{"paper_id":"d4b73afc-729a-44cc-bcdf-6d2f4f5224e0","body_text":"REVIEW ARTICLE\nPhysiotherapy for pelvic pain and female sexual dysfunction:\nan untapped resource\nBary Berghmans1\nReceived: 2 October 2017 / Accepted: 29 November 2017 / Published online: 9 January 2018\n# The Author(s) 2018. This article is an open access publication\nAbstract\nIntroduction and hypothesis Chronic pelvic pain (CPP) in women is a complex syndrome. Pain sensation and intensity often do\nnot correspond with the identified lesion location but are felt elsewhere, leading to muskuloskeletal and myofascial disorders and\nsexual dysfunction (SD). Although physical aspects are prevalent, they are often underdiagnosed and undertreated due to lack of\nunderstanding regarding its origin and distribution. Frequently, patients experience pelvic pain as psychological distress resulting\nin physical complaints, leading clinicians to prescribe medication or surgical intervention to correct or alleviate these symptoms,\noften with insufficient results. Because pelvic floor muscle disorders contribute significantly to CPP and SD, there is rationale for\nphysiotherapy. However, physiotherapy is a widely underused and untapped resource, which has its place in the multidisciplinary\napproach to these health problems.\nMethods Computer-aided and manual searches and methodological quality assessment were carried out for meta-analyses,\nsystematic reviews, and randomized controlled trials (RCTs) published between 1990 and 2017 investigating classification,\nassessment, and (physiotherapeutic) treatment of pelvic pain and/or female SD defined by the keywords below. Expert opinions\nwere sought via interviews.\nResults Due to a lack of sufficient relevant medical information, referral data, and test results, focused physiotherapy is difficult\nto administer adequately. However, recent quality studies indicate significant clinical effects of physiotherapy for CPP and female\nSD, and experts advocate a multidisciplinary approach that includes physiotherapy.\nConclusions Because of its holistic approach, physiotherapy can contribute significantly to the multidisciplinary assessment and\ntreatment of CPP and female SD.\nKeywords Chronic pelvic pain . Sexual dysfunction . Vulvodynia . V estibulodynia. Dyspareunia . Va gi n i s m. Sensitization .\nPhysiotherapy . Multidisciplinary\nIntroduction\nChronic pelvic pain (CPP) is defined as abdominal pain below\nthe umbilicus for at least 6 months [ 1]. It is a complex and\nconfusing health problem affecting the quality of life of many\nwomen with several types of urogynecological disorders [ 2],\noften resulting in depression, anxiety, and fatigue [ 3]. CPP ,\nwith its basis in the central nervous system, involves emotion-\nal, cognitive, behavioral, and sexual responses [ 4]. CPP syn-\ndrome (CPPS) is CPP without a proven infection or obvious\nlocal pathology and is related to symptoms suggestive of low-\ner urinary tract, bowel, gynecological, and sexual dysfunction\n(SD) [3]. Pain sensation and intensity often do not correspond\nwith the identified lesion location but are felt elsewhere, lead-\ning to a wide array of musculoskeletal and myofascial disor-\nders and SD [ 4], and the syndrome frequently coexists with\nchronic pelvic floor dysfunction—in most cases with the pres-\nence of physical findings [5].\nThe underlying mechanism of this phenomena is partially\nexplained by repeated or prolonged somatic and visceral sen-\nsory input of nociceptors, resulting in lowering their activation\nthreshold, and sensitization of previously non-involved affer-\nent nerve fibers. This is called peripheral sensitization [ 6].\nNotice Manuscript related to the 13th Ulf Umsten lecture on the 22\nJune 2017 , during the 42th IUGA Annual Meeting, V ancouver, Canada.\n* Bary Berghmans\nbary.berghmans@maastrichtuniversity.nl\n1 Pelvic Care Center Maastricht, Maastricht University Medical\nCentre, P .O.Box 5800, 6202 az Maastricht, The Netherlands\nInternational Urogynecology Journal(2018) 29:631–638\nhttps://doi.org/10.1007/s00192-017-3536-8\n\nInitially, functionally Bsilent^ fibers may be activated after\nbeing sufficiently sensitized by exciting stimuli, increasing\nthe excitability of nociceptors [7]. Electrical impulses initiate\nneurotransmitter release from central terminals in nociceptors\nthat propagate the signal across synapses to dorsal-horn neu-\nrons. Greater stimulus intensities are associated with greater\nrelease of neuropeptides, including substance P , from central\nterminals of C fibers. This mechanism generates a greater\npostsynaptic response. The intense afferent bombardment of\nnoxious information through viscerosomatic convergence,\nand ongoing somatosensorial input from muscle and skin at\nthe dorsal horn of a segment in the spinal cord, leads to central\nsensitization perceived in the brain as prolonged, intense pain\n[4]. With central sensitization initiation, amplification, and\nperpetuation of pain, perception becomes manifest as\nallodynia, hyperalgesia, and referred pain.\nConvergence of neural inputs often hinders precise locali-\nzation and discrimination of sensory information. It also forms\nthe basis for referred pain and explains why visceral patholo-\ngies are commonly felt as pain in somatic structures innervat-\ned by the same spinal segment [pelvic floor muscles (PFM), in\nparticular]. Furthermore, since visceral afferent fibers termi-\nnate over several spinal segments above and below the seg-\nment level of input, referred pain may be present in areas\nremote from the affected visceral organ. This up-regulation\nof the sensory system further effects interneurons that connect\nto alpha and gamma motoneurons, leading to segmental over-\nactivity of PFM, spasm, and contracture. This pelvic floor\ndysfunction and myofascial pain can then lead to SD, such\nas dyspareunia or vaginism, as the PFM tighten, becoming\ninflexible and incapable of accommodating penetration during\nintercourse.\nMyofascial pain is an expression of dysfunction in the\nmuscle and surrounding myofascial/connective tissue [7 ].\nAccording to Simons et al. [8], myofascial pain has a lifetime\nprevalence of up to 85% in the general population.\nNevertheless, physicians traditionally underdiagnose and of-\nten overlook this issue. The presence of myofascial trigger\npoints (MTrPs) in the symptomatic region is a distinctive fea-\nture. MTrPs are small, palpable, hyperirritable nodules located\non taut bands of skeletal muscle in an area of sustained con-\ntracture [9] and can be active or latent. Active points are spon-\ntaneously painful areas that do not require physical stimuli,\nwhereas latent points are painful only upon physical palpation.\nPatterns of referred pain are often predictable and can be doc-\numented by anatomical mapping. MTrPs may also cause mo-\ntor and autonomic disturbances, affecting the function of vis-\nceral organs [ 9], are commonly found in many chronic pain\nconditions, and, when active, typically present as a regional\npain syndrome [7].\nSimons et al. [ 10] noted that in the pelvis, MTrPs can be\nfound in the vagina, anorectum, urethra, pubic bone, vagina,\ncoccyx, abdomen, lower back, and backside of thighs.\nThey may also refer pain from those areas back to the pelvic\nregion, making myofascial pelvic pain difficult to localize\n[11]. Women with myofascial pelvic pain often demonstrate\nsymptoms of dyspareunia, painful urination (dysuria), and\ndifficulty in defecating (dyschezia), though these symptoms\nmay be expressions of other, nonrelated, pelvic floor or pelvic\nviscera problems [10].\nPelvic-floor-related SD comprise vaginism, dyspareunia,\nand (chronic) pelvic pain. Many authors report that in patients\nwith CPP and/or SD the role of the pelvic floor is of the utmost\nimportance [ 12–14]. In 57% of women with an overactive\npelvic floor, dyspareunia has been reported and is felt to be\nsecondary to stretching of shortened PFM, stimulation of\npainful regions and/or local adhesions, fibrosis, or organ dys-\nfunction [15]. Because pelvic pain following sexual activity is\noften sustained for up to 3 days [16], these symptoms can have\nsignificant negative impact on the integrity of physical rela-\ntionships and a woman ’s quality of life, inducing feelings of\nfear, anxiety, and depression [17]. Considering there is a clear\nand deep relationship between PFM disorders, CPPS, and\nfemale SD, one would expect that there is an important role\nfor physiotherapy in these patients; in fact, however, the op-\nposite is true. In relevant clin ical practice, physiotherapy\nseems to be a widely underused strategy —an untapped re-\nsource—to\ndecrease CPP and improve sexual function. In this\npaper, we hypothesize that physiotherapy has a place in the\nmultidisciplinary treatment approach to women with CPPS\nand SD.\nMethods\nTo support our hypothesis, we conducted computer-aided and\nmanual literature searches and methodological quality assess-\nment of meta-analyses, systematic reviews, and randomized\ncontrolled trials (RCTs) published between 1990 and 2017\nrelated to physiotherapeutic assessment and treatment of pel-\nvic pain and/or female SD. Existing classification and models\nof assessment and interventions used by other relevant health\ncare professionals were reviewed. Keywords defined were\n(chronic) pelvic pain, sexual dysfunction, vulvodynia,\nvestibulodynia, dyspareunia, vaginism, sensitization, physio-\ntherapy, and multidisciplinary. Key-opinion leaders from gy-\nnecology, urology, sexology, and physiotherapy, all well-\nknown experts in the field, were interviewed about their opin-\nion and clinical expertise.\nResults\nThe literature search revealed 109 studies; 32 met our criteria,\nof which there were no meta-analyses, 27 (systematic) re-\nviews, and five RCTs.\n632 Int Urogynecol J (2018) 29:631–638\n\nClassifications and models\nTo more reliably diagnose female SD, we consulted the\nAmerican Physiatric Association’ s (APA) Diagnostic and\nStatistical Manual of Mental Disorders 5 (DSM-V) of classi-\nfied mental disorders with associated criteria [ 1]. These clas-\nsifications include psychogenic and organic causes of abnor-\nmal desire, arousal, orgasm, and sexual pain disorders based\non physiologic and psychologic pathophysiology and in-\ncludes a personal distress criterion for most diagnoses.\nAlthough the AP A recognizes that female SD for many wom-\nen is physically disconcerting [1], the DSM classifications are\nspecifically limited to psychiatric disorders and are not\nintended to be used for evaluating or differentiating physical\naspects of SD [ 1]. Moreover, sexual disorders, such as\ndyspareunia and vaginism, are typically diagnosed indepen-\ndent of etiology, which may be largely or entirely physical in\nsome instances.\nDyspareunia and vaginism are both in the spectrum of\npainful intercourse, the difference being a matter of severity\n[18]. The DSM V classification stresses that they are penetra-\ntion disorders in that any form of vaginal penetration, such as\nwith tampons, finger, vaginal dilators, gynecological exami-\nnations, and intercourse, are painful (dysparenuria and\nvaginism) or impossible (vaginism). These conditions are still\noften underdiagnosed and therefore inadequately treated de-\nspite affecting millions of women worldwide [19]. Moreover,\npsychiatrists and psychologists find it difficult to differentiate\nbetween dyspareunia and vaginism [ 1]. The prevalence of\ndyspareunia and vaginism is about 8 –16%, mostly involving\ndiagnoses of vulvar vestibulitis or vulvodynia [20]. Other lit-\nerature estimates the prevalence of female SD resulting from\nchronic pelvic and sexual pain to be 26% (range 7–58%) [21].\nProvoked vestibulodynia (PVD) is another common subtype\nof vulvodynia, affecting ~12% of women [ 22]. V aginism is\nreported to affect up to 21% of women <30 years [23], with an\ncumulative incidence of 10% of women unable to have sexual\nintercourse because of pain.\nGynecologists and related medical professionals frequently\nfocus on assessment, evaluation, and treatment of peripheral\nmanifestations and location of CPPS. Central sensitization and\nmyofascial dysfunction are overlooked in many cases, proba-\nbly due to lack of training in the assessment of myofascial\ndysfunction [7]. Little more than one decade ago physiother-\napy for pelvic pain and female SD was almost nonexistent,\nwith few studies reporting on this subject. The well-known\npsychiatrist Rosemary Basson [24]c a t e g o r i z e dt h ed i a g n o s i s\nand definition of major categories of women ’s SD and their\nmanagement. V aginism was defined as persisting or recurrent\ndifficulties in allowing vaginal entry of any object, despite the\nwoman’s expressed wish to do so. The behavioral component\nwas mentioned as the main source for management, without\nany reference to physiotherapy. For dyspareunia, the authors\nof that article suggested treatment with cyclic antidepressants,\nwith or without pelvic muscle physiotherapy, without any fur-\nther specification [ 24]. Important work by this group intro-\nduced the concept of a circular response cycle in women,\ntermed the female sexual response cycle [ 25]. Their research\nstated that: next to sufficient sexual stimuli and motivation, the\nwomen’s state of mind, thought processes, beliefs, and emo-\ntions, might be the most important part of the sexual response\ncycle; the woman most likely would become more aroused\nand would desire sex more when in safe and secure surround-\nings and circumstances; and mentioned that anxiety or distrac-\ntion because of pain or discomfort may limit the woman to be\nopen or agree to having sex, which could hinder sexual arous-\nal and desire. Therefore, in this cycle, there are not only psy-\nchological factors but physiological and physical factors that\nalso play an important role. The question, then, is: Why did\nthey relegate physiotherapy to a minor role in this cycle?\"\nThere is a new, evolving model in which each individual is\nse\nen as a social –psychosomatic entity with an intricate and\nvariable interaction of physical factors (genetic,\nphenotypically, biochemical, etc), psychological factors\n(mood, personality, behavior, etc.), and social factors\n(cultural, familial, socioeconomic, medical, etc.) [ 26]. This\nrecent biopsychosocial model applies to disciplines ranging\nfrom medicine to psychology to sociology; its novelty,\nacceptance, and prevalence vary across disciplines and\ncultures [ 26, 27]. However, this model is very useful for\nunderstanding and evaluating the complexity of pelvic pain\nand female SD, which are often multifactorial, requiring a\nmultidisciplinary assessment and treatment approach.\nSo far, there has been a tendency to view pelvic pain,\ndyspareunia, and vaginism as psychological distress resulting\nin a form of somatic or physical symptoms, for which medica-\ntion or surgical intervention is necessary. The medical doctor,\npsychiatrist, or psychologist often considers these symptoms to\nbe initiated and/or perpetuated by emotional responses, such as\nanxiety and depression. With this in mind, and to answer the\nquestion of where physiotherapy fits in the sex response cycle, it\nis important to understand the rationale of and relationship be-\ntween the medical International Classification of Diseases\n(ICD)-10, the APA’s DSM V , and International Classification\nof Functions (ICF) guidelines for pelvic physiotherapy [28].\nWhereas medical doctors use the ICD-10 to code the diag-\nnosis of pelvic pain and SD, and psychiatrists, psychologists,\nand sexologists use the DSM V to classify them, physiother-\napists use the ICF (Table 1)[ 28].\nUsing the ICF, the physiotherapist tries to influence the con-\nsequences of pelvic pain and SD on three different levels: organ\n(impairment/disorder level, e.g., intravaginal pain at penetra-\ntion), personal (disability level, e.g., inability to have intercourse),\nand social–societal (restriction of participation, e.g., avoidance of\nsexual relationship = behavioral consequence). Where as the\nDSM V acts mainly on the psychological aspects of the personal\nInt Urogynecol J (2018) 29:631–638 633\n\nand social–societal levels with the focus on (changing inade-\nquate) behavior, the ICF incorporates organ levels considering\nlocal physical disorders and impairments [28].\nIn Basson’s sex response cycle (Fig. 1), elements such as\npsychological and biological processing, arousal and respon-\nsive sexual desire, multiple reasons and incentives for instigat-\ning or agreeing to sex, and motiv ation require both adequate\npsychological and physical responses. Local pain or MTrP ,\noveractive PFM, central sensitization-related hyperalgesia,\nand anxiety may hinder the state of mind around sex and/or\nsexual activity. In this setting, pelvic physiotherapy may be an\nimportant treatment co-interevention with psychological\ncounseling.\nAs an example of this interplay, the cause of pelvic pain and\ndyspareunia might be due to an injury to the PFM, connective\ntissue, or fascia as a result of a birth trauma, sexual or physical\nabuse, or episiotomy during vaginal delivery. This can lead to\nshortened and weak PFM, with MTrPs and restriction of con-\nnective tissue resulting in chronic pelvic pain and dyspareunia.\nOngoing and unresolved local injuries may lead to spinal cord\ncentral sensitization, and dorsal-root reflexes at the spinal cord\nlevel lead to referred symptoms of frequency, urgency, and\nnocturia, and the eventual development of noninfectious cysti-\ntis. This, in turn, provokes more pain, urgency, frequency, and\nnocturia, resulting in further contraction/tension of PFM, with\nfurther shortening and restriction of connective tissue. [13, 14].\nTo date, it was the rare clinician who, when assessing cystitis,\nwould take into consideration that its cause is related to a latent\ninjury of the pelvic floor, with consequential central sensitiza-\ntion and dorsal-root reflexes. Most likely, the clinician would\ncontinue the diagnostic process with invasive techniques or\nprescription of medication, rather than referring the patient to\npelvic physiotherapy. Women with pelvic pain and SD consti-\ntute a group of patients with significant morbidity. They do not\nmerely experience pain; the pain causes difficulty in walking,\nmaintaining a normal life, work ability, and social interactions.\nTable 1 Definitions of the International Classification of Functioning\nTerms: impairment, disability, and restriction in participation\nTerminology Definition\nImpairment Loss or abnormality of psychological,\nphysiological, or anatomical structure\nor function at organ level\nDisability Restriction or loss of ability of a person to\nperform functions/activities in a normal\nmanner\nRestriction in\nparticipation\nDisadvantage due to impairment or disability\nthat limits or prevents fulfillment of a\nnormal role (depends on age, sex,\nsociocultural factors) for the person\none of more reasons \nfor sexual ac/g415vity: \nnot currently aware \nof sexual desire\nwillingness to \nfind/be recep/g415ve\nsexual s/g415muli with \nappropriate context\nsubjec/g415ve arousal\nmore \nintense \narousal & \nresponsive \ndesire\nemo/g415onal & physical \nsa/g415sfac/g415on\nbiological\ninforma/g415on \nprocessing\npsychological\nFig. 1 The female sexual response cycle (adapted from [25])\n634 Int Urogynecol J (2018) 29:631–638\n\nAs mentioned, pelvic pain and female SD are often related\nto PFM dysfunction, such as overactive or underactive pelvic\nfloor or coordination disorders. Stress as the central factor\nprovokes a vicious cycle, with pain leading to muscle tension,\npressure, nerve entrapment, and reduced circulation, which\nresults in muscle shortening, which leads to restricted move-\nment, creation of MTrPs, and further pain as a consequence\n[29]. The cause of stress and/or pain is not a simple or single\nproblem but is complex and multiple. By the time women with\nCPP are diagnosed with PFM dysfunction, they already have\nundergone many unsuccessful therapeutic trials that often pro-\nvided no adequate relief. According to the interviewed key-\nopinion leaders, for such women, self-empowerment is essen-\ntial, and the role of physiotherapy is critical. It is not just the\npelvic floor but the global impact of pain on the body. Many\npatients not only have pelvic pain but many other musculo-\nskeletal manifestations. The role of physiotherapy is to get to\nthe heart of the matter by starting with the basics: helping the\npatient to stand, sit, and walk differently. In doing so, the\nmusculoskeletal impact of decreased strain and improved\ncomfort is the first result many patients notice. Then, the phys-\niotherapist can move on to working specifically on the pelvic\nfloor.\nA multidisciplinary protocol, with a central role being\nphysiotherapy, was developed at the University College\nHospital, London, UK, with reported high levels of clinical\nefficacy and patient satisfaction (personal communication, Dr.\nSohier Elneil, 2017). Physiotherapists need to be specifically\ntrained and skilled in how to help patients avoid pain using\ncognitive and/or behavioral models, how to actively listen,\nand then how to display empathy for the emotional compo-\nnent of their patients’ disease [29].\nIn case of a referral to a pelvic physiotherapist, an accurate\nmedical diagnosis is very important to determine the severity\nand impact of the disorder and to estimate success or failure of\npelvic floor physiotherapy. In many cases, the presumed med-\nical diagnosis (indication ’) lacks accuracy, and physiothera-\npists are thus confronted with heterogeneity and unclear grade\nof severity, which may limit success or even result in failure.\nThat many women with dyspareunia or vaginism have high\nlevels of anxiety in response to facing a physical examination\nof external and internal pelvic structures leads to conditions\nbeing underdiagnosed [30]. Relevant scientific studies show\nthat medical doctors did not specify pain location in 93%,\nduration in 44%, pathology in 74%, comorbidities in 95%,\nand additional inclusion/exclusion criteria in 65% of cases\nreferred to physiotherapy [ 2, 31]. In a review by Kavvadias\net al., which included 69 articles, the site of pain was specified\nin only 45% of studies, and only 20% of medical doctors\nperformed a digital examination of pelvic MTrPs for diagnosis\n[32]. Thus, because of lack of sufficient relevant medical in-\nformation, referral data, and test results, focused physiothera-\npy was difficult to administer adequately.\nThere is a recent tendency to more frequently involve phys-\niotherapists in the multidisciplinary assessment and treatment of\nfemale SD and pain management. Multidisciplinary guidelines\n[2] and protocols (University College Hospital, 2017) are now\navailable, and the Pain Clinic of the University Medical Center\nGroningen (UMCG), Groningen, The Netherlands, has devel-\noped the Pain Medicine Management Model. Whereas, in the\npast, the patient was assessed by one medical doctor and follow-\ned immediately by a treatment, assessment is now based on the\npatient’s complaint, and a multidisciplinary approach to both\nevaluation and treatment is central to the new model. Through\na multidisciplinary assessment, including a thorough history and\nphysical exam, with additional testing/examination, as indicated,\nthe team develops a comprehensive diagnosis that includes pre-\nsumed pathophysiology of the (dominant) pain mechanism. The\nUMCG multidisciplinary pain center team consists of a medical\nteam (urologist, gynecologist, surgeon), a psychologist (psychol-\nogist/psychiatrist/sexologist), and a physiotherapist. This team\nassess predominant nociceptive, neuropathic, nonneuropathic,\nsomatic, visceral, and referred ne uropathy, evaluating for the\npresence of peripheral and central sensitization and taking into\naccount any provoking and perpetuating biopsychosocial factors.\nThe assessment takes 1 h in each discipline. The patient can then\nbe classified and the plan of care tailored accordingly [33].\nIn the following paragraphs, physiotherapeutic assesment\nand treatment are described and scientific evidence discussed.\nPhysiotherapeutic assessment and treatment\nCacchioni et al. examined and reported in detail sexual thera-\npy for women involving body work: i.e., touch [ 34]. Women\nseeking advice for sexual problems are assessed and treated\nusing close scrutiny, measurement, and response to touch of\nthe genital area by health-care providers, including a medical\ndoctor and pelvic physiotherapist [ 34]. Treatment may also\ninvolve instructing the woman in genital self-touch. A useful\ntool for managing CPP and female SD might be the so-called\nfive-step ALLOW algorithm introduced by Sadovsky and\nMulhall [ 35]. Only once the current step has been fulfilled\nsatisfactorily for both the patient and the physiotherapist is\nthe next step initiated:\nStep 1: A: ask the patient whether you can proceed, then\nStep 2: L: legitimize each part of the body work in such a\nway that the patient feels completely in control\nStep 3: L: limitations, meaning that before and during body\nwork the physiotherapist is, at all times, aware of his/\nher own competence and skill level and the patient’s\nemotions and feelings, referring, if necessary, to an-\nother professional\nStep 4: O: be open for further discussion and evaluation with\nthe patient and, if necessary, other competent col-\nleagues or disciplines of the multidisciplinary team\nInt Urogynecol J (2018) 29:631–638 635\n\nStep 5: W: work to develop a treatment plan with the patient\nand other disciplines\nPhysical exam\nBefore beginning the physical exam, the physiotherapist in-\nforms the patient about the nature of the procedure, helps the\npatient feel comfortable, and sets clear boundaries [ 34]. The\nphysiotherapist also explains the difference between the ob-\njectives and execution of the physical exam to be performed\nby their physician and physiotherapist. The physiotherapist\nattends to women’s immediate complaints of sexual discom-\nfort or displeasure, using body work to encourage them to feel\nmore in control during the procedures and sexual activities.\nPatients have described the body work as therapeutic and\nempowering. Assessment and treatment modalities use visu-\nalization and hands-on techniques that stimulate patient recon-\nnection with their bodies, rather than simply expressing a sen-\nsation of objective feelings. These strategies are often highly\nvalued by patients because of the careful and gradual ap-\nproach, which encourages women to be active participants\nin the overall process [ 34].\nAfter a general inspection of posture and stability of spine\nand pelvis, the physical exam begins with inspection of the\nabdominal wall and observation of the patient ’sb r e a t hw h i l e\nin the supine position. The perineal region is then examined,\nobserving skin (color, temperature), scars, irregularities, mois-\nture, etc. Next, a neuromuscular exam, assessing dermatomes,\nmyotomes, searching for MTrPs, allodynia (skin-rolling test,\npinch-and-roll technique), hyperalgesia (Wartenberg pin-\nwheel), nerve entrapment, a nd pain points is performed.\nMuscle activity (tone) of lower back, hip, leg, and abdominal\nmuscles is examined using palpation. Pelvic floor muscle ac-\ntivity (tone), spasms, and relaxation is assessed using internal\npalpation and/or biofeedback [7, 36].\nMore detailed information can be found elsewhere [ 37].\nTreatment\nInformation about the patient’s underlying health problem and\neducation are always the starting point of treatment. Education\nincludes explaining CPP pathophysiology and female SD, in-\nvolvement of PFM, healthy vulvovaginal and sexual behaviors,\nfactors influencing pain intensity, relaxation techniques, sexual\nfunction, and recovery of nonpainful sexual activities [ 38].\nPhysiotherapist-assisted stretching of the muscles of the back,\nlower extremities, and abdomen, in addition to nerve gliding to\nfacilitate movement in restricted nerves, is important [ 30].\nStretching and strengthening techniques are then introduced to\naddress muscle weakness, allowing for balance and stability.\nAs central sensitization and myofascial involvement may con-\nt r i b u t et oC P Pa n da s s o c i a t e dS D ,physiotherapists use strategies\nthat address treatment of MTrPs and pain regions, especially\nthose that have been clinically tested and enhanced by scientific\nstudies. Myofascial release involves physiotherapy and manual\ntherapy modalities, including deep-pressure massage, stretching,\njoint mobilization, foam rollers [39], and other triggerpoint re-\nlease techniques, such as vibration, transversal or flat palpation\n[39, 40] and dry needling [ 41]. At each session, ~30 min is\ndedicated to these manual techniques to increase flexibility, de-\ncrease TrP-related pain and tension, and increase balance and\nstability. Other pain management strategies, including general\nand specific respiratory and relaxation exercises, aim to enhance\npatient’s self-management and self-empowerment skills [11, 42].\nAredo et al. reported:Bthis dual approach addresses physiologi-\ncal and psychological components of chronic myofascial pain,\nalleviates MTrP-related pain, and furnishes patients with coping\nstrategies to redirect their focus during a painful episode^ [7].\nOther frequently used treatment modalities are pain manage-\nment programs to promote behavior change [43], PFM training\n[44, 45], biofeedback, electrical stimulation [46], and balloons\nand pelots for dilitation of vaginal tissues [47]. Goldstein et al.\ndescribed a program of PFM training for vulvodynia [ 30]i n -\nvolving pelvic and core mobilization and stabilization tech-\nniques; connective tissue, visceral, and neural mobilization;\nand internal and external MTrP° release. Biofeedback and elec-\ntrical stimulation assisted in decreasing tender points and tissue\nrestrictions. The aim was to restore the proper length of the PFM\nand tissues, decreasing neural tension and dyspareunia. V aginal\ndilators are recommended to normalize muscle tone, desensitize\nhypersensitive areas of vulva and vagina, and restore sexual\nfunction [48]. The daily home maintenance program involves\nrelaxation and respiratory exercises, PFM training, stretching\ntechniques, and the use of vaginal dilatators, if indicated [38].\nScientific evidence for pelvic physiotherapy\nRecently, some qualitative studies have been published on the\neffects of pelvic physiotherapy for CPP and female SD. Weiss\net al. reported that regular in-clinic and at-home PFM training\naugments the support function of the pelvic floor, increases\nblood flow, and stimulates PFM proprioception, contributing\nto more intense orgasm [49]. In a review on chronic pelvic floor\ndysfunction, Hartmann et al. concluded that referral to a pelvic\nphysiotherapist should occur routinely as part of the multidisci-\nplinary approach for all women who present with any type of\nvulvovaginal pain [5]. Research indicates that pelvic physiother-\napy is safe and effective and can dramatically improve symp-\ntoms related to CPP and chronic PFD. Pelvic physiotherapy\nstimulates self-empowerment of women and supports recovery\nof function they may have lost due to pain and dysfunction.\nSadownik et al. [ 50], in a qualitative retrospective study;\nBrotto et al. [ 51], in a longitudinal prospective study;\nGoldstein et al. [30], in a report of the expert committee of the\nFourth International Consultation on Sexual Medicine; and\n636 Int Urogynecol J (2018) 29:631–638\n\nGoldfinger et al. [ 52], in an RCT; emphasize the efficacy of\npelvic physiotherapy as part of the multidisciplinary approach\nfor CPP and SD. Goldstein et al. stated that physiotherapist-\nassisted stretching of all muscles related to the pelvis, abdomen,\nlow back and upper legs, in addition to nerve gliding to facilitate\nmovement in restricted nerves, is necessary to improve CPP and\nSD [ 30]. The authors reported that stretching exercises and\nstrength training restored balance and stability, proper PFM\nand fascia tissue length, and decreased neural tension and\ndyspareunia. In a RCT Goldfinger et al. investigated effects on\nprovoked vestibulodynia by comparing cognitive behavioral\ntherapy and multimodal physiotherapy [52]. The physiotherapy\nprotocol combined education, PFM exercises, manual tech-\nniques, surface electromyographic biofeedback, progressive\nvaginal penetration exercises through the use of four silicone\nvaginal dilators of varied diameter, stretching of hip muscles,\ndeep breathing, global body relaxation exercises, and pain man-\nagement techniques. They concluded that both interventions are\neffective treatment options for women with provoked\nvestibulodynia. Sadownik et al. stated that behavioral change\nstimulated by physiotherapy that enhances the patient’s bodily\nexperience is an important aspect in improving self-efficacy and\ndecreasing the experience of overly negative cognitions [50].\nOne RCT found that vaginal electrical stimulation improved\nthe sexual experience of women with PFD who scored low on\nthe Female Sexual Function Index (FSFI) [ 53]. A longitudal\nprospective study showed that transcutaneous electrical nerve\nstimulation (TENS) was feasible and beneficial for treatment-\nresistant provoked vestibulodynia [54]. In an RCT of women\nwith pelvic and sexual pain, Zoorob et al. concluded that pelvic\nphysiotherapy improves sex life and decreases pain in an equiv-\nalent response to injections [55]. An RCT comparing the effect\nof physiotherapy with surgery resulted in similar outcomes [56].\nConclusions\nCPP and female SD are prevalentand multifactorial issues that\nthreaten women’s quality of life. As part ofthe multidisciplinary\nteam, and because of its holistic and whole-body approach, pel-\nvic physiotherapy can contributesignificantly to assessing and\ntreating such women, and clinical and scientific research indi-\ncate its efficacy and safety. Therole of pelvic physiotherapy for\nthese patients remains a relatively untapped resource. Further\nhigh-quality RCTs are warranted for several physiotherapeutic\nmodalities and protocols and to determine their long-term effects\nin the integrated treatment plan of women with CPP and SD.\nAcknowledgements I would like to express my gratitude to Sohier\nElneil, Ph.D., M.D., gynecologist; Bert Messelink, M.D., urologist and\nsexologist; Fetske Hogen Esch, pelvic physiotherapist; Maura Seleme,\nPh.D., pelvic physiotherapist; Nucelio Lemos, Ph.D., M.D.; gynecolo-\ngist, for their advice and contributions to this manuscript; and Steven\nSwift, M.D., gynecologist, for his correction of the English language.\nCompliance with ethical standards\nConflicts of interest None.\nOpen Access This article is distributed under the terms of the Creative\nCommons Attribution 4.0 International License (http://\ncreativecommons.org/licenses/by/4.0/), which permits unrestricted use,\ndistribution, and reproduction in any medium, provided you give appro-\npriate credit to the original author(s) and the source, provide a link to the\nCreative Commons license, and indicate if changes were made.\nReferences\n1. 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Iran J Reprod Med. 2014;12(1):7–14.\n638 Int Urogynecol J (2018) 29:631–638","source_license":"CC0","license_restricted":false}