A patient has drawn my attention to Robyn’s recent posting regarding the benefits of Bartholin’s glands surgery. As the one who first described this operation (1,2), I feel compelled to comment. Properly done, microsurgical removal of the Bartholin’s glands ranks with the Glazer protocol, as one of our best weapons in the war against vulvar vestibulitis syndrome.

Without doubt, vulvar vestibulitis syndrome or vulvodynia is among the most vexatious problems in Women’s Health. I witness on a daily basis the grief and suffering it can cause. However, I would also point out that Medicine has made large strides in understanding the fundamental mechanisms by which this nasty condition operates. The old aphorism… “knowledge is power”… probably holds true here. The recognition that
Vulvodynia conforms to the general model of a sympathetically maintained pain syndrome (SMP) opens new doors. So much so, that the desperation and nihilism which so pervade these pages need to be re-assessed in the cold light of clinical fact. The practical corollaries of this knowledge now provide Medicine with a firm platform from which to effectively diagnose and (usually) resolve vulvodynia…no matter how severe or how long lasting.

WHY HAS VULVODYNIA BEEN SO DIFFICULT FOR MOST DOCTORS TO UNDERSTAND?
Vulvodynia is a condition characterized by burning or itching of the central vulva, with tenderness surrounding the vaginal opening. Any mechanical pressure can amplify the symptoms from a simple discomfort to a sharp pain. Severity can vary from minor to disabling. Mild degrees feel like a yeast infection, but anti-fungal medication doesn’t really help. Moderate cases evoke persistent vulvar burning and loss of sexual pleasure. In more severe cases, patients cannot have intercourse at all. Finally, a percentage of women have constant, disabling vulvar pain, bad enough to dominate daily life and cause withdrawal from normal activities. Despite the consistency with which symptoms are described from person to person, misdiagnosis remains common amongst general Ob/Gyn’s. The most common error is to categorize the problem as a chronic yeast infection, despite the absence of the classical signs. Another error is to misinterpret this discomfort as a psychological problem or as a loss of sexual desire. What has produced this impasse, still present after so many years?

In truth, this impasse goes well beyond the difficulties that Ob/Gyn’s have in trying to diagnose vulvodynia. A parallel can be drawn between military surgeons not understanding causalgia complicating gunshot injuries, orthopedists not understanding Sudeck's atrophy following wrist fracture, and cardio-thoracic surgeons not understanding the pain of reperfusion syndrome after re-vascularization of an ischemic limb (3).

The root cause of these problems is that, from the earliest days of medical school, our profession is drilled to explain any chronic pain in terms of a structural disease process. For example, if you have a persistent pain of your big toe, the well-trained physician will think of everything from gout, to a jogging fracture or even a hidden rose thorn. Most, however, will not think in terms of a chronic regional pain syndrome. Namely, a chronic pain loop which arises through malfunction of the local pain nerves themselves, rather than as a result of actual tissue damage.

WHAT IS A SYMPATHETICALLY MAINTAINED PAIN?
The first clinical example of an SMP (also termed causalgia or reflex sympathetic dystrophy) was made during the American Civil War by S. Wier Mitchell, while caring for soldiers who had suffered gunshot wounds to major peripheral nerves. Writing several decades before the sympathetic nervous system had been defined, Mitchell recognized all of the essential elements of an SMP: namely,
i. the burning nature of this pain;
ii. spread beyond the distributions of the injured peripheral nerve;
iii. the seemingly bizarre phenomena of allodynia (perception of non-noxious stimuli as being painful);
iv. hyperalgesia (exquisite pain triggered by light touch),
v. the accompanying vasomotor instability, edema and disrupted sweating;
vi. the tendency toward impaired motor function in the regional musculature;
vii. the eventual onset of dystrophic contracture with osteoporosis; and
viii. the associated emotional lability.
These observations were extended during World Wars 1 & II, and the Korean War. However, “causalgia” was thought to be just a tragic curiosity of military conflict, until analogous pain syndromes were recognized following closed trauma without nerve injury to either the upper or lower limb…such as fracture, cold injury, ischemia, or prolonged immobilization. Over the years, these various SMP’s have been given more than 20 different names, depending on the precipitating injury, the Nation concerned, and the medical specialty treating the patient. To this list (of chronic pain syndromes affecting the limbs), urologists likely can add interstitial cystitis, and gynecologists, vulvar vestibulitis, as SMP’s of the uro-genital tract.

HOW DOES THIS CONCEPT RELATE TO VULVODYNIA?
The clinical features of vulvodynia neatly fit the model of an SMP (2). Specifically, vulvodynia begins as a sudden exaggerated response to any of a variety of tissue insults (e.g., yeast infection, childbirth trauma, hysterectomy, or CO, laser burn). Once established, the syndrome spreads to become a relentless, regionalized, burning pain. Examination usually localizes the pain and tenderness to discrete foci of dysaesthetic erythema, surrounding the ducts of Bartholin’s or Skene’s glands. Allodynia is reflected by the discomfort produced by wearing jeans or even normal underwear and hyperalgesia by the exquisite tenderness evoked by gentle palpation with a cotton swab. Motor dysfunction is manifested by the chronic painful spasm of the pelvic floor muscles. Vasomotor instability is a prominent feature of vulvodynia, especially in areas of vascular rebound after C02 laser treatment. Minor trophic changes are also common, such as hymenal fibrosis or recurrent tearing of the fourchette skin.

WHY IS THIS CONCEPT IMPORTANT?
The view that vulvodynia might be an SMP opens several therapeutic windows (see Table). First, a search must be made to identify and suppress the trigger factors that first initiated the vulvar hyperalgesia syndrome (eg. by long-term Nizoral or Diflucan regimens for chronic yeast colonization). Second, aberrant nerve signals passing through the spinal cord can often be stabilized (eg. with Elavil, Zoloft or Neurontin). Third, therapy should focus primarily on strategies for breaking any regional pain loops (eg. by the Glazer protocol to rehabilitate the hypertonic pelvic floor muscles). Fourth, topical estrogen and testosterone can be used to improve trophic (ie. nutritive) conditions within the mucosae or genital skin, respectively. A bland emollient can also help in this regard. Finally, in the small subset of vulvodynia patients who do not respond to medical therapy alone, there is definitely a role for surgical resection of the worst areas of pain. Surgery is seldom curative in itself…but it does make it possible for biofeedback to resolve cases that were hitherto too severe.

POTENTIAL THERAPIES
• Treat initiating events (Nizoral, Diflucan)
• Stabilize dorsal horn (Tricyclics & SSRI's or anti-epileptic drugs)
• Correct regional motor dysfunction (Biofeedback)
• Improve tissue tropism (Estrogen, testosterone or barrier creams)
• Resect worst areas of mucosal pain loop (Vestibulectomy or Bartholin's gland removal)

Table 36. Potential therapeutic windows for managing chronic, sympathetically maintained pain syndromes. (Adapted from Reid R: Debate: The low oxalate diet and calcium citrate regime: The Con view. J Gynecol Surg

WHEN SURGERY IS BEING CONSIDERED
A. Vestibulectomy: Given the limitations of medical therapy, it is understandable why patients with chronic pain emanating from visible foci of peri-hymenal erythema would be treated by cold-knife resection and closure by downward advancement of the vaginal mucosa. This approach is technically easy, and has an estimated 50% success rate. However, vestibulectomy also has some substantial drawbacks including disfigurement and scarring, vascular rebound at the incision site or obstruction of the Bartholin's ducts…thus worsening the underlying pain.
B. Microsurgical Removal Of The Bartholin’s Glands: Findings from my research group indicated that, in the presence of a deep lancinating pain radiating out of the Bartholin's fossa, gland removal delivered success rates of 81%. These results were described prior to Dr Howard Glazer’s landmark paper outlining the role of biofeedback in rehabilitating pelvic floor hypertonus and relieving other secondary sites of myofascial pain. When patients who initially did not respond to surgery were subsequently re-treated with the Glazer protocol, success in this most severe subset rose to >95%. Because Bartholins’ glands removal is done by a very precise microsurgical technique, surgery has a very low morbidity rate and produces little change in vulvar anatomy. Major risk is that of having the surgery, but still being unable to get the levator muscles out of spasm. Biggest drawback of this philosophy is that, from the technical viewpoint, this surgery is very difficult…requiring advanced microsurgical skills (not a usual part of the gynecologist’s training). Hence, there are very few centres able to offer this option.

FURTHER INFORMATION
Those seeking further information, including case studies of prior patients, should visit our website @ www.vulvarpain.net