Prior to incorporating sexual pain management into an existing practice or opening a new practice, it is important for the health care team to be clear about their philosophical stance regarding pain, sexuality, and wellness. It should be determined if the approach to treating sexual pain will be from a predominantly clinical, traditional medical “illness-based” model (or from a wellness perspective) and whether a patient will be managed entirely by one health care provider or by a team of providers. Philosophies about treating each woman with sexual pain on an individual basis or within a partner/family systems framework should be clarified. It is important for health care providers to be clear about their philosophies on chronic pain, including the use of narcotics and other controlled substances to manage pain. Decisions about the use of alternative therapies including massage, stress management, homeopathy, herbology, acupuncture, hypnosis, etc., are also important. Goals or endpoints for care, limitations of clinical services (medical, surgical, psychological) and triage routes should be established. Lastly, a statement(s) regarding beliefs about sexual pain and goals of the care team should be agreed upon and compiled in the form of a mission statement [2].

When designing a center that can address the complexity of sexual pain, the potential etiologies of sexual pain can serve as a framework from which to identify members of the health care team, collaborating professionals, modes of assessment, diagnostic testing, and treatment options. Although a wide range of disorders can be associated with chronic pain, most sexual concerns arise from one or more of six basic categories: neurological, dermatologie, mus-culoskeletal, inflammatory, infectious, and psychological [1–7].

Sexual pain disorders are multifaceted and, as such, best results are obtained when sexual pain is addressed by a multidisciplinary team. Identification of the members of the team is based on the specific skill set of each member of the team. As an aggregate, the team must possess the skills needed to accomplish the specific goals of sexual pain management. These goals include [1, 3, 5–7]

1 Identification of the specific disease process (e.g., lichen sclerosus, endometriosis, etc.) or disorder (e.g., pelvic floor dysfunction, irritable bowel syndrome, etc.) causing the sexual pain;

2 Initiate proper treatment of the specific disease or disorder;

3 Reduction in inflammation, vulvar hypersensitivity, and hyperreactivity;

4 Restoration of tissue elasticity, moisture, integrity, and removal of chemical allergens, dietary, and lifestyle irritants;

5 Identification, treatment, and suppression of recurrent infection according to specific species type;

6 Restoration of adequate strength and tonus to the pelvic core, and superficial and deep pelvic floor muscles;

7 Comprehensive management of individual and couple/family psycho-behavioral issues to facilitate sexual and psychological wellness.

An integrated approach to treating the sexual pain patient has as its goal an understanding of how various illness states, physical sensations, and psychological processes have interacted to cause suffering in a woman who presents for care. In addition, it is imperative to understand the issues surrounding the initiation of pain problem, its chronology, and the progression of the pain to its present state (e.g., vestibularpain, hypertonus of the pelvic floor, depression, etc.) so that appropriate interventions can be designed. Integrated does not always mean interdisciplinary. Theoretically, an integrated approach could be carried out by one (very busy) provider or it can be carried out by a number of collaborating subspecialists, depending on the complexity and severity of the problem. In most cases, sexual pain is treated by several members of an integrated team who view the patient as a functional unit of mind and body, and who work together so that healing occurs in an integrated fashion [1, 2].

The sexual pain care team can involve several key professionals. In our center, these include:

Sexual Pain Team (within the center):

Team Leaders:

Urologist or gynecologist/surgeon (MD) and medical sexologist (PhD, NP)

Team Members:

OB/GYN nurse practitioners

Manual physical therapist: specialization in pelvic floor disorders

Massage/craniosacral/yoga therapist: specialization in neuromuscular re-education

Compounding pharmacist

Hypnotherapist: specialization in pain/stress management

Nutritionist

Homeopathist

Sexual relationship therapists: specialization in pain, sexual trauma, and eye movement desensitization and retraining (EMDR)

Marriage and family therapists

Research coordinator

Support Services (outside the center):

Consulting dermatologist

Consulting dermatopathologist

Consulting infectious disease specialist

Consulting acupuncturist/herbalist

Consulting anesthesiologist/pain management specialist

Consulting colorectal surgeon

Consulting gynecologic surgeon

Consulting internist or family practitioner

The structure of our team, and the individual duties within the group, have been established with a thorough understanding of the specific skills of each individual team member. As such, other sexual pain teams might have a gynecologist, dermatologist, infectious disease specialist, or pain management specialist as a team leader.

In some treatment centers, members of the entire sexual pain team have offices “under one roof.” In such a clinical setting, a patient can be provided with the full variety of services that she requires, and can see many team members during serial appointments with specialists who are located within the same physical space. This type of clinical program requires a very significant investment in time, space, financial resources, and organizational support. This can be accomplished in the setting of an academic medical center if administrators are aware of the large scope of sexual pain clinic. Alternatively, the sexual pain care team may be located in a free standing “center” but this often requires significant financial investment of the team leaders.