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Living Beyond Silent Pain: Physiotherapy for Vulvodynia

Vulvodynia refers to the pain in the vulva persisting for more than three months, without an identifiable infection or other medical causes (Bornstein et al., 2016). The vulva comprises the external female genitalia, including the mons pubis, clitoris, labia majora and minora, and associated glands in the region.

Up to 28% of women are affected by vulvodynia (Bachmann et al., 2006), and nearly half of them report a negative impact on their sexual and psychological well-being.

It is important to remember that vulvodynia is a symptom, not a diagnosis. It’s comparable to saying “I have elbow pain.” When the pain is felt at the vestibule, in particular, it is termed vestibulodynia. If felt at the clitoris, it is termed clitorodynia.

The pain may be provoked (e.g. tampon or speculum insertion, vaginal penetration, contact of sweat, lubricant, or underwear), unprovoked (spontaneous), or a mix of both.

Symptoms are further classified as the following:

  • Primary: When symptoms have always been present – like from the time you became sexually active or started wearing tampons.
  • Secondary: When symptoms arise after a period of no pain; commonly after vaginal delivery, menopause, stress, or trauma.

Just a quick side note: Vulvar pain can be caused by identifiable factors, including:

  • Infection: Thrush or herpes
  • Inflammatory conditions: Lichen sclerosus or lichen planus
  • Trauma: Cuts or obstetric anal sphincter injuries
  • Hormonal factors: Menopausal or lactational
  • Latrogenic causes: Chemotherapy or radiation

Simply put: your body has decided that your vulva is at risk and requires protection. Even with just sweat, lubricants, underwear, sexual activity, or no signs of infections, your body goes into a protective state.

  1. The immune system gets activated, triggering an immune response that leads to inflammation and swelling. In some cases, redness may also occur.
  2. Nerves in the area become hyper-alert to thoroughly assess and process the perceived danger.
  3. Due to crosstalk between tissues, muscles, and fascia, there may be tightening or impaired function as a protective mechanism to prevent further damage. This condition is known as vaginismus, although it doesn’t always occur.

Vigilance results in a lot of information being transmitted to the brain for processing. In essence, this vigilance is the desired defence mechanism in the presence of a perceived threat.

Read here about how you can perform a monthly vulva self-exam for greater awareness.

WHAT DO MY EMOTIONS HAVE TO DO WITH PAIN?

The emotional centre of the brain, known as the limbic centre, gets activated as the brain processes the information to manage the threat response. So if you are feeling anxious, unhappy, or stressed, it is likely to intensify the pain, as these emotions can heighten the inflammatory response.

After all, emotions are chemical responses.

All of these processes occur automatically as a protective response to a perceived threat, even if there is no real threat. The sensation, however, is entirely real, involving inflammation, sensitivity, and pain.

WHAT ARE OTHER SYMPTOMS THAT MAY CORRELATE WITH VULVODYNIA?

A growing area of research suggests that women with vulvodynia may experience other bodily disturbances that correlate with their symptoms. These may include:

  1. Restless leg syndrome
  2. Chronic fatigue syndrome
  3. Fibromyalgia
  4. Temporomandibular joint disorder (TMJ)
  5. Irritable bowel syndrome
  6. Multiple chemical sensitivities
  7. Neck injury (Whiplash included)
  8. Anxiety or panic attacks
  9. Depression

Fear not! Hope is here…

HOW CAN PHYSIOTHERAPY HELP?

Physiotherapy plays a vital role in addressing vulvodynia, which is not a one-size-fits-all concern and requires a multimodal approach (Morin, Carroll & Bergeron 2017). Utilising a personalised approach, physiotherapy focuses on calming the mind-body connection to manage how the brain perceives threats from the vulva.

WHAT DOES PHYSIOTHERAPY MANAGEMENT LOOK LIKE?

  • Working alongside your doctor to help identify the best course of treatment.
  • Making recommendations for appropriate vaginal moisturisers and lubrication.
  • Designing a personalised pelvic floor muscle program with appropriate stretches.
  • Introducing graded touch and tissue desensitisation techniques.
  • Possibly using electrical stimulation devices to calm nerve signals.
  • Recommending a dilator program, using vaginal trainers.
  • Discussing approaches to a fulfilling intimate relationship.
  • Referral to a sexual counsellor or psychologist to address changes in body image, sexuality, fear, anxiety, and coping.
  • Supporting your emotional and physical health.
  • Helping you embrace life!

To summarise:

  1. There are changes in the areas of the brain responsible for the movement (motor) and feelings (sensory) associated with the vulva.
  2. There are changes in the sensitivity of how the nerves supply the vulva and its surrounding areas.
  3. There are changes in how much attention the brain pays attention to the vulva
  4. The brain believes that the vulva is threatened.
  5. Due to the proximity of the vulva and the pelvic floor structures (muscles and fascia), tension is likely.
  6. It’s complex.
  7. Physiotherapy helps in making sense of the symptoms you are feeling and how you can embrace life amid it all.

If you feel we can help you with how you are feeling, please call or WhatsApp us at 9780 7274, or email us at help@embracephysio.sg so we can talk about your experience and how we can give you the right care.

Feel free to look through our website, where you can learn about other women’s health conditions we treat. This is a safe space where we can discuss how we can help you with physiotherapy.

Note: While I am a physiotherapist, I am not your personal physiotherapist. The contents of this website are for informational purposes only and are not intended to serve as personal medical advice.

References:

  1. Bornstein, J, Goldstein, AT, Stockdale, CK, Bergeron, S, Pukall, C, Zolnoun, D & Coady, D 2016, ‘2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia’, Obstet Gynecol, vol. 127, no. 4, pp. 745-51.
  2. Morin, M, Carroll, MS & Bergeron, S 2017, ‘Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia’, Sex Med Rev, vol. 5, no. 3, pp. 295-322. Available from: PubMed. [26 April 2020].
  3. https://www.embracephysio.sg/wp-content/uploads/2021/08/Vulva-self-exam-eBook-1-compressed.pdf
  4. https://www.mayoclinic.org/diseases-conditions/vulvodynia/symptoms-causes/syc-20353423#:~:text=Overview,and%20has%20no%20clear%20cause.
  5. https://www.nhs.uk/conditions/vulvodynia/#:~:text=Vulvodynia%20is%20persistent%2C%20unexplained%20pain,to%20help%20relieve%20the%20pain.
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