Vulvodynia

Vulvodynie : évaluation de l'acupuncture

1. Systematic Reviews and Meta-Analysis

☆☆☆	Evidence for effectiveness and a specific effect of acupuncture
☆☆	Evidence for effectiveness of acupuncture
☆	Limited evidence for effectiveness of acupuncture
Ø	No evidence or insufficient evidence

1.1. Calafiore 2024

Calafiore D, Marotta N, Curci C, Agostini F, De Socio RI, Inzitari MT, Ferraro F, Bernetti A, Ammendolia A, de Sire A. Efficacy of Rehabilitative Techniques on Pain Relief in Patients With Vulvodynia: A Systematic Review and Meta-Analysis. Phys Ther. 2024 Jul 2;104(7):pzae054. https://doi.org/10.1093/ptj/pzae054

Objective	Vulvodynia is a chronic clinical condition characterized by provoked or non-provoked vulvar pain for at least 3 months of unknown etiology. The onset of vulvodynia involves a complex interplay of peripheral and central pain mechanisms, such as pelvic floor muscle and autonomic dysfunction, and interpersonal factors. A stepwise approach of pelvic floor physical therapy as medical management is suggested. In this scenario, by this meta-analysis of randomized controlled trials, we aimed to evaluate the efficacy of rehabilitation interventions in patients with vulvodynia.
Methods	On October 13, 2022, PubMed, Scopus, and Web of Science were systematically searched for randomized controlled trials that assessed the efficacy of the rehabilitative approach to pain during intercourse in patients with vulvodynia. The quality assessment was performed with the Cochrane risk-of-bias tool for randomized trials. The trial registration number is CRD42021257449. At the end of the search, 9 studies were included for a total of 332 patients. A pairwise meta-analysis was performed to highlight the efficacy of rehabilitative approaches for reducing pain during intercourse, as measured with a visual analog scale or a numerical rating scale.
Results	Meta-analysis showed that all these rehabilitative approaches had an overall effect size of -1.43 (95% CI = -2.69 to -0.17) in decreasing vulvodynia pain in terms of the visual analog scale. In the subgroup analysis, a significant effect size in acupuncture (effect size = -2.36; 95% CI = -3.83 to -0.89) and extracorporeal shockwave therapy (effect size = -2.94; 95% CI = -4.31 to -1.57; I2 = 58%) was observed. According to the Cochrane risk-of-bias tool, a low risk of bias for outcome selection in 89% of studies.
Conclusion	Findings from this meta-analysis suggested that the physical agent modalities and complementary medicine techniques in people with vulvodynia appear to be more effective than placebo, sham, or waiting list. Further evidence on physical agent modalities and complementary therapies are warranted in the future.
Impact	This was the first systematic review and meta-analysis of randomized controlled trials to provide evidence on the efficacy of rehabilitation interventions in patients with vulvodynia.

1.2. Andrews 2011 ∅

Andrews JC. Vulvodynia interventions–systematic review and evidence grading. Obstet Gynecol Surv. 2011;66(5):299-315. [192687].

Introduction	State of the art guidance exists for management of vulvodynia, but the scientific basis for interventions has not been well described. Although there are many interventional therapies, and their use is increasing, there is also uncertainty or controversy about their efficacy.
Objective	To systematically assess benefits and harms of interventional therapies for vulvodynia and vestibulodynia.
Methods	The following databases were searched, using MeSH terms for studies related to the treatment of vulvodynia or vulva pain/pruritus/dysesthesia/hyperesthesia/hypersensitivity: MEDLINE, PsycINFO, Scopus, Cochrane Library, EBSCO Academic, and Google Scholar. Using Medical Subject Reference sections of relevant original articles, reviews, and evidence-based guidelines were screened manually. Manual searching for indirect evidence supporting interventions was done whenever no direct evidence was found for a treatment described within a review or guideline. Each modality is assessed with a grading system similar to the Grades of Recommendation, Assessment, Development, and Evaluation system. The grading system assesses study quality, effect size, benefits, risks, burdens, and costs.
Results	For improvement of pain and/or function in women with vestibulodynia (provoked localized vulvodynia), there was fair evidence that vestibulectomy was of benefit, but the size of the effect cannot be determined with confidence. There was good evidence of a placebo effect from multiple studies of nonsurgical interventions. There was fair evidence of lack of efficacy for several nonsurgical interventions. There were several interventions for which there were insufficient evidence to reliably evaluate. There was insufficient evidence to judge harms or to judge long-term benefits. For clinically meaningful improvement of pain in women with generalized unprovoked vulvodynia, there was insufficient evidence for benefit of any intervention. There was fair evidence of a placebo effect in people with neuropathic pain and functional pain syndromes, from multiple studies of interventions. Based on indirect evidences from studies of patients with other pain disorders, interventions may be selected for future research.
Conclusion	There is fair evidence for effectiveness of vestibulectomy for vestibulodynia; however, there is uncertainty about the size of the absolute effect, because of the risk of bias inherent in studies of pain interventions without a placebo control group. Providers and patients looking for evidence-based interventions for generalized unprovoked vulvodynia may need to rely on indirect evidences from studies of neuropathic pain and functional pain syndromes. TARGET AUDIENCE: Obstetricians & gynecologists, family physicians. LEARNING OBJECTIVES: After completion of this educational activity, the obstetrician/gynecologist should be better able to identify potential causes of vulvar pain to facilitate diagnosis of vulvodynia and vestibulodynia, distinguish between the symptoms of localized, provoked vulvodynia and generalized unprovoked vulvodynia to select the most appropriate therapies, evaluate the efficacy of surgical and nonsurgical interventions for the treatment of generalized unprovoked and localized, provoked vulvodynia. In addition, assess the benefits and risks of interventional therapies for vulvodynia and vestibulodynia to improve patient care.
Acupuncture	There was insufficient evicence for use of acupuncture.

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. European Academy of Dermatology and Venereology (EADV, Europe) 2021 ⊕

van der Meijden WI, Boffa MJ, Ter Harmsel B, Kirtschig G, Lewis F, Moyal-Barracco M, Tiplica GS, Sherrard J. 2021 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol. 2022 Jul;36(7):952-972. https://doi.org/10.1111/jdv.18102

Vulvodynia. Acupuncture alone or associated with lidocaine has shown effectiveness in small clinical trials, both on pain relief and sexual functioning. Improvement of the quality of the study protocols including comparing different acupuncture strategies are on-going.

2.2. European Academy of Dermatology and Venereology (EADV, Europe) 2017 ⊕

van der Meijden WI, Boffa MJ, Ter Harmsel WA, Kirtschig G, Lewis FM, Moyal-Barracco M, Tiplica GS, Sherrard J. 2016 European guideline for the management of vulval conditions. J Eur Acad Dermatol Venereol. 2017;31(6):925-941. [182132].

Vulvodynia: Acupuncture (Ib, B)

2.3. British Association for Sexual Health and HIV (BASHH, UK) 2014 ⊕

Clinical Effectiveness Group. 2014 UK national guideline on the management of vulval conditions. London (UK): British Association for Sexual Health and HIV (BASHH); 2014 Feb. 22 p. [60 references] [164581].

Alternative regimens : Topical local anaesthetic e.g. 5% lidocaine ointment or 2% lidocaine gel. A trial of local anaesthetic may be considered although irritation is a common side effect. (IV,C) Cognitive behavioural therapy and psychotherapy (IIb,B, acupuncture (IIb, C)

2.4. British Society for the Study of Vulval Disease (BSSVD, UK) 2010 ⊕

Mandal D, Nunns D, Byrne M, Mclelland J, Rani R, Cullimore J, Bansal D, Brackenbury F, Kirtschig G, Wier M. Guidelines for the management of vulvodynia. Br J Dermatol. 2010;162(6):1180-5. [156228].

Acupuncture may be considered in the treatment of unprovoked vulvodynia; Grade of recommendation C; evidence level IIb

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