Vulvodynia

Published on 16/03/2015 by admin

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Vulvodynia

Bethanee J. Schlosser and Ginat W. Mirowski

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

Vulvodynia is defined by the International Society for the Study of Vulvovaginal Disease as ‘vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder.’ Vulvodynia includes burning, stinging, irritation, and rawness, but does not indicate a specific etiology. Vulvodynia is a complex disorder of unknown etiology attributed to altered sensory perception and is a diagnosis of exclusion. Previous terms included burning vulva syndrome, vestibular adenitis, vulvar vestibulitis syndrome, dysesthetic vulvodynia, essential vulvodynia, and general or localized vulvar dysesthesia. Current classification divides vulvodynia into generalized and localized types which are subcategorized into provoked (requiring physical stimulus to elicit pain), unprovoked (pain in the absence of stimulus), and mixed (provoked and unprovoked).

A thorough examination and appropriate laboratory testing should be performed to exclude infections, dermatoses, and neoplasms. Neurologic conditions and referred pain from the genitourinary or gastrointestinal tracts should also be excluded. This chapter will focus on strategies for the management of vulvodynia.

Management Strategy

Management should focus on excluding other etiologies of vulvar pain. Symptomatic relief is a priority. In addition to the physical discomfort, patients also find vulvodynia psychologically distressing and socially embarrassing. A multidisciplinary approach to the treatment of vulvodynia includes dermatology, gynecology, rehabilitation medicine, physical therapy, neurology, gastroenterology, urology, and others as indicated.

Once vulvodynia is diagnosed and all other potential etiologies of vulvar pain have been excluded, treatment options include topical anesthetics, antidepressants (tricyclics, selective serotonin reuptake inhibitors), anticonvulsants, and pelvic floor physical therapy. Relief may not be immediate, and the patient should be advised to undergo an adequate course of therapy before determining treatment failure. Surgical intervention (vestibulectomy) should be reserved for the treatment of refractory cases of localized vulvodynia.

Specific investigations

image Clinical visual and manual examination of the vulva, vagina, oral cavity, conjunctivae, total body skin, scalp, and nails

image Clinical palpation of inguinal lymph nodes

image Sensory testing for light touch and cotton swab evaluation of the vulva and vaginal vestibule

image Normal saline wet mount of vaginal secretions (Trichomonas vaginalis, bacterial vaginosis, atrophic vaginitis)

image pH assessment of vaginal secretions (bacterial vaginosis, atrophic vaginitis, inflammatory vaginitis)

image Whiff test (bacterial vaginosis)

image KOH microscopic examination (fungi, scabies infestation)

image Microbiologic cultures (bacterial, fungal, viral)

image Tape test, if perianal pruritus present (Enterobius vermicularis, pinworms)

image Papanicolaou smear (in conjunction with gynecology)

image Colposcopy of vulva (in conjunction with gynecology)

image Biopsy, if lesion present

image Blood glucose (recurrent candidiasis in diabetes mellitus)

image Patch testing (allergic contact dermatitis)

image Evaluation for the presence of primary or concomitant psychiatric disorders

First-line therapies

image Antidepressants (amitriptyline, desipramine, etc.) A
image Topical lidocaine A
image Anticonvulsants (oral gabapentin, oral pregabalin, topical gabapentin) C
image Pelvic floor physical therapy C

Second-line therapies

image Electromyographic biofeedback B
image Nitroglycerin cream B
image Acupuncture C

Third-line therapies

image Botulinum toxin A
image Topical nifedipine A
image Enoxaparin A
image Urinary oxalate reduction therapy B
image Surgery D
image Hypnosis E
image Cognitive behavioral therapy/psychotherapy E
image Spinal cord stimulator E

[/level-membership-for-dermatology-category][not-level-membership-for-dermatology-category]

Vulvodynia

Bethanee J. Schlosser and Ginat W. Mirowski

Evidence Levels:  A Double-blind study  B Clinical trial ≥ 20 subjects  C Clinical trial < 20 subjects  D Series ≥ 5 subjects  E Anecdotal case reports

Vulvodynia is defined by the International Society for the Study of Vulvovaginal Disease as ‘vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder.’ Vulvodynia includes burning, stinging, irritation, and rawness, but does not indicate a specific etiology. Vulvodynia is a complex disorder of unknown etiology attributed to altered sensory perception and is a diagnosis of exclusion. Previous terms included burning vulva syndrome, vestibular adenitis, vulvar vestibulitis syndrome, dysesthetic vulvodynia, essential vulvodynia, and general or localized vulvar dysesthesia. Current classification divides vulvodynia into generalized and localized types which are subcategorized into provoked (requiring physical stimulus to elicit pain), unprovoked (pain in the absence of stimulus), and mixed (provoked and unprovoked).

A thorough examination and appropriate laboratory testing should be performed to exclude infections, dermatoses, and neoplasms. Neurologic conditions and referred pain from the genitourinary or gastrointestinal tracts should also be excluded. This chapter will focus on strategies for the management of vulvodynia.

Management Strategy

Management should focus on excluding other etiologies of vulvar pain. Symptomatic relief is a priority. In addition to the physical discomfort, patients also find vulvodynia psychologically distressing and socially embarrassing. A multidisciplinary approach to the treatment of vulvodynia includes dermatology, gynecology, rehabilitation medicine, physical therapy, neurology, gastroenterology, urology, and others as indicated.

Once vulvodynia is diagnosed and all other potential etiologies of vulvar pain have been excluded, treatment options include topical anesthetics, antidepressants (tricyclics, selective serotonin reuptake inhibitors), anticonvulsants, and pelvic floor physical therapy. Relief may not be immediate, and the patient should be advised to undergo an adequate course of therapy before determining treatment failure. Surgical intervention (vestibulectomy) should be reserved for the treatment of refractory cases of localized vulvodynia.

Specific investigations

image Clinical visual and manual examination of the vulva, vagina, oral cavity, conjunctivae, total body skin, scalp, and nails

image Clinical palpation of inguinal lymph nodes

image Sensory testing for light touch and cotton swab evaluation of the vulva and vaginal vestibule

image Normal saline wet mount of vaginal secretions (Trichomonas vaginalis, bacterial vaginosis, atrophic vaginitis)

image pH assessment of vaginal secretions (bacterial vaginosis, atrophic vaginitis, inflammatory vaginitis)

image Whiff test (bacterial vaginosis)

image KOH microscopic examination (fungi, scabies infestation)

image Microbiologic cultures (bacterial, fungal, viral)

image Tape test, if perianal pruritus present (Enterobius vermicularis, pinworms)

image Papanicolaou smear (in conjunction with gynecology)

image Colposcopy of vulva (in conjunction with gynecology)

image Biopsy, if lesion present

image Blood glucose (recurrent candidiasis in diabetes mellitus)

image Patch testing (allergic contact dermatitis)

image Evaluation for the presence of primary or concomitant psychiatric disorders

First-line therapies

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image Antidepressants (amitriptyline, desipramine, etc.) A
image Topical lidocaine A
image Anticonvulsants (oral gabapentin, oral pregabalin, topical gabapentin) C