To contract or not to contract: should we use pelvic floor muscle exercises in the treatment of dyspareunia

Pelvic floor physiotherapy incorporates pelvic floor muscle (PFM) exercises (PFMEs), i.e. various tasks involving contraction and relaxation. These are widely used as an integral part of conservative treatment for different pelvic health conditions (e.g. urinary incontinence). Currently, there is a debate about the adoption of PFMEs for pelvic pain conditions, specifically dyspareunia. The prevailing belief within both the physiotherapy community and wider social media platforms is that PFMEs for dyspareunia are not appropriate and may even be harmful. The aim of this study was to investigate the role of PFMEs in the treatment of dyspareunia, including an exploration of potential mechanisms through which these exercises may alter its symptoms. Specifically, the authors addressed the following questions: What is the rationale for PFMEs in dyspareunia? What are the documented side effects, if any? What are the outcomes following PFMEs? A list of relevant studies was compiled from extensive searches conducted for the purpose of other reviews performed by the authors, and additional, complementary searches utilizing a combination of keywords associated with dyspareunia, physiotherapy and PFMEs. The inclusion criteria were any studies discussing and investigating the use of PFMEs, such as (but not limited to) repeated contractions or hold contractions as a sole intervention or as part of multimodal treatment. Data were extracted and narratively synthesized to identify arguments advocating for and against PFMEs in the treatment of dyspareunia. Part of the narrative analysis included 10 studies involving women with different types of dyspareunia, such as vulvodynia, postpartum dyspareunia, dyspareunia related to menopause and dyspareunia in cancer survivors. Pelvic floor muscle exercises were implemented as a main intervention or as a part of multimodal physiotherapy. All of the studies reported positive results favouring interventions involving PFMEs across various outcomes, such as pain intensity, sexual function, symptom severity and inconvenience, and PFM morphometry and function. None of the studies reported any side effects following interventions incorporating PFMEs. These exercises may have multiple applications in the treatment of dyspareunia. It appears essential to consider PFMEs as a multifaceted intervention that can be adapted in various forms for diverse objectives that extend beyond simple strengthening. Contrary to prevailing beliefs, PFMEs have been widely incorporated in research studies that have reported positive outcomes and demonstrated the safety of the interventions implemented.