In 2012, The Journal of Sexual Medicine published an article, What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetrician/gynecologists. The results from the survey revealed that though Ob/gyns routinely (63%) assess their patients’ sexual activities, only 40% of them ask their female patients about sexual problems. Sexual problems may include low desire, difficulty lubricating, pain during intercourse, lack of pleasure or inability to orgasm. Ob/gyn respondents to this survey also reported that they inquired even less frequently about sexual satisfaction, sexual orientation/identity or pleasure with sexual activity.3 Fast forward six years, I would not hesitate to say that these numbers have improved as we at PHRC regularly receive pelvic floor physical therapy referrals from Ob/gyns for sexual dysfunction. Interestingly, the patients that are referred to us from Ob/gyns and other speciality physicians and providers cover across the lifespan – young adults, postpartum, perimenopausal, etc. These women express similar complaints, namely painful intercourse.
Painful intercourse aka dyspareunia is probably one of the most common diagnoses that my colleagues and I treat at PHRC. Oftentimes we find that the pelvic floor muscles of our female patients with dyspareunia are hypertonic and/or filled with myofascial trigger points. Read Shannon’s blog for more specifics on Your Pelvic Floor: What Is It Good For? Manual therapy combined with other physical therapy treatment techniques can successfully address these myofascial findings. Sometimes this is enough to resolve pain during intercourse. Sometimes it is not. Just as frequently as we see tight muscles or knots contributing to a patient’s pain symptoms, we also sometimes discover hormonal and psychological components – meaning the treatment is multifactorial. What does this mean exactly? A brief spiel on hormones: all the vulvovaginal tissues (the clitoris, vestibule, vaginal walls, etc.) are estrogen and testosterone dependent. Disrupting the available hormones to these tissues can create fragility that is aggravated with friction or intercourse. Check out our blogs on how these hormones may be impacted by oral birth control pills, postpartum, or perimenopasual. If a patient presents with vulvovaginal atrophy, using topical hormones can help restore the integrity of these tissues.
And what about the psychological component? Pain is a mind-body experience meaning there are both physical and psychological factors. When I say psychological it does not mean that the pain is in your head. This is never the case. Pain during intercourse can create and reinforce this negative psycho-emotional feedback loop. If the women pushes through the pain, the brain can start to associate sex with pain and even just fear or anticipation can increase the pain response. Pavlov. These psycho-emotional components can not be physically manipulated. This is where sex therapy comes in. Sex therapists are licensed providers that have at least a master’s degree in counseling or therapy related field with additional specific sex therapy training. They know their stuff and have become one of my most relied upon referrals for my patients with dyspareunia. They help address some of those aforementioned parts of sexuality that are sometimes missed by other medical providers (i.e. low desire, sexual satisfaction, pleasure, etc.). And those of my patients that have fallen into this pain loop have benefited immensely from working with a sex therapist. Sex therapists can collaborate with patients to help break this pain cycle.
However, their skills and expertise go much beyond this; I have found that some patients have had difficulty transitioning their successes with physical therapy to the sexual relationship. What do I mean by this? At reassessment, their pelvic floor muscle are normal and they can insert their largest dilator on their own comfortably, but when they attempt intercourse they are either still experiencing some discomfort or not experiencing much pleasure. In these cases, sex therapists can work with their patients and partners on restoring the pleasure piece. Including a significant other in the treatment process also makes it it less about fixing her sexual problem and more about developing a healthy partnership and sex life.
Now let’s delve a little into the research which focuses on cognitive behavioral therapy (CBT), which can be delivered by a sex therapist, as a way of reducing fear of pain and reestablishing satisfying sexual functioning. Cognitive behavioral therapy can help bridge the gap between physical therapy and pain reduction in the sexual situation. Modalities may include education and information about how dyspareunia affects desire and arousal; education concerning a multifactorial view of pain; education about sexual anatomy; progressive muscle relaxation; diaphragmatic breathing; vaginal dilation; distraction techniques focusing on sexual imagery; rehearsal of coping self-statements; communication skills training; and cognitive restructuring.4
In a relatively recent randomized clinical trial, researchers assessed how group cognitive behavioral therapy vs. a topical steroid impacted dimensions of dyspareunia in patients with vestibulodynia (pain in the vestibule, a common co-diagnosis). The intervention consisted of either 13 weeks of group CBT that included 10, two-hour group sessions with prescribed home exercises or twice daily application of 1% hydrocortisone cream for 13 weeks. Results revealed that though both groups showed statistically significant reductions in pain during intercourse and improvements in sexual function immediately following interventions and at six-month follow up, the group CBT group showed significantly more pain reduction (via McGill Pain Questionnaire) and improvements in sexual function (via Female Sexual Function Index) at six-month follow up. Similarly, though both groups showed statistically significant reductions in psychological adjustment (via Pain Catastrophizing Scale) the group CBT group had significantly greater reductions in pain catastrophizing post treatment. Additionally, those that received group CBT reported higher treatment satisfaction and self-reported improvements in pain and sexuality.1
Brotto and colleagues took these findings a little bit further in 2015 by researching the impact of a multidisciplinary approach on dyspareunia and sexual functioning in women with provoked vulvodynia (pain in the vulva, another common co-diagnosis). In their study, 116 women were enrolled in a 10-week hospital-based program that integrated psychological skills training, pelvic floor physical therapy and medical management. Participants attended the following courses: an introductory one-hour gynecologist group education seminar discussing the pathophysiology of provoked vestibulodynia and the medical, behavioral and surgical treatment; a one-hour gynecologist or psychologist led educational seminar reviewing the circular sexual response cycle and impact of genitalia pain on sexual desire, arousal and satisfaction; three two-hour counselor or psychologist led sessions that utilized the fear-avoidance model and CBT to illustrate the link between problematic thoughts, feelings, behaviors and pain. The women also attended three individual one-hour pelvic floor physical therapy sessions that focused primarily on providing education about the role of the pelvic floor muscles and their relationship in maintaining pain with provoked vestibulodynia; biofeedback with surface electromyography; pelvic floor muscle relaxation; and use of vaginal dilators. Manual therapy was not performed due to limited treatment time (though I anticipate this would have further strengthened the intervention). Lastly, participants had a final discharge appointment with a gynecologist to discuss their progress during the program, how to use the information and skills acquired during the program once discharged from the program and recommendations for ongoing professional management. Following this protocol, the authors observed strong significant reductions in dyspareunia and sex-related distress as well as improvements in sexual arousal and overall sexual functioning. Modest significant improvements were also observed in sexual desire, lubrication, orgasmic function and sexual satisfaction. All findings were maintained at two to three month follow up.2
Though both of these studies took a group CBT approach and neither specifically included the women’s partners in their interventions, I would 100% of the time recommend sex therapy for patients that have fallen into the pain cycle. The evidence in these studies suggest great benefits and the anecdotal evidence I have seen in the clinic is overwhelming. You can locate a sex therapist in your area here: https://www.aasect.org/referral-directory and many also offer video appointments.
References:
- Bergeron et al. A randomized clinical trial comparing cognitive-behavioral therapy and a topical steroid for women with dyspareunia. Journal of Consulting and Clinical Psychology. 2016; 84(3);259-268.
- Brotto LA et al. Impact of a multidisciplinary Vulvodynia program on sexual functioning and dyspareunia. J Sex Med. 2015;12:238-47.
- Sobecki JN et al. What we don’t talk about when we don’t talk about sex: results of a national survey of U.S. obstetrician/gynecologists. J Sex Med. 2012 May; 9(5):1285-94.
- Ter Kuile MM et al. Cognitive behavioral therapy for sexual dysfunctions in women. Psychiatry Clinic N Am. 2010; 33: 595-610.
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.