Overview

Physical therapists use their hands to localize and treat tissue restrictions. With advanced training, they apply these skills not only to external structures (i.e., hip and low back musculature) but also to structures within the pelvis. Though the pelvic floor muscles are an integral part of pelvic function, they are influenced by the structures within the pelvic bowl (the viscera: urethra, bladder, uterus, rectum, and anus), ligaments, and fascia. Appropriate treatment addresses abnormalities in all of these structures, which allows for rehabilitation of the pelvic floor muscles.

In addition, it is not uncommon to see an imbalance in the muscles and fascia of the pelvic floor of a woman with chronic vulvar pain. For example, pelvic floor hypertonicity can be driven by chronic low back and hip pain created by an abnormal balance of strength and tension between the muscles of the pelvis, hip, and lower back. Therefore, increased hip pain may cause an exacerbation in symptoms related to pelvic floor muscle hypertonus, including vulvarburning andintroital dyspareunia. A skilled physical therapist will use the techniques discussed in this chapter to evaluate and correct these imbalances.

Myofascial Release

The myofascial system is a slightly mobile, continuous, laminated sheath of connective tissue that envelops all the somatic and visceral structures of the body. In addition, it covers visceral organs, muscles, bones, and nerves. In the healthy state, strength and mobility are largely influenced by myofascial control. In the unhealthy state (which may follow trauma, or result from poor posture, scarring, or inflammation), the fascial system can become restricted and adherent, thereby reducing flexibility and stability and creating chronic pain [4].

Myofascial release is a manual therapy technique that uses light stretch to cause increased blood flow. This technique has been shown to restore myofascial mobility, tissue hydration, and muscle length [4]. Women’s health physical therapists have successfully utilized myofacial release to treat vulvodynia [2, 5–7], interstitial cystitis [8, 9], and dyspareunia [10]. In a study surveying women’s health physical therapists, 96% used soft tissue mobilization and myofascial release to treat women with provoked vestibulodynia(PVD) [11].

Traveil and Simons define a trigger point as a nodule within a palpably tight band of the muscle or fascia, which is exquisitely tender upon compression. Pressure applied to a trigger point will cause referred pain and tenderness [ 12]. In addition, trigger points can also disturb the proprioceptive, nociceptive, and autonomie functions of the affected region. Muscles containing trigger points are shortened, have limited range of motion, are weak and hypertonic, and present with a loss of coordination [9, 13, 14]. Studies have shown that trigger points are the key components of pain in up to 93% of patients presenting to a pain clinic [15].

Dyspareunia, as well as bladder and bowel dysfunction, can be a result of pelvic floor trigger points. Unfortunately, symptoms are highly variable and may include pain characterized as sharp, dull, achy, superficial, or deep [13, 14, 16, 17]. Trigger points typically occur in muscle because of trauma, repetitive overuse, or inflammation [ 16]. Trigger points associated with pelvic pain have been well documented in the following muscles: levator ani, obturator internus, coccygeus, abdominals, gluteals, adductors, piriformis, quadratus lumborum, paraspinals, iliotibial band/tensor fascia lata, quadriceps, and hamstrings [18]. Trigger points in the posterior pelvis typically refer pain to the rectum, anus, coccyx, and sacrum, while trigger points in the anterior pelvis create genital pain.

Trigger points can go unrecognized until a skilled practitioner locates them and recreates the patient’s symptoms. Manual therapies used to eliminate trigger points include skin rolling, strumming, and stripping of the affected muscle fibers. Physical therapists also use stretching, proprioceptive neuromuscular facilitation (i.e., contract/relax and reciprocal inhibition), active release techniques, and other muscle energy techniques to help facilitate muscle relaxation and lengthening. Trigger point injections and intramuscular injections of botulinum toxin type A can also be used to augment manual release techniques [19].

Weiss found an 83% reduction in symptoms, including a decrease in neurogenic bladder inflammation, central sensitization, and pelvic floor hypertonicity through manual release of myofascial trigger points [8]. In addition, Anderson et al. reported a 72% improvement in chronic pelvic pain and urinary symptoms using a combination of myofascial trigger point release of the pelvic floor muscles and paradoxical relaxation [20].

Visceral manipulation is a physical therapy technique used to improve tissue and organ mobility. The technique allows for the diagnosis and treatment of adhesions, fixations, and spasm in the viscera of the thorax, abdomen, and pelvis. The benefits of this technique are improved tissue metabolism, increased serotonin production, vasodilatation, and improved function of the respiratory and digestive systems [21]. For example, symptoms of an overactive bladder (urinary urgency/frequency, and pain) may be caused by excessive tone within the pelvic floor muscles, bladder, and urethra. If the bladder or urethra is in spasm, the surrounding muscles will respond with reflexive splinting. Manual release of the pelvic floor muscles will be beneficial but shortlived unless the abnormal tone in the viscera (bladder and urethra) is also treated. In the clinical experience of the authors, effective treatment includes releasing tension in both the musculoskeletal and the visceral systems simultaneously.

When visceral manipulation was used to treat women with generalized vulvodynia (GVD) or PVD, there was a 71% improvement in overall symptoms and a 62% improvement in sexual function (i.e., decreased dyspareunia, increased intercourse frequency, and increased desire) [11]. In addition, the American Society for Colposcopy and Cervical Pathology published Vulvodynia Guidelines that included visceral manipulation in its multidisciplinary approach to treating women with vulvar pain [3]. When women’s health physical therapists were surveyed, 33% reported having utilized visceral manipulation for treatment of women with PVD [11].

The nervous system, from its origin in the brain to its most distal nerve endings in the extremities, also requires mobility. When the cervical spine is flexed or extended, it causes increase neural tension throughout the entire nervous system. If there are restrictions (e.g., disc herniation, spinal stenosis, myofascial restrictions, and muscle spasm) and nerve mobility is impeded, there will be an adverse increase in neural tension which can lead to neuropathic pain.