By: Katie Hunter
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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Henzell, H., Berzins, K., Langford J. (2017). Provoked vestibulodynia: current perspectives. International Journal of Women’s Health, 9, 631-642.
- National Vulvodynia Association. What is Vulvodynia?. Retrieved on January 10, 2019 from https://www.nva.org/what-is-vulvodynia/.
- 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.
- Prendergast, SA. Pelvic floor physical therapy for vulvodynia: a clinician’s guide. (2017). Obstetrics and Gynecology Clinics of North America, 44(3), 509-522.