Vulvodynia: Vulvar Pain

What is vulvodynia?
Vulvodynia is defined as chronic vulvar discomfort or pain that can last anywhere from a few months to a few years. Vulvar vestibulitis is a type of vulvodynia in which pain is only experienced when pressure is applied to the vestibule, which is the area surrounding the entrance to the vagina. In this condition, pain commonly occurs during sex and during insertion of tampons.

Vulvodynia affects a woman's ability to engage in sexual activities and can even interfere with her daily functioning. It can diminish her ability to work, engage in physical activity and to participate in other forms of social interaction.

Symptoms of Vulvodynia
The main symptoms of vulvodynia are burning, stinging, irritation or rawness in the female genitalia. Burning sensations are the most common symptom, but the pain associated with vulvodynia is different for every woman. Vulvodynia varies in persistence and location. A woman may experience constant or intermittent pain and it may be localized or diffuse. In many cases pain occurs spontaneously.

What causes vulvodynia?
The actual cause of vulvodynia is unknown; it may be the result of multiple factors. Doctors hypothesize that it may be caused by these potential conditions:

  • An injury to, or irritation of, the nerves in the vulva.
  • Localized hypersensitivity to candida (a yeast-like fungus).
  • Allergic reaction to environmental irritants.
  • High levels of oxalate crystals in the urine (oxalate is the salt of oxalic acid, which is a powder that comes from certain plants such as spinach); the crystals get lodged in the vulvar tissue, causing pain.
  • Spasms of the muscles that support the pelvic organs.
However, there is no evidence that it is caused by infection or that it is an STD.

Diagnosing Vulvodynia
A woman is diagnosed with vulvodynia when her symptoms of pain have lasted for at least 6 months and when other causes of vulvar pain (i.e. vulvovaginal infections) have been ruled out. Diagnosis can also involve biopsy of any questionable areas, which is when a small piece of tissue is cut out for microscopic examination. Vulvovaginal infections can be ruled out by testing for fungus (yeast infection), trichomoniasis, chlamydia, gonorrhea, or bacterial infection. A doctor can test for yeast infection by examining vaginal secretions microscopically for the presence of yeast forms. Chlamydia can be tested for when a clinician sends a sample of vaginal secretions to a lab that can look for the bacterium Chlamydia trachomatis. Gonorrhea is diagnosed through gram stain, detection of bacterial genes or DNA (from the bacterium Neisseria gonorrhoeae), and culture. Gram stain involves smearing a sample of vaginal secretions on a slide and staining it with a dye. This will show whether or not the bacteria is present. Secretions can also be analyzed for presence of the genes of the bacteria. Culture involves incubating a sample of the vaginal secretions to allow the bacteria (if present) to multiply.

Treatment for Vulvodynia
Currently there is no specific cure for vulvodynia. Instead, treatments are provided to aid in symptom relief. These treatments include drug therapies such as tricyclic antidepressants or anticonvulsants, nerve blocks, interferon, biofeedback, diet modification, and topical corticosteroids. The antidepressants are for women who become depressed because the vulvodynia has interfered with their quality and way of life. Interferon is a protein designed to protect against viral infection. Biofeedback is a training program designed to develop the individual's ability to control the involuntary nervous system. Using this technique, the woman may be able to relax the muscles in the pelvic organs that may be having spasms and causing pain.

Surgery is an option for some women only when other treatments do not produce satisfactory relief. There are two types of surgery available: scalpel and laser. Scalpel surgery involves excising the sensitive areas around the vaginal vestibule and then pulling the healthy skin over the excised area. Recovery time for this procedure can take weeks. Laser surgery involves the same procedure but instead of a scalpel, a laser is used. Recovery time for laser surgery can take longer and be more painful than with scalpel surgery.

Another type of laser surgery involves using a flashlamp-excited dye laser to solidify symptomatic blood vessels below the skin or to remove chronically painful Bartholin's glands (located on each side of the vaginal opening). In one study, this surgery had a success rate of 92.5% in patients complaining of pain only on the surface of the vaginal area; those complaining of pain on the surface plus deeper pain had an 80.3% success rate. Pudendal nerve decompression is a surgery in which the pudendal nerve is cut. The basis of this surgery is that the pudendal nerve may be a source for the pain involved in vulvodynia. This surgery is performed through an incision near the anus. In one particular study, this surgery provided relief in 9 out of 11 women.

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