Handout 3 - AUGS/IUGA 2014 Scientific Meeting

IUGA 2014
July 21 – 26
Washington
Urogenital Pain SIG meeting in
Washington, Tuesday, July 22,
6-8 pm
Maura Seleme
Chronic pelvic pain
Chronic pelvic pain is a prevalent condition which can
present a major challenge to health care providers
 complex etiology and poor response to therapy.
 multifactorial condition and quite often, poorly managed.
 requires knowledge of all pelvic organ systems and their
association with other systems and conditions,including
muscleskeletal, neurologic, urologic, gynaecological and
psychological aspects
 requires multidisciplinary approach.
The European Association of Urology (EAU)
Guidelines
Sexuality and Pelvic Pain
In general human sexuality has three
aspects – sexual function, sexual selfconcept, and sexual relationships.
 Pain can affect self-esteem, ones ability to
enjoy sex and relationships.
 Healthy sexuality is a positive and lifeaffirming part of human being.

Female sexual response
Masters & Johnson 1966
desire
excitement
resolution
desire, arousal, orgasm Kaplan 1979
basis for DSM-IV definitions
Sexual response cycle

During the sexual response cycle, the
different phases are controlled by a
different part of the brain and spinal cord.
Chronic pelvic pain can cause disturbance.
Rosenbaum 2008
Sexual response
cycle

The Desire Phase begins in the “pleasure centers” of the
brain and controls a person’s sexual appetite or drive.
Pain or even the fear of pain can decrease desire,
making the person uninterested in sex.

The Arousal Phase is associated with woman’s labia,
vagina, and clitoris. This swelling causes an erection in
the clitoris and release of lubricating fluids. If a person
experiences pain at the time of becoming excited, the
excitement may be reversed, the lubrication will stop,
leading to dryness.
Sexual response cycle

The Orgasm Phase describes a genital reflex
controlled by the spinal cord, which causes
the genital muscles to contract, involuntarily
releasing sexual tension and swelling that
build up during the excitement phase. In
some cases, pain prevents people from
reaching this phase.
Female sexual response cycle
Vasculogenic
 clitoral & vaginal insufficiency
 ↓ genital blood flow related to atherosclerosis
iliohypogastric/pudendal arterial bed
Goldstein 1998

↓ pelvic blood flow due to aortailiac disease →
clitoral & vaginal wall smooth muscle fibrosis →
vaginal dryness, dyspareunia
Berman 1999
Female sexual response cycle
Vasculogenic
atherosclerosis → clitoral cavernosal artery wall tickening, loss
corporal smooth muscle & replacement fibrous connective
tissue
 possibly atherosclerotic changes in smooth muscle interfere
with normal relaxation and dilitation responses to sexual
stimulation
 alterations circulating estrogen levels (menopause) → smooth
muscle changes
 traumata iliohypogastric/pudendal arterial bed and chronic
perineal pressure (biking) ↓ vaginal and clitoral blood flow→
FSD

Berman 2000
Female sexual response cycle
Neurogenic
 spinal cord injury more difficult orgasm (Viagra)
 diseases central/peripheral nervous system (diabetis)
 incomplete: regain psychogenic capacity arousal and
vaginal lubrication
 the pudendal nerve can be involved(surgery, trauma,
cancer, birth trauma, ederly women, prolonged
sitting,chonic constipation)
Sipsky 1995
Female sexual response cycle
Hormonal

dysfunction hypothalamic/pituitary axis, castration,
premature ovarian failure, ↑ age, chronic birth control
→ hormonal FSD

↓ estrogen & testosteron → ↓ libido, vaginal dryness,
lack sexual arousal, emotional lability, sleep
disturbances

estrogen = ok → ↑ integrity vaginal mucosal tissue, ↑
vaginal sensation, vasocongestion, secretion → ↑
arousal
Berman 2000
Female sexual response cycle
Hormonal
estrogen ≠ ok → ↓ clitoral intracavernosal, vaginal
and urethral blood flow
 estrogen ≠ ok → clitoral fibrosis, thinner vaginal
tissue, ↓vaginal submucosal vasculature


thus: ↓ estrogen → ↓ vaginal & clitoral tissue → FSD
Berman 2000
Female sexual response cycle
Hormonal
testosterone = ok → central & peripheral effects also
in vagina
 vaginal epithelium responds to testosterone
replacement like estrogen replacement
 androgens role in regulating vaginal smooth muscle
relaxation and blood flow
 ↓ androgen receptor expression noted in vaginal subepithelium in women having estrogen replacement →
persistent symptoms vaginal atrophy and dryness in
menopausal women (impaired androgen
responsiveness) → FSD
Berman 2000

Female sexual response cycle
Musculogenic

pelvic floor muscles: levator ani, bulbocavernosus,
ischiocavernosus (eprineal membrane) voluntary contraction
intensifies sexual arousal and orgasm
 perineal membrane involuntary rythmic contractions during
orgasm
 levator ani modulates motor responses during orgasm and
vaginal receptivity
Berman 2000
PFM dysfunctions

underactive (hypotone) pelvic floor

overactive (hypertone) pelvic floor

disorder coordination pelvic floor

dysfunction, pelvic pain, dyspareunia, ↓ vaginal
sensation, ↓ intensity orgasm
Female sexual response cycle
Psychogenic

emotional and relational issues affect sexual arousal
 self-esteem, body image, quality relationship
 depression, mood disorders ↔ sexual response
 medication (serotinin re-uptake inhibitors) ↓ desire,
arousal, genital sensation, difficulty achieving orgasm
Berman 2000
Psychogenic
Sexual abuse

unsafe situations
– at home
– education
– incest
– violence

undesirable intimidation
– at school
– at work
– unequal situation

undesirable penetration
– partner (desired/undesired)
– health care provider (desired/undesired)
– perpetrator
Sexual abuse

psychosomatic dysfunction
– fear, depressive complaints, cognitive problems, personal
problems, sleep disturbance, social problems
 urological dysfunction
– dysfunctional voiding, chronic pelvic pain syndrome
(CPPS), enuresis, incontinence,
 gynaecological dysfunction
– CPPS, dyspareunia, vaginismus, focal vulvitis
 sexual dysfunction
“Patients who reported having sexual, physical or emotional abuse show a
higher rate of reporting symptoms of pelvic pain”
The European Association of Urology (EAU)
Guidelines
Pelvic Pain and sexual dysfunctions

Pelvic pain in a women is associeted with
significant sexual dysfunction
Randolph,2006

the most frequente complaint cited by patients
with CPP is sexual dysfunction
Zondervan,1998

CPP specifically involves areas intimately
connected to sexuality, which may negatively
impact one’s body image and sexual self-esteem
and also affects both partners in the relationship
Heinberg 2004,Smith 2007
Sexual dysfunctions

sexual pain disorders:
– vaginism
– dyspareunia
– (chronic) pelvic pain
Tu et al 2008
Dyspareunia
DSM-IV :
“contineously recurrent or persisting genital pain in
women related to coïtus and not solely caused by
vaginism or deminished lubrication and not solely a
consequence of a somatic health problem”

prevalence: globally 3-18% ???!!!
Dutch outpatient sexology 37%
Vaginism
DSM-IV / ICD-10

“ involuntary contraction of
muscles in outer third vagina and
often pelvic floor, which limits or
prevents intercourse or vaginal
penetration”

Prevalence & incidence sexual dysfunction

prevalence dyspareunia, vaginism 8%-16%:
mostly vulvar vestibulitis, vulvodynia, overlap
Engman et al 2004

vaginism affects up to 21% of women < 30
years
Laumann et al 1999

cumulative incidence inability sexual
intercourse because of pain 10%
female sexual dysfunctions (FSD)

age-related
 progressive
 highly prevalent, 30-50% US females
Laumann 1999

risk factors: aging, hypertension, smoking,
hypercholesterolemia
Hsuch 1998
Sexual problems - DSM

always 2 aspects:
– dysfunction
– significant suffering
Sexual Dysfunctions

lack operational definitions in current chronic pelvic pain
research Williams et al 2004
 in studies:
– location pain not specified in 93%
– duration pain not specified in 44%
– pathology not specified in 74%
– co-morbidities not specified in 95%
– additional inclusion/exclusion criteria not specified in
65%
“So, PT difficult, often not enough information!! “
PFM overactivity ↔ vaginism

compared with normal subjects in women with vaginism
elevated emg in m. levator ani, puborectalis and
bulbocavernosus, both at rest and with induced vaginism
(attempted insertion of a dilator)
Shafik & El-Sibai 2002
PFM overactivity ↔ sexual activity

effect overactive pelvic floor (OAPF) on urinary tract is dynamic

pain associated with sexual activity may be either dyspareunia
or vaginism or non-coital sexual pain Basson et al 2000

dyspareunia varies from localized introital tenderness to diffuse
deep soreness

often sustained for 3 days after sexual activity Salonia et al 2004

57% with OAPF report dyspareunia related to stretching of
shortened pelvic floor, stimulation painful regions or organ
dysfunction/adhesions Meadows 1999, Munarriz et al 2002, Beji et al
2003, FitzGerald & Kotarinos 2003
Chronic Pelvic Pain
prevalence 38 of 1000 women, aged 15-73
Vercellini 2007
39% women, always, often, sometimes PP
Kavvadias 2010
single most common indication in gyn clinic (20%)
Vercellini 2007
etiology (pathophysiology in 2 of 3 unknown) Mathias 1996
psychological stress and functio laesa; what is first, joint complaints or
PF
variability in treatment and no clinical guidelines
Jarell 2005
intervention symptom directed because of unknown etiology: problem
complex and multifactorial
Stones 05, Bower and Frawley 07
29
Basson
2001
Copyright ©2005 CMA Media Inc.
Basson, R. CMAJ 2005;172:1327-1333
Basson
2001
Managing sexual dysfunction

"ALLOW" algorithm: a sample management plan
the body work of sexual therapy
Cacchioni 2010
Assessment: history taking





overview findings
explanation nature, causes, severity
analysis & evaluation available treatment options
benefits and disadvantages or risks treatment option
encouragement patient to participate actively in the decisionmaking process
Hatzichristou 2004
Assessment: history taking

thorough pain history:
– site of pain confirmed by pain diagram
– duration of pain
– nature of onset or precipitating event
– pain characteristics
– response of pain to activity and associated symptoms
Hopwood 2000
Physical assessment
key elements physical examination in sexual dysfunction






complete genital exam
secondary sexual characteristics (e.g., gynecomastia)
body hair, fat distribution
blood pressure, heart rate, peripheral pulses, edema
vibratory sensation
lower extremity strength and co-ordination
Hatzichristou 2001
Physical assessment

physical assessment
– visually inspect perineum at rest. Genital hiatus may appear
small and perineal body displaced anteriorly, especially if
shortened position PFM
– observe PFM contraction, relaxation and bearing down.
– check sensation/neurological integrity: the anal wink reflex
may be absent due to an already contracted PFM.
– watch out: be aware of body work in relation to patient’s
intimacy and reaction
Cacchioni 2010
Palpate internal vagina/rectum
Evaluation of
–
–
–
–
–
presence of pain.
pelvic floor muscle tone (lack validity and/or reliability
testing) Devreese et al 2004, Reissing et al 2004
relaxation PFM (e.g., absent, partial, full Messelink et al 2003
spasm
muscle contractile activity as measured by




digital palpation (PFM contractility, symmetry and co-ordination)
surface electromyography
(manometry)
(transperineal and transabdominal ultrasound)
Interventions










information & education
relaxation exercises
respiration exercises
PFMT
massage
triggerpoints Anderson et al 2009
biofeedback
electrical stimulation Tu et al 2005
balloons
multidisciplinary:
– change of cognitions
– scoring fear using VAS-scale
PFMT






find / feel / force / follow through:
4 Fs
co-contraction synergists
contract abdominals-contract PF-relax PF-relax
abdominals
different levels
PFME in combination with respiration
review: pelvic floor physiotherapy for women with
urogenital dysfunction: indications and methods
Minerva Urologica e Nefrologica 2011 March;63(1):101-7
Rosenbaum 2011
management of female pelvic and sexual pain disorders
PFMT

objective:evaluate effect PFMT on female sexual dysfunctions

methods: no RCT, n=26, sexual dysfunction (sexual desire,
arousal, orgasmic disorders and/or dyspareunia), ten
sessions, two-digit palpation (assessment of pelvic floor
muscle, PFM, strength), intravaginal electromyography (EMG)
Female Sexual Function Index (FSFI), once or twice a week
Piassarolli 2010
PFMT

results: all parameters sign. improvement 69% women
presenting grade 4 or 5 (FSFI)

conclusions: PFMT improved muscle strength and
electromyography, contraction amplitudes, with improved
sexual function, indicating that this physiotherapy approach
may be successfully used for treatment female sexual
dysfunctions
Piassarolli 2010
PFMT

involvement pelvic floor in sexual function and dysfunction is
examined, as well as potential role of pelvic floor rehabilitation
in treatment. Further research validating physical therapy
intervention is necessary
Rosenbaum 2007

no RCT, n=3!!!! biofeedback, functional electrical stimulation,
pelvic floor muscle exercises, and vaginal cones
complete rehabilitation can provide beneficial effect on sexual
function
larger trial, on more extended female population, is currently
in progress, in order to confirm findings
effectiveness of complete PFR scheme, together with lack of
side effects, makes it suitable approach to sexual dysfunction
that is associated with UI
Rivalta 2009
Evidence interventions
–
Cochrane database systematic reviews was searched for
evidence of effectiveness interventions PFM pain or
abnormal muscle tone
–
results: no reviews regarding PFMT, nor use adjunctive
therapies, nor lifestyle modifications for PFM pain.
Evidence interventions
–
PEDro database two papers:
systematic review of Chronic Pelvic Pain in Women
Kirste et al 2002
-
1 RCT Peters et al 1991
–
flexible biopsychosocial approach seems most promising
–
cognitive-behavioural stress management intervention aimed
at improving coping with pain and strategies for stressful life
events may be indicated in sub-sample patients
evidence interventions
–
objective: evaluate the effects of early pelvic floor muscle
training after vaginal delivery on sexual function
–
methods: RCT PFMT VS controls, n=75 primipara, start 4th
postpartum month, end 7th, sexual function and PFM strength
scores
–
results: all scores sign higher, BUT only within group results
–
conclusions: PFM training improves PFM function, and
starting after the puerperal period, exercise appears to have
positive effects on female sexual function
Citak 2010
Evidence interventions
most promising treatment PFM pain / abnormal PFM tone
seems
- manual therapy techniques for reducing muscle
tension
- PFMT exercises to reinforce normal muscle contraction &
relaxation, coordination
- supplementary use of sEMG
- possibly electrical stimulation for pain relief and assisted
muscle activation and release
- patient advice, education regarding recognition aggravating
factors and encouragement to adhere to home exercise
programs seem important element in success therapy
Bo, Berghmans et al, 2007
Evaluation
Invasive and non-invasive treatment
by films and explanations”
Maura Regina Seleme
PhD PT
Before start the treatment…

Following initial evaluation, all patients should be provided with a detailed
review of findings and explanation of the nature and likely causes of their
problem

if the initial findings do not preclude direct treatment for the sexual problem,
patients should be informed as to the available treatment options and the
likely benefits and disadvantages or risks of each option

patients should always be encouraged to participate actively in the decisionmaking process – motivation !
Hatzichristou 2004
Assessment: history taking
Basic principles for sexual history-taking
• allow the patient to feel in control
• provide explanations for answers
• help the patient feel less abnormal (destigmatize)
• provide encouragement and positive support
• initiate the discussion of sensitive topics
• defer sensitive questions
• be aware of patient's cultural background
• ensure confidentiality
• avoid judgmentalism
Gregoire A 1999
Associated pathology
( ) Diabetes
( ) Obesity
( ) lower back pain
( ) SDT - sexually transmitted disease
( ) Depression
( ) Neurological Disease Which one? ______
Medicine:____________________________
Urogynecology
( ) Age of sexual initiation
( ) Urinary infection ( ) Frequency
( ) Regular period (menstruation) ( ) yes ( ) no
Use of birth control method ( ) yes
which?___________
( ) Menopause? Start Date__________
Treatment:___________
Anorectal
( ) Constipation
( ) Hemorrhoids
( ) Anal incontinence
Difficulty to control
( ) flatulence
( ) Faeces
Surgery????
DATES
Hysterectomy
Prolapses
Other
COMMENTS:__________________________________________
___________________________________________________
______________
Obstetric history
Children dates
Vaginal Delivery
Cesarean
Epidural anesthesia
Forceps delivery
Episiotomy
Lacerations
Pregnancy weight
Baby weight
Urinary Incontinece before
delivery
Urinary Incontinence after
delivery
Urinary behavior
Frequency:
day:________ night:_________
(
(
(
(
)
)
)
)
dysuria ( ) abdominal strength
difficulty to control the uriny
urgency
( ) pain
burning feeling
Urinary incontinence
Start Date:____________________
Incontinence
( ) daytime
( ) nighttime
With some effort ( )
urgently ( )
Which kind of urinary incontinence ?
Pain

deep into pain history:
– site of pain confirmed by pain diagram
– duration of pain
– nature of onset or precipitating event
– pain characteristics
– response of pain to activity and associated symptoms
Hopwood 2000
Visual analog scale
Em que número a paciente situa sua
Every session:
Session 1:
Session 2:
...........
Last session:
Abdominal evaluation by film
Pelvis mobility by film
Hips movement shown by film
Coccix evaluation shown by film
Pirifomis muscle shown by film
Pubis evaluation shown by film
Contraction – relaxation
shown by film
Volontary Contraction
No contraction pelvic floor,
No relaxation pelvic floor
No contraction and als non relaxation pelvic floor
Messelink, Benson and Berghmans
ICS Standartisation
Anal Contraction by film
Inspection – movement during
coughing
pushing
Valsalva and perineum bulging
down
Clitoris reflex
Sensibility
Evaluation before invasive
techniques – finding
external pain
Tonus of the center tendineum
Finding Internal Pain
How to do the palpation?
Find pain !!!!
Pelvic floor dysfunction should be classified
according to “ICS Standartisation”
By palpation of the pelvic floor muscles, the contraction and relaxation
are qualified:
Voluntary contraction can be absent, weak, normal or strong, and
voluntary relaxation can be absent, partial or complete.
 Involuntary contraction and relaxation is absent or present.
 Based on these signs, pelvic floor muscles can be classified as
follows:
• non-contracting pelvic floor
• non-relaxing pelvic floor
• non-contracting, non-relaxing pelvic floor.

Messelink, Benson and Berghmans
ICS Standartisation
Deep muscles
Palpation of superficial muscle
10 s
Slow Contraction
Fast Contraction
Contraction and relaxation 15 seconds
Information !

information anatomy
& PFM
Talking about perineum !!!!!
Find and Feel
the perineum
Find and Feel
the perineum
Find and Feel

Hypopressive Gymnastic
CONCEPTS
It’s a postural technique
that promotes lifting
of the pelvic organs,
towards the diaphragm,
reducing the intraabdominal pressure and
inducing a reflex
contraction of the pelvic
floor muscles.
Caufriez 1986, Penners 2002,
Caufriez,1991, Berghmans, 2010, Costa
2011, Stupp, 2011, Seleme 2011, Latorre
2011, Giraudo, 2011, Resende, 2012
The Hypopressive Technique
(SPECULUM VIEW)

This video shows the up- and
inward movement of the vaginal
(wall), into the direction of the
diaphragm. This lift has the same
duration as the aspiration
manoeuvre of the diaphragma
Courtesy J Amostegui, Spain 2005
IUGA 2009,2010 and 2011,2012
ICS 2009,2010 and 2011
Electromyographic
research
This movie, done in
Portugal in 2008,
shows the
diaphragma
aspiration
manoeuver.
•
As we can see,
during the aspiration
time, the
electromyography
sensors capture
significative signs of
contraction from both
pelvic floor (upper)
and abdominal
muscles (botton).
Escola Superior de Tecnologia da Saúde de Lisboa. Research
Labs, Portugal.
SELEME M, DABBADIE L, RAMOS L, 2008.
Iuga – 2009-2010-2011
ICS – 2009 -2010
MRI - Analisys
The image on top demonstrates the abdominal muscles during rest, and the
image beside is after an abdominal muscle contraction. The angle between
uterus and vagina changes from 31 degrees at rest (first image) to 45
degrees after diaphragmatic aspiration (second image).
Berghmans et al, 2010: Pelvic floor reabilitation. In Atlas of Bladder Disease.
David Staskin D.R Ed.Springer 2010
Seleme et al.Ginastica Hipopressiva in Urofisioterapia. In Aplicaçoes Técnicas
Fisioterapeuticas nas Disfunçoes Miccionais e do Assoalho Pélvico-Ed. Paulo
Palma – Brasil 2010
MRI – analysis
These images show a distance between the levator ani muscles and the sacrum
of 83.8 mm during rest (first image) and of 76.8 mm during a diaphragmatic
aspiration (second image).
Berghmans et al, 2010: Pelvic floor reabilitation. In Atlas of Bladder Disease. David
Staskin D.R Ed.Springer 2010
Ginastica Hipopressiva in Urofisioterapia – Aplicaçoes Técnicas Fisioterapeuticas nas
Hypopressive Gymnastics
How to do?
Hypopressive Gymnastics

Pelvic floor muscles are not well
recognized by all women (Bump et al,
1996; Sengler et al, 2002; Bump et al,
2007)

Up to 30% of women cannot contract
adequately those muscles (Bo et al, 2007).
Hypopressive Gymnastics
The most significant factor seems to be the
reflex pelvic floor muscle contraction:

Based on that, maybe Hypopressive Gymnastic
can be used as first approach for pelvic floor disorders,
especially in people who do not accept invasive
techniques, such as vaginal or anal probes and
intravaginal or intrarectal digital therapy

REDUCE PAIN AND PROMOTE REFLEX CONTRACTION IN
PATIENTS WITH SEXUAL DYSFUNCTION
Seleme,2010,2011; Resende 2011;Costa 2011;
Stupp 2012; Latorre 2011; Berghmans 2012
The Statics and Dynamics AbdominoPelvic: Biomechanics of trashbin
The Statics and Dynamics Abdomino-Pelvic:
Biomechanics of trashbin
Use evidence-based program!!!!!

PFM training – SUI level 1, grade A ICI 2012
Program based on evidence Bø 1990,1999,
DiNubile 1991,
Mørkved 2002, 2003 , Bø 2004,Bø & Berghmans 2007
8-12 MAXIMAL contractions– inward & upward
6-8s contraction & relaxation
4 fast contractions– 8s of relaxation
3 sustained contractions 20s
respiration
contraction
relaxation
perception
Invasive Techniques

to show before the examination and first treatment an anatomical board with the
muscles and intern organs localization
Talking about perineum !!!!!
Electrotherapy


GOAL
It can be used to reduce the pain:
TENS !!!!!!
Conventional TENS– It will be responsible for the pain “gate closing”.
Frequency between 90 e 130 Hz
Chronic pain !!!!!
TENS Endorphin liberation–besides stimulating the liberation of β-endorphin,
it also causes the muscle fiber relaxation, toxins removal and local
metabolism improvement. To do so, it is used frequency always lower
than 10 Hz and impulse duration around 180 up to 250 μseg.
Acute pain !!!!!!!
Fall & Madersbacher 1994
AGNE, Jones Eduardo. Eu sei
eletroterapia.
Santa Maria: Pallotti, 2009.
Eletroterapy
Manual therapy and sexual
dysfunction
Myofacial Training Effects:
Relaxation
Enhanced flexibility
Increase of blood circulation
Pain reduction
Sensory perception
Scar tissue manipulation
Reduction of fibrotic adhensions
Reduction of hypertonicity
GRIESE, Maurenne. Preparing for Birth: Perineal Massage. 2000
CASSAR, Mario-Paul. Manual de massagem terapêutica. São Paulo: Manole,
2001.
BECK-GALLAGHER, Krista. Episiotomy – Is It Necessary? 2000.
Myofascial Techniques
Myofascial techniques
Picture illustrates techniques of palpation myofascial restrictions and trigger
points. When you reach the restricted area you can find or feel nodules,
bands or thickness. Pressure on this area will produce pain over there and
you will feel pain radiating to adjacent or distant areas which is called
radiating pain
Vercellini 2007
Musculoskeletal findings in cpps
in case of pain
> tenderness at different abdominal muscle regions
> higher pelvic floor tenderness scores
sign.< control PF (unable to maintain 10 seconds of relaxation, 78% vs 20%)
Musculoskeletal findings in cpps
frequent positive pelvic musculoskeletal findings in CPP → investigation of
somatic pain generators necessary
patients presenting with urologic symptoms often active TrPs anteriorly and
laterally within levator musculature or in obturator internus
Srinivasan 2007
patients with perirectal pain often TrPs within posterior levator complex and
piriformis muscle
Srinivasan 2007
Musculoskeletal disorders in
cpps
results
N (%) with trigger point present in that muscle
Hip girdle musculature
Gluteus Medius/Minimus
Adductor Muscles
Obturator Externus
Iliacus
Psoas Major/Minor
Abdominal wall musculature
Rectus abdominis
Internal Obliques
Transversus
External Obliques
Hip Girdle/Trunk
Gluteus Maximus
Piriformis
Quadratus lumborum
31 (69%)
33 (72%)
24 (52%)
26 (56%)
31 (67%)
31 (67%)
16 (35%)
16 (35%)
15 (33%)
21 (46%)
27 (59%)
24 (52%)
Tu et al 2008
Localisation Trp
aim:
find tender spot in tight muscle strand
provoke local twitch response
recognize pain
Howard 2003
Manual therapy and sexual
dysfunction
Biofeedback & Sexual
dysfunctions




As for other pelvic dysfunctions we may deduct
that biofeedback provides:
Larger perineal muscles perception.
Progressive increase or reduction of the
muscle activity (Hypoactivity or hyperactivity)
Neuromuscular re-education +++ use of
antagonists
Relaxation – as important as the work
Kegel AH,1948 Bridges et al,1988, Peattie et al 1988; Laycock,1988,2002;Hahn et al,1991;Whitehead
WE, Wald A, Norton NJ,2001; Haslam J,2002 Bo K,2003; Morkved,2003;
Hay-Smith et al,2006.Bo et al ,2007;Dumoulin, Hay-Smith ., 2007; Berghmans,2008.
Biofeedback through
manometry

Biofeedback through
manometry – a good
device, can be useful for
sexual physiotherapeutic
treatment (allows better
adaptation to the vaginal
canal size, muscle
stretching on the big
opening)
Dabbadie at al, 2005
Biofeedback through EMG
Biofeedback through EMG –
nowadays it can be as stable as
the pressure registration.
 It allows the use of small probes,
applying biofeedback and
electrotherapy at the same time
(ideal on dyspareunias)
 It doesn´t allow variables of
muscle stretching and can be
modified according to hormonal
impregnation and vaginal
opening size.

Dabbadie e Seleme,2005
Receive the action
Potential of the Motor
Unit Muscle fiber
depolarization contraction repolarization – rest
Binder,2002
Biofeedback
Biofeedback by wirelles
Biofeedback
Biofeedback
Complex movements, but
possible.........
Amateur photos by Bary Berghmans
Vaginal Cones
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Theory: the cone weight intend to motivate the training so that
the women contract firmly with progressive weight.
Use Period (15-20 min) adequate
It can cause  blood supplement O2 consumption, fatigue &
muscle sore
Synergist contractions instead of MAPs contractions
Refined protocol if used as BF
Arvonen et al 2001,
Plevnik 1985,
Hay-Smith et al 2001,
ICI 2005
Other painful regions ...
Piriformis Muscles
Other painful regions ...
Adductors Muscles
Conclusion
Rehabilitation Techniques
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