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

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

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

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

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

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

7. Sample characteristics – chart review AGE:M=38, R= 24 - 58 68% ~never had vaginal penetration (remainder: partial/no thrusting) 58% ~never used tampon 33% ~never had gyne exam with speculum; of those who did, 71% only with pediatric speculum. Diagnoses Physical Therapist VaginismusVaginismus + PVD 77%19% Referring Physician VaginismusVaginismus + PVDVaginismus + GVDPVD 49%12%2%7%

8. Assessment information Pelvic floor assessment:  Notable anxiety (as observed by PT): 62% M-tone -3 to +3 M-contract 0-5 M-relax 0-4 Pain – rest 0-10 Pain – ins. 0-10 Pain- move 0-10 Pain- after 0-10 Mean2.72.11.9.3662 Range1-32-4 0-31-100-100-6 Mode3220780

9. Assessment information Pelvic floor assessment:  significant hypertonicity, poor voluntary control, poor ability to relax muscles post-contraction. M-tone -3 to +3 M-contract 0-5 M-relax 0-4 Pain – rest 0-10 Pain – ins. 0-10 Pain- move 0-10 Pain- after 0-10 Mean2.72.11.9.3662 Range1-32-4 0-31-100-100-6 Mode3220780

10. Assessment information Pelvic floor assessment:  High degree of self-reported pain with insertion; relatively low pain post-insertion. M-tone -3 to +3 M-contract 0-5 M-relax 0-4 Pain – rest 0-10 Pain – ins. 0-10 Pain- move 0-10 Pain- after 0-10 Mean2.72.11.9.3662 Range1-32-4 0-31-100-100-6 Mode3220780

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

12. Therapy Process - Outcome MILESTONESAVERAGE SESSION Small dilator6 Small dilator6 Medium dilator8 Medium dilator8 Tampons10 Tampons10 Large dilator13 Large dilator13 Dildo (option)20 Dildo (option)20 Speculum22 Speculum22 Gyne exam22 Gyne exam22 Intercourse18 Intercourse18

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

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

15. Therapy gains GAINACHIEVED (Y/N) Intercourse100% Enjoy sex100% ↓ Anxiety 86% Gynecological exam100% Use tampons100% ↑ Understanding100% Hope92%

16. Therapy gains (FSFI – healthy controls * ) Cronbach’s alpha:.88; *Rosen et al., 2000 FSFI Scales Post-treatmentVaginismus Healthy controls* P-value Desire5.36.9.013 Arousal15.416.8ns Lubrication1618.6.03 Orgasm11.812.7ns Satisfaction10.812.8.009 Pain10.813.9.03 Full Scale 25.930.5.005

17. Therapy gains (FSFI – patient controls * ) Cronbach’s alpha:.88; *Rosen et al., 2000 FSFI Scales Post-treatmentVaginismusFSAD*P-value Desire5.34.7ns Arousal15.49.7.000 Lubrication1610.9.001 Orgasm11.87.1.001 Satisfaction10.88.2.002 Pain10.810.6ns Full Scale 25.919.2.000

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

19. Summary – PT 1  Women with lifelong vaginismus present with significant pelvic floor pathology, pain, and anxiety.  Progress in PT is variable with some women needing many more sessions - but most women needing 30 sessions or less (more sessions/longer treatment time compared to vulvodynia). (more sessions/longer treatment time compared to vulvodynia).  PT interventions are similar to interventions used in the treatment of vulvodynia. (Less focus on pain desensitization, more focus on conscious awareness on relaxing/dropping the pelvic floor).

20. Summary – PT 2  Women reach therapy goals of intercourse, pleasure with sexual activity, reproductive hygiene and health care, and overall understanding and hope.  Patient satisfaction with PT intervention and outcome is very high.

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

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