The Diagnosis and Treatment of Vaginismus KCNPNM Annual Conference April 2014 By Jean D. Koehler, Ph.D. And Susan Dunn, P.T. Koehler Disclosures • Proctor and Gamble – Consultant and interviewer for Stage 3 clinical trials on testosterone patch for women – 2003-2004 • Proctor and Gamble- Regional Consultant’s Board- 2004- 2005 • Ortho-McNeil- Pharmaceuticals- Advisory Board of Female Sexual Dysfunction expertsNovember 2004 • Boeringer Ingleheim- Speaker’s Bureau-2010 Vaginismus Definition Proposed by Rosemary Basson, M.D. The persistent or recurrent difficulties of the woman to allow vaginal entry of the penis, a finger, and/or any object despite the woman’s expressed desire to do so. There is often phobic avoidance, involuntary pelvic floor muscle contraction, and the anticipation/fear/experience of pain. Structural abnormalities must be ruled out/addressed. Basson et al, 2004 DSM V- 302.76 (Women’s) Genito-Pelvic Pain/Penetration Disorders • Marked vulvovaginal pain in penetration attempts (dyspareunia) • Marked anxiety about penetration or anticipated penetration • Marked tightening of pelvic floor muscles during attempted penetration (was called Vaginismus in prior manuals) Types of Vaginismus • Primary- never achieved attempted coitus • Secondary- onset after pain free coitus • Total- penetration not possible through the PC muscle • Partial- penetration achieved, but painful • Situational- only with some penetrants – with penis but not speculum or visa versa – with larger sized partner but not smaller sized – with gyn exam, but not with coitus Incidence of Sexual Pain Disorders US general population data- Michael et al, 1994 • Consistent coital pain in females-10-15% International general population data- Lewis et al, 2004 • Vaginismus- 6% • Coital pain- 2-20% The Cochrane Database of Systemic Reviews- McGuire and Hawton, 2002 Vaginismus in medical settings- 4-12% Vaginismus in sexual Dysfunction Clinics- 5-17% Women of childbearing age- est. .5-1% Graziottin, A. 2008 The BIO-PSYCHO-SOCIAL APPROACH TO VAGINISMUS DIAGNOSIS and TREATMENT Factors Impacting Changes in Female Sexual Function Variables from Mid Aged Woman’s Sexual Functioning Study Europe and Australia (Graziottin & Dennerstein in press,2005) Partner status Wellbeing Interpersonal Psychological Stress Sexual Function Throughout a Woman’s Lifespan Menopause Sociocultural c. J Alexander ‘05 Stress Parity Biological Exercise BMI Age Health Medical Conditions That May Lead to Vaginismus • PVD- provoked vestibulodynia- one of most common causes of dyspareunia in pre-menopausal women (Smith 2014) • Estrogen, testosterone deficiency – OC use before 16, and for up to 2-4 years (Davis 2013) – Vulvovaginal atrophy in menopausal women (Hope 2010) • Pelvic floor disorders • Vaginal infection- i.e. recurrent yeast, herpes, bacterial vaginosis, HPV? • Vulvar dermatoses, i.e. lichens sclerosis • Allergy to condoms, semen • Endometriosis • Radiation therapy • Injury from force –rape • Prior painful vaginal/urological medical interventions- especially in childhood/teen years- iatrogenic? • Female Genital Mutilation • Genetic abnormalities- i.e. septate hyman Psycho-social Conditions Correlating to Vaginismus- Research Results • Pre-existing General Anxiety Disorder1 • Personality features- fear of new experiences, catastrophizing thoughts about pain, disgust propensity, low self-esteem2, 3 • Specific fear of penile vaginal penetration • Less self stimulation • Increased prevalence of desire and arousal problems 2 2 2 • 1- Watts and Nettle, 2010 • 2- van Lankveld et al., 2010 • 3- Borg, C. et al. 2012 Possible Psychosocial CausesClinical Observations • Strict religious proscriptions against sexual interaction/especially coitus • Body Myths • Phobia to vaginal penetration, sometimes of any orifice • Sexual abuse or assault history• Poor or unsure relationship with sexual partner • Fear of unplanned pregnancy, delivery pain • Secretly unwanted pregnancy • Stuck developmentally as a “good little girl”, not wanting to grow up sexually and disappoint parents The New Treatment Team for Sexual Pain Disorders • Pelvic Pain MD/NP • Pelvic Floor Physical Therapist • Certified Sex Therapist/ Psychotherapist Case Example of the team approach Tara Role of the Gyn Provider • When the patient presents painful penetration as the reason for the office visit • When the providers notices an inability to perform a speculum exam Sexual History for Vaginismus • Is she in a sexually active relationship? • Is penetration possible? If so, is it painful? • Is it painful only at penetration? When else? • Describe the pain? Locations, intensity, sharp/dull, etc. • How anxious does she feel at the thought of penetration? • Can she insert a tampon or finger without pain? • How long has this been a problem? • Was the onset sudden or gradual? Is it present all the time? • Is pain experienced at times other than with intercourse? • Is she able to become aroused and climax at all with self or partner? • How anxious does she feel about the thought of a genital • examination? If so, what about it makes her anxious? • Has she ever had a traumatic sexual experience or history of physical/emotional/sexual abuse? • What does she believe is causing her penetration pain? – Koehler adapted from Crowley T,2009 & Kingsberg SA,2007 Preparing for the Initial Exam with a Primary Vaginismus Patient LISTEN-to your patient if she expresses fear and WATCH - for fearful body language –Let her decide who will be present –Let her decide the extent of the initial exam –Ask her if she can think of anything to facilitate the exam EXPLAIN THE EXAM –First show a film to all new pelvic exam patients if you can or –Describe each step in advance as you proceed –Offer sedation(Valium 5mg.) if needed –Let her know she can interrupt the exam at any time without being a failure REASSURE HER that you will let her have control of the exam – Pacing of insertion – Inserting speculum herself – Using a pediatric speculum – Starting with your finger only while the patient bears down – Or postponing internal exam pending completion of physical therapyor sex therapy EDUCATE HER • Give her a mirror to see her vulva • Explain her anatomy/correct misinformation • Clarify what structures are normal or abnormal • Ask her how she’s coping during the exam • If exam is normal, explain how her fear and pelvic floor hypertonus tricks her into believing she’s too small for penetration What if you still can’t examine her? • Have her practice the Rosenbaum Mindfulness Protocol • In case that doesn’t work, in the same visit: – Give her contact info of either a pelvic floor P.T. or – Sex therapist or – Both – Let her choose which approach appeals to her Rosenbaum Mindfulness Protocol • Uses mindfulness accompanied by systematic desensitization to reduce anxiety • Can be first practiced at home • Can be practiced in the provider’s exam room ahead of the examination or on a prior day • See handout for protocol • Rosenbaum and Padoa- 2012 • Rosenbaum- 2011 Further At-home steps when no sex therapist or pelvic floor physical therapist available • Once she has proceeded through these steps, she may continue to utilize the anxiety reduction techniques as they apply to self-touch of the genitals, self-touch of the vulvar vestibule and vaginal finger insertion. • She may further apply these techniques for gradual dilator use with the practitioner and with her partner. This progression includes self-insertion of the dilator, self-insertion with her partner holding dilator as well, her partner inserting the dilator with the client holding it as well, and finally, her partner inserting the dilator. The Role of the Gyn Provider in Secondary Vaginismus TREAT ANY CO-MORBID MEDICAL CONDITIONS IF POSSIBLE Case example of Secondary vaginismus originating with medical problems What Other Office-Based Treatments Can Medical Providers Try? Provider- led Modified Sensate Focus • Good for couples seeking infertility treatment – diagnosed with primary vaginismus – no sex therapist or pelvic floor physical therapist in the area – Results: • • • • Most resolved vaginismus Half became pregnant Nonpregnant evaluated for other sources of infertility See handout • Jindal and Jindal, 2010 Botulinum Toxin (Botox) • Botox for treatment resistant cases – No good controlled studies and adverse events need to be documented – But pre vs. post treatment show it’s effectiveness • Ferreira and Souza 2012 Meta-Analysis • Adverse events – two cases of mild stress incontinence – one case of excessive vaginal dryness of 82 patients in one study Pacik,P. Aesth Plast Surg (2011) 35:1160–1164 What predicts successful treatment? • Reducing penetration fears • Attributing the problem to psychological causes • Positive attitude toward one’s genitalia • Strong wish to become pregnant • Better sexual knowledge • Homework compliance • Pretreatment martial satisfaction van Lankveld et al., 2010 What predicts longer treatment? • • • • • Pretreatment sexual desire problems Fear of STI’s Negative parental attitudes towards sex Previous operations for vaginismus History of physical abnormality- like septum vaginitis • van Lankveld et al., 2010 What doesn’t predict treatment outcome? • Sexual abuse history– Higher rate among vaginismus patients, but sexual abuse history doesn’t predict future vaginisimus • Other sexual dysfunctions in either partner vanLankveld, Jacques et al. 2010 ; Pregnancy Considerations Sexual pain patients wishing to conceive should avoid these topical or intravaginal agents: • Gabapentin • Baclofen • Diazepam • Amitriptyline » Rosenbaum TY and Padoa. ACME Information: Managing Pregnancy and Delivery in Women with Sexual Pain Disorders. Review. J Sex. Med., Vol. 9, Issue 7, Article first published online: 3 JUL 2012 REFER HER IF NEEDED To a Pelvic Floor PT and/or Certified Sex Therapist – Before proceeding with the exam if she prefers – If she is unable to complete the exam – For treatment of nonmedical causes of her vaginismus – If there are mixed psychogenic and medical causes Vulvodynia • Defined by the International Society for the Study of Vulvovaginal Diseases (ISSVD) as vulval discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder. • Patients can be further categorized by anatomical region (i.e. generalized vuvlodynia, hemivulvodynia, clitorodynia) and also by whether the pain is provoked or unprovoked. Vulvar Vestibulitis Syndrome • A subset of vulvodynia, is the most frequent cause of dyspareunia in premenopausal women. (Mena et al, J Nerv Ment. Dis 1997: 185:561-69) • Prevalence 9.8 – 15% in general gynecologic practice • Diagnoses by severe pain to pressure or touch on the vulvar vestibule or introitus and vulvar erythema of varying degrees. • The ISSVD 2003 classification is under vulvodynia Dyspareunia Muscle Atrophy Interstitial Cystitis Constipation Abdominal pain Vaginal Stenosis Incontinence Pubic Symphysis Pain Pelvic Organ Prolapse Piriformis Syndrome Diastasis Recti Vestibulodynia Vulvar Vestibulitis Vaginismus/anismus Levator ani syndrome Pudendal Neuralgia Iliopsoas Syndrome Episiotomy pain Coccydynia Obturator Internus Syndrome Post Operative pain Sciatica Role of the Physical Therapist • Team approach with other health care providers. • Physical Therapist focuses on neuromuscular/orthopedic/myofascial contribution to symptoms What to Expect Many patients perceive physical therapy for these diagnoses to be different than physical therapy for other orthopedic/spine rehabilitation. Same therapy…….different body part Patient should expect a complete musculoskeletal evaluation of the symptomatic area. Patient Profile • • • • • Teen through adult life span Male and female Sedentary and high end athlete Varying socio-economic Various cultural backgrounds Questionnaire will include: Pain with activity Bowel movements/Urination Sitting vs. standing vs. supine vs. prone Intercourse pain (with superficial and/or deep penetration/orgasm/positional dependent) Urologic changes with intercourse/orgasm Patient should fill out questionnaire that addresses sexual history i.e. abuse/pregnancies/pathology/psychiatric Address Structure and Biomechanics Mobilize/Stabilize Thoracic spine, Lumbar spine and SI Joints LLD, Postural abnormalities Muscle imbalance Address Connective Tissue Restrictions and MTrPs Connective Tissue Mobilization, Dry Needling Surrounding the bony pelvis Anterior, medial, lateral and posterior thighs Abdomen, low back, buttocks Nerve Mobilization Seating Adaptations/Work Modifications • Nerve Roots: S2, S3, S4 • 50% sensory, 20% motor and 30% autonomic Iliopsoas Pelvic Floor Muscles Abdominal Wall Superficial Layers • Traction – Constipation, Childbirth, strenuous squatting • Compression – Cycling, Horseback riding, prolonged sitting • Surgical – Hysterectomies, corrective sx for prolapse – Common etiology for nerve entrapment • Visceral-Somatic Interaction – Chronic bladder infections, yeast infections, bacterial prostatitis • Childbirth, Constipation, Strenuous Squatting • “Cyclist’s Syndrome” • Hysterectomy, Correction of prolapse, Orthopedic Surgeries • • • • • Gynecological surgeries requiring lithotomy position Jackknife position Risk of muscle damage/scarring/adhesions with surgeries Total Hip arthroplasty – muscle stays intact but may be damaged when the femur is elevated and exposed Ito et al – “…short ER’s, especially conjoined tendon, are at high risk of being damaged and their detachment might be inevitable during the superior and/or posterior capsular release that is necessary to mobilize the femur during DAA in certain cases” • Chronic bladder infections, yeast infections, bacterial prostatitis Modalities for Pelvic Pain • Biofeedback/Pressure perionometry/surface electromyography • Ultrasound • Vaginal Dilators • Electrical Stimulation • Weight Training for the pelvic floor Perineal Ultrasound Decrease soft tissue tension Increase blood flow Decrease hypertrophy/scar tissue Not appropriate for all patient types and contra-indicated for some diagnoses. Vaginal Dilators • Protocol varies depending on diagnosis • Common diagnoses that are appropriate for vaginal dilators: Dyspareunia, constipation, vaginal stenosis, muscle hypertonicity Therapeutic exercise How to find and utilize a pelvic pain Physical Therapist • • • • State organizations (KPTA) National Organizations (APTA) National Pelvic Pain Organizations Talk to local P.T.’s and they can normally refer you to the appropriate office. FYI…………………… • Insurance – these diagnoses are usually covered. Case Examples of patients successfully treated with only pelvic floor PT SEX THERAPISTS PROVIDE • Thorough psycho-social evaluation • Individual therapy for anxiety and depression • Relationship therapy or involving partner in supporting her treatment • Insight therapy for negative/shameful sexual attitudes • Education on sexual anatomy and function to reduce penetration fears • Sexual Abuse/Trauma treatment • Cognitive therapy, insight therapy, hypnosis, EMDR, educational videos, bibliotherapy, exposure therapy ter Kuile 2013 • At-home patient-led dilator therapy (No touching or live sexual demonstrations are ever done in the sex therapist’s office!) Case Example of Vaginismus Patients successfully treated with sex therapy alone Shawna Preparing the patient to return to gyn provider • Cognitive therapy to decatastrophize • Positive imaging • Giving her control of the exam by educating her gyn • Using an anxiolytic ahead if wanted • Giving her permission not to complete the exam the first time back • Preparing her for vaginal delivery Who Are Sex Therapists and How Do I Find One? • licensed psychotherapists from any psychotherapy discipline with additional training in sexual health and illness • Certification or Diplomate by AASECT – – CST or DST after their names • (The American Association of Sexuality Educators, Counselors and Therapists) • Licensure in FL • www.aasect.org- find a therapist by state Treatment Success Rates 75%-100% Rate Independent Study Cited 100% @100% 98-100% 97.7% 95% 91.42% 87% 75-100% Biswas & Ratnam, 1995 Butcher, 1999 Masters & Johnson, 1970 Schnyder, Schnyder-Luthi,et. al., 1998 Katz & Tabisel, 2002 Nasab & Faroosh, 2003 Scholl, 1988 Studies cited in Heiman, 2002 - www.vaginismus.com Resources for Becoming an Effective Female Sexual Medicine Provider Establish a team of related FSD providers – Pelvic Floor Physical Therapist: www.apta.org – Certified Sex Therapist-www.aasect.org – Sexual Medicine Specialist• AASECT certified sexuality counselors in medical field • Training from ISSWSH – Urologists, Internists, and Endocrinologists who are interested in sexual medicine References Books for Providers • Textbook of Sexual Medicine William Maurice, M.D. • Sexual Pharmacology- Fast Facts R.T. Segraves, M.D. • Sex In America: A Definitive Survey Michael et al • The Journal of Sexual Medicine www.blackwellpublishing.com/jsm Vaginal Dilators Syracuse Medical Devices (315) 637-9275 Individually sold and inexpensive Provider Education in Female Sexual Medicine and Psychology 1- “Women’s Sexual Health Course for N.P.’s” June 27-29, 2014- Dallas Sponsored by The International Society for the Study of Women’s Sexual Medicine www.isswsh.org 2-ISSWSH annual meetings, membership and list serve 3-The American Association of Sexuality Educators, Counselors, and Therapists annual meetings and trainingswww.aasect.org Resources for Patients Private Pain- It’s about life not just sex by Ditza Katz and Ross Lynn Tabisel -2005 www.vaginismus.com–self-help books, online forums, and other resources Internet Chat rooms – Google “Vaginismus support groups” [email protected] 502-897-2717 Dunn Physical Therapy, PLLC Louisville, Kentucky 502-899-9363 [email protected] Sources Barral, Jean-Pierre, Manual Therapy for the Prostate, North Atlantic Books, Ca, 2005. 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