Benha university Hospital, Egypt
Dysesthesia= abnormal sensation
1. Hyperesthesia: Light touch is perceived as painful
2. Allodynia: a different sensation is perceived than that applied. E.g burning sensation instead of touch.
1991, the term vulvodynia & its subsets were introduced by the International Society for the study of Vulval Diseases (ISSVD).
Chronic vulval discomfort characterized by burning, stinging, rawness or irritation
2. Dysaesthetic vulvodynia.
1 & 2 constitute vulval pain syndromes because the main complaint is pain rather than itching.
Intermittent swelling & pain of the labia usually prior to menstruation, which resolves soon after.
The cause remains elusive; however, many respond to maintenance treatment with antifungals.
E.g. Lichen sclerosis, psoriasis
The filamentous projections of epithelium are found within the vestibule & inner labia minora is now considered a variant of normal.
It is not associated with HPV
Benha university Hospital
is the cleft between labia minora & lies below the hymenal ring. In order to observe it , the folds of labia minora must be separated
Its lateral border is Hart’s line (visual landmark on the inner fold of the labia minora & represents the beginning of the labia’s keratinized skin).
The medial boundary: The hymen separating the vestibule & the vagina.
The vestibule is bounded superiorly by the clitoris & inferiorly by the posterior fourchette.
There are 6 openings into it:
The uretheral meatus: 2.5 cm below the clitoris
Two Skene’sducts: one on each side of the uretheral orifice
The vaginal orifice (the introitus): occupies the lower two- thirds of the vestibule
Two Bartholin’s ducts: open outside the hymen
It is covered by non-keratinized squamous epithelium
It acts as a buffer zone between the acidic environment of the vagina & the basic environment of the labia
Chronic condition characterized by
. Severe pain on vestibular touch or attempted vaginal entry
. Tenderness to pressure localized within the vestibule.
. Erythema confined to the vestibule
. Bacterial & viral infection:
A history of candidiasis is the single most consistently reported.
HPV is now thought to be coincidental
. Iatrogenic factors:
multiple use of topical agents e.g antifungal agents,high potency topical steroids, soaps, bubble bath
. Marital disharmony
. Genetic predisposition:
Rare in black or Asian populations. More common among first degree relatives.
. Dietary oxalate in combination with calcium
cause burning of the vulva
Symptoms increased at time of menstruation. Low level of estrogen has been found. VV develop postnatally with decreased E. OCP increases the risk of VV.
. Levator hypertonia.
failed to find any specific diagnostic features
PATHOPHYSIOLOGY & MECHANISM OF PAIN
. Nocireceptor pain pathway & sensitization
. Inflammatory mediators.
20-40 yrs. Mean age is 30.5 yr
-History of provoked pain (superficial dysparunia, pain during gyn examination)
History of using multiple, inappropriate topical medications
-6 mo from the onset of symptoms to exclude women recovering from acute vulval inflammation from other causes (Curnow et al,1996)
Tenderness is specific for VV.
Pain on touching the vestibule can occur with a variety of infective or inflammatory conditions, which exclude a diagnosis of VV.
Vestibular erythema is a subjective finding often present on normal examination, however, if it is associated with VV , the degree of erythema does not correlate with symptoms.
. Cotton swab test (Friedrich,1987)
a cotton tipped swab is applied gently to normal skin as a control & then around different areas of the external genitalia. Q-tip can be used.
In VVS: hyperaethesia may be
. generalized throughout the vestibule
. focal involving the opening of the ducts of the major vestibular glands
. localized to one area e.g posterior fourchette.
. Vulval algesiometer (Curnow et al,1996)
hand-probe applied to the skin giving variable degrees of pressure producing recorded numerical results. It is not routinely available
Value (Davis & Hutchison,1999)
1. Exclusion of subclinical HPV or localized yeast infection
2. Diagnosis of VV:
dense inflammatory acetowhitening with or without satelites
Metaplasia around the opening of the Bartholin duct
30%: spontaneous remission &
50% of this remission occurred within 12 mo (Peckhman et al, 1989).
Other causes of vulvodynia.
1. Dysaesthetic vulvodynia. 2. Cyclic vulvitis
3. Vulval dermatoses 4.Vestibular papillomatosis
All the treatments are based on level lII evidence.
No curative therapy.
A multidisciplinary approach is recommended. Clinical psychologist, physiotherapist & psychosexual counselor
Lines of therapy
C. Biofeedback therapy
explain the condition, allaying any fears.
It is not infectious or related to cancer.
B. Medical Local:
1.Strict vulval hygiene: water to clean the vulva only, avoid scented products & antiseptics. Avoid nylon clothing or tight jeans. Warm sitz baths, Burows solution
2.Emollients: Short –term soothing of skin, can be used as a soap substitute. E.g.aqueous cream BP or emulsifying ointment BP 3. Lignocaine cream makes penetrative sex possible as well as acting as lubricant. It is applied 15 min before sex. Potential sensitiser, can irritate skin. Emollients& Lignocaine cream are the first line treatments
4. Corticosteroid commonly used but results variable. Potential sensitiser, can cause skin atrophy & secondary infection.
. Complimentary creams: aloe vera, calendula, Zinc oxide. Benefits are unknown. Patient often keen to try. Irritancy can occur
.. Other topical agents: e.g. Estrogen, Capsaicin cream to reduce neural response., ketoconazole. Results are variable
Interferon jell or injection: not routinely used.
Laser vaporization: abandoned
1. Antidepressant: to reduce neural feedback e.g amitriptylin (tryptizol) start with low dose & increase to relieve symptoms (10-25 mg tds). Duration: 3-6 mo. Usually of benefit for continuos pain
2. Calcium citrate: (Calcium pharco) 2 tab (chewable) tds for at least 1 yr.
3. low oxalate diet: Scientific basis not substantiated, but patients very keen to try.
4. Corticosteroid: short term with topical corticosteroid
5. Fluconazole: 100-200 mg/d for 1-2 mo. Or 150 mg /w for 3mo
Interferon( IM) failed to produce significant results
. Acute episode may respond to doxycyclin or fluconazole
C. Biofeedback therapy:
to overcome pelvic floor muscle dysfunction.
Kegels exercise or electromyographic biofeedback (Glazer et al, 1995).
Portable biofeedback machines with special vaginal skin sensor
Not routinely available, main studies included patients on amitryptilin
*Contraction /relaxation exercise (Kegel ‘s exercise) to gain control over the muscles surrounding her introits The patient must learn first how to identify the muscle for herself. She is advised to sit on the toilet with her legs spread as far apart as possible. If she then starts & stops the flow of urine, she becomes aware of the pubococcygeus action. Once the muscle is identified, the woman can practice contracting it repeatedly whenever she has time. She simply flexes this muscle 20 times in a row 3 to 5 times every day till it is firm.
pain management strategies (such as the pain- gate theory), Not usually of benefit as pain is on provocation (Nunns & Dobbs,2003).
Requires structured sessions usually with clinical psychologist
sex education (non-coital sex, sensate focus),
pelvic floor exercise.
Similar results as surgery
*Technique of sensate focus
1st stage: Non genital contact. Active partner pleasure
2nd stage: Non genital contact. Passive partner pleasure
3rd stage: Breast & genital contact:
4th stage: Sexual intercourse
all other treatment has been exhausted
. Excision of small focal lesions if these seem to be the only symptomatic areas (Getsch, 1996).
. Modified or partial vestibulectomy:
a horseshoe shaped area of the vestibule & inner labial fold is excised followed by dissection of the posterior vaginal wall. The vaginal wall is then advanced to cover the skin defect. Postoperative complications are uncommon.
Greater excision of the vestibular tissue including close to the uretheral meatus & clitoris (Woodruf,1985).
Excision of the periuretheral glands is associated with success of 95% (Marinoff & Turner,1991)
. Total vestibulectomy:
excision of the entire vestibule sparing the periclitorial & periuretheral epithelium & advancing the vaginal epithelium to the labia minora laterally & the perineal body posteriorly.
. Vestibuloplasty: enlarge the vaginal orifice by vertical incision of the posterior vaginal interoitus which is then closed horizontaly
. Partial excision of the perineal body: in recurrent & persistent perineal body fissure.
Initial success :
.VV is a clearly defined entity.
.The etiology is still unknown & may be multifactorial
. Emollients & Lignocaine cream are the first line treatments
. The multidisciplinary approach is recommended.
Coetaneous dysaesthesia causing chronic continuous non- localized vulval pain or burning.
Hyperesthesia is caused by altered coetaneous perception, either centrally or at nerve root.
More common in patient past the third decade, typically peri or post-menopausal
a long history of multiple, inappropriate use of topical agents.
Rectal, perineal & uretheral discomfort.
Dysparunia is not the principal problem.
No discomfort from Gyn examination
Unlike VV where pain is provoked, women with D V have more constant neuralgic type pain
in the region of the vulva occasionally involving the perianal area.
Pain is burning or aching & is often analogous to other neuralgic pain syndromes such as post- herpetic neuralgia.
.Vulva is normal
Complications Psychological distress: anxiety, depressive symptoms Marital conflict Sexual dysfunction: reduced sexual arousal, negative feeling in sex.
.Amitryptyline: controls pain centrally. Useful for constant pain. It is the first line of treatment
.Low oxalate diet: As for VV
.Emollients: As for VV
.Complimentary creams: As for VV
.Topical lignocaine: less benefit as effects are short lived.
B. Pain control skills (e.g. pain-gate-theory). Useful for patient where pain controls life-style
C. Acupuncture: will help a minority of patient
Diagnosis of vulvodynia (Davis & Hutchison,1999)
Physical findings on the vulva
Erythema No erythema
Acetic acid Dysesthesia
-ve +ve Faint Dense
Physiologic physiologic Vaginal exam, wet prep, culture
dermatitis, dermatoses, trauma -ve +ve