On the case... for a dozen years in a young woman By Susan Hoffstetter, PhD, WHNP-BC, FAANP

Why has a 30-year-old woman never been able to enjoy pain-free sex?

30-year-old woman named CL presents to the office as a Anew patient. Her health his- tory is notable for ; irri- table bowel syndrome (IBS), diarrhea dominant; and dyspareunia since the onset of sexual activity at age 18. CL has never been pregnant. CL tells the nurse practitioner (NP) that her dys- menorrhea has been well managed since age 15 with combination oral contraceptives (COCs) and an occa- sional NSAID on day 1 of her period. She does not take any medication for her IBS, and she avoids foods that might cause bouts of diarrhea. CL tells the NP she is seeking relief of the pain partner for 6 months and that they periencing itching and burning in she experiences during sex, which have had sex 3 times, which caused the vulvar area. The symptoms are has worsened over the past 6 months great discomfort. She says she tried present on most days and worsen and which she fears might ruin her various over-the-counter (OTC) lubri- with her period. She ascribes the current relationship. She tearfully tells cants and different positions, to no symptoms to yeast infections (3-4 the NP that three prior relationships avail. Although CL says she enjoys in the past year), which she treats ended badly because she was unable cuddling and kissing with her part- with OTC antifungal creams. She also to have comfortable, enjoyable sex. ner, she has been avoiding this type reports that, in the past year, she has Although she said she was able to tol- of contact for the past 2 months been treated by another healthcare erate sexual touching and intercourse because of fear that it would lead provider (HCP) for bacterial vagino- in the past, her symptoms have been to intercourse. At the same time, sis with a vaginal gel. In addition, gradually getting worse. she wants to enjoy intercourse and she has gone to an urgent care She goes on to tell the NP that please her partner. center twice for treatment of urinary she has been dating her current tract infections— even though she What else would be is unsure whether the urine culture We invite readers to submit helpful to know about findings were positive or negative. interesting and elucidating case CL’s symptoms and A year ago, at the suggestion of reports. Please see our Guidelines health history? a friend to whom she mentioned for AuthorsA for more information about this short-form article option. CL tells the NP she feels she is “a the painful sex, CL went to a clinic mess down there.” She reports ex- for sexually transmitted disease

NPWomensHealthcare.com April 2020 Women’s Healthcare 37 In the absence of abnormal or a “razor blade” sensation. During sensation in the vulvar area. The test penile thrusting, she experiences is done prior to digital palpation visible findings other than vaginal pain rated as a 6. After sexual and an attempt at insertion of a mild erythema of the touching, she has heightened burn- speculum. A standard cotton tip ap- ing pain in the vestibule area rated plicator is used to apply light touch majora, the NP performs as a 4; the pain lasts 12 to 24 hours. starting on the upper inner thigh and following in a clockwise fashion a cotton-swab test to Which differential in a manner that includes the labia specifically localize any diagnoses would you majora, the vestibular duct openings consider at this point? for Skene's and Bartolin glands, the areas of altered sensation CL describes chronic vulvar itching /hood, and the perineum. The and burning, significant vestibu- patient is asked to rate her pain on a in the vulvar area lar pain during and after sex, and scale of 0 to 10 at each location (Fig- vaginal pain with thrusting. These ure). CL’s cotton- swab test produces testing and a Pap smear with a hu- symptoms may have similar or over- scores of 0 on the inner thighs and man papillomavirus (HPV) co-test. lapping causes such as: , 2 at the clitoris, and 2 She reports that all findings were • Vulvitis; at the perineal body. Pain at the ves- negative but adds that she hesitates • Chronic or chronic im- tibular gland duct openings is rated to “go through that again” because balance in vaginal microbiome; at 6-7 for the Skene’s glands and 7-8 the speculum examination was • Vulvar dermatoses (eg, lichen scle- for the Bartholin glands. very painful. She says, “I don’t even rosus); Because CL has high vestibular use tampons because they hurt • Vulvar cancer (pruritus is the most pain scores, the NP does not per- too much.” She tells the NP that common early symptom); form a speculum exam. The NP uses she wears a panty liner every day • Vulvovaginal atrophy (associated a cotton swab to obtain a vaginal because she does not take her COC with the patient’s prolonged COC specimen for pH and microscopic consistently; when she forgets to use); wet mount evaluation. The pH is take a pill or takes it late, she has • ; and 4.0. A whiff test is negative. Mature some spotting. She remarks that she • . squamous epithelial cells are present, never feels really clean because of with no pseudohyphae, clue cells, or the frequent diarrhea, and uses fem- What would you motile trichomonads seen on the wet inine wipes daily. include in your mount. A vaginal specimen is sent for As she tears up again, CL tells the problem-focused fungal culture to assess for infection NP that, over the past few months, physical examination? caused by atypical Candida species. she has felt more stressed than usual The NP begins with inspection of The culture results are negative. because of worries about her relation- the and vestibule to assess for Pelvic floor muscle (PFM) as- ship and because of work pressures anatomic changes or variations, pig- sessment is done using one finger with a new boss. She laughs a little mentation changes, lesions, and in- inserted into the vagina without as she says, “I don’t drink, use drugs, tegrity of vulvar tissues. The inspec- touching the vestibule. The Oxford or smoke, but when I get home from tion reveals normal vulvar structures Grading System uses a 6-point scale work, all I want to do is take a long hot and mildly erythematous, dry labia to measure PFM strength: 0 = no bath with some scented oils to help majora with no other pigmentation contraction; 1 = flicker; 2 = weak; 3 = me relax and feel clean.” changes or lesions. The moderate; 4 = good (with lift); and 5 The NP seeks more details about are moist and pink. Vulvar hair is = strong. CL’s PFM strength is rated a the dyspareunia, and asks CL to rate absent; CL reports that she has been 4. Palpation of the levator ani group the pain she experiences during removing this hair with a razor and and obturator internus muscles re- and after sexual intercourse using a shaving cream for years. veals hypertonicity and tenderness. Likert scale, with 0 = no pain and 10 In the absence of abnormal = maximum pain. CL rates the pain visible findings other than mild er- Based on the history she feels in the vestibule area when ythema of the labia majora, the NP and exam findings, her partner’s penis enters the vagina performs a cotton-swab test to spe- what is the diagnosis? as an 8, and describes it as burning cifically localize any areas of altered CL has three interconnected diagno-

38 April 2020 Women’s Healthcare NPWomensHealthcare.com ses contributing to the dyspareunia: Figure. Cotton-swab test checkpoints contact vulvitis, vulvodynia, and vaginismus. Vulvitis may be caused by chronic Pubis or recurrent infection by pathogens Inner thigh such as Candida, herpes simplex virus, or HPV; contact with allergens or irritants; or injury/ trauma. CL Clitoris has reported regular use of vulvar contact irritants such as panty liners, Urethral meatus feminine wipes, shaving cream, and Skene’s gland os scented bath oils. Pubic hair shaving Labia majora may heighten one’s sensitivity to contact irritants. CL’s physical exam Labia minora and wet mount findings tend to rule Introitus out infection as the cause of the vul- vitis. The labia majora dryness may be related to prolonged use of COCs. Bartholin’s gland Vulvodynia is defined as vulvar duct os discomfort (usually described as Perineum burning pain) occurring in the ab- sence of relevant visible findings Anus or a specific, clinically identifiable, neurologic disorder.1 It is a diagnosis of exclusion when all other potential remain undiagnosed.9 Vulvodynia is dynia have increased perception of causes have been ruled out and classified as localized or generalized. pain when taking COCs, stopping when symptoms persist longer than Localized vulvodynia is subdivided COCs does not necessarily lead to 3 months.1 The etiology of vulvody- into primary, in which vestibular resolution of the symptoms.12 nia is unknown but may be related pain begins during the first attempt Vaginismus is defined as recurrent to genetic susceptibility, chronic at vaginal penetration, or secondary, or persistent involuntary spasm of inflammation, a combination of in which pain occurs after a period the musculature of the outer third of factors (eg, PFM abnormalities, of pain-free sex. Generalized vulvo- the vagina that interferes with vaginal neuropathic pain, anxiety, primary/ dynia may include all of the vulva penetration and that causes personal secondary ), or be limited to one side, with pain distress or interpersonal difficulties.13 regionally elevated cytokines pro- occurring in the absence of a trig- duced by vulvar vestibule-specific gering event. Of note, about 10% of What can the NP fibroblasts, hormonal changes, or women with generalized vulvodynia offer CL as first-line dietary oxalates.2-8 Chronic inflam- have a coexisting pain syndrome treatment? mation related to the contact irri- such as interstitial cystitis/painful Because studies on the cause and tants, recurrent infections, hormonal bladder syndrome, IBS, fibromyalgia, treatment of vulvodynia are limited, changes, or chronic skin conditions or chronic fatigue syndrome.10 the American College of Obstetri- acts as a trigger. Normal sensations Prolonged use of COCs as a risk cians and Gynecologists recom- are perceived as abnormal, resulting factor for vulvodynia is controver- mends that therapy be based on in heightened sensitivity. sial. Several studies have supported evidence from descriptive studies, Estimates of vulvodynia preva- the theory that use of COCs or pro- expert reports, and clinical experi- lence range from 3% to 18%.9 Onset gesterone-only contraceptives in ence— with the understanding that is most likely to occur between the females younger than age 18 causes the condition is difficult to treat and ages of 18 and 25 years. Among down-regulation of estrogen recep- that no single approach is successful symptomatic women, 60% see an tors, leading the vestibular epithe- for all women.14 average of three HCPs before receiv- lium to become thin and fragile.11,12 Individualized treatment usually ing the correct diagnosis and 40% Although some women with vulvo- involves multiple therapies over

NPWomensHealthcare.com April 2020 Women’s Healthcare 39 time.9 Treatment is considered in amounts of water-soluble lubrication. a combination of interventions to a step-wise progression, starting A low-oxalate diet has been sug- decrease CL’s dyspareunia and to im- with self-management and moving gested to reduce high levels of oxalate prove her sexual function.17,18 Inter- upward on the scale of complexity. in urine. However, little evidence sup- ventions include biofeedback, which Total symptom resolution can be un- ports the efficacy of this dietary modi- can help CL learn to relax her PFMs; realistic. Primary goals are symptom fication in reducing vulvar pain.7,8 external soft tissue mobilization and reduction, return of satisfactory sex- myofascial release techniques; trig- ual function, and improved quality What types of ger point pressure; and transcutane- of life. Patient education concerning pharmacologic agents ous electrical stimulation applied to the manageability yet chronicity of are appropriate? the sacral nerve. The physical thera- this neuropathic condition is essen- Topical medications can be used on pist or NP may teach CL how to use tial in setting realistic goals and in in- a short-term basis.17 Options include vaginal dilators to gradually over- stituting a treatment plan that leads lidocaine 5% ointment, doxepin 5% come the tension in the PFMs. When to improvement and satisfaction. cream in water-soluble base, gab- CL is ready to resume sexual activity, Mental health counseling is an apentin 2%-6% in watersoluble base, she can use the dilator to prepare important component. Approxi- and amitriptyline 2% with baclofen herself for and facilitate penetration. mately 50% of women with vulvody- 2% in water-soluble base. When topi- nia have a concordant diagnosis of cals are used, those with an ointment When is surgery an anxiety.15 An increased occurrence base, rather than a cream base, are option? of childhood physical/sexual abuse preferred.17 Cream bases contain For women who continue to experi- in women with vulvodynia has been more preservatives and stabilizers, ence intractable symptoms after all reported.16 Referral to a mental which can act as contact irritants and other treatments have been tried, health specialist with expertise in cause burning on application. vestibulectomy—excision of the ves- women’s sexual health and chronic The next line of treatment is the tibule with vaginal advancement—is pain conditions can be helpful. use of oral neuropathic pain modula- an option. Patient selection is critical Self-management is essential in tors, either antidepressants (eg, ami- for success; women can consider this CL’s case. She is educated to avoid use triptyline, desipramine, venlafaxine) option only if symptoms are confined of feminine hygiene wipes/washes, or anticonvulsants (eg, gabapentin, to the vestibule. Success rates range panty liners (at times other than pregabalin, lamotrigine, topira- from 60% to 85%.19,20 Referral to a menses), and repetitive use of OTC mate).17 Side-effect profiles and pelvic and reconstructive surgeon is antifungals.9 She is encouraged to patient tolerance drive dosing regi- advised in these cases. stop removing her vulvar hair, which mens. Pruritus can be managed with provides a protective barrier for sensi- an antihistamine such as hydroxyzine Reflection for practice tized vestibular tissues. She is advised or cetirizine. In addition, nerve blocks, Vulvodynia is a complex chronic pain to avoid exposure to very hot water topical nitroglycerin, topical capsa- condition. The interrelated physical, in bathtubs and hot tubs, which can icin, interferon injection, and trigger psychological, and psychosexual com- exacerbate vestibular discomfort. point injections have shown some ponents make management challeng- Application of unscented, hypoaller- efficacy in treating vulvodynia.17 ing for both clinician and patient. CL genic emollients to the vulvar skin Vaginal valium, injectable botulinum has sought an NP’s help in seeking re- and sitz baths in lukewarm water can toxin, and topical baclofen have been lief of her dyspareunia. The treatment be soothing, however. used in the treatment of vaginismus. plan focuses on symptom reduction CL and her partner should explore to allow for sexual functioning that alternatives to penetrative sex (eg, What role does provides intimacy and satisfaction. light physical contact with her genita- physical therapy play Total relief of pain may not be achiev- lia). As pain diminishes with treatment in CL’s treatment? able. A multidisciplinary approach over time, CL can consider restarting Pelvic floor physical therapy (PT) is to treatment may produce the best penetrative sex. The NP advises her to an essential component of treat- results. In fact, when available, referral implement strategies for PFM relax- ment for CL once she can withstand to vulvovaginal disease specialists ation, to adopt positions during inter- cotton-swab touch with lowered can facilitate an individualized, coor- course that minimize pressure on vestibular pain scores. A person with dinated, comprehensive approach to sensitive areas, and to use liberal expertise in pelvic floor PT may use treatment. =

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