Medical and Psychosexual Assessment of a Cohort of Patients

Marek Jantos, M.A. and Gordon White, F.A.C. Ven., M.F.P.H.M.,M.H.P.

OBJECTIVE: To study medical, psychosexual, personality and relationship parameters and the resulting illness behaviour and psychopathology in patients with the vestibulitis syndrome.

STUDY DESIGN: Following full medical screening, questionnaires were administered that included assessment of vulvar pain, sexual history, personality, depression and illness behavior. The 50 patients who met the diagnostic criteria of vestibulitis syndrome formed the cohort of this study. RESULTS: Medical and psychological conditions most frequently reported included vulvovaginal candidiasis (96%), premenstrual syndrome (85%), dysmenorrhea (85%), urologic symptoms (67%), depression (60%), change in body image (63%) and suicidal ideation (57%). The mean duration of dyspareunia-associated vulvar pain was 85 months (range, 2-480), with an associated decrease in sexual interest, desire and activity (91%). Although patients satisfied a number of somatization disorder criteria related to age, course of the condition, gastrointestinal symptoms, sexual problems and multiple pain sites, there was insufficient evidence for such a diagnosis. Patients scored high on personality scales, including organization, concern about mistakes and personal standards.

CONCLUSION- Common medical profiles, personality traits and psychoosexual problems highlight the parallelism between the vestibulitis syndrome and somatization disorders, but subtle variations allow differentiation on clinical assessment. (j Reprod Med 1997;42: 145-152)

Keywords: vulvar diseases, vestibulitis.

Introduction

More than a century ago in 1889 Skene(1) described pain on touch and examination of the vulva, and in 1928 Kelly(2) observed the occurrence of tender areas close to the hymenal ring sufficient to cause the patient to cry aloud. In 1976 Pelisse and Hewitt(3) described 30 patients with erythematous vulvitis with chronic inflammatory cells in the submucosal tissue. Then, in 1983, Woodruff and Parmley(4) described 15 patients with infection of the minor

vestibular glands; subsequently, in 1986, Peckham et al(5)reported on 67 women with a condition they called focal vulvitis. A year later, in 1987, Friedrich(6) offered the first classification, describing the condition as the vulvar vestibulitis syndrome. He described a syndrome composed of pain on penetration (entry dyspareunia), tenderness to touch at the introitus and mild to moderate introital erythema.

Patients frequently report additional symptoms and signs, variously described as vulvodynia (burning), that may persist for some hours and days either after intercourse or tampon insertion or removal. Others complain of urinary symptoms that include frequency and dysuria. Swelling of the vulvar tissue and occasional pain in the upper thighs are also associated.

Studies(5,6) have shown that the condition generally occurs between the ages of 20 and 45 years and can persist for many years, severely inhibiting sexual activity and even destroying relationships. Goetsch(7) reported a prevalence of 15% of vulvar vestibulitis patients in a general gynecology population. Furthermore, she raised the issue of genetic predisposition based on her finding that 32% of patients had a female relative with dyspareunia or tampon intolerance.

Patients describe vestibular pain and discomfort as easily provoked by any pressure against the vulva and vestibule. Some patients find it uncomfortable to sit for extended periods of time, and some have difficulty walking, exercising or wearing tight jeans. Others find that the condition fluctuates with the time of day, course of the menstrual cycle, stress levels and general fatigue.

On vulvar examination, tenderness is readily elicited using a cotton-tipped applicator just distal to the hymenal ring but proximal to Hart's line. While the tenderness can occur anywhere around the hymenal ring and sometimes the whole area is involved, most commonly the sensitivity is found at the 4 and 8 o'clock positions and can be associated with local brisk vasomotor disturbances. Tenderness can sometimes be elicited by digital pressure over the lateral walls of the vagina at the level of the pubococcygeus muscle and over the base of the bladder.

The etiology of the condition remains elusive, and while efforts have been made to find an infectious cause, microbiologic and virologic investigations have not been rewarding.(8,9) Repeated biopsy has shown only scattered mild chronic inflammation. The minor vestibular glands are seen to be clear in the lumen but are generally packed around with inflammatory cells.

The adverse effects on sexual activity and consequent relationship problems lead to repeated unsuccessful consultation with multiple physicians. With the persistent symptoms, paucity of clinical features and lack of demonstrable pathology, the possibility of a psychogenic etiology has often been considered. Patients have been most reluctant to accept any suggestion of a psychological cause of their problem even in the presence of obvious emotional liability and dependence. The pain is real to them, is reproducible and can often be modified or diminished through self-help measures. Despite the drawbacks associated with the diagnosis of vestibulitis, it is noteworthy that for many patients such a diagnosis becomes a positive turning point, enabling them to pursue a course of treatment with some degree of hope and optimism.

Lynch,(10) in a review of a cohort of vulvodynia patients, identified certain general health and psychological characteristics, including recurrent headaches, low back pain, irritable bowel symptoms, fatigue, insomnia, high levels of depression with suicidal tendencies, anger and evidence of obsessive-compulsive behavior, pointing to perfectionistic tendencies. Schover et al(11) observed an association with a history of sexual trauma, depression and substance abuse, marital conflict and chronic nongenital pain syndromes that together may suggest some form of somatization disorder. On account of these reported observations, it is necessary to approach the assessment of vestibulitis syndrome in a holistic and multidisciplinary manner.

The goals of this study were to identify the medical and psychological characteristics of our cohort and, in particular, to study the psychosexual and relationship patterns, personality characteristics, illness behaviour and any psychopathology that may be associated with the condition.

Materials and Methods

Patients were seen at the Sexual Medicine Unit, at Woden Valley Hospital (Gilmore Clinic). Initially all were screened medically, undergoing a physical assessment with a vulvar and pelvic examination, including laboratory screening to identify any sexually transmitted diseases. Subsequently patients completed a psychosexual evaluation that was followed by an electromyographic (EMG) assessment of the pelvic floor. Based on this comprehensive assessment, medical treatment was outlined, psychosexual counselling provided and appropriate biofeedback-assisted neuromuscular rehabilitation advised. All patients were given a pamphlet on vestibulitis that included a summary of the condition and a list of various treatments available, including a series of home (self-help) techniques to alleviate symptoms.

Clinically patients were considered to have vestibulitis if they had the three characteristics described by Friedrich.(6) Further inquiry was also made for each of the following: urinary frequency with or without incontinence, vulvar dryness with or without pruritus, and a sensation of swelling and vulvar burning.

The psychosexual assessment carried out included a general vulvar pain questionnaire developed by the Gilmore Clinic, a Sexual History Form,(12) personality assessment using a Multidimensional Perfectionism Scale (MPS),(13,14)depression questionnaire (using the Beck Depression Inventory [BDI])(15) and an assessment of the patient's response to illness using the Illness Behavior Questionnaire (IBQ).(16) Patients were also assessed against the various criteria of somatization disorders, as outlined in the Diagnostic and Statistical Manual, fourth edition (DSM IV).(17)

Table 1 Reported Occurrence of Medical Symptoms

Table 2 BDI Analysis

Subsequently an EMG assessment of the pelvic floor was carried out using a single-user vaginal sensor (T6050, Thought Technology, Ltd., Montreal, Quebec, Canada) and computerised electromyographic analysis using the Glazer Pelvic Muscle Rehabilitation Program, Version 2.2 (by Gary E. Jarvis, 1995; American Biomedical Equipment, Tampa, Florida). The procedure is described elsewhere.(18,19)

Results

Demographic Variables

The mean age of the 50 patients was 32 years (range, 16-64), 23 (46%) were married, 14 (28%) were single, and 13 (26%) were in stable or other relationships. The average number of sexual partners for the cohort was seven (with a range of 0-35). The average number of medical consultations in the past 12 months related to this condition was nine. All patients were white.

Medical Variables

Information on specific symptoms was sought from the cohort to determine the pattern of their past medical history; the results are summarized in Table 1. The presence of vulvovaginal candidiasis or thrush was counted even if the condition had not been diagnosed in the laboratory by swab or culture. Premenstrual syndrome was considered if patients reported having a cyclic history of breast tenderness, fatigue, swelling of the lower extremities, bloating, mood changes, abdominal cramps and tension/anxiety headaches during the period 7-10 days before the onset of menses.

Psychological Profile

The psychological data were obtained from two primary sources, self-reports obtained from the clinic questionnaire and assessments made at the time of the first visit using the BDI, MPS and IBQ.

A total of 30 (60%) patients reported suffering from depression and 25 (50%) from anxiety; 27 (54%) suffered from headaches and migraines, and 19 (38%) were affected by insomnia.

Using the BDI for clinical assessment, the prevalence of depression was much higher, with 89% of patients scoring in the mild to potentially serious range of depression scores and over half (57%) reporting suicidal ideation or intent (Table 11).

Depression Scale Analysis

Table 11 lists the results obtained from assessments using the BDI.

The scores obtained from the MPS confirmed the presence of perfectionistic traits. Patients scored in the high range on two subscales, organisation and personal standards, and in the medium range on concern with mistakes, doubts about performance and parental criticism.

The IBQ, which quantifies the way in which individuals experience and respond to their illness, assisted in examining the patients' attitudes, ideas, affects and attributions and provided insight into illness-related behaviour. The IBQ helps to delineate the psychosocial dimension of physical disease in patients who may present with a mixture of problems.(20) Furthermore, the IBQ provides information that may be relevant to patient management. The data from this study revealed a low level of concern and anxiety about the patients' health, with no evidence of phobic or hypochondrial behaviour (low score on hypochondriasis scale, mean of 31). Patients had a preoccupation with symptoms and affirmation that a disease was present (high score on disease conviction, mean of 66) and a disbelief that the symptoms were of psychogenic origin (low score on psychological vs. somatic scale, mean of 42). However, a number of the chronic sufferers (30%) perceived themselves as being in need of psychiatric, rather than medical, treatment, with a tendency to feel responsible for and deserving of their illness. Patients reported experiencing considerable difficulty in expressing their feelings (high scores on affective inhibition, mean of 60), with increased irritability and anger (high scores on irritability, mean of 50), and suffered high levels of anxiety and depression (high scores on affective disturbance, mean of 70). Patients scored low on denial (mean of 40), indicating a realistic outlook on life stresses.

Patients gave no evidence of general hypochondriasis but a firm conviction that their chronic pain was of organic origin.

Table 3 Comparison with Somatoform Disorder

The lack of a diagnosis rise to feelings of anger and irritability, and the chronicity of the symptoms gave rise to high levels of anxiety and depression.

Psychosexual Parameters

The mean duration of vulvar pain with a corresponding history of dyspareunia was 85 months (range, 2-480). The group's mean pain rating was 8.5, where the severity of the pain was assessed subjectively on a scale of 0-10 (where 0 is no pain and 10 the worst possible pain).

The impact of vulvar pain on sexual functioning appeared to be most significant. With the onset of vulvar discomfort, 95% of patients reported pain associated with sexual activity, and 91% confirmed a decrease in sexual interest, desire, arousability and activity.

Comparisons with Somatoform Disorders

The diagnostic criteria for somatization disorderly focuses on a history of multiple physical complaints starting before the age of 30 and lasting for several years. The symptoms must be suggestive of a general medical condition but are not fully explained by medical assessment. The disorder is characterized by a combination of pain, gastrointestinal, sexual and pseudoneurologic symptoms. Table III presents the results of comparisons between somatoform disorder and the characteristics of our vestibulitis cohort.

Discussion

The vestibule of the vulva is covered with squamous epithelium that is not only nonkeratinous but also non-pigmented and devoid of normal skin appendages other than minor mucus-secreting glands located circumferentially around the hymen, with openings at the ductal orifices of Bartholin's gland, Skene's ducts and the urethra. The vestibule is supplied by the pudendal nerves of S-3 and S-4 origin. Krantz(21) found that the hymenal area was generally lacking in specialized nerve endings except for pain nociceptors.

The etiology of the vestibular syndrome may have its inception in physical or chemical trauma (e.g., candidiasis and its treatment, childbirth, episiotomy, C02 laser burn, sexually transmitted diseases, physical assault). Candidiasis has long been considered a common factor in the background of these patients. In our group a prior history of vulvovaginal candidiasis was reported by 96%. While most of these reports were undocumented and could represent misdiagnosis, many had been treated as thrush by their general practitioners and prescribed topical creams. Many had purchased anticandidal creams over the counter from their pharmacists. In Friedrich's studies,(6) 63% of women reported candidiasis, as did 67% of Peckham's(5) patients, and in Schover's study,(11) 44% of patients reported a history of chronic vaginitis. Lynch(10) noted that recurrent vulvovaginitis was the second-most common provocative factor in vulvodynia according to patient's reports. Despite multiple trials using topical antifungal creams and pessaries, the outcome in our patients was generally unsuccessful, and the effect on vulvar discomfort and pain per se was poor or nonexistent, with some even reporting an exacerbation of symptoms.(22)

The vestibulitis syndrome appears to start with physiologic pain arising from damaging stimuli that progress to hyperalgesia (exaggerated response to painful stimuli) and ultimately resulting in allodynia (painful response to light touch). Our clinical observations and data suggest that vestibular pain is mediated by peripheral sensitization of nerve endings, which become increasingly responsive to both painful and innocuous stimuli.

EMG assessment of superficial and pelvic musculature shows muscle instability and hypertonicity,(18) reflective of an irritable (sensitized), hyperactive nerve, consistent with hyperalgesia and allodynia. Both of these conditions are associated with pathologic pain. Recent animal studies(23) provide evidence of pPostaglandins inducing allodynia by sensitizing nociceptors. Further clinical studies are required to establish the role of prostaglandin nerve sensitization and vulvar pain.

Whatever the etiology of the vestibulitis syndrome, the condition has a major adverse affect on the sexual and relationship functioning of affected individuals. This emphasises the need to examine the condition in a psychosexual context.

Demographically, the mean age of patients in this study was similar to that in previous studies. The lifetime number of sexual partners was different from that reported by Lynch(10) but comparable to that reported by Peckham et al.(5) A higher percentage of our patients (42%) reported a history of sexually transmitted diseases. It is possible that this higher reporting could be due to patients' being seen in a sexual medicine unit, where they receive comprehensive treatment for all sexually related conditions. Previous clinical observations strongly suggest a link between chronic pelvic pain, including dyspareunia, with a history of sexual abuse or trauma as either a child or adult. In our study, 26% reported such a history as compared with 19% in Schover's(11) study and 12% in Friedrich's group.(6)

It is generally accepted that about 30% of patients of reproductive age will report having the premenstrual syndrome (PMS),(24-26) whereas in our series the rate was considerably higher (85%), with a large percentage of patients (85%) also suffering from dysmenorrhea. The vestibulitis/PMS/dysmenorrhea relationship noted in this study adds complexity to the understanding and treatment of vestibulitis on several counts. PMS is often defined as "distressing, physical, psychological and behavioral symptoms, not caused by organic factors, which recur regularly during the same phase of each menstrual (or ovarian) cycle, and which significantly regress or disappear during the remainder of the cycle.(11,27) The emphasis is on "symptoms not caused by organic factors," thus, by default, pointing to psychogenic problems.

Several studies(28,29) point to a correlation between PMS and dysmenorrhea. Our data confirm such a relationship. Some explain the PMS/dysmenorrhea relationship in purely psychological terms; others link it to local hormone synthesis of Prostaglandins and their mediation of immune and inflammatory mechanisms.(30) Menstrual pain has been shown to be associated with high levels of endometrial prostaglandin production, which contributes to vasoconstriction and may result in myometrial ischemia.(31) Prostaglandins may also contribute to pain induction (allodynia) and a lowered threshold for pain.(30,32) The general question then arises, what other possible links exist between vestibulitis, PMS and dysmenorrhea? There is a need to examine this relationship more closely.

Persistence of pain tends to have a debilitating effect on the patient's psychological well-being. Chronic pain is frequently associated with depression, and estimates of the prevalence of mood disorder in chronic pain patients vary considerably, reflecting both the shortcomings of the measures and diagnostic procedures used and variations in the populations studied. Lynch(10) noted that depression was present in all his older patients and in 80% of the younger ones. Schover et al(11) found a 36% prevalence of depressive symptoms and 42% somatization. Our patients tend to underreport the incidence of depression. Only 69% of patients gave a history of depression on self-report questionnaires, while our clinic assessment, using the BDI, showed 91% to be mildly to severely depressed, with 57% revealing the presence of suicidal ideation or intent.

Since PMS itself can lead to disruption of personal and professional lives and since the incidence of depression in PMS is about 50%, it is not possible to exclude the effect of the premenstrual depressive component on our vestibulitis patients. Further study is required to determine whether depressive episodes in vestibulitis syndrome are linked to perfectionistic traits, PMS or endogenous factors or are a reflection of the vestibulitis per se.

Following the observation made by Lynch(10) that many vulvodynia patients present with obsessive compulsive and perfectionistic tendencies, an attempt was made to identify the presence or absence of such personality traits in this group of patients. Frost et al(13,14) identified the multidimensional nature of this construct and designed a scale to measure it, reporting that perfectionism has been associated with a wide variety of psychopathologies, including depression, suicide, eating disorders, irritable bowel syndrome, abdominal pain, obsessive compulsive personality disorder, sexual dysfunction and others.

Patients in our study obtained medium to high scores on subscales of organization, personal standards, concern with mistakes, doubts about performance and parental criticism.

There is some evidence that the high level of depression assessed in this cohort (91%) was not only related to chronic pain but it could have been linked in part to perfectionistic tendencies. This view is supported by patients' high concern with body image on account of vulvar pain, their perception of pain as punishment and a sense of hopelessness reflected in suicidal ideation and/or intent.

Assessment of illness-related behaviour provides confirmation of our patients' overall conviction of the presence of disease of organic and not psychogenic origin. Patients scored high on the affective disturbance scale, indicating high levels of anxiety and depression. However, our results show that there was no evidence of phobic or hypochondriacal behavior. High scores on the affective inhibition scale confirmed that patients experienced considerable difficulty expressing feelings. This is consistent with research that patients with chronic pain and depression share an inability to modulate or express intense, unacceptable feelings.(33) This may be especially the case among a group of individuals with perfectionistic tendencies, who may perceive the expression of intense feelings as a sign of weakness.

In the past there has been a tendency to view vulvar pain as indicative of a somatization disorder. This may have been in part due to a poor medical understanding of the condition and a tendency to perceive the problem as "originating in the head" and thus, by implication, reflecting on the person's emotional and mental state. According to the diagnostic criteria in the DSM IV, patients in this study satisfied a number of criteria for somatization disorder (Table 3). Specifically, patients reported the onset of symptoms in their early adult years, and the course of the symptoms appeared to be chronic. There was no evidence of manipulative sexual avoidance behaviour in our cohort. Furthermore, based on Goetsch's study,(7) the incidence of vestibulitis is far greater than that of somatization disorders. Somatization disorders can overlap with a multitude of general medical conditions, and thus it is not surprising that vestibulitis patients satisfy some of these criteria. This parallelism highlights the fact that unless the medical attendant is skilled in properly diagnosing and identifying the subtle differences, patients will not only be suspected of having somatization disorder, but their medical and psychological burden will become unnecessarily more complex.

Acknowledgments

The authors wish to acknowledge the permission given for this study by the Ethics Committee, Department of Health and Community Services, Australian Capital Territory.

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