Handout - Kristene Whitmore - International Urogynecological

Kristene E Whitmore, MD
Professor of Surgery/Urology and
OBGYN
Chair of Urology, FPMRS
Drexel University College of Medicine
Philadelphia, Pennsylvania
Susan Kellogg-Spadt, PhD, CRNP
Director of Sexual Medicine
The Pelvic & Sexual Health Institute
Professor of OB/GYN
Drexel University College of Medicine
Philadelphia, Pennsylvania
Erica Fletcher PT MTC
Fletcher Physical Therapy
Narberth, Pennsylvania
Kristene E Whitmore, MD
Professor of Surgery/Urology
and OBGYN
Chair of Urology, FPMRS
Drexel University College of
Medicine
Philadelphia, Pennsylvania
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
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Majority of women consider sexual health an
important part of their overall health
WHO considers maintenance of sexual health a
responsibility of health care professionals
WHO defines FSD as:
“the various ways in which an individual is
unable to participate in a sexual relationship
… as she would wish.”
Maverick, C. et al. JAMA, 1999;281:2173-4

Global Study of Sexual Attitudes and Behaviors Study
◦ only14% of Americans aged 40-80 y.o. reported that a
physician inquired about their sexual health concerns within
the past 3 years

Berman et al 2003
◦ On line survey of women with sexual health concerns who had
consulted a physician:
◦ 52% - “physician didn’t want to hear about their problems”
◦ 87% - “no follow up re: the complaint at subsequent visits
Laumann et al. Archives Sex Behav, 2006;35:145-64.
Berman et al. Fertility Sterility 2003;79:572-6

Survey: N=125, 3rd and 4th year medical students
-75.2% - considered taking a sexual history as an important part
of their future career
-57.6% - considered themselves “adequately trained” in this area

Survey: 101 US and Canadian medical schools
◦ Only 10 hours of human sexuality education in 67% of programs
(including contraception, STD prevention and treatment, etc.)
Wittenberg et al. J Sex Med, 2009; 6:362-8
Solursh et al. Intl J Impot Research, 2003; 15:541-5
Orgasm (s)
Plateau
Sexual
Excitement/
Tension
Arousal
Satisfaction
Desire
Time following sexual
stimulation
Basson R. Obstet Gynecol. 2001;98:350-3.
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Circular model, begins with
neutrality, influenced by goal
of emotional intimacy
Physical desire may be
reactive, rather than
spontaneous
Satisfaction = subjective
reaction to the experience
Importance of environment
and stimuli that are
conducive to sexual
expression
Basson, R, Sexual Dysfunction in Medicine, 2001,vol2, no3.,pp.72-77.
Basson, R, Sexual Desire and Arousal Disorders,
NEJM,2006,vol354,pp1497-1505.
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SWAN 2003 – Study of Women’s Health Across the Nation
2400 multiethnic midlife women in 6 US cities
(Hispanic, Caucasian, AA, Chinese, Japanese)
Reported many motivations for engaging in sexual play.
Primary = desire for emotional closeness

40% = never/rarely experience physical desire at initiation
or between experiences

87% = satisfied with their sexual relationships
Basson, R, Sexual Dysfunction in Medicine, 2001,vol2,
no3.,pp.72-77. Basson, R, Sexual Desire and Arousal
Disorders, NEJM,2006,vol354,pp1497-1505.
Female sexual function POSITIVELY affected by:

Stable mental health (past and current)

Positive emotional well being and self image

Rewarding past sexual experiences

Positive feelings for a partner

Positive expectations for the relationship
Basson, R. NEJM, 2006;354:1497-1506; Goldstein a et al, Female
Sexual Function and Dysfunction, 2006. Leiblum,SR. J Gend Spec. Med.
1999;2:41-5
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Primary mechanisms: VASOCONGESTION

Genital vasocongestion begins within 30 sec of erotic stimuli

Parasympathetic and Sympathetic nerves release:
◦ Nitric oxide =
 mediate vasodilatation
◦ Acetycholine =
 blocks noradrenergic vasoconstrictive mechanisms
 promotes endothelial release of nitric oxide
◦ VIP (vasoactive intestinal polypeptide) =
 relaxation of vaginal sm. muscle permitting vaginal expansion
 arteriolar dilatation facilitates transudation of fluid for lubrication
Glaser,R.Institute of Behavioral Medicine. Research, Ohio State Univ. 2004,
Laumann, EO, Paik, A, Rosen, RC. JAMA, 1999,28:6,537-544.,
Basson, R. Sexual desire and Arousal Disorders in Women. NEJM,2006,
vol 354,pp1497-1505.
HORMONE

40% of women with symptomatic vaginal atrophy due to low levels
of estrogen confirm “adverse effects” on sexual function

Low estrogen levels are associated with reduced baseline vaginal
vasocongestion (i.e., in the nonstimulated state)
Glaser,R.Institute of Behavioral Medicine. Research, Ohio State Univ. 2004,
Laumann, EO, Paik, A, Rosen, RC. JAMA, 1999,28:6,537-544.,
Basson, R. Sexual desire and Arousal Disorders in Women. NEJM,2006,
vol 354,pp1497-1505.
Lower Estrogen Levels Are Associated With
Increased Prevalence of Sexual Problems
% Reporting Problems
60
<50 pg/mL Estradiol
>50 pg/mL Estradiol
50
40
30
20
10
0
Vaginal
Dryness
Bothered by
Problem
Dyspareunia
(intensity)
Pain With
Penetration
n = 93; significance not reported.
Sarrel PM. J Womens Health Gend Based Med. 2000;9:S25-S32.
Adapted from Sarrel PM. Sexuality and menopause. Obstet Gynecol. 1990;75(4 Suppl):26S-30S,
©1990, with permission from the American College of Obstetricians and Gynecologists.
Burning
Princeton Consensus Statement on Female
Androgen Insufficiency

Female androgen insufficiency consists of a pattern
of clinical symptoms in the presence of:
– Decreased bioavailable testosterone
– Normal estrogen status
– Clinical symptoms include impaired sexual
function, mood alterations, and diminished
energy and well-being
Bachmann G, et al. Fertil Steril. 2002;77:660-5.

Peak androgen production mid 20’s
◦ Halved by age 60

Large scale study: FSD + low FAI
◦ Significant decrease in desire, mood, well being

Premenopausal women: HSDD + A-lowest quartile
◦ Significant decrease in desire, energy
Laumann, EO, Paik, A, Rosen, RC. JAMA, 1999,28:6,537-544.
Muniarez,R, Goldstein,I et al. 2001 Female Sexual Function Forum, Boston University,
Davis, SR et al, Menopause, in press 2006.

Neurotransmitters regulate mood, cognition, and behavior,
including sexual motivation and reward seeking
Stahl SM. Essential Psychopharmacology. 2nd ed. New York, NY:
Cambridge University Press; 2000.
Foote SL et al. In: Bloom FE and Kupfer CJ et al. Psychopharmacology.
1995.
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Orgasm:
◦ clitoral, urethral, anterior fornix,
labial &/or “other” erotic
stimulation

Clitoral orgasm:
most common
◦ mediated by clitoral branch of the
pudendal nerve

Deep vaginal orgasm:
approx 30% of women
Hyde J. Biological Substrates of Human Sexuality,2005, APA.
Goldstein et al. Women’s Sexual Function and Dysfunction, 2006,
Taylor-Francis.
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Hypogastric nerve:
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Pelvic nerve:
◦ uterus/cervix
stimulation
◦ vaginal/”G Spot”, cervix,
rectal stimulation

Vagus nerve:
◦ cervix, uterus, “other
erogenous zones”
stimulation
Hyde J. Biological Substrates of Human Sexuality,2005, APA.
Goldstein et al. Women’s Sexual Function and Dysfunction, 2006,
Taylor-Francis. Komisaruk, Beyer-Flores, Whipple. The Science of
Orgasm, 2006, Johns Hopkins University Press.
Sexual activity appears to be “good” for overall health …
- Intercourse/ orgasm burns 200 calories
- Raises HR & BP to “heart healthy” levels
(who needs jogging?)
- Regulates body temperature
- Increases pain thresholds (40%)
- Speeds wound healing
- Increases immunoglobin levels (30%)
Glaser,R.Institute of Behavioral Medicine. Research, Ohio State Univ. 2004.
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National Health and Social Life Survey (1999):
Strong assoc between urinary tract sxs and
- arousal disorders
(odds ratio 4.2)
- sexual pain disorders
(odds ratio 7.6)
Screening, identifying, and managing sexual
complaints can result in significant
improvement in overall QOL for women
Laumann, EO. et al. JAMA, 1999;281:537-44
Laumann, EO. et al. Arch Sex Behav, 2006;35:145-61
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Hypoactive sexual desire disorder

Sexual aversion disorder
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Sexual arousal disorder
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Orgasmic disorder
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Dyspareunia
◦ The persistent or recurrent lack of sexual fantasies, thoughts,
desires and receptivity to sexual contact.
◦ The persistent or recurrent fear or aversion of sexual contact.
◦ The persistent or recurrent inability to become sexually
aroused, often characterized by inadequate vaginal lubrication
for penetration.
◦ The persistent or recurrent inability to orgasm.
◦ Pain during sexual intercourse.
** Must cause personal and/or interpersonal distress
Basson et al 2000. Report of the International Consensus
Development Conference on FSD: Definitions and Classifications
.J Urol. 163;888-893.
Sexual
function based primarily on intimacy
Important
to understand and quantify genital
responses but also consider how sexual
stimuli are “processed”

Is sexual behavior “processed” as:
◦ Trust, closeness, pleasure … OR
◦ Threat, vulnerability, pain …
Important to assess if sexual symptoms are:
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reflecting normative changes across the lifespan
adaptations to a particular situation
related to her medical illness
of unexplained etiology
Important to assess if patient is experiencing
distress as a result of sexual changes, or
simply reporting that they occur
Assess partner’s role and sexual function
“It Takes Two To Tango!”
The Female Sexual Function Index (FSFI)
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19 items, internal consistency, test-retest reliability
Discriminates FSD in 5 domains:
 desire, arousal, orgasm, satisfaction and pain
The Sexual Function Questionnaire (SFQ)
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31 items, reliability and validity established
Discriminates FSD in 7 domains, including partner
satisfaction
Rosen, R et al. J Sex and Marital Therapy, 2000, 26,191-208
Rosen,R Fertil Steril 2002;77 Suppl 5 89-93.
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Women may be unable to separate these two
Dyspareunia leads to fear of more pain and
altered arousal (psychological and physical)
Poor arousal can lead to poor lubrication,
which can lead to dyspareunia
Bimik, HM, et al. Arch Sex. Beh, 2005; 34:11-21
Affects ALL aspects of the female sexual response
(eg: desire, arousal, orgasm, satisfaction)
Dyspareunia : 2 types
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
Superficial (entry) :
◦ often due to inflammation at the introitus associated with: UTI,
urethritis, vaginitis, provoked vestibulodynia
Deep (thrusting) :
◦ often occurs in women with CPP related to bladder, uterine,
ovarian, bowel or pelvic floor muscle pathology
Hypersensitivity disorders can cause or complicate FSD
symptoms in urogynecology
IC/PBS, HT-PFD, PVD, etc
Meston,CM etal.Ann Rev Clin Psychol,
2007;3:233-56
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Localized or generalized (or both)
Superficial or deep (or both)
Aggravated by penetration or thrusting (or both)
Primary or Secondary
Constant or Episodic
May or may not have a clearly discernable
sentinel event
Mean time to diagnosis 4.4 yrs
Bachmann GB et al. JRM 2006:
http://www.reproductivemedicine.com/features/2006
junfeature.htm
•Ripping
•Tearing
•Burning
•Friction
•Irritation
•Itching
•“Deep” pain
•Feeling of need to urinate during vaginal
intercourse
•Feeling that something is “hitting” or
“blocking”
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Inspection of external genitalia
• Muscle tone, skin color/texture/turgor/thickness, pubic hair
• Cotton swab test (pain mapping): vulva, vestibule, hymenal ring,
Bartholin’s and Skene’s glands
• Vulvar atrophy, vulvar dystrophy, vulvar vestibulitis, HPV infection
• Retract clitoral hood and expose clitoris
• Examine posterior fourchette and hymenal ring
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Bimanual vaginal examination
•
•
•
•
•
•
•
•
Palpate rectovaginal surface, levator muscles, vaginismus, bladder/urethra
Episiotomy scars, strictures, vaginal adhesions, vaginal atrophy, vaginal pH
Speculum examination and Pap smear
Evaluate for prolapse, vaginal length, vaginal mobility
Perform uterus, adnexa, rectal examination
Rectal disease, vaginismus, levator ani myalgia, IC, UTI
Postoperative or postradiation changes, stricture
Fibroids, endometriosis, masses, cysts
Dhingra, C, et al, J of Women’s Health 2011
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Vulvoscopy
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Perineometry
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Biothesiometry
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Ph testing/ Microscopy
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Doppler flow studies
Rosen, R et al. J Sex and Marital Therapy, 2000, 26,191-208
Rosen,R Fertil Steril 2002;77 Suppl 5 89-93.

Identify and treat all pain generators of CPP
IC/PBS, VVS, HTPFD, Constipation, IBS, Endometriosis

Identify and treat co-existing sexual dysfunctions:
Hypoactive Sexual Desire Disorder
Female Arousal Disorder
Female Orgasm Disorder
Partner concerns
Counseling

More than 50% of women with sexual pain also have
HSDD/ avoidance secondary to fear of pain
Whitmore K.E. et al JSM 2007 (4): 720-727
Gynecologic/Vulvar
Musculoskeletal
DYSPAREUNIA
Gastrointestinal
Urologic

The pain is REAL!

Impacts QOL

History taking/accurate diagnosis: KEY
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Realistic expectations

Multi-disciplinary approach is necessary
Kristene E Whitmore, MD
Professor of Surgery/Urology and OBGYN
Chair of Urology, FPMRS
Drexel University College of Medicine
Philadelphia, Pennsylvania
Duration
◦ Non-cyclical pain persisting for at least 6 months
Location
•Pelvis
•Lower abdomen
•Low back
Perception of Pain
•Sharp
•Burning
•Pressure/Discomfort
•Medial aspects of thigh
•Inguinal Area
•Dull ache
•Throbbing
Modality of Pain
Continuous
Cyclic
The Standardisation of Terminology in Lower Urinary Tract Function: Report from the Standardisation Sub-Committee of
the International Continence Society. P. Abrams, et al. Urology. 2003 Jan;61(1):37-49.
Classification/Taxonomy of CPP Syndromes
Syndrome - a complex of concurrent symptoms and
signs that is collectively indicative of a disease,
dysfunction or disorder.
•Nociceptive - Non-neural tissues
•Somatic – Achy/throbbing; localized
•Visceral – Intermittent, poorly localized, viscera
•Neuropathic – Lesion, somatosensory
•Centrally-Generated - CRPS
•Peripherally-Generated
•Mononeuropathy – pudendal nerve entrapment
Lorig, KR., et al :Medical Care, 37(1):5-14, 1999

The complex of CPP
Syndromes includes:
◦
◦
◦
◦
◦
◦
◦
◦
◦
Lower Urinary Tract Pain
Male Genital Pain
Female Genital Pain
Gastrointestinal Pain
Musculoskeletal Pain
Neuropathic Pain
Psychological overlay
Sexual Pain
Extra-Pelvic CoMorbidities
Symptoms
• Bladder Pain
 Pain, pressure of
discomfort
 Bladder/referred
Signs
•Bladder Pain
•Supra-pubic, Bladder
tenderness
• Urethral Pain
• Intermittent/Persistent
 Voiding/intercourse
•Urethral Pain
•Urethral
tenderness
The Standardisation of Terminology in Lower Urinary Tract Function: Report from the Standardisation Sub-Committee of
the International Continence Society. P. Abrams, et al. Urology. 2003 Jan;61(1):37-49.
Symptoms
•
Vulvodynia (skin)
• Vulvar, vestibular or clitoral
• Uterine/Tubal Pain
• Dysmenorrhea, infection,
endometriosis, adenomyosis
• Vaginal Pain (Dyspareunia)
• Superficial/deep
• Pelvic Floor Pain
(Musculoskeletal)
• Bulging, Evacuation Dysfunction,
dyspareunia
• Pelvic Organ Malignancy
• Urinary, GI Dysfunction
• Pain following Pelvic Surgery
• Organ/ nerve injuries, discharge,
mesh
Signs
•Vulvodynia
•Tenderness, fissures, ulcers or
inflammation
•Uterine/Tubal
•Tenderness, erythema, discharge,
adnexal mass, enlarged uterus
•Dyspareunia
•Identify pain generators
•Pelvic Floor
•Trigger Points
•POPQ score
•Pelvic Organ malignancy
•Mass, radiation changes,
scarring
•Pain Following Pelvic surgery
•Tenderness,
discharge,extrusion
Tunitsky E, Abbott S, Barber MD Interrater reliability of the International Continence Society and International
Urogynecological Association (ICS/IUGA) classification system for mesh-related complications Am J Obstet Gynecol. 2012
May;206(5):442.e1-6.
Symptoms- Persistent, Episodic
◦ Prostate Pain – Dyspareunia
◦ Scrotal Pain – Urinary tract / STD
◦ Testicular Pain- Localized
◦ Penile Pain –not primarily urethral
◦ Urethral Pain –LUTS, Sexual Dysfunction
◦ Epididymal Pain – Scrotal/Testicular pain
◦ Sexual Pain – Dyspareunia, ED
Signs
◦
◦
◦
◦
◦
◦
Prostate
Scrotal
Testicular
Penile
Urethral
Epididymal
Tenderness
Evaluation
•Prostate Pain –
secretion culture,
UA, CPSI
•Scrotal Pain
•Testicular Pain
•Penile Pain
•Urethral Pain
•Epididymal
Pain
•Sexual Pain
•IIEF
Part III: Pain Terms, A Current List with Definitions and Notes on Usage" (pp 209-214) Classification of
Chronic Pain, Second Edition, IASP Task Force on Taxonomy
US
GI Symptoms Anorectal
• Chronic proctalgia –
episodic > 20 minutes
◦ Levator ani syndrome –
sitting/defecation
◦ Proctalgia fugax –episodic,
seconds to minutes
◦ Anal fissure –bright red
bleeding with BM, anal
pain/spasm
◦ Abscess –tenesmus,
drainage
◦ Hemorrhoids—
engorgement, itching, lump
GI Symptoms - Colorectal
IBS –abdominal pain ≥ 3
days/week, ≥ 3 months;
• Improvement with
defecation, chg in BM
frequency/consistency
Colitis –abdominal/anal pain
Crohn’s Disease –intermittent
or persistent abdominal
pain
◦ Crohn’s disease –anal
pain
during
flare
Drossman DA,
Corazziari
E, Delvaux
M, Spiller RC, Talley NJ, Thompson WG, Whitehead WE.Rome III: The Functional.
Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon; 2006
GI Signs- Identify Pain Generators

Tendernes
s

Tendernes
s
Anorectal
◦ Chronic proctalgia
◦ Levator ani syndrome
◦ Proctalgia fugax – usually asymptomatic
◦ Anal fissure – separation of the anoderm,
◦ Abscess –collection and drainage
◦ Hemorrhoids –skin tags, thrombosis, prolapse on straining.
◦ Anorectal Crohn’s disease – skin tags, hemorrhoids, fissures, anal
ulcers,
strictures, abscess/ fistula
Colorectal
◦ IBS –abdominal
◦ Colitis –abdominal / rectal
◦ Crohn’s disease –abdominal
GI Evaluation

Anorectal/Colorectal
◦ CRADI, US, CT, MRI
Drossman DA, Corazziari E, Delvaux M, Spiller RC, Talley NJ, Thompson WG, Whitehead WE.Rome III: The
Functional. Gastrointestinal Disorders. 3rd ed. McLean, VA: Degnon; 2006
Symptoms


Pelvic floor muscle pain- pain with sitting,
possible bladder and bowel evacuation
dysfunction, vulvodynia, dyspareunia, myalgia
Coccyx pain syndrome - pain in the coccyx,
provoked by sitting, cycling, bending , or
standing. May also include introital dyspareunia
and bowel evacuation dysfunction.
◦ SIJD- Pain walking/bending
◦ Sacro-spinous ligament- Pain sitting
ACOG PRACTICE BULLETIN CLINICAL MANAGEMENT GUIDELINES FOR OBSTETRICIAN–GYNECOLOGISTS
NUMBER 51, MARCH 2004
SymptomsPulling/throbbing that limits
physical activity
◦ Infiltration of sacral nerves
–peri-menstrual,
Signs- Nerve Distribution
Tenderness, Trigger Points
•Infiltration of sacral
nerves
bowel/bladder evacuation
dysfunction
◦ Somatic neuropathic pain –
nerve injury (stretching, blunt
trauma, compression,
entrapment, suture ligature)
•Somatic neuropathic
pain –
Mense, S., D. G. Simons, et al., Eds. (2001). Muscle pain: understanding its nature,
diagnosis and treatment. Philadelphia, Lippincott Williams & Wilkins
Symptoms
◦ Pudendal neuropathy – Constant burning/intense
lancinating pain. There is no pain in supine position.
◦ Neuroma formation/ Maladaptive neuronal plasticity Continuous neuropathic pain in the nerve distribution.
de Boer RD et al. Distribution of signs and symptoms of complex regional pain syndrome type I in patients
meeting the diagnostic criteria of the International Association for the Study of Pain.
Eur J Pain. 2011 Sep;15(8):830.e1-8
Symptoms

Complex regional pain
syndrome (CRPS):
Skin changes, intense
burning pain, the pain
spreads, heightened by
stress. Association with
systemic disorders.
Signs
Complex regional pain syndrome
(CRPS):
Increased skin sensitivity, changes in
skin temperature, changes in skin
color, changes in skin texture.
◦ CRPS 1 –tissue injury
◦ CRPS 2 –nerve injury
de Boer RD et al. Distribution of signs and symptoms of complex
regional pain syndrome type I in patients meeting the diagnostic
criteria of the International Association for the Study of Pain.
Eur J Pain. 2011 Sep;15(8):830.e1-8
Symptoms

.

Pain following mesh
injury –pain or bleeding
during sexual
intercourse, pain during
physical activity,
spontaneous pain, or
feeling mesh
Signs
Pain following mesh injury
–local tenderness with
combination of redness and
purulent discharge, mesh
extrusion
Tarlov’s cyst –localization Tarlov’s cyst –affected
of the cyst.
nerve root.
Interrater reliability of the International Continence Society and International Urogynecological
Association (ICS/IUGA) classification system for mesh-related complications . Am J Obstet Gynecol.
2012 May;206(5):442.e1-6
Negative affective, cognitive and
psychosocial state of chronic pain
Symptoms-
Signs
Fear –agitation and dread,
imminence of danger, mood
changes.
Fear –avoidance
Anxiety
affect, avoidance
–Fear, panic attack
Alappattu MJ, Bishop MD. Psychological factors in chronic pelvic pain in
women: relevance and application of the fear-avoidance model of pain.
.
Phys Ther. 2011;91:1542-50
Anxiety
– de-conditioning, negative
Symptoms
Signs

Depression altered
mood, sadness,
despair,, sexual
dysfunction, thoughts
of death /suicide,
sleep disorder
Depression –altered mood,
agitation, restlessness, irritability,
weight change, difficulty
concentrating , fatigue

Catastrophizing –
Catastrophizing –rumination,
helplessness, magnification

exaggerated
orientation,
maladaptive coping
mechanism, worrying,
helplessness,
hopelessness.
Anger –extreme
Anger –facial expression, muscle
tension , eye contact
displeasure, rage,
indignation,
Gustin
SM, Wilcox SL, Peckor
CC et al. Similarity of suffering: equivalence of psychological and psychosocial
factors
in
neuropathic
and
non-neuropathic
orofacial pain patients. Pain 2011 Apr;152(4):825-32
hostility.
◦ Fibromyalgia
◦ Chronic fatigue
syndrome
◦ Autoimmune Disorders
 Sjogren’s Syndrome
 Temporo Mandibular Joint
Disorder/Migraine
◦ Generalized
Hypersensitivity/Asthma
◦ Sleep Disorders
A Guide for Physicians Considering Chronic Fatigue Syndrome .
National Chronic Fatigue Syndrome and Fibromyalgia Association
 Pain,
pressure, or discomfort
perceived to be related to the
urinary bladder and associated
with LUTS
◦ Greater than 6 weeks duration in
the absence of infection or other
identifiable conditions
Hanno,PM. Et al: Diagnosis and treatment of interstitial cystitis/bladder pain syndrome. American Urological
Association Guideline 2011
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, van Kerrebroeck P, Victor A, Wein A. The
Standardisation of terminology of lower urinary tract function: Report from the Standardisation Subcommittee of

35% of 987 women with IC/BPS had IBS
◦ Similar prevalence to men with
IC/BPS
◦ Coexistence of psychological
disorders
◦ History of sexual and physical abuse
◦ Similar healthcare utilization
Nickel,JC,Berger,R,Pontari,M. Changing paradigms for chronic pelvic pain: a report from the chronic pelvic pain/chronic prostatitis scientific workshop. Rev Urol,2006;8(1):2835.
Williams, R, Hartmann, K et al: Recognition and treatment of irritable bowel syndrome among women with chronic pelvic pain. American Journal of Obstetrics and Gynecology
2005;192:761-767
–
–
–
Constillation of persistant & distressing symptoms
Chronic Multisymptom Illnesses (CMI)
• Multifocal musculoskeletal pain, fatigue, memory
and/or mood difficulties
• FM, CFS, Gulf War Illness, Sick Building Syndrome
• Chronic h/a, TMJ, IBS
65% of CP/CPPS pts expressed characteristics of FBS
• IBS (35%)
• Chronic h/a (36%)
• FM (5%)
• Rheumatological symptoms (21%)
• Psychological disturbances (48%)
Submitted to UROL, Approaching urologic pelvic pain as a functional somatic syndrome: rationale and implications for patient care and
Prolonged Noxious Stimuli
Upregulation
Allodynia
NMDA = N-methyl-D-aspartate; AMPA = α-amino-3-hydroxy-5-methyl-isoxazole-4-propionic
acid;
NK = neurokinin; PKC = protein kinase C; NO = nitric oxide.
CGRP = calcitonin gene-related peptide.
Reprinted with permission from Brookoff D. Hosp Pract. 2000;35:45-52,59.
Cross Sensitization
• Transmission
of noxious
stimuli from a
diseased pelvic
organ to an
adjacent normal
structure
• Axon
convergence at
DRG – antidromic
propagation to
adjacent organ
• Inter-neuronal
interaction in DH
• Convergence
of afferents in
the brain of two
different organs
Malykhina, A. Neural mechanisms of pelvic organ cross-sensitization. Neuroscience,2007;149:660-672







Abdominal wall trigger points
Neurologic exam (pin vs light touch)
Vestibulitis/vaginitis (estrogen status)
Urethral hypersensitivity (Q-tip or
catheter)
Bladder base/trigone tenderness
Pelvic floor muscles: tenderness,
tension, awareness
◦ Levator ani muscle tenderness
◦ Objective evaluation of pelvic floor tone
and stability with ISEMG, perineometry
Uterus/adnexa
Determine each site where tenderness is located
ISEMG
= iliac spine electromyography.

Q-tip touch sensitivity test1
◦ Preclitoral area, anterior fourchette,
interlabial sulci, minor vestibular sulci,
minor vestibular and Bartholin gland ostia,
posterior fourchette, perineum
1. Kaufman RH et al. Chicago, Yearbook. 1989:299-360. 2. Whitmore K. Comprehensive
assessment of pelvic floor dysfunction. Issues in Incontinence. 1998.

Pelvic floor muscle contraction
0: nil
1: flicker of muscle contraction
2: weak contraction
3: medium – slight lift of examiner’s finger, no
resistance
◦ 4: strong – elevation of examiner’s finger
against light resistance
◦ 5: very strong – elevation of examiner’s finger
against strong resistance
◦
◦
◦
◦
Isherwood PJ, Rane A. Br J Obstet Gynaecol. 2000;107:1007-1011.

Muscle hypertonus
0: no pressure/pain with examination
1: comfortable pressure with examination
2: uncomfortable pressure with examination
3: moderate pain with examination,
intensifies with pelvic floor muscle
contraction
◦ 4: severe pain with examination, unable to
perform pelvic floor muscle contraction
because of pain
◦
◦
◦
◦
Spadt S et al. Issues in incontinence. 1998;1:2-10.
Distribution of data when comparing perineometry and digital assessment of
pelvic floor contraction strength. #s above markers indicate #of Women, vertical
lines indicate grouping of perineometry scores into six categories
Isherwood P, and A Rane. Brit J of Obstet Gynecol. 2000; 107:1007-11.
Routine
Optional
Urinalysis
Voiding log, questionnaires
Urine culture
Urine cytology, renal
ultrasound, cystoscopy
(hematuria)
Urodynamics
Cystoscopy/hydrodistention



Many questionnaires are used1
O’Leary-Sant, University of
Wisconsin validated in studies1
PUF questionnaire clinically
useful1
◦ Correlates with PST outcome2
◦ Scores2
 Controls: ≤2
 IC patients
 >15 highly suggestive of IC/PBS (≥84%)
 ≥20 highly indicative of IC/PBS (91%)
PUF = Pelvic Pain and Urgency/Frequency Patient Symptom Scale.
1. Nickel JC. Med Clin North Am. 2004;88:467-481. 2. Parsons CL et al. Urology.
Leakage*
(0-3
scale)
Amount
Voided
Activity
6:50 AM
425 mL
Getting up/breakfast
0
Yes
16 oz coffee
6 oz orange juice
7:45
150 mL
Leaving for work
0
Slight
…
8:20
350 mL
At work
0
Yes
8 oz coffee
9:10
…
Cough
2
Yes
…
9:15
300 mL
Working
0
Yes
10 oz water
12:25 PM
275 mL
Working/at lunch
0
Yes
8 oz water
2:45
400 mL
Bending
1
Yes
4 oz water
5:30
250 mL
Leaving work
0
Yes
…
6:30
125 mL
Exercise class
2
Slight
12 oz water
7:45
…
Dinner
0
No
4 oz wine, 8 oz water
8:20
375 mL
At home
0
Yes
4 oz water
10:50
250 mL
Getting ready for bed
0
Yes
…
Time
Urge
Present
Fluid Intake
Amount/Type
* 0 = no leakage; 1 = drops; 2 = wet underwear or light pad; 3 = soaked pad or clothing.





Majority of patients have improved symptoms after
anesthetic instillation
Intravesical anesthetic solution may help diagnose
bladder origin of pain in patients with suspected IC
May be better tolerated than PST
◦ Relieves pain instead of inducing it
Does not necessarily support urothelial dysfunction
diagnosis
Valuable option but not validated as diagnostic tool
for IC
Hunner Lesion
BUT cystoscopy is NOT required for diagnosis and
a negative cystoscopy does NOT rule out IC
Sant GR. Interstitial Cystitis. Lippincott, Williams & Wilkins; 1997.






Education
Behavior modification
Exercise and exercises (eg, relaxation,
stretch)
Avoidance of flare initiators
Diet modification
Support groups

Organ-specific therapy

Neuromodulation4

Immunomodulation5

Physiotherapy3,5

Cognitive behavioral therapy3,5,7
◦ Pentosan polysulfate (PPS)1
◦ Intravesical therapies – DMSO, GAGs, alkalinized lidocaine2
◦ Surgery – cautery, laser, cystectomy3
◦ Amitriptyline, gabapentin, pregabalin1,5
◦ Neurostimulation
◦ Botulinum toxin type A
◦ Hydroxyzine
◦ Cyclosporine, mycophenolate mofetil
◦ Specific pelvic floor physiotherapy6
◦ General physiotherapy (massage therapy)
◦ Directed at depression, maladaptive coping mechanisms, social interaction
including sexual functioning
DMSO = dimethyl sulfoxide.
1. Phatak S, Foster HE. Nat Clin Pract Urol. 2006;3:45-53; 2. Hanno P. Int Urogynecol J. 2005;16:S2-S34; 3.
Moldwin RM et al. Urol. 2007;69:73-81; 4. Karsenty G et al. EAU-EBU Update Series 4, 2006:47-61; 5. Dell JR,
Parsons CL. J Reprod Med. 2006;49:243-252; 6. Weiss J. J Urol. 2001;166:2226-2231; 7. Morley S et al. Pain.
1999;80:1-13.

Organ-specific therapy1,2,3
◦ -Blockers
◦ Skeletal muscle relaxants

Neuromodulation1,2
◦ Amitriptyline, gabapentin, pregabalin
◦ Neurostimulation

Immunomodulation1,2
◦ No evidence at present

Physiotherapy1,2
◦ Specific pelvic floor physiotherapy

Cognitive behavioral therapy1,2
◦ Directed at depression, maladaptive coping mechanisms, social
interaction including sexual functioning
1. Peters KM et al. Urol. 2007: 70:16-18. 2. Moldwin RM. Int Urogynecol J Pelvic Floor Dysfunct. 2005
16:S30-S31; 3. Moldwin RM et al. Urol. 2007;69:73-81.

Vagina/vulva (eg, vulvodynia)1
◦ Local anesthetics, antibiotics, antifungals, pain
management, surgery

Uterus/ovaries (eg, chronic PID)2
◦ Antibiotics, hormones, surgery

Peritoneum (eg, endometriosis)3
◦ Hormones, surgery

Bowel (eg, IBS)4
◦ Bulking agents, antidiarrheal agents,
anticholinergics
1. Baker DA. Conn’s Current Therapy, 1223, 2005. 2. Shrier LA, Conn’s Current Therapy, 1231, 2005. 3.
Adamson GD, Conn’s Current Therapy, 1198, 2005. 4. Christensen J, Conn’s Current Therapy, 593, 2005.
Treatment
Indication
PPS 100 mg TID1 ± dietary modifications2
Treatment of bladder pain or discomfort
associated with IC
DMSO3
Analgesia, mast cell inhibition, increase in
bladder capacity
New or Proven Optimal Adjunctive Treatments*
Rationale for Use
Tricyclic antidepressants
Amitriptyline
Anticholinergic and sedative effects
Antihistamines
Hydroxyzine
Stabilization of mast cells and blocking of
histamine release
Anticholinergics
Oxybutynin
Reduction of urgency and frequency
Anticonvulsants
Gabapentin1
Pain modulation
Intravesical anesthetic instillations5
Treatment of acute pain and flares
*Not indicated for IC.
1. Evans RJ. Rev Urol. 2002;4(suppl 1):S16-S20. 2. Butrick CW. Clin Obstet Gynecol.
2003;46:811-823.
3. Dell JR, Parsons CL. J Reprod Med. 2004;49:243-252. 4. Parsons CL et
al. Female Patient. May 2002(suppl):12-17. 5. Moldwin RM et al. Urology. 2007;69:73-81.


Trigger Point Injections:
◦ Procaine/ marcaine +/- solumedrol.
◦ Pelvic floor muscle trigger points.
◦ Obturator internus, coccygeus, ilio-coccygeus,
pubo-coccygeus, prirformis.
Nerve Blocks:
◦ Pudendal, Genito-femoral, hypogastric, sacral,
lumbo-sacral.
◦ UTZ, CT quidance.
Biochemical differences
Among Clinical
Preparations
Acceptor affinities
Complex size
Formulation
Intracellular target
May yield differences in
therapeutic profile
Dose
Efficacy
Safety
Duration
“Units of biological activity of (Btx-products) cannot be compared to nor
converted into Units of any other botulinum toxin or any toxin assessed with any
other specific assay method.” Reltz, A, et al. Eur Urol, 2004: 45; 510-515
Release of Ach from Motor Nerve
Terminal
BoNT
1mL BoNT
Patient Profiles
Neurogenic basis
•N = 59, spinal cord injury (53): American Spinal
Injury Association Class (A=33, B=10, C=5, D=4,
E=1)
•Multiple sclerosis (6)
•Mean NDO history 63 months (range 3 months –
24 years)
Withdrawls
•2 patients in the 200 U group
- AE (uretheral sticture) prior to study drug
administration
- Lack of efficacy at week 6; protocol violation
Demographics
•Mean age, 41 years (range 20-72)
•61% male, 39% female, 93% caucasian
Baseline measures
•No differences between groups
Schurch B, et al. J Urol. 2005; 174:196-200
Schurch B, et al. J Urol. 2005; 174: 196-200
BoNT Dose
Schurch B, et al. J Urol. 2005; 174: 196-200








67 patients with refractory IC/PBS, mean 42.5 yrs
BTX group: 44 pts. 200 U (15 pts) or 100 U (29 pts)
suburothelial, then HD 2 wks later
Control group: HD only
ICSI ↓ in all groups
3 mo: VAS ↓, Functional and cystometric bladder
capacity ↑, significant only in BTX group
6 mo: 71 % of BTX group moderate to marked
improvement on GRA
12 and 24 mo: BTX 55% and 30% success vs
Controls 26% and 17% (p=0.002)
Retention: 200u-47%, 100u-10%
Kuo HC, Chancellor MB. BJU Int. 2009 Sep;104(5):657-61








26 pts with refractory IC/BPS
100 U BTX injected in 10 trigonal sites.
Retreatment allowed 3 mo after
All pts had subjective improvement at 1 and 3 mo
Significant improvement with pain, frequency,
nocturia, ICSI/ICPI, QoL
MCC ↑ x 2
Effective treatment at 9 mo in >50% pts
Transient significant ↓ nerve growth factor and
brain-derived neurotrophic factor
No voiding dysfunction or retention.
Pinto et al., Eur Urol. 2010 Sep;58(3):366-8








12 women and 3 men with refractory PBS, mean 58
yrs
200 U (20, 1cc) BTX in trigone and lateral walls
1- 3 mo: 87% pts had subjective improvement
1- 3 mo: ↓ VAS, frequency, nocturia
5 mo: ↑ VAS, frequency, nocturia compared to
baseline
12 mo: pain recurred in all pts
9 pts had dysuria at 1 mo, 4 at 3 mo, 2 at 5 mo
3 pts transient PVR >150cc
Giannantoni A et al. J Urol. 2008 Mar;179(3):1031-4







7 women with intractable genital pain
20-40 U BTX A at vestibule, levator ani, or
the perineal body
Repeat injections every 2 weeks if
symptoms perstisted.
In all patients, pain disappeared
5 patients- 2 Injections; 2 patients- 1
Injection.
VAS improved from 8.3 to 1.4
Mean follow-up 11.6 months, no side
effects
Yoon, H et al. Int. J. Impotence Res. 2007; 19: 84-87





12 women with PVD
BTX A injection under epithelium
7 received 35 U, 5 received 50 U
VAS 8.1→2.8 (35U) and 7.4→1.8 (50U)
(p<0.0001)
Effect duration 8-14 wks, no side effects
•Dykstra, DD et al. J. Reproductive Med; 51: 467470






12 women with CPP and HTPFD
40 U B/L PR, PC
F/U at 2, 4, 8, 12 wks
Dyspareunia VAS 80→28 (p=0.01)
Dysmenorrhea VAS 67→28 (p=0.03)
25% ↓ manometry at 3 mo (p<0.0001)
Jarvis et al. J. OB & GYN. 2004; 44: 46-50







Double blinded RCT 7, 6mos.
60 women with CPP > 2y and PF spasm
30 received 80 U into PFM (BTX group), 30 Saline.
BTX group: Dyspareunia VAS 66→12 (p<0.001),
nonmenstrual pelvic pain VAS 51→22 (P=0.009)
Placebo: only dyspareunia ↓ significantly (VAS 64 vs
27)
Vag manometry ↓ significantly in both groups 4932cm H20, 44-39cm H20
However no difference in pain scores between 2
groups
•Abbott et al. OB & Gynecol. 2006; 180: 915-923
Figure 1 Schematic representation of entry point and
injection sites for BOTOX (left hand side only
represented).
Jarvis SK, et al. Pilot study of botulinum toxin type A in the treatment of chronic pelvic pain associated with spasm of the levator ani
muscles. Aust and New Zeal J Obstet Gynecol, 2004, 44:46-50.






67 women with sexual dysfunction (variable
presentations)
20 U every 2-3 mo into levator ani
EMG guided needle placement
Mean of 2.4 injections/subject
Symptom reduction 46-76%
“Cure” rate 20-46%
•Bertosali et al. J. It. OB & GYN 2006; 28: 264-268


Keshtgar, AS et al. J. Pediatric Surg. 2007; 42: 672-174
◦ 42 children age 4-16 yrs with idiopathic constipation
randomized to BTX vs myectomy of the IAS
◦ Conclusion: equally effective but less invasive
Maria, G et al. Amer. J. Gastroent. 2006; 101 25702575
◦ 24 adults with chronic outlet obstruction constipation
◦ 60 U to puborectalis
◦ Conclusion: decrease in constipation symptoms and
improved ano-rectal angle
SNM for the treatment of female lower urinary
tract, pelvic floor, and bowel disorders.
• FDA approved for iOAB, UUI, and chronic
nonobstructive urinary retention.
• SNM reduces LUT symptoms by acting on central
nervous system
• Has potential to treat bladder, urethral sphincter,
anal sphincter and pelvic muscles SIMULTANEOUSLY.
• Can also be used in treatment of chronic
constipation, IC/BPS, sexual dysfunction, and
neurogenic disorders
•SNS now approved by the FDA for Fecal Incontinence
Whebe, SA, et al. Curr Opin Ob/Gyn, 2010;22:414-419

Comiter:
◦
◦
◦
◦
◦
◦
◦
◦
25 pts, prospective.
17 pts to implant, 22 mos follow-up.
Frequency—17.1-10.2
Nocturua—4.5-2.0.
Mean voided volume—11ml-214ml.
Pain—5.8-2.3 (VAS).
ICSI—16.5-8.2.
ICPI—14.5-7.2.







Retrospective, case-controlled review
34 ♀’s w/ IC/BPS. Median age 41 years
Stage 1 & 2 InterStim placements
Mean Pre/Post op # voids 17.8/8.1
Mean Pre/Post op PUF scores- 21.61/9.22
Mean Pre/Post op VASP 6.5/2.4
Minimum 6 yr f/u showed adequate
improvement of IC/BPS symptom
Marinkovi, SP, et al. Int Urogyn J 2011; 22:407-412
Diagnose and Treat
All Sources of Pain
Erica Fletcher PT MTC
Fletcher Physical Therapy
Narberth , PA
Evaluate and treat
musculoskeletal imbalances
of the pelvic girdle
Normal Function
•
•
•
•
Maintain bowel and bladder continence
Support viscera
Aides in sexual function
Stabilizes the pelvis

Counter balances respiratory diaphragm

Synergistic action with abdominals

Synergistic with multifidi

Transfers forces through the fascial system

Lymphatic pump
Superficial Layer
• Ischiocavernosus
• Bulbospongiosus
• Transverse perineal muscles
• External anal sphincter




Just deep to
genitalia
Superficial
transverse
perineal
Bulbocavernosus
/
bulbospongiosu
s
Ischiocavernosus

Bulbocavernosus


Ischiocavernosus


Transverse Perineal


Vaginal sphincter
Impedes drainage
from deep dorsal
veins from clitoris
Responsible for
erection, orgasm
Pudendal S2-S4
Levator Ani
•Pubococcygeus
•Puborectalis
•Iliococcygeus
•Tendinous
Arch
Deep Layer
Contractions of levator ani:
◦
◦
◦
◦
Widen the vaginal introitus
Elongate the vagina
Assist in uterine elevation
Enhance sexual pleasure
Obturator
Internus
◦ Originates on
arcuate line of
ilium
◦ Attaches to
tendinous arch of
levator ani before
taking a 90° turn
to gr trochanter



Ischial spine to the
anococcygeal
ligament and
coccyx
Parallel with the
sacrospinous
ligament
Stabilizes the
sacrum and coccyx
Multifactoral Influences:
• Visceral
• Hormonal
• Inflammatory
• Neuropathic
• Musculoskeletal
• Psychosexual
Dyspareunia
• Superficial
• Deep
Genital pain
• Neuropathic
• dermatological
Research links HTPF to:
• Vaginismus
• Dyspareunia
• Vulvar Vestibulitis
• Interstitial Cystitis
• Urgency- Frequency Syndrome
• Proctalgia Fugax
• Pudendal Neuralgia
Bassaly et al. (2011)
•
•
•
186 patients identified with IC
78.3% at least 1 myofascial trigger point
67.9% had 6 or > trigger points
Associated with Sexual Pain Syndromes
Characterics of High tone:
•
•
•
•
•
Pain to palpation
Trigger points
Decreased motor control
Decreased strength
Resistance to stretch
Trigger Point:
A discrete, focal, hypersensitive spots located
in a taut band of skeletal muscle. They
produce pain locally and in a referred pattern
and often accompany chronic
musculoskeletal disorders.
Travell, Janet; Simons David; Simons Lois (1999). Myofascial Pain and Dysfunction: The Trigger Point
Manual (2 vol. set, 2nd Ed.). USA: Lippincott Williams & Williams
•
Musculoskeletal imbalance compensation
•
Visceral-somatic reflex
•
Dermatological-somatic reflex
•
•
•
•
•
•
•
Observation of vulva
Width of introitus
Palpation for tenderness
Muscle tone
Presence of trigger points
Muscle strength
Neuromuscular control
Pelvic Floor Clock
12:
00
Obturator
internus
Obturator internus
9:0
0
3:00
Levator Ani
Levator Ani
6:0
Scoring Muscle Hypertonus:
0 no pressure/pain with exam
1 comfortable pressure with exam
2 uncomfortable pressure with exam
3 moderate pain with exam, intensifies with
PF contraction
4 severe pain with exam, unable to contract
PF due to pain
Modified Oxford Scale
0 no response
1 flicker contraction <1 sec
2 weak contraction, not fluttering
3 moderate contraction, increase pressure,
small degree of lift
4 good contraction, firm pressure, lift of PF
5 strong contraction, good grip and lift
against resistance
Myofasical Release Techniques:
Direct pressure/compression
Strumming
Lateral stretching
Contract-relax
•
•
•
•
•
Breaks pain-spasm-pain cycle
Restores normal muscle tone
Restores normal length tension relationship
Increases blood flow
Increase elasticity of tissue at vaginal opening
•
•
•
•
Increase proprioception
Decreases nerve impingement
Decrease fear of vaginal penetration
Restores sexual function
Weiss et al (2001)
 42 pts with urgency-freq syndrome or IC
 1-2 visits of PT, 8-12 wks
 83% of urgency-freq patients/70% of IC pts
had marked or mod improvement in
symptoms
Oyama et al. 2004
•
•
•
Patients with IC and HTPF (n=21)
Transvaginal massage 2x/wk x 5 wks
Statisically significant improvement in:
 Symptom and problem index (O’Leary Sant
Questionnaire)
 Pain and urgency VAS
 Physical and mental component from Quality-of-Life
Scale
The patient actively
learns to:
• Increase awareness of
pelvic floor
• Recruit the correct muscle
group
• Identify faulty muscle
patterns
• Restore proper
coordination and strength
of muscle contraction


•

May add training with dilator
insertion
Decrease anxiety related to
vaginal penetration
Increase flexibility of
introitus and PFM
GOAL: stabilization of spasm
& return of sexual function
Herman, H. Physical therapy for female sexual dysfunction. In Women’s Sexual Function and Dysfunction (eds) I Goldstein et al, 2005, Iondon, Taylor Francis

The pelvic floor,
piriformis,
gluteus maximus
and multifidi are
the only muscles
that attach to
both the sacrum
and innominate.
 Compresse
s inf aspect
of pubic
symphysis
and SI
joints
 Pelvic
Floor
 Transversus
Abdominus
 Multifidus
 Diaphragm



Diaphragm works
synergistically with
PFM, multifidi and
transversus
abdominals
Inhale =
Contraction of
diaphragm with or
with out TrA and
PFM
Exhale =
contraction of TrA,
PF



Lack of form
closure inherent
in the structure
Structural
insuffiency
present due to
parturition
potential
Greater potential
for mobility




Greater
potential of
mobility
Increased
necessity
optimal neural
control
Optimal
coordination of
muscles
Need for healthy
 Inadequat
e force
closure
facilitates
joint
dysfuncti
on


Muscle resting tone and ability to contract
and relax is altered in the presence of
metabolic inflammatory properties.
C fiber facilitation influences muscle
properties

Hypertonicity
◦
◦
◦
◦
◦
◦
◦
◦
◦
Iliopsoas
Quadratus Lumborum
Pectineus
Piriformis
TFL
Lateral quad
Rectus femoris
Hamstring
Short adductors
◦ Pelvic Floor

Inhibited contraction
◦
◦
◦
◦
◦
Multifidi
Gluteals
Rectus Abdominus
Transverse Abdominus
Long Adductors
Connective Tissue Changes
• Loss of sarcomeres
• Loss of GAG
• Binding of fascia
• Restriction of nutrition and blood supply
• Eventual abnormal movement and firing
pattern
Akeson WH, Woo SL-Y, et al. (1973) The connective tissue response to immobilization: biochemical changes in periarticular
connective tissue of the rabbit knee. Clin Orthop, 93: 356-362.
TaberyJC, Tabery C, et al. (1972) Physiological and structural changes in the cat’s soleus muscle due to immobilization at
different lengths by plaster casts. Am J Physiol, 224: 231-244.





The cycle of joint dysfunction continues
Inflammation can be of visceral or urogenital
tissue, but still affects somatic homeostasis
Somatovisceral convergence
Viscerosomatic convergence
The sequella event
•
•
•
•
•
•
•
Suprapubic pain
Sacral/Coccyx pain
Perineal pain
Rectal pain
Pain with sitting (golf ball)
LBP
Groin Pain






Joint restrictions of the thoracic and lumbar
spine
Hypermobolity of the sacroiliac joint
Positional faults of the sacrum, and
innominate,
Fascial restriction proximal and distal to the
pelvis
High tone pelvic floor dysfunction
Up regulated sympathetic nervous system
Chronic Pelvic Pain:
• Upper chest breathing
• Decreased lower lateral rib excursion
• Increased muscle tone abdominals
• Increased intra-abdominal pressure
• Increased stress on pelvic floor
Haugstad GK, Haugstad TS, Kirste UM et al. (2006) Posture, movement patterns, and body awareness in
women with chronic pelvic pain. J of Psych Research, 61: 637-644.
•
•
•
•
•
•
Structural alignment
Mobility of the spine, rib cage and extremities
External Musculature tone and strength
Internal musculature tone and strength
Breathing pattern
Connective tissue health
Manual Therapy Techniques:
Soft tissue massage
Muscle energy techniques
Joint mobilizations
Manual stretching
Internal Massage
Home Exercise Program:
Stretching
Strengthening
Stabilization exercises
Self-help techniques
Self-internal massage
Empower the patient
Physical demands on musculoskeletal system:
• IADL’s
• Work activities
• Child care activities
• Sexual activities
• Recreational activities

The Balance of Mobility and Stability
•
•
•
Decrease structural imbalances with manual
therapy treatment and exercises
Treat high tone pelvic floor with internal
massage concomitantly with structural
treatment
The pelvic floor tone will normalize with
improved pelvic girdle function
Goals:
• Normalize pelvic floor resting tone
• Normalize pelvic floor contractile abilities
• Normal ROM of the spine and hips
• Pelvic girdle stability with sustained loads
• Restore sexual function
• Return to recreational exercise
.
Iliococcygeus
Pubococcygeus
Puborectalis
Obturator
Internus
Susan Kellogg PhD CRNP
Director of Sexual Medicine
The Pelvic & Sexual Health Institute
Professor of OB/GYN
Drexel University College of Medicine
Philadelphia, Pennsylvania
Myorelaxant drugs
(relax skeletal muscle/ inhibit spasm)
-mataxolone/Skelaxin
-cyclobenzaprine/Flexeril
-tizanadine/Zanaflex
Butrick CW. 2009. Obstet Clin N America 36;707-722.
Suppository Rx-PV or PR suppositories:
*diazepam/Valium 5-10mg (QD-TID)
*baclofen/Kemstro 30mg (QD-TID)
*belladonna/opioid/ B & O 12.5/30
(PRN)
Suppositories used to facilitate local
muscle relaxation and inhibit spasm
most often in conjunction with PT and
dilators, daily, then 3x per week, then
PRN
Butrick CW. 2009. Obstet Clin N America 36;707-722 ; Rogalski M , KelloggSpadt,Set al 2010. Intl Urogyn J;895-99.
Anxiolytic + myorelaxant
(binds to benzodiazepine sites on GABAA receptor)
-diazepam / Valium 2mg QD-TID
-lorazepam / Ativan 1mg QD - PRN
-alprazolam /Xanax .25-.50mg
Anticonvulsants:
-gabapentin/Neurontin
-pregabalin/ Lyrica
SRNIs
- duloxetine HCL /Cymbalta
- mulnacipran / Savella
Rogalski et al 2010 Intl J Urogyn 2010; Butrick CW. 2009. Obstet Clin N America





Rogalski et al 2010
N=26
21 premenopausal, 5 menopausal; 8
multiparous; 18 nulliparous.
100% HTPFD; 85% dyspareunia/PVD,
81% CPP, 61% IC
Interventions: PT, TrP injx and 10 mg
diazepam vaginal suppositories,
inserted nightly for 30 days.
Rogalski, M, Kellogg-Spadt, S et al, 2010, Intl Urogyn J, 895-99




25 /26=“ improved sexual comfort”
Abstinence reversed in 6/7
Perineometry baseline muscle pressures
decreased significantly, both at rest and
post-voluntary contraction return to rest.
Visual analog pain ratings decreased
significantly with palpation of PFM muscles
evaluated pre and post-therapy.
.
Rogalski, M , KelloggSpadt S, et al,2010,Intl Urogyn J. 895-899






Carrico et al 2010
F/U: Safety and efficacy of diazepam
suppositories
11 pts (IC-PFD) V5-10 supp. TID
After 30d: 64% “moderate/marked
improvement” and no s/e
Serum levels WNL (mean 0.29 (0.2-1.0
mcg/ml)
36% mild drowsiness; no respiratory
suppression;no pain worsened
Carrico DJ, Burks FF and Peters KM 5/2010, Urology Times



HTPFD associated with:
“Myofascial pain” a condition in which
there may be several trigger points
limited to a particular muscle area of
the body.
The pain and spasm associated with
trigger points can lead to a vicious pain
cycle in which pain causes more spasm
and spasm causes more pain.



TrP needling: a method of directly
inactivating TrP's -particularly those
refractory to myotherapy.
TrP is penetrated with fine needle,
eliminating TrP as a painful focus.
Needle inserted w/o medication (or lidocaine
and antinflammatory medications can be
added.)
www.American HealthandWellness.com 2010.
PFM TrP Injx
Objective: Inactivate a taut muscle band
unresponsive to manual PT
-Typically require a series (1-8). Each session
results in longer sustained relief.
-ID TrP: digital palpation (elicits local twitch and
pain)
-21-25gauge needle/ 1-3ml local anesthetic
-Some clinicians add cortisone or traumeel to
lidocaine
Butrick CW. 2009. Obstet Clin N America 36;707-722; Langford
CF et al. Neu roUrodyn 2007;26;1;59-65.
PFM TrP Injx
-Kang et al. N=104 Levator spasm
Lidocaine .5cc /triamcinolone .5cc
Painfree 30.1%/moderate to mild relief 64.7%
-Langford et al N=18 Levator spasm
Bupivicaine and lidocaine 5 ml/TrP
Painfree 33% / 39% >50% improvement in s/s
Kang et al Dis Colon Rectum 2000,1288-91 ;Langford CF et al. Neurourodyn 2007,59-65; Doumouchtsis et al 2010 epub.
PFM TrP Injx
-Doumouchtsis et al 2010
N=53 perineal pain/ dyspareunia
10ml bupivicaine/100mg
hydrocortisone/1500 u hyaluronidase 2
injections 1 month apart
*27 /53 painfree
*16/53 mild pain but able to resume
intercourse within 8 weeks
Kang et al Dis Colon Rectum 2000,1288-91 ;Langford CF et al. Neurourodyn 2007,59-65; Doumouchtsis et al 2010 epub.
Susan Kellogg PhD CRNP
Director of Sexual Medicine
The Pelvic & Sexual Health Institute
Professor of OB/GYN
Drexel University College of Medicine
Philadelphia, Pennsylvania
*Goal assessment
*Education -models of A&P vagina, vulva, PFM
*De-emphasize psychopathology
*Review of visit parameters
*Graduated exam schedule with sub-goals
*Reassurance RE: “who is in control”
- participation in mirror exam
- pt. touches w QTIP & inserts speculum
- counting before digital exam “1,2,3…”
- performing bulge technique
** Reed et al 52 SP / 43 controls
Cytokine alterations at baseline with exagg.
proinflammatory response when exposed to candida
and other mechanical, irritative, infective, allergic
trauma =stimulated neural hyperplasia (NGF)
= muscular guarding (HT-PFD)

Studies suggest cytokine alterations present as a local
allodynia (PVD) or a central sensitization syndrome
(UGVD)
Reed BD et al. JRM 2003;48:858-64;Bornstein J et al Gynecol Obstet Invest 2004; 58:171-78.;
Bohm-Starke N et al. Pain 2001;94:177-183;Witkin SS et al. Am J Obstet Gynecol 2002:187:589-594.
** Foster 36 SP / 69 controls

Genetic polymorphism of allele 2 = > IL-1B, TNF-a,
NGF

Dysfunction in the normal “braking mechanisms” for
inflammation: MC1-r
Foster D et al. JRM 2004:49:503-509;




Babula et al.
N= 221
SP= 122 / controls = 99
Buccal swabs: SP demonstrated variant mannose
binding lectin (MBL) gene = > vaginal susceptibility to
candida and other organisms
Babula O et al Am J Obstet Gynecol 2004:191:762-766.
30- 84% women with SP demonstrate umbilical
hypersensitivity and/or +PST suggesting
?urogenital sinus relationship
Women with SP > controls: depression, high stress levels,
early coitarche (+/- consent), vaginal strept infections, low pH,
OCP use and low level androgen / estrogen receptor binding
Fitzpatrick CC et al 1993 Obstet Gyencol. 81;860-62; Kahn et al 2004 Proceedings from National Consensus Panel on Vulvodynia, Atlanta Ga..
Goldstein A & Klingman D, 2004 Proceedings from National Consensus Panel on Vulvodynia, Atlanta Ga
** 16-18% women =
chronic sexual pain >
3mos.
Caucasians / African
American women equally
affected


s/s exac. by intercourse
(59%) speculum insertion
(42%) exercise (14%)
Hypersensitivity /
erythema glandular ostia
Bachmann, GA et al. Vulvodynia. http://www.reproductivemedicine.com/features/2006junfeature.htm / Results of NIH Grant R01-HD040119
Masheb R et al. Pain Med 2004;5;349-358.
Reid R et al. JRM1988:33:523-32..
*Amitriptyline (45-60%)
McKay M JRM1993;38:9-13;Paganoetal;Munday et al
*Anticonvulsants (13%)
Ben-David B etal; Anesh Anal 1989;89:1459-60
*Species specific antifungal therapy(15-67%)
Sobel JD et al. NEJM. 2004;351:876-883; Pagano etal, Bornstein etal.
*Cognitive behavioral therapy(38-83%)
-
Bergeron S et al. Pain. 2001;9:40-51;Daniellson et al;McKay et al; Glazer etal;ter Kuile etal
*Vestibulectomy(61-94%)
Haefner HK et al. Clin Obsytet Gynecol 2000;43:689-700;Goldstein etal;Bornstein etal
Bachmann GB et al. JRM 2006;http://wwwreproductivemedicine.com/features/2006junfeature.htm
*0.025% capsaicin cream QD x 12 wks(59%)
N = 52. Steinberg A et al. Am J Obstet2005;192:1549-53.
*0.3mL depomedrol / lidocaine injx q 3 wks x
4-6 (68%)
N = 10. Murina F et al. JRM 2001;46:713-16.
*topical 5% lidocaine qhs x 7 wks(57%)
N = 30. Zolnoun DA et al. Obstet Gyencol 2003;102:84-87
*d/c OCPs; change OCPs +/- topical E
cream(s) (60%)
Bohm-Starke N et al. JRM 2004;49(11) 888-92/ N = 40/Greenstein A et al JSM 2007 Nov 4(6)19679-83./Stratton P et al. Obstet
Gynecol 2007 110(5)1041-9.
Steinberg et al. Am J Obstet Gynecol 2005; 192:1549-53; Murina F et al JRM 2001;46:713-716/Zolnoun DA et al. Obstet Gyencol 2003;102:84-87/ Bohm-Starke N
et al. JRM 2004;49(11) 888-92.
*po montelukast 10mg / d x 2.5 yrs.(40%)
N = 29.Kamdar N et al. JRM 2007 52(10)912-6.
*surgery combined with postop PFM PT(64%)
N = 111. Goetsch MF. JRM 2007 52(7)597-603. 64% complete resolution
*neogyn cream
N=40 Donders JSM 2012 Marked improvement s/s.
*acupuncture treatment (“signif.”)
N=8. Rx x 10.signif decreases in pain. JSM 2010.Curran S, Brotto LA, Fisher H, Knudson G, Cohen T.
N=8. Rx x 10.signif decreases in pain. JSM 2009.Pukall et al.
*hypnotherapy treatment(“signif.”)
Steinberg et al. Am J Obstet Gynecol 2005; 192:1549-53; Murina F et al JRM 2001;46:713-716/Zolnoun DA et al. Obstet Gyencol 2003;102:84-87/ Bohm-Starke N
et al. JRM 2004;49(11) 888-92



Constant burning, difficulty
with prolonged sitting
Central sensitization with
“neural wind up” at the level
of the spinal cord, c fiber
reactivation
Pain likened to neuralgia
with hyperesthesia over
cutaneous distribution of
pudendal, iliohypogastric,
ilioinguinal and/or
genitofemoral nerves.
Margesson LJ and Stewart EG in Women’s Sexual Function and Dysfunction, eds Goldstein I et al. London: Taylor Francis, 2005.
* Anticonvulsants, SNRIs + pain management
* Multilevel anesthetic nerve blocks x 5
(caudal epidural,pudendal,local vestibular)
N = 27.Rapkin AJ et al. Am J Obstet Gynecol 2007 Oct .
* Implanted neuromodulation (SNS/PNS)

N =22. Peters KM et al. 2007 BJU 100(4)835-9
Margesson LJ and Stewart EG in Women’s Sexual Function and Dysfunction, eds Goldstein I et al. London: Taylor Francis, 2005 / Ben-David B et al.
Anesth Anal 1999;89:1459-60 / Bachmann GB et al. JRM 2006:http://www.reproductivemedicine.com/features/2006junfeature.htm..
*** 3 of 4 American women during lifetime



5% develop RVVC, many have SP
20-65% of women and providers who “dx
yeast” are wrong
Fungal cultures / PCR with species ID &
sensitivity most reliable for Dx and TOC
Sobel JD et al. NEJM 2004:351-876-883; Nuirjesy, P et al. Am J Obstet Gyn 1995: 173:820-3.
…(seldom done).

C. albicans




Fluconazole 200mg. Q4d x 3 ; qwk x 24.
Recurr. 13% vs. 85%.

Itraconizole 200mg. 2x/wk x 12 weeks.

Negative cultures x 12 weeks.
Non c. albicans
Intravaginal boric acid powder
capsules/suppositories 600mg. bid x 14
d
Efficacy 85%

“Long Term Azoles”
Efficacy 50 - 60 %
Itraconizole 200 mg. Qd x 10-14d
Clortrimazole 100 mg. Qd x 10-14d
Butaconizole q5d x 3-5 doses

Nystatin 100,000u inserts BID x 90d



Clortrimazole 500 mg. Q mo. X 6 mos.


Acute s/s reduced by 1/3.

Sobel JD et al. NEJM 2004:351-876-883; Nyirjesy, P et al. Am J Obstet Gyn 1995: 173:820-3
Contact irritant dermatitis





adhesive on minipads
soaps, shampoos, conditioners, powders, deodorants, body
washes
detergents, dryer sheets, fabric softeners, chemicals in
unlaundered clothing
additives to deodorant tampons, pads and sprays
cetyl alcohol, propylene glycol, methyl paraben,
benzalkonium chloride, lidocaine
Ridley CM et al. The Vulva. Oxford: Blackwell Science, 1999:163.


Avoidance associated with “all or none”
phenomena and cultural scripting.
Sequelae: feelings of inadequacy,
decreased sexual interest, depression.

Basson (2000): Physical intimacy is a
means to achieve emotional intimacy (a
crucial need for women).

Assessment:
◦ ask if “physically intimate” rather than
“sexually active”
◦ ask what causes / does not cause pain
◦ describe last encounter and frequency
rate

Assessment:
◦ ask subjective response of patient/
partner
◦ ID patient / partner goals for intimate
expression
◦ evaluate level of sexuality education

Resexualization/Rescripting
◦ cueing through erotic reading, films
◦ self-stimulation with lubes, dilators
vibrators
◦ redefining “normal and adequate”
sexual functioning

Resexualization/Rescripting
◦ Start with NON-INTERCOURSE (sensate focus)
exercises
◦ graduated goals for physical intimacy
◦ Antispasmodics/ anticholinergics
◦ Lubricants/moisturizers
◦ Analgesia: topical,oral,suppository


Outercourse: “Creative Thrusting”
◦ Interfemoral, intergluteal, intermammary
◦ missionary and “spoon” positions
Intercourse: “Careful Thrusting”
◦ angled missionary
◦ side lying
◦ rear entry with forward lean

Comfort Measures
◦ Baths
◦ Ice
◦ Pre-coital internal massage
◦ limit time/frequency
◦ introduce novelty/relaxation
◦ negotiate activity expectations
◦ alternate “his and her” sexual encounters
◦ Triage: sex/marital therapy

30 y.o. G0P0. Severe IC/PFD/PVD. Newly
married; “N/V from pain with thrusting”;
couple motivated. About to go on
honeymoon in 3mos- Desperate!

56 y.o. G2P2, moderate PVD;IC;PFD
abstinent/isolated x 9 years, because
of pain with any
Penetration/thrusting. Husband
upset, wife distressed. Oral play not
an option. Self described as “sexually
conservative.”

There is a need for increased awareness
of CPP conditions

Detection of IC, PVD, HTPFD important

Majority of cases can be managed

Pain DOES NOT have to preclude sexplay.

Creativity of the provider and couple = A MUST!!!

Research elucidates co-occurrence

Female partners of men with ED/PE

Male partners of women with SP
Oberg et al.JSM. 2005 2:160-180
N= 926 Swedish women; 18-65yo
 ED =30x greater risk of HSDD
 DE =25.9x greater risk FSAD
 PE=4x greater risk FOD
 M-HSD=greater risk FOD



Blumel JE et al. Menopause 2004;1;78-81.
N=534 women ceased sex w/ male partner
#1 reason in women <age 45= ED
Jodoin et al. 2005. WCS presentation.


75 women with PVD
Attributional Style Questionnaire

*Female pain = increased M psychological
distress


Internal attributions of responsibility for pain
were associated with better dyadic cohesion and
lower pain intensity.
(vs. pain attributed to the partner)
Connor et al. 2008. Fam Process. 47(2) 137-8

13 couples; women with PVD

Male partners: increased feelings of isolation


Need assistance in coping
EG: Reframing vaginal intercourse and exploring
alternative pleasuring strategies

More “couples” sexual research warranted

If treating MSD, ask about FSD

If treating FSD, ask about MSD

Sexual pain Rx should always involve both
partners
THANK YOU FOR YOUR KIND ATTENTION!
 71


yo G3P3. Post hysterectomy x 19 years.
On oral HRT.
Experiences PAIN and tearing of the
posterior fourchette with any type of finger,
vibrator or penis entry.
 Tears
heal after 1-3 days but reopen with
each act of sexplay
Physical examination:
Atrophic Vaginitis
Fissures in Posterior fouchette
TVL: 9cm, GH: 4cm, PB: 4cm
Bladder non- tender, no prolapse
Testing
◦
◦
◦
◦
RUA: negative. PVR: 10cc
Digital exam:
 Strength: 3/5
Manometry
 20-49-21
 0-32-0
Vulvoscopy- LSA

Treatment
◦
◦
◦
◦
◦
◦
Topical estrogen
Clobetasol daily- MWF (4 weeks)
Pre- Coital Lubricant
Coital Position Education
Limit Intercourse to 5 minutes
Post-Coital Ice



57 y.o. G4P4
CC: Difficulty with desire
HPI:
◦ Gradual onset for past 12 months
◦ Previous desire level 7/10 in her 40’s, current level 0/10
◦ Arousal and orgasm intact
◦ Partner sexual function normal
◦ Current sexual frequency 3/week
◦ Some dyspareunia related to dryness
◦ Denies self stimulation
◦ Denies relationship problems, sexual trauma, other
triggers
◦ Married to same partner for 40 years
◦ Describes hair loss, and hot flashes



PMHx:
◦ Fibromyalgia
◦ Heart disease
◦ HTN
◦ History of elevated prolactin years earlier- treated
with Bromocriptine
◦ On Lexapro until 3 months ago
PSHx:
◦ Hysterectomy 1990
◦ Defibrillator 2004
◦ Left lumpectomy 1983 (benign)
Meds:
◦ Diltiazem, ASA, HCTZ, Diovan

SocHx:
◦ No smoking, no EtOH
◦ Retired teaching assistant

PE:
◦
◦
◦
◦
◦
VSS, 65.5 inches, 194 lbs
Sensation intact
Vulva/internal genitalia normal
No prolapse
PFM 0/5

Lab evaluation:
◦
◦
◦
◦
◦
◦
◦
◦
◦
Cholesterol 183
HDL 66
LDL 103
TG 73
Prolactin 13.2
TSH 2.64
Estradiol <10
Total testosterone 5
Sex hormone binding globulin 55
 Free androgen index 0.32

Differential diagnosis?

Management plan?

62yo, G3P3, Dx: IC, PFD,FSAD: voids 16
x/d, widowed and now repartnered and very
active with a 76 y.o. man with a penile
implant. She also complains that the
implant hurts her bladder muscles in female
superior position. She can’t orgasm during
coitus “like she used to.”

Physical examination:
◦
◦
◦
◦
Tender posterior bladder wall
Atrophic Vaginitis
+ Q-tip sensitivity test
HTPFD
 Contraction 2 / 5
 Tenderness 2 / 4

Testing:
◦ RUA: +2 RBC’s, PVR: 55cc
◦ Manometry:
 40-53-41
 0-11-0

Treatment:
◦
◦
◦
◦
◦
◦
◦
◦
Counseling with partner
Diet, Uribel, Elmiron
PT
Valium Suppositories, Trigger Point injections,
Topical Estrogen
Dilators w/Partner
Position Counseling
Pre-Coital- Moisturizer and Lubricant, Lidocaine,
Levsin, Belladonna Suppositories
Post- Coital- Valium Suppositories, Ice



22 y.o. G0
CC: Pain with intercourse
HPI:
◦ Dyspareunia for 4 years
◦ Early in relationship had pain free intercourse
◦ Pain with intercourse at opening of vagina
 Feels ’inflamed’, ‘rubbing’
◦ No help with lubricants
◦ Good arousal and orgasm
◦ Sexual frequency 1/week
◦ Partner sexual function normal
 Live in different cities- see on weekends
◦ In relationship for 5 years




HPI ctnd:
◦ Thinks may have started with OCP onset
◦ Denies sexual trauma
◦ Causing significant strain on relationship/ feelings of
guilt
◦ Uses Dial soap, cotton underwear, sleeps in her
underwear, denies douche/bubble baths
◦ Denies pain with tight clothing, bicycle riding, sitting
PMHx:
◦ None
Meds:
◦ Recently stopped her oral contraceptive
SocHx:
◦ Non smoker
◦ Rare EtOH
◦ Student

PE:
◦
◦
◦
◦
◦
VSS, 63 inches, 170 lbs
Redness and tenderness around vestibule
Tenderness over levators bilaterally
Uterus and cervix, internal organs unremarkable
PFM 4/5, delayed relaxation
◦ Vaginal culture obtained: negative

Differential diagnosis?

Management plan?
Case Study #5






49yo: urgency/frequency/constipation
Superficial and deep dyspareunia; postcoital
pain
Vaginal and urine cultures negative
Irregular menses x 2 yrs; mild hot flashes
Pain with prolonged sitting in “hard chairs”
Has to strain to start urine stream and to
have bowel movements
Case Study #5

Physical Examination:
◦ + tender posterior bladder wall
◦ HTPFD
 Contraction 1 / 5
 Tenderness 4 / 4

Testing:
◦ RUA; -, PVR: 125cc
◦ Manometry
 55-60-54
 0-8-1
◦ Hormones- ↓’d E and T

Treatment:
Topical Estrogen and Testosterone
Diet, Prelief, anti-cholinergics, α- blocker
PT, trigger point injections, Botox
Dilator Therapy
Stress Management, Yoga
Pre-coital Lubricant, Levsin, Valium Suppositories,
Lidocaine
◦ Post-Coital Ice
◦
◦
◦
◦
◦
◦



49 y.o. G0
CC: Never had an orgasm…feels it could end her marriage
HPI:
◦ Never had an orgasm in her life, second marriage, currently
married for 11 years
◦ Describes only felt arousal sensation twice in entire marriage
◦ Used to have sex 4-5/wk, now 1/6 months
◦ Partner sexual function normal
◦ ‘never thought about’ masturbating in her life
◦ Partner and her ‘just don’t discuss their sex life”
◦ Straddle injury to vulva as a child, not sure sensation is normal

HPI ctnd:

PMHx:

Meds:

Soc Hx:
◦
◦
◦
◦
History of sexual abuse by her grandfather age 5
History of antidepressant use in the past- none currently
LMP 1 year ago
“feels tired’ all the time
◦ Infertility
◦ Vitamins
◦ ½ ppd smoker

PE:
◦ VSS, 62 inches, 155 lbs
◦ Pelvic exam





External genitalia normal
Uterus, cervix unremarkable
Mild levator tenderness
No prolapse
Mild vulvovaginal atrophy

Differential diagnosis?

Management?