The evaluation and management of female sexual dysfunction

,; ,; ,; ,; ,

Applied Evidence

The evaluation and management of female sexual dysfunction

J Fam Pract. 2017 December;66(12):722-728

PDF Download

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed, text revision). Washington, DC; 1994.

2. Shifren, JL, Monz BU, Russo PA, et al. Sexual problems and distress in United States women: prevalence and correlates. Obstet Gynecol. 2008;112:970-978.

3. Lewis RW, Fugl-Meyer KS, Bosch R, et al., Epidemiology/risk factors of sexual dysfunction. J Sex Med. 2004;1:35-39.

4. Laumann E, Paik A, Rosen RC. Sexual dysfunction in the United States prevalence and predictors. JAMA. 1999;281:537-544.

5. Office of the Surgeon General. The Surgeon General’s Call to Action to Promote Sexual Health and Responsible Sexual Behavior, Rockville, MD; 2001.

6. Pauls RN, Kleeman SD, Segal JL, et al. Practice patterns of physician members of the American Urogynecologic Society regarding female sexual dysfunction: results of a national survey. Int Urogynecol J Pelvic Floor Dysfunct. 2005;16:460-467.

7. American Psychiatric Association. Sexual Dysfunction. In: Diagnostic and Statistical Manual of Mental Disorders (5thed). Washington, DC; 2013.

8. Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol. 2009. 113:1124-1136.

9. ACOG Practice Bulletin No. 119: Female sexual dysfunction. Obstet Gynecol. 2011;117:996-1007.

10. Clayton AH, Hamilton DV. Female sexual dysfunction. Psychiatr Clin North Am. 2017;40:267-284.

11. Morrissey D, El-Khawand D, Ginzburg N, et al. Botulinum Toxin A injections into pelvic floor muscles under electromyographic guidance for women with refractory high-tone pelvic floor dysfunction: a 6-month prospective pilot study. Female Pelvic Med Reconstr Surg. 2015;21:277-282.

12. Hatzichristou D, Rosen RC, Derogatis LR, et al. Recommendations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med. 2010;7(1 Pt 2):337-348.

13. Kegel, A. Sexual functions of the pubococcygeus muscle. West J Surg Obstet Gynecol. 1952;60:521-524.

14. Shafik A. The Role of the levator ani muscle in evacuation, sexual performance and pelvic floor disorders. Int Urogynecol J. 2000;11:361-376.

15. Kinsey A, Pomeroy WB, Martin CE, et al. Sexual behavior in the human female. W. B. Saunders:Philadelphia, PA; 1998.

16. Lowenstein L, Gruenwald, Gartman I, et al. Can stronger pelvic muscle floor improve sexual function? Int Urogynecol J. 2010;21:553-556.

17. Kanter G, Rogers RG, Pauls RN, et al. A strong pelvic floor is associated with higher rates of sexual activity in women with pelvic floor disorders. Int Urogynecol J. 2015;26:991-996.

18. Wehbe SA, Kellogg-Spadt S, Whitmore K. Urogenital complaints and female sexual dysfunction. Part 2. J Sex Med. 2010;7:2304-2317.

19. Messelink B, Benson T, Berghmans B, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn. 2005;24:374-380.

20. Haylen BT, de Ridder D, Freeman RM, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29:4-20.

21. Montenegro ML, Mateus-Vasconcelos EC, Rosa e Silva JC et al. Importance of pelvic muscle tenderness evaluation in women with chronic pelvic pain. Pain Med. 2010;11:224-228.

22. Lukban JC, Whitmore KE. Pelvic floor muscle re-education treatment of the overactive bladder and painful bladder syndrome. Clin Obstet Gynecol. 2002;45:273-285.

23. Kalmbach DA, Arnedt JT, Pillai V, et al. The impact of sleep on female sexual response and behavior: a pilot study. J Sex Med. 2015;12:1221-1232.

24. Aversa A, Bruzziches R, Francomano D, et al. Weight loss by multidisciplinary intervention improves endothelial and sexual function in obese fertile women. J Sex Med. 2013;10:1024-1033.

25. Pauls RN, Kleeman SD, Karram MM. Female sexual dysfunction: principles of diagnosis and therapy. Obstet Gynecol Surv. 2005;60:196-205.

26. Herati AS, Shorter B, Tai J, et al. Differences in food sensitivities between female interstitial cystitis/painful bladder syndrome (IC/PBS) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients. J Urol. 2009;181(4)(Suppl):22.

27. Farrell J, Cacchioni T, The medicalization of women’s sexual pain. J Sex Res. 2012;49:328-336.

28. De Andres J, Sanchis-Lopez NM, Asensio-Samper JM, et al. Vulvodynia—an evidence-based literature review and proposed treatment algorithm. Pain Pract. 2016;16:204-236.

29. Herbenick D, Reece M, Schick V, et al. Women’s use and perceptions of commercial lubricants: prevalence and characteristics in a nationally representative sample of American adults. J Sex Med. 2014:11:642-652.

30. Donders GG, Bellen G. Cream with cutaneous fibroblast lysate for the treatment of provoked vestibulodynia: a double-blind randomized placebo-controlled crossover study. J Low Genit Tract Dis. 2012;16:427-436.

31. Belkin ZR, Krapf JM, Goldstein AT. Drugs in early clinical development for the treatment of female sexual dysfunction. Expert Opin Investig Drugs. 2015;24:159-167.

32. Islam A, Mitchel J, Rosen R, et al. Topical alprostadil in the treatment of female sexual arousal disorder: a pilot study. J Sex Marital Ther. 2001;27:531-540.

33. Oyama IA, Rejba A, Lukban JC, et al. Modified Thiele massage as therapeutic intervention for female patients with interstitial cystitis and high-tone pelvic floor dysfunction. Urology. 2004;64:862-865.

34. Bedaiwy MA, Patterson B, Mahajan S. Prevalence of myofascial chronic pelvic pain and the effectiveness of pelvic floor physical therapy. J Reprod Med. 2013;58:504-510.

35. Wehbe SA, Fariello JY, Whitmore K. Minimally invasive therapies for chronic pelvic pain syndrome. Curr Urol Rep. 2010;11:276-285.

36. Ger GC, Wexner SD, Jorge JM, et al. Evaluation and treatment of chronic intractable rectal pain—a frustrating endeavor. Dis Colon Rectum. 1993;36:139-145.

37. Billups KL, Berman L, Berman J, et al. A new non-pharmacological vacuum therapy for female sexual dysfunction. J Sex Marital Ther. 2001;27:435-441.

38. Miles T, Johnson N. Vaginal dilator therapy for women receiving pelvic radiotherapy. Cochrane Database Syst Rev. 2014;9:Cd007291.

39. Goldstein I. Current management strategies of the postmenopausal patient with sexual health problems. J Sex Med. 2007;4(Suppl 3):235-253.

40. Modelska K, Cummings S. Female sexual dysfunction in postmenopausal women: systematic review of placebo-controlled trials. Am J Obstet Gynecol. 2003;188:286-293.

41. Constantine G, Graham S, Portman DJ, et al. Female sexual function improved with ospemifene in postmenopausal women with vulvar and vaginal atrophy: results of a randomized, placebo-controlled trial. Climacteric. 2015;18:226-232.

42. Kingsberg SA, Woodard T. Female sexual dysfunction: focus on low desire. Obstet Gynecol. 2015;125:477-486.

43. Simon JA, Kingsberg SA, Shumel B, et al. Efficacy and safety of flibanserin in postmenopausal women with hypoactive sexual desire disorder: results of the SNOWDROP trial. Menopause. 2014; 21:633-640.

44. Curtis Nickel J, Baranowski AP, Pontari M, et al. Management of men diagnosed with chronic prostatitis/chronic pelvic pain syndrome who have failed traditional management. Rev Urol. 2007;9:63-72.

45. Rogalski MJ, Kellogg-Spadt S, Hoffmann AR, et al. Retrospective chart review of vaginal diazepam suppository use in high-tone pelvic floor dysfunction. Int Urogynecol J. 2010:21:895-899.

46. Langford CF, Udvari Nagy S, Ghoniem GM. Levator ani trigger point injections: an underutilized treatment for chronic pelvic pain. Neurourol Urodyn. 2007;26:59-62.

47. Abbott JA, Jarvis SK, Lyons SD, et al. Botulinum toxin type A for chronic pain and pelvic floor spasm in women: a randomized controlled trial. Obstet Gynecol. 2006.108:915-923.

48. Kamanli A, Kaya A, Ardicoglu O, et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol Int. 2005;25:604-611.

49. Brotto LA, Erskine Y, Carey M, et al. A brief mindfulness-based cognitive behavioral intervention improves sexual functioning versus wait-list control in women treated for gynecologic cancer. Gynecol Oncol. 2012;125:320-325.

General examination: What to look for

The external pelvic examination begins with visual inspection of the vulva, labia majora, and labia minora. Often, this is best accomplished gently with a gloved hand and a cotton swab. This inspection may reveal changes in pubic hair distribution, vulvar skin disorders, lesions, masses, cracks, or fissures. Inspection may also reveal redness and pain typical of vestibulitis, a flattening and pallor of the labia that suggests estrogen deficiency, or pelvic organ prolapse.

The internal pelvic examination begins with a manual evaluation of the muscles of the pelvic floor, uterus, bladder, urethra, anus, and adnexa. Make careful note of any unusual tenderness or pelvic masses. Pelvic floor muscles (PFMs) should voluntarily contract and relax and are not normally tender to palpation. Pelvic organ prolapse and/or hypermobility of the bladder may indicate a weakening of the endopelvic fascia and may cause sexual pain. The size and flexion of the uterus, tenderness in the vaginal fornix possibly indicating endometriosis, and adnexal fullness and/or masses should be identified and evaluated.

Neurologic exam of the pelvis will involve evaluation of sensory and motor function of both lower extremities and include a screening lumbosacral neurologic examination. Lumbosacral examination includes assessment of PFM strength, anal sphincter resting tone, voluntary anal contraction, and perineal sensation. If abnormalities are noted in the screening assessment, a complete comprehensive neurologic examination should be performed.

It’s important to assess pelvic floor muscle strength

Sexual function is associated with normal PFM function.^13,14The PFMs, particularly the pubococcygeus and iliococcygeus, are responsible for involuntary contractions during orgasm.¹³ Orgasm has been considered a reflex, which is preceded by increased blood flow to the genital organs, tumescence of the vulva and vagina, increased secretions during sexual arousal, and increased tension and contractions of the PFMs.¹⁵

Systemic estrogen in oral form, transdermal preparations, and topical formulations may increase sexual arousal and decrease dyspareunia.

Lowenstein et al found that women with strong or moderate PFM contractions scored significantly higher on both orgasm and arousal domains of the female sexual function index (FSFI) compared with women with weak PFM contractions.¹⁶ Orgasm and arousal functions may be associated with PFM strength, with a positive association between pelvic floor strength and sexual activity and function.^17,18

The function and dysfunction of the PFMs have been characterized as normal, overactive (high tone), underactive (low tone), and non-functioning.

Normal PFMs are those that can voluntarily and involuntary contract and relax.^19,20
Overactive (high-tone) muscles are those that do not relax and possibly contract during times of relaxation for micturition or defecation. This type of dysfunction can lead to voiding dysfunction, defecatory dysfunction, and dyspareunia.¹⁹
Underactive, or low-tone, PFMs cannot contract voluntarily. This can be associated with urinary and anal incontinence and pelvic organ prolapse.
Nonfunctioning muscles are completely inactive.¹⁹

How to assess. There are several ways to assess PFM tone and strength.²⁰ The first is intravaginal or intrarectal digital palpation, which can be performed when the patient is in a supine or standing position. This examination evaluates PFM tone, squeeze pressure during contraction, symmetry, and relaxation. However, there is no validated scale to quantify PFM strength. Contractions can be further divided into voluntary and involuntary.¹⁹

During the examination, the physician should ask the patient to contract as much as she can to evaluate the maximum strength and sustained contraction for endurance. This measurement can be done with digital palpation or with pressure manometry or dynamometry.

Examination can be focused on the levator ani, piriformis, and internal obturator muscles bilaterally and rated by the patient’s reactions. Pelvic muscle tenderness, which can be highly prevalent in women with chronic pelvic pain, is associated with higher degrees of dyspareunia.²¹ Digital evaluation of the pelvic floor musculature varies in scale, number of fingers used, and parameters evaluated. Lukban et al has described a zero to 4 numbered scale that evaluates tenderness in the pelvic floor.²² The scale denotes “1” as comfortable pressure associated with the exam, “2” as uncomfortable pressure associated with the exam, “3” as moderate pain associated with the exam and that intensifies with contraction, and “4” indicating severe pain with the exam and inability to perform the contraction maneuver due to pain.

Effective treatment includes multiple options

Lifestyle modifications can help

Lifestyle changes may help improve sexual function. These modifications include physical activity, healthy diet, nutrition counseling, and adequate sleep.^23,24

Identifying medical conditions such as depression and anxiety will help delineate differential diagnoses of sexual dysfunction. Cardiovascular diseases may contribute to arousal disorder as a result of atherosclerosis of the vessels supplying the vagina and clitoris. Neurologic diseases such as multiple sclerosis and diabetes can affect sexual dysfunction by impairing arousal and orgasm. Identification of concurrent comorbidities and implementation of lifestyle changes will help improve overall health and may improve sexual function.²⁵

Manual therapies, including transvaginal technique, may relieve female sexual dysfunction that results from a variety of causes.

In addition, Herati et al²⁶ found food sensitivities to grapefruit juice, spicy foods, alcohol, and caffeine were more prevalent in patients with interstitial cystitis and chronic pelvic pain. Avoiding irritants such as soap and other detergents in the perineal region may help decrease dysfunction.²⁷ Finally, foods high in oxalate and other acidic items may cause bladder pain and worsening symptoms of vulvodynia.²⁸