|
Article Excerpt
Provoked vestibulodynia, formerly known as vulvar vestibulitis syndrome, is currently defined as a pain disorder confined to the vaginal opening with hypersensitivity to mechanical stimuli such as touch, pressure, and vaginal penetration (Moyal-Barracco & Lynch, 2004). It is the most frequent cause of superficial dyspareunia in young women (Harlow, Wise, & Stewart, 2001 ). The symptoms interfere with the patient's sexual function and psychological well-being, and the impact the disease has on the affected women may increase over time. Many affected women become sexually abstinent and often describe loss of sexual desire, which has usually accelerated as the symptoms become manifest (Graziottin & Brotto, 2004; Reissing, Khalife, Cohen, & Amsel, 2003; Van Lankveld, Weijenborg, & ter Kuile, 1996). Signs of anxiety and depression are also common features in the patients, but studies on involved psychological factors have not reached consistent results. Some studies report that women with vestibulodynia have higher rates of depression and anxiety than controls (Gates & Galask, 2001; Nylander-Lundqvist & Bergdahl, 2003). It is not clear, however, whether these differences reflect the cause or effect of the disease (Green & Hetherton, 2005; Meana, Binik, Khalife, & Cohen, 1997b; Van Lankveld et al., 1996).
Hypertonicity of the pelvic floor has been proposed to be an important factor for the maintenance of pain, and an increased tension of the pelvic floor is often found during a gynecological examination (Abramov, Wolman, & David, 1994; Reissing, Binik, Khalife, Cohen & Amsel, 2004; Reissing, Lord, Binik, & Khalife, 2005). Interventions to restore the function of the pelvic floor muscles using EMG-biofeedback or physiotherapy are also generally recommended (Bergeron et al., 2002; Danielsson, Torstensson, Brodda-Jansen, & Bohm-Starke, 2006; Glazer, Rodke, Swencionis, Hertz, & Young, 1995; Graziottin & Brotto, 2004; Haefner et al., 2005; Rosenbaum, 2005).
The etiology of provoked vestibulodynia is considered multifactorial, including both physical and psychosexual causes (Graziottin & Brotto, 2004). For some women, previous physical trauma to the mucosa, such as recurrent vulvovaginal candidiasis, may have initiated the dyspareunia, while for others a combination of negative experiences related to emotional, psychological, and sexual factors are more predominant causes (Gates & Galask, 2001; Harlow & Stewart, 2005; Meana, Binik, Khalife & Cohen, 1997a; Meana, Binik, Khalife, & Cohen, 1997b; Nunns & Mandal, 1997; Rylander, Berglund, Krassny, & Petrini, 2004; Sackett, Gates, Heckman-Stone, Kobus, & Galask, 2001).
Several studies investigating pain mechanisms in provoked vestibulodynia have observed an increased peripheral innervation in the vestibular mucosa (Bohm-Starke, Hilliges, Falconer, & Rylander, 1998; Bornstein, Goldschmid, & Sabo, 2004; Westrom & Willen, 1998). Quantitative sensory testing (QST) has been performed, suggesting a peripheral sensitization of the vestibular sensory nerves (Bohm-Starke, Hilliges, Brodda-Jansen, Rylander, & Torebjork, 2001; Pukall, Binik, Khalife, Amsel, & Abbott, 2002). Yet other studies have revealed an enhanced systemic pain perception with decreased pain thresholds in other parts of the body as well and frequently complain of bodily pain in women with vestibulodynia (Danielsson, Eisemann, Sjoberg, & Wikman, 2001; Granot, Friedman, Yarnitsky, & Zimmer, 2002; Pukall, Binik, Khalife, Amsel, & Abbott, 2002; Reissing et al., 2005).
The complex clinical features of prolonged dyspareunia, which in many cases severely affect the patients' psychosexual health, have to be addressed during treatment (Graziottin & Brotto, 2004). Few studies have been published concerning description and evaluation of psychosexual treatment models for women with provoked vestibulodynia or vulvar vestibulitis syndrome (Schover, Youngs, & Cannata, 1992; Wijma & Wijma, 1997; Wijma, Jansson, Nilsson, Hallbook, & Wijma, 2000; Bergeron et al., 2001). In our clinical work, more detailed or hands-on instructions regarding integrated physiological and psychosexual treatment models have been requested by colleagues and other health providers taking care of these patients. Vestibulectomy was initially the most common treatment with a success rate, including complete and partial response, of 50-100% (Bornstein, Goldik, Stolar, Zarfati, & Abramovici, 1997; Bornstein, Maman, & Abramovici, 2001; Haefner, 2000). Lately there has been an urge for more individualized treatments, and the importance of pain management, pelvic floor rehabilitation, and the impact of psychosexual factors has increasingly been acknowledged (Graziottin & Brotto, 2004; Haefner et al., 2005). A multimodal approach including pelvic floor relaxation, pain management, sex therapy, and cognitive behavioral therapy (CBT) are often recommended, but there is limited documentation on how these treatments should be carried out (Haefner et al., 2005; Wijma, Jansson, Nilsson, Hallbook, & Wijma, 2000). The purpose of this study was therefore to standardize and evaluate a combined physical and psychosexual therapy for women with provoked vestibulodynia. The main outcome measures were coital pain and intercourse frequency. Sexual functioning, stressors in life, and general treatment outcome were also evaluated.
Materials and Methods
The study is an evaluation of 27 women who were treated with a combination of physical and psychosexual therapy for provoked vestibulodynia during 1999-2004. All the women were referred to a vulvar open care unit due to superficial dyspareunia. The inclusion criteria for the study follow: (a) provoked pain confined to the area around the vaginal opening, (b) severe pain at most intercourse attempts, and (c) duration of symptoms for at least 12 months.
Exclusion criteria follow: (a) vulvo-vaginal infection (b) vulvar dermatosis (c) unprovoked vulvar pain (d) other ongoing treatment for vestibulodynia, and (e) medication or therapy for major medical or psychiatric illness.
Twenty-seven women were recruited for...
|
