Postpartum Vaginal Pain

Symptoms – After childbirth, the No. 1 vaginal complaint is pain upon penetration (dyspareunia) and touch. One study found that 45 percent of new mothers have vaginal pain.Causes – The most common cause of this pain is episiotomy scarring.
Others include:
• vaginal tearing;
• soft-tissue trauma from a forceps or vacuum delivery;
• prolonged lying in stirrups, which can strain lower-body muscles;
• stretching of, and pressure on, the pudendal and levator ani nerves (which run into the pelvis) as the baby passes through the birth canal (more likely with longer deliveries);
• abstaining from sex toward the end of pregnancy and after childbirth;
• vaginal tightening and “protective” guarding in response to pain; and
• “rock-bottom estrogen levels during breastfeeding,” according to Elizabeth G. Stewart, M.D., amember of the National Vulvodynia Association Medical Advisory Board and author of The V Book.
Despite all these strikes against a new mother’s body, “the vulva and vagina usually heal beautifully,” says Dr. Stewart. “They have an excellent blood supply and they’re rather forgiving. Many women heal by their six-week checkup. If not, they need to have a conversation with their doctor.”
However, Stewart cautions, pudendal nerve stretching can take up to six months to resolve, and sometimes it doesn’t recover fully.
She adds that, for unclear reasons, pregnancy can occasionally trigger chronic vestibulitis. Women with this condition report that any pressure on the vulvar vestibule (the tissue around the vaginal opening) causes pain and/or burning.
“Vestibulitis is often missed and instead blamed on the episiotomy, the pelvic muscles or the vague observation that ‘things are different after childbirth,’” Stewart says. Treatment – Because each woman’s treatment plan will depend on her individual circumstances, your physical therapist will devote your first visit to an evaluation. Then she’ll likely use a combination of several of the following:
• Hands-on techniques – These may include scar-tissue mobilization, myofascial manipulation (of muscle and deep connective tissue), connective tissue manipulation (of skin and superficial tissue), trigger-point release (to relax tense “knots”), vaginal stretching, and neural mobilization and stretching. Your physical therapist may work either inside or outside the vagina, depending on your problem and your pain sensitivity. She may also teach you and your partner how to do some manual techniques at home.• Ultrasound – Physical therapists can apply ultrasound’s deep, penetrating heat to episiotomy scars to help soothe and heal the tissue.• Kegel exercises – These vaginal relax-and-contract exercises promote blood flow to damaged tissue; help relax tense, guarded muscles; and help increase vaginal elasticity. (Of course, they’re also famous for helping women regain vaginal muscle tone after childbirth.)Studies show that 49 percent of women use the wrong muscles – stomach and thigh muscles versus pelvic muscles – to do Kegels. That’s why many physical therapists enlist biofeedback machines to monitor and display muscle function. Either you can insert a tampon-size probe into the vagina or, if this is too painful, the therapist can place sensors on your skin. Daily Kegels are vital.
Physical therapist Rhonda Kotarinos, M.S., P.T., a past president of the APTA Section on Women’s Health and a past board member of the International Pelvic Pain Society, often postpones Kegels until the new mother has responded to hands-on techniques. If the patient has shortened pelvic muscles, Kotarinos explains, they must first be “lengthened, then strengthened.”
• Dilators – Your physical therapist may recommend that you use increasingly larger dilators at home to stretch and desensitize the vagina.• Referrals – Your therapist may send you to your gynecologist for injections of a local anesthetic; a prescription for a topical anesthetic; or, if you’re nursing, a prescription for topical estrogen cream. “For some reason, the word isn’t out about estrogen cream,” says Stewart. “If you’re breastfeeding, making it part of treatment is important.”
Typically, PT visits are weekly, and the longer you’ve been in pain, the longer you’ll be in treatment. Perlis says that most postpartum vaginal-pain patients see her for 10 to 20 visits. She and Kotarinos both say that the vast majority of their patients are significantly improved or cured.