The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment

Sexual function and pelvic floor function in men with systemic sclerosis compared to healthy controls: a cross-sectional study

OBJECTIVES

This cross-sectional study aimed to compare the sexual function (SF) and pelvic floor function of men with systemic sclerosis (SSc) with age-matched healthy controls (HC) and to identify the implications of clinical features on SF.

MATERIAL AND METHOD

Twenty SSc males and 20 HC aged 18-70 years completed eleven questionnaires assessing SF [International Index of Erectile Function (IIEF), Male Sexual Health Questionnaire (MSHQ)]; sexual quality of life: Sexual Quality of Life Questionnaire-Male (SQoL-M); pelvic floor function: Pelvic Floor Impact Questionnaire-Short Form 7 (PFIQ-7), fatigue, depression, physical fitness, functional disability, and quality of life. Clinical data were collected.

RESULTS

Significantly worse SF was observed in patients (median IIEF erectile function 12 in SSc versus 29 in HC, p < 0.001), with 70% reporting erectile dysfunction (ED) compared to 15% in HC. However, no significant difference was observed regarding pelvic floor function (median PFIQ7 8.8 in SSc versus 7.0 in HC, p = 0.141). Impaired SF was associated with higher disease activity, increased systemic inflammation, more pronounced fatigue, reduced physical fitness, severe depression, impaired overall quality of life, dyspepsia, and arthralgias (p < 0.05 for all).

CONCLUSIONS

Sexual dysfunction is highly prevalent in our SSc patients, whereas pelvic floor dysfunction is unlikely to be associated with these problems.

Efficacy and safety of visnadine in the treatment of symptoms of sexual dysfunction in heterosexual women: a systematic review of randomized clinical trials

OBJECTIVE

To synthesize the primary evidence on the efficacy and safety of visnadine on symptoms of sexual dysfunction (SD) in heterosexual women.

METHODS

We conducted a systematic review of randomized clinical trials (RCTs) with a primary search without language restriction in PubMed/Medline, Scopus, Embase, Web of Science, Cochrane Library, and international clinical trial registries. Trials reporting the use of visnadine by any route in women with SD were eligible. We performed screening, data extraction, and risk of bias assessment in a double-blind approach. The primary outcomes were the Female Sexual Function Index (FSFI) and its domains. Secondary outcomes were safety, arousal, lubrication, pleasure, orgasm, negative sensations, duration, and overall satisfaction.

RESULTS

Initially, 242 records were retrieved. We selected nine papers for full-text reading and finally included two RCTs: one with a parallel design and one with a crossover design with a total of 96 patients. One study compared visnadine aerosol with a placebo, while the other compared different frequencies of visnadine aerosol use. Visnadine use showed a statistically significant improvement (p < 0.05) in overall FSFI scores, regardless of the frequency of use. A meta-analysis was not possible due to the high clinical and methodological heterogeneity between available studies.

CONCLUSION

RCTs regarding the use of visnadine for the Female SD are scarce and methodologically limited. This preliminary evidence shows visnadine as a potentially effective and safe option to alleviate some of the clinical symptoms of SD in heterosexual women. However, future better-designed randomized studies with larger sample numbers are required.

Affective neuroscience: applications for sexual medicine research and clinical practice

INTRODUCTION

Affective neuroscience is the study of the brain substrates of emotional, embodied experiences. Affective neuroscience theory (ANT) is based on experimental evidence that all mammals are hardwired with 7 primary subcortical emotional operating systems, or "core emotions," that have overlapping but distinct circuits buried in the deep, ancient parts of the brain. Imbalances in the 7 core emotions can affect multiple aspects of the individual's psychosocial well-being (eg, depression, anxiety, substance abuse). Here, we propose that core emotions can also influence sexual function and, specifically, that imbalances in core emotions are the bridge connecting psychiatric symptoms (eg, anhedonia) to sexual dysfunction (eg, anorgasmia).

OBJECTIVES

In this targeted review and commentary, we outline potential connections between ANT and sexual medicine research and clinical practice. We summarize ANT by defining the 3-level BrainMind and core emotions; examining how they relate to personality, behavior, and mental health; and determining the implications for sexual health research and clinical practice.

METHODS

A targeted literature review was conducted. Case studies were adapted from client files and clinician interviews and then anonymized.

RESULTS

We propose a novel organizational schema for implementing affective balance therapies for sexual dysfunction, which integrate psychoeducational, somatic, and cognitive therapeutic approaches under the ANT framework. We provide 3 patient case studies (anorgasmia, hypersexuality, spinal cord injury) outlining the implementation of this approach and patient outcomes.

CONCLUSION

ANT has practical translational applications in sexual health research and clinical practice. By integrating our understanding of the role of core emotions in human sexuality, clinicians can better tailor treatments to address sexual dysfunction.

[Physiotherapeutic differential diagnosis of back pain associated with endometriosis]

BACKGROUND

Endometriosis (EM) is one of the most common gynecologic conditions in our society. The diagnosis takes an average of 7 to 10 years. To shorten this period, this syndrome needs more attention. The aim of this article is to show overlaps between EM and low back pain (LBP) and to describe their relevance for physiotherapeutic screening.

OBJECTIVES

What clinical signs do the syndromes EM and LBP have in common and to what extent can physiotherapeutic screening take gynecological aspects into account and be adapted accordingly?

RESULTS

To answer this question, the two syndromes were screened for overlaps. These overlaps were then related to the existing literature and case studies. The current research situation shows overlaps of the two syndromes with regard to the etiology, the pain mechanism as well as a psychosocial aspect. The literature shows that more women than men are affected by LBP and other chronic pain syndromes. EM occurs almost exclusively in women and, like LBP, is considered a chronic pain syndrome. Thus, a common pain mechanism of the two syndromes is discussed in the literature. The most frequent overlap of the two syndromes is shown by the occurrence of LBP as a frequent symptom of EM. This connection can be justified by structural causes as well as by a reflex pain presentation.

CONCLUSION

In a physiotherapeutic setting, evidence of EM can be observed in the history and physical examination. Considering these factors may help shorten the diagnosis time of endometriosis by referring for further evaluation if gynecologic involvement is suspected in LBP. A comprehensive history is important and should cover urologic, gynecologic, as well as sexual history. In this article, the term woman is used to refer to the biological female sex and is not related to individual gender identity. The clinical picture mainly affects women, which is why in the following work, as far as it concerns the people suffering from the disease, it is not used in the opposite sense.

Sexual dysfunction among early-onset colorectal cancer survivors: Sex-specific correlates of sexual health discussions between patients and providers

PURPOSE

To examine the prevalence of female sexual dysfunction (FSD), male erectile dysfunction (ED), and the prevalence and correlates of sexual health discussions between early-onset CRC survivors and their health care providers.

METHODS

An online, cross-sectional survey was administered in partnership with a national CRC advocacy organization. Respondents (n = 234; diagnosed < 50 years, 6-36 months from diagnosis/relapse) were colon (36.8%) and rectal (63.3%) cancer survivors (62.5% male). The Female Sexual Function Index (FSFI-6) was used to measure FSD, and the International Index of Erectile Function (IIEF-5) was used to measure ED. Survivors reported whether a doctor communicated with them about sexual issues during/after treatment.

RESULTS

Among females (n = 87), 81.6% had FSD (mean FSFI-6 score = 14.3 [SD±6.1]). Among males (n = 145), 94.5% had ED (mean IIEF-5 score = 13.6 [SD±3.4]). Overall, 59.4% of males and 45.4% of females reported a sexual health discussion. Among the total sample, older age of diagnosis and relapse were significantly associated with reporting a discussion, while female sex was negatively associated with reporting a sexual health discussion. Among males, older age at diagnosis and relapse, and among females, older age of diagnosis, were significantly associated with reporting a sexual health discussion.

CONCLUSION

The prevalence of FSD and ED were high (8 in 10 females reporting FSD, almost all males reporting ED), while reported rates of sexual health discussion were suboptimal (half reported discussion). Interventions to increase CRC provider awareness of patients at risk for not being counseled are needed to optimize long-term health outcomes.

Effects of Pelvic Floor Muscle Physiotherapy on Urinary, Bowel, and Sexual Functions in Women with Deep Infiltrating Endometriosis: A Randomized Controlled Trial

Background and Objectives: Endometriosis is a chronic and recurrent disease defined as the presence and proliferation of endometrial glands and stroma outside the uterine cavity. It affects up to 6-10% of women of reproductive age and can be classified into superficial, ovarian, and deep infiltrating endometriosis (DIE). Deep infiltrating endometriosis can be associated with pain symptoms and pelvic floor muscle hypertone. Moreover, it may be responsible of bowel, urinary, and sexual dysfunctions with impairment of women's quality of life. Few studies have investigated the role of physiotherapy in women with DIE. Here, we aimed first to evaluate the effects of pelvic floor physiotherapy (PFP) on urinary, bowel, and sexual functions. Secondly, we aimed to evaluate the effects of ultrasound visual feedback during PFP on pelvic floor and subjective modifications in the frequency of sexual intercourse. Materials and Methods: This randomized controlled trial was conducted between June 2018 and December 2019 at our tertiary center. Nulliparous women with DIE and superficial dyspareunia were enrolled. At first examination, levator hiatal area (LHA) assessed with 3D/4D transperineal ultrasound, pain symptoms, urinary, bowel, and sexual functions were evaluated. Then, women were randomly assigned to no intervention (control group) or treatment with five individual sessions of PFP (experimental group), and after four months women underwent a second examination. Urinary, bowel, and sexual functions were assessed with validated questionnaires at first and second examinations. In particular, the Bristol Female Lower Urinary Tract Symptoms questionnaire was used to evaluate urinary symptoms, the Knowles-Eccersley-Scott-Symptom questionnaire to assess the presence of constipation, and the Female Sexual Function Index to investigate sexual function. Study outcomes were the comparisons among groups in terms of differences in actual changes in median of questionnaire scores between first and second examinations. Results: Thirty women (17 in the experimental group and 13 in the control group) completed the study. No significant differences were found between the two groups regarding urinary, bowel, and sexual functions, although women in the experimental group showed a tendency towards an improvement in constipation symptoms. Conclusion: In women with DIE, PFP does not appear to affect urinary, bowel, and sexual functions. Therefore, despite the improvement in superficial dyspareunia, chronic pelvic pain, and PFM relaxation with high treatment satisfaction, women should be informed about the unclear impact of PFP on urinary, bowel, and sexual functions. Larger studies are necessary to further investigate the impact of PFP on these functions.

Lumbar endoscopic spine surgery for persistent genital arousal disorder/genitopelvic dysesthesia resulting from lumbosacral annular tear-induced sacral radiculopathy

BACKGROUND

Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by distressing, abnormal genitopelvic sensations, especially unwanted arousal. In a subgroup of patients with PGAD/GPD, cauda equina Tarlov cyst-induced sacral radiculopathy has been reported to trigger the disorder. In our evaluation of lumbosacral magnetic resonance images in patients with PGAD/GPD and suspected sacral radiculopathy, some had no Tarlov cysts but showed lumbosacral disc annular tear pathology.

AIM

The aims were 2-fold: (1) to utilize a novel multidisciplinary step-care management algorithm designed to identify a subgroup of patients with PGAD/GPD and lumbosacral annular tear-induced sacral radiculopathy who could benefit from lumbar endoscopic spine surgery (LESS) and (2) to evaluate long-term safety and efficacy of LESS.

METHODS

Clinical data were collected on patients with PGAD/GPD who underwent LESS between 2016 and 2020 with at least 1-year follow-up. LESS was indicated because all had lumbosacral annular tear-induced sacral radiculopathy confirmed by our multidisciplinary management algorithm that included the following: step A, a detailed psychosocial and medical history; step B, noninvasive assessments for sacral radiculopathy; step C, targeted diagnostic transforaminal epidural spinal injections resulting in a temporary, clinically significant reduction of PGAD/GPD symptoms; and step D, surgical intervention with LESS and postoperative follow-up.

OUTCOMES

Treatment outcome was based on the validated Patient Global Impression of Improvement, measured at postoperative intervals.

RESULTS

Our cohort included 15 cisgendered women and 5 cisgendered men (mean ± SD age, 40.3 ± 16.8 years) with PGAD/GPD who fulfilled the criteria of lumbosacral annular tear-induced sacral radiculopathy based on our multidisciplinary management algorithm. Patients were followed for an average of 20 months (range, 12-37) post-LESS. Lumbosacral annular tear pathology was identified at multiple levels, the most common being L4-L5 and L5-S1. Twenty-two LESS procedures were performed in 20 patients. Overall, 80% (16/20) reported improvement on the Patient Global Impression of Improvement; 65% (13/20) reported improvement as much better or very much better. All patients were discharged the same day. There were no surgical complications.

CLINICAL IMPLICATIONS

Among the many recognized triggers for PGAD/GPD, this subgroup exhibited lumbosacral annular tear-induced sacral radiculopathy and experienced long-term alleviation of symptoms by LESS.

STRENGTHS AND LIMITATIONS

Strengths include long-term post-surgical follow-up and demonstration that LESS effectively treats patients with PGAD/GPD who have lumbosacral annular tear-induced sacral radiculopathy, as established by a multidisciplinary step-care management algorithm. Limitations include the small study cohort and the unavailability of a clinical measure specific for PGAD/GPD.

CONCLUSION

LESS is safe and effective in treating patients with PGAD/GPD who are diagnosed with lumbosacral annular tear-induced sacral radiculopathy.

Safety and efficacy of fractional CO2 laser treatment to the vestibule: a randomized, double-blind, sham-controlled, prospective 3-site clinical study in women with vestibular pain

BACKGROUND

Data are limited regarding fractional CO2 laser as a nonhormonal treatment for vestibular pain.

AIM

We sought to perform what is, to our knowledge, the first multisite prospective randomized, double-blind, sham-controlled clinical trial to assess the safety and efficacy of fractional CO2 laser treatment to the vestibule in women with vestibular pain.

METHODS

Subjects (n = 70) meeting inclusion/exclusion criteria at each of 3 sites were randomized 2:1 to active or sham (zero energy) fractional CO2 laser treatment using the vestibular probe (SmartXide2 V2LR - MonaLisa Touch, DEKA, Florence, Italy). Subjects in each treatment arm received 3 treatments 4 weeks apart. At the initial follow-up (week 12), subjects were unblinded and those initially assigned to sham started active treatment.

OUTCOMES

Outcome measures included changes from baseline in sexual activity diaries and scores for the Vulvoscopic Genital Tissue Appearance Scale (VGTA), vestibular cotton-tipped swab testing, McGill Pain Questionnaire, Female Sexual Function Index (FSFI), Female Sexual Distress Scale-Revised (FSDS-R), and the O'Leary-Sant voiding and pain indices, the Interstitial Cystitis Symptom Index (ICSI) and Interstitial Cystitis Problem Index (ICPI).

RESULTS

After active treatment, VGTA scores significantly improved in 5 parameters. Pain associated with cotton-tipped swab testing was significantly reduced at weeks 4 through 16 (mean change from baseline -0.64 [95% CI, -0.79 to -0.50] and -1.31 [95% CI, -1.46 to -1.16], respectively). FSFI pain domain scores improved significantly at weeks 12 and 16 (mean change from baseline 0.925 [95% CI, 0.10-1.75] and 1.22 [95% CI, 0.40-2.05], respectively). FSFI total scores increased significantly at weeks 12 and 16 (mean change from baseline 6.24 [95% CI, 2.64-9.85] and 4.96 [95% CI, 1.36-8.57], respectively). FSDS-R scores decreased significantly at weeks 12 and 16 (mean change from baseline -5.84 [95% CI, -8.80 to -2.87] and -9.15 [95% CI, -12.11 to -6.18], respectively). ICSI scores decreased significantly at weeks 12 and 16 (mean change from baseline -0.91 [95% CI, -1.65 to -0.18] and -0.754 [95% CI, -1.49 to -0.02], respectively). ICPI scores decreased significantly at week 16 (mean change from baseline -0.99 [95% CI, -1.63 to -0.34]). In contrast, there were no significant changes in outcomes in the sham arm. No serious adverse events occurred.

CLINICAL IMPLICATIONS

Fractional CO2 laser treatment in women with vestibular pain resulted in improvement from baseline in multiple key outcome measures of vestibular health.

STRENGTHS AND LIMITATIONS

Strengths of the study were that it was a multisite prospective randomized double-blind, sham-controlled clinical trial that included multiple measures related to vestibular pain and sexual function. Limitations were the nonvalidated primary outcome measure and limited study cohort.

CONCLUSION

Fractional CO2 laser therapy is a safe and effective nonhormonal treatment for vestibular pain.

A Comprehensive Treatment Protocol for Endometriosis Patients Decreases Pain and Improves Function

Purpose

The purpose of this paper is to evaluate the efficacy of a multimodal, outpatient neuromuscular protocol in treating remaining sensitization and myofascial pain in endometriosis patients post-surgical excision.

Patients and Methods

A retrospective longitudinal study was conducted for women aged 22 to 78 with a history of surgically excised endometriosis. 60 women with an average duration of pain of 8.63 ± 7.65 years underwent a treatment protocol consisting of ultrasound guided trigger point injections, peripheral nerve blocks, and pelvic floor physical therapy for 6 weeks. Concomitant cognitive behavioral therapy once weekly for a total of 12 weeks was also undertaken. Pain intensity and pelvic functionality were assessed at new patient consults and 3-month follow ups using Visual Analogue Scale (VAS) and Functional Pelvic Pain Scale (FPPS).

Results

At new patient consults, average VAS and FPPS were 7.45 ± 2.11 (CI 6.92-7.98) and 14.35 ± 6.62 (CI 12.68 -16.02), respectively. At 3-month follow ups, average VAS and FPPS decreased to 4.12 ± 2.44 (CI 3.50-4.73; p < 0.001) and 10.3 ± 6.55 (CI 8.64-11.96; p < 0.001), respectively. Among FPPS categories, sleeping, intercourse, and working showed the highest statistical significance.

Conclusion

Data suggests the multimodal protocol was effective in treating the remaining underlying sensitization and myofascial pain seen in Endometriosis patients post-surgical excision, particularly in decreasing pain and improving function during work and intercourse.

Sexual Dysfunction After Traumatic Injury Can Be Corrected by Transcranial Magnetic Stimulation: A Case Report

Neurogenic sexual dysfunction (NSD) is a common problem in patients after spinal and pelvic trauma. New treatment is needed beyond medicine or psychological therapies. A 24-year-old man who fell from a six-floor building suffered from subsequent NSD. Repetitive transcranial magnetic stimulation (rTMS) was the only method used to treat his NSD caused by multiple spinal and pelvic injuries. The therapy lasted for 3 courses. Motor and sensory conduction, as well as sexual function, were evaluated before and after the rTMS intervention. Improvements on patient's nerve conduction and sexual activity were confirmed at a 1-year follow-up. Our findings indicate that rTMS delivered a novel, positive and low-cost modality treatment to the patient with NSD. Clinical efficacy and potential mechanisms by which rTMS regulate NSD need to be investigated by further clinical trials.

Treatment of Sexual Dysfunction in Women with Systemic Autoimmune Rheumatic Disorders: A Systematic Review

Introduction

Female sexual dysfunction (SD) is an under-recognized and undertreated problem in patients with systemic autoimmune rheumatic disorders (SARDs).

Objectives

To summarize and evaluate the existing treatment modalities for SD in females with SARDs.

Methods

A systematic review was conducted following the PRISMA guidelines. Electronic databases were searched up to April 2022 for studies that assessed the use of pharmacological and non-pharmacological treatment modalities for the management of SD in females with SARDs. Randomized and observational studies were included. (PROSPERO: CRD42022296381).

Results

Seven studies with 426 females with SD were included. Seven different treatment modalities belonging to 5 different classes (androgen therapy, phosphodiesterase-5 inhibitors, exercise, education and local creams) were evaluated in patients with systemic lupus erythematosus, rheumatoid arthritis and systemic sclerosis. The majority of the studies were of low methodological quality. Standardized patient education and 8-week aerobic walking programs were successful in improving female SD. Local creams improved dyspareunia in females with systemic sclerosis. Testosterone did not significantly improve SD in patients with systemic lupus erythematosus. Accordingly, tadalafil did not result in a significant improvement of SD in females with systemic sclerosis, based on the Female Sexual Function Index.

Conclusion

There is a lack of sufficient evidence to recommend a certain management strategy for SD in females with SARDs. Nonpharmacological therapy and lubricant creams may be beneficial in females with SARDs. No benefit was demonstrated after androgen therapy or tadalafil. Still, no definite conclusions can be drawn due to the important limitations of the available literature. Overall, our results may be considered preliminary and further research in the field is mandatory.

Opioid-Induced Sexual Dysfunction in Cancer Patients

Simple Summary

Sexual disorders affect up to 80% of cancer patients, depending on the type of cancer, yet they are commonly overlooked and untreated. Opioid-induced sexual dysfunction (OISD) is reported in half of opioid users. The pathophysiology of OISD—still a subject for research—may include disorders of both the endocrine and nervous systems, expressed in, among other things, erectile dysfunction and declined sexual desire, sexual arousal, orgasm, and general satisfaction with one’s sex life. The etiology of sexual dysfunction in cancer patients is usually multifactorial, so the management should be multifaceted and individualized by targeting pathophysiological factors. The treatment options for OISD are few and include testosterone replacement therapy, bupropion, opioid antagonists, phosphodiesterase type 5 inhibitors, plant-derived substances, and non-pharmacological treatments, although the evidence is insufficient. One of the treatment options may also be a choice of an opioid that is less likely to cause sexual dysfunction, yet further research is necessary.

Abstract

Sexual dysfunction is common in patients with advanced cancer, although it is frequently belittled, and thus consistently underdiagnosed and untreated. Opioid analgesics remain fundamental and are widely used in cancer pain treatment. However, they affect sexual functions primarily due to their action on the hypothalamus–pituitary–gonadal axis. Other mechanisms such as the impact on the central and peripheral nervous systems are also possible. The opioid-induced sexual dysfunction includes erectile dysfunction, lack of desire and arousal, orgasmic disorder, and lowered overall sexual satisfaction. Around half of the individuals taking opioids chronically may be affected by sexual dysfunction. The relative risk of sexual dysfunction in patients on chronic opioid therapy and opioid addicts increased two-fold in a large meta-analysis. Opioids differ in their potential to induce sexual dysfunctions. Partial agonists and short-acting opioids may likely cause sexual dysfunction to a lesser extent. Few pharmaceutical therapies proved effective: testosterone replacement therapy, PDE5 inhibitors, bupropion, trazodone, opioid antagonists, and plant-derived medicines such as Rosa damascena and ginseng. Non-pharmacological options, such as psychosexual or physical therapies, should also be considered. However, the evidence is scarce and projected primarily from non-cancer populations, including opioid addicts. Further research is necessary to explore the problem of sexuality in cancer patients and the role of opioids in inducing sexual dysfunction.

The Most Common Functional Disorders and Factors Affecting Female Pelvic Floor

The pelvic floor (PF) is made of muscles, ligaments, and fascia, which ensure organ statics, maintain muscle tone, and are involved in contractions. This review describes the myofascial relationships of PF with other parts of the body that determine the proper functions of PF, and also provides insight into PF disorders and the factors contributing to them. PF plays an important role in continence, pelvic support, micturition, defecation, sexual function, childbirth, and locomotion, as well as in stabilizing body posture and breathing, and cooperates with the diaphragm and postural muscles. In addition, PF associates with distant parts of the body, such as the feet and neck, through myofascial connections. Due to tissue continuity, functional disorders of muscles, ligaments, and fascia, even in the areas that are distant from PF, will lead to PF disorders, including urinary incontinence, fecal incontinence, prolapse, sexual dysfunction, and pain. Dysfunctions of PF will also affect the rest of the body.

Assessment of the Pelvic Floor and Associated Musculoskeletal System: Guide for Medical Practitioners

OBJECTIVES

This study aimed to assist practitioners in performing an accurate assessment of the external and internal pelvic musculoskeletal (MSK) systems to improve appropriate diagnosis and referral of patients with pelvic floor disorders or pelvic pain and to improve understanding of physical therapy (PT) treatment principles, thereby improving communication between practitioners and encouraging a multidisciplinary approach.

METHODS

A referenced review of the anatomy of the pelvic floor muscles, pelvis, and surrounding structures, followed by a detailed assessment of anatomy, posture, and gait, is presented. A thorough description of PT assessment and treatment is included with clinical relevance.

RESULTS

When proper assessments are routinely performed, MSK conditions can be recognized, allowing for prompt and appropriate referrals to PT. Assessment and treatment by qualified physical therapists are integral to pelvic health care. After efficient medical assessment, MSK dysfunction can be addressed expeditiously, thereby avoiding further decline. Left unaddressed, pelvic dysfunction may become chronic.

CONCLUSIONS

We propose a guide for MSK assessment of the pelvis and associated structures that can be used for both clinical and research purposes. This guide is designed for health care providers caring for women with pelvic floor disorders, including physicians, advanced practice providers, and nurses. This guide serves to improve communication among multidisciplinary practitioners to refine MSK assessment and treatment approaches and thereby advance clinical care and research.

Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy

INTRODUCTION

Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted.

OBJECTIVES

To systematically appraise the current literature on efficacy of PFPT modalities related to PFH.

METHODS

PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included. Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients' perceived effect.

RESULTS

The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.

CONCLUSION

The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2021;XX:1-22.

Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial

OBJECTIVES

Deep infiltrating endometriosis (DIE) is associated with chronic pelvic pain, dyspareunia and pelvic floor muscle hypertonia. The primary aim of this study was to evaluate the effect of pelvic floor physiotherapy (PFP) on the area of levator ani hiatus during Valsalva maneuver, assessed using transperineal ultrasound, in women with DIE suffering from superficial dyspareunia.

METHODS

This was a randomized controlled trial of 34 nulliparous women diagnosed with DIE and associated superficial dyspareunia. After an initial clinical examination, all patients underwent three-dimensional/four-dimensional (3D/4D) transperineal ultrasound to measure the levator hiatal area (LHA) at rest, on maximum pelvic floor muscle contraction and on maximum Valsalva maneuver, and were asked to rate their pain symptoms using a numerical rating scale (NRS). Eligible women were assigned randomly (1:1 ratio) to no intervention (control group, 17 women) or treatment with five individual sessions of PFP (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and LHA on transperineal ultrasound. The primary outcome measure was the percentage change in LHA on maximum Valsalva maneuver between the baseline and follow-up examinations. The percentage changes in pain symptoms between the two examinations, including superficial and deep dyspareunia, dysmenorrhea, chronic pelvic pain, dysuria and dyschezia, were also evaluated.

RESULTS

Thirty women, comprising 17 in the study group and 13 in the control group, completed the study and were included in the analysis. The percentage change in LHA on maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0 ± 24.8% vs -0.5 ± 3.3%; P = 0.02), indicating better pelvic floor muscle relaxation. After PFP treatment, the NRS score for superficial dyspareunia remained almost unchanged in the control group (median change in NRS (Δ-NRS), 0 (interquartile range (IQR), 0-0)) while a marked reduction was observed in the study group (median Δ-NRS, -3 (IQR, -4 to -2); P < 0.01). Moreover, there was a significant difference between the PFP and control groups with regards to the change in chronic pelvic pain (median Δ-NRS, 0 (IQR, -2 to 0) vs 0 (IQR, 0-1); P = 0.01).

CONCLUSIONS

In women with DIE, PFP seems to result in increased LHA on Valsalva maneuver, as observed by 3D/4D transperineal ultrasound, leading to improved superficial dyspareunia, chronic pelvic pain and pelvic floor muscle relaxation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

The Effect of Pelvic Floor Rehabilitation on Males with Sexual Dysfunction: A Narrative Review

INTRODUCTION

Increasing evidence has suggested that pelvic floor exercises and manual physical therapy may improve premature ejaculation (PE) and erectile dysfunction (ED) in males.

OBJECTIVES

To examine the effects of pelvic floor physical therapy treatment in men suffering from PE and ED.

METHODS

We searched Google Scholar, PubMed, Medline, PEDro databases from inception till January 2020 applying the following keywords: pelvic floor, erectile dysfunction, impotence, physiotherapy, exercises, rehabilitation, and pelvic floor muscle exercises.

RESULTS

The review included 37 papers reporting on PE and ED, of which 5 were randomized controlled trials, 2 meta-analyses, and 4 observational studies. Pelvic floor physical therapy treatment included education and rehabilitation. The rehabilitation part encompassed manual therapy techniques that contribute to the normalization of muscle tone and improvement of muscle relaxation. Moreover, exercises, according to the patients' clinical assessment were presented. Most of the studies reported that by strengthening the pelvic floor muscles (PFMs), ED and PE can be improved if manual physical therapy treatments are combined with PFM training.

CONCLUSIONS

A multifaceted approach should be chosen by physical therapists when evaluating and treating ED and PE and contending with both musculoskeletal dysfunction and behavioral contributions. It is recommended that exercises be monitored and situations involving, that is, hyperactivity/increased tone of the PFMs should be avoided. PFM training is simple, safe, and noninvasive; therefore, it should be a preferred approach in the management of ED and PE. This paper presents narrative reviews with a potential bias that systematic reviews or meta-analyses do not have, however, we strove to be all-encompassing and unbiased. There is a demand for high-quality scientific reviews examining the effectiveness of PFM training, manual therapy, and the rationale of pelvic floor physical therapy, in general, in treating individuals with PE and ED.

Relationship Between Sexual Function and Pelvic Floor and Hip Muscle Strength in Women With Stress Urinary Incontinence

INTRODUCTION

The pelvic floor muscle (PFM) could affect female sexual functions. The hip muscles are morphologically and functionally linked to PFM and are important elements of female sexual attraction.

AIM

To determine the relationship between female sexual function and hip muscle strength and PFM functions in women with stress urinary incontinence (SUI).

METHODS

A total of 42 women with SUI were recruited in this study. Female sexual function was measured using the pelvic organ prolapse urinary incontinence sexual function questionnaire (PISQ). PFM functions were measured using a perineometer. Hip muscle strength was measured using a Smart KEMA tension sensor. The relationship between female sexual function and PFM function and hip muscle strength was assessed using Pearson correlation coefficients and multiple regression analyses with forward selection.

MAIN OUTCOME MEASURES

PISQ score, PFM functions (strength and endurance), and strength of hip extensor, abductor, and adductor were the main outcome measures.

RESULTS

For the behavioral/emotive domain in the PISQ, hip extensor strength (r = 0.452), PFM strength (r = 0.441), PFM endurance (r = 0.362), and hip adductor strength (r = 0.324) were significantly correlated and hip extensor strength emerged in multiple regression. For the physical domain in the PISQ, hip abductor strength (r = 0.417), PFM endurance (r = 0.356), hip adductor strength (r = 0.332), and PFM strength (r = 0.322) were significantly correlated and hip abductor strength entered in multiple regression. For partner-related domain in the PISQ, hip adductor (r = 0.386) and abductor strength (r = 0.314) were significantly correlated and hip adductor strength appeared in multiple regression. For the PISQ total score, hip extensor strength (r = 0.484), PFM endurance (r = 0.470), hip adductor strength (r = 0.424), hip abductor strength (r = 0.393), and PFM strength (r = 0.387) were significantly correlated and hip extensor strength and PFM endurance emerged in multiple regression.

CONCLUSION

The female sexual function could be related to not only PFM functions but also hip muscle strength in women with SUI. Hwang UJ, Lee MS, Jung SH, Ahn SH, Kwon OY. Relationship Between Sexual Function and Pelvic Floor and Hip Muscle Strength in Women With Stress Urinary Incontinence. Sex Med 2021;9:100325.

Effects of Exercise-Based Interventions on Urogenital Outcomes in Persons with Spinal Cord Injury: A Systematic Review and Meta-Analysis

In this systematic review, objectives were to investigate dropout rates, adverse events, and effects of exercise-based therapies on urogenital function and quality of life (QoL) in persons with spinal cord injury (SCI). Database searches were conducted on MEDLINE, EMBASE, and CINAHL for studies examining any form of exercise intervention on urogenital function and/or QoL in adults with SCI. Quality of publications was evaluated using the Joanna Briggs Institute critical evaluation tools. When possible, Hedges' g was calculated for overall effect sizes. Subgroup analyses were conducted on sex and injury severity. Ten studies (228 participants) were included in this review. Three studies examined pelvic floor muscle training, and seven studies examined locomotor training. Overall quality of evidence was low because of small sample sizes and non-randomized designs in most studies. Dropout rates ranged from 12% to 25%, and adverse events were reported only in some studies investigating locomotor training. For lower urinary tract (LUT) outcomes, urodynamic findings were mixed despite moderately positive changes in maximum bladder capacity (g = 0.50) and bladder compliance (g = 0.37). Fairly consistent, but small, improvements were observed in LUT symptoms, primarily bladder awareness and incontinence. LUT QoL improved in most cases. Fewer data were available for sexual outcomes, and only minor improvements were reported. Subgroup analyses, based on sex and severity of injury, were inconclusive. There is some indication for the potential benefit of exercise on urogenital outcomes in persons with SCI, but there is insufficient evidence given the number of studies and heterogeneity of outcome measures.

Recovery time period and quality of life after hysterectomy

Background: Women who had undergone hysterectomy have to overcome problems related to sexual and reproductive health. They often suffer a decline in self-esteem due to sexual dysfunction and the inability to give birth, along with their quality of recovery. This study aims to describe the relationships between recovery time and the components of quality of life after hysterectomy.

D esign and methods: 103 women post-hysterectomy from several community-integrated health center in Surabaya were selected using the total sampling technique.

Results: Findings show that there is relationship between recovery time period and sexual activity (P=0.000). However, no significant relationship exists between recovery time period personal relationships and social support.

Conclusions: It is recommended that nurses should improve their social support for women and families during recovering, to avoid pathological stress and improve quality of life.

Transperineal Ultrasound Visual Feedback Assisted Pelvic Floor Muscle Physiotherapy in Women With Deep Infiltrating Endometriosis and Dyspareunia: A Pilot Study

A prospective study with the aim to evaluate the effects of pelvic floor physiotherapy was conducted among women with deep infiltrating endometriosis (DIE) and associated dyspareunia. At initial evaluation superficial and deep dyspareunia were assessed using a numerical rating scale, and levator hiatus area (LHA) was assessed with 3-D/4-D transperineal ultrasound. Women underwent five individual sessions of ultrasound visual feedback assisted pelvic floor physiotherapy. One month after the therapy, dyspareunia and LHA were reassessed and compared with pre-therapy data. Pelvic floor physiotherapy seems to improve both superficial and deep dyspareunia and pelvic floor muscle relaxation in women with DIE.

Rethinking endometriosis care: applying the chronic care model via a multidisciplinary program for the care of women with endometriosis

Endometriosis is a chronic, painful disease without a cure. Due largely to chronic pain, endometriosis can lead to significant physical, mental, relationship, and financial burdens. Within the conventional single provider model of care—in which the patient is primarily taken care of by her physician and complementary strategies based on psychology, nutrition, pain medicine, pelvic physical therapy, and so on may not be readily available in a coordinated manner—most women with endometriosis live with unresolved pain and the consequences of that pain. We therefore propose that there is an urgent need to search for alternative models of care. In the current paper, we discuss our experiences with an model of care in which we adopt a long-term, patient-focused, and multidisciplinary chronic care model for women with endometriosis. Our objective is to improve long-term clinical outcomes for women with endometriosis. For geographical areas and healthcare systems in which it is feasible, we propose consideration of this multidisciplinary model of care as an alternative to the single provider model and offer guidance for those considering establishment of such a program. We also initiate a conversation about which clinical outcomes pertaining to endometriosis are important and should be tracked to assess the efficacy and value of multidisciplinary and other endometriosis healthcare models.