Alessandra Graziottin1, 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
What do women with vulvodynia complain of? There are two key issues: pain at intercourse and/or vulvar pain.
“I’ve had pain and burning near the entrance to my vagina for a long time. My doctor says it’s probably vulvodynia”.
What do women with vulvodynia complain of? There are two key issues: pain at intercourse and/or vulvar pain.
Pain is emotionally detrimental and consciously avoided. However, it is absolutely crucial for our survival. Pain perception is one of the most complicated measurable traits because it is an aggregate of several phenotypes associated with peripheral and central nervous system dynamics, responsiveness to stress and inflammatory state.
Vulvodynia is defined as chronic vulvar pain in the absence of objective clinical or laboratory findings to explain the symptoms. Itching is absent or is a minor symptom that does not produce a need to scratch.
Nevertheless, a good working definition for vulvodynia is a vulvar condition where the dominant symptom is a variation on the pain theme.
Box 1
Vulvar pain
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Vulvar pain is often described as having a burning quality |
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Other patients describe their problem as “irritation”, “stinging”, “raw feelings”, “crawling”, or just “vulvar awareness” |
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Discomfort has also been referred to as “the pain down there” or as “feminine pain” |
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Vulvar pain can be: |
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- provoked: it occurs in response to stimulation |
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- unprovoked: it occurs independently of stimulation |
Dyspareunia is genital pain experienced just before, during or after sexual intercourse. Patients with dyspareunia may complain of a well-defined and localized pain, or express a general disinterest in and dissatisfaction with intercourse that stems from the associated discomfort. The most common pain with dyspareunia occurs during coitus, but some women experience pain afterwards, while others report pain at both times. Pain before coitus may result from irritation of the external genitalia or the vasocongestion that occurs during the excitement phase. Patients with dyspareunia are more likely than the general population to report pain with insertion of a tampon or digit, or during a gynecologic examination.
Box 2
Marinoff Dyspareunia Scale
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0 No dyspareunia |
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1 Causes discomfort but does not interfere with frequency of intercourse |
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2 Sometimes prevents intercourse |
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3 Completely prevents intercourse |
Dyspareunia has been associated with a more negative attitude toward sexuality, with more sexual function impairment and with lower levels of relationship adjustment.
Women with dyspareunia, not surprisingly, have been found to have a lower frequency of intercourse and lower levels of desire and arousal, and to be less orgasmic with oral stimulation and intercourse. When tenderness is elicited during the examination, the physician can ascertain if this pain is similar to her dyspareunia.
There are two major pain patterns in women with vulvodynia: vestibulodynia (vulvar vestibulitis syndrome) or generalized vulvodynia. Vestibulodynia, the most frequent type of vulvodynia, is defined as burning or pain that is localized strictly to the vestibule of the vulva and is provoked by pressure or friction in the vestibule. Pain is commonly associated with intercourse, tampon use, tight clothes, and bicycle riding, among others, and spontaneous pain is minimal or absent.
The second pattern of vulvodynia is generalized vulvodynia, which is associated with burning or pain that is not limited to the vestibule and may occur without touch or pressure. When asked to localize this sort of pain, patients are frequently unable to do so, and are only able to indicate the general area where the pain is experienced.
Dyspareunia is an important component of vulvodynia and it can occur as an isolated symptom.
Dyspareunia is a component of vulvar pain related to the ‘provocation’ of sexual intercourse and it may be the only symptom, especially in provoked vestibulodynia.
The symptom of vulvar pain must be fully evaluated. As pain is subjective, the patient’s history provides the main evaluation. Examination and investigations provide further understanding of the pain syndrome and exclude other conditions.
Box 3
Vulvar pain evaluation
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l Baseline and ongoing regular evaluation of pain severity |
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l An initial detailed history to include: chronology of onset and progression, characteristics and site of pain, including radiation, aggravating and relieving factors, associated symptoms |
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l Questions about thoughts, emotions and behavior associated with pain |
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l Detailed examination, not only of the painful area but of the whole patient, particularly musculoskeletal and nervous systems |
Vulvar pain can only be measured subjectively. The most reliable and well-understood method is a numerical rating scale, from 0 (no pain) to 10 (extreme pain), with half-points marked. This is superior to the widely used visual analogue scale (VAS), which is a 10-cm line with ‘no pain’ marked at one end, and ‘extreme pain’ at the other. Alternatively, a simple verbal rating scale can be used, e.g. ‘none’, ‘mild’, ‘moderate’, ‘severe’. Both numerical and verbal scales can be used by patients without the need for paper and pen, unlike the VAS.
Because pain is multidimensional, a single rating scale combines these dimensions in unknown quantities. Depending on the clinical question, treatment, patient and setting, it can be helpful to assess separately pain intensity, pain distress, and interference of pain with activities of daily life. It can also be helpful to ask about average pain, worst pain (as even if this only occurs rarely, it can still reveal what patients should avoid) and pain on, for example, bladder voiding. Pain reduction or relief is measured directly using a percentage, from 0% = no relief up to 100% = total relief.
Classically, pain can be considered to have three dimensions: sensory-discriminative, motivational-affective and cognitive-evaluative. The most used and validated multidimensional tools for the measuring pain are the long and short forms of the McGill Pain Questionnaire (Fig. 5.1). The questionnaire consists primarily of three major classes of word descriptors - sensory, affective and evaluative - that are used by patients to specify subjective pain experience. It also contains an intensity scale and other items to determine the properties of the pain experience. The questionnaire was designed to provide quantitative measures of clinical pain that can be treated statistically.
Fig. 5.1
The Short Form McGill Pain Questionnaire (adapted from Melzack R, 1987, with permission)
In conclusion, vulvar pain analysis and quantification is optimal for a comprehensive understanding of the patient’s experience and for effective treatment planning. Pre- and post-treatment quantification of vulvar sensitivity can lead to advances in the optimization of treatment success.