Guidelines for the management of vulvodynia

A comparison of cognitive-behavioral couple therapy and lidocaine in the treatment of provoked vestibulodynia: study protocol for a randomized clinical trial

Background

Provoked vestibulodynia (PVD), a frequent form of chronic genital pain, is associated with decreased sexual function for afflicted women, as well as impoverished sexual satisfaction for women and their partners. Pain and sexuality outcomes for couples with PVD are influenced by interpersonal factors, such as pain catastrophizing, partner responses to pain, ambivalence over emotional expression, attachment style and perceived relationship and sexual intimacy. Despite recommendations in the literature to include the partner in cognitive-behavioral therapy targeted at improving pain and sexuality outcomes, no randomized clinical trial has tested the efficacy of this type of intervention and compared it to a first-line medical intervention.

Methods

This bi-center, randomized clinical trial is designed to examine the efficacy of cognitive-behavioral couple therapy compared to topical lidocaine. It is conducted across two Canadian university-hospital centers. Eligible women diagnosed with PVD and their partners are randomized to one of the two interventions. Evaluations are conducted using structured interviews and validated self-report measures at three time points: Pre-treatment (T1: prior to randomization), post-treatment (T2), and 6-month follow-up (T3). The primary outcome is the change in reported pain during intercourse between T1 and T2. Secondary outcomes focus on whether there are significant differences between the two treatments at T2 and T3 on (a) the multidimensional aspects of women’s pain and (b) women and partners’ sexuality (sexual function and satisfaction), psychological adjustment (anxiety, depression, catastrophizing, self-efficacy, and quality of life), relationship factors (partner responses and dyadic adjustment) and self-reported improvement and treatment satisfaction. In order to detect an effect size as small as 0.32 for secondary outcomes, a sample of 170 couples is being recruited (27% dropout expected). A clinically significant decrease in pain is defined as a 30% reduction.

Discussion

The randomized clinical trial design is the most appropriate to examine the efficacy of cognitive-behavioral couple therapy, a recently developed and pilot-tested psychosocial intervention for couples coping with PVD, in comparison to a frequent first-line treatment option, topical lidocaine. Findings from this study will provide important information about empirically supported treatment options for PVD, and inform future treatment development and research for this patient population.

Trial registration

Clinicaltrials.gov NCT01935063; registration date: 27 August 27 2013.

Spanish consensus on vulvar disorders in postmenopausal women

INTRODUCTION

The consequences of vulvar disorders in terms of health, sexuality, and quality of life are usually undervalued, with disparities in the conceptual, diagnosis and treatment criteria.

AIM

The objective of this guide will be to analyse the factors associated with the diagnosis and treatment of vulvar disorders and to provide recommendations for the most appropriate diagnostic and therapeutic measures.

METHODOLOGY

A panel of experts from various Spanish scientific societies related to sexual health (Spanish Menopause Society [SMS] and the Asociación Española de Patología Cervical y Colposcopia [AEPCC]) met to reach a consensus on these issues and to decide the optimal timing and methods based on the best evidence available.

RESULTS

We recommend a biopsy of all vulvar lesions with an uncertain diagnosis, especially with asymmetry, irregular borders, variegated and irregular colour and diameter >6mm. For vulvodynia, we recommend the use of lubricants or topical treatments with lidocaine or bupivacaine, amitriptyline, baclofen or triamcinolone. For vulvar epithelial disorders, we recommend beginning with topical corticosteroids of moderate to high potency. For sexual dysfunction, a multidisciplinary approach is the best management strategy in these patients.

Psychological treatment for vaginal pain: does etiology matter? A systematic review and meta-analysis

INTRODUCTION

Classification of vaginal pain within medical or psychiatric diagnostic systems draws mainly on the presumed presence or absence (respectively) of underlying medical etiology. A focus on the experience of pain, rather than etiology, emphasizes common ground in the aims of treatment to improve pain and sexual, emotional, and cognitive experience. Thus, exploring how vaginal pain conditions with varying etiology respond to psychological treatment could cast light on the extent to which they are the same or distinct.

AIM

To examine the combined and relative efficacy of psychological treatments for vaginal pain conditions.

METHODS

A systematic search of EMBASE, MEDLINE, PsycINFO, and CINAHL was undertaken. Eleven randomized controlled trials were entered into a meta-analysis, and standardized mean differences and odds ratios were calculated. Effect sizes for individual psychological trial arms were also calculated.

MAIN OUTCOME MEASURES

Main outcome measures were pain and sexual function.

RESULTS

Equivalent effects were found for psychological and medical treatments. Effect sizes for psychological treatment arms were comparable across vaginal pain conditions.

CONCLUSIONS

Effectiveness was equivalent regardless of presumed medical or psychiatric etiology, indicating that presumed etiology may not be helpful in selecting treatment. Research recommendations and clinical implications are discussed.

Female reproductive tract pain: targets, challenges, and outcomes

Pain from the female reproductive tract (FRT) is a significant clinical problem for which there are few effective therapies. The complex neuroanatomy of pelvic organs not only makes diagnosis of pelvic pain disorders difficult but represents a challenge to development of targeted therapies. A number of potential therapeutic targets have been identified on sensory neurons supplying the FRT but our knowledge on the basic neurophysiology of these neurons is limited compared with other viscera. Until this is addressed we can only guess if the new experimental therapies proposed for somatic, gastrointestinal, or bladder pain will translate to the FRT. Once suitable therapeutic targets become clear, the next challenge is drug delivery. The FRT represents a promising system for topical drug delivery that could be tailored to act locally or systemically depending on formulation. Development of these therapies and their delivery systems will need to be done in concert with more robust in vivo and in vitro models of FRT pain.

Chronic testicular pain in adult men: an integrative literature review

Past investigations of chronic testicular pain provide a sparse representation of the men with this condition and lack key details to aid our understanding of this important men's health condition. As a chronic pain syndrome, more research is necessary to understand the phenomenon of chronic testicular pain and the pain experience of these men. This integrative literature review provides a summary of the current state of the science of chronic testicular pain in men, identifies the gaps in our knowledge, and provides recommendations to address this knowledge gap.

Providing holistic care for women with chronic pelvic pain

Chronic pelvic pain (CPP) is one of the most common pain conditions affecting women and can have a significant impact on quality of life. Assessment of women with CPP is best approached in a comprehensive, systematic manner that includes exploration of physiological and psychological causes. A range of treatment options that draw from conventional medicine and complementary and alternative modalities should be offered. The women's health nurse plays a pivotal role in all aspects of care.

Neuromodulation of pelvic visceral pain: review of the literature and case series of potential novel targets for treatment

Chronic pelvic pain (CPP) is complex and often resistant to treatment. While the exact pathophysiology is unknown, the pain states resultant from conditions such as interstitial cystitis and the like yield patients with a presentation that bears a striking similarity to neuropathic syndromes that are known to respond to neuromodulation. While there has been past success using the sacral region as a target for spinal cord stimulation (SCS) to treat these patients, there remains to be a consensus on the optimal location for lead placement. In this article, the authors discuss the potential etiology of CPP, examine the current literature on lead placement for SCS as a method of treatment, as well as present several cases where novel lead placement was successfully employed.

[Vulvodynia and chronic pelvic and perineal pain]

OBJECTIVE

To define vulvodynia and to describe the main approaches to treatment.

MATERIAL AND METHODS

Review of the literature concerning vulvodynia.

RESULTS

Vulvodynia is defined as chronic vulvar discomfort, usually with a burning nature, with no relevant clinical lesions and no clinically identifiable neurological lesion. Localized provoked vulvodynia essentially affects young women and is responsible for major sexual and psychological repercussions. Treatment consists of local anaesthetics, drugs used to treat neuropathic pain, physiotherapy and psychotherapy. Vestibulectomy is only very rarely indicated.

CONCLUSION

Many unknowns persist especially concerning the aetiology of vulvodynia. Evaluation of symptoms and treatment have not been clearly defined. However, symptomatic management provide satisfactory long-term results.

Junior doctors' understanding of vulval pain/vulvodynia: a qualitative survey

AIM

The objective of this survey is to explore junior doctors' understanding of vulvodynia using a questionnaire.

METHOD

Fifty-six copies of the questionnaire were handed out at three hospitals: Norfolk and Norwich University Hospital, Colchester University Hospital, and Royal Free Hospital in London. The questionnaire was anonymous, containing 11 questions asking about different aspects of diagnosis and management of vulvodynia. The doctors were asked to write their post or level of Obstetrics and Gynaecology speciality training e.g. ST1, ST2, ST3, etc.

RESULTS

The results highlight the limited amount of awareness and understanding of vulval pain among junior doctors.

CONCLUSION

There is little understanding about vulvodynia among junior gynaecologists. Most of them did not have any form of basic training about the condition even after reaching the final stages of the speciality training. In view of the estimated prevalence, there is a need for including some form of local and/or regional teaching about the causes and management of vulvar pain, particularly for those who are about to finish their speciality training.