Abstract
Vulvodynia, or chronic vulvar pain, is a common but poorly understood condition. Affected women report negative impacts in terms of sexual functioning, relationship adjustment, psychological well-being and overall quality of life. Although the etiology of vulvodynia is not well understood, it appears as if different levels of pathophysiology are implicated. Accordingly, therapeutic options are targeted at a variety of mechanisms. Unfortunately, few randomized, controlled trials exist, and few combination therapies have been examined; however, the quality and breadth of the treatment literature is improving. Further studies are needed to more fully investigate the mechanisms involved in the development and maintenance of vulvodynia, and more research in the area of treatment outcome is needed.
Keywords
Vulvodynia, or chronic vulvar pain, is a common problem affecting 16% of women in the general population [1]. Despite its high prevalence and negative impact on a woman's life, vulvodynia has only recently received systematic attention from health professionals, researchers and funding agencies. This increased attention is also reflected in the formation of several organizations devoted to vulvodynia that provide essential information to patients and health professionals. For example, the National Vulvodynia Association (NVA) [101] is a patient-advocacy group that offers support, referrals and education to vulvar pain sufferers, as well as research funds to investigators. In addition, the International Society for the Study of Vulvovaginal Disease (ISSVD) [102] offers patient referrals and education. It has recently promoted the use of a pain-based classification system for vulvodynia.
Definitions & prevalence of vulvodynia
In 2003, the ISSVD defined vulvodynia as vulvar pain or discomfort, usually described as burning, that cannot be explained by any physical problem [2]. Vulvodynia can be generalized, indicating that the pain affects the entire vulvar area, or localized, referring to pain in a particular vulvar region (e.g., vestibule, clitoris) (Box 1). Generalized and localized vulvodynia are subdivided according to the temporal pattern of the pain: provoked pain (i.e., elicited by physical contact to the area), unprovoked pain (i.e., occurs independently of external stimulation), or a mixed pain presentation. Provoked pain can result from sexual and/or nonsexual activities.
This review will focus on a common subtype of vulvodynia known as provoked vestibulodynia (PVD), formerly vulvar vestibulitis syndrome. PVD refers to provoked pain localized to the vulvar vestibule (i.e., vaginal introitus). The most common presenting symptom of PVD is that of introital dyspareunia, frequently described as a burning and/or sharp pain [3]. PVD affects 12% of women in the general population [4].
Assessment issues & diagnostic considerations in PVD
History of the pain
Every evaluation must start with a thorough history of the pain. Although a patient may present with localized superficial dyspareunia, one can only assume that a diagnosis of PVD is likely. Also, a detailed history of any previous injuries, such as those affecting nerves (e.g., following pelvic surgery), and other conditions (e.g., back pain and chronic inflammation) is important to document. Questions regarding the location, quality and temporal characteristics (e.g., when the pain occurs) of the pain are critical for differential diagnosis [5,6] (for further information on differential diagnosis, see [7]). Asking specific questions regarding where and when the patient experiences the pain, and how the sensation can be described, can usually reveal if PVD is the only issue, if PVD is one of two or more issues (e.g., unprovoked generalized vulvodynia), or if something other than PVD is responsible for the discomfort (e.g., infections and dermatological conditions). As many women may not be comfortable or knowledgeable with describing exactly where the genital pain is experienced, incorporating a diagram of the vulvar and pelvic areas into the assessment is often helpful in localizing the pain and assessing its patterns during particular activities (e.g., sexual intercourse or tampon insertion).
International Society for the Study of Vulvovaginal Disease (ISSVD) terminology and classification of vulvodynia*
Generalized: specifies involvement of the whole vulva
Localized: specifies involvement of a part of the vulva, such as the vestibule (vestibulodynia, formerly termed vulvar vestibulitis syndrome) or clitoris (clitorodynia)
Provoked (the pain is elicited by physical contact): sexual, nonsexual or both kinds of situation can lead to provoked pain
Unprovoked: the pain occurs without a specific physical trigger (i.e., spontaneously)
Mixed: provoked and unprovoked presentation
Please note that the term vulvodynia is reserved for those patients presenting without identifiable pathology. If patients present with vulvar pain in the presence of identifiable pathology the terminology is as follows: Vulvar pain related to a specific disorder, specified as infectious, inflammatory, neoplastic, or neurologic. Adapted with permission from [2].
Other essential information related to diagnosis can also be gleaned from careful questioning. Asking when the pain started can clarify whether the woman has primary or secondary PVD. Primary PVD is diagnosed when the pain has been present since the first intercourse attempt or tampon insertion, whereas secondary PVD is diagnosed when the pain develops after a period of pain-free vaginal penetration activities. Knowing this information may help in terms of treatment avenues and expectations, as it has been shown that women with primary PVD benefit less from surgical intervention than those with secondary PVD [8]; this difference may be related to data indicating that women with primary PVD have a more systemic pain problem than women with secondary PVD [9].
Also key is gathering information regarding past treatments undertaken for the pain, specifically, which remedies helped or exacerbated the pain. Questions related to other factors are useful, including examining fluctuations in pain intensity with respect to the menstrual cycle, sexual arousal levels and feelings of stress and relaxation. Detailed questioning regarding the functional effects of the pain (i.e., how the pain has affected the patients’ relationships, sexual functioning, psychological health and quality of life) will provide a thorough understanding of the pain and clarify therapeutic options. For example, if significant sexual and couple issues are evident, then a recommendation for couples therapy, integrating pain management and sexual/relationship therapy, would be appropriate. In addition to the importance of a detailed history of the pain for diagnostic and treatment purposes, asking questions regarding the pain is essential for understanding and validating the patient's pain experience. Some patients report that the information they provide regarding the pain may not be taken into consideration, leading to diagnostic delays [10]. Such delays may result in deferred treatments, which may lead to or exacerbate negative psychological symptoms and further increase pain intensity. Therefore, a careful and detailed initial assessment can potentially benefit the patient in many ways. This assessment should also include a meticulous physical examination.
Physical assessment of PVD
Friedrich proposed the following diagnostic criteria for PVD [11]:
Pain upon vestibular touch or attempted vaginal entry;
Tenderness to pressure of the vulvar vestibule;
Physical findings limited to vestibular erythema (i.e., redness) of varying degrees.
Although the first two criteria have been shown to be reliable, the criterion related to erythema is not [3]. It is the least specific of Friedrich's criteria, as erythema can also be present in the vulvas of nonaffected women and its presence and severity is based on subjective judgment [7]. The diagnosis of PVD requires that all possible physical explanations for the pain be ruled out [2]. Thus, a thorough examination for infectious (e.g., candidiasis and herpes), inflammatory (e.g., lichen planus), neoplastic (e.g., squamous cell carcinoma) and neurological (e.g., spinal nerve compression) conditions should be conducted. If other conditions are diagnosed, they must be treated, recognizing that the pain may not resolve after successful treatment.
The most reliable indicator for PVD is tenderness to vestibular pressure [3]. This indicator forms the basis of the cotton-swab test, the main gynecological diagnostic tool for PVD. Given a patient's complaint of superficial dyspareunia and the careful exclusion of other factors that may contribute to the pain, a positive response to the cotton-swab test provides strong support for the diagnosis of PVD. During the cotton-swab test, a cotton-tipped applicator is used to palpate different areas of the vulva, including the labia majora, labia minora and the vestibule. If the patient reports pain in response to vestibular palpation, the diagnosis of PVD is confirmed. Although the test is often performed in a clockwise or counter-clockwise manner around the vaginal introitus, this order may sensitize the vestibular area and lead to increased pain for the patient [3,12,13]. In addition, recording pain intensity ratings (e.g., on a 0–10 numerical or visual analogue scale) after palpation is helpful for gauging pain severity and for monitoring treatment effects.
Proposed etiologies of PVD
Although numerous etiological factors have been proposed [9,14], the etiology or etiologies of PVD are unknown. It is likely that different levels of pathophysiology are involved in the development and maintenance of PVD.
Factors related to the vestibule & pelvic floor
Comparisons of vestibular tissue in women with and without PVD have revealed abnormalities that could potentially contribute to an increase in sensitivity of the vulvar vestibule. Studies have demonstrated the presence of inflammatory infiltrates in the vestibular tissue of women with PVD [15]; however, this pattern has also been found in control tissue samples [16]. Increased density of nerve fiber innervation [15,17], the presence of pain-related peptides [18] and an increase in blood flow [19] have also been reported. These findings are consistent with reports demonstrating lower genital pain thresholds in affected versus nonaffected women via quantitative sensory testing (QST) [20,21].
Although the cause of these vestibular abnormalities is unknown, some researchers have suggested that injury to the developing vestibule may contribute to the development of PVD. Studies have reported that earlier versus later age of menstrual tampon use and of first sexual intercourse are associated with an increased risk of PVD [1]. These activities could potentially damage the sensitive vestibular tissue, leading to increased innervation and sensitivity of the affected area [22]. In addition, other local changes may occur: a common response to provoked pain involves protective reactions of the muscles surrounding the painful area, in this case, the pelvic floor muscles.
Pelvic floor muscle function in women with PVD
Controlled studies have examined pelvic floor muscle function in women with PVD. Reissing et al. found that women with PVD had significantly more restriction of the vaginal opening, higher levels of vaginal muscle tension, and lower vaginal muscle strength as compared with control women [23]. In fact, 90% of women with PVD demonstrated some form of pelvic floor pathology, leading the authors to suggest that this kind of pathology should be considered a core characteristic of women with PVD. Remarkably, the pattern of findings suggests that the increase in muscle tension does not cause the pain of PVD but, in fact, results from the pain. Current research also indicates that factors outside the genital/pelvic area (e.g., systemic and genetic factors) may contribute to the development and maintenance of PVD.
Systemic & genetic factors implicated in PVD
Several systemic factors have been proposed as etiological pathways to PVD, including hormonal and bacterial factors. For example, women with an early age of menarche and oral contraceptive use have an increased risk of developing PVD later in life [24,25], possibly owing to prolonged exposure to progestins and estrogens, which may increase the sensitivity of the vestibular mucosa [25–28]. Support for a bacterial contribution comes from studies indicating a strong association between a history of repeated yeast infections and PVD [24].
Some researchers have proposed that genetic factors are implicated in PVD, in particular, alleles associated with severe and prolonged pro-inflammatory immune responses [29]. Based on this and other evidence, the investigators have suggested that women with PVD may have a susceptibility to developing chronic vestibular inflammation after experiencing an initial inflammatory response in the region. One implication of these findings is that this potent inflammatory response could result in increased pain sensitivity not only in genital, but also nongenital body regions. Supporting this conclusion are studies indicating a generalized increase in pain sensitivity in PVD patients via self-report and QST methods [20,30–34]. These results indicate that CNS factors may also play a role in the development and maintenance of PVD.
CNS function in women with PVD
Pukall et al. found evidence of altered central sensory processing in response to painful vestibular stimulation in women with PVD as compared with nonaffected women [35]. Although the same brain areas were activated in both groups, women with PVD had consistently higher activation levels than control women, indicating an augmentation of sensory processing in the patient group. These results are consistent with their heightened sensitivity to pressure on the vestibule. Furthermore, Kuchinad, Pukall and Bushnell demonstrated that women with PVD exhibit differences in gray matter density; in particular, an increase was found in the hippocampus and basal ganglia, and a decrease was found in the frontal cortex as compared with control participants [36]. Although these results are preliminary, these neural alterations suggest that the pain of PVD may be mediated by abnormalities in the CNS.
Role of psychosocial factors in PVD
In the past, some researchers and clinicians posited that the pain of PVD was caused by psychological factors; however, there appears to be consensus that PVD results from a multitude of factors [37] and that heightened distress may result from the pain condition. Indeed, most sufferers report significant and negative impacts of the pain on their psychological well-being, sexual functioning and relationship adjustment.
Psychological impact of PVD
Pain disorders are often associated with psychological difficulties and reduced quality of life; likewise, many women with PVD experience distress and decreased quality of life [7,38,39]. Increased depression and more negative self-concept have been noted among women with vulvar pain [40,41], and approximately a quarter of respondents (102 of 428; 23.8%) in one study reported having considered suicide while experiencing vulvar pain [42]. Moreover, the majority of women (42 of 76; 60%) with vulvar pain in one study reported feeling out of control of their bodies and 31 (42%) reported feeling out of control of their lives [38]. Interestingly, anxiety can predict pain intensity among women with PVD, and women who attribute their pain to psychosocial factors report higher pain ratings, less overall psychological adjustment, and reduced relationship adjustment [43]. Such research suggests that PVD has a pervasive impact on a woman's life.
Effects of PVD on sexual & relationship function
PVD has negative implications for women's sexual functioning, as sexual intercourse and other forms of vaginal penetration are explicitly linked to the experience of severe pain. In a recent survey, 65 of 75 (87%) women with vulvodynia reported that the pain had at least a moderate impact on their sex life, with 31 (41%) reporting an extreme or disabling effect [38]. Unfortunately, all aspects of the sexual response cycle can be impacted by vulvar pain; affected women report decreased desire, arousal, orgasm and frequency of intercourse [41,44,45]. Over 50% of women stop having sexual intercourse altogether [38,46]. Of women who continue having intercourse, feelings of obligation to please a partner and deriving pleasure from intercourse that overrides the pain may be contributing factors [42]. For example, Gordon et al found that 82 out of 428 women in their study (19.2%) reported experiencing emotional and/or physical pleasure from sexual intercourse that outweighed the pain [42].
Given the sexual consequences of PVD, it is no surprise that intimate relationships may also be negatively affected. One study suggested that women with PVD fear that the pain will ruin their relationships [42], perhaps contributing to more relationship dissatisfaction [39,40]. Over time, pain, conflict and distress often become associated with intimacy, and couples may begin to avoid all forms of sexual activity. Couples may use avoidance as a coping strategy to help reduce distress, and to relieve the anxiety experienced with the sexual aspects of their relationship. However, not all research indicates a negative impact on intimate relationships. For example, some studies report no significant differences in relationship functioning between women with PVD and control women [45,47,48], and the majority of women in one study reported that an understanding partner helped them cope with the pain [42].
Treatment
A number of treatment recommendations exist for PVD, ranging from medical interventions to psychosocial treatments. However, most of these therapeutic options have yet to be empirically validated through controlled studies and/or randomized controlled trials (RCTs). Without such information, clinicians lack effective and safe guidelines for managing vulvar pain [6]. Typically, treatments for PVD fall into one of several categories: topical, systemic, surgical, psychological, pelvic floor muscle retraining techniques and lifestyle modifications.
Topical treatment options
Topical therapies for PVD include the application of creams or gels to the vestibule, and usually represent a first-line approach for managing vulvar pain. Topical anesthetics (e.g., lidocaine) are typically applied to the introitus prior to sexual intercourse, with the goal of decreasing pain associated with penetration. In one study, 61 women with PVD applied 5% lidocaine ointment to the vestibule for approximately 7 weeks. Nightly application of lidocaine was associated with decreased pain and an increased ability to have intercourse [49]. Other creams (e.g., cromolyn cream) are applied to the introitus approximately 3–4 times per day or on a nightly basis to provide symptomatic relief. In one of the few RCTs investigating treatment for PVD, cromolyn cream proved no more effective than placebo cream [50]. Although case reports and preliminary research suggest promising results regarding the application of topical anesthetics [7], RCTs are lacking and concerns regarding such treatments exist in the literature [6]. For example, women may have difficulty applying the appropriate amount to the correct location, or may experience an intense burning sensation upon application. Partners may also experience a dulling of sensation during intercourse from the topical solution [6,51]. In addition, while other topical solutions such as nitroglycerin or estrogen-based creams have been utilized in the treatment of PVD, their effectiveness has not been determined through the use of RCTs.
Systemic medications
Low-dose tricyclic antidepressants (TCAs), such as amitriptyline, are commonly used to treat chronic pain conditions, and have been used in the treatment of vulvar pain. For example, Reed et al found that women with unprovoked generalized vulvodynia and those with PVD reported significant improvement in pain symptoms post-treatment [52]. Other oral medications have also been used to manage vulvar pain, including anticonvulsant medication (e.g., gabapentin) and selective serotonin reuptake inhibitors (SSRIs). However, these medications are typically used for the treatment of unprovoked generalized vulvodynia, and little is known regarding their utility for managing PVD. In some cases, the side-effect profile of some of these medications may prohibit or limit their use [51].
Surgical intervention
Of all treatments, surgical options for PVD have received the most research attention and support. Several forms of vestibulectomy exist [53]; many involve the surgical excision of the hymen and the painful portion of the vestibule to a depth of 2–3 mm, with mobilization of the vaginal mucosa to cover the excised area [6,51]. This surgery is typically recommended for women with severe and unremitting symptoms of PVD and for those who have tried other treatments without success [54], although some experts argue that it should be used as a first-line treatment [55]. Vestibulectomy has the highest reported success rate for treating PVD, with rates typically exceeding 60% [56].
The effectiveness of surgery has also been tested via randomized trials. In a randomized investigation, Bergeron et al compared vestibulectomy, group cognitive-behavioral therapy (CBT) and pelvic floor biofeedback (i.e., muscle exercises) among women with PVD [57]. Women were assessed at pretreatment, post-treatment, and 6-month follow-up with regard to pain and sexual and psychological function. While all three treatments were associated with significant reductions in pain and improved sexual and psychological function at post-treatment and 6-month follow-up, women assigned to the vestibulectomy group experienced significantly greater pain reduction. Vestibulectomy remained superior with regard to reduced pain evoked by the cotton-swab test after 2.5 years, yet both vestibulectomy and group CBT were associated with equal improvements in pain ratings during intercourse [58]. The results of this study provide validation for vestibulectomy as a treatment option for PVD. However, seven of 29 (24%) participants assigned to receive vestibulectomy chose not to undergo the procedure, and the researchers note that caution is thus warranted when interpreting these findings. Given the invasiveness of this procedure, the inherent risks associated with surgery (e.g., hemorrhage and infection), the finding that not all women who underwent the surgery experienced benefits (i.e., two reported increased or unchanged pain post-treatment), and the availability of other potentially effective treatments (e.g., CBT), this treatment option may not appeal to all women with PVD [57]. Some recommend the surgery as a last resort, to be discussed with the patient only after other noninvasive treatments have failed. However, others recommend surgery as a first-line treatment option given the high degree of satisfaction and low rate of complications postsurgery [55]. Procedures for and variations of the surgery have recently been outlined [53,59].
Therapeutic options targeting psychological components
Empirical support has been found for psychological interventions aimed at managing PVD. CBT typically includes a combination of pain management and sex therapy. The goals of treatment are multifaceted, and include methods to increase adaptive coping skills and sexual function, and to decrease dyspareunia. Specific techniques include cognitive restructuring of maladaptive pain-related thoughts, relaxation and breathing exercises and the identification of sexual needs [60]. CBT is effective in increasing sexual and psychological function and decreasing pain, and group CBT has been shown to be equivalent to vestibulectomy in improving self-reported pain during intercourse at 2.5 year follow-up [58]. In addition, one partially randomized study found no differences in outcome for women who received behavioral therapy compared with women who received both behavioral and surgical interventions for PVD [61]. Furthermore, 28 out of 34 women (82%) in this study chose to receive behavioral treatment without accompanying surgery. Given these findings, the researchers recommended behavioral approaches as the first-line treatment for PVD [61]. CBT, behavioral approaches and other forms of psychotherapy and psychoeducation may represent an attractive alternative option for affected women who are unwilling to undergo surgery.
Recently, other promising psychological interventions have gained attention. For example, Pukall et al. investigated the use of hypnotherapy among eight women with PVD in a preliminary study [62]. Participants reported significantly less pain, and increased sexual functioning and satisfaction at 1 and 6 month follow-up. Acupuncture may also be a promising intervention for PVD. In a preliminary investigation, Powell and Wojnarowska examined 12 women with vulvodynia who received 5 weekly acupuncture treatments [63]. While three women reported no effect of acupuncture, nine women reported improvements in pain symptoms.
Pelvic floor muscle treatments
Biofeedback appears to be another viable option for PVD, and is based on the finding that women with vulvar pain have increased hypertonicity (i.e., muscle tension) of the pelvic floor muscles [64]. Biofeedback teaches women awareness of and control over their pelvic floor muscles, with the goal of reducing pain. It involves having patients visually monitor their level of pelvic floor muscle tension via the use of a vaginal sensor connected to a display monitor. Two studies have shown decreased pain following biofeedback treatment [65,66]. Biofeedback was also evaluated in two randomized treatment outcome studies, demonstrating pain reduction and increases in sexual function [57,67].
Pelvic floor physical therapy, which includes biofeedback as one component, also appears to be an effective treatment option [60]. Typical pelvic floor physiotherapy treatment for PVD includes the following components: education; manual techniques such as stretches, massages, desensitization and mobilization of the pelvic floor muscles; biofeedback; electrotherapy; and dilation exercises [68]. Bergeron et al. found that approximately 70% of women with PVD who received pelvic floor physical therapy reported moderate to great improvement in their symptoms [69]. Specifically, therapy was associated with pain reduction during intercourse and gynecological examinations, and increases in sexual function [69].
Lifestyle modifications
Women with vulvar pain are often advised to make changes in their lives such as avoiding vaginal douches, using mild soaps, wearing cotton underwear and wearing loose-fitting clothing. While a recent study indicated that the majority of clinicians recommend such modifications to their patients with vulvar pain, the effectiveness of these changes has not been validated [51,70].
Other treatment options
Botulinum toxin A (Botox®) has recently been used in the management of chronic pain disorders involving a muscular component, including vulvar pain. Botox is a neurotoxin that inhibits acetylcholine release at neuromuscular junctions, with the effect of muscle paralysis. Yoon et al. injected the vulvas of seven women with Botox at the sites of vestibular pain [71]. All women reported reductions in pain and improvements in sexual function, and the authors did not observe common side effects (e.g., infection or nausea) typically associated with this substance. However, these results must be interpreted with caution, as they are preliminary and uncontrolled.
Proposed treatment algorithm for vulvodynia
Recently, Haefner et al. proposed a treatment algorithm for idiopathic vulvodynia [51]. These authors recommend starting with relatively noninvasive palliative or therapeutic methods and, if improvement is not achieved, treatment options progress to more invasive methods. According to this algorithm, once the diagnosis of vulvodynia has been established, treatment should follow the following pattern: vulvar care measures, topical medications, oral medications, injections, biofeedback/pelvic floor physical therapy, low oxalate diet with calcium citrate supplementation (note that the effectiveness of this particular treatment option has not been established) and psychotherapy. Vestibulectomy is recommended as a last resort, and is reserved only for those patients with PVD who desire this treatment avenue. This algorithm offers a step-by-step guide and is helpful for many healthcare professionals working with affected women; however, some healthcare professionals suggest that surgery or other treatment options (e.g., psychotherapy, oral medications and pelvic floor physical therapy) should be considered as first-line options [55]. No single treatment is effective for all women, and in most cases, pain improvement may take weeks, months or even years. It is important to discuss realistic goals of treatment and potential treatment avenues with patients, as this process can facilitate communication about what treatments are and are not acceptable to each patient. Indeed, many treatment avenues exist, allowing for some degree of patient choice in her care.
Conclusion: ongoing challenges & unmet needs
Knowledge regarding PVD has increased substantially over the past 10 years. Research examining quality of life among women with PVD has increased, and several treatment options have been investigated. Unfortunately, however, PVD remains a challenge for clinicians to manage, and it continues to have negative consequences for women's health, sexual functioning, quality of life and psychological well-being. Currently, some of the challenges facing clinicians and researchers include:
Inadequate training of healthcare professionals in the assessment, diagnosis and treatment of vulvar pain;
A lack of methodologically sound studies examining the etiology and impact of PVD;
A dearth of RCTs with which to support the effectiveness of various therapies for PVD and to guide potential treatment avenues;
The relative absence of integrated and multidisciplinary clinical and research approaches to PVD.
There is a need for healthcare professionals to receive education and training regarding vulvar pain and its management. In a recent survey of 167 clinicians, almost 85% felt they did not receive adequate training related to the treatment of vulvar pain [70]. While it is difficult to train clinicians in the absence of empirically based treatment guidelines, it is important that professionals involved in women's care be educated with regards to the best available literature and practice guidelines. In addition, there is an urgent need for methodologically sound research investigating the etiological, psychosocial and psychosexual correlates of PVD. In particular, the quality of women's relationships and partner function should be addressed, since there is some suggestion that vulvar pain may be differentially associated with relationship adjustment [43]. Similarly, treatments for PVD need to be systematically investigated using RCTs. Given the large range of therapeutic options available and the risks associated with potential treatments, data are needed to determine the effectiveness of the variety of options. Finally, a multidisciplinary approach to PVD is needed, as PVD is associated with various difficulties. Focusing on only one aspect of the condition (e.g., pain) may not address other areas (e.g., sexual function). Patients should be included in decisions regarding the management of their pain, and should be given choice with regard to what treatment options they wish to pursue. A positive relationship with knowledgeable healthcare providers can be a valuable resource for women with vulvar pain, and the support received from such relationships may allow women to cope more effectively with their pain.
Future perspective
A multidimensional and multidisciplinary approach to PVD is recommended and should be applied to, at a minimum, the following areas: pain characteristics and sequelae (e.g., intrapersonal and interpersonal factors), predisposing factors, the vulvar vestibule and pelvic floor, and generalized/central processes. In addition, a multimodal approach to the treatment of PVD is needed in order to target the many areas affected in PVD.
Executive summary
Vulvodynia, or chronic vulvar pain, has recently received increased attention from health professionals, researchers and funding agencies.
A pain-based classification for vulvodynia has recently been promoted by the International Society for the Study of Vulvovaginal Disease (ISSVD).
Vulvodynia is a prevalent condition, affecting 16% of women in the general population.
Vulvodynia can be either generalized or localized. These types of vulvodynia are subdivided according to the temporal pattern of the pain (i.e., provoked, unprovoked or mixed).
Provoked vestibulodynia (PVD) is a common form of vulvodynia that affects 12% of women in the general population. In PVD, the pain occurs in response to pressure localized to the vulvar vestibule.
Self-reported pain history and pain upon cotton-swab palpation of the vestibule form the basis for the diagnosis of PVD.
Obtaining a detailed history of the pain is essential for diagnostic and treatment purposes, and for understanding and validating the patient's pain experience.
Several etiological factors for PVD have been proposed, including inflammatory processes, pelvic-floor muscle hypertonicty, systemic and genetic factors and altered CNS functioning.
Increased research attention to possible etiological factors suggests that different levels of pathophysiology are likely involved in the development and maintenance of PVD.
PVD often has negative impacts on psychological, sexual and relationship functioning, including decreased quality of life and lower frequency of intercourse.
Not all research indicates that PVD interferes with women's relationships, and an understanding partner can help women cope with pain.
Treatment recommendations for PVD are plentiful. However, most proposed therapies lack validation, and few have been subjected to randomized controlled trials (RCTs).
Proposed treatments for PVD include topical agents, systemic medications, surgical interventions, psychological interventions, pelvic floor physical therapy, lifestyle modifications and alternative treatments. Recently, other therapies such as Botox® have been investigated.
Research investigating treatments for PVD has increased substantially in recent years. Although more research is needed, a number of interventions appear promising, including surgical and psychological approaches.
A treatment algorithm has recently been proposed. It recommends the following sequence: vulvar care measures, topical medications, oral medications, injections, biofeedback/pelvic floor physical therapy, low oxalate diet with calcium citrate supplementation (note: the effectiveness of this option has not been investigated), psychotherapy and vestibulectomy. However, others suggest starting with more invasive treatments, such as the vestibulectomy.
Clinicians and researchers face several challenges in this area. Currently, there is a need for more education and training regarding PVD, increased research examining the etiology and impact of PVD, and more RCTs. Multidisciplinary approaches should be applied to this condition.
Patients should be included in treatment decisions, and a positive relationship between women and their healthcare providers should be fostered. Positive patient–clinician relationships can provide support and help women cope with pain.
A multidimensional approach is recommended in order to increasingly understand pain characteristics, predisposing variables and beneficial treatments associated with PVD.
Footnotes
The authors have no relevant financial interests, including employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties related to this manuscript.