Special Feature

Making Strides in Provoked Localized Vulvodynia

By Catherine Leclair, MD, Associate Professor, Department of OB/GYN, Oregon Health & Science University, Portland, OR, is Associate Editor for OB/GYN Clinical Alert.

Dr. Leclair reports no financial relationships relevant to this field of study.

You've seen her before. she's often young and partnered, but might be midlife and changing the status of her relationship. Sometimes she presents for an annual exam and mentions her pain later during the visit. Occasionally she actually presents with the complaint of dyspareunia. Either way, you listen and empathize, hoping that she may just have a yeast infection or an ovarian cyst — something easy and straightforward to fix in the 15 minutes you are allotted for office visits these days. Yet, this time she does not have a simple explanation and you are faced with a more challenging problem.

Provoked localized vulvodynia (PLV), formerly known as vulvar vestibulitis syndrome, is a complex sexual pain disorder affecting 8-15% of the population and believed to be the most common cause of dyspareunia.1,2 Despite descriptions of sexual pain disorders in early gynecologic textbooks, only recently have clinical experts begun to make progress describing the spectrum of this common and distressing pain condition and in identifying knowledge gaps for research. The American College of Obstetricians and Gynecologists, the American Society for Colposcopy and Cervical Pathology, the International Society for the Study of Vulvovaginal Disease (ISSVD), and the National Vulvodynia Association have worked diligently to educate clinicians and the National Institutes of Health has issued specific requests for proposals for research in this field.

For most women with PLV, the condition exists as part of a complex triad with localized pain in the vulvar vestibule coexisting with tender pelvic-floor muscles and psychosexual dysfunction. It's understandable why the focus has been more on the painful vestibular skin than the other parts of the triad. Many patients and practitioners easily identify the tender vestibule as the source of the problem. However, increasing evidence shows that each part of the triad can contribute significantly to compromises in quality of life, sexual function, and psychological well-being.3,4 Women with PLV report high rates of sexual dysfunction with poor arousal, low desire, and impaired orgasm. Mood disturbances, anxiety, psychological distress, and relationship compromise are frequently identified comorbidities in women with PLV, as the extremely personal nature of vulvar pain is difficult to discuss with family, friends, or physicians. Although millions of women have vulvar pain, only 70% will seek care for this pain, and the average patient will visit at least three health care providers before a diagnosis is secured.5 It's likely you will see her in your office after she's failed to improve after seeing one of your local colleagues. She's hoping that you have the answer to the question of why she has pain.

Clinically, we use Freidrich's criteria to diagnosis PLV: complaint of penetrative pain with vaginal intercourse, provoked tenderness (allodynia) of the vestibule upon Q-tip examination, and erythema of the vestibule. A diagnosis of PLV is made after all other vulvar conditions (dermatologic, infectious, anatomic) are ruled out. Although the cause of PLV remains unknown, the vestibule of affected women shows histologic changes — increased inflammation and nerve tissue density — not seen in controls.6,7 These observations led the ISSVD to propose in 2004 that the term vulvar vestibulitis syndrome be replaced with provoked localized vulvodynia or vulvar vestibulodynia, since the evidence suggested a local neuro-inflammatory etiology rather than a traditional inflammatory or infectious response.

With the precise pathophysiology of PLV unknown, a wide variety of treatments has been proposed including oral and topical neuromodulators, pelvic floor rehabilitation, psychosexual counseling, and vestibulectomy (surgical excision of painful vestibule). Most clinical trials have evaluated therapies that address only one component of the pain triad (e.g., either painful vestibular skin or tender pelvic floor muscles or sexual dysfunction) with improvement ranging from 38-80%. These inconsistent results from single modality therapies suggest the pain of PLV reflects a complex interaction. An expanded theory of PLV as a complex pain triad with disruption in pelvic-floor muscle function and behavioral changes coexisting with localized vestibular allodynia may explain the inconsistent results with vestibulectomy, a single modality therapy directed only at the painful skin. Despite recognition that a multidisciplinary approach may have benefit, few studies have approached PLV in this manner.

So as she sits in your office hoping for a simple cure for her pain, what do you have to offer her? Since PLV is believed to be a chronic pain disorder, direct treatment to the nervous system, whether central or local, has been advocated. Oral neuromodulators such as tricyclic antidepressants (amitriptyline, nortriptyline, desipramine), gabapentin, pre-gabelin, and the mixed serotonin nor-epinephrine reuptake inhibitors (duloxetine, venlafaxine) are often offered as first-line therapy. Topical neuromodulators represent another option for PLV treatment since local therapy maximizes drug delivery to the painful vestibular skin and lowers the potential for systemic side effects. However, it is unclear whether the pain of PLV is best managed by medications targeting central (brain and spinal cord) or local (pain receptors and peripheral nerves) pathways. Only a limited body of research has focused on local therapies. Topical 5% lidocaine, 2-6% gabapentin cream, and 2% amitriptyline-baclofen cream have been reported to be effective, but the evidence comes primarily from case series. A randomized, blinded clinical trial by Foster found that topical 5% lidocaine ointment was no better than placebo cream in treating chronic pain at the vestibule.8 Despite this disappointing result, topical lidocaine (4% aqueous or 2% gel) should be offered for palliation of pain with intercourse since it will successfully reduce vestibular pain for some women who attempt intercourse. For best results, you should instruct your patient to place lidocaine on the vestibular skin at least 10-15 minutes before attempts at penetration.

Diagnosing pelvic floor musculoskeletal pain is challenging for most gynecologists. Pelvic floor dysfunction — termed pelvic-floor myalgia or vaginismus — may include signs and symptoms of hypertonicity (tense, contracted muscles), tenderness (burning pain with touch), and poor function (inability to contract/relax pelvic-floor muscles). A history of burning pain inside the vagina with clenching and anticipatory anxiety often correlates with pelvic floor myalgia on exam. Although the prevalence of pelvic-floor myalgia with PLV has not been formally reported, data from the Program in Vulvar Health at Oregon Health & Science University suggest that at least 50% of women with vulvar pain have concomitant pelvic-floor myalgia. It is unclear whether vestibular pain precipitates secondary pelvic-floor myalgia or whether the tense musculature leads to difficult penetration and subsequent PLV. Nonetheless, a talented pelvic floor physical therapist is a vital participant in the therapy team. Rehabilitation of pelvic-floor muscles through physical therapy has been shown to reduce PLV.9 Pelvic floor rehabilitation includes mind-body awareness, muscle manipulation, biofeedback, and dilator training; these are proven strategies that slowly but surely allow women with PLV to gain control over painful and tense muscles and confidence to proceed with penetrative sexual activity. Importantly, studies evaluating a combined approach of PT and other therapies (vestibulectomy, topical or oral neuro-modulator) demonstrate enhanced efficacy in reducing dyspareunia compared to either therapy alone.10,11

Vestibulectomy is the gold standard therapy for women with PLV, with a wide reported range in the success (60-80%). Studies evaluating surgical outcome have found a close relationship between pain outcomes and other components of the pain triad (psycho-sexual well being and pelvic floor muscles). An important factor affecting recovery is emotional well-being.12 This suggests that successful resumption of sexual intercourse after vestibulectomy may require attention to the emotional state of the woman. Other studies have documented improved surgical outcome and decreased dyspareunia when pelvic floor rehabilitation is performed perioperatively. These results suggest that successful recovery requires more than the simple removal of painful skin. In other words, most women require additional treatment (pelvic-floor muscles and/or psychosexual support) beyond vestibulectomy to become fully functional.

Perhaps your patient has the nerve to convey to you that she is suffering — not only physically but also emotionally and sexually. If you listen carefully, you may hear heart-wrenching stories of unconsummated marriage or unwanted sexual touch from a beloved partner that generates anxiety and terrible guilt. Sexual dysfunction is the norm for women suffering from PLV, and this leads to high rates of depression and relational compromise. Spano and Lamont have proposed a model that explains these findings;13 chronic dyspareunia results in anticipatory anxiety (due to the distress from painful sexual encounters), which then leads to poor arousal and tense pelvic-floor muscles. Poor arousal and tense muscles maintains painful intercourse, resulting in increased dyspareunia and, ultimately, in negative feelings about intimacy. Thus, it is not surprising that treating the psychosexual distress that is inherent in PLV improves sexual outcomes and reduces pain. A number of studies support sexual counseling as a crucial step that finally enables women with PLV to resume full sexual activity without pain, even when other treatments such as vestibulectomy and pelvic floor rehabilitation have been completed.

So how do you proceed to manage your patient and support her as she navigates this complex and emotionally challenging diagnosis? Validating and naming this condition for women who often feel embarrassed and isolated in their pain is the first step toward beginning treatment. Vulvar pain conditions don't develop overnight, so the expectation for a quick cure is naïve. PLV is associated with localized pain in the vulvar vestibule, psychosexual dysfunction, and tender pelvic-floor muscles, and each contributes significantly to compromise quality of life, sexual function, and psychological well-being. Although there is no single treatment option that consistently provides a cure for PLV, studies support that a multidisciplinary treatment plan offers the most promising hope of alleviating all aspects of pain.

Caring for these patients provides a great opportunity to be a clinician. The challenge of working through a complex diagnosis and managing a condition that requires skill in office practice, a thoughtful approach to medical and surgical therapy, and a cognitive-behavioral approach to psychosocial distress brings out the best in the obstetrician gynecologist. Educate physical therapists and mental health providers in your area about PLV so that you can confidently refer your patient for supportive care. Initiating therapy in any of the three domains (pain triad) of PLV will likely improve your patient's pain. These strategies will allow forward strides in the care for the woman with provoked localized vulvodynia.


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