Vulvodynia-Pain/soreness of ext skin Know what is meant by “Vulvodynia”:- Q.1:-When
to write on your prescription that she is suffering from Vulvodynia??
What is the working defn & diagnose?? Ans:- Let us talk about commonest
etiology first , This entity usually as a consequence of irritation or
hypersensitivity of the nerve fibres in the vulval skin Vulvodynia is a chronic
pain syndrome that affects the vulvar area and occurs without an identifiable
cause. For the diagnosis to be made symptoms must last at least 3 months. There
is another group who defines Vulvodynia as vulvar discomfort, most often
described as burning pain, occurring in the absence of relevant visible
findings by the clinicians or a specific
neurologic disorder which is ,
clinically identifiable. However it is distressing both for clinicians & pt
alike.
.
Q.2; What are the symp of
vulvodynia ?? Vulvodynia is for
the sensation of vulval burning, stinging, irritation or sharp pain and
soreness, that occurs in the vulva and entrance to the vagina in the absence of
any obvious skin condition or infection. It may be constant, intermittent or
happen only when the vulva is touched, but vulvodynia is usually defined as
lasting for years.The sensation of burning and soreness of the vulva can be
continuous (unprovoked vulvodynia), or on light touch, e.g. from sexual
intercourse or tampon use (provoked vulvodynia). 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. Some cases of
vulvodynia are idiopathic where no particular cause can be determined.
Q.3: What was the early
nomenclature of vulvodynia when we were
MD students(1970-73)???? Ans:-Women who have unprovoked Vulvodynia
were formerly known as having dysaesthetic (or dysesthetic) vulvodynia where
pain was felt without touch. Vestibulodynia is the term replacing vestibulitis
where pain is felt on light touch. Many women have symptoms which overlap
between both conditions.
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. This type of pain can
occur even when the area is not touched.
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 longterm pain from any cause
you can have good days and bad days. Remarkable 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 and urethra. Some women also have pain when
they empty their bowels. Unprovoked vulvodynia can have an effect on sexual
activity and is associated with pain during foreplay and penetration.
a. Vulvar Pain Related to
a Specific Disorder
Infectious (e.g.
candidiasis, herpes, etc)
Inflammatory (e.g. lichen
planus, immunobullous disorders, etc.)
Neoplastic (e.g. Pagets
disease, squamous cell carcinoma, etc)
Neurologic (e.g. herpes
neuralgia, spinal nerve compression, etc.)
Vulvodynia
Generalised
Provoked (sexual,
nonsexual, or both)
Unprovoked
Mixed (provoked and
unprovoked)
Localized (vestibulodynia,
clitorodynia, hemivulvodynia, etc)
Provoked (sexual,
nonsexual, or both)
Unprovoked
Mixed (provoked and
unprovoked)
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 (hemivulvodynia).It gives us two
types of vulvodynia.
Patients with pain
localized to the vestibule have a normal appearing vulva, other than erythema
at times. The erythema tends to be most prominent at the duct
openings(Bartholin’s, Skene’s and vestibular ducts).
There are of two types-
hyper (low pain thresholds) and allodynia (pain to light touch)
It can have a number of
other causes, such as persistent vaginal thrush or other vaginal infections,
sensitivity to something touching the vulva, such as soap, bubble bath or
medicated creams (known as irritant contact dermatitis),a drop in the hormone
oestrogen causing diyness of the vulva, particularly during the menopause,a
recurrent herpes infection,lichensclerosus or lichen planus (skin conditions
that can cause intense irritation and soreness of the vulva),in rare cases,
Behcet’s disease (a condition of the blood vessels that can cause genital
ulcers) or Sjogren’s syndrome (a disorder of the immune systemthat can cause
vaginal dryness)
There are many diseases
that can cause vulvar pain but don’t qualify for the condition known as vulvodynia.
Q.5: What are D/D??
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Podophyllin overdose
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Pemphigus
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Crohns’s disease
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Condylox overdose
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Pemphigoid
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Bartholin’s abscess
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Behcet’s disease
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Atrophy
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Trauma
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Apthous ulcers
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Lichen sclerosus
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Prolapsed urethra
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Herpes (simplex and zoster)
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Lichen planus
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Vulvar intraepithelial
neoplasia
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Candidiasis
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Sjorgen’s disease
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Carcinoma
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The exact etiology of
vulvodynia is unknown. There most likely is not one single etiology
The cause of vulvodynia is
unknown.
It’s thought it may be the
result of a problem with the nerves supplying the vulva, although it’s not
clear what causes this.
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THEORY
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DESCRIPTIONS
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Embryologic development
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A Common embrologic
origin for distict anatomic sites may predispose to similar pathologic
responses when challenged
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Infection
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Candida infection in
patients with vestibular pain have been studied. The exact association is
difficult todetermine since many patients report Candida infections without
verified testing for yeast. Bazin et al. found little association of
infection.
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Inflammation “-itis” (as in vestibulitis)has been excluded
from the recent
ISSVD terminology since
studies found a lack of association between excised tissue and inflammation.
Bohm-Starke et al.
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found a low expression
of the inflammatory markers cyclooxygenase 2 and inducible nitric oxide
synthase in the vestibular pain as well as in healthy control subjects.
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Genetic/ Immune factors
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A genetic association of
localized vulvar pain has been suggested by some researchers
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N europathways
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Kermit Krantz exami9ned
the nerve characteristics of the vulva and vagina. The region of the hymeneal
ring was richly supplied with free nerveendings. No corpuscular endings of
any form were observed. Only free nerve endings were observed in the fossa
navicularis. A sparsity of nerve endings occurred in the vagina as compared
to the region of the fourchette, fossa navicularis and hymeneal ring. More
recent studies have analyzed the nerve factors, thermoreceptors and
nociceptors in women with vulvar pain.
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Q.8. Further points for clinicians:- Possible triggers that have been suggested
include A) damage due to previous surgery or childbirth) trapped nerves or a history of severe vaginal thrush)
Vulvodynia is not contagious. It has nothing to do with personal hygiene and
isn’t a sign of cancer.D) These are needed to be rule out before treating you
for vulvodynia. Some women can have a combination of problems, for example
recurrent thrush and vulvodynia, with both needing proper treatment to reduce
pain.
Having chronic pain can
also affect relationships, reduce sex drive, and cause low mood and depression.
Pain in the genital area is often difficult to talk about with friends and it’s
not uncommon to feel isolated.
Usually there is nothing
to see on examination as the problem lies with the nerve fibres themselves
which are not visible to the skin. Just because your doctor cannot see anything
does not mean that there is nothing physically present.
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.
Mai Hoo
na !!! Let the scientist & epidemiologist fight
about etiology of vulvodynia:
Neurologist at Lokshaba and Dermatologists at Rajja Sobha, We the pretty
clinicians must know how to treat such distressing cases other wise if we refer
all cases to (DM for GDM, PCO, Hirsutism, hypothyroidism ), cardio for ESS HTN
in preg women, neuro for radiating pain
in leg Ortho(LBP) surgeon ( endometriosis)
we have to starve along with Wife./ wives & children !!! Mai Hoo na !!! Treatment of
localized vulvar pain (vestibulodynia)
Take home message from Mai Hoo na !!! (Dr Pal) for
vulvodynia:-a) topical
medications
lidocaine/ prilocaine b) vulvar
care measures c) tricyclic antidepressants d) gabapentin (Neurontin) started at 300 mg poqd x 3
days, then 300 mg po hid x 3 days, then 300 mg pot id. it can gradually be
increased to 3600mg po total daily
started at 300 mg poqd x 3 days, then 300 mg po hid x 3 days, then 300
mg pot id. it can gradually be increased to 3600mg po total daily
e) intralesional and trigger point injections f) biofeedback like cpp g)
acupuncture
e) vestibulectomy
surgical excision. B
Dr Pal : Be truthful:-Honestly speaking I rely
on gabapentin, TLC, assure the
couple& relatives that though distressing it is not going to cancer, & physiotherapy (biofeedback) and rely
finally on dermatologist who should be better involved if no improvement .
Another confession (don’t tell it my wife!!):-
The dermatologist lady
dermatologist to whom I refer such cases of hirsutism, Acne, pigmentary disorders , vulval irritation
( who happens to be my classmate )
will always scold me over phone at 11 p,
m,” Srimanta-I shall sue U for daily referring so many pts to me for-for instance A) Obstet cholestasis, B) Pigmentation after consuming OCP, C) Acne,, D) Acanthosis, E) PCO cases
with acne, F) ab hair growth, G) Ring worm, H) allergic
rashes I) condom rashes and so many skin diseases which are normal preg changes
She, my classmate daily threaten me as
my cases insist they should be examined early as because they are referred by
an old doctor. !! What to do, She is 76 yrs too?? What do members feel about me-pathetic position-abuse
from lady classmate –mother 6 grand children? I am anxiously waiting for your
suggestions what do you tackle an angry aged Lady?? Do, young members when
faced with such abusing words from girl friends or boyfriends –play with cross
bat ??? Any suggestion ?/. Pl let me know urgently!!!!!
and the frequencies of
visit will vary with each person. Success rates in the 60 to 80 percent range
have been reported.
It has been suggested that
vulvar burning may be associated with elevated levels of oxalate in the urine.
It is produced by several tissues in the human body during normal metabolism.
The use of oral calcium citrate along with a low oxalate diet is controversial
but may help some women.
Trigger point steroid and bupivacaine
injections have been successful for some
patients with localized vulvodynia. It is recommended that not over 40 mg of
triamcinolone be injected monthly. Draw up the triamcinolone prior to the
hupivacaine to prevent contamination of the triamcinolone. Interferon has a
varied response long term and is used less frequently today.
INTRALESIONAL AND TRIGGER POINT INJECTIONS
Very few studies have been
done using acupuncture for vulvar pain. Three studies have evaluated
acupuncture for vulvar pain therapy, with a variety of outcomes.
Surgical excision of the
vulvar vestibule has met with success in up to 80% of reported cases, but
should be reserved for women with long standing and localized vestibular pain
where other management has failed. The patient should undergo Q-tip testing to outline
the areas of pain prior to anesthesia while in the operating room. Often the
incision will need to extend to the opening of Skene’s ducts onto the vestibule. It is carried down
laterally along Hart’s line to the perianal skin and the mucosa should be
undermined above the hymeneal ring. The specimen should be excised superior to
the hymeneal ring. The vaginal tissue is further undermined and brought down to
close the defect. The defect should be closed in two layers using absorbable
3’0 and 4’0 sutures.
Many sufferers will see
several doctors before a correct diagnosis is made. Many gynecologists are not
familiar with this family of conditions, but awareness has spread with time.
Sufferers 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 are told that the
pain is “in their head”.
VAGINISMUS
It is important to
evaluate for vaginismus in the patients with vulvodynia , particularly
localized vulvodynia. Some women also
have problems such as vaginismus (where the muscles around the vagina tighten
involuntarily), interstitial cystitis (a painful bladder condition), painful
periods and painful sexual intercourse and irritable bowel syndrome (IBS).
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