Careful history taking (in a safe atmosphere/setting)
An educative gyneco-sexological examination that the patient is able to follow with a hand mirror (and when applicable with the partner present)
Providing information about provoked vestibulodynia (PVD), its natural course, treatment options, and a treatment plan
Involvement of the patient and partner in the decision process about potential treatment options
Prescription of an inert cream (simple eye ointment or petroleum jelly 20 % in cetomacrogol) to protect the vestibular area and to urge the woman to touch the painful area (mucosal desensitization) (local corticosteroids are contraindicated)
Vaginal EMG biofeedback, pelvic floor physiotherapy (by a registered pelvic floor physical therapist) with the aim of alleviating pelvic floor hypertonia
Homework assignments that comprised self-exploration of the genitals and biofeedback by means of digital control, or with the aid of vaginal dilators and lubricants, together with a temporary coitus prohibition
A hygienic protocol, e.g., no vaginal douching, no press-on panty liners
Normalizing, reframing, and encouraging sexual activity without penetration to avoid development of feelings of guilt
If appropriate, individual sexological counseling that aims to improve the woman’s self-image, body image, and autonomy, with the aid of a registered psychologist/sexologist
If appropriate, sexological partner-relation therapy that primarily aims to improve physical and noncoital sexual contact, with the aid of a registered psychologist/sexologist
If appropriate, nerve stimulation by means of transcutaneous electrical nerve stimulation
If appropriate in some cases of persistent PVD, surgical intervention (vestibulectomy) as an additional form of treatment to facilitate breaking the vicious circle of irritation, pelvic floor muscle hypertonia, and sexual maladaptive behavior (end-of-line treatment)
18.6.2 Psychosocial Aspects/Biopsychosocial Approach
Research into the treatment of PVD still pays too little attention to the biopsychosocial model. From this perspective, all the phases of the treatment process are interdependent. It is only for didactical reasons that we discuss the phases separately, according to the following standard categorization [22]:
Problem and patient orientation
Diagnostic phase
Indication and differential diagnosis
Informed consent and shared decision-making
It is important to note that these stages are interdependent – like buttoning up a white lab coat: If you start at the wrong buttonhole or miss one, the coat will not fit properly!
After the aforementioned phases, the therapeutic phase and the follow-up and evaluation phase will follow (described later in the section on Specific Diagnostic Aspects).
18.6.2.1 Problem and Patient Orientation
The acquaintance phase is especially important when dealing with patients who are coping with chronic illness. These patients are often at the end of their tether, because they have been looking for treatment for many years. In women with PVD, a quest of 5 years or more is no exception [19], and the mean number of physicians consulted prior to diagnosis is three [4]. PVD patients are likely to be feeling ashamed about having to reveal their very intimate problems to yet another health-care provider. During history taking, it is important to decrease the woman’s anxiety level by selecting a low-pressure setting, somewhere in private, with the woman fully clothed and not sitting on an examination table [19]. An important first step toward recovery is for patients to understand and accept their diagnosis. Providing clear and concise information is essential (psychoeducation). Over the years, women with PVD are likely to have received misinformation or ambivalent information from the different health-care providers [23].
PVD has a highly negative impact on quality of life. Patients are often young women at the start of their sexual life, when the couples’ problem-solving skills (as a duo) still need time to develop. A negative male attitude toward PVD was found to be a significant predictor of decreased dyadic adjustment and sexual satisfaction, as well as increased psychological distress, although it failed to predict sexual functioning. These findings indicate that partners should be involved in the treatment of PVD [24]. It is likely that facilitative male partner responses will improve sexual functioning, whereas solicitous and negative responses may be detrimental. Psychological interventions that target partner responses can help to improve the sexual functioning of the affected couple [25, 26]. However, it is suggested that PVD is not necessarily associated with general relationship maladjustment of the woman and her partner [27].
Especially the lack of a clear or acceptable cause is experienced as an extra burden. All in all, this supplementary stress makes the patient (hyper)sensitive to the course of events during the first encounter. A reassuring but sensitive approach combined with ample communication about the current emotions and feelings often helps a lot. Whereas in acute situations, swift medical action can be a blessing; in these cases, it is essential to take your time. Festina lente (make haste slowly)!
18.6.2.2 Diagnostic Phase
As there are no clear causal pathways in the case of syndrome diagnoses, the diagnosis of PVD is mostly determined by exclusion. Even then PVD is difficult to recognize, because if the women is sufficiently sexually aroused, intercourse can still be pleasurable, even in the presence of PVD. In some cases, the pain manifests itself after sexual intercourse.
Case History: Continued
After she has given her consent, Bianca Olive is gynecologically examined, while she watches herself with a hand mirror. Her vulvar skin is reddish. There is no visible vaginal discharge. Upon request, it is difficult for her to relax her pelvic floor muscles. There are two bright red spots at 5 and 7 o’clock visible in the vulvar introitus, which are extremely painful when touching them with a wet cotton swab. Careful examination, after explicit permission of Bianca, with one gloved, lubricated finger, reveals firmly tightened levator muscles, eliciting the pain she recognizes when starting penetration.
18.6.2.3 Indication and Differential Diagnosis
Because there is no clear etiology and there are so many targets (i.e., risk factors to deal with), in the eyes of beginners or outsiders, the indication process and the differential diagnosis appear to be “trial and error driven.” However, in the hands of an experienced clinician, the complaints and behavior of the patient become usually quite easily meaningful, and thereby a diagnostic and therapeutic pathway emerges for all involved. However, between sharing a rationale and complying with a treatment regime often lies a great distance – at least for the patient. This makes patient education more than a moral but a legal obligation. In case of PVD, it is a sine qua non.
18.6.2.4 Informed Consent and Shared Decision-Making
In many countries, informed consent is already a legal condition to start treatment, while shared decision-making is rapidly gaining ground as a moral condition. However, research has shown that in practice, neither of these conditions are adequately met [28]. This can even be a problem when treating illness with a clear biomedical cause. We know that adherence to lifestyle changes is extremely low in most chronic illnesses such as rheumatic arthritis, multiple sclerosis, etc., but in the case of chronic sexual problems, it is almost nil. We therefore pay ample attention to both conditions as follows:
18.6.3 Informed Consent
In medical practice, understanding why things happen does not guarantee therapeutic success. Moreover, even when success is possible, the way to achieve it is not always the solution the patient is seeking. In some situations, as we already pointed out when discussing the etiology of PVD, a reaction or symptom can have a protective function. In such cases, it is very difficult to eradicate, because the problem is also a solution. It is precisely this functional characteristic that raises the (ethical) question of whether health professionals should try to resolve the problem. Especially when there is no clear biomedical pathology, it is important to discuss and deliberate explicitly with the patient about the aims of the treatment process and the potential positive and negative consequences. In the case of PVD, the following possible aims could be discussed:
Promoting quality of life in general
Promoting quality of sexual life in particular, with or without intercourse
Reducing morbidity and complaints
Attempting to make intercourse non-harmful and as pleasurable as possible
Sometimes a patient’s grasping of the situation, or gaining a clearer understanding, resolves the problem or the request for help. If the request for help persists, the elements that make up the vicious circle need to be clearly explained, and special attention must be paid to the need for full symptom prevention.
18.6.4 Shared Decision-Making
It should be clear to all those involved that the only way to resolve this sexual variant of the old “chicken and the egg dilemma” is to establish a different means of “sexual self-management.” The object of this self-management should not be the act of sexual intercourse, but full symptom prevention. The term “self-management” in itself stresses that this can only be achieved with the active involvement and participation of the patient and/or couple. Just like many other lifestyle issues, such as eating, drinking, physical activity, etc., sexual habits are difficult to change. Besides informed consent and sexual literacy, shared decision-making is a sine qua non for the treatment of PVD. Therefore, preferably during the whole process, but at least when you have established the diagnosis of PVD, explain to the patient what you are going to do and repeatedly ask for her consent. Keep in mind that in psychological terms, these patients are at risk anyway. They may also have been “mistreated” medically and been traumatized for years. If a gynecological examination is needed, do it in an educational way, and give maximum control to the patient. Ask her whether she wants her partner, if present, to be involved; ask her if she would like to use a hand mirror to see what is happening. Listen to her answers carefully, and look closely at how the patient and her partner interact as a couple. Having to make changes to their sexual lifestyle will put extra stress on the relationship. Therefore, careful observation might provide important information about the need to reconsider some treatment aims or procedures. In the end, it should be clear exactly which aims have been set, for which reasons and which procedures are needed. The patient should not only be informed but should also be the one who has made the decision to start treatment. This means that the patient and/or couple should be sexually literate in general, but particularly about the most important therapeutic options regarding PVD.
18.7 Specific Therapeutic Aspects
18.7.1 Therapeutic Phase
In terms of the actual treatment, it is of eminent importance to keep in mind that the primary aim is not the reuptake of intercourse, but full symptom prevention: breaking the vicious circle! As stated previously (see the section on Aims and Strategies), several different, but not mutually exclusive, strategies can be used.
18.7.2 Follow-Up and Evaluation Phase
The importance of follow-up and evaluation lies in the opportunity to make adjustments to the current case and to learn from it, in order to improve the approach to future cases (reflection). Given the complex nature of PVD, a number of possible pitfalls can be distinguished and thereby points for evaluative reflection.
18.7.2.1 Examples of Patient-Related Topics for Reflection
Some patients are unwilling to adopt a psychosocial stance and insist on receiving somatic treatment. If this occurs, it is important to realize that it is unbearable for many patients that their PVD complaints are rooted in more fundamental psychological or interpersonal (sexual) problems. This means that our good news, i.e., that we have solved the puzzle, is perceived by the patient as bad news. When discussing future action, the rules of a bad news consultation should be followed. Do not try persuasion, but ask questions about the patient’s emotions and what the message means to her.
Make a decision in the multidisciplinary meeting regarding who will be the one to talk with the patient.
Sometimes young patients are accompanied by one of their parents, or a dominant partner, whose ideas and behavior interfere with the treatment process. It is important to address these types of disturbance first, before actual treatment can start. An elegant strategy is to relate PVD to the theme of autonomy versus dependency.
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