Chronic pelvic pain syndrome (CPPS) and chronic vulvar pain syndrome (CVPS): evaluation of psychosomatic aspects

Pain Characteristics, Psychosocial Wellbeing, and Sexual Wellbeing of Women Diagnosed With Provoked Vestibulodynia and a History of Sexual Abuse

OBJECTIVE

Provoked vestibulodynia (PVD) is a common chronic pain condition characterized by pain at the vulvar vestibule elicited by touch. Both PVD and sexual abuse lead to negative psychosocial and sexual consequences. However, little is known about the wellbeing of women with PVD and a history of sexual abuse. The aim of this study was to characterize a sample of women seeking treatment for PVD who have experienced sexual abuse.

METHODS

A total of 404 women diagnosed with PVD completed self-report questionnaires of PVD symptoms and psychosocial and sexual wellbeing before and after participating in a multidisciplinary PVD treatment program. History of sexual abuse was assessed via self-report, and women were dichotomized into groups.

RESULTS

No significant differences were found on sociodemographic variables, baseline psychosocial or sexual functioning between women with and without a self-reported history of sexual abuse (n = 40 and n = 364, respectively). Significantly more women with a history of sexual abuse than without reported other comorbid chronic pain conditions and radiating PVD pain. History of sexual abuse did not affect improvements in sexual distress scores following multidisciplinary treatment for their PVD.

CONCLUSION

Ten percent of women in our sample self-reported a history of sexual abuse, but the two groups did not differ significantly with respect to their baseline psychosocial or sexual functioning concerns, and both groups reported reductions in sexual distress following treatment for PVD. These findings indicate that a history of sexual abuse does not significantly affect the efficacy of multidisciplinary treatment approaches for PVD.

Differences in depression, posttraumatic stress disorder, and lifetime trauma exposure in formerly abused women with mild versus moderate to severe chronic pain

Although associations between intimate partner violence, chronic pain, depression, posttraumatic stress disorder (PTSD), and lifetime trauma exposure are well known, previous studies are limited by their recruitment of women from shelters. These relationships were explored with a community-based sample of formerly abused women ( N = 84). Seventy-seven percent of women reported pain of >3 months duration, and 75% had moderate to severe pain. Based on logistic regression analysis, women with moderate to severe chronic pain were significantly less likely to be employed, had more depressive symptoms, and were in the abusive relationship longer than women in mild chronic pain. Both pain severity groups had equally high levels of depressive and PTSD symptoms and multiple trauma exposures. Findings document the persistence of significant symptomatology in formerly abused women.

Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach

This article reviews the literature on management of chronic cyclical pelvic pain (CCPP). Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library, Current Contents, and EMBASE were searched using MeSH terms including all subheadings and keywords: "cyclical pelvic pain", "chronic pain", "dysmenorrheal", "nonmenstrual pelvic pain", and "endometriosis". There is a dearth of high-quality evidence for this common problem. Chronic pelvic pain affects 4%-25% of women of reproductive age. Dysmenorrhea of varying degree affects 60% of women. Endometriosis is the commonest pathologic cause of CCPP. Other gynecological causes are adenomyosis, uterine fibroids, and pelvic floor myalgia, although other systems disease such as irritable bowel syndrome or interstitial cystitis may be responsible. Management options range from simple to invasive, where simple medical treatment such as the combined oral contraceptive pill may be used as a first-line treatment prior to invasive management. This review outlines an approach to patients with CCPP through history, physical examination, and investigation to identify the cause(s) of the pain and its optimal management.

Prevalence and correlates of depression in treatment-seeking women with vulvodynia

This study aimed to examine rates and correlates of depression in a treatment-seeking sample of women with vulvodynia. A total of 53 women were independently diagnosed with vulvodynia and assessed with state-of-the-art measures of major depressive disorder (MDD) and depressive symptom severity as well as psychometrically established measures of pain severity, general functioning, sexual function and quality of life. Current and lifetime prevalence rates for MDD were 17% (n = 9) and 45% (n = 24), respectively. Women with current MDD reported significantly greater pain severity, and worse functioning and quality of life than women without current MDD. Among those with lifetime MDD, the majority (62.5%) reported that their first depressive episode occurred before the onset of vulvodynia. Rates of current MDD appeared to be lower than rates of MDD among other samples of treatment seeking chronic pain patients. In summary, co-morbid MDD is related to greater pain severity and worse functioning among women with vulvodynia.

Life events in patients with vulvodynia

OBJECTIVE

Vulval pain, in the absence of pathology, may have a psychological basis that relates to life events. This study aimed to determine the nature of such events.

DESIGN

Structured questionnaire about patient's symptoms and early-life events.

SETTING

Private practice physiotherapist specialising in pelvic floor disorders.

POPULATION

Patients with vulvodynia as their primary symptom and control patients being treated for urinary tract disorder or post-childbirth routine physiotherapy who had no vulval pain on direct questioning.

METHODS

Questionnaire applied to consecutive patients referred for treatment. Seventy-eight consecutive women presenting with vulvodynia (mean age 34 years, mean duration of symptoms 48 months) and 78 controls (mean age 39 years).

MAIN OUTCOME MEASURES

Incidence of life events.

RESULTS

A similar proportion of both groups were married. Being in a new relationship (P < 0.04), adverse current or previous relationships (39 versus 9%, P < or = 0.01), parental divorce (26 versus 9%, P < or = 0.001), history of termination of pregnancy, and adverse childbirth experiences (P < 0.04) were more common in patients than in controls. A history of sexual abuse was not more common in patients with vulvodynia compared with controls (13 versus 10%, P = not significant). Lack of libido was common in patients with vulvodynia (94 versus 29%, P < 0.0001).

CONCLUSIONS

Adverse life experiences, including conflict, are common in women with vulvodynia. These factors may be important in mediating the genesis of pain through stress-related mechanisms. Sexual interest is diminished in these women. Sexual abuse is not a factor in most of these women. These findings have implications for treatment.

Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts

Medically unexplained symptoms (MUS) are frequently associated with a history of traumatization. The first purpose of the present review paper was to investigate systematically the evidence for such relation in a subset of clinical samples with MUS presenting with functional somatization: chronic pelvic pain, irritable bowel syndrome and conversion and somatization disorder. The second purpose was to critically review three dominant models explaining the relation between trauma and MUS (i.e. dissociation, conversion and hierarchical cognitive models). The latter model in particular adequately accounts for the non-volitional and non-intentional character of MUS and explains how traumata can affect the development of MUS without assuming that previous trauma is a necessary prerequisite of MUS. The cognitive model, however, lacks integration with current neurobiological findings, indicative of central stress-and central nervous system alterations in MUS. The final purpose of the present paper was, therefore, to review current neurobiological studies focused on trauma and MUS and to formulate a research agenda to integrate these neurobiological developments with cognitive models for MUS.

Adult-onset vulvodynia in relation to childhood violence victimization

Researchers have failed to find a consistent association between childhood victimization and vulvodynia, a debilitating, unexplained vulvar pain condition. However, selection bias associated with case ascertainment, and differential reporting bias between clinic-based cases and controls, may explain in part the inconsistent findings. In 2000-2003, the authors identified 125 women experiencing symptoms of vulvar pain consistent with vulvodynia and 125 age- and community-matched controls from the Boston, Massachusetts-area general population. Telephone-administered questionnaires were used to obtain medical, psychiatric, and reproductive histories. Self-administered surveys assessed childhood exposure (age <12 years) to physical and sexual abuse and to poor family support. After author adjustment for socioeconomic position, women with vulvar pain versus controls were 2.6 times more likely to report never/rarely receiving childhood family support, such as comfort, encouragement, and love (95% confidence interval (CI): 1.3, 5.1). Adult-onset vulvodynia was strongly associated with abuse as a child more than a few times physically (odds ratio (OR) = 4.1, 95% CI: 1.7, 10.0) or sexually (OR = 6.5, 95% CI: 1.2, 35.1). When abused women were compared with those with no history of abuse, the association was largely confined to those harmed by a primary family member (OR = 3.6, 95% CI: 1.6, 8.0 for physical abuse; OR = 4.4, 95% CI: 0.9, 22.9 for sexual abuse). Additional population-based studies of clinically confirmed cases of vulvodynia are needed to replicate this association.

Is childhood abuse a risk factor for chronic pain in adulthood?

Childhood sexual and physical abuse often are viewed as important factors in the development and persistence of chronic pain syndromes in adulthood. Nevertheless, earlier reviews on this issue have reached conflicting conclusions regarding the veracity of the relationship. In this critical review of existing research on childhood abuse and pain in adulthood, surprisingly mixed evidence is found, with significant effects found most consistently in very large cross-sectional studies that rely on self-reported abuse status. The few prospective studies that are available do not support the relationship. When examining the literature from the perspective of epidemiological standards for inferring causation, the authors conclude that the evidence does not demonstrate a causal relationship. It appears that any overall relationship between childhood abuse and pain in adulthood probably is modest in magnitude, if it exists at all. Clinical implications and suggestions for future research directions are discussed.

Childhood victimization and pain in adulthood: a prospective investigation

Evidence of the relationship between childhood abuse and pain problems in adulthood has been based on cross-sectional studies using retrospective self-reports of childhood victimization. The objective of the current study was to determine whether childhood victimization increases risk for adult pain complaints, using prospective information from documented cases of child abuse and neglect. Using a prospective cohort design, cases of early childhood abuse or neglect documented between 1967 and 1971 (n = 676) and demographically matched controls (n = 520) were followed into young adulthood. The number of medically explained and unexplained pain complaints reported at follow-up (1989-1995) was examined. Assessed prospectively, physically and sexually abused and neglected individuals were not at risk for increased pain symptoms. The odds of reporting one or more unexplained pain symptoms was not associated with any childhood victimization or specific types (i.e. sexual abuse, physical abuse, or neglect). In contrast, the odds of one or more unexplained pain symptoms was significantly associated with retrospective self-reports of all specific types of childhood victimization. These findings indicate that the relationship between childhood victimization and pain symptoms in adulthood is more complex than previously thought. The common assumption that medically unexplained pain is of psychological origin should be questioned. Additional research conducting comprehensive physical examinations with victims of childhood abuse and neglect is recommended.

The role of psychiatric disorders in fibromyalgia

The cardinal features of fibromyalgia are chronic widespread pain in the presence of widespread tenderness as measured by multiple tender points. Despite extensive investigations, the etiology of this syndrome remains unclear. Increased rates of psychiatric disorders, particularly depressive, anxiety, and somatoform disorders, are apparent in clinic populations. Epidemiologic evidence suggests that this is also true for community subjects. Depression, generalized psychological distress, and other psychological factors have been shown to be associated with the onset and persistence of fibromyalgia symptoms. However, the bodily processes through which such factors may lead to the onset of fibromyalgia are unclear. Recent investigations have demonstrated altered stress system responsiveness, most notably the hypothalamic-pituitary-adrenal stress axis, in patients with fibromyalgia. These findings, and one promising avenue for investigating the interaction between psychological and biological factors in the onset of chronic pain syndromes including fibromyalgia, are discussed.