DR. RICHARD MARVEL 'article'

[Guest guest]

HI C... Yes I've heard of Dr. Marvel hon. Here's just one of his articles. No personal idea though. I thought it was well done for differentiation of various types of V. pain.

Hope you find some good information that might fit 'you'. (Forgive my own markings, when I save something I highlight all over the place (like I do my books) *smile*

Dee~

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If It’s Not Vulvar Vestibulitis,

What Is It?

By Marvel, M.D.

Dr. Marvel is an Assistant Professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of land in Baltimore.

Vulvar vestibulitis syndrome (VVS), a subset of vulvodynia, is a chronic vulvar pain condition associated with dyspareunia (painful sexual intercourse).

This syndrome has been described for more than 100 years, beginning with a publication by Skene (1889) entitled, "Treatise on the Diseases of Women." The first modern U.S. publication on VVS by Woodruff and Parmley (1983) referred to the condition as "infection of the minor vestibular glands."

The term vulvar vestibulitis was coined by Friedrich (1987) who established three criteria based on his observations of 87 patients. According to this definition, women should be diagnosed with VVS when they present with:

1) severe pain on vestibular touch or attempted vaginal entry;

2) tenderness to pressure localized within the vulvar vestibule and

3) physical findings confined to vestibular erythema redness of varying degrees.

The evaluation of patients with vulvar pain and dyspareunia requires careful investigation to rule out other causes for the pain, localized tenderness and erythema. If additional physical findings or treatable conditions exist, this precludes a diagnosis of VVS.

The differential diagnosis is extensive and requires taking a thorough history as well as performing a physical examination and laboratorytests.

Vulvovaginal disorders that produce 'similar symptoms' to those associated with VVS can be divided into several categories including

infection,

dermatoses,

dermatitis,

iatrogenic (treatment-induced) conditions,

atrophy, and

dysesthetic vulvodynia.

'Infection'One of the most common vulvovaginal disorders is yeast infection, characterized by itching, burning, and a thick white discharge.

Recurrent yeast infection, which may be an initiating factor for VVS, should be ruled out by careful wet mount evaluation (KOH preparation), as well as culture.

A culture is important for several reasons: 1) the sensitivity of a wet mount, i.e., the likelihood of seeing yeast organisms when present, is only 70% percent;

2) 'non-candidal' albican yeasts are difficult to identify microscopically; and

3) 'non-candidal' yeasts are less likely to respond to common yeast treatments.

If identified, recurrent yeast infections usually respond to appropriate anti-fungal treatment, although a prolonged course of therapy may be required. A regimen that I have found successful in about 50 percent of women with recurrent yeast infection is 'Diflucan 100-200 mg weekly for 3-4 months'.

'Cyclic vulvovaginitis',

A similar, possibly identical syndrome to recurrent yeast infection, has been described by Dr. Marilynne McKay.

Patients experience entry dyspareunia, vestibular burning, itching, irritation and aching after intercourse. The symptoms are usually cyclic, i.e., they wax and wane. Cyclic vulvovaginitis is believed to be due to subclinical candidal infection and, likewise, responds to 100-200 mg of Diflucan weekly for 4-6 months.

I usually treat patients for 4 months and then wean the dosage to once a month as a prophylactic regimen to prevent recurrence of symptoms.

A bacterial infection that may be confused with VVS is cytolytic vaginosis. In this condition there is an overgrowth of the normal lactobacilli of the vagina. This leads to an overproduction of hydrogen peroxide resulting in a burning discomfort and pain with intercourse.

History reveals a cyclic pattern–symptoms are usually most significant in the luteal phase of the menstrual cycle and relieved by menses. A wet mount reveals no pathogenic organisms, an increase in the normal bacteria, cellular debris, and naked nuclei from epithelial cells.

The symptoms can be easily controlled with one or two douches in the second half of the menstrual cycle using 1 teaspoon of baking soda dissolved in one quart of water.

Cytolytic vaginosis, cyclic vulvovaginitis and recurrent yeast infection must be ruled out before a patient is diagnosed with VVS.

Other common vaginal infections should be excluded as well, but they are generally acute conditions and tend not to be confused with VVS.'Dermatoses'

There are several dermatologic conditions that can cause symptoms similar to those of VVS. 'Lichen sclerosus' is a common skin disease that can affect the vulva and produce symptoms of itching and burning. The disorder causes visible skin changes with thickening or sometimes thinning of the skin of the vestibule, vulva, perineum and perianal skin.

Lichen sclerosus usually presents as thin, white parchment-like skin with wrinkling. It is diagnosed by vulvar biopsy and generally responds to treatment with a potent topical corticosteroid for several weeks.

'Lichen planus' is a generalized skin disease that sometimes affects only the vulva. Patients present with burning, irritation, soreness and dyspareunia.

In some cases of lichen planus, the vestibule has ulcerations and the entire mucosa is eroded. Patients with this disorder may also present with sores in the oral cavity: oral examinations frequently reveal a reticulated, gray, lacy pattern of whitened mucosa in the mouth.

Diagnosis is confirmed by vulvar biopsy. Treatment consists of local or systemic steroids; one-half of a 25 mg hydrocortisone suppository can be inserted intravaginally twice a day for two months. Once improvement is noted, the medication may then be used once or twice a week for maintenance.

'Desquamative vaginitis' is a dermatological condition with purulent discharge, severe erythema, and erosions of the vaginal and vestibular mucosa.

Some experts believe that desquamative vaginitis is a severe form of lichen planus.

When this disease affects the vagina and/or the vulva, it is treated with the same regimen as lichen planus, i.e., intravaginal suppositories of hydrocortisone, alternating with 2% clindamycin cream for two weeks, then completing the course of vaginal hydrocortisone.'Dermatitis'

Over time, exposure to local vaginal/ vulvar irritants can lead to contact dermatitis, producing burning, itching, and painful intercourse.

There are a multitude of vulvar irritants that can cause contact dermatitis. Some common offenders are scented or deodorant soaps, douches, perfumes, feminine sprays and dyes in toilet tissues. Because these irritants may cause symptoms similar to those of a yeast infection, many patients who have contact dermatitis are treated with an anti-fungal cream.

Instead of finding relief, some of these patients have a negative reaction to the medication’s carrier molecules (e.g., propylene glycol), as discussed by Dr. Ledger in a recent NVA newsletter. (See Spring 2000 issue.) This can create a vicious cycle, resulting in a prolonged exacerbation of symptoms.

The best treatment approach for contact dermatitis is to eliminate all irritants to the vulva and provide symptomatic relief through warm soaks with Tannic acid (tea) or Domborrow’s solution (a soothing astringent).

Other helpful measures include wearing loose clothing and white cotton undergarments to provide adequate ventilation and keep the vulva dry. After bathing, using a hair dryer to dry the vulva is recommended.

In some cases, a low potency corticosteroid cream may be prescribed. For many patients, symptoms tend to resolve with this approach, but in severe cases systemic corticosteroids may be required.

If vulvar itching is the predominant symptom, or there is a history of adverse reaction to a treatment, allergic contact dermatitis should be suspected. Many agents included in topical preparations, e.g., preservatives, cause allergic reactions which can be diagnosed by patch testing.

Some common substances that can result in allergic reactions are local anesthetics (e.g., Benzocaine), perfumes, clotrimazole, butalbital, thiabendazole, benzol peroxide, and even topical corticosteriods themselves.

A repeated open application test (ROAT) for allergens can be performed by applying the suspected product three times a day to a 5 x 5 cm area on the forearm and then checking for a reaction. If specific allergens are identified in any of the products or treatment agents the patient is using, they should be discontinued immediately.

The local application of potent or super potent steroid creams for more than three to four weeks can also cause dermatitis.

After prolonged use of these creams, the vulvar skin can become irritated and patients report poor tolerance of local medications and post-coital irritation or swelling. Examination reveals erythema, telangiectasia (abnormal blood vessels) and a papular rash.

This condition, steroid rebound dermatitis, is treated by tapering the potent steroid cream over several weeks. A low potency steroid, such as 1% hydrocortisone, can then be used for maintenance and relief without the risk of rebound dermatitis.

Potent steroids should be reserved 'exclusively' for biopsy proven dermatoses such as lichen sclerosus.Atrophy (W.Lack of ESTROGEN)

In postmenopausal women, a lack of estrogen can lead to severe atrophic vaginitis which may cause burning, irritation and pain with intercourse.

On exam, the vagina is pale, there is thinning of the vaginal mucosa, and a yellow vaginal discharge may be present. This condition responds well to treatment with a vaginal estrogen cream which often resolves the symptoms. Dysesthetic Vulvodynia

Dysesthetic vulvodynia is a 'neuropathic' pain condition characterized by constant vulvar burning. It is not limited to focal areas of tenderness and is not necessarily exacerbated by touch or pressure.

This disorder is more common in postmenopausal women or younger women with a history of back injury.

Treatment usually involves the use of tricyclic antidepressants such as amitriptyline or anticonvulsants such as Neurontin.

Surgical resection is 'not' recommended for dysesthetic vulvodynia as the failure rate is significant.

Genital fissures

(My thought...these fissures are common in many patients but often cannot be seen with the naked eye but can with a colposcope. DT)

Patients who have chronic, nonhealing posterior fissures (small tears in genital skin near bottom 6 o'clock area DT) also present with vulvar pain, burning and entry dyspareunia. Many complain of a "tearing" sensation with intercourse as well as post-coital spotting.

On exam, these patients have an area of scarring, usually at the most posterior portions of the fourchette ,which can easily tear upon even gentle separation of the labia. A modified posterior vestibulectomy with vaginal advancement is the most successful treatment for this condition.

In this surgery, skin of the perineum and posterior vestibule is removed and vaginal tissue is brought down and sutured to the surrounding skin.Summary

Although the foregoing is by no means a comprehensive list of vulvovaginal disorders, I have reviewed the conditions that are most likely to be confused with V V S. As is the case with all medicine, a thorough evaluation and careful diagnosis is the key to successful treatment.