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Herman & Wallace Blog

How to Discuss Vulvar Pain: an Update to Terminology

Earlier this year, 3 prominent societies representing pelvic health met to discuss and update terminology for vulvar pain. The result is the “2015 Consensus Terminology and Classification of Persistent Vulvar Pain.” A complete list of the updated terminology can be accessed on the website of the International Pelvic Pain Society. The updated document takes into account the additions of the terms Primary versus Secondary Vulvodynia, intermittent versus persistent pain, and considers research-based interventions for the suspected etiologies of pain. Some of the other updates are highlighted below.

  • Replace the term “unprovoked” with “spontaneous”
  • Use the term “vulvar” rather than “vulvodynia” in the title of the terminology
  • Vulvar pain definition removes the word “burning” from description

Vulvar pain can have a known cause, and the categories within vulvar pain caused by a specific disorder are: infectious, inflammatory, neoplastic, neurologic, trauma, iatrogenic, and hormonal deficiencies. Vulvodynia, defined as vulvar pain at least 3 months in duration, and without a clear identifiable cause, is described as having “potential associated factors.” There are also descriptor terms such as localized, provoked, or mixed, and terms such as intermittent, persistent, constant, immediate or delayed.

The terminology document recognizes that a patient may have a specific condition or diagnosis, and also be diagnosed with vulvodynia. As this consensus document is designed to replace the ISSVD terminology from the 2003 publication, becoming familiar with the updates is valuable for pelvic rehabilitation providers. The evaluation and treatment of vulvar pain is introduced in the Insitute’s Pelvic Floor Level 1 continuing education course, and further developed in the Level 2B course. For an immersion in the topic of vulvar pain, check out the Institute’s course on Vulvodynia: Assessment and Treatment instructed by Dee Hartmann. Your next opportunity to take the course is this March in Houston.

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Updated Guidelines in Managing Perineal Tears

Guidelines for the management of 3rd and 4th degree tears were updated and published last month by The Royal College of Obstetricians & Gynaecologists. The purpose of the guidelines are to provide evidence-based guidelines on diagnosis, management and treatment of 3rd and 4th degree perineal tears. These types of tears are also referred to as obstetric anal sphincter injuries, or OASIS. The authors acknowledge an increased rate of reported anal sphincter injuries in England that may in part be due to increased awareness and detection of the issue. In terms of classification of anal sphincter injuries, the following is recommended (note the different levels at grade 3:

Rectum

- 1st degree tear: injury to the perineal skin and/or the vaginal mucosa
- 2nd degree tear: injury to the perineum involving the perineal muscles but not involving the anal sphincter.
- 3rd degree tear: injury to the perineum involving the the anal sphincter complex
- Grade 3a tear: Less than 50% of the external anal sphincter (EAS) thickness is torn.
- Grade 3b tear: More than 50% of the EAS thickness is torn.
- Grade 3c tear: Both the EAS and the internal anal sphincter (OAS) are torn.
- 4th degree tear: Injury to the perineum involving the anal sphincter complex (EAS and IAS) and the anorectal mucosa.

Risk factors for anal injury are also outlined in the guidelines, although the authors point out that accurate prediction based on the risk factors is not reliable. The noted risk factors are as below:

- Asian ethnicity
- Nulliparity
- Birthweight greater than 4 kg (8.8 lb)
- Shoulder distocia
- Occipito-posterior position
- Prolonged 2nd stage labor
- Instrumented delivery

Recommendations worth noting include Level A evidence that warm compression during the 2nd stage of labor reduces the risk of OASIS. A noted best practice recommendation is that “Women should be advised that physiotherapy following repair of OASIS could be beneficial.” Guidelines such as these from The Royal College of Obstetricians & Gynaecologists can help in creating common language and in making recommendations that improve communication and expectations between patients and providers.

If you are interested in learning more about anal tears, Herman & Wallace offers several courses which cover the topic. For postpartum care specifically, check out Care of the Postpartum Patient.

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Upcoming Continuing Education Courses

Pregnancy Rehabilitation - Seattle, WA (SOLD OUT)

Feb 22, 2020 - Feb 23, 2020
Location: Pacific Medical Centers

Manual Therapy Techniques for the Pelvic Rehab Therapist - Pasadena, CA

Feb 22, 2020 - Feb 23, 2020
Location: Huntington Hospital

Pelvic Floor Level 2B - Alexandria, VA (SOLD OUT)

Feb 28, 2020 - Mar 1, 2020
Location: Inova Physical Therapy Center

Pelvic Floor Level 2B - Fort Worth, TX (SOLD OUT)

Feb 28, 2020 - Mar 1, 2020
Location: University of North Texas Health Science Center

Pediatric Functional Gastrointestinal Disorders - Charlotte, NC

Feb 28, 2020 - Mar 1, 2020
Location: Novant Health

Rehabilitative Ultrasound Imaging: Orthopedic Topics - Raleigh, NC

Feb 28, 2020 - Feb 29, 2020
Location: Rex Hospital

Pelvic Floor Series Capstone - Phoenix, AZ (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: 360 Sports Medicine & Aquatic Rehabilitation Centers

Pelvic Floor Level 1 - Salida, CO (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: Heart of the Rockies Regional Medical Center

Pelvic Floor Level 1 - Columbia, MO

Mar 6, 2020 - Mar 8, 2020
Location: University of Missouri-Smiley Lane Therapy Services

Pelvic Floor Level 1 - Princeton, NJ (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: Princeton Healthcare System

Pelvic Floor Level 1 - New Orleans, LA (SOLD OUT)

Mar 6, 2020 - Mar 8, 2020
Location: Ochsner Health System

Mobilization of the Myofascial layer: Pelvis and Lower Extremity- Grand Rapids, MI

Mar 6, 2020 - Mar 8, 2020
Location: Spectrum Health System

Bowel Pathology and Function -Salt Lake City, UT

Mar 7, 2020 - Mar 8, 2020
Location: Veterans Administration - Salt Lake City

Postpartum Rehabilitation - Washington, DC (SOLD OUT)

Mar 7, 2020 - Mar 8, 2020
Location: GWUH Outpatient Rehabilitation Center

Pelvic Floor Level 1 - Virginia Beach, VA (SOLD OUT)

Mar 13, 2020 - Mar 15, 2020
Location: Sentara Therapy Center - Princess Anne

Pelvic Floor Level 2A - Philadelphia, PA (SOLD OUT)

Mar 13, 2020 - Mar 15, 2020
Location: Thomas Jefferson University

Pelvic Floor Level 1 - Manchester, NH (SOLD OUT)

Mar 13, 2020 - Mar 15, 2020
Location: Franklin Pierce University

Meeks Method for Osteoporosis - Minneapolis, MN

Mar 14, 2020 - Mar 15, 2020
Location: Park Nicollet Clinic--St. Louis Park

Pelvic Floor Level 2A - Minneapolis, MN (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: Allina Hospitals and Clinics

Nutrition Perspectives for the Pelvic Rehab Therapist - San Diego, CA

Mar 20, 2020 - Mar 22, 2020
Location: Comprehensive Therapy Services

Pelvic Floor Level 1 - Birmingham, AL (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: Shelby Baptist Medical Center

Mobilization of Visceral Fascia: The Urinary System - Carlsbad, CA

Mar 20, 2020 - Mar 22, 2020
Location: Tri-City Medical Center

Pelvic Floor Level 1 - Bellingham, WA (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: PeaceHealth- St. Joseph Medical Center

Pelvic Floor Level 1 - Los Angeles, CA (SOLD OUT)

Mar 20, 2020 - Mar 22, 2020
Location: Mount Saint Mary’s University

Breastfeeding Conditions - Phoenix, AZ

Mar 21, 2020 - Mar 22, 2020
Location: Banner Physical Therapy and Rehabilitation

Breathing and the Diaphragm: Orthopedic Therapists - Sterling Heights, MI

Mar 27, 2020 - Mar 29, 2020
Location: Henry Ford Macomb Hospital

Breathing and the Diaphragm: Pelvic and Orthopedic Therapists - Sterling Heights, MI

Mar 27, 2020 - Mar 29, 2020
Location: Henry Ford Macomb Hospital

Pelvic Floor Level 1 - Corvallis, OR (SOLD OUT)

Mar 27, 2020 - Mar 29, 2020
Location: Albany Sport & Spine Physical Therapy

Breast Cancer Rehabilitation - Alexandria, VA

Mar 28, 2020 - Mar 29, 2020
Location: Inova Physical Therapy Center