Multidisciplinary Treatment for Provoked Vestibulodynia: Treatment Trajectories, Predictors, and Moderators of Sexual Distress and Pain

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

BACKGROUND

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

PUROPOSE

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

RESULTS

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

CONCLUSION

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

Individualized multidisciplinary therapy for vulvodynia

OBJECTIVE

The main objective of this review was to develop strategies for individualizing multidisciplinary therapy for vulvodynia.

METHODS

We conducted two literature searches; the first one focused on clinical trials assessing vulvodynia treatments published after the recommendations of the expert committee of the Fourth International Consultation on Sexual Medicine. The second search targeted studies identifying predictive factors and mediators of vulvodynia treatments, published from the earliest date to October 2022.

RESULTS

Based on data from 55 relevant studies, we developed models of individualized multidisciplinary therapy targeting groups of women less responsive to multidisciplinary therapy (characterized by women with higher vulvar pain intensity, impaired sexual functioning, and vulvodynia secondary subtype) and to physical therapy, as an isolated treatment (characterized by women with increased pelvic floor muscle tone and vulvodynia primary subtype). Each individualized multidisciplinary therapy model comprises three components: psychotherapy, medical care, and physical therapy. These components provide distinct therapeutic modalities for distinct subgroups of women with vulvodynia; the women subgroups were identified according to the characteristics of women, the disease, partners, and relationships. Additionally, for women with provoked vestibulodynia who exhibit less benefits from vestibulectomy (such as those with higher levels of erotophobia, greater vulvar pain intensity, and the primary subtype) and encounter resistance to individualized multidisciplinary therapy, we suggest additional conservative treatments before performing vestibulectomy.

CONCLUSION

Our study is a pioneer in the development of models that allow the individualization of multidisciplinary therapy for vulvodynia and represents a significant advance in the clinical practice of gynecologists, physiotherapists, and psychologists.

Multimodal and Interdisciplinary Interventions for the Treatment of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023

Introduction

Localized provoked vulvodynia (LPV) is a chronic condition characterized by pain in the vulvar vestibule, which can be provoked by pressure or touch and which is not tied to a clear underlying cause. Research into the etiology of and most appropriate treatment strategy for LPV is still limited.

Methods

Using Arksey and O'Malley's model for scoping reviews, we evaluated the research question: what is the current evidence regarding the efficacy/effectiveness of multimodal or interdisciplinary interventions for the treatment of LPV? We collated and analyzed articles from 2010 to 2023 to capture the current research landscape.

Results

Our review identified 27 studies, which either compared treatments between classes (eg pharmacologic versus psychologic modalities) or described interdisciplinary treatment programs. We identify several trends in the literature. First, outcome measures are inconsistent between studies, often unvalidated, and may not adequately mirror patient concerns. Second, the absence of appropriate comparator groups in many studies restricts providers' ability to appraise which treatments may be most efficacious. Third, selection bias and demographic homogeneity limit generalizability. Finally, we highlight the need for head-to-head trials of vestibulectomy with other treatments considered first line for vulvodynia management.

Conclusion

There is insufficient evidence to suggest the superiority of one treatment modality for LPV relative to others or to recommend a particular interdisciplinary management strategy. Future research should use a head-to-head design where sham control is impossible, incorporate patient-centered outcome measures, and investigate impacts of treatment among diverse samples of LPV patients.

Impact of a single-session psychosocial counseling intervention for women with vulvodynia

OBJECTIVE

To evaluate the impact of a single session of psychosocial counseling on patients with vulvodynia.

METHODS

Patients diagnosed with vulvodynia at a vulvovaginal specialty clinic were randomly assigned to receive either a one-on-one 30- to 45-min psychosocial counseling session with a psychosexual counselor plus written educational materials (intervention group) or written materials alone (control group). They completed a survey before and 6 weeks after randomization that included demographic information and validated measures of sexual function and illness perception.

RESULTS

Thirty-one of 38 (81.6%) women approached chose to participate; 26 of the 31 (83.9%) completed the 6-week follow-up survey. Only the intervention group showed improvement in knowledge about vulvovaginal and sexual health, as well as in most measures of improvement in illness perception, as measured by the Brief Illness Perception Questionnaire (P < 0.05). When compared directly with those in the control group, patients in the intervention group reported increased understanding of their vulvar symptoms (P < 0.005) and lessened emotional impact of these symptoms (P = 0.035).

CONCLUSION

Patients receiving one session of the one-on-one psychosocial counseling intervention reported improved understanding and lessened emotional impact of their vulvar symptoms, compared with the control group. This study suggests that improvement may occur following minimal intervention and supports the need for further study.

Feasibility and acceptability of somatocognitive therapy in the management of women with provoked localized vestibulodynia-ProLoVe feasibility study

Background

Provoked vestibulodynia (PVD) is a prevalent chronic pain condition especially among young women. Pain is localized to the vulvar vestibule and is provoked by touch or pressure, such as penetrative intercourse. PVD can have profound consequences, adversely affecting a woman’s sexual life, relation to her partner, and her psychological health. There is an urgent need for well-designed randomized clinical trials (RCTs) to identify the most effective interventions for this neglected women’s health condition.

Aims

The primary aim of this study is to assess the feasibility of undertaking a full-scale RCT of somatocognitive therapy (SCT), a multimodal physiotherapy intervention, for women with PVD. The secondary aim is to evaluate the implementation and acceptability of SCT and its potential treatment effectiveness in PVD. In the full-scale RCT, SCT will be compared to standard PVD treatment.

Methods

A multimethod feasibility study with a single-arm before-after trial and qualitative interviews. Ten women with PVD, aged 18–33 were recruited from the Vulva Clinic at Oslo University Hospital. The intervention took place at Oslo Metropolitan University. Participants were assessed at baseline, post-treatment, and the 8-month follow-up with the tampon test and self-report questionnaires. The main feasibility outcomes were evaluation of recruitment rate, adherence to assessment tools, and follow-up rate. The participants’ experiences with the primary outcome and the intervention were explored with semi-structured interviews.

Results

Ten out of 18 eligible patients were recruited over 11 weeks. None were lost to follow-up. Adherence to self-report questionnaires was excellent. Adherence to tampon tests and to the reporting of treatments was good, whereas adherence to the 14-day diary was poor. No adverse events were reported. The tampon test was suboptimal as a primary outcome. SCT was found to be an acceptable treatment, based on Global Perceived Effect scores and the participants’ experiences.

Conclusion

The findings suggest that it is feasible to deliver a full-scale RCT of the SCT intervention for women with PVD. Some changes are suggested to optimize the protocol, such as increasing recruitment sites, change of primary outcome measures, and adding a booster session.

Trial registration

ClinicalTrials.govNCT04208204. Retrospectively registered on December 23, 2019.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01022-2.

The Biopsychosocial Puzzle of Painful Sex

Genital pain associated with sex is a prevalent and distressing problem with a complex research and clinical profile. This article reviews the historical context of the "sexual pain disorders" and the circuitous trajectory that has led from the first mention of painful sex in ancient documents to the latest diagnostic category of genito-pelvic pain penetration disorder in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders as well as in other existing and proposed nomenclatures. Prominent etiologic research and emergent theoretical models are critically assessed, as is the latest treatment outcome research of note. Finally, the review points to a number of extant needs in the research and clinical effort, including an integrated biopsychosocial and multidisciplinary approach, randomized clinical trials, targeting of treatment barriers, and expansion of the entire enterprise to include populations that have not been considered. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Predictors of vaginal penetration in women with Provoked Vestibulodynia

This study examined whether time, treatment type, baseline individual differences, and treatment satisfaction affected the vaginal intercourse trajectories of women with Provoked Vestibulodynia (PVD) before and after psychological treatment. Women (N = 130) who received CBT or MBCT completed questionnaires prior to and 2-4 weeks, 6-, and 12-months following treatment. The odds of women engaging in vaginal penetration increased by 31% at each assessment. Baseline individual differences and treatment satisfaction predicted maintenance of or re-engagement in vaginal penetration at post-treatment. Findings suggest that women who refrain from vaginal intercourse after treatment differ from women who continue or resume this activity.

Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia

BACKGROUND AND AIM

The goal was to evaluate the moderators of mindfulness-based cognitive therapy (MBCT) and cognitive behavioral therapy (CBT) to improve dyspareunia, reduce pain catastrophizing, and improve overall sexual function in women with provoked vestibulodynia (PVD). Both treatments effectively reduced self-reported pain, sexual dysfunction, and pain catastrophizing in women with PVD.

METHODS

A total of 130 women with PVD were assigned to CBT or MBCT.

OUTCOMES

Potential moderators included (i) PVD subtype (primary or secondary), (ii) baseline pain intensity, (iii) trait mindfulness, (iv) treatment credibility, (v) relationship duration, and (vi) age. Outcomes were pain intensity, sexual function, and pain catastrophizing at 4 time points: before and after treatment and 6- and 12-month follow-up. Moderation was tested using multilevel models, nesting 4 time points within participants. The interaction of the moderator, time effect, and treatment group was evaluated for significance, and a simple slope analysis of significant interactions was performed.

RESULTS

Pain reduction across 4 time points was the greatest in women who were younger, in relationships of shorter duration, and with greater baseline pain. Treatment credibility moderated pain intensity outcomes (B = 0.305, P < .01) where those with higher treatment credibility ratings (for that particular treatment) improved more in MBCT than CBT. PVD subtype moderated pain catastrophizing (B = 3.150, P < .05). Those with primary PVD improved more in the CBT condition, whereas women with secondary PVD improved more in the MBCT condition. Relationship length moderated sexual function (B = 0.195, P < .01). Women in shorter relationships improved more with MBCT, whereas women in longer relationships improved more on sexual function with CBT. No other tested variables moderated outcomes differentially across both treatment conditions.

CLINICAL IMPLICATIONS

Women who present with high credibility about mindfulness, in shorter relationships, and with secondary PVD might respond better to MBCT whereas those with primary PVD and longer relationships might respond better to CBT.

STRENGTHS & LIMITATIONS

Clinical sample. Half the women who were not sexually active were omitted from analyses of sexual function.

CONCLUSION

Overall, treatment credibility, relationship length, and PVD subtype were found to moderate improvements differently in MBCT and CBT. These findings may assist clinicians in individualizing psychological treatment for women with PVD.

CLINICAL TRIAL REGISTRATION

This clinical trial was registered with clinicaltrials.gov, NCT01704456. Brotto LA, Zdaniuk B, Rietchel L, et al. Moderators of Improvement From Mindfulness-Based vs Traditional Cognitive Behavioral Therapy for the Treatment of Provoked Vestibulodynia. J Sex Med 2020;17:2247-2259.

Scoring and Interpretation of the FSFI: What can be Learned From 20 Years of use?

INTRODUCTION

Over the past 20 years, the Female Sexual Function Index (FSFI) has been considered the gold standard for the measurement of sexual function in women, with over 1,000 published manuscripts citing the article. Despite the measure's widespread usage and excellent psychometric properties, there has been some confusion over how to best implement and score the measure and interpret corresponding findings.

AIM

The aim of the current article is to provide guidance, drawing from 20 years of use, on how to best implement the FSFI in research settings and interpret results based on the validation studies that have been conducted to date.

METHODS

The overview of scoring and interpretation procedures found in this article is drawn from a review of the published literature on the psychometric properties of the FSFI.

MAIN OUTCOME MEASURE

The measure of interest for the present review is the FSFI.

RESULTS

This review article provides information about implementing, scoring, and interpreting the full-scale FSFI. Domain-level scoring and interpretation procedures are also discussed across the 5 domains of the FSFI: arousal, satisfaction, desire, pain, and lubrication. Additionally, guidance is provided for evaluating translated versions of the FSFI and using the measure to examine sexual function in culturally diverse populations.

CLINICAL IMPLICATIONS

Guidance on appropriately scoring and interpretating the FSFI has the potential to strengthen our empirical understanding of sexual function, and consequently, to guide theory-driven treatment development and clinical practice.

STRENGTH & LIMITATIONS

The present review provides applied guidance for the appropriate use of the FSFI specifically, but does not cover other common measures of sexual function or adaptations of the original measure.

CONCLUSION

It is our hope that the guidance found in this review will ultimately lead to more rigorous and appropriate usage of the FSFI in research settings. Meston CM, Freihart BK, Handy AB, et al. Scoring and Interpretation of the FSFI: What can be Learned From 20 Years of use? J Sex Med 2020;17:17-25.