Cream With Cutaneous Fibroblast Lysate for the Treatment of Provoked Vestibulodynia: A Double-Blind Randomized Placebo-Controlled Crossover Study

Pharmacological Treatments for Localized Provoked Vulvodynia: A Scoping Review

Introduction

Localized provoked vulvodynia (LPV) is a chronic pain condition without an identifiable cause that is localized to a portion of the vulva and provoked by pressure or touch. LPV is a commonly occurring but poorly understood condition lacking consensus on management.

Method

This scoping review used Arksey and O'Malley's approach to identify and evaluate literature published between 2010 and 2023 that addressed the question: What is the current evidence on the efficacy or effectiveness of pharmacological treatments in the management of LPV?

Results

This review evaluated 18 papers reporting on the efficacy or effectiveness of oral, topical, and injectable medications. Seven of the studies were randomized controlled trials. Oral gabapentin and oral desipramine showed some improvement in sexual function compared to placebo. Small sample sizes and methodological issues limited confidence in interpreting findings. Pain was reduced in descriptive studies of tricyclic antidepressants, milnacipran, injectable anesthetics, and botulinum toxin. Where pain did not improve with treatment, some oral medications improved participants' mood and sexual function. Some topical agents may be effective in reducing peripherally mediated neuropathic pain. Botulinum toxin was the most well-studied injectable but yielded mixed outcomes related to pain, quality of life, and sexual function.

Conclusion

There is a lack of convincing evidence to draw conclusions about the efficacy or effectiveness of pharmacological therapies for LPV. The breadth of therapies for treating LPV warrants the development of evidence-based, consensus guidelines for measuring treatment outcomes and improving comparisons across studies. Recommendations for research include addressing methodological shortcomings and diversifying the participant pool to increase the generalizability of findings.

Treatment of Provoked Vulvodynia: A Systematic Review

BACKGROUND

Treatment recommendations for provoked vulvodynia (PVD) are based on clinical experiences and there is a need for systematically summarizing the controlled trials in this field.

AIM

To provide an overview of randomized controlled trials and non-randomized studies of intervention for PVD, and to assess the certainty of the scientific evidence, in order to advance treatment guidelines.

DATA SOURCES

The search was conducted in CINAHL (EBSCO), Cochrane Library, Embase (Embase.com), Ovid MEDLINE, PsycINFO (EBSCO) and Scopus. Databases were searched from January 1, 1990 to January 29, 2021.

STUDY ELIGIBILITY CRITERIA

Population: Premenopausal women with PVD.

INTERVENTIONS

Pharmacological, surgical, psychosocial and physiotherapy, either alone or as combined/team-based interventions.

CONTROL

No treatment, waiting-list, placebo or other defined treatment.

OUTCOMES

Pain during intercourse, pain upon pressure or touch of the vaginal opening, sexual function/satisfaction, quality of life, psychological distress, adverse events and complications.

STUDY DESIGN

Randomized controlled trials and non-randomized studies of interventions with a control group.

STUDY APPRAISAL AND SYNTHESIS METHODS

2 reviewers independently screened citations for eligibility and assessed relevant studies for risk of bias using established tools. The results from each intervention were summarized. Studies were synthesized using a narrative approach, as meta-analyses were not considered appropriate. For each outcome, we assessed the certainty of evidence using grading of recommendations assessment, development, and evaluation (GRADE).

RESULTS

Most results of the evaluated studies in this systematic review were found to have very low certainty of evidence, which means that we are unable to draw any conclusions about effects of the interventions. Multimodal physiotherapy compared with lidocaine treatment was the only intervention with some evidential support (low certainty of evidence for significant treatment effects favoring physiotherapy). It was not possible to perform meta-analyses due to a heterogeneity in interventions and comparisons. In addition, there was a heterogeneity in outcome measures, which underlines the need to establish joint core outcome sets.

CLINICAL IMPLICATIONS

Our result underscores the need of stringent trials and defined core outcome sets for PVD.

STRENGTH AND LIMITATIONS

Standard procedures for systematic reviews and the Population Intervention Comparison Outcome model for clinical questions were used. The strict eligibility criteria resulted in limited number of studies which might have resulted in a loss of important information.

CONCLUSION

This systematic review underlines the need for more methodologically stringent trials on interventions for PVD, particularly for multimodal treatments approaches. For future research, there is a demand for joint core outcome sets. Bohm-Starke N, Ramsay KW, Lytsy P, et al. Treatment of Provoked Vulvodynia: A Systematic Review. J Sex Med 2022;19:789-808.

Clinicopathologic Diagnostic Criteria for Vulvar Lichen Planus

OBJECTIVE

The aim of the study was to describe the clinical and histopathologic features required for a clinicopathologic diagnosis of vulvar lichen planus (LP), which is divided into 3 types: erosive, classic, and hypertrophic.

MATERIALS AND METHODS

The International Society of the Study of Vulvovaginal Diseases tasked the Difficult Pathologic Diagnoses committee with development of a consensus document for the clinicopathologic diagnosis of vulvar LP, lichen sclerosus, and differentiated vulvar intraepithelial neoplasia. The LP subgroup reviewed the literature and formulated diagnostic criteria, then approved by the International Society of the Study of Vulvovaginal Diseases membership.

RESULTS

The clinicopathologic diagnosis of erosive LP incorporates 5 criteria: (a) a well-demarcated, glazed red macule or patch at labia minora, vestibule, and/or vagina, (b) disease affects hairless skin, mucocutaneous junction, and/or nonkeratinized squamous epithelium, (c) evidence of basal layer damage, categorized as degenerative or regenerative, (d) a closely applied band-like lymphocytic infiltrate, and (e) absent subepithelial sclerosis. The clinicopathologic diagnoses of classic and hypertrophic LP each require a characteristic clinical appearance accompanied by hyperkeratosis, hypergranulosis, acanthosis, basal layer degeneration, a closely applied lymphocytic infiltrate, and absent dermal sclerosis, with hypertrophic LP showing marked epithelial abnormality compared with classic LP.

CONCLUSIONS

Clinicopathological correlation yields the most reliable diagnosis of vulvar LP. Disease appearance overlaps with other physiologic, dermatologic, infectious, and neoplastic entities; a low threshold for biopsy at all morphologically distinct areas is recommended. Use of the histopathologic criteria described in this document may reduce the nondiagnostic biopsy rate for clinically diagnosed LP.

Treatment of Vulvodynia: Pharmacological and Non-Pharmacological Approaches

Vulvodynia is a common, recurrent, vulvar pain condition with debilitating consequences for affected women's health and quality of life. The heterogeneity of women suffering from vulvodynia as well as its uncertain and likely multifactorial etiology pose a significant challenge to identifying any kind of "gold standard" treatment. Thus, treatment providers must be well versed in the various options and the evidence for each. In this review, we begin with pharmacological treatments, followed by non-pharmacological treatments, surgery, and finally multimodal treatments. For each approach, we briefly discuss the method, mechanism of action, and empirical support for the treatment. In sum, pharmacological treatments that may be beneficial but require further research include antinociceptive agents (lidocaine, capsaicin), anti-inflammatory agents (corticosteroids, interferon), neuromodulating medications (anticonvulsants and antidepressants), hormonal agents, and muscle relaxants (e.g., botulinum toxin). There is strong evidence to support and recommend non-pharmacological interventions including psychological therapy, pelvic floor physical therapy, as well as surgery (i.e., vestibulectomy for provoked vestibulodynia) for the treatment of vulvodynia. We conclude this review with a discussion of issues that may have hindered progress of treatment efficacy and effectiveness, and recommendations for moving the field forward.

Outcome Measurement Instruments for Provoked Vulvodynia: A Systematic Review

OBJECTIVE

The objective of this study was to detail the outcome measurement instruments used in randomized control trials and observational studies investigating therapeutic interventions for provoked vulvodynia.

MATERIALS AND METHODS

We searched Ovid Medline, Embase, Emcare, and PyschINFO libraries from database inception through April 2017. We included randomized control trials and observational studies of provoked vulvodynia that used instruments to measure the outcome of therapeutic interventions.

RESULTS

A total of 2299 articles were retrieved and 25 were eligible for inclusion in accordance with the selection criteria. The included studies measured 26 different outcomes, using 110 outcome measurement instruments. Patient-reported outcomes were most commonly measured (144/166, 86%), followed by physician-reported outcomes (20/166, 12%). The most commonly measured outcomes were patient-reported psychological impact of disease (27/166, 16%), patient-reported improvement in dyspareunia (25/166, 15%), and patient-reported reduction in pain (24/166, 14%). The Pain Catastrophizing Scale, the Beck Depression Inventory, and the State Trait Anxiety Questionnaire were the most commonly used instruments to measure psychological impact.The most commonly measured clinician-rated outcome was an improvement in pain (17/166, 10%), which was most frequently assessed by the cotton swab test. Only 34 (31%) outcome measurement instruments were specific to vulvodynia (26/110, 23%) or sexual functioning (8/110, 7%).

CONCLUSIONS

There is a wide range of outcome measurement instruments used in provoked vulvodynia studies, resulting in inconsistency of reporting and difficulty in comparing and combining findings for systemic review. There is a pressing need for the development of validated, reliable instruments and consensus on a core outcome set for further research purposes.

A systematic review of drug treatment of vulvodynia: evidence of a strong placebo effect

BACKGROUND

Vulvodynia is the most common type of chronic pelvic pain and dyspareunia in premenopausal women. The effect of drugs for the treatment of vulvodynia remains poorly discussed.

OBJECTIVES

To conduct a systematic review of randomised controlled studies which assess medications used to treat vulvar pain in vulvodynia.

SEARCH STRATEGY

Web of Science, Cochrane Library, EBSCO Academic, LILACS and MEDLINE were searched from 1985 to September 2016.

SELECTION CRITERIA

Randomised controlled trials comparing any kind of medication for vulvodynia treatment with placebo or with another medication in adult patients were included.

DATA COLLECTION AND ANALYSIS

The two investigators independently conducted data extraction. The synthesis was provided by the pain reduction index. Study quality assessment was performed using the Cochrane Handbook for Systematic Reviews of Intervention and analysis of publication bias was conducted.

MAIN RESULTS

Five studies were included in qualitative synthesis. Number of participants varied from 30 to 133 participants among the eligible studies, resulting in a total of 297 patients. The pain reduction rates of patients with vulvodynia assessed by Q-tipped cotton test and visual analogue scale varied between studies. Placebo was shown to be as effective as any medication.

CONCLUSIONS

There is a need for further studies evaluating topical monotherapy for the treatment of vulvodynia, as they are the main drugs used in clinical practice.

TWEETABLE ABSTRACT

No medication has shown impact on vulvar pain in vulvodynia. There is evidence of a placebo effect.

An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for the assessment of sexual health of women with pelvic floor dysfunction

AIMS

The terminology in current use for sexual function and dysfunction in women with pelvic floor disorders lacks uniformity, which leads to uncertainty, confusion, and unintended ambiguity. The terminology for the sexual health of women with pelvic floor dysfunction needs to be collated in a clinically-based consensus report.

METHODS

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA), and the International Continence Society (ICS), assisted at intervals by many external referees. Internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus). Importantly, this report is not meant to replace, but rather complement current terminology used in other fields for female sexual health and to clarify terms specific to women with pelvic floor dysfunction.

RESULTS

A clinically based terminology report for sexual health in women with pelvic floor dysfunction encompassing over 100 separate definitions, has been developed. Key aims have been to make the terminology interpretable by practitioners, trainees, and researchers in female pelvic floor dysfunction. Interval review (5-10 years) is anticipated to keep the document updated and as widely acceptable as possible.

CONCLUSION

A consensus-based terminology report for female sexual health in women with pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

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.

Does Degree of Vulvar Sensitivity Predict Vulvodynia Characteristics and Prognosis?

Although women with vulvodynia typically have increased vulvar sensitivity, data on characteristics associated with the degree of vulvar sensitivity are lacking. We measured vulvar sensitivity using cotton swab test and vulvodolorimeter among a subset of 335 women, aged younger than 70 years, in the longitudinal Woman to Woman Health Study. Comparing the vulvodynia screening results from their online/paper survey to that at the time of the examination, 42 women had ongoing vulvodynia, 66 had a recent remission, 22 control participants had a recent onset of vulvodynia, and 205 control participants remained asymptomatic. Vulvar sensitivity was greater in each vulvodynia group compared with the control group (P < .001), and was associated with younger age at first onset of pain (P = .025), pain after intercourse (P = .008), describing the pain as a "pressure," "burning," or "irritating" (P = .015, P = .005, and P = .006, respectively), with increased severity of pain ever (P = .012), and with subsequent persistent or relapsing vulvodynia (P < .001 for each). A score of >1 for the cotton swab summary score best differentiated case from control participants (sensitivity 71.9%; specificity 72.0%). Although 13.8% of women with vulvodynia had no increased sensitivity on cotton swab testing, they did not differ in most clinical characteristics or clinical course from those with increased vulvar sensitivity.

PERSPECTIVE

This study showed that women with vulvodynia have more vulvar sensitivity than control women, but the spectrum of sensitivity is broad. Furthermore, those with and without vulvar sensitivity did not differ in most vulvar pain characteristics or in prognosis, suggesting a positive swab test is not required to substantiate the diagnosis.

A review of the available clinical therapies for vulvodynia management and new data implicating proinflammatory mediators in pain elicitation

Localised provoked vulvodynia (LPV) is a common, chronic, and disabling condition: patients experience profound pain and a diminished quality of life. The aetiologic origins of vulvodynia are poorly understood, yet recent evidence suggests a link to site-specific inflammatory responses. Fibroblasts isolated from the vestibule of LPV patients are sensitive to proinflammatory stimuli and copiously produce pain-associated proinflammatory mediators (IL-6 and PGE₂ ). Although LPV is a multifactorial disorder, understanding vulvar inflammation and targeting the inflammatory response should lead to treatment advances, especially for patients exhibiting signs of inflammation. NFκB (already targeted clinically) or other inflammatory components may be suitable therapeutic targets.

TWEETABLE ABSTRACT

Vulvodynia is a poorly understood, prevalent, and serious women's health issue requiring better understanding to improve therapy.

Vulvar vestibulodynia: strategies to meet the challenge

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

Treatment of Female Sexual Pain Disorders: A Systematic Review

Sexual pain disorders affect women's sexual and reproductive health and are poorly understood. Although many treatments have been evaluated, there is no one "gold standard" treatment. The aim of this systematic review was to investigate what treatments for female sexual pain have been evaluated in clinical studies and their effectiveness. The search strategy resulted in 65 papers included in this review. The articles were divided into the following categories: medical treatments; surgical treatments; physical therapies; psychological therapies; comparative treatment studies; and miscellaneous and combined treatments. Topical and systemic medical treatments have generally been found to lead to improvements in, but not complete relief of, pain, and side effects are quite common. Surgical procedures have demonstrated very high success rates, although there has been variability in complete relief of pain after surgery, which suggests less invasive treatments should be considered first. Physical therapies and psychological therapies have been shown to be promising treatments, supporting a biopsychosocial approach to sexual pain disorders. Although most of the interventions described have been reported as effective, many women still experience pain. A multidisciplinary team with active patient involvement may be needed to optimize treatment outcome.

Psychological treatment for vaginal pain: does etiology matter? A systematic review and meta-analysis

INTRODUCTION

Classification of vaginal pain within medical or psychiatric diagnostic systems draws mainly on the presumed presence or absence (respectively) of underlying medical etiology. A focus on the experience of pain, rather than etiology, emphasizes common ground in the aims of treatment to improve pain and sexual, emotional, and cognitive experience. Thus, exploring how vaginal pain conditions with varying etiology respond to psychological treatment could cast light on the extent to which they are the same or distinct.

AIM

To examine the combined and relative efficacy of psychological treatments for vaginal pain conditions.

METHODS

A systematic search of EMBASE, MEDLINE, PsycINFO, and CINAHL was undertaken. Eleven randomized controlled trials were entered into a meta-analysis, and standardized mean differences and odds ratios were calculated. Effect sizes for individual psychological trial arms were also calculated.

MAIN OUTCOME MEASURES

Main outcome measures were pain and sexual function.

RESULTS

Equivalent effects were found for psychological and medical treatments. Effect sizes for psychological treatment arms were comparable across vaginal pain conditions.

CONCLUSIONS

Effectiveness was equivalent regardless of presumed medical or psychiatric etiology, indicating that presumed etiology may not be helpful in selecting treatment. Research recommendations and clinical implications are discussed.

Vulvodynia

Vulvodynia is a complex disorder reported by up to 16% of women in the general population. While most patients describe it as burning, stinging, irritation, or rawness, it is underreported and underrecognized by providers. Vulvodynia is costly both economically and psychologically due to its negative impact on quality of life. Vulvodynia is a diagnosis of exclusion with unknown etiology and may involve multiple sources of pain in the same woman. Thus, there are no clinical or histopathologic criteria for the diagnosis other than consideration and careful evaluation to exclude other causes of pain. Successful therapy often requires a multidisciplinary approach with more than one therapeutic intervention to address the physical, psychological, psychosexual, and relationship components.

Vulvodynia and proctodynia treated with topical baclofen 5 % and palmitoylethanolamide

BACKGROUND

The prevalence of idiopathic vulvodynia and proctodynia is high. Pain management with anti-depressants and anti-epileptics may induce undesirable side effects. Therefore, topical baclofen cream and palmitoylethanolamide might be new therapeutic options.

CASE

A 33-year-old woman with intractable chronic vulvar and anal pain had to abstain from sexual intercourse and could neither cycle nor sit for more than 5 min. The patient did not respond to standard treatments. We prescribed a combination of topical baclofen 5 % and palmitoylethanolamide 400 mg, three times daily. After 3 months her symptoms decreased more than 50 % and sexual intercourse was possible again without pain.

CONCLUSION

Topical baclofen and palmitoylethanolamide can be a viable treatment option in chronic vulvodynia and proctodynia.

Female reproductive tract pain: targets, challenges, and outcomes

Pain from the female reproductive tract (FRT) is a significant clinical problem for which there are few effective therapies. The complex neuroanatomy of pelvic organs not only makes diagnosis of pelvic pain disorders difficult but represents a challenge to development of targeted therapies. A number of potential therapeutic targets have been identified on sensory neurons supplying the FRT but our knowledge on the basic neurophysiology of these neurons is limited compared with other viscera. Until this is addressed we can only guess if the new experimental therapies proposed for somatic, gastrointestinal, or bladder pain will translate to the FRT. Once suitable therapeutic targets become clear, the next challenge is drug delivery. The FRT represents a promising system for topical drug delivery that could be tailored to act locally or systemically depending on formulation. Development of these therapies and their delivery systems will need to be done in concert with more robust in vivo and in vitro models of FRT pain.