VESTIBULODYNIA AND VULVODYNIA
2013 Vulvodynia Guideline update
J Low Genit Tract Dis. 2014 Apr;18(2):93-100.
Stockdale CK1, Lawson HW.
Vulvodynia is a complex disorder that can be difficult to treat. Most patients describe it as burning, stinging, irritation, or rawness. Vulvodynia is a costly disease both economically and on its negative impact on patient quality of life. Although many treatment options are available, no one treatment is effective for all patients, thus the need to individualize management. Measures such as gentle vulvar care, medication, biofeedback training, physical therapy, sexual counseling and surgery, as well as complementary and alternative therapies are available to treat the condition with varying success.
Dyspareunia in women
Am Fam Physician. 2014 Oct 1;90(7):465-70.
Seehusen DA1, Baird DC2, Bode DV1.
Dyspareunia is recurrent or persistent pain with sexual activity that causes marked distress or interpersonal conflict. It affects approximately 10% to 20% of U.S. women. Dyspareunia can have a significant impact on a woman's mental and physical health, body image, relationships with partners, and efforts to conceive. The patient history should be taken in a nonjudgmental way and progress from a general medical history to a focused sexual history. An educational pelvic examination allows the patient to participate by holding a mirror while the physician explains normal and abnormal findings. This examination can increase the patient's perception of control, improve self-image, and clarify findings and how they relate to discomfort. The history and physical examination are usually sufficient to make a specific diagnosis. Common diagnoses include provoked vulvodynia, inadequate lubrication, postpartum dyspareunia, and vaginal atrophy. Vaginismus may be identified as a contributing factor. Treatment is directed at the underlying cause of dyspareunia. Depending on the diagnosis, pelvic floor physical therapy, lubricants, or surgical intervention may be included in the treatment plan.
Vulvodynia
Best Pract Res Clin Obstet Gynaecol. 2014 Oct;28(7):1000-12. doi: 10.1016/j.bpobgyn.2014.07.009. Epub 2014 Jul 18.
Eppsteiner E1, Boardman L2, Stockdale CK3.
Vulvodynia is a complex disorder reported by up to 16% of women in the general population. While most patients describe it as burning, stinging, irritation, or rawness, it is underreported and underrecognized by providers. Vulvodynia is costly both economically and psychologically due to its negative impact on quality of life. Vulvodynia is a diagnosis of exclusion with unknown etiology and may involve multiple sources of pain in the same woman. Thus, there are no clinical or histopathologic criteria for the diagnosis other than consideration and careful evaluation to exclude other causes of pain. Successful therapy often requires a multidisciplinary approach with more than one therapeutic intervention to address the physical, psychological, psychosexual, and relationship components.
Vulvodynia
Obstet Gynecol Clin North Am. 2014 Sep;41(3):453-64. doi: 10.1016/j.ogc.2014.05.005. Epub 2014 Jul 9.
Shah M1, Hoffstetter S2.
Vulvar pain and discomfort (vulvodynia) are common conditions that can have a significant impact on a patient's quality of life. Vulvodynia is a difficult condition to evaluate and treat. This article gives the primary gynecologist a basic framework with which to identify, diagnose, and begin treatment for these patients and refer if necessary. Initial evaluation and physical examination are discussed in detail. Treatments ranging from self-management strategies to nonpharmacologic and pharmacologic therapies will be explored. Because vulvodynia is a chronic pain disorder, diagnosis is the key to beginning treatment and support for this patient population.
Vulvodynia: Current state of the biological science
Pain. 2014 Sep;155(9):1696-701. doi: 10.1016/j.pain.2014.05.010. Epub 2014 May 22.
.Wesselmann U1, Bonham A2, Foster D3. No abstract available
Etiology, diagnosis, and clinical management of vulvodynia
Int J Womens Health. 2014 May 2;6:437-49. doi: 10.2147/IJWH.S37660. eCollection 2014.
Sadownik LA1.
Chronic vulvar pain or discomfort for which no obvious etiology can be found, ie, vulvodynia, can affect up to 16% of women. It may affect girls and women across all age groups and ethnicities. Vulvodynia is a significant burden to society, the health care system, the affected woman, and her intimate partner. The etiology is multifactorial and may involve local injury or inflammation, and peripheral and or central sensitization of the nervous system. An approach to the diagnosis and management of a woman presenting with chronic vulvar pain should address the biological, psychological, and social/interpersonal factors that contribute to her illness. The gynecologist has a key role in excluding other causes for vulvar pain, screening for psychosexual and pelvic floor dysfunction, and collaborating with other health care providers to manage a woman's pain. An important component of treatment is patient education regarding the pathogenesis of the pain and the negative impact of experiencing pain on a woman's overall quality of life. An individualized, holistic, and often multidisciplinary approach is needed to effectively manage the woman's pain and pain-related distress.
Chronic pelvic floor dysfunction
Best Pract Res Clin Obstet Gynaecol. 2014 Oct;28(7):977-90. doi: 10.1016/j.bpobgyn.2014.07.008. Epub 2014 Jul 17.
Hartmann D1, Sarton J2.
The successful treatment of women with vestibulodynia and its associated chronic pelvic floor dysfunctions requires interventions that address a broad field of possible pain contributors. Pelvic floor muscle hypertonicity was implicated in the mid-1990s as a trigger of major chronic vulvar pain. Painful bladder syndrome, irritable bowel syndrome, fibromyalgia, and temporomandibular jaw disorder are known common comorbidities that can cause a host of associated muscular, visceral, bony, and fascial dysfunctions. It appears that normalizing all of those disorders plays a pivotal role in reducing complaints of chronic vulvar pain and sexual dysfunction. Though the studies have yet to prove a specific protocol, physical therapists trained in pelvic dysfunction are reporting success with restoring tissue normalcy and reducing vulvar and sexual pain. A review of pelvic anatomy and common findings are presented along with suggested physical therapy management.
Psychosexual aspects of vulvovaginal pain
Best Pract Res Clin Obstet Gynaecol. 2014 Oct;28(7):991-9. doi: 10.1016/j.bpobgyn.2014.07.007. Epub 2014 Jul 17.
Bergeron S1, Likes WM2, Steben M3.
Vulvovaginal pain problems are major health concerns in women of childbearing age. Controlled studies have shown that vulvovaginal pain can adversely affect women and their partners' general psychological well-being, relationship adjustment, and overall quality of life. These women have significantly lower levels of sexual desire, arousal, and satisfaction, as well as a lower intercourse frequency than normal controls. They also report more anxiety and depression, in addition to more distress about their body image and genital self-image. Empirical studies indicate that specific psychological and relationship factors may increase vulvovaginal pain intensity and its psychosexual sequelae. Randomized clinical trials have shown that psychosexual interventions, namely cognitive-behavioral therapy (CBT), are efficacious in reducing vulvovaginal pain and improving associated psychosexual outcomes. Women reporting significant psychological, sexual, and/or relationship distress should be referred for psychosexual treatment. A multimodal approach to care integrating psychosexual and medical management is thought to be optimal.
Can Fear, Pain, and Muscle Tension Discriminate Vaginismus from Dyspareunia/Provoked Vestibulodynia? Implications for the New DSM-5 Diagnosis of Genito-Pelvic Pain/Penetration Disorder.
Arch Sex Behav. 2014 Nov 15. [Epub ahead of print]
Lahaie MA1, Amsel R, Khalifé S, Boyer S, Faaborg-Andersen M, Binik YM.
.
Fear has been suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia. Unfortunately, this has not been systematically investigated. The primary purpose of this study, therefore, was to investigate whether fear as evaluated by subjective, behavioral, and psychophysiological measures could differentiate women with vaginismus from those with dyspareunia/provoked vestibulodynia (PVD) and controls. A second aim was to re-examine whether genital pain and pelvic floor muscle tension differed between vaginismus and dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women with dyspareunia/PVD, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia/PVD and no-pain control groups. Moreover, behavioral measures of fear and vaginal muscle tension were found to discriminate the vaginismus group from the dyspareunia/PVD and no-pain control groups. Genital pain did not differ significantly between the vaginismus and dyspareunia/PVD groups; however, genital pain was found to discriminate both clinical groups from controls. Despite significant statistical differences on fear and vaginal muscle tension variables between women suffering from vaginismus and dyspareunia/PVD, a large overlap was observed between these conditions. These findings may explain the great difficulty health professionals experience in attempting to reliably differentiate vaginismus from dyspareunia/PVD. The implications of these data for the new DSM-5 diagnosis of Genito-Pelvic Pain/Penetration Disorder are discussed.
Body Image in Women with Primary and Secondary Provoked Vestibulodynia: A Controlled Study.
J Sex Med. 2014 Nov 13. doi: 10.1111/jsm.12765. [Epub ahead of print]
Maillé DL1, Bergeron S, Lambert B.
INTRODUCTION: Provoked vestibulodynia (PVD) is a women's genito-pelvic pain condition associated with psychosexual impairments, including depression. Body image (BI) has been found to be different in women with primary (PVD1) and secondary (PVD2) PVD. No controlled study has compared BI in women with PVD1 and PVD2 and investigated its associations with sexual satisfaction, sexual function, and pain.
AIMS: The aims of this study were to (i) compare BI in women with PVD1, PVD2, and asymptomatic controls and (ii) to examine associations between BI and sexual satisfaction, sexual function, and pain during intercourse in women with PVD.
METHODS: Fifty-seven women (20 with PVD1, 19 with PVD2, and 18 controls) completed measures of BI, sexual satisfaction, sexual function, pain during intercourse, and depression.
MAIN OUTCOME MEASURES: The main outcome measures were (i) Global Measure of Sexual Satisfaction Scale, (ii) Female Sexual Function Index, and (iii) pain numerical rating scale.
RESULTS: Controlling for depression, women with PVD1 reported more body exposure anxiety during sexual activities than women with PVD2 and controls F(2,51) = 4.23, P = 0.02. For women with PVD, more negative BI during sexual activities was associated with lower sexual satisfaction (β = -0.45, P = 0.02) and function (β = -0.39, P = 0.04) and higher pain during intercourse (β = 0.59, P = 0.004). More positive body esteem was associated with higher sexual function (β = 0.34, P = 0.05).
CONCLUSIONS: Findings suggest that women with PVD1 present more body exposure anxiety during sexual activities than women with PVD2 and asymptomatic women. Body esteem and general attitudes toward women's genitalia were not significantly different between groups. Higher body exposure anxiety during sexual activities was associated with poorer sexual outcomes in women with PVD. Further studies assessing interventions targeting BI during sexual activities in this population are needed, as improving BI during sexual interactions may enhance sexual outcomes in women with PVD.
Transcutaneous Electrical Nerve Stimulation as an Additional Treatment for Women Suffering from Therapy-Resistant Provoked Vestibulodynia: A Feasibility Study.
J Sex Med. 2014 Nov 12. doi: 10.1111/jsm.12740. [Epub ahead of print]
Vallinga MS1, Spoelstra SK, Hemel IL, van de Wiel HB, Weijmar Schultz WC.
INTRODUCTION: The current approach to women with provoked vestibulodynia (PVD) comprises a multidimensional, multidisciplinary therapeutic protocol. As PVD is considered to be a chronic pain disorder, transcutaneous electrical nerve stimulation (TENS) can be used as an additional therapy for women with otherwise therapy-resistant PVD.
AIMS: The aims of this study were to evaluate whether TENS has a beneficial effect on vulvar pain, sexual functioning, and sexually-related personal distress in women with therapy-resistant PVD and to assess the effect of TENS on the need for vestibulectomy.
METHODS: A longitudinal prospective follow-up study was performed on women with therapy-resistant PVD who received additional domiciliary TENS. Self-report questionnaires and visual analog scales (VASs) were completed at baseline (T1), post-TENS (T2), and follow-up (T3).
MAIN OUTCOME MEASURES: Vulvar pain, sexual functioning, and sexually-related personal distress were the main outcome measures.
RESULTS: Thirty-nine women with therapy-resistant PVD were included. Mean age was 27 ± 5.6 years (range: 19 to 41); mean duration between TENS and T3 follow-up was 10.1 ± 10.7 months (range: 2 to 32). Vulvar pain VAS scores directly post-TENS (median 3.4) and at follow-up (median 3.2) were significantly (P 0.01) lower than at baseline (median 8.0). Post-TENS, sexual functioning scores on the Female Sexual Functioning Index questionnaire had improved significantly (P = 0.2); these scores remained stable at follow-up. Sexually-related personal distress scores had improved significantly post-TENS (P = 0.01). Only 4% of the women who received TENS needed to undergo vestibulectomy vs. 23% in our previous patient population.
CONCLUSION: The addition of self-administered TENS to multidimensional treatment significantly reduced the level of vulvar pain and the need for vestibulectomy. The long-term effect was stable. These results not only support our hypothesis that TENS constitutes a feasible and beneficial addition to multidimensional treatment for therapy-resistant PVD, but also the notion that PVD can be considered as a chronic pain syndrome.
Impact of a Multidisciplinary Vulvodynia Program on Sexual Functioning and Dyspareunia
J Sex Med. 2014 Oct 30. doi: 10.1111/jsm.12718. [Epub ahead of print]
Brotto LA1, Yong P, Smith KB, Sadownik LA.
INTRODUCTION: For many years, multidisciplinary approaches, which integrate psychological, physical, and medical treatments, have been shown to be effective for the treatment of chronic pain. To date, there has been anecdotal support, but little empirical data, to justify the application of this multidisciplinary approach toward the treatment of chronic sexual pain secondary to provoked vestibulodynia (PVD).
AIM: This study aimed to evaluate a 10-week hospital-based treatment (multidisciplinary vulvodynia program [MVP]) integrating psychological skills training, pelvic floor physiotherapy, and medical management on the primary outcomes of dyspareunia and sexual functioning, including distress.
METHOD: A total of 132 women with a diagnosis of PVD provided baseline data and agreed to participate in the MVP. Of this group, n = 116 (mean age 28.4 years, standard deviation 7.1) provided complete data at the post-MVP assessment, and 84 women had complete data through to the 3- to 4-month follow-up period.
RESULTS: There were high levels of avoidance of intimacy (38.1%) and activities that elicited sexual arousal (40.7%), with many women (50.4%) choosing to focus on their partner's sexual arousal and satisfaction at baseline. With treatment, over half the sample (53.8%) reported significant improvements in dyspareunia. Following the MVP, there were strong significant effects for the reduction in dyspareunia (P = 0.001) and sex-related distress (P 0.001), and improvements in sexual arousal (P 0.001) and overall sexual functioning (P = 0.001). More modest but still statistically significant were improvements in sexual desire, lubrication, orgasmic function, and sexual satisfaction. All improvements were retained at 2- to 3-month follow-up.