Unexplained vulvar pain, sexual dysfunction, and psychological disability characterize vulvodynia, a syndrome that seems to be prevalent and underdiagnosed or misdiagnosed. Only since 1983 has vulvodynia been recognized as a diagnosis in the medical literature. We have had numerous requests from Medscape members to provide more information on this disorder. We invite you find out more about vulvodynia in this easy-to-navigate collection of recent MEDLINE abstracts compiled by the editors at Medscape.
Graziottin A, Castoldi E, Montorsi F, Salonia A, Maga T
J Sex Marital Ther. 2001;27:503-512
Vulvodynia is a clinical syndrome that may include unexplained vulvar pain, sexual dysfunction, and psychological disability. It is a multifactorial syndrome that should be diagnosed, if possible, with an intradisciplinary approach. This article discusses the diagnosis and treatment of vulvodynia, starting with a summary of the complex nervous system within the pelvis. Different clinical pictures and different subtypes of the syndrome have been described in order to identify the etiologic aspects that are essential for diagnosis and subsequent treatment. Clinical evaluation should stress attention to detailed "pain-mapping" and evaluation of past and present history. The gynecological examination should be an overall patient evaluation, incorporating global physical impression, change in posture due to pain and careful examination of the pelvic floor. Examination of the pelvic floor is frequently omitted. Leading to an incorrect diagnosis of psychogenic pain. Such a misdiagnosis can result in the dismissal of appropriate treatment. Proper evaluation requires a comprehensive, multidisciplinary approach that includes medical, rehabilitative, and psychological issues.
Masheb RM, Nash JM, Brondolo E, Kerns RD
Pain.. 2000;86:3-10
Vulvodynia, or chronic vulvar discomfort, has become an increasingly recognized complaint in the medical literature. However, classification, assessment, and treatment for vulvodynia have not been universally established. There is a serious need for greater understanding of this disorder since evidence suggests, although not life-threatening, vulvodynia appears to have a significant impact on quality of life. This article reviews the medical and psychological literature on vulvodynia published since 1983, the first year vulvodynia was recognized as a diagnosis in the medical literature. The purpose of this article is to provide a review of the literature on diagnostic issues, treatment options, and psychosocial sequelae with the aim of highlighting areas in need of future research. Finally, suggestions are made for considering vulvodynia from a multidimensional, chronic pain perspective.
Harlow BL, Stewart EG
J Am Med Womens Assoc.. 2003;58:82-88
Objectives: To estimate the prevalence of unexplained chronic vulvar
pain (burning or sharp knifelike pain or pain on contact) in an ethnically
diverse population-based sample of women.
Methods: We used town census directories to identify 4915 women age 18
to 64 from 5 ethnically diverse Boston communities and asked them to complete
a self-administered questionnaire pertaining to current and past chronic lower
genital tract discomfort (response rate 68%). We calculated the cumulative
incidence and 95% confidence intervals by demographic and reproductive
characteristics. Approximately 16% of respondents reported histories of
chronic burning, knifelike pain, or pain on contact that lasted for at least 3
months or longer, and nearly 7% were experiencing the problem at the time of
the survey. Chronic vulvar pain on contact decreased with increasing age, but
the cumulative incidence of chronic burning and knifelike pain was similar
across all ages. Contrary to earlier clinical assessments, white and African
American women reported similar lifetime prevalences. However, Hispanic women
were 80% more likely to experience chronic vulvar pain than were white and
African American women. Women with histories of chronic vulvar pain were 7 to
8 times more likely to report difficulty and great pain with their first
tampon use than were women without such histories. Nearly 40% of women chose
not to seek treatment, and of those who did, 60% saw 3 or more doctors, many
of whom could not provide a diagnosis.
Conclusion: Chronic unexplained vulvar pain is a highly prevalent
disorder that is often misdiagnosed.
Gordon AS, Panahian-Jand M, Mccomb F, Melegari C, Sharp S
J Sex Marital Ther.. 2003;29(Suppl 1):45-58
This article presents data contributed by 428 highly educated, internet-savvy women who frequented various vulvar pain discussion lists. The age range was in the reproductive years and older and over 90% were Caucasians. No country of origin was given. They had a number of distressing symptoms, including vulvar pain at rest and with contact, burning, itching, redness, and inflammation. Most felt that they had either vulvar vestibulitis, vulvodynia, or both, although they had other vulvar conditions as well. Many felt that yeast infections, stress, antibiotics, infections, and chemicals played a contributing role. There were a number of comorbidities, including irritable bowel syndrome, fibromyalgia, and interstitial cystitis. Sexual abuse was not a major issue. The vulvar pain destroyed or altered their sex lives, lowered their self-esteem, and affected their relationships. Often, they relied upon understanding partners, support groups, and hobbies but not the medical profession for comfort.
Hansen A, Carr K, Jensen JT
J Reprod Med.. 2002;47:854-860
Objective: To describe the demographics, presenting symptoms,
physical examination and laboratory findings, and initial diagnoses in a
cohort of women referred for evaluation of vulvovaginal problems. STUDY
Design: Descriptive review of medical records of new patients referred
for evaluation of vulvar problems between January 1, 1996, and December 31,
1999. Electronic medical records and other documents were manually abstracted.
Results: Three hundred twenty-two women met the study criteria. The
majority were Caucasian (93.8%) and married (63.9%). The mean age was 41
years, with a range of 13-88. The majority reported at least one vaginal
delivery (72.9%) or cesarean section (10.6%). The most common symptoms were
vulvar pain (86.3%), dyspareunia (70.8%), itching (36.0%) and skin changes
(18.0%). Most patients received a diagnosis in more than one evaluation
category. Prevalent diagnoses included Bartholin fossa pain (12.1%), vulvar
vestibulitis (19.9%), restriction and fissuring of the posterior labial
commissure (20.1%), dysesthetic vulvodynia (32.3%), pelvic floor dysfunction
(39.8%) and dermatologic conditions (47.5%).
Conclusion: Women presenting for evaluation of vulvar disorders
represent a heterogeneous population. Among women with vulvar pain,
abnormalities of the skin and pelvic floor are common and should be ruled out
prior to making a diagnosis of vulvar vestibulitis or dysesthetic vulvodynia.
Sadownik LA
J Reprod Med.. 2000;45:679-684
Objective: To define the demographic and clinical characteristics of
women presenting with vulvodynia. STUDY
Design: Vulvodynia patients seen by the author between September 1996
and June 1999 were included in the study. Patients completed a standardized
questionnaire and were interviewed and clinically examined.
Results: Three hundred one patients completed the questionnaire. The
average age was 38 years old, 72% reported postsecondary education, 54% were
nulligravid, and 55% were married. Average duration of symptoms was 38 months.
Patients reported dyspareunia (71%), vulvar burning (57%) and vulvar itching
(46%). One-third reported problems with sexual response. The majority (64%)
reported a "history" of yeast infections. Over 64% of the time all
therapeutic interventions tried by patients made the vulvar symptoms no better
or worse. Approximately 55% reported another chronic health condition.
Positive physical findings were often limited to inflammation in the vestibule
(25%) and pain on palpation of the posterior vestibule (69%). Patients
reported that their vulvodynia limited their physical activities.
Conclusion: Physicians should approach management of vulvodynia using a
chronic pain model that emphasizes multidisciplinary health care and
"improvement" in health, rather than single interventions and cure
of disease.
Schmidt S, Bauer A, Greif C, Merker A, Elsner P, Strauss B
J Reprod Med.. 2001;46:377-384
Objective: To compare the psychological and quality of life profiles
of women with different subsets of vulvodynia and identify differential
response patterns to a combined gynecologic-dermatologic treatment program.
STUDY
Design: Fifty-three women with vulvar dermatoses, dysesthetic
vulvodynia and vulvar vestibulitis were recruited from a combined dermatologic
and gynecologic vulvar clinic and completed instruments related to quality of
life (QoL) and psychologic symptomatology. A repeated measurement design was
employed. However, only 33 women could be assessed at the second point of
measurement.
Results: Women with different subsets of vulvodynia showed (1) distinct
quality of life and psychological profiles, and (2) different response
patterns to treatment. There were significant differences on most QoL scales,
with patients with dysesthetic vulvodynia and with vulvar dermatoses showing
greater impairment than patients with vestibulitis. However, patients with
vestibulitis displayed a highly specific pattern of psychologic symptomatology.
Patients with vulvar dermatoses had an improvement in problems related to
intimacy than patients with vulvar pain syndromes.
Conclusion: Treatment intervention studies seem to be indispensable in
order to gain a better understanding of the complex interplay between
different subsets of vulvodynia and psychological symptoms concurrently with
differential treatment reactions.
Reed BD, Haefner HK, Punch MR, Roth RS, Gorenflo DW, Gillespie BW
J Reprod Med.. 2000;45:624-632
Objective: To determine whether women with vulvodynia differ from
women with chronic pelvic pain and normal controls in their psychological
functioning, somatic preoccupation, pain experience and sexual functioning.
STUDY
Design: Cross-sectional, self-report study of women presenting to
University of Michigan specialty and general clinics for the treatment of
vulvodynia or chronic pelvic pain or seeking a routine gynecologic
examination. All subjects completed questionnaires assessing demographic
characteristics, pain, depressive symptoms, general affective state, marital
adjustment, functional activity, somatic complaints, exposures, and medical
and sexual history. Univariate analyses, chi 2 tests, analyses of variance and
logistic regression were used to assess associations between these variables
and the diagnostic category.
Results: Women with vulvodynia (n = 31) were similar to asymptomatic
control women (n = 23) in demographic characteristics, sexual relationship
variables, sexual behaviors, current and past depression, somatic sensitivity,
and history of sexual or physical abuse. Women with chronic pelvic pain (n =
18) were younger and less educated than the other two groups and were more
likely to have a history of physical and sexual abuse, to report recent
depression and to screen positive for current depression, to have more work
absences and to have more somatic complaints.
Conclusion: Women with vulvodynia are psychologically similar to
control women but differ significantly from women with chronic pelvic pain. A
primary psychological cause of vulvodynia is not supported.
Gaitonde P, Rostron J, Longman L, Field EA
Dent Update.. 2002;29:75-76
The 'dynias' are a group of chronic focal pain syndromes with a predilection for the orocervical and urogenital regions. This is a case report of stomatodynia (burning mouth syndrome) and vulvodynia coexisting in a middle-aged woman. The dynias are an enigma in terms of aetiology, which is multifactorial, making clinical investigations difficult and often requiring liaison with other specialties.
Tschanz C, Salomon D, Skaria A, Masouye I, Vecchietti GL, Harms M
Dermatology.. 2001;202:371-372
We have observed 3 cases of vulvodynia after CO2 laser (pulse or scan) treatment of condylomata acuminata (n = 1) or bowenoid papulosis (n = 2) of the female genital mucosa. Laser treatment was associated with a considerable delay in healing (3-4 months) and chronic pain. The histology of the treated areas showed a scar tissue and severe mucosal atrophy. The occurrence of painful scars following CO2 laser treatment could be related to an inadequate laser technique considering the morphology of the vagina.
Fischer M, Marsch WC
Cutis.. 2001;67:235-238
Vulvodynia is a symptom of chronic, painful vulvar discomfort of multicausal origin. Vulvar cancer is an underestimated cause of vulvodynia. Even early stages of vulvar neoplasia can lead to aching lesions. Three cases of vulvar carcinoma eliciting persistent pain have been diagnosed within a 2-year period. In 2 of our case studies, women had antecedent periods of vulvar pruritus of long duration (5 and 20 years, respectively). We conclude that early histologic examination of all visible vulvar lesions is necessary to exclude the presence of malignant vulvar neoplasia.
Pukall CF, Payne KA, Binik YM, Khalife S
J Sex Marital Ther.. 2003;29(Suppl 1):111-120
Current approaches to the conceptualization of vulvodynia focus either on issues of sexuality or underlying pathophysiology but tend to neglect the central symptom of pain. An adequate understanding of this condition will not be achieved, however, without examining all three factors and how they interact. A multiaxial pain approach has provided data regarding the intensity, location, temporal pattern, underlying system, and sensory quality of vulvodynic pain. In addition, standardized vulvar pain measurement techniques, including a new device called a vulvalgesiometer, have been developed, making possible the collection of reliable pain ratings. To date, this approach has been promising for the differential diagnosis, classification, and understanding of vulvar pain conditions.
Stewart EG
Curr Opin Obstet Gynecol.. 2002;14:483-488
Clinical studies on the myriad benign diseases of the vulva and vagina have long been outnumbered by emphasis on other areas of obstetrics and gynecology. The complexity of vulvovaginal diseases emerges in the recent literature. As clinicians embrace available knowledge, women's health will improve. This review encompasses current developments in candida, bacterial vaginosis, lichen sclerosus and vulvodynia.
Bates CM, Timmins DJ
Int J STD AIDS.. 2002;13:210-212
Two cases are described of treatment-resistant vulvodynia that responded well to gabapentin. Gabapentin, an anti-epileptic drug, has been used in the treatment of neuropathic pain such as diabetic neuropathy and post-herpetic neuralgia. However, there has been little experience of its use in the relief of symptoms in vulvodynia and we add our observations to the one report of its use in these circumstances that has been published so far.
O'Hare PM, Sherertz EF
J Womens Health Gend Based Med.. 2000;9:565-569
Vulvodynia (vulvar burning and itching) is a symptom complex with a number of potential triggering/exacerbating factors. We reviewed the management and outcomes of 60 patients seen in a referral dermatology clinic for vulvodynia. The composite patient profile is that of a 44-year-old white woman with a 2-year history of vulvar burning who has tried multiple topical therapies. Dermatological factors in these patients included candidiasis (37%), atopy (27%), dermatographism (27%), and irritant contact dermatitis (83%). Identification of these factors and directed management led to symptomatic improvement in 72% of patients within 4 months. No patients were treated with amitriptyline. A dermatological approach to discern the contributing factors for individual patients with vulvodynia can be helpful in directing therapeutic management.
Walsh KE, Berman JR, Berman LA, Vierregger K
J Gend Specif Med.. 2002;5:21-27
Objective: To evaluate the safety and efficacy of topical
nitroglycerin cream for the treatment of vulvar pain in women with vulvodynia.
Methods: A total of 34 women diagnosed with vulvodynia were included in
this study. Patients were treated with 0.2% nitroglycerin cream in the clinic.
The cream was applied directly to the skin at the genital/vulvar area where
the pain was located. Patients who did not experience any adverse side effects
were instructed to use the cream at home at least three times per week, 5-10
minutes prior to sexual relations. Patients completed a pretreatment pain
scale at baseline and a posttreatment pain scale questionnaire 4-6 weeks
later.
Results: Twenty-one patients completed both the pre- and posttreatment
pain scale questionnaires, and 13 patients completed only the posttreatment
pain questionnaire. Thirty-one patients (91.5%) stated that
"overall" their pain had improved. Analysis of the pre- and
posttreatment questionnaires revealed a significant decrease in pain intensity
on a scale of 0 (no pain) to 5 (excruciating pain; 3.95-2.57; P < .000).
There was also a significant decrease in the frequency of overall painful
episodes on a scale of 0 (never) to 4 (always; 3.25-2.15, P < .006). All 21
patients reported "improvement" of pain during sexual activity
(3.65-2.15; P < .005).
Conclusion: Topical nitro-glycerine is safe and effective in providing
temporary relief of introital dyspareunia and vulvar pain in women with
vulvodynia. Women who completed this study experienced significant improvement
in their overall pain and pain with sexual activity after nitroglycerin use. A
larger placebo-controlled study is necessary to establish the optimum dosage
level and to minimize the side effects.
Glazer HI
J Reprod Med .. 2000;45:798-802
Objective: To determine the long-term follow-up status of
dysesthetic vulvodynia patients who were asymptomatic at the termination of
treatment using surface electromyography (sEMG)-assisted pelvic floor muscle
rehabilitation.
Study Design: A chart review of the years 1994-1996 identified 62
patients with a diagnosis of dysesthetic vulvodynia on initial evaluation and
who were asymptomatic at the termination of treatment. Forty-three of these
patients responded to a survey requesting information on their pain,
maintenance activities and treatments, daily functioning and sexual status
since treatment termination.
Results: Thirty-eight of the 43 patients (88.4%) reported experiencing
no vulvar pain since completion of treatment. Three patients reported a single
episode of pain, and two patients reported two episodes each. All five of
these patients reported the absence of any vulvar pain for a mean period of
19.8 months prior to completion of the survey. One hundred percent of the 43
dysesthetic vulvodynia patients studied reported being pain free a mean of
39.5 months after successful treatment termination. No vulvar pain-related
treatments or significant restrictions on daily activities were reported. All
patients reported sexual interest, pleasure and activity.
Conclusion: Surface electromyography-assisted pelvic floor muscle
rehabilitation is an effective and long-term cure for dysesthetic vulvodynia.
Medscape Ob/Gyn & Women's Health 8(1), 2003. © 2003 Medscape
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