Tender point examination in women with vulvar vestibulitis syndrome

Distinct neural signaling characteristics between fibromyalgia and provoked vestibulodynia revealed by means of functional magnetic resonance imaging in the brainstem and spinal cord

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.

An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia (PVD): Alterations of Spinal Cord and Brainstem Connectivity

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.

An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia: Alterations of Brain Connectivity

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.

New Insights about Chronic Pelvic Pain Syndrome (CPPS)

BACKGROUND

Chronic pelvic pain syndrome (CPPS) is one of the common diseases in urology and gynecology. CPPS is a multifactorial disorder where pain may originate in any of the urogynecological, gastrointestinal, pelvic musculoskeletal, or nervous systems. The symptoms of CPPS appear to result from an interplay between psychological factors and dysfunction in the immune, neurological, and endocrine systems. The aim of this article was to present new insight about CPPS in order to raise awareness of nursing and medical staff in the identification and diagnosis of the syndrome and to promote an appropriate treatment for each woman who suffers from CPPS.

METHODS

A literature review about the factors associated with CPPS and therapeutic interventions for CPPS was conducted.

RESULTS

CPPS represents a chronic pain syndrome that combines anatomic malfunction of the pelvic floor muscles with malfunction of pain perception linked with psychological and cognitive factors.

CONCLUSIONS

The therapeutic interventions in CPPS cases should, consequently, follow a multidisciplinary approach.

Predictors of Pelvic Floor Muscle Dysfunction Among Women With Lumbopelvic Pain

BACKGROUND

There is evidence to suggest that a large proportion of individuals seeking care for lumbopelvic pain also have pelvic floor muscle dysfunction (PFMD). Because the majority of physical therapists do not have the requisite training to adequately assess pelvic floor musculature, determining predictors of PFMD could be clinically useful.

OBJECTIVE

The objective was to establish a combination of factors (self-report and physical) predictive of PFMD in women with lumbopelvic pain.

DESIGN

This was a cross-sectional study.

METHODS

Participants completed a battery of self-report and physical assessments (masked assessors). Three clinical findings characterized PFMD: weakness of the pelvic floor, lack of coordination of the pelvic floor, and pelvic floor muscle tenderness on palpation (bilateral obturator internus). Univariate and multivariate logistic regression analyses were used to determine the extent to which different predictors were associated with PFMD.

RESULTS

One hundred eight women with self-reported lumbopelvic pain (within the past week) were included in the study (mean age = 40.4 years; SD = 12.6 years). None of the examined factors predicted pelvic floor muscle weakness. Two factors independently predicted pelvic floor muscle tenderness on palpation: very strong and/or uncontrollable urinary urges (odds ratio [OR] = 2.93; 95% confidence interval [CI] = 1.13-7.59) and Central Sensitization Inventory scores of 40 or greater (OR = 3.13; 95% CI = 1.08-9.10).

LIMITATIONS

The sample consisted of young women, some of whom were not actively seeking care. Additionally, the technique for assessing pelvic floor muscle tenderness on palpation requires further validation.

CONCLUSIONS

Women who have lumbopelvic pain, uncontrollable urinary urgency, and central sensitization were, on average, 2 times more likely to test positive for pelvic floor muscle tenderness on palpation. Further studies are needed to validate and extend these findings.

Thermal and Mechanical Pain Thresholds of Women With Provoked Localized Vulvodynia: A Pilot Study

Context

Vulvodynia is a chronic pain condition defined as vulvar pain lasting at least 3 months in the absence of gross anatomic or neurologic findings. Provoked, localized vulvodynia (PLV), a subtype of vulvodynia, is characterized by vestibular pain in response to light touch. The cause of PLV remains largely unknown, and triggering events have yet to be determined.

Objective

To evaluate vestibular and peripheral experimental pain thresholds in patients with PLV to further define the somatosensory profile of these patients.

Methods

After informed consent was provided, eligible participants completed a questionnaire and underwent quantitative sensory testing at the forearm and posterior vestibule. Detection and pain thresholds to thermal (cold and heat) and mechanical (pressure) stimuli were measured.

Results

Seventeen participants with PLV and 16 control participants were included. Participants in the PLV group scored lower on the patient health questionnaire 9 (PHQ-9) compared with those in the control group (P<.05) and had higher ratings of self-reported genital pain with sex (P<.001) and daily activity (P<.05). Forearm pain thresholds to cold (P<.01) and heat (P<.01) stimuli were also lower in the PLV group compared with those in the control group. Vestibular pain thresholds to cold (P<.05) and pressure (P<.01) stimuli were also lower in the PLV group.

Conclusion

Lower scores on the PHQ-9 and higher self-reported genital pain ratings of patients with PLV highlight the significant impact of this poorly understood condition on quality of life. Quantitative sensory testing results demonstrated that vestibular cold allodynia may be a somatosensory feature of PLV. Reduced forearm pain thresholds in these patients suggest altered sensory processing at extrapelvic sites, although it is unclear whether these measurements are related to central sensitization.

Pressure Pain Threshold and Anxiety in Adolescent Females With and Without Juvenile Fibromyalgia: A Pilot Study

OBJECTIVES

Reduced pain thresholds have been documented in adult fibromyalgia, but there are no quantitative studies of altered pain sensitivity in adolescents with juvenile fibromyalgia (JFM). The current study examined differences in pressure pain sensitivity between adolescent females with JFM and healthy controls. The relationship between levels of anxiety and pain were also examined.

METHODS

A total of 34 JFM (15.4±1.4 y old) and 31 controls (14.5±1.3 y old) completed self-report measures of pain and anxiety. Pressure pain threshold was assessed (palm and forehead sites) with a hand-held algometer. Participants indicated the first sensation of pain and then rated the intensity of pain on a Numerical Rating Scale.

RESULTS

Adolescents with JFM exhibited greater sensitivity to pressure pain compared with controls. While the difference between JFM and controls was only observed at the forehead, the intensity of pain produced by the pressure algometry at both sites was significantly higher in the JFM participants compared with controls. Correlations between clinical pain and anxiety were significant for the JFM group only. No relationships were observed between anxiety and pressure pain for either group.

DISCUSSION

This study is a first step toward investigating mechanisms of altered pain processing in adolescents with JFM. Adolescents with JFM were found be more sensitive to pressure pain than their healthy peers, which suggests a propensity for sensitization of peripheral and/or central nociceptive information often reported in adult fibromyalgia, and which does not appear to be affected by anxiety.

A common pronociceptive pain modulation profile typifying subgroups of chronic pelvic pain syndromes is interrelated with enhanced clinical pain

Provoked vestibulodynia (PVD) and painful bladder syndrome (PBS), subgroups of chronic pelvic pain syndromes (CPPS), are considered to share common biophysiological peripheral mechanisms. In addition, indications of a pronociceptive pain profile coexisting with psychological vulnerability suggest common dysfunctional pain processing and pain modulation in these 2 subgroups of CPPS. We therefore aimed at comparing the pain profile and psychological traits of patients with PVD and PBS to see whether the pain profile contributes to intersubject variability of clinical pain symptoms. Patients with PVD (n = 18) and PBS (n = 21) were compared with healthy controls (n = 20) in their responses to (1) pain psychophysical tests applied to both referred (suprapubis) and remote (hand) body areas and (2) pain-related psychological factors (pain catastrophizing, depression, anxiety, and somatization). We found a similar pronociceptive pain profile in the 2 subgroups of CPPS-enhanced facilitation (ie, hyperalgesia in the referred body area [P < 0.001]) and inefficient inhibition (ie, reduced conditioned pain modulation [P < 0.001] that were associated with both enhanced pain ratings evoked during trigger point examination [P < 0.037]) and higher Brief Pain Inventory ratings (P = 0.002). The latter was also correlated with pain catastrophizing (r = 0.504, P = 0.001) and depression symptoms (r = 0.361, P = 0.024). The findings suggest common mechanisms underlying a dysfunctional nociceptive system in both PVD and PBS. The intersubject variability in the level of dysfunction and its association with disease severity recommends a personalized pain treatment that may alleviate daily pain and dysfunction in patients with CPPS.

Recent advances in understanding provoked vestibulodynia

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.

Provoked Vestibulodynia

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.

Active and Passive Components of Pelvic Floor Muscle Tone in Women with Provoked Vestibulodynia: A Perspective Based on a Review of the Literature

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.

The relationship between fibromyalgia and pressure pain threshold in patients with dyspareunia

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.

Turn-amplitude analysis as a diagnostic test for myofascial syndrome in patients with chronic pelvic pain

Myofascial pain syndrome of the pelvic floor is a common cause of chronic pelvic pain. The etiology of this neuromuscular pain disorder is unknown and symptoms can vary widely. Research attempting to identify an appropriate diagnostic test has, to date, not been fruitful. This study aimed to investigate the utility of turns-amplitude analysis, which involves analyzing electromyography data of the levator ani and anal sphincter muscles, as a diagnostic tool.

BACKGROUND:

Myofascial pain syndrome of the pelvic floor (MPSPF) is a common disease in the context of chronic pelvic pain (CPP); however, there is currently no gold-standard test to diagnose it.

OBJECTIVE:

To validate the turns-amplitude analysis (TAA) as a diagnostic test for MPSPF in patients with CPP.

METHODS:

A case-control study was performed, and patients were consecutively sampled within a specified period of time. A total of 128 patients were included: 64 patients with CPP (32 men and 32 women) and 64 control patients (32 men and 32 women). The same operator conducted all tests. Electromyography of the TAA is based on the collection of motor unit potentials that measure the number of changes in the signal and the mean amplitude of the changes. The electromyogram transfers the data to a graphical point cloud, which enables the patient’s results to be compared with the results of the healthy subjects.

RESULTS:

In patients and control subjects, the sensitivity and specificity of the proposed diagnostic test showed a marked clinical significance: the sensitivity was 83%, and the specificity was 100%. A positive predictive value of 1 (95% CI 1 to 1) and a negative predictive value of 0.85 (95% CI 0.77 to 0.93) were observed.

CONCLUSION:

TAA is a reliable diagnostic test to detect MPSPF. Further studies are needed to reproduce these results.

Vulvar vestibulodynia: strategies to meet the challenge

Vulvodynia is a condition that affects approximately 8% to 12% of women during their lifetimes. Vulvar vestibulodynia (VVD), the most common form of this condition, is characterized by pain with touch at the vulvar vestibule and resulting entryway dyspareunia. Studies suggest a multifactorial etiology; hormonal effects, muscle dysfunction, personality, psychosocial factors, and inflammatory mediators may all play some role in the development of this condition. Both peripheral and central sensitization to pain have been implicated in the development of enhanced pain experienced by women with VVD. Recommendations for the treatment of this condition exist; however, treatments of this condition have not been well studied. Few prospective placebo-controlled trials exist, and many of those that do have failed to show clinically relevant efficacy associated with traditional therapies. New studies into the etiology of this condition, as well as potential new therapies, are emerging, but the optimal approach has yet to be defined. Proper vulvar hygiene is recommended, and traditional therapies such as topical medications and centrally acting oral medications may continue to play a role in treatment. Newer studies elucidating the effects of personality and cognitive factors as well as pelvic floor muscle dysfunction in the development of this condition lend support for the inclusion of cognitive behavioral therapy and physical therapy/surface electromyographic biofeedback in the treatment regimen. Surgery for this condition exists, with success rates of 60% to 90%; however, it is recommended only in cases that have failed to respond to traditional therapy.

Reliability and Convergent Validity of the Algometer for Vestibular Pain Assessment in Women with Provoked Vestibulodynia

OBJECTIVE

Women with provoked vestibulodynia (PVD) suffer pain at the entry of the vagina elicited by pressure as during vaginal penetration. To quantify vestibular pain, we developed a new instrument, an algometer. The aim of this study was to investigate the test-retest reliability of the algometer and evaluate its convergent validity for vestibular pain assessment in women with PVD.

METHODS

Twenty-six women with PVD participated in the study. Vestibular pain was assessed with the new algometer and the already known vulvalgesiometer during two different sessions 2 to 4 weeks apart. At each session, the pressure pain threshold (PPT) and pressure pain tolerance (PPTol) were measured twice at the 3, 6, and 9 o'clock sites of the vestibule in random order. The test-retest reliability (intra- and inter-session) of the algometer was calculated using the intraclass correlation coefficient (ICC) and standard error of measurement (SEM). Its convergent validity was evaluated by the correlation coefficients between PPTs and PPTols measured by the algometer and those measured with the vulvalgesiometer.

RESULTS

Intra-session reliability at all three sites for PPTs and PPTols in both sessions was excellent (ICC = 0.859 to 0.988, P ≤ 0.002). Inter-session reliability was good to excellent (ICC = 0.683 to 0.922, SEM = 15.06 to 47.04 g, P ≤ 0.001). Significant correlations were found between the two tools for all sites for PPTs (r = 0.500 to 0.614, P ≤ 0.009) and PPTols (r = 0.809 to 0.842, P < 0.001).

DISCUSSION

Findings showed that the algometer is a reliable and valid instrument for measuring PPTs and PPTols in the vestibular area in women with PVD. This technology is promising for pinpointing treatment mechanisms and efficacy.

Fear Avoidance and Pain Catastrophizing among Women with Sexual Pain

Aim: Among women under 30 years of age, around 20% report recurrent sexual pain. Although the amount of studies investigating sexual pain has increased, little is known about the role of psychosocial factors. The present study used the fear-avoidance model from musculoskeletal pain as a theoretical frame of reference, and examined fear-avoidance beliefs, avoidance behaviors, pain catastrophizing and symptoms of anxiety and depression among women (18–35 years) reporting sexual pain. Methods: The study was cross-sectional, based on a sample of 133 women, where 37 women (27.8%) reported sexual pain often or always. Results: Women with pain reported higher levels of fear avoidance and pain catastrophizing as well as depression and anxiety, with fear avoidance and pain catastrophizing reaching similar levels as has been reported in other long-term pain populations. The level of anxiety and depression did not reach clinical levels. Fear-avoidance beliefs and pain catastrophizing were related to sexual pain and to pain intensity in the regression analysis. Conclusion: The data are in line with, and give further support to, a fear-avoidance perspective in female sexual pain, emphasizing the role of fear and avoidance of pain/sex.

Psychological factors in genital pain: The role of fear-avoidance, pain catastrophizing and anxiety sensitivity among women living in Sweden

Objectives One in five women under the age of 30 report recurrent genital pain and pain during sexual intercourse. Female genital pain negatively affects sexual and general health, as well as dyadic function and quality of life. Although the current field of research and clinical expertise in general agree upon a biopsychosocial conceptualization, there is still a lack of theoretical models describing the psychosocial mechanisms involved in the development of genital pain. Originally developed to outline the transition from acute to chronic back pain, the fear avoidance (FA) model has lately been proposed as a possible tool in illustrating the mechanisms involved in genital pain. However, only few studies have empirically tested the components of the FA model empirically. The aim of the present study is to examine fear avoidance beliefs, pain catastrophizing, and symptoms of depression and anxiety among women reporting genital pain, and to relate these concepts to sexual satisfaction/function and the characteristics of pain. Methods The study was a population-based study using a postal questionnaire administered to 4052 women (age 18-35). Of these 944 (response rate: 23%) took part in the study. Results Genital pain of six months duration was reported by 16.1% of the women. Women with pain reported elevated levels of symptoms of anxiety, fear avoidance beliefs, pain catastrophizing and anxiety sensitivity. Symptoms of anxiety also predicted pain in the explanatory model together with vaginal tension and fungal infection. Vaginal tension has previously been described as a fear-response to painful intercourse and the results thereby seem to give further support to viewing genital pain from a fear avoidance perspective. Furthermore, fear avoidance beliefs seem to be of similar importance as lack of desire for the experience of sexual satisfaction and could also predict pain during specific activities among women with pain. The results also indicate that sexual satisfaction is related to a specific pain-related fear, rather than a heightened level of general anxiety. Conclusions The study had a low response rate, but still indicates that genital pain is common and is associated with several aspects of fear and avoidance. In sum, the results support the FA model by giving strong support for fear reactions (vaginal tension) and fear avoidance beliefs, and moderate support for negative affect. In the model negative affect drives pain catastrophizing. Implications It seems that the experience of genital pain among women in the general population is common and could be associated with increased levels of anxiety and fear-avoidance beliefs. However, the associations should not be understood in isolation from physiological mechanisms but seem to indicate interactions between, e.g. fungal infections, negative appraisals of pain and symptoms, lack of sexual function and satisfaction and increased pain experience. It is possible that psychological mechanisms work in the transition from acute physiological pain to chronic psychologically maintained pain in terms of secondary reactions to, e.g. repeated fungal infections by adding emotional distress, fear of pain and avoidance behaviours.

Central changes associated with chronic pelvic pain and endometriosis

BACKGROUND

Chronic pelvic pain (CPP) is a significant public health problem with 1 million affected women in the UK. Although many pathologies are associated with CPP, the pain experienced is often disproportionate to the extent of disease identified and frequently no pathology is found (chronic pelvic pain syndrome). The central nervous system (CNS) is central to the experience of pain and chronic pain conditions in general are associated with alterations in both the structure and function of the CNS. This review describes the available evidence for central changes in association with conditions presenting with CPP.

METHODS

A detailed literature search was performed to identify relevant papers, however, this is not a systematic review.

RESULTS

CPP is associated with central changes similar to those identified in other pain conditions. Specifically these include, alterations in the behavioural and central response to noxious stimulation, changes in brain structure (both increases and decreases in the volume of specific brain regions), altered activity of both the hypothalamic-pituitary-adrenal axis and the autonomic nervous system (ANS) and psychological distress.

CONCLUSIONS

The evidence reviewed in this paper demonstrates that CPP is associated with significant central changes when compared with healthy pain-free women. Moreover, the presence of these changes has the potential to both exacerbate symptoms and to predispose these women to the development of additional chronic conditions. These findings support the use of adjunctive medication targeting the CNS in these women.

A Psychological View of Sexual Pain among Women: Applying the Fear-Avoidance Model

Aim: The purpose of this paper is to examine how well research findings on dyspareunia (intercourse pain) fit the fear-avoidance (FA) model on pain. Results: The evidence suggests that the experience of pain in dyspareunia functions similarly to the pain reported in other pain conditions. There are also accumulating data showing that the central mechanisms of the FA model, such as catastrophizing, fear, hypervigilance and disability, are central to the experience of sexual pain. However, there are also some potential differences between sexual pain and other pain conditions that demand further attention in terms of the role of the partner, specific emotional consequences of avoidance and the effect of hypervigilance on sexual arousal. Conclusion: The results demonstrate the relevance of the FA model in sexual pain. They also imply that treatment methods for fear and avoidance in other pain conditions offer new avenues for treating sexual pain problems in the clinic. Future studies should focus on expanding how the mechanisms in the FA model contribute to sexual pain, as well as how treatments based on the model may be applied clinically.

Evoked pain analgesia in chronic pelvic pain patients using respiratory-gated auricular vagal afferent nerve stimulation

OBJECTIVE

Previous vagus nerve stimulation (VNS) studies have demonstrated antinociceptive effects, and recent noninvasive approaches, termed transcutaneous-vagus nerve stimulation (t-VNS), have utilized stimulation of the auricular branch of the vagus nerve in the ear. The dorsal medullary vagal system operates in tune with respiration, and we propose that supplying vagal afferent stimulation gated to the exhalation phase of respiration can optimize t-VNS.

DESIGN

Counterbalanced, crossover study.

PATIENTS

Patients with chronic pelvic pain (CPP) due to endometriosis in a specialty pain clinic. INTERVENTIONS/OUTCOMES: We evaluated evoked pain analgesia for respiratory-gated auricular vagal afferent nerve stimulation (RAVANS) compared with nonvagal auricular stimulation (NVAS). RAVANS and NVAS were evaluated in separate sessions spaced at least 1 week apart. Outcome measures included deep-tissue pain intensity, temporal summation of pain, and anxiety ratings, which were assessed at baseline, during active stimulation, immediately following stimulation, and 15 minutes after stimulus cessation.

RESULTS

RAVANS demonstrated a trend for reduced evoked pain intensity and temporal summation of mechanical pain, and significantly reduced anxiety in N = 15 CPP patients, compared with NVAS, with moderate to large effect sizes (η(2) > 0.2).

CONCLUSION

Chronic pain disorders such as CPP are in great need of effective, nonpharmacological options for treatment. RAVANS produced promising antinociceptive effects for quantitative sensory testing (QST) outcomes reflective of the noted hyperalgesia and central sensitization in this patient population. Future studies should evaluate longer-term application of RAVANS to examine its effects on both QST outcomes and clinical pain.

Challenging atrophied perspectives on postmenopausal dyspareunia: a systematic description and synthesis of clinical pain characteristics

This study investigated the clinical attributes of postmenopausal dyspareunia. The authors obtained a systematic description of pain symptomatology from 182 postmenopausal dyspareunia sufferers using a structured interview, quantitative sensory testing, a standardized pain measure, and gynecological examination. The authors conducted a cluster analysis to examine whether sufferers could be categorized using clinical pain and gynecological factors. The authors delineated 6 subgroups, each exhibiting distinct combinations of pain and gynecological characteristics. The results support the hypothesis that, similarly to premenopausal dyspareunia, postmenopausal dyspareunia is a heterogeneous condition.

The prevalence of fibromyalgia in other chronic pain conditions

Central sensitivity syndromes (CSS) include fibromyalgia syndrome (FMS), irritable bowel syndrome, temporomandibular disorder, restless legs syndrome, chronic fatigue syndrome, and other similar chronic painful conditions that are based on central sensitization (CS). CSS are mutually associated. In this paper, prevalence of FMS among other members of CSS has been described. An important recent recognition is an increased prevalence of FMS in other chronic pain conditions with structural pathology, for example, rheumatoid arthritis, systemic lupus, ankylosing spondylitis, osteoarthritis, diabetes mellitus, and inflammatory bowel disease. Diagnosis and proper management of FMS among these diseases are of crucial importance so that unwarranted use of such medications as corticosteroids can be avoided, since FMS often occurs when RA or SLE is relatively mild.

Cognitive behavioral therapy for sexual dysfunctions in women

Sexual dysfunctions in women are classified into disorders of desire, arousal, orgasm, and pain (including dyspareunia and vaginismus). As the cognitive behavioral treatment (CBT) procedures differ among these sexual disorders, the treatments for each disorder are reviewed separately. The efficacy of CBT differs depending on the specific sexual dysfunction to be treated. It is concluded that only a few CBT treatments for women's sexual dysfunction have yet been empirically investigated in a methodologically sound way and little is known about which of the treatment components are most effective.

Impact of educational seminars on women with provoked vestibulodynia

OBJECTIVE

Provoked vestibulodynia (PVD) is a common genital pain condition characterized by severe pain upon vaginal penetration. The treatment of women with PVD suggests variable efficacy across modalities. The emotional toll of PVD, because of the intimate and interpersonal nature of this sexually-provoked pain, and the relationship between PVD and anxiety, depression, and a host of subclinical emotional symptoms that may interfere with treatment, has been well documented. The role of the gynaecologist in identifying and managing these psychological symptoms has never been addressed. The goal of this study was to examine the efficacy of a brief, gynaecologist-led educational seminar on measures of psychological symptoms and sexual health.

METHODS

Twenty-nine women with PVD participated in three one-hour educational seminars led by a gynaecologist with expertise in the management of PVD. Participants completed questionnaires before, immediately after, and six months after the third session.

RESULTS

There were significant improvements in psychological symptoms of depression, anxiety, somatization, hostility, paranoid ideation, psychoticism, and the global severity index, both immediately post-seminar and at the six-month follow-up. Sexual arousal, orgasm, overall sexual function, and sexual distress also significantly improved in response to the seminars.

CONCLUSION

Gynaecologist-led educational seminars delivered in a group format have a significant positive impact on psychological symptoms and sexual functioning in women who suffer from PVD.

Current perspectives in vulvodynia

Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Although its etiology is not well understood, it appears to be multifactorial. As such, treatment options are targeted to reduce singular symptoms in a piecemeal fashion. A number of randomized, controlled trials have been conducted and at least one paper on combination therapy has been published; however, further systematic research is needed in order to more fully inform clinical practice.

Negative affect and somatically focused anxiety in young women reporting pain with intercourse

After a long history of privileging psychosexual etiological factors over pain and physiological processes, dyspareunia has enjoyed 1 decade of pointed research focused on the presenting problem of pain. Although it is generally acknowledged that certain affective and cognitive styles may play a role in an individual's experience of pain in general, investigations into these questions specifically as they pertain to pain that occurs during sex are relatively scarce. To add to this growing body of knowledge, 759 women aged 18 to 29 completed questionnaires about current sexual functioning, gynecologic history, expectations about intercourse, and various personality and health-related anxiety measures. One-hundred-one women (14% of the sample) reported pain during intercourse on at least 50% of attempts. This group of women significantly differed from 536 women reporting pain on less than 10% of intercourse attempts on personality constructs related to emotional and relational well-being (e.g., neuroticism, extraversion, agreeableness), as well as anxiety sensitivity, anxiety related to physical health concerns, and the amplification of somatosensory experiences. This affective and cognitive profile is consistent with previous studies that have found an attentional hypervigilance to health and pain-related information in women with dyspareunia, all of which could prove germane to cognitive-behavioral treatments targeting this disorder.

Overlap between orofacial pain and vulvar vestibulitis syndrome

OBJECTIVES

To explore the prevalence of orofacial pain (OFP) among patients with vulvar vestibulitis syndrome (VVS) and to examine the relationship between signs and symptoms of OFP and clinical characteristics of women with VVS, we investigated differences in psychologic characteristics and severity of painful intercourse.

METHODS

In this cross-sectional exploratory study, 137 women with VVS completed questionnaires that assessed levels of pain, anxiety, somatization, and presence of signs and symptoms suggestive of clinical and subclinical OFP. Demographic data were gathered from medical records.

RESULTS

OFP was found to be a highly prevalent (78%) condition among women with VVS. Compared with women who had no OFP symptoms (n=30), those with symptoms (n=64) reported higher levels of anxiety (45.0 vs. 37.8, Bonferroni adjusted P=0.017), somatization (125.2 vs. 96.0, Bonferroni adjusted P<0.001), and psychologic distress (62.8 vs. 56.0, Bonferroni adjusted P=0.002). Although we observed a similar trend among women with subclinical OFP (n=43), this trend only reached statistical significance with respect to somatization. Differences were not detected for demographics, duration of pain, and severity of pain during intercourse across the 3 groups.

DISCUSSION

OFP is a common condition among women with VVS. Because severity and duration of painful intercourse did not differ by OFP classification but psychologic characteristics did, we must begin to question a unidimensional focus on vestibular mucosa as a reason for pain and persistent distress.

ORIGINAL RESEARCH—SEXUAL PAIN DISORDERS: Effectiveness of Hypnosis for the Treatment of Vulvar Vestibulitis Syndrome: A Preliminary Investigation

INTRODUCTION

Vulvar vestibulitis syndrome (VVS) is a common cause of vulvar pain. Therapeutic options target different pain systems believed to be involved in its development and maintenance. Most treatments target the pain component with the assumption that sexual function will increase once the pain has decreased, yet this is not necessarily the case.

AIMS

Research has supported the effectiveness of hypnosis for many chronic pain disorders, and a case report demonstrated pain reduction and an increase in intercourse pleasure in a woman with VVS. This preliminary study examined the effectiveness of hypnosis on pain and psychosexual function in VVS. METHODS; Eight women suffering from VVS completed a hypnosis screening assessment, an interview, pain and psychosexual questionnaires, a gynecologic examination, vestibular pain threshold measurement, a psychosexual assessment, and six hypnotherapy sessions. The physical examinations, interview, and questionnaires were repeated at 1 and 6 months posttreatment.

MAIN OUTCOME MEASURES

These included pain ratings during the gynecologic examination, vestibular pain thresholds, scores on the McGill Pain Questionnaire and Pain Catastrophizing Scale, and responses to questions on intercourse-related and nonintercourse-related pain. Measures of psychosexual function included the Female Sexual Function Index, State-Trait Anxiety Scale, Beck Depression Inventory-II, and the Brief Symptom Inventory.

RESULTS

Results indicated significant decreases in gynecologic examination pain and in several measures assessing intercourse pain, and nonsignificant increases in threshold. Some indices of noncoital vulvar pain decreased. Overall sexual function, particularly sexual satisfaction, increased at posttreatment. There were no differences on any psychological measure. Participants reported satisfaction with the treatment and rated their VVS pain reduction as average.

CONCLUSIONS

Hypnotherapy appears to be a promising treatment for reducing intercourse pain and some aspects of noncoital vulvar pain, and for restoring sexual function in women with VVS. These results suggest that a large controlled trial should be considered.