Chelle/New Concepts in Vulvodynia - Libby , MD (2003)

[Guest guest]

Chelle, that is an excellent article!! I would like take it to

my new doctor, but don’t know her well enough to know if she would be insulted.

That article is a pdf file and you can save it and put it in our permanent VPD files.

It has excellent information in it!

nne

From:

VulvarDisorders [mailto:VulvarDisorders ] On

Behalf Of Chelle

Sent: Tuesday, April 08, 2008 12:19 AM

To: Vulvardisorders

Subject: 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