Clinical Management of Vulvodynia

By Marek Jantos Ph.D.

In an era of pharmacology where the focus on resolving sexually related difficulties has become “pill-focussed” (Lieblum & Rosen, 2000), chronic urogenital pain has not received the same attention. Current literature on female dyspareunia, and in particular vulvodynia, highlights the paucity of effective clinical protocols for the management of the disorder (Sandownik, 2000). There are signs of greater consensus and consistency in diagnosis and treatment emerging, especially among professionals who are directly involved with research and clinical management of vulvodynia (Reed et al., 2008), but this may not reflect the trend among the wider community of clinicians.

A survey of clinicians seeking to determine practice patterns in relation to management of vulvar pain syndromes found considerable uncertainty in relation to treatment (Updike & Wiesenfeld, 2005). Of 327 providers contacted, 167 responded by completing an extended survey outlining their treatment practices. The majority of responders were tertiary specialists who worked in the following settings: in a private group practice setting (33%); solo practice (26%); university practice (31%); a multidisciplinary group practice (8%). Approximately 20% of the practitioners indicated they saw more than 20 vulvar pain patients per month, while 40% saw between one to five patients per month. Most of the respondents (85%) felt that the treatment of vulvodynia was not addressed adequately in their training programs and that the terminology in relation to the vulvar pain syndrome was confusing. In relation to treatment, therapeutic drugs were the frontline modality. The most common drugs used were tricyclic antidepressants (89%) and the anticonvulsant, gabapentin (68%). Both of these non-specific pharmaceutical agents were used on the assumption that vulvodynia was caused by a form of neuropathy. Only 21% of the respondents felt that vulvar pain had a psychologic cause, with psychiatric care being recommended more often for generalized than for localized vulvodynia. However, most practitioners acknowledged that due to the negative impact of vulvodynia on quality of life and relationships, some form of counselling was warranted. In general the study concluded that “It is impossible to practice evidence-based medicine in the care of women with vulvodynia with so few clinical trials” (Updike & Wiesenfeld, 2005 p. 1406). Until there is prospective comparative data available, clinicians must rely on personal experience and expert consensus.

A large proportion of vulvodynia patients report attending multiple medical consultations before receiving a diagnosis (Jantos & Burns, 2007; Harlow & Stewart, 2003). Patients repeatedly expressed concern that their complaints were being overlooked and not addressed effectively (Green et al., 2001; Sandownik, 2000). Lack of diagnosis, confusion in classification, inappropriate referrals and poor therapeutic outcomes also contributed to a high level of disappointment and frustration among referring doctors, “Numerous physicians have seen these patients, and numerous interventions were tried. On average, >64% of the time these interventions made the patients’ symptoms no better or worse. No single treatment or combination of treatments were perceived as consistently improving symptoms” (Sandownik, 2000).

This has caused some to appraise the general quality of treatment for women with dyspareunia as “shockingly poor” (Kaler, 2005). Others attribute the lack of progress in diagnosis and management of vulvodynia to the inappropriate classification of the condition as a psychiatric disorder or a sexual dysfunction (Binik et al., 1999; Binik, 2005; Pukall at al., 2003). Classifying vulvodynia as a psychiatric disorder or a sexual dysfunction has resulted in therapy being misdirected: “…sufferers are referred to mental health care professionals by gynaecologists and other medical specialists who can find no organic basis for the pain and imply to the women that it is all in their heads. Mental health care professionals may make a variety of diagnoses and assumptions about the nature of the pain, ranging from poor sexual technique to somatisation and then treat the women accordingly. These diagnoses rarely help, and women find themselves increasingly frustrated by an endless series of referrals and little pain relief” (Binik, 2003, p. 69).

Patients who persist in searching for a physical cause are likely to meet with spoken or implied suggestions that the “pain is in their head” (Binik, 2000).

Classifying the problem as psychological has been found to have a detrimental impact on the patients themselves (Kaler, 2005). How the pain is defined and categorized not only has bearing on the therapeutic outcomes but on their own self-perception and self-esteem. In a sociological study examining the effects of vulvar pain on women’s self concepts and social relations, the views held by the women themselves, by their partners, or by the medical professionals were found to have significant impact on the women (Kaler, 2005). When vulvodynia patients were asked if they had received unhelpful medical advice or treatment for their pain, 34% mentioned being told that their problems were “psychological” or “all in the head” as the most unhelpful thing that they had been told (Kaler, 2005).

Two recent consensus statements specifically addressed questions of terminology, diagnosis and management (Haefner et al., 2005; Bachmann et al., 2006). The vulvodynia guideline (Haefner et al., 2005), based on a comprehensive review of literature and cumulative experience of a panel of practitioners, sought to offer clinicians guidance on management of cases from the time of diagnosis through to the selection of treatments. The guideline was set out in the form of an algorithm designed to assist with decision making at various levels of intervention. Some of the optional therapies listed ranged from oral medications to surface electromyography (SEMG) biofeedback, physical therapy, and surgical excisions. However, due to the complexities of chronic vulvar pain, the guidelines acknowledged the reality that no single treatment is successful for all women and no rapid resolution of symptoms is likely.

The most recent survey, approximately three years following the first survey, looked at the diagnostic and treatment practices among vulvodynia researchers and members of the ISSVD (Reed et al., 2008). The survey results reflect an emerging consensus on diagnostic and treatment preferences. For diagnosis, the majority of practitioners find that a history of pain, together with tenderness on examination, described as producing a burning sensation, rawness or stinging, constitute a reliable basis for the diagnosis of vulvodynia. The findings also showed that Friedrich’s criteria, published in 1987, are still most widely used and cited. In particular, the first two criteria; reported pain on touch or attempted vaginal entry, and tenderness to pressure localized within the vulvar vestibule, are most commonly used. Little additional value was conferred from the use of the third criterion, vestibular erythema (Bergeron et al., 2001; Masheb et al., 2004; Reed et al., 2008). In relation to treatment, the most commonly used therapies included: continued use of tricyclics antidepressants, pelvic floor therapies, psychological counselling and sex therapy. Non-medical therapies, such as pelvic floor related therapies, were rated as most effective. The majority of survey participants (87.5%) were aware of cases where full remission of symptoms occurred (Reed et al., 2008), signifying a more effective approach to management.

The management of vulvodynia, and the improved outcomes reported, reflect a growing perception that vulvodynia has a physiological and possibly neuropathic basis (Reed et al., 2008). Further research on pain mechanisms mediating symptoms of chronic vulvar pain are needed (Devoe, 2007). Information regarding the diagnosis and management of vulvodynia needs to be widely disseminated and education and training opportunities provided for primary and tertiary care providers.