Lichen Sclerosus and the Pelvic Floor

Lichen Sclerosus (LS) is a chronic inflammatory condition of the anogenital skin (most commonly the vulva in women) that can lead to symptoms such as itch (pruritus), pain (especially vulvar burning or tearing), dyspareunia (pain with sexual activity), and sexual dysfunction.  Typical clinical appearance includes pale or white “parchment-like” skin, thinning/thickening, scarring, loss of normal vulvar architecture (for example labial fusion, clitoral hood adhesions), and impaired elasticity of the vulvar tissue.  

 Because of the fragile tissue, scarring, reduced elasticity, and chronic symptoms, patients may develop secondary issues: pain with intercourse, micro-tears, fissuring, changes in sensation, and narrowing or fusion of vulvar structures.  These changes can lead to or contribute to pelvic floor dysfunction. For example, the pelvic floor muscles may become hypertonic (over‐active) in response to guarding or chronic pain, myofascial pain may develop in surrounding muscles, the pelvic tissues may receive reduced circulation/tissue mobility, and sexual function may be impaired. 

While LS medical treatments focus on the skin/inflammation, many patients also have overlapping pelvic floor muscle or fascial issues due to their vulvar skin symptoms, and this is where PFPT can assist in the treatment of symptoms. 

Pelvic Floor Physical Therapy (PFPT) is a specialized area of physical therapy that addresses dysfunction of the pelvic floor muscles—such as weakness, overactivity (tightness), poor coordination, myofascial pain, scar tissue restrictions, and impaired function of associated structures (bladder, bowel, sexual). 

For women experiencing conditions like dyspareunia, vulvodynia, chronic pelvic pain, urinary/bowel dysfunction, PFPT is well established as a first-line conservative treatment. It aims to restore optimal pelvic floor muscle length, strength, coordination, to desensitize pain pathways, improve tissue mobility and support functional goals (such as comfortable sex, sitting, bowel/bladder function). 

In the context of vulvar pain (including conditions such as vestibulodynia, vulvodynia), PFPT treatment may include myofascial release of pelvic floor muscles, soft tissue mobilization of vulvar and surrounding tissues, coordination of the pelvic floor and diaphragm with breathing and coordination exercises, scar-tissue mobilization, and nervous‐system down-regulation.  

When a patient with LS develops pelvic floor muscle hypertonicity, guarding, pain with sexual activity, and other pelvic floor complaints, PFPT is an excellent adjunct to the dermatologic/medical care of LS. 

What PFPT MAY help with 

Reducing pelvic floor muscle hypertonicity and associated pain. Because the vulvar tissues may be sensitive, scarred or have decreased elastic, patients may guard or hold pelvic floor muscles in chronic tension. PFPT helps to identify and release these overactive muscles and improve pelvic floor mobility. 

Improved circulation, tissue mobility and reduced muscle tension may reduce secondary pain from the pelvic floor muscles themselves (rather than just the skin.) 

Improving sexual function and reducing dyspareunia. Because LS may lead to uncomfortable sexual activity (due to skin changes, tearing, vulvar pain), PFPT can help: by mobilizing tissues, teaching use of vulvar moisturizers/lubricants, guiding dilator therapy (to gently restore introital/vaginal elasticity), and normalizing pelvic floor muscle function (so muscles don’t pre-emptively spasm or tighten with insertion). 

Supporting quality of life, vulvar comfort, tissue mobility. Given that LS can lead to scarring, adhesion formation (for example clitoral hood fusion, labial changes), PFPT can assist with scar‐tissue mobilization, myofascial release, education in how to use a dilator at home, and encourage maintenance of tissue mobility, which may reduce tearing, fissuring, or discomfort with certain movements, sitting, or wearing underwear.  

Relaxation/neuromuscular education, is also part of PFPT, which is helpful given the overlap of pelvic pain and nervous‐system sensitization in chronic vulvar conditions.  

Many resources on LS note that even when inflammation is controlled, residual pain and pelvic floor dysfunction may remain, and PT can be helpful in the treatment of these symptoms..

What PFPT DOES NOT do 

• PFPT is not a treatment for the inflammatory skin disease of LS. It does not treat the underlying autoimmune, dermatologic, or inflammatory mechanism of LS, nor does it reverse the primary dermatologic lesions or fully halt the scarring process of LS itself. 

• The mainstay of treatment for LS remains ultra-potent topical corticosteroids and maintenance therapy along with appropriate dermatologic/gynecologic monitoring. 

• Thus, PFPT should be framed as an adjunctive therapy for the secondary consequences of LS (pelvic floor dysfunction, myofascial pain, dyspareunia, sexual dysfunction) and not as a substitute for dermatologic management. 

When to consider PFPT 

• A patient with LS who reports symptoms such as pelvic floor tightness, pain with sitting or wearing underwear, pain with intercourse, pelvic floor muscle spasms, or urinary or bowel symptoms may be a good candidate for pelvic floor PT.  

• When dermatologic/medical therapy for LS is underway (e.g., topical steroid treatment), but the patient continues to have pain or increased muscle tension. 

• Early referral to PFPT may help prevent chronic muscle guarding, scar-tissue restrictions, and bowel or bladder dysfunction. 

What a PFPT program might include 

• Hands-on manual therapy: myofascial release of pelvic floor muscles, soft tissue mobilization around vulvar/adjoining tissues, scar-tissue mobilization (if any adhesions present). 

• Education: on vulvar tissue care (moisturizers, lubricants, gentle hygiene), dilator/wand use (if introital narrowing or trauma present) to maintain tissue mobility.  

• Pelvic floor retraining: breathing and relaxation exercises (to reduce hypertonicity), coordination exercises (so muscles can relax and contract appropriately). 

• Home-program: exercises/sessions for the patient to maintain gains between visits (important in chronic conditions). 

• Collaboration: clear communication with the patient’s dermatologist/gynecologist managing the LS, so everyone is aware of the scar/adhesion status, tissue fragility, and sexual function concerns. 

What to set as realistic expectations 

• Emphasize that PFPT is supportive, not curative for LS itself. Make this clear to the patient: PFPT may help improve comfort, reduce pelvic floor–related pain, improve sexual/functional outcomes. 

• Progress may be gradual.  

• The baseline dermatologic/inflammatory control of LS still matters a lot. If the skin disease is uncontrolled, the pelvic floor will remain reactive. So PFPT works best when the dermatologic side is well managed via topical corticosteroid.  

• Patients may need ongoing maintenance PFPT or “booster” sessions if there are triggers, flares of LS, or changes in sexual activity. 

• Outcomes may vary depending on the extent of scarring, tissue changes and if there are other pelvic floor, hip, lower-back, or pelvic organ prolapse issues. 

For patients living with lichen sclerosus who are experiencing pelvic floor symptoms, chronic vulvar pain, or dyspareunia, pelvic floor physical therapy is a valuable additional therapy. While it cannot replace the dermatologic/inflammatory treatment of LS (namely ultra-potent topical corticosteroids and vigilant follow-up), PFPT may significantly improve comfort, function, sexual experience, and overall quality of life by addressing the neuromuscular/muscle/myofascial sequelae of the disease. 

Clinicians and patients should adopt a multidisciplinary mindset: controlling the inflammation and skin disease of LS and then address the pelvic floor and functional symptoms. Referral to a skilled pelvic health physical therapist with experience in vulvar pain/pelvic floor disorders is an important step in the care of patients with lichen sclerosus. 

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Disclaimer: This blog is here for your help. It is the opinion of a Licensed Physical Therapist. If you experience the symptoms addressed you should seek the help of a medical professional who can diagnose and develop a treatment plan that is individualized for you.