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

Investigating the overlapping presentation of irritable bowel syndrome and vulvodynia: a scoping review of the evidence and mechanisms

INTRODUCTION

Vulvodynia is a complex and multifactorial medical condition characterized by pain in the vulvar area without any identifiable cause. Vulvodynia is underdiagnosed, leading to increased risk of sexual dysfunction and reduced quality of life. Irritable bowel syndrome (IBS) is a gastrointestinal disorder predominantly affecting women. Vulvodynia and IBS frequently co-occur in women, with a 2- to 4-fold increased likelihood of IBS diagnosis in those with vulvodynia. These conditions may share underlying causes, highlighting the need for research to better understand their shared pathophysiology and develop effective therapeutics.

OBJECTIVE

The aim of this scoping review was to assess the evidence of simultaneous presentation of IBS and vulvodynia.

METHODS

A comprehensive search was conducted in 6 databases between inception of database and August 2023: PubMed, Web of Science, Scopus, Science Direct, Google Scholar, and Cochrane Library. Studies included primary research about IBS and vulvodynia in terms of presentation overlap, diagnosis, or treatment. Data were extracted from eligible studies, summarized, and collated.

RESULTS

Of the 306 unique articles identified, 33 were included in the final analysis: 20 cross-sectional studies, 4 case-control studies, 2 case reports, 4 cohort studies, 2 quasi-experimental studies, and 1 randomized trial. Common themes included a high prevalence of overlapping vulvodynia and IBS with a significant diagnostic delay in vulvodynia, mast cell involvement and visceral hypersensitization as common pathophysiology, and the need for a multimodal treatment.

CONCLUSION

Our review adds to the evidence that there is an association between vulvodynia and IBS. Despite this, research on the underlying molecular mechanisms of this association is scarce, and diagnostic delays persist for vulvodynia. Increasing awareness of the overlap of these conditions will improve screening for vulvodynia in the patient population with IBS, thereby improving the diagnostic delay, and understanding the pathophysiology will enable treatment strategies that address both conditions.

Chronic Vulvar Pain and Health-Related Quality of Life in Women with Vulvodynia

The aim of this study was to investigate the severity of chronic vulvar pain in women with vulvodynia and its impact on their health-related quality of life (QL). The study group consisted of 76 women aged 19 to 58. The study was carried out using the diagnostic survey method, i.e., (1) the questionnaire technique, comprising (A) the author's questionnaire (76 questions) and (B) the WHOQOL-BREF questionnaire, and (2) the VAS. When analyzing the severity of vulvar pain on the VAS, the highest proportion of women rated it at level 6 (23.68%). This was significantly determined by certain personal characteristics (age < 25 years old) and sociodemographic characteristics (marital status: unmarried women, divorcees, widows; high school education), each at p < 0.05. Vulvodynia causes a significant deterioration (64.47%) in QL, which is mainly caused by a reduction in the ability to perform activities of daily living (27.63%) and a decrease in sexual satisfaction (27.63%). The level of stress significantly exacerbates pain (p < 0.05). The severity correlates significantly (p < 0.05) and negatively (r < 0) with QL perception, which was rated worst in the physical domain. The use of treatment resulted in a significant improvement in the physical and psychological domains (p < 0.05), and the latter was particularly influenced by physiotherapy (p < 0.05).

Exploring the health care experiences of women diagnosed with vulvodynia

BACKGROUND

Although seeking diagnosis and treatment for chronic pain should be straightforward, this is not typically the case for those living with vulvodynia, who often describe it as a battle, frequently involving misdiagnosis, dismissal, and gender-based discrimination.

AIM

This study explored the health care experiences of women living with vulvodynia in the United Kingdom.

METHODS

As they are less explored in literature, experiences postdiagnosis and across varying health care settings were specifically considered. Interviews were conducted with 6 women aged 21 to 30 years to explore their experiences when seeking help for vulvodynia.

OUTCOMES

Through interpretative phenomenological analysis, 5 themes emerged: the impact of diagnosis, patients' perception of health care, self-guidance and lack of direction, gender as a barrier to effective care, and a lack of consideration of psychological factors.

RESULTS

Women often experienced difficulties before and after diagnosis, and many felt that their pain was dismissed and ignored due to their gender. Pain management was felt to be prioritized by health care professionals over well-being and mental health.

CLINICAL IMPLICATIONS

There is a need for further exploration of gender-based discrimination experiences among patients with vulvodynia, health care professionals' perceptions of their capabilities in working with such patients, and the impact of improving professionals' training in working with these patients2.

STRENGTHS AND LIMITATIONS

Health care experiences after diagnosis are rarely examined within literature, with studies predominantly focusing on experiences surrounding diagnosis, intimate relationships, and specific interventions. The present study provides an in-depth exploration of health care experiences through participants' lived experiences and gives insight into an underresearched area. Women with negative experiences of health care may have been more likely to participate than those with positive experiences, which may have resulted in their overrepresentation. Furthermore, participants were predominantly young White heterosexual women, and almost all had comorbidities, further limiting generalizability.

CONCLUSION

Findings should be used to inform health care professionals' education and training to improve outcomes for those seeking care for vulvodynia.

#ItsNotInYourHead: A Social Media Campaign to Disseminate Information on Provoked Vestibulodynia

Provoked Vestibulodynia (PVD) is a type of localized vulvodynia (or pain in the vulva). The estimated prevalence of this condition is about 12% of the general population and approximately 20% of women under the age of 19. Many women who live with PVD suffer in silence for years before receiving a diagnosis. Whereas cognitive behavioral therapy (CBT) was already known to be effective for managing symptoms of PVD, there has recently been a published head-to-head comparison of CBT versus mindfulness-based therapy for the primary outcome of pain intensity with penetration. The trial revealed that both treatments were effective and led to statistically and clinically meaningful improvements in sexual function, quality of life, and reduced genital pain, with improvements retained at both 6- and 12-month follow-ups. We then undertook an end-of-grant knowledge translation (KT) campaign focused on the use of social media to disseminate an infographic video depicting the findings. Social media was strategically chosen as the primary mode of dissemination for the video as it has broad reach of audience, the public can access information on social media for free, and it presented an opportunity to provide social support to the population of women with PVD who are characterized as suffering in silence by starting a sensitive and empowering dialogue on a public platform. In this paper, we summarize the social media reach of our campaign, describe how and why we partnered with social media influencers, and share lessons learned that might steer future KT efforts in this field.

Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives

INTRODUCTION

Persons with vulvodynia (a chronic vulvar pain condition) suffer many barriers to diagnosis and treatment, several of which may be exacerbated by the sociocultural and geographical context in which they live.

AIM

We drew on the experiences of patients with vulvodynia who were living in small urban and rural communities to learn what they perceived as the major barriers to diagnosis and treatment as well as to probe for possible solutions.

METHODS

For this qualitative case study, we conducted 3 focus groups with a total of 10 participants, drawn from patients seen at our academic tertiary referral center, with a goal of understanding their lived experience with vulvodynia.

MAIN OUTCOME MEASURES

The patient dialogue was coded into themes and temporally grouped to illustrate struggles and victories in diagnosis and treatment.

RESULTS

Participants confirmed that healthcare provider knowledge and attitudes as well as system challenges (specialist and allied healthcare provider availability) are major barriers to timely diagnosis. Of novel interest are other factors that exacerbate distress and delay diagnosis such as patients' inadequate knowledge of sexual functioning and sociocultural messages regarding "normal" sexual activity. Our work suggests that a disease prevention framework that includes comprehensive sexual education before or at the onset of sexual activity may be of benefit in reducing the burden of vulvodynia when added to strategies to increase healthcare provider knowledge and improve access to effective treatments.

CONCLUSION

While healthcare provider knowledge and attitudes are often at the forefront of barriers to diagnosis, our study suggests that to minimize patient distress and expedite diagnosis, resources must also be directed to promoting comprehensive sexual health education. Webber V, Miller ME, Gustafson DL, et al. Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives. Sex Med 2020;8:757-766.

Women's appraisal of the management of vulvodynia by their general practitioner: a qualitative study

BACKGROUND

Provoked Vulvodynia (PVD) is the most common cause of vulvar pain. General practitioners (GPs) are insufficiently familiar with it, causing a delay in many women receiving correct diagnosis and treatment. Besides patients factors, this delay can partly be explained by the reluctance of GPs to explore the sexual context of PVD and by their negative emotional reactions such as helplessness and frustration when consulted by patients with medically unexplained symptoms like PVD.

OBJECTIVE

To gain insight into how women with PVD perceive and evaluate condition management by their GP, in order to support GPs in the consultation of women with PVD.

METHODS

We performed face-to-face in-depth interviews with women diagnosed with PVD. The interviews were recorded, transcribed verbatim and thematically analysed. The Consolidated Criteria for reporting Qualitative Research (COREQ-criteria) were applied.

RESULTS

Analysis of the interviews generated four interrelated themes: Doctor-patient relationship, Lack of knowledge, Referral process and Addressing sexual issues. Empathy of the GP, involvement in decision-making and referral were important factors in the appreciation of the consultation for women with PVD who were referred to a specialist. Because women were reluctant to start a discussion about sexuality, they expected a proactive attitude from their GP. The communication with and the competence of the GP ultimately proved more important in the contact than the gender of the GP.

CONCLUSION

Women with PVD prefer a patient-centred approach and want GPs to acknowledge their autonomy and to address sexuality proactively.

Women's Experiences of Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward Diagnosis

Vulvodynia is the experience of idiopathic pain characterized by burning, soreness, or throbbing in the external female genitalia or vulva and is estimated to be experienced by 4-16% of the female population, yet only half of women seek help regarding their symptoms. Of the women who do seek help, only around 2% obtain a diagnosis. Therefore, the aim of the current study was to explore the experiences of women with vulvodynia on their journey toward diagnosis, by using semi-structured interviews and an interpretative phenomenological analysis (IPA) methodology. Eight women were interviewed, and their experiences were analyzed and interpreted into three master themes, each with constituent sub-themes: (1) The Journey Is a Battle, (2) "What Is Vulvodynia?": Ambivalence Toward Diagnosis, and (3) Patriarchy, Women, and Sex. Overall, women perceived a healthcare system which was dismissive and shaming, with an inadequate knowledge of vulvodynia. This in turn impacted on women's psychological well-being. Psychological understanding, one-to-one therapy, and consultation and training for healthcare professionals may help to improve the psychological well-being of women with vulvodynia.

Facilitators and barriers in the diagnostic process of vulvovaginal complaints (vulvodynia) in general practice: a qualitative study

BACKGROUND

The gap between the relatively high prevalence of provoked vulvodynia (PVD) in the general population and the low incidence in primary care can partly be explained by physicians' lack of knowledge about the assessment and management of PVD.

OBJECTIVES

To recognize barriers and facilitators of GPs in the diagnostic process of women presenting with recurrent vulvovaginal complaints.

METHODS

A qualitative focus group study in 17 Dutch GPs, five men and 12 women. An interview guide, based on the scientific literature and the expertise of the researchers, including a vignette of a patient, was used to direct the discussion between the GPs. The interviews were audiotaped and transcribed verbatim. A systematic text analysis of the transcripts was performed after data saturation was reached.

RESULTS

Analysis of the interviews generated three major themes: Identifying and discussing sexual complaints, importance of gender in professional experience, and coping with professional uncertainty. Within these themes, the reluctance regarding sexual complaints, male gender, negative emotional responses when faced with professional uncertainty, as well as lack of education were barriers to the diagnostic process and management of PVD. Female gender and understanding that patients can profit from enquiring about sexual health issues were found to be facilitating factors.

CONCLUSIONS

To improve the care for women with PVD, attitude and skills of GPs regarding taking a sexual history and performing a vulvovaginal examination should be addressed, as well as GPs' coping strategies regarding their professional uncertainty.

Web-based education about vulvodynia and its care among student healthcare staff: A quasi-experimental study

Student healthcare providers are the type of primary healthcare professionals who usually have first contact with young women who have problems with intimacy, such as vulvar pain - known as vulvodynia. However, a need to increase healthcare professionals' level of knowledge of vulvodynia and its care has been identified. This study aimed to assess the awareness and knowledge of vulvodynia and its care among student healthcare providers, before and after Web-based education. The study design was national, descriptive and quasi-experimental, and was conducted across Finland. A total of 79 participants completed baseline measurements, 58 completed web-based education and 30 took part in a follow-up survey. A survey instrument called 'Awareness and knowledge of vulvodynia and its care' was developed for this study, and the data were collected using a web-based questionnaire. Descriptive statistical methods were used to evaluate the participants' awareness and knowledge of vulvodynia and its care before and after web-based education. The primary results indicated that the participants' awareness and knowledge of vulvodynia and its care was statistically significantly improved following web-based education.

Women's Subjective Experiences of Living with Vulvodynia: A Systematic Review and Meta-Ethnography

Vulvodynia, the experience of an idiopathic pain in the form of burning, soreness, or throbbing in the vulval area, affects around 4-16% of the population. The current review used systematic search strategies and meta-ethnography as a means of identifying, analyzing, and synthesizing the existing literature pertaining to women's subjective experiences of living with vulvodynia. Four key concepts were identified: (1) Social Constructions: Sex, Women, and Femininity: Women experienced negative consequences of social narratives around womanhood, sexuality, and femininity, including the prioritization of penetrative sex, the belief that it is the role of women to provide sex for men, and media portrayals of sex as easy and natural. (2) Seeking Help: Women experienced the healthcare system as dismissive, sometimes being prescribed treatments that exacerbated the experience of pain. (3) Psychological and Relational Impact of Vulvodynia: Women experienced feeling shame and guilt, which in turn led to the experience of psychological distress, low mood, anxiety, and low self-esteem. Moreover, women reported feeling silenced which in turn affected their heterosexual relationships and their peer relationships by feeling social isolated. (4) A Way Forward: Women found changing narratives, as well as group and individual multidisciplinary approaches, helpful in managing vulvodynia. The findings of the review conclude that interventions at the individual level, as well as interventions aimed at equipping women to challenge social narratives, may be helpful for the psychological well-being of women with vulvodynia.

Vulvodynia attitudes in a sample of Canadian post-graduate medical trainees

Physicians play a critical role in addressing sexual health in medical practice, including pain during intercourse. Vulvodynia is a prevalent cause of pain, however, related training is limited and variable. In addition, physician attitudes toward pain and sexuality may affect behaviour and therefore patient outcomes. This study's objectives were to: 1) determine whether post-graduate trainees hold more positive attitudes toward women presenting with vulvovaginal pain with (versus without) an identifiable cause; and 2) examine attitudinal predictors of comfort treating vulvodynia and attitudes toward patients with this presentation. Residents in Canadian Obstetrics and Gynecology (OBGYN) and Family Medicine (FM) programs participated in an online survey (N=99). Respondents completed questionnaires related to demographics, sexuality-related training, sexual attitudes, and comfort treating and attitudes toward vulvovaginal pain and its symptoms. Residents reported significantly more positive attitudes toward patients with visible pathology versus no identifiable cause for vulvovaginal pain, regardless of medical specialty, p<.001. In OBGYN residents, general comfort discussing sexuality in medical practice significantly predicted comfort treating vulvodynia and its symptoms (p<.001), and attitudes toward women with vulvodynia (p<.05). Demographic, training, and attitudinal variables did not significantly predict vulvodynia outcome measures in FM residents. This study of medical residents identified different attitudes based on vulvovaginal pain presentation, and identified predictors of attitudes and comfort treating vulvodynia in OBGYN residents. Findings suggest pathways by which health care experiences may influence outcomes in this population, and have important implications for resident training.

Is uncertain vulvovaginal candidiasis a marker of vulvodynia? A study in a Dutch general practice research database

Background

A recent Dutch study in general practice showed a clear relationship between the diagnosis of vulvovaginal candidiasis (VVC) and symptoms suggestive of provoked vulvodynia (PVD). PVD accounts for the largest group of vulvar pains, but is often not recognised by GPs.

Aim

To investigate whether diagnostic uncertainty about VVC in general practice could also point to the diagnosis of PVD, and whether and how this diagnostic uncertainty affects management.

Design & setting

An observational study in 2014 in Dutch general practices of the NIVEL Primary Care Database.

Method

Women with an uncertain diagnosis of VVC were distinguished from those with certain VVC based on the occurrence of recurrent episodes and persisting complaints, despite treatment. Factors known to be associated with PVD were hypothesised to be more prevalent in women with uncertain VVC. Data on symptom management by GPs were collected.

Results

In total 7066 women with VVC or uncertain VVC were included. Uncertain VVC was found to account for 28% of these patients. Compared to VVC, the group uncertain VVC included significantly more women with female genital symptoms, tiredness, irritable bowel syndrome (all P<0.001), feeling anxious, reduced sexual desire, depressive disorder, relationship problems, and micturition symptoms (all P<0.05). Compared to VVC, the group uncertain VVC included significantly higher mean numbers of telephone consultations (P<0.001), more referrals to gynaecology (P = 0.009), and higher mean numbers of prescriptions per patient (P<0.001).

Conclusion

This study's findings indicate that uncertain VVC could be a marker of PVD. GPs might reconsider their diagnostics and management when women present recurrent and persistent vulvovaginal complaints, especially if accompanied by dyspareunia, functional syndromes, micturition symptoms, and psychological conditions.

Long-term assessment of effectiveness and quality of life of OnabotulinumtoxinA injections in provoked vestibulodynia

BACKGROUND

Provoked vestibulodynia is a relatively common condition that affects sexual activity. Multidisciplinary care is indicated and OnabotulinumtoxinA injections are safe and effective treatment in this indication.

AIMS

To assess the long-term efficacy of OnabotulinumtoxinA in provoked vestibulodynia.

MATERIALS AND METHODS

Twenty-one patients treated with OnabotulinumtoxinA injections (50U in each bulbospongiosus muscle) 24 months prior to the study were included. Data on pain [assessed using a visual analogue scale (VAS)], quality of life [measured by the Dermatology Life Quality Index (DLQI)] and quality of sex life [assessed using the Female Sexual Function Index (FSFI)] were collected before treatment, and 3 and 24 months after injection.

RESULTS

Nineteen patients participated in the study and 37% had no pain after 24 months. Significant improvements were noted in the VAS, DLQI and FSFI scores between baseline and 24 months post treatment (P < 0.0001). After 24 months, 18 patients (95%) were able to have sexual intercourse. This study was open and non-controlled.

DISCUSSION AND CONCLUSION

100U OnabotulinumtoxinA injections constitute an effective treatment in provoked vestibulodynia with results maintained after 2 years. They significantly improve pain, and have a positive impact on patient quality of life and sex life. Beneficial effects continue in the long-term, allowing patients to resume sexual activity.

Pelvic examination experiences in women with and without chronic pain during intercourse

INTRODUCTION

Although pelvic examinations (PEs) are an important component of women's health, some women experience difficulty during PEs due to anxiety and pain. These difficulties may be heightened in women with chronic pain during sexual intercourse. Some evidence suggests that this population experiences pain and distress during PEs, but their experiences in this context have not been empirically investigated from a multidimensional perspective.

AIMS

The aims of this study were to compare the PE experiences of women with and without pain during intercourse and to examine predictors of negative experiences in each group.

METHOD

Women with vulvovaginal pain (n = 90), pelvic pain (n = 89), and women without current intercourse pain (n = 207) completed an online survey including sections assessing demographics, gynecological and medical history, and PE experiences. Respondents completed questionnaires assessing vaginal penetration cognitions and body image.

MAIN OUTCOME MEASURES

Participants rated their most recent PE on numerical scales for pain, embarrassment, anxiety, and the overall quality of the experience.

RESULTS

Women with pelvic and vulvovaginal pain during intercourse reported significantly more pain and anxiety during their most recent PE compared with the no pain group, and women with a higher number of lifetime gynecological diagnoses reported significantly more pain. Multiple regression analyses indicated that various predisposing, examination-related, and psychological factors predicted specific PE ratings in each group.

CONCLUSIONS

The results provide empirical support that PEs are more physically and emotionally difficult for women who experience chronic pain during intercourse. These findings have important clinical implications, as PEs are a critical part of complete reproductive care and play an essential role in the assessment/management of sexual pain, including Genito-Pelvic Pain/Penetration Disorder.

[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.