Vulvodynia

Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause.[1] Symptoms typically include a feeling of burning or irritation.[2] It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months.[3]

Vulvodynia
SpecialtyGynecology

The exact cause is unknown but is believed to involve a number of factors, including genetics, immunology, and possibly diet.[2] Diagnosis is by ruling out other possible causes.[2] This may or may not include a biopsy of the area.[2]

Treatment may involve a number of different measures; however, none is universally effective, and the evidence to support their effectiveness is often poor.[2] Some of these measures include improved vulvar care, dietary changes, medications, counselling, and, if conservative treatment is not effective, surgery.[2] It is estimated to affect up to 16% of women.[2]

Signs and symptoms

Pain is the most notable symptom of vulvodynia, and can be characterized as a burning, stinging, irritation or sharp pain that occurs in the vulva and entrance to the vagina. It may be constant, intermittent or happen only when the vulva is touched, but vulvodynia usually has a long duration.[4]

Symptoms may occur in one place or the entire vulvar area. It can occur during or after sexual activity, when tampons are inserted, or when prolonged pressure is applied to the vulva, such as during sitting, bike riding, or horseback riding.[5] Some cases of vulvodynia are idiopathic where no particular cause can be determined.[4]

Vulvar vestibulitis
Main article: Vulvar vestibulitis

Vulvar vestibulitis syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis or "localized (to the vestibule) provoked vulvodynia"[6] refers to pain localized to the vestibular region. It tends to be associated with a highly localized "burning" or "cutting" type of pain. The pain of vulvodynia may extend into the clitoris; this is referred to as clitorodynia.[7]

Vulvar vestibulitis syndrome is the most common subtype of vulvodynia that affects premenopausal women – the syndrome has been cited as affecting about 10%–15% of women seeking gynecological care.[8][9]

Causes

A wide variety of possible causes and treatments for vulvodynia are currently being explored. Moreover, there are probably several causes of vulvodynia, and some may be individual to the patient.

Possible causes include Sjögren syndrome, the symptoms of which include chronic vaginal dryness. Others include genetic predisposition to inflammation,[10] allergy or other sensitivity (for example: oxalates in the urine), an autoimmune disorder similar to lupus erythematosus or to eczema or to lichen sclerosus, infection (e.g., yeast infections, bacterial vaginosis, HPV, HSV), injury, and neuropathy—including an increased number of nerve endings in the vaginal area. Some cases seem to be negative outcomes of genital surgery, such as a labioplasty. Initiation of hormonal contraceptives that contain low- dose estrogen before the age of 16 could predispose women to vulvar vestibulitis syndrome. A significantly lower pain threshold, especially in the posterior vestibulum, has also been associated with the use of hormonal contraceptives in women without vulvar vestibulitis syndrome.[11] Pelvic floor dysfunction may be the underlying cause of some women's pain.[12]

Diagnosis

The condition is one of exclusion and other vulvovaginal problems should be ruled out. The diagnosis is based on the typical complaints of the patient, essentially normal physical findings, and the absence of identifiable causes per the differential diagnosis. Cotton swab testing is used to differentiate between generalized and localized pain and delineate the areas of pain and categorize their severity. Patients often will describe the touch of a cotton ball as extremely painful, like the scraping of a knife. A diagram of pain locations may be helpful in assessing the pain over time. The vagina should be examined, and tests, including wet mount, vaginal pH, fungal culture, and Gram stain, should be performed as indicated. Fungal culture may identify resistant strains.[13]

It is estimated that only half of affected women will seek medical help, among whom many will see several doctors before a correct diagnosis is made. Only 2% of the people that seek help do obtain a diagnostic.[14] Many gynecologists are not familiar with this family of conditions, but awareness has spread with time. Affected women are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients have been told that the pain is "in their head" (a medical stance more associated with the 1970s than with modern medicine).[15]

Differential diagnosis
  1. Infections: urinary tract infection,[16] candidiasis, herpes, HPV
  2. Inflammation: lichen planus
  3. Neoplasm: Paget's disease, vulvar carcinoma
  4. Neurologic disorder: neuralgia secondary to herpes virus, spinal nerve injury

Treatment

There are a number of possible treatments with none being uniformly effective.[2] Treatments include:

Lifestyle

A number of lifestyle changes are often recommended such as using cotton underwear, not using substances that may irritate the area, and using lubricant during sex.[2] The use of alternative medicine has not been sufficiently studied to make recommendations.[2]

Counseling
  1. Education and accurate information about vestibulodynia: Gynaecologist-led educational seminars delivered in a group format have a significant positive impact on psychological symptoms and sexual functioning in women who have provoked (caused by a stimulus such as touch or sexual activity) vestibulodynia.[17] Provoked vestibulodynia, whilst similar in some respects, is different to vulvodynia which this article refers to.
  2. Biofeedback, physical therapy and relaxation: Biofeedback, often done by physical therapists, involves inserting a vaginal sensor to get a sense of the strength of the muscles and help a patient get greater control of her muscles to feel the difference between contraction and relaxation. Sessions are linked with at-home recommendations including often Kegel exercises (e.g., hold for 9 seconds, relax for 30 seconds, for 10–15 sets), and relaxation.

Medications

A number of medications have been used to treat vulvodynia.[2] Evidence to support their use, however, is often poor.[2] These include creams and ointments containing lidocaine, estrogen or tricyclic antidepressants.[2] Antidepressants and anticonvulsants in pill form are sometimes tried but have been poorly studied.[2] Injectable medications included steroids and botulinum toxin have been tried with limited success.[2]

Surgery

Vestibulectomy, during which the nerve fibers to the area are cut out, may be recommended if other treatments have not been found to be effective.[2] There have been no high quality studies looking at surgery as a treatment.[2] While improvement has been noted in 60% to 90%, those who were treated without surgery improved in 40 to 80% of cases.[2]

Epidemiology

The percentage of women affected is not entirely clear, but estimates range as high as 16%.[2] Many other conditions that are not truly vulvodynia (diagnosis is made by ruling out other causes of vulvar pain) could be confused with it. Vulvar pain is a quite frequent complaint in women's health clinics. Vulvodynia is a new term in the medical literature.

References
  1. Feldhaus-Dahir, M (2011). "The causes and prevalence of vestibulodynia: A vulvar pain disorder". Urologic Nursing. 31 (1): 51–4. doi:10.7257/1053-816X.2012.31.1.51. PMID 21542444.
  2. Stockdale, C. K.; Lawson, H. W. (2014). "2013 Vulvodynia Guideline update". Journal of Lower Genital Tract Disease. 18 (2): 93–100. doi:10.1097/LGT.0000000000000021. PMID 24633161. S2CID 410660.
  3. Bornstein, J.; Goldstein, A. T.; Stockdale, C. K.; Bergeron, S.; Pukall, C.; Zolnoun, D.; Coady, D. (April 2016). "ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia". J Sex Med. 13 (4): 607–12. doi:10.1016/j.jsxm.2016.02.167. PMID 27045260.
  4. "Persistent Vulvar Pain". American College of Obstetricians and Gynecologists. Retrieved 30 October 2020.
  5. National Research Center for Women and Families (October 2007). "Vulvodynia and Genital Pain". Archived from the original on 25 July 2011. Retrieved 27 August 2009.
  6. Moyal-Barracco, M; Lynch, P. J. (2004). "2003 ISSVD terminology and classification of vulvodynia: A historical perspective". The Journal of Reproductive Medicine. 49 (10): 772–7. PMID 15568398.
  7. "What is Vulvodynia?". The National Vulvodynia Association. Retrieved 29 January 2019.
  8. Bergeron, Sophie; Binik, Yitzchak M.; Khalifé, Samir; Meana, Marta; Berkley, Karen J.; Pagidas, Kelly (1997). "The treatment of vulvar vestibulitis syndrome: Towards a multimodal approach". Sexual and Marital Therapy. 12 (4): 305–311. doi:10.1080/02674659708408174.
  9. Bergeron, Sophie; Binik, Yitzchak M.; Khalifé, Samir; Pagidas, Kelly (1997). "Vulvar Vestibulitis Syndrome: A Critical Review". The Clinical Journal of Pain. 13 (1): 27–42. doi:10.1097/00002508-199703000-00006. PMID 9084950.
  10. Gerber, Stefan; Bongiovanni, Ann Marie; Ledger, William J.; Witkin, Steven S. (2003). "Interleukin-1β gene polymorphism in women with vulvar vestibulitis syndrome". European Journal of Obstetrics & Gynecology and Reproductive Biology. 107 (1): 74–77. doi:10.1016/S0301-2115(02)00276-2. PMID 12593899.
  11. Basson, Rosemary; Weijmar Schultz, Willibrord (2007). "Sexual sequelae of general medical disorders". The Lancet. 369 (9559): 409–424. doi:10.1016/S0140-6736(07)60197-4. PMID 17276781. S2CID 44628975.
  12. Kellogg-Spadt, S (October 2003). "Differential Diagnosis of Pelvic Floor Dysfunction and Vulvar Pain". Retrieved 11 September 2012.
  13. Haefner, H. K.; Collins, M. E.; Davis, G. D.; Edwards, L; Foster, D. C.; Hartmann, E. D.; Kaufman, R. H.; Lynch, P. J.; Margesson, L. J.; Moyal-Barracco, M; Piper, C. K.; Reed, B. D.; Stewart, E. G.; Wilkinson, E. J. (2005). "The vulvodynia guideline". Journal of Lower Genital Tract Disease. 9 (1): 40–51. doi:10.1097/00128360-200501000-00009. PMID 15870521. S2CID 18081230.
  14. Reed, Barbara Diane; Harlow, Siobán Denise; Sen, Ananda; Legocki, Laurie Jo; Edwards, Rayna Monique; Arato, Nora; Haefner, Hope Katharine (February 2012). "Prevalence and demographic characteristics of vulvodynia in a population-based sample". American Journal of Obstetrics and Gynecology. 206 (2): 170.e1–170.e9. doi:10.1016/j.ajog.2011.08.012. PMC 3779055. PMID 21963307.
  15. Shallcross, Rebekah; Dickson, Joanne M.; Nunns, David; Taylor, Kate; Kiemle, Gundi (1 April 2019). "Women's Experiences of Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward Diagnosis". Archives of Sexual Behavior. 48 (3): 961–974. doi:10.1007/s10508-018-1246-z. ISSN 1573-2800. PMC 6418055. PMID 30047005.
  16. Khasriya, Rajvinder; Barcella, William; De Iorio, Maria; Swamy, Sheela; Gill, Kiren; Kupelian, Anthony; Malone-Lee, James (2018). "Lower urinary tract symptoms that predict microscopic pyuria". International Urogynecology Journal. 29 (7): 1019–1028. doi:10.1007/s00192-017-3472-7. PMC 6004270. PMID 28971220.
  17. Brotto, L. A.; Sadownik, L; Thomson, S (2010). "Impact of educational seminars on women with provoked vestibulodynia". Journal of Obstetrics and Gynaecology Canada. 32 (2): 132–8. doi:10.1016/s1701-2163(16)34427-9. PMID 20181314.
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