Case Study: The Power of “Explaining” Pelvic Pain

Tracey was referred to WMHP with dyspareunia, vulvodynia, and pelvic floor muscle dysfunction following gynaecological surgery.  This case study explores the impact of psychological and social factors on Tracey’s pain experience. It highlights the importance of following a biopsychosocial approach incorporating therapeutic neuroscience concepts when developing an effective treatment program. 
 
Assisting patients to understand and address not only the biology involved, “the issues in the tissues”, but also the psychological and social factors contributing to their symptoms is an essential component to successful outcomes.
 

Subjective Assessment

  • History:
    • Tracey, a 64-year-old multiparous female, was referred to WMHP from a Urogynaecologist, with dyspareunia, vulvodynia, pelvic pain and pelvic floor muscle dysfunction.  These symptoms commenced following a vaginal hysterectomy, Anterior and posterior repair and TVT sling. 
    • Prior to surgery Tracey had a large vaginal prolapse and stress urinary incontinence and had unsuccessfully trialed conservative treatment including a pessary.
    • At her initial physio consultation, Tracey reported her main problem was inability to tolerate vaginal penetration since surgery due to severe pain. She was also experiencing pelvic pain with walking and exercise such as golf. In addition, she reported debilitating thoracic pain and spasm which commenced a few months post operatively.
  • Previous treatment: Tracey had two reviews at a Urogynaecologist clinic and was told “everything was well healed and there was nothing physically wrong”.
     
  • Bladder and bowel: both normal function.
     
  • Sexual function: Prior to the surgery Tracey reported no problems with intercourse, it was pain free and enjoyable despite the prolapse. Currently she was avoiding all forms of intimacy with her husband. 
     
  • Psychosocial questioning:
    • What was happening in your life when the pain started? Tracey described experiencing post-operative complications related to an adverse drug reaction which resulted in her being transferred to ICU. This was very traumatic for her and her husband compounded by the fact he was present when the incident occurred. Tracey had ongoing concerns her pain indicated “something must have gone wrong” as she had been reassured pre-operatively that it was a very routine procedure. One family member, who works in the medical field, was becoming frustrated with her slow recovery making statements like ‘you’ve healed and should be better by now’. Finally, their cherished elderly family pet became sick and had to be euthanized.
       
    • How does the pain make you feel about yourself? Tracey described feeling something was ‘missing’, grieving the loss of her uterus, a symbol of her womanhood. She was deeply saddened she couldn’t enjoy intimacy with her husband as they had a strong relationship and had been looking forward to their life together as “empty nesters”. She was distressed that she couldn’t return to golf (as this was her main form of exercise and social interaction) or be actively involved with her grandchildren as she had pre-operatively. Overall, she reported feeling ‘sad, irritable, tired, lonely and had lost confidence.’
    • Is there anything you avoid? Intercourse, intimacy, golf, going out socially, active involvement with her grandchildren.

Objective Assessment

  • Normal appearance of vaginal tissues on visual inspection
  • Negative Q-tip testing at vulval vestibule 
  • Internal vaginal examination:
    • Anticipatory spasm, pain and increased resting tension of the levator ani > perineals. 
    • Spasm quickly settled during the examination with slow relaxed breathing and one finger insitu.
    • Sluggish pelvic floor muscle contraction and sluggish partial relaxation on command. 

Impression

Tracey’s case highlights the significant impact pelvic pain can have on a person’s quality of life and the importance of psychological and social factors in the development of symptoms. Following surgery Tracey developed reactive pelvic floor muscle spasm, vaginal pain, back pain, sensitisation of the pelvic tissues and central sensitisation. These symptoms would have been aggravated by her limited knowledge and understanding regarding the cause of her pain leading to subsequent fear, anxiety, avoidance behaviours, catastrophisation and unhelpful thoughts and beliefs about her symptoms. This was compounded by a lack of validation from her medical specialist and family and the isolating grief she was experiencing regarding her losses.
 

Treatment Program

Tracey was treated with a biopsychosocial approach to management. Key treatment areas included:
  • Education regarding her pain experience:  Tracey was provided with a cogent explanation for the cause of her symptoms introducing relevant therapeutic neuroscience concepts. Greatest importance was to help Tracey understand the role of the brain in her pain experience. A lack of understanding of the cause of one’s own pain leads to fear-avoidance behavior and catastrophisation, intensifying the pain experience. Knowledge helps alleviate fear and turns down the bodies warning system, assisting with a reduction in pain and the suffering associated with this, resulting in calming of the sensitised nervous system. Tracey’s triggers and soothers were identified, empowering her to make effective choices regarding her daily activities, thoughts, and reactions to certain situations.
     
  • General relaxation: Tracey commenced a daily general relaxation program, aiming to help calm her sensitive nervous system and improve her awareness and control over increased muscle tension throughout her body, particularly the pelvic region. She was encouraged to regularly “check in” with how she was feeling physically and emotionally through the day and practice moment to moment relaxation.
     
  • Pelvic floor re-education: Instruction in pelvic floor muscle down training / relaxation including design of a home program to normalise muscle tension.
     
  • Desensitisation with vaginal trainers: rather than using trainers to ‘stretch out’ the vagina, Tracey was educated that their purpose was to change her response to penetration.  This graded exposure retrains the sensitised nervous system, emotional response and reflex pelvic floor muscle tension.
     
  • Intimacy: Tracey’s husband attended all her appointments which helped him understand her condition and increase his support of her and her treatment. They were educated about the importance of returning intimacy to their relationship and were encouraged to explore enjoyable non-penetrative forms of intimacy together. When appropriate they were guided as how to resume intercourse in a safe, enjoyable way with emphasis on arousal.
     
  • General exercise advice: Tracey commenced a graded daily walking program and was provided with advice regarding returning gradually to golf, (initially using the practice fairway, playing with the assistance of a golf buggy to minimise walking, and eventually increasing to walking 18 holes). 

Outcome

After 6 months of treatment, Tracey and her husband were enjoying a healthy, pleasurable, pain free sexual relationship, and she had returned to 18 holes of golf twice per week.  She was very adherent with the individualised biopsychosocial management program implemented, embracing both physical and psychological treatment techniques, which contributed to her excellent response to treatment.