Vulvovaginal Pain and Dyspareunia. Part 1

MedicineToday 2014; 15(7): 41-46 PEER REVIEWED FEATURE 2 CPD POINTS Vulvovaginal pain and dyspareunia 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 ‘VULVODYNIA’ 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 vulva and/or vagina 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. MedicineToday x JULY 2014, VOLUME 15, NUMBER 7 41 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2014. Vulvovaginal pain AND dyspareunia CONTINUED • 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. candidiasis, 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. lichen planus, a great deal of physical stress: sensation to nearby viscera, particularly immunobullous disorders, etc.) urination, 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 rash, 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. hyperalgesia. 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 pelvic pain 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 perception 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. itch, pain medicine, poorly recognised. The role Most patients with vulvovaginal

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