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Vulvodynia is defined as symptoms of chronic vulval soreness, burning, or pain, as opposed to pruritus or itching. The term vulvodynia was adopted as a general heading, and where cause was unfounded, such as an active dermatosis or acute infection. Currently, vulvodynia applies to this set of symptoms, whatever their origin; it is often nonetheless applied only to those cases.
This form of vulvodynia stems from erosion of the surfaces and is common in such conditions as fissured lichen sclerosus, erosive lichen planus, herpes simplex, or severe Candida infection. It can be confirmed or excluded by history and examination. The symptoms usually subside when the underlying condition is treated. Occasionally symptoms persist, and the patient is then best considered as having vulvodynia.
Cyclical vulvitis holds an uncertain place in classification, mainly because in itself it is not well defined, but it is best noted here. It concerns patients who have cyclical symptoms and may respond to prolonged anti- Candida treatment; signs are usually indefinite and the microbiological findings.
Such patients fall into two main groups although we shall see there is some overlap. Their presentation and management will be described, and the developing views on etiology, which largely endorse the current clinical approach.
Dysesthetic vulvodynia is largely found among postmenopausal women. The symptoms are constant and unprovoked; therefore, if the woman is sexually active, she does not complain of dyspareunia.
One investigator, using MRI, found sacral meningeal cysts in 10 out of 17 patients, and 9 of the 10 were pain-free 6 months after appropriate surgery. However, others, using the same technique, found no such lesions in
Some patients are depressed, whether primarily or as a result of the pain, and a few may even be at risk of suicide; many suffer great limitation of activity. Not infrequently there is a history of other chronic pain such as glossodynia. Formal assessment of these patients as a group has yielded somewhat discrepant results. There is no abnormality on examination.
Mildly affected patients are helped by 5% lignocaine ointment and those more severely affected are improved by oral amitriptyline, in lower dosages than those used to treat depression. It is important to explain to the patient that the drug is not being given as an antidepressant as such, and a useful word to employ is neuralgia, citing some common example such as pain after herpes zoster. This older age group does not tolerate large dosages well, but a starting dosage of 10 mg at night, increasing by 10 mg weekly up to a maximum daily dosage of 70 mg to 100 mg, is usually safe and effective. When symptoms have been controlled at a given level the dosage can slowly be reduced; several months of treatment may be needed. If the response is unsatisfactory, alternative drugs such as doxepin or carbamazepine.
In this second main group the patients are young, often frustrated after fruitless consultations, and sometimes concerned by other problems such as irritable bowel syndrome or back pain. The symptoms often have an acute onset after some trigger such as surgery, childbirth, or an infection. The patients complain of pain on attempted vaginal entry, that is, with intercourse or using tampons, and demonstrate acute tenderness in the vestibule on pressure with a cotton-wool tip, together with variable erythema.
The histology shows nonspecific inflammatory changes, but it has now been shown that such changes occur also in normal vestibular tissue. It is now accepted that the human papillomavirus is not involved; nor are the minor vestibular glands (the orifices of which are often to be seen in the vestibule) now thought to be relevant.