title: Relationship between nongenital tender point tenderness and intravaginal muscle pain intensity: ratings in women with provoked vestibulodynia and implications for treatment.
abstract: BACKGROUND
  Vulvodynia is a chronic vulvar pain disorder and fibromyalgia is a chronic widespread musculoskeletal pain disorder, both of unknown etiology. Association of these conditions is well documented. Intravaginal algometer measurement of tenderness to pressure applied to the pelvic floor muscles helps define vulvodynia associated with musculoskeletal factors. Women with both vulvodynia and fibromyalgia might have increased pelvic muscle pain compared to women with vulvodynia alone, defining the possible link of these 2 conditions.
  
  
  OBJECTIVE
  We sought to: (1) correlate pain intensity during the nongenital tender point tenderness examination to pain intensity with the vaginal algometer in women with provoked vestibulodynia, and (2) determine whether subjects with provoked vestibulodynia and fibromyalgia had higher pain intensity scores with the vaginal algometer than those without fibromyalgia.
  
  
  METHODS
  In all, 92 subjects referred for vulvar pain were confirmed to have provoked vestibulodynia using the cotton swab test. A diagnosis of fibromyalgia was made if pain was present (numeric rating scale >1) in at least 11 sites of the 18-point nongenital tender point tenderness exam. Vaginal pain sensitivity was measured using an intravaginal pressure algometer, where 0.1, 0.3, and 0.5 kg/cm2forces were applied digitally in random assignment by force and location to the right and left iliococcygeus muscle regions and the posterior vaginal wall. Both tender point tenderness and algometer pain intensity were reported on a 0 (no pain) to 10 (worse pain) numeric rating scale. Correlations were computed between the composite pain intensity (total of rating scale from each pressure threshold at specified site) of nongenital and those of iliococcygeus regions and the posterior vaginal wall. Independent t tests were used to determine differences in iliococcygeus regions and the posterior vaginal algometer pain ratings and presence or absence of fibromyalgia. The significance level was at P < .05. The data were expressed as mean ± SD.
  
  
  RESULTS
  A significant correlation was found between numeric rating scale pain scores on the nongenital tender point tenderness exam and algometer testing on the iliococcygeus region (r = 0.44, P < .0001) and the posterior vaginal wall (r = 0.45, P < .0001). Subjects with fibromyalgia by tender point tenderness had significantly higher iliococcygeal pain (6.14 ± 2.07 vs 3.74 ± 2.22, P = .0001) and posterior vaginal wall pain (5.67 ± 2.10 vs 3.07 ± 2.16, P < .0001) than women without fibromyalgia by tender point tenderness.
  
  
  CONCLUSIONS
  Women with provoked vestibulodynia who experience more severe pain with nongenital tender point palpation also experience more deep vaginal pain on pelvic exam. Those who fulfill the diagnosis of fibromyalgia show significantly more intense deep vaginal pain to palpation of iliococcygeus muscles and posterior vaginal wall. Further research using a more precise definition of fibromyalgia is necessary to confirm this relationship, but findings suggest that women with provoked vestibulodynia coexisting with fibromyalgia have greater risk of superimposed vaginal muscle pain and may be candidates for early adjunctive pelvic floor physical therapy. These findings need to be explored in women with generalized, nonprovoked vulvodynia.
authors.affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. Electronic address: phillina@rutgers.edu.
authors.forename: Nancy
authors.initials: N
authors.lastname: Phillips
authors.affiliation: Department of Clinical Pharmacology, University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Candace
authors.initials: C
authors.lastname: Brown
authors.affiliation: Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ.
authors.forename: Gloria
authors.initials: G
authors.lastname: Bachmann
authors.affiliation: Department of Preventative Medicine, University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Jim
authors.initials: J
authors.lastname: Wan
authors.affiliation: Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY.
authors.forename: Ronald
authors.initials: R
authors.lastname: Wood
authors.affiliation: Department of Clinical Pharmacology, University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Dagny
authors.initials: D
authors.lastname: Ulrich
authors.affiliation: Department of Clinical Pharmacology, University of Tennessee Health Science Center, Memphis, TN.
authors.forename: Candi
authors.initials: C
authors.lastname: Bachour
authors.affiliation: Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY.
authors.forename: David
authors.initials: D
authors.lastname: Foster
mesh_terms: D005260:Female; D005356:Fibromyalgia / Q000150:complications / Q000503:physiopathology*; D006801:Humans; D018482:Muscle, Skeletal / Q000503:physiopathology; D010147:Pain Measurement; D017773:Pelvic Floor / Q000503:physiopathology; D014621:Vagina / Q000503:physiopathology; D056650:Vulvodynia / Q000150:complications / Q000503:physiopathology*
keywords: fibromyalgia; pain intensity ratings; vestibulodynia