 |
      |
VULVODYNIA Vulvodynia is a chronic and often debilitating condition that is poorly understood in the medical community. It usually affects white premenopausal women and may be primary or secondarily related to another condition. The term refers to a complex of symptoms, typically chronic burning, stinging, irritation and/or pain, in the vulva without concrete explanation or physical findings. These symptoms often lead to dysparunia and avoidance of sexual encounters. This constellation of symptoms described broadly by this term also incorporates related conditions, such as vulvar vestibulitis, vulvar dermatoses, cyclical vulvitis (candidiasis), vulvar papillomatosis, and essential vulvodynia. Currently, the umbrella term “vulvodynia” has two subcategories: vulvar vestibulitis and vulvar dysasthesia, the latter referring to symptoms that are more generalized. Diagnostic criteria are chronic pain or burning over three months in duration without visible lesions. Some suggest using the “Q-tip test” to elucidate a diagnosis. However, the description and diagnostic criteria are in a state of constant flux due to the continued debate regarding this elusive condition. While inflammatory or immunological processes and changes in innervation are often blamed, the etiology of this condition is poorly understood and, as such, it is mainly a diagnosis of exclusion. Other conditions that must be excluded in making this diagnosis are irritant and allergic dermatitis, atrophic vaginitis, recurrent herpes simplex or zoster, lichen sclerosis or planus, sjogren’s syndrome, vulval intraepithelial neoplasia and carcinoma. In addition, some reports suggest a relationship between vulvodynia and interstitial cystitis and fibromyalgia. In the past, mental/emotional symptoms were also thought to be causative for concomitant factors, however, this has not been supported in the literature. The association between sexual and/or physical abuse and vulvodynia has been refuted. In addition, patients usually exhibit symptoms of depression, but this appears to be related more to the pain and sexual dysfunction rather than to a true depressive disorder. With unknown etiology and ever-changing diagnostic criteria, it is no wonder that successful treatment of this condition is rare. Research evidence providing clear support for any therapy is scant and often fraught with methodological problems. In addition, there is some evidence that many patients improve with time regardless of treatment and in many others the symptoms eventually remit spontaneously. At any rate, if treatment is attempted, conservative treatment is recommended. A good starting point for any patient with this condition is individual and/or couples therapy and referrals for education and support (www.nva.org, www.vulvarpainfoundation.org). As this is a relatively new and novel condition, many individuals may have been suffering from these symptoms for some time before they receive the correct diagnosis. Next, identification and elimination of all potential irritants is suggested. Common offenders are dietary oxalates, detergents, soaps, lubricants, pads or liners, etc. Self-care options, such as sitz baths, ice packs, topical salves and/or lidocaine may help diminish symptoms temporarily, especially pre- and post-coitus. Some evidence supports the use of acupuncture, biofeedback, and physical therapy. Complementary options include a combination of approaches, including topical ointment of a combination of vitamin A tincture of thuja and lomatium, 75,000-150,000 beta-carotene, 1000 mg calcium citrate (to reduce oxalates). Topical estrogen (1/4 tsp qhs) may help by improving epithelial maturation or local immune function. Theoretically, a trial of remedies that specifically target nerve dysfunction, like folic acid, B12, hypericum, may be helpful. Kava, through its muscle relaxing effects, and ginkgo, which increases blood flow, may also be considered. Topical cromolyn (4%) has been reported to be effective in a small number of patients. Case reports support the use of homeopathic Traumeel injections and/or trigger point injections. Conventional treatment options include topical applications, such as anesthetic ointments (2-5% lidocaine) and corticosteroids. Systemic therapies, such as tricyclic antidepressants and gabapentin, have been used successfully. Some patients may respond to interferon injections. Surgery and laser therapy, which is reserved for patients with symptoms limited to the vestibule and entails removal of the effected mucosa, is variably (40-100%) curative and, therefore, may be considered for refractory patients. In short, due to the uncertainty about etiology, it may be wise to assume that a number of causative factors are involved in the pathogenesis of vulvodynia. As such, a combination of treatments may be warranted to achieve desired results. ACOG. Educational bulletin on vulvar nonneoplastic epithelial
disorders. Int J Gynaecol Obstet 1998; 60:181-8 |