Jessica Thomason, MD, FACOG

Vulvodynia         is defined as chronic vulvar discomfort with a duration of at least         three months. This discomfort can be expressed as pain, burning,         itching, dyspareunia (painful sexual intercourse), stinging, rawness, or         "irritation" of a constant or intermittent nature. The         prevalence rate is not well-established, but an article by Martha         Goetsch, M.D., (American Journal of Obstetrics and Gynecology, 1991)         reported the prevalence rate of Vulvar Vestibulitis Syndrome to be 15%         in her general gynecologic private practice. Early results from a survey         by the National Vulvodynia Association found the mean age of women with         vulvodynia to be 43.  Age         ranges have been reported from 11-75 years.
 

       Vulvodynia can be classified as primary, meaning the pain has been present       since first sexual experience or tampon use, or as secondary,       beginning after first tampon         use or first sexual experience. It can also be classified as pure,         occurring only with touch (such as with sexual intercourse, riding a         bicycle, during wiping of the perineum after voiding) or as mixed,         occurring both with touch and at other times (e.g.,         spontaneously when one is sitting). It can be organic, i.e., have an         identifiable cause, or idiopathic, meaning it does not have an         identifiable cause. There         are several classification schemes for dyspareunia (painful sexual         intercourse). For example, it can be classified according to type and         severity. The type can be superficial, i.e., located only at the opening         of the vagina, or deep, i.e., located deep within the vaginal cavity, or         both. Dyspareunia can also be classified according to its severity. In         Type 1, sexual intercourse causes discomfort but does not prevent         intercourse from occurring; in Type 2, the pain frequently prevents         intercourse; and in Type 3, intercourse is completely prevented because         of pain. 
 

            To         understand vulvodynia, it is important to review the anatomy of the         nerve supply in the pelvis. The vulva receives nervous input from three         major nerves: the pudendal, ilioinguinal, and genitofemoral. The         pudendal nerve originates from the S2-S4 region of the spinal cord         and has three branches: the inferior hemorrhoidal (rectal) nerve, the         perineal nerve, and the dorsal nerve of the clitoris. It functions to         transmit sensory signals to the genitalia and perineum and also supplies         motor function to the pelvic floor and external sphincters of the         urethra and rectum. Both the ilioinguinal and genitofemoral nerves         originate in the L1-L2 area of the spinal cord; they have sensory         functions, but not motor functions. The ilioinguinal nerve transmits         sensory signals to the inguinal (groin) area, symphysis (mons pubis) and         anterior vulva. The genitofemoral nerve transmits sensory signals to the         anterior vulva and the labia majora. Types         of Neuropathic Pain Many         physicians have conceptualized vulvodynia as neuropathic (nerve) pain,         which can be classified as one of the following three types. Allodynia         is the term used to describe a painful response to a stimulus that does         not ordinarily cause pain; for example, touching a healthy person’s         arm with a feather does not normally cause a painful sensation, but if         such touch was perceived as painful, the sensation would be         classified as allopathic pain. Hyperalgesiadescribes an exaggerated pain reaction to a stimulus that is         normally painful. Dysesthesia is the perception of an unpleasant and         abnormal sensation produced by a non-noxious stimulus. Women with         vulvodynia may experience all three types of neuropathic pain, but many         pain specialists consider vulvodynia to be primarily an allodynia.  

Nociceptors         are receptors that transmit pain caused by injury to body tissue. There         are many types of nociceptive damage which can cause vulvar pain.         Nociceptive damage can result from neurologic compression, either from a         stretch injury, transection (cutting) of a nerve, or infection of a         nerve. It also can occur from pelvic floor descent, i.e., prolapse of the         pelvic floor with stretching of the pudendal nerve through "Alcock's         canal." (Alcock's canal is an area where the pudendal nerve runs         very near to the hipbone).

Vulvar         pain also can result from damage to nerves from tumors, cysts or         surgery; soft tissue injury from an episiotomy or vaginal delivery;         laser ablation of the vulvar skin; a car accident; a straddle injury; vaginal atrophy caused by a lack of estrogen;         chronic skin irritation from application of medications such as steroids         or Aldara and infective agents such as viruses (e.g., HPV). Furthermore,         vaginal surgery can increase the risk of pudendal nerve injury. 

 A         variety of factors need to be considered to make an accurate diagnosis         of vulvodynia. Initially, it is important to take a careful medical         history. In particular, one should look for an initiating factor such as         surgery, childbirth, or change of sexual partner. Other factors to         explore are a relationship between vulvodynia and the menstrual cycle;         urethral symptoms; other medical conditions; any medications used ( past         or present); any family history (other female family members who have         experienced similar symptoms); the use of menstrual pads or panty liners;         trauma to the perineum from excessive exercising or bicycle riding; and         contraception use.  

There         are multiple aspects of the gynecologic examination. To minimize pain on         the patient’s first visit, the use of an intravaginal speculum may not         be necessary. Since pain is usually located on the vulva, a careful,         thorough examination of this area may be all that is required initially         to localize the pain. To start, it is important to evaluate the         following: the size and shape of the clitoris, the clitoral hood and         labia minora; possible inflammation of the Bartholin glands and minor         vestibular glands (using the Q-tip test); and Fox Fordyce spots         (normal anatomic spots on the labia minora). The labia should be         examined for lesions, the perianal area should be checked for whiteness         and/or fissuring, and the general color of the genital and anal skin         should be noted. Next, a neurological examination should be carried out,         evaluating reflexes in the vaginal and rectal areas, as well as     allodynia.

 During         the internal examination of the vagina, the pelvic muscles should be         palpated. Areas surrounding the vulva should be evaluated for pain         including any coccygeal (tailbone) pain, mons pubis (area around the         pubic bone) pain, upper inner thigh pain, pyriformis (pelvic floor         muscle) pain, and sciatic pain. Any pelvic prolapse should also be noted. Colposcopic examination         should be performed in some cases to rule out conditions such as         condylomatous vaginitis, lichenoid vaginitis, lichen planus, and other         dermatologic conditions. If there are any suspicious lesions, a biopsy         should be performed to confirm the diagnosis.              

    In         some cases, an array of laboratory tests are also necessary. These         include potassium hydroxide and normal saline wet mounts for microscopic         examination of vaginal secretions. This evaluation also can be done with         the vulvar skin and perianally, if needed. Laboratory tests should be         performed to rule out metabolic diseases such as hypothyroidism,         hyperthyroidism, glucose intolerance, and autoimmune diseases. In order         to rule out menopause or premature ovarian failure, blood levels of         certain hormones such as serum estradiol and follicle stimulating         hormone should be measured. 

Multidisciplinary         Approach         

Ideally,         the evaluation and treatment of vulvodynia should involve a         multi-disciplinary approach. A neurological examination, including an         EMG of the pelvis, should be completed. A gastroenterologist may be         needed to examine sphincter integrity and check for intestinal         inflammatory disease. A dermatologist should evaluate if the pain is         resulting from any dermatoses. To manage pain medications and evaluate         trigger points, an         anesthesiologist may be needed. If the patient exhibits depression, a         referral to a psychiatrist may be appropriate. A physical therapist         skilled in the use of biofeedback may be needed for a biofeedback         evaluation of the pelvic floor musculature. In certain cases in which         the patient has undergone prior vulvar surgery, a consultation with a         plastic surgeon may be         indicated if major skin grafting is required at subsequent surgery.         Finally, a referral to a vulvar disease specialist may be appropriate.

Once         the initial work up and all necessary referral visits have been         completed, it         is important to treat any underlying conditions found during the course         of the examinations. Some of these underlying conditions are infections:         if yeast is found, antifungals are prescribed; if bacterial vaginosis is         found, antibacterials are prescribed; for herpes simplex, antivirals are         used; for human papillomavirus, ablative therapy (application of certain         topical biochemicals) is performed; if there’s a Bartholin gland         abscess, the gland should be excised.

 All         possible trauma to the area should be avoided including wearing tight         clothing, excessive exercising, and motorcycle or bicycle riding. The         physician should repair vaginal prolapses and revise scars created         during previous surgeries, vaginal deliveries, or pelvic floor injury. 

Any medications or vaginal products that might be causing an         allergic reaction should be discontinued including anesthetics,  topical         antibiotics, antifungals, antiseptics, corticosteroids, and  spermicides.         All materials that come in contact with the vulvar region such  as         condoms, latex, rubber, and panty liners, as well as  over-the-counter         personal hygiene products which may contain additives that are         irritating to the vulva should be avoided. Substances that sting  upon application, e.g., soaps, alcohol, douches, and gentian violet,  should         also be avoided.

In         some cases, vulvar symptoms may be the result of dermatological         disorders such as lichen sclerosus, eczema, atrophic vulvitis, or         contact dermatitis. Some other dermatological conditions to be ruled out         are Candida vulvitis, lichen simplex, Herpes simplex and Crohn’s disease of the         vulva. Vaginal or vulvar atrophy due         to perimenopause, menopause, or prolonged breast feeding can be treated         with hormone therapy. Similarly, one should treat any underlying         metabolic diseases such         as Crohn’s, Sjogren’s syndrome, and Systemic Lupus Erythematosus to         see if         vulvar symptoms are eliminated.

 Patients         with chronic vulvar pain which does not result from an underlying         disease and does not have an identifiable cause are treated with an         "antineuralgic" medication. The classic approach is to         prescribe a tricyclic depressant such as Elavil, beginning with doses as         low as 5 or 10 mg. daily to minimize side effects. Typically, doses are gradually increased to a maximum of         50-100mg. The difficulty with prescribing Elavil is that many patients         discontinue the drug because of its sedating side effect. Tricyclic         antidepressants with a better side effect profile include desipramine         and nortriptyline. The         serum serotonin reuptake inhibitors such as Zoloft and Paxil also may be         prescribed. These medications have had most benefit in chronic pain         syndromes such as fibromyalgia. They can be very useful because they         have a less sedating effect than the tricyclics. Alternately, or in         conjunction with an antidepressant, anticonvulsants         such as Tegretol, Depakote, or Neurontinmay be prescribed for pain relief.      Topical         anesthetic agents that may provide short-term relief include Xylocaine         (lidocaine), Hurricaine (benzocaine), and Zonalon (topical doxepin). In         some cases, a referral to a pelvic floor dysfunction therapist for         biofeedback training may be recommended. Finally, if the patient has         Vulvar Vestibulitis Syndrome, surgery may be recommended.      An         important part of treatment is helping the patient to develop realistic         outcome goals. In general, the shorter the duration of the syndrome, the         better the outcome. The         patient needs to develop positive coping mechanisms to control the pain         such as exercise, distraction techniques, and active participation in         managing the pain.         

               VULVAR         VESTIBULITIS

The         etiology of Vulvar Vestibulitis Syndrome (VVS) is often idiopathic,         i.e., without identifiable cause. Dyspareunia at the entrance to the         vagina is the essential characteristic of this condition.         Sometimes it occurs secondary to dermatological conditions such as         lichen sclerosus or desquamative vaginitis. Frequently, the initiating         factor in VVS appears to be a history of serial antibiotic use for         urinary tract infections, acne, sinus infections, or vaginitis, or the         use of highly progestational agents such as certain birth control         medications. Symptoms always intensify from the use of panty liners or         menstrual pads. VVS involves inflammation of the Bartholin glands and/or         the minor vestibular glands at the base of the hymen.

Treatment         begins by instructing the patient to stop attempts at intravaginal         penetration and inviting the husband/partner to the patient’s next         examination. Topical estrogen such as Estrace cream should be applied to         gland openings to relieve symptoms of burning and reduce inflammation. The use of topical and         intravaginal steroids also may be beneficial.

Some         of the commonly used treatments for VVS do not appear to have a high         success rate. One of the popular alternative methods, the low-oxalate         diet plus calcium citrate, does not work for most VVS patients.  Likewise, oral corticosteroids are ineffective. Interferon         injections, a fairly common medical treatment, also has not been         successful in many cases. Another treatment sometimes used, the         superficial lasering of the vestibular gland openings, has actually         made symptoms worse in many patients.

 For         most patients with VVS, surgery appears to have the highest  success         rate, especially if the condition has been of short duration. Of  127 vestibulectomies performed at WomenNow Health care, 108         women were evaluated five years after surgery. “Success” was  defined         as the ability to engage in sexual intercourse without pain and  with         normal frequency. “Improved” was defined as the ability to  engage in         intercourse with occasional discomfort during or afterwards; the         experienced discomfort, however, did not inhibit frequency of  episodes. 

Seventy-five         percent of patients were determined to be a success post-surgically,         eighteen percent were improved and three percent were failures. No         patient’s symptoms worsened as a result of surgery.

Complete removal of both the major and minor vestibular glands was         critical to success of the procedure. Fifteen percent of patients         subsequently became pregnant. Eight percent required a second procedure         such as a skin graft at the perineal body posteriorly, removal of a         suture granuloma, or, in         one case, a second surgery to remove a gland that wasn’t removed         during the first procedure.

Chronic         vulvar pain, whether intermittent or constant, can be a debilitating         symptom that         deserves appropriate work-up and disease specific therapy. As the         millenium draws to a close, it is unwarranted and unjustified that a         woman should have to live with the fear of suffering from such pain or         being told that it’s “all in your head.”

There         is hope associated with treating this disorder, and vulvodynia patients         need to       be directed toward health care providers who are interested, dedicated and       competent in helping them. In particular, surgery for Vulvar Vestibulitis       Syndrome should no longer be considered a last effort, because there is       excellent data reported from various investigators nationwide showing high       success rates with this form of therapy. Such surgery does not have to be       cosmetically disfiguring and can help to restore normal sexual function       between loving couples.

Articles

Vulvodynia is defined as chronic vulvar discomfort with a duration of at least three months. This discomfort can be expressed as pain, burning, itching, dyspareunia (painful sexual intercourse), stinging, rawness, or "irritation" of a constant or intermittent nature.

Jessica Thomason, MD, FACOG

Articles

Vulvodynia: Causes, Diagnosis and Modern Therapy