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5 Articles in Volume 4, Issue #3
At-Home Teaching Materials for Chronic Pain
Diagnosis and Management of Generalized Vulvodynia
Failed Back Surgery Syndrome
Objective Documentation of Spine Pain
Trends in Pain Syndrome Diagnostic Technology

Diagnosis and Management of Generalized Vulvodynia

The prevalence of generalized vulvodynia (previously referred to as generalized vulvar dysesthesia) may have been historically under-recognized by the medical profession.

Vulvodynia is defined as chronic vulvar itching, burning, and/or pain that causes physical, sexual, and psychological distress. Over the years, the term has been applied to a wide variety of vulvar conditions because specific diagnostic criteria were not established. Although the prevalence of chronic vulvar pain in the U.S. is unknown, for the past decade estimates have ranged from the low to mid-hundred thousands. While it was previously thought that chronic vulvar pain is a rare complaint, it may simply have been under-recognized by the medical profession — in fact, the disorder only received a diagnostic code about five years ago. Last fall, the National Institute of Child Health and Human Development funded a 5-year prevalence study on vulvodynia in the general population. According to epidemiologist Bernard Harlow, PhD, associate professor of Obstetrics, Gynecology, and Reproductive Epidemiology, Harvard Medical School, “the preliminary data suggests that possibly millions of women may be affected at some point during their lifetime.”

After a 1997 workshop at the National Institutes of Health, practitioners began to conceptualize vulvodynia as a pain problem. In 1999, at the annual meeting of the International Society for the Study of Vulvovaginal Disease, a two-year trial of specific pain terminology was proposed. This new terminology includes generalized vulvar dysesthesia (VDY), formerly known as dysesthetic or essential vulvodynia, burning vulva syndrome, pudendal neuralgia, or perineal pain syndrome. It is characterized by pain that may be located anywhere on the vulva. Localized vulvar dysesthesia refers to pain that can be consistently localized by point-pressure mapping within specific areas of the vulva, and mixed dysesthesia describes pain on touch in the vulvar vestibule as well as pain in other areas of the vulva.

Essential Characteristics

VDY can take the form of burning or any combination of stinging, irritation, itching, pain, or rawness anywhere from the mons pubis (bony protrusion where the pubic hairline begins) to the anus. It may be diffuse or focal, unilateral or bilateral, constant or sporadic. Women with VDY frequently have difficulty describing and localizing their pain. Many feel that they have a constant yeast infection. Others mention constant irritation, a feeling of continual swelling, a raw sensation, or the sense that they are sitting on a hard knot or ball. Brief paresthesias (abnormal sensations such as burning, prickling or tingling) also are characteristic. Involvement of the urethral meatus (opening of the urethra) leads to symptoms resembling those of a urinary tract infection — i.e. , frequency, urgency, and dysuria — with negative urine cultures.

Dyspareunia (painful intercourse) may or may not be a feature of VDY, although intercourse may trigger pain. Tight pants or undergarments or even the movement of pubic hair also may provoke discomfort. At the same time, it is not unusual for women to report symptom-free periods lasting days or weeks.

The pain of VDY may be neuropathic in nature. Neuropathic pain states originate with an injury to the sensory nervous system itself, which continues to transmit pain signals even when acute injury is absent. Neuropathic pain is most commonly a result of peripheral neuropathy, nerve or root compressions, trauma, or other injuries to the peripheral nervous system. Any surgical incision damages sensory nerves and can cause chronic neuropathic pain, even when the original neural injury is insignificant or unapparent.

As it crosses the sacrospinous ligament and courses along the pelvic sidewall, the pudendal nerve is vulnerable to traction (pulling), pressure, and injury from a wide variety of insults. Injuries from unicycles or horseback riding are documented examples of sports trauma leading to vulvar pain. Injury from descent of the presenting part of the fetus during delivery, recognized in the pathophysiology of prolapse and incontinence, also is a possible etiology of VDY. Some types of vaginal surgery may injure the pudendal nerve, resulting in VDY.

The pinformis, pubococcygeus, and obturator internus and externus muscles (pelvic floor muscles) as well as the sacroiliac joint, commonly refer pain to the perineum, vagina, and rectal areas. Branches of the pudendal nerve lie directly over the belly of the obturator internus muscle. Any injury or orthopedic condition affecting these muscles and joints — e.g. injury to the back, hips, or knees, or repetitive musculoskeletal or postural stressors — can result in vulvar pain.

Pain also may be referred to the vulva from a ruptured disc or scarring around sacral nerve roots after disc surgery, spinal stenosis, or significant spinal arthritis. In addition, neurologic disease such as multiple sclerosis may lead to vulvar pain, as may a solitary neurofibroma (benign nerve tumor).

The neuropathic viruses varicella zoster and herpes simplex may lead to post-herpetic neuralgia manifesting as VDY. When a lesion thought to be herpes simplex turns out to be culture-negative, herpes zoster may be present. VDY should be considered when a woman with a history of herpes is successfully suppressed on acyclovir but continues to complain of irritative symptoms or pain.

Diagnosis

Since irritation, burning, and sometimes an increase in discharge are features of VDY, many women believe they have yeast or other vaginitis symptoms. Patients often are treated for bacterial and/or yeast infections, but multiple antifungals and antibiotics fail to resolve irritative symptoms. Women whose VDY mimics a urinary tract infection will have negative urine cultures, fail to respond to antibiotics, and have a negative urologic workup. Many women are sent to dermatologists to determine whether there is a skin etiology for the chronic symptoms, especially since VDY sometimes involves fissuring with sexual activity. Topical steroids usually are of no benefit. In the postpartum and menopausal periods, estrogen cream may be soothing for a short time but will not dispel discomfort or dyspareunia.

The diagnosis of VDY is largely a diagnosis of exclusion. A careful history is essential to ascertain the type of pain as well as it’s behavior and location.

The diagnosis of VDY is largely a diagnosis of exclusion. A careful history is essential to ascertain the type of pain as well as it’s behavior and location. The clinician should inquire about any initiating factors or associated events such as medical illness, pelvic or vulvovaginal surgery, childbirth, injury to the back or hips, or development of a vulvar lesion that may provide clues to etiology. Any history of sports injury, back surgery, herniated disc, arthritis, spinal stenosis, and hip dislocation also is important. In addition, the clinician should ask about occupational and leisure-time activities that might affect the back or pelvis.

During the physical, it is important to look for skin or oral lesions suggestive of disease or dermatosis. Labial and anal muscle reflexes should be tested, and the patient should be asked to point out areas of pain and identify areas tender to the touch.

To look for evidence of VDY, the clinician can untwist the end of a cotton swab to create a cotton wisp and move it across the vulva and vestibule to assess the patient’s response to light touch. If the cotton wisp feels like a pinch, knife, sandpaper, or other irritant, allodynia (a stimulus that is ordinarily not painful producing pain) is present. The stick of the cotton swab may then be broken, forming a sharp point, to test for areas of hypo- or hyper-esthesia (decreased or increased intensity of feeling). These abnormal findings are easily missed without proper testing. When findings are abnormal inside as well as outside the vestibule, both VDY and vestibulodynia (VBY) may be present. However, even with careful testing, there may be no significant findings.

To rule out vulvar dermatitis or dermatosis, colposcopy and biopsy may be necessary. Any suspicious lesions should be cultured for both herpes simplex and varicella zoster viruses. To rule out a tumor, herniated disc, severe arthritis, spinal stenosis, or arachnoiditis, x-ray or magnetic resonance imaging (MRI) may be useful. A loss of urinary or bowel control and/or the anal wink reflex requires a workup for a spinal cord lesion.

Treatment

Once VDY is diagnosed, the clinician should provide education and support and refer the patient for evaluation if depression is present. Most patients experience a huge sense of relief once a concrete diagnosis is made, feeling reassured that their pain is real and that the condition is neither malignant nor communicable. Couples and sexual counseling are valuable when dyspareunia is present, but sexual relations should be limited until pain is controlled. The patient also should be counseled to avoid known sources of inflammation such as scents, dyes, chemicals, and other substances that might cause irritation when in contact with the skin; to wear loose, comfortable clothes; and to avoid thong underwear and biking.

The daily use of mini-pads should be curtailed for both chemical and mechanical reasons. (If secretions are a problem, women should be advised to change their underwear as often as necessary.) Hydration through sitz baths in comfortably warm water is a mainstay of any vulvar care.

If any orthopedic, neurologic, dermatologic, or urologic findings are contributing to the pain, the patient should be treated or referred, as appropriate. Physical therapy with a focus on the back or pelvic floor also may be helpful. Topical anesthetics such as EMLA cream or lidocaine may be of value. If the patient experiences frequent recurrences of herpes simplex or an active outbreak of the varicella zoster virus, herpes suppression is important. However, acyclovir alone will not relieve vulvar dysesthesia. Any vaginal atrophy should be treated with topical estrogen; even breast cancer patients are now permitted to use the vaginal estrogen ring by many oncologists.

The tricyclic antidepressants have proven useful in managing VDY. Whereas amitriptyline was the tricyclic originally used for neuropathic pain, nortriptyline appears to offer equal efficacy, is less sedating and has fewer anticholinergic side effects such as dry mouth, constipation, and palpitations. However, if one tricyclic is not helpful, others should be tried, e.g. desipramine, imipramine, doxepin. The dosages are the same for all tricyclics (20 to 150 mg daily).

Unfortunately, besides taking weeks to work, tricyclics work unevenly, so that “good days” and “bad days” are common. The leading reasons for failure are an inadequate dosage over too short a period of time or an intolerance of side effects. If the patient fails to improve after three months of therapy at a daily dosage of 100 to 150 mg, another agent should be tried. Tricyclics are contraindicated in patients with urinary retention and glaucoma. Caution is advised in patients with cardiac arrhythmias. Tricyclics potentiate selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Paxil; when a patient takes both an SSRI and more than 50 mg. daily of a tricyclic, monitoring of drug levels may be necessary. Tricyclics also are sun sensitizers, so patients should be advised to avoid prolonged exposure to sunlight.

When the tricyclics are not helpful, anticonvulsants may be tried instead. Although carbamazepine and dilantin originally were used for VDY, the drug levels and monitoring of blood chemistries that are required make them less attractive alternatives than the newer anticonvulsant, gabapentin (Neurontin). The preferable initial dosage of gabapentin is 100 mg daily at bedtime and it may be increased by 100 mg every two days. Beginning with a low dosage and increasing the amount gradually can minimize side effects. If the drug is well tolerated, doses as high as 3600 mg daily may be used if necessary. Gabapentin lacks the anticholinergic side effects of the tricyclics and is preferred by physicians because of its favorable side-effect profile. It may produce sedation, dizziness, and ataxia in certain patients, but some of the side effects, e.g. sedation, may be transient.

VDY should be regarded as a chronic pain syndrome and treated accordingly, with an emphasis on a multidisciplinary approach and improvement in symptoms rather than single interventions and a “cure.”

Once an effective dose of either the tricyclic or anticonvulsant is achieved, it usually is maintained for several months, then gradually tapered in weekly decrements. Some women are not able to remain comfortable off the medications, most of which are safe for long-term use. However, gabapentin must be discontinued during pregnancy. While the tricyclics have not been linked to birth defects, the avoidance of all medications during the first trimester is advised. Consequently, many women taper their medication once they begin trying to conceive.

Acupuncture, massage therapy, and stress management often are helpful adjuncts in managing vulvar pain. Pain clinics also may provide valuable consultation, although few are experienced with VDY. Contrary to popular belief, opioids may be helpful in the management of neuropathic pain. The risk of drug addiction in a general medical population without a history of drug abuse is likely to be very low.

Conclusion

The diagnosis of VDY is largely a diagnosis of exclusion, complicated by the fact that the condition often mimics other entities such as yeast and urinary tract infections. Management consists of education and counseling, the elimination of chemical and other irritants, treatment of any underlying disorders, and medical therapy with tricyclics or anti-convulsants when necessary. VDY should be regarded as a chronic pain syndrome and treated accordingly, with an emphasis on a multidisciplinary approach and improvement in symptoms rather than single interventions and a “cure.” n

Last updated on: January 28, 2012
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