Chronic Vulvar Pain Research Articles

Potential for Selection Bias in Studies of the Association of Hormonal Contraception and Chronic Vulvar Pain.

Background: Hormonal contraceptive use is common among reproductive-aged women, but research evaluating its etiological relationship to vulvodynia remains mixed. We sought to evaluate this association and examine the potential for bias due to care-seeking behavior. Materials and Methods: We conducted a case-control study of women recruited from a large health care network database from 2008 to 2011. Of 26,455 eligible respondents, 1168 met the case definition for chronic vulvar pain (CVP). We matched each case to three controls by age and used conditional logistic regression to calculate odds ratios (ORs) for prior hormonal contraception (HC) use and CVP, stratifying cases by whether or not they sought care for their vulvar pain. We also simulated the influence of potential biases due to care seeking, using parameters based on this dataset. Results: HC users had higher odds of CVP (adjusted OR = 2.6, 95% confidence interval [CI]: 2.2-3.2). Effect estimates were stronger when cases were restricted to care seekers (adjusted OR = 2.9, 95% CI: 2.2-3.7). Effect estimates decreased slightly as time increased between HC initiation and pain onset. Our simulations suggested that effect estimates may be spuriously strengthened when cases are restricted to care-seeking women, but controls are recruited from the general population. Conclusions: Our results suggest an association between antecedent HC use and CVP that is potentially spuriously strengthened in case-control studies when cases are restricted to care seekers but controls are not.

An Investigation of Descending Pain Modulation in Women With Provoked Vestibulodynia: Alterations of Brain Connectivity.

Provoked Vestibulodynia (PVD) is the most common vulvodynia subtype (idiopathic chronic vulvar pain). Functional magnetic resonance imaging (fMRI) studies indicate that women with PVD exhibit altered function in a number of pain modulatory regions in response to noxious stimulation, such as in the secondary somatosensory cortex, insula, dorsal midcingulate, posterior cingulate, and thalamus. However, previous neuroimaging studies of PVD have not examined periods of time before and after noxious stimulation or investigated functional connectivity among pain modulatory regions. Fourteen women with PVD and 14 matched Control participants underwent five fMRI runs with no painful stimuli interleaved randomly with five runs with calibrated, moderately painful heat stimuli applied to the thenar eminence. As recent findings indicate that pain processing begins before and continues after painful stimulation, 2-min periods were included in each run before and after the stimulus. Functional brain connectivity was assessed during both trials of Pain and No Pain stimulation for each group using structural equation modeling (SEM). Analyses of variance (ANOVAs) on connectivity values demonstrated significant main effects of study condition, and group, for connectivity among pain modulatory regions. Most of the differences between the Pain and No Pain conditions found only in the PVD group take place before (i.e., thalamus to INS, ACC to S1, thalamus to S1, and thalamus to S2) and after pain stimulation (i.e., INS to amygdala, PPC to S1, and thalamus to S2). Such differences were not observed in the Control group. These findings further support previous results indicating that women with PVD have altered pain processing compared to pain-free women.

Reduced concentrations of vaginal metabolites involved in steroid hormone biosynthesis are associated with increased vulvar vestibular pain and vaginal muscle tenderness in provoked vestibulodynia: An exploratory metabolomics study.

Provoked vestibulodynia (PVD) is a chronic vulvar pain disorder characterized by hypersensitivity and severe pain with pressure localized to the vulvar vestibule. Knowledge regarding pathophysiological mechanisms contributing to the etiology and production of symptoms in PVD remains incomplete but is considered multifactorial. Using a cross-sectional observational study design, data from untargeted metabolomic profiling of vaginal fluid and plasma in women with PVD and healthy women was combined with pain testing and brain imaging in women with PVD to test the hypotheses that women with PVD compared to healthy women show differences in vaginal and plasma metabolites involved in steroid hormone biosynthesis. Steroid hormone metabolites showing group differences were correlated with vulvar vestibular pain and vaginal muscle tenderness and functional connectivity of brain regions involved in pain processing in women with PVD to provide insight into the functional mechanisms linked to the identified alterations. Sensitivity analyses were also performed to determine the impact of hormonal contraceptive use on the study findings. Women with PVD compared to healthy controls had significant reductions primarily in vaginal fluid concentrations of androgenic, pregnenolone and progestin metabolites involved in steroidogenesis, suggesting localized rather than systemic effects in vagina and vulvar vestibule. The observed reductions in androgenic metabolite levels showed large effect size associations with increased vulvar vestibular pain and vulvar muscle tenderness and decreases in androgenic and progestin metabolites were associated with decreased connectivity strength in primary sensorimotor cortices. Women with PVD showed symptom-associated reductions in vaginal fluid concentrations of metabolites involved in the biosynthesis of steroid hormones previously shown to affect the integrity of vulvar and vaginal tissue and nociceptive processing. Deficiency of certain steroids may be an important mechanism contributing to the pathophysiology of symptoms in PVD may provide potential diagnostic markers that could lead to new targets for therapeutic intervention.

Are you in pain if you say you are not? Accounts of pain in Somali-Canadian women with female genital cutting.

As a rite of passage to womanhood, 2 million girls undergo female genital circumcision (FGC)-the tradition of cutting, and often removing parts of the vulva-every year. The current study is the first to focus on the connection between peripheral nerve damage and chronic neuropathic pain in women with FGC. We used mixed methods-quantitative, qualitative, and physiological-to study chronic pain in Somali-Canadian women (N = 14). These women have the most extensive form of FGC, which includes removal of the glans clitoris, labia minora, medial portion of the labia majora, and stitching together the remaining parts of the labia majora. Our results indicate a multifaceted pain experience in women with FGC. Although they report good overall health and very low pain levels on the short form of the McGill Pain Questionnaire, pressure-pain quantitative sensory testing of the vulvar region applied through vulvalgesiometers shows pain thresholds consistent with those reported by women with chronic vulvar pain. Furthermore, qualitative interviews reveal a considerable amount of often debilitating pain in daily life. These results challenge the use of assessment tools offering elicited verbal pain language and highlight the importance of culturally sensitive ways of conceptualizing, measuring, and managing pain.

Psychosocial factors associated with pain and sexual function in women with Vulvodynia: A systematic review.

Background and objectiveVulvodynia is a prevalent chronic vulval pain condition affecting 10%–28% of women, and significantly impacting their health and quality of life. It is currently poorly understood and biomedical treatments achieve only modest benefits for pain and sexual functioning. A wider psychosocial conceptualization of this condition may improve outcomes. There is currently no coherent understanding of how psychosocial factors may contribute to outcomes in Vulvodynia. The aim of this review is to identify and systematically review psychosocial factors associated with pain and sexual outcomes and to inform a psychosocial model of Vulvodynia.Databases and data treatmentObservational/experimental studies reporting on the association between psychosocial factors and pain/sexual outcomes in adult women with Vulvodynia were eligible. Two reviewers independently conducted eligibility screening, data extraction and quality assessment. Twenty‐one studies were included, all focused on women with Provoked Vestibulodynia (PVD). Most of the studies were low‐to‐medium quality.Results/ConclusionA range of general/pain‐related distress and avoidance processes, and sex/intimacy avoidance or engagement processes were significantly associated with pain, sexual functioning or sexual distress and sexual satisfaction, supporting the role of a psychosocial approach to PVD. Depression, anxiety, catastrophizing, pain‐anxiety, pain acceptance, body‐exposure anxiety, attention to sexual cues, partner hostility and solicitousness, self‐efficacy and penetration cognitions are highlighted as potentially important treatment targets in PVD. Due to the limited data available, developing a psychosocial model was not possible. Directions for future research include examining the replicability and generalizability of the factors identified, exploring differences/similarities across Vulvodynia subsets and testing tailored theoretically based treatments.SignificanceThe systematic review highlights the role of psychosocial factors associated with pain and sexual functioning in Vulvodynia. The review findings reveal that Vulvodynia presents both similar and unique cognitive, behavioural and interpersonal features compared to other chronic pain conditions. There may be important roles for negative sexual cues, body image–related factors during intercourse, partner factors, self‐efficacy beliefs and penetration cognitions, in relation to pain and sexual functioning.

Czy terapia Recover skutecznie zmniejsza ból u kobiet z wulwodynią?

Introduction: Vulvodynia (Vd) is a form of chronic vulvar pain and other discomfort that persists for more than three months in the absence of any evident vulvovaginal pathology. Provoked Vd is one of the reasons of dyspareunia. Vd is classified as a functional pain syndrome that is mediated by pelvic floor muscles dysfunction (PFMD overactive state) and psychological predisposition. Treatment standards do not exist, although multidisciplinary therapy seems to be the most effective. Material and methods: Retrospective study was performed within 121 women with Vd who undergo Recover therapy. Nineteen therapeutic sessions were included, with manual pelvic therapy, initial general physiotherapy and psychological consultations performed during minimum 5 days. Vd patients with PFMD overactive state were qualified by a gynecologist to the therapy, who also summarizes the treatment. Pain rate and characteristics of vulvar discomfort were assessed before and 2 and 6 months after therapy, recorded in NRS. Results: Vulvar pain and discomfort subjective reduction by 65% was confirmed after therapy, even more, 2/3 of women reported a minimum 50% relief in pain, the improvements were maintained over the time. The best treatment results in dyspareunia women caused by provoked Vd were obtained. The outcome was not dependent on the duration of Vd. Conclusions: In the center when women with vulvar diseases and Vd are treated, interdisciplinary Vd therapeutic program was developed. Recover therapy can lead to clinically meaningful improvement in Vd pain, according to chronic pain therapy assessment criteria. Randomized clinical trial with control group is indicated, when other key parameters of IMMPACT consensus, for Recover therapy assessment, would be taken under consideration.

Multimodal physical therapy versus topical lidocaine for provoked vestibulodynia: a multicenter, randomized trial

Provoked vestibulodynia is the most common subtype of chronic vulvar pain. This highly prevalent and debilitating condition is characterized by acute recurrent pain located at the entry of the vagina in response to pressure application or attempted vaginal penetration. Although physical therapy is advocated as a first-line treatment for provoked vestibulodynia, evidence supporting its efficacy is scarce. The purpose of this study was to establish the efficacy of multimodal physical therapy compared with topical lidocaine, a frequently used first-line treatment. We conducted a multicenter, parallel-group, randomized clinical trial in women diagnosed as having provoked vestibulodynia recruited from the community and 4 Canadian university hospitals. Women were randomly assigned (1:1) to receive either weekly sessions of physical therapy or overnight topical lidocaine (5% ointment) for 10 weeks. Randomization was stratified by center using random permuted blocks from a computer-generated list managed by an independent individual. Physical therapy entailed education, pelvic floor muscle exercises with biofeedback, manual therapy, and dilation. Assessments were conducted at baseline, posttreatment, and 6-month follow-up. Outcome assessors, investigators, and data analysts were masked to allocation. The primary outcome was pain intensity during intercourse evaluated with the numeric rating scale (0-10). Secondary outcomes included pain quality (McGill-Melzack Pain Questionnaire), sexual function (Female Sexual Function Index), sexual distress (Female Sexual Distress Scale), satisfaction (numeric rating scale of 0-10), andparticipants' impression of change (Patient Global Impression of Change). Intention-to-treat analyses were conducted using piecewise linear-growth models. Among 212 women who were recruited and randomized, 201 (95%) completed the posttreatment assessment and 195 (92%) completed the 6-month follow-up. Multimodal physical therapy was more effective than lidocaine for reducing pain intensity during intercourse (between-group pre-post slope difference, P<.001; mean group postdifference, 1.8; 95% confidence interval, 1.2-2.3), and results were maintained at 6-month follow-up (mean group difference, 1.8; 95% confidence interval, 1.2-2.5). The physical therapy group also performed better than the lidocaine group in all secondary outcomes (pain quality, sexual function, sexual distress, satisfaction, and participants' impression of change) at posttreatment and 6-month follow-up. Moreover, the changes observed after physical therapy were shown to be clinically meaningful. Regarding participants' impression of change, 79% of women in the physical therapy group reported being very much or much improved compared with 39% in the lidocaine group (P<.001). The findings provide strong evidence that physical therapy is effective for pain, sexual function, and sexual distress and support its recommendation as the first-line treatment of choice for provoked vestibulodynia.

Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives.

IntroductionPersons with vulvodynia (a chronic vulvar pain condition) suffer many barriers to diagnosis and treatment, several of which may be exacerbated by the sociocultural and geographical context in which they live.AimWe drew on the experiences of patients with vulvodynia who were living in small urban and rural communities to learn what they perceived as the major barriers to diagnosis and treatment as well as to probe for possible solutions.MethodsFor this qualitative case study, we conducted 3 focus groups with a total of 10 participants, drawn from patients seen at our academic tertiary referral center, with a goal of understanding their lived experience with vulvodynia.Main Outcome MeasuresThe patient dialogue was coded into themes and temporally grouped to illustrate struggles and victories in diagnosis and treatment.ResultsParticipants confirmed that healthcare provider knowledge and attitudes as well as system challenges (specialist and allied healthcare provider availability) are major barriers to timely diagnosis. Of novel interest are other factors that exacerbate distress and delay diagnosis such as patients’ inadequate knowledge of sexual functioning and sociocultural messages regarding “normal” sexual activity. Our work suggests that a disease prevention framework that includes comprehensive sexual education before or at the onset of sexual activity may be of benefit in reducing the burden of vulvodynia when added to strategies to increase healthcare provider knowledge and improve access to effective treatments.ConclusionWhile healthcare provider knowledge and attitudes are often at the forefront of barriers to diagnosis, our study suggests that to minimize patient distress and expedite diagnosis, resources must also be directed to promoting comprehensive sexual health education.Webber V, Miller ME, Gustafson DL, et al. Vulvodynia Viewed From a Disease Prevention Framework: Insights From Patient Perspectives. Sex Med 2020;8:757–766.

Mad Insight

This poem is informed by the relationships between gender, race, chronic pain, hysteria, and the role of dominant discourses in shaping interpretations of bodily and psychic pain. Drawing on my lived experience as a non-binary person with chronic vulvar pain, or vulvodynia, I challenge the psychiatrization of chronic pain and propose hysteria as a potential state of resistance and refusal (Dumaresque, 2019). I weave fog throughout this poem as a metaphor that captures pain, madness, and perception. Fog symbolizes disruption and disorientation; yet, fog also gestures to the potentiality of being displaced from normative insight (Bruce, 2017). I engage William Connolly’s (2010) reading of perception as formed through discipline to think through the silent but subversive waves of knowledge and power that carve the lenses through which we story ourselves and others (Erickson, 2016). As Thomas King (2003) writes, “the truth about stories is that’s all we are” (p. 32). This poem is situated in a reading of madness and hysteria as sites of affective protest (Dumaresque, 2019). I ask, what can be resourced from our becoming un-hinged? This poem contributes to mad knowledge that is intersectional and in-service to disrupting medical and psychiatric violence, whiteness, hetero/cis-governance, and “compulsory able-bodymindedness” (Sheppard, 2018, p. 59).

Vulvar pain: The revealing scenario of leading comorbidities in 1183 cases

ObjectivesThis study set out to investigate the epidemiological characteristics and comorbidities of chronic vulvar pain. Secondary goals were to identify the preferred approaches for managing vulvodynia in Italy. Study DesignA cross-sectional study (the VuNet -Vulvodynia Network project) was performed in consecutive female patients with chronic vulvar pain attending 21 Italian medical centers (public hospitals, university clinics and private outpatient services) in the period December 2016 to November 2018. Study data were entered by healthcare professionals in a special web-based medical record system (PRIDE- Progetto Rete Italiana Dolore vulvarE). These data covered epidemiological aspects, demographic characteristics, obstetric and gynecological history, presence and duration of current and/or past symptoms, associated disorders, details of physical examination and treatment approaches. ResultsA total of 1183 subjects with a diagnosis of chronic vulvar pain were included in the study. The main reason for consultation was superficial dyspareunia, present in 64.2 % of the women. 43.4 % of the sample reported comorbid sexual disorders (of desire in 22.1 % and arousal in 21.3 %). 48.3 % of the patients reported prolonged pain lasting between one and five years. Factors associated with vulvar pain included a relatively high family history of diabetes mellitus (father = 8.6 %; mother = 8.4 %), recurrent vulvovaginal candidiasis (32 %), and urinary tract infections (37.4 %: recurrent cystitis in 19.5 % and post-coital cystitis in 17.9 %). Irritable bowel syndrome (28 %), constipation (23.5 %), headache (25.7 %: migraine in 18.0 % and menstrual headache in 7.7 %), allergies (17.5 %: food allergies in 10.1 %, respiratory allergies in 7.4 %), anxiety (15.0 %), dyschezia (11.7 %), invalidating dysmenorrhea/endometriosis (11.1 %), and major depression (7.6 %) were also reported. Vestibulodynia was diagnosed in 837 of the 1183 patients (70.8 %) and generalized vulvodynia in 323 (27.3 %). Notably, 69.1 % of the patients stated that previous therapies had not changed their pain. ConclusionsThe diagnoses of vestibulodynia and vulvodynia must be considered in patients with chronic vulvar pain. The VuNet study contributes to a more comprehensive reading of the predisposing, precipitating and maintaining factors that contribute to vulvar pain, and of the key comorbidities.

Exploring the neural correlates of touch and pain in women with provoked vestibulodynia.

Group differences in touch and pain thresholds-and their neural correlates-were studied in women with provoked vestibulodynia (PVD; N = 15), a common subtype of vulvodynia (chronic vulvar pain), and pain-free control women (N = 15). Results from quantitative sensory testing and self-report measures indicated that, as compared with control participants, women with PVD exhibited allodynia (ie, pain in response to a normally nonpainful stimulus) and hyperalgesia (ie, an increased response to a normally painful stimulus) at vulvar and nonvulvar sites. In addition, brain imaging analyses demonstrated reduced difference scores between touch and pain in the S2 area in women with PVD compared with control participants, supporting previous findings of allodynia in women with PVD. There were no significant reductions in difference scores between touch and pain for regions related to cognitive and affective processing of painful stimuli. The results of this study contribute important information to the general pain and vulvodynia literatures in elucidating the specific sensorimotor neural mechanisms that underlie hyperalgesia in a chronic pain population. These results have implications for differentiating neural processing of touch and pain for women with and without PVD. Future research should attempt to examine alterations related to hyperalgesia in commonly comorbid conditions of PVD.

Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges

IntroductionChronic vulvar pain is a multidimensional condition with great variability in clinical presentation among affected women. In a companion article, part 1, we reviewed and recommended assessment and measurement tools for vulvar pain and related outcomes with a view toward improving consistency and comparison across studies. Yet methodological challenges to conducting research with this population remain and can further hinder conclusions regarding etiology and treatment. AimTo discuss methodological challenges to conducting vulvar pain research alongside recommended solutions. MethodsThe expert authors reviewed the scientific evidence related to the study of vulvar pain and made decisions regarding methodological challenges and mitigation strategies via discussion and consensus. Main Outcome MeasureWe articulated key challenges to conducting research in this area and formulated recommendations for mitigating these challenges. ResultsChallenges to the field include selection and sample biases, heterogeneity of the condition, inclusion of the partner, and neglect of the multidimensional aspects of vulvar pain. 2 key recommendations are more careful and detailed tracking and characterization of research samples and greater multidisciplinary collaboration to better capture the complexity of chronic vulvar pain. Clinical ImplicationsThis methodological critique points to several challenges to clinical research with populations struggling with chronic vulvar pain and makes suggestions for how to mitigate these issues. Strength & LimitationsComments in this expert review raise awareness regarding core challenges to the study of vulvar pain and can inform study design of clinical research with this population. The content of this review is based on expert knowledge and opinion rather than a formal systematic review or extended consultation process. ConclusionA careful reflection upon methodological challenges facing clinical research of vulvar pain and ways to mitigate such challenges is crucial for improving the quality, generalizability, and uptake of research findings.Rosen NO, Bergeron S, Pukall CF. Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges. J Sex Med 2020; 17:595–602.

Aetiology, diagnosis, and clinical management of vulvodynia.

Chronic vulvar pain or discomfort for which no obvious aetiology can be found, i.e. vulvodynia, can affect up to 16% of women, and it may be found in girls and women across all age groups and ethnicities. Most patients describe it as burning, stinging, irritation, or rawness. The symptoms may spread to the whole vulva (generalised vulvodynia) or only to part of it, such as the clitoris (clitorodynia) or the vestibule of the vagina (vestibulodynia). This condition is often underreported and underrecognised by health care providers. Vulvodynia is a significant burden to society, the health care system, the affected women, and their intimate partners. It has a negative impact on quality of life. Vulvodynia is a diagnosis of exclusion with unknown aetiology. The gynaecologist plays a key role in excluding other causes of vulvar pain, and collaborating with other health care providers to manage the patient’s pain. Although many therapeutic options are available, such as vulvar care measures, psychological approaches, local treatment, oral medications, surgical procedures, electrical nerve stimulation, and laser therapy, there is no single treatment effective for all patients. That is why individualised management is needed. An individualised, holistic, and often multidisciplinary approach is needed to effectively manage the patient’s pain and pain-related distress.

Recommendations for the Study of Vulvar Pain in Women, Part 1: Review of Assessment Tools

IntroductionThe etiology and consequences of chronic vulvar pain are multidimensional, resulting in highly variable clinical presentations and no established treatment algorithm. Inconsistent use of measurement tools across studies is a significant barrier to drawing conclusions regarding etiology and treatment. In a companion paper, we review additional methodological challenges to the study of chronic vulvar pain and potential solutions. AimTo review and recommend assessment and measurement tools for vulvar pain and associated key outcomes. MethodsThe authors reviewed the scientific evidence related to measurement of vulvar pain and made decisions regarding recommendations via discussion and consensus. Main Outcome MeasureWe assessed measurement tools for vulvar pain and related outcomes and considered advantages and disadvantages of their use. ResultsEmpirically validated measurement tools are available and should be used uniformly across studies to support comparisons and pooling of results. There is, at times, a trade-off between advantages and disadvantages when selecting a particular tool, and researchers should be guided by their specific research aims, feasibility, and potential to gain further knowledge in the field. Researchers should incorporate a biopsychosocial assessment of vulvar pain and its consequences. Clinical ImplicationsThis review provides a comprehensive list of measurement tool recommendations for use in clinical research, and in some cases, clinical practice. Strengths & LimitationsThis expert review can guide study design and decision-making for those researching vulvar pain and its consequences. The review content and recommendations are based on expert knowledge of the literature rather than a formal systematic review. ConclusionA thorough consideration of vulvar pain assessment tools is essential for continued progress toward identifying factors involved in the development and maintenance of vulvar pain and developing empirically supported treatments.Rosen NO, Bergeron S, Pukall CF. Recommendations for the Study of Vulvar Pain in Women, Part 1: Review of Assessment Tools. J Sex Med 2020; 17:180–194.

013 Pelvic Floor Biometry Assessed Using 3D Translabial Ultrasound in Women with Vulvodynia Submitted to Physical Therapy: A Randomized Controlled Trial

Vulvodynia is a prevalent chronic vulvar pain which has strong negative effects over quality of life of women and their partners. Pelvic floor muscles (PFM) hypertonicity is known to play an important role in its pathophysiology. For many years, studies investigating whether physical therapy was efficient on changing muscle status of PFM of women with vulvodynia used digital and electromyography assessments, with inconsistent findings. The four-dimensional translabial ultrasound (4D-TLUS) is proven to be efficient on measuring biometry of PFM. Recent studies found that biometric measures of PFM of women with vulvodynia differ from those of healthy controls. However, there is a lack of scientific evidence of whether physical therapy is effective on promoting changes on PFM of women with vulvodynia. This knowledge would contribute to improve knowledge about the mechanism throughout physical therapy is effective for treating women with vulvodynia, and to guide future studies aiming to increase effect of treatment for this disabling condition.

Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia

IntroductionVulvodynia is a debilitating, chronic vulvar pain condition. Community-based case-control studies have consistently shown associations between early-life chronic stressors and vulvodynia onset. AimWe examined rumination as a specific stress response involved in the psychobiological mechanism of vulvodynia. MethodsA psychosocial survey with questions specific to early-life traumatic events and rumination were administered to 185 matched case-control pairs of women with and without vulvodynia. Conditional logistic regression was used to examine associations between rumination constructs (ie, total rumination, emotion-focused, instrumental, and searching for meaning) and vulvodynia onset. Conditional logistic regression was also used to determine whether these associations depended on early-life stressors (ie, severity of childhood abuse and of self-reported antecedent traumatic events). Age at interview, antecedent pain disorders, any childhood abuse, and antecedent psychiatric morbidity were included as covariates. Main Outcome MeasuresWe estimated the odds of rumination in relation to the onset of vulvodynia within a community-based and clinically confirmed sample of women with and without vulvodynia. ResultsVulvodynia was associated with the highest tertile of emotion-focused (odds ratio [OR] = 2.1; 95% CI = 1.2, 3.2) and instrumental (OR = 2.1; 95% CI = 1.1, 4.0) rumination. These associations were attenuated after additional adjustment for antecedent psychiatric morbidity. Among women who reported rumination about early-life stressors before vulvar pain in cases or matched reference age in control subjects, those with vulvodynia were >2 times more likely to report the highest tertile of total rumination (OR = 2.3; 95% CI = 1.1, 5.0) compared with those without vulvodynia. Clinical ImplicationsHealthcare providers may be able to identify subsets of women who could benefit from preventive measures before the development of vulvodynia. Strength & LimitationsThis is the first study to use a community-based and clinically confirmed sample of women with and without vulvodynia to examine the associations between rumination about early-life trauma and the onset of vulvodynia. However, as with all retrospective studies, the reporting of information (eg, traumatic events) was subject to recall bias and misclassification. ConclusionOur findings indicate that a prolonged cognitive stress response (ie, rumination) may be 1 important mechanism by which early-life chronic stressors contribute to the onset vulvodynia. Prospective studies are recommended to examine whether and how cognitive, affective, and physiological components of prolonged stress responses interact to influence the development of vulvodynia. Understanding both the psychobiological and behavioral mechanisms may help in addressing and treating individuals to potentially reverse the development of vulvodynia.Khandker M, Brady SS, Rydell SA, et al. Early-life Chronic Stressors, Rumination, and the Onset of Vulvodynia. J Sex Med 2019;16:880–890.

081 Patient Techniques Aimed at Easing Chronic Vulvar Pain Prior to Internal Assessment

Reducing abnormal tension in pelvic floor muscles (PFMs) in women with vulvar vestibulitis (provoked vestibulodynPVD) was found by Glazer in 1995 to improve sexual function and decrease complaints of chronic vulvar pain. Multiple studies since have confirmed the presence of abnormal tension in PFMs in women with PVD when compared to matched, asymptomatic controls. Though its pathophysiology remains unclear, PVD may be caused by inciting events in patients’ histories. Histories that includes recurrent yeast or bacterial infections, urinary or bladder infections, endometriosis, or chronic bowel dysfunction can have a lasting, negative impact, causing PFM dysfunction as well as elevated tension in the affected viscera. Though this may not occur in all, many women with PVD present with both elevated PFM tone and residual abnormal visceral tension. Though PFM dysfunction appears to be a primary driver of chronic vulvar pain, it is possible that the muscular dysfunction is secondary to abnormal tension in the surrounding abdominal and pelvic viscera, fascia, and muscle. Together, these abnormal physical findings make internal assessment, whether digital or with a speculum, painful, difficult at best, or often impossible.

Differentiating overlapping symptoms of vulvodynia and pudendal neuralgia.

Vulvodynia is defined as a chronic vulvar pain non-associated with infectious, inflammatory, neoplastic or hormonal disorders. To present a case demonstrating the difficulty in assessing concomitant disease in vulvodynia. A 26-year-old woman, presented with persistent vulvodynia. She received oral and topical medications and behavioural interventions to lessen sexual pain and restore sexuality. As sexual pain decreased, the patient reported symptoms previously not mentioned: continuous, intense periclitoral pain and numbness at the perineum when sitting for a long time. These new symptoms suggest the involvement of the peripheral neural system. The physical evaluation confirmed right-side pelvic distortion, and pathological increase in lumbar lordosis, which caused neuralgia radiating to the external genitalia and perineum, and overlapping with sexual pain. After diagnosing pudendal neuralgia according to the Nantes criteria, physical treatment and relaxation exercises to de-contract the spine were added to the vulvodynia regimen. During treatment, vulvodynia was sometimes present but never unbearable, allowing satisfactory sex. With physical therapy, the symptoms of pudendal neuralgia decreased. Differentiating the presence of two conditions with overlapping symptoms is difficult because the vestibular pain had shadowed pudendal neuralgia symptoms at initial assessment. Syndromes of chronic pain tend to associate with each other and one syndrome may shadow symptoms of the concomitant condition affecting adjacent anatomical areas. Only the accurate identification of all the syndromes involved allows adopting the correct treatment.

Antenatal Vulvar Pain Management, Labour Management, and Postpartum Care of Women With Vulvodynia: A Survey of Physicians and Midwives

ObjectiveTo examine maternity providers' recommendations for pregnant women with vulvodynia regarding management of vulvar pain and postpartum care, and to examine if, and how, a woman's chronic vulvar pain affects providers' examination and management during labour. MethodsThis research was part of a larger study that invited physicians and midwives to answer a questionnaire regarding pregnancy and childbirth care in women with vulvodynia. To achieve the current objectives, the questionnaire included both dichotomous (yes or no) and open-ended items. The current sample (n = 116) consisted of 75 physicians and 41 midwives. ResultsOver 60% of the sample reported making recommendations for vulvar pain management during pregnancy, and 32.8% of providers reported making special postpartum care recommendations for women with vulvodynia. Differences between physicians and midwives were noted for some of these recommendations. For example, to manage vulvar pain, only physicians recommended the use of/change in medications (P< 0.001) and only midwives recommended complementary medicines (P = 0.02) and the use of lubricants (P = 0.006) and made recommendations for sexual well-being (P = 0.02). The majority of the sample (75%) reported that a woman having vulvodynia affected labour examination and management; providers most frequently reported minimizing exams and early use of epidural. Over 80% of midwives and 54% of physicians minimized exams during labour for women with vulvodynia (P = 0.01). ConclusionFurther research is needed to understand the optimal provision of care for pregnant and postpartum women with vulvodynia. We advocate for increased education of vulvodynia aimed at providers of antenatal, labour, and postnatal care.

An Online Cross-Sectional Comparison of Women With Symptoms of Persistent Genital Arousal, Painful Persistent Genital Arousal, and Chronic Vulvar Pain

BackgroundPersistent genital arousal disorder (PGAD) is an understudied condition characterized by unwanted physiologic genital arousal in the absence of subjective sexual arousal. Markos and Dinsmore (Int J STD AIDS 2013;24:852–858) theorized that PGAD shares a number of similarities with vulvodynia (unexplained chronic vulvar pain [CVP]), including symptom characteristics and comorbidities. AimTo compare medical histories, symptom characteristics, pain characteristics, and daily functioning among women with persistent genital pain (PGA) (n = 42), painful PGA (n = 37), and CVP (n = 42) symptoms. MethodsAn online cross-sectional survey was conducted from October 2015 through April 2016. OutcomesSelf-report measures of symptoms, diagnosed medical conditions, pain characteristics (McGill Pain Questionnaire), catastrophizing (Pain Catastrophizing Scale), and daily functioning (Functional Status Questionnaire) were collected. ResultsAll 3 groups reported similar medical diagnoses and high frequencies of other chronic pelvic pain conditions. Women in all 3 groups reported comparable ages at symptom onset and timing of symptom expression (ie, constant vs intermittent). Women in the 2 PGA groups reported significantly greater feelings of helplessness than women in the CVP group. Women in the painful PGA and CVP groups endorsed significantly more sensory terms to describe their symptoms compared with women in the PGA group, whereas women in the painful PGA group reported significantly more affective terms to describe their symptoms compared with women in the CVP group. Women in the 2 PGA groups reported that their symptoms interfered significantly with most areas of daily functioning. Clinical ImplicationsGiven the similarities between PGA and CVP symptoms, women with PGA may benefit from similar assessment, treatment, and research approaches. Strengths and LimitationsLimitations of the present study include its sole use of self-report measures; the presence of PGA or CVP symptoms was not confirmed by clinical assessment. However, the anonymous design of the online survey could have resulted in a larger and more diverse sample. ConclusionThe results of this study provide some initial support for the conceptualization of persistent genital arousal as a subtype of genital paresthesias/discomfort. These results also further highlight the negative impact that PGA symptoms have on many domains of daily living and the need for further research on this distressing condition.Jackowich RA, Pink L, Gordon A, et al. An Online Cross-Sectional Comparison of Women With Symptoms of Persistent Genital Arousal, Painful Persistent Genital Arousal, and Chronic Vulvar Pain. J Sex Med 2018;15:558–567.