VULVODYNIA AND VESTIBULODYNIA
The lifetime prevalence of vulvodynia has been reported as high as 28% in the adult population.
(Bachmann et al 2006)
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.
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).
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 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)).
Actual Statements from Past Patients:
“After 5 years, we still haven’t consummated our marriage.”
"I saw over 12 doctors who could not diagnose my problem."
Actual Statements from Other Healthcare Professionals:
“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.
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
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.
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.
Learn more about Phenotypes of Vulvodynia & Vestibulodynia and Hypertonic Pelvic Floor Muscle Dysfunction on our blog:
Healing from Vulvodynia & Vestibulodynia
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.
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
Vulvodynia and Vestibulodynia Resources for Patients:
- NVA - National Vulvodynia Association
- When Sex Hurts There is Hope Blog
- Beyond Pelvic Pain
- 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!