Exploring the neural correlates of touch and pain in women with provoked vestibulodynia

A conceptual model for managing sexual pain with somatocognitive therapy in women with provoked vestibulodynia and implications for physiotherapy practice

Somatocognitive therapy is a multimodal physiotherapy treatment developed in the early 2000s to alleviate the burden of chronic pelvic pain. In recent years, somatocognitive therapy has been further developed to treat women with provoked vestibulodynia. This prevalent gynecological pain condition is a subgroup of chronic pelvic pain and the most common form of vulvodynia. Provoked vestibulodynia is a neglected multifactorial pain condition of unknown cause, adversely affecting women's sexual life, relation to their partners and their psychological health. Pain is located at the vulvar vestibule and is provoked by touch or pressure such as sexual intercourse. In the management of sexual pain, somatocognitive therapy combines bodily exploration, pain education, cognitive coping strategies and structured homework to improve sexual function and reduce pain. To support these processes, developing a sound therapeutic alliance with the patient is essential. The aim of this article is to provide a conceptual model for managing provoked vestibulodynia with somatocognitive therapy, including a theoretical rational for this treatment. We base our conceptual model on the biopsychosocial model, i.e., considering the complex interplay of biomedical, emotional/cognitive, psychosexual and interpersonal factors in provoked vestibulodynia management. In addition, implications for practice and a detailed description of somatocognitive therapy for provoked vestibulodynia will be provided, to allow replication in clinical practice and in clinical trials.

Symptom-associated alterations in functional connectivity in primary and secondary provoked vestibulodynia

ABSTRACT

Primary provoked vestibulodynia (PVD) is marked by the onset of symptoms at first provoking vulvar contact, whereas secondary PVD refers to symptom onset after some period of painless vulvar contact. Different pathophysiological processes are believed to be involved in the development and maintenance of primary PVD and secondary PVD. The primary aim of this study was to test the hypotheses that the resting state functional connectivity of the brain and brain stem regions differs between these subtypes. Deep clinical phenotyping and resting state brain imaging were obtained in a large sample of a women with primary PVD (n = 46), those with secondary PVD (n = 68), and healthy control women (n = 94). The general linear model was used to test for differences in region-to-region resting state functional connectivity and psychosocial and symptom assessments. Direct statistical comparisons by onset type indicated that women with secondary PVD have increased dorsal attention-somatomotor network connectivity, whereas women with primary PVD predominantly show increased intrinsic resting state connectivity within the brain stem and the default mode network. Furthermore, compared with women with primary PVD, those with secondary PVD reported greater incidence of early life sexual abuse, greater pain catastrophizing, greater 24-hour symptom unpleasantness, and less sexual satisfaction. The findings suggest that women with secondary PVD show greater evidence for central amplification of sensory signals, whereas women with primary PVD have alterations in brain stem circuitry responsible for the processing and modulation of ascending and descending peripheral signals.

Exclusive manual perineal rehabilitation with lidocaine 2% gel in the treatment of provoked vestibulodynia: results from a single-arm interventional study

As of now, there is no adequate therapeutic strategy for provoked vestibulodynia (PVD). Pelvic Floor Muscle Therapy (PFMT) is a widely used technique in general pelvic floor rehabilitation. The objective of this study is to examine the effects of exclusive manual perineal rehabilitation with lidocaine 2% gel on PVD. During the first session, recruited patients (n = 68; mean age 31 ± 8.6; range: 18–52) received a questionnaire (Q1) on general well-being and health, pain of the genital area, sexual function, and symptoms during vaginal penetration. This questionnaire was based on a generalised questionnaire on the quality of life, the Medical Outcomes Study 36-item (SF-36), the Female Sexual Function Index (FSFI), and the Visual Analogue Scale (VAS). A second identical questionnaire with an additional set of open-ended questions concerning the assessment of the treatment was collected after treatment (Q2). A total of 45 questionnaires were completed. Statistical results showed a significant improvement of all items before and after treatment (p < 0.001): perceived general well-being and health, perceived vulvar pain, perceived sexual function, and perceived vaginal penetration. In conclusion, exclusive manual perineal rehabilitation using lidocaine 2% gel seems to be a safe and effective treatment option for vulvodynia in women.