Presentation on theme: "The Diagnosis and Treatment of Vaginismus"— Presentation transcript:
1The Diagnosis and Treatment of Vaginismus KCNPNM Annual ConferenceApril 2014By Jean D. Koehler, Ph.D.And Susan Dunn, P.T.
2Koehler DisclosuresProctor and Gamble – Consultant and interviewer for Stage 3 clinical trials on testosterone patch for women –Proctor and Gamble- Regional Consultant’s BoardOrtho-McNeil- Pharmaceuticals- Advisory Board of Female Sexual Dysfunction experts- November 2004Boeringer Ingleheim- Speaker’s Bureau-2010Ask: “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.
3Vaginismus 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
4DSM V- 302.76 (Women’s) Genito-Pelvic Pain/Penetration Disorders Marked vulvovaginal pain in penetration attempts (dyspareunia)Marked anxiety about penetration or anticipated penetrationMarked tightening of pelvic floor muscles during attempted penetration(was called Vaginismus in prior manuals)
5Types of Vaginismus Primary- never achieved attempted coitus Secondary- onset after pain free coitusTotal- penetration not possible through the PC musclePartial- penetration achieved, but painfulSituational- only with some penetrantswith penis but not speculum or visa versawith larger sized partner but not smaller sizedwith gyn exam, but not with coitus
6Incidence of Sexual Pain Disorders US general population data- Michael et al, 1994Consistent coital pain in females-10-15%International general population data- Lewis et al, 2004Vaginismus- 6%Coital pain- 2-20%The Cochrane Database of Systemic Reviews- McGuire and Hawton, 2002Vaginismus in medical settings- 4-12%Vaginismus in sexual Dysfunction Clinics- 5-17%Women of childbearing age- est. .5-1%Graziottin, A. 2008Graziottin, A. Dyspareunia and vaginismus… Current Sex. Health Rep. 2008; 5:443-50
7The BIO-PSYCHO-SOCIAL APPROACH TO VAGINISMUS DIAGNOSIS and TREATMENT
8Interpersonal 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 statusWellbeingInterpersonalPsychologicalStressSexual FunctionThroughout a Woman’sLifespanMenopauseStressSocioculturalBiologicalParityExerciseBMIHealthAgec. J Alexander ‘05
9Medical Conditions That May Lead to Vaginismus PVD- provoked vestibulodynia- one of most common causes of dyspareunia in pre-menopausal women (Smith 2014)Estrogen, testosterone deficiencyOC use before 16, and for up to 2-4 years (Davis 2013)Vulvovaginal atrophy in menopausal women (Hope 2010)Pelvic floor disordersVaginal infection- i.e. recurrent yeast, herpes, bacterial vaginosis, HPV?Vulvar dermatoses, i.e. lichens sclerosisAllergy to condoms, semenEndometriosisRadiation therapyInjury from force –rapePrior painful vaginal/urological medical interventions- especially in childhood/teen years- iatrogenic?Female Genital MutilationGenetic abnormalities- i.e. septate hymanSusan 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 2010Hormonal 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 MedicineVolume 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
10Psycho-social Conditions Correlating to Vaginismus- Research Results Pre-existing General Anxiety Disorder1Personality features- fear of new experiences, catastrophizing thoughts about pain, disgust propensity, low self-esteem2, 3Specific fear of penile vaginal penetration2Less self stimulation2Increased prevalence of desire and arousal problems21- Watts and Nettle, 20102- van Lankveld et al., 20103- Borg, C. et al. 20121-Watts and Nettle. JSM 2010;7: Significant and substantial increase in GAD in vaginismic women, many reported being generally anxious prior to vaginismus2- 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:
11Possible Psychosocial Causes- Clinical Observations Strict religious proscriptions against sexual interaction/especially coitusBody MythsPhobia to vaginal penetration, sometimes of any orificeSexual abuse or assault history-Poor or unsure relationship with sexual partnerFear of unplanned pregnancy, delivery painSecretly unwanted pregnancyStuck developmentally as a “good little girl”, not wanting to grow up sexually and disappoint parentsBody 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 PTUnwanted 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
12The New Treatment Team for Sexual Pain Disorders Pelvic Pain MD/NPPelvic Floor Physical TherapistCertified Sex Therapist/ PsychotherapistThere 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.
13Case Example of the team approach Tara Jean and Susan’s shared clients like KL and TO. Susan, any others you can remember?
14Role of the Gyn Provider - When the patient presents painful penetration as the reason for the office visitWhen the providers notices an inability to perform a speculum examSusan 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.
15Sexual 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 genitalexamination? If so, what about it makes her anxious?Has she ever had a traumatic sexual experience or history ofphysical/emotional/sexual abuse?What does she believe is causing her penetration pain?Koehler adapted from Crowley T,2009 & Kingsberg SA,2007Kingsberg SA, Janata JW. Female sexual disorders: assessment,diagnosis, and treatment. Urol Clin N Am 2007;34:497–506Crowley T, Goldmeier D, Hiller J. Diagnosing and managingvaginismus. BMJ 2009;338:b2284
16Preparing for the Initial Exam with a Primary Vaginismus Patient
17LISTEN-to your patient if she expresses fear and WATCH - for fearful body language Let her decide who will be presentLet her decide the extent of the initial examAsk her if she can think of anything to facilitate the exam
18EXPLAIN THE EXAMFirst show a film to all new pelvic exam patients if you can orDescribe each step in advance as you proceedOffer sedation(Valium 5mg.) if neededLet her know she can interrupt the exam at any time without being a failure
19REASSURE HER that you will let her have control of the exam Pacing of insertionInserting speculum herselfUsing a pediatric speculumStarting with your finger only while the patient bears downOr postponing internal exam pending completion of physical therapyor sex therapy
20EDUCATE HER Give her a mirror to see her vulva Explain her anatomy/correct misinformationClarify what structures are normal or abnormalAsk her how she’s coping during the examIf exam is normal, explain how her fear and pelvic floor hypertonus tricks her into believing she’s too small for penetrationSusan’s last slide
21What if you still can’t examine her? Have her practice the Rosenbaum Mindfulness ProtocolIn case that doesn’t work, in the same visit:Give her contact info of either a pelvic floor P.T. orSex therapist orBothLet her choose which approach appeals to her
22Rosenbaum Mindfulness Protocol Uses mindfulness accompanied by systematic desensitization to reduce anxietyCan be first practiced at homeCan be practiced in the provider’s exam room ahead of the examination or on a prior daySee handout for protocolRosenbaum and Padoa- 2012Rosenbaum- 2011Rosenbaum TY and Padoa A. Managing pregnancy and delivery in womenwith sexual pain disorders. J Sex Med 2012;9:1726–1735.
23Further 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.
24The Role of the Gyn Provider in Secondary Vaginismus
25TREAT ANY CO-MORBID MEDICAL CONDITIONS IF POSSIBLE Case example of Secondary vaginismus originating with medical problemsInsufficient 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
26What Other Office-Based Treatments Can Medical Providers Try?
27Provider- led Modified Sensate Focus Good for couples seeking infertility treatmentdiagnosed with primary vaginismusno sex therapist or pelvic floor physical therapist in the areaResults:Most resolved vaginismusHalf became pregnantNonpregnant evaluated for other sources of infertilitySee handoutJindal and Jindal, 2010
28Botulinum Toxin (Botox) Botox for treatment resistant casesNo good controlled studies and adverse events need to be documentedBut pre vs. post treatment show it’s effectivenessFerreira and Souza 2012 Meta-AnalysisAdverse eventstwo cases of mild stress incontinenceone case of excessive vaginal dryness of 82 patients in one studyPacik,P. Aesth Plast Surg (2011) 35:1160–1164Ferreira and Souza . Botulinum Toxin for vaginismus treatment . Review Pharmacology. 89(5-6):
29What predicts successful treatment? Reducing penetration fearsAttributing the problem to psychological causesPositive attitude toward one’s genitaliaStrong wish to become pregnantBetter sexual knowledgeHomework compliancePretreatment martial satisfactionvan Lankveld et al., 20102- vanLankveld, Jacques et al. Women’s Sexual Pain Disorders. J Sexual Medicine 2010; 7:
30What predicts longer treatment? Pretreatment sexual desire problemsFear of STI’sNegative parental attitudes towards sexPrevious operations for vaginismusHistory of physical abnormality- like septum vaginitisvan Lankveld et al., 2010
31What doesn’t predict treatment outcome? Sexual abuse history-Higher rate among vaginismus patients, but sexual abuse history doesn’t predict future vaginisimusOther sexual dysfunctions in either partnervanLankveld, Jacques et al ;
32Pregnancy Considerations Sexual pain patients wishing to conceive should avoid these topical or intravaginal agents:GabapentinBaclofenDiazepamAmitriptylineRosenbaum 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
33REFER HER IF NEEDEDTo a Pelvic Floor PT and/or Certified Sex TherapistBefore proceeding with the exam if she prefersIf she is unable to complete the examFor treatment of nonmedical causes of her vaginismusIf there are mixed psychogenic and medical causesSusan may modify esp for distant patients.
34VulvodyniaDefined 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.
35Vulvar 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 practiceDiagnoses 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
37Role of the Physical Therapist Team approach with other health care providers.Physical Therapist focuses on neuromuscular/orthopedic/myofascial contribution to symptoms
38What to ExpectMany patients perceive physical therapy for these diagnoses to be different than physical therapy for other orthopedic/spine rehabilitation. Same therapy…….different body partPatient should expect a complete musculoskeletal evaluation of the symptomatic area.
39Patient Profile Teen through adult life span Male and female Sedentary and high end athleteVarying socio-economicVarious cultural backgrounds
40Questionnaire will include: Pain with activityBowel movements/UrinationSitting vs. standing vs. supine vs. proneIntercourse pain (with superficial and/or deep penetration/orgasm/positional dependent)Urologic changes with intercourse/orgasmPatient should fill out questionnaire that addresses sexual history i.e. abuse/pregnancies/pathology/psychiatric
41PT Treatment Address Structure and Biomechanics Mobilize/Stabilize Thoracic spine, Lumbar spine and SI JointsLLD, Postural abnormalitiesMuscle imbalanceAddress Connective Tissue Restrictions and MTrPsConnective Tissue Mobilization, Dry NeedlingSurrounding the bony pelvisAnterior, medial, lateral and posterior thighsAbdomen, low back, buttocksNerve MobilizationSeating Adaptations/Work Modifications41
42Pudendal Nerve Nerve Roots: S2, S3, S4 50% sensory, 20% motor and 30% autonomicSusan 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
43Course 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
48Mechanism of Injury Traction Compression Surgical Constipation, Childbirth, strenuous squattingCompressionCycling, Horseback riding, prolonged sittingSurgicalHysterectomies, corrective sx for prolapseCommon etiology for nerve entrapmentVisceral-Somatic InteractionChronic bladder infections, yeast infections, bacterial prostatitis48
49Traction 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
50Compression 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
51Cycling adaptationsAdaptations 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 fit51
52Surgical 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
53Surgeries Gynecological surgeries requiring lithotomy position Jackknife positionRisk of muscle damage/scarring/adhesions with surgeriesTotal Hip arthroplasty – muscle stays intact but may be damaged when the femur is elevated and exposedIto 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”
54VisceralChronic bladder infections, yeast infections, bacterial prostatitisChronic 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 PN54
55Modalities for Pelvic Pain Biofeedback/Pressure perionometry/surface electromyographyUltrasoundVaginal DilatorsElectrical StimulationWeight Training for the pelvic floor
63How to find and utilize a pelvic pain Physical Therapist State organizations (KPTA)National Organizations (APTA)National Pelvic Pain OrganizationsTalk to local P.T.’s and they can normally refer you to the appropriate office.FYI……………………Insurance – these diagnoses are usually covered.
64Case Examples of patients successfully treated with only pelvic floor PT Susan will explain
65SEX THERAPISTS PROVIDE Thorough psycho-social evaluationIndividual therapy for anxiety and depressionRelationship therapy or involving partner in supporting her treatmentInsight therapy for negative/shameful sexual attitudesEducation on sexual anatomy and function to reduce penetration fearsSexual Abuse/Trauma treatmentCognitive therapy, insight therapy, hypnosis, EMDR, educational videos, bibliotherapy, exposure therapyter Kuile 2013At-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, psychiatry4- After initially certified, must meet specific sex therapy continuing education requirements to renew certification5- are required to follow a strict set of ethical guidelines from their area of licensure and subspecialty certification6-MM ter Kuile. Therapist aided exposure therapy. Vaginismus. J of Consulting and Clinical Psychology of 35 women could have coitus and sig. less pain
66Case Example of Vaginismus Patients successfully treated with sex therapy alone Shawna
67Preparing the patient to return to gyn provider Cognitive therapy to decatastrophizePositive imagingGiving her control of the exam by educating her gynUsing an anxiolytic ahead if wantedGiving her permission not to complete the exam the first time backPreparing her for vaginal delivery
68Who Are Sex Therapists and How Do I Find One? licensed psychotherapists from any psychotherapy discipline with additional training in sexual health and illnessCertification or Diplomate by AASECT –CST or DST after their names(The American Association of Sexuality Educators, Counselors and Therapists)Licensure in FLfind a therapist by state
70Resources for Becoming an Effective Female Sexual Medicine Provider
71Establish a team of related FSD providers Pelvic Floor Physical Therapist:Certified Sex Therapist-www.aasect.orgSexual Medicine Specialist-AASECT certified sexuality counselors in medical fieldTraining from ISSWSHUrologists, Internists, and Endocrinologistswho are interested in sexual medicine
72References Books for Providers Textbook of Sexual MedicineWilliam Maurice, M.D.Sexual Pharmacology- Fast FactsR.T. Segraves, M.D.Sex In America: A Definitive SurveyMichael et alThe Journal of Sexual Medicine
73Vaginal Dilators Syracuse Medical Devices (315) 637-9275 Individually sold and inexpensive
74Provider Education in Female Sexual Medicine and Psychology 1- “Women’s Sexual Health Course for N.P.’s”June 27-29, DallasSponsored by The International Society for the Study of Women’s Sexual Medicine2-ISSWSH annual meetings, membership and list serve3-The American Association of Sexuality Educators, Counselors, and Therapists annual meetings and trainings-
75Resources for Patients Private Pain- It’s about life not just sexby Ditza Katz and Ross Lynn Tabisel -2005books, online forums, and other resourcesInternet Chat roomsGoogle “Vaginismus support groups”
76502-897-2717 firstname.lastname@example.org Susan may add her contact info.
78SourcesBarral, 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, 1993Winsisch G, Braun EM, Anderhuber F, Piriformis muscle: Clinical anatomy and consideration of the piriformis syndrome, Surg Radiol Anat. 2007, Feb: 29 (1):
79ResourcesBenson 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. 2011Rummer E, Prendergast S. De-Mystifying Pudendal Neuralgia as a Source of Pelvic Pain: A Physical Therapist’s Approach.79
80Thank you for your attention! Questions and Comments?