New Concepts in Vulvodynia - Libby , MD (2003)

[Guest guest]

Libby (Vulvar Specialist - Charlotte, NC) gave me this handout last week, you can access it online in it's entirety at the link below. I tried to copy and paste it, but it's just too long....Hugs, Chelle Overall it's interesting and mentions many things we've discussed. http://www.urmc.rochester.edu/smd/obgyn/programs/residency/docs/Vulvodynia.pdf New concepts in vulvodynia Libby , MD Charlotte, NC Vulvodynia is chronic vulvar burning/pain without clear medical findings. The etiology of vulvodynia is unknown and health care professionals should

thoroughly rule out specific, treatable causes or factors such as dermatoses or group B Streptococcus infections. Vulvodynia is divided into 2 classes: vulvar vestibulitis syndrome is vestibule-restricted burning/pain and is elicited by touch; dysesthetic vulvodynia is burning/pain not limited to the vestibule and may occur without touch/pressure. After diagnosis, critical factors in successful patient management include education and psychological support/counseling. Unfortunately, clinical trials on potential vulvodynia therapies have been few. Standard therapy includes treating neuropathic pain (eg, tricyclic medications, gabapentin) thought to play a role. Additional therapies may be considered: pelvic floor rehabilitation combined with surface electromyography, interferon alfa, estrogen creams, and surgery. Importantly, any therapy should be accompanied by patient

education and psychological support. Because definitive data on effective therapies are lacking, further clinical investigations of treatment options are warranted. (Am J Obstet Gynecol 2003;189:S24-S30.) Key words: Vulvodynia, vulvar vestibulitis syndrome, dysesthetic vulvodynia Vulvodynia is defined as chronic vulvar burning, stinging, rawness, soreness, or pain in the absence of objective clinical or laboratory findings to explain these symptoms. Itching is absent or is a minor symptom that does not produce a need to scratch. Although believed in the past to be uncommon, vulvodynia is now recognized as a fairly frequent syndrome. Data from a population-based study funded by the National Institutes of Health (NIH) found that

15.7% of women reported lower genital tract discomfort persisting 3 months or longer.1 Its frequency is underestimated partially because some physicians dismiss this problem as psychological and relatively unimportant. Also, affected women are reluctant to discuss their symptoms, which are perceived as unusual and possibly ‘‘all in the head.’’ As vulvodynia receives increased attention by both the medical profession and the media, more women are aggressively seeking care; thus, the increased frequency of vulvodynia is being realized. Recently, the term vulvar dysesthesia has been suggested as a more appropriate designation for vulvodynia, but this new terminology has not yet been universally adopted and will not be used in this article. Etiology The etiology of vulvodynia is unknown, and there may be multiple causes of this nonspecific syndrome. Initially, psychosexual dysfunction was commonly believed to be the cause of vulvodynia.2 Chronic subclinical yeast infection was also believed to play a role,3 but clinicians have found antifungal medications to be generally inadequate for patients with undocumented yeast infections. In the 1980s, subclinical human papillomavirus infection was reported as a frequent cause of vulvodynia, primarily because normal vulvar skin can often exhibit large, clear epidermal cells that mimic koilocytes on biopsy.4,5 The advent of sophisticated testing for

human papillomavirus has demonstrated that this virus is absent in most women with vulvar pain.6,7 Recently, different causes have been implicated, including neuropathic pain, particularly complex regional pain syndrome (formerly called reflex sympathetic dystrophy), and pudendal neuralgia.8,9 The role of neuropathic pain in vulvodynia is supported by good response rates when patients are treated for neuropathic pain. Other possible causes of vulvodynia include an increase in cutaneous nerves and mast cells.10,11 Most clinicians believe that vulvodynia is not an inflammatory condition; however, there is evidence supporting the presence of increased inflammation in

patients with vulvodynia.12,13 In addition, most women with vulvodynia exhibit pelvic floor abnormalities, which may serve as causative, permissive, or aggravating factors.14,15 Interestingly, the onset of vulvodynia in some women has been preceded by laser therapy, commonly used for genital wart or malignancy removal.16 Scientists addressing pain at the recent vulvodynia workshop at the NIH (April 14 and 15, 2003) discussed other factors that may well be operative, including pain originating in the pudendal nerve, levator ani nerve, and pelvic nerves. Cross sensitization and cross-talk between 1 or more of these nerves and others may explain some aspects of

regionalized pain. Abnormalities of sensation, with amplification of sensation by altered central sensitization and increased nerve fiber generation in the presence of injury were reported as well. Information showing a pain-susceptibility gene and gender factors also was introduced. Influences by inflammogenic products from a subgroup of fibroblasts were discussed, as was referred visceral pain perhaps playing a role in the discomfort of vulvodynia. Myofascial pain as a factor in women with trigger points was discussed. Data were presented showing that estrogen can both lower the pain threshold and also be a potent mediator of peripheral nerve remodeling. In addition, information regarding pharmacologic therapy to include the use of selective serotonin reuptake inhibitor was discussed, and capsaicin as a depleter of substance P was presented. Visceral K opioid and K agonists were discussed, and there were suggestions that

combining analgesic therapies may be beneficial. In addition, the manifestation of vulvodynia may be caused by more than 1 factor and may vary in each patient.17 Although most clinicians find that depression and anxiety are common and appear to exacerbate vulvodynia, clinical studies do not support psychosexual dysfunction as a cause for vulvodynia, and patients do not have a higher-than-background incidence of childhood sexual or physical abuse.18, 19 However, interstitial cystitis, headaches, fibromyalgia, and irritable bowel syndrome are overrepresented in women with vulvodynia, and depression is commonly present, worsening a patient's symptoms.2 The clinical management of vulvodynia should begin with a careful examination to rule out skin disease and infection as causes of vulvar burning or pain (Table 1). These conditions can sometimes be mistaken for vulvodynia, particularly when the

abnormality is limited to the vagina. Diagnosis Before the diagnosis of vulvodynia can be made, specific causes of burning and irritation must be ruled out. Infection, particularly that caused by Candida albicans, is often the first working diagnosis. However, itching is the predominant symptoms in C albicans infections with secondary pain and rawness. Burning, soreness, rawness, and irritation are common with yeast infections caused by C glabrata, C parapsilosis, C krusei, and Saccharomyces cerevisiae. A vaginal fungal culture may be required because these organisms can be difficult to detect with only microscopic analysis of vaginal secretions. In contrast to C albicans, most other yeast infections do not produce pseudohyphae or hyphae in the vagina, but

only small, budding yeasts. Also, these types yeast infections are often resistant to therapy, so a lack of improvement with antifungal therapy does not rule out a role for yeasts in vulvodynia. The identification of yeast does not ensure that the cause of symptoms has been identified, but women with chronic symptoms deserve treatment in case their symptoms are related. In addition to a fungal culture, a routine vaginal culture is indicated for any patient with unexplained, chronic vulvovaginal symptoms. Although nonpathogens that do not benefit from treatment are occasionally identified, an occasional patient exhibits a heavy growth of group B Streptococcus. Although group B Streptococcus (ie, S agalactiae) are usually asymtomatic colonizers in the vagina, many clinicans believe that they occasionally produce vulvar burning or irritation.20, 21 Patients who

test positive for group B Streptococcus may benefit from penicillin administration. For the rest of the article....go to: http://www.urmc.rochester.edu/smd/obgyn/programs/residency/docs/Vulvodynia.pdf

[Guest guest]

Thank you for this article, I am going to give it to my GYN in Mt. Sharon

New Concepts in Vulvodynia - Libby , MD (2003)

Libby (Vulvar Specialist - Charlotte, NC) gave me this handout last week, you can access it online in it's entirety at the link below. I tried to copy and paste it, but it's just too long....Hugs, Chelle

Overall it's interesting and mentions many things we've discussed.

http://www.urmc.rochester.edu/smd/obgyn/programs/residency/docs/Vulvodynia.pdf

New concepts in vulvodynia

Libby , MD

Charlotte, NC

Vulvodynia is chronic vulvar burning/pain without clear medical findings. The etiology of vulvodynia is unknown and health care professionals should thoroughly rule out specific, treatable causes or factors such as dermatoses or group B

Streptococcus infections. Vulvodynia is divided into 2 classes: vulvar vestibulitis syndrome is vestibule-restricted burning/pain and is elicited by touch; dysesthetic vulvodynia is burning/pain not limited to the vestibule and may occur without touch/pressure. After diagnosis, critical factors in successful patient management include education and psychological support/counseling. Unfortunately, clinical trials on potential vulvodynia therapies have been few. Standard therapy includes treating neuropathic pain (eg, tricyclic medications, gabapentin) thought to play a role. Additional therapies may be considered: pelvic floor

rehabilitation combined with surface electromyography, interferon alfa, estrogen creams, and surgery. Importantly, any therapy should be accompanied by patient education and psychological support. Because definitive data on effective therapies are lacking, further clinical investigations of treatment options are warranted. (Am J Obstet Gynecol 2003;189:S24-S30.)

Key words:

Vulvodynia, vulvar vestibulitis syndrome, dysesthetic vulvodynia

Vulvodynia is defined as chronic vulvar burning, stinging, rawness, soreness, or pain in the absence of objective clinical or laboratory findings to explain these symptoms. Itching is absent or is a minor symptom that does not produce a need to scratch. Although believed in

the past to be uncommon, vulvodynia is now recognized as a fairly frequent syndrome. Data from a population-based study funded by the National Institutes of Health (NIH)

found that 15.7% of women reported lower genital tract discomfort persisting 3 months or longer.

1 Its frequency is underestimated partially because some physicians dismiss this problem as psychological and relatively unimportant. Also, affected women are reluctant to discuss their symptoms, which are perceived as unusual and possibly ‘‘all in the head.’’ As vulvodynia receives increased attention by both the medical profession and the media,

more women are aggressively seeking care; thus, the increased frequency of vulvodynia is being realized. Recently, the term vulvar dysesthesia has been suggested

as a more appropriate designation for vulvodynia, but this new terminology has not yet been universally adopted and will not be used in this article.

Etiology

The etiology of vulvodynia is unknown, and there may be multiple causes of this nonspecific syndrome. Initially, psychosexual dysfunction was commonly believed to be the cause of vulvodynia.

2 Chronic subclinical yeast infection was also believed to play a role,3 but clinicians have found antifungal medications to be generally inadequate for patients with undocumented yeast infections. In the 1980s, subclinical human papillomavirus infection was reported as a frequent cause of vulvodynia, primarily because normal vulvar skin can often exhibit large, clear epidermal cells that mimic koilocytes on biopsy.4,5 The advent of sophisticated testing for human papillomavirus has demonstrated that this virus is absent in most women with vulvar pain.6,7

Recently, different causes have been implicated,

including neuropathic pain, particularly complex regional pain syndrome (formerly called reflex sympathetic dystrophy), and pudendal neuralgia.

8,9 The role of neuropathic pain in vulvodynia is supported by good response rates when patients are treated for neuropathic pain. Other possible causes of vulvodynia include an increase in cutaneous nerves and mast cells.

10,11 Most clinicians believe that vulvodynia is not an inflammatory condition; however, there is evidence supporting the presence of increased inflammation in patients with vulvodynia.

12,13 In addition, most women with vulvodynia exhibit pelvic floor abnormalities, which may serve as causative, permissive, or aggravating factors.14,15 Interestingly, the onset of vulvodynia in some women has been preceded by laser therapy, commonly used for genital wart or malignancy removal.

16

Scientists addressing pain at the recent vulvodynia workshop at the NIH (April 14 and 15, 2003) discussed other factors that may well be operative, including pain originating in the pudendal nerve, levator ani nerve, and pelvic nerves. Cross sensitization and cross-talk between 1 or more of these nerves and others may explain some aspects of regionalized pain. Abnormalities of sensation, with amplification of sensation by altered central sensitization and increased nerve fiber generation in the presence of injury were reported as well. Information showing a pain-susceptibility gene and gender factors also was introduced. Influences by inflammogenic products from a subgroup of fibroblasts were discussed, as was referred visceral pain perhaps playing a role in the discomfort of vulvodynia. Myofascial pain as a factor in women with trigger points was discussed. Data were presented showing that estrogen can both lower the pain threshold and also be a potent mediator of peripheral nerve remodeling. In addition, information regarding pharmacologic therapy to include the use of selective serotonin reuptake inhibitor was discussed, and capsaicin as a depleter of substance P was presented. Visceral K opioid and K agonists were discussed, and there were suggestions that combining analgesic therapies may be beneficial.

In addition, the manifestation of vulvodynia may be caused by more than 1 factor and may vary in each patient.17 Although most clinicians find that depression and anxiety are common and appear to exacerbate vulvodynia, clinical studies do not support psychosexual dysfunction as a cause for vulvodynia, and patients do not have a higher-than-background incidence of childhood sexual or physical abuse.18, 19 However, interstitial cystitis, headaches, fibromyalgia, and irritable bowel syndrome are overrepresented in women with vulvodynia, and depression is commonly present, worsening a patient's symptoms.2 The clinical management of vulvodynia should begin with a careful examination to rule out skin disease and infection as causes of vulvar burning or pain (Table 1). These conditions can sometimes be mistaken for vulvodynia, particularly when the abnormality is limited to the vagina.

Diagnosis

Before the diagnosis of vulvodynia can be made, specific causes of burning and irritation must be ruled out. Infection, particularly that caused by Candida albicans, is often the first working diagnosis. However, itching is the predominant symptoms in C albicans infections with secondary pain and rawness. Burning, soreness, rawness, and irritation are common with yeast infections caused by C glabrata, C parapsilosis, C krusei, and Saccharomyces cerevisiae. A vaginal fungal culture may be required because these organisms can be difficult to detect with only microscopic analysis of vaginal secretions. In contrast to C albicans, most other yeast infections do not produce pseudohyphae or hyphae in the vagina, but only small, budding yeasts. Also, these types yeast infections are often resistant to therapy, so a lack of improvement with antifungal therapy does not rule out a role for yeasts in vulvodynia. The identification of yeast does not ensure that the cause of symptoms has been identified, but women with chronic symptoms deserve treatment in case their symptoms are related.

In addition to a fungal culture, a routine vaginal culture is indicated for any patient with unexplained, chronic vulvovaginal symptoms. Although nonpathogens that do not benefit from treatment are occasionally identified, an occasional patient exhibits a heavy growth of group B Streptococcus. Although group B Streptococcus (ie, S agalactiae) are usually asymtomatic colonizers in the vagina, many clinicans believe that they occasionally produce vulvar burning or irritation.20, 21 Patients who test positive for group B Streptococcus may benefit from penicillin administration.

For the rest of the article....go to:

http://www.urmc.rochester.edu/smd/obgyn/programs/residency/docs/Vulvodynia.pdf

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