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Vulvodynia: An evidence-based approach to medical management
Abstract
• Objective: To present key concepts in the diagnosis and treatment of vulvodynia. • Methods: Review of the literature with case presentations. • Results: Vulvodynia is a condition of vulvar discomfort that affects millions of women each year. The etiology is unknown. Treatment goals are to reduce pain, improve quality of life, and recover sexual function if it has been affected. There is no single effective treatment for vulvodynia, and there is no high-quality evidence of beneficial effect for any intervention. Rapid resolution of symptomatic chronic vulvodynia is unusual and improvement of pain may take months. • Conclusion: The quality of evidence for efficacy for pain relief and for sexual function ranges from none to fair. In the absence of good quality evidence, providers and patients must discuss available evidence and make choices that are not based on confident recommendations.
... The current management approach to vulvodynia is redolent of neuropathic pain treatment, usually involving adjunctive therapy since monotherapy often fails to yield an effective response. Pharmacological and non-pharmacological interventions include oral and topical medications, local and regional injections, cognitive therapy, physical therapy and surgery (Andrews 2010;Bates and Timmins 2002). Literature reports regarding evidence of efficacy for pain reduction by pharmacological intervention of generalized unprovoked vulvodynia vary from fair to poor. ...
... Literature reports regarding evidence of efficacy for pain reduction by pharmacological intervention of generalized unprovoked vulvodynia vary from fair to poor. The majority of these reports lack high-quality evidence (Andrews 2010). However, adequate substantiation of efficacy has been reported for xylocaine (5 %), oral pregabalin, oral or topical gabapentin, oral duloxetine and selective serotonin reuptake inhibitors (SSRIs). ...
... However, adequate substantiation of efficacy has been reported for xylocaine (5 %), oral pregabalin, oral or topical gabapentin, oral duloxetine and selective serotonin reuptake inhibitors (SSRIs). Moreover, there is evidence of poor efficacy for topical capsaicin, nitroglycerin, oral tricyclic antidepressants or venlafaxine, pentosan polysulfate, opioids, tramadol, carbamazepine, lamotrigine, oxcarbazepine, topiramate and valproic acid (Andrews 2010;Fischer 2004;Phillips and Bachmann 2010). Based on these promising case reports and retrospective investigations previously performed on allodynia and vulvodynia, it was decided to conduct systemic and topical gabapentin studies in order to validate streptozotocin-induced diabetes as an animal model of vulvodynia. ...
Neuropathic vulvodynia is a state of vulval discomfort characterized by a burning sensation, diffuse pain, pruritus or rawness with an acute or chronic onset. Diabetes mellitus may cause this type of vulvar pain in several ways, so this study was conducted to evaluate streptozotocin-induced diabetes as a neuropathic pain model for vulvodynia in female rats. The presence of streptozotocin (50 mg/kg i.p.)-induced diabetes was initially verified by disclosure of pancreatic tissue degeneration, blood glucose elevation and body weight loss 5–29 days after a single treatment. Dynamic (shortened paw withdrawal latency to light brushing) and static (diminished von Frey filament threshold pressure) mechanical allodynia was then confirmed on the plantar foot surface. Subsequently, both static and dynamic vulvodynia was detected by application of the paradigm to the vulval region. Systemic gabapentin (75 mg/kg, i.p.) and topical gabapentin (10 % gel) were finally tested against allodynia and vulvodynia. Topical gabapentin and the control gel vehicle significantly increased paw withdrawal threshold in the case of the static allodynia model and also paw withdrawal latency in the model for dynamic allodynia when compared with the streptozotocin-pretreated group. Likewise, in the case of static and dynamic vulvodynia, there was a significant antivulvodynia effect of systemic and topical gabapentin treatment. These outcomes substantiate the value of this model not only for allodynia but also for vulvodynia, and this was corroborated by the findings not only with systemic but also with topical gabapentin.
Electronic supplementary material
The online version of this article (doi:10.1007/s00210-015-1145-y) contains supplementary material, which is available to authorized users.
... Compromised pelvic floor muscle integrity, i.e., hypertonic, dysfunctional muscles can precipitate chronic pelvic pain, including referred pain to the vulvar region [61][62][63]. Studies link hypovitaminosis D and chronic musculoskeletal pain [6,64,65]. ...
The synergistic relationship between food and well-being is beyond doubt. With the discovery that vitamins and minerals eradicate deficiency diseases, the role of these essential nutrients in maintaining health and mitigating disease has been confirmed for centuries. Indeed, there is now abundant evidence that comestibles enhance health through complex biological mechanisms [1–4].
... There is no strong evidence of benefit for any treatment intervention. 15,16 What works for one person may not work for another and it is a process of trial and error. Despite this, most women do improve with treatment. ...
Background:
Vulvodynia is a chronic vulvar pain condition. Localised provoked vestibulodynia (LPV) is the most common subset of vulvodynia, the hallmark symptom being pain on vaginal penetration. Young women are predominantly affected. LPV is a hidden condition that often results in distress and shame, is frequently unrecognised, and women usually see a number of health professionals before being diagnosed, which adds to their distress and confusion.
Objective:
The aim of this article is to inform health providers about the assessment and management of LPV.
Discussion:
Diagnosis is based on history. Examination is used to support the diagnosis. Management is multidisciplinary and includes psychological, physical and pharmacological therapies. With appropriate intervention, most women can expect significant reduction in pain and improved quality of life.
... Los objetivos fundamentales de este abordaje terapéutico en pacientes con vulvodinia son reducir el dolor, mejorar la calidad de vida y recobrar la función sexual si ésta se encuentra afectada 26 . ...
Vulvodynia consists of chronic vulvar pain or burning for 3 months in patients without visible injuries. The etiology of this common syndrome is unknown. A multidisciplinary approach is required for accurate diagnosis and proper treatment.Because there are usually no apparent lesions, the area of pain must be mapped by passing a cotton swab back and forth. The main objectives of treatment are to reduce pain, improve quality of life and regain sexual function, if affected. This syndrome is difficult to treat and the therapeutic approach should be sequential and include oral medications, topical applications, intralesional injections, physical therapy and surgical measures. The optimal treatment remains to be established.
... Compromised pelvic floor muscle integrity, i.e., hypertonic, dysfunctional muscles can precipitate chronic pelvic pain, including referred pain to the vulvar region [61][62][63]. Studies link hypovitaminosis D and chronic musculoskeletal pain [6,64,65]. ...
... [57][58][59][60]. Compromised pelvic floor muscle integrity, i.e., hypertonic, dysfunctional muscles can precipitate chronic pelvic pain, including referred pain to the vulvar region [61][62][63]. Studies link hypovitaminosis D and chronic musculoskeletal pain [6,64,65]. ...
Vulvar pain is a complex disorder of varied etiologies. Vulvodynia refers to chronic vulvar pain without specific identifiable cause and may have many associated factors. It carries significant negative effect on woman’s health, self-esteem, relationships and quality of life. As vulvodynia is a diagnosis of exclusion, it is imperative to exclude all treatable causes before assigning vulvodynia as the cause of vulvar pain. In the absence of specific tests, clinical assessment is of utmost importance to find the cause of vulvar pain. Treatment should be holistic and focus not only on the primary site of pain but also on its subsequent impact on the patients’ lifestyle and sexual functioning. There is no strong evidence of benefit of a particular treatment intervention over the others. It is important to individualize the treatment plan as disease course is chronic with fluctuating symptoms and presentation is varied. Usually, various treatment modalities including medical treatments, psychotherapy, physiotherapy and dietary advice are combined because different treatment strategies tackle different facets of chronic vulval and sexual pain.
Introduction:
Vulvodynia is defined as vulvar pain of at least 3 months duration without a clear identifiable cause. There are currently no validated questionnaires that assess the experience of women with localized vulvodynia of the vestibule (vestibulodynia, previously known as vulvar vestibulitis) that meet the requirements of the Food and Drug Administration's Patient Reported Outcome (PRO) Guidance.
Aim:
To develop a new content-valid PRO assessment in accordance with the Food and Drug Administration's PRO guidance to assess the symptoms and impacts of localized vulvodynia.
Material and methods:
Participants were recruited for concept elicitation interviews (ie, interviews with open-ended questions with the goal of eliciting volunteered data about the symptoms and impacts of vulvodynia). Participants were identified as having localized vulvodynia by clinicians who were experts in treating vulvar disorders. Eligibility was confirmed by the recruiting clinician, and informed consent was obtained; participants were then scheduled for in-person interviews. 25 participants were interviewed from United States (US). After concept elicitation interviews, the draft Vulvodynia Experience Questionnaire (VEQ) was developed based on the results. Cognitive interviews were conducted with 20 participants from US sites to assess the content validity of the VEQ (eg, interpretation and clarity of the items, relevance of concepts). The VEQ was further revised after cognitive interviews. All interviews were conducted face-to-face, audio-recorded, transcribed verbatim, anonymized, and analyzed using a qualitative data analysis software program.
Results:
17 unique symptoms and 32 unique impacts were reported during concept elicitation interviews. Pain (n = 25, 100%) and burning (n = 24, 96%) were the most frequently reported symptoms of localized vulvodynia, and negative impact on emotional well-being (n = 25, 100%) was the most frequently reported impact. After analysis, item generation, and cognitive interviews, the resulting VEQ v2.0 contains 3 parts (part 1, pain; part 2, associated symptoms; part 3, impacts) with a total of 25 items that measure the most frequently reported symptoms and impacts of localized vulvodynia.
Strength and limitations:
The VEQ is a multidimensional assessment of the core symptoms and impacts of localized vulvodynia that, after additional psychometric testing including the ability to detect change, may be used in clinical trials to characterize the benefits of novel treatments. The VEQ requires additional testing to establish its cultural relevance and linguistic validity in other countries.
Conclusion:
The VEQ is a novel method of collecting information on localized vulvodynia symptoms and impacts that may be suitable for use in clinical trials after psychometric testing. Goldstein AT, Diez PMQ, Kapanadze S, et al. The Vulvodynia Experience Questionnaire: Qualitative Development of a New Patient-Reported Outcome Measure for Vulvodynia. J Sex Med 2020;XX:XXX-XXX.
Next, the left and right deep levator muscles (pubococcygeus, iliococcygeus and cocygeus), along with the obturator internus muscles are palpated. Myofacsial restrictions in these muscles are often related to deep penetrating discomfort with entry and/or thrusting [11].
Women with sexual pain and pelvic floor dysfunction often have weak PFMs upon squeeze and have difficulty maintaining the contraction and relaxing the muscle to baseline.
Placebo responses have been large across a number of clinical trials for treatment of women's sexual dysfunction. Studying placebo responses may elucidate predictors of symptom reduction and responsiveness to intervention.
To determine the correlates of placebo response in participants enrolled in a clinical trial for female sexual dysfunction.
We analyzed data from 16 women with sexual arousal and orgasmic dysfunction who were randomized to receive 8 weeks of placebo treatment within a larger randomized controlled trial. Using nonparametric correlations, we tested whether age, length of relationship, psychological symptoms, and scores on self-report measures predicted change in sexual function with placebo treatment.
Female Sexual Function Index.
Consistent with findings from other studies, we found a significant improvement in sexual function scores after 8 weeks of treatment with placebo. We also found that age and length of relationship predicted the magnitude of change in sexual function across treatment. Changes in relationship adjustment, but not relationship adjustment at baseline, predicted the magnitude of improvement in sexual function scores. We observed no relationship between psychological symptom severity and change in sexual function.
Participant age and length of relationship predicted subsequent magnitude of change in sexual function scores during treatment with placebo. In addition, relationship adjustment covaried with changes in sexual function. Our findings suggest that "placebo effects" may represent underlying factors that influence the way in which women respond to the process of treatment.
A patient with severe dyspareunia caused by vulvar vestibulitis, associated with human papillomavirus infection, was treated by intramuscular interferon β. The treatment was well tolerated and no side effects were reported. A complete resolution of the vestibulitis was noticed 2 months later. No recurrence was noted during a year of follow-up.
Vulvodynia, defined as vulvar pain, soreness or burning as opposed to pruritus, is a common and important problem. Despite its high prevalence and associated distress, the etiology, diagnosis and management of this disorder have not been clearly delineated. On the basis of recent advances in psychosomatic medicine, vulvodynia can be considered a somatiform disorder affecting the vulva. Psychosomatic assessment is useful in patients with vulvodynia. This review covered recent advances in psychosomatic medicine with reference to somatization disorders and their application to vulvodynia. According to the literature, vulvodynia shares some basic criteria by which functional pain disturbances are defined. Thus, all patients with vulvodynia should undergo psychologic and sexual evaluation since in some instances psychotherapy may offer the only successful approach to the alleviation of vulvar pain.
To determine whether vestibulectomy is an effective long-term treatment and investigate the levels of patient satisfaction in women with localized provoked vulvodynia, and to provide long-term follow-up data from a cohort of women whose short-term success rates have been published previously.
A retrospective case note review of 110 women with localized provoked vulvodynia and follow-up patient questionnaire. Patients were asked to quantify their pain scores before surgery, at 2 months after surgery and 1 year after surgery and score their satisfaction levels.
Mean pain scores continued to improve throughout the first postoperative year. The mean score was 9.17 preoperatively, 5.24 at 2 months after surgery and 2.48 at 1 year after surgery. Eighty-three percent of patients would recommend the procedure as effective treatment of localized provoked vulvodynia. The overall mean satisfaction score was 7.96, and long-term success appears to be reflected by short-term results.
Vestibulectomy is an effective long-term treatment for women with provoked localized vulvodynia; the procedure is associated with high levels of patient satisfaction and low complication rates. Shortterm success appears to be a good indicator of long-term improvement, and improve- ment continues throughout the first postoperative year.
The cost-effectiveness of two treatment strategies for vulvar vestibulitis syndrome (VVS) was compared. Our prospective study consisted of 55 patients with human papillomavirus (HPV)- and non-HPV-associated VVS of at least 6 months' duration treated with intralesional recombinant alpha interferon injections, followed by surgery for nonresponders and responders compared with a hypothetical model of surgery alone. The setting was a private-practice multispecialty center for vulvovaginal disorders. Improvement was defined by patients' subjective evaluation of change in the level of introital dyspareunia and the ability to have sexual relations and objective evidence of change in the degree of erythema and tenderness to touch within the vestibule. Statistical analyses of the overall probability of improvement, overall costs and the cost per patient treated were done. Twenty-seven (49%) of 55 patients treated with alpha interferon had substantial or partial improvement. Of the 28 (51%) who did not improve following alpha interferon, 19 elected to have surgery. Surgery resulted in substantial improvement in 84% of the patients and partial improvement in 11%. Statistical analysis comparing the group treated with alpha interferon (some of whom went to surgery with the hypothetical model of surgical treatment alone) showed significant cost-saving in the group first treated with alpha interferon. At the level of effectiveness achieved in this study, intralesional alpha interferon as a first choice in the treatment of VVS is cost-effective.
The prototype of surgical treatment for vulvar vestibulitis has been the Woodruff vulvoplasty. A simpler surgery could be less morbid, technically easier, and equally effective.
Twelve patients underwent vestibular revision, nine with local anesthesia. They were followed up for between 6 months and 6 years. Outcome was judged by ease of healing and relief of tenderness. This was a feasibility study.
Ten of 12 patients had complete resolution of vestibulitis. Two others had improvement. Other causes of dyspareunia remain in 2 subjects. Issues of patient histories, postoperative healing, and functional outcome are reported.
A simple surgery seems well suited to this problem. Additional causes of dyspareunia need to be recognized preoperatively and clarified. Development of granulation tissue in areas of wound separation can create sites of continued pain. Postoperatively, reflex vaginismus should be expected and needs therapy to complement the surgical treatment.
We describe here a series of selected patients from an established vaginitis research clinic diagnosed with vulvovestibulitis (VV) who underwent surgical intervention for focal disease. Long-term results of surgical correction are reported and characteristic histopathology findings associated with vulvar vestibulitis are emphasized.
A retrospective chart review was carried out to extract relevant clinical, histologic, and outcome data. Tissue blocks of resected specimens were re-examined for specific inflammatory response.
Complete data and long-term follow up were available in 16 patients who underwent surgical intervention. All were cared for by the same practitioner (CM). The mean (+/- S.D.) age and gravidity on presentation were 26.9 +/- 5.3 years and 0.9 +/- 1.5, respectively. All but one was caucasian, and 70% were nulliparous. Symptoms included entry dyspareunia (100%), discharge (70%), burning (66%), itching (20%) and other (30%). All patients had focal tenderness; other findings were erythema (50%), acetowhite staining (80%), edema (20%), micropapules (20%) and condyloma (10%). After diagnosis, initial duration of conservative management was 9.4 +/- 6.9 months (1-26 months). No patients received interferon therapy. Because of persistent symptoms the 16 subjects underwent targeted partial perineoplasties. Initial histopathology results revealed chronic inflammation, parakeratosis, hyperkeratosis, edema, koilocytosis and acanthosis. When tissue blocks were cut and stained with Giemsa, large numbers of mast cells were identified. Mean postoperative follow up was 42.0 +/- 22.4 months (10-70 months). Follow up after surgery showed an overall improvement in 15/16 patients (93.8%).
VV affects primarily white, nulliparous women. In the carefully selected subject, surgical intervention has a high success rate, even on long-term follow up. Although the exact etiology for this condition has yet to be elucidated, the presence of mast cells supports an association with other genitourinary inflammatory syndromes such as interstitial cystitis; and allows for speculation about a possible role played by mast cell activation in the etiology of VV.
To evaluate the efficacy of a combination of subtotal perineoplasty and interferon (IFN) infiltration of the remaining anterior vestibule in the treatment of vulvar vestibulitis.
Nineteen women with vulvar vestibulitis were randomized to undergo either a total perineoplasty or a subtotal perineoplasty without removal of the anterior vestibule. The second group was further treated 6 weeks later with injection of the anterior vestibule by IFN. Differences in outcome between the groups were analyzed using Fisher's exact test.
The combination of subtotal perineoplasty and IFN injections was successful in 7 of 10 women, similar to the outcome of the group undergoing total perineoplasty (6 of 9 patients).
A combination of subtotal perineoplasty and IFN injections to the anterior vestibule is as effective as total perineoplasty and has less surgical complications.
This study evaluated the effectiveness of vestibulectomy in relieving coital pain and improving sexual function in women diagnosed with vulvar vestibulitis. Vulvar vestibulitis syndrome, a chronic, nonspecific inflammation of the vulvar vestibule, probably represents the most frequent subtype of premenopausal dyspareunia. Participants were 38 women who underwent vestibulectomy at a university hospital between 1986 and 1994. Telephone interviews were conducted to assess whether vestibulectomy or other subsequent treatments affected coital pain and sexual functioning. Length of postoperative follow-up ranged from 1.1 to 10 years, with a mean of 3.3 years. Vestibulectomy yielded a positive outcome for 63.2% of the participants and moderate to no improvement for the other 36.8%. The surgery was linked to a significant increase in intercourse frequency for the entire sample and to an increase in oral and manual stimulation for the women with successful surgical outcomes. No other factors were significantly associated with treatment outcome.
To examine the effectiveness of a 6-month treatment consisting of a weekly oral dose of 150 mg fluconazole for women with vestibulitis, and to explore the causes of treatment failure.
Forty women with vestibulitis were randomized to either of two treatment groups. One group received a 6-month low oxalate diet with calcium citrate complement, as a placebo, and the second group the same diet and calcium citrate with the addition of a weekly oral tablet of 150 mg fluconazole. The women were examined 3 months after completing treatment, for response to therapy.
The addition of intensive 6-month fluconazole treatment did not lead to an outcome better than that attained by maintaining a low oxalate diet with calcium citrate supplementation. The satisfactory response rate was 15 and 30%, respectively. The presence of 'complicated vestibulitis', candidiasis concomitant with vestibulitis, decreases the satisfactory response rate regardless of the type of treatment administered (odds ratio 19.9, 95% CI 1.6, 250).
Prolonged oral fluconazole is an ineffective treatment of vestibulitis, whether pure or complicated by concomitant vulvovaginal candidiasis. The coexistence of candidiasis and vestibulitis - complicated vestibulitis - might represent a subset of vestibulitis that is resistant to the currently available medical therapy.
Refractory genitourinary pain is a common but difficult condition to treat. Examples of chronic genitourinary pain include orchalgia, interstitial cystitis, pain after bladder suspension surgery, nonbacterial prostatitis, and genital pain related to lumbosacral neuropathy. We report our experience with oral gabapentin treatment for this condition. Gabapentin is an anticonvulsant with unclear but therapeutic effects on neurologic pain.
Twenty-one patients referred with refractory genitourinary pain were treated with oral gabapentin. There were 9 men and 12 women. In the male patients, the location of pain was testicle (4), bladder (2), penis (1), or prostate (2). In female patients, the pain was located in the urethra (4), bladder (6), vulva (1), or vagina (1). The dose of gabapentin was titrated from 300 up to 2,100 mg/day. Subjective pain severity and 10-cm visual pain scale was used before and 6 months after therapy.
The mean dose of gabapentin was 1,200 mg/day (range 300-2,100 mg). Ten of 21 patients reported subjective improvement of their pain. The remaining patients did not perceive any improvement. Gabapentin was well tolerated; only 4 patients dropped out due to side effects. The most common adverse effects were dizziness and drowsiness. Five of 8 patients with interstitial cystitis reported improvement.
Although only 10 of 21 patients improved with gabapentin, this cohort included only patients with refractory genitourinary pain that failed a wide range of prior treatments. Gabapentin belongs in the armaterium of the urologist who treats genitourinary pain.
To evaluate the results of surgical treatment for superficial dyspareunia, as manifested by patient satisfaction, as well as epidemiologic characteristics of women with this medical problem.
A questionnaire was sent to 69 women six months after the operation. It included questions about treatment before surgery and the impact of pain on the sexual relationship before and after the operation. Demographic, social and general health data were recorded before the operation. All patients returning the questionnaire were examined.
Fifty-four (78%) patients replied. Half of those abstained from sexual relations before surgical treatment. Sixty-seven percent of patients required more than six visits to various physicians, before vestibulitis was diagnosed. Prior to surgery, 80% of patients received conservative treatment, whereas after surgery only 34% required it. A moderate to excellent improvement was reported after surgery by 45 (83%) patients. Repeat surgery (n = 7) resulted in further improvement in four patients. There were no major operative complications. Forty-five patients (83%) were satisfied with the results and would recommend the surgery to other women with this clinical problem.
Surgical treatment for superficial dyspareunia from vestibulitis is quite safe and results in a high rate of patient satisfaction.
To evaluate the safety and efficacy of topical nitroglycerin cream for the treatment of vulvar pain in women with vulvodynia.
A total of 34 women diagnosed with vulvodynia were included in this study. Patients were treated with 0.2% nitroglycerin cream in the clinic. The cream was applied directly to the skin at the genital/vulvar area where the pain was located. Patients who did not experience any adverse side effects were instructed to use the cream at home at least three times per week, 5-10 minutes prior to sexual relations. Patients completed a pretreatment pain scale at baseline and a posttreatment pain scale questionnaire 4-6 weeks later.
Twenty-one patients completed both the pre- and posttreatment pain scale questionnaires, and 13 patients completed only the posttreatment pain questionnaire. Thirty-one patients (91.5%) stated that "overall" their pain had improved. Analysis of the pre- and posttreatment questionnaires revealed a significant decrease in pain intensity on a scale of 0 (no pain) to 5 (excruciating pain; 3.95-2.57; P < .000). There was also a significant decrease in the frequency of overall painful episodes on a scale of 0 (never) to 4 (always; 3.25-2.15, P < .006). All 21 patients reported "improvement" of pain during sexual activity (3.65-2.15; P < .005).
Topical nitroglycerin is safe and effective in providing temporary relief of introital dyspareunia and vulvar pain in women with vulvodynia. Women who completed this study experienced significant improvement in their overall pain and pain with sexual activity after nitroglycerin use. A larger placebo-controlled study is necessary to establish the optimum dosage level and to minimize the side effects.
To determine the characteristics of vulvar pain as to location and provocation by touch and pressure in order to confirm that current International Society for the Study of Vulvovaginal Disease definitions of vulvar vestibulitis (provoked vestibulodynia) and vulvodynia (generalized vulvodynia) effectively describe and differentiate these 2 subsets.
The charts of all women diagnosed with vulvodynia at their initial clinic visit between November 2002 and June 2003 were reviewed for this study. Each patient was evaluated by questionnaire, interview in person and by physical examination to ascertain the location and provoked vs. spontaneous nature of the pain as primary criteria for the differentiation of provoked vestibulodyniafrom generalized vulvodynia.
Sixty patients were included in the analysis. Four (6.7%) described provoked pain only in the vestibule (vulvar vestibulitis, provoked vestibulodynia), and 5 women (8.3%) experienced only unprovoked pain that was not confined to the vestibule (dysesthetic vulvodynia, unprovoked generalized vulvodynia). Other patients fell into patterns not specifically recognized or identified by a name. Sixteen (26.7%) experienced both provoked and unprovoked pain always limited to the vestibule, and 21 (35.0%) described provoked and unprovoked pain that extended beyond the vestibule at least occasionally. Six (10.0%) patients described only provoked pain primarily but not limited to the vestibule, and 8 patients each described a unique pattern.
This study suggests that the criteria of location and only provoked vs. only unprovoked pain alone do not describe 2 distinct subsets of vulvodynia; rather, there is overlap in provoked vs. unprovoked pain and location.
To assess the efficacy of topical capsaicin in the treatment of vulvar vestibulitis syndrome.
Thirty-three consecutive women referred for vulvar vestibulitis syndrome were treated with topical capsaicin 0.05 %. The capsaicin cream was applied twice a day for 30 days, then once a Day for 30 days, and finally 2 times a week for 4 months.
In 19 patients (59%), improvement of symptoms was recorded, but no complete remission was observed. Symptoms recurred in all patients after the use of capsaicin cream was discontinued. A return to a twice-weekly topical application of the cream resulted in the improvement of symptoms. Severe burning was reported as the only side effect by all the patients.
Response to treatment was only partial, possibly due to the concentration of the compound being too low, or to the need for more frequent than daily applications. The therapeutic role of capsaicin should hence be confined to a last-choice medical approach.
To study the outcome and complications of surgical treatment for vulvar vestibulitis syndrome and to identify patient characteristics that may have influenced the outcome.
Relevant patient characteristics were extracted retrospectively from the medical records of 155 women aged 40 years or younger who had received surgical treatment for vulvar vestibulitis syndrome. To assess outcome and complications, 126 of these 155 women (81%) participated in a telephone interview, conducted 1 to 4 years after surgery.
After surgery 93% of the patients could have sexual intercourse compared with 78% before surgery; this increase was statistically significant (Mantel-Haenszel odds ratio 3.43, 95% confidence interval [CI] 1.48-7.96). In 62% of the women (95% CI 53-70%), sexual intercourse was painless after surgery. Eighty-nine percent (95% CI 84-95%) would recommend surgical treatment to other women experiencing vulvar vestibulitis syndrome. There were no major complications. Decreased lubrication during sexual arousal was the most frequently reported adverse effect (24%, 95% CI 16-32%), followed by the development of a Bartholin's cyst (6%, 95% CI 2-10%). More of the women aged 30 years or younger reported that they could have sexual intercourse after surgery, and more of them would recommend surgical treatment to other patients than women aged 31 years or older.
Surgical treatment for vulvar vestibulitis syndrome achieved high success rates with an acceptable rate of complications. Age of 30 years or younger was associated with a better outcome.
III.
Vulvodynia is a chronic pain disorder of the vulva that occurs in the absence of visible infectious, inflammatory, neoplastic, or neurological findings. Multiple treatment modalities are used, often with insufficient results. We report the successful use of a spinal cord stimulator to treat vulvodynia symptoms in a patient who had unsuccessful prior conservative therapies.
A postmenopausal woman presented with 15 years of treatment for vulvar and vaginal burning and deep pelvic pain. She had been taking multiple pain medications with inadequate relief. After successful test stimulation, a permanent spinal cord stimulator was implanted. At 10 months posttreatment, her pain improved by 80%, and the patient no longer requires oral medication.
The use of spinal cord stimulation was successful in a patient with vulvodynia and unsuccessful multiple prior therapies and whose symptoms were diffuse in nature.