Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges

Image-based documentation of vulvodynia pain location

Aims: Better documentation of vulvar pain is needed. We examined pain locations marked on general body and genital specific outlines among women with vulvodynia. Methods: 62 women (mean age 32.1 ± 9.5 years) with vulvodynia marked their pain on a digital genital specific outline (22 segments) and 59 of those women also marked their pain on a digital general body outline (48 segments). We used ImageJ software to determine body surface area (BSA) for each outline. Results: On the general body outline, 24/48 segments were marked; 22/22 segments were marked on the genital specific outline. There was a moderate correlation (r = 0.43; p = 0.001) between the BSA marked on the general body outline and the BSA marked on the genital area outline. Conclusions: Findings support concurrent validity of the BSA as a measure of pain location using either outline.

Internet-based Treatment for Vulvodynia (EMBLA) - A Randomized Controlled Study

BACKGROUND

Internet-based ACT (Acceptance and commitment therapy) treatment may improve accessibility and reduce stigma related to seeking health care, but there are a lack of studies investigating internet-based treatment using ACT principles for women with vulvodynia.

AIM

The aim of this study was to investigate the effects of an internet-based treatment of pain during intercourse for women with provoked vulvodynia compared with no intervention during the waiting period before clinical treatment.

METHODS

A multicenter randomized controlled trial was conducted during 2016 to 2020, in which 99 participants were included. Participants were randomized to either a 6 week guided internet-based treatment using ACT principles or usual care. Data were collected at baseline, 6 weeks after baseline, and approximately 10 months after baseline.

OUTCOMES

Pain-related (pain during intercourse, tampon test, impact of pain on sexual function) and pain behavior-related outcomes (attempts at intercourse, sexual activities besides intercourse, willingness to perform the tampon test, chronic pain acceptance questionnaire) were used as outcomes.

RESULTS

Treatment was efficacious in what concerns pain during intercourse and pain acceptance. Less pain during intercourse among women in the intervention group was observed at both post-treatment (primary endpoint, P = .01, Cohen's d = 1.4, 95% CI = 0.33, 2.4), and follow-up (P = .04). Absolut mean difference between groups for pain during intercourse at post-treatment was -2.84, (95 % CI = -4.91, -0.78), and -1.58 at follow-up, (95 % CI = -3.17, 0.02), where the intervention group rated less pain than controls. No differences between groups over time were found for tampon test measures or impact of pain on sexual function. There was a significant difference between groups at all timepoints indicating fewer attempts at intercourse among participants in the intervention group. At post-treatment, women who underwent internet-based treatment reported higher pain acceptance and a rise in activity engagement compared with the control group.

CLINICAL IMPLICATIONS

There is an indication that internet-based treatment could be incorporated into clinical practice as a complement to clinical treatment.

STRENGTHS & LIMITATIONS

Study strengths included using several forms of recruitment and an intervention built by different professions with long experience of treating patients with vulvodynia. High dropout rate was a limitation of this study.

CONCLUSION

Internet-based treatment may have an impact on pain during intercourse and positive effects on pain acceptance. However, conclusions must be drawn with caution due to the small sample size. Engström AH, Bohm-Starke N, Kullinger M, et al. Internet-based Treatment for Vulvodynia (EMBLA) - A Randomized Controlled Study. J Sex Med 2022;19:319-330.

Comparing Vestibule Examination Techniques: Light Touch, Serial Forces, and the Lidocaine Test

OBJECTIVE

The purpose of this study was to compare techniques and pain scales that assess tenderness in the vulvar vestibule in provoked vestibulodynia, using the cotton swab test and a vulvalgesiometer, and assess topical lidocaine solution with each.

MATERIALS AND METHODS

This randomized study at a specialty vulvar clinic evaluated tender vestibules of reproductive-aged women with vestibulodynia using light rolling cotton swab touch at 6 sites and evaluated the vulvalgesiometer at 2 sites, randomizing the order of the initial tool. Participants reported pain using the Numerical Rating Scale 0-10 and the Verbal Pain Scale 0-3. With the vulvalgesiometer, the pain tolerance threshold was measured using forces of 10, 25, 50, 100, 200, and 300 g. After both initial tests, lidocaine 4% topical solution was applied for 3 minutes, and the swab test and vulvalgesiometer were repeated in the order initially performed, constituting the lidocaine test. Data analysis used t tests, Fisher exact tests, Wilcoxon signed rank tests, and Spearman rank correlation.

RESULTS

Sixteen patients completed the study, 8 starting with each instrument. Light swab touch evoked significant pain, and lidocaine reduced pain to zero or mild levels. The pain threshold was 25 g, and only 38% could tolerate testing past 100 g without lidocaine. The Verbal Pain Scale correlated well with the Numerical Rating Scale.

CONCLUSIONS

Light rolling cotton swab touch using the 4-item verbal scale can map vestibulodynia tenderness that can be extinguished by lidocaine, consistent with distinguishing a mucosal condition. Forces by vulvalgesiometer of greater than 100-200 g may evoke pain other than mucosal allodynia.

Exploring Relationships Between Genito-Pelvic Pain/Penetration Disorder, Sex Guilt, and Religiosity Among College Women in the U.S

INTRODUCTION

Despite a growing body of research on psychosocial factors in Genito-Pelvic Pain/Penetration Disorder (GPPPD) during sexual intercourse, there are few studies examining adolescent and young adult women's experiences with painful sex and the effects of religiosity, sexual education, and sex guilt.

AIM

The purpose of the study was to examine the occurrence of GPPPD among sexually active female college students, including psychosocial factors of religiosity and religious practice, sexual education, sex guilt, and sexual distress.

METHODS

Data were collected from 974 college women from a university in the Northeastern U.S. We limited our sample to sexually active women (n = 593, 60.9%; mean age: 18.96) who responded to the questionnaire item, "In general, do you feel pain with sexual intercourse?" Participants completed the Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS), Revised Mosher Sex Guilt Scale, Abbreviated Santa Clara Strength of Religious Faith Questionnaire, 10-item Gender Role Beliefs Scale, and measures on sexual wellness and practice and sexual education experiences. Data were analyzed using standard bivariate and regression analyses as well as path analysis.

MAIN OUTCOME MEASURES

Women were asked, "In general, do you feel pain with sexual intercourse?" and categorized into one of three pain groups: occasional (10%-25% of the time), frequent (50% or more), and no pain (less than 10%).

RESULTS

GPPPD with sex was prevalent among young college women, with 113 (19.1%) reporting frequent pain and 143 (24.1%) occasional pain (control n = 337, 56.8%). Numerous statistically significant factors were identified, including frequency of sex, ability to orgasm, sensations during intercourse, presence of a steady sexual partner, expectations of painful sex, sex guilt, and sexual distress. Sex guilt acted as full mediator between religiosity and painful sex.

IMPLICATIONS

Healthcare providers should proactively initiate conversations with young female patients about painful intercourse to identify issues and normalize language on pain with sex. Educators are urged to teach evidence-based information on pain-free and guilt-free sexual experiences inside and outside religious contexts.

CONCLUSION

Painful sex affects adolescent and young adult women at a similar rate as non-college adult women and while religiosity does not directly impact young women's GPPPD, religiosity does lead to painful sex if it causes sex guilt. Further research is needed into the mechanisms of religion-based sexual shaming and among religiously conservative women who practice abstinence until marriage. Azim KA, Happel-Parkins A, Moses A, et al. Exploring Relationships Between Genito-Pelvic Pain/Penetration Disorder, Sex Guilt, and Religiosity Among College Women in the U.S. J Sex Med 2021;18:770-782.