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19 Articles in Volume 19, Issue #6
Arthrofibrosis: Targeting Hormones after Childbirth to Relieve Frozen Shoulder, Inflamed Joints
Can CGRP Help Clarify Why Migraine Is More Common in Women?
Case Report: Managing Chronic Pelvic Pain in Men
CGRP Monoclonal Antibodies for Chronic Migraine: Year 1 of Clinical Use
Chronic Pelvic Pain as a Form of Complex Regional Pain Syndrome
Correspondence: Continuing the “Pain Specialist” Dialogue
Endometriosis and its Misunderstood Etiology
Evolving Management Strategies for Osteoarthritic Pain
Gamma PEMF Therapy: A Pilot Study For Its Use in Managing Opioid Addiction
Guest Editorial: Sex Differences in Pain
How to Provide Effective Pain Management to LGBTQ Individuals
Interscalene Peripheral Nerve Stimulation for Post-Operative Chronic Shoulder Pain
New ICD-11 Codes Set to Improve Pain Care in the Primary Setting
Perspective: Could NGF Antagonists Be the Safest, Most Efficacious Class of Drug We Have to Treat Pain?
Rheumatoid Arthritis and Cognition: Is There a Genetic Link?
Targeting Nerves Provides Alternative to Opioids for Joint Arthroplasty
The Sex Question in Primary and Pain Care
What is capsaicin’s role in treating osteoarthritis?
When Pain Clinicians Have to Be the Villain: Communication Strategies to Bridge the Divide

The Sex Question in Primary and Pain Care

Meryl J. Alappattu, PT, DPT, PhD, on why HCPs need to be asking about sexual pain.

A Q&A with Meryl J. Alappattu, PT, DPT, PhD, a research professor at the University of Florida’s Department of Physical Therapy, who specializes in chronic pelvic pain conditions.


PPM: In your opinion, is sexual health something that primary care doctors should be asking patients about just as regularly as they ask about physical and mental health? Why or why not?

Dr. Alappattu: YES. Sexual health is a broad term and, according to the World Health Organization, is a state of physical, mental, and social well-being related to sexuality. I consider sexual activity, like many other physical and functional activities, an instrumental activity of daily living. We ask patients about their ability to exercise, dress and feed themselves independently, about their social and family support. I recognize that sexual activity and sexual health may not be the most comfortable topic for providers to discuss, but if our patients cannot be honest and open with us as healthcare providers about sexual dysfunction, to whom else can they turn for help?

PPM: Dyspareunia (ie, persistent or recurrent genital pain that occurs before, during, or after intercourse) may affect up to 25% of the general population with increased prevalence among older women. What types of musculoskeletal factors may contribute to dyspareunia and in what ways might this type of pain prevent patients from obtaining a proper diagnosis?

Dr. Alappattu: The pelvic floor muscles or muscles around the pelvic region may contribute to pain. Sometimes, organs in the abdomino-pelvic cavity can refer pain to different areas of the pelvis and mimic musculoskeletal pain, so it’s important to identify what may be contributing to the pain. Proper diagnosis is an interesting term to describe pelvic pain. Some diagnoses related to pelvic pain are diagnoses of exclusion, meaning physicians have ruled out serious medical pathology and aren’t quite sure why the pain is persisting. One such example is vulvodynia. Other conditions, such as endometriosis, may indicate pathology, but patients also report pain with intercourse or activities that put pressure on the pelvic floor muscles. Pelvic pain, regardless of diagnosis, may have visceral, musculoskeletal, and emotional and/or physiological factors that contribute to the pain experience. This is why it’s incredibly important to have a multi-disciplinary team providing care for these patients.

Some diagnoses related to pelvic pain are diagnoses of exclusion, meaning physicians have ruled out serious medical pathology and aren’t quite sure why the pain is persisting. One such example is vulvodynia. (Image: 123RF)

PPM: Why is a physical exam not always enough to properly diagnose a chronic pelvic pain condition?

Dr. Alappattu: A physical examination is one component of identifying potential contributing factors to pelvic pain. But it cannot be used alone to understand the persistent pelvic pain experience. Providers need to understand how this pain is affecting the patient socially, emotionally, and physically. You can’t get this information from a physical exam alone. As I mentioned, some physical exams do not actually indicate that anything is “wrong” but a patient continues to experience pain. Could it be that the patient is depressed or anxious about their pain and fear that it will never get better? Could it be that the severe pain the patient experiences with intercourse is negatively impacting her marriage? Is he unable to sit for more than 5 minutes at a time and is embarrassed to explain to his colleagues why she is getting up so frequently? Asking patients directly how their pain is affecting their lives may also provide insight on what other health professionals need to be involved in the patient’s care.

PPM: What can providers ask their patients to adequately assess for sexual pain?

Dr. Alappattu: Providers can quite simply ask, “Are you sexually active?” (sexual activity being penetrative or non-penetrative intercourse, oral sex, masturbation). If the patient responds “Yes,” then ask, “Do you have pain with sexual activity?” If the patient responds “Yes,” then follow up with: “If it’s OK with you, let’s talk a little bit more about that. Where does it hurt, exactly? When does it hurt? Are there positions that are more painful than others?”

These types of open and direct questions will get the conservation started. If providers are looking for a validated questionnaire to assess sexual pain, the 11-point Numerical Pain Rating Scale is simple to administer to all patients: “Over the last 7 days, rate the [highest/lowest/average] pain you experienced with sexual activity from 0 to 10 with 0 being no pain and 10 being your worst imaginable pain.” To assess sexual function as a whole in women, the Female Sexual Function Index (FSFI) is widely used to assess the domains of desire, arousal, lubrication, orgasm, satisfaction and pain. (Note: Interpret scores with caution for patients who are abstaining from sexual activity for reasons other than pain.)  For men, the International Index of erectile Function (IIEF-5) or the Sexual Health Inventory for Men (SHIM) are both commonly used.

PPM: In general, what types of therapy may be recommended for ongoing sexual pain?

Dr. Alappattu: A variety of different therapies may be recommended for sexual pain, including medications, physical therapy, couples counseling, sexual therapy, and cognitive behavioral therapy. Regardless of the therapies used, it is important for providers to regularly communicate with each other about their shared patients and discuss progress in symptoms and/or barriers to treatment.


More on managing chronic pain conditions in women in our HealthyWomen summit coverage.

Last updated on: October 7, 2019
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Improving the Sex Lives of Patients With Chronic Pain
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