Trauma-Informed Treatment for Persistent Vulvodynia

Objectives: Vulvodynia is a form of chronic pelvic pain that occurs in 10% of the female population. This condition has a complex and multifactorial etiology. The impact of adverse childhood events (ACEs) on vulvodynia pain is noteworthy, exacerbating distress and intensifying pain symptoms in affected individuals. The presence of ACEs presents challenges to the effectiveness of traditional treatment interventions. This case report outlines a comprehensive trauma-informed treatment strategy for addressing persistent vulvodynia in a patient with a trauma history.

Methods: A 30-year-old female patient presented to physiotherapy with provoked localized vulvodynia. Previous treatment had included physiotherapy (4 different clinics), urogynecology, plastic surgery consult, and psychotherapy. Her symptoms persisted and she continued to have pain and a burning sensation at the vestibule. This restricted her ability to sit, walk, stand, perform housework, care for her child, or engage in sexual activity. She was unable to wear underwear or pants due to her vulvar pain. At her evaluation, she disclosed a six-year history of physical, emotional, and sexual abuse as a teenager. Upon questioning, she also disclosed a history of dissociation during traumatic events, including not only her abuse, but prior gynecological or physical therapy treatments.

A trauma-informed plan of care was created which emphasized consent, control, emotional safety, and compassionately listening to avoid re-traumatization. The patient was educated on somatic techniques to listen to her body’s cues and communicate openly with the physiotherapist. The treatment plan focused on patient education and empowerment, pain neuroscience education, pelvic floor stretches, diaphragmatic breathing, and manual therapy. Specific manual therapy techniques included strain counter-strain techniques and myofascial release of abdominal, hip, adductor and pelvic floor musculature.
The Numeric Pain Rating Scale (NPRS) was used to assess her pain with the Q-tip test. The Marinoff Dyspareunia Scale was used to assess her pain with sexual intercourse. Outcome measures were evaluated at the evaluation and at the end of care.

Results: The patient was seen for 15 physical therapy visits over six months. She was also seen concurrently with gynecology for medication and Botox treatments, as well as sex therapy and psychotherapy. Her Q-tip test reduced from 9/10 to 3/10 on the NRPS, exceeding the minimally clinically important difference. The Marinoff dyspareunia scale reduced from 3 to 1. She was able to return to previously painful activities, such as wearing underwear and blue jeans, and unlimited sitting, standing, and walking.

Conclusions: Adverse childhood events can adversely affect the pelvic floor and the nervous system. Adopting trauma-informed practices can assist patients in overcoming effects of trauma and improve communication, plan of care adherence, and overall outcomes. Trauma-informed practice should be standard of care with all patients, even with those who have not experienced trauma, as it encourages empowerment, choice, collaboration, and safety.