Nina Bohm‐Starke and Ulrika Johannesson There is currently no general consensus on the optimal treatment for vulvodynia. Recommended guidelines are mainly based on expert opinion, and various treatments algorithms have been described in the literature [1, 2]. For individual treatment options, the overall level of evidence is very low [3, 4]. Approximately 30 randomised controlled trials (RCTs) have been published for the treatment of localised provoked vulvodynia, but so far none for the generalised unprovoked subtype. Further limitations are the lack of repeated studies for specific treatments and that the studies are usually very small [3]. Furthermore, no core outcome set for variables measuring treatment outcome has been agreed upon, and thus each RCT has its own unique protocol, making it very difficult to compare the trials [5]. Another possible consequence of the limited established treatment guidelines is the discrepancy of healthcare provided in different countries and regions. In some countries, vulval clinics receive referrals from larger areas and regions, whereas in other parts specialised care is absent. As a result, the level of care largely depends on local resources and knowledge. For PVD, there is a general opinion that a multidisciplinary approach has the best chance for a sustainable and effective treatment outcome [6]. It is suggested that management should be provided in a step‐by‐step process and include interventions for pelvic floor dysfunction and psychosocial health together with medical management to reduce pain sensitivity. However, the treatment approach may differ depending on the severity of PVD. A woman with minor symptoms might improve by general care measures and psychosexual support. On the other hand, in more severe cases, when initial care is not effective, a multidisciplinary team of gynaecologist, dermatologist, physical therapist, psychologist, and/or sexual therapist might be needed to deal with the complexity of the vulvodynia. A careful consultation with a physician who recognises the problem and who can give the correct information and diagnosis is usually a great relief for the patient. Often, many years might have passed since the first symptoms until diagnosis. Basic skin care measures using a soap substitute may help in the case of an irritant problem, and general information to avoid pain provocation, including painful sex, is given. At some clinics, educational information is provided explaining possible triggers initiating the pain and the interplay between peripheral and central pain mechanisms modulating pain processing over time. Further explanation of the behavioural models of fear and avoidance is also important for the woman to understand the mechanisms maintaining the pain. The aim of physical therapy is to restore the function of the PFMs. Most women with PVD have an increased muscle tone and find it difficult to voluntarily contract and relax the muscles. It has been argued whether the muscle dysfunction is the cause or the consequence of the pain, and some experts regard it as a protective pain reflex. Physical therapy may be provided by pelvic floor specialists, but also general physiotherapists and midwives trained in pelvic floor anatomy and function can be of help. During the therapy, the goal is to enhance muscle elasticity and circulation, therefore normalising muscle tone and increasing the ability to discriminate between contracted and relaxed muscles. As part of the therapy, reduction of the fear of pain and vaginal penetration is often achieved, which in turn may desensitise the painful vestibular mucosa [7]. As for other PVD treatment options, no standardised protocol for physical therapy exists. One RCT has been published where physical therapy showed better outcomes for pain during intercourse and sexual function compared to topical lidocaine [8]. Manual therapy for PFMs is the most commonly described method and can be performed by various techniques including massage, stretching, and myofascial trigger point therapy [9]. The focus is to restore the muscle function, and the therapy is often part of a multimodal physical therapy, including self‐exercises at home [7]. However, if the mucosa around the vaginal opening is very pain sensitive and/or if the muscle tone is high, the patient might have to start with light smearing and touching exercises for desensitisation before the increased muscle tone can be addressed [10]. If the patient has taken part in a multidisciplinary treatment model, simultaneous pain management and supportive psychosocial intervention may have an additive effect on improvement. Electromyography (EMG) biofeedback for vulvodynia was first described in the 1990s [11] and might be used for women who do not improve with manual physical therapy or have difficulties performing exercises at home. The assistance of visual feedback relating to muscle activity is relevant in women with pain since many have difficulty achieving an adequate PFM contraction with only verbal instructions [7]. A plastic probe, connected to surface electrodes and an EMG device, is inserted in the vagina for practice at home. The EMG device can be programmed for a series of short phasic contractions (10 seconds) and/or longer endurance contractions (60 seconds). The bioelectrical muscle activity is registered, and the device instructs the woman when to contract. Feedback on quality of the contractions and relaxations is provided by light and/or sound. One RCT including treatment with cognitive behavioural therapy (CBT), EMG biofeedback, or surgery for PVD has been published, and long‐term evaluation showed similar results for all three treatments regarding pain during intercourse at 6 months’ follow‐up [12]. Vaginal dilators are often recommended for women with various genito‐pelvic pain/penetrative disorders [13]. The use of the dilators is considered to facilitate the brain‐body connection and may decrease anxiety and pain related to vaginal penetration. Some small studies have reported on positive outcomes for pain intensity and sexual function [14]. The dilators exist in several forms and are commercially available. Instructions how to use them can be given by physiotherapists or midwives [15, 16]. Psychosocial interventions are considered first‐line treatments for vulvodynia [1, 2]. They include various forms of CBT, sex therapy, and psychoeducation. The therapies can either be performed individually, together with partners, or in groups depending on need and available competence. Often, the interventions target multiple dimensions of vulvodynia, such as maladaptive thoughts, emotions, behaviour, and couple interactions. The overall aim is to increase adaptive coping strategies and reduce psychological distress and to improve sexual well‐being and relationship satisfaction [17]. Concomitant mood disorders such as anxiety and depression and abuse in childhood should be screened for, and psychiatric consultation or more trauma‐oriented CBT is needed in some cases. There is a growing body of literature supporting CBT for PVD. Group CBT was investigated together with EMG biofeedback and surgery in one RCT for women with provoked vestibulodynia [12]. Women in the CBT group reported improvement regarding pain at intercourse at 6 months’ follow‐up, and after 2.5 years the result was similar to those who had surgery. In another RCT analysing the effect of CBT compared to topical corticosteroid, CBT had significantly better results for treatment satisfaction, reduction of severe pain, and sexual function [18]. Mindfulness‐based CBT or CBT for 8 weeks has shown a similar improvement for penetrative pain, pain sensitivity, and sex‐related distress at 12 months’ follow‐up [19]. New third‐generation acceptance‐based approaches of CBT for vulvodynia have been investigated in small studies. The first approach targets relationship factors that have a role in vulvodynia and comprises a 12‐week couple’s therapy intervention. The result was associated with significant post‐treatment improvements in pain and sexual function for women and in sexual satisfaction for both women and their partners [20]. Mindfulness‐based group CBT has also been evaluated in comparison to standard CBT, showing improvement for pain catastrophising, hypervigilance, and sexual function and distress. In a subset of women, mindfulness was superior to CBT in reducing pain during intercourse [21]. Internet‐based CBT (iCBT) programmes have been shown to be effective for other chronic pain conditions [22]. Since access to specialised care for vulvodynia is limited in certain areas, this could be an option to provide equality of care, especially for less severe cases. Some preliminary iCBT studies for PVD are in progress, but have not yet been evaluated. The scientific evidence for medical treatment for vulvodynia is also low. Even so, various medications are often tried and might be helpful in individual cases. In the following section, the most commonly used medications will be described in terms of indication, mode of action, and reported results. Topical application of lidocaine 2–5% gel or ointment is often used in an attempt to decrease pain in the mucosa around the vaginal opening. Local anaesthetics block the afferent transmission in sensory nerves, and repeated application is thought to decrease the sensitisation of the vestibular nociceptors [23]. In one uncontrolled study, 5% lidocaine was applied overnight with a favourable outcome for pain during intercourse [24]. However, this result was not confirmed in a study where women with PVD were randomised to topical lidocaine or placebo 4 times per day for 12 weeks with the tampon test as primary outcome [25]. Despite this result, some women may benefit from the intermittent use of lidocaine in cases of intense pain with vestibular touch [26]. It should be noted that the 5% ointment may cause some burning pain, and the 2% gel might be an alternative in these cases. Capsaicin is a vanilloid receptor agonist found in chili peppers, and the transdermal patches are approved for post herpetic neuralgia. The mechanisms involved in the anti‐nociceptive effect are unclear, but depletion of substance P from primary afferent C nerve fibres after repeated administration is one possible explanation. For vulvodynia, topical capsaicin 0.025% and 0.05% cream has only been tried in two small uncontrolled studies reporting improvement of pain and sexual function, but the effect needs to be confirmed [27, 28]. The theory behind a possible reduction of pain sensitivity in vulvodynia is interesting, but one major drawback for clinical use is the severe burning pain that occurs when applied to the mucosa. Tricyclic antidepressants (TCAs) are first‐line treatment for neuropathic pain conditions. The mode of action is not fully understood, but is thought to be achieved by repeated stimulation of β2‐adrenoreceptors and increased levels of noradrenaline, modulating nociceptive signalling [29]. It was concluded in one systematic review on the effect of antidepressants for vulvodynia (mixed subtypes) that there is insufficient evidence to recommend antidepressants on a general basis. However, amitriptyline is often used for generalised unprovoked vulvodynia, but it is also tried for women with PVD. The only RCT evaluating TCAs in PVD compared low‐dose oral desipramine with placebo and found no superior effect of desipramine [25]. Topical 2% amitriptyline cream has been tried in one prospective, but uncontrolled trial, where more than half of the participants reported improvement [30]. Despite the poor scientific support, it is evident that some women with vulvodynia respond well to TCAs, but more research is needed to recognise characteristics that may predict a favourable treatment outcome. For patients with intense mucosal pain sensitivity, a systemic TCA might be an option in doses of 50–100 mg at night. The main side effects of amitriptyline are mouth dryness, constipation, and drowsiness. Nevertheless, many patients report positive effects on sleep quality and improvement of mood disorders. Newer generations of antidepressants such as selective serotonin and norepinephrine reuptake inhibitors (SSRIs and SNRI)s are regularly used for chronic pain conditions [29], but lack support as treatment for vulvodynia. Only small and uncontrolled studies alone, or in combination with other medications have shown a beneficial effect [31]. Anticonvulsants are also widely used for neuropathic pain conditions. The mechanism of action is thought to be by affecting voltage‐gated sodium channel function at nerve terminals, attenuating depolarisation and the release of pain‐promoting neurotransmitters such as glutamate and substance P [32]. There are a limited number of studies where gabapentin and pregabalin have been used for PVD. One retrospective study analysed the effect of 2–6% topical gabapentin for minimum 8 weeks’ treatment in both generalised and localised vulvodynia and showed significant pain reduction with no major side effects [33]. In two RCTs for PVD, 1200–3000 mg/day of gabapentin versus placebo for 6 weeks resulted in no difference for pain associated with the tampon insertion [34], but improved sexual function was obtained [35]. Currently, the scientific evidence for using anticonvulsants for vulvodynia is poor. Nevertheless, some women do respond, and future studies may clarify the subgroups of vulvodynia that could benefit from the treatment. The different pain characteristics of the generalised unprovoked and provoked subtypes of vulvodynia may play a role in which women will obtain symptom relief with the use of various neuromodulating agents. The role of inflammation relating to the onset and maintenance of symptoms in PVD is debated. Several attempts at anti‐inflammatory intervention have been tried without convincing results. No systemic anti‐inflammatory agent has been evaluated, including NSAIDs, which anecdotally are reported as non‐effective by patients with vulvodynia. Corticosteroids are fundamental in treating inflammatory conditions, and the theoretical basis has also been tempting in vulvodynia.
37
Vulvodynia – Management
Provoked vulvodynia (PVD)
Basic vulval care
Pelvic floor physical therapy
Psychosocial interventions
Medical management
Antinociceptive agents
Antidepressants
Anticonvulsants
Anti‐inflammatory agents
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
