Vulvodynia

Vulvodynia refers to a disorder of vulvar pain, burning, and discomfort that interferes with the quality of life. No discernible physical lesion other than perhaps some redness of the vestibule is present. The cause can sometimes be attributed to trauma, but in many other cases its origin is unknown.

Localized vulvodynia / Vulvar vestibulitis

The condition is one of exclusion and other vulvovaginal problems should be ruled out. Infections, such as Yeast infections and Bacterial vaginosis, and the diseases listed in the differential diagnosis need to be considered. The pain may be generalized or localized in the vulvar region. Localized, vulvodynia in the vestibular region is referred to as vulvar vestibulitis and also vestibulodynia. The pain of vulvodynia may extend into the clitoris; this is referred to as Clitorodynia. It is unclear if these conditions are manifestations of the same disease process as the differential diagnosis is the same and the cause unknown. The pain may be provoked by contact with an object, as is the case with vulvar vestibulitis, or it may be constant.

Possible causes

A wide variety of possible causes and treatments for vulvodynia are currently being explored. Some possible causes include: allergy or other sensitivity to chemicals or organisms normally found in the environment, autoimmune disorder similar to lupus erythematosus, chronic tension or spasm of the muscles of the vulvar area, infection, injury, chemical sensitivity and neuropathy. Some cases seem to be negative outcomes of genital surgery, such as a labiectomy. Dr. John Willems, head, division of obstetrics and gynecology, Scripps Clinic believes that vulvodynia is a subset of fibromyalgia. Vulvodynia is also frequently found in patients suffering from interstitial cystitis. Recent (2006/2007) literature also suggests this may be a symptom of late onset (3 months to 2 years post transplant) chronic graft vs host disease (cGVHD) for bone marrow and peripheral stem cell transplant patients.

Diagnosis

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

There is no uniform treatment approach and numerous proposed treatments are based primarily on empirical experience and opinion. Treatment is often very different from physician to physician and many patients will have to change their course of treatment when primary attempts fail. Treatments include:

1. Vulvar care measures: cotton underwear, no synthetics; avoidance of vulvar irritants (douching, shampoos, perfumes, detergents); water cleaning only (no soaps); cotton menstrual pads; lubrication for intercourse; rinsing and patting dry the vulva after urination.
2. Medications: topicals, oral, and injectable medication that include anesthetics, estrogens, tricyclic antidepressants compounded into a topical form or systemic, local steroids.
3. Diet: a low-oxalate diet (for vulvodynia associated with oxalate kidney stones).
4. Biofeedback and physical therapy: Physical therapists go inside the vagina and physically work out the the muscles. The vestibule can be worked out by massaging the area over time. Stretching exercises may also be incorporated.
5. 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% (Stewart, 2002) to as high as 93% (Goldstein et al, 2006). There are over 20 studies citing a success rate greater than 80% (Goldstein, online).

The guidelines in Vulvovaginal health may be of some help.
Patients may also change birth control methods: active birth control may be taken continuously so as to eliminate menstration, which can aggravate symptoms.

Sex
Sufferers are often encouraged to explore sexual activity besides intercourse, which is often a major source of pain. Dry sex is strongly discouraged as it may cause further irritation, whilst oral sex will often be less painful. Patients may seek the assistance of a sex therapist.

Vulvodynia in the 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. Again, the topic was treated with ignorance about the severe and debilitating nature of the two conditions and made so many mistakes regarding the treatment of them both as to render the episode devoid of anything accurate or informative.

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.

References

ACOG Committee on Gynecologic Practice (2006). "ACOG Committee Opinion Number 345: Vulvodynia". Obstet Gynecol 108 (4): 1049–1052.  PMID 17012483

Stewart, Elizabeth; Paula Spencer (2002). The V Book: A Doctor\'s Guide to Complete Vulvovaginal Health. Bantam Trade Paperback, pp. 297-328. ISBN 0-553-38114-8. 

Goldstein, Andrew T.; Marinoff, Stanley C. & Christopher, Kurt et al. (2006), "Surgical Treatment of Vulvar Vestibulitis Syndrome: Outcome Assessment Derived from a Postoperative Questionnaire", The Journal Of Sexual Medicine 3 (5): 923-931 PMID 17012483

Goldstein, Andrew (2005), 14 Different Treatments for Vulvar Vestibulitis Syndrome, <http://www.ourgyn.com/content/index.php?option=com_content&task=view&id=18&Itemid=66>. Retrieved on 2007-10-25

What Your Doctor May Not Tell You About Fibromyalgia, by R. Paul St. Amand, MD and Claudia Craig Marek, Warner Wellness, 2006.

Vulvodynia-Treatment Kits include soothing Calendula Creme: http://www.Vulvodynia-Treatment.com

See also

Biofeedback
Gabapentin

External links

• National Vulvodynia Association
• Clinical Management of Vulvodynia
• Interstitial Cystitis Support Group of Manhattan
• Interstitial Cystitis Network
• Vulvar Pain Foundation
• Vulvodynia Treatment
• Vulvodynia-Treatment.com
• 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)

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