Vulvar Discomfort Research Articles

Screening for Neuropathic Pain, Anxiety and Other Associated Chronic Pain Conditions in Vulvodynia: A Pilot Study

Vulvodynia has been defined by the International Society for the Study of Vulvovaginal Diseases (ISSVD) as vulvar discomfort, which is most often described as a burning pain, occurring in the absence of relevant visible findings or a specific, clinically identifiable, neurological disorder (1). Much remains to be understood regarding the patho genesis, natural history, and management of this distressing condition. As postulated for many chronic pain syndromes, the involvement of both peripheral and central sensitization mechanisms in the pathogenesis of vulvodynia has been suggested (2, 3). The characteristics of the pain experienced by patients with vulvodynia suggests the involvement of a neuropathic component in vulvodynia; this includes: hyperalgesia, paraesthesia, dysesthesia and allodynia. In addition, the ineffectiveness of common pain-killers, the effectiveness of certain anticonvulsants (4), anti-depressants and transcutaneous electrical nerve stimulation (TENS) (5) are occasionally reported in association with vulvodynia. The primary objective of the present study was to generate further evidence in support of the existence of a neuropathic component underlying the pathogenesis of vulvodynia. An additional aim was to determine the presence of anxiety, depression and other chronic pain conditions in patients with vulvodynia.

Update on the diagnosis and treatment of vulvodynia

ContextVulvodynia is a complex and multifactorial clinical condition. It is defined as chronic vulvar discomfort characterized by burning, stinging or irritation. Its diagnostic difficulty and treatment are known. ObjectivesTo review the medical literature of the last 10 years from a critical point of view. Evidence acquisitionA search was made in “Medline/Pubmed” and the Cochrane Library using the terms “vulvodynia” and “vestibulodynia” to which “etiology,” epidemiology, “diagnosis”, “neurophysiological test” and “treatment or management,” were added. Evidence synthesisIn spite of the advances achieved in all of the aspects of vulvodynia, the methodology used at present in many cases does not have the desirable statistical soundness: there are few control or placebo-controlled groups and double-blind studies. Uniformity is lacking in the scales, indexes and questionnaires for the correct evaluation of pain before and after the treatment and debatable diagnostic criteria are used. The limited use of neurophysiological diagnostic resources that validate the clinical findings has been observed in the studies analyzed. In most of the works, the medical treatments have been shown to be ineffective. Physiotherapy and cognitive-behavioral therapy seem to be promising therapeutic tools. Surgery (vestibulectomy) stands out by its demonstrated efficacy in the publications studied. ConclusionsA multidisciplinary approach is always necessary. Topical medical, psychological, and physical therapy treatments may have some added effects and become an alternative to surgery. New pathways of research and more regulated studies are required.

Puesta al día en el diagnóstico y tratamiento de la vulvodinia

ContextVulvodynia is a complex and multifactorial clinical condition. It is defined as chronic vulvar discomfort characterized by burning, stinging or irritation. Its diagnostic difficulty and treatment is known. ObjectivesTo review the medical literature of the last 10 years from a critical point of view. Evidence AcquisitionA search was made in Medline/Pubmed and the Cochrane Library using the terms vulvodynia and vestibulodynia to which etiology, epidemiology, diagnosis, neurophysiological test and treatment or management, were added. Evidence SynthesisIn spite of the advances achieved in all of the aspects of vulvodynia, the methodology used at present in many cases does not have the desirable statistical soundness: there are few control or placebo-controlled groups and double-blind studies. Uniformity is lacking in the scales, indexes and questionnaires for the correct evaluation of pain before and after the treatment and debatable diagnostic criteria are use. The limited use of neurophysiological diagnostic resources that validate the clinical findings has been observed in the studies analyzed. In most of the works, the medical treatments have been shown to be ineffective. Physiotherapy and cognitive-behavioral therapy seem to be promising therapeutic tools. Surgery (vestibulectomy) stands out by its demonstrated efficacy in the publications studied. ConclusionsA multidisciplinary approach is always necessary. Topical medical, psychological and physical therapy treatments may have sum effects and become an alternative to surgery. New pathways of research and more regulated studies are required.

�Vulvar syringoma: A rare case report�

SUMMARY Syringomas are intraepidermal eccrin sweat gland adenomas which can usually be seen in adolescent ages. Typical involvement includes the malar areas and the lower eyelids, however vulvar involvement is rare. These lesions are characterized with papules which are small, yellowish, firm seperated from each other and can be 1-5 mm in diameter, and are often associated with increased vulvar discomfort and itching. The lesions are generally multiple, bilateral and symmetrical. A 35-year-old woman presenting with a 3-year history of vulvar papules, sometimes itching and increasing in time is presented to our clinic. The patient has been diagnosed as syringoma with clinical and histopathological results. Due to the fact that the patient is symptomatic, we preferred laser vaporization as a treatment option and presented our case with the preoperative and postoperative pictures.

Vulvodynies et douleur pelvipérinéales chroniques

To define vulvodynia and to describe the main approaches to treatment. Review of the literature concerning vulvodynia. Vulvodynia is defined as chronic vulvar discomfort, usually with a burning nature, with no relevant clinical lesions and no clinically identifiable neurological lesion. Localized provoked vulvodynia essentially affects young women and is responsible for major sexual and psychological repercussions. Treatment consists of local anaesthetics, drugs used to treat neuropathic pain, physiotherapy and psychotherapy. Vestibulectomy is only very rarely indicated. Many unknowns persist especially concerning the aetiology of vulvodynia. Evaluation of symptoms and treatment have not been clearly defined. However, symptomatic management provide satisfactory long-term results.

Pre-ramus passage of inside–out transobturator sling

Groin pain after transobturator tape is not uncommon. Differential diagnosis and treatment strategies are becoming elaborated in the literature. A patient presented with partial improvement in her stress incontinence and persistent groin and vulvar discomfort for 3months after "inside-out" transobturator tape. The sling was removed secondary to malposition anterior to the inferior pubic ramus, i.e., a trans-vulvar passage. Her vulvar and groin complaints resolved. Recommendations are made to facilitate the "inside to out" transobturator dissection and trocar passage to prevent this complication.

Case Report: Vulvar Lichen Sclerosus in a Premenarchal Girl with a Complicated Biopsy

Lichen sclerosus is a T-lymphocyte mediated chronic cutaneous disorder with predilection for the vulva. In prepubertal girls, lichen sclerosus presents as vulvar discomfort, pruritus, bruising/bleeding, discharge, dysuria, or painful defecation. Diagnosis and treatment of lichen sclerosus is of utmost importance in the prevention of complications such as scarring, adhesions, atrophy, or long-term sexual dysfunction. We discuss a case of a 4-year-old female with an atypical presentation of genital lichen sclerosus and a complicated biopsy.

Vulvodynia in Preadolescent Girls

Although vulvodynia occurs in approximately 7% of adult American women, we hypothesize that vulvodynia also occurs in young girls and that they respond to treatments that are similar to those used in women with this disorder. This is a retrospective case study of vulvodynia in preadolescent girls seen in our referral practice. Records of all office visits and any telephone or e-mailed follow-up were reviewed. Between October 1996 and April 2006, 6 girls ages 4 to 11 years were evaluated and diagnosed with vulvodynia. Pain had been present for several months to 7 years, and most patients had been seen by several physicians before having this diagnosis made. Treatment was typically initiated with a tricyclic antidepressant, and 5 of the 6 girls noted improvement in their symptoms, including 2 who had marked improvement, and another 3 with substantial improvement who were able to discontinue therapy without a recurrence. Vulvodynia does occur among young girls and, when treated as a neuropathic pain disorder, was found to dramatically improve or remit in the majority of those treated in this small case series. This underrecognized disorder should be considered in cases of ongoing vulvar discomfort, regardless of age.

Vulvar Pruritus and Burning Sensation in Women with Psoriasis

Approximately 80% of psoriatic individuals experience pruritus, of varying intensity. This study evaluated the frequency of vulvar itching and burning and its influence on well-being in women with psoriasis. A total of 93 women were included in the study. Psoriasis severity was assessed according to the Psoriasis Area and Severity Index, the intensity of vulvar discomfort by visual analogue scale and depressive symptoms by Beck's Depression Inventory. On admission 41 (44.1%) women experienced vulvar discomfort, 18 (19.4%) itching, 10 (10.8%) burning and 13 (14.0%) both itching and burning sensations. Psoriatic lesions on the vulva were found in 22 (23.7%) women. No significant correlation was found between burning or itching intensity and global psoriasis severity (r = 0.19, p = 0.26). Patients with vulvar discomfort had psoriatic lesions on the vulva more often than women without discomfort (43.6% vs. 8.2%, p < 0.001). In addition, patients with vulvar discomfort more frequently demonstrated depressive symptoms (p < 0.05). We conclude that vulvar discomfort is an important clinical problem in women with psoriasis and should be taken into consideration during treatment.

Vulvodynia: Strategies for Treatment

Introduction In 2003, the International Society for the Study of Vulvovaginal Disease (ISSVD) revised its definition of the frequently used and well-accepted term ‘‘vulvodynia.’’ The new classification acknowledges that vulvar pain can be attributed to diagnosable disorders such as infections, dermatologic disorders, neoplastic processes, and neurologic disorders. The other category is vulvodynia, pain not related to a specific, identifiable disorder. Vulvodynia is often described as a vulvar discomfort with sensations of burning, irritation, or rawness. In addition, the ISSVD further expanded its classification of vulvodynia into generalized and localized pain. These categories are further subdivided to provoked pain or unprovoked pain. Additionally, there is a category for pain that is both provoked and unprovoked (mixed). Vestibulodynia (previously termed vestibulitis) is a pain localized to the vestibule. The suffix ‘‘-itis’’ has been excluded from the recent ISSVD terminology because studies found a lack of association between excised tissue and inflammation. Other terminologies have classified vestibulodynia as primary or secondary; in the primary subset, the pain has been present since the first tampon use or intercourse, and with secondary vestibular pain, women have had painless tampon insertion or intercourse, then the vestibular pain develops at a later time.

Vulvite d’hypersensibilité aux protéines séminales : 3 cas

Contact sensitivity deserves to be assessed in acute vulvitis as well as chronic vulvar dermatitis with a specific orientation toward semen allergy whenever the pathology is post-coital. Three observations of semen allergy are reported. Two women presented with post-coital vulvitis due to delayed hypersensitivity to semen proteins without associated specific IgE. The type 2 allergy was confirmed by positive patch-tests and disappearance of symptoms when using condoms. Another woman presented with oedematous vulvitis associated with asthma and malaise per and post-sexual intercourse. Positive prick-tests with husband's semen and blood tests for specific IgE led to the diagnosis of type 1 hypersensitivity to semen, with disappearance of both vulvar and systemic symptoms with the use of condoms. Immediate or delayed type hypersensitivity may be discovered using prick and patch tests respectively. The observation of vulvitis or vulvar discomfort should promote such investigations, whenever a post-coital chronology is suggested. The good clinical pertinence of positive skin tests must be emphasized. Although type I hypersensitivity to semen is documented in the literature, with easy detection of specific IgE, delayed type 2 allergy presents as an as yet under-diagnosed etiology of post-coital vulvitis. Patch tests may help to confirm that contact dermatitis may be due to seminal proteins.

The Vulvodynia Guideline

To provide a review of the literature and make known expert opinion regarding the treatment of vulvodynia. Experts reviewed the existing literature to provide new definitions for vulvar pain and to describe treatments for this condition. Vulvodynia has been redefined by the International Society for the Study of Vulvovaginal Disease as vulvar discomfort in the absence of gross anatomic or neurologic findings. Classification is based further on whether the pain is generalized or localized and whether it is provoked, unprovoked, or both. Treatments described include general vulvar care, topical medications, oral medications, injectables, biofeedback and physical therapy, dietary changes with supplementations, acupuncture, hypnotherapy, and surgery. No one treatment is clearly the best for an individual patient. Vulvodynia has many possible treatments, but very few controlled trials have been performed to verify efficacy of these treatments. Provided are guidelines based largely on expert opinion to assist the patient and practitioner in dealing with this condition.

Treatment of Undifferentiated Vulvar Intraepithelial Neoplasia With 5% Imiquimod Cream

To assess the efficacy of 5% imiquimod cream on undifferentiated vulvar intraepithelial neoplasia (VIN), a disease caused by high-risk human papillomavirus. Prospective, uncontrolled study. University hospital vulvar clinic. Patients Twelve consecutive patients treated with 5% imiquimod cream for undifferentiated VIN between March 1, 1999, and May 31, 2001. Self-application of 5% imiquimod cream, initially 3 times a week, then adjusted according to tolerance, for up to 7 months according to clinical response. Therapeutic response, clinically assessed by successive photographs and histologically confirmed for complete responders, was scored as complete, partial (> or =50% decrease in lesion size), or failure. Tolerance was evaluated at each visit. A total of 3, 4, and 5 patients achieved complete response, partial response (> or =75% reduction in lesion size for all such cases), and failure, respectively. Mean duration of treatment was 3.6 months (37.3 applications), 5.0 months (50.7 applications), and 3.4 months (25.2 applications) for complete responders, partial responders, and failures, respectively. Follow-up after treatment was 5 to 18, 14 to 32, and 2 to 28 months, respectively, with 1 partial responder lost to long-term follow-up. No patient developed invasive carcinoma. All but 2 patients experienced vulvar discomfort, resulting in treatment withdrawal for 3. Two patients had flulike symptoms. Imiquimod cream could be a therapeutic option for undifferentiated VIN. Although poorly tolerated, this self-applied treatment could spare patients, either totally or partially, the classic painful and sometimes mutilating treatments of VIN. Controlled, randomized studies are needed to evaluate its efficacy and tolerance.

Vulvar Discomfort in Hospitalized Dermatological Patients – Preliminary Results

Background: The frequency and importance of pruritus vulvae and vulvodynia are frequently underestimated. We conducted a survey to examine the prevalence and characteristics of these complaints. Methods: Using a questionnaire which we developed, patients hospitalized at the University Dermatology Clinic Halle were questioned about any vulvar complaints and their characteristics. Results: 108 questionnaires were evaluated. Of the respondents, 27 (25.2%) had current or past genital problems. Vulvodynia was present in 3, pruritus vulvae in 16, and both symptoms (pain and itching) in 8 patients of this group. Pain was described as burning or stabbing. Dyspareunia was, however, only reported by 7 patients. While the symptoms disappeared within a week in 10 patients, the duration of complaints in 10 other cases was 1–6 months, and even longer than 6 months in another 3 cases. The patients showed a surprising willingness to talk about their problems. Only 4 patients did not talk about their complaints. Conclusion: Current and chronic vulvar complaints are apparently frequent in hospitalized patients in a dermatological clinic. The assumption that such complaints are taboo does not appear to be confirmed. However, in taking a patient’s history, specific questions about genital problems should be asked.

Fungal Culture Findings in Cyclic Vulvitis

In Brief Objective To estimate the prevalence of fungal infection in cyclic vulvitis. Methods We retrospectively reviewed 40 cases of cyclic vulvitis. We examined the historic characteristics, physical findings, and laboratory results in this population, including the results of potassium hydroxide preparations of vaginal secretions and fungal cultures. Results The median age was 32 years and the mean duration of symptoms was 3.8 years. Thirty women (75%) reported prior antifungal therapies. Fungal cultures were positive in 24 of 39 (61.5%). Candida albicans was the species isolated in 13 of 24 cases (54%). Potassium hydroxide wet mounts contained evidence of fungal infection in 15 of 37 cases (40.5%). The sensitivity of the potassium hydroxide preparation was only 61%. Potassium hydroxide preparations were more sensitive when the species isolated was C albicans. Conclusions Many women with cyclic vulvitis have positive vaginal fungal cultures. Potassium hydroxide preparations of vaginal secretions are not sufficiently sensitive to exclude fungal infection in this setting, possibly because of the relatively high incidence of fungal species other than C albicans. Fungal culture should be considered in the evaluation of women with recurrent episodes of vulvar discomfort, even when potassium hydroxide wet mounts do not contain fungal elements. Vaginal fungal cultures are positive in 61.5% of women with cyclic vulvitis.

Fungal culture findings in cyclic vulvitis

Objective: To estimate the prevalence of fungal infection in cyclic vulvitis. Methods: We retrospectively reviewed 40 cases of cyclic vulvitis. We examined the historic characteristics, physical findings, and laboratory results in this population, including the results of potassium hydroxide preparations of vaginal secretions and fungal cultures. Results: The median age was 32 years and the mean duration of symptoms was 3.8 years. Thirty women (75%) reported prior antifungal therapies. Fungal cultures were positive in 24 of 39 (61.5%). Candida albicans was the species isolated in 13 of 24 cases (54%). Potassium hydroxide wet mounts contained evidence of fungal infection in 15 of 37 cases (40.5%). The sensitivity of the potassium hydroxide preparation was only 61%. Potassium hydroxide preparations were more sensitive when the species isolated was C albicans. Conclusions: Many women with cyclic vulvitis have positive vaginal fungal cultures. Potassium hydroxide preparations of vaginal secretions are not sufficiently sensitive to exclude fungal infection in this setting, possibly because of the relatively high incidence of fungal species other than C albicans. Fungal culture should be considered in the evaluation of women with recurrent episodes of vulvar discomfort, even when potassium hydroxide wet mounts do not contain fungal elements.

Evaluation of the surgical treatment of vulvar vestibulitis

Objective: To assess the efficacy of perineoplasty in the management of vulvar vestibulitis. Study design: Forty-two women who had undergone operative perineoplasty for the treatment of vulvar vestibulitis completed a questionnaire, a mean of 4.8 years postoperatively. Results: Vulvodynia was constant or daily in 29 (69%) before surgery and in eight (19%) of respondents after surgery. In all, 27 (80%) of 34 women who had preoperative vulvar discomfort reported that the discomfort was much better or absent following surgery. Before surgery, 26 (70%) of 37 women who were not celibate for reasons other than vulvar vestibulitis, were celibate because of vulvar vestibulitis or always had pain during coitus and sometimes had to discontinue coitus because of pain. In contrast, only two (5.7%) of 35 women had this degree of dyspareunia following surgery. Similarly, 28 (85%) of 33 sexually active women who had dyspareunia before surgery reported that intercourse was much less painful or pain-free following surgery. Conclusion: Perineoplasty has a role in the management of vulvar vestibulitis for women who do not achieve satisfactory relief of vulvodynia and/or dyspareunia with nonoperative treatments.

Vulvodynia and its differential diagnoses.

Vulvodynia is the symptom of chronic vulvar discomfort characterized by the patient's complaint of burning and sometimes stinging or rawness. It is a multifactorial problem in which no single etiologic factor or pathogenetic mechanism has been identified. Patients with vulvodynia exhibit several features of neuropathic pain, such as allodynia, hyperalgesia, dysesthesia, and chronic pain in the absence of ongoing noxious stimuli. The treatment of vulvodynia has, in the past, focused on irradicating suspected infective causes, such as human papillomavirus, with varying success. More recently, approaches mimicking the therapy of other chronic pain syndromes, eg, the use of low-dose antidepressants, has met with some success. There is a need for uniformity in terminology and therapeutic approach, epidemiologic studies, and controlled trials to advance our management of this problem.

Benign enlargement of the labia minora: report of two cases

2 cases of bilateral hypertrophy of the labia minora are recorded. The patients presented with vulvar discomfort and redundant labia and reduction vulvoplasty was carried out. The resected specimens showed marked hyperplasia of the non-hair-bearing sebaceous glands, acanthosis, keratosis, and hyperpigmentation of the epithelium and a variable degree of neoangiogenesis and fibrosis in the upper dermis. No cause was established clinically or pathologically. The etiology and pathogenesis of this condition are briefly discussed.