Hypothesis / aims of study
Chronic pelvic pain syndrome is defined as pain in the pelvic region that lasts for more than six months and is not due to pregnancy, menstrual cycle, local trauma, or pelvic surgery and its prevalence is between 5.7 – 26.6% in women worldwide (1). Chronic pelvic pain syndrome is usually caused by musculoskeletal problems like pelvic floor muscle tension and spasm. Physiotherapy techniques such as transvaginal massage can be used to reduce these tension and muscle spasms and relieve pain. Thiele’s massage is applied in cases of pelvic floor muscle sensitivity and spasm such as chronic pelvic pain syndrome and dyspareunia, while transverse friction massage is used to relieve pain in musculoskeletal problems and to soften adhesions. The aim of this study was to investigate and compare the effectiveness of two different transvaginal massage tecniques, transverse friction massage and Thiele’s massage, on pain and sexual functions in females with chronic pelvic pain syndrome.
Study design, materials and methods
The study was conducted between February- April 2023 after ethical approval was obtained. All individuals participating in the study were informed in detail about the study and signed informed consent was obtained from all individuals. 20 women referred by a urologist participated in the study between 20-60 years old.
While individuals with chronic pelvic pain syndrome, pelvic floor tenderness and spasm were included the study; individuals with neurological deficit, severe prolapse, pelvic malignancy, receiving radiotherapy and undergoing urogynecological surgery in the last 6 months were excluded.
20 females participated in the study and randomized into two groups which included 10 participants. The individuals in the group 1 recieved transverse friction massage and the individuals in the group 2 recieved Thiele’s massage. Presence of tenderness, scar tissue, trigger points and spasm in the pelvic floor muscles evaluated by digital palpation, pain levels evaluated by Visual Analog Scale (VAS) and McGill Melzack Pain Questionnaire (MMPQ), sexual functions evaluated by Female Sexual Function Index (FSFI).
Thiele’s Massage was applied to the Thiele’s group in the lithotomy position for 30 minutes, 2 days a week for 4 weeks. The Thiele’s massage technique was performed longitudinally from the origin to the insertion of the muscles. 15-20 repetitions were applied to each muscle group. The pressure started without irritating the participants and was increased by entering the pressure. Transverse friction massage was applied to the transverse friction group by the same physiotherapist with the same frequency and duration in lithotomy position. It was applied for 3-5 minutes on each tense muscle group and trigger points, crossing the direction of the muscle fibers. The total treatment duration was approximately 30 minutes. It was started unidigitally and continued bidigitally according to the patient's tolerance. At the end of the treatment, the same evaluations were re-evaluated by the same physiotherapist for all participants.
Results
Significant improvements were observed in pain, according to VAS and MMPQ scores, after the intervention compared to the pre-intervention in both groups (p<0,05). The FSFI total score of the transverse friction group improved significantly after the intervention, while no significant difference was detected in the Thiele’s group (p>0,05). In addition, while there was a significant difference in all sub-parameters of sexual functions in the transverse friction group (p<0,05), no significant difference was found in the sub-parameters of lubrication, orgasm and satisfaction in the Thiele’s group in FSFI (p>0,05). When two groups were compared with each other, no statistically significant difference was found in any of the parameters between the groups (p>0.05).
Interpretation of results
This randomized controlled trial was the first study to compare two different transvaginal massage techniques in women with chronic pelvic pain syndrome. The majority of previous studies, supporting our study, were that Thiele’s massage reduced pelvic pain in female patients with chronic pelvic pain syndrome who has pelvic floor muscle spasm, trigger points and tenderness (2). We can explain the effect mechanism of Thiele’s massage in reducing pain with stripping movements from origin to the insertion of the muscles, providing elongation in the spasmatic muscles, thus reducing the tone and relaxation in the hypertonic pelvic floor muscles. We can explain that the pain relief mechanism of transverse friction massage in the pelvic floor muscles with its similarities to the mechanism of myofascial release and trigger point treatments applied to the pelvic floor muscles in the previous studies (3). Briefly, these mechanisms are restoring the proper alignment of the connective tissue by moving the muscle fibers, providing pain control with the activation of the spinal reflex mechanism and muscle relaxation, relieving the pain by providing the transport of endogenous opiates with vasodilation in the pelvic floor muscles. Tone changes of pelvic floor muscles encountered in chronic pelvic pain syndrome are one of the important causes of dyspareunia in women. Significant improvements were observed in the pain sub-parameter of the FSFI, which assess sexual functions, in both groups compared to pre-intervention. Despite the improvement in dyspareunia, no significant difference was found in the total score of sexual functions in the Thiele’s group. We support the idea that this is because the stripping technique of Thiele’s massage can create friction and cause reductions in lubrication.