C o n s e rvative Management of Female Patients With Pelvic Pain Hollis Herm a n he primary symptoms of Female patients with hy p e r t o nus of the pelvic musculature can ex p e- h y p e rtonus of the pelvic rience pain; burning in the cl i t o r i s , u r e t h r a , vag i n a , or anu s ; c o n s t i- m u s c u l a t u r e in female p a t i o n ; u r i n a ry frequency and urge n cy ; and dy s p a r e u n i a . P hy s i c a l patients include pain; t h e r a py techniques are effective in treating female patients with Tb u rning in the clitoris, ure t h r a , pelvic pain, and can successfully reduce the major symptoms asso- vagina or anus; constipation; uri- ciated with it. Using a treatment plan individualized for each patient’s n a ry frequency and urgency; and s y m p t o m s , these techniques can provide considerable relief to d y s p a reu nia (DeFranca, 1996). patients with debilitating pelvic pain. T h e re are many names for hyper- tonus diagnoses involving these symptoms including: levatore s ani syndrome (Nicosia, 1985; Salvanti, 1987; Sohn, 1982), ten- alignment and instability are pre- Olive, 1998), vaginal pH alter- sion myalgia (Sinaki, 1977), sent (Lee, 1999). Patients have ation, dermatological disease, p roctalgia fugax (Swain, 1987), functional impairment with sit- c a n c e rou s vulvar disease, epi- coccygodynia (Dittrich, 1951; ting, walking, urination, and s i o t o m y, laceration, birthing trau- Thiele, 1937; 1963; Wa t e r s , defecation (DeFranca, 1996), and ma with forceps or vacuum 1992), dyspareunia (Glatt, 1990), with household and community extraction, vaginal infection, uri- vaginismus (Hall, 1952), animus, activities of daily living. A high n a ry tract infection, inflamma- vulvodynia (MacLean, 1995; resting baseline, excessive signal tion, skin irritation from chemi- M a r i n o ff & Tu rn e r, 1992; Reid, v a r i a b i l i t y, and a low net rise on cals, nerve irritation from entrap- 1993; Secor, 1992), vulvar s u rface EMG (sEMG) is common- ment, neuro h o r monal alteration vestibulitis (deJong, 1995; Spadt, ly re c o rde d. Muscle hypert o n u s p a rticularly estrogen deficiency 1995), interstitial cystitis, puden- can be palpated on external and ( G l a z e r, Romanzi, & Polaneczky, dal neuralgia (Tu r n e r, 1991), i n t e rnal pelvic floor muscle 1999), psychiatric disord e r s , pelvic pain (Baker, 1993), and examination. Muscle weakness is instability of the pelvis (Lee, u rethral syndrome (Steege, m e a s u red in the levatores ani, 1999), prolapse, vasocongestion, M e t z g e r, & Levy 1998). obturator internus, gluteus and sexual trauma. Physical ther- The objective findings in medius, iliopsoas, adductor, and apy treatment coverage of dys- patients with hypertonus include lateral hip rotator muscles. Some p a reunia may be denied under its pain on palpation to the geni- d e g ree of dyspareunia is usually p r i m a ry ICD-9 code if viewed as talia, pain on palpation of the re p o rted. a psychiatric or sexual dysfunc- perineal region from 3 to 9 tion rather than an anatomic or o’clock, or pain in the ure t h r a , D y s p a re u n i a physiologic dysfunction. perineal body, perianal area, pos- D y s p a reunia is better defined M a r i n o ff and Tu rner (1992) terior thigh, gluteal, and abdomi- as painful penetration rather defined three levels of dyspare u- nal areas (Costello, 1998). than painful intercourse, as nia (see Table 1). Burning, sting- S a c roiliac, coccyx, symphysis many patients re p o r t painful ing, irritation, rawness, tearing, pubis, lumbosacral joint mal- gynecologic examinations using and searing pain are the most speculums or a gloved examining common complaints with pene- digit. Causes for dyspareunia can tration during and afterw a rd. If include: abscess, fissure, adhe- these symptoms are felt at the Hollis Herman, M S , P T, O c s, is a sions from prior surg e ry, adhe- i n t roi tus, superficial stru c t u re s P hysical T h e rapist in Pri vate Pra c t i c e sions causing conditions such as such as the genitalia, perineal in Cambri d g e, MA. endometriosis (Blackwell & b o d y, posterior fourchette, epi- UROLOGIC NURSING / December 2000 / Volume 20 Number 6 393 Table 1. Pelvic Floor Muscle T h r ee Levels of Dyspare u n i a E x e rc i s e s Using sEMG with pelvic pain Level 1: Painful intercourse not severe enough to prevent the activity. patients, Glazer, Rodke, and Level 2: Painful intercourse which limits frequency of the activity. Swencionis (1995) demonstrated unstable and abnormally high Level 3: Abstinence from intercourse because of severe pain. resting baselines (tension). Unstable and weak amplitudes w e r e re c o rded during phasic, tonic, and endurance voluntary Table 2. contractions. The use of sEMG Treatment for Dyspareunia of Musculoskeletal Origin was proposed as an objective method for forming a diff e re n t i a l 1 . C o rrect any joint(s) malalignment to promote pain-free joint(s) mobility. diagnosis between functional 2 . Teach the patient self-correction joint(s) techniques (musculoskeletal) vulvovaginal (see Tables 3, 4, & 5). pain syndromes and other 3 . Stabilize the joint(s) with muscle stabilization exerc i s e s . s o u rces of vulvovaginal pain such as infections. Stabilizing 4 . Eliminate trigger points in all of the muscles. muscle variability overall and 5 . Eliminate or reduce scar adhesions and tissue restrictions (see Table 6). p r edominantly at rest was a 6 . Teach pelvic floor muscle awareness using a biofeedback device (see major factor in effective tre a t- Table 7). ment, rather than focusing on 7 . C o rrect muscle imbalances by down training (relaxation) and up train- i n c reases in the contractile ing (stre n g t h e n i n g ) . amplitude. Glazer and Mac- Conkey (1996) proposed simulta- 8 . Re-educate the pelvic floor muscles to be relaxed upon penetration. neous use of diff e rent muscle 9 . Combine down training with dilators (see Table 8). combinations to enhance the 1 0 . Educate about positions for intimacy. pelvic floor muscles contraction, 1 1 . Educate about lubricants. in order to “break” the re s t i n g tension level and reduce pain. Thus, the “Glazer protocol” (see Table 3) consists of two 20- Table 3. minute exercise sessions per day. G l a z e r ’s Pro t o c o l Each session is 60 repetitions of 10-second contractions altern a t- Patient is supine, semi-reclining, sitting, or standing. ing with 10-second re l a x a t i o n phases. Patients are asked to con- Contract the pelvic floor muscles up and in as hard as possible. tract the pelvic floor muscles maximally with all other sur- You may contract any other muscles along with the pelvic floor muscles. rounding muscles. They are re q u i r ed to use home sEMG Hold the contraction for 10 seconds. training devices with intravagi- Relax for 10 seconds. nal sensors. Over time the clinician may Repeat 60 times twice a day. o b s e rve increased contractile amplitudes, decreased variability of the contraction and re l a x a t i o n amplitude, and faster rise and re c o v e ry times with subjective siotomy site, and superf i c i a l establish that the cause is muscu- re p o rts of less pain. muscle layer may be implicated. loskeletal rather than fungal, bac- A c c o rding to Glazer, after If deeper pain occurs, adhesion terial, viral, or otherwise infec- t r eatment the sEMG demon- of the vaginal canal, adhesive tious is essential for eff e c t i v e strates a reduction in the hyper- disease, cervix and uterine dys- physical therapy treatment. Once tonicity and instability associat- function, levatores ani muscle the diagnosis is established that ed with chronic uncoord i n a t e d trigger points, or sacroiliac and pelvic pain is of musculoskeletal d i s c h a rge of fast twitch fibers symphysis pubis joint dysfunc- origin, treatment may include the seen in the resting sEMG of vul- tion may be involved. steps listed in Table 2. Following vovaginal pain patients. Va r i a t i o n s When evaluating patients o ffice treatment to correct the on “Glazer’s protocol” that have with dyspareunia, it is import a n t joint malalignment, the patient had equally significant t re a t m e n t to first rule out any medical con- can continue with self-corre c- results are two 15-minute rather ditions. Diff e rential diagnosis to tions at home. than two 20-minute sessions. 394 UROLOGIC NURSING / December 2000 / Volume 20 Number 6 Table 4. P r otocol for Using sEMG and Dilators 1 .