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Vulvodynia 

Vulvodynia

 

 
 
Tags:  fibromyalgia 
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Published:  January 11, 2012
 
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Slide 1: VULVAL PAIN SYNDROME BY DR SARITA SABHARWAL SENIOR CONSULTANT MATA CHANAN DEVI HOSPITAL
Slide 2: Vulval pain syndrome The term vulval pain syndrome comprises enigmatic causes of vulval pain and include a heterogeneous group of women who are difficult to manage.  VPS can be classified as following – 1. Dysaesthetic vulvodynia 2. Vestibulodynia [Vulval vestibulitis] 
Slide 3: Dysaesthetic vulvodynia This term was introduced by ISSVD {international society for study of vulval diseases}.  It is defined as ‘chronic vulvar discomfort’ characterized by burning , stinging, rawness or irritation of vulva .  It may be generalized or localized ; provoked or unprovoked pain.  It’s a constant neuralgic type of pain. 
Slide 4: Dysaesthetic vulvodynia {contd}      Clinical examination is normal. Women are typically premenopausal or postmenopausal. They have a long history of multiple or inappropriate use of topical agents. There is h/o superficial dyspareunia which is not usually reported as these women are less sexually active. Sexual dysfunction is common.
Slide 5: Dysaesthetic vulvodynia {contd} There may be h/o rectal, perineal or urethral discomfort.  It may be associated with other chronic pain syndromes like glossodynia or chronic low backache.  There is great level of psychological distress as compared to other vulvodynias. 
Slide 6: Vestibulodynia  It is defined as -Severe pain on vestibular touch or vaginal entry. -Tenderness localized within the vestibule on pressure. -Physical findings of erythema confined to the vestibule.
Slide 7: Vestibulodynia{ contd}   Clinical examination demonstrates tenderness within the vestibule Common test used is the cotton swab test
Slide 8: Vestibulodynia{ contd}      Another test is to use algesiometer where variable degrees of pressure is applied. Vestibular erythema may or may not be present and if present the degree of redness does not correlate with the degree of symptoms. Gynaecological examination is painful. There is tampon intolerance. There may be h/o use of multiple topical medications.
Slide 9: Vestibulodynia{ contd}     Women typically are Caucasians , aged 20-24 years who present with h/o provoked pain or superficial dyspareunia. Pain may be present from the first attempted sexual intercourse or after a period of normal sexual activity. Fear , anger and frustration are commonly encountered in these women A period of at least 6 months is given before labeling the condition as vestibulodynia
Slide 10: Assessment Most imperative to exclude the following diseases before arriving at the diagnosis of VPS The common ones are-Inflammatory vulval diseases like Lichen Sclerosus and Eczema. -Tight posterior fourchette and Fragile Fissured Vulval Syndrome -Symptomatic Dermographism
Slide 11: Assessment  Less common causes are – -Apthous ulceration -Erosive Lichen Planus -Bullous Disorders -Herpes Simplex infections -Pudendal Canal syndrome
Slide 12: Aetiology  Exact cause is not known . The following are the possible causes1. Candida infection - leads to the generation of an immune response causing inflammation and pain even in absence of an active infection. 2. Iatrogenic - like use of topical agents for pain like antifungal creams, soaps, bubble baths and hygiene sprays etc. 3. Psychological disorders - like stress and anxiety leading to increased pain perception.
Slide 13: Aetiology contd. 4.Genetic predisposition - more common in Caucasians and is less common in Blacks and Asian population. 5.Dietary factors - high oxalate diet causing increase in urinary excretion of oxalates leading to burning micturition & vulvodynia. 6.Hormonal causes - include estrogen deficiency and oral contraceptive pill intake.Mucosal atrophy makes nerve endings superficial
Slide 14: Aetilogy contd. 7. Tension in levator ani muscles could be one of the causes. 8. It may be a part of Complex Regional Pain Syndrome {CRPS} like fibromyalgia , interstitial cystitis,overactiv ebladder,irritable bowel syn. The cause being ‘Wind Up’ phenomenon in which there is increased activity in the dorsal horn cells of spinal cord after repetitive activation of the primary afferent C-fibers.
Slide 16: Management   Spontaneous recovery may occur sometimes . Management options include – -Vulvar care -Topical therapy -Oral medications -Biofeedback and Physical therapy -Intralesional injections -Interferon therapy -Low oxalate diet -Surgical treatment -Multidisciplinary approach
Slide 17: Vulvar care         100% cotton under wears. No under wears at night. No soaps to be used on vulva. Use of plain water. Use of lubricants before intercourse like KY jelly. Use of natural oils like olive oil, sweet almond oil and wheat gram oil. Vulva should be patted dry after washing. If dryness is more use of Vaseline is advised.
Slide 18: Topical therapy Lignocaine jelly 2%  Lignocaine & Prilocaine jelly  Evalon cream  Topical Amitriptyline 2% cream 
Slide 19: Oral medications Antidepressants are the first line therapy.They block reuptake of serotonin & noradrenalin and relieve pain by inhibition of Na channel. Most commonly used– Amitriptyline  Dose -5-10mg before bedtime. May be increased weekly by 10-25mg depending on response. Maximum dose 150mg/night  Side effects are-dry mouth -drowsiness -constipation -overdose results in seizures, MI, thrombocytopenia. # Less commonly used antidepressants are Nortriptyline, Desipramine, Venlafaxine. 
Slide 20: Anticonvulsants contd Carbamazepine is also used  Starting dose is 100mg orally at night, increased to 200400mg BD . Maximum dose is 1200mg.  Side effects are - dizziness - drowsiness and confusion - blurred vision - rash - increased liver transaminases - agranulocytosis and thrombocytopenia. # Less commonly used anticonvulsant is Topiramate  # Other drugs used are Tramadol and analogue of Codeine.
Slide 21: Anticonvulsants  - - - Gabapentin started at a dose of 300mg OD for 3 days followed by 300mg BD for 3 days followed by 300mg TDS Maximum dose is 3600mg/day and no more than 1200mg should be given at a time .Dose adjustment is required in renal insufficiency. A time of 3-8 wks is required for the drug to become effective. # Side effects areSomnolence Dizziness GIT symptoms Mild peripheral edema Gait and balance problems in elderly.
Slide 22: Biofeedback and physical therapy It involves measuring nerve and muscle tension of pelvic floor by a meter or colored light Patient has to self assess the tension and try to relax.  In a study conducted by Hartmann and Nelson a group of women with vulvodynia undergoing physical therapy were studied. 71% women showed 50% improvement in symptoms . 
Slide 23: Intralesional injections Includes trigger point injections of steroids and Bupivacaine in a dose of 20-40mg Triamcinalone with 25% Bupivacaine monthly.  Injections may also be given as a pudendal block. 
Slide 24: Interferon therapy Includes intravestibular injections of 1.5 million units of interferon – alpha.  Disadvantages – - only short term relief - extremely painful - not routinely available. 
Slide 25: Low oxalate diet Avoid foods like spinach, beetroot, wheat germ, chocolate, tea etc.  Calcium citrate supplementation - to bind the oxalates and increase their urinary excretion. 
Slide 26: Surgical treatment Last mode of treatment , used when other treatment options fail.  Modified Vestibulectomy- PROCEDURE OF CHOICE.  Preoperative psychological counseling and post operative sex therapy increases the success of surgery.  other surgical procedures are - Local Excision - Perineoplasty and LASER Vaporisation # They are less effective than Vestibulectomy and hence are not commonly used. 
Slide 31: Modified Vestibulectomy  Complications- Blood loss - Wound infection - Granulation tissue formation - Chronic fissuring - Bartholin’s duct cyst formation - Decreased lubrication - Continued pain
Slide 32: Multidisciplinary approach  This employs the following- Clinical Psychologists - Pain Management teams - Psychosexual Counselors - Clinicians - Physiotherapists - Partner support is a must.
Slide 33: Pain management The `Pain Gate Theory ’ of Melzack and Wall’s is employed. The theory states that the pain messages from the gates of spinal cord travel to the brain . These gates tend to be more in women with stress, tension and anxiety.  Therapies like relaxation , exercise and mobility close these gates and hence relieve the pain. 
Slide 34: Key points for clinical practice A detailed history and clinical examination is necessary for diagnosis of these two groups.  Surgical option is only available for Vestibulodynia.  Tricyclic antidepressants are the first line management for Dysaesthetic Vulvodynia.  A multidisciplinary approach is beneficial for chronic patients. 
Slide 35: THANK YOU

   
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