IC and Vulvar Pain

VULVAR PAIN

What is Vulvodynia?

The term vulvodynia is derived from "vulva" and the Greek word "odynia" meaning pain (pronounced vul-vo-DIN-ee-ah). There are two basic subtypes of vulvodynia, and they are not always easy to distinguish from each other:

Vulvar Vestibulitis Syndrome (vulvar dysesthesia localized in the vestibule)
Generalized Vulvodynia

There are several other conditions that cause chronic vulvar pain that may coexist with vulvodynia. The most common of these are:

Cyclic Vulvovaginitis: Recurrent burning and itching symptoms at the same stage of the menstrual cycle each month. Many women have cyclical bouts of yeast infections and some have other causes for their symptoms.
Vulvar Dermatoses: There are many dermatologic conditions that may cause pain in the vulva. The most common include: allergic or contact dermatitis, lichen sclerosus, lichen simplex chronicus and lichen planus. These conditions may cause symptoms of itching and burning. Scratching the vulva and overusing topical medications may inflame the tissue, causing swelling and additional pain.

Many doctors are still not familiar with vulvodynia and, as a result, patients are frequently misdiagnosed or go undiagnosed. The pain of vulvodynia isn't always accompanied by visible skin changes and sometimes patients are told, "It's all in your head." But the condition is very real.

THE VULVA

The vulva is considered to be the visible parts of the female genitalia. The parts most often affected by vulvodynia include the inner labia; the clitoral glans; the paraurethral (Skene's) glands located on each side of the urethral opening; the vulvovaginal (Bartholin's) glands located on each side of the vaginal opening; the membranes surrounding the vaginal opening (called the "introitus"); small "minor" vestibular glands around the vaginal opening; and the hymen.

DIAGRAM OF VULVAR ANATOMY

VulvarDiagram (19869 bytes)

Careful diagnostic evaluation is important in order to distinguish these conditions from each other, from other conditions with similar symptoms, and to choose the most effective treatment.

Vulvar Vestibulitis Syndrome - Inflammation around the "vestibule," or opening to the vagina. This condition may occur alone or in combination with other types of vulvar pain. Symptoms of vulvar vestibulitis include sensations of burning, dry, raw, or tight skin, and may range from mild to severe. Pain is usually caused by external touch, or by pressure caused by intercourse, tampon insertion, tight pants, bicycling or horseback riding. A minority of patients, however, may have symptoms without touching or pressure. Some patients with vulvar vestibulitis only have discomfort with intercourse. Others are uncomfortable on a daily basis and find it difficult to sit or walk. Some women cannot tolerate intercourse, while others can, although there is usually some degree of discomfort. Women with severe, enduring pain may develop vaginismus, which is a spasm of the pelvic floor muscles that makes intercourse or tampon insertion difficult or impossible.

Generalized Vulvodynia - Vulvar pain caused by irritated or inflamed nerves. Pain may encompass the inner labia, or may extend beyond the vulva to the anus or groin area, or down the inner thighs. Some women experience sharp pains or deep aching.

WHO GETS VULVODYNIA?

In 2003, the first comprehensive analysis of vulvodynia was reported in the April 2003 issue of The Journal of the American Women's Medical Association. Researchers found that the prevalence of vulvodynia had been significantly underestimated. Based on survey data, the researchers conservatively estimate that approximately five percent of all women will experience this condition before age 25, and it is likely that the actual number of women affected is much larger. Contrary to earlier assumptions, white and African American women reported similar incidence rates. However, Hispanic women were shown to be 80 percent more likely to experience symptoms compared to white and African American women.

Most patients are of childbearing age, but young girls and postmenopausal women can get the condition as well. Vulvar vestibulitis and generalized vulvodynia are the most common forms of vulvodynia that occur in IC patients. A study published in the journal Urology (May '97) revealed that 10 percent of women with interstitial cystitis also have symptoms of vulvodynia.

WHAT CAUSES VULVODYNIA?

The precise cause of vulvodynia is unknown. Various theories suggest infection (viral, fungal, or bacterial); an allergic response to environmental irritants; an autoimmune response to the body's own chemistry; irritation ("dysfunction") of the muscles that support the bladder, uterus, and rectum (called the "pelvic floor muscles"); or irritation of the nerves that innervate the vulva. There is no evidence that vulvodynia is a sexually transmitted disease. However, Candida albicans (the cause of yeast infections) can be passed to your partner during sexual activity.

HOW IS VULVODYNIA DIAGNOSED?

The hallmark of vulvar vestibulitis syndrome is an exquisite sensitivity of the tiny gland openings at the entrance to the vagina when touched with a cotton-tipped applicator. This is called the "touch test." In addition, about two-thirds of patients with vulvar vestibulitis have visible, tiny red spots at these points. Others may have inflamed surface blood vessels that the doctor can see with the aid of a magnifying instrument called a colposcope.

In dysesthetic vulvodynia there may or may not be visible skin irritation and/or generalized sensations of irritation or burning upon touch or pressure. If skin rashes are present, their cause should be investigated.

Even when Candida is suspected of causing chronic vulvar irritation, it cannot always be seen on cultures. It is thought that some women with a history of Candida infections may develop a hypersensitivity to very low concentrations of Candida.

Vulvar dermatoses are skin disorders, but it is important to rule out overuse of medications (especially topical steroids), or infectious causes (such as herpes, human papilloma virus and allergic reactions). Skin lesions need to be evaluated and classified in order to choose the most effective treatment. A biopsy may be helpful in this category.

TREATMENTS

Like other chronic conditions, vulvodynia can have periods of flare and remission. At present, there are treatments that offer partial to complete relief, including:

Oral medications such as antihistamines including Atarax and Vistaril inhibit mast cells from releasing substances that can irritate mucous membranes.
Oral medications that may control dysesthetic vulvodynia caused by nerve irritation include tricyclic antidepressants such as Elavil and Tofranil, and anticonvulsants such as Tegretol and Neurontin. Pelvic Floor Therapy and/or Biofeedback may be used to help normalize pelvic muscle function.
>Topical Estrogen Cream may be used to soothe and moisten vaginal tissues. Please consult your doctor before using.
Interferon, an antiviral drug injected into the affected area, works best in patients who also have human papilloma virus.
Anti-Candida creams such as clotrimazole or azole. For stubborn cases, low dose, suppressive therapy of Diflucan once or twice a week may be required for several months.
A low-oxalate diet and supplements of calcium citrate. Oxalate crystals, which are normal by-products of the body's metabolism, are excreted in the urine. Oxalates are very acidic, and can irritate the mucous membranes of the vulva when overproduced. One theory maintains that an oxalate "insult" to the skin over a long period of time is the cause of vulvar pain. Calcium citrate alkalinizes the urine and suppresses the secretion of oxalates. A low-carbohydrate, low-oxalate diet may also be helpful. Examples of foods that are high in oxalates include all beans, beer, beets, berries, celery, chard, chocolate, eggplant, some grapes, green peppers, peanuts, rutabaga, spinach, squash and tofu.
Surgery removes the hypersensitive tissue of the vestibule and hymen. It works best for women with pure vulvar vestibulitis who experience pain only upon touch (tampon insertion, intercourse, etc.). Often considered as a last resort, surgery has a high success rate for appropriate candidates.

SELF-HELP TIPS

There are a number of self-help remedies that patients and their doctors have found that provide some relief or may prevent flare-ups or worsening of symptoms. These include:

Wear only cotton underwear and loose clothing. Try stockings and thigh-highs instead of pantyhose.
During sex, avoid the use of lubricants that contain preservatives and chemicals. Pure almond oil or vegetable oil or commercial lubricants with glycerin (such as Astroglide) are usually tolerated the best. Apply these at the initiation of sexual activity, since being touched is often as painful as intercourse itself.
Use only white or unbleached toilet tissue and 100 percent cotton fiber sanitary products.
Try baking soda soap for washing clothes. Wash new underwear before wearing and always rinse thoroughly after hand washing to remove soap residue. Avoid fabric softener liquids or dryer sheets.
Avoid the use of perfumed creams and soaps, Vaseline, oils, lanolin, bubble bath, bath oils or so-called "feminine deodorant" products.
Use a bidet (a low basin with a spray device used for washing the genitals) if one is available.
Rinse the vulva with clear water from a squeeze-bottle after urinating to help to ease burning.
Use baking soda douches to temporarily soothe inflamed areas.
Wash hair in the sink to avoid getting shampoo on the vulvar area while in the shower.
Place a compress of Aveeno (a powdered oatmeal bath treatment) over the vulva three to four times a day. Put two tablespoons of Aveeno in one quart of water. Mix in a jar and refrigerate. Patients report that this is especially helpful after intercourse or when symptoms are in a state of "flare."
Avoid contraceptive devices and creams that can irritate sensitive tissues.
Don't sit or remain in a wet bathing suit.
Avoid constipation or a full bladder, since any fullness may put pressure on the vulva. Exercise and lots of fiber from whole grains, fruits, and vegetables are the key to regularity. If this isn't enough, daily use of a psyllium product such as Konsyl may help.
Try applying a prescription of 5 percent lidocaine (Xylocaine) topical ointment to the vestibule 10 to 15 minutes before intercourse. This can make sex more comfortable for some women. Check with your doctor for a prescription and instructions on use. Ointments may be tolerated better than creams because they do not contain any preservatives.
Always check with your doctor before initiating any home remedy or treatment. Discharge from vaginal yeast or bacterial infections can irritate vulvar tissues. If you suspect such an infection, see your doctor promptly for diagnosis and treatment.

FINDING HELP

For more information, please contact the

National Vulvodynia Association
PO Box 4491
Silver Spring, MD 20914-4491
http://www.nva.org/
301-299-0775 (phone)
301-299-3999 (fax)