HOUSTON -- There are no fast or easy cures for vulvodynia, but most patients improve with appropriate management and emotional support, Dr. Elizabeth Edwards said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.
Vulvodynia--also called vulvar dysesthesia--is characterized by chronic vulvar burning, soreness, irritation, or stinging in the absence of objective abnormalities like infection or skin disease. The current thinking is that it is caused by a complex regional pain syndrome, pudendal neuralgia, or other neuropathy. Therefore, the first step is to rule out any other condition that could produce these symptoms, said Dr. Edwards of Wake Forest University, Winston-Salem, N.C.
She begins with an evaluation of the patient's vulva and vagina and vaginal secretions, looking for conditions such as lichen planus, lichen sclerosus, and eczema. When examining the vagina, she includes an inspection under magnification, just to be certain she hasn't missed anything. In. addition, she looks for bacterial or fungal infections, including all species of Candida. She also checks vaginal secretions for bacterial vaginosis and lactobacilli, as well as for white blood cells and immature epithelial cells, which usually signal the presence of inflammation.
If all other diagnoses have been excluded, or if the patient's symptoms persist despite therapy for any disorder that is found, the diagnosis is vulvodynia caused by neuropathy. The next step is to identify the subset of vulvodynia that the case best fits: vestibulitis or generalized dysesthetic vulvodynia.
As the name implies, vestibulitis refers to pain that's limited to the vestibule, and it occurs only in response to pressure, although even a touch with a cotton swab can hurt. Erythema may be present.
Patients with dysesthetic vulvodynia have a more variable condition. The pain may be present one day but not the next; it moves from place to place and is not limited to the vestibule.
Sometimes pain is elicited by touch, and sometimes it arises spontaneously As in patients with vestibulitis, erythema is not a reliable sign, because it is not consistently present.
First-line therapy is similar for either type of vulvodynia and consists of patient education and support, tricyclic medications, and nonspecific supportive care.
Amitriptyline and desipramine .can relieve pain and itching, but it's important to refer to these as tricyclic medications, not antidepressants, so that patients won't conclude that you really believe they're depressed, Dr. Edwards said.
She starts patients on 5 mg per day of a tricyclic antidepressant and increases the dose up to 150 mg per day in 5-mg increments, until patients feel comfortable.
Patients who don't respond to tricyclics may do well on gabapenrin: Dr. Edwards starts them on 100 mg per day and will go up to as much as 3,600 mg per day in three or four divided doses, which has proven effective as a treatment for other forms of neuropathy.
When it comes to supportive care, lidocaine jelly or ointment, applied about 20 minutes before intercourse, decreases pain but doesn't relieve it completely. She instructs patients to avoid irritating products like scented douches and soaps, to use lukewarm rather than hot water when bathing, and not to wash excessively.
About 30% of vulvodynia patients will have evidence of inflammation in their vaginal secretions for reasons that remain unclear. In those cases, Dr. Edwards recommends treating the inflammation as well as the vulvodynia.
Pelvic floor rehabilitation can make "an enormous difference" to patients in whom electromyography shows high resting tension and poor contractile strength, Dr. Edwards said.
The right exercise regimen can minimize pain and restore sexual function. However, the therapy takes a long time to produce results, it requires special equipment, and properly trained practitioners may not be available in all communities. Most patients also benefit from sex therapy.
If first-line therapy proves inadequate, Dr. Edwards may recommend a course of interferon[alpha] injections to patients with vestibulitis. She injects 1 million units around the periphery of the vestibule three times a week for a total of 12 injections, then waits a few months. The injections aren't unduly painful, and the major side effect is flulike symptoms that appear briefly after the first injection. About 20% of patients improve on this regimen.
Patients with vestibulitis who don't respond to any of these approaches may wish to consider vestibulectomy, which can be very effective in properly selected candidates.
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