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Actual Gynecology
and Obstetrics

Extracorporeal Shock Wave Therapy for the Treatment of Vulvodynia. Feasibility Study.
Karel Hurt, Olga Švestková, Michael Halaška, Daniel Driák, Ivana Rakovičová, Martin Musálek, Aneta Krajcová
Actual Gyn 2019, 11, 18-22
Publication date: 2019-03-19
Manuscript ID: 1119002
Number of views: 17014
How to cite this article: Hurt K, Svestkova O, Halaska M, Driak D, Rakovicova I, Musalek M, Krajcova A. Extracorporeal Shock Wave Therapy of Vulvodynia: A Feasibility Study. Actual Gyn. 2019;11:18-22

Introduction: There are no sufficient therapy strategies for vulvodynia in women. Extracorporeal shock wave therapy (ESWT) is widely used for the treatment of musculoskeletal diseases, muscle spasticity, hypertonus, renal and biliary calculi, urological and recently andrological disorders. We examined the effect of ESWT on vulvodynia in women.  
Methods: A prospective study was conducted between 2015 and 2018 years. The feasibility study involved thirty women with vulvodynia for at least 3 months. The patients received perineally applied ESWT treatment weekly (3 000 pulses each for 4 consecutive weeks). The device used was a standard electromagnetic shock wave unit with a focused shock wave handpiece. The access area was changed after every 500 pulses. Six areas covered the whole vulva and perineum. The grade of pain was evaluated with the visual analogue scale of 11 degrees (VAS, 0-10) before and after the treatment and Cotton Swab test (CST, Goetsch scale 0-4) at the same terms. Follow-ups were done after 1, 4, and 12 weeks having finished the last ESWT. Ethical committee agreement and written consents were provided. 
Results: 29 women completed the study. In VAS and CST testing we proved significant differences between before and all the follow-ups (P < 0.001; P < 0.05) respectively. The reduction of pain in VAS was 53 %; CST 47 % in the last testing. 
Conclusions: ESWT seems to reduce significantly the pain perception in our group of treated patients.  We are encouraged to explore this technique further. The method is easily repeatable, inexpensive, and free of any side effects.

Key words: vulvodynia, chronic pelvic pain syndrome, CPPS, extracorporeal shock wave therapy, ESWT


Chronic pelvic pain syndrome (CPPS) in women is currently considered a frequent pain condition (1–6). Several subgroups of CPPS are recognised, vulvodynia being the most frequent one (7,8). A study of National Institutes of Health (NIH) states that 15.7% of women report pain of lower genital tract lasting for 3 or more months. Other studies cite prevalence of 9–12% (4,9–12). Vulvodynia is characterised as burning, stabbing or pain in absence of objective clinical or laboratory findings, which could explain the symptom (2,7,13). A therapeutic standard comprises treatment of neuropathic pain (14,15). Auxiliary treatment methods include pelvic rehabilitation, superficial electromyography, administration of interferon alpha, topical oestrogens, botulinum toxin A and/or surgical intervention most often based on denervation of the vulva (11,16-20). Also myofascial pain and pelvic hypertonicity are discussed as possible causal factors, as well as myofascial trigger points and the possibility of their blockade (2). Current treatment methods seem to be insufficient. Most authors describe only treatment of the proper pain. The majority of patients is treated for infection, although no infection was proven (21-23). Therefore, we strove to find a simple, safe, and modern method to solve this issue.
Extracorporeal Shock Wave Therapy (ESWT) appears as one of therapeutic possibilities. The use of electromagnetic, electrohydraulic or piezoelectric ESW changed therapeutic options in many fields of medicine. The application of ESWT in the treatment of urolithiasis and biliary lithiasis is frequent (24). Low intensity ESWT (Li-ESWT) is widely used in orthopaedics primarily in the treatment of degenerative conditions, arthropaties or plantar fasciitis (25-27). ESWT can also be utilised in the treatment of non-union of long bone fracture and non-healing defects, e.g. chronic diabetic and non-diabetic ulcers (28-30), muscle spasticity and hypertonus (31-33), and Pey ronie´s disease and erectile dysfunction. Recently, ESWT started to be used in the therapy of CPPS in males (34-36).
The aim of our feasibility study was the possibility to use ESWT in the treatment of vulvodynia. Obtaining a significant clinical pain perception decrease would have hold promise for further practical use.

Material and methods

Study design

The study was part of a prospective controlled study carried out in 2015-2018. The research protocol was approved by the Ethical Committee of Faculty Hospital Na Bulovce, Prague, Czech Republic. All patients signed an informed consent to participate in the study. Patients were recruited from centres 1 and 3 in the list of authors. Treatment principles, application, and evaluation were approved by the authors of the study. We report the results of feasibility study to set basic criteria for this method.


Study participants

Thirty women, aged 27 – 52 years, with objectively dia­gnosed vulvodynia lasting at least three months participated in the study.


Inclusion criteria

Compliance with diagnostic criteria for vulvodynia (at least three months lasting pain, everyday pain) and following criteria:

  • vulvar vestibulitis syndrome or
  • dysesthetic vulvodynia,
  • • positive Cotton Swab Test


Exclusion criteria

  • acute pelvic inflammatory disease during last 6 months
  • endometriosis
  • oncological condition during last 5 years
  • clinically manifested haematological condition
  • myocardial infarction, cardiac arrhythmia during last 6 months
  • severe dermatological condition in the access area
  • severe metabolic condition


Degree of pain evaluation

The degree of pain was evaluated with help of 10-centimetre Visual Analog Scale (VAS, 0 = no pain, 10 = maximum pain) and Cotton Swab Test (Goetsch scale, 0 = no pain, 4 = maximum pain).


Study participants were treated with ESWT (3000 pulses once a week for four consecutive weeks). Energy flux density used was 0.25 mJ/mm2, frequency 4 Hz, focus penetration depth 0 – 30 mm, stand-off II (Fig. 1). The patients were treated in supine position. Six access areas were sufficient to cover the whole vulva and perineum (Fig. 2). We used DUOLITH® SD1 (STORZ MEDICAL AG, Tägerwilen, Switzerland) unit.


Fig. 1 ESWT handpiece


Fig. 2 Access areas in the vulvar region


Treatment results evaluation

The evaluation of pain perception decrease was based on differences of the VAS and CST degree of pain rating before and after treatment. Follow-up examinations took place 1, 4 and 12 weeks after last application of ESWT. Further examinations, i.e. dopplerometry, oximetry etc., were performed which are outside of the scope of this paper. In concordance with established clinical practice, changes of 30% and higher were considered significant.

Statistical analysis

The data were tested for normality with skewness, kurtosis, Shapiro-Wilk, and Kolmogorov-Smirnov tests. In case of normal distribution we used ANOVA, in case the normality criteria were not met, non-parametric Wilcoxon signed-rank test for two related samples was used. We evaluated difference between the value before the study start and the respective follow-up. The level of significance (alpha error) was set at 5% (two-tailed test) for our analysis. The Bonferroni correction was applied with resulting adjusted p = 0.017.


Twenty-nine patients completed the study. One patient was excluded because of having had not participated in all follow-ups. The normal distribution criteria were not met. Therefore, non-parametric Wilcoxon signed-rank test for two related samples was used for the result before treatment and the respective follow-up results. Because of non-parametric distribution of data, medians were used as the main reference parameters. Median VAS value before treatment was 6.2, median CST value 3.3, after treatment was median VAS value 2.67 and median CST value 0.7. Further consecutive results are given in (Tab. 1). We observed statistically significant differences between reported pain before treatment and at all of the follow-ups (p-value < 0.001 and < 0.05 in VAS and CST, respectively). The reduction of pain was 53% in VAS and 47% in CST at last follow-up.


According to databases available this is the first study on use of ESWT for therapy of vulvodynia in women. ESWT induces the hyperstimulation of nociceptors and change in CNS patterns can play a significant role in treatment of CPPS and especially vulvodynia (36). Published studies discuss possible disruption of nerve pulses by ESWT (32,36). Autonomous nerve system and co-ordination between smooth and striated muscles can play significant role in changes of structures treated with ESWT (37,38). Clinical studies report stimulation of growth factors, propagation and formation of new blood vessels (angioneogenesis) (29). Moreover, ESWT can be used without any demonstrable side effects. These factors are stressed in many orthopedic and urologic studies (35), in this case the authors refer to the use of low intensity ESW, however. High tolerability of ESWT enables its use without anaesthesia and we see the limitation in use mainly in disorders accounted in exclusion criteria above. Although it is known that the effect of ESWT is intensity-dependent, we did not exceed the energy flux density of 0.25 mJ/mm 2 because of possible pain intolerance.


Extracorporeal Shock Wave Therapy seems to be an effective method for the treatment of vulvodynia in women. Our feasibility study proved a statistically significant pain reduction before and after treatment in our patients. Similarly to some CPPS studies in males, this technique offers a modern physical method capable ofdecreasing or even eliminating the use of analgesics and supportive therapy. ESWT is simply reproducible and economically effective (disregarding the initial investment in a quality apparatus). Further discussion regarding specifictypes of usage and a randomised double-blind study is needed.


  1. Hoffman D. Understanding Multisymptom Presentations in Chronic Pelvic Pain: The Inter-relationships Between the Viscera and Myofascial Pelvic Floor Dysfunction. Current Pain and Headache Reports. 2011;15(5):343-6
  2. Bhide AA, Puccini F, Bray R, Khullar V, Digesu GA. The pelvic floor muscle hyperalgesia (PFMH) scoring system: a new classification tool to assess women with chronic pelvic pain: multicentre pilot study of validity and reliability. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2015;193:111-3
  3. Thibault-Gagnon S, McLean L, Goldfinger C, Pukall C, Chamberlain S. Differences in the Biometry of the Levator Hiatus at Rest, During Contraction, and During Valsalva Maneuver Between Women With and Without Provoked Vestibulodynia Assessed by Transperineal Ultrasound Imaging. Journal of Sexual Medicine. 2016;13(2):243-52
  4. Fenton BW. Limbic associated pelvic pain: A hypothesis to explain the diagnostic relationships and features of patients with chronic pelvic pain. Medical Hypotheses. 2007;69(2):282-6
  5. Fenton BW, Brobeck L, Witten E, Von Gruenigen V. Chronic Pelvic Pain Syndrome-Related Diagnoses in an Outpatient Office Setting. Gynecologic and Obstetric Investigation. 2012;74(1):64-7
  6. Carvalho J, Vieira AL, Nobre P. Latent Structures of Female Sexual Functioning. Archives of Sexual Behavior. 2012;41(4):907-17
  7. Binik YM. The DSM Diagnostic Criteria for Vaginismus. Archives of Sexual Behavior. 2010;39(2):278-91
  8. Desrochers G, Bergeron S, Khalife S, Dupuis MJ, Jodoin M. Fear Avoidance and Self-efficacy in Relation to Pain and Sexual Impairment in Women With Provoked Vestibulodynia. Clinical Journal of Pain. 2009;25(6):520-7
  9. Farrar JT, Young JP, LaMoreaux L, Werth JL, Poole RM. Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain. 2001;94(2):149-58
  10. Kuo TLC, Ng LG, Chapple CR. Pelvic floor spasm as a cause of voiding dysfunction. Current Opinion in Urology. 2015;25(4):311-6
  11. Luginbuehl H, Baeyens JP, Taeymans J, Maeder IM, Kuhn A, Radlinger L. Pelvic floor muscle activation and strength components influencing female urinary continence and stress incontinence: A systematic review. Neurourology and Urodynamics. 2015;34(6):498-506
  12. Moller L, Josefsson A, Bladh M, Lilliecreutz C, Sydsjo G. Reproduction and mode of delivery in women with vaginismus or localised provoked vestibulodynia: a Swedish register-based study. Bjog-an International Journal of Obstetrics and Gynaecology. 2015;122(3):329-34
  13. Reissing ED, Binik YM, Khalife S, Cohen D, Amsel R. Vaginal spasm, pain, and behavior: An empirical investigation of the diagnosis of vaginismus. Archives of Sexual Behavior. 2004;33(1):5-17
  14. Bourcier AP. Physical therapy for female pelvic floor disorders. [Editorial]. Current Opinion in Obstetrics & Gynecology. 1994;6(4):331-335
  15. Gentilcore-Saulnier E, McLean L, Goldfinger C, Pukall CF, Chamberlain S. Pelvic Floor Muscle Assessment Outcomes in Women With and Without Provoked Vestibulodynia and the Impact of a Physical Therapy Program. Journal of Sexual Medicine. 2010;7(2):1003-22
  16. Hurt K, Halaska M, Driak D, Sottner O. Vulvodynia evaluation by oximetry. International Urogynecology Journal. 2008;19:S143
  17. Hurt K, Halaska M, Sottner O, Krcmar M, Krajcova A. Vulvodynia and oximetry. International Urogynecology Journal. 2007;18:S143
  18. Bergeron S, Binik YM, Khalife S, Pagidas K, Glazer HI, Meana M, et al. A randomized comparison of group cognitive-behavioral therapy, surface electromyogra­phic biofeedback, and vestibulectomy in the treatment of dyspareunia resulting from vulvar vestibulitis. Pain. 2001;91(3):297-306
  19. Bornstein J, Abramovici H. Combination of subtotal perineoplasty and interferon for the treatment of vulvar vestibulitis. Gynecologic and Obstetric Investigation. 1997;44(1):53-6
  20. Morin M, and Bergeron S. Pelvic floor rehabilitation in the treatment of dyspareunia in women. Sexologies. 2009;18(2):91-4
  21. Bonham A. Vulvar Vestibulodynia: Strategies to Meet the Challenge. Obstetrical & Gynecological Survey. 2015;70(4):274-83
  22. Dargie E, Holden RR, Pukall CF. The Vulvar Pain Assessment Questionnaire inventory. Pain. 2016;157(12):2672-86
  23. Dewitte M, Borg C, Lowenstein L. A psychosocial approach to female genital pain. Nature Reviews Urology. 2018;15(1):25-41
  24. Perez C, Chen H, Matula TJ, Karzova M, Khokhlova VA. Acoustic field characterization of the Duolith: Measurements and modeling of a clinical shock wave therapy device. Journal of the Acoustical Society of America. 2013;134(2):1663-74
  25. Cayton T, Harwood AE, Smith GE, Totty JP, Carradice D, Chetter IC. Extracorporeal shockwave therapy for the treatment of lower limb intermittent claudication: Study protocol for a randomised controlled trial (the SHOCKWAVE 1 trial). Trials. 2017;18:104
  26. 26. D’Agostin MC, Frairia R, Romeo P, Amelio E, Berta L, Bosco V, et al. EXTRACORPOREAL SHOCKWAVES AS REGENERATIVE THERAPY IN ORTHOPEDIC TRAUMATOLOGY: A NARRATIVE REVIEW FROM BASIC RESEARCH TO CLINICAL PRACTICE. Journal of Biological Regulators and Homeostatic Agents. 2016;30(2):323-32
  27. Pavone V, Cannavo L, Di Stefano A, Testa G, Costarella L, Sessa G. Low-Energy Extracorporeal Shock-Wave Therapy in the Treatment of Chronic Insertional Achilles Tendinopathy: A Case Series. Biomed Research International. 2016;2016:7123769
  28. Daliri SS, Forogh B, Razavi SZE, Ahadi T, Madjlesi F, Ansari NN. A single blind, clinical trial to investigate the effects of a single session extracorporeal shock wave therapy on wrist flexor spasticity after stroke. Neurorehabilitation. 2015;36(1):67-72
  29. Kisch T, Wuerfel W, Forstmeier V, Liodaki E, Stang FH, Knobloch K, et al. Repetitive shock wave therapy improves muscular microcirculation. Journal of Surgical Research. 2016;201(2):440-5
  30. Qureshi AA, Ross KM, Ogawa R, Orgill DP. Shock Wave Therapy in Wound Healing. Plastic and Reconstructive Surgery. 2011;128(6):721e-7e
  31. Marinelli L, Mori L, Solaro C, Uccelli A, Pelosin E, Curra A, et al. Effect of radial shock wave therapy on pain and muscle hypertonia: a double-blind study in patients with multiple sclerosis. Multiple Sclerosis Journal. 2015;21(5):721e-7e
  32. Smania N, Picelli A, Munari D, Geroin C, Ianes P, Waldner A, et al. Rehabilitation procedures in the management of spasticity. European Journal of Physical and Rehabilitation Medicine. 2010;46(3):423-38
  33. Vidal X, Morral A, Costa L, Tur M. Radial extracorporeal shock wave therapy (rESWT) in the treatment of spasticity in cerebral palsy: A randomized, placebo-controlled clinical trial. Neurorehabilitation. 2011;29(4):413-9
  34. Zimmermann R, Cumpanas A, Miclea F, Janetschek G. Extracorporeal Shock Wave Therapy for the Treatment of Chronic Pelvic Pain Syndrome in Males: A Randomised, Double-Blind, Placebo-Controlled Study. European Urology. 2009;56(3):418-24
  35. Palmieri A, Imbimbo C, Longo N, Fusco F, Verze P, Mangiapia F, et al. A First Prospective, Randomized, Double-Blind, Placebo-Controlled Clinical Trial Evaluating Extracorporeal Shock Wave Therapy for the Treatment of Peyronie’s Disease European Urology. 2009;56(5):e43-4
  36. Wess OJ. A neural model for chronic pain and pain relief by extracorporeal shock wave treatment. Urological Research. 2008;36(6):327-34
  37. Tepeköylü C, Primessnig U, Pölzl L, Graber M, Lobenwein D, Nägele F, et al. Shockwaves prevent from heart failure after acute myocardial ischaemia via RNA/protein complexes. Journal of Cellular and Molecular Medicine. 2017;21(4):791-801
  38. Holfeld J, Tepekoylu C, Reissig C, Lobenwein D, Scheller B, Kirchmair E, et al. Toll-like receptor 3 signalling mediates angiogenic response upon shock wave treatment of ischaemic muscle. Cardiovascular Research. 2016;109(2):331-43