MedicineToday 2014; 15(7): 41-46

PEER REVIEWED FEATURE 2 CPD POINTS

Vulvovaginal and

Key points • Patients with vulvovaginal Part 1: An often pain, particularly when it is chronic, are often distressed and frustrated by both the challenging presentation pain and its adverse effects on sexual functioning. GAYLE FISCHER MB BS, MD, FACD; JENNIFER BRADFORD MB BS, FRANZCOG; • Vulvovaginal pain can be TRACEY CRAGG BSc, GradDipPhty, MAPA divided into: – lesional pain, where the Patients presenting with chronic vulvovaginal pain are often perplexing pain is directly attributable to diagnose and treat, particularly when examination appears to be to an observable vulval/ vaginal lesion or disease normal. This first part of a two-part article discusses the aetiology, – nonlesional pain, where pathophysiology and clinical presentation of vulvovaginal pain. the pain is experienced in the absence of observable atients presenting with chronic vulvovag- THE DIFFERENCE BETWEEN ‘’ vulvovaginal pathology and inal pain are often perplexing to diagnose AND VULVOVAGINAL PAIN physical examination is and treat, particularly when examination ‘Vulvodynia’ is a term familiar to every doctor normal for the patient’s age appears to be normal. Although many with an interest in vulvovaginal disease. The and ethnic group. P patients have an observable skin disease of the term was developed initially by the International • Patients with nonlesional and/or that explains their symp- Society for the Study of Vulvar Disease (ISSVD) vulvovaginal pain are likely toms, some do not. These latter patients, we in 1983. Their current definition is ‘vulvar dis- to have a physical cause for believe, almost always have a physical cause for comfort, most often described as burning pain, their pain, but lateral and their pain, but lateral and multidisciplinary occurring in the absence of relevant visible multidisciplinary thinking is thinking is necessary to arrive at the correct findings or a specific, clinically identifiable necessary to arrive at the diagnosis. neurologic disorder’.1 correct diagnosis. In this first part of a two-part article, the The ISSVD has also produced a system of • It can be helpful to consider principles of the aetiology, pathophysiology and classifying vulvovaginal pain, where patients vaginal dyspareunia as a clinical presentation of vulvovaginal pain are are categorised into those with an identifiable subset of vulvovaginal pain described. The second part will cover the cause and those that fit their case definition for rather than a separate entity. ­management of vulval pain. vulvodynia (Box 1).1 The term ‘vulvodynia’ in

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 Copyright _Layoutand 1 Blacktown17/01/12 Hospital,1:43 PM Sydney, Page 4and a Conjoint Senior Lecturer in Gynaecology at the University of Western Sydney. Ms Cragg is Senior Women’s Health Physiotherapist at the Royal North Shore Hospital, Sydney, NSW.

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• the complex anatomical structure of The convergence in the spinal cord of 1. ISSVD TERMINOLOGY AND CLASSIFICATION OF VULVAR PAIN the bony pelvis and lower spine, and afferent impulses from viscera, skin and (2003)1 its vulnerability to damage muscle can also lead to the phenomenon • the central position of the vulva and of referred pain. Sciatica is an obvious A. Vulvar pain related to a specific vagina in the pelvic myofascial example of this phenomenon, but it is less disorder ­complex, which facilitates pain well known that pain may also be referred 1. Infectious (e.g. , ­referral from other pelvic viscera to the vulva and distal vagina. This con- herpes, etc.) • the fact that this area is subject to vergence can also lead to alterations of 2. Inflammatory (e.g. , a great deal of physical stress: sensation to nearby viscera, particularly immunobullous disorders, etc.) ­, menstruation, defaecation, the bladder. It is not uncommon for patients 3. Neoplastic (e.g. Paget’s disease, childbirth and friction from clothes with vulval pain to complain of frequency, squamous cell carcinoma, etc.) and pads urgency, lower abdominal pain and burn- 4. Neurological (e.g. herpes • personal hygiene habits that may ing on urination. neuralgia, spinal nerve inadvertently exacerbate the original Autonomic dysfunction may lead to compression, etc.) problem loss of control of the vascular system of • the high levels of anxiety and fear the vulva. The result is a variable degree B. Vulvodynia that are often attached to problems of erythema of the vulval skin and the 1. Generalised involving the genital area epithelium of the introitus. This is often a. Provoked (sexual, nonsexual • the crucial importance of the genital misinterpreted as a , and treated with or both)* area in a woman’s sexual wellbeing corticosteroid creams. The vasoconstrict- † b. Unprovoked and self-esteem. ing action of these medications is followed c. Mixed (provoked and by a reflex vasodilatation that may increase unprovoked) Innervation erythema and produce discomfort. 2. Localised (vestibulodynia, The innervation to the posterior vulva and clitorodynia, hemivulvodynia, etc.) perianal skin is provided by the pudendal Pain sensation a. Provoked (sexual, nonsexual nerve, which originates from the S2–S4 Pain sensation is mediated by three types or both) nerve roots. The anterior vulval skin is of afferent fibres, the large myelinated type b. Unprovoked supplied by the ilioinguinal and genitofem- A-beta fibres, the smaller myelinated type c. Mixed (provoked and oral nerves, arising from the L1 and L1–L2 A nerve fibres and the poorly myelinated unprovoked) nerve roots, respectively. The latter nerves or nonmyelinated type C fibres. The type ABBREVIATION: ISSVD = International Society for are predominantly sensory, but the puden- A fibres are responsible for touch and the the Study of Vulvar Disease. dal nerve contains motor, sensory and other types are responsible for pain per- * ‘Provoked’ means that pain is in response to sympathetic fibres that supply the complex ception; the pain mediated by type C fibres friction, pressure, intercourse, insertion etc. autonomic reflexes of the pelvic organs. often has a burning quality. Type A fibres † ‘Unprovoked’ means that the pain occurs spontaneously. The epithelium of the vagina proper (that can become involved in pain sensation, is, deep to the hymenal ring) is not nor- and when this occurs patients may develop mally sensitive to pain. . This increased sensitivity to this classification is what is termed in this The pudendal nerve supplies both the pain explains why patients with vulval pain article ‘nonlesional vulvovaginal pain’. We anal and urinary sphincters whereas the often find pressure from clothes painful prefer to avoid the term vulvodynia as it is muscles of the pelvic floor are mostly inner- and difficult to cope with. a descriptor not a diagnosis, and its wide- vated via direct branches from the sacral When patients experience chronic pain, spread use has suggested a diagnosis. We plexus (S3–S5), with some input from the afferent sensory processes appear to believe this is confusing. pudendal nerve, both voluntarily from become sensitised, with the type C fibres higher centres in the brain and reflexly via of the vulval vestibule discharging more PATHOPHYSIOLOGY OF the spinal cord. easily to lower levels of stimulation and at VULVOVAGINAL PAIN It is known that there is a relationship lower thresholds, or even spontaneously. The mechanisms involved in vulvovaginal between muscle function in the pelvis and This phenomenon has been termed pain are still very poorly understood. There pain, and studies have demonstrated that ‘wind-up’. There may be associated patho- are many reasons why the vulva and vagina patients with have higher levels logical changes in the dorsal horn connec- are a pain-prone partCopyright of the body, _Layout including 1 17/01/12 of resting1:43 PM musclePage 4 tone than normal tion and perhaps also in higher centres. the following: persons. Secondarily, it is common for pelvic floor

42 MedicineToday x JULY 2014, VOLUME 15, NUMBER 7 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2014. muscle tone to increase and, in turn, to women to give the history chronologically. 2. VULVOVAGINAL PAIN: HISTORY contribute to a pain reflex via the dorsal In addition to the usual history taking that TAKING. horn; it is helpful to understand this mech- applies to any patient with chronic disease, anism of pain in a situation it is important in patients with vulvovaginal Pain history when there is no apparent noxious stimulus pain to make sure that the history of the • Duration of current episode of pain present. pain is obtained and a systems review is • History of similar pain previously The exact mechanisms involved in these undertaken. • Historical triggers: phenomena are still far from clear and, – exacerbating/relieving factors History of the pain outside of the specialties of neurology and – associated symptoms, e.g. , pain medicine, poorly recognised. The role Most patients with vulvovaginal pain will , back pain of higher centres is also not well under- not volunteer the symptoms that help to – history of skin disease either vulval stood, although it is known that depressed make a diagnosis. They will, for example, or elsewhere and anxious patients have more problems complain about ‘reduced libido’ instead of • Pain descriptors: with chronic pain, and that mental state is dyspareunia; similarly, a patient is unlikely – sharp/dull/burn/sting/formication/ integral to pain experience. Descending to volunteer that her vulvovaginal pain stabbing* inhibitory and facilitatory signals are started during an episode of acute gener- – associated itch? thought to link the limbic system, which alised . A careful and comprehen- • Continuous or episodic: is integral to mood and anxiety modula- sive history of the pain is therefore essential, – length of episodes tion, to peripheral pain sites via the spinal and should cover the duration, location – triggers for episodes cord at the dorsal horn. and type of pain, triggers and previous • Pain location: Despite the gaps in our knowledge it is treatments, as listed in Box 2. – on/within the majora important to have a concept of how pain – central Systems review can occur in the absence of observable – bilateral/unilateral abnormality, particularly when it comes to As vulvovaginal pain is often referred, a – anterior/posterior explaining the diagnosis to the patient and, complete systems review should be under- – referral patterns indeed, accepting it oneself. taken (Box 2). Of particular importance • Previous treatments: is disease, dysfunction or injury to the – effective Lesional and nonlesional lumbosacral spine, lower intestinal tract – ineffective vulvovaginal pain and anus, and lower limbs, because pain • Impact on quality of life/sex/ Patients presenting with vulvovaginal referral in the lower pelvis is usually pos- relationships pain can be divided into two main groups: terior to anterior. • those with lesional pain – the pain is Systems review directly attributable to an observable How history taking helps • Bladder vulval or vaginal lesion or disease diagnosis • Menstrual cycle/period problems • those with nonlesional pain – the Pain due to an observable lesion (such • Bowel problems pain is experienced in the absence of as an ulcer or a fissure) or a dermatosis • Musculoskeletal review: any observable vulvovaginal (i.e. lesional pain) is usually well localised – congenital problems pathology and the physical and has the following features: – injury examination is normal for the • frequently provoked by physical – orthopaedic/neurosurgical patient’s age and ethnic group. stimuli such as friction during operations It must be remembered that the pre- intercourse or when inserting or – sciatica/other neuralgic leg senting symptoms may sometimes be due pulling out a tampon, rubbing, symptoms to coexisting lesional and nonlesional scratching or wearing tight clothes – orthotics ever worn aetiologies. • often accompanied by the symptoms – foot/knee problems of the causative dermatosis * More pain descriptors are listed in Box 3. HISTORY TAKING • usually bilateral Patients with vulvovaginal pain, particu- • often worse during the night, when larly when the duration of the pain is long, there are fewer external stimuli complex symptoms than lesional pain. are frequently distressed and frustrated, • resolves promptly when the Descriptions of this type of pain used by making the taking ofCopyright a history _Layout challenging. 1 17/01/12 underlying1:43 PM Page condition 4 resolves. patients are listed in Box 3, and features We find it helpful to encourage these Nonlesional pain presents with more include the following:

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3. PATIENT DESCRIPTIONS OF TABLE. DIFFERENCES BETWEEN LESIONAL AND NONLESIONAL NONLESIONAL VULVOVAGINAL VULVOVAGINAL PAIN PAIN. Lesional pain Nonlesional pain • Burning Pain and itch Pain, no itch • Rawness • Dryness Pain is described as sharp like Pain is described as burning and other • Crawling a cut dysaesthesias • Irritation Worse with walking Improved with walking • Vulval awareness • Itch or ‘almost itch’ Worse at night (in bed) Improved with rest • Stabbing Usually bilateral May be unilateral • Pulsing • Stinging Well localised Poorly localised • Stinging on application of topical Normalising the lesion improves If there is a lesion, symptoms are unchanged therapy the pain when the vulva normalises • Discomfort when wearing tight clothes • Discomfort when sitting as opposed The differences between lesional and intercourse and/or tampon insertion. More to standing or lying nonlesional vulvovaginal pain are sum- often dyspareunia is accompanied by pain • Discomfort exacerbating with exercise marised in the Table. at other times. It is the history of this back- or worse at the end of the day ground pain that will help make the A NOTE ABOUT VAGINAL diagnosis. DYSPAREUNIA • typically best on first arising, gets We find it more helpful to consider vaginal Pubococcygeus muscle spasm worse throughout the day and dyspareunia as a subset of vulvovaginal Before discussing vaginal dyspareunia improves with rest at night pain rather than as a separate entity. Indeed, further, it is important to mention pubo- • often positional – worsened by many patients with this type of pain will coccygeal dysfunction, in which the pubo­ ­prolonged sitting and improved by say that they experience exactly the same coccygeus muscle goes into spasm as soon walking. pain when they are not attempting sexual as any pressure is applied to the introitus. • hyperalgesia is characteristic of intercourse. This is found in many patients, either as ­neuropathic pain and describes Like any other vulvovaginal pain, vag- a result of any condition that causes vul- severe pain experienced from mild inal dyspareunia may be lesional or nonle- vovaginal pain or, less commonly, in pain stimuli such as light touch – sional. It is essential to differentiate vaginal response to emotional stress and anxiety. this can cause extra confusion (superficial/entry) dyspareunia (felt in the The patient describes a sharp, tearing because ­application of diverse topical vagina) from abdominal (deep) dyspareunia sensation on intromission and immediate ­therapies seems to cause pain, which (felt in the abdomen). The first is usually relief as soon as intercourse ceases. Tam- is inevitably attributed to the caused by problems in the lower pelvis, and pon insertion often causes the same symp- ­products themselves but is actually the second by problems in the upper pelvis toms. It is unusual for this pain to linger hypersensitivity to touch or abdomen. There is widespread confusion after intercourse ceases unless there is also • poor localisation of pain is often a about the term ‘deep’ dyspareunia, which a lesion that has been irritated during feature of neuropathic pain – when many doctors think means ‘deep in the intercourse. asked to localise this sort of pain, vagina’. Our experience is that the impor- Pubococcygeus muscle spasm is detect- patients are often unable to do so, tant distinction is between abdominal as able on per vaginal examination (Figures and are only able to indicate the opposed to vaginal dyspareunia, and that 1 to 5). Very severe spasm may sometimes ­general area the pain is experienced it does not matter (in a diagnostic ) make insertion of the examining finger • unilateral pain is usually referred how deep in the vagina it is felt. impossible, and any attempt to do so is from the spine – patients will localise Dyspareunia can occur as the only pre- described as severe pain by the patient. a portion of skin on the affected side senting symptom whether the patient has However, a patient who is relaxed with you but examinationCopyright will show _Layout normal 1 17/01/12a lesion 1:43 orPM not. Page In other4 words, the patient as a doctor but apprehensive about inter- skin and no tenderness at this site. has no symptoms except during course may appear deceptively normal.

44 MedicineToday x JULY 2014, VOLUME 15, NUMBER 7 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2014. Lesional dyspareunia VAGINAL EXAMINATION FOR PUBOCOCCYGEUS MUSCLE SPASM When dyspareunia is due to an ulcer or fissure, patients usually complain of the sort of pain experienced when a finger is cut – that is, nociceptive pain. This pain, which is mediated by in the skin, is usually well localised and often accompanied by a small amount of post- coital bleeding (with bright red blood). If the patient has a that is prone to fissuring, such as , the pain may occur as a result of intercourse and then typically last for several days, until the fissure has healed. Figure 1. Contraction of pubococcygeus Figure 2. Relaxation of pubococcygeus Dyspareunia due to local physical causes muscle demonstrating functional muscle demonstrating increase of usually improves promptly when the under- reduction in introital dimensions. functional introital dimensions lying dermatological condition is healed. However, it must be recognised that by the time effective treatment for the dermatosis is initiated, secondary pubococcygeus ­muscle dysfunction may have developed, and the dyspareunia will continue.

Nonlesional dyspareunia Patients with nonlesional vaginal dyspare- unia often have a history of a background of poorly localised or unilateral pain of the types listed in Box 3. The pain mechanism is either a neuropathy or pubococcygeus Figure 3. Palpation of medial aspect of Figure 4. Palpation of pubococcygeus dysfunction. Some patients with nonle- right pubic ramus. muscle. sional vulvovaginal pain deny actual dys- pareunia but say that they no longer want to have sex due to fear of possible pain and low libido.

EXAMINATION OF THE PATIENT WITH VULVOVAGINAL PAIN Patients with vulvovaginal pain are rarely so uncomfortable that they are unable to be examined but they may experience severe Figure 5. Palpation of medial aspect tenderness around the introitus and in the of left pubic ramus. vagina. Speculum examination may be difficult, and we recommend a small straight-bladed instrument, even in mul- tiparous women, but only if it is tolerated. dermatosis. The typical location is at the Usually there is an accompanying vulval six o’clock position on the introitus or in rash such as , candidiasis, Step one: exclude vulvovaginal the sulcus between the and ­psoriasis or lichen sclerosus. dermatoses or lesions majora. Even tiny fissures at the introitus Other abnormalities that may cause pain The most common local physical finding may cause severe dyspareunia, so it is include erosions and areas of inflammation, that causes acute vulvalCopyright pain _Layout is fissure. 1 17/01/12 important 1:43 PM to Page look 4 closely, especially in including the classic petechial rash seen in Fissuring may occur in almost any vulval ­vulval sulcae, and to gently stretch the skin. desquamative inflammatory vulvovaginitis,

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a typically painful condition. However, it with one finger palpating the bone directly REFERENCES should be ensured that the abnormal area through the vaginal skin (Figures 1 to 5). 1. Moyal-Barracco M, Lynch PJ. 2003 ISSVD ter- corresponds to the location of the pain. This site is adjacent to the insertion of the minology and classification of vulvodynia: a historical Surgical and obstetric scarring often pubococcygeus, and this muscular insertion perspective. J Reprod Med 2004; 49: 772-777. make it difficult to distinguish between can be avoided if the examiner is careful. normal and abnormal appearances on The literature on dyspareunia com- FURTHER READING genital skin. An assessment by an experi- monly refers to the ‘Q-tip test’ where a Damsted-Petersen C, Boyer SC, Pukall CF. Current enced gynaecologist may be necessary. cotton wool tip is used to explore the intro- perspectives in vulvodynia. Women’s Health (Lond itus. We do not use this technique as we Eng) 2009; 5: 423-436. Step two: if there is no lesion find that a cotton wool tip may irritate and Note the site of the pain, including particu- that far more information is gained by the COMPETING INTERESTS: None. larly whether it is unilateral or bilateral and use of the educated examining finger. whether it radiates. Ask the patient to locate The colposcopy and acetic acid tech- Online CPD Journal Program the pain if possible. Apply light fingertip nique used on the uterine to detect pressure to determine whether hyperalgesia areas of abnormality is not applicable to exists. If the sort of pressure that would the vulva except when vulval intraepithelial normally cause a sensation of light touch neoplasia is suspected. The application of produces a sensation of pain, apply the same acetic acid to this site will make any inflam- light pressure to the inner thigh and ask matory dermatosis appear white (and is the patient if she can notice a difference. therefore not helpful diagnostically) and Note whether there is introital muscular also usually provokes intense pain in spasm. Tightness, resistance and pain on benign dermatoses. © SHUTTERSTOCK/VLADGRIN gentle downward pressure at the six o’clock Is vulvovaginal pain always position in the posterior vaginal introitus SUMMARY due to observable vulvovaginal indicate this. Patients who may have bony Vulvovaginal pain has discernible aetiol- pathology? pelvic outlet pain, related to ‘pelvic girdle’ ogies and pathophysiology, and in this Review your knowledge of this topic and bony dysfunction, often have point tender- regard is no different from pain elsewhere earn CPD/PDP points by taking part in ness on palpation of the medial aspect of in the body. The presentation may be chal- MedicineToday’s Online CPD Journal Program. the pubic rami, and this tenderness to pal- lenging, however, because of the distress Log in to pation will reproduce their pain. This exam- and frustration caused by the pain and its www.medicinetoday.com.au/cpd ination should be performed very gently effects on sexual functioning. MT

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