Best Practice & Research Clinical Obstetrics and Gynaecology 28 (2014) 977e990
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Chronic pelvic floor dysfunction Dee Hartmann, PT, DPT a, *, Julie Sarton, DPT, WCS b, 1 a b
Dee Hartmann Physical Therapy, 1417 West Grand Avenue, Chicago, IL 60642, USA Sarton Physical Therapy, 13891 Newport Avenue, Suite 285, Tustin, CA 92780, USA
Keywords: pelvic floor muscle dysfunction women's health physical therapy manual therapy organ system dysfunction vulvar pain sexual dysfunction
The successful treatment of women with vestibulodynia and its associated chronic pelvic floor dysfunctions requires interventions that address a broad field of possible pain contributors. Pelvic floor muscle hypertonicity was implicated in the mid-1990s as a trigger of major chronic vulvar pain. Painful bladder syndrome, irritable bowel syndrome, fibromyalgia, and temporomandibular jaw disorder are known common comorbidities that can cause a host of associated muscular, visceral, bony, and fascial dysfunctions. It appears that normalizing all of those disorders plays a pivotal role in reducing complaints of chronic vulvar pain and sexual dysfunction. Though the studies have yet to prove a specific protocol, physical therapists trained in pelvic dysfunction are reporting success with restoring tissue normalcy and reducing vulvar and sexual pain. A review of pelvic anatomy and common findings are presented along with suggested physical therapy management. © 2014 Elsevier Ltd. All rights reserved.
Introduction Chronic pelvic pain (CPP), pelvic floor dysfunction (PFD), and sexual pain are among the most common yet challenging medical conditions that physicians and allied health-care providers face in clinical practice. Provoked vestibulodynia (PVD), a chronic vulvar pain disorder, straddles them all e it is often considered a symptom of CPP (though not related to pelvic organ pathology), it has been correlated with chronic pelvic floor muscle dysfunction (PFMD) [1e4], and it occurs (but not solely)
* Corresponding author. Tel.: þ1 312 650 5242; Fax: þ1 312 324 0577. E-mail addresses: [email protected] (D. Hartmann), [email protected] (J. Sarton). 1 Tel.: þ1 714 770 8222; Fax: þ1 714 770 8228.
http://dx.doi.org/10.1016/j.bpobgyn.2014.07.008 1521-6934/© 2014 Elsevier Ltd. All rights reserved.
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with sexual contact [5e7]. The prevalence of female sexual dysfunction resulting from concomitant chronic pelvic and sexual pain was estimated in 2006 to be 26% (range 7e58%) [8]. Unfortunately, many clinicians are not well equipped to assess and diagnose women plagued by the comorbid disorders [9]. Vulvologists, looking primarily at the vulva, work to accurately diagnose and treat PVD, which, by definition according to the International Society for the Study of Vulvovaginal Diseases, has no definable disease or diagnosable cause associated with it [5e7]. Physicians have historically been taught to investigate the pelvic viscera (e.g., bladder, urethra, uterus, ovaries, and bowel) as pain generators when attempting to identify the possible causation of pain [10], yet 28e55% of exploratory laparoscopic surgeries report negative findings [11e14]. When treating women with chronic pain, physicians and other health-care providers (those outside of the psychosexual counseling realm) have struggled to deal with their patients' comorbid sexual dysfunction, with 38% of patients thinking that the problem “will just go away [15].” Pelvic floor muscle (PFM) disorders are major contributors to a multitude of dysfunctions, with one recent study suggesting that the increase in the demand for care of PFMD (inclusive of all disorders, including incontinence) is predicted to increase by 35% in the next 17 years, with >1.6 million patient visits predicted for the year 2030 [16]. Beginning in the mid-1990s, PFMD was identified as a contributing factor to the pain of vulvodynia and PVD. Hypertonic PFMs were identified and successfully treated using surface electromyography or biofeedback, and complaints of vulvar pain and sexual dysfunction were decreased [2e4,17,18]. Physical therapists, by nature of their training, bring a much broader approach to the management of chronic vulvar and pelvic pain. As specialists, women's health physical therapists (WHPTs) have received extensive education in the treatment of chronic pelvic dysfunction. They have utilized a variety of manual therapy techniques to treat comorbid conditions of PFD, including biofeedback. WHPTs utilize interventions that restore normal function to all systems (musculoskeletal, fascial, and visceral) throughout the body. They have played an integral role in the multidisciplinary team working to decrease pain associated with CPP, PFD, and PVD [1e4,19e39]. A recent multisite, randomized, and blinded trial compared a specific PFM myofascial therapy treatment protocol to nonspecific therapeutic massage in 81 women with interstitial cystitis/painful bladder syndrome (IC/PBS). The results suggested that, of the 78 who completed the 3-month, 10treatment trial, 59% of those who received myofascial treatment reported improvement (moderate or marked) versus 26% of the massage-only group [32]. Though there is some thought that IC/PBS and PVD may coexist more than reported e though there was no mention of the vulvar pain in the previous study e it may be surmised that the therapy provided might also benefit those with PVD. Gentilcore-Saulnier et al. compared PFM behavior in women with and without PVD and how those with PVD responded to a physical therapy treatment. The study included eight patient visits with a protocol that included patient education, intervaginal manual therapy, biofeedback, electrical stimulation, use of vaginal dilators, and instruction in a home exercise program that prescribed the use of daily PFM exercises. Their prospective, cross-sectional study suggested that the presence of PVD alters PFM responsiveness to pain, with increased muscle activity (greater in the superficial PFMs than in the deep PFMs) following painful stimuli at the posterior vulvar vestibule. Pelvic floor (PF) physical therapy normalized the overall PFM tone, flexibility, strength, and ability to relax following active contraction. Following WHPT, there was decreased pain responsiveness in the PFM, reduced pressure sensitivity at the vaginal opening with reduced pain at the vulva, and improved tolerance to vaginal penetration [31]. In two retrospective reviews of physical therapy treatment of women with vulvodynia, Bergeron et al. reported a 71% success rate of moderate or great improvement in vulvar pain, as well as decreased pain with intercourse and gynecological exam, and increased intercourse frequency, desire, and arousal [37]. Hartmann reported that 71% of those receiving physical therapy for vulvar pain reported decreased vulvar pain symptoms and 62% reported improved sexual function [42]. Bergeron's protocol included patient education on PFM response to vulvar pain and the importance of muscle control (e.g., relaxation during vaginal insertion), internal and external manual therapy (including myofascial release, trigger-point pressures, and massage), biofeedback, electrical stimulation, and home exercises including use of vaginal dilators, manual stretching of the vaginal tissue, and PFM exercises [37]. Hartmann's protocol included internal and external manual therapy (soft tissue mobilization, myofascial release, and visceral manipulation), internal and external therapeutic exercise, electrical
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stimulation, biofeedback, and a home exercise program including twice-daily PFM exercises [42]. In a 10-year follow-up survey, Hartmann found 13 of the original 24 women and asked about their current symptoms. Ninety-two percent suggested mild to no current or intermittent symptoms, and 85% reported vulvar pain symptoms completely or greatly resolved with no further physical therapy intervention. When comparing symptomology in 2007 to 1997, continued symptom reduction had occurred in 89% versus 71% of those responding 10 years earlier, quality-of-life issues improved in 79% versus 50%, and improved sexual function improved in 75% versus 62%. Sixty-seven percent reported continued daily PFM exercises as prescribed during their treatment 10 years previously [43]. The purpose of this article is to describe and review the normal and abnormal functional anatomy of the pelvis, to discuss common problems caused by PFD, and to summarize suggested assessment and intervention modalities that might be utilized by WHPTs when dealing with patients with chronic PFD. No specific treatment protocols for women with PVD have been studied and/or validated. Some portions of the material presented in this article are solely the views of the individual authors as a result of their independent years of clinical experience. Functional anatomy of the pelvis To understand the functional anatomy of the pelvis, it is essential to appreciate the integration of the static support provided by the bony pelvis along with several additional anatomical systems e the musculoskeletal, the fascial, and the visceral systems. To better define pelvic function, Wei and Delancey suggest that the descriptor “pelvic floor” (PF) should be used to refer to all the structures of support within the pelvic cavity, including the musculature. PF support begins with the abdominal peritoneum cranially and continues inferiorly through the viscera (bladder, urethra, uterus, and rectum), the endopelvic fascia, the deep PFMs, and the perineal membrane before ending caudally in the superficial portion of the PFMs [44,45] (Fig. 1). Together, the levator ani (pubococcygeus, puborectalis, and iliococcygeus muscles) and coccygeus form the PFMs. The total sum of the muscular
Fig. 1. The pelvic floor structures according to DeLancey and Wei begin superiorly at the peritoneum and continue inferiorly throughout the pelvic viscera, endopelvic fascia, levator ani muscles, perineal membrane, and superficial genital muscles. PFM: pelvic floor muscles. Modified from Primal Pictures with labels added (images copyright Primal Pictures LTD, http://www. Primalpictures.com).
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attachments of the PFMs, the fascial attachments of the viscera (e.g., pubocervical and uterosacral ligaments), and the static support of bony pelvis combines to form the functional and structural support for the pelvic contents. The normal function of the PFMs (i.e., the ability to actively and fully contract and relax) contributes to the most inferior support of the pelvic viscera, control of continence via input to the urethral and anal sphincters, maintenance of normal sexual function and orgasmic activity, and core stability at the base of the trunk. The quality of the pelvic support can be altered by abnormalities in any of the supportive systems, be it in the PFMs (e.g., PFM spasm or laxity), the fascia (e.g., uterine or bladder prolapse), or the viscera (e.g., urethral or rectal spasm). From an anatomical perspective, the sling-like support of the PFMs attaches anteriorly at the inferior pubic rim and travels posteriorly to attach at the coccyx and sacrum. Normal contraction of the PFMs shortens the length of the muscles, creating a lift to the perineal body, pulling it up and in toward the pelvic cavity. Normal relaxation returns the muscles to their original length, allowing the perineal body to drop to its original position. In supine and with normal PFM function, the position of the perineal body should be above the plane of the ischial tuberosities. Hypotonic (i.e., laxity or decreased tone) PFMs allow the perineal body to drop below the plane of the tuberosities whereas hypertonic (i.e., elevated tension or spasm) PFMs cause a pull upward of the perineal body, keeping it more superior to the ischial tuberosities than in normal function. When hypertonicity is present, the resting position of the perineal body is further upward into the pelvis, similar to where it would be at the end of a full, voluntary contraction of normal functioning PFMs. The presence of chronic hypertonicity leaves the PFMs unable to release and return the perineal body to a normal position. This chronic hypertonicity can be visualized easily during an external clinical exam of the perineum. Other major components within the anterior compartment are the paired obturator internus muscles. They are fan-shaped and originate from a broad section of the anterolateral wall of the pelvis at the inner surface of the obturator foramen, the ischiopubic ramus, and the inner surface of the femur. Their fibers narrow and become band-like as they traverse inferior, running posterior to the ischial tuberosities where they make a 120 turn upward to insert at the greater trochanters of each femur (Figs. 2 and 3). Their function is to externally or laterally rotate the hip with extension (i.e., to turn the toes and knee outward in standing) and to abduct the hip when flexed (i.e., drop the knee out to the side when the knees and hips are flexed while in the supine position). Pelvic floor dysfunction Chronic PFD, CPP, PFMD, and PVD usually, but not always, coexist. There are rare clinical cases who present with no physical findings; however, those cases are, by far, not the norm. The complexity is elucidated by the European Association of Urology in their “Guidelines on Chronic Pelvic Pain.” They list 15 definitions relating to female pelvic pain, implicating involvement of PFMs, bladder, urethra, uterus, vagina, vulva, clitoris, pudendal nerve, rectum, and perineum [46]. Visceral disorders within the pelvis that are known to contribute to pain include PBS/IC, irritable bowel syndrome (IBS), dysmenorrhea, and endometriosis. Chronic, abnormal stimuli that are present with these visceral pain disorders can slowly upregulate the spinal cord, disrupting sacral reflexes that regulate sensation and pain [47]. Fascial laxity and resulting organ prolapse may contribute to the pain puzzle as can bony irregularities (e.g., sacroiliac joint dysfunction and hip pain). Pelvic floor muscle dysfunction Understanding pain related only to PFMD can be equally confusing as it has received multiple labels over time e coccydynia, levator (spasm) syndrome, tension myalgia of the PF, PF spasticity, urethral/ anal sphincter dyssynergia, vaginismus, and shortened PF [39]. The progression of PFMD occurs in two stages: the first, neuromuscular, and the second, musculodystrophic. Following some injury or insult (e.g., coccygeal injury with a fall, chronic hip pain, or recurrent yeast or urinary tract infections), free calcium is released, disturbing the sarcoplasmic reticulum and causing hypertonicity within the muscle. In the presence of ATP, calcium ions stimulate the actin/myosin activity, increasing metabolic activity. The release of various neurotransmitters, including serotonin, histamine, kinins, and
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Fig. 2. Medial view of the pelvic floor muscles. PFM: pelvic floor muscles. Modified from Primal Pictures with labels added (images copyright Primal Pictures, http://www.primalpictures.com).
Fig. 3. Inferior view for pelvic floor muscles with associated muscles and structures. PFM: pelvic floor muscles. Modified from Primal Pictures with labels added (images copyright Primal Pictures, http://www.primalpictures.com).
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prostaglandins, stimulate muscle nociceptors and set up a neural circuit between the central nervous system, nociceptors, and motor units [27]. Over time, the hypertonic muscles enter the musculodystrophic phase while attempting to adjust to the overall increase in metabolic activity. When that adjustment fails, localized fibrosis begins and atrophied muscle tissue is replaced by less metabolically active and extensible connective tissue [48]. An example of this phenomenon can be seen when bladder and urethral function are impacted by PFMD. Once PFM hypertonicity becomes chronic and full range of motion is reduced, the tension may obstruct voiding or make it impossible, with severe cases requiring intermittent self-catheterization. Not only will the PFMD cause restriction in the urethra but it can also inhibit the detrusor during bladder filling and emptying, resulting in urinary urgency, frequency, and hesitation [19]. Patients will involuntarily contract their PFMs for extended periods in response to the urgency, reflexively inhibiting bladder filling and emptying. With time, the PFMs lose their flexibility and are unable to normally relax. It then becomes impossible to separate the visceral from the muscular dysfunction as each drives the other e more muscular tension creates more urgency and increased urgency creates more PFM tension. The vicious cycle begins (Table 1). Physical therapy assessment Medical history The intake interview includes a traditional physical therapist's review of biomechanical systems but adds additional questions related to bowel and bladder function (including intake of fluids), menstrual and vaginal health, and a full history of sexual function, including questions on desire, arousal, and Table 1 Possible causes of pelvic floor muscle dysfunction (PFMD). Faulty biomechanics
Postural and structural dysfunction
Injury to the pelvic floor muscles
Faulty cumulative behaviors of the pelvic floor muscles
Inflammatory pain disorders involving pelvic viscera
1. Dysfunction of the lumbosacral spine or pelvic girdle e hips, pelvis, pubic symphysis, sacroiliac joints, sacrococcygeal joint 2. Lower kinetic chain irregularities e knees, feet, subtalar joints 3. Hypermobility throughout the pelvic cavity 1. Scoliosis 2. Short leg syndrome 3. Small hemi-pelvis 4. Perpetuation of typical pelvic pain posture e anterior pelvic tilt, increased thoracic kyphosis, lumbar lordosis 1. Childbirth 2. Pelvic surgery 3. Falls with landing on sacrum or coccyx, uncontrolled “slip” or stepping unexpectedly off a curb, creating a shear force at the pubic symphysis 4. Repetitive movement injuries seen with high-velocity sports with altered postures (e.g., gymnastics, dance) 1. Repetitive minor trauma or straining with chronic constipation or urinary obstruction 2. Abnormal chronic holding patterns a. History of sexual abuse b. Sexual guilt c. Pain with first attempted tampon use, penile intercourse, or vaginal exam d. Urinary urgency or frequency e. Urinary or fecal incontinence f. General stress, anxiety, tension g. Traumatic toilet training, history of bedwetting 3. Prolonged constriction or extended sitting with unequal weight bearing (e.g., occupational posture) or lack of motion (e.g., long car rides) 1. Irritable bowel syndrome (diarrhea, constipation) 2. Endometriosis 3. Chronic cystitis, painful bladder syndrome 4. Dysmenorrhea
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orgasm (Table 2). Because of the coexistence of PFM and visceral dysfunction, it is imperative to get a full and comprehensive history that includes a pelvic organ system review. It is often impossible to ascertain which came first e the PFMD that caused the pelvic organ functional complaints (e.g., PFM hypertonicity compromising the ease of bowel movements resulting in a complaint of constipation) or the chronic visceral dysfunction that was driving the PFM tension (e.g., chronic diarrhea that caused PFM hypertonicity). Regardless of the initiating trigger, both must be treated to reach maximum success with treatment. Table 2 Functional history questions. Examples given are for average function typically found in women without complaints of pain and possible responses for women with abnormal function and a history of pain. Question Bladder function How often do you empty your bladder? How much and what do you drink? Do you have pain when you empty? Do you feel empty afterwards? Do you have to push to start or does the urine just come out? Do you ever lose urine? Do you have a history of chronic urinary tract infections? Bowel function How often do you have a BM? Do you have a history of IBS? Do you need to strain to empty What consistency are your stools?
Average function
Possible abnormal function
6e8/day, including 1/night or every 3.5e4 h 1/2 my body weight in ounces No, not even after intercourse
Every hour or so; up multiple times/night
Yes No, flow just starts after I sit down to go No, not even with exercise No
3/day to 3/week No No Formed, soft, easy to expel
Do you feel empty after a BM? Do you ever have pain with BM? Menstrual history Do you have a history of painful periods?
No
Do you use tampons?
Yes with no trouble
Vaginal history Do you have a history of chronic yeast infections? Sexual history Are you currently sexually active? Do you have pain with sex? Do have any sexual desire? Did you always have pain with sex?
Can you have an orgasm? When you are intimate, do you get wet (arousal)? Where does it hurt when you try to have sex? How long does the pain last? Is there anything you can do to make the pain go away? Even though you don't have sex, are you still hugging, kissing, and touching?
Yes No
Not a lot, don't want to have to empty Yes, very often after intercourse and into the next day No, often have to go again quickly Yes, often have to think about it and push a little to get it started Yes, often with laughing, lifting, etc. Yes, often treated with antibiotics, even with no culture or testing Often less or more than average Yes (with constipation and/or diarrhea) Yes, often even when it's soft 1) Large and hard (problem with diet) or 2) Soft and pencil thin but hard to get out (non-relaxing anal sphincters) No, still feel like there is more there Yes (tailbone, abdomen, or low back) Yes, with a lot of cramping with long, heavy bleeding; often have used oral contraceptive with help No, it hurt when I tried it for the first time or it hurts now
No
Yes, often with no resolution even with, treatment; lots of burning pain
Yes No Yes No
No, it hurts too much and I don't want it Yes No, it's been too long; it hurts too much 1) Yes, it hurt the first time I tried (primary vestibulodynia/dyspareunia) 2) No, it was fine before but now it hurts (secondary vestibulodynia/dyspareunia) Yes, with clitoral stimulation only but it's harder to have and it isn't as intense Sometimes but often need to use a lubricant or perhaps not at all Mostly at the bottom of the vaginal opening Ranges from a few minutes to days Sit in a hot tub, ice, go to sleep
Yes, with clitoral stimulation and/or intercourse Yes NA NA NA NA
Yes, I try to do what I can No, I don't want to lead him on
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Education Every patient receives a brief education in PF anatomy. A plastic pelvic model with removable PFMs is used to describe and visualize the anatomy of the pelvis. Viewing the PFM orientation allows patients to see the anatomy in three dimensions, helps them to understand the intimate relationship between the muscles and organs, and seems to assist patients with voluntary PFM activation during the physical exam. The model is shown in Fig. 4.
Fig. 4. Digital assessment of vulvar pain with testing at 3, 6, and 9 o'clock around the introital opening. Hand positioning used at 3 and 9 o'clock can be used for insertion into the vagina with severe pelvic muscle spasm to avoid pressure on the urethra. A) 3 o'clock position on the introitus on the patient's left; B) 6 o'clock position on the introitus at the midline (posterior fourchette), superior to the anus; and C) 9 o'clock position on the introitus on the patient's right. Published previously and with permission. Hartmann D. Chronic vulvar pain from a physical therapy perspective. Dermatol Ther. 2010;23(5):505e13.
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Physical assessment 1. Traditional physical therapy evaluation: The assessment begins with evaluation and gross assessment of posture, gait, and generalized strength and mobility. Common physical findings in those with chronic pain are shown in Table 3. 2. Abdominal and hip assessment: Women are asked to undress from the waist down and lay supine and covered on a treatment table. The initial exam continues with gentle palpation of the abdomen, assessing for visceral tone and connective tissue health in the abdominal musculature. Passive hip mobility is assessed bilaterally as is the tone in the hip musculoskeletal complexes (e.g., psoas, iliacus, and deep external rotator muscles). Elevated tension throughout the abdomen, decreased hip mobility, and increased tension in the hips are common findings in those with a history of pain and dysfunction. 3. Visual exam of the perineum and vulva: The goal is to screen for any abnormal findings (Table 4). If disease is suspected, the appropriate referral is made. The perineal body position at rest is noted. Gross PFM function can be reviewed visually with a request for active contract and release of the PFM, “like trying to hold back urine or gas and then relaxing.” Perineal body mobility can be recorded, noting any change in resting position following the contraction/relaxation of the PFM. It is not uncommon following active mobility of the PFM for the perineal body to return to a more relaxed, inferior position. For more details, see the section covering internal exam. 4. Vulvar sensitivity assessment: The Q-tip test, which assesses pain levels by touching various points around the introitus with a cotton swab, has become the gold standard for diagnosing vestibulodynia [49e51]. Patient pain perception is graded during the test using an 11-point numeric pain rating scale of 0e10, with 0 representing “no pain at all” and 10 suggesting the “worst possible pain.” Changes in the scale over the course of treatment are an accepted measure of progress, both clinically and with research. A study by Reed et al [51]. has suggested that deeper palpation into the hymenal remnant in the vestibule was highly correlated with an accurate diagnosis of vulvodynia and was also predictive of associated PFM involvement. The first author has found equal success using a modified Q-tip test. It is accomplished by assessing pain at three points on the opening using a gloved (non-latex) and lubricated (natural oil) single-digit palpation at 3, 6, and 9 o'clock (Fig. 4). The pressure used is often minimal and gauged by patient tolerance. The results of this modified Qtip test might be recorded as “pain of 7/10 at 3 o'clock, 6/10 at 6, and 5/10 at 9 o'clock.” The technique has proven to be a reliable tool for measuring change in perceived vulvar pain before and after treatment sessions and over the duration of the treatment. 5. Internal examination: Intervaginal, single-digital assessment continues with particular attention paid to patient pain tolerance. With time, education, patience, and a gentle touch, internal exams are usually completed on the first visit. Digital palpation allows for differentiating the function and state of tension of the superficial PFMs (bulbospongiosus, ischiocavernosus, and superficial transverse perineal muscles), the deep PFMs (levator ani and coccygeus), the obturator internus muscles,
Table 3 Gross Physical Findings. Common findings outside of pelvis that are typically associated with chronic pelvic floor muscle dysfunction. Gross assessment
Specific findings
Pelvic pain posture
1. Increased lumbar lordosis (arched low back) or thoracic kyphosis (rounded shoulders, forward head) 2. Associated muscle tension e iliopsoas, piriformis, hip deep external rotators , abdominals, hip adductors, and/or quadratus lumborum Abnormalities in the distribution of the sciatic, pudendal, and/or obturator nerves Weakness in abdominals, hamstrings, hip flexors, trunk extensors (also includes the pelvic floor muscles) Elevated abdominal visceral tension e most notably the colon, small intestines, rectum, uterus, urethra, and bladder
Pelvic innervation Deconditioned core muscle strength Pain and tension with palpation of the abdominal cavity
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Table 4 Possible abnormal findings. Generalized possible findings with visual inspection of the perineum. Visual findings Perineum is Dry? Wet? Excoriated? Perineal body below ischial tuberosities? Perineal body above ischial tuberosities? No perineal body movement with attempted pelvic floor muscle contraction? Vulva is Missing labia majora and or labia minora? Scars and/or scar adhesions? Unusual discharge and/or odor? Fissure or tears at the posterior fourchette? Introital opening reduced in size?
Possible etiology with positive findings Atrophic vaginitis Excessive discharge, yeast infection, vaginal disorder Urinary incontinence Hypotonic pelvic floor muscles Hypertonic pelvic floor muscles Pelvic floor muscle dysfunction (hypo- or hypertonic)
Lichen sclerosis History of episiotomy or vulvar surgery, lichen sclerosus Yeast or bacterial infection Lichen planus or sclerosus, chronic yeast or bacterial infection, pelvic floor muscle hypertonicity Lichen planus or sclerosus chronic pelvic floor muscle dysfunction
the pelvic viscera (urethra, bladder, uterus, and rectum), and the fascial support of the pelvis (arcus tendineus fascia pelvis (ATFP) and arcus tendineus of levator ani) [31]. Normal PFM tone creates a visible, mildly concave surface of the perineum in reference to the plane of the ischial tuberosities with the perineal body sitting slightly superior. A single digit is inserted into the introitus at the level of the perineal body and progresses above the hymenal ring to reach the PFMs. As insertion occurs, PFM resting tone can be evaluated by noting the relative size and position of the opening created by the PFMs. Normal PFM resting tone allows for easy, pain-free digital insertion. With normal tone, the opening in the PFMs sits just above the introitus and the perineal body. By contrast, elevated PFM resting tone causes the vaginal muscular opening to be smaller in circumference, further superior into the pelvic cavity with more distance between the perineal body at the surface of the perineum. The muscle tension pulls the perineal body inward, creating an increased concavity of the perineum. Conversely, with PFM laxity, there is little to no space between the PFMs and the perineal body. The lack of PFM tone causes the perineum to appear mildly convex, often falling inferior to the plane of the ischial tuberosities. The digital grading of PFM function is completed using the modified Oxford scale of 0e5, with 0 being indicative of no perceptible active PFM contraction and 5 suggestive of normal PFM contractility [52]. The active range of motion of the PFMs is quantified numerically using a plus/minus system such that reporting might be recorded as “PFM function 3/5.” Many clinicians suggest that someone with elevated PFM tension and resting tone has “weak PFMs.” In actuality, there is a decreased active range of motion that is caused by hypertonicity or reflexive splinting (unconscious contraction of the PFMs) which occurs prior to penetration (sexual or nonsexual). The poor contractile force of the hypertonic PFMs (e.g., perhaps recorded as 2/5 on the modified Oxford scale) is followed by a slow, incomplete release of tension, returning the PFMs only to the level of the original, elevated resting tone. The reporting of PFM function therefore should include the digital measure of PFM function with the Oxford scale as well as a digital measure of PFM release and resting tone (e.g., “PFM function 2/5 with poor and incomplete release of elevated resting tone”). In women with PVD, the more common anterior pelvic findings include some combination of the following: elevated PFM resting tone, taut bands and/or active trigger points in the PFM, elevated tone of both obturator internus muscles, increased tension in one or both tendinous arch(es) of the pelvic fascia and/or the levator ani, and increased tone or visceral spasm in the urethra, bladder, uterus, or rectum. Abnormal internal tension or tone is digitally sensed as a stiffness or bulkiness in the tissues being assessed. When palpating the urethra, for instance, the assessing digit would be at 12:00 in the vaginal canal where the urethra is supported by the periurethral fascia behind the pubic symphysis. With normal tone, the musculature of the urethra is relaxed on itself and feels like a soft, shallow mound of tissue running approximately 4 cm in length along the backside of the symphysis. When the
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urethra has increased tone, it feels like a straw or a pencil that can be rolled over. Too much pressure on the tense urethra can cause complaints of pain or urinary urgency. Likewise, the rectum, when palpated vaginally at 6:00, has similar properties. Pressure on a tense, round bowel may create pain or the sense of urgency common to passing gas or stool. Elevated rectal tension appears to increase complaints of pressure and pain at the posterior fourchette (6:00). Following release of the tension via physical therapy, the complaints of pain are typically reduced, often to zero. It is not uncommon as part of the initial patient visit to also complete an assessment of the posterior pelvis via the anus to identify abnormal tension in the anal sphincters, coccygeus muscles, posterior pelvic ligaments (anococcygeal, sacrotuberous, and sacrospinous), and the fascial structures attaching to and around the ischial spines (Figs. 2 and 3). Bimanual exams of the sacrococcygeal and sacroiliac joints can be completed when dysfunction is suspected. Anterior and posterior PFM function and resting states should not be assumed to be equal as very often they are not. Physical therapy intervention According to the American Physical Therapy Association, the overall goal of physical therapy intervention is to restore normal function while working to reduce any negative psychological impact associated with the disease, pain, or dysfunction being addressed [53]. It is incumbent on all healthcare providers who treat women with CPP to be aware of the pain's overwhelming impact on the patient's quality of life. Physical dysfunctions may be more readily addressed and treated but the psychology of pain cannot be ignored. Regular referrals to mental health providers may make the difference between full and partial recovery. Without access to adjunctive care, all providers must do what they can to address emotional issues associated with chronic pain, including sexual dysfunction. Women's health physical therapy will be much less successful if the treating therapist is unable or unwilling to discuss sexual function as she goes through her chosen treatment protocol. Intervention is driven by organ system dysfunction and physical findings. If urinary urgency and frequency are noted in the intake, for example, it is necessary to review dietary as well as bladder habits (Table 1). If bladder dysfunction is left unaddressed, it may cause the PFMs to remain in a constant state of excessive holding, thus contributing to additional PFM hypertonicity and possible vulvar pain and sexual dysfunction. The same holds true for bowel dysfunction. Discussions around daily food intake can often lead to suggestions for small changes (e.g., eliminating dairy and/or gluten intake, or decreasing sugar consumption) that can impact overall pelvic function by correcting chronic constipation or diarrhea. Abnormal physical findings throughout the body, discovered through the assessment process, need to be addressed for full recovery of pelvic health. Manual therapy is pivotal to successful treatment. Modalities like soft tissue mobilization, myofascial release, joint manipulation, visceral mobilization, therapeutic exercise, and neural mobilization can be used to correct musculoskeletal dysfunction throughout the body as well as within the pelvic cavity. Any exercise prescription should include a home exercise program designed to improve core stability and correction of any gait or postural imbalances as indicated. The importance of proper PFM function is stressed regularly, beginning with the initial visit and addressed during each successive treatment session. Before full PFM function can be restored through active PFM exercise, however, any associated abnormalities within the pelvis also must be corrected. Manual therapy techniques can be applied with good success e pelvic visceral tension can be eased, obturator internus muscles spasm can be relaxed along with accessory hip muscle tension, and PFM hypertonicity can be reduced. Once the tension in these tissues, muscles, and fascia is released in the clinic e usually on the first visit for women with PVD e the palpated pain at the introitus is typically reduced. When patients realize that the release of pelvic and associated myofascial tensions can impact their complaints of vulvar pain, their compliance with their individualized home exercise program improves. Twenty-two years of clinical experience has shown the first author that renewal of motor function and overcoming reflexive splinting of the PFMs is pivotal in recovery for most, if not all, patients with PFMD and PVD. The advantages of regular PFM exercise are increased blood flow, improved PF support, decreased posterior fourchette fissuring, improved proprioception of the PFM position, and increased intensity of orgasm [40]. Though the home exercise prescription is obviously dependent on individual
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PFM function during initial evaluation, it typically involves working up to two 5-min sessions of PFM exercises a day (once in the morning and once in the evening). Both fast-twitch and slow-twitch muscle fibers are present in the PFM and are addressed separately in the exercise regime. For the majority of patients, the prescribed PFM exercise alternates a sustained PFM contraction of five counts, followed by a total muscle release, with five quick, successive PFM contractions followed by release. If during the first week of doing the PFM exercises the sensation of contraction or relaxation cannot be sensed, the exercises are to end for that session, with more time added as the muscles are able. Likewise, if there is ever an increase in any symptoms, the exercises are to be stopped until the next WHPT visit. It is suggested to the patient that the PFM exercises can be used any time that discomfort is felt, such as before and after a vaginal exam, with increased distress or anxiety, or if pain occurs while driving or sitting. Active contraction and relaxation of the PFM is suggested before, during, and after intercourse and can be helpful in the first few weeks of use. Summary Treating patients with chronic PFD is challenging for all those in the health-care arena. Chronic pelvic and vulvar pain are certainly no exception. It is incumbent on all those who deal with this difficult population of women to be compassionate, understanding, and thorough in their assessment and treatment approach. The unknown factors related to the causes of chronic pelvic and vulvar pain continue to stymie practitioners. However, therapy that is directed toward finding the comorbid physical abnormalities throughout the body and correcting them appears to be a logical and successful approach. Referral to a WHPT should occur routinely as part of the multidisciplinary approach for all women who present with any type of vulvovaginal pain. Research indicates that PF physical therapy is safe and effective, and can dramatically improve symptoms related to PVD and chronic PFD. Working together, the health-care team can make progress as each member contributes his or her expertise. Women, when given the correct tools, can learn to manage their bodies and recover the function they may have lost due to the pain and dysfunction.
Practice points Physical therapists trained in treating chronic pelvic dysfunctions take a whole-body approach to treating women with a history of vulvar and sexual pain. Multiple organ systems (muscular, fascial, visceral, and bony) can contribute to chronic pelvic floor muscle dysfunction and must be assessed and treated for the most complete recovery. Helping women to regain normal pelvic floor muscle function appears to be key in recovering normal vulvar sensitivity and sexual function.
Research agenda Analysis of physical findings throughout multiple organ systems in women with chronic pelvic floor muscle dysfunction needs to be completed. Various manual physical therapy treatment protocols need to be assessed and compared to each other as well as to controls with no treatment and to those undergoing other interventions (pharmacology, surgery, and psychotherapy). Long-term outcomes following physical therapy intervention need to be assessed.
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Conflict of interest statement Neither author has a conflict of interest to declare, financial or otherwise. References [1] Davila GW. Introduction to the 2008 IUGA sexual dysfunction in women roundtable. Int Urogyne J 2009;20(1):S3e4. [2] Glazer HI, Rodke G, Swencionis C, et al. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med 1995; Apr;40(4):283e90. [3] Glazer HI. Dysethetic vulvodynia. Long-term follow-up after treatment with surface electromyography-assisted pelvic floor muscle rehabilitation. J Reprod Med 2000;45(10):798e802. [4] Glazer HI, Jantos M, Hartmann EH, et al. Electromyographic comparisons of the pelvic floor in women with dysesthetic vulvodynia and asymptomatic women. J Reprod Med 1998 Nov;43(11):959e62. [5] Moyal-Barracco M, Lynch PJ. 2003 ISSVD terminology and classification of vulvodynia: a historical perspective. J Reprod Med 2004;49:772e7. [6] Goldstein AT, Marinoff SC, Haefner HK. 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A randomized comparison of group cognitive behavioral therapy, surface elec*[18] Bergeron S, Binik YM, Khalife tromyographic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain 2001; Apr;91(3):297e306. [19] FitzGerald MP, Kotarinos R. Rehabilitation of the short pelvic floor. I: background and patient evaluation. Int Urogynecol J Pelvic Floor Dysfunct 2003;14(4):261e8. [20] Prendergast SA, Weiss JM. Screening for musculoskeletal causes of pelvic pain. Clin Obstet Gynecol 2003;46(4):773e82. [21] Weiss JM. Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the urgency-frequency syndrome. J Urol 2001;166(6):2226e31. [22] Montenegro ML, Vasconcelos EC, Candido Dos Reis FJ, et al. Physical therapy in the management of women with chronic pelvic pain. Int J Clin Pract 2008;62(2):263e9. [23] Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction associated with chronic Pelvic floor pain: management strategies. Cur Pain Headache Rep 2007;11(5):359e64. *[24] Hartmann D. Chronic vulvar pain from a physical therapy perspective. Dermatol Ther 2010;23(5):505e13. *[25] FitzGerald MP, Anderson RU, Potts J, et al. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. J Urol 2009;182(2):570e80. [26] Goldfinger C, Pukall CF, Gentilcore-Saulnier E, et al. A prospective study of pelvic floor physical therapy: pain and psychosexual outcomes in provoked vestibulodynia. J Sex Med 2009;6(7):1955e68. [27] Baker PK. Musculoskeletal problems. In: Steege JF, Levy BS, editors. Chronic pelvic pain: an integrated approach. Philadelphia: WB Saunders; 1998. p. 215e40. *[28] Baker PK. Musculoskeletal origins of chronic pelvic pain: diagnosis and treatment. In: Ling FW, editor. Obstetrics and gynecology clinics of North America. Philadelphia: WB Saunders; 1993. p. 719e42. [29] Lee D. The pelvic girdle: an approach to the examination and treatment of the lumbo-pelvic-hip region. 3rd ed. Edinburgh, Scotland: Churchill Livingstone; 2004. [30] Barral J-P, Anderson S, Bensky D. Urogenital manipulation. Seattle: Eastland Press; 1993. *[31] Gentilcore-Saulnier E, McLean L, Goldfinger C, et al. Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program. J Sex Med 2010;7:1003e22. *[32] Fitzgerald MP, Payne CK, Lukacz ES, et al. Interstitial cystitis collaborative research network. Randomized multicenter clinical trial of myofascial physical therapy in women with interstitial cystitis/painful bladder syndrome and pelvic floor tenderness. Urol 2012; Jun;187(6):2113e8. [33] Lovinga S, Nordlingb J, Jaszczakc P, et al. Does evidence support physiotherapy management of adult female chronic pelvic pain? A systematic review. Scand J Pain 2012;3:70e81. 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[35] Fitzwater JB, Kuehl TJ, Schrier JJ. Electrical stimulation in the treatment of pelvic pain due to levator ani spasm. J Repro Med 2003;48(8):573e7. *[36] Kennedy CM, Nygaard IE, Saftlas A, et al. Vulvar disease: a pelvic floor pain disorder? Am J Obstet Gynecol 2005;192(6): 1829e34. *[37] Bergeron S, Brown C, Lord MJ, et al. Physical therapy for vulvar vestibulitis syndrome: a retrospective study. J Sex Mar Ther 2002;28:183e92. [38] Bergeron S, Lord MJ. The integration of pelvi-perineal re-education and cognitive behavioural therapy in the multidisciplinary treatment of the sexual pain disorders. Br Ass Sex Relationship Ther 2003;18(2):135e41. [39] Bo K, Berghmans B, Morkved S, et al., editors. Evidence-based physical therapy for the pelvic floor: Bridging science and clinical practice. Edinburgh, Scotland: Churchill Livingstone Elsevier; 2007. [40] Weiss PM, Rich J, Swisher E. Pelvic floor spasm: the missing link in chronic pelvic pain. Contemporary OB/GYN; October 1, 2012., http://contemporaryobgyn.modernmedicine.com. *[42] Hartmann EH, Nelson CA. The perceived effectiveness of physical therapy treatment on women diagnosed with either vulvar vestibulitis syndrome or dysesthetic vulvodynia. J Sect Women's Health 2001;25:13e8. [43] Hartmann D, Nelson CA. Ten years after physical therapy for vulvodynia: are there lasting benefits? (abst). J Repro Med 2008;53(11). [44] Wei JT, Delancey JOL. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol 2004;47(1): 3e17. [45] www.primalpictures.com, 2009. Primal Pictures Ltd. London, UK. [46] Fall M, Baranowski AP, Elneil S, et al. Guidelines on chronic pelvic pain. European Association of Urology; 2008. http:// www.uroweb.org/fileadmin/user_upload/Guidelines/Chronic%20Pelvic%20Pain.pdf. [47] Allen RE, Hosker GL, Smith AR, et al. Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 1990;97(9):770e9. [48] Cantu RI, Grodin AJ, Stanborough RW. Myofascial manipulation: theory and clinical application. NY, NY: Aspen Publishers; 1992. [49] Friedrich EG. Vulvar vestibulitis syndrome. J Reprod Med 1987;32:110. *[50] Strauhal MJ, Frahm J, Morrison P, et al. Vulvar pain: a comprehensive review. J Womens Health Phys Ther 2007;31(3). [51] Reed BD, Haefner HK, Edwards L. A survey on diagnosis and treatment of vulvodynia among vulvodynia researchers and members of the international society for the study of vulvovaginal disease. J Reprod Med 2008;53(12):921e9. [52] Laycock J. Clinical evaluation of the pelvic floor. In: Schussler B, Laycock J, Norton P, et al., editors. Pelvic floor reeducation. London: Springer-Verlag; 1994. [53] Description of physical therapy e what is physical therapy? World Confederation for Physical Therapy www.WCPT.org.
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4
Chronic pelvic floor dysfunction Dee Hartmann, PT, DPT a, *, Julie Sarton, DPT, WCS b, 1 a b
Dee Hartmann Physical Therapy, 1417 West Grand Avenue, Chicago, IL 60642, USA Sarton Physical Therapy, 13891 Newport Avenue, Suite 285, Tustin, CA 92780, USA
Keywords: pelvic floor muscle dysfunction women's health physical therapy manual therapy organ system dysfunction vulvar pain sexual dysfunction
The successful treatment of women with vestibulodynia and its associated chronic pelvic floor dysfunctions requires interventions that address a broad field of possible pain contributors. Pelvic floor muscle hypertonicity was implicated in the mid-1990s as a trigger of major chronic vulvar pain. Painful bladder syndrome, irritable bowel syndrome, fibromyalgia, and temporomandibular jaw disorder are known common comorbidities that can cause a host of associated muscular, visceral, bony, and fascial dysfunctions. It appears that normalizing all of those disorders plays a pivotal role in reducing complaints of chronic vulvar pain and sexual dysfunction. Though the studies have yet to prove a specific protocol, physical therapists trained in pelvic dysfunction are reporting success with restoring tissue normalcy and reducing vulvar and sexual pain. A review of pelvic anatomy and common findings are presented along with suggested physical therapy management. © 2014 Elsevier Ltd. All rights reserved.
Introduction Chronic pelvic pain (CPP), pelvic floor dysfunction (PFD), and sexual pain are among the most common yet challenging medical conditions that physicians and allied health-care providers face in clinical practice. Provoked vestibulodynia (PVD), a chronic vulvar pain disorder, straddles them all e it is often considered a symptom of CPP (though not related to pelvic organ pathology), it has been correlated with chronic pelvic floor muscle dysfunction (PFMD) [1e4], and it occurs (but not solely)
* Corresponding author. Tel.: þ1 312 650 5242; Fax: þ1 312 324 0577. E-mail addresses: [email protected] (D. Hartmann), [email protected] (J. Sarton). 1 Tel.: þ1 714 770 8222; Fax: þ1 714 770 8228.
http://dx.doi.org/10.1016/j.bpobgyn.2014.07.008 1521-6934/© 2014 Elsevier Ltd. All rights reserved.
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with sexual contact [5e7]. The prevalence of female sexual dysfunction resulting from concomitant chronic pelvic and sexual pain was estimated in 2006 to be 26% (range 7e58%) [8]. Unfortunately, many clinicians are not well equipped to assess and diagnose women plagued by the comorbid disorders [9]. Vulvologists, looking primarily at the vulva, work to accurately diagnose and treat PVD, which, by definition according to the International Society for the Study of Vulvovaginal Diseases, has no definable disease or diagnosable cause associated with it [5e7]. Physicians have historically been taught to investigate the pelvic viscera (e.g., bladder, urethra, uterus, ovaries, and bowel) as pain generators when attempting to identify the possible causation of pain [10], yet 28e55% of exploratory laparoscopic surgeries report negative findings [11e14]. When treating women with chronic pain, physicians and other health-care providers (those outside of the psychosexual counseling realm) have struggled to deal with their patients' comorbid sexual dysfunction, with 38% of patients thinking that the problem “will just go away [15].” Pelvic floor muscle (PFM) disorders are major contributors to a multitude of dysfunctions, with one recent study suggesting that the increase in the demand for care of PFMD (inclusive of all disorders, including incontinence) is predicted to increase by 35% in the next 17 years, with >1.6 million patient visits predicted for the year 2030 [16]. Beginning in the mid-1990s, PFMD was identified as a contributing factor to the pain of vulvodynia and PVD. Hypertonic PFMs were identified and successfully treated using surface electromyography or biofeedback, and complaints of vulvar pain and sexual dysfunction were decreased [2e4,17,18]. Physical therapists, by nature of their training, bring a much broader approach to the management of chronic vulvar and pelvic pain. As specialists, women's health physical therapists (WHPTs) have received extensive education in the treatment of chronic pelvic dysfunction. They have utilized a variety of manual therapy techniques to treat comorbid conditions of PFD, including biofeedback. WHPTs utilize interventions that restore normal function to all systems (musculoskeletal, fascial, and visceral) throughout the body. They have played an integral role in the multidisciplinary team working to decrease pain associated with CPP, PFD, and PVD [1e4,19e39]. A recent multisite, randomized, and blinded trial compared a specific PFM myofascial therapy treatment protocol to nonspecific therapeutic massage in 81 women with interstitial cystitis/painful bladder syndrome (IC/PBS). The results suggested that, of the 78 who completed the 3-month, 10treatment trial, 59% of those who received myofascial treatment reported improvement (moderate or marked) versus 26% of the massage-only group [32]. Though there is some thought that IC/PBS and PVD may coexist more than reported e though there was no mention of the vulvar pain in the previous study e it may be surmised that the therapy provided might also benefit those with PVD. Gentilcore-Saulnier et al. compared PFM behavior in women with and without PVD and how those with PVD responded to a physical therapy treatment. The study included eight patient visits with a protocol that included patient education, intervaginal manual therapy, biofeedback, electrical stimulation, use of vaginal dilators, and instruction in a home exercise program that prescribed the use of daily PFM exercises. Their prospective, cross-sectional study suggested that the presence of PVD alters PFM responsiveness to pain, with increased muscle activity (greater in the superficial PFMs than in the deep PFMs) following painful stimuli at the posterior vulvar vestibule. Pelvic floor (PF) physical therapy normalized the overall PFM tone, flexibility, strength, and ability to relax following active contraction. Following WHPT, there was decreased pain responsiveness in the PFM, reduced pressure sensitivity at the vaginal opening with reduced pain at the vulva, and improved tolerance to vaginal penetration [31]. In two retrospective reviews of physical therapy treatment of women with vulvodynia, Bergeron et al. reported a 71% success rate of moderate or great improvement in vulvar pain, as well as decreased pain with intercourse and gynecological exam, and increased intercourse frequency, desire, and arousal [37]. Hartmann reported that 71% of those receiving physical therapy for vulvar pain reported decreased vulvar pain symptoms and 62% reported improved sexual function [42]. Bergeron's protocol included patient education on PFM response to vulvar pain and the importance of muscle control (e.g., relaxation during vaginal insertion), internal and external manual therapy (including myofascial release, trigger-point pressures, and massage), biofeedback, electrical stimulation, and home exercises including use of vaginal dilators, manual stretching of the vaginal tissue, and PFM exercises [37]. Hartmann's protocol included internal and external manual therapy (soft tissue mobilization, myofascial release, and visceral manipulation), internal and external therapeutic exercise, electrical
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stimulation, biofeedback, and a home exercise program including twice-daily PFM exercises [42]. In a 10-year follow-up survey, Hartmann found 13 of the original 24 women and asked about their current symptoms. Ninety-two percent suggested mild to no current or intermittent symptoms, and 85% reported vulvar pain symptoms completely or greatly resolved with no further physical therapy intervention. When comparing symptomology in 2007 to 1997, continued symptom reduction had occurred in 89% versus 71% of those responding 10 years earlier, quality-of-life issues improved in 79% versus 50%, and improved sexual function improved in 75% versus 62%. Sixty-seven percent reported continued daily PFM exercises as prescribed during their treatment 10 years previously [43]. The purpose of this article is to describe and review the normal and abnormal functional anatomy of the pelvis, to discuss common problems caused by PFD, and to summarize suggested assessment and intervention modalities that might be utilized by WHPTs when dealing with patients with chronic PFD. No specific treatment protocols for women with PVD have been studied and/or validated. Some portions of the material presented in this article are solely the views of the individual authors as a result of their independent years of clinical experience. Functional anatomy of the pelvis To understand the functional anatomy of the pelvis, it is essential to appreciate the integration of the static support provided by the bony pelvis along with several additional anatomical systems e the musculoskeletal, the fascial, and the visceral systems. To better define pelvic function, Wei and Delancey suggest that the descriptor “pelvic floor” (PF) should be used to refer to all the structures of support within the pelvic cavity, including the musculature. PF support begins with the abdominal peritoneum cranially and continues inferiorly through the viscera (bladder, urethra, uterus, and rectum), the endopelvic fascia, the deep PFMs, and the perineal membrane before ending caudally in the superficial portion of the PFMs [44,45] (Fig. 1). Together, the levator ani (pubococcygeus, puborectalis, and iliococcygeus muscles) and coccygeus form the PFMs. The total sum of the muscular
Fig. 1. The pelvic floor structures according to DeLancey and Wei begin superiorly at the peritoneum and continue inferiorly throughout the pelvic viscera, endopelvic fascia, levator ani muscles, perineal membrane, and superficial genital muscles. PFM: pelvic floor muscles. Modified from Primal Pictures with labels added (images copyright Primal Pictures LTD, http://www. Primalpictures.com).
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attachments of the PFMs, the fascial attachments of the viscera (e.g., pubocervical and uterosacral ligaments), and the static support of bony pelvis combines to form the functional and structural support for the pelvic contents. The normal function of the PFMs (i.e., the ability to actively and fully contract and relax) contributes to the most inferior support of the pelvic viscera, control of continence via input to the urethral and anal sphincters, maintenance of normal sexual function and orgasmic activity, and core stability at the base of the trunk. The quality of the pelvic support can be altered by abnormalities in any of the supportive systems, be it in the PFMs (e.g., PFM spasm or laxity), the fascia (e.g., uterine or bladder prolapse), or the viscera (e.g., urethral or rectal spasm). From an anatomical perspective, the sling-like support of the PFMs attaches anteriorly at the inferior pubic rim and travels posteriorly to attach at the coccyx and sacrum. Normal contraction of the PFMs shortens the length of the muscles, creating a lift to the perineal body, pulling it up and in toward the pelvic cavity. Normal relaxation returns the muscles to their original length, allowing the perineal body to drop to its original position. In supine and with normal PFM function, the position of the perineal body should be above the plane of the ischial tuberosities. Hypotonic (i.e., laxity or decreased tone) PFMs allow the perineal body to drop below the plane of the tuberosities whereas hypertonic (i.e., elevated tension or spasm) PFMs cause a pull upward of the perineal body, keeping it more superior to the ischial tuberosities than in normal function. When hypertonicity is present, the resting position of the perineal body is further upward into the pelvis, similar to where it would be at the end of a full, voluntary contraction of normal functioning PFMs. The presence of chronic hypertonicity leaves the PFMs unable to release and return the perineal body to a normal position. This chronic hypertonicity can be visualized easily during an external clinical exam of the perineum. Other major components within the anterior compartment are the paired obturator internus muscles. They are fan-shaped and originate from a broad section of the anterolateral wall of the pelvis at the inner surface of the obturator foramen, the ischiopubic ramus, and the inner surface of the femur. Their fibers narrow and become band-like as they traverse inferior, running posterior to the ischial tuberosities where they make a 120 turn upward to insert at the greater trochanters of each femur (Figs. 2 and 3). Their function is to externally or laterally rotate the hip with extension (i.e., to turn the toes and knee outward in standing) and to abduct the hip when flexed (i.e., drop the knee out to the side when the knees and hips are flexed while in the supine position). Pelvic floor dysfunction Chronic PFD, CPP, PFMD, and PVD usually, but not always, coexist. There are rare clinical cases who present with no physical findings; however, those cases are, by far, not the norm. The complexity is elucidated by the European Association of Urology in their “Guidelines on Chronic Pelvic Pain.” They list 15 definitions relating to female pelvic pain, implicating involvement of PFMs, bladder, urethra, uterus, vagina, vulva, clitoris, pudendal nerve, rectum, and perineum [46]. Visceral disorders within the pelvis that are known to contribute to pain include PBS/IC, irritable bowel syndrome (IBS), dysmenorrhea, and endometriosis. Chronic, abnormal stimuli that are present with these visceral pain disorders can slowly upregulate the spinal cord, disrupting sacral reflexes that regulate sensation and pain [47]. Fascial laxity and resulting organ prolapse may contribute to the pain puzzle as can bony irregularities (e.g., sacroiliac joint dysfunction and hip pain). Pelvic floor muscle dysfunction Understanding pain related only to PFMD can be equally confusing as it has received multiple labels over time e coccydynia, levator (spasm) syndrome, tension myalgia of the PF, PF spasticity, urethral/ anal sphincter dyssynergia, vaginismus, and shortened PF [39]. The progression of PFMD occurs in two stages: the first, neuromuscular, and the second, musculodystrophic. Following some injury or insult (e.g., coccygeal injury with a fall, chronic hip pain, or recurrent yeast or urinary tract infections), free calcium is released, disturbing the sarcoplasmic reticulum and causing hypertonicity within the muscle. In the presence of ATP, calcium ions stimulate the actin/myosin activity, increasing metabolic activity. The release of various neurotransmitters, including serotonin, histamine, kinins, and
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Fig. 2. Medial view of the pelvic floor muscles. PFM: pelvic floor muscles. Modified from Primal Pictures with labels added (images copyright Primal Pictures, http://www.primalpictures.com).
Fig. 3. Inferior view for pelvic floor muscles with associated muscles and structures. PFM: pelvic floor muscles. Modified from Primal Pictures with labels added (images copyright Primal Pictures, http://www.primalpictures.com).
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prostaglandins, stimulate muscle nociceptors and set up a neural circuit between the central nervous system, nociceptors, and motor units [27]. Over time, the hypertonic muscles enter the musculodystrophic phase while attempting to adjust to the overall increase in metabolic activity. When that adjustment fails, localized fibrosis begins and atrophied muscle tissue is replaced by less metabolically active and extensible connective tissue [48]. An example of this phenomenon can be seen when bladder and urethral function are impacted by PFMD. Once PFM hypertonicity becomes chronic and full range of motion is reduced, the tension may obstruct voiding or make it impossible, with severe cases requiring intermittent self-catheterization. Not only will the PFMD cause restriction in the urethra but it can also inhibit the detrusor during bladder filling and emptying, resulting in urinary urgency, frequency, and hesitation [19]. Patients will involuntarily contract their PFMs for extended periods in response to the urgency, reflexively inhibiting bladder filling and emptying. With time, the PFMs lose their flexibility and are unable to normally relax. It then becomes impossible to separate the visceral from the muscular dysfunction as each drives the other e more muscular tension creates more urgency and increased urgency creates more PFM tension. The vicious cycle begins (Table 1). Physical therapy assessment Medical history The intake interview includes a traditional physical therapist's review of biomechanical systems but adds additional questions related to bowel and bladder function (including intake of fluids), menstrual and vaginal health, and a full history of sexual function, including questions on desire, arousal, and Table 1 Possible causes of pelvic floor muscle dysfunction (PFMD). Faulty biomechanics
Postural and structural dysfunction
Injury to the pelvic floor muscles
Faulty cumulative behaviors of the pelvic floor muscles
Inflammatory pain disorders involving pelvic viscera
1. Dysfunction of the lumbosacral spine or pelvic girdle e hips, pelvis, pubic symphysis, sacroiliac joints, sacrococcygeal joint 2. Lower kinetic chain irregularities e knees, feet, subtalar joints 3. Hypermobility throughout the pelvic cavity 1. Scoliosis 2. Short leg syndrome 3. Small hemi-pelvis 4. Perpetuation of typical pelvic pain posture e anterior pelvic tilt, increased thoracic kyphosis, lumbar lordosis 1. Childbirth 2. Pelvic surgery 3. Falls with landing on sacrum or coccyx, uncontrolled “slip” or stepping unexpectedly off a curb, creating a shear force at the pubic symphysis 4. Repetitive movement injuries seen with high-velocity sports with altered postures (e.g., gymnastics, dance) 1. Repetitive minor trauma or straining with chronic constipation or urinary obstruction 2. Abnormal chronic holding patterns a. History of sexual abuse b. Sexual guilt c. Pain with first attempted tampon use, penile intercourse, or vaginal exam d. Urinary urgency or frequency e. Urinary or fecal incontinence f. General stress, anxiety, tension g. Traumatic toilet training, history of bedwetting 3. Prolonged constriction or extended sitting with unequal weight bearing (e.g., occupational posture) or lack of motion (e.g., long car rides) 1. Irritable bowel syndrome (diarrhea, constipation) 2. Endometriosis 3. Chronic cystitis, painful bladder syndrome 4. Dysmenorrhea
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orgasm (Table 2). Because of the coexistence of PFM and visceral dysfunction, it is imperative to get a full and comprehensive history that includes a pelvic organ system review. It is often impossible to ascertain which came first e the PFMD that caused the pelvic organ functional complaints (e.g., PFM hypertonicity compromising the ease of bowel movements resulting in a complaint of constipation) or the chronic visceral dysfunction that was driving the PFM tension (e.g., chronic diarrhea that caused PFM hypertonicity). Regardless of the initiating trigger, both must be treated to reach maximum success with treatment. Table 2 Functional history questions. Examples given are for average function typically found in women without complaints of pain and possible responses for women with abnormal function and a history of pain. Question Bladder function How often do you empty your bladder? How much and what do you drink? Do you have pain when you empty? Do you feel empty afterwards? Do you have to push to start or does the urine just come out? Do you ever lose urine? Do you have a history of chronic urinary tract infections? Bowel function How often do you have a BM? Do you have a history of IBS? Do you need to strain to empty What consistency are your stools?
Average function
Possible abnormal function
6e8/day, including 1/night or every 3.5e4 h 1/2 my body weight in ounces No, not even after intercourse
Every hour or so; up multiple times/night
Yes No, flow just starts after I sit down to go No, not even with exercise No
3/day to 3/week No No Formed, soft, easy to expel
Do you feel empty after a BM? Do you ever have pain with BM? Menstrual history Do you have a history of painful periods?
No
Do you use tampons?
Yes with no trouble
Vaginal history Do you have a history of chronic yeast infections? Sexual history Are you currently sexually active? Do you have pain with sex? Do have any sexual desire? Did you always have pain with sex?
Can you have an orgasm? When you are intimate, do you get wet (arousal)? Where does it hurt when you try to have sex? How long does the pain last? Is there anything you can do to make the pain go away? Even though you don't have sex, are you still hugging, kissing, and touching?
Yes No
Not a lot, don't want to have to empty Yes, very often after intercourse and into the next day No, often have to go again quickly Yes, often have to think about it and push a little to get it started Yes, often with laughing, lifting, etc. Yes, often treated with antibiotics, even with no culture or testing Often less or more than average Yes (with constipation and/or diarrhea) Yes, often even when it's soft 1) Large and hard (problem with diet) or 2) Soft and pencil thin but hard to get out (non-relaxing anal sphincters) No, still feel like there is more there Yes (tailbone, abdomen, or low back) Yes, with a lot of cramping with long, heavy bleeding; often have used oral contraceptive with help No, it hurt when I tried it for the first time or it hurts now
No
Yes, often with no resolution even with, treatment; lots of burning pain
Yes No Yes No
No, it hurts too much and I don't want it Yes No, it's been too long; it hurts too much 1) Yes, it hurt the first time I tried (primary vestibulodynia/dyspareunia) 2) No, it was fine before but now it hurts (secondary vestibulodynia/dyspareunia) Yes, with clitoral stimulation only but it's harder to have and it isn't as intense Sometimes but often need to use a lubricant or perhaps not at all Mostly at the bottom of the vaginal opening Ranges from a few minutes to days Sit in a hot tub, ice, go to sleep
Yes, with clitoral stimulation and/or intercourse Yes NA NA NA NA
Yes, I try to do what I can No, I don't want to lead him on
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Education Every patient receives a brief education in PF anatomy. A plastic pelvic model with removable PFMs is used to describe and visualize the anatomy of the pelvis. Viewing the PFM orientation allows patients to see the anatomy in three dimensions, helps them to understand the intimate relationship between the muscles and organs, and seems to assist patients with voluntary PFM activation during the physical exam. The model is shown in Fig. 4.
Fig. 4. Digital assessment of vulvar pain with testing at 3, 6, and 9 o'clock around the introital opening. Hand positioning used at 3 and 9 o'clock can be used for insertion into the vagina with severe pelvic muscle spasm to avoid pressure on the urethra. A) 3 o'clock position on the introitus on the patient's left; B) 6 o'clock position on the introitus at the midline (posterior fourchette), superior to the anus; and C) 9 o'clock position on the introitus on the patient's right. Published previously and with permission. Hartmann D. Chronic vulvar pain from a physical therapy perspective. Dermatol Ther. 2010;23(5):505e13.
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Physical assessment 1. Traditional physical therapy evaluation: The assessment begins with evaluation and gross assessment of posture, gait, and generalized strength and mobility. Common physical findings in those with chronic pain are shown in Table 3. 2. Abdominal and hip assessment: Women are asked to undress from the waist down and lay supine and covered on a treatment table. The initial exam continues with gentle palpation of the abdomen, assessing for visceral tone and connective tissue health in the abdominal musculature. Passive hip mobility is assessed bilaterally as is the tone in the hip musculoskeletal complexes (e.g., psoas, iliacus, and deep external rotator muscles). Elevated tension throughout the abdomen, decreased hip mobility, and increased tension in the hips are common findings in those with a history of pain and dysfunction. 3. Visual exam of the perineum and vulva: The goal is to screen for any abnormal findings (Table 4). If disease is suspected, the appropriate referral is made. The perineal body position at rest is noted. Gross PFM function can be reviewed visually with a request for active contract and release of the PFM, “like trying to hold back urine or gas and then relaxing.” Perineal body mobility can be recorded, noting any change in resting position following the contraction/relaxation of the PFM. It is not uncommon following active mobility of the PFM for the perineal body to return to a more relaxed, inferior position. For more details, see the section covering internal exam. 4. Vulvar sensitivity assessment: The Q-tip test, which assesses pain levels by touching various points around the introitus with a cotton swab, has become the gold standard for diagnosing vestibulodynia [49e51]. Patient pain perception is graded during the test using an 11-point numeric pain rating scale of 0e10, with 0 representing “no pain at all” and 10 suggesting the “worst possible pain.” Changes in the scale over the course of treatment are an accepted measure of progress, both clinically and with research. A study by Reed et al [51]. has suggested that deeper palpation into the hymenal remnant in the vestibule was highly correlated with an accurate diagnosis of vulvodynia and was also predictive of associated PFM involvement. The first author has found equal success using a modified Q-tip test. It is accomplished by assessing pain at three points on the opening using a gloved (non-latex) and lubricated (natural oil) single-digit palpation at 3, 6, and 9 o'clock (Fig. 4). The pressure used is often minimal and gauged by patient tolerance. The results of this modified Qtip test might be recorded as “pain of 7/10 at 3 o'clock, 6/10 at 6, and 5/10 at 9 o'clock.” The technique has proven to be a reliable tool for measuring change in perceived vulvar pain before and after treatment sessions and over the duration of the treatment. 5. Internal examination: Intervaginal, single-digital assessment continues with particular attention paid to patient pain tolerance. With time, education, patience, and a gentle touch, internal exams are usually completed on the first visit. Digital palpation allows for differentiating the function and state of tension of the superficial PFMs (bulbospongiosus, ischiocavernosus, and superficial transverse perineal muscles), the deep PFMs (levator ani and coccygeus), the obturator internus muscles,
Table 3 Gross Physical Findings. Common findings outside of pelvis that are typically associated with chronic pelvic floor muscle dysfunction. Gross assessment
Specific findings
Pelvic pain posture
1. Increased lumbar lordosis (arched low back) or thoracic kyphosis (rounded shoulders, forward head) 2. Associated muscle tension e iliopsoas, piriformis, hip deep external rotators , abdominals, hip adductors, and/or quadratus lumborum Abnormalities in the distribution of the sciatic, pudendal, and/or obturator nerves Weakness in abdominals, hamstrings, hip flexors, trunk extensors (also includes the pelvic floor muscles) Elevated abdominal visceral tension e most notably the colon, small intestines, rectum, uterus, urethra, and bladder
Pelvic innervation Deconditioned core muscle strength Pain and tension with palpation of the abdominal cavity
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Table 4 Possible abnormal findings. Generalized possible findings with visual inspection of the perineum. Visual findings Perineum is Dry? Wet? Excoriated? Perineal body below ischial tuberosities? Perineal body above ischial tuberosities? No perineal body movement with attempted pelvic floor muscle contraction? Vulva is Missing labia majora and or labia minora? Scars and/or scar adhesions? Unusual discharge and/or odor? Fissure or tears at the posterior fourchette? Introital opening reduced in size?
Possible etiology with positive findings Atrophic vaginitis Excessive discharge, yeast infection, vaginal disorder Urinary incontinence Hypotonic pelvic floor muscles Hypertonic pelvic floor muscles Pelvic floor muscle dysfunction (hypo- or hypertonic)
Lichen sclerosis History of episiotomy or vulvar surgery, lichen sclerosus Yeast or bacterial infection Lichen planus or sclerosus, chronic yeast or bacterial infection, pelvic floor muscle hypertonicity Lichen planus or sclerosus chronic pelvic floor muscle dysfunction
the pelvic viscera (urethra, bladder, uterus, and rectum), and the fascial support of the pelvis (arcus tendineus fascia pelvis (ATFP) and arcus tendineus of levator ani) [31]. Normal PFM tone creates a visible, mildly concave surface of the perineum in reference to the plane of the ischial tuberosities with the perineal body sitting slightly superior. A single digit is inserted into the introitus at the level of the perineal body and progresses above the hymenal ring to reach the PFMs. As insertion occurs, PFM resting tone can be evaluated by noting the relative size and position of the opening created by the PFMs. Normal PFM resting tone allows for easy, pain-free digital insertion. With normal tone, the opening in the PFMs sits just above the introitus and the perineal body. By contrast, elevated PFM resting tone causes the vaginal muscular opening to be smaller in circumference, further superior into the pelvic cavity with more distance between the perineal body at the surface of the perineum. The muscle tension pulls the perineal body inward, creating an increased concavity of the perineum. Conversely, with PFM laxity, there is little to no space between the PFMs and the perineal body. The lack of PFM tone causes the perineum to appear mildly convex, often falling inferior to the plane of the ischial tuberosities. The digital grading of PFM function is completed using the modified Oxford scale of 0e5, with 0 being indicative of no perceptible active PFM contraction and 5 suggestive of normal PFM contractility [52]. The active range of motion of the PFMs is quantified numerically using a plus/minus system such that reporting might be recorded as “PFM function 3/5.” Many clinicians suggest that someone with elevated PFM tension and resting tone has “weak PFMs.” In actuality, there is a decreased active range of motion that is caused by hypertonicity or reflexive splinting (unconscious contraction of the PFMs) which occurs prior to penetration (sexual or nonsexual). The poor contractile force of the hypertonic PFMs (e.g., perhaps recorded as 2/5 on the modified Oxford scale) is followed by a slow, incomplete release of tension, returning the PFMs only to the level of the original, elevated resting tone. The reporting of PFM function therefore should include the digital measure of PFM function with the Oxford scale as well as a digital measure of PFM release and resting tone (e.g., “PFM function 2/5 with poor and incomplete release of elevated resting tone”). In women with PVD, the more common anterior pelvic findings include some combination of the following: elevated PFM resting tone, taut bands and/or active trigger points in the PFM, elevated tone of both obturator internus muscles, increased tension in one or both tendinous arch(es) of the pelvic fascia and/or the levator ani, and increased tone or visceral spasm in the urethra, bladder, uterus, or rectum. Abnormal internal tension or tone is digitally sensed as a stiffness or bulkiness in the tissues being assessed. When palpating the urethra, for instance, the assessing digit would be at 12:00 in the vaginal canal where the urethra is supported by the periurethral fascia behind the pubic symphysis. With normal tone, the musculature of the urethra is relaxed on itself and feels like a soft, shallow mound of tissue running approximately 4 cm in length along the backside of the symphysis. When the
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urethra has increased tone, it feels like a straw or a pencil that can be rolled over. Too much pressure on the tense urethra can cause complaints of pain or urinary urgency. Likewise, the rectum, when palpated vaginally at 6:00, has similar properties. Pressure on a tense, round bowel may create pain or the sense of urgency common to passing gas or stool. Elevated rectal tension appears to increase complaints of pressure and pain at the posterior fourchette (6:00). Following release of the tension via physical therapy, the complaints of pain are typically reduced, often to zero. It is not uncommon as part of the initial patient visit to also complete an assessment of the posterior pelvis via the anus to identify abnormal tension in the anal sphincters, coccygeus muscles, posterior pelvic ligaments (anococcygeal, sacrotuberous, and sacrospinous), and the fascial structures attaching to and around the ischial spines (Figs. 2 and 3). Bimanual exams of the sacrococcygeal and sacroiliac joints can be completed when dysfunction is suspected. Anterior and posterior PFM function and resting states should not be assumed to be equal as very often they are not. Physical therapy intervention According to the American Physical Therapy Association, the overall goal of physical therapy intervention is to restore normal function while working to reduce any negative psychological impact associated with the disease, pain, or dysfunction being addressed [53]. It is incumbent on all healthcare providers who treat women with CPP to be aware of the pain's overwhelming impact on the patient's quality of life. Physical dysfunctions may be more readily addressed and treated but the psychology of pain cannot be ignored. Regular referrals to mental health providers may make the difference between full and partial recovery. Without access to adjunctive care, all providers must do what they can to address emotional issues associated with chronic pain, including sexual dysfunction. Women's health physical therapy will be much less successful if the treating therapist is unable or unwilling to discuss sexual function as she goes through her chosen treatment protocol. Intervention is driven by organ system dysfunction and physical findings. If urinary urgency and frequency are noted in the intake, for example, it is necessary to review dietary as well as bladder habits (Table 1). If bladder dysfunction is left unaddressed, it may cause the PFMs to remain in a constant state of excessive holding, thus contributing to additional PFM hypertonicity and possible vulvar pain and sexual dysfunction. The same holds true for bowel dysfunction. Discussions around daily food intake can often lead to suggestions for small changes (e.g., eliminating dairy and/or gluten intake, or decreasing sugar consumption) that can impact overall pelvic function by correcting chronic constipation or diarrhea. Abnormal physical findings throughout the body, discovered through the assessment process, need to be addressed for full recovery of pelvic health. Manual therapy is pivotal to successful treatment. Modalities like soft tissue mobilization, myofascial release, joint manipulation, visceral mobilization, therapeutic exercise, and neural mobilization can be used to correct musculoskeletal dysfunction throughout the body as well as within the pelvic cavity. Any exercise prescription should include a home exercise program designed to improve core stability and correction of any gait or postural imbalances as indicated. The importance of proper PFM function is stressed regularly, beginning with the initial visit and addressed during each successive treatment session. Before full PFM function can be restored through active PFM exercise, however, any associated abnormalities within the pelvis also must be corrected. Manual therapy techniques can be applied with good success e pelvic visceral tension can be eased, obturator internus muscles spasm can be relaxed along with accessory hip muscle tension, and PFM hypertonicity can be reduced. Once the tension in these tissues, muscles, and fascia is released in the clinic e usually on the first visit for women with PVD e the palpated pain at the introitus is typically reduced. When patients realize that the release of pelvic and associated myofascial tensions can impact their complaints of vulvar pain, their compliance with their individualized home exercise program improves. Twenty-two years of clinical experience has shown the first author that renewal of motor function and overcoming reflexive splinting of the PFMs is pivotal in recovery for most, if not all, patients with PFMD and PVD. The advantages of regular PFM exercise are increased blood flow, improved PF support, decreased posterior fourchette fissuring, improved proprioception of the PFM position, and increased intensity of orgasm [40]. Though the home exercise prescription is obviously dependent on individual
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PFM function during initial evaluation, it typically involves working up to two 5-min sessions of PFM exercises a day (once in the morning and once in the evening). Both fast-twitch and slow-twitch muscle fibers are present in the PFM and are addressed separately in the exercise regime. For the majority of patients, the prescribed PFM exercise alternates a sustained PFM contraction of five counts, followed by a total muscle release, with five quick, successive PFM contractions followed by release. If during the first week of doing the PFM exercises the sensation of contraction or relaxation cannot be sensed, the exercises are to end for that session, with more time added as the muscles are able. Likewise, if there is ever an increase in any symptoms, the exercises are to be stopped until the next WHPT visit. It is suggested to the patient that the PFM exercises can be used any time that discomfort is felt, such as before and after a vaginal exam, with increased distress or anxiety, or if pain occurs while driving or sitting. Active contraction and relaxation of the PFM is suggested before, during, and after intercourse and can be helpful in the first few weeks of use. Summary Treating patients with chronic PFD is challenging for all those in the health-care arena. Chronic pelvic and vulvar pain are certainly no exception. It is incumbent on all those who deal with this difficult population of women to be compassionate, understanding, and thorough in their assessment and treatment approach. The unknown factors related to the causes of chronic pelvic and vulvar pain continue to stymie practitioners. However, therapy that is directed toward finding the comorbid physical abnormalities throughout the body and correcting them appears to be a logical and successful approach. Referral to a WHPT should occur routinely as part of the multidisciplinary approach for all women who present with any type of vulvovaginal pain. Research indicates that PF physical therapy is safe and effective, and can dramatically improve symptoms related to PVD and chronic PFD. Working together, the health-care team can make progress as each member contributes his or her expertise. Women, when given the correct tools, can learn to manage their bodies and recover the function they may have lost due to the pain and dysfunction.
Practice points Physical therapists trained in treating chronic pelvic dysfunctions take a whole-body approach to treating women with a history of vulvar and sexual pain. Multiple organ systems (muscular, fascial, visceral, and bony) can contribute to chronic pelvic floor muscle dysfunction and must be assessed and treated for the most complete recovery. Helping women to regain normal pelvic floor muscle function appears to be key in recovering normal vulvar sensitivity and sexual function.
Research agenda Analysis of physical findings throughout multiple organ systems in women with chronic pelvic floor muscle dysfunction needs to be completed. Various manual physical therapy treatment protocols need to be assessed and compared to each other as well as to controls with no treatment and to those undergoing other interventions (pharmacology, surgery, and psychotherapy). Long-term outcomes following physical therapy intervention need to be assessed.
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