Download Vulvar Vestibulitis Subtype

VULVODYNIA
Clinical Aspects and Research Initiative
Gloria A. Bachmann, M.D.
Nidhi Gupta, M.D.
Women’s Health Institute
UMDNJ-Robert Wood Johnson Medical School
Defining Vulvodynia
The International Society for
Study of Vulvovaginal Diseases
(ISSVD) defines vulvodynia as
‘chronic vulvar discomfort,
characterized by the woman’s
complaint of burning, stinging,
irritation or rawness’
Types of Vulvar Pain
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PAIN from an
IDENTIFIABLE
ETIOLOGY
VULVODYNIA

Vulvar
Vestibulitis
Subtype
(provoked)
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Dysesthetic
Vulvodynia
Subtype
(unprovoked)
Pain from an
Identifiable Etiology
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Infections such as chronic
vulvovaginitis caused by Candida or
other pathogens
Dermatoses and Dermatitis that
involve the vulva such as Lichen
Sclerosus, Lichen Planus, irritants and
allergic dermatitis
Vaginismus
Vulvodynia:
Vulvar Vestibulitis Subtype
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1.
2.
3.
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Friedrich’s criteria diagnostic:
1. Severe pain on vestibular touch or
attempted vaginal entry.
2. Tenderness to pressure localized
within the vulvar vestibule
3. Physical findings confined to
vestibular erythema of various degrees
Pain is provoked and localized
Commonly seen in women aged 50
years or less
Vulvodynia:
Dysesthetic Vulvodynia Subtype
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Pain is constant and may be felt
beyond the confines of vulvar
vestibule
Usually pain is unprovoked
Diagnosed mainly in women who
are peri- or postmenopausal
Vulvodynia:
Prevalence Statistics
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Harvard-based study (n=16,000)
estimates a 16% life time prevalence*
UMDNJ-based study estimates:
 21% prevalence of chronic
gynecologic pain
 13.5% prevalence of vulvodyniatype pain
* Harlow BL, Stewart EG. A population-based
assessment of chronic unexplained vulvar pain: have
we underestimated the prevalence of vulvodynia?
J Am Med Women's Assoc 2003;58:82-88
Vulvodynia:
Demographics
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Older data suggest the highest
prevalence in white women
Accounts for 10 million doctor
visits/year
Upwards of 14 million women are
affected in their lifetime
Recent data suggest Hispanic
women 80% more likely to have
vulvar pain than other racial groups
Etiology:
Vulvar Vestibulitis Subtype
Prior vulvovaginal Candidiasis
 Hypersensitivity to chemicals
 Human Papilloma virus infection
 High levels of urinary oxalates
 Neurological dysfunction

Candida Etiology:
Vulvar Vestibulitis Subtype
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In 1989 Ashman and Ott proposed cross
reaction between Candida albicans
antigens and self-antigen in vulvovaginal
tissue
Affected tissue has locally elevated
concentrations of inflammatory cells and
pro-inflammatory cytokines
These suggest a hyper-immune response,
possibly from persistent antigen from the
Candida
Proposed Etiologies:
Vulvar Vestibulitis Subtype
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Calcium oxalate crystals in urine
may act as irritant to the vulva
Reduced estrogen receptor
expression causing alteration in vulvar
sensation*
CNS etiology, similar to other regional
pain syndromes
* Eva LJ, MacLean AB, Reid WMN, et al. Estrogen
Receptor Expression in Vulvar Vestibulitis Syndrome.
Am J Obstet Gynecol 2003;189:1-4.
Proposed Inflammatory Etiology:
Vulvar Vestibulitis Subtype
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An inflammatory event releases
cytokines that sensitize nociceptors in
the nerve fibers of the vulva*
Increased intraepithelial nerve
endings in vestibulitis patients have
been reported. Prolonged neuronal
firing sensitizes neurons in dorsal
horn of spinal cord, with subsequent
abnormal interpretation as pain from
touch**
Etiology: Dysesthetic
Vulvodynia Subtype
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Etiology not definitively known
Childhood trauma and OCP’s
possible contributors
Sympathetic pain loops caused by
repeated irritation/trauma leads
to continuous vulvar symptoms*
* Davis GD, Hutchison CV. Clinical Management of
Vulvodynia. Clinical Obstetrics and Gynecology.
June 1999; 42(2):pp 221-233.
Vulvodynia:
Assessment of the Patient
OB/GYN history
 Detailed pelvic exam to
exclude pathology
 Vaginal culture
(in selected cases)
 Pap smear

Vulvodynia:
Assessment of the Patient
Vaginal pH
 Urinanalysis for oxalate content
(select cases)
 Biopsy of abnormal vulvar areas
 Psychosocial assessment
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Vulvodynia:
Assessment of Pain Intensity
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Clinician Assessment:
Q–tip test
Vulvalagesiometer- A device developed at
McGill University for nominal scale vulvar pain
measurement*
Vulvar Algesiometer- Developed by
Curnow to quantify pain by nominal scale**
* Pukall CF, Payne KA, Binik YM, Khalife S. Pain measurement in
vulvodynia. Journal of Sex and Marital Therapy. 29 Suppl 1:11120,2003.
** Curnow JS, Barron I, Morrison G., et al. Vulval algesiometer.
Med Biol Eng Comput 1996;34:266-9.
Vulvodynia:
Assessment of Pain Intensity
Patient Assessment:
 McGill-Melzack Pain Questionnaire78 pain words grouped in 20 subclasses
of 3-5 descriptive words*
 Subclasses are grouped in four sections,
sensory, affective, evaluative and
miscellaneous.
 Provides information on timeline,
location and a quantitative measure of
clinical pain.
Vulvodynia:
Differential Diagnosis
Exclude other pain causes:
1. Vaginitis, Candida, urethritis,
interstitial cystitis, Herpes,
Bartholin adenitis
2. Vulvar Dermatoses and
Dermatitis such as eczema
3. Vaginismus, entry and deep
dyspareunia
4. Atrophic Vulvo-Vaginitis
Vulvodynia:
Diagnosis
“Diagnosis
made after
thorough
evaluation
fails to
identify pain
etiology”
Vulvodynia: Management
Vulvar Vestibulitis Subtype:
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Non-Pharmacologic
Pharmacologic
Surgical
Dysesthetic Vulvodynia Subtype:
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Non-Pharmacologic- Not
Pharmacologic
Surgical- Not recommended
recommended
NonPharmacologic Management:
Vulvar Vestibulitis Subtype
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Patient education and counseling
Physical therapy and biofeedback
Life-style modification
Application of ice and local
anesthetics to the vulvar region as
needed
NonPharmacologic Management:
Vulvar Vestibulitis Subtype
Low Oxalate Diet
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Oxalate is a metabolic breakdown
product from certain food types
Oxalates excreted in urine as crystals
Vulvar surface contact with oxalate
crystals causes irritation and burning
Low oxalate diet (with calcium citrate
supplementation) may be beneficial
NonPharmacologic Management:
Vulvar Vestibulitis Subtype
Calcium Citrate and the Low
Oxalate Diet
Degradation of vulvar collagen and
hyaluronic acid also increase oxalate pool
 Calcium citrate inhibits hyaluronidase and
the release of oxalates and acts as a free
radical scavenger *
 1200 mg of calcium citrate daily
aids in further reducing urinary oxalate
levels **
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Biofeedback:
Vulvar Vestibulitis Subtype
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Surface electromyographic biofeedback
data suggest persistent vulvar injury
leads to chronic reflex pain, resulting in
increased muscle tension*
Pelvic floor muscle instability may be
present
If pelvic floor abnormalities present,
physical therapy often beneficial
* Glazer H, Ledger WJ. Clinical Management of
Vulvodynia. Rev Gynecol Pract. 2002;2:83-90.
Physical Therapy:
Vulvar Vestibulitis Subtype
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Physical therapy reduces muscle
tension and spasm, decreasing pain
levels by 40-60% *
Physical therapist can retrain
dysfunctional pelvic floor muscles
* Hartmann EH, Nelson C. The Perceived Effectiveness
of Physical Therapy Treatment on Women
Complaining of Vulvar Pain and Diagnosed With
Either Vulvar Vestibulitis Syndrome or Dysesthetic
Vulvodynia. Journal of the Section on Women’s
Health. 2001;25:13-18.
Physical Therapy:
Vulvar Vestibulitis Subtype
Physical therapy components:
 Pelvic floor exercise
 Myofascial release
 Trigger point pressure
 Massage
Resource: The American Physical Therapy
Association (800-999-APTA) or
(www.apta.org)
Medical Management:
Vulvar Vestibulitis Subtype
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Topical estrogens:
 Improve epithelial maturation
 Inhibit production of
inflammatory mediators
(cytokines and interleukin-1)
 Lower pain threshold*
*Cutolo M,Sulli A,Seriolo B,et al.Estrogens,the
immune response and autoimmunity.Clin Exp
Rheumatol.1995;13:217-226
Medical Management:
Vulvar Vestibulitis Subtype
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Topical estrogen creams useful
for women with thin vaginal
epithelium and/or lose of
vulvar adipose tissue
Can be used with other
pharmacologic agents
Medical Management:
Vulvar Vestibulitis Subtype
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Tricyclic antidepressants
(Amitriptyline-10mg hs: dose up
to 150mg daily)
Fluconazole
Gabapentin (anticonvulsant),
Venlafaxine-efficacy not proven
Selective serotonin receptor
inhibitors (SSRIs)-efficacy not
proven
Medical Management:
Vulvar Vestibulitis Subtype
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Corticosteroids: (topical and
injections)
Topical anesthetics
(nitroglycerin & lidocaine)
Alpha Interferon injections
Capsaicin cream (immune
response modifier)
Surgical Management:
Vulvar Vestibulitis Subtype
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Excision of affected vulvar area to
remove neural hyperplasia
Surgery reserved for nonresponders to conservative
treatments
Data suggest a success rate varying
from 40-100%
Long term data lacking
Surgical Procedures:
Vulvar Vestibulitis Subtype
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Types: focal excision, vestibuloplasty,
vestibulectomy and perineoplasty
Vestibulectomy excises a U shaped
area of the vestibule from 5mm lateral
to the urethra and the posterior
fourchette
Perineoplasty excises the vestibule
from below and lateral the urethral
meatus to the anal canal with the
vaginal mucosa undermined 1-2cm.
Pharmacologic Management:
Dysesthetic Vulvodynia Subtype
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Amitriptyline: first line therapy
Other tricyclic antidepressantsdesipramine and imipraminemay be effective *
Selective serotonin reuptake
inhibitors efficacy not proven
* McKay M. Dysesthetic Vulvodynia: treatmnet
with amitryptyline. J Reprod Med 1993 ; 38:9-13