Interstitial cystitis/painful bladder syndrome (IC/PBS) is one potential cause of sexual pain in up to 70% of women and men who complain of pain with penetration and/or thrusting. Once considered rare, IC/PBS is being diagnosed with more frequency, however early diagnosis is often missed. Women presenting with symptoms of IC/PBS often report urinary urgency and frequency, dyspareunia, nocturia, and pelvic pain. Current research leads experts to believe that there is an overlap between CP/CPPS and IC/PBS in men. Pelvic pain in men is associated with erectile dysfunction and premature ejaculation as well as leading to decreased libido and arousal.
The causes of sexual pain in women and men with chronic pelvic pain (CPP) vary.
The anatomic proximity of the vagina and the bladder can result in a mechanical irritation during penetrative vaginal intercourse. Additionally, there is a shared innervation and muscular support of the bladder and pelvis, thus resulting in shared symptoms.Men typically associate sexual pain with CP/CPPS and present with a variety of symptoms such as perineal, urethral, testicular, ejaculatory pain as well as pelvic floor muscle dysfunction. In women, sexual pain often results from IC/PBS, vaginitis, provoked vestibulodynia and pelvic floor muscle dysfunction.
Both women and men presenting with the symptoms of chronic pelvic pain (CPP) and sexual pain should be evaluated for IC/PBS. The diagnosis of IC/PBS in this patient population can be difficult due to the ambiguity and subjective nature of the symptoms, and the diversity of potential etiologies. It is also important to remember that psychological factors may trigger the pain cycle and should be included in the sexual pain assessment. Another integral component in evaluating these patients is examination of the pelvic floor muscles, as pelvic floor hypertonus is often a contributory factor in sexual dysfunction associated with IC/PBS.
Patients with IC/PBS with dyspareunia can experience ramifications in personal relationships and self-image. The common response to actual or perceived pain with intercourse is avoidance. As a result these women and men are left with feelings of inadequacy, decreased sexual interest, isolation and depression. Education from their healthcare provider plays an important role in helping the patient maintain sexual intimacy in their relationships.
There are a variety of self-care approaches that can help the patient and their partners achieve some level of sexual intimacy and give the patient a sense of control over his or her life. Below is a list of some “helpful hints” that the patient and/or patient’s partner can do to make sexual activity less painful:
• Explore alternatives to vaginal intercourse such as oral or manual pleasuring
• “Creative thrusting” (outercourse)
o Avoidance of vaginal penetration by using positions such as interfemoral, intergluteal and/or intermammary for comfort
• “Careful thrusting”
o Different coital positions used to decrease pain and symptom flares such as angled missionary, side lying or “spoon” position, and/or rear entry with forward lean.
• Limit thrusting time to 5-10 minutes
• Consider pre-medication 15-20 minutes prior to sexual activity
o Smooth muscle antispasmodics, anticholinergics, anti-anxiety agents, topical analgesia, vaginal suppository, or pain medication.
• Use a hypoallergenic, nonirritating lubrication
• Timed voiding
o Before and after sexual activity
• Ice, heat, baths
• Dilate prior to vaginal intercourse
o With or without internal massage
• Negotiate activity expectations
• Alternate “his” and “her” sexual encounters
Other comfort measures may include pre- and post-coital voiding, or the application of ice packs to the suprapubic or genital area after intercourse to offer some symptomatic relief. Relaxation of the pelvic floor muscles through the use of Theile massage prior to intercourse can be incorporated into the couple’s sexual repertoire. Along with the help of their healthcare provider, the couple can devise alternative methods for sexplay so that their bladder symptoms are not a deterrent. Creativity, along with a balance of attitude modulation, negotiation, psychotherapy, and pharmacological therapies, IC/PBS and sexual pain can be effectively managed in order that the couple maintains a healthy relationship.
Currently, we are conducting a variety of research studies to look at the association among interstitial cystitis, pelvic floor dysfunction, provoked vestibulodynia, neuropathic pain, and other chronic pain syndromes. Some of these studies include:
• A retrospective chart review of the use of vaginal diazepam suppositories as an adjunctive treatment for patients with the diagnosis of high tone pelvic floor dysfunction (HTPFD), bladder pain, and sexual pain.
• The use of Osteopathic Manipulation Therapy for the treatment of chronic pelvic pain.
• The correlation of symptoms to the location of myofascial pain in patients with chronic pelvic pain in order to identify an association between the location of trigger points and pelvic pain symptoms to more effectively diagnose and treat patients with chronic pelvic pain. This study is being done in conjunction with Robert Moldwin, MD.
• Characterising neuropathic comorbidities and the presence of true neuropathic pain symptoms in patients with chronic pelvic pain as well as examining their physical and mental health status. This study is being done in conjunction with Robert Moldwin, MD.
• Identifying trigger points in the pelvic floor muscles with EMG then administering 60U of Botulinum toxin “A” into those trigger points.
By Kristene Whitmore, Jennifer Yonaitis Fariello and the Pelvic and Sexual Health Institute, Philadelphia, PA