Vulvar Pain Research Articles

Managing Vulvodynia with Central Sensitization: Challenges and Strategies.

Background: Vulvodynia is defined as a chronic idiopathic vulvar pain condition. This study aimed to investigate the effect of central sensitization on the prognosis of neuromodulator treatment for vulvodynia. Method: A total of 105 patients with vulvodynia who underwent pelvic mapping pain exploration were included and scored according to the Convergence PP Criteria for pelvic pain and central sensitization. The patients were treated according to chronic pelvic pain guidelines, and their response to treatment was evaluated. Results: A total of 35 out 105 patients (33%) with vulvodynia had central sensitization, which was associated with comorbidities, dyspareunia, pain with micturition, and pain with defecation. Dyspareunia and pain with defecation were independent prognostic factors for central sensitization. Patients with central sensitization experienced more pain during intercourse, urination, or defecation, had more comorbidities, and responded worse to treatment. They required more treatment, with a longer response time (over 2 months). Patients with localized vulvodynia were treated with physiotherapy and lidocaine, while patients with generalized vulvodynia were treated with neuromodulators. Amitriptyline was effective in treating patients with generalized spontaneous vulvodynia and dyspareunia. Conclusions: Overall, this study highlights the importance of considering central sensitization in the diagnosis and treatment of vulvodynia and the need for individualized treatment based on the patient's symptoms and underlying mechanisms. Vulvodynia patients with central sensitization had more pain during intercourse, urination, or defecation, and responded worse to treatment, requiring more time and medication.

(085) Topical Capsaicin for Provoked Vestibulodynia

Abstract Introduction Provoked vestibulodynia (PVD), occurs when pain is localized in the vulvar vestibule and triggered by any vestibular contact (sexual or otherwise). PVD is the most common form of vulvodynia and there is currently no approved treatment. Capsaicin cream is hypothesized to improve vestibular allodynia in patients with neuroproliferative PVD by binding to the vanilloid receptor (TRPV1) on the C- afferent nociceptors and thereby causing defunctionalization of the TRPV1. Although capsaicin has been utilized as a treatment for vulvodynia, very little is known about its effectiveness in improving vestibular pain and sexual function. Objective Investigate the therapeutic potential of capsaicin cream as treatment for PVD. Methods Patients who were prescribed 0.025% capsaicin compounded in VersaBase cream were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed with a prescription list from a compounding pharmacy. Adult patients with documented vulvodynia were included. Female Sexual Dysfunction (FSD) was measured before and after treatment with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Results Twenty-five patients responded to the follow-up questionnaire. Average age at presentation was 30 years (range 18-52 years). Self-reported ethnicity of the study population was 76% White, 4% Latina, 4% Asian, 4% Mixed, and 4% Middle Eastern, with no response from 8% of participants. After consistent daily usage, 80% of patients were able to tolerate capsaicin application for the full 20 minutes. Washing the cream off with cold water was helpful for tolerating capsaicin application for 72% of patients, and 8% of patients found applying a topical anesthetic such as lidocaine helpful. The median amount of time required to increase tolerance to the full 20 minutes was 1-2 weeks. On a VAS scale, the mean pain score while initially applying capsaicin was 8.96, and the median was 10. While 48% of patients found capsaicin improved their vulvar pain, 56% of patients would recommend capsaicin as a treatment for vulvar pain. The mean FSDS score was 35.96 at baseline compared to 25.09 at follow-up (p < 0.0001). On a VAS scale, the mean self-reported vulvar pain score was 8.2 at baseline compared to 5.35 when using capsaicin consistently (p < 0.0001). The mean FSFI pain domain score was 0.98 at follow-up compared to 2.45 at baseline (p = 0.005). While not statistically significant, the mean total FSFI score was 15.44 at baseline compared to 17.84 at follow-up. Conclusions Capsaicin cream is a promising treatment for PVD. Among patients who are able to tolerate consistent daily usage, capsaicin cream significantly decreases vulvar pain. Patients should be counseled that topical capsaicin is initially severely painful, even with the use of topical anesthetics such as lidocaine. Emotional distress and trauma were reported among patients who were not able to tolerate capsaicin application. However, patients who were able to tolerate capsaicin reported feeling “grateful” and “satisfied” with the treatment. Capsaicin cream should be considered for patients who have failed more conservative treatments and proper counseling regarding application should be reviewed. Disclosure No

(031) Update from the Female Genitopelvic Pain Subcommittee of the International Consultation of Sexual Medicine on a systematic review of the efficacy and safety of treatments for vulvodynia

Abstract Introduction Literature on vulvodynia treatment is heterogeneous regarding intervention type and study quality. A recently published systematic review (SR) of treatments focusing on randomized controlled trials (RCTs) and non-RCTs for provoked vestibulodynia (a vulvodynia subtype) concluded that most studies had very low certainty of evidence, which limited the ability to draw conclusions. In addition, the authors noted that their strict eligibility criteria resulted in a restricted number of included studies. It suggests a need for broader, more inclusive SRs to be conducted, which could inform much needed intervention recommendations for vulvodynia. Objective The Female Genitopelvic Pain Subcommittee is conducting a SR of treatments for vulvodynia to assess their effectiveness, safety, and acceptability. The results will provide stakeholders with empirically based treatment recommendations for patients with vulvodynia. Methods Selection criteria: Interventions of interest consist of pharmacological, surgical, psychological, physical therapy, and acupuncture treatments of premenopausal women with clinician-diagnosed vulvodynia (primary, secondary), defined as idiopathic, chronic (≥3 months) vulvar pain. Included studies are RCTs, SRs, and comparative observational studies. Primary outcomes are pain and sexuality, safety, and adverse events, with additional outcomes focusing on mood and quality of life. Selection of studies was done in DistillerSR by two independent reviewers. Conflicts were resolved by discussion or by involving a third reviewer, with excluded studies documented. Full-text screening adheres to the same process. Search methods: A comprehensive search strategy was developed by an information specialist and was peer reviewed. Numerous electronic databases were searched from 1997 to present. No language limit was used. Published filters for controlled trials and other study designs were applied. PubMed/MEDLINE was used to develop the search strategy, which was translated into other databases. A limited grey literature search was also conducted. Data collection and analysis: Data extraction and risk of bias assessment (ROB) will be done in DistillerSR using pre-piloted data extraction forms. Studies will be extracted by one reviewer and independently checked by a second reviewer. Disagreements will be resolved by discussion or by involving a third reviewer. We will extract study characteristics and outcome data. For ROB, we will use the Cochrane Risk of Bias tool and the ROBINS-I tool. We will narratively synthesize the results by comparisons and outcomes. If appropriate, we will conduct a meta-analysis for studies regarded as suitably homogeneous. Last, the certainty of the body of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results The search yielded 10,171 references after duplicates were removed for title and abstract screening. Of these, 599 full-text articles were assessed for inclusion. All screening and preliminary data extraction will be completed by October 2022. General characteristics of the included studies, including interventions identified, will be presented. Conclusions We will report on interim progress of the SR. It will be an opportunity to gather initial input from stakeholders on this evidence-based approach. Discussion of possible multi-organization involvement will also help unify intervention recommendations for those with vulvodynia. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Andrew Goldstein – Daré Bioscience (employee), Incyte (consultant), Gynecologic Cancers Research Foundation (Board of Directors, Research Funding).

(081) The Psychosocial Barriers Associated with Vulvodynia and Vestibulodynia

Abstract Introduction At least 8-16% of people with a vulva are affected by generalized vulvodynia and vestibulodynia. These conditions impact interpersonal relationships, individual behaviors, and the psychological health of couples and individuals. Recent reviews suggest there is no comprehensive understanding on how psychosocial factors impact patients with these conditions. Objective The aim of this review is to analyze, evaluate, and synthesize vulvodynia and vestibulodynia research regarding psychosocial barriers present in the literature from 2012-2022 in the United States and Canada. In addition to psychosocial barriers, structural determinants and environmental barriers were included to comprehensively evaluate all aspects. Methods We searched PubMed, CINAHL, Embase, Web of Science, APA PsychInfo, and Academic Search Premier to retrieve eligible journal articles in March of 2022. A search string of key terms and subject headings including Medical Subject Headings were used systematically to search these databases. The reference list was reviewed with an additional reviewer to reduce bias. Results A total of 671 papers were discovered and narrowed down to 74 papers that explored at least one psychosocial barrier for patients or providers in the United States and Canada. The findings of the literature search revealed the various psychosocial barriers that patients commonly face such as pain, anxiety, depression, catastrophization, fear, lack of self-efficacy, low desire and arousal, negative body image, stigma, distress, post-traumatic stress disorder (PTSD), child maltreatment and abuse, mistrust, invalidation and isolation, low levels of self-compassion, negative partner support, low relationship satisfaction, lack of physical affection, emotional regulation, and avoidance and lack of approach goals. In addition to psychosocial barriers, structural determinants, and environmental barriers, such as delayed diagnosis, low health literacy, cost, transportation, and racial disparities also adversely impacted individuals with vulvodynia. Conclusions This review serves to educate and inform providers and physicians of the unique barriers that patients experience when navigating health care services and treatments for vulvodynia and vestibulodynia. More research is needed to understand and better educate patients and providers on vulvar pain conditions to improve outcomes. Disclosure No

(087) Why Should Pelvic Floor Physical Therapy be Included in Treatment of Vestibulodynia?

Abstract Introduction Vestibulodynia, vulvar pain localized to the vestibule without an identifiable cause, has a multifactorial etiology including neurologic, hormonal, inflammatory, psychologic, and musculoskeletal factors. Key pathophysiologic drivers likely vary from patient to patient. Published studies demonstrate that compared to controls, patients with provoked vestibulodynia are more likely to have pelvic floor hypertonicity and decreased pelvic floor strength, as measured by dynamometric speculum and ultrasound. Further, observational studies describe improvement of vestibulodynia symptoms with pelvic floor physical therapy, suggesting a causal relationship between pelvic floor hypertonicity and vestibulodynia. Objective To describe the pathophysiologic mechanism by which pelvic floor dysfunction and myofascial trigger point development could cause vestibuoldynia, with a focus on pelvic floor anatomy. Methods Literature about vestibulodynia, pelvic floor dysfunction, and pelvic floor anatomy was reviewed and synthesized in conjunction with expert clinical experience of pelvic floor physical therapists and gynecologists. Results The pelvic floor consists of the levator ani muscles (iliococcygeus, pubococcygeus, and puborectalis) and ischiococcygeus, which form a basket to support the pelvic organs. The puborectalis inserts in the posterior vestibule, and hypertonicity can cause allodynia in this region. The levator ani are innervated by the levator ani nerve, which originates from S3-S5 and traverses the visceral surface of the muscles. Some cadaveric studies suggest dual innervation of the levator ani by the pudendal nerve, which originates from S2-S4 and courses over the inferior surface of the muscles. Pelvic floor hypertonicity, increased resting tone of the pelvic floor muscles, can result from many factors including stress, bladder and rectum voiding habits, and painful pelvic processes (i.e. interstitial cystitis, endometriosis). Increased muscle tone can promote sensitization of muscle afferent fibers and neuropathic upregulation. This may be perceived as vestibulodynia because the vestibule contains visceral and somatic sensory nerve fibers, whose signals are integrated at the same spinal levels as those from the levator ani. This anatomy allows for somatovisceral convergence of afferent signals, and thus perception of vestibular pain. Hypertonicity of the pelvic floor muscles decreases circulation creating localized hypoxia that can promote development of myofascial trigger points (tender nodules) in the pelvic floor. These trigger points can cause allodynia, perceived in the vestibule. In some cases, vestibulodynia may develop first and promote pelvic floor hypertonicity. Conclusions As pelvic floor hypertonicity can contribute to the pathogenesis of vestibulodynia, it is imperative for clinicians to include pelvic floor tone evaluation in their assessment of vestibulodynia. If pelvic floor hypertonicity is present, it should be treated concurrently with vestibular pain through a combination of pelvic floor physical therapy, trigger point injections, and botulinum toxin injections as pelvic floor hypertonicity and vestibulodynia may each perpetuate the other. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Johnson & Johnson.

(091) Preferred Physical Characteristics of Lidocaine Film for Women with Vestibulodynia

Abstract Introduction Vestibulodynia (VBD) is the most common cause of sexual pain in the United States, affecting up to 28% of reproductive-aged women during their lifetime. First-line treatment for VBD includes topical lidocaine therapy prior to vulvovaginal manipulation (tampon use, intercourse, tight clothing) to reduce symptoms. Limitations of topical therapy include messy application, inability to apply to the affected area, and transfer of drugs affecting the sexual partner. The purpose of this study was to describe the physical characteristics of a vulvar film designed for insertional sexual pain in women with VBD to optimize the device design. Objective This study explored individuals’ preferred physical characteristics of lidocaine film for women with Vestibulodynia. Methods Participants completed a blend of demographic and sexual history questionnaires followed by focus group discussions. Participants were eligible if they were 1) heterosexual female, 2) aged 18 to 51 years, 3) able and willing to provide written informed consent 4) have vulvodynia, vestibulodynia, or dyspareunia. Women who reported no episodes or attempts of vaginal intercourse in the prior 18 months were excluded. A total of six semi-structured 60-minute focus group discussions with 3-4 participants each, were audio-recorded, transcribed verbatim, and coded for content. All focus groups had participants of varying socioeconomic status, marital status, age, and racial/ethnic background. Women visually examined a new film technology designed for application to the vulvar vestibule prior to penetration. The device is a U-shaped, thin, and flexible short-acting lidocaine 5% film. The strip is clear, smooth, and has a nonslip texture. To apply the film, an easy-to-remove backing is peeled and applied to the vestibule for 5 minutes. After 5 minutes, lidocaine drug delivery into the vulvar tissue is complete and film is removed, preventing drug release onto partner during intercourse like current topical lidocaine therapy. This study was approved by the University of North Carolina Institutional Review Board. Results Twenty women participated in the focus group portion of the study. Across all groups, the mean age for the participants was 33.3 years, most women were educated with at least some college (93%), white (78.6%), married (75%), and had income greater than $100,000 (50%). Across all groups, 75% of women were interested in trying the commercial device. A major common physical theme that emerged across all groups was the desire for ease and accuracy of use, with an interest in multiple sizes or custom sizes. One group of women desired an additional wing-like vaginal flap to deliver lidocaine beyond the hymenal ring and one group of women desired round/oval shape to reach the upper vestibule. Across all groups, women were interested in the film being loaded with other acceptable medications or in combination with lidocaine. Conclusions Additional research and provider education efforts are needed to better communicate about and treat vulvodynia symptoms provoked by penetrative intercourse. Efforts to support and connect patients with symptoms should be considered. Vulvar films may be an acceptable treatment for vulvar pain provoked by penetrative intercourse. Disclosure No

(188) The Female Genitopelvic Pain Subcommittee of the International Consultation of Sexual Medicine: Update on a systematic review of the efficacy and safety of pharmacological, surgical, psychological, and physical therapy treatments for vulvodynia

Abstract Introduction Literature on vulvodynia treatment is heterogeneous in terms of intervention type and study quality. A recently published systematic review (SR) of treatments focusing on randomized controlled trials (RCTs) and non-RCTs for provoked vestibulodynia (a vulvodynia subtype) concluded that most studies had very low certainty of evidence, which limited the ability to draw conclusions. The authors noted that their strict eligibility criteria resulted in a restricted number of included studies. It suggests a need for broader, more inclusive SRs to be conducted, the results of which could inform much needed intervention recommendations for vulvodynia. Objective The Female Genitopelvic Pain Subcommittee is conducting a SR of treatments for vulvodynia to assess their effectiveness, safety, and acceptability. The results will provide stakeholders with empirically based treatment recommendations for patients with vulvodynia. Methods Selection criteria: Interventions of interest include pharmacological, surgical, psychological, and physical therapy treatments of premenopausal women with clinician-diagnosed vulvodynia (primary, secondary), defined as idiopathic, chronic (≥3 months) vulvar pain. Included studies are RCTs, SRs, and comparative observational studies. The primary outcomes are pain and sexual outcomes, and safety and adverse events, with additional outcomes focusing on mood and quality of life. Selection of studies was done in DistillerSR by two independent reviewers. Conflicts were resolved by discussion or by involving a third reviewer with excluded studies documented. Full-text screening is adhering to this same process. Search methods: A comprehensive search strategy was developed by an information specialist and was peer reviewed. Numerous electronic databases were searched. No language limit was used, and a date limit was set (1997 or later). Published filters for controlled trials and other study designs were applied. PubMed/MEDLINE was used to develop the search strategy, which was then translated into other databases. A limited grey literature search was also conducted. Data collection and analysis: Data extraction and risk of bias assessment (ROB) will be done in DistillerSR using pre-piloted data extraction forms. Studies will be extracted by one reviewer and independently checked by a second reviewer. Disagreements will be resolved by discussion or by involving a third reviewer. We will extract study characteristics and outcome data. For ROB, we will use the Cochrane Risk of Bias tool and the ROBINS-I tool. We will narratively synthesize the results by comparisons and outcomes. If appropriate, we will conduct a meta-analysis for studies regarded as suitably homogeneous. Last, the certainty of the body of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Results After duplicates were removed, the search yielded 10,171 references for title and abstract screening. Of these, 599 full-text articles were assessed for inclusion. All screening and preliminary data extraction will be completed by October 2022. General characteristics of the included studies including interventions identified will be presented. Conclusions We will report on interim progress of the SR. It will be an opportunity to gather initial input from stakeholders on this evidence-based approach. Discussion of possible multi-organization involvement will also help unify intervention recommendations for those with vulvodynia. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Andrew Goldstein – Daré Bioscience (employee), Incyte (consultant), Gynecologic Cancers Research Foundation (Board of Directors, Research Funding).

(135) Keratin Pearl Excision for Clitorodynia and Female Sexual Dysfunction

Abstract Introduction Clitoral adhesions occur when the clitoral prepuce adheres to the glans clitoris. This can cause accumulation of desquamated epithelial cells under the prepuce, resulting in the formation of smegmatic pseudocysts and keratin pearls. A keratin pearl is a focus of central keratinization within concentric layers of squamous cells. Presence of these firm, millimeter-sized masses can lead to clitoral irritation and hypersensitivity (similar to a grain of sand in the eye). Although keratin pearls have been described in the literature, there is little known about their clinical presentation or association with female sexual dysfunction (FSD). Objective Investigate the effectiveness of keratin pearl excision as a treatment for clitoral pain and female sexual dysfunction. Methods A retrospective chart review was conducted in two metropolitan gynecology clinics specializing in vulvar pain between January 2017 and December 2021. Patients presenting with clitoral pain (clitorodynia) were identified in the electronic medical record through a search of physician-entered diagnoses and confirmed via review of the clinical notes. Adult patients with documented clitoral pain as well as clitoral adhesions (clitoral phimosis) and keratin pearls noted on exam were included in the study. Female Sexual Dysfunction (FSD) was measured with the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R). Prospective data was collected via an electronic follow-up survey. Data were presented in means and percentages. Results Fifty-eight patients met inclusion criteria. Average age at presentation was 35 years (range 19-73 years). Self-reported ethnicity of the study population was 81% White, 7% Hispanic, 5% Asian, 2% Black, with no response from 5% of participants. Preliminary results show that patients reported a 66% decrease in mean clitoral discomfort (p < 0.0001) and a 52% reduction in mean difficulty with orgasm (p = 0.019) after excision of keratin pearls. Patients who completed the follow-up questionnaire (n = 18) had a mean FSFI total score of 18.3 compared to mean total baseline FSFI of 13.11 (p = 0.03). The mean FSFI score for pain was 2.85 at follow up compared to 1.52 at baseline (p = 0.01). The mean FSFI score for orgasm was 3.36 at follow up compared to 2.16 at baseline (p = 0.03). Although not statistically significant, most likely because of a small sample size, the mean FSFI score was higher at follow-up than at baseline for lubrication (45%), arousal (42%), satisfaction (19%), and desire (17%). Patients had no change in mean FSD-R score from baseline to follow up. Conclusions Clitorodynia associated with clitoral adhesions and keratin pearls occurs in women of all ages. Excising keratin pearls may reduce female sexual dysfunction. These preliminary results suggest that excising keratin pearls may improve clitoral discomfort and reduce difficulty with orgasm. Excising keratin pearls may also lead to an improvement in overall female sexual function. Disclosure No

Nocturnal Vulval Pain in Girls-A Subset of Vulvodynia?

The aims of the authors' case series were to outline the clinical features of prepubertal nocturnal vulval pain syndrome and to look at management and outcomes. Clinical details of prepubertal girls experiencing episodes of nocturnal vulval pain with no identifiable cause were recorded and analyzed. Parents completed a questionnaire to look at outcomes. Eight girls with age at onset of symptoms between 3.5 and 8 years (mean 4.4 years) were included. Each patient described intermittent episodes of vulval pain lasting between 20 minutes and 5 hours, starting 1-4 hours after falling asleep. They were crying and rubbing or holding the vulva with no obvious cause seen. Many were not fully awake and 75% had no recollection of the events. Management focused on reassurance alone. The questionnaire showed that 83% had full resolution of symptoms with a mean duration of 5.7 years. Prepubertal nocturnal vulval pain syndrome may be a subset of vulvodynia (generalized, spontaneous, intermittent) to be included in the clinical spectrum of night terrors. Recognizing the clinical key features should aid prompt diagnosis and reassurance of the parents.

Vulvodynia: A practical guide in treatment strategies.

Vulvodynia is a debilitating condition characterized by chronic vulvar pain, with a detrimental impact on the patient's overall quality of life. Its etiology is multifactorial, but still in the process of being clearly outlined. Vulvodynia is not a single entity. It is a heterogeneous condition characterized by multiple triggers, making it challenging to define a reference standard for its treatment. In this manuscript we selected all articles including the following key criteria: "vulvodynia". The primary outcomes observed included the resolution of chronic pelvic pain, dyspareunia and sexual satisfaction, psychological well-being, and overall quality of life. Most pharmacologic treatments require further evidence to be recommended. On the other hand, non-pharmacologic approaches such as psychotherapy, physical therapy, and surgery have received stronger support. This review summarizes pros and cons of adopting available treatments. Multimodal approaches should be introduced to improve patient outcomes. Further investigations are warranted to improve patients' quality of life.

Efficacy of Two Laser Treatment Strategies for Breast Cancer Survivors With Genitourinary Syndrome of Menopause.

Background A typical symptom of patients with genitourinary syndrome of menopause (GSM) is dyspareunia. Dyspareunia has been thought to be caused by vaginal dryness. In recent years, a survey of breast cancer survivors (BCS) with GSM has shown that para-hymen is the most painful. Dyspareunia and superficial vulvar pain (vulvodynia) may be closely linked. A recent study showed that vulvodynia is very common in BCS. Therefore, we believe treatment targeting the vagina and the vulva is necessary for pain in BCS with GSM. We hypothesized that treating both the vagina and the vulva would solve the problem of BCS with GSM. We compared the vaginal erbium SMOOTH mode laser (VEL) and neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser (VEL+Nd:YAG) combination treatment over time. This study explores therapeutic targets for pain in BCS with GSM. Methodology This retrospective, case-control study targeted sexually active BCS who reported GSM with vulvodynia and dyspareunia. After all women enrolled in the VEL treatment group had completed treatment, we treated women enrolled in the VEL+Nd:YAG treatment group. A total of 256 women who received either VEL+Nd:YAG or VEL were enrolled. Propensity score (PS)-matching analysis was used to compare two-year postoperative data retrospectively. The PS-matching results registered 102 patients in the VEL+Nd:YAG group and 102 patients in the VEL group. Symptoms were assessed using the visual analog scale (VAS) for vulvodynia before and after laser treatment for one, three, six, 12, and 24 months after completion. As a preliminary study, the vulvodynia swab test confirmed the causative location of dyspareunia. Moreover, the Female Sexual Function Index (FSFI) and Vaginal Health Index Score (VHIS) were assessed. FSFI and VHIS were treated as supplement research because the conditions were unmet. Results In the vulvodynia swab test, dyspareunia, and para-hymen (especially at 4 o'clock and 9 o'clock), all felt pain, and only a few felt pain in the vagina and labia. FSFI improved significantly in the VEL+Nd:YAG group and persisted for two years. VHIS improved equally in both groups and was not significantly different. After the first laser application, the VEL+Nd:YAG and the VEL groups showed sustained efficacy and safety in vulvodynia. Baseline VAS scores (8.74 ± 0.72 vs. 8.79 ± 0.74; p = 0.564) were similar in both groups. Both groups had a significant (p < 0.001) decrease in the VAS score. The VAS values in the VEL+Nd:YAG group and the VEL group decreased from the pretreatment to 3.79 ± 0.63 (p < 0.001 vs. baseline) and 5.56 ± 0.89 (p < 0.001 vs. baseline) after the third treatments, respectively. After 24 months, the VAS value in the VEL+Nd:YAG group and the VEL group was at 4.43 ± 1.38 (p < 0.001 vs. baseline) and 5.56 ± 0.89 (p < 0.001 vs. baseline), respectively. The side effects in both groups were short-term and minor. Conclusions Both VEL+NdYAG and VEL effectively and safely treat GSM dyspareunia and vulvodynia in BCS. Comparing the two groups, we confirmed that VEL+Nd:YAG treatment of the vaginal vestibule and vaginal opening reduced superficial vulvar pain more effectively, extensively, and over a longer period than VEL. The results of the vulvodynia swab test, FSFI, and VHIS suggest that the vulva and the vagina are important therapeutic targets for pain in BCS with GSM. The importance of treating the vulvar area for superficial pain and dyspareunia in GSM has been emphasized.

Everything I wish I had learned during residency about the vulva

To identify areas of improvement and assess current residency education in the field of vulvovaginal conditions including, vulvar pain, vulvovaginal infections, and vulvar dermatoses.

PD14-01 FRACTIONAL CARBON DIOXIDE VAGINAL LASER FOR THE TREATMENT OF URINARY SYMPTOMS: 24 MONTHS RESULTS

You have accessJournal of UrologyCME1 Apr 2023PD14-01 FRACTIONAL CARBON DIOXIDE VAGINAL LASER FOR THE TREATMENT OF URINARY SYMPTOMS: 24 MONTHS RESULTS Nataljia Kovacevic, Bernadette Zwaans, Royal Oak, Mi, Ly Hoang Roberts, Evelyn Shea, Lisa Vergos, Danielle Tenney, Larry Sirls, Priya Padmanabhan, and Kenneth Peters Nataljia KovacevicNataljia Kovacevic More articles by this author , Bernadette ZwaansBernadette Zwaans More articles by this author , Royal OakRoyal Oak More articles by this author , Mi Mi More articles by this author , Ly Hoang RobertsLy Hoang Roberts More articles by this author , Evelyn SheaEvelyn Shea More articles by this author , Lisa VergosLisa Vergos More articles by this author , Danielle TenneyDanielle Tenney More articles by this author , Larry SirlsLarry Sirls More articles by this author , Priya PadmanabhanPriya Padmanabhan More articles by this author , and Kenneth PetersKenneth Peters More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003261.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Fractional carbon dioxide laser (fCO2) has been proposed to treat frequency, urgency, urge urinary incontinence (UUI), and stress urinary incontinence (SUI) in genitourinary symptoms of menopause (GSM). The laser’s thermal effects help collagen remodeling, thereby improving vaginal tissue integrity and urethral support. Our aim was to prospectively measure the effect of vaginal fCO2 laser therapy on SUI and overactive bladder (OAB) symptoms at 24 months. METHODS: Women over 18 years with urogenital symptoms were enrolled in an open-label prospective trial. Participants underwent 3 laser treatments, each 6 weeks apart. Patients were required to be off vaginal estrogen for 3 months prior to receiving any treatments. Patients were offered additional annual treatment sessions. Follow up consisted of 6, 12-, 18-, and 24-month visits during which various questionnaires were administered including the Incontinence-Quality of Life (I-QOL), Overactive Bladder Questionnaire short form (OABq-SF), and Questionnaire for Urinary Incontinence Diagnosis (QUID). A voiding diary was collected at baseline, 6-, 12-, and 24- month visits. ANOVA analysis was used to compare means at each time point. RESULTS: 100 patients were enrolled at time of analysis. Baseline urinary symptoms consisted of 44.8% of patients with SUI, 57.1% with UUI, and 75.4% with frequency. Significant reduction in SUI episodes was observed at 6, and 24 months (p=0.0135; Figure 1), and participants noted improvement on QUID-SUI at 6, 12, and 24 months (p<0.0001). Number of urge leaks did not significantly improve on voiding diary (=0.0512), but significant subjective improvement was noted for OAB/UUI based on QUID-UUI and OABq-SF symptom scores at each time point (p<0.0001; Figure 1). Mean Patient Global Impression of Improvement scores improved at each treatment and follow up visit, with 46.4% reporting significant symptom improvement by 24 months. Participants had improvement between baseline and 24 months in vulvar dryness (50.9% vs 25%) and vulvar pain (48% vs 13%). CONCLUSIONS: This represents the longest prospective follow-up of laser effects on GSM associated urinary symptoms. Significant subjective improvement was noted for SUI and OAB/UUI up to 24 months after treatment. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e412 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nataljia Kovacevic More articles by this author Bernadette Zwaans More articles by this author Royal Oak More articles by this author Mi More articles by this author Ly Hoang Roberts More articles by this author Evelyn Shea More articles by this author Lisa Vergos More articles by this author Danielle Tenney More articles by this author Larry Sirls More articles by this author Priya Padmanabhan More articles by this author Kenneth Peters More articles by this author Expand All Advertisement PDF downloadLoading ...

Clinical progress note: Evaluation and management of neonatal herpes simplex virus disease.

Clinical progress note: Evaluation and management of neonatal herpes simplex virus disease.

The Association Between Immune-Related Conditions Across the Life-Course and Provoked Vulvodynia

Vulvodynia, impacts up to 8% of women by age 40, and is hypothesized to manifest through an altered immune-inflammatory response. To test this hypothesis, we identified all women born in Sweden between 1973 and 1996 diagnosed with localized provoked vulvodynia (N76.3) and/or vaginismus (N94.2 or F52.5) between 2001 and 2018. We matched each case to two women from the same birth year with no vulvar pain ICD codes. As a proxy for immune dysfunction, we used Swedish Registry data to capture 1) immunodeficiencies, 2) single organ and multiorgan autoimmune conditions, 3) allergy and atopies, and 4) malignancies involving immune cells across the life course. Women with vulvodynia, vaginismus or both were more likely to experience immune deficiencies (OR 1.8, 95% CI, 1.2–2.8), single organ (OR 1.4, 95% CI, 1.2–1.6) and/or multi-organ (OR 1.6, 95% CI, 1.3–1.9) immune disorders, and allergy/atopy conditions (OR 1.7, 95% CI, 1.6–1.8) compared to controls. We observed greater risk with increasing numbers of unique immune related conditions (1 code: OR = 1.6, 95% CI, 1.5–1.7; 2 codes: OR = 2.4, 95% CI, 2.1–2.9; 3 or more codes: OR = 2.9, 1.6–5.4). These findings suggest that women with vulvodynia may have a more compromised immune system either at birth or at points across the life course than women with no vulvar pain history. PerspectiveWomen with vulvodynia are substantially more likely to experience a spectrum of immune related conditions across the life course. These findings lend support to the hypothesis that chronic inflammation initiates the hyperinnervation that causes the debilitating pain in women with vulvodynia.

Current Practices in Brazil on Diagnosis and Management of Women With Vulvodynia.

Vulvodynia (VVD) is a frequent and harrowing condition for which diagnosis and management remain insufficient. Our study aimed to describe and compare vulvovaginal signs and symptoms of Brazilian women with VVD and controls and describe previous medical assessment, past treatments, and vulvar pain relief among women with VVD. This cross-sectional descriptive study included Brazilian women with (n = 151) and without VVD (n = 106). All women were assessed for vaginal infection, vulvar pain intensity by means of a cotton swab test based on a numerical rate scale, and answered the Female Sexual Function Index questionnaire and a structured instrument about current vulvar symptoms. Previous treatments were assessed in the VVD group, and vulvar pain relief achieved with previous treatments was qualified through a 4-point Likert scale. Volunteers were mainly White, with mean age of 30 years. Vulvovaginal signs and symptoms were significantly more frequent in women with VVD (p < .05), and vulvar pain duration was 5.8 (±4) years. More than 50% consulted with three or more physicians, and 49% remained without a conclusive diagnosis. Previous diagnosis and treatment of vulvovaginal infection were often reported by women with VVD. Most of the tried prescriptions were self-reported as providing only low vulvar pain relief. Prolonged duration of vulvar pain, multiple visits to health care professionals, and poor relief of pain are common aspects in the clinical history of women with VVD. In addition to pain, vulvar fissure, edema, erythema, vaginal discharge, and foul odor are common and should be considered to avoid misdiagnosis. Appropriate treatments to VVD are still poorly reported.

Cross-cultural Adaptation and Validation of the Hebrew Version of the Vulvar Functional Status Questionnaire (VQ)

Background: As yet, no Hebrew language vulvar functional status questionnaire exists. Aims: To perform a cross-cultural adaptation of a Hebrew version of the Vulvar Functional Status Questionnaire (VQ), a validated tool used for evaluating dyspareunia among women, and to evaluate the psychometric properties of this version by examining the correlations between results of the questionnaire among women with pain during intercourse and quality of life, level of anxiety, and pelvic floor function. Methods: The English version of the VQ underwent cross-cultural adaptation to Hebrew according to accepted guidelines. Eighty Hebrew-speaking women with vulvar pain, aged older than 18 years, participated in the study. Participants completed the VQ-Hebrew (VQ-H) (see Supplemental Digital Content, available at: https://links.lww.com/JWHPT/A89), the Hebrew versions of the health-related quality-of-life questionnaire (SF-12), the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), and the State-Trait Anxiety Inventory (STAI). All the participants completed the VQ-H again after 2 to 3 weeks. Psychometric properties (test-retest reliability, internal consistency, convergent validity, and factor analysis) were calculated. Results: The VQ-H demonstrated excellent test-retest reliability: intraclass correlation coefficients ranged from 0.898 to 0.958 (P < .001); the Cronbach α was excellent (0.935). A significant correlation was found between the VQ-H and SF-12 scores (r =−0.360, P = .001). However, the correlation between the VQ-H and STAI and PISQ-12 scores was not statistically significant (r = 0.172, P = .127 and r =−0.185, P = .100, respectively). Factor analysis revealed a 4-factor solution representing daily function and pain provoked by or related to various activities. Conclusion: The VQ-H is a valid and reliable instrument. Its scores reflect the impaired function in all domains of vulvar pain among Hebrew-speaking women.

Validation of a clinical tool for vestibular trophism in postmenopausal women

Objective This study aimed to develop and validate a clinical tool to assess vestibular trophism in women with genitourinary syndrome of menopause (GSM). Methods In this cross-sectional study, the principal investigator’s center and three external reviewers assessed the vestibular images of postmenopausal women using a multi-item tool defined as vestibular trophic health (VeTH), which assessed five criteria: petechiae, pallor, thinning, dryness and redness. Dryness, dyspareunia, vulvar pain and the Vaginal Health Index (VHI) were also evaluated. Results Analysis of the intraclass correlation coefficient (0.76; confidence interval 0.62–0.82) and Cronbach’s alpha coefficient (0.78; confidence interval 0.64) indicated an inter-rater reliability and reproducibility of VeTH in the 70 women enrolled in the study. The observed covariance between a high VeTH score and the symptom severity demonstrated a significant correlation, which was not evident between VeTH and the total VHI score. Conclusions The vulvar vestibule is the main location of genital tenderness, primarily responsible for burning/pain and entry dyspareunia because of its capacity to develop an excess of nociceptors upon sexual hormone deprivation. Our study indicated that VeTH can be a reproducible tool for the morphological classification of vestibular trophism and bears a significant correlation with the severity of the symptoms.

Chronic Vulvar Pain and Health-Related Quality of Life in Women with Vulvodynia.

The aim of this study was to investigate the severity of chronic vulvar pain in women with vulvodynia and its impact on their health-related quality of life (QL). The study group consisted of 76 women aged 19 to 58. The study was carried out using the diagnostic survey method, i.e., (1) the questionnaire technique, comprising (A) the author's questionnaire (76 questions) and (B) the WHOQOL-BREF questionnaire, and (2) the VAS. When analyzing the severity of vulvar pain on the VAS, the highest proportion of women rated it at level 6 (23.68%). This was significantly determined by certain personal characteristics (age < 25 years old) and sociodemographic characteristics (marital status: unmarried women, divorcees, widows; high school education), each at p < 0.05. Vulvodynia causes a significant deterioration (64.47%) in QL, which is mainly caused by a reduction in the ability to perform activities of daily living (27.63%) and a decrease in sexual satisfaction (27.63%). The level of stress significantly exacerbates pain (p < 0.05). The severity correlates significantly (p < 0.05) and negatively (r < 0) with QL perception, which was rated worst in the physical domain. The use of treatment resulted in a significant improvement in the physical and psychological domains (p < 0.05), and the latter was particularly influenced by physiotherapy (p < 0.05).

Towards improved sexual health among women with provoked vestibulodynia: experiences from a somatocognitive therapy approach

Purpose Provoked vestibulodynia (PVD) is a common reason for sexual pain in young women. Furthermore, this persistent vulvar pain condition can have a significant negative impact on an individual’s sexual health and well-being. As knowledge about effective treatments is limited, the aim of this study was to gain insight into meaningful processes towards improved sexual health, supported by a multimodal physiotherapy intervention. Methods Through individual semi-structured interviews, this longitudinal, qualitative study explored the experiences of ten young women with PVD who took part in a somatocognitive therapy program. Participants were interviewed towards the end of their therapy period, and again one year later, to develop insight into therapeutic processes unfolding over time. Results Through analysis we identified the following themes: (1) Developing positive feelings of embodiment, (2) Developing a greater awareness of internal feelings and bodily states, and (3) Developing sex-positive beliefs and behaviours. Conclusion The findings show how individually tailored physiotherapy emphasising embodiment and sexual health can promote meaningful processes towards improved sexual health for women living with PVD.