New Research On Vulvodynia Management

Key Messages

  • Vulvodynia is a condition of the skin, muscles and nerves, and all elements need to be addressed for optimal management
  • New data from large RCT finds Multimodal Physiotherapy a more effective treatment than topical lidocaine in women with provoked vestibulodynia
Vulvodynia affects 10-20% of women, and its prevalence is on the rise.  It affects women across the lifespan, and its pathophysiology is still poorly understood.  Associate Professor Melanie Morin, Canadian researcher and Pelvic Floor Physiotherapist, recently presented an update on Provoked Vestibulodynia (PVD) at the International Continence Society 2018 in Philadelphia. Her fascinating presentation outlined the latest in pathophysiology and management of PVD, and the exciting results of a soon-to-be published large randomised clinical trial of multimodal physiotherapy in women with PVD.

What Is Vulvodynia?

A new consensus statement was released in 2015 by 3 leading societies (ISSVD, ISSWSHS and IPPS), defining vulvodynia as “vulvar pain of at least 3 months duration, without clear identifiable cause, which may have potential associated factors”1. It is a diagnosis of exclusion, and a positive Q-tip test must occur1.  
 
Vulvodynia is then further classified as:
  • Generalised (affecting all of the vulva), localised (eg. the vestibule), or mixed1
  • Provoked (when the area is touched), unprovoked, or mixed1
  • Primary (pain since first penetration – tampon, intercourse etc.), or secondary (previous non-painful penetration)1

Why Does PVD Occur?

The pathophysiology of PVD is still poorly understood, but several mechanisms have been proposed, which can often co-exist1. The 2015 Consensus Statement outlines these factors as:
  • localized neuroproliferation and central sensitisation
  • neurogenic inflammation 
  • musculoskeletal factors, such as pelvic floor muscle (PFM) overactivity 
  • psychological factors 
  • genetic predisposition
  • hormonal factors
  • co-morbidities, such as other chronic pain conditions 
  • structural defects

How To Treat PVD?

To effectively treat PVD, three key areas need to be addressed: SKIN, MUSCLE, and NERVE.

SKIN

Women need to be educated about how to look after their delicate vulval skin, and be referred for medical management. Ideally to a Vulval Dermatologist or Gynaecologist specialising in PVD if there is any suspicion of co-existing skin conditions, eg. thrush, dermatitis, or lichen sclerosis. 
 

MUSCLE

Women with PVD commonly have overactivity and increased tension in their pelvic floor muscles.  A/Prof Morin and her team have published several papers over the past few years about the involvement of the PFM’s in PVD2-5.  They have found that PFM overactivity is significantly associated with pain intensity, and that the dysfunction can be in the active OR passive components of the muscle. 
 
The active component refers to the ability of the muscle to contract and relax, and this responds well to pelvic floor muscle relaxation or ‘downtraining’.  The passive component refers to the passive tissue structure, and responds well to stretching of these structures, eg. using vaginal trainers and manual therapy.
 

NERVE

Many studies show evidence of peripheral and central sensitisation in women with PVD. Women with PVD have been found to have widespread lower pain thresholds, and PVD also commonly co-exists with other chronic pain condition such as fibromyalgia and irritable bowel syndrome.  A/Prof Morin and her team also recently investigated pain inhibitory mechanisms in women with PVD, and found increased levels of hyperalgesia in many of these women6
 
The nervous system can be effectively treated with a combination of local and global strategies:
  • Local: graded exposure and vulval desensitisation exercises eg. self-touch and vaginal trainers.
  • Global: strategies to wind down a sensitised central nervous system, such as therapeutic pain neuroscience education, mindfulness and relaxation and, wellbeing strategies including diet, general wellbeing and sleep.

New RCT Investigating Multimodal Physiotherapy For PVD 

Major organisations such as the American College of Gynecologists recommend Multimodal Physiotherapy as a first line treatment for PVD. However, until recently, there have only been 3 small uncontrolled trials supporting its use.
 
A/Prof Morin presented her soon-to-be published findings from a large randomised controlled trial on the efficacy of Multimodal Physiotherapy compared to topical lidocaine7
 
The Multimodal Physiotherapy intervention was a 10-week program, consisting of:
  • Education (e.g. pathophysiology, lifestyle advice, skin care, relaxation techniques, therapeutic pain neuroscience education, sexual function)
  • Manual therapy (internal and external)
  • Biofeedback 
  • Vaginal trainers
  • Home exercise program 5 days/week
Morin reported clinically and statistically significant improvement in the physiotherapy group for pain intensity with intercourse, pain quality, sexual distress and sexual function after the intervention, and results were maintained at 6 months.  77% of women in the physiotherapy group reported being ‘very much’ or ‘much improved’ compared to 38% in the lidocaine group.  This exciting study provides strong evidence supporting Multimodal Physiotherapy in reducing pain and sexual dysfunction in women with PVD.
 

Take Home Message

A/Prof Morin’s key take home message was the importance of a multimodal approach to treatment. She highlighted the need to treat the whole person, by addressing local tissue changes, as well as central and peripheral sensitisation, to get the best outcomes for women with PVD. 
 
 
References 
Bornstein J, Goldstein AT, Stockdale CK, et al. (2016). Consensus vulvar pain terminology committee of the International Society for the Study of Vulvovaginal Disease (ISSVD), the International Society for the Study of Women’s Sexual Health (ISSWSH), and the International Pelvic Pain Society (IPPS) 2015 ISSVD, ISSWSH and IPPS consensus terminology and classification of persistent vulvar pain and vulvodynia. Obstet Gynecol, 127(4), 745–751.
 
M. Morin, et al. (2014). Morphometry of the pelvic floor muscles in women with and without provoked vestibulodynia using real time 4D ultrasound. J Sex Med, 11(3): 776–785 
 
M. Morin, et al. (2017). Heightened pelvic floor muscle tone and altered contractility in women with provoked vestibulodynia. J Sex Med, 14(4): 592-600.
 
F. Fontaine, M. Morin et al. Pelvic floor muscle morphometry and function in women with primary and secondary provoked vestibulodynia, J Sex Med, accepted.
 
J. Benoit-Piau, M. Morin et al. (2018). Psycho-social variables and pelvic floor muscle function are related to pain intensity in women with provoked vestibulodynia. Clin J Pain, (epub).
 
6 Gougeon, Morin, Marchand, Léonard, Waddell, Girard, Bureau. Assessment of central pain processing in women with PVD. Unpublished, data presented at ICS 2018. 
 
Morin, M., Dumoulin, C., Bergeron, S., Mayrand, M., Khalife, S., Waddell, G., Dubois, M. (2016). Randomized controlled trial of multimodal physiotherapy treatment compared to overnight topical lidocaine in women suffering from provoked vestibulodynia. Clinical trials.gov NCT01455350. Protocol published - Contemporary Clinical Trials, 46, 52-59