Mucosal versus muscle pain sensitivity in provoked vestibulodynia.

BACKGROUND: An estimated 8.3%-16% of women experience vulvovaginal discomfort during their lifetime. Frequently these patients report provoked pain on contact or with attempted intercourse, commonly referred to as provoked vestibulodynia (PVD). Despite the burden of this condition, little is known about its potential etiologies including pelvic floor muscular dysfunction and mucosal components. This knowledge would be beneficial in developing targeted therapies including physical therapy. OBJECTIVE: To explore the relative contribution of mucosal versus muscle pain sensitivity on pain report from intercourse among women with PVD. DESIGN: In this proof of concept study, 54 women with PVD underwent a structured examination assessing mucosal and pelvic muscle sensitivity. METHODS: We examined three mucosal sites in the upper and lower vestibule. Patients were asked to rate their pain on cotton swab palpation of the mucosa using a 10-point visual analog scale. Muscle pain was assessed using transvaginal application of pressure on right and left puborectalis, and the perineal muscle complex. The Gracely pain scale (0-100) was used to assess the severity of pain with intercourse, with women rating the lowest, average, and highest pain levels; a 100 rating the highest level of pain. RESULTS: The lower vestibule's mucosa 5.81 (standard deviation =2.83) was significantly more sensitive than the upper vestibule 2.52 (standard deviation =2.6) (P<0.01) on exam. However, mucosal sensitivity was not associated with intercourse pain, while muscle sensitivity was moderately associated with both average and highest intensity of intercourse pain (r=-0.46, P=0.01 and r=-0.42, P=0.02), respectively. CONCLUSION: This preliminary study suggests that mucosal measures alone may not sufficiently capture the spectrum of clinical pain report in women with PVD, which is consistent with the empirical success of physical therapy in this population.

Vulvar skin atrophy induced by topical glucocorticoids.

Steroid-induced skin atrophy is the most frequent and perhaps most important cutaneous side effect of topical glucocorticoid therapy. To date, it has not been described in vulvar skin. A patient presented with significant vulvar skin atrophy following prolonged steroid application to treat vulvar dermatitis. The extensive atrophy in the perineum resulted in secondary "webbing" and partial obstruction of the genital hiatus and superimposed dyspareunia. Prolonged use of topical steroids may result in atrophic changes in vulvar skin. Further research in clinical correlates of steroid-induced atrophy in the vulvar region is warranted.

Erythema and burning pain in the vulva: a possible phenotype of erythromelalgia.

We report a case of burning vulvar pain accompanied by erythema responding to an oral combination of a benzodiazepine and a beta blocker. The positive response to two medication classes used in the treatment of erythromelalgia supports the possibility of a localized manifestation of this disorder in the genital region.

Psychosexual correlates of persistent postsurgical pain in patients with vulvodynia.

OBJECTIVE: To examine long-term reports of pain and psychologic correlates of pain in women after vestibulectomy. METHODS: In a retrospective cross-sectional exploratory study, 37 women who had undergone vestibulectomy between January 1989 and January 2008 completed questionnaires assessing demographic information, self-reported levels of pain, anxiety, somatization, psychologic distress, and sexual function. RESULTS: Eight women reported being completely pain free after surgery. The remaining 29 women reported various levels of pain during intercourse (as measured by the Gracely pain scale) and decreased sexual function (as measured by a sexual functioning questionnaire). Various measures of psychologic distress were associated with average intercourse-related pain, including brief symptom inventory (P=0.002), Pennebaker inventory of limbic languidness (P=0.002), perceived stress scale (P=0.04), and Spielberger trait-anxiety inventory (P=0.01). These same measures of psychological distress were similarly associated with general, unprovoked vaginal pain. CONCLUSION: The present data suggest that the pathophysiology of localized vulvodynia may be more complex in some women, leading to a suboptimal response to surgical treatment.