Pelvic Floor Biometric Changes Assessed by 4D Translabial Ultrassound in Women with Vulvodynia Submitted to Physical Therapy: A Pilot Study of a Randomized Controlled Trial

Abstract

Background Vulvodynia is a disabling condition in which pelvic floor muscles' (PFM) hypertonicity plays an important role. Aim To evaluate biometric changes in PFM in women with vulvodynia undergoing kinesiotherapy treatment protocol (KTP). Methods A single-blinded randomized controlled trial of 57 women with vulvodynia randomly assigned to either KTP + amitriptyline or amitriptyline alone (controls) for treatment. Four-dimensional translabial ultrasound assessed PFM regarding symphysis-levator distance at rest, anorectal angle at rest, excursion of the levator plate angle, and levator hiatal narrowing. Volunteers underwent a vaginal examination for a cotton swab test (CST), fulfillment of Friedrich criteria score and PFM power of contraction, and completed a diary of sexual pain and frequency of vaginal intercourse. Outcomes were assessed at baseline and after 8 weeks of treatment. Outcomes Primary outcomes were differences in biometric parameters assessed by four-dimensional translabial ultrasound after treatment, between groups. Secondary outcomes were changes in clinical variables (CST, Friedrich criteria, PFM power of contraction, frequency of intercourse, and intensity of sexual pain) between groups and correlation analysis between biometric parameters and clinical variables. Results Only the KTP group had statistically significant changes in biometric parameters after treatment (symphysis-levator distance: 0.22 ± 0.2, 95% CI = 0.1–0.4, P = .008; levator hiatal narrowing: −0.33 ± 0.2, 95% CI = −1 to −0.2, P = .04). Comparisons between groups showed that symphysis-levator distance (0.3, 95% CI = 0.2–0.6, P = .005) and excursion of levator plate angle (4.9, 95% CI = −0.4 to 10.1, P = .02) improved significantly after KTP treatment. Clinical variables showed greater improvement in the group treated with KTP for CST (difference of −3.7, 95% CI = −7 to −0.4, P = .01), Friedrich criteria (difference of −1.9, 95% CI = −3.2 to −0.6, P = .003), PFM power of contraction (0.3, 95% CI = 0.1–0.6, P = .05) and intensity of sexual pain (reduction of 1.7, 95% CI = −3.1 to −0.2, P = .01). Some clinical and biometric variables correlated positively, for example, frequency of vaginal intercourse and anorectal angle (P = .04; r = 0.25), or inversely, for example, pain intensity at CST and anorectal angle (P = .004, r = −0.31). Clinical Implications This study provides evidence on efficiency of a physical therapy protocol for improvement of symptoms of vulvodynia and hypertonicity changes. Conclusion This pilot study suggests that KTP for women with vulvodynia promoted significant changes in PFM biometric measures, consistent with alterations in hypertonicity and clinical improvement.

Vulvodynia: A practical guide in treatment strategies

“…A recent single‐blinded RCT by Bardin et al 69 used a four‐dimensional transtibial ultrasound to assess pelvic floor biometric changes in women undergoing PFPT. Women were assigned to one of two groups, either amitriptyline with kinesiotherapy treatment protocol (KTP) or amitriptyline alone.…”

Individualized multidisciplinary therapy for vulvodynia

“…53 Similarly, no differences were detected after vestibulectomy, 29,73 and therapy with local anesthetics. 74 Among the studies included in our review that evaluated the outcomes predictors of centrally acting treatments, 21,22,24,32,41,42,67 three of them 21,24,32 investigated the influence of the vulvodynia subtype but did not detect any impact. Regarding psychological treatments, among the studies in our review that investigated the influence of vulvodynia subtypes 16,26,29 no difference was detected in pain reduction after 2.5 years of CBT completion, 29 nor in the resumption of vaginal penetration after MBCT or CBT.…”

Evaluation and Treatment of Vulvodynia: State of the Science

“…Diazepam vaginal suppositories and tablets have been prescribed to treat vulvodynia 18 and vulvar pain related to hypertonic pelvic floor muscles. 11 , 43 , 44 , 45 Studies conducted on the use of vaginal diazepam have targeted women with pelvic pain related to hypertonic pelvic floor muscles 46 , 47 , 48 but not specifically vulvodynia. There were 2 small‐sample double‐blind RCTs 46 , 47 of vaginal diazepam for hypertonic pelvic floor dysfunction that showed no reduction in vulvar pain.…”

“…One RCT using amitriptyline alone and amitriptyline with triamcinolone cream did not reduce vulvar pain in women with PV. 27 A second RCT of amitriptyline, and amitriptyline with physical therapy, 45 showed amitriptyline alone reduced vulvar pain but not dyspareunia. Amitriptyline with physical therapy reduced vulvar pain and dyspareunia.…”

“…Pelvic floor physical therapy is used to treat pelvic floor dysfunction and hypertonic pelvic floor muscles associated with vulvodynia (Table 4 ). 45 , 53 , 54 Pelvic floor physical therapy includes dilators, EMG biofeedback, and TENS.…”