By Talli Rosenbaum
Special to Vibrance Associates
and Newshe.com

Talli Y. Rosenbaum is a licensed physical therapist specializing in urogynecological and pelvic floor rehabilitation in Tel Aviv and Jerusalem, Israel. She is a member of the International Society for the Study of Women's Sexual Health and the International Pelvic Pain Society.

Painful Intercourse is known by the term" dyspareunia" (pronounced dis pa roo ne a). Every woman has probably experienced it once or twice in her life, either due to a yeast infection, perhaps after childbirth, or due to vaginal dryness. When intercourse is always painful, even sometimes impossible, and there is no clear identifiable medical cause, women are often made to feel that perhaps the problem is "psychological". This feeling is even further strengthened by the fact that dyspareunia is considered a mental health, rather than medical diagnosis, as evidenced by the fact that it is listed in the DSM IV psychiatric diagnosis manual.

There is no doubt this condition greatly affects a woman's psychological state, the relationship with her partner, and her sex life, but whether or not painful intercourse should be considered a sexual dysfunction rather than a pain disorder which affects sexuality (amongst other functions) is under debate. After all, someone with chronic back pain who is unable to work isn't said to have a work dysfunction. In fact, a group of researchers at McGill University has been working on reclassifying dyspareunia as a painful condition that limits sexual activity, rather than a sexual disorder per se.

The fact remains, however, that more often that not, pain with intercourse has a physiological source. Among the possible medical causes of painful intercourse are vulvar vestibulitis, vulvodynia, and interstitial cystitis. Other causes can be painful stitches after childbirth, pressure on spinal nerves or nerves in the pelvis, such as the pudendal nerve, or hormonal changes leading to vaginal dryness and even narrowing of the vaginal entrance. Tight muscles of the pelvic floor, the muscles inside the vagina that help to control bladder and bowel function and are normally active during sexual excitement, may be a source of pain as well.

Vulvar vestibulitis, named as a disease only in the mid 1980s, is probably one of the most common causes of pain with intercourse. It is a diagnosis based on the patient's complaint, as well as physical findings, which include pain at certain points along the vestibule (the vaginal "entrance") when touched with cotton swab. Because the appearance of the vulva is often normal, and because not all gynecologists actually look at or examine the outer vulva, it is a diagnosis that may often be missed.

While the causes of vestibulitis are not well defined, it is understood that multiple systems are involved. These include the pelvic floor muscles, which are often tight and unstable, the vascular system, the nervous system, and the mucosal system. Studies have found a proliferation of both nociceptors (cells which receive pain signals) and mast cells (cells which react to inflammation) in the vestibular tissue. Because the tissues are actually inflammed, women may react to pain by contracting the pelvic floor, a condition know as pelvic floor hypertonus. Overly contracted pelvic floor muscles perpetuate the painful condition by preventing healing and making attempted intercourse even more painful.

Vulvodynia, of which vulvar vestibulitis is a subset, refers to vulvar pain, which is often chronic and unremitting. Interstitial cystitis is a condition of urinary urgency, frequency and bladder and pelvic pain, of which dyspareunia is often a feature. Vaginismus is defined as a condition whereby vaginal penetration is prevented by "spasm of the outer two thirds of the vagina" although presence of muscle spasm has never actually been substantiated.

Patients who present with a great deal of anxiety regarding penetration, are unable to insert a finger or a tampon, or undergo a gynecological exam are often given this diagnosis. While vaginismus has historically been treated almost exclusively by sex therapists and may exist as an isolated condition, it is now understood in many cases to be a secondary reaction to the presence of primary vestibulitis.

What unites all these conditions is that they require a multidisciplinary mind/body approach, and that treatment with a physical therapist trained in pelvic floor and urogynecological rehabilitation should be part of the treatment team. A physical therapist takes a thorough history, does a general muscular and skeletal exam, a vulvar and pelvic floor exam and treats using a combination of modalities.

The history is very important in determining the patients major complaint in addition to linking the sexual problem with other systems, such as urinary function problems, or back pain, for example. The history taking also helps the patient and therapist determine together what are her goals for treatment and what the treatment plan should be.

A thorough evaluation will assess the patient's posture, mobility, and strength, as well as her movements and breathing, in order to get a sense of how she uses her body. The spine, sacrum and pelvis are checked for alignment, mobility and balance. The muscles, particularly of the pelvis, abdominals, and legs are assessed for length, strength, and presence of trigger points. A trigger point is a hyperirritable spot, usually within a muscle, that is painful on compression and can refer pain to different areas. Often these points are found in the internal muscles of the vagina and the pelvic floor, buttocks, and hips.

The vulvar and pelvic floor assessment is an important part of the physical therapist's examination. The vulva is observed for areas of redness, raised areas, or swelling, and is palpated to note areas of tenderness. The vagina and perineum is checked and palpated for tender areas, and in the case of women who have given birth or had surgery, areas of tenderness caused by scar tissues from surgical or episiotomy stitches are examined.

The internal exam allows the therapist to assess pelvic floor muscle tension and tightness, tone, range of motion and muscle strength. The internal exam also enables the therapist to assess internal muscle trigger points, the integrity of the pelvic organs and the presence of bladder, uterus, or rectal prolapse. If the history warrants it, i.e., the patient reports anal pain or constipation, an anorectal internal exam should be performed as well.

Physical therapy treatment is based on the history and physical findings. The treatment will usually combine a home program of exercise, deep breathing and relaxation with behavioral techniques consisting of self care, baths with oils such as tea tree and lavender, self application of vitamin E oil , and getting acquainted with one's own vulva by looking in the mirror, self touch and eventually insertion of a finger or dilator. Typically, dilators of increasing width are gradually introduced and the patient continues to work with them at home until the largest dilator can be inserted without pain. In many cases, treatment focuses not only on pain relief, but on helping to reduce the anxiety associated with penetration; this may be achieved with hands-on assistance and involves anatomy identification, instruction in muscle relaxation, and insertion of the dilators.

Manual therapy techniques are very effective in improving muscle and connective tissue mobility, mobilizing tight fascia and viscera, mobilizing joints, and providing relaxation. Basic manual techniques include myofascial release, visceral manipulation and external and internal trigger point muscle massage. Myofascial release is a very effective hands-on technique that provides sustained pressure into myofascial restrictions to eliminate pain and restore motion. Visceral manipulation is a therapeutic approach to relieving abnormal tissue tensions of and around the organs thereby promoting and improving organ function. Trigger point therapy is a bodywork technique that involves the applying of local pressure to tender muscle tissue in order to relieve referred pain and dysfunction.

Modalities refer to the equipment available for treatment. One important tool for assessment and treatment purposes is pelvic floor electromyography (EMG), a biofeedback instrument that measures muscle activity. Treatment with biofeedback focuses on providing awareness of, and strengthening the pelvic floor muscles as well as decreasing the tightness which often prevents penetration or contributes to discomfort during intercourse. Other modalities available to physical therapists include heat/cold application, ultrasound and electrical stimulation.

Ultrasound, a method of deep heat used in the treatment of muscle, joint and tissue pain, is effective in promoting healing and breaking down adhesive tissue and is an appropriate modality to use for a woman with intercourse pain secondary to an extensive perineal repair. Transcutaneous electrical nerve stimulation (TENS) has been used effectively for the purposes of decreasing pain as has electrical muscle stimulation for assisting in muscle strengthening.

Physical therapy is a profession known for musculoskeletal assessment and treatment for the purpose of decreasing pain, facilitating normal motion, and improving function in all daily (and nightly!) activities. Treating painful intercourse requires simply applying these principles to the pelvic and vulvar areas. It is wise to seek a skilled and experienced therapist with knowledge in the areas of women's sexual health and Urogynecology to complement the health care team involved in treating women with symptoms of painful intercourse. (March, 2003)

References:

Bergeron et al. Physical Therapy for Vulvar Vestibulitis Syndrome: A Retrospective Study. J Sex Marital Therapy (2002); 28: 183-92.

Binik, I., Meana, M. et al. The Sexual Pain Disorders: Is the Pain Sexual or the Sex Painful? Annual Review of Sex Research (1999); 10:210-235.

Bohm-Starke N, Hilliges M, Brodda-Jansen G, Rylander E and Torebjork E Psychophysical evidence of nociceptor sensitization in vulvarvestibulitis syndrome.Pain 2001 Nov;94(2):177-183

Bornstein, J., Sabo, E. et al. A mathematical model for the histopathologic diagnosis of vulvar vestibulitis based on a histomorphometric study of innervation and mast cell activation. J Reprod Med (2002); 9:742.

Glazer, H., Rodke, G et al. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med (1995); 40:283-90.

Graziottin, A Clinical Approach: Vulvar Vestibulitis Syndrome Proceedings of the Vancouver ISSWSH meeting Oct 2002 pp82-86.

Hay-Smith, EJ. Therapeutic ultrasound for postpartum perineal pain and dyspareunia. Cochrane Database Syst Rev 2000(2);CD000945.

Rosenbaum, T Physical Therapy Treatment of Vulvodynia: A hands-on Approach. National Vulvodynia Newsletter Winter 2002 Vol.VIII, issue 1.

Travell, J. and Simons, D. 1992. Myofascial pain and dysfunction: The trigger point manual. Vol.2. Williams and Wilkins, Baltimore.