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Bridget Keller, MD Stacey Seibel, PhD, LP

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1 Bridget Keller, MD Stacey Seibel, PhD, LP
Vulvodynia Bridget Keller, MD Stacey Seibel, PhD, LP

2 Case Study 28 y.o. G1P1001 married female presents with chief complaint of dyspareunia and vulvar pain. Pain is burning, raw and occurs with sexual intercourse, touch and tampon use. Pain is localized to a specific area that she can show you. She has seen at least 3 other physicians for this complaint with no relief. She is frustrated. Evaluation? Diagnosis? Treatment options?

3 Objectives Discuss diagnosis and classification of vulvodynia
Review vulvar anatomy Identify treatment strategies and discuss the importance of multidisciplinary treatment

4 Vulvodynia ISSVD Definition Diagnosis of exclusion
“Chronic vulvar discomfort, most often described as burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable neurologic disorder” Diagnosis of exclusion

5 Vulvodynia Prevalence Incidence
1 in 4 women affected at some point in life 3-7% reproductive aged women Incidence 3.2% All ethnicities Highest incidence of symptom onset women age 18-25

6 ISSVD Classification Vulvar pain due to a specific disorder (not vulvodynia) Infection Inflammatory Lichen sclerosus, contact dermatitis Neoplastic Neurologic Pudendal nerve entrapment, spinal nerve compression

7 ISSVD Classification Generalized Localized
Provoked (sexual, non sexual or both) Unprovoked Mixed Localized If confined to vestibule – “Provoked vestibulodynia”

8 ISSVD Classification Vulvar pain related to a specific disorder is not considered vulvodynia Infections Inflammatory or dermatologic condition Neoplasm Neurologic disorder (nerve entrapment, spinal nerve compression)

9 Vestibulodynia: Overview
Chronic pain/discomfort around opening of vagina (e.g., the vestibule) Often inflammation and irritation around the vestibule Resultant pain with vaginal penetration (e.g., intercourse; tampon insertion) Presenting Complaint: “Sex hurts” Pain can also occur with wearing tight clothing, sitting, exercise, and pelvic exams

10 Pathophysiology Generalized vulvodynia – neuropathic pain syndrome
Co-morbid conditions Interstitial cystitis Fibromyalgia IBS Depression Chronic fatigue syndrome


12 Vulvodynia Assessment
Clinical History Risk factors Co morbid conditions Psychosocial issues Physical Exam Visual exam Cotton swab test Neurosensory exam Pelvic floor exam

13 Vulvodynia Assessment



16 Vulvodynia Assessment
Clinical History Risk factors Co morbid conditions Psychosocial issues Physical Exam Visual exam Cotton swab test Neurosensory exam Pelvic floor exam

17 Vulvodynia: Treatment
Standard of care is a combination of medical, physical therapy and/or psychotherapy services Individualized multidisciplinary care The majority of women with vulvodynia can develop healthy, painless (and enjoyable) sexual relationships Primarily treatable Remission rates 17-25% in population based studies

18 Treatment: Medical Vulvar self care Topical medication Oral medication
Lidocaine, estrogen Oral medication TCA, Gabapentin Injectable medication Nerve blocks Surgery Vestibulectomy Dietary modifications

19 Treatment: Medical Topical Medications/vestibulodynia
Zolnoun, et al 5% Lidocaine ointment to affected area at night. Soak cotton ball in 5% ointment and apply cotton ball directly to vestibule nightly for 3 months % improvement in ability to have intercourse at follow up. 2% Lidocaine jelly to affected area minutes prior to sexual activity and as needed up to 5 times daily Reduces allodynia response on vulva

20 Treatment: Medical Oral medications/unprovoked generalized vulvodynia
Amitriptyline 10 mg q HS increase weekly up to 150 mg Gabapentin 300 mg PO increase by 300 mg every 3 days to 3600 mg daily Systematic Review states insufficient evidence to support use of antidepressant (JSexMed 2012;Sept 13) Oral Despiramine and Topcial Lidocaine for provoked vestibulodynia: a RCT (Obstet Gynecol 2010; ) Oral despiramine and topical lidocaine as monotherapy or in combination failed to reduce pain more than placebo

21 Treatment: Medical Vestibulectomy For provoked vestibulodynia only
Superficial removal of affected area of vestibule with or without vaginal advancement May be done in office under local anesthesia or in OR Last resort treatment Requires commitment to self care after surgery and physical therapy treatment after healing Reported success rates 60-95%

22 Treatment: Medical Vulvodynia Interventions – Systematic Review and Evidence Grading (Obstet Gynecol Surv May;66(5): Insufficient evidence to support any non-surgical therapies for vestibulodynia Single RPCT demonstrate lack of evidence for topical 5% xylocaine, oral desipramine, oral fluconazole, topical cromolyn, topical nifedipine, and botox injections. Fair evidence of benefit of vestibulectomy Placebo effect demonstrated Insufficient direct evidence for efficacy of any intervention for generalized unprovoked vulvodynia

23 Non-Medical Impact of Vulvodynia
Adverse impact on perception of self as a woman Sense of body betrayal Feelings of inadequacy/abnormality Disconnect from genitals due to representation of something negative /painful Relationship discord Other sexual health concerns in both partners (e.g., low sexual desire; erectile dysfunction) Psychiatric impact (e.g., depression; hopelessness; anxiety)

24 Impacting Factors: Non-Medical
Self-protective response to physical pain Body tenses up in anticipation of pain = pain History of negative and/or unhealthy sexual experiences (e.g., trauma) Psychiatric Co-morbidity (e.g., anxiety) Sex as a linear concept (A = B = C) Expectation that all intimacy will lead to sex Muscle tension at “point of no return” Unhealthy relationship dynamics Can I trust he/she will respect boundaries?

25 Treatment: Physical Therapy
Goal: Relaxation of pelvic floor muscles with vaginal penetration through use of multiple modalities to restore sexual function Vaginal dilators A gradual approach to being able to receive penetration without pain Anatomy and physiology education Education in exercises for home Biofeedback Trigger point injections

26 Treatment: Psychotherapy Basics
Patient and partner education Shifting intimacy dynamics Breaking the association that all intimacy leads to expectation of intercourse Expectation = muscle tension = pain Even once physical components are treated, pain may remain present. Necessity of shifting intimacy dynamics. Ban on intercourse until body is healed Golden opportunity to bolster non-penetrative intimacy Slowly pushing the limits of intimacy Avoiding a 0 to 1000 approach (this does not work) Allowing touch to be a positive experience again

27 Treatment: Psychotherapy Basics…
Often awkward, “clinical” and painless intercourse occurs prior to spontaneous, pleasurable and painless intercourse Do not trust until experience absence of pain Addressing impact to sense of self as a sexual being Development of a healthy overall sexuality Learning to cope with chronic pain Impacts nearly every aspect of one’s life Treating co-occurring psychiatric concerns (e.g., depression; anxiety)

28 Question: 28 y.o. G1P1001 with localized, burning vulvar pain that is worse with intercourse and tampon insertion. Her diagnosis is most likely A. Generalized vulvodynia B. Recurrent vulvar candidasis C. Provoked Vestibulodynia D. Pudendal nerve entrapment

29 Question: 28 y.o. G1P1001 with localized, burning vulvar pain. Exam reveals vestibular erythema and a positive cotton swab test. You prescribe A. Topical 5% lidocaine B. Pelvic Floor Physical Therapy C. Sexual counseling D. all of the above

30 Question: Recommendations for the treatment of vulvodynia typically include which two (2) of the following: A. Scheduling intercourse B. Slowly increasing non-sexual intimacy C. Increased sexual frequency as a means of de- sensitization D. Initial ban on penetrative sex

31 Contact Information Stacey Seibel, PhD, LP Bridget Keller, MD


33 References Vulvodynia: An Under-Recognized Pain Disorder Affecting 1 in 4 Women and Adolescent Girls. National Vulvodynia Association. Slides reproduced with permission. Clin Anat Jan;26(1): Vulvar Pain: Anatomic and Recent Pathophysiologic Considerations. J Sex Med Sep 13. A Systematic Review of the Utility of Antidepressant Pharmacotherapy in the Treatment of Vulvodynia Pain. Obstet Gynecol Surv may;66(5): Vulvodynia Interventions – Systematic Review and Evidence Grading

34 References Acta Obstet Gynecol Scand Nov;89(11): Surgical Treatment of Vulvar Vestibulitis: a Review. Obstet Gynecol Sep;116(3): Oral Despiramine and Topical Lidocaine for vulvodynia: a Randomized Controlled Trial. Br J Dermatol Jun;162(6): Guidelines for the Management of Vulvodynia. Obstet Gynecol 2003;102: Zolnoun DA, Hartmann KE, Steege JF. Overnight 5% Lidocaine Treatment for Vulvar Vestibulitis J Low Genit Tract Dis 2005;9(1): Haefner, HK, et al. The VulvoDynia Guideline.

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