Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial
Ghaderi F, Bastani P, Hajebrahimi S, Jafarabadi MA, Berghmans B. Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. International Urogynecology Journal. 2019;30(11):1849-1855. doi:10.1007/s00192-019-04019-3Link to Original Article: https://pubmed.ncbi.nlm.nih.gov/31286158/
Key Points
- Dyspareunia, the symptom of painful sexual intercourse, is a common sexual dysfunction in reproductive-aged women.
- Musculoskeletal factors, particularly pelvic floor muscle dysfunction, play an important role in dyspareunia.
- Pelvic floor rehabilitation techniques, including electrotherapy, manual therapy, and pelvic floor muscle exercises, were found to significantly improve pelvic floor muscle strength, endurance, sexual function, and pain in women with dyspareunia.
- Digital biofeedback and education about pelvic floor anatomy and function were important components of the treatment approach.
- The effects of pelvic floor rehabilitation were sustained at a 3-month follow-up.
- These findings suggest that pelvic floor rehabilitation is an important part of a multidisciplinary treatment approach to dyspareunia.
Introduction
Dyspareunia is a condition characterized by persistent or recurrent pain or discomfort during vaginal penetration. The prevalence of dyspareunia varies across cultures, with rates ranging from 8% to 21% in the USA and even higher in undeveloped or developing countries. The causes of dyspareunia are multifactorial and include pelvic floor injury, pelvic inflammatory disease, infections, interstitial cystitis, adhesions, and psychosocial factors such as depression and anxiety.
Pelvic floor rehabilitation is a crucial component of the multidisciplinary treatment approach for dyspareunia. Physiotherapists use various techniques and modalities, including manual techniques, transcutaneous electrical neural stimulation, and functional electrical stimulation, to improve symptoms. Manual techniques, such as myofascial release and intravaginal massage, aim to release trigger and tender points and increase strength and awareness of the pelvic floor muscles.
Education and biofeedback are also important aspects of treatment. Instructing women about pelvic floor anatomy and self-control of muscle activity helps them relax or contract the muscles as needed. Biofeedback, particularly using digital palpation, improves patient awareness and can be more effective than instrumental biofeedback.
Research on dyspareunia has primarily focused on pain, neglecting the evaluation of pelvic floor muscle strength, activity, and tone. Previous studies have indicated that pelvic floor rehabilitation is an effective approach for treating dyspareunia, but most of these have been retrospective or observational. Therefore, this study aims to assess the effects of pelvic floor rehabilitation on dyspareunia through a randomized controlled clinical trial.
Materials and Methods
This research paper conducted a randomized controlled clinical trial to investigate the effects of pelvic floor rehabilitation on women with dyspareunia. The study included 64 women who were referred to the physiotherapy clinic with dyspareunia. The participants met specific criteria for inclusion, including experiencing pain during vaginal intercourse. Exclusion criteria included a history of other pathophysiological conditions or ongoing treatment for dyspareunia. The participants were randomly allocated into two groups, with the experimental group receiving physiotherapy treatments once a week for three months, while the control group received no treatment. Various assessments were conducted, including a functional vaginal examination, evaluation of pelvic floor muscle strength, assessment of pain severity, and administration of the Female Sexual Function Index questionnaire. Treatment sessions involved techniques to release trigger points in the pelvic floor and high-frequency transcutaneous electrical nerve stimulation. The participants also received instructions for graded pelvic floor muscle exercises and were provided with a diary checklist for exercise monitoring. Statistical analysis was performed using SPSS software, and the results were presented as mean and standard deviation, median and range, or frequency and percentage. The study found that pelvic floor rehabilitation significantly improved pelvic floor muscle strength and endurance, reduced pain severity, and improved sexual function in women with dyspareunia.
Results
The study included 64 eligible women who were randomized into an experimental group (n=32) or a control group (n=32). Initially, the two groups had similar baseline characteristics, except for the severity of pain and pelvic floor muscle (PFM) strength and endurance. After treatment, significant differences were observed between the two groups. The experimental group showed significant improvement compared to the control group in PFM strength (mean difference of 2.01 on the 0-5 Oxford scale), PFM endurance (mean difference of 6.26 seconds), and Female Sexual Functioning Index (mean difference of 51.05 on a scale of 2-95). These improvements were statistically significant (p<0.05). Moreover, the Visual Analog Scale (VAS) scores decreased considerably in the experimental group during the study, with a mean difference of 7.32 before and after treatment. This superiority of the experimental group in VAS scores continued three months after the last treatment session, with a mean difference of 7.57 compared to the control group. These findings demonstrate that the experimental treatment led to significant improvements in pain severity, PFM strength and endurance, sexual functioning, and VAS scores.
Discussion
This research study aimed to explore the effectiveness of a pelvic floor rehabilitation program in improving symptoms of dyspareunia in women. The program consisted of various techniques including digital biofeedback, intravaginal manual techniques, supervised pelvic floor muscle exercises (PFMEs), and electrotherapy. The study found that the program led to significant improvements in genito-pelvic pain, sexual function, pelvic floor muscle (PFM) strength, and endurance.
Previous studies on biofeedback and soft-tissue mobilization in treating dyspareunia were limited and had varying results. However, recent clinical trials and guidelines have supported the use of PFMEs and myofascial release for dyspareunia treatment. The use of digital biofeedback, which enhances patient awareness of PFMs, was found to be effective in relaxing PFMs and reducing pain during intercourse.
The study focused on patients with musculoskeletally and myofascially based dyspareunia and excluded other causal factors. The program also incorporated a supervised PFME regime and a combination of clinic and at-home exercises. Maximal contractions were used to reduce pelvic floor tone. After 12 weeks of treatment, there was a significant improvement in PFM strength and endurance. Transcutaneous electrical nerve stimulation (TENS) was also found to be beneficial in reducing genito-pelvic pain.
The study assessed sexual function using the Female Sexual Function Index questionnaire and found significant improvements in desire, arousal, lubrication, orgasm, satisfaction, and pain-free intercourse. Furthermore, transvaginal techniques such as myofascial release and massage were effective in improving circulation and reducing trigger points in PFMs.
The findings suggest that a multifaceted intervention, including manual techniques, PFMEs, and education, is effective in managing dyspareunia symptoms. Physical therapists play a crucial role in diagnosing and treating dyspareunia, and a multidisciplinary approach is necessary. However, the study's limitations include the absence of objective outcomes for PFM strength and endurance.
Conclusion
In conclusion, this study supports the use of a pelvic floor rehabilitation program, including digital biofeedback, manual techniques, PFMEs, and electrotherapy, in improving symptoms of dyspareunia. It emphasizes the importance of a comprehensive approach involving physical therapists and the need for further research on objective outcomes.
Opportunities for Future Research
1. Investigate the long-term effects of pelvic floor rehabilitation on dyspareunia by conducting a follow-up study beyond the 3-month time frame used in this study.
2. Explore the potential benefits of combining pelvic floor rehabilitation techniques with other treatment modalities, such as cognitive behavioral therapy or medication, to enhance the overall effectiveness of dyspareunia treatment.
3. Examine the impact of different types and frequencies of pelvic floor exercises on dyspareunia symptoms to identify the most optimal exercise regimen for improving sexual function and reducing pain.
4. Evaluate the efficacy of pelvic floor rehabilitation techniques in different populations, including women with different cultural backgrounds, ages, and comorbidities, to determine if the interventions are universally effective or need to be tailored to specific groups.
5. Investigate the underlying mechanisms of how pelvic floor rehabilitation techniques, such as manual therapy and electrotherapy, alleviate dyspareunia symptoms to gain a better understanding of the physiological changes that occur.
6. Conduct a cost-effectiveness analysis of pelvic floor rehabilitation in the treatment of dyspareunia, taking into account factors such as healthcare utilization, medication use, and quality of life outcomes.
