Introduction

Are you experiencing persistent, unexplained pain at the entrance of your vagina? If yes, you might be dealing with vestibulodynia.

Vestibulodynia is a condition that causes pain at your vestibule or vaginal entrance.¹ Pelvic floor dysfunction describes a wide range of symptoms and anatomical abnormalities resulting from abnormal pelvic floor muscular activity.² Even though these two conditions are distinct, they are interrelated and can significantly impact women's health. In women with vestibulodynia, dysfunction of the pelvic floor muscles has been linked to the worsening of vestibulodynia.³ 

Hence, this article provides an overview of the relationship between vestibulodynia and pelvic floor dysfunction and offers insights into diagnosis, treatment options, and the importance of treating these conditions.

Understanding vestibulodynia

Definition and types of vestibulodynia

Vulvodynia is a condition of chronic and recurring pain and discomfort in the vulvar region. When the pain in your vulvar region is restricted only to the inner lips of the vulva or vestibule (the region containing the urethral and vaginal aperture), then it is known as vestibulodynia.^4,5 It is the most common type of vulvodynia and was previously referred to as vulvar vestibulitis.⁴ 

Typically, sexually active women between the ages of 20 and 40 experience vestibulodynia.⁴ Provoked vestibulodynia is the most common type, where pain occurs when pressure of any kind, like friction or touch, is applied, such as during sexual intercourse, tampon insertion, or gynaecological exams.^1,6 Provoked vestibulodynia is of two types:

• Primary (congenital) provoked vestibulodynia: You may experience pain at the initial attempt of any vaginal penetration, such as the first time you insert a tampon or have intercourse. This condition is present at birth (congenital)^1,6
• Secondary (acquired) provoked vestibulodynia: In this type, the pain may develop after days, months, or even years following painless vaginal penetration. It takes time for this condition to develop⁶

Causes of vestibulodynia

Based on its cause, vestibulodynia can be classified into three subtypes:

• Neuroproliferative vestibulodynia: arises due to an excessive number of nerve endings in the vestibule and results in extreme sensitivity to touch 
• Hormonally-mediated vestibulodynia: occurs due to low levels of free testosterone and/or oestrogen, often linked to hormonal birth control, breastfeeding, or menopause
• Inflammatory vestibulodynia: caused by chronic inflammation of the vestibule due to allergic reactions or infections⁷

Symptoms and manifestations

The manifestation and symptoms of vestibulodynia can differ from woman to woman. Common symptoms include:

• A stinging, burning, or cutting sensation at the vaginal entrance
• Pain which is brought on by sports like jogging, cycling, or horseback riding, tight clothes, or extended periods of sitting
• Urination that hurts, especially after having sex
• Pain when the vestibule is touched
• Raw and sensitive vestibule^4,7 

Diagnosis of vestibulodynia

Most of the time, vestibulodynia has no visible symptoms, which can make it difficult to properly diagnose.

Diagnosis usually consists of:

• Comprehensive medical history and symptom discussion
• Physical examination
• Testing for vaginal infections, including yeast infections, using a sample of vaginal discharge
• "Touch test" with a cotton swab to identify highly sensitive spots in the vestibule
• Pelvic examination to thoroughly inspect the vulva and vagina
• During the pelvic exam, if any skin alterations are discovered, a biopsy or colposcopy will be performed^4,8 

Exploring pelvic floor dysfunction

Source: BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons 11 July 2017 Available at: https://commons.wikimedia.org/wiki/File:Pelvic_Muscles_(Female_Inferior).png 

Pelvic floor dysfunction is a condition that causes the pubococcygeus, puborectalis, and transverse perineal muscles, which collectively make up the pelvic floor, at the back portion of the vestibule to become painful and tense. Because these muscles receive less blood flow, which lowers the oxygen supply to the cells, lactic acid builds up in them. This lactic acid is what causes the burning, throbbing, stabbing, and aching sensations that so many women experience.⁹ Moreover, it can cause severe pain and redness in the vestibule.⁹

Source: Openstax, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons. Available at: https://commons.wikimedia.org/wiki/File:1116_Muscle_of_the_Female_Perineum.png 

Causes of pelvic floor dysfunction

The main factors that contribute to pelvic floor dysfunction include menopause, obesity, and pregnancy. Some women are born with naturally weaker connective tissue and fascicles, which puts them at hereditary risk for having pelvic floor dysfunction.¹⁰

Symptoms of pelvic floor dysfunction

• Women with pelvic floor dysfunction frequently experience urinary symptoms, including urgency, frequency, and incomplete bladder emptying
• Stress urinary incontinence (leakage during physical activities)
• Haemorrhoids, constipation, and anal fissures (tears in the anal region) 
• Prolapse (bulging in the vagina due to descent of pelvic organs)
• Sexual dysfunction (pain during intercourse, muscle spasms, and urine leakage)
• Hip and/or low back discomfort ^9,11 

Diagnosis of pelvic floor dysfunction

Diagnosis involves:

• Assessing symptoms and medical history 
• Inquiring about your bladder and bowel habits, straining during bowel movements, and any sex-related pain or information on previous pregnancies
• Physical examination to evaluate the control of your pelvic floor muscles, looking for weakness, knots, or spasms. It may also involve a pelvic and rectal exam 
• Tests, such as urodynamic testing, to examine bladder function¹²

Association between vestibulodynia and pelvic floor dysfunction

Studies have shown pelvic floor muscle dysfunction as a frequent cause of vestibulodynia. According to research, individuals with provoked vestibulodynia are more likely to have reduced pelvic floor strength and hypertonicity.¹³ 

Our pelvic floor is made up of several muscles that form a supportive "basket" in order to hold up various pelvic organs. These supportive muscles include the levator ani muscles and the coccygeus. One of these levator ani muscles, known as the puborectalis, connects to the back part of the vaginal entrance.¹³ However, if this muscle is hypertonic (too tight or tense), it can cause pain in that area, a condition known as allodynia. 

Numerous factors, including stress, bad bathroom habits, or other painful conditions like interstitial cystitis (a bladder condition) and endometriosis (where tissue similar to the lining of the uterus grows outside the uterus), can cause this hypertonicity.¹³ When these muscles are continuously tense, the nerve fibres in them may become extremely sensitive, thereby causing pain signals.¹³

Nerve fibres in the vestibule transmit sensory information to the same spinal levels as the levator and muscles. This means that if the pelvic floor muscles are sending pain signals, the brain might interpret these signals as coming from the vestibule, causing pain there (vestibulodynia).¹³

Moreover, when the pelvic floor muscles are hypertonic, they can reduce blood flow, causing localised hypoxia (oxygen deficiency). This can lead to the formation of painful spots called myofascial trigger points in the pelvic floor. The vestibule may experience pain or allodynia as a result of these trigger sites.¹³

Sometimes vestibulodynia might occur first and cause hypertonicity (resulting in the pelvic floor muscles becoming tense as a reaction), thereby creating a cycle of pain and muscle tightness.¹³

Treatment approaches

Clinicians must evaluate pelvic floor tone while assessing vestibulodynia since pelvic floor hypertonicity may be a contributing factor in the pathophysiology of the condition. Since pelvic floor hypertonicity and vestibulodynia might worsen one another, if pelvic floor hypertonicity exists, it must be treated alongside vestibular discomfort. 

Treatment uses a mix of:

• Pelvic floor physical therapy 
• Trigger point injections (target specific muscle knots in the pelvic floor that contribute to vestibulodynia) 
• Botulinum toxin injections to lessen extreme muscular tension and spasms^13,14,15 

For some people, symptoms of vestibulodynia resolve on their own, though it might take months or even years. Below are some common management strategies:

• Temporary relief can be obtained using cool gel packs and local anaesthetic creams containing lignocaine, and topical 2% amitriptyline cream
• In severe situations, corticosteroid injections and nerve blocks may be helpful
• Using anticonvulsant medications and tricyclic antidepressants
• In extreme cases, surgical excision may be explored⁴
• Coordinated breathing exercises, stretching targeted muscles and manual muscle manipulations can also help alleviate the pain¹⁶

Therapeutic interventions for pelvic floor dysfunction should be personalised and often require a multidisciplinary approach.¹⁷

Pelvic floor physical therapy

You can determine which muscles in your pelvic floor are too tight with the assistance of a physical therapist. They can give you stretches to relax these muscles and enhance your coordination.¹²

Changes in lifestyle

• Diet: to treat urine frequency and incontinence, avoid alcohol, caffeine, acidic meals and beverages, concentrated sugar, artificial sweeteners, spicy foods, and cigarettes¹⁷ 
• Reducing weight: to relieve pressure on the pelvic floor, if overweight 
• Kegel exercises: strengthen the pelvic floor
• Core exercises: help support and strengthen the pelvic floor¹⁷

Biofeedback

It involves using sensors and video by physical therapists to measure contractions and relaxations of your pelvic floor muscles and offering guidance.¹²

Impact of vestibulodynia and pelvic floor dysfunction on mental health

Women with vestibulodynia and pelvic floor dysfunction may experience adverse impacts on their psychological well-being, interpersonal interactions, and personal behaviours. 

Vestibulodynia can be challenging to diagnose and may be misdiagnosed, leading to delays in appropriate treatment and thereby affecting the quality of patients' life.¹⁸ 

Research has identified numerous psychosocial barriers commonly faced by patients with vestibulodynia, including: 

• Pain 
• Anxiety 
• Depression 
• Fear 
• Poor support from partners 
• Low relationship satisfaction^18,19

Education about the condition and support for it must also be part of the treatment. Psychosocial therapies, including couples counselling, sexual education, and psychiatric treatments such as cognitive behavioural therapy can be helpful to improve mental health.⁴

Women suffering from vestibulodynia can greatly benefit from the support and resources provided by organisations such as the Vulval Pain Society and British Society for the Study of Vulval Disease.

Summary

• Vestibulodynia is a condition characterised by chronic pain at the vestibule or vaginal entrance and is often triggered by touch or pressure 
• Pelvic floor dysfunction contributes to vestibulodynia by causing hypertonicity, where the pelvic floor muscles become overly tight and sensitive, leading to pain signals that the brain may interpret as coming from the vestibule 
• For effective treatment, a multidisciplinary approach is necessary involving lifestyle changes, medication, and pelvic floor physical therapy