Provoked vestibulodynia is the most common subtype of chronic vulvar pain. This highly prevalent and debilitating condition is characterized by acute recurrent pain located at the entry of the vagina ...in response to pressure application or attempted vaginal penetration. Although physical therapy is advocated as a first-line treatment for provoked vestibulodynia, evidence supporting its efficacy is scarce.
The purpose of this study was to establish the efficacy of multimodal physical therapy compared with topical lidocaine, a frequently used first-line treatment.
We conducted a multicenter, parallel-group, randomized clinical trial in women diagnosed as having provoked vestibulodynia recruited from the community and 4 Canadian university hospitals. Women were randomly assigned (1:1) to receive either weekly sessions of physical therapy or overnight topical lidocaine (5% ointment) for 10 weeks. Randomization was stratified by center using random permuted blocks from a computer-generated list managed by an independent individual. Physical therapy entailed education, pelvic floor muscle exercises with biofeedback, manual therapy, and dilation. Assessments were conducted at baseline, posttreatment, and 6-month follow-up. Outcome assessors, investigators, and data analysts were masked to allocation. The primary outcome was pain intensity during intercourse evaluated with the numeric rating scale (0–10). Secondary outcomes included pain quality (McGill-Melzack Pain Questionnaire), sexual function (Female Sexual Function Index), sexual distress (Female Sexual Distress Scale), satisfaction (numeric rating scale of 0–10), and participants’ impression of change (Patient Global Impression of Change). Intention-to-treat analyses were conducted using piecewise linear-growth models.
Among 212 women who were recruited and randomized, 201 (95%) completed the posttreatment assessment and 195 (92%) completed the 6-month follow-up. Multimodal physical therapy was more effective than lidocaine for reducing pain intensity during intercourse (between-group pre-post slope difference, P<.001; mean group postdifference, 1.8; 95% confidence interval, 1.2–2.3), and results were maintained at 6-month follow-up (mean group difference, 1.8; 95% confidence interval, 1.2–2.5). The physical therapy group also performed better than the lidocaine group in all secondary outcomes (pain quality, sexual function, sexual distress, satisfaction, and participants’ impression of change) at posttreatment and 6-month follow-up. Moreover, the changes observed after physical therapy were shown to be clinically meaningful. Regarding participants’ impression of change, 79% of women in the physical therapy group reported being very much or much improved compared with 39% in the lidocaine group (P<.001).
The findings provide strong evidence that physical therapy is effective for pain, sexual function, and sexual distress and support its recommendation as the first-line treatment of choice for provoked vestibulodynia.
Objective: This 13-week randomized clinical trial aimed to compare group cognitive-behavioral therapy (GCBT) and a topical steroid in the treatment of provoked vestibulodynia, the most common form of ...dyspareunia. Method: Participants were 97 women randomly assigned to 1 of 2 treatment conditions and assessed at pretreatment, posttreatment and 6-month follow-up via structured interviews and standard questionnaires pertaining to pain (McGill Pain Questionnaire, 11-point numerical rating scale of pain during intercourse), sexual function (Female Sexual Function Index, intercourse frequency), psychological adjustment (Pain Catastrophizing Scale, Painful Intercourse Self-Efficacy Scale), treatment satisfaction, and participant global ratings of improvements in pain and sexuality. Results: Intent-to-treat multilevel and covariance analyses showed that both groups reported statistically significant reductions in pain from baseline to posttreatment and 6-month follow-up, although the GCBT group showed significantly more pain reduction at 6-month follow-up on the McGill Pain Questionnaire. The 2 groups significantly improved on measures of psychological adjustment, and the GCBT group had significantly greater reductions in pain catastrophizing at posttreatment. Both groups' sexual function significantly improved from baseline to posttreatment and 6-month follow-up, and the GCBT group was doing significantly better at the 6-month follow-up. Treatment satisfaction was significantly higher in the GCBT group, as were self-reported improvements in pain and sexuality. Conclusions: Findings suggest that GCBT may yield a positive impact on more dimensions of dyspareunia than a topical steroid, and support its recommendation as a first-line treatment for provoked vestibulodynia.
What is the public health significance of this article?
This study shows that group cognitive-behavioral therapy is an effective treatment for women with dyspareunia due to provoked vestibulodynia.
•Pelvic floor muscle training is a feasible treatment for women with vaginal atrophy.•Pelvic floor muscle training decreased symptoms and signs of vaginal atrophy.•Pelvic floor training reduced the ...impact of vaginal atrophy on women’s quality of life and sexuality.
Treatments for genitourinary syndrome of menopause (GSM) may not be suitable for all women, may not be completely effective, and may cause adverse effects. Therefore, there is a need to explore new treatment approaches. The objectives were to evaluate the feasibility of using a pelvic floor muscle training (PFMT) program in postmenopausal women with GSM, and to investigate its effect on symptoms, signs, activities of daily living (ADL), quality of life (QoL) and sexual function.
Postmenopausal women with GSM participated in a single-arm feasibility study embedded in a randomized controlled trial (RCT) on PFMT for urinary incontinence. This substudy was composed of two pre-intervention evaluations, a 12-week PFMT program and a post-intervention evaluation.
Feasibility was defined as study completion and participation in physiotherapy sessions and in-home exercises. The effects of the PFMT program were assessed by measuring GSM symptoms (‘Most Bothersome Symptom’ approach, ICIQ-UI SF), GSM signs (Vaginal Health assessment scale), GSM’s impact on ADL (Atrophy Symptom questionnaire), QoL and sexual function (ICIQ-VS, ICIQ-FLUTSsex) and leakage episodes.
Thirty-two women participated. The study completion rate was high (91%), as was participation in treatment sessions (96%) and in-home exercises (95%). Post-intervention, there were significant reductions in GSM symptoms and signs (p < 0.01) as well as in its impacts on ADL, QoL and sexual function (p < 0.05).
A study including a PFMT program is feasible, and the outcomes indicate PFMT to be an effective treatment approach for postmenopausal women with GSM and urinary incontinence. This intervention should be assessed through a RCT.
This cross-sectional study aims to determine the prevalence and determinants of depressive symptoms in first-time expectant fathers during their partner’s third trimester of pregnancy. As part of a ...prospective study examining depressive symptoms in men over the first postnatal year, 622 men (mean age = 34.3 years, ±5.0 years) completed standardized online self-report questionnaires measuring depressed mood, physical activity, sleep quality, social support, marital adjustment, life events, financial stress, and demographics during their partner’s third trimester of pregnancy. The Edinburgh Depression Scale was used to assess depressed mood. Partners also completed the Edinburgh Depression Scale in the third trimester. The results revealed that 13.3% of expectant fathers exhibited elevated levels of depressive symptoms during their partner’s third trimester of pregnancy. Significant independent factors associated with antenatal depressive symptoms in men were poorer sleep quality, family history of psychological difficulties, lower perceived social support, poorer marital satisfaction, more stressful life events in the preceding 6 months, greater number of financial stressors, and elevated maternal antenatal depressive symptoms. These findings highlight the importance of including fathers in the screening and early prevention efforts targeting depression during the transition to parenthood, which to date have largely focused only on women. Strategies to promote better sleep, manage stress, and mobilize social support may be important areas to address in interventions tailored to new fathers at risk for depression during the transition to parenthood.
Abstract Objective The goals of the present study were to estimate the incidence and course of full and partial Post-Traumatic Stress Disorder (PTSD) following childbirth and to prospectively ...identify factors associated with the development of PTSD symptoms at 1 month following childbirth. Methods The sample comprised 308 women, with assessments at four time points: 25–40 weeks gestation, 4–6 weeks postpartum, 3 and 6 months postpartum. Current and prior PTSD were assessed by the Structured Clinical Interview for DSM-IV (SCID-I) and the Modified PTSD Symptom Scale Self-Report (MPSS-SR). Results Incidence rates of PTSD varied according to time of measurement and instrument used, with higher rates of full and partial PTSD using the MPSS-SR at 1 month postpartum (7.6% and 16.6%, respectively). Multivariate logistic regression showed that higher anxiety sensitivity (OR = 1.75; 95% CI = 1.19‒2.57, p = .005), history of sexual trauma (OR = 2.81; 95% CI = 1.07‒7.37, p = .036), a more negative childbirth experience than expected (OR = 0.96; 95% CI = 0.94‒0.98, p = .001), and less available social support at 1 month postpartum (OR = 0.40; 95% CI = 0.17‒0.96, p = .041) independently predicted full or partial PTSD at 1 month following childbirth. Conclusion Our results indicate that a history of sexual trauma and anxiety sensitivity can increase the probability of developing PTSD after childbirth. The findings highlight the importance of screening and providing more tailored services for women at high risk.
Abstract
The objectives of this study were to evaluate the prevalence of depressive symptoms in the third trimester of pregnancy and at 3 months postpartum and to prospectively identify risk factors ...associated with elevated depressive symptoms during pregnancy and with postpartum onset. About 364 women attending antenatal clinics or at the time of their ultrasound were recruited and completed questionnaires in pregnancy and 226 returned their questionnaires at 3 months postpartum. Depressed mood was assessed by the Edinburgh Postnatal Depression Scale (EPDS; score of ≥ 10). The rate of depressed mood during pregnancy was 28.3% and 16.4% at 3 months postpartum. Among women with postpartum depressed mood, 6.6% were new postpartum cases. In the present study, belonging to a non-Caucasian ethnic group, a history of emotional problems (e.g. anxiety and depression) or of sexual abuse, comorbid anxiety, higher anxiety sensitivity and having experienced stressful events were associated with elevated depressed mood during pregnancy. Four risk factors emerged as predictors of new onset elevated depressed mood at 3 months postpartum: higher depressive symptomatology during pregnancy, a history of emotional problems, lower social support during pregnancy and a delivery that was more difficult than expected. The importance of identifying women at risk of depressed mood early in pregnancy and clinical implications are discussed.
Pelvic floor muscle (PFM) dysfunctions are reported to be involved in provoked vestibulodynia (PVD). Although heightened PFM tone has been suggested, the relative contribution of active and passive ...components of tone remains misunderstood. Likewise, alterations in PFM contractility have been scarcely studied.
To compare PFM tone, including the relative contribution of its active and passive components, and muscular contractility in women with PVD and asymptomatic controls.
Fifty-six asymptomatic women and 56 women with PVD participated in the study. The PVD diagnosis was confirmed by a gynecologist based on a standardized examination.
PFM function was evaluated using a dynamometric speculum combined with surface electromyography (EMG). PFM general tone was evaluated in static conditions at different vaginal apertures and during repeated dynamic cyclic stretching. The active contribution of tone was characterized using the ratio between EMG in a static position and during stretching and the proportion of women presenting PFM activation during stretching. Contribution of the passive component was evaluated using resting forces, stiffness, and hysteresis in women sustaining a negligible EMG signal during stretching. PFM contractility, such as strength, speed of contraction, coordination, and endurance, also was assessed during voluntary isometric efforts.
Greater PFM resting forces and stiffness were found in women with PVD compared with controls, indicating an increased general tone. An increased active component also was found in women with PVD because they presented a superior EMG ratio, and a larger proportion of them presented PFM activation during stretching. Higher passive properties also were found in women with PVD. Women with PVD also showed decreased strength, speed of contraction, coordination, and endurance compared with controls.
Findings provide further evidence of the contribution of PFM alterations in the etiology of PVD. These alterations should be assessed to provide patient-centered targeted treatment options.
The use of a validated tool investigating PFM alterations constitutes a strength of this study. However, the study design does not allow the determination of the sequence of events in which these muscle alterations occurred-before or after the onset of PVD.
Findings support the involvement of active and passive components of PFM tone and an altered PFM contractility in women with PVD. Morin M, Binik YM, Bourbonnais D, et al. Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia. J Sex Med 2017;14:592-600.
It has been suggested that pelvic floor muscles (PFMs) play an important role in provoked vestibulodynia (PVD) pathophysiology. Controversy in determining their exact contribution may be explained by ...methodological limitations related to the PFM assessment tools, specifically the pain elicited by the measurement itself, which may trigger a PFM reaction and introduce a strong bias.
The aim of this study was to compare PFM morphometry in women suffering from PVD to asymptomatic healthy control women using a pain‐free methodology, transperineal four‐dimensional (4D) ultrasound.
Fifty‐one asymptomatic women and 49 women suffering from PVD were recruited. Diagnosis of PVD was confirmed by a gynecologist following a standardized examination. All the participants were nulliparous and had no other urogynecological conditions. The women were evaluated in a supine position at rest and during PFM maximal contraction.
Transperineal 4D ultrasound, which consists of a probe applied on the surface of the perineum without any vaginal insertion, was used to assess PFM morphometry. Different parameters were assessed in sagittal and axial planes: anorectal angle, levator plate angle, displacement of the bladder neck, and levator hiatus area. The investigator analyzing the data was blinded to the clinical data.
Women with PVD showed a significantly smaller levator hiatus area, a smaller anorectal angle, and a larger levator plate angle at rest compared with asymptomatic women, suggesting an increase in PFM tone. During PFM maximal contraction, smaller changes in levator hiatus area narrowing, displacement of the bladder neck, and changes of the anorectal and of the levator plate angles were found in women with PVD compared with controls, which may indicate poorer PFM strength and control.
Using a reliable and pain‐free methodology, this research provides sound evidence that women with PVD display differences in PFM morphometry suggesting increased tone and reduced strength. Morin M, Bergeron S, Khalifé S, Mayrand M‐H, and Binik YM. Morphometry of the pelvic floor muscles in women with and without provoked vestibulodynia using 4D ultrasound. J Sex Med 2014;11:776–785.
To estimate whether treatment gains for provoked vestibulodynia participants randomly assigned to vestibulectomy, biofeedback, and cognitive-behavioral therapy in a previous study would be maintained ...from the last assessment-a 6-month follow-up-to the present 2.5-year follow-up. Although all three treatments yielded significant improvements at 6-month follow-up, vestibulectomy resulted in approximately twice the pain reduction as compared with the two other treatments. A second goal of the present study was to identify predictors of outcome.
In a university hospital, 51 of the 78 women from the original study were reassessed 2.5 years after the end of their treatment. They completed 1) a gynecologic examination involving the cotton-swab test, 2) a structured interview, and 3) validated pain and sexual functioning measures.
Results from the multivariate analysis of variance conducted on the pain measures showed a significant time main effect (P<.05) and a significant treatment main effect (P<.01), indicating that participants had less pain at the 2.5-year follow-up than at the previous 6-month follow-up. Results from the multivariate analysis of variance conducted on sexual functioning measures showed that participants remained unchanged between the 6-month and 2.5-year follow-up and that there were no group differences. Higher pretreatment pain intensity predicted poorer outcomes at the 2.5-year follow-up for vestibulectomy (P<.01), biofeedback (P<.05), and cognitive-behavioral therapy (P<.01). Erotophobia also predicted a poorer outcome for vestibulectomy (P<.001).
Treatment gains were maintained at the 2.5-year follow-up. Outcome was predicted by pretreatment pain and psychosexual factors.
II.
Fear has been suggested as the crucial diagnostic variable that may distinguish vaginismus from dyspareunia. Unfortunately, this has not been systematically investigated. The primary purpose of this ...study, therefore, was to investigate whether fear as evaluated by subjective, behavioral, and psychophysiological measures could differentiate women with vaginismus from those with dyspareunia/provoked vestibulodynia (PVD) and controls. A second aim was to re-examine whether genital pain and pelvic floor muscle tension differed between vaginismus and dyspareunia/PVD sufferers. Fifty women with vaginismus, 50 women with dyspareunia/PVD, and 43 controls participated in an experimental session comprising a structured interview, pain sensitivity testing, a filmed gynecological examination, and several self-report measures. Results demonstrated that fear and vaginal muscle tension were significantly greater in the vaginismus group as compared to the dyspareunia/PVD and no-pain control groups. Moreover, behavioral measures of fear and vaginal muscle tension were found to discriminate the vaginismus group from the dyspareunia/PVD and no-pain control groups. Genital pain did not differ significantly between the vaginismus and dyspareunia/PVD groups; however, genital pain was found to discriminate both clinical groups from controls. Despite significant statistical differences on fear and vaginal muscle tension variables between women suffering from vaginismus and dyspareunia/PVD, a large overlap was observed between these conditions. These findings may explain the great difficulty health professionals experience in attempting to reliably differentiate vaginismus from dyspareunia/PVD. The implications of these data for the new DSM-5 diagnosis of Genito-Pelvic Pain/Penetration Disorder are discussed.
PDF
