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La vulvodinia e le sue comorbilità: come fare una diagnosi globale
Abstract
La storia medica di una paziente fornisce informazioni essenziali per determinare la corretta diagnosi di vulvodinia. È importante porre domande specifiche, per ricevere informazioni dettagliate; ed è ugualmente essenziale formulare domande a risposta aperta che consentano alla paziente di descrivere con esattezza la sua condizione.
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Vulvar pain occurring in the absence of an underlying recognizable disease has become an increasingly common clinical problem. Members of the International Society for the Study of Vulvovaginal Disease (ISSVD) astutely recognized this idiopathic vulvar pain as a unique entity in 1976 and, at that time, used the term burning vulva syndrome to identify it. Subsequently, the ISSVD renamed the disorder vulvodynia and suggested that two clinically distinctive subsets, dysesthetic vulvodynia and vestibulitis, might exist. However, recent studies have failed to confirm an inflammatory pathogenesis for vestibulitis, and in 1999 that term was deleted from the ISSVD classification. In 2003, at the 17th World Congress, the ISSVD reestablished vulvodynia as the preferred term for vulvar pain occurring in the absence of an underlying recognizable disease and, from a standpoint of classification, identified generalized and localized subsets. The ISSVD further noted that in either subset, pain could occur spontaneously and/or could develop as a result of physical provocation. The purpose of this recommended nosology is to further communication among the various specialties that care for women with vulvodynia and to assist in the formulation of studies regarding the pathophysiology and treatment of the disorder.
Vulvar pain occurring in the absence of an underlying recognizable disease has become an increasingly common clinical problem. Members of the International Society for the Study of Vulvovaginal Disease (ISSVD) astutely recognized this idiopathic vulvar pain as a unique entity in 1976 and, at that time, used the term burning vulva syndrome to identify it. Subsequently, the ISSVD renamed the disorder vulvodynia and suggested that two clinically distinctive subsets, dysesthetic vulvodynia and vestibulitis, might exist. However, recent studies have failed to confirm an inflammatory pathogenesis for vestibulitis, and in 1999 that term was deleted from the ISSVD classification. In 2003, at the 17th World Congress, the ISSVD reestablished vulvodynia as the preferred term for vulvae pain occurring in the absence of an underlying recognizable disease and, from a standpoint of classification, identified generalized and localized subsets. The ISSVD further noted that in either subset, pain could occur spontaneously and/or could develop as a result of physical provocation. The purpose of this recommended nosology is to further communication among the various specialties that care for women with vulvodynia and to assist in the formulation of studies regarding the pathophysiology and treatment of the disorder.
This chapter will do the following: update the word “psychogenic;” suggest a pathophysiologic reading of the psychogenic contribution to chronic pelvic pain (CPP) via the stress-induced corticotropin-releasing factor signaling pathways, and differentiate predisposing, precipitating and maintaining factors; summarize the pertinent evidence; focus on the differential diagnosis between a prominent “psychogenic” versus somatic etiology for CPP; highlight the common diagnostic mistakes with a focus on iatrogenic factors and the nocebo effect; and discuss the psychological and sexual consequences of CPP.
The author examines vulvar vestibulitis syndrome, a women's health condition that is rarely discussed in family therapy literature. An argument is made regarding the relevancy to couple therapists. A review of diagnosis, prevalence rates, and treatment is provided. The empirical research findings for psychological, interpersonal, and sexual correlates are presented, and implications for couple therapists are discussed.
IntroductionNormal Finding on VulvoscopyVulvoscopic Finding of VulvodyniaVulvoscopic Finding of Ulcerative ConditionsConclusion
References
Pain is a complex subjective experience, associated with neurovegetative, affective and cognitive rapid changes. Biological, psychosocial and contextual factors may contribute. Chronic inflammation, of whatever cause, is the leading contributor to chronic pain. The mast cell directs both the inflammatory process and the shift to chronic pain, mediating through the production of Nerve Growth Factor (NGF) and other neurotrophic molecules. Women, in the fertile age, are biologically more vulnerable to chronic inflammation, as fluctuations of estrogens are agonist factors of mast cells degranulation, mostly in the premenstrual phase. Pain is defined as “nociceptive” when it indicates an ongoing damage; “neuropathic” when it becomes a disease per se.
Chronic Pelvic Pain (CPP) indicates an invalidating, persistent or recurrent pelvic pain, persisting for more than 6 months. CPP is the main complaint of 10–15% of gynaecologic consultations, leading to 40% of diagnostic laparoscopies and 15% of hysterectomies. Comorbidity, i.e. the coexistence of pathologies and painful syndromes in different pelvic organs, is another common feature. Cystitis, vulvar vestibulitis, endometriosis, irritable bowel syndrome all play an important role and contribute to identifying the hyperactive mast cell and related chronic inflammation as the common pathophysiologic factor. The paper reviews nociception characteristics, the emerging role of mast cells, the pathophysiology of comorbidity, biological, psychosexual and contextual predictors, and stresses the need to move from a “hyperspecialistic” perspective to a multisystemic reading of CPP, with special attention to the urologic perspective.
These guidelines for the management of lichen sclerosus have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.
The construction and application of the vulvalgesiometer are described. This manually-applied device allows for the quantifiable measurement of pressure-pain thresholds in the external female genital region. A set of five vulvalgesiometers exerting pressures from 3 to 950 g was used in two studies. The goal of the first study was to examine the ability of the vulvalgesiometers to discriminate between women with and without provoked vestibulodynia (PVD). In a matched sample of affected and non-affected women, women with PVD exhibited significantly lower vestibular pressure-pain thresholds as compared to control women. As well, approximately half the sample of women with PVD described the sensation elicited at pressure-pain threshold as similar to the pain experienced during sexual intercourse. The goal of the second study was to investigate the inter-rater reliability of the vulvalgesiometers. In this separate sample of women with and without PVD, each participant was tested for pressure-pain threshold by two different investigators at different times. Results demonstrated high levels of inter-rater reliability, indicating that the vulvalgesiometers can be consistently used by different investigators. Further, results indicated significant negative correlations between pressure-pain thresholds and pain intensity ratings recorded during the cotton-swab test, suggesting that the lower the threshold, the higher the pain ratings during vestibular palpation. The vulvalgesiometers can be utilized for several purposes, including treatment outcome studies and measuring the degree of PVD severity.
Psychogenic causes of chronic pelvic pain and impact of chronic pelvic pain on psychological status (including physical and sexual abuse) In: Vercellini P (ed) Chronic pelvic pain in women
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The vulvalgesiometer as a device to measure genital pressure-pain threshold
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