Melissa L. Dawson, DO, MS; Nima M. Shah, MD; Rebecca C. Rinko, DO; The evaluation and management Clinton Veselis, MD; Kristene E. Whitmore, MD of female Department of OB/GYN, Drexel University College of Medicine, Philadelphia, Pa Patients often fail to bring it up, and physicians may be

Melissa.Dawson.DO@ reluctant to discuss it, but ignoring sexual dysfunction gmail.com can disrupt a woman’s most intimate relationships. Drs. Dawson, Shah, Rinko, and Veselis report no potential conflict of interest relevant to this article. Dr. Whitmore dis- closes that she receives grants/ research support from Allergan (makers of Botox), as well as he care of women with female sexual disorders has from Astellas Pharma US and PRACTICE made great strides since Masters and Johnson first Coloplast Corp. RECOMMENDATIONS began their study in 1957. In 2000, the Sexual Func- ❯ Obtain a detailed his- T tion Health Council of the American Foundation for Uro- tory and evaluate obstet- logic Disease defined the classification system for female ric, gynecologic, sexually transmitted disease, sexual sexual dysfunction, which was eventually published and offi- abuse, urinary and bowel cially defined in theDiagnostic and Statistical Manual of Men- complaint, and surgical his- tal Disorders-IV-TR.1 There are now definitions for sexual desire tory in women of all ages. B disorders, sexual arousal disorders, orgasmic disorder, and ❯ Consider a variety of lifestyle sexual pain disorders. and pharmacologic ap- Female sexual dysfunction (FSD) has complex physi- proaches, as well as biofeed- ologic and psychological components that require a detailed back in combination with screening, history, and physical examination. Our goal in this physical therapy, review is to provide family physicians with insights and prac- to address your female pa- tical advice to help screen, diagnose, and treat female sexual tient’s sexual dysfunction. B dysfunction, which can have a profound impact on patients’

Strength of recommendation (SOR) most intimate relationships. A Good-quality patient-oriented evidence B Inconsistent or limited-quality patient-oriented evidence Understanding the types  C Consensus, usual practice, of female sexual dysfunction opinion, disease-oriented Most women consider sexual health an important part of their evidence, case series overall health.2 Factors that can disrupt normal sexual function include aging, socioeconomics, and other medical comor- bidities. FSD is common in women throughout their lives and refers to various sexual dysfunctions including diminished arousal, problems achieving orgasm, , and low desire. Its prevalence is reported as high as 20% to 43%.3,4 The World Health Organization and the US Surgeon Gen- eral have released statements encouraging health care provid- ers to address sexual health during a patient’s annual visits.5 Unfortunately, despite this call to action, many patients and providers are initially hesitant to discuss these problems.6 The Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) provides the definition and diagnostic

722 THE JOURNAL OF FAMILY PRACTICE | DECEMBER 2017 | VOL 66, NO 12 guidelines for the different components of Evaluating the patient FSD. Its classification of sexual disorders was Initially, many patients and providers may simplified and published in May 2013.7 There hesitate to discuss sexual dysfunction, but are now only 3 female dysfunctions as op- the annual exam is a good opportunity to posed to 5 in DSM-IV. broach the topic of sexual health. • Female hypoactive desire dysfunc- tion and female arousal dysfunction Screening and history were merged into a single syndrome Clinicians can screen all patients, regard- labeled female sexual interest/arousal less of age, with the help of a validated sex disorder. questionnaire or during a routine review of • The formerly separate dyspareunia systems. There are many validated screening (painful intercourse) and vaginismus tools available. A simple, integrated screen- are now called genitopelvic pain/pen- ing tool to use is the Brief Sexual Symptom etration disorder. Checklist for Women (BSSC-W), created • Female orgasmic disorder remains as by the International Consultation in Sexual a category and is unchanged. Medicine.12 Although recommended by the American Congress of Obstetricians and Gy- ❚ To qualify as a dysfunction, the prob- necologists,9 the BSSC-W is not validated. lem must be present more than 75% of the The questionnaire includes 4 questions that time, for more than 6 months, causing signifi- ascertain personal information regarding an The prevalence cant distress, and must not be explained by a individual’s overall sexual function satisfac- of female sexual nonsexual mental disorder, relationship dis- tion, the problem causing dysfunction, how dysfunction is as tress, substance abuse, or a medical condition. bothersome the symptoms are, and if the high as 43%. Substance- or medication-induced sex-​ patient is interested in discussing it with her ual dysfunction falls under “Other Dysfunc- provider.12 tions” and is defined as a clinically significant It’s important to obtain a detailed ob- disturbance in sexual function that is pre- stetric and gynecologic history that includes dominant in the clinical picture. The criteria any sexually transmitted diseases, sexual for substance- and medication-induced sex- abuse, urinary and bowel complaints, or sur- ual dysfunction are unchanged and include geries. In addition, you’ll want to differenti- neither the 75% nor the 6-month require- ate between various types of dysfunctions. A ment. The diagnosis of sexual dysfunction thorough physical examination, including an due to a general medical condition and external and internal pelvic exam, can help to sexual aversion disorder are absent from the rule out other causes of sexual dysfunction. DSM-5.7 ❚ A common symptom. Female sexual General examination: disorders can be caused by several com- What to look for plex physiologic and psychological factors. The external pelvic examination begins with A common symptom among many women visual inspection of the vulva, labia majora, is dyspareunia. It is seen more often in post- and labia minora. Often, this is best accom- menopausal women, and its prevalence plished gently with a gloved hand and a cot- ranges from 8% to 22%.8 Pain on vaginal en- ton swab. This inspection may reveal changes try usually indicates vaginal atrophy, vaginal in pubic hair distribution, vulvar skin disor- dermatitis, or provoked vestibulodynia. Pain ders, lesions, masses, cracks, or fissures. In- on deep penetration could be caused by en- spection may also reveal redness and pain dometriosis, , or uterine typical of vestibulitis, a flattening and pallor leiomyomas.9 of the labia that suggests estrogen deficiency, The physical examination will reproduce or . the pain when the vulva or vagina is touched ❚ The internal pelvic examination with a cotton swab or when you insert a fin- begins with a manual evaluation of the mus- ger into the vagina. The differential diagnosis cles of the pelvic floor, uterus, bladder, ure- is listed in the TABLE.9-11 thra, anus, and adnexa. Make careful note

JFPONLINE.COM VOL 66, NO 12 | DECEMBER 2017 | THE JOURNAL OF FAMILY PRACTICE 723 TABLE What’s causing your patient’s sexual pain?9-11

Superficial Deep • Atrophy • Adenomyosis • Condylomas • Endometriosis • Infectious lesions • High-tone pelvic floor dysfunction • Provoked vestibulodynia • Interstitial cystitis • Trauma • Irritable bowel syndrome • • Pelvic adhesive disease • Vulvovaginitis • Pelvic congestion syndrome • Pelvic inflammatory disease • Sexual abuse history • Uterine leiomyomas • Uterine retroversion • Other generalized pain disorders Systemic estrogen of any unusual tenderness or pelvic masses. vulva and vagina, increased secretions dur- in oral form, Pelvic floor muscles (PFMs) should volun- ing sexual arousal, and increased tension and transdermal tarily contract and relax and are not normally contractions of the PFMs.15 preparations, tender to palpation. Pelvic organ prolapse Lowenstein et al found that women with and topical and/or hypermobility of the bladder may strong or moderate PFM contractions scored formulations indicate a weakening of the endopelvic fas- significantly higher on both orgasm and may increase cia and may cause sexual pain. The size and arousal domains of the female sexual function sexual arousal flexion of the uterus, tenderness in the vagi- index (FSFI) compared with women with weak and decrease nal fornix possibly indicating endometriosis, PFM contractions.16 Orgasm and arousal func- dyspareunia. and adnexal fullness and/or masses should tions may be associated with PFM strength, be identified and evaluated. with a positive association between pelvic floor ❚ Neurologic exam of the pelvis will in- strength and sexual activity and function.17,18 volve evaluation of sensory and motor func- The function and dysfunction of the tion of both lower extremities and include a PFMs have been characterized as normal, screening lumbosacral neurologic exami- overactive (high tone), underactive (low nation. Lumbosacral examination includes tone), and non-functioning. assessment of PFM strength, anal sphincter • Normal PFMs are those that can vol- resting tone, voluntary anal contraction, and untarily and involuntary contract and perineal sensation. If abnormalities are noted relax.19,20 in the screening assessment, a complete • Overactive (high-tone) muscles are comprehensive neurologic examination those that do not relax and possibly should be performed. contract during times of relaxation for micturition or defecation. This type of It’s important to assess dysfunction can lead to voiding dys- pelvic floor muscle strength function, defecatory dysfunction, and Sexual function is associated with normal dyspareunia.19 PFM function.13,14 The PFMs, particularly the • Underactive, or low-tone, PFMs can- pubococcygeus and iliococcygeus, are re- not contract voluntarily. This can be sponsible for involuntary contractions dur- associated with urinary and anal in- ing orgasm.13 Orgasm has been considered a continence and pelvic organ prolapse. reflex, which is preceded by increased blood • Nonfunctioning muscles are com- flow to the genital organs, tumescence of the pletely inactive.19

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❚ How to assess. There are several ways diabetes can affect sexual dysfunction by im- to assess PFM tone and strength.20 The first is pairing arousal and orgasm. Identification of intravaginal or intrarectal digital palpation, concurrent comorbidities and implementation which can be performed when the patient is of lifestyle changes will help improve overall in a supine or standing position. This exami- health and may improve sexual function.25 nation evaluates PFM tone, squeeze pressure In addition, Herati et al26 found food during contraction, symmetry, and relaxation. sensitivities to grapefruit juice, spicy foods, However, there is no validated scale to quan- alcohol, and caffeine were more prevalent in tify PFM strength. Contractions can be further patients with interstitial cystitis and chronic divided into voluntary and involuntary.19 pelvic pain. Avoiding irritants such as soap During the examination, the physician and other detergents in the perineal region should ask the patient to contract as much may help decrease dysfunction.27 Finally, as she can to evaluate the maximum strength foods high in oxalate and other acidic items and sustained contraction for endurance. may cause bladder pain and worsening This measurement can be done with digi- symptoms of vulvodynia.28 tal palpation or with pressure manometry or dynamometry. Topical therapies worth considering ❚ Examination can be focused on the Lubricants and moisturizers may help , piriformis, and internal obtura- women with dyspareunia or symptoms of tor muscles bilaterally and rated by the pa- vaginal atrophy. Manual tient’s reactions. Pelvic muscle tenderness, ❚ Zestra, for instance, which is applied therapies, which can be highly prevalent in women with to the vulva prior to sexual activity, has been including chronic pelvic pain, is associated with higher proven more effective than placebo for im- transvaginal degrees of dyspareunia.21 Digital evaluation proving desire and arousal.29 technique, may of the pelvic floor musculature varies in scale, ❚ Neogyn is a non-hormonal cream con- relieve female number of fingers used, and parameters taining cutaneous lysate and has been shown sexual evaluated. Lukban et al has described a zero to improve vulvar pain in women with vul- dysfunction to 4 numbered scale that evaluates tender- vodynia. A double-blind placebo-controlled that results ness in the pelvic floor.22 The scale denotes randomized crossover trial followed 30 pa- from a variety “1” as comfortable pressure associated with tients over 3 months and found a significant of causes. the exam, “2” as uncomfortable pressure as- reduction in pain during sexual activity and a sociated with the exam, “3” as moderate pain significant reduction in erythema.30 associated with the exam and that intensifies ❚ Alprostadil is a prostaglandin E1 ana- with contraction, and “4” indicating severe logue that increases genital vasodilation pain with the exam and inability to perform when applied topically and is currently un- the contraction maneuver due to pain. dergoing investigational trials.31,32 Patients can also choose from many over-the-counter lubricants that contain water-based, oil- Effective treatment includes based, or silicone-based ingredients. multiple options Lifestyle modifications can help Don’t overlook physical therapy Lifestyle changes may help improve sexual Manual therapies, including the transvaginal function. These modifications include physi- technique, are used for female sexual dys- cal activity, healthy diet, nutrition counsel- function that results from a variety of causes, ing, and adequate sleep.23,24 including high-tone pelvic floor dysfunc- Identifying medical conditions such as tion. The transvaginal technique can identify depression and anxiety will help delineate dif- myofascial pain; treatment involves inter- ferential diagnoses of sexual dysfunction. Car- nal release of the PFMs and external trigger diovascular diseases may contribute to arousal point identification and alleviation. disorder as a result of atherosclerosis of the One pilot study, which involved trans- vessels supplying the vagina and clitoris. Neu- vaginal Thiele massage twice a week for rologic diseases such as multiple sclerosis and 5 weeks on 21 symptomatic women with IC

JFPONLINE.COM VOL 66, NO 12 | DECEMBER 2017 | THE JOURNAL OF FAMILY PRACTICE 725 and high-tone pelvic floor dysfunction found compounds such as tibolone may improve it decreased hyptertonicity of the pelvic floor sexual function, although it is not FDA ap- and generated statistically significant im- proved for that purpose.40 provement in the Symptom and Problem ❚ Ospemifene (Osphena) is a selective Indexes of the O’Leary-Sant Questionnaire, estrogen receptor modulator that acts as an Likert Visual Analogue Scales for urgency estrogen agonist in select tissues, including and pain, and the Physical and Mental Com- vaginal epithelium. It is FDA approved for ponent Summary from the SF-12 Quality-of- dyspareunia in postmenopausal women.41,42 Life Scale.33 Transvaginal physical therapy A daily dose of 60 mg is effective and safe is also an effective treatment for myofascial with minimal adverse effects.42 Studies sug- pelvic pain.34 gest that testosterone, although not FDA ap- ❚ , which can be used in proved in the United States for this purpose, combination with pelvic floor physical ther- improves sexual desire, pleasure, orgasm, apy, teaches the patient to control the PFMs and arousal satisfaction.39 The hormone has by visualizing the activity to achieve con- not gained FDA approval because of con- scious control over contraction of the pelvic cerns about long-term safety and efficacy.42 floor and ceasing the cycle of spasm.35 Ger et ❚ Non-hormonal drugs including al36 investigated patients with levator spasm flibanserin (Addyi), a well-tolerated sero- and found biofeedback decreased pain; relief tonin receptor 1A agonist, 2A antagonist The treatment was rated as good or excellent at 15-month shown to improve sexual desire, increase of female sexual follow-up in 6 out of 14 patients (43%). the number of satisfying sexual events, and dysfunction may Home devices such as Eros Therapy, an reduce distress associated with low sexual require FDA-approved, nonpharmacologic battery- desire when compared with placebo.43 The a multimodal operated device, provide vacuum suction FDA has approved flibanserin as the first systematic to the clitoris with vibratory sensation. Eros treatment targeted for women with hypoac- approach Therapy has been shown to increase blood tive sexual desire disorder (HSDD). It can, targeting flow to the clitoris, vagina, and pelvic floor however, cause severe hypotension and genitopelvic and increase sensation, orgasm, lubrication, syncope, is not well tolerated with alcohol, pain. and satisfaction.37 and is contraindicated in patients who take Vaginal dilators allow increasing lengths strong CYP3A4 inhibitors, such as flucon- and girths designed to treat vaginal and pel- azole, verapamil, and erythromycin, or who vic floor pain.38 In our practice, we encourage have liver impairment. pelvic muscle strengthening tools in the form ❚ Buproprion, a mild dopamine and nor- of kegal trainers and other insertion devices epinephrine reuptake inhibitor and acetyl- that may improve PFM coordination and choline receptor antagonist, has been shown strength. to improve desire in women with and without depression. Although it is FDA approved for Pharmacotherapy has its place major depressive disorder, it is not approved The treatment of FSD may require a multi- for female sexual dysfunction and is still un- modal systematic approach targeting genito- der investigation. pelvic pain. But before the best options can ❚ Tricyclic antidepressants such as nor- be found, it is important to first establish the triptyline and amitriptyline may be effective cause of the pain. Several drug formulations in treating neuropathic pain. Starting doses have been effectively used including hor- of both amitriptyline and nortriptyline are monal and non-hormonal options. 10 mg/d and can be increased to a maximum ❚ Conjugated estrogens are FDA ap- of 100 mg/d.44 Tricyclic antidepressants are proved for the treatment of dyspareunia, still under investigation for the treatment of which can contribute to decreased desire. FSD. Systemic estrogen in oral form, transdermal ❚ Muscle relaxants in oral and topi- preparations, and topical formulations may cal compounded form are used to treat in- increase sexual desire and arousal and de- creased pelvic floor tension and spasticity. crease dyspareunia.39 Even synthetic steroid Cyclobenzaprine and tizanidine are FDA-

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approved muscle relaxants indicated for used needle electromyography guidance and muscle spasticity. a transperineal approach, found that the dys- ❚ Cyclobenzaprine, at a starting dose pareunia visual analog scale improved sig- of 10 mg, can be taken up to 3 times a day nificantly at Weeks 12 and 24. Keep in mind, for pelvic floor tension. Tizanidine is a cen- however, that onabotulinumtoxinA should be trally active alpha 2 agonist that’s superior reserved for patients who fail conventional to placebo in treating high-tone pelvic floor treatments.47,48 dysfunction.44 ❚ Other medications include benzodi- Addressing psychological issues azepines such as oral clonazepam and intra- Sex therapy is a traditional approach that vaginal diazepam, although they are not FDA aims to improve individual or couples’ sexual approved for high-tone pelvic floor dysfunc- experiences and help reduce anxiety related tion. Rogalski et al reviewed 26 patients who to sex.42 Cognitive behavioral sex therapy in- received vaginal diazepam for bladder pain, cludes traditional sex therapy components sexual pain, and levator hypertonus.45 They but puts greater emphasis on modifying found subjective and sexual pain improve- thought patterns that interfere with intimacy ment assessed on FSFI and the visual analog and sex.42 pain scale. PFM tone significantly improved Mindfulness-based cognitive-behavioral during resting, squeezing, and relaxation treatments have shown promise for sexual phases. Multimodal therapy can be used for desire problems. It is an ancient eastern Three months muscle spasticity and high-tone pelvic floor practice with Buddhist roots. This therapy is after trigger dysfunction. a nonjudgmental, present-moment aware- point injections, ness comprised of self-regulation of attention 13 of 18 women Trigger point and Botox injections and accepting orientation to the present.49 improved, Although drug therapy has its place in the Although there is little evidence from pro- resulting in management of sexual dysfunction, other spective studies, it may benefit women with a success rate modalities that involve trigger point injec- sexual dysfunction after intervention with sex of 72%. tions or botulinum toxin injections to the therapy and cognitive behavioral therapy. PFMs may prove helpful for patients with Female sexual dysfunction is common high-tone pelvic floor dysfunction. and affects women of all ages. It can negatively A prospective study investigated the role impact a women’s quality of life and overall of trigger point injections in 18 women with well-being. The etiology of FSD is complex, levator ani muscle spasm with a mixture of and treatments are based on the causes of 0.25% bupivacaine in 10 mL, 2% lidocaine in the dysfunction. Difficult cases warrant refer- 10 mL, and 40 mg of triamcinolone in 1 mL ral to a specialist in sexual health and female combined and used for injection of 5 mL per pelvic medicine. Future prospective trials, trigger point.46 Three months after injections, randomized controlled trials, the use of vali- 13 of the 18 women improved, resulting in a dated questionnaires, and meta-analyses will success rate of 72%. Trigger point injections continue to move us forward as we find better can be applied externally or transvaginally. ways to understand, identify, and treat female ❚ OnabotulinumtoxinA (Botox) has sexual dysfunction. JFP also been tested for relief of levator ani mus- CORRESPONDENCE Melissa L. Dawson, DO, MS, Department of OB/GYN, Drexel cle spasm. Botox is FDA approved for upper University College of Medicine, 207 N Broad St. 4th Floor, and lower limb spasticity but is not approved Philadelphia, PA 19107; [email protected]. for pelvic floor spasticity or tension. It may reduce pressure in the PFMs and may be useful in women with high-tone pelvic floor References dysfunction.47 1. American Psychiatric Association. Diagnostic and Statistical Man- ual of Mental Disorders (4th ed, text revision). Washington, DC; In a prospective 6-month pilot study, 1994. 28 patients with pelvic pain who failed con- 2. Shifren, JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. servative treatment received up to 300 U Bo- 2008;112:970-978. tox into the pelvic floor.11 The study, which 3. Lewis RW, Fugl-Meyer KS, Bosch R, et al., Epidemiology/risk fac-

JFPONLINE.COM VOL 66, NO 12 | DECEMBER 2017 | THE JOURNAL OF FAMILY PRACTICE 727 tors of sexual dysfunction. J Sex Med. 2004;1:35-39. 28. De Andres J, Sanchis-Lopez NM, Asensio-Samper JM, et al. Vulvo- 4. Laumann E, Paik A, Rosen RC. Sexual dysfunction in the United dynia—an evidence-based literature review and proposed treat- States prevalence and predictors. JAMA. 1999;281:537-544. ment algorithm. Pain Pract. 2016;16:204-236. 5. Office of the Surgeon General.The Surgeon General’s Call to Action 29. Herbenick D, Reece M, Schick V, et al. Women’s use and percep- to Promote Sexual Health and Responsible Sexual Behavior, Rock- tions of commercial lubricants: prevalence and characteristics in ville, MD; 2001. a nationally representative sample of American adults. J Sex Med. 2014:11:642-652. 6. Pauls RN, Kleeman SD, Segal JL, et al. Practice patterns of physi- cian members of the American Urogynecologic Society regarding 30. Donders GG, Bellen G. 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