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FEMALE SEXUALITY & PELVIC FLOOR BY DR SHASHWAT JANI

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FEMALE SEXUALITY & PELVIC FLOOR BY DR SHASHWAT JANI

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FEMALE SEXUALITY & PELVIC FLOOR BY DR SHASHWAT JANI

  1. 1. Female Sexuality & Pelvic Floor Dr. Shashwat Jani. M. S. ( Obs – Gyn ) Diploma in Advance Laparoscopy. Consultant Assistant Professor, Smt. N.H.L. Municipal Medical College. Sheth V. S. General Hospital , Ahmedabad. Mobile : +91 99099 44160. E-mail : drshashwatjani@gmail.com
  2. 2. • Sexuality is a multi- dimensional concept with ethical, psychological, biological and cultural dimensions. • Sexuality reflects human character and the way in which people interact.
  3. 3.  Sexuality is the lifelong process of acquiring information and developing values about one’s identity, relationships and intimacy.  It includes learning sexual development, reproductive health, interpersonal relationships, affection, body image, and gender roles.
  4. 4. “In view of the pervicacious gonadal urge in human beings, it is not a little curious that science develops its sole timidity about the pivotal point of the physiology of sex.” “ There is no man or woman who does not face in his or her lifetime the concerns of sexual tensions.” 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 4
  5. 5. • The WHO in its international human rights and consensus documents recognizes the rights of all persons, free of coercion, discrimination, and violence, to the highest attainable standard of health, including sexual health. • This includes among other things, sexual education, sexual and reproductive health care services, and the right to pursue a satisfying, safe, and pleasurable sexual life. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 5
  6. 6. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 6
  7. 7.  Women are sexual from the day they are born to the day they die.  However, as with other aspects of development, the way a woman experiences and expresses her sexuality is individual and changes over her lifespan.  These changes are influenced by biological factors such as puberty, pregnancy, and menopause.  They are also heavily influenced by individual psychological variables and by broader relationship, social, and cultural factors. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 7
  8. 8. Infancy The sexual response, including erection and vaginal lubrication, is present from birth, and erection has been observed in utero. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 8
  9. 9. Preadolescence • There is great variability in the timing of physical and behavioural developmental changes in sexuality. • However, for most children, pubertal changes start in late childhood (also called preadolescence) and lead to increased sexual interest. • Adrenarche occurs on average around age 10. • It produces some of the pubertal changes and also leads to experiences of sexual attraction. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 9
  10. 10. Adolescence • The increased sexual interest that starts in puberty continues through adolescence. • As a girl transitions to womanhood, she must come to terms with her sexuality, make sexual choices, and create a healthy sexual identity. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 10
  11. 11. PREGNANCY AND CHILD-BEARING  Pregnancy is a time of significant change as a couple transition to their role as parents.  Genital vasocongestion is intensified throughout pregnancy.  The incidence of postpartum dyspareunia is related to the degree of perineal trauma.  Assisted vaginal deliveries are associated with the highest risk of dyspareunia. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 11
  12. 12. Infertility • For many infertile couples, sexual activity becomes equated with reproduction, pressure, and disappointment. • The focus becomes conception rather than pleasure and sharing, which results in reduced desire, arousal, and pleasure. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 12
  13. 13. Sexuality & Menopause • The decrease in Sexuality can also be a result of health problems, the effects of aging, vaginal dryness from decreased estrogen production, and/or a noticeable decline in the sexual interest and ability of male partners. • Moreover, although with increasing age more women report sexual problems, fewer women are distressed about such problems. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 13
  14. 14. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 14
  15. 15. Dr Shashwat Jani. +91 99099 44160. External Sex Organs 5-Dec-16 15
  16. 16. External Sex Organs • Pudendum – External female genitals – This word derives from a Latin word that means “something to be ashamed of.” • Vulva – External female sexual structures, which include the mons veneris, the labia majora and minora, the clitoris, and the vaginal opening – Latin for “wrapper” or “covering” 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 16
  17. 17. Dr Shashwat Jani. +91 99099 44160. • The Mons Veneris – Fatty tissue covering the joint of pubic bones below abdomen and above clitoris – Serves as a cushion during intercourse – Covered with pubic hair at puberty • The Labia Majora – Large folds of skin that run downward from the mons along the sides of the vulva – Shields inner genetailia • The Labia Minora – Hairless, light colored membranes located between the labia majora 5-Dec-16 17
  18. 18. Dr Shashwat Jani. +91 99099 44160. • The Clitoris – Female sex organ located above urethral opening • Shaft : body of clitoris, approximately 1 inch long – Corpora cavernosa » Spongy tissue in clitoral shaft that becomes engorged with blood in response to sexual stimulation • Glans : extremely sensitive tip of clitoris, covered by hood – Prepuce » Fold of skin covering the glans of the clitoris • Develops from the same embryonic tissue as the penis 5-Dec-16 18
  19. 19. Clitoris-Anatomy & Blood Supply • Blood supply – Iliohypogastric - pudendal arterial bed – Internal pudendal artery branches to form common clitoral artery --> dorsal and cavernosal clitoral arteries • Consists of fused midline corpora cavernosa – Unable to trap venous blood – With sexual stimulation, engorgement, rather than erection occurs 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 19
  20. 20. Vagina - Anatomy & Blood Supply • Labia minora surrounds vagina; protected by outer labia majora • Labia minora enclose the vestibule which contains: – Clitoris – Vaginal opening -- Urethral opening • Innervation – Autonomic – Somatic motor fibers of S2-S4 innervate bulbocavernosis and ischiocavernosus muscles – Pudendal nerve—sensory to introitus • Main arterial supply (extensive anastomosis) – Vaginal branches of the uterine arteries – Vaginal branches of the pudendal arteries – Ovarian arteries
  21. 21. Uterus  Uterine / cervical glands secrete mucus during sexual arousal.  Uterine / pelvic procedures interrupt vaginal innervation --> negative impact on later sexuality. Disruption of uterosacral and cardinal ligaments can result in genital arousal and orgasm difficulties. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 21
  22. 22. Pelvic floor • The PF consists of 3 muscle layers: • Superficial perineal layer: innervated by the pudendal nerve – Bulbocavernosus – Ischiocavernosus – Superficial transverse perineal – External anal sphincter (EAS) • Deep urogenital diaphragm layer: innervated by pudendal nerve – Compressor urethera – Uretrovaginal sphincter – Deep transverse perineal • Pelvic diaphragm: innervated by sacral nerve roots S3-S5 – Levator ani: pubococcygeus (pubovaginalis, puborectalis), iliococcygeus – Coccygeus/ischiococcygeus – Piriformis – Obturator internus 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 22
  23. 23. Pelvic Floor Muscles • Non-voluntary spasm of pelvic floor = Vaginismus • Laxity or hypotonia of pelvic floor, associated with – vaginal hypoanesthesia – anorgasmia – incontinence “ Ask all women with voiding dysfunction about their sexual function . “ 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 23
  24. 24. Female Sexuality Physiology • Physiological changes during arousal Enlargement of clitoris Dilation of arterioles, increased vaginal and clitoral blood flow Seeping of vascular transudate across vaginal membrane ---> lubrication Expansion and tenting of upper 1/2 of vagina Response mediated by nitric oxide (role for sildenafil) 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 24
  25. 25. • The pelvic diaphragm has a crucial role in sexual response. • Pelvic organs that become engorged during sexual arousal are the clitoris, labia minora and vestibular bulbs on either side of the female urethra. • Vascular changes occurring with arousal are mediated by autonomic nerves. The autonomic sympathetic and parasympathetic fiber innervation to the vagina originates from the hypogastric and sacral plexus through the uterovaginal nerves. • The somatic sensory innervation from the skin arises from the dorsal nerve of the clitoris to the pudendal nerve. • Clitoral innervation receives sympathetic input from T1 L3 spinal nerve roots and parasympathetic innervation from nerve roots S2S4. Any insult to the pelvic floor can potentially lead to denervation of the female erectile tissues with sexual dysfunction following. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 25
  26. 26. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 26
  27. 27. Health Concerns Pelvic Floor  A healthy pelvic floor is strong and flexible, and can contract and relax easily.  Pelvic floor strength and flexibility vary from person to person.  Some people go through life without problems, while others experience troublesome symptoms becasue their pelvic floor muscles are too weak, too tense, too inflexible, poorly coordinated, or a combination of these. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 27
  28. 28. Pelvic floor problems can be divided into two broad categories: • Low Tone Pelvic Floor Dysfunction (weakness of the pelvic floor). • High Tone Pelvic Floor Dysfunction (painful, tense pelvic floor). There are concrete steps you can take prevent or treat either type of problem. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 28
  29. 29. Health Concerns That Affect Female Sexuality 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 29
  30. 30. Infertility • Failure to conceive a planned and wanted pregnancy creates profound stress on the relationship. • Each phase of the investigation and treatment of infertility can affect sexual function. • Scheduling sexual activity to aid in the investigation or to facilitate treatment can heighten performance anxiety and create problems achieving arousal. • Common Female problems include vaginismus and dyspareunia. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 30
  31. 31. In a study of couples undergoing IVF, nearly 50% of the women and 15% of the men reported that their infertility was the most upsetting experience of their lives. In 2 studies of couples, the majority reported decrease in sexuality after infertility treatment. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 31
  32. 32. BENIGN GYNAECOLOGICAL CONCERNS  It is possible that both benign and malignant conditions could have an effect on sexuality.  Treatments for pathologic conditions will therefore inevitably affect sexuality.  Counsel women in advance of treatment with respect to the potential for changes in their sexuality. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 32
  33. 33. • Any neuromuscular disruption in the pelvis caused by disease, a vulvar disorder, or gynaecologic surgery affecting pelvic organs or nerves can have an effect on sexuality. • A study by Ertunc suggested that fundal and posterior fibroids are associated with dyspareunia, but only posterior fibroids affected the results of the sexuality. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 33
  34. 34. AUB Kuppermann reported that 42% of patients found that abnormal uterine bleeding has negative effect on their sexuality. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 34
  35. 35. PELVIC PROLAPSE • Much of the research suggests that urinary or fecal incontinence, rather than the prolapse, plays a significant role with respect to sexual dysfuction. • 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. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 35
  36. 36. Post hysterectomy • A study by Roovers et al. showed that hysterectomy, by any method of access, improves sexuality significantly. • In a 2006 review, Ghielmetti et al. sought to determine whether gynaecological operations have an effect on sexuality. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 36
  37. 37. • In 36 articles detailing the results from 4534 patients . . . They found prolapse operations, particularly posterior repair with levator plication, seemed to cause deterioration in sexuality. • Incontinence procedures had a worsening effect on sexuality, and hysterectomy improved sexuality. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 37
  38. 38. TAH or TAH WITH BSO • Sudden loss of ovarian hormones can have a negative effect on sexuality. • A Cochrane Review ( 2012 ) states that “Until more data become available, prophylactic oophorectomy should be approached with great caution.” 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 38
  39. 39. Dermatological conditions • Common vulvar dermatologies such as lichen sclerosus and lichen simplex chronicus can cause dyspareunia because of decreased elasticity in the skin, fissures, and diminished calibre of the introitus. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 39
  40. 40. Vaginal Cosmetic Surgeries • The largest study to date, undertaken in 2011, involved 322 women, of whom 96% reported functional improvement in sexuality. • Ali and Thabet compared clitorolabioplasty with clitoro-labiectomy and found significant differences in sex scores and sexuality in the labioplasty group and thus recommended this surgery over the labiectomy. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 40
  41. 41. • Goodman looked at labiaplasties, clitoral hood reductions, combined labiaplasty/clitoral hood reductions, vaginoplasties and/or perineoplasties, and combined labiaplasty and/or reduction of the clitoral hood plus vaginoplasty/perineoplasty. • A total of 91% of patients undergoing such procedures were satisfied with the outcomes, and there was a statistically significant improvement in sexuality. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 41
  42. 42. Key Points  There is increasing acknowledgement of the strong link between normal pelvic floor function and healthy female sexual function.  Elucidating processes 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 life and functionality. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 42
  43. 43.  A multitude of factors modify and influence female sexuality, playing different roles in the pathophysiology of female sexual disorders.  Estrogens and androgens are important to the normal functioning of the female sexual cycle.  Hormone replacement therapy with both estrogen and testosterone has a role in improving sexuality when sex hormone deficiencies are implicated. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 43
  44. 44.  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. 5-Dec-16 Dr Shashwat Jani. +91 99099 44160. 44
  45. 45. 5-Dec-16 45 Dr Shashwat Jani. +91 99099 44160.

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