Non-pharmacological therapeutic approaches to painful sexual dysfunction in women: integrative review

Isabelle Maria Mendes de Araújo Thainara Julianne Lima Monteiro Mayara Líddya Ferreira Siqueira About the authors

ABSTRACT

BACKGROUND AND OBJECTIVES:

Sexual dysfunctions associated with pain symptoms can affect female genito-pelvic functionality. The objective of this study was to identify non-pharmacological analgesic therapies used in painful sexual dysfunctions to guide clinical and therapeutic practice in comprehensive care of women’s sexual health.

CONTENTS:

An integrative review, carried out in the Pubmed, LILACS, Scielo, PEDro and Biblioteca Virtual de Saúde databases. The searches were performed using the combinations: “dysfunction” AND “pain” AND “sexual” AND “treatment”. The inclusion criteria allowed the analysis of six articles published between January 2009 and August 2019. It was observed that dysfunctions in the muscles of the pelvic floor may be associated with pain and sexual dysfunctions, thus, non-pharmacological analgesic interventions can provide greater muscle relaxation and perineal self-perception, reducing painful symptoms in the sexual response cycle.

CONCLUSION:

The treatment of painful sexual dysfunctions with the use of non-pharmacological resources, using techniques such as perineal massage, myofascial release, muscle training, biofeedback, vaginal dilators, electrostimulation, and radiofrequency aim to improve sexual performance and quality of life for women.

Keywords:
Pelvic pain; Sexuality; Women’s health

RESUMO

JUSTIFICATIVA E OBJETIVOS:

Disfunções sexuais associadas a sintomas dolorosos podem repercutir sobre a funcionalidade gênito-pélvica feminina. O objetivo deste estudo foi identificar terapêuticas não farmacológicas analgésicas utilizadas em disfunções sexuais dolorosas a fim de contribuir com a prática clínica e terapêutica no cuidado integral à saúde sexual feminina.

CONTEÚDO:

Trata-se de revisão integrativa realizada nas bases de dados Pubmed, LILACS, Scielo, PEDro e Biblioteca Virtual da Saúde. As buscas foram realizadas utilizando as combinações: “dysfunction” AND “pain” AND ‘’sexual’’ AND ‘’treatment’’. Os critérios de inclusão permitiram a análise de seis artigos publicados no período de janeiro de 2009 a agosto de 2019. Observou-se que as disfunções na musculatura do assoalho pélvico podem estar associadas a quadros álgicos e disfunções sexuais, de modo que intervenções não farmacológicas analgésicas podem proporcionar maior relaxamento muscular e autopercepção perineal, reduzindo, assim, sintomas dolorosos no ciclo de resposta sexual.

CONCLUSÃO:

O tratamento de disfunções sexuais dolorosas com utilização de recursos não farmacológicos, através de técnicas como a massagem perineal, liberação miofascial, treinamento muscular, biofeedback, dilatadores vaginais, eletroestimulação e radiofrequência visam proporcionar melhora no desempenho sexual e na qualidade de vida feminina.

Descritores:
Dor pélvica; Saúde da mulher; Sexualidade

INTRODUCTION

Sexual dysfunction (SD) has become more frequent in women. It’s a health matter involving biological, psychological, relational and sociocultural factors; therefore, it presents multifactorial causes. SD can include dysfunction in sexual desire/excitement, orgasm dysfunction, and genito-pelvic pain11 Santos SR, Oliveira CM. Disfunção sexual na mulher: uma abordagem prática. Rev Port Med Geral Fam. 2015;31(5):351-3.. Among the dysfunctions and disorders that affect women’s sexual health, dyspareunia, a discomfort after or during sexual intercourse, characterized as nuisance, burning, or even pain that compromises sexual performance, stands out. In a study conducted in the USA, the incidence of dyspareunia is estimated to be between 8 and 21% among women22 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. 1999;281(6):537-44..

Nevertheless, there are still obstacles in the process of adherence to pelvic rehabilitation33 Ghaderi F, Bastani P, Hajebrahimi S, Jafarabadi MA, Berghmans B. Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. Int Urogynecol J. 2019;30(11):1849-55.. Dyspareunia44 Holanda JB, Abuchaim ES, Coca KP, Abraão AC. Disfunção sexual e fatores associados relatados no período pós-parto. Acta Paul Enferm. 2014;27(6):573-8. is one of the main sexual dysfunctions in the puerperium, compromising the desire, satisfaction, and frequency of sexual intercourse, possibly related to the postpartum period, the presence of episiotomy and/or lacerations, and breastfeeding. It’s also important to highlight that dyspareunia affects the sexual life of women with endometriosis and in the climacteric period55 Lima RV, Pereira AMG, Beraldo FB, Gazzo C, Martins JA, Lopes RGC. Função sexual feminina em mulheres com suspeita de endometriose com infiltração profunda. Rev Bras Ginecol. 2018;40(3):115-20.. Another painful sexual dysfunction is vaginismus, when there is involuntary and spasmodic contraction in the muscles of the vaginal canal that may be related to psychological factors, hypertonia of the pelvic floor muscles (PFM), and hypersensitivity in the vaginal introitus, thus impeding penetration66 Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018; 29(5):631-8..

Painful scenarios may be associated with traumatic events66 Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018; 29(5):631-8. in the PFM region, such as sexual violence or episiotomies, and congenital factors of the vaginal canal formation. Thus, there are repercussions on genito-pelvic functionality and female sexual performance.

The characteristic process of pain in the genital region may also be related to inflammatory situations, such as infections, making the vulvar and vaginal area hypersensitive to the touch. Another factor that contributes to the sensation of pain during sexual activity is genitourinary syndrome of menopause (GSM), associated with vaginal atrophy, reduced lubrication, and vaginal dryness77 Amaral AD, Pinto AM. Female genito-pelvic pain/penetration disorder: review of the related factors and overall approach. Rev Bras Ginecol Obstet. 2018;40(12):787-93..

Among the SD, vulvodynia also stands out, which is characterized by vulvar hypersensitivity, pain and irritation in the female genital region88 Bachmann GA, Brown CS, Phillips NA, Wood R, Foster DC. Effect of gabapentin on sexual function in vulvodynia: a randomized, placebo-controlled trial. Am J Obstet Gynecol. 2019;220(1):89. E1-89. E8.. There are cases of chronic genito-pelvic pain associated with vulvodynia, with pain at the slightest increase in pressure on the genitals even in activities of daily living (ADL). Such signs and symptoms become relevant during the pelvic functional assessment and definition of therapeutic plan99 Kim SJ, Kim J, Yoon H. Sexual pain and IC/BPS in women. BMC Urol. 2019;19(1):47..

Painful SD usually impact directly sexually active women, and the genito-pelvic dysfunction can generate limitations and restrictions of activities and female social participation, according to the International Classification of Functioning, Disability and Health (ICF)66 Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018; 29(5):631-8.. Thus, in women’s health, physical therapy involving therapeutic management in different modalities plays an important role in the reinsertion of these women in the functional and painless cycle of sexuality.

In that sense, the objective was to identify non-pharmacological analgesic therapies used in different SD to contribute to clinical and therapeutic practice in the comprehensive care of women’s sexual health.

CONTENTS

The present study presents an integrative review performed in the following databases: Pubmed, LILACS, Scielo, PEDro and Biblioteca Virtual de Saúde (BVS - Virtual Health Library). The guiding question was “identify which non-pharmacological therapeutic modalities are used to induce analgesia in women with painful SD”. Searches were performed using the combinations: “dysfunction” AND “pain” AND “sexual” AND “treatment”. Inclusion criteria were complete articles published from January 2009 to August 2019 in Portuguese, English, and Spanish; studies with the methodological design of a randomized controlled clinical trial presenting analysis for the outcome pain; non-randomized clinical trials with subject relevance; review articles that presented in the title and abstract non-pharmacological intervention for analgesia in pelvic rehabilitation for sexual dysfunction.

The articles identified through the initial search strategy were analyzed according to the eligibility criteria defined by the search protocol and classified based on the Agency for Healthcare Research and Quality (AHRQ) categorization for the classification of evidence1010 Galvão CM. Níveis de evidência. Acta Paul. Enferm. 2006;19(2):5-5. in seven levels: level 1, evidence from systematic review or meta-analysis of all relevant randomized controlled clinical trials or from clinical guidelines based on systematic reviews of randomized controlled trials; level 2, evidence from at least one well-designed randomized controlled clinical trial; level 3, evidence from well-designed clinical trials without randomization; level 4, evidence from well-designed cohort and case-control studies; level 5, evidence from systematic review of descriptive and qualitative studies; level 6, evidence from a single descriptive or qualitative study; level 7, evidence from opinion of authorities and/or expert committee report.

The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines1111 Galvão TF, Pansani TSA, Harrad D. Principais itens para relatar Revisões sistemáticas e meta-análises: a recomendação PRISMA. Epidemiol Serv Saúde. 2015;24(2):335-42.. The research steps are shown in figure 1, according to the methodological procedure proposed in the study. Duplicate studies in the databases were excluded.

Figure 1
Study selection

After the databases search, a total of 463 studies were found, of which 24 were from Scielo, 425 from Pubmed, 14 from PEDro and BVS. Therefore, 20 studies in Portuguese, English and Spanish were considered to be in agreement to the eligibility criteria. Six articles were included in the present review, which indicated non-pharmacological therapeutic modalities for analgesia related to sexual dysfunction, as described in table 1. The 14 excluded articles did not address non-pharmacological therapies for SD.

Through the survey of articles, table 1 presents characteristics of the six included articles, which present therapeutic modalities for female sexual dysfunction.

Table 1
Characteristics of articles included in the review

Based on the AHRQ1010 Galvão CM. Níveis de evidência. Acta Paul. Enferm. 2006;19(2):5-5. classification, the articles analyzed in the integrative review presented levels of evidence 2, 3, 5, and 6, corroborating the scientific literature66 Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018; 29(5):631-8.,1616 Stein SR, Pavan FV, Nunes EFC, Latorre GFS. Entendimento da fisioterapia pélvica como opção de tratamento para as disfunções do assoalho pélvico por profissionais de saúde da rede pública. Rev Ciênc Med. 2018;27(2):65-72.,1717 Retzky SS, Rogers JRRM. Urinary incontinence in women. Clin Symposia. 1995;47(3):2-32. for clinical and therapeutic practice in sexual dysfunctions. Manual therapeutic resources, such as perineal massage and myofascial release, as well as electrotherapeutic resources for the reduction of pain in the sexual response cycle stand out.

The genito-pelvic functionality is associated with PFM performance, which, when weakened, potentiate the emergence of dysfunctions in the genitourinary system1818 Gosling JA, Dixon JS, Critchley HO, Thompson SA. A comparative study of the human external sphincter and periurethral levator ani muscle. Br J Urol. 1981;53(1):35-41.,1919 Assis TR, Sá AC, Amaral WN, Batista EM, Formiga CK, Conde DM. Efeito de um programa de exercícios para o fortalecimento dos músculos do assoalho pélvico de multíparas. Rev Bras Ginecol Obstet. 2013;35(1):10-5.. PFM also play an important role in sexual function, therefore, training these muscles is imperative for increasing voluntary contraction capacity, resistance, and pelvic muscle relaxation1414 Barreto KL, Mesquita YA, Santos Junior FFU, Gameiro MO. Treinamento da força muscular do assoalho pélvico e os seus efeitos nas disfunções sexuais femininas. Motri. 2018;14(1):424-7..

Besides PFM training, studies11 Santos SR, Oliveira CM. Disfunção sexual na mulher: uma abordagem prática. Rev Port Med Geral Fam. 2015;31(5):351-3.,77 Amaral AD, Pinto AM. Female genito-pelvic pain/penetration disorder: review of the related factors and overall approach. Rev Bras Ginecol Obstet. 2018;40(12):787-93.,1414 Barreto KL, Mesquita YA, Santos Junior FFU, Gameiro MO. Treinamento da força muscular do assoalho pélvico e os seus efeitos nas disfunções sexuais femininas. Motri. 2018;14(1):424-7. point out the relevance of other non-pharmacological therapeutic modalities for treatment of painful sexual dysfunctions due to greater efficacy, low cost, and low potential risk to women’s health.

Perineal massage/Thiele massage

The use of the perineal massage technique in cases of women with dyspareunia associated with CPP exhibits satisfactory results for the reduction of pain during sexual intercourse. The massage promotes relaxation of the perineal muscles, thus relieving tension points in the muscle path and a desensitization in the region, which reduces the recurrence of pain processes, not only during sexual intercourse, but also collaborating positively in cases of pelvic pain. Therefore, it provides beneficial results in quality of life of women with dyspareunia/CPP1212 Silva APM, Montenegro ML, Gurian MBF, Mitidieri AM, Silva LL, Benedicto PL, et al. Perineal massage improves the dyspareunia caused by tenderness of the pelvic floor muscles. Rev Bras Ginecol Obstet. 2017;39(1):26-30.. There are also other techniques with this type of action, as will be described in the article.

With manual techniques it’s possible to induce analgesia in the PFM and decrease their contractile activity. Through massage techniques performed in the vaginal canal of women with dyspareunia, it’s possible to deactivate painful trigger points and stimulate the region’s blood circulation, an important aspect in the process of restoring muscle activity22 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. 1999;281(6):537-44.. In that way, physical therapy, through non-pharmacological techniques and manual therapeutic resources, such as myofascial release, contributes successfully to the treatment of pain caused by muscular/myofascial dysfunctions66 Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018; 29(5):631-8..

Muscle training of the pelvic region

The rehabilitation and strengthening of the PFM have satisfactory effects on women’s sexual life. PFM training and awareness have been suggested as techniques to help in the treatment of female sexual dysfunctions1414 Barreto KL, Mesquita YA, Santos Junior FFU, Gameiro MO. Treinamento da força muscular do assoalho pélvico e os seus efeitos nas disfunções sexuais femininas. Motri. 2018;14(1):424-7.,1919 Assis TR, Sá AC, Amaral WN, Batista EM, Formiga CK, Conde DM. Efeito de um programa de exercícios para o fortalecimento dos músculos do assoalho pélvico de multíparas. Rev Bras Ginecol Obstet. 2013;35(1):10-5..

PFMT promotes increased strength of the urogenital trigone and levator ani muscles, improving the sensory-motor reflex response, involuntary contraction of the PFM during orgasm, pelvic blood flow, and vaginal lubrication1313 Piassaroli VP, Hardy E, Andrade NF, Ferreira NO, Ossis MJO. Treinamento dos músculos do assoalho pélvico nas disfunções sexuais femininas. Rev Bras Ginecol Obstet. 2010; 32(5):234-40..

Pressure and electromyographic biofeedback

The use of proprioceptive sensory stimuli through the biofeedback device favors the process of recognition and self-perception of the perineal region and PFM. Pressure biofeedback involves introducing an inflatable endocavitary probe into the vaginal region, which must be associated with muscle contraction to gain strength and resistance. The device allows visual feedback of the PFM pressure levels. Furthermore, the association of biofeedback with PFM training exercises increases strength, perception, and muscle performance2020 Cacchioni T, Wolkowitz C. Treating women's sexual difficulties: the body work of sexual therapy. Sociol Health Illn. 2011;33(2):266-79..

The therapeutic proposal of the biofeedback technique in cases of patients with dyspareunia consists of reducing the pain-spasm-pain cycle present during penetration. It’s a low-cost technique and promotes results for pain reduction and perineal desensitization33 Ghaderi F, Bastani P, Hajebrahimi S, Jafarabadi MA, Berghmans B. Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. Int Urogynecol J. 2019;30(11):1849-55.,2020 Cacchioni T, Wolkowitz C. Treating women's sexual difficulties: the body work of sexual therapy. Sociol Health Illn. 2011;33(2):266-79..

Vaginal dilators

Vaginal dilators contribute to positively increase the elasticity of the vaginal canal, playing a non-pharmacological therapeutic role for vaginismus and dyspareunia. This management helps in the myofascial adaptive process of the vagina, allowing the progression in the size of dilators according to the patient’s acceptance process, respecting her comfort limits, in order to contribute to the reduction of pain perception during sexual intercourse66 Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018; 29(5):631-8.,2020 Cacchioni T, Wolkowitz C. Treating women's sexual difficulties: the body work of sexual therapy. Sociol Health Illn. 2011;33(2):266-79.. According to a Cochrane review2121 Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;(12):CD001760., systematic desensitization, which may include techniques of relaxation and use of progressively larger dilators, seems to be effective when compared to cognitive therapy or pharmacological interventions2222 Carvalho JC, Agualusa LM, Moreira LM, Costa JC. Terapêutica multimodal do vaginismo: abordagem inovadora por meio de infiltração de pontos gatilho e radiofrequência pulsada do nervo pudendo. Rev Bras Anestesiol. 2017;67(6):632-6..

Electrostimulation

Electrostimulation presented efficacy as a non-pharmacological therapy applied to sexual dysfunction due to its therapeutic effects such as analgesia, muscle relaxation and increased local circulation2222 Carvalho JC, Agualusa LM, Moreira LM, Costa JC. Terapêutica multimodal do vaginismo: abordagem inovadora por meio de infiltração de pontos gatilho e radiofrequência pulsada do nervo pudendo. Rev Bras Anestesiol. 2017;67(6):632-6.,2323 Wolpe RE, Toriy MAS, Zombowski K, Sperandio FF. Atuação da fisioterapia nas disfunções sexuais femininas: uma revisão sistemática. Acta Fisiatr. 2015;22(2):87-92., promoting improvement in pain complaints and perineal sensitivity. This technique consists of the intravaginal placement of a vaginal electrode or surface electrode in the perineal region, with low frequency TENS or medium/high frequency for muscle strengthening, which promotes electrical stimuli in the pudenda and sacral region. The intensity must be adjusted to the sensory-motor level according to the therapeutic objective and patient comfort. This modality also induces pelvic floor awareness, analgesia, and muscle strengthening.

Therapy with microablative fractional radiofrequency (MAFRF)

There are frequent changes in the female genital region during the postmenopausal period, such transformations can impact on pelvic functionality. This set of alterations with the reduction of vaginal lubrication, vaginal stenosis due to loss of the elastic component and the reduction of collagen, pain scenarios, discomfort and dyspareunia can negatively interfere in sexual performance and personal satisfaction during sexual intercourse.

This alterations complex is known as the GSM1515 Kamilos MF, Borrelli CL. Nova opção terapêutica na síndrome geniturinária da menopausa: estudo piloto utilizando radiofrequência fracionada microablativa. Einstein. 2017;15(4):445-51.. One possible treatment is the application of laser or MAFRF directly into the vaginal canal and introitus in order to stimulate neocollagenesis and neoelastogenesis in the vaginal mucosa and accelerate the process of restructuring of the epithelial cells of the genital region. Thus, the application of the MAFRF technique contributes satisfactorily in reducing the effects of vaginal dryness and dyspareunia, reducing complaints of pain1515 Kamilos MF, Borrelli CL. Nova opção terapêutica na síndrome geniturinária da menopausa: estudo piloto utilizando radiofrequência fracionada microablativa. Einstein. 2017;15(4):445-51..

In summary, the non-pharmacological therapeutic modalities applied to painful SD have been presenting efficacy and scientific evidence, however, the literature is still incipient, and more randomized controlled clinical studies comparing techniques and demonstrating their effectiveness are needed.

CONCLUSION

The treatment of painful SD with the use of non-pharmacological resources has the objective of promoting female sexual health by inducing analgesia and relaxation of PFM through techniques such as perineal massage, myofascial release, PFMT, biofeedback, vaginal dilators, electrostimulation, and radiofrequency.

REFERENCES

  • 1
    Santos SR, Oliveira CM. Disfunção sexual na mulher: uma abordagem prática. Rev Port Med Geral Fam. 2015;31(5):351-3.
  • 2
    Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. 1999;281(6):537-44.
  • 3
    Ghaderi F, Bastani P, Hajebrahimi S, Jafarabadi MA, Berghmans B. Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. Int Urogynecol J. 2019;30(11):1849-55.
  • 4
    Holanda JB, Abuchaim ES, Coca KP, Abraão AC. Disfunção sexual e fatores associados relatados no período pós-parto. Acta Paul Enferm. 2014;27(6):573-8.
  • 5
    Lima RV, Pereira AMG, Beraldo FB, Gazzo C, Martins JA, Lopes RGC. Função sexual feminina em mulheres com suspeita de endometriose com infiltração profunda. Rev Bras Ginecol. 2018;40(3):115-20.
  • 6
    Berghmans B. Physiotherapy for pelvic pain and female sexual dysfunction: an untapped resource. Int Urogynecol J. 2018; 29(5):631-8.
  • 7
    Amaral AD, Pinto AM. Female genito-pelvic pain/penetration disorder: review of the related factors and overall approach. Rev Bras Ginecol Obstet. 2018;40(12):787-93.
  • 8
    Bachmann GA, Brown CS, Phillips NA, Wood R, Foster DC. Effect of gabapentin on sexual function in vulvodynia: a randomized, placebo-controlled trial. Am J Obstet Gynecol. 2019;220(1):89. E1-89. E8.
  • 9
    Kim SJ, Kim J, Yoon H. Sexual pain and IC/BPS in women. BMC Urol. 2019;19(1):47.
  • 10
    Galvão CM. Níveis de evidência. Acta Paul. Enferm. 2006;19(2):5-5.
  • 11
    Galvão TF, Pansani TSA, Harrad D. Principais itens para relatar Revisões sistemáticas e meta-análises: a recomendação PRISMA. Epidemiol Serv Saúde. 2015;24(2):335-42.
  • 12
    Silva APM, Montenegro ML, Gurian MBF, Mitidieri AM, Silva LL, Benedicto PL, et al. Perineal massage improves the dyspareunia caused by tenderness of the pelvic floor muscles. Rev Bras Ginecol Obstet. 2017;39(1):26-30.
  • 13
    Piassaroli VP, Hardy E, Andrade NF, Ferreira NO, Ossis MJO. Treinamento dos músculos do assoalho pélvico nas disfunções sexuais femininas. Rev Bras Ginecol Obstet. 2010; 32(5):234-40.
  • 14
    Barreto KL, Mesquita YA, Santos Junior FFU, Gameiro MO. Treinamento da força muscular do assoalho pélvico e os seus efeitos nas disfunções sexuais femininas. Motri. 2018;14(1):424-7.
  • 15
    Kamilos MF, Borrelli CL. Nova opção terapêutica na síndrome geniturinária da menopausa: estudo piloto utilizando radiofrequência fracionada microablativa. Einstein. 2017;15(4):445-51.
  • 16
    Stein SR, Pavan FV, Nunes EFC, Latorre GFS. Entendimento da fisioterapia pélvica como opção de tratamento para as disfunções do assoalho pélvico por profissionais de saúde da rede pública. Rev Ciênc Med. 2018;27(2):65-72.
  • 17
    Retzky SS, Rogers JRRM. Urinary incontinence in women. Clin Symposia. 1995;47(3):2-32.
  • 18
    Gosling JA, Dixon JS, Critchley HO, Thompson SA. A comparative study of the human external sphincter and periurethral levator ani muscle. Br J Urol. 1981;53(1):35-41.
  • 19
    Assis TR, Sá AC, Amaral WN, Batista EM, Formiga CK, Conde DM. Efeito de um programa de exercícios para o fortalecimento dos músculos do assoalho pélvico de multíparas. Rev Bras Ginecol Obstet. 2013;35(1):10-5.
  • 20
    Cacchioni T, Wolkowitz C. Treating women's sexual difficulties: the body work of sexual therapy. Sociol Health Illn. 2011;33(2):266-79.
  • 21
    Melnik T, Hawton K, McGuire H. Interventions for vaginismus. Cochrane Database Syst Rev. 2012;(12):CD001760.
  • 22
    Carvalho JC, Agualusa LM, Moreira LM, Costa JC. Terapêutica multimodal do vaginismo: abordagem inovadora por meio de infiltração de pontos gatilho e radiofrequência pulsada do nervo pudendo. Rev Bras Anestesiol. 2017;67(6):632-6.
  • 23
    Wolpe RE, Toriy MAS, Zombowski K, Sperandio FF. Atuação da fisioterapia nas disfunções sexuais femininas: uma revisão sistemática. Acta Fisiatr. 2015;22(2):87-92.

Publication Dates

  • Publication in this collection
    08 Oct 2021
  • Date of issue
    Jul-Sep 2021

History

  • Received
    16 July 2020
  • Accepted
    11 July 2021
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