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Vulvodynia - guidance on diagnosis and treatment

Evidence-based advice on conditions not covered by official guidelines. This week, the underdiagnosed syndrome of Vulvodynia

Evidence-based advice on conditions not covered by official guidelines. This week, the underdiagnosed syndrome of Vulvodynia

Clinical picture

• An underdiagnosed syndrome with pain and burning of the female external genital organs. In gynaecological practice, up to 15% of women admit having experienced vulvar pain at some stage of their lives.

• It is a complicated clinical problem which may cause significant physical incapacity and psychological distress as well as sexual and marital problems.

• Acknowledgement of the multidimensional character of the condition and an empathetic approach are cornerstones of successful management.

• There is very little evidence-based data.

Diagnosis

• A patient with vulvodynia will find a gynaecological examination painful. A speculum examination, cervical smear or bimanual palpation are not necessary for the diagnosis, and it is better not to perform these if the patient is unwilling.

• Vulvodynia is often associated with vaginismus – involuntary muscle spasms or tension of the pelvic floor muscles.

• Ask the patient whether she has any symptomless days. Does the pain vary according to her menstrual cycle? Is the pain associated with intercourse?

• Exclude the possibility of underlying premalignant and malignant conditions. Consider taking a biopsy of any vulvar lesions under local anaesthesia, and consult a dermatologist if necessary.

Vulvar vestibulitis syndrome

• The most common subtype of vulvodynia.

• The vestibule is painful to touch – for example during intercourse.

• The pain is easy to localise, for example with the tip of a cotton-tipped swab.

• Sharp pain is usually experienced at the five and seven o'clock positions in the posterior vestibule, more rarely in the paraurethral area at the anterior vestibule, or sometimes in both.

• The sites of point tenderness in the posterior vestibule may coincide with erythema, which corresponds to the position of vestibular glands.

• The aetiology is unknown. Some cases seem to be provoked by recurrent fungal or bacterial infections or the use of oral contraceptives.

Dysaesthetic vulvodynia (essential vulvodynia)

• Differs from the above conditions in that patients are usually older (over 40), the pain is continuous and diffuse around the entire vulvar region, and the pain may radiate to the anal area, lower back and thighs. It is usually not associated with dyspareunia.

• The pain is aggravated in the evening.

• Also known as pudendal neuralgia.

• Palpating with a cotton-tipped swab will not elicit pain in the vestibule only, but pain may be felt throughout the vulvar region and outside the vulvar region.

• Hyperaesthesia is believed to result from altered innervation of the skin and mucous membranes. The pain is neuropathic.

Differential diagnosis

• Genital herpes, other ulcerative vulvar conditions.

• Vulvovaginitis, for instance candida.

• Desquamative inflammatory vaginitis – purulent vaginitis caused by aerobic bacteria).

• Vulvar dermatoses – for instance lichen planus or lichen sclerosus. Refer to a dermatologist.

Treatment, follow-up, prognosis

• Talk about dyspareunia. Has the condition affected the patient's relationship or mood? Does the couple have alternative forms of satisfactory sexual activity?

• Explain the relevant anatomy, with the aid of a mirror and drawing if needed.

• Skin oil (from a pharmacy) can be applied to the painful areas at bedtime, with the aid of a mirror at first.

• It is important that the patient learns to identify the pelvic floor muscles and how to relax them. A physiotherapist can advise.

• Involve the partner in discussions.

• Lubricants or anaesthetic gels may ease coitus.

• Basic care: the patient should be told to wash the genital area only once a day using water alone, to wear loose clothing, and not to wear underwear at night.

• Set simple and realistic goals. Improvement will take a long time; emphasise the importance of following instructions.

• Make a follow-up appointment; every three months until there is a turn towards the better.

• Vulvar vestibulitis syndrome may remain unchanged for years, but the severity will vary. Spontaneous remission is possible.

• Few effective treatments are available for vulvar vestibulitis syndrome. Good information will help the patient to cope. Suggest temporary withdrawal of oral contraceptives, perhaps for six months.
If pelvic floor muscles are tightened or there is vaginismus, refer to a physiotherapist. If there is no response to treatment, refer to a specialist for vestibulectomy. If there are recurrent yeast infections, consider prophylaxis, for instance fluconazole 150mg once a week for at least two months.

• For dysaesthetic vulvodynia treatment is tricyclic antidepressants, usually amitriptyline, with initially 10mg at bedtime followed by dose increases every few weeks until the pain disappears. Amitriptyline 20mg-40mg at bedtime is usually a sufficient maintenance dose.
Since response is slow to develop, treatment should be continued for several months, after which dose reduction could be attempted.

If the patient does not tolerate amitriptyline (or other tricyclics), consider pregabalin 75mg x 2, gradually increasing the dose. Surgical treatment (vestibulectomy) is contraindicated since the pain is neuropathic.

Candida infection is one differential diagnosis for vulvodynia

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