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    Chronic sexual pain: a layered guide to evaluation

     

    MYOFASCIAL LAYER – THE PELVIC FLOOR

    Just under the surface of the vulva lies the invisible layer of the PF, made up of muscles and the fascia covering and attaching them to each other, and forming their origins and insertions into bone and cartilage. Whether sexual pain begins in this layer or not, the PF almost always contributes to its intensity and chronicity. Muscle spasms, muscle shortening, myofascial trigger points, and secondary dystrophic changes add to nerve irritation and compression. Patients often sense both PF and PN pain as a foreign object in the vaginal canal, which corresponds to the bulkiness of muscles remaining in an abnormal contracted state. Dysfunction of the PF is a common component of all types of CPP and is “the missing link” in making a complete diagnosis.21 In women with sexual pain, it is crucial that the PF be systematically evaluated.

    The vast majority of women who have been told they have “vaginismus” actually suffer from LPV and severe PF dysfunction. Painful experiences from touching, sexual activity, and medical exams understandably result in avoidance of vulvar contact, which is often misinterpreted as a psychological problem. For these patients, perform exams under anesthesia only as a last resort, because with muscle relaxation, important PF and nerve findings may disappear. Oral or intravaginal diazepam is an option an hour before an exam, but you may underappreciate the severity of myofacial abnormalities with this premedication.

    PF evaluation needs to attend both vaginally and rectally to superficial and deep myofascial structures. Palpate the bulbocavernosus, ischiocavernosus, transverse perineal, levator ani (puborectalis, pubococcygeus, iliococcygeus), obturator internus, piriformis, and anal sphincter for tenderness, high tension, tight bands, trigger points, bilateral symmetry, and hypertrophy or atrophy, and the connective tissue for string-like restrictions. Constrictions around the courses of nerves hinder normal stretching and gliding in the tissues during sexual activity, causing burning pain. Dry-needling tight bands and trigger points, or injecting them with 0.5 cc lidocaine, then palpating to confirm their release and effect on pain, is a useful diagnostic tool.

    Note findings of vaginal relaxation, pelvic organ prolapse, and Bartholin’s cysts, but keep in mind that these are usually not sexual pain generators. Many patients with unappreciated LPV have had small Bartholin’s cysts surgically excised without benefit. If they are present, be sure to continue to evaluate all layers for more likely causes of sexual pain.

    PTs who specialize in PF dysfunction have taken up the challenge of caring for women with sexual pain, and can help us improve our PF exam skills.22

     

    Deborah Coady, MD, FACOG
    Dr Coady is Clinical Assistant Professor of Obstetrics and Gynecology at NYU Langone Medical Center, New York.

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