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Chronic pelvic pain (CPP) is associated with psychological distress and decreased quality of life in both men and women. Pain itself is an emotional experience  and all chronic pain conditions can result in and be perpetuated by depression, anxiety, and sleep disturbances . However, patients with CPP may deal with additional challenges. CPP affects functions that are intimate and difficult to discuss with others. There are generally no outward signs of disability, such as assisted walking devices and sufferers don’t typically appear disabled. Furthermore, many individuals with symptoms of pelvic pain see several doctors before receiving an adequate diagnosis and this itself may be cause of psychological distress. CPP specifically involves areas intimately connected to sexuality which may negatively impact one’s body image and sexual self-esteem . The typical female pelvic pain patient may have suffered from painful periods upon menarche, experienced pain with sexual relations, and may have been challenged with infertility when attempting pregnancy. These challenges affect a woman’s self perception in her role identity as a woman, leaving her feeling damaged, dysfunctional and disconnected from her body.
While all types of chronic pain affect functioning, CPP is most closely related to pelvic floor functioning that is associated with bothersome symptoms including urinary frequency, urgency and bowel complaints, that affect quality of life (QoL) in many emotional, physical and social dimensions . Bladder symptoms affect social and recreational activities, limit exercise and physical activity, and have a negative impact on mental health, affecting self-esteem and mood . Bothersome urogenital symptoms, in addition to pelvic pain, are particularly associated with distress related to sexual activity . Women with sexual distress are more likely to report sexual difficulty related to pelvic floor symptoms, including sexual avoidance due to vaginal prolapse or sexual activity restriction due to fear of urinary incontinence . Men with chronic pelvic pain have a higher incidence of lower urinary tract symptoms that affect their sexual functioning as well .
Overactive bladder (OAB) with or without incontinence negatively affects sexual health, reducing sexual desire and ability to achieve orgasm . Bladder Pain Syndrome/ Interstitial Cystitis (BPS/IC) characterized by a constellation of symptoms including urgency, frequency, dyspareunia, nocturia and pelvic pain and is also correlated with decreased sexual functioning .
Women and men with CPP struggle with associated sexual dysfunction. During sexual activity, pain can occur with arousal and with orgasm in both men and women. Painful intercourse affects over 40% of women with CPP. Painful intercourse may be perceived deep in the pelvis secondary to endometriosis or pelvic adhesions. Painful intercourse in women can also be superficial due to several possible causes including vulvar pain syndrome/vulvodynia, the most common cause of superficial dyspareunia in women in their childbearing years, affecting 12–21% of women in this population . Men with chronic pelvic pain have a higher incidence of erectile dysfunction and premature ejaculation . Pelvic and genital pain syndromes, commonly associated with bladder symptoms, are highly correlated with decreased QoL and sexual dysfunction . Sexual dysfunction in all domains, including desire, arousal, orgasm as well as painful intercourse is common in both men and women with CPP.
CPP conditions affect pelvic floor function, sexual function, and quality of life. Depression, anxiety and other psycho-social characteristics, are commonly associated with CPP and patients with CPP may present with these characteristics in the clinic . Furthermore, patients who suffer with CPP will likely encounter challenges in their significant intimate relationships . Often clients present to practitioners with their partners and challenging relationship dynamics may be observed in the clinic. Hence, medical practitioners, including physical therapists, must be able to address these psychosocial components in their management of patients with CPP.
Female Sexual Pain Disorders: Classification
Sexual pain disorders (SPD) are common in both men and women with CPP. Sexual pain disorders in women have been traditionally divided into vaginismus and dyspareunia, with the former diagnosis implying a fear-based reactive inability to allow vaginal penetration and the latter implying a condition characterized by the essential experience of pain with sexual intercourse or other vaginal penetration . The proposal to replace these two Diagnostic and Statistical Manual- IV (DSM-IV) sexual dysfunction categories with “genito-pelvic pain/penetration disorder” [7, 8] recognizes the significant overlap in these conditions, as well as their non-sexually related symptoms. Pain and anxiety are understood to be salient components of both vaginismus  and vulvar pain syndrome/vulvodynia (VPS/VVD) .
There are a variety of possible etiological causes for dyspareunia that may be hormonal, such as in atrophic vaginitis, dermatological, such as the various lichens conditions, infectious, inflammatory or mechanical, as with a thick or inflexible hymen. Therefore, women with symptoms of sexual pain should undergo a thorough vulvovaginal examination in order to determine the possible organic components and contributors to pain.
A recognized component of these chronic pelvic and sexual pain related conditions is overactivity of the pelvic floor muscles. Pelvic floor muscle therapy, which is aimed to normalize pelvic floor muscle function, has become a standard intervention [19, 37, 40, 44].
The Bio-Psycho-Social Paradigm
While the classic approach to sexual pain had been to treat medically if organic findings were present and consider psychological etiologies in the absence of physical findings, sexual pain disorders are currently understood to have multi-factorial components . Therefore, we appreciate that treatment should follow the bio-psycho-social paradigm. Recognizing the multi-dimensional nature of SPDs, the current biopsychosocial treatment paradigm designates treatment of the medical aspects of SPD to physicians and the psychological aspects including anxiety and aversion, to mental health professionals such as psychologists or sex therapists. In this model, treatment of the overactive pelvic floor muscles, or what is referred to as “pelvic floor dysfunction” is designated to physical therapists. However, several problems exist with this model. The relaxing and containing atmosphere of the mental health environment, is not one in which the patient is likely to feel the most anxious. However, in the medical and physical therapy settings, where pelvic examination and treatment is a salient component of the intervention, it is most likely that the patient’s anxiety will be most present. The patient may also experience a response of disassociation. Therefore, a treatment model that attributes treatment of anxiety only to the mental heath professional, and not to medical professionals who directly confront that anxiety, is insufficient.
Moreover, overactivity of the pelvic floor is not merely an isolated state, but is often related to emotional states. Pelvic floor muscle activity has been found to be reactive in response to anxiety, fear of penetration and fear of pain, and most recently has been found to be reactive to visual stimuli of even non-sexual related scary films . Increased pelvic floor muscle tension may be a baseline state as well, related to early habits such as rigid toilet training. The experience of physical therapy, which involves internal examination and muscle treatment, or other potentially exposing treatments, may elicit significant emotional responses, trigger past traumatic episodes and if not properly identified, may result in dissociation which may be misinterpreted as cooperation.
DESCRIBING THE SUBJECT
From a Compartmentalized Biopsychosocial Model to an Integrative Approach
Addressing biopsychosocial components in medical and physical therapy practice is an important step to make.
Proposed biological and physiological mechanisms of CPP are understood to be related to visceral, musculoskeletal, hormonal and other processes and may be related to alteration in central pain processing, local tissue mast cell and nerve proliferation, and overactivity of the pelvic floor musculature. CPP is also associated with psychological, relational and sexual distress as mentioned previously.
Many women suffering from CPP also present with sexual pain disorders. The main psychological feature associated with sexual pain is anxiety. Higher catastrophizing, fears of pain, hypervigilance and lower self-efficacy have been associated with increased intercourse pain intensity [16, 36]. Vaginismus has been traditionally defined as a reflexive reaction of vaginal spasm in anticipation of intercourse and associated with increased levels of aversion and disgust . The reflexive contraction associated with vaginismus has been understood to be related to fear and threat . Doctors and physical therapists are typically examining patients with pelvic and sexual pain, and this reflexive response is observed in the clinic.
An additional psychological factor of relevance to medical practitioners and physical therapists is body image. When a woman perceives her body as damaged and dysfunctional, she may disconnect and detach herself from her physical self and in particular, her genitalia. There does not appear to be research that has examined efficacy of physical therapy interventions for pelvic pain, that also measure the patient’s emotional presence and connection with her body during treatment. However, it is likely that patients may completely disconnect and disassociate during physical interventions such as internal trigger point massage therapy, particularly if the intervention feels painful or embarrassing.
The social component of the biopsychosocial paradigm should not be ignored. Social construction of gender and sexuality directly shape the fear and distress of women with sexual pain . Social factors are related to women’s perceptions of her role in society and include the perception that women must allow vaginal intercourse for satisfactory sex, to please her partner or fulfill his need for sex . This perception is often related to feelings of guilt, responsibility for the lack of intimacy and lack of autonomy in her intimate relationships. These feelings of guilt and responsibility may compel her to engage in sexual intercourse when she is neither aroused nor interested. Furthermore, these feelings may compel her to undergo painful and difficult treatments while emotionally disconnecting. Medical and physical therapy practitioners should consider the possible affects of these social messages and consider whether clients may be undergoing painful treatment just to please their partner.
Addressing Anxiety in Medical and Physical Therapy Treatment of CPP