Does Test Order Affect Sensitivity in Vulvodynia?

Abstract & Commentary

By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.

Synopsis: The order of testing for sensitivity in the vulva and thumb does not affect the results.

Source: Reed BD, et al. Effect of Test Order on Sensitivity in Vulvodynia. J Reprod Med. 2007;52:199-206.

This research team looked at the sensitivity measurements to pressure at both the vulva and thumb as they randomly assigned the order of tests. This was repeated a week later on the contralateral side. Among 13 women with vulvodynia and 20 control patients, there was a strong correlation between the two visits, and there was no order effect noted.

Commentary

Don't you just love articles like this one? It's like finding a nugget of gold when you weren't even looking for anything valuable. When I first read the title, I had no idea of where the authors would lead me, but I'm glad I stuck with it. It reinforces concepts that we all have learned, but sometimes forget in the midst of a busy practice.

The concept is straightforward enough. The authors wanted to know whether it made any difference in sensitivity if the vulva was tested first, or if a peripheral site (in this case the thumb) was touched first. Why would they even ask the question? I think we have all had the experience and possibly the suspicion that certain physical findings we discovered were due to a previous aspect of the examination. Essentially, the accuracy of our physical examination might be tainted by the order in which various maneuvers are done.

Here the authors chose an area far from the vulva. They also evaluated patients with a chronic condition that was unlikely to change week to week. By using standardized pressure (you'll have to read the article to see the ingenuous testing device), they looked at whether sensitivity testing of the vulva was affected if that area were evaluated before or after the thumb, an area unlikely to have cross-sensitization. Since the areas are so far apart, it shouldn't surprise us that there was no effect of the order of testing and that the sensitivity was stable over time, both in the patients with vulvodynia as well as the pain-free controls.

So now you're asking why I'm taking up your valuable time and wasting precious space in this issue to address what should be something that we could each have logically deduced on our own. It's because we run across this every day in our practices, but don't realize it and don't appreciate it. In fact, this may be something very new to some of the readership, so read on.

In the evaluation of the patient with pelvic pain, and especially the patient with dyspareunia, we sometimes forget that the order in which we do the examination might make a difference. More specifically, we sometimes forget that the introitus should be looked upon as a separate entity, an anatomic site from which specific pain symptoms might arise. Let's be more concrete to make a point: if a patient presents with dyspareunia, question to ask whether it's deep or entrance pain. Admittedly, sometimes the patients won't know specifically, but it helps to try to get that answered before the examination starts. Before a bimanual is performed, and even before a speculum is placed, the introitus and particularly the vestibule should be evaluated. The most effective technique to check for vulvar vestibulitis is to gently separate the labia and press the Skene's and Bartholin's gland duct openings with a moistened cotton tip swab.

The patient should be asked if that is their coital pain or not. If there is not tenderness, then the rest of the examination should proceed as usual; however, if there is tenderness, differentiating whether that is their pain or a different pain is a critical piece of the puzzle. If we forget to do this introital Q-tip test, we run the risk of looking right past the etiology of her pain, doing a bimanual, and finding that she is tender throughout the pelvic area. In reality, the pain may well be coming from a sensitized and now very painful introitus that is being stretched by our vaginal fingers as part of the routine pelvic.

So that is the clinical take home lesson from what might otherwise be considered a not very useful research article. (And you thought that the Q-tip test was associated with checking for urethral support). Not so! I'll wager that the Q-tip test that you do in patients with entrance dyspareunia will be far more useful than in those patients with incontinence issues.