A Multidisciplinary Approach to the Study of Vulvodynia

By Marek Jantos Ph.D.

With pain as its primary symptom, vulvodynia has perplexed medical and allied health professionals for more than a hundred years. To date a multidisciplinary approach to the study of the disorder has enriched discussion and encouraged productive controversy (Binik, 2005). Such controversy has been unavoidable given the nature of the topics involved.
Because vulvodynia is defined as an idiopathic pain condition in which the absence of pathology is a defining feature (Moyal-Borracco & Lynch, 2003), it generates considerable debate regarding its etiologies, management and classification. In other chronic pain conditions the lack of pathology is a recognized anomaly and a lack of association between visible pathology, pain severity and disability is not questioned (Steege et al., 1997; Jantos, 2007). However, in relation to urogenital pain, such an absence is viewed with suspicion. As a result, some regard vulvodynia as a sexual dysfunction (APA, 2000; Basson, 2005), while others see it as a somatoform disorder (Dobson & Friendrich, 1978; Lynch, 2008). However, a growing number of researchers and clinicians view it as pain syndrome (Binik et al., 1999; Haefner et al., 2000; Pukall et al., 2003). How the condition is perceived and classified will ultimately influence the way it is managed and will affect the selection of the primary case manager, be it a pain therapist, a sex therapist or a physician (Binik, 2005).

Because chronic vulvar pain impacts upon many aspects of the individual’s wellbeing, the discussion of etiology, classification and management inherently involves discussion of the complexities of human sexuality, of chronic pain, and calls for a multidisciplinary outlook (Steege et al., 1998; Sandownik, 2000; Innamaa & Nunns, 2005). To appreciate the need for a multidisciplinary approach, it is important to briefly reflect on the intricate nature of human sexuality and the complexity of chronic pain.

In relation to sexuality, the human sexual response is an ultimate example of the blending of mind and body and requires more than a discussion of biology and psychology (Schultz et al., 2005). Sexuality consists of an intricate interaction between physiology, emotions, attitudes, values and lifestyle, and requires a detailed scientific approach (Phillips, 2000). To illustrate, at the physiological level it is coordinated by subtle neurologic, muscular, vascular and endocrine system changes (Bachmann & Phillips, 1998). At the emotional level it is associated with self-esteem, personal fulfillment, happiness and interpersonal bonding. At the social level, values, norms and lifestyle practices shape the way in which the most intimate affections find expression (Phillips, 2000). If sexuality, as an idiom for the expression of emotional and physical intimacy is thwarted, the ramifications for personal wellbeing and for relationships are wide-ranging (Sargeant & O’Callaghan, 2007; Desrosiers et al., 2008). Many of these multidimensional aspects of sexuality have been examined in relation to vulvodynia and generate diverse and often inconsistent findings. Some of these will be reviewed in this chapter.

The complexity of studying chronic pain also brings together contributions from many disciplines, each sharing a unique perspective on the topic. Chronic pain is a far more complex phenomenon than acute pain (Steege, 1998; Merskey & Bogduk, 1994). Aristotle considered pain to be a passion of the soul, characterized by a mingling of sensation and emotion (Blackwell, 1989). The modern definition of pain maintains the Aristotelian view defining pain as an “unpleasant sensory and emotional experience”(Merskey & Bogduck, 1994). The word pain derives from the Greek term poine, meaning punishment (Blackwell, 1989). In ancient times pain was perceived as a punishment from the gods. In modern times vulvodynia patients are often burdened by guilt, stemming from their own perception that their pain is a form of punishment (Jantos & White, 1997). Hence, the experience of pain is associated with significant emotional distress, anxiety and depression (Jantos & Burns, 2007). The sensory and emotional aspects of pain need to be recognized and studied in a scientific and multidisciplinary manner. Clinicians who tend to view vulvodynia as an expression of emotional tension or psychosexual conflict, inadvertently reinforce certain misconceptions about chronic pain that add to the patient’s distress and may be counterproductive in restoring the individual’s sense of wellbeing (Reed et al., 2000; Kaler, 2005).

When the themes of sexuality and chronic pain are brought together, as in the study of vulvodynia, the complexity increases, creating a multifaceted and composite discussion, which often lacks any general consensus. As a result, some have advocated the formation of a new multidisciplinary subspecialty of sexual medicine (Goldstein, 2007), while others have proposed the establishment of a new science of vulvology, with a specific focus on the study of the vulva (Micheletti et al., 2002).

This thesis contributes towards a multidisciplinary approach to the study of vulvodynia and approaches the topic from a psychophysiological perspective. In recognizing pain, as a “sensory and emotional experience” (Merskley & Bogduk, 1994), the thesis seeks to avoid the traditional dualistic perspective in which the physical and the emotional aspects are seen as separate entities and instead examines their unique interaction, as reflected in the experience of the patient.