Physical Therapy for Vulvar Vestibulitis Syndrome: A Retrospective ...

Journal of Sex & Marital Therapy, 28:183–192, 2002
Copyright © 2002 Brunner-Routledge
0092-623X/02 $12.00 + .00
Physical Therapy for Vulvar Vestibulitis
Syndrome: A Retrospective Study
SOPHIE BERGERON
Department of Sexology, Université du Québec à Montréal and Sex and Couple Therapy
Service, Department of Psychology, McGill University Health Centre (Royal Victoria
Hospital), Montréal, Québec, Canada
CLAUDIA BROWN
Physiothérapie Polyclinique Cabrini, Montréal, Québec, Canada
MARIE-JOSÉE LORD
Physio-Équilibre, Pointe-Claire, Québec, Canada
MONICA OALA
Department of Education/Counseling Psychology, McGill University, Montréal,
Québec, Canada
YITZCHAK M. BINIK
Department of Psychology, McGill University and Sex and Couple Therapy Service,
Department of Psychology, McGill University Health Centre (Royal Victoria Hospital),
Montréal, Québec, Canada
SAMIR KHALIFÉ
Departments of Obstetrics and Gynecology, McGill University and Jewish General Hospital,
Montréal, Québec, Canada
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 fre-
quent 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 ap-
plied 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 physi-
cal therapy or other subsequent treatments impacted on pain dur-
This research was supported by a Medical Research Council of Canada postdoctoral
fellowship to S. Bergeron and by a Medical Research Council of Canada research grant to Y.
M. Binik.
Address correspondence to Sophie Bergeron, Department of Sexology, Université du
Québec à Montréal, C.P. 8888, Succursale Centre-Ville, Montréal, Québec, Canada, H3C 3P8.
E-mail: bergeron.sophie@uqam.ca
183

---

184
S. Bergeron et al.
ing intercourse and sexual functioning. Length of treatment follow
up ranged from 2 to 44 months, with a mean of 16 months. Physi-
cal 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 re-
sulted 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 edu-
cated than nonsuccessful patients. Findings demonstrate that physi-
cal therapy is a promising treatment modality for dyspareunia as-
sociated with vulvar vestibulitis.
Recent epidemiological estimates indicate that up to 21% of women under
the age of 30 complain of consistent recurring pain during intercourse, or
dyspareunia (Laumann, Paik, & Rosen, 1999). Vulvar vestibulitis syndrome
(VVS) is suspected to be the most frequent cause of dyspareunia in pre-
menopausal women (Friedrich, 1988; Meana, Binik, Khalifé, & Cohen, 1997).
This condition is characterized by a burning pain that is elicited via pressure
to the vulvar vestibule or attempted vaginal penetration. VVS sufferers report
more functional interference with their sex life than any other group of
dyspareunic women (Meana et al., 1997). In fact, all aspects of their sexual
response cycle are negatively affected: they have significantly lower inter-
course frequency, lower levels of desire and arousal, and less orgasmic suc-
cess with intercourse and partner manual stimulation than normal controls
(Meana et al., 1997; Van Lankveld, Weijenborg, & Ter Kuile, 1996). Because
of a lack of scientific attention and reductionist conceptualizations of the
syndrome, among other reasons, the etiological determinants of VVS are not
well known. However, its development has been associated with repeated
yeast infections and other urogenital inflammatory conditions (Bergeron,
Binik, Khalifé, & Pagidas, 1997; Goetsch, 1991).
Recent evidence suggests that the pelvic-floor musculature may play a
role in the maintenance of VVS. Reissing, Binik, Khalifé, and Cohen (2001)
investigated pelvic-floor hypertonicity in three groups of women: those with
vaginismus, those with VVS, and no-pain controls. Results show that women
with vaginismus had the highest average muscle tension, significantly higher
than that of women with VVS, which was in turn significantly higher than
that of no-pain controls. These findings suggest that chronic-pelvic-floor
hypertonicity likely contributes to the pain experienced during intercourse
and should be dealt with directly in treatment via physical therapy.
Apart from sex therapy/pain management, physical therapy is one of
the few treatments for VVS that is noninvasive and has no known negative

---

Vulvar Vestibulitis Syndrome
185
side effects. The main goal of physical therapy is to rehabilitate pelvic-floor
musculature by (a) increasing awareness and proprioception; (b) improving
strength, speed, endurance, and muscle discrimination; (c) decreasing hy-
pertonicity and improving voluntary relaxation; (d) increasing elasticity of
the tissues at the vaginal opening, and (e) decreasing fear of vaginal penetra-
tion. These goals are achieved through education about the role of the pel-
vic-floor musculature in the maintenance of VVS pain, manual techniques
(for example, stretching), electromyographic (EMG) biofeedback, electrical
stimulation, and patient home exercises.
Glazer, Rodke, Swencionis, Hertz, and Young (1995) were the first to
suggest that EMG biofeedback—one of the components of physical therapy—
may be a promising treatment for VVS. Results of their first study demon-
strated that after an average of 16 weeks of practice, 22 of the 28 women
who were abstaining from intercourse at the beginning of treatment resumed
this activity, and 52% of the women in the entire sample reported pain-free
intercourse. Although conducted retrospectively with a mixed group of women
with vulvar pain, this study was important in view of the fact that biofeed-
back had been shown to be beneficial for other pain conditions (Arena &
Blanchard, 1996). The same team replicated these results with a homoge-
neous sample of women with VVS (McKay et al., 2001). Although the design
was described as prospective, no pretreatment values were reported and the
information regarding pain intensity and sexual functioning was minimal.
Bergeron, Binik, Khalifé, Pagidas, Glazer, Meana, et al. (2001) conducted
a randomized treatment-outcome study comparing group cognitive-behav-
ioral sex therapy/pain management, EMG biofeedback, and vestibulectomy.
Findings demonstrated that VVS women who took part in biofeedback sig-
nificantly reduced their pain from pre- to posttreatment. The average reduc-
tion of pain during intercourse was 35%, and 34.6% of participants reported
great improvement or complete relief of their pain. However, women as-
signed to this condition were significantly less satisfied and had a signifi-
cantly higher drop-out rate than women assigned to the two other condi-
tions, possibly because of the lengthy home-exercise program and the
repetitive nature of the treatment. We suspected that we might increase the
success and adherence rates if our patients benefited from all the compo-
nents of physical therapy as opposed to biofeedback alone. There currently
are no published studies concerning the outcome of physical therapy for
VVS.
The objectives of the present study were to retrospectively evaluate the
effectiveness of physical therapy in relieving dyspareunia and improving
sexual functioning as well as to identify factors associated with posttreat-
ment outcome. We also wanted to determine whether physical therapy was
effective enough to warrant inclusion in a randomized controlled trial for
VVS.

---

186
S. Bergeron et al.
METHOD
Subjects
Participants were 35 women who had consulted a gynecologist for dys-
pareunia and were then referred for physical therapy upon diagnosis of VVS.
They were recruited from a pool of 81 VVS patients who initially took part in
physical therapy. We were able to contact 57 of these women: 50 verbally
agreed to participate, and 35 returned their signed consent form. At the time
of the assessment interview, the majority of women were married (51.4%) or
cohabiting with their partners (22.9%). Others were either dating one partner
(11.4%) or single (14.3%). Their mean age was 35.1 years (range = 20–66).
The mean level of education was 15.6 years of schooling (range = 9–19),
which is equivalent to an undergraduate university degree.
Prior to physical therapy, all participants underwent a thorough gyneco-
logical examination including the cotton-swab test. This test involves the
application of pressure with a cotton-tipped applicator to various points all
around the vestibule and has been shown to reliably identify patients with
VVS (Bergeron, Binik, Khalifé, Pagidas, & Glazer, 2001). Vaginal/cervical
cultures were taken when indicated and all active infections were treated.
Patients included in the study met the following selection criteria: (a) moder-
ate to severe pain during intercourse, (b) moderate to severe pain in re-
sponse to the cotton-swab test, (c) pain limited to the vulvar vestibule, (d)
no active infections, and (e) presence of VVS for a minimum of 6 months.
MATERIALS AND PROCEDURE
Physical Therapy Sessions
Physical therapy was conducted by one of two physical therapists trained
and experienced in pelvic-floor physical rehabilitation. The first phase of
treatment focused on educating patients regarding how the pelvic-floor
musculature tends to contract when the pain of VVS is experienced. The
therapists underlined the importance of controlling these muscular reactions
and taught the patients that maintaining a relaxed pelvic-floor during inter-
course considerably decreases the sensation of pain.
Manual techniques used for proprioception, normalization of muscle
tone, pain modification, and mobilization were applied on the surface of the
perineum and internally by vaginal and sometimes anal palpation. These
techniques included, among others, myofascial release, trigger-point pres-
sures, and massage.
The therapists introduced Biofeedback early in the treatment to assist
the patients in pelvic-floor muscle training by enabling them to visualize
their muscle activity. EMG activity was monitored via an intracavity vaginal

---

Vulvar Vestibulitis Syndrome
187
probe and displayed to the patients on a video monitor. As the patients
contracted and relaxed the pelvic-floor, the EMG display provided feedback.
Electrical stimulation consisted of bipolar, biphasic, low-frequency cur-
rent with a rectangular waveform used via the same intracavity probe as that
used for biofeedback. Goals were proprioceptive awareness of the area,
learning of the contraction, desensitization, and pain control.
Patient exercises also were given with the objective of training the women
to easily contract and relax the muscles of the pelvic-floor, using exercises
adapted from those popularized by Kegel (1948). The advantage of follow-
ing this exercise program in physical therapy as opposed to sex therapy is
that patients benefit from the direct supervision of a health professional
specialized in treating the pelvic-floor musculature. Home exercises also
included vaginal dilatation with dilators and/or dildos and stretching using
the biofeedback probe. Patients were encouraged to involve their partner in
the practice of these exercises. More specifically, interested partners attended
at least one physical therapy session and were shown how to conduct the
manual stretching techniques.
Telephone Interview Procedure
A research assistant contacted women with VVS who have completed physi-
cal therapy and who inquired about their interest in participating in a short,
confidential telephone interview regarding their treatment. We sent consent
forms to the women who verbally agreed to take part in the study. Once a
woman returned her signed consent form, the research assistant called her
to conduct a structured telephone interview comprising 46 questions per-
taining to sociodemographics, the outcome of the physical therapy, current
pain during intercourse, other treatments, and sexual functioning. The mean
length of the interviews was 23 min.
The change in introital dyspareunia following physical therapy was
measured on a 7-point scale ranging from “a lot worse” to “complete relief of
pain.” Success was defined a priori as “great improvement” or “complete
relief of pain.” Any ratings below those were considered nonsuccessful out-
comes.
RESULTS
Outcome of Physical Therapy
The mean number of physical therapy sessions was 6.6 (range = 1–16) and
the mean length of treatment follow up was 15.8 months (range = 2–44). On
the basis of our a priori criteria, we determined that physical therapy was
successful for 51.5% of women and could be considered nonsuccessful for
the other 48.5%. More specifically, 8.6% of participants reported complete

---

188
S. Bergeron et al.
relief of their pain, 42.9% reported a great improvement, 20.0% reported a
moderate improvement, 17.1% reported little improvement, 8.6% reported
no improvement, and 2.9% (N = 1) reported being a bit worse. Finally, 88.6%
of participants said that they would undergo physical therapy again, and
81.8% attributed their improvement to the physical therapy treatment.
Impact of Physical Therapy on Pain and Sexual Functioning
We performed paired-samples t-tests to evaluate the impact of physical therapy
on pain and sexual functioning (see Table 1). Pain intensity experienced
during intercourse and during gynecologic examinations was significantly
lower in the 6 months preceding the assessment interview than in the 6
months preceding the physical therapy, and this was true for the entire sample
as well as for successful and nonsuccessful cases taken separately. Sexual
desire was significantly higher at posttreatment than at pretreatment for the
entire sample as well as for successful and nonsuccessful cases taken sepa-
rately. Sexual arousal also was significantly higher at posttreatment than at
pretreatment for the entire sample as well as for the group of successful
cases. The monthly frequencies of manual stimulation, oral stimulation, in-
tercourse, and masturbation were higher at posttreatment than at pretreat-
ment for the entire sample, although this difference was only significant for
intercourse. Similar findings were found in the group of successful cases.
Using Wilcoxon signed ranks tests, we analyzed pre- to posttreatment
differences for categorical variables. Participants as a whole reported signifi-
cantly less interference of pain with intercourse (Wilcoxon, p < .0001), less
frequent pain experiences (Wilcoxon, p < .0001), and less fear of vaginal
penetration (Wilcoxon, p < .0001).
TABLE 1. Pain and Sexual Functioning
Successful
Nonsuccessful
Entire sample
Pain intensity
Mean Mean
Sig
Mean Mean
Sig
Mean Mean
Sig
(0 to 10)
before after
before after
before after
Intercourse pain
8.2
2.3
.0001*
8.1
5.9
.01*
8.2
3.9
.0001*
Gynecological pain
5.4
1.9
.0001*
6.5
3.4
.01*
5.9
2.6
.0001*
Levels of desire and Mean Mean
Sig
Mean Mean
Sig
Mean Mean
Sig
arousal (0 to 10)
before after
before after
before after
Sexual desire
4.9
7.4
.0001*
4.4
6.2
.01*
4.7
6.8
.0001*
Sexual arousal
5.4
8.2
.01*
5.8
6.9
.10
5.6
7.5
.001*
Sexual behavior
Mean Mean
Sig
Mean Mean
Sig
Mean Mean
Sig
(per month)
before after
before after
before after
Manual stimulation
4.1
4.8
.45
3.6
4.5
.06
3.9
4.7
.13
oral stimulation
2.9
3.1
.66
2.8
3.6
.10
2.8
3.3
.14
intercourse
2.4
5.6
.0001*
1.5
3.4
.08
1.9
4.6
.0001*
masturbation
1.9
1.9
.92
2.4
3.1
.23
2.1
2.5
.34
*Statistically significant difference between two means

---

Vulvar Vestibulitis Syndrome
189
Use of Other Treatments
Some participants reported having tried other means of alleviating their pain
during intercourse following physical therapy. More specifically, 54.3% used
a cream or gel (such as lubricant jelly or anesthetic gel, 48.6% took part in
some form of psychotherapy (such as individual, sex and/or couple therapy,
or relaxation exercises), 37.1% reported applying a variety of small measures
(for example, changing soaps or wearing cotton underwear), 20.0% tried
alternative treatments (such as homeopathic remedies or acupuncture), 23.5%
had other medical treatments (such as hormone replacement therapy), and
17.1% underwent a vestibulectomy at some point during the follow-up pe-
riod. These categories were not mutually exclusive, and thus many women
may have tried more than one type of treatment. Chi-square analyses re-
vealed no association between outcome and the use of creams, c2 (5, 35) =
2.30, p = .81, psychotherapy, c2 (5, 35) = 2.52, p = .77, small measures, c2
(5, 35) = 6.77, p = .24, alternative treatments, c2 (5, 35) = 3.60, p = .61, other
medical treatments, c2 (5, 35) = 4.78, p = .44, nor vestibulectomy, c2 (5, 35) =
1.51, p = .91.
Variables Associated with Outcome
Using independent-samples t-tests for continuous variables and Mann-Whitney
tests for categorical variables, we compared successful and nonsuccessful
cases. Age, length of follow-up, number of physical therapy sessions, pretreat-
ment pain intensity, pretreatment frequency of intercourse, compliance with
home exercises, marital status, and confidence in treatment did not signifi-
cantly differ between the two groups. However, successful responders were
significantly less educated than nonsuccessful responders (t = –2.7, p < .01).
DISCUSSION
The results of the present study demonstrate that physical therapy is a poten-
tially effective treatment in relieving dyspareunia due to VVS. More than half
of the women in the sample reported a great improvement or complete relief
of their pain. In addition, the majority of participants attributed their im-
provement to physical therapy and said that they would take part in this
treatment again. Satisfaction with treatment is an important component of
any modality, because its absence may lead to a failure to follow through
with the recommended intervention. It is noteworthy that in comparison to
results from outcome studies of vestibulectomy (see, for example, Bergeron,
Bouchard, Fortier, Binik, & Khalifé, 1997), the present findings show that
physical therapy does not result in a large proportion of women reporting a
complete relief of their pain—which is the case for vestibulectomy. Rather, a
higher proportion of them report moderate and substantial improvements.

---

190
S. Bergeron et al.
Therapists should discuss these differential treatment effects when making
treatment recommendations to patients.
Pain during intercourse and during gynecological examinations was sig-
nificantly reduced at posttreatment compared to pretreatment for the entire
sample of women, as well as for successful and nonsuccessful cases taken
separately. These results indicate that even patients who can be considered
nonsuccessful responders benefited from a pain reduction. The same pat-
tern of results also was found for sexual desire; patients as a whole, as well
as when divided into successful and nonsuccessful responders, reported
significantly more desire at posttreatment than at pretreatment. Sexual arousal
was significantly improved at posttreatment for the group of successful cases
as well as for patients as a whole. Since sexual desire and arousal are not
directly addressed by physical therapy, we hypothesize that the posttreat-
ment changes seen in the pain-related variables—less pain during intercourse,
less interference of pain with intercourse, less-frequent pain experiences,
and less fear of vaginal penetration—are the factors mediating the increases
in desire and arousal.
Intercourse frequency was significantly higher at posttreatment than at
pretreatment for the group of successful cases and for the entire sample.
This makes sense in view of the findings regarding the reduction of pain
intensity during intercourse and the increases in sexual desire and arousal.
However, the posttreatment average frequency of intercourse of 4.6 times
per month is well below the norm for women in this age range, which is 7.5
times per month (Laumann, Gagnon, Michael, & Michaels, 1994). We have
found almost identical intercourse frequency results in our randomized treat-
ment outcome study of VVS and have suggested that multimodal treatment
approaches including sex and couple therapy may be essential in achieving
significant improvements in all areas negatively affected by VVS (Bergeron,
Binik, Khalifé, Meana, et al., 1997; Binik, Bergeron, & Khalifé, 2000; Binik,
Meana, & Berkley, 1999).
In terms of factors associated with posttreatment outcome, results show
that women considered to be successful cases were significantly less edu-
cated than those considered nonsuccessful. It is possible that the more-edu-
cated women were more skeptical of the effectiveness of physical therapy
for VVS, although confidence in treatment was not related to outcome. This
finding will need to be replicated in a more rigorous study before any firm
conclusions can be drawn regarding its significance.
Considering the retrospective nature of this study, inquiring about the
use of other treatments appeared important in order to provide a more de-
tailed and comprehensive report of the effectiveness of physical therapy.
Since a significant number of study participants had used other methods to
alleviate their pain following the therapy, it is possible that some of these
measures, particularly those known to be efficacious (for example,
vestibulectomy), contributed to the overall outcome. However, results of
Chi-square analyses did not reveal any significant association between par-

---

Vulvar Vestibulitis Syndrome
191
ticipation in those concomitant treatments and outcome.
The present study is retrospective and uncontrolled, which limits inter-
pretation of the findings. There is an urgent need for more randomized,
prospective treatment outcome studies of dyspareunia. This research none-
theless constitutes a first step in evaluating the effectiveness of physical therapy
for VVS, a highly prevalent pain syndrome that impacts negatively on sexual
functioning and overall quality of life.
REFERENCES
Arena, J. G., & Blanchard, E. B. (1996). Biofeedback and relaxation therapy for
chronic pain disorders. In R. J. Gatchel & D. C. Turk (Eds.), Psychological ap-
proaches to pain management: A practitioner’s handbook (pp. 179–230). New
York: Guilford Press.
Bergeron, S., Binik, Y. M., Khalifé, S., Meana, M., Berkley, K. J., & Pagidas, K. (1997).
The treatment of vulvar vestibulitis syndrome: Toward a multimodal approach.
Sexual and Marital Therapy, 12, 305–311.
Bergeron, S., Binik, Y. M., Khalifé, S., & Pagidas, K. (1997). Vulvar vestibulitis syn-
drome: A critical review. The Clinical Journal of Pain, 13, 27–42.
Bergeron, S., Binik, Y. M., Khalifé, S., Pagidas, K, & Glazer, H. I. (2001). Vulvar
vestibulitis syndrome: Reliability of diagnosis and evaluation of current diag-
nostic criteria. Obstetrics & Gynecology, 98, 45–51.
Bergeron, S., Binik, Y. M., Khalifé, S., Pagidas, K., Glazer, H. I., Meana, M., & Amsel,
R. (2001). A randomized comparison of group cognitive-behavioral therapy,
surface electromyographic biofeedback, and vestibulectomy in the treatment of
dyspareunia resulting from vulvar vestibulitis. Pain, 91, 297–306.
Bergeron, S., Bouchard, C., Fortier, M., Binik, Y. M., & Khalifé, S. (1997). The surgi-
cal treatment of vulvar vestibulitis syndrome: A follow-up study. Journal of Sex
& Marital Therapy, 23, 317–325.
Binik, Y. M., Bergeron, S., & Khalifé, S. (2000). Dyspareunia. In S. R. Leiblum, & R.
C. Rosen (Eds.), Principles and practice of sex therapy, (3rd ed.; pp. 154–180).
New York: Guilford Press.
Binik, Y. M., Meana, M., & Berkley, K. (1999). The sexual pain disorders: Is the pain
sexual or is the sex painful? Annual Review of Sex Research, 40, 210–235.
Friedrich, E. G. (1988). Therapeutic studies on vulvar vestibulitis. Journal of Repro-
ductive Medicine, 33, 514–517.
Glazer, H. I., Rodke, G., Swencionis, C., Hertz, R., & Young, A. W. (1995). The
treatment of vulvar vestibulitis syndrome by electromyographic biofeedback of
pelvic-floor musculature. Journal of Reproductive Medicine, 40, 283-290.
Goetsch, M. F. (1991). Vulvar vestibulitis: Prevalence and historic features in a gen-
eral gynecologic practice population. American Journal of Obstetrics and Gy-
necology, 161, 1609–1617.
Kegel, A. (1948). Progressive resistance exercise in the functional restoration of the
perineal muscles. American Journal of Obstetrics and Gynecology, 56, 238–248.
Laumann, E. O., Gagnon, J. H., Michael, R. T., & Michaels, S. (1994). The social
organization of sexuality. Chicago: University of Chicago Press.

---

192
S. Bergeron et al.
Laumann, E. O., Paik, A., & Rosen, R. C. (1999) Sexual dysfunction in the United
States: Prevalence, predictors and outcomes. Journal of the American Medical
Association, 281, 537–545.
McKay, E., Kaufman, R. H., Doctor, U., Berkova, Z., Glazer, H. I., & Redko, V. (2001).
Treating vulvar vestibulitis with electromyographic biofeedback of pelvic-floor
musculature. Journal of Reproductive Medicine, 46, 337–342.
Meana, M., Binik, Y. M., Khalifé, S., & Cohen, D. (1997). Biopsychosocial profile of
women with dyspareunia. Obstetrics and Gynecology, 90, 583–589.
Reissing, E., Binik, Y. M., Khalifé, & Cohen, D. (2001). Spasm and muscular tension
in women with vaginismus, vulvar vestibulitis syndrome and matched controls.
Unpublished manuscript, McGill University.
Van Lankveld, J. J. D. M., Weijenborg, P. T. H. M., & Ter Kuile, M. M. (1996). Psycho-
logic profiles of and sexual function in women with vulvar vestibulitis and their
partners. Obstetrics and Gynecology, 88, 65–70.

---