Vulval Pain Syndromes

VULVODYNIA

It appears that as the classification and terminology of vulvodynia evolves it may be becoming more perplexing for many health professionals to comprehend. Typically, 'vulvodynia' is a term used to describe chronic burning and/or pain in the vulva without objective physical findings to explain the symptoms (Lotery et al., 2004). Within the spectrum of vulvodynia, there are several subsets. The two main ones are vulval vestibulitis and dyaesthetic vulvodynia. Others described by Julius and Metts (1999) include: papulosquamous vulvar dermatoses, vesiculobullous vulvar dermatoses, neoplastic vulvar lesions, and vestibular papillomatosis.

Lotery et al. (2004), advise that there are many common conditions which may cause vulval burning and/or pain, and recommend that these are excluded when evaluating chronic vulval symptoms. These include:

Irritant dermatitis, caused by irritants such as: soap, panty-liners, moistened wipes, douches, lubricants, or excessive vaginal discharge. Candidiasis can cause vulval burning, and its treatment has been reported to improve symptoms. Other causes include: vulvo-vaginal atrophy, recurrent Herpes simplex infection, Herpes zoster and post-herpetic neuralgia, lichen sclerosus, Behcet's syndrome, and vulval intraepithelial neoplasia.

To date, while it cannot be said that there is no specific cause underlying the burning in these patients, it would be reasonable to suggest that we are unable to determine what it is (Kaufman et al., 1994 cited by Lotery et al., 2004).

Historically, there have been some links made between vulvodynia and sexual and physical abuse. Most relevant studies have failed to demonstrate this link (Edwards et al., 1997). Studies in which patients have more depressive symptoms and somatic complaints than controls do not differentiate between cause and effect (Lotery et al., 2004). James Aikens et al. (2003) showed that increased scores for somatic depressive symptoms were due to a lack of sexual interest and chronic pain, with no significant difference in cognitive affective symptoms or depressive history disorder.

Epidemiology

There are few data on the incidence and prevalence of vulvodynia. The age-range seems to lie between 20 and 60 years, and it appears to be limited almost exclusively to Caucasian women. Risk-taking sexual behaviour and a history of sexually transmitted diseases are rare. Obstetric and gynaecological history is usually unexceptional (Julius and Metts, 1999).

Initial history to determine possible cause

1. Elicit exact symptoms and location of symptoms, any previous diagnosis and treatments, use of skin irritants.

2. Examination of skin: If there is an obvious abnormality swab for microscopy and culture, and consider a skin biopsy. If a diagnosis is made, treat accordingly. It is suggested that vaginal swabs should be taken routinely for microscopy and cultures to rule out yeast, bacterial infections, etc. (Lotery et al., 2004).

DYSAESTHETIC VULVODYNIA

Dysaesthetic vulvodynia is a diagnosis given to cases of unprovoked vulval burning not limited to the vestibule and with no demonstrable abnormalities (McKay, 1988). It is mainly described in older women, who have burning that extends beyond the vaginal introitus to involve the labia majora and occasionally the inner thighs and anus. Uncontrolled observations have made links between diffuse vulval pain with low back pain or trauma, Herpes simplex virus, and pelvic surgery, which some investigators describe as pudendal neuralgia (McKay, 1993; Turner and Marinoff, 1991). However, there has been no data to support pudendal nerve dysfunction as a cause of vulval pain (Lotery et al., 2004).

Table 13 Management of dyaesthetic vulvodynia

Typical history

Physical findings

Suggested treatment

• Usually postmenopausal or perimenopausal

• Usually no cutaneous changes erythematous

• Tricyclic antidepressants

• Gabapentin

• Diffuse, unremitting burning pain that is not cyclic and can be unprovoked

• ?consider other therapies, e.g. acupuncture (Lotery et al. 2004)

• Less dyspareunia or point tenderness

• Counselling and support than in vulvar vestibulitis

Adapted from: Julius & Metts 1999 and Lotery et al. 2004.

VULVAL VESTIBULITIS (VESTIBULITIS)

Vulvar vestibulitis is typified by painful areas on the skin of the vestibules. In 1987 Friedrich set out a diagnostic criterion for vulval vestibulitis:

• Severe pain on vestibular touch or attempted vaginal entry

• Tenderness to pressure localised within the vulvar vestibule when touched with a swab

• Physical findings of erythema limited to the vulvar vestibule

It is worth bearing in mind that the vestibular area of the vagina covers many parts, including:

• Bartholin's glands

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