Female Health SA


Chronic Pelvic Pain



Chronic pelvic pain is pain that occurs below the belly button and lasts for at least six months. It may or may not be associated with menstrual periods.

Chronic pelvic pain may be a symptom caused by one or more different conditions, but in many cases, is a chronic condition due to abnormal function of the nervous system (often called "neuropathic pain").

Causes:

  • Gynaecologic causes e.g. endometriosis, uterine fibroids, pelvic inflammatory disease and pelvic adhesive disease
  • Irritable bowel syndrome
  • Painful bladder
  • Pelvic floor pain
  • Abdominal myofascial pain
  • Physical, sexual or mental abuse


Pelvic floor physiotherapy focusses on the abdominal myofascial pain and the pelvic floor pain. The treatment consists of releasing the tightness, either by manual trigger point release, dry needling, fascia mobilisation and/or pelvic girdle alignment, in the following muscles:

  • Abdomen
  • Vagina
  • Hips
  • Thighs
  • Lower back


Localized Vulvar Pain Syndrome



Vestibulodynia:


  • Severe pain and discomfort in the vestibule area of the vulva. The vestibule is where the vulva (area of the skin on the outside) meets with the vagina
  • It is an extremely sensitive part of your body and contains the Bartholin's gland (which produces vaginal lubrication), the urethra (where you pass urine) and a few the small minor vestibule glands which also produce vaginal secretions.
  • The vestibule is hypersensitive on touch, such as during intercourse and on insertion of tampons or tight clothes. Itching is not usually a feature of the condition. An excessive sensitivity of the nerve fibres and even, on occasions, overgrowth of the nerve fibres in the area are believed to be responsible for symptoms.
  • Although the pain on light touch is the main symptom, tension in the lower pelvic floor muscles during attempted sex can lead to increased pain and subsequent avoidance of sex. If communication breaks down between a couple then this can lead to further disharmony.


Vulvodynia:


  • Vulvodynia is the sensation of vulvar burning and soreness in the absence of any obvious skin condition or infection. The sensation of burning and soreness of the vulva can be continuous (unprovoked vulvodynia), or on light touch, e.g. from sexual intercourse or tampon use (provoked)
  • The vulvar burning and soreness are usually the consequences of irritation or hypersensitivity of the nerve fibres in the vulvar skin. The abnormal nerve fibre signals from the skin are felt as a sensation of pain by the woman. This type of pain can occur even when the area is not touched. (Neuropathic pain)
  • The pain described by women with unprovoked vulvodynia is often of a burning, aching nature. The intensity of pain can vary from mild discomfort to a severe constant pain which can even prevent you from sitting down comfortably.
  • Vulvodynia is not only restricted to the vulva. It can be experienced in the inside of the thighs, upper legs and even around the anus (back passage) and urethra (where you pass urine). Some women also have pain when they empty their bowels. Unprovoked vulvodynia can influence sexual activity and is associated with pain during foreplay and penetration.


Treatment:


  • Pain that originates from nerve fibres is best treated with drugs that alter the way in which the nerve fibres send their impulses to the spinal cord and give the sensation of pain e.g.
    • Tricyclic antidepressants.
    • Creams and lotion applied to the vulvar area which do act as soothing agents, but it is generally best to avoid all creams unless they have been prescribed by your doctor.
    • Vaginal lubricants can help during intercourse.
    • Aqueous cream is a very bland plain cream which may be used instead of soap when washing


Causes:


  • Infection e.g. candida
  • Inflammation e.g. lichen sclerosis
  • Neoplasms e.g. squamous cell carcinoma
  • Neurological e.g. nerve injury
  • Trauma e.g. obstetrical
  • Hormonal deficiencies e.g. menopause
  • Iatrogenic e.g. radiation



Lichen sclerosis:

Lichen sclerosis appears as white thin patchy skin around the vulva and anus. An overactive immune system or an imbalance of hormones may play a role. Previous skin damage at a site on your skin may increase the likelihood of lichen sclerosis at that location. Lichen sclerosis is not contagious and cannot be spread through sexual intercourse.

Anyone can get lichen sclerosis, but postmenopausal women have a higher risk.

Symptoms may include:

  • Itching (pruritus), which can be severe
  • Discomfort or pain
  • Smooth white spots on your skin
  • Blotchy, wrinkled patches
  • Easy bruising or tearing
  • In severe cases, bleeding, blistering (red or purple) or ulcerated lesions
  • Painful intercourse Diagnosis can be made by a physical examination or a biopsy.


Treatment:


  • Treatments help reduce itching, improve your skin's appearance and decrease further scarring e.g. corticosteroids, immune - modulating medications and physiotherapy for painful intercourse
  • Avoid washing with soap or bubble bath – use plain water or an emollient wash instead, such as aqueous cream (but avoid leaving aqueous cream on the skin after washing)
  • Avoid rubbing or scratching the area
  • Gently dab your genitals dry after urination, to stop your urine from irritating the skin
  • Apply a barrier cream or ointment, such as petroleum jelly, to affected areas after washing and before and after urinating
  • Avoid wearing tight or restrictive clothes and wear underwear made from natural materials such as cotton or silk – women may find it helps to wear stockings rather than tights
  • For women who find sex painful, it may help to use a lubricant, a vaginal dilator and physiotherapy to release tight pelvic floor muscles.


Vaginism



Vaginismus is the result of an involuntary vaginal muscle spasm, which makes any kind of vaginal penetration painful or impossible e.g. sexual intercourse, gynaecological examinations and even tampon insertion.

The severity of vaginismus, as well as the pain during penetration (including sexual penetration), varies from woman to woman.

Factors contributing to vaginism:

  • urinary tract infections
  • vaginal yeast infections
  • sexual abuse, rape, other sexual assault, or attempted sexual abuse or assault
  • fear of pain associated with penetration, particularly the popular misconception of "breaking" the hymen upon the first attempt at penetration, or the idea that vaginal penetration will inevitably hurt the first time it occurs
  • stress
  • negative emotional reaction towards sexual stimulation, e.g. disgust both at a deliberate level and at a more implicit level
  • strict conservative moral education, which also can elicit negative emotions


Persistent Genital Arousal Syndrome (PGAD)



Persistent genital arousal disorder (PGAD) is a phenomenon, in which afflicted women experience spontaneous genital arousal, unresolved by orgasms and triggered by sexual or nonsexual stimuli, eliciting stress. Masturbation and orgasms offer little or no relief.


The primary symptom of PGAD is a series of ongoing and uncomfortable sensations in and around the genital tissues, including the clitoris, labia, vagina, perineum and anus.


These sensations can include wetness, itching, pressure, burning, pounding, pins and needles. It feels to the patient that they are about to experience an orgasm or they may experience waves of spontaneous orgasms. Episodes of intense arousal may occur several times a day for weeks, months, or even years.


However, these symptoms happen in the absence of sexual desire.


The condition can lead to psychological symptoms due to the persistent discomfort and impact on day-to-day living e.g. anxiety, depression, guilt and insomnia.


People with chronic, or incurable, persistent genital arousal disorder may eventually lose their notion of sexual pleasure, because the orgasm becomes associated with relief from pain rather than an enjoyable experience.


Causes can be:


  • Central neurological changes e.g. brain lesion
  • Peripheral neurological changes (e.g. pelvic nerve hypersensitivity or entrapment) vascular changes (e.g. pelvic congestion)
  • Mechanical pressure against genital structures
  • Medication-induced changes o Psychological changes (stress)
  • Initiation or cessation of treatment with antidepressant medication and other mood stabilizers
  • Onset of menopause
  • Overactive bladder


Pudendal Neuralgia



Pudendal Neuralgia is a pelvic pain syndrome causing nerve-like pain in the areas where the pudendal nerve travels to. The pain can be described as sharp, shooting or burning pain in the territory of the nerve.


The pudendal nerve innervates the skin of the vulva, labia, and clitoris in women. It also innervates the perineum, anus, a portion of the urethra, part of the rectum and vagina and the majority of the pelvic floor muscles. It has a vast distribution and when problems arise, people may experience pain in any of those areas and have issues with urinary, bowel and/or sexual function.


Physiotherapy is an effective treatment option for this pelvic pain syndrome aiming for movement of the nerve without irritation.


Causes can be:

  • Hypertonic muscles: Too tight pelvic floor muscles can cause compression along the course of the nerve and thus result in neural inflammation.
  • Myofascial trigger points: Trigger points in the obturator internus muscles can cause the muscle to become hypertonic. In turn, this hypertonic muscle will compress the nerve.
  • Connective tissue restrictions may irritate the dermatomal distribution of the pudendal nerve e.g. cannot tolerate wearing underwear. Tight connective tissue irritates the superficial nerve branches.
  • Biomechanical/joint dysfunction: Sacroiliac joint dysfunction—The pudendal nerve runs out of the sacrum and through the sacroiliac joint ligaments. The space between those ligaments could be affected by a positional change of the joint, which in turn could compress the nerve. Changes in the mobility of the SI joint can also negatively impact the nerve at different locations along its course.
  • Neural sensitivity and ischemia: Aggravating factors such as repetitive yeast or bacterial infections can sensitize the nerve. Visceral disease states can affect peripheral nerves and it is plausible that nerve irritation can irritate visceral structures.
  • The pudendal nerve is rarely the sole driver of the symptoms but is rather one impairment of a myofascial syndrome comprised of many parts. This is one reason why interventions directed at the nerve alone, such as nerve blocks, often provide limited or no relief.




Suite 13, Netcare Pretoria East Hospital
Cnr Garsfontein Road & Netcare Ave
Pretoria East


Antoinette Jansen van Vuuren