Tackling vulvodynia

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ORIGINAL ARTICLE, p 617 Women with vulvodynia often attend vulval clinics and consult dermatologists. Vulvodynia has been defined by the International Society for the Study of Vulvar Disease as vulval discomfort, most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder.1 Patients can be further classified by the anatomical site of the pain (e.g. generalized vulvodynia, hemivulvodynia, clitorodynia) and also by whether pain is provoked or unprovoked. There are many issues with women with chronic vulval pain, and psychological and psychosexual morbidity is not uncommon. The ideal treatment package is a multidisciplinary approach with the clinician assessing the patient, making a diagnosis and starting basic management. Referral to other health professionals, e.g. for psychosexual counselling, pain management and physiotherapy, may be necessary depending on the individual needs of the patient. Recently the British Society for the Study of Vulval Diseases published guidance on the management of women with vulvodynia recommending this multidisciplinary approach.2 As dermatologists are seeing patients at the initial referral, it may be appropriate for them to triage these patients and remain as a ‘lead’ for those who might need to see two or three different health professionals. Patients frequently complain that their care is disjointed. The paper by Pelletier and colleagues3 is of great interest as it gives credibility to the use of physical agents in the management of women with provoked vestibulodynia where sexual pain is the main problem. The phenomenon of allodynia within the vestibule in these patients is hard to overcome. Current strategies focus on desensitization with massage, biofeedback or psychosexual counselling to help make the patient less phobic about vulval touch. No perfect study addresses all these issues and it would be difficult as women with provoked vestibulodynia are a heterogeneous group. Local effective medical treatments for allodynia remain elusive and include topical anaesthetic gels and surgery (modified vestibulectomy); this latter is carried out less frequently in recent years. There is some evidence that intralesional injections into the vulva may be of benefit in patients with provoked vulvodynia, and various drugs have been suggested. Murina et al.4 gave subcutaneous injections of 40 mg methylprednisolone acetate and 10 mg of lidocaine hydrochloride in 10 mL of normal saline into the vestibule in 22 women with vestibulodynia. Follow up was for a period up to 2 years. In their results they state that 15 women (68%) responded ‘favourably’ to the treatment, and 32% with complete remission, which was said to occur about 15 days after treatment. It is worth noting that these favourable results are comparable with those achieved with less invasive, and less time consuming (for the patients) options. Similar positive results were obtained in trials looking at betamethasone and lidocaine infiltration.5, 6 Botulinum toxin A injections, as suggested in this paper, can now also be considered for these patients, and its use in the treatment of chronic pain has been well documented especially in the treatment of muscle hypertonicity. It remains important to make an accurate diagnosis and ensure that dermatological conditions of the vulva are excluded before making such a diagnosis of vulvodynia. In a paper by Bowen et al.7 61% of patients with ‘vulvodynia’ actually had a relevant dermatological condition of the vulva and were rediagnosed after a biopsy. If botulinum toxin A is to be used then a multidisciplinary approach combining this treatment with physiotherapy and/or psychosexual therapy should also be considered. Funding sources None. Conflicts of interest None declared.