2Case Study28 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?
3Objectives Discuss diagnosis and classification of vulvodynia Review vulvar anatomyIdentify treatment strategies and discuss the importance of multidisciplinary treatment
4Vulvodynia 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
5Vulvodynia Prevalence Incidence 1 in 4 women affected at some point in life3-7% reproductive aged womenIncidence3.2%All ethnicitiesHighest incidence of symptom onset women age 18-25
6ISSVD ClassificationVulvar pain due to a specific disorder (not vulvodynia)InfectionInflammatoryLichen sclerosus, contact dermatitisNeoplasticNeurologicPudendal nerve entrapment, spinal nerve compression
7ISSVD Classification Generalized Localized Provoked (sexual, non sexual or both)UnprovokedMixedLocalizedIf confined to vestibule – “Provoked vestibulodynia”
8ISSVD ClassificationVulvar pain related to a specific disorder is not considered vulvodyniaInfectionsInflammatory or dermatologic conditionNeoplasmNeurologic disorder (nerve entrapment, spinal nerve compression)
9Vestibulodynia: Overview Chronic pain/discomfort around opening of vagina (e.g., the vestibule)Often inflammation and irritation around the vestibuleResultant 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
17Vulvodynia: Treatment Standard of care is a combination of medical, physical therapy and/or psychotherapy servicesIndividualized multidisciplinary careThe majority of women with vulvodynia can develop healthy, painless (and enjoyable) sexual relationshipsPrimarily treatableRemission rates 17-25% in population based studies
18Treatment: Medical Vulvar self care Topical medication Oral medication Lidocaine, estrogenOral medicationTCA, GabapentinInjectable medicationNerve blocksSurgeryVestibulectomyDietary modifications
19Treatment: 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 dailyReduces allodynia response on vulva
20Treatment: Medical Oral medications/unprovoked generalized vulvodynia Amitriptyline 10 mg q HS increase weekly up to 150 mgGabapentin 300 mg PO increase by 300 mg every 3 days to 3600 mg dailySystematic 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
21Treatment: Medical Vestibulectomy For provoked vestibulodynia only Superficial removal of affected area of vestibule with or without vaginal advancementMay be done in office under local anesthesia or in ORLast resort treatmentRequires commitment to self care after surgery and physical therapy treatment after healingReported success rates 60-95%
22Treatment: MedicalVulvodynia Interventions – Systematic Review and Evidence Grading (Obstet Gynecol Surv May;66(5):Insufficient evidence to support any non-surgical therapies for vestibulodyniaSingle 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 vestibulectomyPlacebo effect demonstratedInsufficient direct evidence for efficacy of any intervention for generalized unprovoked vulvodynia
23Non-Medical Impact of Vulvodynia Adverse impact on perception of self as a womanSense of body betrayalFeelings of inadequacy/abnormalityDisconnect from genitals due to representation of something negative /painfulRelationship discordOther sexual health concerns in both partners (e.g., low sexual desire; erectile dysfunction)Psychiatric impact (e.g., depression; hopelessness; anxiety)
24Impacting Factors: Non-Medical Self-protective response to physical painBody tenses up in anticipation of pain = painHistory 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 sexMuscle tension at “point of no return”Unhealthy relationship dynamicsCan I trust he/she will respect boundaries?
25Treatment: Physical Therapy Goal: Relaxation of pelvic floor muscles with vaginal penetration through use of multiple modalities to restore sexual functionVaginal dilatorsA gradual approach to being able to receive penetration without painAnatomy and physiology educationEducation in exercises for homeBiofeedbackTrigger point injections
26Treatment: Psychotherapy Basics Patient and partner educationShifting intimacy dynamicsBreaking the association that all intimacy leads to expectation of intercourseExpectation = muscle tension = painEven once physical components are treated, pain may remain present. Necessity of shifting intimacy dynamics.Ban on intercourse until body is healedGolden opportunity to bolster non-penetrative intimacySlowly pushing the limits of intimacyAvoiding a 0 to 1000 approach (this does not work)Allowing touch to be a positive experience again
27Treatment: Psychotherapy Basics… Often awkward, “clinical” and painless intercourse occurs prior to spontaneous, pleasurable and painless intercourseDo not trust until experience absence of painAddressing impact to sense of self as a sexual beingDevelopment of a healthy overall sexualityLearning to cope with chronic painImpacts nearly every aspect of one’s lifeTreating co-occurring psychiatric concerns (e.g., depression; anxiety)
28Question:28 y.o. G1P1001 with localized, burning vulvar pain that is worse with intercourse and tampon insertion. Her diagnosis is most likelyA. Generalized vulvodyniaB. Recurrent vulvar candidasisC. Provoked VestibulodyniaD. Pudendal nerve entrapment
29Question:28 y.o. G1P1001 with localized, burning vulvar pain. Exam reveals vestibular erythema and a positive cotton swab test. You prescribeA. Topical 5% lidocaineB. Pelvic Floor Physical TherapyC. Sexual counselingD. all of the above
30Question:Recommendations for the treatment of vulvodynia typically include which two (2) of the following:A. Scheduling intercourseB. Slowly increasing non-sexual intimacyC. Increased sexual frequency as a means of de- sensitizationD. Initial ban on penetrative sex
33ReferencesVulvodynia: 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
34ReferencesActa 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 VestibulitisJ Low Genit Tract Dis 2005;9(1): Haefner, HK, et al. The VulvoDynia Guideline.