Distinguishing the Different Causes and Treatments for Pelvic Pain

Vaginal burning, pelvic discomfort while sitting, and pain from penetration are symptoms that often result in the general diagnosis of “pelvic pain”. You may have googled your symptom(s) and found answers that sound scary and confusing. Vulvodynia, Vestibulodynia, Vaginismus? What are they and how are they different? More importantly, how do treatments differ?  The treatment comes down to the anatomy - the difference between muscle and tissue. It is important to understand your symptoms because they may dictate a multidisciplinary treatment approach.

The vulva is the external genitalia: the labia, clitoral area and urethral opening. The vestibule is the tissue between the vulva and the vagina. 

Vulvodynia: The vulva is made up of tissue. Causes of tissue irritation can be hormonal insufficiency, dermatological skin conditions, muscle dysfunction, childbirth, pelvic surgeries, nerve irritations, yeast infections, and bacterial vaginosis. The sensation of burning and irritation in the vulvar area, specifically, is called Vulvodynia. This sensation and pain can remain even when the skin condition or infection has cleared up.  Symptoms can be constant, unprovoked vulvodynia, or exhibited only with touch, provoked vulvodynia. 

Vestibulodynia (Vulvar Vestibulitis): The tissue between the vulva and the vagina, the vulvar vestibule, is very susceptible to break down. The vestibule contains highly sensitive nerve endings that can become easily irritated. Irritation frequently occurs from repetitive yeast infections. Other causes of tissue break down and irritation can be hormonal imbalances: oral contraceptives, hormone suppression therapy, menopause, breastfeeding etc. A lack of, or imbalance of, specific hormones can compromise the tissue, resulting in pain, discomfort and burning. The tissue will typically look irritated upon inspection. 

Vaginismus: This is pain in the pelvic floor muscles. The tissue is intact, there is no visible change to the skin but muscle spasms occur. Muscle spasms can make it painful, make it difficult or impossible to have sexual intercourse, insert a tampon or have a gynecological exam. When the muscles that surround the vaginal opening are in constant spasm, over a period of time, they can end up shortened and contracted. 

What treatment can I expect?

Treating these conditions may require a multi-disciplinary approach.  If the pain is tissue-related, it should be treated medically by a physician.  If the tissue is red, pale or atrophied this will cause pain and prevent you from improving with physical therapy. It is important to visually check this periodically! If vaginismus exists alone, without the overlap of vulvodynia and vestibulodynia (irritated tissue), physical therapy by itself is highly effective. Manual therapy, the use of vaginal dilators and down training of the area will help resolve the constant contraction of muscles. In conjunction with physical therapy, the muscles can be chemically altered with Botox to relax the muscles. It is equally important to find the root cause of the shortened, contracted muscles. Often there are multiple causes of pelvic pain. Because of this, it can be challenging to treat and resolve. Make sure all issues are being addressed by the clinicians on your care team!