Follow Us On
Contact Us
info@ampainsoc.org847.375.4715
American Pain Society
4700 W Lake Ave
Glenview, IL 60025
Costantino Benedetti, MD, Department Editor
Cindy, a 36-year-old woman who has suffered with pelvic pain for 10 years (see Elliott, 1996, p. 4), and her husband were initially seen for a consultation. Much of this meeting involved discussion of the husband's negative and distancing reaction to Cindy's chronic pelvic pain. He was angry, believing that the pelvic pain was a ploy to avoid sex, as no diagnostic or treatment approach had been fruitful. We discussed the common medical and psychological characteristics of patients presenting with CPP. We also discussed the psychophysiology of emotional states and how they affect the nerves and muscles. We explored the couple's sexual and relationship problems. The husband's feeling cheated regarding the sexual relationship was discussed. Consultation and questionnaire information revealed no history of sexual abuse or other significant historical factors that might have contributed to the development or exacerbation of the pain.
The pelvic exam by Dr. McDonald confirmed the diagnosis of secondary vaginismus. When I explained the treatment for this problem and the very high success rate, both Cindy and her husband were relieved.
After the consultation, we proceeded to the MMPI-2 to evaluate psychological status changes caused by the pelvic pain and concomitant relationship and social problems. Results were valid and indicated elevations on 1, 3, 7, and 2. The patient was experiencing moderate levels of depression, exacerbated by a strong tendency to feel guilty and to ruminate. She had become hypersensitive to her body and was acutely aware of any changes in her pain or in her pelvic, bowel, or urinary system.
The results of the pelvic exam and medical work-up revealed a grouping of at least 5 tender areas or trigger points along her ilioinguinal distribution and scar line from a previous surgery. She was treated with local anesthetic injections on the first visit. The patient reported immediate pain relief. I talked with the couple after the medical treatment and reinforced the impact of stress and emotions on the pain and muscles. I recommended that they postpone sexual activity until further notice. We wanted to get the pelvic pain under more control before tackling the vagi-nismus. Negative sexual experiences would not only exacerbate the ilioinguinal recovery but also would make the vaginismus more entrenched. We recommended that the patient start on Zoloft (25 mg progressing to 75 mg) due to the depression symptoms and, more importantly, the extensive ruminations.
The patient returned to the clinic a week later. She reported 5 hours of pain relief, followed by a severe return of pain worse than before treatment for 3 days. She began to catastrophize regarding the efficacy of this approach. We were able to allay her fears by discussing the common progression of local anesthetic injections (which she had not heard in the previous session). She and her husband received information on skills for managing “predicting and prejudicing” (see the section in this article on cognitive-behavioral therapy for details).
The couple were also given the initial skills for more adaptive communication. The husband was resistant, because the homework involved feelings. He did not believe that he needed to change and only wanted her to stop having pain. The husband's sexual advances during the week were discussed in light of the previous session's proscription. He was again made aware of the negative effect on treatment efficacy and of the further delay in resuming sex that might result if advances were not curbed.
Medical treatment was increasingly successful in easing the effect of the pelvic trigger points. Cindy began to have longer and longer periods of reduced, if not absent, pain. She also experienced decreasing radiation of pain symptoms. Her husband became more supportive as treatment became more successful, and Cindy became more available to nonpenetration sexual advances and involvement. He was increasingly able to avoid making proscribed sexual advances. We were able to set up a communication system that allowed her to “check-in” with her sexual interest, instead of immediately saying “No” as a reflexive defense. He was able to listen to her response and not accuse her of faking disinterest.
At the fifth session of medical treatment and after a significant, consistent reduction in pain symptoms, we decided to begin vaginismus treatment (see the section on sex therapy for details). Cindy responded quickly to the dilators, moving from the #11/2 to the #4 in under 3 weeks. She noticed a reduction in her residual pelvic pain after starting Kegel exercises and as the vaginismus dissipated. The husband became even more of an ally as he saw the success of this process. Transition to the penis and intercourse was made without difficulty.
At our last follow-up session, Cindy reported limited pain (1/10), with an occasional flare-up (5/10). She could now attribute flares to an increase in unmanaged stress or feeling. She was able to use treatment skills to prevent catastrophizing, which would have in the past escalated the pain due to increased muscle tension. The couple reported returning to an enjoyable, satisfying sexual relationship. Intercourse was no longer physically or psychologically painful for either of them. She was also able to return to social interaction with friends. With structured help, she slowly resumed the physical activities that she enjoyed. She reported an enhanced quality of life that also helped her manage her pain and residual predictions of future pain.
