1. Other Pelvic Pain Sydromes: Vulvadynia, Vulvar Vestibulitis, and Vaginismus Marie Fidela R. Paraiso, M.D. Head, Division of Urogynecology Professor of Surgery Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Cleveland, OH

2. Disclosure of Financial Relationship None

3. Learning Objectives After this lecture, the participant will be able to: 1. Cite the definitions and types of vulvar dysesthesias. 2. Know the differential diagnosis and evaluation of vulvar pain. 3. List the treatment options of vulvodynia and vulvar vestibulitis.

4. Vulvar Dysesthesia -- Subtypes  Focal -- “vulvar vestibulitis”, “vestibulodynia”  Generalized – “essential vulvodynia”, “dysesthetic vulvodynia”

5. Vulvar Dysesthesia A chronic vulvar discomfort, manifested by burning, stinging, irritation or rawness

6. Vaginismus Vaginismus  Vaginismus is an involuntary spasm of the muscles surrounding the vagina. The spasms close the vagina.  It is a disorder of sexual dysfunction with several possible causes, including past sexual trauma or abuse, psychological factors, or a history of discomfort with sexual intercourse. Sometimes no cause can be found.

7. Vulvar Dysesthesia -- Prevalence  Unknown  Estimated to be 200,000 American women or up to 15% of general Gyn practices

8. Vulvar Dysesthesia -- Prevalence  In specialty practices of patients with vulvar pain, about 60% have vulvar vestibulitis and 40% have generalized dysesthesia  Patients with vestibulitis tend to be younger; patients with generalized dysesthesia span all age groups

9. Vulvar Vestibulitis  Severe pain on vestibular touch or attempted vaginal entry  Tenderness to pressure localized within the vulvar vestibule, especially over the Bartholin glands  Physical findings show vestibular erythema of various degrees

10. Generalized Vulvar Dysesthesia  Constant, unremitting vulvar burning  Few abnormal physical findings  Description of pain is similar to that of post-traumatic neuralgia and glossodynia, suggesting a problem with cutaneous perception, either centrally or at the nerve root

11. Vulvar Dysesthesia -- Etiology  Unknown  Best described as neuropathic, due to burning quality and to lack of response to treatment with narcotics

12. Other Possible Etiologies  Contact irritation  Topical medicines  Allergy  Trauma / Laser / Surgeries / Abuse  Infection –Yeast – maybe –HPV – probably not

14. Coexisting Conditions to Consider  Endometriosis  Interstitial cystitis  Functional bowel disorders  Psychiatric disorders  Past or current abuse situations

16. Symptoms of Vulvar Vestibulitis  Vulvar pain or burning with touching or contact  Dyspareunia  Difficult vaginal entry (vaginismus)  Urethral pain, dysuria, urgency  Depression, anxiety

17. Vulvar Dysesthesia – Symptom Subtypes  Focal vulvar vestibulitis – patients describe pain only with touching, intercourse, contact; they may describe no pain at all otherwise  Generalized dysesthetic vulvodynia – patients describe burning pain most times, not really caused by touching

18. Vulvar Dysesthesia – Physical Examination  Observe the patient during the history to understand the level of distress  Careful and gentle vulvar inspection -- ? lesions, ulcers, erythema  Use a moistened cotton swab to assess vestibular tenderness

23. Vulvar Dysesthesia – Physical Examination, cont’d. Gentle vaginal palpation with one finger to assess levator muscle tightness and tenderness: ? vaginismus Speculum examination: inspection, pH and wet prep, culture for yeast, other cultures and pap smear as indicated Abdominal and bimanual examinations: ? pelvic or suprapubic pain

25. Differential Diagnosis of Visible Vulvar Pain Conditions  Infection: viral, yeast, bacterial  Atrophy  Trauma  Dermatoses  Tumors  Vulvar vestibulitis

26. Lichen sclerosis

27. Chemical vulvitis from 5-FU cream

28. Plasma cell vulvitis

29. General Treatments of Vulvar Dysesthesia  Local skin care; avoidance of all vulvar irritants  Low oxalate diet; calcium citrate  Topical estrogen  Topical lidocaine  Medical therapy, low dose

30. Medical Therapy of Vulvar Dysesthesia Amitriptyline (Elavil) 10 –125 mg daily Gabapentin (Neurontin) 300 – 2700 mg daily – Gabapentin 6% ointment (some use 4%) – Dissolve gabapentin powder Ethoxy Diglycol. Levigate mixture into PCCA and lipoderm base and dispense at 6%. Apply 0.5mL (pea sized) amount to affected area TID. Pregabalin (Lyrica) off label NSAIDs

31. Medical Therapy of Vulvar Dysesthesia  Elavil and Neurontin result in improvement in pain scores in most patients by 30% to 80%  Few women report complete cure with medical therapy

32. Secondary Treatments of Focal Vulvar Dysesthesia (Vulvar Vestibulitis) Secondary Treatments of Focal Vulvar Dysesthesia (Vulvar Vestibulitis)  High-dose medical therapy  Physical therapy with biofeedback  Psychosexual evaluation  Surgery

33. Secondary Treatments of Generalized Vulvar Dysesthesia (Essential Vulvodynia) Secondary Treatments of Generalized Vulvar Dysesthesia (Essential Vulvodynia)  High-dose medical therapy  Psychosexual evaluation  Anesthesia pain assessment  Spinal cord neuromodulation

34. Therapy for Vaginismus Therapy for Vaginismus  Education  Specialized physical therapy; dilator use  Sex therapy

35. Surgery for Vulvar Vestibulitis  Bilateral Bartholin gland excision  Partial vestibulectomy with vaginal flap advancement  Note: In the very select group of patients with vulvar vestibulitis who failed all other therapies, cures of 70% to 90% have been reported