Utilizing multimodal physical therapy for women complaining of sexual pain: a clinical perspective

Extract

Female sexual pain, or dyspareunia, has any number of culpable etiologies. When considering chronic vulvar or superficial pain associated with vulvodynia, symptoms can be localized to pain only at the vulva, as in provoked vestibulodynia (PVD), or generalized, creating pain throughout the perineum and/or beyond, as in generalized vulvodynia. The etiology can be quite varied, including issues related to structure, inflammation, infection, neoplasm, neurology, or trauma as well by iatrogenic causes, or hormonal insufficiencies.¹ The diagnosis of “vulvodynia” is listed in both the ICD10 (code 94.819) and the DSM-5-TR, where it is included in the diagnosis of genito-pelvic pain/penetration disorder (GPPPD) and described as “persistent or recurrent difficulties with one (or more) of the following: vaginal penetration during intercourse; marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts; marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration; marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration” and having persisted for “a minimum duration of approximately 6 months” as well as “cause clinically significant distress in the individual…not better explained by a nonsexual mental disorder or as a consequence of a severe relationship distress (e.g., partner violence) or other significant stressors and is not attributable to the effects of a substance/medication or another medical condition”.² Likewise, complaints of deep dyspareunia have been attributed to gynecologic conditions, nongynecologic conditions, central sensitization and GPPPD, or some combination of the above.³ Alternative precursors include psychosocial issues, including anxiety, past sexual abuse, or vaginismus. This perspective will discuss clinical approaches gleaned from the author following nearly 30 years of practice specializing in the treatment of women with chronic vulvar pain (CVP) prior to retirement in 2017. Its focus will deal primarily with multimodal physical therapy, defined as clinical use of multiple physical therapy modalities, and its application to the treatment of dyspareunia associated with CVP or localized PVD, the most prominent subtype of vulvodynia.