PART II – Pelvic floor Physiotherapy Treatment For Dyspareunia (Pain during intercourse)

estibulodynia (PVD), a component of dyspareunia, is effectively treated with Pelvic Floor Physiotherapy/Rehabilitation (PFP/PFR).  Clinically, I have seen great success with PFP treatment for PVD, which is comforting news for women who suffer from this life-altering condition.

One of the important elements of dyspareunia that was discussed in Part I was the pain/spasm cycle  (see diagram). Treatment of dyspareunia, in particular PVD, involves applied techniques that assist with breaking the pain cycle that leads to decreased spasm, discomfort, and eventually pain-free intercourse and sexual activity.

Treatment techniques for vestibulodynia

One of the most important components of treatment is education.  Educating the patient is vital in the patient’s understanding and control of the pain.  Often patients have very little knowledge and understanding about pelvic floor muscles (PFMs) and PVD.  The relationship between pain and tension, potential pain control methods, and knowledge of the pain cycle, will all serve to decrease anxiety responses during intimate situations. The key to effective treatment is providing patients with these tools so they can control their pain.  

In order to break the pain cycle, the patient must learn to limit the magnitude of the protective response to vestibular pressure (pressure near the entrance of the vagina), and to consciously relax the muscles of the pelvic floor for penetration. However, in order for the patient to fully relax the PFMs for penetration, she must first be able to identify these muscles. Clinically, one of the major complaints from women is that they are not fully aware of how to contract the PFMs or even find them!  This sense of awareness is termed proprioception. The key to relaxation of the pelvic floor is to increase the patient’s proprioception or awareness of the musculature. The patient must first be able to identify the muscles in order to fully relax and contract them. This also teaches the patient to establish control of her PFMs—an important part of decreasing pain.

Education also allows women to identify stress in the pelvic region during a normal day and relax the PFMs during these situations.  Many women hold tension in this area and aren’t aware of this until they have PFP treatment.  Sometimes, the relaxation established through PFP is enough to diminish their pain significantly or completely.

PFP treatment also empowers the patient because she learns to play an active role in controlling her pain.  As she learns to sufficiently relax, her anxiety reactions to penetration decrease, and this, in turn, further decreases pain—the pain cycle is broken!

The physiotherapist will also use specific treatment techniques to increase the patient’s proprioception of the PFMs.   These can include:

  1. Manual techniques – Directive pressure and light tapping are utilized to facilitate PFM awareness and contraction in order to facilitate relaxation of these muscles.  It also increases the connection between the brain, muscle, and nerve—the neuromuscular connection—which will assist with PFM relaxation
  2. Biofeedback – The patient is able to visualize the pelvic floor musculature through monitoring electromyographic (EMG) activity and its simultaneous display on a computer screen. Establishing the neuromuscular connection and reinforcing the PFM contraction and post-contractile relaxation through instant visual feedback assist the patient in learning to completely relax the muscle.
  3. Electrical stimulation (EMS) – The application of an electrical current, via an intra-cavity electrode, produces a reflex muscle contraction. This leads to better compression of the PFMs, subsequently improving active contraction and post-contractile relaxation.

Other techniques are also used to facilitate relaxation of the PFMs.  These can include:

  1. Mobilization of muscle, myofascia, and soft tissue to normalize muscle tone – Stretching techniques and trigger point release can decrease pelvic floor hypertonicity (i.e. tightness or increased tone). This will also limit protective muscular reactions and increase the elasticity of the tissues at the vaginal entrance.  Often, scar tissue deep in the vagina is the cause of deep dyspareunia (i.e. pain deep in the     vaginal region. Releasing and breaking down the adhesions and tightness eliminates this pain.  Another common symptom of PVD is pain associated with small tearing in the vaginal or     vestibular tissue, also known as genital fissures, which often leave scar tissue at the vaginal opening.  Stretching techniques will help to     relieve     the scar tissue, restore elasticity to the     region, and prevent further tearing.
  2.  Biofeedback – This technique is used to teach the patient how to relax the pelvic floor muscles in preparation for intercourse.
  3. Relaxation and breathing techniques

Another common symptom and complaint with PVD is pain and hypersensitivity in the vestibular region. This occurs because the nerve endings and receptors become altered and hypersensitive detecting every sensation as pain.  Manual Desensitization techniques, which involve applying normal tactile sensations and cues in this region, are used to normalize the patient’s sensations and nerve pathways in this area. EMS can also be used.

As treatment progresses, additional techniques are implemented to prepare the tissues for comfortable penetration. Insertion techniques with accommodators or dilators are integrated in treatment with the patient and partner, if comfortable, to teach the patient to stay relaxed during sexual intercourse. Insertion techniques also enable the patient to stretch the PFMs at home.  Improving control of PFM contraction and relaxation is another valuable tool in reinforcing the patient’s ability to control pain.

Typically treatment sessions are once a week for 8-12 weeks, although this will vary depending on the condition and individual.  Progress can be slow, but pain-free intercourse is often achieved upon completion of PFP. Other conditions associated with dyspareunia that won’t be covered in this article can be more difficult and challenging to treat such as vaginismus.  Vaginismus is a condition that involves involuntary muscle spasms at the entrance to the vagina, making sexual intercourse painful or impossible.  It often has a psychological component that requires psychotherapy intervention along with intensive pelvic floor physiotherapy.

Helpful Tips to remember:

  • The “squeeze and let go” technique of the PFMs—this is a very simple, yet very useful, technique to ensure complete relaxation of the pelvic floor, particularly just before penetration.
  • Progress slowly and remember to breath!
  • Relax your entire body, not just your pelvic region. Tension anywhere in your body will also indirectly increase the PFM tone.
  • Use communication tools with your partner—i.e. non verbal cues are better than verbal cues, such as screaming, which can increase tension and ultimately pain.
  • Always use lubrication, even if you are pain free. This will prevent recurrence of the pain cycle.
  • Pain will fluctuate with a woman’s cycle due to hormonal changes. Two to three days prior to menstruation and the end of the cycle are often more sensitive times.
  • Avoid using plastic sanitary napkins, which can irritate the condition.  Cotton pads are available.