Oral Presentation AGES XXVIII Annual Scientific Meeting 2018

Dyspareunia: Find the Sore Spot! (5790)

Prathima Chowdary

Sexual pain in women is associated with significant morbidity and financial cost to the individual as well as their partners, families and the wider community. Chronic pelvic pain (CPP) is estimated to affect 15% of women aged 18-50 years2. There is a complex interplay of biological, behavioural, environmental and societal factors compounded by complex neurogenic innervation of closely related visceral and somatic structures, by the intimate nature of the area and impact on personal relationships and sexuality. Epidemiologic studies reveal a high community prevalence of chronic pelvic pain in women of reproductive age, with reported rates of 14.7 percent in the U.S.2

Once a diagnosis of possible pelvic floor dysfunction as a contribution to chronic pelvic pain is made, objective measurements and physiotherapy as a method of low-risk treatment is a logical, inexpensive and nonsurgical approach to treatment3 . 85% of patients with chronic pelvic pain present with dysfunction or impairments of the musculoskeletal system – eg poor posture and pelvic floor muscle imbalances 1.

Pelvic floor muscle (PFM) pain and increased tension are commonly associated with pelvic, vulval and sexual pain presentations and is an emerging reason for referral to pelvic floor physiotherapy. The addition of biofeedback provides the patient with objective information regarding the adequacy of pelvic floor training and objective assessment of changes in the baseline tone and strength for the physician3.  The relationship between the symptom of PFM pain and the sign of altered PFM tension is not well understood but co-occurrence is frequently observed with causality difficult to prove. These 'tissue-focused' interventions play an important role, however there is strong evidence for a biopsychosocial approach to management of persistent pelvic floor muscle pain due to the high prevalence of contributing psychological variables. Both peripheral and central abnormalities have been implicated in vulvar / sexual pain indicating central hypersensitivity and therefore an inherent need to address central nervous system dysfunction.

PFM dysfunction, mainly increased tension, plays a significant role in the maintenance and exacerbation of pelvic and sexual pain.  Identification of a myofascial syndrome as a cause or contributing factor is a critical step in management of patients with chronic pelvic pain. Failure to recognise pelvic floor dysfunction could certainly contribute to the 24% to 40% negative laparoscopy rate in patients with chronic pelvic pain8. Attention to the pelvic floor musculature during pelvic examinations is an effective and inexpensive diagnostic strategy that can be life-changing for patients with pelvic pain, yet requires minimal time and effort.

Further Reading:

1. A.K. Srinivasan, J.D. Kaye, R. Moldwin, Myofascial dysfunction associated with chronic pelvic floor pain: management strategies, Curr Pain Headache Rep, 11 (2007), pp. 359–364
2. P. Latthe, M. Latthe, L. Say, M. Gulmezoglu, K.S. Khan, WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity, BMC Public Health, 6 (2006), p. 177
3. Sinaki M, Meritt J, Stilwell G. Tension myalgia of the pelvic floor. Mayo Clin Proc. 1977;52:717-722
4. Prendergast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol. 2003;46(4):773-782.
5. Howard FM. Chronic pelvic pain. Obstet Gynecol. 2003;101(3):594-611.

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  2. Mathias S, Kupperman M, Liberman R, Lipschutz R, Steege J. Chronic pelvic pain; prevalence, health related quality and economic correlates. Obstet Gynecol. 1996;87:321-327.
  3. Jarvis S, Abbott J, Lenart M, Steensma A. Vancaille T. Pilot study of botulinium toxin type A in the treatment of chronic pelvic pain as associated with spasm of the levator ani muscles. Aust N Z J Obstet Gynaecol.2004;44:46-50.
  4. Abbott J, The use of botulinum toxin in the pelvic floor for women with chronic pelvic pain – A New Answer to Old Problems? The Journal of Minimally Invasive Gynaeology. 2008.11.006
  5. M. Fall, A.P. Baranowski, S. Elneil, D. Engeler, J. Hughes, E.J. Messelink, F. Oberpenning, C. de, A.C. Williams, EAU guidelines on chronic pelvic pain, Eur Urol, 57 (2010), pp. 35–48
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  9. Carolyn Vandyken, Cred MDT, CCMA, Sandra Hilton. Physical therapy in the treatment of central pain mechanisms for female sexual pain. Sex Med Rev 2016; 1-11.
  10. Bergeron S, Binik YM, Khalife S, Pagidas K, Glazer HI, Meana M, et al. A randomised comparison of group cognitive- behavioural therapy, surface electromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting in vestibulitis. Pain 2001; 91; 297-306.
  11. Morin M, Dumoulin C, Bergeron S, Mayrand M, Khalife S, Waddell G, Dubois M, Randomised clinical trial of multimodal physiotherapy treatment copared to overnight lidocain ointment in women with provoked vestibulodyania; design and methods. 2016 Contemporary Clinical Trials 46 52-59
  12. Moseley, G. L., & Butler, D. S. (2015). Fifteen Years of Explaining Pain: The Past, Present, and Future. Journal of Pain, 16(9), 807-813.
  13. Rosenbaum, Talli. Physiotherapy treatment of sexual pain disorders. Journal of sex and marital therapy, 31:329-340,2005.