Physiotherapy Treatment for Vulval Pain
An update for the Vulval Pain Society Handbook.
16th July 2020
I was recently asked by the Vulval Pain Society (VPS) to write an update for their handbook regarding Physiotherapy treatment for vulval pain. I wrote the original section on Physiotherapy in their handbook several years ago, and things have moved on in this area of treatment quite a lot. I would highly recommend the VPS handbook for anyone suffering with vulval pain, and the VPS website and support groups are sources of invaluable advice. This blog aims to outline the key areas that have changed in my practice over the past few years.
Due to the recognition of the fact that a large proportion of women with vulval pain will have hypertonic (overactive) pelvic floor muscles, a key thing that has changed in treatment is the emphasis placed on pelvic floor muscle awareness and relaxation (although we always gave this attention in treatment, it would now be a key area of focus). We also have a much greater understanding of the changes that go on within the central and peripheral nervous systems of people with long term pain, and their complex nature. This means that we would tend to put a much greater focus on calming the nervous system during treatment both in clinic, and also in your home exercise plan.
Calming the Central Nervous System:
Pain is the bodies way of identifying a threat. This anticipation of threat puts our nervous system into a state of high alert. If you can calm the central nervous system and decrease the “threat response”, this can help to reduce pain. Mindfulness, meditation, visualisation or gentle yoga can all be helpful in achieving this. You may wish to try the Calm or Headspace apps, or look for specific yoga for pelvic pain classes online (see resources below). If you get good at identifying and managing stress and tension in the body as a whole, this will help you to recognise and address the tension in your pelvic floor muscles.
Pelvic floor muscle awareness and relaxation:
I would now actively discourage anyone with vulval pain from doing pelvic floor muscle (Kegel) exercises, unless you absolutely need to and it has been confirmed that you do not have a hypertonic (overactive) pelvic floor. Instead the focus needs to be on your awareness and conscious relaxation of your pelvic floor. It is important that you regularly “check in” with your pelvic floor muscles throughout the day, and relax them if you notice they are tense (particularly if you are busy or stressed). It is important to try to become aware of this tendency to hold tension in the muscles, and that you learn to release it. You may find that when you are having a flare up of your pain, relaxing your pelvic floor muscles regularly brings you some relief from your symptoms.
To relax your pelvic floor muscles effectively, combine doing so with correct breathing. This means breathing from the diaphragm and abdomen, rather than the ribs, shoulders and neck. Place one hand on your upper chest, and another on your belly. As you breathe in through your nose, let your abdomen gently swell out into your lower hand. Your diaphragm lowers as you do this, so it is the natural time to relax and lower your pelvic floor muscles. As you exhale, your diaphragm will rise and you can allow your pelvic floor muscles to do the same. Try to inhale for 5-7 seconds, and exhale for the same length of time as you do this. Repeat for 5 breaths. Try to do this several times per day.
It can be incredibly helpful to combine your breathing with adopting yoga positions that put the pelvic floor muscles on a stretch, such as: happy baby, child’s pose, goddess pose and prayer stretch. Any position that opens up your hips and pelvis in this way is helpful and (along with the breathing and meditation) is another reason yoga can be beneficial for vulval pain.
You may also want to try visualising what is happening to your pelvic floor muscles as you try to relax them. Some people find it helpful to imagine their pelvic floor muscle like a large tight flower that is beginning to bloom, and gradually opens up (relaxes) as you breathe in. Some people like to picture the pelvic floor as a jelly fish swimming; lifting and lowering as it moves through the water. Other people find it helpful to picture what is happening to the bones in the pelvis as the pelvic floor muscles relax – you could picture your coccyx and pubic bone becoming further apart, or the space between your sitting bones widening.
Once you have mastered pelvic floor awareness and relaxation, and your pain is under control, you can move on to improving the strength (if needed) and the function of your muscles. This will then help to resolve any other issues you may have with bladder and bowel control.
Myofascial trigger points:
In the past ten years or so there has been some focus on myofascial trigger points as a source of pain within the pelvic floor of women with vulval conditions. There is currently some debate within our professional field about what myofascial trigger points actually are (or are not), and their usefulness in treatment. It is believed to be preferable to describe areas previously thought to be trigger points within the pelvic floor as “tension myalgia” – this simply means a tight and painful muscle or area within a muscle. It is not incorrect in treatment to want to release this tension myalgia within the pelvic floor, and this can be achieved through a combination of manual therapy (either in clinic, or yourself at home if you have been taught how to do this correctly), and through your own awareness and relaxation of the muscles (and therefore gradual lengthening). It can not be done through manual therapy alone, and the manual therapy always needs to be carried out below the level of discomfort that your body perceives as a threat (it should not cause pain). Easing the tension myalgia will increase the blood flow to the area, relieve any swelling, aid relaxation of the pelvic floor, and allow the muscle and surrounding structures to move more freely – ultimately this will lead to greater comfort.
Biofeedback and real time ultrasound:
I would now tend not to use EMG biofeedback in clinic, preferring to use real-time ultrasound as a means of helping someone to learn how to relax their pelvic floor muscles effectively. Real-time ultrasound scanning allows us to “see” inside the body, and show a picture on a screen of what the pelvic floor muscles are doing as you try to relax them, and the changes to the pelvic floor that occur simply as a result of deep breathing. This can be incredibly helpful.
Hopefully these tips and suggestions will help you to understand what you can be doing at home to help to reduce the tension in your pelvic floor muscles, and will help you to understand where treatment has changed over the past few years.
Always seek a diagnosis from a Gynaecologist with a special interest in vulval conditions, and always work with a specialist pelvic health physiotherapist if you are trying to address known hypertonic (overactive) pelvic floor muscles.
Vulval Pain Society: www.vulvalpainsociety.org
Incredibly helpful website, handbook, conferences and support groups.
You may find some useful information about your condition on these websites, which have excellent Physiotherapy blogs:
“Heal pelvic pain” by Amy Stein and “Ending female pain” by Isa Herrera are both excellent self-help resources for patients. Likewise “The Explain Pain handbook – the protectometer” by David Butler and Lorimer Moseley can be a very useful read. All on Amazon.
Pelvic pain and yoga resources:
Isa Herrera – www.pelvicpainrelief.com
Dustienne Miller – www.yourpaceyoga.com
Shelley Prosko – www.physioyoga.ca
You may wish to watch this video by Isa Herrera explaining the benefits of yoga for pelvic pain: https://www.facebook.com/IsaHerreraPelvicHealer/videos/966715480206340/?inf_contact_key=a0282ffb6bf746ed824fae086672c97f97328390a62d7ce1fa13f1fa504e69ad
Guided pelvic floor muscle relaxation and stretches:
Brianne Grogan –