Our expert says:
Vulvodynia literally means pain in the vulva. It is characterized by itching, burning, stinging or stabbing in the area around the opening of the vagina. Pain can vary from constant to intermittent, or only occur on attempted vaginal penetration with sexual intercourse. Symptoms of vulvodynia may range from mildly irritating to completely disabling. While a distinct sore, or area of redness may be visible, often the vagina shows no abnormalities or infections on gynecological evaluation. Unfortunately, many doctors are unaware that these conditions even exist and may mistakenly suggest to patients that this is a psychological condition. It is common for women with vulvodynia to suffer for many years and see many doctors before being correctly diagnosed.
Vulvodynia, as with most chronic pain conditions, has a profound impact on quality of life. It often affects one’s ability to engage in sexual activity and can interfere with daily functioning. It can impair one’s ability to work, engage in physical activity and participate in a social life. These limitations can negatively affect self – image and may sometimes lead to depression.
1) Incidence: up to 15% of women seeking care from gynecologists (age 15 to 80’s)
2) Associated factors
a. Acute onset
b. New partner
c. Post surgery
d. Post abortion
e. Post vaginal infection
f. Post EBV
g. Post vaginal trauma: rape, laser, chemical burn
3) Associated health problems
a. Interstitial cystitis
c. Chronic pelvis pain
d. Chronic fatigue
Embryology and Anatomy:
The origin of the vestibule is derived from the urogenital sinus (endoderm) with the posterior urogenital sinus becoming the Skene’s ducts in the female and prostate gland in males. A second focus of posterior urogenital sinus becomes the Bartholin’s glands in the female and the female and Cowper’s gland in the male. The nerve supply is from S2 (labia) and S3 & S4 (vestibule and vagina).
What causes Vulvodynia?
The cause of vulvodynia is unknown. It may be the result of multiple factors such as:
· an injury to, or irritation of, the nerves that innervate the vulva
· a localized hypersensitivity or allergy to Candida
· an inflammatory response to environmental irritants
· high levels of oxolate crystals in the urine
· spasms of the muscles that support the pelvic organs
There is no evidence that vulvodynia is caused by viral or bacterial infection or that it is a sexually transmitted disease.
Vulvodynia is diagnosed when other causes of vulvar pain, such as active yeast infection, herpes, skin disorders and other bacterial infections are ruled out or treated. There are many causes for vulvodynia and more than one cause may be found for the pain. Since successful treatment of vulvodynia depends on determining the cause, a careful evaluation is critical to success. Evaluation includes an extensive questionnaire to make sure that other reasons for pain are not missed and that we know as much about you as possible. During the physical exam, we will carefully evaluate the source(s) of your pain. Finally, by putting all of this information together, we can recognize patterns of symptoms that fit into the different subtypes of vulvodynia that will allow us to offer you specific treatment options.
There are many causes for vulvodynia and for many women, there may be more than one cause. All of the causes need to be addressed in order to treatment to have the best chance of success. Listed below are some of the reasons for vulvar pain and/or itching:
· Pudendal neuralgia – results from the irritation of the major nerve that goes to the vulva
· Pelvic floor tension myalgia (vaginismus) – the pelvic floor muscles go into painful spasm as a result of other types of pain.
· Chronic urethritis
· Interstitial cystitis
· Chronic vaginitis
· Contact dermatitis
· Lichen planus
· Seborrheic dermatitis
· Lichen sclerosus
· Lichen simplex chronicus
· Herpetic infections
· Systemic autoimmune diseases
· Atrophic vulvitis
· HPV (Human papilloma virus)
· Lichen simplex chronicus
· VIN (Vulvar intraepithelial neoplasia)
· Vulvar vestibilutis – is localized entirely in the vulvar vestibule and is painful only to touch, pressure, or insertion (e.g. intercourse, tampon, etc) On exam, only the tiny vestibular and/or periurethral glands are tender.
· Essential vulvodynia - is generalized pain of the vulva that is present most of the time. On examination, the vulvar skin may show many superficial vessels.
· Vulvar fissures - with intercourse, the skin of the vagina splits and the woman will notice burning with urination.
· Clitoral adhesions – occur as a result of vaginal or vulvar infections and cause the clitoris to stick to the skin around it. Pain is localized to the clitoris.
· Scar tissue – can result from childbirth, vaginal surgery, or Bartholin gland surgery.
NOTE: Many women with vulvar symptoms have more than one identifiable problem.
History: See history form
Discharge: wet prep, culture (all patients with vulvar complaints should have a vaginal culture)
Skin: hypertrophic, papillary changes, fissures, etc
Pain mapping: Q-tip, type of pain (burning, sharp, itching, ache), attempt to reproduce source of pain
· Vestibule (thickened polyposis, thin, tears, erythema, ectasia, acetowhite, focal tenderness)
· Posterior voiurchette (erythema, thin skin, tears or fissures, acetowhite)
· Vestibular glands
· Urethral meatus
· Skene’s glands
· Posterior cul de sac
· Uterine position
Colposcopy with acetic acid and biopsy (should be performed on all patients with chronic vulvar complaints not associated with vaginitis)
A thorough evaluation of the woman with vulvodynia is important in order to identify underlying problems that contribute to the pain or may cause the pain. Testing may include some or all of the tests described below:
· Vaginal cultures
· Cervical cultures
· Pap smear
· Colposcopy with acetic acid and biopsy
· Blood testing – diabetes and insulin resistance
· Stool evaluation
· Food allergy testing
· Immune evaluation for Candida and/or hormonal allergies
· Nerve blocks
Currently there is no cure for vulvodynia. However, over 80% of women with vulvodynia achieve complete relief of their symptoms with a multidisciplinary approach. Patients are encouraged to review all of the treatment options and, in consultation with their health care team, determine the best approach for them. At present there are numerous treatments that offer partial or complete relief.
Reassurance: Most of these women have been told that there is nothing wrong (implying it is all in there heads). They need reassurance that the pain is real and that there are many treatment options.
Information: Patients who are an active participant in treatment decisions invariably do better than patients who are passive. Likewise, treatment decisions that are imposed on a patient reinforce her lack of control. There is no one treatment that will cure them, but through hard work and patience, relief is achieved by over 85% of women when they take advantage of the resources available in a multidisciplinary program.
Vulvar comfort measures: see patient handout in Appendix
Low oxalate diet: High levels of oxalate in the urine seem to contribute to vulvar pain in some women. We don’t understand why lowering the oxolate in the urine helps some women and has no effect on others. Perhaps the oxalate acts as a skin irritant. Serum and urine oxalate levels can be determined to see if a 2 – 3 month trial of a low oxalate diet combined with calcium citrate (this neutralizes oxalates in the urine) might be of benefit.
Biofeedback: Women by teaching women to relax the muscles that are tense or in spasm. It is possible that spasms in the pelvic floor muscles can cause compression of the nerves, resulting in pain. Correcting the muscle abnormalities by retraining the muscles leads to pain relief in many.
Medications for nerve pain: Neurontin, Tegretol and Dilantin are anti-seizure medications that are also quite helpful for nerve – related pain. The medications are initially started at a low dose and gradually increased until pain relief is attained or side effects (such as drowsiness) limit their use. These medications can also be applied externally in an ointment prepared by a compounding pharmacy.
Other oral medication: Guanefesin is a mucolytic drug with few side effects and notable success in relieving pain for some women.
Tricyclic antidepressants: Block the nerve conduction of most of the pain impulses. The tricyclics have been widely used in this country since the early 1960’s and appear quite safe. They inhibit the uptake of norepinephrine and serotonin at the neuron juncture, thereby altering the transmission of nerve impulses. The doses used for pain relief are much lower than the doses for treatment of depression and so side effects are not often a problem. If side effects are a problem, these medications can be compounded in an ointment and applied to the vulva.
Antidepressants: Depression does not cause pain, but chronic pain and the difficulty in finding appropriate support can result in depression. Antidepressants such as Prozac, Paxil, Zoloft, Wellbutrin, Serzone and others may be helpful in lifting the depression.
Topical therapy: A variety of topically applied medications are available including oestrogen, testosterone, steroids, anti-fungal creams, anti-viral anti-bacterial creams and topical anaesthetics. Most are available in special aquaphor preparations for those who are sensitive to most creams. In addition, a number of over-the-counter preparations may be helpful including vegetable oil, cocoa butter and grape-seed oil.
Antihistamine: Non-sedating antihistamine such as Claritin, Zyrtec and Allegra may e helpful in relieving some of the local allergic symptoms of vulvodynia. Leukotrine inhibitors such as Accolate or Singulair may.
Food allergy treatment: Some women notice that their symptoms worsen after eating certain foods. An elimination diet may help identify food sensitivities in some women, while others require specific skin testing to identify culprits.
Candida allergy treatment: Candida albicans is a yeast or fungus that is a normal part of the skin, bowel or vagina. However, women who develop frequent or resistant vaginal yeast infections may be at risk for developing allergies to Candida. This means that even after the vaginal yeast infection is successfully treated, the normal amount of Candida present on the skin or in the vagina may set off an allergic reaction. Treatment consists of long term anti-fungal medications and oral desensitization to Candida.
Physical therapy: Muscles that have become shortened as a result of prolonged spasm can be progressively stretched by the physical therapist. In addition, scar tissue can be stretched and softened, allowing tissues to move normally. Associated treatments include EMG and biofeedback.
The information provided does not constitute a diagnosis of your condition. You should consult a medical practitioner or other appropriate health care professional for a physical exmanication, diagnosis and formal
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