sign in sign up
<<
Home , Atrophic vaginitis, Dyspareunia, Vaginitis

MedicineToday 2014; 15(8): 43-50

PEER REVIEWED FEATURE 2 CPD POINTS

Vulvovaginal pain and Key points • The most likely explanation in Part 2: Multidisciplinary a patient with chronic vulvovaginal pain who has a management genuinely normal is neuropathy, GAYLE FISCHER MB BS, MD, FACD; JENNIFER BRADFORD MB BS, FRANZCOG; referred pain and/or pelvic TRACEY CRAGG BSc, GradDipPhty, MAPA musculoskeletal dysfunction. • These neuromuscular Nonlesional vulvovaginal pain is more challenging to manage than disorders are amenable to neuropathic pain-directed lesional pain, which usually resolves with resolution of the underlying medication, physiotherapy problem. The required multidisciplinary approach includes neuropathic and/or counselling. pain-directed medication, physiotherapy and counselling. • Occasionally, patients with psychiatric conditions have vulvovaginal pain as a any patients presenting with chronic observable vulval or vaginal lesion or disease) symptom of their condition. vulvovaginal pain have an observable usually resolves promptly with resolution of the • Patients with vulvovaginal skin disease of the and/or underlying condition. Nonlesional pain (where pain and an apparently Mthat explains their symptoms. Others, the physical examination appears normal) is normal examination should however, do not, but we believe that these more challenging to manage and usually never be dismissed. Once patients almost always have a physical cause for requires a multidisciplinary approach. lesional causes have been their pain, although the correct diagnosis is not In this second part of a two-part article, the excluded, patients should be easily made. various causes of lesional and nonlesional categorised into nonlesional Patients with chronic vulvovaginal pain are ­vulvovaginal pain are discussed in detail and diagnostic groups and often perplexing to diagnose and treat, particu- the management of nonlesional pain illustrated specific targeted therapy larly when examination appears to be normal. with case studies. Part 1 of the article, ­published initiated. Lesional pain (pain directly attributable to an in the July 2104 issue of Medicine Today,

Associate Professor Fischer is a Visiting Dermatologist at the Royal North Shore Hospital, Sydney, and Associate Professor of Dermatology at the University of Sydney. Dr Bradford is a Visiting Gynaecologist at Westmead Hospital and Blacktown Hospital, Sydney, and a Conjoint Senior Lecturer in at the University of Western Sydney. Ms Cragg is Senior Women’s Health Physiotherapist at the Royal North Shore Hospital, Sydney, NSW.

MedicineToday x AUGUST 2014, VOLUME 15, NUMBER 8 43 Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014 Vulvovaginal pain and dyspareunia CONTINUED

DERMATOLOGICAL VULVOVAGINAL TABLE. DIFFERENCES BETWEEN LESIONAL AND NONLESIONAL PAIN CONDITIONS CAUSING PAIN. Lesional pain Nonlesional pain Pain and Pain, no itch • • Group A streptococcal cellulitis Pain is described as sharp like a cut Pain is described as burning and other dysaesthesias Inflammatory conditions where the dominant symptom is pain Worse with walking Improved with walking • Worse at night (in bed) Improved with rest • Desquamative inflammatory vulvovaginitis Usually bilateral May be unilateral • Chronic fixed drug eruption Well localised Poorly localised • Immunobullous disease • Nonspecific acute genital ulceration Normalising the lesion usually If there is a lesion, symptoms are unchanged • Hidradenitis suppurativa improves the pain when vulva normalises • Crohn’s disease of the vulva • Behçet’s disease The three most common vulval der- Many genital dermatoses are episodic, and • Hailey–Hailey disease matoses – , psoriasis and lichen thus it may be necessary to examine the • Drug reactions sclerosus – usually cause itch. Pain may patient on a day when she is most Inflammatory conditions where the also occur, due to excoriation from symptomatic. dominant symptom is itch scratching or fissuring. Dyspareunia, if • Dermatitis present, is usually due to friction causing PAIN WITH NO OBSERVABLE LESION • Psoriasis raw areas. In a patient presenting with chronic pain • Chronic vulvovaginal and its variants (burning, stinging, ‘aware- • Chronic vulvovaginal candidiasis (CVVC) is also principally an itchy condi- ness’, throbbing, stabbing, formication and Neoplasia tion but pain often occurs, particularly with sometimes itch) who has a genuinely nor- • Eroded extramammary Paget’s insertion or intercourse. CVVC mal physical examination, evidence is disease characteristically flares premenstrually, increasing that the most likely explanation • Ulcerated VIN or SCC and improves during menses. Examination is neuropathy, referred pain and/or pelvic may be normal in the first two weeks of musculoskeletal dysfunction.2,3 The source Other conditions the . of this neuromuscular pain may be visceral • Dermatological conditions and infec- pelvic problems such as prolapse and con- • Chronic idiopathic fissures tions that are predominantly painful rather stipation, or spinal disease or dysfunction, • tissue than itchy are uncommon, and are listed or both. An important practice point is that • Vulval varicosities in the Box. nonlesional pain can follow an episode of Vulval varicose veins are another pos- painful vulvovaginal skin disease (for ABBREVIATIONS: SCC = squamous cell carcinoma; VIN = vulvar intraepithelial neoplasia. sible cause of vulvovaginal pain. They can example, genital herpes or vaginal candid- cause a dull ache, particularly after long iasis) and persist after the skin problem has periods of standing. been resolved. Even though there has been ­covered the aetiology, pathophysiology Patients with vulval skin conditions a historical dermatological trigger for the and clinical presentation of vulvovaginal usually have observable signs. However, pain, such patients should be included in pain.1 recognising these signs involves knowing this group. what is normal and abnormal for a patient’s A difficulty in making a diagnosis of PAIN WITH AN OBSERVABLE LESION age, hormonal status and racial group, and nonlesional pain is that some common Vulvovaginal pain is usually caused by then the performing of a thorough exam- dermatological conditions causing pain infections and inflammatory dermatolog- ination that includes stretching the skin may have subtle, easily missed examination ical conditions that result in , to look for subtle fissures. A speculum findings. For example, it should always be ulceration, blisters, fissures and adhesions examination is essential to rule out vaginal assumed that fissuring is caused by a der- (Box). Less commonly, tumours, benign epithelial causes, but because of the pain matosis, even if no rash is seen. In addition, and malignant, cause the pain. this may not be possible at the first visit. many common dermatoses have observable

44 MedicineToday x AUGUST 2014, VOLUME 15, NUMBER 8 Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014 examination findings that are intermittent; the classic examples are chronic vulvovag- AN APPROACH TO THE DIAGNOSIS AND TREATMENT OF inal candidiasis and vulval psoriasis, both VULVOVAGINAL PAIN of which tend to be most easily recognisable premenstrually. If a skin disease is present, Patient presents with vulvovaginal pain it should always be assumed to be the cause of the vulvovaginal pain until proven otherwise. Take history: Occasionally, patients with psychiatric • nature and timing of pain conditions can experience vulvovaginal • whether pain only associated with intercourse or present at other times pain as a symptom of their condition • symptoms of dermatoses (somatoform disorder). Our experience is that pain due primarily to psychiatric ­disease is not more common in the vulvo- Perform systems review of any associated vaginal region than in any other part of the pelvic/lumbosacral disorders body.

HISTORY TAKING AND DIAGNOSIS Perform physical examination: The features of lesional and nonlesional • lesion, fissure or rash vulvovaginal pain noted on history taking • hyperaesthesia, pubococcygeus spasm are discussed in detail in part 1 of this arti- cle, as is the physical examination and investigation of women with such pain.1 A Perform investigations: summary of the differences between • low vaginal swab in every case lesional and nonlesional pain is given in • biopsy if necessary, to exclude certain conditions the Table, and an approach to the diagnosis and treatment of vulvovaginal pain is ­outlined in the flowchart. Vulva appears normal Vulva abnormal and/ MANAGEMENT OF NONLESIONAL and swabs negative or swabs positive VULVOVAGINAL PAIN Exclude dermatological or infective causes Categorise patient by Treat any visible abnormality Before assuming that a patient has non­ symptoms and/or infection lesional pain, ensure that their vulvovaginal examination is truly normal (see the flow- chart). If seeing them on a ‘good day’ and the examination seems normal, reschedule Neuropathic pain: Referred pain: Somatisation disorder: an examination on a ‘bad day’. A low bilateral, constant, burning pain, more bizarre history and affect ­vaginal swab should always be taken for burning* pronounced on one side, culture to exclude candidiasis, even if the history of back injury* examination does not suggest it. There are patients with observable skin disease in whom the skin disease is not Treat by: Exclude gross pathology Treat by: responsible for their symptoms. Nonethe- • counselling and and treat by: • counselling and less, a trial of treatment for the observed education • counselling and education skin condition must be undertaken to • medication education • medication ensure that it has been confidently excluded • physiotherapy • tackle depression as a cause for the pain. • medication (possibly) if present

Some patients have pain due to coexist- * Introital dyspareunia may supervene on neuropathic and referred pain. ing lesional and nonlesional causes. In these

MedicineToday x AUGUST 2014, VOLUME 15, NUMBER 8 45 Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014 Vulvovaginal pain and dyspareunia CONTINUED

cases, adequate control of an observable Comment Oral medications vulval dermatosis may not completely Nora presents with a typical history and As with other forms of neuropathic pain, improve the pain, and a nonlesional cause examination for a patient with neuropathic the use of oral medication can relieve should be sought. pain. Although atrophy is present, this has ­vulvovaginal neuropathic pain. The most been excluded as a cause of her discomfort effective medications include: Categorise patients by an adequate trial of topical oestrogen. • the tricyclic antidepressants Although it is often challenging, we find it The erythema may relate to loss of sympa- amitriptyline and nortriptyline ­ helpful to attempt to categorise patients thetic control of skin vasculature and can (off-label use) – 10 to 50 mg at night into those likely to have neuropathic pain, also be a side effect of daily use of oestrogen • doxepin (off-label use) – 10 to 30 mg those with referred or musculoskeletal pain and/or topical corticosteroid cream. at night appears to be useful in and those who have a somatoform disorder. Neuropathic pain commonly localises patients whose main neuropathic The latter is a diagnosis of exclusion. to a horseshoe-shape involving the peri- symptom is itch The appropriate management of patients neum, introitus and lower majora • pregabalin – 25 mg at night initially, in these diagnostic groups is illustrated by bilaterally. It may radiate to the groin or increasing to 75 mg twice daily the three cases below and summarised in inner thighs. In some patients the discom- (150 mg/day) if tolerated and then the flowchart. fort is unilateral, or even confined to one increased gradually to a maximum small spot, usually on the mucosal surface of 300 mg twice daily (600 mg/day) CASE 1: NEUROPATHIC PAIN of the ; in others, the area • gabapentin – 100 to 300 mg at night Case scenario affected is periclitoral. initially, increasing to twice daily Nora is a 72-year-old woman who complains (200 to 600 mg/day) and then slowly of a constant and poorly localised burning Management – general advice increased up to three times a day sensation in the vulva. The pain is least severe and therapeutic interventions (300 to 900 mg/day; some patients in the morning after rest in bed and builds up Before recommending medication to a require total daily doses of more during the day, especially with physical activ- patient with neuropathic pain, it is essential than 1800 mg. ity. Certain positions are more uncomfortable to provide an explanation. Many patients It is very important when commencing than others, particularly sitting. present having seen many doctors and tried all of these medications to start with a very The pain is not always associated with many treatments without success, and are low dose and slowly increase it, as many dyspareunia, but she has developed a dis- understandably frustrated and sceptical. patients find the side effects initially difficult taste for because she is Many state that they do not wish to be to cope with. fearful that it will exacerbate the pain. The ‘pill-poppers’, as if taking medication indi- The side effects of tricyclic antidepres- burning sensation is not severe, although cates a psychological weakness. Many have sants include drowsiness, disorientation, she finds it debilitating. It rarely wakes her deduced from experience that the problem dry mouth, blurred vision, constipation, at night but she finds that it is constant and is perhaps ‘all in their heads’, and reason- hypotension and conduction defects caus- exhausting. She relates that she has ‘good ably resist this idea and its implications. ing palpitations. They should not be used and bad’ days and that bad days occur after The explanation that their pain has a real in patients with narrow angle glaucoma. increased stress or physical activity. but not visible aetiology often comes as a Many patients will not hear of taking a When questioned, she reports that she welcome revelation. tricyclic antidepressant because of the stig- has chronic low back pain, and that the General advice includes reassurance, matisation involved, and it is therefore vulval burning started shortly after a lumbar vulval skin care, minimisation of topical important to explain that you are not using discectomy for sciatica. therapy (which is often irritating) and with- the drug as an antidepressant but as a pain Adequate trials of topical and drawal of topical corticosteroids. Rest is an reliever. Because of this concern, any side corticosteroid preparations did not help important component of treating this con- effect may cause patients to quickly give her, and in fact caused stinging. She s­elf-­ dition. As the pain improves, many patients up taking amitriptyline or nortriptyline. medicates daily with topical oestrogen become rapidly more active, causing a They need to be encouraged to persevere cream, which does not sting but is also temporary relapse. as it is usually the first two weeks that are ineffective. Therapeutic interventions include oral the most difficult. The tricyclic antidepres- Vulval examination shows no abnormality medication, physiotherapy and, sometimes, sants are best given at night to minimise other than some degree of atrophy consistent counselling, and are often used together. drowsiness. Dry mouth problems can be with her age, and vague erythema of both Although some surgical techniques may counteracted by taking one drop of pilo- . Palpation reveals hyperalgesia have a role, we believe they are rarely carpine 1% eye drops in a glass of water in but no pubococcygeus spasm. necessary. the morning (off-label use).

46 MedicineToday x AUGUST 2014, VOLUME 15, NUMBER 8 Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014 Gabapentin and pregabalin may be com- Complementary medicine, counselling dryness. Some hypo-oestrogenic patients, bined with low-dose tricyclics. and explanation particularly those with a tendency to der- If a medication is effective, most patients Some patients appear to benefit from acu- matitis elsewhere or who are atopic, may who respond will notice obvious, if small, puncture and chiropractic treatment and also develop a mild dermatitis of the intro- improvements in their pain within four to some find that counselling is helpful, par- itus and labia minora. They may then com- six weeks. The dose should then be slowly ticularly if the counsellor has expertise in plain as well of itching or . The increased until no more pain is felt. This chronic pain management. group who are prone to the vulvovaginal can take up to one year. Once the pain has In some patients, just an explanation of effects of postmenopausal oestrogen defi- been relieved it may be necessary for the what is happening is all that is needed. If ciency, however, are also the age group most patient to remain on their medication the pain is not severe, some patients prefer likely to experience neuropathic pain. As a indefinitely, although an attempt is usually to live with it rather than take medication result, the atrophy may not be the cause of made to reduce them once the pain has or they embark on other therapies. their vulval pain. been ­adequately controlled for some Examination shows a pale mucosa, with months. A note about topical oestrogen little lubrication and loss of normal rugosity. At the time of writing, we do not believe Topical oestrogen is a treatment for symp- In younger lactating patients, however, there that there is sufficient evidence for the use tomatic atrophic , which occurs in may be little to see other than a somewhat of compounded topical neuromodulating lactating or menopausal women and, rarely, dry surface. agents. An integral part of the effect of these in women with conditions such as starva- responds to topical compounds is on spinal neurological tion and anorexia nervosa. oestrogen. If there is no response after six ­function, which topical agents cannot Atrophic vaginitis is due to oestrogen weeks of treatment, it is important to con- change. Further, topical agents may cause deficiency and usually presents with dys- sider other causes for the patient’s discom- hypersensitivity reactions and they are pareunia alone, which patients often cor- fort. Additionally, the speculative use of expensive. rectly identify as being associated with topical oestrogen vaginally in healthy,

Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014 Vulvovaginal pain and dyspareunia CONTINUED

premenopausal women is not only unnec- and may have a history of a back injury from lower limbs. A gentle but thorough assess- essary but often causes topical hypersensi- lifting, falling off a horse, a skiing or motor ment may take more than one session, tivity reactions. We frequently see patients vehicle accident or falling on the coccyx. because of the high levels of and who have been prescribed topical oestrogen Childbearing often worsens the pain. Exac- fear in this patient group. with no benefit, but who have been told to erbations can be associated with episodes Resting tone, trigger points and pain continue it. We see no logic in this reason- of worse low back pain. scores of pelvic floor, hip and relevant spi- ing, and suggest that topical oestrogen Anorectal disease and dysfunction may nal muscles are assessed, as well as the should be ceased if it is not helpful. also cause referred vulvovaginal pain, presence or absence of prolapse and any although in these cases the pain is typically apparent fascial defects. A more generalised CASE 2: REFERRED PAIN central. musculoskeletal assessment is also per- Case scenario In Jane’s case, the lumbosacral dysfunc- formed, including assessment of gait and Jane is a 42-year-old woman who, in her tion has caused referred pubococcygeus posture, generalised muscle tone and youth, was a keen horse rider. She has had dysfunction, leading to dyspareunia. breathing patterns, and specific examina- many injuries, and these have left her with tion of the lumbar spine and pelvic girdle chronic low back pain. She now has two Management – physiotherapy plus identification of any trigger points in young children and during both It is important in women with referred the abdominal, hip, gluteal and back she experienced right buttock pain and coc- vulvovaginal pain to rule out gross spinal muscles. cydynia. She has gained 15 kg in weight in pathology, although this is very unusual. the past five years. Management of any anorectal problems is Physiotherapy management Jane presents with a constant unilateral also essential. Education is an important first step when burning sensation in the right labium majus Management of this type of pain is using physiotherapy techniques in women associated with right-sided vaginal dyspare- ideally physiotherapy delivered by a phys- with referred vulvovaginal pain. A clear unia. Treatment with various topical ther- iotherapist skilled in both the pelvic and explanation of the possible causes of their apies has been ineffective. spinal regions.2,4 Neuromodulating drugs pain and the nature of chronic pain is External examination is completely may be necessary. General measures such essential. Behaviour and lifestyle modifi- ­normal. On pelvic examination, however, as lifestyle modification and weight loss cation such as correct posture, good back there is obvious tenseness of the pubococcy- will help. care, good bladder and bowel habits, vulval geus, which is more pronounced on the right hygiene, avoidance of aggravating factors, side. Gentle palpation of this muscle repro- The role of physiotherapy in the stress reduction and incorporation of duces her dyspareunia. management of female appropriate general exercise and relaxation Physiotherapy is an essential element of activities/techniques into daily life is Comment treating many patients with nonlesional important. The nerve supply to the vulva and anus vulvovaginal pain. In these patients, Physical techniques aim to increase originates from the L1-2 and S2-4 nerve retraining of the pelvic floor muscles will awareness and proprioception, normalise roots via the genitofemoral and pudendal reduce resting muscle tone and in turn tone, improve muscle discrimination and nerves (see pathophysiology in Part 1 of reduce dorsal horn sensitivity. relaxation, desensitise and increase tissue this article).1 Compression or injury to these The role of physiotherapy is either as elasticity and reduce the fear of vaginal nerves may result in pain referred to the an alternative to medication or to allow penetration.2 Techniques may include myo- vulva, similar to sciatica. There is much an eventual withdrawal of medication. It fascial massage and trigger point release. overlap between this problem and neuro- has high levels of patient acceptance and Vaginal dilators may be used both during pathic pain, but in referred pain, the pain the psychological support of the physio- sessions and as part of the patient’s home is often unilateral or much more pro- therapist should not be underestimated. program. Once normalisation of resting nounced on one side, may have a shooting, We recommend physiotherapy if the pelvic floor muscle tone had been achieved, ‘electric shock’, stabbing or cramping com- patient is well enough and young enough further attention may need to be directed ponent and may have been of sudden onset. to embark on it. to improving the strength, endurance, The patient is often much younger, and co-ordination and timing of these may present from early in the third decade Physiotherapy history muscles. of life. The physiotherapy history is similar to the Treatment of coexisting lumbar spine When questioned, patients with pain medical history. Physical examination, and sacroiliac joint dysfunction, using referred to the vulvovaginal region may also however, concentrates on the musculoskel- joint mobilisation and muscle energy give a history of low back pain or sciatica, etal components of the spine, and techniques, is often necessary.

48 MedicineToday x AUGUST 2014, VOLUME 15, NUMBER 8 Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014 CASE 3: SOMATOFORM DISORDER brought in by relatives who are desperate insert . They may insist on wearing Case scenario for an end to the misery and expense that pads and liners at all times because they Alison is a 19-year-old woman who presents the patient inflicts on all the family mem- feel this is hygienic, which further exacer- with her mother. She has been suffering from bers, who are inevitably controlled by the bates their skin problem. As a result, they vulvovaginal pain since she was 14 years of patient. Often these patients have seen may find themselves in a vicious cycle. Not age, and says that the pain can radiate to numerous doctors and are angry and frus- surprisingly, anxiety and depression com- involve her entire body at times. It has inter- trated. If a patient does come by herself, she monly supervene. fered greatly with her quality of life. She is often remarks that her family has insisted Unlike patients with a somatoform unable to have intercourse and has not been that she sees a doctor. These patients may ­disorder who are commonly angry, these able to sustain a relationship. Although she be quite unco-operative when examination patients present as sad and anxious. Even started a university degree, she dropped out is attempted. when they lack insight into their condition half way through her first year and now rarely This type of patient experiences pain as they are usually receptive to the suggestion leaves the house because of her pain. a manifestation of an underlying psychiatric of psychiatric help and antidepressant Alison and her mother have visited over illness, and may have a medication. 20 doctors and she has been extensively tested or Münchausen syndrome. They derive Any patient with a longstanding vulvo- to rule out a sexually transmitted or other secondary gain from the pain, and do not vaginal problem, particularly where pain is infection. She has had three biopsies, two EUAs wish to recover as the pain satisfies their part of the symptomatology, may become (examination under anaesthetic), a laparos- needs; it is their relatives who want a solu- depressed and the depression will exacerbate copy and a cystoscopy. No abnormality has tion. A psychiatrist is one doctor that these the pain. For many patients, the concept of been detected. She has taken large doses of patients usually flatly refuse to see. They long-term control of a condition that cannot neuropathic pain-relieving medications with medicalise their problem, and as soon as be cured is very difficult to accept. no improvement. Most of the history is given they encounter a doctor who refuses to by Alison’s mother, whose communication legitimise their medical model, they seek SURGICAL TREATMENT FOR PATIENTS style reveals despair. Alison’s affect is one of help elsewhere. WITH VAGINAL DYSPAREUNIA passive aggression. Our approach is to help the relatives Five surgical approaches have been advo- Examination is normal but Alison is cope with the patient. It is best for both cated in the medical literature for women exquisitely sensitive to even the lightest touch. parties if the secondary gain in truncated. with vulvovaginal pain: Your attempt to examine her is met with Unfortunately, the relatives are often unwit- • Fenton’s procedure, where the minimal co-operation. It takes some time to tingly part of the problem, and patience superficial muscles of the posterior permit a brief examination and after a few and persistence are needed to convince introitus are incised to increase the seconds she clamps her legs together and them of the real nature of the illness. dimensions of the introitus pushes you away, stating that she is sick of • vestibulectomy, where the sensitive being ‘poked and prodded’. Depression and other conditions area of the introitus is excised, and the affecting pain-coping ability lining of the vagina is undermined Comment Depressed patients may also experience and advanced to cover the defect Patients with are a very pain as a manifestation of their depression, • surgical excision of persistent skin difficult group to diagnose and in many but a more common scenario is a patient fissures cases impossible to treat. It takes experience with a painful physical vulval condition • intramuscular injection of to be able to recognise this condition, and who copes poorly due to a concurrent botulinum toxin even so it is inevitably a diagnosis of depressive illness. As a result, a physical • surgical decompression of the exclusion. condition that would normally be mildly pudendal nerve. Typically with a somatoform disorder, painful is experienced as excruciating. the complaint is of constant pain, often with Patients with obsessive compulsive dis- Vestibulectomy a burning quality, that does not fit easily order may also find physical vulvovaginal The rationale for vestibulectomy is that the with physiological pain patterns. There is conditions extremely difficult to cope with. inside of the vagina is not sensitive to pain, a bizarreness to the descriptions, which may Washing rituals may further irritate their and replacing sensitive introital skin with change with each consultation. The pain is skin, they may become irrationally focused vaginal lining will eradicate the pain.5 often not confined to the vulva and may on infection, particularly genital herpes, Advocates of this procedure claim a very generalise to involve the whole body. and because disgust is a major issue for high success rate where other treatments Patients with psychogenic pain rarely them, they may experience great difficulty have failed. The difficulty is the patients come to the consultation alone. They are touching themselves to apply creams or have all been characterised as having

MedicineToday x AUGUST 2014, VOLUME 15, NUMBER 8 49 Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014 Vulvovaginal pain and dyspareunia CONTINUED

‘’, which is a descriptor rather consider that careful and comprehensive FURTHER READING than a diagnosis, and therefore represent a nonsurgical treatment usually suffices. heterogeneous population. Andrews JC. Vulvodynia interventions – systematic In our practice, we have never needed CONCLUSION review and evidence grading. Obstet Gynecol Surv to resort to this procedure. We are of the The differences between lesional and non- 2011; 66: 299-315. opinion that vestibulectomy may not be lesional vulvovaginal pain are discernible Damstetd-Petersen C, Boyer SC, Pukall CF. Current necessary when an accurate diagnosis leads if a careful and comprehensive history and perspectives in vulvodynia. Women’s Health to effective (nonsurgical) treatments. examination are performed. Causes of (Lond Eng) 2009; 5: 423-436. lesional pain include infections and inflam- Surgical excision of skin fissures matory dermatological conditions that Hartman D. Chronic vulvar pain from a physical Surgical excision of skin fissures is rarely result in inflammation, ulceration, blisters, therapy perspective. Dermatol Ther 2010; 23: ­­ indicated. Persistent fissures should always fissures and adhesions, and also tumours. 505-513. be assumed to be due to a skin condition, Lesional pain usually resolves with resolu- Mandal D, Nunns D, vByrne M et al. Guidelines for but the clinical signs may be very subtle tion of the underlying problem. Evidence the management of vulvodynia. Br J Dermatol 2010; indeed, and easily missed. Surgery carried is accumulating that the majority of women 162: 1180-1185. out on chronically inflamed vulval skin may presenting with nonlesional vulvovaginal result in a worsening of the underlying pain have a neuromuscular disorder that is Nunns D, Mandal D, Byrne M, et al. Guidelines for condition. amenable to treatment with a multidisci- the management of vulvodynia. Br J Dermatol 2010; There is a very small group of patients plinary approach that includes neuropathic 162: 1180-1185. in whom the primary problem appears to pain-directed medication, physiotherapy Pelletier F, Parratte B, Penz S, et al. Efficacy of high be fissuring without any evidence of under- and counselling. doses of botulinum toxin for treating provoked lying inflammation. This is the only group The patient presenting with vulvovag- vestibulodynia. Br J Dermatol 2011; 163: 617-622. where such surgery is indicated. inal pain who has an apparently normal examination should never be dismissed. Steege JF, Zolnoun DA. Evaluation and treatment of Botulinum toxin treatment An initial search should always be made dyspareunia. Obstet Gynecol 2009; 113: 1124-1136. Intralesional botulinum toxin, which is for a dermatological/lesional cause for their injected directly into the muscle, symptoms. Once lesional causes are ruled COMPETING INTERESTS: None. is used to temporarily paralyse the muscular out, an attempt should be made to catego- spasm that causes the pain. It does appear rise these patients into nonlesional diag- to be effective as an adjunct to physiotherapy, nostic groups so that specific targeted Online CPD Journal Program enabling patients who have a great deal of therapy may be initiated. MT trouble releasing the pelvic floor to progress List three with exercises. This therapy is still in an REFERENCES components experimental stage. The effect lasts about of the multi­ three months, and the injections have to be 1. Fischer G, Bradford J, Cragg T. Vulvovaginal disciplinary repeated. Side effects include the possibility pain and dyspareunia. Part 1: An often challenging management of urinary and faecal incontinence, and the presentation. Med Today 2014; 15(7): 41-46. of nonlesional cost is not inconsiderable. 2. Chaitow L. Chronic pelvic pain: pelvic floor vulvovaginal At this stage we still see it as something problems, sacroiliac dysfunction and the trigger point pain. to be considered when more conservative connection. J Bodywork Movement Ther 2007; 11: therapy has failed. 327-339. 3. Butler DS, Mosely GL. Explain pain. 2nd ed. Surgical decompression of the Adelaide: Noigroup Publications; 2003. pudendal nerve 4. Morin M, Bergeron S. Pelvic floor rehabilitation in Pudendal neuralgia has been suggested the treatment of dyspareunia in women. Sexologies © SHUTTERSTOCK/CLIPAREA as a cause of pain in the distribution of 2009; 18: 91-94. Review your knowledge of this topic the pudendal nerve. The diagnosis is con- 5. Bergeron S, Khalife S, Glazer HI, Binik YM. and earn CPD points by taking part in MedicineToday’s Online CPD Journal Program. firmed with pudendal nerve block. Sur- Surgical and behavioral treatments for gical decompression of this nerve where vestibulodynia: two-and-one-half-year follow-up Log in to it runs in Alcock’s canal is sometimes and predictors of outcome. Obstet Gynecol 2008; www.medicinetoday.com.au/cpd performed. As with vestibulectomy, we 111: 159-166.

50 MedicineToday x AUGUST 2014, VOLUME 15, NUMBER 8 Permission granted by Medicine Today for use by Jean Hailes for Women’s Health for educational purposes. © Medicine Today 2014