ORIGINAL RESEARCH & REVIEWS

PAIN

Treatment of Provoked Vulvodynia: A Systematic Review

Nina Bohm-Starke, MD, PhD,1 Karin Wilbe Ramsay, PhD,2 Per Lytsy, MD, PhD,2
Birgitta Nordgren, PT, PhD,3,4 Inga Sj€
oberg, MD, PhD,5 Klas Moberg,2 and Ida Flink, PhD6

ABSTRACT

Background: Treatment recommendations for provoked vulvodynia (PVD) are based on clinical experiences
and there is a need for systematically summarizing the controlled trials in this field.
Aim: To provide an overview of randomized controlled trials and non-randomized studies of intervention for
PVD, and to assess the certainty of the scientific evidence, in order to advance treatment guidelines.
Data Sources: The search was conducted in CINAHL (EBSCO), Cochrane Library, Embase (Embase.com), Ovid
MEDLINE, PsycINFO (EBSCO) and Scopus. Databases were searched from January 1, 1990 to January 29, 2021.
Study Eligibility Criteria: Population: Premenopausal women with PVD. Interventions: Pharmacological, surgical,
psychosocial and physiotherapy, either alone or as combined/team-based interventions. Control: No treatment, waiting-
list, placebo or other defined treatment. Outcomes: Pain during intercourse, pain upon pressure or touch of the vaginal
opening, sexual function/satisfaction, quality of life, psychological distress, adverse events and complications. Study
design: Randomized controlled trials and non-randomized studies of interventions with a control group.
Study Appraisal and Synthesis Methods: 2 reviewers independently screened citations for eligibility and
assessed relevant studies for risk of bias using established tools. The results from each intervention were summa-
rized. Studies were synthesized using a narrative approach, as meta-analyses were not considered appropriate. For
each outcome, we assessed the certainty of evidence using grading of recommendations assessment, development,
and evaluation (GRADE).
Results: Most results of the evaluated studies in this systematic review were found to have very low certainty of evi-
dence, which means that we are unable to draw any conclusions about effects of the interventions. Multimodal phys-
iotherapy compared with lidocaine treatment was the only intervention with some evidential support (low certainty
of evidence for significant treatment effects favoring physiotherapy). It was not possible to perform meta-analyses
due to a heterogeneity in interventions and comparisons. In addition, there was a heterogeneity in outcome meas-
ures, which underlines the need to establish joint core outcome sets.
Clinical Implications: Our result underscores the need of stringent trials and defined core outcome sets for PVD.
Strength and Limitations: Standard procedures for systematic reviews and the Population Intervention Com-
parison Outcome model for clinical questions were used. The strict eligibility criteria resulted in limited number
of studies which might have resulted in a loss of important information.
Conclusion: This systematic review underlines the need for more methodologically stringent trials on interven-
tions for PVD, particularly for multimodal treatments approaches. For future research, there is a demand for joint
core outcome sets. Bohm-Starke N, Ramsay KW, Lytsy P, et al. Treatment of Provoked Vulvodynia: A Sys-
tematic Review. J Sex Med 2022;19:789−808.

5

Received November 30, 2021. Accepted February 8, 2022. Department of Clinical Sciences, Obstetrics and Gynecology, Umea Univer-


1 sity, Umea, Sweden;
Department of Clinical Sciences, Division of Obstetrics and Gynecology,
Karolinska Institutet Danderyd Hospital, Stockholm, Sweden; 6
Center for Health and Medical Psychology, School of Law, Psychology and
2
Swedish Agency for Health Technology Assessment and Assessment of €
Social Work, Orebro €
University, Orebro, Sweden
Social Services, Stockholm, Sweden; Copyright © 2022 The Authors. Published by Elsevier Inc. on behalf of the
3 International Society for Sexual Medicine. This is an open access article
Department of Neurobiology, Care Sciences and Society, Karolinska Insti-
tutet, Huddinge, Sweden; under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
https://doi.org/10.1016/j.jsxm.2022.02.008
4
Womens Health and Allied Health Professionals Theme, Medical Unit
Occupational Therapy and Physiotherapy, Karolinska University Hospital,
Solna, Sweden;

J Sex Med 2022;19:789−808 789

790
Copyright © 2022 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual
Medicine. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
Key Words: Provoked Vulvodynia; Vestibulodynia; Vulvar Pain; Pain Management; Physiotherapy; Cognitive
Behavior Therapy
TWITTER MESSAGE
Systematic review concludes that evidence for treatment of pro-
voked vulvodynia is poor. There is a great need of more methodo-
logically stringent trials and development of core outcome sets.
INTRODUCTION
Provoked localized vulvodynia (PVD) is a common and debil-
itating chronic vulvar pain condition, affecting approximately 7
−13% of premenopausal women.1,2 Women with PVD describe
a sharp pain or burning sensation, localized at the entry of the
vagina during touch, pressure, and attempted or accomplished
vaginal intercourse.3 The pain does not only affect sexual func-
tion and satisfaction,4 but is also associated with psychological
distress,5,6 relational dissatisfaction and a lower quality of life.7
Yet, it is a neglected pain condition,8 and many women are left
without correct diagnosis and treatment.9
According to the 2015 Consensus Terminology and Classifica-
tion of Persistent Vulvar Pain and Vulvodynia, PVD conveys pain
in the vulvar entry lasting more than 3 months, appearing in the
absence of another recognizable vulvar disease.3 Although the eti-
ology is ambiguous, several psychosocial and pathophysiological
mechanisms are believed to contribute to pain onset and
maintenance3,10 Numerous treatment approaches, each based on
its own assumed mechanism, have been developed and evaluated
with varying results (for a review, see Rosen et al, 2019).11 There
is however a lack of controlled trials exploring treatment
effects,12 thus current state of evidence remains unclear.
To date there is no “gold standard” treatment for women with
PVD.11 Non-pharmacological as well as pharmacological and
surgical treatments have been tested, both individually and in
combination. Non-pharmacological options have primarily been
variations of cognitive-behavioral therapy (CBT), pelvic floor
physical therapy, and alternative therapies such as acupuncture
and Transcutaneous Electrical Nerve Stimulator (TENS). Phar-
macological and medical options include agents targeting periph-
eral and central pain mechanisms, muscle relaxants and surgical
interventions.10 However, most treatment studies have involved
heterogeneous samples, and not only women with PVD, despite
it being the most common type of vulvar pain in premenopausal
women. Yet, as there is no updated systematic review of different
treatments’ effects on PVD, current state of evidence is still to be
determined.
Current treatment recommendations are largely based on
clinical experiences.10,13,14 In previous systematic reviews on
Bohm-Starke et al
treatment for provoked vulvodynia, a mixture of study designs
and study populations have been included which limits the cer-
tainty of evidence.15,16 Thus, there is an urgent need for system-
atically summarizing the few controlled trials that exist in this
field. In Sweden, this need has been noted at a national level,
and the current systematic review was initiated as an assignment
from the Swedish government with the aim to establish national
recommendations for PVD treatment.
The aim was to provide an overview of randomized controlled
trials (RCTs) and non-randomized studies of interventions
(NRSIs) of the effect of treatment approaches for women with
PVD, in order to advance treatment guidelines. Considering the
various treatment approaches, we included all identified con-
trolled trials for this selected group.
METHODS
This systematic review was conducted at the Swedish Agency
for Health Technology Assessment and Assessment of Social
Services, SBU, following a protocol preregistered on PROS-
PERO (preregistered 01/08/2020, number CRD42020196455;
https://www.crd.york.ac.uk/prospero/. The assessment also cov-
ered diagnostic methods, but these results are reported else-
where.17 The systematic review was performed and reported in
accordance with the PRISMA guidelines.18,19
Eligibility Criteria
The research question and the inclusion criteria were formu-
lated using the PICO (Population Intervention Comparison
Outcome) model for clinical questions with the following defini-
tions20:
Population. The target population was premenopausal
women with provoked vulvodynia (PVD) diagnosed accord-
ing to 2015 Consensus Terminology and Classification of
Persistent Vulvar Pain and Vulvodynia.3 Study populations
with up to 25% postmenopausal woman or with other forms
of vulvodynia were accepted. No limit concerning population
size was used.
Interventions. Pharmacological (systemic, topical or local),
surgical, psychosocial and physiotherapy were considered,
either alone or as combined/team-based interventions. No
restrictions concerning treatment duration or follow-up time
were applied.
J Sex Med 2022;19:789−808
Treatment of Provoked Vulvodynia
Control. The control conditions were no treatment, waiting-
list, placebo or other defined control treatment.
Outcomes. Included outcomes were pain during intercourse,
pain upon pressure or touch of the mucosa around the vaginal
opening, sexual function or satisfaction, quality of life, and psy-
chological distress (anxiety and depressive symptoms), adverse
events and complications.
Study Design. Included study designs were randomized con-
trolled trials (RCT) and non-randomized studies of interventions
(NRSI) with a control group.
Publication Type. Original studies published in peer-reviewed
scientific journals from 1990 and onwards were searched. Accepted
languages were English, Swedish, Norwegian, or Danish. Conference
abstracts, book chapters and theses were excluded.
Information Sources
The literature search was performed by an information specialist
(K.M.) and included the databases CINAHL (EBSCO), Cochrane
Library, Embase (Embase.com), Ovid MEDLINE, PsycINFO
(EBSCO) and Scopus. In addition, the following sources were
searched for systematic reviews that were not included in the review
but were used to control for additional primary studies: CADTH
publication database, CRD Database (including HTA Database,
DARE, NHS EED), Epistemonikos, Evidence search (NICE), KSR
Evidence and PROSPERO. Reference lists from published articles
were scrutinized for additional inclusion.
Search Strategy
Treatment studies for PVD started to appear in the beginning of
1990s and databases were searched from January 1, 1990 to January
29, 2021. The search strategy is based on the population provoked
vulvodynia for which appropriate controlled vocabulary and relevant
text word terms have been identified. Duplicates were removed
using a deduplication method in EndNote.21 The detailed search
strategy is available in Appendix A (Tables Search Strategy).
Study Screening and Selection
2 authors (K.W.R., P.L.) screened the titles and abstracts
independently using the web-based screening tool Rayyan.22
Full-text articles were retrieved if 1 or both reviewers considered
a study potentially eligible. At least 2 authors (I.F., I.S., B.N., N.
B.S.) read the full-text articles independently and checked them
for eligibility against the prestated criteria, and any disagreement
was resolved by discussion. At least 2 authors (I.F., I.S., B.N., N.
B.S., K.W.R., P.L.) independently assessed eligible studies for
risk of bias using established tools developed by Cochrane for
randomized controlled studies,23,24 and non-randomized con-
trolled studies of interventions.25 Swedish versions of the tools
J Sex Med 2022;19:789−808
791
were used which included an extra question regarding potential
conflicts of interests of the study authors. The outcomes of the
studies were assessed as having either high risk of bias, some con-
cern, or low risk of bias, based on risks of bias in the following
domains: randomization, adherence, missing outcome data, mea-
surement and reporting. Any disagreement was resolved by dis-
cussion involving at least 3 authors. Studies with high risk of bias
were excluded from the subsequent analysis.
Data Extraction
For included studies, we extracted country of origin, sample
size, mean age of the participants, description of the intervention
and the control intervention, length of follow-up, drop-out rate,
and outcome data. It was also checked if the study was registered
in a clinical trials registry, and whether the registration date was
prior to enrollment of the first participants or reported date of
study start. For outcomes, the following data were extracted:
- Pain during intercourse − self reported pain during intercourse or
sexual activity rated on a visual analogue scale (VAS) or a numeric
scale (NRS). For some studies, data was extracted from question-
naires using various functional descriptors of coital pain.
- Pain upon pressure or touch − pain ratings (VAS, NRS) during a
gynecological examination using a cotton swab test or a vulvar alge-
siometer.
- Sexual function and satisfaction − data was extracted from the
Female Sexual Function Index (FSFI; first choice), or an equivalent
questionnaire evaluating sexual health, such as Index of Sexual Sat-
isfaction 0−100 (ISS) or Global Sexual Functioning 0−1, (GSF)
(second choice).
- Quality of life − various validated instruments regarding different
aspects of QoL.
- Mental distress − data was extracted from various validated instru-
ments assessing anxiety and depressive symptoms such as Beck
Depression Inventory, Generalized Anxiety Disorder 7) and State-
Trait Anxiety Inventory of Spielberger, state domain.
- Adverse events (AE), complications and negative treatment effects
− if reported, adverse events and complications were divided into
mild or severe. Firstly, data on the proportion of participants with
AEs was extracted and secondly data on other descriptions of AEs
and complications.
Synthesis and Statistical Analysis
Our intention was to perform meta-analyses when compara-
ble outcomes were reported from studies with similar compari-
sons of interventions, but that was not applicable. The results
from each intervention were summarized in tables where effect-
sizes, depending on the type of outcomes, were expressed as
mean difference (MD), risk difference (RD) or risk ratio (RR)
with 95% confidence intervals (CI), or alternatively, as “signifi-
cant/non-significant” if no other information was available. If no
comparative analysis between study groups was reported in the
original study, the effect-size was calculated with 95% CI using
Review Manager.26
792
Assessment of Evidence
For each outcome, we assessed the certainty of evidence that
an intervention was superior, inferior, or equivalent to the con-
trol, using grading of recommendations assessment, develop-
ment, and evaluation (GRADE), where the certainty of evidence
is expressed as high (++++, moderate (+++o), low (++oo) or very
low (+ooo).27 Thresholds for effect sizes were not integrated in
the rating.28
RESULTS
Search Results and Study Selection
The search of databases yielded 2873 records, from which 72
articles were examined in full text. Of these, 33 articles reporting
data from 30 studies fulfilled the eligibility criteria and were
assessed for risks of bias. The final sample consisted of 27 articles
with low or moderate risk of bias from 22 unique RCTs and 2
non-randomized studies (Figure 1).
Figure 1. Flow-chart from the literature search. Number of articles are larger than the number of studies since data from the same study
are reported in separated publications. RCT = randomized controlled trial; NRSI = non-randomized studies of interventions.
Bohm-Starke et al
Pharmacological Treatments
A large variety of pharmacological treatments has been investi-
gated for provoked vulvodynia. In total, 16 articles based on 14
studies (13 RCTs and 1 NRSI) with low or moderate risk of bias
were identified, and are presented in Tables 1−3. All results on
pharmacological treatments were assessed to have very low cer-
tainty of evidence.
Oral Medications. Pain reduction was the main rationale for
the various oral medications. Gabapentin, an anticonvulsant,
and desipramine, which is a tricyclic antidepressant drug, are
often used as first line treatments for neuropathic pain.29 The
substances were used in randomized double-blinded placebo-
controlled trials. For gabapentin, sexual function improved for
the intervention group, and for desipramine, sexual satisfaction
improved, both compared to placebo30−32 (Table 1). The anti-
inflammatory substance palmitoylethan olamide (PEA) was used
in combination with oral transpolydatine for 2 months in 1 small
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Treatment of Provoked Vulvodynia

Table 1. Pharmacological oral medications
Certainty of
Citation [reference] Participants evidence Down rating
Follow-up time Comparison Study design Outcomes (no studies) Effect (GRADE) (GRADE)

Bachman et al, 201930 Gabapentin - placebo RCT RCT Pain during intercourse 27 (1) MD 0,0 Very low Precision -3y
Brown et al, 201831 (VAS 0−10) (-0.9 to 0.8)
Pain at pressure or touch 83 (1) MD -0,3 Very low Precision -3y
(tampon test, VAS 0−10) (-0.7 to 0.1)
After 6 wk treatment Sexual function (FSFI) 63 (1) MD 1,3 Very low Precision -3z
(0.4−2.2), favor
gabapentin
Mild side-effects (no. participants) 83 (1) NS Not assessed
Serious side-effects (no. participants) 83 (1) I: 0 % Not assessed
C: 0 %
Foster et al, 201032 Desipramine − placebo* RCT Pain during intercourse 47 (1) NS Very low Precision -3y
(NRS 0−10)
Pain at pressure or touch 65 (1) NS Very low Precision -3y
(cotton-swab test, NRS 0−3)
After 12 wk treatment Depression (BDI) 56 (1) NS Very low Precision -3y
Sexual satisfaction (ISS) 56 (1) P = .006, favor Very low Precision -3z
desipramine
Mild side-effects (no. participants 65 (1) I: 3 % Not assessed
C: 0 %
Serious side-effects (no. participants) 65 (1) I: 0 % Not assessed
C: 0 %
Foster et al, 201032
Desipramine + topical RCT Pain during intercourse 47 (1) NS Very low Precision -3y
lidocaine − placebo* (NRS 0−10)
After 12 wk treatment Pain at pressure or touch 56 (1) NS Very low Precision -3y
(cotton-swab test, NRS 0−3)
Depression (BDI) 65 (1) NS Very low Precision -3y
Sexual satisfaction (ISS) 56 (1) NS Very low Precision -3y
Mild side-effects (no. participants) 67 (1) I: 3 % Not assessed
C: 0%
Serious side-effects (no. participants) 67 (1) I: 0 % Not assessed
C: 0 %
Murina et al, 201333 PEA + transpolydatin − RCT Pain during intercourse (MDS) 20 (1) NS Very low Precision -3y
placebo Risk of bias -1x
After 2 mo treatment Mild side-effects (no. participants) 20 (1) I: 20 % Not assessed
C: 10 %
Serious side-effects (no. participants) 20 (1) I: 0 % Not assessed
C: 0 %
*
2 treatment arms from the same study (Foster 2010).
y
Small study population, only 1 study, no statistical significant difference.
z
Small study population, only 1 study.
x
Limitations in data reporting.
BDI = Beck Depression Inventory (0−63); C = control; CI = confidence interval; FSFI = Female Sexual Function Index (2−36); I = intervention; ISS = Index of Sexual Satisfaction (0−100); MD = mean difference;
MDS = Marinoff Dyspareunia Scale (0−3); NRS = Numeric Rating Scale; NS = non-statistical significant difference; RCT = Randomized controlled study; VAS = Visual analogue scale.

793
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Table 2. Pharmacological topical treatments
Citation [reference] Study Participants Certainty of evidence Down rating
Follow-up time Comparison design Outcomes (no studies) Effect (GRADE) (GRADE)

Donders et al, 201234 Fibroblast lysate- RCT Pain during intercourse (VAS 0−10) 26 (1) MD 1.3 (0.1−2.5), favor Very low Precision -3*
placebo fibroblast lysate
After 12 wk treatment Pain at pressure or touch (cotton-swab 26 (1) NS Very low Precision -3y
test VAS 0−10)
Mild side-effects (proportion of 26 (1) I: 10% C: 3% Not assessed
participants)
Serious side-effects (proportion of 26 (1) I: 0% C: 0% Not assessed
participants)
Nyrijesy et al, 200135 Cromolyn sodium RCT Pain during intercourse (proportion with 26 (1) NS Very low Precision -3y Risk
cream 4% − placebo 50% general improvement)# of bias -1z
After 3 mo treatment Mild side-effects (proportion of 26 (1) I: 17% C: 0% Not assessed
participants)
Serious side-effects (proportion of 26 (1) I: 0% C: 0% Not assessed
participants)
Foster et al, 201032 Lidocaine − placebo{ RCT Pain during intercourse (NRS 0−10) 47 (1) NS Very low Precision -3y
Pain at pressure or touch (cotton-swab 65 (1) NS Very low Precision -3y
test, NRS 0−3)
After 12 wk treatment Depression (BDI) 61 (1) NS Very low Precision -3y
Sexual function (ISS) 58 (1) NS Very low Precision -3y
Mild side-effects (proportion of 65 (1) I: 0% C: 0% Not assessed
participants)
Serious side-effects (proportion of 65 (1) I: 0% C: 0% Not assessed
participants)
Langlais et al, 201737 Estrogen - placebo RCT Pain during intercourse (VAS 0−10) 20 (1) RR 1,40 (0.67−2.94) Very low Precision -3*
After 8 wk treatment Sexual function (FSFI, 10% improvement) 20 (1) RR 1.33 (0.74−2.41) Very low Precision -3y
Mild side-effects (proportion of 20 (1) I: 0% C: 30% Not assessed
participants)
Bornstein et al, 201038 Nifedipine − placebo NRSI Pain during intercourse (VAS 0−10) 20 (1) NS Very low Precision -3y Risk
of bias -1x
After 6 wk treatment Pain at pressure or touch (cotton-swab 20 (1) NS Very low Precision -3y Risk
test VAS 0−10) of bias -1x
Serious side-effects (proportion of 20 (1) I: 0% C: 0% Not assessed
participants)
Murina et al, 201839 Diazepam − placebo RCT Pain during intercourse (MDS 0−3) 42 (1) Statistical significant Very low Precision -3*
difference, favor
diazepam
After 2 mo treatment Mild side-effects (proportion of 42 (1) I: 10% C: 0% Not assessed
participants)
Serious side-effects (proportion of 42 (1) I: 0% C: 0% Not assessed
J Sex Med 2022;19:789−808

participants)
*
Small study population, only 1 study.
y
Small study population, only 1 study, no statistical significant difference.

Bohm-Starke et al
z
Limitations in reporting, no intention to treat (ITT) analysis.
x
Risk for confounding (not randomized).
{
Other treatment arms from this study are reported in Table 1.
#
Outcome is not exclusively reported as pain during intercourse.C = control; CI = confidence interval; FSFI = Female Sexual Function Index (2−36); I = intervention; ISS = Index of Sexual Satisfaction (0−100);
MD = mean difference; MDS = Marinoff Dyspareunia Scale (0−3); NRS = Numeric Rating Scale; NS = non-statistical significant difference; RCT = Randomized controlled trial; VAS = visual analogue scale.
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Treatment of Provoked Vulvodynia

Table 3. Pharmacological treatments by injections
Citation [reference] Participants (no Certainty of evidence
Follow-up time Comparison Study design Outcomes studies) [reference] Effect (GRADE) Down rating (GRADE)
Haraldson et al, Botulinum toxin RCT RCT RCT Pain during 174 Narrative assessment Very low Precision -3y
202040 A − placebo intercourse (VAS 0 (3) NS
Petersen et al, 200941 −10, 0−100 and [40,41,42]
Diomande et L, 201942 MDS)
Pain at pressure or 31 NS Very low Precision -3z
touch (1)
(VAS 0−10) [42)
3−6 mo after Sexual function 128 50 U: RD 1.37 (-0.90 Very low Precision -3y
treatment (FSFI) (2) to 3.67)
[40,41] 20 U: NS
Mild side-effects 143 50 U: NS Not assessed
(no. participants) (2) 20 U: I: 14 %, C: 6 %
[40,41]
Serious side-effects 174 I: 0 % Not assessed
(no. participants) (3) C: 0 %
[40,41,42]
Farajun et al, 201243 Enoxaparin - RCT Pain during 38 29 vs 4 % reduction Very low Risk of bias -1x
placebo intercourse (1) P = .057 Precision -3z
(data from
questionnaire) *
3 mo after treatment Pain at pressure or 38 30 vs 11 % reduction Very low Risk of bias -1x
touch (cotton-swab (1) P = .004, favor Precision -3{
test, NRS 0−10) enoxaparin
Serious side-effects 38 I: 0 % Not assessed
(no. participants) (1) C: 0 %
*
Unknown questionnaire.
y
Small study population, no statistical significant difference.
z
Small study population, only 1 study, no statistical significant results.
x
Limitations in data reporting.
{
Small study population, only 1 study.C = control; CI = confidence interval; FSFI = Female Sexual Function Index (2−36); I = intervention; ISS = Index of Sexual Satisfaction (0−100); MDS = Marinoff Dyspareu-
nia Scale (0−3); NRS = Numeric Rating Scale; NS = non-statistical significant difference; RCT = randomized controlled trial; RD = risk difference; VAS = Visual analogue scale.

795
796
RCT.33 No significant difference in treatment effect compared to
placebo was reported (Table 1).
Topical Medications. For topical medications, 5 RCTs and 1
NRSI study were identified, each one investigating the effect of
different substances (Table 2).
2 substances with potential anti-inflammatory effect were
evaluated in double-blinded RCTs. In 2 separate studies, cutane-
ous fibroblast lysate and cromolyn sodium creams were applied
externally on the vestibule for 3 months. For fibroblast lysate,
the intervention group reported significantly less pain during
intercourse compared to placebo after 12 weeks’ treatment, but
no difference was found in pain intensity during cotton-swab
test.34 No significant difference in pain during intercourse was
obtained for the cromolyn sodium cream compared to placebo
(Table 2).35
Repeated application of topical lidocaine gel or cream is rec-
ommended in clinical guidelines to decrease pain sensitivity in
the vestibular mucosa.11 However, the treatment effect has
only been studied in comparison to placebo in 1 double-
blinded 12-week RCT.32 No differences in pain variables
related to pain during intercourse, tampon test, or cotton swab
test were observed between the groups. Non-significant differ-
ences were neither obtained for depression nor sexual function
(Table 2).
The role of local hormonal status has been discussed as a pos-
sible etiological factor in PVD.36 The effect of topical conjugated
estrogen- or placebo cream was investigated in a double-blinded
8-week RCT without any proven effect for reduction of pain
during intercourse or improved sexual function (Table 2).37
Studies on other topical treatment included 1 non-random-
ized but double-blinded study investigating the effect of nifedi-
pine cream that previously has been reported to heal anal
fissures.38 The result showed no differences in pain during inter-
course or cotton swab test between the groups. Daily application
of vaginal diazepam 5 mg tablets for 2 months in combination
with TENS was evaluated in a double-blinded placebo- con-
trolled trial.39 The aim of the study was possible improvements
in pain and pelvic floor muscle (PFM) function due to muscle
relaxing effect of diazepam. The intervention group reported sig-
nificant less pain during intercourse after 2 months’ treatment
and 10% experienced a mild drowsiness (Table 2).
Treatment by Injections. The neurotoxin botulinum toxin
A (BTA) has been evaluated in 3 double-blinded RCTs with a
total of 186 participants. BTA was injected in either PFM, or in
the vestibular submucosal tissue. 1 study reported significantly
less pain during intercourse or tampon use at 3 months after 1
treatment. The positive effect was no longer present at the 6
months’ follow-up, despite repeated treatment.40 For the other 2
studies, no significant favorable effect of BTA was reported com-
pared to placebo for variables related to pain or sexual
Bohm-Starke et al
function.41,42 The results were not combined statistically due to
various aspects of study heterogeneity (Table 3).
Subcutaneous injections of enoxaparin (low-molecular-weight
heparin) with the aim to block the enzyme heparinase and thus
hamper potential neuroproliferation in the vestibular mucosa
was used in 1 small double-blinded RCT.43 No difference in
pain during intercourse was obtained between the study groups,
but less pain for vestibular touch and pressure was reported in
the intervention group (Table 3).
Physiotherapeutic Treatments
4 randomized controlled trials for physiotherapeutic treat-
ments were included. The results could not be combined for sta-
tistical synthesis due to the differences of the various
interventions. The result of one of the studies was assessed as
having low certainty of evidence,44 as opposed to the rest, which
had very low certainty of evidence (Table 4).45−47
The study with some proven evidence of effect was an RCT
where the intervention group received a combination of physio-
therapeutic treatments for 10 weeks.44 The treatment consisted
of education and information, exercises for pelvic floor muscles
(PFM) using EMG biofeedback, as well as manual physiother-
apy. The intervention group was further instructed to perform
home exercises for PFM function and vaginal dilation. The con-
trol group used topical lidocaine cream every night for the equiv-
alent period of time. There were significantly better results in the
intervention group for pain during intercourse and sexual func-
tion, when the treatment was completed, but also at 6 months’
follow-up (Table 4).
Improvement in pain during intercourse and sexual function
was reported in a 20-session RCT using transcutaneous electrical
nerve stimulation (TENS).47 Both the intervention and control
group used the same device, but the intervention group received
higher frequency compared to a simulated treatment with low
frequency for the control group (Table 4).
1 RCT evaluating EMG biofeedback for PFM rehabilitation
vs topical lidocaine45 and another RCT comparing traditional
acupuncture to sham-procedures,46 didn’t show any significant
findings in favor for the intervention group regarding pain or sex-
ual function (Table 4).
Psychological Treatments
The effect of psychological treatments was evaluated in 5 dif-
ferent studies, 4 RCTs48−51 and 1 partly randomized study.52
The treatments were either performed as a single intervention, or
in combination with various other interventions. Due to the het-
erogeneity of the studies, no statistical synthesis of the results
could be done. All study results were assessed to have very low
certainty of evidence.
All studies evaluated the effect of either cognitive behavior
therapy (CBT) or mindfulness-based interventions including
J Sex Med 2022;19:789−808
J Sex Med 2022;19:789−808

Treatment of Provoked Vulvodynia

Table 4. Physiotherapeutic treatments
Certainty of
Citation [reference] Study Participants evidence
Follow-up time Comparison design Outcomes (no studies) Effect (GRADE) Down rating (GRADE)

Morin et al, 202144 Combined physiotherapy RCT Pain during intercourse 201 (1) MD 1,8 (1.2−2.3), favor Low Precision -1y Risk of bias -1z
− topical lidocaine (NRS 0−10) physiotherapy
After 10 wk treatment Sexual function (FSFI) 201 (1) MD -4,4 (-6.1 to -2.7), Low Precision -1y Risk of bias -1z
favor physiotherapy
Mild side-effects (no. 201 (1) Physiotherapy: 0% Not assessed
participants) Lidocaine: 16%
Serious side-effects (no. 201 (1) Physiotherapy: 0% Not assessed
participants) Lidocaine: 0%
Murina et al, 200845 TENS − simulated RCT Pain during intercourse 40 (1) MD -1.3 (-1.8 to -0.8), Very low Precision -3y
treatment (MDS) favor TENS*
After 10 wk treatment Sexual function (FSFI) 40 (1) MD 7,5 (3.3−11.7), Very low Precision -3y
favor TENS*
Danielsson et al, 200646 EMG biofeedback − Pain during intercourse 34 (1) NS Very low Precision -3x Risk of bias -1z
topical lidocaine (VAS 0−100)
12 mo’ follow-up Pain at pressure or touch 34 (1) NS Very low Precision -3x Risk of bias -1z
(vulvar-algesiometer,
mmHg)
Sexual satisfaction (VAS 34 (1) NS Very low Precision -3x Risk of bias -1z
0−100)
Quality of life (NRS 0 34 (1) NS Very low Precision -3x Risk of bias -1z
−100)
Mild side-effects (no. 34 (1) EMG: some Lidocaine: Not assessed
participants) some
Hullender Rubin et al, Traditional acupuncture RCT Pain during intercourse 14 (1) NS Very low Precision -3x Risk for bias -1{
201947 −non-traditional (VAS 0−100)
acupuncture (sham
procedure)
After 6 mo treatment Pain at pressure or touch 14 (1) NS Very low Precision -3xRisk of bias -1{
(cotton-swab test,
VAS 0−100)
Mild side-effects (no. 14 (1) I: 32 C: 36 Very low
events)
Serious side-effects (no. 14 (1) I: 0 C: 0 Very low
events)
*
Calculation of mean difference (MD) was done from study data, since no differences between groups were presented in the study.
y
Small study population, only 1 study.
z
Non-blinded study, risk for anticipated effects could have affected the outcome.
x
Small study population, only 1 study, no statistical significant results.
{
Large drop-out rate.C = control; CI = confidence interval; FSFI = Female Sexual Function Index (2−36); I = intervention; ISS = Index of Sexual Satisfaction (0−100); MD = mean difference; MDS = Marinoff
Dyspareunia Scale (0−3); NRS = Numeric Rating Scale; NS = non-statistical significant difference; RCT = randomized controlled trial; VAS = Visual analogue scale.

797
798
CBT-techniques, with various potentially active treatment arms
for the control groups. CBT for PVD aims at facilitating pain
management through systematic work with behaviors and cogni-
tions related to pain and sexual arousal. Several techniques are
applied, such as pelvic floor relaxation, cognitive strategies, and
communication skills training. Mindfulness-based interventions
add the component of acceptance and mindfulness training to
these basic CBT-techniques. In one 12-weeks RCT, group CBT
was compared to either EMG biofeedback for pelvic floor reha-
bilitation or surgery, where part of the sensitive vestibular
mucosa was removed in a standardized procedure (vestibulec-
tomy).48 Variables related to pain and sexual function were mea-
sured after completed treatment and at 6 months’ follow-up.
The results at both occasions showed significantly less pain dur-
ing intercourse and pain upon touch and pressure (cotton-swab
test) for participants who had undergone surgery as compared to
CBT and EMG biofeedback (Table 5). Differences in results
from the cotton-swab test were in favor for surgery compared to
the 2 other interventions at a 2.5 years’ follow-up, reported in a
separate publication.53 Concerning pain during intercourse, the
long-term effect only showed a significant difference between
surgery and EMG biofeedback.
Individual or group-based CBT compared to topical hydro-
cortisone or physiotherapy was investigated in 2 RCTs.49,50 In
the first study, the result of 10 sessions group CBT vs application
of topical lidocaine during a 13-week RCT showed no significant
differences in pain during intercourse or sexual function between
the groups.49 In the second study, participants were randomized
to either 8 sessions of individual CBT or to physiotherapy with
additional home exercises for both groups.50 After treatment, sig-
nificantly less pain during the cotton-swab test was obtained in
the group receiving physiotherapy, but this difference was not
found at the 6 months’ or 12 months’ follow-ups (Table 5).
Mindfulness-based CBT (mCBT) has been evaluated in another
2 studies. In the first study, the allocated interventions were either
group mCBT or group CBT for 8 weeks.51 The results showed less
pain during intercourse up to 6 months after treatment completion
for the mCBT group, but the difference was no longer observed
after 12 months. The treatment effect of mCBT in group has also
been compared to a therapy consisting of digital PVD education
and support.52 The effect on sexual function was in favor for
mCBT up to 3 months after completed treatment. For anxiety and
depressive symptoms, significantly better results were found up to 6
months after treatment in the mCBT group, but there were no dif-
ferences in pain upon pressure and touch (Table 5).
Other Treatments
3 additional studies evaluating other categories of treatments
fulfilled the eligibility criteria (Table 6).54−56 The study results
were all assessed to have very low certainty of evidence.
Low level laser therapy or simulated treatment via a vaginal
probe with the aim to reduce pain was evaluated in a double-
Bohm-Starke et al
blinded 6-weeks RCT.55 In a 2-week RCT, the effect of transcra-
nial electric stimulation vs sham stimulation for PVD was inves-
tigated.56 The intervention is a non-invasive method using direct
current towards specific areas of the brain in an attempt to reduce
pain during intercourse. None of the studies found any signifi-
cant differences for variables related to pain, sexual satisfaction,
anxiety or depression between the study groups (Table 6).
Low intensity shock-wave treatment via a vaginal probe was
evaluated in a small double-blinded RCT over 6 weeks.54 The
control group received simulated treatment with the same device.
Significant less pain during intercourse was reported in the active
treatment group 1 and 3 months’ posttreatment, but no effect
on sexual function was obtained (Table 6).
Side-Effects. None of the studies reported any serious adverse
event, but mild side-effects occurred. In general, data on side-
effects was heterogeneously assessed and reported.
DISCUSSION
The main finding of this systematic review is the evident lack
of methodologically sound trials evaluating treatment effects for
women with PVD. A diversity of treatment approaches was iden-
tified, but in most cases only 1 single study fulfilled the selection
criteria. Consequently, our conclusions rely on a very restricted
research basis, and data could not be merged into meta-analyses
due to the heterogeneity in interventions as well as in outcome
measures. This does not mean that effective treatments for PVD
do not exist, but it underscores the need of stringent trials and
defined core outcome sets.
Most results had a very low certainty of evidence, which
means that we are unable to conclude on the effects of the inter-
ventions. The only intervention where some evidence could be
proven (with low certainty) was multimodal physiotherapy,
when compared with lidocaine treatment.44 It is worth noting
that the more extensive physiotherapeutic intervention that
included various pelvic floor muscle exercises but also informa-
tion and education, resulted in improvements in both intercourse
pain and in sexual function, compared to the less complex, yet
commonly used, topical lidocaine treatment. Although based on
findings from only 1 study, this indicates that women with PVD
benefit from more complex interventions, where several compo-
nents are combined to manage pain and its consequences.
The lack of controlled studies on this group has repeatedly
been pointed out in literature.11,13,14,16,57 Yet, a recent system-
atic review of treatment effects has been warranted to enable evi-
dence-based treatment recommendations. Unfortunately, our
findings do not serve this purpose, instead the need of rigorous
treatment studies can once more be stated.
The results demonstrate that even studies evaluating effects of
frequently used treatment options for PVD are missing. For
instance, we cannot draw any conclusions about the effects of
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J Sex Med 2022;19:789−808

Treatment of Provoked Vulvodynia

Table 5. Psychological treatments
Certainty of
Citation [reference] Participants evidence
Follow-up time Comparison Study design Outcomes (no studies) Effect (GRADE) Down rating (GRADE)

Bergeron et al, 200148 CBT in group - Biofeedback/ RCT Pain during intercourse 76 (1) Significant lower pain ratings Very low Risk of bias -1* Precision -2y
EMG - Vestibulectomy (NRS 0−10) for vestibulectomy
compared to other
interventions
After 12 wk treatment Pain at pressure or touch 76 (1) Significant lower pain ratings Very low Risk of bias -1* Precision -2y
(cotton-swab test, for vestibulectomy
NRS 0−10) compared to other
interventions
Sexual function (GSF) 76 (1) NS for all comparisons Very low Risk of bias -1* Precision -3z
Bergeron et al, 2016 49
CBT in group − topical RCT Pain during intercourse 69 (1) NS Very low Risk of bias -1* Precision -3z
hydrocortisone (NRS 0−10)
After 13 wk treatment Sexual function (FSFI) 69 (1) NS Very low Risk of bias -1* Precision -3z
Goldfinger et al, 2016 50
CBT − physiotherapy RCT Pain during intercourse 20 (1) NS Very low Risk of bias -1x Precision -3z
(NRS 0−10)
After 8−24 wk treatment Pain at pressure or touch 20 (1) P = .03, favor physiotherapy Very low Risk of bias -1x Precision -3y
(cotton-swab test,
NRS 0−10)
Sexual function (FSFI) 20 (1) NS Very low Risk of bias -1x Precision -3z
Guillet et al, 201951 Mindfulness based cognitive NRSI Pain during intercourse 64 (1) P = .03, favor MCT Very low Risk of bias -2{ Precision -2y
therapy − CBT in group (NRS 0−10)
After 8 wk treatment Pain at pressure or touch 117 (1) NS Very low Risk of bias -1# Precision -3z
(NRS 0−10)
Sexual function (FSFI) 98 (1) NS Very low Risk of bias -2{ Precision -3z
Brotto et al, 2020 52
Mindfulness based CBT in RCT Pain at pressure or touch 31 (1) MD 0.02 (1.3 to 1.3) Very low Risk of bias -1x Precision -3z
group − education and (tampon test,
support NRS 0−10)
Sexual function (FSFI) 31 (1) MD 12.5 (0.7−24.3), Very low Risk of bias -1x Precision -3y
favor mCBT
After 8 wk treatment Anxiety symptoms 31 (1) MD3.4 (5.8 to 1.0), Very low Risk of bias -1x Precision -3y
(GAD-7) favor mCBT
Depressive symptoms 31 (1) MD -2.0 (6.6 to 2.6) Very low Risk of bias -1x Precision -3z
(BDI)
*
Large drop-out rate, no blinding.
y
Small study population, only 1 study.
z
Small study population, only 1 study, no statistical significance.
x
No blinding.
{
Partly randomized, no blinding, large drop-out rate.
#
Partly randomized, no blinding.BDI = Beck Depression Inventory (0−63); CBT = cognitive behavior therapy; CI = confidence interval; FSFI = Female Sexual Function Index (2−36); GAD-7 = Generalized Anxi-
ety Disorder 7 (0−21); GSF = Global Sexual Functioning (0−1); MCT = Mindfulness based cognitive therapy; mCBT = mindfulness based CBT; MD = mean difference; NRS = Numeric Rating Scale; NS = non-
statistical significant difference; RCT = Randomized controlled trial; VAS = Visual analogue scale.

799
 800
Table 6. Other treatments
Certainty of
Citation [reference] Study Participants evidence Down rating
Follow-up time Comparison design Outcomes (no studies) Effect (GRADE) (GRADE)

Lev-Sagie et al, 201754 Low level laser therapy − RCT Pain during intercourse 34 (1) NS Very low Precision -3z
simulated treatment (NRS 0−10)
Pain at pressure or touch 34 (1) NS Very low Precision -3z
(cotton-swab test)
NRS 0−10)
After 6 wk treatment Sexual satisfaction 34 (1) NS Very low Precision -3z
(proportion with negative
effect on sexual life)
Side-effects 34 (1) I: 0% Not assessed
(proportion of C: 0%
participants)
Morin et al, 201755 Transcranial electric RCT Pain during intercourse 39 (1) NS Very low Precision -3z
stimulation−simulated (VAS 0−10)
treatment
After 2 wk treatment Sexual function (FSFI) 39 (1) NS Very low Precision -3z
Anxiety (State-Trait Anxiety 39(1) NS Very low Precision -3z
Inventory of Spielberger,
state domain)
Depression (BDI) 39 (1) NS Very low Precision -3z
Mild side-effects (proportion 39 (1) Various, some* Not assessed
of participants) were
significantly more
frequent in the
intervention group,
others not
Gruenwald et al, 202156 Low intensity shock-wave RCT Pain during intercourse 32y (1) MD -2.6 (-4.0 to -1.2)y, Very low Risk of bias -1{
therapy − simulated (VAS 0−10) favor shock-wave Precision -3x
treatment
1 mo after completed Pain at pressure or touch 32y (1) MD 7.8 (-2.4 to 18.0)y Very low Risk of bias -1{
treatment (vulvar-algesiometer, Precision -3x
mm Hg)
Sexual function (FSFI) 32y (1) MD -1.0 (-4.5 to 3.0)y Very low Risk of bias -1{
Precision -3z
Mild side-effects 32 (1) I: 4% Not assessed
(proportion of C: 0%
participants)
*
Burning sensation, erythema, itch.
y
Calculation was made since no analysis of differences between groups were reported in the study. Some uncertainty exists regarding the correct number of participants for the various outcomes.
J Sex Med 2022;19:789−808

z
Small study population, only 1 study, no statistical significant results.
x
Small study population, only 1 study.
{
Some shortcomings concerning randomization and reporting.BDI = Beck Depression Inventory (0−63); C = control; CI = confidence interval; FSFI = Female Sexual Function Index (2−36); I = intervention; MD

Bohm-Starke et al
= mean difference; NRS = Numeric Rating Scale; NS = non-statistical significant difference; RCT = randomized controlled trial; VAS = Visual analogue scale.
Treatment of Provoked Vulvodynia
neither surgical interventions, nor multimodal or team-based
interventions. Noticeable, not a single study of the effect of vesti-
bulectomy surgery fulfilled the selection criteria, despite its long
tradition as a treatment for severe cases of PVD. There have been
non-controlled cohort studies of vestibulectomy indicating posi-
tive effects,16 including on long term follow-ups.58 Yet, consider-
ing the lack of control groups in these studies, the effects of
placebo or spontaneous recovery cannot be ruled out. Multi-
modal interventions are well-established treatment options for
PVD, often recommended by specialists and in treatment guide-
lines. A combination of pain management, pelvic floor exercises
and psychosocial interventions intuitively make sense, and corre-
sponds with treatment for other chronic pain conditions.51,59,60
Nevertheless, controlled studies are needed to document the
effects.
Women with PVD is a heterogeneous group and there might
be subgroups who would benefit from different types of interven-
tions. Preferred treatment option might for instance depend on
whether the condition is primary or secondary, the age of the
woman, and if she is able to engage in intercourse or not. These
characteristics should ideally be well described in clinical studies,
and it is desirable that strict adherence to the Consensus guide-
lines from 2015 is maintained regarding definition of PVD and
method of diagnosis.3 Indeed, the effect of psychological treat-
ments has been found to depend on individual characteristics.52
To explore this further, future studies should preferably include
analyses of potential predictors and moderators of treatment
effects.
In this evaluation, standard procedures and tools for system-
atic reviews were used, and the research question as well as the
inclusion criteria were formulated and preregistered using the
PICO (Population Intervention Comparison Outcome) model
for clinical questions. Hence, our results present a state-of-art
overview of current evidence for treatment options for women
with PVD, following the golden standard for systematic reviews.
Yet, there are some inevitable shortcomings. The strict eligi-
bility criteria resulted in a very limited number of studies. Only
studies of premenopausal women with specifically PVD were
included, excluding samples with predominantly generalized vul-
vodynia, and other age groups. In a few cases, specific informa-
tion about the study sample was missing, and if this information
could not be achieved (eg, by contacting the authors), these stud-
ies were excluded. Similarly, all trials without a defined control
group were excluded, which might be questioned considering
the increasing critique of controlled group designs as the only
way of assuring high internal validity in intervention studies.61
Replicated single-case experimental designs is a promising alter-
native, recently gaining recognition as being able to provide a
strong basis for establishing intervention effects.61,62 However,
studies with non-traditional designs were outside the scope of
the current review. On the one hand, our strict eligibility criteria
might have resulted in a loss of important information. Further
more, this review provides an up-to-date picture of current
J Sex Med 2022;19:789−808
801
evidence. Besides our meticulous selection of studies, conclusions
were further complicated by the wide range of outcome measures
used in the included trials. This underscores the need of joint
defined core outcome sets for intervention trials in this field,
pointed out by several earlier reviews.63,64 Conjoint agreements
on which outcomes to focus on is a prerequisite for advancing
the knowledge about effective treatments for women with PVD.
CONCLUSIONS
This systematic review, aiming at summarizing existing con-
trolled trials of the effects of different treatments for women with
PVD, underlines the need for more research in this field, in par-
ticular trials evaluating multimodal treatment approaches. Specif-
ically, methodologically rigorous studies of treatment effects,
using joint core outcome sets are demanded. This is a key for
enabling evidence-based treatment guidelines and enhanced
health care for women with PVD.
Corresponding Author: Nina Bohm-Starke, MD, PhD,
Department of Clinical Sciences, Division of Obstetrics and
Gynecology, Karolinska Institutet Danderyd Hospital, Stock-
holm 17177, Sweden. Tel: 46812355000; E-mail: nina.bohm-
starke@ki.se
Conflict of Interest: The authors report no conflicts of interest.
Funding: None.
STATEMENT OF AUTHORSHIP
Nina Bohm-Starke: Conceptualization, Investigation, Writ-
ing - Original Draft, Writing - Review & Editing, Visualization,
Supervision; Karin Wilbe Ramsay: Conceptualization, Method-
ology, Validation, Formal Analysis, Resources, Data Curation,
Investigation, Writing - Review & Editing, Project Administra-
tion; Per Lytsy: Conceptualization, Methodology, Validation,
Formal Analysis, Resources, Data Curation, Investigation, Writ-
ing - Review & Editing, Project Administration; Birgitta Nordg-
ren: Conceptualization, Investigation, Writing - Review &
Editing; Inga Sj€oberg: Conceptualization, Investigation, Writing
- Review & Editing; Klas Moberg: Methodology, Software, Data
Curation, Writing - Review & Editing, Project Administration;
Ida Flink: Conceptualization, Investigation, Writing - Original
Draft, Writing - Review & Editing, Visualization, Supervision.
REFERENCES
1. Harlow BL, Stewart EG. A population-based assessment of
chronic unexplained vulvar pain: Have we underestimated the
prevalence of vulvodynia? J Am Med Womens Assoc (1972)
2003;58:82–88.
2. Harlow BL, Kunitz CG, Nguyen RH, et al. Prevalence of symp-
toms consistent with a diagnosis of vulvodynia: Population-
802
based estimates from 2 geographic regions. Am J Obstet
Gynecol 2014;210:40. e1-8.
3. Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD,
ISSWSH and IPPS consensus terminology and classification
of persistent vulvar pain and vulvodynia. Obstet Gynecol
2016;127:745–751.
4. Chisari C, Monajemi MB, Scott W, et al. Psychosocial factors
associated with pain and sexual function in women with vulvo-
dynia: A systematic review. Eur J Pain 2021;25:39–50.
5. Reed BD, Legocki LJ, Plegue MA, et al. Factors associated
with vulvodynia incidence. Obstet Gynecol 2014;123:225–
231.
6. Chisari C, Chilcot J. The experience of pain severity and pain
interference in vulvodynia patients: The role of cognitive-
behavioural factors, psychological distress and fatigue. J Psy-
chosom Res 2017;93:83–89.
7. Tribo MJ, Canal C, Banos JE, et al. Pain, anxiety, depression,
and quality of life in patients with vulvodynia. Dermatology
2020;236:255–261.
8. Bornstein J, Preti M, Radici G, et al. Vulvodynia: A neglected
chronic pain diagnosis. Pain 2019;160:1680–1681.
9. Lua LL, Hollette Y, Parm P, et al. Current practice patterns for
management of vulvodynia in the United States. Arch Gyne-
col Obstet 2017;295:669–674.
10. Bergeron S, Reed BD, Wesselmann U, et al. Vulvodynia. Nat
Rev Dis Primers 2020;6:36.
11. Rosen NO, Dawson SJ, Brooks M, et al. Treatment of vulvody-
nia: Pharmacological and non-pharmacological approaches.
Drugs 2019;79:483–493.
12. Guidozzi F, Guidozzi D. Vulvodynia - an evolving disease. Cli-
macteric 2022:141–146.
13. Sorensen J, Bautista KE, Lamvu G, et al. Evaluation and treat-
ment of female sexual pain: A clinical review. Cureus 2018;10:
e2379.
14. Stenson AL. Vulvodynia: Diagnosis and management. Obstet
Gynecol Clin North Am 2017;44:493–508.
15. Andrews JC. Vulvodynia interventions−systematic review and
evidence grading. Obstet Gynecol Surv 2011;66:299–315.
16. De Andres J, Sanchis-Lopez N, Asensio-Samper JM, et al.
Vulvodynia−an evidence-based literature review and proposed
treatment algorithm. Pain Pract 2016;16:204–236.
17. Swedish Agency for Health Technology and Assessment of
Social Services. [Diagnostik och behandling provocerad vesti-
bulodyni: En systematisk o€versikt och utv€ardering av medicin-
ska, sociala och etiska apekter].. Stockholm: Swedish Agency
for Health Technology and Assessment of Social Services;
2021. p. .326.https://www.sbu.se/326e.
18. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items
for systematic reviews and meta-analyses: The PRISMA
Statement. Open Med 2009;3:e123–e130.
19. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020
statement: An updated guideline for reporting systematic
reviews. BMJ 2021;372:n71.
Bohm-Starke et al
20. Schardt C, Adams MB, Owens T, et al. Utilization of the PICO
framework to improve searching PubMed for clinical ques-
tions. BMC Med Inform Decis Mak 2007;7:16.
21. Bramer WM, Giustini D, de Jonge GB, et al. De-duplication of
database search results for systematic reviews in EndNote. J
Med Libr Assoc 2016;104:240–243.
22. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan-a web
and mobile app for systematic reviews. Syst Rev 2016;5:210.
23. Sterne JA, Hernan MA, Reeves BC, et al. ROBINS-I: A tool for
assessing risk of bias in non-randomised studies of interven-
tions. BMJ 2016;355:i4919.
24. Higgins JPT, Sterne JAC, Savovic J, et al. A revised tool for
assessing risk of bias in randomized trials. In: Chandler J,
Clarke M, McKenzie J, Boutron I, V W, eds. Cochrane Methods
Cochrane Database of Systematic Reviews. 2016. Available at:
10.1002/14651858.CD201601.
25. Sterne JAC, Savovic J, Page MJ, et al. RoB 2: A revised tool
for assessing risk of bias in randomised trials. BMJ
2019;366:l4898.
26. Review Manager (RevMan). [Computer program]. Version 5.3.
Copenhagen: The Nordic Cochrane Centre, The Cochrane Col-
laboration; 2014.
27. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: An emerging
consensus on rating quality of evidence and strength of rec-
ommendations. BMJ 2008;336:924–926.
28. GRADE. Available at: https://www.gradeworkinggroup.org/.
Accessed April 27, 2021.
29. Cavalli E, Mammana S, Nicoletti F, et al. The neuropathic pain:
An overview of the current treatment and future therapeutic
approaches. Int J Immunopathol Pharmacol 2019;33:1–10.
30. Bachmann GA, Brown CS, Phillips NA, et al. Effect of gabapen-
tin on sexual function in vulvodynia: A randomized, placebo-
controlled trial. Am J Obstet Gynecol 2019;220:89. e1-89 e8.
31. Brown CS, Bachmann GA, Wan J, et al. Gabapentin for the
Treatment of Vulvodynia: A Randomized Controlled Trial.
Obstet Gynecol 2018;131:1000–1007.
32. Foster DC, Kotok MB, Huang LS, et al. Oral desipramine and
topical lidocaine for vulvodynia: A randomized controlled trial.
Obstet Gynecol 2010;116:583–593.
33. Murina F, Graziottin A, Felice R, et al. Vestibulodynia: Synergy
between palmitoylethanolamide + transpolydatin and transcu-
taneous electrical nerve stimulation. J Low Genit Tract Dis
2013;17:111–116.
34. Donders GG, Bellen G. Cream with cutaneous fibroblast lysate
for the treatment of provoked vestibulodynia: A double-blind
randomized placebo-controlled crossover study. J Low Genit
Tract Dis 2012;16:427–436.
35. Nyirjesy P, Sobel JD, Weitz MV, et al. Cromolyn cream for
recalcitrant idiopathic vulvar vestibulitis: Results of a placebo
controlled study. Sex Transm Infect 2001;77:53–57.
36. Reed BD, Harlow SD, Legocki LJ, et al. Oral contraceptive use
and risk of vulvodynia: A population-based longitudinal study.
BJOG 2013;120:1678–1684.
J Sex Med 2022;19:789−808
Treatment of Provoked Vulvodynia
37. Langlais EL, Lefebvre J, Maheux-Lacroix S, et al. Treatment of
secondary vestibulodynia with conjugated estrogen cream: A
pilot, double-blind, randomized placebo-controlled trial. J
Obstet Gynaecol Can 2017;39:453–458.
38. Bornstein J, Tuma R, Farajun Y, et al. Topical nifedipine for
the treatment of localized provoked vulvodynia: A placebo-
controlled study. J Pain 2010;11:1403–1409.
39. Murina F, Felice R, Di Francesco S, et al. Vaginal diazepam
plus transcutaneous electrical nerve stimulation to treat vesti-
bulodynia: A randomized controlled trial. Eur J Obstet Gyne-
col Reprod Biol 2018;228:148–153.
40. Haraldson P, Muhlrad H, Heddini U, et al. Botulinum
toxin A as a treatment for provoked vestibulodynia: A
randomized controlled trial. Obstet Gynecol 2020;136:
524–532.
41. Petersen CD, Giraldi A, Lundvall L, et al. Botulinum toxin type
A-a novel treatment for provoked vestibulodynia? Results
from a randomized, placebo controlled, double blinded study.
J Sex Med 2009;6:2523–2537.
42. Diomande I, Gabriel N, Kashiwagi M, et al. Subcutaneous bot-
ulinum toxin type A injections for provoked vestibulodynia: A
randomized placebo-controlled trial and exploratory subanaly-
sis. Arch Gynecol Obstet 2019;299:993–1000.
43. Farajun Y, Zarfati D, Abramov L, Livoff A, et al. Enoxaparin
treatment for vulvodynia: A randomized controlled trial.
Obstet Gynecol 2012;120:565–572.
44. Morin M, Dumoulin C, Bergeron S, et al. Multimodal physical
therapy versus topical lidocaine for provoked vestibulodynia:
A multicenter, randomized trial. Am J Obstet Gynecol
2021;224:189. e1-189 e12.
45. Danielsson I, Torstensson T, Brodda-Jansen G, et al. EMG bio-
feedback versus topical lidocaine gel: A randomized study for
the treatment of women with vulvar vestibulitis. Acta Obstet
Gynecol Scand 2006;85:1360–1367.
46. Hullender Rubin LE, Mist SD, Schnyer RN, et al. Acupuncture
augmentation of lidocaine for provoked, localized vulvodynia:
A feasibility and acceptability study. J Low Genit Tract Dis
2019;23:279–286.
47. Murina F, Bianco V, Radici G, et al. Transcutaneous electrical
nerve stimulation to treat vestibulodynia: A randomised con-
trolled trial. BJOG 2008;115:1165–1170.
48. Bergeron S, Binik YM, Khalife S, et al. A randomized compari-
son of group cognitive−behavioral therapy, surface electro-
myographic biofeedback, and vestibulectomy in the treatment
of dyspareunia resulting from vulvar vestibulitis. Pain
2001;91:297–306.
49. Bergeron S, Khalife S, Dupuis MJ, et al. A randomized clinical
trial comparing group cognitive-behavioral therapy and a topi-
cal steroid for women with dyspareunia. J Consult Clin Psy-
chol 2016;84:259–268.
J Sex Med 2022;19:789−808
803
50. Goldfinger C, Pukall CF, Thibault-Gagnon S, et al. Effective-
ness of cognitive-behavioral therapy and physical therapy for
provoked vestibulodynia: A randomized pilot study. J Sex
Med 2016;13:88–94.
51. Guillet AD, Cirino NH, Hart KD, et al. Mindfulness-based group
cognitive behavior therapy for provoked localized vulvodynia:
A randomized controlled trial. J Low Genit Tract Dis
2019;23:170–175.
52. Brotto LA, Bergeron S, Zdaniuk B, et al. Mindfulness and cog-
nitive behavior therapy for provoked vestibulodynia: Mediators
of treatment outcome and long-term effects. J Consult Clin
Psychol 2020;88:48–64.
53. Bergeron S, Khalife S, Glazer HI, et al. Surgical and behavioral
treatments for vestibulodynia: Two-and-one-half year follow-up
and predictors of outcome. Obstet Gynecol 2008;111:159–166.
54. Gruenwald I, Gutzeit O, Petruseva A, et al. Low-intensity
shockwave for treatment of vestibulodynia: A randomized
controlled therapy trial. J Sex Med 2021;18:347–352.
55. Lev-Sagie A, Kopitman A, Brzezinski A. Low-level laser therapy
for the treatment of provoked vestibulodynia-a randomized, pla-
cebo-controlled pilot trial. J Sex Med 2017;14:1403–1411.
56. Morin A, Leonard G, Gougeon V, et al. Efficacy of transcranial
direct-current stimulation in women with provoked vestibulo-
dynia. Am J Obstet Gynecol 2017;216:584. e1-584 e11.
57. Loflin BJ, Westmoreland K, Williams NT. Vulvodynia: A review
of the literature. J Pharm Technol 2019;35:11–24.
58. David A, Bornstein J. Evaluation of long-term surgical success
and satisfaction of patients after vestibulectomy. J Low Genit
Tract Dis 2020;24:399–404.
59. Skelly AC, Chou R, Dettori JR, et al. Noninvasive nonpharma-
cological treatment for chronic pain: A systematic review
update.. RockvilleMD: Agency for Healthcare Research and
Quality; 2020. p. .227.https://www.ncbi.nlm.nih.gov/books/
NBK556229/.
60. Guzman J, Esmail R, Karjalainen K, et al. Multidisciplinary
rehabilitation for chronic low back pain: Systematic review.
BMJ 2001;322:1511–1516.
61. Kazdin AE. Single-case experimental designs. Evaluating inter-
ventions in research and clinical practice. Behav Res Ther
2019;117:3–17.
62. Natesan P, Hedges LV. Bayesian unknown change-point
models to investigate immediacy in single case designs. Psy-
chol Methods 2017;22:743–759.
63. Davenport RB, Voutier CR, Veysey EC. Outcome measure-
ment instruments for provoked vulvodynia: A systematic
review. J Low Genit Tract Dis 2018;22:396–404.
64. Sadownik LA, Yong PJ, Smith KB. Systematic review of treat-
ment outcome measures for vulvodynia. J Low Genit Tract
Dis 2018;22:251–259.
804 Bohm-Starke et al

APPENDIX A. SEARCH STRATEGY

CINAHL via EBSCO 29 January 2021
Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 (MH "Vulvar Vestibulitis") 18
2 (MH "Vulvodynia") 43
3 TI ("genito-pelvic pain*" or "genitopelvic pain*") OR AB ("genito-pelvic pain*" or "genitopelvic pain*") 16
4 TI "primary VVS" OR AB "primary VVS" 2
5 TI "secondary VVS" OR AB "secondary VVS" 2
6 TI "sexual pain disorder*" OR AB "sexual pain disorder*" 43
7 TI vestibulitis OR AB vestibulitis 113
8 TI vestibulodynia OR AB vestibulodynia 126
9 TI ((vulva* or vulvovaginal) N3 (discomfort* or hypersensitivity or pain*)) OR AB ((vulva* or vulvovaginal) N3 362
(discomfort* or hypersensitivity or pain*))
10 TI vulvodynia OR AB vulvodynia 400
11 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR S9 OR S10 799
Limiters - Published Date: 19900101-20211231; Language: Danish, English, Norwegian, Swedish
The search result, usually found at the end of the documentation, forms the list of abstracts.
AB = Abstract AU = Author DE = Term from the thesaurus MM = Major Concept TI = Title TX = All Text. Performs a keyword search of all the database's
searchable fields ZC = Methodology Index * = Truncation “ “ = Citation Marks; searches for an exact phrase

Cochrane Library via Wiley 29 January 2021 (CDSR, CENTRAL)

Title: Provoked vulvodynia
Search terms Items found
Provoked vulvodynia
1 MeSH descriptor: [Dyspareunia] this term only 204
2 MeSH descriptor: [Vulvitis] this term only 13
3 #1 AND #2 3
4 MeSH descriptor: [Vulvar Vestibulitis] explode all trees 39
5 MeSH descriptor: [Vulvodynia] explode all trees 79
6 ((genito-pelvic next/1 pain*) or (genitopelvic next/1 pain*)):ti,ab,kw 7
7 "primary VVS":ti,ab,kw 2
8 "secondary VVS":ti,ab,kw 0
9 (sexual next/1 pain next/1 disorder*):ti,ab,kw 7
10 vestibulitis:ti,ab,kw 75
11 vestibulodynia:ti,ab,kw 92
12 ((vulva* or vulvovaginal) NEAR/3 (discomfort* or hypersensitivity or pain*)):ti,ab,kw 122
13 vulvodynia:ti,ab,kw 153
14 {OR #3-#13} with Cochrane Library publication date Between Jan 1990 and Dec 2021, in Cochrane Reviews, CDSR/2
Cochrane Protocols, Special collections
15 {OR #3-#13} with Publication Year from 1990 to 2021, in Trials Central/289
The search result, usually found at the end of the documentation, forms the list of abstracts.
:au = Author; MeSH = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy this term only = Does not
include terms found below this term in the MeSH hierarchy :ti = title :ab = abstract :kw = keyword * = Truncation “ “ = Citation Marks; searches for an exact
phrase CDSR = Cochrane Database of Systematic Review CENTRAL = Cochrane Central Register of Controlled Trials, “trials”

J Sex Med 2022;19:789−808

Treatment of Provoked Vulvodynia 805

Embase via Elsevier 29 January 2021

Title: Provoked vulvodynia
Search terms Items found
Provoked vulvodynia
1 'vestibulodynia'/de 73
2 'vulvar vestibulitis'/de 418
3 'vulvodynia'/de 1,592
4 'genito-pelvic pain*':ti,ab,kw OR 'genitopelvic pain*':ti,ab,kw 110
5 'primary vvs':ti,ab,kw 21
6 'secondary vvs':ti,ab,kw 5
7 'sexual pain disorder*':ti,ab,kw 196
8 vestibulitis:ti,ab,kw 520
9 vestibulodynia:ti,ab,kw 495
10 ((vulva* OR vulvovaginal) NEAR/3 (discomfort* OR hypersensitivity OR pain*)):ti,ab,kw 1,234
11 vulvodynia:ti,ab,kw 1,329
12 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 3,258
13 #12 NOT ('chapter'/it OR 'conference abstract'/it) AND [1990−2021]/py AND ([danish]/lim OR [english]/lim 2,176
OR [norwegian]/lim OR [swedish]/lim)
The search result, usually found at the end of the documentation, forms the list of abstracts.
/de= Term from the EMTREE controlled vocabulary /exp = Includes terms found below this term in the EMTREE hierarchy /mj = Major Topic :ab = Abstract :
au = Author :ti = Article Title :ti:ab = Title or abstract * = Truncation “ “ = Citation Marks; searches for an exact phrase
Medline via OvidSP 29 January 2021
Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 Dyspareunia/ and Vulvitis/ 75
2 Vulvar Vestibulitis/ 55
3 Vulvodynia/ 439
4 (genito-pelvic pain* or genitopelvic pain*).ti,ab,kf. 76
5 primary VVS.ti,ab,kf. 13
6 secondary VVS.ti,ab,kf. 3
7 sexual pain disorder*.ti,ab,kf. 97
8 vestibulitis.ti,ab,kf. 352
9 vestibulodynia.ti,ab,kf. 277
10 ((vulva* or vulvovaginal) adj3 (discomfort* or hypersensitivity or pain*)).ti,ab,kf. 716
11 vulvodynia.ti,ab,kf. 754
12 or/1−11 1,716
13 limit 12 to (yr = "1990 -Current" and (danish or english or norwegian or swedish)) 1,577
The final search result, usually found at the end of the documentation, forms the list of abstracts.
.ab. = Abstract .ab,ti. = Abstract or title .af. = All fields Exp = Term from the Medline controlled vocabulary, including terms found below this term in the
MeSH hierarchy .kf. = Keyword heading word .sh. = Term from the Medline controlled vocabulary ti. = Title / = Term from the Medline controlled vocabulary,
but does not include terms found below this term in the MeSH hierarchy * = Focus (if found in front of a MeSH-term) * or $ = Truncation (if found at the
end of a free text term) .mp = text, heading word, subject area node, title “ “ = Citation Marks; searches for an exact phrase ADJn = positional operator that
lets you retrieve records that contain your terms (in any order) within a specified number (n) of words of each other.
PsycInfo via EBSCO 29 January 2021
Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 TI ("genito-pelvic pain*" or "genitopelvic pain*") OR AB ("genito-pelvic pain*" or "genitopelvic pain*") 54
OR KW ("genito-pelvic pain*" or "genitopelvic pain*")
2 TI "primary VVS" OR AB "primary VVS" OR KW "primary VVS" 0
(continued)

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806 Bohm-Starke et al

Continued
Search terms Items found
3 TI "secondary VVS" OR AB "secondary VVS" OR KW "secondary VVS" 0
4 TI "sexual pain disorder*" OR AB "sexual pain disorder*" OR KW "sexual pain disorder*" 120
5 TI vestibulitis OR AB vestibulitis OR KW vestibulitis 81
6 TI vestibulodynia OR AB vestibulodynia OR KW vestibulodynia 139
7 TI ((vulva* or vulvovaginal) N3 (discomfort* or hypersensitivity or pain*)) OR AB ((vulva* or vulvovaginal) N3 162
(discomfort* or hypersensitivity or pain*)) OR KW ((vulva* or vulvovaginal) N3 (discomfort* or
hypersensitivity or pain*))
8 TI vulvodynia OR AB vulvodynia OR KW vulvodynia 195
9 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 484
Limiters - Published Date: 19900101-20211231; Language: Danish, English, Norwegian, Swedish
The search result, usually found at the end of the documentation, forms the list of abstracts.
AB = Abstract AU = Author DE = Term from the thesaurus MM = Major Concept TI = Title TX = All Text. Performs a keyword search of all the database's
searchable fields ZC = Methodology Index * = Truncation “ “ = Citation Marks; searches for an exact phrase

Scopus via Elsevier 29 January 2021

Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 TITLE-ABS-KEY ("genito-pelvic pain*" OR "primary VVS" OR "secondary VVS" OR "sexual pain disorder*" 2,382
OR vestibulitis OR vestibulodynia OR ((vulva* OR vulvovaginal) W/3 (discomfort* OR hypersensitivity OR pain*))
OR vulvodynia) AND (EXCLUDE (DOCTYPE,"ch")) AND (LIMIT-TO (PUBYEAR,2021) OR LIMIT-TO
(PUBYEAR,2020) OR LIMIT-TO (PUBYEAR,2019) OR LIMIT-TO (PUBYEAR,2018) OR LIMIT-TO
(PUBYEAR,2017) OR LIMIT-TO (PUBYEAR,2016) OR LIMIT-TO (PUBYEAR,2015) OR LIMIT-TO
(PUBYEAR,2014) OR LIMIT-TO (PUBYEAR,2013) OR LIMIT-TO (PUBYEAR,2012) OR LIMIT-TO
(PUBYEAR,2011) OR LIMIT-TO (PUBYEAR,2010) OR LIMIT-TO (PUBYEAR,2009) OR LIMIT-TO
(PUBYEAR,2008) OR LIMIT-TO (PUBYEAR,2007) OR LIMIT-TO (PUBYEAR,2006) OR LIMIT-TO
(PUBYEAR,2005) OR LIMIT-TO (PUBYEAR,2004) OR LIMIT-TO (PUBYEAR,2003) OR LIMIT-TO
(PUBYEAR,2002) OR LIMIT-TO (PUBYEAR,2001) OR LIMIT-TO (PUBYEAR,2000) OR LIMIT-TO
(PUBYEAR,1999) OR LIMIT-TO (PUBYEAR,1998) OR LIMIT-TO (PUBYEAR,1997) OR LIMIT-TO
(PUBYEAR,1996) OR LIMIT-TO (PUBYEAR,1995) OR LIMIT-TO (PUBYEAR,1994) OR LIMIT-TO
(PUBYEAR,1993) OR LIMIT-TO (PUBYEAR,1992) OR LIMIT-TO (PUBYEAR,1991) OR LIMIT-TO
(PUBYEAR,1990)) AND (LIMIT-TO (LANGUAGE,"English") OR LIMIT-TO (LANGUAGE,"Swedish")
OR LIMIT-TO (LANGUAGE,"Danish") OR LIMIT-TO (LANGUAGE, "Norwegian"))
The search result, usually found at the end of the documentation, forms the list of abstracts.
TITLE-ABS-KEY = Title or abstract or keywords ALL = All fields PRE/n = "precedes by." The first term in the search must precede the second by a specified
number of terms (n). W/n = "within." The terms in the search must be within a specified number of terms (n) in any order. * = Truncation “ “ = Citation
Marks; searches for an exact phrase LIMIT-TO (SRCTYPE, "j" = Limit to source type journal LIMIT-TO (DOCTYPE, "ar" = Limit to document type article
LIMIT-TO (DOCTYPE, "re" = Limit to document type review EXCLUDE (DOCTYPE, "ch") = Book Chapter

CRD Database 29 January 2021

Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 MeSH DESCRIPTOR Vulvar Vestibulitis EXPLODE ALL TREES 1
2 MeSH DESCRIPTOR Vulvodynia EXPLODE ALL TREES 4
3 ("genito pelvic pain*" or "genitopelvic pain*" or "primary VVS" OR "secondary VVS" or "sexual pain disorder*" 8
or vestibulitis or vestibulodynia or "vulva pain" or "vulvar pain" or " vulvovaginal pain" or vulvodynia)
4 #1 OR #2 OR #3 8
The search result, usually found at the end of the documentation, forms the list of abstracts.

J Sex Med 2022;19:789−808

Treatment of Provoked Vulvodynia 807

Epistemonikos 29 January 2021

Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 title:("genito pelvic pain*" OR "genitopelvic pain*" OR "primary VVS" OR "secondary VVS" OR "sexual pain disorder*" 45
OR vestibulitis OR vestibulodynia OR "vulva pain" OR "vulvar pain" OR " vulvovaginal pain" OR vulvodynia) OR
abstract:("genito pelvic pain*" OR
"genitopelvic pain*" OR "primary VVS" OR "secondary VVS" OR "sexual pain disorder*" OR vestibulitis OR
vestibulodynia OR "vulva pain" OR "vulvar pain" OR " vulvovaginal pain" OR vulvodynia)
Limit to Systematic Review
The search result, usually found at the end of the documentation, forms the list of abstracts.

Evidence Search 29 January 2021

Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 ("genito pelvic pain*" or "genitopelvic pain*" or "primary VVS" OR "secondary VVS" or "sexual pain disorder*" 23
or vestibulitis or vestibulodynia or "vulva pain" or "vulvar pain" or " vulvovaginal pain" or vulvodynia)
Limit to Evidence type: Systematic Reviews, Health Technology Assessments
The search result, usually found at the end of the documentation, forms the list of abstracts.

International HTA Database 29 January 2021

Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 (Vulvar Vestibulitis[mhe]) 2
2 (Vulvodynia[mhe]) 1
3 ("genito pelvic pain*" or "genitopelvic pain*" or "primary VVS" OR "secondary VVS" or "sexual pain disorder*" 4
or vestibulitis or vestibulodynia or "vulva pain" or "vulvar pain" or " vulvovaginal pain" or vulvodynia)
4 #1 OR #2 OR #3 4
The search result, usually found at the end of the documentation, forms the list of abstracts.

KSR Evidence 29 January 2021

Title: Provoked vulvodynia
Search terms Items found
Population: Provoked vulvodynia
1 "genito pelvic pain*" or "genitopelvic pain*" or "primary VVS" OR "secondary VVS" or "sexual pain disorder*" or 42
vestibulitis or vestibulodynia or "vulva pain" or "vulvar pain" or " vulvovaginal pain" or vulvodynia
The search result, usually found at the end of the documentation, forms the list of abstracts.

J Sex Med 2022;19:789−808

808 Bohm-Starke et al

Appendix B Risk of bias in randomized studies, assessed with the ROB-2 tool
Study Randomization Deviations Missing outcome Measurement Reporting Overall judgement

Bachmann 2019* Low Low Low Low Low Low

Bardin 2020 Some concerns Some concerns Some concerns Low Some concerns High
Bergeron 2001 Low Low Some concerns Some concerns Low Some concerns
Bergeron 2008* Low Low Some concerns Some concerns Low Some concerns
Bergeron 2016 Low Low Some concerns Some concerns Low Some concerns
Bornstein 1995 Some concerns Some concerns Low High Some concerns High
Brotto 2019 Some concerns Low Some concerns Some concerns Low Some concerns
Brotto 2020* Some concerns Low Some concerns Some concerns Low Some concerns
Brown 2018 Low Low Low Low Low Low
Danielsson 2006 Low Some concerns Some concerns Low Low Some concerns
Diomande 2019 Low Low Low Low Low Low
Donders 2012 Some concerns Low Low Low Low Low
Farajun 2012 Low Low Low Low Some concerns Some concerns
Foster 2010 Low Low Low Low Low Low
Goldfinger 2016 Some concerns Low Low Some concerns Some concerns Some concerns
Gruenwald 2021 Some concerns Low Some concerns Low Low Some concerns
Guillet 2019 Low Low Some concerns Some concerns Low Some concerns
Haraldsson 2020 Low Low Low Low Low Low
Hullender 2019 Low Some concerns Some concerns Low Low Some concerns
Langlais 2017 Low Low Low Low Some concerns Some concerns
Lev-Sagie 2017 Some concerns Low Low Low Some concerns Some concerns
Morin 2017 Low Low Low Low Low Low
Morin 2020 Low Low Low Some concerns Low Some concerns
Murina 2008 Low Low Low Low Low Low
Murina 2013 Low Low Low Low Some concerns Some concerns
Murina 2018 Low Low Low Low Some concerns Some concerns
Nyirjesy 2001 Low Some concerns Some concerns Low Some concerns Some concerns
Petersen 2009 Low Low Low Low Low Low
Weijmar Schultz 1996 Some concerns Some concerns Low High Some concerns High
*
Follow-up study with complementary results to a primary study

Risk of bias in non-randomized studies, assessed with the ROBINS-I tool

Study Confoun-ding Selection Classifi-cation Devia-tions Missing outcome Measure-ment Reporting Overall judgement

Bornstein 2010 Some concerns Low Some concerns Low Some concerns Low Some concerns Some concerns
Brotto 2015 Some concerns Low Low Some concerns Some concerns High Some concerns High
Kamdar 2007 High High Some concerns Some concerns Low High Some concerns High
Tommola 2012 High High Low Low Low Some concerns Some concerns High

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