SEPTEMBER 2006

UNEXPLAINED V-PAIN:
VULVODYNIA AND DYSPAREUNIA
Understanding why internal or external pain is never normal


By Dr. Elizabeth Stewart
Medical Advisor to the Vagisil Women’s Health Center^SM @www.vagisil.com

As a "vulvovaginal specialist," V-pain, known medically as vulvodynia syndrome, is a subject in which I take intense interest. Perhaps you have never heard of the term "vulvodynia?" While it’s documented in medical textbooks of the 1800s, it wasn’t until 1983 that we had a name for this large group of vulvar symptoms that include chronic stinging, irritation, pain, rawness, burning and/or painful intercourse.

V-pain affects many women in fact, a recent survey conducted by Harris Interactive® for the Vagisil Women’s Health Center^SM (VWHC) revealed that seven percent of women 18 and older indicated that they have experienced vaginal pain occasionally, and one percent of these women reported experiencing vaginal pain regularly.

In Boston at the Brigham and Women’s Hospital where I serve on the staff, Dr. Bernard Harlow and I just completed the first epidemiologic study of vulvar pain sponsored by the National Institutes of Health. In that study, 16 percent of women reported chronic burning, knifelike pain, or pain on vulvar contact that lasted for at least three months. (Harlow BL, Stewart EG A population-based assessment of chronic unexplained vulvar pain: have we underestimated the prevalence of vulvodynia? JAMA 2003; 58:82-8.)

Personally, I suspect that vulvodynia affects many more women than most doctors have traditionally believed. In a month in my own specialty practice I see more than 100 patients with vulvar pain.

To clear up any confusion about the terms I’ll be using, here are their definitions based on new categorizations from the International Society for the Study of Vulvovaginal Disease in 2003:

• Vulvodynia (VVD) (say "VUL-vo-DIN-nee-ah"): spontaneous, generalized pain in the vulvar area. There may or may not be pain with intercourse, which is called dyspareunia (say “dis-par-OON-ee-ah”). You may also hear vulvodynia used as the overall term for any kind of painful vulvar symptoms, including the following conditions.
• Vestibulodynia (VBD) (say "vess-TIB-u-lo-DIN-ee-ah"): pain on touch in a part of the vulva known as the vestibule, the area between the thin inner lips. It almost always causes painful intercourse. Also called vulvar vestibulitis or just vestibulitis, it’s a specific kind of vulvodynia localized in the vestibule.
• Clitorodynia (say "KLIT-or-oh-DIN-ee-ah"): another localized form of vulvodynia with pain in or around the clitoris.

Clinicians consider VBD and VVD chronic pain conditions. Although the exact cause of vulvar pain hasn’t yet been confirmed, one of the leading theories concerns a glitch in the central nervous system. Nerve endings don’t work well and messages get all mixed up, so that touching hurts or burning is present for no apparent reason.

Diagnosis: Vulvodynia or Vestibulodynia

Vulvar pain is complicated to diagnose because there are virtually no physical signs of the disease. Women complain of severe pain and/or inability to be touched, but when the physician does an examination, nothing looks unusual other than some redness.

Theorectically VVD and VBD are primarily pain disorders that come from abnormal pain circuits set up in the central nervous system. VVD and VBD may be two different kinds of pain disorders. VVD may involve pain from nerve injury. VBD may involve pain from nerve inflammation.

I believe VBD is a form of inflammatory pain. The nerve is not injured but is so continuously bombarded by inflammation that signal changes occur in the spinal cord to keep the pain going.

What to Rule Out First:

The diagnosis of VBD or VVD is made after a process of elimination, ruling out other possible causes of V-pain are ruled out. These include:

• Infections – these include, but are not limited to, yeast, herpes, human papillomavirus (HPV), trichomonas (trich)
• Trauma – including sexual assault and other physical injuries
• Systemic disease -- e.g. Crohn’s disease, lupus and Sjogren’s syndrome in which immune cells attack and destroy the body’s glands that produce tears and saliva; it is characterized by dry mouth and eye as well as vaginal dryness among other areas of the body
• Precancerous conditions – vulvar intraepithelial neoplasia (VIN), vulvar cancer
• Irritants – e.g. soaps, sprays, douches, antiseptics, suppositories, laser treatment
• Various kinds of skin conditions, such as eczema, which is a non contagious inflammation of the skin

Treatment

If you think you have VBD, I suggest you try the following:

• Read and learn about the problem; you could join a support group
• Eliminate any possible trigger by suppressing yeast infection, treating a skin disorder or controlling any other source of inflammation
• Eliminate all possible vulvar irritants; use healthy hygiene and comfort measures
• Schedule a visit with your OB/GYN
• While waiting for your appointment use Vagisil® Anti-Itch Creme or Maximum Strength Vagisil® Anti-Itch Medicated Wipes, which are topical anesthetics formulated to provide instant, long-lasting relief of most itching, irritation and burning of the external genital area. Be sure to follow the package directions.

Clitoral Pain (Clitorodynia)

Clitoral pain is, like VBD, a form of localized vulvodynia. With this condition, the pain centers in the clitoris, with or without associated pain in the vestibule or vulva. It’s the newest V-pain problem to be acknowledged. Many clinicians, unfamiliar with clitorodynia, still assign any problem related to the clitoris to a sexual or psychological problem.

Diagnosis: Clitorodynia

Diagnosis is made by the description of pain localized to the clitoral area. Women often have a hard time describing the pain, but refer to a constant aching or soreness. Sitting increases it, as does clothing, exercise, and sexual activity. Pain worsens with the engorgement of sexual stimulation, making intercourse impossible for many.

On exam, the Q-tip test is negative (meaning the vestibule is fine), but touching the clitoris produces the pain.

Cause

Clinicians now suspect that most cases of clitorodynia are caused by pain after herpes, postherpetic neuralgia. Other possible causes include various skin diseases. More difficult to deal with is clitoral pain from trauma. I have seen injury to the clitoris from violent stimulation with a vibrator, straddle injuries from bikes and balance beams, and damage caused by parachute harnesses. Extensive or deep laser treatment and harsh chemicals can cause pain. All the drugs that help vulvodynia have potential to help clitorodynia.

Treatment

Same as above with vulvodynia.

When you meet with the doctor, be sure to request a blood test (HSV serology) that measures antibodies to herpes to make sure you have never been exposed to herpes. The virus does not always produce the classic blisters described in texts.