VESTIBULODYNIA. by Dr.

[Guest guest]

HI Chelle , just ran across this in my 'stuff' , it's kinda neat finding things I haven't seen in a while.*smile* Sorry no link as it was a fee charged one so it's long be forewarned. If it is truncated and you don't see it all, let me know and I'll send it privately.

Hope it helps hon,

Dee

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The Vestibulodynia term, formerly vestitbulitis, is a term Dr. E. uses (she calls it VBY) and I know the term was approved by the ISSVD.Here's one line from their previous definition (I'm assuming) at: http://www.issvd.org/VulvarPain.pdf (from an article (PDF file) on what is Vulvar Pain) Localized Vulvodynia (vestibulitis) is pain that is caused by something touching the vestibule. Generalized vulvodynia is pain and burning on or around the vulva (large and small lips as well as, at times, the vestibule). The area hurts most of the time, even when nothing is touching it.I'm also adding Dr. Eliz.G.s article here on Vestibulodynia for info (it's long) *of course* Believe me I'd love to just pass on the URL but it was from a fee charged site and it's been expired for me and far too much $ for me to rejoin it. *sigh* Vulvar pain syndromes: Vestibulodynia, formerly Vestibulitis Gunther , MDRecommendations - My recommendations for treating women with VBY (Vestibulodynia) include:a.. Education and support.a.. Elimination of all irritants.a.. Healthy vulvar hygiene and comfort measures.a.. Daily topical estrogen cream to the vestibule. I tell patients to discard the vaginal applicator, place 1/4 teaspoon of the cream on their fingertip, and apply to the vestibule at bedtime on an ongoing basis.a.. Physical therapy to the pelvic floor with biofeedback.a.. A tricyclic antidepressant (eg, nortriptyline, starting at 10 mg HS and increasing by 10 mg HS every five days to 50 mg HS. A maximum dose of 100 to 150 mg per day may be tried before deciding on lack of efficacy.a.. Topical xylocaine (5 percent in a neutral base) to the vestibule ten minutes before intercourse, if desired, and after intercourse, if necessary.

Criteria for vestibulodynia (VBY) include: severe pain upon vestibular touch or attempted vaginal entry, tenderness to pressure localized within the vulvar vestibule, and physical findings limited to vestibular erythema. These features are chronic, typically of at least three to six months duration and lasting years. The diagnosis should not be made in women complaining of vestibular pain of only a few weeks' duration.VBY can be primary or secondary. Primary VBY refers to introital dyspareunia dating from initiation of sexual activity or (among women who have never been sexually active) intolerable pain consistently present upon insertion of a tampon or vaginal speculum. Secondary VBY describes women who have introital dyspareunia that develops after a period of comfortable sexual relations, tampon use, or speculum examinations. There are no unique histological findings in primary versus secondary disease. However, the difference in clinical history suggests the possibility of separate etiologies.INCIDENCE AND EPIDEMIOLOGY - The incidence of VBY is unknown, but the disease is not uncommon. One British study, for example, found the prevalence of VBY was 1 to 3 percent among 150 consecutive new female patients attending a walk-in genitourinary medicine clinic. In an American series, 18.5 percent of women reported evoked or unevoked pain in the genitals persisting longer than three months.Most women with VBY are white, young (mean age 32 years), and nulliparous.

(meaning a woman who's never given birth, DT) Disease prevalence is not related to socioeconomic level.HISTOLOGY AND PATHOGENESIS - Inflammation of the minor vestibular glands was originally considered a pathologic finding; however, the same nonspecific inflammatory infiltrate has now been demonstrated in 'healthy' vestibular tissue.The ducts of the vestibular glands contain intraepithelial axons that are closely applied to serotonin-containing neuroendocrine cells. Substance P immunoreactive axons have also been found in submucosal nerves of the vestibule and in the duct epithelium . Both serotonin and substance P are inflammatory mediators that may be the source of neurogenic inflammation operant in vestibular pain.(See "Pain theory" below). For example, a study comparing biopsies from 32 women with vestibulitis to 30 normal controls demonstrated complement along the dermoepithelial junction, perivascular IgM, and fibrinogen. The authors proposed that vascular injury leading to fibrinogen leakage, antigenic stimulation of IgM, and leakage of other tissue injury products that activate the complement cascade was mediated by altered central neuronal processing initiated by release of vasodilatory substance P from C fibers of the vestibule.In another study, moderate to severe inflammation in tissue sections from women with VBY was associated with an increase in the number of neuroendocrine cells expressing serotonin and CXCR2, the shared interleukin-8 receptor. The inflammatory cytokines, interleukin-1b and tumor necrosis factor-a, have also been found to be elevated in women with VBY.ETIOLOGY - No single agent or factor can be held responsible for the majority of cases of VBY, which is best categorized as a chronic pain syndrome of unknown etiology . However, several risk factors and associations have been observed.Infection - A history of vulvovaginal candidiasis (yeast infection) is the single most consistently reported feature reported by women with VBY. Candida has been proposed as a 'causative' organism , but the presence of yeast has not been found to be more prevalent in patients with VBY than in asymptomatic women and antifungal treatment usually failed to relieve VBY and may aggravate symptoms. An autoimmune association between Candida and VBY has also been proposed, although not documented. Human papillomavirus and other sexually transmitted diseases do 'not' appear related to VBY.Hyperoxaluria - Excessive urinary oxalate excretion has been proposed as an etiology of vulvar pain, based upon a case report of only one patient in whom complete remission of symptoms occurred with a low oxalate diet and use of calcium citrate (see "Diet" below). The low-oxalate diet and treatment with calcium citrate (to bind the oxalate) has been strongly endorsed by many women with VBY and VDY; however, a controlled study of urinary oxalate excretion did 'not' show differences in women with and without pain. By comparison, in another series 14 percent of women with pain improved with a low oxalate diet and calcium citrate. It is a slight possibility that oxalate acts as an irritant to aggravate ongoing pain of VBY, but is not a primary cause of VBY.Allergy - (Mast cells/ cromolyn) Levels of IgE consistent with vaginal allergy have been detected in vaginal fluid of women with VBY, but treatment with antihistamines has not been effective .

(COMMENT: I'd disagree with that as it can offer some relief if not major help or a cure. Dee T) Mast cells have also been noted in biopsy specimens from women with VBY. A double-blind, randomized study showed no reduction in pain in women with VBY taking cromolyn compared to those administered placebo.Gene polymorphism - Homozygosity of allele 2 of the gene encoding the interleukin 1 receptor antagonist occurs in just over fifty percent of women with VBY. This suggests polymorphism in this gene may be a factor influencing susceptibility to VBY, severity of symptoms, or both [30].Hormones - Many women complain their pain is worse around the time of menses [31,32], while others only obtain pain relief during their menstrual periods. One study linked oral contraceptive pill (OCP) use, especially in women under age 17, to an increased risk of vestibular pain [33].

(COMMENT..They know today that the OC Pill can trigger V pain in in a large number of women, Dee T) However, this may represent a marker for early age of first sexual intercourse, which is also a risk factor for VBY. Current OCP use and duration of use are not significant factors. Both normal and low serum estrogen levels have been found in women with VBY. There are many 'numerous' anecdotal reports of efficacy of topical estrogen for relief of vestibular pain.A strong association of VBY with the postpartum period has been reported. Thirty-nine percent of women delivering first or second babies developed nonfocal introital dyspareunia (median duration 5.5 months) and cesarean delivery was not protective.Somatization - A psychiatric basis for vulvar pain should be a diagnosis of exclusion . There is no definitive evidence for a causal relationship between VBY and psychological problems, childhood sexual or physical abuse, or partners with psychosexual abnormalities .Pain that interferes with sexual functioning is a cause of secondary depression in women . A study of women suffering from VBY found these women had more bodily complaints than unaffected controls, and considered this an indication of a psychosomatic component to their illness . However, another controlled study did not report differences in nongenital aches and pains between women affected and unaffected with VBY.Disorders of the pelvic floor - Muscles of the pelvic floor may be destabilized, either from cutaneous vulvar disturbances or from joint abnormalities of the spine or pelvis. This destabilization perpetuates vulvar tissue inflammation by its effects on local autonomic (sympathetic) mediated activity, leading to vascular changes and histamine release. Patients with VBY demonstrate muscular instability at rest, poor muscle recovery, elevated resting baseline tension, reduced muscle activity, and reduced contraction strength. A protocol of internal and external soft tissue mobilization, internal and external therapeutic exercise, and pelvic floor retraining with biofeedback results in improvement in women who have evidence of such muscle dysfunction.Interstitial cystitis - Interstitial cystitis (IC) refers to a syndrome of urinary frequency, nocturia, hypogastric pain, bladder tenderness on palpation, and negative urine cultures. It is as poorly understood as VBY. Diagnostic criteria include a history of frequency, nocturia and dyspareunia, with bladder and urethral tenderness on bimanual examination. A small number of cases of IC associated with VBY have been reported. The epidermis of the vestibule, bladder mucosa, and urethra share a common embryological derivation from the urogenital sinus. Neural hyperplasia noted in VBY is also found in biopsies from women with IC. However, defects in the urogenital epithelium of the bladder of patients with IC detected by special staining could not be found in patients with VBY.Pain theory - A chronic inflammatory condition from one of a variety of insults in the mucous membrane of the vestibule may ultimately result in inflammatory or nociceptive pain.The sensory innervation of the posterior vulva is from branches of the pudendal nerve; the anterior vulva is supplied by branches of the ilioinguinal nerve and the genital branch of the genitofemoral nerve. These nerve fibers consist of two types:a.. Type A-beta fibers, which are responsible for touch b.. Type C fibers, which mediate perception of noxious stimuli (nociception).In addition, the vulva has an autonomic nerve supply via the hypogastric plexus located in the pararectal tissue. Sympathetic innervation comes via the hypogastric nerve and parasympathetic input comes from the pelvic nerve. Interactive neuronal pathways from higher origins in the brain have been identified, but need further elucidation.Inflammatory mediators are released in tissue with chronic inflammation and are elevated in women with VBY compared to asymptomatic controls. These chemical intermediates (eg, interleukin-1b, tumor necrosis factor, serotonin, bradykinin, histamine, sensitize C fibers which are normally subresponsive to mechanical stimulation. In addition, the synthesis of sensory neuropeptides (eg, calcitonin gene-related peptide (CGRP) and substance P) from the activated C fibers is increased during inflammation. These substances have proinflammatory effects and reinforce the inflammatory response in affected tissue. The cytokines may not be the final common pathway to hyperalgesia, instead they may act on the unique neural organization of the vestibule secondarily through the release of neurokinins such as substance P.Prolonged firing of C fibers in the vestibule results in hyperalgesia. In addition to these events in the vestibule, transport of CGRP and substance P to the dorsal horn of the spinal cord sensitizes central neurons in the cord. These sensitized wide-dynamic range (WDR) neurons then respond to light touch on the vulva by passing through the large myelinated A-fiber mechanoreceptors to the cord; they change the signal sent to the brain from one of light touch to one of pain (allodynia). Eventually, spontaneous signals arising in the dorsal horn can pass by the sympathetic efferent nerves to the A-fiber mechanoreceptors. Continuous stimulation of the A-fiber mechanoreceptors and misreading by the WDR neurons results in continuous burning or pain in the vulva.In summary, sensitization of vestibular type C nerve fibers occurs by insults that vary from woman to woman. Ongoing release of cytokines and neurokines leads to prolonged neuronal firing that sensitizes the WDR neurons in the dorsal horn to respond abnormally so that the sensation of touch is transformed into that of pain (allodynia).This theory is supported by two studies that have shown a significant increase in the number of intraepithelial nerve endings in women with VBY compared to controls. Neurochemical characterization of these nerve fibers revealed only calcitonin gene-related peptide, known to exist in nociceptive afferent nerves, suggesting that the free nerve endings within the epithelium were nociceptors . A statistically significant linear correlation was found between inflammation and nerve bundle density.In addition, women with VBY have increased superficial blood flow and erythema in the posterior vestibule, most probably caused by neurogenic inflammation. Quantitative sensory testing in these women showed allodynia to mechanical testing with von Frey filaments, a lower pain threshold to heat, and a higher threshold to cold compared to controls. These findings support the hypothesis that women with VBY have increased innervation and/or sensitization of thermoreceptors and nociceptors in the vestibular mucosa.CLINICAL MANIFESTATIONS - VBY is asymptomatic (no symptoms or pain) unless the vestibule is touched. All women with VBY have introital pain with attempted intercourse; both thermal and incisive pressure type pain have been described and constitute the major feature of this syndrome. In one study over one-third of the patients had constant burning in the vestibule, three-quarters had excessive vaginal discharge, and ten percent had chronic urinary tract symptoms. Other complaints include discomfort with insertion of a tampon or speculum, tight clothing (eg, pants with a prominent inseam), washing or wiping the vestibule, sitting, biking, or horseback riding.Pelvic pain and deep dyspareunia are not features of VBY, but may occur if interstitial cystitis or endometriosis is also present. Some women experience constant irritative symptoms often misinterpreted as Candidal infection. Longstanding VBY may result in chronic burning in the vestibule misinterpreted as vaginal burning by women who are unfamiliar with the vestibule.DIAGNOSISHistory - Diagnosis of primary VBY can often be made by history alone: dyspareunia with first attempt at sexual activity or inability to use a tampon or tolerate a vaginal speculum. Secondary vestibulitis, developing after a period of comfortable sexual relations or vaginal procedures, may appear after childbirth, repeated infection, long-term dermatosis, or treatment of the vestibule with laser or chemicals.A sexual history is essential to confirm that the relationship is loving and not abusive and that sexual technique is adequate. Nonreceptive and unlubricated intercourse could cause VBY. Symptoms suggestive of VBY are listed in Table 1. TABLE 1 PATIENTS COMMENTS THAT SHOULD RAISE SUSPICION OF VESTIBULODYNIAa.. I can't use tampons because they hurt.b.. You need to use your smallest speculum when you examine mec.. My last doctor told me to relax mored.. I always have a yeast infection, but therapy doesn't help.e.. My episiotomy stitches and area still hurts.f.. I'm too tight down there.g.. Sex has been painful since menopauseAssociated symptoms -

Associated symptoms include urinary frequency, urethral or bladder burning, and a history of frequent urinary tract infections with negative cultures. Common diagnoses are trigonitis, chronic cystitis, interstitial cystitis, and urethral syndrome. Irritable bowel syndrome, fibromyalgia, migraines, depression, chronic fatigue syndrome, temporomandibular joint syndrome, and endometriosis are pain conditions that may be associated with VBY.Physical examination - The vulva should be evaluated to confirm normal architecture and exclude dermatoses or other medical conditions. The mouth and skin should also be checked for lesions suggesting lichen sclerosus or lichen planus. Palpation over the labia and perineum and in the interlabial folds is performed to determine if tender areas exist outside the vestibule. With the labia minora gently parted, the examiner uses a moist cotton-tipped applicator to discern whether there is pain with pressure at one or more points around the vestibule.Such tenderness is easily overlooked in general gynecology evaluations without careful exposure and Q-tip evaluation of the vestibule.Erythema is often present and can be diffuse, in patches, or focal red spots near the minor vestibular gland openings. Fissuring, especially posteriorly at the 6 o'clock location, may occur. However, the mucosa may also appear normal.A bimanual exam will confirm that the examining hand does not elicit vaginal, cervical, or pelvic tenderness after it passes beyond the vestibule. If there is tenderness over the bladder or upon palpation through the anterior vaginal wall, interstitial cystitis is a consideration.Laboratory - A vaginal pH, wet mount, and yeast culture should be performed to exclude vaginitis. Excessive discharge that is normal by microscopy may represent altered neural control of vestibular gland secretions. Paradoxically, women with VBY complain of and have excessive vaginal discharge, but may feel extremely dry. Herpes, gonorrhea, and chlamydia cultures should be obtained if appropriate.Colposcopy is helpful in evaluation of the vulva for possible abnormality of the epidermis, but is not routinely used. Acetic acid (vinegar wash)significantly worsens vulvar pain.DIFFERENTIAL DIAGNOSIS - Differentiating Candida from VBY is problematic since both can produce irritative symptoms and tenderness in the vestibule. Yeast must be excluded by examining the woman when she has maximum symptoms, which have not been treated by oral or topical antifungals in the preceding two weeks, and by obtaining a yeast culture on Sabaraud's medium. If a woman has had repeated yeast infections, her inflammatory symptoms will require at least six to eight weeks of antifungal suppression (eg, fluconazole 150 mg PO weekly) before regressing. Persistent dyspareunia with a negative Sabaraud's culture after appropriate antifungal suppression suggests VBY. PCR testing could be a helpful adjunct to yeast cultures. (See "Overview of vaginitis" section on Candida vulvovaginitis).Dermatoses involving the vestibule can account for significant dyspareunia. Lichen sclerosus and lichen planus cause well described lesions, synechiae, and introital narrowing contributing to dyspareunia. Biopsy may be necessary. If the dermatoses are controlled by ultrapotent topical steroids, ongoing vestibular tenderness may represent VBY.

TREATMENT - The huge sense of relief from having a concrete diagnosis cannot be underestimated. Confirmation that the pain is real and the condition is not malignant or communicable is also reassuring. Provision of accurate informational handouts is important. Both vulvar pain societies, the National Vulvodynia Association and the Vulvar Pain Foundation, have newsletters, outreach for women, and Web sites . Couples and sexual counseling are valuable, but are limited until the pain is controlled. Open communication between partners and pursuing alternatives to vaginal sex can be encouraged.Treatment of VBY is largely anecdotal. Currently available therapeutic strategies can be frustrating for both the patient and the physician because they require time and effort from both parties to achieve improvement. Successful therapy often necessitates more than one type of therapeutic intervention, and there are patients who do not respond to any modality.Vulvar care - Attention to vulvar care is essential. Scents, dyes, chemicals, or contactants of any sort should be avoided. Clothing should be comfortable, loose, and cotton. Abrasive activities, such as biking, should be eliminated. Daily use of mini-pads must be curtailed; instead women can change their underwear as often as necessary if secretions are a problem.Hydration through sitz baths in comfortable warm water is a mainstay of any vulvar care regimen. If sexual intercourse is possible, a lubricant is advised. Since many women react to preservatives in commercial products, a small dab of vegetable oil is helpful. Crushed ice or small frozen foods (eg, peas, corn) in a plastic bag or a condom with the end tied shut mold nicely to vulvar anatomy and provide significant relief of burning in the vestibule or post-coital soreness.Diet - It is reasonable to have a trial of eliminating foods high in oxalate (show table 2) based upon anecdotal evidence, although this has not been supported in controlled studies. Removing all dietary oxalate is difficult and unhealthy since it is contained in many fruits, vegetables, and grains.Drugs - Topical steroids, anti-inflammatory agents, topical testosterone or estrogen, antibiotics, antimycotics, and retinoid compounds have not been that effective in the majority of cases but have helped some patients. Topical anesthetics such as 5 percent xylocaine may afford temporary relief and permit intercourse for some women. In the gel or cream form anesthetics may be irritating; they can be given as an ointment or compounded in a neutral base. Capsaicin, the active irritant in hot peppers, has been tried in a number of studies, but has not been widely successful.A preliminary study treated 22 women with VBY by submucous infiltration of a 1 mL solution of methylprednisolone acetate (MA) (40 mg) and lidocaine cloridrate (LC) (10 mg in saline) into the vulvar vestibule. The volume of injection was 1 mL on day 1 (ie, MA 40 mg, LC 10 mg), 0.5 mL on day 8 (ie, MA 20 mg, LC 5 mg), and 0.3 mL (ie, MA 12 mg, LC 3 mL) on day 15 using a 26 gauge needle attached to a 2.5 mL syringe. Seven women had complete remission of symptoms, eight had marked improvement, and seven had no improvement over nine months. It is important to massage the tissue into which the drug is injected to avoid precipitation of drug.Tricyclic antidepressants also can be useful when taken in combination with other therapies. British dermatologists, for example, found that 75 percent of women who avoided irritants and used bland topical emollients, topical anesthetics, and tricyclic antidepressants improved within two years . In addition, researchers from France and Australia reported a 60 to 70 percent response with amitriptyline.Nortriptyline (starting at 10 mg TID and increasing by 10 mg every five days to 50 mg TID to a maximum dose of 100 to 150 mg per day) is the least sedating tricyclic and has the fewest anti-cholinergic side effects (dry mouth, constipation, sweating, palpitations). If one tricyclic is not helpful, other members of the family (desipramine, imipramine, doxepin, amitriptyline) may work. However, tricyclics take weeks to have an effect. A common reason for failure is an inadequate dosage for a short period. Three months of 100 to 150 mg without improvement would prompt moving to another agent.Anticonvulsants can be tried in women who fail tricyclics. Carbamazepine and dilantin are helpful, but require monitoring of drug levels. These tests can be avoided with the use of Gabapentin or Neurontin (100 mg HS, increasing by 100 mg every two days to 3 g in divided doses). Neurontin does not have the anti-cholinergic side effects of the tricyclics and is popular for its low side effect profile, although it may produce sedation (transient), dizziness, and ataxia. Side effects may be prevented by low doses initially with gradual increases. Interferon - Interferon injected into the vestibule was proposed for treatment of VBY when HPV was thought to be the etiology. Subsequently, it was noted that some, but not all, women with VBY have a deficiency in interferon alpha production . This subpopulation of affected women theoretically may be responsive to this treatment.Interferon therapy has yielded mixed results. An early study reporting 88 percent success has not been duplicated. Subsequent series found that interferon produced a 49 percent response in women with and without a histologic diagnosis of HPV. My experience with interferon has been unimpressive.I continue to offer it (interferon alpha 2b 1 million units subcutaneously three times per week into the vestibule) to women since there are few options, but my results are little better than placebo.Surgery - Surgical treatment is a highly controversial area, particularly in view of the unknown etiology of VBY. Modified vestibulectomy, which is removal of a horseshoe shaped area of the vestibule with advancement of the posterior vagina onto the perineum creating a cushion of thick squamous epithelium to facilitate intercourse, has yielded the best results. Postoperative complications are uncommon, but may include dehiscence, hematoma, infection, uneven healing, or nodular excrescences along the suture line requiring additional procedures. Stenosis of Bartholin's duct may lead to cyst formation.The outcome of surgery in properly selected women (ie, those who have pain only in the vestibule) is complete or partial remission in 60 and 16 percent, respectively . Post-operative sex therapy increases surgical success rates.A simplified surgical approach to VBY involves excision limited to the tender areas of the vestibule. In one study using this technique, ten of twelve patients had complete resolution and two others had improvement of pain.The procedure can be done in the office under local anesthesia.Carbon dioxide laser vaporization of the vestibule is 'not' recommended because healing is prolonged and complications include scarring and further pain. The Candela laser has also been used, but is not widely available.Recommendations - My recommendations for treating women with VBY include:a.. Education and support.a.. Elimination of all irritants.a.. Healthy vulvar hygiene and comfort measures. a.. Daily topical estrogen cream to the vestibule. I tell patients to discard the vaginal applicator, place 1/4 teaspoon of the cream on their fingertip, and apply to the vestibule at bedtime on an ongoing basis.a.. Physical therapy to the pelvic floor with biofeedback.a.. A tricyclic antidepressant (eg, nortriptyline, starting at 10 mg HS and increasing by 10 mg HS every five days to 50 mg HS. A maximum dose of 100 to 150 mg per day may be tried before deciding on lack of efficacy.a.. Topical xylocaine (5 percent in a neutral base) to the vestibule ten minutes before intercourse, if desired, and after intercourse, if necessary.

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