The Mystery of Vulvodynia: Can It Be Solved?

1.0 ANCC CONTACT HOURS The mystery of vulvodynia: Can it be solved?

By Helen E. Harrison, MSN, RN, APRN-C

VULVODYNIA is a vulvar pain syn- Mary’s story tion of a daily topical amitriptyline/ drome characterized by persistent One day Mary (not her real name), a baclofen cream to the vulvar area. vulvar pain without an identifiable healthy young adult, noticed vaginal Mary’s burning pain lessened but cause. It can affect women of any pruritus, a white vaginal discharge, didn’t completely resolve. Sometimes age, whether or not they’re sexually and a burning pain localized to the the burning sensation was so severe active. By some estimates, millions of vulvar vestibule. She assumed she’d that she could hardly sit. She contin- women are affected.1 developed a vaginal yeast infection ued her sexual relationship with her Because the disorder isn’t well un- (vulvovaginal candidiasis) and used boyfriend, but the burning pain wors- derstood, diagnosis may be delayed an over-the-counter topical antimy- ened after intercourse. She returned to or missed, and treatment isn’t always cotic product. When signs and the urogynecologist, who prescribed a effective. As the following case his- symptoms persisted, she saw her gy- topical anesthetic, lidocaine cream. tory illustrates, this persistent pain necologist, who diagnosed bacterial Now, Mary’s burning vulvar pain syndrome can have a significant im- vaginosis and prescribed intravaginal is fairly well controlled but flares still pact on the woman’s health as well as clindamycin therapy for 1 week. Al- occur. Her pain can be triggered by on her intimate relationships.2 This though Mary’s vaginal discharge and vulvar irritation from intercourse or article discusses signs and symp- pruritus resolved, the localized burn- occur without warning. She says she toms, physical and psychological ing pain persisted. Mary was referred gets depressed at times thinking

effects, treatment, and patient educa- to a urogynecologist, who diagnosed she’ll have to suffer with this painful COTT S OY

tion for patients with vulvodynia. vulvodynia and prescribed applica- disorder for the rest of her life. R

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. Origins unknown The cardinal sign of Mary’s condition meets criteria for a localized vulvar pain Conducting point-pressure vulvodynia diagnosis set forth in a syndrome is significant testing consensus statement endorsed by sev- tenderness upon point- eral expert organizations in 2015.3,4 pressure testing of the In this statement, vulvar pain is classi- vulvar vestibule with a fied into two categories: persistent cotton-tipped swab in a vulvar pain with an identifiable cause, circumferential pattern such as an infection, tumor, or other around the vestibule. (See known disorder, and vulvodynia, de- Conducting point-pressure fined as persistent vulvar pain without testing.) Point-pressure a known cause that’s been present for testing helps to map the at least 3 months. Pain may be gener- location and severity of alized, localized to a specific structure vestibular pain. Women such as the vulvar vestibule or clitoris, with localized, provoked or mixed.3 Localized vulvar pain syn- vulvodynia will have pain drome, the focus of this article, is the out of proportion to the most common type of vulvodynia.4 pressure from the touch of The disorder can be further classified the cotton swab, particu- according to how pain is provoked, larly in the areas between onset characteristics, and pain pat- 4 and 8 o’clock.4 testing, and inability to tolerate tern. Vulvodynia can coexist with an- Vulvodynia can have profound vaginal contact; for example, during other identifiable disorder.3,4 physical, emotional, and psychologi- intercourse. Lab tests, biopsy, and/or By definition, the exact cause of cal effects on a woman. Besides imaging studies aren’t diagnostic but vulvodynia is unknown. It probably making intercourse extremely un- may be performed to rule out other involves the interaction of several comfortable, the pain affects many potential sources of pain.3,4 factors, such as genetics, inflamma- everyday activities such as biking and tory disorders, hormonal responses, even sitting for prolonged periods. Treatment challenges weakened pelvic floor muscles, and Dealing with the day in, day out Alleviating the symptoms of vulvo- neurologic mechanisms.3-5 (See Pos- symptoms of this unexplained chron- dynia can be a challenge because no sible risk factors for vulvodynia.) ic pain syndrome can cause hopeless- treatment works for all women. In ness, depression, and despair. fact, a treatment that works well for Clinical manifestations one woman may be ineffective for Patients with vulvodynia may report Diagnosis another.8 The patient must work dyspareunia (painful intercourse) Vulvodynia is diagnosed primarily by closely with the healthcare provider and significant pain upon contact evaluating the woman’s health history to find the best treatment for her. with the vulvar vestibule.6 Women and clinical manifestations, and ruling Treatment options include pelvic often describe the pain as burning, out other vaginal disorders. Key diag- floor muscle rehabilitation (physical hot, stabbing, cutting, or throbbing. nostic indicators include a history of therapy to the pelvic floor with bio- Pain may be primary (provoked by persistent burning vulvar pain for feedback), topical and oral pharma- touch or contact with a stimulus) or 3 months or more with no identifi- cotherapy, local nerve blocks, and as secondary (arising spontaneously). 4 able cause, positive point-pressure a last resort, surgery.7,8 • Pelvic floor muscle rehabilitation 4,17 conducted with biofeedback helps Possible risk factors for vulvodynia the patient learn how to manage • excessive or abnormal immune response symptoms by modifying normal • chronic inflammation of the vulvar vestibule body functions. Performing exercises • local nerve injury or irritation to strengthen and relax the muscles • genital infection, particularly with Candida albicans and bacterial vaginosis of the pelvic region may help reduce • genetic susceptibility to chronic vestibular inflammation pain in the pelvic area.9 Exercises are • pelvic floor muscle weakness or dysfunction usually done twice a day. A small • oral contraceptive use vaginal probe provides data on the • psychological factors. effectiveness of treatment. Overall

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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. relief of pain symptoms is usually sible and avoid swimming in highly seen after performing the exercises chlorinated pools. for several months.7,9 • douches and feminine sprays or • Topical anesthetics, especially topi- powders. cal lidocaine, may reduce pain if • scented products and other poten- applied at least 20 minutes before the tially irritating chemicals in soaps patient engages in sexual activities.9 and clothing. Tell women to wash According to one study, 36% to 76% with nonscented, pH-neutral soap. of women who used topical lidocaine • washcloths and towels. Advise reported improved intercourse.10 women to use their fingertips to gen- The patient should be aware of tly wash the vulva and pat the area several issues associated with the use dry or use a hair dryer to minimize of topical lidocaine to facilitate sexual direct contact. intercourse. Because it can cause pe- • activities that put direct pressure nile numbness, the patient’s partner on the vulva, such as biking or may need to wear barrier protection. horseback riding. In addition, oral sex should be avoid- • antifungal or steroid creams, which ed when the patient uses this therapy.7 can exacerbate symptoms. If symptoms Warn the patient to avoid overuse persist or intensify, patients should because of the small risk of lidocaine contact their healthcare provider to toxicity.9 Teach her to recognize signs discuss other treatment options. and symptoms of lidocaine toxicity, Performing exercises Teach patients to avoid prolonged which include central nervous sys- hot soaks, but a 5- to 10-minute sitz tem effects (confusion, agitation, to strengthen and bath in warm water twice daily may ataxia, visual changes, hearing loss) relax muscles of the be soothing. After bathing, patients and cardiovascular effects such as pelvic region may should apply a thin film of petroleum 11 bradycardia. help reduce pain. jelly to the vulva to maintain hydration. • Various compounded topical Applying a cooled gel pack or creams containing drugs such as ga- crushed ice in a plastic bag to the vul- bapentin, amitriptyline, ketoprofen, and provides short-term and va may help relieve burning pain after ketamine, and baclofen, or hormones sometimes long-term relief for intercourse. A bag of frozen peas or such as estrogen and testosterone, some women.5,7 corn is a convenient alternative. Teach are also options.5,7,12 By using topical • Local injections. Nerve blocks may patients to wrap the gel pack or bag applications, patients may avoid ad- help some women with persistent in a soft cloth and to avoid prolonged verse reactions associated with oral pain unresponsive to other interven- contact to prevent frostbite of delicate formulations. tions. These are administered by an tissues.7,13 Topical products containing anesthesia provider or an expert in Some women find that ingesting capsaicin, the active ingredient in pain management.7 certain substances, such as caffeine, hot peppers, have been studied with • Surgical intervention to remove the processed foods, or sugar, triggers mixed results. Most women can’t affected tissue of the vaginal vesti- symptoms. Suggest that patients try tolerate the extreme burning sensa- bule (vestibulectomy) may be con- eliminating one type of food at a time tion associated with the initial use of sidered if other treatments fail.5,7,8 to determine if symptoms improve.5 this product.7 It’s not recommended for women • Oral medications prescribed for with generalized vulvodynia.5 Facing psychosocial effects neuropathic pain are effective for According to Goesling, Clauw, and some patients. These include tricyclic Other interventions Hassett, 30% to 60% of patients who antidepressants (nortriptyline and Teach women to avoid activities have persistent pain also suffer from desipramine), antiepileptic drugs (ga- and products that may trigger pain, depression.14 As discussed above, bapentin, pregabalin), and serotonin/ such as:7,13 some medications used to treat norepinephrine reuptake inhibitors • synthetic underwear, pantyhose, vulvodynia, such as venlafaxine and (venlafaxine, duloxetine).7,12 tight jeans, and thongs. Loose cotton duloxetine, also help to treat depres- • Local injection of botulinum toxin clothing is best. Patients should re- sion.14 Additional measures may be type A (BTX-A) interrupts pain signals move wet swimsuits as soon as pos- recommended to treat depression, www.Nursing2017.com January l Nursing2017 l 37

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. such as therapy with a mental Communication, 6. Stockdale CK, Lawson HW. 2013 Vulvodynia 5,14 Guideline update. J Low Genit Tract Dis. 2014; healthcare professional. education, and support 18(2):93-201. Women with vulvodynia often re- Women must be persistent in working 7. Stewart EG. Treatment of vulvodynia. UpToDate. port higher levels of stress and frus- with their healthcare provider to find 2016. www.uptodate.com. 8. Haefner HK, Collins ME, Davis GD, et al. The vulvo- tration, primarily due to the impact of what therapy works best for them. dynia guideline. J Low Genit Tract Dis. 2005;9(1):40-51. the pain on their sexual life, as well as Education and ongoing support are 9. Groysman V. Vulvodynia: new concepts and review feelings of inadequacy and low self- crucial. The National Vulvodynia of the literature. Dermatol Clin. 2010;28(4):681-696. 15 10. Nunns D, Mandal D, Byrne M, et al. Guidelines worth. Cognitive behavior therapy Association (www.nva.org) offers in- for the management of vulvodynia. Br J Dermatol. can help patients cope with anxiety formation and resources for both pa- 2010;162(6):1180-1185. related to the pain of vulvodynia.9 tients and healthcare professionals. ■ 11. Kapitanyan R. Local anesthetic toxicity. Medscape. 2015. http://emedicine.medscape.com/ Cognitive behavioral therapy con- article/1844551-overview. sists of mental counseling treatments REFERENCES 12. National Vulvodynia Association. Vulvodynia that help people understand the re- 1. Cox KJ, Neville CE. Assessment and management treatments. www.nva.org/what-is-vulvodynia/ options for women with vulvodynia. J Midwifery treatment. lationship between their thoughts, Womens Health. 2012;57(3):231-240. 14. Goesling J, Clauw DJ, Hassett AL. Pain and de- 16 beliefs, and behaviors. This treat- 2. Jodoin M, Bergeron S, Khalifé S, Dupuis MJ, pression: an integrative review of neurobiological and psychological factors. Curr Psychiatry Rep. 2013; ment helps patients identify negative Desrochers G, Leclerc B. Attributions about pain as predictors of psychological symptomatology, sexual 15(12):421. or destructive thought patterns and function, and dyadic adjustment in women with 15. Sadownik LA. Etiology, diagnosis, and clinical replace them with positive and real- vestibulodynia. Arch Sex Behav. 2011;40(1):87-97. management of vulvodynia. Int J Womens Health. 3. International Society for the Study of 2014;6:437-449. istic beliefs and expectations. In one Vulvovaginal Disease. ISSVD terminology: 16. National Alliance on Mental Illness. study, women with vulvodynia who clarification of vulvar diseases—persistent vulvar Psychotherapy. www.nami.org/Learn-More/ pain & vulvodynia. 2015. www.issvd.org/issvd- Treatment/Psychotherapy. underwent cognitive behavioral ther- terminology-classification-of-vulvar-diseases. 17. National Vulvodynia Association. What causes apy had a 21% to 38% reduction in 4. Iglesia C. Clinical manifestations and diagnosis vulvodynia? www.nva.org/what-is-vulvodynia/ pain symptoms.9 of localized vulvar pain syndrome (formerly what-causes-vulvodynia. vulvodynia, vestibulodynia, vulvar vestibulitis, or Sex therapy may be an option Helen E. Harrison is an APRN at Christiana Hospital in focal vulvitis). UpToDate. 2016. www.uptodate.com. Newark, Del. for couples to help them explore alter- 5. The American College of Obstetricians and Gynecologists. Frequently asked questions. FAQ The author and planners have disclosed no potential conflicts of interest, financial or otherwise. native sexual activities and provide 127. Vulvodynia. 2014. www.acog.org/Patients/ 5,9 mutual support to one another. FAQs/Vulvodynia. DOI-10.1097/01.NURSE.0000510741.45681.2a

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