Propel Physiotherapy

Physiotherapy managment for vulvodynia

What is vulvodynia?

Before delving into what Vulvodynia is, let’s have an anatomy lesson focusing on the vulva. The vulva constitutes the external genitalia for individuals with a vagina.
The vulva serves to protect the vagina and urethra and plays a significant role in the sexual response for females. It encompasses various structures, including the labia (outer and inner), clitoris, mons pubis, vestibule, and everything in between.

Vulvodynia is defined as pain in the vulval area. The pain need to be persisting for longer than over three months, and lacks a known cause.

The symptoms of vulvodynia includes:

  • Pain
  • Burning
  • Stinging
  • Itching
  • Irritation

Subcategories of Vulvodynia include:

  • Clitorodynia (pain in the clitoris)
  • Vestibulodynia (pain in the vestibule region of the vulva)

Regardless of the pain’s specific location or type, individuals with vulvodynia experience chronic discomfort in the vulval area. The overusage of tight underwear or pants and warmer temperatures can often increase the symptoms of vulvodynia. The biggest symptom of vulvodynia is painful penetrative intercourse.

What causes vulvodynia?

Vulvodynia is classified as having an unknown cause. However, potential factors associated with the condition include:

Hormonal imbalances:

The vestibule is highly sensitive to estrogen and androgens, and imbalances can result in irritation. This is a common contributing factor, especially in postnatal women (before menstruation has returned) and perimenopausal and postmenopausal women.

Tight pelvic floor muscles and muscles around the pelvic area:

Approximately 90% of individuals with vulvodynia presents with overactive and tight pelvic floor muscles with poor pelvic floor relaxation (despite all prompts to relax pelvic floor).

Inflammatory conditions:

Conditions like Lichen sclerosus and Lichen planus usually contribute to vulvodynia.

Infections:

Recurrent and poorly managed infections like bacterial vaginosis and chronic thrush may play a role.

Nerve-related factors:

Neuroproliferation (excessive and increased nerve endings in the area) or irritation to the nerves supplying the vulva, such as the pudendal nerve, can contribute to pain.

Iatrogenic causes:

Vulvodynia may arise due to medical procedures, postoperative pain, cancer treatment, hormone therapy, trauma, or perineal tears/ episiotomy associated with childbirth or lacerations due to genital mutilation.

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How do we treat vulvodynia?

Based on the latest systematic review, having a multidisciplinary team is very important to manage vulvodynia (Calafiore et al., 2024). Vulvodynia can be rather tricky to diagnose, thus, a referral from your general practitioner to the gynaecologist or specialist is very important. The gynaecologist would usually take a full history to check in on any infections or inflammatory conditions that may be contributing to vulvodynia. Here, at Propel Physiotherapy, we specialize in complex cases, and are highly experienced in treating vulvodynia and vaginismus. Thus, we work very closely with the a team of specialist gynaecologists who specializes in treating complex vulvodynia and vaginismus cases. We communicate very closely with the specialist gynaecologists to ensure the best possible treatment outcome for the client.

Pelvic floor physiotherapy for vulvodynia

Based on research, pelvic floor physiotherapy is the best conservative management and is proven to alleviate vulvodynia and pain with intercourse. We would normally monitor the vulvodynia area using a Q-tip test to ensure that the medications that were prescribed by the gyanecologist has been effective with improving vulvodynia. We are in communication with the gyanecologist (if need be) to discuss the client if the symptoms worsen or has not improved.

Then, we begin to work on pelvic floor relaxation with the client. Due to vulvodynia, the muscles around the vaginal and vulval area, the pelvic floor muscles tightens and becomes overactive in response to protecting the vulval area from pain. Thus, we work closely with clients to teach them to relax their pelvic floor muscles. It usually involves a combination of techniques including providing feedback about pelvic floor relaxation, massaging the pelvic floor muscles and guiding the clients to check in on their pelvic floor and improving their pelvic floor awareness.

Then, we would work closely together with the client to start using vaginal dilators. This helps to stretch the superficial perineal muscles, and further aids to prepare the client for penetrative intercourse in the long term.

Depending on the complexity of the case, we might involve other practitioners, such as the psychologist, and the sexologist to further improve the outcomes and to achieve goals for the client.

For further tips, please read the article for Vulvodynia: Do’s, Don’ts

Citations:

Dario Calafiore, Nicola Marotta, Claudio Curci, Francesco Agostini, Rita Ilaria De Socio, Maria Teresa Inzitari, Francesco Ferraro, Andrea Bernetti, Antonio Ammendolia, Alessandro de Sire, Efficacy of Rehabilitative Techniques on Pain Relief in Patients With Vulvodynia: A Systematic Review and Meta-Analysis, Physical Therapy, Volume 104, Issue 7, July 2024, page 54