Evaluation and Management of Female Sexual Dysfunction
Patients often fail to bring it up, and clinicians may be reluctant to discuss it, but ignoring sexual dysfunction can disrupt a woman’s most intimate relationships.
Normal PFMs are those that can voluntarily and involuntarily contract and relax.19,20
Overactive (high-tone) muscles are those that do not relax and possibly contract during times of relaxation for micturition or defecation. This type of dysfunction can lead to voiding dysfunction, defecatory dysfunction, and dyspareunia.19
Underactive, or low-tone, PFMs cannot contract voluntarily. This can be associated with urinary and anal incontinence and pelvic organ prolapse.
,Nonfunctioning muscles are completely inactive.19
How to assess. There are several ways to assess PFM tone and strength.20 The first is intravaginal or intrarectal digital palpation, which can be performed when the patient is in a supine or standing position. This examination evaluates PFM tone, squeeze pressure during contraction, symmetry, and relaxation. However, there is no validated scale to quantify PFM strength. Contractions can be further divided into voluntary and involuntary.19
During the exam, ask the patient to contract as much as she can to evaluate the maximum strength and sustained contraction for endurance. This measurement can be done with digital palpation or with pressure manometry or dynamometry.
Examination can be focused on the levator ani, piriformis, and internal obturator muscles bilaterally and rated by the patient’s reactions. Pelvic muscle tenderness, which can be highly prevalent in women with chronic pelvic pain, is associated with higher degrees of dyspareunia.21 Digital evaluation of the pelvic floor musculature varies in scale, number of fingers used, and parameters evaluated.
Lukban et al have described a 0 to 4 numbered scale that evaluates tenderness in the pelvic floor.22 The scale denotes “1” as comfortable pressure associated with the exam, “2” as uncomfortable pressure associated with the exam, “3” as moderate pain associated with the exam that intensifies with contraction, and “4” indicating severe pain with the exam and inability to perform the contraction maneuver due to pain.
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