Chronic Pelvic Pain Syndrome (CPPS) is a multifactorial, debilitating disorder combining the dysfunction of pelvic floor musculature and malfunction of pain perception (1). The prevalence of Vulvodynia in CPPS patients with chronic musculoskeletal pain is 36.4% compared to 16% among women without CPPS (2). This original study aims to assess the efficacy of resolving Vulvodynia by treating underlying Neuromuscular Dysfunction in women with CPPS.

38 female patients between the ages of 18 to 76 with CPPS and confirmed vulvodynia who presented to an outpatient pelvic rehabilitation practice were the participants of this original retrospective longitudinal study. 

Inclusion criteria:
1.	Completion of at least 6 weeks of pelvic floor physical therapy
2.	History of CPPS for greater than 6 months
3.	Full gynecological consultation with necessary workup.
4.	Completion of 8-12 weeks of topical estrogen/testosterone hormonal cream for vulvodynia symptoms. 
5.	Standard pretreatment evaluations with detailed history and physical examination, including an internal pelvic floor examination.
6.	Positive Q-Tip Test at first patient visit 

Exclusion criteria:
1.	Active infection 
2.	Malignancy 
3.	Active Pregnancy
4.	Not concomitantly participating in pelvic floor physical therapy  
5.	Negative Q-Tip Test at first patient visit 

The neuromuscular protocol consisting of ultrasound-guided trigger point injections to pelvic floor musculature with peripheral nerve blocks once a week for six weeks was developed for patients with CPPS who failed to improve after six weeks of pelvic floor physical therapy. Patients concomitantly attended pelvic floor physical therapy that included internal release of the pelvic floor hypertonic musculature, visceral mobilization, scar tissue mobilization, skin rolling along the lower abdomen and buttocks, nerve gliding along the pudendal and posterior femoral cutaneous nerves, and diaphragmatic breathing. 

Patient response to treatment was measured prior to treatment and 3 months after treatment was initiated, with the Visual Analogue Scale (VAS) to calculate pelvic pain and the Functional Pelvic Pain Scale (FPPS) to gauge pelvic functionality. Functionality categories evaluated were working, walking, bowel, lifting, running, sleeping, intercourse, and bladder. Patients ranked all categories from 0 to 4, representing regular function and serious debilitation, respectively. Hence, all patients were summarized by an overall pelvic function score ranging 0 and 32 and pain score ranging 0 to 10. Statistical significance of VAS and FPPS was determined using paired two sample t-test with P value less than 0.05.

40.66 years (SD 16.45) was the average age of the 38 patients and 8.57 years (6.84) was the average duration of pelvic pain. 
Out of the 38 women, 21 (55%) reported their vulvodynia had resolved at their 3 month follow up visit and 17 (45%) reported unresolved vulvodynia. 

For the 38 women, mean VAS before treatment was 6.45 (Standard deviation [SD] 1.95); P < .05, 95% confidence interval (CI) 5.83 to 7.07. After treatment mean VAS score was 4.21, (SD 2.71); P < .05, 95% CI 3.35 to 5.07. Mean FPPS score before treatment was 11.66, (SD 5.37); P < .05, 95% CI 9.95 to 13.37. After treatment mean FPPS score was 7.24, (SD 4.88); P < .05, 95% CI 5.69 to 8.79. 

For the 21 women, mean VAS before treatment was 6.24 (Standard deviation [SD] 1.70); P < .05, 95% confidence interval (CI) 5.51 to 6.97. After treatment mean VAS score was 3.81, (SD 2.86); P < .05, 95% CI 2.59 to 5.03. Mean FPPS score before treatment was 11.90, (SD 5.92); P < .05, 95% CI 9.37 to 14.43. After treatment mean FPPS score was 6.62, (SD 5.97); P < .05, 95% CI 4.07 to 9.17. 

Additionally, in the 21 women whose vulvodynia resolved, statistically significant results were found in 5 FPPS categories: Sleeping, Working, Lifting, Bowel, and Bladder. For the 17 women whose vulvodynia was unresolved, statistically significant results were found only in 3 FPPS categories: Sleeping, Intercourse, and Bowel. Figures 1 and 2 summarize these results.

The difference in statistically significant improvements seen in FPPS categories for vulvodynia resolved patients compared to vulvodynia unresolved patients suggests the importance of ameliorating pelvic pain and improving overall pelvic functionality, thereby resolving vulvodynia. 

The improvement seen in patients is because the protocol addresses the underlying myofascial and neuropathic dysfunction often seen in vulvodynia patients (3).  Working with pelvic floor physical therapy to decrease myofascial constriction, increase blood flow and decrease neurogenic inflammation to the peripheral nerves innervating the vulva resolved the vulvodynia in 21 patients. 

The 17 patients who did not respond, had Endometriosis that had not yet been surgically removed, potential recurrence of Endometriosis, or Stage IV Endometriosis with significant scar tissue along the course of the pudendal, genitofemoral and ilioinguinal nerves.

Our investigation confirmed statistically significant advantageous results in both pain and function for women between ages 18-76 with the diagnosis of CPPS and confirmed vulvodynia who underwent our comprehensive, multimodal outpatient neuromuscular protocol. 

55% of patients reported their vulvodynia resolved at their 3 month follow up, suggesting the benefits of our protocol in improving quality of life for patients with vulvodynia. Our study aims to collect 6 month follow up data and note resolved vulvodynia in remaining patients.

Grinberg K, Sela Y, Nissanholtz-Gannot R. New Insights about Chronic Pelvic Pain Syndrome (CPPS). Int J Environ Res Public Health. 2020;17(9):3005. Published 2020 Apr 26. doi:10.3390/ijerph17093005
Biasi, G., Di Sabatino, V., Ghizzani, A., & Galeazzi, M. (2014). Chronic pelvic pain: comorbidity between chronic musculoskeletal pain and vulvodynia. Reumatismo, 66(1), 87-91. https://doi.org/10.4081/reumatismo.2014.768
Chronic Pelvic Pain: ACOG Practice Bulletin, Number 218. Obstet Gynecol. 2020;135(3):e98-e109. doi:10.1097/AOG.0000000000003716