Female chronic pelvic pain - vulvodynia

This leaflet is for women who are suffering with pain in the genital region including the vulva, perineum (area between the vagina and back passage), vagina or pelvic floor muscles. You may have heard this called vulvodynia, provoked localised vulvodynia, vestibulodynia, vaginismus or dyspareunia (pain on intercourse). For the purposes of the leaflet we have chosen to call the condition vulvodynia. Commonly tampon use, touch, wearing tight clothing and intercourse are painful or impossible. Some women who suffer with endometriosis also have symptoms of vulvodynia.

The symptoms of vulvodynia may include:

• Pain: this can vary in intensity and type. It may be localised to the vulval and perineal region, for some patients there may also be symptoms in the lower abdomen, hips, buttocks and back passage.
• Skin changes: change may occur during the post-natal period or around the menopause. Other conditions such as lichen sclerosis may cause some changes. Symptoms include redness, dryness and sometimes fissuring (tiny cuts) in the vagina. Your doctor or consultant may prescribe creams, tablets, hormone treatments or advice on lubrication.
• Urinary symptoms: these can include urinary urgency, frequency, pain on urination and incontinence. Also see our information leaflet titled ‘urgency and urge urinary incontinence’.
• Bowel function: this may include pain on bowel movements, constipation or difficulty in emptying the bowel. Also see our information leaflet titled ‘Bowel Management’.
• Sexual function: this may include the inability to allow penile entry due to pain and muscle spasm.
• Psychological symptoms: these may include worry, stress, poor work life balance, anxiety, depression, poor sleep pattern and concern about health in the short and long term.

What is chronic pain?

Pain is an unpleasant sensory and emotional experience, usually associated with tissue damage; this pain can range in intensity from mild to severe. Pain is useful; it warns us that something is too hot, tight, stretched or overused. Pain does not always equal harm, for example a paper cut can be very painful while there may be far less pain following a serious injury.

Pain is considered 'chronic pain' when it has lasted longer than three months. Nerve fibres can become hypersensitive and can send incorrect signals about the nature of the pain to the brain. Abnormal sensations may be perceived from stimulation that would normally not be painful. This is commonly known as central sensitisation and the pain experience becomes complicated and multifactorial.

Chronic pain will worsen with stress, anxiety, lack of sleep, depression and any activity or situation when pain impacts on life. It is like turning the volume button up on the body’s nervous system. Many of the treatments suggested will try and reduce this volume and settle down the nervous system.

Commonly with any area of pain we try to protect that area by contracting the muscles more tightly. Around the pelvis, this will often occur in the pelvic floor, abdominal and diaphragm muscles. All of these muscles can be overused and may become tight and short. This can have an unhelpful effect and can reduce circulation, cause compression of little nerves in the area and prevent movement, which can cause more pain.

How can physiotherapy help with the chronic pain management of this condition?

A skilled physiotherapist will perform a detailed assessment to ascertain your problems. They will observe your overall movement patterns identifying structures that may contribute to your problem (including nerves, muscles, tissue, joints and organs). For most women the pelvic floor muscles will be a part of this assessment as they commonly contribute to the problem they can be evaluated by feeling externally and internally via the vagina and possibly the back passage.

Manual therapy techniques may be used as appropriate to encourage normal movement and function. Local techniques to release trigger points or connective tissue restrictions may be used. Exercises may be taught to restore a normal movement pattern and prevent a reoccurrence.

The nervous system including the brain needs to be taught to stop perceiving a threat and allow improved movement patterns. We can do this by down training the nervous system using breathing techniques, relaxation and stress management. We encourage daily exercise; walking is a very effective way to encourage endorphin release (these are hormones which reduce pain and produce a feeling of wellbeing).

Bladder and bowel management may also be taught if appropriate. If you are interested please see separate leaflets on ‘Urgency and urge urinary incontinence’ and ‘Bowel management’.

The pelvic floor muscles

Why your pelvic floor muscles are important

Pelvic floor muscles are important for bladder and bowel control and support of the pelvic organs. The pelvic floor muscles act together with the deep abdominal muscles to provide a support for the spine, pelvis and pelvic organs. This supporting action, often known as core stability, is needed all the time to help our bodies move and balance.

Those who are sexually active may find that exercising the muscles improves satisfaction for both partners.

What does the pelvic floor need to do?

To work properly, the pelvic floor needs to:

• be strong and work at the right time (before an action)
• work as part of the core team (providing postural support/stability)
• be able to relax

How do you work the pelvic floor muscles?

Try to imagine either that you need to stop yourself from passing wind or that you are stopping the flow of urine mid-stream. You should feel a slight lift and tightening inside the vagina. Try not to tighten the bottom muscles or hold your breath.

For more information on working the pelvic floor please see video.

Pelvic floor muscle exercises video

Pelvic floor muscle exercises video Pelvic health and obstetric physiotherapy

Please scroll down to the video section of the webpage and select pelvic floor exercises video.

Relaxation of the pelvic floor muscles

For women with vulvodynia it is very important to learn how to fully relax as well as contract the pelvic floor muscles.

Correct breathing patterns are really helpful

Either lie down on your back with your knees bent up or go forward on your hands and knees. As you breathe in your diaphragm should lower, your ribs expand and your tummy relax. Let the pelvic floor muscles relax too. With time and practice you will manage to co-ordinate your breathing with relaxing the tummy and the pelvic floor.

Pelvic floor letting go

To let go of your pelvic floor muscles imagine that you are widening around the back passage and dropping the perineum; you will feel a widening between the sit bones but not a feeling of pushing down.

Sit up in a good posture; imagine you have picked up a marble with the muscles around the back passage.

Breathe out and on the in breath try and let go of the marble, then let go again and again – without pushing down, just dropping. The goal is that the body will remember that as you breathe in the pelvic floor muscles should release automatically.

Lift and let go in five stages

• Lift the pelvic floor muscles by first closing around the back passage, then lift the underneath muscles up and forward to work the whole of the pelvic floor. Ensure that you do not squeeze the glutei muscles (the large bottom muscles)
• Then let go of your muscles in five stages:
  • Imagine a block of flats with three story, a basement and a wine cellar.
  • Lift pelvic floor to the top.
  • Let go through each floor, softening, relaxing and widening through the pelvic floor.
  • Finishing all the way down in the wine cellar.

Relaxation is the initial key to your pain relief. Once you have mastered relaxation, gently learning to work the pelvic floor muscles with your abdominal muscles whilst continuing to breathe is important. These muscles will support and protect the body whilst doing your normal day-to-day activities.

General advice to help reduce and treat symptoms:

Exercise: Walking 30 minutes a day

Stretching the pelvic muscles (as taught by your physiotherapist).

Stress management: Evaluate your work/life balance

Explore mindfulness meditation

Yoga or Tai chi

Counselling

Drug management: Discuss pain and skin management options, with your consultant or GP.

Healthy living: Weight management

Constipation management, fluid/fibre balance

Washing: Use water only, avoiding all shampoos, soaps, bubble bath or antiseptic in the vulva region

Clothing: Wear loose fitting cotton underwear, airflow tights or stockings. Wash underwear in water only.

Period management Use unbleached tampons or pads.

Barrier creams: A barrier cream may be useful when swimming or if stinging occurs on passing urine.

Smear tests: Request a child’s size speculum and use breathing techniques to relax.

Dilators: These can be helpful when learning to introduce penetration to your treatment. See resource list for suggestions.
Always use with a lubrication.

Lubrication: With intercourse or dilator/dildo/vibrator always use lubrication to reduce friction, and moisturise for dryness.
Always look at the ingredients and aim for an organic, paraben free, glycerine free product eg YES

Trigger point release: Trigger points are tight usually painful areas within a muscle. Your physiotherapist may have treated and released these in clinic. It is possible to treat yourself using a trigger point release wand eg EZ Magic or a TheraWand.

Your first visit to the physiotherapy department

Your initial 1:1 appointment will include an assessment, both verbal and physical when we will usually offer a vaginal examination. You will be seen by an expert physiotherapist who has had post graduate training and experience in this field.

For further physiotherapy advice

For further advice you can leave a message for the pelvic health physiotherapists on 01223 217422.