Overview Vaginismus, classified under Genito-Pelvic Pain/Penetration Disorder in the DSM-5, is a complex condition characterized by involuntary contraction of the pelvic floor muscles, leading to painful or impossible vaginal penetration. Despite its significant impact on physical and psychosocial well-being, it is often misdiagnosed or dismissed. As physiotherapists with expertise in pelvic health, we propose an evidence-based, biopsychosocial approach that complements your care and improves outcomes for affected patients. Prevalence and Clinical Presentation Estimates suggest that up to 1–6% of women may experience lifelong vaginismus, although secondary cases are likely underreported (Reissing et al., 2004). Patients typically present with: Involuntary pelvic floor muscle tightness Severe anxiety or panic associated with penetration Avoidance of gynecologic exams or intimacy No identifiable anatomical cause Pathophysiology and Assessment Van der Velde & Everaerd (2001) conducted EMG studies revealing increased pelvic floor muscle activity even in anticipation of penetration. This supports the use of neuromuscular retraining as part of therapy. Physiotherapists trained in pelvic health assess: Resting tone and reactivity of pelvic muscles (levator ani, obturator internus) Breathing and movement patterns Psychomotor responses during examination Validated tools like the Vaginal Penetration Cognition Questionnaire (VPCQ) and Pelvic Floor Distress Inventory (PFDI) are used to track treatment progress. Evidence-Based Interventions Several RCTs support the effectiveness of pelvic floor physiotherapy: Brotto et al. (2015) found that women with genito-pelvic pain, including vaginismus, who received structured physiotherapy along with education showed improved sexual function and pain reduction compared to controls. Reissing et al. (2005) reported that pelvic floor retraining, combined with exposure therapy, led to statistically significant improvements in pain-free penetration and psychological outcomes. Interventions include: Internal and external myofascial release Use of graduated vaginal dilators with physiotherapist guidance Neuromuscular re-education and breathing control Trauma-informed care principles Interdisciplinary collaboration with sexual health therapists or psychologists when needed When to Refer Consider referring patients with: Reported inability to tolerate vaginal exams or intercourse Primary vaginismus or secondary cases after childbirth, trauma, or surgery Coexisting pelvic floor hypertonicity or vaginismus diagnosed by exclusion Resistance or failure with purely psychological interventions Conclusion Physiotherapy offers a critical, evidence-backed pathway to healing for women with vaginismus. By addressing the muscular and behavioral components of the disorder, we support your patients’ progress with a personalized, respectful, and effective care model. We look forward to collaborating in a multidisciplinary model to provide optimal patient care. References: Brotto, L. A., Yong, P., Smith, K. B., & Sadownik, L. A. (2015). Impact of a multidisciplinary vulvodynia program on sexual functioning and dyspareunia: A prospective study. Journal of Sexual Medicine, 12(1), 238–247. https://doi.org/10.1111/jsm.12721 Reissing, E. D., Binik, Y. M., Khalifé, S., Cohen, D., & Amsel, R. (2005). A randomized comparison of group cognitive–behavioral therapy and a validated education program for women with vulvar vestibulitis syndrome. Journal of Consulting and Clinical Psychology, 73(6), 1071–1081. https://doi.org/10.1037/0022-006X.73.6.1071 Van der Velde, J., & Everaerd, W. (2001). The relationship between involuntary pelvic floor muscle activity and sexual pain in women with dyspareunia and vaginismus: An electromyographic study. Journal of Psychosomatic Obstetrics & Gynecology, 22(4), 205–212. https://doi.org/10.3109/01674820109049983 Reissing, E. D., Binik, Y. M., Khalifé, S., Cohen, D., & Amsel, R. (2004). Etiological correlates of vaginismus: Sexual and physical abuse, sexual knowledge, sexual self‐schema, and relationship adjustment. Journal of Sex & Marital Therapy, 30(1), 47–59. https://doi.org/10.1080/00926230490247079
Dyspareunia and the Role of Pelvic Floor Physiotherapy: A Clinical Perspective for Physician Collaboration
Introduction: Dyspareunia affects a significant proportion of reproductive-age and perimenopausal women. Despite its prevalence and impact on quality of life, it remains underdiagnosed and undertreated. As physiotherapists specializing in pelvic health, we are seeking to collaborate with physicians to improve access to evidence-based care. Clinical Definition and Subtypes Dyspareunia can be categorized into superficial and deep types. Superficial dyspareunia is commonly linked to vestibulodynia, vaginismus, or dermatological conditions, whereas deep dyspareunia may be associated with endometriosis, pelvic inflammatory disease, or myofascial pelvic pain (Morin et al., 2017). Evidence-Based Interventions A robust body of literature supports pelvic floor physiotherapy as a first-line conservative treatment. Notably: Bergeron et al. (2001) conducted a landmark RCT comparing cognitive behavioral therapy, EMG biofeedback, and vestibulectomy in women with provoked vestibulodynia. Biofeedback-guided pelvic floor therapy significantly improved pain scores and patient satisfaction. Morin et al. (2017) performed a controlled study that showed a statistically significant reduction in pain and enhancement in sexual function after 10 sessions of targeted physiotherapy in patients with vestibulodynia. Zhao et al. (2020) conducted an RCT evaluating the effects of pelvic floor muscle training in women with dyspareunia and reported improved outcomes in muscle coordination, reduced hypertonicity, and pain reduction. These studies confirm that physiotherapy offers not only symptomatic relief but also long-term improvements in sexual function, partner relationships, and emotional well-being. Physiotherapy Approach Our clinical protocol includes: Internal and external pelvic floor muscle evaluation Myofascial trigger point release Manual therapy for pelvic asymmetries Graded desensitization and mirror therapy Multidisciplinary coordination for psychological support if needed Our outcomes are systematically tracked using validated tools such as the Female Sexual Function Index (FSFI), Vulvar Pain Functional Questionnaire (V-Q), and pain mapping scores. Referral Indicators Consider referring patients with: Pain during penetration not explained by infection or anatomical abnormalities Diagnosed vestibulodynia, vaginismus, or pelvic floor hypertonicity Postpartum or menopausal onset of dyspareunia Refractory pain despite pharmacological or surgical intervention Closing Pelvic floor physiotherapy is not an adjunct but a central pillar in the comprehensive management of dyspareunia. Interprofessional collaboration ensures a biopsychosocial approach that restores function and quality of life. We welcome the opportunity to co-manage your patients and provide individualized, evidence-based care. References: 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. Pain, 91(3), 297–306. https://doi.org/10.1016/S0304-3959(00)00448-5 Morin, M., Carroll, M. S., Bergeron, S., & Dumoulin, C. (2017). Pelvic floor muscle function in women with and without provoked vestibulodynia: A prospective case-control study. The Journal of Sexual Medicine, 14(11), 1381–1389. https://doi.org/10.1016/j.jsxm.2017.09.002 Zhao, Y., Xie, W., Liu, J., Zhu, Y., Chen, B., & Song, Y. (2020). Effects of pelvic floor muscle training on sexual function and pelvic floor dysfunction in women with dyspareunia: A randomized controlled trial. International Urogynecology Journal, 31(9), 1781–1789. https://doi.org/10.1007/s00192-019-04000-5
Pelvic Organ Prolapse: The Role of Pelvic Floor Physiotherapy in Conservative Management
Clinical Overview Pelvic Organ Prolapse (POP) is the descent of one or more pelvic organs—bladder (cystocele), uterus (uterine prolapse), or rectum (rectocele)—into or through the vaginal canal due to loss of support from the pelvic floor muscles, ligaments, and fascia. This is typically a result of levator ani avulsion, connective tissue laxity, or neuropathic injury following childbirth, chronic strain, or aging. Symptoms include: Sensation of vaginal “heaviness” or bulging Visible prolapse at or near the introitus Urinary hesitancy, urgency, or incomplete voiding Constipation or rectal pressure Dyspareunia or reduced sexual sensation Prevalence and Impact POP affects approximately 50% of parous women, although not all cases are symptomatic (Hagen & Stark, 2011). Its impact on quality of life, sexual function, and mental health can be significant—even in early stages. Evidence-Based First-Line Management: Physiotherapy Recent guidelines and systematic reviews recommend pelvic floor muscle training (PFMT) as the first-line conservative management for Stage I–III POP (NICE, ICS). The POPPY trial (Hagen et al., 2014), a multicenter RCT, demonstrated that individualized PFMT over 16 weeks led to: Clinically significant improvement in prolapse symptoms (measured by POP-SS) Improvement in POP-Q staging Reduction in prolapse severity on examination Better sexual function scores compared to control No reported adverse effects Physiotherapy Intervention Includes: Digital pelvic floor assessment (Oxford scale, Modified Brink, or EMG) Supervised, progressive PFMT tailored to POP-Q findings Symptom management education: posture, breath mechanics, bowel/bladder habits Intra-abdominal pressure control through breathwork and load management Behavioral coaching for voiding, defecation, and sexual activity Collaborative pessary fitting (as per gynecologist referral) Ideal Referral Candidates: POP Stage I–III (non-surgical candidates or surgery-averse) Postpartum patients with vaginal laxity or pelvic heaviness Patients with concurrent stress or mixed urinary incontinence Patients requiring pre- or post-operative pelvic floor conditioning Those seeking prevention of POP recurrence following prior treatment Multidisciplinary Collaboration Pelvic floor physiotherapists complement gynecologic and urogynecologic care through: Preventing progression in early-stage prolapse Enhancing surgical outcomes when used pre- or post-operatively Reducing surgical burden in healthcare systems Educating patients on long-term pelvic health maintenance Conclusion High-quality RCTs support pelvic floor physiotherapy as an effective, low-risk, first-line treatment for women with symptomatic POP. Early intervention can delay or eliminate the need for surgical correction in many cases, and it significantly improves functional outcomes and quality of life. Prompt referral for PFMT should be considered standard care for women with mild to moderate prolapse. References Hagen, S., Stark, D. (2011). Conservative management of pelvic organ prolapse in women: A systematic review of randomized controlled trials. BJOG: An International Journal of Obstetrics & Gynaecology, 118(8), 868–878. https://doi.org/10.1111/j.1471-0528.2011.02955.x Hagen, S., Stark, D., Glazener, C. M., Dickson, S., Barry, S. J., & Logan, J. (2014). Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): A multicentre randomised controlled trial. The Lancet, 383(9919), 796–806. https://doi.org/10.1016/S0140-6736(13)61977-7
Stress urinary incontinence (SUI)
Stress urinary incontinence (SUI) affects up to 1 in 3 women globally and is a major contributor to decreased quality of life, social withdrawal, and even depression in otherwise healthy individuals (Bo et al., 2017). As physiotherapists, we are often the first non-surgical, non-pharmacologic point of contact for these patients. With increasing evidence supporting pelvic floor muscle training (PFMT) as a first-line intervention, this article summarizes key findings from high-quality randomized controlled trials (RCTs) that position physiotherapy as an essential part of multidisciplinary SUI care. Defining SUI and Its Clinical Impact SUI is characterized by involuntary urine leakage during effort or physical exertion, such as coughing, sneezing, laughing, or exercising (Haylen et al., 2010). Though often considered a “normal” part of aging or childbirth, untreated SUI leads to avoidable complications, including: Reduced physical activity Increased fall risk in elderly women Sexual dysfunction Higher risk of urinary tract infections For physicians managing this condition, timely referral to physiotherapy can significantly improve patient outcomes and reduce long-term costs. Pelvic Floor Muscle Training: The Gold Standard in Conservative Management A large body of RCTs supports PFMT as the gold standard non-invasive treatment for SUI. In a landmark RCT by Dumoulin et al. (2018), women randomized to supervised PFMT showed a 56% cure rate and a 74% improvement rate, significantly outperforming the control group. This study emphasized the importance of supervision by trained pelvic physiotherapists for optimal outcomes. Another meta-analysis of 31 RCTs involving 1,817 women by Woodley et al. (2020) confirmed that PFMT increases the likelihood of cure or improvement (RR 8.38, 95% CI 3.68–19.07) compared to no treatment or placebo. The findings led to PFMT being recommended as a Grade A recommendation by the International Continence Society and European Association of Urology. Biofeedback and Adjunct Therapies: Enhancing Results Biofeedback devices are commonly used to facilitate neuromuscular control, and their efficacy is supported by several RCTs. Glazener et al. (2011) conducted a multicenter trial with 600+ participants and found that adding biofeedback improved adherence and muscle isolation skills, though long-term differences in outcomes were modest. For patients struggling with proprioception or technique, biofeedback remains a useful adjunct, especially in the early stages of therapy. Other adjuncts include vaginal weights, electrical stimulation, and behavioral therapies. While none of these outperformed PFMT alone in most RCTs, they offer additional options for patients who fail to progress with exercises alone (Berghmans et al., 2013). PFMT vs. Surgical Options: When to Refer While mid-urethral slings remain the gold standard for surgical management, many patients prefer to exhaust conservative options first, especially in cases of mild to moderate SUI. According to a Cochrane review (2017), physiotherapy can delay or avoid surgery in up to 65% of cases when followed consistently over 3–6 months. Moreover, post-operative physiotherapy helps in strengthening the pelvic support structures and preventing recurrence or complications. Therefore, physiotherapy is relevant before and after surgical management. Physician-Physiotherapist Collaboration: What We Need From You For optimal outcomes, physicians are encouraged to: Refer patients early when symptoms appear, rather than after years of discomfort. Share relevant obstetric, surgical, or urological history to aid our evaluation. Encourage adherence to home exercise programs, as this is a major predictor of success. Collaborate on complex cases (e.g., mixed incontinence, pelvic organ prolapse, or prior pelvic surgery). Conclusion and Key Takeaway Stress urinary incontinence is not just a “nuisance” — it is a treatable medical condition with profound quality-of-life implications. Physiotherapists play a critical role in conservative management, and early referral can result in high cure rates without the need for surgery or medication. Physicians who collaborate with pelvic floor physiotherapists provide patients with a holistic, evidence-based approach that aligns with global best practice guidelines. Key References: Bo, K., Hilde, G., & Stær-Jensen, J. (2017). Physiotherapy for female stress urinary incontinence: A review of randomized controlled trials. International Urogynecology Journal, 28(6), 887–899. https://doi.org/10.1007/s00192-017-3362-9 Dumoulin, C., Cacciari, L. P., & Hay-Smith, E. J. C. (2018). Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database of Systematic Reviews, 10, CD005654. https://doi.org/10.1002/14651858.CD005654.pub4 Glazener, C. M. A., et al. (2011). Pelvic floor muscle training and biofeedback for the treatment of stress urinary incontinence: A multicentre randomized controlled trial. BMJ, 342, d373. https://doi.org/10.1136/bmj.d373 Haylen, B. T., et al. (2010). An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourology and Urodynamics, 29(1), 4–20. https://doi.org/10.1002/nau.20798 Woodley, S. J., et al. (2020). Pelvic floor muscle training for urinary incontinence in women: Cochrane systematic review and meta-analysis. BJOG, 127(10), 1281–1293. https://doi.org/10.1111/1471-0528.16214 Berghmans, B., et al. (2013). Electrical stimulation with non-implanted electrodes for overactive bladder in adults. Cochrane Database of Systematic Reviews, 6, CD010098. https://doi.org/10.1002/14651858.CD010098.pub2
Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians
Overactive Bladder (OAB): A Clinical Overview for Referring Clinicians Overview: Overactive bladder (OAB) is a symptom-based syndrome characterized by urinary urgency, usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of UTI or other overt pathology (ICS, 2002). It affects approximately 30% of adults over 40 and becomes increasingly prevalent with age (Hsu et al., 2019). Etiology and Pathophysiology While detrusor overactivity is the urodynamic correlate in many cases, OAB can also occur due to: Neurological disorders (e.g., MS, Parkinson’s) Impaired bladder compliance Pelvic floor dysfunction (hypertonic or hypotonic) Psychological factors (e.g., anxiety, trauma history) Iatrogenic causes (e.g., medications, radiation) Notably, Fontaine et al. (2021) emphasized that detrusor overactivity is not present in all OAB cases, necessitating a broader diagnostic lens. Initial Management: First-Line Conservative Interventions According to current guidelines and high-quality randomized trials, behavioral and physiotherapeutic interventions are the cornerstone of initial management. 1. Bladder Retraining: Evidence supports scheduled voiding with progressive delay intervals, combined with urge suppression strategies (Scaldazza et al., 2017). Techniques include reverse Kegels, diaphragmatic breathing, sensory distraction, and pelvic floor relaxation. 2. Pelvic Floor Physiotherapy: Pelvic health physiotherapists assess and rehabilitate both hypertonic and hypotonic pelvic floors. Contrary to popular assumptions, many OAB patients present with tight pelvic floor musculature that exacerbates urgency/frequency symptoms. 3. Lifestyle Modifications: Elimination of bladder irritants (e.g., caffeine, alcohol, acidic foods) Managing constipation Fluid management and pre-bedtime voiding Supine leg elevation in patients with peripheral edema These non-invasive measures have high patient adherence and low adverse event profiles, making them ideal first-line strategies, particularly in older adults or those with polypharmacy concerns. Pharmacological Interventions If conservative measures prove insufficient, consider the following pharmacologic options: Anticholinergics (e.g., oxybutynin, solifenacin): Effective but associated with dry mouth, constipation, and cognitive risk, especially in the elderly (Welk & McArthur, 2020). β3-Adrenergic Agonists (e.g., mirabegron): Similar efficacy with improved CNS safety profile; preferred in patients at risk for anticholinergic burden (Yamaguchi et al., 2014). Medication adherence is often suboptimal due to side effects, with >50% discontinuing within 6 months (Benner et al., 2010). Combination therapy with behavioral interventions improves outcomes. Advanced Options for Refractory Cases If pharmacological and behavioral therapies fail: Percutaneous Tibial Nerve Stimulation (PTNS): Effective for OAB symptom reduction with a favorable safety profile (Keller et al., 2017). Botulinum Toxin A Injections: FDA-approved for refractory OAB but requires intermittent self-catheterization in some patients. Sacral Neuromodulation: Considered in severe cases with mixed incontinence or when other modalities fail. Referral Recommendations Refer patients for pelvic floor physiotherapy when: Symptoms persist despite lifestyle changes Pelvic floor dysfunction is suspected (e.g., concomitant pelvic pain, constipation) Pharmacologic therapy is contraindicated or declined Patients prefer non-invasive, functional approaches Conclusion for Clinical Practice OAB is a multifactorial condition with a significant impact on quality of life. Evidence-based management emphasizes a stepwise approach beginning with behavioral therapy and physiotherapy, progressing to pharmacological and neuromodulation therapies as needed. Collaborative care involving physiotherapists, urologists, and family physicians ensures optimal outcomes. Key References Benner, J., Nichol, M., Rovner, E., Jumadilova, Z., Alvir, J., Hussein, M., & Brubaker, L. (2010). Patient‐reported reasons for discontinuing overactive bladder medication. BJU International, 105(9), 1276–1282. https://doi.org/10.1111/j.1464-410x.2009.09036.x Fontaine, C., Papworth, E., Pascoe, J., & Hashim, H. (2021). Update on the management of overactive bladder. Therapeutic Advances in Urology, 13, 17562872211039034. https://doi.org/10.1177/17562872211039034 Hsu, Y. P., Chuang, F. C., Chang, S. J., & Yang, S. S. (2019). Prevalence and associated factors of overactive bladder among the elderly in Taiwan. International Urogynecology Journal, 30(7), 1091–1099. https://doi.org/10.1007/s00192-018-3776-4 Keller, N., Schmid, S., & Haemmerle, B. (2017). Successful therapy of overactive bladder syndrome with percutaneous tibial nerve stimulation: A case report. The International Annals of Medicine, 1(11), 387. https://doi.org/10.24087/iam.2017.1.11.387 Scaldazza, C., Morosetti, C., Giampieretti, R., Lorenzetti, R., & Baroni, M. (2017). PTNS vs. pelvic floor muscle training in women with OAB: A randomized study. International Braz J Urol, 43(1), 121–126. https://doi.org/10.1590/s1677-5538.ibju.2015.0719 Welk, B., & McArthur, E. (2020). Dementia risk in patients treated for OAB: Anticholinergic vs beta‐3 agonists. BJU International, 126(1), 183–190. https://doi.org/10.1111/bju.15040 Yamaguchi, O., Marui, E., Kakizaki, H., Homma, Y., Igawa, Y., Takeda, M., & Ohkawa, S. (2014). Mirabegron 50 mg for OAB in Japanese patients: A phase III trial. BJU International, 113(6), 951–960. https://doi.org/10.1111/bju.12649