Editing Vulvodynia

{{About|the chronic pain syndrome of the vulvar area|the deathcore band|Vulvodynia (band)}}{{Short description|Chronic pain syndrome of the vulvar area}}
{{Use dmy dates|date=February 2021}}
{{Infobox medical condition
| name            = Vulvodynia
| field           = [[Gynecology]]
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Vulvodynia is a [[chronic pain]] condition that affects the [[vulva]]r area and occurs without an [[Idiopathic disease|identifiable cause]].<ref>{{cite journal |pmid=21542444 |year=2011 |last1=Feldhaus-Dahir |first1=M |title=The causes and prevalence of vestibulodynia: A vulvar pain disorder |journal=Urologic Nursing |volume=31 |issue=1 |pages=51–4 |doi=10.7257/1053-816X.2012.31.1.51 }}</ref> Symptoms typically include a feeling of burning or irritation.<ref name="Stock2013">{{cite journal |pmid=24633161 |year=2014 |last1=Stockdale |first1=C. K. |title=2013 Vulvodynia Guideline update |journal=Journal of Lower Genital Tract Disease |volume=18 |issue=2 |pages=93–100 |last2=Lawson |first2=H. W. |doi=10.1097/LGT.0000000000000021 |s2cid=410660 }}</ref> It has been established by the [[ISSVD]] that for the diagnosis to be made symptoms must last at least three months.'''<ref>{{cite journal | date = Apr 2016 | title = ISSVD, ISSWSH, and IPPS Consensus Terminology and Classification of Persistent Vulvar Pain and Vulvodynia | journal = J Sex Med | volume = 13 | issue = 4| pages = 607–12 | doi = 10.1016/j.jsxm.2016.02.167 | pmid = 27045260 | last1 = Bornstein | first1 = J. | last2 = Goldstein | first2 = A. T. | last3 = Stockdale | first3 = C. K. | last4 = Bergeron | first4 = S. | last5 = Pukall | first5 = C. | last6 = Zolnoun | first6 = D. | last7 = Coady | first7 = D. }}</ref>'''

<!-- Cause and Diagnosis -->
The causes of vulvodynia are  not fully understood, but there are many sub-types of vulvodynia with different causes,<ref name=Female/> including an excess of nerve fibers, hormonal imbalances, inflammation, and muscular dysfunction. Some factors influencing the disease may include [[genetics]], [[immunology]], and possibly [[diet (nutrition)|diet]].<ref name=Stock2013/> Diagnosis is by ruling out other possible causes.<ref name=Stock2013/> This may or may not include a biopsy of the area.<ref name=Stock2013/>

<!-- 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.<ref name=Stock2013/> Some of these measures include [[medication]]s, [[pelvic floor physical therapy]], [[surgery]], and [[counselling]].<ref name=Stock2013/> Vulvodynia is estimated to affect up to 10-28% of women.<ref name=Harlow/>

==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.<ref name=":0" />

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.<ref>{{cite news | title = Vulvodynia and Genital Pain | url = http://www.center4research.org/2010/03/vulvodynia-and-genital-pain/ | access-date = 2009-08-27 | date = October 2007 | author = National Research Center for Women and Families | url-status = dead | archive-url = https://web.archive.org/web/20110725153526/http://www.center4research.org/2010/03/vulvodynia-and-genital-pain/ | archive-date = 25 July 2011| author-link = National Research Center for Women and Families }}</ref> The pain can be provoked by touch ("provoked") or constant ("unprovoked"). Some cases of vulvodynia are [[Idiopathy|idiopathic]] where no specific cause can be determined.<ref name=":0">{{Cite web|title=Persistent Vulvar Pain|url=https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2016/09/persistent-vulvar-pain|access-date=30 October 2020|website=American College of Obstetricians and Gynecologists}}</ref>

===Vestibulodynia===
{{Main|Vestibulodynia}}

Vestibulodynia, formerly known as vulvar vestibulitis syndrome (VVS), or simply vulvar vestibulitis,<ref>{{cite journal |pmid=15568398 |year=2004 |last1=Moyal-Barracco |first1=M |title=2003 ISSVD terminology and classification of vulvodynia: A historical perspective |journal=The Journal of Reproductive Medicine |volume=49 |issue=10 |pages=772–7 |last2=Lynch |first2=P. J. }}</ref> refers to pain localized to the [[vulval vestibule|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.<ref>{{cite journal |doi=10.1080/02674659708408174 |title=The treatment of vulvar vestibulitis syndrome: Towards a multimodal approach |journal=Sexual and Marital Therapy |volume=12 |issue=4 |pages=305–311 |year=1997 |last1=Bergeron |first1=Sophie |last2=Binik |first2=Yitzchak M. |last3=Khalifé |first3=Samir |last4=Meana |first4=Marta |last5=Berkley |first5=Karen J. |last6=Pagidas |first6=Kelly }}</ref><ref>{{cite journal |doi=10.1097/00002508-199703000-00006 |pmid=9084950 |title=Vulvar Vestibulitis Syndrome: A Critical Review |journal=The Clinical Journal of Pain |volume=13 |issue=1 |pages=27–42 |year=1997 |last1=Bergeron |first1=Sophie |last2=Binik |first2=Yitzchak M. |last3=Khalifé |first3=Samir |last4=Pagidas |first4=Kelly }}</ref>

===Clitorodynia===

The pain of vulvodynia may extend into the [[clitoris]]; this is referred to as [[clitorodynia]].<ref>{{Cite web|url=https://www.nva.org/what-is-vulvodynia/|title=What is Vulvodynia?|website=The National Vulvodynia Association|access-date=2019-01-29}}</ref> Clitorodynia may be sometimes caused by [[clitoral|clitoris]] adhesions, a condition where the hood of the clitoris becomes stuck to the clitoris itself. Symptoms may include pain, hypersenstivity, 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.<ref>{{cite journal |last1=Romanello |first1=Jennifer |last2=Myers |first2=Monica |last3=Nico |first3=Elsa |last4=Rubin |first4=Rachel |journal=Sexual Medicine Reviews |date=March 2023 |volume=11 |issue=3 |title=Clitoral adhesions: a review of the literature |pages=196–201 |url=https://academic.oup.com/smr/article-abstract/11/3/196/7087163?redirectedFrom=PDF&casa_token=4N18Cq_HLWgAAAAA:8ADgli4HWPwXtmHI9U7RDf9T3S6uqVdLZJf-k0dcjwdKlFWFNUO4DNewRmQNQkGYQCQOVXliYVbx#409757386 |doi=10.1093/sxmrev/qead004 |pmid=36973166 |access-date=29 March 2024}}</ref> The prevalence of clitoral adhesions is unknown. Clitorodynia has been neglected in medical research and under-recognized in clincical practice.<ref>{{cite news |last1=Gross |first1=Rachel |title=News: Half the World Has a Clitoris. Why... (The New York Times) - Behind the headlines - NLM |url=https://www.ncbi.nlm.nih.gov/search/research-news/17461/#:~:text=Why%20Don't%20Doctors%20Study%20It%3F&text=The%20organ%20is%20%E2%80%9Ccompletely%20ignored,devastating%20to%20women's%20sexual%20health. |access-date=29 March 2024 |work=NCBI |agency=The New York Times |date=October 2022 |language=en}}</ref>

==Causes==
Vulvodynia has many different sub-types and causes. The disease is highly idiopathic. Identifying the cause is important to determine the appropriate treatment.<ref name="Female" />

Pain confined to the [[vulval vestibule]], known as [[vestibulodynia]], has at least three known sub-types:<ref name="Female">{{cite book |last1=Goldstein |first1=Andrew |editor-first1=Andrew T. |editor-first2=Caroline F. |editor-first3=Irwin |editor-first4=Jill M. |editor-first5=Sue W. |editor-first6=Gail |editor-last1=Goldstein |editor-last2=Pukall |editor-last3=Goldstein |editor-last4=Krapf |editor-last5=Goldstein |editor-last6=Goldstein |title=Female Sexual Pain Disorders: Evaluation and Management |date=2020 |pages=157–162 |edition=2 |doi=10.1002/9781119482598 |isbn=978-1-119-48266-6 |url=https://onlinelibrary.wiley.com/doi/book/10.1002/9781119482598}}</ref> 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 condition|chronic]] [[vaginal dryness]]. Others include genetic predisposition to inflammation,<ref name="pmid12593899">{{cite journal |doi=10.1016/S0301-2115(02)00276-2 |pmid=12593899 |title=Interleukin-1β gene polymorphism in women with vulvar vestibulitis syndrome |journal=European Journal of Obstetrics & Gynecology and Reproductive Biology |volume=107 |issue=1 |pages=74–77 |year=2003 |last1=Gerber |first1=Stefan |last2=Bongiovanni |first2=Ann Marie |last3=Ledger |first3=William J. |last4=Witkin |first4=Steven S. }}</ref> 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 infection]]s, [[bacterial vaginosis]], [[Human papillomavirus|HPV]], [[Herpes simplex virus|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.<ref>{{cite journal |doi=10.1016/S0140-6736(07)60197-4 |pmid=17276781 |title=Sexual sequelae of general medical disorders |journal=The Lancet |volume=369 |issue=9559 |pages=409–424 |year=2007 |last1=Basson |first1=Rosemary |last2=Weijmar Schultz |first2=Willibrord |s2cid=44628975 }}</ref> [[Pelvic floor dysfunction]] may be the underlying cause of some women's pain.<ref>{{cite news | title = Differential Diagnosis of Pelvic Floor Dysfunction and Vulvar Pain | url = http://www.medscape.org/viewarticle/465853| access-date = 2012-09-11 | date= October 2003 | author=Kellogg-Spadt, S}}</ref>

Many co-morbidities are commonly associated with vulvodynia, including [[fibromyalgia]], [[irritable bowel syndrome]], [[interstitial cystitis]], [[pelvic floor dysfunction]], [[endometriosis]], [[major depressive disorder|depression]] and [[anxiety|anxiety disorders]].<ref name="Hill 2021">{{cite journal |last1=Hill |first1=DA |last2=Taylor |first2=CA |title=Dyspareunia in Women. |journal=American Family Physician |date=15 May 2021 |volume=103 |issue=10 |pages=597–604 |pmid=33983001}}</ref>

==Diagnosis==
The condition is one of exclusion and other vulvovaginal problems should be ruled out. The diagnosis is based on the typical complaints of the patient, essentially normal physical findings, and the absence of identifiable causes per the differential diagnosis. Cotton swab testing is used to differentiate between generalized and localized pain and delineate the areas of pain and categorize their severity. Patients often will describe the touch of a cotton ball as extremely painful, like the scraping of a knife. A diagram of pain locations may be helpful in assessing the pain over time. The vagina should be examined, and tests, including wet mount, vaginal pH, fungal culture, and Gram stain, should be performed as indicated. Fungal culture may identify resistant strains.<ref>{{cite journal |pmid=15870521 |year=2005 |last1=Haefner |first1=H. K. |title=The vulvodynia guideline |journal=Journal of Lower Genital Tract Disease |volume=9 |issue=1 |pages=40–51 |last2=Collins |first2=M. E. |last3=Davis |first3=G. D. |last4=Edwards |first4=L |last5=Foster |first5=D. C. |last6=Hartmann |first6=E. D. |last7=Kaufman |first7=R. H. |last8=Lynch |first8=P. J. |last9=Margesson |first9=L. J. |last10=Moyal-Barracco |first10=M |last11=Piper |first11=C. K. |last12=Reed |first12=B. D. |last13=Stewart |first13=E. G. |last14=Wilkinson |first14=E. J. |doi=10.1097/00128360-200501000-00009|s2cid=18081230 |doi-access=free }}</ref>

Surveys have estimated that only about half of the women who meet the criteria for vulvodynia will seek medical help.<ref name="Harlow"/> Many will see several doctors before a correct diagnosis is made.<ref name="Harlow"/> Less than 2% of the people who seek help obtain a diagnosis.<ref>{{Cite journal|last1=Reed|first1=Barbara Diane|last2=Harlow|first2=Siobán Denise|last3=Sen|first3=Ananda|last4=Legocki|first4=Laurie Jo|last5=Edwards|first5=Rayna Monique|last6=Arato|first6=Nora|last7=Haefner|first7=Hope Katharine|date=February 2012|title=Prevalence and demographic characteristics of vulvodynia in a population-based sample|url= |journal=American Journal of Obstetrics and Gynecology|language=en|volume=206|issue=2|pages=170.e1–170.e9|doi=10.1016/j.ajog.2011.08.012|pmc=3779055|pmid=21963307}}</ref> Many gynecologists are not familiar with this family of conditions. Affected women are also often hesitant to seek treatment for chronic vulvar pain, especially since many women begin experiencing symptoms around the same time they become sexually active. Moreover, the absence of any visible symptoms means that before being successfully diagnosed many patients have been told that the pain is "in their head".<ref>{{Cite journal|last1=Shallcross|first1=Rebekah|last2=Dickson|first2=Joanne M.|last3=Nunns|first3=David|last4=Taylor|first4=Kate|last5=Kiemle|first5=Gundi|date=2019-04-01|title=Women's Experiences of Vulvodynia: An Interpretative Phenomenological Analysis of the Journey Toward Diagnosis|url= |journal=Archives of Sexual Behavior|language=en|volume=48|issue=3|pages=961–974|doi=10.1007/s10508-018-1246-z|issn=1573-2800|pmc=6418055|pmid=30047005}}</ref> The misattribution of women's vulvo-vaginal pain to a psychological origin rather than a medical one is traceable back to the influence of Freudian [[psychoanalysis]].<ref name="ImperfectIntercourse">{{cite journal |last1=Srajer |first1=Hannah |title=Imperfect Intercourse: Sexual Disability, Sexual Deviance, and the History of Vaginal Pain in the Twentieth-Century United States |journal=Journal of American History |date=March 2023 |volume=109 |issue=4 |pages=782–803 |doi=10.1093/jahist/jaad001 |url=https://academic.oup.com/jah/article/109/4/782/7109655 |access-date=29 March 2024}}</ref>

===Differential diagnosis===
# Infections: [[urinary tract infection]],<ref>{{cite journal|doi=10.1007/s00192-017-3472-7| title=Lower urinary tract symptoms that predict microscopic pyuria | year=2018 | last1=Khasriya | first1=Rajvinder | last2=Barcella | first2=William | last3=De Iorio | first3=Maria|author3-link=Maria De Iorio | last4=Swamy | first4=Sheela | last5=Gill | first5=Kiren | last6=Kupelian | first6=Anthony | last7=Malone-Lee | first7=James | journal=International Urogynecology Journal | volume=29 | issue=7 | pages=1019–1028 | pmid=28971220 | pmc=6004270 }}</ref> [[candidiasis]], [[herpes]], [[Human papillomavirus infection|HPV]], [[vaginitis]]
# Dermetological diseases: [[lichen sclerosus]], [[lichen planus]]
# Neoplasm: [[Extramammary Paget's disease|Paget's disease]], [[vulvar carcinoma]]
# Neurologic disorder: [[neuralgia]] secondary to herpes virus, spinal nerve injury,<ref>{{Cite journal |last1=Torres-Cueco |first1=Rafael |last2=Nohales-Alfonso |first2=Francisco |date=2021-06-21 |title=Vulvodynia—It Is Time to Accept a New Understanding from a Neurobiological Perspective |journal=International Journal of Environmental Research and Public Health |volume=18 |issue=12 |pages=6639 |doi=10.3390/ijerph18126639 |doi-access=free |issn=1661-7827 |pmc=8296499 |pmid=34205495}}</ref> [[pudendal nerve entrapment]]

In recent years, diagnostic algorithms for the diagnosis of the various sub-types of and causes of vulvar pain have been developed and refined. The [[International Society for the Study of Women's Sexual Health]] ([[ISSWSH]]) supports this diagnostic algorithm.<ref>https://www.isswsh.org/images/Persistent_Vulvar_Pain_Diagnostic_and_Treatment_Algorithm.jpg</ref>

==Treatment==
There are a number of possible treatments with none being uniformly effective.<ref name=Stock2013/> Treatments include:

===Medications===
A number of medications have been used to treat vulvodynia.<ref name=Stock2013/> Evidence to support their use, however, is often poor.<ref name=Stock2013/> These include creams and ointments containing [[lidocaine]], [[estrogen]] or [[tricyclic antidepressant]]s.<ref name=Stock2013/> Antidepressants and anticonvulsants in pill form are sometimes tried but have been poorly studied.<ref name=Stock2013/> Injectable medications included [[steroid]]s and [[botulinum toxin]] have been tried with limited success.<ref name=Stock2013/>

===Physical therapy===
Many patients who have vulvodynia also have high-tone pelvic floor, meaning that their pelvic floor muscles are too tight. This may contribute to their pain in the area. [[Pelvic floor physical therapy]] may help treat the [[pelvic floor dysfunction]] and help the patient gain greater control over their pelvic floor muscles.

===Surgery===
[[Vestibulectomy]] is a surgery to remove the [[vulval vestibule]], and it may be recommended for certain patients. It has been suggested as a first-line treatment for neuroproliferative [[vestibulodynia]].<ref>{{cite journal |last1=King |first1=Michelle A. |last2=Mitchell |first2=Leia S. |last3=Belkin |first3=Zoe |last4=Goldstein |first4=Andrew T. |title=Vulvar Vestibulectomy for Neuroproliferative-Associated Provoked Vestibulodynia: A Retrospective Analysis |journal=Journal of Gynecologic Surgery |date=April 2018 |volume=34 |issue=2 |pages=58–62 |doi=10.1089/gyn.2017.0030 |url=https://www.liebertpub.com/doi/pdf/10.1089/gyn.2017.0030 |access-date=29 March 2024 |language=en |issn=1042-4067}}</ref> It has successful long-term outcomes,<ref name="Longterm">{{cite journal |last1=Arik |first1=David |last2=Bornstein |first2=Jacob |title=Evaluation of Long-Term Surgical Success and Satisfaction of Patients After Vestibulectomy |journal=Journal of Lower Genital Tract Disease |date=October 2020 |volume=24 |issue=4 |pages=399–404 |url=https://oce.ovid.com/article/00128360-202010000-00013/HTML |doi=10.1097/LGT.0000000000000552|pmid=32569021 }}</ref> but is often only offered after conservative measures have failed.

===Lifestyle===
A number of lifestyle changes are often recommended such as using cotton underwear, not using substances that may irritate the area, and using [[personal lubricant|lubricant]] during sex.<ref name=Stock2013/> The use of alternative medicine has not been sufficiently studied to make recommendations.<ref name=Stock2013/>

===Counseling===
Gynaecologist-led educational seminars delivered in a group format have a significant positive impact on psychological symptoms and sexual functioning in women who have provoked (caused by a stimulus such as touch or sexual activity) [[vestibulodynia]] (pain localized in the [[vulvar vestibule]]).<ref>{{cite journal |pmid=20181314 |year=2010 |last1=Brotto |first1=L. A. |title=Impact of educational seminars on women with provoked vestibulodynia |journal=Journal of Obstetrics and Gynaecology Canada |volume=32 |issue=2 |pages=132–8 |last2=Sadownik |first2=L |last3=Thomson |first3=S |doi=10.1016/s1701-2163(16)34427-9}}</ref>

==Epidemiology==
The percentage of women affected is not entirely clear, but estimates range between 10-28%.<ref name="Hill 2021" /><ref name="Harlow" /> Many other conditions that are not truly vulvodynia (diagnosis is made by ruling out other causes of vulvar pain) could be confused with it. Vulvar pain is a quite frequent complaint in women's health clinics.

==Patient communities==

Given the difficulty of getting diagnosed and treated for vulvodynia,<ref name="Harlow">{{cite journal |last1=Harlow |first1=Bernard |last2=Kunita |first2=Christine |last3=Nguyen |first3=Ruby |last4=Rydell |first4=Sarah |last5=Turner |first5=Rachel |last6=MacLehose |first6=Richard |title=Prevalence of symptoms consistent with a diagnosis of vulvodynia: population-based estimates from 2 geographic regions |journal=American Journal of Obstetrics and Gynecology |date=January 2014 |volume=210 |issue=1 |pages=40.e1–8 |doi=10.1016/j.ajog.2013.09.033 |pmid=24080300 |pmc=3885163 }}</ref> patients have formed communities to help each other access healthcare and to advocate for better recognition of the disease.

Founded in 1994, the [[National Vulvodynia Association]] (NVA) is a non-profit that helps connect patients to each other and to medical providers who can help them. They maintain a healthcare provider referral list and have geographically-organized patient support groups. The NVA secured the first funding for vulvodynia research in the 1990s, and it continues to provide seed grants for research on vulvodynia.<ref name="NVA">{{cite web |title=NVA |url=https://www.nva.org/ |website=National Vulvodynia Association |access-date=29 March 2024}}</ref>

[[Tight Lipped]] is a second, younger community of vulvodynia patients. Founded in 2019, Tight Lipped started as a story-telling podcast focused on ending the stigma and mystery surrounding vulvovaginal pain. It has evolved into a grassroots, patient-led organization devoted to changing how chronic vulvovaginal pain conditions like vulvodynia are understood by the medical community and by society.<ref name="LATImes">{{cite news |last1=Brown |first1=Kailyn |title=Painful sex? Broken vaginas? This underground zine normalizes the taboo |url=https://www.latimes.com/lifestyle/story/2024-01-18/opening-up-zine-from-tight-lipped-normalizes-the-taboo-about-vaginal-pain |access-date=29 March 2024 |work=Los Angeles times}}</ref><ref name="Tight Lipped">{{cite web |title=Tight Lipped |url=https://www.tightlipped.org/ |website=Tight Lipped |access-date=29 March 2024}}</ref>

There are several online communities of patients on sites like [[Facebook]] and [[Reddit]]. Because medical knowledge is so hard to access, patients resort to other patients' knowledge to get help.

==References==
{{Reflist}}

== External links ==

{{Medical resources
| ICD10           =
| ICD9            = {{ICD9|625.7}}
| MeSH            = D056650
| ICD10CM         = {{ICD10CM|N94.81}}
}}
{{Female diseases of the pelvis and genitals}}
{{Authority control}}

[[Category:Chronic pain syndromes]]
[[Category:Gynaecologic disorders]]
[[Category:Neurocutaneous conditions]]
[[Category:Pain]]