Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource

Introduction and hypothesis Chronic pelvic pain (CPP) in women is a complex syndrome. Pain sensation and intensity often do not correspond with the identified lesion location but are felt elsewhere, leading to muskuloskeletal and myofascial disorders and sexual dysfunction (SD). Although physical aspects are prevalent, they are often underdiagnosed and undertreated due to lack of understanding regarding its origin and distribution. Frequently, patients experience pelvic pain as psychological distress resulting in physical complaints, leading clinicians to prescribe medication or surgical intervention to correct or alleviate these symptoms, often with insufficient results. Because pelvic floor muscle disorders contribute significantly to CPP and SD, there is rationale for physiotherapy. However, physiotherapy is a widely underused and untapped resource, which has its place in the multidisciplinary approach to these health problems.

Computer-aided and manual searches and methodological quality assessment were carried out for meta-analyses, systematic reviews, and randomized controlled trials (RCTs) published between 1990 and 2017 investigating classification, assessment, and (physiotherapeutic) treatment of pelvic pain and/or female SD defined by the keywords below. Expert opinions were sought via interviews.

Due to a lack of sufficient relevant medical information, referral data, and test results, focused physiotherapy is difficult to administer adequately. However, recent quality studies indicate significant clinical effects of physiotherapy for CPP and female SD, and experts advocate a multidisciplinary approach that includes physiotherapy.

Because of its holistic approach, physiotherapy can contribute significantly to the multidisciplinary assessment and treatment of CPP and female SD.

Chronic pelvic pain . Sexual dysfunction . Vulvodynia . V estibulodynia. Dyspareunia . Va gi n i s m. Sensitization . Physiotherapy . Multidisciplinary

Chronic pelvic pain (CPP) is defined as abdominal pain below the umbilicus for at least 6 months [ 1]. It is a complex and confusing health problem affecting the quality of life of many women with several types of urogynecological disorders [ 2], often resulting in depression, anxiety, and fatigue [ 3]. CPP , with its basis in the central nervous system, involves emotion- al, cognitive, behavioral, and sexual responses [ 4]. CPP syn- drome (CPPS) is CPP without a proven infection or obvious local pathology and is related to symptoms suggestive of low- er urinary tract, bowel, gynecological, and sexual dysfunction (SD) [3]. Pain sensation and intensity often do not correspond with the identified lesion location but are felt elsewhere, lead- ing to a wide array of musculoskeletal and myofascial disor- ders and SD [ 4], and the syndrome frequently coexists with chronic pelvic floor dysfunction—in most cases with the pres- ence of physical findings [5]. The underlying mechanism of this phenomena is partially explained by repeated or prolonged somatic and visceral sen- sory input of nociceptors, resulting in lowering their activation threshold, and sensitization of previously non-involved affer- ent nerve fibers. This is called peripheral sensitization [ 6]. Notice Manuscript related to the 13th Ulf Umsten lecture on the 22 June 2017 , during the 42th IUGA Annual Meeting, V ancouver, Canada. * Bary Berghmans [email protected] 1 Pelvic Care Center Maastricht, Maastricht University Medical Centre, P .O.Box 5800, 6202 az Maastricht, The Netherlands International Urogynecology Journal(2018) 29:631–638 https://doi.org/10.1007/s00192-017-3536-8 Initially, functionally Bsilent^ fibers may be activated after being sufficiently sensitized by exciting stimuli, increasing the excitability of nociceptors [7]. Electrical impulses initiate neurotransmitter release from central terminals in nociceptors that propagate the signal across synapses to dorsal-horn neu- rons. Greater stimulus intensities are associated with greater release of neuropeptides, including substance P , from central terminals of C fibers. This mechanism generates a greater postsynaptic response. The intense afferent bombardment of noxious information through viscerosomatic convergence, and ongoing somatosensorial input from muscle and skin at the dorsal horn of a segment in the spinal cord, leads to central sensitization perceived in the brain as prolonged, intense pain [4]. With central sensitization initiation, amplification, and perpetuation of pain, perception becomes manifest as allodynia, hyperalgesia, and referred pain. Convergence of neural inputs often hinders precise locali- zation and discrimination of sensory information. It also forms the basis for referred pain and explains why visceral patholo- gies are commonly felt as pain in somatic structures innervat- ed by the same spinal segment [pelvic floor muscles (PFM), in particular]. Furthermore, since visceral afferent fibers termi- nate over several spinal segments above and below the seg- ment level of input, referred pain may be present in areas remote from the affected visceral organ. This up-regulation of the sensory system further effects interneurons that connect to alpha and gamma motoneurons, leading to segmental over- activity of PFM, spasm, and contracture. This pelvic floor dysfunction and myofascial pain can then lead to SD, such as dyspareunia or vaginism, as the PFM tighten, becoming inflexible and incapable of accommodating penetration during intercourse. Myofascial pain is an expression of dysfunction in the muscle and surrounding myofascial/connective tissue [7 ]. According to Simons et al. [8], myofascial pain has a lifetime prevalence of up to 85% in the general population. Nevertheless, physicians traditionally underdiagnose and of- ten overlook this issue. The presence of myofascial trigger points (MTrPs) in the symptomatic region is a distinctive fea- ture. MTrPs are small, palpable, hyperirritable nodules located on taut bands of skeletal muscle in an area of sustained con- tracture [9] and can be active or latent. Active points are spon- taneously painful areas that do not require physical stimuli, whereas latent points are painful only upon physical palpation. Patterns of referred pain are often predictable and can be doc- umented by anatomical mapping. MTrPs may also cause mo- tor and autonomic disturbances, affecting the function of vis- ceral organs [ 9], are commonly found in many chronic pain conditions, and, when active, typically present as a regional pain syndrome [7]. Simons et al. [ 10] noted that in the pelvis, MTrPs can be found in the vagina, anorectum, urethra, pubic bone, vagina, coccyx, abdomen, lower back, and backside of thighs. They may also refer pain from those areas back to the pelvic region, making myofascial pelvic pain difficult to localize [11]. Women with myofascial pelvic pain often demonstrate symptoms of dyspareunia, painful urination (dysuria), and difficulty in defecating (dyschezia), though these symptoms may be expressions of other, nonrelated, pelvic floor or pelvic viscera problems [10]. Pelvic-floor-related SD comprise vaginism, dyspareunia, and (chronic) pelvic pain. Many authors report that in patients with CPP and/or SD the role of the pelvic floor is of the utmost importance [ 12–14]. In 57% of women with an overactive pelvic floor, dyspareunia has been reported and is felt to be secondary to stretching of shortened PFM, stimulation of painful regions and/or local adhesions, fibrosis, or organ dys- function [15]. Because pelvic pain following sexual activity is often sustained for up to 3 days [16], these symptoms can have significant negative impact on the integrity of physical rela- tionships and a woman ’s quality of life, inducing feelings of fear, anxiety, and depression [17]. Considering there is a clear and deep relationship between PFM disorders, CPPS, and female SD, one would expect that there is an important role for physiotherapy in these patients; in fact, however, the op- posite is true. In relevant clin ical practice, physiotherapy seems to be a widely underused strategy —an untapped re- source—to decrease CPP and improve sexual function. In this paper, we hypothesize that physiotherapy has a place in the multidisciplinary treatment approach to women with CPPS and SD.

To support our hypothesis, we conducted computer-aided and manual literature searches and methodological quality assess- ment of meta-analyses, systematic reviews, and randomized controlled trials (RCTs) published between 1990 and 2017 related to physiotherapeutic assessment and treatment of pel- vic pain and/or female SD. Existing classification and models of assessment and interventions used by other relevant health care professionals were reviewed. Keywords defined were (chronic) pelvic pain, sexual dysfunction, vulvodynia, vestibulodynia, dyspareunia, vaginism, sensitization, physio- therapy, and multidisciplinary. Key-opinion leaders from gy- necology, urology, sexology, and physiotherapy, all well- known experts in the field, were interviewed about their opin- ion and clinical expertise.

The literature search revealed 109 studies; 32 met our criteria, of which there were no meta-analyses, 27 (systematic) re- views, and five RCTs. 632 Int Urogynecol J (2018) 29:631–638 Classifications and models To more reliably diagnose female SD, we consulted the American Physiatric Association’ s (APA) Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-V) of classi- fied mental disorders with associated criteria [ 1]. These clas- sifications include psychogenic and organic causes of abnor- mal desire, arousal, orgasm, and sexual pain disorders based on physiologic and psychologic pathophysiology and in- cludes a personal distress criterion for most diagnoses. Although the AP A recognizes that female SD for many wom- en is physically disconcerting [1], the DSM classifications are specifically limited to psychiatric disorders and are not intended to be used for evaluating or differentiating physical aspects of SD [ 1]. Moreover, sexual disorders, such as dyspareunia and vaginism, are typically diagnosed indepen- dent of etiology, which may be largely or entirely physical in some instances. Dyspareunia and vaginism are both in the spectrum of painful intercourse, the difference being a matter of severity [18]. The DSM V classification stresses that they are penetra- tion disorders in that any form of vaginal penetration, such as with tampons, finger, vaginal dilators, gynecological exami- nations, and intercourse, are painful (dysparenuria and vaginism) or impossible (vaginism). These conditions are still often underdiagnosed and therefore inadequately treated de- spite affecting millions of women worldwide [19]. Moreover, psychiatrists and psychologists find it difficult to differentiate between dyspareunia and vaginism [ 1]. The prevalence of dyspareunia and vaginism is about 8 –16%, mostly involving diagnoses of vulvar vestibulitis or vulvodynia [20]. Other lit- erature estimates the prevalence of female SD resulting from chronic pelvic and sexual pain to be 26% (range 7–58%) [21]. Provoked vestibulodynia (PVD) is another common subtype of vulvodynia, affecting ~12% of women [ 22]. V aginism is reported to affect up to 21% of women <30 years [23], with an cumulative incidence of 10% of women unable to have sexual intercourse because of pain. Gynecologists and related medical professionals frequently focus on assessment, evaluation, and treatment of peripheral manifestations and location of CPPS. Central sensitization and myofascial dysfunction are overlooked in many cases, proba- bly due to lack of training in the assessment of myofascial dysfunction [7]. Little more than one decade ago physiother- apy for pelvic pain and female SD was almost nonexistent, with few studies reporting on this subject. The well-known psychiatrist Rosemary Basson [24]c a t e g o r i z e dt h ed i a g n o s i s and definition of major categories of women ’s SD and their management. V aginism was defined as persisting or recurrent difficulties in allowing vaginal entry of any object, despite the woman’s expressed wish to do so. The behavioral component was mentioned as the main source for management, without any reference to physiotherapy. For dyspareunia, the authors of that article suggested treatment with cyclic antidepressants, with or without pelvic muscle physiotherapy, without any fur- ther specification [ 24]. Important work by this group intro- duced the concept of a circular response cycle in women, termed the female sexual response cycle [ 25]. Their research stated that: next to sufficient sexual stimuli and motivation, the women’s state of mind, thought processes, beliefs, and emo- tions, might be the most important part of the sexual response cycle; the woman most likely would become more aroused and would desire sex more when in safe and secure surround- ings and circumstances; and mentioned that anxiety or distrac- tion because of pain or discomfort may limit the woman to be open or agree to having sex, which could hinder sexual arous- al and desire. Therefore, in this cycle, there are not only psy- chological factors but physiological and physical factors that also play an important role. The question, then, is: Why did they relegate physiotherapy to a minor role in this cycle?" There is a new, evolving model in which each individual is se en as a social –psychosomatic entity with an intricate and variable interaction of physical factors (genetic, phenotypically, biochemical, etc), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.) [ 26]. This recent biopsychosocial model applies to disciplines ranging from medicine to psychology to sociology; its novelty, acceptance, and prevalence vary across disciplines and cultures [ 26, 27]. However, this model is very useful for understanding and evaluating the complexity of pelvic pain and female SD, which are often multifactorial, requiring a multidisciplinary assessment and treatment approach. So far, there has been a tendency to view pelvic pain, dyspareunia, and vaginism as psychological distress resulting in a form of somatic or physical symptoms, for which medica- tion or surgical intervention is necessary. The medical doctor, psychiatrist, or psychologist often considers these symptoms to be initiated and/or perpetuated by emotional responses, such as anxiety and depression. With this in mind, and to answer the question of where physiotherapy fits in the sex response cycle, it is important to understand the rationale of and relationship be- tween the medical International Classification of Diseases (ICD)-10, the APA’s DSM V , and International Classification of Functions (ICF) guidelines for pelvic physiotherapy [28]. Whereas medical doctors use the ICD-10 to code the diag- nosis of pelvic pain and SD, and psychiatrists, psychologists, and sexologists use the DSM V to classify them, physiother- apists use the ICF (Table 1)[ 28]. Using the ICF, the physiotherapist tries to influence the con- sequences of pelvic pain and SD on three different levels: organ (impairment/disorder level, e.g., intravaginal pain at penetra- tion), personal (disability level, e.g., inability to have intercourse), and social–societal (restriction of participation, e.g., avoidance of sexual relationship = behavioral consequence). Where as the DSM V acts mainly on the psychological aspects of the personal Int Urogynecol J (2018) 29:631–638 633 and social–societal levels with the focus on (changing inade- quate) behavior, the ICF incorporates organ levels considering local physical disorders and impairments [28]. In Basson’s sex response cycle (Fig. 1), elements such as psychological and biological processing, arousal and respon- sive sexual desire, multiple reasons and incentives for instigat- ing or agreeing to sex, and motiv ation require both adequate psychological and physical responses. Local pain or MTrP , overactive PFM, central sensitization-related hyperalgesia, and anxiety may hinder the state of mind around sex and/or sexual activity. In this setting, pelvic physiotherapy may be an important treatment co-interevention with psychological counseling. As an example of this interplay, the cause of pelvic pain and dyspareunia might be due to an injury to the PFM, connective tissue, or fascia as a result of a birth trauma, sexual or physical abuse, or episiotomy during vaginal delivery. This can lead to shortened and weak PFM, with MTrPs and restriction of con- nective tissue resulting in chronic pelvic pain and dyspareunia. Ongoing and unresolved local injuries may lead to spinal cord central sensitization, and dorsal-root reflexes at the spinal cord level lead to referred symptoms of frequency, urgency, and nocturia, and the eventual development of noninfectious cysti- tis. This, in turn, provokes more pain, urgency, frequency, and nocturia, resulting in further contraction/tension of PFM, with further shortening and restriction of connective tissue. [13, 14]. To date, it was the rare clinician who, when assessing cystitis, would take into consideration that its cause is related to a latent injury of the pelvic floor, with consequential central sensitiza- tion and dorsal-root reflexes. Most likely, the clinician would continue the diagnostic process with invasive techniques or prescription of medication, rather than referring the patient to pelvic physiotherapy. Women with pelvic pain and SD consti- tute a group of patients with significant morbidity. They do not merely experience pain; the pain causes difficulty in walking, maintaining a normal life, work ability, and social interactions. Table 1 Definitions of the International Classification of Functioning Terms: impairment, disability, and restriction in participation Terminology Definition Impairment Loss or abnormality of psychological, physiological, or anatomical structure or function at organ level Disability Restriction or loss of ability of a person to perform functions/activities in a normal manner Restriction in participation Disadvantage due to impairment or disability that limits or prevents fulfillment of a normal role (depends on age, sex, sociocultural factors) for the person one of more reasons for sexual ac/g415vity: not currently aware of sexual desire willingness to find/be recep/g415ve sexual s/g415muli with appropriate context subjec/g415ve arousal more intense arousal & responsive desire emo/g415onal & physical sa/g415sfac/g415on biological informa/g415on processing psychological Fig. 1 The female sexual response cycle (adapted from [25]) 634 Int Urogynecol J (2018) 29:631–638 As mentioned, pelvic pain and female SD are often related to PFM dysfunction, such as overactive or underactive pelvic floor or coordination disorders. Stress as the central factor provokes a vicious cycle, with pain leading to muscle tension, pressure, nerve entrapment, and reduced circulation, which

in muscle shortening, which leads to restricted move- ment, creation of MTrPs, and further pain as a consequence [29]. The cause of stress and/or pain is not a simple or single problem but is complex and multiple. By the time women with CPP are diagnosed with PFM dysfunction, they already have undergone many unsuccessful therapeutic trials that often pro- vided no adequate relief. According to the interviewed key- opinion leaders, for such women, self-empowerment is essen- tial, and the role of physiotherapy is critical. It is not just the pelvic floor but the global impact of pain on the body. Many patients not only have pelvic pain but many other musculo- skeletal manifestations. The role of physiotherapy is to get to the heart of the matter by starting with the basics: helping the patient to stand, sit, and walk differently. In doing so, the musculoskeletal impact of decreased strain and improved comfort is the first result many patients notice. Then, the phys- iotherapist can move on to working specifically on the pelvic floor. A multidisciplinary protocol, with a central role being physiotherapy, was developed at the University College Hospital, London, UK, with reported high levels of clinical efficacy and patient satisfaction (personal communication, Dr. Sohier Elneil, 2017). Physiotherapists need to be specifically trained and skilled in how to help patients avoid pain using cognitive and/or behavioral models, how to actively listen, and then how to display empathy for the emotional compo- nent of their patients’ disease [29]. In case of a referral to a pelvic physiotherapist, an accurate medical diagnosis is very important to determine the severity and impact of the disorder and to estimate success or failure of pelvic floor physiotherapy. In many cases, the presumed med- ical diagnosis (indication ’) lacks accuracy, and physiothera- pists are thus confronted with heterogeneity and unclear grade of severity, which may limit success or even result in failure. That many women with dyspareunia or vaginism have high levels of anxiety in response to facing a physical examination of external and internal pelvic structures leads to conditions being underdiagnosed [30]. Relevant scientific studies show that medical doctors did not specify pain location in 93%, duration in 44%, pathology in 74%, comorbidities in 95%, and additional inclusion/exclusion criteria in 65% of cases referred to physiotherapy [ 2, 31]. In a review by Kavvadias et al., which included 69 articles, the site of pain was specified in only 45% of studies, and only 20% of medical doctors performed a digital examination of pelvic MTrPs for diagnosis [32]. Thus, because of lack of sufficient relevant medical in- formation, referral data, and test results, focused physiothera- py was difficult to administer adequately. There is a recent tendency to more frequently involve phys- iotherapists in the multidisciplinary assessment and treatment of female SD and pain management. Multidisciplinary guidelines [2] and protocols (University College Hospital, 2017) are now available, and the Pain Clinic of the University Medical Center Groningen (UMCG), Groningen, The Netherlands, has devel- oped the Pain Medicine Management Model. Whereas, in the past, the patient was assessed by one medical doctor and follow- ed immediately by a treatment, assessment is now based on the patient’s complaint, and a multidisciplinary approach to both evaluation and treatment is central to the new model. Through a multidisciplinary assessment, including a thorough history and physical exam, with additional testing/examination, as indicated, the team develops a comprehensive diagnosis that includes pre- sumed pathophysiology of the (dominant) pain mechanism. The UMCG multidisciplinary pain center team consists of a medical team (urologist, gynecologist, surgeon), a psychologist (psychol- ogist/psychiatrist/sexologist), and a physiotherapist. This team assess predominant nociceptive, neuropathic, nonneuropathic, somatic, visceral, and referred ne uropathy, evaluating for the presence of peripheral and central sensitization and taking into account any provoking and perpetuating biopsychosocial factors. The assessment takes 1 h in each discipline. The patient can then be classified and the plan of care tailored accordingly [33]. In the following paragraphs, physiotherapeutic assesment and treatment are described and scientific evidence discussed. Physiotherapeutic assessment and treatment Cacchioni et al. examined and reported in detail sexual thera- py for women involving body work: i.e., touch [ 34]. Women seeking advice for sexual problems are assessed and treated using close scrutiny, measurement, and response to touch of the genital area by health-care providers, including a medical doctor and pelvic physiotherapist [ 34]. Treatment may also involve instructing the woman in genital self-touch. A useful tool for managing CPP and female SD might be the so-called five-step ALLOW algorithm introduced by Sadovsky and Mulhall [ 35]. Only once the current step has been fulfilled satisfactorily for both the patient and the physiotherapist is the next step initiated: Step 1: A: ask the patient whether you can proceed, then Step 2: L: legitimize each part of the body work in such a way that the patient feels completely in control Step 3: L: limitations, meaning that before and during body work the physiotherapist is, at all times, aware of his/ her own competence and skill level and the patient’s emotions and feelings, referring, if necessary, to an- other professional Step 4: O: be open for further discussion and evaluation with the patient and, if necessary, other competent col- leagues or disciplines of the multidisciplinary team Int Urogynecol J (2018) 29:631–638 635 Step 5: W: work to develop a treatment plan with the patient and other disciplines Physical exam Before beginning the physical exam, the physiotherapist in- forms the patient about the nature of the procedure, helps the patient feel comfortable, and sets clear boundaries [ 34]. The physiotherapist also explains the difference between the ob- jectives and execution of the physical exam to be performed by their physician and physiotherapist. The physiotherapist attends to women’s immediate complaints of sexual discom- fort or displeasure, using body work to encourage them to feel more in control during the procedures and sexual activities. Patients have described the body work as therapeutic and empowering. Assessment and treatment modalities use visu- alization and hands-on techniques that stimulate patient recon- nection with their bodies, rather than simply expressing a sen- sation of objective feelings. These strategies are often highly valued by patients because of the careful and gradual ap- proach, which encourages women to be active participants in the overall process [ 34]. After a general inspection of posture and stability of spine and pelvis, the physical exam begins with inspection of the abdominal wall and observation of the patient ’sb r e a t hw h i l e in the supine position. The perineal region is then examined, observing skin (color, temperature), scars, irregularities, mois- ture, etc. Next, a neuromuscular exam, assessing dermatomes, myotomes, searching for MTrPs, allodynia (skin-rolling test, pinch-and-roll technique), hyperalgesia (Wartenberg pin- wheel), nerve entrapment, a nd pain points is performed. Muscle activity (tone) of lower back, hip, leg, and abdominal muscles is examined using palpation. Pelvic floor muscle ac- tivity (tone), spasms, and relaxation is assessed using internal palpation and/or biofeedback [7, 36]. More detailed information can be found elsewhere [ 37]. Treatment Information about the patient’s underlying health problem and education are always the starting point of treatment. Education includes explaining CPP pathophysiology and female SD, in- volvement of PFM, healthy vulvovaginal and sexual behaviors, factors influencing pain intensity, relaxation techniques, sexual function, and recovery of nonpainful sexual activities [ 38]. Physiotherapist-assisted stretching of the muscles of the back, lower extremities, and abdomen, in addition to nerve gliding to facilitate movement in restricted nerves, is important [ 30]. Stretching and strengthening techniques are then introduced to address muscle weakness, allowing for balance and stability. As central sensitization and myofascial involvement may con- t r i b u t et oC P Pa n da s s o c i a t e dS D ,physiotherapists use strategies that address treatment of MTrPs and pain regions, especially those that have been clinically tested and enhanced by scientific studies. Myofascial release involves physiotherapy and manual therapy modalities, including deep-pressure massage, stretching, joint mobilization, foam rollers [39], and other triggerpoint re- lease techniques, such as vibration, transversal or flat palpation [39, 40] and dry needling [ 41]. At each session, ~30 min is dedicated to these manual techniques to increase flexibility, de- crease TrP-related pain and tension, and increase balance and stability. Other pain management strategies, including general and specific respiratory and relaxation exercises, aim to enhance patient’s self-management and self-empowerment skills [11, 42]. Aredo et al. reported:Bthis dual approach addresses physiologi- cal and psychological components of chronic myofascial pain, alleviates MTrP-related pain, and furnishes patients with coping strategies to redirect their focus during a painful episode^ [7]. Other frequently used treatment modalities are pain manage- ment programs to promote behavior change [43], PFM training [44, 45], biofeedback, electrical stimulation [46], and balloons and pelots for dilitation of vaginal tissues [47]. Goldstein et al. described a program of PFM training for vulvodynia [ 30]i n - volving pelvic and core mobilization and stabilization tech- niques; connective tissue, visceral, and neural mobilization; and internal and external MTrP° release. Biofeedback and elec- trical stimulation assisted in decreasing tender points and tissue restrictions. The aim was to restore the proper length of the PFM and tissues, decreasing neural tension and dyspareunia. V aginal dilators are recommended to normalize muscle tone, desensitize hypersensitive areas of vulva and vagina, and restore sexual function [48]. The daily home maintenance program involves relaxation and respiratory exercises, PFM training, stretching techniques, and the use of vaginal dilatators, if indicated [38]. Scientific evidence for pelvic physiotherapy Recently, some qualitative studies have been published on the effects of pelvic physiotherapy for CPP and female SD. Weiss et al. reported that regular in-clinic and at-home PFM training augments the support function of the pelvic floor, increases blood flow, and stimulates PFM proprioception, contributing to more intense orgasm [49]. In a review on chronic pelvic floor dysfunction, Hartmann et al. concluded that referral to a pelvic physiotherapist should occur routinely as part of the multidisci- plinary approach for all women who present with any type of vulvovaginal pain [5]. Research indicates that pelvic physiother- apy is safe and effective and can dramatically improve symp- toms related to CPP and chronic PFD. Pelvic physiotherapy stimulates self-empowerment of women and supports recovery of function they may have lost due to pain and dysfunction. Sadownik et al. [ 50], in a qualitative retrospective study; Brotto et al. [ 51], in a longitudinal prospective study; Goldstein et al. [30], in a report of the expert committee of the Fourth International Consultation on Sexual Medicine; and 636 Int Urogynecol J (2018) 29:631–638 Goldfinger et al. [ 52], in an RCT; emphasize the efficacy of pelvic physiotherapy as part of the multidisciplinary approach for CPP and SD. Goldstein et al. stated that physiotherapist- assisted stretching of all muscles related to the pelvis, abdomen, low back and upper legs, in addition to nerve gliding to facilitate movement in restricted nerves, is necessary to improve CPP and SD [ 30]. The authors reported that stretching exercises and strength training restored balance and stability, proper PFM and fascia tissue length, and decreased neural tension and dyspareunia. In a RCT Goldfinger et al. investigated effects on provoked vestibulodynia by comparing cognitive behavioral therapy and multimodal physiotherapy [52]. The physiotherapy protocol combined education, PFM exercises, manual tech- niques, surface electromyographic biofeedback, progressive vaginal penetration exercises through the use of four silicone vaginal dilators of varied diameter, stretching of hip muscles, deep breathing, global body relaxation exercises, and pain man- agement techniques. They concluded that both interventions are effective treatment options for women with provoked vestibulodynia. Sadownik et al. stated that behavioral change stimulated by physiotherapy that enhances the patient’s bodily experience is an important aspect in improving self-efficacy and decreasing the experience of overly negative cognitions [50]. One RCT found that vaginal electrical stimulation improved the sexual experience of women with PFD who scored low on the Female Sexual Function Index (FSFI) [ 53]. A longitudal prospective study showed that transcutaneous electrical nerve stimulation (TENS) was feasible and beneficial for treatment- resistant provoked vestibulodynia [54]. In an RCT of women with pelvic and sexual pain, Zoorob et al. concluded that pelvic physiotherapy improves sex life and decreases pain in an equiv- alent response to injections [55]. An RCT comparing the effect of physiotherapy with surgery resulted in similar outcomes [56].

CPP and female SD are prevalentand multifactorial issues that threaten women’s quality of life. As part ofthe multidisciplinary team, and because of its holistic and whole-body approach, pel- vic physiotherapy can contributesignificantly to assessing and treating such women, and clinical and scientific research indi- cate its efficacy and safety. Therole of pelvic physiotherapy for these patients remains a relatively untapped resource. Further high-quality RCTs are warranted for several physiotherapeutic modalities and protocols and to determine their long-term effects in the integrated treatment plan of women with CPP and SD.

I would like to express my gratitude to Sohier Elneil, Ph.D., M.D., gynecologist; Bert Messelink, M.D., urologist and sexologist; Fetske Hogen Esch, pelvic physiotherapist; Maura Seleme, Ph.D., pelvic physiotherapist; Nucelio Lemos, Ph.D., M.D.; gynecolo- gist, for their advice and contributions to this manuscript; and Steven Swift, M.D., gynecologist, for his correction of the English language. Compliance with ethical standards Conflicts of interest None. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http:// creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appro- priate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

1. American Psychiatric Association. Diagnostic and statistical man- ual of mental disorders. 5th ed. Arlington, V A: American Psychiatric Association; 2013. 2. Engeler D, Baranowski AP, Borovicka J, Cottrell AM, Dinis- Oliveira P , Elneil S, Hughes J, Messelink EJ, Williams AC. Guidelines Associates: Goonewardene S, Schneider MP. EAU Guidelines on Chronic Pelvic Pain. Limited update March 2017. 3. Laursen BS, Bajaj P , Olesen AS, Delmar C, Arendt-Nielsen L. Health related quality of life and quantitative pain measurement in females with chronic non-malignant pain. Eur J Pain. 2005;9(3):267–75. 4. Hoffman D. Understanding multis ymptom presentations in chronic pelvic pain: the inter-relationshipsbetween the viscera and myofascial pelvic floor dysfunction. Curr Pain Headache Rep. 2011;15:343–6. 5. Hartmann D, Sarton J. Chronic pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. 2014;28:977–90. 6. Willard F. Basic mechanisms of pain. In: Audette JF, Bailey A, editors. Integrative pain medicine: the science and practice of com- plementary and alternative medicine in pain management. Totowa, NJ: Humana Press; 2008. p. 19–61. 7. Aredo JV , Heyrana KJ, Karp BI, Shah JP , Stratton P . Relating chronic pelvic pain and endometriosis to signs of sensitization and Myofascial pain and dysfunction. Semin Reprod Med. 2017;35:88–97. 8. Simons DG. Clinical and etiological update of myofascial pain from trigger points. J Musculoskeletal Pain. 1996;4(1–2):93–122. 9. Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunc- tion: the trigger point manual. V ol 1. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999. 10. Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunc- tion: the trigger point manual, vol. 2. Baltimore, MD: Williams & Wilkins; 1992. 11. Pastore EA, Katzman WB. Recognizing myofascial pelvic pain in the female patient with chronic pelvic pain. J Obstet Gynecol Neonatal Nurs. 2012;41(5):680–91. 12. Knoepp LR, Shippey SH, Chen CC, Cundiff GW, Derogatis LR, Handa VL. Sexual complaints, pelvic floor symptoms, and sexual distress in women over forty. J Sex Med. 2010;7(11):3675–82. 13. Faubion SS, Shuster L T, Bharucha AE. Recognition and manage- ment of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc. 2012;87(2):187–93. 14. Fashokun TB, Harvie HS, Schimpf MO, Olivera CK, Epstein LB, Jean-Michel M, et al. Sexual activity and function in women with and without pelvic floor disorders.Int Urogynecol J. 2013;24(1):91–7. 15. Kotarinos RK. Pelvic floor physical therapy in urogynecologic dis- orders. Curr Womens Health Rep. 2003;3(4):334–9. 16. Salonia A, Zanni G, Nappi RE, Briganti A, Dehò F, Fabbri F, et al. Sexual dysfunction is common in women with lower urinary tract symptoms and urinary incontinence: results of a cross-sectional study. Eur Urol. 2004;45(5):642–8. discussion 648 Int Urogynecol J (2018) 29:631–638 637 17. Lahaie MA, Amsel R, Khalifé S, Boyer S, Faaborg-Andersen M, Binik YM. Can fear, pain, and muscle tension discriminate vaginis- mus from dyspareunia/provoked vestibulodynia? Implications for the new DSM-5 diagnosis of Genito-pelvic pain/penetration disor- der. Arch Sex Behav. 2015;44(6):1537–50. 18. Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vag- inismus. BMJ. 2009;338:b2284. 19. Pacik PT. Understanding and treating vaginismus: a multimodal approach. Int Urogynecol J. 2014;25:1613–20. 20. Engman M, Lindehammar H, Wijma B. Surface electromyography diagnostics in women with partial vaginismus with or without vul- var vestibulitis and in asymptomatic women. J Psychosom Obstet Gynaecol. 2004;25(3–4):281–94. 21. Hayes RD, Bennett CM, Fairley CK, et al. What can prevalence studies tell us about female sexual difficulty and dysfunction? J Sex Med. 2006;3(4):589–95. 22. Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Wom Assoc. 2003;58:82. 23. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. 1999, JAMA, 1999;281(6):537– 44. Erratum in: JAMA 281(13):1174 24. Basson R. Women's sexual dysfunction: revised and expanded def- initions. CMAJ. 2005;172:1327–33. 25. Basson R. Human sex-response cycles. J Sex Marital Ther. 2001;27(1):33–43. 26. Santrock JW . A topical approach to human life-span development. 3rd ed. St. Louis, MO: McGraw-Hill; 2007. 27. Penney JN. The biopsychosocial model of pain and contemporary osteopathic practice. Int J Osteopath Med. 2010;13(2):42–7. 28. WHO-publication. International classification of functioning, dis- ability and health. Geneva: ICF; 2001. 29. Rosenbaum TY . How well is the multidisciplinary model working? J Sex Med. 2011;8:2957–8. 30. Goldstein A T, Pukall CF, Brown C, PharmD BS, Stein A, Kellogg- Spadt S. Vulvodynia: assessment and treatment. J Sex Med. 2016;13:572–90. 31. Williams RE, Hartmann KE, Steege JF. Documenting the current definitions of chronic pelvic pain: implications for research. Obstet Gynecol. 2004;103(4):686–91. 32. Kavvadias T, Baessler K, Sc huessler B. Pelvic pain in urogynaecology. Part I: evaluation, definitions and diagnoses. Int J Urogynecol. 2011;22:385–93. 33. Wijma AJ, Paul van Wilgen C, Meeus M, Nijs J. Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: the first step in pain neuroscience education. Physiother Theory Pract. 2016;32(5):368– 84. https://doi.org/10.1080/ 09593985.2016.1194651. 34. Cacchioni T, Wolkowitz C. Treating women ’s sexual difficulties: the body work of sexual therapy. Sociol Health Illn. 2011;33(2). ISSN 0141 –9889):266–79. https://doi.org/10.1111/j.1467-9566. 2010.01288.x. 35. Sadovsky R, Mulhall JP . The potential value of erectile dysfunction inquiry and management. Int J Clin Pract. 2003;57:601–8. 36. Bo K, Frawley HC, Haylen BT, Abramov Y , Almeida FG, Berghmans B, et al. An international Urogynecological association (IUGA)/international continence society (ICS) joint report on the terminology for the conservative and nonpharmacological manage- ment of female pelvic floor dysfunction. Int Urogynecol J. 2017;28(2):191–213. https://doi.org/10.1007/s00192-016-3123-4. 37. Bernards A TM, Berghmans LCM, Hendriks EJM, et al. Dutch guidelines for physiotherapy in patients with stress urinary inconti- nence: an update. Int Urogynecol J. 2014;25(2):171–9. https://doi. org/10.1007/s00192-013-2219-3. 38. Morin M, Dumoulin C, Bergeron S, Mayrand M, Khalifé S, Waddell G, et al. Randomized clinical trial of multimodal physio- therapy treatment compared to overnight lidocaine ointment in women with provoked vestibulodynia: design and methods. Contemp Clin Trials. 2016;46:52–9. 39. FitzGerald MP , Payne CK, Lukacz ES, Y ang CC, Peters KM, Chai TC, et al. Randomized multicenter clinical trial of myofascial phys- ical therapy in women with interstitial cystitis/painful bladder syn- drome and pelvic floor tenderness. J Urol. 2012;187(6):2113–8. 40. Anderson RU, Sawyer T, Wise D, Morey A, Nathanson BH. Painful myofascial trigger points and pain sites in men with chronic prostatitis/ chronic pelvic pain syndrome. J Urol. 2009;182(6):2753–8. 41. Ay S, Evcik D, Tur BS. Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial. Clin Rheumatol. 2010;29(1):19–23. 42. Desai MJ, Bean MC, Heckman TW, Jayaseelan D, Moats N, Nava A. Treatment of myofascial pain. Pain Manag. 2013;3(1):67–79. 43. Jensen MP , Turner JA, Romano JM. Self-efficacy and outcome expectancies: relationship to chronic pain coping strategies and ad- justment. Pain. 1991;44(3):263–9. 44. Clemens JQ, Nadler RB, Schaeffer AJ, Belani J, Albaugh J, Bushman W. Biofeedback, pelvic floor re-education, and bladder training for male chronic pelvic pain syndrome. Urology. 2000;56(6):951–5. 45. Berghmans B. Pelvic floor muscle training: what is important? A mini-review. Obstet Gynecol Int J. 2017;6(4):00214. https://doi. org/10.15406/ogij.2017.06.00214. 46. Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction as- sociated with chronic pelvic floor pain: management strategies. Curr Pain Headache Rep. 2007;11(5):359–64. 47. Gentilcore-Saulnier E, McLean L, Goldfinger C, et al. Pelvic floor muscle assessment outcomes in women with and without provoked vestibulodynia and the impact of a physical therapy program. J Sex Med. 2010;7:1003e22. 48. Kellogg-Spadt S, Iorio J, Fariello JY , et al. V aginal dilation: when it’s indicated, and tips on teaching it. Obstet Gynecol Manage. 2012;24:12. 49. Weiss PM, Rich J, Swisher E. (2012). Pelvic floor spasm: the miss- ing link in chronic pelvic pain. Contemporary OB/GYN; October 1, http://contemporaryobgyn.modernmedicine.com. 50. Sadownik LA, Seal BN, Brotto LA. Provoked vestibulodynia — Women’s experience of participating in a multidisciplinary vulvodynia program. J Sex Med. 2012;9:1086–93. 51. Brotto LA, Y ong P , Smith KB, Sadownik LA. Impact of a multi- disciplinary vulvodynia prog ram on sexual functioning and dyspareunia. J Sex Med. 2015;12:238–47. 52. Goldfinger C, Pukall CF, Th ibault-Gagnon S, McLean L, Chamberlain S. Effectiveness of cognitive-behavioral therapy and physical therapy for provoked vestibulodynia: a randomized pilot study. J Sex Med. 2016;13:88–94. 53. A yd ınS ,A rıoğ lu A ydınC ,B a t m a zG ,D a n s u kR .E f f e c to fv a g i n a l electrical stimulation on female sexual functions: a randomized study. J Sex Med. 2015;12:463–9. 54. V allinga MS, Spoelstra SK, Hemel ILM, van de Wiel HBM, Weijmar Schultz WCM. Transcutaneous electrical nerve stimulation as an ad- ditional treatment for women suffering from therapy-resistant pro- voked vestibulodynia: a feasibilitystudy. J Sex Med. 2015;12:228–37. 55. Zoorob D, South M, Karram M, Sroga J, Maxwell R, Shah A, et al. A pilot randomized trial of levator injections versus physical ther- apy for treatment of pelvic floor myalgia and sexual pain. Int Urogynecol J. 2015;26:845–52. 56. Eftekhar T, Sohrabi M, Haghol lahi F, Shariat M, Miri E. Comparison effect of physiotherapy with surgery on sexual func- tion in patients with pelvic floor disorder: a randomized clinical trial. Iran J Reprod Med. 2014;12(1):7–14. 638 Int Urogynecol J (2018) 29:631–638