Vulvodynia

Odyne was the "Greek goddess of pain." Therefore, the term vulvodynia literally means "vulvar pain." Vulvodynia is currently defined as "vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable disease" This classification acknowledges that vulvar pain may be attributable to diagnosable and treatable disorders such as infections (yeast, trichomonas), dermatologic disorders (lichen sclerosus, lichen planus, plasma cell vulvitis), hormonal (atrophic vulvovaginitis) and neurologic disorders (pudendal neuralgia, pudendal nerve entrapment, and post-herpetic neuralgia.) However, these definable causes of vulvar pain are not defined as vulvodynia.  Therefore, while many women are referred to the Centers for Vulvovaginal Disorders with the diagnosis of "vulvodynia," the physicians at the CVVD only rarely give this diagnosis because they are very skilled in the diagnosis of the specific diseases that cause vulvar pain.   

It is estimated that 1.3 % of women have vulvodynia.  In 2002, a sample of women were invited to participate in a web-based survey and 94.5% responded. A history of pain of vulvar pain  was reported by 28 %, with 7.8% reporting pain within the past six months, 3 % reporting pain that lasted three or more months, and 1.7% reporting pain lasting three or more months that occurred within the past six months. The authors concluded that as many as 14 million women in the United States may experience chronic vulvar pain during their lifetime.  Thus, even if only a small percentage of these women have true vulvodynia, the number of women with the problem is enormous. Unfortunately, at least 30% will suffer without seeking medical care.

The cause of vulvodynia remains elusive, but it most likely occurs from a variety of sources and represents many different disease processes.  Possible causes include abnormalities of embryologic development, genetic and/or immunologic factors, hormonal factors, peripheral and central neuropathy (nerve damage), allergic reactions, tightness of the muscles of the pelvic floor, and nerve entrapment. In essence, it is likely that there are many different diseases that yield similar symptoms and cause "vulvodynia."

It is also very important to know what  does not  cause vulvodynia. In the past decade many of the earlier theories regarding the etiology vulvodynia have been called into question. Recent studies have shown that HPV (human papilloma virus) does not play a significant role in vulvodynia.    In addition, the early hypothesis of increased urinary oxalate has also been refuted. Lastly, despite the fact that many women with vulvodynia report a past history of candidiasis, its role as a causative agent of vulvodynia is also uncertain largely because the inaccuracy of self diagnosis of candidiasis.

While a  few clinicians believe that vulvodynia occurs directly as a result of psychological or sexual dysfunction.  This viewpoint, however, is rejected by most patients and by the physicians of  the Centers for Vulvovaginal Disorders. However, almost all agree that the presence of chronic pain, such as with vulvodynia, can have profound psychosocial ramifications.

Treatment

Some patients find relief from vulvodynia with topical anesthetics. All topical anesthetics may cause initial burning and stinging upon application; the discomfort lasts for a few minutes until the area is numb.  The longer the ointment is on the area the deeper the anesthesia. 

The most commonly prescribed topical medication is lidocaine  Rarely, the sexual partner experiences numbness as well.  The long-term use of overnight topical lidocaine has been proposed as a specific therapy for vulvodynia. The authors theorized that the regular application of lidocaine to interrupt the painful impulses may minimize feedback amplification of pain and allow for healing.  Benzocaine, which is the anesthetic in VagicaineTM and VagisilTM, is a skin sensitizer and is a common cause of allergic contact dermatitis; thus we do not recommend their use in patients with vulvodynia.  Similarly, diphenhydramine (Benadryl) is in many topical anesthetic and anti-itch preparations, and is another common sensitizer to be avoided.  Some patients benefit symptomatically from the application of plain petrolatum or zinc oxide, perhaps because these agents minimize friction or prevent urine from touching the vestibule

Topical medications that have been used include estradiol , capsaicin, atropine, testosterone, nitroglycerine, doxepin, amitriptyline, baclofen, and gabapentin. Unfortunately, there are few adequate trials assessing the efficacy or safety of these medications in women with vulvodynia.  Though not supported by controlled trials, the authors have found that for women who have developed vestibulodynia while on oral contraceptives, a compound of topical estradiol  and testosterone can be very effective. 

Topical therapies that patients describe as not having significant benefit for vulvodynia are important to note in order to avoid side effects and symptom exacerbation.  Although topical corticosteroids logically should improve the pain of vestibulodynia, they generally do not. In addition, the use of chronic topical corticosteroids on the vulva may produce dermal atrophy or a steroid dermatitis, characterized by erythema and burning.  Topical antifungals are often used empirically by many clinicians since early theories as to the cause of vulvodynia included hypersensitivity to Candida species.  However, topical antifungal therapy generally does not improve vulvodynia. To the extent that these preparations provide some relief, it is most likely due to the soothing properties in the vehicle itself. Furthermore, these topical preparations may cause a superimposed irritant or allergic vulvovaginitis. 

Antidepressants are commonly used in the treatment of many chronic pain conditions.  A common treatment for vulvodynia is the use of oral tricyclic antidepressants, such as amitriptyline (Elavil), nortriptyline (Pamelor), and desipramine (Norpramin). These medications numb nerves that cause the pain sensations.  The dosages of tricyclic antidepressants used for vulvodynia are significantly less than those used for depression.  

Other antidepressants have been used for pain control.  Many physicians have prescribed selective serotonin reuptake inhibitors (Paxil, Prozac, Zoloft, Celexa, Lexapro) for women with vulvodynia, but in general, this class has not been shown to be effective for pain relief in the majority of women.  However, a newer class of medications, the selective norepinephrine reuptake inhibitors (SNRI's) have been more effective in treating vulvodynia.  These include venlafaxine (Effexor XR ) and duloxetine (Cymbalta).

Gabapentin (Neurontin) and Lyrica have been used to treat chronic pain conditions, including vulvodynia   Gabapentin tends to have fewer side effects than the tricyclic antidepressants.

Physical therapy of the pelvic floor muscles is commonly employed in the treatment of vulvodynia, for both local and generalized pain.  Physical therapy is effective in decreasingh the tightness of the muscles of the pelvic floor, increasing blood flow and oxygenation of the vulvar tissues,  increasing pelvic floor strength, desensitizing local tissues, and improving vulvovaginal elasticity . Physical therapists with experience in vulvodynia can be very helpful. They frequently do a thorough evaluation and assessment of pelvic muscle tone, posture, mobility, and muscle strength. Then specific exercises can be prescribed, often with excellent results.   

 Recently, the use of  botulinum toxin A (Botox) has been successfully used for the treatment of vulvodynia. Small clinical trials have shown significant reduction in pain scores in women with vulvodynia after intra-levator injections of botulinum toxin A. It is not known if the decreased pain is a result of botulinum toxin A's ability to block nerve conduction or in its ability to decrease spasm of the muscles of the pelvic floor. It is the opinion of the physicians at the Centers for Vulvovaginal Disorders that due to the high cost of Botox, it should be used only to augment pelvic floor physical therapy in women with recalcitrant muscle tightness.

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