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Dr. Ellison Melrose // #ClinicalTuesday // www.ptonice.com In today's episode of the PT on ICE Daily Show, Dry Needling Division faculty member Ellison Melrose discusses the benefits of utilizing dry needling as a treatment for sexual dysfunction in women. Take a listen to the episode or check out the full show notes on our blog at www.ptonice.com/blog. If you're looking to learn more about our Extremity Management course or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don't forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab. EPISODE TRANSCRIPTION ELLISON MELROSEGood morning PT on ICE Daily Show I am coming to you live from Durango, Colorado this morning in my truck so excuse the background, but we are here to talk about First of all, my name is Dr. Ellison Melrose. I am lead faculty with the dry needling division of ICE. I am coming to you today to talk about dry needling in the pelvic health space, particularly for sexual dysfunction in females or in women. And I wanted to highlight two common diagnoses we have, which is vulvodynia and vaginismus. So let's dive right into that. First, I want to highlight in 2018, there was a joint report done by both the International Urogynecology Association and International Continence Society that overviewed sexual function and dysfunction. They did a deep dive into things like the proper screening, what proper history or physical subjective objective exam would look like. And then they had a huge section on the prevalence of pelvic floor dysfunction in folks that had sexual dysfunction as well. So that's what I wanted to highlight today. We, in the pelvic floor practice or pelvic floor space, we see it often where pelvic floor dysfunction and sexual dysfunction is highly linked and correlated. what I, what this report, um, highlighted is that there's actually 37 different diagnoses of sexual dysfunction that can be attributed to some form of pelvic floor dysfunction. And that's a lot, right? So, um, there granted, I mean, if you look at all of the, the nitty gritty diagnoses, um, we may be thinking maybe we're over medicalizing this, patient population a little bit with specific diagnoses, but it highlights the fact that there's so many people out there that have pelvic floor dysfunction that is contributing to a form of sexual dysfunction. 45% of women that have urinary incontinence will complain of sexual dysfunction at some point in their life. Of that 45%, 34% of that is hyposexual desire disorder. Um, and 44% of those are a brand of sexual pain disorder, which is either dyspareunia or a non-coital, so a genital pain that's not associated with intimacy. And that's what I wanted to highlight. Two most common diagnosis that we see in the clinic that can be challenging for us as pelvic floor PTs often are both vulvodynia and vaginismus. And we'll kind of get into potentially why these can be challenging diagnoses for us. DRY NEEDLING FOR VULVODYNIA Um, but for vulvodynia, the clinical definition of this is anyone that has had pain in or around the vulva region for at least three months without a clear ideology of symptoms. So they don't have, They've had negative cultures, so they don't have either fungal or bacterial infection going on here. And so there's this idiopathic pain presentation in the vulva region. And then vaginismus is a recurrent or a persistent muscle spasm of the pelvic floor, which inhibits any form or enables penetration and there's different forms of vaginismus and different diagnosis underneath that umbrella of vaginismus. And we can kind of dive into that when we talk about vaginismus specifically. I wanted to highlight these two diagnoses particularly because without a proper diagnosis, oftentimes the internal assessment can either be very challenging or it can be very non-therapeutic and actually traumatizing to some of these folks. So if we don't have a particular subjective exam that allows us to understand what is going on with our patients, the whole pelvic floor assessment may be not therapeutic. So for both of these diagnoses, everything starts in the subjective exam. Let's start with vulvodynia. So vulvodynia, oftentimes folks may have symptoms similar to that of a yeast infection or a UTI that then kind of snowballs from there. They may have actually had recurrent yeast infections or UTIs in the past and are familiar with those symptoms, but, and so they do their normal treatment with that, which a lot of times is either over-the-counter medication or they might phone up their OBGYN and say, well, let's get some of these either antifungals or antibiotics on board ahead of time while we wait for the culture. Well, culture comes back negative and the symptoms are still persisting. Sometimes they may get taken away with some of the medication a little bit, but the symptoms overall typically will persist past that. Um, and for folks that have this at this point, it is no longer a, um, you know, bacterial or yeast causing these symptoms. There is a brand of neuropathic pain going So a lot of times they have either had this for quite a long time, at least three months, they've seen other providers that have either provided a medical treatment or something that has been ineffective. And so symptoms have continued. When we think about neuropathic pain and the chronicity and the persistent pain or the chronic pain side of things here, this actually heightened symptoms typically. Um, other subjective things that you might see in these folks is that they may have, um, some sensitivity to, uh, like touch in, in the vulva region, right? So wearing specific type of clothing may be uncomfortable where they may have other brands of, uh, nerve related symptoms like itching or burning. Um, which oftentimes are two symptoms that we think about for either a yeast infection or ATI. And so that's why they get mismanaged in their medical treatment. So it all starts in the subjective exam. And while an internal assessment in these folks isn't out of the question, it can definitely be helpful. It doesn't always, it's not the most efficient way to go about treating this pain presentation. when we think about neuropathic pain, we need to think about, okay, why is this nerve so irritated? And a lot of times in vulvodynia, they see that there is either a irritation of the nerve. Sometimes there can even be, you know, some, some changes in the myelin sheath of these nerves. So there's actual nerve damage associated with it. Depending on maybe what the original cause of the, nerve irritation was. And so when we dive into, we've highlighted their subjective complaints, we know what's going on here, where do we go from there, the internal assessment may be valuable in order to see is this maybe a hypertonicity issue. So if we have tight pelvic floor musculature, can we teach them to relax their pelvic floor and allow for improved blood flow to the pudendal nerve that could be contributing to some of these symptoms. So there is a lot, there is value in that. And I believe that there is, um, oftentimes in the pelvic health space, we are so used to, um, you know, trying to treat, the patient's symptoms ourselves, whereas we can teach our patients to help themselves with learning how to relax their pelvic floor. So there is a benefit in the vulvodynia patient population to utilize the internal assessment. But when we think about efficiency, so how can we treat a neuropathic pain presentation the most efficiently in our in our clinical setting? I am in the dry needling space, and so we use dry needling a ton outside of the pelvic floor world for treating various different brands of pain, one of which is neuropathic pain. So dry needling can be a super efficient tool to improve, to talk to the nervous system and do a nervous system reset to the nerve in question, which oftentimes is the lupudendal nerve. So dry needling is a very efficient tool in order to improve those neuropathic symptoms. With that being said, everything we do physically, manually, we need to highlight that this is a persistent pain diagnosis at this point. And so we need to be utilizing our pain neuroscience education. um, educating these folks about, um, what, what happens to our nervous system when we have had pain for a long period of time. Um, and, and that pain doesn't necessarily equal damage at this point or else everything that we do with our, our manual skills or dry needling, uh, will only get us so far. Right. So, um, vulvodynia again a lot of times these patients come in to us with chronic symptoms so they've been going at this for a very long time they've had typically a medical mismanagement where they've been having some medications on board that weren't helping their symptoms they have a lot of sensitized nervous system and so we want to make sure that we are using the most clinically efficient tool to treat these symptoms. Oftentimes as well, you might actually get some reproduction of symptoms with dry needling when we're approximating the pudendal nerve or getting close to that pudendal nerve, which can be helpful in almost diagnosing, right? So using our tools to help with localizing their symptoms. So that is how we would use dry needling in a case for vulvodynia and in a patient population where we would still likely be able to utilize the internal assessment. DRY NEEDLING FOR VAGINISMUS Now let's pivot to vaginismus. Let's talk a little bit more about different diagnoses under the umbrella of vaginismus and then how we would and why we would use dry needling in this patient population. So, Vaginismus, there's two different diagnoses and underneath that we have two other subdivisions. So we have both primary and secondary vaginismus. So again, a reminder vaginismus is either a persistent muscle spasm of the pelvic floor. It's either persistent or it's associated with something and we'll get into that. Primary means that this has been forever. So this has always been an issue. Um, sometimes there may be a congenital malformation of the genital track on board with this patient population as well. Um, and if that is the case, even things like typically their first, um, like, uh, association with any form of penetration, uh, is oftentimes a, when they get their menstrual cycle. So, um, having a tampon and they're unable to actually insert a tampon into their vagina. Um, from there, then they, they often with this congenital, um, malformation or having it be a primary diagnosis is they, they often are treated fairly medicalized in that state and, and they may require some form of surgical procedure to, widen the vaginal canal. So that's primary vaginismus. Secondary vaginismus is acquired. So it wasn't always an issue, but it could be acquired from a form of trauma. So either an emotional or a physical trauma that then caused muscles in the pelvic floor to spasm. And this can be either global. So what I mean by global is that it's every time anything is enters the vaginal canal, there is a muscle spasm associated with that or it's situational, meaning that things like inserting a tampon may be possible, but physical intimacy with, um, or sexual intimacy is not possible. So there's no, uh, penetration available during, uh, sexual intimacy. Um, so those are the different kind of clinical or, diagnosis we find under the umbrella of vaginismus. Oftentimes in pelvic floor PT, we will see, um, a lot more probably of the secondary vaginismus in that they've, you know, they've never had, they hadn't always had issues, but then something caused or something triggered an issue, which causes the pelvic floor muscles to, um, to spasm, right? And that could be a traumatic birth of vaginal delivery. It could be a sexual trauma. So a, um, yeah, a sexual assault or something of the sort. It could be a, uh, traumatic pelvic exam by their OBGYN, uh, which we've, I see a ton in the clinic and, um, so it could be, a natural physical trauma with that. And then it could also be heightened with a, um, an emotional trauma as well. So a lot of times, I mean, this is a very intimate part of our body. And so there's a lot of times a very, uh, pertinent, uh, or very prevalent emotional, well, um, 70%, I would say probably about 70% of your initial evaluation evaluation, is going to be a subjective exam. Understanding the why behind these patient symptoms is crucial to dictate the course of your treatment or even the course of your assessment in that initial evaluation, right? Like, are we going to be doing an internal assessment on these folks? And a lot of times, probably, probably not, right? So what does day one look like or our initial evaluation look like with folks that have vaginismus? and how and what does our course of treatment look like for them. So typically education goes a long way with folks that have had either a physical or an emotional trauma that has caused muscle spasms here, right? So teaching folks about the anatomy of the pelvic floor musculature uh, why they feel like there's a brick wall when they try to insert a tampon. Right. Um, how, uh, what a Kegel is. Right. So anytime people have any association with the pelvic floor, they are often just think, Oh, I should be doing Kegels. Right. Um, and teaching them what, what a Kegel or what a pelvic floor muscular muscle contraction is and educating like the benefits of relaxing the pelvic floor. And this is just all done through education. So no even physical touch or assessment has been done at this point, but just educating folks around the anatomy of the pelvic floor. Anatomy and physiology of the pelvic floor can go a long way here. We also want to educate about vaginismus itself. So vaginismus is another brand of chronic pain, right? So these folks have typically had pain for an extended period of time, Um, there's not a diagnostic criteria for, for duration of symptoms like there is for vulvodynia. Um, but there is a pain cycle on board here, right? So it all starts in the brain. So it, it either the, the brain perceives an emotional trauma due to either a physical trauma or, or purely emotional that registers discomfort or, or fear associated with, uh, penetration either from a previous, uh, you know, exam with a speculum from a previous sexual encounter, um, from a trauma traumatic birth, right? So the brain remembers those things, which is then going to be causing, it causes muscle guarding. So public for guards, the tight muscles in the public for cause the penetration to be painful. or impossible at sometimes. And then this difficulty in pain reinforces that alarm, the amygdala alarm that's going on up in the brain, right? That reinforces that this is a threat, right? The nervous system then remembers this pain, and so every time our brain is their, their brain is thinking about, you know, either having to go to the OBGYN or having a sexual encounter, anything like that. Um, it is going to remember that and we are going to get the same physical symptoms as the, the tight muscles, um, which is often going to lead to, you know, decrease blood flow to the nervous system, which is going to cause potentially, you know, perceived as pain by these folks. And so they're going to avoid those, uh, you know, avoid whatever is causing this pain cycle, right? And those folks, which ultimately, especially if this is a sexual nature is going to, um, reduce the desire to either have sexual intimacy with their partner or, um, and it…
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