Multifaceted Therapeutic Approaches for the Management of Dyspareunia: A Narrative Review

2.1. Search Strategy

Seventy-four articles were identified, out of which 30 were removed for duplicity, and 44 articles were screened for eligibility. Twelve articles were included according to the criteria set by the authors. The results of the literature search strategy are described in a flow chart in Fig. (1).

3.1. Characteristics of the Articles

Twelve articles were included and summarized, which are presented in Table 1. According to the hierarchy of level of evidence from top to bottom, three systematic reviews examined the efficacy of manual treatment, antenatal perineal massage, and pelvic floor muscle training [23, 29, 31], and each demonstrated its effective outcome in managing the symptoms of dyspareunia. Two Randomized Controlled Trials (RCTs) and one non-randomized controlled trial showed the efficacy of pelvic floor muscle training [20-22], while a third RCT found that transvaginal massage improved dyspareunia symptoms [25], indicating that a multifaceted intervention may sound to be more effective in treating this sexual dysfunction rather than stand-alone treatment. The Valsalva maneuver also reduced chronic pelvic pain linked to dyspareunia by increasing the levator hiatus area [27] with anatomical consideration. In a pilot trial [24], pelvic floor physiotherapy improves the tonicity of the pelvic floor muscles and outperforms both superficial and deep dyspareunia. The pain associated with penetrative vaginal dysfunction was significantly reduced or resolved when low-dose high-frequency movement-based dilator therapy was used, according to a retrospective study conducted [26]. A qualitative review examined whether the acceptability of multimodal PFPT was satisfactory for gynecological cancer survivors with dyspareunia [30]. Moreover, a literature study found that visceral therapy is an excellent addition to traditional gynecological treatments [28]. In general, the interpretation of the result showed that each of the therapy modalities seems to be beneficial in managing the symptoms. However, none of the studies address the management based on the etiological complexity of the dyspareunia. Therefore, commenting on the efficacy of each treatment method seems to be promising. Table 2 summarizes the different physical therapeutic interventions- therapeutic benefits with the level of evidence.

4.1. Pelvic Floor Muscle Training/ Rehabilitation

Pelvic Floor Muscle Training (PFMT) involves a combination of two or more interventions, such as manual therapy techniques and other modalities, to enhance the functioning and strength of the to-be-trained muscles. With the literature review, we identified three randomized controlled trials for PFMT. In an RCT by Ghaderi F et al., participants in the experimental group received a treatment program consisting of digital biofeedback, intravaginal manual techniques, supervised pelvic floor muscle exercises, and electrotherapy with high-frequency transcutaneous electrical nerve stimulation (TENS) at 110 Hz for 80 ms pulse duration and maximal tolerable intensity to relieve pain, and the study resulted that pelvic floor rehabilitation program improves genito-pelvic pain, sexual function, pelvic floor muscle (PFM) strength, and endurance in women with symptomatic dyspareunia [22]. Another RCT by Schvartzman R et al. concluded that pelvic floor muscle training improves pain, pelvic floor muscle functioning, sexual function, and quality of life in women with dyspareunia [20]. Del Forno S et al. suggested that pelvic floor muscle training requires an informative session, digital evaluation, and physio- therapeutic measures. It restored the normal pelvic floor tone and improved muscle coordination [25].

In a 12-week therapy program for gynecological cancer survivors women with dyspareunia, which was part of the qualitative analysis by Cyr et al. in 2023, participants learned about the pathophysiology of dyspareunia and several pain-reduction tactics, such as the use of moisturizing agents, lubricants, breathing exercises, relaxation and therapeutic electromyography biofeedback, and manual therapy approaches, and the same study result suggested that multimodal pelvic floor physical therapy found to be acceptable for gynecological cancer survivors with dyspareunia in terms of symptomatic measures [30].

In a recent systematic review by Fernández-Pérez P et al., literature reflected that multimodal care with TENS, infrared therapy, myofascial release, intravaginal massage, perineal stretching, abdominal training, pelvic floor muscle training, extracorporeal shockwave therapy, transvaginal massage, and Thiele's massage as combination therapy and in conjunction with other treatment means, such as diazepam, or hormonal therapy, are quite efficacious in reducing pain intensity, the severity of dyspareunia, sexual distress, catastrophism, anxiety and improve perineal function, lubrication, and levator ani muscle contractility as well as dramatically change the quality of life among women with dyspareunia [29].

Awareness and general education related to the anatomy of the pelvic floor to make them aware of how to command their pelvic floor tone to increase muscle recognition and proprioception may assist in improving muscle tissue elasticity, its relaxation, and restoration of normal activity, which then helps to reduce pain in this sexual disorder [22, 32]. Therefore, focusing from the etiological perspective on the quality of adherence to exercise of pelvic floor muscle will direct to achieving the desired results of relieving dyspareunia symptoms of pain and associated problems.

4.2. Biofeedback

The learning and developing of self-control over physiological processes with visual, acoustic, and verbal feedback is achieved with biofeedback therapy in which autonomic and neuromuscular activity is measured basically to intervene in function that is otherwise outside awareness or under less voluntary control [33]. Biofeedback-assisted training is also one of several effective physical therapy techniques, with evidence that it positively affects pain reduction, overall symptom relief, and quality of life [33]. Moreover, biofeedback is also one of the several physiotherapy techniques that manage myofascial pain syndrome, pain in pelvic floor musculature and connecting fascia that may occur alone with no concomitant medical pathology, or it may exist as sequela to urological, gynecological, and colorectal medical conditions or other muscular-skeletal-neural problems [34]. Aalaie et al. concluded that biofeedback and electrical stimulation favor the Female Sexual Function Index score in patients with sexual dysfunction and stress incontinence, and the researcher suggested that to improve sexual function, biofeedback seems to benefit more than those receiving electrical stimulation [35].

Del Forno et al. intervened in deep endometriosis and dyspareunia problems with five individual sessions of PFM physiotherapy of 30 minutes each at alternative weeks 1, 3, 5, 8, and 11; during the first session itself, patients were given education regarding the pelvic floor muscles and five individual ultrasound-visual feedback-assisted pelvic floor physiotherapy sessions and the results showed favorable outcome, indicating PFM physiotherapy seems to increase levator hiatal area (LHA) leading to improved superficial dyspareunia, chronic pelvic pain, and pelvic floor muscle relaxation in women [25]. With this context, the prescription of biofeedback therapy is mainly directed to address the hypertonic state of the pelvic floor muscle, basically when considering the symptoms of dyspareunia, and its application may require combination therapy with other means or modalities for achieving a desired result.

4.3. Perineal Massage

Therapeutically, perineal massage has different applications, such as antenatal perineal massage and Thiele massage. In the past, perineal massage has been conventionally used in the antenatal period; therefore, it is also known as antenatal perineal massage (APM). It involves stretching the pelvic floor lining in preparation for labor to ease pain and discomfort, and it is known to reduce the incidence of episiotomy, third- and fourth-degree perineal tears, postpartum perineal pain, and anal incontinence [36]. APM is useful in reducing perineal trauma pain [37] and anal sphincter injury [38], and only a handful of studies have established a positive correlation of therapeutic perineal massage with the treatment of dyspareunia. Another massage technique, Thiele massage, is a scar reduction technique that appears to be very helpful for women with chronic pelvic pain caused by tenderness of the levator ani muscle and dyspareunia [21, 39]. Gommesen et al. found the association of perineal length with the risk of dyspareunia and suggested minimizing the extent of perineal trauma to manage the dyspareunia symptoms [40]. A systematic review by Milka et al. identified two RCTs where experimental groups received APM 5–10 minutes per day, but there were no specifications about how the technique was administered [31]. Perineal massage is theorized to work because it might increase the flexibility of the soft tissues and decrease the hypertonicity of the musculature around the perineum. In addition to it, because of the assertive preconceived notions of the procedure, it might motivate the patient to adhere to the massage, which might result in vaginal birth [37]. With this limited evidence, it can be stated that Thiele massage may improve dyspareunia symptoms, albeit with variations in outcomes across different aspects of sexual function.

4.4. Manual Therapy

Manual therapy (MT) procedures are the recommended course of treatment for many musculoskeletal pain syndromes [41], and their applicability is entirely based on clinical reasoning. Biomechanical, neuro-physiological, psychological, and non-specific characteristics function as mediators or moderators for treatment to be more insightful [42]. MT has also been widely incorporated to treat gynecological and obstetrics conditions, such as infertility, dys- menorrhea, pelvic pain, and menopause [43]. Wurn et al. suggested that cases of orgasm dysfunction and dyspareunia can be treatable by a distinctive site-specific protocol of manual soft-tissue therapy, and the therapy also seems to improve other aspects of sexual dysfunction [44]. In a systematic review, Trahan et al. examined the efficacy of manual therapy in reducing pelvic pain among females with dyspareunia and concluded that manual therapy is a non-invasive, non-surgical intervention that could be an addition to current gynecological and medical treatments of sexual pain [23]. However, further literature is required to develop evidence-based guidelines for the management of dyspareunia using manual therapy techniques.

4.5. Vaginal Dilator Therapy

A vaginal dilator is a smooth and cylindrical tool that comes in variable sizes and is used to minimize vaginal stenosis and scarring, prevent adhesions, promote improved vaginal healing, relax pelvic floor muscles, and prevent pain [45-47] and is generally indicated for gynecological cancers, Mullerian agenesis, dyspareunia, and pelvic floor disorders [48]. It has been shown more effective than the finger technique, which involves the use of one or two fingers to dilate the vaginal opening according to the level of spasm and state of the dysfunction [49]. Movement-Based Dilator Therapy (MBDT) is another intra-vaginal dilator method using non-threatening or painless exposures for those patients who classically experience pain with vaginal penetration, and this neurophysiological proprioceptive neuromuscular facilitation (PNF)-contract-relax technique uses a 1:2 ratio of contraction to relaxation and can be applied systematically to produce a desirable effect on the puborectalis, pubococcygeus, iliococcygeus, and obturator internus muscles bilaterally [26]. Miles et al. found that 58% of patients experienced complete resolution of dyspareunia with MBDT, and based on the evidence, it was concluded that MBDT could be classified as a time-limited adjunct for chronic pelvic pain with a dyspareunia symptom, especially in premenopausal patients [26]. Though vaginal dilator therapy seems to be a promising therapeutic option, psychosocial barriers, such as unfavorable accompanying symptoms, negative perceptions, uncertainty, and other unhelpful circumstances, may reduce adherence to the therapy, hence thereby reducing its effect. Further, positive communication and rapport with healthcare providers, patient support programs [45], psychological counseling, and relaxation therapy may thereby assist the patient in overcoming those emotional obstacles.

4.6. Extracorporeal Shockwave Therapy

Extracorporeal Shock Wave Therapy (ESWT) is known for its fewer adverse effects in treating musculoskeletal disorders, such as tendinopathies, spasticity, wounds, and delayed fracture healing [50]. The therapeutic appli- cability of ESWT is well-established in the literature related to specific gynecological dysfunction [27]. The physical forces generated by low-intensity shockwaves affect tissue mechanics and can trigger the release of growth and anti-inflammatory factors [51, 52]. Although it is known that the effect of ESWT is intensity-dependent, it seems to reduce pain perception even in the treatment of vulvodynia [53, 54].

Hurt et al., in an intervention study, administered weekly perineal ESWT for four consecutive weeks to a total of 4000 pulses with treatment parameters with the inclusion of an energy flux density of 0.35 mJ/mm², frequency of 4 Hz, focus zone spanning from 0 to 30 mm, and therapeutic efficiency from 0 to 90 mm, and the results suggested that ESWT significantly reduced subjective pain associated with dyspareunia. Moreover, this study also described its therapeutic effectiveness [27]. However, an interventional study design with a randomized controlled trial is required to establish the definite therapeutic effect of ESWT on managing sexual pain symptoms.

4.7. Visceral Therapy

Visceral therapy involves the three-dimensional dynamics of the body’s biomechanics: the muscular-skeletal structure, muscular and fascial structure, connective tissue and the organs, reflex activity in the central and peripheral nervous system, and the circulation and draining of fluid systems in the human body [55, 56]. This technique has been used to treat chronic abdominal pain [57], diastasis recti [58], pelvic floor disorders [59], and painful sexual dysfunction [60]. A literature review by Wojcik M et al. discussed dyspareunia as a genital pain, which may result from an imbalance between the female genital organs and their surrounding tissues with other structures of the skeletal or visceral system, with impaired mobility and motility of organs, intra-organ movement, vascular drainage, a pressure gradient between the urogenital and diaphragmatic cylinders, dysfunctions in the area of the broad ligament of the uterus in which visceral therapy aims at restoring intra-organ movement, reducing tension, focusing on the area of the two cylinders of the trunk, and supporting the functioning of the vascular system in the vicinity of the uterus [28]. In general, visceral treatment for reproductive system dysfunction involves restoring postural balance, breathing, pelvic activity, and balancing the pressures between the diaphragms in the body [61, 62]. However, the clinical applicability and effectiveness of this treatment require further randomized controlled trials to contrast the varied treatment strategies, dosages, and duration of treatment sessions.

To manage dyspareunia effectively, multifaceted treatment options are available. Most of the cases remain undiagnosed due to multiple reasons, starting from hesitancy of the patient in discussing with the clinicians to the complexity of the diagnostic process. Each physical therapeutic intervention is under-researched to date; therefore, a conclusion regarding the dose and response ratio cannot be generalized. Secondly, limited literature on the effect of a single therapy vs. combination therapy on the management of dyspareunia has generated further issues. This narrative review poses certain limitations in terms of subjectivity, selection bias, and lack of systematic and quantitative analysis, which is restricted to critically analyzing the most efficacious treatment method for managing this sexual pain dysfunction, which usually affects all the domains from physical to psychological aspects of the woman. Due to the predominantly qualitative approach, the findings of this review are not conclusive and cannot be used to generalize about the definite management strategies for the categories of superficial and deep dyspareunia. However, the findings of these studies imply that public health, policymakers, and research are needed regarding the categories of dyspareunia management. Therefore, for a thorough and enhanced understanding of the utility of each of the different therapeutic means for managing this sexual pain dysfunction, systematic reviews of randomized controlled trials comparing different treatment strategies, dosages, and durations of sessions are required to figure out this complex women’s health issue to generate highest quality evidence-based therapeutic means. However, clinicians and health care providers must place great emphasis on the multidisciplinary approach to determine how this challenging sexual health dysfunction can be best supported or treated with a single or combination of physical therapeutic means.