Download Pelvic Pain

Physiotherapy & Chronic Pelvic Pain
When can physiotherapists help and what do we do??
FOCUS TOPIC
The clinical reasoning behind
the approach
Taryn Hallam
Women’s Health Training Associates
Alana Health Care for Women
Ph 0488 982 796 (direct)
Which piece of the CPP puzzle can
physiotherapists assist with??
Let’s start by understanding the traditional role of
physiotherapists….
Expertise lies largely in Striated Skeletal Muscle
Function / Dysfunction
 1 Anatomy and Physiology of Striated Muscle Function
 2 Movement disorders related to Muscle Dysfunction
 3 Pain related to Muscle / Myofascial Dysfunction
Basic Principles of Myofascial Based Pain
1. All skeletal muscles have both a motor and sensory
innervation via somatic nerves (eg pudendal, sciatic etc)
2. Normal muscle function / activation does not usually
activate nociceptors or cause “pain”
3. Overactive / hypertonic striated skeletal muscle can
activate pain signals ……
1
Within the Muscle Itself
Ischemic Pain
Myofascial Trigger Point
Information on Myofascial Trigger Points…
What is a Myofascial Trigger Point?
Defined as
‘a hyperirritable electrically active loci in skeletal
muscle that is associated with a palpable nodule within
a taught band”
Commonly associated with a dysfunctional motor
endplate
ie localised, usually <1cm diameter area of mm
overactivity
Results in
•
•
•
•
Local pain + specific referred pain pattern
Pain either constant (active) or only on palpation (latent)
Motor dysfunction / reduced ROM
Associated autonomic dysfunction
Sikdar et al 2009,
Basic Principles of Myofascial Based Pain
1. All skeletal muscles have both a motor and sensory
innervation via somatic nerves (eg pudendal, sciatic etc)
2. Normal muscle function / activation does not usually
activate nociceptors or cause “pain”
3. Overactive / hypertonic striated skeletal muscle can
activate pain signals in either ……
1
The Muscle Itself
Ischemic Pain
Myofascial Trigger Point
2
Other Structures
Compression from hypertonic mm contraction
The traditional role of physiotherapists….
Expertise lies largely in Muscle Function / Dysfunction
 1 Anatomy and Physiology of Muscle Function
 2 Movement disorders related to Muscle Dysfunction
 3 Pain related to Muscle / Myofascial Dysfunction
How does this link with
Chronic Pelvic Pain in a
gynaecological setting??
Link between Muscle Overactivity and
Chronic Pelvic Pain Syndromes
Direct Muscle
Based Pain
 CPP
Muscle Induced
Nerve Compression
 CPP
1. Generalised hypertonia of muscles
in/around the pelvic region
2. Myofascial trigger points with referred
pain patterns in/around the pelvis
Skeletal Muscle Hypertonicity of the Pelvic Floor
“Pelvic Floor Myalgia”
Superficial Pelvic Floor mm
Deep Pelvic Floor mm
Symptoms Commonly Associated with Pelvic Floor Myalgia





Generalised Pain Through Pelvis
Dyspareunia ++++ (entry and deep)
Dyschezia
Pain on bladder Filling
End of Void Pain
How Do We Assess for Hypertonicity
3 Main Assessments
1. Observation of Range of Movement
2. EMG
3. Manometry
Observation – Range of Movement
Normal Pelvic Floor Contraction
Tightening
here
“Tightening of the vaginal and anal openings,
with an inward lift at the perineum”
How does this relate to the Anatomy?
Remember there are two main levels to the pelvic floor
Inward drawing
of perineum here
What happens in Hypertonic Pelvic Floor
Decreased Range of Movement on the “Squeeze”
1.
Minimal tightening
Minimal lift
Only partial reversal of movement on the relax
2.
Minimal opening
Minimal ‘drop’
Reduced “POP-Q” measurements at rest
3.
1.
2.
Reduced GH (overactive superficial)
Reduced GH + PB (overactive deep)
EMG
1.
Raised resting EMG level >4uV
Manometry
1.
2.
Raised resting pressure eg 68cmH20
Incomplete reduction in pressure on “relaxation”
Referred Pain from Myofascial Trigger Points
.
PELVIC FLOOR TRIGGER POINTS
Referred Pain from Myofascial Trigger Points
.
ABDOMINAL & PELVIC TRIGGER POINTS
Images from Real Bodywork iPhone App “Muscle Trigger Points”
Referred Pain from Myofascial Trigger Points
.
TRUNK / SPINAL TRIGGER POINTS
Images from Real Bodywork iPhone App “Muscle Trigger Points”
Link between Muscle Overactivity and
Chronic Pelvic Pain Syndromes
Direct Muscle
Based Pain
 CPP
Muscle Induced
Nerve Compression
 CPP
Nerve Entrapments & CPP
Question???
Which nerves, if entrapped, can
be a source of neuropathic pain in
the urogenital and anorectal
region????
Pudendal Nerve & Branches
Dorsal Nerve of
Clitoris branch
Perineal
Nerve Branch
Inferior Rectal
Nerve Branch
PUDENDAL NERVE
Pudendal Neuralgia
1
1
2
3
2
3
Compression /
Damage to nerve
Pudendal Nerve - Course
• Originates at S2,3,4 from Onuf’s nucleus
• Passes between the Piriformis and
Coccygeus, leaving pelvis through the
lower part of greater sciatic foramen
• Crosses the ischial spine and re-enters
pelvis through lesser sciatic foramen
under levators
• Inferior rectal nerve branches off before
remainder travels through alcock’s canal
to supply perineum and clitoris.
Locations of Pudendal Nerve Entrapment
Filler 2009
Four subtypes of PNE syndromes:
1.
Entrapment at the exit of the greater sciatic
notch in concert with the piriformis muscle
2.
Entrapment at the level of the ischial spine,
sacrotuberous ligament and lesser sciatic
notch entrance
3.
Entrapment in association with obturator
internus muscle spasm at the entrance of
the alcock canal
4.
Distal entrapment of terminal branches.
But is the pudendal nerve the only nerve
that result in a neuralgia of this region??
The ‘Other’ nerves in the region……
= Genital Branch of Genito-femoral Nerve
=
Obturator nerve
= Pudendal
= Posterior Femoral Cutaneous Nerve
i. Perineal branches (lateral to anus & labia majora)
ii.Inferior cluneal branches (infer gluts)
2 Genital Branch of Genitofemoral Nerve
Genitofemoral Nerve
particularly Genital Branch…..
• Originates from the upper lumbar
plexus with nerve roots L1/L2
• Emerges on the anterior surface
of psoas major and divides into
two branches
• Genital Branch:
• In males travels through inguinal
canal and supplies scrotal skin
• In females supplies skin of mons
pubis and labia majora
• Femoral Branch:
• Cutaneous supply to upper femoral
triangle
Genitofemoral Neuralgia
• Presents as paresthesias, burning pain
and occasionally numbness over the
lower abdomen that radiates into:
• the inner thigh in both men and women
• Labia majora in women
• Bottom of the scrotum in men
• Pain does not radiate beyond the knee
• Made worse by extension of the lumbar
spine  traction on the nerve
• Patient’s commonly adopt a bent-forward
novice skier’s positions
3 Perineal Branch of Posterior Femoral
Cutaneous nerve…..
Posterior Femoral Cutaneous Nerve
and it’s branches……
• Stems from the sacrum and courses through the
greater sciatic foramen below piriformis in the
company of the sciatic nerve
• Runs it’s descending course beneath the gluteus
maximus then splits into 3 branches
• Primary branch runs down the outer thigh and deep into
the tissue at the back of the knee
• Gluteal Branches: 3-4 Inferior cluneal nerves (gluteal
branches), arise from the posterior turn upward aroudn
the lower border of the glutues maximus, and supply the
skin covering the lower and lateral part of the muscle.
• Perineal branches of Posterior Femoral Cutan: are
distributed to the skin at the upper and medial side of the
thigh, with one long perineal branch skin of scrotum in the
male and labia majorus in the female.
So we now have 2 links between muscle
Dysfunction and CPP Symptoms
Direct
Myalgia 
CPP
Muscle Induced
Neuralgia 
CPP
But is this the whole picture of the role
of physio in CPP??
To understand the “other” physio role in CPP….
Traditional Pain Classifications
3 Traditional Classifications
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
Physiotherapists role in Chronic Pelvic Pain
Traditional Pain Classifications
Where did physiotherapy usually fit within this model?
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
Physiotherapists role in Chronic Pelvic Pain
Traditional Pain Classifications
Where did physiotherapy usually fit within this model?
Primary Focus
Somatic / Myofascial Pain
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
Physiotherapists role in Chronic Pelvic Pain
Traditional Pain Classifications
Where did physiotherapy usually fit within this model?
Primary Focus
Somatic / Myofascial Pain
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
Physiotherapists role in Chronic Pelvic Pain
Traditional Pain Classifications
Where did physiotherapy usually fit within this model?
Primary Focus
Somatic / Myofascial Pain
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
2 With a role also in some
neuropathic entrapment pains
Problems with this categorisation….
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
We now know chronic pain is much more
complex than this
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
Central Sensitisation
Central Sensitisation
Central Sensitisation
Central Sensitisation
We now know chronic pain is much more
complex than this
Central Sensitisation
Viscero-somatic and
Somato-visceral Convergence
Visceral
Pain
Somatic
Pain
Note – great summary article
Donna Hoffman (2011)
Current Pain and Headache
Reports, vol 15, pp 343-346
Backround Principles for Understanding
Somato - Visceral Convergences
CNS
BRAIN
Autonomic Nerves to Viscera / blood
vessels
Somatic Nerves to Muscles and
Skin of the Pelvis
eg Pudendal (S2,3,4)
eg Hypogastric (T10-L2)
Spinal Cord
eg Genitofemoral,
Ilioinguinal (L1- L2)
eg Pelvic Splanchnic (S2,3,4)
But let’s just focus on the sensory afferents to the
dorsal horn for a minute….
Convergence  Antidromic Propogation
Note: What is Antidromic Propogation??
= an impulse moving in the opposite direction to normal
Example
1. Nociceptive Stimulus triggers impulse
toward CNS along sensory afferent fibre
2. Antidromic impulse then causes
inflammatory mediators to be
released back into peripheral
tissues.
2. Normally Neurotransmitter release in dorsal
horn triggers action potential in 2nd order
neurone up to somatosensory cortex but
…it can also refires an antidromic impulse back
down a different afferent fibre located in the
same dorsal horn.
Somatovisceral / Viscerosomatic Convergence can
occur whenever there is a common dorsal horn
CNS
BRAIN
Autonomic Nerves to Viscera / blood
vessels
Somatic Nerves to Muscles and
Skin of the Pelvis
eg Pudendal (S2,3,4)
eg Hypogastric (T10-L2)
Spinal Cord
eg Genitofemoral,
Ilioinguinal (L1- L2)
eg Pelvic Splanchnic (S2,3,4)
3 Types of Convergence
1 Viscero-Visceral convergence
“Pathology in one organ creates pathology
in another organ
• Noxious afferent signals from visceral
disease converge with other visceral
afferents in the spinal cord.
• Antidromic signal is activated back down
to alternate organ
• Release of inflammatory
neurotransmitters by afferent nerve
antidromically into alternate visceral
structures causes a neurogenic
inflammation in visceral structures.
Therefore…. Inflammation in viscera can cause inflammation, hyperalgesia
and overactivity in viscera with the same nerve root supply.
Example of Viscero-visceral convergence
• Berkley 2005 showed in a rat model, induced colon
inflammation produced signs of inflammation in otherwise
healthy tissue of the bladder and uterus
also that….
• Rats with endometriosis showed reduced volume voiding
threshold in the bladder
• Brinkert et al 2007 showed explained that severe
menstrual pain induced intestinal hypersensitivity.
This explains why so many of my patients
have
endometriosis
AND
irritable bowel syndrome
AND
bladder pain syndrome etc…
2 Viscero-somatic convergence
• General visceral afferent sending
noxious signal from visceral disease
converges with somatic afferents in
the spinal cord.
• Antidromic signal activated down
somatic afferent to skeletal muscle
• Release of inflammatory
neurotransmitters into skeletal
muscle by afferent nerve working
antidromically causes inflammation,
hyperalgesia and overactivity in
somatic structures.
Therefore…. Inflammation in viscera can cause inflammation, hyperalgesia
and overactivity in skeletal muscle with the same nerve root supply.
Example of Viscero-somatic convergence
• Wesselmann and Laid 1997 showed that
• induced uterine inflammation in rats produced inflammation of
muscles of the trunk, perineum, thighs and proximal tail.
• Patients with dysmenorrhea and endometriosis can develop
Muscular hyperalgesia, inflammation and overactivity in the rectus
abdominus
3 Somato-visceral convergence
• Myofascial trigger points or hyperactive
muscle fibres  ischemia  decreased pH
 activation of local nociceptors.
• Somatosensory afferents activated and
synapse with second order neurones but
neurotransmitters also activate visceral
afferents antidromically
• Signals are then sent back to visceral
structures antidromically
• Release of inflammatory neurotransmitters
by afferent nerve working antidromically back
into visceral structures causes inflammation
in visceral structures.
Therefore…. Overactivity of musculature can cause neurogenic
inflammation in viscera of same nerve root supply.
Example of Somato-visceral convergence
Dogweiller et al 1998
• somatic afferent C-fibres were activated by injecting a pseudo-
rabies virus into the tail muscle of rats.
• Impulses were shown to transmit via somatic afferents to the spinal
cord
• This was then followed by inflammatory mediators shown to be
released into the bladder causing a haemorrhagic cystitis
Concluded that this model shows how activation of somatic afferents
from overactive musculature may create neurogenic inflammation in the
bladder of patients with IC.
IC / BPS and Myofascial Pain
Bassaly et al 2011
Myofascial Pain and Pelvic Floor Dysfunction in patients with Interstitial Cystitis
Performed a restrospective chart review on 186 patients with a diagnosis of IC from April 2007
to Dec 2008
RESULTS
 Roughly 1 in 5 IC/BPS patients had no identifiable trigger points.
However…
 78.3% of IC/BPS patients demonstrated myofascial pain with at least one
pelvic floor or rectus abdominus myofascial trigger point, and
 67.9% of patients had 6 or more separately identifiable trigger points.
 Most common location of MfTP were obturator internus, puborectalis, arcus
tendineus and iliococcygeus.
Research: Physiotherapy and IC/BPS
Weiss et al 2001
Pelvic floor myofascial trigger points: manual therapy for interstitial cystitis and the
urgency-frequency syndrome
Subjects
45 women and 7 men
- 10 with IC with avg duration of 14 years
- 42 with UF with avg duration of 6 years
Treatment
Manual therapy to the pelvic floor
1-2/week for 8-12 weeks
Results
• 35/42 (83%) with urgency/frequency syndrome had moderate , marked or complete
resolution of symptoms
• 7/10 (70%) with IC had moderate to marked improvement.
• In 10 patients who underwent EMG mean resting PF tension decreased from 9.73 to
3.61mV
Oyama et al 2004
Pilot study : Modified Thiele Massage as Therapeutic Intervention for Female
Patients with Interstitial Cystitis and High Tone Pelvic Floor Dysfunction
N = 21 women with Classic IC and High Tone Pelvic Floor
Treatment
• Total of 10 Intra-vaginal Thiele Massages, Twice per week for 5 weeks
• Motion performed 10-15 times during each session to each of the following
muscles in order:
• Coccygeus
• Iliococcygeus
• Pubococcygeus
• Obturator Internus
• At the practitioners discretion  10-15sec of ischemic compression was
applied to trigger points.
Oyama et al 2004
Pilot study : Modified Thiele Massage as Therapeutic Intervention for Female
Patients with Interstitial Cystitis and High Tone Pelvic Floor Dysfunction
Results – at completion of protocol
Statistically significant improvement was seen in
• Symptom and Problem Indexes of the OLS Questionnaire
• Likert Visual Analogue Scales for urgency and pain
• Modified Oxford scale in all muscles
p < 0.015, p < 0.039
p< 0.001, p < 0.005
p < 0.05
Results – long term ~4.5month post Rx
Statistically significant improvement were still seen in
• Symptom and Problem Indexes of the OLS Questionnaire
p< 0.049 , p = 0.02
• Likert Visual Analogue Scales for urgency and pain
p = 0.004, p = 0.005
• Modified Oxford Scale for three of four muscles in the pelvic floor
p = 0.05
Conclusions.
Thiele massage appears to be very helpful in improving irritative bladder symptoms in
patients with interstitial cystitis and high-tone pelvic floor dysfunction
Fitzgerald et al 2012
Multicentre RCT of 10 scheduled treatments of myofascial
physical therapy vs global therapeutic massage.
Subjects:
N = 81 women diagnosed with IC/PBS and demonstrable
pelvic floor tenderness, with symptom duration <3years.
Results:
Moderate or marked improvement in pain occurred in:
• 26% of global therapeutic massage group
• 59% of myofascial physical therapy group p = 0.0012
Post treatment pain was the most common Rx adverse event
Physiotherapists role in Chronic Pelvic Pain
What is the Summary of All of This??
Traditionally there were 3 Separate Classifications of Pain
Visceral
Pain
Somatic
Pain
Neuropathic
Pain
We now have 4 links between somatically driven muscle
dysfunction, neuropathic pain and visceral pain  CPP
1.
Direct myofascial pain from skeletal muscle
Ischemic Pain
Myofascial TP
• Generalised hypertonic striated mm  ischemia  CPP
• Myofascial Trigger Points  localised and referred CPP
Neuropathic CPP
2.
Neuropathic CPP secondary to compression of
nerves by dysfunctional hypertonic skeletal mm
Viscerosomatic Convergence
3.
Myofascial dysfunction and pain secondary to
visceral pathology via viscerosomatic convergence
Somatovisceral Convergence
4.
Visceral Pathology and pain secondary to somatic
dysfunction via somato-visceral convergence
THE END
Pelvic Pain – Dyspareunia and Vaginismus
A mental health diagnosis?
physical diagnosis?
both?
Taryn Hallam
Women’s Health Training Associates
Alana Health Care for Women
Ph 0488 982 796 (direct)
Starting Note -
Estimate of My Current CPP Patient Caseload….
Probably average about 15-20 CPP pt’s / week
BPS / IC
5%
VAGINISMUS
5%
Generalised
DYSPAREUNIARectal
90%
Pain
Non-Menstrual
10%
Pelvic Pain
60%
DYSPAREUNIA? VAGINISMUS?
Mental Health or Physical?
Who defines them?
Does it matter?
History of the term ‘Dyspareunia’
Origin:
• Dys • Para • Eun =
Latin for “Bad”
Greek for “side by side” ie parallel
Greek for “bed”
Led to Greek word “Dyspareunos” = “Badly Mated”
“Dyspareunia” officially coined by Barnes in 1874.
Background of Dyspareunia
Through Time:
• ~ 3000 yrs ago:
Ramessieum Papyri linked vulvar pain during
intercourse with menstrual pain and irregularity
• ~2000yrs ago:
Soranus of Ephesus (Roman Physician)
rejected link with uterus and menstruation,
described a localized vulvar condition causing
pain with intercourse
• 16th Century:
Hildanus suggested mismatched anatomies /
disproportionately long penises
• 1874:
Barnes coins the term Dyspareunia “difficult
mating” suggesting multiple physical
pathologies that could cause ‘interference’ with
intercourse
Then last century……
Influence of psychoanalytic movement created change in perception
 dyspareunia began being considered a “hysterical” symptom
 interest in physical pathologies began waning, and
 treatment began to focused more on psychosexual issues.
• 1987
Dyspareunia & vaginismus listed together in DSM-III-R
under mental health category “Sexual Pain Disorder”
• 2000
Dyspareunia and Vaginismus listed separately in the
DSM-IV
Since 1980 Dyspareunia / Vaginismus in the DSM
Diagnostic and Statistical Manual of Mental Disorders
About the DSM
• Published by the American Psychiatric Association
• Provides a common language / standard criteria for classification of mental disorders
• Editions:
• DSM-I
• DSM-II
• DSM-III
• DSM-IV
• DSM-IV TR
1952
1968
1980
1994
2000
• Current edition is the DSM-IV-TR (4th edition, Text Revision), published in 2000
• DSM V is due out in 2013
Vaginismus and Dyspareunia in the DSM-IV TR
Listed under “Sexual Psychiatric Disorders”
Category:
Sexual Disorders and Dysfunctions
“primary characteristic is impairment in
normal sexual functioning. This can
refer to an inability to perform or reach
an orgasm, painful sexual intercourse, a
strong repulsion of sexual activity…”
Dyspareunia
Female Orgasmic Disorder
Female Sexual Arousal Disorder
Gender Identity Disorder
Hypoactive Sexual Desire Disorder
Male Erectile Disorder
Premature Ejaculation
Sexual Aversion Disorder
Vaginismus
DSM IV Criteria
(current – till next year)
DSM-IV
DSM-IV
Vaginismus
Dyspareunia
Defined as:
a. Recurrent or persistent involuntary spasm of
the musculature of the outer third of the vagina
that interferes with sexual intercourse
Defined as:
a.
Recurrent or persistent genital pain
associated with sexual intercourse in either
male or a female
b.
b.
The disturbance causes marked distress or
interpersonal difficulty
c.
The disturbance is not caused exclusively
by Vaginismus or lack of lubrication
The disturbance causes marked distress or
interpersonal difficulty
Sub-Specifications:
Type:
Lifelong vs Acquired
Type:
Generalized vs Situational
Due to:
Psychological vs Combined Factors
Sub-Specifications
Type:
Lifelong vs Acquired
Type:
Generalized vs Situational
Due to:
Psychological vs Combined Factors
DSM IV Criteria
(current – till next year)
DSM-IV
DSM-IV
Vaginismus
Dyspareunia
Defined as:
a. Recurrent or persistent involuntary spasm of
the musculature of the outer third of the vagina
that interferes with sexual intercourse
Defined as:
a.
Recurrent or persistent genital pain
associated with sexual intercourse in either
male or a female
b.
b.
The disturbance causes marked distress or
interpersonal difficulty
c.
The disturbance is not caused exclusively
by Vaginismus or lack of lubrication
The disturbance causes marked distress or
interpersonal difficulty
Sub-Specifications:
Type:
Lifelong vs Acquired
Type:
Generalized vs Situational
Due to:
Psychological vs Combined Factors
Sub-Specifications
Type:
Lifelong vs Acquired
Type:
Generalized vs Situational
Due to:
Psychological vs Combined Factors
DSM-IV
Vaginismus
“Recurrent or persistent involuntary spasm of the musculature of the outer
third of the vagina that interferes with sexual intercourse”
Commonly held belief that involuntary spasm is caused by:
• Anxiety
• History of sexual abuse
• Religious / cultural beliefs surrounding sexual intercourse
BUT DOES THE RESEARCH VALIDATE THIS????
Clinical Review
Crowley, Goldmeier and Hiller - ‘Diagnosing and managing vaginismus’
British Medical Journal, 2009 vol 338
 “Critical reviews of the literature conclude that studies are so methodologically flawed that no
conclusions can be made about the aetiology of vaginismus”
 The relevance of abuse history appears to be unclear
 Some research suggests a higher incidence of childhood sexual abuse amongst women with vaginismus
 Other research indicates history of abuse as the least correlated factor
However…..
 Negative views about sexuality and negative views about sexual activity before marriage have
been reported as commonly associated.
 And…….Negative views about sexuality appear to have a stronger relationship to vaginismus that sexual
abuse history
 Countries where there is taboo surrounding girls discussing sex appear to have higher rates of
vaginismus
 Cultures in which a brides virginity is regarded as crucial appear to have higher rates of
vaginismus
 However, Religiosity as a general rule has NOT been shown to be associated with vaginismus
So there does seem to be some links……
Predominantly between negative attitudes toward sexual
intercourse and vaginismus
But is there always a psychological link we can make to
explain the vaginismus??
3 Recent Cases in my clinic
CASE #1
CASE #2
27yo female - virgin
28yo female - virgin
Never used tampons-couldn’t
insert & didn’t like thought
Never used tampon because
could never achieve insertion
In long term relationship for
past 3 years (not married
Married for 3 years unconsummated
OCD, Depression
Anxiety Disorder - Medicated
Statement in First Session
Statement in First Session
“my partner has been
understanding, but he wants
to know that I am actively
doing something to try to fix
the problem”
.
“my husband is very
understanding, he puts no
pressure on me. But it just feels
like we may never have
intercourse”
(tears within 3min)
Let’s just talk about
this for a minute
Vaginismus and Anxiety / Stress
- does the pelvic floor spasm due to stress?
NORMAL
OVERACTIVE
3 Recent Cases in my clinic
CASE #1
CASE #2
CASE #3
27yo female - virgin
28yo female - virgin
26yo female - virgin
Never used tampon, couldn’t
insert & doesn’t like thought)
Never used tampon because
could never achieve insertion
Never used tampon because
could never achieve insertion
In long term relationship for
past 3 years (not married
Married for 3 years unconsummated
Not currently in Relationship.
3 ended due to vaginismus
OCD, Depression - medicated
Anxiety Disorder - Medicated
No diagnosed mental health
disorder
Statement in First Session
Statement in First Session
“my partner has been
understanding, but he wants
to know that I am actively
doing something to try to fix
the problem”
.
“my husband is very
understanding, he puts no
pressure on me. But it just feels
like we are may never have
intercourse”
(tears within 3min)
Statement in First Session
“My issue is simply that I
can’t have sex. I haven’t been
abused, I’m not from any
religious cult that’s against
sex, my parents had no issue
with sex.”
Other Significant Information……
CASE #1
CASE #2
CASE #3
27yo female - virgin
28yo female - virgin
26yo female - virgin
Never used tampon, couldn’t
insert & doesn’t like thought)
Never used tampon because
could never achieve insertion
Never used tampon because
could never achieve insertion
In long term relationship for
past 3 years (not married
Married for 3 years unconsummated
Not currently in Relationship.
3 ended due to vaginismus
OCD, Depression - medicated
Anxiety Disorder - Medicated
No diagnosed mental health
disorder
Statement in First Session
Statement in First Session
“my partner has been
understanding, but he wants
to know that I am actively
doing something to try to fix
the problem”
.
“my husband is very
understanding, he puts no
pressure on me. But it just feels
like we are may never have
intercourse”
(tears within 3min)
Statement in First Session
“My issue is simply that I
can’t have sex. I haven’t been
abused, I’m not from any
religious cult that’s against
sex, my parents had no issue
with sex.”
Conclusion – Dyspareunia and Vaginismus
A mental health diagnosis?
physical diagnosis?
both?
Mental Health Diagnosis only …… Not sure –
if it is, they are becoming cured before coming to me