«Chronic vulvar pain as addressed by physical therapy»

Dee Hartmann

Physical therapist, Center for Genital Health and Education, Boulder, Colorado, EUA

Chronic vulvar pain identified as provoked vestibulodynia (PVD) is an idiopathic pain syndrome located at the opening of the vagina. Diagnosed by positive Q-tip testing at points around the introitus, PVD is best treated through a multidisciplinary approach which includes physical therapy.

Physical therapists, by training, address abnormal function throughout the body. Those with specialty training in women’s health also assess and treat pelvic dysfunctions and the symptoms they cause. In the case of PVD, the greatest loss of function is the ability to tolerate any type of vaginal penetration and more specifically, to have pleasurable, pain-free sex.

Dee Hartmann

In my 30 years of experience, patients taught me that vulvar pain may be the first problem noticed (i.e., pain with attempting to insert a tampon or with first attempted penetration during a sexual experience) or one that occurs after other persistent disorders are onboard (i.e., recurrent UTI or yeast infections or hip and/or low back pain or injury). Likewise, sexual pain can be the presenting problem or one that develops over time.

Whichever the case, the body responds with chronic tension throughout the pelvis and surrounding areas. For the most complete recovery, all areas require attention and care.

To do that, an overall look at posture and gait may be indicated as a first step. That is followed by assessment of the pelvic and abdominal viscera, fascia, and muscle as well as the bony structures throughout the spine, pelvis, hips, and beyond.

Dee Hartmann foi a coordenadora do curso "Impacto da dor vulvar crónica e do trauma na função sexual feminina", que se realizou durante o XV Congresso Português de Ginecologia

Chronic pelvic and/or abdominal dysfunction can create tension and pain in the organs of the pelvis (urethra, bladder, uterus, rectum), the internal pelvic support systems (i.e., uterosacral and pubocervica ligaments, arcus tendinous of levator ani and pelvic fascia), the bony structures (i.e., sacroiliac joints, pubic symphysis), and, finally, muscles (i.e., pelvic floor muscles (PFM), obturator internus and psoas muscles).

Just like pain, PFM overactivity may be present from the beginning or may start following a series of other symptoms. But whatever the case, PFM overactivity is typically the number one problem when it comes to PVD and sexual pain.

Pelvic floor muscle tone dictates the physical size of the vaginal opening. When there is PFM underactivity, the introitus may gape open and be quite inferior to a plane created by the ischial tuberosities. With normal PFM tone, the vaginal opening is located just superior to that plane.

However, when the muscles are overactive and tone is high, the opposite occurs, and the perineal body is pulled superior into the pelvis (above the plane of the ischial tuberosities) and the introitus is much smaller in diameter. Along with that increased tone, comes tension and pain at the introitus, all contributing to painful penetration.

There are 5 exercises that often help women with PVD reduce pain at the opening before any type of vaginal penetration, be it with a tampon, sex toy, finger, or speculum exam. The first is deep lateral diaphragmatic breathing followed by bilateral hip stretches, stretching of the urachus in the lower abdomen, active bridging, and active PFM mobility. You can view the exercises in a video presentation here. But more times than not, just getting rid of the pain is not enough.

Dee Hartmann com Pedro Vieira Baptista e José Martinez de Oliveira

Losing the incredibly personal and intimate experiences of sexual function can be stressful, traumatic, and shame producing. When you add on the overall events of life, the drive and ability to experience sexual desire, arousal, and pleasure are all but eliminated.

Unfortunately, this not only happens to those with chronic vulvar pain but can plague women throughout their entire life cycle, from menarche to the childbearing years and on throughout menopause.

To help women through these trying issues, we need to help them understand what they can do to help themselves, not only with easing pain but with also finding their own sexual desire, arousal, and pleasure. It’s not an easy task but it is very possible. There is hope.

Artigo publicado na Women`s Medicine de setembro/dezembro, revista de referência na área da Ginecologia/Obstetrícia e Saúde da Mulher em Portugal.
Veículo único de partilha de conhecimento e de experiência entre os diversos profissionais a nível nacional. 



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