Vulvodnia: causes, signs, how to treat?

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

Epidemiology

Population-based statistics suggest that approximately 16% of the world's women report stories of chronic pain in the genital area. Among the prospective factors of vulvodynia development in this number of women are recurrent vaginal infections (most often yeast and bacterial vaginosis), the use of oral contraceptives (especially early use) and an anamnesis of destructive therapies (for example, the use of trichloroacetic acid). There is some evidence of genetic susceptibility for women with specific genetic variants. More than 40% of women live throughout their lives with this problem, not even suspecting that there is a medical term and this is being treated. This proves in the first place, the need to promote knowledge about the problem of vulvodynia, and secondly, the importance of an annual medical examination of each woman in order to avoid complications.

[1], [2], [3], [4], [5], [6], [7], [8], [9]

Causes of the vulvodynia

Vulvodynia is a term used to describe a condition in which women experience a feeling of severity and soreness in the vulva area without the absence of any obvious skin condition or infection. This pathology is characterized by chronic discomfort in the vulva, and discomfort can range from mild to severe and debilitating. Vulvodina is not associated with the underlying disease. The exact cause is unknown. It is not caused by an infection that is transmitted sexually or by another infection, skin disease or cancer, although they can also cause pain. This is different from the pain that is deep in the pelvis or inside the vagina. Vaginal pain can be chronic and can last for years in some women. This often occurs in the absence of physical signs or visible anomalies. This can be a serious diagnosis and can interfere with sexual activity and cause painful feelings while (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 of vulvodynia. This can affect women of all ages and races. It can begin as early as adolescence and can occur both before and after menopause. This can occur during menstruation or regardless 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 some versions. Some theories suggest that vulvodynia can be associated with nerve damage or irritation, an abnormal response to irritation or inflammation. It is also associated with an allergic reaction, muscle spasms, frequent use of antibiotics. Other suspicious reasons include the recent use of chemical stimuli, the history of destructive therapy, such as a carbon dioxide laser or cryotherapy, or allergic reactions.

Vulvodnia can have a number of other reasons, such as:

• persistent vaginal candidiasis or other vaginal infections;
• sensitivity to something touching the vulva, for example soap, bubble bath or medical creams (known as irritating contact dermatitis);
• reduction of hormone estrogen, causing dryness of the vulva, especially during menopause;
• recurrent herpes infection;
• infection of lichen sclerosis or lichen (skin conditions that can cause intense irritation and tenderness of the vulva);
• In rare cases, Behcet's disease (a condition of blood vessels that can cause genital ulcers) or Sjogren's syndrome (an immune system disorder that can cause vaginal dryness).

[10], [11], [12], [13]

Risk factors

Risk factors for vulvodynia include:

• damage or irritation of the nerves around the vulva;
• high density of analgesic nerve fibers in the vulva;
• a high level of inflammatory substances in the vulva, for example, because of such inflammation, genetic susceptibility may develop;
• weak or unstable pelvic floor muscles;
• unusual or long-term reaction to infection, trauma or other environmental factors;
• changes caused by hormones;
• frequent infections of yeast etiology;
• sexually transmitted infections (STIs);
• chemical irritation of the external genitalia, caused by soap, female hygiene products or detergents in clothing;
• rash on the genital area;
• previous laser procedures or operations on external genitalia;
• irritation of the nerves, trauma or muscle spasms in the pelvic region;
• diabetes;
• precancerous or cancerous conditions on the cervix.

[14], [15], [16], [17], [18], [19]

Pathogenesis

The pathogenesis of vulvodynia is not fully understood. There is debate about whether there are changes in the inflammatory infiltration in the vulvar tissue of women with vulvodynia. Some studies have shown an increase in inflammatory cells or mast cells, while others found that inflammatory cell infiltrates were minor. More recently, the samples of the vulva biopsy showed an increased proliferation of neurons and a branching in the vulvar tissue of women with vulvodynia in comparison with the tissue of asymptomatic women. Therefore, whatever reason was the basis for the development of this pathology, in the pathogenesis, the nervous sensitivity of a particular site or a large mucosa is mainly disturbed. Inflammatory or proliferative changes in vulvodynia should not be.

[20], [21], [22], [23]

Symptoms of the vulvodynia

Signs of vulvodynia can be described differently by each woman. But the main symptom of vulvodynia is constant pain in or around the vulva with normal functions.

The pain described by women with unprovoked vulvodynia often has a burning, painful character. The intensity of pain can range from mild discomfort to severe permanent pain, which can even be felt in sitting position. The pain is usually continuous and can interfere with sleep. Pain can be in the form of a burning sensation, stinging or caused by a touch, for example, during sex or when inserting a tampon.

As with prolonged pain for any reason, you can have good days and bad days. Itching is usually not a sign of the condition. Pain in vulvodynia is not always limited to the area of the vulva (the area of the skin on the outside of the vagina). It can be pain around the inner thighs, upper legs and even around the anus (anus) and the urethra. Some women also have pain when they go to the toilet.

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

Duration of vulvodynia should be at least 3 months. The first signs can begin with minor unpleasant sensations. Then the pain can be localized or spread.

Stages

Stages of vulvodynia can be limited to a local reaction - it is localized vulvodynia, and when the process spreads further, the generalized stage develops. Although such a staged condition is conditional, but all the same to prevent the spread of the process it is necessary to treat when the first signs appear.

[24], [25], [26]

Forms

There are different types of vulvodynia. Unprovoked vulvodynia is a process in which pain is felt, regardless of external conditions and there are no provocations (gynecological examination, sexual relations). The burning sensation and soreness of the vulva can be continuous (unprovoked vulvodynia) or with a light touch, for example, from sexual intercourse or the use of a tampon (provoked vulvodynia). Women who had unprovoked vulvodynia were previously known to have a dyspeptic vulvodynia, where the pain was felt without touch. Vestiubulodinia is a term that replaces vestibulitis, when the pain is felt with a light touch.

Dysentic vulvodynia develops with a violation of sensitivity in the vulva and vagina. In addition to the symptoms of vulvodynia, there is an increased sensitivity in the genital area, most often due to surgical interventions or traumatic births. This condition is the cause of vulvodynia, as a result of irritation or hypersensitivity of the nerve fibers of the skin. Abnormal signals of nerve fibers from the skin are felt as a feeling of pain in a woman. This type of pain can occur even if there are no irritations in this area. Dysentic vulvodynia usually occurs in women who are prone to the postmenopausal period. The pain that occurs in women with this subtype of vulvodynia usually represents a diffuse, irresistible, burning pain that is not cyclic. Patients with diesel vulvodynia have less dyspareunia. Hyperesthesia is believed to be due to altered skin perception.

Constant vulvodynia is one of the most severe forms, because symptoms affect a woman all the time. Idiopathic vulvodynia is one whose cause is unknown. This kind of pathology can be attributed to young girls and women who have no associated problems and pathologies.

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

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, because they treat herpetic infection and the symptoms of vulvodynia gradually decrease.

Candida vulvodynia is associated with frequent candidiasis infections, so the identification of candida in women makes it an etiological factor.

Vulvodina in postmenopause is most common. This is due to several factors - during this period, the number of estrogen decreases in women. This factor leads to disruption of mucosal trophism in the vagina and vulva, and this leads to dryness. It is this that can cause painful sensations, and in the initial stages, when there are no changes in the mucous, vulvodynia appears.

Vulvodynia and pregnancy is a frequently discussed problem, because it is important whether this syndrome will not harm a child and whether pregnancy itself can cause vulvodynia.

Studies show that women who have vulvodynia can have a normal pregnancy, and that in some cases, the severity of pain decreases during pregnancy. However, women with this disease often have a cesarean section.

[27], [28], [29], [30], [31]

Complications and consequences

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

[32], [33], [34], [35], [36]

Diagnostics of the vulvodynia

The diagnosis of vulvodynia depends on carefully collected anamnesis, after all, subjective sensations are very important in this case, and then confirm physical examination. An anamnesis should include information about the onset and nature of pain, provoking and releasing factors, medical evaluation at the moment, and attempts at treatment and their impact on pain. Sometimes a woman may not know that the sensitivity is in the vulva area and she can describe the pain as a pain in the vagina or pelvis.

Physical examination is an important part of the diagnostic process. As a rule, you can not see anything at the examination, since the problem is in the nerve fibers themselves, which are not visible on the skin. Vulva can be erythematous in women with vulvodynia, but the presence of a rash or altered mucosa or skin is not consistent with vulvodynia and requires further evaluation or biopsy. Vaginal examination should be done to exclude other common causes of vulvovaginal discomfort (eg, candidiasis, bacterial vaginosis).

Once cutaneous and mucosal diseases have been excluded in patients with three or more months of vulvar discomfort, a cotton swab test is required. Using a moistened swab, the vulva is tested starting from the hips, and moves medially (an area located outside the hymen). In this area, palpation is carried out in the area of 2, 4, 6, 8 and 10 hours using light pressure. The patient is offered to assess pain on a scale of 0 to 10 (0 = no pain and 10 = severe pain when worn).

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

Analyzes are used infrequently, only to exclude vaginosis and study the flora of the vagina. There are no specific tests confirming vulvodynia, and the diagnosis is made on the basis of characteristic symptoms. However, since vulvar and vaginal infections (yeast infection, bacterial vaginosis, vaginitis) are sometimes associated with pain and itching, cultures or other diagnostic tests can be ordered to exclude infections. Even if there is no clear evidence of infection, it is necessary to take a sample of cells from the vagina to check for an infection, such as a yeast infection or bacterial vaginosis. The analysis includes a smear test on the culture of bacteria and yeast, as well as blood tests to assess the levels of estrogen, progesterone and testosterone.

Instrumental studies are also used for differential diagnosis. A doctor can use a special magnifying device for colposcopy.

Biopsy is one of the methods of excluding malignant processes. When a biopsy is performed, the doctor first treats the genital area with painkillers, and then a small piece of tissue is taken for examination under a microscope.

[37], [38], [39], [40], [41], [42], [43]

Differential diagnosis

Differential diagnosis is performed to exclude objective causes of pain in the vulva. As noted above, biopsies, cultures, or both should be used to rule out other causes of pain or vulvar irritation, including atypical candidiasis, bacterial vaginosis, trichomoniasis, and herpes simplex.

Vestibulodinia is a pain in contact with the mucosa, which is caused more often by sexual intercourse. Vulvodina has no specific cause and worries, regardless of irritation.

Another pathology with which to differentiate vulvodynia is vulvitis. This is a focal inflammation of the vulva area. It is characterized by input dyspareunia, discomfort at opening the vagina, positive smear analysis, soreness localized inside the vulva, and focal or diffuse vestibular erythema.

Vestibulitis is one of the frequent causes of pain, therefore, also carry out differentiation. 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, apparently, are caused by yeast vaginitis.

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

Vulvar dermatosis and vulvovaginosis include mucosal damage. Erosions or ulcers can be the result of excessive irritation. If the patient has blisters or ulcers, scratches, the cause may be a blistering disease. Differential diagnoses of papular-ray lesions and vesicouretic lesions should be carried out at the initial stage, with the exclusion of the causes of vulvodynia.

Symphysitis is an inflammation of the symphysis that can cause painful sensations. But at the same time there is a localization of pain and with palpation of the symphysis the pain intensifies.

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

Dyspareunia is pain in intercourse. Can accompany vulvodynia, and can be a separate diagnosis.

[44], [45], [46], [47], [48], [49]

Treatment of the vulvodynia

Vulvodynia can be cumulated both by treatment and by household remedies. Not all treatments will be effective for every woman, and a woman may have to try different treatments to find the most effective option for her.

Despite surgical treatment, pharmaceutical therapy, psychological treatment, physical therapy and biological therapy and behavioral modification, there is still no consensus as to which procedure or procedures gives the maximum. A combination of treatments is often used, and although there are several options for treating vulvodynia, much of the literature supports the conclusion that vulvodynia treatment is unusual and a particular inciting 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 emphasizes the need to study this condition.

Analgesics for vulvodynia are one of the means of symptomatic therapy, however, conventional medications here will be ineffective. 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 was seen in retrospective studies. When used in older populations, it is recommended to start with lower doses. It is recommended to avoid use in patients with cardiac abnormalities, and a sharp discontinuation of medication is not recommended.

1. Amitriptyline is a drug from a group of tricyclic substances that, in addition to vulvodynia symptoms, can relieve stress, improve sleep and reduce anxiety, which in one way or another is associated with this problem. The dosage of the drug increases by accretion, with postpenny withdrawal. The recommended regimen begins with 10 mg per day, gradually increasing to 40-60 mg per day. Patients should continue to take the highest tolerated dose, which alleviates the symptoms within four to six months, and then gradually reduces the dosage to the minimum amount necessary to control the symptoms. Side effects of the drug are frequent - it is 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 pill before bed. If it causes drowsiness in the morning, and it's hard for you to get out of bed, try to pick up the dosage a little.
2. Hormonal therapy vulvodina is used more often in postmenopausal women, when additional hormone therapy is needed to correct other symptoms. Often use preparations of estrogens, or if necessary combine them with progesterone. Therapy with potent topical corticosteroids should be limited to short-term use.

Premarin is a preparation of the estrogen series. It is used with vulvodynia, when there are violations of trophic mucosa and dryness of the vulva. Dosage of the drug - one tablet once a day for the 21st day, and then a break for 10 days. Method of administration is oral. Side effects with long-term use are telangiectasias, loose skin, groove formation and slight bruising. Powerful steroids can also cause overdosed dermatitis, an inflammatory reaction with erythema, and a burning sensation that occurs when the steroid is removed.

1. Neo pentotrans is a combined remedy, which includes metronidazole (an antibacterial agent) and miconazole (an antifungal drug). This remedy can be used with vulvodynia, the etiology of which is associated with infection. It is believed that some types of vulvodynia are a reaction to yeast, which can from time to time be detected and not detected during examination. Therefore, if yeast is found, then this preparation can be used. The method of application of the drug is intravaginal, the dosage is one suppository at night for seven days. Since mainly local action is manifested, the side effects are burning or itching.
2. Ointments with vulvodynia are used as local anesthetics. Medications, such as lidocaine ointment, can provide temporary relief of symptoms. Women can be recommended to use lidocaine 30 minutes before sexual intercourse to reduce your discomfort. Side effects are manifested in local reactions. It often happens when the use of lidocaine starts to cause a burning sensation, which can last several minutes before it relieves pain. Try to give the lidocaine time to work, but if the burning continues for 10 minutes, rinse it thoroughly.

Physiotherapy in the treatment of vulvodynia is also widely used. Two methods that are currently being investigated are neurostimulation and a spinal infusion pump. Neuro-stimulation involves the delivery of low-voltage electrical stimulation to a particular nerve. This can replace pain with a tingling sensation. The spinal infusion pump is an implanted device that can deliver drugs with a low dose to the spinal cord and neural roots. It can dull the pain.

A physiotherapist can teach a woman exercises (for example, compress and release the pelvic floor muscles) to help relax the muscles around your vagina. Since spasm of the vaginal muscles aggravates the pain and discomfort of vulvodynia, physical therapy using biofeedback and gynecological instruments has been successful in many patients. Biological feedback training helps patients learn the exercises to strengthen weakened pelvic floor muscles and relax those same muscles, which leads to less pain.

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

Home treatment

Treatment in the home, first of all, implies some recommendations, simple following which can significantly reduce the symptoms of vulvodynia.

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

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

Use the sessile tubs. Two or three times a day, sit in a comfortable, warm (not hot) or cool water with Epsom salts or colloid oat flour for 5-10 minutes.

Avoid pulling pantyhose and nylon underwear. Tight clothing restricts the airflow in the genital area, which often leads to an increase in temperature and humidity, which can cause irritation.

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

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

Do not use deodorized swabs. Deodorant can be annoying. If tampons are irritating, switch to 100 percent cotton pads.

Avoid actions that put pressure on your vulva, for example, on a bicycle or riding.

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

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

Psychosexual counseling is helpful when pain affects the intimacy between you and your partner. This is a type of therapy whose purpose is to solve problems such as fear and anxiety about sex, and restore a physical relationship with your partner.

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

Try to reduce stress, since it can increase the pain of vulvodynia read several relaxation tips to relieve stress. To correct the pain that occurs when sitting, using a pillow in the shape of a donut can help.

Vulvodynia can cause dramatic changes in lifestyle. This can reduce a patient's ability to walk, exercise, sit for a long time or engage in sexual activities. All these normal actions can aggravate the pain of the vulva. Many women with vulvodynia were diagnosed with a psychological problem due to lack of physical activity. Patients may be worried or angry because the diagnosis is delayed after numerous visits to the doctor, and as their problems increase, it can be a serious health problem. Many patients with vulvovodinia worry that they will never be able to recover. Patients should be supported with the recognition that vulvodynia is not a psychosomatic condition and that it does not have a predisposition to cancer or other life-threatening conditions. It should be clarified that the improvement will occur with appropriate treatment, but successful treatment may take months or years, and patients may have periodic exacerbations and remissions. Many patients receive assistance from referral to a group that provides information and emotional support.

Treatment with herbs and homeopathy for this pathology has no proven effectiveness.

Surgical treatment should be used in cases when all forms of treatment failed. Many cases of vulvodynia that do not respond to drug therapy respond to vulvovectomy or laser treatment. Vestibuloectomy or surgical removal of the vulva tissue containing the vestibular glands facilitates symptoms in two thirds of patients. Complications of operations include wound hematoma, partial or complete wounding, uneven healing, requiring minor revision, and stenosis of the Bartholin duct to form a cyst. In cases of localized vulvodynia or vestibulodynia, surgery to remove the affected skin and tissues (vestibulmectomy) relieves pain in some women.

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

How to live with vulvodynia? In most cases this condition is treated with several methods of treatment.

Prevention

Prevention can be complex, because the cause of this disorder is not clear. But annual preventive examinations at the gynecologist can be one of the best means of preventing many pathologies, including vulvodynia.

[50], [51], [52], [53], [54]

Forecast

The prognosis for recovery from vulvodynia is unclear until the end. Many women complain of this disorder for many years, and it is traditionally considered chronic. However, recent evidence suggests that about half of women who reported that they had prolonged pain in the vulva no longer have vulvodynia symptoms. Therefore, it is reasonable to think that the symptoms of a significant proportion of women with this disorder may decrease. The prognosis for women receiving appropriate treatment is good enough.

Vulvodynia refers to pain in the vulva and vaginal opening, for which no reason can be identified. Symptoms of pathology are very pronounced and can affect the daily activity of a woman. Since many women can not pay attention to this symptom, it is important to know that it is better to consult a doctor, because early treatment is more effective.