Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program

Pelvic floor muscle activity during fast voluntary contractions in continent and incontinent women

AIMS

Stress urinary incontinence (SUI) has also been attributed to a lower speed of contraction of the pelvic floor muscles (PFM). Therefore, PFM assessment and training implement fast voluntary contractions (FVC). The purpose of the study was to explore FVC regarding feasibility, on-/offset and rate of activity determination, as well as differences between continent (CON) and stress urinary incontinent (SUI) women.

METHODS

Fifty women were included and examined by means of PFM EMG during rest, maximum voluntary contractions (MVC), and five FVC. MVC-peak activity was used to normalize EMG-data. On-/offset of muscle activity was determined as mean of rectified rest activity plus 1 standard deviation. Linear regression was calculated for rate of activity from onset to peak, peak to offset, and within 200 ms after both onset and peak. Peak activity and time variables related to onset, peak, and offset were calculated.

RESULTS

On-/offsets were evaluable for 234/222 of 250 FVC by a computer-based algorithm, 16/28 on-/offsets had to be determined manually. There was no significant difference between groups (CON/SUI) regarding FVC peak (92.1/99.3 %MVC), time to peak (514.2/525.6 ms), and increase of activity (182.8/182.1 %MVC/s). The SUI group showed a significantly slower activity decrease (-120.7/-74.4 %MVC/s).

CONCLUSIONS

FVC analyses were shown to be feasible. The significant difference observed between the groups did not refer to activity increase but instead to a prolonged relaxation phase in the SUI group. This prompts to reconsider the interpretation of FVC in PFM testing and training.

Morphometry of the nulliparous pelvic floor

OBJECTIVES

To describe morphometry of the pelvic floor in a large population of nulliparous women, comparing those with and those without pelvic pain. We also aimed to assess its association with characteristics such as age and body mass index (BMI).

METHODS

This was a prospective study performed between January 2013 and November 2015 in non-pregnant nulliparous women attending a general gynecology clinic. Following collection of demographic data, women were examined using translabial four-dimensional (4D) ultrasound. Dynamic volumes of pelvic floor muscle were obtained at rest, on maximal contraction and on Valsalva maneuver, and analyzed at a later date by an assessor blinded to demographic details. Standard measurements for each volume included levator hiatal area and anteroposterior and transverse diameters, and pubovisceral muscle length and width. Subanalysis was performed comparing women with and those without pelvic pain. Linear regression analysis was performed to assess the association between characteristics, including age and BMI, and levator hiatal area at rest.

RESULTS

Three hundred and sixty eight nulliparous women were examined using translabial 4D ultrasound. Median levator hiatal area was 10.62 cm² at rest, 11.95 cm² on Valsalva maneuver and 8.18 cm² on maximal contraction. There was no difference between women with and those without pelvic pain when comparing biometric measurements of the pelvic floor musculature, except for in pubovisceral muscle width during the contraction phase. Regression analysis demonstrated that higher age and BMI were associated with increased levator hiatal area measurement.

CONCLUSIONS

Pelvic floor morphometry in nulliparous women is unchanged by pelvic pain, but levator hiatal area is increased in women with higher BMI and age. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Vaginal diazepam plus transcutaneous electrical nerve stimulation to treat vestibulodynia: A randomized controlled trial

OBJECTIVE

To assess the effectiveness of vaginal diazepam in addition to transcutaneous electrical nerve stimulation (TENS) in the treatment of vestibulodynia (VBD).

STUDY DESIGN

This study was a randomized, double-blind, placebo-controlled trial. Forty-two patients with VBD were randomized, 21 underwent diazepam and TENS (diazepam group) and 21 received placebo and TENS (placebo group). Vulvar pain was assessed on a on a 10-cm visual analogue scale (VAS) and dyspareunia according to the Marinoff dyspareunia scale. Vaginal surface electromyography (EMG) and vestibular current perception threshold (CPT) testing were performed at baseline and 60 days after treatment. The primary endpoints included the change in pain and dyspareunia from baseline to 60 days of pain and dyspareunia. The secondary endpoints was the variation in objectivity of pelvic floor muscle (PFM) function and vestibular nerve fiber current perception threshold (CPT).

RESULTS

The VAS scores for pain from basal values of 7.5 and 7.2 for the diazepam and placebo, respectively, showed significant (p 0.01) decreases from 4.7 to 4.3, but this difference was not statistically significant. The Marinoff dyspareunia scores in the diazepam group showed a significant difference (p 0.05) from values measured in the placebo group. The ability to relax the PFM after contraction (difference between maximal contraction and rest tone) was significantly greater for the diazepam group versus the placebo group (3.8 μv and 2.4 μv, respectively, p 0.01). The CPT values for all of the nerve fibers increased after the treatment, but this increase was significant in the diazepam group only for the values at a 5-Hz stimulation (C fibers) with a change of 47.8% vs 26.9% (p < 0.05). Only two patients reported a mild drowsiness in the diazepam group.

CONCLUSIONS

The present study provided indications that vaginal diazepam plus TENS is useful to improve pain and PFM instability in women with VBD.

Differentiating overlapping symptoms of vulvodynia and pudendal neuralgia

Context

Vulvodynia is defined as a chronic vulvar pain non-associated with infectious, inflammatory, neoplastic or hormonal disorders.

Objectives

To present a case demonstrating the difficulty in assessing concomitant disease in vulvodynia.

Methods

A 26-year-old woman, presented with persistent vulvodynia. She received oral and topical medications and behavioural interventions to lessen sexual pain and restore sexuality. As sexual pain decreased, the patient reported symptoms previously not mentioned: continuous, intense periclitoral pain and numbness at the perineum when sitting for a long time. These new symptoms suggest the involvement of the peripheral neural system. The physical evaluation confirmed right-side pelvic distortion, and pathological increase in lumbar lordosis, which caused neuralgia radiating to the external genitalia and perineum, and overlapping with sexual pain. After diagnosing pudendal neuralgia according to the Nantes criteria, physical treatment and relaxation exercises to de-contract the spine were added to the vulvodynia regimen.

Results

During treatment, vulvodynia was sometimes present but never unbearable, allowing satisfactory sex. With physical therapy, the symptoms of pudendal neuralgia decreased.

Conclusion

Differentiating the presence of two conditions with overlapping symptoms is difficult because the vestibular pain had shadowed pudendal neuralgia symptoms at initial assessment. Syndromes of chronic pain tend to associate with each other and one syndrome may shadow symptoms of the concomitant condition affecting adjacent anatomical areas. Only the accurate identification of all the syndromes involved allows adopting the correct treatment.

An automated intravaginal dynamometer: Reliability metrics and the impact of testing protocol on active and passive forces measured from the pelvic floor muscles

AIMS

(1) To determine the reliability of an automated dynamometer designed to assess pelvic floor muscle (PFM) strength and resistance to passive elongation. (2) To evaluate the impact of PFM length and rate of tissue elongation on dynamometric outcomes.

METHODS

At each of two sessions, twenty nulliparous women performed three maximum voluntary contractions (MVC) of their PFMs with the dynamometer set to two different anteroposterior (AP) diameters (25 mm, 35 mm). Next, with PFMs relaxed, the arms of the dynamometer opened three times to 40 mm at two speeds (25 mm/s, 50 mm/s). Outcomes included baseline force, peak force, relative peak force, rate of force development (RFD), stiffness and stress relaxation. Repeated-measures ANOVAs were used to test trial, day, and task effects (α = 0.05), and intra-class correlation coefficients (ICCs) were computed.

RESULTS

Forces measured on MVC were higher with the larger AP diameter, and passive resistance was higher for the faster rate of tissue elongation. The between-trial reliability of all outcomes was excellent (0.82 < ICC < 0.98) for all measures except for peak force during the passive elongation task (0.56 < ICC < 0.93). Between-day reliability was good to excellent for active and passive RFD (0.75 < ICC < 0.93), stiffness (ICC = 0.77) and relative peak force (0.71 < ICC < 0.87); absolute force (0.11 < ICC < 0.85) and stress relaxation responses (0.19 < ICC < 0.98) tended to be less reliable.

CONCLUSIONS

The reliability of the dynamometer is adequate for both clinical and research applications. Relative forces were more reliable than absolute forces. Dimensions and rate of tissue elongation should be controlled and reported with all pelvic floor muscle assessments as these parameters impact outcomes.

Association between lumbopelvic pain and pelvic floor dysfunction in women: A cross sectional study

BACKGROUND

The prevalence, cost and disability associated with lumbopelvic pain continues to rise despite the range of available therapeutic interventions, indicating a deficiency in current approaches. A literature base highlighting a correlation between lumbopelvic pain and pelvic floor function is developing; however, the features that characterize this correlation have yet to be fully established.

PURPOSE

The purpose of this study was to determine the prevalence and characteristics of pelvic floor muscle function among women with lumbopelvic pain.

METHODS

A cross-sectional study was conducted on non-pregnant women presenting with lumbopelvic pain to one of seven outpatient orthopaedic clinics in Canada. Potential participants underwent a screening process to assess for pelvic floor muscle dysfunction.

RESULTS

A total of 182 women were recruited and 97 were excluded, leaving 85 participants (n = 85). Of these, 95.3% were determined to have some form of pelvic floor dysfunction. Specifically, 71% of the participants had pelvic floor muscle tenderness, 66% had pelvic floor weakness and 41% were found to have a pelvic organ prolapse. Participants with combined low back pain and pelvic girdle pain presented with higher levels of disability and increased characteristics of pelvic floor dysfunction.

CONCLUSIONS

Our findings corroborate and extend recent research supporting the hypothesis that a high proportion of pelvic floor muscle dysfunction is present among women with lumbopelvic pain. Specifically, increased pelvic floor muscle pressure-pain sensitivity represented the most frequent characteristic, the clinical implications of which require further study.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource

Introduction and hypothesis

Chronic pelvic pain (CPP) in women is a complex syndrome. Pain sensation and intensity often do not correspond with the identified lesion location but are felt elsewhere, leading to muskuloskeletal and myofascial disorders and sexual dysfunction (SD). Although physical aspects are prevalent, they are often underdiagnosed and undertreated due to lack of understanding regarding its origin and distribution. Frequently, patients experience pelvic pain as psychological distress resulting in physical complaints, leading clinicians to prescribe medication or surgical intervention to correct or alleviate these symptoms, often with insufficient results. Because pelvic floor muscle disorders contribute significantly to CPP and SD, there is rationale for physiotherapy. However, physiotherapy is a widely underused and untapped resource, which has its place in the multidisciplinary approach to these health problems.

Methods

Computer-aided and manual searches and methodological quality assessment were carried out for meta-analyses, systematic reviews, and randomized controlled trials (RCTs) published between 1990 and 2017 investigating classification, assessment, and (physiotherapeutic) treatment of pelvic pain and/or female SD defined by the keywords below. Expert opinions were sought via interviews.

Results

Due to a lack of sufficient relevant medical information, referral data, and test results, focused physiotherapy is difficult to administer adequately. However, recent quality studies indicate significant clinical effects of physiotherapy for CPP and female SD, and experts advocate a multidisciplinary approach that includes physiotherapy.

Conclusions

Because of its holistic approach, physiotherapy can contribute significantly to the multidisciplinary assessment and treatment of CPP and female SD.

Provoked vestibulodynia: current perspectives

Provoked vestibulodynia (PVD) refers to vulvar pain of at least 3 months duration, localized to the vestibule, provoked by touch and sexual activity and occurring in the absence of a clear identifiable cause. The clinical spectrum ranges from mild with distressing discomfort through to severe and disabling pain. Current understanding is that PVD is one of many chronic pain conditions characterized by sensitization of peripheral and central nociceptive pathways, with pain arising due to dysfunctional neuronal activity in the absence of painful stimuli. Pathophysiology is not well understood but is likely a complex interplay of environmental, genetic, psychological and immune factors. Care is multidisciplinary and follows general principles of chronic pain management with the addition of specific therapy tailored to address pelvic floor overactivity, and sexual and relationship difficulties. More recently, the therapeutic use of placebo is gaining traction in chronic pain research and is a very promising adjunctive therapy. The majority of women with PVD are managed outside of tertiary clinic settings, and care depends on availability and affordability of specialized services; however, much can be done by the primary health provider. PVD is common, and highly treatable, especially with early intervention, but unfortunately, many clinicians are unaware of this condition, and the biggest hurdle for women accessing treatment is obtaining a diagnosis. With treatment, most women can expect significant improvement, often with fairly simple interventions, although some women will benefit from referral to specialized centers. The aims of this article are twofold: firstly, to summarize current literature concerning PVD pathophysiology and management; secondly, to provide a framework for clinicians unfamiliar with vulvar medicine to understand and manage PVD.

Pelvic Floor Muscle Training With and Without Electrical Stimulation in the Treatment of Lower Urinary Tract Symptoms in Women With Multiple Sclerosis

PURPOSE

The aim of this study was to evaluate the effect of intravaginal neuromuscular electrical stimulation (NMES) and transcutaneous tibial nerve stimulation (TTNS) on lower urinary tract symptoms (LUTS) and health-related quality of life in women undergoing pelvic floor muscle (PFM) training (PFMT) with multiple sclerosis (MS) and to compare the efficacy of these 2 approaches.

DESIGN

Randomized controlled trial.

METHODS

Thirty women with MS and LUTS were randomly allocated to 1 of 3 groups and received treatment for 12 weeks. Ten women in group 1 received PFMT with electromyographic (EMG) biofeedback and sham NMES. Ten women in group 2 underwent PFMT with EMG biofeedback and intravaginal NMES, and 10 subjects in group 3 received PFMT with EMG biofeedback and TTNS. Multiple assessments, performed before and after treatment, included a 24-hour pad test, 3-day bladder diary, assessment of PFM function (strength and muscle tone), urodynamic studies, and validated questionnaires including Overactive Bladder Questionnaire (OAB-V8), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and Qualiveen instrument.

RESULTS

All groups showed reductions in pad weight, frequency of urgency and urge urinary incontinence episodes, improvement in all domains of the PFM assessment, and lower scores on the OAB-V8 and ICIQ-SF questionnaires following treatment. Subjects in group 2 achieved significantly greater improvement in PFM tone, flexibility, ability to relax PFMs, and OAB-V8 scores when compared to subjects in groups 1 and 3.

CONCLUSION

Results suggest that PFMT alone or in combination with intravaginal NMES or TTNS is effective in the treatment of LUTS in patients with MS. The combination of PFMT and NMES offers some advantage in the reduction of PFM tone and symptoms of overactive bladder.

Myotonometry Reliably Measures Muscle Stiffness in the Thenar and Perineal Muscles

Purpose: The authors investigated the reliability of myotonometry-measured muscle tone in the thenar and perineal muscles. Methods: Participants were women aged 18-50 years who were asymptomatic for thumb and pelvic floor dysfunction (interrater study n=20; intrarater study n=43) or who were symptomatic for vulvodynia (interrater study n=14; intrarater study n=32). Mechanical properties (stiffness, frequency, decrement, relaxation time, and creep) of the muscles were measured using a myotonometer (MyotonPRO) while the muscles were in a relaxed state. Measures were performed twice by two assessors. Intra- and interrater reliability were determined using intra-class correlation coefficients (ICCs) and absolute reliability using the standard error of measurement and a minimum detectable change. Results: The primary property of interest, muscle stiffness, showed very good interrater (ICC 0.85-0.86) and intrarater (ICC 0.82-0.88) reliability in the thenar eminence. In the perineal muscles, reliability results ranged from good to very good for interrater (ICC 0.70-0.86) and intrarater (ICC 0.80-0.91) reliability for muscle stiffness. Absolute reliability was confirmed, with all measures showing minimal variance. Conclusions: Muscle stiffness of the smaller muscles of the body can be reliably measured using the MyotonPRO. The device could be used as a reference standard in the development of a digital palpation scale that would facilitate accurate diagnosis of muscle tone.

2016 European guideline for the management of vulval conditions

Vulval conditions may present to a variety of clinicians, such as dermatologists, gynaecologists and general practitioners. Women with these conditions are best managed by a multidisciplinary approach, which includes clear referral pathways between disciplines or access to a specialist multidisciplinary vulval service. Informed consent is a prerequisite for all examinations, investigations and treatments. Consent is particularly important for intimate examinations of the anogenital area, and a chaperone should be offered in all cases. All efforts should be made to maintain a patient's dignity. Depending on symptoms and risk factors, screening for sexually transmitted infections (STI) should be considered. If the patient presents with vulval itch, particularly if also complaining of increased vaginal discharge, vulvaginal candidiasis should be excluded. Sexual dysfunction should be considered in all patients with vulval complaints, either as the cause of the symptoms or secondary to symptoms, and assessed if appropriate. This guideline covers several aspects, such as diagnosis and treatment, of the more common vulval conditions (relatively) often encountered at vulval clinics, i.e. vulval dermatitis (eczema), psoriasis, lichen simplex chronicus, lichen sclerosus, lichen planus, vulvodynia and vulval intraepithelial neoplasia (VIN).

Recent advances in understanding provoked vestibulodynia

Vulvodynia refers to pain in the vulva of at least 3 months’ duration in the absence of a recognized underlying cause. Provoked, localized vestibulodynia is the term used to describe superficial pain confined to the vulvar vestibule, provoked by touch. This review will focus on provoked vestibulodynia with regard to its suggested causative factors and will discuss the role of inflammation, vulvovaginal infections, mucosal nerve fiber proliferation, hormonal associations, central pain mechanisms, pelvic floor muscle dysfunction, and genetic factors.

Clinical observations, epidemiological studies, and data from basic research emphasize the heterogeneity of vulvar pain syndromes. There is a critical need to perform prospective, longitudinal studies that will allow better diagnostic criteria and subgrouping of patients that would lead to improvements in our understanding of provoked vestibulodynia and its treatment.

A Role for Bradykinin Signaling in Chronic Vulvar Pain

Chronic vulvar pain is alarmingly common in women of reproductive age and is often accompanied by psychological distress, sexual dysfunction, and a significant reduction in quality of life. Localized provoked vulvodynia (LPV) is associated with intense vulvar pain concentrated in the vulvar vestibule (area surrounding vaginal opening). To date, the origins of vulvodynia are poorly understood, and treatment for LPV manages pain symptoms, but does not resolve the root causes of disease. Until recently, no definitive disease mechanisms had been identified; our work indicates LPV has inflammatory origins, although additional studies are needed to understand LPV pain. Bradykinin signaling is one of the most potent inducers of inflammatory pain and is a candidate contributor to LPV. We report that bradykinin receptors are expressed at elevated levels in LPV patient versus healthy control vestibular fibroblasts, and patient vestibular fibroblasts produce elevated levels of proinflammatory mediators with bradykinin stimulation. Inhibiting expression of one or both bradykinin receptors significantly reduces proinflammatory mediator production. Finally, we determined that bradykinin activates nuclear factor (NF)κB signaling (a major inflammatory pathway), whereas inhibition of NFκB successfully ablates this response. These data suggest that therapeutic agents targeting bradykinin sensing and/or NFκB may represent new, more specific options for LPV therapy.

PERSPECTIVE

There is an unmet need for the development of more effective vulvodynia therapies. As we explore the mechanisms by which human vulvar fibroblasts respond to proinflammatory/propain stimuli, we move closer to understanding the origins of chronic vulvar pain and identifying new therapeutic targets, knowledge that could significantly improve patient care.

Active and Passive Components of Pelvic Floor Muscle Tone in Women with Provoked Vestibulodynia: A Perspective Based on a Review of the Literature

AIM

Pelvic floor muscle (PFM) dysfunctions, especially elevated tone or tension, are suggested to play an important role in the pathophysiology of provoked vestibulodynia (PVD). However, the involvement of the PFMs remains misunderstood as the assessment of muscle tone is complex and requires a thorough understanding of muscle physiology in relation to the characteristics and limitations of current PFM assessment tools. The aim of this review was to describe the structures and mechanisms involved in muscle tone in normally innervated muscle, and to discuss and relate these concepts to the PFM findings in women with PVD.

METHODS

A narrative overview of the literature retrieved from searches of electronic databases and hand searches.

RESULTS

Muscle tone in a normally innervated muscle comprises both active (contractile) and passive (viscoelastic) components. Current methods for evaluating PFM tone such as digital palpation, ultrasound imaging, pressure perineometry, dynamometry, and electromyography may evaluate different components. Research findings suggestive of PFM hypertonicity in women with PVD include elevated general PFM tone, changes in viscoelastic properties, and at least in some women, abnormal increases in electrogenic activity.

CONCLUSION

There is a growing body of evidence to support the involvement of PFM hypertonicity in the pathophysiology of PVD. Limitations of the instruments as well as their properties should be considered when evaluating PFM tone in order to obtain better insight into which component of PFM tone is assessed. Future research is required for further investigating the underlying mechanisms of PFM hypertonicity, and studying the specific effects of physiotherapeutic interventions on PFM tone in women with PVD.

A review of the available clinical therapies for vulvodynia management and new data implicating proinflammatory mediators in pain elicitation

Localised provoked vulvodynia (LPV) is a common, chronic, and disabling condition: patients experience profound pain and a diminished quality of life. The aetiologic origins of vulvodynia are poorly understood, yet recent evidence suggests a link to site-specific inflammatory responses. Fibroblasts isolated from the vestibule of LPV patients are sensitive to proinflammatory stimuli and copiously produce pain-associated proinflammatory mediators (IL-6 and PGE₂ ). Although LPV is a multifactorial disorder, understanding vulvar inflammation and targeting the inflammatory response should lead to treatment advances, especially for patients exhibiting signs of inflammation. NFκB (already targeted clinically) or other inflammatory components may be suitable therapeutic targets.

TWEETABLE ABSTRACT

Vulvodynia is a poorly understood, prevalent, and serious women's health issue requiring better understanding to improve therapy.

Psychosexual disorders and dermatologists

Sexual problems that are psychological in origin, rather than physiological, are called psychosexual disorders. Multiple factors, such as general health of the patient, chronic illnesses, psychiatric/psychological disorders, and socio-cultural factors, alone or in combination can be attributed to the development of psychosexual dysfunctions. The symptoms of these disorders vary for each individual and differ with gender. These disorders may be categorized as sexual dysfunction, paraphilias, and gender identity disorders. Dermatologists are sometimes consulted for sexual dysfunctions in their routine practice by the patients visiting sexually transmitted infections (STI) clinics because a majority of the patients believe that these problems are caused by dysfunctions in the sex organs, and because people are hesitant to go to sexuality clinics and psychiatrists for such problems. Sometimes these patients are referred from other specialties such as urology or gynecology; most often, we attempt to search for STIs or other dermatoses on the genitalia and refer them back. We often underestimate the prevalence of sexual concerns of the patients or feel uncomfortable discussing matters of sexuality with them. Dermatologists should understand basic sexual medicine and ask patients for sexual problems. They should be trained to manage such patients accordingly. In this review, we will be focusing on sexual dysfunctions, their etiopathogenesis, and management from a dermatologist's perspective.

Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist

Answer questions and earn CME/CNE Sexual concerns are prevalent in women with cancer or cancer history and are a factor in patient decision making about cancer treatment and risk-reduction options. Physical examination of the female cancer patient with sexual concerns, regardless of the type or site of her cancer, is an essential and early component of a comprehensive evaluation and effective treatment plan. Specialized practices are emerging that focus specifically on evaluation and treatment of women with cancer and sexual function problems. As part of a specialized evaluation, oncologists and their patients should expect a thorough physical examination to identify or rule out physical causes of sexual problems or dysfunction. This review provides oncology professionals with a description of the physical examination of the female cancer patient with sexual function concerns. This description aims to inform anticipatory guidance for the patient and to assist in interpreting specialists' findings and recommendations. In centers or regions where specialized care is not yet available, this review can also be used by oncology practices to educate and support health care providers interested in expanding their practices to treat women with cancer and sexual function concerns. CA Cancer J Clin 2016;66:241-263. © 2016 American Cancer Society.

Vulvar vestibulodynia: strategies to meet the challenge

Vulvodynia is a condition that affects approximately 8% to 12% of women during their lifetimes. Vulvar vestibulodynia (VVD), the most common form of this condition, is characterized by pain with touch at the vulvar vestibule and resulting entryway dyspareunia. Studies suggest a multifactorial etiology; hormonal effects, muscle dysfunction, personality, psychosocial factors, and inflammatory mediators may all play some role in the development of this condition. Both peripheral and central sensitization to pain have been implicated in the development of enhanced pain experienced by women with VVD. Recommendations for the treatment of this condition exist; however, treatments of this condition have not been well studied. Few prospective placebo-controlled trials exist, and many of those that do have failed to show clinically relevant efficacy associated with traditional therapies. New studies into the etiology of this condition, as well as potential new therapies, are emerging, but the optimal approach has yet to be defined. Proper vulvar hygiene is recommended, and traditional therapies such as topical medications and centrally acting oral medications may continue to play a role in treatment. Newer studies elucidating the effects of personality and cognitive factors as well as pelvic floor muscle dysfunction in the development of this condition lend support for the inclusion of cognitive behavioral therapy and physical therapy/surface electromyographic biofeedback in the treatment regimen. Surgery for this condition exists, with success rates of 60% to 90%; however, it is recommended only in cases that have failed to respond to traditional therapy.

Mucosal versus muscle pain sensitivity in provoked vestibulodynia

BACKGROUND

An estimated 8.3%-16% of women experience vulvovaginal discomfort during their lifetime. Frequently these patients report provoked pain on contact or with attempted intercourse, commonly referred to as provoked vestibulodynia (PVD). Despite the burden of this condition, little is known about its potential etiologies including pelvic floor muscular dysfunction and mucosal components. This knowledge would be beneficial in developing targeted therapies including physical therapy.

OBJECTIVE

To explore the relative contribution of mucosal versus muscle pain sensitivity on pain report from intercourse among women with PVD.

DESIGN

In this proof of concept study, 54 women with PVD underwent a structured examination assessing mucosal and pelvic muscle sensitivity.

METHODS

We examined three mucosal sites in the upper and lower vestibule. Patients were asked to rate their pain on cotton swab palpation of the mucosa using a 10-point visual analog scale. Muscle pain was assessed using transvaginal application of pressure on right and left puborectalis, and the perineal muscle complex. The Gracely pain scale (0-100) was used to assess the severity of pain with intercourse, with women rating the lowest, average, and highest pain levels; a 100 rating the highest level of pain.

RESULTS

The lower vestibule's mucosa 5.81 (standard deviation =2.83) was significantly more sensitive than the upper vestibule 2.52 (standard deviation =2.6) (P<0.01) on exam. However, mucosal sensitivity was not associated with intercourse pain, while muscle sensitivity was moderately associated with both average and highest intensity of intercourse pain (r=-0.46, P=0.01 and r=-0.42, P=0.02), respectively.

CONCLUSION

This preliminary study suggests that mucosal measures alone may not sufficiently capture the spectrum of clinical pain report in women with PVD, which is consistent with the empirical success of physical therapy in this population.

Can Fear, Pain, and Muscle Tension Discriminate Vaginismus from Dyspareunia/Provoked Vestibulodynia? Implications for the New DSM-5 Diagnosis of Genito-Pelvic Pain/Penetration Disorder

Fear has been suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia. Unfortunately, this has not been systematically investigated. The primary purpose of this study, therefore, was to investigate whether fear as evaluated by subjective, behavioral, and psychophysiological measures could differentiate women with vaginismus from those with dyspareunia/provoked vestibulodynia (PVD) and controls. A second aim was to re-examine whether genital pain and pelvic floor muscle tension differed between vaginismus and dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women with dyspareunia/PVD, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia/PVD and no-pain control groups. Moreover, behavioral measures of fear and vaginal muscle tension were found to discriminate the vaginismus group from the dyspareunia/PVD and no-pain control groups. Genital pain did not differ significantly between the vaginismus and dyspareunia/PVD groups; however, genital pain was found to discriminate both clinical groups from controls. Despite significant statistical differences on fear and vaginal muscle tension variables between women suffering from vaginismus and dyspareunia/PVD, a large overlap was observed between these conditions. These findings may explain the great difficulty health professionals experience in attempting to reliably differentiate vaginismus from dyspareunia/PVD. The implications of these data for the new DSM-5 diagnosis of Genito-Pelvic Pain/Penetration Disorder are discussed.

The effect of pelvic floor muscle training alone or in combination with electrostimulation in the treatment of sexual dysfunction in women with multiple sclerosis

Background:

Sexual dysfunction (SD) affects up to 80% of multiple sclerosis (MS) patients and pelvic floor muscles (PFMs) play an important role in the sexual function of these patients.

Objectives:

The objective of this paper is to evaluate the impact of a rehabilitation program to treat lower urinary tract symptoms on SD of women with MS.

Methods:

Thirty MS women were randomly allocated to one of three groups: pelvic floor muscle training (PFMT) with electromyographic (EMG) biofeedback and sham neuromuscular electrostimulation (NMES) (Group I), PFMT with EMG biofeedback and intravaginal NMES (Group II), and PFMT with EMG biofeedback and transcutaneous tibial nerve stimulation (TTNS) (Group III). Assessments, before and after the treatment, included: PFM function, PFM tone, flexibility of the vaginal opening and ability to relax the PFMs, and the Female Sexual Function Index (FSFI) questionnaire.

Results:

After treatment, all groups showed improvements in all domains of the PERFECT scheme. PFM tone and flexibility of the vaginal opening was lower after the intervention only for Group II. All groups improved in arousal, lubrication, satisfaction and total score domains of the FSFI questionnaire.

Conclusion:

This study indicates that PFMT alone or in combination with intravaginal NMES or TTNS contributes to the improvement of SD.

Diagnostic value of pelvic floor surface electromyography in functional anorectal pain

AIM: To assess the diagnostic value of pelvic floor surface electromyography (sEMG) in functional anorectal pain (FARP) using receiver operating characteristic (ROC) curve analysis.

METHODS: The parameters of pelvic floor sEMG in 118 patients with FARP and 103 normal controls were measured according to the Glazer protocol. Parameters included amplitude (AVG), coefficient of variance (CV), onset time and median frequency (MF). The ROC curve was plotted to assess the diagnostic value of pelvic floor sEMG.

RESULTS: Compared with the control group, the FARP group had a lower AVG (23.81 ± 13.75 vs 30.55 ± 16.14, P < 0.05) and a higher CV (0.43 ± 0.12 vs 0.30 ± 0.07, P < 0.05) during the tonic phase and a higher CV during the endurance phase (0.40 ± 0.15 vs 0.28 ± 0.09, P < 0.05). The critical value of CV during the tonic and endurance phases were 0.35 and 0.31, respectively, and the areas under ROC curve were 0.813 and 0.761.

CONCLUSION: CV during the tonic and endurance phases has better diagnostic value in FARP.

Pelvic floor muscle dysfunctions are prevalent in female chronic pelvic pain: a cross-sectional population-based study

BACKGROUND

No current standardized set of pelvic floor muscle (PFM) outcome measures have been specifically tested for their applicability in a general female chronic pelvic pain (CPP) population. We aimed to compare PFM function between a randomly selected population-based sample of women with CPP and age-matched pain-free controls using multiple standardized intravaginal examination measures recommended by the International Continence Society.

METHODS

This was a cross-sectional, population-based and controlled study with randomly selected participants among women in Denmark. We reported blinded findings from a set of standardized vaginal PFM examination manoeuvres in 50 female participants (24 with CPP, 26 pain free). A preliminary pilot study ensured the intra- and intertester reliability of the test procedure. PFM outcomes were resting tone, relaxation capacity, strength, surface electromyographic activity and mechanosensitivity. Statistical analyses included unpaired t-tests, Fisher's exact tests and Mann-Whitney tests.

RESULTS

The examination protocol was a reliable and predictable clinical measurement of associated PFM dysfunction in female CPP. Women with CPP had higher PFM resting tone and decreased maximal PFM strength and relaxation capacity compared with pain-free controls. Enhanced PFM pressure-pain sensitivity measured by palpometry during examination was also associated to CPP.

CONCLUSION

This controlled, single-blinded study with randomly selected participants provides new population-based information regarding associated PFM dysfunction in women with CPP using multiple intravaginal examination methods. However, to identify women with CPP who will benefit from a physiotherapeutic specialized intervention, future prospective randomized controlled trials using these reliable and predictive outcomes are needed.

Living with genital pain: Sexual function, satisfaction, and help-seeking among women living in Sweden

Background and aims Female genital pain is a debilitating problem that negatively affects several aspects of the life of women. Several studies present figures of prevalence indicating that the problem affects nearly 20% of young women. However, many women fail to consult health care and the estimated prevalence therefore remains insecure. Historically, genital pain was commonly viewed as either physiological or psychosexual. Although the current field of research and clinical expertise in general agree upon a biopsychosocial conceptualization, less is known about the manifestation of the problem in everyday life and the experience of seeking health care among afflicted women. The objectives of the present study was to examine genital pain in a general female population living in Sweden cross-sectionally in terms of prevalence, sexual function, sexual satisfaction and help seeking, and to identify possible predictors of genital pain among women. Methods The study was a population-based study using a postal questionnaire administered to 4052 women (age 18--35). Of these 944 (response rate: 23%) took part in the study. Results Genital pain of six months duration was reported by 16.1% of the women. Women with pain more commonly reported fungal infections, other pain problems, sexual dysfunctions and symptoms of anxiety than pain-free women and in addition lower sexual satisfaction. There were no differences in sexual frequency. Pain was most commonly reported during sexual intercourse, but many women also experienced pain during non-sexual activities, with pain durations of several hours after the pain eliciting activity was interrupted. Of those reporting pain, 50% had sought care for their pain. The most common was to counsel a doctor and to receive topical treatment. However, the experienced effects of the treatments were on average low. In the explanatory model, fungal infections, and sexual dysfunctions were associated with genital pain. Conclusions The study had a low response rate, but still indicates that genital pain is common and negatively affects several aspects of women' life, not just sexual activities. Although many women report pro-longed pain experiences, many fail to consult health care and among those who seek care the effects of treatment are on average poor. There are strong associations between sexual dysfunctions (lack of sexual arousal, vaginal muscle tension hindering intercourse) and genital pain that, based on previous findings in this field of research, might be viewed in terms of circular maintaining processes. Implications Female genital pain is not just limited to the sexual context, but often negatively affects several situations in women' life. The size of the problem calls for immediate development of preventive interventions and treatment programs that focus on sexual education and to encourage a healthy sexuality among women and their partners. There is a need to identify methods in order to assemble evidence based interventions of female genital pain. Such methods are currently lacking, resulting in poor treatment options for women with pain.

Rationale and design of a multicenter randomized clinical trial of extended release gabapentin in provoked vestibulodynia and biological correlates of response

INTRODUCTION

Few randomized controlled trials (RCTs) have been conducted to establish evidence-based management protocols for provoked vestibulodynia (PVD), a chronic vulvar pain condition affecting approximately 14 million women in the U.S. We describe the rationale and design of an NIH funded multicenter clinical trial utilizing an extended release formulation of gabapentin (G-ER), an intervention that preliminary data suggest may be efficacious for this condition.

OBJECTIVES

1) to determine if pain from tampon insertion (primary outcome measure) is lower in PVD patients when treated with G-ER compared to when treated with placebo and 2) to determine if G-ER reduces vulvar mechanical hyperalgesia, vaginal muscle pain to palpation, the number and intensity of somatic tenderpoints, spontaneous and provoked pain to intradermal capsaicin with an accompanying increase in cardiac beat-to-beat variability and to identify mechanistically-based PVD subtypes. Additional outcomes include subject reported intercourse pain and summative 24-hour pain.

METHODS

This 16-week, randomized, double-blind, placebo-controlled, crossover study will enroll 120 women 18 years and older who report tenderness localized to the vulvar vestibule, pain with tampon insertion, and, when sexually active, insertional dyspareunia. Electronically entered daily diaries will be used to determine if pain is lower in PVD subjects when treated with G-ER (up to 3000 mg/d) compared to when treated with placebo. Psychophysiological measures will be obtained at baseline and after 2 weeks at the maximum tolerated dose.

CONCLUSION

We will conduct the first multicenter RCT to confirm efficacy of an agent that is currently used in clinical practice for treating PVD.

A Psychological View of Sexual Pain among Women: Applying the Fear-Avoidance Model

Aim: The purpose of this paper is to examine how well research findings on dyspareunia (intercourse pain) fit the fear-avoidance (FA) model on pain. Results: The evidence suggests that the experience of pain in dyspareunia functions similarly to the pain reported in other pain conditions. There are also accumulating data showing that the central mechanisms of the FA model, such as catastrophizing, fear, hypervigilance and disability, are central to the experience of sexual pain. However, there are also some potential differences between sexual pain and other pain conditions that demand further attention in terms of the role of the partner, specific emotional consequences of avoidance and the effect of hypervigilance on sexual arousal. Conclusion: The results demonstrate the relevance of the FA model in sexual pain. They also imply that treatment methods for fear and avoidance in other pain conditions offer new avenues for treating sexual pain problems in the clinic. Future studies should focus on expanding how the mechanisms in the FA model contribute to sexual pain, as well as how treatments based on the model may be applied clinically.

Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain

Myofascial pelvic pain (MFPP) is a major component of chronic pelvic pain (CPP) and often is not properly identified by health care providers. The hallmark diagnostic indicator of MFPP is myofascial trigger points in the pelvic floor musculature that refer pain to adjacent sites. Effective treatments are available to reduce MFPP, including myofascial trigger point release, biofeedback, and electrical stimulation. An interdisciplinary team is essential for identifying and successfully treating MFPP.