Pain-Related Anxiety in Chronic Vulvar Pain Conditions Associated with Vulvodynia
Authors: Krapf J , Mautz T , Pukall C , Goldstein A 
Published: July 2022

ABSTRACT

Introduction
Chronic, idiopathic vulvar pain (vulvodynia) is often treated as a unilateral condition. However, there are likely multiple causes to vulvar pain, relating to nerves, muscles, hormones, and inflammation, as well as psychosocial factors. Pain-related anxiety is a known contributor to the cycle of chronic pain. Rates of pain-related anxiety have been explored in vulvodynia associated with hypertonic pelvic floor muscle dysfunction; however, the roles in other associated genitopelvic pain conditions are still unknown.

Objective
Evaluate pain-related anxiety in the context of chronic vulvar pain conditions associated with vulvodynia: pudendal neuralgia (PN), hypertonic pelvic floor dysfunction (PFD), provoked vestibulodynia (PVD), and lichen sclerosus (LS).

Methods
A retrospective chart review was conducted for all new patients presenting to two metropolitan gynecology clinics specializing in vulvar pain for one full year. Patients were evaluated by a vulvar pain specialist to receive a specific vulvar pain diagnosis based on history and physical examination. Pain-related anxiety scores were measured with the Pain Anxiety Symptoms Scale-20 (PASS-20) prior to evaluation. Adult women presenting with vulvar pain who completed the PASS-20 and received a diagnosis of hypertonic pelvic floor muscle dysfunction were included in the study. Patients with concomitant vulvovaginal infections were excluded. Patients were grouped according to diagnosis: pudendal neuralgia (PN), overactive pelvic floor dysfunction alone (PFD), provoked vestibulodynia (PVD), or vulvar lichen sclerosus (LS). Independent two-tailed t-tests and one-way ANOVAs were performed comparing the distributions and scores for each of the four aspects of the PASS-20.

Results
126 patients were included in the analysis: PN (17), PFD (43), PVD (57), and LS (9). Pain-related anxiety was highest for those with PN (mean score=47.18, SD=24.66) with 76.5% scoring above the 30-point cutoff for maladaptive levels of pain-related anxiety. This was followed by those with PFD (mean=37.02, SD=18.91, 65.1% scored &gt;30), PVD (mean=32.53, SD=17.60, 43.9% scored &gt;30), and LS (mean=23.44, SD=19.98, 33.3% scored &gt;30). The PN group scored highest in cognitive, fear, and physiological anxiety, while the PFD group scored higher in escape and avoidance. One-way ANOVAs with post-hoc analysis yielded significant differences between the cognitive anxiety scores of PN vs PFD (p=0.03), PN vs PVD (p&lt;0.01), and PN vs LS (p&lt;0.01); as well as with the physiological anxiety scores of PN vs PFD (p=0.02), PN vs PVD (p=0.01), and PN vs LS (p&lt;0.01). Comparing PFD and PVD, those with PFD alone had significantly higher scores in cognitive anxiety (t(498) = 2.12, p&lt;0.04) and fear of pain (t(495) = 2.76, p&lt;0.006).

Conclusions
Vulvar pain conditions in addition to hypertonic PFD can differentially impact pain-related anxiety. Notably, patients with PN have higher cognitive, physiologic, and fear-related anxiety compared to patients with other distressing vulvar pain conditions. Differences in pain-related anxiety between the additional vulvar pain conditions and PFD alone may reflect the severity of hypertonic PFD, which was not delineated in this study. These findings highlight the importance of identifying all causes of genitopelvic pain in the evaluation of vulvodynia, as well as acknowledging and addressing the role of pain-related anxiety in chronic genitopelvic pain.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; Consultant to SST, Ipsen, Amag, Lupin, an employee of Dare, and received research funding from Elen, Ipsen, En