Treatment of Provoked Vulvodynia: A Systematic Review

Internet-based treatment for provoked vulvodynia: factors associated with treatment outcomes

INTRODUCTION

Previous research has indicated that internet-based Acceptance and Commitment Therapy (ACT) can reduce pain during intercourse and increase pain acceptance in individuals with provoked vulvodynia, but the factors associated with treatment outcomes remain unknown.

AIM

This study aimed to investigate factors associated with changes in pain acceptance following an internet treatment based on ACT.

METHODS

This exploratory study used data from the EMBLA study, a multicenter randomized controlled trial that investigated the effects of internet-based ACT for provoked vulvodynia. The examined factors included sociodemographics, medical history, pain and sexual behavior, and psychosocial characteristics. Linear regression analysis was employed to assess the association of these factors with pain acceptance, including interaction effects. Results were adjusted for multiple testing using Bonferroni correction.

OUTCOMES

The outcome measure was pain acceptance assessed on the scale Chronic Pain Questionnaire-Revised, which comprises two sub-scales: activity engagement and pain willingness.

RESULTS

Before adjustment, greater improvement in overall pain acceptance and the subscale activity engagement was seen participants in the intervention group who had a history of physical violence or sexual assault. Increased time spent on the treatment platform per week was also associated with greater improvement in pain acceptance. Participants who reported gastrointestinal problems before the internet-based treatment showed better treatment outcomes in activity engagement. Previous contact with a psychologist or counselor was associated with less improvement in activity engagement. The intervention was less effective on the subscale pain willingness with increased age and for those reporting urinary problems. No associations remained statistically significant after adjustment for multiple testing.

CLINICAL IMPLICATIONS

Previous exposure to violence and sexual assault, concomitant gastrointestinal or urinary problems, and adherence to treatment should be further investigated in larger studies on factors associated with treatment outcomes after internet treatment based on ACT, especially regarding pain.

STRENGTHS AND LIMITATIONS

This was a novel and exploratory study and provides information for researchers in future investigations of how individual characteristics may influence treatment outcomes. A range of variables were explored in the models, underscoring the importance of future studies to strengthen the findings. One limitation concerns the sample size, which was fairly small considering the nature of the study.

CONCLUSION

After correcting for multiple testing, no factors were found to be statistically associated with changes in pain acceptance after the treatment.

Treatment Strategies for Painful Pelvic Floor Conditions: A Focus on the Potential Benefits of Cannabidiol

Painful conditions of the pelvic floor include a set of disorders of the pelvic region, discreetly prevalent in the female population, in which pain emerges as the predominant symptom. Such disorders have a significant impact on quality of life as they impair couple relationships and promote states of anxiety and irascibility in affected individuals. Although numerous treatment approaches have been proposed for the management of such disorders, there is a need to identify strategies to promote muscle relaxation, counter pelvic pain, and reduce inflammation. The endocannabinoid system (ECS) represents a complex system spread throughout the body and is involved in the regulation of numerous physiological processes representing a potential therapeutic target for mood and anxiety disorders as well as pain management. Cannabidiol (CBD), acting on the ECS, can promote relief from hyperalgesia and allodynia typical of disorders affecting the pelvic floor and promote muscle relaxation by restoring balance to this delicate anatomical region. However, its use is currently limited due to a lack of evidence supporting its efficacy and harmlessness, and the mechanism of action on the ECS remains partially unexplored to this day. This comprehensive review of the literature examines the impact of pain disorders affecting the pelvic floor and major treatment approaches and brings together the main evidence supporting CBD in the management of such disorders.

Localized provoked vulvodynia as an immune-mediated inflammatory disease: rationale for a new line of research

Localized provoked vulvodynia (LPV), also called vulvar vestibulitis or provoked vestibulodynia, is a major cause of dyspareunia that severely impacts sexual health. At the tissue level, lymphocytic inflammation and hyperinnervation are characteristic pathological features, explaining the main symptoms and signs. A recent experimental animal study suggests that the histopathological findings of LPV may be due to mucosal CD4 Th17 immune responses to microbial antigens. We hypothesize that LPV is an immune-mediated inflammatory disease and challenge the concept of LPV as a chronic pain syndrome of unknown cause. Since most treatment modalities currently used in LPV are no better than placebo, we therefore warrant future research investigating the possible presence of CD4 Th17 cells and IL17 cytokine in affected tissues together with treatment trials that include inhibitors of the IL17 pathway.

Pelvic floor muscle activation in response to pressure stimuli applied to the vulvar vestibule: an observational study comparing women with and without provoked vestibulodynia

BACKGROUND

The nature of pelvic floor muscle (PFM) involvement in provoked vestibulodynia (PVD) is poorly understood.

AIM

We aimed to determine if PFM electromyographic (EMG) activity in anticipation of or response to pressure applied to the posterior vaginal fourchette differs between those with and without PVD, and if the magnitude of PFM response is associated with pressure pain sensitivity, psychological or psychosexual function.

METHODS

This was an observational case-control study. Forty-two volunteers with PVD and 43 controls with no vulvar pain participated. Five on-line questionnaires were completed, then participants underwent a laboratory-based evaluation of vulvar pain sensitivity. EMG activation of the PFMs, hip adductor, and upper trapezius muscles was measured before, during, and after pressure stimuli (low, moderate) were applied, in random order, to the posterior vaginal fourchette and the posterior thigh (control site).

OUTCOMES

EMG amplitude of the pubovisceralis (PV), bulbocavernosus (BC), and external anal sphincter (EAS) muscles. Secondary outcomes were EMG activation of the hip adductor brevis and upper trapezius muscles, questionnaire scores reflecting psychological/psychosexual outcomes, pressure pain threshold (PPT) at the vulvar vestibule, pain reported on a tampon test, and heart rate/heart rate variability.

RESULTS

Compared to controls, EMG activation of the PV and EAS, but not the BC, was higher in anticipation of the pressure applied to the vaginal fourchette, was higher in all PFMs while the pressure was applied, and remained higher than baseline after the pressure was removed among those with PVD. EMG response amplitudes were modulated by the intensity of the pressure applied, with the largest responses reaching over 40% MVC in the EAS among those with PVD. PFM EMG amplitudes were associated with greater pain sensitivity and lower sexual function, but not with pain catastrophizing, central sensitization, depression, anxiety, or stress.

CLINICAL IMPLICATIONS

While some anticipatory activation was observed, EMG responses were primarily observed during and after the application of the pressure. Among those with PVD, digital assessment of PFM tone might reflect PFM responses to pain at the vulvar vestibule, and interventions to reduce local pain sensitivity may be an important first step to successful improvements in vaginal function.

STRENGTHS AND LIMITATIONS

This study includes a robust analysis of EMG activation. However, the cross-sectional design precludes the determination of causal relationships.

CONCLUSIONS

Those with PVD demonstrate higher PFM responses and a higher prevalence of anticipatory activation in the PV and EAS muscles than controls in response to pressure applied at the vulvar vestibule.

Beyond vulvodynia: from a correct diagnosis to a multidisciplinary care program. A referral center experience

BACKGROUND

Vulvodynia is a chronic pain condition without an identifiable cause. As such, it is a diagnosis of exclusion, and all other causes of vulvar pain should be excluded. Although a standard treatment for vulvodynia has not been established yet, multidisciplinary care programs appear to be effective.

PUROPOSE

The aim of this retrospective monocentric study was to analyze the prevalence of vulvodynia among women referred to our institution for a suspected diagnosis and to evaluate the efficacy of a multidimensional treatment plan. The primary outcome was the prevalence of vulvodynia following differential diagnosis. Secondary outcomes included: prevalence of the differential diagnoses, symptom resolution rate following treatment, and the relation between persistence of symptoms and (a) patients' age; (b) coexisting chronic overlapping pain conditions (COPCs).

RESULTS

After having ruled out all other causes of vulvar pain, only 40.1% of women were considered as affected by vulvodynia. The most frequent differential diagnoses included lower genital tract infections (25.3%), vulvar lichen sclerosus (17.6%) and vulvovaginal atrophy (8.2%). Following a multidisciplinary care program, resolution of symptoms was observed in 13.6% cases, improvement in 64.3% and persistence in 21.9%. We did not find a statistically significant association between persistence of symptoms and age > 38 years (OR 2.10; p = 0.30). Women with one or more COPCs other than vulvodynia had a 75% increased risk of not obtaining a resolution of symptoms (OR 1.75; p = 0.44).

CONCLUSION

A thorough differential diagnosis and a multidisciplinary care program may represent a first way out of the muddle in the management of these patients.

Efficacy of Rehabilitative Techniques on Pain Relief in Patients With Vulvodynia: A Systematic Review and Meta-Analysis

OBJECTIVE

Vulvodynia is a chronic clinical condition characterized by provoked or non-provoked vulvar pain for at least 3 months of unknown etiology. The onset of vulvodynia involves a complex interplay of peripheral and central pain mechanisms, such as pelvic floor muscle and autonomic dysfunction, and interpersonal factors. A stepwise approach of pelvic floor physical therapy as medical management is suggested. In this scenario, by this meta-analysis of randomized controlled trials, we aimed to evaluate the efficacy of rehabilitation interventions in patients with vulvodynia.

METHODS

On October 13, 2022, PubMed, Scopus, and Web of Science were systematically searched for randomized controlled trials that assessed the efficacy of the rehabilitative approach to pain during intercourse in patients with vulvodynia. The quality assessment was performed with the Cochrane risk-of-bias tool for randomized trials. The trial registration number is CRD42021257449. At the end of the search, 9 studies were included for a total of 332 patients. A pairwise meta-analysis was performed to highlight the efficacy of rehabilitative approaches for reducing pain during intercourse, as measured with a visual analog scale or a numerical rating scale.

RESULTS

Meta-analysis showed that all these rehabilitative approaches had an overall effect size of -1.43 (95% CI = -2.69 to -0.17) in decreasing vulvodynia pain in terms of the visual analog scale. In the subgroup analysis, a significant effect size in acupuncture (effect size = -2.36; 95% CI = -3.83 to -0.89) and extracorporeal shockwave therapy (effect size = -2.94; 95% CI = -4.31 to -1.57; I2 = 58%) was observed. According to the Cochrane risk-of-bias tool, a low risk of bias for outcome selection in 89% of studies.

CONCLUSION

Findings from this meta-analysis suggested that the physical agent modalities and complementary medicine techniques in people with vulvodynia appear to be more effective than placebo, sham, or waiting list. Further evidence on physical agent modalities and complementary therapies are warranted in the future.

IMPACT

This was the first systematic review and meta-analysis of randomized controlled trials to provide evidence on the efficacy of rehabilitation interventions in patients with vulvodynia.

Development of a core outcome set for treatment studies for provoked vestibulodynia

BACKGROUND

There is an inconsistency in treatment outcomes used in clinical trials for provoked vestibulodynia (PVD), which makes it impossible to compare the effects of different interventions.

AIM

In this study, we completed the first step in creating a core outcome set (COS), defining what outcomes should be measured in clinical trials for PVD.

METHODS

Identification of outcomes used in studies was done by extracting data from clinical trials in a recently published systematic review and via review of clinical trials for PVD registered on ClinicalTrials.gov. The COS process consisted of 2 rounds of Delphi surveys and a consensus meeting, during which the final COS was decided through a modified nominal group technique.

OUTCOMES

Consensus on what outcomes to include in a COS for PVD.

RESULTS

Forty scientific articles and 92 study protocols were reviewed for outcomes. Of those, 36 articles and 25 protocols were eligible, resulting in 402 outcomes, which were then categorized into 63 unique outcomes. Participants consisted of patients, relatives/partners of patients, health care professionals, and researchers. Out of 463 who registered for participation, 319 and 213 responded to the first and second surveys, respectively. The consensus meeting consisted of 18 members and resulted in 6 outcomes for the COS to be measured in all treatment trials regardless of intervention: insertional pain (nonsexual), insertional pain (sexual), provoked vulvar pain by pressure/contact, pain-related interference on one's life, pain interference on sexual life, and sexual function.

CLINICAL IMPLICATIONS

Critical outcomes to be measured in clinical trials will allow for accurate comparison of outcomes across treatment interventions and provide solid treatment recommendations.

STRENGTHS AND LIMITATIONS

The major strengths of the study are the adherence to methodological recommendations and the intentional focus on aspects of diversity of participating stakeholders (eg, status such as patients with lived experience and researchers, inclusiveness with respect to sexual identity), the latter of which will allow for broader application and relevance of the COS. Among the limitations of the study are the low rate of participants outside North America and Europe and the lower response rate (about 50%) for the second Delphi survey.

CONCLUSION

In this international project, patients, health care professionals, and researchers have decided what critical outcomes are to be used in future clinical trials for PVD. Before the COS can be fully implemented, there is also a need to decide on how and preferably when the outcomes should be measured.

Chronic pelvic pain; more than just the bladder

PURPOSE OF REVIEW

Chronic pelvic pain is much of a burden to those who suffer from it. Additionally, in many patients medical doctors, such as urologists are unable to identify a cause or clear pathology that can explain the pain. Still numerous patients and doctors keep on searching for a cause, focussing particularly on the pelvic organs. Lots of diagnostics and treatment methods are used but often without success. In recent years, we have gained increased insight into the mechanisms of pain and adapted the terminology accordingly.

RECENT FINDINGS

Two aspects of chronic pelvic pain have gained more attention. First, the myofascial aspects, especially the role of the pelvic floor muscles in maintaining the pain and as a therapeutic option. Second, the role of the brain and the psychological aspects intertwine with the pain and its consequences also open up for alternative management options. In terminology chronic pain is now included in the ICD-11, a historical change. Introducing chronic primary pain (no cause found) helps us to look away from the organ and deal with the patient as a whole human being.

SUMMARY

The findings reported here are helpful for your daily practice. Looking from a broad perspective gives the patient the feeling of being seen and heard. Working together in a multidisciplinary team makes your work easier and gives more satisfaction.

VIDEO ABSTRACT

http://links.lww.com/COU/A44.

Efficacy of Physiotherapy for Treating Vulvodynia: A Systematic Review

OBJECTIVES

We set out to assess the efficacy of physiotherapy for vulvodynia.

MATERIALS AND METHODS

PubMed, Embase, Scopus, Web of Science, SciELO, PEDro, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched in February 2023. Two authors selected and extracted the data independently. The risk of bias was assessed using the Cochrane Risk of Bias tool (Rob 2). Because of the high heterogeneity presented between the studies, it was not possible to carry out qualitative analysis. The results were presented narratively. This systematic review was registered with the PROSPERO database.

RESULTS

A total of 2,274 articles were retrieved. Seven studies met the criteria and were included in a systematic review, which included a total of 477 patients. The interventions included were electromyography biofeedback ( n = 2), transcutaneous electrical nerve stimulation ( n = 1), transcranial direct current stimulation ( n = 1), low-intensity shockwave ( n = 1), physiotherapy treatment ( n = 1), and pelvic floor exercise with behavioral modification ( n = 1). All studies evaluated pain reduction, 5 evaluated sexual function, and 2 evaluated quality of life. All interventions were effective for the main outcomes; only the transcranial direct current stimulation intervention showed no significant difference when compared with the placebo or sham group. Three studies presented a high risk of bias due to the lack of blinding.

CONCLUSIONS

The studied interventions (electromyography biofeedback, transcutaneous electrical nerve stimulation, shockwave, physiotherapy, and pelvic floor exercise) seem to improve pain, sexual function, and quality of life. However, the heterogeneity of the studies prevented meta-analysis. In addition, well-designed trials are needed to improve the certainty of this evidence.

A conceptual model for managing sexual pain with somatocognitive therapy in women with provoked vestibulodynia and implications for physiotherapy practice

Somatocognitive therapy is a multimodal physiotherapy treatment developed in the early 2000s to alleviate the burden of chronic pelvic pain. In recent years, somatocognitive therapy has been further developed to treat women with provoked vestibulodynia. This prevalent gynecological pain condition is a subgroup of chronic pelvic pain and the most common form of vulvodynia. Provoked vestibulodynia is a neglected multifactorial pain condition of unknown cause, adversely affecting women's sexual life, relation to their partners and their psychological health. Pain is located at the vulvar vestibule and is provoked by touch or pressure such as sexual intercourse. In the management of sexual pain, somatocognitive therapy combines bodily exploration, pain education, cognitive coping strategies and structured homework to improve sexual function and reduce pain. To support these processes, developing a sound therapeutic alliance with the patient is essential. The aim of this article is to provide a conceptual model for managing provoked vestibulodynia with somatocognitive therapy, including a theoretical rational for this treatment. We base our conceptual model on the biopsychosocial model, i.e., considering the complex interplay of biomedical, emotional/cognitive, psychosexual and interpersonal factors in provoked vestibulodynia management. In addition, implications for practice and a detailed description of somatocognitive therapy for provoked vestibulodynia will be provided, to allow replication in clinical practice and in clinical trials.

Self-compassion, perfectionism, impostor phenomenon, stress and anxiety in patients with localized provoked vulvodynia

Studies have shown that psychological distress has a role in the symptomology of localized provoked vulvodynia. Therefore, psychosocial support has been presented as a valuable part of the treatment. However, little is known about which psychological variables that coincide with localized provoked vulvodynia. The purpose of this study was to identify qualities of psychological distress in patients with localized provoked vulvodynia. Patients with localized provoked vulvodynia were consecutively recruited to participate in this cross-sectional questionnaire-based study. Participants completed a self-report questionnaire measuring perfectionism, impostor phenomenon, self-compassion, anxiety and perceived stress. A sample of 30 patients were included. Questionnaire results suggestive of perfectionism was seen in 63%, impostor phenomenon in 80%, low self-compassion in 27%, anxiety in 43% and perceived stress in 23% of the participants. The level of self-compassion was higher in patients in a committed relationship. The investigated qualities appear to be more common in patients with localized provoked vulvodynia than in comparable groups. Impostor phenomenon and perfectionism were particularly common, with more than half of the study population scoring above the cutoff for clinical significance. This motivates research to investigate if interventions targeting impostor phenomenon and perfectionism, may aid in the treatment of localized provoked vulvodynia.

"It's all my fault": a qualitative study of how heterosexual couples experience living with vulvodynia

INTRODUCTION

Vulvodynia, a chronic genital pain disorder with a high lifetime prevalence among women, has a significant negative impact on both women and their partners. Although there is a growing body of literature on the experiences of women with vulvodynia, there has been little research on the condition's implications for partners and romantic relationships. The aim of this study is to explore how heterosexual couples experience living with vulvodynia.

MATERIAL AND METHODS

Eight Norwegian women diagnosed with vulvodynia by gynecologists were recruited with their partners (couples aged 19-32 years). Data was collected via individual semi-structured interviews and analyzed using inductive thematic analysis.

RESULTS

Three main themes were identified in the analysis: Mysterious disorder, Social exclusion and Sexual expectations. The results show that the couples struggle with understanding the pain, as well as navigating their social and sexual lives. We discuss these findings in light of a new theoretical model: the fear-avoidance-endurance model of vulvodynia.

CONCLUSIONS

Heterosexual couples living with vulvodynia experience communication difficulties with partners, health professionals, and their social network. This sustains avoidance and endurance behavior, increasing pain and dysfunction over time and giving rise to feelings of powerlessness and loneliness. Social expectations regarding male and female sexuality also promote guilt and shame for both parties in couples affected by vulvodynia. Our results suggest that heterosexual couples living with vulvodynia, as well as health professionals treating them, should be helped to communicate more effectively in order to break vicious circles of maladaptive avoidance and endurance behavior.

Preferred physical characteristics of lidocaine thin film for women with vestibulodynia

Introduction

Vestibulodynia (VBD) is the most common cause of sexual pain in the United States, affecting up to 15% of reproductive-aged women during their lifetime with limited treatment options. The purpose of this study was to describe ideal physical characteristics of a vulvar film designed for insertional sexual pain in sexually active women with VBD.

Methods

Twenty women were recruited to participant in one of six, semi-structured 60-minute focus group discussions regarding treatment options for VBD. Heterosexual women, aged 18-51 years old with a diagnosis of vulvodynia, vestibulodynia or insertional dyspareunia fit the inclusion criteria. Those who reported no episodes of vaginal intercourse in the prior 18 months were excluded. A new vulvar film technology loaded with 50 mg of 5% lidocaine was introduced to the group. Participants took part in focus groups on a rolling basis depending on availability. Focus group discussions were audio-recorded and transcribed verbatim. Two study investigators coded the transcripts using inductive coding and merged their respective projects to resolve disagreements. We analyzed data related to each code to develop code clusters and higher-level primary topics regarding device preferences. Data related to each of these primary topics was analyzed to assess the range of participant attitudes and preferences and to identify patterns within each primary topic.

Results

One hundred and sixteen women were recruited, and twenty women were enrolled. The mean age for the participants was 33.3 years. Most women were educated with at least some college (93%), White (78.6%), married (75%), and had income greater than $100,000 (50%). Analysis of the focus group discussions identified five common topics addressed by participants: desired loaded medication, film size, film shape, film flexibility, and ease and accuracy of use. Concerns across topics included comfort, sexual spontaneity, and efficacy. Interest in loading the device with other acceptable medications or combination with lidocaine was independently noted in 2/6 (33%) of the focus groups.

Discussion

Mucoadhesive vulvar thin films may be an acceptable drug delivery system for insertional sexual pain for women with VBD.

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.

An initial proof of concept: A replicated single-case study of a CBT group treatment with partner involvement for vulvodynia

Vulvodynia is common and has an immense impact on affected women and their partners. Psychological factors have been found to contribute to pain maintenance and exacerbation, and treatments addressing psychological factors have yielded positive results. This study employed a replicated single-case experimental design to examine a cognitive behavioral therapy (CBT) group treatment with partner involvement in vulvodynia. Repeated measures of pain intensity related to pain-inflicting behaviors were collected weekly throughout baseline and treatment phases. Associated outcomes were measured pre-, post- and at two follow-up assessments. Participants were 18-45-year-old women, in a stable sexual relationship with a man, experiencing vulvodynia. Five women completed the treatment consisting of 10 group sessions and 3 couple sessions. Data were analyzed through visual inspection and supplementary nonparametric calculations. The study showed promising results of the CBT treatment in alleviating pain intensity in connection to specific pain-inflicting behavior since three out of five participants showed improvements. For the participants who improved, sexual function, pain catastrophizing, avoidance, and endurance behavior changed during treatment and were maintained at follow-ups. These results warrant further study of the CBT treatment, in larger, and controlled formats.