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Vulvodynia: New Treatments

Vulvodynia is characterized by intractable burning pain and acquired introital dyspareunia, for which no obvious cause can be found. Mild to moderate cases of vulvodynia are associated with persistent vulvar burning and loss of sexual pleasure. In more severe cases, patients cannot have intercourse. Finally, a percentage of women have constant, disabling vulvar pain, bad enough to dominate daily life and cause withdrawal from normal activities.

Is Vulvodynia a Sympathetically Maintained Pain?

The questions haunting the management of vulvar pain syndromes are still the most basic ones--what establishes these chronic pain loops and how are they maintained? The answers probably lie in considering vulvodynia.

The clinical features of vulvodynia fit the model of a sympathetically maintained pain (SMP). Specifically, vulvodynia begins as a sudden exaggerated response to any of a variety of tissue insults (e.g., yeast infection, childbirth trauma, hysterectomy, or a CO2 laser burn).

Vulvodynia sometimes responds to selective serotonin reuptake inhibitors (Paxil, Zoloft) or traditional tricyclic antidepressants (Elavil, Pamelor).

Medical Treatments for Vulvodynia

Within clinics specializing in vulvar pain, treatment of vulvodynia has been a challenge in the past 15 years. Traditionally, vulvodynia has been subdivided according to patterns of redness. The term vulvar vestibulitis syndrome describes the triad of introital dyspareunia, painful erythema at the hymen.

In our experience, a more important distinction is whether the Bartholin's glands are involved. Most patients have pain only on the surface, which could arise either from focal hypervascularity.

Regardless of disease pattern, the efficacy of symptom-relieving agents is poor. Medical regimens can be curative, but results are unpredictable and limited. For example, topical 5FU cream.

In one case of episodic hyperoxaluria accompanied by mucosal soreness, the patient received calcium citrate to reduce crystal formation in the urine and was advised to avoid oxalate-rich foods, which led to a relief of the pain syndrome. Five years have lapsed since this case report.

Vestibulectomy for Vulvodynia

Given the limitations of medical therapy, patients in the visible foci of perihymenal erythema generally have been treated by cold-knife resection of the minor vestibular glands and the adjacent hymen, with closure by downward advancement of the vaginal mucosa.

As a first surgical option, vestibulectomy is more invasive and perhaps less effective than selective photothermolysis. In refractory cases, vestibulectomy is probably insufficient because the removal of hyperemic surface mucosa does not address the problem.

The major complication of dye laser therapy was acute mixed bacterial cellulitis severe enough to require treatment.

Pretreatment with topical intravaginal antibiotics, using 

Intraoperative medications with corticosteroids, antihistamines, and anti-inflammatory drugs to
Intravaginal instillation of 30 g of polymyxin/bacitracin ointment at the end.
Application of specially formulated zinc oxide paste 3 per 

Selective Photothermolysis with Visible Light Lasers

We have explored a variety of laser therapies in search of a more reliable and less mutilating approach. In the mid-1980s we treated 36 patients with vulvodynia with the CO2 laser. Two strategies were used: (1) irritative acetowhite vestibular epithelium, showing low-grade koilocytotic atypia on biopsy, was photovaporized to the second surgical plane; (2) erythematous lamina propria.

On the basis of these observations we hypothesized that the FEDL (an instrument designed specifically for the photocoagulation of small blood vessels within the superficial dermis of facial and upper body port-wine stains) might offer an efficacious but nonmorbid alternative to the bare fiber argon laser.

Role of Resective Surgery

Our findings indicated that in the presence of deep pain we had to address the problem of angry vessels radiating out of the Bartholin's fossa before surface hypervascularity.

Current Protocol for Managing Vulvodynia

The data in our studies were collected primarily between 1989 and 1991. Throughout the years, we found marked Bartholin's fossa pain the pivotal prognostic determinant.

Essentials of Diagnostic Assessment

Because of the poor efficacy of pelvic floor exercises and initial photothermolysis in patients with extreme Bartholin's gland pain, different protocols are now used. Hence, the initial diagnostic workup addresses several important issues. To set landmarks that will define progress (or lack thereof).

Surface-Only Vulvodynia

At first, patients with deep pain responded poorly to serial FEDL therapy. Now, we use different protocols based on the presence and severity of Bartholin's fossa tenderness. Patients with surface-only pain or surface pain plus mild to moderate gland tenderness are started on biofeedback-controlled.

Vulvodynia With Severe Bartholin's Gland Pain

Patients with surface-plus-deep pain need remedial pelvic floor exercises and serial photothermolysis.