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