Chronic pelvic pain.

Chronic pelvic pain is pain lasting longer than 6 months and is estimated to occur in 15% of women. Causes of pelvic pain include disorders of gynecologic, urologic, gastroenterologic, and musculoskeletal systems. The multidisciplinary nature of chronic pelvic pain may complicate diagnosis and treatment. Treatments vary by cause but may include medicinal, neuroablative, and surgical treatments.

Long-term well-being after surgical or conservative treatment of severe vulvar vestibulitis.

OBJECTIVE: To compare long-term well-being of women who needed surgery or did not need surgery in the treatment of severe vulvar vestibulitis syndrome. We also attempted to identify factors explaining differences in the treatment response. DESIGN: An observational case-control study. SETTING: University Hospital Vulva clinic. POPULATION: Sixty-six women diagnosed with severe vulvar vestibulitis and treated initially by conservative management during 1994-2005. Thirty-nine women did not respond and underwent posterior vestibulectomy and 27 were managed without surgery. METHODS: Baseline patient characteristics, degree of dyspareunia, and details of management were collected from hospital charts. At the follow-up visit current dyspareunia, sexual well-being, somatic and mental health, and social support were analyzed. Vestibular tenderness was measured by swab-touch test. MAIN OUTCOME MEASURES: Visual analogue scale for dyspareunia, sexual well-being, vestibular tenderness, and overall patient satisfaction at follow-up. RESULTS: Dyspareunia decreased significantly in both groups. The visual analogue scale decreased 66.7% in the surgery group and 78.1% in the conservative treatment group (p= 0.407). Posterior swab-touch test was negative more frequently after vestibulectomy. Long-term sexual well-being did not differ between the two groups. Overall, 89% of the women in both groups were satisfied with the treatment. Women with atopic skin problems were less likely to need surgery (odds ratio 0.2; 95% confidence interval 0.1-0.7). CONCLUSION: Women with severe vulvar vestibulitis syndrome who do not respond to conservative management achieve good long-term well-being and decrease of dyspareunia by posterior vestibulectomy. The response is comparable to that achieved by conservative management among women who do not need surgery.

Vulvodínia: diagnóstico, classificação e tratamento / Vulvodynia: diagnosis, classification and treatment

Vulvodínia é um desconforto vulgar crônico caracterizado pela queixa de ardência, prurido ou irritação, na ausência de achados específicos. O diagnóstico deve ser firmado por anamnese detalhada, ausência de causas infecciosas ou dermatológicas documentadas, e presença de dor em resposta a uma suave pressão sobre os lábios vaginais, intróito ou remanescentes himenais. Na anamnese, a dor relatada geralmente está presente durante e após a relação sexual. Outros fatores também podem estar envolvidos com o inicio do sintoma. Pressupostos afirmando que esta síndrome seria apenas um distúrbio psicológico estão sendo abandonados, pois mecanismos inflamatórios e fatores genéticos foram encontrados na patogênese da doença, alem dos fatores psicossexuais. Várias opções de tratamento têm sido utilizadas, embora as evidências para muitas destas terapias estejam incompletas. Pesquisas estão sendo realizadas no mundo todo com o objetivo de encontrar causas mais específicas e inequívocas desta patologia, bem como, para desenvolver métodos de tratamento baseados em evidenciais.

Sacral neuromodulation in the treatment of vulvar vestibulitis syndrome.

BACKGROUND: Vulvar vestibular syndrome is a chronic pain syndrome that typically results in pain and irritation of the vulvar vestibule and has few effective options for treatment. CASE: A 42-year-old woman presented with symptoms consistent with chronic vulvar vestibular syndrome that was refractory to multiple attempted therapies. The patient was offered sacral neuromodulation for treatment. She underwent a standard two-phase surgical implantation with good result at 2 years postimplantation. CONCLUSION: Sacral neuromodulation was shown to be a valid treatment option for this patient and resulted in excellent patient satisfaction at 2-year follow-up. Although the exact mechanism of action is unknown, sacral neuromodulation may be a viable option for the management of chronic pain syndromes of the vulva and vagina.

Understanding women's sexual health: a case-based approach.

Female sexual dysfunction is complex and its management challenging. In this review, we discuss female sexual response and the definitions of female sexual disorders. Evidence-based strategies for the evaluation and multidisciplinary treatment of female sexual dysfunction are presented in a case-oriented manner applicable to everyday clinical practice.

[Use of transcutaneous electrical stimulation and biofeedback for the treatment of vulvodynia (vulvar vestibular syndrome): result of 3 years of experience]. / Utilizzo dell'elettro-analgesia transcutanea e del biofeedback nel trattamento della vulvodinia: risultati di 3 anni di esperienza.

AIM: The safety, tolerability and efficacy of physical therapy with biofeedback and trans electrical nerve stimulation (TENS) with intravaginal probe for the treatment of vulvar pain and vulvar discomfort in women with vulvodynia, is evalued in the present study. Vulvodinia is a cronic syndrome of unexplained vulvar pain. Patients typically present with a history of intermittent or continuous, localized, vulvar pain, frequently accompanied by sexual dysfunction like entry dispareunia, burning and hiching localized to the vulvar vestibule. METHODS: From January 2005 and June 2007, a total 145 women diagnosed with vulvodynia presented in the ambulatory for the Diagnosis and Treatment of Vulvar Pain and Pelvic Floor Dysfunction, Clinical ''Santa Famiglia'', Rome. Patients were treated with weekly biofeedback (BFB) and transcutaneous electroanalgesia (TENS), in association with functional electrical stimulation (FES) and home-therapy with stretching exercise of pelvic floor. RESULTS: Hundred forty-five women completed both the biofeedback and trans electric nerve stimulation treatment for a total of 10 application, with a improvement of vulvar pain in 75.8% of cases. CONCLUSION: The pelvic floor relaxation with biofeedback and ellectroanalgesia is safe and effective in improvement in vulvar pain and dyspareunia in women with vulvodynia.

Transcutaneous electrical nerve stimulation to treat vestibulodynia: a randomised controlled trial.

OBJECTIVE: To assess the efficacy of transcutaneous electrical nerve stimulation (TENS) in the treatment of vestibulodynia. DESIGN: Double-arm randomised placebo-controlled trial. SETTING: An outpatient department for vulval disease. POPULATION: Forty women with vestibulodynia, a vestibular discomfort mostly reported as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder. METHODS: Twice a week active TENS or sham treatment were delivered through a vaginal probe via a calibrated dual channel YSY-EST device. Women of both groups underwent 20 treatment sessions. MAIN OUTCOME MEASURES: Visual analogue scale (VAS), the short form of the McGill-Melzack Pain Questionnaire (SF-MPQ), the Marinoff Scale for dyspareunia and the Female Sexual Function Index questionnaire (FSFI) were assessed at baseline, at the end of treatment and at follow up 3 months after the end of treatment. RESULTS: The VAS and SF-MPQ scores (6.2 +/- 1.9 and 19.5 +/- 11.9 before treatment, respectively) improved significantly in the active TENS group (2.1 +/- 2.7, P= 0.004 and 8.5 +/- 10.7, P= 0.001, respectively), but not in the placebo group. The Marinoff dyspareunia scale and the FSFI also showed a significant improvement. CONCLUSIONS: TENS is a simple, effective and safe short-term (3 months) treatment for the management of vestibulodynia.

Male partners of women with provoked vestibulodynia: attributions for pain and their implications for dyadic adjustment, sexual satisfaction, and psychological distress.

INTRODUCTION: Provoked vestibulodynia is a female genital pain condition that results in sexual dysfunction and impacts negatively on the couple. Although patients' causal attributions have been linked to worse psychosexual outcomes, no study has documented the male partners' perspective of this distressing problem and its potential influence on their psychosexual adaptation. AIM: To identify whether male partners' attributions for vestibulodynia are possible predictors of their dyadic adjustment, sexual functioning, sexual satisfaction, and psychological distress, as well as of women's pain and sexual functioning. METHODS: Thirty-eight women with vestibulodynia first completed measures of pain intensity and sexual functioning. Male partners responded to mailed questionnaires assessing their own attributions for genital pain as well as their psychological distress, relationship adjustment, sexual functioning, and sexual satisfaction. MAIN OUTCOME MEASURES: Women completed the McGill-Melzack Pain Questionnaire (MPQ) and the Female Sexual Function Index (FSFI). Attributions of male partners were measured using an adapted version of the Attributional Style Questionnaire (ASQ)-Partner Version. Men also filled out the Brief Symptom Inventory (BSI), the Dyadic Adjustment Scale (DAS), the Sexual History Form (SHF), and the Global Measure of Sexual Satisfaction (GMSEX). RESULTS: All four negative attribution dimensions and higher levels of women's pain intensity successfully predicted increased psychological distress in male partners. Higher levels of both internal and global attributions were associated with men's poorer dyadic adjustment, whereas global and stable attributions were related to their lower sexual satisfaction. Attributions failed to significantly predict sexual functioning in male partners and women's pain and sexual functioning. CONCLUSIONS: Evaluation and treatment of sexual pain problems should involve both partners and should explore the role of negative attributions.

The use of amielle vaginal trainers as adjuvant in the treatment of vestibulodynia: an observational multicentric study.

OBJECTIVE: To assess the effectiveness of a specific set of vaginal dilators (Amielle Comfort) as a part of vestibulodynia therapy. STUDY DESIGN: Fifteen women referred for vestibulodynia, localized vulvodynia, were advised to use vaginal dilators (Amielle Comfort) accompanied by standardized instructions, after previously receiving 1 or more therapies for the vestibulodynia. RESULTS: The post-treatment Marinoff scale for dyspareunia significantly improved in patients after vaginal dilator treatment compared with baseline values (2.2 +/- 0.4 vs 1.1 +/- 0.9; P < .01), and the Female Sexual Function Index scores were significantly improved compared with the prestudy values (16.3 +/- 5.5 vs 25.3 +/- 7.5; P < .01). CONCLUSION: Among women with previous therapy for vestibulodynia, vaginal dilator use was associated with improvement in symptoms. Vaginal dilators can play an important role in overcoming pelvic floor muscular responses that remain and sometimes increase after pain perception has decreased.

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

OBJECTIVE: To estimate whether treatment gains for provoked vestibulodynia participants randomly assigned to vestibulectomy, biofeedback, and cognitive-behavioral therapy in a previous study would be maintained from the last assessment-a 6-month follow-up-to the present 2.5-year follow-up. Although all three treatments yielded significant improvements at 6-month follow-up, vestibulectomy resulted in approximately twice the pain reduction as compared with the two other treatments. A second goal of the present study was to identify predictors of outcome. METHODS: In a university hospital, 51 of the 78 women from the original study were reassessed 2.5 years after the end of their treatment. They completed 1) a gynecologic examination involving the cotton-swab test, 2) a structured interview, and 3) validated pain and sexual functioning measures. RESULTS: Results from the multivariate analysis of variance conducted on the pain measures showed a significant time main effect (P<.05) and a significant treatment main effect (P<.01), indicating that participants had less pain at the 2.5-year follow-up than at the previous 6-month follow-up. Results from the multivariate analysis of variance conducted on sexual functioning measures showed that participants remained unchanged between the 6-month and 2.5-year follow-up and that there were no group differences. Higher pretreatment pain intensity predicted poorer outcomes at the 2.5-year follow-up for vestibulectomy (P<.01), biofeedback (P<.05), and cognitive-behavioral therapy (P<.01). Erotophobia also predicted a poorer outcome for vestibulectomy (P<.001). CONCLUSION: Treatment gains were maintained at the 2.5-year follow-up. Outcome was predicted by pretreatment pain and psychosexual factors. LEVEL OF EVIDENCE: II.

The treatment of provoked vestibulodynia: a critical review.

OBJECTIVE: To carry out a critical review of published studies concerning the treatment of provoked vestibulodynia. METHODS: MEDLINE, PsycINFO, and Cochrane were used to identify treatment studies published between January 1996 and December 2006. All studies published in English that dealt specifically with the treatment of provoked vestibulodynia were included in the review regardless of their methodological quality. Thirty-eight treatment studies were thus examined in the present paper. RESULTS: Since 1996, surgical treatment has received somewhat less empirical attention. Nevertheless, it still boasts the best success rates, which range from 61% to 94%. More studies have focused on medical treatments, yielding success rates varying between 13% and 67%. Behavioral treatments have been the least studied, although 35% to 83% of patients benefit from them. Despite these interesting results, only 5 of the 38 treatment studies reviewed are randomized clinical trials. Furthermore, the majority of studies have several methodological weaknesses, such as the absence of (1) control or placebo group, (2) double-blind evaluation, (3) pretreatment pain evaluation, and (4) validated measures of pain and sexual functioning. DISCUSSION: On the basis of the results of the reviewed prospective studies and the randomized clinical trials, vestibulectomy is the most efficacious treatment to date. Though some medical treatments seem little effective, others appear promising and should be investigated further, as is the case with behavioral treatments. Additional randomized clinical trials are necessary to confirm the efficacy of surgery and validate nonsurgical treatments for provoked vestibulodynia.

Multilevel local anesthetic nerve blockade for the treatment of vulvar vestibulitis syndrome.

OBJECTIVE: Vulvar vestibulitis syndrome is a major cause of dyspareunia. This pilot study was designed to evaluate a novel treatment approach. STUDY DESIGN: This is a prospective study of 27 women with vulvar vestibulitis. The protocol included 5 treatment sessions with caudal epidural, pudendal nerve block, and vestibular infiltration of local anesthetic agents. RESULTS: There were significant improvements in vestibular pain as determined by the vulvalgesiometer, McGill pain questionnaire, self-report, and the Female Sexual Functioning Inventory. CONCLUSION: Serial multilevel nerve blocks administered for the treatment of vulvar vestibulitis is a conceptually neurophysiologically based modality that may be effective and merits a placebo-controlled study.