A psychophysiological perspective on vulvodynia.

Abstract

The study of human sexuality opens an intriguing window into human existence and the individual’s sense of wellbeing. From a population standpoint, sexuality is an integral part of human reproduction, but from the perspective of the individual, sexuality can also be a source of pleasure and the basis of interpersonal bonding and happiness (O’Donohue & Geer, 1993). Sexuality crosses many dimensions of the human experience, any difficulties encountered in the expression of emotional and physical intimacy can have a wide and multidimensional impact (Basson, 2005). Vulvodynia is a prevalent chronic pain condition in women affecting the lower urogenital tract (Moyal‐Barracco & Lynch, 2003; Harlow & Stewart, 2003). It interferes with an array of activities, including sexual intimacy, and compromises quality of life (Sandownik, 2000; Jantos & Burns, 2007; Arnold et al., 2006). The disorder can significantly undermine self-esteem, impacts on relationships, and engenders significant psychological distress in the form of anxiety and depression (Jantos & White 1997; Masheb et al., 2005; Jantos & Burns, 2007; Jantos, 2008). Various causes have been theorized and many treatments proposed, but there is no consensus on its classification and management (Masheb et al., 2000; Bachmann et al., 2006). The practical and theoretical implications of a proper understanding of the disorder and its accurate classification are important (Lynch, 2008; Binik, 2005). Structure and outline of the thesis This thesis consists of three publications which include two research studies (Chapter 3 & 4) and a discussion paper (Chapter 5). The two research papers assess the psychosexual and psychophysiological profile of a cohort of women diagnosed with vulvodynia and the discussion paper focuses on conservative management of vulvodynia and other conditions linked to pelvic floor dysfunction. As an introduction to the three publications, the first chapter discusses the role of sexuality in general wellbeing. It provides a historical background to the study of vulvar pain and introduces classification systems that address the issue of painful sexual intercourse. It also reviews current perspectives on the nature of the disorder, its prevalence, etiology and management. Chapter 2 outlines the rationale, aims and structure of the research studies. Vulvodynia is a poorly understood but prevalent disorder that has been identified as a neglected women’s health problem (Binik, 2003; Haefner et al., 2000). Therefore, further information is needed about the population affected by the disorder, about the impact on wellbeing, and about the potential mechanisms mediating symptoms of pain, so that protocols can be developed for its effective management. Chapters 3, 4 and 5 are reprints of the three publications forming the core of this thesis. Chapter 3, entitled Vulvodynia: Development of a Psychosexual Profile, is a retrospective study of seven hundred and forty-four patients. It examines the age of symptom onset, the age distribution of the clinical cohort and the age related risk of developing the condition. The study identifies a range of psychosexual changes associated with the disorder. Chapter 4, entitled Vulvodynia: A Psychophysiological Profile Based on Electromyographic Assessment, is also a retrospective study. It is based on five hundred and twenty-nine patient cases and sought to assess the location and temporal characteristics of chronic vulvar pain, the relationship between psychological and physiological variables in the experience of pain, and the role of dysfunctional pelvic muscles in mediating the symptoms of vulvodynia. Both of these research studies make an original contribution to the current understanding of vulvodynia and present data derived from the largest clinical sample studied to date. Chapter 5 entitled Electromyographic Assessment of Female Pelvic Floor Disorders, is a review of literature examining pelvic floor anatomy and physiology and views pelvic muscle dysfunction as the primary mechanism mediating a spectrum of pelvic disorders, including vulvodynia. It reviews research on the applications of surface electromyography (SEMG) in relation to vulvodynia and a range of pelvic disorders associated with both hypertonic and hypotonic muscle states. Guidelines are suggested for conservative management of these disorders. Chapter 6 discusses the contribution of the three publications to the current understanding of vulvodynia and draws on the research findings of this thesis, and other literature, to arrive at several key recommendations in relation to its classification and management. The primary recommendation of the thesis is that vulvodynia should be seen as a chronic pain syndrome rather than a psychiatric disorder or a sexual dysfunction and that the management of pain should be the foremost priority.