Article

Pelvic floor muscle activation in response to pressure stimuli applied to the vulvar vestibule: an observational study comparing women with and without provoked vestibulodynia

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Background The nature of pelvic floor muscle (PFM) involvement in provoked vestibulodynia (PVD) is poorly understood. Aim We aimed to determine if PFM electromyographic (EMG) activity in anticipation of or response to pressure applied to the posterior vaginal fourchette differs between those with and without PVD, and if the magnitude of PFM response is associated with pressure pain sensitivity, psychological or psychosexual function. Methods This was an observational case–control study. Forty-two volunteers with PVD and 43 controls with no vulvar pain participated. Five on-line questionnaires were completed, then participants underwent a laboratory-based evaluation of vulvar pain sensitivity. EMG activation of the PFMs, hip adductor, and upper trapezius muscles was measured before, during, and after pressure stimuli (low, moderate) were applied, in random order, to the posterior vaginal fourchette and the posterior thigh (control site). Outcomes EMG amplitude of the pubovisceralis (PV), bulbocavernosus (BC), and external anal sphincter (EAS) muscles. Secondary outcomes were EMG activation of the hip adductor brevis and upper trapezius muscles, questionnaire scores reflecting psychological/psychosexual outcomes, pressure pain threshold (PPT) at the vulvar vestibule, pain reported on a tampon test, and heart rate/heart rate variability. Results Compared to controls, EMG activation of the PV and EAS, but not the BC, was higher in anticipation of the pressure applied to the vaginal fourchette, was higher in all PFMs while the pressure was applied, and remained higher than baseline after the pressure was removed among those with PVD. EMG response amplitudes were modulated by the intensity of the pressure applied, with the largest responses reaching over 40% MVC in the EAS among those with PVD. PFM EMG amplitudes were associated with greater pain sensitivity and lower sexual function, but not with pain catastrophizing, central sensitization, depression, anxiety, or stress. Clinical implications While some anticipatory activation was observed, EMG responses were primarily observed during and after the application of the pressure. Among those with PVD, digital assessment of PFM tone might reflect PFM responses to pain at the vulvar vestibule, and interventions to reduce local pain sensitivity may be an important first step to successful improvements in vaginal function. Strengths and limitations This study includes a robust analysis of EMG activation. However, the cross-sectional design precludes the determination of causal relationships. Conclusions Those with PVD demonstrate higher PFM responses and a higher prevalence of anticipatory activation in the PV and EAS muscles than controls in response to pressure applied at the vulvar vestibule

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

ResearchGate has not been able to resolve any citations for this publication.
Article
Full-text available
Bio-impedance measurements are widely used to assess various physiological parameters. Contemporary skin electrodes for bio-impedance measurements are cumbersome and novel electrode designs are needed to allow fast and easy placement, long-term stability and user comfort. This investigation introduces dry, printed, bio-compatible electrode arrays, made of screen-printed carbon and inkjet-printed PEDOT:PSS that measure bio-impedance non-invasively and stably. Two contact impedance measurements yield the lowest normalized values of soft electrodes reported to date. Four contact bio-impedance measurements from the radial, ulnar, common carotid and superficial temporal arteries were performed, demonstrating the ability to capture blood pulsation in different areas with small form factor. Owing to the unique properties of the printed electrodes reported here, we were able to demonstrate for the first time blood pulsation in the face, continuous blood pulsation measurement during simultaneous muscle activation and signal stability over many hours.
Article
Full-text available
Background Treatment recommendations for provoked vulvodynia (PVD) are based on clinical experiences and there is a need for systematically summarizing the controlled trials in this field. Aim To provide an overview of randomized controlled trials and non-randomized studies of intervention for PVD, and to assess the certainty of the scientific evidence, in order to advance treatment guidelines. Data Sources The search was conducted in CINAHL (EBSCO), Cochrane Library, Embase (Embase.com), Ovid MEDLINE, PsycINFO (EBSCO) and Scopus. Databases were searched from January 1, 1990 to January 29, 2021. Study Eligibility Criteria Population: Premenopausal women with PVD. Interventions: Pharmacological, surgical, psychosocial and physiotherapy, either alone or as combined/team-based interventions. Control: No treatment, waiting-list, placebo or other defined treatment. Outcomes: Pain during intercourse, pain upon pressure or touch of the vaginal opening, sexual function/satisfaction, quality of life, psychological distress, adverse events and complications. Study design: Randomized controlled trials and non-randomized studies of interventions with a control group. Study Appraisal and Synthesis Methods 2 reviewers independently screened citations for eligibility and assessed relevant studies for risk of bias using established tools. The results from each intervention were summarized. Studies were synthesized using a narrative approach, as meta-analyses were not considered appropriate. For each outcome, we assessed the certainty of evidence using grading of recommendations assessment, development, and evaluation (GRADE). Results Most results of the evaluated studies in this systematic review were found to have very low certainty of evidence, which means that we are unable to draw any conclusions about effects of the interventions. Multimodal physiotherapy compared with lidocaine treatment was the only intervention with some evidential support (low certainty of evidence for significant treatment effects favoring physiotherapy). It was not possible to perform meta-analyses due to a heterogeneity in interventions and comparisons. In addition, there was a heterogeneity in outcome measures, which underlines the need to establish joint core outcome sets. Clinical Implications Our result underscores the need of stringent trials and defined core outcome sets for PVD. Strength and Limitations Standard procedures for systematic reviews and the Population Intervention Comparison Outcome model for clinical questions were used. The strict eligibility criteria resulted in limited number of studies which might have resulted in a loss of important information. Conclusion This systematic review underlines the need for more methodologically stringent trials on interventions for PVD, particularly for multimodal treatments approaches. For future research, there is a demand for joint core outcome sets. Bohm-Starke N, Ramsay KW, Lytsy P, et al. Treatment of Provoked Vulvodynia: A Systematic Review. J Sex Med 2021;XX:XXX–XXX.
Conference Paper
Full-text available
Introduction: Provoked vestibulodynia (PVD) is a chronic pain condition characterized by severe sharp and/or burning pain at the vulvar vestibule when pressure is applied to this area. Although it affects roughly one in five women, and has a negative impact on quality of life for approximately half of them, PVD remains poorly understood. The literature suggests that women with PVD have enhanced pain sensitivity, likely due, at least in part, to changes in central nervous system (CNS)-mediated pain processing, leading to allodynia (pain is perceived in response to a normally non-painful stimulus) and hyperalgesia (lower thresholds for pain sensitivity and tolerance). Indeed, there are limited standards for the evaluation of CNS-mediated sensitization in general, which has implications for conditions such as PVD. The cotton swab test is recommended as a standard assessment of pain sensitivity in women with PVD. Yet this test is poorly controlled, with methods varying based on clinician preference and experience: some use lubrication while others don’t, and variable amounts of pressure are applied. In the literature, pressure pain threshold (PPT) and temporal summation of pain (TS) are two quantitative methods to evaluate allodynia and hyperalgesia. Objective: To determine the between-day test-retest reliability of PPT and TS measured at the vulvar vestibule using an electronic vulvalgesiometer (eVGM; Figure 1). Methods: Females over 18 years of age, both with and without symptoms consistent with PVD, were recruited from the local community. Exclusion criteria were pregnancy, menopause, and diagnosed gynecologic conditions (e.g., pelvic organ prolapse, urinary incontinence, vaginal infection). Participants attended two laboratory-based assessments within one week following the start of their menstrual cycle. At each of the two assessments, PPT (Figure 2) and TS (Figure 3) were determined using the eVGM. The eVGM engages a cotton swab into a collet. When the tip of the cotton swab is pressed, it compresses a spring interfaced with a force sensor, allowing the user to see, in real time, the force being applied during testing. Using this eVGM, PPT was defined as the force (in grams) at which women first reported pain when the cotton-swab was applied at the 6 o’clock position of the vestibule. For TS, the force determined as the PPT was applied at the same location ten times (approximately one per second). Participants rated their pain on the first and last application of this force on a 0 (no pain at all) to 10 (worst pain ever) scale. TS was defined as the difference in pain rating between the last and first application. Results: Twenty-four women participated; 14 reported no history of vulvar pain, while 10 reported symptoms of vulvar pain including PVD and deep dyspareunia. Demographic data are presented in Table 1. PPT demonstrated good reproducibility and TS demonstrated acceptable reproducibility (Table 2). Conclusions: This approach to measuring pain sensitivity using the eVGM appears to have adequate repeatability for use as an outcome in research and in clinical settings.
Article
Full-text available
Introduction: The Female Sexual Function Index (FSFI) is a patient-reported outcome measure measuring female sexual dysfunction. The FSFI-19 was developed with 6 theoretical subscales in 2000. In 2010, a shortened version became available (FSFI-6). Aim: To investigate the measurement properties of the FSFI-19 and FSFI-6. Methods: A systematic search was performed of Embase, Medline, and Web of Science for studies that investigated measurement properties of the FSFI-19 or FSFI-6 up to April 2018. Data were extracted and analyzed according to COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines. Evidence was categorized into sufficient, insufficient, inconsistent, or indeterminate, and quality of evidence as very high, high, moderate, or low. Main outcome measures: The Main Outcome Measure is the evidence of a measurement property, and the quality of evidence based on the COSMIN guidelines. Results: 83 studies were included. Concerning the FSFI-19, the evidence for internal consistency was sufficient and of moderate quality. The evidence for reliability was sufficient but of low quality. The evidence for criterion validity was sufficient and of high quality. The evidence for structural validity was inconsistent of low quality. The evidence for construct validity was inconsistent of moderate quality. Concerning the FSFI-6, the evidence for criterion validity was sufficient of moderate quality. The evidence for internal consistency was rated as indeterminate. The evidence for reliability was inconsistent of low quality. The evidence for construct validity was inconsistent of very low quality. No information was available on structural validity of the FSFI-6, and measurement error, responsiveness, and cross-cultural validity of both FSFI-6 and FSFI-19. Clinical implications: Conflicting and lack of evidence for some of the measurement properties of the FSFI-19 and FSFI-6 indicates the importance of further research on the validity of these patient-reported outcome measures. We advise researchers who use the FSFI-19 to perform confirmatory factor analyses and report the factor structure found in their sample. Regardless of these concerns, the FSFI-19 and FSFI-6 have strong criterion validity. Pragmatically, they are good screening tools for the current definition of female sexual dysfunction. Strength & limitation: A strong point of the review is the use of predefined guidelines. A limitation is the use of a precise rather than a sensitive search filter. Conclusions: The FSFI requires more research on structural validity (FSFI-19 and FSFI-6), reliability (FSFI-6), construct validity (FSFI-19), measurement error (FSFI-19 and FSFI-6), and responsiveness (FSFI-19 and FSFI-6). Further corroboration of measurement invariance (both across cultures and across subpopulations) in the factor structure of the FSFI-19 is necessary, as well as tests for the unidimensionality of the FSFI-6. Neijenhuijs KI, Hooghiemstra N, Holtmaat K, et al. The Female Sexual Function Index (FSFI)-A Systematic Review of Measurement Properties. J Sex Med 2019;16:640-660.
Article
Full-text available
Healthy biological systems exhibit complex patterns of variability that can be described by mathematical chaos. Heart rate variability (HRV) consists of changes in the time intervals between consecutive heartbeats called interbeat intervals (IBIs). A healthy heart is not a metronome. The oscillations of a healthy heart are complex and constantly changing, which allow the cardiovascular system to rapidly adjust to sudden physical and psychological challenges to homeostasis. This article briefly reviews current perspectives on the mechanisms that generate 24 h, short-term (~5 min), and ultra-short-term (<5 min) HRV, the importance of HRV, and its implications for health and performance. The authors provide an overview of widely-used HRV time-domain, frequency-domain, and non-linear metrics. Time-domain indices quantify the amount of HRV observed during monitoring periods that may range from ~2 min to 24 h. Frequency-domain values calculate the absolute or relative amount of signal energy within component bands. Non-linear measurements quantify the unpredictability and complexity of a series of IBIs. The authors survey published normative values for clinical, healthy, and optimal performance populations. They stress the importance of measurement context, including recording period length, subject age, and sex, on baseline HRV values. They caution that 24 h, short-term, and ultra-short-term normative values are not interchangeable. They encourage professionals to supplement published norms with findings from their own specialized populations. Finally, the authors provide an overview of HRV assessment strategies for clinical and optimal performance interventions.
Article
Full-text available
Many factors can influence the way in which we perceive painful events and noxious stimuli, but less is known about how pain perception is altered by explicit knowledge about the impending sensation. This study aimed to investigate the impact of explicit cueing on anxiety, arousal, and pain experience during the anticipation and delivery of noxious thermal heat stimulations. Fifty-two healthy volunteers were randomised to receive explicit instructions about visual cue-stimulus temperature pairings, or no explicit instructions about the cue-stimulus pairs. A pain anxiety task was used to investigate the effects of explicit cueing on anticipatory anxiety, pain experience and electrophysiological responses. Participants who received explicit instructions about the cue-stimulus pairs (i.e., the relationship between the colour of the cue and the temperature of the associated stimuli) reported significantly higher subjective anxiety prior to the delivery of the thermal heat stimuli (p = .025, partial eta squared = .10). There were no effects of explicit cueing on subsequent pain intensity, unpleasantness, or the electrophysiological response to stimulus delivery. The perceived intensity and unpleasantness of the stimuli decreased across the blocks of the paradigm. In both groups anticipating the ambiguous cue elicited the largest change in electrophysiological arousal, indicating that not knowing the impending stimulus temperature led to increased arousal, compared to being certain of receiving a high temperature thermal stimulus (both p < .001). Perceived stimulus intensity varied between ambiguous and non-ambiguous cues, depending on the temperature of the stimulus. Together these findings highlight the impact and importance of explicit cueing and uncertainty in experimental pain studies, and how these factors influence the way healthy individuals perceive and react to noxious and innocuous thermal stimuli.
Article
Full-text available
Vulvovaginal pain problems are major health concerns in women of childbearing age. Controlled studies have shown that vulvovaginal pain can adversely affect women and their partners' general psychological well-being, relationship adjustment, and overall quality of life. These women have significantly lower levels of sexual desire, arousal, and satisfaction, as well as a lower intercourse frequency than normal controls. They also report more anxiety and depression, in addition to more distress about their body image and genital self-image. Empirical studies indicate that specific psychological and relationship factors may increase vulvovaginal pain intensity and its psychosexual sequelae. Randomized clinical trials have shown that psychosexual interventions, namely cognitive-behavioral therapy (CBT), are efficacious in reducing vulvovaginal pain and improving associated psychosexual outcomes. Women reporting significant psychological, sexual, and/or relationship distress should be referred for psychosexual treatment. A multimodal approach to care integrating psychosexual and medical management is thought to be optimal.
Article
Full-text available
The aim of this study was to identify variations in nervous thresholds in different phases of the menstrual cycle in eumenorrheic women and users of oral contraceptives. An observational study was performed including 56 volunteers, consisting of 30 eumenorrheic women who were non-users of oral contraceptives and 26 users of oral contraceptives. An electrical stimulator was employed to assess their nervous thresholds, with pulses applied at a fixed frequency of 2,500 Hz, modulated at 50 Hz, with phase variances of 20 μs, 50 μs and 100 μs. Sensitivity, motor and pain thresholds were evaluated during five menstrual cycle phases: phase 1 - menstrual, phase 2 - follicular, phase 3 - ovulatory, phase 4 - luteal and phase 5 - premenstrual. The results indicated low sensitivity thresholds of 100 μs for non-users of oral contraceptives and 50 μs for oral contraceptive users in phase 5. Low motor thresholds of 20 μs, 50 μs and 100 μs were observed for non-users of oral contraceptives in phase 5, while that of oral contraceptive users was 100 μs. Finally, a low pain threshold of 100 μs was observed in phase 5, but only in the oral contraceptive group. Nervous thresholds vary systematically across the phases of the menstrual cycle, with or without the use of oral contraceptives. These variations should be taken into account during research performed in women.
Article
Full-text available
Chronic hyperactivity of pelvic floor musculature characterized by co-morbidity of urological, gynaecological, gastro-intestinal and sexological complaints is associated with mood disorders, sexual dysfunctions, anxiety disorders and traumatic sexual and/or physical experiences. Based on a review of available scientific data and on clinical observations a theoretical framework for the pathogenesis of hyperactive pelvic floor disorders is conceptualized in defining the Hyperactive Pelvic Floor Syndrome (HPFS). Hypotheses on the etiology of this syndrome with comorbidity of symptoms concerning gastro-intestinal, uro-genital and sexual functions are operationalized in a multifacettal, multidisciplinary clinical approach in diagnosis and treatment of the complex symptomatology of patients with long histories of unsuccessful medical, surgical and psychiatric treatments that in general do not take into account the psychophysiological aspects of muscle tension originating from psychological, psycho-social and/or psycho-sexual distress and resulting in physical symptoms that tend to be fixated by a vicious circle of pain, anxiety and muscle tension.
Article
Full-text available
Unlabelled: Vulvodynia (VVD) is a chronic pain disorder wherein women display sensitivity to evoked stimuli at the vulva and/or spontaneous vulvar pain. Our previous work suggests generalized hyperalgesia in this population; however, little is known about central neurobiological factors that may influence pain in VVD. Here we investigated local (vulvar) and remote (thumb) pressure-evoked pain processing in 24 VVD patients compared to 13 age-matched, pain-free healthy controls (HCs). As a positive control we also examined thumb pressure pain in 24 fibromyalgia patients. The VVD and fibromyalgia patients displayed overlapping insular brain activations that were greater than HCs in response to thumb stimulation (P < .005 corrected). Compared to HCs, VVD participants displayed greater levels of activation during thumb stimulation within the insula, dorsal midcingulate, posterior cingulate, and thalamus (P < .005 corrected). Significant differences between VVD subgroups (primary versus secondary and provoked versus unprovoked) were seen within the posterior cingulate with thumb stimulation and within the precuneus region with vulvar stimulation (provoked versus unprovoked only). The augmented brain activation in VVD patients in response to a stimulus remote from the vulva suggests central neural pathology in this disorder. Moreover, differing central activity between VVD subgroups suggests heterogeneous pathologies within this diagnosis. Perspective: The presence of augmented brain responses to pressure stimuli remote from the vulva was observed in vulvodynia patients. These findings may guide treatment decisions for better response, as brain mechanisms may be a factor in some VVD patients.
Article
Full-text available
In Study I, the Pain Catastrophizing Scale (PCS) was administered to 425 undergraduates. Analyses yielded a three component solution comprising (a) rumination, (b) magnification, and (c) helplessness. In Study 2, 30 undergraduate participants were classified as catastrophizers ( n = 15) or noncatastrophizers ( n = 15) on the basis of their PCS scores and participated in a cold pressor procedure. Catastrophizers reported significantly more negative pain-related thoughts, greater emotional distress, and greater pain intensity than noncatastrophizers. Study 3 examined the relation between PCS scores, negative pain-related thoughts, and distress in 28 individuals undergoing an aversive electrodiagnostic medical procedure. Catastrophizers reported more negative pain-related thoughts, more emotional distress, and more pain than noncatastrophizers. Study 4 examined the relation between the PCS and measures of depression, trait anxiety, negative affectivity, and fear of pain. Analyses revealed moderate correlations among these measures, but only the PCS contributed significant unique variance to the prediction of pain intensity. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Full-text available
Interval estimates of the Pearson, Kendall tau-a and Spearman correlations are reviewed and an improved standard error for the Spearman correlation is proposed. The sample size required to yield a confidence interval having the desired width is examined. A two-stage approximation to the sample size requirement is shown to give accurate results.
Article
Full-text available
This article presents the development of a brief, self-report measure of female sexual function. Initial face validity testing of questionnaire items, identified by an expert panel, was followed by a study aimed at further refining the questionnaire. It was administered to 131 normal controls and 128 age-matched subjects with female sexual arousal disorder (FSAD) at five research centers. Based on clinical interpretations of a principal components analysis, a 6-domain structure was identified, which included desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. Overall test-retest reliability coefficients were high for each of the individual domains (r = 0.79 to 0.86) and a high degree of internal consistency was observed (Cronbach's alpha values of 0.82 and higher) Good construct validity was demonstrated by highly significant mean difference scores between the FSAD and control groups for each of the domains (p < or = 0.001). Additionally, divergent validity with a scale of marital satisfaction was observed. These results support the reliability and psychometric (as well as clinical) validity of the Female Sexual Function Index (FSFI) in the assessment of key dimensions of female sexual function in clinical and nonclinical samples. Our findings also suggest important gender differences in the patterning of female sexual function in comparison with similar questionnaire studies in males.
Article
Full-text available
To estimate the prevalence of unexplained chronic vulvar pain (burning or sharp knife like pain or pain on contact) in an ethnically diverse population-based sample of women. We used town census directories to identify 4915 women age 18 to 64 from 5 ethnically diverse Boston communities and asked them to complete a self-administered questionnaire pertaining to current and past chronic lower genital tract discomfort (response rate 68%). We calculated the cumulative incidence and 95% confidence intervals by demographic and reproductive characteristics. Approximately 16% of respondents reported histories of chronic burning, knife like pain, or pain on contact that lasted for at least 3 months or longer, and nearly 7% were experiencing the problem at the time of the survey. Chronic vulvar pain on contact decreased with increasing age, but the cumulative incidence of chronic burning and knife like pain was similar across all ages. Contrary to earlier clinical assessments, white and African American women reported similar lifetime prevalences. However, Hispanic women were 80% more likely to experience chronic vulvar pain than were white and African American women. Women with histories of chronic vulvar pain were 7 to 8 times more likely to report difficulty and great pain with their first tampon use than were women without such histories. Nearly 40% of women chose not to seek treatment, and of those who did, 60% saw 3 or more doctors, many of whom could not provide a diagnosis. Chronic unexplained vulvar pain is a highly prevalent disorder that is often misdiagnosed.
Article
Full-text available
This study investigated the roles of vaginal spasm, pain, and behavior in vaginismus and the ability of psychologists, gynecologists, and physical therapists to agree on a diagnosis of vaginismus. Eighty-seven women, matched on age, relationship status, and parity, were assigned to one of three groups: vaginismus, dyspareunia resulting from vulvar vestibulitis syndrome (VVS), and no pain with intercourse. Diagnostic agreement was poor for vaginismus; vaginal spasm and pain measures did not differentiate between women in the vaginismus and dyspareunia/VVS groups; however, women in the vaginismus group demonstrated significantly higher vaginal/pelvic muscle tone and lower muscle strength. Women in the vaginismus group also displayed a significantly higher frequency of defensive/avoidant distress behaviors during pelvic examinations and recalled past attempts at intercourse with more affective distress. These data suggest that the spasm-based definition of vaginismus is not adequate as a diagnostic marker for vaginismus. Pain and fear of pain, pelvic floor dysfunction, and behavioral avoidance need to be included in a multidimensional reconceptualization of vaginismus.
Article
Full-text available
Heart rate variability (HRV) analysis is commonly used as a quantitative marker depicting the activity of autonomous nervous system (ANS) that may be related to mental stress. For mobile applications, short term ECG measurement may be used for HRV analysis since the conventional five minute long recordings might be inadequately long. Short term analysis of HRV features has been investigated mostly in ECG data from normal and cardiac patients. Thus, short term HRV features may not have any relevance on the assessment of acute mental stress. In this study, we obtained ultra short term HRV features from 24 subjects during baseline stage and Stroop color word test. We validated these HRV features by showing significant differences in HRV features existed between the two stages. Our results indicated that ultra short term analysis of heart rate and RR intervals within 10 s, RMSSD and PNN50 within 30 s, HF within 40 s, LF/HF, normalized LF, and normalized HF within 50 s could be reliably performed for monitoring mental stress in mobile settings.
Article
Objective Pelvic floor muscle (PFM) tone, which includes active and passive components, is argued to be increased in many pelvic health conditions, including those involving pain. This study systematically reviewed evidence for increased pelvic floor muscle tone in pelvic health conditions. Data sources Electronic databases (PubMed, CINAHL and EMBASE) were searched up to May 31st 2021. The search strategy included variants of pelvic and/or floor, muscle and tone using keywords and MeSH terms. Study eligibility criteria Studies were included if they investigated increased tone of the PFM and reported measures of active or mechanical properties of the PFM in humans with any pelvic health condition, including pain, bowel, urogenital or sexual dysfunctions. Studies of any design were included, except systematic and narrative reviews. Reference lists of studies, reviews and book chapters were searched for additional studies. Study appraisal and synthesis methods Data were extracted using a standardized form, including measurement tool and outcome measure. Risk of bias was analysed using a modified ROBINS-I tool and a score was allocated to determine whether the study provided "convincing” interpretation (comparison with condition-free control group, valid measure, no application issues). Results In total, 151 studies were included, reporting 8 different tools (EMG, dynamometry, manometry, digital palpation, defecography, ultrasound, MRI, other). The most common pelvic health condition was pelvic pain (n=16 conditions) followed by bowel, and urogenital conditions. Most studies were cross-sectional (57% of studies). A healthy control group was infrequently included for comparison (27%). Methods that have not been validated or applied in a manner that precluded convincing interpretation was common (94%). Of the 15 measurement tools that provided convincing evidence, 10 demonstrated greater tone in a pelvic health condition (all pain) than in controls, and 5 showed no difference. Conclusion Despite the large literature, few studies provide convincing evidence for increased tone/overactivity of pelvic floor muscles in pelvic health conditions. Interpretation is hampered by design and measurement issues. Terminology was often inaccurate. Few studies investigate male, transgender and pediatric groups.
Article
Introduction The terminology for female and male pelvic floor muscle (PFM) assessment has expanded considerably since the first PFM function and dysfunction standardization of terminology document in 2005. New terms have entered assessment reports, and new investigations to measure PFM function and dysfunction have been developed. An update of this terminology was required to comprehensively document the terms and their definitions, and to describe the assessment method and interpretation of the finding, to standardize assessment procedures and aid diagnostic decision making. Methods This report combines the input of members of the Standardisation Committee of the International Continence Society (ICS) Working Group 16, with contributions from recognized experts in the field and external referees. A logical, sequential, clinically directed assessment framework was created against which the assessment process was mapped. Within categories and subclassifications, each term was assigned a numeric coding. A transparent process of 12 rounds of full working group and external review was undertaken to exhaustively examine each definition, plus additional extensive internal development, with decision making by collective opinion (consensus). Results A Terminology Report for the symptoms, signs, investigations, and diagnoses associated with PFM function and dysfunction, encompassing 185 separate definitions/descriptors, has been developed. It is clinically based with the most common assessment processes defined. Clarity and user‐friendliness have been key aims to make it interpretable by clinicians and researchers of different disciplines. Conclusion A consensus‐based Terminology Report for assessment of PFM function and dysfunction has been produced to aid clinical practice and be a stimulus for research.
Article
Introduction The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination. Objectives The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function. Methods We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions. Results Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed. Conclusion Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. J Sex Med 2020;XX:XXX–XXX.
Article
The general purpose of normalization of EMG amplitude is to enable comparisons between participants, muscles, measurement sessions or electrode positions. Normalization is necessary to reduce the impact of differences in physiological and anatomical characteristics of muscles and surrounding tissues. Normalization of the EMG amplitude provides information about the magnitude of muscle activation relative to a reference value. It is essential to select an appropriate method for normalization with specific reference to how the EMG signal will be interpreted, and to consider how the normalized EMG amplitude may change when interpreting it under specific conditions. This matrix, developed by the Consensus for Experimental Design in Electromyography (CEDE) project, presents six approaches to EMG normalization: (1) Maximal voluntary contraction (MVC) in same task/context as the task of interest, (2) Standardized isometric MVC (which is not necessarily matched to the contraction type in the task of interest), (3) Standardized submaximal task (isometric/dynamic) that can be task-specific, (4) Peak/mean EMG amplitude in task, (5) Non-normalized, and (6) Maximal M-wave. General considerations for normalization, features that should be reported, definitions, and “pros and cons” of each normalization approach are presented first. This information is followed by recommendations for specific experimental contexts, along with an explanation of the factors that determine the suitability of a method, and frequently asked questions. This matrix is intended to help researchers when selecting, reporting and interpreting EMG amplitude data.
Article
Introduction Overactive pelvic floor (OPF) muscles are defined as muscles that do not relax, or may even contract, when relaxation is needed, for example, during micturition or defecation. Conditions associated with OPF are multifactorial and include multiple possible etiologies and symptom complexes. The complex interplay between biological and psychosocial elements can lead to the persistence of OPF symptoms along with psychological and emotional distress. Objectives (1) To review and contextualize, from a pathophysiologic perspective, the evidence for OPF, (2) to provide an overview of common clinical presentations and comorbidities of OPF, and (3) to discuss the effect of OPF on sexual function in men and women. Methods Review of the updated literature on the pathophysiology of OPF was carried out. OPF-associated conditions were overviewed, with special emphasis on the impact on sexual function in men and women. Results Individuals with suspected OPF often present with a combination of gastrointestinal, gynecological, musculoskeletal, sexual, and urological comorbidities, mostly accompanied by psychoemotional distress. In both women and men, sexual function is significantly impaired by OPF and genitopelvic pain penetration disorders are often the primary manifestation of this condition. Women with OPF report less sexual desire, arousal, and satisfaction; more difficulty reaching orgasm; lower frequencies of intercourse; more negative attitudes toward sexuality; and more sexual distress than women without sexual pain. The most frequently reported sexual dysfunctions in men with OPF include erectile dysfunction, premature ejaculation, and ejaculatory pain. Conclusion The complex pathophysiology of OPF involving multisystemic comorbidities and psychosocial factors emphasize the importance of a biopsychosocial assessment for guiding effective and personalized management. Padoa A, McLean L, Morin M, et al. “The Overactive Pelvic Floor (OPF) and Sexual Dysfunction” Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response. Sex Med 2020;XX:XXX–XXX.
Article
Introduction: Emergent evidence suggests that pelvic floor muscle (PFM) dysfunction contributes to dyspareunia, the experience of pain on vaginal penetration. Electromyography (EMG) is a valuable tool for the assessment of neuromuscular control and could be very useful in enhancing our understanding of PFM involvement in sexual function and in conditions such as dyspareunia. However, PFM EMG must be interpreted within the context of the many factors that can influence findings. Aim: To outline the main factors to consider when evaluating PFM EMG for female sexual function and dyspareunia and to synthesize the literature in which EMG has been acquired and interpreted appropriately in this context. Methods: Standards for the acquisition and interpretation of EMG were retrieved and consulted. An exhaustive search of four electronic databases (Embase, CINAHL, PubMed, and PsycLit) and hand searching references from relevant articles were performed to locate articles relevant to PFM involvement in sexual function and in dyspareunia in which EMG was used as a primary outcome. Study outcomes were evaluated within the context of the appropriate application and interpretation of EMG and their contribution to knowledge. Main outcome measures: A synthesis of the evidence was used to present the current state of knowledge on PFM involvement in sexual function and in dyspareunia. Results: Few standards documents and no practice guidelines for the acquisition and interpretation of PFM EMG are available. Some cohort studies with small samples of women have described the role of the PFMs in female sexual function. The literature on PFM involvement in dyspareunia also is limited, with outcomes suggesting that higher than normal tonic activation and higher than normal reflex responses might be present in the superficial PFM layer and might be characteristic features of dyspareunia. The data are less clear on the involvement of the deep layer of the PFMs in dyspareunia. Conclusion: Guidelines for the application and interpretation of PFM EMG in the context of sexual function and dyspareunia are needed. When interpreted within the context of their strengths and limitations, EMG data have contributed valuable information to our understanding of PFM involvement in dyspareunia. The literature to date suggests that the superficial PFMs might have higher than normal tone and exaggerated responses to tactile or penetrative provocation in at least some women with dyspareunia. McLean L, Brooks K. What Does Electromyography Tell Us About Dyspareunia? Sex Med Rev 2017;5:282-294.
Article
Chronic vulvar pain is alarmingly common in women of reproductive age and is often accompanied by psychological distress, sexual dysfunction, and a significant reduction in quality of life. Localized provoked vulvodynia (LPV) is associated with intense vulvar pain concentrated in the vulvar vestibule (area surrounding vaginal opening). To date, the origins of vulvodynia are poorly understood, and treatment for LPV manages pain symptoms, but does not resolve the root causes of disease. Until recently, no definitive disease mechanisms had been identified; our work indicates LPV has inflammatory origins, although additional studies are needed to understand LPV pain. Bradykinin signaling is one of the most potent inducers of inflammatory pain and is a candidate contributor to LPV. We report that bradykinin receptors are expressed at elevated levels in LPV patient versus healthy control vestibular fibroblasts, and patient vestibular fibroblasts produce elevated levels of proinflammatory mediators with bradykinin stimulation. Inhibiting expression of one or both bradykinin receptors significantly reduces proinflammatory mediator production. Finally, we determined that bradykinin activates nuclear factor (NF)κB signaling (a major inflammatory pathway), whereas inhibition of NFκB successfully ablates this response. These data suggest that therapeutic agents targeting bradykinin sensing and/or NFκB may represent new, more specific options for LPV therapy. Perspective There is an unmet need for the development of more effective vulvodynia therapies. As we explore the mechanisms by which human vulvar fibroblasts respond to proinflammatory/propain stimuli, we move closer to understanding the origins of chronic vulvar pain and identifying new therapeutic targets, knowledge that could significantly improve patient care.
Article
Eighty patients with vaginismus were seen in the Human Sexuality Clinic, McMaster University Medical Center, between 1972 and 1976. The diagnosis was made based on history and physical demonstration of perineal muscular spasm. The patients were classified according to the presenting complaint as well as to the degree of muscle spasm experienced at the time of physical examination. In the management of these patients, relaxation, self and mutual pleasuring exercises, Kegel exercises, and physical examination played an important role in successful treatment. Certain male problems were identified during treatment, including situational impotence and premature ejaculation. In our series the women who chose to be treated without an involved partner had comparable success rates to those choosing conjoint therapy. With the use of the combination of available techniques with special emphasis on the pelvic assessment as an educational experience for the patient, good success can be obtained in treating vaginismus with the conjoint approach or office management of the woman alone.
Article
OBJECTIVE: A standardized tampon insertion and removal test, the Tampon Test provides an alternative to sexual intercourse pain as an outcome measure for vulvodynia research. We report upon the reliability, validity, and responsiveness to change of the Tampon Test as an outcome measure for vulvodynia clinical trials. METHODS: Outcome measures were assessed in women enrolled in the Vulvar Vestibulitis Clinical Trial, a randomized clinical trial of oral desipramine and topical lidocaine effectiveness. Reliability estimates of the Tampon Test using the Kappa statistic evaluated week-to-week measures at baseline. Tampon Test construct and discriminant validity were assessed through correlation with other outcome measures. Patients' ability to regularly perform the Tampon Test was compared with regularity of reporting intercourse pain. RESULTS: During the 2-week baseline phase, women with vulvodynia reported stable mean Tampon Test scores 4.6 +/- 2.6 (week -2); 4.6 +/- 2.7 (week -1); and 4.7 +/- 2.8 (week 0) with moderate week-to-week reliability (weighted Kappa 0.52). Over an 8-week phase of trial intervention, change in the Tampon Test measure significantly correlated to a number of outcome measures, including daily pain (r=0.42), intercourse pain (r=0.35), cotton swab vestibular pain (r=0.38), and the Brief Pain Inventory (r=0.49). Women with vulvodynia study participants performed the Tampon Test 96.3% of the requested time, which was twofold higher adherence than intercourse pain measurement (49.7%). CONCLUSION: The Tampon Test reflects a real life experience that is reliable, with good construct validity as shown by the breadth of correlated outcome measures. The Tampon Test is an appropriate outcome measure for vulvodynia research that can be considered for use as the primary efficacy endpoint in clinical trials of treatments for vulvodynia.
Article
Objective To study the correlation between palpation, perineometry and transperineal ultrasound for assessment of pelvic floor muscle contraction and to define a contraction scale for ultrasound measurements.Methods Cross-sectional study of 608 women examined with palpation of pelvic floor muscle contraction using the Modified Oxford Scale (MOS) and measurements of the vaginal squeeze pressure with a vaginal balloon connected to a fiberoptic microtip transducer (perineometry). Transperineal ultrasound was used for measurements of levator hiatal area and antero-posterior (AP) diameter in the plane of minimal hiatal dimensions at rest and at contraction. The pelvic floor muscle contraction was expressed in percent change between rest and contraction. Spearman's rank test was used to test for correlation between different assessment methods.ResultsSignificant correlations were found between all assessment methods (p<0.001). Palpation correlated with perineometry (rs=0.74), percent change in hiatal area (rs=0.67) and percent change in AP diameter (rs=0.69). Perineometry correlated with percent change in hiatal area (rs=0.60) and percent change in AP diameter (rs=0.66). We defined a contraction scale based on the proportional change in the AP diameter. In this population, change in AP diameter <7% corresponded to absent contractions, 7-18% corresponded to weak contractions, 18-35% change corresponded to normal contractions, and change > 35% corresponded to strong contractions.Conclusions We found moderate to strong correlation between ultrasound measurements and palpation and perineometry. The proportional change in AP diameter was the ultrasound measurement with strongest correlation to palpation and perineometry and formed the basis for the contraction scale for ultrasound measurements.
Article
Fear has been suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia. Unfortunately, this has not been systematically investigated. The primary purpose of this study, therefore, was to investigate whether fear as evaluated by subjective, behavioral, and psychophysiological measures could differentiate women with vaginismus from those with dyspareunia/provoked vestibulodynia (PVD) and controls. A second aim was to re-examine whether genital pain and pelvic floor muscle tension differed between vaginismus and dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women with dyspareunia/PVD, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia/PVD and no-pain control groups. Moreover, behavioral measures of fear and vaginal muscle tension were found to discriminate the vaginismus group from the dyspareunia/PVD and no-pain control groups. Genital pain did not differ significantly between the vaginismus and dyspareunia/PVD groups; however, genital pain was found to discriminate both clinical groups from controls. Despite significant statistical differences on fear and vaginal muscle tension variables between women suffering from vaginismus and dyspareunia/PVD, a large overlap was observed between these conditions. These findings may explain the great difficulty health professionals experience in attempting to reliably differentiate vaginismus from dyspareunia/PVD. The implications of these data for the new DSM-5 diagnosis of Genito-Pelvic Pain/Penetration Disorder are discussed.
Article
Medically unexplained chronic vulvar pain, or vulvodynia, is a common condition that affects many aspects of a woman’s life. The most common subtype of vulvodynia is provoked vestibulodynia (PVD), and recent research has demonstrated that its pathophysiology likely involves both peripheral and central dysregulation. In this review, the phenomenon of central sensitization is specifically described and linked to relevant findings in the PVD literature. Recommendations for further research in the area of vulvodynia are made, in particular, the examination of other vulvodynia subtypes and of subtypes within the PVD samples. In addition, support is given for the validation of an existing animal model of provoked vulvar pain in order to understand further spinal involvement and also mechanisms involved in the genesis and persistence of this condition.
Article
To survey commercially available intravaginal probes designed to record electromyography (EMG) from the pelvic floor muscles (PFMs), and to discuss the strengths and limitations of current technology. The MEDLINE EMBASE, CINAHL, PEDRO, and Cochrane databases were searched for articles in which intravaginal probes were described as having been used to record EMG from the PFMs. The World Wide Web was also searched using the Google search engine to find devices used to record EMG from the PFMs. Finally, a Canadian distributer of intravaginal probes was contacted to identify intravaginal EMG probes not identified through other methods. The specifications of each probe were determined through the manufacturer or their website, and each device was acquired by the investigators to verify the specifications and electrode configuration. The devices were evaluated against international standards for recording EMG data. Sixteen different models of commercially available intravaginal probes were identified: seven from published research papers, seven using the World Wide Web, and two through communication with a distributer. The probes vary in shape, dimensions, electrode positioning, and electrode configuration, with many designs prone to recording motion artifact, crosstalk, and/or inappropriate EMG signals. All commercially available intravaginal probes had deficiencies in their design such as problems with probe geometry, electrode size, location, and/or configuration. Improved intravaginal EMG probes should be developed for use in research and clinical practice. Neurourol. Urodynam. © 2013 Wiley Periodicals, Inc.
Article
Psychological stress is suspected to play a key role in the development of work-related musculoskeletal disorders (WMSDs), and work pace may be a primary contributor. The purpose of this study was to observe how psychological stress affects muscle activity recorded from key muscles used to support the shoulder (the trapezius and levator scapulae muscles) during keying tasks. We hypothesized that muscle activity [amplitude of the myoelectric signal (MES)] would increase and the number of periodic rests in muscle activity ('EMG gaps') would decrease when computer work was performed at an increased pace, and with distractions in the environment. Ten healthy volunteers performed three typing tasks (N = no stress; I = stress induced by a work pace reward; IS = stress induced by a work pace reward plus irritation/distraction). Both muscles showed significant increases (p Keywords: COMPUTER TERMINAL WORK; ELECTROMYOGRAPHY; EMG GAPS; UPPER TRAPEZIUS MUSCLE; WMSDS; WORK PACE; WORK-RELATED MUSCULOSKELETAL DISORDERS Document Type: Research Article DOI: http://dx.doi.org/10.1080/02678370210136707 Publication date: June 1, 2002 (document).ready(function() { var shortdescription = (".originaldescription").text().replace(/\\&/g, '&').replace(/\\, '<').replace(/\\>/g, '>').replace(/\\t/g, ' ').replace(/\\n/g, ''); if (shortdescription.length > 350){ shortdescription = "" + shortdescription.substring(0,250) + "... more"; } (".descriptionitem").prepend(shortdescription);(".descriptionitem").prepend(shortdescription); (".shortdescription a").click(function() { (".shortdescription").hide();(".shortdescription").hide(); (".originaldescription").slideDown(); return false; }); }); Related content In this: publication By this: publisher In this Subject: Business By this author: McLean, Linda ; Urquhart, Nathan GA_googleFillSlot("Horizontal_banner_bottom");
Chapter
Clinical examination is the basis of diagnosis of urogynecological disorders. It is important that this examination is performed by a well-trained person with the appropriate skills. The patient should actively participate in the examination and be able to carry out pelvic floor muscle (PFM) contractions in a coordinated way when required. This will form the basis of subsequent pelvic floor exercises and is how the woman will learn the different types of muscle contraction which are integral to this. Digital self examination is an important part of pelvic floor re-education, and a woman should be able to do this herself. There are various grading methods, and, in particular, the P.E.R.F.E.C.T. scheme is an important assessment technique, and necessary when planning a treatment program. The Knack is a useful maneuver that can be taught to guard against stress incontinence.
Article
Central sensitization (CS) has been proposed as a common pathophysiological mechanism to explain related syndromes for which no specific organic cause can be found. The term "central sensitivity syndrome (CSS)" has been proposed to describe these poorly understood disorders related to CS. The goal of this investigation was to develop the Central Sensitization Inventory (CSI), which identifies key symptoms associated with CSSs and quantifies the degree of these symptoms. The utility of the CSI, to differentiate among different types of chronic pain patients who presumably have different levels of CS impairment, was then evaluated. Study 1 demonstrated strong psychometric properties (test-retest reliability = 0.817; Cronbach's alpha = 0.879) of the CSI in a cohort of normative subjects. A factor analysis (including both normative and chronic pain subjects) yielded 4 major factors (all related to somatic and emotional symptoms), accounting for 53.4% of the variance in the dataset. In Study 2, the CSI was administered to 4 groups: fibromyalgia (FM); chronic widespread pain without FM; work-related regional chronic low back pain (CLBP); and normative control group. Analyses revealed that the patients with FM reported the highest CSI scores and the normative population the lowest (P < 0.05). Analyses also demonstrated that the prevalence of previously diagnosed CSSs and related disorders was highest in the FM group and lowest in the normative group (P < 0.001). Taken together, these 2 studies demonstrate the psychometric strength, clinical utility, and the initial construct validity of the CSI in evaluating CS-related clinical symptoms in chronic pain populations. 
Article
Physical therapy (PT) may reduce the pain associated with provoked vestibulodynia (PVD) based on previous findings that pelvic floor muscle dysfunction (PFMD) is associated with PVD symptoms. The goals of this study were: (i) to determine whether women with and without PVD differ on measures of pelvic floor muscle (PFM) behavior; and (ii) to assess the impact of PT treatment for women with PVD on these measures. Eleven women with PVD and 11 control women completed an assessment evaluating PFM behavior using surface electromyography (SEMG) recordings and a digital intravaginal assessment. Women with PVD repeated the assessment after they had undergone eight PT treatment sessions of manual therapy, biofeedback, electrical stimulation, dilator insertions, and home exercises. Superficial and deep PFM SEMG tonic activity and phasic activity in response to a painful pressure stimulus, PFM digital assessment variables (tone, flexibility, relaxation capacity, and strength). At pretreatment, women with PVD had higher tonic SEMG activity in their superficial PFMs compared with the control group, whereas no differences were found in the deep PFMs. Both groups demonstrated contractile responses to the painful pressure stimulus that were significantly higher in the superficial as compared with the deep PFMs, with the responses in the PVD group being higher than those in control women. Women with PVD had higher PFM tone, decreased PFM flexibility and lower PFM relaxation capacity compared with control women. Posttreatment improvements included less PFM responsiveness to pain, less PFM tone, improved vaginal flexibility, and improved PFM relaxation capacity, such that women with PVD no longer differed from controls on these measures. Women with PVD demonstrated altered PFM behavior when compared with controls, providing empirical evidence of PFMD, especially at the superficial layer. A PT rehabilitation program specifically targeting PFMD normalized PFM behavior in women with PVD.
Article
To investigate possible altered CNS excitability in vaginismus. In 10 patients with primary idiopathic lifelong vaginismus, 10 with vulvar vestibulitis syndrome accompanied by vaginismus and healthy controls we recorded EMG activity from the levator ani (LA) and external anal sphincter (EAS) muscles and tested bulbocavernosus reflex (BCR). Pudendal-nerve somatosensory evoked potentials (SEPs) were tested after a single stimulus. Pudendal-nerve SEP recovery functions were assessed using a paired conditioning-test paradigm at interstimulus intervals (ISIs) of 5, 20 and 40ms. EMG in patients showed muscular hyperactivity at rest and reduced inhibition during straining. The BCR polysynaptic R2 had larger amplitude (p<0.01) and longer duration (p<0.01) in patients from both groups than in controls. In controls, paired-pulse SEPs were suppressed at the 5ms ISI for N35-P40 (p<0.05) and P40-N50 ms (p<0.001) and facilitated at the 20ms ISI for N35-P40 (p<0.05) and P40-N50 (p<0.05). No significant differences were found in the paired-pulse N35-P40 in patients and controls but the cortical P40-N50 at 20 ISI was facilitated in patients (p<0.05). EMG activity is enhanced and the cortical SEP recovery cycle and BCR are hyperexcitable in vaginismus. The neurophysiological abnormalities in patients with vaginismus indicate concomitant CNS changes in this disorder.
Article
The McGill Pain Questionnaire consists primarily of 3 major classes of word descriptors--sensory, affective and evaluative--that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of pain experience. The questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically. This paper describes the procedures for administration of the questionnaire and the various measures that can be derived from it. The 3 major measures are: (1) the pain rating index, based on two types of numerical values that can be assigned to each word descriptor, (2) the number of words chosen; and (3) the present pain intensity based on a 1-5 intensity scale. Correlation coefficients among these measures, based on data obtained with 297 patients suffering several kinds of pain, are presented. In addition, an experimental study which utilized the questionnaire is analyzed in order to describe the nature of the information that is obtained. The data, taken together, indicate that the McGill Pain Questionnaire provides quantitative information that can be treated statistically, and is sufficiently sensitive to detect differences among different methods to relieve pain.
Article
The psychometric properties of the Depression Anxiety Stress Scales (DASS) were evaluated in a normal sample of N = 717 who were also administered the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). The DASS was shown to possess satisfactory psychometric properties, and the factor structure was substantiated both by exploratory and confirmatory factor analysis. In comparison to the BDI and BAI, the DASS scales showed greater separation in factor loadings. The DASS Anxiety scale correlated 0.81 with the BAI, and the DASS Depression scale correlated 0.74 with the BDI. Factor analyses suggested that the BDI differs from the DASS Depression scale primarily in that the BDI includes items such as weight loss, insomnia, somatic preoccupation and irritability, which fail to discriminate between depression and other affective states. The factor structure of the combined BDI and BAI items was virtually identical to that reported by Beck for a sample of diagnosed depressed and anxious patients, supporting the view that these clinical states are more severe expressions of the same states that may be discerned in normals. Implications of the results for the conceptualisation of depression, anxiety and tension/stress are considered, and the utility of the DASS scales in discriminating between these constructs is discussed.
Article
The knowledge of surface electromyography (SEMG) and the number of applications have increased considerably during the past ten years. However, most methodological developments have taken place locally, resulting in different methodologies among the different groups of users.A specific objective of the European concerted action SENIAM (surface EMG for a non-invasive assessment of muscles) was, besides creating more collaboration among the various European groups, to develop recommendations on sensors, sensor placement, signal processing and modeling. This paper will present the process and the results of the development of the recommendations for the SEMG sensors and sensor placement procedures. Execution of the SENIAM sensor tasks, in the period 1996-1999, has been handled in a number of partly parallel and partly sequential activities. A literature scan was carried out on the use of sensors and sensor placement procedures in European laboratories. In total, 144 peer-reviewed papers were scanned on the applied SEMG sensor properties and sensor placement procedures. This showed a large variability of methodology as well as a rather insufficient description. A special workshop provided an overview on the scientific and clinical knowledge of the effects of sensor properties and sensor placement procedures on the SEMG characteristics. Based on the inventory, the results of the topical workshop and generally accepted state-of-the-art knowledge, a first proposal for sensors and sensor placement procedures was defined. Besides containing a general procedure and recommendations for sensor placement, this was worked out in detail for 27 different muscles. This proposal was evaluated in several European laboratories with respect to technical and practical aspects and also sent to all members of the SENIAM club (>100 members) together with a questionnaire to obtain their comments. Based on this evaluation the final recommendations of SENIAM were made and published (SENIAM 8: European recommendations for surface electromyography, 1999), both as a booklet and as a CD-ROM. In this way a common body of knowledge has been created on SEMG sensors and sensor placement properties as well as practical guidelines for the proper use of SEMG.
Article
The purpose of this exploratory study was to identify clinical similarities and differences in patients with vaginismus and dyspareunia. Thirty patients who were referred to an outpatient clinic for psychosomatic gynecology and sexology, with either of these two diagnoses, were investigated by means of a standardized interview, physical examination and self-rating questionnaires. Based on the interview, no significant differences were demonstrated between patients with vaginismus and dyspareunia, in the ability to insert a finger into the vagina or to have a gynecological examination. No differences were found in the reported level of pain during coitus (or attempted coitus), inserting one finger into the vagina, or during gynecological examination. Patients with vaginismus, however, more often reported that coitus was impossible. The physical examination and self-rating questionnaires showed no differences at all between patients with vaginismus and dyspareunia in palpated vaginal muscular tension and reported anxiety or tension during the examination. Moreover, in both groups redness and painful areas on the vulva were equally common. Redness and pain on the same location were more frequently present in the dyspareunia group. Patients with dyspareunia reported higher levels of pain during the examination. In conclusion, neither the interview nor the physical examination produced useful criteria to distinguish vaginismus from dyspareunia. A multi-axial description of these syndromes is suggested, rather than viewing them as two separate disorders.
Article
This study assessed the relationship between involuntary pelvic floor muscle activity, muscle awareness and experienced threat in women with and without vaginismus. Information about this relationship may help understand the mechanism of vaginismus. Twenty-two women with vaginismus and seven control women participated in the study. Women were exposed to four emotion-inducing film excerpts. Vaginal electromyography was recorded. Experienced threat was continuously monitored with the use of a lever. Women responded with increased pelvic floor muscle activity to the threatening and sexually-threatening film excerpt. No changes occurred during the neutral and erotic excerpt. The subjective experienced threat as indicated with the lever showed the same response pattern. However, awareness of changes in muscle activity showed a slightly different pattern. Individual data were inspected. In general, agreement was found between recorded changes in muscle activity and experienced threat. The results of the erotic excerpt showed that awareness of changes in muscle activity is not only determined by information from the pelvic floor muscles, but also by other factors like situational information and the expectations of the women. The data support the idea of a general defense reaction as a mechanism of involuntary pelvic floor muscle activity.
Article
Vulvar vestibulitis syndrome (VVS) is a common form of dyspareunia in premenopausal women. The standard test for diagnosing VVS is the cotton-swab test, during which a cotton-swab is applied to various locations of the vulvar vestibule. However, there is much variation in the implementation of this test relating to the precise vestibular locations palpated, the order of palpation, and the force used during palpation. We introduce a new simple, mechanical device, a vulvalgesiometer, to standardize genital pain assessment and present promising preliminary data from women with VVS and nonaffected women. These data indicate that women with VVS have significantly lower vestibular pain thresholds compared with control women. During painful vulvar stimulation with the vulvalgesiometer, women with VVS described the pain with adjectives similar to those used to describe their intercourse pain (e.g., burning). This novel device has several important implications for genital pain measurement in women who suffer from urogenital pain.
Article
The aim of this study was to investigate to what extent women with superficial dyspareunia can be diagnosed for both partial vaginismus (PaV) and vulvar vestibulitis (VVS) and to discover to what extent surface electromyography (sEMG) of the pelvic floor muscles (PFM) can distinguish between women with PaV solely, PaV+ VVS, and asymptomatic women. A total of 224 consecutive women with superficial dyspareunia were examined clinically for both PaV and VVS diagnoses. We examined 47 women with PaV+/-VVS and 27 asymptomatic women with sEMG of the PFM. The results showed that 102/224 women with superficial dyspareunia and 33/47 women with PaV in the sEMG part of the study had both PaV and VVS. All women with VVS had vaginismus, while 42/224 had PaV but not VVS. sEMG measurements revealed no significant differences between the three groups of women (PaV solely, PaV + VVS, and asymptomatic). Almost half of the women with superficial dyspareunia referred to our clinic have both the diagnosis PaV and VVS. sEMG was not a method of any value to distinguish between women with PaV solely, PaV + VVS, or asymptomatic women. The increased tone found clinically in the PFM of women with PaV+/-VVS may be of other origin than electrogenic contractions.
Article
Vaginal sEMG biofeedback and pelvic floor physical therapists' manual techniques are being increasingly included in the treatment of vulvar vestibulitis syndrome (VVS). Successful treatment outcomes have generated hypotheses concerning the role of pelvic floor pathology in the etiology of VVS. However, no data on pelvic floor functioning in women with VVS compared to controls are available. Twenty-nine women with VVS were matched to 29 women with no pain with intercourse. Two independent, structured pelvic floor examinations were carried out by physical therapists blind to the diagnostic status of the participants. Results indicated that therapists reached almost perfect agreement in their diagnosis of pelvic floor pathology. A series of significant correlations demonstrated the reliability of assessment results across muscle palpation sites. Women with VVS demonstrated significantly more vaginal hypertonicity, lack of vaginal muscle strength, and restriction of the vaginal opening, compared to women with no pain with intercourse. Anal palpation could not confirm generalized hypertonicity of the pelvic floor. We suggest that pelvic floor pathology in women with VVS is reactive in nature and elicited with palpations that result in VVS-type pain. Treatment interventions need to recognize the critical importance of addressing the conditioned, protective muscle guarding response in women with VVS.
Article
This case-control survey compared health history and health care use of women with vulvodynia with a control group reporting absence of gynecologic pain. Women with a clinically assessed diagnosis of vulvodynia and asymptomatic controls were matched for age and mailed a confidential survey that evaluated demographics, health history, use of the health care system, and history of vulvodynia. Participants were all current or former ambulatory patients within a university health care system. Of the 512 questionnaires mailed to valid addresses, 70% (n = 91) of cases and 72% (n = 275) of controls responded, with 77 cases and 208 controls meeting eligibility criteria. Women with vulvodynia reported a substantial negative impact on quality of life, with 42% feeling out of control of their lives and 60% feeling out of control of their bodies. Forty-one percent indicated a severe impact on their sexual lives. When comorbidities were evaluated individually and adjusted for age, fibromyalgia (odds ratio 3.84, 95% confidence interval 1.54-9.55) and irritable bowel syndrome (odds ratio 3.11, 95% confidence interval 1.60-6.05) were significantly associated with vulvodynia. On a multivariate level, vulvodynia was correlated with a history of chronic yeast vaginitis and urinary tract infections. This survey highlights the psychological distress associated with vulvodynia and underscores the need for prospective studies to investigate the relationship between chronic bladder and vaginal infections as etiologies for this condition. As well, the association of vulvodynia with other comorbid conditions, such as fibromyalgia and irritable bowel syndrome, needs to be further evaluated. II-2.
Article
The influence of contextual factors on the pain evoked by a noxious stimulus is not well defined. In this study, a -20 degrees C rod was placed on one hand for 500 ms while we manipulated the evaluative context (or 'meaning') of, warning about, and visual attention to, the stimulus. For meaning, a red (hot, more tissue damaging) or blue (cold, less tissue damaging) visual cue was used. For warning, the stimulus occurred after the cue or they occurred together. For visual attention, subjects looked towards the stimulus or away from it. Repeated measures ANCOVA was significant (alpha=0.0125). Stimuli associated with a red cue were rated as hot, with the blue cue as cold (difference on an 11 point scale approximately 5.5). The red cue also meant the pain was rated as more unpleasant (difference approximately 3.5) and more intense (difference approximately 3). For stimuli associated with the red cue only, the pain was more unpleasant when the stimulus occurred after the cue than when it didn't (difference approximately 1.1). Pain was rated as more intense, and the stimulus as hotter, when subjects looked at the red-cued stimulus than when they didn't (difference approximately 0.9 for pain intensity and approximately 2 for temperature). We conclude that meaning affects the experience a noxious stimulus evokes, and that warning and visual attention moderate the effects of meaning when the meaning is associated with tissue-damage. Different dimensions of the stimulus' context can have differential effects on sensory-discriminative and affective-emotional components of pain.
Consensus vulvar pain terminology committee of the International Society for the Study of vulvovaginal disease (ISSVD), the International Society for the Study of Women's study of Women's sexual health (ISSWSH), and the international pelvic pain society
  • J Bornstein
  • A T Goldstein
  • C K Stockdale
Bornstein J, Goldstein AT, Stockdale CK, et al. Consensus vulvar pain terminology committee of the International Society for the Study of vulvovaginal disease (ISSVD), the International Society for the Study of Women's study of Women's sexual health (ISSWSH), and the international pelvic pain society. Obstet Gynecol. 2016;127(4):745-751. https://doi.o rg/10.1097/AOG.0000000000001359.
Vulvar Vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria
  • S Bergeron
  • Y M Binik
  • S Khalife
  • K Pedigas
  • H Glazer
Bergeron S, Binik YM, Khalife S, Pedigas K, Glazer H. Vulvar Vestibulitis syndrome: reliability of diagnosis and evaluation of current diagnostic criteria. Obstet Gynecol. 2001;98(1):45-51. https://doi.org/10.1097/00006250-200107000-00009.
Assessment of pelvic floor muscle contraction with palpation
  • I Volloyhaug
  • S Morkved
  • O Salvensen
  • K Salvensen
Volloyhaug I, Morkved S, Salvensen O, Salvensen K. Assessment of pelvic floor muscle contraction with palpation, perineometry Downloaded from https://academic.oup.com/jsm/advance-article/doi/10.1093/jsxmed/qdae171/7916735 by guest on 20 December 2024
Manual for the Depression Anxiety Stress Scales
  • L P Lovibond
  • S H Lovibond
Lovibond LP, Lovibond SH. Manual for the Depression Anxiety Stress Scales. 2nd ed. Sydney, New South Wales:Sydney Psychology Foundation; 1995.