Pelvic pain is a common diagnosis that we see as pelvic floor therapists. Pelvic pain is pain located in the lower abdomen, but above pubic symphysis, and is associated with various causes; myofascial pain, neuropathies, endometriosis, painful bladder, and irritable bowel syndromes. A common symptom of pelvic pain is deep dyspareunia or pain with deep vaginal penetration. Vulvar pain is different, as it is below pubic symphysis, and has several sub-classifications. These sub-classifications can often be confusing. The National Vulvodynia Association has a free online education that explains the different sub-types very succinctly. This article focuses on provoked vestibulodynia, which is the most commonly studied.
PVD or Provoked Vestibulodynia often has superficial dyspareunia which can negatively affect sexual functioning, which can lead to changes in psychological function and quality of life. Women with PVD often complain of greater pain during and after intercourse, pain catastrophization, and allodynia when compared to women with superficial dyspareunia but without PVD. These symptoms indicate central nervous system upregulation or sensitivity. This study sought to investigate the impact of these symptoms.
Pelvic pain encompassed a variety of complaints: “dysmenorrhea, deep dyspareunia, dyschezia, chronic pelvic pain, back pain, or diagnosed or suspected endometriosis”. Participants were excluded if postmenopausal or if self reported never sexually active.
One hundred twenty nine participants were divided into those with pelvic pain and PVD (43), and those with pelvic pain alone (87). For this study PVD was diagnosed as superficial dyspareunia (>4/10) and positive Q-tip test with a fixed pressure of 30g. Those with did not meet this criteria were considered to have pelvic pain alone.
The two groups were compared for superficial and deep sexual discomfort severity, sexual quality of life; fear avoidance, feelings of guilt, frustration, etc, physical examination of trigger points along abdominal wall (positive Carnett test), and numeric pain scale of various painful lumbo-pelvic regions.
Of the 129 participants notable findings in both the two groups include 31% had confirmed endometriosis, 40% suspected of endometriosis, and in the remaining 18% had no confirmed or suspected endometriosis. The authors found that the pelvic pain + PVD group had significantly more superficial dyspareunia (p=<.001) and deep dyspareunia (p=.001) which was rated >7/10 for both. This group was also had greater (3x more likely to have) depression symptoms, greater anxiety, and catastrophizing, and was more likely to have painful bladder syndrome than the pelvic pain alone group. There were no differences between the two groups for irritable bowel syndrome or abdominal wall tenderness.
This research is consistent with other research findings. The authors explore various causes of the findings including; cross- sensitization - where there may be cross talk of nerve signals from viscera to viscera and viscera to muscular structures that converge in the spinal cord. The authors note that the poor relationship between PVD and irritable bowel and PVD and abdominal wall tenderness limit that theory. They explore the psychological symptoms may be a consequence of pelvic pain or it may be that having anxiety/depression may make women more sensitive to developing pelvic pain and PVD. This sounds like a little chicken or egg theory. The authors suggest that those with PVD and pelvic pain may benefit from a more intensive multi-disciplinary approach including; “medical, surgical, psychological, or physical therapy approaches”.
Bao, C., Noga, H, Allaire, C. et al. “Provoked Vestibulodynia in Women with Pelvic Pain” Sex Med 2019; 1-8
We are all familiar with the old saying, “You are what you eat.” A functional medicine lecture I attended recently at the Cleveland Clinic explained how chronic pain can be a result of how the body fails to process the foods we eat. Patients who just don’t seem to get better despite our skilled intervention make us wonder if something systemic is fueling inflammation. Even symptoms of vulvodynia, an idiopathic dysfunction affecting 4-16% of women, have been shown to correlate to diet.
In a single case study of a 28 year old female athlete in Integrative Medicine (Drummond et al., 2016), vulvodynia and irritable bowel syndrome (IBS) were addressed with an elimination diet. After being treated by a pelvic floor specialist for 7 months for vulvodynia, the patient was referred out for a nutrition consultation. Physical therapy was continued during the vegetarian elimination diet. In the patient’s first follow up 2 weeks after starting eliminating meat, dairy, soy, grains, peanuts, corn, sugar/artificial sweeteners, she no longer had vulvodynia. The nutrition specialist had her add specific foods every 2 weeks and watched for symptoms. Soy, goat dairy, and gluten all caused flare ups of her vulvodynia throughout the process. Eliminating those items and supplementing with magnesium, vitamin D3, probiotics, vitamin B12, and omega-3 allowed the patient to be symptom free of both vulvodynia and IBS for 6 months post-treatment.
On the more scientific end of research, Vicki Ratner published a commentary called “Mast cell activitation syndrome” in 2015. She described how mast cells appear close to blood vessels and nerves, and they release inflammatory mediators when degranulated; however, mast cell activation syndrome (MCAS) involves mast cells that do not get degranulated properly and affect specific organs like the bladder. She proposed measuring the number of mast cells and inflammatory mediators in urine for more expedient diagnosis of interstitial cystisis and bladder pain syndrome.
Sigrid Regauer’s correspondence to Ratner’s article followed in 2016 relating MCAS to bladder pain syndrome (BPS), interstitial cystitis (IC), and vulvodynia. He described vulvodynia as a pain syndrome with excessive mast cells and sensory nerve hyperinnervation, often found with BPS and IC. The vulvodynia patients had mast cell hyperplasia, most of which were degranulated, and 70% of the patients had comorbidities due to mast cell activation such as food allergies, histamine intolerance, infections, and fibromyalgia.
Considering the association between mast cells and acute inflammatory responses and how mast cells release proinflammatory mediators, it makes sense that dysfunctions such as vulvodynia as well as IC and BPS can result from an excessive amount and dysfunctional granulation of mast cells. Enhanced activation of mast cells causes histamine release, stimulating peripheral pain neurotransmitters (Fariello & Moldwin 2015). If medication and therapy do not solve a patient’s pain, perhaps eliminating the consumption of inflammatory foods could positively affect the body on a cellular level and relieve irritating symptoms of vulvodynia. Pardon the parody, but patients on the brink of being “insane in the brain” from vulvodynia will likely try anything to resolve being “inflamed in the membrane.”
Drummond, J., Ford, D., Daniel, S., & Meyerink, T. (2016). Vulvodynia and Irritable Bowel Syndrome Treated With an Elimination Diet: A Case Report.Integrative Medicine: A Clinician’s Journal, 15(4), 42–47.
Ratner, V. (2015). Mast cell activation syndrome. Translational Andrology and Urology, 4(5), 587–588. http://doi.org/10.3978/j.issn.2223-4683.2015.09.03
Regauer, S. (2016). Mast cell activation syndrome in pain syndromes bladder pain syndrome/interstitial cystitis and vulvodynia. Translational Andrology and Urology, 5(3), 396–397. http://doi.org/10.21037/tau.2016.03.12
Fariello, J. Y., & Moldwin, R. M. (2015). Similarities between interstitial cystitis/bladder pain syndrome and vulvodynia: implications for patient management. Translational Andrology and Urology, 4(6), 643–652. http://doi.org/10.3978/j.issn.2223-4683.2015.10.09
Unfortunately one of the most common things we hear in pelvic rehab is “I hope you can help me, you’re my last hope.” In severe cases, this translates to the patient having little hope of surviving their life with pelvic pain. In severe but not necessarily life-threatening cases, being a patient’s last hope can also mean “please help me have sex in my relationship or my partner is going to leave me.” This situation places a lot of pressure on the patient and also on the therapist. How long did it take this patient to find her way to pelvic rehab? Research tells us that most women have been through multiple physicians, under- or misdiagnosed, and that many have failed attempts at intervention with medications or procedures.
It’s clear to women that they are being judged when they go to medical appointments complaining of pelvic pain or pain with intercourse. Although it seems really old school to hear that a provider said “It’s all in your head.” or “How much do you like your partner?” or “Well, you’re getting older, sex isn’t that important.” these dismissive phrases are still used. A study by Nguyen et al., 2013 reported that women who reported chronic pain were more likely to perceive being stereotyped by doctors and others. Interestingly, among the group of women who had chronic vulvar pain, the women who sought care for their condition reported feeling more stigmatized. Because the support a woman perceives may influence her willingness to seek out help for chronic vulvar pain, we need to keep educating our peers, the public, and the providers about the real challenges women face, and the power of rehabilitation in overcoming those challenges.
Vulvodynia is a common pelvic pain condition, and one that typically is associated with painful intercourse, or dyspareunia. (Arnold et al., 2006) It's estimated that by the age of 40, as many as 8% of women will have or have had a diagnosis of vulvodynia (Harlow et al., 2014), and this is clearly a significant quality of life issue.
Physical therapy has been shown to be successful in treating vulvar pain and pain with intercourse, including as part of a multidisciplinary approach. (Brotto et al., 2015) That's why Herman & Wallace is so eager to help empower more therapists to help patients live a life free of vulvar pain and dyspareunia. You can learn more about our courses and other resources at https://www.hermanwallace.com/continuing-education-courses.
Arnold, L. D., Bachmann, G. A., Kelly, S., Rosen, R., & Rhoads, G. G. (2006). Vulvodynia: characteristics and associations with co-morbidities and quality of life. Obstetrics and gynecology, 107(3), 617.
Brotto, L. A., Yong, P., Smith, K. B., & Sadownik, L. A. (2015). Impact of a multidisciplinary vulvodynia program on sexual functioning and dyspareunia. The journal of sexual medicine, 12(1), 238-247.
Harlow, B. L., Kunitz, C. G., Nguyen, R. H., Rydell, S. A., Turner, R. M., & MacLehose, R. F. (2014). Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions. American journal of obstetrics and gynecology, 210(1), 40-e1.
Nguyen, R. H., Turner, R. M., Rydell, S. A., MacLehose, R. F., & Harlow, B. L. (2013). Perceived stereotyping and seeking care for chronic vulvar pain. Pain Medicine, 14(10), 1461-1467.
There's a lot going on in the world of pelvic rehab, and continuing education is no exception! This March, Herman & Wallace is hosting NINE courses around the country. It's a lot to keep up with, so we thought you might appreciate a brief overview of what's coming up next!
Pelvic pain can have many sources, and Elizabeth Hampton wants to help you quickly get to the source. Finding the Driver in Pelvic Pain empowers you to play detective in order to help even the most complex patients. Don't miss out on Finding the Driver in Pelvic Pain in San Diego, CA on March 4-6, 2016
How important is a good diet? For most of us eating healthy is important, and for many pelvic rehab patients it is a necessity. That's why Megan Pribyl wrote her "Nutrition Perspectives for the Pelvic Rehab Therapist" course. This beginner level course is intended to expand the your knowledge of the metabolic underpinnings for local to systemically complex disorders. Don't miss out on Nutrition Perspectives for the Pelvic Rehab Therapist - Kansas City, MO - March 5-6, 2016!
Fascial mobilization is a rising star in pelvic rehab treatment techniques, and Ramona Horton is excited to share it with you! "Mobilization of the Myofascial Layer: Pelvis and Lower Extremity" is the best opportunity you'll get to learn about the evaluation and treatment of myofascia for pelvic dysfunction. Check it out on our continuing education course page. Ramona will be teaching these techniques in Santa Barbara, CA on March 11-13.
Sometimes the newborn is the one to get all the attention, but what about the new mother? Be sure that you can help postpartum women with symptoms like postural dysfunction, pelvic girdle dysfunction, diastasis recti abdominis and more by attending Care of the Postpartum Patient in Seattle, WA this March 12-13, taught by the wonderful Holly Tanner!
12% of women in the US have vulvar pain for 3 or more months at some stage in their life. It takes a multidisciplinary approach to address all the causes and co-morbidities, and that is exactly what you'll get at Dee Hartmann's Vulvodynia: Assessment and Treatment in Houston, TX on March 12-13, 2016. Dee aims to address the vicious cycle of pain, visceral and sexual dysfunction, and the general hit to quality of life that patients with vulvodynia suffer from.
The sacroiliac joint, pelvic girdle, and pelvic ring sure can take a beating, and Peter Philip knows how to keep you moving. Through exercise and stabilization, the pelvic rehab practitioner can quickly treat pain in the lumbopelvic-hip complex. Learn all about the direct and indirect anatomy that influences the sacroiliac joint, and then get ready to find and treat the source of pain and dysfunction in Sacroiliac Joint Treatment in Minneapolis, MN on March 19-20, 2016.
The menopause transition is not something many people look forward to. For some women it goes more smoothly than others, and it's the less fortunate ones who need access to a well-trained pelvic care professional. Michelle Lyons is flying in from Ireland to help you to become that pro! Be it vaginal atrophy, sexual health dysfunction, pelvic organ prolapse, or any other of the myriad possible symptoms of menopause, you'll be equipped to handle them all after attending Menopause: A Rehabilitation Approach in Atlanta, GA on March 19-20, 2016.
The following post comes to us from Dee Hartmann, PT, DPT who is the author and instructor of Vulvodynia: Assessment and Treatment. To learn evaluation and treatment techniques for vulvar pain, join Dee in in Houston, TX this March 12-13. Early registration pricing expires soon!
I recently heard a young, vivacious urologist present treatment options for overactive bladder to a group of nursing professionals (SUNA). To my delight as the only PT in the audience, I was pleased that physical therapy was her first line of treatment for this difficult population of chronic pelvic pain patients. As a women’s health PT, we know that chronic vulvar pain suffers experience many of the same dysfunctions, including pelvic floor muscle over-activity.
The physician’s presentation included two very emphatic statements—“physical therapy always hurts” and “no one in this group of patients should ever do Kegel exercises”. She went on to explain that anyone with pelvic floor muscle over activity should only be taught to relax; that “if they were seeing a practitioner who was telling them to do Kegels, they needed to find another PT”. As she’s not a PT, I challenged her on her second comment. I was too annoyed to address the first.
I appreciate that, as a urologist, she may not know that we learned some time ago that rest for chronic muscle tension, like chronic low back, has been proven ineffective. Rather, research suggests that increased mobility and strengthening prove more effective in the long term to decrease pain by restoring normal muscle function. As pelvic floor muscles are voluntary, striated muscles, it only makes sense that the same findings apply. Those who oppose active pelvic floor muscle active exercise suggest that the over-active state of the pelvic floor muscles causes vulvar pain. I agree. However, simply relaxing dysfunctional pelvic floor muscles and expecting them to work effectively seems a bit short-sighted. Normal pelvic floor muscle function is integral to efficient core stability as well as sphincteric control, pelvic visceral support, and sexual function. Why not begin rehab for these ladies with an active exercise program, directed at renewing pelvic floor muscle motor control, with resulting decreased introital pain, improved function (sphincteric , supportive, and sexual), and improved core support?
As for the urologist’s first statement, mark me down as totally opposed. My professional experience suggests the need to replicate familiar vulvar pain and then find abnormal physical findings in the trunk, hips, viscera, and pelvis that are contributory. Rather than utilizing any treatment that causes additional pain, addressing associated abnormal findings that immediately decrease pelvic floor muscle resting tone and palpated vulvar pain, seems much more productive.
 Waddell G. "Simple low back pain: rest or active exercise?" Ann Rheum Dis 1993;52:317.
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.
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.