2015 ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia

Efficacy of Rehabilitative Techniques on Pain Relief in Patients With Vulvodynia: A Systematic Review and Meta-Analysis

OBJECTIVE

Vulvodynia is a chronic clinical condition characterized by provoked or non-provoked vulvar pain for at least 3 months of unknown etiology. The onset of vulvodynia involves a complex interplay of peripheral and central pain mechanisms, such as pelvic floor muscle and autonomic dysfunction, and interpersonal factors. A stepwise approach of pelvic floor physical therapy as medical management is suggested. In this scenario, by this meta-analysis of randomized controlled trials, we aimed to evaluate the efficacy of rehabilitation interventions in patients with vulvodynia.

METHODS

On October 13, 2022, PubMed, Scopus, and Web of Science were systematically searched for randomized controlled trials that assessed the efficacy of the rehabilitative approach to pain during intercourse in patients with vulvodynia. The quality assessment was performed with the Cochrane risk-of-bias tool for randomized trials. The trial registration number is CRD42021257449. At the end of the search, 9 studies were included for a total of 332 patients. A pairwise meta-analysis was performed to highlight the efficacy of rehabilitative approaches for reducing pain during intercourse, as measured with a visual analog scale or a numerical rating scale.

RESULTS

Meta-analysis showed that all these rehabilitative approaches had an overall effect size of -1.43 (95% CI = -2.69 to -0.17) in decreasing vulvodynia pain in terms of the visual analog scale. In the subgroup analysis, a significant effect size in acupuncture (effect size = -2.36; 95% CI = -3.83 to -0.89) and extracorporeal shockwave therapy (effect size = -2.94; 95% CI = -4.31 to -1.57; I2 = 58%) was observed. According to the Cochrane risk-of-bias tool, a low risk of bias for outcome selection in 89% of studies.

CONCLUSION

Findings from this meta-analysis suggested that the physical agent modalities and complementary medicine techniques in people with vulvodynia appear to be more effective than placebo, sham, or waiting list. Further evidence on physical agent modalities and complementary therapies are warranted in the future.

IMPACT

This was the first systematic review and meta-analysis of randomized controlled trials to provide evidence on the efficacy of rehabilitation interventions in patients with vulvodynia.

Guideline No. 445: Management of Chronic Pelvic Pain

OBJECTIVE

To provide evidence-based recommendations for the management of chronic pelvic pain in females.

TARGET POPULATION

This guideline is specific to pelvic pain in adolescent and adult females and excluded literature that looked at pelvic pain in males. It also did not address genital pain.

BENEFITS, HARMS, AND COSTS

The intent is to benefit patients with chronic pelvic pain by providing an evidence-based approach to management. Access to certain interventions such as physiotherapy and psychological treatments, and to interdisciplinary care overall, may be limited by costs and service availability.

EVIDENCE

Medline and the Cochrane Database from 1990 to 2020 were searched for articles in English on subjects related to chronic pelvic pain, including diagnosis, overlapping pain conditions, central sensitization, management, medications, surgery, physiotherapy, psychological therapies, alternative and complementary therapies, and multidisciplinary and interdisciplinary care. The committee reviewed the literature and available data and used a consensus approach to develop recommendations. Only articles in English and pertaining to female subjects were included.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Family physicians, gynaecologists, urologists, pain specialists, physiotherapists, and mental health professionals.

TWEETABLE ABSTRACT

Management of chronic pelvic pain should consider multifactorial contributors, including underlying central sensitization/nociplastic pain, and employ an interdisciplinary biopsychosocial approach that includes pain education, physiotherapy, and psychological & medical treatments.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Pain Specialist Management of Sexual Pain-II: Interventional

INTRODUCTION

Treatment of female sexual pain often requires the use of diverse modalities crossing multiple medical disciplines. Interventional procedures are important in the diagnosis and treatment of female sexual pain. Pain specialists and other medical specialties can provide these capabilities.

OBJECTIVES

To provide a current summary of the procedures used in the diagnosis and treatment of female sexual pain.

METHODS

The internet, PubMed, and the Cochrane Library were searched for relevant articles on female sexual pain within the clinical purview and scope of the practice of pain management.

RESULTS

A thorough review of the literature was conducted to include basic science studies, clinical trials, systematic reviews, consensus statements, and case reports. An effort was made to also include a sampling of information on real-world patient self-directed therapies. Descriptions of interventional procedures for the diagnosis and treatment of sexual pain were made and clinical studies reviewed. The evidence for the use of various interventional treatment strategies for sexual pain was assessed.

CONCLUSIONS

The process of care for female sexual pain employs an interdisciplinary biopsychosocial model that includes a role for interventional procedures commonly performed by pain management specialists. These specialists are a resource of knowledge, skills, and abilities that can be used to improve the care of women with chronic sexual pain.

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.

Effect of oestriol gel on dyspareunia in postmenopausal women in 2 weeks of treatment: a pilot study

This brief report evaluates the early effect of ultra-low dose 0.005% oestriol vaginal gel on dyspareunia in postmenopausal women within the first 2 weeks of treatment. This was a prospective and multicentre single-arm pilot study and the effect of the treatment on dyspareunia was evaluated by using a diary. In total 23 women and 150 coitus were studied. 8 coitus were painless in the first week and 42 during the second week (p < .0001). A reduction in pain from the baseline was seen in 116 (77.3%) out of the 150 coitus. 0.005% oestriol vaginal gel produced a rapid and progressive improvement in dyspareunia from the very first days of treatment in postmenopausal women.IMPACT STATEMENTWhat is already known on this subject? Local oestrogen therapy has shown efficacy in the treatment of genitourinary syndrome of menopause (GSM) and dyspareunia when used for a duration of greater than 3 weeks.What do the results of this study add? This study shows that the use of oestriol gel produces clinical effects from the beginning of its use, decreasing dyspareunia in postmenopausal women within just 14 days of daily use.What are the implications of these findings for clinical practice and/or further research? In cases of dyspareunia in relation to menopause, therapy with local oestrogens, in our case oestriol gel, produces an improvement from the beginning of its use. This information is clinically relevant when evaluating therapeutic options.

Vulvodynia: What is available online? A systematic review of information on the internet

AIM

This review aimed to evaluate the quality of medicalinformation online for patients relating to vulvodynia. To our knowledge no evaluation of online patient information exists regarding vulvodynia and, at present, there is no standardized or validated method of evaluating medical information on the internet.

METHODS

A clearly defined protocol was developed to generate keywords relating to vulvodynia. The three most popular search engines worldwide; google.com, yahoo.com, and bing.com, were searched in September 2020. Three assessors evaluated eligible webpages for accuracy, credibility, readability, and reliability.

RESULTS

Forty-five webpages were eligible with 38% given HON certification or Information Standard approval. Only one webpage achieved a DISCERN score of ≥63 indicating excellent reliability. No webpages scored a maximum 10 points for credibility. Eleven percent of webpages were rated "accurate" with score 17 or above. The modal Flesch Kincaid Grade Level was 9 with only 15.6% having a readability grade level of 8 or less.

CONCLUSIONS

It has been shown in previous studies that patient information available online pertaining to gynecological conditions is frequently inaccurate, with limited regulation and low reliability, and our findings are in agreement with this. As patients increasingly look to the internet for medical information and education, we as clinicians, need to ensure the resources available are of a high standard and regulated. Without ensuring safe and effective healthcare resources, we risk misinformation which can negatively impact clinical care.

Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting

BACKGROUND

Vulvar and in particular clitoral pain can affect women with Female Genital Mutilation/Cutting (FGM/C). To date, there is no comprehensive study on the different available treatments for vulvar pain after FGM/C.

AIM

To study the outcome of surgical treatments of vulvar and/or clitoral pain among women living with FGM/C.

METHODS

Retrospective review of the consecutive medical files of all 506 women who consulted at a specialized outpatient clinic for women with FGM/C between April 1, 2010 and December 31, 2017.

OUTCOME

Subjective change in chronic vulvar pain after surgical treatment.

RESULTS

In total, 36.1% of women (n = 183) experienced chronic pain, all types included, among which 2.8% (n = 14) experienced provoked or unprovoked chronic vulvar pain. Among the 14 women with provoked or unprovoked chronic vulvar pain, ten (71.4%) underwent surgical treatment: 7 underwent resection of vulvar scar complications (cysts, bridles, adhesions) with (n = 4) or without (n = 3) concomitant defibulation, 3 had clitoral reconstruction and one had labium reconstruction with removal of peri-clitoral adhesion. Nine out of ten (90%) experienced resolution of pain after surgery and the remaining woman (10%) was lost to follow-up.

CLINICAL IMPLICATIONS

Safe and effective surgical treatments exist and patients with chronic vulvar pain post-FGM/C should be referred to specialists who would consider appropriate indications for surgery and support informed decision-making and treatment.

STRENGTHS & LIMITATIONS

The strengths of this research are the big sample size of women from diverse cultural and religious backgrounds, as well as the availability of pre- and postsurgery iconographic material and histology. Limitations include a subjective reporting of pain without validated questionnaires.

CONCLUSION

Effective surgical treatments for provoked or unprovoked chronic vulvar pain post-FGM/C are clitoral reconstruction, defibulation, cystectomy, and bridle removal. Surgical treatments should be combined with a culturally sensitive multidisciplinary care and follow-up. Bazzoun Y., Aerts L., Abdulcadir J. Surgical Treatments of Chronic Vulvar Pain After Female Genital Mutilation/Cutting. J Sex Med 2022;19:290-301.

Characterizing Differences in Thymic Function in Women With and Without Vulvodynia: A Community-Based Study

OBJECTIVE

The aim of the study was to evaluate the association between vulvodynia and thymic function.

MATERIALS AND METHODS

In this case-control study of 200 clinically confirmed cases of vulvodynia and 205 general population controls residing in the Minneapolis/Saint Paul metropolitan area, we used DNA extracted from whole blood to measure levels of signal joint T-cell receptor excision circles (sjTRECs), a measure of thymic output. We used logistic regression to evaluate the association between vulvodynia and thymic function.

RESULTS

In 405 participants (aged 18-40 years), we observed an association between decreasing thymic function and increasing age. Women with vulvodynia had a steeper decline in sjTREC values across age categories compared with women without vulvodynia. In addition, at younger ages, women with vulvodynia had higher sjTREC values compared with women without vulvodynia. In older women, those with vulvodynia had lower sjTREC than those without vulvodynia. When accounting for recency of vulvar pain onset, women with a shorter time since pain onset had higher thymic function compared with women with a longer time since vulvar pain onset.

CONCLUSIONS

These findings suggest that at younger ages, women with vulvodynia have higher thymic output and a more precipitous decline of thymic function than those without vulvodynia. It also seems that a strong immune inflammatory response is present proximate to the onset of vulvar pain and may wane subsequently over time.

Clinical manifestations and evaluation of postmenopausal vulvovaginal atrophy

INTRODUCTION

It is estimated that 50% of women will suffer a severe form of vulvovaginal atrophy (VVA) related to menopause. Equally, young women may temporarily present this clinical problem while receiving various pharmacological or endocrine treatments or radiotherapy.

AIM

To determine clinical and diagnostic exams required to confirm the presence of VVA (also referred to as atrophic vaginitis, urogenital atrophy, or genitourinary syndrome of menopause) and rule out other genital or pelvic clinical conditions.

MATERIALS AND METHODS

Literature review searches were carried out on the main scientific article search engines (PubMed, SciELO, Cochrane) using different clinical terms, treatments or interventions and comorbidity related to VVA.

RESULTS

The development and severity of VVA depend mainly on the duration of hypoestrogenism. Hypoestrogenism causes changes in the urogenital tissue, generating signs and symptoms, such as dryness, burning, soreness, itching, and irritation of the genital skin. The diagnosis can be made through anamnesis (patient history), questionnaires, physical exam, and, sometimes, complementary exams. Objective vaginal assessment is essential and can be completed with the Vaginal Health Index, the Vaginal Maturation Index, or vaginal pH in the absence of infection or semen. The exclusion of other vulvovaginal organic pathology is essential to reach an accurate diagnosis and provide adequate treatment.

CONCLUSIONS

The specialist should be able to identify VVA, rule out other pathologies that make a differential diagnosis and conduct proper management.

Vulvodynia-It Is Time to Accept a New Understanding from a Neurobiological Perspective

Vulvodynia is one the most common causes of pain during sexual intercourse in premenopausal women. The burden of vulvodynia in a woman's life can be devastating due to its consequences in the couple's sexuality and intimacy, in activities of daily living, and psychological well-being. In recent decades, there has been considerable progress in the understanding of vulvar pain. The most significant change has been the differentiation of vulvar pain secondary to pathology or disease from vulvodynia. However, although it is currently proposed that vulvodynia should be considered as a primary chronic pain condition and, therefore, without an obvious identifiable cause, it is still believed that different inflammatory, genetic, hormonal, muscular factors, etc. may be involved in its development. Advances in pain neuroscience and the central sensitization paradigm have led to a new approach to vulvodynia from a neurobiological perspective. It is proposed that vulvodynia should be understood as complex pain without relevant nociception. Different clinical identifiers of vulvodynia are presented from a neurobiological and psychosocial perspective. In this case, strategies to modulate altered central pain processing is necessary, changing the patient's erroneous cognitions about their pain, and also reducing fear avoidance-behaviors and the disability of the patient.

The efficacy of manipulation as a treatment for myofascial pelvic pain

OBJECTIVE

To evaluate the effect of myofascial manipulation by observing the changes in pelvic floor myofascial scores and electromyography (EMG) data before and after treatment.

METHODS

A total of 106 patients with myofascial pelvic pain (MFPP) were enrolled in a treatment group, and 50 healthy women were enrolled in a control group. The changes in the pelvic floor EMG data in the two groups were monitored by using Myo Trac before and after treatment. Pelvic trigger points and their distribution in the MFPP patients were examined using a finger pressure test. The visual analogue scale was used to assess the severity of pain in both groups. After one course of manipulation (twice per week for a total of 10 times), the effectiveness of the manipulation was analyzed by comparing the changes in pain scores before and after treatment.

RESULTS

The main symptoms of MFPP in the study sample consisted of lower abdominal pain, lumbosacral pain, or mixed pain, which together accounted for 67% of all symptoms. Patients often had multiple trigger points, covering 47.17% of the body. The differences between the treatment group and control group in the changes in pelvic floor muscle strength, number of pain points, pain scores, resting EMG of pelvic floor muscles, and relaxation time after muscle contraction were all statistically significant (P < 0.05). The differences between the pre-treatment and post-treatment groups in the changes in pelvic floor muscle strength, number of pain points, pain scores, resting EMG of pelvic floor muscles, and relaxation time after muscle contraction were all statistically significant (P < 0.05) CONCLUSION: Manipulation is an effective treatment for MFPP and is worthy of further clinical promotion.

Topical treatment of vulvodynia, dyspareunia and pudendal neuralgia: A single clinic audit of amitriptyline and oestriol in organogel

BACKGROUND

Vulvodynia and pudendal neuralgia comprise significant contributors to vulvar-related pain and its impact on daily life.

AIM

A retrospective clinical audit was conducted at the Women's Health & Research Institute of Australia, Sydney, to determine the pattern of use and the efficacy of the application of topical amitriptyline 0.5% plus oestriol 0.03% in organogel (AOO), to the vulvar vestibule in reducing the impact of pain on daily life.

MATERIALS AND METHODS

There were 1174 patients who received a script from May 2017 until February 2020: 1054 patients agreed to be contacted and had a valid email address.

RESULTS

There were 376 (35.7%) patients who replied. Pain with intercourse was the main indication for use. Treatment was rated effective by 51.2% (95% CI: 35.4-66.8%) of patients less than 30 years of age, 66.7% (95% CI: 57.3-74.9%) of patients 30-50 years of age, and 58.3% (95% CI: 50.9-65.4%) in patients over 50. Stinging at the site of application was the most commonly reported side effect.

CONCLUSION

Topical AOO is an effective and well-tolerated treatment for vulvar pain.

The histopathological results of vestibulectomy specimens in localized provoked vulvodynia in Turkey

Introduction

Localized Provoked Vulvodynia (LPV) is a gynecological disease that is difficult to manage. Despite the wide spectrum of pathophysiological mechanisms and treatment modalities, there is limited success in the management of this disease. Surgical treatment is usually performed as the last resort. We aimed to investigate the histopathological results of 38 women with LPV who underwent surgical vestibulectomy.

Methods

of the 55 women that were diagnosed with LPV and underwent vulvar vestibulectomy, 38 patients with complete histopathological results were included in this retrospective study.

Results

in 14 patients, the pathological reports revealed Low-Grade Squamous Intraepithelial Lesions (LGSIL) (36.8%) whereas for 21 cases (55.2%), the findings were concordant with vestibulitis. The remaining three patients (7.8%) were diagnosed with lichen simplex chronicus.

Conclusion

the presence of LGSIL in the surgical specimens of LPV cases is noteworthy. In this group of patients, surgical excision may contribute to the prevention of progression into high-grade lesions. The relationship between Human Papilloma Virus (HPV) infections and LPV should be further investigated.

Vulvodynia

Vulvodynia is a heterogenous, chronic pain condition of unknown etiology that affects 7% to 15% of women. It affects sexual function and quality of life. Vulvodynia can be primary or secondary, localized or generalized, and spontaneous or provoked. Contributing factors for provoked vulvodynia might include vulvovaginal infections, low estrogen states, and underlying anxiety disorder. Generalized vulvodynia likely arises from underlying connective tissue or neurological dysfunction. Vulvodynia treatment must be individualized on the basis of the patient's presentation and physical examination findings. Surgical excision of the vulvar vestibule has high success rates but other modalities showing success include pelvic floor physical therapy and cognitive-behavioral therapy.

Genitopelvic pain: retrospective evaluation of a multimodal treatment efficacy

BACKGROUND

Genitopelvic and sexual pain penetration disorder (GPPD) recognizes a multifaceted etiology. As with syndromes of chronic pain, it responds poorly to medications and its management is difficult. Clinicians consequently favor a multimodal comprehensive approach to tackle the different aspects of the disorder. To treat GPPD women, we chose a multimodal regimen including topical and systemic medications associated with physical interventions and behavioral couple therapy. Our aim was to evaluate the regimen efficacy and the influence that demographic, clinical, and pain characteristics may have on the outcome.

METHODS

Sixty self -referred women requesting medical care for GPPD, who were free of debilitating illness, in stable heterosexual relationships and with healthy and sexually functional partners, were treated according with the multimodal regimen we tailored on the specific needs of these women. As said, it associated topical and systemic medications combined with physical exercises used in behavioral sex therapy, and behavioral couple therapy. Past sexual history, characteristics of pain, vestibular hyperreactivity, pelvic floor hypertonicity, general health, and couple harmony were evaluated and statistically analyzed to determine which characteristics were associated with therapy outcome.

RESULTS

The statistical analysis of an association between demographic, reproductive, pain and medical conditions on one hand and therapy outcome on the other did not find any significance.

CONCLUSIONS

The lack of association between the investigated characteristics and treatment outcome is disappointing; on the other hand, the statistically significant impact of couple harmony (evaluated as partner presence and participation) on the treatment results may be the answer to our search for factors predicting outcome.

The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD

INTRODUCTION

The 2 most well-known classification systems that include sexual medicine diagnoses are the International Classification of Diseases and Statistics (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Sexual medicine experts from international societies representing an array of disciplines have revised and redefined female sexual dysfunctions (FSDs) to reflect current scientific evidence and the state of the art.

AIM

To summarize the evidence and interactive and chronological process by which sexual medicine societies' consensus groups developed the current nomenclature, classifications, and definitions for FSDs.

METHODS

We review the contributions and collaborations of the Fourth International Consultation in Sexual Medicine (ICSM), the International Society for the Study of Women's Sexual Health (ISSWSH), and the World Association of Sexual Health in conjunction with the World Health Organization.

MAIN OUTCOME MEASURES

The ICSM and ISSWSH diagnostic systems are contrasted with the DSM classification. We discuss innovations and strengths; relevant evidence regarding epidemiology, etiology, and risk factors; and key differences. We describe how sexual medicine expertise informed FSD codes in the ICD-11 classification.

RESULTS

ICSM and ISSWSH published evidence-based guidelines on the definitions, nomenclature, and diagnostic criteria for FSD that diverge from the DSM psychiatric compendia. These definitions and nomenclature recommend the separation of female sexual desire and arousal disorders, elaborate on subtypes of arousal problems, broaden the scope of sexual pain definitions, and provide a greater understanding of etiologies and risk factors for FSDs.

CONCLUSIONS

These collaborations among sexual medicine experts and their role in the ICD-11 development process provide confidence that the ICD-11 Sexual Dysfunction codes are based on current scientific evidence for diagnosing and coding FSDs in clinical settings worldwide, can serve as endpoints in clinical trials, and will provide specificity for treatment outcomes for FSD therapies. Parish SJ, Cottler-Casanova S, Clayton AH, et al. The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD. Sex Med 2021;9:36-56.

The International Society for the Study of Vulvovaginal Disease Surgical Oncological Procedure Definitions Committee "Surgical Terminology for Vulvar Cancer Treatment"

OBJECTIVES

The International Society for the Study of Vulvovaginal Disease (ISSVD) Surgical Oncological Procedure Definitions Committee propose a consistent terminology based on well-defined and reproducible anatomic landmarks that can be used by all who are involved in care of patients with vulvar conditions.

MATERIALS AND METHODS

The fundamental principles behind the new terminology contained descriptions of the area extension and depth of the surgical procedure.

RESULTS

Vulvar Surgical Topographic Anatomy LandmarksExtension. The internal border of the vulva is the hymenal ring. The genitocrural folds are the external lateral borders.The vertical line through the clitoris and the anus defines lateral portions of the vulva.The horizontal line from the upper border of the hymenal ring defines anterior and posterior portion of the vulva.Depth. The floor of the vulva is represented by the median perineal fascia or perineal membrane of the urogenital diaphragm.A. Vulvectomy1. Extension: partial/total vulvectomy. Removal of part/entire vulvar/perineal integument independent of the depth.2. Depth: superficial/deep. Removal of the most superficial layer/removal of the vulvar tissue to the superficial aponeurosis of the urogenital diaphragm and/or pubic periosteum.B. Inguinofemoral lymphadenectomy1. Superficial inguinofemoral lymphadenectomy. Removal of the nodes located beside the inguinal ligament and along the great saphenous vein.2. Deep femoral lymphadenectomy. Removal of the nodes below the cribriform lamina and medial to the femoral vein.

CONCLUSIONS

This terminology helps avoid confusion and promote better understanding and exchange of experiences among gynecologic oncologists involved in vulvar carcinoma care.

Vulvar pain: The revealing scenario of leading comorbidities in 1183 cases

OBJECTIVES

This study set out to investigate the epidemiological characteristics and comorbidities of chronic vulvar pain. Secondary goals were to identify the preferred approaches for managing vulvodynia in Italy.

STUDY DESIGN

A cross-sectional study (the VuNet -Vulvodynia Network project) was performed in consecutive female patients with chronic vulvar pain attending 21 Italian medical centers (public hospitals, university clinics and private outpatient services) in the period December 2016 to November 2018. Study data were entered by healthcare professionals in a special web-based medical record system (PRIDE- Progetto Rete Italiana Dolore vulvarE). These data covered epidemiological aspects, demographic characteristics, obstetric and gynecological history, presence and duration of current and/or past symptoms, associated disorders, details of physical examination and treatment approaches.

RESULTS

A total of 1183 subjects with a diagnosis of chronic vulvar pain were included in the study. The main reason for consultation was superficial dyspareunia, present in 64.2 % of the women. 43.4 % of the sample reported comorbid sexual disorders (of desire in 22.1 % and arousal in 21.3 %). 48.3 % of the patients reported prolonged pain lasting between one and five years. Factors associated with vulvar pain included a relatively high family history of diabetes mellitus (father = 8.6 %; mother = 8.4 %), recurrent vulvovaginal candidiasis (32 %), and urinary tract infections (37.4 %: recurrent cystitis in 19.5 % and post-coital cystitis in 17.9 %). Irritable bowel syndrome (28 %), constipation (23.5 %), headache (25.7 %: migraine in 18.0 % and menstrual headache in 7.7 %), allergies (17.5 %: food allergies in 10.1 %, respiratory allergies in 7.4 %), anxiety (15.0 %), dyschezia (11.7 %), invalidating dysmenorrhea/endometriosis (11.1 %), and major depression (7.6 %) were also reported. Vestibulodynia was diagnosed in 837 of the 1183 patients (70.8 %) and generalized vulvodynia in 323 (27.3 %). Notably, 69.1 % of the patients stated that previous therapies had not changed their pain.

CONCLUSIONS

The diagnoses of vestibulodynia and vulvodynia must be considered in patients with chronic vulvar pain. The VuNet study contributes to a more comprehensive reading of the predisposing, precipitating and maintaining factors that contribute to vulvar pain, and of the key comorbidities.

The effects of ageing on female genital and sexual health

This article will explore the impact of ageing on sexual function in older women and will reflect on the social influences on women's sexual ageing, identify the effects of ageing on sexual activity, particularly on genital skin, and consider the concerns from the perspective of older women. The article will then focus on vulval skin conditions and the functional aspects of living with these conditions. Finally, the article provides a starting point for nurses to consider their own knowledge, skills and attitudes through a series of reflective questions and recommendations for those working with older women to aid the identification of issues relating to older women's sexual health and vulval skin conditions, leading to further discussions to promote genital health.

The Clinical Utility of the Vulvar Pain Assessment Questionnaire: A Pilot Study

OBJECTIVE

The aim of the study was to document treatment-seeking experiences of women with chronic vulvar pain, comfort communicating about pain, and test the clinical utility of the screening version of the Vulvar Pain Assessment Questionnaire, screening version (VPAQscreen).

MATERIALS AND METHODS

Patients scheduled for an appointment with the Program in Vulvar Health at Oregon Health and Science University were invited to complete the VPAQscreen and answer descriptive questions about previous treatment-seeking experiences and communication with health care providers. Clinicians provided provisional diagnoses based on VPAQscreen summaries, final diagnoses based on gynecological examination, and commented on alignment with clinical observations. Patients gave feedback on the accuracy and helpfulness of the VPAQscreen summary, characteristics of the questions asked, and whether their comfort communicating increased.

RESULTS

Participants reported previously seeing approximately 5 medical doctors and 2 other health care providers and perceived them as lacking knowledge of vulvar pain syndromes. Providers indicated that VPAQscreen summaries aligned with clinical presentations and suggested provisional diagnoses with more than 80% accuracy. Participants reported that VPAQscreen summaries were helpful and accurate in summarizing symptoms. Most reported that the number, range, and readability of VPAQscreen questions were good or excellent. More than half reported that completing the VPAQscreen increased comfort when speaking with their Oregon Health and Science University physician.

CONCLUSIONS

Patients with vulvar pain often endure a lengthy process of consulting multiple clinicians before securing care. The VPAQscreen was more than 80% accurate in predicting diagnosis at this specialty clinic and was useful in assisting patients with expressing symptoms. The applicability of the VPAQscreen in general practice is unknown, although it shows promise.

Pelvic pain rehabilitation

Chronic pelvic pain is defined as persistent painful condition which lasts for at least six months under umbilicus. Numerous factors are blamed for etiopathogenesis, and quality of life of individuals is adversely affected. Chronic pain as well as functional disorders are accompanied to chronic pelvic pain. The treatment and rehabilitation program should be tailored for specific causes, targeting general pain treatment. Consequently, chronic pelvic pain management can be used to propose personalized treatment options and include patient education, behavioral therapy, and a biopsychosocial approach. Interdisciplinary teamwork and collaboration are essential for facilitating patient-centered rehabilitation.

Vulval Pain in Pediatric and Adolescent Patients

STUDY OBJECTIVE

To describe the experience of a tertiary pediatric and adolescent gynecology service that provides care to children and adolescents who present with vulval pain. Their presentation, associated symptoms, and management is described.

DESIGN

A retrospective analysis of all girls younger than 18 years of age who presented to the gynecology clinic of our tertiary referral Children's Hospital between Jan 2010 and July 2016. Electronic medical records were reviewed and parameters recorded using a standardized data sheet.

SETTING

Gynecology clinic of a tertiary referral children's hospital and private rooms of our director of gynecology.

PARTICIPANTS

Young women younger than 18 years who presented with symptoms suggestive of vulvodynia.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Presenting symptoms, characteristics of associated features, treatment options, and treatment outcomes.

RESULTS

Forty-seven patients with a mean age of 11 years (range, 3-18 years) were identified. At the time of diagnosis 31/47 (65.9%) were premenarchal. Many presented with a symptom other than pain alone. In particular, 35/47 (74.4%) presented with coexisting or previous urinary symptoms. Of patients examined, most had positive cotton tip examination findings (16/17 (94.1%) and 11/13 (84.6%) for pre- and postmenarchal, respectively) with clinical inspection otherwise unremarkable.

CONCLUSION

Children and adolescents with vulval pain have varied presentations. Many of the pre- and postmenarchal patients had coexisting urinary tract symptomatology at the time of diagnosis. This review of patients seen over 5.5 years at a pediatric tertiary referral center provides information on the presenting symptoms, examination features, and response to clinical management.

Provoked Vestibulodynia in Women with Pelvic Pain

INTRODUCTION

Pelvic pain and vulvar pain are common conditions in women. In this study, we sought to characterize the clinical picture of patients with concurrent pelvic pain and provoked vestibulodynia (PVD).

AIM

To analyze the association between sexual/clinical characteristics and a diagnosis of PVD among women with pelvic pain.

METHODS

Cross-sectional analysis of a prospective registry at a tertiary referral center for pelvic pain and endometriosis, involving consecutive non-menopausal sexually active patients 18-49 years-old seen by a single gynecologist from January 2016-December 2017. The sample was divided into 2 groups: pelvic pain with PVD; and pelvic pain alone (without PVD).

MAIN OUTCOME MEASURES

Superficial dyspareunia and deep dyspareunia on a 11-point numeric rating scale, and the sexual quality-of-life subscale of the Endometriosis Health Profile-30 (0-100%).

RESULTS

There were 129 patients that met study criteria: one third with pelvic pain and PVD (n = 42) and two-thirds with pelvic pain alone (without PVD) (n = 87). Women with pelvic pain and PVD had significantly more severe superficial dyspareunia ≥7/10 (OR = 12.00 (4.48-32.16), P < .001), more severe deep dyspareunia ≥7/10 (OR = 4.08 (1.83-9.10), P = .001), and poorer sexual quality of life (Endometriosis Health Profile-30 ≥50%) (OR = 4.39 (1.67-11.57), P = .002), compared with the group with pelvic pain alone. Women with pelvic pain and PVD also had more anxiety, depression, and catastrophizing, more frequent tenderness of the bladder and pelvic floor, and more common diagnosis of painful bladder syndrome. On the other hand, there were no significant differences between the 2 groups in terms of dysmenorrhea, chronic pelvic pain, abdominal wall allodynia, positive Carnett test for abdominal wall pain, functional quality of life, endometriosis, and irritable bowel syndrome.

CONCLUSIONS

In the pelvic pain population, PVD may be associated with more negative impact on dyspareunia, sexual quality of life, and bladder/pelvic floor function, but it may not significantly impact abdominopelvic pain or day-to-day function in general. Bao C, Noga H, Allaire C, et al. Provoked Vestibulodynia in Women with Pelvic Pain. Sex Med 2019;7:227-234.

Combination of Treatments With or Without Surgery in Localized Provoked Vulvodynia: Outcomes After Three Years of Follow-Up

Most vulvodynia patients receive combinations of several treatment modalities for their chronic painful condition. If conservative treatments fail, vestibulectomy is considered to be the ultimate treatment option for localized provoked vulvodynia (LPV). The aim of this descriptive study was to analyze relief of pain, quality of life (QoL), and complications associated with combining surgery with conservative treatments among LPV patients, both in short term and after 3 years of follow-up. The study population consisted of a retrospective patient cohort of surgically (n = 16) and only conservatively (n = 50) treated LPV patients. QoL data were assessed by a validated questionnaire (RAND-36). Data were collected by reviewing patient records and by aid of postal questionnaires. Efficacy of treatments in relief of pain was measured by numerical rating scale (NRS). Two months after surgery, the NRS scores assessed by a physician were lower in the surgery group than in patients treated only conservatively (p = 0.008). However, after a median of 36 months of follow-up, self-reported NRS scores and QoL showed no difference between the two patient cohorts. Complication rate after vestibulectomy was 18.8%. The findings suggest that combining surgery with conservative treatments may result in a more effective short-term reduction of pain. However, the effect seemed to be only temporary, as no long-term benefit was achieved.

Vulvodynia: A Review of the Literature

Objective: To evaluate the literature and educate the pharmacy community about the different treatment options for vulvodynia. Data Sources: Searches were performed through MEDLINE (1946-May 2018) using OVID and EBSCOhost, and Excerpta Medica (1974-May 2018) using EMBASE. Search terms included vulvar vestibulitis syndrome, vestibulodynia, vulvodynia, vulvar pain, provoked vulvar vestibulitis, and vulvodynia treatment. References of all relevant articles were then used to find additional applicable articles. Study Selection and Data Extraction: This review includes articles in the English language and human trial literature. Twenty-five trials explored the use of oral and topical medications in the treatment of vulvodynia. Data Synthesis: Vulvodynia is a poorly understood disease with an unknown etiology. Oral tricyclic antidepressants and gabapentin continue to be the most commonly used treatments for vulvodynia pain. This is due to their ease of use and patient preference. Topical treatments that have efficacy data are amitriptyline, gabapentin, lidocaine, baclofen, and hormones. This route of administration avoids systemic adverse effects and interpatient variability that accompanies oral administration. Alternative therapies more commonly used include physiotherapy, psychotherapy, and surgery. Treatment length may vary due to dose titrations and potential changes in medication therapy. Conclusions: Several medication and alternative therapies may be effective in treating vulvodynia. Current studies used wide dosing ranges, making it difficult to standardize therapy. No consistent method of assessing pain was used between studies, as well as a limited number being randomized and placebo controlled. Additional research is needed to increase knowledge and further develop vulvodynia treatments.

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

BACKGROUND

The gap between the relatively high prevalence of provoked vulvodynia (PVD) in the general population and the low incidence in primary care can partly be explained by physicians' lack of knowledge about the assessment and management of PVD.

OBJECTIVES

To recognize barriers and facilitators of GPs in the diagnostic process of women presenting with recurrent vulvovaginal complaints.

METHODS

A qualitative focus group study in 17 Dutch GPs, five men and 12 women. An interview guide, based on the scientific literature and the expertise of the researchers, including a vignette of a patient, was used to direct the discussion between the GPs. The interviews were audiotaped and transcribed verbatim. A systematic text analysis of the transcripts was performed after data saturation was reached.

RESULTS

Analysis of the interviews generated three major themes: Identifying and discussing sexual complaints, importance of gender in professional experience, and coping with professional uncertainty. Within these themes, the reluctance regarding sexual complaints, male gender, negative emotional responses when faced with professional uncertainty, as well as lack of education were barriers to the diagnostic process and management of PVD. Female gender and understanding that patients can profit from enquiring about sexual health issues were found to be facilitating factors.

CONCLUSIONS

To improve the care for women with PVD, attitude and skills of GPs regarding taking a sexual history and performing a vulvovaginal examination should be addressed, as well as GPs' coping strategies regarding their professional uncertainty.

Vulvodynia: A disease commonly hidden in plain sight

•Vulvodynia affects at least 6% of women, and can be found at any age and in all ethnic groups.•The diagnosis is one of exclusion but is very often missed.•Women with vulvodynia are frequently misdiagnosed as having vaginismus.•Failure to make the diagnosis often leads to irrelevant or deleterious examinations and treatments.

Differentiating overlapping symptoms of vulvodynia and pudendal neuralgia

Context

Vulvodynia is defined as a chronic vulvar pain non-associated with infectious, inflammatory, neoplastic or hormonal disorders.

Objectives

To present a case demonstrating the difficulty in assessing concomitant disease in vulvodynia.

Methods

A 26-year-old woman, presented with persistent vulvodynia. She received oral and topical medications and behavioural interventions to lessen sexual pain and restore sexuality. As sexual pain decreased, the patient reported symptoms previously not mentioned: continuous, intense periclitoral pain and numbness at the perineum when sitting for a long time. These new symptoms suggest the involvement of the peripheral neural system. The physical evaluation confirmed right-side pelvic distortion, and pathological increase in lumbar lordosis, which caused neuralgia radiating to the external genitalia and perineum, and overlapping with sexual pain. After diagnosing pudendal neuralgia according to the Nantes criteria, physical treatment and relaxation exercises to de-contract the spine were added to the vulvodynia regimen.

Results

During treatment, vulvodynia was sometimes present but never unbearable, allowing satisfactory sex. With physical therapy, the symptoms of pudendal neuralgia decreased.

Conclusion

Differentiating the presence of two conditions with overlapping symptoms is difficult because the vestibular pain had shadowed pudendal neuralgia symptoms at initial assessment. Syndromes of chronic pain tend to associate with each other and one syndrome may shadow symptoms of the concomitant condition affecting adjacent anatomical areas. Only the accurate identification of all the syndromes involved allows adopting the correct treatment.

Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study

BACKGROUND

Vulvodynia is a poorly characterized condition with multiple treatment options that have been described as largely ineffective in research settings.

AIM

To describe treatment patterns in women enrolled in the National Vulvodynia Registry and determine if there is an association between selected treatments and patient-reported outcomes such as pain, sexual function, and psychological distress after 6 months of treatment.

METHODS

Participants completed questionnaires on general medical history and patient-reported outcomes using the short-form McGill Pain Questionnaire, the Female Sexual Function Index, the Short Form-12 quality-of-life questionnaire, the Coping Strategies Questionnaire, and the State-Trait Anxiety Inventory. The evaluation also included pain sensitivity assessment of the vaginal mucosa using a cotton-tipped applicator and the vaginal muscles using a single-digit. In this prospective cohort study, all measurements were collected at baseline and again at 6 months after treatment.

OUTCOMES

Type of treatment, number of treatments, self-reported pain intensity, dyspareunia, and pain-related psychological distress measures are reported at baseline and 6 months.

RESULTS

Of 344 women enrolled, 282 received treatment; 78 different treatments were identified and categorized by type (eg, topical, oral, physical therapy) and number. The most commonly used treatments were topical (85%, n = 241), physical therapy (52%, n = 147), and oral medications (45%, n = 128). Notably, 73% of participants received ≥2 treatments. There was no association between type or number of treatments and patient characteristics. At 6 months, women reported improvements in general pain (P = .001), pain during intercourse (P = .001), catastrophizing (P = .000), and anxiety (P = .000). The Short Form-12 quality-of-life questionnaire showed improvements in physical limitations (P = .024), emotional limitations (P = .003), well-being (P = .025), and social function (P = .010). However, all domains of the Female Sexual Function Index indicated worsening in sexual function (P = .000) except for pain.

CLINICAL TRANSLATION

Multi-modal treatments were most commonly used in clinical practice and improvements in patient-reported outcomes such as quality of life, distress, and pain were noted; however, participants who returned at 6 months continued to report poor sexual function.

CONCLUSIONS

Strengths include a prospective and long-term study design that evaluated women in clinical settings. Limitations include a high rate of loss to follow-up for certain measures and inability to evaluate efficacy of individual treatments. In a setting where women were receiving highly specialized care, we found wide variation in the type and number of treatments used to treat vulvodynia. Despite this heterogeneity in treatment selection, women reported significant improvements in all study measures except sexual function. Lamvu G, Alappattu M, Witzeman K, et al. Patterns in Vulvodynia Treatments and 6-Month Outcomes for Women Enrolled in the National Vulvodynia Registry-An Exploratory Prospective Study. J Sex Med 2018;15:705-715.

Pain, psychological distress and motor pattern in women with provoked vestibulodynia (PVD) – symptom characteristics and therapy suggestions

Background and aims:

Provoked vestibulodynia (PVD) represent a longstanding pain syndrome that affects large numbers of women worldwide. However, no standardized guidelines for PVD treatment exist. In a cross-sectional pilot study we examined 30 PVD patients on multidimensional parameters including pain, psychological distress and quality of movement, in order to obtain a broader understanding of the somatic and psychological symptoms in PVD, and for the future to develop better interventions. Additionally, we compare the findings to previously published results regarding the same parameters in women with chronic pelvic pain (CPP).

Methods:

Thirty women with PVD recruited from a tertiary care university clinic of gynecology were assessed for demographic data, pain intensity (VAS), psychological distress (GHQ-30 and Tampa scale of Kinesophobia) and quality of movement (standardized Mensendieck test, SMT).

Results:

Average age of the PVD women was 24.7±3.60 years, 60% of them were in permanent relationships, all were nulliparous, none had been subjected to surgical procedures, 100% were working full or part time and 90% were educated to at least undergraduate level. Mean VAS score was 7.77±1.97 (mean±SD), kinesiophobia 24.4±3.95 and anxiety domain of GHQ-30 9.73±4.06. SMT scores were particularly low for the domains of respiration and gait (less than 50% of optimal scores).

Conclusions:

PVD women display reduced quality of movement, especially for gait and respiration patterns, increased level of anxiety and high average pain scores. These findings are similar to what we have previously reported in CPP patients. However, in contrast to CPP group, PVD women are on average younger, have higher work participation, higher education level and have not been subjected to surgical procedures.

Implications:

Since PVD women display similar, although somewhat less severe, symptom profile than CPP, we suggest that a multidimensional approach to treatment, such as “somatocognitive therapy” should be investigated in this group as it has previously been shown to be promising in treatment of CPP.

Association of Vulvar Symptoms With Pelvic Organ Prolapse and Urinary Incontinence

OBJECTIVE

The aim of this study was to compare vulvar symptoms between urogynecology patients diagnosed with urinary incontinence (UI) and/or pelvic organ prolapse to women presenting for annual gynecological care.

METHODS

This is a retrospective cross-sectional study. Vulvar symptoms (burning, pain, itching, dyspareunia, and discharge) were measured by asking respondents to rate the severity of each symptom from 0 (none) to 10 (most severe). Patient history, diagnoses, and the Urogenital Distress Inventory-6 (UDI-6) score were abstracted from records. Vulvar symptom results were categorized (0, none; 1-3), mild; ≥4, moderate to severe). Logistic regression models explored whether UI symptoms (UDI-6) and urogynecology diagnoses were associated with each vulvar symptom (moderate to severe vs none).

RESULTS

A total of 606 urogynecology patients grouped by the following urogynecology clinical diagnoses: UI (n = 230), prolapse (n = 193), UI + prolapse (n = 183), and 258 controls (general gynecology patients) were included. The mean (± SD) age (years) was 57.5 ± 16.1, 62.4 ± 13.9, 59.0 ± 14.9, and 41.3 ± 13.8 in the UI, prolapse, UI + prolapse, and control groups, respectively (p < .01). Increasing urinary symptoms were associated with all vulvar symptoms (odds ratio [OR], 1.1-1.2 for each 1 point increase in UDI-6; p < 0.05 for all). Prolapse and UI + prolapse diagnoses (compared with controls) were associated with vulvar burning (OR [95% confidence interval {CI}], 2.5 [1.2-5.0] and 2.9 [1.3-6.1] and pain (OR (95% CI), 3.6 [1.5-8.5] and 3.3 [1.4-8.2], respectively). Prolapse diagnoses were also associated with dyspareunia (OR [95% CI], 5.4 [2.2-13.3]).

CONCLUSIONS

Patients with pelvic organ prolapse are more likely to report vulvar burning, pain, and dyspareunia than gynecologic control patients. Urinary symptoms were associated with all vulvar symptoms.

The Vulvar Pain Assessment Questionnaire: Factor Structure, Preliminary Norms, Internal Consistency, and Test-Retest Reliability

BACKGROUND

The Vulvar Pain Assessment Questionnaire (VPAQ) was developed to assist in the assessment and diagnosis of chronic vulvar pain (vulvodynia).

AIM

To further establish the psychometric properties of the VPAQ by examining factor structure, test-retest reliability, internal consistency, and scale normative data, and to gather feedback from those with vulvar pain about the usefulness and accessibility of the questionnaire.

METHODS

182 participants completed a confidential online study and 70 participated again at time 2 (4 weeks later).

OUTCOMES

Participants were asked to complete the full VPAQ, which assesses pain characteristics, effects on various parts of their lives, coping strategies used, and romantic partner factors. Additional questions captured sociodemographics and feedback about the instrument.

RESULTS

Exploratory structural equation modeling indicated that the previously established subscales, except the coping scale, had adequate model fit, and all items loaded significantly onto relevant factors. Pearson product moment correlations (r = 0.57-0.96) established strong 4-week test-retest reliability for most subscale scores, and Cronbach α indicated overall acceptable to high internal consistency (α = 0.56-0.95). Preliminary norms for the scales are supplied. Approximately half the participants reported an increase in their comfort level in discussing a range of topics after completing the VPAQ. Most participants reported that the length, readability, and range of VPAQ questions were "good" or "excellent."

CLINICAL IMPLICATIONS

The results of this study provide further justification for using the VPAQ scales in clinical and research settings, preliminary norms for a vulvar pain population, and suggestions for interpretation.

STRENGTHS AND LIMITATIONS

This study established the psychometric properties of the VPAQ scales using multiple methods at 2 time points and gathered feedback from participants. However, data were collected online so diagnoses could not be confirmed and more than half the initial sample did not complete the survey at time 2.

CONCLUSION

The results of this study suggest that most VPAQ subscales (except the coping subscale) have moderate to strong psychometric properties and that the VPAQ is user friendly. Dargie E, Holden RR, Pukall CF. The Vulvar Pain Assessment Questionnaire: Factor Structure, Preliminary Norms, Internal Consistency, and Test-Retest Reliability. J Sex Med 2017;14:1585-1596.

Women without vulvodynia can have a positive 'Q-tip test': a cross sectional study

BACKGROUND

Vulvodynia is a frequently missed pathology, often confused with vaginismus. The Q-tip test (QTT) is fundamental for the diagnosis; however, there is lack of data about its performance in asymptomatic women.

OBJECTIVE

This study intended to evaluate the QTT for painful vestibular spots in asymptomatic women.

METHODS

Q-tips were gently pressed at different areas of the vulvar vestibule to obtain a 0-10 score representing the pain felt. This was performed in 267 consecutive patients presenting to the gynecology outpatient clinic for reasons other than vulvovaginal complaints. A questionnaire was done to evaluate the possibility of unrecognized vulvodynia.

RESULTS

Out of the 267 women, 18 (6.7%) fitted the diagnosis of vulvodynia and were excluded from the analysis. Of the remaining 249, 41 (16.5%) had a positive QTT. We could not find differences in the sexual activity rate between women with and without a positive QTT. No demographic differences could be found between the two groups. Only depression was more common in women with a positive QTT [31.7% (13/41) versus 10.8% (21/208), p=.001).

CONCLUSIONS

Asymptomatic women can have painful vestibular spots in the absence of vulvodynia. A positive QTT cannot be considered equivalent to vulvodynia, highlighting the need for extensive workup of these women before that diagnosis can be assumed.