Generalized Vulvodynia – Causes, Symptoms, Treatment

Vulvodynia is a vulvar pain of at least three months’ duration without a clear, identifiable cause. It may be generalized or localized with respect to location. It may always occur spontaneously or have to be provoked. It could occur throughout a patient’s life or just with a new partner (primary or secondary) and/or it can be intermittent, persistent, constant, immediate, or delayed in timing. [rx]

Diagnosis of Vulvodynia

The patient should undergo a thorough gynecologic examination. Once all infectious, inflammatory, hormonal, neoplastic, and neurologic causes are investigated and treated, a visual inspection of the vulva and vulvar vestibule should be performed. [rx]

• Cotton swab evaluation – Ask the patient, “Where does it hurt?” and, “Does it hurt before I even touch you?” From the outside in towards the vestibule, mark the area to find the location of the pain. Starting from the inner thigh, move to labia majora, inner labial sulcus, clitoris, and clitoral hood, perineum, and sites within the vestibule. The patient should rate their pain on a scale of 1 to 10.
• Neurosensory – Cotton versus pinprick exam in the same places – note whether it is normal, hypersensitive, sharp, burning, or shooting pain.
• Pelvic muscle exam – Starting with puborectalis and working way into the pelvic muscles.
• Evaluation of pain comorbidity – Interstitial cystitis, endometriosis, temporomandibular joint syndrome, chronic headaches.
• Assessment of factors contributing to pain – Emotional functioning, sleep interference, relationship problems, physical functioning, sexual functioning
• There are no blood tests necessary – A thorough history and physical with medication and drug allergy review should be performed.
• Swabs to test for infection –  Your doctor uses a moistened cotton swab to gently check for specific, localized areas of pain in your vulvar region.
• Biopsy – An examination of tissue removed from the area. This test is not done routinely and is only performed if there is a lesion or abnormal exam finding.

Treatment of Vulvodynia

There are a number of possible treatments with none being uniformly effective.^[2] Treatments include:

• Lifestyle – A number of lifestyle changes are often recommended such as using cotton underwear, not using substances that may irritate the area, and using lubricant during sex.^[rx] The use of alternative medicine has not been sufficiently studied to make recommendations.^[rx]
• Counseling – Education and accurate information about vestibulodynia: Gynaecologist-led educational seminars delivered in a group format have a significant positive impact on psychological symptoms and sexual functioning in women who suffer from Provoked (caused by a stimulus such as a touch or sexual activity) vestibulodynia.^[rx] Provoked vestibulodynia, whilst similar in some respects, is different from vulvodynia which this article refers to.
• Biofeedback – physical therapy and relaxation: Biofeedback, often done by physical therapists, involves inserting a vaginal sensor to get a sense of the strength of the muscles and help a patient get greater control of her muscles to feel the difference between contraction and relaxation. Sessions are linked with at-home recommendations including often Kegel exercises (e.g., hold for 9 seconds, relax for 30 seconds, for 10–15 sets), and relaxation. [rx]
• Massage – Pelvic floor muscle weakness and spasm. Treatment includes exercises, massage, soft tissue work, and joint mobilization. Nerve block, psychotherapy, mindfulness, yoga, and neurostimulation are also helpful in treatment.
• Vulvar self-care – Avoid irritants, directly or through diet.
• Pelvic floor therapy – Many women with vulvodynia have tension in the muscles of the pelvic floor, which supports the uterus, bladder, and bowel. Exercises to relax those muscles can help relieve vulvodynia pain.
• Diet modifications – Talk with your provider about the pros and cons of eliminating certain types of foods from your diets, such as those high in oxalates or sugar. To test for food sensitivity and to determine which foods, if any, are affecting you, eliminate one food or food group at a time. Use a food diary to record your results—you might begin to notice an association between your symptoms and certain foods you wouldn’t have otherwise suspected. This may be especially helpful in women who also have interstitial cystitis.
• Relaxation and breathing techniques – Like biofeedback, learning to recognize when you are tensing your pelvic floor muscles due to stress and then learning specific relaxation techniques to reduce stress and anxiety can help alleviate pain.
• Neurostimulation and spinal infusion pump – If other treatment forms haven’t helped and your pain is severe, your health care professional may have you consult with a professional skilled in neurostimulation or in the use of a spinal infusion pump. With neurostimulation, an electronic device delivers low-voltage electrical stimulation to a targeted nerve or the spinal cord in an attempt to substitute a tingling sensation for pain. A spinal infusion pump is an implanted device that constantly administers a small dose of medication to the spinal cord and nerve roots to help dull pain. Experience treating vulvodynia with these interventions is limited.

Medication

• Oral “pain-blocking” medications – These may be effective in alleviating vulvodynia pain. The classes of drugs are tricyclic antidepressants (TCAs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and anticonvulsants. The TCAs are used most often, and the most commonly used among them are amitriptyline and nortriptyline. Because nortriptyline has fewer side effects, it is usually the first choice. The dose is lower than that which is used to treat depression. Due to side effects, it is suggested, to begin with very low doses and increase gradually. The more commonly used SNRIs are duloxetine and venlafaxine, and the anticonvulsants typically used are gabapentin, pregabalin, lamotrigine, oxcarbazepine, and topiramate.
• Topical medications – applied directly to the vulva can alleviate pain as long as there are no allergens in the ointments. These are usually compounded. Examples combined or used alone are lidocaine, estrogen, testosterone, and gabapentin.
• Tricyclic antidepressants (TCAs) –  have been the focus of both oral and topical therapies due to their dual effects in treating depression and neuropathic pain. Amitriptyline has thus far been the most researched TCA and is widely used by healthcare professionals. However, the wide range of amitriptyline dosing (10 mg to 225 mg taken by mouth daily) and lack of a consistent method of assessing pain further complicate the ability to extrapolate useful efficacy data from studies.^[rx–rx] Additionally, TCA use is associated with adverse effects such as weight gain, fatigue, tachycardia, and seizures.^[rx,rx] The only other TCA researched in vulvodynia is desipramine.
• Selective serotonin reuptake inhibitors (SSRIs) – have not been studied individually but rather in a combination regimen or after the failure of a TCA. These include escitalopram, paroxetine, and citalopram. Oral escitalopram, amitriptyline, and perphenazine were researched in vulvodynia patients in one study. Low-dose serotonin-norepinephrine reuptake inhibitor (SNRI), venlafaxine 75 mg daily, showed that the patient was able to achieve complete remission of symptoms.^[rx] In another SNRI study, milnacipran (titrated up to 200 mg daily) also showed some lowering of pain scores when studied in provoked vestibulodynia.
• Anticonvulsants – When neuropathic pain is suspected, the practitioner may consider starting an anticonvulsant as either monotherapy or in combination with an antidepressant. Thus far, studies have been limited to gabapentin, pregabalin, lamotrigine, and carbamazepine. Although initially marketed as an anticonvulsant, gabapentin has shown efficacy in treating neuropathic pain. For this reason, investigators have studied its use in vulvodynia both topically and orally. In 3 out of 4 trials using oral gabapentin, the dosage was titrated up gradually based on tolerability and efficacy. Therefore, there are wide-ranging dosages (100 mg to 3000 mg orally each day in divided doses), making it difficult to extrapolate specific dose-response relationships.
• Topical lidocaine – has become a popular vulvodynia treatment due to vulvodynia’s similarity to post-herpetic neuralgia. One randomized placebo-controlled study^rx] was performed using topical lidocaine and demonstrated no efficacy over placebo.
• Baclofen’s muscle relaxation –  actions and decreased adverse effect profile make it a feasible treatment option.^[rx,rx]One study found baclofen an effective treatment when combined in cream with amitriptyline.^[rx] Additionally, a case report used a compounded baclofen cream with oral palmitoylethanolamide, which is a fatty acid produced naturally and taken orally as a food supplement to decrease inflammation.
• Gonadal hormones – (ie, estrogen and testosterone) appear to play a role in pain transmission at various sites. Recently, topical creams containing gonadal hormones have been tested to target premenopausal vulvodynia along with the comorbidity of interstitial cystitis/bladder pain syndrome (IC/BPS). IC/BPS and vulvodynia both belong to a larger category of chronic pelvic pain syndromes, which may often overlap. A study of premenopausal patients using estriol cream saw significant improvement in both bladder and vaginal pain symptoms.^[rx]
• Nitroglycerin cream and capsaicin cream – have shown some efficacy when treating vulvodynia. However, they are not frequently used due to the adverse effects experienced exceeding the possible benefits.
• Botulinum toxin A – has been shown to decrease and even cure vulvodynia pain in case studies.⁵ However, the only randomized-controlled trial performed using botulinum toxin A in vulvodynia found no difference from placebo.^[rx] Although rare, botulinum toxin A carries a risk of systemic effects if it spreads beyond the site of injection.
• Triamcinolone, betamethasone, and methylprednisolone – have been studied due to their anti-inflammatory effects and in some cases have improved pain in less than 1 to 2 weeks.^[rx] Due to the use of other medications in combination with corticosteroids, it is difficult to assess their efficacy in these studies. Other alternative therapies requiring more controlled studies include acupuncture, localized transcutaneous electrical nerve stimulation (TENS) therapy applied to the labia majora, and avoiding diets high in oxalates.
• Injectable Therapies – Several injectable therapies exist for vulvodynia pain that is more localized in nature. Those showing efficacy include enoxaparin, botulinum toxin A, and corticosteroids. Although effective, injectable therapies are not often recommended due to their inconvenience and cost.
• Psychological approaches – Cognitive behavioral therapy is associated with a 30% decrease in reported vulvar pain with intercourse [rx]. Although there is no proven connection between vulvodynia and psychological predisposition, pain may be related to interpersonal or individual psychological problems. Marriage, sexual, or individual psychological consultation is also recommended in patients with similar symptoms.
• Physical therapy – Physical therapy has also proven itself as a method of choice in connection with the combined treatment of vulvodynia [rx]. It includes an assessment of the patient’s pelvic muscles, joints, fasciae, and ligaments. The assessment of the adjacent pelvic organs – urinary bladder, large intestine – is also necessary. Most of the therapies include weekly sessions of one or two hours, which are focused most frequently on the training of the muscles of the pelvic fundus, soft tissue mobilization, joint manipulation, muscle relaxation, and general tone balance. Unfortunately, there is no standardized approach regarding effective physical therapy in connection with vulvodynia, and that is why the results cannot be accurately validated nor reproduced.
• Laser therapy – Laser ablation of the vulvar epithelium with the KTP-Nd: YAG laser and the CO₂ laser presents as an alternative to the more aggressive treatment by means of vestibulectomy. Based on the angiogenesis and increased nerve sensitivity, which characterize vulvodynia, the laser is used with the purpose of disturbance of these histological abnormalities, and to cause collagen remodeling, without altering the macroscopic anatomy. Results of laser therapy for vulvodynia are comparable to vestibulectomy. The complete response has been reported in 62% and improvement in 92% of patients [rx].
• Applications of platelet-rich plasma – This is a new, alternative method for the treatment of some gynecological disorders such as vulvar dystrophy, urogenital disorders, female sexual dysfunction, and others [rx]. There is no scientific confirmation of positive results of this treatment for vulvodynia, but it is a potential opportunity and the future will show if it can become a part of the treatment options.

What else can I do to relieve the pain of vulvodynia?

• Avoid tight clothing and pantyhose.
• Wear all-cotton underwear.
• Use cold compresses or gel packs.
• Avoid exercises that put pressure on the vulva, like cycling or horseback riding.
• Wash the area gently with plain water. Don’t use soap in the genital area, don’t douche, and don’t use other possible irritants like deodorants or bubble bath.
• Use a lubricant during sex, but stay away from the lubricants that are flavored or designed to create a cooling or warming sensation.
• If you have to sit down for prolonged periods, it might help to sit on a foam “donut” or some other type of cushion that reduces pressure on the area of the vulva.
• Reduce your stress levels and get adequate sleep.

References