Vulvodynia
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Vulvodynia. Katherine “Casey” Monahan, FNP-C, Dermatology Providence Little Co. of Mary Dermatology & Laser Center. What i s it?. A cause of vulval burning and soreness, usually secondary to irritation or hypersensitivity of nerve fibers in the vulvar skin Diagnosis of exclusion

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Vulvodynia

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Vulvodynia

Vulvodynia

Katherine “Casey” Monahan, FNP-C, Dermatology

Providence Little Co. of Mary Dermatology & Laser Center


What i s it

What is it?

  • A cause of vulval burning and soreness, usually secondary to irritation or hypersensitivity of nerve fibers in the vulvar skin

  • Diagnosis of exclusion

    • Must first rule out relevant infections, inflammatory, neoplastic, and neurologic disorders


What causes it

What causes it?

  • Idiopathic

  • Rarely, back problems cause spinal nerve compression and referred pain

  • Contributory factors include:

    • Infections; genetic factors; spasms of muscles that support the pelvic organs; allergies to chemicals; hormonal changes; damage or irritation to the vulvar nerves; history of sexual abuse; overuse of topical medications


What are the signs on examination

What are the signs on examination?

  • Typically, no changes visible to the skin

    • Redness and/or swelling possible


What a re the symptoms

What are the symptoms?

  • Burning

  • Aching

  • Rawness

  • Soreness

  • Throbbing

  • Swelling

  • Itching – uncommon


What are the symptoms

What are the symptoms?

  • Uprovoked pain, similar to that of post-herpetic neuralgia

  • May be generalized or localized to just the clitoris (clitorodynia) or just one side of the vulva (hemivulvodynia)

  • Intensity can vary from mild, intermittent discomfort to severe, constant pain

  • Duration is typically continuous

  • May be referred to the medial thighs, perianal region (with bowel movements), and/or urethra (with micturation)

  • Worsened by physical contact to the vulva


How do we diagnose it

How do we diagnose it?

  • Thorough history

  • Examination of vagina and work-up

  • Cotton swab testing


How do we best manage it

How do we best manage it?

  • Two-pronged approach: medication and behavioral modification

  • Specifically focused on four different areas:

    • Medications

    • Physical therapy

    • Sexual therapy

    • Holistic treatments and stress management

      • Low-oxalate diet


Management cont d

Management (cont’d)

  • Medications

    • Tricylic antidepressants

    • Anticonvulsants

    • Topicals

    • Trigger-point injections

    • More recently, neurotoxin (Botox) injections


Management cont d1

Management (cont’d)

  • Gentle vulvar care measures

    • Wearing 100% cotton underwear and no underwear at night

    • Avoiding vulvar irritants and douching

    • Using mild soaps for bathing and cleaning the vulva with water only

    • Applying a preservative-free emollient (plain petrolatum, Aloe Vera)


Management cont d2

Management (cont’d)

  • Using lubricant for intercourse

  • Applying cool gel packs to the vulva

  • Rinsing and patting dry the vulva after urination

  • Avoiding tampon use, tight-fitting undergarments, and exercises that apply direct pressure


Vulvodynia vs vestibulodynia

Vulvodynia vs. Vestibulodynia

VULVODYNIA (unprovoked)

VESTIBULODYNIA (provoked)

Pain with light touch

No symptoms at other times

May be generalized or localized

  • Spontaneous pain

  • Burning and soreness

  • Itching uncommon

  • May be generalized or localized


When is surgery an option

When is surgery an option?

  • Vestibulectomy

    • Removes the tender areas of the skin within the vestibule

    • Recommended for refractory vestibulodynia only


The case of vicki c

The Case of Vicki C.

  • Initial visit – 10/04/11. Chief complaint – “Burning vaginal pain”

    Subjective:

    7 wks vaginal pruritus with h/o recurrent vaginal candida

    Presumed yeast infection treated with Monistat 1 ampule

    Awoke with “burning, itching, and swelling”

    Dx’d by Gyn with vestibulitis, rx’d topical corticosteroid cream

    Urgent care visit, rx’d oral prednisone 40mg for a week

    ER visit, rx’d oral prednisone tapered over a week


The case of vicki c1

The Case of Vicki C.

  • Initial visit: 10/04/11. Chief complaint: “Burning vaginal pain”

    Objective:

    Labia majora and minora with moderate erythema, lacy scale

    Assessment:

    Prolonged contact dermatitis versus lichen sclerosus et atrophicus (“LS&A”)

    Plan:

    Vaseline ointment multiple times daily

    Rx’dclobetasol ointment BID for 2-4 weeks as needed


The case of vicki c2

The Case of Vicki C.

  • 11/01/11 visit –1 mo. later

    Subjective:

    Better with clobetasol cream, used for about 3.5 wks

    No longer in “extreme pain,” but still has “tingling, warm sensation,” worse after wiping/contact

    “Feels similar to allergic reaction of lips to strawberries”

    Able to wear regular underwear


The case of vicki c3

The Case of Vicki C.

  • 11/01/11 visit –1 mo. later

    Objective:

    Mild erythema of vaginal inner mucosa

    Assessment:

    Suspect LS&A

    Plan:

    Continue clobetasol cream diluted with Vaseline BID over next 2 wks


The case of vicki c4

The Case of Vicki C.

  • 11/15/11 – 2 wks later

    Subjective:

    Still with significant “deep pain,” affecting quality of life and mood

    Constriction from jeans “unbearable” and even standing at rest painful

    Orgasm intensifies pain

    Tylenol PRN and occasional Vicodin needed

    Objective:

    Same as prior with mild erythema of vaginal inner mucosa


The case of vicki c5

The Case of Vicki C.

  • 11/15/11 – 2 wks later

    Assessment:

    LS&A vs. vulvodynia

    Plan:Clobetasol BID for another month

    Trial Neurontin 300mg TID

    Referred to vulvar specialist


The case of vicki c6

The Case of Vicki C.

  • 12/3/11 – one month later

    Subjective:

    Much better after just one dose of Neurontin

    C/w UCLA vulvar specialist, dx’d with vestibulitis

    Plan to continue Neurontin for at least another 2-3 mos., d/c topicals

    Cultures repeatedat UCLA, all negative


The case of vicki c7

The Case of Vicki C.

  • 12/22/11 – 3 wks later, stable

  • 2/27/12 – 2 mos. later, last visit for this C.C.

    Subjective:

    C/w UCLA vulvadynia specialist

    Treatment: estrogen ring, PT (Women’s Advantage), and Neurontin (now 600mg TID)

    Plan to continue PT and Neurontin for another 6-9 mos.


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