Vulvar vestibular effects of ospemifene: a pilot study.

The study aimed to assess the effects of ospemifene on vulvar vestibule in postmenopausal women with vulvar pain and dyspareunia. Fifty-five postmenopausal women used oral ospemifene 60 mg/d for 60 d. Symptoms of dryness, burning, and dyspareunia were evaluated on a 10 cm visual analog scale. Visual examination of the vulvar vestibule was also conducted. Patients also underwent current perception threshold (CPT) testing obtained from the vulvar vestibule. Fifty-five patients (94.6%) completed the treatment. Hot flashes were the most frequent adverse effects, but this led to a discontinuation of therapy in three patients (5.4%). After therapy, there was a statistically significant decrease from the baseline in the mean scores for dryness, burning, and dyspareunia and reduction of vestibular trophic score (baseline value of 11.2-4.2 after the therapy, p ≤ 002) and cotton swab test scores (2.81 compared with 1.25, p = .001). There was a difference in CPT values for all nerve fibers and more consistent for C fibers (-38% of sensitivity). These results confirm the efficacy of ospemifene on postmenopausal vestibular symptoms and signs; moreover, the drug was effective in normalizing vestibular innervation sensitivity.

Injury to Perineal Branch of Pudendal Nerve in Women: Outcome from Resection of the Perineal Branches.

Background This study describes outcomes from a new surgical approach to treat "anterior" pudendal nerve symptoms in women by resecting the perineal branches of the pudendal nerve (PBPN). Methods Sixteen consecutive female patients with pain in the labia, vestibule, and perineum, who had positive diagnostic pudendal nerve blocks from 2012 through 2015, are included. The PBPN were resected and implanted into the obturator internus muscle through a paralabial incision. The mean age at surgery was 49.5 years (standard deviation [SD] = 11.6 years) and the mean body mass index was 25.7 (SD = 5.8). Out of the 16 patients, mechanisms of injury were episiotomy in 5 (31%), athletic injury in 4 (25%), vulvar vestibulectomy in 5 (31%), and falls in 2 (13%). Of these 16 patients, 4 (25%) experienced urethral symptoms. Outcome measures included Female Sexual Function Index (FSFI), Vulvar Pain Functional Questionnaire (VQ), and Numeric Pain Rating Scale (NPRS). Results Fourteen patients reported their condition pre- and postoperatively. Mean postoperative follow-up was 15 months. The overall FSFI, and arousal, lubrication, orgasm, satisfaction, and pain domains significantly improved (p < 0.05). The VQ also significantly improved (p < 0.001) in 13 (93%) of 14 patients. The NPRS score decreased on average from 8 to 3 (p < 0.0001). All four patients with urethral symptoms were relieved of these symptoms. Conclusion Resection of the PBPN with implantation of the nerve into the obturator internus muscle significantly reduced pain and improved sexual function in women who sustained injury to the PBPN.

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.

Multiple odontogenic abscesses. Thoracic and abdomino-perineal extensiónin an immuno competent patient

Introduction: Odontogenic infection (OI) may lead to death if it extends beyond the buccal area. The virulenceof pathogens and the local and systemic status of the patient influence the propagation of the pathogen, either byanatomical continuity or haemematogenous dissemination. Several severe complications derived from OI havebeen reported in the head, neck and chest. However, OI with an abdominal component, caused by bacteraemiawith dental foci or the direct passage of pus from the thorax to the abdomen, are unusual.Case report: We present the case of a young immunocompetent woman who, after false cure of an odontogenicabscess, again reported gynaecological symptoms. A network of connected abdomino-perineal, thoracic and cervicalabscesses was discovered.Discussion: The peculiarity and severity of this case is a reminder that treatment of an abscessed OI should includeintravenous broad-spectrum antibiotics, together with surgical drainage of the purulent collections. Samplesshould be taken for culture and an antibiogram in order to use specific antibiotics if the initial empirical therapyshows resistance. The diagnosis and follow-up should be by CT, which in our patient showed anatomical continuityof the abscesses from the dental focus. The time sequence of the symptoms, in the absence of any other infectiouscause, revealed the descending odontogenic nature of the process (AU)

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Attributions about pain as predictors of psychological symptomatology, sexual function, and dyadic adjustment in women with vestibulodynia.

The present study examined whether attributions for vulvo-vaginal pain predicted pain intensity, sexual function, as well as psychological and dyadic adjustment in women with vestibulodynia. Women with vestibulodynia (N = 77) completed measures of attributions, pain, psychological distress, sexual functioning, and dyadic adjustment. They also took part in a structured interview and a gynaecological examination for diagnostic purposes. Attributions are represented by: (1) internality (personal responsibility) or externality (cause lies in an external situation); (2) globality (entire life affected by the problem) or specificity (problem affecting only a specific situation); (3) stability (problem will still remain in the future) or instability (weak probability that the problem will be maintained with time); and (4) partner responsibility (partner responsible or not for the problem). Results indicated that attributions were not significantly correlated with pain outcomes. However, after controlling for pain intensity and relationship duration, internal attributions predicted higher dyadic adjustment, both global and stable attributions predicted lower dyadic adjustment and higher psychological distress, whereas global attributions also predicted increased sexual impairment. Findings suggest that cognitive factors, such as attributions, may be related to psychological distress, sexual functioning, and dyadic adjustment in women with vestibulodynia. Results also highlight the importance of adhering to a biopsychosocial perspective focusing on pain reduction, sexual rehabilitation, and relationship enhancement in the treatment of dyspareunia.

The relationship of interstitial cystitis/painful bladder syndrome to vulvodynia.

INTRODUCTION: Many patients have interstitial cystitis/painful bladder syndrome (IC/PBS), a condition of frequency, urgency, and pain affecting more than 1 million women in the United States. The vulva, not the urethra or bladder, may actually be the site of some of the reported pain in women with IC/PBS. PURPOSE: The purpose of this study was to identify the presence of vulvodynia in women diagnosed with IC/PBS. METHOD: A mailed survey was used to identify women with IC/PBS who also reported vulvar pain. The survey also identified related factors, such as menstrual/hormonal status, sexual function, abuse, and sequence of vulvar and bladder pain from adolescence to adulthood. RESULTS: Four-hundred-sixteen women with a documented diagnosis of IC/PBS were mailed a survey. The response rate was 49.6%, with 197 completed surveys returned. Results include vulvar pain in adolescence reported by 10.9% of the respondents, while vulvar pain in adulthood was reported by 48.4% of the women. During the last year, 62.7% of the respondents reported vulvar pain. Ninety-five percent (95%) of the women reported having been sexually active in adulthood, but one-third were not currently sexually active; 27% reported fear of pain as the reason. An abuse history was reported by 28.5% of the women. Of the women who were postmenopausal (two-thirds of the group), 38% used hormone replacement therapy. Birth history showed no correlation to vulvar pain. CONCLUSIONS: The chronic pain that IC/PBS patients feel may not be totally related to their bladder, but instead, may be vulvar pain. The incidence of abuse, past pelvic surgeries, pelvic floor dysfunction, and the chronologic sequence of co-morbid symptoms should be further assessed.

Pain, psychosocial, sexual, and psychophysical characteristics of women with primary vs. secondary provoked vestibulodynia.

INTRODUCTION: Women with provoked vestibulodynia (PVD), a common cause of dyspareunia, are typically considered a homogeneous group. However, research suggests that differences on some factors (e.g., medical history, pain characteristics, psychological functioning, treatment response) exist based upon whether the pain was present at first intercourse (primary PVD: PVD1) or developed at some later point (secondary PVD: PVD2). AIMS: The purpose of this study was to examine differences in demographic variables, pain characteristics, psychosocial and psychosexual adjustment, and pain sensitivity between women with PVD1 and PVD2. METHODS: Twenty-six women suffering from PVD (13 with PVD1 and 13 with PVD2) completed a screening assessment, a standardized gynecological examination, an interview, questionnaires, and a quantitative sensory testing session. MAIN OUTCOME MEASURES: These included pain ratings during the gynecological examination and interview, scores on measures of psychosocial/sexual functioning (e.g., Short Form-36 [SF-36] Health Survey, Female Sexual Function Index), and thresholds and pain ratings during thermal sensory testing over the dominant forearm and vulvar vestibule. RESULTS: The women with PVD1 were more likely to be nulliparous, but they were not significantly different from the women with PVD2 on other demographic variables or in their pain ratings during the gynecological examination. The women with PVD1 reported lower levels of social and emotional functioning and heightened anxiety surrounding body exposure during sexual activity, and they also displayed lower heat pain tolerance over the forearm and lower heat detection and pain thresholds at the vulvar vestibule than the women with PVD2. CONCLUSIONS: The findings from this study support previous research indicating that women with PVD1 and PVD2 differ in a number of domains. Further research is needed to confirm and elaborate on these findings.

Botulinum neurotoxin type A injections for vaginismus secondary to vulvar vestibulitis syndrome.

OBJECTIVE: To investigate whether botulinum neurotoxin type A improves vaginismus and study its efficacy with repeated treatments. METHODS: Outpatients were referred because standard cognitive-behavioral and medical treatment for vaginismus and vulvar vestibular syndrome failed. From this group, we prospectively recruited consecutive women (n=39) whose diagnostic electromyogram (EMG) recordings from the levator ani muscle showed hyperactivity at rest and reduced inhibition during straining. These women were followed for a mean (+/-standard deviation) of 105 (+/-50) weeks. Recruited patients underwent repeated cycles of botulinum neurotoxin type A injected into the levator ani under EMG guidance and EMG monitoring thereafter. At enrollment and 4 weeks after each cycle, women were asked about sexual intercourse; underwent EMG evaluation and examinations to grade vaginal resistance according to Lamont; and completed a visual analog scale (VAS) for pain, the Female Sexual Function Index Scale, a quality-of-life questionnaire (Short-Form 12 Health Survey), and bowel and bladder symptom assessment. RESULTS: At 4 weeks after the first botulinum neurotoxin type A cycle, the primary outcome measures (the possibility of having sexual intercourse, and levator ani EMG hyperactivity) both improved, as did the secondary outcomes, Lamont scores, VAS, Female Sexual Function Index Scales, Short-Form 12 Health Survey, and bowel-bladder symptoms. These benefits persisted through later cycles. When follow-up ended, 63.2% of the patients completely recovered from vaginismus and vulvar vestibular syndrome, 15.4% still needed reinjections (censored), and 15.4% had dropped out. CONCLUSION: Botulinum neurotoxin type A is an effective treatment option for vaginismus secondary to vulvar vestibular syndrome refractory to standard cognitive-behavioral and medical management. After patients received botulinum neurotoxin type A, their sexual activity improved and reinjections provided sustained benefits. LEVEL OF EVIDENCE: III.

[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.

Overlap between orofacial pain and vulvar vestibulitis syndrome.

OBJECTIVES: To explore the prevalence of orofacial pain (OFP) among patients with vulvar vestibulitis syndrome (VVS) and to examine the relationship between signs and symptoms of OFP and clinical characteristics of women with VVS, we investigated differences in psychologic characteristics and severity of painful intercourse. METHODS: In this cross-sectional exploratory study, 137 women with VVS completed questionnaires that assessed levels of pain, anxiety, somatization, and presence of signs and symptoms suggestive of clinical and subclinical OFP. Demographic data were gathered from medical records. RESULTS: OFP was found to be a highly prevalent (78%) condition among women with VVS. Compared with women who had no OFP symptoms (n=30), those with symptoms (n=64) reported higher levels of anxiety (45.0 vs. 37.8, Bonferroni adjusted P=0.017), somatization (125.2 vs. 96.0, Bonferroni adjusted P<0.001), and psychologic distress (62.8 vs. 56.0, Bonferroni adjusted P=0.002). Although we observed a similar trend among women with subclinical OFP (n=43), this trend only reached statistical significance with respect to somatization. Differences were not detected for demographics, duration of pain, and severity of pain during intercourse across the 3 groups. DISCUSSION: OFP is a common condition among women with VVS. Because severity and duration of painful intercourse did not differ by OFP classification but psychologic characteristics did, we must begin to question a unidimensional focus on vestibular mucosa as a reason for pain and persistent distress.

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.