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. 1. Severe pain on vestibular touch or

attempted vaginal entry.2. 2. Tenderness to pressure localized within

the vulvar vestibule3. 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 Sex and 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:1. Vaginitis, Candida, urethritis,

interstitial cystitis, Herpes, Bartholin adenitis

2. Vulvar Dermatoses and Dermatitis such as eczema

3. Vaginismus, entry and deep dyspareunia

4. 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

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 **

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

* Glazer H, Ledger WJ. Clinical Management of Vulvodynia. Rev Gynecol Pract. 2002;2:83-90.

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

* 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)

Medical Management:Vulvar Vestibulitis Subtype

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

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