For example, the vulvoscopist can determine if a lesion is a raised plaque or just a flat macule. In addition, the margins of the lesion can be characterized e. Box 4. Lichen sclerosus, lichen planus, and lichen simplex chronicus are three of the most common non-neoplastic epithelial disorders of the vulva. Lichen sclerosus LS is a non-neoplastic chronic lymphocyte-mediated inflammatory dermatosis with distinctive dermal sclerosis and a predilection for the anogenital skin in women.
Itch is the main symptom but pain occurs if there are erosions or fissures. Dyspareunia occurs in the presence of erosions, fissures or introital stenosis. There is typically no genital mucosal involvement, but the stenosis that may develop at the edge of mucocutaneous junctions can cause severe dyspareunia. The clinical features of lesions are variable depending on the stage and severity of the disease.
Patchy involvement is seen in some, while others have extensive, confluent disease Fig. Areas of pale, thinned, wrinkled, atrophic skin, possible telangiectasia and haemorrhagic blisters, may be evident at sites of lesions Fig. Lichenification or hyperkeratosis may also be the prevalent pattern.
Progressive sclerosis can lead to loss of normal genital structures. Labia minora may become fused or resorbed, the clitoris may be buried and the introitus significantly narrowed. LS in females has two peak ages of presentation. The first of these occurs in prepubertal girls 7. The other peak of incidence is in postmenopausal women. It is important not to confuse childhood sexual or physical abuse with prepubertal lichen sclerosus Figs.
There are three clinical variants that affect the vulva: erosive lichen planus, papulosquamous lichen planus, and hypertrophic lichen planus. Vulvovaginal involvement can be associated with itching, burning, pain, dyspareunia, and destruction of the vulvar and vaginal architecture. The variant that typically affects the vulva and vagina is called erosive LP and this is the most painful form of the disease Fig.
The main symptoms are vulvar burning, occurring spontaneously or after vulvar contact, and severe dyspareunia. In LP the mucosa of the introitus is often denuded with a red, glazed appearance; there may be erythema of the vestibular mucosa with varying degrees of epithelial desquamation or frank erosions. Lichen simplex chronicus is not a specific entity, but rather describes lichenification of the vulva caused by persistent itching and scratching. The skin can become leathery and thickened or, in severe cases, may be excoriated Fig.
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Vulvar pain, if present, is usually a result of irritation from open lesions. Many different diseases may produce erosive, ulcerative, or desquamative lesions of the vulva; vulvar aphthae and genital herpes are the two Fig. Vulvar aphthae are small, shallow ulcers with a yellow base and erythematous rim. They occur acutely and resolve over a few day, and are quite painful. Although attacks tend to be intermittent, they can be very frequent or almost continuous in some patients.
Women with vulvar aphthosis frequently have oral aphthae Fig. Vulvar aphthae are commonly confused with genital herpes, and this is hardly surprising, given that they are painful, acute, recurrent ulcers. The difference is that genital herpes, once past the very brief blister stage, has the appearance of an erosion rather than the typical deeper, ulcerative lesions that are seen in the mouth Fig.
The mucosa of the labia minora and vestibule is generally pink and smooth; however, localized or widespread micropapillary or villiform patterns may sometimes be observed Fig.
These can be misinterpreted as condyloma due to human papillomavirus HPV infection. Some patients may have pruritus or burning, while others will notice an asymptomatic abnormality on the vulvar skin. The lesions may be raised or flat with a rough surface. The lesions may appear white or red or of mixed color Fig. Vestibular tenderness is assessed by applying a cotton tipped swab the Q-tip test; Fig. Gentle touch provokes either hyperesthesia, a heightened intensity relative the degree of applied pressure, or allodynia, the perception of a different sensation to that applied e.
Clinical Management of Vulvodynia 62 7 Fig. The Q-tip touch test has been validated as useful in identifying the exact location of the pain and enabling the patient to classify the areas where it is mild, moderate, or severe. A diagram of pain locations is helpful in assisting the assessment of pain over time. Provoked vestibulodynia patients have reported significantly higher pain ratings at the vulvar vestibule than pain-free controls, demonstrating the utility of this test in distinguishing between vulvodynia patients and control women. Pelvic Floor Evaluation Box 5.
The simple observation of the perineum and introital area in the dorsal lithotomy position during the performance of a Kegel squeeze is often quite revealing.
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The woman squeezes the muscles used to stop the flow of urine for about 10 seconds, and then relaxes them for about 10 seconds. At this point the examiner, if accepted by the patient, should place a generously lubricated single finger in the vagina to assess pelvic floor awareness and the ability to squeeze and relax the levator ani. Many scales are available to document strength, tone, and tenderness, yet all these scales are subjective and unvalidated. We usually used a simple empiric score that allows us to reproduce pelvic floor hypertonus with an acceptable reliability.
Box 6. Pelvic floor hypertonicity score 0 1 2 3 No hypertonicity Mild hypertonicity Moderate hypertonicity Severe hypertonicity Many patients will be found to be most tender along the lateral border of the levator ani, which is where the levator muscles insert onto the arcus tendineus levator ani. Muscular pain can be assessed with insertion of one finger at the introitus as the patient performs a series of contraction and relaxation exercises.
Spontaneous or elicited pain in the lower third of the anterior vaginal wall should be carefully explored, as it may be associated with bladder-related comorbidities cystalgia, urethralgia, post-coital cystitis, intersitial cystitis that are reported in one third of vulvodynia patients. Vaginal Inspection The vagina should be examined for possible evidence of atrophy, ulcerations or abnormal discharge.
Secretions should be collected from the later- 64 7 Clinical Management of Vulvodynia al vaginal walls using a swab. It is recommended that in the assessment of women with vaginal discharge Table 7. A wet mount or saline preparation should be done routinely to identify the presence of yeast cells and mycelia but also to exclude the presence of so-called clue cells indicative of bacterial vaginosis and motile trichomonads. Table 7. Biopsies are not generally performed when the physical examination and history have ruled everything else out.
The routine use of magnetic resonance imaging MRI is usually recommended in patients with unprovoked pain. MRI may not be necessary, however, as the incidence of pathology, for example sacral cysts, causing referred pain to the vulva is very low. Pelvic floor surface electromyography EMG is a test that should not be performed routinely. Objective identification of pelvic floor hypertonic dysfunction can be obtained using various techniques. The most common is surface EMG, which is often performed as a part of a pelvic floor evaluation by physical 7 How to Make a Comprehensive Diagnosis of Vulvodynia and its Comorbidities 65 therapists and nurse clinicians trained in the evaluation and management of patients with pelvic floor dysfunction.
In patients with hypertonic dysfunction we find the following listed in order of prevalence : - elevated and unstable resting baseline activity; - poor recovery, poor postcontraction and relaxation; - spasms with sustained contractions and poor strength. How to Treat Vulvodynia 8 Treatment for any medical disorder should be directed at the underlying mechanisms or pathophysiological processes involved. This is difficult to achieve with vulvodynia in view of the heterogeneity of factors involved in the etiology of the disorder.
Indeed, vulvodynia may be a final result of or common pathway for several pathological processes, such that any one management strategy may not be adequate for all women complaining of vulvar pain. Many women with vulvodynia experience loss of hope, which can lead to psychological, and emotional issues. A lead clinician should triage patients and consider referral to other healthcare professionals who are experienced in the management of vulvodynia, e. Urologist, Physiotherapist, Gastroenterologist, Clinical Psychologist, and pain-management teams.
It is recommended that the patient be asked about the types and outcomes of treatment she may have already used. It is important to bear these in mind, but the clinician should remember that not all treatments are delivered in the same fashion by all providers, and that not all patients adhere to treatment regimens as recommended. Multimodal and multidisciplinary interventions should be part of a treatment strategy for patients with vulvodynia.
Multimodal interventions constitute the use of more than one type of therapy for the care of patients with chronic pain. Multidisciplinary interventions are multimodality Clinical Management of Vulvodynia. The literature indicates that the use of multidisciplinary treatment programs compared with conventional treatment programs is effective in reducing the intensity of pain reported by patients. The proposal is derived from a cluster analysis of patients that explored whether subgroups exist among women with vulvodynia with respect to pain-related and personality variables.
This is the first level of treatment that each physician must recommend to any patient with vulvodynia. Skin reactions to topical medications are not uncommon, and it is often the base that the cream or gel is to blame rather the active ingredient. Topical lidocaine gels or ointments can be used in women with provoked vestibulodynia making penetrative sex possible. It is generally advised that the gel or ointment is applied 15—20 minutes prior to sex, and patients should to be warned of the possibility of irritation.
Some reactions are associated with topical anesthetics such as stinging, erythema and edema. Benzocaine, an anesthetic frequently found in overthe-counter topical preparation, should be avoided due to its frequent association with allergic contact dermatitis. It is also important to warn patients of the potential affects on the partner, such as penile numbness male partners may prefer to wear condoms.
Partners should also be advised to avoid oral contact. Lidocaine can burn when applied, but can be mixed with a little vaseline the use of vaseline can reduce the lidocaine burning effect. If the patient cannot tolerate this, consider 2. Topical compound of estradiol applied to the vestibule can be helpful in women with a pale and thin vestibular surface. Recurrent yeast should be considered as a triggering factor see Chapter 6. In this case, long term maintenance therapy with a suppressive prophylactic regimen may be required.
Weekly treatment with fluconazole or mg for months has been shown to be effective in preventing symptomatic vulvovaginal candidiasis, and use of an individualized, decreasing regimen can lead to efficient prevention of recurrence in the long term. It was originally developed in the early s as a screening technique for the selection of women with chronic pain most likely to achieve satisfactory pain relief by implant of an electrical stimulator. The management of chronic pain such as in chronic neuropathies, postherpetic neuralgia and trigeminal neuralgia by TENS is supported by a large number of clinical trials.
It has been demonstrated that TENS is of significant benefit in the management of vestibulodynia, but it is essential to use appropriate and validated stimulation parameters. It should be inserted into the vagina up to 20 mm.
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The nociceptive system is best suited to the new situation through a gradual increasing of day numbers between TENS sessions. Oral Agents A survey of clinicians has indicated that oral medications are more likely to be used for the treatment of generalized vulvodynia than for provoked vestibulodynia. Trycyclic antidepressant TCAs are an appropriate pharmacological management option in the treatment of vulvodynia, in particular for unprovoked and generalized pain.
Originally used to treat depression, this class of medication is now commonly prescribed to treat chronic pain. Amitriptyline is the most commonly used TCA for this indication. Amitriptyline should be started at a low dose, with slow titration until either the patient responds or has unacceptable side effects. Furthermore it cannot be abruptly stopped and needs to be tapered according to the side effects. Side effects in some patients might influence compliance with treatment to a level that can cause withdrawal.
Common side effects are: fatigue, dry mouth, weight gain, constipation; occasionally, cardiac and arrhythmic effects can occur, so TCAs should be used with caution in the elderly. Box 5. The best results for pain are achieved with daily doses of venlafaxine mg and duloxetine 60 mg. The strength of the pain-relieving action of SNRIs is lower than that of tricyclic antidepressants, with a combined NNT number-needed-to-treat value in painful neuropathies of about 5 for the two SNRIs and 2. Other drugs that can be used in vulvodynia patients are gabapentin and pregabalin.
Gabapentin is an antiepileptic medication that is now indicated for the treatment of chronic pain. Although pregabalin has a mechanistically similar action to gabapentin and shares similar advantages, such as a lack of pharmacokinetic interactions with other medications or enzyme induction, there are several differences between the two drugs. Unlike gabapentin, pregabalin exhibits linear pharmacokinetics after oral administration, with low intersubject variability. This provides a more predictable dose-response relationship, because plasma concentrations increase linearly with increasing dose.
Gabapentin requires disproportionately larger dosage increases to achieve increases in plasma concentrations.
Clinical Management of Vulvodynia - Tips and Tricks | Alessandra Graziottin | Springer
The large doses required for some patients receiving gabapentin could worsen dose-dependent adverse effects, such as dizziness and som- 8 How to Treat Vulvodynia 73 nolence. The linear pharmacokinetics of pregabalin impart a better-defined effective dosage range and may provide the basis for the efficacy of either fixed- or flexible-dosage regimens.
Despite these preclinical data, it is unclear if pregabalin has a clinical advantage over gabapentin, as the two drugs have not been compared in clinical trials. Although no specific studies in vulvodynia have yet been conducted, one case report indicated that pregabalin is successful in managing the pain of generalized vulvodynia. Combination therapy should preferably use drugs with complementary mechanisms.
Trigger Point Injection The use of injectable therapy in the management of vestibulodynia can be useful, in selected patients, the main objective being the inactivation of the trigger point, thereby reducing pain. The therapy should be used in combination with other approaches as a complementary treatment or like treatment of a residual disease. Various combinations of drugs have been suggested, but we currently think that only two regimens should be used: corticosteroid plus anesthetics and botulinum toxin see section on pelvic floor dysfunction Table 8.
Clinical Management of Vulvodynia 74 8 Table 8. We think that there is not a substantial difference between generalized vulvodynia and pudendal neuralgia, so that pudendal nerve block can be a possible therapy in patients with generalized vulvodynia Table 8. Table 8. The needle is inserted through the vaginal wall, is directed towards the spine and then passed through the sacrospinous ligament. As soon as the needle has passed through the ligament, a loss of resistance is felt. Various pudendal nerve block approaches have been described via different routes: transvaginal, transperineal and transgluteal.
The main problem associated with these approaches is the risk for the patient, as this is a blind technique in a vascularized region close to the bowel and bladder. However, the approach can be guided by different imaging technique utilizing fluoroscopy or computed tomography. Surgery Surgical excision of the vestibule may be considered in patients with local provoked vulvodynia vestibulodynia after other non-surgical measures have been tried. The procedure that yields the best result is modified vestibulectomy in which a horseshoe-shaped area of the vestibule and inner labial fold is excised, followed by advancement of the posterior vaginal wall Fig.
Factors that limit direct comparison are differences in numbers of patients, presence of associated comorbidities Clinical Management of Vulvodynia 76 8 such as painful bladder syndrome, other medical treatment at the time of surgery, the technique used, definition of success, and length of follow-up. First and foremost, however, patient selection is crucial. In addition, adequate counseling and support should be given to the patient both pre- and postoperatively. The thinnest possible tissue section was removed and sent for pathological examination.
The vaginal epithelium was pulled out and attached to the skin of the perineum, replacing the excised area by interrupted dissolving sutures and the retain hymen is used as a flap Box 7. Physical therapy is effective in lowering pelvic floor hypertonus and a variety of techniques, including pelvic floor exercises, external and internal soft tissue self-massage, trigger point pressure, biofeedback and use of vaginal trainers, can be used.
Biofeedback techniques are key to attaining this target. With a vaginal probe, levator ani activity can be monitored by the patient and her therapist, and with careful coaching the patient can be taught how to contract and then relax her pelvic floor using various protocols. Generally the goal is to teach muscle awareness and relaxation. Manual therapy techniques are especially important for patients with myofascial pain disorders and include myofascial release, trigger point release, soft tissue mobilization, and massage.
These internal techniques can be complemented by the patient being educated in the use of vaginal dilators for self massage. Sexual partners should also be educated in these techniques in order to encourage and provide further supportive therapy at home. The presence of the dilator provides propioception to the musculature during exercise, augmenting improved pelvic floor contraction and relaxation.
Vaginal dilatation can also diminish the anxiety associated with penetration as the woman has complete control of vaginal entry. Botulinum neurotoxin BoNT : The primary mode of action of BoNT is chemodenervation of muscle via blockade of presynaptic acetylcholine release at the neuromuscular junction, with subsequent paralysis.
In therapeutic use, BoNT has also demonstrated effectiveness in the treatment of pelvic pain disorders characterized by functional abnormalities of muscle tension and relaxation, such as vaginismus. BoNT can be injected into the bulbospongiosus and pubococcygeus muscles. The majority of studies of BoNT in vulvar pain syndrome are targeted at pelvic floor spasm or inhibition of muscle spasticity.
These trials represent some optimistic preliminary data that warrants further research in order to standardize dosing and optimize the number of injections. Clinical Management of Vulvodynia 78 8 Box 8. Manual therapies used to eliminate trigger points include skin rolling, strumming and stripping of the affected muscle fibers Typically, pelvic floor dysfunction must be treated as part of a multimodal treatment plan and a physical therapist with experience in vulvodynia needs to be involved in the interdisciplinary treatment of the disease.
Action Towards Psychosexual Ramification of the Syndrome Vulvar pain has physical, psychological and relationship aspects. Patients with localized and generalized vulvar pain need varying degrees of sexual counseling and emotional support. Because living with chronic genital pain often has psychosexual consequences, some women may benefit from adjunct counseling or sex therapy. Cognitive-behavioral therapy is a useful psychological approach to reduce vulvar pain and improve sexual function. It is important to keep in mind that decreasing dyspareunia does not necessarily lead to a restoration of sexual function, especially in women with long-term vulvodynia.
In these cases sex therapy, couples counseling, psychotherapy, or a combination is often very helpful. Antibiotics precipitated a yeast infection, for which she was also treated; — she complains of dyspareunia, with stinging and burning pain in the vestibule during and after intercourse; — she has had increasing pain with intercourse, to the point that she has had to stop having sex.
Moderate pelvic floor hypertonicity score 2 Swab test severe Fig. Am J Obstet Gynecol J Reprod Med Backman H, Widenbrant M, Bohm-Starke N et al Combined physical and psychosexual therapy for provoked vestibulodynia-an evaluation of a multidisciplinary treatment model. Obstet Gynecol Vulvodynia. Int J Gynecol Pathol Bornstein J, Goldschmid N, Sabo E Hyperinnervation and mast cell activation may be used as histopathologic diagnostic criteria for vulvar vestibulitis.
Int J Clin Pract Dionisi B, Anglana F, Inghirami P Use of transcutaneous electrical stimulation and biofeedback for the treatment of vulvodynia vulvar vestibular syndrome : result of 3 years of experience. In: Studd J ed The management of the menopause. Mondadori, Milan Graziottin A Sexual pain disorders: dyspareunia and vaginismus. Current Sexual Health Reports,Vol. Blackwell Publishing, pp Graziottin A Psychogenic causes of chronic pelvic pain and impact of chronic pelvic pain on psychological status including physical and sexual abuse.
In: Vercellini P ed Chronic pelvic pain in women. SOPHY project: an observational study of vaginal pH and lifestyle in women of different ages and in different physiopathological conditions. Part I. SOPHY project: an observational study of vaginal pH, lifestyle and correct intimate hygiene in women of different ages and in different physiopathological conditions. Part II. Minerva Ginecol — Gunter J Is there an association between vulvodynia and interstitial cystitis? In: Potts JD ed Genitourinary pain and inflammation.
Curr Opin Neurol — 86 Clinical Management of Vulvodynia Jerome L Pregabalin-induced remission in a year-old woman with a year history of vulvodynia. J Reprod Med Murina F, Bernorio R, Palmiotto R The use of amielle vaginal trainers as adjuvant in the treatment of vestibulodynia: an observational multicentric study. Maturitas 63, 2. Fast Fact Series. Int J Gynaecol Obstet Read more. Eclipse myeclipse tips and tricks. Twitter Tips, Tricks, and Tweets. Tips and Tricks in Laparoscopic Urology. Knoppix Hacks: Tips and Tricks. Visual Studio. NET Tips and Tricks. Publisher: Springer , This specific ISBN edition is currently not available.
View all copies of this ISBN edition:. Buy New Learn more about this copy. About AbeBooks. Customers who bought this item also bought. Stock Image. Vulvodynia Alessandra Graziottin, Filippo Murina. Published by Springer Milan , Milan London New Hardcover Quantity Available: 1. Seller Rating:. Published by Springer New Hardcover Quantity Available: Published by Springer Verlag New Hardcover Quantity Available: 2. Revaluation Books Exeter, United Kingdom. Published by Springer. Lifespan David Sinclair Inbunden.
Spara som favorit. Skickas inom vardagar. Skickas inom vardagar specialorder. Despite being seen routinely in everyday clinical practice, it remains a neglected disorder that may take many years to diagnose. This book eases the way for physicians, including General Practitioners and Gynecologists, who are motivated to improve the lives of women suffering from vulvodynia. Passar bra ihop.
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