Clinical Management of Vulvodynia: Tips and Tricks
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Pain experienced in these situations, fear and anguish may contribute to a specific vulnerability towards the potential aggressive meaning implicit in vaginal penetration and may contribute to vaginismus, hyperactive pelvic floor and a fobic attitude to intercourse, contributing to lifelong dyspareunia. Potential precipitating iatrogenic factors contributing to dyspareunia include:.
A further side effect of this attitude is its negative impact on the partner and family of the woman affected with vulvodynia.
Acupuncture for the Treatment of Vulvodynia
Key point : Physicians should increase their attention to the potential iatrogenic role implicit in their diagnostic or therapeutic behaviors involving the pelvic organs, vulva and perineum at any age in the lifespan. In severe cases, sexual aversion may be reported. Definitions of vulvodynia have varied widely, mirroring the difficulties in understanding and substantiating the clinical reality and the pathophysiology of vulvar pain. Of interest and concern is the fact that the condition was not officially recognized until , was overlooked for more than 80 years, and then resurfaced in gynecological texts in the s.
The classification of vulvodynia is based upon the site of the pain, whether it is generalized or localized, and whether it is provoked, unprovoked, or mixed.
Impact of Vulvodynia on Physical and Psychosexual Health. Vulvodynia is a prevalent and highly distressing disorder, with major health, psychosexual, interpersonal and social consequences. Lastly, there is a category for pain that is both provoked and unprovoked mixed. Vestibulodynia , which is a type of vulvodynia, is pain that is localized only to the vulvar vestibule, and it is also classified as primary or secondary. In the primary subset, the pain has been present since the first tampon use or intercourse, and with secondary vestibulodynia women have had painless tampon insertion or intercourse, with the subsequent development of vestibular pain.
Contrary to earlier assessments, white and black women were reported to have a similar lifetime prevalence. The authors concluded that as many as 14 million women in the United States may experience chronic vulvar pain during their lifetime. Thus, even if only a small percentage of these women have true vulvodynia, the number of women with the problem is enormous.
The etiology of vulvodynia is unknown. It most likely occurs from a variety of sources and represents many different disease processes. Possible causes include abnormalities of embryologic development, as recent research indicates that primary vestibulodynia is due to a defect in the primitive urogenital sinus and may therefore be thought of as a congenital disorder. Several researchers have found an increased number of C-afferent nociceptors in the vestibular mucosa of women with vestibulodynia.
It is likely that the increased density of nociceptors is at least partially responsible for the extreme pain experienced by women who suffer from vestibulodynia. Nevertheless, the increase in nociceptive pain does not completely account for all of the symptoms of vulvodynia; Pukall et al. Lastly, other data have implicated allergic reactions, 16,19 myofascial hypertonicity, 18 and nerve entrapment or injury as potential causes of vulvar pain.
Earlier theories regarding the etiology of vulvodynia have recently been questioned. The role of human papilloma virus, increased urinary oxalate, and a prior history of candidiasis, as causative agents of vulvodynia is uncertain. A few clinicians believe that vulvodynia occurs directly as a result of psychological or sexual dysfunction. This viewpoint, however, is rejected by most patients and by the majority of the clinicians who treat these patients. Almost all experts agree that the presence of chronic pain, such as with vulvodynia, can have profound psychosocial consequences.
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In , thought leaders at a National Institute of Health-sponsored conference on vulvodynia concluded that generalized, non-provoked vulvodynia is described most accurately when it is thought of as a complex regional pain syndrome CRPS , similar to other CRPS such as fibromyalgia and interstitial cystitis. All women with vulvar pain should have a thorough physical examination.
The goal of this exam is to find evidence of an identifiable disease, which can cause vulvovaginal pain. The vulva should be examined for evidence of infection, trauma, or dermatitis. Specifically, the observer should note any inflammation, induration, excoriation, fissures, ulceration, lichenification, hypopigmentation, hyperpigmentation, scarring, or architectural changes of the vulva. Using a colposcope can greatly enhance the visual inspection of the vulva dermatologic diseases are discussed below as any abnormalities found on visual examination of the vulva should be biopsied, and the tissue sent to a dermatopathologist.
However, biopsies of the vulvar vestibule should be performed with caution; when the only physical finding is erythema, as the results of these biopsies are almost always nondiagnostic.
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After the visual exam, a sensory exam should be completed. A moistened cotton swab should be used to palpate the labia majora, interlabial sulcus, perineum, prepuce, labia minora, clitoris, and vulvar vestibule. The vagina should then be examined by inserting a pediatric-sized speculum through the hymen without touching the vestibule to avoiding causing the patient pain. The vaginal mucosa should be examined for loss of rugae and erythema, which is suggestive of atrophy. Additionally, erosions, ulcerations, or synechiae could indicate erosive lichen planus. Discharge should be obtained for a wet mount and culture to rule on infectious or inflammatory vaginitis.
A digital exam is then performed using only one finger as described above for LAS. The urethra and bladder are then palpated; tenderness can be evidence of interstitial cystitis.
Clinical Management of Vulvodynia
Sign In Help. Vulvodynia Vulvodynia is defined as a chronic discomfort or pain, consisting of burning, stinging, irritation, and rawness on the vulva. Download as PDF. Set alert.
About this page. Learn more about Vulvodynia. Vulvodynia Steven D. Vulvodynia Bernard L. Infectious e.forum2.quizizz.com/indesign-cs6-creacin-de-objetos-coleccin.php
Persistent Vulvar Pain - ACOG
Inflammatory e. Clinicians should consider stopping use of all topical medications before prescribing a new course of therapy as they may be contributing to burning pain symptoms. Commonly prescribed topical medications include a variety of local anesthetics which can be applied immediately before intercourse or in extended use , estrogen cream, and tricyclic antidepressants compounded into topical form. Although topical steroids generally do not help patients with vulvodynia, trigger-point injections of a combination of steroid and bupivacaine have been successful for some patients with localized vulvodynia 7.
Note that a compounding pharmacy may be needed to formulate topical medications. Choosing the proper vehicle for topical medications is important because creams contain more preservatives and stabilizers than ointments and often produce burning on application, whereas ointments are usually better tolerated 4. Tricyclic antidepressants and anticonvulsants also can be used for vulvodynia pain control.
Tips and Tricks
When first prescribing these medications, clinicians should avoid polypharmacy. One drug should be prescribed at a time. Before prescribing antidepressants or anticonvulsants for a patient of reproductive age, the clinician should emphasize the need for contraception.
Tricyclic antidepressants and anticonvulsants take up to 3 weeks to achieve adequate pain control. Patients usually develop tolerance to some of the adverse effects of these medications particularly sedation, dry mouth, and dizziness. Amitriptyline often is used as a first-line agent beginning at an oral dose of 5—25 mg nightly and increased by 10—25 mg each week, generally not to exceed a total of mg daily 4. If cessation is necessary, tricyclic antidepressants should not be stopped suddenly; weaning the patient by 10—25 mg every few days is indicated.
Gabapentin, used to manage neuropathic pain disorders, is the most studied and used anticonvulsant for vulvodynia 4.
Dosage can be increased over time from mg total daily to a maximum dose of 3, mg daily 1, mg by mouth three times a day , and may need adjustment to avoid adverse effects. It is unusual, however, to experience adverse effects that lead to discontinuation. In elderly patients with vulvodynia, it may exacerbate gait and balance problems.
Women with vulvodynia should be assessed for pelvic floor dysfunction 4. Biofeedback and physical therapy, including pelvic floor physical therapy, can be used to treat localized and generalized vulvar pain. These techniques are particularly helpful if there is concomitant vaginismus. Biofeedback aids in developing self-regulation strategies for confronting and reducing pain. Physical therapy treatment techniques include internal vaginal and rectal and external soft-tissue mobilization and myofascial release; trigger-point pressure; visceral, urogenital, and joint manipulation; electrical stimulation; therapeutic exercises; active pelvic floor retraining; biofeedback; bladder and bowel retraining; instruction in dietary revisions; therapeutic ultrasonography; and home vaginal dilation 4, Although physical therapy has been shown to be effective in treating vulvodynia, the approach is individualized, and outcomes are difficult to validate or reproduce An emerging treatment for vulvodynia is transcutaneous electrical nerve stimulation.