Provoked vestibulodynia: current perspectives

Abstract

Provoked vestibulodynia (PVD) refers to vulvar pain of at least 3 months duration, localized to the vestibule, provoked by touch and sexual activity and occurring in the absence of a clear identifiable cause. The clinical spectrum ranges from mild with distressing discomfort through to severe and disabling pain. Current understanding is that PVD is one of many chronic pain conditions characterized by sensitization of peripheral and central nociceptive pathways, with pain arising due to dysfunctional neuronal activity in the absence of painful stimuli. Pathophysiology is not well understood but is likely a complex interplay of environmental, genetic, psychological and immune factors. Care is multidisciplinary and follows general principles of chronic pain management with the addition of specific therapy tailored to address pelvic floor overactivity, and sexual and relationship difficulties. More recently, the therapeutic use of placebo is gaining traction in chronic pain research and is a very promising adjunctive therapy. The majority of women with PVD are managed outside of tertiary clinic settings, and care depends on availability and affordability of specialized services; however, much can be done by the primary health provider. PVD is common, and highly treatable, especially with early intervention, but unfortunately, many clinicians are unaware of this condition, and the biggest hurdle for women accessing treatment is obtaining a diagnosis. With treatment, most women can expect significant improvement, often with fairly simple interventions, although some women will benefit from referral to specialized centers. The aims of this article are twofold: firstly, to summarize current literature concerning PVD pathophysiology and management; secondly, to provide a framework for clinicians unfamiliar with vulvar medicine to understand and manage PVD.

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

“…Consistent with previous studies, many of our participants expressed positive responses to interdisciplinary vulvodynia treatment when they could access it, but such treatments were complicated by inconsistent care teams, a lack of specialists in the area, limited access to provincially funded therapists, or coming with a high private healthcare cost. 6 , 9 , 36 , 47 , 48 In addition, participants in our group suggested that even if such resources were available closer to home, they were unlikely to avail of them owing to the lack of anonymity in smaller communities.…”

Myofascial Pelvic Pain: An Overlooked and Treatable Cause of Chronic Pelvic Pain

“…Pelvic floor PT is also recommended in the treatment of interstitial cystitis 51 . If a patient with MPPS has accompanying vestibulodynia, the midwife can consider introducing dilators, with or without the help of pelvic floor PT, and medications such as lidocaine, topical estrogen and testosterone, and vaginal diazepam (this is an off‐label use of these medications) 52 . Finally, if pelvic organ prolapse is noted, a patient may benefit from a urogynecology referral along with pelvic floor PT.…”

Predictors of Mucosal and Muscle Pain in Vulvodynia: A Cross-Sectional Analysis From the National Vulvodynia Registry

“…To assess pain sensitivity of the pelvic floor muscles, single-digit pressure of approximately 2 kg (calibrated by an algometer just before the exam) was performed at the bulbocavernosus (at 5 o'clock and 7 o'clock), levator muscles (at 7 o'clock and 5 o'clock, respectively), and the perineal complex at 6 o'clock, as previously described. 28 A summary score (range 0−50) for static mucosal pain was generated by adding 5 numeric rating scale (NRS) scores (0−10) from cotton swab sensitivity tests at 10 o'clock, 7 o'clock, 6 o'clock, 5 o'clock, and 2 o'clock of the vestibule. A summary score (range 0−50) for muscular pain was generated by adding the 5 NRS pain scores (0−10) from pressure applied to the bulbocavernosus, levator complex, and the perineal body.…”

“…8 Recent investigations propose further tailoring treatment based on these associated factors-for example, psychological distress, 3,11,12 hormonal deficiency, 23 inflammatory markers, 9,15 presence of comorbid pain conditions, 9,34,35 or pelvic floor dysfunction. 28,31 Diagnostic criteria and examination recommendations for PVD have traditionally focused on the vestibular mucosa. However, recent evidence suggests that pain with vestibular contact may be inadequate to characterize penetration pain in women with PVD, as it disregards pain with pelvic floor muscle activation.…”