Vulvodynia Quiz

Definition and Diagnosis

• Vulvodynia is defined as vulvar pain of at least 3 months' duration without a clear identifiable cause, which may have potential associated factors.
• It is a diagnosis of exclusion and an idiopathic pain disorder.
• Only 1.4% of women seeking medical advice are correctly diagnosed, despite affecting 3-7% of the reproductive age group.

Aetiology

• The cause of vulvodynia is unknown.
• Contributing factors include:
  • Neuropathy (increased nerve fibers in the region or spinal nerve injury)
  • Chronic vaginal dryness
  • Sjögren's syndrome
  • Genetic predisposition to inflammation
  • Allergy or sensitivities
  • Pelvic floor dysfunction

Anatomical Correlation and Pathophysiology

• The vulva is innervated by:
  • Anterior labial branch of the IIN
  • GFN
  • Branches of pudendal nerve
• The pelvic floor muscles are divided into three groups:
  • Superficial (urogenital diaphragm)
  • Middle
  • Deep pelvic floor muscles (anal triangle muscles and associated pelvic and hip muscles)
• The pudendal artery, vein, and nerve passing through Alcock's canal provide neurovascular function of the pelvic floor.

Classification

• Vulvodynia can be classified as:
  • Generalized or localized
  • Primary or secondary
  • Provoked or unprovoked
  • Intermittent, persistent, or constant
  • Immediate or delayed

Differential Diagnoses

• Infections:
  • Candidiasis
  • Trichomoniasis
  • Herpes
  • Human papillomavirus
• Inflammatory conditions:
  • Lichen planus
  • Lichen sclerosus
  • Lichen simplex
  • Contact dermatitis
• Neurologic disorders:
  • Pudendal nerve, IIN, or GFN injury, entrapment, or neuropathy
  • Tarlov cysts
• Trauma:
  • Straddle injury
  • Female genital mutilation
  • Accidents
  • Sexual abuse
• Neoplastic conditions:
  • Squamous cell carcinoma
• Oestrogen deficiencies
• Iatrogenic:
  • Persistent post-surgical pain
  • Nerve injury
  • Surgical positioning: lithotomy, laparoscopic trocar injury

History and Physical Examination

• Detailed pain history, including psychosocial and sexual history, should be taken.
• Complete gynaecological examination, including external genitalia, per vaginal, and per rectal examination.

Examination

• Cotton sensory test
• Neurosensory check—cotton vs pin prick
• Pelvic floor muscle examination

Pain Comorbidities

• Interstitial cystitis
• Endometriosis
• Chronic headache
• Hypermobility syndrome
• Temporomandibular dysfunction

Treatment

• Multidisciplinary and multimodal approach is crucial for success of therapy.
• Conservative/self-management:
  • Exercise and physical therapy
  • Healthy diet (especially low-oxalate diet)
  • Stress management
  • Psychotherapy (including mindfulness and CBT)
  • Sexual therapy
  • Acupuncture
• Medications:
  • Simple analgesics
  • TCAs (commonly amitriptyline and nortriptyline)
  • SNRIs (commonly duloxetine and venlafaxine)
  • Anticonvulsants (commonly gabapentin, pregabalin, topiramate, lamotrigine, and carbamazepine)
  • Topical (antifungal, corticosteroids, lidocaine, oestrogen, testosterone, ketamine, and gabapentin)
• Interventions:
  • Nerve blocks (GFN, IIN, or pudendal nerve block)
  • Pulsed RF of nerves
  • Neuromodulation:
    • TENS
    • Peripheral nerve neuromodulation
    • SCS
• Surgery:
  • Reserved for provoked vestibular vulvodynia

Chronic Pelvic Pain

• Chronic pelvic pain is defined as abdominal pain located below the umbilicus, including lower back pain with or without radiation into the thighs, which may be acute, chronic, or intermittent.
• In females, chronic pelvic pain is defined as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months' duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.

Incidence

• Chronic pelvic pain is more prevalent in females, affecting 14-40% of women in the reproductive age group.
• The prevalence of chronic pelvic pain is comparable to that of asthma and low back pain.
• 20-70% of patients have an improper or wrong diagnosis.
• The time period from presentation to diagnosis varies between 6.7 ± 6.2 years.

Anatomical Correlation of Pain Generators

• One or more anatomical structures can be pain generators in most cases.
• Female pelvic pain generators include:
  • Urethra
  • Bladder
  • Vulva
  • Vagina
  • Uterus
  • Ovaries
  • Pelvic floor
  • Peritoneum/endometriosis
  • Bowel
  • Post-surgical/neuropathic
  • MSK
  • Psychosocial
• Male pelvic pain generators include:
  • Urethra
  • Bladder
  • Penis
  • Scrotum
  • Prostate
  • Pelvic floor
  • Peritoneum
  • Bowel
  • Post-surgical/neuropathic
  • MSK
  • Systemic
  • Psychosocial

Causes

• Gynaecological conditions:
  • Endometriosis
  • Adhesions
  • Chronic pelvic inflammatory disease
  • Pelvic congestion syndrome
  • Ovarian remnant syndrome
  • Recurrent haemorrhagic ovarian cysts
  • Myomata uteri (degenerating)
  • Adenomyosis
  • Uterine retroversion
  • Pelvic floor and hip muscle pain
  • Visceral hyperalgesia
  • Neoplasms
• Urological conditions:
  • Urinary retention
  • Urethral syndrome
  • Interstitial cystitis
  • Pyelonephritis
  • Neoplasms
• Abdominal conditions:
  • Neuropathies
  • Porphyrias
  • IBS
  • Bowel obstruction
  • Diverticulitis
  • Hernia
  • Neoplasms
• Neurological conditions:
  • Nerve entrapment syndromes
  • Generalized myofascial pain syndrome
  • Fibromyalgia
• Musculoskeletal conditions:
  • SIJ pain
  • Hip pain
  • Pubic dysfunction
  • Spine pathology
• Psychological conditions:
  • Depression
  • PTSD (history of abuse/trauma)
  • Anxiety disorders
  • Personality disorder

Chronic Pelvic Pain

• Chronic pelvic pain is defined as abdominal pain located below the umbilicus, including lower back pain with or without radiation into the thighs, which may be acute, chronic, or intermittent.
• In females, chronic pelvic pain is defined as intermittent or constant pain in the lower abdomen or pelvis of at least 6 months' duration, not occurring exclusively with menstruation or intercourse and not associated with pregnancy.

Incidence

• Chronic pelvic pain is more prevalent in females, affecting 14-40% of women in the reproductive age group.
• The prevalence of chronic pelvic pain is comparable to that of asthma and low back pain.
• 20-70% of patients have an improper or wrong diagnosis.
• The time period from presentation to diagnosis varies between 6.7 ± 6.2 years.

Anatomical Correlation of Pain Generators

• One or more anatomical structures can be pain generators in most cases.
• Female pelvic pain generators include:
  • Urethra
  • Bladder
  • Vulva
  • Vagina
  • Uterus
  • Ovaries
  • Pelvic floor
  • Peritoneum/endometriosis
  • Bowel
  • Post-surgical/neuropathic
  • MSK
  • Psychosocial
• Male pelvic pain generators include:
  • Urethra
  • Bladder
  • Penis
  • Scrotum
  • Prostate
  • Pelvic floor
  • Peritoneum
  • Bowel
  • Post-surgical/neuropathic
  • MSK
  • Systemic
  • Psychosocial

Causes

• Gynaecological conditions:
  • Endometriosis
  • Adhesions
  • Chronic pelvic inflammatory disease
  • Pelvic congestion syndrome
  • Ovarian remnant syndrome
  • Recurrent haemorrhagic ovarian cysts
  • Myomata uteri (degenerating)
  • Adenomyosis
  • Uterine retroversion
  • Pelvic floor and hip muscle pain
  • Visceral hyperalgesia
  • Neoplasms
• Urological conditions:
  • Urinary retention
  • Urethral syndrome
  • Interstitial cystitis
  • Pyelonephritis
  • Neoplasms
• Abdominal conditions:
  • Neuropathies
  • Porphyrias
  • IBS
  • Bowel obstruction
  • Diverticulitis
  • Hernia
  • Neoplasms
• Neurological conditions:
  • Nerve entrapment syndromes
  • Generalized myofascial pain syndrome
  • Fibromyalgia
• Musculoskeletal conditions:
  • SIJ pain
  • Hip pain
  • Pubic dysfunction
  • Spine pathology
• Psychological conditions:
  • Depression
  • PTSD (history of abuse/trauma)
  • Anxiety disorders
  • Personality disorder