INTRODUCTION:

The International Society for the Study of Vulvar Diseases defines vulvodynia as chronic pain or discomfort involving the vulva for more than 3 months and for which no obvious aetiology can be found^[^1-2].In fact, women with vulvodynia often do not use the word “pain” to describe their discomfort. Rather they use phrases such as itching, burning, stinging, irritation, stabbing, and/or rawness^[3].The classification of vulvodynia is currently based on a description of the pain. A woman’s symptoms may be “generalized” to the whole vulva (generalized vulvodynia) or “localized” to a specific area such as the clitoris (clitorodynia) or the vestibule of the vagina (vestibulodynia)^[4-5]. The pain may be “provoked” (caused by direct touch, inserting a tampon, or sexual touch), “unprovoked” (present without touch), or have a “mixed” pattern^[6]. The characteristics of a woman’s pain may wax and wane over time ^[7]. A woman may initially notice pain begin to notice monthly episodes of unprovoked vestibular discomfort (“it feels like I get a yeast infection every month before my period”), and finally, daily episodes of unprovoked vulvar discomfort (“I feel burning all over the vulva all the time”)^[8-10]. Vulvodynia affects women of all ages, reproductive stages, and ethnicities. It is a chronic vulvar pain condition^[11]. It is a heterogeneous and multifactorial gynecological condition with an estimated prevalence 9-12% broad and substantial effect on quality of life due to physical disabilities, psychological distress and sexual dysfunction. It estimates to affect 4-8% of women at any one time and 10-20% in their lifetime^[12]. The pain usually is present during and after bicycle riding, tampon insertion, prolonged sitting, and wearing tight clothes. In some women the pain is spontaneous^[13]. It is characterized by chronic discomfort in the vulvar region; the discomfort may range from mild to severe and debilitating. The diagnosis depends on a consistent history, lack of a documented infectious or dermatologic cause, and in most women, tenderness when gentle pressure is applied by a cotton swab to the vulva, introitus, or hymeneal areas^[14-15]. Vulvar Pain stems from 2 primary channels: the musculoskeletal system and the central nervous system^[16]. If vulvar pain persist due to musculoskeletal and myofascial restrictions, it will increasing flexibility through manual therapy, therapeutic exercises and yoga can also help^[17]. Vulvar pain is driven from central nervous system, strengthening the parasympathetic nervous system response via pranayama, medication and gentle movement can be effective in decreasing symptoms and pain^[18]. Pelvic floor exercise, include increased pelvic floor tone, instability of pelvic floor muscles control, and phobic avoidance. Initial goals of physical therapy are to increase the patient’s awareness of her ability to locate, contract, and fully relax these muscles, and address reflex guarding and/or muscles spasm (vaginismus reflex)^[19-20].

MATERIALS AND METHODOLOGY:

Once the study is approved by the institutional review broad, a total of 40 subjects among 50 female volunteers with vulvodynia were taken by simple random sampling method into the experimental study at A.C.S Medical College and hospital, with an inclusion criteria of age group of 20 to 50 years, vulvar pain present for at least 6 months, vulvar symptoms of pain, itching, burning and/or tenderness of the vulva and exclusion criteria active Vulvovaginal infection and severe mental illness. The subjects were fully explained about the study and benefits of participating assuring confidentiality of their personal details, they were then asked to fill the consent form in acceptance with their participation in the study which is duly signed by the participant and the researcher. Demographic information including the name, age, gender, occupation, height, weight was collected prior to the pre-test measurement.

The samples were divided into two groups with group A – 20 subjects performed pelvic floor muscle exercises training (kegels exercise, isometrics of gluteus, adductors, pelvic bridging, wall squats, jumping jacks, dead bug crunch, split tabetop, bird dog) with behavioural modifications (not to wear tight clothes, stop riding bicycle for 2 months during the exercise sessions, not to sit continuously for more than 30 minutes) and group B – 20 subjects performed pranayama and yoga (malasana, votkattasana, reclined bound angle, child pose, partial sirasasana. The baseline measurements were taken by using short form McGill pain questionnaire, VAS andKessler Psychological distress scale (K10). The procedure is done by performing technique for 15-30 minutes for 5 days per week for 6 weeks. After the study of 6 week the post-test measurement were taken and compared with pre-test.

Blinding:

The investigator assessing the outcomes remained blind to the patients allocation during the whole study period. Then the statistician who conducted outcome analyses was blinded to the group allocation by renaming the groups with numbers.

RESULT:

After a thorough analysis of the recorded data, it has been found that there was a significant difference between the mean values and standard deviation of the two groups, group A pelvic floor exercise have more beneficial effect than the yoga for reducing the pain intensity.

DISCUSSION:

In this study, 40 females were selected based on the inclusion criteria from 75 volunteers have undergone pelvic floor exercise muscle training and asked to fill a questionnaire to know their level of the pain. This is done performing exercise responsiveness to reduce pain. The patient should be informed about the natural history of vulvodynia and realistic information about its treatment. Mean values and standard deviations shows significant difference in the Mc Gill questioner, VAS which is a scale value and Kessler Psychological distress scale (K10) in both groups, but group A shows better significance than group B. Hence pelvic floor muscle training with behavioral modification showed better improvement than yoga in both pain and psychological factors.

Counseling should include acknowledging her pain as real and that no single treatment is effective^[21]. She may therefore require a combination of therapy and improvement in the symptoms may take weeks to months. Educational seminars led by gynecologists with expertise in the management of vulvodynia in group format have been found to have a signiﬁcant positive effect on psychological and sexual function in these women^[22].The initial management includes emphasis on gentle vulvar care measures to minimize vulvar irritation. A recent study on the effectiveness of vulvar care demonstrated a statistically signiﬁcant improvement in dyspareunia, burning, itching and pain^[23-31]. Medical therapies include topical, intralesional and oral drugs. There is evidence in support of the use of 2% or 5% lidocaine ointment, which improves symptoms^[32]. A dysfunction of pelvic floor muscle is common; the exercise improved vaginal flexibility, and improved pelvic floor muscle tone including increased instability of the pelvic floor muscles, poor pelvic floor muscle control, and phobic avoidance^[33]. Vulvoscopy microscopes can be combined with photography, which permits the pathologic lesion to be photographed and to be followed over time to assess treatment benefit. Another obvious benefit of vulvoscopy photography is the educational value for the patient^[34]. Vulvar vestibulitis is a major cause of entry dyspareunia in young women. It causes bacterial vaginosis, candidiasis, use of oral contraception and nulli-pregnancy as risk factors for vestibulitis^[35]. Initial goals of physical therapy are to increase the patient’s awareness of her pelvic floor muscles. Women with vulvodynia often have pelvic floor muscle dysfunction (PFMD). Pelvic floor resting muscle tone is higher and contractions are slower and weaker in women with vulvodynia than in healthy women. PFMD can be assessed by using a 1-finger digital examination of the muscles. The focus of exercises should be on the relaxation of the pelvic floor muscles; a gentle, sub-maximal contraction followed by relaxation can be helpful for women to perceive the sensation of the pelvic floor relaxing. It is improving the symptoms and quality of life in women with vulvodynia^[36-37]. The mean value shows that as mean value of pelvic floor exercise training increase compare to the yoga. The physical therapy is a common treatment for vulvodynia. A large percentage of patients have vulvodynia or other similar pain or sexual dysfunctions. For this condition, treatment usually consists of internal pelvic floor massage or pelvic floor exercise to improve the pain intensity of the patient^[38]. Physical therapist also includes exercises for core strengthening and hip, back and leg flexibility, as well as a lot of patient education on things like posture, stress reduction and relaxation techniques. Females are preferred to the physical therapist, they are often really happy to have their pain validation in a way that a bunch of medical tests or even surgeries may have not been able to^[39-45]. The surgical technique that is currently practised, modiﬁed vestibulectomy, is considered in women with localised provoked vulvodynia after exhausting the other treatment options. This procedure involves excising a ‘U’-shaped vestibular mucosa to Hart’s line (the edges of the vulvar vestibule) and advancing out the posterior vaginal mucosa to cover the defect. Modiﬁed vestibulectomy is associated with high levels of patient satisfaction and low complication rates^[26]. It is evident that chronic vulvar pain affects psychosexual health with exacerbation of symptoms of depression, anxiety, somatisation and sexual function. Psychosocial therapy such as cognitive behavioural therapy (CBT) is behaviour oriented and assists in establishing a personal control of pain by self-management skills that alters the woman’s thoughts and behaviour on pain, emotional and sexual function. Psychosexual counselling offers basic sexual function assessment and provides education, information and support groups for individuals or couples^[46]. Combined physical therapy with biofeedback and transcutaneous electrical nerve stimulation (TENS) with intravaginal probe in vulvar pain demonstrated considerable improvement in vulvar pain^[47]. These therapies aim to desensitize the pelvic ﬂoor area. In the series reported by Bergeron et al. with 35 women, physical therapy yielded a complete or great improvement for 51% of participants and a moderate improvement for 20% of participants^[48].Many treatments used for women with vulvodynia are based solely upon expert opinion like cognitive-behavioral therapy (CBT) and supportive psychotherapy (SPT) in women with vulvodynia^[49]. Pelvic ﬂoor physical therapy is effective in women with evidence of pelvic ﬂoor muscle hypertonicity. It is most useful in women with vaginismus, back pain and spasm of muscles. This therapy includes internal and external therapeutic exercises, pelvic ﬂoor retraining and biofeedback that reduce the introitus tenderness and resumption of sexual intercourse^[50]. Thisstudy concludes that regular physical activities are required to have a perfect physical and mental well-being^[51]. Result suggested that stretching program and pelvic floor muscle strengthening can be used as an alternative for pain relief medicines in primary dysmenorrhea^[52].

CONCLUSION:

Vulvodynia is a complex syndrome associated to sexual dysfunctions and worsening of quality of life. The successful treatment requires intervention addressing a broad field of possible pain contributors. According to our results group A, Physical Therapy may play a pivotal role in improving symptoms, as first line of treatment, further investigations and high-quality studies are neededin order to introduce Physical Therapy as an integral component of the multidisciplinary approach to vulvodynia, according to a standard specific protocol, which is statistically proven. Therefore group A shows more significant effect than group B in pain and psychological distress.

ACKNOWLEDGEMENT:

I would like to thank the authorities of Dr. MGR Educational and Research Institute, University and the Principal Faculty of Physiotherapy for providing me with facilities required to conduct the study.

ETHICAL CONSIDERATIONS:

The manuscript is approved by the Institutional Review board of faculty of physiotherapy. All the procedures were performed in accordance with the ethical standards of the responsible ethics committee of both (Institutional and national) on human experimentation and the Helsinki Declaration of 1964 (as revised in 2008).

CONFLICT OF INTEREST:

All contributing authors declare that they have no Conflicts of interest. This study was approved by Institutional Review Board of Physiotherapy, Dr. MGR Educational and Research Institute University, Chennai.

FUNDING:

This is a self-funded study.

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Received on 11.03.2018 Modified on 12.04.2018

Research J. Pharm. and Tech 2018; 11(10): 4447-4451.

DOI: 10.5958/0974-360X.2018.00814.4

TEST	PELVIC FLOOR MUSCLE TRAINING (GROUP –A)			YOGA (GROUP –B)
	McGill Pain que	VAS	Kessler Psychological distress scale(K10)	McGill Pain que	VAS	Kessler Psychological distress scale(K10)
PRE-TEST	276	140	74	280	144	76
MEAN	13.8	7	3.7	14	7.2	3.8
SD	1.516	0.795	0.571	1.169	0.768	0.696
POST-TEST	163	60	33	237	67	50
MEAN	8.15	3	1.65	11.85	3.35	2.5
SD	1.182	0	0.489	0.988	0.745	0.513