Vulvodynia is a chronic pain condition that affects the vulvar area and occurs without an identifiable cause. Symptoms typically include a feeling of burning or irritation. It has been established by the ISSVD that for the diagnosis to be made symptoms must last at least three months.
Cause and diagnosis It is likely there are multiple factors that contribute to the manifestation of vulvodynia, although often no identifiable trigger event can be found. Clinicians generally agree that vulvodynia is an 'umbrella' diagnosis encompassing many sub-types with different causes, including an excess of nerve fibers, hormonal imbalances, inflammation, and muscular dysfunction. Of note, one common precipitating event is a severe yeast infection, to quote the British Association of Dermatologists: "Secondary [acquired] vulvodynia may follow inflammation in the vulva, such as that caused by thrush or the overuse of topical and vaginal anti-thrush treatments." This is corroborated by the UK's Vulval Pain Society: "Some women have a sudden onset of symptoms following a specific event: a commonly recognised event is a severe attack of thrush followed by anti-thrush treatment. Once the attack of thrush settles following treatment, soreness and burning may persist as vestibulodynia." Research on mice models has found that giving females repeated thrush infections leads to chronic pain of their vulva. In When Sex Hurts, one of the leading books on vulvodynia written by notable researchers in the field, Dr Andrew Goldstein and Irwin Goldstein, the authors write: "We can't tell you how many women tell us that their vulvar pain began after a yeast infection or a series of them." Some factors influencing the disease may include genetics, immunology, and possibly diet. Of note, women with genes coding for stronger inflammatory responses are thought to be of increased risk of developing vulvodynia. Diagnosis is by ruling out other possible causes and performing a Q-tip test. This may or may not include a biopsy of the area.
Treatment and epidemiology Treatment may involve a number of different measures; however, as vulvodynia has many sub-types, none is universally effective, and the evidence to support their effectiveness is often poor. Some of these measures include medications, pelvic floor physical therapy, surgery, and counselling. Vulvodynia is estimated to affect up to 10-28% of women.
Signs and symptoms Pain is the most notable symptom of vulvodynia, and can be characterized as a burning, stinging, irritation or sharp pain that occurs in the vulva and entrance to the vagina. It may be constant, intermittent or happen only when the vulva is touched, but vulvodynia usually has a long duration. Symptoms may occur in one place ("localized") or the entire vulvar area ("generalized"). It can occur during or after sexual activity, when tampons are inserted, or when prolonged pressure is applied to the vulva, such as during sitting, bike riding, or horseback riding. The pain can be provoked by touch ("provoked") or constant ("unprovoked"). Some cases of vulvodynia are idiopathic where no specific cause can be determined.
Vestibulodynia
Vestibulodynia, formerly known as vulvar vestibulitis syndrome (VVS), or simply vulvar vestibulitis, refers to pain localized to the vestibular region. It tends to be associated with a highly localized "burning" or "cutting" type of pain. Vestibulodynia is the most common subtype of vulvodynia that affects premenopausal women – the syndrome has been cited as affecting about 10%–15% of women seeking gynecological care.
Clitorodynia The pain of vulvodynia may extend into the clitoris; this is referred to as clitorodynia. Clitorodynia may be sometimes caused by clitoris adhesions, a condition where the hood of the clitoris becomes stuck to the clitoris itself. Symptoms may include pain, hypersensitivity, hyposensitivity, difficulty with arousal, muted or absent orgasm. Clitoral adhesions are common among female patients with lichen sclerosus, but also occur among the general population. The prevalence of clitoral adhesions is unknown. Clitorodynia has been neglected in medical research and under-recognized in clincical practice.
Causes Vulvodynia has many different sub-types and causes. The disease is highly idiopathic. Identifying the cause is important to determine the appropriate treatment. Pain confined to the vulval vestibule, known as vestibulodynia, has at least three known sub-types: neuroproliferation, hormonally-mediation, and inflammation. Neuroproliferation can be present from birth or acquired later in life. This type of vestibulodynia is known as neuroproliferative vestibulodynia. Hormonally-mediated vestibulodynia can be caused by hormonal medications like oral birth control. Inflammatory vestibulodynia can develop as part of an immune response. Other possible causes include Sjögren syndrome, the symptoms of which include chronic vaginal dryness. Others include genetic predisposition to inflammation, allergy or other sensitivity (for example: oxalates in the urine), an autoimmune disorder similar to lupus erythematosus or to eczema or to lichen sclerosus, infection (e.g., yeast infections, bacterial vaginosis, HPV, HSV), injury, and neuropathy—including an increased number of nerve endings in the vaginal area. Some cases seem to be negative outcomes of genital surgery, such as a labioplasty. Initiation of hormonal contraceptives that contain low- dose estrogen before the age of 16 could predispose women to vulvar vestibulitis syndrome. A significantly lower pain threshold, especially in the posterior vestibulum, has also been associated with the use of hormonal contraceptives in women without vulvar vestibulitis syndrome. Pelvic floor dysfunction may be the underlying cause of some women's pain. Many co-morbidities are commonly associated with vulvodynia, including fibromyalgia, irritable bowel syndrome, interstitial cystitis, pelvic floor dysfunction, endometriosis, depression and anxiety disorders.
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