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P-059 - Multimodal and Interdisciplinary Interventions for the Treatment of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023.

POSTER ABSTRACT
Location:  Exhibit Hall
Abstract Title: Multimodal and Interdisciplinary Interventions for the Treatment of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023.


Background: Chronic pain is a significant public health burden that impacts the social, emotional, and physical functioning of those living with it.1 Among chronic pain conditions is vulvodynia, a vulvar pain condition of at least 3 months’ duration unrelated to a clear underlying cause.2 Localized provoked vulvodynia (LPV), the most prevalent vulvodynia subtype, is characterized by pain in the vulvar vestibule, and is provoked by pressure or touch, such as vaginal penetration.2,3

The Vulvodynia Guideline and its 2013 update4,5 provide a treatment algorithm consisting of vulvar care measures, topical, oral and injectable medications, physiotherapy, dietary modification, and psychological therapies, with vestibulectomy representing the last line in therapy. In the absence of professional society-endorsed guidelines with recommendations graded by evidence, many clinicians derive their management strategies from these publications. Research into the most appropriate treatment strategy for LPV remains limited.

Purpose/Objectives: Allodynia, pelvic muscle tension and myalgia, and psychological and relationship distress are frequent hallmarks of LPV. Multimodal therapy seems to be an intuitive approach. However, existing recommendations for multimodal management are largely extrapolated from findings in other chronic pain conditions,6 with limited evidence describing how pain due to vulvodynia directly maps onto the mechanisms of other chronic pain conditions.7 To evaluate multimodal interventions specifically directed towards management of vulvodynia, this scoping review aims to synthesize literature published between 2010 and 2023 evaluating the efficacy or effectiveness of multimodal approaches to the management of LPV. We collated and analyzed articles from 2010 to 2023 to capture the current research landscape. We highlight interventions that show beneficial effects, discuss gaps in the LPV treatment literature and provide recommendations for future research.

Methods: We used Arksey and O’Malley’s model for scoping reviews to identify the current evidence regarding the efficacy/effectiveness of multimodal or interdisciplinary interventions for the treatment of LPV.8 The inclusion and exclusion criteria and the search strategy were developed by a health sciences librarian in collaboration with subject experts. A PubMed search used controlled vocabulary and keywords relating to LPV, then translated into other databases. The initial search was conducted in June 2021 and updated in March 2023. All citations were uploaded to Covidence and screened for relevance. Full text review was conducted independently by two team members with conflicts resolved by the content experts, by consensus when indicated. Study details were extracted and reported narratively. Treatment modalities were categorized as physical, psychological, pharmacological, or interdisciplinary/multimodal and reported separately. This abstract reports on the efficacy/effectiveness multimodal or interdisciplinary interventional studies only. Somatocognitive therapy is reported with psychological interventions, elsewhere.

There is no consensus regarding terminology describing interventions that incorporate multiple treatment modalities into a single treatment program. Authors referred to these interventions as multidisciplinary or interdisciplinary. We refer to these as interdisciplinary. We refer to studies comparing interventions across classes not integrated into a single treatment program as multimodal.9


Results: We identified 27 studies, primarily published in Canada, the US, and Europe. Participants were young, partnered, educated, nulliparous, with 3-7y pain duration. Race, ethnicity and sexual orientation were underreported.

Physiotherapy versus Pharmacologic: One RCT produced three publications10-12 comparing topical lidocaine 5% versus weekly physiotherapy. Both treatments showed improvements in pain and sexual distress, but PT yielded some superior outcomes both after treatment and at 6-months.

Psychotherapy versus Pharmacologic: Three RCTs compared couple CBT with topical 5% lidocaine, with overlapping participants.13-15 Both therapies yielded improvements in sexual and psychological outcomes; CBT was sometimes superior for psychological outcomes. Two RCTs compared group CBT with topical hydrocortisone 1%, an inappropriate medication for LPV.16-17

Psychotherapy versus Physiotherapy: One RCT compared individual CBT with PT.18 Both groups showed equally improved dyspareunia. CBT resulted in improved sexual functioning and PT resulted in reduced pelvic muscle tone.

Multimodal versus Multimodal: One RCT compared acupuncture with “non-traditional” acupuncture, both groups also using topical lidocaine 5% with insufficient recruitment.19

Descriptive Studies Involving Multiple Interventions/Interdisciplinary Classes: Multiple studies described results of a combination of PT and lidocaine 2%, 26 oral amitriptyline, topical creams, and behavioral sex therapy,27 and 5% dextrose injections after topical anesthetic followed by compression prior to “central” vestibulectomy,37 two with positive results.26, 28 Two case series,33 one reported in a series of publications,6,29-32 evaluated interdisciplinary programs with mixed results for pain and sexual functioning.

Multimodal/Interdisciplinary Management Followed by Vestibulectomy versus Continued Multimodal/Interdisciplinary Management: Five cohort studies,20-22,24-25, 34 a case report 23 and a case series35 reported results of patients choosing surgical intervention after multimodal/interdisciplinary management, with cohort studies comparing results to those who continued multimodal/interdisciplinary management. Two cohort studies found vestibulectomy clearly superior, one for dyspareunia25 and the other for improved sexual functioning.31 Vestibulectomy was superior for CST pain in 3/5 studies,22,25,34 vulvar pain in one,24 with no difference in vulvar sensitivity in one.25 CST pain was incongruent with dyspareunia in two studies.25,34 There were mixed findings for intercourse frequency after treatment.20, 23 Overall, vestibulectomy was not superior for quality of life outcomes. There were many methodological issues. Adverse events were reassuring low.

Conclusions/Implications for future research and/or clinical care: There is insufficient evidence to suggest the superiority of one treatment modality for LPV relative to others or to recommend a particular interdisciplinary management strategy. Outcome measures are inconsistent between studies, often unvalidated, and may not adequately mirror patient concerns. The absence of appropriate comparator groups in many studies restricts providers’ ability to appraise which treatments may be most efficacious. Selection bias and demographic homogeneity limit generalizability. Finally, we highlight the need for head-to-head trials of vestibulectomy with other treatments considered first line for vulvodynia management. Future research should use a head-to-head design where sham control is impossible, incorporate patient-centered outcome measures, and investigate impacts of treatment among diverse samples of LPV patients.


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