Fig. 20.1
The Fear-Avoidance Model of Pain detailing how maladaptive thinking can perpetuate the cycle of pain and lead to avoidance of or hypervigilance for pain with sexual activity
According to the model, pain or negative experiences (e.g., urinary leakage during sex, “failed” attempts at intercourse) result in particular ways of thinking about vaginal penetration that may be adaptive (“This is not feeling good, I think I need more sexual stimulation”) or maladaptive. Distorted thought patterns include magnification (e.g., “This will get worse”), rumination (e.g., “Something must be seriously wrong with me”), and helplessness (e.g., “Nothing can help me”). Research studies demonstrate the presence of catastrophizing thoughts [21] and their impact on pain maintenance and/or exacerbation [15, 22]. Catastrophizing thoughts result in specific fears of pain and vaginal penetration. In fact, ter Kuile and her colleagues [23] found that reduction in specific “coital fears ” was the best predictor for successful treatment outcome in women with lifelong vaginismus . To cope with fear, the patient may avoid all activities related to pain and/or she may be hypervigilant for stimuli that are associated with specific fearful thoughts (e.g., pain, genital incompatibility). The latter can result in an exaggerated attention to physical sensations and increased anxiety that facilitates the experience of pain during attempted vaginal penetration . For example, researchers have noted increased attentional bias and negative affect towards pain-related stimuli in women with provoked vestibulodynia [24]. When sexual activity and intercourse are attempted, the woman experiences preexisting or increasing pelvic muscle hypertonus and/or defensive pelvic muscle reactivity. Increased muscle tone, along with lack of sexual arousal and lubrication, results in further worsening of pain. The inability to “achieve” (pain-free) penetration in turn contributes to negative experiences, confirms negative (maladaptive) expectations, and further exacerbates and perpetuates the cycle of pain and pelvic floor pathology .
20.3 Sexuality-Related Factors
Two psychosocial factors that are not explicitly included in the original fear-avoidance model of pain are sexual function and relationship factors. They are, however, an integral part of our extended model that we call the “vicious cycle of pain” with our patients (see Fig. 20.2).
Fig. 20.2
Numerous factors contribute to the cause, maintenance, and exacerbation of the Vicious Cycle of Pain
Researchers have found evidence of low sexual satisfaction , impaired sexual function across the sexual response (desire, arousal, lubrication, orgasm), as well as elevated sexuality-related distress in women who experience POPF [24–26]. It is not surprising that pain affects sex in negative ways; what is disconcerting is that the fear and anticipation of pain can rob a couple of all affection and opportunities to find intimate connection and meaning. In clinical practice, it is not uncommon to hear a woman relate how she is reluctant to kiss or embrace her partner or respond to his affection for fear that this may result in an attempt at intercourse. Fear of a painful experience, “rejecting” the partner yet again, and/or not being able to “finish what she started” will keep a woman at a “safe” but lonely distance. In addition, focusing on intercourse as the predominant, heterosexual script may also detract from other opportunities to experience sexual connection. As a result, women report guilt and shame about not being able to be—what they perceive as adequate sexual partners, above and beyond the distress their partners may actually experience [27, 28]. An attempt at intercourse, motivated by guilt, obligation, fear of losing the partner, or mental calculations of when the couple “should be” intimate results in sexuality that is far from intrinsically motivated and further increases the likelihood of negative sexual experiences and low satisfaction [29–31].
20.4 Relationship Factors
Partners of patients with POPF may be told about symptoms of pain, but they are also involved in triggering pain in a sexual context. Despite this, relationship adjustment has been reported as often quite positive overall [26, 32]. However, partners can influence the symptomatic person’s experience of pain and sexual adjustment in numerous ways. Rosen and her colleagues have conducted several investigations highlighting that partner responses to pain that are negative (hostility and frustration) or solicitous (attention and sympathy) are associated with increased pain intensity and decreased sexual satisfaction [33]. On the other hand, facilitative responses (encouragement and adaptive coping) were associated with decreased pain intensity and increased sexual function [34, 35]. The researchers demonstrated that on days when a woman perceives her partner to respond in a facilitative manner, her and the partner’s sexual function was improved. In a recent study, the researchers confirmed the negative effects of a woman’s experience with pain associated with intercourse on both partners; taken together the available research suggests that that couples may benefit either from treatment that includes addressing relationship factors , or conjoint therapy may be recommended [36].
20.5 Psychosocial Interventions for Non-psychologists
Many health care professionals who are likely to work with persons experiencing POPF are not trained to conduct psychotherapy with their patients. However, the inclusion of psychoeducational aspects to the primary intervention is feasible and likely to increase treatment adherence, success, and maintenance. A good beginning point can be providing your patient with an extended and detailed version of the fear-avoidance model of pain—as described earlier, we refer to it as the “vicious cycle of pain” with patients (see Fig. 20.2). It can be used to highlight the multidimensional and multi-determined dimensions of pain, muscle reactivity, and chronic hypertonus. It can also identify potential roadblocks in treatment (e.g., critical partner, significant anxiety), provide rationale for multimodal treatment (e.g., sex therapy, relaxation), and identify problems that could lead to an iatrogenic effect of physical therapy treatment interventions (e.g., sexual abuse, PTSD).
Draw or hand the model to the patient and ask her to personalize how the “links in the chain” in the vicious cycle apply to her specific situation (in point format as this is more effective for review). This can be done in the office or at home. Links in the chain can be discussed—if and when appropriate, during your primary treatment. You may also help the client to identify when and whom to consult should sex therapy, pain management, or psychological treatment be necessary. Furthermore, it is very helpful to explain to the patient that treatment can tackle any of the links of the chain but it may take the breaking of more than one link to “break the chain” or “break the vicious cycle” and arrive at satisfactory treatment outcome. This practical approach highlights the integrity of and rationale for a multimodal and/or multidisciplinary treatment approach and motivates the patient to address psychosocial factors in her pain experience.
20.5.1 A Word of Caution
Despite the integral role of psychosocial factors in the “vicious cycle of pain,” it cannot be assumed that variables contributing to the development of problems of POPF are the same variables that maintain and exacerbate the problem/symptoms and vice versa. Hence, when highlighting the role of psychological factors, clinicians need to refrain from pathologizing patients and continuously highlight that “the pain is real.” Or, as some colleagues explain, “Yes! The pain is in your head!” and then promptly continue to explain the role of central and cortical processes involved in the integration of sensory-discriminative, cognitive-evaluative, and affective-motivational dimensions of pain (see more below) [37–39].
20.6 Pain Management: Breaking the Chains of the Vicious Cycle of Pain
When closely examining the Fear-Avoidance Model of Pain and considering the accumulated literature on the role of mental health in affecting pain and its treatment [40–42], it is of little surprise that pain management techniques have been demonstrated as highly effective for chronic and recurrent pain [43] and pain associated with POPF [8]. Pain management can be delivered in a group format or to individuals in a variety of health care settings. However, in the general practice setting, a rationale for including the “brain” (i.e., the chains in the vicious cycle of pain) in the treatment of what the patient experiences as “physical” pain can be helpful. Once the patient understands that focusing on psychosocial factors does not invalidate her pain experience, she will be motivated to give pain management strategies a chance.
A very basic description of the Gate Control Theory of Pain [38] (see Fig. 20.3) can assist in identifying thoughts, feelings, activities, and circumstances that “open the gate” to (more) pain. Pain signals do not merely travel up the spinal cord (afferent nerve fibers) to be processed in the brain as nociceptive; there are also efferent nerve fiber pathways that descend the spinal cord from centers in the brain that process thoughts and emotions. These messages carry the response to the pain signal back to the receptor organ (e.g., to withdraw one’s finger from a flame). Importantly though, they also serve to modulate processing of pain signals in the dorsal horn of the spinal cord, with a potential to augment (“opening the gate”), impede, or even prevent (“closing the gate”) processing of pain signals (Fig. 20.3).
Fig. 20.3
Basic conceptual representation of the Gate Control Theory of Pain, which outlines how thoughts and emotions can alter the experience of pain
The drawing of the “vicious cycle of pain” provides a perfect summary of potential factors that are likely to “open or close the gate” for patients. In addition, a pain journal can further identify and elucidate behavioral and situational triggers for pain. In Table 20.1, the example of a pain journal is similar to a “thought record” used in cognitive behavioral therapy (CBT ). The advantage of using this expanded and standardized version of the pain journal is that the patient (and therapist) can examine particular behaviors that trigger, maintain, and worsen pain—but also how thoughts and emotions can be adaptive or maladaptive in the management of pain. This clarifies further the different links of the vicious cycle of pain. Discussion of pain responses in the context of the Gate Control Theory of pain and what “opens or closes the gate” for a particular patient will encourage adaptive problem solving and help the patient generate alternative re/actions that make sense in her context. Detailed planning and anticipating barriers are crucial to assure that the patient understands the treatment rationale and gives the intervention a try (Table 20.1).
Table 20.1
The Thought Record or diary is a systematic record of situational and behavioral triggers , thoughts, and emotions that exacerbate negative experiences, as well as adaptive coping responses
Date | Activity | Pain rating (0–10) | Thoughts | Feelings | Reflectionsa |
|---|---|---|---|---|---|
– | Made love without penetration (finger insertion) | 6 with insertion, 3 when his finger was inserted, 1 afterwards (for 10 min) | I can’t believe I have pain even with finger insertion; this is really bad; I must be a lost cause; nothing helps me; it is only going to get worse | Defeated, guilty because we can’t enjoy sex even without penetration; hopeless, sad, angry (with thought, why can’t I have sex like other women?) | This was just before my period and I am often more sensitive and burn more easily, could this be the reason why I had pain with finger insertion? I don’t usually have pain unless we include penile penetration? Mmm…feeling a little black & white…a little more hopeful… |
– | – | – | – | – | – |
20.7 When Fear and Anxiety Take Center Stage
More often than not, patients present with elevated fear and anxiety. Rosenbaum introduced a number of techniques that can assist therapists in effectively working with the anxious patient. This includes the “Rosenbaum Protocol ” (see Table 20.2), a step-by-step exposure to interventions helping patients to recognize and contain growing anxiety and remain present during examination and treatment [44]. Rosenbaum expanded this approach to include mindfulness-based treatment methods to reduce a goal-driven approach and negative self-judgment by the patient (Fig. 20.2) [45].
Table 20.2
The Rosenbaum Protocol for working with severely anxious patients
Step 1 | Lying on the table. The client is asked to lie on the table, fully dressed, covered with a sheet. She is asked to rate her level of anxiety from low to high (0–5), and then asked what she needs in order to reach the number 0. These needs may include lying on her side in a more protected posture, the practitioner moving away from the table, or, she may need to get up off the table and go back to sitting in the chair, where she was able to rate herself at 0. Other “lowering anxiety” tools are introduced including deep breathing techniques. The exercise is repeated until she is able to lie on the table on her back with her knees flexed and together, and rate herself at 0–1 |
Step 2 | Lying on the bed, fully dressed (with pants) and covered with a sheet, the client is asked to bend her knees and separate her legs. She is reminded that if she feels anxious with her knees open, she may do what she needs to relieve her anxiety, which is likely to be a return to the position of knees bent and together. This exercise is repeated until she is able to rate her anxiety level with her legs apart at 0–1 |
Step 3 | As in Step 2 but without the sheet. Covering herself again with the sheet is considered to be one of the lowering anxiety options available to her |
Step 4 | As in Step 2 but wearing shorts instead of long pants, first with and then without the sheet |
Step 5 | As in Step 2 but with underwear only, with and without the sheet |
Step 6 | As in Step 2 without underwear, with and without the sheet |
The mindfulness approach involves teaching a patient how to attend to the pain experience rather than avoid it and then examine thoughts and feelings that accompany the pain. This approach can be complementary to and shares many similarities with CBT [8, 46]. Mindfulness differs in that where CBT may aim to alter the content of cognitions, mindfulness focuses on the relationships, and reactions to those thoughts. For example, rather than attempting to change the maladaptive cognitions related to pain (e.g., “This will never get better…”), a mindful approach may advocate attending to the pain while observing one’s thoughts in a compassionate and nonjudgmental way.
In addition to learning “from oneself” how psychosocial factors contribute to maintaining the vicious cycle of pain, in a mindful approach to treatment, the client is invited to observe her reactions without judgement. It is normal for the body to react in protective ways when pain is experienced (e.g., eye blink when approached). It may be helpful to explain to a patient that pain is adaptive and people who suffer from congenital abnormalities that reduce pain thresholds are prone to injury and illness [39]. It is also important to note that a mere mental reflection on one’s experience with pain may not suffice in changing behavior and/or contribute to treatment adherence, symptom reduction, and better quality of life. Rosenbaum suggests that responses to pain, such as catastrophization, avoidance, and procrastination, may not be cognitively driven and cannot be intellectually resolved [45]. Encouraging the patient to “stay with the feeling” may allow her—sometimes for the first time, to fully experience her feelings and explore her thoughts related to pain. Experiencing intense emotion , realizing that they subside without negative consequences, and that they are limited in time and experience, can be a powerful corrective experience [13]. Occasionally, however, emotions can be overwhelming and cause excessive distress. Some patients appear to be unable to access and/or experience their emotions. This may be a time to consider a referral to a mental health care professional. To paraphrase a patient, “Vulvodynia used to be my enemy…now, vulvodynia is a bit of a friend because it forced me to put a magnifying glass to my anxiety problems and finally tackle them—I am feeling so much better now… even though my pain is still not at zero!”
20.8 Including the Partner in Treatment
Surprisingly, few researchers have examined dyadic factors and partner characteristics in couples with problems associated with POPF. With the results of an emergent body of literature [33–35] and borrowing from the chronic pain literature [47], we can assume that partners play a critical role in the pain (and treatment) experience. The couple may use their existing strengths to use a “teamwork approach” that identifies and removes interpersonal roadblocks and accelerates treatment. This can be achieved through partner participation in physical therapy sessions (potentially focusing on educational elements), taking part in homework exercises, and helping the couple improving communication, especially regarding POPF.
20.9 Sexual Intimacy in Couples with POPF
Rosen and her colleagues elegantly demonstrated the importance of adaptive coping in decreasing pain and increasing sexual adjustment and satisfaction for both partners [45]. While treatment may resolve POPF problems for many patients, others will have to adjust to pain or occasional pain and require tools to live a fulfilled life. Communicating about pain and sex and reconsidering sexual scripts and stereotypes are important centerpieces to this.
Basson’s circular model of sexual response can be helpful to start the conversation. Figure 20.4 shows the original, basic model [48] but other references are included which outline recent variations and expansions of the model [46, 49, 50]. In essence, it is explained to the couple (or woman) that in long-term, committed relationships, spontaneous sexual desire may occur but more often than not, a woman may be at a relatively neutral place with regard to sex. The first step in starting a cycle of sexual response is arousal (not desire). Stimuli that serve to arouse her range considerably and depend on the individual woman, e.g., having had a particularly good day, romantic dinner, gentle caresses, closeness felt as a result of other daily activities, starting a role play, or a specific song. Some pleasure with arousal will increase the woman’s desire to receive or give more stimulation. The dance between arousal and desire results in a physically and emotionally satisfying experience (that may or may not include intercourse). This experience results in an increase in closeness and intimacy in the couple (Fig. 20.4).
Fig. 20.4
Overactive Pelvic Floor: Gastrointestinal Morbidities
Female Voiding Dysfunction
Medical Therapies for the Treatment of Overactive Pelvic Floor
The Pelvic Floor and Male Sexual Function
Objective Assessment of the Overactive Pelvic Floor
A Tale of Two Pain States: The Integrative Physical Therapy Approach to the Overactive Pelvic Floor
Basson’s Circular Model of Sexual Response is an intimacy-based model of arousal and desire
Related posts:
Overactive Pelvic Floor: Gastrointestinal Morbidities
Female Voiding Dysfunction
Medical Therapies for the Treatment of Overactive Pelvic Floor
The Pelvic Floor and Male Sexual Function
Objective Assessment of the Overactive Pelvic Floor
A Tale of Two Pain States: The Integrative Physical Therapy Approach to the Overactive Pelvic Floor
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
