VULVODYNIA

VULVODYNIA
Clinical Aspects and Research Initiative
Presentation by:Gloria A. Bachmann, M.D. and Nidhi Gupta, M.D.
Women’s Health Institute, UMDNJ-Robert Wood Johnson Medical School


Defining Vulvodynia
The International Society for Study of Vulvovaginal Diseases (ISSVD) defines vulvodynia as ‘chronic vulvar discomfort, characterized by the woman’s complaint of burning, stinging, irritation or rawness’

Types of Vulvar Pain
* PAIN from an IDENTIFIABLE ETIOLOGY
* VULVODYNIA

Pain from an Identifiable Etiology
* Infections such as chronic vulvovaginitis caused by Candida or other pathogens
* Dermatoses and Dermatitis that involve the vulva such as Lichen Sclerosus, Lichen Planus, irritants and allergic dermatitis
* Vaginismus

Vulvodynia: Vulvar Vestibulitis Subtype
* Friedrich’s criteria diagnostic:
* 1. Severe pain on vestibular touch or attempted vaginal entry.
* 2. Tenderness to pressure localized within the vulvar vestibule
* 3. Physical findings confined to vestibular erythema of various degrees
* Pain is provoked and localized
* Commonly seen in women aged 50 years or less

Dysesthetic Vulvodynia Subtype
* Pain is constant and may be felt beyond the confines of vulvar vestibule
* Usually pain is unprovoked
* Diagnosed mainly in women who are peri- or postmenopausal

Vulvodynia: Prevalence Statistics
* Harvard-based study (n=16,000) estimates a 16% life time prevalence*
* UMDNJ-based study estimates:

Vulvodynia: Demographics
* Older data suggest the highest prevalence in white women
* Accounts for 10 million doctor visits/year
* Upwards of 14 million women are affected in their lifetime
* Recent data suggest Hispanic women 80% more likely to have vulvar pain than other racial groups

Etiology: Vulvar Vestibulitis Subtype
* Prior vulvovaginal Candidiasis
* Hypersensitivity to chemicals
* Human Papilloma virus infection
* High levels of urinary oxalates
* Neurological dysfunction

Candida Etiology: Vulvar Vestibulitis Subtype
* In 1989 Ashman and Ott proposed cross reaction between Candida albicans antigens and self-antigen in vulvovaginal tissue
* Affected tissue has locally elevated concentrations of inflammatory cells and pro-inflammatory cytokines
* These suggest a hyper-immune response, possibly from persistent antigen from the Candida

Proposed Etiologies: Vulvar Vestibulitis Subtype
* Calcium oxalate crystals in urine may act as irritant to the vulva
* Reduced estrogen receptor expression causing alteration in vulvar sensation*
* CNS etiology, similar to other regional pain syndromes

Proposed Inflammatory Etiology: Vulvar Vestibulitis Subtype
* An inflammatory event releases cytokines that sensitize nociceptors in the nerve fibers of the vulva*
* Increased intraepithelial nerve endings in vestibulitis patients have been reported. Prolonged neuronal firing sensitizes neurons in dorsal horn of spinal cord, with subsequent abnormal interpretation as pain from touch**

Etiology: Dysesthetic Vulvodynia Subtype
* Etiology not definitively known
* Childhood trauma and OCP’s possible contributors
* Sympathetic pain loops caused by repeated irritation/trauma leads to continuous vulvar symptoms*

Vulvodynia: Assessment of the Patient
* OB/GYN history
* Detailed pelvic exam to exclude pathology
* Vaginal culture (in selected cases)
* Pap smear

Vulvodynia: Assessment of the Patient

* Vaginal pH
* Urinanalysis for oxalate content (select cases)
* Biopsy of abnormal vulvar areas
* Psychosocial assessment

Vulvodynia: Assessment of Pain Intensity
Clinician Assessment:
* Q–tip test
* Vulvalagesiometer- A device developed at McGill University for nominal scale vulvar pain measurement*
* Vulvar Algesiometer- Developed by Curnow to quantify pain by nominal scale**

Vulvodynia: Assessment of Pain Intensity
Patient Assessment:
* McGill-Melzack Pain Questionnaire- 78 pain words grouped in 20 subclasses of 3-5 descriptive words*
* Subclasses are grouped in four sections, sensory, affective, evaluative and miscellaneous.
* Provides information on timeline, location and a quantitative measure of clinical pain.

Vulvodynia: Differential Diagnosis
Exclude other pain causes:

o Vaginitis, Candida, urethritis, interstitial cystitis, Herpes, Bartholin adenitis
o Vulvar Dermatoses and Dermatitis such as eczema
o Vaginismus, entry and deep dyspareunia
o Atrophic Vulvo-Vaginitis

Vulvodynia: Diagnosis
“Diagnosis made after thorough evaluation fails to identify pain etiology”

Vulvodynia: Management
Vulvar Vestibulitis Subtype:
* Non-Pharmacologic
* Pharmacologic
* Surgical

Dysesthetic Vulvodynia Subtype:
* Non-Pharmacologic- Not recommended
* Pharmacologic
* Surgical- Not recommended

NonPharmacologic Management: Vulvar Vestibulitis Subtype
* Patient education and counseling
* Physical therapy and biofeedback
* Life-style modification
* Application of ice and local anesthetics to the vulvar region as needed

NonPharmacologic Management: Vulvar Vestibulitis Subtype
Low Oxalate Diet
* Oxalate is a metabolic breakdown product from certain food types
* Oxalates excreted in urine as crystals
* Vulvar surface contact with oxalate crystals causes irritation and burning
* Low oxalate diet (with calcium citrate supplementation) may be beneficial

NonPharmacologic Management: Vulvar Vestibulitis Subtype
Calcium Citrate and the Low Oxalate Diet
* Surface electromyographic biofeedback data suggest persistent vulvar injury leads to chronic reflex pain, resulting in increased muscle tension*
* Pelvic floor muscle instability may be present
* If pelvic floor abnormalities present, physical therapy often beneficial

Biofeedback: Vulvar Vestibulitis Subtype
Physical Therapy: Vulvar Vestibulitis Subtype
* Physical therapy reduces muscle tension and spasm, decreasing pain levels by 40-60% *
* Physical therapist can retrain dysfunctional pelvic floor muscles

Physical Therapy: Vulvar Vestibulitis Subtype
Physical therapy components:
* Pelvic floor exercise
* Myofascial release
* Trigger point pressure
* Massage
Medical Management: Vulvar Vestibulitis Subtype
* Topical estrogens:
* Topical estrogen creams useful for women with thin vaginal epithelium and/or lose of vulvar adipose tissue
* Can be used with other pharmacologic agents
* Tricyclic antidepressants (Amitriptyline-10mg hs: dose up to 150mg daily)
* Fluconazole
* Gabapentin (anticonvulsant), Venlafaxine-efficacy not proven
* Selective serotonin receptor inhibitors (SSRIs)-efficacy not proven
* Corticosteroids: (topical and injections)
* Topical anesthetics (nitroglycerin & lidocaine)
* Alpha Interferon injections
* Capsaicin cream (immune response modifier)
* Excision of affected vulvar area to remove neural hyperplasia
* Surgery reserved for non- responders to conservative treatments
* Data suggest a success rate varying from 40-100%
* Long term data lacking
* Types: focal excision, vestibuloplasty, vestibulectomy and perineoplasty
* Vestibulectomy excises a U shaped area of the vestibule from 5mm lateral to the urethra and the posterior fourchette
* Perineoplasty excises the vestibule from below and lateral the urethral meatus to the anal canal with the vaginal mucosa undermined 1-2cm.

Pharmacologic Management: Dysesthetic Vulvodynia Subtype
* Amitriptyline: first line therapy
* Other tricyclic antidepressants- desipramine and imipramine-may be effective *
* Selective serotonin reuptake inhibitors efficacy not proven

Vulvodynia.ppt