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Awad-Igbaria Y, Abu-Ata S, Nakhleh-Francis Y, Lowenstein L, Ginat K, Bornstein J, Palzur E, Shamir A. Exploring venlafaxine effects on chronic vulvar pain: Changes in mood and pain regulation networks. Neuropharmacology 2024; 243:109788. [PMID: 37984764 DOI: 10.1016/j.neuropharm.2023.109788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023]
Abstract
The etiology of idiopathic pain conditions, such as Provoked vulvodynia (PV), is multifactorial. The efficiency of venlafaxine, serotonin-noradrenaline reuptake inhibitor (SNRIs) in modulating vulvar pain led to the hypothesis that PV might involve central mechanisms. Here, we investigate whether vulvar pain is associated with gene-expression changes in mood, stress and pain systems, including amygdala (Amg), medial prefrontal cortex (mPFC), and periaqueductal gray matter (PAG). Additionally, we examined the analgesic and anxiolytic effects of venlafaxine. We found that the development of chronic vulvar pain in an animal model of PV is associated by overexpression of genes related to neuronal-activity and neuroinflammation in the Amg, mPFC, and PAG. Additionally, changes in the expression of GABA and serotonin synthesis, and reuptake were noted in the Amg and mPFC. Unsurprisingly, anxiety-like behavior and emotional-disorder were observed in rats with chronic vulvar pain. Nevertheless, treatment with venlafaxine (37.5 mg/kg) for one month significantly improves the vulvar hypersensitivity, as well as reduces the anxiety level. More critically, the long-term gene expression adaptation in serotonin receptor and synthesis, GABA synthesis, neuroplasticity, and neuroinflammation in the Amg, mPFC, and PAG, were modulated by venlafaxine in rats with vulvar pain. Our findings suggest that vulvar hypersensitivity induced by inflammation might associated with gene expression changes in brain areas that are involved in mood, stress and pain regulation. These changes probably play a role in central sensitization, and anxiety. Strikingly, enhancing the activity of serotonin and noradrenaline via venlafaxine treatment in rats with vulvar pain induces analgesic and anxiolytic effects.
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Affiliation(s)
- Yaseen Awad-Igbaria
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel; Research Institute of Galilee Medical Center, Nahariya, Israel.
| | - Saher Abu-Ata
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel; Research Institute of Galilee Medical Center, Nahariya, Israel
| | - Yara Nakhleh-Francis
- Research Institute of Galilee Medical Center, Nahariya, Israel; Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
| | - Lior Lowenstein
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel; Research Institute of Galilee Medical Center, Nahariya, Israel; Department of Obstetrics and Gynecology, Galilee Medical Center, Nahariya, Israel
| | - Karen Ginat
- Psychobiology Research Laboratory, Mazor Mental Health Center, Akko, Israel
| | - Jacob Bornstein
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel; Research Institute of Galilee Medical Center, Nahariya, Israel
| | - Eilam Palzur
- Research Institute of Galilee Medical Center, Nahariya, Israel
| | - Alon Shamir
- Psychobiology Research Laboratory, Mazor Mental Health Center, Akko, Israel; Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
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Bhuiyan J, Habeshian KA, Booser AC, Gomez-Lobo V, Dowlut-McElroy T. Botulinum Toxin Injections as a Treatment of Refractory Vulvodynia in Adolescents: A Case Series. J Pediatr Adolesc Gynecol 2023; 36:497-500. [PMID: 37301425 PMCID: PMC10527077 DOI: 10.1016/j.jpag.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 04/09/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Vulvodynia involves vulvar discomfort that occurs in the absence of an identifiable cause. Because vulvodynia is often accompanied by myofascial pain and pelvic floor tension, transvaginal botulinum toxin (BT) injection into the pelvic floor has been proposed as a possible treatment. METHODS Retrospective case series RESULTS: Three adolescents with vulvodynia had a suboptimal response to treatment with several interventions, including neuromodulators (oral and topical), tricyclic antidepressants (oral and topical), and pelvic floor physical therapy. Subsequently, these patients underwent BT injections to the pelvic floor as treatment with varying responses. CONCLUSION In select adolescent patients with vulvodynia, transvaginal BT injection into the pelvic floor can be an effective treatment. Further studies are needed to assess the optimal dosing, frequency, and sites of BT injections in the treatment of vulvodynia in pediatric and adolescent patients.
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Affiliation(s)
- Julia Bhuiyan
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | | | - Adam C Booser
- Department of Anesthesiology, Children's Mercy Hospital, Kansas City, Missouri
| | - Veronica Gomez-Lobo
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland; Pediatric and Adolescent Gynecology, Department of Surgery, Children's National Hospital, Washington, D.C
| | - Tazim Dowlut-McElroy
- Pediatric and Adolescent Gynecology, Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri.
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Villa-Muñoz P, Albaladejo-Belmonte M, Nohales-Alfonso FJ, Alberola-Rubio J, Garcia-Casado J. Treatment of Vestibulodynia with Submucosal Injections of IncobotulinumtoxinA into Targeted Painful Points: An Open-Label Exploratory Study. Toxins (Basel) 2023; 15:476. [PMID: 37624233 PMCID: PMC10467121 DOI: 10.3390/toxins15080476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/19/2023] [Accepted: 07/21/2023] [Indexed: 08/26/2023] Open
Abstract
The studies carried out to date on vulvodynia treatment with botulinum neurotoxin type A (BoNT/A) have followed generic injection protocols and reported contradictory outcomes on its effects. The aim of the present study was thus to propose a protocol for injecting BoNT/A into targeted painful points, to comprehensively assess the clinical effect of BoNT/A treatment and identify the risk/protective factors for successful treatment. Thirty-five vestibulodynia patients were treated with submucosal injections of incobotulinumtoxinA and assessed 8, 12 and 24 weeks after their treatment. Their clinical and pelvic statuses were assessed from self-reported questionnaires (Visual Analogue Scale (VAS), Female Sexual Function Index (FSFI), Marinoff's Dyspareunia Scale (MDS), Hospital Anxiety and Depression Scale (HADS), Catastrophizing Scale (CS)), physical examinations and surface electromyography (sEMG). The patients reported a reduction in provoked vestibulodynia ( FSFI, p < 0.01;
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Affiliation(s)
- Paula Villa-Muñoz
- Servicio De Ginecología Y Obstetricia, Hospital Universitari I Politècnic La Fe, 46026 Valencia, Spain; (P.V.-M.); (F.J.N.-A.)
| | - Monica Albaladejo-Belmonte
- Centro De Investigación E Innovación En Bioingeniería (CI2B), Universitat Politècnica De València, 46022 Valencia, Spain;
| | - Francisco J. Nohales-Alfonso
- Servicio De Ginecología Y Obstetricia, Hospital Universitari I Politècnic La Fe, 46026 Valencia, Spain; (P.V.-M.); (F.J.N.-A.)
| | | | - Javier Garcia-Casado
- Centro De Investigación E Innovación En Bioingeniería (CI2B), Universitat Politècnica De València, 46022 Valencia, Spain;
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Albaladejo-Belmonte M, Villa-Munoz P, Nohales-Alfonso FJ, Monfort-Ortiz R, Mira-Tomas JM, Alberola-Rubio J, Garcia-Casado J. Changes in pelvic floor electrical activity and vulvar pain after botulinum toxin treatment of vestibulodynia: are clinical and electrophysiological outcomes related? . Annu Int Conf IEEE Eng Med Biol Soc 2023; 2023:1-4. [PMID: 38082636 DOI: 10.1109/embc40787.2023.10340830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Vestibulodynia is a gynecological condition with different treatment options available, including botulinum neurotoxin type A (BoNT/A) injections into the vulvar vestibule. Unlike other treatments, no studies have assessed changes in the myoelectrical activity of the pelvic floor muscles (PFM) after BoNT/A treatment. The aim of this study was thus to evaluate these changes and to correlate them with changes in vulvar pain sensitivity. To do this, 35 patients with vestibulodynia were recruited, the myoelectrical activity of their left and right PFM was recorded with surface electromyography (sEMG), and their vulvar pain sensitivity was monitored according to Visual Analogue Scale (VAS) and an algometer, both before and after BoNT/A treatment. According to our results, patients' signals during PFM relaxation showed a significantly higher power than those of healthy women at baseline, as shown by their root mean square values (RMS), but became similar at follow-up. Patients' mean vulvar pain VAS scores significantly decreased after treatment. Furthermore, baseline-to-follow-up differences of RMS at PFM rest vs. mean VAS were significantly correlated (CC=0.48, p<0.01) so that higher reductions in the PFM activity power were associated with higher decreases in vulvar pain.Clinical Relevance- Altered PFM electrophysiological condition of patients with vestibulodynia becomes similar to healthy women's after BoNT/A treatment. This study also points to a relationship between the evolution of clinical and PFM electrophysiological conditions.
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De Seta F, Ianniello P, Carlucci S, Nappi L, Sorrentino F, Stabile G. New Topical Therapy for Provoked Vestibulodynia: Improvement of Psychological and Sexual Well-Being. Int J Environ Res Public Health 2023; 20:1931. [PMID: 36767294 PMCID: PMC9915117 DOI: 10.3390/ijerph20031931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 01/14/2023] [Accepted: 01/18/2023] [Indexed: 06/18/2023]
Abstract
Vulvodynia is a vulvar discomfort that occurs in the absence of any specific, clinically identifiable disorder. Few therapies have shown to be effective for the treatment of vulvodynia. In our recently published study, we tested a drug-free gel in women affected by vulvar vestibulitis. It is a cosmetic gel which acts locally without any metabolic, pharmacological or immunological effect. In order to further promote the validity of this new product, in this manuscript we analyzed the results obtained from the administration of four questionnaires in the same two groups of women affected by PVD and treated with a placebo and the new product. The questionnaires used: Female Sexual Function Index Scoring (FSFI), Female Sexual Distress Scale (FSDS), Hospital Anxiety and Depression Scale (HADS), and health-related quality of life measured by SF-36 (SF-36). The results obtained by this current analysis showed that the new gel has also proven benefits on women's quality of life and sexual function, including improvements in arousal, desire, orgasm and satisfaction.
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Affiliation(s)
- Francesco De Seta
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34100 Trieste, Italy
| | - Patrizia Ianniello
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34100 Trieste, Italy
| | - Stefania Carlucci
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34100 Trieste, Italy
| | - Luigi Nappi
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Felice Sorrentino
- Department of Medical and Surgical Sciences, Institute of Obstetrics and Gynecology, University of Foggia, 71121 Foggia, Italy
| | - Guglielmo Stabile
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, 34100 Trieste, Italy
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Castro J, Harrington AM, Chegini F, Matusica D, Spencer NJ, Brierley SM, Haberberger RV, Barry CM. Clodronate Treatment Prevents Vaginal Hypersensitivity in a Mouse Model of Vestibulodynia. Front Cell Infect Microbiol 2022; 11:784972. [PMID: 35118009 PMCID: PMC8803747 DOI: 10.3389/fcimb.2021.784972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/27/2021] [Indexed: 12/18/2022] Open
Abstract
IntroductionImproved understanding of vestibulodynia pathophysiology is required to develop appropriately targeted treatments. Established features include vulvovaginal hyperinnervation, increased nociceptive signalling and hypersensitivity. Emerging evidence indicates macrophage-neuron signalling contributes to chronic pain pathophysiology. Macrophages are broadly classified as M1 or M2, demonstrating pro-nociceptive or anti-nociceptive effects respectively. This study investigates the impact of clodronate liposomes, a macrophage depleting agent, on nociceptive signalling in a mouse model of vestibulodynia.MethodsMicroinjection of complete Freund’s adjuvant (CFA) at the vaginal introitus induced mild chronic inflammation in C57Bl/6J mice. A subgroup was treated with the macrophage depleting agent clodronate. Control mice received saline. After 7 days, immunolabelling for PGP9.5, F4/80+CD11c+ and F4/80+CD206+ was used to compare innervation density and presence of M1 and M2 macrophages respectively in experimental groups. Nociceptive signalling evoked by vaginal distension was assessed using immunolabelling for phosphorylated MAP extracellular signal-related kinase (pERK) in spinal cord sections. Hyperalgesia was assessed by visceromotor response to graded vaginal distension.ResultsCFA led to increased vaginal innervation (p < 0.05), increased pERK-immunoreactive spinal cord dorsal horn neurons evoked by vaginal-distension (p < 0.01) and enhanced visceromotor responses compared control mice (p < 0.01). Clodronate did not reduce vaginal hyperinnervation but significantly reduced the abundance of M1 and M2 vaginal macrophages and restored vaginal nociceptive signalling and vaginal sensitivity to that of healthy control animals.ConclusionsWe have developed a robust mouse model of vestibulodynia that demonstrates vaginal hyperinnervation, enhanced nociceptive signalling, hyperalgesia and allodynia. Macrophages contribute to hypersensitivity in this model. Macrophage-sensory neuron signalling pathways may present useful pathophysiological targets.
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Affiliation(s)
- Joel Castro
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Andrea M. Harrington
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, SA, Australia
| | - Fariba Chegini
- Musculoskeletal Neurobiology Laboratory, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, SA, Australia
| | - Dusan Matusica
- Pain and Sensory Neurobiology Laboratory, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, SA, Australia
| | - Nick J. Spencer
- Visceral Neurophysiology Laboratory, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, SA, Australia
| | - Stuart M. Brierley
- Visceral Pain Research Group, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Bedford Park, SA, Australia
| | - Rainer V. Haberberger
- School of Biomedicine, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Christine M. Barry
- Musculoskeletal Neurobiology Laboratory, College of Medicine and Public Health, Flinders Health and Medical Research Institute (FHMRI), Flinders University, Adelaide, SA, Australia
- *Correspondence: Christine M. Barry,
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Falsetta ML, Wood RW, Linder MA, Bonham AD, Honn KV, Maddipati KR, Phipps RP, Haidaris CG, Foster DC. Specialized Pro-resolving Mediators Reduce Pro-nociceptive Inflammatory Mediator Production in Models of Localized Provoked Vulvodynia. J Pain 2021; 22:1195-1209. [PMID: 33813057 PMCID: PMC8484336 DOI: 10.1016/j.jpain.2021.03.144] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 03/05/2021] [Accepted: 03/24/2021] [Indexed: 12/25/2022]
Abstract
Localized provoked vulvodynia (LPV) is the most common cause of chronic dyspareunia in premenopausal women, characterized by pain with light touch to the vulvar vestibule surrounding the vaginal opening. The devastating impact of LPV includes sexual dysfunction, infertility, depression, and even suicide. Yet, its etiology is unclear. No effective medical therapy exists; surgical removal of the painful vestibule is the last resort. In LPV, the vestibule expresses a unique inflammatory profile with elevated levels of pro-nociceptive proinflammatory mediators prostaglandin E2 (PGE2) and interleukin-6 (IL-6), which are linked to lower mechanical sensitivity thresholds. Specialized pro-resolving mediators (SPMs), lipids produced endogenously within the body, hold promise as an LPV treatment by resolving inflammation without impairing host defense. Ten of 13 commercially available SPMs reduced IL-6 and PGE2 production by vulvar fibroblasts, administered either before or after inflammatory stimulation. Using a murine vulvar pain model, coupling proinflammatory mediator quantification with mechanical sensitivity threshold determination, topical treatment with the SPM, maresin 1, decreased sensitivity and suppressed PGE2 levels. Docosahexaenoic acid, a precursor of maresin 1, was also effective in reducing PGE2 in vulvar fibroblasts and rapidly restored mouse sensitivity thresholds. Overall, SPMs and their precursors may be a safe and efficacious for LPV. Perspective: Vulvodynia, like many pain conditions, is difficult to treat because disease origins are incompletely understood. Here, we applied our knowledge of more recently discovered vulvodynia disease mechanisms to screen novel therapeutics. We identified several specialized pro-resolving mediators as likely potent and safe for treating LPV with potential for broader application.
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Affiliation(s)
- Megan L Falsetta
- Department of Obstetrics and Gynecology, University of Rochester, School of Medicine and Dentistry Rochester, New York; Department of Pharmacology and Physiology, University of Rochester, School of Medicine and Dentistry, Rochester, New York.
| | - Ronald W Wood
- Department of Obstetrics and Gynecology, University of Rochester, School of Medicine and Dentistry Rochester, New York
| | - Mitchell A Linder
- Department of Obstetrics and Gynecology, University of Rochester, School of Medicine and Dentistry Rochester, New York
| | - Adrienne D Bonham
- Department of Obstetrics and Gynecology, University of Rochester, School of Medicine and Dentistry Rochester, New York
| | - Kenneth V Honn
- Department of Pathology, Wayne State University, School of Medicine, Detroit, Michigan
| | - Krishna Rao Maddipati
- Department of Pathology, Wayne State University, School of Medicine, Detroit, Michigan
| | | | - Constantine G Haidaris
- Department of Microbiology and Immunology, University of Rochester, School of Medicine and Dentistry Rochester, New York
| | - David C Foster
- Department of Obstetrics and Gynecology, University of Rochester, School of Medicine and Dentistry Rochester, New York
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Hong DG, Hwang SM, Park JM. Efficacy of ganglion impar block on vulvodynia: Case series and results of mid- and long-term follow-up. Medicine (Baltimore) 2021; 100:e26799. [PMID: 34397737 PMCID: PMC8322564 DOI: 10.1097/md.0000000000026799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/17/2021] [Accepted: 07/12/2021] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Vulvodynia is a common chronic gynecological disease that affects approximately 16% of women, although it is rarely diagnosed. However, no known effective treatment exists. The etiology of vulvodynia is unknown and may be heterogeneous and multifactorial, so it is difficult-if not impossible-to improve this condition using 1 treatment method. Reports have shown that vulvodynia has an element of neuropathic pain. Although the role of the sympathetic nervous system in neuropathic pain is controversial, sympathetic nerve blocks have long been used to treat patients with chronic pain giving good results. A ganglion impar block (GIB), a sympathetic nerve block technique, may effectively manage pain and discomfort in patients with vulvodynia. PATIENT CONCERNS Four patients suffering from chronic vulvar pain for 6 months-10 years were referred by gynecologists. The gynecologists could not identify the cause of the chronic vulvar pain, and symptoms were not improving by conservative therapy with medication. Patients complained of various chronic vulvar pain or discomfort. The initial visual analog scale (VAS) scores were 8 or 9 out of 10, and Leeds assessment of neuropathic symptoms and signs pain scale score was more than 12 out of 24. The review of gynecological medical records confirmed whether they showed allodynia during the cotton swab test and hyperalgesia to pin-prick test. DIAGNOSES All patients were diagnosed with vulvodynia. INTERVENTIONS All patients were treated with a GIB, once in 2 patients, 3 times in 1 patient, and 4 times (1 alcoholic neurolysis) in the other patient, under fluoroscopic guidance. OUTCOMES After the procedures, the VAS score and the leeds assessment of neuropathic symptoms and signs (LANSS) pain scale score were decreased to less than 2 and 5, respectively, in all patients. Follow-up observations for 6 months-2 years revealed that 2 patients' symptoms entirely or nearly entirely improved and did not require further treatment. The pain of the remaining patients were well controlled with medications only. LESSONS GIB is a good treatment option for patients suffering from chronic pain and discomfort caused by vulvodynia.
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Affiliation(s)
- Dae Gy Hong
- Department of Obstetrics and Gynecology, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Seong-Min Hwang
- Department of Anesthesiology and Pain Medicine, Kyungpook National University Hospital, Daegu, South Korea
| | - Jun-Mo Park
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
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Ruoss CM, Howard EA, Chan K, Stevenson PG, Vancaillie T. Topical treatment of vulvodynia, dyspareunia and pudendal neuralgia: A single clinic audit of amitriptyline and oestriol in organogel. Aust N Z J Obstet Gynaecol 2021; 61:270-274. [PMID: 33427301 PMCID: PMC8247999 DOI: 10.1111/ajo.13292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/30/2020] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Chantelle M. Ruoss
- Women’s Health and Research Institute of Australia (WHRIA)SydneyNew South WalesAustralia
| | - Elizabeth A. Howard
- Women’s Health and Research Institute of Australia (WHRIA)SydneyNew South WalesAustralia
| | - Karen Chan
- Women’s Health and Research Institute of Australia (WHRIA)SydneyNew South WalesAustralia
| | - Paul G. Stevenson
- Telethon Kids InstitutePerth Children’s HospitalPerthWestern AustraliaAustralia
| | - Thierry Vancaillie
- Women’s Health and Research Institute of Australia (WHRIA)SydneyNew South WalesAustralia
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Boo B, Kamath R, Arriaga-Gomez E, Landry J, Emanuel E, Joo S, Saldías Montivero M, Martinov T, Fife BT, Chatterjea D. Tetrahydrocannabinol Reduces Hapten-Driven Mast Cell Accumulation and Persistent Tactile Sensitivity in Mouse Model of Allergen-Provoked Localized Vulvodynia. Int J Mol Sci 2019; 20:ijms20092163. [PMID: 31052404 PMCID: PMC6539044 DOI: 10.3390/ijms20092163] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/23/2019] [Accepted: 04/26/2019] [Indexed: 01/06/2023] Open
Abstract
Vulvodynia is a remarkably prevalent chronic pain condition of unknown etiology. An increase in numbers of vulvar mast cells often accompanies a clinical diagnosis of vulvodynia and a history of allergies amplifies the risk of developing this condition. We previously showed that repeated exposures to oxazolone dissolved in ethanol on the labiar skin of mice led to persistent genital sensitivity to pressure and a sustained increase in labiar mast cells. Here we sensitized female mice to the hapten dinitrofluorobenzene (DNFB) dissolved in saline on their flanks, and subsequently challenged them with the same hapten or saline vehicle alone for ten consecutive days either on labiar skin or in the vaginal canal. We evaluated tactile ano-genital sensitivity, and tissue inflammation at serial timepoints. DNFB-challenged mice developed significant, persistent tactile sensitivity. Allergic sites showed mast cell accumulation, infiltration of resident memory CD8+CD103+ T cells, early, localized increases in eosinophils and neutrophils, and sustained elevation of serum Immunoglobulin E (IgE). Therapeutic intra-vaginal administration of Δ9-tetrahydrocannabinol (THC) reduced mast cell accumulation and tactile sensitivity. Mast cell-targeted therapeutic strategies may therefore provide new ways to manage and treat vulvar pain potentially instigated by repeated allergenic exposures.
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Affiliation(s)
- Beebie Boo
- Biology Department, Macalester College, Saint Paul, MN 55105, USA.
| | - Rohit Kamath
- Biology Department, Macalester College, Saint Paul, MN 55105, USA.
| | | | - Jasmine Landry
- Biology Department, Macalester College, Saint Paul, MN 55105, USA.
| | | | - Sookyong Joo
- Biology Department, Macalester College, Saint Paul, MN 55105, USA.
| | | | - Tijana Martinov
- Center for Immunology, University of Minnesota, Minnesota, MN 55455, USA.
| | - Brian T Fife
- Center for Immunology, University of Minnesota, Minnesota, MN 55455, USA.
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Bachmann GA, Brown CS, Phillips NA, Rawlinson LA, Yu X, Wood R, Foster DC. Effect of gabapentin on sexual function in vulvodynia: a randomized, placebo-controlled trial. Am J Obstet Gynecol 2019; 220:89.e1-89.e8. [PMID: 30365922 DOI: 10.1016/j.ajog.2018.10.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 10/04/2018] [Accepted: 10/17/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sexual dysfunction is common in women with vulvodynia. OBJECTIVE The purpose of this study was (1) to evaluate whether extended-release gabapentin is more effective than placebo in improving sexual function in women with provoked vulvodynia and whether there is a relationship between treatment outcome and pelvic pain muscle severity that is evaluated by palpation with standardized applied pressure and (2) to evaluate whether sexual function in women with provoked vulvodynia would approach that of control subjects who report no vulvar pain either before or after treatment. STUDY DESIGN As a secondary outcome in a multicenter double-blind, randomized crossover trial, sexual function that was measured by the Female Sexual Function Index was evaluated with gabapentin (1200-3000 mg/d) compared with placebo. Pain-free control subjects, matched by age and race, also completed Female Sexual Function Index for comparison. RESULTS From August 2012 to January 2016, 230 women were screened at 3 academic institutions, and 89 women were assigned randomly to treatment. Gabapentin was more effective than placebo in improving overall sexual function (adjusted mean difference, 1.3; 95% confidence interval, 0.4-2.2; P=.008), which included desire (mean difference, 0.2; 95% confidence interval, 0.0-3.3; P=.04), arousal (mean difference, 0.3; 95% confidence interval, 0.1-0.5; P=.004), and satisfaction (mean difference, 0.3; 95% confidence interval, 0.04-0.5; P=.02); however, sexual function remained significantly lower than in 56 matched vulvodynia pain-free control subjects. There was a moderate treatment effect among participants with baseline pelvic muscle pain severity scores above the median on the full Female Sexual Function Index scale (mean difference, 1.6; 95% confidence interval, 0.3-2.8; P=.02) and arousal (mean difference, 0.3; 95% confidence interval, 0.1-0.6; P=.01) and pain domains (mean difference, 0.4; 95% confidence interval, 0.02-0.9; P=.04). CONCLUSION Gabapentin improved sexual function in this group of women with provoked vulvodynia, although overall sexual function remained lower than women without the disorder. The most statistically significant increase was in the arousal domain of the Female Sexual Function Index that suggested a central mechanism of response. Women with median algometer pain scores >5 improved sexual function overall, but the improvement was more frequent than the pain domain. We hypothesize that gabapentin may be effective as a pharmacologic treatment for those women with provoked vulvodynia and increased pelvic muscle pain on examination.
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Affiliation(s)
- Gloria A Bachmann
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Candace S Brown
- Department of Clinical and Translational Sciences, University of Tennessee Health Science Center, Memphis, TN
| | - Nancy A Phillips
- Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ.
| | - Leslie A Rawlinson
- Department of Clinical and Translational Sciences, University of Tennessee Health Science Center, Memphis, TN
| | - Xinhua Yu
- School of Public Health, Division of Epidemiology, Biostatistics & Environmental Health, University of Memphis, Memphis, TN
| | - Ronald Wood
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NJ
| | - David C Foster
- Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NJ
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Abstract
The study aimed to assess the effects of ospemifene on vulvar vestibule in postmenopausal women with vulvar pain and dyspareunia. Fifty-five postmenopausal women used oral ospemifene 60 mg/d for 60 d. Symptoms of dryness, burning, and dyspareunia were evaluated on a 10 cm visual analog scale. Visual examination of the vulvar vestibule was also conducted. Patients also underwent current perception threshold (CPT) testing obtained from the vulvar vestibule. Fifty-five patients (94.6%) completed the treatment. Hot flashes were the most frequent adverse effects, but this led to a discontinuation of therapy in three patients (5.4%). After therapy, there was a statistically significant decrease from the baseline in the mean scores for dryness, burning, and dyspareunia and reduction of vestibular trophic score (baseline value of 11.2-4.2 after the therapy, p ≤ 002) and cotton swab test scores (2.81 compared with 1.25, p = .001). There was a difference in CPT values for all nerve fibers and more consistent for C fibers (-38% of sensitivity). These results confirm the efficacy of ospemifene on postmenopausal vestibular symptoms and signs; moreover, the drug was effective in normalizing vestibular innervation sensitivity.
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Affiliation(s)
- Filippo Murina
- a Lower Genital Tract Disease Unit , V. Buzzi Hospital, University of Milan , Milan , Italy
| | - Stefania Di Francesco
- a Lower Genital Tract Disease Unit , V. Buzzi Hospital, University of Milan , Milan , Italy
| | - Silvia Oneda
- a Lower Genital Tract Disease Unit , V. Buzzi Hospital, University of Milan , Milan , Italy
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13
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Lamvu G, Alappattu M, Witzeman K, Bishop M, Robinson M, Rapkin A. 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. [PMID: 29631955 DOI: 10.1016/j.jsxm.2018.03.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 02/21/2018] [Accepted: 03/10/2018] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Georgine Lamvu
- Division of Surgery, Gynecology Section, Veteran Affairs Medical Center, Orlando, FL, USA; University of Central Florida, Orlando, FL, USA.
| | - Meryl Alappattu
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA; Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL, USA
| | - Kathryn Witzeman
- Women's Integrated Health Program, Department of Obstetrics and Gynecology, Denver Health, Denver, CO, USA
| | - Mark Bishop
- Department of Physical Therapy, University of Florida, Gainesville, FL, USA; Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL, USA
| | - Michael Robinson
- Center for Pain Research and Behavioral Health, University of Florida, Gainesville, FL, USA; Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Andrea Rapkin
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at the University of California-Los Angeles, Los Angeles, CA, USA
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Abstract
Vulval and vaginal symptoms are common after the menopause and are frequently assumed to be due to the normal physiological changes that occur at this time. However, there are several important dermatoses that can occur in this patient group which need accurate diagnosis and appropriate management. This review discusses the clinical features and basic management of some of the common vulval problems occurring after the menopause.
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Affiliation(s)
- Fiona M Lewis
- Frimley Health NHS Trust and St Johns's Institute of Dermatology, Guy's and St Thomas' NHS Trust, London, UK
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Gardella B, Iacobone AD, Porru D, Musacchi V, Dominoni M, Tinelli C, Spinillo A, Nappi RE. Effect of local estrogen therapy (LET) on urinary and sexual symptoms in premenopausal women with interstitial cystitis/bladder pain syndrome (IC/BPS). Gynecol Endocrinol 2015; 31:828-32. [PMID: 26291799 DOI: 10.3109/09513590.2015.1063119] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The association between vulvodynia and interstitial cystitis/bladder pain syndrome (IC/BPS), a chronic, debilitating disease of unknown etiology, may involve sex hormone-dependent mechanisms regulating vulvo-vaginal health. We aimed to prospectively investigate the effects of 12 weeks of local estrogen therapy (LET) on urinary/bladder and sexual symptoms in premenopausal women with IC/BPS. Thirty-four women (mean age: 36.1 ± 8.4) diagnosed with IC/BPS were treated vulvo-vaginally three-times/week with estriol 0.5 mg cream and tested by validated questionnaires (ICSI/ICPI, pain urgency frequency [PUF], female sexual function index [FSFI]) and by cotton swab testing, vaginal health index (VHI) and maturation index (MI) before and after treatment. Vulvodynia was present in 94.1% of IC/BPS women. A significant positive effect of LET was evident on urinary and sexual function (p < 0.001, for both) following 12 weeks, as well as an improvement of the VHI (p < 0.001) and the MI (p < 0.04). The results of this open study indicate that 12 weeks of local estriol cream at vaginal and vestibular level may ameliorate urinary/bladder pain symptoms, as well as may improve domains of sexual function. The association between vulvar pain and bladder pain could, therefore, be related to a vaginal environment carrying signs of hypoestrogenism, but further studies are needed to clarify this issue.
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Affiliation(s)
- Barbara Gardella
- a Research Centre for Reproductive Medicine, Section of Obstetrics and Gynecology, IRCCS Policlinico San Matteo , Pavia , Italy
- b Department of Clinical, Surgical, Diagnostic and Pediatric Sciences , University of Pavia , Pavia , Italy
| | - Anna Daniela Iacobone
- a Research Centre for Reproductive Medicine, Section of Obstetrics and Gynecology, IRCCS Policlinico San Matteo , Pavia , Italy
| | - Daniele Porru
- c Unit of Urology, Fondazione IRCCS San Matteo , Pavia , Italy , and
| | - Valentina Musacchi
- a Research Centre for Reproductive Medicine, Section of Obstetrics and Gynecology, IRCCS Policlinico San Matteo , Pavia , Italy
| | - Mattia Dominoni
- a Research Centre for Reproductive Medicine, Section of Obstetrics and Gynecology, IRCCS Policlinico San Matteo , Pavia , Italy
| | - Carmine Tinelli
- d Clinical Epidemiology and Biometric Unit, Fondazione IRCCS Policlinico San Matteo , Pavia , Italy
| | - Arsenio Spinillo
- a Research Centre for Reproductive Medicine, Section of Obstetrics and Gynecology, IRCCS Policlinico San Matteo , Pavia , Italy
- b Department of Clinical, Surgical, Diagnostic and Pediatric Sciences , University of Pavia , Pavia , Italy
| | - Rossella E Nappi
- a Research Centre for Reproductive Medicine, Section of Obstetrics and Gynecology, IRCCS Policlinico San Matteo , Pavia , Italy
- b Department of Clinical, Surgical, Diagnostic and Pediatric Sciences , University of Pavia , Pavia , Italy
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Neĭmark AI, Shelkovnikova NV, Neĭmark BA, Sizovv KA. [The role of human papilloma virus in development of chronic urethritis and vulvodynia in females: perspectives of immunomodulating therapy]. Urologiia 2012:35-38. [PMID: 22876631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The article is devoted to combined affection of the lower urinary tracts and genitalia in women with human papilloma virus (HPV) infection which manifests with persistent recurrent urethritis, pelvic pain syndrome. The colposcopic and urethrocystoscopic features, disturbed microcirculation of urethral and vaginal mucosa in virus infection promoting recurrences and persistence of HPV are discussed. Immunomodulators (inosin pranobex-groprinosin) are recommended for more effective treatment.
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