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Vulvodynia

Vulvodynia is defined as symptoms of chronic vulval soreness, burning, or pain, as opposed to pruritus or itching. If the history seems unclear, the patient should be asked if the feelings give rise to a desire to scratch; pruritus is not consistent with vulvodynia.

The term vulvodynia was adopted as a general heading, and where cause was unfounded, such as an active dermatosis or acute infection, the term "burning vulva syndrome" was employed. Shortly afterwards, the latter term was discarded. Currently, vulvodynia applies to this set of symptoms, whatever their origin; it is often nonetheless applied only to those cases in which the cause is not so obvious.

VULVODYNIA RELATED TO INFECTION AND DERMATOSES

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.

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 are variable. Vaginal hypersensitivity to Candida has been postulated.

VULVODYNIA WITHOUT EVIDENCE OF AN ACTIVE DERMATOSIS OR INFECTION

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, is discussed.

Dysesthetic Vulvodynia (Originally Essential Vulvodynia)

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. The pain or burning may affect the perianal and perineal region and the inner thighs, as well as the vulva. 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 their 17 patients, and such investigation is not indicated as a routine measure. 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.

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.

Vulval Vestibulitis

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.

The recognition of some overlap between dysesthetic vulvodynia and vulval vestibulitis, in that in the latter, the pain may be helped by amitriptyline and in some cases may change into a constant, unprovoked affair, has gradually led to the concept that both may be pain syndromes.  This view well explains the absence of an infective cause, the essentially normal histology and the onset in relation to a trigger factor in vestibulitis, and the similarity of dysesthetic vulvodynia to such conditions as glossodynia and facial neuralgia.

The two conditions may be satisfactorily categorized as complex regional pain syndromes, akin for example to reflex sympathetic dystrophy. Pain in these syndromes persists in the absence of tissue injury. This pain is initiated by mediators following perhaps some minor lesion; "inappropriate" impulses in nonmyelinated pain fibers then reach the dorsal horn neurons. Thence fibers transmit impulses to the thalamus, parietal lobe, and other areas of the brain, and a complex interaction is set.

Treatment

The classification of vulvodynia has not yet been incorporated into that of other vulval diseases, which is at present being restructured with the aim of achieving a more rational system based on an etiologic and morphologic listing in the manner of standard dermatologic texts. Vulvodynia should be linked with them, for instance under a general heading of functional disorders.

The challenge now is to begin to understand its mechanisms, which are unfamiliar to most of us. The best milieu for management of the patient with vulvodynia is probably the multidisciplinary vulval clinic, where interested staff can give full attention to the problem and where there is, should it prove necessary, access to a pain clinic.