Vaginismus and Vestibulodynia: Common Diagnoses of Vaginal Pain and How Pelvic Floor Physical Therapy Can Help

By Dr. Katie Ihlenfeldt, PT, DPT

Pain “down there” can be stressful to deal with because one, it is such a vulnerable part of our body but two, there are a lot of systems going on down there. Your bladder, reproductive organs, colon, and pelvic floor muscles converge in the pelvis so there’s a lot of systems that could be a source or contributor of pain.  This is partially why I think it takes so long for people to see a pelvic floor physical therapist when they are dealing with pain; the medical system needs to rule out possible issues with all the above before they end up referring someone to a pelvic floor physical therapist.  

Do I think this is the right system to go about when someone comes in with pelvic pain? Nope. 

I think as soon as someone is coming to their provider reporting pelvic pain, pelvic floor physical therapy should be the first referral while they are ruling out other possible causes. I say this because in many cases the pelvic floor muscles are the source or at least a contributor to symptoms and pelvic floor physical therapy is a conservative method of treatment. I’ll be the first to admit it’s important to be seeing an additional medical provider to rule out any other possible conditions but there is no harm in starting pelvic floor physical therapy in the meantime.  On top of all that, a pelvic floor therapist is going to tell you if they believe something outside of the pelvic floor or musculoskeletal system is involved. Either way, pelvic floor physical therapy can be SO beneficial for a lot of these conditions and it’s a shame that we are usually one of the last providers people see. 

Below I’m going to give a brief overview of vaginismus and vestibulodynia, two of the more common diagnoses given to those with vaginal pain. 

Vaginismus

What is it?

- Can also be referred to as a “hypertonic pelvic floor” 

- When your pelvic floor muscles contract involuntarily in anticipation of penetration 

What causes it?

- Sexual or medical trauma

- Large life change or stressful event

- Painful sexual experience, sometimes occurring postpartum after perineal/vaginal tearing

- Low back/hip/tailbone injury 

- Frequent UTIs/bladder infections/yeast infections 

- Hx of abdominal surgery

- Sometimes cause is unknown

Signs and symptoms:

- Vaginal pain that occurs with sexual penetration

- Vaginal pain with the use of tampons and during pelvic exams 

- Feeling a “roadblock” or “hitting a wall” during sexual penetration

- Painful orgasm

- Constipation 

- Urinary hesitancy, frequency, and stress incontinence 

What pelvic floor physical therapy can do:

Treatment usually includes breathing techniques, stretching and strengthening exercises, pelvic floor muscle coordination based on what you specifically need, and manual soft tissue releases. Manual therapy could include abdominal tissue, spinal muscles, hip/gluteal muscles, and possibly internal pelvic floor muscles.  A pelvic wand or dilators are also commonly prescribed for this condition to help people perform self-release of the pelvic floor muscles at home if deemed appropriate. 

Vestibulodynia 

What is it?

-Pain experienced at the entrance of the vagina (vestibule)

-Pain experienced on other parts of the vulva

-Considered to be a nerve-related pain 

What causes it?

-Causes of vestibulodynia are largely unknown

-Could be caused by neuron proliferation or an increased number of pudendal nerve endings

-Hypersensitivity of pudendal nerve endings 

-Sexual or medical trauma 

-Hx of chronic yeast infections, UTIs, bladder infections

-Low back, tailbone, hip injury

-Reaction from being exposed to irritants in soaps, laundry detergent, or panty liners

Signs and symptoms:

-Burning, stinging, or “knife-like” pain 

-Pain with intercourse, pelvic exams, or use of tampons

-Pain with prolonged sitting 

-Pain with tight-fitting clothing; underwear, pants, shorts 

-Tender, raw or red area along the vestibule 

What can pelvic floor physical therapy do to help?

This is where the orthopedic exam is so important! When dealing with nerve pain we need to determine where/which nerves are involved; in the case of vestibulodynia it usually is caused by the pudendal nerve or even a nerve coming from the lumbar spine. Exercises and stretches to improve nerve mobility can help with symptoms.  This type of pain can also cause the pelvic floor muscles to increase in tension in a response to the pain. As with vaginismus, treatment includes specified manual soft tissue treatment, stretches, and exercises based on what specifically the individual needs. Dilators and wands may also be prescribed based on how the pelvic floor muscles present. 

As I mentioned early, we see a lot of people after years of them going to different doctors trying to figure out what’s going on before coming to pelvic floor physical therapy.  It’s heartbreaking at times because people have been told their pain is “in their head” and to “just try to relax” or “have a glass of wine”; all of this advice does not solve the original issue and in my opinion is dangerous advice coming from a medical provider.  

If you are someone that can relate to the symptoms above or know someone that does, let them know pelvic floor physical therapy exists and can help!!