A Prospective 2-Year Examination of Cognitive and Behavioral Correlates of Provoked Vestibulodynia Outcomes

Predictors of sexual satisfaction among patients with chronic pain

Objectives

Sexual satisfaction is an important aspect of quality of life. Chronic pain, depression and anxiety, and relational problems correspond with higher risk for sexual difficulties. Less is known about how risk factors for sexual dysfunction and other problems-such as medical conditions, pain severity, and medication side effects-affect the sexual satisfaction of people with chronic pain. Using a biopsychosocial framework, this study explored factors related to sexual satisfaction among patients presenting for evaluation of chronic pain.

Methods

Researchers used a hierarchical multiple regression analysis to model potential predictors of sexual satisfaction. Variables analyzed were demographic features, medical history, average pain severity, depressed mood, anxiety, and perceived significant other support. Data collection involved administration of retrospective questionnaires and chart review. The sample included male and female participants (N = 134) presenting for evaluation at a multidisciplinary pain rehabilitation clinic.

Results

Medical history (i.e., medical conditions, surgical history, and medications) and clinical self-report variables (i.e., pain severity, depressed mood, anxiety, and perceived significant other support) were associated with sexual satisfaction. In this sample, antidepressant use and higher pain severity were unique predictors of lower sexual satisfaction. Married marital status and higher levels of perceived significant other support were predictive of greater sexual satisfaction.

Discussion

Findings highlight the importance of understanding the unique impact of biopsychosocial variables on the sexual satisfaction of patients presenting for evaluation at a multidisciplinary pain rehabilitation clinic. Further exploration of protective factors that account for sexual satisfaction among individuals with chronic pain may help inform screening, referrals, and treatment.

Psychological Treatment of Persistent Genital Arousal Disorder/Genitopelvic Dysesthesia Using an Integrative Approach

Persistent genital arousal disorder/genitopelvic dysesthesia (PGAD/GPD) is characterized by persistent, unwanted physiological genital arousal (i.e., sensitivity, fullness, and/or swelling) in the absence of sexual excitement or desire which can persist for hours to days and causes significant impairment in psychosocial well-being (e.g., distress) and daily functioning. The etiology and course of PGAD/GPD is still relatively unknown and, unsurprisingly, there are not yet clear evidence-based treatment recommendations for those suffering from PGAD/GPD. We present the case of a 58-year-old woman with acquired persistent genital arousal disorder, which began in March 2020; she believed she developed PGAD/GPD due to a period of significant distress and anxiety related to the COVID-19 pandemic. After seeking medical diagnosis and treatment from multiple healthcare providers and trying a combination of pharmacological and medical treatment modalities, she presented for psychological treatment. An integrative therapy approach (3 assessment sessions, 11 treatment sessions), which included cognitive behavior therapy, distress tolerance and emotion regulation skills from dialectical behavior therapy, and mindfulness practice, was utilized. The patient reported improvements anecdotally (e.g., decreased impact on occupational and social functioning, greater self-compassion, less frequent and shorter duration of PGAD/GPD flare-ups, improved ability to cope with PGAD/GPD symptoms, and decreased need for sleeping medication) and on self-report measures (e.g., lower PGAD/GPD catastrophizing, lower anxiety and depression, and greater overall quality of life).We report the use of an integrative (i.e., psychoeducational, cognitive behavioral, dialectical behavioral, and mindfulness-based) intervention, which may be an effective psychological treatment for PGAD/GPD.

Fear Learning in Genital Pain: Toward a Biopsychosocial, Ecologically Valid Research and Treatment Model

Although fear learning mechanisms are implicated in the development, maintenance, exacerbation, and reduction of genital pain, systematic research on how fear of genital pain emerges, spreads, persists, and reemerges after treatment is lacking. This paper provides an overview of the literature on pain-related fear, integrates the ideas on learning and sexual arousal responding, and specifies the pathways through which compromised learning may contribute to the development and persistence of genital pain. In order to refine theories of genital pain and optimize treatments, we need to adopt a biopsychosocial framework to pain-related fear learning and uncover potential moderators that shape individual trajectories. This involves examining the role of physiological processes, subjective experiences, as well as partner and relational cues in fear acquisition, excessive generalization and impaired safety learning, extinction of fear, counterconditioning, and return of fear. Recent methodological advances in fear conditioning and sex research are promising to enable more symptom-specific and ecologically valid experimental paradigms.

Predictors of Mucosal and Muscle Pain in Vulvodynia: A Cross-Sectional Analysis From the National Vulvodynia Registry

Diagnostic criteria for provoked vestibulodynia (PVD) rely on mucosal pain in the vulvar vestibule, with less emphasis on pain from pelvic floor muscles. It is unknown how psychosocial variables associated with PVD are differentially associated with mucosal versus muscle pain. Analysis of data from the National Vulvodynia Registry (n = 202) revealed several factors associated with increased mucosal pain: pain duration (P = .043), the McGill sensory subscore (P = .0086) and the Gracely pain scale (P< .001). Increased mucosal pain was also associated with decreased arousal (P = .036). On the other hand, factors significantly associated with greater muscle pain included number of comorbid pain conditions (P = .001), decreased intercourse frequency post PVD onset (P = .02) and higher scores on the McGill sensory (P = .0001) and affective (P = .0002) subscores, the Gracely pain scale (P = .0012), and state anxiety (P < .001). Sexual function was also significantly impacted by high pelvic floor muscular pain, with lower scores for arousal (P = .046), orgasm (P = .0014) and satisfaction (P = .013), and higher pain (P = .01). Significant differences in the relationship between muscle and mucosal pain for pain duration (P = .005), McGill affective score (P = .001), orgasm (P = .049), change in intercourse frequency (P = .027), and state anxiety (P = .030) suggest the possibility of mucosal or muscle pain predominant PVD subtypes. PERSPECTIVE: Patients with higher pelvic floor muscle pain scores than mucosal pain scores may represent different subgroups or characteristics of patients with provoked vestibulodynia. This research highlights the importance of assessment of the pelvic floor muscles in addition to the cotton swab test of the vestibule.

Psychosocial Factors Influence Sexual Satisfaction among Women with Vulvodynia

Vulvodynia affects about 8% of women, many of whom report a negative impact on their ability to have sexually satisfying relationships. In this study, we examined predictors of sexual satisfaction in 207 women with clinically confirmed vulvodynia. We adapted a model examining resilience in chronic pain patients originally developed by Sturgeon and Zautra to include resilience factors (communication with partner about sexual health and coping strategies) and vulnerable factors (abuse history, pain intensity, rumination). These variables were regressed onto sexual satisfaction. In the full model, only emotion-based rumination was predictive of sexual satisfaction. Thus, focusing on emotion-based rumination in clinical intervention may improve sexual satisfaction.

Vulvodynia

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.

Genito-Pelvic Pain Through a Dyadic Lens: Moving Toward an Interpersonal Emotion Regulation Model of Women's Sexual Dysfunction

Researchers and clinicians alike widely acknowledge the inherently interpersonal nature of women's sexual dysfunctions given that both partners impact and are impacted by these difficulties. Yet theoretical models for understanding the role of interpersonal factors in women's sexual dysfunctions are severely lacking and have the potential to guide future research and inform more effective interventions. The most widely studied sexual dysfunction in women that has espoused a dyadic approach by including both members of affected couples is genito-pelvic pain/penetration disorder (GPPPD). In this article we use the example of GPPPD to introduce a novel interpersonal emotion regulation model of women's sexual dysfunction. We first review current knowledge regarding distal and proximal interpersonal factors in GPPPD. Then, we describe our theoretical model and consider relevant pain and sex-related research on emotion regulation processes-emotional awareness, expression, and experience-in the context of GPPPD, including sexual function, satisfaction, and distress. Next, we review how existing theories from the fields of chronic pain and sex and relationships research have informed our model and how our model further builds on them. Finally, we discuss the implications of our model and its applications, including to other sexual dysfunctions in women.

Avoiding or enduring painful sex? A prospective study of coping and psychosexual function in vulvovaginal pain

BACKGROUND

Recurring vulvovaginal pain is common, with evident effects on affected women's lives. Little is known about how affected women cope with painful sexual activities and how coping relates to pain intensity and psychosexual functioning over time. This prospective study explored the impact of avoidance and endurance on sexual function over time. Additionally, patterns of coping were studied on an individual level to increase knowledge about coping and its relation to psychosexual functioning.

METHODS

One hundred and seventeen women, 18-35 years old, with recurring vulvovaginal pain answered questionnaires at two measurement points, five months apart, assessing avoidance and endurance coping, pain intensity and psychosexual functioning. A multiple regression model explored the predictive value of avoidance and endurance on sexual function over time. Cluster analyses investigated patterns of coping and stability within the clusters. These subgroups were compared on psychosexual outcomes.

RESULTS

Avoidance at baseline was the only significant predictor of sexual function five months later. Distinct and stable subgroups with different patterns of coping were identified, where avoidance and endurance coping were used both separately and combined. Women who both avoided and endured had the most unfavourable outcomes in terms of psychosexual functioning.

CONCLUSIONS

Avoidance of sexual activities was related to reduced sexual function over time, which calls for attention and clinical interventions targeting avoidance. Additionally, women who both avoid and endure sexual activities despite pain possibly need tailored interventions, as women with this coping pattern reported the lowest levels of psychosexual functioning.

SIGNIFICANCE

In this prospective study, avoidance of sexual activities predicted sexual function over time, when controlling for pain intensity. Subgroups of women using distinct patterns of coping were identified. Those who both avoided and endured had the lowest levels of psychosexual functioning.

Anxiety Mediates the Relation Between Childhood Sexual Abuse and Genito-Pelvic Pain in Adolescent Girls

Previous research has demonstrated associations between child sexual abuse, anxiety, and genito-pelvic pain, but no study to date has examined whether sexual abuse may be associated with genito-pelvic pain through victims' elevated anxiety. The present study aimed to determine whether anxiety mediates the relationship between child sexual abuse and genito-pelvic pain. Using self-report questionnaires, data were gathered from 218 sexually active adolescent girls recruited from seven metropolitan high schools. As expected, results revealed a significant indirect effect of sexual abuse on the development of genito-pelvic pain through trait anxiety. This study thus suggests that anxiety may be one of the mechanisms by which child sexual abuse leads to an increased risk of developing genito-pelvic pain in this population.

Vulvodynia: a consideration of clinical and methodological research challenges and recommended solutions

Vulvodynia, an idiopathic chronic vulvar pain, is a prevalent genital pain condition that results in significant impairment to sexual, relational, and psychological functioning of affected women and their romantic partners. Despite its high prevalence, there remain gaps in knowledge and health care access for women coping with vulvodynia, given its varied clinical presentation and no widely accepted treatment protocol. The past several decades have seen important advancements in understanding vulvodynia and developing effective treatments; however, progress has been impeded due to clinical and methodological challenges in conducting research with this vulnerable population. This review presents a brief overview of vulvodynia correlates, consequences, etiology, and treatment, and then turns its attention to considering the clinical and methodological challenges that hinder vulvodynia research. Identifying these barriers alongside potential mitigating solutions is essential to developing empirically supported treatments for all women affected by vulvodynia, across all age and minority groups. Potential solutions will require researchers to broaden eligibility criteria, examine subgroups of women, and expand definitions of treatment outcomes, and may be best facilitated by more active collaboration among research groups and across relevant disciplines. Engagement in these solutions may contribute to more representative findings and the development and dissemination of empirically based treatment options for this complex pain condition.

Coping with pain in intimate situations: Applying the avoidance-endurance model to women with vulvovaginal pain

BACKGROUND AND AIMS

Chronic vulvovaginal pain is strikingly common and has a serious impact on women's lives. Nevertheless, there are few longitudinal studies focusing on mechanisms involved in the pain development. One area of interest is how women cope with sexual activities and how this affects their pain. In this study, avoidance and endurance coping behaviors were explored as possible mediators of the relation between catastrophizing and pain, cross-sectionally and longitudinally.

METHODS

251 women (18-35 years old) with vulvovaginal pain were recruited in university settings and filled out questionnaires about their pain, catastrophizing and coping behaviors at two occasions, with five months in between. Multiple mediation models were tested, exploring avoidance and endurance as mediators of the relation between catastrophizing and pain.

RESULTS

The results showed that avoidance was an influential mediator of the link between catastrophizing and pain. Using multiple mediation models we found that although the indirect effects of both avoidance and endurance were significant cross-sectionally, only avoidance was a significant mediator in the combined model exploring associations over time.

CONCLUSIONS

This study indicates that the strategies women with vulvovaginal pain use for coping with sexual activities are important for the course of pain. Avoidance and, to a lesser degree, endurance strategies were identified as important mediators of the effects of catastrophizing on pain. When exploring the links over time, only avoidance emerged as a significant mediator.

IMPLICATIONS

In this longitudinal study, catastrophizing was linked to vulvovaginal pain, via avoidance and endurance of sexual activities. Hence, targeting catastrophizing early on in treatment, as well as addressing coping, may be important in clinical interventions.

Comorbidities Among Women With Vulvovaginal Complaints in Family Practice

BACKGROUND

The lifetime prevalence of women suffering from provoked vestibulodynia (PVD) is estimated to be approximately 15%. The etiology of PVD is not yet clear. Recent studies approach PVD as a chronic multifactorial sexual pain disorder. PVD is associated with pain syndromes, genital infections, and mental disorders, which are common diseases in family practice. PVD, however, is not included in the International Classification of Primary Care. Hence, the vulvovaginal symptoms, which could be suggestive of PVD, are likely to be missed.

AIM

To explore the relationship between specific vulvovaginal symptoms that could be suggestive of PVD (genital pain, painful intercourse, other symptoms/complaints related to the vagina/vulva), and related diseases such as pain syndromes, psychological symptom diagnoses, and genital infections in family practice.

METHODS

A retrospective analysis of all episodes from 1995 to 2008 in 784 women between 15 and 49 years were used to determine the posterior probability of a selected diagnosis in the presence of specific vulvovaginal symptoms suggestive of PVD expressed in an odds ratio. Selected comorbidities were pain syndromes (muscle pain, general weakness, irritable bowel syndrome [IBS]), psychological symptom diagnoses (anxiety, depression, insomnia), vulvovaginal candidiasis, and sexual and physical abuse.

RESULTS

Women with symptoms suggestive of PVD were 4 to 7 times more likely to be diagnosed with vulvovaginal candidiasis and 2 to 4 times more likely to be diagnosed with IBS. Some symptoms suggestive of PVD were 1 to 3 times more likely to be diagnosed with complaints of muscle pain, general weakness, insomnia, depressive disorder, and feeling anxious.

CONCLUSION

Data from daily family practice showed a clear relationship between symptoms suggestive of PVD and the diagnoses of vulvovaginal candidiasis and IBS in premenopausal women. Possibly, family doctors make a diagnosis of vulvovaginal candidiasis or IBS based only on clinical manifestations in many women in whom a diagnosis of PVD would be more appropriate.

Sexual pain disorders

PURPOSE OF REVIEW

The purpose of this review was to assess recent research (the last 18 months) and its impact on understanding sexual pain disorders relevant to daily clinical practice.

RECENT FINDINGS

It has been highlighted that sexual pain is related to the number of tender points, pressure pain threshold, more deliberate fear and less global positive affective associations with sexual stimuli, episiotomy, attachment styles, drug abuse and the influence of ambivalence over emotional expression in couples.The efficacy of a multidisciplinary vulvodynia programme of treatment, another type of therapy based on the fear-avoidance and pain self-efficacy model and a novel cognitive-behavioral couple therapy has been stated.

SUMMARY

There is a gradual advance in the knowledge of sexual pain disorder etiology. At the same time different therapeutics strategies have been increasing, but it is necessary to introduce guidelines on the basis of the evidence to approach with efficacy this severe disorder.

VIDEO ABSTRACT

http://links.lww.com/YCO/A31.