other pelvic pain sydromes: vulvadynia, vulvar vestibulitis, and vaginismus marie fidela r. paraiso,...
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Other Pelvic Pain Sydromes: Other Pelvic Pain Sydromes: Vulvadynia, Vulvadynia,
Vulvar Vestibulitis, and Vulvar Vestibulitis, and VaginismusVaginismus
Marie Fidela R. Paraiso, M.D.Marie Fidela R. Paraiso, M.D.Head, Division of UrogynecologyHead, Division of Urogynecology
Professor of SurgeryProfessor of SurgeryCleveland Clinic Lerner College of Medicine at Cleveland Clinic Lerner College of Medicine at
Case Western Reserve UniversityCase Western Reserve UniversityCleveland, OHCleveland, OH
Disclosure of Financial Disclosure of Financial RelationshipRelationship
NoneNone
Learning ObjectivesLearning Objectives
After this lecture, the participant will be able After this lecture, the participant will be able to:to:
1. Cite the definitions and types of vulvar 1. Cite the definitions and types of vulvar dysesthesias.dysesthesias.
2. Know the differential diagnosis and 2. Know the differential diagnosis and evaluation of vulvar pain.evaluation of vulvar pain.
3. List the treatment options of vulvodynia 3. List the treatment options of vulvodynia and vulvar vestibulitis.and vulvar vestibulitis.
Vulvar Dysesthesia -- Vulvar Dysesthesia -- SubtypesSubtypes
Focal -- “vulvar vestibulitis”, Focal -- “vulvar vestibulitis”,
“vestibulodynia”“vestibulodynia”
Generalized – “essential vulvodynia”, Generalized – “essential vulvodynia”,
“dysesthetic vulvodynia”“dysesthetic vulvodynia”
Vulvar DysesthesiaVulvar Dysesthesia
A chronic vulvar discomfort, A chronic vulvar discomfort,
manifested by burning, stinging, manifested by burning, stinging,
irritation or rawnessirritation or rawness
VaginismusVaginismus
Vaginismus is an involuntary spasm of the muscles Vaginismus is an involuntary spasm of the muscles
surrounding the vagina. The spasms close the vagina.surrounding the vagina. The spasms close the vagina.
It is a disorder of sexual dysfunction with several It is a disorder of sexual dysfunction with several
possible causes, including past sexual trauma or possible causes, including past sexual trauma or
abuse, psychological factors, or a history of discomfort abuse, psychological factors, or a history of discomfort
with sexual intercourse. Sometimes no cause can be with sexual intercourse. Sometimes no cause can be
found.found.
Vulvar Dysesthesia -- Vulvar Dysesthesia -- PrevalencePrevalence
UnknownUnknown
Estimated to be 200,000 American Estimated to be 200,000 American
women or up to 15% of general women or up to 15% of general
Gyn practicesGyn practices
Vulvar Dysesthesia -- Vulvar Dysesthesia -- PrevalencePrevalence
In specialty practices of patients with vulvar pain, In specialty practices of patients with vulvar pain,
about 60% have vulvar vestibulitis and 40% have about 60% have vulvar vestibulitis and 40% have
generalized dysesthesia generalized dysesthesia
Patients with vestibulitis tend to be younger; Patients with vestibulitis tend to be younger;
patients with generalized dysesthesia span all age patients with generalized dysesthesia span all age
groupsgroups
Vulvar VestibulitisVulvar Vestibulitis
Severe pain on vestibular touch or Severe pain on vestibular touch or
attempted vaginal entryattempted vaginal entry
Tenderness to pressure localized within Tenderness to pressure localized within
the vulvar vestibule, especially over the the vulvar vestibule, especially over the
Bartholin glandsBartholin glands
Physical findings show vestibular Physical findings show vestibular
erythema of various degreeserythema of various degrees
Generalized Vulvar Generalized Vulvar DysesthesiaDysesthesia
Constant, unremitting vulvar burningConstant, unremitting vulvar burning
Few abnormal physical findingsFew abnormal physical findings
Description of pain is similar to that of Description of pain is similar to that of
post-traumatic neuralgia and glossodynia, post-traumatic neuralgia and glossodynia,
suggesting a problem with cutaneous suggesting a problem with cutaneous
perception, either centrally or at the nerve perception, either centrally or at the nerve
rootroot
Vulvar Dysesthesia -- Vulvar Dysesthesia -- EtiologyEtiology
UnknownUnknown
Best described as Best described as neuropathicneuropathic, due to , due to
burning quality and to lack of response burning quality and to lack of response
to treatment with narcotics to treatment with narcotics
Other Possible EtiologiesOther Possible Etiologies Contact irritationContact irritation Topical medicinesTopical medicines AllergyAllergy Trauma / Laser / Surgeries / AbuseTrauma / Laser / Surgeries / Abuse InfectionInfection
– Yeast – maybeYeast – maybe– HPV – probably notHPV – probably not
Coexisting Conditions to Coexisting Conditions to ConsiderConsider
EndometriosisEndometriosis Interstitial cystitisInterstitial cystitis Functional bowel disordersFunctional bowel disorders Psychiatric disordersPsychiatric disorders Past or current abuse situations Past or current abuse situations
Symptoms of Vulvar VestibulitisSymptoms of Vulvar Vestibulitis
Vulvar pain or burning with touching or Vulvar pain or burning with touching or contactcontact
DyspareuniaDyspareunia Difficult vaginal entry (vaginismus)Difficult vaginal entry (vaginismus) Urethral pain, dysuria, urgencyUrethral pain, dysuria, urgency Depression, anxietyDepression, anxiety
Vulvar Dysesthesia – Vulvar Dysesthesia – Symptom SubtypesSymptom Subtypes
Focal vulvar vestibulitis – patients describe Focal vulvar vestibulitis – patients describe
pain only with touching, intercourse, pain only with touching, intercourse,
contact; they may describe contact; they may describe no pain at all no pain at all
otherwiseotherwise
Generalized dysesthetic vulvodynia – Generalized dysesthetic vulvodynia –
patients describe burning pain most times, patients describe burning pain most times,
not really caused by touchingnot really caused by touching
Vulvar Dysesthesia – Vulvar Dysesthesia – Physical ExaminationPhysical Examination
Observe the patient during the history to Observe the patient during the history to
understand the level of distressunderstand the level of distress
Careful and gentle vulvar inspection -- ? Careful and gentle vulvar inspection -- ?
lesions, ulcers, erythemalesions, ulcers, erythema
Use a moistened Use a moistened cotton swabcotton swab to assess to assess
vestibular tendernessvestibular tenderness
Vulvar Dysesthesia – Vulvar Dysesthesia – Physical Examination, Physical Examination, cont’d.cont’d.
Gentle vaginal palpation with one finger to Gentle vaginal palpation with one finger to
assess levator muscle tightness and assess levator muscle tightness and
tenderness: ? vaginismustenderness: ? vaginismus
Speculum examination: inspection, pH and Speculum examination: inspection, pH and
wet prep, culture for yeast, other cultures wet prep, culture for yeast, other cultures
and pap smear as indicatedand pap smear as indicated
Abdominal and bimanual examinations: ? Abdominal and bimanual examinations: ?
pelvic or suprapubic pain pelvic or suprapubic pain
Differential Diagnosis of Visible Differential Diagnosis of Visible Vulvar Pain ConditionsVulvar Pain Conditions
Infection: viral, yeast, bacterialInfection: viral, yeast, bacterial AtrophyAtrophy TraumaTrauma DermatosesDermatoses TumorsTumors Vulvar vestibulitisVulvar vestibulitis
Lichen Lichen
sclerosissclerosis
Chemical vulvitis Chemical vulvitis
from 5-FU creamfrom 5-FU cream
Plasma cell Plasma cell
vulvitisvulvitis
General Treatments of Vulvar General Treatments of Vulvar DysesthesiaDysesthesia
Local skin care; avoidance of all vulvar Local skin care; avoidance of all vulvar irritantsirritants
Low oxalate diet; calcium citrateLow oxalate diet; calcium citrate Topical estrogenTopical estrogen Topical lidocaineTopical lidocaine Medical therapy, low doseMedical therapy, low dose
Medical Therapy of Medical Therapy of Vulvar DysesthesiaVulvar Dysesthesia
Amitriptyline (Elavil) 10 –125 mg dailyAmitriptyline (Elavil) 10 –125 mg daily
Gabapentin (Neurontin) 300 – 2700 mg dailyGabapentin (Neurontin) 300 – 2700 mg daily
– Gabapentin 6% ointment (some use 4%) Gabapentin 6% ointment (some use 4%)
– Dissolve gabapentin powder Ethoxy Diglycol. Levigate mixture into PCCA Dissolve gabapentin powder Ethoxy Diglycol. Levigate mixture into PCCA
and lipoderm base and dispense at 6%.and lipoderm base and dispense at 6%.
Apply 0.5mL (pea sized) amount to affected area TID.Apply 0.5mL (pea sized) amount to affected area TID.
Pregabalin (Lyrica) Pregabalin (Lyrica) off labeloff label
NSAIDsNSAIDs
Medical Therapy of Vulvar Medical Therapy of Vulvar DysesthesiaDysesthesia
Elavil and Neurontin result in improvement Elavil and Neurontin result in improvement
in pain scores in most patients by 30% to in pain scores in most patients by 30% to
80%80%
Few women report complete cure with Few women report complete cure with
medical therapymedical therapy
Secondary Treatments of Focal Secondary Treatments of Focal Vulvar DysesthesiaVulvar Dysesthesia (Vulvar Vestibulitis) (Vulvar Vestibulitis)
High-dose medical therapyHigh-dose medical therapy
Physical therapy with biofeedbackPhysical therapy with biofeedback
Psychosexual evaluationPsychosexual evaluation
SurgerySurgery
Secondary Treatments of Secondary Treatments of Generalized Vulvar Dysesthesia Generalized Vulvar Dysesthesia
(Essential Vulvodynia)(Essential Vulvodynia)
High-dose medical therapyHigh-dose medical therapy
Psychosexual evaluationPsychosexual evaluation
Anesthesia pain assessmentAnesthesia pain assessment
Spinal cord neuromodulationSpinal cord neuromodulation
Therapy for VaginismusTherapy for Vaginismus
EducationEducation
Specialized physical therapy; dilator Specialized physical therapy; dilator
useuse
Sex therapySex therapy
Surgery for Vulvar VestibulitisSurgery for Vulvar Vestibulitis
Bilateral Bartholin gland excisionBilateral Bartholin gland excision
Partial vestibulectomy with vaginal flap Partial vestibulectomy with vaginal flap
advancementadvancement
Note: In the very select group of patients Note: In the very select group of patients
with vulvar vestibulitis who failed all other with vulvar vestibulitis who failed all other
therapies, cures of therapies, cures of 70% to 90%70% to 90% have been have been
reportedreported
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