Perineal Massage Improves the Dyspareunia Caused by Tenderness of the Pelvic Floor Muscles

Massagem perineal melhora a dispareunia causada por tensão dos músculos do assoalho pélvico

ABSTRACT

Aim:

To evaluate the long-term effectiveness of perineal Thiele massage in the treatment of women with dyspareunia caused by tenderness of the pelvic floor muscles.

Methods:

A total of 18 women with diagnoses of dyspareunia caused by tenderness of the pelvic floor muscles were included in the study. The women were divided in two groups: the dyspareunia (D) group - 8 women with dyspareunia caused by tenderness of the pelvic floor muscles; and the chronic pelvic pain group (CPP) group - 10 women with dyspareunia caused by tenderness of the pelvic floor muscles associated with CPP. Each patient filled out the Visual Analogue Scale (VAS), the McGill Pain Index, the Female Sexual Function Index (FSFI) and the Hospital Anxiety and Depression Scale (HADS). After an evaluation, the women underwent transvaginal massage using the Thiele technique over a period of 5 minutes, once a week for 4 weeks.

Results:

All women had significant improvements in their dyspareunia according the VAS and the McGill Pain Index (p < 0,001), but the HADS scores did not show significant differences. Regarding sexual function, the D group showed improvements on all aspects of sexual function, while the CPP group showed differences only in the pain domain.

Conclusion:

Thiele massage is effective in the treatment of dyspareunia caused by tenderness of the pelvic floor muscles with a long-term pain relief.

Keywords:
Dyspareunia; physical therapy; pelvic pain; pelvic floor; women's health

RESUMO

Objetivo:

Avaliar a eficácia em longo prazo da massagem perineal de Thiele no tratamento de mulheres com dispareunia provocada pela tensão dos músculos do assoalho pélvico.

Métodos:

Foram incluídos no estudo dezoito mulheres com diagnóstico de dispareunia provocada pela tensão dos músculos do assoalho pélvico. As mulheres foram divididas em dois grupos: o grupo dispareunia (D) - 8 mulheres com dispareunia causada pela tensão dos músculos do assoalho pélvico; e o grupo de dor pélvica crônica (DPC): 10 mulheres com dispareunia causada pela tensão dos músculos do assoalho pélvico associados à DPC. Cada paciente preencheu Escala Visual Analógica (EVA), Índice de Dor de McGill, Índice de Função Sexual Feminino (IFSF) e Escala Hospitalar de Ansiedade e Depressão (EHAD). Após a avaliação, as mulheres foram submetidas a massagem transvaginal utilizando a técnica de Thiele ao longo de um período de 5 minutos, 1 vez por semana durante 4 semanas.

Resultados:

Todas as mulheres tiveram melhora significativa da dispareunia de acordo com a EVA e o Índice de Dor de McGill (p < 0,001), mas na pontuação do EHAD não mostraram diferenças significativas. Em relação à função sexual, o grupo D apresentou melhora de todos os aspectos da função sexual, enquanto o grupo DPC mostrou diferenças apenas no domínio dor.

Conclusão:

A massagem perineal de Thiele é eficaz no tratamento da dispareunia causada pela tensão dos músculos do assoalho pélvico, com alívio da dor a longo prazo.

Palavras chaves:
dispareunia; fisioterapia; dor pélvica; assoalho pélvico; saúde da mulher

Introduction

Dyspareunia is an important sexual dysfunction commonly encountered in the clinical practice that causes a negative impact in the quality of life of women.¹ Dyspareunia is usually associated with multifactorial conditions (organic, behavioral, or psychological factors) that make the diagnosis and early treatment difficult.² Most women regard dyspar-eunia as an ordinary symptom, very often not reporting pain during gynecological consultations,³ and that over the time can aggravate the symptom and favor the emergence of chronic diseases. One of them is chronic pelvic pain (CPP), which is defined as continuous or recurrent pain in the lower abdomen or pelvis lasting at least 6 months and sufficiently intense to interfere in daily life activities.^4,5 Among women with CPP, dyspareunia is one of most common complaints. In a retrospective study evaluating the medical records of 955 women with CPP, it was observed that 64% of women had symptoms characteristic of dyspareunia and, among these, in 22% of cases they were potentially caused by tenderness of the pelvic floor muscles, mainly in the levator ani muscle.⁶ Tenderness of the levator ani muscle is one of the most common causes of dyspareunia.

Despite its high prevalence, to this date there are few studies addressing the evaluation⁷ and treatment of dyspar-eunia⁸ caused by tenderness of the pelvic floor muscles in the literature. Recently, a research group developed a study proposing the use of Thiele massage in the treatment of women with CPP caused by tenderness of the pelvic floor muscles. The results were promising, with great relief of pain during the treatment and after a month of follow-up.⁹

Therefore, the objective of this study is to evaluate the long-term effectiveness of Thiele massage in the treatment of women with dyspareunia caused by tenderness of the pelvic floor muscles associated or not with CPP.

Methods

An open, parallel, nonrandomized clinical assay was per-formed with women who consecutively attended at a uni-versity hospital. The study was approved by the Research Ethics Committee, and all participants gave written informed consent. A total of 29 women were initially recruited, and 18 of them completed the entire protocol (►Fig. 1). Women in reproductive age, sexually active, with diagnosis of dyspar-eunia caused by tenderness of the pelvic floor muscles associated or not with CPP were included in study. Subjects with cognitive disorders, diabetes mellitus, neuropathy, vasculopathy, genital prolapses and who were using anti-depressants were excluded.

Before the clinical examination, each patient filled out a detailed form containing information about the character-istics of the pain and their personal history, and completed the Visual Analogue Scale (VAS),¹⁰ McGill Pain Index,¹¹ Female Sexual Function Index (FSFI)^12,13 and Hospital Anxi-ety and Depression Scale (HADS).¹⁴

The physical examination consisted of a general evalua-tion, an investigation of the trigger points, an inspection of the external genitalia, a traditional bimanual pelvic exami-nation and a unidigital vaginal palpation. The unidigital palpation was performed to identify the tenderness of the muscles. All women included in the study always received clinical care from the same professionals, who were blinded to all study data. The subjects were divided into two groups: the dyspareunia (D) group, which was composed of 8 women with a mean age of 31.3 ± 6.4 years with isolated dyspar-eunia, that is, women with dyspareunia caused exclusively by tenderness of the pelvic floor muscles; and the CPP group, which was composed of 10 women with a mean age of 35.0 ± 6.2 years with dyspareunia caused by tenderness of the pelvic floor muscles associated with CPP.

Fig. 1
Patient enrollment flowchart.

After the evaluation, the women underwent a transvagi-nal massage using the Thiele technique, which consists of a massage from the origin to the insertion of the muscle with an amount of pressure tolerable by the patients, over a period of 5 minutes.¹⁵ Thiele massage was repeated once a week for 4 weeks. During this period, the patients were informed about the characteristics of the pelvic floor, and advised not to have intercourse. All women were re-evaluated after 1, 4, 12 and 24 weeks.

Statistical Analysis

Considering that the standard deviation obtained using the VAS in the women with CPP was 20 mm, and considering p < 0.05 as the level of statistical significance, 10 participants from each group would be required to obtain an 80% power of the test and to identify a difference of 30 mm in the pain VAS, which is considered the minimum relevant clinical change for pain, using the JMP software (SAS Campus Drive, building T, Cary, NC, USA) for the calculation.

The continuous variables were expressed as mean and standard deviation values, and the statistical analysis was conducted using the GraphPad Prism 5.0 software (Graph-Pad Software, University of California San Diego, San Diego, CA, USA). The presence of normal distribution was deter-mined using the Kolmogorov-Smirnov test. Multiple varia-bles were analyzed using the ANOVA test, with the Bonferroni post test. We considered a significance level of 5%.

Results

At the end of 4 weeks of treatment, all groups showed a significant improvement of the dyspareunia, describing no pain or little discomfort during intercourse. The VAS and McGill pain index scores showed significant improvement during all periods of follow-up (►Fig. 2). The HADS scores did not show significant differences throughout the periods of follow-up (data not shown). Regarding sexual function, in the D group we observed improvements of all aspects of sexual function (►Table 1). The CPP group only had a significant improvement in the pain domain, with no im-provement of general sexual function (►Table 2).

Fig. 2
Assessment of pain in all groups during the study's follow-up periods. Multiple variables were analyzed using the ANOVA test, with the Bonferroni post hoc test. We considered a significance level of 5%.

Table 1
Sexual function scores of the dyspareunia group during the study's follow-up periods

FSFI	Evaluation	1 week	4 weeks	12 weeks	24 weeks	p
TOTAL	18.8 (5.9)	27.5 (3.2)*	28.9 (3.6)*	28.4 (3.7)*	26.0 (4.3)*	< 0.0001
Desire	2.6 (1.0)	4.1 (0.7)*	3.9 (1.1)*	4.1 (0.9)*	3.9 (1.1)*	0.0003
Arousal	3.0 (1.4)	4.4 (0.7)*	4.2 (1.1)*	4.1 (0.8)	3.8 (0.8)	0.005
Lubrication	3.1 (1.2)	4.3 (1.1)*	4.9 (0.9)*	4.6 (1.0)*	4.4 (1.0)*	0.0003
Orgasm	3.5 (1.4)	4.4 (1.3)	4.9 (1.0)*	4.8 (0.6)*	4.4 (0.9)	0.007
Satisfaction	4.2 (1.5)	5.2 (0.5)	5.5 (0.4)*	5.6 (0.5)*	4.9 (1.0)	0.005
Pain	2.2 (1.2)	4.8 (1.1)*	5.2 (0.6)*	4.9 (0.7)*	4.5 (1.2)*	< 0.0001

• Abbreviation: FSFI, Female Sexual Function Index. Data in means (standard deviation) (n 1/4 8). *p < 0.001; Evaluation: first evaluation before treatments; 1 week: one week of follow-up after treatment; 4 weeks: four weeks of follow-up after treatment; 12 weeks: twelve weeks of follow-up after treatment; 24 weeks: twenty-four weeks of follow-up after treatment.

Table 2
Sexual function scores of chronic pelvic pain group during the study's follow-up periods

FSFI	Evaluation	1 week	4 weeks	12 weeks	24 weeks	p
TOTAL	17.6 (5.9)	22.8 (5.7)	22.7 (5.3)	21.2 (5.3)	22.1 (5.9)	0.058
Desire	2.9 (1.3)	3.3 (1.1)	3.4 (0.8)	2.8 (0.8)	3.6 (1.2)	0.18
Arousal	3.0 (1.4)	3.5 (0.8)	3.4 (1.1)	3.3 (1.2)	3.5 (0.9)	0.39
Lubrication	3.1 (1.2)	4.3 (0.8)	4.2 (1.1)	3.9 (1.2)	4.0 (1.3)	0.07
Orgasm	2.8 (1.6)	3.7 (1.1)	4.1 (1.2)*	3.7 (1.0)	3.7 (1.1)	0.06
Satisfaction	3.8 (1.4)	4.3 (0.8)	4.1 (0.8)	3.9 (1.5)	4.2 (1.5)	0.77
Pain	1.8 (0.4)	3.5 (1.5)*	3.5 (1.2)*	3.5 (1.1)*	3.0 (0.8)*	0.003

• Abbreviation: FSFI, Female Sexual Function Index. Data in means (standard deviation) (n 1/4 10). *p < 0.05; Evaluation: first evaluation before treatments; 1 week: one week of follow-up after treatment; 4 weeks: four weeks of follow-up after treatment; 12 weeks: twelve weeks of follow-up after treatment; 24 weeks: twenty-four weeks of follow-up after treatment.

Discussion

According to our results, Thiele Massage is an effective approach in the treatment of dyspareunia caused by tender-ness of the pelvic floor muscles, with a long-term pain relief.

In both groups, at first evaluation, the pain scores were high enough to interrupt intercourse. After treatment and during follow-up, these scores decreased significantly, main-ly in the D group. The same could be observed about the FSFI scores. A low FSFI score is a potential risk for the develop-ment of serious sexual dysfunctions and compromising of sexual response cycle.^16,17 The improvement of these scores clearly reflects an important increase in the sexual satisfac-tion and in the quality of life of women.

Despite the fact that the CPP group had important im-provements in the pain and sexual aspects, those changes were not as significant as in the D group. This can be explained by the multifactorial aspects of the physiopathol-ogy of CPP.^18,19

Sexual function is highly complex, depending on biologi-cal, psychological and sociocultural factors, as well as inter-personal experiences. Therefore, more studies are necessary to assess the sexual needs of women with CPP. In order to be effective in this population, therapeutic interventions should take into account all the experiences of women.^20,21

During the study, data regarding the frequency of inter-course before and after the treatment, as well as information about changes in the quality of the sexual relationship of the women were not collected. These data would be important, once repeated pain episodes during intercourse may gener-ate anguish, anxiety and interpersonal issues, leading wom-en to anticipate a previous negative experience and avoid sex.²² In addition, women who know their own bodies and better understand their sexuality tend to develop higher quality relationships.

Finally, our study showed for the first time that Thiele massage is a successful long-term therapy for dyspareunia caused by tenderness of the pelvic floor muscles.

Conclusion

Thiele massage is an effective long-term method for the treatment of dyspareunia caused by tenderness of the pelvic floor muscles. It is a simple technique, easy to learn, and women or their partners could perform it without risk. Therefore, Thiele massage may be accessible even to the women who cannot afford to attend a regular physical therapy rehabilitation program. Thus, the welfare of women could be long lasting, with the improvement of their sexual satisfaction and, consequently, their quality of life.

Acknowledgements

This project was approved by the Research Ethics Commit-tee of the institution under the number 6914/2010. The authors have no conflicts of interest to declare. The authors acknowledge FAEPA and CAPES for financial support.

References

• ¹
  Pasqualotto EB, Pasqualotto FF, Sobreiro BP, Lucon AM. Female sexual dysfunction: the important points to remember. Clinics (Sao Paulo) 2005;60(1):51-60
• ²
  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(4): 374-380
• ³
  Lara LA, Rosa e Silva AC, Romão AP, Junqueira FR. [The assessment and management of female sexual dysfunction]. Rev Bras Ginecol Obstet 2008;30(6):312-321
• ⁴
  Campbell F, Collett BJ. Chronic pelvic pain. Br J Anaesth 1994; 73(5):571-573
• ⁵
  Grace V, Zondervan K. Chronic pelvic pain in women in New Zealand: comparative well-being, comorbidity, and impact on work and other activities. Health Care Women Int 2006;27(7):585-599
• ⁶
  Tu FF, As-Sanie S, Steege JF. Prevalence of pelvic musculoskeletal disorders in a female chronic pelvic pain clinic. J Reprod Med 2006;51(3):185-189
• ⁷
  Revicky V, Mukhopadhyay S, Morris E. Dyspareunia in gynaecolog-ical practice. Obstetrics, Gynaecol Reprod Med 2012;22(6):148-154
• ⁸
  Wolpe RE, Toriy AM, Silva FP, Zomkowski K, Sperandio FF. Atuação da fisioterapia nas disfunções sexuais femininas: uma revisão sistemática. Acta Fisiátr 2015;22(2):87-92
• ⁹
  Montenegro ML, Mateus-Vasconcelos EC, Candido dos Reis FJ, Rosa e Silva JC, Nogueira AA, Poli Neto OB. Thiele massage as a therapeutic option for women with chronic pelvic pain caused by tenderness of pelvic floor muscles. J Eval Clin Pract 2010;16(5): 981-982
• ¹⁰
  Langley GB, Sheppeard H. The visual analogue scale: its use in pain measurement. Rheumatol Int 1985;5(4):145-148
• ¹¹
  Melzack R. The McGill pain questionnaire: from description to measurement. Anesthesiology 2005;103(1):199-202
• ¹²
  Pacagnella RdeC, Martinez EZ, Vieira EM. [Construct validity of a Portuguese version of the Female Sexual Function Index]. Cad Saude Publica 2009;25(11):2333-2344
• ¹³
  Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26(2):191-208
• ¹⁴
  Botega NJ, Bio MR, Zomignani MA, Garcia C Jr, Pereira WA. [Mood disorders among inpatients in ambulatory and validation of the anxiety and depression scale HAD]. Rev Saude Publica 1995; 29(5):355-363
• ¹⁵
  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(5):862-865
• ¹⁶
  Payne KA, Binik YM, Amsel R, Khalifé S. When sex hurts, anxiety and fear orient attention towards pain. Eur J Pain 2005;9(4):427-436
• ¹⁷
  Abdo CH, Fleury HJ. Aspectos diagnósticos e terapêuticos das disfunções sexuais femininas. Rev Psiquiatr Clin (Santiago) 2006; 33(3):162-167
• ¹⁸
  Fleury HJ, Abdo CH. Dor genital feminina. Diagn Tratamento 2013; 18(3):124-127
• ¹⁹
  Nogueira AA, Reis FJ, Poli Neto OB. Management of chronic pelvic pain in women. Rev Bras Ginecol Obstet 2006;28(12):733-740
• ²⁰
  Verit FF, Verit A, Yeni E. The prevalence of sexual dysfunction and associated risk factors in women with chronic pelvic pain: a cross-sectional study. Arch Gynecol Obstet 2006;274(5): 297-302
• ²¹
  Romão AP, Gorayeb R, Romão GS, et al. Chronic pelvic pain: multifactorial influences. J Eval Clin Pract 2011;17(6):1137-1139
• ²²
  Rosenbaum TY. Physiotherapy treatment of sexual pain disorders. J Sex Marital Ther 2005;31(4):329-340

Publication Dates

• Publication in this collection
  Jan 2017

History

• Received
  25 May 2016
• Accepted
  09 Nov 2016