Treatment PlanGoing Beyond

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• Pain is one of the most noxious stimuli for humans. We have evolved to avoid pain for survival.
• The unpleasantness of pain results in anxiety about anticipated pain and avoidance behaviour.
• Anxiety is associated with fight or flight or the sympathetic automatic nervous system response.
• Anxiety is associated with increased heart rate, tensing of muscles , release of adrenalin, along with many other body sensations.
• The pelvic floor, which automatically tenses normally, will tense even more when experiencing anxiety. Then the introitus tightens, causing a tense tight muscle wall that hurts if pushed against.
• Tension in the pelvic floor often happens unconsciously for patients.
• Pelvic floor exercises can help the patient become aware of this response. Once they are aware and have more confidence detecting the pattern, they can make changes and take control of their pelvic floor.

Purpose:  When patients experience the pain, many patients will feel as though it is "everywhere" on the vulva and vagina. Pain mapping helps them to localize their pain and feel more in control.

• Lie back against pillow, bend knees, let the knees fall apart.
• Observe genital area with large hand mirror.
• Kegel and observe (imagine stopping your flow of urine while passing urine). Release the Kegel.
• Apply lubricant on finger or thumb. Touch at 3 – 6 – 9 o’clock genital area where the
  figure of 8 muscle groups cross in three locations. Start with labia majora, labia
  minora, and then the vulvar vestibule.
• Kegel and observe (imagine stopping your flow of urine while passing urine). Release the Kegel.
• Observe again.
• Kegel and repeat with touch 3 – 6 – 9 o’clock with lubricant. Grade discomfort out of 10 for each area touched.
• Journal what you see. Identify thoughts, emotions, and behaviours (cognitive behavioural journaling).
• Reminder to patients of their anatomy and how variable the findings can be.

Notes:

• If possible, have the patient do this exercise more than once in a private place and make note of their observations each time they do the exercise.

• Completing this exercise several times can help the patient become more aware of both the physical and psychological processes occurring with vulvar pain. Journaling about each practice can help patients develop an awareness and also notice changes in their experiences over time.  Often, patients notice changes in thoughts, emotions, and the quality and intensity of physical sensations.

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• In addition, many patients notice changes in their avoidance behavior. It can be helpful to discuss these exercises at follow-up appointments to gain further insight into the pain experience.

Masters and Johnson developed “Sensate Focus” as a component of sex therapy, and it has been used in most sex therapy settings for several decades. It was originally designed to minimize “anticipatory anxiety,” or the anxiety that a partner has prior to a sexual encounter when fearing the outcome of that encounter. It also targets “spectatoring,” which Masters and Johnson described as “watching oneself” while being sexual.

We will use these exercises very deliberately to heighten your sense of awareness when being sexual with a partner. There are three stages to Sensate Focus that we would like you to consider practicing at home with your partner. Each session takes about an hour to complete, and we recommend practicing this exercise approximately once per week.

Rules: When practicing Stage 1, there is no sexual intercourse or touching of genital and sexual areas of the body (i.e., breasts, penis, vulva, vagina, testicles or clitoris). You can be naked, or you can wear underwear or relaxed clothing, if that feels more comfortable.
Set times and dates aside where there can be private time to do the exercise; turn off the phone, and eliminate other distractions.

Goals:

1.    To relax

2.    To fully tune in to the sensations that you are receiving. (If you find it helpful, you may want to silently note/describe the sensations using words in your head such as cold, smooth, tingling, prickly, soft, vibrating, etc.)

3.    To communicate to the partner giving touch with directions on how to touch (e.g., keep touching there, that feels good, that is too hard, move to the right a bit)

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Purpose:   The patient takes charge of designing and setting up an intimate encounter. What factors need to be in place in order to enjoy it more? What factors are likely to get in the way?

This exercise can be used in conjunction with the circular sexual response cycle or dual control model.

Ask the patient to identify what types of intimacy they would like to explore with a partner (i.e., holding hands, hugging one another, cuddling, sexual encounter, or someone else they imagine).Ask the patient to identify what factors need to be in place to enjoy the encounter more (e.g., context, setting, time of day, privacy, etc.).

Give patients the option to discuss or not discuss the exercise with their partner. They can try out the ideas they have, or simply reflect on them.

Reflection: Patients can journal about the intimate encounter before and after completing the exercise. Using a cognitive behavioural therapy framework for the journaling can be helpful. Specifically, patients can journal about their thoughts, emotions, physical sensations, and behaviours pre- and post- experience. This can help patients to gain insight into the role of multiple aspects of their experience during intimate encounters, identify barriers to intimacy, and gain a sense of control and empowerment in their intimate life.

+ In the follow-up appointment review how did it went? What did you notice or what did you learn?

Purpose:  This exercise can be used to introduce the patient (and their partner(s)) to different types of touch. This exercise can be used before introducing sensate focus.

Using a simple diagram of a human body, use the colours green, amber and red to colour in the sketch of their body according to:

‍Green =neutral touch – OK to touch (in public)  

‍Amber=erotic touch - proceed with caution  

‍Red= do not touch! STOP

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Given that many patients with vulvodynia are particularly sensitive to touch, it is important that touch starts in a neutral area. If touch does not start from a place of neutrality, the patient can experience an acceleration to amber and red very quickly. As a result, the potential for intimacy can be inhibited and the sexual encounter can "shut down".

Often, portrayals of sexuality in the media and in pornography are not realistic. These portrayals often progresses quickly, and can even be rough or violent, which does not translate well to intimate encounters in real life.

Understanding one's own and one's partners green, yellow, and red zones can help increase insight into how to engage in touch in a more positive and constructive way.

PURPOSE:  To reduce avoidance of physical touch, normalizes conversations and feedback about touch, increases confidence and communication about touch. This exercise is completed with a partner.

1. Choose 2 green body areas each. This exercise does not include genitalia.

2. Take turns giving and receiving touch. The giver focuses on the pleasure of giving touch to one of the chosen green areas.

3. The receiver gives positive feedback and then gives constructive feedback on how it can be better (e.g., trim nails, use hand lotion with lanolin, warm up your hands/body, shave, etc.). The receiver also gives constructive feedback on how the touch can be improved (e.g., including faster ,slower, harder, softer) as well as what part of the hand to use (e.g., finger pads, tips of fingers, flats of hands, just a few fingers) and role models as necessary. Have partner practice until it is better and give positive feedback.

4. Next, the giver and receiver switch roles. The receiver becomes the giver of touch. This switch is repeated 4 times, so that each person has had a chance to play each role twice.

This exercise is helpful for practicing giving and receiving feedback about touch without getting defensive. If someone gets upset during the exercise, it is recommended that partners take a break and set a time to come back to try the exercise again.

It can be helpful to journal about the exercise. Using a cognitive behavioural therapy framework, it can be helpful to to identify thoughts, emotions, physical sensations, and behaviours that emerge both before and after the exercise. Journaling can help patients identify the various components of their experience and it can also help partners to identify the factors that need to be in place in order to have more successful touch, which can later inform components of a sexual encounter.*

Book a follow up appointment. This exercise can be practiced across several appointments. It is recommended that patients focus on touching "green" areas until it is pleasurable and partners feel confident. Once several sessions have been dedicated to "green" areas, partners can advance to "amber" and then "red" areas. Each individual needs to have agreed to move on to more erotic touch.