Physiotherapy Interventions for Lifelong Vaginismus

1. Physiotherapy Interventions for Lifelong Vaginismus Presentation given at the 36thAnnual Meeting of the Society for Sex Therapy and Research Elke D. Reissing, Ph.D., C.Psych. Heather Armstrong, Ph.D. (cand.)

2. Acknowledgment Caroline Allen, M.A., P.T. Staff and patients at Pelvic Support Physiotherapy

3. Why lifelong vaginismus? To avoid diagnostic confusion with women who suffer from dyspareunia and who are no longer engaging in intercourse. To focus on women who experience severe vaginal penetration problems and have NEVER been able to experience vaginal penetration. No research on effectiveness of PT

4. PT for dyspareunia Pelvic floor pathology has been consistently associated as a causal, maintaining and/or exacerbating factor in women with vulvodynia (e.g., Reissing et al., 2005). The physiotherapy approach for treating vulvodynia has been well described in the literature (e.g., Rosenbaum & Owens, 2008). Outcome for PVD is excellent but more variable for generalized vulvodynia (e.g., Bergeron et al., 2010; Gentilcore-Saulnier et al., 2010).

5. Pelvic floor pathology in vaginismus Historical origin of vaginal spasm interfering with intercourse is not useful as the sole diagnostic criterion - but suggests pelvic floor involvement in vaginal penetration problems. Comparative study b/w women with vaginismus and PVD found no significant differences in pelvic floor pathology between groups (as assessed by 2 PT, EMG, and 2 gynecologists; Reissing et al., 2004). Online survey of women with vaginismus: PT interventions were reported as most helpful (Reissing, man in prep.) Anecdotally in our city, first line intervention as per physician/OBGYN referral.

6. Retrospective chart review and interview Sample: Consecutively treated women with vaginismus at one PT clinic. (Defined as: never having experienced vaginal penetration; partial penetration without thrusting; partial attempts). Measure: Had to rely on what was in PT files. Recruitment (letter/email from PT to former patients): Chart review: tacit; had to state they want to be excluded (3 participants excluded: acquired vag (1), moved (1), discontinued early (1)) PhoneInterview: Had to rely on patients taking the initiative to contact us for participation in interview. N=46 N=12

7. Sample characteristics – chart review AGE:M=38, R= 24 - 58 68% ~ never had vaginal penetration (remainder: partial/no thrusting) 58% ~ never used tampon 33% ~ never had gyne exam with speculum; of those who did, 71% only with pediatric speculum.

8. Assessment information Pelvic floor assessment: Notable anxiety (as observed by PT): 62%

9. Assessment information Pelvic floor assessment:  significant hypertonicity, poor voluntary control, poor ability to relax muscles post-contraction.

10. Assessment information Pelvic floor assessment:  High degree of self-reported pain with insertion; relatively low pain post-insertion.

11. Physiotherapy interventions INTERVENTION Applied/patient Patient education (100%) Internal manual therapy (100%) Modified Kegel exercises* (94%) Home exercises (client) (98%) Use of dilators (83%) Home exercises (partner) (71%) Biofeedback (educational) (78%) Electrical stimulation (37%) *with resistance/contact, focusing on conscious “dropping” of pelvic floor.

12. Therapy Process - Outcome MILESTONES AVERAGE SESSION Small dilator 6 Medium dilator 8 Tampons 10 Large dilator 13 Dildo (option) 20 Speculum 22 Gyne exam 22 Intercourse 18

13. Termination Number of sessions: M = 20 (R=1-126) (minus 1-10 sessions: M-29) 1-10 ~ 35% …(able to have intercourse (n=2); early termination (n=12)) 11-20 ~ 22% 21-30 ~ 30% 31-40 ~ 7% 41-126 ~ 7%

14. Interview data (N=12) Relationship status: Married (58%), Dating (25%), Single (17%) Number of sessions: M=31; (R=14-51) Time since termination: M=25 month (R=9-44 months) Satisfaction with PT: 9/10 (R=8-10) Success with PT: 9/10 (R=6-10) N.B. ↓ satisfaction and ↓ success associated with early termination due to lack of resources to pay PT.

15. Therapy gains GAIN ACHIEVED (Y/N) Intercourse 100% Enjoy sex 100% ↓ Anxiety 86% Gynecological exam 100% Use tampons 100% ↑ Understanding 100% Hope 92%

16. Therapy gains (FSFI – healthy controls*) Cronbach’s alpha: .88; *Rosen et al., 2000

17. Therapy gains (FSFI – patient controls*) Cronbach’s alpha: .88; *Rosen et al., 2000

18. Therapy gains (Female Sexual Distress Scale, FSDS) Overall: M=17 (R=2-37) 58% 15 42% The lower the scores on the FSFI, the higher the FSDS, (p<.01) High sexual distress not related to self-reported PT course, outcome, or satisfaction.

19. Summary – PT1 Women with lifelong vaginismus present with significant pelvic floor pathology, pain, and anxiety. Progress in PT is variable with some women needing many more sessions - but most women needing 30 sessions or less (more sessions/longer treatment time compared to vulvodynia). PT interventions are similar to interventions used in the treatment of vulvodynia. (Less focus on pain desensitization, more focus on conscious awareness on relaxing/dropping the pelvic floor).

20. Summary – PT2 Women reach therapy goals of intercourse, pleasure with sexual activity, reproductive hygiene and health care, and overall understanding and hope. Patient satisfaction with PT intervention and outcome is very high.

21. BUT….Summary - Sexuality Formal measures indicate that post-treatment, a significant number of women have not experienced full sexual rehabilitation. Almost half of the women still were sexually distressed. Higher distress was noted in women with lower sexual function (FSFI scores).

22. Conclusions PT is an excellent treatment option for lifelong vaginismus and merits further evaluation. BUT, much like in women with PVD there appears to be no linear relationship between symptom reduction and healthy sexual function. This suggests that PT interventions need to be integrated with interventions that specifically target sexual rehabilitation.