OBGYN.net Conference Coverage From IPPS - Simsbury Connecticut - April/May, 1999
Dr. Perry: "Good morning, we're here at the Pennsylvania Inn in the greater Hartford area, it's our annual International Pelvic Pain Society meeting. We have this morning, Dr. John Gibbons, with us who is speaking on the topic of vulvodynia here at our conference. I'm Paul Perry from Birmingham, Alabama, and I'm Chairman of the Board. Dr. Gibbons, I'd just like to ask you a couple of questions. First, as you know, our main thrust is public education regarding chronic pelvic pain and professional education. From a public education standpoint, if you want to speak to the women in general about vulvodynia, the concept, and what it is - how would you explain it?"
Dr. Gibbons: "Vulvodynia is a poorly understood chronic condition that involves pain in the genital area of the female. It can be divided into several categories - dysesthetic vulvodynia is the professional term for the subset of these conditions characterized by unexplained constant burning pain. Another subset is vulvar vestibulitis, and in patients whose condition is solely limited to that aspect of the broad category of vulva pain, in those patients, their complaints are pain on touch or pressure so that insertion of tampons or sexual relations become exquisitely painful and finally impossible."
Dr. Perry: "You've seen from a professional stand-point that many patients will sort of fall through the cracks, so to speak, because the diagnosis is missed?"
Dr. Gibbons: "Absolutely, the patients that I see have characteristically been to two, three, four, sometimes five or six specialists attempting to get help for this condition. They have been told that they have chronic yeast infections. Some of them have been told that they have a psychosomatic disorder; they have seen therapists. They have gone through every imaginable category of allied health provider trying to seek some understanding of their condition. Often they are rejected by their families; there's usually tension in the marriage because of the sensitive and interpersonal nature of their complaints, so that these women are close to desperate by the time they reach a knowledgeable health professional."
Dr. Perry: "Do you also think that the professional care of these women could be improved if we could educate the physicians who are caring for them to pick up one or two clues in the history, or do one or two things in the physical examination that would tip them off to the diagnosis, and get them on the proper course?"
Dr. Gibbons: "I think undoubtedly. I think the first thing is to recognize that this collection of symptoms that we know in medicine as a syndrome does exist. While we're not clear about causes, we are clear about the existence of the problem. We're clear about the impact that it has on our patients, and we have a list of accepted treatment modalities that can be applied with varying degrees of success - but we can certainly help these women. The first step for the physician is an appreciation that the problem does exist, an understanding of how these women present, and what physical finding are or are not present. And finally then, an understanding of what treatment modalities are available."
Dr. Perry: "What do you think would be the key as far as physical diagnosis is concerned?"
Dr. Gibbons: "Most of these women have very few physical findings. As a matter of fact, the women with dysesthetic vulvodynia - I apologize for using that big word - are those women are the patients who have constant burning discomfort in the area of the external genitalia and often in the areas surrounding it, the so-called "saddle" area where the body would come in contact with a riding saddle. Those patients have almost no physical findings. They are perfectly normal in every aspect of examination. Women who have vestibulitis, on the other hand, have very few visible physical findings but always have exquisite tenderness of those delicate tissues at the entrance to the vagina when those tissues are lightly touched with a Q-tip, for example."
Dr. Perry: "Let's talk about that Q-tip test for just a minute because I think that probably is the most neglected part of the physical examination in these women in causes of diagnosis of vestibulitis to be missed more often. Could you give us a little idea about where the examination should be taken?"
Dr. Gibbons: "Of course, the area that is in question here is known as the vulvar vestibule; vestibule is a familiar term - the entry way. This area of the body is demarcated by a line between the labia majora - the larger lips, and running down the base of the labia minora - the smaller lips, so that the tissue inside those smaller vaginal lips extending upward toward the hymen and including the hymen is what we refer to as the "vestibule." That area of the body also includes the urinary meatus - the outlet from the bladder and various glands that surround those structures. The physician then in examining that area uses a cotton tipped applicator, which is simply a Q-tip. Some physicians prefer that it be wet and others just take it dry. The secret though, is very, very light pressure along specific points in that area and where there is tenderness, asking the patient to characterize the tenderness on a scale of 0-10, whether it's no pain or exquisite pain and then plotting that on a diagram. Most physicians will find that in women with vestibulitis, the tenderness is most pronounced just below the hymenal margin and around the orifices of the so-called "Bartholin" gland ducts."
Dr. Perry: "You know that's one of our crusades, Dr. Gibbons, is to try to get every physician who care for women, that when a women comes in with that complaint, to do the Q-tip test because if you don't do it, the diagnosis which can be totally debilitating will be missed. Let's turn just a little bit down to treatment of these different conditions. I know vulvodynia is a fairly broad category, so let's think primarily of the dysesthetic vulvodynias first, and give us some idea about how you approach that in your treatment."
Dr. Gibbons: "The mainstay of treatment for women with dysesthetic vulvodynia aside from the usual measures that we take in all of these patients to avoid vulvar irritation, and to get irritants and allergens out of the picture - and those are general measures of vulvar hygiene. The mainstay of treatments for these women is in the use of tricyclic antidepressants, not because we think that these women are depressed but because we know that these drugs are effective in various pain syndromes, such as the neuralgia that women get after an attack of shingles. So that these drugs, I think of all of the pharmacologic agents that have been composed for this syndrome are the most effective, and I would say that's the mainstay. There are other drugs and techniques that can be used. I want to mention particularly - biofeedback, which I think is achieving more and more respect as a modality of therapy that can be terribly effective by itself but even more effective if combined with other measures."
Dr. Perry: "Great. What about vulvar vestibulitis? We see a lot of different treatments; I think one of that is because the ideology is so confusing, and maybe, mostly factorial. But do you have a regiment that you go through in your practice?"
Dr. Gibbons: "It really depends very much on the presentation of the woman. I think the first thing is to make sure that all the measures are taken to exclude other causes for the pain. So we have to be sure that there's no dermatitis there, that there's no vaginitis or vulvovaginitis, that there's no other cause for the signs and symptoms that you see this woman exhibiting. Once that's been ruled out, I think in vestibulitis, one - get rid of the allergens and the irritants, go through the list of vulvar hygiene methods with the patient. If the area is acutely irritated and some of them are simply because they've been irritated sometimes by women attempting to press the area to get rid of the discomfort, and soothing compresses can be applied. So there's a list of easy things that can be done at first. There are two really accepted treatments that seem to be specific for vulvar vestibulitis. To mention the first, interferon injections which were described by Benson Howards/Hollards from Hartford here about ten years ago as being extraordinarily effective, have still been found to be, perhaps 50% effective in the treatment of groups of these women. It is not an easy regiment to follow; it involves three injections right directly into that area per week, for a 4-week course. Aside from some local discomfort, there may be constitutional or systemic discomfort associated with at least the early injections. Of even more success, but obviously a step that takes great consideration, is the surgical removal of the tissues that are involved. We refer to that as a U-shaped vestibulectomy with perineorrhaphy, and it involves a removal of a crescent-shaped piece of tissue, basically the lower two-thirds of the vestibule including that portion of the hymen, undermining or freeing up the back wall of the vagina and then bringing that down to cover that surgical defect. The operation is very effective in carefully chosen cases. In my own experience, some 75% of women in a carefully selected series will have complete relief, another 15% will have enough relief so that they are back to functioning and back happily in their personal relationships, and there's about a 10% failure rate. Bornstein's group from Israel reports in the pure vestibulitis patient an even higher success rate with surgery. But I have to emphasize how carefully these patients must be selected before entering into that sort of radical therapy."
Dr. Perry: "Dr. Gibbons, we really appreciate you being with us this morning, and as one that has benefited from your experience, and we want to be thanking OBGYN.net for allowing us to share this with our other colleagues. Thank you very much."
Dr. Gibbons: "Thank you."