"Sexual health and function for women with pelvic floor disorders" presented at Urofair Nursing Symposium at Grand Hyatt Hotel, on Sat 14 July 2018 About Dr. Martha Tara Lee Dr. Martha Tara Lee is Relationship Counselor and Clinical Sexologist of Eros Coaching. She is a certified sexuality educator with AASECT (American Association of Sexuality Educators, Counselors, and Therapists) as well as certified sexologist with ACS (American College of Sexologists). Martha holds a Doctorate in Human Sexuality, Masters in Counseling, Certificates in Sex Therapy, Practical Counselling and Life Coaching, as well as two other degrees. She was recognised as one of ‘Top 50 Inspiring Women under 40′ by Her World Singapore in July 2010 and ‘Top 100 Inspiring Women by CozyCot Singapore in March 2011. Subscribe so you don't miss a thing! http://www.ErosCoaching.com Social media links https://www.facebook.com/eroscoaching https://twitter.com/drmarthalee https://www.linkedin.com/in/leemartha Programs Ready Get Sex Go http://www.eroscoaching.com/rgsg Sex Jumpstart http://www.eroscoaching.com/sex-jumpstart Tongue Twisters http://www.eroscoaching.com/tongue-twisters Sex Possible http://www.eroscoaching.com/sex-possible Clean and Clear http://www.eroscoaching.com/clean-and-clear Books Orgasmic Yoga: Masturbation, Meditation and Everything In-Between https://www.amazon.com/Orgasmic-Yoga-Masturbation-Meditation-Between/dp/1515118193 Love, Sex and Everything In Between https://www.amazon.com/Love-Sex-Everything-Between-Martha/dp/9814484199/ref=reg_hu-rd_add_1_dp From Princess to Queen http://www.eroscoaching.com/queen

1. Sexual Health and
Function for
Women with Pelvic
Floor Disorders
Urofair 2018
Jul 12 - 14,2018
Grand Hyatt Singapore

2. Dr. Martha Lee
Relationship Counselor & Clinical Sexologist
• Doctorate in Human Sexuality
• Masters in Counselling
• Masters in Public Policy and Mgmt
• Bachelor of Arts (Comm)
• Cert in Sex Therapy
• Cert in Practical Counselling
• Cert in Life Coaching

3. Agenda
1. Types of Pelvic Floor Disorders
2. Statistic related to Pelvic Floor
Disorders
3. Pelvic Floor Dysfunction &
Women’s Sexual Concerns
4. DSM-5 Female Sexual
Dysfunctions
5. Assessment Tools

4. Types of Pelvic Floor Disorders
1. Urinary incontinence, or
lack of bladder control
2. Fecal incontinence, or
lack of bowel control
3. Pelvic organ prolapse,
a condition in which the
uterus, bladder and
bowel may "drop" onto
the vagina and cause a
bulge through the vaginal
canal

5. Radical Hysterectomy
Damage to the innervation of the pelvic floor musculature
Shortness of the vagina
Decrease lubrication
Oophorectomy Dyspareunia
Decrease in desire???
Pelvic Radiotheraphy
Chemotherapy
Vulvectomy
Decrease lubrication
Dyspareunia
Fibrosis and stenosis
Tiredness
Nausea, vomiting
Depression
Anatomic anomalies

6. Pelvic Prolapse
• Much of the research suggests
that urinary or fecal incontinence,
rather than the prolapse, plays a
significant role with respect to
sexual dysfunction.
• As fear of incontinence may
adversely affect women’s
sexuality.. So, emptying the
bladder before intercourse,
performing Kegel exercises, and
anticipating incontinence during
intercourse can help alleviate
some of the associated stress.

7. Infographic: What's Going on Down There? | The Oregon Clinic. (2017). Retrieved from
https://www.oregonclinic.com/blog/infographic-whats-going-down-there

8. Infographic: What's Going on Down There? | The Oregon Clinic. (2017). Retrieved from
https://www.oregonclinic.com/blog/infographic-whats-going-down-there

9. Infographic: What's Going on Down There? | The Oregon Clinic. (2017). Retrieved from
https://www.oregonclinic.com/blog/infographic-whats-going-down-there

10. Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual Dysfunction in the United States. JAMA, 281(6), 537.
doi:10.1001/jama.281.6.537
“Sexual dysfunction is an important public health
concern, and emotional problems likely contribute
to the experience of these problems.”

11. Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual Dysfunction in the United States. JAMA, 281(6), 537.
doi:10.1001/jama.281.6.537
• A national probability sample of 1749 women and 1410 men aged 18 to
59 years at the time of the survey.
• Sexual dysfunction is more prevalent for women (43%) than men (31%)
and is associated with various demographic characteristics, including
age and educational attainment.
• Women of different racial groups demonstrate different patterns of
sexual dysfunction.
• Differences among men are not as marked but generally consistent
with women.
• Experience of sexual dysfunction is more likely among women and men
with poor physical and emotional health.
• Moreover, sexual dysfunction is highly associated with negative
experiences in sexual relationships and overall wellbeing.

12. Urinary incontinence
and/or pelvic organ
prolapse affects nearly a
third of premenopausal
women and as many as
45% of postmenopausal
women.
An evaluation of 103
female patients of an
incontinence clinic found
that 46% admitted
urinary symptoms
affected their sexual life.
J. Berman MD. (n.d.). Berman Sexual Health. Retrieved from
http://www.bermansexualhealth.com/index.php/sexual-health/sexual-
pain/pelvic-floor/20-sexual-function-in-women-with-pelvic-floor-
disorders?showall=1&limitstart=

13. A retrospective review of
100 surgeries including
anterior and posterior
repair found that,
postoperatively, 61% of
patients enjoyed “regular”
intercourse, and 30% had
stopped having sex.
Aparunea and
dysparunea were
common after prolapse
surgery and up to 50%
of women ceased
intercourse after
surgery.
J. Berman MD. (n.d.). Berman Sexual Health. Retrieved from
http://www.bermansexualhealth.com/index.php/sexual-health/sexual-
pain/pelvic-floor/20-sexual-function-in-women-with-pelvic-floor-
disorders?showall=1&limitstart=

14. • Hypoactive Sexual Desire
Disorder
• Sexual Arousal Disorder
• Sexual Aversion Disorder
• Female Orgasm Disorder
• Sexual Pain Disorder
 Dyspareunia
 Vaginismus
Female sexual
interest/ arousal
disorder
Genito-pelvic
pain/penetration
disorder
DSM-5 Female Sexual Dysfunctions

15. Frigidity
Inhibited Sexual Desire
Disorder - DSM-3
Hypoactive sexual desire
disorder - DSM-3-R
Female sexual interest/
arousal disorder - DSM-5
A Name is Just a Name?

16. More on DSM-5
• Sexual dysfunctions (except substance-/medication-
induced sexual dysfunction) now
– Require a duration of approximately 6 months
– More exact severity criteria
• Subtypes for all disorders include only
– “Lifelong vs. acquired” and
– “Generalized vs. situational”
• Two subtypes were deleted:
– “Sexual dysfunction due to general medical condition”
and
– “Due to psychological versus combined factors”

17. Sexual Response

18. Causes of Female Sexual Dysfunction
Desire:
Psychological factors
Emotional or physical distress
Menopause, decreased hormone levels
Medications (including antidepressants and anxiolytics, antihypertensive agents)
Arousal
Psychological factors
Trauma or surgery
Medication (including antidepressants and anxiolytics, antihypertensive agents)
Orgasm
Emotional or sexual abuse
Decreased hormone levels
Trauma or surgery
Medications (including amphetamines, antipsychotics, antidepressants and
anxiolytics, antihypertensive agents)
Sexual Pain
Psychological factors
Infection
Endometriosis
Medications that cause decreased vaginal lubrication

19. Pelvic Physical Therapy | EMH Physical Therapy. (2018) Retrieved from http://emhphysicaltherapy.com/category/pelvic-
physical-therapy/

20. Sexual dysfunction and chronic pain: the role of psychological
variables and impact on quality of life
• Complete psychometric assessment data were available for 151 patients,
74 males (49%) and 77 females (51%) ranging in age from 22 to 69 years
(mean 44).
• A majority had pain affecting the musculoskeletal system and connective
tissues (90%), predominantly in the lower back, lumbar spine, sacrum or
coccyx regions, for a mean of 10 years (range 6 months to 41 years), and
had not undergone any surgery for their pain (58%).
• Most patients were married (57%) and had no health insurance (70%).
• Many took opioid analgesics (74.8%), antidepressants (46%) and non-
steroidal anti-inflammatory agents (33%).
• The most commonly used antidepressants were tricyclics (53%) and
selective serotonin reuptake inhibitors (34%).
Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008

21. Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008

22. Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008

23. Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008
“Sexual dysfunction was common,
and using stepwise multiple
regression analysis was found to be
more frequently reported by those
with greater disability and
depression, shorter pain duration,
and infrequent use of coping self-
statements.”

24. Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008

25. Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008

26. Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008

27. Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of
psychological variables and impact on quality of life. European Journal of Pain, 9(6), 643-643.
doi:10.1016/j.ejpain.2004.12.008

28. “Although sexual dysfunction was again
commonly reported, subjects perceived
it had less importance in quality of life
than did other factors. The combined
results support the previously proposed
notion of adaptation to the impact of
chronic illness on sexual function. In
conclusion, sexual dysfunction is
common in this population and is
predicted by psychological factors and
pain duration. However, other issues
impact more significantly on quality of
life. Therapeutic approaches to
sexual dysfunction in these patients
might best be focused on improving
psychological factors, particularly
depression and coping skills.”
Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of psychological variables and
impact on quality of life. European Journal of Pain, 9(6), 643-643. doi:10.1016/j.ejpain.2004.12.008

29. • Frequency
• Duration
• Intensity
Kegel Exercise

30. I’ve tried doing
“Kegels” on my own.
I don’t know if I’m
doing them right and
I usually lose
interest. How can I
stick to a regular
program?
QuestionQuestion

31. There are home pelvic muscle
training systems, such as
PeriCoach, a device +
smartphone app that are easy
to use and allow women to see
real-time biofeedback on their
phone while doing kegel
exercises. PeriCoach tracks
your progress, sends
reminders and helps you
contract the muscles that
matter.
Answer
www.pericoach.com/

32. Ben-Wa Balls Jade Stone

33. Key Points
• There is increasing acknowledgement of the strong link between
normal pelvic floor function and healthy female sexual function.
• Elucidating process that lead to specific pelvic floor and sexual
dysfunctions will potentially provide a path for timely diagnosis and
new, more effective treatment modalities, which will ultimately lead to
better quality of the life and functionality.
• There is a close association between healthy pelvic floor function and
female sexuality. Disorders in the former are closely associated with
female sexual dysfunction.
• Pelvic floor muscle strengthening plays an important role in the
maintenance of healthy pelvic floor function and in improvement of
sexuality.
Jani, S. Female Sexuality and Pelvic Floor. Retrieved from https://www.slideshare.net/ShashwatJani/female-sexuality-pelvic-floor-
by-dr-shashwat-jani

34. Sex History Questions
Pain
1. What is the pain score (out of 10) on a good to
average day and a bad day? (10 is the worst pain
ever)
2. What is the nature of the pain? Does it radiate?
Are there any aggravating or relieving factors?
3. Do you have any other pain, such as back pain?
4. Is the pain relieved by standing or lying flat
(pudendal neuralgia)?
5. If sexual intercourse is painful is the discomfort at
the entrance to the vagina or deep inside?
Nunns, D., & Murphy, R. (2012). Assessment and management of vulval pain. BMJ, 344(mar28 1), e1723-e1723.
doi:10.1136/bmj.e1723

35. Functioning
1. What do you miss as a result of the pain?
2. How does the pain affect your life?
Sexual functioning (if appropriate)
1. Is vaginismus (involuntary tightening of the pelvic floor muscles
on penetration) a problem? Do you have difficulties having
sexual intercourse (vaginismus, dyspareunia)?
2. How do you feel about sex (avoidance, loss of libido)
3. Is a lack of lubrication (poor arousal) a problem?
Sex History Questions
Nunns, D., & Murphy, R. (2012). Assessment and management of vulval pain. BMJ, 344(mar28 1), e1723-e1723.
doi:10.1136/bmj.e1723

36. Previous failed treatments
1. What was adherence like?
2. What were the side effects?
3. How long was the treatment used for?
Other
1. Do you have any past or current gynaecological problems?
2. Do you have any skin problems such as eczema or psoriasis?
3. Is there a relevant medical or surgical history, such as thyroid
dysfunction?
Sex History Questions
Nunns, D., & Murphy, R. (2012). Assessment and management of vulval pain. BMJ, 344(mar28 1), e1723-e1723.
doi:10.1136/bmj.e1723

37. Assessment Questionnaires
1. PISQ-12 - New Patient Pelvic Organ Prolapse/ Urinary
Incontinence Sexual Function Questionnaire. Link:
https://goo.gl/DZ3s5N
2. PISQ-31 - To Measure Sexual Function in Women with
Urinary Incontinence or Pelvic Organ Prolapse. Link:
https://goo.gl/2VrkRC
3. SF-12 - The Short Form-12 Health Survey consists of two
summary measures, physical component scores (PCS-
12) and mental component scores (MCS-12) [23]. It is the
short-form of the SF-36 measure.
https://www.hss.edu/physician-files/huang/SF12-RCH.pdf

38. The PISQ-12 is a short-form of the PISQ-31 measure [21]. It is a
condition-specific measure that evaluates sexual function in
heterosexual women who suffer from UI and/or POP. The PISQ-12
measures three domains: behavioral-emotive (items 1 – 4),
physical (items 5 – 9) and partner-related (items 10 – 12).
It is a self-administered questionnaire, and responses are graded
on a five-point Likert scale ranging from 0 (always) to 4 (never).
Items 1 – 4 are reversely scored and a total of 48 is the maximum
score [22]; higher scores indicate better sexual function. Up to two
missing responses are accepted. The total score sum with missing
val is calculated by multiplying the number of items by the mean of
the responses to the items reported by that person. The PISQ-12
is reported as a single sexual function score. It does not report the
separate domains [7].

39. The Female Pelvic Health
Center
New Patient Pelvic Organ Prolapse/Urinary Incontinence
Sexual Function Questionnaire
Instructions: Following are a list of questions about you and your partner’s sex
life. All information is strictly confidential. Your confidential answers will be used
only to help doctors understand what is important to patients about their sex
lives. Please check the box that best answers the question for you. While
answerin the questions, consider your sexuality over the past six months. Thank
you for your help.

40. The Female Pelvic Health Center
Sexually not active (Please do not fill out the rest of the form)
1. How frequently do you feel sexual desire? This feeling may include wanting to have sex,
planning to have sex feeling frustrated due to lack of sex, etc.
Daily Weekly Monthly Less than Once a month Never
2. Do you climax (have an orgasm) when having sexual intercourse with your partner?
Always Usually Sometimes Seldom Never
3. Do you feel sexually excited (turned on) when having sexual activity with your partner?
Always Usually Sometimes Seldom Never
4. How satisfied are you with the variety of sexual activities in your current sex life?
Always Usually Sometimes Seldom Never
5. Do you feel pain during sexual intercourse?
Always Usually Sometimes Seldom Never
6. Are you incontinent of urine (leak urine) with sexual activity?
Always Usually Sometimes Seldom Never
New Patient Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire. Retrived from
fphcenter.com/sites/default/files/Sexual%20Function%20questionnaire%206.1.12.pdf

41. 7. Does fear of incontinence (either stool or urine) restrict your sexual activity?
Always Usually Sometimes Seldom Never
8. Do your avoid sexual intercourse because of bulging in the vagina (either the bladder,
rectum or vagina falling out?)?
Always Usually Sometimes Seldom Never
9. When you have sex with your partner, do you have negative emotional reactions such as
fear, disgust or guilt?
Always Usually Sometimes Seldom Never
10. Does your partner have a problem with erections that affects your sexuality activity?
Always Usually Sometimes Seldom Never
11. Does you partner have a problem with premature ejaculation that affects your sexual
activity?
Always Usually Sometimes Seldom Never
12. Compared to orgasms you have had in the past, how intense are the orgasm you have
had in the past six months?
Much less intense Less intense Same Intensity More intense
Much more intense
v
v v v v
v
The Female Pelvic Health Center
New Patient Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire. Retrived from
fphcenter.com/sites/default/files/Sexual%20Function%20questionnaire%206.1.12.pdf

42. Stage 1
•Without genital touch
Stage 2
•With genital touch
Stage 3
•Go with the flow
Sensate Focus

43. Source: https://sexualityresources.com/sites/default/files/documents/VR%20pamphlet%2017.pdf

44. • Enjoying being close
to each other
• Touching and stroking
• Kissing
• Massaging
• Talking
• Holding hands
Focus on Showing your Feelings for
One Another in Other Ways by

45. 1. Sex Is Bigger ThanAny
Body Part
2. Even If You’re Afraid To
Ask —Ask
3. Don’t Wait, Act Now
4. You Are NotAlone
5. Don’t Give Up
Takeaways

46. We need:
Self knowledge
Facts
Options
Techniques
Honesty

47. Website Source:
Women's Pelvic Health | Houston Methodist. (n.d.). Retrieved from https://www.houstonmethodist.org/womens-services/pelvic-
health
Infographic: What's Going on Down There? | The Oregon Clinic. (2017). Retrieved from
https://www.oregonclinic.com/blog/infographic-whats-going-down-there
Infographic: Pelvic Floor Disorders ? Nonsurgical Treatments. (n.d.). Retrieved from https://www.nichd.nih.gov/newsroom/digital-
media/infographics/PelvicFloorDisorders-nonSurgical
Diastasis Recti 101 Infographic. (2016). Retrieved from https://www.duodiary.com/blog/2016/8/16/diastasis-recti-101-infographic
Pelvic Floor Dysfunction & Women’s Sexual Concerns | ISSM. (n.d.). Retrieved from http://www.issm.info/news/sex-health-
headlines/pelvic-floor-dysfunction-womens-sexual-concerns/
Retrieved from http://www.bermansexualhealth.com/index.php/sexual-health/sexual-pain/pelvic-floor/20-sexual-function-in-
women-with-pelvic-floor-disorders?showall=1&limitstart=/
Pelvic Physical Therapy | EMH Physical Therapy. (2018). Retrieved from http://emhphysicaltherapy.com/category/pelvic-
physical-therapy/
Journals Source:
Nunns, D., & Murphy, R. (2012). Assessment and management of vulval pain. BMJ, 344(mar28 1), e1723-e1723.
doi:10.1136/bmj.e1723
Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual Dysfunction in the United States. JAMA, 281(6), 537.
doi:10.1001/jama.281.6.537
Kwan, K. S., Roberts, L. J., & Swalm, D. M. (2005). Sexual dysfunction and chronic pain: the role of psychological variables and
impact on quality of life. European Journal of Pain, 9(6), 643-643. doi:10.1016/j.ejpain.2004.12.008
Luber, K.M, Boero,, S, Choe J.Y. The demographics of pelvic floor disorders: Current observations and future projections.
Presented at the Sixty-seventh Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Kamuela, Hawaii,
November 14-19, 2000

48. Dr. Martha Tara Lee, D.H.S.
Relationship Counselor & Clinical Sexologist
Eros Coaching Pte Ltd
Website: www.ErosCoaching.com
Email: drmarthalee@eroscoaching.com