Associations between vaginismus and localised provoked vestibulodynia (LPV) and conception and mode of delivery were evaluated in approximately 450 000 Swedish women. Although their aetiologies differ, both disorders were combined in the analysis. Their prevalence (0.6%) is much lower than the 3–7% point prevalence of LPV alone in reproductive-aged women in the USA (Harlow BL et al., J Am Med Womens Assoc 2003;58:82–8; Arnold LD, et al., AJOG 2007;196:128.e1–6). The reduced percentage in the Swedish cohort is likely due to the fact that many women do not discuss this problem with their caregivers and many clinicians have not been trained adequately to diagnose these conditions. Less than 2% of women with vulvodynia symptoms received an accurate diagnosis (Reed BD, et al., AJOG 2012;206:170.e1–9).
Women with vaginismus and LPV were less likely to become pregnant, and those that did conceive were more likely to deliver by elective or requested caesarean section. This highlights an additional area in which genital pain disorders negatively impact quality of life. Women with LPV also have an increased incidence of other pelvic or urogenital pain conditions, such as irritable bowel syndrome and interstitial cystitis, as well as other non-pelvic pain conditions, such as fibromyalgia, chronic headache and temporomandibular disorders (Lamvu G, et al., Medscape CME/CE 2013, www.medscape.org/viewarticle/780555). In addition to a decreased frequency of sexual intercourse because of physical pain, nulliparity may also be a secondary consequence of affected women taking anti-pain medications with varying degrees of safety in pregnancy. The current multidisciplinary treatment regimen for women with LPV typically includes anti-epileptics, tricyclic antidepressants, serotonin uptake inhibitors, neuroanalgesics, as well as topical formulations containing anaesthetics, hormones and other active ingredients.
It is reasonable to expect that women with chronic vulvovaginal pain would require different and/or additional pain management strategies during labour. In the Swedish study there was no difference in utilisation of labour pain-relieving methods between women with and without vaginismus or LPV. This lack of focus on pain medication specifically for women with a genital pain disorder might explain why these women had an increased rate of perineal lacerations. It is possible that their pain was less well-managed, resulting in reduced control during the second stage of labour. This underscores the importance of obstetricians and midwives discussing and developing a labour pain relief strategy for women with genital tract pain well in advance of parturition. Research focusing on alternative, more beneficial intervent-ion strategies during labour and delivery for these women is totally lacking.
Localised provoked vestibulodynia is a heterogeneous pain disorder and unique factors may predispose, trigger and perpetuate disease in discrete subsets (Lamvu G, et al., Medscape CME/CE 2013, www.medscape.org/viewarticle/780555). Subgroups of women with disparate underlying pathophysiology are likely to be affected differently by conception, pregnancy and childbirth. To understand how best to care for these women during pregnancy and delivery, future studies that differentiate between LPV subgroups and examine phenotypic factors that influence reproductive patterns and modes of childbirth, as well as the effectiveness of specific pain-relief interventions, are needed.
Disclosure of interests
The authors have no conflict of interest.