DEEP DYSPAREUNIA

In our previous posts we have been talking about Dyspareunia as apposed to the superficial pain of the vulva, Deep Dyspareunia is caused by deep penetration of the penis into the pelvis.

Deep Dyspareunia is usually due to pelvic pathology and the following conditions are commonly encountered.
1   Endometriosis
2   Adenomyosis
3   Acute and Chronic Pelvic Infections
4   Pelvic Congestion Syndrome
5   Adnexal Pathology
6   Retroverted Uterus
7   Residual Ovary Syndrome
8   Interstitial Cystitis
9   Dry Atrophic Tissues
10 Psychosocial Problems

Endometriosis is a condition, the cause of which we do not understand. In spite of lots of research.
In this condition the lining of the uterus can survive outside the uterus, and with each menstrual cycle has some bleed, as a result of that , some scar tissue forms. Often the blood collects and forms cysts of varying sizes. This can happen at any age group. The main symptom is painful periods, abdominal discomfort, pain on defecation and deep dyspareunia. We talked about clinical history in examination in previous posts but if you are looking for the cause of deep dyspareunia it is important to have an ultrasound and an MRI, so that diagnosis of some of the other conditions can be made.

Endometriosis also causes infertility, the definitive diagnosis is established by a surgical procedure called Laparoscopy, which in simple words mean Key Hole surgery of peeping in the belly.When Endometrios is minor it appears as dark spots which can be lasered or diathermy and this gives relief to the patient. This should be followed by oral contraception, so that the periods are small or none. With this treatment, the chances of endometriosis recurring are minimised. This often helps the women to get pregnant if they were having difficulty.

                                                 Diathermy of Endometriotic Implants
                                                 during Laparoscopy.

Endometriosis grows under the influence of hormone oestrogen, therefore it grows during reproductive years. It eases off during pregnancy and after menopause. It is a painful condition, the main treatment needs to suppress oestrogens which can be done by many drugs, the simplest being Progesterone and continuous oral contraceptive pill.
The other part of the treatment is pain relief, and this can be done by non steroidal antinflammatory drugs.
If the endometriosis is advanced and has made large cysts , they have to be surgically removed, either by key hole surgery or open surgery. The largest endometriosis I have removed were about the size of two cantaloupes , one on each ovary.
For what ever reason this patient had no pain. The diagnosis was made by Ultrasound.
The youngest patient  of endometriosis I have treated with laparoscopic diathermy was thirteen years of age. I was a bit reluctant to do this , but her mother assured me that her pain was very severe and I had to do something.

Endometriosis in itself is a very large topic and needs an individual post which I will do at a later date. But for now, you can remember that this is one of the main causes of Deep Dyspareunia.

Adenomyosis is similar to Endometriosis and here the endometrial implants are within the muscle of the uterus. Month after month there is small bleeding within the muscles of the uterus, as a result the uterus enlarges in size and the patient has heavy and painful periods. She feels as if there is a lump in her belly. When the uterus becomes enlarged it falls backwards, what is called retroverted uterus. This cause chronic pelvic pain and deep dyspareunia. This can also cause pelvic congestion adding to the symptoms. Adenomyosis  until recent times was ignored as there were no definitive diagnostic criteria. Recently with the help of colour ultrasound and MRI it has become easy.

There is no definite cure for adenomyosis but we suppress the oestrogens with the pill, intrauterine device called Mirena. The cure is hysterectomy in older women, who do not desire any children and a definitive diagnosis is made when the uterus is in your hand.

    The remaining causes of Deep Dyspareunia will be covered in forthcoming posts.     

 

VULVODYNIA

In my previous blog we talked about Rena's story when her honeymoon became a disaster.
We talked about the reasons and their management.
Today we have a similar story about Ashley, due to another cause of Vulval pain.
This is called Vulvodynia. She has been having this painful condition for almost a year, her social and marital life is very strained and stressed and she is already seeing two clinicians without any satisfactory resolution.
Vulvodynia was described for the first time in 1880. It was already mentioned in my previous post as Super Sensitivity of the Vulva. However it was ignored almost for a hundred years, then in 1975 International Society of Vulvo Vaginal Diseases, called it Burning Vulval Syndrome.

It is a very poorly recognised female pain disorder although one in four women suffer it sometime during their lifespan from adolescence to post menopause.

The current definition of Vulvodynia by ISSVD is:
"Chronic Vulval discomfort, most often described as burning pain, occurring in the Absence of relevant visible findings or a specific, clinically identifiable, neurological disorder"

We do not yet understand the full story of Vulvodynia.

Misdiagnosis is the commonest cause of suffering, when only one point four percent  seeking medical advise are correctly diagnosed. It affects the quality of life , the women get confused, there is delay in treatment and they self medicate.
Vulvodynia can be generalised , that means that it is all over the vulva, or it can be localised, the most common sites are the vestibule and the clitoral area.

And then it is called Vulvo Vestibulitis or Clitoral Vestibulitis.
When a patient comes to you with vulval pain , you take a detailed history, of how long she has had the pain,and the events that started the pain.
Sexual activity can it be continued and Psycho Sexual relationships with her partner. It is also worthwhile to know if she has had any operation in that area, and has she had a child.
The hygiene practices are also important to know.
On examination ,  we should inspect the vulva, look for any ulcers, scarring and muscle spasms, called vaginismus.
We take swabs, skin scrapings, and cervical cytology to exclude any other diseases.
One of the very simple tests is to give a cotton wool swab to the patient and ask them to show where the pain is most.
The three criteria for the diagnosis of vulvodynia , is very mild pain on touch, no positive findings and mild redness of the vulva. There are very little minor glands in the vestibule that get inflamed and cause pain.
The vulvodynia can be classified into three categories : One is the intercourse despite being painful that can be carried out with some degree of discomfort. Second Category has to be discontinued due to pain and the Third is sex cannot happen.

Vulvodynia was primarily thought to be psycho sexual but we think that there is neural problems, these most often resolve in time.
Treat any existing problems that you may have come across during your investigation.
The explanation of the condition given to the patient and the reassurance that about seventy five percent can be treated helps them.
The general advice should emphasis is that they should not self medicate and get a clear cut diagnosis.
They can wash themselves with a freshly prepared saline solution consisting of two teaspoons of salt in a litre of water. They can use cold packs to relieve the pain, do not use commercial perfumes or antiseptics and wear light clothing. Try and improve your relationships and relieve the stress.
Follow the treatment for vaginismus , you may need help of a physiotherapist who is happy to give you bio feed back treatment. Electromagnetic treatment has been tried.
Neurological Antidepressants such as Amitriptyline with a small starting dose of 10mgs. It is thought to act as nerve membrane stabiliser.
Local lubricants (water based) are useful, oestrogen cream is useful in peri menopausal women.
Five percent Xylocaine cream can be applied at the time of intercourse.
Surgically vestibulectomy has been tried with significant improvement.
Now because we think that there is a neurological involvement we are doing more studies on the refining the diagnostic criteria and treatment of this very elusive condition.

The various other Vulvo Vaginal problems will be discussed in future posts.