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

Guided internet-based acceptance and commitment therapy for provoked vestibulodynia: A randomized controlled trial

BACKGROUND

Provoked vestibulodynia (PVD) causes suffering in many women's lives due to its impact on relationships, sexual functioning and functioning in other key domains.

OBJECTIVE

Here, we report a randomized controlled trial conducted to examine whether Acceptance and Commitment Therapy (ACT) with a focus on values-based exposure, delivered online, benefits women with PVD.

METHODS

Participants (n = 88) were randomized to either guided online ACT for 10 weeks or a wait-list control group. Outcomes were assessed at baseline, post treatment and 1 year later. Analyses were based on intention to treat using linear mixed models.

RESULTS

There were significant group differences on the primary outcomes, Female Sexual Index and Female Sexual Distress Scale, in favour of online ACT with moderate effect sizes. Differences were also found on several secondary outcomes and therapeutic process measures, all in favour of ACT. No differences were found at post-treatment for depression or anxiety. At the 1-year follow-up, results were maintained and a difference between baseline and follow-up was also found for depression.

CONCLUSION/SIGNIFICANCE

In summary, a relatively brief, guided, online version of ACT appears to produce benefits for women with PVD and related impacts on daily functioning. 50% to 60% of the women who participated in the treatment reliably improved in sexual functioning and distress.

Help-seeking experiences and intimate partner support in vulvodynia: A qualitative exploration

BACKGROUND

Vulvodynia is a poorly understood chronic pain condition characterized by persistent and unexplained pain in the vulva. Given the intimate nature of the pain, partners may play an important role in promoting self-management and help-seeking behaviours among women with vulvodynia.

OBJECTIVES

The current study aimed to explore the role of partner support in pain experiences and help-seeking behaviours among women with vulvodynia.

DESIGN

A qualitative interpretive design was used.

METHODS

Ten women with vulvodynia (M age = 37.9 years) were interviewed using a semi-structured non-directive topic guide. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes around help-seeking experiences were constructed from the data: (1) 'It's Been a Battle' - Failed by the Healthcare System; (2) 'It's Just the Vulva' - Dismissed by Healthcare Professionals; and (3) 'I Diagnosed Myself' - The Patient Becomes the Expert. Participants described negative help-seeking experiences characterized by long delays to diagnosis, lack of awareness and understanding from healthcare professionals, minimization of symptoms, and having to advocate for and demand care. A further three themes pertaining to partner support were also developed: (1) 'That Person to Listen to You' - Source of Emotional Support; (2) 'Why Don't You Try This?' - Finding Solutions Together; and (3) 'He Forgets that it's Still There' - Vulvodynia is a Foreign Concept. Partners provided emotional support and showed empathy and understanding, and practical support by accompanying women to medical appointments and help with pain management. However, participants felt partners' understanding of vulvodynia was limited and that this impacted their relationships.

CONCLUSIONS

Findings highlight a lack of continuity of care and multidisciplinary approach to treatment, with help-seeking experiences being mainly negative in this sample. Increasing public awareness of vulvodynia and improving healthcare access is crucial to improving physical and psychological outcomes for this group. Partners can play an important role in supporting people with vulvodynia; however, other outlets of support should be further explored.

Managing recurrent vulvovaginal thrush from patient and healthcare professional perspectives: A systematic review and thematic synthesis

OBJECTIVE

This systematic review aims to identify what is known about patient and healthcare professional experiences of managing recurrent vulvovaginal thrush by synthesising published findings.

METHODS

Five databases were searched for studies on patient and healthcare professional experiences managing recurrent thrush. Two reviewers independently screened and quality assessed qualitative, quantitative, and mixed-methods studies. Findings from eligible studies were thematically synthesised.

RESULTS

720 papers were identified, and 29 were included. Four descriptive themes were developed to depict the repeated management of recurrent thrush. These themes were: (re)experiencing impacts, (re)identifying recurrent thrush, (re)considering consultations, and (re)trying treatments. An analytic high-order frame of 'interwoven and reoccurring uncertainties' was used to understand these themes.

CONCLUSIONS

Patients and healthcare providers face uncertainties when managing recurrent thrush. The inconsistencies raised across papers suggests an unaddressed gap in knowledge about patient experiences and their informational and support needs; this includes insights about this condition's diagnosis, management, treatment, impacts, and meaning.

PRACTICE IMPLICATIONS

This review has implications for patient education, health promotion, and communication between patients and providers. Our interpretations suggest the need for more research and resources to help support patients and clinicians in managing this condition to promote more understanding, communication, and collaborative care.

Exploring the health care experiences of women diagnosed with vulvodynia

BACKGROUND

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

AIM

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

METHODS

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

OUTCOMES

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

RESULTS

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

CLINICAL IMPLICATIONS

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

STRENGTHS AND LIMITATIONS

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

CONCLUSION

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

Clinical empathy in GP-training: Experiences and needs among Dutch GP-trainees. "Empathy as an element of personal growth"

OBJECTIVE

Clinical empathy has been described as a key component of effective person-centeredness in patient-physician communication. Yet little is known about general practitioner (GP) trainees' experiences and opinions regarding clinical empathy, empathy-education and the development of empathic skills. This study aimed to explore trainees' experiences with clinical empathy during GP training.

METHODS

This study used focus group interviews. GP trainees at two Dutch universities were approached by e-mail. Focus groups were conducted between April and November 2018. Six focus groups were conducted: two with starting trainees, two with trainees at the end of their first year and two with trainees at the end of their 3 years' training. Two experienced qualitative researchers analyzed the focus groups. During the thematic analysis the differences and similarities between the various stages of education were taken into account and a framework for the identified themes and subthemes was developed.

RESULTS

Thirty-five GP trainees took part. Four main themes could be identified. Starting trainees experienced frictions regarding the influence of personal affective reactions on their medical competencies. Trainees at the end of their first year indicated that they reached a balance between empathic involvement and their responsibility to carry out relevant medical tasks, such as following GP guidelines. Trainees at the end of their three years' training recognized the mutual relationship between the development of the behavioral part of clinical empathy and personal growth. All trainees stated that their needs concerning education changed during their GP training and proposed changes to the curriculum.

CONCLUSIONS

GP trainees face various obstacles in developing empathic skills and behavior. Particularly they mention handling personal affective reactions. Trainees express a clear wish for clinical empathy, in its theoretical as well as its skill and emotional aspects, to play a central role in the curriculum.

PRACTICE IMPLICATIONS

More explicit attention to be paid to empathy by embedding theoretical education, explicit attention to skill training and assessment of empathic behavior by patients and supervisors.

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

INTRODUCTION

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

AIM

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical management of neuroproliferative-associated vestibulodynia: a tutorial on vestibulectomy with vaginal advancement flap

Provoked vestibulodynia is an often underdiagnosed and mismanaged medical condition that impacts the lives of many women. When symptoms are due to a dramatically increased density of pain fibers in the vestibular endoderm, the condition is referred to as neuroproliferative-associated vestibulodynia. Unfortunately, assessment of pain fiber density can only be performed after surgery during histologic examination. First-line therapies for this condition often include topical or oral medications targeting hyperalgesia and allodynia at the vulvar vestibule. However, in the setting of refractory disease, surgical treatment should be considered. The surgical video (Video 1) highlights anatomical landmarks as well as key surgical steps when performing a vulvar vestibulectomy with a vaginal advancement flap for the treatment of neuroproliferative-associated vestibulodynia. Surgeons should have a thorough understanding of pertinent vulvar anatomical landmarks before performing this procedure (Figure 1). The goal of vulvar vestibulectomy, as described in this video, is to excise the entirety of the vestibule containing the pathologic density of afferent pain fibers. This tutorial serves to identify key anatomical landmarks including Hart's line as well as outline the meticulous dissection required for successful completion of this procedure. We describe our surgical instrumentation as well as provide insight into steps that can be taken to minimize postoperative morbidity.