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Feature: CE Connection

The mystery of vulvodynia

Can it be solved?

Harrison, Helen E. MSN, RN, APRN-C

Author Information
doi: 10.1097/01.NURSE.0000510741.45681.2a

In Brief

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Figure

VULVODYNIA is a vulvar pain syndrome characterized by persistent vulvar pain without an identifiable cause. It can affect women of any age, whether or not they're sexually active. By some estimates, millions of women are affected.1

Because the disorder isn't well understood, diagnosis may be delayed or missed, and treatment isn't always effective. As the following case history illustrates, this persistent pain syndrome can have a significant impact on the woman's health as well as on her intimate relationships.2 This article discusses signs and symptoms, physical and psychological effects, treatment, and patient education for patients with vulvodynia.

Mary's story

One day Mary (not her real name), a healthy young adult, noticed vaginal pruritus, a white vaginal discharge, and a burning pain localized to the vulvar vestibule. She assumed she'd developed a vaginal yeast infection (vulvovaginal candidiasis) and used an over-the-counter topical antimycotic product. When signs and symptoms persisted, she saw her gynecologist, who diagnosed bacterial vaginosis and prescribed intravaginal clindamycin therapy for 1 week. Although Mary's vaginal discharge and pruritus resolved, the localized burning pain persisted. Mary was referred to a urogynecologist, who diagnosed vulvodynia and prescribed application of a daily topical amitriptyline/baclofen cream to the vulvar area.

Mary's burning pain lessened but didn't completely resolve. Sometimes the burning sensation was so severe that she could hardly sit. She continued her sexual relationship with her boyfriend, but the burning pain worsened after intercourse. She returned to the urogynecologist, who prescribed a topical anesthetic, lidocaine cream.

Now, Mary's burning vulvar pain is fairly well controlled but flares still occur. Her pain can be triggered by vulvar irritation from intercourse or occur without warning. She says she gets depressed at times thinking she'll have to suffer with this painful disorder for the rest of her life.

Origins unknown

Mary's condition meets criteria for a vulvodynia diagnosis set forth in a consensus statement endorsed by several expert organizations in 2015.3,4 In this statement, vulvar pain is classified into two categories: persistent vulvar pain with an identifiable cause, such as an infection, tumor, or other known disorder, and vulvodynia, defined as persistent vulvar pain without a known cause that's been present for at least 3 months. Pain may be generalized, localized to a specific structure such as the vulvar vestibule or clitoris, or mixed.3 Localized vulvar pain syndrome, the focus of this article, is the most common type of vulvodynia.4 The disorder can be further classified according to how pain is provoked, onset characteristics, and pain pattern. Vulvodynia can coexist with another identifiable disorder.3,4

By definition, the exact cause of vulvodynia is unknown. It probably involves the interaction of several factors, such as genetics, inflammatory disorders, hormonal responses, weakened pelvic floor muscles, and neurologic mechanisms.3-5 (See Possible risk factors for vulvodynia.)

Clinical manifestations

Patients with vulvodynia may report dyspareunia (painful intercourse) and significant pain upon contact with the vulvar vestibule.6 Women often describe the pain as burning, hot, stabbing, cutting, or throbbing. Pain may be primary (provoked by touch or contact with a stimulus) or secondary (arising spontaneously).4

The cardinal sign of localized vulvar pain syndrome is significant tenderness upon point-pressure testing of the vulvar vestibule with a cotton-tipped swab in a circumferential pattern around the vestibule. (See Conducting point-pressure testing.) Point-pressure testing helps to map the location and severity of vestibular pain. Women with localized, provoked vulvodynia will have pain out of proportion to the pressure from the touch of the cotton swab, particularly in the areas between 4 and 8 o'clock.4

Figure
Figure:
Conducting point-pressure testing

Vulvodynia can have profound physical, emotional, and psychological effects on a woman. Besides making intercourse extremely uncomfortable, the pain affects many everyday activities such as biking and even sitting for prolonged periods. Dealing with the day in, day out symptoms of this unexplained chronic pain syndrome can cause hopelessness, depression, and despair.

Diagnosis

Vulvodynia is diagnosed primarily by evaluating the woman's health history and clinical manifestations, and ruling out other vaginal disorders. Key diagnostic indicators include a history of persistent burning vulvar pain for 3 months or more with no identifiable cause, positive point-pressure testing, and inability to tolerate vaginal contact; for example, during intercourse. Lab tests, biopsy, and/or imaging studies aren't diagnostic but may be performed to rule out other potential sources of pain.3,4

Treatment challenges

Alleviating the symptoms of vulvodynia can be a challenge because no treatment works for all women. In fact, a treatment that works well for one woman may be ineffective for another.8 The patient must work closely with the healthcare provider to find the best treatment for her.

Treatment options include pelvic floor muscle rehabilitation (physical therapy to the pelvic floor with biofeedback), topical and oral pharmacotherapy, local nerve blocks, and as a last resort, surgery.7,8

  • Pelvic floor muscle rehabilitation conducted with biofeedback helps the patient learn how to manage symptoms by modifying normal body functions. Performing exercises to strengthen and relax the muscles of the pelvic region may help reduce pain in the pelvic area.9 Exercises are usually done twice a day. A small vaginal probe provides data on the effectiveness of treatment. Overall relief of pain symptoms is usually seen after performing the exercises for several months.7,9
  • Topical anesthetics, especially topical lidocaine, may reduce pain if applied at least 20 minutes before the patient engages in sexual activities.9 According to one study, 36% to 76% of women who used topical lidocaine reported improved intercourse.10

The patient should be aware of several issues associated with the use of topical lidocaine to facilitate sexual intercourse. Because it can cause penile numbness, the patient's partner may need to wear barrier protection. In addition, oral sex should be avoided when the patient uses this therapy.7

Warn the patient to avoid overuse because of the small risk of lidocaine toxicity.9 Teach her to recognize signs and symptoms of lidocaine toxicity, which include central nervous system effects (confusion, agitation, ataxia, visual changes, hearing loss) and cardiovascular effects such as bradycardia.11

  • Various compounded topical creams containing drugs such as gabapentin, amitriptyline, ketoprofen, ketamine, and baclofen, or hormones such as estrogen and testosterone, are also options.5,7,12 By using topical applications, patients may avoid adverse reactions associated with oral formulations.

Topical products containing capsaicin, the active ingredient in hot peppers, have been studied with mixed results. Most women can't tolerate the extreme burning sensation associated with the initial use of this product.7

  • Oral medications prescribed for neuropathic pain are effective for some patients. These include tricyclic antidepressants (nortriptyline and desipramine), antiepileptic drugs (gabapentin, pregabalin), and serotonin/norepinephrine reuptake inhibitors (venlafaxine, duloxetine).7,12
  • Local injection of botulinum toxin type A (BTX-A) interrupts pain signals and provides short-term and sometimes long-term relief for some women.5,7
  • Local injections. Nerve blocks may help some women with persistent pain unresponsive to other interventions. These are administered by an anesthesia provider or an expert in pain management.7
  • Surgical intervention to remove the affected tissue of the vaginal vestibule (vestibulectomy) may be considered if other treatments fail.5,7,8 It's not recommended for women with generalized vulvodynia.5

Other interventions

Teach women to avoid activities and products that may trigger pain, such as:7,13

  • synthetic underwear, pantyhose, tight jeans, and thongs. Loose cotton clothing is best. Patients should remove wet swimsuits as soon as possible and avoid swimming in highly chlorinated pools.
  • douches and feminine sprays or powders.
  • scented products and other potentially irritating chemicals in soaps and clothing. Tell women to wash with nonscented, pH-neutral soap.
  • washcloths and towels. Advise women to use their fingertips to gently wash the vulva and pat the area dry or use a hair dryer to minimize direct contact.
  • activities that put direct pressure on the vulva, such as biking or horseback riding.
  • antifungal or steroid creams, which can exacerbate symptoms. If symptoms persist or intensify, patients should contact their healthcare provider to discuss other treatment options.

Teach patients to avoid prolonged hot soaks, but a 5- to 10-minute sitz bath in warm water twice daily may be soothing. After bathing, patients should apply a thin film of petroleum jelly to the vulva to maintain hydration.

Applying a cooled gel pack or crushed ice in a plastic bag to the vulva may help relieve burning pain after intercourse. A bag of frozen peas or corn is a convenient alternative. Teach patients to wrap the gel pack or bag in a soft cloth and to avoid prolonged contact to prevent frostbite of delicate tissues.7,13

Some women find that ingesting certain substances, such as caffeine, processed foods, or sugar, triggers symptoms. Suggest that patients try eliminating one type of food at a time to determine if symptoms improve.5

Facing psychosocial effects

According to Goesling, Clauw, and Hassett, 30% to 60% of patients who have persistent pain also suffer from depression.14 As discussed above, some medications used to treat vulvodynia, such as venlafaxine and duloxetine, also help to treat depression.14 Additional measures may be recommended to treat depression, such as therapy with a mental healthcare professional.5,14

Women with vulvodynia often report higher levels of stress and frustration, primarily due to the impact of the pain on their sexual life, as well as feelings of inadequacy and low self-worth.15 Cognitive behavior therapy can help patients cope with anxiety related to the pain of vulvodynia.9

Cognitive behavioral therapy consists of mental counseling treatments that help people understand the relationship between their thoughts, beliefs, and behaviors.16 This treatment helps patients identify negative or destructive thought patterns and replace them with positive and realistic beliefs and expectations. In one study, women with vulvodynia who underwent cognitive behavioral therapy had a 21% to 38% reduction in pain symptoms.9

Sex therapy may be an option for couples to help them explore alternative sexual activities and provide mutual support to one another.5,9

Communication, education, and support

Women must be persistent in working with their healthcare provider to find what therapy works best for them. Education and ongoing support are crucial. The National Vulvodynia Association (www.nva.org) offers information and resources for both patients and healthcare professionals.

Possible risk factors for vulvodynia4,17

  • excessive or abnormal immune response
  • chronic inflammation of the vulvar vestibule
  • local nerve injury or irritation
  • genital infection, particularly with Candida albicans and bacterial vaginosis
  • genetic susceptibility to chronic vestibular inflammation
  • pelvic floor muscle weakness or dysfunction
  • oral contraceptive use
  • psychological factors.

REFERENCES

1. Cox KJ, Neville CE. Assessment and management options for women with vulvodynia. J Midwifery Womens Health. 2012;57(3):231–240.
2. Jodoin M, Bergeron S, Khalifé S, Dupuis MJ, Desrochers G, Leclerc B. Attributions about pain as predictors of psychological symptomatology, sexual function, and dyadic adjustment in women with vestibulodynia. Arch Sex Behav. 2011;40(1):87–97.
3. International Society for the Study of Vulvovaginal Disease. ISSVD terminology: clarification of vulvar diseases—persistent vulvar pain & vulvodynia. 2015. www.issvd.org/issvd-terminology-classification-of-vulvar-diseases.
4. Iglesia C. Clinical manifestations and diagnosis of localized vulvar pain syndrome (formerly vulvodynia, vestibulodynia, vulvar vestibulitis, or focal vulvitis). UpToDate. 2016. www.uptodate.com.
5. The American College of Obstetricians and Gynecologists. Frequently asked questions. FAQ 127. Vulvodynia. 2014. www.acog.org/Patients/FAQs/Vulvodynia.
6. Stockdale CK, Lawson HW. 2013 Vulvodynia Guideline update. J Low Genit Tract Dis. 2014;18(2):93–201.
7. Stewart EG. Treatment of vulvodynia. UpToDate. 2016. www.uptodate.com.
8. Haefner HK, Collins ME, Davis GD, et al. The vulvodynia guideline. J Low Genit Tract Dis. 2005;9(1):40–51.
9. Groysman V. Vulvodynia: new concepts and review of the literature. Dermatol Clin. 2010;28(4):681–696.
10. Nunns D, Mandal D, Byrne M, et al. Guidelines for the management of vulvodynia. Br J Dermatol. 2010;162(6):1180–1185.
11. Kapitanyan R. Local anesthetic toxicity. Medscape. 2015. http://emedicine.medscape.com/article/1844551-overview.
12. National Vulvodynia Association. Vulvodynia treatments. www.nva.org/what-is-vulvodynia/treatment.
14. Goesling J, Clauw DJ, Hassett AL. Pain and depression: an integrative review of neurobiological and psychological factors. Curr Psychiatry Rep. 2013;15(12):421.
15. Sadownik LA. Etiology, diagnosis, and clinical management of vulvodynia. Int J Womens Health. 2014;6:437–449.
16. National Alliance on Mental Illness. Psychotherapy. www.nami.org/Learn-More/Treatment/Psychotherapy.
17. National Vulvodynia Association. What causes vulvodynia? www.nva.org/what-is-vulvodynia/what-causes-vulvodynia.
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