5 Tips to Reduce Vulvodynia Symptoms

In Female Pelvic Pain by Emily Tran2 Comments

Vulvodynia can affect up to 25% of women in their lifetime.1 The vulva is the anatomical term for the external genitalia in women that includes the clitoris, labia, mons pubis, and vestibule (vaginal opening).  Vulvodynia has received specific diagnostic terminology as we now know there are various causes and presentations of symptoms that can be considered “vulvodynia”.3  Box 1 contains a description of the specific terminology that was determined at the 2015 terminology consensus conference.

The most common form of vulvodynia is provoked vestibulodynia (PVD)2 which is pain with touch to the vaginal opening, most often seen with attempted tampon use, penetrative sex, and pelvic exams. It is important to note that PVD can be primary or secondary.3 Primary PVD means that the woman has had pain since first attempt of penetration. Secondary indicates that there was a time in their life without pain on attempted penetration (i.e. sex or tampon use).

The causes of provoked vulvodynia are often multifactorial and include genetic, hormonal, inflammatory, musculoskeletal, neurological, psychosocial, and structural defects.3 Therefore, treating this type of condition often requires a biopsychosocial approach involving a multidisciplinary team. In the providers examination, they should consider each of these factors and determine what additional providers are required to add to the patient’s team. Check out this blog for more information on a typical gynecological exam and diagnosing female sexual dysfunction.

In addition to addressing the musculoskeletal and neuromuscular impairments, pelvic health physical therapists regularly refer their patients to gynecologists, urologists, and urogynecologists to address vulvovaginal tissue health and psychologists to address psychosocial factors. A provider may also consider a referral to pain management if the patient would benefit from pharmacological treatments or other noninvasive procedures to aid in neurological and neuromuscular causes of pain.

In 2017, the Obstetrics and Gynecology Clinics of North America published a clinician’s guide for pelvic floor physical therapy evaluation and treatment of vulvodynia.4 Approximately 90% of women diagnosed with provoked vestibulodynia have pelvic floor dysfunction4 meaning that the pelvic floor muscles are a large contributing factor in conditions like dyspareunia, vaginismus, and vulvodynia. Including a pelvic floor muscle exam during gynecological pelvic exams will lead to a more thorough evaluation of the patient and understanding of their condition. The full article, Pelvic Floor Physical Therapy: A Clinician’s Guide, gives a detailed description on how to assess the pelvic floor muscles.

In treating the pelvic floor muscles, patients with vulvodynia often have a hypertonic or high-tone pelvic floor dysfunction. This means that the muscles are being overused throughout the day, which often leads to compression of the pelvic nerves and blood vessels with subsequently increased pelvic pain. To address this, the focus is on relaxing the pelvic floor muscles, regulating the nervous system, and normalizing the surrounding pelvic musculature to improve blood flow, nerve and muscle function, and physical biomechanics.

Prendergast (2017) explains that the literature supports a combination of physical therapy techniques for vulvodynia.4 Along with addressing this hypertonic muscle dysfunction in the clinic with manual therapy, physical therapists can simultaneously provide neuromuscular re-education, education on pain physiology, offer behavioral and lifestyle modifications, desensitize the central and peripheral nervous systems, and provide a home exercise program. We emphasize the importance of participating in their home exercise program as this augments the progress made in the clinic. This will also lead to more permanent lifestyle changes at home.

Since women are often looking for quick and easy go-to exercises and remedies to address their chronic pelvic pain, I am reviewing my top 5 home remedies for chronic pelvic pain and vulvodynia.

  1. Pelvic floor drops: also known as the “reverse kegel” or pelvic floor relaxation exercise. This is lengthening and opening of the pelvic floor muscles; the opposite action of a contraction where the muscles shorten, close, and draw-in cephalically. The patient lies supine on a yoga mat, couch, or bed with their knees and hips bent and slightly apart from each other. Their legs can be supported with pillows and blankets or free floating. Coordinating this with the breath, as they inhale, I have the patient imagine their pelvic floor is a flower and they are “blooming the flower” or try to open the muscles like they are passing gas. They should practice this for 3-5 breaths daily and whenever they are having pain. Here is a video demonstrating the pelvic floor drop.
  2.  Diaphragmatic breathing: Also while lying on their back with knees bent towards their chest, the patient should take a breath in so that their belly rises higher than their chest. On the exhale, let the belly fall. The patient can place one hand on the abdomen and one hand on the chest to help guide the belly hand to rise up on the inhale. They should practice this 3-5 minutes daily and when you notice an increase in muscle tension or symptoms. The patient can practice breathing and pelvic floor drops together.
  3.  Heat/sitz baths: Applying heat to the abdomen, lower back, and pelvis (with lots of towel layers to protect the skin from burning) for 10-15 minutes per day can help relieve muscle tension, spasms, and pain and improve blood flow. Warm (not hot) baths with epsom salt can also alleviate pelvic pain related to muscle tension, hemorrhoids, fissures, and irritated tissues. This can also be done while practicing the diaphragmatic breath and pelvic floor drops.
  4.  Child’s pose: the child’s pose position with the knees towards your chest and apart is the best position for the pelvic floor muscle relaxation. Because the pelvic floor muscles attach laterally to the obturator fascia, the position of the hips can impact the position of the pelvic floor. Imagine the pelvic floor is a hammock; when the hips are in neutral or extended, the hammock is pulled taut. When the hips are flexed and externally rotated, the hammock is slackened, which allows the muscles to lengthen and drop. This pose for 1-5 minutes combined with breathing and pelvic floor relaxation can relieve pain and improve motor control.
  5. Foam rolling the posterior hip muscles: As mentioned above, the hip position and surrounding musculature can impact the function of the pelvic floor muscles. Trigger points in the obturator internus and piriformis muscles can aggravate pelvic pain symptoms. Foam rolling these muscles at home can reduce trigger points, improve blood flow and nerve function, and alleviate pain.

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Are you unable to come see us in person? We offer virtual physical therapy appointments too!

Due to COVID-19, we understand people may prefer to utilize our services from their homes. We also understand that many people do not have access to pelvic floor physical therapy and we are here to help! The Pelvic Health and Rehabilitation Center is a multi-city company of highly trained and specialized pelvic floor physical therapists committed to helping people optimize their pelvic health and eliminate pelvic pain and dysfunction. We are here for you and ready to help, whether it is in-person or online. 

Virtual sessions are available with PHRC pelvic floor physical therapists via our video platform, Zoom, or via phone. The cost for this service is $75.00 per 30 minutes. For more information and to schedule, please visit our digital healthcare page.

In addition to virtual consultation with our physical therapists, we also offer integrative health services with Jandra Mueller, DPT, MS. Jandra is a pelvic floor physical therapist who also has her Master’s degree in Integrative Health and Nutrition. She offers services such as hormone testing via the DUTCH test, comprehensive stool testing for gastrointestinal health concerns, and integrative health coaching and meal planning. For more information about her services and to schedule, please visit our Integrative Health website page

PHRC is also offering individualized movement sessions, hosted by Karah Charette, DPT. Karah is a pelvic floor physical therapist at the Berkeley and San Francisco locations. She is certified in classical mat and reformer Pilates, as well as a registered 200 hour Ashtanga Vinyasa yoga teacher. There are 30 min and 60 min sessions options where you can: (1) Consult on what type of Pilates or yoga class would be appropriate to participate in (2) Review ways to modify poses to fit your individual needs and (3) Create a synthesis of your home exercise program into a movement flow. To schedule a 1-on-1 appointment call us at (510) 922-9836

 

References

  1. Henzell, H., Berzins, K., Langford J. (2017). Provoked vestibulodynia: current perspectives. International Journal of Women’s Health, 9, 631-642.
  2. National Vulvodynia Association. What is Vulvodynia?. Retrieved on January 10, 2019 from https://www.nva.org/what-is-vulvodynia/.
  3. Bornstein, J., Goldstein, A., et al. (2015). 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of vulvar pain and vulvodynia. Obstetrics and Gynecology, 127(4), 745-751.
  4. Prendergast, SA. Pelvic floor physical therapy for vulvodynia: a clinician’s guide. (2017). Obstetrics and Gynecology Clinics of North America, 44(3), 509-522.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

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