NOTE: This article contains sexual content intended for a mature audience.
Inserting a tampon is painful. You dread pelvic exams because they hurt. When you have sex it burns and stings. Does this sound familiar? Painful sexual intercourse can be due to a lot of reasons; one of those being vulvodynia.
Historically, pain with sex has always been an issue, but its cause hasn't always been so clear. Only in recent decades has it been understood as a condition that is truly recognized, labeled, studied and appropriately treated. Identifying the true cause of the symptoms is critical for successfully resolving them.
Vulvodynia involves pain around the vaginal and/or urethral openings. This area is called the vestibule. For pain felt outside the inner fold (labia minora) of the vulva, it’s likely tied to other conditions such as an orthopedic issue, pudendal neuralgia, or PGAD. The reason for this distinction is because the skin of the vestibule is physiologically different from the skin around the inner fold and beyond.
Similarly, certain dermatologic conditions (e.g., lichen sclerosus, lichen planus, shingles, etc.) can cause burning at or around the vestibule. These conditions require effective medical management along with physical therapy treatment of the underlying muscle tension.
While these other conditions deserve our attention, they are beyond the scope of this blog article. We'll save those for a future post.
So let’s focus on pain that is local to the vestibule. There are a lot of potential causes for burning or sharp sensations here. If the burning is in the urethra and/or vaginal opening region (i.e., the vestibule), without any pain outside the folds of the vulva, then the vulvodynia condition is more accurately called vestibulodynia which translates into “pain in the vestibule."
[Image courtesy of Heather Edwards Creations]
Just a quick shout out to my dear friend and pelvic health colleague, Heather Edwards, for creating the above image. This is just one of 7 different varieties of crotch genitalia anatomy available in various colors, labels, and black and white that can be purchased for educational purposes at HeatherEdwardsCreations.
TYPES OF VULVODYNIA
There are specific types of vulvar/vestibule pain. And with those types come specific causes and therefore specific treatments:
- Primary or congenital vulvodynia: For some, burning around the vagina or urethra has always been there. This is called primary or congenital vulvodynia and is why you’ve never been able to use a tampon, have a pelvic exam, or tolerate any touch in that area
- Acquired vulvodynia: For others, the burning is a new thing. Maybe tampons and exams were fine. Sex may even have been fine for months or years — until it wasn’t. In that case, it may be acquired vulvodynia presenting in either...
- ‘Provoked’ (only with touch/insertion) state
- ‘Non-provoked’ (there all the time) state
[Image courtesy of Alcove Education]
Current research indicates four potential paths to acquired vulvodynia:
- Hormonal - altered response of the hormonal receptors in the area that leads to dryness, irritation, and thinning
- Neuroproliferative - increase in the number of nerve endings in the area, causing it to become more sensitized
- Inflammatory - local inflammation due to infection, medication or external agent irritation
- Muscloskeletal - tension in the pelvic muscles, also known as Pelvic Floor Muscle Dysfunction (PFMD)
There is an amazing resource for those trying to understand more of this condition. Vulvodynia.com provides a chart and publications reviewing the differential diagnosis and recommended treatments. Take note that there can also be, and often are, overlapping components of each of these categories.
In my clinical experience, the musculoskeletal version of vestibulodynia is common. But where does it come from? Pelvic floor muscle dysfunction can occur for a variety of reasons including in response to trauma, surgery, childbirth, inflammation, sexual abuse, and anxiety. Once the muscle tension occurs, it can drive neuropathic upregulation where the area becomes more sensitive and/or painful.
For those with musculoskeletal driven vulvodynia, physical therapy should be considered one of the primary forms of treatment. Additionally, a combination of other interventions may be indicated, such as yoga, cognitive behavioral therapy, vaginal diazepam, and botox injections.
Each physical therapy visit will be tailored to your particular situation. Typically they will include some version of the following:
- Manual treatments: External and/or internal hands-on techniques to reduce muscular or connective tissue restrictions in the area
- Neuromuscular re-education: Retraining of the muscles and nerves to communicate effectively. This may be through Redcord neuromuscular activation training, biofeedback, and other mechanisms
- Relaxation exercises: Learning how to relax a muscle is often needed before strengthening can occur
- Full body treatment: Let’s not ignore the rest of the body attached to the pelvis! A qualified PT should be able to evaluate all of the postural and mechanical issues that may be helping perpetuate tension through the pelvic region
If you have questions regarding your pelvic pain, contact one of our pelvic physical therapy experts. We can help you in determining your next steps. Click here to find an Activcore location near you.
To learn more about pelvic floor dysfunction, check out our Pelvic Health page.
- Vulvodynia: Definition, Prevalence, Impact and Pathophysiological Factors. Pukall, C., Goldstein, A., et al. J Sex Med 2016;13:291-304.
- Recent advances in understanding provoked vestibulodynia. Lev-Sagie, A., Witkin, S. 2016.
- Polymorphisms of the Androgen Receptor Gene and Hormonal Contraceptive Induced Provoked Vestibulodynia. Goldstein, A., Belkin, Z., et al. J Sex Med 2014; 11:2764-2771.
ABOUT THE AUTHOR:
Beth Kemper is a physical therapist and double board certified Women’s Health Clinical Specialist (WCS) and Pelvic Rehabilitation Practitioner (PRPC). She has more than 20 years of experience in the study and practice of pelvic health.
Beth works as the Lead Physical Therapist at Activcore in Atlanta, Georgia, located just 2 miles from Emory University. She also serves as Activcore's National Director of Pelvic Health.
With an extensive clinical background and education, Beth is uniquely qualified to handle more complex conditions like pelvic floor dysfunction, including bowel, bladder and sexual health problems. She holds a double Bachelors degree in Biology and Chemistry from Meredith College, as well as a Masters degree in Physical Therapy from Emory University, ranked among the top 10 PT schools in the country. She also has advanced post-graduate training in manual therapeutic interventions and pelvic rehabilitation for all genders and throughout the lifespan.
Beth is the founding physical therapist member of Emory Hospital's Pelvic Multidisciplinary Team. She also co-founded a PT clinic in her hometown of Asheville, NC before returning to settle in Decatur, GA. She is a mother, dancer, hiker, wife, friend, runner and physical therapist, passionate about pelvic therapy.
Beth goes beyond the pelvic floor and looks at the whole body to help you recover from pain and injury, and safely return to a fulfilling life of sport, activity and wellness. She is among less than 1% of all physical therapists across the United States who possess dual board certification as both a Women’s Health Clinical Specialist (WCS) and a Pelvic Rehabilitation Practitioner (PRPC) for all genders. These designations make her exceptionally equipped to treat you from head to toe. Additionally, she is recognized nationally as a leading authority in the application of Redcord, a suspension exercise system designed to help you develop a smarter, balanced body through the power of neuromuscular activation. [READ MORE]