Physiotherapy Interventions for Physiotherapy Interventions for Lifelong VaginismusLifelong Vaginismus

Presentation given at the 36Presentation given at the 36 thth Annual Meeting of Annual Meeting of the Society for Sex Therapy and Researchthe Society for Sex Therapy and Research

Elke D. Reissing, Ph.D., C.Psych.Elke D. Reissing, Ph.D., C.Psych.

Heather Armstrong, Ph.D. (cand.)Heather Armstrong, Ph.D. (cand.)

Acknowledgment Acknowledgment

Caroline Allen, M.A., P.T. Caroline Allen, M.A., P.T.

Staff and patients Staff and patients

at at Pelvic Support PhysiotherapyPelvic Support Physiotherapy

Why lifelong vaginismus?Why lifelong vaginismus?

To avoid diagnostic confusion with women who To avoid diagnostic confusion with women who suffer from dyspareunia and who are no longer engaging suffer from dyspareunia and who are no longer engaging in intercourse. in intercourse.

To focus on women who experience severe vaginal To focus on women who experience severe vaginal penetration problems and have NEVER been able to penetration problems and have NEVER been able to experience vaginal penetration. experience vaginal penetration.

No research on effectiveness of PT No research on effectiveness of PT

PT for dyspareuniaPT for dyspareunia

Pelvic floor pathology has been consistently associated as a Pelvic floor pathology has been consistently associated as a causal, maintaining and/or exacerbating factor in women with causal, maintaining and/or exacerbating factor in women with vulvodynia vulvodynia (e.g., Reissing et al., 2005).(e.g., Reissing et al., 2005).

The physiotherapy approach for treating vulvodynia has been The physiotherapy approach for treating vulvodynia has been well described in the literature well described in the literature (e.g., Rosenbaum & Owens, 2008)(e.g., Rosenbaum & Owens, 2008)..

Outcome for PVD is excellent but more variable for generalized Outcome for PVD is excellent but more variable for generalized vulvodynia vulvodynia (e.g., Bergeron et al., 2010; Gentilcore-Saulnier et al., 2010).(e.g., Bergeron et al., 2010; Gentilcore-Saulnier et al., 2010).

Pelvic floor pathology in vaginismusPelvic floor pathology in vaginismus

Historical origin of vaginal spasm interfering with intercourse is Historical origin of vaginal spasm interfering with intercourse is not useful as the sole diagnostic criterion - but suggests pelvic floor not useful as the sole diagnostic criterion - but suggests pelvic floor involvement in vaginal penetration problems.involvement in vaginal penetration problems.

Comparative study b/w women with vaginismus and PVD found Comparative study b/w women with vaginismus and PVD found no significant differences in pelvic floor pathology between groups no significant differences in pelvic floor pathology between groups (as assessed by 2 PT, EMG, and 2 gynecologists; Reissing et al., 2004).(as assessed by 2 PT, EMG, and 2 gynecologists; Reissing et al., 2004).

Online survey of women with vaginismus: PT interventions were Online survey of women with vaginismus: PT interventions were reported as most helpful reported as most helpful (Reissing, man in prep.)(Reissing, man in prep.)

Anecdotally in our city, first line intervention as per physician/OBGYN referral.Anecdotally in our city, first line intervention as per physician/OBGYN referral.

Retrospective chart review and interview Retrospective chart review and interview

Sample: Consecutively treated women with vaginismus at one PT Sample: Consecutively treated women with vaginismus at one PT clinic.clinic.

(Defined as: (Defined as: never having experienced vaginal penetration; never having experienced vaginal penetration; partial penetration without thrusting; partial attemptspartial penetration without thrusting; partial attempts).).

Measure: Had to rely on what was in PT files. Measure: Had to rely on what was in PT files.

Recruitment (letter/email from PT to former patients): Recruitment (letter/email from PT to former patients):

- Chart reviewChart review: tacit; had to state they want to be : tacit; had to state they want to be excludedexcluded(3 participants excluded: acquired vag (1), moved (1), discontinued early (1))(3 participants excluded: acquired vag (1), moved (1), discontinued early (1))

- PhonePhone InterviewInterview:: Had to rely on patients taking the initiative to Had to rely on patients taking the initiative to contact us for participation in interview. contact us for participation in interview.

N=46

N=12

Sample characteristics – chart reviewSample characteristics – chart review

AGE:AGE: MM=38, =38, RR= 24 - 58= 24 - 58

68% ~68% ~ never had vaginal penetration never had vaginal penetration (remainder: partial/no thrusting)(remainder: partial/no thrusting)

58% ~58% ~ never used tamponnever used tampon

33% ~33% ~ never had gyne exam with speculum;never had gyne exam with speculum;

of those who did, 71% only with pediatric speculum. of those who did, 71% only with pediatric speculum.

Diagnoses

Physical Therapist

Vaginismus Vaginismus + PVD

77% 19%

Referring Physician

Vaginismus Vaginismus + PVD

Vaginismus + GVD

PVD

49% 12% 2% 7%

Assessment informationAssessment information

Pelvic floor assessment:Pelvic floor assessment:

Notable anxiety Notable anxiety (as observed by PT): (as observed by PT): 62%62%

M-tone-3 to +3

M-contract 0-5

M-relax0-4

Pain – rest 0-10

Pain – ins. 0-10

Pain- move 0-10

Pain- after0-10

Mean 2.7 2.1 1.9 .3 6 6 2

Range 1-3 2-4 2-4 0-3 1-10 0-10 0-6

Mode 3 2 2 0 7 8 0

Assessment informationAssessment information

Pelvic floor assessment:Pelvic floor assessment:

significant hypertonicity, poor voluntary control, poor ability to significant hypertonicity, poor voluntary control, poor ability to relax muscles post-contraction. relax muscles post-contraction.

M-tone-3 to +3

M-contract 0-5

M-relax0-4

Pain – rest 0-10

Pain – ins.0-10

Pain- move 0-10

Pain- after0-10

Mean 2.7 2.1 1.9 .3 6 6 2

Range 1-3 2-4 2-4 0-3 1-10 0-10 0-6

Mode 3 2 2 0 7 8 0

Assessment informationAssessment information

Pelvic floor assessment:Pelvic floor assessment:

High degree of self-reported pain with insertion; relatively low High degree of self-reported pain with insertion; relatively low pain post-insertion. pain post-insertion.

M-tone-3 to +3

M-contract 0-5

M-relax0-4

Pain – rest 0-10

Pain – ins.0-10

Pain- move 0-10

Pain- after0-10

Mean 2.7 2.1 1.9 .3 6 6 2

Range 1-3 2-4 2-4 0-3 1-10 0-10 0-6

Mode 3 2 2 0 7 8 0

Physiotherapy interventionsPhysiotherapy interventions

INTERVENTIONINTERVENTION Applied/patient Applied/patient

Patient educationPatient education (100%)(100%)Internal manual therapyInternal manual therapy (100%)(100%)Modified Kegel exercises* Modified Kegel exercises* (94%)(94%)Home exercises (client) Home exercises (client) (98%)(98%)

Use of dilatorsUse of dilators (83%)(83%)

Home exercises (partner)Home exercises (partner) (71%)(71%)

Biofeedback (educational)Biofeedback (educational) (78%)(78%)

Electrical stimulationElectrical stimulation (37%)(37%)

*with resistance/contact, focusing on conscious “dropping” of pelvic floor. *with resistance/contact, focusing on conscious “dropping” of pelvic floor.

Therapy Process - OutcomeTherapy Process - Outcome

MILESTONESMILESTONES AVERAGE SESSIONAVERAGE SESSION

Small dilatorSmall dilator 66

Medium dilatorMedium dilator 88

TamponsTampons 1010

Large dilatorLarge dilator 1313

Dildo (option)Dildo (option) 2020

SpeculumSpeculum 2222

Gyne examGyne exam 2222

IntercourseIntercourse 1818

TerminationTermination

Number of sessions: Number of sessions:

M = 20 (R=1-126)M = 20 (R=1-126)

(minus 1-10 sessions: (minus 1-10 sessions: M-29M-29))

1-10 ~ 35% …1-10 ~ 35% …(able to have intercourse (n=2); early termination (able to have intercourse (n=2); early termination (n=12))(n=12))

11-20 ~ 22%11-20 ~ 22%

21-30 ~ 30%21-30 ~ 30%

31-40 ~ 7%31-40 ~ 7%

41-126 ~ 7%41-126 ~ 7%

Interview data Interview data (N=12)(N=12)

Relationship status:Relationship status: Married (58%), Dating (25%), Single (17%)Married (58%), Dating (25%), Single (17%)

Number of sessions:Number of sessions: MM=31; (=31; (RR=14-51)=14-51)

Time since termination:Time since termination: MM=25 month (=25 month (RR=9-44 months)=9-44 months)

Satisfaction with PT: Satisfaction with PT: 9/10 (9/10 (RR=8-10)=8-10)

Success with PT: Success with PT: 9/10 (9/10 (RR=6-10)=6-10)

N.B. ↓ satisfaction and ↓ success associated with early termination due to lack of N.B. ↓ satisfaction and ↓ success associated with early termination due to lack of resources to pay PT. resources to pay PT.

Therapy gainsTherapy gains

GAINGAIN ACHIEVED (Y/N)ACHIEVED (Y/N)

IntercourseIntercourse 100%100%

Enjoy sexEnjoy sex 100%100%

↓ ↓ Anxiety Anxiety 86%86%

Gynecological examGynecological exam 100%100%

Use tamponsUse tampons 100%100%

↑ ↑ UnderstandingUnderstanding 100%100%

HopeHope 92%92%

Therapy gains (FSFI – healthy controlsTherapy gains (FSFI – healthy controls**))

Cronbach’s alpha: .88; *Rosen et al., 2000Cronbach’s alpha: .88; *Rosen et al., 2000

FSFI ScalesFSFI Scales Post-Post-treatmenttreatmentVaginismusVaginismus

Healthy Healthy controls*controls*

P-valueP-value

DesireDesire 5.3 6.9 .013

ArousalArousal 15.4 16.8 ns

LubricationLubrication 16 18.6 .03

OrgasmOrgasm 11.8 12.7 ns

SatisfactionSatisfaction 10.8 12.8 .009

PainPain 10.8 13.9 .03

Full ScaleFull Scale 25.9 30.5 .005

Therapy gains (FSFI – patient controlsTherapy gains (FSFI – patient controls**))

Cronbach’s alpha: .88; *Rosen et al., 2000Cronbach’s alpha: .88; *Rosen et al., 2000

FSFI ScalesFSFI Scales Post-Post-treatmenttreatmentVaginismusVaginismus

FSAD* FSAD* P-valueP-value

DesireDesire 5.3 4.7 ns

ArousalArousal 15.4 9.7 .000

LubricationLubrication 16 10.9 .001

OrgasmOrgasm 11.8 7.1 .001

SatisfactionSatisfaction 10.8 8.2 .002

PainPain 10.8 10.6 ns

Full ScaleFull Scale 25.9 19.2 .000

Therapy gains (Female Sexual Distress Scale, Therapy gains (Female Sexual Distress Scale, FSDSFSDS))

Overall: Overall: MM=17 (=17 (RR=2-37)=2-37)

58% 15 58% 15 42%42%

The lower the scores on the FSFI, the higher the FSDS, (p<.01)The lower the scores on the FSFI, the higher the FSDS, (p<.01)

High sexual distress not related to self-reported PT course, High sexual distress not related to self-reported PT course, outcome, or satisfaction. outcome, or satisfaction.

Summary – PTSummary – PT11

Women with lifelong vaginismus present with significant pelvic Women with lifelong vaginismus present with significant pelvic floor pathology, pain, and anxiety. floor pathology, pain, and anxiety.

Progress in PT is variable with some women needing many more Progress in PT is variable with some women needing many more sessions - but most women needing 30 sessions or lesssessions - but most women needing 30 sessions or less

(more sessions/longer treatment time compared to vulvodynia).(more sessions/longer treatment time compared to vulvodynia).

PT interventions are similar to interventions used in the treatment PT interventions are similar to interventions used in the treatment of vulvodynia. of vulvodynia. (Less focus on pain desensitization, more focus on conscious awareness on (Less focus on pain desensitization, more focus on conscious awareness on relaxing/dropping the pelvic floor). relaxing/dropping the pelvic floor).

Summary – PTSummary – PT22

Women reach therapy goals of intercourse, pleasure with sexual Women reach therapy goals of intercourse, pleasure with sexual activity, reproductive hygiene and health care, and overall activity, reproductive hygiene and health care, and overall understanding and hope. understanding and hope.

Patient satisfaction with PT intervention and outcome is very Patient satisfaction with PT intervention and outcome is very high. high.

BUT….Summary - SexualityBUT….Summary - Sexuality

Formal measures indicate that post-treatment, a significant number Formal measures indicate that post-treatment, a significant number of women have not experienced full sexual rehabilitation. of women have not experienced full sexual rehabilitation.

Almost half of the women still were sexually distressed. Almost half of the women still were sexually distressed.

Higher distress was noted in women with lower sexual function Higher distress was noted in women with lower sexual function (FSFI scores). (FSFI scores).

ConclusionsConclusions

PT is an excellent treatment option for lifelong vaginismus and PT is an excellent treatment option for lifelong vaginismus and merits further evaluation. merits further evaluation.

BUT, much like in women with PVD there appears to be no linear BUT, much like in women with PVD there appears to be no linear relationship between symptom reduction and healthy sexual function. relationship between symptom reduction and healthy sexual function.

This suggests that PT interventions need to be integrated with This suggests that PT interventions need to be integrated with interventions that interventions that specifically target sexual rehabilitation. specifically target sexual rehabilitation.