therapies for chronic pelvic pain and vulvodynia

by Diane K. Newman, RNC, MSN, CRNP, FAAN

The standard treatment for both CPP and vulvodynia is medication and the goal of drug therapy is to relieve pain and discomfort. However, these drugs produce side effects and their effectiveness tends to diminish over time. Unfortunately, evidence-based research on successful treatment outcomes is severely lacking.

Self-care practices, dietary interventions, and muscle relaxation training using adjunct techniques are a few of the other treatment modalities being more widely used in these chronic pelvic disorders.

Self-care practices

As a means of controlling pain and perineal irritation, women with pelvic disorders will readily integrate self-care practices. Common practices include heat in the form of a heating pad applied to the area of pain, soaking in a tub bath (e.g. Aveeno bath) or the application of hot compresses to the pain site. Moist heat is effective at decreasing muscle spasm and trigger point tension, as well as at improving circulation. Also, certain hygiene practices may be helpful in women with vulvar irritation (See Table 3.)

Dietary Interventions

Women who experience vulvar pain due to CPP and vulvodynia may benefit from a low oxalate diet. Oxalate is a chemical substance found in foods of plant origin. (See Table 4 for listing of foods with low, moderate and high oxalate content.) These women have been shown to have higher levels of calcium oxalate in their urine that peaks in relation to intensity of pain along with symptoms of urinary urgency, frequency, muscle and joint pain, and rectal itching and burning. Foods containing little or no oxalate include meat, fish, eggs, and dairy products and foods with high oxalate levels are nuts; citrus fruits; wheat products; tea; cocoa products; spices such as ginger, pepper, and cinnamon; soy and peanut products; and tomatoes. Several women who tried a low-oxalate diet as their first course of action experienced significant pain reduction, however, a low-oxalate diet alone is not always sufficient to reduce symptoms. It usually is necessary to combine the diet with additional treatment in order to achieve optimal recovery.

Vitamin Supplementation

A compound known to treat hyperoxaluria and inhibit hyaluronidase release, calcium citrate has been extremely helpful in reducing symptoms. Citrate's structure is similar to oxalates and competes with it in the tissues. After combining citrate and diet together for about three months, most women see about a 70% reduction in symptoms. If used in excess, calcium citrate can be irritating and dosages often must be reduced and readjusted. Two tablets (200mg) of calcium citrate taken orally three times a day is the dose recommended to neutralize oxalate in the urine. Women with vulvodynia may experience the most benefit from a low oxalate diet and ingestion of calcium oxalate.

Muscle Relaxation Training

Chronic pelvic pain may be caused or perpetuated by excess muscle tension in the pelvic floor, hips and low back. Therefore, treatment that includes posture re-education, relaxation, manual therapy, a home program to stretch the affected muscles; and modalities for pain relief can be effective. Treatments to reduce pain and muscle spasm, restore joint movement and muscle length, will be ineffective if the woman continues to adopt prolonged faulty postures and poor body mechanics, so posture re-education is an important part of a muscle relaxation program. Because prolonged sitting often increases pelvic pain, education about a correct sitting posture is paramount for women with chronic pelvic disorders.

Pelvic floor muscle relaxation training, or reverse "Kegel"exercises, is useful in reducing this muscle tension prior to a stretching or exercise routine. When muscle spasm is present, rehabilitating the pelvic muscle can be central in resolving pain. As a result, the prolonged nature of their pain and associated depressive illness, women with pelvic pain tend to reduce their level of activity over time. Consequently, therapeutic exercise is important in the management of the condition. General exercise, especially a walking program, is aimed at increasing aerobic capacity, improving circulation, decreasing stress levels and encouraging the body to increase endorphin production. Running or high impact aerobics may cause increased pelvic floor muscle spasm and should be avoided.

Adjunct Treatments

Muscles that have increased tension may benefit from Biofeedback therapy even when the woman or clinician cannot detect any change. This is particularly true of the pelvic floor muscles as denervation damage may lead to impaired sensation. The woman is instructed to visualize high levels of resting activity and fleeting muscle spasms while using biofeedback technology equipment. This type of muscle training may improve the effectiveness of other muscle relaxation efforts while strengthening weak pelvic muscles thus reducing pain. A biofeedback-assisted exercise program that stabilizes the pelvic floor muscles can reduce and eliminate symptoms of CPP and vulvodynia (Glazer, Rodke, et al, 2000.) The biofeedback program is usually combined with a home routine of pelvic floor exercises and rectal massage to stretch scar tissue in the pelvic floor muscles and reduce trigger points. Treatment may take several weeks or months for success, as acquired muscle tension must be 'unlearned'.

Electrical stimulation using vaginal, rectal or surface electrodes may be included in the course of treatment and provides pain relief. At selected frequencies, electrical stimulation is used to produce rhythmic contraction and relaxation of the pelvic floor muscles, which may reduce muscle spasm and trigger points by fatiguing the muscle and restoring a more normal pattern of muscle activity. Repeated muscle contractions may also help to disperse products of inflammation caused by chronic muscle spasm. Electrical stimulation may give immediate reduction in the level of pain early in treatment, which allows the woman to participate more fully in the treatment program and gives her hope that treatment will be effective.

References

Baker, PK. (1993) Musculoskeletal Origins of Chronic Pelvic Pain. Contemporary Management of Chronic Pelvic Pain, 20(4) December:719-742.05-227.

Duleba, A.J., Keltz, M.D., Olive, D.L. (1996) Evaluation and Management of Chronic Pelvic Pain. Journal American Association Gynecologic Laparoscopists, February 1996, 3 (2), 205-227.

Glazer,H.I.,Rodke,G.,Swencionis,C., Hertz,R.,Young,A.W.(2000) "Treatment of Vulvar Vestibulitis Syndrome with Electromyographic Biofeedback of Pelvic Floor Musculature". Journal of Reproductive Medicine, 40(4),11 pp.

Metts, J.F. (1999) Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and Management. American Family Physician, 59(6),1547-1556.

Newman, DK. (2000) "Pelvic Disorders in Women: Chronic Pelvic Pain and Vulvodynia". OstomyWound Management: December 46(12): 48-54.

Paavonen, J. (1995) "Vulvodynia - a complex syndrome of vulvar pain". Acta Obstet Gynecol Scand. 74,243-247.

Steege,J.F. (1997) Office Assessment of Chronic Pelvic Pain. Clinical Obstetrics and Gynecology, Vol.40(3),554-563.

Steege,J.F.,Metzger,D.A.,Levy, B.S. (1998) Chronic Pelvic Pain: An Integrated Approach. W.B.Saunders,Philadelphia, PA.

Yount,J.J., Solomons, C.C.,Willems, J.J., St. Amand, R.P. (1997) "Effective Nonsurgical Treatments for Vulvar Pain". Women's Health Digest, 3(2),88-93.

Posted: October 2007