Manual Therapy for Treating Vulvar Burning and Pain

So often, we think of vulvodynia as a condition of the skin. And it is….kind of. Vulvodynia is a long-term pain (or burning, discomfort, or itching) that is present in the outer genitals, also known as the vulva. This condition is defined as a discomfort that has lasted longer than 3 months. The symptoms of vulvodynia can vary. In some patients, it is provoked (brought on by touch or stimulation), and in some cases, it is unprovoked (present without stimulation). Some patients have pain just in the outer vulva, while others also present with pelvic floor muscle tension or urethra, bladder, or vaginal canal irritation.

The definition of vulvodynia itself states there is no known reason. This means it is not because of a skin disruption, hormonal disorder, herpes or other skin conditions, or active infection, such as yeast. This means we really don’t know just why a person has symptoms once they have been medically ruled out.

When we look at the symptoms of neuralgia (an irritated or overly talkative nerve), we find symptoms listed such as pain, hypersensitivity, burning, tingling, itching, or trigger points. Certainly, there is a lot of overlap between neuralgia symptoms and vulvodynia symptoms.

When there is compression of a nerve, it can create neuralgia of the affected dermatome. In fact, in studies, we find neural proliferation of the peripheral nerve with vulvodynia in cell biopsy in women or in animal models (1, 2). Often, neural compression is part of the problem, and this is why we see treatment models proving effective at times with nerve blocks or nerve decompression (3, 4).

Of course, when treating such patients, we can and should still employ proven topical agents to make the treatments comfortable and effective, such as lidocaine solutions (5). Vulvodynia is best treated and managed as a team, with manual therapy and patient education from pelvic health providers being a very important limb of treatment.

By treating fascial tunnels that nerves run through, treating the fascia around the clitoris, and treating the deep fascia and tissues of the labia majora and mons, we can have an effect on the pudendal nerve branches, as well as the genitofemoral and ilioinguinal nerves supplying this region. In Lumbar Nerve Manual Assessment and Treatment scheduled for May 17-18, and Sacral Nerve Manual Assessment and Treatment scheduled for May 31-June 1, both heavy manual therapy classes, we learn to decompress the neurovascular bundle from proximal to distal and to treat distal soft tissue structures that may be compressing nerves.

Resources:

1. Goetsch MF, Morgan TK, Korcheva VB, Li H, Peters D, Leclair CM. Histologic and receptor analysis of primary and secondary vestibulodynia and controls: a prospective study. Am J Obstet Gynecol. 2010;202:614.e1–614.e8. doi: 10.1016/j.ajog.2010.01.028.
2. Bornstein J. Vulvar disease. Cham: Springer International Publishing; 2019. Vulvar pain and vulvodynia; pp. 343–367.
3. Vulvodynia treatments, National Vulvodynia Association (nva.org)
4. Possover M, Forman A. Pelvic Neuralgias by Neuro-Vascular Entrapment: Anatomical Findings in a Series of 97 Consecutive Patients Treated by Laparoscopic Nerve Decompression. Pain Physician. 2015 Nov;18(6):E1139-43. PMID: 26606029.
5. Loflin BJ, Westmoreland K, Williams NT. Vulvodynia: A Review of the Literature. J Pharm Technol. 2019 Feb;35(1):11-24. doi: 10.1177/8755122518793256. Epub 2018 Aug 20. PMID: 34861006; PMCID: PMC6313270.

AUTHOR BIO:
Nari Clemons, PT, PRPC

Nari Clemons, PT, PRPC (she/her) has been teaching with the institute since 2004. She has written the following courses: Lumbar Nerve Manual Assessment /Treatment and Sacral Nerve Manual Assessment/Treatment. She has co-authored the PF Series Capstone course with Allison Ariail and Jenna Ross, and the Boundaries, Self Care, and Meditation Course (the burnout course) with Jenna Ross. In addition to teaching the classes she has authored, Nari also teaches all the other classes in the PF series: PF1, PF2A, PF2B, and Capstone. She was one of the question authors for the PRPC, and she has presented at many conferences, including CSM.

Nari’s passions include teaching students how to use their hands more receptively and precisely for advanced manual therapy skills while keeping it simple enough to feel successful. She also is an advocate for therapists learning how to feel well and thrive as they care for others, which is a skill that can be developed. “Basically, I love helping therapists learn to help themselves and others more while having a lot of fun doing it.” Nari lives in Portland Oregon, where she runs a local study/mentoring group and has a private practice, Portland Pelvic Therapy. Her interests include meditation, working out, nature, and being constantly humbled from raising her three amazing teenagers!