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Physiotherapy management in women vulvodynia

Insight about condition/ Introduction                    

The international study society for vulvar pain defines vulvodynia as chronic pain in the vulvar region for more than 3mo nths without any known reasons. It can be generalized or localized with respect to location.

Figure : Vulva region 

 The vulva is the external female genitalia which include the mons pubis, labia majora, labia minora, clitoral hood, clitoris, and vestibule.

Book an Appointment with Karthika Lakshmi for all the concerns related to physiotherapy.

Symptoms 

Vulvodynia implies that the pain is idiopathic, rather than pain their major symptoms will be itching, burning, stinging, irritation, stabbing, and/or rawness. Pain can be continuous or intermittent, often aggravated by activities such as sitting at a desk, bicycle riding, and sexual intercourse.

 The pain and discomfort of vulvodynia affects the quality of life in women with this condition. 

Vulvodynia is widely divided in to localized involving particular spot in vulva which include clitorodynia, vestibulodynia or it can be generalized pain can’t be specified, it can either be provoked in which symptoms increases with touch or pressure unprovoked in which the pain will be persistent or mixed pain that will be constant and also increases with touch or pressure. 

Causes 

Although a single cause for this condition has not been identified, the Vulvodynia Association lists several possibilities, 

  • Including abnormalities of embryological development 
  • Weak pelvic floor muscles
  • Excitation of the sensitive nerves which surround the vulva
  • Wearing tight clothing, vaginismus spasm of vaginal muscles
  • Current infection or inflammatory skin condition
  • Hormonal changes caused due to menopause
  • Breastfeeding                                         
  • Vaginal delivery
  • Obesity 
  • Abuse
  • Stress. 

The posterior introitus and the posterior hymenal remnants are the most common sites of increased sensitivity. Prevalence is thought to affect about 15 in 100 women, it affects women of all ages, reproductive stages, and ethnicities. It is not contagious or not related to hygiene or hygiene products. 

Vulvodynia is one type of ‘complex regional pain syndrome’. It may be primary with no known cause and secondary following another condition, usually one in which there is inflammation in the vulva, such as that from thrush. Remission of vulvodynia is more common in secondary vulvodynia which makes its management much easier than in primary vulvodynia as the cause of pain is much more clear in secondary type.

Pathogenesis of vulvodynia is still under research. Several theories have been postulated, which have credited roles to hormonal changes, infectious and inflammatory conditions, and psychological factors in its pathogenesis. Immunological changes in women such as altered level of interleukin which leads to decreased regulation of inflammatory changes leading to neuropathic changes. Inflammatory response to genitourinary tract infection like Candida, Human Papillomavirus (HPV) may lead to vulvodynia. Allodynia increases the number of sensory nerve endings; this makes the vulvar region hypersensitive to touch leading to provoked type of vulvodynia.  

Manidip Pal in his study has explained the mechanism of voluntary contraction of pelvic floor muscles often by controlling urine and stools may lead to hyper contractility of muscles causing pelvic floor dysfunction. This may occur due to lifestyle changes, work nature and environmental changes. This type of pelvic floor dysfunction is seen most commonly in school children and computer based job professionals as they have to sit in a place for a long time which in turn leads to controlling the urine often.

EMG of Pelvic floor muscle showed increased muscle tone (hyper-contractility) and lack of relaxation that leads to spasm of muscle which in turn causes introital narrowing and muscular pain (vaginismus).

Hormonal factors like oral contraceptive pills, menstruation, menopause, breast feeding, pregnancy and other major hormonal changes may lead to vulvodynia by affecting lubrication, sensitivity, Ph alteration.

Psychological factors like sleep disorders, post-traumatic stress, depression, and hyper-vigilance are also found to be causes of psychological pain.

Physiotherapy Management                  

      Figure : Sitz bath/ cool tub

Cool tub/Sitz bath refers to immersion of body parts into cold water. As cryotherapy is already used for the perineal region in previous studies in this study ‘cool tub’ is chosen as management of vulvodynia to reduce spasm and hypersensitivity causing vulvar pain. Jessica R. Edler, MS, et, in their study have clearly explained the effects of cold water sitz bath procedure. He has also proved that water at 10°C to 20°C can be maintained by adding ice to the water and letting it melt completely before sitting into it or by changing the water in between the treatment. 

It’s also proven that taking a sitz bath in water at 10°C to 20°C is effective in reducing pain in the urogenital problems. This cold water sitz bath/ cool tub is commonly used in reducing pain during postpartum period, Bartholdi’s gland cyst hemorrhoids and so on. 

Must Read: Different Types of Exercises and Its Benefits

Perineal massage is also an effective management to relieve spasm and reduce sensitivity with touch and pressure. Perineum is the term referring to the area between vagina and anus.                                              

Figure : Perineum region 

 Self perineal massage techniques and its uses can be taught to patients after examination. Best when taught by a physiotherapist in person as there are various techniques available.

Figure : Various position for perineal massage 

Trigger point release can be done by your therapist if any trigger is found causing the pain.

Must Read: Effective help for painful intercourse – Physiotherapy

Mirror therapy is a technique where certain stretching and exercises are done with the guidance of the mirror. The Physiotherapist will guide you do the particular exercise in their presence in front of a mirror with the reflected image you will know what exactly to be done.                                     

  Figure : Mirror therapy

 

 

Self-stretching exercises for pelvic floor muscle will be taught.

     

Perineal stretching 

Certain lifestyle modification also can help like

  •  Avoid tight clothing and pantyhose.
  • Wear all-cotton underwear.
  • Avoid exercises that put pressure on the vulva, like cycling or horseback riding.
  • Wash the area gently with plain water. Don’t use soap in the genital area, don’t douche, and don’t use other possible irritants like deodorants or bubble bath.
  • Use a lubricant during sex, but stay away from the lubricants that are flavored or designed to create a cooling or warming sensation.
  • If you have to sit down for prolonged periods, it might help to sit on a foam “donut” or some other type of cushion that reduces pressure on the area of the vulva.
  • Reduce your stress levels and get adequate sleep.
  • Muscle strengthening exercises are not included in the treatment protocol as the condition commonly includes muscle spasm. If required once the pain and sensitivity is completely cured can start after proper assessment. Working with a physical therapist trained in pelvic floor disorders can help to relax these muscles. 

When you have any of the above mentioned symptoms meet OBG physiotherapist who will be able to provide you proper treatment and home advice required to you based on the underlying cause.


Must Read: Behind Closed Doors: The Importance of Sexual Health Counselling



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