Vulvodynia

• Vulvodynia
  • term used to describe unexplained vulvar pain, sexual dysfunction, and resultant psychological disability (1,2)
  • strict definition of vulvodynia, a term developed by the International Society for the Study of Vulvar Disease (ISSVD) in 1983, is “chronic rawness, irritation, burning and soreness in the absence of abnormal findings except redness at times” (3)
    • the salient point is that the definition does not include itch (3) Even if patients are lost for words when it comes to describing their symptoms and call them "itch", vulvodynia is not a sensation that induces a desire to scratch
    • vulvar pain often has a burning quality. Some patients experience allodynia (defined as pain resulting from stimuli which would not normally cause pain), such as touch or pressure
  • incidence of vulvodynia may be more than 15% among patients attending gynecology clinics
• vulvodynia is any vulvar condition where the dominant symptom is a variation on the pain theme, not itch (3)
  • secondary vulvodynia is pain that is attributable to an observable vulvar or vaginal lesion
    • dermatologic conditions which cause inflammation, ulceration, blisters, fissures and adhesions, and conditions that cause vaginitis
  • primary vulvodynia is pain that is experienced in the absence of any observable vulvar pathology
    • chronic pain conditions which are not caused by a local skin or vaginal problem
      • includes neuropathic pain, referred pain, and introital dyspareunia in patients with a normal vulva ( latter condition is commonly known as the "vulvar vestibulitis syndrome".)
      • very occasionally, patients with psychiatric conditions can experience vulvar pain as a symptom
• Investigation and diagnosis:
  • evaluation of the patient with vulvodynia should include detailed medical and sexual history, systemic and pelvic examination, microbiologic cultures, colposcopy and biopsy if it is necessary
• Treatment
  • if organic vulvodynia then treatment depends on cause
  • idiopathic vulvodynia
    • biofeedback therapy is an excellent first choice for this condition (4)
      • can be undertaken by a therapist (usually a psychologist or pelvic floor physiologist) with experience in the Glazer protocol or a similar regime
      • biofeedback device is a surface electromyography (EMG) unit
      • the EMG sensor is inserted into the vagina and the patient is taught Kegel-like exercises while observing the results on the EMG screen (5)
    • tricyclic antidepressants and other drugs used to treat neuropathic pain are sometimes useful as an adjunct to treatment with biofeedback
    • combination of local analgesia and steroid therapy (methylprednisone and lidocaine) has been as effective for vulvar vestibulitis syndrome, which is a subset of vulvodynia (4)

Notes:

• although the aetiology of vulvodynia often remains undiagnosed, this condition is is reported to be associated with yeast or bacterial infections, HPV infections, chronic use of chemicals (such as 5 FU), dermatologic alterations (such as lichen sclerosis, planus, simplex), trauma (such as childbirth, vaginal operations), and rarely neurological disorders (such as genitofemoral neuralgia, dysethesias associated with spinal disc problems, herpes zoster) (4)

Reference:

1. Paavonen J. Vulvodynia—a complex syndrome of vulvar pain, Acta Obstet Gynecol Scand 1995;74: 243–247.
2. Glazer HI, Ledger WJ. Review clinical management of vulvodynia. Rev Gynaecol Pract 2002;2: 83–90.
3. Fischer G. Management of vulvar pain, Dermatol Ther 2004;17: 134–149.
4. Dede M et al. Successful treatment of persistent vulvodynia with submucous infiltration of betamethasone and lidocaine. Eur J Obstet Gynecol Reprod Biol. 2006 Feb 1;124(2):258-9.
5. Glazer GI et al. Treatment of vulvar vestibulitis syndrome with electromyographic biofeedback of pelvic floor musculature.J Reprod Med. 1995 Apr;40(4):283-90.