Intimate arenas: dealing with pelvic pain

Patients with pain relating to sexual function can find it hard to access the advice they need, but help is at hand from specialist physiotherapists. Louise Hunt reports.


Building confidence 

The psychologists’ approach gave Ms Petersen ideas for how to incorporate sexual activity-related goals as part of overall goals in the pain management programme. 
‘I started looking at ways that it could be used to explore graded exposure, in the same way that conventional programmes build up sitting and walking tolerance,’ Ms Petersen says.
‘For example, you can suggest patients use a vibrator to explore where their tolerance and baseline is. The key is to not be scared to address sexual activity,’ says Ms Petersen. She adds that the service has developed a model to help give clinicians confidence in treating intimacy issues, and that an outline is available on the Faculty of Pain Medicine’s website at
Much can be learned from women’s health physios, who are more likely to see patients initially with pelvic pain. Although, she says, pelvic pain physiotherapists are increasingly upskilling to treat long-term pelvic pain and men’s issues. 
‘They are excellent at dealing with the intimate issues, and have good bio-mechanical skills for dealing with women’s health issues such as prolapses,’ says Ms Petersen, who spoke at the first World Congress on Abdominal and Pelvic Pain in Amsterdam in 2013. 
Taking a bio-psychosocial perspective can help these very complex patients, she says. ‘The general feedback was they would only approach pain with more traditional biomechanical approaches including manual therapy, but with chronic pain it is not just about treating the structural cause, but the nervous system as a whole.’
Her patients have pain symptoms that develop gradually. Over time, this causes changes in the nervous system that are not explained by a particular pathology. For example, she says, take a patient with bladder pain. Their brain perceives a threat and this activates the immune system causing real inflammation, although tests show there is no infection. 
‘It can be really difficult to treat and patients often end up in a cycle of repeated investigations and being treated with antibiotics they didn’t need,’ she says. 
‘Research shows that neurogenic inflammation is possibly caused by an overactive nervous system and physiotherapists can play a huge part in explaining this to patients,’ she says.
Ms Petersen’s advice is to identify what to do with patients with complex long-term pain and how to refer them to specialist centres. ‘They also need to be able to explain pain and why a traditional mechanical approach might not work.’
There is a shortage of research and guidelines into how to manage long-term APP or on how to adapt conventional pain management programmes to treat these patients, says Ms Petersen. 

The Fife way

Other pain management physiotherapists agree that joint working is the way forward. This has been happening for some time at Fife Integrated Pain Management Service. 
Fiona McAslan, advanced physiotherapy practitioner in pain management with the service, says the women’s health and pain management specialists work together.
‘Our women’s health team changed its name to pelvic health physiotherapy to reflect the change in focus to a more holistic one. It encompasses the wide variety of conditions in both men and women that they see,’ she says. 
‘All team members have had training in basic pain management and I have regularly presented at their study days. The pain and pelvic health physio teams are already expanding their joint working. Shadowing opportunities and peer discussion sessions are used and we are looking at more training opportunities. Patients go through a triage system to ensure they are treated by the most appropriate approach.
‘We are dealing with patients who have reached the “end of the road” in terms of investigation and so we liaise with pelvic health at this point if the patient has not tried specialist pelvic health physio in the first instance. 
‘If this is still not successful, they can refer back to our service which can focus in greater depth on the bio-psychosocial issues, helped by access to pain psychologists. I can accept we are lucky that some pelvic health physiotherapists have worked in pain management in the past, which has made the adoption of a bio-psychosocial approach easier.      
‘I would agree that, in general, physiotherapists in pain management may not be fully confident in dealing with bladder, bowel and sexual function. However, our pain team has received training in dealing with these issues as they are not confined to pelvic pain/abdominal pain, but can be present in all pain conditions.’ fl

More information 

What the CSP networks offer

The Pelvic, Obstetric and Gynaecological Physiotherapy professional network (formerly known as the Association of Chartered Physiotherapists in Women’s Health) has 600 members. It offers specialist training courses in the developing area of chronic pelvic pain, including the bio-psychosocial approach. 
Members work in a range of settings, some of which are similar to the integrated pain management service in Fife. Others work in independent private practice. 
Both men and women with pelvic dysfunction symptoms often have problems in securing referrals to a healthcare professional with the appropriate knowledge, skills and experience. 
The specialist internal pelvic floor examination and treatment techniques that may be used with this client group are taught at postgraduate level, with training programmes that are compliant with CSP guidance (PD092, 2012). The network delivers several short courses related to pelvic health and is about to introduce a new advanced course. Many of the physiotherapists attending the courses have backgrounds in managing and treating musculoskeletal (MSK) conditions.
In many ways, this is a sub-speciality of MSK physiotherapy practice and collaboration involving both groups can only be positive. Physiotherapy has a big role to play, not only in the treatment, but also in facilitating self-management with the aim of increasing activity levels and improving people’s quality of life.
Martin Hey, the chair of the Physiotherapy Pain Association, a CSP professional network, and a consultant physiotherapist in pain management at Mid Yorkshire Hospitals NHS Trust, added: ‘I fully support the assertion that for complex care in patients with longer-term APP problems a better, dual understanding would afford more empathic, inclusive, coordinated and, hopefully, effective care.’ 
Louise Hunt

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