www.kjurology.org http://dx.doi.org/10.4111/kju.2013.54.1.48 Sexual Dysfunction A Retrospective Study of the Management of Vulvodynia Yongseok Jeon, Youngjun Kim, Bosun Shim, Hana Yoon, Youngyo Park, Bongsuk Shim, Woosik Jeong, Donghyun Lee Department of Urology, Ewha Womans University School of Medicine, Seoul, Korea Purpose: Vulvodynia is characterized by chronic vulvar pain caused by sexual inter- Article History: course and often results in female sexual dysfunction. Because the causes of vulvodynia received 11 June, 2012 10 September, 2012 are not clear, many patients do not receive optimal treatment. Recently, gabapentin accepted and botulinum toxin A have both been shown to be effective treatments for vulvodynia. In this study, we retrospectively analyzed the clinical outcomes of botulinum toxin A and gabapentin treatment for chronic pain in women with this condition. Materials and Methods: Seventy-three women with vulvar pain were administered ei- ther gabapentin (n=62) or botulinum toxin A (n=11) injections. Effectiveness was meas- ured by use of a visual analogue scale (VAS). We analyzed the treatment method, treat- ment duration, success of treatment, and side effects or adverse reactions. Results: Pain levels in both groups significantly decreased after treatment. In the gaba- pentin group, the VAS score decreased from 8.6 before treatment to 3.2 after treatment (p＜0.001). The VAS score in the botulinum toxin A group was reduced from 8.1 to 2.5 (p＜0.001). Side effects for both therapies were few and subsided with treatment with general antibiotics and nonsteroidal antiinflammatory drugs. Conclusions: Gabapentin and botulinum toxin A are safe and effective treatments for vulvodynia. This condition can cause sexual dysfunction and affect quality of life. Corresponding Author: Hana Yoon However, with proper management, satisfactory outcomes for women with vulvodynia Department of Urology, Ewha Womans can be achieved. University School of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Keywords: Dyspareunia; Gabapentin; Type A botulinum toxins; Vulvodynia Seoul 158-710, Korea TEL: +82-2-2650-5157 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, FAX: +82-2-2654-3682 distribution, and reproduction in any medium, provided the original work is properly cited. E-mail: [email protected] INTRODUCTION ent areas of the vulva at different times, and it may be con- stant or occur only every once in a while. Vulvar vestibulitis Vulvodynia is a condition in women that is characterized syndrome is specifically characterized by pain in the vesti- by chronic vulvar pain. It may be present constantly, inter- bule and usually occurs in premenopausal women. In this mittently, or only with intromission during sexual inter- condition, pain occurs with vaginal entry by the penis or course. The term vulvodynia was originally coined by a tampon [1,2]. McKay [1], and it has been adopted by the International Patients with vulvodynia usually describe their pain as Society for the Study of Vulvar Disease Task Force to de- a chronic burning in the vulvovestibular area that typically scribe any vulvar pain [2]. There are no standardized clas- lasts more than 3 months. Before a diagnosis of vulvodynia sifications for vulvodynia largely because it is a multi- is made, other vulvovaginal problems should be ruled out factorial condition in which certain subsets coexist within [3,4]. Vulvodynia not only causes pain, but often leads to others. Generalized vulvodynia, or essential vulvodynia, sexual dysfunction, including arousal and orgasmic diffi- usually occurs in postmenopausal or perimenopausal culty [3,4]. For many women, it reduces overall personal women and is exhibited by diffuse, unremitting, and burn- health and quality of life. ing pain that is not cyclic [1-4]. This pain may occur in differ- The etiology of vulvodynia is not clear, and because of Korean Journal of Urology Ⓒ The Korean Urological Association, 2013 48 Korean J Urol 2013;54:48-52 A Retrospective Study of the Management of Vulvodynia 49 FIG. 1. The process of pain mapping and intralesional botulinum toxin A injection. (A) Using the Q-tip test, all painful areas were checked for intensity and localization. (B) Pain was scored by use of a visual analogue scale and mapped. (C) Botulinum toxin A was injected on the basis of the pain map (20 IU in each site, up to a maximal total dose of 100 IU). this, many patients do not receive optimal treatment. The formed on all 164 vulvar pain patients. Patients with ab- most common type of vulvodynia is vulvar vestibulitis syn- normal test results suggesting definitive infection, benign drome, which usually has an acute onset [5]. Vulvodynia tumor, or painful bladder syndrome were excluded, result- is generally associated with vaginitis, changes in sexual ac- ing in 73 patients with a diagnosis of vulvodynia of un- tivity, and a history of medical procedures on the vulva such known etiology. as cryotherapy or laser treatment (after which it often be- Using the Q-tip test, a cotton-tip was used to confirm pain comes a chronic problem). With vulvodynia in general, vul- in the vulvovestibular area and to measure its intensity var pain is variable in intensity, from mild to disabling. and localization (Fig. 1A, B). The patient’s objective pain Patients may feel burning, stinging, rawness, aching, sore- intensity was evaluated by use of a visual analogue scale ness, or throbbing that occurs in the vulva, labia, or vagina. (VAS) and was scored from 0 to 10. All pain characteristics A large proportion of patients attend multiple medical con- were self-recorded by the patient on a questionnaire. sultations before receiving a diagnosis, and no single treat- Patient data were analyzed according to treatment (either ment or combination of treatments have been shown to con- botulinum toxin A injection or gabapentin oral medi- sistently improve the symptoms. Recently, gabapentin a cation), treatment response, treatment duration, side ef- γ-aminobutyric acid (GABA) analogue anticonvulsant and fects, and pre- and posttreatment changes in VAS score. botulinum toxin A have been shown to be effective in treat- The method of vulvodynia treatment was selected accord- ing vulvodynia [3,6]. In this study, we performed a retro- ing to patient preference or response to previous treat- spective analysis of the clinical characteristics and the out- ment. Gabapentin was prescribed to the patients who pre- comes of these 2 drugs in the treatment of patients with ferred to take oral medication, with an initial dose of 300 vulvodynia. mg per day that was flexibly increased depending on response. Gabapentin administration was intended for at MATERIALS AND METHODS least 2 months, although the actual duration depended on patient willingness and response. This study was conducted by use of data from 73 patients Intralesional injection of botulinum toxin A (Botox, presenting with sexual dysfunction and vulvodynia out of Allegran Inc., Irvine, CA, USA) was used for patients who 164 total women with vulvar pain who visited our clinic preferred an injectable treatment and for those experienc- from 2002 to 2010. We reviewed the patients’ medical his- ing no pain relief from gabapentin oral treatment after tories and noted the type of drugs administered for pain more than 3 months. For treatment with botulinum toxin treatment and the duration of treatment. We also per- A, the entire vulvovestibular pain area was mapped with formed physical examinations, including a vaginal exami- a Q-tip. The drug was injected into the submucosal layer nation and vulvovaginal pain mapping with a cotton tip, at each painful area, after the pain in that area was re- to determine the location and degree of pain and to rule out confirmed (Fig. 1B, C). The dose of botulinum toxin A at other treatable causes of vulvar pain, such as infections of each injection site was 20 IU, and the total number of in- the vagina or uterus and genitourinary benign or malig- jection sites was limited to 5. The minimum total dose was nant tumors. Vulvodynia was diagnosed if the patient had 40 IU and the maximum dose was 100 IU. Two weeks after no other causes of vulvar pain that occurred either only dur- the injection, a telephone interview was conducted to check ing sexual activity or constantly. To rule out other painful, for any adverse reactions. If significant pain persisted at treatable, vulvar diseases, the patients’ previous and cur- any area of the vulvar vestibule at the 4-week follow-up, rent medical histories and medications were reviewed and additional injections were administered by use of the same urinalysis, urine culture with sensitivity test, papanico- method. After the second round of injections, no further laou test smears, and basic hematological tests were per- treatments were administered. Side effects, adverse re- Korean J Urol 2013;54:48-52 50 Jeon et al TABLE 1. Patient ages and treatment characteristics Characteristic Gabapentin Botulinum toxin A No. of patients 62 11 Age (y), mean±SD (range) 45.7±9.0 (31–65) 39.9±9.5 (25–55) Treatment duration (mo) 2.3±1.8 (0.5–6) NA Follow-up, 12.7 (6–24) Dose, mean (range) 329.03 mg/d (300–900 mg/d) 59.1 IU (40–100 IU; median, 50 IU) Side effect Nausea (6.5%, 4/62) Temporary pain on injection site (18.2%, 2/11) Drowsy (9.7%, 6/62) SD, standard deviation. actions, and treatment outcomes were assessed at 4 and 8 weeks after the initial injections. Every 2 months after the final round of injections, change in pain level and total dose received were recorded. All procedures were performed in an outpatient clinic with informed consent.