IPPS Blog

May Is Pelvic Pain Awareness Month!

April 27, 2018

May Is Pelvic Pain Awareness Month!

While there are many causes to be aware of and advocate for, one close to our hearts at the International Pain Society is abdomino-pelvic pain, and we are excited to report that May is Pelvic Pain Awareness Month! This designation for May was created by the International Pelvic Pain Society last year. So let’s talk a few moments about what is pelvic pain, how impactful the diagnosis can be, and what we can do!

By: Kaitlyn Parrotte, PT, DPT, OCS, CFMT
Edited by: Amy Stein, DPT, BCB-PMD

According to the American College of Obstetricians and Gynecologists, chronic pelvic pain is described as a “noncyclical pain of at least 6 months’ duration that appears in locations such as the pelvis, anterior abdominal wall, lower back, or buttocks, and that is serious enough to cause disability or lead to medical care.”1 While the incidence and prevalence of chronic pelvic pain in men and women are reported in an inconsistent manner,2 some estimates compare its global prevalence to asthma (4.3%-8.6%), and one to the prevalence of low back pain (23.2 +/- 2.9%).3 Individuals who suffer from chronic pelvic ad abdominal pain also often present with other complicating factors such as depression, anxiety, poor sleep, difficulty with work, and/or relationship issues. Also, many people with chronic pain are commonly disabled by fear that activity will make things worse.2 Furthermore, pelvic pain is puzzling as it is a multisystem disorder, which includes sexual, bowel, urinary, gynecological, and musculoskeletal symptoms. It is challenging to determine a clear mechanism of pain with this diagnosis, and the term “pelvic pain” does not take into account the many signs and symptoms that may be occurring outside of the anatomical pelvis.2  

Due to the complicated nature of this condition, there is a significant economic burden associated with management of it. In the United States, approximately $881.5 million was spent on chronic pelvic pain to cover the costs of direct healthcare. Additionally, approximately $2 billion was spent as an overall cost, which includes direct medical costs and indirect costs, such as those related to absenteeism from work.3 Besides economic burdens on individuals suffering from chronic abdominal and pelvic pain, there are also many challenges for the healthcare system to deal with. For instance, while a diagnosis of chronic pain in the United States typically yields more than 80% of physician referrals, it is estimated that only about 15% of individuals with chronic pelvic pain consult primary care providers, and only 40% of this group are referred to specialists for further investigation.3 Furthermore, if specialist care is involved in the management of chronic pelvic pain, it is often spread between multiple specialties, such as urology, gynecology, urogynecology, colorectal services, pain medicine, and even occasionally spinal services, rheumatology, and neurology. Thus, there is a risk that patients may be passed back and forth between different teams of the same speciality, or between different specialties, and may not receive consistent or effective care.2  In a nutshell: chronic abdomino-pelvic pain can be a debilitating condition that can have significant consequences on an individual’s physical, mental, economic, and social well-being.

Hopefully, if you were not already passionate about raising awareness of pelvic pain, you now have some insight as to why this cause is so important! Now the question lies, what can you do? How can you get involved?

One thing that you can take action is by hosting a local event to raise awareness and/or funds for research and educational programs that will promote more effective diagnosis and treatment for those suffering from abdomino-pelvic pain; these funds can be directly donated to IPPS! While hosting an event may seem overwhelming, it is actually easier than you think! Here is a guide to help you plan one:

How to plan and host a Pelvic Pain Awareness Event

Step One: decide what type of event and where

Some ideas are to host a bar night, a get together at a coffee shop with a musician, a lecture in the form of grand rounds or a community education event in the name of pelvic pain awareness.

*bar night: easiest option: no planning other than location, an agreement from the bar to donate a portion of the proceeds, and getting people to come.

*more involved: plan a speaker night for pelvic pain awareness--could be yourself and/or other speakers. Location could be your office, coffee shop, hospital, or restaurant/bar.

Examples of previous events:

1. Coffee shop example: Milwaukee’s 2017 event was held at a coffee shop.   Healthcare providers were invited. When response was low, the event was opened up to patients, friends and family. There was a flyer posted in the clinic. Attendees ordered from the menu and the coffee shop donated 20% of what was ordered. Several patients wrote checks to IPPS who could not attend.

2. Speaker event example: “Girls Night Out” style event in Los Angeles: This event was held in a Speakeasy. Cocktails and hors d’ouvers were served. Entry fee was required, but the fee was offset quite a bit by corporate sponsors. There were approximately 50 people (due to room size) and we sold out.  There were 4 speakers- 2 urogyns, 1 PT, and 1 sex therapist.  It was designed as a community event, but other providers did purchase tickets to attend, too.

3. Bar night example: “Asked a friend to use part of his bar for non-profit event.”  The bar gave reduced food prices and first drink free.  2 PT’s and 1 MD collected an entrance fee for food and drink tickets on the event planning website Eventbrite and at the door. All proceeds went to IPPS.

The to do list:

  1. Choose a date in May.
  2. Speak with venue. Many bars are willing to donate up to 20% of proceeds to a charity for 1-2 hours: it brings people into the bar/restaurant, it shows support for the community and they write it off as a donation: (Provide them with www.pelvicpain.org and let them know we are a non-profit 501c3).
  3. Arrange speakers if planned.
  4. Make flyer with template provided (See attached).
  5. Entrance fee: Suggested donation (i.e., $25 food/drink value, charge $45) vs. donation from venue proceeds.
  6. Raffle option: Reach out to local and pelvic pain vendors for prizes (i.e., hot packs, massages, free spin class, restaurant gift certificate, etc.). Can have raffle tickets sold at the bar. (e.g. $6=1 ticket, $1=2 tickets, $20=5 tickets)
  7. If you have industry connections, you could ask for support for the event as well.

Getting the word out:

· Display the flyer in your clinic (see attached template)

·        Contact Heather: heather@fusionwellnesspt.com  to get posted on IPPS Twitter, website, and Facebook accounts.

· Post on your social media. Let them know this is happening across the country.

· Do a press release with a local paper.

Getting funds to IPPS:

Send checks to IPPS Business office.

Questions:  Contact Debbie Callif: debbie@callif.org   262-240-1202 or Amy Stein: amy@beyondbasicspt.com  212-354-2622

If hosting an event is not a possibility, you can still contribute in many ways:

  1. Meet with practitioners in your area to educate them on chronic pelvic pain and build a referral network for patients.
  2. Host a community outreach program at your clinic, at a local gym, at a workout studio, or at a community center, to help make the general public more aware of what pelvic pain is, and what can be done about it. This way, you are better equipping patients to be able to advocate for themselves!
  3. Donate funds for research and educational programs at the International Pelvic Pain Society website (https://wjweis.association-service.org/securesite/ipps/donations.aspx).

There are many ways to contribute! So circle the month of May in your calendars and consider how you can participate. Together, we can help bring chronic pelvic pain into the forefront of healthcare, to ensure individuals dealing with this condition are receiving consistent and effective care.

Sources:

  1. Andrews J, Yunker A, Reynolds WS, Likis FE, et al. Noncyclic chronic pelvic pain therapies for women: comparative effectiveness. AHRQ Comparative Effectiveness Reviews, Rockville (MD), 2012.
  2. Baranowski AP, Lee J, Price C, Hughes J. Pelvic pain: a pathway for care developed for both men and women by the British Pain Society. Br J Anaesth. 2014;112(3):452–9.  
  3. Ahangari A. Prevalence of chronic pelvic pain among women: an updated review. Pain Physician. 2014;17(2):E141–7.

The Twisted Trunk: Implications for Abdominal and Pelvic Pain

March 26, 2018

The Twisted Trunk: Implications for Abdominal and Pelvic Pain

While attending the 3rd World Congress of Abdominal and Pelvic Pain Conference last October in Washington, DC, I had the pleasure of listening to the lecture of Dr. Diane Lee, BSR, FCAMPT, CGIMS. Dr. Lee discussed the impact that altered pelvic biomechanics and non-optimal function in the abdominal wall and pelvic floor have on pelvic pain. Dr. Lee is a practicing Physiotherapist and Women’s Health clinical specialist in Canada. As an author, instructor, fellow and the owner and director of her own therapy clinic, Dr. Lee has made a significant contribution to this field. Her lecture, The Twisted Trunk: Implications for Abdominal and Pelvic Impairment and Pain is summarized below.

By Sigourney Cross
Pelvic Health and Rehabilitation Center, Berkeley, CA
www.pelvicpainrehab.com

The Integrated Systems Model

Dr. Lee poses the question, “Would you race a car that had its wheels out of alignment around a racetrack?” Most people would answer no. Many people who are seeking relief from their pelvic floor symptoms have comorbidities or other conditions that can be contributing factors. When clinicians are deciding whether to start treatment at the pelvic floor or to look elsewhere first and see how the pelvic floor responds, Dr. Lee suggests using the Integrated Systems Model (ISM). Learn more about the ISM approach on Dr. Lee’s website here. The ISM is an “evidence informed clinical reasoning framework to optimize strategies for function and performance.”4 This approach helps clinicians in their clinical decision making in the assessment and treatment of patients. It helps identify which patients need specific training of the muscles of the trunk and pelvic floor and those who do not by assessing motor control.

The ISM and Motor Control

Motor control is the process of how humans and animals use their brain to activate and coordinate muscles to perform a task or skill. The motor control response to pain varies from person to person because the following three dimensions influence it.

  1. Sensorial Dimension-Location and behavior of primary complaint
  2. Cognitive Dimension-Beliefs and attitudes about their experiences
  3. Emotional Dimension-Feelings associated with experiences

Because motor control varies based on an individual’s thoughts, beliefs, and experiences surrounding that task, this makes it challenging for clinicians to assess. There is not one universal strategy of muscle activation for control. Each strategy is unique to not only the individual but also to the task itself. Some people may brace and stiffen during pain while others can loosen and destabilize. The goal of rehabilitation or using motor learning strategies is to remove, modify or enhance an individual’s adaptation based on the unique solution adopted from the patient.3 Physical Therapists must take a thorough history to understand which of the above dimensions is creating the largest barrier to changing their motor control strategy. We can then implement this change through patient education, building trust, movement, and touch to change the sensory input in order to change the motor output.

Before focusing on the pelvic floor in isolation, it’s important look at the patient’s overall alignment and motor control. Some patients may only need motor control training strategies to re organize their muscle recruitment dys-synergies. These dys-synergies can come from the pelvic floor reacting to varying processes in the body including the following:

  1. Excessive intra-abdominal pressure–This can be caused by varying factors whether it be an abdominal trauma, an acute syndrome such a pancreatitis or different exercises.
  2. Poor foot control creating an ascending force up the lower extremities-This causes internal rotation of the leg, which put forces on the obturators’, which are connected to the pelvic floor.
  3. A descending force from the thorax-This can cause a rotation within the thorax.
  4. Pulls from the coccyx on the dura-This can come from an old spinal concussion or disc protrusion.
  5. Twists in the trunk
What is a twist in the trunk?

A twist in the trunk occurs when there is an incongruent rotation between the thorax and the pelvis or to put it simply, when the pelvis and thorax are going in opposite directions. This is a significant finding because all of the multi segmental muscles of the trunk are important in motor control and movement.2

There is a significant correlation between the presence of pelvic floor diagnoses and movement diagnoses of the spine and hip. In a study by Wente & Spitznagle, 2017, they found that out of 225 patients with urinary urgency and frequency almost 50% of them had hip or spine impairments and 18% had either thoracic or pelvic girdle impairments.

Consider a very common case. A 31-year-old mother, five months postpartum, feels persistent pelvic girdle pain that increases with large steps. Using the ISM approach, you would start by picking a meaningful task. This could be a task that causes pain, a movement the patient finds difficult, or a task the patient avoids altogether. Once the task is picked you then analyze the task and identify areas of the body with suboptimal alignment and poor biomechanics. The goal with this type of analysis is to find the driver or the patient’s sub optimal movement strategy. The driver is what is going to be the most impactful impairment you can change. While analyzing this new mom’s posture (Learn more about posture here), thorax rotation, single leg stance and active bent SLR a common suboptimal strategy was found. As shown in the picture above, this is an over-activation of the iliocostalis (one of the deep muscles of the back that connects from your ribs to your hip) and an under activation of the deep abdominals.5 This imbalance of your muscles pulling your ribs one direction and your pelvis the other causes twists in the trunk. Physical therapists can correct misalignments with varying techniques including manual therapy techniques and therapeutic exercise. Correcting this patients alignment and getting the “twists” out of her trunk, allowed her to restore control at her thorax and use a more optimal movement pattern. It changed her motor control strategy, therefore allowing her to perform her meaningful tasks without pelvic girdle pain.

What do we do with this information?

This lecture has been very meaningful to my clinical practice in the sense that it helps explain why some patients may still feel lingering pelvic floor symptoms when there is no longer impairment at the tissue level. I think it is important to understand that examining the pelvic floor in isolation may not reveal all the contributing factors causing patients symptoms. Although there are many individuals who require specific isolated pelvic floor muscle training, It’s important to be cognizant of identifying the individuals who do not, and who would benefit more from treating misalignment of the trunk and creating more optimal biomechanics, motor control and recruitment strategies. If you are struggling with pelvic floor symptoms the physical therapists at the Pelvic Health and Rehabilitation Center can help!

We thank Dr. Diane Lee for a fantastic lecture. To view the presentation in its entirety please start on page 185 here.

~~~

References:

1Hodges & Smeets. Contemporary theory of motor adaptation in pain. Clin J pain. 2015
2Hodges, P W. Pain and motor control: From the laboratory to rehabilitation. Journal of Electromyography and Kinesiology: Official Journal of the International Society of Electrophysiological Kinesiology. 2011;21(2): 220–228
3Hodges, Van Dillen, McGill, Brumagne, Hides, Moseley. Consensus from the Evidence. Pain and motor control. Journal of electromyography and Kinesiology. 2013; 21.
4Lee D, Lee LJ. The Pelvic Girdle. An integration of Clinical Expertise and Research. 2007-2013.
5Macintosh JE, Bogduk N. The attachments of the lumbar erector spinae. Spine Phila Pa. 1991;(7):783-92.
6Wente KR, Spitznagle TM. Movement-Related Urinary Urgency: A Theoretical Framework and Retrospective, Cross-sectional Study. Journal of Women’s Health Physical Therapy: May 2017; 41(2) 83–90.

Posted by IPPS Admin on March 26, 2018, 12:00AM

A Biopsychosocial Approach to Vulvodynia

March 19, 2018

A Biopsychosocial Approach to Vulvodynia

Throughout my years of practice I’ve treated many women with vulvodynia. I’ve noticed that it’s rare for women to return to 100% solely with physical therapy treatment; even though their musculoskeletal impairments may have returned to normal, some women continue to feel pain. In my experience, it takes a team of practitioners to treat vulvodynia, such as a physician who specializes in vulvar pain, a pelvic floor physical therapist, and a psychologist.

By Malinda Marshall
Pelvic Health and Rehabilitation Center, Los Gatos, CA
www.pelvicpainrehab.com

When I first looked through the schedule of the 3rd World Congress on Abdominal and Pelvic Pain for October 2017, I was excited to see that there was a session on vulvar pain and a talk scheduled for Caroline F. Pukall, Ph.D, entitled “Vulvodynia: A Biopsychosocial Approach.” Dr. Pukall is a professor of Psychology and the director of Sex Therapy Service at Queen’s University in Kingston, Ontario, Canada. In 2015, Stephanie wrote a blog post on the International Consensus Conference on Vulvodynia Nomenclature. Dr. Pukall was one of the 28 participants in this consensus meeting. She is well versed in the terminology of vulvodynia. Her presentation turned out to be every bit as interesting as I hoped it would be: she discussed the terminology of vulvodynia, the biopsychosocial indicators for vulvodynia, and the various levels of pathophysiology of vulvodynia. She also came to the conclusion that treatment for vulvodynia needed to include doctors, physical therapists, and psychologists.

Vulvodynia is diagnosed as pain in the vulva for more than three months without an identifiable cause. However, there is a difference between vulvodynia and persistent vulvar pain: Dr. Pukall states persistent vulvar pain has an identifiable cause, such as an infection, inflammation, neoplasm (tissue grow such as a tumor), neurological, traumatic, iatrogenic (caused by a medical procedure), and/or hormonal cause. Vulvodynia is diagnosed by exclusion of these causes.

Within vulvodynia, there are many subgroups of the pain. It can be localized to one area, generalized throughout the vulva, or a mixture of the two. It can be provoked, such as with sexual intercourse, spontaneous, or both. The pain can be constantly there or intermittent. The onset of pain may be primary, meaning the pain was always there to begin with, or it can be secondary, meaning it developed later on. Dr. Pukall pointed out an important fact in her talk, which is that a patient can have vulvar pain from a specific disorder, such as lichen sclerosus, at the same time as having vulvodynia. This is important for us to keep in mind when treating vulvar pain.

As Dr. Pukall pointed out, its complex and patient-specific causes and features mean that treating vulvodynia is not simple and clear cut. It’s important to address all contributing factors; the biological, psychological, and social elements. The biological components of vulvodynia include hormonal changes, inflammation, genetics, comorbidities (such as diabetes, obesity, high blood pressure, etc. ), and musculoskeletal, neurological, structural symptoms — all the physical things that are happening in the pelvic area, that one might expect to provide clues as to how to treat the condition. Just as important, though, are the psychological contributing factors to vulvar pain. These include mood, behavior, and self-perception. Dr. Pukall discussed how anxiety and avoidance are associated with decreased sexual function, and how hypervigilance, catastrophizing, and fear of pain can all cause increased pain. According to Dr. Pukall, women with lower “self-efficacy” (one’s belief in one’s ability to succeed) tend to have increased pain and poorer sexual function.

The last part of Dr. Pukall’s “biopsychosocial approach” refers to social factors that contribute towards vulvodynia — that is, things going on with the people around you that can feed into your pain. These social factors include problematic arousal, low desire, attachment, intimacy, communication, emotional expression, goals, abuse, and partner responses. A partner who suggests stopping all sexual activity may actually be causing more harm than good. This response can cause increased pain and lower couple sexual wellbeing. Having a partner who encourages adaptive coping and expresses positive feeling about engaging in any sexual activity, not penetrative sex, tends to bring benefits for both members of the couple. Pain seems to be modulated by the partner’s response to pain.

The take-home message for the practitioners in the audience was that the pathophysiology of vulvodynia includes pain, musculoskeletal, psychological, social, and interpersonal factors, and that the treatment for vulvodynia should include a medical doctor, a physical therapist, and a psychologist. I came out of the lecture hall determined to pass on Dr. Pukall’s message. In fact, looking at Dr Pukall’s list, I can’t help thinking that a biopsychosocial approach to vulvodynia could probably do us all a power of good!

We thank Dr. Caroline Pukall for a fantastic lecture. You can view her powerpoint lecture here. Please scroll down to page 155. You can also follow Dr. Pukall on Twitter at @QSexLab.

Posted by IPPS Admin on March 19, 2018, 12:00AM

Mechanistic Interplay among Peripheral, Spinal and Brain Adaptions to Chronic Visceral Pain

March 12, 2018

Mechanistic Interplay among Peripheral, Spinal and Brain Adaptions to Chronic Visceral Pain

For those of you following our journey through the 3rd World Congress on Abdominal and Pelvic Pain (#WCAPP17), here is another light-bulb lecture explaining the interconnections of chronic visceral pain. The presenter, Melissa A. Farmer, PhD, is a researcher at the Feinberg School of Medicine at Northwestern University with a long-standing relationship with the International Pelvic Pain Society (the organizer for #WCAPP17). So, needless to say, she has an impressive resume and a passion for understanding pelvic pain. Just check out her wrap sheet. I’ve chosen a few interesting nuggets from her lecture.

By Britt Van Hees
Pelvic Health and Rehabilitation Center, Berkeley, CA
www.pelvicpainrehab.com

Three Camps

Pain, pain, pain. There are three camps of pain chronification:

Cortical reorganization: occurring in the brain

Spinal central sensitization: occurring at the spinal cord

Nociceptive sensitization: occurring at the sensory nerve level

Each of these camps have their own combination of modifiers that can lead to sensitization.

Pause- so this is where one can get overloaded with information, so I took some creative liberties and decided to draw a picture.

As you see from the drawing, there are several areas where our brain and our body can modify signals related to pain. At the “nociceptor sensitization camp” the sensory nerves can become extra excited, and maybe throw too much input into the nervous system. For example, do you remember the last sunburn you had? Remember how sensitive your skin was- even the slightest touch was immensely painful. Well, now imagine that you don’t have a sunburn but your nerves are sending that same intense signal, as if your tissue was still burned. This nervous system mix up is called allodynia, when normally non-painful stimulus is extremely painful.

At the “stream of spinal central sensitization” the spinal cord can send information upstream, to the brain, or downstream, to the peripheral nerve, to modify signals related to pain. For example, #1 on the list, prolonged dorsal horn firing, is similar to an echo. This is when your hand-nerve yells “watch out” to your spinal cord, and your spinal cord yells to your brain “watch out….watch out….watch out….watch out….watch out… watch out…watch out….” well you get the idea. A single signal potentiates into multiple.

Finally we have the “lake of cortical reorganization”, or in layman’s terms, brain change. Here you can have tidepools of emotional distress or reefs of prior history or insert another water-based metaphor here. Essentially, upcoming signals are then interpreted within the framework of the brain where it decides if it’s enough to produce a pain response. How this all works is a bit murky, pardon the pun, but we do know that our interpretation of nociceptive signals greatly impacts how the brain choose to deal with them.

Somatic vs. Visceral: Crosstalk

Dr. Farmer also touched on the differences between somatic and visceral pain and the crosstalk that can occur between the two.

When comparing sensations from somatic (aka your body) and visceral structures (aka your organs), there are several differences. Somatic pain has a distinct quality, like a sharp or pinching sensation. It correlates specifically to the intensity, duration and location of the stimulus and is caused by tissue injury and inflammation. One easy example of somatic pain is the ankle pain one might experience following a sprain. Conversely, visceral pain is diffuse in quality and generally is found along the midline of the body. It doesn’t have the same on/off switch and tends to correlate very poorly with its stimulus. Just think how you felt the last time you had food poisoning…yah not fun.

Okay, that seems reasonable, now we have some ways to separate out different types of pain. However, sometimes messages can get muddled when somatic and visceral structures start to talk to one another – called crosstalk. This can happen when sensory fibers of pelvic organs synapse close by where other somatic or visceral structures synapse at the spinal cord. You can see how it can get confusing when a problem in one organ might feel like a problem in a completely separate organ or body part.

One case of this is viscero-somatic pain, when a visceral structure creates body pain. A well-known example of viscero-somatic pain is when during a heart attack someone might report significant left arm pain. In the pelvis however, this would look like a patient complaining of low back pain when the stimulus is actually coming from uterine contractions.

This crosstalk can also go the opposite direction, somato-visceral pain. This could happen with vulvar inflammation. A patient may have multiple yeast infections leading to inflammation of the vulva (somato-), but then also experience bladder pain (visceral). And it doesn’t stop there.

Viscero-visceral pain, yup that happens. Stimulus from one organ can be confused with stimulus from another organ. This can even lead to changes in how the organs function. This type of viscero-visceral pain is one explanation for the high prevalence of irritable bowel syndrome in women with endometriosis.

What does this mean for patients?

So now what? All of this can be quite overwhelming. It’s important for both patient and practitioners to educate themselves regarding the different facets of pain. Great resources including Dr. Farmer’s research and books like Explain Pain or Pelvic Pain Explained can be very helpful in help navigating these uncertain waters. Since knowledge is power, the more we understand the cause, the better we can treat pain together.

Thank you again for the enlightening presentation Dr. Farmer! If you want to check out the whole presentation, which we recommend, look here.

 
Posted by Jennifer Ford on March 12, 2018, 12:00AM

Autonomic Dysregulation in Functional Gastrointestinal Disorders

March 5, 2018

Autonomic Dysregulation in Functional Gastrointestinal Disorders

At the 3rd World Congress on Abdominal and Pelvic Pain organized by the International Pelvic Pain Society, Professor Qasim Aziz spoke about Autonomic Dysregulation in Functional Gastrointestinal Disorders. Qasim Aziz, MBBS, FRCP, PhD is Professor of Neurogastroenterology at Barts and The London School of Medicine and Dentistry at Queen Mary, University of London. Professor Aziz taught us how the autonomic nervous system plays a role in chronic pain conditions and functional gastrointestinal disorders. This understanding has led to the use of new treatments that modulate the autonomic nervous system.

By Melinda Fontaine
Pelvic Health and Rehabilitation Center, Berkeley, CA
www.pelvicpainrehab.com

The autonomic nervous system is made up of the brain, the parasympathetic and sympathetic nervous systems, and the enteric (gut) nervous system. The autonomic nervous system works without us having to think about it, and helps with things like keeping our heart beating and digesting our food. The parasympathetic nervous system is affectionately called the “rest and digest” system because it is active when we are relaxed and helps with digestion. When you add stress to the equation, big changes occur. Stress can be in any form: deadlines, anxiety, drama, attack on your health, lack of sleep, not enough self care, etc. When stress is applied to the system, the peripheral nervous system releases neurotransmitters which dock on the immune cells and increase the inflammatory immune response through the vagus nerve.

Now if all that sounded like scientific mumbo-jumbo, the important piece to remember is “through the vagus nerve”. The vagus nerve is part of the parasympathetic “rest and digest” nervous system and innervates the heart, lungs, and digestive system.

A number of studies have been done on the role of the peripheral nervous system and vagus nerve. Decreased peripheral nervous system/vagus nerve activity has been found in patients with irritable bowel syndrome,1 functional dyspepsia,2 and delayed gastric emptying after meals.3 Could we increase the vagus nerve activity to eliminate these and other symptoms? Possibly! There are three treatments being explored to stimulate the vagus nerve and decrease pain and inflammation.

  1. Cognitive Behavioral Therapy increased vagus nerve/parasympathetic activity in patients with irritable bowel syndrome over the course of 24 weeks.4
  2. Deep Breathing increased vagus nerve/parasympathetic activity and decreased pain in the esophagus in response to acid.4
  3. Vagus Nerve Stimulation improved movement of food through the digestive system,5 reduced abdominal pain,6 and decreased inflammation.7

Cognitive Behavioral Therapy is a common method of psychotherapy and Deep Breathing has been around for ages, but Vagus Nerve Stimulation is new, and I would like to explain it a little here. For more information about how this idea relates to chronic pelvic pain, see Liz’s post about Dr. Chelimsky’s presentation.

Applying electrical current to the vagus nerve through an implantable or external device amplifies the signals sent through the nerve. The devices work by attaching electrodes to the vagus nerve either at the ear or the neck. Not all these devices are available in the United States, and they currently require a doctor’s prescription. These devices have also been studied for use on headaches, seizures, depression, fibromyalgia and chronic pelvic pain.8 These treatment are relatively new and are still being studied, but the research is promising.

Of course this information made me very excited about this new vagus nerve treatment idea.  I want to run right out and get my hands on a stimulator. After some research, I learned that the FDA released the first non-invasive vagus stimulator in 2017, gammaCore. This device applies stimulation at the neck for the acute treatment of pain associated with episodic cluster headache in adult patients. It is available by physician prescription only, and the list price of gammaCore therapy is $575.00 per month.

Thus, for now I will have to use the treatment strategies most available to me. I like to remind patients that pelvic pain is rarely ever caused by one thing, so a multimodal approach that includes physical therapy is necessary. This research shows us how the parasympathetic nervous system needs to be considered in our treatment approach. I teach patients to breathe deeply during our sessions and encourage them to practice on their own. I use Nicole’s blog about diaphragmatic breathing to teach the technique. Sometimes I encourage patients to seek out psychotherapy, such as cognitive behavioral therapy, as a piece of their treatment. One day, I may also be able to recommend vagal nerve stimulation as part of a complete treatment approach.

We thank Professor Qasim Aziz for a fantastic lecture. Please click here to view his entire lecture.

~~~

References:

1Liu Q, et al. Autonomic functioning in irritable bowel syndrome measured by heart rate variability: A meta-analysis. Journal of Digestive Diseases 2013; 14: 638-646
2Dal K, et al. Decreased parasympathetic activity in patients with functional dyspepsia. European Journal of Gastroenterology & Hepatology 2014, 26:748-752
3Guo WJ, et al. Impaired vagal activity to meal in patients with functional dyspepsia and delayed gastric emptying. J Int Med Res 300060517726442. 2017
4Botha C, Farmer A, et al. Preliminary report: modulation of parasympathetic nervous system tone influences oesophageal pain hypersensitivity. GUT 2015, 64:611-7
5Frokjaer JB, et al. Modulation of vagal tone enhances gastroduodenal motility and reduces somatic pain sensitivity. Neurogastroenterol Motil 2016; 28, 592-598
6Kovacic et al. Neurostimulation for abdominal pain-related functional gastrointestinal disorders in adolescents: a randomised, double-blind, sham-controlled trial. Lancet Gastroenterol Hepatol 2017; 2: 727-737
7Beckers AB, et al. Gastrointestinal disorders in joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type: a review for the gastroenterologist. Neurogastroenterol Motil 2017; 29: doi: 10.1111/nmo.13013. Epub 2017 Jan 13
8Chakravarthy, et al. Review of vagal nerve stimulation in use of chronic pain management. Current Pain and Headache Reports Journal 2015; 19:54

 
Posted by Jennifer Ford on March 5, 2018, 12:00AM


When Sex Hurts: A Diagnostic Algorithm

February 26, 2018

When Sex Hurts: A Diagnostic Algorithm

Most people know that I am a fan of sexy science. So when I saw that the World Congress on Pelvic Pain (WCAPP) had an entire section dedicated to sexual dysfunction I was pretty stoked. You may already be imagining some very arousing presentations; or you may think listening to a talk on intercourse would induce the same amount of blushing as watching Fifty Shades of Grey with your parents. Instead, the audience is treated to the latest evidence-based medicine related to pelvic pain and sex. Although, since most research, including studies on sexual health, involves the use of rodents, many of the presentations consisted of some pretty steamy rat pornography.

By Rachel Gelman
Pelvic Health and Rehabilitation Center, San Francisco
www.pelvicpainrehab.com

In addition to some randy rats, we had the pleasure of hearing Dr. Andrew Goldstein’s presentation “When Sex Hurts: A Diagnostic Algorithm.” You may remember Dr. Goldstein from a prior post that discussed the relationship between oral contraceptive pills and vulvodynia.

At #WCAPP17, Dr. Goldstein discussed the vicious cycle of pain with sex. In the image below taken from his presentation one can see how dyspareunia (pain with sex) can lead to anxiety surrounding these symptoms, which can lead to pelvic floor dysfunction that can contribute to further sexual dysfunction and relationship dysfunction which can therefore cause more pain with sex. Due to this common cycle developing, Goldstein recommends some form of therapy for any patient that presents with dyspareunia.

While Dr. Goldstein believes most patients benefit from counseling, he acknowledges that treatment for patients with painful sex should not be one size fits all. He emphasized that determining the driver behind the symptoms helps create an individualized treatment plan. His presentation focused on vulvodynia and vestibulodynia as these two conditions are often the cause of painful sex. Often vestibulodynia is a result of multiple factors and his presentation focused on the following three: hormonal, neuroproliferative and musculoskeletal.

Hormonal

As you may recall from prior posts, the vestibule is rich in androgen and estrogen receptors. Testosterone is actually responsible for producing mucin, a component of lubricant. So if a patient presents with pain with initial penetration during sex, or pain in the vaginal opening with any form of penetration as well as vaginal dryness, it would be important to check if there is a hormonal imbalance. Other than doing lab work to assess hormone levels, specifically looking at Sex-hormone binding globulin (SHBG), free testosterone,1 your health care provider may perform a Q-tip test, not to check for ear wax, but to assess sensitivity of the vestibule. Dr. Goldstein reports that if there is allodynia of the entire vestibule that is more indicative that the symptoms are coming from a hormonal imbalance or an inflammatory driver.2 Whereas, if the posterior region of the vestibule is the only area tender upon palpation the driver is most likely overactive pelvic floor muscles, which will be discussed more in-depth shortly. Certain medications such as oral contraceptives, tamoxifen or spironolactone have been shown to cause hormonal imbalances in patients that could potentially cause dyspareunia and/or vulvodynia. Dr. Goldstein also discussed research that certain diseases and surgical procedures such as breast Cancer and/or oophorectomy could impact hormone levels and again lead to vulvodynia or sexual dysfunction.3 If a hormonal imbalance is the primary driver for a patient’s symptoms, treatment should focus on trying to improve hormone levels which may consist of stopping a certain medication or using a topical estrogen/testosterone. Again, Goldstein stressed the importance of understanding the pathophysiology behind the symptoms before determining a treatment.

Neuroproliferative

Neuro-what? If I was studying for the SATs I would really hope this word would be on the test because it came up a lot during this presentation. Neuroproliferative basically means too many nerves, and you may be surprised to hear that having too many nerves in the vestibule is a bad thing. Not all nerve fibers are created equal and there are several types in the human body. In patients with proliferative vestibulodynia they may present with an increased amount of a certain type of nerve fiber: C-afferent nociceptors.4 (For a quick review about nerve fibers or to help you prep for going on Jeopardy this site from my alma mater University of Washington breaks it down). To be brief, c-afferent nociceptors communicate pain. As mentioned earlier, if a patient presents with sensitivity around the entire vestibule this can be a sign that an individual’s condition is neuroproliferative in nature. Goldstein points out that neuroproliferation could be congenital or acquired. If a patient also presents with hypersensitivity in the umbilical region it may indicate that a patient has congenital neuroproliferative vestibulodynia due to the fact that the umbilicus and the vestibule are derived from the same tissue during development.5 Patients with congenital neuroproliferative vestibulodynia may have specific subjective reports such as pain with first attempt at intercourse or tampon use. Patients with acquired neuroproliferative vulvodynia may report a history of chronic yeast infections or an onset of symptoms after an allergic reaction.6 These patients may also demonstrate elevated levels of immune mediators such as mast cells,7 and proinflammatory cytokines such as TNF, IL-1b, IL-6 and IL-8.8 The causation of the symptoms and the length of time since symptom onset will determine appropriate treatment which can range from medications such as capsaicin, oral SNRIs, TCAs or topical gabapentin, botox injections or in some cases a vestibulectomy.

Musculoskeletal

Obviously here at The Pelvic Health and Rehabilitation Center, the myofascial cause of sexual dysfunction is what we treat on a daily basis. If you have read prior posts, you may recall that inside the pelvis is a bowl of muscles known as the pelvic floor. If these muscles become restricted or hypertonic it will restrict blood flow to the area. A lack of blood flow means there is a lack of oxygen and a build up of lactic acid which is a perfect storm for: pelvic pain. Dr. Goldstein reports patients with overactive pelvic floor muscles may present with sensitivity at the posterior portion of the vestibule only. Patients with hypertonic pelvic floors will present with tenderness upon palpation of the muscles and may report vaginal fissures in the posterior vestibule post-coitus. An individual may also report a variety of symptoms including: constipation, urinary frequency, urgency and or hesitancy. A provider may check your pelvic floor tone using an EMG, along with an internal examination to assess if hypertonus is present. Pelvic floor physical therapy has been shown to be an effective treatment for patients with musculoskeletal dysfunction as a cause of their symptoms!9 Other treatment may include medications such as diazepam, yoga, hypnosis and cognitive behavioral therapy which can help facilitate relaxation of the pelvic floor.

In conclusion, Dr. Goldstein advocates for a multidisciplinary approach when it comes to treating patients with sexual dysfunction. Most patients require more than one provider and require an individualized treatment plan. It is important to choose a treatment plan based on the cause of a patient’s symptoms, and there may be several factors involved in a patient’s presentation. As always, Goldstein stressed the need for more studies looking at women’s sexual health so that clinicians can provide better evidence-based medicine to their patients.

We thank Dr. Andrew Goldstein for a fantastic lecture!

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References:

1Burrows LJ, Goldstein AT. The Treatment of Vestibulodynia with Topical Estradiol and Testosterone. Sexual Medicine. 2013;1(1):30-33. doi:10.1002/sm2.4.
2Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH, and IPPS consensus terminology and classification of persistent Vulvar pain and Vulvodynia. The Journal of Sexual Medicine. 2016;13(4):607–612. doi:10.1016/j.jsxm.2016.02.167.
3Tucker, P. E., Saunders, C., Bulsara, M. K., Tan, J. J. S., Salfinger, S. G., Green, H., & Cohen, P. A. (2016). Sexuality and quality of life in women with a prior diagnosis of breast cancer after risk-reducing salpingo-oophorectomy. Breast, 30, 26-31.
4Bohm-Starke N et al. Neurochemical characterization of the vestibular nerves in women with vulvar vestibulitis syndrome. Gynecol Obstet Invest 1999; 48:270.
5Burrows LJ, Klingman D, Pukall CF, et al. : Umbilical hypersensitivity in women with primary vestibulodynia. J Reprod Med. 2008;53(6):413–6
6Harlow BL, He W, Nguyen R. Allergic Reactions and Risk of Vulvodynia. Annals of epidemiology. 2009;19(11):771-777. doi:10.1016/j.annepidem.2009.06.006.
7Bornstein J, Cohen Y, Zarfati D, Sela S, Ophir E. Involvement of heparanase in the pathogenesis of localized vulvodynia. Int J Gynecol Pathol. 2008;27:136–41.
8Foster DC, Piekarz KH, Murant TI, et al. Enhanced synthesis of proinflammatory cytokines by vulvar vestibular fibroblasts: Implications for vulvar vestibulitis. Am J Obstet Gynecol 2007;196;346.e1-346.e8.
9Morin M, Carroll M-S, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev 2017;5:295–322.

Posted by IPPS Admin on February 26, 2018, 12:00AM