Managing Pregnancy and Delivery in Women with Sexual Pain Disorders.

Rosenbaum TY, Padoa A.  J Sex Med 2012; 9: 1726-1735.
MJ Strauhal, PT, BCB-PMD
Journal Club 10-10-12

This journal club involved discussion of the following topics related to the article.  There is a lot more on the recording. 

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 Application to pelvic floor (PF) physical therapy:

·         The PF physical therapist may be the first (or one of many) provider to have a discussion regarding the desires or fears associated with pregnancy and labor/ delivery with the patient suffering from a sexual pain disorder (SPD)

·         The PF PT should be knowledgeable about the practical concerns of their SPD patients regarding pregnancy and labor/ delivery

·         The PF PT should be knowledgeable about the safety of PT interventions for women with SPD that are either trying to conceive or are currently pregnant

Aim of the article:

·         Discuss pregnancy and birth outcomes in women with SPD and address practical concerns of patients and practitioners regarding management during pregnancy, pelvic examination, labor, and delivery

Methods:

·         Review of relevant literature

·         Recommendations based on clinical expertise of the authors

o   Talli Rosenbaum, PT, MSc in Clinical Sociology and Counseling, Certified Sex Therapist

o   Anna Padoa, MD, head of Urogynecology and Pelvic Floor Service at Assaf Harofe Medical Center

Considerations for PF PT’s as they review this article:

·         Is it within the scope of practice for a PF PT to bring up the discussion of pregnancy potential with patients with SPD when no penetrative sex is currently occurring?

·         Do lubricants, topical lidocaine, and other topical agents used in treatment of SPD harm sperm and sperm motility?

·         What are the potential medications a women with SPD may be taking and their risks/ safety during conception and pregnancy (excellent Table on page 1729)?

·         In a low risk pregnancy, where sexual intercourse is permitted, the use of a dilator or vaginal probe is considered safe.  True or false?  Why?

·         During a low risk pregnancy, the use of intravaginal manual therapy techniques is contraindicated.  True or false?  Why?

·         Is sexual history a standard part of your PT intake?

·         In studies of women’s perception of pelvic examination, what factors have been cited as influencing feelings of control and comfort?

·         How do you assess and address anxiety in your SPD patients?

·         What is your knowledge base/ skill level regarding:

o   Somatization

o   Dissociative reactions

o   Hypervigilance

o   Abuse flashbacks

o   Catastrophizing

o   Anxiety disorders

§  The Rosenbaum Mindfulness-Based Protocol briefly described

§  Recommended reading: Rosenbaum T. Addressing anxiety in-vivo in physiotherapy treatment of women with severe vaginismus: a clinical approach. J Sex Marital Ther 2011; 37: 89-93.

§  Are you familiar with sensate focus techniques?

·         http://womenshealth.stanford.edu

·         How might mindfulness be used to enhance the patient’s experience of PT?  (see section The Role of Mindfulness in Childbirth)

·         Do you regularly recommend a counselor or sex therapist to your patients with SPD?

·         On page 1731 it states, “In patients with SPD and in sexual abuse survivors in particular, vaginal examinations should be performed only when indicated.”

o   Do you agree with this statement?

o   What other options for examination do you offer your SPD patients?

o   How do you give your patients “maximum control over the examination”?

·         Is there increased risk of perineal/ vulvovaginal trauma during vaginal delivery in women who have undergone a vestibulectomy?

·         Is there a connection between SPD and increased risk of obstetric pelvic floor damage?

 

Introduction:

·         SPD, including vaginismus and dyspareunia are prevalent in women in childbearing years

o   How prevalent are these conditions?

·         Preventing or facilitating pregnancy are major concerns for premenopausal sexually active women

·         There is little research relating to pregnancy and birth concerns in women with vaginismus and provoked vestibulodynia (PVD, the most common cause of dyspareunia in this population)

·         The DSM-IV (Diagnostic and Statistical Manual of Mental Disorders IV) lists vaginismus and dyspareunia as sexual dysfunctions

o   There is a proposal to replace these with “genito-pelvic/ penetration disorder”

o   This reflects a conceptual shift away from only a sexual context to pain disorders that have nonsexual sequelae

·         Women with SPD without “organic” infertility may seek advice regarding:

1.      Contraception/ prevention of pregnancy

§  Necessary when no penetrative sex is occurring?

·         Is it possible to get pregnant with outercourse?

§  Appropriate type of birth control:

·          OC’s are discouraged in women with PVD.

o   Why are OC’s discouraged in women with PVD?

·         Barrier methods may be painful

·         Physicians are hesitant to insert an IUD in nulliparous women

2.      Pelvic examination

§  The need for ongoing pelvic or ultrasound examination during pregnancy

3.      Fertility intervention

§  Facilitation of pregnancy without intercourse

·         How familiar are you with self insemination techniques?

§  The need for lubricants and topical lidocaine that may potentially harm sperm or impair sperm motility

§  The safety of conceiving while being managed with oral and topical agents and the safety of these agents throughout pregnancy

§  The effect that pregnancy and birth will have on pain symptoms

4.      Mode of delivery

§  Pain management during L & D

§  Higher risk for birth intervention? (i.e., induction, forceps, vacuum, C-section)

§  The effects that birth will have on pain symptoms

·         Is there any evidence to support the claim that the stretching effect on the PF will improve SPD?

5.      Safety of PF PT during pregnancy, including the use of dilators, biofeedback with an intravaginal probe, manual therapy, and other interventions

·         Sexual history is not a standard component of prenatal, L & D, or US tech intake

o   Pregnant patients with SPD may be embarrassed about revealing that they have not previously had intercourse or undergone a pelvic exam

§  These women may be vulnerable to a potentially traumatic experience

§  Practitioners should screen for SPD and be knowledgeable, understanding, and cooperative

 

Suggested Reading

Hilton S, Vandyken C.  The puzzle of pelvic pain- a rehabilitation framework for balancing tissue dysfunction and central sensitization, part I: pain physiology and evaluation for the physical therapist. J Womens Health Phys Ther. 2011; 35: 103-111.

Vandyken C, Hilton S.  The puzzle of pelvic pain- a rehabilitation framework for balancing tissue dysfunction and central sensitization, part II: a review of treatment considerations.  J Womens Health Phys Ther. 2012; 36: 44-54.

Alappattu MJ, bishop MD.  Psychological factors in chronic pelvic pain in women: relevance and application of the fear-avoidance model of pain.  Phys Ther. 2011; 91: 1542-1550.

 Dunleavy K, Slowik AK.  Emergence of delayed posttraumatic stress symptoms related to sexual trauma: patient-centered and trauma-cognizant management by physical therapists.  Phys Ther. 2012; 92: 339-351.

Olsson CB, Grooten WJA, Nilsson-Wikmar L, Harms-Ringdahl K, Lundberg M.  Catastrophizing during and after pregnancy: associations with lumbopelvic pain and postpartum physical ability.  Phys Ther. 2012; 92: 49-57.