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Vulvodynia management
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Vulvodynia management
problems. This can lead to psychological upset. Some patients may have a combination of vulvodynia with another vulval problem, e.g., irritant dermatitis or thrush, and both conditions may require treatment. There is no accreditation process for clinicians managing vulvodynia, but it would be expected, as a part of good medical practice, that a general gynaecologist should be able to 1) take a vulval, pain and sexual history, 2) examine the patient 3) start basic treatment and 4) refer onwards if the patient does not respond to treatment or if the clinician is not confident. This will enable patients to effectively pass through the clinical pathway. Not infrequently patients get ‘stuck’ at a certain level of healthcare and do not progress to more potentially effective treatments.
David Nunns
Abstract Vulvodynia is defined as vulval discomfort, most often described as a burning pain occurring in the absence of relevant visible findings such as infection or skin disease, or a specific, clinically identifiable neurologic disorder. Before vulvodynia is diagnosed patients presenting with vulval pain need a careful history and clinical examination to avoid missing subtle, relevant dermatological conditions of the vulva. Women with vulvodynia form a diverse group with different levels of symptoms, experiences and expectations of treatment. When making a diagnosis of vulvodynia clinicians should identify subtypes of vulvodynia and explore the key treatment needs of each patient. Based on current evidence, the prognosis for many women with vulvodynia is hopeful if an early diagnosis can be made and correct, individualized treatment given. Clinical outcomes for patients should include a reduction in symptoms (including pain and painful sex), an increase in function (eg less disrupted sleep, increase mobility) and confidence in self-management through education and empowerment (eg greater engagement in self management). Clinicians not familiar with assessment and management with vulvodynia should refer onto secondary level care. Gynaecologists play an important role in assessment and management of patients, and it is within the remit of a general gynaecologists core competencies for them to provide basic care.
What is the cause of vulvodynia? A cause for symptoms remains elusive but is likely to be multifactorial. Difficulty in determining an exact cause relates to a long history of symptoms prior to a diagnosis and other factors which may have protracted symptoms such as topical treatments (e.g. inappropriate medications), psychological and psychosexual factors. A history of genital tract inflammation most often vulvovaginal candidiasis is the single most consistently reported feature reported by women. Many women recall an acute attack with the onset of symptoms and many complain of repeated attacks of candidiasis prior to an accurate diagnosis, however, many studies rely on self-reporting and confirmatory microbiology is rarely documented. Colonisation rates of candida in women with provoked pain are not increased compared to control. Irritant dermatitis usually causes vulval inflammation and settles once the irritant is removed and the skin begins to heal. Although irritancy is unlikely to be responsible for initiating symptoms, it may possibly protract symptoms against a background of vulval pain. Multiple use of topical agents on the skin of women with vulvodynia is common and these are many potential irritants that can come into contact with the skin including prescription based treatments (e.g. antifungals), over-the-counter preparations, soaps, bubble-baths and scented hygiene sprays. Irritancy from topical medications is commoner on the vulva compared to skin elsewhere as the stratum corneum of the vulval skin functions less efficiently as a protective barrier. Many women complain of being allergic to many products and there is an increased background incidence of atopy within the group as a whole. Psychological and psychosexual morbidity are common in women with vulvodynia, but it remains debatable as to whether these factors could be responsible for the onset of symptoms. Certain personality traits of women with vulvodynia suggest a proneness to stress and anxiety, which may ultimately, influence pain perception and symptoms an some studies link a stressful period in the women’s life such as marital disharmony and suggested that poor arousal could result in reduced lubrication during sexual intercourse leading to vulvo-vaginal irritation and a cycle of irritative vulval symptoms. Several studies have failed to show high rates of previous unpleasant sexual experiences or sexual and physical abuse compared to controls. Hypertonicity in the levator ani muscles when the vulval/ vestibular area is touched is common and is often seen as a
Keywords vestibulodynia; vulval pain; vulvodynia
Introduction Vulval pain is a common clinical problem in both primary and secondary level care and has been defined by the International Society for the Study of Vulval diseases as ‘vulval discomfort, most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder’. It is a neuropathic pain syndrome. The suffix ‘dynia’ refers to pain and vulvodynia is analogous to a variety of other neuropathic pain syndromes. Patients can be further classified by the anatomical site of the pain (e.g., generalised vulvodynia, hemivulvodynia, clitorodynia) and also by whether pain is provoked or unprovoked. Patients with provoked pain usually complain of sexual pain and were formerly diagnosed as having ‘vestibulitis’. This is incorrect as there is no evidence that vulvodynia is an inflammatory condition and patient with provoked pain should now be diagnosed as vestibulodynia. The clinician’s perception is that these patients are difficult and chronic, but this is possibly as a result of late diagnosis, a lack of clinical recognition and use of inappropriate treatments usually antifungals. Patients can lose confidence in health professionals and can become isolated in their condition through embarrassment and an unwillingness to discuss
David Nunns FRCOG MD is a Consultant Gynaecological Oncologist at Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
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protective guarding response. Subtle hypertonicity has been objectively measured with pelvic floor muscle electromyography and patients with provoked vestibulodynia demonstrate levator ani instability, poor muscle recovery after a contraction and elevated resting baseline tension when there was no attempt to provoke pain. Whether pelvic floor muscle tension is responsible for the perpetuation of symptoms remains to be answered, but much of the original work in the 1980s with biofeedback therapy to overcome levator hypertonia had promising results.
ISSVD classification of vulval pain A) Vulval pain related to an specific disorder C Infectious (e.g. vulval candidiasis, herpes, etc.) C Inflammatory (e.g. lichen sclerosus, lichen planus, etc.) C Neoplastic (e.g. Vulval intraepithelial neoplasia (VIN), squamous cell carcinoma, etc.) C Neurologic (e.g. herpes neuralgia, etc.) B) Vulvodynia C Generalized Provoked (sexual, nonsexual, or both) Unprovoked Mixed (provoked and unprovoked) C Localized (vestibulodynia, clitorodynia, hemivulvodynia, etc.) Provoked (sexual, nonsexual, or both) Unprovoked Mixed (provoked and unprovoked) ISSVD 2007
Vulvodynia is a chronic pain syndrome Acute pain has an important protective function as it limits further harm and encourages healing. This pain is usually inflammatory, is associated with tissue damage or injury and clinically exhibits sensory hypersensitivity, which is characterized by hyperalgesia and allodynia. Hyperalgesia is the exaggerated response to noxious substances through a general increase in the responsiveness of tissues. Allodynia is the production of pain by stimuli that do not usually cause pain by a reduction in the sensory threshold of neurons. If pain persists beyond 3e6 months, in some patients a neuropathic pain cycle can become established as a result of both central or peripheral nervous system sensitization. This neuropathic pain is not usually inflammatory and the phenomena of hyperalgesia and allodynia may or may not be present. The pain is classically described as burning, stabbing, shooting, aching, or like an electric shock. The reasons why vulvodynia may develop remain unclear, but recurrent vulval inflammation may be a factor. Vestibular neuronal proliferation has also been demonstrated in patients with vestibulodynia so it is possible that vulvodynia is a chronic pain syndrome where there are an excess of dysfunctional vulval skin nociceptors. It has long been assumed that inflammatory pain can lead to neuropathic pain, but this has never been proven in vulvodynia. Recent animal studies, however, have confirmed that an allodynia response can be generated in the vulva secondary to repeated attacks of vulvovaginal candidiasis independent of tissue inflammation. After three attacks of treated vulvovaginal candidiasis, 40% of mice tested showed a sustained allodynia response. The vulval skin of mice examined after treatment for vulvovaginal candidiasis demonstrated neuronal proliferation in the absence of inflammation. In humans some studies have shown an increase in the intraepithelial nerve fibre density among women with provoked pain which fits into the inflammatory to neuropathic pain model. Central and peripheral sensitization may be responsible for the perpetuation of symptoms once the original tissue ’trauma’ has resolved and also explain why tricyclic anti-depressants, which influence pain perception centrally, help alleviate symptoms in women with unprovoked vulvodynia. The message is clear, early diagnosis and appropriate treatment of vulval symptoms is crucial to prevent both peripheral and central nervous system processes becoming established to produce a chronic pain syndrome.
Table 1
dermatoses e.g. small fissures in the interlabial sulci caused by dermatitis. Other more subtle cases are recurrent candidiasis and idiopathic vulval fissuring. Vulval fissuring is either due to a dermatological problem of the skin eg eczema or idiopathic. Idiopathic fissuring is often an overlooked cause of sexual pain and patients can demonstrate quite dramatic splitting at the fourchette after sex.
Patient assessment History taking A detailed pain history should be taken and the consultation should focus on ‘information gathering’ as much as ‘information giving’ on the part of the clinician. One common mistake is that clinicians give a diagnosis of vulvodynia too early in a consultation with a vulvodynia patient leading to premature discussion of treatments (information giving) without adequate clinical information. Ideally, clinicians should try and build up a profile of the patient’s level and experience of pain so that management can be tailored. This might include questions on the degree, site, radiation and nature of the pain. There are many means of objectively assessing pain levels including asking the patient to score the pain out of 10 and standardised questionnaires (eg Brief Pain Inventory). Asking questions such as ‘what do you miss as a result of the pain?’ can give the clinician a greater insight into the impact of the pain on the patients’ life. Patients with sexual pain should have an adequate sexual history taken asking specifically about the presence of vaginal lubrication, vaginismus and sexual avoidance. Understandably such a comprehensive history can be difficult in the context of a busy clinic but investing time at this stage will bring focus to the patient’s problems, provide better patient satisfaction and avoid unnecessary valueless follow-up consultations. Not infrequently vulvodynia can lead to secondary psychosexual problems such as avoidance, phobia of touch, loss of libido and vaginismus (see below). Recognition of this as the main problem for the patient is crucial so that treatment can focus on sexual rehabilitation either through self-management (increasing communication with partners, use of lubricant and vaginal dilators) or with a psychosexual counsellor.
The differential diagnosis of vulval pain There is a wide differential diagnosis of women presenting with vulval pain. With the exception of vulvodynia, the majority of conditions listed in Table 1 present with a clinically obvious lesion. The most commonly missed problems are common
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For patients with a combination of symptoms it can be helpful to ask the patients ‘what is the main problem?’ Often this can be sexual pain and much evidence points to a positive benefit from early psychosexual therapy and this would be the preferred initial treatment rather than trials of ‘medical’ treatments e.g. topical agents, as the latter has limited benefit when used alone. If vulvodynia is diagnosed subgroups outlines in Table 1 should be defined as management options are significantly different. Pudendal neuralgia (PN), a nerve entrapment syndrome, can present with symptoms similar to vulvodynia but the management may be different. Patients with PN usually experience pain on sitting and are relieved by standing or lying. There may be a sensation of a lump or fullness in the vagina. Asking about the presence of a back problem or history of a pelvic or coccyx injury might be helpful as some patients with unilateral vulval pain may develop pain radiating to the vulva from a low spinal/coccyx problem. Other skin diseases should be enquired about. The history should cover exposure to potential irritants and allergens such as over the counter products, recently used creams, irritancy from incontinence of urine, scented sanitary pads or panty liners.
Gynaecologists role in the treatment of vulvodynia Provoked pain (vestibulodynia) Desensitisation techniques eg massage, use of vaginal trainers Local anaesthetic jels and ointment prescription and instruction Local injection into the vulva (steroids, Botox etc) Surgery (vestibulectomy) Referral for physiotherapy for physical treatments eg biofeedback Referral for sexual therapy for advanced counselling/therapy Unprovoked pain Drug treatment eg. Tricyclic anti-depressants, gabapentin, pregabalin Local anaesthetic jels and ointment use Referral for Pain management for advanced drug treatment (eg venlafaxine), nerve blocks (eg pudendal block, regional anaesthetics) Referral for cognitive behavioural therapy For all Discussion of holistic therapies eg acupuncture Information giving on patient information and access to support groups Table 2
Clinical examination When evaluating the patient it is essential that all the secondary causes of pain are excluded before a diagnosis of vulvodynia is made and this requires a detailed examination of the vulva. Not infrequently a diagnosis of vulvodynia can be made overlooking relevant dermatoses such as lichen planus, dermatitis or lichen sclerosus. General examine of all the skin surfaces should be carried out particularly the oral cavity as vulval dermatological problems such as lichen planus may involve other sites. A speculum examination should be carried as this might reveal a vaginal reason for pain eg erosive lichen planus or desquamative inflammatory vaginitis which presents as vaginal erythema with a purulent, culture-negative discharge. A holistic view is always important when examining pain patients to look for clues of anxiety, and apprehension. This may be relevant as many treatments may involve physical therapy to ‘desensitise’ the vulva.
and self-empowerment. Many patients respond to simple measures, many of which involve self-help and patient education. The current referral pattern of patients to secondary care may mean vulvodynia patients with chronic pain or psychosexual problems may need onwards referral to a vulval service where multidisciplinary (MDT) approach can be helpful. This will depend on the individual needs of the patient. The role of the general gynaecologist in managing the vulvodynia patient is to make a diagnosis, counsel the patient, direct to patient support groups and start basic treatment (Table 2). Patients resistant to treatment will need referral on to the vulval service (Table 3). The MDT approach for patients with complex needs includes a variety of health professionals including physiotherapy, pain management, psychosexual therapists, gynaecologists and dermatologists. Combining treatment is likely to produce greater benefit. The evidence base is poor, but the British Society for the Study of Vulval Diseases, a society representing health professionals who have an interest in vulval disease has produced national guidance on the management based on existing evidence (see below). This guidance focuses on stratifying patient care depending on needs with a focus on self-management and care within primary, secondary healthcare and vulval services. The current referral pathway in the United Kingdom for patients is often disjointed which can result in patient hitting ‘bottle-necks’ in care. Patients welcome a health professional who can lead and coordinate care. Table 4 outlines a ‘shared decision making’ approach for women with
Vulvodynia e what investigations are required? Vulvodynia can be diagnosed at the bedside often at the first visit. Vaginal microbiological swabs can be helpful especially for patients with intermittent flare-ups of symptoms to detect candida and streptococcus infections. Not infrequently patients remain convinced that vulvovaginal candidiasis is a cause for symptoms. It can be helpful to give the patient a series of vaginal swabs to take herself when she is symptomatic. If serial swabs are positive for candida then maintenance treatment with regular antifungals may be helpful in addition to the vulvodynia strategies. A vulval biopsy is not necessary to make a diagnosis and there is little benefit in taking random biopsies. Treatment can be started at the initial visit if the history and examination point to a diagnosis and further investigation may not be necessary.
The multidisciplinary vulval team for vulvodynia General practitioner Gynaecologist Dermatologist Genito-urinary medicine physician Physiotherapists Psychosexual counselling Pain management
How is vulvodynia treated? Think of the 4 ‘P’s The outcomes of effective treatment should include 1) a reduction in symptoms level (eg a reduction in the level of pain) 2) improved function (eg ability to work, have greater satisfying sexual contact), 3) confidence in self-managing symptoms through education
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Table 3
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Example of ‘Shared decision making e options in the management of unprovoked vulvodynia’ e information for patients combinations of treatments should be considered
What is the treatment?
How is it taken?
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What are the disadvantages?
Gabapentin/pregabalin
Acupuncture
Topical anaesthetic jels
Amitriptyline is a pain modifying drug which may help improve your pain control. It is different from other pain relief drugs. It is can be helpful for nerve pain, for example shooting, stabbing or burning pains. Amitriptyline is also used to treat depression, but is prescribed to improve symptoms and increase function. It is given for a variety of other chronic pain conditions eg shingles The starting dose for amitriptyline for pain is 10 mg once a day. The dose is usually taken 1 or 2 hours before normal sleep time. Your dose of amitriptyline may be slowly increased to between 50 mg and 75 mg a day depending on how helpful it is for your pain relief. The average dosage is 60 mg daily (although up to 100 mg daily can be used). The tablets are available in 10 and 25 mg forms. It may be 2 weeks before you start to see a real benefit. Pain relief and improved function. This a drug which has great benefit for neuropathic pain in other sites of the body (includes Vulvodynia) The most common side effects of this drug are drowsiness, dry mouth, constipation, feel lightheaded or dizziness. Most of these side effects will improve after several days, so it is worth pursuing with treatment.
Gabapentin or pregabalin are pain modifying drugs which may help improve your pain control. They are prescribed for pain relief for neuropathic pain. It is given for a variety of other chronic pain conditions eg shingles. There may be some benefit for those patients who suffer from anxiety.
Acupuncture is a collection of procedures which involves the stimulation of points on the body using a variety of techniques, such as penetrating the skin with needles that are then manipulated manually or by electrical stimulation.
Topical anaesthetic agents contain weak amount of a local anaesthetic such as lidocaine. The anaesthetic can ‘numb’ the nerves in the skin temporarily and may be used safely on a regular basis, provided you do not become sensitised (develop a reaction) to them.
The starting dose for gabapentin for pain is 300 mg once a day. Like for TCAD, they are dosage is increased according to the level of pain. Your doctor will guide on taking the drugs. Pregabalin (Lyrica) is a drug which is very similar to gabapentin, but is reported to have fewer side-effects and is possibly more effective. The dosage of this drug is different and you will need to discuss this with your doctor. Pain relief and improved function. This a drug which has great benefit for neuropathic pain in other sites of the body (includes Vulvodynia) The most common side effects of this drug are drowsiness, dry mouth, constipation, feel lightheaded or dizziness. Most of these side effects will improve after several days, so it is worth pursuing with treatment.
For vulvodynia the needles are usually inserted into various parts of the body (legs, lower abdomen, wrists). The needle are not usually inserted into the vulva.
Prescribed as either a gel or ointment and in different strengths. 2% gel is the weaker preparation and like KY jelly. 5% ointment is stronger and a thicker ointment. It can be used repeatedly.
Pain relief and improved function without taking drugs. It is a long established treatment for pain.
Pain relief and improved function. When the drug is absorbed through the skin there can be rapid pain relief. Topical local anaesthetics can sting on application. If this causes significant discomfort then the treatment should be avoided. Partners can become numb with sexual intercourse.
Minor discomfort from the needle insertion although this does not seem to stop treatment
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71 What are the benefits of this method?
Tricyclic anti-depressants (TCAD) (commonly nortryptyline or amitriptyline)
vulval pain. This table is for patients and is designed to enable then to self-evaluate different and combined treatment options. Engaging patients in ‘shared decision making’ might improve treatment compliance and therefore clinical outcomes. Think of the ‘4 Ps’ when planning treatment (see below).
The drug is not addictive. The drug is not given as an antidepressant but there can be potential benefits in mood at higher dosages. Some patients have benefit from the drug as it helps them sleep The drug is not addictive. The drug is not given as an antidepressant but there can be potential benefits in mood at higher dosages. Some patients have benefit from the drug as it helps them sleep
When first prescribed use a test dose on a small area of the vulva.
A series of 12 patients who had not responded to conventional treatment included two patients who felt significant improvement and three who believed their symptoms had improved and wished to continue acupuncture treatment. There are no long-term follow-up studies. Access to treatment e most patients will have to pay for the treatment. Some pain clinics might provide the service Gabapentin is the best studied drug for vulvodynia. There are reports of complete pain relief in up to 80% of women taking the drugs, but there are no long term follow-up studies. Amitriptyline is the best studied drug for vulvodynia. There are reports of complete pain relief in up to 47% of women taking the drugs, but there are no long term followup studies.
Patient education and reassurance An explanation of the condition including the nature of the diagnosis, the role of chronic pain pathways and acknowledgement of painful sex is helpful as many patients will not have heard this from a health professional. In the absence of a diagnosis, a void in understanding of symptoms can lead to worry and a lack of confidence in health professionals which can potentially impact on compliance with treatment. Reassurance is essential especially with regards fertility in younger women. Informal patient support and information through patient organisations such as the Vulval Pain Society (www. vulvalpainsociety.org) and the National Vulvodynia Association (www.nva.org) can be helpful. Sensible vulval skin care should be practiced to reduce the chance of contact sensitivity. Patient should be told to give treatments time to work, address the pain holistically, combine treatments and self-educate. Self-management should be encouraged.
Pain modification Pain modifying drugs (PMD) play a role in pain management and are useful for moderate to severe unprovoked pain (more than 5/ 10 on a pain scale). They address the central and peripheral components of neuropathic pain and usually reduce pain level and flare ups. Patients with lesser degree of pain may on balance decline PMD due to a balance of function without pain but sideeffect gain. The drugs are more likely to work when patients are motivated to start treatment. PMDs include amitriptyline and/or gabapentin. For amitriptyline (an antidepressant if used in higher doses), a dose of 10 mg/day, increasing every week until the pain is controlled, has been suggested. The average dosage is 60 mg/ day, although up to 100 mg/day can be used. Side effects usually settle within two weeks. Patients intolerant of the side effects can try nortryptyline. The duration of treatment is debatable, but some patients continue long-term. Patients who are intolerant of drugs, have severe pain or have a decline in function as a result of pain should be referred to the vulval service, specifically pain management services. Subsequent management may include nerve blocks, intralesional injections, transcutaneous electrical nerve stimulation (TENS machines) and acupuncture as examples. The latter two treatments can be accessed at any time. Local anaesthetic gels/ointment prior to sex are worthy of mention as first-line treatment. Occasionally, contact dermatitis can develop so they should be used with caution.
Other comments
Physical therapy
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Many studies demonstrate pelvic floor muscle hypertonicity in patients with vulvodynia which further exacerbates the pain cycle. Patient are not often aware of this and treatment aims to relax and desensitise (‘make less sensitive’) these muscles. Whether this is secondary effect of vulval pain or a synchronous problems is not clear.
Table 4
This success rates are variable. Some women get great benefit other find the treatment stings. There are no long-term follow-up studies.
Acupuncture
What are the success rates of treatment?
Table 4 (continued )
Tricyclic anti-depressants (TCAD) (commonly nortryptyline or amitriptyline)
Gabapentin/pregabalin
Topical anaesthetic jels
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Does surgery have a role to play?
There are variety of techniques evidenced in the literature including pelvic floor exercises, use of vaginal dilators, digital pelvic floor trigger point therapy to name a few. Access to these treatments will depend on the skillset of the local physiotherapist. The original papers reported success with biofeedback therapy using surface electromyographic (sEMG) signals from the pelvic to help overcome pelvic floor muscle dysfunction in women with vestibulodynia.
The modified vestibulectomy is the procedure of choice for patients with vestibulodynia. It involves excision of a horseshoeshaped area of the vestibule followed by dissection of the posterior vaginal wall to cover the skin defect. In a large series of follow-up patients by Eva, 59% of patients had pain free sex and the majority of patient had no regrets about surgery when followed up long-term. In an RCT, 78 women with vestibulodynia were randomized to one of three arms: 1) group cognitive e behavioural therapy (12 weeks duration), 2) pelvic floor biofeedback therapy (12 weeks duration), and 3) vestibulectomy. At follow-up at six months, all patients reported significant improvements in pain scoring. Sexual functioning with surgery had the highest success rates; however, one concern was the high number of participants randomized to surgery who declined to be included in the study. The study did support both non-surgical treatments for vestibulodynia and suggested that patients prefer a behavioural approach to treatment than a surgical one. Surgery does have some caution and those gynaecologists who are prepared to offer this type of treatment should ideally 1) work closely with vulval service dedicated to the management of women with vulval conditions and 2) offer adequate pre and post treatment support and clinical care for patients.
Psychological and psychosexual therapy and support Basic level psychological support should be given by all health professionals which includes reassurance that there is no underlying medical problem, challenge abnormal beliefs about symptoms, recognizing the ‘body-mind’ connection and the role of stress and how it amplifies pain perception (stress can produce the ‘flight-fight’ response which increases the sensation of pain). Some patients require more than basic support in a clinic consultation and mindfulness/cognitiveebehavioural therapy (CBT) self-management or formal referral to a clinical psychologist may be needed. CBT can play an important role in addressing many issues that women with vulvodynia face. Figure 1 outlines the ‘hot-cross bun’ connection that can exist between thoughts, emotions, physical sensations and behaviour. Some women with vestibulodynia may require sexual therapy and this can be structured over several sessions with a psychosexual counsellor, preferably with the woman’s partner. Much of sexual therapists work, however, is basic education on the anatomy of the vulva and pelvis and sexual response cycle which could be outlined within the clinic consultation prior to referral. Psychosexual counselors can help improving physical non-coital sexual contact, overcome pelvic floor muscle hypertonia using ‘sensate’ focus therapy (structured goal setting), and helping low libido and anorgasmia.
Service provision for women with vulval conditions e a ‘vulval service’ In the UK many women with vulval conditions attend vulval clinics for care. Over recent years a large number of these clinics have been set up around the UK. According to the British Society for the Study of Vulval Diseases (BSSVD), a professional society dedicated to the care of women with vulval conditions, there are around 80 such clinics in the UK. Around two-thirds are multidisciplinary with the remainder being single discipline. Different
A ‘hot-cross bun’ diagram of how behaviors, thoughts, physical sensation and emotions may be interlinked in patients with vulvodynia Behaviours Avoid intimacy Becomes withdrawn emotionally Push self to make up for it Physical sensations Muscle tension = Further pain Headaches Irritable bowel symptoms Sinking feeling in stomach
Thoughts I’m less of a woman I better not lead my partner on He might find someone else I’ll try and make up for it in other ways
Emotions Fear/Anxiety Stress Guilt Depression
Figure 1
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Disease (BSSVD) Guideline Group. Guidelines for the management of vulvodynia. Br J Dermatol 2010; 162: 1180e5. Framework for the management of vulval skin disorders: An evidencebased framework for improving the initial assessment and care of women with vulval disorders from the RCOG. This guidance is intended for the general gynaecologist, with advice on when to refer to the specialist multidisciplinary team. www.rcog.org.uk/womens-health/ clinical-guidance/management-vulval-skin-disorders-green-top-58. Nunns D, Mandal D, Byrne M, et al; British society for the study of vulval. Standards of care for women with a vulval condition. https://www.pcc-cic. org.uk/sites/default/files/articles/attachments/standards_of_care_ vulval_conditions_report.pdf. Stockdale CK, Lawson HW. 2013 Vulvodynia Guideline update. J Low Genit Tract Dis 2014 Apr; 18: 93e100. Vulval Pain Society: Support and information for women with vulvodynia. Contains information on workshops for women and links to patient support groups PO Box 7804, Nottingham, NG3 5ZQ. www. vulvalpainsociety.org.
combinations of consultants work within the clinics from specialities such as genitourinary medicine (GUM), dermatology and gynaecology. The British Society for the Study of Vulval Disease working with other stakeholders have developed standards for the care of women with vulval conditions focussing on a vulval service rather than vulval clinics (see further reading). A ‘vulval service’ is defined as an MDT of health professionals interested in vulval disorders across different specialities. The aim of these standards is to support equitable access to high-quality care for people with vulval conditions. These standards are intended to form a basis for the development of any NICE quality standards for vulval conditions. If services are delivered to these standards, there is every expectation that outcomes for people with vulval conditions will improve. The levels of care that women with a vulval problem receive is stratified from level 1 (self care), level 1(GP), level 2 (secondary healthcare) and level 3 (vulval service). It would be expected that women with vulvodynia might receive care at every level depending on clinical need.
Conclusions
Practice points
Our ‘tool-kit’ of skills as a gynaecologist is limited when managing some patients with vulvodynia and referral to health professionals may be necessary. However, we do have an important role to play in assessment, triage, counselling and starting basic treatment which is likely to benefit many women. The patient experience of vulvodynia is poor as a result of a health system that often fails them in terms of delayed diagnosis and poor clinical recognition, so as gynaecologists we have to move forwards with this group of patients to provide the tenets of quality care that we wish for any patient; clinical effectiveness, safety and a good patient experience. Based on the current literature, the prognosis can be promising for women with vulvodynia who receive correct individualised treatment. Labelling this condition as a chronic illness with no cure would be wrong particularly when the evidence suggested that a significant proportion of patients benefit. A
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FURTHER READING British Society for the Study of Vulval Diseases. UK multidisciplinary specialist society for vulval disease. www.bssvd.org.
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Vulvodynia is a cause of chronic genital pain that has a variety of clinical presentations and treatment options and can be classified as provoked (vestibulodynia) or unprovoked but many patients have both symptoms The history should be tailored to the presenting complaint and may include a pain and psychosexual history if appropriate A clinical examination is essential to exclude other overlooked causes of vulval pain (e.g., fissures, lichen sclerosus and lichen planus) The role of the generalist in secondary care is to make a diagnosis, counsel the patient, give written information, direct to patient support groups and start basic treatment The current referral pattern of patients to secondary care may mean vulvodynia patients with chronic pain or psychosexual problems may need onwards referral to a vulval service where a multidisciplinary approach can be helpful. This will depend on the individual needs of the patient Good evidence for effective care is lacking
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Vulvodynia management
problems. This can lead to psychological upset. Some patients may have a combination of vulvodynia with another vulval problem, e.g., irritant dermatitis or thrush, and both conditions may require treatment. There is no accreditation process for clinicians managing vulvodynia, but it would be expected, as a part of good medical practice, that a general gynaecologist should be able to 1) take a vulval, pain and sexual history, 2) examine the patient 3) start basic treatment and 4) refer onwards if the patient does not respond to treatment or if the clinician is not confident. This will enable patients to effectively pass through the clinical pathway. Not infrequently patients get ‘stuck’ at a certain level of healthcare and do not progress to more potentially effective treatments.
David Nunns
Abstract Vulvodynia is defined as vulval discomfort, most often described as a burning pain occurring in the absence of relevant visible findings such as infection or skin disease, or a specific, clinically identifiable neurologic disorder. Before vulvodynia is diagnosed patients presenting with vulval pain need a careful history and clinical examination to avoid missing subtle, relevant dermatological conditions of the vulva. Women with vulvodynia form a diverse group with different levels of symptoms, experiences and expectations of treatment. When making a diagnosis of vulvodynia clinicians should identify subtypes of vulvodynia and explore the key treatment needs of each patient. Based on current evidence, the prognosis for many women with vulvodynia is hopeful if an early diagnosis can be made and correct, individualized treatment given. Clinical outcomes for patients should include a reduction in symptoms (including pain and painful sex), an increase in function (eg less disrupted sleep, increase mobility) and confidence in self-management through education and empowerment (eg greater engagement in self management). Clinicians not familiar with assessment and management with vulvodynia should refer onto secondary level care. Gynaecologists play an important role in assessment and management of patients, and it is within the remit of a general gynaecologists core competencies for them to provide basic care.
What is the cause of vulvodynia? A cause for symptoms remains elusive but is likely to be multifactorial. Difficulty in determining an exact cause relates to a long history of symptoms prior to a diagnosis and other factors which may have protracted symptoms such as topical treatments (e.g. inappropriate medications), psychological and psychosexual factors. A history of genital tract inflammation most often vulvovaginal candidiasis is the single most consistently reported feature reported by women. Many women recall an acute attack with the onset of symptoms and many complain of repeated attacks of candidiasis prior to an accurate diagnosis, however, many studies rely on self-reporting and confirmatory microbiology is rarely documented. Colonisation rates of candida in women with provoked pain are not increased compared to control. Irritant dermatitis usually causes vulval inflammation and settles once the irritant is removed and the skin begins to heal. Although irritancy is unlikely to be responsible for initiating symptoms, it may possibly protract symptoms against a background of vulval pain. Multiple use of topical agents on the skin of women with vulvodynia is common and these are many potential irritants that can come into contact with the skin including prescription based treatments (e.g. antifungals), over-the-counter preparations, soaps, bubble-baths and scented hygiene sprays. Irritancy from topical medications is commoner on the vulva compared to skin elsewhere as the stratum corneum of the vulval skin functions less efficiently as a protective barrier. Many women complain of being allergic to many products and there is an increased background incidence of atopy within the group as a whole. Psychological and psychosexual morbidity are common in women with vulvodynia, but it remains debatable as to whether these factors could be responsible for the onset of symptoms. Certain personality traits of women with vulvodynia suggest a proneness to stress and anxiety, which may ultimately, influence pain perception and symptoms an some studies link a stressful period in the women’s life such as marital disharmony and suggested that poor arousal could result in reduced lubrication during sexual intercourse leading to vulvo-vaginal irritation and a cycle of irritative vulval symptoms. Several studies have failed to show high rates of previous unpleasant sexual experiences or sexual and physical abuse compared to controls. Hypertonicity in the levator ani muscles when the vulval/ vestibular area is touched is common and is often seen as a
Keywords vestibulodynia; vulval pain; vulvodynia
Introduction Vulval pain is a common clinical problem in both primary and secondary level care and has been defined by the International Society for the Study of Vulval diseases as ‘vulval discomfort, most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurologic disorder’. It is a neuropathic pain syndrome. The suffix ‘dynia’ refers to pain and vulvodynia is analogous to a variety of other neuropathic pain syndromes. Patients can be further classified by the anatomical site of the pain (e.g., generalised vulvodynia, hemivulvodynia, clitorodynia) and also by whether pain is provoked or unprovoked. Patients with provoked pain usually complain of sexual pain and were formerly diagnosed as having ‘vestibulitis’. This is incorrect as there is no evidence that vulvodynia is an inflammatory condition and patient with provoked pain should now be diagnosed as vestibulodynia. The clinician’s perception is that these patients are difficult and chronic, but this is possibly as a result of late diagnosis, a lack of clinical recognition and use of inappropriate treatments usually antifungals. Patients can lose confidence in health professionals and can become isolated in their condition through embarrassment and an unwillingness to discuss
David Nunns FRCOG MD is a Consultant Gynaecological Oncologist at Nottingham University Hospitals, Nottingham, UK. Conflicts of interest: none declared.
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protective guarding response. Subtle hypertonicity has been objectively measured with pelvic floor muscle electromyography and patients with provoked vestibulodynia demonstrate levator ani instability, poor muscle recovery after a contraction and elevated resting baseline tension when there was no attempt to provoke pain. Whether pelvic floor muscle tension is responsible for the perpetuation of symptoms remains to be answered, but much of the original work in the 1980s with biofeedback therapy to overcome levator hypertonia had promising results.
ISSVD classification of vulval pain A) Vulval pain related to an specific disorder C Infectious (e.g. vulval candidiasis, herpes, etc.) C Inflammatory (e.g. lichen sclerosus, lichen planus, etc.) C Neoplastic (e.g. Vulval intraepithelial neoplasia (VIN), squamous cell carcinoma, etc.) C Neurologic (e.g. herpes neuralgia, etc.) B) Vulvodynia C Generalized Provoked (sexual, nonsexual, or both) Unprovoked Mixed (provoked and unprovoked) C Localized (vestibulodynia, clitorodynia, hemivulvodynia, etc.) Provoked (sexual, nonsexual, or both) Unprovoked Mixed (provoked and unprovoked) ISSVD 2007
Vulvodynia is a chronic pain syndrome Acute pain has an important protective function as it limits further harm and encourages healing. This pain is usually inflammatory, is associated with tissue damage or injury and clinically exhibits sensory hypersensitivity, which is characterized by hyperalgesia and allodynia. Hyperalgesia is the exaggerated response to noxious substances through a general increase in the responsiveness of tissues. Allodynia is the production of pain by stimuli that do not usually cause pain by a reduction in the sensory threshold of neurons. If pain persists beyond 3e6 months, in some patients a neuropathic pain cycle can become established as a result of both central or peripheral nervous system sensitization. This neuropathic pain is not usually inflammatory and the phenomena of hyperalgesia and allodynia may or may not be present. The pain is classically described as burning, stabbing, shooting, aching, or like an electric shock. The reasons why vulvodynia may develop remain unclear, but recurrent vulval inflammation may be a factor. Vestibular neuronal proliferation has also been demonstrated in patients with vestibulodynia so it is possible that vulvodynia is a chronic pain syndrome where there are an excess of dysfunctional vulval skin nociceptors. It has long been assumed that inflammatory pain can lead to neuropathic pain, but this has never been proven in vulvodynia. Recent animal studies, however, have confirmed that an allodynia response can be generated in the vulva secondary to repeated attacks of vulvovaginal candidiasis independent of tissue inflammation. After three attacks of treated vulvovaginal candidiasis, 40% of mice tested showed a sustained allodynia response. The vulval skin of mice examined after treatment for vulvovaginal candidiasis demonstrated neuronal proliferation in the absence of inflammation. In humans some studies have shown an increase in the intraepithelial nerve fibre density among women with provoked pain which fits into the inflammatory to neuropathic pain model. Central and peripheral sensitization may be responsible for the perpetuation of symptoms once the original tissue ’trauma’ has resolved and also explain why tricyclic anti-depressants, which influence pain perception centrally, help alleviate symptoms in women with unprovoked vulvodynia. The message is clear, early diagnosis and appropriate treatment of vulval symptoms is crucial to prevent both peripheral and central nervous system processes becoming established to produce a chronic pain syndrome.
Table 1
dermatoses e.g. small fissures in the interlabial sulci caused by dermatitis. Other more subtle cases are recurrent candidiasis and idiopathic vulval fissuring. Vulval fissuring is either due to a dermatological problem of the skin eg eczema or idiopathic. Idiopathic fissuring is often an overlooked cause of sexual pain and patients can demonstrate quite dramatic splitting at the fourchette after sex.
Patient assessment History taking A detailed pain history should be taken and the consultation should focus on ‘information gathering’ as much as ‘information giving’ on the part of the clinician. One common mistake is that clinicians give a diagnosis of vulvodynia too early in a consultation with a vulvodynia patient leading to premature discussion of treatments (information giving) without adequate clinical information. Ideally, clinicians should try and build up a profile of the patient’s level and experience of pain so that management can be tailored. This might include questions on the degree, site, radiation and nature of the pain. There are many means of objectively assessing pain levels including asking the patient to score the pain out of 10 and standardised questionnaires (eg Brief Pain Inventory). Asking questions such as ‘what do you miss as a result of the pain?’ can give the clinician a greater insight into the impact of the pain on the patients’ life. Patients with sexual pain should have an adequate sexual history taken asking specifically about the presence of vaginal lubrication, vaginismus and sexual avoidance. Understandably such a comprehensive history can be difficult in the context of a busy clinic but investing time at this stage will bring focus to the patient’s problems, provide better patient satisfaction and avoid unnecessary valueless follow-up consultations. Not infrequently vulvodynia can lead to secondary psychosexual problems such as avoidance, phobia of touch, loss of libido and vaginismus (see below). Recognition of this as the main problem for the patient is crucial so that treatment can focus on sexual rehabilitation either through self-management (increasing communication with partners, use of lubricant and vaginal dilators) or with a psychosexual counsellor.
The differential diagnosis of vulval pain There is a wide differential diagnosis of women presenting with vulval pain. With the exception of vulvodynia, the majority of conditions listed in Table 1 present with a clinically obvious lesion. The most commonly missed problems are common
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For patients with a combination of symptoms it can be helpful to ask the patients ‘what is the main problem?’ Often this can be sexual pain and much evidence points to a positive benefit from early psychosexual therapy and this would be the preferred initial treatment rather than trials of ‘medical’ treatments e.g. topical agents, as the latter has limited benefit when used alone. If vulvodynia is diagnosed subgroups outlines in Table 1 should be defined as management options are significantly different. Pudendal neuralgia (PN), a nerve entrapment syndrome, can present with symptoms similar to vulvodynia but the management may be different. Patients with PN usually experience pain on sitting and are relieved by standing or lying. There may be a sensation of a lump or fullness in the vagina. Asking about the presence of a back problem or history of a pelvic or coccyx injury might be helpful as some patients with unilateral vulval pain may develop pain radiating to the vulva from a low spinal/coccyx problem. Other skin diseases should be enquired about. The history should cover exposure to potential irritants and allergens such as over the counter products, recently used creams, irritancy from incontinence of urine, scented sanitary pads or panty liners.
Gynaecologists role in the treatment of vulvodynia Provoked pain (vestibulodynia) Desensitisation techniques eg massage, use of vaginal trainers Local anaesthetic jels and ointment prescription and instruction Local injection into the vulva (steroids, Botox etc) Surgery (vestibulectomy) Referral for physiotherapy for physical treatments eg biofeedback Referral for sexual therapy for advanced counselling/therapy Unprovoked pain Drug treatment eg. Tricyclic anti-depressants, gabapentin, pregabalin Local anaesthetic jels and ointment use Referral for Pain management for advanced drug treatment (eg venlafaxine), nerve blocks (eg pudendal block, regional anaesthetics) Referral for cognitive behavioural therapy For all Discussion of holistic therapies eg acupuncture Information giving on patient information and access to support groups Table 2
Clinical examination When evaluating the patient it is essential that all the secondary causes of pain are excluded before a diagnosis of vulvodynia is made and this requires a detailed examination of the vulva. Not infrequently a diagnosis of vulvodynia can be made overlooking relevant dermatoses such as lichen planus, dermatitis or lichen sclerosus. General examine of all the skin surfaces should be carried out particularly the oral cavity as vulval dermatological problems such as lichen planus may involve other sites. A speculum examination should be carried as this might reveal a vaginal reason for pain eg erosive lichen planus or desquamative inflammatory vaginitis which presents as vaginal erythema with a purulent, culture-negative discharge. A holistic view is always important when examining pain patients to look for clues of anxiety, and apprehension. This may be relevant as many treatments may involve physical therapy to ‘desensitise’ the vulva.
and self-empowerment. Many patients respond to simple measures, many of which involve self-help and patient education. The current referral pattern of patients to secondary care may mean vulvodynia patients with chronic pain or psychosexual problems may need onwards referral to a vulval service where multidisciplinary (MDT) approach can be helpful. This will depend on the individual needs of the patient. The role of the general gynaecologist in managing the vulvodynia patient is to make a diagnosis, counsel the patient, direct to patient support groups and start basic treatment (Table 2). Patients resistant to treatment will need referral on to the vulval service (Table 3). The MDT approach for patients with complex needs includes a variety of health professionals including physiotherapy, pain management, psychosexual therapists, gynaecologists and dermatologists. Combining treatment is likely to produce greater benefit. The evidence base is poor, but the British Society for the Study of Vulval Diseases, a society representing health professionals who have an interest in vulval disease has produced national guidance on the management based on existing evidence (see below). This guidance focuses on stratifying patient care depending on needs with a focus on self-management and care within primary, secondary healthcare and vulval services. The current referral pathway in the United Kingdom for patients is often disjointed which can result in patient hitting ‘bottle-necks’ in care. Patients welcome a health professional who can lead and coordinate care. Table 4 outlines a ‘shared decision making’ approach for women with
Vulvodynia e what investigations are required? Vulvodynia can be diagnosed at the bedside often at the first visit. Vaginal microbiological swabs can be helpful especially for patients with intermittent flare-ups of symptoms to detect candida and streptococcus infections. Not infrequently patients remain convinced that vulvovaginal candidiasis is a cause for symptoms. It can be helpful to give the patient a series of vaginal swabs to take herself when she is symptomatic. If serial swabs are positive for candida then maintenance treatment with regular antifungals may be helpful in addition to the vulvodynia strategies. A vulval biopsy is not necessary to make a diagnosis and there is little benefit in taking random biopsies. Treatment can be started at the initial visit if the history and examination point to a diagnosis and further investigation may not be necessary.
The multidisciplinary vulval team for vulvodynia General practitioner Gynaecologist Dermatologist Genito-urinary medicine physician Physiotherapists Psychosexual counselling Pain management
How is vulvodynia treated? Think of the 4 ‘P’s The outcomes of effective treatment should include 1) a reduction in symptoms level (eg a reduction in the level of pain) 2) improved function (eg ability to work, have greater satisfying sexual contact), 3) confidence in self-managing symptoms through education
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Table 3
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Example of ‘Shared decision making e options in the management of unprovoked vulvodynia’ e information for patients combinations of treatments should be considered
What is the treatment?
How is it taken?
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What are the disadvantages?
Gabapentin/pregabalin
Acupuncture
Topical anaesthetic jels
Amitriptyline is a pain modifying drug which may help improve your pain control. It is different from other pain relief drugs. It is can be helpful for nerve pain, for example shooting, stabbing or burning pains. Amitriptyline is also used to treat depression, but is prescribed to improve symptoms and increase function. It is given for a variety of other chronic pain conditions eg shingles The starting dose for amitriptyline for pain is 10 mg once a day. The dose is usually taken 1 or 2 hours before normal sleep time. Your dose of amitriptyline may be slowly increased to between 50 mg and 75 mg a day depending on how helpful it is for your pain relief. The average dosage is 60 mg daily (although up to 100 mg daily can be used). The tablets are available in 10 and 25 mg forms. It may be 2 weeks before you start to see a real benefit. Pain relief and improved function. This a drug which has great benefit for neuropathic pain in other sites of the body (includes Vulvodynia) The most common side effects of this drug are drowsiness, dry mouth, constipation, feel lightheaded or dizziness. Most of these side effects will improve after several days, so it is worth pursuing with treatment.
Gabapentin or pregabalin are pain modifying drugs which may help improve your pain control. They are prescribed for pain relief for neuropathic pain. It is given for a variety of other chronic pain conditions eg shingles. There may be some benefit for those patients who suffer from anxiety.
Acupuncture is a collection of procedures which involves the stimulation of points on the body using a variety of techniques, such as penetrating the skin with needles that are then manipulated manually or by electrical stimulation.
Topical anaesthetic agents contain weak amount of a local anaesthetic such as lidocaine. The anaesthetic can ‘numb’ the nerves in the skin temporarily and may be used safely on a regular basis, provided you do not become sensitised (develop a reaction) to them.
The starting dose for gabapentin for pain is 300 mg once a day. Like for TCAD, they are dosage is increased according to the level of pain. Your doctor will guide on taking the drugs. Pregabalin (Lyrica) is a drug which is very similar to gabapentin, but is reported to have fewer side-effects and is possibly more effective. The dosage of this drug is different and you will need to discuss this with your doctor. Pain relief and improved function. This a drug which has great benefit for neuropathic pain in other sites of the body (includes Vulvodynia) The most common side effects of this drug are drowsiness, dry mouth, constipation, feel lightheaded or dizziness. Most of these side effects will improve after several days, so it is worth pursuing with treatment.
For vulvodynia the needles are usually inserted into various parts of the body (legs, lower abdomen, wrists). The needle are not usually inserted into the vulva.
Prescribed as either a gel or ointment and in different strengths. 2% gel is the weaker preparation and like KY jelly. 5% ointment is stronger and a thicker ointment. It can be used repeatedly.
Pain relief and improved function without taking drugs. It is a long established treatment for pain.
Pain relief and improved function. When the drug is absorbed through the skin there can be rapid pain relief. Topical local anaesthetics can sting on application. If this causes significant discomfort then the treatment should be avoided. Partners can become numb with sexual intercourse.
Minor discomfort from the needle insertion although this does not seem to stop treatment
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71 What are the benefits of this method?
Tricyclic anti-depressants (TCAD) (commonly nortryptyline or amitriptyline)
vulval pain. This table is for patients and is designed to enable then to self-evaluate different and combined treatment options. Engaging patients in ‘shared decision making’ might improve treatment compliance and therefore clinical outcomes. Think of the ‘4 Ps’ when planning treatment (see below).
The drug is not addictive. The drug is not given as an antidepressant but there can be potential benefits in mood at higher dosages. Some patients have benefit from the drug as it helps them sleep The drug is not addictive. The drug is not given as an antidepressant but there can be potential benefits in mood at higher dosages. Some patients have benefit from the drug as it helps them sleep
When first prescribed use a test dose on a small area of the vulva.
A series of 12 patients who had not responded to conventional treatment included two patients who felt significant improvement and three who believed their symptoms had improved and wished to continue acupuncture treatment. There are no long-term follow-up studies. Access to treatment e most patients will have to pay for the treatment. Some pain clinics might provide the service Gabapentin is the best studied drug for vulvodynia. There are reports of complete pain relief in up to 80% of women taking the drugs, but there are no long term follow-up studies. Amitriptyline is the best studied drug for vulvodynia. There are reports of complete pain relief in up to 47% of women taking the drugs, but there are no long term followup studies.
Patient education and reassurance An explanation of the condition including the nature of the diagnosis, the role of chronic pain pathways and acknowledgement of painful sex is helpful as many patients will not have heard this from a health professional. In the absence of a diagnosis, a void in understanding of symptoms can lead to worry and a lack of confidence in health professionals which can potentially impact on compliance with treatment. Reassurance is essential especially with regards fertility in younger women. Informal patient support and information through patient organisations such as the Vulval Pain Society (www. vulvalpainsociety.org) and the National Vulvodynia Association (www.nva.org) can be helpful. Sensible vulval skin care should be practiced to reduce the chance of contact sensitivity. Patient should be told to give treatments time to work, address the pain holistically, combine treatments and self-educate. Self-management should be encouraged.
Pain modification Pain modifying drugs (PMD) play a role in pain management and are useful for moderate to severe unprovoked pain (more than 5/ 10 on a pain scale). They address the central and peripheral components of neuropathic pain and usually reduce pain level and flare ups. Patients with lesser degree of pain may on balance decline PMD due to a balance of function without pain but sideeffect gain. The drugs are more likely to work when patients are motivated to start treatment. PMDs include amitriptyline and/or gabapentin. For amitriptyline (an antidepressant if used in higher doses), a dose of 10 mg/day, increasing every week until the pain is controlled, has been suggested. The average dosage is 60 mg/ day, although up to 100 mg/day can be used. Side effects usually settle within two weeks. Patients intolerant of the side effects can try nortryptyline. The duration of treatment is debatable, but some patients continue long-term. Patients who are intolerant of drugs, have severe pain or have a decline in function as a result of pain should be referred to the vulval service, specifically pain management services. Subsequent management may include nerve blocks, intralesional injections, transcutaneous electrical nerve stimulation (TENS machines) and acupuncture as examples. The latter two treatments can be accessed at any time. Local anaesthetic gels/ointment prior to sex are worthy of mention as first-line treatment. Occasionally, contact dermatitis can develop so they should be used with caution.
Other comments
Physical therapy
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Many studies demonstrate pelvic floor muscle hypertonicity in patients with vulvodynia which further exacerbates the pain cycle. Patient are not often aware of this and treatment aims to relax and desensitise (‘make less sensitive’) these muscles. Whether this is secondary effect of vulval pain or a synchronous problems is not clear.
Table 4
This success rates are variable. Some women get great benefit other find the treatment stings. There are no long-term follow-up studies.
Acupuncture
What are the success rates of treatment?
Table 4 (continued )
Tricyclic anti-depressants (TCAD) (commonly nortryptyline or amitriptyline)
Gabapentin/pregabalin
Topical anaesthetic jels
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Does surgery have a role to play?
There are variety of techniques evidenced in the literature including pelvic floor exercises, use of vaginal dilators, digital pelvic floor trigger point therapy to name a few. Access to these treatments will depend on the skillset of the local physiotherapist. The original papers reported success with biofeedback therapy using surface electromyographic (sEMG) signals from the pelvic to help overcome pelvic floor muscle dysfunction in women with vestibulodynia.
The modified vestibulectomy is the procedure of choice for patients with vestibulodynia. It involves excision of a horseshoeshaped area of the vestibule followed by dissection of the posterior vaginal wall to cover the skin defect. In a large series of follow-up patients by Eva, 59% of patients had pain free sex and the majority of patient had no regrets about surgery when followed up long-term. In an RCT, 78 women with vestibulodynia were randomized to one of three arms: 1) group cognitive e behavioural therapy (12 weeks duration), 2) pelvic floor biofeedback therapy (12 weeks duration), and 3) vestibulectomy. At follow-up at six months, all patients reported significant improvements in pain scoring. Sexual functioning with surgery had the highest success rates; however, one concern was the high number of participants randomized to surgery who declined to be included in the study. The study did support both non-surgical treatments for vestibulodynia and suggested that patients prefer a behavioural approach to treatment than a surgical one. Surgery does have some caution and those gynaecologists who are prepared to offer this type of treatment should ideally 1) work closely with vulval service dedicated to the management of women with vulval conditions and 2) offer adequate pre and post treatment support and clinical care for patients.
Psychological and psychosexual therapy and support Basic level psychological support should be given by all health professionals which includes reassurance that there is no underlying medical problem, challenge abnormal beliefs about symptoms, recognizing the ‘body-mind’ connection and the role of stress and how it amplifies pain perception (stress can produce the ‘flight-fight’ response which increases the sensation of pain). Some patients require more than basic support in a clinic consultation and mindfulness/cognitiveebehavioural therapy (CBT) self-management or formal referral to a clinical psychologist may be needed. CBT can play an important role in addressing many issues that women with vulvodynia face. Figure 1 outlines the ‘hot-cross bun’ connection that can exist between thoughts, emotions, physical sensations and behaviour. Some women with vestibulodynia may require sexual therapy and this can be structured over several sessions with a psychosexual counsellor, preferably with the woman’s partner. Much of sexual therapists work, however, is basic education on the anatomy of the vulva and pelvis and sexual response cycle which could be outlined within the clinic consultation prior to referral. Psychosexual counselors can help improving physical non-coital sexual contact, overcome pelvic floor muscle hypertonia using ‘sensate’ focus therapy (structured goal setting), and helping low libido and anorgasmia.
Service provision for women with vulval conditions e a ‘vulval service’ In the UK many women with vulval conditions attend vulval clinics for care. Over recent years a large number of these clinics have been set up around the UK. According to the British Society for the Study of Vulval Diseases (BSSVD), a professional society dedicated to the care of women with vulval conditions, there are around 80 such clinics in the UK. Around two-thirds are multidisciplinary with the remainder being single discipline. Different
A ‘hot-cross bun’ diagram of how behaviors, thoughts, physical sensation and emotions may be interlinked in patients with vulvodynia Behaviours Avoid intimacy Becomes withdrawn emotionally Push self to make up for it Physical sensations Muscle tension = Further pain Headaches Irritable bowel symptoms Sinking feeling in stomach
Thoughts I’m less of a woman I better not lead my partner on He might find someone else I’ll try and make up for it in other ways
Emotions Fear/Anxiety Stress Guilt Depression
Figure 1
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Disease (BSSVD) Guideline Group. Guidelines for the management of vulvodynia. Br J Dermatol 2010; 162: 1180e5. Framework for the management of vulval skin disorders: An evidencebased framework for improving the initial assessment and care of women with vulval disorders from the RCOG. This guidance is intended for the general gynaecologist, with advice on when to refer to the specialist multidisciplinary team. www.rcog.org.uk/womens-health/ clinical-guidance/management-vulval-skin-disorders-green-top-58. Nunns D, Mandal D, Byrne M, et al; British society for the study of vulval. Standards of care for women with a vulval condition. https://www.pcc-cic. org.uk/sites/default/files/articles/attachments/standards_of_care_ vulval_conditions_report.pdf. Stockdale CK, Lawson HW. 2013 Vulvodynia Guideline update. J Low Genit Tract Dis 2014 Apr; 18: 93e100. Vulval Pain Society: Support and information for women with vulvodynia. Contains information on workshops for women and links to patient support groups PO Box 7804, Nottingham, NG3 5ZQ. www. vulvalpainsociety.org.
combinations of consultants work within the clinics from specialities such as genitourinary medicine (GUM), dermatology and gynaecology. The British Society for the Study of Vulval Disease working with other stakeholders have developed standards for the care of women with vulval conditions focussing on a vulval service rather than vulval clinics (see further reading). A ‘vulval service’ is defined as an MDT of health professionals interested in vulval disorders across different specialities. The aim of these standards is to support equitable access to high-quality care for people with vulval conditions. These standards are intended to form a basis for the development of any NICE quality standards for vulval conditions. If services are delivered to these standards, there is every expectation that outcomes for people with vulval conditions will improve. The levels of care that women with a vulval problem receive is stratified from level 1 (self care), level 1(GP), level 2 (secondary healthcare) and level 3 (vulval service). It would be expected that women with vulvodynia might receive care at every level depending on clinical need.
Conclusions
Practice points
Our ‘tool-kit’ of skills as a gynaecologist is limited when managing some patients with vulvodynia and referral to health professionals may be necessary. However, we do have an important role to play in assessment, triage, counselling and starting basic treatment which is likely to benefit many women. The patient experience of vulvodynia is poor as a result of a health system that often fails them in terms of delayed diagnosis and poor clinical recognition, so as gynaecologists we have to move forwards with this group of patients to provide the tenets of quality care that we wish for any patient; clinical effectiveness, safety and a good patient experience. Based on the current literature, the prognosis can be promising for women with vulvodynia who receive correct individualised treatment. Labelling this condition as a chronic illness with no cure would be wrong particularly when the evidence suggested that a significant proportion of patients benefit. A
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FURTHER READING British Society for the Study of Vulval Diseases. UK multidisciplinary specialist society for vulval disease. www.bssvd.org.
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Vulvodynia is a cause of chronic genital pain that has a variety of clinical presentations and treatment options and can be classified as provoked (vestibulodynia) or unprovoked but many patients have both symptoms The history should be tailored to the presenting complaint and may include a pain and psychosexual history if appropriate A clinical examination is essential to exclude other overlooked causes of vulval pain (e.g., fissures, lichen sclerosus and lichen planus) The role of the generalist in secondary care is to make a diagnosis, counsel the patient, give written information, direct to patient support groups and start basic treatment The current referral pattern of patients to secondary care may mean vulvodynia patients with chronic pain or psychosexual problems may need onwards referral to a vulval service where a multidisciplinary approach can be helpful. This will depend on the individual needs of the patient Good evidence for effective care is lacking
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