VULVODYNIA Clinical Aspects and Research Initiative Gloria A

VULVODYNIA Clinical Aspects and Research Initiative Gloria A. Bachmann, M. D. Nidhi Gupta, M. D. Women’s Health Institute UMDNJ-Robert Wood Johnson Medical School

Defining Vulvodynia The International Society for Study of Vulvovaginal Diseases (ISSVD) defines vulvodynia as ‘chronic vulvar discomfort, characterized by the woman’s complaint of burning, stinging, irritation or rawness’

Types of Vulvar Pain n n PAIN from an IDENTIFIABLE ETIOLOGY VULVODYNIA n Vulvar Vestibulitis Subtype (provoked) n Dysesthetic Vulvodynia Subtype (unprovoked)

Pain from an Identifiable Etiology n n n 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

Vulvodynia: Vulvar Vestibulitis Subtype n 1. 2. 3. n n Friedrich’s 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

Vulvodynia: Dysesthetic Vulvodynia Subtype Pain is constant and may be felt beyond the confines of vulvar vestibule n Usually pain is unprovoked n Diagnosed mainly in women who are peri- or postmenopausal n

Vulvodynia: Prevalence Statistics n n Harvard-based study (n=16, 000) estimates a 16% life time prevalence* UMDNJ-based study estimates: n 21% prevalence of chronic gynecologic pain n 13. 5% prevalence of vulvodyniatype 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 2003; 58: 82 -88

Vulvodynia: Demographics n n 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

Etiology: Vulvar Vestibulitis Subtype Prior vulvovaginal Candidiasis n Hypersensitivity to chemicals n Human Papilloma virus infection n High levels of urinary oxalates n Neurological dysfunction n

Candida Etiology: Vulvar Vestibulitis Subtype n n n 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

Proposed Etiologies: Vulvar Vestibulitis Subtype n n n 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, Mac. Lean AB, Reid WMN, et al. Estrogen Receptor Expression in Vulvar Vestibulitis Syndrome. Am J Obstet Gynecol 2003; 189: 1 -4.

Proposed Inflammatory Etiology: Vulvar Vestibulitis Subtype n n 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**

Etiology: Dysesthetic Vulvod Subtype n n n Etiology not definitively known Childhood trauma and OCP’s 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.

Vulvodynia: Assessment of the Patient OB/GYN history n Detailed pelvic exam to exclude pathology n Vaginal culture (in selected cases) n Pap smear n

Vulvodynia: Assessment of the Patient Vaginal p. H n Urinanalysis for oxalate content (select cases) n Biopsy of abnormal vulvar areas n Psychosocial assessment n

Vulvodynia: Assessment of Pain Intensity n n n Clinician Assessment: Q–tip test Vulvalagesiometer- A device developed at Mc. Gill 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 1: 11120, 2003. ** Curnow JS, Barron I, Morrison G. , et al. Vulval algesiometer. Med Biol Eng Comput 1996; 34: 266 -9.

Vulvodynia: Assessment of Pain Intensity Patient Assessment: n Mc. Gill-Melzack Pain Questionnaire 78 pain words grouped in 20 subclasses of 3 -5 descriptive words* n Subclasses are grouped in four sections, sensory, affective, evaluative and miscellaneous. n Provides information on timeline, location and a quantitative measure of clinical pain.

Vulvodynia: Differential Diagnosis Exclude other pain causes: 1. Vaginitis, Candida, urethritis, interstitial cystitis, Herpes, Bartholin adenitis 2. Vulvar Dermatoses and Dermatitis such as eczema 3. Vaginismus, entry and deep dyspareunia 4. Atrophic Vulvo-Vaginitis

Vulvodynia: Diagnosis “Diagnosis made after thorough evaluation fails to identify pain etiology”

Vulvodynia: Management Vulvar Vestibulitis Subtype: n n n Non-Pharmacologic Surgical Dysesthetic Vulvodynia Subtype: n n n Non-Pharmacologic- Not Pharmacologic Surgical- Not recommended

Non. Pharmacologic Management: Vulvar Vestibulitis Subtype n n Patient education and counseling Physical therapy and biofeedback Life-style modification Application of ice and local anesthetics to the vulvar region as needed

Non. Pharmacologic Management: Vulvar Vestibulitis Subtype Low Oxalate Diet n n 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

Non. Pharmacologic Management: Vulvar Vestibulitis Subtype Calcium Citrate and the Low Oxalate Diet Degradation of vulvar collagen and hyaluronic acid also increase oxalate pool n Calcium citrate inhibits hyaluronidase and the release of oxalates and acts as a free radical scavenger * n 1200 mg of calcium citrate daily aids in further reducing urinary oxalate levels n **

Biofeedback: Vulvar Vestibulitis Subtype n n n 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. 2002; 2: 83 -90.

Physical Therapy: Vulvar Vestibulitis Subtype n n 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 Women’s Health. 2001; 25: 13 -18.

Physical Therapy: Vulvar Vestibulitis Subtype Physical therapy components: n Pelvic floor exercise n Myofascial release n Trigger point pressure n Massage Resource: The American Physical Therapy Association (800 -999 -APTA) or (www. apta. org)

Medical Management: Vulvar Vestibulitis Subtype n Topical estrogens: n Improve epithelial maturation n Inhibit production of inflammatory mediators (cytokines and interleukin-1) n Lower pain threshold* *Cutolo M, Sulli A, Seriolo B, et al. Estrogens, the immune response and autoimmunity. Clin Exp Rheumatol. 1995; 13: 217 -226

Medical Management: Vulvar Vestibulitis Subtype n n Topical estrogen creams useful for women with thin vaginal epithelium and/or lose of vulvar adipose tissue Can be used with other pharmacologic agents

Medical Management: Vulvar Vestibulitis Subtype n n Tricyclic antidepressants (Amitriptyline-10 mg hs: dose up to 150 mg daily) Fluconazole Gabapentin (anticonvulsant), Venlafaxine-efficacy not proven Selective serotonin receptor inhibitors (SSRIs)-efficacy not proven

Medical Management: Vulvar Vestibulitis Subtype Corticosteroids: (topical and injections) n Topical anesthetics (nitroglycerin & lidocaine) n Alpha Interferon injections n Capsaicin cream (immune response modifier) n

Surgical Management: Vulvar Vestibulitis Subtype n n Excision of affected vulvar area to remove neural hyperplasia Surgery reserved for nonresponders to conservative treatments Data suggest a success rate varying from 40 -100% Long term data lacking

Surgical Procedures: Vulvar Vestibulitis Subtype n n n Types: focal excision, vestibuloplasty, vestibulectomy and perineoplasty Vestibulectomy excises a U shaped area of the vestibule from 5 mm 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 -2 cm.

Pharmacologic Management: Dysesthetic Vulvodynia Subtype Amitriptyline: first line therapy n Other tricyclic antidepressantsdesipramine and imipraminemay be effective * n Selective serotonin reuptake inhibitors efficacy not proven n * Mc. Kay M. Dysesthetic Vulvodynia: treatmnet with amitryptyline. J Reprod Med 1993 ; 38: 9 -13