Vulvodynia

Vulvodynia is defined by the International Society for the Study of Vulval Disease as chronic vulvar discomfort, especially characterised by patient’s complaint of burning, stinging, irritation and rawness.

Its exact cause is unknown, but a close association to the following factors may suggest possible causation or contributory effects: 

·    Present and previous genital warts infection have been suggested, though recently some doubts have been casted on this theory.

·    Chemical irritation of the vulva with detergents, deodorants and soap may lead to chemical dermatitis which can develop into neuropathic pain with chronic irritation.

·   Vulval skin disease or rash including lichen sclerosus.

·   Cyclic vulvovaginitis following recurrent candida infections in diabetic patients, those on steroids therapy and those using antibiotics repeatedly.

·   Surgery or laser treatment can lead to neuropathic pain related to the pudendal nerve.

·   Pelvic muscle spasm secondary to other pathologies in the pelvis leading to neuropathic pain is a possibility. This is especially so as patients with vulvodynia may suffer from other conditions such as interstitial cystitis, irritable bowel syndrome and endometriosis.

·   Previous abuse both physical and sexual has been suggested in the past but recent reports doubted the significance of this issue.

·   Severe hypo-oestrogenism in postmenopausal women.

The main distressing issue for patients who are suffering with this problem is their inability to have a normal sexual relationship because of the severe pain inflicted during and after sexual intercourse. This could have a very bad effect on the partners’ relationship. Genital examination might show no visual abnormality. However, vaginal discharge, scratch marks and red raw appearance could be noticeable. Q-tip test might reveal severe tenderness in different areas in cases of vestibulitis with no sign of acute inflammation or any other pathology (allodynia).

Both bacterial and viral swabs should be taken and vulval biopsies might be needed to exclude skin disease and vulval intraepithelial neoplasia. These could be colposcopically directed to aceto white areas. With early lichen sclerosus the skin would be pale and atrophic with some areas of purpura. However, in advanced cases hyperkeratosis would be seen.

Management is usually difficult and long supportive treatment would be needed in most cases.  Anti candida treatment should be used liberally but antibiotics should be used only when pathogenic organisms are isolated. Fluconazole 150 mg every week for 4 weeks then on alternate weeks for further 8 weeks should be used in cases of cyclic vulvovaginitis. Both oestrogen and corticosteroid creams could be useful as appropriate but excessive use of steroids could worsen the condition by causing skin atrophy. Using a potent corticosteroid cream could relieve symptoms caused by lichen sclerosus. Different protocols could be used for that purpose. Clobetasol propionate cream [Dermovate] could be used twice daily for 3 months or once daily for one month, twice weekly for one month with review at 2-3 months. Maintenance treatment could be affected with weaker perpetrations [Edwards et al, 2002]

It is u.nfortunate that vulval pain is usually recurrent and needs continued effort by the patient and her treating physician as mentioned before. Supportive therapy is most important to prevent vulval irritation. This should include strict attention to hygiene, avoid chemical exposure and use only water for washing the vulva. Furthermore, unbleached toilet paper, cotton sanitary products and well-rinsed cotton underwear should be used.

Other means used to treat difficult and persistent cases especially vestibulitis include topical local anaesthetic ointment twice daily. Interferon injections have been reported to have some favourable effect but more evidence is needed. For severe non-responsive cases surgery in the form of perineoplasty or vestibular excision has been described. However, perineoplasty was shown to be more effective than just excision of the vestibule [Bornstein et al, 1993 and Kehoe and Luesley, 1999]. On the other, hand laser treatment has been popular but is not used frequently now as it could cause more local discomfort.

Tricyclic antidepressants are useful to reduce nerve sensitivity and irritation and could be used in all cases of vulvar pain. It is needed in only smaller doses in comparison to those used in the treatment of depression. Releasing muscular spasm with biofeedback under the supervision of a trained physiotherapist proved useful and should be tried by all patients with recurrent symptoms.

Clitoral pain 

Clitoral pain is not a common presentation in the chronic pelvic pain clinic. This may reflect a genuine low incidence or under reporting by the affected patients. In most cases there is no specific cause but history of trauma to the clitoris can be a predisposing factor. This includes rough masturbation and laser treatment for HPV lesions. In one case excessive bruising and tenderness after repeated masturbation episodes over a long period of time was almost mistaken for endometriosis. A biochemical cause has also been suspected as it has been reported by patients with uncontrolled diabetes. In few cases it might be caused by neuralgia of the anterior branch of the pudendal nerve causing severe tenderness of the clitoris itself. Rarely a neuroma of the clitoris might follow genital mutilation causing chronic vulvar pain and dyspareunia [Fernández-Aguilar and Noël, 2003]. Similar injury could cause epidermoid inclusion cysts in the clitoris which could present with pain and sporadic discharge [Hanly and Ojeda, 1995]. Mild and moderate rest-pain could be felt but severe pain could follow contact, light touch or pressure on the clitoris [Gordon AS, 2002]. The main scenario would be severe pain felt during or after intercourse, while wearing tight clothing, after sitting for long periods of time and during physical exercise. All these predisposing factors relate to actual physical touching or stimulation of the clitoris itself and patients might learn how to avoid them when possible. This is especially so for the type of clothing used. Patients could also have symptoms related to other types of pelvic pain including interstitial cystitis. However, a more elaborate list of associated conditions was published by [Gordon AS, 2002] including multiple sclerosis, Guillain Barrie Syndrome, lichen sclerosus, spondylolisthiasis, urethral sphincter syndrome and vaginismus as well as past history of a hysterectomy. 

Treatment involves tricyclic antidepressants as well as other medications used for neuropathic pain. However, desensitising nerve supply by repeated injections of a local anaesthetic lateral and anterior to the base of the clitoris could have a quicker and more satisfying effect. Such blocks could be repeated as required. Furthermore, patients should be advised to avoid any trauma to the area especially those predisposing factors usually responsible for the pain attacks in the individual case. In the short term, either cold or warm compresses could be used to provide some comfort. In most cases good pain relief could be expected if repeated trauma to the area could be avoided. However, with long history of the condition it might be more difficult to control the pain attacks and permanent cure would be less likely.