Vulvodynia

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Vulvodynia
Classification and external resources
ICD-9 625.7

Vulvodynia (also called "vestibulodynia"[1]) is a chronic pain syndrome categorized in the ICD-9 group 625—specifically ICD-9 625.7, which is for pain and other disorders of the female genital organs.[2] It refers to pain of the vulva unexplained by vulvar or vaginal infection or skin disease.[3]

Contents

[edit] Symptoms

Pain is the most notable symptom of vulvodynia, and can be characterized as a burning, stinging, irritation or sharp pain that occurs in the vulva, including the labia and entrance to the vagina. It may be constant or intermittent, but vulvodynia is usually defined as lasting for at least 3 months.

Symptoms may occur in one place or the entire vulvar area. It can occur during or after sexual activity, when tampons are inserted, or when prolonged pressure is applied to the vulva, such as during sitting, bike riding, or horseback riding. It can also occur for no particular reason.[4]

It may interfere with a woman’s emotional well-being, at times leading to depression.[5]

[edit] Vulvar vestibulitis

The pain may be localized to the vulvar region. Localized vulvodynia in the vestibular region (the entry point into the vagina) is referred to as vulvar vestibulitis or vestibulodynia. It often causes dyspareunia, or pain with sexual intercourse (though dyspareunia also affects men). The pain of vulvodynia may extend into the clitoris; this is referred to as clitorodynia.

The pain may be provoked by contact with an object, such as with the insertion of a tampon or penis or with the pressure from sitting on a bicycle seat, or it may be constant, as in the case of generalized vulvodynia. Some women have had pain since their first penetration (primary vulvar vestibulitis) while some have had it after a period of time with pain free penetration (secondary vulvar vestibulitis).[6]

[edit] Possible causes

The condition is one of exclusion and other vulvovaginal problems should be ruled out.

A wide variety of possible causes and treatments for vulvodynia are currently being explored.

Some possible causes include: genetic predisposition to inflammation ("Interleukin-1beta gene polymorphism in women with vulvar vestibulitis syndrome".), allergy or other sensitivity (for example: oxalates in the urine), an autoimmune disorder similar to lupus erythematosus or to eczema or to Lichen Sclerosus, infection (e.g., yeast infections, bacterial vaginosis, HPV), injury, and neuropathy--including an increased number of nerve endings in the vaginal area. Some cases seem to be negative outcomes of genital surgery, such as a labiectomy.

Vulvodynia can be confused with other vulvo-vaginal problems such as chronic tension or spasm of the muscles of the vulvar area called vaginismus. This is particularly difficult to distinguish as muscular spasms can cause pain and pain can cause muscular spasms.

Dr. John Willems, head, division of obstetrics and gynecology, Scripps Clinic believes that vulvodynia is a subset of fibromyalgia. This is not, however, based on peer reviewed medical studies. Anecdotally, vulvodynia is also found in patients suffering from interstitial cystitis.

Each of these conditions may be due to nutritional deficiencies that cause musculoskeletal and neurological problems. (The Role of Magnesium in Fibromyalgia). This is controversial as there is no scientific evidence of a link between this specific pain condition and magnesium in diet.

Recent literature (ca. 2006/2007) also suggests this may be a symptom of late onset (3 months to 2 years post transplant) chronic graft vs host disease (cGVHD) for bone marrow and peripheral stem cell transplant patients.

[edit] Diagnosis

The condition is one of exclusion and other vulvovaginal problems should be ruled out. The diagnosis is based on the typical complaints of the patient, essentially normal physical findings, and the absence of identifiable causes per the differential diagnosis. A cotton “swab test” is used to delineate the areas of pain and categorize their severity. Patients often will describe the touch of a cotton ball as extremely painful, like the scraping of a knife.

Many sufferers will see several doctors before a correct diagnosis is made. Many gynecologists are not familiar with this family of conditions, but awareness has spread with time. Sufferers are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients are told that the pain is "in their head".

[edit] Differential diagnosis

  1. Infections: candidiasis, herpes, HPV
  2. Inflammation: lichen planus
  3. Neoplasm: Paget's disease, vulvar carcinoma
  4. Neurologic disorder: neuralgia secondary to herpes virus, spinal nerve injury

[edit] Treatment and disease management

There is no uniform treatment approach for vulvodynia or vulvar vestibulitis. Women have shown improved symptoms from a variety of treatments. Some find 100% relief from particular treatments, while others may experience only temporary or partial relief. Responses to the various and many treatments being tried are highly variable, with many patients often trying several treatments over the course of their diagnosis depending upon their levels of relief, the preferred method(s) of their doctor(s), and the affordability of these treatments; many treatments are still experimental and often not covered by health insurance — or the particular doctor using them does not take insurance. Treatments include:

  1. Over the Counter Care: Wearing cotton underwear (no synthetics); avoidance of vulvar irritants (douching, shampoos, perfumes, laundry detergents); cleaning the vagina with water only (no soaps); cotton menstrual pads; lubrication (Astroglide, vitamin E oil, olive oil) for intercourse or used daily to minimize irritation; rinsing and patting dry the vulva after urination; using a pad when sitting to alleviate pressure.
  2. Diet: Following a low-oxalate diet may help those whose urine oxalate levels are high and may be causing or exacerbating irritation. The level of oxalates can be tested by taking a 24-hour urine sample. Those following a low-oxalate diet often take a calcium citrate supplement. There is no evidence that this diet helps sufferers with normal oxalate levels in their urine.
  3. Alternatives to Penetration: Sufferers are often encouraged to explore sexual activity besides penetrative intercourse, which is often a major source of pain. Patients may seek the assistance of a sex therapist to learn specific techniques and ways to maintain a positive image of sexual intimacy and one's body.
  4. Medications: Patients have found variable success using topical creams and gels including estrogen and/or testosterone, often specially made through a compounding pharmacy; oral medicines including testosterone, antidepressants also used for pain disorders (e.g., nortriptyline, amitriptyline), and anti-anxiety drugs; and injectable medications including anesthetics, estrogens, tricyclic antidepressants compounded into a topical form or systemic, local steroids.
  5. Biofeedback, Physical Therapy and Relaxation: Biofeedback, often done by physical therapists, involves inserting a vaginal sensor to get a sense of the strength of the muscles and help a patient get greater control of his or her muscles to feel the difference between contraction and relaxation. Sessions are linked with at-home recommendations including often Kegel exercises (e.g., hold for 9 seconds, relax for 30 for 10-15 sets) and relaxation (breathing deep into the gut). Other physical therapy involves direct manipulation of the muscles; the therapist may go inside the vagina and physically press on and stretch the muscles. (One may practice stretching along with Kegel's at home using a dilation kit or series of different size dildos. This is a common treatment for those suffering primarily from vaginismus, but may also help individuals with vaginismus that results from and worsens preexisting pain.) Other therapists encourage strengthening one's core, believing that the pelvic region overcompensates for the work the core muscles should be doing, causing strain and pain.
  6. Surgery: Vestibulectomy. During a vestibulectomy, the innervated fibers are excised. A vaginal extension may be performed, in which vaginal tissue is pulled forward and sewn in place of the removed skin. The success rate of a vestibulectomy varies from a low of 60% (Stewart, 2002) to as high as 93% (Goldstein et al., 2006). There are over 20 studies citing a success rate greater than 80% (Goldstein, online).

[edit] Mental health

Like many other people suffering from pain disorders, those afflicted with vulvodynia may often be impacted by the frustration of finding a diagnosis, subsequently confronted with an area of medicine that is still in relative infancy. The cause is still unknown and treatment success varies. Therefore, many become frustrated and sometimes depressed with a lower quality of life.

[edit] Related disorders

[edit] Vulvodynia in the media

In Season 4, Episode 2 "The Real Me" of Sex and the City, Charlotte is diagnosed with vulvodynia and prescribed antidepressants. This episode was received with much criticism, notably from the National Vulvodynia Association, which objected to the portrayal of the condition as a fleeting, minor condition. Season 1, Episode 3 ("In Which Addison Finds the Magic") of Private Practice includes a couple seeking treatment for vulvar vestibulitis and vaginismus.

Susanna Kaysen, well-known for her novel, Girl, Interrupted, and its film adaptation, has also published The Camera My Mother Gave Me, a novel concerning her own experience with vulvodynia and its debilitating symptoms.

[edit] See also

[edit] References

Text document with red question mark.svg
 This article includes a list of references, related reading or external links, but its sources remain unclear because it lacks inline citations. Please improve this article by introducing more precise citations where appropriate. (April 2009)
  1. ^ Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0. 
  2. ^ http://www.icd9data.com/2009/Volume1/580-629/617-629/625/default.htm
  3. ^ http://medical-dictionary.thefreedictionary.com/vulvodynia
  4. ^ National Research Center for Women and Families (October, 2007). "Vulvodynia and Genital Pain". http://www.center4research.org/wmnshlth/2007/vulvodynia.html. Retrieved 2009-08-27. 
  5. ^ Gumus, I. et al. (2008). Vulvodynia: Case report and review of literature. Gynecologic & Obstetric Investigation, 65(3): 155-161.
  6. ^ http://www.ourgyn.com/content/index.php?option=com_content&task=view&id=18&Itemid=66

ACOG Committee on Gynecologic Practice (2006). "ACOG Committee Opinion Number 345: Vulvodynia" ([dead link] – Scholar search). Obstet Gynecol 108 (4): 1049–1052. PMID 17012483. http://www.greenjournal.org/cgi/content/citation/108/4/1049.  PMID 17012483

Stewart, Elizabeth; Paula Spencer (2002). The V Book: A Doctor's Guide to Complete Vulvovaginal Health. Bantam Trade Paperback. pp. 297–328. ISBN 0-553-38114-8. 

Goldstein, Andrew T.; Marinoff, Stanley C.; Christopher, Kurt; Johnson, Crista (2006), "Surgical Treatment of Vulvar Vestibulitis Syndrome: Outcome Assessment Derived from a Postoperative Questionnaire", The Journal of Sexual Medicine 3 (5): 923–931, doi:10.1111/j.1743-6109.2006.00303.x  PMID 17012483

Goldstein, Andrew (2005), 14 Different Treatments for Vulvar Vestibulitis Syndrome, http://www.ourgyn.com/content/index.php?option=com_content&task=view&id=18&Itemid=66, retrieved 2007-10-25 

What Your Doctor May Not Tell You About Fibromyalgia, by R. Paul St. Amand, MD and Claudia Craig Marek, Warner Wellness, 2006.

[edit] External links

Retrieved from "http://en.wikipedia.org/wiki/Vulvodynia"