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VULVAL PAINVULVAL PAIN
SYNDROMESYNDROME
BYBY
DR SARITA SABHARWALDR SARITA SABHARWAL
SENIOR CONSULTANTSENIOR CONSULTANT
MAT...
Vulval pain syndromeVulval pain syndrome
 The term vulval pain syndrome comprisesThe term vulval pain syndrome comprises
...
Dysaesthetic vulvodyniaDysaesthetic vulvodynia
 This term was introduced by ISSVDThis term was introduced by ISSVD
{inter...
Dysaesthetic vulvodynia {contd}Dysaesthetic vulvodynia {contd}
 Clinical examination is normal.Clinical examination is no...
Dysaesthetic vulvodynia {contd}Dysaesthetic vulvodynia {contd}
 There may be h/o rectal, perineal orThere may be h/o rect...
VestibulodyniaVestibulodynia
 It is defined asIt is defined as
-Severe pain on vestibular touch or vaginal-Severe pain on...
Vestibulodynia{ contd}Vestibulodynia{ contd}
 Clinical examinationClinical examination
demonstratesdemonstrates
tendernes...
Vestibulodynia{ contd}Vestibulodynia{ contd}
 Another test is to use algesiometer whereAnother test is to use algesiomete...
Vestibulodynia{ contd}Vestibulodynia{ contd}
 Women typically are Caucasians , aged 20-24Women typically are Caucasians ,...
AssessmentAssessment
Most imperative to exclude the following diseasesMost imperative to exclude the following diseases
be...
AssessmentAssessment
 Less common causes are –Less common causes are –
-Apthous ulceration-Apthous ulceration
-Erosive Li...
AetiologyAetiology
 Exact cause is not known . The following are theExact cause is not known . The following are the
poss...
Aetiology contd.Aetiology contd.
4.Genetic predisposition - more common in4.Genetic predisposition - more common in
Caucas...
Aetilogy contd.Aetilogy contd.
7. Tension in levator ani muscles could be one of7. Tension in levator ani muscles could be...
ManagementManagement
 Spontaneous recovery may occur sometimes .Spontaneous recovery may occur sometimes .
 Management o...
Vulvar careVulvar care
 100% cotton under wears.100% cotton under wears.
 No under wears at night.No under wears at nigh...
Topical therapyTopical therapy
 Lignocaine jelly 2%Lignocaine jelly 2%
 Lignocaine & Prilocaine jellyLignocaine & Priloc...
Oral medicationsOral medications
 Antidepressants are the first line therapy.They block re-Antidepressants are the first ...
Anticonvulsants contdAnticonvulsants contd
 Carbamazepine is also usedCarbamazepine is also used
 Starting dose is 100mg...
AnticonvulsantsAnticonvulsants
 Gabapentin started at a dose ofGabapentin started at a dose of
- 300mg OD for 3 days foll...
Biofeedback and physical therapyBiofeedback and physical therapy
 It involves measuring nerve and muscleIt involves measu...
Intralesional injectionsIntralesional injections
 Includes trigger point injections of steroidsIncludes trigger point inj...
Interferon therapyInterferon therapy
 Includes intravestibular injections of 1.5Includes intravestibular injections of 1....
Low oxalate dietLow oxalate diet
 Avoid foods like spinach, beetroot, wheatAvoid foods like spinach, beetroot, wheat
germ...
Surgical treatmentSurgical treatment
 Last mode of treatment , used when otherLast mode of treatment , used when other
tr...
Modified VestibulectomyModified Vestibulectomy
 Complications-Complications-
- Blood loss- Blood loss
- Wound infection- ...
Multidisciplinary approachMultidisciplinary approach
 This employs the following-This employs the following-
- Clinical P...
Pain managementPain management
 The `Pain Gate Theory ’ of Melzack andThe `Pain Gate Theory ’ of Melzack and
Wall’s is em...
Key points for clinical practiceKey points for clinical practice
 A detailed history and clinical examinationA detailed h...
THANK YOUTHANK YOU
Vulvodynia
Vulvodynia
Vulvodynia
Vulvodynia
Vulvodynia
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Transcript of "Vulvodynia"

  1. 1. VULVAL PAINVULVAL PAIN SYNDROMESYNDROME BYBY DR SARITA SABHARWALDR SARITA SABHARWAL SENIOR CONSULTANTSENIOR CONSULTANT MATA CHANAN DEVI HOSPITALMATA CHANAN DEVI HOSPITAL
  2. 2. Vulval pain syndromeVulval pain syndrome  The term vulval pain syndrome comprisesThe term vulval pain syndrome comprises enigmatic causes of vulval pain andenigmatic causes of vulval pain and include a heterogeneous group of womeninclude a heterogeneous group of women who are difficult to manage.who are difficult to manage.  VPS can be classified as following –VPS can be classified as following – 1. Dysaesthetic vulvodynia1. Dysaesthetic vulvodynia 2. Vestibulodynia [Vulval vestibulitis]2. Vestibulodynia [Vulval vestibulitis]
  3. 3. Dysaesthetic vulvodyniaDysaesthetic vulvodynia  This term was introduced by ISSVDThis term was introduced by ISSVD {international society for study of vulval{international society for study of vulval diseases}.diseases}.  It is defined as ‘chronic vulvar discomfort’It is defined as ‘chronic vulvar discomfort’ characterized by burning , stinging,characterized by burning , stinging, rawness or irritation of vulva .rawness or irritation of vulva .  It may be generalized or localized ;It may be generalized or localized ; provoked or unprovoked pain.provoked or unprovoked pain.  It’s a constant neuralgic type of pain.It’s a constant neuralgic type of pain.
  4. 4. Dysaesthetic vulvodynia {contd}Dysaesthetic vulvodynia {contd}  Clinical examination is normal.Clinical examination is normal.  Women are typically premenopausal orWomen are typically premenopausal or postmenopausal.postmenopausal.  They have a long history of multiple orThey have a long history of multiple or inappropriate use of topical agents.inappropriate use of topical agents.  There is h/o superficial dyspareunia which is notThere is h/o superficial dyspareunia which is not usually reported as these women are lessusually reported as these women are less sexually active.sexually active.  Sexual dysfunction is common.Sexual dysfunction is common.
  5. 5. Dysaesthetic vulvodynia {contd}Dysaesthetic vulvodynia {contd}  There may be h/o rectal, perineal orThere may be h/o rectal, perineal or urethral discomfort.urethral discomfort.  It may be associated with other chronicIt may be associated with other chronic pain syndromes like glossodynia orpain syndromes like glossodynia or chronic low backache.chronic low backache.  There is great level of psychologicalThere is great level of psychological distress as compared to otherdistress as compared to other vulvodynias.vulvodynias.
  6. 6. VestibulodyniaVestibulodynia  It is defined asIt is defined as -Severe pain on vestibular touch or vaginal-Severe pain on vestibular touch or vaginal entry.entry. -Tenderness localized within the vestibule-Tenderness localized within the vestibule on pressure.on pressure. -Physical findings of erythema confined to-Physical findings of erythema confined to the vestibule.the vestibule.
  7. 7. Vestibulodynia{ contd}Vestibulodynia{ contd}  Clinical examinationClinical examination demonstratesdemonstrates tenderness within thetenderness within the vestibulevestibule  Common test used isCommon test used is the cotton swab testthe cotton swab test
  8. 8. Vestibulodynia{ contd}Vestibulodynia{ contd}  Another test is to use algesiometer whereAnother test is to use algesiometer where variable degrees of pressure is applied.variable degrees of pressure is applied.  Vestibular erythema may or may not be presentVestibular erythema may or may not be present and if present the degree of redness does notand if present the degree of redness does not correlate with the degree of symptoms.correlate with the degree of symptoms.  Gynaecological examination is painful.Gynaecological examination is painful.  There is tampon intolerance.There is tampon intolerance.  There may be h/o use of multiple topicalThere may be h/o use of multiple topical medications.medications.
  9. 9. Vestibulodynia{ contd}Vestibulodynia{ contd}  Women typically are Caucasians , aged 20-24Women typically are Caucasians , aged 20-24 years who present with h/o provoked pain oryears who present with h/o provoked pain or superficial dyspareunia.superficial dyspareunia.  Pain may be present from the first attemptedPain may be present from the first attempted sexual intercourse or after a period of normalsexual intercourse or after a period of normal sexual activity.sexual activity.  Fear , anger and frustration are commonlyFear , anger and frustration are commonly encountered in these womenencountered in these women  A period of at least 6 months is given beforeA period of at least 6 months is given before labeling the condition as vestibulodynialabeling the condition as vestibulodynia
  10. 10. AssessmentAssessment Most imperative to exclude the following diseasesMost imperative to exclude the following diseases before arriving at the diagnosis of VPS-before arriving at the diagnosis of VPS-  The common ones are-The common ones are- -Inflammatory vulval diseases like Lichen-Inflammatory vulval diseases like Lichen Sclerosus and Eczema.Sclerosus and Eczema. -Tight posterior fourchette and Fragile Fissured-Tight posterior fourchette and Fragile Fissured Vulval SyndromeVulval Syndrome -Symptomatic Dermographism-Symptomatic Dermographism
  11. 11. AssessmentAssessment  Less common causes are –Less common causes are – -Apthous ulceration-Apthous ulceration -Erosive Lichen Planus-Erosive Lichen Planus -Bullous Disorders-Bullous Disorders -Herpes Simplex infections-Herpes Simplex infections -Pudendal Canal syndrome-Pudendal Canal syndrome
  12. 12. AetiologyAetiology  Exact cause is not known . The following are theExact cause is not known . The following are the possible causes-possible causes- 1. Candida infection - leads to the generation of1. Candida infection - leads to the generation of an immune response causing inflammation andan immune response causing inflammation and pain even in absence of an active infection.pain even in absence of an active infection. 2. Iatrogenic - like use of topical agents for pain2. Iatrogenic - like use of topical agents for pain like antifungal creams, soaps, bubble baths andlike antifungal creams, soaps, bubble baths and hygiene sprays etc.hygiene sprays etc. 3. Psychological disorders - like stress and3. Psychological disorders - like stress and anxiety leading to increased pain perception.anxiety leading to increased pain perception.
  13. 13. Aetiology contd.Aetiology contd. 4.Genetic predisposition - more common in4.Genetic predisposition - more common in Caucasians and is less common in Blacks andCaucasians and is less common in Blacks and Asian population.Asian population. 5.Dietary factors - high oxalate diet causing5.Dietary factors - high oxalate diet causing increase in urinary excretion of oxalates leadingincrease in urinary excretion of oxalates leading to burning micturition & vulvodynia.to burning micturition & vulvodynia. 6.Hormonal causes - include estrogen deficiency6.Hormonal causes - include estrogen deficiency and oral contraceptive pill intake.Mucosaland oral contraceptive pill intake.Mucosal atrophy makes nerve endings superficialatrophy makes nerve endings superficial
  14. 14. Aetilogy contd.Aetilogy contd. 7. Tension in levator ani muscles could be one of7. Tension in levator ani muscles could be one of the causes.the causes. 8. It may be a part of Complex Regional Pain8. It may be a part of Complex Regional Pain Syndrome {CRPS} like fibromyalgia , interstitialSyndrome {CRPS} like fibromyalgia , interstitial cystitis,overactiv ebladder,irritable bowel syn. Thecystitis,overactiv ebladder,irritable bowel syn. The cause being ‘Wind Up’ phenomenon in whichcause being ‘Wind Up’ phenomenon in which there is increased activity in the dorsal horn cellsthere is increased activity in the dorsal horn cells of spinal cord after repetitive activation of theof spinal cord after repetitive activation of the primary afferent C-fibers.primary afferent C-fibers.
  15. 15. ManagementManagement  Spontaneous recovery may occur sometimes .Spontaneous recovery may occur sometimes .  Management options include –Management options include – -Vulvar care-Vulvar care -Topical therapy-Topical therapy -Oral medications-Oral medications -Biofeedback and Physical therapy-Biofeedback and Physical therapy -Intralesional injections-Intralesional injections -Interferon therapy-Interferon therapy -Low oxalate diet-Low oxalate diet -Surgical treatment-Surgical treatment -Multidisciplinary approach-Multidisciplinary approach
  16. 16. Vulvar careVulvar care  100% cotton under wears.100% cotton under wears.  No under wears at night.No under wears at night.  No soaps to be used on vulva.No soaps to be used on vulva.  Use of plain water.Use of plain water.  Use of lubricants before intercourse like KY jelly.Use of lubricants before intercourse like KY jelly.  Use of natural oils like olive oil, sweet almond oilUse of natural oils like olive oil, sweet almond oil and wheat gram oil.and wheat gram oil.  Vulva should be patted dry after washing.Vulva should be patted dry after washing.  If dryness is more use of Vaseline is advised.If dryness is more use of Vaseline is advised.
  17. 17. Topical therapyTopical therapy  Lignocaine jelly 2%Lignocaine jelly 2%  Lignocaine & Prilocaine jellyLignocaine & Prilocaine jelly  Evalon creamEvalon cream  Topical Amitriptyline 2% creamTopical Amitriptyline 2% cream
  18. 18. Oral medicationsOral medications  Antidepressants are the first line therapy.They block re-Antidepressants are the first line therapy.They block re- uptake of serotonin & noradrenalin and relieve pain byuptake of serotonin & noradrenalin and relieve pain by inhibition of Na channel. Most commonly used–inhibition of Na channel. Most commonly used– AmitriptylineAmitriptyline  Dose -5-10mg before bedtime. May be increasedDose -5-10mg before bedtime. May be increased weekly by 10-25mg depending on response. Maximumweekly by 10-25mg depending on response. Maximum dose 150mg/nightdose 150mg/night  Side effects are-Side effects are- -dry mouth-dry mouth -drowsiness-drowsiness -constipation-constipation -overdose results in seizures, MI, thrombocytopenia.-overdose results in seizures, MI, thrombocytopenia. # Less commonly used antidepressants are Nortriptyline,# Less commonly used antidepressants are Nortriptyline, Desipramine, Venlafaxine.Desipramine, Venlafaxine.
  19. 19. Anticonvulsants contdAnticonvulsants contd  Carbamazepine is also usedCarbamazepine is also used  Starting dose is 100mg orally at night, increased to 200-Starting dose is 100mg orally at night, increased to 200- 400mg BD . Maximum dose is 1200mg.400mg BD . Maximum dose is 1200mg.  Side effects areSide effects are - dizziness- dizziness - drowsiness and confusion- drowsiness and confusion - blurred vision- blurred vision - rash- rash - increased liver transaminases- increased liver transaminases - agranulocytosis and thrombocytopenia.- agranulocytosis and thrombocytopenia. # Less commonly used anticonvulsant is Topiramate# Less commonly used anticonvulsant is Topiramate # Other drugs used are Tramadol and analogue of# Other drugs used are Tramadol and analogue of Codeine.Codeine.
  20. 20. AnticonvulsantsAnticonvulsants  Gabapentin started at a dose ofGabapentin started at a dose of - 300mg OD for 3 days followed by300mg OD for 3 days followed by - 300mg BD for 3 days followed by300mg BD for 3 days followed by - 300mg TDS300mg TDS - Maximum dose is 3600mg/day and no more thanMaximum dose is 3600mg/day and no more than 1200mg should be given at a time .Dose adjustment is1200mg should be given at a time .Dose adjustment is required in renal insufficiency.required in renal insufficiency. - A time of 3-8 wks is required for the drug to becomeA time of 3-8 wks is required for the drug to become effective.effective. # Side effects are-# Side effects are- - SomnolenceSomnolence - DizzinessDizziness - GIT symptomsGIT symptoms - Mild peripheral edemaMild peripheral edema - Gait and balance problems in elderly.Gait and balance problems in elderly.
  21. 21. Biofeedback and physical therapyBiofeedback and physical therapy  It involves measuring nerve and muscleIt involves measuring nerve and muscle tension of pelvic floor by a meter ortension of pelvic floor by a meter or colored light Patient has to self assesscolored light Patient has to self assess the tension and try to relax.the tension and try to relax.  In a study conducted by Hartmann andIn a study conducted by Hartmann and Nelson a group of women with vulvodyniaNelson a group of women with vulvodynia undergoing physical therapy were studied.undergoing physical therapy were studied. 71% women showed 50% improvement in71% women showed 50% improvement in symptoms .symptoms .
  22. 22. Intralesional injectionsIntralesional injections  Includes trigger point injections of steroidsIncludes trigger point injections of steroids and Bupivacaine in a dose of 20-40mgand Bupivacaine in a dose of 20-40mg Triamcinalone with 25% BupivacaineTriamcinalone with 25% Bupivacaine monthly.monthly.  Injections may also be given as aInjections may also be given as a pudendal block.pudendal block.
  23. 23. Interferon therapyInterferon therapy  Includes intravestibular injections of 1.5Includes intravestibular injections of 1.5 million units of interferon – alpha.million units of interferon – alpha.  Disadvantages –Disadvantages – - only short term relief- only short term relief - extremely painful- extremely painful - not routinely available.- not routinely available.
  24. 24. Low oxalate dietLow oxalate diet  Avoid foods like spinach, beetroot, wheatAvoid foods like spinach, beetroot, wheat germ, chocolate, tea etc.germ, chocolate, tea etc.  Calcium citrate supplementation - to bindCalcium citrate supplementation - to bind the oxalates and increase their urinarythe oxalates and increase their urinary excretion.excretion.
  25. 25. Surgical treatmentSurgical treatment  Last mode of treatment , used when otherLast mode of treatment , used when other treatment options fail.treatment options fail.  Modified Vestibulectomy- PROCEDURE OFModified Vestibulectomy- PROCEDURE OF CHOICE.CHOICE.  Preoperative psychological counseling and postPreoperative psychological counseling and post operative sex therapy increases the success ofoperative sex therapy increases the success of surgery.surgery.  other surgical procedures areother surgical procedures are - Local Excision- Local Excision - Perineoplasty and LASER Vaporisation- Perineoplasty and LASER Vaporisation # They are less effective than Vestibulectomy and# They are less effective than Vestibulectomy and hence are not commonly used.hence are not commonly used.
  26. 26. Modified VestibulectomyModified Vestibulectomy  Complications-Complications- - Blood loss- Blood loss - Wound infection- Wound infection - Granulation tissue formation- Granulation tissue formation - Chronic fissuring- Chronic fissuring - Bartholin’s duct cyst formation- Bartholin’s duct cyst formation - Decreased lubrication- Decreased lubrication - Continued pain- Continued pain
  27. 27. Multidisciplinary approachMultidisciplinary approach  This employs the following-This employs the following- - Clinical Psychologists- Clinical Psychologists - Pain Management teams- Pain Management teams - Psychosexual Counselors- Psychosexual Counselors - Clinicians- Clinicians - Physiotherapists- Physiotherapists - Partner support is a must.- Partner support is a must.
  28. 28. Pain managementPain management  The `Pain Gate Theory ’ of Melzack andThe `Pain Gate Theory ’ of Melzack and Wall’s is employed. The theory states thatWall’s is employed. The theory states that the pain messages from the gates ofthe pain messages from the gates of spinal cord travel to the brain . Thesespinal cord travel to the brain . These gates tend to be more in women withgates tend to be more in women with stress, tension and anxiety.stress, tension and anxiety.  Therapies like relaxation , exercise andTherapies like relaxation , exercise and mobility close these gates and hencemobility close these gates and hence relieve the pain.relieve the pain.
  29. 29. Key points for clinical practiceKey points for clinical practice  A detailed history and clinical examinationA detailed history and clinical examination is necessary for diagnosis of these twois necessary for diagnosis of these two groups.groups.  Surgical option is only available forSurgical option is only available for Vestibulodynia.Vestibulodynia.  Tricyclic antidepressants are the first lineTricyclic antidepressants are the first line management for Dysaesthetic Vulvodynia.management for Dysaesthetic Vulvodynia.  A multidisciplinary approach is beneficialA multidisciplinary approach is beneficial for chronic patients.for chronic patients.
  30. 30. THANK YOUTHANK YOU
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