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AUGS/IUGA Scientific Meeting 2019
Multi Disciplinary Assessment and Treatment of Chr ...
Multi Disciplinary Assessment and Treatment of Chronic Pelvic Pain and Sexual Dysfunction - Nursing Perspective
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Leah will be speaking on medications for the management of chronic pelvic pain. Alright, so everyone hear me okay? Alright, great. So I just wanted to call your attention to my e-mail address here at the bottom. I'm more than happy to answer e-mails if you have questions after today. I also wanted to let you know that all my slides are available within the app, so don't feel like you have to take pictures if you want to just listen. Feel free. Alright, here are my disclosures. I will indicate which drugs are indicated for the use in the treatment of pain as I go through a lot of the medications that I'm going to discuss are off-label, not indicated for pain. And this presentation is based on my experience and that of my mentors, so it's not necessarily evidence-based because we just don't have a whole lot of evidence when it comes to treating pelvic pain in urogynecology. These are my objectives. So as we all know, there are many potential sources of pelvic pain in women, and for this talk I'm going to be focusing on the most common types of pain that we see in urogynecology. This includes pain from muscle spasm, bladder pain, vulvodynia, and dyspareunia. Treatment of pain in this patient group almost always involves a combination of multiple modalities. No one treatment or combination works best for every woman. The most common treatments include pelvic floor physical therapy, neuromodulating medications, both oral and topical, and muscle relaxants, again, both oral and topical. Finding the one that works best will require some trial and error, and patience is really essential during this period. And while my goal is always to eliminate pain completely, I think a more realistic treatment goal is to reduce pain by approximately 80% and to reduce the frequency and intensity of pain flares. So how to choose a medication for treating pain. It's important to be aware of several characteristics of your patient and her pain. Is her pain affecting her ability to go to work or school? Is it constant or intermittent? Has she tried medications before and had reactions? Are you concerned that she might misuse or divert her prescriptions? And does she have reasonable expectations about what to expect six and 12 months down the line? You really do need patient buy-in when you're treating pain. And then finally, how will you follow up with her? Are you going to follow up by email, by phone, by portal, or in person? In a very busy practice, it's important that you set those boundaries in the beginning. So as I began treating women with pelvic pain, I felt a little overwhelmed by the number and type of medications I began to prescribe. My expertise was in OB-GYN, not in pain management. But becoming comfortable with and using a variety of medications has really made it easier, better for both the patient as well as for myself in terms of feeling comfortable. In addition, you'll get better pain relief, fewer side effects, lower possible doses, all of the things that I mentioned here on the slide. This is an algorithm that I developed based on the current body of evidence about pain management as well as my own clinical experience. Treatment decisions can be based in part on whether pain is chronic or intermittent. So this first slide talks about intermittent pain and the various types of pain. Another important distinction is what type of pain the patient is having. So I've divided my algorithm into muscle pain, bladder pain, vulvar pain, and dyspareunia. The order of the medications that you see here pretty closely follows what I do in practice. This algorithm goes over the treatment of chronic pain. In all cases, I would continue with the intermittent treatments from the prior slide. And then you can decide to add or substitute each treatment depending on the patient's preference and ability to tolerate each medication. For example, you might treat a patient with muscle pain with an oral gabapentin, an oral muscle relaxer at bedtime, and then replace gabapentin with pregabalin after two months. So anti-epileptic medications. The first drug that I typically try in this group is gabapentin. Both gabapentin and pregabalin are anti-epileptic medications that treat pain by binding to calcium channels, which inhibits the release of several neurotransmitters involved in pain transmission from the site of pain to the brain. There is one small pilot study using gabapentin to treat pelvic pain that showed that it did improve pain scores and mood as compared to placebo. Pregabalin is chemically related to gabapentin and was designed to facilitate diffusion across the blood-brain barrier. There are no published studies of pregabalin for women with chronic pelvic pain. In the United States, most insurers require a trial of gabapentin and sometimes also a tricyclic antidepressant before they will cover pregabalin. Both medications should be started at a low dose and then titrated up slowly until the patient feels pain relief or side effects, whichever comes first. The most common side effects with gabapentin are dizziness and drowsiness, both of which tend to improve with time. Pregabalin causes similar side effects, but it can also cause lower extremity edema and weight gain. A treatment trial should continue for approximately two months to assess benefit. There is abuse potential with both medications as they cause a feeling of euphoria, especially when combined with opioids. Pregabalin in the United States is a controlled substance and many U.S. states have implemented regulations to reduce the risk of misuse and abuse. Tricyclic antidepressants include amitriptyline, nortriptyline, and dezepramine. They work to block the reuptake of serotonin and norepinephrine and they're thought to potentiate endogenous opiate receptors and modulate descending pain pathways, thereby decreasing pain sensitivity. Most trials of tricyclic antidepressants are conducted Most trials of tricyclic antidepressants are older, use small sample sizes, and poor study design. In studies of tricyclic antidepressants for chronic pain, between 40 to 60 percent of patients obtain partial relief. These medications should also be started at a low dose and slowly increased every few weeks as needed and tolerated. Side effects can definitely be limiting with this class of medications. The most common side effects including morning fatigue, dry mouth, and constipation. I do not use tricyclics in patients with heart disease or arrhythmias due to the risk of heart block, MI, and changes in heart rhythms. I recommend a baseline EKG for women over 40 before you start a tricyclic. I also consult with a patient's cardiologist or primary care provider if there's any question about safety. I typically start with amitriptyline. It has some anticholinergic benefits. So for people with bladder pain and overactive bladder, it can be a good fit for their symptoms. I tend to see pretty good relief at lower doses, although I know that studies show that higher doses are sometimes required. The nice thing about these medications is they're very inexpensive, they're generic, and they are pretty affordable. The next group of medications I'm going to talk about are serotonin norepinephrine reuptake inhibitors, also called SNRIs. This includes diloxetine, venlafaxin, and milnisiprin. These drugs work by inhibiting reuptake of both norepinephrine and serotonin and can be used to treat anxiety, depression, as well as chronic pain syndromes, although the pain-relieving mechanism is not known. The most common side effect with this group is nausea, which can be avoided by starting with a low initial dose and increase every one to two weeks. That's sort of a trend with all these medications, start low and go slow. To stop this class of medications, you also need a very slow taper over weeks to months. There are studies of diloxetine in combination with other medications in men with chronic prostatitis and chronic pelvic pain syndrome that show benefit. There are no published studies of SNRIs in women with pelvic pain. I was interested to hear Brooke speak the other day about milnisiprin being used for vulvodynia. Next group of medications is muscle relaxers. These work to temporarily reduce overall muscle tone. It's been suggested that up to 85% of women with chronic pelvic pain have dysfunction of the musculoskeletal system, and I definitely think that's true in my patient population. Muscle spasm can cause pain, but it can also develop in response to pain, such as with bladder infection. You feel the urge to go, you know it's going to hurt, you tense your muscles and you try to void through that pain. Addressing muscle spasm is an important part of pain management. I typically start with cyclobenzaprine. It, again, has some anticholinergic benefits. It does not have antidepressant benefit. It is very sedating. Most of these medications are sedating, so it can improve sleep. Tizanidine is typically less sedating, although it does interact with fluoroquinolone, so you need to be careful when you're prescribing multiple treatments. So vaginal treatments are relatively new within this field. There have been studies that look at diazepam that I'm going to go into in just a moment. They're a popular option as they have few systemic side effects. So the hope is that you get the benefit of the treatment without the sedation and potentially systemic risks. One hypothesis for their benefit is that there's crosstalk between the epithelial cells of the vulva and the vagina and other cell types, such as mast cells and nerve endings and nociceptors. Traditionally, higher doses of medications are needed due to their poor absorption. So if you had asked me what vaginal treatments I used five years ago, I would say diazepam. I've since started using baclofen in place of diazepam just because I feel like you're getting more muscle spasm relief with baclofen without the benzodiazepine risk and concern about oversight from regulating bodies. There are two studies of diazepam that showed no benefit, although anecdotally I will say some patients say that it works very, very well. Those studies did look at systemic absorption and it was minimal. You can compound suppositories to give a combination of different medications. Really, the sky's the limit. Most compounding pharmacies that have women's health branches are willing to work with you and tell you what they have given with other providers. Vulvar topical treatments are another area of interest of mine. And really, treatment of vulvar pain deserves its own lecture, but I'm going to briefly talk about a few topical treatments that I use in my practice. These treatments have been recommended by experts in the management of vulvar pain. These are not my ideas. The first one that's mentioned here, the hydrocortisone and pramoxan, is Anusol HC. It's available both branded as well as generic, and it's available without compounding. The mechanism of action is probably similar to that of medications that are taken orally. There are several small trials showing the benefit of topical gabapentin for vulvar pain. The one that I mentioned here is from Dr. Buttrick. The advantage of compounding, again, is the ability to use a base that's non-irritating and maximizes absorption into the tissue. For your patients who are sensitive to every version of estrogen cream, primer and cream, using a compounded base can reduce the chances of her having a reaction. So bladder treatments are typically done in the office, although I do have a handful of patients that do their own bladder installations at home. There are many good studies of anesthetic bladder installations for bladder pain syndrome. The best study combination includes a combination of alkalinized lidocaine and heparin, and that combination seems to work better than just lidocaine or heparin alone. The studies regarding this treatment were first published in the early 2000s. The thing that's lacking, though, is studies of which interval and duration are best. So is it once a week for six weeks? Is it three times a week for six months? Really, I base that decision on how the patient's feeling and whether it's helping and how willing and able she is to come to the office. In my practice, we also add a corticosteroid in the form of hydrocortisone to the mixture. Again, there's not a whole lot of evidence for that. It's just sort of biologically plausible that it could be helpful. DMSO is sort of my second line, bladder treatment for bladder pain. DMSO is a byproduct of papermaking, and it works to treat bladder pain by acting as an anti-inflammatory, an analgesic, a smooth muscle relaxer, and an inhibitor of mast cells. In the United States, glycosaminoglycans are not available commercially. They can be compounded. The options include hyaluronic acid, chondroitin sulfate, and pentosin polysulfate sodium. The theory behind their benefit is that they target that gag layer of the urothelium and help to repair breaks in that layer that could potentially cause pain. Pelvic floor trigger point injections are a treatment that delivers a dose of local anesthetic, again, sometimes with a corticosteroid, to painful muscles inside the vagina. This is a skill that advanced practice nurses and physician assistants can learn and perform. I would encourage you to work with a provider who's comfortable and does these injections on a regular basis and find a patient who's willing to let you be there first. The goal of these injections is to temporarily numb the painful area, break the pain flare, and reset the nerves transmitting and receiving pain signals. In one small study that compared weekly trigger point injections with pelvic floor physical therapy, there was a similar reduction in pain scores in both groups. Trigger point injections have several potential benefits. They can help to confirm the diagnosis, eliminate pain temporarily, and potentially predict the benefit of botulinum toxin injections. Most patients can tolerate these injections in the office, although the thing you need to watch out for is bleeding. They can bleed a lot, so you just have to go into it being sure that you're prepared if they start to bleed a lot. It's important when you do these injections to target all of the tight and tender pelvic floor muscles, so if they're only having pain on the left, I still inject on the right to be sure that there's balance there, because what happens when you do a trigger point injection is you temporarily weaken and numb that muscle, but if all of the other muscles are not weakened and numbed, then they're going to sort of transfer the load to the other side, the other areas. You can pre-treat before trigger point injections with some lidocaine gel. Let it sit for five or ten minutes in their vagina. Pelvic floor botulinum toxin injections work by inducing a reversible flaccid paralysis of the innervated muscle and can decrease pain associated with spasm. Typically it works within two to five days and lasts between two and three months. There are several small studies showing benefit. Pain improves in between 58% and 83% of patients. The most common side effects are constipation, fecal incontinence, and urinary retention. These numbers seem high for the percentages. The dose of Botox used in this particular study was 300 units. In my practice, we typically start with 200 units, and as a result see a smaller risk of things like constipation and retention. The benefit of Botox, at least in one particular study, seemed to depend on the patient's past history with women who have had a sling most likely to benefit and people with chronic bowel disorders least likely. In my own practice, I feel like as long as I have discussed all of the risks and benefits, most women who get to this point in their treatment are willing to try it. It is possible after a series of injections, you've been doing it, you know, two or three injections for the patient to develop antibodies to Botox, and when that happens, the Botox becomes less beneficial and doesn't seem to last as long. So if you're finding that in your patients, that may be why there's not a good fix for that. So I mentioned the dose of pelvic floor Botox. We typically start with 200. You can go up to 460 units every 12 weeks. We very rarely get that high. In my practice, we sometimes combine the Botox with either a corticosteroid and or a local anesthetic. In some patients, we use a, the commercial name is Expirel. It's a long-lasting version of bupivacaine, so it tends to last for two days, three days even, so it can help with the flare that often happens after the Botox injections. Many of our patients will have this in the office, but not everybody can tolerate that. You, in the United States, almost always need prior approval to get this covered by insurance. It is not FDA approved to treat pelvic pain. We have a template, a letter that we use to help get it approved, and then sending along copies of abstracts showing benefit in women with pelvic pain, which I have found to be very helpful in getting it approved. The flares that happen after injection, typically quiet within a week or two, using a muscle relaxer during that period can be helpful. So opioids are a complicated topic for many reasons. I'm just trying to get my, sorry. Let me go back and then. All right. So I don't prescribe opioids to manage chronic pelvic pain unless all other options have been exhausted. The patient is seen by a pain management specialist. The patient has a signed opioid medication agreement, and she has random urine drug screens on a regular basis, or maybe an irregular basis. Managing patients on narcotics in a urogynecology practice is time consuming and not always in your or the patient's best interest. For example, do you have access to the gas chromatography talk screens, time for monthly visits, access to tools to assess functional improvements with opioids? In my area, however, there are very few pain management providers willing to treat pelvic pain. So I do have a handful of patients that I manage who meet the criteria that I mentioned. I also want to mention Tramadol here because Tramadol, when I became a nurse practitioner, I always thought of as sort of a safer alternative. Tramadol is, in fact, an opioid. It is now a controlled substance, and you should use it with the same care in prescribing that you do with any other opioid medication. It has a similar risk of addiction, abuse, diversion. It is not actually a safer alternative. It just has different side effects compared to, say, oxycodone or hydrocodone. So there will be a point in your patient's care that you're out of ideas for what to do next. You may have tried everything without much improvement. It's at this point that I suggest referral to someone outside of our specialty who can look at the case from a different perspective or can help your patient learn to cope with the pain that nobody else can figure out how to get under control. So my first line is often physiatry, a pain management specialist, an orthopedist, definitely a mental health provider if they're not already in touch with that type of provider. So since we have some time, I want to do a case study. So this is based not on a particular single patient but sort of on a combination of patients. So Adrienne is a 35-year-old who's had pelvic pain forever. She was previously managed by pain management, but she came to my practice because that person had too many patients on opioids in their practice, and so they were looking for someone else to prescribe opioids. She is hoping that you can help her with new options. She's currently taking methadone, 25 milligrams a day. She also has neck pain and knee pain. She's disabled, has two children, and is divorced. So Adrienne tries bladder installations. She tries gabapentin, muscle relaxers, pelvic floor Botox injections. She has a hysterectomy with a BSO, which helps for about five minutes. And then she tells you that she wants to get off of her methadone. So really at the end of all of this, we are currently in a place that is not good. She is not coping well with her pain, and I am not coping well with her. So I am doing my best to reach out for help both within my own practice and within other specialists in my area. The story is not over for Adrienne. So in summary, pain is a journey. It is a journey for you as a prescriber and someone who wants desperately to help your patients. Pain is also a journey for your patient, who when she comes to you may not know what she wants other than to not feel pain anymore. So I would encourage you to give her the time and space she needs to figure out what's going to work, and also for you to figure out what you're comfortable with, what your boundaries are, and what you can do to help her. Thank you very much. Adrienne is involved in research and is finalizing her Ph.D. investigating sexual function in women with overactive bladder. She's published numerous studies and provides advice to governmental bodies, including the National Health Service in England and CCGs throughout the U.K. She will be speaking on how women want to be approached about sexual function. Very long-winded, but yes, I'm Angie. Thank you very much. I've been busy. So welcome, everybody. Thank you very much for coming along to this session. I'm going to talk to you about female sexual function and discussing the topic. But it's not just about introducing the topic. I actually want to talk a bit more about the terminology that we're using and different things related to the female sexual cycle. Here are my disclosures. The reality is sexual practices are changing. In the real world, we know that people's identities and sexual behaviors are changing. There are differences between the sexes and between the age groups now. And if we actually look at the national attitudes and lifestyles, over the past 30 years, there have been significant changes in women's sexuality. We're having far more partners over the course of a lifetime. We're having less vaginal sex. We're having more same-sex relationships. And 30 years ago, they'd never even ask a woman if she masturbated. Now, a third of women admit to masturbating within the past month. And so these changes are affecting women. Women are becoming more and more open about things, differing views. As clinicians, we need to change our views in line with this. There's also misconceptions about age and sexuality. The general rule used to be that if you were retired, then you retired from life and sex and everything else. But that's actually not the case. And the older adults have far more time on their hands and lots of other things to help them along the way. So we now know that the frequency of sexual activity, although, yes, the younger you are, the more practice you're getting in, the older you are, there is still having sex regularly every month. It may only be once or twice a month. However, they go for quality rather than quantity. But the question is, we're using lots of different terms and what do they actually mean? So we talk about a woman's sexuality. What is sexuality? And the reality is that sexuality is not actually just her sexual activity, but it's about the woman's perception of her own self-image and the formation of relationships with other people. So you then say, well, what is sexual activity? And sexual activity is the typical question that we ask our patients. Are you sexually active? Well, what does that mean? If you look at the ICS and iUGA terminology for sexual function, the assessment of sexual activity status should be self-defined and not limited to women who engage in sexual intercourse. If you look at the definition of sexual function according to the Female Sexual Function Index, sexual activity can include caressing, foreplay, masturbation and vaginal intercourse. But vaginal intercourse is defined as penile penetration of the vagina and doesn't include any other forms of penetration. And sexual stimulation can include foreplay with a partner, self-stimulation or even sexual fantasy. But again, all of these have different timelines. Some questionnaires will say within the last four weeks. Some may say within the past six months. So you can have a woman who is in a relationship and has been married for many years but her partner has been away travelling in the last four weeks who would be classed as sexually inactive versus a woman who had a one-night stand for the first time in five years last weekend who is now sexually active. So we have to be really careful about how we clarify things. And when we're reading literature, how we interpret them. We also then need to think purely about what is sexual function. And sexual function is a physiological thing. There are two basic physiological principles. So you have the vasoconstriction of the genitals and the increased tension throughout the body. But for women, we actually need a little bit more. There's got to be a psychological aspect to it. So that desire has to come into it. And that is mediated through the dopamine and serotonin parts in the brain to bring that desire. And that desire then leads into the arousal phase which is where the parasympathetic nervous system kicks in. And it starts to engorge the clitoris. It causes increase of the arterial dilation around the vagina. And it allows for expansion of the inner two-thirds of the vagina to accommodate penetration of some variety. Through that plateau, you then come into the orgasm stage where you get a congestion in the outer third of the vagina. You get the elevator sling contraction. And you get the more physiological things with the increase in blood pressure and heart rate and respiratory rate before the resolution side of things. But without that psychological desire phase, then it's actually very difficult for women to have sexual function. And it's very much a key that in order to have that desire phase, you have to have good previous experiences. So we know that is triggered not only by sexual stimulus but by situational variables, relationship status, how happy you are, a previous good example. And so in order to have that sexual desire, there has to be that emotional and physical satisfaction. There has to be the emotional intimacy. And sexual stimuli is just one of those parts going into the female sexual cycle. The problem is, when you don't have that side of things, that sexual desire may be a problem because they have a low libido, they've got a negative body image, embarrassment, most commonly something to do with prolapse or incontinence in the women that I'm seeing in practice. That then leads to them becoming tense or anxiety, which leads to reduced lubrication, and that can then lead to dyspareunia and vaginismus. That then leads to sexual frustration, not only for the woman but potentially also for their partner. And that then leads to emotional and physical dissatisfaction and leads into a cycle of female sexual dysfunction. Now, we've already heard from the previous nursing track about the classification. So it used to be that female sexual dysfunction was classified as the various ways in which an individual was unable to participate in a sexual relationship, as she would wish. In 2013, it changed to a group of disorders characterized by a clinically significant disturbance in a person's ability to respond sexually or to experience pleasure. And it has to have been present for at least six months. It has to occur in 75% to 100% of sexual encounters. And it has to cause distress. If there isn't evidence that it causes distress, it is not a dysfunction. It also goes on to add that the sexual dysfunction is not better explained by a non-sexual mental disorder as a consequence of severe relationship disorders or of significant stresses, and it's not attributable to the effects of a substance, medication, or another medical condition. So for all of our women with some form of pelvic floor disorder, does that mean that we have to attribute it to their pelvic floor disorder rather than something else? And we often see many different problems that women will present with. So it may be a dyspareunial, now genital pelvic pain, a penetration disorder, a lack of desire, or a orgasmic dysfunction. And actually, for women coming into gynecology services, it's incredibly prevalent. We know 40% to 50% of women coming to gynecology clinics will report some form of sexual dysfunction. And actually, in a systematic review in women with incontinence, it can range up to 64%. But like I said, the true rate remains unknown, half the time because people aren't being asked, but also because of the differences in the definitions they're using. There are also differences between the sexes. So we know that actually women are far more likely to lack interest than men. They're far more likely to be unable to achieve an orgasm rather than having an orgasm too quickly. The only thing that is really nice to see is that men are just as anxious about performance as the women are. So what are the sorts of conditions that may cause it? What's the etiology behind it? So for a urogynecology service, we're typically going to see it in women due to hormonal reasons, whether that be due to pregnancy, due to lactation, or post-menopause. And because of physiological problems, not only just for stress and conflict, but because of the psychological components associated with incontinence and prolapse. There may also be underlying medical disorders that will add to it, and there may be many medications that do it. The oral contraceptive pill is one of the most reliable methods of contraception because it doesn't only stop them ovulating, but it also puts people off sex, so therefore they don't have a risk of pregnancy. So, in a Uragani practice there are many different times when we'll see women because of this. Postpartum. We know that many women will experience sexual dysfunction postpartum, and actually there's always questions about when's it normal to resume sex. Well, we know by six months postpartum, the majority of women have had sex, but actually over half of them are still having problems with their sexual function six months postdelivery, and that's not related to mode of delivery or lactation status, but very few of them report it. We know that women with pelvic floor disorders, particularly prolapse more so than incontinence, are more than likely to be sexually inactive because of their pelvic floor disorders. Traditionally, prolapse, for example, not only causes dyspareunia, but women report it causes an obstructive intercourse, or a vaginal laxity where they just have the loss of sensation and can't feel anything, or feel that their husbands no longer have that same sensation. If you look at women who are on the waiting list for surgery and incontinence, for many of them, only 17% of them felt positive about their sex lives. They felt that they had a negative image of their vagina, reduced sensation, so that led to decreased desire, reduced arousal, and then difficulty reaching an orgasm. And for those with incontinence, there was always then the fear of incontinence during orgasm or during penetration that affected the motivation and the willingness to be sexually active. When we look a bit more closely at urinary incontinence, it's actually the women with stress incontinence and detrusor overactivity are more likely to have sexual dysfunction than those normal controls, but the women with detrusor overactivity were more likely to refrain because of incontinence to typically orgasm, rather than women with stress incontinence. And you look at how people cope with this, and the impact on partners, and actually for many women with incontinence, their partners had poorer sexual function and had worse erections and were often unable to fully ejaculate. And when you look at what women actually did to cope with it, many just never told their partners about it. Many women interrupted sex prematurely to go to the toilet in between. Unfortunately, some unhelpful partners just suggested anal intercourse instead. You know, what are women doing? But the question is, why aren't we talking to them about it? Why don't we ask women? And actually, there's lots of different reasons why. Some people don't want to open up a can of worms, they don't have the time, the resources, they have a lack of training or the skillset, they're worried they're going to cause offence, their own personal discomfort, or a lack of awareness about certain issues. And when you look at the American obstetricians and gynaecologists, actually 25% of them reported expressing disapproval about patients' sexual practices. And the patients are never going to open up if you're disapproving of what they're doing. And although people may be asking if they're sexually active, actually very few are asking about whether they have pleasure from sex or their sexual orientation, or if they're satisfied with their sex lives. So how do women want to be approached about sexual activity? We know that there are lots of different ways of talking to people. But are we doing it right? So one of the things of my thesis was actually to run focus groups with women to understand how they wanted to be approached about sexual activity and sexual function, not only to look at the barriers that the women felt were there from a point of view with the clinician, but looking at ways to improve our service delivery to try and get women to open up and talk about things. And we found quite a few core themes. A lot of them were about barriers to discussion. So sexual inactivity was classed as a barrier to discussion. Just because someone is sexually inactive at that time doesn't mean they don't want to become active. The sex of the clinician. Women do want to talk to women. But interestingly, age is also a factor. And so they would rather, if the woman is young, generally they would rather speak to an older woman rather than a younger woman. And if it's only a young woman, they'd rather speak to an older man. And they feel that there's an issue with relation to experience in that sense. The timing of discussion came through. We also looked at some communication factors, how to introduce the discussion, and what women lie about when they talk to clinicians. So when we looked at sexual inactivity, it's not always a cut and dry answer. For many women, well, I don't want to be excluded from something just because I'm not sexually active at the time. But for many of them, actually, their concerns, well, I don't have a partner at the moment, but one of my concerns is embarrassment and anxiety about a new partner and the problems that it's sharing those problems that I have with them. And there's a huge anxiety on whether that's a reason for preventing people from forming new relationships. When we look at whether they wanted the presence of their partner in the room, many women come along with their partner, actually, only one of the women in the room didn't have a problem with discussing the sexual function in front of their partner. All of the rest of them wanted pre-warning to know to leave their partner outside before they came in and discussed the area. One woman, 75 years old, really, really wet. My husband hasn't got a clue I'm terribly incontinent because I avoid sex. It's awful, but I have to wear a pad 24-7, and it's just dripping wet. I avoid it. I get changed in the bathroom. I sleep on the side of the bed. And when he tries it, I put it down to the fact that he's got a defibrillator and I don't want him to die. The stories women will use to try and do it. Another woman simply just said he doesn't need to know everything that's going on down there. He needs to look at that and feel good. And so it was protecting her partner's views and thoughts about it by him not understanding that they had a problem. The most surprising thing is that actually all of the women felt that their assessment won't have been complete if they haven't been asked. It was being upset. It's like negating part of me as a woman. Do they think we're dead in the water and it doesn't matter? And even if they can't do anything about it, talk to me about it. And so by not asking, we're also doing our women a disservice. And when we looked at how to introduce the subject, some women felt if they put their feelings down on paper because they're too embarrassed to bring it up in the session, but if it's on paper and you broach the subject, you can ask more probing questions. And that questionnaires are a good way of gaining consent for people to start the conversations. But the problem is questionnaires don't always work because sometimes with something of personal sex, it doesn't always apply in the same ways. So tick boxes don't give everything. There needs to be a discussion as well. Sometimes I'm A and B, but I'm not that. So they want that opportunity to discuss things. But what they want is pre-warning. Women don't automatically presume when they come into a gynaecology service that they're going to be asked about sex because they're going because of prolapse or incontinence. So they want pre-warning that links them. But not only so they know who to bring in, but so that they have the opportunity to think about what's going to happen and not put it in a letter so that they're mentally prepared to talk about it. So how do we ask them? And yesterday with Brooke, she gave some conversation starters. Again, I'm going to ask you a few questions about your sexual history. I ask all my questions at least once a year because they're important to your overall health. Everything you tell me is confidential. Do you have any questions before we start? Some sort of introduction like that. Or many women with prolapse and incontinence report it can cause problems with your relationships. Is this something you have noticed or would like to discuss? Simple things like that. But a lot of the time, questionnaires can be really useful. They're generic, they can be filled out in private, they're easier for the less experienced clinicians and for many of them are validated. But there's so many out there, what do you use? So when you look at a generic sexual function questionnaire, there's lots. So what do you go for? The brief index of sexual function of women is really useful as an opening conversation starter. It has four questions. Are you satisfied with your sexual function? How long have you been dissatisfied? The problem is one of these. Which one bothers you the most and would you like to talk about it with your healthcare provider? It gives you the consent, the opening. It starts the women thinking and it helps you to start directing your conversation. And we're now sending this out with our clinic letters beforehand, so when they come in with their bladder diary and quality of life questionnaire, this is also with it. If you want one that is the most used in research and the only one that sets a definition of sexual activity, then you need to go for the FSFI. If you want one for partners, so if the partner comes with the patient and they want to talk about it, there is one, the Golombak-Rast Inventory of Sexual Satisfaction is the questionnaire that is for partners and couples to fill out about their sexual functioning as a couple. So if you want to include the husband or the partner, then that's what you need to use. When it comes to condition-specific questionnaires, again, there are quite a lot when it comes to incontinence and prolapse. The International Consultation on Incontinence is the group of modulated questionnaires that is developed to try and bring together all research and outcomes. And their sexual function one, again, is a straightforward four-question one that is readily available and can be used throughout. The PISCU, we heard Dr. Rogers in her keynote lecture yesterday talk about the developments of the PISCU all the way through. The PISCU-IR, the iUGA revised version, is actually the only questionnaire out there that also assesses women who are not sexually active. So it can assess if they're sexually active, why they're not, and if it's bothersome to them. So if you want to be able to apply for both of your patients, that's the one to use. So I've shown you that female sexual dysfunction is very, very common and can have a significant effect on the quality of life. But the communication from us as a healthcare professional is key, and we really have to remember that no one approach is right for everybody, but it's a continuum. And so regular reassessment at regular intervals is vital as women look for our services. Thank you. So how many of you are familiar with MBSR, mindfulness-based stress reduction? A few of you. Well of those few of you, how many of you are certified or have led a class on MBSR? No? And any of you participated in an MBSR class? Got a couple. Okay, well this is great. I feel like I'm going to educate. Okay. There we go. So MBSR is a structured mindfulness program that is utilized in research, but also used in the community. And it was developed by Jon Kabat-Zinn in 1979. It's an eight-week skills-based course, teaches mindfulness skills, and also physical and emotional health. And when you look at some of the reviews of the literature, they really feel that it has a positive potential for being an excellent healthcare intervention. MBSR has been researched and is also used clinically in many chronic diseases such as cancer, depression, anxiety, stress, recovery from addictions, and it's also used as an adjunct in chronic pain, which is what we're going to kind of focus on. Because there's not really very many studies done for pelvic pain. There have been multiple studies to date using MBSR to manage irritable bowel symptoms. And we all know that irritable bowel can also cause chronic pelvic pain. So we can utilize some of that research. The big landmark NIH study was completed by Gay Lord from the University of North Carolina Chapel Hill. And it was completed in 2011, and it found that MBSR over the control group reduced symptoms by 26.4 versus 6.2 for the control. And after they were tested three months later, they found that the symptoms were reduced even more to 38.2, showing that as women practiced these skills, they got even better pain relief. So these are some of the skills and activities that are taught in the MBSR program. Sounds kind of funny. Mindful eating of a raisin. And they actually spend like 15 minutes on this. No joke. Body scan exercise, which we're all familiar with. Meditation using the breath. Gentle, mindful yoga. It's more stretching. And they're also taught that body sensations are simply sensations, and they shouldn't be judged. So it helps reduce catastrophizing. MBSR is also targeted to improve emotional intelligence, which involves the awareness of the self to be able to solve a problem and also to be able to help others solve their problems. And emotional resilience is the ability to adapt to a stressful situation. And choiceless awareness, which sounds kind of funny, but it is the complete freedom to choose without any external forces. So why think about MBSR for chronic pelvic pain? Well, we do know that chronic pelvic pain has been associated with anxiety and depression. It is a chronic condition that can be viewed by the patient as very stressful. And mindfulness therapies can reduce anxiety, depression, and stress. So using a variety of search engines available at my university, I found about 128 articles. And luckily, two papers had already completed reviews. So that made things pretty easy. So of those 128 articles, I found only one. And luckily, two papers had already completed reviews. So that made things pretty easy. So of those, 32 were pertinent. And of those, 10 papers were reviewed. Three papers are going to be discussed, two review articles, and one study. So the first one was a review that was done by a nurse practitioner, Sharon Prassman. So the first one was a review that was done by a nurse practitioner, Sharon Prassman. And what she found was that MBSR is an effective treatment for reducing stress and anxiety for patients and health professionals. And MBSR is an effective treatment for reducing stress and anxiety for patients and health care providers. Also therapeutic for health care providers, enhancing their interactions with patients. And nurse practitioners can safely and effectively use this intervention in a variety of patient populations. The next review article was done by Ball. And he happened to be a gynecologist. And I think that he was kind of thinking in the same terms that I was. Can we use data on just general pain and infer that to chronic pelvic pain? So some of the key points were that chronic pain has a significant impact on partner's quality of life and on a patient's quality of life and is often resistant to surgical and medical treatment. Psychological and somatic causes require a multidisciplinary approach. Patient self-management is now recognized as a tool for empowering patients to cope better with chronic condition. And mindfulness can help do that. Mindfulness meditation in chronic pain shows its most prominent effect on psychological aspects of living with chronic pain by improving associated depression and quality of life. So he made the conclusion that chronic pain and chronic pelvic pain are similar in their psychogenesis. So research on chronic pain can be utilized to understand if treatment might be effective for pelvic pain. And then I wanted to just introduce you to this study. And this study was actually done by one of our own AUGS members. They actually wanted to see if it would help with interstitial cystitis and bladder pain. This study was done by Gregory Cantor and also his other participants. And it was in the International Urogynecology Journal in 2016. And he randomized 20 patients. Eleven were in usual care and nine to MBSR. And they found that the global response score increased from 87.5 percent versus 36.4 to the control group. The pain score improved. The visual analog score did not have any kind of a change. But 86 percent of those in the MBSR group felt that they were empowered. And there's that word again, empowered, to control their symptoms. So in conclusion, or the conclusion that he came up with, was that this study provides some evidence to support the role of MBSR as a novel complementary treatment for interstitial cystitis bladder pain syndrome in patients undergoing concomitant first and second line therapies. So I would like for you to consider mindfulness intervention in your toolbox of treatment options for your patients with chronic pelvic pain. And I do have some handouts available. It's on the web, so it's like on the app. It will help you find out about more information on MBSR, how to find mindfulness programs in your area. There are ones that are certified that you can do research studies with, so that's a very structured program. And it can also tell you how to become a certified MBSR instructor. Thank you. And we're going to open this up to questions, and we are right on time. So we have 15 minutes for questions. Thank you very much. Barry Bergmans, Maastricht, the Netherlands. I saw yesterday a very nice presentation on medication, and I saw one today also. What I would like to see as a clinician is now having this whole momentum of medication, mindfulness, physical therapy, and I would be a medical doctor. I would say also as a physical therapist, actually. Now, how do you proceed? What is now the patient selection? What kind of medication I would use for what kind of patient? The assessment to choose for a certain medication or for mindfulness or for a combination, I think that would be very helpful if we have algorithms related to this and this within iUGA. Oaks. Yeah, so the choice of sort of what to do first, I think, depends on the patient preference, on her ability to pay or have time for therapies like physical therapy, and also her goals. So if she's terribly bothered by this and is not able to work currently because it's so bad, then I sort of throw everything at her and do it all. For somebody who's trying to work three jobs and doesn't currently have the time or the money for physical therapy, because in the U.S. there's often a copay associated with it, there may be a travel issue that she can't get there, she doesn't have a car. So in that case, I would probably stick with things that cost less, so medication and mindfulness. There's also people in between where they don't want to use a medication first, but they're willing to do physical therapy. I offer all options to all patients, and then they and I sort of work together to figure out what's the best fit. But I could imagine that the physical therapist would say exactly the opposite and say, yes, but with all the side effects that medications have and all the things that are related to this and physical therapy has no side effects, so it leaves all the options open, so they feel better and things like that. So patient preference, I can imagine. But as clinicians, I think it's important that we have an idea, physically, psychologically, with medication, how to proceed in this. And it cannot be only the patient preference, in my view, but maybe. I completely agree, and I'm actually the number one referrer of physical therapists in my entire state, so I'm very pro-PT. I wish all of my patients would do it first, last, and always. Unfortunately, that's just not reality in my patients. Yeah, go ahead, please. I think one of the things when I'm counseling the women, particularly with regards to whether it be pain or even incontinence or prolapse, it's about getting them to understand that it's about a package of care. No one thing is going to make them better. There are multiple different things that have led to where they are now, so that they need a multiple, multi-modality treatment in order to rectify all aspects of that. So I think it's the counseling that we give the women when we're talking about the treatment options to work through. Actually, there is a role for everybody, and there's going to be overlap between what we do, but there are certain aspects that, as a PT, that I can't manage as a nurse, that as a nurse can't be managed, that as a clinician, that as a drug, something else can do, that we need the psychologists for, the cognitive behavioral therapy, the mindfulness. So I think it's more about advising women that they need a package and having them availability to all options and giving them working through all the different aspects. I have one question for the physical therapist. Is it a problem if a patient is on pain medications? Do you find that that interferes? Because many patients come to us on those pain medications, and I don't think that we're really going to get them to go off of those pain medications necessarily, so it's a quandary. Hi. Beth Shelley, physical therapist. It is not a problem to have a person on pain medicine when they enter into physical therapy, and in some cases that is a goal that we work towards, is to decrease the dosage or the frequency or maybe even change to something that's not an opioid. So that's really a useful thing. Can I ask a question? Absolutely. All right. So I am very aware of the mindfulness approach, and I use that very much in my practice. I am a sole practitioner. I see one patient at a time for 45 minutes. I have nice, quiet music. We have an office dog. I mean, you know, we've kind of got the thing going on. But what I'm not quite sure, and I'm sure that there is some variety, do we have any research guidance as to how many minutes they have to practice, how often in a week, how long does it take to get good at this? I know for biofeedback I find my best success if I can see them one time a week for three weeks in a row and then I can kind of let them go. And there's always a variety because the older patient takes a little longer and maybe even a younger patient is less. So I just wonder if there's any such guidance. I feel not able to structure what I ask them to practice. Are you talking about mindfulness? Yes. Well, I, you know, mindfulness in and of itself is one option. I'm talking mostly about an actual program. The program is an eight-week program, and they can do that online. There are some free ones they can be a part of. There are some in-person ones, but those are usually expensive. There are many of them now in the adult education places where, you know, like a school district or a university, continuing ed. I'm in the middle of Iowa. Right. So, you know, an online program is an option. So, you know, pick up, you know, get the handout, and it will give you some guidance. We, you know, just doing a mindfulness-type thing is, just like meditation, is going to be helpful for anxiety. You know, I think that's been shown. But how much they need to do, I think that would be up to the patient and how much they feel they're getting a benefit. There's a lot of information on John Patterson's website, and he discusses this. And there's quite a few YouTube videos about him discussing some of these issues. You know, what I found from reading a lot of that is to be flexible. If trying to be mindful causes your patient anxiety, which it does for mine, I can't do that. How do you not think of this? Well, that's kind of part of the problem. You know, the first time you go out to go run, you don't decide, all right, I'm going to run a marathon. Right? You have to practice it to get used to it. If it's causing you anxiety, then reduce the amount that you're doing. Or, you know, part of it is practice. You know, use those analogies. But he talks a lot about that and dosing and some of the concerns with patients. Well, one of the things that I liked about the MBSR is they bring up lots of ways to be mindful. And you get to pick the one that fits for you. So you can do mindful eating. So every time you sit down to eat, you really eat mindfully. Or when you wash your dishes or clean your house, you just think about what you're doing. That's what's being mindful. Taking a walk, you notice the beautiful sky, you notice the trees, you notice the flowers, those kinds of things. So you're really focusing on one thing. And they let you decide what you want to do. If you want to do yoga, that is a mindful activity. Just to add to the previous comment, not only is it okay for them to be on medication, oftentimes it can be beneficial. So the big thing to realize is that some patients who are so upregulated, so we talked about the centralization in the previous sessions, sometimes their bodies are such that it's hard for them to do the PT that we want to do. So it can be beneficial. And then since I don't prescribe, often we'll say to my patient, we might get to a point where they can reduce what they're doing. So I might send them back to the referring practitioner and say, well, we might be able to reduce. We can work together and we can partner. So I think that's the important part of that is the partnership that we can do. It's not one is exclusively doing one kind of treatment and another is doing the other. So if we have a realization of what we do as practitioners separately, but then work with each other, that's how we benefit our patients. So I felt it was worthwhile to add on to that, that it's not only okay, it can be very good. Just one comment more. It's very important from our assessment that we are going to try to map what is happening with that specific patient so that we get a relation with that patient about what is so stressful for her. What is the anxiety? What is the nature of her problem? And what is the extent of this problem, the severity? And what is then the possibility from the different treatment options? Discussing that even in our team, our pain team, our multimodal team, or whatever you want to call it. But it starts for me at the assessment, the counseling of the patient, to get the feeling where this patient has the problem and not just saying we can do mindfulness or we can give medication or we can do physical therapy. I think when you get to know the patient in that first two sessions, like we do with all the patients, we get an idea about it and how the expectations that this woman has can be fulfilled and how this fits with our expectations. I think that's a major thing. And for this, we can create algorithms in this way and try to see how many of those patients can fit into the categories, into our algorithms. I think it should start there and not only with the different treatment options. I think the challenge with that is I completely agree that getting to know the patient is fundamental, but the challenge is there are going to be certain things that we are never going to be able to influence. We can't make their husband help more at home. We can't change the fact that they feel they're being bullied by a boss at work or that they can't cope with work. There are certain life stressors that although we can be there for them to talk about and open up about, we can't necessarily influence. So by giving them ways and coping mechanisms and ways in which that they can try and manage things, I think that's what we need to look at. So yes, we need to find out about it, but we need to know that actually there's going to be lots that we just need to try and help them, give them skills to manage rather than actually treating in those circumstances as well. Any other questions? Comments? We have one more. She's coming up to the microphone. My name is Corey Hewitt, and I'm a physical therapist in Richmond, Virginia. And I find that for sensuality, sexuality, often I have to create a picture for them. And there's a great poem, Dance Me to the End of Love. It is into a book as well, and it has beautiful pictures of why someone wants to become intimate and nurture and cherish another person. And so sometimes if we can look at that from the different five senses, it helps to create the mindful picture that we're working towards. It's a nice way to end this. Any other questions?
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Leah Moynihan, RNC, MSN, Angie Rantell, BSc (Hons), PG Cert, RN, NMP, Jan Baker, MS, APRN
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