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

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.

Full text

Perineal Massage Improves the Dyspareunia
Caused by Tenderness of the Pelvic Floor
Muscles
Massagem perineal melhora a dispareunia causada por
tensãodosmúsculosdoassoalhopélvico
Ana Paula Moreira da Silva1Mary Lourdes Montenegro2Maria Beatriz Ferreira Gurian1
Andreia Moreira de Souza Mitidieri1Lucia Alves da Silva Lara1Omero Benedicto Poli-Neto1
Julio Cesar Rosa e Silva1
1Department of Gynecology and Obstetrics, Faculdade de Medicina
de Ribeirão Preto, Universidade de São Paulo, SP, Brazil
2Division of Gynecology, University of Pittsburgh Cancer Institute,
Pittsburgh, Pennsylvania, United States
Rev Bras Ginecol Obstet
Address for correspondence Ana Paula Moreira da Silva, MSc,
Departamento de Ginecologia e Obstetrícia, Faculdade de Medicina
de Ribeirão Preto, Universidade de São Paulo, Avenida Bandeirantes
3900, 14049-900, Ribeirão Preto, SP, Brazil
(e-mail: apmoreira2010@hotmail.com).
Keywords
►dyspareunia
►physical therapy
►pelvic pain
►pelvic floor
►women’s health
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.
received
May 25, 2016
accepted
November 9, 2016
DOI http://dx.doi.org/
10.1055/s-0036-1597651.
ISSN 0100-7203.
Copyright © by Thieme Publicações Ltda,
Rio de Janeiro, Brazil
THIEME
Original Article

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.1Dyspareunia is
usually associated with multifactorial conditions (organic,
behavioral, or psychological factors) that make the diagnosis
and early treatment difficult.2Most women regard dyspar-
eunia as an ordinary symptom, very often not reporting pain
during gynecological consultations,3and 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 characterist ic 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 evaluation7and treatment of dyspar-
eunia8caused by tender ness 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 par ticipants 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
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 dispareu-
nia 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 AmassagemperinealdeThieleéeficaz 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
Rev Bras Ginecol Obstet
Perineal Massage Improves Dyspareunia Silva et al.

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.
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 p ressure 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 partici-
pants from each group would be required to obtain an 80%
power of the test and to identif y 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
Fig. 1 Patient enrollment flowchart.
Rev Bras Ginecol Obstet
Perineal Massage Improves Dyspareunia Silva et al.

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).
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.
Table 1 Sexual function scores of the dyspareunia group during the study’sfollow-upperiods
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) (n¼8).

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.
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 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) (n¼10).

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.
Rev Bras Ginecol Obstet
Perineal Massage Improves Dyspareunia Silva et al.

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 sho uld
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.
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