SAN FRANCISCO -- Inpatients with refractory vulvodynia, screening for and treating concomitant interstitial cystitis is often the key to improving both conditions, Dr. Jennifer Gunter said at the annual meeting of the American College of Obstetricians and Gynecologists.
Among 56 women who were referred to a tertiary care clinic for refractory vulvodynia, 50 had at least two signs or symptoms of interstitial cystitis, including urinary frequency, nocturia at least twice per night, dysuria, a history of multiple culture-negative urinary tract infections, and periurethral pain. Of these patients, three declined evaluation for interstitial cystitis, consisting of cystoscopy and bladder hydrodistention.
Evaluations confirmed a diagnosis of interstitial cystitis in 33 patients who met National Institutes of Health criteria for the presence of glomerulations or Hunner's ulcer seen on cystoscopy. Three other patients had been diagnosed with interstitial cystitis prior to referral, for a total of 36 of 47 patients (77%) with interstitial cystitis. Three other patients (6%) had equivocal findings on cystoscopy, and eight patients (17%) had no sign of interstitial cystitis on cystoscopy.
"There was a very strong association between the two conditions," said Dr. Gunter of the University of Kansas Medical Center, Kansas City.
The 39 patients with a diagnosis of interstitial cystitis or equivocal findings were offered treatment for both conditions. Six-month follow-up data on 35 of these patients showed that treatment cut daily pain scores in half, on average.
Prior to combination therapy, patients reported an average daily pain score of 7.1 based on an 11-point Likert scale, with a score of 11 indicating the worst pain. After 6 months of combination therapy, the average daily pain score was 3.6.
Investigators also gave their clinical impressions of the patients' pain; they rated 12 of 35 patients (34%) as significantly improved, meaning these patients had no pain and felt that they needed no further therapy. Moderate improvement was seen in 14 patients (40%), meaning the patient was happy with therapy but had some residual pain on exam. Seven patients (20%) had minimal improvement (still had severe pain on exam), and two patients (6%) did not improve with treatment.
The patients' mean age was 35 years. Some had reported vulvodynia for as long as 20 years, with a mean duration of pain of 4 years. All had failed multiple treatments for vulvodynia, including either tricyclic antidepressants or gabapentin. Dr. Gunter said that about half of patients referred for vulvodynia respond to initial treatment with tricyclic antidepressants.
After evaluation for interstitial cystitis, all patients continued treatment for vulvodynia with standard therapies, including tricyclic antidepressants, gabapentin, carbamazepine, biofeedback, and topical therapies. Patients diagnosed with interstitial cystitis added therapy such as dietary modifications, antihistamines, pentosan polysulfate, biofeedback, antidepressants, or therapeutic hydrodistention.
Check for signs and symptoms of interstitial cystitis as part of the workup for refractory vulvodynia and treat both conditions in patients diagnosed with interstitial cystitis, Dr. Gunter advised.
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