Vulvodynia

Dr Ketan Gajjar Dr Gajendra Tomar Assistant Professor Dept.of Obstetrics & Gynecology Shri Krishna Hospital & Pramukh Swami Medical College Karamsad.Anand.Gujarat

Vulvodynia
In 1991, ISSVD described Vulvodynia as chronic vulval discomfort characterized by burning, stinging, rawness or irritation.

vulval pain syndromes

Vulval Vestibulitis Dysasthetic Vulvodynia

vulval pain syndromes Vulval vestibulitis, a cause of introital dysparunia among the women of reproductive age and dysasthetic Vulvodynia; a condition where constant localized vulval pain is experienced, together form the vulval pain syndromes as these relates to vulval pain when infection and organic causes have been excluded.

 The diagnosis vulval dermatosis (lichen sclerosus), vestibular papillomatosis and cyclical vulvitis do not fit into a diagnosis of vulval pain syndrome. Vestibular papillomatosis where filamentous projections of epithelium are found within the vestibule and inner labia minora is now considered a variant of normal.

 Cyclical vulvitis causes intermittent swelling and pain of the labia usually prior to menstruation, which resolves soon after. The patients responded to maintenance treatment with antifungal.

History

 Lynch introduced the term Vulvodynia in 1985 and in 1991 McKay on behalf of ISSVP defined several district subsets of Vulvodynia, which have now been adopted for general clinical care.

Diagnosis and clinical features:

(A)Vulval vestibulitis : is diagnosed clinically on history and examination. friedrich (1987) defined the condition and included three criteria for diagnosis :

(A) Vulval vestibulitis (1)Severe pain on vestibular touch or attempted vaginal entry. (2)Tenderness to pressure localized within the vestibule. (3)The physical findings of erythema confined to the vestibule.

Diagnostic tests
Test : A swab test is a useful way to demonstrate tenderness within the vestibule. A cotton tipped swab is applied

gently to normal skin as a control and than around different areas of the external genitalia.

Diagnostic tests

In vulval vestibulitis pain on light touch is elicited typically in the vestibular area so called allodynia where

innocuous stimuli cause pain.

Diagnostic tests
These hyperesthesia can be generalized throughout the vestibule or can be more focal involving the opening of the ducts of the major vestibular glands (focal vestibulitis) or the posterior fourchette. The swab test does quantify the tenderness but it is non reproducible and operation dependent.

Diagnostic tests
Other objective method for assessment of hyperesthesia is by using a hand probe applied to skin which gives variable degree of pressure producing a recorded numerical result with the degree of symptoms correlating with the numerical result. it is known as vulval algesiometer. Disadvantage : Not freely available.

Differential Diagnosis

(1) Inflammatory / infective vulval condition which also presents with 1st & 3rd criteria / pain and erythema) but not hyperesthesia which is specific to vulval vestibulitis.

Differential Diagnosis
The patient of VV presents typically with : 1.20 40 year age 2. Caucasian 3. Provoked pain such as superficial dysparunia

Differential Diagnosis 4. Tampoon intolerance 5. Pain during gynecological examination 6. Patient may have pain from their first attempt at sexual intercourse or they may have been a period of normal sexual activity with the development of pain subsequently.

Differential Diagnosis

7. Usually there is 6 months period between onset of symptoms and diagnosis and the lady must be in fear, anger & frustration by that time.

Differential Diagnosis

7. Women are eratophobic and they had conservative attitudes to sex. 8. These are also risk factors in psycho-sexual dysfunction such as Vaginismus and Anorgasmia.

Dysasthetic Vulvodynia

Dysasthetic Vulvodynia
It is a cutaneous diathesis causing non localized vulval pain. Constant neuralgic type of pain in the region of vulva or perineal region occasionally. The nature of pain is burning or

aching & is after analogous with neuralgic pain syndromes such as post
herpetic neuralgia.

Dysasthetic Vulvodynia

Clinical examination of vulva normal. Erythema is anatomical variant. Allodynia : not usually seen.

Dysasthetic Vulvodynia

Peri or post menopausal women with h/o multiple inappropriate use of topical agents prior to the diagnosis. Superficial dysparunia is not consistently reported.

Dysasthetic Vulvodynia

Patient may experience perineal, rectal and urethral discomfort as in perineal pain syndrome. Marital conflict Sexual dysfunction

Assessment
Differential Diagnosis : 1. 2. 3. 4. 5. 6. lichen sclerosus Eczema Tight post fourchette Fragile fissured vulval syndrome Symptomatic dermographism Apthous ulceration

Differential Diagnosis 6. Erosive lichen planus 7. Bullous disorder 8. Herpes simplex infections 9. sacral meningeal cysts. 10.Pudendal canal syndrome.

Prevalence : not exactly known but 1.3 15% wide range

Etiology
(1) A h/o vulvovaginal candidiasis is a single most consistently reported by women with vulval vestibulitis though colonization rates of Candida in women with VV are not increased compared to controls.

+ h/o repeated attacks of thrush prior to accurate diagnosis is present.

Etiology (2) Iatrogenic Factors : Multiple use of topical agents Prescription based OTC preparations Soaps Bubble baths Scented hygiene sprays

Etiology

Irritancy from topical medication is commoner on vulva compared to skin elsewhere as the stratum

corneum of the vulval skin functions less efficiently as a protective barrier.

Etiology
(3) Psychological & psychosexual morbidity : Stress and anxiety influence pain perception & symptoms.

(4) Genetic predisposition Predominantly Caucasians

Etiology
(5) Dietary factors : Calcium oxalate crystals in urine causes vulval burning

(6) Hormonal factors : Low levels of serum estrogen h/o taking OCPills especially before 17 years age

Etiology
(7) HPV infection (8) Pelvic floor muscle touch on vulval / vestibular area leads to tension in levator ani muscle as a protective guarding response.

Etiology
(8) Pelvic floor muscle : In patients with VV there is poor muscle recovery after conception and levator ani instability. (9) Histopathology model : Chronic nonspecific inflammatory process in lamina propria and periglandular tissue of vulva.

etiology (10) Patho physiology : Central & Peripheral sensitization : CNS & PNS sensitization leading to hyperesthesia due to previous trauma. increase intra epithelial nerve fibre density among women with VV

Treatment

 In 30% women symptoms resolve without treatment out of which in 50% it resolves with in one year.
Strict vulval hygiene should be encouraged.

Treatment

Medical management : Local anesthetic jellies / emollients for VV- First line treatment Advantage : it makes penitritive sex possible It acts as a lubricant

Treatment

Drug : Lignocaine is preferred. reason : lower incidence of sensitization apply 15 20 min prior to sex warn patients against irritancy

Treatment emollients such as a aqueous cream BP or emulsifying ointment BP are soothing and fragrance free and can be used liberally in vulval area and as a soap substitute.

Treatment
Role of steroid creams remains to be defined. Results are unpredictable Contact allergy is a potential problem can be helpful only in VV and not in D.Vd.

Treatment

Other agents : Capsaicin cream Ketoconazole cream Interferon gel

Treatment
Tricyclic anti depressant agent :
Useful in : Post herpetic neuralgia & D.Vd.

Amitrytyline
Mechanism of action : acts by increasing the activity of the descending inhibitory tracts within the CNS and so modifying the activity within the dorsal horn of spinal cord.

Treatment

dose 10mg/day increase every week until control is achieved 60mg/day average dose max : 150mg/day

Treatment
Other agents: Imipramine, duthicpin , nortryptyline. Side Effects : Dry mouth, wt. gain, sedation , hangover effects. Duration of treatment. : 6 months

treatment

(6) Interferon therapy was popular in 1980 systemic/ local short term success long term studies : not successful

treatment
(7) Biofeed back therapy helps to overcome pelvic floor muscle dysfunction in women with VV

Kegels exercises using portable home biofeed back machines with a special vaginal skin sensor 22/78 patients with aparunia allowed penitritive sex after 16 weeks (4 months) of therapy.

Surgery Last resort in patients with vulval vestibulitis removal of vulval skin is aim Best results with modified vestibulectomy in which horseshoe shaped area of the vestibule and inner labial fold is excised followed by dissection of posterior vaginal wall vaginal tissue is then advanced to cover the skin defect.

 Post op complications are uncommon women who respond to lignocaine gel prior to sex have a more successful outcome.
In one series of kehoes (n=37) 59% had a complete response, 30% had partial response, 30% had no response Other surgeries : Vestibuloplasty not good results .

 Success rates of surgery can be improved by adjutant therapy to help rehabilitate the patient post operatively. Rehabilitation Pre operative psychological assessment Post operative sex therapy & success one of surgery.

 even one session of psychosexual counseling helps to overcome Pelvic floor hypertonia and poor vaginal lubrication. Vaginal dilators have been suggested post operatively.

 Laser vaporization of vestibule : not affective Side Effects : hyperemia , pain

Multi disciplinary approach : clinical psychologists pain management teams Psychosexual councilor Physiotherapists

 clinical psychologist : pain coping mechanism pain management team : pain gate theory Psychosexual counselor : sexual rehabilitation improving physical non coital sexual contact. Place a ban on penitritive sex during the phase of treatment. Physiotherapist : biofeed back acupuncture

Melzak & walls pain gate therapy Melzak & walls pain gate therapy has been widely used in pain management and is useful for women with constant pain. The theory states the spinal cord has a series of gates into which incoming pain messages pass from all over the body.

Melzak & walls pain gate therapy The kind of message which emerge from the gates to reach the brain eventually depends on social and psychological factors in the women like with stress tension and anxiety, more gates are open so more pain messages pass through to the brain and the person experiences high levels of pain.

 Factors which close the gate and prevents pain messages getting through include relaxation, exercise & mobility.

 Finally, Effort should focus on 1. good quality research and 2. raising awareness of this condition as an important aspect of womens health.

Key massage : Detailed history and clinical examination is necessary to make diagnosis and distinguish between the 2 subgroups. Surgery should only be considers for Patients with vulval vestibulitis. Tricyclic anti depressants are the first line treatment for dysasthetic Vulvodynia. Multidisciplinary approach may be beneficial for chronic patients.

Thank you