N National V Vulvodynia AA Association Volume XIII, Issue I Winter 2007 Differentiating Vulvodynia and Pudendal Neuralgia By Richard P. Marvel, MD Dr. Marvel is the director of the Center for Pelvic Pain at the Greater Baltimore Medical Center in Maryland and an assistant professor in the department of obstetrics and gynecology at the Johns Hopkins University School of Medicine. Chronic vulvar pain disorders are commonly under- Each subgroup was further subcategorized as provoked, diagnosed and according to the research, their preva- unprovoked, or mixed pain. Although terms such as lence is quite high. Goetsch’s survey of a general gyne- localized provoked vulvodynia are useful in research cology practice estimated the prevalence of vulvar papers, they can be quite cumbersome in discussions vestibulitis to be 15 percent. In a community-based with patients. The revised definitions were debated at a survey, Harlow estimated the prevalence of chronic 2004 consensus meeting of national vulvodynia experts. unexplained vulvar pain at seven percent. At this meeting it was decided that the term vulvodynia be maintained and defined as ‘vulvar pain of at least The classic definition of vulvodynia is “vulvar pain, three to six months duration without a verifiable cause.’ burning, rawness or irritation” present for more than six It was further decided that descriptors such as general- months, which cannot be attributed to any other cause. ized or localized be used with an accurate pain map, but Vulvar vestibulitis is a subset of vulvodynia in which that further sub-classification, such as provoked vs. the burning or pain only occurs with light touch in the unprovoked, was not warranted. For the remainder of vestibule, the area immediately surrounding the vaginal this article, the terms generalized vulvodynia and vul- opening. The International Society for the Study of var vestibulitis will be utilized for simplicity. Vulvovaginal Disease developed a new set of definitions for vulvodynia in 2003. They created two subgroups: (i) localized vulvodynia and (ii) generalized vulvodynia. See PUDENDAL NEURALGIA, page 2 Multilevel Nerve Blocks in the Treatment of Vulvodynia By Andrea J. Rapkin, MD and John S. McDonald, MD Dr. Rapkin is a professor of obstetrics and gynecology at the David Geffen School of Medicine at the University of California – Los Angeles (UCLA) and the director of the UCLA Pelvic Pain Clinic. Dr. McDonald is the chairman of the department of anesthesiology and the director of the residency training program at the Harbor-UCLA Medical Center. any characteristics of neuropathic or nerve pain, such as burning and extreme sensitivity to both painful and nonpainful stimuli (hyperalgesia and allodynia, respectively), are also classic features of vulvodynia. M Because there are no abnormal anatomic features associated with vulvodynia, the pain has been characterized as neuropathic in etiology, and in some cases, a variant of pudendal neuropathy or neuralgia. Neuropathic pain is a chronic abnormal state that evolves over time, ultimately leading to a number of changes in the central nervous system (brain and spinal cord) and peripheral (somatic and autonomic) nervous system. See NERVE BLOCKS, page 10 Pudendal Neuralgia (from page 1) Diagnostic Precautions other findings. Women who have a combination of A critical component of the definition of vulvodynia several disorders causing vulvar pain are more com- disorders, including the newer definitions, is that a plex to evaluate and manage. Each patient is unique physical exam reveals no sign of any other condition. and has a different mix of components related to her In order to make an accurate diagnosis, a careful pain syndrome. Pain is interpreted in a context of an evaluation, including a limited sensory exam of the individual’s past experiences and emotions. In order vulvar skin, is critical. A wet prep should be per- to maximize the effectiveness of treatments, all com- formed and cultures obtained for yeast, because vagi- ponents need to be identified and managed concur- nal inflammation can upregulate the pain fibers and rently. Patients commonly present with co-morbid lead to focal localized tenderness in the vestibule. In conditions such as interstitial cystitis, endometriosis this case, it is not truly vestibulitis because treatment and irritable bowel syndrome. The existence of other of the infection and/or inflammation can lead to conditions does not preclude the diagnosis of vul- resolution of the allodynia (hypersensitivity to non- vodynia, and for a woman to reach maximum well- painful stimuli) and pain with intercourse. being, all identifiable conditions must be concur- rently managed. It is vital to understand that many chronic pain syndromes involve a combination of several distinct Some common vulvar diseases can exist with few entities. It is quite common in clinical practice to find clinical signs and mimic the symptoms of vulvodynia. multiple clinical syndromes in women with chronic An irritant or chemical dermatitis, chronic yeast vulvar pain. As the etiology of vestibulitis is not cur- vulvovaginitis, lichen sclerosus, inflammatory vagini- rently known, it is not possible to rule it out despite tis, and pudendal neuralgia are some of the more common diagnoses. Careful evaluation can confirm NVA News or eliminate various conditions. The evaluation should National Vulvodynia Association always begin with a careful history. I always start my P.O. Box 4491, Silver Spring, Md. 20914-4491 evaluation with a detailed pain questionnaire. An (301) 299-0775; FAX: (301) 299-3999 excellent questionnaire that can be downloaded and www.nva.org used by any practitioner can be obtained from the International Pelvic Pain Society (www.pelvicpain. NVA News is published three times per year. org). This questionnaire is aimed at women with chronic pelvic pain, but is also very helpful for diagnos- Editor: ing vulvar pain conditions. An attempt should be Phyllis Mate made to obtain and review the patient's records from prior health evaluations. For vulvar pain, the most Contributor: Christin Veasley useful records are vaginal culture and wet smear results. I begin the interview by asking the patient to Layout: Andrea Hall “tell her story” from the very beginning, when her vulvar pain first started. Patience is a virtue. The National Vulvodynia Association is an educa- tional, nonprofit organization founded to disseminate Diagnostic Procedures information on treatment options for vulvodynia. The A careful pain history is included in the evaluation. NVA recommends that you consult your own health SCORED care practitioner to determine which course of I use the mnemonic to remember the treatment or medication is appropriate for you. multiple aspects of the pain. Site, or exactly where is the symptom located? Does the pain occur on the entire vulva, inner labia, vestibule, clitoral or peria- NVA News, copyright 2008 by the National nal area? Is it on one side or bilateral? A unilateral Vulvodynia Association, Inc. All Rights Reserved. complaint, or pain only on the right or left side of the Permission for republication of any article herein vulva, is highly suggestive of neuropathy. Character may be obtained by contacting the NVA Executive Director at 301-299-0775. See PUDENDAL NEURALGIA, page 3 Page 2 NVA News/Winter 2007 Pudendal Neuralgia (from page 2) of pain refers to pain quality such as burning, irritation, vestibule, pelvic floor, urethra, bladder, cervix, cul de sharp, stabbing, aching or gnawing. Onset involves sac, uterus and adnexa is performed. Upon rectal or not only when the pain started, but whether it started vaginal exam, palpation of the sacrospinous ligament suddenly or gradually. Also, was there some type of and the sciatic notch can reveal the tenderness of the episode that preceded or triggered the pain? Radia- pudendal nerve in cases of pudendal nerve entrap- tion of the pain can occur and affect the anus, rectum, ment. These women generally have significant ten- vagina or clitoris. Exacerbation refers to factors that derness to palpation of the lateral portion of the elicit or worsen the pain. Finally, Duration takes into sacro-spinous ligament and the sciatic notch, which account how long the pain lasts and when it occurs, as reproduces the pain they experience with sitting. well as the total number of months or years it has existed. Although infrequently used by most clinicians, I highly recommend examination of cutaneous sensa- In some cases, the pain can be cyclical, varying with tion to light touch with a Q-tip, not only in the the menstrual cycle or even the seasons. The pain’s vestibule, but across the skin of the entire vulva, mons association with sexual intercourse is very important. pubis, inner thigh, and medial buttock. The results of In the case of vulvar vestibulitis, the pain only occurs the Q-tip test indicate whether there is normal sensa- with some type of pressure on the vestibular tissue. tion, paresthesia (tingling, prickling, or numbness), Intercourse, gynecologic exam, Q-tip exam, or even allodynia (pain from non-painful stimuli) or clothing can elicit the pain. Taking a complete medi- hypoesthesia (decreased sensitivity). Next, the skin is cal history, including psychological or psychiatric tested for pinprick sensation. During this part of the disorders, also can be helpful. exam, I use a broken Q-tip across the inner thigh, buttock, outer vulva and inferior mons pubis. This is A careful gynecologic evaluation, including a brief probably the most enlightening part of the exam, sensory exam, is required. Speculum exam and evalu- because it is one of the best ways to evaluate the ation of a wet mount is performed. If skin abnormali- function of the pudendal nerve. Side to side and ties are observed, a careful vulvoscopy is often very different nerve distributions are tested repeatedly to helpful. A single digit pain mapping pelvic exam also check for consistency. The most common finding in is performed. During this exam, tenderness of mul- women with pudendal nerve dysfunction is hyperal- tiple sites can be determined and an attempt is made gesia (extreme sensitivity to painful stimulus) in the to reproduce the pain or dyspareunia.