Pain Relief: The L.A. Pain Clinic Guideby Sota Omoigui

VULVODYNIA

Vulvodynia is a medical term that means ‘painful vulva’. It feels like a wicked yeast infection – only worse. Burning, itching and pain are experienced in the skin of the vaginal entryway and sometimes the labia or clitoris. The term can cover a wide variety of vulvar pain syndromes including various infections and skin disorders. Some cases of vulvodynia may be due to compression or infection leading to inflammation of the pudendal nerve, one of the main nerves that relays sensation to and from the genitals. The term is also used to refer to vestibulitis or Vulvar Vestibulitis Syndrome (VVS), which is an inflammation of the vestibule, or opening into the vagina and the tissues immediately around the vaginal opening. This condition is sometimes also called ‘vestibular adenitis’. Symptoms of vulvodynia or vestibulitis can range in severity from mild to severe. In mild cases, a burning or stinging sensation is noted during intercourse or when tampons are inserted. Upon touching the area with a cotton swab, pain is felt when the hymen and inner vaginal lips are touched. There also may be redness and swelling. In severe cases, the pain can be agonizing and much of the vulvar can be reddened, swollen and very inflamed. Often the edges of the inner vaginal lips are very sensitive and the pain so severe that it makes walking difficult. There may be a constant itching or stinging sensation in the grooves between the large and small vaginal lips. Wearing underwear may be very uncomfortable as the slightest touch to the area may result in excruciating pain. Other signs include pain or discomfort upon touching the pubic hair, over the vulvar skin or in certain spots. These sensations may extend to the rectal area or skin of the perineum. The clitoris can become involved, becoming painful or hypersensitive and there may be shooting pains from the clitoris up the abdomen. Sexual intercourse and urination may be very painful. Sometimes vestibulitis may be part of bladder and/or urethral inflammation as seen in the interstitial cystitis or urethral syndrome. The lining of both vagina and bladder arise from the same tissue during fetal development; thus when one becomes inflamed, the inflammation may spread to the adjoined areas. There may be an association between vestibulitis and chronic candida infection, human papiloma and herpes simplex virus infection. Overuse of topical corticosteroid creams to treat vulvar itching may cause thinning and sloughing of the top layers of skin. Vestibulitis may occur with the use of the acne drug Acutane or the anti-cancer drug fluorouracil. There may also be an association with high levels of urine oxalate and with the fibromyalgia syndrome, an inflammatory muscle pain disorder.
Keep the vulvar clean and dry. Install a bidet that removes the need to wipe with toilet paper and which delivers both a rinse and an air dry. There are many brands that can be found online. One company that offers several models is Sanicare.com (800 878-4791 or 254 592-8076). Rinsing with plain or distilled water several times a day may be helpful. Perfumed or even plain soaps may aggravate the irritation. Natural glycerin soap may be helpful as it has no residual drying effects. A hand held shower massager is preferable to an overhead nozzle as it makes it much easier to wash away any soap residue that remains after washing. Washing the vulvar area with distilled water instead of tap water may help avoid irritation from chlorine. After washing, a hand held blow dryer (on cool) may be used to further dry the skin prior to applying corn starch. Carefully avoid all potential irritants in your underwear, such as laundry soaps and bleaches. You may use a mild non-perfumed soap such as Castile soap and run twice through the rinse cycle. Or you may do without underwear all together. If you must wear pantyhose or stockings for work, wear brands with a cotton crotch over the all-cotton underwear. Then slit the pantyhose crotch to relieve binding. Or you may use old fashioned garter belts and stockings. A product called Scantihose is available from several online retailers and was designed to avoid bumps and ridges in clothing. It extends completely up the leg, unlike older stockings that can’t be worn with shorter skirts. To relieve pressure on the vulvar area when sitting you may use a pressure relief cushion such as Isch-Dish available at www.spanamerica.com (Ph: 800 962-5542). If you have pain with urination, you may apply A & D Ointment, Desitin or Vaseline to soothe and protect the inflamed area. Another way to help painful urination is to pour a cup of water while urinating: this dilutes the urine and helps to wash away any irritating residue. You may also sit slightly forward when urinating as this directs the stream straight down and it does not touch the skin. Do pelvic floor muscle exercises daily or as often as you can.
In a few people vulvodynia clears up on its own after 6-12 months. Vulvar pain that is due to infection e.g. ureaplasma, candida or strep will respond to the appropriate treatment. Topical estrogen creams e.g. Estrace (0.01% Estradiol) may provide relief. Estrace thickens or toughens the skin, and increases blood supply. It may help you even if you have not reached menopause or do not have estrogen deficiency. If you find vaginal creams painful (possibly from the additives such as alcohol or parabens), your physician may mix 5-10% Lidocaine solution in a petroleum gel base or mineral oil e.g. Emu oil. This will help to reduce the sensitivity in your vulvar area as well as make sex more tolerable. Compresses made from prophyllin powder may provide soothing relief. Take herbal supplements such as Quercetin, Rutin, Curcumin, Red Wine tablets, Cinnamon and Ground Clove Extracts. These contain polyphenols which are the best anti-inflammatory agents that nature has provided to us. Drugs that help control vaginal nerve inflammation include a subcutaneous injection of the biologic drug Kineret as well as an intravenous (IV) or intramuscular (IM) injection of cortisone, plus an IV infusion of the anti-seizure drug Depacon combined with IV infusion of magnesium sulfate and IV mini bolus doses of Ketamine. Oral medications that are used to treat the pain include anti-seizure medications e.g. Trileptal, Topamax, Lyrica or Neurontin; antidepressants like Lexapro, and strong pain relievers like oxycodone or hydromorphone. Injection of immune enhancing drugs (e.g. interferon alpha-2b) into the vulvar area that is infected with the human papilloma virus may provide relief of pain and other symptoms. In addition to medications, heat destruction (thermocoagulation), cold destruction (cryo-neurolysis) or nerve block of the pudendal nerve with local anesthetic, steroids or glycerol may provide good long-term relief. A side effect of these procedures may be prolonged numbness of the vulvar. Before any procedure your doctor should explain the risks and benefits to you. Biofeedback and pelvic muscle exercises involving relaxation and muscle strengthening may be helpful. Vulvar pain due to skin conditions such as dermatitis, lichen sclerosis may be relieved with topical corticosteroids. Reducing the amount of oxalate in your diet may be helpful. These include tea, spinach, beer, berry juices, baked beans in tomato sauce, peanuts, peanut butter creams, pecans, soybean curd, concord grapes e.t.c. In addition, do not take more than 250 mg of Vitamin C a day (because it is a chemical precursor of calcium oxalate). Only drink small amounts of milk or dairy products to reduce the amount of calcium oxalate in the body. our physician may prescribe calcium citrate to neutralize high blood or urine levels of oxalate. If intercourse is painful, you can apply xylocaine jelly to numb the sore areas. During your menstrual period, if you cannot tolerate a tampon string, you may cut off the string prior to insertion. If menstrual pads are too painful, you may use rolls of absorbent cotton. Soothing relief may be obtained by applying warm soaked tea bags to the area. This can be done by placing the tea bags on menstrual pads to hold them in place or you can take a sitz bath in which tea bags have been soaked. Surgical treatment may include removal of painful areas such as the vulvar (bartholin’s) glands, excision of the pudendal nerve and/ or laser therapy to destroy underlying vulvar blood vessels. Psychological counseling by a therapist experienced in chronic illness can help in coping with this disorder.

Call your Doctor: if your pain is severe or if you have a reaction to your medications.

National Organization: : National Vulvodynia Association (www.nva.org), P.O. Box 4491, Silver Spring, Maryland 20914-4491. Phone: 301 949-5114 or 301 299-0775 The Vulvar Pain Foundation, Post Office Drawer 177, Graham, North Carolina 27253. Phone: 910 226-0704.