Download Submission template for Capstone Project Case Report

Submission template for Capstone Project Case Report
TITLE OF CASE
Vulvodynia: Real pain, real psychological effects.
AUTHORS OF CASE Please indicate corresponding author by *
Kristy Endebrock
SUMMARY Up to 150 words summarising the case presentation and outcome
L.M. is a 26-year-old G0P0 Caucasian female, who presented to the office complaining of
dyspareunia. She stated the pain was worse with penile insertion and lasted throughout
sexual intercourse. Vulvar pain continued one day following sexual intercourse and she
reported associated pain with urination one day following sexual intercourse. She denied
any pain with menstruation. On physical examination, no vulvar lesions or vaginal discharge
were noted. She was then diagnosed as having vulvar vestibulitis with possible interstitial
cystitis.
Estrace and EMLA cream were initiated. During her follow-up visit, a PST was performed and
found to be negative. Her symptoms continued to persist, so estrace and EMLA cream were
discontinued and vulvar injections were initiated. The patient noted relief for several
months; however, at her last office visit, she reported no relief of her symptoms. Therefore,
she was referred to the Vulvodynia Vestibulitis Clinic at the University of Michigan. Her
appointment at U of M was on 10/15/08, and she was to schedule an OB/GYN office visit
following her appointment.
BACKGROUND Why you think this case is important/why you decided to write it up
Vulvodynia is a commonly misdiagnosed condition. Patients are often repeatedly treated for
vaginal infections in hopes of reducing any inflammation causing pain. On the other hand,
some practitioners, who do not understand this condition, have dismissed their patient’s
pain.1 This case demonstrates the importance of diagnosing and treating women who suffer
from vulvodynia. If their pain is not managed, many women experience depression and
sexual avoidance. Therefore, practitioners need to understand and recognize the
presentation of this condition in order to provide the proper care these women need.
CASE PRESENTATION Presenting features, medical/social/family history
*Patient presented to the office on 11/12/07*
HPI:
L.M. is a 26 y/o G0P0 Caucasian female with a c/o dyspareunia.
Pain associated with penile insertion and throughout sexual intercourse.
Pain continues one day following sexual intercourse.
Dysuria for one day following sexual intercourse.
Denies pain with menstrual cycles.
LMP = 10/16/07
Age of menarche = 15 y/o
Length of menstruation = 5 days
Cycle length = 28 days
Last pap smear = September 2006; normal.
PMH:
Seasonal depression
PSH:
Tonsillectomy, 1996
Wisdom teeth removed, 1998
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Breast augmentation, 2006
Meds:
Ortho Nuvum 777
Celexa 20mg PO daily
Allergies:
NKDA
Family
Social
Hx:
Father = skin cancer
Maternal grandmother = breast cancer in her forties
Maternal aunt = breast cancer in her forties
Paternal grandfather = prostate cancer
Hx:
Recently married and works as a sales representative.
Deals with stress and heavy lifting at work.
Denies illicit drug use.
Smokes approximately 2 cigarettes per month since 2002.
Consumes approximately 10 beers per month since 2002.
ROS:
Skin: Easy bruising.
GU: Dysuria for one day following sexual intercourse.
Otherwise, unremarkable.
PE:
Vitals: Ht = 64’
Wt = 120lbs
BP = 110/72
Gen: Well groomed and appears to be in good health.
CV: RRR. Normal S1S2. No murmurs.
Resp: CTA B/L
GI: Abdomen soft, non-tender. NBSx4. No guarding.
GU: No lesions, discharge, or odor.
INVESTIGATIONS If relevant
Vaginal Culture:
- Vaginitis
- GC
- Chlamydia
Potassium Sensitivity Test (1/24/08):
Overall negative test, patient tolerated well
No rescue solution given
DIFFERENTIAL DIAGNOSIS If relevant
Vulvar vestibulitis with possible interstitial cystitis.
TREATMENT If relevant
11/12/07:
Estrace cream to vestibule nightly
EMLA cream applied at least one hour prior to sexual activity
1/14/08:
EMLA cream no longer effective
Injection of 1% lidocaine with epinephrine and 0.3mL kenalog to focused areas of
pain around vaginal introitus
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1/24/08:
Vestibular gland injections with 6mL 1:10 solution of 40mL kenalog and 0.25%
marcaine
Amitriptyline 25mg nightly
2/7/08:
Vestibular gland injections with 7cc 1:10 solution of 40mL kenalog and 0.25%
marcaine
3/28/08:
Vestibular gland injections with 4cc 40mL kenalog and 0.25% marcaine
9/4/08:
Pateint follow-up to kenalog treatment; no relief
Patient referred to Vulvodynia Vestibulitis Clinic at U of M
OUTCOME AND FOLLOW-UP
Vestibular gland injections were no longer successfully managing vulvar pain. Therefore, she
was referred to the Vulvodynia Vestibulitis Clinic at U of M with an appointment on 10/15/08.
DISCUSSION including very brief review of similar published cases (how many
similar cases have been published?)
1.
2.
3.
4.
What is the pathophysiology of vulvodynia?
How is vulvodynia diagnosed?
What is the management of vulvodynia?
What is the prevalence of vulvodynia, and how many similar cases have occurred?
1. The International Society for the Study of Vulvar Disease (ISSVD) has characterized
vulvodynia as burning, stinging, irritation, or rawness in the vulvar region. 7
Vulvodynia is a chronic condition lasting at least three to six months in duration and
causes physical, sexual, and psychological distresses. 9 Although research is ongoing,
little is known about the causes of vulvodynia.1,7-9,11 Current theory is that affected
women are more likely to have altered contractile characteristics of the pelvic floor
musculature.9 Therefore, pelvic floor muscle rehabilitation with biofeedback has been
designed to improve muscle function and reduce vulvar pain.
Several studies have proposed another possible etiology of vulvodynia. These studies
identified minor immunologic changes in women with vulvodynia, such as altered
levels of interleukin-1 and tumor necrosis factor in vestibular tissue. These changes
could result in a decreased ability to down-regulate the inflammatory response. This
may in turn be associated with neuropathic changes.9 More recently, vulvar biopsy
specimens have shown increased neuronal proliferation and branching in the vulvar
tissue of women with vulvodynia compared with tissue of asymptomatic women.9
Vulvodynia has also been attributed to changes in estrogen concentration and
increased urinary oxalates.11 One study suggests estrogen affects sensory
discrimination and pain sensitivity at multiple sites within the central and peripheral
nervous systems.11 However, dietary oxalate consumption and oral contraceptive use
have been refuted as causes of vulvodynia.5,6
2. Vulvodynia is a diagnosis of exclusion. It is important to get a thorough patient
history in order to rule out any underlying cause of vulvar pain, such as vaginal
infection, inflammation, neoplasm, or neurological disorder. If a patient complains of
vaginal secretions or if they are noted on physical examination, cultures should be
ordered to rule out an active infection. Occasionally, the patient may not be aware
that the tenderness is originating from the introitus and may describe the pain as
deeper into the vagina. Confirmation of the pain during physical examination will
clarify this issue.9
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Physical examination is very important in the diagnostic process. In patients with
vulvodynia, the vulva may be erythematus. Erythema is most commonly visualized
at the five and seven o’clock positions or on a horseshoe-shaped area of the lower
vestibulum.8 If a rash, altered skin, or altered mucosa are present, it is inconsistent
with vulvodynia and warrants further investigation and possible biopsy.3,9 A second
test used on physical examination is the Q-tip test. In this test, a cotton swab is
used to gently indent the skin on several locations around the labia, introitus, and
hymenal remnants.9 This pressure will elicit pain in almost all patients with
vulvodynia, especially in the area of the posterior introitus and hymenal
remnants.8,9,11
3. A variety of treatment options are available for women who have vulvodynia.
However, it is important to realize that successful therapy often requires trial and
error because individual response varies greatly between medications. The general
approach to these patients is to determine and eliminate any triggering factors and
maintain good vulvar hygiene.12
Pelvic floor muscle rehabilitation has been found to be beneficial in patients with
evidence of pelvic floor muscle hypertonicity. It is thought to decrease introital
tenderness and enable women to engage in sexual intercourse with less discomfort.79,12
When beginning pharmacologic therapy, a TCA is typically the first agent used.
Depending on the provider and the severity of the patient’s pain, a topical anesthetic
may also be prescribed. If treatment with TCAs is found to be unsuccessful,
management with medications that decrease neuronal hypersensitivity is the next
treatment option. Examples include Norpramin, Neurontin, Paxil, and Effexor. 7-9,12
Local nerve blocks may be used if symptoms continue to persist despite oral and
topical medications. An observational study of 22 women evaluated the effectiveness
of methylprednisolone acetate and lidocaine cloridrate solution injected into the
vestibule. Results showed seven women had complete remission of their symptoms,
eight women stated they were markedly improved, while seven had no improvement
in their pain over nine months.12 Lastly, it is very important to recognize that if a
patient remains unresponsive to medical treatment, they should be referred to a
specialist who can better help manage their symptoms.
4. Many articles have been published educating practitioners on diagnosing and
managing vulvodynia patients. However, there is limited literature available
regarding similar case reports. Likewise, conflicting data exists in the determination
of the prevalence of vulvodynia. An article published by Dr. Metts in 1999
determined the prevalence of vulvodynia to be as high as fifteen percent. This article
also found the mean age distribution to be between the second and sixth decade of
life and almost exclusively in white females.8
In a more recent article published by Dr. Reed in 2006, three studies were analyzed.
Each study systematically addressed the prevalence of vulvar pain in various clinical
settings and determined the prevalence to be much greater than was previously
estimated. One of the three studies found 15 percent of the patients in a successful
gynecologist’s office have vulvodynia. The second study found 1.7 percent of the
women, who answered their internet survey, complained of vulvar pain. Lastly, the
third study found 8.6 percent, in a population-based study of symptomatic women in
the Boston area, to have vulvodynia. When completed, the analysis of these studies
extrapolated the prevalence of vulvodynia to occur in more than 2.4 million women in
the United States and approximately 15 affected women in a family practice of 2,000
patients.9
A third article that was published in 2004 found the prevalence of chronic vulvar pain
or burning to be unknown. It also estimated a lifetime cumulative incidence of
chronic vulvar pain to be approximately 16 percent, estimating that 14 million women
in the United States could experience vulvodynia in their lifetime.7 As previously
stated, most articles were published to educate practitioners on how to provide care
for vulvodynia patients. Many articles touched on the prevalence of vulvodynia,
however each had conflicting results. It is important to recognize that more research
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is needed in order to fully understand the etiology and prevalence of vulvodynia.
In regards to the patient presented in the case study, it appears as though diagnosis
and management was sufficient. It was important to exclude interstitial cystitis as a
possible cause of her pain because these patients have a high risk of acquiring
vulvodynia.4 However, from research found on the management of vulvodynia
patients, a TCA should have been used first line. If the TCA was found to be
ineffective, another oral medication used to decrease neuronal hypersensitivity could
have been initiated. Likewise, if this patient still experienced no relieve from her
symptoms, the injections given were an appropriate next step in her management. It
was also important that as her symptoms continued to persist despite medical
management, she was referred to the Vulvodynia Vestibulitis Clinic at U of M for
further care.
LEARNING POINTS/TAKE HOME MESSAGES 3 to 5 bullet points
Vulvodynia is a very painful condition that also causes depression and sexual
avoidance. It is important to not only treat these patients symptomatically, but to
also provide emotional and psychological support. There are many support groups
available for these women:
o National Vulvodynia Association (www.nva.org)
o Vulvar Pain Foundation (www.vulvarpainfoundation.org)
Vulvodynia is a diagnosis of exclusion. Therefore, it is important to exclude
infectious, inflammatory, neoplastic, and neurologic disorders as a cause of vulvar
pain.
Response to medication is highly variable; successful therapy often requires trial and
error. Thus, it is important to realize there are a variety of treatment options
available for vulvodynia, including vulvar hygiene, topical anesthetics, TCAs, and
many other pharmacological agents.
Vulvodynia can be a frustrating condition for both the patient and the practitioner. It
is important to realize that if multiple treatment options fail, there are vulvodynia
clinics available for patient referral.
REFERENCES
1. Bachmann, Gloria, Janice McElhiney, Shillena Peters, and Raymond Rosen.
"Vulvodynia: Real condition, real pain." Sexuality, Reproduction and Menopause 4
(2006): 71-73.
2. Boardman, Lori. "Topical Therapy for Vulvodynia." National Vulvodynia Association 11
(2005): 1-11.
3. Bowen, A. R., A. Vester, L. Marsden, S. R. Florell, H. Sharp, and P. Summers. "The
Role of Vulvar Skin Biopsy in the Evaluation of Chronic Vulvar Pain." American Journal
of Obstetrics and Gynecology (2008).
4. Gardella, Barbara, Daniele Porru, Francesca Ferdeghini, Eva Gabellotti, Rossella
Nappi, Bruno Rovereto, and Arsenio Spinillo. "Insight into Urogynecologic Features of
Women with Interstitial Cystitis/Painful Bladder Syndrome." European Association of
Urology 54 (2008): 1145-153.
5. Harlow, B. L., A. F. Vitonis, and E. G. Stewart. "Influence of Oral Contraceptive Use
on the Risk of Adult-onset Vulvodynia." Journal of Reproductive Medicine 53 (2008):
102-10.
6. Harlow, B. L., H. A. Abenhaim, A. F. Vitonis, and L. Harnack. "Influence of Dietary
Oxalates on the Risk of Adult-onset Vulvodynia." Journal of Reproductive Medicine 53
(2008): 171-78.
7. Lotery, Helen, Neil McClure, and Rudolph Galask. "Vulvodynia." The Lancet 363
(2004): 1058-060.
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8. Metts, Julius. “Vulvodynia and Vulvar Vestibulitis: Challenges in Diagnosis and
Management.” American Family Physician (1999).
9. Reed, Barbara. “Vulvodynia: Diagnosis and Management.” American Family Physician
73 (2006): 1231-38.
10. Stewart, Elizabeth, and Robert Barbieri. "Clinical Manifestations and diagnosis of
vestibulodynia." 31 May 2008. Up To Date. 30 Oct. 2008.
11. Stewart, Elizabeth, and Robert Barbieri. "Clinical Manifestations and diagnosis of
vulvodynia." 31 May 2008. Up To Date. 21 Oct. 2008.
12. Stewart, Elizabeth, and Robert Barbieri. "Treatment of Vulvar Pain." 31 May 2008. Up
To Date. 21 Oct. 2008.
Date:
November 5, 2008
PLEASE SAVE YOUR TEMPLATE WITH THE FOLLOWING FORMAT:
Author’s last name and date of submission, eg,
Smith_June_2008.doc
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