Well done and useful for both clinicians and women with vulvodynia! Agree that pelvic floor PT is essential to treatment, along with identifying and treating the underlying cause.
"Pelvic floor physical therapy remains one of the most valuable interventions available" There is no clinical study to support this statement for vulvodynia, and pfpt should not be prescribed especially without knowing the underlying cause and ruling out comorbidities that could contribute to further harm. Especially now that we know there is a high prevalence of EDS among vulvodynia patients, pfpt should not be so easily recommended. Vulvodynia can be caused by many other conditions that require very different therapeutic approaches, such as musculoskeletal issues from hip and spine abnormalities, autoimmune conditions, venous conditions (pelvic congestion syndrome as an example), and many others; no amount of pfpt will resolve such problems.
So, I have to disagree with you on this, especially for patients who have vulvodynia secondary to hypertonic pelvic floor dysfunction. As a sexual medicine physician who sees a good number of patients with vulvodynia, I can attest personally that for the correct patient, PFPT can be extremely beneficial.
Now, I wholeheartedly agree that there are numerous, non-pelvic floor related causes for vulvodynia - including what you listed above, and you are once again correct that PFPT alone will not treat those patients. I additionally agree with you that pan-referrals to PFPT without appropriate work up may not provide significant benefit. That said, rare is the patient with vulvodynia who does not have some degree of pelvic floor issue, if for no other reason that chronic pain causes a reflexive spasming of the pelvic floor musculature as a compensatory/protective mechanism.
I'm happy to provide journal articles, such as this one, that show a positive correlation with PFPT and vulvodynia.
van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sexual Medicine Reviews. 2021;10(2). doi:https://doi.org/10.1016/j.sxmr.2021.03.00
Dr. Babb, I appreciate your perspective and agree that PFPT can be very helpful for some patients, particularly when hypertonic pelvic floor dysfunction is clearly part of the clinical picture. I also agree that many patients with vulvodynia may develop pelvic floor guarding or secondary muscle tension as a response to chronic pain.
My concern is more about how broadly PFPT is recommended, especially for vulvodynia, and especially when the underlying cause of the pain has not been fully evaluated.
While I respect your clinical experience, I think it is important that we remain mindful of social desirability bias. You may be hearing sincere patient impressions, but that is not necessarily the same as clinical evidence of efficacy. Patients may want to please their doctor, justify trying a treatment, or report improvement because they expect it to help. Without controlled clinical data, we cannot separate true efficacy from such biases or placebo responses.
The reference you provided is a review, and it includes only one study directly related to vulvodynia (PVD specifically) that included an extremely small sample size (11 patients) with a pretty restrictive exclusion criteria:
(The exclusion criteria for all participants consisted of: current major medical, psychiatric, or other pain conditions, the use of medications that interfere with pain processing, pregnancy, previous vestibular surgery, postmenopausal status, urinary or bowel incontinence, and the presence of a pacemaker. Additionally, for the PVD group, the women had to have experienced vulvar pain during intercourse over the previous six months, and were excluded if they were unwilling to abstain from other vulvar pain treatments until the follow-up sessions were complete.)
The results were not compelling, and the small sample size and exclusion criteria tremendously limit its generalizability.
Not included in the review was the study by Morin et al (10.1016/j.ajog.2020.08.038), and even here the exclusion criteria is limited to only PVD (patients with any other vulvodynia subtype (e.g., unprovoked) or any other vulvar pain condition were excluded).
I think we may actually agree on the larger point: PFPT can be valuable for the right patient, but it should ideally follow a careful evaluation of the underlying contributors to pain rather than functioning as a default referral. I would love to see leaders in the field emphasize something like, “Let’s fully evaluate the possible causes of pain first, then choose evidence-based treatment options, supported by randomized, placebo-controlled clinical trials, that are best supported for that patient’s presentation.”
Thank you for your response. I completely agree with your statement, "I think we may actually agree on the larger point: PFPT can be valuable for the right patient, but it should ideally follow a careful evaluation of the underlying contributors to pain rather than functioning as a default referral," and recognize that bias may be present regardless of setting. Honestly, the idea of simply referring a patient to PFPT without doing a full evaluation for all types of potential etiologies is wild to me, but then again, I'm a subspecialist, and am often the 7th or 8th clinician a patient has seen for their concerns.
I think you have also hit on another pressure point within female sexual medicine - the lack of high-quality RCTs. Without soapboxing too much, the dearth of evidence for conditions related to female sexual pain (and female sexual dysfunction, overall) is horrible, especially when compared to medical research as a whole. Most of what's out there, especially in the non-sexual medicine literature, is scant and based on reviews, not blind RCTs. Why that's the case is a whole different story...and maybe, another article!
Thank you for your comments, and I appreciate the dialogue!
Well done and useful for both clinicians and women with vulvodynia! Agree that pelvic floor PT is essential to treatment, along with identifying and treating the underlying cause.
Thank you so much!
"Pelvic floor physical therapy remains one of the most valuable interventions available" There is no clinical study to support this statement for vulvodynia, and pfpt should not be prescribed especially without knowing the underlying cause and ruling out comorbidities that could contribute to further harm. Especially now that we know there is a high prevalence of EDS among vulvodynia patients, pfpt should not be so easily recommended. Vulvodynia can be caused by many other conditions that require very different therapeutic approaches, such as musculoskeletal issues from hip and spine abnormalities, autoimmune conditions, venous conditions (pelvic congestion syndrome as an example), and many others; no amount of pfpt will resolve such problems.
So, I have to disagree with you on this, especially for patients who have vulvodynia secondary to hypertonic pelvic floor dysfunction. As a sexual medicine physician who sees a good number of patients with vulvodynia, I can attest personally that for the correct patient, PFPT can be extremely beneficial.
Now, I wholeheartedly agree that there are numerous, non-pelvic floor related causes for vulvodynia - including what you listed above, and you are once again correct that PFPT alone will not treat those patients. I additionally agree with you that pan-referrals to PFPT without appropriate work up may not provide significant benefit. That said, rare is the patient with vulvodynia who does not have some degree of pelvic floor issue, if for no other reason that chronic pain causes a reflexive spasming of the pelvic floor musculature as a compensatory/protective mechanism.
I'm happy to provide journal articles, such as this one, that show a positive correlation with PFPT and vulvodynia.
van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, Pelger RCM, Hagenaars-van Miert CHAC, Laan ETM. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sexual Medicine Reviews. 2021;10(2). doi:https://doi.org/10.1016/j.sxmr.2021.03.00
Thank you for the comment!
Dr. Babb, I appreciate your perspective and agree that PFPT can be very helpful for some patients, particularly when hypertonic pelvic floor dysfunction is clearly part of the clinical picture. I also agree that many patients with vulvodynia may develop pelvic floor guarding or secondary muscle tension as a response to chronic pain.
My concern is more about how broadly PFPT is recommended, especially for vulvodynia, and especially when the underlying cause of the pain has not been fully evaluated.
While I respect your clinical experience, I think it is important that we remain mindful of social desirability bias. You may be hearing sincere patient impressions, but that is not necessarily the same as clinical evidence of efficacy. Patients may want to please their doctor, justify trying a treatment, or report improvement because they expect it to help. Without controlled clinical data, we cannot separate true efficacy from such biases or placebo responses.
The reference you provided is a review, and it includes only one study directly related to vulvodynia (PVD specifically) that included an extremely small sample size (11 patients) with a pretty restrictive exclusion criteria:
(The exclusion criteria for all participants consisted of: current major medical, psychiatric, or other pain conditions, the use of medications that interfere with pain processing, pregnancy, previous vestibular surgery, postmenopausal status, urinary or bowel incontinence, and the presence of a pacemaker. Additionally, for the PVD group, the women had to have experienced vulvar pain during intercourse over the previous six months, and were excluded if they were unwilling to abstain from other vulvar pain treatments until the follow-up sessions were complete.)
The results were not compelling, and the small sample size and exclusion criteria tremendously limit its generalizability.
Not included in the review was the study by Morin et al (10.1016/j.ajog.2020.08.038), and even here the exclusion criteria is limited to only PVD (patients with any other vulvodynia subtype (e.g., unprovoked) or any other vulvar pain condition were excluded).
I think we may actually agree on the larger point: PFPT can be valuable for the right patient, but it should ideally follow a careful evaluation of the underlying contributors to pain rather than functioning as a default referral. I would love to see leaders in the field emphasize something like, “Let’s fully evaluate the possible causes of pain first, then choose evidence-based treatment options, supported by randomized, placebo-controlled clinical trials, that are best supported for that patient’s presentation.”
Dr. Stevens,
Thank you for your response. I completely agree with your statement, "I think we may actually agree on the larger point: PFPT can be valuable for the right patient, but it should ideally follow a careful evaluation of the underlying contributors to pain rather than functioning as a default referral," and recognize that bias may be present regardless of setting. Honestly, the idea of simply referring a patient to PFPT without doing a full evaluation for all types of potential etiologies is wild to me, but then again, I'm a subspecialist, and am often the 7th or 8th clinician a patient has seen for their concerns.
I think you have also hit on another pressure point within female sexual medicine - the lack of high-quality RCTs. Without soapboxing too much, the dearth of evidence for conditions related to female sexual pain (and female sexual dysfunction, overall) is horrible, especially when compared to medical research as a whole. Most of what's out there, especially in the non-sexual medicine literature, is scant and based on reviews, not blind RCTs. Why that's the case is a whole different story...and maybe, another article!
Thank you for your comments, and I appreciate the dialogue!