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Vulvodynia

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Vulvodynia

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Vulvodynia

  1. 1. Benha university Hospital, Egypt Email:elnashar53@hotmail.com Aboubakr Elnashar
  2. 2. Odynia= pain 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. Aboubakr Elnashar
  3. 3. 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 Aboubakr Elnashar
  4. 4. Causes 1.Vulvar vestibulitis. 2. Dysaesthetic vulvodynia. 1 & 2 constitute vulval pain syndromes because the main complaint is pain rather than itching. 3.Cyclic vulvitis. 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. Aboubakr Elnashar
  5. 5. 4.Vulval dermatoses. E.g. Lichen sclerosis, psoriasis 5.Vestibular papillomatosis. 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 Aboubakr Elnashar
  6. 6. Benha university Hospital Email:elnashar53@hotmail.com Aboubakr Elnashar
  7. 7. The vestibule: 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. Aboubakr Elnashar
  8. 8. 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 Aboubakr Elnashar
  9. 9. Aboubakr Elnashar
  10. 10. DEFINE (Friedrich,1987) 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 PREVALENCE unknown: 1.5-15% Aboubakr Elnashar
  11. 11. AETIOLOGY Unclear ,Multifactorial . 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 Aboubakr Elnashar
  12. 12. . 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 Hormonal factors: 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. Aboubakr Elnashar
  13. 13. HISTOPATHOLOGY failed to find any specific diagnostic features PATHOPHYSIOLOGY & MECHANISM OF PAIN . Nocireceptor pain pathway & sensitization . Inflammatory mediators. Aboubakr Elnashar
  14. 14. Clinical picture Age 20-40 yrs. Mean age is 30.5 yr History -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) Aboubakr Elnashar
  15. 15. Friedrich critera: 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. Aboubakr Elnashar
  16. 16. . 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. Aboubakr Elnashar
  17. 17. . 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 Aboubakr Elnashar
  18. 18. Colposcopy(vulvoscopy): 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 Periglandular erythema. Aboubakr Elnashar
  19. 19. Aboubakr Elnashar
  20. 20. COMPLICATIONS . Psychological morbidity: anxiety, depressive symptoms, somatization, hypochondrial symptoms . Sexual dysfunction: superficial dysparunia, reduced sexual arousal. Aboubakr Elnashar
  21. 21. NATURAL HISTORY 30%: spontaneous remission & 50% of this remission occurred within 12 mo (Peckhman et al, 1989). Aboubakr Elnashar
  22. 22. D.D. Other causes of vulvodynia. 1. Dysaesthetic vulvodynia. 2. Cyclic vulvitis 3. Vulval dermatoses 4.Vestibular papillomatosis Aboubakr Elnashar
  23. 23. TREATMENT All the treatments are based on level lII evidence. No curative therapy. A multidisciplinary approach is recommended. Clinical psychologist, physiotherapist & psychosexual counselor Aboubakr Elnashar
  24. 24. Lines of therapy A. Reassurance B. Medical C. Biofeedback therapy D. Behavioral E. Surgical Aboubakr Elnashar
  25. 25. A. Reassurance: explain the condition, allaying any fears. It is not infectious or related to cancer. Aboubakr Elnashar
  26. 26. 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 Aboubakr Elnashar
  27. 27. 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 Aboubakr Elnashar
  28. 28. Systemic: 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. Aboubakr Elnashar
  29. 29. 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 Aboubakr Elnashar
  30. 30. 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 Aboubakr Elnashar
  31. 31. *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. Aboubakr Elnashar
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  33. 33. Aboubakr Elnashar
  34. 34. D. Behavioral: 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), partner therapy, pelvic floor exercise. Similar results as surgery Aboubakr Elnashar
  35. 35. *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 Aboubakr Elnashar
  36. 36. E. Surgery: Indicated: all other treatment has been exhausted I. Vestibulectomy. . Excision of small focal lesions if these seem to be the only symptomatic areas (Getsch, 1996). . Modified or partial vestibulectomy: best results 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. Aboubakr Elnashar
  37. 37. 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. Aboubakr Elnashar
  38. 38. II. Other . 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 : 60-90% Aboubakr Elnashar
  39. 39. Complications: Wound hematoma, dehiscence, infection, uneven healing, Bartholin cyst. Postoperative pain Aboubakr Elnashar
  40. 40. CONCLUSION .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. Aboubakr Elnashar
  41. 41. Aboubakr Elnashar
  42. 42. Define Coetaneous dysaesthesia causing chronic continuous non- localized vulval pain or burning. Etiology Hyperesthesia is caused by altered coetaneous perception, either centrally or at nerve root. Aboubakr Elnashar
  43. 43. Clinical picture Age: More common in patient past the third decade, typically peri or post-menopausal History: 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 Aboubakr Elnashar
  44. 44. .Pain: 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 Aboubakr Elnashar
  45. 45. Complications Psychological distress: anxiety, depressive symptoms Marital conflict Sexual dysfunction: reduced sexual arousal, negative feeling in sex. Aboubakr Elnashar
  46. 46. Treatment A. Medical .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 Aboubakr Elnashar
  47. 47. Diagnosis of vulvodynia (Davis & Hutchison,1999) Physical findings on the vulva Erythema No erythema Acetic acid Dysesthesia Coetaneous Mucosal -ve +ve Faint Dense Physiologic physiologic Vaginal exam, wet prep, culture dermatitis, dermatoses, trauma -ve +ve Vestibulitis vulvovaginitis Aboubakr Elnashar
  48. 48. Aboubakr Elnashar

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