Clinical Management of Vulvodynia: Tips and Tricks 2011th Ed.

1. Epidemiology of Vulvar Pain and its Sexual Comorbidities

Alessandra Graziottin^{1, 2} and Filippo Murina³

(1)

Center of Gynecology and Medical Sexology, H. San Raffaele Resnati, Milan, Italy

(2)

Graziottin Foundation for the cure and care of pain in women, Italy

(3)

Department of Vulvar Disease V. Buzzi Hospital Obstetrics and Gynecological Clinic, University of Milan, Milan, Italy

Abstract

In the United States, up to 15% of all women suffer from chronic vulvar pain, which may be assumed to be vulvodynia, at some point in their lives. Hence, up to 14-million women are affected by vulvodynia during their lifetimes, with the condition accounting for 10-million doctor visits annually. Results from research on the epidemiology (the study of the distribution and causes) of vulvodynia have helped to clarify the magnitude of the problem.

Vulvodynia is not a rare condition. Studies suggest that up to 15% of gynecology clinic populations have the disorder at any given time.

In the United States, up to 15% of all women suffer from chronic vulvar pain, which may be assumed to be vulvodynia, at some point in their lives. Hence, up to 14-million women are affected by vulvodynia during their lifetimes, with the condition accounting for 10-million doctor visits annually. Results from research on the epidemiology (the study of the distribution and causes) of vulvodynia have helped to clarify the magnitude of the problem.

Vulvodynia was first described by Thomas in 1880 as hyperaesthesia of the vulva, that is “excessive sensibility of the nerves supplying the mucous membrane of some portion of the vulva”.

The prevalence of vulvodynia may be underestimated, partially because some physicians dismiss the problem as being psychological in origin and relatively unimportant. Also, affected women may be reluctant to discuss their symptoms, which they may perceive as unusual and possibly ‘all in the mind’.

In a 2003 survey of 5000 women between the ages of 18 and 64 (3358 surveys returned and analyzed; 67.16% response rate), 15.6% of respondents reported a history of chronic burning, knife-like or sharp pain, or pain on contact, that lasted for 3 months or longer, at some point during their lives (Harlow and Stewart, 2003).

As vulvodynia receives increased attention by both the medical profession and the media, however, more women are aggressively seeking care. As a result, a higher prevalence for vulvodynia than had previously been recognized is coming to be appreciated.

A 2001 study of women in the Boston area revealed that chronic burning, knife-like pain, or pain on contact, that lasted at least 3 months or longer in the lower genital tract occurred frequently. These symptoms were reported by White, African American, and Hispanic women of all ages, and nearly 40% of these women chose not to seek treatment. Of the women who sought treatment, 60% consulted three or more doctors, and 40% remained undiagnosed after three medical consultations. These researchers estimated that about 16% of women experience symptoms consistent with vulvodynia in their lifetimes.

Symptom onset was most prevalent between the ages of 18 and 25 years, with lowest prevalence after age 35 years. Compared with controls, women with vulvar pain were seven-times more likely to report difficulty and pain with their first tampon use.

TIP: This complaint, too often dismissed as a minor information, is of the highest clinical importance: it should immediately suggest to evaluate: 1) the hymen, to diagnose more rare anomalies (1%) such as a tighten hymen, cribrous or septum; 2) the levator ani, to exclude or diagnose an hyperactivity of this muscle, contributing to: levator ani myalgia and narrowing of the vaginal entrance, thus contributing to vaginismus and dyspareunia; lifelong obstructive constipation; postcoital cystitis, if the adolescent already has sexual intercourse.

Although women of reproductive age were most affected, it was found that almost 4% of women between the ages of 45 and 54 years, and another 4% aged 55 to 64 years, reported burning or knife-like vulvar pain or pain on contact; in 50% of these cases, pain limited sexual intercourse.

In the USA, various degrees of dyspareunia (difficult or painful coitus) are reported by 21% of coitally active women, and by 10.5% of women between 40 and 80 years (Laumann et al., 1999). In Europe, 14% of women aged between 20 and 70 years reported coital pain (Fig. 1.1).

Lifelong mild vaginismus contributing to lifelong dyspareunia may occur in 10–15% of women. Severe vaginismus, preventing intercourse, may be complained of by 0.5–1% of women in reproductive age, although precise estimates are lacking.

Fig. 1.1

Prevalence of dyspareunia

Compared with controls, women with vulvodynia have been shown to be significantly more likely to report chronic medical conditions, including bladder pain syndrome/interstitial cystitis, fibromyalgia and irritable bowel syndrome (IBS).

It has been estimated that among women with urologist-diagnosed interstitial cystitis (IC), more than half (51.4%) were diagnosed with vulvodynia. This strong link may be related to a common etiology for these two conditions. The vulva and bladder are both derived from the embryonic urogenital sinus and share common sacral nerve innervation pathways. Moreover, both the vagina and the urethra are surrounded by the levator ani. Hyperactivity of this muscle, reducing the vaginal entrance and causing coital pain (“introital dyspareunia”) may reduce/block the vaginal lubrication and congestion of the cavernous vascular bulb, predispose to recurrent mechanical coital trauma of the vestibular mucosa and of the urethra/trigonal area, thus contributing to the bladder pain syndrome and vulvar vestibulitis. Data suggest that women with IC report lifelong dyspareunia and fear of intercourse since adolescence significantly more than controls (Peters KM et al., 2007). Conditions that affect the bladder may therefore lead to symptoms in the vulva, and vice versa.

Between 12% and 68% of patients diagnosed with IBS/IC report vulvodynia symptoms.

TIP: Physicians should routinely ask their vulvodynia patients if they:

·               had obstructive constipation since childhood (lifelong);

·               had difficulty in inserting tampons since adolescence;

·               recall having had coital pain and/or fear of intercourse since the first sexual experiences (lifelong dyspareunia and/or vaginismus);

·               suffer from bladder pain symptoms (burning, urge, frequency…);

·               have recurrent cystitis 24–72 hours after intercourse (“post-coital cystitis”).

These symptoms cluster key vulvodynia’s comorbidites, suggest a common pathophysiologic predisposing factor in the hyperactive pelvic floor and may be addressed with a multimodal treatment aimed at relaxing the pelvic floor (see Chapter 8). This would move patient from comorbidity to cotreatment, thus improving different symptoms and quality of life while saving costs.

Box 1

Vulvodynia and its comorbidities

Conclusions

Vulvodynia is highly prevalent, affecting 12–15% of women in the lifespan. Coital pain, namely vaginismus and dyspareunia, are the sexual symptoms that most frequently may predispose to vulvodynia, when lifelong, i.e. since the very first sexual experiences; or be consequent to it, when, more rarely, vulvar pain precedes intercourse. Vulvodynia is frequently associated to significant comorbidities (recurrent cystitis/bladder pain syndrome; irritable bowel syndrome; obstructive constipation; endometriosis; and also headache and fibromyalgia) that should be investigated and addressed in a multimodal multidisciplinary approach. A comprehensive evalution is key for a successful outcome.