Vulvodynia: City without sex

22. February 2012
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Burning or stinging pains in the pubic area, often happening over years, are suggestive of a vulvodynia. The disease burdens patients and challenges physicians, established therapies keep on failing. Success in some individual cases comes from surgery.

Stories out of real life: in one episode of “Sex And The City” Charlotte York had to be treated on account of vaginal pain. When her doctor diagnosed vulvodynia, he said tersely: the condition wouldn’t be grave, just uncomfortable. Charlotte was given a low dose antidepressant, and the world seemed to be back in order. Physicians and patients’ organisations in the U.S. led an assault against this image, first and foremost among the voices were the representatives of the National Vulvodynia Association. Their allegation: The soap opera played down a serious, chronic illness that carries great suffering for patients and their partners.

Agony

In a case of vulvodynia, a light touch of the genital area becomes a torturous ordeal – even if it only comes from underwear or tampons. The pain sometimes described as unbearable can spread to the anus and affect the daily lives immensely: in extreme cases, for long periods of time sufferers can’t even sit down. Other patients report of itching and pain when urinating, as well as with any pulling or pulling efforts. Inevitably, love-life is severely limited, penetration turns out virtually impossible.

Not rare – but rarely diagnosed

In the U.S. alone millions of people are affected, as a population-based study found. In it, researchers interviewed 2269 women from Michigan. Their result: approximately 8.3 percent were suffering at the time of data collection from a vulvodynia. Added to that, nearly 18 percent had at least at one point in their lives similar symptoms. The authors commented, that vulvodynia is consequently considered a frequent, although rarely diagnosed, disease with high prevalence among sexually active women of all ages. Of 208 women for whom the condition’s criteria fitted the bill, only 101 had sought medical help, and in only three cases the correct diagnosis had actually been made. “So far no doctor has been able to help, since most did not even know what vulvodynia is”: statements such as this one arise in a self-help forum. Affected patients search out quite a number of doctors before the condition is diagnosed. How a vulvodynia originates, however, remains unclear.

Cause: an enigma

Despite numerous investigations, scientists have still not been able to find any causal origins. Rather, they have developed numerous hypotheses: Infections from trichomonas, via yeasts or human papillomavirus, appear more than suspicious. Often these do not heal properly, and the inflammation persists at subclinical levels. Other risk factors are medicines in the genitourinary tract, including any long-term antibiotic therapy. Hormones have also been mentioned, whether topical or systemic – the latter case relating to oral contraceptions. Hypersensitivity reactions to personal care products or oxalate in the diet also come into question. Another possible trigger scrutinised by gynecologists is early, regular sexual intercourse. Not completely to be ruled out are the effects of surgery in the genital area. Other studies see the blame in autoimmune diseases – such as systemic lupus erythematosus or lichen sclerosus. Human geneticists have also reported of mutations in the genes affected in areas which encode for messenger proteins such as interleukin-1β. The anomalies involved here were, in comparison to the normal population, associated with considerably lengthier inflammatory events.

Neurologists and psychiatrists at a loss to understand it

From a neurological point of view, it could be that too many nerve endings are located in the vaginal area. One clue: gynecologists at the University of Rochester School of Medicine and Dentistry, USA, studied patients with vulvodynia for their cutaneous reaction to capsaicin (known as an effective means of stimulation of various nociceptors). The women had significantly more pain when receiving the stimulus, together with a higher resting heart rate and a lower systolic blood pressure at rest than in control cases. Meanwhile, psychiatrists discuss depression as well as anxiety disorders, whereby there is little to suggest the involvement of psychosexual triggers. A relationship with trauma has not been able to be demonstrated.

Evidence: none

Given the vague situation, one study conclusion remains: typical triggers of vulvodynia don’t exist, but a multiplicity of factors seem to be relevant. What arises from this troublesome situation, is that numerous treatment strategies have been developed: diet without oxalic acid, TENS, local anaesthetics or hormones are supposed to improve the symptoms. By way of trial, tricyclic antidepressants, SSRIs or gabapentin have also been employed. With these drugs there have been long years of experience accumulated in dealing with fibromyalgia as well as with neuropathic pain. Other physicians have recommended relaxation techniques from yoga to progressive muscle relaxation as per Jacobson technique. And sex therapies are supposed to provide ways for a happier love-life by showing alternatives to painful intercourse. Help in mild cases can be obtained by local anaesthetic plus lubricant.

All treatments are like the poking around in the fog, according to a meta-analysis; randomised clinical trials are lacking. Researchers at Vanderbilt University in Nashville, Tennessee, found no evidence – apart from some for the placebo. Nevertheless there is one exception.

Scalpel used against pain

With vulvar vestibulitis syndrome (VVS), a particular form of vulvodynia, surgery can actually help, with strong evidence for this. Symptoms: VVS patients complain of redness and inflammation of the vaginal opening; it’s hardly surprising that all current studies turn up negative results. Histologically, there are plenty of findings pointing at chronic inflammatory processes, but without there being an active infection. Gynecologists partly take off affected skin layers and remove them as part of a vestibulectomy and, if necessary, also areas of the hymenal ring. Finally, they cover up the area with a section of sliding plastic. In order to critically investigate the safety and success of this method, Finnish physicians have carried out a retrospective cohort study with 57 patients, involving interviews, questionnaires, gynecological examinations and tests to assess the pain from contact sensitivity. Overwhelming results: 91 percent of women were satisfied with the outcome of surgery. Accordingly, using various scales in scoring pain, collected data indicated a decrease in pain and with problems during sexual intercourse. Where no VVS was present, the surgical method failed as well.

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