VULVODYNIAClinical Aspects and Research Initiative Gloria A. Bachmann, M.D. 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 • Vulvar Vestibulitis Subtype(provoked) • Dysesthetic Vulvodynia Subtype(unprovoked)
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
Vulvodynia: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: • 21% prevalence of chronic gynecologic pain • 13.5% prevalence of vulvodynia-type pain *Harlow BL, Stewart EG. A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? J Am Med Women's Assoc 2003;58:82-88
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 * Eva LJ, MacLean AB, Reid WMN, et al. Estrogen Receptor Expression in Vulvar Vestibulitis Syndrome. Am J Obstet Gynecol 2003;189:1-4.
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* * Davis GD, Hutchison CV. Clinical Management of Vulvodynia. Clinical Obstetrics and Gynecology. June 1999; 42(2):pp 221-233.
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** * Pukall CF, Payne KA, Binik YM, Khalife S. Pain measurement in vulvodynia. Journal of Sexand Marital Therapy. 29 Suppl 1:111-20,2003. ** Curnow JS, Barron I, Morrison G., et al. Vulval algesiometer. Med Biol Eng Comput 1996;34:266-9.
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: • Vaginitis, Candida, urethritis, interstitial cystitis, Herpes, Bartholin adenitis • Vulvar Dermatoses and Dermatitis such as eczema • Vaginismus, entry and deep dyspareunia • 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- Notrecommended • 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 • Degradation of vulvar collagen and hyaluronic acid also increase oxalate pool • Calcium citrate inhibits hyaluronidase and the release of oxalates and acts as a free radical scavenger * • 1200 mg of calcium citrate daily aids in further reducing urinary oxalate levels **
Biofeedback:Vulvar Vestibulitis Subtype • 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 pelvicfloor abnormalities present, physical therapy often beneficial * Glazer H, Ledger WJ. Clinical Management of Vulvodynia. Rev Gynecol Pract. 2002;2:83-90.
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 *Hartmann EH, Nelson C. The Perceived Effectiveness of Physical Therapy Treatment on Women Complaining of Vulvar Pain and Diagnosed With Either Vulvar Vestibulitis Syndrome or Dysesthetic Vulvodynia. Journal of the Section on Women’s Health. 2001;25:13-18.
Physical Therapy:Vulvar Vestibulitis Subtype Physical therapy components: • Pelvic floor exercise • Myofascial release • Trigger point pressure • Massage Resource: The American Physical Therapy Association (800-999-APTA) or (www.apta.org)
Topical estrogens: Improve epithelial maturation Inhibit production of inflammatory mediators (cytokines and interleukin-1) Lower pain threshold* *Cutolo M,Sulli A,Seriolo B,et al.Estrogens,the immune response and autoimmunity.Clin Exp Rheumatol.1995;13:217-226 Medical Management:Vulvar Vestibulitis Subtype
Medical Management:Vulvar Vestibulitis Subtype • Topical estrogen creams useful for women with thin vaginal epithelium and/or lose of vulvar adipose tissue • Can be used with other pharmacologic agents
Medical Management:Vulvar Vestibulitis Subtype • 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
Medical Management:Vulvar Vestibulitis Subtype • Corticosteroids: (topical and injections) • Topical anesthetics (nitroglycerin & lidocaine) • Alpha Interferon injections • Capsaicin cream (immune response modifier)
Surgical Management:Vulvar Vestibulitis Subtype • 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
Surgical Procedures:Vulvar Vestibulitis Subtype • 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 * McKay M. Dysesthetic Vulvodynia: treatmnet with amitryptyline. J Reprod Med 1993 ; 38:9-13