| |
Vulvar Pain Syndromes (also know as Vulvodynia)
|
Deborah Coady, MD |
| |
|
Dena Harris, MD |
Vulvodynia is classified as chronic vulvar pain or discomfort, including burning, stinging, irritation or rawness of the female genitalia. The word vulvodynia actually means painful vulva. This condition can severely impact the quality of life for affected women and may prohibit participation in sexual activity, physical exercise, and even social activities. However, it is believed to be underreported because of its lack of visible signs, and often a womans embarrassment and lack of hope in finding care for her intimate condition delays treatment Also, the majority of ob/gyns, urologists, and general doctors do not have specific training, knowledge, or even interest in providing care for women with intimate pain. And as many as one in six women may be affected by vulvodynia at some point in their lives!
Vulvodynia does not have one set cause, but several factors can contribute to the development of chronic vulvar pain. A history of recurring vaginitis, as well as allergies or injury can cause this condition. Some women can point to a particular event associated with the beginning of their pain, others cannot. Some women may in fact have a form of vulvodynia from birth. Often other organs in the pelvic region are involved in the pain process, especially the bladder and bowels.
There are two main types of vulvodynia. Both are now felt to be primarily related to injury to the local and sometimes general nerve system to some degree. Generalized or dysesthetic vulvodynia symptoms occur throughout the vulvar anatomy and can occur constantly or on and off. Patients have reported pain in the labia majora, labia minora, vestibule, clitoris and/or inner thighs.
Vulvar vestibulitis syndrome, or vestibulodynia, causes pain only in the vestibule and usually only occurs with touch or pressure to the area. Burning sensations are the most common symptom.
Vulvar dermatoses, caused by dermatologic conditions and often present in the form of itching and burning, are other conditions that can cause chronic vulvar pain. Cyclic vulvovaginitis, which occurs at the same stage of the menstrual cycle can also coexist with vulvodynia.
Treatment for vulvodynia often cures the condition, and in all women does help to relieve symptoms. Trigger point injections can be used to insert a steroid medication as well as numbing agents into the exact points where pain is felt. Topical agents, such as estrogen and testosterone, can be applied daily to reduce pain. Pelvic floor physical therapy treats abnormal muscle and nerve function, and allows patients to counteract pelvic hypertonicity. Pelvic nerve blocks may be inserted to calm the nerves in the pelvic area. Many oral medications also help soothe the injured nerves. BOTOX® injections can help reduce muscle spasms. Surgical approaches are also sometimes necessary.
Careful care of the vulva, avoiding toxins, and the use of cotton underwear, toilet tissue free of bleach, lubricants free of preservatives and chemicals, and non-perfumed soaps and creams can help mitigate symptoms and prevent flare-ups. Some helpful web sites to obtain hypoallergenic products are:
Vulvodynia Education Links
Recommended Reading
by Dr. Deborah Coady and Nancy Fish, MSW, MPH to Seal Press; 2011
The V Book:
A Doctor's Guide to Complete Vulvovaginal Health (Paperback)
by Elizabeth G. Stewart and, Paula Spencer ; Bantam; 2002
Heal Pelvic Pain:
The Proven Stretching, Strengthening, and Nutrition Program for Relieving Pain, Incontinence,& I.B.S, and Other Symptoms Without Surgery
by Amy Stein ; McGraw Hill; 2008
Headache in the Pelvis
5th Edition (Paperback)
by David Wise; National Center for Pelvic Pain; 5 edition, May 1, 2008
Explain Pain
Orthopedic Physical Therapy Products
by David Butler PT and Dr. Lorimer Moseley. Orthopedic Physical Therapy Products. 2003
Back to Top
Overnight Lidocaine Treatment for Vulvar Pain Syndromes
Helps nerve dysfunction involved in vestibular burning pain. Improvement occurs in 75% within 2 months of use. Lidocaine 5% liquid or gel, compounded without additives, by mail order via College Pharmacy: 800-888-9358. Call them to give your insurance information and confirm mailing address.
At the start of use, apply a small amount to the vestibule twice a day to assess sensitivity. A mild amount of temporary stinging is normal at first. Then at bedtime: apply the lidocaine liquid thoroughly to a small cotton ball, its size and shape adjusted to that of your vestibule. Be sure cotton ball is very wet. Apply a coating of lidocaine to the vestibule with your finger, then separate your labia and tuck the cotton ball slightly into and over the opening, but not inside the vagina. Leave in place overnight while you sleep.
Pudendal Nerve Perineural Injections, and Pelvic Floor Muscle Injections
 The pudendal nerves arise from fibers of the sacral nerve roots in the lower back, and course through the muscles and ligaments of the pelvic floor. These nerves are responsible for sensation and muscle function in the pelvic floor, vulva, anus, and base of the bladder. They relay pain messages to the spinal cord and to the brain. Pudendal nerve pain (neuralgia) may occur when the nerve is injured, inflamed, compressed, restricted, or "trapped". This can be caused by inappropriate pelvic floor muscle spasms, recurrent microtrauma from certain repetitive flexion exercises, or tendinous or bony abnormalities around the course of the pudendal nerve. Over time, the nerve malfunctions, developing abnormal fibers and producing local chemicals, which send pain signals described as burning, stinging, itching, crushing, aching, or numbness, to the level of the brain. Neuropathy, a more complicated nerve disorder, may also develop with chronic cases.
A pudendal nerve perineural injection is usually composed of a local anesthetic, to calm down the overactive signaling by the nerve, and a steroid, to treat the chronic inflammatory process. It may be diagnostic, in that if the pain is temporarily relieved, then the pudendal nerve is held responsible for that pain. Usually a series of 3-4 nerve injections, combined with pelvic floor muscle physical therapy, is used to treat the pudendal nerve pain.
The easiest approach to the pudendal nerve is trans-vaginally, by the same method used for decades to provide pain relief during childbirth. A needle guide is inserted with the fingers, as in a pelvic exam, to allow the needle and the medication to reach the area around and bathe the right or left pudendal nerve, located on the sidewall of the pelvic floor.
Pelvic floor muscle injections, also known as trigger point injections, are used to treat localized tense, taut bands, which feel like a "pulled muscle" in the vagina. Using a similar technique and local anesthetic, the bands are injected and the medication massaged into the affected muscles. Pelvic floor muscle physical therapy, performed soon after, is an important adjunct.
Vaginal Dilators (At Home Therapy for Vulvar Pain)
 A vaginal dilator can help you gain confidence and awareness of your vagina and pelvic floor muscles in privacy. It will help you discover how these muscles are triggered to tense up, and then you will be able to focus on ways to relax the muscles and keep them soft. As you learn more about how your pelvic floor muscles respond, it will be easier for you to gently introduce dilators of progressively larger sizes into your vagina. With practice, inserting dilators will become comfortable and routine, and you will be able to transfer that skill to your sexual activities.
Select a time and place that allows privacy and relaxation. Liberally lubricate the dilator and your vulva with a lubricant of your choice--eg. Glide, Sylk (order via www.sylk.co.uk). Begin with the smallest dilator, but before inserting it, scan your body for any areas of tension, paying attention to your abdomen, buttocks, and thighs. When you feel you are relaxed, slip the dilator gently into your vagina. If you notice discomfort, burning, or tightening, attempt one of these strategies:
- Follow your breath as you let go and soften the muscles of the pelvic floor. It is easier to relax the muscles in the relaxation phase of the breath cycle--try counting aloud as you exhale.
- Visualize your vagina and pelvic floor in a state of softness and stretchy elasticity carefully attend to the rest of your body-- keep your belly soft and your legs limp and relaxed, and your breathing easy and gentle.
Try to keep the dilator comfortably within your vagina for 15 minutes at a time. This allows the pelvic floor muscles to tire and fully relax around the dilator. Perform the exercise daily if possible. When the smaller dilator is no longer a challenge; progress to the next largest size. When you are using a dilator that is approximately the size of your partner's penis, add intercourse to your sexual sharing. Initially use positions where you feel you have the most control over the pacing, depth, and intensity of penetration.
In addition, specialized pelvic floor muscle physical therapy is available to help you.
Order dilator kits at www.vaginismus.com.
Trigger Point Injections
Trigger point injections are a procedure for treating pain. They are used to treat painful areas that contain trigger points, or knots of muscle that form when muscles do not relax. A needle containing a local anesthetic is inserted into the trigger point to make it inactive and therefore alleviate the pain. The procedure takes just a few minutes, is very  safe, and has minimal side effects. Trigger point injections not only relieve pain, but also loosen the muscles which are causing the pain to therefore help with pelvic floor physical therapy.
Bladder Instillations
Bladder instillations are a treatment method used to relieve painful bladder symptoms. During this procedure, the bladder is filled with a solution and held for a certain amount of time. The procedures are usually given in 6 weekly installations and symptoms tend to mitigate as the process continues. Bladder instillation is a simple procedure and side effects are minimal.
Back to Top
|
|
