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.