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Hypertonic Pelvic Floor, Vaginismus, and Dyspareunia

 

This page will present hypertonic pelvic floor, vaginismus, and dyspareunia. All three are used interchangeably by many providers and patients incorrectly, and there are many symptoms that overlap. It’s important to differentiate between all of them to correctly assess patients so they can receive proper treatments (Bornstein et al., 2014). In addition, there are many reasons for why these issues can occur, which are not all psychological. Structural, anatomical and immune system issues can cause hypertonic pelvic floor, dyspareunia, and vaginismus symptoms, such as hip abnormalities, spine issues, endometriosis, cancers, mast cell issues, and connective tissue disorders (Bornstein et al., 2015; Zhu et al., 2013). Overall, it is imperative that all three are treated with multiple specialists to receive the best outcome such as with a vulvar specialist, gynecologist/urologist, pelvic floor physical therapist, orthopedic physical therapist, cognitive therapist specializing in sexual disorders and chronic pain, and a pain management expert (Committee Opinion, 2016).

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Hypertonic Pelvic Floor

Many people with endometriosis, adenomyosis, urinary dysfunction, bladder and bowel issues, spine injuries, vulvodynia and vestibulodynia, and pudendal neuralgia have hypertonic pelvic floor (Butrick, 2009; Cameron et al., 2019). Trauma to the pelvis from an accident, child birth, or poor posture can also contribute to pelvic floor hypertonicity. Men also have pelvic floor dysfunction and the inability to relax the pelvic floor, which can contribute to conditions such as erectile dysfunction, hard flaccid, and urinary and fecal incontinence (Pastore et al., 2014; Yani et al., 2022).

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In a review by Kapurubandara et al. (2022), a lack of consensus exists on how pelvic floor dysfunction is characterized after the in-depth assessment of five studies. The authors strove to find diagnostic tests which can screen and detect for pelvic floor myofascial pain. "Vaginal palpitation" is often used as a reference test among most providers. Ultimately, the results revealed that no diagnostic tests exists that are better than vaginal palpitation.

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From personal experience and from seeing this on Facebook groups regularly, patients are often sent to pelvic floor physical therapy with an umbrella diagnosis of “pelvic floor hypertonicity.” Again, this does not tell the origination of the issue itself, and if not assessed and screened for accordingly, there can be worsening issues or no improvement.

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For example, I was sent to pelvic floor PT by my third local gynecologist without having a proper diagnosis. After attending session after session, I kept getting worse and worse to the point that I could barely walk after doing dry needling, lengthening, stretches, and relaxation techniques. (1) The treatments were too rough (2) my joints are lax with EDS (unknown to me at the time) (3) I had significant hip dysplasia, and cam impingement which were missed many times (also unknown to me at the time) (4) I was told my issues were mental or my brain was just too overactive. However, after two sessions of orthopedic PT my pain symptoms decreased by so much and I was up walking, despite being told by many pelvic floor PTs that it would take years to undo this. I would argue that we are not there yet for multiple symptom patients with structural abnormalities that surround the pelvis. The medical system has failed me with pelvic floor dysfunction despite doing everything they told me to do in a linear fashion.

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There many people that have hypertonic pelvic floor but cannot relax the pelvis due to having weak muscles too. The fascia, musculosketal system, and organs contribute to pelvic floor dysfunction. Pelvic floor physical therapists need to be able to effectively treat, evaluate, and assess for pelvic and sexual health (Stein et al., 2019).Therefore, a combination of strengthening and lengthening and relaxing the pelvis will be sufficient to begin to relax the pelvis (Stein et al., 2019).

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Current treatments:

  • Pelvic floor physical therapy with a focus on lengthening, calming down the nervous system (the actual nerves, not anxiety) relaxing, and desensitization

    • Myofascial release

    • Trigger point therapy

    • Dry needling

  • Cognitive therapy

  • Meditation and mindfulness

  • Muscle relaxants (valium suppositories, oral pills: baclofen, flexiril)

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Vaginismus

In a review by Lahaie and colleagues (2010), vaginismus has been characterized as an “involuntary vaginal muscle spasm” of a person with a vagina that prohibits coitus, finger entry, dilation, and tampon insertion. Despite one's desire to have penetration, the person is not able to fulfill the act.

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Symptoms of Vaginismus

  • High-muscle tension in pelvic floor region

  • Fear of penetration (vaginal, speculum, tampon insertion)

  • Psychological symptoms: Interpersonal factors such as negative attitudes towards sexual behaviors, a history of child maltreatment or abuse, lack of sexuall education

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While it is deemed as treatable by many clinics, many patients are misdiagnosed with it and may actually have vestibulodynia (hormonally-mediated, neuroproliferative, acquired neuroproliferative) and some form of pelvic floor dysfunction. See the vestibulodynia page. The authors of this review suggested that physicians claim vaginismus is treatable “easily,” but there are not many papers to support this (Lahaie et al., 2010). Furthermore, there is no agreed upon classification for the muscles that spasm before intercourse or dilation. In addition, there is no evidence that supports that vaginal muscles spasm on their own upon receiving a threat (Goldstein, n.d).

 

Pacik et al. (2014) discussed that vaginismus has a high rate of success unlike vestibulodynia and vulvodynia. However, this may be solely because the patients that underwent his botox procedure with aggressive dilation were screened effectively in comparison to other patients. For some reason, the questions I received from his clinic were different than the ones he used for his study, and did not properly address the location of my pain, or any structural abnormalities. The questions were high level and did not even scratch the surface of the pain symptoms I was experiencing with dilation or pentration. They were primarily psychological screening questions at best and focused on lubrication. Obviously, if you experience pain at a young age, it will be anxiety producing and you will have pain anticipation.

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In 2015, Lahaie et al. conducted a study to assess whether fear (subjective, behavioral, and psycho physiological) could be differentiated between people with provoked vestibulodynia in comparison to vaginismus while also evaluating muscle tension differences.  While there are many overlapping symptoms between all conditions, patients who had a fear of vaginal penetration actively avoided any type of penetration and had multiple, failed attempts at having sexual intercourse. Fear and muscle tension were significantly greater in the vaginismus groups compared to the dyspareunia and PVD groups, which supports that vestibulodynia has less of a psychological component than vaginismus.

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Current treatments:

  • Pelvic floor physical therapy with a focus on lengthening, relaxing, and desensitization

  • Cognitive therapy

  • Meditation and mindfulness

  • Botox

 

As someone who was misdiagnosed with vaginismus at the start of my medical journey, I highly recommend that providers assess their patients properly. Ask them where their pain is. Do not deem it as psychological or mental until the pain has been assessed for, especially if their backs are raising off the exam table while performing an internal or pelvic exam. My  gynecological pain was deemed as psychological for many years to which I made no progress in cognitive therapy, and the pain still remained. For many years, I thought the pain was in my head/mental. However, now that I have a diagnosis of Ehlers-Danlos syndrome, endometriosis, neuroproliferative vestibulodynia, SI joint dysfunction, hip dysplasia and CAM impingement, it is likely that everything was contributing to the pain and structural dysfunction.

 

Dyspareunia

Dyspareunia which means “painful sex” can refer to both external (superficial) and internal pain (deep). Dyspareunia can affect 10-28% people with a vulva in a life time (Harlow et al., 2014) There are many reasons to why dyspareunia can occur which is often attributed to lack of lubrication, inflammatory, structural, and psychosocial reasons (Harlow et al., 2014). Often times, dyspareunia is characterized as "deep dyspareunia" which can be caused by a number of factors:

  • Endometriosis

  • Adenomyosis

  • Ovarian cysts

  • Structural abnormalities

  • Rheumatological diseases

  • Pudendal neuralgia

  • Vestibulodynia (hormonally-mediated, neuroproliferative vestibulodynia, acquired neuroproliferative vestibulodynia)

  • Vulvodynia

  • Hip abnormalities (dysplasia, labral tears, femoroacetabular impingement)

 

It's important to note that endometriosis is one of the most prevalent diseases to contribute to deep dyspareunia (Yong et al., 2017).  The disease, depending on the stage, can spread pervasively around the peritoneal cavity and even emerge in all organs of the body. If the endometriosis, or even adenomyosis, is not removed or treated effectively by excision with a knowledgeable specialist or suppressed, no amount of pelvic floor PT or cognitive therapy will alleviate the pain with penetration, speculum exams, or dilation. Surgery may not be a viable option for everyone, but there are no good options currently for people with endometriosis or adenomyosis.

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In a randomized controlled trial by Gahderi et al. (2019), the effects of pelvic floor rehabilitation techniques on dyspareunia were evaluated among 64 women (32 experimental with electrotherapy, manual therapy, 32 no treatment) After three months of pelvic floor rehabilitation, the experimental group had significant improvement in pelvic floor strength and endurance. The authors reported that many dyspareunia patients have overactive pelvic floor muscle and also weak muscles. Both strengthening exercises and reducing resting tone of the pelvic floor are recommended along with a multidisciplinary team (Gahderi et al., 2019).

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References

 

Bornstein, J., Goldstein, A. T., Stockdale, C. K., Bergeron, S., Pukall, C., Zolnoun, D., Coady, D., & consensus vulvar pain terminology committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), the International Society for the Study of Womenʼs Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS) (2016). 2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. Journal of lower genital tract disease, 20(2), 126–130. https://doi.org/10.1097/LGT.0000000000000190

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Butrick C. W. (2009). Pelvic floor hypertonic disorders: identification and management. Obstetrics and Gynecology clinics of North America, 36(3), 707–722. https://doi.org/10.1016/j.ogc.2009.08.011

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Cameron, B., Sabourin, J., Sanaee, M. S., Koenig, N. A., Lee, T., & Geoffrion, R. (2019). Pelvic floor hypertonicity in women with pelvic floor disorders: A case control and risk prediction study. Neurourology and Urodynamics, 38(2), 696–702. https://doi.org/10.1002/nau.23896

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Committee Opinion No 673: Persistent Vulvar Pain. (2016). Obstetrics and gynecology, 128(3), e78–e84. https://doi.org/10.1097/AOG.0000000000001645

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Ghaderi, F., Bastani, P., Hajebrahimi, S., Jafarabadi, M. A., & Berghmans, B. (2019). Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. International urogynecology journal, 30(11), 1849–1855. https://doi.org/10.1007/s00192-019-04019-3

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Goldstein, Irwin. (n.d.). Vestibulodynia. San Diego Sexual Medicine. https//www.sandiegosexualmedicine.com/female-issues/vaginismus

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Harlow, B. L., Kunitz, C. G., Nguyen, R. H., Rydell, S. A., Turner, R. M., & MacLehose, R. F. (2014). Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions. American Journal of Obstetrics and Gynecology, 210(1), 40.e1–40.e408. https://doi.org/10.1016/j.ajog.2013.09.033

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Lahaie, M. A., Boyer, S. C., Amsel, R., Khalifé, S., & Binik, Y. M. (2010). Vaginismus: a review of the literature on the classification/diagnosis, etiology and treatment. Women's Health, 6(5), 705–719. https://doi.org/10.2217/whe.10.46

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Kapurubandara, S. C., Lowes, B., Sansom-Daly, U. M., Deans, R., & Abbott, J. A. (2022). A systematic review of diagnostic tests to detect pelvic floor myofascial pain. International urogynecology journal, 33(9), 2379–2389. https://doi.org/10.1007/s00192-022-05258-7

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MacNeill C. (2006). Dyspareunia. Obstetrics and gynecology clinics of North America, 33(4), 565–viii. https://doi.org/10.1016/j.ogc.2006.09.003

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Lahaie, M. A., Amsel, R., Khalifé, S., Boyer, S., Faaborg-Andersen, M., & Binik, Y. M. (2015). Can Fear, Pain, and Muscle Tension Discriminate Vaginismus from Dyspareunia/Provoked Vestibulodynia? Implications for the New DSM-5 Diagnosis of Genito-Pelvic Pain/Penetration Disorder. Archives of sexual behavior, 44(6), 1537–1550. https://doi.org/10.1007/s10508-014-0430-z

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Pastore, A. L., Palleschi, G., Fuschi, A., Maggioni, C., Rago, R., Zucchi, A., Costantini, E., & Carbone, A. (2014). Pelvic floor muscle rehabilitation for patients with lifelong premature ejaculation: a novel therapeutic approach. Therapeutic advances in urology, 6(3), 83–88. https://doi.org/10.1177/1756287214523329

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Pacik P. T. (2014). Understanding and treating vaginismus: a multimodal approach. International urogynecology journal, 25(12), 1613–1620. https://doi.org/10.1007/s00192-014-2421-y

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Stein, A., Sauder, S. K., & Reale, J. (2019). The Role of Physical Therapy in Sexual Health in Men and Women: Evaluation and Treatment. Sexual Medicine Reviews, 7(1), 46–56. https://doi.org/10.1016/j.sxmr.2018.09.003

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Yani, M. S., Eckel, S. P., Kirages, D. J., Rodriguez, L. V., Corcos, D. M., & Kutch, J. J. (2022). Impaired Ability to Relax Pelvic Floor Muscles in Men With Chronic Prostatitis/Chronic Pelvic Pain Syndrome. Physical therapy, 102(7), pzac059. https://doi.org/10.1093/ptj/pzac059

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Yong P. J. (2017). Deep Dyspareunia in Endometriosis: A Proposed Framework Based on Pain Mechanisms and Genito-Pelvic Pain Penetration Disorder. Sexual medicine reviews, 5(4), 495–507. https://doi.org/10.1016/j.sxmr.2017.06.005

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Zhu, L., & Zhang, X. (2013). Zhejiang da xue xue bao. Yi xue ban = Journal of Zhejiang University. Medical sciences, 42(4), 461–463. https://doi.org/10.3785/j.issn.1008-9292.2013.04.015

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