Published in the National Vulvodynia Association Newsletter (winter 2002 Volume VIII, Issue I). In the past, women who complained of pain with intercourse and did not present with obvious physical signs of infection or disease, were given the diagnosis of “dyspareunia” meaning “pain with intercourse.” Dyspareunia is classified in the psychiatric diagnostic manual (DSM-IV) as a “sexual pain disorder.” In recent years, as the medical community has become more involved in evaluation and treatment of dyspareunia, it has been suggested that “sexual pain disorders” be reclassified as “pain conditions that interfere with sexual activity.” A woman suffering from dyspareunia secondary to vulvodynia, for example, usually experiences other limitations that affect quality of life. In addition to having difficulty inserting a tampon and undergoing a gynecological exam, she may not be able to sit for prolonged periods, which may impact her ability to function in the workplace. More often than not, dyspareunia is related to an existing condition such as vulvodynia or vulvar vestibulitis, and may co-exist with other pain syndromes associated with vulvodynia such as interstitial cystitis and chronic pelvic pain. Furthermore, there are other medical and musculoskeletal conditions that cause chronic pain, and limit mobility and fitness, which may affect one’s ability to engage in comfortable sexual activity. Clearly a team approach to the treatment of dyspareunia is critical. The traditional interdisciplinary model suggested in the literature includes the family physician, urologist, gynecologist, pain specialist and sex or marital therapist. While pelvic floor biofeedback, a critical tool available to physical therapists, has demonstrated efficacy, literature reporting on the contribution that can be made by a urogynecological physical therapist using other modalities has been limited. In a recent retrospective study evaluating physical therapy’s effect on pain during sexual intercourse, over 51 percent of participants reported complete or major reduction of pain and 20 percent reported moderate improvement. However, there have not been any controlled studies documenting the efficacy of physical therapy in the treatment of vulvar pain syndromes, and no standard protocol has been suggested. The lack of a standardized treatment protocol most likely stems from what physical therapists have known for decades, i.e., that no two patients are alike and no single protocol will be suitable for all patients. Physical therapists are trained to regard each patient uniquely and holistically, determining an appropriate course of treatment with each patient through a comprehensive evaluation. The evaluation consists of taking a thorough history, observing posture, strength, mobility, endurance and tissue integrity, assessing function, and providing an individualized program combining suitable exercises and appropriate hands-on techniques. History Taking a thorough history provides the patient with an opportunity to describe her symptoms and discuss her main difficulties. The questions asked should relate to the patient’s main complaints, her medical, gynecological and sexual history, and her daily activities including work, home and exercise routine, diet, and medications. The physical therapist should also ask about urinary function, as vulvar pain patients often present with urinary frequency, urgency or even incontinence. Questions about sexual history are asked in order to assess general sexual function and identify difficulties in the area of desire, arousal and orgasm. While certain questions are standard, the history-taking evolves differently for each patient, and often the patient herself finds the experience enlightening, discovering patterns and connections she may have never realized before. The history taking also provides the woman with an opportunity to have her symptoms taken seriously, possibly for the very first time. Evaluation The physical therapy exam should assess the patient’s posture, mobility, and strength, as well as the patient’s movements and breathing, in order to get a sense of how she uses her body. Particular attention should be paid to the pelvic area. In order to assess areas of tightness and decreased mobility, it is important to lay the hands on various areas of the body including the thoracic diaphragm, rib cage, and pelvic area. The viscera (abdominal and pelvic organs) should be evaluated to note tight or hypomobile areas, or what is referred to as torsion, a problem of alignment or position. The spine, sacrum and pelvis are also checked for alignment and mobility to note areas of too much or too little mobility, misalignment, or imbalance. The muscles, particularly of the pelvis, abdominals, and legs are assessed for length, strength, and presence of trigger points. A trigger point is a hyperirritable spot, usually within a muscle, that is painful on compression and can refer pain to different areas. Often these points are found in the internal muscles of the vagina and the pelvic floor, buttocks, and hips. An important part of the physical therapist’s examination is the vulvar and pelvic floor assessment. The vulva is observed for areas of redness, raised areas, or edema, and is palpated to note areas of tenderness. The vagina and perineum is checked and palpated for tender areas, and in the case of women who have given birth or had surgery, areas of tenderness caused by scar tissues from surgical or episiotomy stitches are examined. The timing and method of the internal exam is determined based on the patient’s history. In most cases, an internal exam using one finger can be done even on the first visit. Patients presenting with primary vestibulitis, who never inserted a tampon or had intercourse, or who otherwise display anxiety about such an exam, not only is the exam deferred, but treatment will be rendered to prepare her to undergo this exam in the future. The internal exam allows the therapist to assess pelvic floor muscle tension and tightness, tone, range of motion and muscle strength. For the purpose of accuracy and objective reporting, muscle strength and resting tone should also be measured using the EMG biofeedback technology. The internal exam also enables the therapist to assess internal muscle trigger points, the integrity of the pelvic organs and the presence of bladder, uterus, or rectal prolapse. If the history warrants it, i.e., the patient reports anal pain or constipation, an anorectal internal exam should be performed as well. Treatment It is important for the physical therapist to listen to the patient’s goals in designing a treatment plan. Discussing these goals with the patient is critical in determining the focus and type of treatment. For example, the treatment goal of vestibulitis patients is typically pain-free intercourse; women who suffer from constant vulvar pain primarily seek pain relief. Whereas some well-intentioned physical therapists may see themselves as “healers” and patients as passive recipients of treatment, the best approach to managing vulvar pain is a cooperative one in which patient and therapist work together. The therapist provides the patient with various home exercises and a home treatment regime, which may include stretching, inserting a finger into the vagina, applying pure Vitamin E to the vulva, or bathing with certain oils, e.g., tea tree oil. Daily application of the oil using direct touch to the perineum and vestibule is intended to decrease hypersensitivity of the area and increase tolerance to touch. Histologic studies have determined that there is a proliferation of mast cells (cells that respond to inflammation) and nociceptors (pain receptors) in vulvar tissue of vestibulitis patients. The application of light touch, plus the gradual addition of other touch sensations such as light vibration, provides sensory integration and decreases tactile hypersensitivity by “overriding” messages of pain nerve fibers with those of touch nerve fibers. Often, the patient is taught breathing and relaxation techniques to perform at home. Some patients with urinary problems, such as urgency and frequency, may be instructed to keep a “bladder diary” and are encouraged to urinate at less frequent intervals. Patients who cannot undergo the vaginal internal exam may be instructed in using a finger or small dilator to gently stretch the vaginal opening. Typically, dilators of increasing width are gradually introduced and the patient continues to work with them at home until the largest dilator can be inserted without pain. In many cases, treatment focuses not only on pain relief, but on helping to reduce the anxiety associated with penetration; this may be achieved with hands-on assistance and involves anatomy identification, instruction in muscle relaxation, and insertion of the dilators. Therapeutic Exercise Based on the initial examination, the therapist provides the patient with home exercises. These generally include deep breathing, stretching, and strengthening exercises, particularly of the trunk and pelvis. The exercises are designed to provide optimal balance, stability, strength and mobility, particularly in the region of the lower back and pelvis. Patients are also instructed in how to perform pelvic floor exercises properly and in accordance with specific needs, based on whether muscles are weak, unstable, hyper or hypotonic. Hands-on treatment techniques: Manual therapy techniques are very effective in improving muscle and connective tissue mobility, mobilizing tight fascia and viscera, mobilizing joints, and providing relaxation. Physical therapists tend to be eclectic in their employment of various techniques, often incorporating skills gleaned from advanced courses in alternative techniques such as reflexology or craniosacral therapy. However, basic manual techniques in the treatment of vulvovaginal pain syndromes should include myofascial release, visceral manipulation and external and internal trigger point muscle massage. Myofascial release is a very effective hands-on technique that provides sustained pressure into myofascial restrictions to eliminate pain and restore motion. Visceral manipulation was developed by French osteopath Jean Pierre Barral over 20 years ago. It is a therapeutic approach to relieving abnormal tissue tensions of and around the organs thereby promoting and improving organ function. Trigger point therapy is a bodywork technique that involves the applying of local pressure to tender muscle tissue in order to relieve referred pain and dysfunction. Modalities/equipment The most important tool available for assessment and treatment purposes is pelvic floor electromyography (EMG), a biofeedback instrument that measures muscle activity. Other modalities available to physical therapists include heat/cold application, ultrasound and electrical stimulation. Ultrasound, a method of deep heat used in the treatment of muscle, joint and tissue pain, is effective in promoting healing and breaking down adhesive tissue and is an appropriate modality to use for a woman with intercourse pain secondary to an extensive perineal repair. Transcutaneous electrical nerve stimulation (TENS) has been used effectively for the purposes of decreasing pain as has electrical muscle stimulation for assisting in muscle strengthening. Electrical stimulation has also shown efficacy in reducing symptoms of urinary urgency and frequency by relaxing bladder contractions. Managing vulvar pain with physical therapy requires applying the principles of musculoskeletal assessment and treatment to the pelvic and vulvar areas. It is wise to seek a skilled an experienced therapist with knowledge in the areas of women’s sexual health and urogynecology to complement the health care team involved in treating women with vulvodynia. References: Bergeron et al. Physical Therapy for Vulvar Vestibulitis Syndrome: A Retrospective Study. J Sex Marital Therapy (2002); 28: 183-92. Binik, I., Meana, M. et al. The Sexual Pain Disorders: Is the Pain Sexual or the Sex Painful? Annual Review of Sex Research (1999); 10:210-235. Bornstein, J., Sabo, E. et al. A mathematical model for the histopathologic diagnosis of vulvar vestibulitis based on a histomorphometric study of innervation and mast cell activation. J Reprod Med (2002); 9:742. Glazer, H., Rodke, G et al. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature. J Reprod Med (1995); 40:283-90. Graziottin, A. Clinical Approaches to Dyspareunia. J Sex Marital Therapy (2001); 27:489-501. Gunter, J., Clark, M. and Weigel, J. Is there an association between vulvodynia and interstitial cystitis? J Obstet Gynecol. (2000); 95(4 Supp. 1):S4. Hay-Smith, EJ. Therapeutic ultrasound for postpartum perineal pain and dyspareunia. Cochrane Database Syst Rev 2000(2);CD000945. Sand, PK. Pelvic floor stimulation in the treatment of mixed incontinence complicated by a low-pressure urethra. Obstet Gynecol (1996); 88:757-760. Travell, J. and Simons, D. 1992. Myofascial pain and dysfunction: The trigger point manual. Vol.2. Williams and Wilkins, Baltimore. For More information and Talli Rosenbaum's website see: http://www.physioforwomen.com