Continuing our Education: Vestibulodynia, Vulvar Pain, and Beyond


Fiona McMahon PT, DPT

In a blog a few posts back, we covered some of our new skills we developed with our friends, Kelli Wilson PT, DPT, FAAOMPT, and Sara Sauder PT, DPT in addressing issues of the male pelvic floor. In this post, we will cover the new techniques and latest information we learned in issues concerning pelvic floor dysfunction in individuals of the female anatomy.

As experienced and expert physical therapists, we are all extremely comfortable with treating disorders of the pelvic floor, but the thing is, there is so much new information coming out, that even if your latest training was two years ago, chances are, there is a lot of new information out there to discover, which can really help your patients.

One of the most interesting things we learned about was in regards to hormonally mediated vestibulodynia and vulvar atrophy. Although many of us know how to spot these conditions, learning about the specific mechanism that causes them in cases of long term birth control use was fascinating. Long term birth control use can actually suppress the production of estradiol and testosterone from the ovaries and cause the liver to increase levels of sex binding hormone globulin, which takes even more of these hormones out of circulation. When this happens, the vulvar tissue can shrink, become thin, and friable (tear easily). This can cause burning and pain. It is important for PT’s to be able to screen for this condition so we may refer our patients to MDs who can get them on a different method of birth control or prescribe them topical treatments as needed.

We also learned more about conditions such as interstitial cystitis, lichens planus and sclerosis, pelvic congestion, vaginal adhesions, as well as other current medical treatments that are now available for our patients who are in pain.

All in all, it was a great course and we look forward to bringing our new knowledge to our patients to help them be more successful in our physical therapy treatments.

For most of last year, myself, Sara, and Amy worked together to contribute a chapter to the International Society for the Study of Women’s Sexual Health latest textbook on female pelvic pain which will be available soon on Amazon, and is an essential tool for practitioners treating pelvic and sexual pain from both a medical, mental health and physical therapy perspective. Check out the following excerpts from our chapter detailing treatment of pelvic pain here:

On who is an appropriate candidate for physical therapy:

“Ideal candidates for pelvic floor physical therapy referral are patients with pelvic floor musculoskeletal dysfunction or those who have been treated by clinicians for pelvic pathology but have not experienced symptom resolution. Clinicians can identify appropriate patients by palpating the vulva, performing a digital examination of thevaginal and rectal muscles, and performing a moist cotton swab test on the vestibule. If the patient reports reproduction of any of her sexual or pelvic pain symptoms with this examination, she is likely affected by pelvic floor dysfunction”

On what pelvic floor physical therapy is:

“Physical therapy intervention for the dysfunctional pelvic floor incorporates a comprehensive approach addressing specific tissue characteristics, strength, alignment, and neuromuscular control. Manual therapy is a hands‐on approach to correct tissue restrictions, improve alignment, and enhance blood flow. Different manual techniques may be used to achieve different objectives.”

Check out the full text: Musculoskeletal Management of Pelvic and Sexual Pain Disorders available here.



Pukall C, Goldstein A, Bergeron S, et al. Vulvodynia: definition, prevalence, impact, and pathophysiological factors. J Sex Med. 2016; 13(3): 291-304

Burrows L. Basha M. Goldstein A., et al. The effects of hormonal contraceptives on female sexuality: a review. J Sex Med. 2012;9 (9) 2213-23

Spring Pelvic Health 101 is Coming

Fiona McMahon, DPT, PT

Pelvic Health 101 is back with some old favorites like, “Something’s wrong with my what?” and “Why is pooping so difficult?” We have also added a new course on pediatric pelvic floor issues.

If you have questions, we have answers. Join us for lectures and question and answer opportunities with expert pelvic health physical therapists, childbirth educators, and nutritionists. Please reserve your spot early at Remember spots fill up quickly. As always, light refreshments will be served.


Anatomy of An Irritated Vestibule

By Riva Preil

Vestibulodynia (VBD, also called vulvar vestibulitis or vestibulitis) is a specific type of vulvodynia (refer to “Vulvo-what-ia?”, November 26 blog for details).  Both are considered chronic pain syndromes involving hypersensitivity of the central nervous system.  Whereas vulvodynia is believed to be caused by direct nerve injury, VBD is most likely due to repetitive inflammation around the nerve which interferes with the normal transmission of messages through the central nervous system.  New connections are made between receptor cells, the spinal cord, and the brain, and ordinarily non-noxious (non-painful) stimuli send messages to the brain which scream “PAIN!” loud and clear.  Therefore, tight jeans, wiping after toileting, water pressure while showering, cycling, gynecological speculum examinations, tampon usage, and intercourse may become very painful for an individual with VBD.

VBD can be sub-divided into primary VBD and secondary VBD.  Primary VBD refers to pain with the first attempt at vaginal penetration (either when first attempting to use a tampon or when an individual becomes sexually active).  Women who experience this generally suffer from other forms of painful conditions such as urinary dysfunction, constipation, irritable bowel syndrome (IBS), temporomandibular joint (TMJ) dysfunction, interstitial cystitis (IC), or fibromyalgia.  Secondary VBD refers to the development of pain with penetration after successfully tolerating pain free tampon usage or intercourse.  It is believed that certain triggers may be connected with the development of VBD, such as yeast infection, frequent urinary tract infections (UTI), human papillomavirus (HPV), or herpes, to name a few.

To be continued…