A Conceptual Model for the Pathophysiology of Vulvar Vestibulitis Syndrome

Division of Advanced Laparoscopy and Pelvic Pain, Department of Obstetrics and Gynecology, and Center for Women's Health Research, University of North Carolina, Chapel Hill, North Carolina 27599-7570, USA.
Obstetrical and Gynecological Survey (Impact Factor: 1.86). 06/2006; 61(6):395-401; quiz 423. DOI: 10.1097/01.ogx.0000219814.40759.38
Source: PubMed


Vulvar vestibulitis syndrome (vestibulitis), the most common type of chronic vulvovaginal pain, impairs the psychologic, physical, and reproductive health of approximately 10% of women at some point in their lives. Research on the pathophysiology of vestibulitis suggests abnormalities in 3 interdependent systems: vestibular mucosa, pelvic floor muscles, and central nervous system pain regulatory pathways. To date, causes and relative contributions of these abnormalities to the development and maintenance of vestibulitis remain poorly understood. Research consistently supports the conceptualization of vestibulitis as a chronic pain disorderg-akin to fibromyalgia, irritable bowel disorder, and temporomandibular disorder (TMD)-that is far more complex than vestibular hypersensitivity alone. Nevertheless, the clinical diagnosis of vestibulitis continues to rely on subjective report of pain during intercourse and vestibular sensitivity on clinical examination after exclusion of other gynecologic disorders. We propose that current diagnostic criteria, which are based on highly subjective patient and clinician measures, are not sufficient to describe and properly classify the heterogeneous clinical presentations of this disorder. To inform clinical care or research, we must be able to objectively characterize women with vestibulitis. This narrative review critically appraises current conceptualization of vestibulitis and presents a context for studying vestibulitis as a chronic pain disorder, emphasizing the need for objective assessment of clinical features.

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Available from: Katherine Eubanks Hartmann, Feb 11, 2014
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    • "Moreover, women who experience significant psychologic distress are less likely to respond to treatment [4] [14] [15]. Certain psychologic characteristics may precede or be affected by persistent pain [1] [6] [16]. When psychologic distress is measured at 1 point in time (e.g. "
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    ABSTRACT: To examine long-term reports of pain and psychologic correlates of pain in women after vestibulectomy. In a retrospective cross-sectional exploratory study, 37 women who had undergone vestibulectomy between January 1989 and January 2008 completed questionnaires assessing demographic information, self-reported levels of pain, anxiety, somatization, psychologic distress, and sexual function. Eight women reported being completely pain free after surgery. The remaining 29 women reported various levels of pain during intercourse (as measured by the Gracely pain scale) and decreased sexual function (as measured by a sexual functioning questionnaire). Various measures of psychologic distress were associated with average intercourse-related pain, including brief symptom inventory (P=0.002), Pennebaker inventory of limbic languidness (P=0.002), perceived stress scale (P=0.04), and Spielberger trait-anxiety inventory (P=0.01). These same measures of psychological distress were similarly associated with general, unprovoked vaginal pain. The present data suggest that the pathophysiology of localized vulvodynia may be more complex in some women, leading to a suboptimal response to surgical treatment.
    International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 06/2011; 113(3):225-8. DOI:10.1016/j.ijgo.2010.12.018 · 1.54 Impact Factor
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    • "It has been hypothesized that genital pain and inflammation may provoke PFM dysfunctions by (1) destabilizing the PFM, inducing tensions and poor muscle control [20]; (2) triggering a defensive-like reaction toward pain during penetration attempts [33] [34]; (3) intruding the underlying muscle tissues and causing hypersensitivity in the PFM [39]. Others have suggested that PFM dysfunctions may initiate an increase in mucosal sensitivity [40]. It is likely that a vicious cycle involving pain and further muscle dysfunctions is implicated, potentially compounded by the involvement of cognitive, affective, and behavioural factors. "

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    • "Many studies have suggested that pelvic floor muscle dysfunctions are associated with sexual pain (Glazer et al., 1998; Reissing et al., 2004, 2005; White, Jantos, & Glazer, 1997). It has been hypothesized that pelvic floor dysfunctions may precipitate the onset of dyspareunia namely by increasing mucosal sensitivity (Zolnoun et al., 2006) or by closing the vaginal hiatus and preventing penetration in the case of vaginismus (Basson et al., 2000). Another hypothesis is that vulvo-vaginal pain may trigger pelvic floor dysfunctions (Glazer et al., 1998; Reissing, Binik, Khalife, Cohen, & Amsel, 2004; Reissing, Brown, Lord, Binik, & Khalife, 2005). "
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    ABSTRACT: The sexual pain disorders dyspareunia and vaginismus are highly prevalent yet misunderstood women's sexual health problems. We have proposed the adoption of a treatment approach integrating pelvic floor rehabilitation and cognitive-behavioral therapy in order to target the multidimensional aspects of these complex conditions. Looking back on the work that has been published in the area of sexual pain since we introduced this model in 2003, the present paper focuses on the progress that has been achieved since then, with an emphasis on the pelvic floor musculature and psychological factors. Specifically, the continuing debate about the classification of sexual pain is briefly summarized. Findings from treatment outcome research are reported. Growing evidence indicates that pelvic floor rehabilitation and cognitive-behavioral therapy lead to significant improvements in pain and sexual functioning, although there are still only a handful of published randomized controlled trials and only one study focusing on the integration of these two modalities. Recent advances concerning the role of the pelvic floor as well as cognitive and affective variables in the etiology of sexual pain are reviewed, with results showing that higher levels of anxiety, fear of pain, hypervigilance and catastrophizing, in addition to lower levels of self-efficacy, may contribute to the exacerbation of pain and associated sexual dysfunction. In terms of avenues for future research, two new measurement instruments for assessing the pelvic floor musculature are described, namely the dynamometric speculum and transperineal ultrasound. Ongoing challenges involved in the adoption of an integrated treatment approach are discussed.
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