Topical Nifedipine for the Treatment of Localized Provoked Vulvodynia: A Placebo-Controlled Study

Pharmacological Treatments for Localized Provoked Vulvodynia: A Scoping Review

Introduction

Localized provoked vulvodynia (LPV) is a chronic pain condition without an identifiable cause that is localized to a portion of the vulva and provoked by pressure or touch. LPV is a commonly occurring but poorly understood condition lacking consensus on management.

Method

This scoping review used Arksey and O'Malley's approach to identify and evaluate literature published between 2010 and 2023 that addressed the question: What is the current evidence on the efficacy or effectiveness of pharmacological treatments in the management of LPV?

Results

This review evaluated 18 papers reporting on the efficacy or effectiveness of oral, topical, and injectable medications. Seven of the studies were randomized controlled trials. Oral gabapentin and oral desipramine showed some improvement in sexual function compared to placebo. Small sample sizes and methodological issues limited confidence in interpreting findings. Pain was reduced in descriptive studies of tricyclic antidepressants, milnacipran, injectable anesthetics, and botulinum toxin. Where pain did not improve with treatment, some oral medications improved participants' mood and sexual function. Some topical agents may be effective in reducing peripherally mediated neuropathic pain. Botulinum toxin was the most well-studied injectable but yielded mixed outcomes related to pain, quality of life, and sexual function.

Conclusion

There is a lack of convincing evidence to draw conclusions about the efficacy or effectiveness of pharmacological therapies for LPV. The breadth of therapies for treating LPV warrants the development of evidence-based, consensus guidelines for measuring treatment outcomes and improving comparisons across studies. Recommendations for research include addressing methodological shortcomings and diversifying the participant pool to increase the generalizability of findings.

Evaluation and Treatment of Vulvodynia: State of the Science

Vulvodynia affects 7% of American women, yet clinicians often lack awareness of its presentation. It is underdiagnosed and often misdiagnosed as vaginitis. The etiology of vulvodynia remains unknown, making it difficult to identify or develop effective treatment methods. The purpose of this article is to (1) review the presentation and evaluation of vulvodynia, (2) review the research on vulvodynia treatments, and (3) aid the clinician in the selection of vulvodynia treatment methods. The level of evidence to support vulvodynia treatment varies from case series to randomized controlled trials (RCTs). Oral desipramine with 5% lidocaine cream, intravaginal diazepam tablets with intravaginal transcutaneous electric nerve stimulation (TENS), botulinum toxin type A 50 units, enoxaparin sodium subcutaneous injections, intravaginal TENS (as a single therapy), multimodal physical therapy, overnight 5% lidocaine ointment, and acupuncture had the highest level of evidence with at least one RCT or comparative effectiveness trial. Pre to posttest reduction in vulvar pain and/or dyspareunia in non-RCT studies included studies of gabapentin cream, amitriptyline cream, amitriptyline with baclofen cream, up to 6 weeks' oral itraconazole therapy, multimodal physical therapy, vaginal dilators, electromyography biofeedback, hypnotherapy, cognitive behavioral therapy, cold knife vestibulectomy, and laser therapy. There is a lack of rigorous RCTs with large sample sizes for the treatment of vulvodynia, rendering it difficult to determine efficacy of most treatment methods. Clinicians will be guided in the selection of best treatments for vulvodynia that have the highest level of evidence and are least invasive.

Treatment of Provoked Vulvodynia: A Systematic Review

BACKGROUND

Treatment recommendations for provoked vulvodynia (PVD) are based on clinical experiences and there is a need for systematically summarizing the controlled trials in this field.

AIM

To provide an overview of randomized controlled trials and non-randomized studies of intervention for PVD, and to assess the certainty of the scientific evidence, in order to advance treatment guidelines.

DATA SOURCES

The search was conducted in CINAHL (EBSCO), Cochrane Library, Embase (Embase.com), Ovid MEDLINE, PsycINFO (EBSCO) and Scopus. Databases were searched from January 1, 1990 to January 29, 2021.

STUDY ELIGIBILITY CRITERIA

Population: Premenopausal women with PVD.

INTERVENTIONS

Pharmacological, surgical, psychosocial and physiotherapy, either alone or as combined/team-based interventions.

CONTROL

No treatment, waiting-list, placebo or other defined treatment.

OUTCOMES

Pain during intercourse, pain upon pressure or touch of the vaginal opening, sexual function/satisfaction, quality of life, psychological distress, adverse events and complications.

STUDY DESIGN

Randomized controlled trials and non-randomized studies of interventions with a control group.

STUDY APPRAISAL AND SYNTHESIS METHODS

2 reviewers independently screened citations for eligibility and assessed relevant studies for risk of bias using established tools. The results from each intervention were summarized. Studies were synthesized using a narrative approach, as meta-analyses were not considered appropriate. For each outcome, we assessed the certainty of evidence using grading of recommendations assessment, development, and evaluation (GRADE).

RESULTS

Most results of the evaluated studies in this systematic review were found to have very low certainty of evidence, which means that we are unable to draw any conclusions about effects of the interventions. Multimodal physiotherapy compared with lidocaine treatment was the only intervention with some evidential support (low certainty of evidence for significant treatment effects favoring physiotherapy). It was not possible to perform meta-analyses due to a heterogeneity in interventions and comparisons. In addition, there was a heterogeneity in outcome measures, which underlines the need to establish joint core outcome sets.

CLINICAL IMPLICATIONS

Our result underscores the need of stringent trials and defined core outcome sets for PVD.

STRENGTH AND LIMITATIONS

Standard procedures for systematic reviews and the Population Intervention Comparison Outcome model for clinical questions were used. The strict eligibility criteria resulted in limited number of studies which might have resulted in a loss of important information.

CONCLUSION

This systematic review underlines the need for more methodologically stringent trials on interventions for PVD, particularly for multimodal treatments approaches. For future research, there is a demand for joint core outcome sets. Bohm-Starke N, Ramsay KW, Lytsy P, et al. Treatment of Provoked Vulvodynia: A Systematic Review. J Sex Med 2022;19:789-808.

Use of calcium channel blockers in dermatology: a narrative review

Introduction: Calcium channel blockers (CCB) are commonly used for cardiovascular diseases. The evidence supporting the use of CCB in dermatology is mostly anecdotal and limited to case reports or small case series.Areas covered: This review article is divided into two parts. The first part discusses the therapeutic use of CCB in dermatology. The second part focuses on mucocutaneous adverse reactions due to the administration of CCB.Expert opinion: The use of CCB in dermatology is mainly based on its properties as a vasodilator and the inhibition of muscle contractions, such as pernio, anal fissures, facial wrinkles, and painful leiomyoma. However, there remain other modes of action to explain its clinical use in calcinosis, keloid, pressure ulcer, and fibromatosis. Compared to oral CCB, the lack of systemic side effects would make topical use of CCB an attractive alternative in the treatment of skin diseases, but the evidence for topical CCB is still limited, and there is a lack of standardized topical formulation. The main mucocutaneous adverse effects of CCB include gingival hyperplasia, phototoxicity, eczema, psoriasis and risk of skin cancers. Plausible factors for these adverse events include CCB's photoinstability, aldosterone synthesis inhibition, disturbed calcium homeostasis and immunosuppressive properties.

Outcome Measurement Instruments for Provoked Vulvodynia: A Systematic Review

OBJECTIVE

The objective of this study was to detail the outcome measurement instruments used in randomized control trials and observational studies investigating therapeutic interventions for provoked vulvodynia.

MATERIALS AND METHODS

We searched Ovid Medline, Embase, Emcare, and PyschINFO libraries from database inception through April 2017. We included randomized control trials and observational studies of provoked vulvodynia that used instruments to measure the outcome of therapeutic interventions.

RESULTS

A total of 2299 articles were retrieved and 25 were eligible for inclusion in accordance with the selection criteria. The included studies measured 26 different outcomes, using 110 outcome measurement instruments. Patient-reported outcomes were most commonly measured (144/166, 86%), followed by physician-reported outcomes (20/166, 12%). The most commonly measured outcomes were patient-reported psychological impact of disease (27/166, 16%), patient-reported improvement in dyspareunia (25/166, 15%), and patient-reported reduction in pain (24/166, 14%). The Pain Catastrophizing Scale, the Beck Depression Inventory, and the State Trait Anxiety Questionnaire were the most commonly used instruments to measure psychological impact.The most commonly measured clinician-rated outcome was an improvement in pain (17/166, 10%), which was most frequently assessed by the cotton swab test. Only 34 (31%) outcome measurement instruments were specific to vulvodynia (26/110, 23%) or sexual functioning (8/110, 7%).

CONCLUSIONS

There is a wide range of outcome measurement instruments used in provoked vulvodynia studies, resulting in inconsistency of reporting and difficulty in comparing and combining findings for systemic review. There is a pressing need for the development of validated, reliable instruments and consensus on a core outcome set for further research purposes.

A systematic review of drug treatment of vulvodynia: evidence of a strong placebo effect

BACKGROUND

Vulvodynia is the most common type of chronic pelvic pain and dyspareunia in premenopausal women. The effect of drugs for the treatment of vulvodynia remains poorly discussed.

OBJECTIVES

To conduct a systematic review of randomised controlled studies which assess medications used to treat vulvar pain in vulvodynia.

SEARCH STRATEGY

Web of Science, Cochrane Library, EBSCO Academic, LILACS and MEDLINE were searched from 1985 to September 2016.

SELECTION CRITERIA

Randomised controlled trials comparing any kind of medication for vulvodynia treatment with placebo or with another medication in adult patients were included.

DATA COLLECTION AND ANALYSIS

The two investigators independently conducted data extraction. The synthesis was provided by the pain reduction index. Study quality assessment was performed using the Cochrane Handbook for Systematic Reviews of Intervention and analysis of publication bias was conducted.

MAIN RESULTS

Five studies were included in qualitative synthesis. Number of participants varied from 30 to 133 participants among the eligible studies, resulting in a total of 297 patients. The pain reduction rates of patients with vulvodynia assessed by Q-tipped cotton test and visual analogue scale varied between studies. Placebo was shown to be as effective as any medication.

CONCLUSIONS

There is a need for further studies evaluating topical monotherapy for the treatment of vulvodynia, as they are the main drugs used in clinical practice.

TWEETABLE ABSTRACT

No medication has shown impact on vulvar pain in vulvodynia. There is evidence of a placebo effect.

Recruitment methods in a clinical trial of provoked vulvodynia: Predictors of enrollment

BACKGROUND

Successful recruitment in clinical trials for chronic pain conditions is challenging, especially in women with provoked vulvodynia due to reluctance in discussing pain associated with sexual intercourse. The most successful recruitment methods and the characteristics of women reached with these methods are unknown.

OBJECTIVE

To compare the effectiveness and efficiency of four recruitment methods and to determine socioeconomic predictors for successful enrollment in a National Institutes of Health-sponsored multicenter clinical trial evaluating a gabapentin intervention in women with provoked vulvodynia.

METHODS

Recruitment methods utilized mass mailing, media, clinician referrals and community outreach. Effectiveness (number of participants enrolled) and efficiency (proportion screened who enrolled) were determined. Socioeconomic variables including race, educational level, annual household income, relationship status, age, menopausal status and employment status were also evaluated regarding which recruitment strategies were best at targeting specific cohorts.

RESULTS

Of 868 potential study participants, 219 were enrolled. The most effective recruitment method in enrolling participants was mass mailing ( p < 0.001). There were no statistically significant differences in efficiency between recruitment methods ( p = 0.11). Relative to clinician referral, black women were 13 times as likely to be enrolled through mass mailing (adjusted odds ratio 12.5, 95% confidence interval, 3.6-43.1) as white women. There were no differences in enrollment according to educational level, annual income, relationship status, age, menopausal status, or employment status and recruitment method.

CONCLUSION

In this clinical trial, mass mailing was the most effective recruitment method. Race of participants enrolled in a provoked vulvodynia trial was related to the recruitment method.

Treatment of Female Sexual Pain Disorders: A Systematic Review

Sexual pain disorders affect women's sexual and reproductive health and are poorly understood. Although many treatments have been evaluated, there is no one "gold standard" treatment. The aim of this systematic review was to investigate what treatments for female sexual pain have been evaluated in clinical studies and their effectiveness. The search strategy resulted in 65 papers included in this review. The articles were divided into the following categories: medical treatments; surgical treatments; physical therapies; psychological therapies; comparative treatment studies; and miscellaneous and combined treatments. Topical and systemic medical treatments have generally been found to lead to improvements in, but not complete relief of, pain, and side effects are quite common. Surgical procedures have demonstrated very high success rates, although there has been variability in complete relief of pain after surgery, which suggests less invasive treatments should be considered first. Physical therapies and psychological therapies have been shown to be promising treatments, supporting a biopsychosocial approach to sexual pain disorders. Although most of the interventions described have been reported as effective, many women still experience pain. A multidisciplinary team with active patient involvement may be needed to optimize treatment outcome.

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.

Vulvodynia and proctodynia treated with topical baclofen 5 % and palmitoylethanolamide

BACKGROUND

The prevalence of idiopathic vulvodynia and proctodynia is high. Pain management with anti-depressants and anti-epileptics may induce undesirable side effects. Therefore, topical baclofen cream and palmitoylethanolamide might be new therapeutic options.

CASE

A 33-year-old woman with intractable chronic vulvar and anal pain had to abstain from sexual intercourse and could neither cycle nor sit for more than 5 min. The patient did not respond to standard treatments. We prescribed a combination of topical baclofen 5 % and palmitoylethanolamide 400 mg, three times daily. After 3 months her symptoms decreased more than 50 % and sexual intercourse was possible again without pain.

CONCLUSION

Topical baclofen and palmitoylethanolamide can be a viable treatment option in chronic vulvodynia and proctodynia.

[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.

[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.