Vulvodynia: causes, signs, how to treat?

Vulvodynia is a problem, it would seem, of older women, but today, unfortunately, there are no such age restrictions. The prevalence of this problem is very wide, and an unclear concept of the etiology and methods of treatment leads to later diagnosis. Therefore, any woman should know about this problem, and immediately seek help when the first signs appear.

Epidemiology

Population-based statistics indicate that approximately 16% of women worldwide report a history of chronic genital pain. Among the suspected factors for the development of vulvodynia in this proportion of women are recurrent vaginal infections (most commonly yeast and bacterial vaginosis), oral contraceptive use (especially early use), and a history of destructive treatments (eg, trichloroacetic acid). There is some evidence of genetic susceptibility for women with specific genetic variants. More than 40% of women live with this problem throughout their lives without even knowing that there is a medical term or treatment for it. This proves, first of all, the need to promote knowledge about the problem of vulvodynia, and secondly, the importance of an annual medical examination of each woman to avoid complications.

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Causes vulvodynia

Vulvodynia is a term used to describe a condition in which women experience a feeling of heaviness and soreness in the vulvar area without the absence of any obvious skin condition or infection. This condition is characterized by chronic discomfort in the vulvar area, and the discomfort can range from mild to severe and debilitating. Vulvodynia is not associated with an underlying medical condition. The exact cause is unknown. It is not caused by a sexually transmitted infection or other infection, skin disease, or cancer, although these can also cause pain. This is different from pain that is deep in the pelvis or inside the vagina. Vaginal pain can be chronic and can last for years in some women. It often occurs in the absence of physical signs or visible abnormalities. It can be a serious diagnosis and can interfere with sexual activity and cause pain when doing so (dyspareunia).

Although research continues, little is known about the causes of vulvodynia. Because the cause is poorly understood, it is difficult to predict who is at risk for vulvodynia. It can affect women of all ages and races. It can begin as early as adolescence and can occur before or after menopause. It can occur during menstruation or independently of the menstrual cycle.

Since the exact causes are unknown, there are many risk factors for this pathology.

The causes of this pathology are considered in the light of several versions. Some theories suggest that vulvodynia may be related to damage or irritation of nerves, abnormal response to irritation or inflammation. It is also associated with an allergic reaction, muscle spasms, frequent use of antibiotics. Other suspected causes include recent use of chemical irritants, a history of destructive therapy such as carbon dioxide laser or cryotherapy, or allergic reactions.

Vulvodynia can have a number of other causes, such as:

• persistent vaginal candidiasis or other vaginal infections;
• sensitivity to anything that touches the vulva, such as soap, bubble baths, or medicated creams (known as irritant contact dermatitis);
• decreased hormone estrogen, causing vulvar dryness, especially during menopause;
• recurrent herpes infection;
• lichen sclerosus or lichen planus infection (skin conditions that can cause intense irritation and soreness of the vulva);
• in rare cases, Behcet's disease (a blood vessel condition that can cause genital ulcers) or Sjogren's syndrome (an immune system disorder that can cause vaginal dryness).

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Risk factors

Risk factors for vulvodynia include:

• damage or irritation to the nerves around the vulva;
• high density of pain-relieving nerve fibers in the vulva area;
• high levels of inflammatory substances in the vulvar area, for example, genetic susceptibility may develop due to such inflammation;
• weak or unstable pelvic floor muscles;
• an unusual or long-term reaction to an infection, injury, or other environmental factor;
• changes caused by hormones;
• frequent yeast infections;
• sexually transmitted infections (STIs);
• chemical irritation of the external genitalia caused by soap, feminine hygiene products, or detergents in clothing;
• rash on the genital area;
• previous laser procedures or surgeries on the external genitalia;
• nerve irritation, injury or muscle spasms in the pelvic area;
• diabetes;
• precancerous or cancerous conditions of the cervix.

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Pathogenesis

The pathogenesis of vulvodynia is not fully understood. There is controversy about whether there are changes in the inflammatory infiltrate in the vulvar tissue of women with vulvodynia. Some studies have found an increase in inflammatory cells or mast cells, while others have found that the inflammatory cell infiltrates were insignificant. More recently, vulvar biopsy specimens have shown increased neuronal proliferation and branching in the vulvar tissue of women with vulvodynia compared to tissue of asymptomatic women. Therefore, whatever the underlying cause, the pathogenesis mainly involves disturbance of nerve sensitivity of a single site or a large area of the mucosa. Inflammatory or proliferative changes should not be present in vulvodynia.

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Symptoms vulvodynia

The symptoms of vulvodynia may be described differently by each woman. But the main symptom of vulvodynia is persistent pain in or around the vulva with normal function.

The pain described by women with unprovoked vulvodynia is often of a burning, aching nature. The intensity of the pain can range from mild discomfort to severe, constant pain that may even be felt while sitting. The pain is usually continuous and may interfere with sleep. The pain may be burning, stinging, or triggered by touch, such as during sex or when inserting a tampon.

As with long-term pain from any cause, you may have good days and bad days. Itching is not usually a sign of the condition. The pain of vulvodynia is not always limited to the vulva (the area of skin on the outside of the vagina). It can be pain around the inner thighs, upper legs, and even around the anus (back passage) and urethra. Some women also have pain when they go to the toilet.

There are usually no physical signs or changes that accompany vulvodynia, but sometimes there are signs of inflamed skin.

The duration of vulvodynia should be at least 3 months. The first signs may begin with minor discomfort. Then the pain may be localized or widespread.

Stages

The stages of vulvodynia can be limited to a local reaction - this is localized vulvodynia, and when the process spreads further, a generalized stage develops. Although such staging is conditional, but still, to prevent the spread of the process, it is necessary to treat when the first signs appear.

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Forms

There are different types of vulvodynia. Unprovoked vulvodynia is a process in which pain is felt regardless of external conditions and there is no provocation (pelvic examination, sexual intercourse). The sensation of burning and soreness of the vulva can be continuous (unprovoked vulvodynia) or with light touch, such as from intercourse or using a tampon (provoked vulvodynia). Women who had unprovoked vulvodynia were previously known as having dyspepsia vulvodynia, where pain was felt without touch. Vestibulodynia is a replacement term for vestibulitis, where pain is felt with light touch.

Dysthetic vulvodynia occurs when there is a disturbance of sensitivity in the vulva and vagina. In addition to the symptoms of vulvodynia, there is increased sensitivity in the genital area, most often due to surgical interventions or traumatic childbirth. This condition causes vulvodynia as a result of irritation or hypersensitivity of the nerve fibers of the skin. Abnormal signals of the nerve fibers from the skin are felt as a sensation of pain in a woman. This type of pain can occur even if there is no irritation in this area. Dysthetic vulvodynia usually occurs in women who are postmenopausal. The pain that occurs in women with this subtype of vulvodynia is usually diffuse, uncontrollable, burning pain that is not cyclical. Patients with dysthetic vulvodynia have less dyspareunia. Hyperesthesia is believed to be due to altered skin perception.

Constant vulvodynia is one of the severe forms, since the symptoms bother the woman all the time. Idiopathic vulvodynia is the one whose cause is unknown. This type includes pathology in young girls and women who do not have any associated problems and pathologies.

Dietary vulvodynia is one of the types in which the triggering factor is a violation of the diet. This is taken into account in the general principles of vulvodynia treatment.

Herpetic vulvodynia is a process in which the process of pain in the vulva is associated with the herpes virus. This is one of the favorable options, since the herpes infection is treated and the symptoms of vulvodynia gradually decrease.

Candidal vulvodynia is associated with frequent candidal infections, so the identification of Candida in women allows us to consider it as an etiologic factor.

Vulvodynia is most common in postmenopause. This is due to several factors - during this period, women have a decrease in estrogen levels. This factor leads to a disruption in the trophism of the mucous membrane in the vagina and vulva, which leads to dryness. This can cause painful sensations, and in the initial stages, when there are no changes in the mucous membrane, vulvodynia appears.

Vulvodynia and pregnancy is a frequently discussed issue because it is important to consider whether the syndrome will harm the baby and whether the pregnancy itself can cause vulvodynia.

Research shows that women who have vulvodynia can have normal pregnancies, and that in some cases the pain improves during pregnancy. However, women with the condition are more likely to have a cesarean section.

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Complications and consequences

The consequences and complications are more psychological, since there are no anatomical changes. Complications may include: anxiety, depression, sleep disorders, sexual dysfunction, relationship problems, and decreased quality of life. Relationship problems may arise because intercourse is painful. One study shows that 60% of women with vulvodynia cannot have sex. Therefore, psychological correction has a certain place in the treatment of vulvodynia.

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Diagnostics vulvodynia

The diagnosis of vulvodynia depends on a careful history, since subjective sensations are very important, and then a confirmatory physical examination. The history should include information about the onset and nature of the pain, triggers and relievers, current medical evaluation, and treatment attempts and their effect on the pain. Sometimes a woman may not be aware that the tenderness is in the vulvar area and may describe the pain as vaginal or pelvic pain.

A physical examination is an important part of the diagnostic process. Typically, nothing is visible on examination because the problem is in the nerve fibers themselves, which are not visible on the skin. The vulva may be erythematous in women with vulvodynia, but the presence of a rash or abnormal mucosa or skin is not consistent with vulvodynia and requires further evaluation or biopsy. A vaginal examination should be done to rule out other common causes of vulvovaginal discomfort (eg, candidiasis, bacterial vaginosis).

Once mucocutaneous diseases have been ruled out in patients with three or more months of vulvar discomfort, a cotton swab test should be performed. Using a moistened swab, the vulva is tested starting at the thighs and moving medially (the area beyond the hymen). In this area, the 2, 4, 6, 8, and 10 o'clock positions are palpated using light pressure. The patient is asked to rate the pain on a scale of 0 to 10 (0 = no pain and 10 = severe pain when worn).

Vaginal discharge should be evaluated for active vulvovaginal candidal infection. If infection is diagnosed, treatment with antifungal agents should precede treatment of vulvodynia. Treatment of possible yeast infection without confirmation by a strong positive potassium hydroxide reaction is not recommended, and yeast culture should be performed if there is uncertainty about infection.

Tests are used infrequently, only to rule out vaginosis and examine the vaginal flora. There are no specific tests to confirm vulvodynia, and the diagnosis is made based on the characteristic symptoms. However, because vulvar and vaginal infections (yeast infection, bacterial vaginosis, vaginitis) are sometimes associated with pain and itching, cultures or other diagnostic tests may be ordered to rule out infections. Even if there is no visual evidence of infection, a sample of cells from the vagina may be taken to check for an infection such as a yeast infection or bacterial vaginosis. Tests include a swab to look for bacteria and yeast, and blood tests to evaluate estrogen, progesterone, and testosterone levels.

Instrumental examinations are also used for differential diagnostics. The doctor may use a special magnifying device to perform a colposcopy.

A biopsy is one of the methods to rule out malignant processes. When performing a biopsy, the doctor first treats the genital area with a painkiller, and then a small piece of tissue is taken for examination under a microscope.

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Differential diagnosis

Differential diagnosis is performed to exclude objective causes of vulvar pain. As noted above, biopsy, culture, or both should be used to exclude other causes of vulvar pain or irritation, including atypical candidiasis, bacterial vaginosis, trichomoniasis, and herpes simplex.

Vestibulodynia is pain when in contact with the mucous membrane, which is most often caused by sexual intercourse. Vulvodynia has no specific cause and bothers regardless of irritation.

Another pathology that vulvodynia must be differentiated from is vulvitis. This is a focal inflammation of the vulvar area. It is characterized by entrance dyspareunia, discomfort when opening the vagina, a positive smear test, localized pain inside the vulva, and focal or diffuse vestibular erythema.

Vestibulitis is one of the common causes of pain, so differentiation is also carried out. Chronic vestibulitis lasts from several months to several years, and patients may experience dyspareunia and pain when trying to insert a tampon. The etiology of visceral vestibulitis syndrome is unknown. Some cases seem to be caused by yeast vaginitis.

Cyclic vulvovaginitis is probably the most common cause of vulvodynia and is thought to be caused by a hypersensitivity reaction to Candida. Although vaginal smears and cultures are not always positive, microbiological evidence should be sought by obtaining candida or fungal cultures during the asymptomatic phase. The pain is usually worse immediately before or during menstrual bleeding. Therefore, it is necessary to differentiate vulvodynia from symptoms of vulvovaginitis.

Vulvar dermatoses and vulvovaginoses include mucosal lesions. Erosions or ulcers may result from excessive irritation. If the patient has blisters or ulcers, scratches, the cause may be vesicular disease. Differential diagnoses of papuloradial lesions and vesicoradial lesions should be made at the initial stage when excluding the causes of vulvodynia.

Symphysitis is an inflammation of the symphysis, which can cause painful sensations. But there is a localization of pain and when palpating the symphysis, the pain intensifies.

Bartholinitis is an inflammation of the Bartholin glands. This is an acute process, in which there is sharp pain and there are external signs of inflammation. Therefore, this diagnosis is easy to identify.

Dyspareunia is pain during sexual intercourse. It may accompany vulvodynia, or it may be a separate diagnosis.

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Treatment vulvodynia

Vulvodynia can be managed with both treatment and home remedies. Not all treatments will be effective for every woman, and a woman may need to try different treatments to find the one that works best for her.

Despite treatment with surgery, pharmaceutical therapy, psychological treatment, physical therapy, and biological and behavioral therapy, there is still no consensus on which procedure or procedures provide the greatest benefit. A combination of treatments is often used, and although there are several treatment options for vulvodynia, the majority of the literature supports the conclusion that treatment of vulvodynia is uncommon and a specific precipitating cause can be diagnosed in a relatively small percentage of patients. Consideration of these factors should be an integral part of the treatment of women with vulvodynia, and this highlights the need to study this condition.

Painkillers for vulvodynia are one of the means of symptomatic therapy, but conventional medications will not be effective here. Steroids, tricyclic antidepressants, or anticonvulsants can help reduce chronic pain. Antihistamines can reduce itching.

Tricyclic antidepressants are the most commonly used form of oral medication. Evidence of efficacy has been seen in retrospective studies. When used in older populations, starting with lower doses is recommended. It is recommended to avoid use in patients with cardiac abnormalities, and abrupt discontinuation of the medication is not recommended.

1. Amitriptyline is a tricyclic drug that, in addition to treating vulvodynia symptoms, can relieve stress, improve sleep, and reduce anxiety associated with the problem. The dosage is increased gradually, with gradual tapering. The recommended regimen starts with 10 mg per day, gradually increasing to 40-60 mg per day. Patients should continue to take the highest tolerated dose that provides symptomatic relief for four to six months, and then gradually reduce the dosage to the minimum amount needed to control symptoms. Side effects of the drug are common - constipation, dry mouth, and sometimes blurred vision. The most common effect is fatigue and drowsiness, which affects many women. If this happens, try taking the tablets before bed. If it makes you sleepy in the morning and you have trouble getting out of bed, try adjusting the dosage a little.
2. Hormonal therapy for vulvodynia is used more often in postmenopausal women, when additional hormone therapy is needed to correct other symptoms. Estrogen preparations are most often used, or, if necessary, they are combined with progesterone preparations. Therapy with potent topical corticosteroids should be limited to short-term use.

Premarin is an estrogen drug. It is used for vulvodynia, when there are disorders of the mucous trophism and dryness of the vulva. The dosage of the drug is one tablet once a day for 21 days, and then a break of 10 days. The method of administration is oral. Side effects with prolonged use are telangiectasia, looseness of the skin, formation of grooves and easy bruising. Powerful steroids can also cause overdose dermatitis, an inflammatory reaction with erythema and a burning sensation that occurs when the steroid is removed.

1. Neo penotran is a combination drug that includes metronidazole (antibacterial) and miconazole (antifungal). This drug can be used for vulvodynia, the etiology of which is associated with infection. It is believed that some types of vulvodynia are a reaction to yeast, which can be detected from time to time and not detected during examination. Therefore, if yeast is detected, this drug can be used. The method of administration of the drug is intravaginal, the dosage is one suppository at night for seven days. Since the effect is mainly local, the side effects are burning or itching.
2. Vulvodynia ointments are used as local anesthetics. Medicines such as lidocaine ointment can provide temporary relief from symptoms. Women may be advised to apply lidocaine 30 minutes before intercourse to reduce your discomfort. Side effects are local reactions. It is very common for lidocaine to cause a burning sensation that may last for several minutes before it relieves the pain. Try to give the lidocaine time to work, but if the burning continues for 10 minutes, rinse it off thoroughly.

Physical therapy is also widely used to treat vulvodynia. Two methods currently being investigated are neurostimulation and spinal infusion pumps. Neurostimulation involves delivering low-voltage electrical stimulation to a specific nerve. This can replace pain with a tingling sensation. A spinal infusion pump is an implanted device that can deliver low-dose medications to the spinal cord and nerve roots. This can dull the pain.

A physical therapist can teach a woman exercises (such as squeezing and releasing the pelvic floor muscles) to help relax the muscles around your vagina. Because vaginal muscle spasm can worsen the pain and discomfort of vulvodynia, physical therapy using biofeedback and gynecologic instruments has been successful in many patients. Biofeedback training helps patients learn exercises to strengthen weakened pelvic floor muscles and relax these same muscles, resulting in less pain.

Another way to relax the muscles in the vagina and desensitize is to use a set of vaginal trainers. These are smooth cones that gradually increase in size and length that can be inserted into the vagina.

Home treatment

Treatment at home primarily involves some recommendations, simple adherence to which can significantly reduce the symptoms of vulvodynia.

Home remedies and self-care measures can provide relief for many women. Some self-care measures to relieve vulvodynia pain include:

Try cold compresses or gel packs. Place them directly on the external genital area to relieve pain and itching.

Use sitz baths. Sit in comfortable, warm (not hot) or cool water with Epsom salts or colloidal oatmeal for 5 to 10 minutes two to three times a day.

Avoid pull-up pantyhose and nylon underwear. Tight clothing restricts air flow to the genital area, which often leads to increased heat and humidity, which can cause irritation.

Wear white cotton underwear to increase ventilation and dryness. Try sleeping without underwear at night.

Avoid hot baths. Spending time in hot water can cause discomfort and itching.

Don't use deodorant tampons. Deodorant can irritate. If tampons irritate, switch to 100 percent cotton pads.

Avoid activities that put pressure on your vulva, such as cycling or horseback riding.

Avoid foods that can make urine more irritating to the skin of the genital area. These foods include beans, berries, nuts, and chocolate.

Use lubricants. If you are sexually active, apply lubricant before sex. Do not use products containing alcohol, fragrances, or heating or cooling agents.

Psychosexual counseling is helpful when pain is affecting intimacy between you and your partner. It is a type of therapy that aims to address issues such as fear and anxiety about sex, as well as rebuilding your physical relationship with your partner.

Try not to avoid sex, as this can make your vulva more sensitive; if sex is painful, try to find a more comfortable position.

Try to reduce stress as it can increase vulvodynia pain read some relaxation tips to relieve stress. For pain that occurs when sitting, using a donut-shaped pillow can help.

Vulvodynia can cause drastic changes in lifestyle. It can reduce the patient's ability to walk, exercise, sit for long periods of time, or engage in sexual activity. All of these normal activities can make vulvar pain worse. Many women with vulvodynia have been diagnosed with a psychological problem due to lack of physical activity. Patients may become anxious or angry as diagnosis is delayed after numerous visits to the doctor, and as their problems escalate, it may become a serious health problem. Many patients with vulvodynia worry that they will never recover. Patients should be supported in recognizing that vulvodynia is not a psychosomatic condition, and that there is no predisposition to cancer or other life-threatening conditions. It should be explained that improvement will occur with appropriate treatment, but it may take months or years for treatment to be successful, and patients may have periods of exacerbation and remission. Many patients benefit from referral to a group that provides information and emotional support.

Herbal treatment and homeopathy for this pathology have not been proven effective.

Surgical treatment should be used in cases where all forms of treatment have failed. Many cases of vulvodynia that do not respond to medical therapy respond to vulvectomy or laser treatment. Vestibulectomy, or surgical removal of the vulvar tissue containing the vestibular glands, relieves symptoms in two-thirds of patients. Complications of surgery include wound hematoma, partial or complete wound dehiscence, uneven healing requiring minor revision, and stenosis of the Bartholin duct with cyst formation. In cases of localized vulvodynia or vestibulodynia, surgery to remove the affected skin and tissue (vestibulectomy) relieves pain in some women.

Laser therapy for the treatment of idiopathic vulvodynia has been used with some success and can reduce the need for surgical therapy in many cases.

How to live with vulvodynia? In most cases, this condition can be treated using several treatment methods.

Prevention

Prevention can be difficult because the cause of this disorder is unknown. But annual preventive examinations with a gynecologist can be one of the best means of preventing many pathologies, including vulvodynia.

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Forecast

The prognosis for recovery from vulvodynia is unclear. Many women complain of this disorder for many years, and it has traditionally been considered chronic. However, recent data suggest that about half of women who report having long-term vulvar pain no longer have symptoms of vulvodynia. Therefore, it is reasonable to think that symptoms may improve in a significant proportion of women with this disorder. The prognosis for women who receive appropriate treatment is quite good.

Vulvodynia refers to pain in the vulva and vaginal opening for which no cause can be identified. The symptoms of the condition are very pronounced and can affect a woman’s daily activities. Since many women may not pay attention to this symptom, it is important to know that it is better to see a doctor as early treatment is more effective.