1. VULVAL PAINVULVAL PAIN
SYNDROMESYNDROME
BYBY
DR SARITA SABHARWALDR SARITA SABHARWAL
SENIOR CONSULTANTSENIOR CONSULTANT
MATA CHANAN DEVI HOSPITALMATA CHANAN DEVI HOSPITAL

2. Vulval pain syndromeVulval pain syndrome
 The term vulval pain syndrome comprisesThe term vulval pain syndrome comprises
enigmatic causes of vulval pain andenigmatic causes of vulval pain and
include a heterogeneous group of womeninclude a heterogeneous group of women
who are difficult to manage.who are difficult to manage.
 VPS can be classified as following –VPS can be classified as following –
1. Dysaesthetic vulvodynia1. Dysaesthetic vulvodynia
2. Vestibulodynia [Vulval vestibulitis]2. Vestibulodynia [Vulval vestibulitis]

3. Dysaesthetic vulvodyniaDysaesthetic vulvodynia
 This term was introduced by ISSVDThis term was introduced by ISSVD
{international society for study of vulval{international society for study of vulval
diseases}.diseases}.
 It is defined as ‘chronic vulvar discomfort’It is defined as ‘chronic vulvar discomfort’
characterized by burning , stinging,characterized by burning , stinging,
rawness or irritation of vulva .rawness or irritation of vulva .
 It may be generalized or localized ;It may be generalized or localized ;
provoked or unprovoked pain.provoked or unprovoked pain.
 It’s a constant neuralgic type of pain.It’s a constant neuralgic type of pain.

4. Dysaesthetic vulvodynia {contd}Dysaesthetic vulvodynia {contd}
 Clinical examination is normal.Clinical examination is normal.
 Women are typically premenopausal orWomen are typically premenopausal or
postmenopausal.postmenopausal.
 They have a long history of multiple orThey have a long history of multiple or
inappropriate use of topical agents.inappropriate use of topical agents.
 There is h/o superficial dyspareunia which is notThere is h/o superficial dyspareunia which is not
usually reported as these women are lessusually reported as these women are less
sexually active.sexually active.
 Sexual dysfunction is common.Sexual dysfunction is common.

5. Dysaesthetic vulvodynia {contd}Dysaesthetic vulvodynia {contd}
 There may be h/o rectal, perineal orThere may be h/o rectal, perineal or
urethral discomfort.urethral discomfort.
 It may be associated with other chronicIt may be associated with other chronic
pain syndromes like glossodynia orpain syndromes like glossodynia or
chronic low backache.chronic low backache.
 There is great level of psychologicalThere is great level of psychological
distress as compared to otherdistress as compared to other
vulvodynias.vulvodynias.

6. VestibulodyniaVestibulodynia
 It is defined asIt is defined as
-Severe pain on vestibular touch or vaginal-Severe pain on vestibular touch or vaginal
entry.entry.
-Tenderness localized within the vestibule-Tenderness localized within the vestibule
on pressure.on pressure.
-Physical findings of erythema confined to-Physical findings of erythema confined to
the vestibule.the vestibule.

7. Vestibulodynia{ contd}Vestibulodynia{ contd}
 Clinical examinationClinical examination
demonstratesdemonstrates
tenderness within thetenderness within the
vestibulevestibule
 Common test used isCommon test used is
the cotton swab testthe cotton swab test

8. Vestibulodynia{ contd}Vestibulodynia{ contd}
 Another test is to use algesiometer whereAnother test is to use algesiometer where
variable degrees of pressure is applied.variable degrees of pressure is applied.
 Vestibular erythema may or may not be presentVestibular erythema may or may not be present
and if present the degree of redness does notand if present the degree of redness does not
correlate with the degree of symptoms.correlate with the degree of symptoms.
 Gynaecological examination is painful.Gynaecological examination is painful.
 There is tampon intolerance.There is tampon intolerance.
 There may be h/o use of multiple topicalThere may be h/o use of multiple topical
medications.medications.

9. Vestibulodynia{ contd}Vestibulodynia{ contd}
 Women typically are Caucasians , aged 20-24Women typically are Caucasians , aged 20-24
years who present with h/o provoked pain oryears who present with h/o provoked pain or
superficial dyspareunia.superficial dyspareunia.
 Pain may be present from the first attemptedPain may be present from the first attempted
sexual intercourse or after a period of normalsexual intercourse or after a period of normal
sexual activity.sexual activity.
 Fear , anger and frustration are commonlyFear , anger and frustration are commonly
encountered in these womenencountered in these women
 A period of at least 6 months is given beforeA period of at least 6 months is given before
labeling the condition as vestibulodynialabeling the condition as vestibulodynia

10. AssessmentAssessment
Most imperative to exclude the following diseasesMost imperative to exclude the following diseases
before arriving at the diagnosis of VPS-before arriving at the diagnosis of VPS-
 The common ones are-The common ones are-
-Inflammatory vulval diseases like Lichen-Inflammatory vulval diseases like Lichen
Sclerosus and Eczema.Sclerosus and Eczema.
-Tight posterior fourchette and Fragile Fissured-Tight posterior fourchette and Fragile Fissured
Vulval SyndromeVulval Syndrome
-Symptomatic Dermographism-Symptomatic Dermographism

11. AssessmentAssessment
 Less common causes are –Less common causes are –
-Apthous ulceration-Apthous ulceration
-Erosive Lichen Planus-Erosive Lichen Planus
-Bullous Disorders-Bullous Disorders
-Herpes Simplex infections-Herpes Simplex infections
-Pudendal Canal syndrome-Pudendal Canal syndrome

12. AetiologyAetiology
 Exact cause is not known . The following are theExact cause is not known . The following are the
possible causes-possible causes-
1. Candida infection - leads to the generation of1. Candida infection - leads to the generation of
an immune response causing inflammation andan immune response causing inflammation and
pain even in absence of an active infection.pain even in absence of an active infection.
2. Iatrogenic - like use of topical agents for pain2. Iatrogenic - like use of topical agents for pain
like antifungal creams, soaps, bubble baths andlike antifungal creams, soaps, bubble baths and
hygiene sprays etc.hygiene sprays etc.
3. Psychological disorders - like stress and3. Psychological disorders - like stress and
anxiety leading to increased pain perception.anxiety leading to increased pain perception.

13. Aetiology contd.Aetiology contd.
4.Genetic predisposition - more common in4.Genetic predisposition - more common in
Caucasians and is less common in Blacks andCaucasians and is less common in Blacks and
Asian population.Asian population.
5.Dietary factors - high oxalate diet causing5.Dietary factors - high oxalate diet causing
increase in urinary excretion of oxalates leadingincrease in urinary excretion of oxalates leading
to burning micturition & vulvodynia.to burning micturition & vulvodynia.
6.Hormonal causes - include estrogen deficiency6.Hormonal causes - include estrogen deficiency
and oral contraceptive pill intake.Mucosaland oral contraceptive pill intake.Mucosal
atrophy makes nerve endings superficialatrophy makes nerve endings superficial

14. Aetilogy contd.Aetilogy contd.
7. Tension in levator ani muscles could be one of7. Tension in levator ani muscles could be one of
the causes.the causes.
8. It may be a part of Complex Regional Pain8. It may be a part of Complex Regional Pain
Syndrome {CRPS} like fibromyalgia , interstitialSyndrome {CRPS} like fibromyalgia , interstitial
cystitis,overactiv ebladder,irritable bowel syn. Thecystitis,overactiv ebladder,irritable bowel syn. The
cause being ‘Wind Up’ phenomenon in whichcause being ‘Wind Up’ phenomenon in which
there is increased activity in the dorsal horn cellsthere is increased activity in the dorsal horn cells
of spinal cord after repetitive activation of theof spinal cord after repetitive activation of the
primary afferent C-fibers.primary afferent C-fibers.

16. ManagementManagement
 Spontaneous recovery may occur sometimes .Spontaneous recovery may occur sometimes .
 Management options include –Management options include –
-Vulvar care-Vulvar care
-Topical therapy-Topical therapy
-Oral medications-Oral medications
-Biofeedback and Physical therapy-Biofeedback and Physical therapy
-Intralesional injections-Intralesional injections
-Interferon therapy-Interferon therapy
-Low oxalate diet-Low oxalate diet
-Surgical treatment-Surgical treatment
-Multidisciplinary approach-Multidisciplinary approach

17. Vulvar careVulvar care
 100% cotton under wears.100% cotton under wears.
 No under wears at night.No under wears at night.
 No soaps to be used on vulva.No soaps to be used on vulva.
 Use of plain water.Use of plain water.
 Use of lubricants before intercourse like KY jelly.Use of lubricants before intercourse like KY jelly.
 Use of natural oils like olive oil, sweet almond oilUse of natural oils like olive oil, sweet almond oil
and wheat gram oil.and wheat gram oil.
 Vulva should be patted dry after washing.Vulva should be patted dry after washing.
 If dryness is more use of Vaseline is advised.If dryness is more use of Vaseline is advised.

18. Topical therapyTopical therapy
 Lignocaine jelly 2%Lignocaine jelly 2%
 Lignocaine & Prilocaine jellyLignocaine & Prilocaine jelly
 Evalon creamEvalon cream
 Topical Amitriptyline 2% creamTopical Amitriptyline 2% cream

19. Oral medicationsOral medications
 Antidepressants are the first line therapy.They block re-Antidepressants are the first line therapy.They block re-
uptake of serotonin & noradrenalin and relieve pain byuptake of serotonin & noradrenalin and relieve pain by
inhibition of Na channel. Most commonly used–inhibition of Na channel. Most commonly used–
AmitriptylineAmitriptyline
 Dose -5-10mg before bedtime. May be increasedDose -5-10mg before bedtime. May be increased
weekly by 10-25mg depending on response. Maximumweekly by 10-25mg depending on response. Maximum
dose 150mg/nightdose 150mg/night
 Side effects are-Side effects are-
-dry mouth-dry mouth
-drowsiness-drowsiness
-constipation-constipation
-overdose results in seizures, MI, thrombocytopenia.-overdose results in seizures, MI, thrombocytopenia.
# Less commonly used antidepressants are Nortriptyline,# Less commonly used antidepressants are Nortriptyline,
Desipramine, Venlafaxine.Desipramine, Venlafaxine.

20. Anticonvulsants contdAnticonvulsants contd
 Carbamazepine is also usedCarbamazepine is also used
 Starting dose is 100mg orally at night, increased to 200-Starting dose is 100mg orally at night, increased to 200-
400mg BD . Maximum dose is 1200mg.400mg BD . Maximum dose is 1200mg.
 Side effects areSide effects are
- dizziness- dizziness
- drowsiness and confusion- drowsiness and confusion
- blurred vision- blurred vision
- rash- rash
- increased liver transaminases- increased liver transaminases
- agranulocytosis and thrombocytopenia.- agranulocytosis and thrombocytopenia.
# Less commonly used anticonvulsant is Topiramate# Less commonly used anticonvulsant is Topiramate
# Other drugs used are Tramadol and analogue of# Other drugs used are Tramadol and analogue of
Codeine.Codeine.

21. AnticonvulsantsAnticonvulsants
 Gabapentin started at a dose ofGabapentin started at a dose of
- 300mg OD for 3 days followed by300mg OD for 3 days followed by
- 300mg BD for 3 days followed by300mg BD for 3 days followed by
- 300mg TDS300mg TDS
- Maximum dose is 3600mg/day and no more thanMaximum dose is 3600mg/day and no more than
1200mg should be given at a time .Dose adjustment is1200mg should be given at a time .Dose adjustment is
required in renal insufficiency.required in renal insufficiency.
- A time of 3-8 wks is required for the drug to becomeA time of 3-8 wks is required for the drug to become
effective.effective.
# Side effects are-# Side effects are-
- SomnolenceSomnolence
- DizzinessDizziness
- GIT symptomsGIT symptoms
- Mild peripheral edemaMild peripheral edema
- Gait and balance problems in elderly.Gait and balance problems in elderly.

22. Biofeedback and physical therapyBiofeedback and physical therapy
 It involves measuring nerve and muscleIt involves measuring nerve and muscle
tension of pelvic floor by a meter ortension of pelvic floor by a meter or
colored light Patient has to self assesscolored light Patient has to self assess
the tension and try to relax.the tension and try to relax.
 In a study conducted by Hartmann andIn a study conducted by Hartmann and
Nelson a group of women with vulvodyniaNelson a group of women with vulvodynia
undergoing physical therapy were studied.undergoing physical therapy were studied.
71% women showed 50% improvement in71% women showed 50% improvement in
symptoms .symptoms .

23. Intralesional injectionsIntralesional injections
 Includes trigger point injections of steroidsIncludes trigger point injections of steroids
and Bupivacaine in a dose of 20-40mgand Bupivacaine in a dose of 20-40mg
Triamcinalone with 25% BupivacaineTriamcinalone with 25% Bupivacaine
monthly.monthly.
 Injections may also be given as aInjections may also be given as a
pudendal block.pudendal block.

24. Interferon therapyInterferon therapy
 Includes intravestibular injections of 1.5Includes intravestibular injections of 1.5
million units of interferon – alpha.million units of interferon – alpha.
 Disadvantages –Disadvantages –
- only short term relief- only short term relief
- extremely painful- extremely painful
- not routinely available.- not routinely available.

25. Low oxalate dietLow oxalate diet
 Avoid foods like spinach, beetroot, wheatAvoid foods like spinach, beetroot, wheat
germ, chocolate, tea etc.germ, chocolate, tea etc.
 Calcium citrate supplementation - to bindCalcium citrate supplementation - to bind
the oxalates and increase their urinarythe oxalates and increase their urinary
excretion.excretion.

26. Surgical treatmentSurgical treatment
 Last mode of treatment , used when otherLast mode of treatment , used when other
treatment options fail.treatment options fail.
 Modified Vestibulectomy- PROCEDURE OFModified Vestibulectomy- PROCEDURE OF
CHOICE.CHOICE.
 Preoperative psychological counseling and postPreoperative psychological counseling and post
operative sex therapy increases the success ofoperative sex therapy increases the success of
surgery.surgery.
 other surgical procedures areother surgical procedures are
- Local Excision- Local Excision
- Perineoplasty and LASER Vaporisation- Perineoplasty and LASER Vaporisation
# They are less effective than Vestibulectomy and# They are less effective than Vestibulectomy and
hence are not commonly used.hence are not commonly used.

31. Modified VestibulectomyModified Vestibulectomy
 Complications-Complications-
- Blood loss- Blood loss
- Wound infection- Wound infection
- Granulation tissue formation- Granulation tissue formation
- Chronic fissuring- Chronic fissuring
- Bartholin’s duct cyst formation- Bartholin’s duct cyst formation
- Decreased lubrication- Decreased lubrication
- Continued pain- Continued pain

32. Multidisciplinary approachMultidisciplinary approach
 This employs the following-This employs the following-
- Clinical Psychologists- Clinical Psychologists
- Pain Management teams- Pain Management teams
- Psychosexual Counselors- Psychosexual Counselors
- Clinicians- Clinicians
- Physiotherapists- Physiotherapists
- Partner support is a must.- Partner support is a must.

33. Pain managementPain management
 The `Pain Gate Theory ’ of Melzack andThe `Pain Gate Theory ’ of Melzack and
Wall’s is employed. The theory states thatWall’s is employed. The theory states that
the pain messages from the gates ofthe pain messages from the gates of
spinal cord travel to the brain . Thesespinal cord travel to the brain . These
gates tend to be more in women withgates tend to be more in women with
stress, tension and anxiety.stress, tension and anxiety.
 Therapies like relaxation , exercise andTherapies like relaxation , exercise and
mobility close these gates and hencemobility close these gates and hence
relieve the pain.relieve the pain.

34. Key points for clinical practiceKey points for clinical practice
 A detailed history and clinical examinationA detailed history and clinical examination
is necessary for diagnosis of these twois necessary for diagnosis of these two
groups.groups.
 Surgical option is only available forSurgical option is only available for
Vestibulodynia.Vestibulodynia.
 Tricyclic antidepressants are the first lineTricyclic antidepressants are the first line
management for Dysaesthetic Vulvodynia.management for Dysaesthetic Vulvodynia.
 A multidisciplinary approach is beneficialA multidisciplinary approach is beneficial
for chronic patients.for chronic patients.

35. THANK YOUTHANK YOU