Authors: Karen Louise Stoner, Michaela Briscoe, Nicholas Aquilina
Organisation: Malta Health Student’s Association
University of Malta - Faculty of Health Sciences.
Dyspareunia:
Dyspareunia originally stems from an Ancient Greek phrase translating into ‘difficult mating’. Medically, it is a sexual condition with the presentation of genital pain during intercourse or sexual related activities. Although quite common amongst women of reproductive age, it presents an oftentimes neglected and overlooked area of women’s health, particularly sexual.
Pathology and Etiology
Pathology has been defined as "that branch of medicine which treats of the essential nature of disease" and etiology is the study of causation, or origin. (MedicineNet, 2020)
When treating dyspareunia, it is vital to narrow down the initial and dispersing factors to arrive at the correct understanding of the condition. The various conclusions of the pathophysiology of presenting dyspareunia include vaginismus, lack of lubrication, atrophy and vulvodynia (vulvar vestibulitis). Other less quoted, yet still valid conclusions are endometriosis, pelvic congestion, adhesions or infections, and adnexal pathology. Disorders of the urethral, cystitis and interstitial cystitis may also result in the presentation of dyspareunia symptoms. Studies have shown, however, that this lack of a narrowed down etiology, due to the multifaceted dimensions of the conditions, can lead to delayed and difficult diagnosis. (Heim, Lutz., 2001)
Practitioners will sometimes aim to stimulate or recreate the pain experienced by patients to try and decipher the cause or main concern. An example of this can be seen in the instance of vulvar vestibulitis. This presents when the vagina is felt with a cotton swab or spontaneous spasms of the vaginismus occurs on examination with a finger or speculum. Examination of the lateral vaginal wall, uterus, adnexa and structures of the urethral may assist in identifying the root or trigger of the problem. A holistic understanding of the current organic diagnosis in conjunction with the psychological perspective and anticipated malice brought about by the pain needs to be addressed. (Heim, Lutz., 2001)
Prevalence:
The prevalence of dyspareunia can alter depending on the population and size of population being sampled. Post-partum patients tend to have higher rates of experiencing dyspareunia when compared to nonparous women. This is the same with those who have experienced sexual assault versus those who have not had any trauma to the vagina. There are many studies that have gone into these specific situations, however, not many of high validity have portrayed the image of the general public. A survey carried out by the authors of this paper, attempted to get a general idea of the Maltese public. However, due to small sample size, this can not be deemed reliable.
The Maltese Population:
A survey was created and distributed amongst the Maltese population by sharing it via the Malta Health Student’s Association social media page. The survey had a total of 65 participants. Results reveal that the majority of people (64.6%) who participated in the survey did not know the meaning of the term ‘dyspareunia’.
This predicts that there is a lack of knowledge about this pathology and substantiates the need for more education (assumed based on the small sample side. Further research is required to explore this further). When asked if they had ever experienced dyspareunia or had been with someone who underwent such an experience, the response generated showed that 50.8% of participants answered ‘no’ whilst 41.8% answered ‘yes’. Given such a small sample size, it was surprising to find that such a large percentage admitted to having or have been with someone who has experienced dyspareunia when compared to similar studies. 7.7% of participants claimed that they were not aware if they had experienced or been with someone who experienced it.
Another question focused on, should the situation arise, would the person disclaim that they were in pain to their partner? The greater part of the respondents claimed that they would. The vast majority of the remainder (41.5%) stated that it would depend on the partner. This might be predictive of the anxiety certain patients feel towards their sexuality, pain, or lack of addressing the issue, which is later addressed in the Occupational Therapy portion of this paper.
Finally, the survey looked into the medical aspect of the condition. Although there were a variety of causes reported for this sexual dysfunction when asked, the vast majority reported anxiety, vaginismus, vaginitis, postpartum trauma and vaginal trauma as what they thought were the main causes of dyspareunia. When asked which medical professional they would most likely consult for this condition, participants replied that they would consult with a general practitioner, gynecologist and midwife in this order. This is further delved into in the ‘multidisciplinary approach’ section of the paper.
The Multidisciplinary Team:
With so many women having experienced dyspareunia, it is ideal that healthcare professionals, across the multidisciplinary team, should be prepared with the appropriate knowledge and advice to patients they may come across. Whether the healthcare professional is taking a history, noting reactions to treatments, or by the patient informing the practitioner of the dyspareunia, this paper aims to show that it is fundamental for the practitioner to understand how to; note the symptoms and indicators of dyspareunia, educate, and treat the patient. (Abraham et al., 2019)Such signs may include unilateral or bilateral pelvic pain, gluteal region pain, internal vaginal, peripheral vaginal, and labial pain. Decreasing pain is often a main outcome measure, particularly in physiotherapy and occupational therapy (Enderby et al., 2006). Therefore, pain from dyspareunia should not be neglected.
As previously discussed, the etiology of dyspareunia is multifactorial and it is precisely this reason that a multidisciplinary approach is required to treat and manage it. (Ghaderi et al., 2019)
Chronic pelvic pain affects both quality of life and functionality of patients. It has been shown to negatively impact work activities, sometimes ability to sit for prolonged periods, ability to exercise, sexual function; and by result; self-esteem, intimacy, and relationships. As previously mentioned, it is often difficult to identify the precise etiology of pain and thus, this may prove frustrating for the patient and left with many unanswered questions. A question is posed; do women experiencing dyspareunia know, or are fully informed, on where to turn for medical advice and the array of treatment options offered?
To quote Frank, Robert in 1948; ‘Most frequently the family physician is the first to be consulted, particularly by newlyweds whom he has known since childhood or adolescence. Too often the general practitioner, because he has not been instructed in medical school, proves ill qualified to be a useful counselor. Moreover, he will find little useful guidance in the textbooks’.
Although this is not recent evidence, there is still some truth in this statement. Referring back to the survey distributed around on our social media platforms, the question ‘Which medical personnel would you seek should you experience dyspareunia?’ was asked.
As shown in the chart, the replies were the following:
GP
Gynecologist/ genital specialist
Midwife
Sex therapist
Nurse
Emergency Room
Physiotherapist
‘I don’t know’
With the vast majority opting for gynecologist. Whilst a gynecologist does occupy a vital role within the team, only three people mentioned physiotherapist, with just one specifically mentioning a women’s health physiotherapist. This alludes that the general public is not educated on the different professions that deal with dyspareunia. However, with this small sample size, further research is required.
Treatment:
Healthcare practitioners strive for a non-pharmaceutical approach where possible. Studies have shown that prescription of medicine, can sometimes have adverse effects to the condition in which the patient feels disregarded, and thus, disregards the pharmaceutical prescription guidelines. (Chiatti et al., 2012). In the case of physiotherapy, dyspareunia can be addressed in a number of ways. Musculoskeletal factors play an important role in the diagnosis, treatment, and management modalities of dyspareunia. Rehabilitating the pelvic floor muscles, for this reason, is fundamental to treat this dysfunction. (Ghaderi et al., 2019) One of which is addressing muscle flexibility in the form of stretching (with particular focus on adductors, obturator internus, piriformis, hamstrings, and iliopsoas muscles). The patient may also attempt to use a vaginal dilator to help manually stretch internally. This may result in pain for the patient since penetration happens, and thus, the practitioner should receive carefully and regular feedback from the patient. Myofascial release and deep, intravaginal, soft-tissue manipulation may be performed to restore connective tissue pliability, particularly in the case of scar tissue formation. This can then be transferable and taught for the patient to perform self-treatment. This is an extremely intimate procedure and may also result in pain and spasm, if the patient is not made comfortable. (Abraham et al., 2019) It is fundamental that the professional treats dyspareunia as any other condition, and does not shy away from the topic of sex. If they do not feel able to treat it themselves, they are still to handle the situation with ease and refer accordingly. (Lee et al., 2018).
In a study by Ghaderi et al, 64 women with dyspareunia participated in being allocated randomly into two groups; an experimental/treatment group and a control group. The treatment group included electrotherapy, manual therapy, and pelvic floor muscle exercises. Prior to the treatment, which lasted three months, an evaluation on pelvic floor muscle strength [and endurance], pain, and sexual dysfunction was taken. This was also taken three months follow-up. Results showed improvement in the treatment group when compared to the control. Using the Oxford Scale, there was a mean increase of 2.01 in muscle power, a mean difference in pain (VAS score) of 7.32. By using the Sexual Functional Index score, there was a mean difference of 51.05. This proves, with need for further research and similar studies, the statistical significance of such a treatment programme on dyspareunia.
Education:
Cross-comparing multiple studies on the topic, a common thread has been educating the woman on her pelvic floor anatomy and physiology(Abraham et al., 2019)(Fisher, 2007). Explaining the funnel-shaped structure of the pelvic floor anatomy and the three main components consisting of the
Levator ani muscles (puborectalis; U-shaped sling) (pubococcygeus) (iliococcygeus; the actual ‘levator’ of the three)
Coccygeus muscle (the smaller, most posterior pelvic floor component
And the fascia covering the muscles is fundamental.
Studies have shown that by taking the time to explain this, the woman is able to visualise her anatomy better and isolate the muscles more leading to more effective and selective targeting during treatment(Fisher, 2007) (Bo et al.). When patients think of their pelvic floor muscles, due to media and uninformed information from practitioners, ‘Kegel's’ are often what come to mind. Kegel’s, in fact, cause increased tension in the pelvic floor muscles which could result in the potential increase of pain, and thus, adverse treatment. Exercise prescription by the physiotherapist should focus on relaxation of the pelvic floor muscles. This can be done via, diaphragmatic breathing, and as explained above, imagery. The following is an example of an image that can be shown to a patient whilst demonstrating the exercise.
(Fisher, 2007)
This shows a seated position with flat feet on the ground with intent on the ‘sit bones’. On inhalation, the patient is guided to image the sit bones moving away from each other. On exhalation, the bones are to glide inwards gently whilst avoiding contraction. The hands in the picture depict the movement of the pelvic floor. Evidence shows that this is effective with targeting pelvic floor muscles using terminology and descriptive wording as well as actual imagery.
Evidence also shows that women are not always able to immediately locate their pelvic floor muscles. Unlike the hamstrings or biceps, which are oftentimes visible and palpable, the pelvic floor muscles are intimately positioned within the anatomy. (Kiyosaki et al., 2012). In a study from Loyola University Chicago; school of nursing, they quote ‘Centuries of yoga practice have provided a guide to help practitioners of yoga reconnect to the power of the pelvis.’ In healthcare and exercise prescription, the modalities of relaxation, meditation, and muscle mind connection offered by yoga techniques, does indeed, help the patient focus on isolating their pelvic floor muscles. This is a tool often used in the treatment/ management of dyspareunia. (Tenfelde, 2014).
Occupational therapy:
Occupational Therapy can be defined as “the art and science of helping people do the day-to-day activities that are important and meaningful to their health and well-being through engagement in valued occupations.” (Willard and Spackman’s,. 2019). This is important as occupational therapists value the importance of one's desire to participate in occupations. Occupations give meaning and purpose to the client and differ from person to person. This can be called occupational need, and gives people the opportunity and ability to freely choose their own desired occupations.
However, if these needs are not met, the person may feel imbalanced and without fulfilment. Research has gone into the exclusion of sex and treating sexual dysfunctions within occupational therapy. This goes against the client-centred approach practitioners strive towards. Holistically, sex can be considered an occupation and is, of course, a healthy expression of one’s sexuality. To quote Couldrick: ‘sexual expression may be of higher priority to an individual than other activities of daily living’, The lack of attention and treatment towards such a condition as dyspareunia might indeed lead to habitual precarious occupations as a form of venting away from their sexual needs. (Pollard and Sakellariou, 2007)
Occupational Therapists, take on a holistic view of the person. The relation between the environment, social, cultural and spiritual needs of the person is regarded with importance. It therefore, seems unwarranted, for the exclusion of addressing sex within treatment and why it was felt to be included in this paper. Research has gone into the occupational therapist promoting sexual aids or helping/ finding ways for client’s with sexual dysfunction to masturbate. This, however, was frowned upon by other professionals and the general public. Sometimes, even the patient themselves would see this type of treatment as unprofessional. Thus, this presents the practitioner with ethical dilemmas that cannot be ignored. Penna and Sheehy 2000, Earle 2001) (Stoner 1999). The findings of this study are rather old and there is an apparent gap in research regarding contemporary views on such an approach.
When looking at dysfunction, occupational therapists may not only examine the physical aspect, but also play a key role in the mental health of the client. Adopting theories and approaches from psychology, occupational therapists found an important link between occupations and mental health. This is due to the fact that someone's emotional state can drastically affect one's ability to participate in occupations.
Women who suffer from Dyspareunia often demonstrate signs of anxiety and depression due to their condition. The problems faced by these women may affect their day to day lives , participation in other occupations, self-esteem, and outlook towards sex. (Landry and Bergeron, 2010)
Anxiety often presents when faced with new and uncertain complications. In the case of dyspareunia, some women may almost develop a fear of intercourse due to the overriding anxiety and guilt towards the occupation. Some may also find difficulty in disclosing the pain they feel during intercourse for fear that they would be judged and believe it would have a negative impact on their relationship. It has also been found that some women do not disclose pain during intercourse as they feel it is their duty to please their partner. This lack of being able to have sex has also been linked to cases of depression. (Khandker et al., 2011). Without this volition, - as described by Kielhofner in the Model of Human Occupation, is the sense that guides individuals to choose and experience occupations which are meaningful to them and that allows them to be self competent in them leading to occupational justice. Without it, different aspects of daily life which are integral to Occupational therapy, such as productivity, leisure and self-care are affected. Moreover, aspects of one's cognition may be impacted greatly and so problems with decision making and solving memory and attention can be affected.
It is this which outlines the role of the occupational therapist within the multidisciplinary approach to treatment and management of dyspareunia.
Examples in Practice:
Endometriosis
Endometriosis is a condition that affects 10% of the female reproductive population. It is often painful. Endometriosis occurs when the endometrium or similar tissue grows outside of the uterus. It usually spreads to pelvic organs and can, but rarely, spread beyond. The symptoms of this condition are severe dysmenorrhea, pain on urination or defecation, heavy bleeding during menstruation, sometimes infertility, and dyspareunia. This has a negative effect on the women’s overall quality of life. Studies have shown that the sex-life aspect of endometriosis is often neglected. (Lukic et al., 2015) Looking at sex as a whole, its many physiological aspects include vascular supply, hormones, nervous supply, and immune systems. Imbalances or pathologies amongst these leads to dysfunction. It is a disruption amongst these that can account for the pathogenesis of dyspareunia.
67 women with endometriosis who experienced deep dyspareunia underwent laparoscopic surgery. After this surgery, a significant decrease in VAS score (pain outcome measure) was noted six months post-op. Laparoscopies are invasive and not readily available for everyone. It is for this reason, treatment (as mentioned above), from the multidisciplinary team is fundamental to treat the multifaceted dimensions of sex and its dysfunctions. (Lukic et al., 2015)
Postpartum:
After birth, especially if complications such as tears in the vagina arise, sutures are rather common to be done on the patient. Dyspareunia can be the result of scarring and scar tissue forming in the vicinity of the sutures. In such cases reassurance and appropriate referral to a multidisciplinary team has to be the course of action. (Fitzpatrick and O'Herlihy, 2007)
A particular study found that 8% of women had persistent perineal pain at one year following vaginal delivery (Kainu et al ., 2001). Another study shows that, when comparing an episiotomy to spontaneous tears, the risk and prevalence of dyspareunia did not increase. This comments on the generality of sexual dysfunction and thus enhances the previous statement that due to varied etiology, diagnosis is taxing. (Signorello er al., 2001). On the other hand operative vaginal delivery (forceps/vacuum) and third and fourth degree tears increase the risk of dyspareunia (Leeman et al., 2016 ; Fodstad et al.,2016). This correlates with findings of increased scar tissue and increased trauma to the vagina enhancing symptoms of dyspareunia.
It is to be noted that superficial dyspareunia can be secondary to scar tissue formation, poor anatomical reconstruction following perineal trauma or vaginal dryness and atrophy. Until this point, midwives are equipped with general techniques of how to manage dyspareunia. If perineal pain and dyspareunia persists at 3 months postpartum, with completely healing sutures, a referral to a women’s health physiotherapist is advisable. (Manresa et al., 2019)
Painful intercourse post partum can often be linked to the following physiological sources; painful stitches after childbirth, pressure on spinal nerves in the pelvis [such as the pudendal nerve], hormonal changes accounting for the vaginal dryness, narrowing of the vaginal entrance, and tight muscles of the pelvic floor, amongst others.
Conclusion:
Outlining the major symptoms, pathologies, scenarios, and different effects on life, it is evident through research that the multidisciplinary team is fundamental in treatment and management of dyspareunia. Further research is suggested to look at the public’s perception towards professionals such as occupational or physiotherapists and their treatment methods. Improvements to the survey carried out would be a larger sample size and perhaps individual outlooks of male and female.
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