

• History
• Possible muscle dysfunction?
• Clients may have a combination of symptoms
• Pelvic pain, with/without sitting,
  difficulty with pelvic exams urinary frequency,
  constipation, dyspareunia, bowel/bladder
  incontinence, history of trauma including
  tailbone injury/fall. Some have discomfort from
  first tampon use/sexual penetration.

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Initial Evaluation

• Content of initial exam is determined by the
  chief complaint, urgency of symptoms, and patient
  receptiveness for evaluation techniques.
• Further assessment often continues into
  follow-up visits.
• Goal is to investigate the relationships
• between a variety of muscle groups,
  alignment, and soft tissue.

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Initial Evaluation Examination

• Thorough anatomy instruction using pelvic model
  and diagrams. Active Kegel exercises are
  instructed and may complete the 1st visit
• External/Internal muscle exam
• Surface EMG assessment may use external
  electrodes (like EKG) or internal sensor
• Palpation of abdominal, hip and spine musculature
  to assess possible tender/trigger points
• Postural Exam in standing, sitting, supine to
  assess alignment, poor posture habits,
  involvement of lumbar spine and asymmetries of SI
  joints/pubic symphysis

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Pelvic Floor Muscle Visual/External Exam

• Skin and perineal observation
• Palpation of external pelvic clock
• Palpation at vaginal introitus
• Vestibular irritability (Q-Tip Test)

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Manual Exam/ MMT

• Assess tone and sensation of vaginal
  walls/muscles
• Grade pelvic floor muscle strength 1-5 for
  lift, symmetry, endurance
• Assess levator ani and obturator internus for
  trigger points/spasm
• Note myofascial restrictions, tightness of
  introitus

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EMG Evaluation

• Gives baseline measurement of muscle function
• Allows viewing of muscle contraction, relaxation,
  endurance and evidence of spasm
• Increases sensory awareness for muscle isolation
• Patients gain confidence
• Shows muscle improvement in comparable measures,
  often before symptom changes

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EMG Reveals Muscle Tension Averages of 10 Sec.
Hold/Rest (Dyspareunia)
Pelvic floor EMG using vaginal sensor patient
with dyspareunia 6/20/2006 Pain 6/10 Average
resting tension w/exercise 9.43 mV (Goal lt2-3)

Initial Baseline Quick Contract/Relax Reps
of 10 sec Contract/10 sec Relax
Post-ex 8/17/2006 Pain 1/10 Average resting
tension w/exercise 5.60 mV
Prolonged Reps with 10 sec Contract/10 sec Relax
(More consistent relax)
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Client Feedback

• Several times, I had read descriptions of the
  Kegel exercises and had attempted them, but I was
  never sure I was doing them correctly.
  Consequently I never continued for more than a
  few days.
• When I used the sensor and actually saw those
  twinges register on a computer screen, I felt
  like a bad novelist who wanted to shout, Eureka,
  I found it. Thats IT. Actually seeing the
  graphs changed my attitude about the possible
  effectiveness of the exercises.

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Pelvic Floor Dysfunctions

• Dr. Kegel applied his treatment strategies to a
  variety of symptom complaints
• Primary focus initially urinary incontinence
• Dr. Kegel noted sexually oriented problems of
  painful intercourse and orgasm responses
  sometimes improved with exercise
• His research concluded muscle imbalances and scar
  healing influenced sexual dysfunction
• More recently, muscle rehab found to have benefit
  for constipation/ bowel control

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More than Biofeedback!

• EMG alone reaches only basic weakness
• Doesnt address soft tissue/scar restrictions or
  severe muscle spasm/imbalances
• Only partially addresses needs for urge and
  frequency symptoms
• Updated approach is to include synergistic
  muscles for core stabilization, including the
  pelvic brace exercises

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New Kegels with Abs Pelvic Brace

• Core team includes
• Pelvic Floor Muscles
• Transverse Abdominals
• Multifidus
• Diaphragm!
• OK to feel lower abdominals co-contract!
• They are synergistic and necessary for higher
  intensity pelvic floor contraction.
• Support combination of Kegels plus abs Pelvic
  Brace
• Core training includes lifting pelvic floor while
  pulling in abs and keeping spine neutral

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Muscle Rehab Needs Variety

• Match strategies similar to other muscles
• Warm up/ basic active motions
• Include higher intensity workout phase
• Variety for interest!
• Core stabilization
• Train to contract with exhale, in different
  positions
• Maintain neutral spine while contracting pelvic
  floor plus transverse abdominals
• Elevator and mid-range target practice
• Functional dynamic training with sit to stand,
  squat, lunge, lift

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Treatment Programs
Treatments for pelvic muscle disorders,
including sexual
dysfunctions,
are similar to other
musculo-skeletal interventions

• Scar/ myofascial mobilization (MFR)/ trigger
  point pressure release, strain-counterstrain of
  tender points
• Therapeutic ultrasound for deep heat/scar
  softening heat and cold modalities
• Electrical stimulation for decreasing pain,
  spasm, and for some urinary urgency
• TENS for pain modulation, including dysmenorrhea
• Therapeutic exercises for stretches,
  strengthening
• Postural instruction

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Physical Therapy

• PT is one component of sexual pain management
• Several medical specialists may be needed,
  depending on symptoms and progress
• Pharmaceutical may help, though many women are
  hypersensitive with allergic responses
• Topical
• Oral
• Injection- Botox?
• Mental health providers
• Coordination of services can improve outcomes

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Physical Therapy Referral

• Medical referral by MD, DO, NP
• May require insurance pre-authorization helpful
  to preauthorize for 4-6 visits
• Best to use diagnosis related to musculo-skeletal
  or neurological (pelvis pain, pelvic floor muscle
  dysfunction, pelvic relaxation, muscle spasm,
  adhesions, weakness)
• PAIN diagnoses NOT covered by some insurances
• General or specific instructions (Evaluate and
  treat pelvic floor rehab, modalities PRN, EMG
  testing and training, soft tissue/scar
  mobilization)
• EMG more accurate and preferred term to
  biofeedback

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Summary

• Physical Therapy can provide a variety of
  treatment strategies to meet individual needs
• Clients may benefit from education programs to
  increase knowledge of mechanics and to avoid
  functional losses
• Rehabilitation may include pelvic floor muscle
  treatments, abdominal strengthening, scar soft
  tissue mobilization, stretches, heat/cold
  electrical modalities, and postural activities