Talli Rosenbaum

REVIEWS: Pelvic Floor Involvement in Male and Female Sexual Dysfunction and the Role of Pelvic Floor Rehabilitation in Treatment: A Literature Review

INTRODUCTION The sphincteric and supportive functions of the pelvic floor are fairly well understood, and pelvic floor rehabilitation, a specialized field within the scope and practice of physical therapy, has demonstrated effectiveness in the treatment of urinary and fecal incontinence. The role of the pelvic floor in the promotion of optimal sexual function has not been clearly elucidated. AIM To review the role of the pelvic floor in the promotion of optimal sexual function and examine the role of pelvic floor rehabilitation in treating sexual dysfunction. MAIN OUTCOME MEASURE Review of peer-reviewed literature. RESULTS It has been proposed that the pelvic floor muscles are active in both male and female genital arousal and orgasm, and that pelvic floor muscle hypotonus may impact negatively on these phases of function. Hypertonus of the pelvic floor is a significant component of sexual pain disorders in women and men. Furthermore, conditions related to pelvic floor dysfunction, such as pelvic pain, pelvic organ prolapse, and lower urinary tract symptoms, are correlated with sexual dysfunction. CONCLUSIONS The involvement of the pelvic floor in sexual function and dysfunction is examined, as well as the potential role of pelvic floor rehabilitation in treatment. Further research validating physical therapy intervention is necessary.

Continuing Medical Education: The Role of Pelvic Floor Physical Therapy in the Treatment of Pelvic and Genital Pain‐Related Sexual Dysfunction (CME)

INTRODUCTION Chronic pelvic pain (CPP) in women and men is associated with significant sexual dysfunction. Recently, musculoskeletal factors have been recognized as significant contributors to the mechanism of pelvic pain and associated sexual dysfunction, and in particular, pelvic floor muscle hypertonus has been implicated. AIM The purpose of this Continuing Medical Education article is to describe the musculoskeletal components involved in pelvic and genital pain syndromes and associated sexual dysfunction, introduce specific physical therapy assessment and intervention techniques, and provide suggestions for facilitating an effective working relationship among practitioners involved in treating these conditions. METHODS A review of the relevant literature was performed, clarifying current definitions of pelvic pain, elucidating the role of musculoskeletal factors, and determining the efficacy of physical therapy interventions. RESULTS A review of the role of physical therapy for the treatment of pelvic pain and related sexual dysfunction. CONCLUSIONS Physical therapy treatment of pelvic pain is an integral component of the multidisciplinary approach to CPP and associated sexual dysfunction.

PTSD and Sexual Dysfunction in Men and Women

INTRODUCTION Difficulties in sexual desire and function often occur in persons with posttraumatic stress disorder (PTSD), but many questions remain regarding the mechanisms underlying the occurrence of sexual problems in PTSD. AIM The aim of this review was to present a model of sexual dysfunction in PTSD underpinned by an inability to regulate and redirect the physiological arousal needed for healthy sexual function away from aversive hyperarousal and intrusive memories. METHOD A literature review pertaining to PTSD and sexual function was conducted. Evidence for the comorbidity of sexual dysfunction and PTSD is presented, and biological and psychological mechanisms that may underlie this co-occurrence are proposed. MAIN OUTCOME MEASURES This manuscript presents evidence of sexual dysfunction in conjunction with PTSD, and of the neurobiology and neuroendocrinology of PTSD and sexual function. RESULTS Sexual dysfunction following trauma exposure may be mediated by PTSD-related biological, cognitive, and affective processes. CONCLUSIONS The treatment of PTSD must include attention to sexual dysfunction and vice versa.

CME Information: Sexual Health and Religion: A Primer for the Sexual Health Clinician (CME)

INTRODUCTION Sexual health is an integral part of the multifaceted human experience that is driven both by biological factors and psychological facets. Religion may provide a moral code of conduct or a sexual compass as to sexual norms and behaviors. AIM The aim of this study was to summarize the integration of sexuality and religion. METHOD A review of published literature and religious texts was conducted. RESULTS The integration of religion with country or state politics and laws is a complicated dilemma and will not be discussed in the scope of this article. The extent to which an individual incorporates their religious doctrine into their sexual life is a personal and individualized choice. The sexual medicine health professional will likely encounter a diverse patient population of distinct religious backgrounds, and a primer on religion and sexuality is a much needed adjunctive tool for the clinician. CONCLUSION Because religion can influence sexuality and dictate, in part, the behavioral and medical treatments for sexual complaints, the clinician should be familiar with religious guidelines regarding sexuality, and treatment should be customized and individualized. Failure to do so can impact compliance with the therapeutic interventions. Religious awareness also solidifies the therapeutic alliance between clinician and patient as it demonstrates respect and acknowledgment for patients beliefs and autonomy.

Ethical and Sociocultural Aspects of Sexual Function and Dysfunction in Both Sexes

AIMS This study aimed to highlight the salient sociocultural factors contributing to sexual health and dysfunction and to offer recommendations for culturally sensitive clinical management and research as well for an ethically sound sexual health care, counseling and medical decision-making. BACKGROUND There are limited data on the impact of sociocultural factors on male and female sexual function as well as on ethical principles to follow when clinical care falls outside of traditional realms of medically indicated interventions. METHODS This study reviewed the current literature on sociocultural and ethical considerations with regard to male and female sexual dysfunction as well as cultural and cosmetic female and male genital modification procedures. RESULTS It is recommended that clinicians evaluate their patients and their partners in the context of culture and assess distressing sexual symptoms regardless of whether they are a recognized dysfunction. Both clinicians and researchers should develop culturally sensitive assessment skills and instruments. There are a number of practices with complex ethical issues (eg, female genital cutting, female and male cosmetic genital surgery). Future International Committee of Sexual Medicine meetings should seek to develop guidelines and associated recommendations for a separate, broader chapter on ethics.

Physical Therapy Treatment of Persistent Genital Arousal Disorder During Pregnancy: A Case Report

Introduction.  Persistent genital arousal disorder (PGAD) is described as the spontaneous, intrusive, and unwanted genital arousal in the absence of sexual interest and desire. Whether the etiology of this disorder is essentially central or peripheral is unclear; however, a presenting symptom may be persistent engorgement of genital erectile and vascular tissue. Aim.  To describe a case of a distressed 27 year old pregnant woman with symptoms consistent with PGAD, and the intervention leading to the resolution of symptoms. Methods.  A patient with symptoms of PGAD was assessed. Information regarding this condition was offered. A manual therapy treatment was provided to decrease muscle hypertonus near the pudendal nerve, and a home intervention was suggested. Results.  Complete resolution of symptoms per patients report 1 week later. Conclusion.  Treatment with pelvic floor manual therapy directed at the pudendal nerve may provide safe and significant relief from PGAD symptoms in a pregnant woman patient. Rosenbaum TY. Physical therapy treatment of persistent genital arousal disorder during pregnancy: A case report. J Sex Med 2010;7:1306–1310.INTRODUCTION Persistent genital arousal disorder (PGAD) is described as the spontaneous, intrusive, and unwanted genital arousal in the absence of sexual interest and desire. Whether the etiology of this disorder is essentially central or peripheral is unclear; however, a presenting symptom may be persistent engorgement of genital erectile and vascular tissue. AIM To describe a case of a distressed 27 year old pregnant woman with symptoms consistent with PGAD, and the intervention leading to the resolution of symptoms. METHODS A patient with symptoms of PGAD was assessed. Information regarding this condition was offered. A manual therapy treatment was provided to decrease muscle hypertonus near the pudendal nerve, and a home intervention was suggested. RESULTS Complete resolution of symptoms per patients report 1 week later. CONCLUSION Treatment with pelvic floor manual therapy directed at the pudendal nerve may provide safe and significant relief from PGAD symptoms in a pregnant woman patient.

JSM HIGHLIGHTSCME Information: Sexual Health and Religion: A Primer for the Sexual Health Clinician (CME)

INTRODUCTION Sexual health is an integral part of the multifaceted human experience that is driven both by biological factors and psychological facets. Religion may provide a moral code of conduct or a sexual compass as to sexual norms and behaviors. AIM The aim of this study was to summarize the integration of sexuality and religion. METHOD A review of published literature and religious texts was conducted. RESULTS The integration of religion with country or state politics and laws is a complicated dilemma and will not be discussed in the scope of this article. The extent to which an individual incorporates their religious doctrine into their sexual life is a personal and individualized choice. The sexual medicine health professional will likely encounter a diverse patient population of distinct religious backgrounds, and a primer on religion and sexuality is a much needed adjunctive tool for the clinician. CONCLUSION Because religion can influence sexuality and dictate, in part, the behavioral and medical treatments for sexual complaints, the clinician should be familiar with religious guidelines regarding sexuality, and treatment should be customized and individualized. Failure to do so can impact compliance with the therapeutic interventions. Religious awareness also solidifies the therapeutic alliance between clinician and patient as it demonstrates respect and acknowledgment for patients beliefs and autonomy.

Managing Pregnancy and Delivery in Women with Sexual Pain Disorders (CME)

INTRODUCTION Vaginismus and dyspareunia most commonly affect women in their childbearing years, yet sexual function, and not childbirth, has been the focus of most research. AIM The aim of this study is to discuss pregnancy and birth outcomes in women with sexual pain disorders (SPDs) and address practical concerns of patients and practitioners regarding management during pregnancy, pelvic examination, labor, and delivery. METHODS Review of the relevant literature and recommendations based on clinical expertise of the authors. RESULTS A review of SPD, conception, and birth outcomes is provided as well as clinical recommendations for prenatal, labor, and delivery management of women with SPD. CONCLUSIONS Practitioners involved in obstetrical care should be knowledgeable about SPD and provide appropriate modifications and interventions.

Sexual Function before and after Total Hip Replacement: Narrative Review.

Background More than 1 million total hip replacements (THRs) are performed every year worldwide. Achieving decreased pain, increased mobility, and improved quality of life (QoL) are key factors in the decision to undergo THR. Sexual activity is a valued component of QoL; however, little is known about how THR affects sexual functioning or the extent to which health care providers address sexuality in THR patients. Aim The aim of the study was to assess the literature regarding sexuality and sexual function in patients before and after THR. Methods PubMed, Google Scholar, and PEDro databases were searched without search limitations from inception until December 2013 for terms relating to sexual function and THR. Results Sexual activity before and after a THR is an important QoL issue. In patients with end-stage hip osteoarthritis, THR has been reported to have beneficial effects in restoring sexual satisfaction and performance. While research has recently been conducted to determine the range of motion of the hip joints necessary to execute certain sexual positions, there remains a lack of validated guidelines and the risks related to sexual activity after THR is rarely discussed between patients and medical staff. Conclusions The ability to move comfortably is included among the many physical and psychosocial factors influencing sexual functioning. Practitioners should be encouraged to question their THR patients about sexual concerns and to provide counseling related to physical and functional aspects of sexual activity. Rehabilitation that focuses specifically on activities of daily living of sex should include sexual counseling, therapeutic exercise, and advice regarding sexual positions. Rehabilitation provided by physical therapists may help decrease pain, and facilitate greater self-awareness, self-confidence, and improved body image, all of which encourage and affirm optimal sexual health. Meiri R, Rosenbaum TY, and Kalichman L. Sexual function before and after total hip replacement: Narrative review.

How Well Is the Multidisciplinary Model Working

The classical approach to sexual dysfunction has traditionally followed a divergent paradigm. If an organic, physiologically based etiology was identified and could be addressed medically, the practitioner most likely involved in treatment would be a medical health provider, such as a physician, nurse practitioner, physician assistant, or pelvic floor physical therapist. If no organic cause was identified, the patient would leave the office with a referral to a mental health provider with the implicit (or even explicit) message that the problem is primarily “in your head.” This “either/or” mentality continues to pit medical vs. mental health practitioners against one another in the battle of “whose patient is this?” Case discussions at multidisciplinary conferences are a predictable forum for participants to offer their often unidimensional perspectives. The case of a healthy young man with erectile dysfunction (ED), for example, can become the battleground over the significance of the insufficiently tumescent penis. To the physicians, the meaning is physiological; it may be a potential marker for heart disease, and anyways, why subject the client to talk therapy when a phosphodiesterase type 5 inhibitor can easily solve the problem? To sex therapists, however, blood flow is secondary to context, and ED may have psychological or sociological significance. Is this an unconsummated marriage in a traditional society where the man, with little or no prior experience, is expected to perform on his wedding night with his equally anxious or possibly vaginistic bride? What role does anxiety play in this man’s life? What is the meaning of pleasure and why does he have difficulty achieving it? A paradigm shift has occurred, in theory at least, as the multifactorial nature of sexual problems has become better appreciated, in part due to publications in The Journal of Sexual Medicine ( JSM ) [1]. This is particularly true in the area of women’s sexual health [2]. The biopsychosocial model of women’s sexual function posits that physiological and organic factors, together with emotional wellbeing, mood, social and cultural influences, and relationship context, all play a role in sexual function. Practically, however, this model continues to be problematic as medical practitioners deal with the “physical part” while mental health practitioners address the psyche. Too often, the woman’s “issues” are compartmentalized in treatment, leaving the woman feeling fragmented and her treatment, unintegrated. We can look at sexual pain disorders to exemplify this problem. Sexual pain disorders are understood to have multifactorial components. While research has focused on physiological mechanisms, cognitive and affective factors are recognized to have an important role [3]. Higher catasrophizing, fear of pain, hypervigilance, and lower self-efficacy have all been associated with increased intercourse pain intensity [4]. Traditional biopsychosocial conceptualizations of vaginismus and dyspareunia compartmentalize the treatment by designating the physiological aspects to physicians, and the psychosocial aspects including anxiety and aversion, to mental health professionals including psychotherapists and sex therapists. In this algorithm, treatment of the pelvic floor muscles (the physical manifestation of the emotionally anxious state) is designated to physiotherapists. This design is problematic for many reasons. In the physiotherapy clinical setting, for example, fear avoidance and anxiety are significant characteristics of the patient’s response, which mirrors their experience in sexual intercourse. Treatment, which attends to pelvic floor dysfunction without addressing the patient’s emotional experience of vulnerability and fear or the meaning of penetration in her sexual and nonsexual life, or the dynamics of her relationship may not only fail to help but may also cause additional harm. The physiotherapist may be perceived as one other coercive voice in her life. Addressing the patient’s anxiety and vulnerability later in the comfort and nonjudgmental psychotherapy office replaces the physiotherapy room as the safe and containing place. As a pelvic floor physiotherapist, I struggled with my limitations in a multidisciplinary model that attributed to me only the woman’s pelvic floor. While physiotherapists know how to deal with pain avoidance, the treatment model is based on cognitive and behavioral motivation (“you can 2957