Vulvodynia

Vulvodynia is a chronic pain syndrome that affects the vulvar area and often occurs without an identifiable cause or visible pathology^[1] categorized in the ICD-9 group 625—specifically ICD-9 625.7, which is for pain and other disorders of the female genital organs.^[2] It refers to pain of the vulva unexplained by vulvar or vaginal infection or skin disease.^[3]

The term "vulvodynia" simply refers to "vulvar pain", and does not imply a specific cause.^[4]

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, including the labia and entrance to the vagina. It may be constant, intermittent or happen only when the vulva is touched, but vulvodynia is usually defined as lasting for years.

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.

Vulvar vestibulitis

Main article: Vulvar vestibulitis

Vulvar Vestibulitis Syndrome (VVS), vestibulodynia, or simply vulvar vestibulitis is vulvodynia 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.

Vulvar Vestibulitis Syndrome (VVS) 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.^[6]

Possible 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: genetic predisposition to inflammation,^[7] 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.^[8] Pelvic floor dysfunction may be the underlying cause of some women's pain.^[9]

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. A cotton “swab test” is used to 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.

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".

Differential diagnosis

1. Infections: 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 and disease management

There is no uniform treatment approach for vulvodynia or vulvar vestibulitis. Women have shown improved symptoms from a variety of treatments. Some find 100% relief from particular treatments, while others may experience only temporary or partial relief. Responses to the various and many treatments being tried are highly variable, with many patients often trying several treatments over the course of their diagnosis depending upon their levels of relief, the preferred method(s) of their doctor(s), and the affordability of these treatments; many treatments are still experimental and often not covered by health insurance — or the particular doctor using them does not take insurance. Treatments include:

1. Over the Counter Care: Wearing cotton underwear (no synthetics); avoidance of vulvar irritants (douching, shampoos, perfumes, laundry detergents); gently wash the vaginal area and labia with cool water only – using a washcloth is most effective – but do not use soap; cotton menstrual pads; rinsing and patting dry the vulva after urination; using a pad when sitting to alleviate pressure.
2. Lubrication: (for intercourse or used daily to minimize irritation) If you have problems with yeast, or are worried you will, avoid lubricants with glycerine in them, which acts like a sugar and will only add to your problems. Neem oil is a good topical treatment for irritation that is also anti-fungal so very safe if you are prone to yeast, and water-based lubricant are often suggested by doctors. Vitamin E and olive oil can also create bacterial growth so avoid using them topically.
3. Diet: Following a low-oxalate diet may help those whose urine oxalate levels are high and may be causing or exacerbating irritation. The level of oxalates can be tested by taking a 24-hour urine sample. Those following a low-oxalate diet often take a calcium citrate supplement. There is no evidence that this diet helps sufferers with normal oxalate levels in their urine.
4. There is some evidence that probiotics taken daily may help.^[10]
5. Alternatives to Penetration: Sufferers are often encouraged to explore sexual activity besides penetrative intercourse, which is often a major source of pain. Patients may seek the assistance of a sex therapist to learn specific techniques and ways to maintain a positive image of sexual intimacy and one's body.
6. 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 suffer from Provoked (caused by a stimulus such as touch or sexual activity) Vestibulodynia.^[11]
7. Medications: Patients have found variable success using topical creams and gels including estrogen and/or testosterone, often specially made through a compounding pharmacy; oral medicines including testosterone, antidepressants also used for pain disorders (e.g., nortriptyline, amitriptyline), and anti-anxiety drugs; and injectable medications including anesthetics, estrogens, tricyclic antidepressants compounded into a topical form or systemic, local steroids.
8. 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 for 10–15 sets) and relaxation (breathing deep into the gut). Other physical therapy involves direct manipulation of the muscles; the therapist may go inside the vagina and physically press on and stretch the muscles.^[12] (One may practice stretching along with Kegel's at home using a dilation kit or series of different size dildos. This is a common treatment for those suffering primarily from vaginismus, but may also help individuals with vaginismus that results from and worsens preexisting pain.) Other therapists encourage strengthening one's core muscles, believing that the pelvic region overcompensates for the work the core muscles should be doing, causing strain and pain.
9. Injection: This may be performed under CT, flurosocopy/C-arm or ultrasound guidance where the pudendal nerve is identified in its canal (where it is commonly compressed).^[13] Usually cortisone and local anaesthetic is injected and in rare cases, the nerve may be destroyed (ablated), if the pain is severe and unrelenting. In the latter instance, the trade off is permanent vulval numbness.
10. Surgery: Vestibulectomy. During a vestibulectomy, the innervated fibers are excised. A vaginal extension may be performed, in which vaginal tissue is pulled forward and sewn in place of the removed skin. The success rate of a vestibulectomy varies from a low of 60%^[14] to as high as 93%.^[15][16] There are over 20 studies citing a success rate greater than 80%.^{[citation needed]}

Mental health

Like many other people suffering from pain disorders, those afflicted with vulvodynia may often be impacted by the frustration of finding a diagnosis, subsequently confronted with an area of medicine that is still in relative infancy. The cause is still unknown and treatment success varies. Therefore, many become frustrated and sometimes depressed with a lower quality of life.

Media

In Season 4, Episode 2 "The Real Me" of Sex and the City, Charlotte is diagnosed with vulvodynia and prescribed antidepressants. This episode was received with much criticism, notably from the National Vulvodynia Association, which objected to the portrayal of the condition as a fleeting, minor condition.

Season 1, Episode 3 ("In Which Addison Finds the Magic") of Private Practice includes a couple seeking treatment for vulvar vestibulitis and vaginismus.

Susanna Kaysen, well known for her novel, Girl, Interrupted, and its film adaptation, has also published The Camera My Mother Gave Me, a novel concerning her own experience with vulvodynia and its debilitating symptoms.

Vulvodynia was featured in the TLC documentary television series Strange Sex episode "Pleasure and Pain".

Vulvodynia (and female sexual dysfunction) was featured in the season 9 True Life episode "I Can't Have Sex."

See also

• Biofeedback
• Gabapentin
• Bartholinitis
• Endometriosis

References

External links

• New Holistic Approach 2014 VulvodyniaPain.com
• British Association of Dermatologists Care Guide
• National Vulvodynia Association
• Dr. Glazer's Vulvodynia Site
• Vulvodynia and TRPV1 (IT)
• Secret Suffering
• Dr. Marjorie Crandall – Candida Allergy and Vulvodynia
• Low Oxalate Info
• Oxalate Content of Food list
• Clinical Management of Vulvodynia
• Interstitial Cystitis Support Group of Manhattan
• Interstitial Cystitis Network
• Vulvar Pain Foundation
• http://vulvodyniasupport.forumotion.net – newly created support forum for Vulvodynia sufferers
• Psychological and medical information about vulvodynia (Polish)
• A Support Community For Couples Struggling With Intimacy Due To Disability
• Vulval Pain Society (UK)
• "IC woman and her trust sidekick, vulvodynia" Article about the impact on, and relationship between, the presence of both vulvodynia and the serious bladder condition, interstitial cystitis in female patients
• Vulvar Vestibulitis Support Network
• Multidisciplinary Vulvodynia Program
• CT sequence demonstrating a pudendal nerve block
• Vulvodynia: Dismissed and Undiagnosed
• Help organisation for pudendal pain