Botulinum Toxin Type A—A Novel Treatment for Provoked Vestibulodynia? Results from a Randomized, Placebo Controlled, Double Blinded Study

Long-term effects of continuous positive airway pressure treatment on sexuality in female patients with obstructive sleep apnea

Introduction

Results from a previous study showed that sexuality was negatively affected in females with untreated obstructive sleep apnea (OSA). Data are sparse on the long-term effects of nocturnal continuous positive airway pressure (CPAP) treatment on sexual difficulties and sexual distress in female patients with OSA.

Aim

The aim of the present study was to investigate the effects after 1 year of CPAP treatment on sexual difficulties, sexual distress, and manifest sexual dysfunction in female patients with OSA. The effect of CPAP on life satisfaction was also investigated.

Methods

Fifty-four therapy-compliant, female patients (age 22–71) received a survey before and after 1 year of nocturnal CPAP treatment. The questions on this survey were drawn from three self-administered questionnaires: two on sexuality and one on life satisfaction. The results were compared with a population sample. The Epworth Sleepiness Scale was used for assessment of daytime sleepiness.

Main Outcome Measures

The Female Sexual Function Index, Female Sexual Distress Scale, Manifest Female Sexual Dysfunction, four questions from Life Satisfaction 11, and the Epworth Sleepiness Scale were all used to measure outcome.

Results

In total, 44 patients responded to the survey (81% response rate). The results were a significant, positive change in manifest female sexual dysfunction, but no significant changes in isolated sexual difficulties or sexual distress. Daytime sleepiness significantly decreased after 1 year. The results from the Life Satisfaction 11 questionnaire remained unchanged after 1 year.

Conclusions

After 1 year of CPAP treatment, female patients with OSA reported reduced manifest sexual dysfunction. However, it cannot be concluded if this result is due to CPAP treatment alone. Furthermore, reduced daytime tiredness was found in the surveyed population. CPAP treatment, per se, does not seem to affect partner relationships. Petersen M, Kristensen E, Berg S, and Midgren B. Long-term effects of continuous positive airway pressure treatment on sexuality in female patients with obstructive sleep apnea. Sex Med 2013;1:62–68.

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.

Etiology, diagnosis, and clinical management of vulvodynia

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.

Perceived stereotyping and seeking care for chronic vulvar pain

OBJECTIVES

We examined stereotyping of chronic pain sufferers among women aged 18-40 years and determined whether perceived stereotyping affects seeking care for women with chronic vulvar pain.

DESIGN

Cross-sectional study using a community-based survey of vulvodynia asking if "Doctors think that people with chronic pain exaggerate their pain," and if "People believe that vulvar pain is used as an excuse to avoid having sex".

SETTING AND PARTICIPANTS

Twelve thousand eight hundred thirty-four women aged 18-40 years in metropolitan Minneapolis/St. Paul, Minnesota.

OUTCOME MEASURES

Women were considered to have a history of chronic vulvar pain if they reported vulvar burning lasting more than 3 months or vulvar pain on contact.

RESULTS

Four thousand nine hundred eighty-seven (38.9%) women reported a chronic pain condition; 1,651 had chronic vulvar pain. Women experiencing chronic pain were more likely than those without to perceive stereotyping from both doctors and others; a dose-response with the number of pain conditions existed. Women with chronic vulvar pain were more likely to believe that people think vulvar pain is an excuse to avoid intercourse. Half of the women with chronic vulvar pain did not seek medical care for it; of these, 40.4% perceived stereotyping from doctors. However, it was women who actually sought care (45.1%) who were more likely to feel stigmatized by doctors (adjusted relative risk = 1.11, 95% confidence interval: 1.01-1.23).

CONCLUSIONS

Perceived negative stereotyping among chronic pain sufferers is common, particularly negative perceptions about physicians. In fact, chronic vulvar pain sufferers who felt stigmatized were more likely to have sought care than those who did not feel stigmatized.

A retrospective study of the management of vulvodynia

PURPOSE

Vulvodynia is characterized by chronic vulvar pain caused by sexual intercourse and often results in female sexual dysfunction. Because the causes of vulvodynia are not clear, many patients do not receive optimal treatment. Recently, gabapentin and botulinum toxin A have both been shown to be effective treatments for vulvodynia. In this study, we retrospectively analyzed the clinical outcomes of botulinum toxin A and gabapentin treatment for chronic pain in women with this condition.

MATERIALS AND METHODS

Seventy-three women with vulvar pain were administered either gabapentin (n=62) or botulinum toxin A (n=11) injections. Effectiveness was measured by use of a visual analogue scale (VAS). We analyzed the treatment method, treatment duration, success of treatment, and side effects or adverse reactions.

RESULTS

Pain levels in both groups significantly decreased after treatment. In the gabapentin group, the VAS score decreased from 8.6 before treatment to 3.2 after treatment (p<0.001). The VAS score in the botulinum toxin A group was reduced from 8.1 to 2.5 (p<0.001). Side effects for both therapies were few and subsided with treatment with general antibiotics and nonsteroidal antiinflammatory drugs.

CONCLUSIONS

Gabapentin and botulinum toxin A are safe and effective treatments for vulvodynia. This condition can cause sexual dysfunction and affect quality of life. However, with proper management, satisfactory outcomes for women with vulvodynia can be achieved.

[How to manage a woman with a sexual complaint in clinical practice?]

OBJECTIVE

To describe the main female sexual dysfunctions, their mechanisms, and the broad outlines of their therapeutic management.

MATERIAL AND METHODS

Review of consensus conferences and published guidelines on this subject and a reflexion from our own clinical experience, in urogynaecological practice.

RESULTS

Female sexual dysfunction is frequent and can present in different ways; pain, problems concerning desire and satisfaction. These symptoms can be associated with concomitant male sexual dysfunction. These symptoms can be managed by a gynaecologist if he/she is trained accordingly. Knowledge of this is essential for a gynaecologist in daily practice but also for an urologist treating both female urinary incontinence or pelvic prolapse and male sexual dysfunction.

CONCLUSION

Women's sexual disorders can considerably affect the quality of life of the partner and the couple. As the patients hesitate to speak of such matters the clinician should begin the dialogue with simple open questions.

Standard operating procedures for female genital sexual pain

INTRODUCTION

Female genital sexual pain (GSP) is a common, distressing complaint in women of all ages that is underrecognized and undertreated. Definitions and terminology for female GSP are currently being debated. While some authors have suggested that GSP is not per se a sexual dysfunction, but rather a localized genial pain syndrome, others adhere to using clearly sexually related terms such as dyspareunia and vaginismus.

AIM

The aims of this brief review are to present definitions of the different types of female GSP. Their etiology, incidence, prevalence, and comorbidity with somatic and psychological disorders are highlighted, and different somatic and psychological assessment and treatment modalities are discussed.

METHODS

The Standard Operating Procedures (SOP) committee was composed of a chair and five additional experts. No corporate funding or remuneration was received. The authors agreed to survey relevant databases, journal articles and utilize their own clinical experience. Consensus was guided by systematic discussions by e-mail communications. MAIN OUTCOME/RESULTS: There is a clear lack of epidemiological data defining female GSP disorders and a lack of evidence supporting therapeutic interventions. However, this international expert group will recommend guidelines for management of female GSP.

CONCLUSIONS

GSP disorders are complex. It is recommended that their evaluation and treatment are performed through comprehensive somato-psychological multidisciplinary approach.

[Update on the diagnosis and treatment of vulvodynia]

CONTEXT

Vulvodynia is a complex and multifactorial clinical condition. It is defined as chronic vulvar discomfort characterized by burning, stinging or irritation. Its diagnostic difficulty and treatment is known.

OBJECTIVES

To review the medical literature of the last 10 years from a critical point of view.

EVIDENCE ACQUISITION

A search was made in Medline/Pubmed and the Cochrane Library using the terms vulvodynia and vestibulodynia to which etiology, epidemiology, diagnosis, neurophysiological test and treatment or management, were added.

EVIDENCE SYNTHESIS

In spite of the advances achieved in all of the aspects of vulvodynia, the methodology used at present in many cases does not have the desirable statistical soundness: there are few control or placebo-controlled groups and double-blind studies. Uniformity is lacking in the scales, indexes and questionnaires for the correct evaluation of pain before and after the treatment and debatable diagnostic criteria are use. The limited use of neurophysiological diagnostic resources that validate the clinical findings has been observed in the studies analyzed. In most of the works, the medical treatments have been shown to be ineffective. Physiotherapy and cognitive-behavioral therapy seem to be promising therapeutic tools. Surgery (vestibulectomy) stands out by its demonstrated efficacy in the publications studied.

CONCLUSIONS

A multidisciplinary approach is always necessary. Topical medical, psychological and physical therapy treatments may have sum effects and become an alternative to surgery. New pathways of research and more regulated studies are required.

Pelvic pain in women: clinical and scientific aspects

PURPOSE OF REVIEW

Pelvic pain is a common complaint of women that is frequently poorly managed. This review considers the current understanding of the mechanisms of pain perception and the development of chronic pain in the context of three gynaecological pain conditions. Recent advances in the management of these conditions are then discussed.

RECENT FINDINGS

Persistent pelvic pain is associated with central changes, reflected by alterations in psychology, brain structure and function, and dysfunction of the hypothalamic-pituitary-adrenal axis. The many similarities among the conditions support the notion that chronic pain should be treated as a symptom in its own right, however, obtaining a diagnosis remains important to patients. Few new treatments have been developed recently, however, older treatments are being subjected to more rigorous testing and improvements in phenotyping should lead to better design of clinical trials.

SUMMARY

Good quality, well designed clinical trials are urgently required to improve the treatment of pelvic pain in women. However, a variety of successful treatments exist and outcomes can be optimized by individualizing treatment strategies in the context of a multidisciplinary package.

Sexual function in female patients with obstructive sleep apnea

INTRODUCTION

Obstructive sleep apnea is defined as repetitive (≥5/hour) partial or complete cessation of breathing during sleep. Whereas obstructive sleep apnea is often considered to be associated with sexual problems in men, studies concerning effects of obstructive sleep apnea on female sexual function and distress are sparse.

AIM

To investigate sexual dysfunction and sexual distress in female patients with obstructive sleep apnea and to determine which factors are of importance for their sexual function.

METHODS

We investigated 80 female patients (ages 28-64) admitted to a sleep laboratory and who after investigation received a diagnosis of obstructive sleep apnea. All subjects answered questions drawn from three self-administered questionnaires on sexuality. The results were compared with a population sample (N=240).

MAIN OUTCOME MEASURE

  Data from nocturnal respiratory recordings. Female Sexual Function Index, Female Sexual Distress Scale and four questions from Life Satisfaction-11 (Lisat-11).

RESULTS

  Female Sexual Function Index indicated that obstructive sleep apnea patients were at a higher risk for having sexual difficulties. Female Sexual Distress Scale showed significantly more sexual distress in the obstructive sleep apnea group. Manifest Female Sexual Dysfunction (combined data from Female Sexual Function Index and Female Sexual Distress Scale) showed that female patients with obstructive sleep apnea also had more sexual dysfunction. Severity of sleep apnea was, however, not related to any of these indices but consumption of psychopharmaca was. In Lisat-11, we found that obstructive sleep apnea females scored lower than women in the population sample regarding life as a whole but not regarding domains of closeness.

CONCLUSIONS

  This study indicates that sexuality of women with untreated obstructive sleep apnea is negatively affected compared with a female population sample. This was not related to severity of obstructive sleep apnea, whereas psychopharmaca may act as an important confounder.

Efficacy of botulinum toxin type A for treatment of persistent myofascial TMD pain: a randomized, controlled, double-blind multicenter study

Evidence of an effect by botulinum toxins is still lacking for most pain conditions. In the present randomized, placebo-controlled, crossover multicenter study, the efficacy of botulinum toxin type A (BTX-A) was investigated in patients with persistent myofascial temporomandibular disorders (TMD). Twenty-one patients with myofascial TMD without adequate pain relief after conventional treatment participated. A total of 50 U of BTX-A or isotonic saline (control) was randomly injected into 3 standardized sites of the painful masseter muscles. Follow-up was performed after 1 and 3 months, followed by a 1-month washout period, after which crossover occurred. Pain intensity at rest was the primary outcome measure, while physical and emotional function, global improvement, side effects, and clinical measures were additional outcome measures. There was no main difference between drugs (ANOVA; P=.163), but there was a significant time effect (P<.001), so BTX-A reduced mean (SD) percent change of pain intensity by 30 (33%) after 1 month and by 23 (30%) after 3 months compared to 11 (40%) and 4 (33%) for saline. The number of patients who received a 30% pain reduction was not significantly larger for BTX-A than after saline at any follow-up visit. The number needed to treat was 11 after 1 month and 7 after 3 months. There were no significant changes after treatment in any other outcome measures, with the exception of pain on palpation, which decreased 3 months after saline injection (P<.05). These results do not indicate a clinical relevant effect of BTX-A in patients with persistent myofascial TMD pain.

The role of botulinum toxin in management of pain: an evidence-based review

PURPOSE OF REVIEW

In the present review we discuss the role of botulinum neurotoxins (BoNTs) in the management of different pain conditions, with evidence-based data on the toxins' efficacy on pain and its mechanisms.

RECENT FINDINGS

Experimental in-vitro studies have reported promising results of a novel recombinant chimera of BoNT A and E that inhibits the calcitonin gene-related peptide exocytosis from brainstem sensory neurons. Animal studies in neuropathic pain rat models have reported an analgesic effect of BoNT A given after the neuropathic procedure and a bilateral antinociceptive effect to the unilateral noxious stimuli. There is a growing body of evidence that BoNTs are effective in myofascial pain syndrome, neuropathic pain, and joint pain. The pre-existing evidence that BoNTs are ineffective in migraine or other headache disorders has not yet been challenged. In other pain syndromes, studies published in the last review year have not contributed significantly in either demonstrating or invalidating the research that has so far proved inconclusive.

SUMMARY

The role of BoNTs in management of pain is not yet well established. Larger studies in neuropathic pain, joint pain, and myofascial pain syndrome are needed to fully ascertain the role for BoNT therapy in those areas.

[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.

The ACTIV study: acupuncture treatment in provoked vestibulodynia

INTRODUCTION

Provoked vestibulodynia (PVD) is a distressing genital pain condition affecting 12% of women. Treatment modalities vary and although vestibulectomy has the highest efficacy rates, it is usually not a first-line option. Acupuncture has a long history in the traditional Chinese medicine (TCM) system and operates on the premise that pain results from the blockage or imbalance of important channels. The main principle of treatment is to move Qi and blood to cease genital pain.

AIM

To explore effect sizes and feasibility in a pilot study of acupuncture for women with PVD.

METHODS

Eight women with PVD (mean age 30 years) underwent 10 1-hour acupuncture sessions. Specific placement of the needles depended on the woman's individual TCM diagnosis. TCM practitioners made qualitative notes on participants' feedback after each session. Main Outcome Measures. Self-reported pain (investigator-developed), pain-associated cognitions (Pain Catastrophizing Scale [PCS], Pain Vigilance and Awareness Questionnaire), and sexual response (Female Sexual Function Index) were measured before and after treatment sessions 5 and 10. Qualitative analyses of TCM practitioner notes were performed along with one in-depth case report on the experience of a participant.

RESULTS

A repeated measures analysis of variance revealed significant decreases in pain with manual genital stimulation and helplessness on the PCS. An examination of effect sizes also revealed strong (though nonsignificant) effects for improved ability to have intercourse and sexual desire. Qualitative analyses were overall more positive and revealed an improvement in perceived sexual health, reduced pain, and improved mental well-being in the majority of participants.

CONCLUSIONS

Effect sizes and qualitative analyses of practitioner-initiated interviews showed overall positive effects of acupuncture, but there were statistically significant improvements only in pain with manual genital stimulation and helplessness. These findings require replication in a larger, controlled trial before any definitive conclusions on the efficacy of acupuncture for PVD can be made.