Often pelvic floor therapists see men for post-prostatectomy urinary leakage. However, at least for me, that quickly led to seeing male patients for pelvic pain and sexual dysfunction. Male sexual dysfunction is a broad category and can consist of erectile dysfunction (ED), ejaculation disorders including premature ejaculation (PE), and low libido -- often there is a pelvic floor muscle (PFM) dysfunction component. Conservative treatment frequently consists of pharmacological and lifestyle changes for this population.
In normal sexual function, the male superficial pelvic floor musculature (bulbocavernosus and ischiocavernosus) work together to create increased intracavernosus pressure by limiting venous return, resulting in an erection. Ejaculation is created by rhythmic contractions of the bulbocavernosus muscle.
The authors of this systematic review were curious if pelvic floor muscle training was effective for treating erectile dysfunction and premature ejaculation diagnoses, and if so to determine whether there is a treatment protocol. Ten studies were found that met the inclusion criteria, five that focused on ED and five that focused on PE. In total, there were 668 participants ranging in age from 30-59 years old. Studies were excluded if participants were post-prostatectomy and/or had a neurological diagnosis. The intervention was a pelvic floor program, and pelvic floor muscle contractions were either taught or supervised. Studies also included supportive treatment including biofeedback, lifestyle changes, and electrical stimulation.
The studies focused on erectile dysfunction listed a combination of hormonal, psychogenic, arteriogenic, and venogenic causes. The pelvic floor training ranged from 5-20 visits over 3-4 months and included a home exercise program. Pelvic floor training was similar in all studies and consisted of maximal quick contractions over one second and submaximal endurance holds over 6-10 seconds. Compliance to home exercise program was not assessed. Between 35% and 47% of participants reported a full resolution of symptoms. Subjective improvements were supported by improved maximal anal pressure and intracavernosus pressure. One study used the International Index of Erectile Function (IIEF) and showed significant improvement (p<0.05).
The studies focused on premature ejaculation noted participants had either lifelong or secondary PE. The pelvic floor training in these studies ranged from 12-20 sessions over 1-3 months. All studies used electrical stimulation as part of the pelvic floor muscle training. Four studies also used biofeedback. Only one study listed a home exercise program but did not report on compliance. The pelvic floor muscle training was compared to nothing in three studies, and to a selective serotonin reuptake inhibitor (SSRI) in the other two studies. Patient reported full resolution of symptoms was 55-83% in two studies, and there was a significant improvement in delay in heterosexual penetrative ejaculation (p<0.05) in three studies.
For both erectile dysfunction and premature ejaculation, pelvic floor muscle exercise prescription was 2-3 times per week with pelvic floor muscle contractions both maximal quick contractions and submaximal endurance holds. Significant results were shown with participants who were taught pelvic floor muscle contractions through a combination of verbal and physical means (typically biofeedback). Specific verbal cues were not reported. The authors suggest that electrical stimulation was helpful for training recruitment patterns; however, there was not a significant difference in outcomes for those with ED when using electrical stimulation. The authors suggest that pelvic floor muscle training can be part of a conservative treatment. It may be used with oral pharmacology for quick results, and may be beneficial with electrical stimulation and biofeedback, though more research is indicated.
If you are interested in learning more about treating male patients, consider attending Male Pelvic Floor: Function, Dysfunction, and Treatment!
Myers, C., Smith, M. “Pelvic floor muscle training improves erectile dysfunction and premature ejaculation: a systematic review” Physiotherapy 105 (2019) 235–243
Most people are told that inguinal hernia repair is a low risk surgery. While death or severe injury is rare, penile or testes pain after hernia repair is not a novel or recent finding. In 1943, Magee first discussed patients having genitofemoral neuralgia after appendix surgery. By 1945, both Magee and Lyons stated that surgical neurolysis gave relief of genital pain following surgical injury (neurolysis is a surgical cutting of the nerve to stop all function). However, it should be noted that with neurolysis, sensory loss will also occur, which is an undesired symptom for sexual function and pleasure. In 1978 Sunderland stated genitofemoral neuralgia was a well-documented chronic condition after inguinal hernia repair.
Let’s do a quick anatomy review. The inguinal canal is located at the lower abdomen and is actually an extension of the external oblique muscles. Is travels along the line from the ASIS to the pubic tubercle, occupying grossly the medial third of this segment. It has a lateral ring where contents from the abdomen exit and a medial ring where the contents of the canal exit superficially. This ring contains the spermatic cord (male), round ligament (female), as well as the ilioinguinal and genitofemoral nerves. For males, in early life, the testes descend from the abdominal cavity to the exterior scrotal sac through the inguinal canal, bringing a layer of the obliques, transverse abdominus, and transversalis fascia with them within the first year of life. Just as a female can experience prolapse from prolonged increased intra-abdominal pressure, a male can have a herniation through the anterior abdominal wall and inguinal canal with increased abdominal pressure. Such pressure inducing activities can be lifting, coughing, and sports activities. When this occurs, an inguinal hernia repair is generally indicated. Because the genitofemoral nerve is within the contents of the inguinal canal, it can be susceptible to surgery in this area. The genitofemoral nerve has sensory innervation to the penis and testes and is responsible for the cremasteric reflex. Symptoms of genitofemoral neuralgia in men can be penis or testes pain, numbness, hypersensitivity, and decreased sexual satisfaction or function.
In 1999 Stark et al noted pain reports as high as 63% post hernia repair. The highest rates of genitofemoral neuralgia are reported with laparoscopic or open hernia repair (Pencina, 2001). The mechanism for GF neural entrapment is entrapment within scar or fibrous adhesions and parasthesia along the genitofemoral nerve (Harms 1984, Starling and Harms 1989, Murovic 2005, and Ducic 2008). It is well known that scar and adhesion densify and visceral adhesions increase for years after surgery. Thus, symptoms can increase long after the surgery or may take years to develop. In 2006, Brara postulated that mesh in the region can contribute to subsequent genitofemoral nerve tethering which can be exacerbated by mesh in the inguinal or the retroperitoneal space. With an anterior mesh placement, there is no fascial protection left for the genitofemoral nerve.
Genitofemoral neuralgia is predominately reported as a result of iatrogenic nerve damage during surgery or trauma to the inguinal and femoral regions (Murovic et al, 2005). However, genitofemoral neuropathy can be difficulty and elusive to diagnose due to overlap with other inguinal nerves (Harms, 1984 and Chen 2011).
In my clinical experience, I have seen such symptoms after hernia repair, but also after procedures near the inguinal region such as femoral catheters for heart procedures, appendectomies, and occasionally after vasectomy.
As a pelvic PT, what are we to do with this information? First off, we can realize that all pelvic neuropathy is not necessarily due to the pudendal nerve. In the anterior pelvis, there is dual innervation from the inguinal nerves off the lumbar plexus as well as the dorsal branch of the pudendal nerve. When patients have a history of inguinal hernia repair, we can consider the genitofemoral nerve as a source of pain. Medicinally, the only research validated options for treatment are meds such as Lyrica or Gabapentin that come with drowsiness, dizziness and a score of side effects. Surgically neurectomy or neural ablation are options with numbness resulting, however, many patients do not want repeated surgery or numbness of the genitals. As pelvic therapists, we can manually fascially clear the path of the nerve from L1/L2, through the psoas, into and out of the canal and into the genitals. We can also manually directly mobilize the nerve at key points of contact as well as doing pain free sliders and gliders and then give the patient a home program to maintain mobility. Pelvic manual therapy can offer a low risk, side-effect free option to ameliorate the sequella of inguinal hernia repair. Come join us at Lumbar Nerve Manual Assessment and Treatment in Chicago this Spring to learn how to effectively treat all the nerves of the lumbar plexus.
Cesmebasi, A., Yadav, A., Gielecki, J., Tubbs, R. S., & Loukas, M. (2015). Genitofemoral neuralgia: a review. Clinical Anatomy, 28(1), 128-135.
Lyon, E. K. (1945). Genitofemoral causalgia. Canadian Medical Association Journal, 53(3), 213.
Magee, R. K. (1943). Genitofemoral Causalgia: New Syndrome. The Journal of Nervous and Mental Disease, 98(3), 311.
Sunderland S. Nerves and nerve injuries. 2nd ed. Edinburgh: Churchill Livingstone, 1978
A question that often comes up in conversation around menopause is that of pelvic health – the effects on bladder, bowel or sexual health…what works, what’s safe, what’s not? Is hormone therapy better, worse or the same in terms of efficacy when compared to pelvic rehab? Do we have a role here?
An awareness of pelvic health issues that arise at menopause was explored in Oskay’s 2005 paper ‘A study on urogenital complaints of postmenopausal women aged 50 and over’ stating ‘…Urinary incontinence and sexual problems, particularly decline in sexual desire, are widespread among postmenopausal women. Frequent urinary tract infections, obesity, chronic constipation and other chronic illnesses seem to be the predictors of UI.’
Moller’s 2006 paper explored the link between LUTS (Lower Urinary Tract Symptoms) and sexual activity at midlife: the paper discussed how lower urinary tract symptoms (LUTS) have a profound impact on women’s physical, social, and sexual well being, and confirmed that LUTS are likely to affect sexual activity. However, they also found that conversely, sexual activity may affect the occurrence of LUTS – in their study a questionnaire was sent to 4,000 unselected women aged 40–60 years, and they found that compared to women having sexual relationship, a statistically significant 3 to 6 fold higher prevalence of LUTS was observed in women with no sexual relationship. They also found that women who ceased sexual relationship an increase in the de novo occurrence of most LUTS was observed, concluding that ‘…sexual inactivity may lead to LUTS and vice versa’.
So, who advises women going through menopause about issues such as sexual ergonomics, the use of lubricants or moisturisers, or provide a discussion about the benefits of local topical estrogen? As well as providing a skillset that includes orthopaedic assessment to rule out any musculo-skeletal influences that could be a driver for sexual dysfunction? That would be the pelvic rehab specialist clinician! Tosun et al asked the question ‘Do stages of menopause affect the outcomes of pelvic floor muscle training?’ and the answer in this and other papers was yes; with the research comparing pelvic rehab vs hormone therapy vs a combination approach of pelvic rehab and topical estrogen providing the best outcomes. Nygaard’s paper looked at the ‘Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence’ and concluded that : ‘…(both pre and postmenopausal women) benefit from motor learning strategies and adopt functional training to improve their urinary symptoms in similar ways, irrespective of hormonal status or HRT and BMI category’.
We must also factor in some of the other health concerns that pelvic health can impact at midlife for women – Brown et al asked the question ‘Urinary incontinence: does it increase risk for falls and fractures?’ They answered their question by concluding that ‘‘… urge incontinence was associated independently with an increased risk of falls and non-spine, nontraumatic fractures in older women. Urinary frequency, nocturia, and rushing to the bathroom to avoid urge incontinent episodes most likely increase the risk of falling, which then results in fractures. Early diagnosis and appropriate treatment of urge incontinence may decrease the risk of fracture.’
If you are interested in learning more about pelvic health, sexual function and bone health at Menopause, consider attending Menopause Rehabilitation and Symptom Management.
Sexual activity and lower urinary tract symptoms’ Møller LA1, Lose G. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):18-21. Epub 2005 Jul 29.
A study on urogenital complaints of postmenopausal women aged 50 and over. Oskay UY1, Beji NK, Yalcin O. Acta Obstet Gynecol Scand. 2005 Jan;84(1):72-8.
Do stages of menopause affect the outcomes of pelvic floor muscle training? Tosun ÖÇ1, Mutlu EK, Tosun G, Ergenoğlu AM, Yeniel AÖ, Malkoç M, Aşkar N, İtil İM. Menopause. 2015 Feb;22(2):175-84. doi: 10.1097/GME.0000000000000278.
‘Impact of menopausal status on the outcome of pelvic floor physiotherapy in women with urinary incontinence.’ Nygaard CC1, Betschart C, Hafez AA, Lewis E, Chasiotis I, Doumouchtsis SK. Int Urogynecol J. 2013 Dec;24(12):2071-6. doi: 10.1007/s00192-013-2179-7. Epub 2013 Jul 17
Erectile dysfunction (ED) is a debilitation complication of radical prostatectomy, which is a treatment for prostate cancer. ED is caused by a variety of causes, diabetic vasculopathy, smoking, high blood pressure, high cholesterol, psychological issues, peripheral vascular disease and medication; we will focus on post-prostatectomy ED and the role of penile rehabilitation in its management.
Radical prostatectomy can result in nerve injury to the penis. Moreover, significant fibrotic changes take place in the corpus cavernosum of the penis postoperatively. It takes approximately 1-2 years for erectile function to return after radical prostatectomy. This is a period of “neuropraxia,” during which there is transient cavernosal nerve dysfunction. However, a prolonged “flaccid state” might lead to irreversible damage to the cavernous tissue 1.
Research on penile hemodynamics in these patients have shown that venous leakage is also implicated in its pathophysiology. An injury to the neurovascular bundles likely leads to smooth muscle cell death, which then leads to irreversible veno-occlusive disease.
There is a potential role of hypoxia in stimulating growth factors (TGF-beta) that stimulate collagen synthesis in cavernosal smooth muscle. Prostaglandin E1 (PGE1) was found to suppress the effect of TGF-β1 on collagen synthesis.
The goal of Penile Rehabilitation is to limit and reverse ED in post-prostatectomy patients. The idea is to minimize fibrotic changes during the period of “penile quiescence” after nerve-sparing radical prostatectomy. Several approaches have been tried, including PGE1 injection, vacuum devices, and phosphodiesterase type 5 (PDE-5) inhibitors.
Mulhall and coworkers followed 132 patients through an 18-month period after they were placed in “rehabilitation” or “no rehabilitation” groups after radical prostatectomy, and 52% of those undergoing rehabilitation (sildenafil + alprostadil) reported spontaneous functional erections, compared with 19% of the men in the no-rehabilitation group 2.
Alprostadil is a vasodilatory prostaglandin E1 that can be injected into the penis or placement in the urethra in order to treat ED. Montorsi, et al. studied the use of intracorporeal injections of alprostadil starting at 1 month after bilateral nerve-sparing radical prostatectomy and reported a higher rate of spontaneous erections after 6 months compared with no treatment 3. Gontero, et al. investigated alprostadil injections at various time points after non–nerve-sparing radical prostatectomy and found that 70% of patients receiving injections within the first 3 months were able to achieve erections sufficient for intercourse, compared with 40% of patients receiving injections after the first 3 months 4.
VCD is an external pump that is used to get and maintain an erection. Raina, et al evaluated the daily use of a VCD beginning within two months after radical prostatectomy, and reported that after 9 months of treatment, 17% of patients using the device had return of natural erections sufficient for intercourse, compared with 11% of patients in the nontreatment group 4.
PDE-5 inhibitors (such as Sildenafil) are the first-line treatment for ED of many etiologies. Several studies have shown that the use of PDE-5 inhibitors might lead to an overall improvement in endothelial cell function in the corpus cavernosum. Chronic use of oral PDE-5 inhibitors suggest a beneficial effect on endothelial cell function. Desouza, et al. concluded that daily sildenafil improves overall vascular endothelial cell function. However, Zagaja, et al. found that men taking oral sildenafil within the first 9 months of a nerve-sparing procedure did not have any erectogenic response 4.
Overall, accumulating scientific literature is suggesting that penile rehabilitation therapies have a positive impact on the sexual function outcome in post-prostatectomy patients. It must be noted that these methods do not cure ED and should be used with caution.
1Penson DF, McLerran D, Feng Z, et al. 5-year urinary and sexual outcomes after radical prostatectomy: results from the prostate cancer outcomes study. J Urol. 2005;173:1701-1705.
2Mulhall J, Land S, Parker M, et al. The use of an erectogenic pharmacotherapy regimen following radical prostatectomy improves recovery of spontaneous erectile function. J Sex Med. 2005; 2:532-540.
3Montorsi F, Guazzoni G, Strambi LF, et al. Recovery of spontaneous erectile function after nerve-sparing radical retropubic prostatectomy with and without early intracavernous injections of alprostadil: results of a prospective, randomised trial. J Urol. 1997;158:1408-1410.
4Gontero P, Fontana F, Bagnasacco A, et al. Is there an optimal time for intracavernous prostaglandin E1 rehabilitation following non- nerve sparing radical prostatectomy? Results from a hemodynamic prospective study. J Urol. 2003;169:2166-2169.
Managing a medical crisis such as a cancer diagnosis can be overwhelming for an individual. Faced with choices about medical options, dealing with disruptions in work, home and family life often leaves little energy left to consider sexual health and intimacy. Maintaining closeness, however, is often a goal within a partnership and can aid in sustaining a relationship through such a crisis. The research is clear about cancer treatment being disruptive to sexual health, yet intimacy is a larger concept that may be fostered even when sexual activity is impaired or interrupted. Last year, when I was asked to speak to the Pacific NW Prostate Cancer Conference about intimacy, I was pleasantly surprised to find a rich body of literature about maintaining intimacy despite a diagnosis of prostate cancer.
Sexual health and sexuality is a social construct affected by many factors including mood, stress, depression, self-image, physiology, psychology, culture, relational and spiritual factors (Beck et al., 2009; Weiner & Avery-Clark, 2017) Prostate cancer treatment can change relational roles, finances, work life, independence, and other factors including hormone levels.(Beck et al., 2009) Exhaustion (on the part of the patient and the caregiver), role changes, changes in libido and performance anxiety can create further challenges. (Beck et al., 2009; Hawkins et al., 2009; Higano et al., 2012) Recovery of intimacy is possible, and reframing of sexual health may need to take place. Most importantly, these issues need to be talked about, as renegotiation of intimacy may need to take place after a diagnosis or treatment of prostate cancer. (Gilbert et al., 2010)
If the patient brings up sexual health, or we encourage the conversation, there are many research-based suggestions we can provide to encourage recovery of intimacy, several are listed below.
- Manage general health, fitness, nutrition, sleep, anxiety and stress
- Redefine sex as being beyond penetration, consider other sexual practices such as massage/touch, cuddling, talking, use of vibrators, medication, aids such as pumps (Usher et al., 2013)
- Participate in couples therapy to understand partners’ needs, address loss, be educated about sexual function (Wittman et al., 2014; Wittman et al., 2015)
- Participate in “sensate focus” activities (developed by Masters & Johnson in 1970’s as “touch opportunities”) with appropriate guidance (Weiner & Avery-Clark 2017)
Within the context of this information, there is opportunity to refer the patient to a provider who specializes in sexual health and function. While some rehabilitation professionals are taking additional training to be able to provide a level of sexual health education and counseling, most pelvic health providers do not have the breadth and depth of training required to provide counseling techniques related to sexual health- we can, however, get the conversation started, which in the end may be most important.
In the men’s health course, we further discuss sexual anatomy and physiology, prostate issues, and look at the research describing models of intimacy and what worked for couples who did learn to renegotiate intimacy after prostate cancer.
Beck, A. M., Robinson, J. W., & Carlson, L. E. (2009, April). Sexual intimacy in heterosexual couples after prostate cancer treatment: What we know and what we still need to learn. In Urologic oncology: seminars and original investigations (Vol. 27, No. 2, pp. 137-143). Elsevier.
Beck, A. M., Robinson, J. W., & Carlson, L. E. (2013). Sexual Values as the Key to Maintaining Satisfying Sex After Prostate Cancer Treatment : The Physical Pleasure–Relational Intimacy Model of Sexual Motivation. Archives of sexual behavior, 42(8), 1637-1647.
Gilbert, E., Ussher, J. M., & Perz, J. (2010). Renegotiating sexuality and intimacy in the context of cancer: the experiences of carers. Archives of Sexual Behavior, 39(4), 998-1009.
Hawkins, Y., Ussher, J., Gilbert, E., Perz, J., Sandoval, M., & Sundquist, K. (2009). Changes in sexuality and intimacy after the diagnosis and treatment of cancer: the experience of partners in a sexual relationship with a person with cancer. Cancer nursing, 32(4), 271-280.
Higano, C. S. (2012). Sexuality and intimacy after definitive treatment and subsequent androgen deprivation therapy for prostate cancer. Journal of Clinical Oncology, 30(30), 3720-3725.
Ussher, J. M., Perz, J., Gilbert, E., Wong, W. T., & Hobbs, K. (2013). Renegotiating sex and intimacy after cancer: resisting the coital imperative. Cancer Nursing, 36(6), 454-462.
Weiner, L., Avery-Clark, C. (2017). Sensate Focus in Sex Therapy: The Illustrated Manual. Routledge, New York.
Wittmann, D., Carolan, M., Given, B., Skolarus, T. A., An, L., Palapattu, G., & Montie, J. E. (2014). Exploring the role of the partner in couples’ sexual recovery after surgery for prostate cancer. Supportive Care in Cancer, 22(9), 2509-2515.
Wittmann, D., Carolan, M., Given, B., Skolarus, T. A., Crossley, H., An, L., ... & Montie, J. E. (2015). What couples say about their recovery of sexual intimacy after prostatectomy: toward the development of a conceptual model of couples' sexual recovery after surgery for prostate cancer. The journal of sexual medicine, 12(2), 494-504.
In a previous post on The Pelvic Rehab Report Sagira Vora, PT, MPT, WCS, PRPC told us how "women with sexually adverse experiences tend to have impaired genital response when in consensual sexual situations, however, women who do not have sexual abuse histories and but have sexual pain tend to have appropriate genital response." Today Sagira helps us understand how the pelvic floor responds to consensual sexual activity in women with a history of sexual trauma.
Today we try to look for answers for questions that came up during the last blogs.
How does the cohort that has had adverse sexual experiences present? How do women with history of sexual trauma process sexual experiences? How does the pelvic floor present or respond to consensual sexual situations when a woman has been abused in the past?
To answer these questions, it’s important to understand two facts about the pelvic floor. 1) the pelvic floor plays a role in emotional processing1, and 2) muscle activity in all muscles, including the pelvic floor, increases with exposure to stress and during anxiety evoking experiences2.
We explored in the last blog that women with sexual abuse histories responded with increased pelvic floor overactivity when watching movie clips with sexually threatening and consensual sexual content. Apparently, for women with sexual abuse history even consensual sexual situations can be experienced as threatening1.
Lehrer et. al. found overactivity in the neuronal and hormonal circuits that increase sexual arousal and activity. These circuits are already overactive in individuals who have Post Traumatic Stress Disorder (PTSD), and increased activity can increase anxiety, fear and other symptoms of PTSD instead of normal sexual arousal and excitement during a sexual experience2. For the woman with PTSD this means that sexual arousal signals impending threat rather than pleasure1. And as we already learned in previous blogs and above that when humans feel threatened they respond by tightening muscles and most notably the pelvic floor muscle.
Significant co-relation is found between sexual abuse, subsequent PTSD and chronic pelvic pain3. Hooker et. al, found irritable bowel syndrome, pelvic pain, and physical and sexual abuse to be the most commonly diagnosed together4. More importantly, when patients were successfully treated for PTSD they continued to be 2.7 times more likely to have pelvic floor dysfunction and 2.4 times more likely to have sexual dysfunction. This builds the case for interventions that are multidisciplinary to help patients of abuse and sexual assault, with the pelvic floor therapist playing a significant role.
In the next blog, lets explore how the pelvic floor therapist can work with a counselor and a sex therapist to help the woman with sexual pain dysfunction.
Anna Padoa and Talli Rosenbaum. The overactive pelvic floor. Springer. 1st ed. 2016
Yehuda R, Lehrner A, Rosenbaum TY. PTSD and sexual dysfunction in men and women. J Sex Med. 2015:12(5):1107-19
Blok BF. Holstege G. The neuronal control of micturition and its relation to the emotional motor system. Prog Brain Res. 1996; 107:113-26
Para ML, Chen LP, Goranson EN, Sattler AL, Colbenson KM, Seime RJ, Et. al. Sexual abuse and lifetime diagnoses of somatic disorders. JAMA. 2013; 302:550-61
Hooker AB, van Moorst BR, van Haarst EP, Van Ootegehem NAM, van Dijken DKE, Heres MHB, Chronic pelvic pain: evaluation of the epidemiology, baseline characteristics, and clinical variables via a prospective and multidisciplinary approach. Clin Exp Obstet Gynecol. 2013; 40:492-8
In a previous post on The Pelvic Rehab Report Sagira Vora, PT, MPT, WCS, PRPC shared that "cognitive-behavioral therapy appears to play a significant role in improving sexual function in women". Today, in part three of her ongoing series on sex and pelvic health, Sagira explores how sexual pain affects sexual dysfunction in women.
After having explored what allows for women to have pleasurable sexual experiences including pain-free sex and mind-blowing orgasms, we now turn towards our cohort that have pain with sex and intimacy. How does this group differ from women who do not have pain with sex? Are there some common factors with this group of women, and perhaps understanding these factors may help the pelvic floor therapist render more effective and successful treatment?
There are few studies exploring sexual arousal in women with sexual pain disorders. However, their findings are remarkable. Brauer and colleagues found that genital response, as measured by vaginal photoplethysmography and subjective reports, was found to be equal in women with sexual pain vs. women who did not have pain, when they were shown oral sex and intercourse movie clips. This and other studies have shown that genital response in women with dyspareunia is not impaired. Genital response in women with dyspareunia is however, effected by fear of pain. When Brauer and colleagues subjected women with dyspareunia to threat of electrical shock (not actual shock) while watching an erotic movie clip they found that women with dyspareunia had much diminished sexual response including diminished genital arousal. But Spano and Lamont found that genital response was diminished by fear of pain equally in women with sexual pain and women without sexual pain.
Fear of pain also resulted in increased muscle activity in the pelvic floor. However, this increase was noted in women with pain and women without sexual pain equally and was noted with exposure to sexually threatening film clips as well as threatening film clips without sexual content. The conclusion, then, from these results is that the pelvic floor plays a role in emotional processing and tightening, or overactivity is a protective response noted in all women regardless of sexual pain history.
The one difference that was noted was with women who had the experience of sexual abuse. For them, pelvic floor overactivity was noted when watching sexually threatening as well consensual sexual content. Women without sexual abuse history did not have increased pelvic floor activity when watching consensual sexual content.
In summary, evidence supports the hypothesis that women with sexually adverse experiences tend to have impaired genital response when in consensual sexual situations, however, women who do not have sexual abuse histories and but have sexual pain tend to have appropriate genital response. Both groups, however, have increased pelvic floor muscle activity in consensual sexual situations. This increase in pelvic floor muscle activity leads to muscle pain, reduced blood flow, reduced lubrication, increased friction between penis and vulvar skin and hence leads to pain.
This brings us to our next questions, how does the cohort that has had adverse sexual experiences present? How do women with history of sexual trauma process sexual experiences? How does the pelvic floor present or respond to consensual sexual situations when a woman has been abused in the past? Please tune in to the next blog for answers…
Blok BF, Holstege G. The neuronal control of micturition and its relation to the emotional motor system. Prog Brain Res. 1996; 107:113-26
Brauer M, Laan E, ter Kuile MM. Sexual arousal in women with superficial dyspareunia. Arch Sex Behav. 2006; 35:191-200
Brauer M, ter Kuile MM, Janssen S, Lann E. The effect of pain-related fear on sexual arousal in women with superficial dyspareunia. Eur J Pain: 2007; 11:788-98
Spano L, Lamont JA. Dyspareunia: a symptom of female sexual dysfunction. Can Nurse 1975;71:22-5
In a previous post on The Pelvic Rehab Report, Sagira Vora, PT, MPT, WCS, PRPC explored the impact that pelvic floor exercises can have on arousal and orgasm in women. Today we hear part two of the conversation, and learn what factors can impact a woman's ability to achieve orgasm.
“An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment.”
Wow, that sounds like paradise! The question is--how to get there? Many of our cohorts and many our female patients have not experienced this or orgasm happens for them rarely. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Some of the reasons cited for lack of orgasm are orgasm importance, sexual desire, sexual self-esteem, and openness of sexual communication with partner by Kontula el. al. in 2016. Rowland found that most commonly-endorsed reasons were stress/anxiety, insufficient arousal, and lack of time during sex, body image, pain, inadequate lubrication.
One factor that comes up consistently, is the ability of women to focus on sexual stimuli. This point has been brought up by various studies and presented in different ways. Chambless talks about mindfulness training and improvements in orgasm ability noted equally in women who practiced mindfulness vs. women who engaged in Kegels and mindfulness. Rosenbaum and Padua note in their book, The Overactive Pelvic Floor, “women who do not have a low-tone pelvic floor and who seek to enhance sexual arousal and more frequent orgasms have not much to gain from pelvic floor muscle training. Actually, a relaxed pelvic floor and mindful attention to sexual stimuli and bodily sensations seem a more effective means of enhancing sexual arousal and orgasm.” Various studies specifically studying the effect of mindfulness training have demonstrated both improved arousal and orgasm ability in women who practiced mindfulness. Brotto and Basson found their treatment group, which consisted of 68 otherwise healthy women, who underwent mindful meditation, cognitive behavioral training and education, improved in sexual desire, sexual arousal, lubrication, sexual satisfaction, and overall sexual functioning.
Cognitive-behavioral therapy appears to play a significant role in improving sexual function in women. Meston et. al. notes, “cognitive behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.”
Alas, there are no magic pills to create the above described “state of altered consciousness,” allowing women a sense of “well-being and contentment.” However, mindfulness training and cognitive behavioral therapy are both accessible and attainable for women who want to improve their ability to enjoy this much desired state. Many Pelvic floor therapist incorporate cognitive behavioral and mindfulness approaches in their practice.
The studies above mention pain as one of the factors for inability to experience arousal and orgasm. Hucker and Mccabe even noted that their mindfulness treatment group demonstrated significant improvements in all domains of female sexual response except for sexual pain. Dealing with sexual pain is a daily battle pelvic floor therapist face each day. So, how do women with sexual pain dysfunction differ from women who are experiencing sexual dysfunction but not pain? Let’s explore this in our next blog…
Chambless DL, Sultan FE, Stern TE, O’Neill C, Garrison S. Jackson A. Effect of pubococcygeal exercise on coital orgasm in women. J Consult CLin Psychol. 1984; 52:114-8
Bratto LA, Basson R. Group mindfulness-based therapy significantly improves sexual desire in women Behav Res Ther. 2014 Jun; 57:43-5
Hucker A. Mccabe MP. Incorporating Mindfulness and Chat Groups Into an Online Cognitive Behavioral Therapy for Mixed Female Sexual Problems. J Sex Res. 2015;52(6):627-33
Kontula O., Mettienen A. Determinants of female sexual orgasms. Socioaffect Neurosci Psychol. 2016 Oct 25;6:31624. doi: 10.3402/snp.v6.31624. eCollection 2016
Meston CM1, Levin RJ, Sipski ML, Hull EM, Heiman JR. Women’s orgasm. Annu Rev Sex Res. 2004;15:173-257. Review
Rosenbaum, Talli Y., Padoa, Anna. The overactive Pelvic floor. 1st ed. 2016
Roland DL, Cempel LM, Tempel AR. Women’s attributions on why they have difficulty reaching orgasm. J. Marital Therapy. 2018 Jan 3:0
When a woman is given a cancer diagnosis, her entire world is turned upside down and inside out. There are so many things to think about; medical treatments, financial concerns, family concerns, and emotional upheaval. Sex may be the last thing that a woman may think about when she is actively going through treatment. However, at what rate are survivors having issues after treatment is complete?
A recent study published in the journal Cancer looked at just this. A 2-year longitudinal study was performed that tracked young adults (18-39 years old) through and after their cancer diagnosis. The most common cancers seen in the samples were leukemia, breast cancer, soft-tissue sarcoma, and non-Hodgkin lymphoma. The patients completed the Medical Outcomes Study Sexual Functioning Scale at 4 months, 6 months, and 24 months after diagnosis. At 2 years after diagnosis over 50% of the patients surveyed reported some degree of sexual dysfunction. Women that were in a committed relationship had an increased likelihood for experiencing sexual dysfunction; while men had increased rate of reporting sexual issues regardless of their relationship status.
Women that undergo cancer treatment have several reasons that could be influencing their sexual function. Fatigue is a complaint that is often expressed by cancer patients. Their body image is often altered due to surgeries that have been performed. Chemotherapy and hormonal therapy often push women into menopause which then leads to vaginal dryness. Additionally, radiation and surgical treatment can lead to scar tissue, fibrosis, and stenosis of the vagina and pelvic floor muscles.
This is where physical therapy can help! In the Pelvic Floor Series Capstone course we teach advanced techniques that help treat pelvic floor issues by working on both the muscles, and the fascia. We also cover techniques that decrease the tenderness in the muscles that then allow you to stretch the muscle with less discomfort.
All of the techniques taught in Capstone are gentle but effective. The cancer survivor is the perfect population to use these gentle techniques on! Think of how rewarding our job will be when we help relieve the pain that may be associated with intercourse, and therefore improve intimacy of a cancer survivor with her partner!
Come join us for Capstone and learn techniques that will take your treatment skills to the next level!
Acquati, Zebrack, Faul, et al. Sexual functioning among young adult cancer patients: A 2-year longitudinal study. Cancer. 2018; 124(2): 398-405.
Neurophysiology is a dynamic and highly complex system of neurological connections and interactions that allow for bodily performance. When all of those connections are working correctly, our bodies can function at optimal levels. When there is a break or injury to those connections, dysfunction results but amazingly in some circumstances, our bodies have work arounds to allow for certain functions to continue working.
If we take the sexual neural control system of the male, for instance, a perfect example of this can be described. Many men were injured fighting in World War II. During their time in battle, many experienced spinal cord injuries. Some of these injuries were severe resulting in complete spinal cord damage at level of injury. A physician, Herbert Talbot, in 1949, documented his examination of 200 men with paraplegia. Two thirds of the men were surprisingly able to achieve erections and some were able to experience vaginal penetration and orgasm. Much of their basic functionality had been lost however amazingly there was preservation of erectile function.
The reason these men with paraplegia were able to maintain erectile or orgasm functionality is due to the physiological function in the sacral spinal cord. A reflex arc is present in this region. The definition of a reflex arc is a nerve pathway that has a reflexive action involving sensory input from a peripheral somatic or autonomic nerve synapsing to a relay neuron or interneuron in the sacral cord segment then synapsing to a motor nerve for output to the muscular region. These messages do not need to travel up the spinal cord to the brain in order to be activated. Instead they work within a ‘loop’ at the sacral spinal cord level. In the case of spinal cord injury, erectile function as well as other functions controlled by reflex arcs, can be preserved.
For women, the same is true. In order for a female to have engorgement of the clitoris or orgasm, the sacral spinal reflex arc needs to be intact. If a woman experiences a spinal cord injury above the sacral region, the ability to have a reflexive orgasm within the sacral spinal reflex arc will remain.
The sacral reflex arc also plays an important role in activation of the pelvic floor muscles during the sexual response cycle. During genital stimulation in both the male and female, the bulbospongiosus or bulbocavernosus begins to activate in a reflexive pattern to hinder the outflow of blood from the region which facilitates erectile tissue of the penis and clitoris to become erect. This can then be followed by rhythmic reflexive contractions of the pelvic floor musculature during orgasm.
To learn more about the implications that neurologic disorders can have on the sexual system, please join us for Neurologic Conditions and Pelvic Floor Rehab, coming to Grand Rapids, MI in September.
Goldstein, I. (2000). Male sexual circuitry. Scientific American, 283(2), 70-75.
Sipski, M. L. (2001). Sexual response in women with spinal cord injury: neurologic pathways and recommendations for the use of electrical stimulation. The journal of spinal cord medicine, 24(3), 155-158.
Wald, A. (2012). Neuromuscular Physiology of the Pelvic Floor. In Physiology of the Gastrointestinal Tract (Fifth Edition)(pp. 1023-1040).