Are the other disorders truly chronic vulvar pain comorbidities or are they contributing/causing pelvic floor muscle overactivity that eventually ends up as sexual pain that is eventually diagnosed as some form of vulvodynia?
This question is related to the QPRN’s publication and the accompanying knowledge translation video by Malgorzata Starzec-Proserpio.
That is an excellent and nuanced question—one that highlights the complexity of chronic vulvar pain syndromes such as vulvodynia.
Vulvodynia as a Chronic Overlapping Pain Condition (COPC)
Vulvodynia is classified as one of the Chronic Overlapping Pain Conditions (COPCs), a group of heterogeneous syndromes that includes:
- Extra-pelvic conditions such as fibromyalgia, chronic fatigue syndrome, and temporomandibular disorders;
- Pelvic conditions like bladder pain syndrome, irritable bowel syndrome, and endometriosis.
These conditions are characterized by distressing symptoms—such as pain and fatigue—that cannot be fully explained by a single identifiable pathology.
Central Sensory Augmentation: A Shared Mechanism
Neuroimaging studies suggest that many COPCs are associated with central sensory augmentation, and shared mechanisms such as central sensitization may underlie increased sensitivity across multiple body regions.
There is ongoing debate as to whether these conditions are:
- Causally linked (e.g., one triggering or worsening another), or
- Co-occurring due to common underlying physiological mechanisms.
Pelvic Floor Muscle Dysfunction: Cause, Consequence, or Component?
Pelvic floor muscle (PFM) tension or overactivity is frequently observed in individuals with vulvodynia.
However, it remains unclear whether this represents:
- A predisposing factor,
- A consequence of pain,
- Simply one component of a broader clinical presentation.
Some hypotheses suggest that pain and inflammation in the pelvic region may lead to PFM dysfunction. Others propose that PFM dysfunction may itself trigger hypersensitivity in the vaginal mucosa, potentially resulting in vulvodynia-like symptoms.
A Vicious Cycle of Pain and Muscle Dysfunction
It is likely that a vicious cycle is involved: pain exacerbates muscle dysfunction, which in turn intensifies pain.
This cycle may be further reinforced by cognitive, emotional, behavioral, and social factors.
A Clinical Perspective: Integrating Systemic and Local Factors
In this context, the suggestion raised in the original question is certainly valid.
On the other hand, clinical observations show that some individuals first develop sexual pain conditions like vulvodynia, and only later experience other COPCs.
While we often cannot establish clear causality, the most clinically useful approach is to:
- Recognize the interplay between systemic pain regulation and local musculoskeletal and sensory changes;
- Tailor treatment strategies accordingly.
References
Till SR, Nakamura R, Schrepf A, As-Sanie S. Approach to Diagnosis and Management of Chronic Pelvic Pain in Women: Incorporating Chronic Overlapping Pain Conditions in Assessment and Management.
Maixner W, Fillingim RB, Williams DA, Smith SB, Slade GD. Overlapping Chronic Pain Conditions: Implications for Diagnosis and Classification.
Chronic Pain Research Alliance Initiative: Chronic Overlapping Pain Conditions.
Kadah S, Soh S-E, Morin M, Schneider M, Heron E, Frawley H. Is there a difference in pelvic floor muscle tone between women with and without pelvic pain?
Kadah S, Soh SE, Morin M, et al. Are pelvic pain and increased pelvic floor muscle tone associated in women with persistent noncancer pelvic pain?
Morin M, Binik YM, Bourbonnais D, Khalife S, Ouellet S, Bergeron S. Heightened Pelvic Floor Muscle Tone and Altered Contractility in Women With Provoked Vestibulodynia.
Bergeron S, Rosen NO, Morin M. Genital pain in women: Beyond interference with intercourse.
