Vulvodynia

Vulvodynia refers to a disorder of vulvar pain, burning,  and discomfort that interferes with the quality of life. No discernible physical lesion other than perhaps some redness of the skin is present. The cause can sometimes be attributed to trauma, but in other cases its origin is unknown.

Localized vulvodynia/ vulvar vestibulitis
The condition is one of exclusion and the diseases listed in the differential diagnosis need to be considered. The pain may be generalized or localized in the vulvar region. Localized vulvodynia in the vestibular region is referred to as vulvar vestibulitis and also vestibulodynia. It is unclear if these conditions are manifestations of the same disease process as the differential diagnosis is the same and the cause unknown. The pain may be provoked by contact with an object, or it may be constant.

Possible causes
A wide variety of possible causes and treatments for vulvodynia are currently being explored. Some possible causes include: allergy or other sensitivity to chemicals or organisms normally found in the environment, autoimmune disorder similar to lupus erythematosus, chronic tension or spasm of the muscles of the vulvar area, infection, injury, chemical sensitivity and neuropathy. Some cases seem to be negative outcomes of genital surgery, such as a labiectomy.

Dr. John Willems, head, division of obstetrics and gynecology, Scripps Clinic believes that vulvodynia is a subset of fibromyalgia. Vulvodynia is also frequently found in patients suffering from interstitial cystitis.

Diagnosis
The diagnosis is based on the typical complaints of the patient, essentially normal physical findings, and the absence of identifiable causes per the differential diagnosis.

A cotton “swab test” is used to delineate the areas of pain and categorize their severity. Patients often will describe the touch of a cotton ball as extremely painful, like the scraping of a knife.

Many sufferers will see several doctors before a correct diagnosis is made. Many gynecologists are not familiar with this family of conditions, but awareness has spread with time. Sufferers are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients are told that the pain is "in their head".

Differential diagnosis
Causes include


 * 1) Infections:  candidiasis, herpes, HPV
 * 2) Inflammation: lichen planus
 * 3) Neoplasm: Paget's disease, vulvar carcinoma
 * 4) Neurologic disorder: neuralgia secondary to herpes virus, spinal nerve injury

Treatment
There is no uniform treatment approach and numerous proposed treatments are based primarily on empirical experience and opinion. Treatment is often very different from physician to physician and many patients will have to change their course of treatment when primary attempts fail. Treatments include:


 * 1) Vulvar care measures: cotton underwear, no synthetics; avoidance of  vulvar irritants (douching, shampoos, perfumes, detergents); water cleaning only (no soaps); cotton menstrual pads; lubrication for intercourse; rinsing and patting dry the vulva after micturition.
 * 2) Medications: topicals, oral, and injectable medication that include anesthetics, estrogens, tricyclic antidepressants compounded into a topical form or systemic, local steroids.
 * 3) Diet: a low-oxalate diet (for vulvodynia associated with oxalate kidney stones).
 * 4) Biofeedback and physical therapy.
 * 5) Surgery: vestibulectomy. During a vestibulectomy, the innervated fibers are excised. A vaginal extension may be performed, in which vaginal tissue is pulled forward and sewn in place of the removed skin.

The guidelines in Vulvovaginal health may be of some help. Patients may also change birth control methods: active birth control may be taken continuously so as to eliminate menstration, which can aggravate symptoms.

Sufferers are often encouraged to explore sexual activity besides intercourse, which is often a major source of pain. Dry sex is strongly discouraged as it may cause further irritation, whilst oral sex will often be less painful. Patients may seek the assistance of a sex therapist.

Additional Resources

 * PMID 17012483
 * What Your Doctor May Not Tell You About Fibromyalgia, by R. Paul St. Amand, MD and Claudia Craig Marek, Warner Wellness, 2006.
 * Vulvodynia - Treatment Kits include soothing Calendula Creme: http://www.Vulvodynia-Treatment.com