Pure versus complicated vulvar vestibulitis: a randomized trial of fluconazole treatment

Exploring Localized Provoked Vulvodynia: Insights from Animal Model Research

Provoked vulvodynia represents a challenging chronic pain condition, characterized by its multifactorial origins. The inherent complexities of human-based studies have necessitated the use of animal models to enrich our understanding of vulvodynia's pathophysiology. This review aims to provide an exhaustive examination of the various animal models employed in this research domain. A comprehensive search was conducted on PubMed, utilizing keywords such as "vulvodynia", "chronic vulvar pain", "vulvodynia induction", and "animal models of vulvodynia" to identify pertinent studies. The search yielded three primary animal models for vulvodynia: inflammation-induced, allergy-induced, and hormone-induced. Additionally, six agents capable of triggering the condition through diverse pathways were identified, including factors contributing to hyperinnervation, mast cell proliferation, involvement of other immune cells, inflammatory cytokines, and neurotransmitters. This review systematically outlines the various animal models developed to study the pathogenesis of provoked vulvodynia. Understanding these models is crucial for the exploration of preventative measures, the development of novel treatments, and the overall advancement of research within the field.

Recruitment methods in a clinical trial of provoked vulvodynia: Predictors of enrollment

BACKGROUND

Successful recruitment in clinical trials for chronic pain conditions is challenging, especially in women with provoked vulvodynia due to reluctance in discussing pain associated with sexual intercourse. The most successful recruitment methods and the characteristics of women reached with these methods are unknown.

OBJECTIVE

To compare the effectiveness and efficiency of four recruitment methods and to determine socioeconomic predictors for successful enrollment in a National Institutes of Health-sponsored multicenter clinical trial evaluating a gabapentin intervention in women with provoked vulvodynia.

METHODS

Recruitment methods utilized mass mailing, media, clinician referrals and community outreach. Effectiveness (number of participants enrolled) and efficiency (proportion screened who enrolled) were determined. Socioeconomic variables including race, educational level, annual household income, relationship status, age, menopausal status and employment status were also evaluated regarding which recruitment strategies were best at targeting specific cohorts.

RESULTS

Of 868 potential study participants, 219 were enrolled. The most effective recruitment method in enrolling participants was mass mailing ( p < 0.001). There were no statistically significant differences in efficiency between recruitment methods ( p = 0.11). Relative to clinician referral, black women were 13 times as likely to be enrolled through mass mailing (adjusted odds ratio 12.5, 95% confidence interval, 3.6-43.1) as white women. There were no differences in enrollment according to educational level, annual income, relationship status, age, menopausal status, or employment status and recruitment method.

CONCLUSION

In this clinical trial, mass mailing was the most effective recruitment method. Race of participants enrolled in a provoked vulvodynia trial was related to the recruitment method.

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.

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.

Etiology, diagnosis, and clinical management of vulvodynia

Chronic vulvar pain or discomfort for which no obvious etiology can be found, ie, vulvodynia, can affect up to 16% of women. It may affect girls and women across all age groups and ethnicities. Vulvodynia is a significant burden to society, the health care system, the affected woman, and her intimate partner. The etiology is multifactorial and may involve local injury or inflammation, and peripheral and or central sensitization of the nervous system. An approach to the diagnosis and management of a woman presenting with chronic vulvar pain should address the biological, psychological, and social/interpersonal factors that contribute to her illness. The gynecologist has a key role in excluding other causes for vulvar pain, screening for psychosexual and pelvic floor dysfunction, and collaborating with other health care providers to manage a woman's pain. An important component of treatment is patient education regarding the pathogenesis of the pain and the negative impact of experiencing pain on a woman's overall quality of life. An individualized, holistic, and often multidisciplinary approach is needed to effectively manage the woman's pain and pain-related distress.

[Update on the diagnosis and treatment of vulvodynia]

CONTEXT

Vulvodynia is a complex and multifactorial clinical condition. It is defined as chronic vulvar discomfort characterized by burning, stinging or irritation. Its diagnostic difficulty and treatment is known.

OBJECTIVES

To review the medical literature of the last 10 years from a critical point of view.

EVIDENCE ACQUISITION

A search was made in Medline/Pubmed and the Cochrane Library using the terms vulvodynia and vestibulodynia to which etiology, epidemiology, diagnosis, neurophysiological test and treatment or management, were added.

EVIDENCE SYNTHESIS

In spite of the advances achieved in all of the aspects of vulvodynia, the methodology used at present in many cases does not have the desirable statistical soundness: there are few control or placebo-controlled groups and double-blind studies. Uniformity is lacking in the scales, indexes and questionnaires for the correct evaluation of pain before and after the treatment and debatable diagnostic criteria are use. The limited use of neurophysiological diagnostic resources that validate the clinical findings has been observed in the studies analyzed. In most of the works, the medical treatments have been shown to be ineffective. Physiotherapy and cognitive-behavioral therapy seem to be promising therapeutic tools. Surgery (vestibulectomy) stands out by its demonstrated efficacy in the publications studied.

CONCLUSIONS

A multidisciplinary approach is always necessary. Topical medical, psychological and physical therapy treatments may have sum effects and become an alternative to surgery. New pathways of research and more regulated studies are required.

Cognitive behavioral therapy for sexual dysfunctions in women

Sexual dysfunctions in women are classified into disorders of desire, arousal, orgasm, and pain (including dyspareunia and vaginismus). As the cognitive behavioral treatment (CBT) procedures differ among these sexual disorders, the treatments for each disorder are reviewed separately. The efficacy of CBT differs depending on the specific sexual dysfunction to be treated. It is concluded that only a few CBT treatments for women's sexual dysfunction have yet been empirically investigated in a methodologically sound way and little is known about which of the treatment components are most effective.

The tampon test for vulvodynia treatment outcomes research: reliability, construct validity, and responsiveness

OBJECTIVE

A standardized tampon insertion and removal test, the Tampon Test provides an alternative to sexual intercourse pain as an outcome measure for vulvodynia research. We report upon the reliability, validity, and responsiveness to change of the Tampon Test as an outcome measure for vulvodynia clinical trials.

METHODS

Outcome measures were assessed in women enrolled in the Vulvar Vestibulitis Clinical Trial, a randomized clinical trial of oral desipramine and topical lidocaine effectiveness. Reliability estimates of the Tampon Test using the Kappa statistic evaluated week-to-week measures at baseline. Tampon Test construct and discriminant validity were assessed through correlation with other outcome measures. Patients' ability to regularly perform the Tampon Test was compared with regularity of reporting intercourse pain.

RESULTS

During the 2-week baseline phase, women with vulvodynia reported stable mean Tampon Test scores 4.6+/-2.6 (week -2); 4.6+/-2.7 (week -1); and 4.7+/-2.8 (week 0) with moderate week-to-week reliability (weighted Kappa 0.52). Over an 8-week phase of trial intervention, change in the Tampon Test measure significantly correlated to a number of outcome measures, including daily pain (r=0.42), intercourse pain (r=0.35), cotton swab vestibular pain (r=0.38), and the Brief Pain Inventory (r=0.49). Women with vulvodynia study participants performed the Tampon Test 96.3% of the requested time, which was twofold higher adherence than intercourse pain measurement (49.7%).

CONCLUSION

The Tampon Test reflects a real life experience that is reliable, with good construct validity as shown by the breadth of correlated outcome measures. The Tampon Test is an appropriate outcome measure for vulvodynia research that can be considered for use as the primary efficacy endpoint in clinical trials of treatments for vulvodynia.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00276068

LEVEL OF EVIDENCE

II.

Surgical and behavioral treatments for vestibulodynia: two-and-one-half year follow-up and predictors of outcome

OBJECTIVE

To estimate whether treatment gains for provoked vestibulodynia participants randomly assigned to vestibulectomy, biofeedback, and cognitive-behavioral therapy in a previous study would be maintained from the last assessment-a 6-month follow-up-to the present 2.5-year follow-up. Although all three treatments yielded significant improvements at 6-month follow-up, vestibulectomy resulted in approximately twice the pain reduction as compared with the two other treatments. A second goal of the present study was to identify predictors of outcome.

METHODS

In a university hospital, 51 of the 78 women from the original study were reassessed 2.5 years after the end of their treatment. They completed 1) a gynecologic examination involving the cotton-swab test, 2) a structured interview, and 3) validated pain and sexual functioning measures.

RESULTS

Results from the multivariate analysis of variance conducted on the pain measures showed a significant time main effect (P<.05) and a significant treatment main effect (P<.01), indicating that participants had less pain at the 2.5-year follow-up than at the previous 6-month follow-up. Results from the multivariate analysis of variance conducted on sexual functioning measures showed that participants remained unchanged between the 6-month and 2.5-year follow-up and that there were no group differences. Higher pretreatment pain intensity predicted poorer outcomes at the 2.5-year follow-up for vestibulectomy (P<.01), biofeedback (P<.05), and cognitive-behavioral therapy (P<.01). Erotophobia also predicted a poorer outcome for vestibulectomy (P<.001).

CONCLUSION

Treatment gains were maintained at the 2.5-year follow-up. Outcome was predicted by pretreatment pain and psychosexual factors.

LEVEL OF EVIDENCE

II.

Vulvar vestibulitis syndrome

Vulvar vestibulitis syndrome (VVS) is one of the most common causes of genital pain and pain with sexual intercourse, affecting up to 15% of women. The syndrome is characterized by severe pain on vestibular touch or attempted vaginal entry, exquisite tenderness to palpation with a cotton swab, and often subtle physical findings confined to vestibular erythema. The etiology of VVS is unknown. However, it is probably best to consider VVS as a chronic local inflammatory condition with a wide variety of etiologic causes. The heterogeneity of potential etiologies for VVS results in the use of multiple treatment regimens in clinical practice. Scientifically rigorous studies are sorely needed to determine the best treatment approach.

Vulvodynia: a therapeutic challenge

Vulvodynia is a poorly understood, distressing and debilitating disorder. The management of this disorder remains insufficient and the lack of consistent terminology is confusing. The management of classic dysesthetic vulvodynia is fairly straightforward, using drugs effective against chronic neuropathic pain. However, vulvar vestibulitis syndrome remains a therapeutic challenge. A pragmatic approach is recommended for the management of patients with vulvar vestibulitis syndrome. In refractory cases, vestibulectomy has a high success rate, although the evidence is based mainly on small, descriptive studies. Comparative studies of conservative versus surgical management of vulvar vestibulitis syndrome are needed.

Should dyspareunia be retained as a sexual dysfunction in DSM-V? A painful classification decision

The DSM-IV-TR (American Psychiatric Association, 2000) classifies dyspareunia as a sexual dysfunction and describes it as a "sexual pain" disorder. This classification has been widely accepted with little controversy despite the absence of a theoretical rationale or supporting empirical data. An examination of the validity of this classification suggests that there is little current justification for the use of the term "sexual pain" or for considering dyspareunia a sexual dysfunction. Dyspareunia fits the current DSM-IV-TR classification criteria for pain disorder better than it fits those for sexual dysfunction. Empirical data from diagnostic, experimental, and therapy outcome studies support this conclusion. The reconceptualization of dyspareunia as a pain disorder rather than as a sexual dysfunction has important implications for the understanding and treatment of this prevalent but neglected women's health problem.