Vulvodynia

1. Vulvodynia Katherine “Casey” Monahan, FNP-C, Dermatology Providence Little Co. of Mary Dermatology & Laser Center

3. 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

4. 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

5. What are the signs on examination? • Typically, no changes visible to the skin • Redness and/or swelling possible

6. What are the symptoms? • Burning • Aching • Rawness • Soreness • Throbbing • Swelling • Itching – uncommon

7. 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

8. How do we diagnose it? • Thorough history • Examination of vagina and work-up • Cotton swab testing

9. 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

10. Management (cont’d) • Medications • Tricylic antidepressants • Anticonvulsants • Topicals • Trigger-point injections • More recently, neurotoxin (Botox) injections

11. 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)

12. 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

13. 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

14. When is surgery an option? • Vestibulectomy • Removes the tender areas of the skin within the vestibule • Recommended for refractory vestibulodynia only

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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.