Vulvodynia

Vulvodynia means “vulva pain”. Vulvodynia is one of the most difficult-to-diagnose diseases. Vulvodynia treatment should be performed step by step.

Vulvodynia , vestibulodynia, vulvar vestibulitis (vulvar vestibulitis syndrome) ... They are clinical conditions that seems to be different from each other, but are usually quite similar to each other. All of these are the terms which include pain in the female genital area as well as associated sexual problems.

Maybe the greatest difficulty for women struggling with vulvodynia, a disease whose causes and treatment are still unclear, must be the period they live until the disease is diagnosed. This is because the condition that can often be overlooked by gynecologists tends to evolve into a variety of problems over the years.

What is vulvodynia? Definition of Vulvodynia

Vulva is the name of the external genital area in women. -Dynia is a supplement used in medicine, which means 'pain'. Thus, vulvodynia means “vulva pain”. To expand the definition further; vulvodynia is a word that refers to conditions where pain, soreness and/or chronic burning exist in the vulva for at least 3 months, without objective clinical and laboratory findings to explain the symptoms.

Vulvar pain can sometimes develop due to infectious factors such as candida (fungal disease),and sometimes due to inflammatory diseases such as lichen sclerosus. For being able to call a vulvar pain “vulvodynia”, there must be any detected infectious, inflammatory, anatomical or neurological cause.

Vulvodynia, first described in 1983, has been named and classified variously over the years.

What are the types of vulvodynia?

Vulvodynia can be expansive, that is, involves the entire vulva, or can be localized, that is, remains confined in only one area. Localized vulvodynia may sometimes involve the clitoris and sometimes one half of the vulva (hemivulvodynia),but most commonly appears as localized in the "vestibulum". The vestibulum is in the entrance area of the vagina. Pain in the vestibulum is called “vestibulodynia”.

Vulvodynia localized in the vestibulum (vestibulodynia) was first named “Vulvar Vestibulitis Syndrome” (VVS) by Friedrich in 1987. However, in studies conducted over time, it has been noticed that all patients have not inflammation in their vestibular region; and therefore, the term “vestibulodynia” has begun to be used more commonly instead of the term ”vestibulitis”.

Vulvodynia is also classified based on the way it occurs, beside the area it affects.

• Unprovoked vulvodynia: It describes vulvar pain that exists even when there is no stimulus in the environment, that is, at rest.
• Provoked vulvodynia: It describes vulvodynia that occurs with a stimulus.

Although the stimulus that triggers vulvodynia is often sexual intercourse, sometimes acts and conditions which cause irritation in the vulva such as wearing tight pants and cycling appear to be provocative (triggers the pain) causes. The most common type of vulvodynia among all types of vulvodynia is “provoked localized vulvodynia”, i.e. “vestibulodynia".

What kind of complaints does vulvodynia / vestibulodynia cause?

The most common reason for patients with vulvodynia to consult a physician is the feeling of “pain, stinging or burning” they experience during sexual intercourse. This painful sexual intercourse is also known as “dyspareunia”. This pain is felt during the penetration of the penis into the vagina, that is, in the entrance part of the vagina. Many patients describe this as a sharp pain similar to the pain that would be felt if “salt is put into the open wound” or would be felt if that area is “cut with a knife”.

Most of the patients state that the pain and burning sensation last for a while after the sexual intercourse. Sometimes bleeding due to skin cracks can be observed during sexual intercourse.

In some patients, the pain caused by vestibulodynia is so severe that even causes the patient to abstain from having sexual intercourse. Reflex contractions of the pelvic floor muscles due to pain may partially or completely prevent the penetration of the penis into the vagina. In such patients, vaginal contraction often masks the underlying vestibulodynia, and causes the patient to receive unnecessary psychological treatment based on the misdiagnosis of vaginismus. However, with a detailed anamnesis, it can be easily understood that the problem is not vaginismus of psychological origin.

Vulvodynia is not always confined to one region. Sometimes pain, itching, shooting, burning and ache involve the entire vulva. This condition may be too serious that prevents the patient from wearing tight pants, cycling, driving and even walking. Localized or generalized vulvodynia can rarely develop for any reason (unprovoked vulvodynia). There is a constant shooting pain in the genital area throughout the day. However, pain, ache and burning sensation are mostly caused by sexual intercourse, use of tampons, gynecological examination, use of pad, wearing tight clothes, sitting for a long time etc. (provoked vulvodynia). In some patients, vulvodynia can sometimes develop as unprovoked and sometimes as provoked.

What is the incidence rate of vulvodynia?

In some of the studies, it was concluded that vulvodynia has such a low incidence rate of 1.3% in the society, while some other studies revealed that 28% of people have experienced a type of vulvodynia at some point in their life. In other words, the results of the studies can conflict with each other. Considering the incidence rate of the disease in the group of patients who applied to our clinic, we can say that it is observed in 5-10% of the society.

What are the causes of vulvodynia?

1. Irritants
2. Previously encountered HPV infection
3. Using oral Contraceptive
4. Vaginal candidiasis
5. Psychological reasons
6. Autoimmune diseases

The underlying causes of vulvodynia have been investigated for years, but they are still unclear. The most common reasons are listed below.

1- Irritants: Daily pads, use of tampons, intim gels (genital hygiene gels),perfumed WC papers, use of soap on the genital area, deodorants and depilatory creams can cause irritation in the the genital area.

2- Previously encountered HPV infection: In a study, HPV infection was found in 54% of 86 women with vulvodynia, but such a high rate has yet to be confirmed in other studies.

3- Use of Oral Contraceptives: Oral contraceptives can pave the way for vulvodynia by disrupting the vaginal flora, increasing the development of vaginal candidiasis, and causing changes in the hormonal system. Especially they can pave the way for the development of vulvodynia, by changing the quality and amount of the mucus secretion, and reducing the protective effect in the vestibular area. Oral contraceptives are the first drugs to be questioned for women diagnosed with vulvodynia, and their use should definitely be discontinued if they are being used.

4- Vaginal candidiasis: Especially patients with chronic vaginal candidiasis (history of vaginal candidiasis development, 4 or more times a year) were observed to be at a higher risk of developing vestibulodynia and generalized vulvodynia. The possible underlying mechanism is thought to be the cellular changes that occur due to the chronic inflammatory process, and the changed perception of pain.

5- Psychological factors: Some studies reported that vulvodynia were more commonly observed in patients with depressive symptoms. In some other studies, such a conclusion could not be reached.

6-Autoimmune diseases: In some studies conducted in recent years, vulvodynia was found to be more common in women with autoimmune diseases such as fibromyalgia and interstitial cystitis. This situation was interpreted suggesting that the tendency towards vulvodynia may increase in the background of autoimmunity. Similarly, a familial tendency was observed in some studies, suggesting that there could be a genetic transition.

Are there any other conditions that cause pain in the vulva?

Yes! Not all pain in the vulva or vestibulum is vulvodynia. All kinds of infection sources, especially candida, trichomoniasis and bacteria, can cause localized or generalized vulvodynia. Chronic irritation that may be due to some conditions such as constant scratching or the use of synthetic clothes is one the causes of vulvodynia, as well.

Vulvodynia can cause vaginismus and then vaginismus can cause vulvodynia. Involuntarily contraction of the vaginal muscles causes pain during sexual intercourse. Skin diseases such as lichen sclerosus, lichen planus and vulvar pemphigus; and precancerous or cancerous diseases of the vulva can appear as the causes of vulvodynia, as well.

Therefore, it is of great importance to make differential diagnosis for patients who come to the clinic with vulvodynia. Sometimes vulvodynia may appear as a symptom of Silk Road disease or Systemic Lupus Erythematosus (SLE).

Vulvodynia During Menopause

Vulvodynia may also appear due to atrophy (thinning) that can occur in the skin as a result of hormonal deficiencies, especially estrogen deficiency during menopause. Sometimes, topical hormonal creams can solve the problem. Therefore, it is very important to identify the underlying factor.

Vulvodynia problem can be overlooked!

Vulvodynia is one of the most difficult-to-diagnose diseases. The reason of this is not that the lack of diagnostic methods for the disease, but the fact that physicians usually do not remember the possibility of a diagnosis of vulvodynia. Most of patients who consult a physician with the complaint of vestibulodynia (vulvar vestibulitis syndrome) are treated for vaginal infections repeatedly, and when the problem cannot be resolved, patients are referred to psychologists, considering that the disease is psychological. However, the source of the problem in vulvodynia is mostly physical, not psychological.

How is the Disease Diagnosed?

As in all diseases, the most important thing is to obtain a detailed anamnesis (history) from the patient when diagnosing vulvodynia. When the patient comes with the complaint of extensive pain in the genital area or pain and burning during sexual intercourse (dyspareunia),first the history of “pain” should be detailed. In other words, detailed questions should be asked, such as when did the pain/ ache start, when does it recur, where is it felt, what increases or decreases it, is it associated with menstrual cycle, what kind of pain (stinging/burning/sharp) is felt, at what stage of the sexual intercourse does it begin to be felt.

Factors that may cause vulvodynia, such as the use of birth control pills, cleaning of the genital area, and the use of daily pads should be among the questions asked to the patient. It should also be questioned whether the person has any other disease or whether she is on any medication for an indefinite period of time.

Then, gynecological examination is started. During the examination, the patient may be asked to show the location of the pain/ache. Especially the cotton-tipped swab test (Q type test) is of great importance in the diagnosis of vestibulodynia.

Pain scoring with cotton-tipped swab test (Q type test)

Q type test is a type of test performed to ascertain whether there are tenderness and pain in the vestibulum by applying clockwise cotton-swab palpations. If the patient expresses that she is feeling pain, the Visual Pain Scoring (VAS) can also be performed by asking the patient to give a score out of 10 for that pain. VAS scoring ensures the result of the treatment to be followed more objectively.

It can be confused with vaginismus!

In some patients, vaginal tone may increase due to vestibulodynia that lasts long or has a high level of pain. Such patients should be examined just like the way patients with primary vaginismus are examined. If the patient has difficulty in being examined, the physician should not insist, and only the level of the problem should be determined with a simple examination.

In these patients, just like in patient with vaginismus, the involuntary contraction of the pelvic floor muscles will decrease within a short time after the start of treatment. At that stage, the underlying pain/ache will begin to rise above the involuntary spasms. When that point is reached, a gynecological examination can be performed once again, and the Q type test can be repeated. Vaginismus and vestibulodynia are concepts quite different from each other.

Vaginismus usually manifests itself with anxiety-related contractions, but patients with vulvodynia or vestibulodynia contract themselves due to the real pain they feel, and consequently, they so not allow their partners to proceed.

First of all, protective measures should be taken!

The first step to take before starting vulvodynia treatment should be to eliminate the factors that increase the pain. These are as follows:

• The use of daily pads or intim gels (if any) should be discontinued.
• The use of oral contraceptives (if any) should be discontinued under the supervision of a physician.
• Synthetic underwear should not be used.
• Tights or tight trousers should not be worn.
• The use of chemical containing shampoos deodorants, etc. that may cause irritation should be avoided.

How is vulvodynia treatment performed?

Vulvodynia treatment should be performed step by step. First, infections in the genital area or urinary tract should be eliminated using appropriate antimicrobial drugs. Then, the active treatment should be started.

Local Anesthetic Creams: Usually creams with local anesthetic effect are recommended as the first option to use in the treatment. There are treatment methods such as applying creams containing 5% lidocaine only before sexual intercourse or applying a tampon to the painful area every night for a certain period of time. In studies, the success rates of creams containing lidocaine have been found to be at different level in studies, making it difficult to take a clear decision. However, they can be tried because of their ease of use and low side effects. Since it causes irritation and reduces sensitivity due to anesthetic effect, it is not preferred in some patients.

Hormone Containing Creams: There are studies showing that estrogen and testosterone containing creams reduce vulva pain.

Injection Treatments: Local or intra-lesion injections of steroid and bupivacaine can be applied in the treatment of localized vulvodynia, and vestibulodynia in particular. In addition, Interferon alpha and Botulinum toxin A treatments can be performed.

Antidepressant Medications: In addition to local treatments, systemic treatments are also applied in vulvodini treatment. Drug therapies involving the use of oral antidepressants are the most common ones among these treatments. Especially tricyclic antidepressants are frequently preferred. However, antidepressants can lead to lack of sexual drive when used for a long time.

Auxiliary Procedures: There are studies showing that some complementary treatments such as biofeedback, physiotherapy, hypnotherapy and acupuncture can be effective when used in addition to all these treatments. However, there is no clear scientific data on any of these methods.

Surgical Procedures: Especially in the treatment of vestibulodynia, surgery is the most effective and successful procedure. Despite their success rates ranging between 80 and 95%, surgical procedures are still considered to be the last-option.

Surgical procedures in the treatment of vulvodynia can be in a variety of forms. The most appropriate surgical procedures from local excision to vestibulectomy and perineoplasty can be preferred for the patient. In our clinic, we mostly perform surgical procedures in the treatment of localized vulvodynia-vestibulodynia. Based on our years of observations on our more than 1000 patients, we can say that the right surgical procedure has a high treatment success rate.

Genital PRP Treatments: Among the new treatment procedures, PRP (Platelet Rich Plasma) and stem cell treatments are promising in the treatment of vulvodynia, as well. These treatments can be performed alone or in conjunction with surgery.

Hyaluronic Acid Injections: In addition, intra-lesion injections of a special hyaluronic acid, which we apply in our clinic and which have been proven to be effective in the treatment of localized vestibulodynia by our scientific study, is one of the procedures that can be preferred for patients who don’t want to have surgical operation or those have vestibulodynia in a very limited area.

Vaginal Laser and Radiofrequency Treatments: Vaginal laser and radiofrequency treatments are two other procedures we perform in our clinics. With these energy-based treatments, quite successful results are achieved in some patients. Energy-based treatments are preferred more commonly, especially in patients with generalized vulvodynia.

Sexual Therapies: An important point to consider after vulvodynia treatment is that the treatment should definitely be completed with sexual therapy. Especially in patients whose have had vulvodynia for a long time, the perception of sexuality equals pain is deeply rooted in the brain. To break this cycle of acquired behavior, we find it appropriate to conduct sexual therapy sessions with cognitive behavioral therapy methods, after the recovery period of the vulvodynia treatment.

Vulvodynia treatment should not be delayed!

Vulvodynia is a serious problem that can affect both the person herself and her relationship. In some cases, the vulva pain is so serious that the woman cannot maintain her social life and may even have to quit her job. Therefore, it is of extremely importance to be able to diagnose vulvodynia correctly and to start an effective treatment as soon as possible. In fact, vulvodynia left untreated for a long time can also cause psychological problems such as depression in the person. This means an exponentially increasing problem. When the right techniques are used for the person, vulvodynia is a problem that can be overcome.