Vulvodynia: Keeping it in Mind
Vulvodynia: Keeping it in Mind
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.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: This NIH-sponsored conference summarizes the current status of science in vulvodynia. The panel calls for evidence-based guidelines for defining, diagnosing, and treating this common disorder that occurs in up to 15% of adult women in the United States.
Source: Bachmann GA, et al. Vulvodynia: a state-of-the-art consensus on definition, diagnosis, and management. J Reprod Med. 2006;51:447-456.
Do you remember in medical school when the professor taught us that unless you think of ectopic pregnancy, you couldn't make the diagnosis? The teaching point wasn't specifically for ectopics, but the generalized concept was that we should have a broad differential diagnosis when confronted by a clinical situation in order to maximize our success in making the correct diagnosis. In the case of ectopic pregnancy, the advent of sensitive pregnancy tests and the wide use of transvaginal ultrasound have put the diagnosis much more in the front of our minds as well as that of our colleagues in the Emergency Department.
Now comes the issue of vulvodynia, ie, painful vulva syndromes. If you recall the great book by Ed Friedrich, he bemoaned the all-too-common approach that the vulva was just in the way as the gynecologist sought to examine the vagina. In fact, the vulva is a critical site for debilitating problems that go undiagnosed because of this persistent tendency to look past it in terms of both history and physical examination.
The article is a summary of the shortcomings of what we know about vulvodynia, its etiology as well as its treatment. There is credible clinical work being done with reasonable data available. Unfortunately, there is precious little evidence-based information. This article is must reading for the practitioner who wishes to be better able to manage these symptoms. The impact of undiagnosed and poorly treated vulvodynia can be enormous, both for the patient as well as her family.
Commentary
While pulling this article, I also recommend pulling a couple of others that are in the same issue. They are articles that represent a couple of the current efforts to address vulvodynia as it presents to the office. Neither fulfills our ideal of randomized, controlled trials, but both attempt to do what we try to do in this periodical every month—help clinicians care for their patients.
The article by Dykstra and Presthus on page 467 of the same issue describes a pilot study using botulinum toxin type A. The 7 patients started with an average pain (score 0-10) of 8.1, then received 35 units of botulinum toxin tape A. Thirteen days later, their average score was 2.9. The duration of effect was 8 weeks. Among the 12 patients who received 50 units, the average baseline score of 7.4 was reduced to 1.8 with a 14 week duration of effect. Promising data, indeed, but more is needed for sure.
Then on page 500 of the same issue of the Journal of Reproductive Medicine, Greenstein and co-authors look at the role of hyperoxaluria in women with vulvar vestibulitis. The concept that oxalates in the urine causes vestibulitis has been floating around well over 15 years. Among the 40 women with vestibulitis in this study, 7 were found to have hyperoxaluria. Of these, 1 benefited from a low oxalate diet and supplemental calcium citrate. The authors conclude that it is not justified to evaluate and treat hyperoxaluria.
Not surprisingly to you, the reader, I happen to have an opinion about these 3 studies. First, I agree with the consensus statement: there needs to be better understanding of what we are dealing with. It is extremely common, and many practitioners fail to appreciate the subtleties of vulvodynia. For that matter, for many patients, their providers miss even the most obvious of signs and symptoms. In the referral area in which I work, I see, on average, a new vulvodynia/vestibulitis patient every day in the office. Regarding the second study, we have used some Botox in our practice with a moderate degree of success, so that paper does not surprise me. Much more has to be done, but it is worth considering especially if the pelvic floor is tender to palpation. Regarding the third article, I have used low oxalate diet/calcium citrate supplementation for several years with only limited success. It does help, however, as part of a bigger therapeutic plan. It is certainly not a cure for any of the hundreds of patients that I have seen with vestibulitis. For patients who don't wish to try other pharmacologic intervention, this is certainly more acceptable. I do have several patients over the years who can now pinpoint specific foods and/or beverages that trigger vestibulitis symptoms.
So what's a busy clinician to do? Here are a few keys that I try to use in helping to keep vulvodynia in focus:
- Any woman (regardless of age) who has recurrent vaginal infections, might have vestibulitis.
- New onset entrance dyspareunia is vestibulitis until proven otherwise.
- Gentle pressure with a cotton-tipped swab at the Bartholin and Skene's glands may prove diagnostic.
- If vestibulitis is suspected, have the patient see what the pain is by using a hand mirror.
- Use topical xylocaine in the office to show her that there is something that can be done to help her.
- Consider a neuropathic treatment such as low-dose tricyclic antidepressant (nortriptyline or amitripy-line) or anticonvulsant (neurontin, lyrica, keppra, etc).
- If at first you don't succeed. . .well, you know the rest.
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