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The Diagnosis and Treatment of Vaginismus

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1 The Diagnosis and Treatment of Vaginismus
KCNPNM Annual Conference April 2014 By Jean D. Koehler, Ph.D. And Susan Dunn, P.T.

2 Koehler Disclosures Proctor and Gamble – Consultant and interviewer for Stage 3 clinical trials on testosterone patch for women – Proctor and Gamble- Regional Consultant’s Board Ortho-McNeil- Pharmaceuticals- Advisory Board of Female Sexual Dysfunction experts- November 2004 Boeringer Ingleheim- Speaker’s Bureau-2010 Ask: “How many of you routinely ask your annual exam patients about having any sexual difficulties? In a study published in 2009, patients reported that only 15% of their physicians did so, but 54% of these same patients believed that their doctors should routinely ask. 44% of those who were sexually active and had a problem sought no help.

3 Vaginismus Definition Proposed by Rosemary Basson, M.D.
The persistent or recurrent difficulties of the woman to allow vaginal entry of the penis, a finger, and/or any object despite the woman’s expressed desire to do so. There is often phobic avoidance, involuntary pelvic floor muscle contraction, and the anticipation/fear/experience of pain. Structural abnormalities must be ruled out/addressed. Basson et al, 2004

4 DSM V- 302.76 (Women’s) Genito-Pelvic Pain/Penetration Disorders
Marked vulvovaginal pain in penetration attempts (dyspareunia) Marked anxiety about penetration or anticipated penetration Marked tightening of pelvic floor muscles during attempted penetration (was called Vaginismus in prior manuals)

5 Types of Vaginismus Primary- never achieved attempted coitus
Secondary- onset after pain free coitus Total- penetration not possible through the PC muscle Partial- penetration achieved, but painful Situational- only with some penetrants with penis but not speculum or visa versa with larger sized partner but not smaller sized with gyn exam, but not with coitus

6 Incidence of Sexual Pain Disorders
US general population data- Michael et al, 1994 Consistent coital pain in females-10-15% International general population data- Lewis et al, 2004 Vaginismus- 6% Coital pain- 2-20% The Cochrane Database of Systemic Reviews- McGuire and Hawton, 2002 Vaginismus in medical settings- 4-12% Vaginismus in sexual Dysfunction Clinics- 5-17% Women of childbearing age- est. .5-1% Graziottin, A. 2008 Graziottin, A. Dyspareunia and vaginismus… Current Sex. Health Rep. 2008; 5:443-50

7 The BIO-PSYCHO-SOCIAL APPROACH TO VAGINISMUS
DIAGNOSIS and TREATMENT

8 Interpersonal Psychological Sexual Function Throughout a Woman’s
Factors Impacting Changes in Female Sexual Function - Variables from Mid Aged Woman’s Sexual Functioning Study Europe and Australia (Graziottin & Dennerstein in press,2005) Partner status Wellbeing Interpersonal Psychological Stress Sexual Function Throughout a Woman’s Lifespan Menopause Stress Sociocultural Biological Parity Exercise BMI Health Age c. J Alexander ‘05

9 Medical Conditions That May Lead to Vaginismus
PVD- provoked vestibulodynia- one of most common causes of dyspareunia in pre-menopausal women (Smith 2014) Estrogen, testosterone deficiency OC use before 16, and for up to 2-4 years (Davis 2013) Vulvovaginal atrophy in menopausal women (Hope 2010) Pelvic floor disorders Vaginal infection- i.e. recurrent yeast, herpes, bacterial vaginosis, HPV? Vulvar dermatoses, i.e. lichens sclerosis Allergy to condoms, semen Endometriosis Radiation therapy Injury from force –rape Prior painful vaginal/urological medical interventions- especially in childhood/teen years- iatrogenic? Female Genital Mutilation Genetic abnormalities- i.e. septate hyman Susan will speak on vestibulodynia. Much of this slide is from vanLankveld, Jacques et al. Women’s Sexual Pain Disorders. J Sexual Medicine 2010; 7: May naturally improve over time. Davis SNP, Bergeron S, Binik YM, and Lambert B. Women with provoked vestibulodynia experience clinically significant reductions in pain regardless of treatment: Results from a 2-year follow-up study. J Sex Med 2013;10:3080–3087. Role of OCP’s in vulvadynia- ISSWSH 2010 Hormonal Contraception and Female Pain, Orgasm and Sexual Pleasure (pages 462–470) Nicole K. Smith, Kristen N. Jozkowski and Stephanie A. Sanders. The Journal of Sexual Medicine Volume 11, Issue 2, pages 462–470, February 2014 The sample included 1,101 women with approximately half (n = 535) using a hormonal contraceptive method exclusively or a combination of a hormonal and nonhormonal method, and about half (n = 566) using a nonhormonal method of contraception exclusively. Hierarchical regression analyses were conducted to examine the relation of hormonal contraceptive use to each of the dependent variables. Women using a hormonal contraceptive method experienced less frequent sexual activity, arousal, pleasure, and orgasm and more difficulty with lubrication even when controlling for sociodemographic variables. Hope et al. Menopause International Vol. 16 No. 2 June 2010

10 Psycho-social Conditions Correlating to Vaginismus- Research Results
Pre-existing General Anxiety Disorder1 Personality features- fear of new experiences, catastrophizing thoughts about pain, disgust propensity, low self-esteem2, 3 Specific fear of penile vaginal penetration2 Less self stimulation2 Increased prevalence of desire and arousal problems2 1- Watts and Nettle, 2010 2- van Lankveld et al., 2010 3- Borg, C. et al. 2012 1-Watts and Nettle. JSM 2010;7: Significant and substantial increase in GAD in vaginismic women, many reported being generally anxious prior to vaginismus 2- vanLankveld, Jacques et al. Women’s Sexual Pain Disorders. J Sexual Medicine 2010; 7: 3- Borg, C et al. Vaginismus: Heightened Harm avoidance and pain catastrophizing cognitions. JSM 2012, 9:

11 Possible Psychosocial Causes- Clinical Observations
Strict religious proscriptions against sexual interaction/especially coitus Body Myths Phobia to vaginal penetration, sometimes of any orifice Sexual abuse or assault history- Poor or unsure relationship with sexual partner Fear of unplanned pregnancy, delivery pain Secretly unwanted pregnancy Stuck developmentally as a “good little girl”, not wanting to grow up sexually and disappoint parents Body myths/phobias-vaginal obstruction, not big enough, will be ripped apart, dilator lost once inside (vagina dropping off after PC), will gush out fluid, vart thus embarrasing self with partner or PT Unwanted pregnancy- warning by Mom that her life will be ruined like Mom’s was when she got pregnant with client; not finished with schooling, not financially prepared

12 The New Treatment Team for Sexual Pain Disorders
Pelvic Pain MD/NP Pelvic Floor Physical Therapist Certified Sex Therapist/ Psychotherapist There are medical causes of sexual pain that only MD’s can treat. There are pelvic floor disorders that cause sexual pain, and physical therapy treatments to relieve it. There are psychosexual factors that can cause or maintain sexual pain.

13 Case Example of the team approach Tara
Jean and Susan’s shared clients like KL and TO. Susan, any others you can remember?

14 Role of the Gyn Provider -
When the patient presents painful penetration as the reason for the office visit When the providers notices an inability to perform a speculum exam Susan wii comment on next few slides. I find it most useful to let each pt know she is in control.  There is never any pressure that an exam must be completed today.  We approach it with an open mind.  I move very slowly, explain what I will be doing iin advance and ask permission.  Some women do better inserting the speculum themselves.  If we do not make it through an exam, then we discuss if going to PT is the next step (generally these pt will do anything to get better).  I also offer trying again another day.  This can also be done with some sedation like Valium 5mg.  I have rarely had to resort to this.  Most pt with vaginismus respond wonderfully to PT - Susan has really helped a number of my patients.  If they are unable to get through a pelvic exam with me, they are usually successful after working with Susan.

15 Sexual History for Vaginismus
Is she in a sexually active relationship? Is penetration possible? If so, is it painful? Is it painful only at penetration? When else? Describe the pain? Locations, intensity, sharp/dull, etc. How anxious does she feel at the thought of penetration? Can she insert a tampon or finger without pain? How long has this been a problem? Was the onset sudden or gradual? Is it present all the time? Is pain experienced at times other than with intercourse? Is she able to become aroused and climax at all with self or partner? How anxious does she feel about the thought of a genital examination? If so, what about it makes her anxious? Has she ever had a traumatic sexual experience or history of physical/emotional/sexual abuse? What does she believe is causing her penetration pain? Koehler adapted from Crowley T,2009 & Kingsberg SA,2007 Kingsberg SA, Janata JW. Female sexual disorders: assessment, diagnosis, and treatment. Urol Clin N Am 2007;34:497–506 Crowley T, Goldmeier D, Hiller J. Diagnosing and managing vaginismus. BMJ 2009;338:b2284

16 Preparing for the Initial Exam with a Primary Vaginismus Patient

17 LISTEN-to your patient if she expresses fear and WATCH - for fearful body language
Let her decide who will be present Let her decide the extent of the initial exam Ask her if she can think of anything to facilitate the exam

18 EXPLAIN THE EXAM First show a film to all new pelvic exam patients if you can or Describe each step in advance as you proceed Offer sedation(Valium 5mg.) if needed Let her know she can interrupt the exam at any time without being a failure

19 REASSURE HER that you will let her have control of the exam
Pacing of insertion Inserting speculum herself Using a pediatric speculum Starting with your finger only while the patient bears down Or postponing internal exam pending completion of physical therapyor sex therapy

20 EDUCATE HER Give her a mirror to see her vulva
Explain her anatomy/correct misinformation Clarify what structures are normal or abnormal Ask her how she’s coping during the exam If exam is normal, explain how her fear and pelvic floor hypertonus tricks her into believing she’s too small for penetration Susan’s last slide

21 What if you still can’t examine her?
Have her practice the Rosenbaum Mindfulness Protocol In case that doesn’t work, in the same visit: Give her contact info of either a pelvic floor P.T. or Sex therapist or Both Let her choose which approach appeals to her

22 Rosenbaum Mindfulness Protocol
Uses mindfulness accompanied by systematic desensitization to reduce anxiety Can be first practiced at home Can be practiced in the provider’s exam room ahead of the examination or on a prior day See handout for protocol Rosenbaum and Padoa- 2012 Rosenbaum- 2011 Rosenbaum TY and Padoa A. Managing pregnancy and delivery in women with sexual pain disorders. J Sex Med 2012;9:1726–1735.

23 Further At-home steps when no sex therapist or pelvic floor physical therapist available
Once she has proceeded through these steps, she may continue to utilize the anxiety reduction techniques as they apply to self-touch of the genitals, self-touch of the vulvar vestibule and vaginal finger insertion. She may further apply these techniques for gradual dilator use with the practitioner and with her partner. This progression includes self-insertion of the dilator, self-insertion with her partner holding dilator as well, her partner inserting the dilator with the client holding it as well, and finally, her partner inserting the dilator.

24 The Role of the Gyn Provider in Secondary Vaginismus

25 TREAT ANY CO-MORBID MEDICAL CONDITIONS IF POSSIBLE
Case example of Secondary vaginismus originating with medical problems Insufficient lub for women not wanting to use E2. This meta-analysis indicates that ospemifene to be an effective and safe treatment for dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Cui Y, Zong HT, Yan HL, Li N, and Zhang Y. Treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy: A systematic review and meta-analysis. J Sex Med **;**:**–**. 2013

26 What Other Office-Based Treatments Can Medical Providers Try?

27 Provider- led Modified Sensate Focus
Good for couples seeking infertility treatment diagnosed with primary vaginismus no sex therapist or pelvic floor physical therapist in the area Results: Most resolved vaginismus Half became pregnant Nonpregnant evaluated for other sources of infertility See handout Jindal and Jindal, 2010

28 Botulinum Toxin (Botox)
Botox for treatment resistant cases No good controlled studies and adverse events need to be documented But pre vs. post treatment show it’s effectiveness Ferreira and Souza 2012 Meta-Analysis Adverse events two cases of mild stress incontinence one case of excessive vaginal dryness of 82 patients in one study Pacik,P. Aesth Plast Surg (2011) 35:1160–1164 Ferreira and Souza . Botulinum Toxin for vaginismus treatment . Review Pharmacology. 89(5-6):

29 What predicts successful treatment?
Reducing penetration fears Attributing the problem to psychological causes Positive attitude toward one’s genitalia Strong wish to become pregnant Better sexual knowledge Homework compliance Pretreatment martial satisfaction van Lankveld et al., 2010 2- vanLankveld, Jacques et al. Women’s Sexual Pain Disorders. J Sexual Medicine 2010; 7:

30 What predicts longer treatment?
Pretreatment sexual desire problems Fear of STI’s Negative parental attitudes towards sex Previous operations for vaginismus History of physical abnormality- like septum vaginitis van Lankveld et al., 2010

31 What doesn’t predict treatment outcome?
Sexual abuse history- Higher rate among vaginismus patients, but sexual abuse history doesn’t predict future vaginisimus Other sexual dysfunctions in either partner vanLankveld, Jacques et al ;

32 Pregnancy Considerations
Sexual pain patients wishing to conceive should avoid these topical or intravaginal agents: Gabapentin Baclofen Diazepam Amitriptyline Rosenbaum TY and Padoa. ACME Information: Managing Pregnancy and Delivery in Women with Sexual Pain Disorders. Review. J Sex. Med., Vol. 9, Issue 7, Article first published online: 3 JUL 2012

33 REFER HER IF NEEDED To a Pelvic Floor PT and/or Certified Sex Therapist Before proceeding with the exam if she prefers If she is unable to complete the exam For treatment of nonmedical causes of her vaginismus If there are mixed psychogenic and medical causes Susan may modify esp for distant patients.

34 Vulvodynia Defined by the International Society for the Study of Vulvovaginal Diseases (ISSVD) as vulval discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder. Patients can be further categorized by anatomical region (i.e. generalized vuvlodynia, hemivulvodynia, clitorodynia) and also by whether the pain is provoked or unprovoked.

35 Vulvar Vestibulitis Syndrome
A subset of vulvodynia, is the most frequent cause of dyspareunia in premenopausal women. (Mena et al, J Nerv Ment. Dis 1997: 185:561-69) Prevalence 9.8 – 15% in general gynecologic practice Diagnoses by severe pain to pressure or touch on the vulvar vestibule or introitus and vulvar erythema of varying degrees. The ISSVD 2003 classification is under vulvodynia

36 Dysfunctions/Common Diagnoses
Dyspareunia Muscle Atrophy Interstitial Cystitis Constipation Abdominal pain Vaginal Stenosis Incontinence Pubic Symphysis Pain Pelvic Organ Prolapse Piriformis Syndrome Diastasis Recti Vestibulodynia Vulvar Vestibulitis Vaginismus/anismus Levator ani syndrome Pudendal Neuralgia Iliopsoas Syndrome Episiotomy pain Coccydynia Obturator Internus Syndrome Post Operative pain Sciatica

37 Role of the Physical Therapist
Team approach with other health care providers. Physical Therapist focuses on neuromuscular/orthopedic/myofascial contribution to symptoms

38 What to Expect Many patients perceive physical therapy for these diagnoses to be different than physical therapy for other orthopedic/spine rehabilitation. Same therapy…….different body part Patient should expect a complete musculoskeletal evaluation of the symptomatic area.

39 Patient Profile Teen through adult life span Male and female
Sedentary and high end athlete Varying socio-economic Various cultural backgrounds

40 Questionnaire will include:
Pain with activity Bowel movements/Urination Sitting vs. standing vs. supine vs. prone Intercourse pain (with superficial and/or deep penetration/orgasm/positional dependent) Urologic changes with intercourse/orgasm Patient should fill out questionnaire that addresses sexual history i.e. abuse/pregnancies/pathology/psychiatric

41 PT Treatment Address Structure and Biomechanics
Mobilize/Stabilize Thoracic spine, Lumbar spine and SI Joints LLD, Postural abnormalities Muscle imbalance Address Connective Tissue Restrictions and MTrPs Connective Tissue Mobilization, Dry Needling Surrounding the bony pelvis Anterior, medial, lateral and posterior thighs Abdomen, low back, buttocks Nerve Mobilization Seating Adaptations/Work Modifications 41

42 Pudendal Nerve Nerve Roots: S2, S3, S4
50% sensory, 20% motor and 30% autonomic Susan and Erin already went over the anatomy of the pelvis and pelvic floor. Now I’d like to focus specifically on the pudendal nerve, its course, what it innervates and what can occur with injury to it. The Pudendal Nerve arises from the sacral nerve roots of S2,3,4; It is a mixed nerve of 50% sensory, 20% motor and 30% autonomic fibers. This make-up is unique to the pudendal nerve. Why is that important???? Motor and sensory nerves innervate somatic structures like skeletal muscles that are under voluntary control. Autonomic nerves innervate structures that are not under voluntary control, like the heart or lungs. Because the pudendal nerve is all of the above that’s the reason why our pelvic floor muscles can maintain a certain amount of activation at all times, Thus, keeping us from peeing our pants or letting things fall out! So remember : S2,3,4 Keeps it up off the floor! 42

43 Course of the Pudendal Nerve
In order to understand how the pudendal nerve can be injured you must first be familiar with its course through the pelvis. So, as I stated before, the PN arises from the sacral nerve roots S2-4, Exits through the greater sciatic foramen, runs anterior to the piriformis, crosses the ischial spine and goes between the sacrospinous and sacrotuberous ligaments, through the lesser sciatic foramen and through a tunnel formed by the splitting of the obturator fascia (or Alcock’s canal) . At Alcock’s canal it then splits into three branches: the inferior rectal, perineal and dorsal branches. 43

44 Iliopsoas

45

46 Pelvic Floor Muscles

47 Abdominal Wall Superficial Layers

48 Mechanism of Injury Traction Compression Surgical
Constipation, Childbirth, strenuous squatting Compression Cycling, Horseback riding, prolonged sitting Surgical Hysterectomies, corrective sx for prolapse Common etiology for nerve entrapment Visceral-Somatic Interaction Chronic bladder infections, yeast infections, bacterial prostatitis 48

49 Traction Injury Childbirth, Constipation, Strenuous Squatting 49
Tractioning of the pudendal nerve occurs with a prolonged or increased bearing down or valsalva as occurs with a vaginal delivery, deep weighted squats and straining to have a bowel movement. 49

50 Compression injury “Cyclist’s Syndrome” 50
There has been a lot of research done in Europe on pudendal neuralgia primarily due to the large cycling population. In the sports world, pudendal neuralgia is commonly termed “cyclist’s syndrome” due to the compression that the saddle/seat applies to the nerve over prolonged rides. There is a HUGE market for adaptive gear and seating for these cyslists. 50

51 Cycling adaptations Adaptations for cycling include changing the angle of the nose of the seat, increased padding in the compression shorts, wider seats and seat cut outs, but its very important to encourage these patients to make sure they have a proper bike fit 51

52 Surgical insult Hysterectomy, Correction of prolapse, Orthopedic 52
With surgical etiology you could have both the initial nerve irritation followed up by scarring and potential nerve entrapment. Again, this is why history is important. This surgery could have taken place a year ago…. It takes up to two years for tissues to bind, reform and “heal” so it is very possible that even though the surgery was months ago that it could still be the primary etiology. 52

53 Surgeries Gynecological surgeries requiring lithotomy position
Jackknife position Risk of muscle damage/scarring/adhesions with surgeries Total Hip arthroplasty – muscle stays intact but may be damaged when the femur is elevated and exposed Ito et al – “…short ER’s, especially conjoined tendon, are at high risk of being damaged and their detachment might be inevitable during the superior and/or posterior capsular release that is necessary to mobilize the femur during DAA in certain cases”

54 Visceral Chronic bladder infections, yeast infections, bacterial prostatitis Chronic inflammation of visceral structures can also cause irritation to the pudendal nerve. There’s a lot going on in a relatively small amount of space…. Adding inflammation to any of these visceral structures and that could cause compression of the pudendal nerve. Chronic inflammation could lead to ischemic injury of the nerve. Interstitial cystitis (or inflammation of the bladder) is a common co-morbidity of PN 54

55 Modalities for Pelvic Pain
Biofeedback/Pressure perionometry/surface electromyography Ultrasound Vaginal Dilators Electrical Stimulation Weight Training for the pelvic floor

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57

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60 Perineal Ultrasound Decrease soft tissue tension Increase blood flow
Decrease hypertrophy/scar tissue Not appropriate for all patient types and contra-indicated for some diagnoses.

61 Vaginal Dilators Protocol varies depending on diagnosis
Common diagnoses that are appropriate for vaginal dilators: Dyspareunia, constipation, vaginal stenosis, muscle hypertonicity

62 Therapeutic exercise

63 How to find and utilize a pelvic pain Physical Therapist
State organizations (KPTA) National Organizations (APTA) National Pelvic Pain Organizations Talk to local P.T.’s and they can normally refer you to the appropriate office. FYI…………………… Insurance – these diagnoses are usually covered.

64 Case Examples of patients successfully treated with only pelvic floor PT
Susan will explain

65 SEX THERAPISTS PROVIDE
Thorough psycho-social evaluation Individual therapy for anxiety and depression Relationship therapy or involving partner in supporting her treatment Insight therapy for negative/shameful sexual attitudes Education on sexual anatomy and function to reduce penetration fears Sexual Abuse/Trauma treatment Cognitive therapy, insight therapy, hypnosis, EMDR, educational videos, bibliotherapy, exposure therapy ter Kuile 2013 At-home patient-led dilator therapy (No touching or live sexual demonstrations are ever done in the sex therapist’s office!) 2-May come from any psychotherapy discipline- clinical psychology, clinical social work, marriage and family therapy, psychiatry 4- After initially certified, must meet specific sex therapy continuing education requirements to renew certification 5- are required to follow a strict set of ethical guidelines from their area of licensure and subspecialty certification 6-MM ter Kuile. Therapist aided exposure therapy. Vaginismus. J of Consulting and Clinical Psychology of 35 women could have coitus and sig. less pain

66 Case Example of Vaginismus Patients successfully treated with sex therapy alone Shawna

67 Preparing the patient to return to gyn provider
Cognitive therapy to decatastrophize Positive imaging Giving her control of the exam by educating her gyn Using an anxiolytic ahead if wanted Giving her permission not to complete the exam the first time back Preparing her for vaginal delivery

68 Who Are Sex Therapists and How Do I Find One?
licensed psychotherapists from any psychotherapy discipline with additional training in sexual health and illness Certification or Diplomate by AASECT – CST or DST after their names (The American Association of Sexuality Educators, Counselors and Therapists) Licensure in FL find a therapist by state

69 Treatment Success Rates 75%-100%
Rate Independent Study Cited 100% Biswas & Ratnam, 1995 @100% Butcher, 1999 98-100% Masters & Johnson, 1970 97.7% Schnyder, Schnyder-Luthi,et. al., 1998 95% Katz & Tabisel, 2002 91.42% Nasab & Faroosh, 2003 87% Scholl, 1988 75-100% Studies cited in Heiman, 2002 -

70 Resources for Becoming an Effective Female Sexual Medicine Provider

71 Establish a team of related FSD providers
Pelvic Floor Physical Therapist: Certified Sex Therapist-www.aasect.org Sexual Medicine Specialist- AASECT certified sexuality counselors in medical field Training from ISSWSH Urologists, Internists, and Endocrinologists who are interested in sexual medicine

72 References Books for Providers
Textbook of Sexual Medicine William Maurice, M.D. Sexual Pharmacology- Fast Facts R.T. Segraves, M.D. Sex In America: A Definitive Survey Michael et al The Journal of Sexual Medicine

73 Vaginal Dilators Syracuse Medical Devices (315) 637-9275
Individually sold and inexpensive

74 Provider Education in Female Sexual Medicine and Psychology
1- “Women’s Sexual Health Course for N.P.’s” June 27-29, Dallas Sponsored by The International Society for the Study of Women’s Sexual Medicine 2-ISSWSH annual meetings, membership and list serve 3-The American Association of Sexuality Educators, Counselors, and Therapists annual meetings and trainings-

75 Resources for Patients
Private Pain- It’s about life not just sex by Ditza Katz and Ross Lynn Tabisel -2005 books, online forums, and other resources Internet Chat rooms Google “Vaginismus support groups”

76 502-897-2717 jkoehler2@coresys.net
Susan may add her contact info.

77 Dunn Physical Therapy, PLLC
Louisville, Kentucky

78 Sources Barral, Jean-Pierre, Manual Therapy for the Prostate, North Atlantic Books, Ca, 2005. Cox, JM, Bakkum BW, Possible Generators of retrotrochanteric gluteal and thigh pain, the Gemelli/OI complex, J Manipulative Physical Therapy 2005, Sept: 28(7); Ito, Yoshiaki, Matsushita, I, et al, Anatomic Mapping of Short ER’s shows the limit of their preservation during THA, Clin Orthop and Related Research, 2012 (470) McKnas K, Christensen A, Johansen O. The internal OI may cause sciatic pain. Pain 2003: 104; Morris VD, Murray, MP et al, A comparison of the effect of age on LA and OI muscle CSA and volumes in nulliparous women, Neurologic Urodyn, 2012 Apr; 31 (4): Murata Y, Ogata S, Ikeda Y, Yamagata M, An unusual cause of sciatic pain as a result of the dynamic motion of the obturator internus, Spine J. 2009, June 9(6). Raj, PP Treatment algorithm overview. Pain Practice 4: Travell, J, Simon, D, Myofascial Pain and Dysfunction, The trigger Point Manual, Lipincott Williams & Wilkins, Volume 2, 1993 Winsisch G, Braun EM, Anderhuber F, Piriformis muscle: Clinical anatomy and consideration of the piriformis syndrome, Surg Radiol Anat. 2007, Feb: 29 (1):

79 Resources Benson J, Griffis K: Pudendal Neuralgia, a severe pain syndrome. Am J Obstet Gynecol 2005;192: Tu F, Hellman K,Backonja M: Gynecological Management of Neuropathic Pain. Am J Obstet Gynecol 2011;205(5): Chiarioni G, Asteria C, Whitehead W: Chronic proctalgia and chronic pelvic pain syndromes: New etiologic insights and treatment options. World J Gastroenterol 2011 October 28;17(40) Hibner M, Desai N, Robertson LJ, Nour M: Pudendal Neuralgia. J Min Inv Gynecol. 2010; 17(2): Stav K, Dwyer P, Roberts L: Pudendal Neuralgia Fact or Fiction? Obstet Gynecol Surv 2009; 64(3): Mahakkanukrauh P, Surin P, Vaidhayakarn P. Anatomical study of the Pudendal Nerve adjacent to the sacrospinous ligament. Clinical Anatomy 2005;18: Robert R, Prat-Pradal D, Labat JJ, Bensignor M, Raoul S, Rebai R, Leborgne J. Anatomic basis for chronic perineal pain: the role of the pudendal nerve. Surg Radiol Anat 1998;20:93-98. Latthe P, Latthe M, Say L, Gulmezoglu M, Khan KS. WHO systematic review of prevalence of chronic pelvic pain: a neglected reproductive health morbidity. BMC Public Health Jul 6;6:177. Wise, D, Anderson R. A Headache in the Pelvis. Occidental, CA: National Center for Pelvic Pain Research, 6th edition. 2011 Rummer E, Prendergast S. De-Mystifying Pudendal Neuralgia as a Source of Pelvic Pain: A Physical Therapist’s Approach. 79

80 Thank you for your attention!
Questions and Comments?


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