VESTIBULITIS / VESTIBULODYNIA - Dr. (part 2)

[Guest guest]

DeeTroll wrote: 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 as well as 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 effective in the majority of cases but has certainly helped some women. 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. (See "Pharmacology of antidepressants"

section on Heterocyclic antidepressants). 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. (See "Pharmacology of antiepileptic drugs"). 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. (Dr. ) 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 (vestibulitis) include: Education and support. Elimination of all irritants. Healthy vulvar hygiene and comfort measures. 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. Physical therapy to the pelvic floor with biofeedback. 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. Topical xylocaine (5 percent in a neutral base) to the vestibule ten minutes before intercourse, if desired, and after intercourse, if necessary. END........... Well that was certainly long enough but I hope of some help. hugs Dee~