Pelvic floor muscle (PFM) training and exercises (i.e. various tasks involving contraction and relaxation of PFMs) are a cornerstone modality used in pelvic floor rehabilitation. They are widely recognized as an integral and effective part of conservative treatment for various PFM conditions, such as urinary incontinence or pelvic organ prolapse [1,2]. However, there is considerable current discussion regarding the adoption of PFM exercises for pelvic pain conditions, specifically dyspareunia (i.e., pain with intercourse). While recent evidence emphasizes the beneficial role of exercise in various musculoskeletal pain conditions, there is a lack of consensus regarding the implementation of PFM exercises in conditions related to dyspareunia. The prevailing belief within the physiotherapy community and on social media platforms is that PFM exercises incorporating repeated PFM contractions for dyspareunia are not only unjustified, but they may even lead to adverse events such as an increase in pain. This stems from the hypothesis that PFM exercise will further increase already greater PFM tone often observed in individuals with dyspareunia, leading to exacerbations of their symptoms [3]. It is crucial to investigate this problem beyond opinions and hypotheses. Therefore, this review aimed to identify relevant evidence exploring the rationale for PFM exercises and their effects in different conditions related to dyspareunia.

This narrative review identified relevant studies through searches conducted for other literature reviews performed by the authors of this study. Additional complementary searches using keywords associated with dyspareunia, physiotherapy, and PFM exercises were also completed. Moreover, reference lists of previous review articles in this area were searched. The studies included and analysed investigated the use of PFM exercises such as repeated or prolonged contractions, provided as a sole intervention or as part of multimodal treatment. Narrative synthesis was divided into two parts: (1) studies providing data on possible mechanisms of action of PFM exercises for the treatment of dyspareunia, and (2) studies investigating the effects of PFM exercises for the treatment of dyspareunia.

Four studies (one pilot randomized control trial, one case-control study and 2 single arm intervention studies) were analysed in part 1. Three studies observed changes suggesting a normalization (decrease) of PFM muscle tone following intervention with PFM exercises, two of which were part of a multimodal physiotherapy intervention. One study demonstrated improvements in the blood supply to PFMs and vulvovaginal tissues, proposing that this could contribute to improvements in dyspareunia symptoms related to dryness or vaginal atrophy. Positive changes in vulvovaginal tissue elasticity were also reported following PFM exercises. Part 2 of the synthesis involved 10 studies (6 randomized controlled trials and 4 single-arm intervention studies) including women with different types of dyspareunia such as vulvodynia, provoked vestibulodynia, postpartum dyspareunia, dyspareunia related to menopause, and dyspareunia in cancer survivors. PFM exercises were assessed as a main intervention (3 studies) or as a part of multimodal physiotherapy treatment (7 studies). Various PFM exercises were implemented including repetitive, close-to-maximum contractions, endurance holds, rapid contractions and podium contractions. PFM exercises were mostly delivered progressively, through a supervised manner and involved concentration on body awareness, coordination, and correct relaxation perception. All of the studies reported positive results favouring therapy involving PFM exercises across outcomes including pain intensity, sexual function, symptom severity and bother, as well as PFM morphometry and function. None of the studies reported any side effects following interventions incorporating PFM exercises.

This is the first review summarizing the data on the potential mechanisms and effects of PFM exercises in the treatment of various types of dyspareunia. PFM exercises may enhance muscle contractility and relaxation, increase strength and endurance, preventing further overload and potential increase in tension and pain, improve blood flow and vaginal mucosal tissue condition and elasticity. Moreover, they could possibly contribute to better awareness and motor acuity of the region, which could provide an additional benefit in the management of pain.

Despite the common belief that PFM exercises are contraindicated in pelvic pain conditions such as dyspareunia, they are widely implemented in various forms in the identified research studies, and demonstrate both improvements in dyspareunia symptoms and safety. Clinical practitioners should be mindful when making generalized statements, especially on social media, discouraging PFM exercises in conditions related to dyspareunia, as they may overlook nuanced points within the literature and eliminate a potentially beneficial intervention. The evidence identified supports that a reconceptualization of the use of PFM exercises is warranted. There is no suggestion that PFM exercises implemented as a singular treatment in a manner aimed at pure muscle hypertrophy are beneficial in dyspareunia, but a variety of functional training methods provided as part of multimodal therapy demonstrate this to be a versatile tool in the management of dyspareunia, and this has implications for their potential wider efficacy in the management of pelvic pain. Future research should focus on comprehensively reporting PFM protocols and outcomes, and further investigating the specifics of their utility within the physiotherapeutic management of dyspareunia.

Todhunter-Brown, A., Hazelton, C., Campbell, P., et al., 2022. Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews. Cochrane Database Syst Rev 9, CD012337. https://doi.org/10.1002/14651858.CD012337.pub2
Bø, K., Anglès-Acedo, S., Batra, A., et al., 2022. International urogynecology consultation chapter 3 committee 2; conservative treatment of patient with pelvic organ prolapse: Pelvic floor muscle training. Int Urogynecol J 33, 2633–2667. https://doi.org/10.1007/s00192-022-05324-0
Stephanie A Prendergast and Elizabeth H Rummer. Pelvic Pain Explained. What everyone needs to know. (2016) Rowman & Littlefield.