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Treating Vulvar Vestibulitis with Electromyographic Biofeedback of Pelvic Flor Musculature Esperanza McKay,
M.D. Raymond H. Kaufman, M.D. Uday Doctor, M.D. From the Department of Obstetrics and Gynecology* and Department of Anesthesiology, Baylor College of Medicine, Houston, Texas, and Department of anesthesiology, University of Texas Medical Branch, Houston, Texas.
ABSTRACT OBJECTIVE: To evaluate the effectiveness of electromyographic biofeedback of pelvic floor musculature in the management of patients with moderate to severe vulvar vestibulitis syndrome.
METHODS: Twenty-nine patients with moderate to severe vulvar vestibulitis syndrome were included in this study. Each patient was given a computerized electromyographic assessment of pelvic floor muscles. They were then provided with a portable electromyographic home trainer biofeedback device and specific instructions were given to perform biofeedback - assisted pelvic floor muscle rehabilitation exercises. The patients received monthly evaluations of the pelvic floor muscles to ensure and motivate compliance and monitor improvement and symptom changes. Patients were evaluated on a monthly basis relative to vestibulodynia and dyspareunia.
RESULTS: Fifteen of the 29 treated patients (51.7%) demonstrated a marked decreased introital tenderness and 14 of these fifteen (93.3%) were able to resume sexual activity without discomfort. Nine patients (31.0%) demonstrated a significant decrease in introital tenderness and pain and 6 of the 9 (66.7%) resumed sexual activity. Thus 20 of the 29 women (69%) became sexually active. Following completion of treatment twenty-four (88.9%) reported negligible or mild pain, 5 of the 29 women did not show any significant improvement and none of these were able to resume sexual activity. Within six months of start of therapy 90% of individuals ultimately resuming sexual activity had done so.
CONCLUSION: Electromyographic biofeedback of pelvic floor musculature is an effective approach to the management of the patient with vulvar vestibulitis.
INTRODUCTION: Vulvodynia is a general term incorporating a broad spectrum of pathology. The vulvar vestibulitis syndrome is one of the more common problems resulting in vulvar pain. The diagnostic criteria usually utilized to establish the diagnosis were proposed by Friedrich1 in 1987 and include: 1) severe pain with vestibular touch or attempted vaginal entry; 2) tenderness to pressure localized within the vulvar vestibule; 3) gross physical finds limited to vestibular erythema. Several attempts have been made to categorize the severity of this problem and the recommendation of Marinoff2 would appear to offer the most reasonable clinical applicability. He categorizes vestibule pain into 4 categories: level 0 - no pain with intercourse; level 1- pain with intercourse which does not prevent completion of coitus; level 2 - pain with intercourse requiring interruption or discontinuance of coitus; level 3 - pain with intercourse preventing any attempt at coitus. Multiple approaches to therapy have been advocated for the management of this distressing problem. These include a Ahypo allergic routine@ attempting to remove all possible noxious agents which may irritate the vulvar vestibule; a low oxalate diet combined with calcium citrate; intra-lesional interferon; perineoplasty or vestibulectomy and biofeedback. The best reported results suggest that perineoplasty or vestibulectomy has been effective in the management of this problem resulting in the ability of almost 80% of patients to resume sexual activity with little or no pain3,4. More recently, Glazer5 has recommended the use of electromyographic biofeedback of pelvic floor musculature as an approach to the management of the vulvar vestibulitis syndrome. The current report is an evaluation of this latter approach to therapy in 29 women diagnosed with level 2 or 3 vulvar vestibulitis.
MATERIALS AND METHODS: The patients entered into the study were women, seen in the practice of a single physician, with a diagnosis of level 2 or 3 vulvar vestibulitis. A careful history was obtained from each patient as to the primary complaint, length of time symptoms had been present and data was obtained on factors which may or may not have contributed to the patients symptoms. Following careful inspection of the vulva, including the vestibule, as well as the vagina, palpation of the vestibule was carried out with a moist cotton - tip applicator and the location of areas of tenderness and erythema were carefully noted. Twenty-nine patients with level 2 or level 3 vulvar vestibulitis were referred for enrollment in the biofeedback program. All 29 women were Caucasian; 24 were married and 5 single; 6 women were nulliparous and 23 had delivered 1 or more children. The ages ranged from 25 to 48 years with a mean of 35. The duration of symptoms ranged from 2 to 5 years with a mean of 3.7 years. Twenty-four of the 29 women were abstinent from intercourse at the time of evaluation and the average duration of abstinence was 12 months. Five of the 29 women had had prior surgery involving the vestibule before being seen. Eight women had reported using various topical treatments and 9 had received Amitriptyline during the course of treatment as well as Hismanal 10mg daily. None of these treatments had been successful. A surface Perry meter TM single user, vaginal sensor, electromyographic (EMG) Perineometer manufactured by SELF regulation systems (SRS), (Redmon Washington) was used. This single user vaginal sensor eliminates concerns about adequate sterilization; is easily inserted by the patient in private, and without the need to completely disrobe. It is associated with minimal discomfort and produces EMG data that correlates 99% with data produced by invasive fine wire stainless steel electrodes. This study used 2 different portable EMG biofeedback instruments specifically developed for use with the above sensors for rehabilitation of pelvic floor muscles (myotrac TM 4003, manufactured by Thought Technology LTD. Montreal, Canada). The other portable EMG biofeedback instrument used for home training is the Thought Technology U Control feedback unit which requires a U - control vaginal sensor. Computerized EMG data acquisition equipment was used in the office for initial and periodic follow-up assessments of pelvic floor muscles. The sEMG signal processing unit consists of a portable 1.5 LB G channel surface EMG unit operating at an analog to digital conversion rate of 1000 per second, producing peak, average minimum and maximum integrated EMG root mean squared measures and median spectral frequency calculations. The assessment protocol software was the Glazer pelvic muscle assessment program, version 2,2 (Bio-Behavioral Medical Rehabilitation Inc., Jacksonville, Florida)5. In the pain clinic a brief history was obtained and pelvic examination was performed to confirm the diagnosis of vulvar vestibulitis. After the patient privately inserted the sensor into the vagina, she was seated, fully clothed in a recliner. The sensor was connected to the computerized EMG system and the clinician, along with the patient viewed the EMG signal on the computer screen. Information was taken for the initial assessment of pelvic floor muscles from resting EMG levels of the pelvic floor muscles over a 1 to 5 minute period. The patient was then asked to tighten the pelvic muscles and to hold the contraction for 10 seconds to make sure she was able to voluntarily contract the correct isolated muscle group. Often, patients had difficulty in isolating the contraction to just the pelvic floor muscles without involvement of the accessory muscles of the legs, abdomen and buttocks. Following this, resting baseline post contraction readings were taken. At this first session and at each subsequent session patients were asked to provide subjective pain ratings on a scale of 1 (least) to 10 (most) in relation to coitus. They were also questioned regarding sexual activity and the frequency and length of home training of the pelvic floor muscles. Information was then gathered for the resting EMG levels of the pelvic floor muscles during one minute. The patient was then asked to perform 8 quick strong muscle contractions of the pelvic muscles. Each muscle contraction was proceeded by a muscle relaxation period of 12 seconds. Each contraction was held for 3 seconds. Once 8 contractions were completed, the next phase of therapy consisted of a series of 8 - 12 second muscle contractions followed by a 12-second muscle relaxation period. The patient was then asked to hold the muscle contraction as long as possible - up to 1 full minute. As this first session was occurring the patient received instructions on how to perform the exercises at home and to improve performance criterion. Specific clinical goals were established for each patient including a resting baseline less than 2.5 - 3.0 MV; strength of muscle contraction greater than 45 MV; and sustained muscle contraction for a 1 full minute greater than 45 MV. Patients were instructed to exercise at home as follows: 60 repetitions of 10 seconds of rest followed by 10 seconds of muscle contraction twice daily with several hours between the 2 practice sessions. They were also instructed that as the number of Alights on@ in the monitor decreased in a contraction (representing fatigue), they were to attempt to strengthen the contraction. Patients were seen on a monthly basis and given in office evaluations at each visit in order to insure continued compliance with the home exercise regime. Data on pain and sexual activity were obtained at each visit. The Epi Info 6 program (CDC Atlanta, Georgia, 1994) was used for calculation of significance of differences between means.
RESULTS The maximal contraction in the pre and post contraction readings were related to the subjective pain rating patients provided when they had coitus. As already stated the level of pain was rated on a scale of 1 (least) to 10 (most). As can be seen in Figure 1, as the maximal contraction strength increased there was a progressive decrease in the degree of pain the patients complained of (p<0.001). There did not appear to be any significant change in the pre and post contraction resting potential in relation to the complaint of dyspareunia. Fifteen (51.7%) of the 29 women studied reported negligible pain with intercourse following 4 to 6 months of therapy and 14 (93.3%) of this group of women became sexually active again. Nine (31%) of the women still had a mild degree of pain and 6 (66.7%) of them resumed satisfactory sexual activity. There was no improvement reported in 5 (17.2%) of the women and none of these were sexually active at the end of a period of 11 months. In all, 24 (84.7%) of the women studied either reported negligible or mild pain and 69% of the 29 women had resumed sexual activity. (Table 1) Figure 2 demonstrates the relation between pain, maximal contraction and sexual activity at each visit to the clinic. As can be seen, maximal muscle contraction was demonstrated within 3 months after the start of therapy and there was a corresponding significant decrease in pain reported with intercourse or touching the introitus during this same period of time. Within 6 months of therapy 88.9% of patients were sexually active at that visit but this decreased to 75% at the eleven-month visit. The level of pain reported significantly decreased.
DISCUSSION The results of this study suggest significant benefit utilizing electromyographic biofeedback of the pelvic floor musculature in the management of women with moderate to severe vulvar vestibulitis. 69% of women who desired to were able to resume normal sexual activity with no or minimal discomfort. These results compare favorably to what has been reported utilizing perineoplasty for the treatment of this problem3,4. The obvious advantage of electromyographic biofeedback is the fact that it is a non surgical procedure which can be performed by the patient in the privacy of her home and requires only periodic follow-up visits to the clinic monitoring the patient=s progress. Morbidity is significantly less than would be anticipated with surgery and it is a cost-effective approach. The rational for studying pelvic floor muscles in-patients with vulvar vestibulitis is the fact that these patients usually demonstrate hyperirritability of the pelvic floor muscles5,6. Travell7 reported that this hyperirritability could be activated by localized tissue disturbances. In the case of vulvar vestibulitis we believe that cutaneous vulvar disturbances may destabilizes the pelvic floor muscles. Travell and Simmons8 reported that such muscle disturbances are reflected in discoordination of the electromyography (EMG) and are prone to develop in muscles that lie within the pain reference zone of the disturbed tissue and in turn reflex back through a dorsal root spinal cord mechanism to perpetuate tissue disturbances via its effect on local tissue (sympathetic mediated activity, including vascular changes and histamine release). One factor that perpetuates the vulvar skin disturbance is destabilization of pelvic floor muscles and thus the restablization of the muscles should allow this condition to resolve. Travell and Simmons8 as well as Glazer5,6 have reported that this type of muscle disturbance is reflected in EMG readings. For this reason EMG readings were used objectively to measure the status of the pelvic floor muscles in the present study. Of the 29 women evaluated 24 (84.7%) reported a significant decrease of pain on touch of the vestibule. Only 20 of these women resumed sexual activity by choice; the other four electing to abstain for the present. Obviously, one of the faults of this study is the fact that it is an opened-ended evaluation of the severity of pain associated with intercourse as well as sexual activity prior, during and after completion of a program of biofeedback. Ideally a randomized Aplacebo@ controlled study evaluating biofeedback should be carried out.
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