Vaginal sEMG biofeedback and pelvic floor physical therapists' manual techniques are being increasingly included in the treatment of vulvar vestibulitis syndrome (VVS). Successful treatment outcomes have generated hypotheses concerning the role of pelvic floor pathology in the etiology of VVS. However, no data on pelvic floor functioning in women with VVS compared to controls are available. Twenty-nine women with VVS were matched to 29 women with no pain with intercourse. Two independent, structured pelvic floor examinations were carried out by physical therapists blind to the diagnostic status of the participants. Results indicated that therapists reached almost perfect agreement in their diagnosis of pelvic floor pathology. A series of significant correlations demonstrated the reliability of assessment results across muscle palpation sites. Women with VVS demonstrated significantly more vaginal hypertonicity, lack of vaginal muscle strength, and restriction of the vaginal opening, compared to women with no pain with intercourse. Anal palpation could not confirm generalized hypertonicity of the pelvic floor. We suggest that pelvic floor pathology in women with VVS is reactive in nature and elicited with palpations that result in VVS-type pain. Treatment interventions need to recognize the critical importance of addressing the conditioned, protective muscle guarding response in women with VVS.

This retrospective study evaluated the effectiveness of physical therapy in relieving painful intercourse and improving sexual function in women diagnosed with vulvar vestibulitis. This syndrome is a frequent cause of premenopausal dyspareunia and is characterized by a sharp, burning pain located within and limited to the vulvar vestibule (vaginal entry) and elicited primarily via pressure applied to the area. Participants were 35 women with vulvar vestibulitis who took part in physical therapy treatment for an average of 7 sessions. We conducted telephone interviews to assess whether physical therapy or other subsequent treatments impacted on pain during intercourse and sexual functioning. Length of treatment follow up ranged from 2 to 44 months, with a mean of 16 months. Physical therapy yielded a complete or great improvement for 51.4% of participants, a moderate improvement for 20.0% of participants, and little to no improvement for the other 28.6%. Treatment resulted in a significant decrease in pain experienced both during intercourse and gynecological examinations; it also resulted in a significant increase in intercourse frequency and levels of sexual desire and arousal. Successful patients were significantly less educated than nonsuccessful patients. Findings demonstrate that physical therapy is a promising treatment modality for dyspareunia associated with vulvar vestibulitis.

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The sexual pain disorders dyspareunia and vaginismus are highly prevalent yet misunderstood women's sexual health problems. We have proposed the adoption of a treatment approach integrating pelvic floor rehabilitation and cognitivebehavioral therapy in order to target the multidimensional aspects of these complex conditions. Looking back on the work that has been published in the area of sexual pain since we introduced this model in 2003, the present paper focuses on the progress that has been achieved since then, with an emphasis on the pelvic floor musculature and psychological factors. Specifically, the continuing debate about the classification of sexual pain is briefly summarized. Findings from treatment outcome research are reported. Growing evidence indicates that pelvic floor rehabilitation and cognitive-behavioral therapy lead to significant improvements in pain and sexual functioning, although there are still only a handful of published randomized controlled trials and only one study focusing on the integration of these two modalities. Recent advances concerning the role of the pelvic floor as well as cognitive and affective variables in the etiology of sexual pain are reviewed, with results showing that higher levels of anxiety, fear of pain, hypervigilance and catastrophizing, in addition to lower levels of self-efficacy, may contribute to the exacerbation of pain and associated sexual dysfunction. In terms of avenues for future research, two new measurement instruments for assessing the pelvic floor musculature are described, namely the dynamometric speculum and transperineal ultrasound. Ongoing challenges involved in the adoption of an integrated treatment approach are discussed.

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