Treatment for Vulvodynia: Here's Why You Need Pelvic Floor Physical Therapy
By: Dr. Julie Sarton
Fact: 1 in 4 women suffer with sexual pain and sexual dysfunction (Hayes et al 2006).
Fact: The lifetime prevalence of vulvodynia has been reported as high as 28% in the adult population (Bachmann et al 2006).
Fact: Forty-five percent of women with vulvodynia pain reported an adverse effect on their sexual life, and 27% an adverse effect on their lifestyle (Arnold et al 2007).
Fact: When treating women with chronic pain, physicians and other health-care providers (those outside of the psychosexual counseling realm) have struggled to deal with their patients' comorbid sexual dysfunction, with 38% of patients thinking that the problem “will just go away,” (Laumann et al 2009).
Fact: Vulvodynia CAN BE HELPED via multi-modal therapy, with pelvic floor PT being a key essential component to treatment (Hartmann D, Sarton J, Chronic pelvic floor dysfunction, Best Practice & Research Clinical Obstetrics and Gynecology 2014).
What is Vulvodynia?
Figure 1: Vulvar Anatomy, courtesy of The National Vulvodynia Association.
The term vulvodynia is a “symptom” literally meaning pain (dynia) in the vulvar region (vulvo). It is used to describe the symptoms of chronic or recurrent pain and discomfort in the vulvar region. If you are like most women, you might not understand exactly what your vulva is and what structures this includes. All you know is that you have pain "down there" (and this is not normal). Essentially, the vulva includes the following: the mons pubis, the clitoris, the labia majora, labia minora, the vulvar vestibule, the urethral opening, the vaginal opening, and Bartholin’s and Skene’s glands. See Figure 1 for full vulvar anatomy.
Women with vulvodynia can have pain that is provoked (such as pain due to intercourse, pain with sitting, wiping after urination, wearing underwear, undergoing an annual exam or tampon insertion), or pain can be unprovoked (pain surfacing without any type of touch, clothing or specific activity). Another important factor to note is that pain can be generalized to the entire vulva, or limited to just one area, such as the vestibule or clitoris.
When the pain and symptoms are limited to the vestibule, this is known as VESTIBULODYNIA. Vestibulodynia is the most common form of vulvodynia and a frequent reason why a lot of women have entrance dyspareunia (pain with penetration during intercourse attempts). See Figure 2 below to understand how this differs from generalized vulvodynia. For a very detailed article on vestibulodynia, please refer to Hartmann and Sarton’s article (Hartmann D, Sarton J, Chronic pelvic floor dysfunction, Best Practice & Research Clinical Obstetrics and Gynaecology (2014)).
Figure 2: Provoked Vestibulodynia (PVD) (left) vs. Generalized Vulvodynia (GVD) (right)
Manifestations of Vulvodynia & Vestibulodynia:
The nature of the vulvodynia pain may vary widely from woman to woman. Symptoms of vulvodynia can include burning, rawness, searing, stinging or a sharp pain in the vulva, vestibule and/or entrance to the vagina. The pain can be constant, intermittent, or only occurring when the vulva is touched, as mentioned above. Common descriptors include:
Pain in vestibule inside the labia minora (pain at the entrance to the vaginal opening)
Uncomfortable tingling and/or burning sensations in vaginal opening
Stinging, itching, or raw feeling in vulvar tissue
Throbbing, aching, soreness, and swelling
Redness may or may not be present
Involvement of the urethral meatus may lead to symptoms resembling a Urinary Tract Infection (urgency and/or frequency, pain with urination)
Hyperalgesia—increased response to stimulus that normally is painful
Dyspareunia—painful intercourse
Pelvic floor muscle hypertonicity (present in 80% of patients)
Light touch triggers pain = allodynia. Tight pants, undergarments, and movement of pubic hair may provoke discomfort and pain.
Prior statements from our past patients, as well as comments made to them from other healthcare professionals:
“After 5 years, we still haven’t consummated our marriage.”
“There is nothing wrong with you…I suggest you get liquored and lubed.”
“It’s in your head….. relax.”
“We can’t find anything…go home and rent a good adult movie.”
“Here is the number to a psychiatrist….call and make an appointment.”
"I was told by my doctor, 'I have other patients with cancer who worry about dying —your problem is minor compared to that.' I responded, 'Did you know the pain is so bad that at times it makes me want to die?'”
Note: NONE of these statements are acceptable, and the good news is that this condition can be helped and even eliminated with the appropriate treatment.
Classifications of Vulvodynia:
Vulvodynia can be classified as primary or secondary. Primary vulvodynia means pain has always been present; for example, pain presents since first tampon insertion or first penetration attempt. Secondary vulvodynia means vulvar pain sets in after a time period of being pain-free. It is critically important to understand that the key to successful treatment is to figure out what set the stage for this change if you present with secondary vulvodynia.
Phenotypes of Vulvodynia & Vestibulodynia
Thankfully, we have come a long way with our understanding of what sets the stage for vulvodynia and vestibulodynia. Recall that the term 'vulvodynia' simply means pain in the vulva—it truly is not a diagnosis, but rather a descriptor of what is happening. This is a label that only tells you that pain is present in the vulva—similar to saying you have “knee pain.”
WE NOW RECOGNIZE THAT THERE ARE DISTINCT ETIOLOGIES OF VULVODYNIA (AND WHILE MANY OF THESE ETIOLOGIES OVERLAP), IT IS ESSENTIAL TO RECOGNIZE THE DISTINCT COMPONENT OF THIS SYNDROME.
This newer and much more relevant categorization occurred when a meeting of the minds came together 3 years ago (The International Society for the Study of Women’s Health, The International Pelvic Pain Society, The International Society for the Study of Vulvovaginal Disease and the The National Vulvodynia Association). Phenotypes of vulvodynia and vestibulodynia were outlined, taking into account what the various underlying causes are. Please see Figure 3 below outlining these phenotypes for vestibulodynia.
Figure 3: Distinct Etiologies of Vulvodynia by The International Society for the Study of Women’s Health, The International Pelvic Pain Society, The International Society for the Study of Vulvovaginal Disease and the The National Vulvodynia Association.
Depending upon the person, which phenotype, the location of pain, the constancy, the severity and the underlying perpetuating factors, symptoms and treatment will vary.
Therefore, each treatment plan will need to be unique!
Recent literature further links associations between vulvodynia and fibromyalgia, chronic fatigue syndrome, yeast infections, recurrent vulvovaginal infections, irritable bowel syndrome, interstitial cystitis and oral contraceptive use.
Therefore, your healing team of practitioners will need to almost always involve a multi-disciplinarian team. Often, a pelvic floor physical therapist serves as a primary player on this healing team, as PTs tend to spend more time with you than most other practitioners (note: find a facility that offers 1 hour PT treatments!) You can rest assured knowing that an experienced PT will help you manage your case, and then refer/collaborate with other team members as needed.
Hypertonic Pelvic Floor Muscle Dysfunction as a Phenotype of Vestibulodynia or Vulvodynia
Increased tone causes a decrease in blood flow and oxygen to the muscles of the pelvic floor. This can lead to a build up of lactic acid. Symptoms of pelvic floor muscle hypertonicity include: generalized vulvar pain or burning, tenderness where the muscle insert in front of and behind (4, 6, and 8 o’clock) the vestibule which causes severe introital dyspareunia (pain with sex), urinary symptoms (frequency, hesitancy, incomplete emptying), constipation, hemorrhoids, and rectal fissures. Physical exam may or may not reveal erythema where the muscles insert at the vestibule, multiple pelvic floor muscular trigger points, muscles weakness, and an inability to hold a sustained contraction.
How Does Pelvic Floor Therapy Help Specifically?
Pelvic floor physical therapy is not new, and pelvic floor muscle hypertonicity was first implicated back in the mid-1990s as a trigger of major chronic vulvar pain. The early studies revealed that hypertonic PFMs (pelvic floor muscles) were successfully treated using surface electromyography or biofeedback, and complaints of vulvar pain and sexual dysfunction were decreased (Hartmann, Sarton 2014).
Today, pelvic floor physical therapists offer a much more comprehensive approach to the management of chronic vulvar and pelvic pain.
As pelvic health specialists who have received extensive education in the treatment of chronic pelvic dysfunction, we can offer an array of highly specialized manual therapy techniques to treat vulvodynia, vestibulodynia, and all the comorbid conditions outlined above. Musculoskeletal, fascial, and visceral aspects should always be evaluated and treated with any and each patient.
The Evidence
In two retrospective reviews of physical therapy treatment of women with vulvodynia, Bergeron et al. reported a 71% success rate of moderate or great improvement in vulvar pain, as well as decreased pain with intercourse and gynecological exam, and increased intercourse frequency, desire, and arousal [37- J. Sarton article]. Furthermore, Hartmann reported that 71% of those receiving physical therapy for vulvar pain reported decreased vulvar pain symptoms and 62% reported improved sexual function [42- J. Sarton article].
What Should Pelvic Floor PT Treatment Include?
Learning your anatomy, what set the stage for your pain, and understanding basic pain science principles integrating this into thought processes and functional living
Internal and external manual therapy (including myofascial release, trigger-point pressures, and contract/relax)
Muscle and motor control of the pelvic floor muscles (relaxation during vaginal insertion)
External work around the bony pelvis consisting of connective tissue manipulation tapping into the somatovisceral reflex.
Other techniques such as MFR and visceral mobilization integration
Biofeedback (manual or traditional)
Home program exercises including use of progressive vaginal dilators, a crystal wand, manual stretching of the vaginal tissue, and PFM and lower body/ hip stretches and exercises
How can I find a good pelvic floor PT?
Bookmark these resources!
Lastly, find a good MD—they are usually yoked with a good PT
Resources for patients:
Irwin Goldstein’s books
Remember, when you work with a highly skilled pelvic floor physical therapist who routinely treats vulvodynia, hope and healing are possible and you will be taking 1 step closer to recovery!