Increasing Orgasm and Decreasing Dyspareunia by a Manual Physical Therapy Technique

Lawrence J. Wurn, LMT; Belinda F. Wurn, PT; C. Richard King, MD; Amanda S. Roscow, MPT; Eugenia S. Scharf, PhD; Jonathan J. Shuster, PhD

Disclosures
In This Article

Methodology

Subjects

Selection. All clinic patients were required to complete a 6-page standard Patient Intake Questionnaire detailing their pain and medical history. Those patients who indicated dyspareunia and sexual dysfunction on the questionnaire (or during their initial evaluation) were asked if they were willing to participate in a research study. Criteria for inclusion were as follows:

  1. Indication of painful intercourse and/or difficulty or inability to orgasm;

  2. Willingness to complete a pre-and post-treatment questionnaire on sexual pain and dysfunction; and

  3. A history indicating likely adhesions due to infectious or inflammatory processes, miscarriage, abdominal and/or pelvic surgery, or trauma within the abdominopelvic area.

A total of 29 women were selected to receive a series of site-specific, manual physical therapy treatments for abdominopelvic pain or dysfunction. Six patients were lost to follow-up.

Gynecologic History. All 23 patients in this study had proven or clinically well-supported suspicion of adhesions. Medical diagnoses included:

Infectious/inflammatory processes (23) 100.0%
Abdominopelvic surgery (20) 87.0%
Confirmed pelvic adhesions (16) 69.6%
Endometriosis (15) 65.2%
Abdominopelvic trauma (7) 30.4%
Pelvic inflammatory disease (1) 4.3%

Characteristics. Study participants were a multiethnic, primarily white group, ranging in age from 25 to 43 years; mean = 33.8 years. The patients were being treated for various types of abdominopelvic pain or dysfunction, including infertility.

Procedures/Interventions

The primary goals of manual therapy are to decrease pain and restore mobility by improving soft-tissue mobility, elasticity, and distensibility. The intent of the manual physical therapy protocol used in this study was to create microfailure of collagenous cross-links, the "building blocks" of adhesions. These unique soft-tissue techniques were developed after extensive study of current, innovative, manual physical therapy methods.

Theoretically, mobilization of the soft tissue may break down collagenous cross-links and adhesions that can cause pain and dysfunction,[13] including dyspareunia and inhibited or absence of orgasms. Thus, following a thorough medical, gynecologic, surgical history and palpatory assessment of the patient's abdomen and pelvis, specific areas of visceral and myofascial cross-linking were determined to be likely adhesion sites due to their restricted mobility.

Focusing on these areas of decreased mobility, the therapist engaged the soft tissues until cross-links were perceived to release. This release was evidenced by increased mobility at the precise sites of visceral and myofascial restrictions after each therapy session. The changes were further demonstrated by improved alignment, biomechanics, and increased range of motion of osseous and soft-tissue structures (eg, improved pelvic floor musculature tone, decreased pelvic floor spasms).

Our professional staff has developed literally hundreds of techniques to address the various conditions and complaints reported by our patients and/or noted by the therapists. A typical technique, shown in Figure 1, is designed to decrease spasm and adhesions between the uterus and the bladder.

Figure.

Uterovesical release

As shown in this example, the therapist engages the uterine fundus and sidewalls and tractions them to the left. To assist and improve the mobility of the soft tissues, the therapist may release the tension of the traction either suddenly or gradually, depending on the desired effect.

In accord with the standards of the American Physical Therapy Association, detailed clinical records were kept of each patient's visit, including treatment dates and duration, symptomatic complaints, areas treated, and treatment techniques performed.[22] Depending on the patient's schedule and geographic location, the frequency and duration of treatment ranged from 2 hours per week for 2+ months to intensive sessions of 2 to 4 hours of treatment daily, performed over 5 days. The standard length of each therapy session was 1 to 2 hours, minus 15 minutes for room preparation and paperwork.

A total of 20/23 (87.0%) patients received the recommended 20 hours of treatment; mean = 19.5 hours. None of the patients received concurrent infertility or pelvic pain therapies during the treatment or 6-week follow-up period.

Data Collection

Study patients were evaluated and treated between October 2002 and January 2004. Since the purpose of this study was to determine the effectiveness of manual soft-tissue therapy in treating female sexual dysfunction -- specifically, increasing orgasm and decreasing dyspareunia -- the data set consisted of the pretreatment and post-treatment scores on 2 assessments of these factors.

1. The Female Sexual Function Index (FSFI), a 19-item questionnaire, was developed in 2000 as a brief, multidimensional self-report instrument for assessing the key factors of sexual function in women. It is easy to administer and psychometrically sound in terms of reliability (test-retest and internal consistency) and construct validity. The FSFI was designed and validated for use in clinical trials or epidemiologic studies. Thus far, it has been validated on clinically diagnosed samples of women with female sexual arousal disorder, female orgasmic disorder, and in women with hypoactive sexual desire disorder.[4,8,9]

The FSFI comprises 6 key dimensions or domains, including orgasm, pain, arousal, desire, lubrication, and satisfaction. The individual domain scores are derived by adding the scores of the individual items constituting the domain and multiplying the sum by the domain factor. The full FSFI score is obtained by adding the 6 individual domain scores.[4]

According to the FSFI authors, "sexual response involves a temporal sequencing and coordination of several phases." Thus, problems in one area may interact with those in another, resulting in a substantial overlap among the diagnostic categories. The FSFI has been designed to assess the relative severity of dysfunction within each domain.[4]

A typical item on the FSFI is Q12:

Over the past 4 weeks, when you had sexual stimulation or intercourse, how difficult was it for you to reach orgasm (climax)?

Response Options:

0 = No sexual activity
1 = Extremely difficult or impossible
2 = Very difficult
3 = Difficult
4 = Slightly difficult
5 = Not difficult

[Note: The complete FSFI questionnaire, instructions and scoring algorithm can be obtained at www.FSFIquestionnaire.com.]

2. Three 10-point scales assessing best, worst, and average pain levels during sexual intercourse were based upon the standard 10-point pain scales used to quantify subjective pain complaints. They were intended to supplement the 3 items representing the pain domain in the FSFI. The worst-best-average nomenclature permitted increased specificity for patients reporting painful intercourse.

The directions for the pain scales (listed as item 20 on the patient pretest and post-test) were simply as follows:

With zero being no pain and ten being the worst pain you could imagine, rate (circle) your own pain levels associated with sexual intercourse over the last four weeks.

My worst pain level during sexual intercourse

12345678910

My best pain level during sexual intercourse

12345678910

My average pain level during sexual intercourse

12345678910

Administration. Since the questionnaire items asked the subjects to rate their responses "over the past 4 weeks...," the pretest was administered at or near the beginning of the actual treatment sessions. The post-test was completed 6 weeks after the last treatment date, thereby allowing 2 weeks post-treatment for the body to assimilate the changes. The post-test was mailed to the patients in a prestamped envelope the previous week. None of the patients had a copy of her pretest responses.

Although all 23 patients completed all 19 items of the FSFI pre-and post-tests, 6 were eliminated from the pain scale analysis due to incomplete data.

Statistical Method. The Wilcoxon signed-rank test[23] was used on the paired difference post-test/pretest for the values where high scores are good ( Table 1 ), and pretest minus post-test where high values are unfavorable ( Table 2 ). Since the questionnaires yielded ordinal (qualitative ranking) data, medians and quartiles are provided in lieu of means and standard deviations.

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