Psychological Profiles Among Women With Vulvar Vestibulitis Syndrome: A Chart Review
Psychological Profiles Among Women With Vulvar Vestibulitis Syndrome: A Chart Review
Psychological Profiles Among Women With Vulvar Vestibulitis Syndrome: A Chart Review
The purpose of this study was to assess the prevalence and type of psychological
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INTRODUCTION
Vulvar vestibulitis syndrome (WS) is thought vulvodynia unrelated to intercourse is more
to be the most common diagnosis underlying characteristic of dysesthetic vulvodynia5,
chronic dyspareunia’. The few community where the precisely defined allodynia of WS
studies of dyspareunia in women under 40 is absent.There may be coexistent contraction
years of age give prevalence rates from 14- of the perivaginal muscles with attempted
2Z%2,3.Defined as severe pain on attempted vaginal entry, mimicking ‘vaginismus’,
vaginal entry, strictly localized hyperalgesial defined problematically as ‘vaginal ~ p a s m ’ ~ ,*L. A. OrOtto, Department
allodynia of the vestibule, and findings but widely considered to involve increased of Psychology. University of
Columbia, tR. Basson
limited to variable erythema4, W S may involuntary tone of the perivaginal muscles British and D. Gehring, BC Center
preclude entry of the penile head or cause without allodynia or other findings. The for Sexuality, Vancouver
painful intercourse, with penile movement presence of both W S and pelvic muscle Hospital, and Department of
Psychiatry and Qepartment
and ejaculation fluid typically increasing the hypertonicity is frequently d o c ~ m e n t e d ~ - of
~ .Obstetrics and Cyneco,ogy,
burning pain. Postcoital vulva1 pain and The etiology ofWS is unclear but histological University of British Columbia,
postcoital dysuria are usual, but ongoing findings are compatible with neurogenic Vancouver, Canada
“Correspondence to: L. A. Brotto, Outpatient Psychiatry Center, University of Washington Medical School, 4225 Roosevelt
Way NE, Suite 306, Seattle, WA 98105, USA. Email: [email protected]
i n f l a r n m a t i ~ n ' ~ -Premorbid
'~. factors with a different mental health clinician was
the potential to influence vulnerability to recommended when there were psychological
W S may be biological, given the recent issues unable to be fully addressed in the
preliminary data on polymorphism of the psychosexual counseling by the physician.
interleukin-1 receptor antagonist gene in Women were advised with respect to vulval
women with WS" and a subgroup of W S is hygiene and shown how to apply topical anti-
linked to chronic or recurrent Candida albicans inflammatory medication (sodium cromo-
overgrowth', and/or is psychological16. To glycate) on to the precise areas of allodynia
date, the literature examining an etiological (using a Icc syringe without a needle). In
role for psychological factors is equivocal"-". women with marked symptoms of over-
Of note there is marked heterogeneity of contraction of perivaginal muscles, the
responses to psychological enquiryI8, raising diagnostic exam was delayed until genital self
the possibility of shadowing psychopathology touch at home, along with a full under-
of a subsample ofwomen with W S by looking standing and acceptance of a detailed vulval
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only at the larger group. Therefore, in order exam, allowed their active participation.
to document the prevalence of specific, subtle Women were recommended pelvic muscle
indications of psychological maladjustment, physiotherapy and surface electromyographic
we conducted a retrospective chart review of biofeedbackwhenever allodynia did not remit
all women receiving a diagnosis of WS who with the other measures. Women were
were referred to a tertiary care facility during advised on stress reduction, and the few
a two-year period. women with troublesome (premenstrual)
vulvodynia were prescribed low dose
METHODS venlafaxine or minimally anticholinergic
tricyclic antidepressant (TCA).If, following an
Subjects
improvement in allodynia, involuntary
Results are based on women consecutively overcontraction of perivaginal muscles
referred to the BC Center for Sexual Medicine remained, a series of conical wax vaginal
For personal use only.
between February 2000 and February 2002, inserts and modified Kegel exercise were
for introital pain with all attempts at penile prescribed. Writen informed consent was
vaginal entry. The center is a tertiary care obtained from all female participants before
facility for the assessment and treatment of the questionnaires were administered. The
sexual dysfunctions in men and women. questionnaires took approximately 20
Follow-up data is based on visits conducted minutes to complete, and these were filled,
12-15 months after primary diagnosis. For either while t h e i r p a r t n e r was being
four patients due to their distance from interviewed, or at home and mailed back to
Vancouver, this information was supplied by the clinic. A brief explanation of how to
the referring physician. Questionnaire com- complete the questionnaires was given by the
pletion is a routine component of assessment physician during t h e clinical interview.
in this clinic; thus, no specific inclusion or Questionnaires that tapped various aspects of
exclusion criteria were employed. Approval personality and psychological functioning as
for this chart review was obtained from the well as sexual and relationship functioning
University of British Columbia and t h e were chosen. Four questionnaires (thePhobia
Vancouver Hospital Ethics Review Boards. Rating Scale, PRS; the Personality Assessment
Screener, PAS; the Golombok Rust Inventory
Instruments and procedures of Sexual Satisfaction, GRISS; and the Fear of
Couples were assessed together and indi- Negative Evaluation, FNE) were used to
vidually over two sessions,with one physician provide broad-based assessment in a relatively
primarily responsible for all assessments and brief, self-report format.
follow-up. The women were given a simple
description of pain physiology such that the Phobia Rating Scale
role of stress and their possible predisposition The 4item PRS was developed for use in our
to the physical sequelae of stress was clarified. clinic, and was adapted from a similar rating
An average of five one-hour visits to the scale used in the clinical assessment of
physician for ongoing conservative therapy patients with a specific phobia. Patients were
included psychosexual counseling and asked to rate (from 0 to 4) the extent to which
encouragement of non-penetrative sex. they feared and avoided any form of vaginal
Additional intensive psychotherapy (either penetration (e.g. tampon, finger or sexual
individual, couple, or group format) by intercourse). Additionally, the dichotomous
true/false statement ‘Although I can insert At each visit allodynia level was assessed
something into my own vagina, I would not on a self-report4-point Likert scale from 0 (no
allow another person to insert anything’ was pain) to 4 (profound pain). Intercourse ability
asked of each participant. was rated on a 3-point Likert scale from 0
(possible and free of pain), 1 (improved but
Personality Assessment Screener still painful) to 2 (not improved). Allodynia
and intercourse improvement scores were
The PAS is a valid and reliable, standardized,
obtained by subtracting the value given at
22-item questionnaire that asks participants
their final visit from the level assessed at the
to rate (false, slightly true, mainly true, very
initial visit.
true) the extent to which they agree with
For analyses in which published normative
statements. It is based on the parent instru-
data do not exist, results were compared to
ment, the PersonalityAssessment Inventoryz4,
data obtained from women participating in
and was developed to identify target areas in
other studies affiliated with our clinic.
need of further assessment. The PAS provides
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Women with W S scored significantly Figure 1 Percentage (%) of women with VVS
higher on the PRS than age-matched sexually (n),
(n = 50) scoring in the normal, (m),
mild, (a),
health women, t (71.99) = -8.06, p < 0.0001 moderate, and (I )clinically significant range
marked
on the Personality Assessment Screener (PAS)
(mean 6.18 and 1.20, respectively). Com-
parisons between women with W S and
an age-matched sexually healthy group
revealed no significant differences on the FNE, t (18.78)= 0.463, p > 0.05; or the GRISS
GRISS subscales of noncommunication (e.g., total score, t (41) = -0.757, p > 0.05. The only
asking your partner what he enjoys about the GRISS subscale to significantly differ between
sexual relationship),t (70)= 0.15, p > 0.05, or these groups was, predictably, the vaginismus
anorgasmia, t (68)= -1.86, p > 0.05. Women subscale, t (44)= -2,692, p = 0.010, with sig-
with W S did score significantly higher on the nificantly higher scores in women with both
For personal use only.
contraction on any of these personality Table 1 Personality Assessment Screener (PAS) profiles and effects of receiving
subscales, p > 0.05. additional psychotherapy among women with VVS who experienced remitted,
modestly improved, and no change in allodynia (n = 39), and intercourse ability
Allodynia and intercourse data at one-year (n = 41). Data represent number of women within each category
follow-upare available for 39 and 41 women,
respectively. There was an overall improve- Allodynia intercourse
ment in allodynia following treatment, Category outcome outcome
~ ~
variables to predict allodynia outcome. This difficulty that require further assessment,
time the FNE, standardized Beta = -0.318, identifies a subgroup with a significant
p = 0.037, emerged as providing the most experience of personal distress and un-
unique variance. happiness, social withdrawal, difficulties
with anger management, intense need to
DISCUSSION exert control, and somatic complaints. The
Unlike erectile dysfunction which may affect finding that only 32.7% showed normal
up to 7%of men under the age of 402,chronic psychological profiles whereas 14.3%scored
dyspareunia in women of this age group has in the markedly clinically significant range,
received little research attention. Given the and almost a quarter of the sample admitted
limited efficacy of the various medical, to thoughts of death and suicide emphasizes
surgical, physical and behavioral therapeutic the distress of some women with this syn-
interventions’$, increased understanding of drome.
subgroups of women with W S may allow The concept that personality inventories
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more effective therapy. The areas of allodynia may reflect significant aspects of personality
are remarkably consistent**.”.and patho- without necessitating the presence of full-
physiological mechanisms may include those scale personality provides the
of neurogenic inflammation and central and rationale for their use in women with W S .
peripheral sensitization of dorsal horn cells The instruments employed mostly assess
in the spinal cord”. In addition to altered aspects of personality that are trait, rather
descending input from the brain, there may than state characteristics. This, combined
be increased afferent input from the typically with the finding that clinically significantly
hypertonic pelvic mu~cles’~. Peripheral sensi- profiles were seen in a similar percentage of
tization from products of i n f l a m ~ n a t i o n ~ ’ women
~ ’ ~ ~ ~ ~with life-long and acquired W S ,
and upregulated nerve growth factor3> supports the concept that stable psycho-
provokes peptide release from sensory nerve logical factors, rather than situation specific
For personal use only.
muscle tone (spasm) that interferes with are the women with significant psychological
intercourse but is not accompanied by features on t h e PAS whose allodynia
allodynia or other findings on physical improved, with complete healing in seven
examination, i.e., women with ‘vaginismus’. (although three of these did receive extra
The lack of significant difference in psycho- intense psychotherapy).In contrast, less than
logical inventories between women with WS a quarter of the women with a normal PAS
and those with ‘vaginismus’ is in keeping and remitted allodynia required additional
with the frequently reported difficulty in psychotherapy. The assessment of FNE
distinguishing these two g r o ~ p s ~Con- -~. appeared especially helpful in predicting
firming the research of yet in outcome given that those with more intense
contrast to s ~ m e ’ ~the
, ~ majority
~, enjoyed fear of others’ negative evaluation had less
non-penetrative sexual stimulation, were improvement in allodynia. This and the result
orgasmic, enjoyed non-sexual physical from the multiple regression analysis support
affection, and felt they could communicate the inclusion of this instrument, as well as
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well with their partners. Therefore, in the vaginal PRS, as both contribute signifi-
reference to the dilemma of ‘do these women cant unique variance in predicting treatment
experience painful sex or sexual pain?5, it response.
would appear to be both. The pain is Regarding the ability to have painless
associated with a degree of phobic fear of intercourse, three variables emerged as
vaginal entry. significant predictors of poor improvement
Although at one year 90.5% had less - high sexual avoidance and vaginismus
allodynia, only 40% reported painless subscores on the GRISS, and an overall
intercourse. Perhaps it is not surprising that clinically significant PAS score. It is of interest
women with lifelong versus acquired that the majority of women with W S who
symptoms showed less improvement in coital progressed to painless intercourse without
pain - there being no positive past memories. the need o f further intense psychotherapy
For personal use only.
This was despite similar improvement in did not show overall high levels of psycho-
allodynia in the two groups. While for some pathology. Failure to follow through with
women, interpersonal difficulties or lack of recommended additional psychotherapy is
a partner were relevant, for others it was the also of predictive value given that only one
residual allodynia, or continuing pelvic of the seven women was able to progress to
muscle hypertonicity, or continued fear of painless intercourse.
pain that resulted in ongoing dyspareunia or Relating the psychological profiles to
their reluctance to attempt penile entry. outcome at one year is problematic since this
Unfortunately, women with WS can rarely is a clinical population, with each couple
capitalize on the clinical report of increased receiving slightly different treatment. The
pain threshold with sexual arousal since the number of physician visits and additional
latter typically lessens as soon as penile psychotherapy received varied, depending on
introital contact is attempted. Moreover, need and ability of the couple. Pelvic muscle
when WS persists, many women become physiotherapy was recommended whenever
avoidant of sexual cues and triggers through the allodynia did not completely remit with
the day resulting in fewer sexual thoughts topical sodium cromoglycate,stress reduction
and lowered sexual self-image.At the time of and avoidance of penetrative sex - but some
sexual interaction, despite the various women could not afford the cost. However,
therapeutic interventions, the risk is that the given that all women were offered the same
woman’s arousability will remain low. Some modalities of treatment whenever they were
physical discomfort for a woman who is deemed necessary, and motivation to follow
nevertheless subjectively and physiologically through may itself be linked to the psycho-
sexually aroused is vastly different to the logical features of these women, the findings
experience of the woman who is unaroused, are of some interest. Another methodological
feeling sexually substandard and who consideration is that the current sample
otherwise strives to excel in all aspects of her represents women seeking treatment for WS,
life. and their personality style may differ from
The majority of women with improved those choosing to live with the condition.
allodynia from the standard five visits for Yet it is of interest that FNE scores were
medical therapy and psychosexual counseling significantly higher than those of women
by the physician did not show a clinically choosing to present for help with orgasmic
significant psychological profile. Of interest problems. The extent to which fear of negative
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