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Vulvodynia

The term vulvodynia is used to describe pain in the vulva, often severe, of unknown cause. Vestibulodynia (formerly vulvar or vulval vestibulitis) is a related term. more...

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Vulvodynia

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A wide variety of possible causes and treatments for vulvodynia are currently being explored. Some possible causes include: allergy or other sensitivity to chemicals or organisms normally found in the environment, autoimmune disorder similar to lupus erythematosus, chronic tension or spasm of the muscles of the vulvar (or vulval) area.

The guidelines in Vulvovaginal health may be of some help.

Vulvodynia is the term used to describe women who experience the sensation of vulval burning and soreness in the absence of any obvious skin condition or infection. The sensation of burning and soreness of the vulva can be continuous (unprovoked vulvodynia) or on light touch eg. sexual intercourse or tampon use (provoked vulvodynia). Women who have unprovoked vulvodynia were formally know as having dysaesthetic vulvodynia where pain was felt without touch. Vestibulodynia is the term replacing vestibulitis where pain is felt on light touch. A recent change in the terminology of these conditions means that the description of women with vulvodynia can be more uniform amongst health professionals and patients. Many women have symptoms which overlap between both conditions.

Dysaesthetic vulvodynia and vestibulitis are now obsolete terms that you'll hear less and less frequently as they are phased out.

This condition is a cause of vulval burning and soreness usually as a consequence of irritation or hypersensitivity of the nerve fibres in the vulval skin. The abnormal nerve fibre signals from the skin are felt as a sensation of pain by the woman. This type of pain can occur even when the area is not touched. Another example of nerve-type (neuropathic pain) like vulvodynia is the pain some people experience with an attack of shingles. Once the rash of shingles has disappeared the area of skin where the rash was can be intensely painful and sore despite the skin appearing normal. The condition is called post-hepatic neuralgia.

The pain described by women with unprovoked vulvodynia is often of a burning, aching nature. The intensity of pain can vary from mild discomfort to a severe constant pain which can even prevent you from sitting down comfortably. The pain is usually continuous and can interfere with sleep. As with long-term pain of any cause you can have good days and bad days. Itching is not usually a feature of the condition. The pain in unprovoked vulvodynia is not always restricted to the vulval area (area of skin on the outside of the vagina) and some women get pain elsewhere. This can be around the inside of the thighs, upper legs and even around the anus (back passage) and urethra (where you pass urine). Some women also have pain when they empty their bowels. Unprovoked vulvodynia can have an affect on sexual activity and is associated with pain during foreplay and penetration. In some women with unprovoked vulvodynia the burning sensation can be generalised over the whole genital area. Alternatively it can be localised to just the clitoris (clitorodynia) or just one side of the vulva (hemi-vulvodynia).

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Multiple therapeutic approaches: don't give up on Tx for persistent vulvodynia
From OB/GYN News, 6/1/04 by Nancy Walsh

LAKE BUENA VISTA, FLA. -- Vulvodynia is not the rarity it has traditionally been considered, and the continuing uncertainty about what causes it is not an obstacle to effective treatment, Dr. Barbara D. Reed said at a meeting of the American Society for Colposcopy and Cervical Pathology.

"We used to think about 150,000-200,000 women in this country had vulvodynia. That number was tossed around for a long time," she said.

"But we did a survey, sending out 3,000 e-mail invitations to women asking them about vulvar pain, and 1,024 responded," she said. Participants ranged in age from 18 to 78 years.

Half reported that they had had vestibular pain with intercourse at some point in their lives, 28% had vestibular pain, and 3% reported that the vestibular pain had persisted for more than 3 months.

Based on the survey results, Dr. Reed now estimates the prevalence of vulvodynia to be 1.7% of the female population. This translates to 15 women in each family physician's practice, and at least double that in each gynecology practice--totaling about 2,400,000 women in the United States, said Dr. Reed, professor of family medicine at the University of Michigan. Ann Arbor.

The condition is characterized by burning, irritating pain and itching and typically is exacerbated with intercourse or tampon use. There is no evidence of an infectious or dermatologic etiology.

Nor is it a psychiatric condition. "Women with vulvodynia are psychologically very similar to controls," she said. They also are not sexually averse, and do not have higher reported rates of childhood sexual or physical abuse, she added.

Preliminary research suggests that local and systemic inflammation involving cytokines such as interleukin-1[beta] may play a role in the pathogenesis.

Many patients have the condition for years and see multiple clinicians and specialists before being given the correct diagnosis. This can be obtained by reproducing the symptoms with the cotton swab test. "I press lightly across the entire area, the labia majora, interlabial sulcus, and along the introitus, to a 2-3 mm depth." Dr. Reed said. Most women rate the pain as 8-10 on a 10-point scale.

Various treatment approaches can be tried, and while little hard data exist concerning efficacy, the majority of patients with this distressing condition can be helped. "Expect improvement. Don't settle for less," she said.

Because vulvodynia is presumed to be a chronic, possibly centrally mediated neuropathic pain syndrome, first-line treatment is usually amitriptyline. Although this recommendation is based only on anecdotal evidence--there are no randomized trials--amitriptyline may work by modulating the transmission of pain impulses, she said.

Most patients tolerate the drug well, starting with a dosage of 25 mg/day and increasing by 25 mg every 2 weeks. Typical effective dosages are 50-100 mg/day, but occasionally dosages up to 250 mg/day are required.

"We also have experience with [selective serotonin reuptake inhibitors] in a small number of women, where there has been a fairly good response to Paxil in particular," she said. Gabapentin also has been helpful for some women in dosages ranging from 900 to 3,600 mg/day.

Another approach that initially showed promise was biofeedback. In a preliminary study that included 33 women with long-term vulvar symptoms, 16 weeks of at-home pelvic floor muscle exercises monitored with a portable electromyographic biofeedback instrument led to an increase in pelvic floor contractions in 95%, decreased resting tension in 68%, and diminished instability of the pelvic floor at rest in 62%.

Before treatment, 28 of the women had abstained from intercourse for an average of 13 months. By the end of the treatment period, 22 of these women had resumed intercourse (J. Reprod. Med. 40[4]:283-90, 1995).

But in a subsequent randomized trial comparing biofeedback with vestibulectomy and cognitive-behavioral therapy, significant improvements in pain were seen in only 24% of the biofeedback patients (Pain 91[3]:297-306, 2001).

"Vestibulectomy, while usually a last resort, is where we have the most data on treatment outcomes," Dr. Reed said. Although the studies have many methodologic limitations, most report at least a 60% response to surgery.

New York Bureau

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