Journal of Gynecology Obstetrics and Human Reproduction
ReviewProvoked vulvar vestibulodynia: Epidemiology in Europe, physio-pathology, consensus for first-line treatment and evaluation of second-line treatments☆
Section snippets
Definitions
Vulvar pain located next to the vestibule, Provoked vulvar vestibulodynia (PVD) is essentially triggered by contact, sexual intercourses, gynecological examination, the introduction of a tampon, but without any vulvar lesions specific to the clinical examination (Consensus on terminology and classification of vulvar pain ISSVD 2003, (1,2)).
The principal complaint is the dyspareunia of intromission, named orificial.
Differential diagnosis: Once sclero-atrophic lichen is discarded the main
Prevalence and epidemiology in Europe
The analysis of the various European registers by the ICD 10 (code N 76.3, of the International Classification of Diseases), the national registers, the important epidemiological studies [4] and surveys of gynecologists of European countries, make it possible to draw up an epidemiological profile European PVD:
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The Italian registry Progetto Vu-net (reported by F Murina), confirms that PVD accounts for 72.6% of all vulvar pain. It affects women of all ages with a peak frequency between 20 and 29
Pathophysiology
All experts agree to involve two physiopathological mechanisms:
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an anatomical entity, the vulvar vestibule particularly rich in nerve endings, unlike other vulvar tissues or the vagina.
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Hyperalgesia phenomena with central and peripheral sensitization.
This sensitization of the peripheral and central nociceptive system explains the existence of chronic pain in areas where no(or little) tissue damage can be found at clinical examination or diagnostics testings. There is therefore, as O. Porta points
Consensus for first-line treatment
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Treatment of local hyperalgesia of the vulvar vestibule by bi-daily application in the long term, of local anesthetics (Lidocaine 2–10%). Local treatment can also be used before sex. Alternatively a topical Amitriptyline or Gabapentin may be proposed. Possible combination with the use of a pelvic sensitization treatment: Amitriptyline first-line, then Pregabalin or Gabapentin in case of comorbidities.
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Perineal rehabilitation: perineal and global external rehabilitation and progressive manual
Second-line therapies
In the event of failure of the first-line therapeutic protocol, numerous therapeutic options have been described, without being able to confirm their true interest and their precise indication, in the light of the results reported in the literature.
Here we report these techniques, which are currently being validated when they are indicated and remain in the domain of centers of expertise:
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Vaginal vestibular infiltrations: local anesthetics, corticosteroids or hyaluronic acid. None of them has
Conclusion
PVD is a very common condition that benefits from a simple diagnosis that can be put in place by any gynecologist consulted in first intention in any European country, after eliminating common vulvar pathologies.
The objective of this work is:
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Disseminate knowledge on the positive diagnosis of PVD to all European gynecologists;
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Encourage the initiation of a consensual multimodal first-line treatment as proposed here.
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Facilitate second-line treatment evaluation studies. In the current state of
Convergences PP Network Consensus
Convergences PP Network Consensus document (*) with the participation of:
(*) Convergences PP is an international non-profit scientific society dedicated to scientific advances, research, knowledge, dissemination and teaching on the theme of chronic pelvic pain (CPP).
Concerning the Provoked Vestibulodynies (PVV), the goal of Convergences PP is:
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Define the disease and spread knowledge about positive diagnosis.
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Present a first-line treatment
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Make a list of existing and published second-line
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Vulvar pain: from childhood to old age
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Vulvar dermatoses: a cross-sectional 5-year study. Experience in a specialized vulvar unit
2022, Anais Brasileiros de DermatologiaCitation Excerpt :Although its etiology is multifactorial, it seems that muscle dysfunction of the pelvic floor is a key factor.14 When vulvar pain is limited to the vestibule and is generally triggered by friction, it is called secondary provoked vestibulodynia.15 In our series, 6 of the 8 patients with vulvar pain were diagnosed with vestibulodynia.
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2021, Journal of Gynecology Obstetrics and Human ReproductionCitation Excerpt :The Viscero-Visceral sensitization mechanisms, as described by Giamberardino [28], account for a common association with painful bladder syndrome through peripheral sensitization phenomena. Similarly, co-morbidities such as hyperesthesia of the vulvar vestibule, are connected with the occurrence of the frequent Provoked Vulvar Vestibulodynia (PVD) [29], which is responsible for introductory dyspareunia. But the most frequently associated disorders are pelvic floor muscle hypertonia and myofascial syndromes [26].
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Symposium of the 5th Congress of Convergences in Pelvic Perineal Pain, Brussels, 25–27 October 2018.