VulvodyniaDiagnosis and Management

 

VulvodyniaDiagnosis and Management

Vulvodynia is a chronic pain syndrome that affects the vulvar area and occurs without an identifiable cause.[1] Symptoms typically include a feeling of burning or irritation.[2] It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least 3 months

Vulvar pain is a common gynecologic complaint. Studies of the general populationhave estimated that chronic vulvar pain is present in 8% to 15%1–3of reproductiveaged women and that this health issue may cost society somewhere between 31 to72 billion dollars annually in the United States.4Many women with chronic vulvarpain report a poor quality of life, seek multiple health care providers, are frequentlymisdiagnosed, and use multiple treatment modalities before experiencing any degreeof symptom relief. It is, therefore, important for any women’s health practitioner toappreciate this condition and have a basic understanding of the diagnosis and man-agement options.The International Society for the Study of Vulvar Disease (ISSVD) along with the In-ternational Society for the Study of Women’s Sexual Health, and the International Pel-vic Pain Society adopted a new classification system for vulvar pain in 2015

CAUSE OF VULVODYNIA

The cause of vulvodynia is not well understood; however, most experts agree that it ismost likely multifactorial and differs by subtype.6,7Epidemiologic studies suggest alink between a history of vulvovaginal infection, particularly recurrent or severe infec-tions, and the subsequent development of vulvodynia. Histologic studies in womenwith PVD compared with controls have demonstrated neuroproliferation of the vesti-bule, increased lymphocytes and mast cells, and increased proinflammatory cyto-kines,6,8–12though results have not been consistent across all studies. GD isconsidered a centrally mediated pain condition similar to other chronic pain conditions(eg, fibromyalgia) by many experts and there have not been any histologic studies todate. Some have suggested hormonal alteration (oral contraceptive pill use, meno-pause) as part of the etiologic pathway in vulvodynia.7Genetic predisposition is sug-gested by the observation that PVD clusters in families.13There is consensus thatfurther study is critical to better understanding the pathophysiology and cause ofvulvodynia.

DIAGNOSISHistory

The diagnosis of vulvodynia is primarily based on clinical history coupled with phys-ical examination and is largely a diagnosis of exclusion. It is important to identify andtreat specific disorders that may be contributing to pain before making a diagnosis ofvulvodynia. A thorough evaluation of the patient’s pain history, sexual history, psy-chosocial situation, medical history, and physical examination are key aspects tocorrectly diagnosing and managing vulvodynia. Recently, a tool called the VulvarPain Assessment Questionnaire (VPAQ) was developed as a disease-specific setof measurement scales designed to capture the biopsychosocial nature of vulvody-nia. Specifically, the VPAQ assesses pain quality, the temporal nature of the pain,associated symptoms, pain intensity, emotional or cognitive functioning, physicalfunctioning, coping strategies, and interpersonal functioning.14Additionally, theISSVD has developed a questionnaire that patients can fill out before their appoint-ments to enable this process Establishing a trusting relationship is of paramount importance, particularlybecause many women have suffered with their condition for long periods oftime, seen multiple providers in the past, and have unsuccessfully tried differenttreatment strategies. It is important to address the women’s feelings and allowfor adequate time to gain a complete picture of the patient’s problem. Assuringconfidentiality and privacy, supporting any emotions that come up, allowingtime for the patient to tell her whole story, and communicating clearly withempathy are some practices that can help build a professional and empatheticrelationship with the patient. In settings in which time is limited, it may be usefulto reassure the patient of the importance of the problem and then schedule herfor additional follow-up at a time when a more comprehensive assessment canbe completed. Understanding what the patient views as her primary problemand what her expectations are around management can help to facilitatepatient-centered care that best aligns with her goals. For example, a womanmay report generalized burning pain, low libido, and dyspareunia and be mostworried about her relationship with her husband, in which case focusing initiallyon relationship counseling while working through the other issues may be themost important aspect of treatment to her

Pain History

Characterizing the patient’s pain by performing a detailed pain history is crucial to thediagnosis of vulvodynia. The interview should elicit location, quality, intensity, andduration of pain episodes. Additional questions that may be helpful include How long has she had pain? Has she always had pain or did it start after a period of no pain (primary vssecondary)? What other conditions or clinical symptoms accompanied the onset of pain (eg,yeast infection, initiation of a new medication)? Are there things that provoke or alleviate the pain? How much impact does the pain have on daily life?Women with PVD will frequently report pain at the opening to the vagina with vaginalpenetration (eg, tampon use, intercourse), whereas women with GD will often reportconstant soreness, burning, or irritating pain throughout the entire vulva

Sexual History

A sensitive and thorough sexual history reassures the patient that her physician under-stands the complexity of the problem and will work to address all facets of her issue. Itmay be useful to start with evaluation of her current sexuality, including desire, arousal,orgasm, sexual frequency, sexual practices (ie, use of sex toys or vibrators; anal,vaginal, or oral sex; use of lubrication), and sexual satisfaction. Understanding the pa-tient’s relationships and level of intimacy can provide insight into how they are copingandthelevelofsupportthattheyhavefromtheirpartner.Patientsexperiencingrelation-ship issues may have difficulty discussing sexuality and may benefit from discussion ofrelated issues such as avoidance behaviors, conflict, or negative partner responses.Patients whohave ahistory ofsexual abuseornegative sexualexperiences, particularlyany childhood trauma, may need additional time to discuss this history and will likelybenefit from a follow-up visit or referral for further management. Many women with vul-vodyniawillfeeldistressaroundissuesofsexualityandmayhavesignificantpsycholog-ical impact as a result. Anxiety, depression, hypervigilance, fear of pain, andcatastrophizing are examples of common psychological issues that women with vulvo-dynia may face, and addressing these can help women in the healing process.

Medical History

The medical history should be comprehensive and pay particular attention to thefollowing: Comorbid conditions (eg, fibromyalgia, temporomandibular joint, and otherchronic pain conditions) Mental health issues (eg, anxiety, depression) Medication use (eg, hormonal therapy, topical genital therapy) Associated symptoms (eg, bowel and bladder dysfunction) Infection history (eg, frequent urinary tract infections, recurrent yeast) Musculoskeletal history (eg, previous surgery or injury affecting the pelvis, hip, orsacrum) Exercise or activity level (eg, inability to ride a bike due to pain) Social support system

Physical Examination

A focused physical and thorough pelvic examination is critical to the diagnosis of vul-vodynia. It is important to understand and acknowledge that patients may have highanxiety around genital touch due to a history of dyspareunia or painful past examina-tions. Involving patients in their own examination using techniques such as the inter-active educational pelvic examination may be helpful.17This technique involveseducating the patient about her anatomy, explaining each step of the examinationto the patient, encouraging the patient to observe the examination with a hand-heldmirror, and allowing time for questions and information exchange.

Vulvar Inspection

The vulvar skin and vaginal mucosa should be carefully inspected to evaluate for ab-normalities such as hypopigmentation, fissuring, scarring, ulceration, or neoplasia.Some practitioners advocate routine use of colposcopy of the vulva or vulvoscopyfor patients with vulvodynia because it may enhance identification of subtle findings(eg, inflammation, fissures, and lichenification); however, application of acetic acid in-creases discomfort and is not necessary. If abnormalities are present, a biopsy may beconsidered for tissue diagnosis to rule out conditions such as lichen sclerosus, lichenplanus, low-grade or high-grade squamous intraepithelial lesions, differentiated vulvarintraepithelial neoplasia, or squamous cell cancer. This is typically done using a 3 to4 mm punch biopsy, a snip biopsy, or an excisional biopsy. There is very little utilityin a biopsy of normal appearing skin and this should be avoided. Erythema of the vulvaor vestibule may be present in vulvodynia but is not part of the diagnostic criteria.Bright erythema of the vestibule, particularly in the area of the Bartholin duct openingsis very commonly seen in PVD and does not warrant a biopsy

Psychological Interventions

The goals of psychotherapy include decreasing pain, strengthening romantic relation-ships, and restoring sexual function by focusing on the thoughts, emotions, behaviors,and ways that couples interact in the setting of genital pain. Counseling may take anindividual, couple, or group format, and there are advantages with each. The mostcommonly used form of psychotherapy is cognitive-behavioral therapy (CBT).Group-based CBT has been evaluated in several clinical trials, shown to significantlydecrease pain during intercourse at 6-month follow-up, and this effect was sustainedover long-term follow-up at 2.5 years.23,24Women who participated in therapy re-ported high satisfaction, less pain catastrophizing, and better sexual function. Psy-chotherapy (individualized, couple, and group therapy) is a validated, safe,noninvasive option for treatment of vulvodynia and should be highly considered asa critical aspect of treatment.20,25Insurance coverage may be an issue for some pa-tients; however, many insurance groups do provide this benefit and women should beencouraged to participate if able

Alternative Therapy

The use of alternative therapy among patients is widespread, but there are few data tosupport efficacy.20There are uncontrolled pilot studies suggesting improvement inpain with acupuncture and hypnosis and a small wait-list controlled study of acupunc-ture that showed improvement in vulvar pain, dyspareunia, and overall sexual func-tion.26The risks of adverse effects are minimal and patients may prefer to try thesetechniques before embarking on surgical or medical management.

Physical Therapy

Pelvic floor physical therapy is a cornerstone of treatment of women with vulvodyniabecause most women have concomitant pelvic floor muscle dysfunction (vaginismus)as a compensatory mechanism to avoid pain (see Stephanie A. Prendergast’s article,“Pelvic Floor Physical Therapy for Vulvodynia: A Clinician’s Guide,” in this issue). Fail-ure to address pelvic floor dysfunction in patients with vulvodynia is likely to result insuboptimal treatment.


REFERENCES1
.Reed BD, Harlow SD, Sen A, et al. Prevalence and demographic characteristicsof vulvodynia in a population-based sample. Am J Obstet Gynecol 2012;206(2):170.e1-9.2.Harlow BL, Stewart EG. A population-based assessment of chronic unexplainedvulvar pain: have we underestimated the prevalence of vulvodynia? J Am MedWomens Assoc 2003;58(2):82–8.3.Arnold LD, Bachmann GA, Rosen R, et al. Assessment of vulvodynia symptomsin a sample of US women: a prevalence survey with a nested case control study.Am J Obstet Gynecol 2007;196(2):128.e1-6.4.Xie Y, Shi L, Xiong X, et al. Economic burden and quality of life of vulvodynia in theUnited States. Curr Med Res Opin 2012;28(4):601–8.5.Bornstein J, Goldstein AT, Stockdale CK, et al. 2015 ISSVD, ISSWSH and IPPSconsensus terminology and classification of persistent vulvar pain and vulvody-nia. Obstet Gynecol 2016;127(4):745–51.6.Havemann LM, Cool DR, Gagneux P, et al. Vulvodynia: what we know and wherewe should be going. J Low Genit Tract Dis 2017;21(2):150–6.7.Pukall CF, Goldstein AT, Bergeron S, et al. Vulvodynia: definition, prevalence,impact, and pathophysiological factors. J Sex Med 2016;13(3):291–304.8.Leclair CM, Leeborg NJ, Jacobson-Dunlop E, et al. CD4-positive T-cell recruit-ment in primary-provoked localized vulvodynia: potential insights into diseasetriggers. J Low Genit Tract Dis 2014;18(2):195–201.9.Goetsch MF, Morgan TK, Korcheva VB, et al. Histologic and receptor analysis ofprimary and secondary vestibulodynia and controls: a prospective study. Am JObstet Gynecol 2010;202(6):614.e1-8.10.Leclair CM, Goetsch MF, Korcheva VB, et al. Differences in primary comparedwith secondary vestibulodynia by immunohistochemistry. Obstet Gynecol 2011;117(6):1307–13.