Pain, psychological distress and motor pattern in women with provoked vestibulodynia (PVD) – symptom characteristics and therapy suggestions

1 Introduction

The longstanding pain conditions of the pelvic region still represent challenges for clinicians in the areas of urology, gynecology, as well as pain management [1, 2]. Some authors divide the chronic gynecological pain into different categories such as chronic pelvic pain (CPP), provoked vestibulodynia (PVD), vestibulitis, vaginismus, interstitial cystitis (IC) or irritable bowel syndrome (IBS), while others do not discriminate among pain arising from the bowel and the internal urinary tract or cyclical and non-cyclical pain [3, 4]. Lack of classification standards might be one of the reasons why different studies find large variations in prevalence of chronic gynecological pain, ranging from 2% [4, 5] through 15%–20% [3, 5] to almost 40% [4, 6]. WHO’s ICD-10 classification itself discerns between cyclical and non-cyclical pain, and separates psychogenic from organic causes of vaginismus and dyspareunia, but gives little assistance in discriminating between non-cyclical provoked and unprovoked pain, or pain originating in the outer genitalia from pain in deeper structures (WHO ICD-10). Furthermore, there is a lack of common understanding of the etiologies and pathogenic pathways leading to chronic gynecological pain. Suggested explanations range from visceral pathology, skin and mucus membrane pathology and musculoskeletal pathology to psychopathology [1, 7]. This in line results in a variety of therapeutic procedures applied in this field, including surgery, antimicrobial agents, lubricants, local anesthetics, physiotherapy or psychotherapy [1, 8].

In 2016, as a result of the significant increase in high-quality etiologic studies published in the last decade, a new 2015 Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia has been published that acknowledges the complexity of the clinical presentation and pathophysiology involved in chronic gynecological pain conditions [2]. The Consensus discriminates between the chronic conditions related to specific disorders (e.g. inflammation) and the idiopathic vulvar pain of at least 3 months’ duration which is characterized as vulvodynia. In current view, vulvodynia is considered to be a complex, heterogenic condition with a number of “potential associated factors” contributing to the symptoms, including: genetic [9], hormonal [10], inflammatory [11], musculoskeletal [12], neurologic [13], psychosocial [14] and structural [15]. The 2015 nomenclature characterizes various types of vulvodynia based on pain location (e.g. localized, generalized, mixed), circumstances that provoke pain response (e.g. provoked or constant) and time of onset (primary secondary).

In this study we focus on two diverse conditions that both might be categorized as gynecological pain, namely CPP and PVD. According to the 2015 Consensus, CPP might be described as generalized constant vulvodynia, while pain related specifically to sexual intercourse or pressure applied to vestibule can be categorized as PVD. However, the diagnostic categorization based on pain localization and pain provoking situation does not answers whether CPP and PVD patients differ on other characteristics known to be important in persistent pain conditions, including emotional, psychological, and physical, or whether it should result in different therapy approaches.

The current guidelines for therapy of the two conditions are not sufficiently corroborated by high quality intervention studies. The 2013 guidelines on CPP from the European Association of Urology [1] recommends multimodal and phenotypically directed treatment options (including psychotherapy and diverse elements of physical therapy), as well as options for pharmacological interventions with α-blockers, antimicrobial drugs and non-steroid anti-inflammatory drugs. For PVD, the 2016 guidelines [2] describe the common use of anesthetics, applied locally or orally, but recommend psychological and physical therapy interventions. In both cases, surgery is described as the last resort, but its effects have not been fully validated.

Here we present the data obtained from a cross sectional pilot study of patients with PVD referred from a tertiary care university clinic, with respect to demographics, pain intensity, pain duration, quality of movement and psychological distress, including fear of movement. Further, we contrast the results to equivalent data from the cohort of patients with CPP and healthy controls from a previous study [16, 17]. We then discuss, whether observed differences and similarities between these two groups give any indication for treatment approaches. Thus, the aims of the study are to (1) describe the demographics and motor patterns of patients with PVD and compare them to those of patients with CPP, (2) assess the level of pain and psychological distress, including fear of movement (kinesophobia) of these women, and, based on these findings, and (3) assess indications for treatment options.

2 Materials and methods

Patients were recruited from a tertiary care University Clinic of Gynecology and consecutively included in the study. The women were between 20 and 35 years of age, all with PVD, according to the criteria established by Friedreich [18], a triad of conditions comprised of (1) pain with penetration during vaginal intercourse or with perineal pressure, (2) tenderness of the vestibular area upon even light touch with a cotton-tipped applicator, and (3) erythema of the vestibular area. The pain duration should be between 1 and 5 years. Diagnostic procedures included (1) obtaining a full medical record, (2) a comprehensive history of pain and previous treatments, and (3) a gynecological examination including a pain-provoking swab test. Exclusion criteria were any evidence of local skin or mucus pathologies and evidence of other serious somatic or psychiatric diseases. The study has been approved by Norwegian Regional Ethics Committee (2010-15/1546).

After inclusion, the patients were examined further at an outpatient facility at the Faculty of Health Sciences Institute of Physiotherapy. Demographic data were obtained and recorded, along with a clinical history. The patients were further assessed by means of a Visual Analog Scale (VAS) [19] for the intensity of pain experience at provocation of the painful area. The Tampa Scale of Kinesiophobia (TSK-13) [20] was used to assess fear of movement/re-injury. General Health Questionnaire (GHQ-30) [21] was applied to assess psychological distress. Finally, the standardized Mensendieck test (SMT) was used to assess several aspects of static and dynamic motor patterns. SMT has been previously standardized and validated for women with CPP [16]. The SMT was video recorded, and later scored by an experienced physiotherapist who was blinded to the status of the subject.

The results obtained from the PVD patients were compared to a study of CPP patients conducted between 2002 and 2008 [17] at a tertiary university clinic, where 60 patients with CPP were examined. The inclusion criteria were lower abdominal pain unrelated to pregnancy that had lasted for at least 6 months. The patients often described the pain as dull aching, sharp cramping or a feeling of painful pressure or heaviness deep within the pelvis. Pain during intercourse was rather common, and some experienced pain during defecation or sitting [17]. Patients with pain that occurred exclusively around menstruation (dysmenorrhoea) or with intercourse (dyspareunia) were not included in this CPP definition [5, 7]. In this study, a group of 15 healthy matched controls were similarly assessed for motor patterns with SMT in order to establish reference values [16].

The patients in both studies were assessed with VAS for pain score [19], psychological distress by means of GHQ-30 [21], and all women, including the healthy controls, were assessed for quality of motor patterns by the SMT (see Haugstad 2006 [16, 17] for further details).

3 Results

All scores are presented as means±SD. The demographic data are shown in Table 1. The mean age of the PVD subjects was 24.7±3.60 years, for CPP subjects 33.29±10.8. None of the women with PVD had ever been pregnant or given birth, the CPP women had on average experienced 1.12±0.88 labors. The PVD women scored 7.77±1.97 on VAS scores (on a scale from 0 to 10 cm), when assessing the pain they felt during provocation (light touch) of the painful area. The CPP women scored 6.68±1.16 on the same VAS scale when asked to assess the average pain the week before examination. The mean score for kinesophobia (fear of movement), assessed by TSK-13, was 24.4±3.95 (lowest score 13). The CPP women were not assessed for kinesophobia. The quality of motor patterns (SMT) is presented in Table 2 and Fig. 1. In PVD group, the scores were particularly low for respiration (3.27±1.10) and gait (3.36±0.62), for CPP women the respective scores were 3.25±1.01 for respiration and 3.66±0.93 for gait. Findings with regards to psychological distress (GHQ-30) are presented in Table 3, main finding being increased scores in the anxiety domain (9.63±4.06, Table 3 for PVD women, 8.55±5.25 for CPP women).

Figure 1:

Thirty women with provoked vestibulodynia (PVD) were recruited from a tertiary care university clinic of gynecology and assessed for quality of motor patterns by means of the standardized Mensendieck test (SMT). The PVD data are presented alongside with data of women with chronic pelvic pain (CPP) and healthy controls from a previously published study [16].

When comparing the PVD and the CPP women in these studies, the main observation was that the PVD women were younger by almost a decade, all were active in the workforce or students, had higher levels of education, lower duration of pain, but higher levels of anxiety in the GHQ score. They had almost comparable VAS scores for pain and GHQ scores for depression. With respect to quality of motor patterns, the PVD and CPP women had similar patterns for respiration, gait, sitting posture and (standing) posture, whereas the movement domain was generally lower for the CPP patients in comparison with the PVD patients.

4 Discussion

The main goal of the study was to describe the characteristics of women with PVD regarding their demographics, pain intensity, pain duration, quality of movement and psychological distress, including fear of movement. Secondarily we wished to compare these findings with those of the CPP patients we have investigated previously [16, 17].

In general, women with PVD displayed increased level of psychological distress with regard to anxiety symptoms (GHQ-30), compared to normative data, high level of localized pain with average duration of more than 3.5 years, and poor respiration and gait patterns (SMT). They were also in general young (in their 20-ies), highly educated and were participating actively in work life. The high level of work participation, despite having a longstanding pain condition, might suggest that women with PVD were coping well with their condition. However, in our material, 40% of women did not have a partner and none had been pregnant. This finding contrasted our earlier CPP study, where 85% of the women were in a relationship, and might in part be related to a mean age difference of almost a decade between those two groups (24.7 in PVD vs. 33.29 in CPP). Probably, the nature of the condition also played a role. PVD affects not only a suffering woman but also impacts the relationship to her partner. A recently published qualitative study [22] with participants recruited from the present sample, focused on PVD women’s personal experiences with pain. The participants described high levels of suffering in the interviews: “Penetration was particularly painful, triggering intense pain that was impossible to ignore”. “The pain was primarily located in the lowest part of the vagina, it was also perceived in the entire body”. They further emphasized that the pain had an emotional aspect: “I can feel it in my soul…it is not only physical …it hits deeper than terms of your emotional life. It feels different than any other pain…that the pain goes through and intersects through my entire body” [23], page 6]. When it comes to the concrete cognitions, the women typically expressed thoughts of being afraid of losing a boyfriend, fear of bonding to a male since that may lead to sexual demands, of not being able to bear a child, of loneliness, and doubts about being “true women” [23], page 6]. The fact that the women were actively participating in the work life and seemed to be successful, combined with the stigma related to a condition that affected sexual functioning, contributed to masking the severity of the PVD symptoms as it was experienced by the affected women.

5 Conclusions

In our study, patients with PVD displayed very high pain scores, high levels of anxiety and less functional breathing and gait pattern. Contrasted to a cohort group of patients with CPP [16, 17] the women with PVD were younger, had higher education, no children, were working full time and had no relevant surgical procedures performed. However, even if women with PVD and women with CPP displayed different characteristics with respect to demographic data and gynecological symptoms, our studies indicate that PVD, like CPP, may belong to the same cluster of pain disorders. A previous study of CPP patients seem to indicate that these patients may benefit from a multimodal therapeutic approach, emphasizing both cognitive, emotional and physical aspects of the condition. This type of approach could also be tested for women with PVD.