1
|
Okui N, Okui MA, Kouno Y, Nakano K. Laser Treatment for Patients With Vulvodynia and Interstitial Cystitis/Bladder Pain Syndrome: A Case Series (The UNICORN-3 Study). Cureus 2023; 15:e41786. [PMID: 37449291 PMCID: PMC10338019 DOI: 10.7759/cureus.41786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 07/18/2023] Open
Abstract
Introduction Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain disorder characterized by urgency, frequency of urination, and pelvic pain. Women with IC/BPS often experience sexual dysfunction, vulvodynia, and vaginal health issues. Combined erbium and neodymium yttrium aluminum garnet (YAG) laser treatments targeting the vagina and vulva have shown promise in improving symptoms. Our study aims to investigate the effectiveness of these combined laser treatments in women with IC/BPS and vulvodynia. Methods Women diagnosed with vulvodynia and IC/BPS underwent combined laser treatment using vaginal erbium:YAG laser (VEL) and neodymium:YAG laser (Nd:YAG). Various parameters were evaluated, including the vulvodynia test, numeric rating scale (NRS-11) for pain, interstitial cystitis symptom index and problem index (ICSI and ICPI), pelvic pain and urgency/frequency symptom score (PUF), and mean urination volume/daily urination frequency in a three-day urination diary. Treatment was administered three times, with intervals of one month between each session, and follow-up evaluations were conducted at six and 12 months. All statistical analyses were designed and programmed by the AI chatbot GPT-4 (chatGPT-4). Results Fifteen female patients diagnosed with vulvodynia and IC/BPS were treated with three sessions of VEL + Nd:YAG. Significant improvements were observed in the vulvodynia test, NRS-11 scores, PUF, ICSI scores, ICPI scores, mean urination volume, and daily urination frequency at six and 12 months (p<0.01). Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test (p=0.007), suggesting a synergistic effect. However, no significant correlations were found at 12 months. Conclusion Combined laser treatments targeting the vagina and vulva showed significant therapeutic effects in women with IC/BPS and vulvodynia. The addition of Nd:YAG to the VEL treatment enhanced outcomes. Short-term improvements in IC/BPS pain scores correlated with improvements in the vulvodynia test, indicating a synergistic effect. Long-term improvements in both vulvodynia and IC/BPS symptoms may occur independently. These findings highlight the importance of comprehensive approaches for treating coexisting vulvodynia and IC/BPS.
Collapse
Affiliation(s)
- Nobuo Okui
- Dentistry, Kanagawa Dental University, Kanagawa, JPN
| | | | - Yuko Kouno
- Urology, Dr Okui's Urogynecology and Urology, Yokosuka, JPN
| | - Kaori Nakano
- Urology, Dr Okui's Urogynecology and Urology, Yokosuka, JPN
| |
Collapse
|
2
|
Ioachim G, Warren HJM, Powers JM, Staud R, Pukall CF, Stroman PW. Distinct neural signaling characteristics between fibromyalgia and provoked vestibulodynia revealed by means of functional magnetic resonance imaging in the brainstem and spinal cord. FRONTIERS IN PAIN RESEARCH 2023; 4:1171160. [PMID: 37283704 PMCID: PMC10240076 DOI: 10.3389/fpain.2023.1171160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/27/2023] [Indexed: 06/08/2023] Open
Abstract
Introduction Fibromyalgia and provoked vestibulodynia are two chronic pain conditions that disproportionately affect women. The mechanisms underlying the pain in these conditions are still poorly understood, but there is speculation that both may be linked to altered central sensitization and autonomic regulation. Neuroimaging studies of these conditions focusing on the brainstem and spinal cord to explore changes in pain regulation and autonomic regulation are emerging, but none to date have directly compared pain and autonomic regulation in these conditions. This study compares groups of women with fibromyalgia and provoked vestibulodynia to healthy controls using a threat/safety paradigm with a predictable noxious heat stimulus. Methods Functional magnetic resonance imaging data were acquired at 3 tesla in the cervical spinal cord and brainstem with previously established methods. Imaging data were analyzed with structural equation modeling and ANCOVA methods during: a period of noxious stimulation, and a period before the stimulation when participants were expecting the upcoming pain. Results The results demonstrate several similarities and differences between brainstem/spinal cord connectivity related to autonomic and pain regulatory networks across the three groups in both time periods. Discussion Based on the regions and connections involved in the differences, the altered pain processing in fibromyalgia appears to be related to changes in how autonomic and pain regulation networks are integrated, whereas altered pain processing in provoked vestibulodynia is linked in part to changes in arousal or salience networks as well as changes in affective components of pain regulation.
Collapse
Affiliation(s)
- Gabriela Ioachim
- Center for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
| | | | - Jocelyn M. Powers
- Center for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
| | - Roland Staud
- Department of Medicine, University of Florida, Gainseville, FL, United States
| | - Caroline F. Pukall
- Center for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
- Department of Psychology, Queen’s University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
| | - Patrick W. Stroman
- Center for Neuroscience Studies, Queen’s University, Kingston, ON, Canada
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, ON, Canada
- Department of Physics, Queen's University, Kingston, ON, Canada
| |
Collapse
|
3
|
Oughourlian TC, Tun G, Antony KM, Gupta A, Mays VM, Mayer EA, Rapkin AJ, Labus JS. Symptom-associated alterations in functional connectivity in primary and secondary provoked vestibulodynia. Pain 2023; 164:653-665. [PMID: 35972459 DOI: 10.1097/j.pain.0000000000002754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022]
Abstract
ABSTRACT Primary provoked vestibulodynia (PVD) is marked by the onset of symptoms at first provoking vulvar contact, whereas secondary PVD refers to symptom onset after some period of painless vulvar contact. Different pathophysiological processes are believed to be involved in the development and maintenance of primary PVD and secondary PVD. The primary aim of this study was to test the hypotheses that the resting state functional connectivity of the brain and brain stem regions differs between these subtypes. Deep clinical phenotyping and resting state brain imaging were obtained in a large sample of a women with primary PVD (n = 46), those with secondary PVD (n = 68), and healthy control women (n = 94). The general linear model was used to test for differences in region-to-region resting state functional connectivity and psychosocial and symptom assessments. Direct statistical comparisons by onset type indicated that women with secondary PVD have increased dorsal attention-somatomotor network connectivity, whereas women with primary PVD predominantly show increased intrinsic resting state connectivity within the brain stem and the default mode network. Furthermore, compared with women with primary PVD, those with secondary PVD reported greater incidence of early life sexual abuse, greater pain catastrophizing, greater 24-hour symptom unpleasantness, and less sexual satisfaction. The findings suggest that women with secondary PVD show greater evidence for central amplification of sensory signals, whereas women with primary PVD have alterations in brain stem circuitry responsible for the processing and modulation of ascending and descending peripheral signals.
Collapse
Affiliation(s)
- Talia C Oughourlian
- UCLA Center for Computer Vision and Imaging Biomarkers, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
- Neuroscience Interdisciplinary Graduate Program, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Guistinna Tun
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Kevin M Antony
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Arpana Gupta
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
- Gonda (Goldschmied) Neuroscience and Genetics Research Center, Brain Research Institute UCLA, University of California Los Angeles, Los Angeles, CA, United States
| | - Vickie M Mays
- Departments of Psychology and Health Policy & Management, Fielding School of Public Health, BRITE Center for Science, Research & Policy, University of California, Los Angeles, Los Angeles, CA, United States
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Andrea J Rapkin
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
| | - Jennifer S Labus
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
- Gonda (Goldschmied) Neuroscience and Genetics Research Center, Brain Research Institute UCLA, University of California Los Angeles, Los Angeles, CA, United States
| |
Collapse
|
4
|
Merlino L, Titi L, Pugliese F, D’Ovidio G, Senatori R, Rocca CD, Piccioni MG. Vulvodynia: Pain Management Strategies. Pharmaceuticals (Basel) 2022; 15:ph15121514. [PMID: 36558965 PMCID: PMC9781267 DOI: 10.3390/ph15121514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Background: Vulvodynia is defined in this international consensus as persistent vulvar pain that occurs for >3 months without an identifiable cause and with several potential associated factors. At present there is no univocal consensus in the therapeutic treatment of vulvodynia. The methods of intervention are based on various aspects including, above all, the management of painful symptoms. Methods: a research on scientific database such as “Pubmed”, “Medline Plus”, “Medscape” was conducted, using the words “women’s genital pain” and “vulvodynia” for the review of the scientific evidence on the assessment and treatment of women’s genital pain. Results: Among the drugs with pain-relieving action, the most effective in the treatment of vulvodynia would seem to be those with antidepressant and anticonvulsant action, even if their mechanisms of action are not known and there are still insufficient studies able to demonstrate their real validity. Among the least effective are non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids. However, the ideal would seem to use a combined treatment with multiple types of drugs. Conclusions: Future studies are needed to draw up a unique therapeutic action plan that considers the stratification of patients with vulvodynia and the variability of the symptom.
Collapse
Affiliation(s)
- Lucia Merlino
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
- Correspondence:
| | - Luca Titi
- Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Francesco Pugliese
- Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, 00161 Rome, Italy
| | - Giulia D’Ovidio
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Senatori
- Italian Society of Colposcopy and Cervicovaginal Pathology (SICPV), 00186 Rome, Italy
| | - Carlo Della Rocca
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 00161 Rome, Italy
| | - Maria Grazia Piccioni
- Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, 00161 Rome, Italy
| |
Collapse
|
5
|
Kelly KJ, Fisher BL, Rosen NO, Hamilton LD. Anxiety and Anticipated Pain Levels of Women With Self-Reported Penetration-Related Genito-Pelvic Pain are Elevated in Response to Pain-related Images. J Sex Med 2022; 19:1281-1289. [DOI: 10.1016/j.jsxm.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 04/20/2022] [Accepted: 04/28/2022] [Indexed: 12/01/2022]
|
6
|
Starzec-Proserpio M, Grigol Bardin M, Fradette J, Tu LM, Bérubè-Lauzière Y, Paré J, Carroll MS, Morin M. High-Intensity Laser Therapy (HILT) as an Emerging Treatment for Vulvodynia and Chronic Musculoskeletal Pain Disorders: A Systematic Review of Treatment Efficacy. J Clin Med 2022; 11:jcm11133701. [PMID: 35806984 PMCID: PMC9267539 DOI: 10.3390/jcm11133701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 01/02/2023] Open
Abstract
High-intensity laser therapy (HILT) has been gaining popularity in the treatment of chronic musculoskeletal pain, including vulvodynia. The objective of this study was to critically appraise and synthesize the available evidence on the efficacy of HILT for reducing pain and improving function in vulvodynia and other chronic primary musculoskeletal pain conditions. Electronic databases and the grey literature were searched. Effects on pain intensity, function, and adverse events were assessed. One study investigating HILT in the treatment of vulvodynia and 13 studies on the treatment of chronic musculoskeletal pain were selected. The study assessing vulvodynia showed favorable results for reducing pain. Regarding chronic musculoskeletal pain, 12 out of the 13 studies selected consistently showed that HILT was more effective than the placebo/active comparator for reducing pain and improving function. The available effect sizes for pain showed large to huge effects. Similar effects were observed for function except for two studies showing moderate effects. The GRADE score was moderate. Conclusions: There are insufficient data to support the use of HILT in vulvodynia, but the promising results encourage further research. HILT appears to be effective in musculoskeletal pain conditions. More high-quality studies are needed to identify effective laser protocols.
Collapse
Affiliation(s)
| | - Marcela Grigol Bardin
- Department of Obstetrics and Gynecology, School of Medical Sciences, Campinas University, São Paulo 13083-887, Brazil;
| | - Julie Fradette
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Research Center, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC J1H 5N4, Canada;
| | - Le Mai Tu
- Urology Service, Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Research Center, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC J1H 5N4, Canada;
| | - Yves Bérubè-Lauzière
- Department of Electrical and Computer Engineering, Université de Sherbrooke, Sherbrooke, QC J1K 2R1, Canada;
| | - Josianne Paré
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Research Center, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC J1H 5N4, Canada;
| | - Marie-Soleil Carroll
- Research Center, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC J1H 5N4, Canada;
| | - Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Research Center, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC J1H 5N4, Canada;
- Correspondence:
| |
Collapse
|
7
|
Yessick LR, Pukall CF, Ioachim G, Chamberlain SM, Stroman PW. An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia (PVD): Alterations of Spinal Cord and Brainstem Connectivity. FRONTIERS IN PAIN RESEARCH 2022; 2:682483. [PMID: 35295532 PMCID: PMC8915748 DOI: 10.3389/fpain.2021.682483] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/13/2021] [Indexed: 12/19/2022] Open
Abstract
The most common subtype of vulvodynia (idiopathic chronic vulvar pain) is provoked vestibulodynia (PVD). Previous imaging studies have shown that women with vulvodynia exhibit increased neural activity in pain-related brain regions (e.g., the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus). However, despite the recognized role of the spinal cord/brainstem in pain modulation, no previous neuroimaging studies of vulvodynia have examined the spinal cord/brainstem. Sixteen women with PVD and sixteen matched Control women underwent a spinal cord/brainstem functional magnetic resonance imaging (fMRI) session consisting of five runs with no painful thermal stimuli (No Pain), interleaved randomly with five runs with calibrated, moderately painful heat stimulation (Pain). Functional connectivity was also assessed in periods before, during, and after, pain stimulation to investigate dynamic variations in pain processing throughout the stimulation paradigm. Functional connectivity in the brainstem and spinal cord for each group was examined using structural equation modeling (SEM) for both Pain and No Pain conditions. Significant connectivity differences during stimulation were identified between PVD and Control groups within pain modulatory regions. Comparisons of Pain and No Pain conditions identified a larger number of connections in the Control group than in the PVD group, both before and during stimulation. The results suggest that women with PVD exhibit altered pain processing and indicate an insufficient response of the pain modulation system. This study is the first to examine the spinal cord/brainstem functional connectivity in women with PVD, and it demonstrates altered connectivity related to pain modulation in the spinal cord/brainstem.
Collapse
Affiliation(s)
| | - Caroline F Pukall
- Department of Psychology, Queen's University, Kingston, ON, Canada.,Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Gabriela Ioachim
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Susan M Chamberlain
- Department of Obstetrics and Gynecology, Queen's University, Kingston, ON, Canada
| | - Patrick W Stroman
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| |
Collapse
|
8
|
Yessick LR, Pukall CF, Ioachim G, Chamberlain SM, Stroman PW. An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia: Alterations of Brain Connectivity. FRONTIERS IN PAIN RESEARCH 2022; 2:682484. [PMID: 35295457 PMCID: PMC8915563 DOI: 10.3389/fpain.2021.682484] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/11/2021] [Indexed: 12/01/2022] Open
Abstract
Provoked Vestibulodynia (PVD) is the most common vulvodynia subtype (idiopathic chronic vulvar pain). Functional magnetic resonance imaging (fMRI) studies indicate that women with PVD exhibit altered function in a number of pain modulatory regions in response to noxious stimulation, such as in the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus. However, previous neuroimaging studies of PVD have not examined periods of time before and after noxious stimulation or investigated functional connectivity among pain modulatory regions. Fourteen women with PVD and 14 matched Control participants underwent five fMRI runs with no painful stimuli interleaved randomly with five runs with calibrated, moderately painful heat stimuli applied to the thenar eminence. As recent findings indicate that pain processing begins before and continues after painful stimulation, 2-min periods were included in each run before and after the stimulus. Functional brain connectivity was assessed during both trials of Pain and No Pain stimulation for each group using structural equation modeling (SEM). Analyses of variance (ANOVAs) on connectivity values demonstrated significant main effects of study condition, and group, for connectivity among pain modulatory regions. Most of the differences between the Pain and No Pain conditions found only in the PVD group take place before (i.e., thalamus to INS, ACC to S1, thalamus to S1, and thalamus to S2) and after pain stimulation (i.e., INS to amygdala, PPC to S1, and thalamus to S2). Such differences were not observed in the Control group. These findings further support previous results indicating that women with PVD have altered pain processing compared to pain-free women.
Collapse
Affiliation(s)
| | - Caroline F Pukall
- Department of Psychology, Queen's University, Kingston, ON, Canada.,Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Gabriela Ioachim
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Susan M Chamberlain
- Department of Obstetrics and Gynecology, Queen's University, Kingston, ON, Canada
| | - Patrick W Stroman
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| |
Collapse
|
9
|
Labus JS, Mayer EA, Tillisch K, Aagaard KM, Stains J, Broniowska K, Van Remortel C, Tun G, Rapkin A. Dysregulation in Sphingolipid Signaling Pathways is Associated With Symptoms and Functional Connectivity of Pain Processing Brain Regions in Provoked Vestibulodynia. THE JOURNAL OF PAIN 2021; 22:1586-1605. [PMID: 34029688 PMCID: PMC10460622 DOI: 10.1016/j.jpain.2021.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/27/2021] [Accepted: 04/29/2021] [Indexed: 10/21/2022]
Abstract
Provoked vestibulodynia (PVD) is a chronic pain disorder characterized by local hypersensitivity and severe pain with pressure localized to the vulvar vestibule. Despite decades of study, the lack of identified biomarkers has slowed the development of effective therapies. The primary aim of this study was to use metabolomics to identify novel biochemical mechanisms in vagina and blood underlying brain biomarkers and symptoms in PVD, thereby closing this knowledge gap. Using a cross-sectional case-control observational study design, untargeted and unbiased metabolomic profiling of vaginal fluid and plasma was performed in women with PVD compared to healthy controls. In women with PVD, we also obtained assessments of vulvar pain, vestibular and vaginal muscle tenderness, and 24-hour symptom intensity alongside resting-state brain functional connectivity of brain regions involved in pain processing and modulation. Compared to healthy controls, women with PVD demonstrated differences primarily in vaginal (but not plasma) concentrations of metabolites of the sphingolipid signaling pathways, suggesting localized effects in vagina and vulvar vestibule rather than systemic effects. Our findings reveal that dysregulation of sphingolipid metabolism in PVD is associated with increased vulvar pain and muscle tenderness, sexual dysfunction, and decreased functional connectivity strength in pain processing/modulatory brain regions. This data collectively suggests that alterations in sphingolipid signaling pathways are likely an important molecular biomarker in PVD that could lead to new targets for therapeutic intervention. PERSPECTIVE: This manuscript presents the results of a robust, unbiased molecular assessment of plasma and vaginal fluid samples in women with provoked vestibulodynia compared to healthy controls. The findings suggest that alterations in sphingolipid signaling pathways are associated with symptoms and brain biomarkers and may be an important molecular marker that could provide new targets for therapeutic intervention.
Collapse
Affiliation(s)
- Jennifer S Labus
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California; Brain Research Institute UCLA, Gonda (Goldschmied) Neuroscience and Genetics Research Center, Los Angeles, California.
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Kirsten Tillisch
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Kjersti M Aagaard
- Division of Maternal-Fetal Medicine, Departments of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; Department of Molecular and Human Genetics, Bioinformatics Research Laboratory, Baylor College of Medicine, Houston, Texas; Department of Molecular and Cell Biology, Baylor College of Medicine, Houston, Texas
| | - Jean Stains
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California
| | | | - Charlotte Van Remortel
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Guistinna Tun
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Andrea Rapkin
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, California; Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, California
| |
Collapse
|
10
|
Morin M, Morin A, Gougeon V, Marchand S, Waddell G, Bureau YA, Girard I, Brassard A, Benoit-Piau J, Léonard G. Transcranial direct current stimulation for provoked vestibulodynia: What roles do psychosexual factors play in treatment response? J Clin Neurosci 2021; 93:54-60. [PMID: 34656261 DOI: 10.1016/j.jocn.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 07/16/2021] [Accepted: 08/01/2021] [Indexed: 11/29/2022]
Abstract
There is growing evidence that provoked vestibulodynia (PVD), a frequent and debilitating condition, is characterized by central sensitization. This study aimed to examine predictive factors of transcranial direct current stimulation (tDCS) efficacy in this chronic pain population. Exploratory analysis derived from a randomized controlled trial was performed to assess predictors of pain reduction among 39 women with PVD who received 10 daily sessions of either active or sham tDCS. Clinical characteristics (e.g. pain intensity, duration and pain sensitivity) and psychosexual factors (e.g. pain catastrophizing, pain-related fear, anxiety, depressive symptoms and vaginal penetration cognitions) were assessed at baseline and used to predict tDCS response at 3-month follow-up. Analysis revealed that higher depressive symptoms and lower negative self-image cognitions were significant predictors of pain reduction at follow-up and accounted for 62.3% of the variance in the active tDCS group. Higher genital incompatibility cognitions were related to poorer response, regardless of treatment group. These findings suggest that women with PVD presenting higher depressive symptoms and lower levels of negative self-image cognitions could derive greater benefits from tDCS. These results suggest that tDCS could be effective in a subgroup of women with PVD - a possibility worth exploring with future prospective larger studies.
Collapse
Affiliation(s)
- Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Annie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Véronique Gougeon
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Serge Marchand
- Department of Surgery, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Guy Waddell
- Department of Obstetrics Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Yves-André Bureau
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Isabelle Girard
- Department of Obstetrics Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Audrey Brassard
- Department of Psychology, Faculty of Arts and Social Sciences, 2500 blvd Université, Sherbrooke, Québec J1K 2Rl, Canada
| | - Justine Benoit-Piau
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada
| | - Guillaume Léonard
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec J1H 5N4, Canada.
| |
Collapse
|
11
|
Xu A, Larsen B, Henn A, Baller EB, Scott JC, Sharma V, Adebimpe A, Basbaum AI, Corder G, Dworkin RH, Edwards RR, Woolf CJ, Eickhoff SB, Eickhoff CR, Satterthwaite TD. Brain Responses to Noxious Stimuli in Patients With Chronic Pain: A Systematic Review and Meta-analysis. JAMA Netw Open 2021; 4:e2032236. [PMID: 33399857 PMCID: PMC7786252 DOI: 10.1001/jamanetworkopen.2020.32236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
IMPORTANCE Functional neuroimaging is a valuable tool for understanding how patients with chronic pain respond to painful stimuli. However, past studies have reported heterogenous results, highlighting opportunities for a quantitative meta-analysis to integrate existing data and delineate consistent associations across studies. OBJECTIVE To identify differential brain responses to noxious stimuli in patients with chronic pain using functional magnetic resonance imaging (fMRI) while adhering to current best practices for neuroimaging meta-analyses. DATA SOURCES All fMRI experiments published from January 1, 1990, to May 28, 2019, were identified in a literature search of PubMed/MEDLINE, EMBASE, Web of Science, Cochrane Library, PsycINFO, and SCOPUS. STUDY SELECTION Experiments comparing brain responses to noxious stimuli in fMRI between patients and controls were selected if they reported whole-brain results, included at least 10 patients and 10 healthy control participants, and used adequate statistical thresholding (voxel-height P < .001 or cluster-corrected P < .05). Two independent reviewers evaluated titles and abstracts returned by the search. In total, 3682 abstracts were screened, and 1129 full-text articles were evaluated. DATA EXTRACTION AND SYNTHESIS Thirty-seven experiments from 29 articles met inclusion criteria for meta-analysis. Coordinates reporting significant activation differences between patients with chronic pain and healthy controls were extracted. These data were meta-analyzed using activation likelihood estimation. Data were analyzed from December 2019 to February 2020. MAIN OUTCOMES AND MEASURES A whole-brain meta-analysis evaluated whether reported differences in brain activation in response to noxious stimuli between patients and healthy controls were spatially convergent. Follow-up analyses examined the directionality of any differences. Finally, an exploratory (nonpreregistered) region-of-interest analysis examined differences within the pain network. RESULTS The 37 experiments from 29 unique articles included a total of 511 patients and 433 controls (944 participants). Whole-brain meta-analyses did not reveal significant differences between patients and controls in brain responses to noxious stimuli at the preregistered statistical threshold. However, exploratory analyses restricted to the pain network revealed aberrant activity in patients. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis, preregistered, whole-brain analyses did not reveal aberrant fMRI activity in patients with chronic pain. Exploratory analyses suggested that subtle, spatially diffuse differences may exist within the pain network. Future work on chronic pain biomarkers may benefit from focus on this core set of pain-responsive areas.
Collapse
Affiliation(s)
- Anna Xu
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Bart Larsen
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Alina Henn
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical Faculty, RWTH (Rheinisch-Westfälische Technische Hochschule) Aachen University, Aachen, Germany
| | - Erica B. Baller
- Department of Psychiatry, University of Pennsylvania, Philadelphia
- Department of Psychiatry, Massachusetts General Hospital, Boston
- Department of Psychiatry, Harvard University, Boston, Massachusetts
| | - J. Cobb Scott
- Department of Psychiatry, University of Pennsylvania, Philadelphia
- VISN4 Mental Illness Research, Education, and Clinical Center at the Corporal Michael J. Crescenz VA (Veterans Affairs) Medical Center, Philadelphia, Pennsylvania
| | - Vaishnavi Sharma
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Azeez Adebimpe
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | | | - Gregory Corder
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Robert H. Dworkin
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Robert R. Edwards
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Clifford J. Woolf
- FM Kirby Neurobiology Center, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurobiology, Harvard Medical School, Boston, Massachusetts
| | - Simon B. Eickhoff
- Institute of Systems Neuroscience, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
- Institute of Neuroscience and Medicine, Brain and Behaviour Sections, Research Centre Jülich, Jülich, Germany
| | - Claudia R. Eickhoff
- Institute of Neuroscience and Medicine, Brain and Behaviour Sections, Research Centre Jülich, Jülich, Germany
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | | |
Collapse
|
12
|
Labus JS, Mayer EA, Aagaard K, Stains J, Broniowska K, Rapkin A. Reduced concentrations of vaginal metabolites involved in steroid hormone biosynthesis are associated with increased vulvar vestibular pain and vaginal muscle tenderness in provoked vestibulodynia: An exploratory metabolomics study. Mol Pain 2021; 17:17448069211041853. [PMID: 34505814 PMCID: PMC8438271 DOI: 10.1177/17448069211041853] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/05/2021] [Indexed: 12/22/2022] Open
Abstract
Provoked vestibulodynia (PVD) is a chronic vulvar pain disorder characterized by hypersensitivity and severe pain with pressure localized to the vulvar vestibule. Knowledge regarding pathophysiological mechanisms contributing to the etiology and production of symptoms in PVD remains incomplete but is considered multifactorial. Using a cross-sectional observational study design, data from untargeted metabolomic profiling of vaginal fluid and plasma in women with PVD and healthy women was combined with pain testing and brain imaging in women with PVD to test the hypotheses that women with PVD compared to healthy women show differences in vaginal and plasma metabolites involved in steroid hormone biosynthesis. Steroid hormone metabolites showing group differences were correlated with vulvar vestibular pain and vaginal muscle tenderness and functional connectivity of brain regions involved in pain processing in women with PVD to provide insight into the functional mechanisms linked to the identified alterations. Sensitivity analyses were also performed to determine the impact of hormonal contraceptive use on the study findings. Women with PVD compared to healthy controls had significant reductions primarily in vaginal fluid concentrations of androgenic, pregnenolone and progestin metabolites involved in steroidogenesis, suggesting localized rather than systemic effects in vagina and vulvar vestibule. The observed reductions in androgenic metabolite levels showed large effect size associations with increased vulvar vestibular pain and vulvar muscle tenderness and decreases in androgenic and progestin metabolites were associated with decreased connectivity strength in primary sensorimotor cortices. Women with PVD showed symptom-associated reductions in vaginal fluid concentrations of metabolites involved in the biosynthesis of steroid hormones previously shown to affect the integrity of vulvar and vaginal tissue and nociceptive processing. Deficiency of certain steroids may be an important mechanism contributing to the pathophysiology of symptoms in PVD may provide potential diagnostic markers that could lead to new targets for therapeutic intervention.
Collapse
Affiliation(s)
- Jennifer S Labus
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Brain Research Institute UCLA, Gonda (Goldschmied) Neuroscience and Genetics Research Center, Los Angeles, CA, USA
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | - Kjersti Aagaard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX, USA
- Department of Molecular and Human Genetics, Bioinformatics Research Laboratory, Baylor College of Medicine, Houston, TX, USA
- Department of Molecular and Cell Biology, Baylor College of Medicine, Houston, TX, USA
| | - Jean Stains
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | | | - Andrea Rapkin
- G. Oppenheimer Center for Neurobiology of Stress and Resilience, Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| |
Collapse
|
13
|
Padoa A, McLean L, Morin M, Vandyken C. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med Rev 2020; 9:76-92. [PMID: 32631813 DOI: 10.1016/j.sxmr.2020.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 03/30/2020] [Accepted: 04/08/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The assessment of pelvic floor muscle (PFM) overactivity is part of a comprehensive evaluation including a detailed history (medical, gynecological history/antecedent), appraisal of the psychosocial contexts of the patient, as well as a musculoskeletal and a neurological examination. OBJECTIVES The aims of this article are to review (i) the assessment modalities evaluating pelvic floor function in women and men with disorders associated with an overactive pelvic floor (OPF), and (ii) therapeutic approaches to address OPF, with particular emphases on sexual pain and function. METHODS We outline assessment tools that evaluate psychological and cognitive states. We then review the assessment techniques to evaluate PFM involvement including digital palpation, electromyography, manometry, ultrasonography, and dynamometry, including an overview of the indications, efficacy, advantages, and limitations of each instrument. We consider each instrument's utility in research and in clinical settings. We next review the evidence for medical, physiotherapy, and psychological interventions for OPF-related conditions. RESULTS Research using these assessment techniques consistently points to findings of high PFM tone among women and men reporting disorders associated with OPF. While higher levels of evidence are needed, options for medical treatment include diazepam suppositories, botulinum toxin A, and other muscle relaxants. Effective psychological therapies include cognitive behavioral therapy, couple therapy, mindfulness, and educational interventions. Effective physiotherapy approaches include PFM exercise with biofeedback, electrotherapy, manual therapy, and the use of dilators. Multimodal approaches have demonstrated efficacy in reducing pain, normalizing PFM tone, and improving sexual function. Multidisciplinary interventions and an integrative approach to the assessment and management of OPF using a biopsychosocial framework are discussed. CONCLUSION Although the efficacy of various intervention approaches has been demonstrated, further studies are needed to personalize interventions according to a thorough assessment and determine the optimal combination of psychological, physical, and behavioral modalities. Padoa A, McLean, L, Morin M, et al. The Overactive Pelvic Floor (OPF) and Sexual Dysfunction. Part 2: Evaluation and Treatment of Sexual Dysfunction in OPF Patients. Sex Med 2021;9:76-92.
Collapse
Affiliation(s)
- Anna Padoa
- Department of Obstetrics and Gynecology, Yitzhak Shamir (formerly Assaf Harofe) Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Linda McLean
- School of Rehabilitation Sciences, Chair in Women's Health Research, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Melanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke and Research Center of the Centre hospitalier de l'Université de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | | |
Collapse
|
14
|
Vandyken B, Keizer A, Vandyken C, Macedo LG, Kuspinar A, Dufour S. Pelvic floor muscle tenderness on digital palpation among women: convergent validity with central sensitization. Braz J Phys Ther 2020; 25:256-261. [PMID: 32563663 DOI: 10.1016/j.bjpt.2020.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Tenderness on palpation of the pelvic floor muscles (PFMs) is a clinical assessment tool used alongside other tests to identify PFM involvement in pelvic complaints including pelvic pain. Although reliability of PFM tenderness has been determined, validity has yet to be established. OBJECTIVES To assess convergent validity of PFM tenderness on digital palpation with the presence of central pain mechanism, as determined by a score of greater than 40 on the Central Sensitization Inventory (CSI). A secondary objective was to assess the agreement between PFM tenderness and self-reported symptoms of PFM sensitivity. METHODS Participants completed a battery of self-report questions, the CSI, and various physical assessments (blinded assessors). Convergent validity was assessed between tenderness on palpation and the CSI. Kappa statistics were used to determine agreement between tenderness on palpation and self-reported perineal pain, urinary urgency, dyspareunia, and dysmenorrhea. RESULTS Ninety-nine female participants with hip or back pain and at least one self-reported symptom of pelvic floor dysfunction were included in the study (mean age 40.56±12.72 years). Convergent validity was found between PFM tenderness on palpation and scores greater than 40 on the CSI (X12=4.2,p=0.04). There was poor agreement between tenderness on palpation with dyspareunia (agreement 62.83%, Kappa=0.27), dysmenorrhea (agreement 55.75%, Kappa=0.14), or perineal pain (agreement 53.04%, Kappa=0.10). CONCLUSIONS PFM tenderness on digital palpation confirmed convergent validity with CSI scores, suggesting central pain mechanisms. Clinicians may need to consider the role of central pain mechanisms in their clinical decision making when treating PFM dysfunction.
Collapse
Affiliation(s)
| | - Alexzandra Keizer
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | | | - Luciana G Macedo
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Ayse Kuspinar
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | - Sinéad Dufour
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada; The WOMB-The World of My Baby, Milton, Ontario, Canada.
| |
Collapse
|
15
|
Abstract
Vulvodynia is a condition that occurs in 8-10% of women of all ages and is characterized by pain at the vulva that is present during sexual and/or non-sexual situations. Diagnosis is established through careful medical history and pelvic examination, including the cotton-swab test. The onset and maintenance of vulvodynia involves a complex interplay of peripheral and central pain mechanisms, pelvic floor muscle and autonomic dysfunction, anxiety, depression and childhood maltreatment as well as cognitive-affective, behavioural and interpersonal factors. Given the absence of empirically supported treatment guidelines, a stepwise approach of pelvic floor physical therapy and cognitive behavioural therapy as well as medical management is suggested, with surgery as the last option. Vulvodynia has a negative effect on the quality of life of women and their partners, and imposes a profound personal and societal economic burden. In addition, women with vulvodynia are more likely to report other chronic pain conditions, which further alters their quality of life. Future efforts should aim to increase girls', women's and healthcare professionals' education and awareness of vulvodynia, phenotype different subgroups of women based on biopsychosocial characteristics among more diverse samples, conduct longitudinal studies and improve clinical trial designs.
Collapse
|
16
|
Padoa A, McLean L, Morin M, Vandyken C. "The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response. Sex Med Rev 2020; 9:64-75. [PMID: 32238325 DOI: 10.1016/j.sxmr.2020.02.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 11/30/2019] [Accepted: 02/02/2020] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Overactive pelvic floor (OPF) muscles are defined as muscles that do not relax, or may even contract, when relaxation is needed, for example, during micturition or defecation. Conditions associated with OPF are multifactorial and include multiple possible etiologies and symptom complexes. The complex interplay between biological and psychosocial elements can lead to the persistence of OPF symptoms along with psychological and emotional distress. OBJECTIVES (1) To review and contextualize, from a pathophysiologic perspective, the evidence for OPF, (2) to provide an overview of common clinical presentations and comorbidities of OPF, and (3) to discuss the effect of OPF on sexual function in men and women. METHODS Review of the updated literature on the pathophysiology of OPF was carried out. OPF-associated conditions were overviewed, with special emphasis on the impact on sexual function in men and women. RESULTS Individuals with suspected OPF often present with a combination of gastrointestinal, gynecological, musculoskeletal, sexual, and urological comorbidities, mostly accompanied by psychoemotional distress. In both women and men, sexual function is significantly impaired by OPF and genitopelvic pain penetration disorders are often the primary manifestation of this condition. Women with OPF report less sexual desire, arousal, and satisfaction; more difficulty reaching orgasm; lower frequencies of intercourse; more negative attitudes toward sexuality; and more sexual distress than women without sexual pain. The most frequently reported sexual dysfunctions in men with OPF include erectile dysfunction, premature ejaculation, and ejaculatory pain. CONCLUSION The complex pathophysiology of OPF involving multisystemic comorbidities and psychosocial factors emphasize the importance of a biopsychosocial assessment for guiding effective and personalized management. Padoa A, McLean L, Morin M, et al. "The Overactive Pelvic Floor (OPF) and Sexual Dysfunction" Part 1: Pathophysiology of OPF and Its Impact on the Sexual Response. Sex Med 2021;9:64-75.
Collapse
Affiliation(s)
- Anna Padoa
- Department of Obstetrics and Gynecology, Yitzhak Shamir (formerly Assaf Harofe) Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Linda McLean
- School of Rehabilitation Sciences, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Melanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke and Research Center of the Centre hospitalier de l'Université de Sherbrooke (CHUS), Sherbrooke, QC, Canada
| | | |
Collapse
|
17
|
Abstract
Group differences in touch and pain thresholds-and their neural correlates-were studied in women with provoked vestibulodynia (PVD; N = 15), a common subtype of vulvodynia (chronic vulvar pain), and pain-free control women (N = 15). Results from quantitative sensory testing and self-report measures indicated that, as compared with control participants, women with PVD exhibited allodynia (ie, pain in response to a normally nonpainful stimulus) and hyperalgesia (ie, an increased response to a normally painful stimulus) at vulvar and nonvulvar sites. In addition, brain imaging analyses demonstrated reduced difference scores between touch and pain in the S2 area in women with PVD compared with control participants, supporting previous findings of allodynia in women with PVD. There were no significant reductions in difference scores between touch and pain for regions related to cognitive and affective processing of painful stimuli. The results of this study contribute important information to the general pain and vulvodynia literatures in elucidating the specific sensorimotor neural mechanisms that underlie hyperalgesia in a chronic pain population. These results have implications for differentiating neural processing of touch and pain for women with and without PVD. Future research should attempt to examine alterations related to hyperalgesia in commonly comorbid conditions of PVD.
Collapse
|
18
|
Persistent Genitopelvic Pain: Classification, Comorbidities, Chronicity, and Interpersonal Factors. CURRENT SEXUAL HEALTH REPORTS 2020. [DOI: 10.1007/s11930-020-00239-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
19
|
Tribó MJ, Canal C, Baños JE, Robleda G. Pain, Anxiety, Depression, and Quality of Life in Patients with Vulvodynia. Dermatology 2019; 236:255-261. [PMID: 31694025 DOI: 10.1159/000503321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/12/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The term vulvodynia refers to vulvar pain of unknown origin lasting at least 3 months. Psychiatric comorbidities are a common feature and, along with pain, may severely affect patients' wellbeing. We aimed to determine the characteristics of pain in vulvodynia, to correlate characteristics with symptoms of anxiety and depression, and to analyse the impact of these factors on patients' quality of life. METHODS This cross-sectional observational study analysed pain, anxiety, and depression and the effects of these factors on quality of life. Pain, anxiety, and depression were assessed using validated tools in 110 women. RESULTS Statistical analyses found correlations between pain and anxiety and between anxiety and worsened quality of life. Patients often reported stinging, burning, pain, itching, and dyspareunia, pointing to the importance of temporal, localisation, punctate pressure, thermal, tactile sensitivity, and emotional tension characteristics. Most patients had severe pain related to psychiatric comorbidities and decreased quality of life. CONCLUSION Using descriptors of pain quality and assessing anxiety and depression might help to define subgroups of patients that may benefit from different therapeutic approaches and thus enable treatments to be tailored to individual patients.
Collapse
Affiliation(s)
- Maria José Tribó
- Department of Dermatology, Hospital Universitari del Mar, Barcelona, Spain
| | - Carla Canal
- School of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain
| | - Josep-E Baños
- School of Health and Life Sciences, Universitat Pompeu Fabra, Barcelona, Spain, .,Department of Experimental and Health Sciences, Laboratory of Neuropharmacology, Universitat Pompeu Fabra, Barcelona, Spain,
| | - Gemma Robleda
- Department of Experimental and Health Sciences, Laboratory of Neuropharmacology, Universitat Pompeu Fabra, Barcelona, Spain.,Mar School of Nursing, University Pompeu Fabra, Barcelona, Spain
| |
Collapse
|
20
|
Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment. Clin Obstet Gynecol 2019; 62:22-36. [PMID: 30383545 DOI: 10.1097/grf.0000000000000412] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patients with pelvic pain suffer from psychological conditions at a disproportionately high rate compared with their peers. We review environmental, genetic, inflammatory, and neurobiological factors that increase vulnerability to developing both of these conditions. We review treatment strategies for chronic pelvic pain in patients who have comorbid psychological conditions, including both nonpharmacologic and pharmacologic options.
Collapse
|
21
|
Bhatt RR, Gupta A, Rapkin A, Kilpatrick LA, Hamadani K, Pazmany E, Van Oudenhove L, Stains J, Aerts L, Enzlin P, Tillisch K, Mayer EA, Labus JS. Altered gray matter volume in sensorimotor and thalamic regions associated with pain in localized provoked vulvodynia: a voxel-based morphometry study. Pain 2019; 160:1529-1540. [PMID: 30817440 PMCID: PMC6586504 DOI: 10.1097/j.pain.0000000000001532] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Multimodal neuroimaging studies provide support for a role of alterations in sensory processing circuits and endogenous pain modulatory systems in provoked vestibulodynia (PVD). In this study, we tested the hypotheses that PVD compared with healthy controls (HCs) would demonstrate gray matter volume (GMV) alterations in regions associated with sensorimotor, corticothalamic, and basal ganglia circuits. We also tested the replicability of previously reported gray matter increases in basal ganglia and hippocampal volumes in PVD vs HCs. In addition, disease specificity of GMV alterations were examined by comparing PVD with another chronic pain disorder. Finally, we examine whether GMV alterations are correlated with symptom measures. Structural magnetic resonance imaging was obtained in 119 premenopausal women (45 PVD, 45 HCs, and 29 irritable bowel syndrome [IBS]). A voxel-based morphometry analysis was applied to determine group differences in the hypothesized regions of interest. Compared with HCs, PVD women exhibited greater GMV in the basal ganglia, hippocampus, and sensorimotor cortices. Compared to patients with IBS, women with PVD had greater GMV in the hippocampus, and sensorimotor network, but lower GMV in the thalamus and precentral gyrus. Regional GMV alterations were associated with patient reports of pain during intercourse and muscle tenderness. The current findings provide further evidence that GMV is increased in PVD compared with HCs in several regions of the sensorimotor network and the hippocampus in patients with PVD. In addition, GMV distinct alterations in the sensorimotor network were identified between 2 pelvic pain disorders, PVD compared with IBS.
Collapse
Affiliation(s)
- Ravi R. Bhatt
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
- Pediatric Pain and Palliative Care Program, UCLA
| | - Arpana Gupta
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
- David Geffen School of Medicine, UCLA
- UCLA Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA
| | - Andrea Rapkin
- David Geffen School of Medicine, UCLA
- Department of Obstetrics and Gynecology, UCLA
| | - Lisa A. Kilpatrick
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
- David Geffen School of Medicine, UCLA
- UCLA Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA
| | - Kareem Hamadani
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
| | - Els Pazmany
- Institute for Family and Sexuality Studies, KU Leuven
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders, University of Leuven
| | - Jean Stains
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
- David Geffen School of Medicine, UCLA
- UCLA Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA
| | - Leen Aerts
- Institute for Family and Sexuality Studies, KU Leuven
- Geneva University Hospitals
| | - Paul Enzlin
- Institute for Family and Sexuality Studies, KU Leuven
| | - Kirsten Tillisch
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
- David Geffen School of Medicine, UCLA
- UCLA Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA
| | - Emeran A. Mayer
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
- David Geffen School of Medicine, UCLA
- UCLA Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA
- Brain Research Institute, UCLA
| | - Jennifer S. Labus
- Gail and Gerald Oppenheimer Family Center for Neurobiology of Stress, UCLA
- David Geffen School of Medicine, UCLA
- UCLA Vatche & Tamar Manoukian Division of Digestive Diseases, UCLA
- Brain Research Institute, UCLA
| |
Collapse
|
22
|
Abstract
Interstitial cystitis/bladder pain syndrome (IC/BPS) and female sexual dysfunction (FSD) are common conditions that substantially reduce women's health. In particular, women with IC/BPS show vulvodynia, a kind of FDS that originates from consistent pain around the vulvar area. There have been many studies attempting to find the underlying mechanisms that induce the chronic pain associated with IC/BPS and vulvodynia and explain why these two conditions often coexist. Proposed theories suggest that pain hypersensitivity is being mediated by peripheral and central sensitization. However, there are still many unknown factors, such as etiologies, that can evoke pain hypersensitivity and may be linking the casual relationship between IC/BPS and vulvodynia. At present, knowledge regarding IC/BPS and vulvodynia are insufficient when considering their clinical importance. Therefore, efforts are necessary to elucidate the issues surrounding IC/BPS and vulvodynia.
Collapse
Affiliation(s)
- Su Jin Kim
- Department of Urology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea.,Current address: Department of Urology, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jayoung Kim
- Departments of Surgery and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA. .,Department of Medicine, University of California Los Angeles, Los Angeles, CA, 90095, USA.
| | - Hana Yoon
- Department of Urology, Medical Research Center, Ewha Womans University School of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
23
|
Jia X, Rana N, Crouss T, Whitmore KE. Gynecological associated disorders and management. Int J Urol 2019; 26 Suppl 1:46-51. [PMID: 31144734 DOI: 10.1111/iju.13974] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 03/18/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic pelvic pain syndrome is complex and involves multiple organ systems. The gynecological aspects of chronic pelvic pain syndrome can be divided into four different areas: intra-abdominal, vaginal, pelvic floor muscles and sexual pain. This article provides an overview of gynecological evaluation in patients with chronic pelvic pain and reviews the most common gynecological diagnoses and their management. METHODS An extensive review of the literature including guidelines from the International Continence Society, the European Association of Urology, and the International Association for the Study of Pain was performed. RESULTS Gynecological evaluation of patients with chronic pelvic pain begins with a thorough history and physical examination. Laboratory tests, imaging studies and diagnostic procedures can be used as adjuncts to make a diagnosis. Treatment modalities include physical therapy, medications, trigger points injections, and surgery. CONCLUSION Common gynecological diagnoses of chronic pelvic pain include endometriosis, adenomyosis, vulvodynia, high tone pelvic floor dysfunction, and genitopelvic pain/penetration disorder. Gynecology is one of the many systems that can be associated with chronic pelvic pain. Managing patients with chronic pelvic pain requires a multimodal and multidisciplinary approach.
Collapse
Affiliation(s)
- Xibei Jia
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Neha Rana
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Tess Crouss
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Kristene E Whitmore
- Division of Female Pelvic Medicine and Reconstructive surgery and Urology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
24
|
Lakshmi M, Khan SD. Sexual Pain Disorders in Women. Sex Med 2019. [DOI: 10.1007/978-981-13-1226-7_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
25
|
Bialas P, Gronwald B, Roloff K, Kreutzer S, Gottschling S, Welsch K, Volk T. Pain in tones - Is it possible to hear the pain quality? A pilot trial. PATIENT EDUCATION AND COUNSELING 2019; 102:134-138. [PMID: 30131265 DOI: 10.1016/j.pec.2018.08.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 06/15/2018] [Accepted: 08/10/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The adequate treatment of chronic pain also calls for measuring its quality not only its intensity. For this reason, this pilot study investigated the non-verbal description of pain quality based on tones, distinguishing between nociceptive and neuropathic pain. METHODS A nociceptive and a neuropathic pain stimulus were applied to 80 chronic pain patients and 80 healthy subjects. Using a tone generator, all participants matched both pain stimuli to an appropriate tone (in Hz). The stimulus intensity was measured using the NRS-scale, and the PainDETECT questionnaire was completed. RESULTS Both groups matched a significantly higher tone to the neuropathic than to the nociceptive pain stimulus. Compared to healthy participants, chronic pain patients allocated higher tones to both pain stimuli. Higher values were also shown for the neuropathic pain stimulus, and chronic pain patients indicated an overall higher intensity of pain as healthy participants. CONCLUSIONS It is possible to differentiate pain stimuli non-verbally through tones, however, whether quality or intensity, was the key factor remains unknown. Future studies could investigate the influence of additional factors. PRACTICAL IMPLICATIONS A practical tool using tones should be developed to detect pain quality in patients - without verbal descriptions - quickly and more precisely.
Collapse
Affiliation(s)
- Patric Bialas
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Germany.
| | - Benjamin Gronwald
- Centre of Palliative Care and Pediatric Pain, Saarland University Medical Center, Kirrbergerstrasse 1, 66421 Homburg/Saar, Germany
| | - Kati Roloff
- Center of Emergency Medicine, Klinik Hirslanden, Witellikerstrasse 40, 8032, Zürich, Switzerland
| | - Svenja Kreutzer
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Germany
| | - Sven Gottschling
- Centre of Palliative Care and Pediatric Pain, Saarland University Medical Center, Kirrbergerstrasse 1, 66421 Homburg/Saar, Germany
| | - Katja Welsch
- Centre of Palliative Care and Pediatric Pain, Saarland University Medical Center, Kirrbergerstrasse 1, 66421 Homburg/Saar, Germany
| | - Thomas Volk
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Germany
| |
Collapse
|
26
|
Diagnosis and management of vulvodynia in postmenopausal women. Maturitas 2018; 108:84-94. [DOI: 10.1016/j.maturitas.2017.11.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 10/25/2017] [Accepted: 11/01/2017] [Indexed: 11/23/2022]
|
27
|
Gupta A, Woodworth DC, Ellingson BM, Rapkin AJ, Naliboff B, Kilpatrick LA, Stains J, Masghati S, Tillisch K, Mayer EA, Labus JS. Disease-Related Microstructural Differences in the Brain in Women With Provoked Vestibulodynia. THE JOURNAL OF PAIN 2018; 19:528.e1-528.e15. [PMID: 29391213 DOI: 10.1016/j.jpain.2017.12.269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 11/06/2017] [Accepted: 12/17/2017] [Indexed: 12/13/2022]
Abstract
Provoked vestibulodynia (PVD) is a chronic pelvic pain disorder affecting 16% of the female population. Neuroimaging studies have highlighted central abnormalities in PVD, similar to other chronic pelvic pain disorders, including brain regions involved in sensory processing and modulation of pain. The aim of the study was to determine alterations in the subvoxel, microstructural organization within tissues in PVD compared with healthy control participants (HCs) and a disease control group (irritable bowel syndrome [IBS]). Diffusion tensor imaging magnetic resonance imaging was conducted in 87 age-matched premenopausal women (29 PVD, 29 HCs, 29 IBS). Statistical parameter mapping of fractional anisotropy (FA) and mean diffusivity (MD) maps were used to identify microstructural difference in the brain specific to PVD or shared with IBS. PVD alterations in microstructural organization of the brain were predominantly observed in fibers associated with sensorimotor integration and pain processing that relay information between the thalamus, basal ganglia, sensorimotor, and insular cortex. PVD, compared with HCs, showed extensive increases in the FA of somatosensory and basal ganglia regions. In contrast, PVD and IBS subjects did not show any FA-related group differences. PVD subjects showed greater MD in the basal ganglia compared with HCs (higher MD in the internal capsule and pallidum) and IBS (higher MD in the putamen and pallidum). Increases in MD were associated with increased vaginal muscle tenderness and vulvar pain. The current findings highlight possible shared mechanisms between 2 different pelvic pain disorders, but also highlight the widespread alterations observed specifically in PVD compared with HCs. PERSPECTIVE Alterations in microstructure in PVD were observed in fibers associated with sensorimotor integration and pain processing, which were also associated with increased vaginal muscle tenderness and vulvar pain. These alterations may be contributing to increased pain sensitivity and tenderness, highlighting the need for new therapies targeting the central nervous system.
Collapse
Affiliation(s)
- Arpana Gupta
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Davis C Woodworth
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Benjamin M Ellingson
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Department of Radiology at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Andrea J Rapkin
- Department of Obstetrics and Gynecology at UCLA, Los Angeles, California
| | - Bruce Naliboff
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Lisa A Kilpatrick
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jean Stains
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California
| | - Salome Masghati
- Department of Obstetrics and Gynecology at UCLA, Los Angeles, California
| | - Kirsten Tillisch
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Emeran A Mayer
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jennifer S Labus
- G. Oppenheimer Center for Neurobiology of Stress and Resilience at UCLA, Los Angeles, California; Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA, Los Angeles, California; David Geffen School of Medicine at UCLA, Los Angeles, California.
| |
Collapse
|
28
|
|
29
|
Pazmany E, Ly HG, Aerts L, Kano M, Bergeron S, Verhaeghe J, Peeters R, Tack J, Dupont P, Enzlin P, Van Oudenhove L. Brain responses to vestibular pain and its anticipation in women with Genito-Pelvic Pain/Penetration Disorder. NEUROIMAGE-CLINICAL 2017; 16:477-490. [PMID: 28932680 PMCID: PMC5596304 DOI: 10.1016/j.nicl.2017.07.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 07/02/2017] [Accepted: 07/22/2017] [Indexed: 01/27/2023]
Abstract
Objective In DSM-5, pain-related fear during anticipation of vaginal penetration is a diagnostic criterion of Genito-Pelvic Pain/Penetration Disorder (GPPPD). We aimed to investigate subjective and brain responses during anticipatory fear and subsequent induction of vestibular pain in women with GPPPD. Methods Women with GPPPD (n = 18) and age-matched healthy controls (HC) (n = 15) underwent fMRI scanning during vestibular pain induction at individually titrated pain threshold after a cued anticipation period. (Pain-related) fear and anxiety traits were measured with questionnaires prior to scanning, and anticipatory fear and pain intensity were rated during scanning using visual analog scales. Results Women with GPPPD reported significantly higher levels of anticipatory fear and pain intensity. During anticipation and pain induction they had stronger and more extensive brain responses in regions involved in cognitive and affective aspects of pain perception, but the group difference did not reach significance for the anticipation condition. Pain-related fear and anxiety traits as well as anticipatory fear ratings were positively associated with pain ratings in GPPPD, but not in HC. Further, in HC, a negative association was found between anticipatory fear ratings and brain responses in regions involved in cognitive and affective aspects of pain perception, but not in women with GPPPD. Conclusions Women with GPPPD are characterized by increased subjective and brain responses to vestibular pain and, to a lesser extent, its anticipation, with fear and anxiety associated with responses to pain, supporting the introduction of anticipatory fear as a criterion of GPPPD in DSM-5. Both subjective and brain responses during anticipation and induction of vestibular pain are increased in women with GPPPD. Between-group differences were found in brain regions involved in cognitive and affective aspects of the pain experience. These results support the addition of pain-related fear and anxiety in the diagnostic criteria of GPPPD in DSM-5.
Collapse
Key Words
- Anticipation of pain
- DSM-5, Diagnostic Statistical Manual of Mental Disorders, fifth edition
- FM, fibromyalgia
- FPQ, Fear of Pain Questionnaire
- GPPPD, Genito-Pelvic Pain/Penetration Disorder
- Genito-pelvic pain/penetration disorder
- HC, healthy controls
- IBS, irritable bowel syndrome
- OFC, orbitofrontal cortex
- PASS, Pain Anxiety Symptoms Scale
- PVD, provoked vestibulodynia
- Pain-related fear and anxiety
- Provoked vestibulodynia
- Q1, Quartile 1
- Q3, Quartile 3
- SAS, statistical analysis software
- SD, standard deviation
- SII, secondary somatosensory cortex
- SMA, supplementary motor area
- SPM8, Statistical Parametric Mapping, SPM8
- SPSS, Statistical Package for Social Sciences
- STAI, State-Trait Anxiety Inventory
- TR/TE, repetition time/echo time
- VAS, Visual Analogue Scale
- Vestibular pain
- aMCC, anterior midcingulate cortex
- dlPFC, dorsolateral prefrontal cortex
- fMRI
- fMRI, functional magnetic resonance imaging
- n, number
- pACC, perigenual anterior cingulate cortex
- vlPFC, ventrolateral prefrontal cortex
- vmPFC, ventromedial prefrontal cortex
Collapse
Affiliation(s)
- Els Pazmany
- Institute for Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Huynh Giao Ly
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Leen Aerts
- Department of Psychology, Université de Montréal, Montreal, Canada
| | - Michiko Kano
- The Frontier Research Institute for Interdisciplinary Sciences, Tohoku University, Sendai, Japan
| | - Sophie Bergeron
- Department of Psychology, Université de Montréal, Montreal, Canada
| | - Johan Verhaeghe
- Department of Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - Ronald Peeters
- Medical Diagnostic Sciences, KU Leuven & Radiology University Hospitals Leuven, Leuven, Belgium
| | - Jan Tack
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - Patrick Dupont
- Laboratory for Cognitive Neurology, Department of Neurosciences, KU Leuven & Medical Imaging Centre, University Hospitals Leuven, Leuven, Belgium
| | - Paul Enzlin
- Institute for Family and Sexuality Studies, Department of Neurosciences, KU Leuven, Leuven, Belgium.,Centre for Clinical Sexology and Sex Therapy, University Psychiatric Centre, KU Leuven, Leuven, Belgium
| | - Lukas Van Oudenhove
- Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| |
Collapse
|
30
|
Levin RJ, Both S, Georgiadis J, Kukkonen T, Park K, Yang CC. The Physiology of Female Sexual Function and the Pathophysiology of Female Sexual Dysfunction (Committee 13A). J Sex Med 2017; 13:733-59. [PMID: 27114190 DOI: 10.1016/j.jsxm.2016.02.172] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 02/22/2016] [Accepted: 02/24/2016] [Indexed: 01/01/2023]
Abstract
INTRODUCTION The article consists of six sections written by separate authors that review female genital anatomy, the physiology of female sexual function, and the pathophysiology of female sexual dysfunction but excluding hormonal aspects. AIM To review the physiology of female sexual function and the pathophysiology of female sexual dysfunction especially since 2010 and to make specific recommendations according to the Oxford Centre for evidence based medicine (2009) "levels of evidence" wherever relevant. CONCLUSION Recommendations were made for particular studies to be undertaken especially in controversial aspects in all six sections of the reviewed topics. Despite numerous laboratory assessments of female sexual function, genital assessments alone appear insufficient to characterise fully the complete sexual response.
Collapse
Affiliation(s)
- Roy J Levin
- Reader in Physiology (Retired), Department of Biomedical Science, University of Sheffield, Sheffield, UK: Section 2.
| | - Stephanie Both
- Department of Psychosomatic Gynecology and Sexology, Leiden University Medical Center, Leiden, The Netherlands: Section 3
| | - Janniko Georgiadis
- Department of Neuroscience, University Medical Center, Groningen, University of Groningen, The Netherlands: Section 4
| | - Tuuli Kukkonen
- College of Social and Applied Human Science, University of Guelph, Guelph, ON, Canada: Section 6
| | - Kwangsung Park
- Department of Urology, Chonnan National University Medical School, Gwangju, Korea: Section 5
| | - Claire C Yang
- Department of Urology, University of Washington, Seattle, WA, USA: Section 1
| |
Collapse
|
31
|
Morin A, Léonard G, Gougeon V, Cyr MP, Waddell G, Bureau YA, Girard I, Morin M. Efficacy of transcranial direct-current stimulation in women with provoked vestibulodynia. Am J Obstet Gynecol 2017; 216:584.e1-584.e11. [PMID: 28302387 DOI: 10.1016/j.ajog.2017.02.049] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 01/29/2017] [Accepted: 02/25/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Provoked vestibulodynia is a highly prevalent condition characterized by acute recurrent pain located at the vaginal entrance in response to pressure application or attempted vaginal penetration. Despite a wide variety of treatments offered to women with provoked vestibulodynia, a high proportion of women are refractory to conventional treatment. Transcranial direct-current stimulation is a noninvasive brain stimulation technique that has been shown effective for improving various chronic pain conditions. Growing evidence suggests that the central nervous system could play a key role in provoked vestibulodynia. Targeting the central nervous system could therefore be a promising treatment for women with provoked vestibulodynia. OBJECTIVE The purpose of this study was to evaluate and compare the efficacy of active and sham transcranial direct-current stimulation in reducing pain intensity during intercourse in patients with provoked vestibulodynia. STUDY DESIGN We conducted a triple-blind, parallel-group, randomized controlled trial. Women aged 17-45 years diagnosed with provoked vestibulodynia by a gynecologist using a validated protocol were randomized to 10 sessions of either active transcranial direct-current stimulation (intensity = 2 mA) or 10 sessions of sham transcranial direct-current stimulation, over a 2-week period. Both active and sham transcranial direct-current stimulation were applied for 20 minutes, with the anode positioned over the primary motor cortex, and the cathode over the contralateral supraorbital area. Outcome measures were collected at baseline, 2 weeks after treatment, and at 3-month follow-up by an evaluator blinded to group assignment. The primary objective was to assess pain intensity during intercourse, using a numerical rating scale. Secondary outcomes focused on sexual function and distress, vestibular sensitivity, psychological distress, treatment satisfaction, and patient impression of change. Statistical analyses were conducted on the intention-to-treat basis, and treatment effects were evaluated using a mixed linear model for repeated measures. RESULTS A total of 40 patients were randomly assigned to receive either active (n = 20) or sham (n = 20) transcranial direct-current stimulation treatments from November 2014 through February 2016. Baseline characteristics were similar between the active and sham transcranial direct-current stimulation groups. In full compliance with the study protocol, every participant followed all courses of the study treatment, including assessments at 2-week and 3-month follow-up. Pain during sexual intercourse was not significantly different between active and sham treatment groups 2 weeks after treatment (P = .84) and at follow-up (P = .09). Mean baseline and 2-week assessment pain intensity were, respectively, 6.8 (95% confidence interval, 5.9-7.7) and 5.6 (95% confidence interval, 4.7-6.5) for active transcranial direct-current stimulation (P = .03) vs 7.5 (95% confidence interval, 6.6-8.4) and 5.7 (95% confidence interval, 4.8-6.6) for sham transcranial direct-current stimulation (P = .001). Nonsignificant differences between the 2 groups were also found in their sexual function and distress after treatment (P > .20) and at follow-up (P > .10). Overall, at 2-week assessment 68% assigned to active transcranial direct-current stimulation reported being very much, much, or slightly improved compared to 65% assigned to sham transcranial direct-current stimulation (P = .82), and still comparable at follow-up: 42% vs 65%, respectively (P = .15). CONCLUSION Findings suggest that active transcranial direct-current stimulation is not more effective than sham transcranial direct-current stimulation for reducing pain in women with provoked vestibulodynia. Likewise, no significant effects were found on sexual function, vestibular sensitivity, or psychological distress.
Collapse
|
32
|
Multimodal Vulvar and Peripheral Sensitivity Among Women With Vulvodynia: A Case-Control Study. J Low Genit Tract Dis 2017; 21:78-84. [PMID: 27753704 DOI: 10.1097/lgt.0000000000000267] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess differences in vulvar and peripheral sensitivity between women with and without vulvodynia. METHODS Women with vulvodynia (n = 41) and age-matched controls (n = 43) seen in the outpatient setting were evaluated via surveys, clinical examination, and multimodal sensory testing (pressure, heat, cold, vibration, and electrical stimulation). The relationships between sensitivity to various sensory modalities and case/control status, as well as by vulvodynia subgroups, were assessed using logistic regression. RESULTS Women with vulvodynia were more sensitive to pressure and to electrical stimuli than were control women at the vulva (median, 22 vs 230 g and 0.495 vs 0.769 mA, respectively; P < 0.001 for each) and at the thumb (median, 2500 vs 4250 g and 0.578 vs 0.764 mA, respectively; P = 0.006 for pressure, P < 0.001 for electrical stimulation). Heat, cold, and vibration detection thresholds did not differ significantly between these groups (P > 0.025). Those reporting spontaneous pain versus provoked pain had greater pressure sensitivity to the thumb (median, 1850 vs 2690 g; P = 0.020) and greater electrical sensitivity at the introitus (0.450 vs 0.608 mA; P = 0.011), and those with primary versus secondary vulvodynia had substantially greater pressure sensitivity to the thumb (median, 2438 vs 3125 g, P = 0.004). However, having localized versus generalized vulvodynia was not associated with differences in pressure or electrical sensitivity. CONCLUSIONS Sensitivities to pressure and electrical stimuli are greater among vulvodynia cases than among controls and support 2 previously defined subgroups-those reporting spontaneous pain versus those whose pain only occurred when provoked, and those with primary versus secondary vulvodynia.
Collapse
|
33
|
Dargie E, Gilron I, Pukall CF. Self-Reported Neuropathic Pain Characteristics of Women With Provoked Vulvar Pain: A Preliminary Investigation. J Sex Med 2017; 14:577-591. [PMID: 28325536 DOI: 10.1016/j.jsxm.2017.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 02/08/2017] [Accepted: 02/19/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Provoked vestibulodynia (PVD) is a common chronic genital pain condition affecting approximately 12% of premenopausal women. Although parallels have been drawn between PVD and neuropathic pain (NP), no studies have examined self-reported NP characteristics in PVD. AIM To explore pain symptoms that resemble NP reported by those with PVD and compare responses with those with an established NP condition. METHODS Women with provoked vulvar pain (PVP; n = 65) completed online questionnaires designed to assess characteristics of NP. Responses were compared with those of women with postherpetic neuralgia (PHN; n = 30). OUTCOMES In addition to a range of descriptive questions, participants completed the McGill Pain Questionnaire, the Self-Complete Leeds Assessment of Neuropathic Signs and Symptoms (S-LANSS), the Neuropathic Pain Symptom Inventory (NPSI), and the Pain Quality Assessment Scale (PQAS). RESULTS PVP exhibits some neuropathic characteristics, typically evoked pain (as opposed to the more constant pain of PHN) indicative of allodynia and hyperalgesia. Specifically, women with PVP scored, on average, higher than the NP cutoff on the S-LANSS, and there were no significant differences between women with PVP and those with PHN on some NPSI subscales. However, women with PHN reported more NP symptoms on the PQAS, S-LANSS, and other NPSI subscales. CLINICAL IMPLICATIONS Validated NP questionnaires could be of particular use for health care professionals who need a more efficient way to assess symptoms of patients with PVP and should be included in future studies investigating the mechanisms and treatment of this pain. STRENGTHS AND LIMITATIONS This study takes a unique approach to the examination of PVP by using multiple validated NP measures to compare pain characteristics with those of a group of participants with PHN, an established NP condition. However, it is limited by self-reported data not confirmed with clinical examination, small size of the PHN group, and the severity of the pain experienced in the PVP group. CONCLUSION Women with PVP report some symptoms suggestive of NP characteristics, and future research should use NP measures in addition to physical examinations to further investigate the mechanisms that maintain this pain condition. Dargie E, Gilron I, Pukall CF. Self-Reported Neuropathic Pain Characteristics of Women With Provoked Vulvar Pain: A Preliminary Investigation. J Sex Med 2017;14:577-591.
Collapse
Affiliation(s)
- Emma Dargie
- Department of Psychology, Queen's University, Kingston, ON, Canada
| | - Ian Gilron
- Department of Anesthesiology and Perioperative Medicine, Queen's University, School of Medicine, Kingston, ON, Canada
| | | |
Collapse
|
34
|
McLean L, Brooks K. What Does Electromyography Tell Us About Dyspareunia? Sex Med Rev 2017; 5:282-294. [PMID: 28330675 DOI: 10.1016/j.sxmr.2017.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 02/13/2017] [Accepted: 02/14/2017] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Emergent evidence suggests that pelvic floor muscle (PFM) dysfunction contributes to dyspareunia, the experience of pain on vaginal penetration. Electromyography (EMG) is a valuable tool for the assessment of neuromuscular control and could be very useful in enhancing our understanding of PFM involvement in sexual function and in conditions such as dyspareunia. However, PFM EMG must be interpreted within the context of the many factors that can influence findings. AIM To outline the main factors to consider when evaluating PFM EMG for female sexual function and dyspareunia and to synthesize the literature in which EMG has been acquired and interpreted appropriately in this context. METHODS Standards for the acquisition and interpretation of EMG were retrieved and consulted. An exhaustive search of four electronic databases (Embase, CINAHL, PubMed, and PsycLit) and hand searching references from relevant articles were performed to locate articles relevant to PFM involvement in sexual function and in dyspareunia in which EMG was used as a primary outcome. Study outcomes were evaluated within the context of the appropriate application and interpretation of EMG and their contribution to knowledge. MAIN OUTCOME MEASURES A synthesis of the evidence was used to present the current state of knowledge on PFM involvement in sexual function and in dyspareunia. RESULTS Few standards documents and no practice guidelines for the acquisition and interpretation of PFM EMG are available. Some cohort studies with small samples of women have described the role of the PFMs in female sexual function. The literature on PFM involvement in dyspareunia also is limited, with outcomes suggesting that higher than normal tonic activation and higher than normal reflex responses might be present in the superficial PFM layer and might be characteristic features of dyspareunia. The data are less clear on the involvement of the deep layer of the PFMs in dyspareunia. CONCLUSION Guidelines for the application and interpretation of PFM EMG in the context of sexual function and dyspareunia are needed. When interpreted within the context of their strengths and limitations, EMG data have contributed valuable information to our understanding of PFM involvement in dyspareunia. The literature to date suggests that the superficial PFMs might have higher than normal tone and exaggerated responses to tactile or penetrative provocation in at least some women with dyspareunia. McLean L, Brooks K. What Does Electromyography Tell Us About Dyspareunia? Sex Med Rev 2017;5:282-294.
Collapse
Affiliation(s)
- Linda McLean
- School of Rehabilitation Science, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada.
| | - Kaylee Brooks
- School of Kinesiology, Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
35
|
Murina F, Graziottin A, Felice R, Gambini D. Alpha Lipoic Acid Plus Omega-3 Fatty Acids for Vestibulodynia Associated With Painful Bladder Syndrome. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 39:131-137. [DOI: 10.1016/j.jogc.2016.12.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 12/04/2016] [Accepted: 12/23/2016] [Indexed: 11/16/2022]
|
36
|
Gupta A, Mayer EA, Fling C, Labus JS, Naliboff BD, Hong JY, Kilpatrick LA. Sex-based differences in brain alterations across chronic pain conditions. J Neurosci Res 2017; 95:604-616. [PMID: 27870423 PMCID: PMC5120652 DOI: 10.1002/jnr.23856] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 06/18/2016] [Accepted: 07/06/2016] [Indexed: 12/17/2022]
Abstract
Common brain mechanisms are thought to play a significant role across a multitude of chronic pain syndromes. In addition, there is strong evidence for the existence of sex differences in the prevalence of chronic pain and in the neurobiology of pain. Thus, it is important to consider sex when developing general principals of pain neurobiology. The goal of the current Mini-Review is to evaluate what is known about sex-specific brain alterations across multiple chronic pain populations. A total of 15 sex difference and 143 single-sex articles were identified from among 412 chronic pain neuroimaging articles. Results from sex difference studies indicate more prominent primary sensorimotor structural and functional alterations in female chronic pain patients compared with male chronic pain patients: differences in the nature and degree of insula alterations, with greater insula reactivity in male patients; differences in the degree of anterior cingulate structural alterations; and differences in emotional-arousal reactivity. Qualitative comparisons of male-specific and female-specific studies appear to be consistent with the results from sex difference studies. Given these differences, mixed-sex studies of chronic pain risk creating biased data or missing important information and single-sex studies have limited generalizability. The advent of large-scale neuroimaging databases will likely aid in building a more comprehensive understanding of sex differences and commonalities in brain mechanisms underlying chronic pain. © 2016 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Arpana Gupta
- Oppenheimer Center for Neurobiology of Stress and Resilience, UCLA, Los Angeles, CA, USA
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Emeran A Mayer
- Oppenheimer Center for Neurobiology of Stress and Resilience, UCLA, Los Angeles, CA, USA
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Department of Psychiatry, UCLA, Los Angeles, CA, USA
- Pain and Interoception Network (PAIN), UCLA, Los Angeles, CA, USA
| | - Connor Fling
- Oppenheimer Center for Neurobiology of Stress and Resilience, UCLA, Los Angeles, CA, USA
| | - Jennifer S Labus
- Oppenheimer Center for Neurobiology of Stress and Resilience, UCLA, Los Angeles, CA, USA
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Department of Psychiatry, UCLA, Los Angeles, CA, USA
- Pain and Interoception Network (PAIN), UCLA, Los Angeles, CA, USA
| | - Bruce D Naliboff
- Oppenheimer Center for Neurobiology of Stress and Resilience, UCLA, Los Angeles, CA, USA
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Jui-Yang Hong
- Oppenheimer Center for Neurobiology of Stress and Resilience, UCLA, Los Angeles, CA, USA
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Lisa A Kilpatrick
- Oppenheimer Center for Neurobiology of Stress and Resilience, UCLA, Los Angeles, CA, USA
- Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Pain and Interoception Network (PAIN), UCLA, Los Angeles, CA, USA
| |
Collapse
|
37
|
Walitt B, Ceko M, Gracely JL, Gracely RH. Neuroimaging of Central Sensitivity Syndromes: Key Insights from the Scientific Literature. Curr Rheumatol Rev 2016; 12:55-87. [PMID: 26717948 DOI: 10.2174/1573397112666151231111104] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/24/2015] [Accepted: 12/29/2015] [Indexed: 12/14/2022]
Abstract
Central sensitivity syndromes are characterized by distressing symptoms, such as pain and fatigue, in the absence of clinically obvious pathology. The scientific underpinnings of these disorders are not currently known. Modern neuroimaging techniques promise new insights into mechanisms mediating these postulated syndromes. We review the results of neuroimaging applied to five central sensitivity syndromes: fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, temporomandibular joint disorder, and vulvodynia syndrome. Neuroimaging studies of basal metabolism, anatomic constitution, molecular constituents, evoked neural activity, and treatment effect are compared across all of these syndromes. Evoked sensory paradigms reveal sensory augmentation to both painful and nonpainful stimulation. This is a transformative observation for these syndromes, which were historically considered to be completely of hysterical or feigned in origin. However, whether sensory augmentation represents the cause of these syndromes, a predisposing factor, an endophenotype, or an epiphenomenon cannot be discerned from the current literature. Further, the result from cross-sectional neuroimaging studies of basal activity, anatomy, and molecular constituency are extremely heterogeneous within and between the syndromes. A defining neuroimaging "signature" cannot be discerned for any of the particular syndromes or for an over-arching central sensitization mechanism common to all of the syndromes. Several issues confound initial attempts to meaningfully measure treatment effects in these syndromes. At this time, the existence of "central sensitivity syndromes" is based more soundly on clinical and epidemiological evidence. A coherent picture of a "central sensitization" mechanism that bridges across all of these syndromes does not emerge from the existing scientific evidence.
Collapse
Affiliation(s)
- Brian Walitt
- National Center for Complementary and Integrative Health, National Institutes of Health, 10 Center Drive, Bethesda, MD 20814, USA.
| | | | | | | |
Collapse
|
38
|
Abstract
Vulvodynia refers to pain in the vulva of at least 3 months’ duration in the absence of a recognized underlying cause. Provoked, localized vestibulodynia is the term used to describe superficial pain confined to the vulvar vestibule, provoked by touch. This review will focus on provoked vestibulodynia with regard to its suggested causative factors and will discuss the role of inflammation, vulvovaginal infections, mucosal nerve fiber proliferation, hormonal associations, central pain mechanisms, pelvic floor muscle dysfunction, and genetic factors. Clinical observations, epidemiological studies, and data from basic research emphasize the heterogeneity of vulvar pain syndromes. There is a critical need to perform prospective, longitudinal studies that will allow better diagnostic criteria and subgrouping of patients that would lead to improvements in our understanding of provoked vestibulodynia and its treatment.
Collapse
Affiliation(s)
- Ahinoam Lev-Sagie
- Department of Obstetrics and Gynecology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Steven S Witkin
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
39
|
Wise NJ, Frangos E, Komisaruk BR. Activation of sensory cortex by imagined genital stimulation: an fMRI analysis. SOCIOAFFECTIVE NEUROSCIENCE & PSYCHOLOGY 2016; 6:31481. [PMID: 27791966 PMCID: PMC5084724 DOI: 10.3402/snp.v6.31481] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 06/29/2016] [Accepted: 07/12/2016] [Indexed: 11/14/2022]
Abstract
Background During the course of a previous study, our laboratory made a serendipitous finding that just thinking about genital stimulation resulted in brain activations that overlapped with, and differed from, those generated by physical genital stimulation. Objective This study extends our previous findings by further characterizing how the brain differentially processes physical ‘touch’ stimulation and ‘imagined’ stimulation. Design Eleven healthy women (age range 29–74) participated in an fMRI study of the brain response to imagined or actual tactile stimulation of the nipple and clitoris. Two additional conditions – imagined dildo self-stimulation and imagined speculum stimulation – were included to characterize the effects of erotic versus non-erotic imagery. Results Imagined and tactile self-stimulation of the nipple and clitoris each activated the paracentral lobule (the genital region of the primary sensory cortex) and the secondary somatosensory cortex. Imagined self-stimulation of the clitoris and nipple resulted in greater activation of the frontal pole and orbital frontal cortex compared to tactile self-stimulation of these two bodily regions. Tactile self-stimulation of the clitoris and nipple activated the cerebellum, primary somatosensory cortex (hand region), and premotor cortex more than the imagined stimulation of these body regions. Imagining dildo stimulation generated extensive brain activation in the genital sensory cortex, secondary somatosensory cortex, hippocampus, amygdala, insula, nucleus accumbens, and medial prefrontal cortex, whereas imagining speculum stimulation generated only minimal activation. Conclusion The present findings provide evidence of the potency of imagined stimulation of the genitals and that the following brain regions may participate in erogenous experience: primary and secondary sensory cortices, sensory-motor integration areas, limbic structures, and components of the ‘reward system’. In addition, these results suggest a mechanism by which some individuals may be able to generate orgasm by imagery in the absence of physical stimulation.
Collapse
Affiliation(s)
- Nan J Wise
- Department of Psychology, Rutgers University - Newark, Newark, NJ, USA;
| | - Eleni Frangos
- Department of Psychology, Rutgers University - Newark, Newark, NJ, USA
| | - Barry R Komisaruk
- Department of Psychology, Rutgers University - Newark, Newark, NJ, USA
| |
Collapse
|
40
|
Reed BD, Plegue MA, Harlow SD, Haefner HK, Sen A. Does Degree of Vulvar Sensitivity Predict Vulvodynia Characteristics and Prognosis? THE JOURNAL OF PAIN 2016; 18:113-123. [PMID: 27789257 DOI: 10.1016/j.jpain.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 08/18/2016] [Accepted: 10/12/2016] [Indexed: 01/13/2023]
Abstract
Although women with vulvodynia typically have increased vulvar sensitivity, data on characteristics associated with the degree of vulvar sensitivity are lacking. We measured vulvar sensitivity using cotton swab test and vulvodolorimeter among a subset of 335 women, aged younger than 70 years, in the longitudinal Woman to Woman Health Study. Comparing the vulvodynia screening results from their online/paper survey to that at the time of the examination, 42 women had ongoing vulvodynia, 66 had a recent remission, 22 control participants had a recent onset of vulvodynia, and 205 control participants remained asymptomatic. Vulvar sensitivity was greater in each vulvodynia group compared with the control group (P < .001), and was associated with younger age at first onset of pain (P = .025), pain after intercourse (P = .008), describing the pain as a "pressure," "burning," or "irritating" (P = .015, P = .005, and P = .006, respectively), with increased severity of pain ever (P = .012), and with subsequent persistent or relapsing vulvodynia (P < .001 for each). A score of >1 for the cotton swab summary score best differentiated case from control participants (sensitivity 71.9%; specificity 72.0%). Although 13.8% of women with vulvodynia had no increased sensitivity on cotton swab testing, they did not differ in most clinical characteristics or clinical course from those with increased vulvar sensitivity. PERSPECTIVE This study showed that women with vulvodynia have more vulvar sensitivity than control women, but the spectrum of sensitivity is broad. Furthermore, those with and without vulvar sensitivity did not differ in most vulvar pain characteristics or in prognosis, suggesting a positive swab test is not required to substantiate the diagnosis.
Collapse
Affiliation(s)
- Barbara D Reed
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Melissa A Plegue
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan
| | - Siobán D Harlow
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Hope K Haefner
- Department of Obstetrics and Gynecology, School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ananda Sen
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
41
|
Abstract
Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Affected women report negative impacts in terms of sexual functioning, relationship adjustment, psychological well-being and overall quality of life. Although the etiology of vulvodynia is not well understood, it appears as if different levels of pathophysiology are implicated. Accordingly, therapeutic options are targeted at a variety of mechanisms. Unfortunately, few randomized, controlled trials exist, and few combination therapies have been examined; however, the quality and breadth of the treatment literature is improving. Further studies are needed to more fully investigate the mechanisms involved in the development and maintenance of vulvodynia, and more research in the area of treatment outcome is needed.
Collapse
Affiliation(s)
- Caroline F Pukall
- Queen's University, Humphrey Hall, 62 Arch Street, Kingston, ON, K7L 3N6, Canada, Tel: +1 613 533 3200; Fax: +1 613 533 2499
| | - Kelly B Smith
- Queen's University, Department of Psychology, Humphrey Hall, 62 Arch Street, Kingston, ON, K7L 3N6, Canada, Tel: +1 613 533 3276; Fax: +1 613 533 2499
| | - Susan M Chamberlain
- Kingston General Hospital, Department of Obstetrics and Gynecology, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada, Tel: +7 613 548 6069; Fax: +7 613 548 1330
| |
Collapse
|
42
|
Zhuo M. Contribution of synaptic plasticity in the insular cortex to chronic pain. Neuroscience 2016; 338:220-229. [PMID: 27530697 DOI: 10.1016/j.neuroscience.2016.08.014] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 08/03/2016] [Accepted: 08/04/2016] [Indexed: 12/20/2022]
Abstract
Animal and human studies have consistently demonstrated that cortical regions are important for pain perception and pain-related emotional changes. Studies of the anterior cingulate cortex (ACC) have shown that adult cortical synapses can be modified after peripheral injuries, and long-term changes at synaptic level may contribute to long-lasting suffering in patients. It also explains why chronic pain is resistant to conventional analgesics that act by inhibiting synaptic transmission. Insular cortex (IC), another critical cortical area, is found to be highly plastic and can undergo long-term potentiation (LTP) after injury. Inhibiting IC LTP reduces behavioral sensitization caused by injury. LTP of glutamatergic transmission in pain related cortical areas serves as a key mechanism for chronic pain.
Collapse
Affiliation(s)
- Min Zhuo
- Department of Physiology, Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; Center for Neuron and Disease, Frontier Institutes of Science and Technology, Xi'an Jiaotong University, Xi'an 710049, China; Centre for the Study of Pain, University of Toronto, Ontario M5S 1A8, Canada.
| |
Collapse
|
43
|
2015 ISSVD, ISSWSH and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. Obstet Gynecol 2016; 127:745-751. [PMID: 27008217 DOI: 10.1097/aog.0000000000001359] [Citation(s) in RCA: 148] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION In 2014, the executive council of the International Society for the Study of Vulvovaginal Disease, the boards of directors of the International Society for the Study of Women's Sexual Health, and the International Pelvic Pain Society acknowledged the need to revise the current terminology of vulvar pain, on the basis of the significant increase in high-quality etiologic studies published in the last decade. MATERIALS AND METHODS The new terminology was achieved in the following 4 steps. The first involved a terminology consensus conference with representatives of the 3 societies, held in April 2015. Then, an analysis of the relevant published studies was used to establish a level of evidence for each factor associated with vulvodynia. The terminology was amended on the basis of feedback from members of the societies. Finally, each society's board accepted the new terminology. RESULTS AND CONCLUSIONS In 2015,the International Society for the Study of Vulvovaginal Disease, International Society for the Study of Women's Sexual Health, and International Pelvic Pain Society adopted a new vulvar pain and vulvodynia terminology that acknowledges the complexity of the clinical presentation and pathophysiology involved in vulvar pain and vulvodynia, and incorporates new information derived from evidence-based studies conducted since the last terminology published in 2003.
Collapse
|
44
|
Physical Therapy in the Treatment of Central Pain Mechanisms for Female Sexual Pain. Sex Med Rev 2016; 5:20-30. [PMID: 27498209 DOI: 10.1016/j.sxmr.2016.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 06/19/2016] [Accepted: 06/23/2016] [Indexed: 01/26/2023]
Abstract
INTRODUCTION The complexity of female sexual pain requires an interdisciplinary approach. Physical therapists trained in pelvic health conditions are well positioned to be active members of an interdisciplinary team addressing the assessment and treatment of female sexual pain. Changes within physical therapy practice in the last ten years have resulted in significant utilization of pelvic floor muscle relaxation and manual therapy techniques to address a variety of pelvic pain conditions, including female sexual pain. However, sexual pain is a complex issue giving credence to the necessity of addressing all of the drivers of the pain experience- biological, psychological and social. AIM This review aims to reconcile current pain science with a plan for integrating a biopsychosocial approach into the evaluation and subsequent treatment for female sexual pain for physical therapists. METHODS A literature review of the important components of skilled physical therapy interventions is presented including the physical examination, pain biology education, cognitive behavioral influences in treatment design, motivational interviewing as an adjunct to empathetic practice, and the integration of non-threatening movement and mindfulness into treatment. MAIN OUTCOME MEASURE A single case study is used to demonstrate the biopsychosocial framework utilized in this approach. RESULTS Appropriate measures for assessing psychosocial factors are readily available and inform a reasoned approach for physical therapy design that addresses both peripheral and central pain mechanisms. Decades of research support the integration of a biopsychosocial approach in the treatment of complex pain, including female sexual pain. CONCLUSION It is reasonable for physical therapists to utilize evidence based strategies such as CBT, pain biology education, Mindfulness Based Stress Reduction (MBSR), yoga and imagery based exercises to address the biopsychosocial components of female sexual pain.
Collapse
|
45
|
Thibault-Gagnon S, Morin M. Active and Passive Components of Pelvic Floor Muscle Tone in Women with Provoked Vestibulodynia: A Perspective Based on a Review of the Literature. J Sex Med 2016; 12:2178-89. [PMID: 26745618 DOI: 10.1111/jsm.13028] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
AIM Pelvic floor muscle (PFM) dysfunctions, especially elevated tone or tension, are suggested to play an important role in the pathophysiology of provoked vestibulodynia (PVD). However, the involvement of the PFMs remains misunderstood as the assessment of muscle tone is complex and requires a thorough understanding of muscle physiology in relation to the characteristics and limitations of current PFM assessment tools. The aim of this review was to describe the structures and mechanisms involved in muscle tone in normally innervated muscle, and to discuss and relate these concepts to the PFM findings in women with PVD. METHODS A narrative overview of the literature retrieved from searches of electronic databases and hand searches. RESULTS Muscle tone in a normally innervated muscle comprises both active (contractile) and passive (viscoelastic) components. Current methods for evaluating PFM tone such as digital palpation, ultrasound imaging, pressure perineometry, dynamometry, and electromyography may evaluate different components. Research findings suggestive of PFM hypertonicity in women with PVD include elevated general PFM tone, changes in viscoelastic properties, and at least in some women, abnormal increases in electrogenic activity. CONCLUSION There is a growing body of evidence to support the involvement of PFM hypertonicity in the pathophysiology of PVD. Limitations of the instruments as well as their properties should be considered when evaluating PFM tone in order to obtain better insight into which component of PFM tone is assessed. Future research is required for further investigating the underlying mechanisms of PFM hypertonicity, and studying the specific effects of physiotherapeutic interventions on PFM tone in women with PVD.
Collapse
Affiliation(s)
| | - Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada.,Research Center, Centre hospitalier universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| |
Collapse
|
46
|
|
47
|
Morin A, Léonard G, Gougeon V, Waddell G, Bureau YA, Girard I, Morin M. Efficacy of transcranial direct-current stimulation (tDCS) in women with provoked vestibulodynia: study protocol for a randomized controlled trial. Trials 2016; 17:243. [PMID: 27179944 PMCID: PMC4867997 DOI: 10.1186/s13063-016-1366-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 04/29/2016] [Indexed: 12/31/2022] Open
Abstract
Background Provoked vestibulodynia is the most common form of vulvodynia. Despite its high prevalence and deleterious sexual, conjugal, and psychological repercussions, effective evidence-based interventions for provoked vestibulodynia remain limited. For a high proportion of women, significant pain persists despite the currently available treatments. Growing evidence suggests that the central nervous system (CNS) could play a key role in provoked vestibulodynia; thus, treatment targeting the CNS, rather than localized dysfunctions, may be beneficial for women suffering from provoked vestibulodynia. In this study, we aim to build on the promising results of a previous case report and evaluate whether transcranial direct-current stimulation, a non-invasive brain stimulation technique targeting the CNS, could be an effective treatment option for women with provoked vestibulodynia. Methods/design This single-center, triple-blind, parallel group, randomized, controlled trial aims to compare the efficacy of transcranial direct-current stimulation with sham transcranial direct-current stimulation in women with provoked vestibulodynia. Forty women diagnosed with provoked vestibulodynia by a gynecologist, following a standardized treatment protocol, are randomized to either active transcranial direct-current stimulation treatment for ten sessions of 20 minutes at an intensity of 2 mA or sham transcranial direct-current stimulation over a 2-week period. Outcome measures are collected at baseline, 2 weeks after treatment and at 3-month follow-up. The primary outcome is pain during intercourse, assessed with a numerical rating scale. Secondary measurements focus on the sexual function, vestibular pain sensitivity, psychological distress, treatment satisfaction, and the patient’s global impression of change. Discussion To our knowledge, this study is the first randomized controlled trial to examine the efficacy of transcranial direct-current stimulation in women with provoked vestibulodynia. Findings from this trial are expected to provide significant information about a promising intervention targeting the centralization of pain in women with provoked vestibulodynia. Trial registration Clinicaltrials.gov, NCT02543593. Registered on September 4, 2015. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1366-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Annie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec, Canada
| | - Guillaume Léonard
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec, Canada
| | - Véronique Gougeon
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec, Canada
| | - Guy Waddell
- Department of Obstetrics Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec, Canada
| | - Yves-André Bureau
- Department of Obstetrics Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec, Canada
| | - Isabelle Girard
- Department of Obstetrics Gynecology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec, Canada
| | - Mélanie Morin
- School of Rehabilitation, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12th Avenue North, Sherbrooke, Québec, Canada.
| |
Collapse
|
48
|
2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. J Low Genit Tract Dis 2016; 20:126-30. [DOI: 10.1097/lgt.0000000000000190] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
49
|
Bornstein J, Goldstein AT, Stockdale CK, Bergeron S, Pukall C, Zolnoun D, Coady D, Bornstein J, Goldstein A, Zolnoun D, Bachmann GA, Bissonnette I, Bergeron S, Starke NB, Burrows L, Coady D, Dellon AL, Farmer M, Foster D, Fox S, Goldstein I, Gracely R, Haefner HK, Kellogg-Spadt S, Marvel R, Barracco MM, Morrison P, Parish S, Prendergast S, Pukall C, Reed B, Stockdale C, Boardman L, Goldstein L, Mate P. 2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia. J Sex Med 2016; 13:607-12. [DOI: 10.1016/j.jsxm.2016.02.167] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
50
|
The relationship between fibromyalgia and pressure pain threshold in patients with dyspareunia. Pain Res Manag 2016; 20:137-40. [PMID: 25996766 PMCID: PMC4447156 DOI: 10.1155/2015/302404] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the number of tender points, pressure pain threshold and presence of fibromyalgia among women with or without dyspareunia. METHODS The present cross-sectional study included 40 patients with dyspareunia and 30 healthy controls. The participants were asked if they had engaged in sexual intercourse during the previous four weeks, and dyspareunia was rated from 0 to 3 based on the Marinoff Dyspareunia Scale. A pressure algometer (dolorimeter) was used to measure the pressure pain threshold. Fibromyalgia was diagnosed based on the 1990 American College of Rheumatology criteria. The depression status of the participants was assessed using the Beck Depression Inventory. RESULTS No statistically significant difference was found with regard to age, body mass index, habits (alcohol use and smoking), educational status and occupational status between the two groups. Total myalgic score, total control score and tender point mean pain threshold were significantly lower in the group with dyspareunia. The number of tender points was significantly higher in patients with dyspareunia. The mean Beck Depression Inventory score was 14.7±8.4 in the dyspareunia group compared with 11.2±7.1 in the control group. Five (12.5%) of the patients with dyspareunia were diagnosed with fibromyalgia, whereas no patients in the control group were diagnosed with fibromyalgia. There was no significant difference between the two groups with regard to the presence of fibromyalgia. CONCLUSION The finding of lower pressure pain thresholds and a higher number of tender points among patients with dyspareunia suggests that these patients may have increased generalized pain thresholds. Additional studies involving a larger number of patients are required to investigate the presence of central mechanisms in the pathogenesis of dyspareunia.
Collapse
|