Victoria A Jackman et al., 2024: Physical Modalities for the Treatment of Localized Provoked Vulvodynia: A Scoping Review of the Literature from 2010 to 2023

Tuesday, 08 October 2024

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Victoria A Jackman 1 , Krisztina Bajzak 2 , Alex Rains 3 , Michelle Swab 4 , Michelle E Miller 2 , Gabrielle S Logan 5 , Diana L Gustafson 6
1Faculty of Medicine, Memorial University, Newfoundland & Labrador, St. John's Canada.
2Discipline of Obstetrics and Gynecology, Memorial University, Newfoundland & Labrador, St. John's Canada.
3Department of Medicine, University of Chicago, Chicago, IL, USA.
4Health Sciences Library, Faculty of Medicine, Memorial University, Newfoundland & Labrador, St. John's Canada.
5Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
6Division of Population Health and Applied Health Sciences, Faculty of Medicine, Memorial University, Newfoundland & Labrador, St. John's Canada.

Abstract

Introduction: Localized provoked vulvodynia (LPV) is a prevalent sexual health condition with significant negative impacts on quality of life. There is a lack of consensus regarding effective management.

Methods: We used Arksey and O'Malley's five-step method to identify, collate, and evaluate literature published between 2010 and 2023. The scoping review investigated the efficacy or effectiveness of interventions in the management of LPV. The aim of this paper is to map the literature on the efficacy or effectiveness of physical interventions.

Results: The review produced 19 primary studies of physical interventions for LPV. These include acupuncture, laser therapy, physiotherapy, transcutaneous electrical nerve stimulation, low-intensity shockwave therapy, transcranial direct current stimulation, and vestibulectomy.

Conclusion: Published studies that investigated a range of physical treatments for LPV showed some positive effects, except for transcranial direct-current stimulation. The remaining modalities demonstrated improved sexual pain and treatment satisfaction, when measured. Findings were mixed for non-sexual pain. There was insufficient evidence to draw conclusions regarding other outcomes. Researchers are encouraged to conduct larger, high-quality studies that sample more diverse patient populations and use patient-oriented outcomes to assess effectiveness of physical modalities.

Int J Womens Health. 2024 May 6:16:769-781. doi: 10.2147/IJWH.S445167. eCollection 2024.
PMID: 38737495 PMCID: PMC11086396

Comments 1

Jens Rassweiler on Tuesday, 08 October 2024 11:00

Context: LPV is a common condition with significant consequences on sexual and general quality of life.
Challenge: There is no consensus on the most effective treatments for managing LPV, leaving patients and clinicians without clear guidance.
Aim: The purpose of this scoping review is to explore the range of physical interventions used for treating LPV and evaluate their efficacy or effectiveness.
Methods
• Framework: The review follows Arksey and O'Malley’s five-step method for conducting scoping reviews, which involves identifying, collecting, and synthesizing relevant literature.
• Time Frame: Research articles from 2010 to 2023 were included, specifically focusing on physical interventions for LPV.
• Key Focus: The goal was to map out the available evidence for different physical treatments and assess how effective these interventions are in managing LPV symptoms.
Results
• Studies Reviewed: A total of 19 primary studies were reviewed, covering a range of physical modalities.

• Interventions: These studies included the following modalities:
o Acupuncture
o Laser therapy
o Physiotherapy
o Transcutaneous Electrical Nerve Stimulation (TENS)
o Low-Intensity Shockwave Therapy (LiSWT)
o Transcranial Direct Current Stimulation (tDCS)
o Vestibulectomy

Efficacy in General
o Most physical treatments showed promising results in improving sexual pain and patient satisfaction with treatment.
o Non-sexual pain outcomes were inconsistent.
o tDCS: This was the only modality that did not show positive outcomes.
o Gaps: Limited evidence was found for other key outcomes like long-term effectiveness or safety.
Efficacy of Li-ESWL
Two studies evaluated the efficacy of low-intensity shockwave therapy at specified dosages.The first was a case series of 14 patients that examined the efficacy of 6 treatment sessions of low-intensity shockwave therapy. Each session involved 3000 shocks to the vestibule with energy determined by patient tolerance. PGIC, CST, and vulvar/ vestibular appearance showed improvement with treatment, although the length of follow-up was not specified, and p-values were not provided.
The second study was a double-blinded RCT which evaluated low-intensity shockwave compared to sham treatments. These were applied to the introitus among 34 participants. The treatment group (n = 24) received 500 pulses of low- intensity shockwaves (0.09 mJmm2) twice weekly for 6 weeks, while the sham group (n = 10) received the same protocol without shockwave generator activation. Participants were evaluated before the first treatment, and at one and three months after the final treatment. Those in the treatment group reported a significant reduction in dyspareunia, increased pain threshold and tolerance, and increased sexual function. The placebo group did not show any changes in measurements. A moderate correlation between reduced dyspareunia and improved sexual function was found. One participant reported self-limited abdominal pain. Authors of both papers concluded that low-intensity shockwave therapy was a feasible treatment for LPV and called for larger randomized studies to further evaluate efficacy.
Conclusions
• Evidence Gaps: There is insufficient high-quality evidence to strongly support any single physical treatment modality for LPV.
• Shortcomings in Current Research:
o Methodological flaws were prevalent in many studies, including small sample sizes and lack of control groups.
o Lack of diversity in participant demographics limits the generalizability of findings.
o Many studies did not report patient-centered outcomes, limiting the real-world applicability of findings.
• Call for Action:
o More rigorous research is needed, with larger, more diverse samples.
o Studies should use validated, patient-oriented outcomes and appropriate comparators.
o Adherence and adverse events must be systematically reported.
o Recommendations for Researchers and Organizations: There is a need for structured guidelines (e.g., GRADE) to ensure consistency in reporting and outcomes. Professional societies in physical therapy (PT) and LPV research should provide clearer guidance for future study designs to enhance rigor and clinical applicability.
This comprehensive review maps the breadth of available research on

Jens Rassweiler

•	Interventions: These studies included the following modalities:
o	Acupuncture
o	Laser therapy
o	Physiotherapy
o	Transcutaneous Electrical Nerve Stimulation (TENS)
o	Low-Intensity Shockwave Therapy (LiSWT)
o	Transcranial Direct Current Stimulation (tDCS)
o	Vestibulectomy

Efficacy in General
o	Most physical treatments showed promising results in improving sexual pain and patient satisfaction with treatment.
o	Non-sexual pain outcomes were inconsistent.
o	tDCS: This was the only modality that did not show positive outcomes.
o	Gaps: Limited evidence was found for other key outcomes like long-term effectiveness or safety.
Efficacy of Li-ESWL
Two studies evaluated the efficacy of low-intensity shockwave therapy at specified dosages.The first was a case series of 14 patients that examined the efficacy of 6 treatment sessions of low-intensity shockwave therapy. Each session involved 3000 shocks to the vestibule with energy determined by patient tolerance. PGIC, CST, and vulvar/ vestibular appearance showed improvement with treatment, although the length of follow-up was not specified, and p-values were not provided. 
The second study was a double-blinded RCT which evaluated low-intensity shockwave compared to sham treatments. These were applied to the introitus among 34 participants. The treatment group (n = 24) received 500 pulses of low- intensity shockwaves (0.09 mJmm2) twice weekly for 6 weeks, while the sham group (n = 10) received the same protocol without shockwave generator activation. Participants were evaluated before the first treatment, and at one and three months after the final treatment. Those in the treatment group reported a significant reduction in dyspareunia, increased pain threshold and tolerance, and increased sexual function. The placebo group did not show any changes in measurements. A moderate correlation between reduced dyspareunia and improved sexual function was found. One participant reported self-limited abdominal pain. Authors of both papers concluded that low-intensity shockwave therapy was a feasible treatment for LPV and called for larger randomized studies to further evaluate efficacy. 
Conclusions
•	Evidence Gaps: There is insufficient high-quality evidence to strongly support any single physical treatment modality for LPV.
•	Shortcomings in Current Research:
o	Methodological flaws were prevalent in many studies, including small sample sizes and lack of control groups.
o	Lack of diversity in participant demographics limits the generalizability of findings.
o	Many studies did not report patient-centered outcomes, limiting the real-world applicability of findings.
•	Call for Action:
o	More rigorous research is needed, with larger, more diverse samples.
o	Studies should use validated, patient-oriented outcomes and appropriate comparators.
o	Adherence and adverse events must be systematically reported.
o	Recommendations for Researchers and Organizations: There is a need for structured guidelines (e.g., GRADE) to ensure consistency in reporting and outcomes. Professional societies in physical therapy (PT) and LPV research should provide clearer guidance for future study designs to enhance rigor and clinical applicability.
This comprehensive review maps the breadth of available research on

Jens Rassweiler

Context: LPV is a common condition with significant consequences on sexual and general quality of life. Challenge: There is no consensus on the most effective treatments for managing LPV, leaving patients and clinicians without clear guidance. Aim: The purpose of this scoping review is to explore the range of physical interventions used for treating LPV and evaluate their efficacy or effectiveness. Methods • Framework: The review follows Arksey and O'Malley’s five-step method for conducting scoping reviews, which involves identifying, collecting, and synthesizing relevant literature. • Time Frame: Research articles from 2010 to 2023 were included, specifically focusing on physical interventions for LPV. • Key Focus: The goal was to map out the available evidence for different physical treatments and assess how effective these interventions are in managing LPV symptoms. Results • Studies Reviewed: A total of 19 primary studies were reviewed, covering a range of physical modalities. • Interventions: These studies included the following modalities: o Acupuncture o Laser therapy o Physiotherapy o Transcutaneous Electrical Nerve Stimulation (TENS) o Low-Intensity Shockwave Therapy (LiSWT) o Transcranial Direct Current Stimulation (tDCS) o Vestibulectomy Efficacy in General o Most physical treatments showed promising results in improving sexual pain and patient satisfaction with treatment. o Non-sexual pain outcomes were inconsistent. o tDCS: This was the only modality that did not show positive outcomes. o Gaps: Limited evidence was found for other key outcomes like long-term effectiveness or safety. Efficacy of Li-ESWL Two studies evaluated the efficacy of low-intensity shockwave therapy at specified dosages.The first was a case series of 14 patients that examined the efficacy of 6 treatment sessions of low-intensity shockwave therapy. Each session involved 3000 shocks to the vestibule with energy determined by patient tolerance. PGIC, CST, and vulvar/ vestibular appearance showed improvement with treatment, although the length of follow-up was not specified, and p-values were not provided. The second study was a double-blinded RCT which evaluated low-intensity shockwave compared to sham treatments. These were applied to the introitus among 34 participants. The treatment group (n = 24) received 500 pulses of low- intensity shockwaves (0.09 mJmm2) twice weekly for 6 weeks, while the sham group (n = 10) received the same protocol without shockwave generator activation. Participants were evaluated before the first treatment, and at one and three months after the final treatment. Those in the treatment group reported a significant reduction in dyspareunia, increased pain threshold and tolerance, and increased sexual function. The placebo group did not show any changes in measurements. A moderate correlation between reduced dyspareunia and improved sexual function was found. One participant reported self-limited abdominal pain. Authors of both papers concluded that low-intensity shockwave therapy was a feasible treatment for LPV and called for larger randomized studies to further evaluate efficacy. Conclusions • Evidence Gaps: There is insufficient high-quality evidence to strongly support any single physical treatment modality for LPV. • Shortcomings in Current Research: o Methodological flaws were prevalent in many studies, including small sample sizes and lack of control groups. o Lack of diversity in participant demographics limits the generalizability of findings. o Many studies did not report patient-centered outcomes, limiting the real-world applicability of findings. • Call for Action: o More rigorous research is needed, with larger, more diverse samples. o Studies should use validated, patient-oriented outcomes and appropriate comparators. o Adherence and adverse events must be systematically reported. o Recommendations for Researchers and Organizations: There is a need for structured guidelines (e.g., GRADE) to ensure consistency in reporting and outcomes. Professional societies in physical therapy (PT) and LPV research should provide clearer guidance for future study designs to enhance rigor and clinical applicability. This comprehensive review maps the breadth of available research on Jens Rassweiler

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