VULVODYNIA Clinical Aspects and Research Initiative

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VULVODYNIAClinical Aspects and Research
Initiative

• Gloria A. Bachmann, M.D.
• Nidhi Gupta, M.D.
• Womens Health Institute
• UMDNJ-Robert Wood Johnson Medical School

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Defining Vulvodynia

• The International Society for Study of
  Vulvovaginal Diseases (ISSVD) defines vulvodynia
  as chronic vulvar discomfort, characterized by
  the womans complaint of burning, stinging,
  irritation or rawness

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Types of Vulvar Pain

• PAIN from an IDENTIFIABLE ETIOLOGY
• VULVODYNIA
• Vulvar Vestibulitis Subtype (provoked)
• Dysesthetic Vulvodynia Subtype (unprovoked)

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Pain from an Identifiable Etiology

• 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

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Vulvodynia Vulvar Vestibulitis Subtype

• Friedrichs 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

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VulvodyniaDysesthetic Vulvodynia Subtype

• 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

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VulvodyniaPrevalence Statistics

• Harvard-based study (n16,000) estimates a 16
  life time prevalence
• UMDNJ-based study estimates
• 21 prevalence of chronic gynecologic pain
• 13.5 prevalence of vulvodynia-type 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
  20035882-88

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VulvodyniaDemographics

• 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

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EtiologyVulvar Vestibulitis Subtype

• Prior vulvovaginal Candidiasis
• Hypersensitivity to chemicals
• Human Papilloma virus infection
• High levels of urinary oxalates
• Neurological dysfunction

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Candida Etiology Vulvar
Vestibulitis Subtype

• 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

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Proposed Etiologies Vulvar Vestibulitis Subtype

• 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 20031891-4.

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Proposed Inflammatory Etiology Vulvar
Vestibulitis Subtype

• 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

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Etiology Dysesthetic Vulvodynia Subtype

• Etiology not definitively known
• Childhood trauma and OCPs 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.

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VulvodyniaAssessment of the Patient

• OB/GYN history
• Detailed pelvic exam to exclude pathology
• Vaginal culture
  (in selected cases)
• Pap smear

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VulvodyniaAssessment 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

• Clinician Assessment
• Qtip 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 1111-20,2003.
• Curnow JS, Barron I, Morrison G., et al.
  Vulval algesiometer. Med Biol Eng Comput
  199634266-9.

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VulvodyniaAssessment of Pain Intensity

• Patient Assessment
• McGill-Melzack Pain Questionnaire- 78 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.

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VulvodyniaDifferential Diagnosis

• Exclude other pain causes
• Vaginitis, Candida, urethritis, interstitial
  cystitis, Herpes, Bartholin adenitis
• Vulvar Dermatoses and Dermatitis such as eczema
• Vaginismus, entry and deep dyspareunia
• Atrophic Vulvo-Vaginitis

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VulvodyniaDiagnosis

• Diagnosis made after thorough evaluation fails
  to identify pain etiology

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Vulvodynia Management

• Vulvar Vestibulitis Subtype
• Non-Pharmacologic
• Pharmacologic
• Surgical
• Dysesthetic Vulvodynia Subtype
• Non-Pharmacologic- Not recommended
• Pharmacologic
• Surgical- Not recommended

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NonPharmacologic ManagementVulvar Vestibulitis
Subtype

• Patient education and counseling
• Physical therapy and biofeedback
• Life-style modification
• Application of ice and local anesthetics to the
  vulvar region as needed

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NonPharmacologic ManagementVulvar Vestibulitis
Subtype

• Low Oxalate Diet
• 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

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NonPharmacologic ManagementVulvar 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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BiofeedbackVulvar Vestibulitis Subtype

• 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. 2002283-90.

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Physical TherapyVulvar Vestibulitis Subtype

• 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 Womens Health. 20012513-18.

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Physical TherapyVulvar 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)

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Medical ManagementVulvar Vestibulitis Subtype

• 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.199513217-226

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Medical ManagementVulvar Vestibulitis Subtype

• Topical estrogen creams useful for women with
  thin vaginal epithelium and/or lose of vulvar
  adipose tissue
• Can be used with other pharmacologic agents

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Medical ManagementVulvar Vestibulitis Subtype

• 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

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Medical ManagementVulvar Vestibulitis Subtype

• Corticosteroids (topical and injections)
• Topical anesthetics (nitroglycerin lidocaine)
• Alpha Interferon injections
• Capsaicin cream (immune response modifier)

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Surgical ManagementVulvar Vestibulitis Subtype

• Excision of affected vulvar area to remove neural
  hyperplasia
• Surgery reserved for non- responders to
  conservative treatments
• Data suggest a success rate varying from 40-100
• Long term data lacking

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Surgical ProceduresVulvar Vestibulitis Subtype

• 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.

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Pharmacologic ManagementDysesthetic Vulvodynia
Subtype

• Amitriptyline first line therapy
• Other tricyclic antidepressants- desipramine and
  imipramine-may be effective
• Selective serotonin reuptake inhibitors efficacy
  not proven
• McKay M. Dysesthetic Vulvodynia treatmnet with
  amitryptyline. J Reprod Med 1993 389-13